Bull Session: On Worthless Research Results

Friday, March 30, 2012

The following blog post uses the word "bullshit" 34 times. If you don't like reading that word, skip this post. The word is there for a reason, though, as you will come to understand if you keep reading.

Pharmaceutical companies are rather worried right now, because of what they call the "pipeline" problem. Exclusive patents for drugs only last so long, and once they expire, rival companies can start making the same drugs and selling them as "generic" versions at a much lower cost. To maintain high profit margins, drug companies must constantly work on developing new drugs, so that their current generation of money-making products can be replaced with something equally lucrative when the time comes. There is a constant need to have new drugs "in the pipeline" (inching their way through clinical trials in the hope of winning regulatory approval). If you have nothing in the pipeline, you face financial ruin when the patents run out on your current top sellers, and you have nothing new to replace them with.

Unfortunately, a lot of big pharmaceutical companies do not have much in the pipeline these days. So far, they have tried to deal with the problem through mergers, but it's not clear that a big drug company with a pipeline problem can improve things very much by acquiring smaller drug companies that also have pipeline problems.

Various explanations have been offered for the pipeline crisis (usually blaming bureaucratic dysfunction, both within the drug companies and within the agencies that regulate them), but an alternative explanation is now being offered which might very well explain the situation better: the pharmaceutical industry has a pipeline problem because the medical research community has a bullshit problem.

For present purposes I will adopt the definition of bullshit offered by the Princeton University philospher Harry Frankfurt; according to him, bullshit is not necessarily false information, but it is information stated with complete indifference to its truth or untruth. If you say something because you think it will help you advance your agenda, but you don't know if it's true or false, and you don't care either way -- that's bullshit. Thus, a bullshitter is not quite the same thing as a liar.

A liar needs to know the truth in order to conceal it and replace it with something else; therefore, a liar has to spend a lot of time worrying about what is true and what isn't. A bullshitter never needs to worry about what is true and what isn't, because he has no use for the truth in any case. According to Frankfurt, this makes bullshitters more dangerous than liars, because bullshitters are less vulnerable to exposure. If you are a liar, and you deliberately falsify information, people can prove you did so; if you are a bullshitter, and you recklessly cite questionable information, no one can prove that you knew it was false. (You can't "know" something is false if you don't care enough even to wonder if it's false.) Liars can be openly accused of fraud; bullshitters usually cannot.

But let's back up a bit. What is going on among medical researchers that can be called bullshit, and how is it creating a pipeline problem for drug companies?

What I'm talking about here is basic research. Scientists (mainly at universities and research hospitals) are studying genes, hormones, neurotransmitters, and various other elements of physiology, and finding connections between these things and various diseases. If they identify a gene that is associated with a particular disease, and they propose a mechanism to explain how that gene (or rather the expression of that gene) can cause the disease, the pharmaceutical industry now has a new "target" for drug development, and can start working on creating a medication which interferes with expression of that gene, or nullifies its effects in some other way.

Contrary to popular belief, the pharmaecutical industry does not operate by cooking up random chemicals and then trying them out to see if they happen to cure anything. Usually the drug companies are chasing down a very specific lead that was suggested by basic research. However, this creates a bit of a problem, if the research which suggested the lead they are chasing down was, in fact, bullshit research. Evidence is mounting that most (not just some -- most) of the basic research that drug makers are relying on is bullshit research, which means that the pharmaceutical industry is mostly wasting its time and money on false leads.

I realize that it sounds like a rather wild claim -- most basic research that drug makers rely on is bullshit? How can that possibly be so? And why would it be that way? Bear with me: these questions are answerable.

The problem of bullshit research is coming to light because pharmaceutical companies have lately become frustrated by the amount of time and money they are wasting in pursuit of false leads. Time and again, the promising idea comes to nothing, and then it turns out that the promising idea arose from research results which must have been wrong (because nobody can reproduce them). And if research results are not reproducible but they got published anyway, it certainly does suggest that nobody involved in the study or its publication really cared all that much whether it was true or not. In short: bullshit.

How much of basic medical research is bullshit? Quite a lot of it, apparently. The pharmaceutical companies are starting to investigate that issue systematically, and so far the results have not been pretty.

At Bayer in 2011, a team of scientists set out to reproduce the results of 47 research studies on "exciting" discoveries in cancer research -- discoveries which Bayer hoped would enable them to make new cancer drugs. In more than 75% of cases, the previously reported findings could not be reproduced, and Bayer had to abandon several of its drug-development projects.

A similar team at Amgen set out to reproduce the results of 53 studies, and had even less success. In more than 88% of cases, the previously reported finding could not be reproduced.

Reproducibility is not a minor issue in science -- it's the main thing that distinguishes science from non-science.  Science is the only human activity in which your ideas may end up being confirmed by people who don't like your ideas -- because those people tried your experiment and, perhaps to their dismay, found that they got the same results you did. That's the cool thing about science that a lot of people overlook: because it's reality-based, it works the same way no matter who you are or how you feel about it. (This tends not to be true of other cultural phenomena, such politics and religion and taste in music.) 

But if that basic condition of reproducibility is not met -- if you're the only one who sees the results you're seeing -- then what you're doing isn't science at all. It's bullshit. At least, it's bullshit if you publish findings that others can't replicate, and you're not especially concerned about that.

Of course, scientists who engage in bullshit research have an easy first line of defense: if you can't reproduce my results, it must be because you're not doing the experiment right. And, in the case of sophisticated experiments involving genetics, cancer, and intra-cellular signaling, it might be very difficult indeed to do the experiment right. Still, experiments have to be reproducible to be worth anything, and the people who report results of experiments need to be cooperative with those who are trying to verify them. The scientists at Bayer and Amgen, in their efforts to reproduce the research that had been reported, ended up having some full and frank discussions with the original researchers -- but this could happen only after they signed non-disclosure agreements with the scientists involved, promising not to report what they learned in the process. So, the Bayer and Amgen scientists can only tell us how many research papers were bullshit -- not which papers were bullshit, or what their authors were bullshitting about. 

But here's a telling example of the attitudes they came up against. Dr. C. Glenn Begley of Amgen had a breakfast meeting at a cancer conference, with the lead scientist of one of the studies he had been trying to replicate. "We went through the paper line by line, figure by figure. I explained that we re-did their experiment 50 times and never got their result. He said they'd done it six times and got this result once, but put it in the paper because it made the best story."

It made the best story. Here we arrive at the heart of darkness, the black hole at the core of the galaxy of bullshit. When people feel that what matters most is to say whatever makes the best story, bullshit happens.

But what is motivating scientists to publish bullshit? Well, they want to have careers. There are only so many university jobs out there for research scientists, and the way to secure one is to get yourself published in one of the more prestigious journals. And the way to get yourself published in one of the more prestigious journals is to say whatever makes the best story. "We've found a gene that causes breast cancer and can be targeted by future drugs!" is the best story you can tell. ("We thought we found such a gene, but it's starting to look as if we were wrong!" is definitely not the best story you can tell.) So people tell the best story. It's bullshit, in the strict sense that you don't know if it's true, and you don't care if it's true. Most of the time, as it turns out, it's also bullshit in the loose vernacular sense that it's not true. 

But why do universities and scientific journals allow bullshit to be published? Well, keep in mind that they are players in the game, too -- so they have just as much motivation as anyone else to tell whatever makes the best story. It isn't just struggling young scientists trying to make a name for themselves who engage in bullshit. Institutions do it too. And they are especially inclined to do it when there is no penalty for doing it.

However, now that pharmaceutical companies are starting to realize that bullshit research is costing them millions of dollars and endangering their financial future, it's possible that things will start to change, and appropriate pressure will start to be put on universities and medical journals to stop tolerating bullshit, and start caring whether or not the research they are funding and publicizing has a basis in reality.

It's when bullshit starts to come into conflict with corporate profits that we are likely to see a decline in tolerance for bullshit. And who could argue that that's a bad thing?       

Gene-Blaming & Exercise Frequency

Thursday, March 29, 2012

I always find, after I've done a weight-training workout, that my evening blood pressure is lower -- and my pulse is higher. Well, I'll live with a slight increase in the latter, if I'm rewarded with a substantial reduction in the former.

A lot of people would like to believe that diabetes is purely genetic in origin. Well, there is certainly a lot of evidence to show that susceptibility to diabetes varies from person to person, and that genetics plays a role in determining how high anyone's risk is.

But there is also a lot of evidence to show that lifestyle plays a role in turning that risk into a reality. And here's a piece of evidence that seems to say a lot: over the past 30 years, China has been transformed from a malnourished country to a one in which people are having to worry about controlling their weight. And during that time, diabetes prevalence in China has increased by a factor of ten. Isn't it remarkable that the gene pool in China could have changed that much in just three decades?

Face it, people: it matters how we live.

Very often, when I read about a health research study, I find myself wishing I could have advised the researchers when they were designing their study, so that I could have persuaded them to gather (or at least present) their data in a way which would actually be useful and interesting.

So it is with a recent study, reported in Diabetes Care under the title "Exercise Therapy in Type 2 Diabetes: Is daily exercise required to optimize glycemic control?". The short answer, at least according to them, is no; you can exercise every other day, and it works just as well (provided the workouts are long enough).

