Calories and Deepities

Friday, June 29, 2012

A Word is a Word

The American philosopher Daniel Dennett uses the term "deepity" to describe a statement which has the air of conveying something profound, but actually doesn't. If you analyze it, a deepity boils down to a kind of play on words, which has two meanings: one insignificant but true, and the other significant but false.

Here's a deepity: "love is just a word". The true part of this is that the word "love" is, of course, a word -- that's true of any word, so the aspect of this deepity which is true is also pretty unimportant. But the thing represented by the word "love" is not "just" a word; it's an emotion, a condition, a human relationship -- so the aspect of this deepity which would be significant, if it were true, is false.

The aspect of a deepity which is true is usually in the form of a tautology -- something that, by definition, can't help being true. The word love is a word, all right. (So is the word artichoke, and what the hell difference does it make?)

The aspect of a deepity which is false is usually a meaning that is implied rather than spelled out. (The things we mean by the word love are mere illusions -- is that the idea?)

People who employ deepities consciously, to win an argument, are naturally hoping that the presence of the true but trivial aspect of their deepity will mislead you into accepting the untrue but important aspect ("evolution is only a theory", and the like).

A lot of the time, though, deepities are used without any conscious intent to deceive. It takes a certain alertness even to recognize a deepity for what it is, and sometimes the people who use them are quite sincere in assuming that both aspects of their deepity -- the insignificant truth, and the significant falsehood -- are equally valid. And when we hear a deepity that we like, we pass it along, without analyzing it and without noticing what is wrong with it. The result is that a lot of deepites are circulating around out there, and they tend to go unchallenged.

A Calorie is a Calorie

A deepity which has been far too widely accepted, in most discussions of diet and obesity, is the classic "a calorie is a calorie". The true but insignificant aspect of this deepity: yes, by golly, a calorie is indeed a calorie -- quite a revelation! But what exactly is the meaning of the significant but false aspect? The implied meaning is: one calorie of chemical energy entering the body as food has exactly the same effect on the body as any other calorie, regardless of whether the calorie comes from fat, protein, or carbohydrate.

I should add that the the people who repeat this deepity only mean it to a certain extent: they think it applies only to the effect of calories on body weight. They don't mean that an all-fat diet or an all-protein diet or an all-carb diet would have the same impact on every aspect of human health. They just mean that, in terms of body weight, the amount of chemical energy you take in is all that matters.

A closely related deepity is the "calories in, calories out" formula as an explanation for weight gain or loss. This is sometimes characterized as an invocation of the laws of thermodynamics (and therefore, supposedly, irrefutable). If you burn more calories than you take in, you lose weight. Therefore, if you exercise more and take in fewer calories: inevitable weight loss! Does this really count as a deepity, you ask? I think it does. The insignificant but true aspect of it is that calories are consumed and calories are used, and body weight is influenced by these factors. The significant but untrue aspect is the implication that diet and exercise are the only factors involved. I'm not trying to overturn the laws of thermodynamics here -- I'm just mentioning that the laws of thermodynamics have to take everything into account, not just the things that humans choose to focus on.

If the caloric value of food is the only factor that matters in terms of body weight, why is it not the only factor that matters in terms of other aspects of health and nutrition? Would people eating a diet consisting of nothing but barbecued chicken have the same health outcomes as people eating a diet consisting entirely of refried beans, so long as they got the same number of calories per day? People have all sorts of ideas about what constitutes a healthy diet, but few people (if any) think that your arteries, for example, are going to do just as well eating anything at all, so long as the calorie count is right. Whatever theory of nutrition and health you subscribe to, you probably don't imagine that a calorie's worth of cheddar cheese and a calorie's worth of watermelon are processed by the body in the same way and have the same impact on body chemistry.

So the deepities about calories ask us to believe, within the context of discussions of obesity, what nobody believes outside that context!

And apparently there is no reason to accept the caloric deepities even within the context of discussions of obesity. Studies of the body-weight impact of different diets are casting considerable doubt on the notion that "a calorie is a calorie".

A recent study looked at the problem of "yo-yo" dieting, in which obese patients lose large amounts of weight for a while, and then bounce back up to their former weight or higher. It has been noted that the bounce-back problem seems to be especially bad in the case of patients whose weight-loss regimen is a low-fat diet. The researchers compared patients on a low-fat diet, a low-carb diet, and a compromise diet which was "low-glycemic index" but not extremely low-carb.

The researchers found that, in all patients, the body tried to oppose the weight-loss trend by ramping down its metabolic rate, burning fewer calories in order to put the pounds back on despite the caloric restriction of the diet. But there was a large difference between diets in terms of how severely the body reacted. For patients on the low-carb diet, the metabolic rate only dropped by 97 calories a day. For patients on the low-fat diet, the metabolic rate dropped by 423 calories a day! (The compromise diet was in between -- the metabolic rate dropped by 297 calories a day.) If low-fat diets are particularly vulnerable to the yo-yo effect, apparently it is because the body works more than four times as hard to undermine that type of diet.

Yeah -- one study, and who knows if it's right. But the thing is, there have been a lot of studies over the years which showed that "a calorie is a calorie" is simply wrong. The body processes different kinds of calories differently, and reacts to them differently. For one thing, fat storage is a process known to be driven by insulin, and foods vary considerably in their effect on insulin levels.

I'm not offering this as a vindication of Dr. Atkins, or as proof that any one diet is necessarily the best one. I'm just pointing out that the long-cherished deepities about calories have had their day; it's time to move on. We know, beyond any reasonable doubt at this point, that the body responds differently to different foods -- in every regard, including body weight. It's time to face that, and start figuring out which sorts of diets can actually work for people.

Legal Dramas

Thursday, June 28, 2012

Affordable Care Act: the Court Decision

My goodness...

Chief Justice Roberts surprised court-watchers today, and broke ranks (very uncharacteristically) with the Supreme Court's conservative block. The result was a 5-to-4 decision which upheld almost all provisions of the Affordable Care Act (including the crucial "individual mandate"). People are speculating madly about why, exactly, Justice Roberts did the unexpected in this case, and also about which party will benefit politically from the decision. I won't hazard a guess; since I guessed wrong about the outcome of the court case, I have to conclude that my crystal ball is not reliable on this subject.

There will be further attempts in congress to kill health care reform, but no judicial reversal of it. For the moment, we can get on with our lives. Most Americans will, at least to some degree, have access to health care for the time being. But I still think it's a good idea for Americans to try to avoid needing it, to the extent that this is possible!

Another Court Decision: Killing Michael Jackson

Oh dear -- Dr. Conrad Murray, who is serving time for killing one of his patients (a patient named Michael Jackson), now wishes he had taken the witness stand in his own defense. Apparently his lawyers disagreed sharply about whether he should testify or not, and Dr. Murray decided to listen to the one who said he shouldn't. Now he wishes he had decided differently, and supposedly the lawyer who urged him not to testify now admits that he was wrong. But was he wrong?

Juries want to hear the defendant defend himself. I would, if I were on the jury. If the jury assumed that Dr. Murray wasn't testifying because he knew that the story he was telling wouldn't hold up under cross-examination, you can hardly blame them. Why else would a defendant not take the stand? If his story made sense and agreed with the evidence, he would have told it. The only reason Murray's lawyer would have had for recommending that he not testify is that he thought Murray would do himself more damage by telling his story than by not telling it. And maybe he was right. It appears that his story wasn't very good. It would have been pretty easy for the prosecutor to poke holes in it.

Dr. Murray killed Michael Jackson by administering the surgical anesthetic propofol, used in this case (very inappropriately) as a sleeping aid. The drug is supposed to be administered only in an operating room, and certainly not dispensed at home to a half-mad former child star. Dr. Murray failed to monitor Jackson properly after administering the drug, then delayed calling for emergency help when Jackson stopped breathing, and then (when he finally did summon help), didn't reveal that the patient had been given propofol. Clearly the actions of a competent physician, acting responsibly.

Seriously: what story could Dr. Murray have possibly told on the witness stand which would have made his actions seem acceptable to a jury? His version of events was that he had given Jackson only a little bit of propofol, but Jackson (being addicted to the drug) probably gave himself a large additional dose of it while Dr. Murray wasn't looking. Does anyone really think a jury would have excused all of Murray's behavior on that basis, even if they believed the story about Jackson adding to the dose himself? Or that they wouldn't have asked themselves how Jackson came to be addicted to propofol in the first place, or why Murray continued supplying that very dangerous drug to a known addict?

Yes, it is probably true that Dr. Murray went to prison because he didn't testify in his own defense. But if he had taken the witness stand, then he would probably have gone to prison (and perhaps for a longer sentence) because he did testify in his own defense. Sometimes you can't win in court, but that does not necessarily mean that the trial is unfair. Sometimes the reason you can't win is that you don't have a case.

The mere fact that a drug has been given FDA approval for doctors to use -- in certain situations, for some patients -- is not enough reason to assume that it's in the best interest of the patient for the doctor to administer that drug in all situations, or for all patients. If Michael Jackson had been undergoing surgery, in a hospital operating room, with proper supervision by an anesthesiologist, administering propofol might have been perfectly appropriate. But in the actual circumstances of the case, administering propofol was homicide, and was punished accordingly. Funny how important context can be.

Anyway, I think that everyone (including, it seems, a doctor or two) needs to let go of the notion that are two kinds of drugs in the world: illegal ones, which are hazardous, and legal ones, which are risk-free. It's not that simple.   

Medical Armageddon, Maybe!

Wednesday, June 27, 2012

Health Care System To Be Wiped Out By Asteroid Tomorrow?

Tomorrow, apparently, is the big day: the Supreme Court will rule on the constitutionality of the Affordable Care Act. I take it for granted that the court will rule in the most irresponsible way it can (probably that would mean outlawing the individual mandate to purchase health insurance, without outlawing the provisions that the individual mandate pays for -- thus throwing the entire health-care industry into legal and financial turmoil). Yeah, I'm cynical, but you can't follow the Supreme Court and be any other way.

What intrigues me is the paradoxical polling data on what American voters think of the matter. To put it briefly, they tend to be against the Affordable Care Act as a whole, but strongly in favor of almost all of its provisions. The one provision they don't like is the individual mandate -- without which they cannot have any of the provisions that they do like!

People really don't like that individual mandate -- the concept of the government requiring them to buy something strikes them as creepy and un-American. (Why that is so much worse than the government taxing them to pay for expensive wars they don't care about is a little unclear, but apparently it's much, much worse.) Anyway, the individual mandate is the deal-breaker -- it prevents people from supporting a reform which they seem to like in every other way.

There are a lot of ironies involved in this saga, and the weirdest of them is that the idea of an individual mandate, now derided by conservatives as "socialism" or worse, started out as a conservative scheme. It was seen by Republicans as a way of getting the health insurance companies on board with health reform (after all, it protects them financially by creating a pool of insurance-buyers who aren't already sick), without using taxes for the purposes. But once this right-wing, pro-big-business proposal was taken up by President Obama, the conservative fingerprints were wiped off it, and it became emblematic of a socialist conspiracy. And tomorrow it will probably be outlawed for that reason. If that happens, a large part of the public will rejoice, thinking that the one provision of the Affordable Care Act which they don't like will be dropped, and they'll be left with just the provisions they do like -- which, of course, cannot be payed for if the individual mandate is no longer there to pay for them!

I have health insurance through my job, so no aspect of this lengthy and insane political fight over health care has affected me directly, and I've tried not to get too excited about it. I guess what I've mainly felt has been embarrassment for my country -- to think that it has taken us this long to make even a feeble baby-step in the direction of health care reform, and even so we're in a state of hysteria about it! And now we're probably about to destroy it. My fear is that there is going to be a lot of collateral damage to the health care system as a whole, and a lot of people (like me) who have been able to stay aloof from the whole thing are going to be impacted directly.

In America we like to imagine that our health care system is the best in the world, but if you compare America to almost any country on the planet, you'll find that we pay more for health care than they do, but we get less health care for our money. We're not an especially healthy country; our longevity is nowhere near the top, and out infant mortality stats are strictly third-world. Our system isn't the best, it is merely the most expensive. And now we may be about to get even less for our money than we have been so far.

Anyway, if the health-care system is about to be devastated by a reckless legal decision, I guess we'd better do what we can to stay healthy on a strictly amateur basis. And I think that, most of the time, we can do that -- even those of us who have diabetes or another chronic health problem. Usually what we do for ourselves has a bigger impact than what the pros can do for us.

Still, though: sometimes you need antibiotics, emergency surgery, or something else that can't be provided on an amateur basis, and you need them right away. I hope some kind of health care system will be left standing (or will be set up after the present one collapses) which can attend to those sorts of needs. There are some health problems that a daily run doesn't solve.

But I guess I'd better keep doing that daily run, and hope that things work out by the time I need a severed limb reattached or something like that.

More on Fructose

Tuesday, June 26, 2012

Fructose & Your Test Results

In my comments about fructose yesterday, I failed to emphasize a point that may be of some importance to a lot of diabetes patients: how does fructose affect your test results?

Home glucose meters work by measuring the electrical current generated by a chemical reaction in the test strip. What drives that reaction is an enzyme in the test strip called glucose oxidase. The more glucose is present in the blood sample applied to the strip, the stronger the reaction, and the stronger the electrical current generated. The meter measures the current, and reports whatever level of blood glucose is expected to generate that much current.

The thing is, the glucose oxidase enzyme in the test strip is very glucose-specific. Other forms of sugar don't react with it. Fructose, to be specific, doesn't react with it. In other words, the rest result that the meter shows you does not reflect "blood sugar" generally. It only reflects how much glucose is in your blood. It says nothing at all about how much fructose is in your blood.

(If you are about to protest that handling fruit before testing, without washing your hands carefully, can give you a false high result -- and that this must mean the meter can detect fructose -- let me point out that the sugar in fruit is not just fructose; fruit contains glucose as well.)

However: just because your meter cannot detect fructose in your blood, you cannot assume that no fructose is in there.

It is sometimes said that, when you digest table sugar, HFCS, and other forms of sugar, the fructose in it is transported "directly" from the intestine to the liver through the portal vein (and that, once the fructose gets into the liver, it is converted to triglyceride). This implies that fructose doesn't get into the circulating blood supply -- only the triglyceride byproduct does. That is is actually not the case! Ingested fructose does get into the bloodstream and circulate -- at least until the liver manages to soak it up and convert it to triglyceride. In experiments, a patient drinking a solution containing both glucose and fructose will typically reach more than triple the normal level of blood fructose within 30 minutes. But whatever fructose spike you experience after a meal is going to be invisible to you, because your glucose meter cannot measure it.

As I noted yesterday, fructose in the bloodstream causes glycation (harmful bonding of sugar to protein) even more aggressively than glucose does. Whatever glucose does to cause diabetic complications, fructose can do it worse. So it does matter how much fructose is circulating in your blood; the problem is that you can't find out. All you can do is look at the consequences, in terms of glycation.

If you want to find out how much glycation is going on inside you, the hemoglobin A1c test (a measurement of glycated hemoglobin) is how you find out. But when you do find out, you may be in for an unhappy surprise: the result might be higher than it "should" be, given the sort of glucose meter readings you've been seeing lately. You might then start brainstorming to see if you can come up with a reason why the A1c result is "wrong".

I've said it before, and I'll say it again: what the A1c test measures is glycation. It does not measure glucose. It gives us a basis for estimating average glucose over the past few months. But if the test shows that there is more glycation going on than your recent glucose levels would suggest, maybe the problem isn't with your glucose levels. Maybe the problem is with your fructose levels. It could be that fructose intake is undermining what would otherwise be a good effort at glycemic control.

Now, it might seem unfair that biochemistry would throw you this particular curve-ball. There are no meters available for home fructose testing, so how on earth are you supposed to track  your fructose? Well, you can't really track it, but you can take sensible precautions. And the most effective precaution is to limit your intake of any kind of sugar which contains fructose. That includes HFCS, table sugar, honey, maple syrup, and agave nectar. All of them are at least half fructose. Reduce your intake of those things, and it's possible you'll get an A1c result next time which is more in line with the level of glucose control you have achieved.

Worth a try, anyway. Nothing is guaranteed when it comes to diabetes management, we can only experiment and hope that the experiment comes out the way we want it to!

Mondays, Saturdays, and that Old Devil Fructose

Monday, June 25, 2012

About Mondays

A thought from xkcd :

About Saturday

I went to a party on Saturday where about half the guests were Irish musicians. Lots of fun, but I had too much to eat, and although my blood sugar hasn't gone up from it, my weight has. Oh well, get back to work on that...

About Fructose

Whenever anyone has tried to blame the current epidemic of obesity and diabetes on the increasing use of HFCS (high-fructose corn-syrup) in processed foods, the HFCS industry has responded vigorously by citing studies which show that HFCS is no worse than table sugar. Well, apparently it isn't any worse than table sugar... but that's not saying much.

Table sugar and HFCS are, both of them, a half-and-half mixture of glucose and fructose. And that's a problem, because both table sugar and HFCS are introducing a lot more fructose into our diet than we would otherwise get, and fructose turns out to be a very troublesome substance 

Glucose and fructose are not equivalent; the body processes them differently, and they are usually obtained from different foods. Any sort of carbohydrate contributes glucose to your diet; starchy foods usually break down into just plain glucose, without any fructose to speak of. Fructose enters the diet mainly in the form of fruit -- or anyway it used to, before the sugar-refining industry came into being.  

Nowadays, with table sugar and HFCS being very heavily used as food additives, we have a large additional source of fructose in our diet. The amount of fructose that most people take in today is far in excess of anything that would occur naturally. In fact, we take in about five times as much fructose today as human beings historically have taken in from the fruit in their diet. And this greatly expanded fructose intake is probably the most important difference between the diet of modern industrial society and any diet that ever existed in primitive societies.

When isolated, tribal societies came into contact with the civilized world, and began eating the foods that came with civilization, they inevitably ended up consuming a lot more fructose than they were accustomed to. It may not be purely a coincidence that they also began to suffer from all the diseases of civilization (obesity, hypertension, diabetes, coronary heart disease, and certain cancers) which had once been rare among them.   

There is every reason to suspect that increasing one's intake of fructose is a step in the wrong direction. However, the popular impression is quite the opposite. Isn't fructose better for you than glucose? After all, fructose is present in fruit; doesn't that mean fructose is good for us? (Not if you're consuming five times as much of it as you would get from eating fruit!)

Also, sugar that includes fructose has a lower glycemic index than starch (which breaks down into glucose only) or glucose itself. Doesn't that mean fructose is the better than glucose, and also better than starch?

Well, if the only issue that matters, in regard to the health impact of a particular form of carbohydrate, is what sort of reading you get on your glucose meter afterwards, then fructose is a safer bet. Unfortunately, that is not the only issue that matters. 

The body processes fructose in the liver, and the liver does not turn it into glucose. Fructose turns into fat instead -- specifically, the liver turns fructose into triglycerides, which circulate in the blood. And if there is one thing you don't need, it's more triglycerides circulating in your blood. Your triglyceride level is a much more reliable predictor of your heart-attack risk than your level of "bad" cholesterol. (And as for your level of "good" cholesterol, or HDL, fructose tends to bring that down rather than up!) 

Okay, so there's strike one against fructose: it has an undesirable impact on lipids. 

And here comes strike two: high intake of fructose interferes with insulin signaling, and appears to promote insulin resistance as a result. The fructose itself may not spike you directly, but it sets you up for bigger spikes in the future by making your cells insensitive to insulin. 

Finally, strike three: although fructose doesn't have much effect, if any, on your glucose meter reading, that doesn't mean it can't do the sort of chemical harm that glucose can do. Glycation (unwanted bonding of sugars to proteins) and Advanced Glycation End-products (AGEs -- toxic waste products that result from glycation) are promoted even more vigorously by fructose than they are by glucose. 