What they did was take thirty Type 2 diabetes patients (average age 60, average BMI 30.4, average HbA1c 7.2), and used Continuous Glucose Monitoring (CGM) to see how their blood glucose profiles responded to (1) no exercise, (2) an hour of cycling every other day, and (3) a half-hour of cycling every day. The study claims that the second and third approaches were equally effective. However, we need to be clear about their measures of effectiveness, if we' re going to draw any conclusions from their study.

The researchers compared the GGM data for the patients in each of these approaches, in terms of what percentage of the time the test subjects were hyperglycemic. For the purposes of this study, to be "hyperglycemic" meant to have blood glucose higher than 10 mmol/l  (which, for readers here in America, means >180 mg/dl).

Now, that is a pretty loose definition of hyperglycemia, given that the glucose spike following a meal in a non-diabetic person is typically about 125 mg/dl. Of course, any number we choose as the definition of hyperglycemia is going to be arbitrary -- one could always argue that it should be lower or higher than the value we picked. But >180? That is pretty far above anything that I would consider acceptable for myself, so I don't know what to make of a study which defines success as "anything less than 181". I'm not convinced that this is the right measure of success.

Since the researchers had a lot of GGM data, they could have presented it very differently. For one thing, they could have set the hyperglycemia cutoff point at various levels (130, 140, 150, etc) and noted what percentage of the time the patients were hyperglycemic under each of these definitions. The researchers could also have compared average glucose levels, rather than time spent below an arbitrary cutoff point.

But they didn't do any of that, so here's what they reported: the percentage of time spent above 180 mg/dL was 32% without exercise, and 24% with exercise (regardless of whether the exercise was 30 minutes daily or 60 minutes on alternate days).

I have to say that these numbers don't look all that good to me. I realize that it's better to be hyperglycemic (however you define that) 24% of the time than 32% of the time, but either way you're spending a pretty sizable chunk of your day in what I would call a toxic state. But these were patients whose glycemic control was not that good going into the experiment, so I shouldn't be surprised if the additional help provided by exercise was not enough to get these patients into what I would consider a normal range.

The thing is, I still want to know more about how the data broke down. For example, in the people who did alternate-day exercise, how did their results on their exercise-free days compare with their results on their exercise days? The total result was supposedly the same as what daily-exercise people were getting -- but did that mean that results were unusually low after the one-hour workous, and unusually high on rest days, and the results averaged out to being these same as with daily half-hour workouts?

I can't call being hyperglycemic 24% of the day "optimized glycemic control", but if the study had released data in a more detailed and useful form, it might have provided clues about how one might go about achieving that kind of optimization.

But when people do these studies, they never consult me first! I find it harder and harder to understand that kind of carelessness.

Diabetic Husbands & Worried Wives

Wednesday, March 28, 2012

When you look at diabetes forum discussions on line, you might expect that the particpants would break down into two categories: men with diabetes (50%) and women with diabetes (50%).

But that's not the way it is. The actual categories are: men with diabetes (20%), women with diabetes (50%),  and women who wish their husbands were doing something about their diabetes (30%).

It's the latter category that I'd like to discuss today.

It is very difficult to know what advice to give to the worried wives of men who seem unwilling to deal with their health problems, or even to acknowledge that they have any health problems. Clearly it is not an easy situation for these women to be in. Their husbands dismiss ominous developments as insignificant, visit the doctor's office only when escorted there at gunpoint, and make mysterious, arbitrary descisions about which medical treatments and procedures they will agree to and which they will refuse. Even when they have received very specific medical advice on what to do, and have agreed (however reluctantly) to do it, they then proceed to do something else.

It's all very maddening, no doubt. But can the wives do anything about it? I hate to say no, but that really might be the correct answer in a lot of cases. 

One of the things I am surest of in life is that it is not possible to manage someone else's diabetes for him. Unless your husband is in a coma, and is therefore powerless to thwart you, you're not in the driver's seat. He is going to be managing his diabetes (or not managing it) as he sees fit, and you have very little say in the matter. 

However, I can't just tell these women to forget about the problem and let their husbands do whatever their husbands are going to do. Obviously the wives can't just drop the subject and stop thinking about it. Telling them to mind their own business would be wrong, because this is their business -- their husband's health affects them, after all. Also, whether we like to admit it or not, society puts some pretty strong gender-based expectations on people; wives are expected to act as guardians of the health of every member of the household. Worried wives of diabetic husbands don't really have a lot of choice about being worried wives; it's more or less their job description, and they can't outsource the responsibility to somebody else.

I wish I could offer some ingenious tricks for worried wives to use to make their husbands more cooperative about looking after their own health. But maybe I can offer them something else -- something that's not as good as a solution to their problem, but not entirely valueless either: maybe I can offer them some insight into why their husbands are being so damned unreasonable about this.

When people talk about mental and behavioral differences between men and women, they like to treat the whole subject as a joke, not as a possible path to greater understanding. We just call attention to a gender difference for the sake of whatever laughs we can get out of it, and then we move on, without examining that difference. So, women like to point out that men won't ask for directions, that men won't ask for help, that men won't admit they're having a problem -- and they leave it at at that.

For example, the historian Doris Kearns Goodwin likes to tell a story about a factory which started employing large numbers of women during World War II, and about an investigation conducted by management to find out why these women were learning their jobs faster than male employees ever had. The answer turned out to be that, when a female employee wasn't sure how to do something, she asked someone for help; a male employee wouldn't do this. Stories like this are told purely for the entertainment value; it's as if everyone knows there is a gene for seeking assistance, and male DNA doesn't include it. It's an amusing oddity, but it doesn't really mean anything.

Well, wait a minute. Of course it means something that men are extremely reluctant to ask for help. Of course it means something that this reluctance is even stronger when the need for help is greater.

First of all, allow me to point out that male reluctance to seek help is not purely a matter of personal preference. Often men avoid requesting help because they know they will be condemned for doing so. To take an extreme example, the reluctance of soldiers to seek help for post-traumatic stress disorder or other psychological problems is pretty much inevitable, given what they know of their superior officers' disdainful -- and even vindictive --attitude towards any man who does seek help for such problems. (The result, of which I'm sure we can all be proud, is the 80% increase in the suicide rate in the U.S. armed forces over the last 9 years. The great majority of the victims have been male.) 

Even in far less extreme situations, men know that seeking help is usually not acceptable to their superiors or their peers. It's all very well to make fun of male factory workers for being less willing than female workers to admit it when they are not sure what to do, but please bear in mind that male workers and females workers might be treated very differently if they speak up in that situation. Men receive a strong message from society that they are supposed to know what they are doing, in all circumstances, regardless of how well or how poorly they have been trained to deal with those circumstances. Men internalize this message, and attempt to live by its cruelest demands. Competence in all things, confident mastery of all situations, disciplined control over one's own body and one's own emotions -- these things are supposed to be natural byproducts of maleness. So what does it say about you if you're a man but you're not like that?

Admitting that you need help with anything at all is, from the male point of view, a declaration that you are not as masculine as you ought to be -- and what could be worse than suffering that particular humiliation? So, men try everything else first -- including wasting a lot of time working things out for themselves by trial and error, and (where that approach fails) coping with the problem by avoiding it. Hence the male tendency to deal with difficult personal problems by pretending they do not exist. Such an approach might have unpleasant consequences in the long term, but a lot of men are unable to imagine any consequences more unpleasant than the self-emasculation involved in saying "I need help" -- or, even worse, letting others help them.

Which brings us back to the subject of why it is so hard to get men to deal with their medical problems. For some men, the act of walking into a doctor's examining room is a kind of ritual humiliation -- a surrender of control, a sacrifice of dignity, a confession of helplessness, a submission to whatever personal criticism and unwelcome instructions the doctor may have to offer. (All that may sound absurdly overstated to women, but they will just have to take my word for it that, to a lot of men, it only begins to hint at the degradation that is involved in being a "patient", even for a matter of minutes.) And, when it's all over, it's really not over at all, if you emerge from the doctor's office with prescriptions for the pharmacy and instructions on how you are now supposed to change the most routine behaviors of your daily life. And if you are going home to someone who will try to monitor and critique your compliance with those instructions... I mean, can a man sink lower? Is it surprising that men become rebellious when they are feeling as wretched as that? Risking death may seem to them a small price to pay for regaining enough personal autonomy to feel as if they are men.

Of course I am not arguing that this is a sensible way for men to look at the situation -- I am merely informing those who are baffled by commonplace male behavior about some of the feelings that might possibly be feeding into it.

Unfortunately, this is the sort of problem that seems inherently unsolvable; you can't browbeat a man into feeling good about a situation in which the main problem, as he sees it, is that people are browbeating him. 

The only hope I can offer here is that men can learn to deal with the problem of managing a chronic disease if they feel that they are in charge -- that they can take the initiative, and get good results through their own efforts and choices, not by following someone else's instructions or submitting to someone else's supervision. If diabetes management is about working on your biceps, not about taking your pills like a good little boy, it is possible for diabetes management to appeal to men as something they would like to do, because it makes them feel in control.

Most approaches to diabetes management make men feel passive and even pushed-around, and I think that's why a lot of men with diabetes are so weirdly uninterested in doing what's necessary. An exercise-centered approach to diabetes management makes men feel active and in charge; a pharmacy-centered approach does not. I'm not sure what wives can say to husbands to encourage them to see things in this light, but it does seem to be their best opportunity to get their husbands doing the right thing (because, for the first time, they actually want to).