Actually, fructose is thought to have other undesirable effects as well, but maybe the three I've mentioned are enough to get the point across: a high intake of fructose is not good for your health, especially if you already have diabetes. A certain amount of fruit is okay, but adding generous amounts of table sugar and HFCS on top of that -- typically multiplying your fructose intake by five? That seems to be where we've gone wrong with the modern diet.

Contrary to what many people seem inclined to assume, people ate high-fat foods even in the old days, before all the current diseases-of-civilization began to proliferate -- but high-fructose foods? Those are new, and they seem to be stirring up a hell of a lot of trouble.

So, anyway, fructose is a problem -- not a solution, as some people claim. You may be advised that certain forms of agave nectar, which contain substantially more fructose than glucose, are a "healthier" alternative to table sugar, HFCS, maple syrup, or honey (all of which are about evenly split between glucose and fructose). The rationale is that the higher proportion of fructose in the agave nectar gives it a lower glycemic index. Unfortunately, as already noted above, choosing a higher-fructose sugar with a lower glycemic index probably amounts to replacing a problem which your glucose meter can detect with a worse problem which your glucose meter can't detect. That doesn't look like a solution to me.

Limiting the fructose in your diet would seem to be a major dietary priority -- and you can't do that without reducing your intake of sugar in nearly all forms, because nearly all forms of sugar available to us are at least half fructose. So, cutting your fructose intake isn't especially easy, but apparently it is well worth doing.


Thursday, June 21, 2012

Hypoglycemia Among the Unmedicated

A reader who (like me) has been controlling diabetes without drugs, and who (unlike me) has been plagued by frequent episodes of hypoglycemia, asked me if I can suggest a possible solution to this problem.

I certainly can't suggest one based on personal experience. I have had just enough experience with hypoglycemia to know that I HATE it! -- but not enough experience to have developed much personal wisdom on the subject.

Hypoglycemia can trigger a wide variety of symptoms, and each of us gets a particular subset of them. For me, an episode of hypoglycemia begins with sudden hunger, accompanied by a growing feeling of weakness throughout my body. Then I start to feel unsteady on my feet, and I begin trembling. Then it gets serious: I develop a feeling of intense nervousness and anxiety, and a rather desperate urge to eat something sugary or starchy, immediately! The feeling is not "I'd really like to have a piece of that cake" but rather "I will die within minutes if I don't eat at least half of that cake!". (No, I don't go ahead and eat half a cake, I'm merely describing a feeling. A lesser dosage of carbohydrate, such as tea with a spoonful of sugar in it, is usually enough to solve the problem for me.)

I don't have hypoglycemic episodes very often. An extremely prolonged workout (such as running a distance of more than 10 miles) will produce hypoglycemia if I don't take in any sugar during the run. Apart from that, I probably don't have a low more than twice a year. It used to happen a bit more often, during the first year after I was diagnosed. I think that, after losing a lot of weight, starting an exercise program, and pulling my blood sugar back down into the normal range, my body was not yet used to the altered state of affairs, so it wasn't stabilized yet, and as a result it swung too low on occasion. But even then, it didn't happen a lot, so I haven't worried about it a lot, or investigated the subject in much depth.

Which is just as well, because it doesn't look as if there is any way you can investigate the subject in much depth. The information I've been able to dig up on hypoglycemia is almost entirely about lows triggered by insulin or oral diabetes drugs; the medical profession has payed very little attention to lows occurring spontaneously in patients who aren't being medicated. The assumption seems to be that hypoglycemia in unmedicated patients is either non-existent or of no concern (because it supposedly not severe enough to harm you).

In fact, I found a web page (last updated in 1998 -- the internet is forever!) entitled "No, You're Not NUTS!", collecting stories from people who are not on insulin or diabetes drugs, but are experiencing frequent lows, and can't get their doctors to take the issue seriously. Sample complaints:

The medical profession does have an unfortunate tendency to assume that whatever is atypical is also unreal or unimportant. Just because what is happening to a particular patient is not typical, that doesn't mean the case should be ignored. This is the sort of thinking which causes doctors not to recognize a heart attack when it occurs in a 38-year-old female, simply because heart attacks in women of that age are atypical. (Plane crashes are atypical too, but that doesn't mean they don't matter and we shouldn't try to do anything about them.)

Anyway, although some unmedicated diabetes patients do indeed have serious problems with hypoglycemia, nobody seems to be trying very hard to figure out why that is.

Possible explanations for hypoglycemia experienced by unmedicated patients are not numerous or especially satisfying:

  1. Some diseases, especially liver diseases such as hepatitis, can trigger lows.
  2. Starvation (as in anorexia) can cause lows.
  3. A (rare) form of pancreatic tumor can lead to excess insulin production, causing lows.
  4. Endocrine disease involving the pituitary and adrenal glands can cause lows.
  5. Heavy alcohol consumption can trigger lows.
  6. An over-reaction to a high can trigger a low; this typically follows a rapid glucose spike after a meal. (I once experienced a reactive low following a high in the form of a do-it-yourself Oral Glucose Tolerance Test).
  7. An over-reaction to a workout can trigger a low.

Items 6 and 7 there are the most likely explanations for frequent lows in unmedicated diabetes patients. But what can such patients do about them?

There I am all but stumped. The usual advice to such people is that they schedule small snacks throughout their day. Two other methods I have heard patients say were helpful to them: a spoonful of corn-starch taken before bed, and doses of fiber supplements taken throughout the day. For anyone wanting to try any of those tricks, my advice would be to do enough testing to make sure you know what effect it is having on you. You don't want to solve one problem by creating another!

Drinking Sugar

Wednesday, June 20, 2012

The Soft-Drink Serving-Size Issue

Sometimes you just have mixed feelings...

...about sugary soft-drinks.

I have been reluctant to weigh in on the controversy over New York's attempt at legally restricting sales of over-sized sugar drinks, because I can see what's silly about the story (you can't buy a 30-ounce mega-cup of Coke, but you can buy two of the 16-ounce version?), and I can also see what's serious about it (don't we have enough epidemiological evidence by now to recognize that a 30-ounce serving of Coke is, in a very real sense, a sugar overdose?).

The soft-drink industry has been working mighty hard, for a mighty long time, at "normalizing" the concept of drinking liquid sugar more and more often, and in ever-larger doses.

And sometimes the methods of persuasion they use are perhaps in questionable taste. Add a "Mega Jug" of Pepsi to your meal at KFC and they'll donate a buck to diabetes research? Surely no one will see any irony in that!

Of course, the soda industry lobbyists are complaining loudly that their industry is being unfairly blamed for health problems it had no role in causing. According to them, rising rates of consumption of sugary soft-drinks in the United States have nothing to do with the rising rates of obesity and diabetes in the United States. The justice of their complaint can perhaps best be evaluated by looking at how these things break down geographically:

Yep, the pattern is clear: no connection whatsoever between soda consumption, diabetes, and obesity! Who could ever have been so mean-spirited as to suggest such a connection in the first place?

I can understand -- sort of -- why some people would complain that New York's attempt at intervening in this situation is producing a "nanny state". On the other hand, I know that nannies exist for a reason. Perhaps New Yorkers need a nanny? (Not Mary Poppins, though -- her concept of a spoonful of sugar helping the medicine go down is probably not what the situation calls for.)

Look, the situation is not all that murky: sugar consumption has gone way up, and sugary soft drinks (served in increasingly gigantic sizes) account for a large share of that trend. Possibly the strong association between rising sugar consumption, rising obesity, and rising diabetes is coincidental -- but how likely is that possibility?

It seems to me that it is time for us to admit that sugar abuse is a legitimate public-health issue, and that governments should attempts to do something about it -- even if we reserve the right to ridicule some of those attempts. I don't see how it can be argued that government should try to do anything about it at all.

Searching Questions

Tuesday, June 19, 2012

Here's the most recent crop of search-phrases which made the folks at Google send people my way...

"can having your sugar drop kill you"

Yeah, sure. Extreme hypoglycemia deprives the brain (and perhaps also the heart) of sufficient chemical energy to maintain life.

How much does your blood sugar have to drop before it's dangerous? This seems to vary a lot from person to person. The general rules of thumb seem to be (for blood sugar measured in units of mg/dl):

Bear in mind that these are general guidelines -- you might turn out to be less vulnerable, or more vulnerable, than this outline suggests.

"if my blood sugar says 70 so what"

Okay, so what?

70 is generally thought of as the bottom end of the normal range. Being at 70 is not necessarily a problem. The question is, if your blood sugar is 70 at the moment you test it, which way is it going? If it's holding steady there or rising, fine. If it's falling, you may be heading into a hypoglycemic episode that will make you feel pretty bad in a little while. Keep an eye on the situation. If you start feeling bad, test again, and be ready with something sweet to fix the problem, if there is a problem. (But don't overcorrect -- a cup of tea with one spoonful of sugar in it may be all you need. You don't have to swallow a whole apple pie.)

"blood sugar testing at what point during the 24-hour period"

My system is to do two tests a day: a fasting test the minute I get out of bed in the morning (I aim for a result under 95, and preferably under 90), then a post-prandial test one hour after a meal (I aim for a result under 140, and preferably under 125).

My goals may be over-ambitious for you (in fact, they're more ambitious than what my doctor asked for), and you may need to test more often than I do (if you're taking insulin, for example), or less often than I do (if you can't afford to go through test strips that fast).

"instead of having my doctor congratulate me on well-controlled"

I guess the rest of this complaint was lost to truncation (folks, a search phrase is not supposed to be in essay form!). But I guess I see where this is going. You expected a pat on the back, and what do you get? Criticism and unreasonable demands that you do more!

Conceivably your definition of "well-controlled" may be more generous than your doctor thinks is prudent. But I certainly know of people who couldn't seem to earn any credibility or respect from their doctors, no matter how remarkable an improvement they managed to make. Sometimes doctors don't believe a big improvement really counts, until they see it sustained over time -- maybe it's a problem that will take care of itself if you keep what you're doing a bit longer. But if your doctor never does come around, you may have to find a more useful doctor.

"if someone has apathy"

Who cares, really?

"diabetics pee to get rid of sugar in blood"

Not exactly. As blood filters through the kidneys, the sugar in it is supposed to be returned back into the bloodstream, not excreted in the urine. However, the chemical sorting process involved can only work efficiently when the amount of sugar in the blood is not abnormally high. When the blood has more sugar in it than the kidneys can return to the bloodstream, the excess leaks into the urine. This is an accidental spillage, not a strategy for reducing blood sugar. Controlling blood sugar is the job of the pancreas (working in conjunction with the liver); the kidneys aren't expected to take part in the regulatory process.

Osmotic pressure causes the flow of urine to increase when a lot of sugar is leaking into the urine, but this is an accidental result rather than a means of "getting rid of sugar".

"is there glucose in everyones urine"

Traces of it, perhaps. The kidney function that returns glucose (blood sugar) to the bloodstream is not absolutely perfect. But it's usually fairly close to perfect, so very little blood sugar spills into the urine unless your blood sugar is abnormally high.

"is sugar the only reason ants would drink urine"

Well, it's the only motive I can think of, but perhaps if they're thirsty and there are no other liquids about, they might drink it for the water that's in it. Anyway, observation of insects is no longer the preferred method for determining if you're diabetic or not, so divert your attention elsewhere.

"ways to get rid of sugar in your urine"

Enough with the urine, people! That's not what's important here!

What matters is how much sugar is in your blood. Sugar in your urine is significant only in the sense that it gives a clue to the amount of sugar in your blood.

The way to get rid of sugar in your urine is to reduce the amount of sugar in your blood to the normal range.

"evenings are depressing"

No, no, you've got it all wrong. Early afternoons are depressing. Evenings are pretty nice.

"the real cause of diabetes not medical bullshit"

It's hard to know how this person defines "medical bullshit". As diabetes is a medical problem, any explanation for it pretty much has to be a medical explanation. Doe this person want an explanation unrelated to medicine? Perhaps a nice conspiracy theory involving Area 51 and the Illuminati?

Assuming that I'm allowed to cite medical reasons without being accused of bullshitting, the "real cause" of diabetes is only partially explicable.

In the case of Type 1, the problem is an auto-immune reaction, in which the body's immune system destroys the beta cells of the pancreas (which produce your insulin supply) -- but nobody knows exactly what causes this auto-immune reaction to occur. It might be triggered by exposure to a virus or to an environmental contaminant.

In the case of Type 2, things are still a bit murky. Development of the disease seems to proceed from diminishing sensitivity to insulin, often coupled with diminished production of insulin. Exactly what drives these developments is unclear, but abdominal obesity and lack of exercise greatly increase the risk, and some gene variants also increase the risk.

"what they don't want you to know about diabetes type 2"

I could tell you -- but I'm part of the "they" who don't want you to know. Boy, are we laughing it up at your expense!

"panicked with type ii diabetes diagnosis i'm thin"

The main thing worth panicking about here is that you may actually have Type 1, so you need to look into that.

Thin people with Type 2 sometimes turn out to have a form of Type 1 which is slightly atypical and can be mistaken for Type 2 because it develops later and more gradually than Type 1 usually does. The thing is, this form of diabetes (sometimes called LADA) requires different treatment than Type 2, and patients with LADA don't do very well, unless the misdiagnosis is recognized and corrected. If you're getting unusually bad results despite doing what the doctor ordered, make sure you don't have LADA.

"what causes an a1c above 6"

A rate of glycation (bonding of sugar to protein) which is higher than can be corrected by the replacement rate of red blood cells.

What typically causes an elevated rate of glycation is an elevated concentration of glucose in the blood. But some people experience a higher glycation rate than others at the same level of blood sugar.

Since glycation is harmful in and of itself, don't assume that an elevated A1c result is okay because you are a "high glycator" and your blood sugar level is actually a bit lower than the test suggests. The thing you really care about is not how much sugar is present, but how much harm that sugar is doing to you -- and more glycation means more harm.

"how long does it take a glycated protein to renew"

It depends on the protein. Hemoglobin is renewed in about 90 days, because hemoglobin is in the red blood cells, and those cells only last about 90 days before they are replaced. Other proteins hang around longer in the system before being recycled (maybe a year) and have more opportunity to become glycated. Hemoglobin is the protein usually tested for glycation simply because it is an easy protein to collect a sample of, not because glycation of other proteins is unimportant.

"what would happen if hemoglobin didn't exist"

Instant death, more or less, so let's hope it doesn't come to that. Hemoglobin is the transporter protein which the body uses to deliver oxygen to tissues throughout the body (in vertebrate animals generally, not just humans -- in fish, the hemoglobin collects its oxygen from gills rather than lungs, but apart from that, it works the same way).

"what its me bore line diabetes"

This could have been more clearly expressed, but my guess is that this person is seeking the meaning of "borderline diabetes". The term means diabetes which hasn't quite reached the diagnosis point, but almost certainly will before long. To doctors, the phrase means "the insurance company rules say that I can't tell you that you're diabetic yet -- which is too bad, because you're heading there fast, and getting it under control would be a lot easier if you started now".

To patients, the phrase means "there's a very slight risk that you might develop diabetes in the very distant future".

"if i go to bed hungry will i lose weight"

Not necessarily, but it's likelier to happen if you go to bed hungry than if you go to bed full.

"what do husbands think about porn"

Hey, Google! Stop sending these people to me. What is this, a joke?

Breakfast & Fraud

Monday, June 18, 2012

Time of Day

I usually do only one post-prandial test per day, and it's most often after lunch -- sometimes after dinner, but almost never after breakfast. Most of the reason I do very little post-breakfast testing is that it's the least convenient time in my day for me to be doing a test. But I also have an excuse: in terms of glycemic response, breakfast is usually not the meal I need to worry about -- even though it tends to be more carb-heavy than lunch or dinner. For whatever reason, my system seems to be more capable of suppressing a post-prandial spike in the morning than it is later in the day. In other words, I can get away with more carbohydrate in the morning than I can later on.

The strange thing about this pattern of mine is that it's apparently quite atypical. Most people report that they are least able to tolerate carbs in the morning. Possibly the real issue is that they take in more carbs in the morning than they do at lunch or dinner, whether they realize it or not, and they are simply challenging their endocrine systems too much in the morning. But most diabetes patients have at least a fairy good awareness of the carbohydrate content of their meals, so if most people report a heightened sensitivity to carbs in the morning, presumably they're not imagining it. That I don't seem to be that way is a lucky break for me, because breakfast is a tough time of day to do the low-carb thing.

I think most of us crave high-carb foods in the morning: toast, muffins, cereal, orange juice, sweetened yogurt, all of that stuff. High-protein, high-fat foods just seem too heavy, too hard to digest, in the early hours of the day. Things such as bacon and eggs do find their way onto the breakfast menu, but we always want to buffer them with something starchy, such as fried potatoes. I don't let myself go crazy with this stuff, but it's hard to avoid taking in more carbs at breakfast than at lunch or dinner. That's why I'm very glad that I can get away with more at breakfast.

I did test after breakfast today (107) and last Thursday (116) to confirm that my pattern higher carb-tolerance in the morning is still working for me. I don't know why it is, but apparently it still is.

I think it's important for all of us with Type 2 diabetes to be aware of the peculiar patterns of our own endocrine systems, so that we can make decisions based on what works for us, not what works for most people. But we also need to be aware that our personal patterns can change, and that we need to gather a little confirming evidence from time to time, just to be sure our patterns are still what they used to be. 

An established fact about ourselves is not necessarily a permanent fact about ourselves. It's especially important to do a periodic recheck of any pattern that happens to be exactly what you want it to be. Because I'm pleased at being most carb-tolerant in the morning (I get to have toast!), I'm going to want to believe that this pattern can be relied upon forever. In other words, I don't want to find out that this pattern has changed, so I'm reluctant to check and see if it has. I need to force myself to do that from time to time.

A Fraud Alert

A friend of mine who works in the hydroponics industry (an industry which mainly supplies equipment to people growing marijuana at home for fun and profit) tells me that it's a good business to be in during a recession. When there are lots of people out of work and desperate to pay the mortgage, sales of hydroponics equipment soar.

That any business at all is doing well these days is, in theory, good news, but some of the boom industries currently thriving are hard to cheer for. One of the biggest growth industries today: Medicare fraud.

The federal Office of Inspector General has put out an alert for diabetes patients, reporting a Medicare scam that we need to watch out for. It usually starts with a letter (often purporting to be from the American Diabetes Association, from Medicare, or some department of government) offering free diabetic supplies (such as meters and test strips). The supplies will actually be delivered to you, whether you ask for them or not. In exchange, you will be asked to fill out a form providing Medicare information or financial information -- which, of course, is the entire purpose of the operation. Medicare is then billed for "free" supplies which you probably didn't even ask for. Or, if you are especially reckless in furnishing financial information, money will be drained from your bank account.

The entities which the letters purport to come from do not send out letters offering people unsolicited free supplies or requesting private information of this type. We are asked to report any such incidents, so that criminal investigations can be launched.

Long-Term Health

Thursday, June 14, 2012

Will You Die?

Yesterday someone did a search on "will you die if your not medicated for diabetes", and Google sent them to me.

The short answer is "yes" -- you and everybody else will die, sooner or later, regardless of whether they are medicated or not, and regardless of whether they are diabetic or not. The question is, how soon will it happen?

So, to rephrase the question, if you have diabetes, will you die sooner if you're not medicated for the condition than if you are?

The answer to that one is: it depends on what else you are doing about your diabetes, besides being medicated for it. Let's divide the Type 2 diabetes population into sub-groups, depending on how they are treating their condition.

  1. People who aren't medicated for their diabetes, and aren't doing anything else about it, either. This would be the group with the poorest prospects. They can expect the remainder of their lives to be both unhealthy and comparatively brief.
  2. People who are medicated for their diabetes, but aren't doing anything else about it. People in this group can expect to live a bit longer than people in the first group, but they too can expect a less-than-normal lifespan and poorer-than-usual health in their later years.
  3. People who are medicated for their diabetes, and are also practicing careful dietary control and are exercising regularly. People in this group have a decent shot at achieving normal health and longevity, or something pretty close to it.
  4. People whose dietary control and exercise regimen enable them to maintain normal glycemia without medication. People in this group can probably have a long and healthy life, if they keep doing what they're doing.