Weight-Loss Surgery For All!

Tuesday, March 27, 2012

Two studies have just been published in the New England Journal of Medicine which say that bariatric surgery (that is, weight-loss surgery) is considerably more effective as a treatment for Type 2 diabetes than standard therapy. 

Both studies compared the rates of "remission" of diabetes (defined slightly differently in the two studies) in surgery patients with the rates in patients who received more conventional diabetes treatment.

One study (known by the catchy acronym STAMPEDE, for "Surgical Treatment And Medications Potentially Eradicate Diabetes Efficiently" -- a contrivance which suggests a higher ratio of marketing to science than some would consider ideal) involved 150 obese patients with uncontrolled Type 2 diabetes (average HbA1c for these patients: 9.2%). Patients were randomly assigned to either bypass surgery, sleeve gastrectomy, or medical therapy (which probably means diabetes drugs -- lifestyle-based therapies are not often acknowledged to be have standing as medical therapy). This study defined remission as an HbA1c result below 6% after 12 months. The remission rate, under this definition, was 42% for the bypass surgery patients, 37% for the sleeve gastrectomy patients, and only 12% for the standard-treatment patients. The gap in effectiveness is pretty large, although it must be admitted that a success rate below 50% is hard to get too excited about.

The second study, conducted at the Catholic University in Rome, involved 60 severely obese patients with "advanced" Type 2. They were randomly assigned to either bypass surgery, biliopancreatic diversion surgery (BPD), or conventional treatment (drugs, but in this case with "strictly monitored diet and lifestyle interventions"). In this study, remision was defined as fasting glucose <100 mg/dl and HbA1c below 6.5%. By that measure (which is less strict than the first study), the success rate was 75% for the bypass surgery patients, 95% for the BPD patients, and 0% (yeah, that's right, zero) for the conventional-treatment patients.

In both studies, the success of the surgery was independent of the amount of weight loss that occurred, so the researchers involved think that the "mechanisms of surgery" are the direct cause of the improvement. That is, remission doesn't occur merely as a consequence of weight loss (regardless of how the weight loss is brought about); something about the surgery itself causes remission of diabetes, whether you lose weight or not.

These are small studies, and one of them was funded by "Ethicon Endo-Surgery", so it would be rash to jump to any dramatic conclusions based on the data coming out of these studies. But doctors are starting to say that bariatric surgery is clearly better than other treatments for Type 2, and should perhaps become the standard treatment, even in those who are not obese.

To be sure, some doctors are cautioning that we need to see evidence that bariatric surgery actually prevents the long-term health problems known as diabetes "complications" -- because that, rather than achieving good numbers on a lab report, is the real goal of any treatment regimen for diabetes. However, it won't surprise me if projects such as the STAMPEDE study do indeed stampede doctors into making surgery the conventional, recommended treatment for Type 2.

My own doubts about bariatric surgery are pretty strong. It seems to me that surgery has so much potential to go disastrously wrong that you just don't sign up for it unless you have to. I don't feel that I have to, but a lot of people feel differently. Well, good luck to them! Maybe it will all work out for them in the long term, and they'll illuminate the path to a better future for more timid diabetes patients like me. But I'm afraid what might happen instead is that they will become prisoners of surgery -- spending the rest of their lives going in for increasingly difficult new procedures to repair problems with the original surgery. I'm afraid that, if I had bariatric surgery, I would end up with a stomach which was the gastrointestinal equivalent of Michael Jackson's disintegrating nose -- an endless, ultimately hopeless maintenance project.


Chocolate, Eggs, & Amateur Diabetes Advice

Monday, March 26, 2012

First, the good news:

...a new study finds that frequent chocolate-eating is associated with a lower Body Mass Index! Yes, that's right, the study found that those who ate chocolate frequently tended to be less fat than people who ate chocolate infrequently!

And now the bad news: the data on the frequency of chocolate consumption by the test subjects was gathered simply by asking them how often they ate chocolate.

So, the headline for this story (which was given in Medscape as "Frequent Chocolate Consumption Linked to Lower BMI", could just as reasonably (and probably more accurately) be rendered as: "Study Finds Fatter People More Reluctant To Admit How Much Chocolate They Eat".

I assume that scientists would not go around asking elected officials "Do you cheat on your spouse?" and then publish a study announcing that infidelity is less common among politicians than among voters, becauses hey, they said so!

This is one of the biggest problems with studies of dietary issues. It is ridiculous to pretend that people are going to give reliable answers to questions about personal habits for which they expect to be judged. Between a fat person and a thin one who eat chocolate frequently, which of the two do you think is likelier to admit ti?

I spent the weekend up at my brother's house, in the foothills of the Sierras. His wife leads a big family craft project every year during the run-up to Easter, taking egg-decoration to the next level.

It's a little less difficult than you would think. The technique involves cutting up silk neckties and wrapping a square of the material tirghtly around each egg. Cooking the eggs in vinegar and water transfers the tie's pattern to the egg. We made a lot of them. And as far as my sister-in-law is concerned, this was a mere practice run.

Meanwhile, outside our cozy craft factory, a storm was blowing in from the Pacific, and we woke up on Sunday to find that snow had fallen during the night. I had thought we were well past any chance of that happening this year.

This was the first time my car ever had snow on it (hey, I live near the coast). No harm done, but with the weather so chilly I decided against doing any outdoor running. My exercise on Sunday was in the gym.

Today was not quite so cold, though, so I did make it outside. Once I was running I felt warm enough.

A reader asked me for some pretty specific medical advice last week, because she had picked up the impression that I'm a physician. I guess I should be doing more to combat that impression. I do say on my home page that I'm not a doctor, but you could easily miss that. Maybe I should say it in more places. Perhaps on every page.

I have never felt uncomfortable writing about diabetes strictly as an amateur. After all, most diabetes patients experience the disease as amateurs. There's nothing wrong with writing from that perspective, and sharing my experiences -- including the experience, common to all diabetes patients who are not doctors, of looking for good information about the disease and having a lot of trouble finding any.

As far as I'm concerned, I am filling a communication gap which doctors could fill themselves, and mostly haven't. Yeah, yeah, I realize that office visits are too short for doctors to be able to explain diabetes in any detail to their patients. But couldn't doctors get together and produce (or at least find) a book that covers the subject well, and give their patients that? I was sent to a class on diabetes when I was diagnosed, but a lot of newly diagnosed patients are not given information in that form, or really in any other form, if the complaints I have heard from confused patients are any indication.

Most of the information that is offered to diabetes patients by "official" sources of medical knowledge is so dumbed-down (on the assumption that we are children, and dopey children at that), and so vague, that it is neither interesting nor useful. I feel as if it's my duty to step in and explain to diabetes patients the things that the medical profession is not explaining to them. It's an assignment which feels familiar to me, because I'm a technical writer. I have years of experience at stepping in between engineers and the people who use their products, to explain what would otherwise go unexplained. And I'm not an engineer myself, any more than I'm a doctor; I'm just unusually determined when I'm trying to dig up information that is not easily available.

As for the question of whether I'm recklessly handing out questionable advice, I would like to point out that, in emphasizing lifestyle adjustments (particularly exercise) over medication, I am hardly staking out a radical position. Doctors are telling people to do the same things I'm telling to people to do; the difference is that doctors assume no one will actually do it, and I assume everyone will.    

Diabetes Risk Factors

Friday, March 23, 2012

We had our spring during the winter, so it's only fair that we're now having our winter during the spring. Lots of clouds and rain lately, and the weather a lot cooler than it was in January.

But I've been pretty lucky this week, in terms of not having to run in the rain. And it isn't really isn't cold enough to be a problem, if you dress for it. A chilly breeze can actually be pretty invigorating when you're running.

A recent study in South Korea compared three risk factors for Type 2 diabetes (obesity, fatty liver, and insulin resistance) on an independent basis, to see how much each of them contributed to the risk of developing Type 2 diabetes.

Unsurprisingly, insulin resistance was the worst of the three risk factors; it nearly quadrupled the risk, while the other two did not even manage to double it. I say "unsuprisingly" because insulin resistance pretty much is Type 2 diabetes; I don't think a very meaningful distinction can be made between them. To the extent that there is a difference between them, it is more legal than medical; I see Type 2 diabetes as the name we start giving to insulin resistance once its effects have become easy to measure. No doubt the accountants for the health-insurance industry would be happy to explain to me why they see an enormous difference between mere insulin resistance and honest-to-goodness diabetes, but until they explain to me how everyone manages to get cured of the first problem on the same day that they develop the second problem, I'm not going to be very impressed with their powers of reasoning.

Anyway, here's how the risk factors break down, individually and in combination:

Risk Factor Diabetes risk is increased by a factor of:
Obesity 1.6
Fatty Liver 1.7
Obesity + Fatty Liver 3.2
Insulin Resistance 3.9
Fatty Liver + Insulin Resistance 6.7
Obesity & Fatty Liver + Insulin Resistance 14.1

What is a little surprising here is the prominence of fatty liver as a cause of Type 2 diabetes. We hear so much about obesity as a risk factor for diabetes that it's a little surprising to hear that there is another risk factor which is slightly worse but gets far less attention. So what is fatty liver, anyway?

Well, fatty liver is pretty much what it says: it's a condition in which liver cells absorb and retain abnormal amounts of fat. Various things can cause this to happen, but the two major causes are alcoholism and obesity. (And, fortunately, it can be reversed by cutting alcohol intake and losing weight.) Of course, if obesity is one of the leading causes of fatty liver, that makes it hard to be confident that fatty liver can truly be evaluated as a risk factor independent of obesity.

But insulin resistance is the heavy hitter among the risk factors -- especially when it is combined with either of the other two. And someone with all three risk factors is fourteen times as likely to develop Type 2 diabetes as someone with none of them!

The study, which began in 2003 by looking at 12,863 nondiabetic individuals, and gathering information on their risk factors, looked again five years later at the 223 individuals who had become diabetic during the interval. Of those 223, 12% had had none of the three risk factors at the outest, 17% had one, 25% had two, and 47% had all three. So, you see, it's possible that someone with none of these three risk factors will develop Type 2 -- but that isn't the way to bet. People with more risk factors are more heavily represented in the diabetic population. 88% of people with diabetes had at least one of the risk factors, and usually more than one.

However, that leaves 12% of the diabetic population who didn't have any risk factors, didn't know they were going to have to deal with this problem, and are really, really annoyed right now.    

Eye Exams: Looking For Signs Of Retinopathy

Thursday, March 22, 2012

Today I felt a real craving to have some small potatoes with dinner, to see if I could get away with it. Well, I guess I did get away with it, as my post-prandial result was 125 (the high end of "normal", based on the data I've seen on non-diabetic glucose profiles).

Still, whatever I might be able to get away with now and then, I shouldn't push it. I can't get into the habit of eating potatoes or rice routinely, or in generous amounts.

Yesterday I went in to see my eye doctor, for my annual eye exam. In addition to the glaucoma test (that little blast of air that makes you jump), I had some "Optomap" retinal images taken. My doctor agreed to share the image files with me, after I explained that the world was waiting anxiously to get a look at them.

The trouble with retinal images is that they look pretty strange even when your retinas are in fine health. For example, this image from my left eye...

...looks to me like the sort of picture that a NASA space probe sends back after a flyby over the surface of one of the moons of Jupiter:

But, according to my eye doctor, my retinas are the picture of health. There are various bad signs that could show up in one of these images; the one that is of particular concern in my case would be any sign of degeneration of the small blood vessels within the retina. The Optomap images give a pretty detailed look at those blood vessles, and mine are apparently fine.

The bright patch, I understand, is the place where the optic nerve comes in from the back of the eyeball. The image above is of my left eye; here's my right:

However hard it may be to believe, that is what healthy retinas look like. What would an unhealthy one look like?

Well, a lot of diabetes patients develop a problem known as diabetic retinopathy (which can lead to blindness); the telltale sign of it in a retinal scan would be red blotches of this sort, indicating that blood was leaking out of smaller blood vessels damaged by diabetes:

Well, my retinal images didn't show anything like that. Which is lucky, because it would not be unusual for a diabetes patient who's 11 years past diagnosis to be showing signs of trouble in this area.

My eye doctor pointed out that this kind of scan is really the only opportunity you're likely to get to have your small blood vessels examined for early signs of the problems that diabetes can cause. My insurance doesn't cover this test, so I had to pay extra for it, but it seems to be worth doing, mainly because it's reassuring to get negative results. I don't know if getting positive results would be terribly useful, but if there's anything at all you can do about a problem, you might as well find out about the problem sooner rather than later. So I'm sure I'll continue to have these scans done every year.

But for right now, I think I'm going to go back to looking at the moons of Jupiter, and see how their small blood vessels are doing. I don't Europa's doing so well, to tell you the truth, but then she's a lot older than me.

Dapagliflozin Is Good, Say Makers Of Dapagliflozin

Wednesday, March 21, 2012

Today I really didn't feel like running at lunchtime. The outcome: I went running at lunchtime.

Tonight I really, really didn't feel like going to the gym to lift weights after dinner. The outcome: I went to the gym after dinner to lift weights.

That's more or less the story of my life these days: an endless cycle of doing what I don't feel like doing, and then doing it again the next day when I still don't feel like it.

Somewhere along the way I just began to understand that it doesn't matter all that much what I feel like doing, because I never feel like doing the right thing. Even if I know it will make me feel better after I've done it, I still don't want to do it, if it's going to cause me even the most temporary strain or discomfort.

Not so long ago, we adults where being urged to find and nurture our "inner child". I think society is over that phase; I hope so, anyway. My inner child is not at all hard to find; he actually occupies a lot more of my interior landscape than he ought to, and I'm better off ignoring him than nurturing him. Let's face it: he's the laziest little bastard that ever curled up on a couch and asked the world to go away. So I have to ignore him and get on with adult life.

I didn't know, when I was a kid, that the definition of "adult life" would some day mean "controlling your diabetes" (back then I'm sure had a racier interpretation), but that's what my inner adult (a rather shy and retiring fellow, whom I need to find and nurture) is dealing with. I should give him as much help as I can. 

In January I wrote about an FDA's decision not to approve (at least for now) the new diabetes drug Dapagliflozin, which alters kidney function so that gluclose is excreted in the urine. (Some of that happens anyway, especially in patients with poorly-controlled diabetes, but Dapagliflozin causes a lot more of it to happen, and at lower blood-sugar levels; take Dapagliflozin and the bees will always be your friends.) Some doctors on the FDA panel were concerned about data from the clinical trials which seemed to show a five-fold increase in the risk of certain cancers in paitients who take the drug. They asked for more data on the risks and benefits of Dapagliflozin. They may have also asked for the new drug to be given a name that's easier to spell -- and if they didn't, they should have.

But now comes a new study which puts a more positive spin on Dapagliflozin:

"Dapagliflozin Effective Addition in Type 2 Diabetes.
Dapagliflozin, a selective inhibitor of sodium-glucose cotransporter 2 (SGLT2), improves glycemic control, stabilizes insulin requirements, and reduces weight without increasing major hypoglycemic episodes when added to insulin therapy in patients with inadequately controlled type 2 diabetes mellitus. These are the findings of a 48-week, randomized, placebo-controlled, multicenter study by John Wilding, MD, from the Diabetes and Endocrinology Research Group, Department of Obesity and Endocrinology, Clinical Sciences Center, University Hospital Aintree, Liverpool, United Kingdom, and colleagues, published in the March 20 issue of the Annals of Internal Medicine."

The study authors have no opinion to offer on whether or not Dapagliflozin actually causes a big increase in the risk of cancer; they say the study wasn't large enough to support any conclusions about that. But it's darned good medicine, anyway!

The study was funded by AstraZeneca and Bristol-Myers Squibb (the pharmaceutcial companies that make Daplagliflozin).

Two of the coathors of the study are consultants to AstraZeneca and Bristol-Myers Squibb (the pharmaceutcial companies that make Daplagliflozin).

Four other coathors are direct employees of AstraZeneca and Bristol-Myers Squibb (the pharmaceutcial companies that make Daplagliflozin).

At least we know that this is unbiased scientific research!

Seven Metrics Of Cardiovascular Health

Tuesday, March 20, 2012

Of the American Heart Association's seven metrics of good cardiovascular health...

  1. Not smoking
  2. Body Mass Index below 25
  3. Regular exercise
  4. At least 3 servings of fruits and vegetables daily
  5. Total cholesterol below 200 mg/dL
  6. Blood pressure below 120/80 mm Hg
  7. Fasting plasma glucose levels below 100 mg/dL

...not much more than 1% of Americans meet all seven of them. In fact, less than 48% of Americans even meet four of them:

Number of Metrics Satisfied %


2.0 1.3 1.2


8.3 6.1 7.5


17.6 15.1 16.6


23.9 23.7 22.4


24.8 24.3 25.5


16.1 20.1 18.0


6.4 8.0 7.3


0.8  1.5 1.4

That's according to an analysis by the CDC. The trend over time has not been good, either. That is, since 1988, the trend has been for more and more Americans to meet fewer and fewer of these metrics.

Maybe it would be worth taking a look at the seven metrics in terms of how difficult they are to accomplish, so that people could work on the easier targets first:

Metric Difficulty

Not smoking

Effortless for most people

At least 3 servings of fruits and vegetables daily

Not difficult

Fasting plasma glucose levels below 100 mg/dL

Not difficult for most people

Regular exercise

Some effort required

Total cholesterol below 200 mg/dL

Considerable effort required

Blood pressure below 120/80 mm Hg

Very difficult

Body Mass Index below 25

Inhumanly difficult

Of course, that's just the way I would rank them myself. For some people the blood pressure metric would be easier, and the non-smoking would be much harder.

So far as I know, the AHA has not ranked the seven metrics in terms of importance; I am assuming that some make more of a difference to your cardiovascular health than others, and I am hoping that ones that are easy for me are more important than the ones that are hard for me. But I'm kind of afraid to research the matter, and find out that my hopes are ill-founded in this regard.

Today I met the fasting glucose requirement handily, and I ran four miles, so here's hoping those things are more important than Body Mass Index!  

Can The A1c Test Be Fooled?