I'm trying to stay in the fourth category for as long as I can; it just looks like the best deal to me.

But to return to the original question: those Type 2 patients who aren't medicated have either the best or worst prospects for longevity, depending on what else they are doing.

It Helps, It Helps!

One of the big problems with doing a scientific study, in hopes of finding out what is or isn't good for human health, is that the results aren't very meaningful unless you look at them over a very long period of time, to see how the issue you're investigating relates to overall health and longevity in the long run.

Most studies aren't like that, of course. Most studies track the test subjects over a relatively short period, and focus on some easily-measurable factor (such as serum cholesterol) on the assumption that this factor relates to health and longevity in a simple and predictable way. In other words, most studies don't come close to answering the question that actually matters.

For example, if we're told that tomatoes are the key to longevity, and that everyone should eat a tomato a day, any skepticism we feel about this suggestion is not going to be alleviated by a study which looks at people over a period of a few months to see how tomatoes affect their lycopene levels. On the other hand, a study that looks at people over a period of a few decades, to see how tomatoes affect their odds of being alive and well at the end of that interval, would be more likely to convince us.

Unfortunately, long-term studies are difficult and expensive to run, and not too many of them happen. When they do, though, we should pay a lot more attention to them than to the usual, short-term, possibly-meaningless health studies which we more often hear about.

Danish researchers recently reported on the results of a 35-year study comparing the health of people who did or didn't engage in regular jogging. The result? The joggers had a 44% reduction in risk of death over the 35-year period, compared to the non-joggers. Based on the statistics collected, joggers can expect to live an average of 6 years longer than non-joggers.

Worth noting: the joggers did not have to exercise as hard or as long as you might think, to reap these rewards. The joggers who got the maximum benefit reported doing 1.0 to 2.5 hours of jogging per week, and at a "low to moderate" pace". In other words, they were doing less than I'm doing. Does that mean I should cut my weekly mileage, and slow down a bit? I don't think so; unlike most of the people in the study, I'm using exercise specifically as a tool for controlling blood sugar, and to make that system work, I need to do more exercise than the average three-times-a-week jogger does. But its good to know that even a lighter exercise workout schedule than mine has large health benefits. 


Hidden Carbs

Wednesday, June 13, 2012

When You Don't Know What's In It

Sometimes you know exactly how much carbohydrate is in a meal -- either because you cooked it yourself at home (in which case you know exactly what you did or didn't put in the soup), or because you are eating something you bought in packaged form at the grocery store (in which case there is a nutritional label for you to read).

But then there are those foods which were prepared by somebody else, but don't come in a package with a nutritional label on it. You order something at a restaurant or cafeteria, or you buy something at the deli counter -- and you wonder whether you are right or wrong in thinking that it seems like a low-carb dish your system can easily handle.

You're not always going to get this one right. Sometimes a low-carb main ingredient is swimming in a sauce that contains a generous amount of sugar or flour or corn-starch. Sometimes the soup turns out to contain more potato or rice or pasta than you had assumed.

This is where post-prandial testing comes in handy. If you have doubts or concerns about how a particular meal might have affected your blood sugar, test afterwards, and find out what the actual impact is -- and learn something from the experience.

I had what I hoped was a low-carb dinner tonight -- a piece of turkey meat-loaf that I bought at a deli counter, and a bunch of asparagus. The turkey meat-loaf was new to me, and as soon as I tasted it I began to wonder what all was in it. There certainly was not an overpowering flavor of turkey, so I imagined that the turkey meat was supplemented with other things -- including, in all probability, a sizable portion of bread-crumbs or other high-carb ingredients. Was my low-carb dinner actually a lot richer in starch than I had been assuming?

Well, the only way to find out was to do a post-prandial test, so I did one. My result after an hour was 130 mg/dl.

Some diabetes patients would be quite happy with that result (and it's within my doctor's guidance), but I usually try to do a little better than that. Non-diabetic people only go up to about 125 after a meal, on average, so I have made it my goal to get post-prandial results under 125 as often as possible. Sometimes I achieve that and sometimes I don't, but whenever a meal pushes me any higher than 125 I make a mental note that this is not the sort of meal that I should have very often in the future.

Don't get me wrong, I'm not panic-struck at having a result of 130 after a meal, and I don't think tonight's dinner did me any harm. I just try to steer my diet toward low-carb meals which result in a very modest glucose spike. The turkey meat-loaf that is sold at that deli-counter is apparently not a low-carb food, and I need to be aware of that.

I'm not fanatical about this stuff, I should probably add. If I said that I never indulged in a high-carb meal, my nose would grow long and poke a hole in my flatscreen monitor. I'm just describing what I am trying to do most of the time, which I think is about as much as we can reasonably expect of ourselves. The trouble with thinking in terms of stern commandments ("if I eat this brownie I will go to hell") is that you start to see any brief surrender to temptation as proof that you have failed and might as well give up entirely. You may need the outlet of the occasional self-indulgence in order to have the strength to behave yourself most of the time. So be it. Just make sure you really are behaving yourself most of the time!   

My Statin Attitude-Problem

Tuesday, June 12, 2012

The Wonder Drug: I Wonder If It Works?

Considering that I have never taken statins (a family of drugs, such as lipitor, which doctors use to bring down cholesterol levels in hopes of preventing atherosclerosis), it may be a little surprising that I have such a negative attitude about them. I don't miss many opportunities to report on research results which suggest that statins are not the wonder-drugs they're usually assumed be. Why do I even care, you may be asking? What have statins ever done to me?

I guess there are three factors that drive my bad attitude toward statins:

  1. I think they have been hyped far beyond reasonable bounds. Advocates of statin therapy have shown an enthusiasm that seems almost unhinged -- half-jokingly proposing that statins be added to municipal drinking water supplies, and quite seriously proposing that statins should be prescribed for everyone, including patients with normal cholesterol levels. That kind of fanaticism is too cult-like for my taste. It does more to raise doubts than to calm them.
  2. The occasionally-acknowledged problem that some patients feel bad when they take statins is abundantly confirmed by the experiences of people I know well, some of whom report feeling so tired and lifeless while on statins that they thought they were dying. The low rate of patient compliance with statin therapy seems to confirm that the number of people who react badly to statins is not small, even though doctors who are eager promoters of statins tend to downplay this issue, and to blame patients for not showing the proper spirit.
  3. Statin therapy is based on an assumption which remains unproved: that using statins to artificially reduce the cholesterol level in the blood will prevent the buildup of arterial plaque, and thereby prevent cardiovascular disease. It sounds like a reasonable enough guess, but we don't know if it's true; it remains an assumption rather than a fact. And isn't that a pretty big thing to be taking for granted, in the case of a heavily-prescribed drug which many patients have trouble tolerating?

Because I'm so disgruntled about these matters, I'm always a good audience for a story about research showing that maybe statins aren't as great we we've been led to believe. Which is why I'm ready to draw conclusions from two recent studies which I'm being told I mustn't draw.

The first is a small study done by Dr Aramesh Saremi of the Phoenix VA Health Care System. The study seems to show that veterans with diabetes and coronary heart disease experienced more rapid plaque buildup in their coronary arteries if they took statins frequently than if they didn't.

Other doctors have rushed in to say that it would be a "horrible mistake" if people concluded from this finding that statins do more harm than good. Well, maybe it would be. The study is small, and it's possible that there is some non-obvious reason explanation for the results. It's possible that the results really don't mean what they appear to mean. However, I think it would also be a horrible mistake to dismiss these results, and not try to get to the bottom of the issue. Do statins really prevent plaque buildup in the arteries, thus preventing coronary heart disease -- or do they simply make lab reports look better, without beneficial consequences to the health of the patient? Seemingly that is a question worth answering. That we don't have an answer to it yet, for such a widely-used drug, is a bit startling all by itself.

The second study that caught my attention today was one led by Dr. Beatrice Golomb of the University of California at San Diego, which found that patients apparently aren't lying about feeling weak and exhausted when they take statins -- there really does seem to be a problem with statins causing fatigue. And it isn't a rare side-effect; Dr. Golomb estimates that 20% to 40% of patients who take statins have enough of a problem in this area for it to be a serious impairment of their quality of life. She notes that this percentage is higher than the percentage of patients who will actually benefit from taking the drugs, and that this raises questions about the appropriateness of prescribing statins widely:

"Statins are fine in patient populations where a mortality benefit has been shown -- i.e., men under 70 with heart disease or primary-prevention patients with raised CRP [I think she means C-reactive protein] or who smoke. But I would think twice for other groups. Primary-prevention patients who don't smoke or don't have raised CRP are far more likely to experience an adverse effect than to have a cardiac event."

It's sort of like the controversy now raging over prostate-cancer screening: it saves some lives, but not nearly as many lives as it damages. It all comes down to a very difficult ethical dilemma, in which you have to decide how many people you're going to make miserable in order to be able to say you saved one of them. Those who are fixated on the one saved life are going to be ready to ignore a lot of ruined lives, but I'm not convinced that's the right way to look at it.

Anyway, I guess I've made clear why I have such a bad attitude about statins. I guess there's one more reason: I improved my cholesterol more dramatically by adopting an exercise program than I ever could have done by taking statins, so the whole subject of statins often seems to me irritatingly superfluous. I have to force myself to remember that some people really can't exercise, or really can't improve their cholesterol by exercising, so statins still have a role to play. Well, maybe they do -- if they actually prevent heart disease, and if the patient can tolerate them. But the former assumption is in doubt, and the latter is known to be untrue in a lot of cases.

Running in the Heat

90 degrees today, and I was running at noon. I chose the route that had the most shade-trees on it, and hoped for the best. Actually, it wasn't that hard (at least there was a breeze blowing), but it does take a little more out of you to run when it's hot outside. The big problem is that you can't cool down afterwards. You take the coldest shower you can stand, and then you get dressed and go back upstairs to the office looking conspicuously sweaty for another hour. 

But I'm known to be a lunchtime exerciser, and I'm not the only one, so it's pretty much okay.

Ineffective Drugs, Dumb Passwords, Dangerous Rest

Monday, June 11, 2012

Burying the Lead

To "bury the lead" is newspaper jargon for beginning a story with matters of lesser importance, delaying introduction of the main point. It's frowned upon as a beginner's mistake -- if not something worse. The kindest interpretation of a buried lead is that the reporter is either too dense to realize that a newspaper story begins with the most important fact, or too dense to realize which fact is the important one. The less charitable interpretation is that the reporter is participating in a propaganda effort, deliberately down-playing a fact which is embarrassing to some powerful person or institution. A buried lead gives reporters and publishers deniability: they can say that they indeed mentioned the embarrassing fact, if anyone challenges them on it -- but by burying that fact, they ensured that it had little impact on readers (who may not have read far enough into the story to find the buried lead).

I often feel that reports of health studies tend to bury the lead: the title and opening paragraph create one impression, and the details that come later create a very different one.

Consider this example from Medscape:

Exenatide Beats Glimepiride in Type 2 Diabetes
June 11, 2012 (Philadelphia, Pennsylvania) -- In patients whose diabetes is not controlled with metformin, the addition of exenatide might be a better option than the sulfonylurea glimepiride, according to a study reported here at the American Diabetes Association 72nd Scientific Sessions and published online June 9 in the Lancet.

Okay, the message is clear: exenatide is the diabetes drug of choice, or at least the drug to add when metformin alone is not getting the job done. This impression persists for a while, as one reads the article.

However, those who plow ahead to the 6th paragraph are going to find some details there which tend to undermine the impression created at the outset.

What percentage of patients who had not succeeded with metformin alone (success is here defined as an A1c result below 7.0) were able to succeed with metformin plus exenatide? The answer turns out to be: 42%.

Admittedly, the numbers are worse (29%) for patients who supplemented metformin with glimepiride instead of exenatide. But the really significant fact, so far as I am concerned -- the buried lead in the case -- is that the metformin-plus-exenatide regimen fails in more than half of cases, not that some other treatment fails even more often.

When a disease is as common and as serious as Type 2 diabetes is, and the best combination drug therapy for it that you've tested has a 42% success rate, I'd say the most significant finding here is that combination drug therapy for Type 2 diabetes fails more often than it works, and the conclusion we should draw from this is that doctors and their patients need to find something better than combination drug thereapy. But they won't look for anything better, if they're content merely to read about which combination drug therapy failed less often than others.

Passwords You Should Not Use

I received a message last Friday which began as follows:

Dear Tom Ross, 
We recently became aware that some LinkedIn passwords were compromised and posted on a hacker website. We immediately launched an investigation and we have reason to believe that your password was included in the post.

About once a week, it seems, some big company has a security disaster in which they accidentally make a bunch of customer information available to criminals. And then, a few million disgruntled people have to adopt a new password, and try to remember it.

One recent article I read on this subject pointed out that large numbers of people use very poorly-chosen passwords -- passwords which are easy for the evil-doers to guess, because they are so commonly used. The article included a list of the 25 most popular passwords, and urged the public to stop using them. A password which is among the top 25 is effectively the same as no password protection at all, because the first thing the bad guys are going to do, when they set out to hack into your account, is to try the popular passwords and see if you used any of them.

I was intrigued to see the list of the most popular passwords. I was hoping to find that other people's choices were dumber than mine. They were.

Common first names made the list ("jennifer" and "michael", for example). So did popular pastimes ("baseball", "football"). Simple numerical sequences are also big ("123456", or even "111111").

Some passwords look as if they might possibly reveal something about the user's sense of self-worth (which I imagine is a little higher in the case of "superman" than it is in the case of "monkey").

The presence of "harley" on the list puzzled me at first, until I remembered how eagerly some motorcyclists embrace the Harley-Davidson brand identity.

Of course I have no idea why "pussy" and "696969" made the cut.

Most of these choices were clearly motivated by a fear of forgetting the password, and I think that is particularly true in the case of the number-one choice, the most popular password of them all: "password".

Don't use that one, folks. The crooks are way ahead of you. 

Rest vs. Aging -- Which is Worse?

Remember the "Dallas Bedrest and Training Study" of 1966? No, of course, you don't -- you may not even have been born then, for all I know. But that was the study which subjected healthy young volunteers to prolonged bedrest, and found that inactivity could have a serious negative impact on (among other things) cardiovascular capacity. The effects were seen at the time as a kind of accelerated aging, and they were also seen as shocking, given that (up to that time) there had been a general assumption that rest was therapeutic, not harmful.

What I didn't realize until I happened upon it today is that, in 1996, there was a follow-up study on the condition of some of the participants in the earlier study, to see if 30 years of aging had had as serious an impact on cardiovascular capacity as the bedrest experiment had had on the same people.

The result? Nope, 30 years of aging did not have as serious an impact on cardiovascular capacity as three weeks of rest.

Evidence of the Untrue

Friday, June 8, 2012

Data Isn't Proof!

The trouble with gathering data on human health is that you can assemble the data you have gathered into a justification for absolutely any hypothesis about human health, no matter how crazy and wrong it may be.

Consider, for example, the "epidemic" of autism which is supposedly going on now. People are demanding explanations for it, and in fact they are inventing explanations for it (the idea that vaccination somehow causes autism has been a particularly popular, and wildly dangerous, delusion of recent years). Not everyone blames vaccination -- some blame pollutants in the environment -- but what everyone seems to agree on is that something has been going on in recent years that caused a steady rise in the incidence of autism. And we need to find out what that mysterious something is.

Actually, there is nothing very mysterious about what that something is. Autism was once regarded as a rare and severe disorder. It is now regarded as commonplace and not necessarily severe. Diagnosis of the disease was uncommon in the past. In more recent years, autism has been much more broadly defined, so that milder impairments now "count" as autism. Children are diagnosed with autism now who would not have been, under the more strict criteria of the past. Also, because there is more institutional help available to children diagnosed with autism than to children diagnosed with various learning disabilities and language disorders, doctors often tell a compassionate lie and diagnose autism when the actual problem is something else.

The outcome, of course, is that diagnosis of autism has been increasing dramatically in recent years. That doesn't mean autism itself has increased.

One study in England bypassed the issue of changes in diagnostic criteria over time, by applying current diagnostic criteria to the adult population (regardless of whether or not the adults in question had ever been diagnosed as autistic when they were children). The result was that, if you diagnose autism according to the looser criteria that are applied to children today, incidence of autism among adults is just as high as it is among children. In other words, there has been no increase over time in the risk of developing autism -- only an increase in the risk of being diagnosed with it.

If you are careless enough (or crafty enough) about what sort of data you choose to regard as significant, it is always possible to get things wrong -- even to the point of defining a non-existent phenomenon into existence, and then demanding an explanation for that non-existent phenomenon (perhaps with consequences very dangerous to society, as in the case of the anti-vaccination cult).

On researcher, Kenneth A. Myers, chose to illustrate this problem by means of a satirical journal article entitled "Cigarette smoking: an underused tool in high-performance endurance training". The article examined various factors related to endurance-sports performance (serum hemoglobin, lung volume, weight loss) and pointed out that they are positively associated with smoking. He concludes:

"In summary, existing literature supports the use of cigarettes to enhance endurance performance through weight loss and increased serum hemoglobin levels and lung volumes. However, athletes continue to neglect smoking and pursue illegal and dangerous methods that have only minor and transient effects on the same physiologic variables. More research is needed to clearly delineate when and how cigarette smoking should be integrated into high-performance training programs. Despite substantial federal financial support for endurance athlete development, we are aware of no such research programs at present."

I suppose I should hasten to add that this statement is intended sarcastically. The point is that cherry-picking the data (while ignoring the big picture) can easily make even a nutty idea sound as if it is backed up by the facts. That is how bad ideas become fashionable, and that is why it takes so long to get rid of them.

The fact that high levels of HDL cholesterol tend to correlate with low heart-attack risk certainly sounds as if it means you can avoid heart attacks by boosting your HDL artificially. But if you run the experiment and it turns out that boosting your HDL artificially doesn't actually prevent heart attacks, you sort of have to let go of the idea.

Sadly, a lot of what is recommended to diabetes patients is based on ideas which seem like reasonable inferences from the available data, but haven't been tested (or have been tested, and found wanting). It certainly sounds reasonable to suggest that people with Type 2 diabetes should substitute whole grains for refined flour. Unfortunately, the practical difference (in terms of glycemic management) between whole grains and refined flour is small to the point of irrelevance. Who cares how reasonable the idea sounds, if it doesn't actually work for you?

I guess my bottom line is that all recommendations about diabetes management -- no matter how reasonable they sound, and no matter what evidence can be cited in favor of them -- should be treated as mere expressions of opinion,to be judged critically and verified carefully. If whatever the experts are recommending to you actually works, in terms of good results, splendid. But if it doesn't work, don't cling to it just because it sounds sensible or because someone in authority is pushing the idea.

The Diet Wars: Putting Low-Carb to the Test

Thursday, June 7, 2012

Is Cutting Carbs Dangerous?

Some may wonder why I spend far more time talking about exercise than I do about diet, in most of these commentaries. Is it because I think exercise is the only thing that matters, and one diet is as good as any other?

No, that's not it. I think it does matter what people eat, if they want to get their diabetes under control, or avoid becoming diabetic in the first place.

The problem is that the contribution of diet to diabetes management, or to human health in general, is a very murky and troubled subject. We don't know enough about it, and the available data is endlessly complex and contradictory. Depending on which subset of the evidence you choose to believe, you can make a plausible-sounding case for (or against) just about any idea of what constitutes a healthy diet.

The result is that people differ as passionately (and unprofitably) about diet as they do about politics, theology, and any other field in which nothing can be proved. Is there even any point in making recommendations about diet, when most people already have fanatical -- or at least unquestioned -- convictions on the subject?