Monday, March 19, 2012

Did you think I was up to no good on St. Patrick's day?


Well, that's more or less true. I played for three hours at a pub in Marin on Friday night, and for four hours at a winery in the Napa Valley on Saturday afternoon, and I can't claim that the foods which fueled these marathon sessions of fiddling were particularly healthy, or particularly diabetes-friendly. So, I was a fairly bad boy -- certainly not a model for you to emulate.

The experience of playing for so long was extremely exhausting (exhausting in ways that long-distance running is not -- it has something to do with the tension involved in performing). As soon as I got home from the Saturday-afternoon performance, I had to take a nap to recover from it

I didn't have a lot of time (or energy) for exercise during all this, but I forced myself to do it, because I knew that the combination of pub-food and no exercise would not be a good one for me. On Saturday morning, after my late night at the pub on Friday, I managed to drag myself out onto the road for a four-mile run. During the week leading up to this, I had not done any running (owing to the combination of bronchitis and rainy weather), and had contented myself with lighter gym workouts. That run on Saturday turned out to be almost amazingly hard for me to do -- I started out feeling bad, and (unusually for me) didn't start feeling any better as the run continued and I got warmed up.

So, it's nice to be able to report that, once I'd completed my musical duties for the weekend and got a good night's sleep on Saturday night, I was able to do a good long trail-run on Sunday afternoon (9.5 miles), and didn't feel bad after the first mile of it.

Today's run didn't feel bad either, and my test numbers were good, so I feel pretty-well recovered from a rather difficult week.

Looking through the search strings that have yielded up references to my site, I sometimes wonder if Google is sending people to me just to send me a message. Somebody types 'sadness poor posture' into a search window and Google sends them my way? What am I, the icon of sorrowful slouching?

But that isn't the worst example. Last week somebody did a search on 'hopelessy alone overweight unhappy type 2 diabetic starving', which practically qualifies as a poem. A glum, miserable poem, to be sure, but a poem nonetheless; a kind of medical haiku. And of course the people at Google said, "Why, let's send this sad person to Tom! Surely they'll have lots to talk about!"

Perhaps there is room for a new poetic sub-genre: diabetic haiku.

Wash hands before each
test -- but do I know there's no
sugar on the towel?

I dropped a test strip.
Why can't I pick it up now?
Fingernail failure.

I am very far
from home. Do carbs really count
if no one sees you?

Well, maybe it's a promising idea, but I think it needs work.

Two other recent search strings bothered me, because of what they suggested about the state of mind of the person doing the search:

The hemoglobin A1c test and the test for sugar in the urine are not the sort of tests that a person can cheat on.

The A1c reflects the amount of glycation (undesirable bonding of sugars to proteins) going on in your red blood cells over a comparatively long period (about 90 days). The reason for the long time-period is that red blood cells have a limited lifespan and eventually get replaced -- but while they last, once they're glycated they stay that way. So, if your blood sugar level declines, this won't be reflected until a lot of the existing (and perhaps heavily-glycated) red blood cells have been replaced.

Anyway, there isn't any short-term action we can take which will fool the A1c test into thinking we've all been good little boys and girls for a longer period -- so please drop that idea.

As for sugar in the urine, why would you want to disguise that? If you're having a problem with that, you and your doctors need to know about it. No good can come of concealing it. And, for the record, I doubt there's anything you can do to disguise the presence of sugar in your urine; if it's there, it can be tested for. 

Might as well just face up to what's actually going on!


Friday, March 16, 2012

No time for blogging today -- when you play Irish music, this is a very busy weekend for you.

Happy St. Patrick's Day!  

Cause And Effect In Health Studies

Thursday, March 15, 2012

A very rainy week. That's part of the reason I've been going to the gym instead of exercising in the great outdoors. Another reason is that my lunch hours have been claimed by other events and activities this week -- including rehearsing the Irish music I'm going to be playing on St. Patrick's Day (at two venues: a pub in Marin tomorrow, and then a winery in Napa on Saturday). Anyway, I've shifted my exercise routine to Plan B: evening workouts at the gym.

Sometimes it is anything but convenient to fit exercise into your day; the trick is to hold on firmly to the idea that you must fit exercise into your day, whether it's convenient or not.

Its a tricky business, this cause-and-effect thing. Whenever we hear that Phenomenon A is strongly associated with Phenomenon B, we can't help assuming that one of them must causing the other. Not only that, we often jump to a conclusion about which of them is causing the other one. We may even jump to that conclusion so fast that we aren't aware of having assumed anything.

For example: a health headline yesterday said that Heliobacter pylori infection in the stomach is associated with elevated hemoglobin A1c levels -- even in people who don't have diabetes. (The bacterium in question causes ulcers, but not always; it's a very common sort of infection, and most of the people who have it are asymptomatic.) 

Without even thinking about it, I jumped to the conclusion that this was a study showing that having elevated blood sugar (as reflected in an elevated A1c result) increases the risk of this kind of infection. High blood sugar is said to cause or intensify just about every health problem; why not stomach infections too?

But it may actually be the other way around: instead of elevated blood sugar promoting this sort of infection, it appears that having this sort of infection promotes elevated blood sugar.

How would that work? Well, any sort of infection tends to elevate blood sugar, because the body's inflammatory response tends to suppress insulin sensitivity. But H. pylori has some special tricks up its sleeve: the bacterium has the ability to regulate the hormones leptin and ghrelin, which themselves regulate metabolism and energy use. It is believed that one of the effects of H. pylori's interference with the endocrine system is elevated blood sguar, especially in overweight patients.

Anyway, the moral of the story is that, when you're trying to analyze a cause-and-effect relationship, don't be too quick to assume which one is the cause and which one is the effect.

Last month I wrote about a study which found that overweight doctors were less likely than normal-weight doctors to give their patients about weight loss. Well, another study is finding that doctors who exercise regularly are the ones likeliest to advise patients to exercise (and to practice other healthy habits, such as not smoking).

Apparently doctors feel more comfortable when they are preaching what they practice.    

Does Pre-Diabetes Have A Definition?

Wednesday, March 14, 2012

The cough is receding and I'm clawing my way back to fitness. I felt strong enough to do some weight-lifting after work tonight, in addition to the aerobic workout. I assume that's why I got such a low post-prandial result, after I came home and had dinner. It was a pretty low-carb dinner, but still -- 89! When your body is fighting off a virus, it's easy to get a high post-prandial result even after a low-carb meal. Weight-lifting can give you a lot of help with that.

Good heavens, is the medical establishment starting to accept the idea that "pre-diabetes" needs to be taken seriously? Such is the implication of a study published in the American Journal of Preventive Medicine.

It seems that doctors have settled on a hemoglobin A1c result of 6.5% as the diagnostic threshold for Type 2 diabetes, but have not settled on any diagnostic threshold for "prediabetes".

I detest the term "prediabetes" to begin with. Perhaps there is a quiet understanding among doctors that prediabetes is just a name for an early stage of Type 2 diabetes, but what patients think it means is "a non-diabetic condition which might someday become diabetes, a few decades from now, if I'm unlucky". Or, to put it more simply, they think it means "a condition that I don't need to worry about right now".

If there is a qualitative difference between prediabetes and Type 2 diabetes, nobody has stepped forward to explain what it is. It seems to be a quantitative difference, and nothing more. Either your A1c result is above 6.4% or it's not, and there the story ends; no one seems to have identified a meaningful difference in the nature or cause of the two conditions. (And it does seem to me that people who say prediabetes isn't a form of Type 2 diabetes owe us an explanation for how the people who progress from prediabetes to Type 2 diabetes manage to get cured of one disease and catch an unrelated one, on the day that their HbA1c result hits 6.5%.)

Okay, anyway... what "prediabetes" means is that your blood sugar is elevated, but not elevated all the way to the diagnostic threshold for Type 2 diabetes. But if we're going to say that your blood sugar is a little higher than normal, we need to start by agreeing on what "normal" means. How high does your blood sugar have to get before it is above normal? What is the diagnostic threshold for prediabletes?

Various numbers have been proposed by professional organizations, including 6.0%, 5.7%, and even 5.5% -- which is remarkable, given that the normal range for the A1c has often been described as "4.0 to 6.0%". Apparently the upper end of "normal" has been dropping of late. The last time I had an A1c test, the result was 5.5%, and the stated "Standard Range" for the test was "4.8 to 5.6%". So, I made it into the normal category, but not by a very wide margin. The lab that did my test has decided that prediabetes starts at 5.7%.

Anyway, the new study looked at the cost-effectiveness of medical intervention triggered by A1c results at various levels. The conclusion: it is cost-effective to treat patients with A1c results of 5.7% or higher. Therefore, 5.7% ought to be the diagnostic threshold of prediabetes, and prediabetes should be treated, not just mentioned.

I feel a little uncomfortable when medical treatment is defined as worth doing only when it is "cost-effective", but given how expensive medical treatment can be, I suppose there is no getting away from the economic realities.

Anyway, there we are: according to one study, at least, pre-diabetes begins when your A1c result hits 5.7%. So I'm still in the clear!   

Thoughts On Pink Slime

Tuesday, March 13, 2012

It was a very rainy day, and I couldn't face going out to run in it. I went to the gym instead.

I'm still not at the top of my game by any means, but I'm getting stronger. I'm coughing less, and when I do it doesn't burn. These are the developments we want to see.

Nothing interferes with your efforts at staying healthy quite like being ill, so I hope to say good riddance to this cold very soon.

"What's in a name? That which we call a rose, by any other name would smell as sweet." So said Shakespeare -- but he said it in an era that did not yet know the art of spin-doctoring. Nowadays there are highly-paid consultants who spend their careers dreaming up names for things -- names intended to make one rose seem sweeter, or less sweet, than all others. 

Typically these newly-crafted names serve a political agenda -- which means that they tend to exist in pairs, ready-made for use by people on either side of an issue ("pro-life" and "pro-choice", for example).

But the pairing of opposed names for the same thing can also occur when names are being used by companies for the sake of marketing or public relations. People who object to the heavy use of high-fructose corn syrup in processed foods like to call it "HFCS", because the use of an acronym for a substance emphasizes its artificiality. Meanwhile, the makers of high-fructose corn syrup are trying to get people to call it "corn sugar", because that makes it sound natural. 

I learned today about an especially interesting pair of words for the same product. The company that makes it (a South Dakota firm called BPI or Beef Products Inc.) likes to call the stuff "lean fine-textured beef". That has rather a nice sound, doesn't it? It seems like a phrase that might be mentioned to you by a waiter at an expensive resort hotel, as he outlines today's luncheon specials. 

But when you see a photograph of what "lean fine-textured beef" actually looks like...

...you begin to understand why people who object to this product like to call it "pink slime". 

The product in question consists of beef trimmings which have been treated with ammonia (to kill germs -- which seems to be necessary because the beef trimmings carry a high risk of contamination) and pulverized into a substance resembling strawberry gelato. This substance is added to ground beef as a low-cost extender. Most grocery-store ground beef contains the stuff (but is not required to mention that fact on the label).

Well, if it were my job to sell that product to fast-food restaurants and school lunch programs, I think I would prefer to call it "lean fine-textured beef", too. Even if we leave aside "pink slime", it's hard to think of alternatives that wouldn't be a lot worse than "lean fine-textured beef". I mean, what else are you going to name a thing like that?

Not one of those names holds a candle to "lean fine-textured beef", and that's certainly the term I would use if I worked for BPI and wanted to maximize sales. However, people suspicious of BPI call the stuff pink slime, and have harshly criticized the U.S. Department of Agriculture for allowing ground beef to include up to 15% pink slime (or, if you prefer, 15% lean fine-textured beef, with an ammonia glaze). Criticism of the USDA has been sharpened considerably by plans to include this product in ground beef for the federal school lunch program.

The USDA has been indignantly defending itself on this issue; they are shocked, shocked! that anyone would think they would approve the use of pink slime in school lunches if it wasn't safe.

The thing is, I'm not sure safety is the issue here, exactly. I think grossness is the issue.

Supposedly drinking urine won't hurt you, but that doesn't mean people want the USDA to allow apple juice to be up to 15% urine, without the consumer being informed of this fact. If it's harmless, than why cover up the fact that it's present? Why not let consumers decide for themselves whether they want to eat pulverized, ammonia-soaked beef trimmings?

I guess that's the problem I tend to have with processed-food makers in general. If there really is nothing wrong with the ingredients you're sneaking into your products, then you shouldn't need to be sneaking them into your products; you should just say "here's what's in here" and let people decide whether or not they want to eat it.   

Bronchitis Weekend!

Monday, March 12, 2012

I'm not in top form right now. I spent the lovely weekend indoors, trying to recover from the virus I came down with on Friday. Actually, it hasn't been that bad. I have that peculiar burning cough which I learned at an early age to call bronchitis, and I have been very much lacking in energy. Lots of dozing, and not much activity.

Looking on the bright side: I didn't have chills or a high fever, and I've certainly had worse coughs than this one. I'm starting to feel stronger and I'm pretty sure I'll be up for a good run tomorrow. Of course, it's predicted to rain tomorrow, and I might just decide to do a gym workout instead. I've never seen "running in the rain" on a list of good ways to get over a virus.

Also on the bright side: my glucose tests aren't bad, especially considering that I've been ill and inactive. Most people with Type 2 tend to get considerably higher numbers whenever the body is fighting off an infection, because the inflammatory response tends to impair insulin sensitivity. Systolic blood pressure is up, but that doesn't surprise me under the circumstances.

Anyway, I'll try to have something more interesting than "I'm not dead" to report tomorrow. 

Apes, DNA, & ADD

Friday, March 9, 2012

I woke up with a sore throat, and felt decidedly below par today. I hope I don't come down with anything that makes me feel worse than I do now.

At lunchtime, I did manage to force myself to go for a run anyway. It was hard, though. I just felt weak, and that continued throughout the entire run. (Often, when I feel iffy at the start, I begin to feel stronger after a few minutes of running -- today there was no improvement at any point in the run.)

Someone at work suggested gargling with peroxide. Sounded awful to me, but I did some web-searching on the subject; apparently it's safe. Still, most people seem to think you should dilute it 50-50 with water. 

I don't know, peroxide creeps me out. I think I'll see if Listerine gets the job done.

I did find out why peroxide is sold in those dark brown plastic bottles: peroxide is easily broken down by exposure to light. 

I don't know why they had to be last in line, but gorillas have finally had their genome sequenced -- the last of the great apes to be accorded this honor. (Humans were first in line, of course, in 2003. Chimpanzees followed in 2005; orangutans finally hit the big time in 2011.)

It was already known that we were more closely related to chimps than to gorillas, and the gorilla gene sequence doesn't change anything in that regard. But it does turn out that 15% of our genome is more similar to that of gorillas than it is to that of chimpanzees. Of course, 15% isn't a large percentage, but I kind of like knowing that we at least have a part of us that's closer to gorillas than to chimps. Because gorillas seem a little more sympathetic.

Gorillas I can imagine working with. In fact, looking back over my employment history, I'm not absolutely sure that I haven't.

Chimpanzees, on the other hand, are just weird. You wouldn't dare turn your back on a single one of them. I've never seen or heard anything about chimps that makes me proud of sharing so much DNA with them.

Come on -- would you trust that guy? (I can't promise that I've never worked with him, either, come to think of it.)

Now that the gorilla genome has been sequenced, we can go to work on the problem of whether it's a gorilla's own fault if he gets fat, or if he develops diabetes.

Gorillas are almost entirely vegetarian, by the way (although they do eat termites -- that's their main source of "meat"). I don't know that gorilla vegetarianism proves anything, but a lot of people have invested a lot of energy into proving either that it means a lot or that it means nothing. Gorillas themselves think the whole argument is a bit of a bore. Why can't these hominids find something more interesting to argue about?


Meanwhile, you will be astounded to learn of a study suggesting that mere immaturity can lead to an incorrect diagnosis of Attention-Deficit/Hyperactivity Disorder. (The youngest children in a classroom are more likely to be diagnosed with ADHD than than the oldest children in the same classroom. Might that say something about the validity of such diagnoses?)

Which is not to say that ADHD doesn't exist, of coure. But every time a disease is discovered or identified, it becomes a "fashionable" diagnosis and suddenly everyone has it -- because now doctors are looking for it, and are primed to see it.

The suddenly increased awareness of autism in recent years, for example, has led doctors and laymen alike to see every shy young person as autistic -- and the new enthusiasm for diagnosing autism has created the false impression of an autism epidemic (an epidemic which, of course, needs to be explained by blaming it on someone or something). Hence the anti-vaccination movement, which works to fight an imaginary epidemic at the cost of unleashing epidemics which are very real and very deadly. It's not a good trade, if you ask me.  

The Futility Of Blaming Genetics

Thursday, March 8, 2012

A better fasting result today (I prefer to be under 90, but so long as I'm under 95 I don't really feel as if I'm getting off course). And getting 99 after dinner is excellent. That was the result of getting a lot of exercise today, and having a comparatively low-carb dinner.

And once again: blood pressure lower than usual after weight-training.

It's nice that biologists have been able to learn so much more about genetics in recent decades, but it's kind of a problem that the public's understanding of the subject has not moved forward one inch during that time.

Genetics, as understood by scientists, is a vastly complex and sophisticated subject. Genetics, as understood by everyone else, is about as complex and sophisticated as your average bumper-sticker.

We laymen tend to assume that the genetic code imprinted on our DNA consists of a list of genes "for" this or that characteristic... and that everything about us is fully determined by those genes. If you're lousy at singing, or if you don't like horseradish, it's because you didn't inherit "the gene for" singing or "the gene for" liking horseradish. And of course the same principle applies to health issues: if you inherited "the gene for" stomach cancer, then you will get stomach cancer... and if you didn't, you won't. Isn't that right?

This simple, black-and-white vision of how genetics works doesn't stand up very well to scrutiny. If there were "a gene for" stomach cancer, than everyone with that gene would have stomach cancer from the start, and nobody who was born without stomach cancer would have to worry about developing it later, because they wouldn't have the gene. Clearly that's not the actual situation; what happens instead is that certain genes raise your risk, because they cause defects in the body's cancer-fighting mechanisms. Those defects don't give you cancer directly, but if a certain kind of cancer cell starts growing (an event which would be triggered by radioactive decay or exposure to a toxin, not by your genes), your body's attempts to stop it will be hampered by a genetic flaw. Most of us have had cancers which we never became aware of, because our bodies were able to put a stop to the problem while it was still just one bad cell or a microscopic clump of them. It's when your body fails in its anti-cancer housekeeping chores that a detectable tumor develops.