Exercise, on the other hand, is far less controversial, because the science on it is clearer. We know what exercise can do for diabetes patients, and for people in general. If not everyone is exercising, it isn't because a lot of people subscribe to a theory which hold exercise to be useless or counterproductive -- it's because exercise is hard to do, and most people would rather not. Reluctance to exercise is a natural human feeling which can be overcome but cannot be eliminated; I don't think I can talk people into thinking of exercise as pure, effortless pleasure. I just think that most people aren't trying as hard to overcome their natural reluctance to exercise as they would if someone had made it clearer to them how much they could benefit from it.

Still, though -- about that diet thing. I don't think there is nothing we can say about diet and health which is, or should be, uncontroversial. Here's one thing which I believe is true, and easily demonstrated to be true: if you have Type 2 diabetes, you have to pay attention to your carbohydrate intake, and limit your carbohydrate intake -- to whatever degree is necessary to prevent your post-prandial glucose from spiking to harmful levels. This is not a matter of treating someone's diet book as if it were holy scripture -- it is a matter of testing your blood sugar after meals, to find out what you can -- and can't -- get away with.

The thing is, for a lot of people with Type 2 diabetes, the amount of carbohydrate they can get away with in a meal is small; therefore, if they eat according to what their glucose meter tells them they can handle, they are inevitably going to be on a diet which is comparatively low in carbohydrate, and probably high in fat. And low-carb, high-fat diets have long been demonized, usually on the assumption that they will give you cholesterol problems which promote heart disease, and also make you gain weight (thus making your diabetes worse instead of better).

Well, a recent Swedish study put that idea to the test, by comparing two (admittedly small) groups of Type 2 diabetes patients. One group went on a low-carb diet (20% carb, 30% protein, 50% fat) and the other went on a low-fat diet (55% carb, 15% protein, 30% fat).

Both groups lost the same amount of weight, so in terms of weight control, either diet can work. But the low-carb patients saw a reduction in blood sugar levels, and a boost in HDL "good" cholesterol; no differences otherwise. The low-fat group saw no improvements.

So there you are. It's a small study, and larger studies might not give quite the same answer. But if cutting carbs is as dreadful an idea as we're often told, the experimental data didn't seem to bear that out. To the extent that there were any differences between the two patient groups, the patients on the low-carb diet did better.

The Race

I just registered on line for the Kenwood footrace -- a hilly 10K race that happens ever Fourth of July. It's a popular local race. I usually do it, because I always know several of the participating runners. My running buddies. People from work. My neighbors. My doctor, one year (he had not done it before, and was unhappy about how steep the hills were and how that had ruined his pace, but of course he was still a lot faster than me).

I was awfully slow last year -- I hope I can manage to improve my finish-time a little in 2012!

The Weakness of Age

Wednesday, June 6, 2012


The gradual loss of lean muscle mass, as a result of aging, is known as sarcopenia, and it is quite a serious health problem: the physical frailty that results from sarcopenia is huge contributor to injuries and disability in elderly people.

Like most problems associated with aging, sarcopenia has long been regarded as something inescapable. Its only cause is the passage of time; therefore, unless you discover a way to set the clock back, you cannot hope to do anything to combat sarcopenia. The older you get, the weaker you get, and that is all there is to it.

Well, maybe. But how do we know that is the case? Studies of the problem have always focused on people who were not only elderly but sedentary. No doubt old people are more often sedentary than active, but that doesn't mean we shouldn't study the active ones, and see if they are experiencing the same loss of lean muscle mass as their inactive contemporaries.

There really are people who stay active, and even competitively athletic, throughout life. Go to any running event or bike rally or triathlon, and you won't find that the participants are all youngsters. There are always a lot of "masters" athletes, well over 40 years old, and often well over 70. In last year's Kenwood Footrace on the 4th of July, one of the runners in the 10K race was 80, and one of the runners in the 3K race was 91.

Wouldn't it be worth checking out the muscles of these older athletes, to see if their muscles are shrinking the same way the muscles of sedentary people their age are shrinking?

Last year a team of researchers actually did that. This study examined "masters" athletes who trained regularly and often participated in competitions (mainly in the "triathlon" sports: running, swimming, and cycling) -- to see if they exhibited any of the familiar signs of sarcopenia. From the authors' abstract:

"Aging is commonly associated with a loss of muscle mass and strength, resulting in falls, functional decline, and the subjective feeling of weakness... Most studies, however, have examined muscle-loss changes in sedentary aging adults. This leaves the question of whether the changes that are commonly associated with muscle aging reflect the true physiology of muscle aging or whether they reflect disuse atrophy. This study evaluated whether high levels of chronic exercise prevents the loss of lean muscle mass and strength experienced in sedentary aging adults."

The study answered that last question in the affirmative: across a range of ages from 40 to over 70, the masters athletes were not losing strength or lean muscle mass over time.

"This study contradicts the common observation that muscle mass and strength decline as a function of aging alone. Instead, these declines may signal the effect of chronic disuse rather than muscle aging."

But, as always, a picture tells a thousand words. Here are some MRI scans of the thigh muscles of three people.

In the first image (of a 40-year-old triathlete), we see that the cross-section of the leg is almost entirely taken up with lean quadriceps muscle (gray in this image). Surrounding it is a white layer of fat.

By contrast, this scan of a 70-year-old triathlete looks... well, pretty much the same. If anything, these legs have more muscle and less fat than the younger pair.

But here's a scan which shows a real contrast: the legs of a sedentary 74-year-old.

Talk about "use it or lose it"! Look at what a large volume of lean muscle tissue has been replaced by fat. If that's what is happening inside your legs, it's hardly surprising if you become unsteady on your feet, and increasingly vulnerable to falls and other injuries.

I'm not even sure I need say anything more about this; the 1000:1 word/picture ratio seems to be holding steady in this case.   

Election-Day Workouts, Fat, Diabetes, and Planetary Science

Tuesday, May 5, 2012

Election Day

It is election day here in California, and nobody cares. I went to the polling place and didn't have to wait in line even for a moment. Not much was on the ballot. Usually we have a lot of ballot initiatives; only two this time.

I generally vote "no" on a ballot initiative unless I feel very, very confident that I know what the actual impact of the thing will be -- and I seldom feel that confident.

Today I was strongly tempted to vote "yes" on an initiative which would have put a heavy tax on cigarettes, allegedly to raise money for cancer research. Who knows where the money would really go, and who knows how the tax would actually influence the behavior of smokers or potential smokers. The only reason I wanted to vote for it was this: tobacco companies were spending so much money on propaganda telling me to vote against it that it filled me with a resentful impulse to punish them for it. In the end, I decided that was not a good enough motive to amend the state constitution.

Early election returns suggest that the tobacco tax will be (narrowly) defeated -- which, weirdly enough, is a little disappointing to me. I don't know if I should admit to being so inconsistent that I'm capable of being disappointed by the failure of an initiative which I voted against myself, but there it is.

Anyway, because it was election day, and it was also Ale Night (something I do with a couple of work friends about once a month), I knew that scheduling was going to be a problem today, and  I wasn't going to be able to fit in a resistance-training workout unless I got up early and did it on the way to work. As I am not an early riser by nature, the really challenging aspect of this plan was that getting up early inevitably involves getting up early.

Well, I did get up early, although getting up 5 or 10 minutes earlier would have served me better. I find it very hard to lift weights under time pressure; that seems to make it a lot harder. The early-morning mood in the gym was nice, though. Guys in the locker room, finishing up their workouts, were getting into business suits and whatnot. It makes you feel a little virtuous just to be there early enough to be part of that terribly serious, terribly adult atmosphere.

But I'm not sure I'm going to make a habit of it.

Abdominal Obesity and Diabetes

For years we've been hearing that obesity increases your risk of developing Type 2 diabetes, and also that abdominal fat is especially risky in this regard. If you are apple-shaped rather than pear-shaped, we are told, you are a sitting duck for the Big D.

How much does abdominal obesity increase your risk? One recent study in the UK found the following:

Don't bother objecting that women seem to pay a higher penalty (for a lesser degree of obesity!) than men do. As I said yesterday, diabetes is not about fairness.

Obviously, based on those numbers, the link-up between abdominal obesity and diabetes risk is a lot stronger than most of us would have guessed, if we had been asked to predict what a study of this sort would show. I myself would have guessed that an obese man's risk of diabetes would be multiplied by two, not twenty-two.

However, it is important to remind ourselves that the connection between abdominal obesity and diabetes has never been adequately explained. We don't know that it's the abdominal obesity that is causing the diabetes, and not the other way around. An association between one condition and another tells you nothing about what is causing what. Suppose that the diabetes is causing the obesity? Or that some unidentified problem is causing both diabetes and abdominal obesity?

Plenty of fat people never develop Type 2 -- and some people who aren't fat do develop Type 2 (although it appears that a lot of the latter really have Type 1 and are being misdiagnosed). There is more going on here than being-apple-shaped-makes-you-diabetic. But what, exactly, is going on?

It appears that abdominal fat has the capacity to function as an endocrine gland, and release hormones which affect other tissues. But exactly how this might cause diabetes (if it does!) remains mysterious. What we are left with is a strong but still-mysterious connection between abdominal fat and diabetes.

One thing I'm reasonably sure of: this is not a simple matter of people inheriting genes which make them fat and diabetic. The rates of obesity and diabetes have both been rising too fast in recent years for the phenomenon to be explained genetically (unless, of course, only obese diabetes patients have been having children lately -- and that seems a bit far-fetched). The "epidemics" of obesity and diabetes have been spreading too fast for a purely genetic cause to be a realistic possibility. People are living differently than they once did, in a way which promotes obesity and diabetes. The trick is finding out which changes in the way people live are responsible for the problem. 

The Transit

Yet another thing I managed to crowd into my schedule today: an observation of the transit of Venus.

That is, the planet Venus moved between earth and the sun this afternoon. This doesn't happen often (my next opportunity to see a transit of Venus would be 105 years from now, and even if my diabetes management program works out splendlidly, I probably won't be around for that).