There are some kinds of health problems (Huntington's Disease, for example) which are tied unambiguously to a particular genetic defect, and can be diagnosed simply on the basis of a DNA test. But that is not typical. Most genetic variants that have any kind of impact on health only increase the probability that a particular health problem will occur. Whether or not the problem actually does occur depends on all sorts of environmental factors (including that very important environment known as the womb) which affect "gene expression". Merely having a gene is not the whole story; a lot hinges on when and (how strongly, and for how long) that gene is "expressed".

The term "epigenetics" has been coined for all of the factors which interact with what's in your DNA. For example: how much of a particular hormone you were exposed to in the womb, and at what point in embryonic development that exposure occurred, and how efficiently your embryonic body absorbed it. Cloned sheep that are identical in their DNA can turn out not even to be the same color, because of the vagaries of epigenetics.

So, the idea that your fate is written clearly and unalterably in your DNA is ridiculously far from the truth. Even so, that's how most of us still see the matter. Whenever any health problem is reported to have a genetic basis, we assume that it has a purely genetic basis. If you have the gene, you get the disease, and there's nothing you can do about it.

I think the reason this simple-minded view of genetics endures, even though it is well known to be false, is that there's something in it for us. Absolution, to be specific. We're not responsible for any health problems we may have, because GENETICS!

This absolution is very much a double-edged sword, however. Sure, treating our genes as all-powerful frees us of the need to take the blame for anything. Unfortunately, it also deprives us of the power to improve anything.

Call me crazy, but I would rather be able to do something about my diabetes (at the price of accepting blame for it) than free of blame for it (at the price of being powerless over it). I mean, for heaven's sake, which matters more here -- being healthy, or avoiding blame? (And it's not as if the people who blame you for being diabetic are all going to accept genetics-based excuses anyway!)

These days a lot of geneticists are spending their careers pouring over the data to find correlations between this or that gene variant and some health problem. When they find something, it makes the news -- but the press accounts often obscure the fact that the correlation between the gene and the health problem is not terribly strong. Often the gene increases your risk noticeably, but you can have the gene without the health problem, and vice versa.

Thus we have this essay, "On the Futility of Screening for Genes That Make You Fat", by a doctor who has clearly had enough of this kind of thing. Okay, a particular gene that has been knicknamed "FTO" increases your risk of obesity by 23%. But the risk is significantly reduced in physically active people, so it's obviously not as if there's nothing you can do about having that gene. And knowing you have that gene doesn't change anything in practical terms -- you have to do the same things to control your weight whether you have that gene or not. Also, the gene is not a useful predictor of obesity-related diseases, such as diabetes (you can predict someone's diabetes risk just as accurately, with or without knowledge of their genetic status, simply on the basis of how much they actually weigh).

The only thing that changes for you if you know you have that gene is that now you have a distraction to focus on. If you didn't know you had that gene, you would just think you were struggling against weight gain, like everyone else. Knowing you have the gene, you may decide to give up the struggle, on the grounds that there's no way you can win because GENETICS!

The things is, when you're struggling against a genetic adversary that only wins 23% of the time (and less than that in active people!), you're not exactly taking on the Red Army single-handed.

People need to stop seeing the power of DNA in this overstated and unrealistic way. What you are is determined by the interaction between what genes you have and what behaviors and experiences you have. It wasn't all settled forever, the moment you were conceived.   

Keep It In Perspective!

Wednesday, March 7, 2012

Well, as I more or less predicted last night, my fasting test was higher than usual this morning; not an entirely astonishing sequel to Ale Night. I was about to add, in my defense, that Ale Night happens maybe once a month for me, so who cares if I take it easy once in a while? Of course, the trouble with the Special Occasion excuse is that life is full of Special Occasions, even if they're not always in the form of Ale Night. I went to a big party just last Friday, for example.

I had a good solid run at lunchtime (climbing up the big hill to Paradise Ridge, for a brief look at the panorama to the west on a brilliantly clear sunny day), and my result after lunch was lower than my fasting test had been. So if my system was a little derailed by Ale Night, at least it was nudged back onto the tracks by Running Uphill.

It's nice that doing hard exercise enables me to make quick course-corrections of this kind, but I'm sure it would be better for me if no course-corrections were ever needed.

It's been dry and windy here of late, and the trees are dumping prodigious amounts of pollen into the air. The windshield of my car is coated with it every morning. I'm starting to have some eye irritation, and some sneezing, but so far nothing worse. No asthma symptoms.

I guess it's time to start taking Claritin. I'll have to keep taking it for about three months, so I'm certainly not going to buy it as "Claritin", which costs a lot more than the generic stuff, which is called loratadine.

Loratadine is an anti-histamine which binds itself to (and reverses the function of) histamine receptors, in order to block an allergic reaction. But the beauty of loratadine is that, unlike most anti-histamines, it doesn't pass easily through the blood-brain barrier, so in most people it doesn't cause drowsiness. I'm sleepy enough in the afternoons as it is; if I take other anti-histamines I'm downright comatose. But loratadine I can handle.

What a lot of people don't understand about loratadine is that it has no value as an ad hoc remedy, taken only when you're actually having an allergy attack. If you wait until then, it won't help you. You have to take a daily dose of loratadine throughout your allergy season, and let it build up in your system.

My allergy season doesn't usually start until mid-April, but we're having an early spring and I might as well get on with it. I spend a lot of time outdoors, and get a lot of exposure to whatever pollen is out there.

Stressed out about diabetes and other scary and/of frustrating issues? Need to put things in perspective?

This won't work for everybody (and in fact it might not work for anyone besides myself), but I sometimes find a certain amount of stress-relief in comparing the vast scale of the universe with the tiny scale of the world I know. Keeping an eye on current events outside planet earth can sometimes help us re-assess our own importance. Here's today's roundup...

The Mars Reconnaissance Orbiter spotted an odd serpentine shape on the surface of the red planet:

...which turned out, on closer examination, to be a dust devil. They have them on Mars, you know; the atmosphere is thin there, but it's windy neverthelesss, and sometimes a tornado-like column of dust rises high above the ground.

Meanwhile, on the surface of the sun, an explosion known as a solar flare sent a huge burst of charged particles flying towards earth; they should get here by late tonight, and may cause bright auroras and/or communications problems.

And much, much further away, we have new images of a cluster of spiral galaxies in Hercules, captured by the VLT Survey Telescope. This view shows just a fraction of them:

Each of those fuzzy spirals contains several billion suns. And the Hercules cluster of galaxies isn't even an unusually large one.

Yeah, right: this whole thing is all about us. No, wait -- it's all about me!

Me and my problems -- those are the issues that matter in the larger scheme of things.

And if that isn't inspiring enough, here are three quotes about health...

Just because your doctor has a name for your condition doesn't mean he knows what it is.
Bertrand Russell
When a lot of remedies are suggested for a disease, that means it cannot be cured.
Anton Chekhov
To be stupid and selfish and to have good health are the three requirements for happiness, though if stupidity is lacking, the others are useless.
Gustave Flaubert

Correlation & Causation

Tuesday, March 6, 2012

I had the opportunity to do a long run today, and I took it -- because I knew I would be going out to dinner tonight with friends from work (at a brewpub!) and I wanted to make up for it in advance, to the extent that I could. It was a low-cab dinner. The ale I had with it was another story.

I had a good post-prandial result 2 hours later, but that might have been artificially lowered by the alcohol in the ale. We'll see what kind of fasting result I get in the morning. Proably not a low result of the sort I got today.

In yesterday's blog post, I discussed a correlation between (1) blood clots and (2) running in the Boston Marathon -- which, recent research suggests, is actually a correlation between (1) blood clots and (2) flying to Boston. Local runners are apparently not at risk -- but we wouldn't know that if no one had thought of comparing  local runners to out-of-state runners who flew to the event. 

The problem of misleading correlations is a huge obstacle to the understanding of human health. No matter how many times we remind ourselves that "correlation is not causation", we can seldom resist the urge to jump to conclusions whenever we hear  that a particular health problem is more common in people who do X (or less common in people who do Y). This is especially true if we already have a bias against X or in favor of Y. People who don't like coffee are always going to be ready to believe a claim that caffeine causes some disorder or other; people who love chocolate are always going to be ready to believe a claim that chocolate prevents some disorder or other. 

For a long time it has been claimed that clinical depression is less common  among devoutly religious people; it was assumed that going to church regularly somehow prevented depression. Now a new study says we've been looking at it backwards: one of the commonest signs of clinical depression is that people stop participating in activities they used to enjoy. Regular church-goers get clinical depression too, but when that happens, they stop going to church;  the people who still go are the ones who aren't depressed, so of course the population of regular church-goers has a lower depression rate. Now, if you like going to church, you probably accepted the earlier claims uncritically. If you don't like going to church, you probably accept the later debunking of those claims uncritically. As long as a finding confirms what we were already inclined to assume, it's bound to seem reasonable to us. That's the way we humans work.