When you work with a bunch of engineers, a rare astronmical event is not likely to pass unnoticed. There were several telescopes set up outdoors at my work site, projecting the image of the sun safely onto cards, revealing that the sphere of earth's sister-planet was passing across the solar surface, apparently swimming with the sunspots.

Either you grasp what is cool about this (about our being able to predict it, observe it, and understand it) or you don't, so I won't argue the matter. I am resigned to living in a society of people who simultaneously depend on science and hold it in contempt.

Lying Cheating Unfair Lab Tests!

Monday, June 4, 2012

"Artificially High" A1c Results 

Somebody ran a search yesterday on the question "what can cause artificially high a1c results?", and Google listed this as a possible site where the answer could be found. So I might as well try to answer it.

The short answer is "probably nothing".

In terms of what the hemoglobin A1c test actually measures (glycated hemoglobin, as a percentage of total hemoglobin), the test is pretty accurate, and isn't going to be thrown off much by any factor that is at all likely to be present. If your test result is 6.4%, then it's a safe bet that 6.4% of your hemoglobin (or a percentage very close to that) is glycated (bonded with sugar).

However, that's not what people have in mind when they think about the A1c test being "off". They regard the A1c test purely as a basis for calculating average blood glucose, and they think of the test as being "off" if a calculation based on the test result yields an estimate of average glucose which they think is wrong, or at least is not what they wanted to hear.

Strictly speaking, the accuracy of a measurement is not determined by how close the result comes to being the result we wanted. Reality tends to be indifferent to our feelings about it. (The best definition of "reality" I know is "that which, when you stop believing in it, doesn't go away".) Still, it is human nature to assess the accuracy of information based on how well it matches up with our feelings (a phenomenon known in science as "confirmation bias"). Therefore, any A1c test result which is less favorable than the result we wanted is bound to be suspect. (If we get the result we wanted, of course, we are delighted to find the measurement was so accurate this time.)

Most people are aware that there can be a disconnect between average blood glucose, as estimated from the A1c result, and actual average blood glucose. What they tend not to realize is that, when there is a serious problem in this area, it usually leads to a result which is lower, not higher, than would be expected for the actual average blood sugar level of the patient in recent months.

If you have donated blood lately, or been through hemodialysis treatment, this has accelerated replacement of red blood cells in your blood supply. The average age of your hemoglobin is younger, and therefore your hemoglobin is less glycated than it otherwise would be. In this case, the test result suggests a lower level of average blood glucose than you have probably been experiencing in reality.

I have never heard of anything that could cause you to have artificially delayed replacement of your red blood cells, and could have stuck you with hemoglobin which is unusually old and therefore unusually glycated. Maybe there is some phenomenon which could cause this, but if there is I haven't been able to find any literature about it.

Turning away from the issue of the hemoglobin replacement rate, and looking at the hemoglobin glycation rate, there certainly are indications that some people are "high glycators" -- that is, they experience more rapid glycation, at a given level of blood glucose, than other people. Ethnic populations differ from one another in this regard. Some people have argued that African-American patients are over-diagnosed with diabetes because they tend to get a higher A1c result than European-American patients with the same average glucose level. Some have even argued that A1c results shouldn't be used as a basis for diagnosing diabetes, because diagnosis on that basis is "unfair" to ethnic populations which tend to be high glycators.

I think the people who argue in this way are missing the point: glycation is harmful! It is damaging to tissues all over the body. It is probably the direct cause of most diabetes "complications". If you have a lot of glycation going on, you have a lot of harm going on. If there is any unfairness here, it isn't a case of doctors unfairly diagnosing diabetes at a lower sugar level in some patients -- it is a case of nature unfairly causing harm at a lower sugar level in some patients.

Suppose, however, that I'm wrong about this. Suppose that the A1c test is "inaccurate" for African-Americans, and often causes them to be diagnosed with diabetes when they don't really have it. If this were true, what would the consequences be?

Pretty clearly, one consequence would be that African-American diabetes patients would have better health outcomes than European-American diabetes patients, simply because a lot of them wouldn't really have diabetes, or at least would have a less severe case of diabetes than their doctors thought. Is this what we see? Not at all. African-American diabetes patients tend to have worse health outcomes, even when they are getting the same medical treatment as other patients who do better. What this suggests to me is that your glycation rate, not your average blood sugar level, is the true measure of how severe your diabetes is. People who happen to be high glycators have to aim for lower blood glucose targets than others, in order to stay healthy.

Being a high glycator doesn't make your A1c result "artificially" high. It makes your A1c result genuinely high. And a genuinely high result can do you harm, whether that seems fair to you or not.

If you want to understand diabetes, you need to begin by letting go of the idea that fairness plays a role here. Diabetes is a disease, and diseases are not about fairness.

Dumbing it Down

Friday, June 1, 2012

Diabetes Made Simple (too Simple)

I had heard, over a year ago, that the American College of Endocrinology (ACE) was planning to put up a web site for diabetes patients, explaining all the things that doctors don't have time to explain to them. I was curious to see what they would do with this seemingly admirable idea, so I kept checking the ACE's site, and couldn't find any link to the site for patients; eventually I gave up looking for it, and figured the ACE had abandoned the scheme.

Not so! The patient site exists, even though the link to it from the ACE site is hidden so well that you'd never find it there if you didn't know the exact name of the thing. Anyway, the patient site is called Blood Sugar Basics, as I found out today from a Medscape article on the subject, and the site has launched an initiative called The Game Plan, which is described as "a simple, step-by-step plan from a trio of coaches designed to help you approach managing type 2 diabetes in a whole new way".

Red flags are flying all over that statement. Diabetes is not a simple disease, and managing diabetes is not a simple process, so I am immediately suspicious that the offer of a "simple" plan is really a promise that all information will be presented in a radically dumbed-down form. I am also immediately skeptical that The Game Plan is really about managing type 2 diabetes "in a whole new way" -- isn't it likely to turn out to be a retread of the same old way?  

Anyway, I visited the site, expecting the worst, and in some places finding it.

The dumbing-down is, indeed, radical. What upsets me is not so much the oversimplification of technical issues on their original appearance, but rather the failure to follow that up with more nuanced information, or at least to  link to that information (for the benefit of readers who might be intelligent enough or brave enough to look beyond the dumbed-down version).

Consider their definition of Type 2 diabetes:

"Type 2 diabetes is the most common form of diabetes -- more than 20 million Americans have been diagnosed with type 2 diabetes and many more are unaware they are at high risk for the condition. In type 2 diabetes, the body does not produce enough insulin and/or the body cannot utilize insulin effectively, which can lead to serious long-term complications."

What does "cannot utilize insulin effectively" mean? That's a vague statement, and quite a misleading one. It sounds as if it means the insulin you produce is useless, and might as well not be there -- and that this situation is not subject to change.

I would have written that definition as:

"Diabetes means the body cannot prevent the level of sugar in the blood from climbing too high for good health. In Type 2 diabetes, the most common form, the hormone insulin fails in its job of holding blood sugar down, because the body isn't as sensitive to insulin as it should be, and/or there isn't enough insulin produced. Boosting insulin-sensitivity is a major goal in managing Type 2."

To me there is no point in defining Type 2 for patients, if the definition you offer them obscures two crucial issues: the role of insulin sensitivity, and the possibility of improving insulin sensitivity. Sensitivity to insulin is a highly changeable thing, and two factors which strongly influence it (exercise and body weight) are within the patient's control. No matter how much or how little insulin a Type 2 patient is able to produce, boosting insulin sensitivity is bound to be helpful, and should be one of the major goals (perhaps the major goal) of any approach to managing the disease. Any definition of Type 2 should highlight this issue, not conceal it.

Then, skipping around, I check out their page of dietary guidelines, and this is the first one listed:

"Choose 100% whole grain breads, whole wheat pasta, brown and wild rices, whole grain crackers, or quinoa in place of white breads, pastas, rices and crackers. Whole grains are high in vitamins, minerals, antioxidants and fiber, and can help manage blood sugar levels."

Good heavens. Where to begin?

This advice strongly implies that the difference in glycemic impact between whole grains and refined grains is large. It is not. To suggest that whole grains "can help manage blood sugar levels" is like suggesting that moving from North Dakota to Vermont is the best way to avoid harsh winters. You have to make more of a change than that, if you want to see improved results.

Not all the dietary guidelines are as dangerously misleading as that one, but all of them are non-quantitative. Eat more of this, eat less of that -- that's about as specific as the advice gets. No mention of serving sizes. No suggestion that you might want to actually test to see how a serving of whole-wheat pasta (recommended twice in the same short list of guidelines!) actually impacts your blood sugar, before deciding to make it a staple.

I can't help but see the avoidance of quantitative information here as a conscious dumbing-down of the subject, on the assumption that Type 2 patients are dimwits. Maybe some diabetes patients really will run away screaming if you present any numbers to them, but I don't see why the website should address only the dopiest members of the diabetic population. Couldn't the site at least link to more serious information for those who might be brave enough to have a look at it?

Then, under Blood Sugar Basics, we have this statement about the hemoglobin A1c test:

"In the A1C test, blood sugar levels are measured as a percentage."

Measured as a percentage of what? That statement is confusing, and it is also crap. The A1c test doesn't measure blood sugar levels at all, as I have explained elsewhere. Look, if you don't want to describe the A1c test to diabetes patients, don't describe it to them. Better to keep silent on the subject than to present it falsely.

The site does not get everything wrong, I'm relieved to say. It emphasizes lifestyle issues more than I thought it would, for one thing, which is gratifying. It makes exercise seem important. These are not small matters, and I wish I could be more enthusiastic about the effort overall.

I suppose that reasonable people can disagree about what a website for diabetes patients ought to be like, but I find it hard to believe that any reasonable person would disagree with this proposition: the site should not insult the intelligence of most of the diabetes patients who visit it. I think the site, in its present form, fails that test. Maybe I'm overestimating the intelligence of patients, but it would be hard to argue that the creators of the ACE's patient site are not underestimating it.  

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