That's why ideas that aren't well-supported by evidence can hang on for decades. Whatever evidence does support an idea (even weak or questionable evidence) is good enough for those who are comfortable with that idea.

Nutrition seems to be an especially problematic field in this regard. All points of view about nutrition (no matter how contradictory they may be) are supported by "overwhelming" evidence, according their proponents. What "overwhelming" means in this context is that there is some evidence, and it has been cited frequently over a long period of time.

I really have no idea at this point whether saturated fat does all of the bad things, some of the bad things, or none of the bad things that it has been accused of doing. The nearest I will get right now to taking a position on the issue is that trans fat (artificially hydrogenated vegetable oil) almost certainly is harmful, while saturated fat is suspected of being harmful and might very well not be.

Some studies have certainly found a correlation between saturated fat consumption and cardiovascular problems, but as with blood clots and the Boston marathon, the reason for the correlation has never been clear, and the assumption that saturated fat is a direct cause of cardiovascular problems may be quite wrong.

But what if it's right?

Hence my butter dilemma. I suspect that I'm going to spend the rest of my life dithering between the belief that butter is harmful and the belief that butter is fine.

An inspiring thought for the day from SMBC :

"Since nearly every cell in the body is replaced within a year, every part of my body you would want to have sex with is under one year old.

You creep."  

Blood Clots, Marathons, & Fear Of Flying

Monday, March 5, 2012

I had a very busy, very musical weekend, which began with a music party on Friday evening -- that is why I didn't have time to do a blog post on Friday. In fact, this was one of the few weekends I've experienced when music-making came into direct conflict with exercise. I went to the state park for a trail-run yesterday, with the intention of doing a long route (about 9 miles). Shortly after I started running, I looked at my watch, did some mental calculations, and realized there was no way on earth I could do that route without making myself late for an Irish music session at Murphy's Irish Pub in Sonoma that afternoon.

On the fly, I worked out an alternate route through the park, which cut the run down to 6 miles and gave me enough time to get home, take a shower, get dressed, grab my fiddle, and get on the road to Sonoma. Fortunately, playing music has taught me how to change course immediately when whatever I started isn't working out very well.

And my glucose numbers were good today, so it doesn't look as if I lost anything by cutting 3 miles off the run I had been planning. The main reason I had been going for 9 miles is that I'd been to a couple of parties and I felt the need to make up for some party food that I wouldn't normally have.

I was reading today about marathon-runners developing blood clots. We're talking here about "DVT", or Deep Vein Thrombosis. That means a blood clot which typically develops in the leg. After the clot forms, days can go by before there are any symptoms -- which makes it hard to figure out what's going on, or when it really started, or what might have caused it. Unfortunately, the clot can travel to the lungs and heart, and cause serious trouble -- life-threatening trouble.

This problem is rare in marathon-runners, but not as rare as doctors think it ought to be (considering how fit the sufferers are), and consequently there have been some attempts to figure out what causes it when it happens. Based on some recent research, the cause may have very little to do with the marathon itself.

Marathons are special events, and people often travel long distances to attend them. Among runners, certain of the larger marathon races have a special mystique. Lots of runners who live nowhere near Boston or New York or Chicago or San Francisco dream of participating in the marathons held annually in those cities, and would be happy to pay the price of a hotel room and airline ticket to do so.

And there you have (or at may have, anyway) the explanation for the blood clots. Some recent research suggests that, when marathon-runners develop blood clots, the problem is not that they ran a marathon, but rather that they had to get on a plane to do it.

The researchers studied two groups of runners who participated in the Boston Marathon -- one group had traveled by air to get there, and the other group had not. Nobody in either group actually suffered DVT (the problem is too uncommon for that to have happened, given the small size of the study), but the chemical markers of coagulant activity in the blood which are thought to warn of potential clot formation were elevated in the runners who traveled by air -- and not elevated in the runners who didn't.

It's one study, and it's a small study -- probably not the last word on the subject. But there has always been plenty of evidence that air travel increases the risk of blood clot formation and DVT; it would make sense that, if some marathon-runners develop such problems, it would be the runners who took a plane to get to the race.

Even though I'm probably not going to run any more marathons, I am pleased to hear that distance running does not appear to be a cause of blood clots. Anyway, the researchers said that, even if marathon-running actually were occasionally the cause of blood clots, that wouldn't be an argument against running, because the risk is so small and the benefit is so large. A tiny increase in the probability of blood clots, set up against a large decrease in the probability of all other cardiovascular problems, would be pretty trivial.

It's funny how, whenever we talk about evaluating risks, we always have to mention air travel.

Usually air travel is mentioned to prove the point that most people are lousy at evaluating risk. After all, lots of people are afraid of flying, or at least nervous about it, even though everyone knows that flying is extremely safe. However, it might be that this extreme safety ought to be examined a little more closely, to make sure it really is as extreme as we're asked to believe.

Part of the reason air travel looks so safe in the statistics is that the safety figures are given in terms of accidents "per passenger-mile". Therefore, if a plane carrying 140 passengers makes a trip to Boston without crashing, the influence of that one safe flight on the statistical record is 140 times as great as the influence of your safe trip there in a car. In effect, the airlines are granted vast numbers of bonus points for every safe trip they make, because there were a lot of people on board. Buses are given fewer bonus points, and cars practically none.

Now, let's be honest: do you think your flight is twice as safe if the plane is full than if it's half empty? I doubt it. In evaluating the safety of a trip by air, most of us mainly interested in a whether or not the trip ends with a safe landing -- regardless of how many passengers racked up how many frequent-flyer miles during the journey.

I'm not saying that flying is actually no safer than driving; I'm merely suggesting that the supposedly enormous disparity in safety between the two is being exaggerated, because the safety stats are evaluated in a way that is extremely favorable to the airlines. (If any bureaucrat in the NTSB ever suggested that the stats be evaluated in a different way, you can bet that the airline lobby would declare war on him -- which is why I don't expect to see anything change in this area.)

But, of course, people have all sorts of reasons for feeling nervous about flying. The claustrophobia of being confined in a cramped space for hours. The general unpleasantness of the way air passengers are treated these days. The complete surrender of control. The possibility that the in-flight film will involve Robin Williams trying to prove what a serious actor he is.

And, of course, the very real possibility of developing DVT. Plane crashes are admittedly rare, but DVT associated with air travel is not. In 2001, The Lancet published an evaluation of the issue in which they estimated that 1 million cases of DVT related to air travel occur in the USA annually -- with 100,000 of those cases resulting in death. A serious problem, clearly. So what can be done about it?

The answer to that depends on what actually causes the problem, and that isn't as clear as it might be. The prolonged physical immobility imposed on air passengers contributes to the problem, but is apparently not the only cause: to judge from a Norwegian study on air pressure, it appears that the reduced air pressure in a high-altitude flight ("pressurized" cabins do not provide anything like sea-level pressure) increases blood coagulation factors significantly, and this could be the primary cause of DVT in airline passengers.

What can be done about the problem?

One thing you can do is be young. The older you are, the greater your vulnerability to DVT. Young airline passengers face very little risk.

If you can't manage to be young, the next best thing is to move. Get up and strech your legs periodically. The longer you sit still, the greater your risk.

The air in pressurized airline cabins tends to be very dry, and people can easily become dehydrated during a long flight -- which seems to increase the risk of blood clots. So, drink.

Drink what, you ask? Passengers are often advised to avoid anything containing alcohol or caffeine, and stick to water. However, the studies that have been done don't bear this out. Neither alcohol nor caffeine (at least in moderation) seem to be a source of trouble in this department. And a Japanese study found that sports drinks (full of electrolytes) work a lot better than water in preventing coagulant factors in the blood.

So, anyway: don't still still for too long, stretch your legs often, move as much as you can, and have some sports drink -- if the airline will let you have any. (If they won't, well, remember that you shouldn't be engaging in air travel in the first place, if you don't like being treated as if you were under arrest.)

Shift Work & Diabetes

Thursday, March 1, 2012

Well, lower glucose numbers today, including a lower fasting number. I don't know if that means I was right to have a late snack last night, or if I'm simply getting over whatever was happening during the last two days that raised my fasting level.

You never do know, really. I guess that's what keeps diabetes interesting. The factors that affect blood sugar are numerous, and mostly unobservable. All we can do is try our best to get things back on an even keel, whenever there is an unwelcome change. No guarantees.

If predictability is what you look for in a disease, diabetes is not the right disease for you.

Once again, I found that my blood pressure was lower than usual on an evening when I had done a weight-training workout. This seems to happen pretty consistently.

There's a rather mean-spirited aphorism to the effect that a German loves his mother -- in principle. I sort of feel that way about scientific research into diabetes-related health issues; I enjoy reading about it -- in principle. But there's a lot of it that I don't enjoy reading at all.

I'm usually not put off by the more technically difficult writing on medical research. I might have been, back in the bad old days, when a reader who stumbled across an unfamiliar term such as "hyperinsulinemic euglycemic clamp" did not have the option of opening a browser window and finding out what it means. But, as things are today, big words just don't scare me. (It's the short ones, used in unfamiliar ways, that are the real challenge: when a paper says "P for trend = .048", what are you supposed to do, run a Google search on "P", and find an article saying that this letter is derived from the Greek pi and is a "voiceless bilabial plosive" in most modern languages?) Anyway, I'm a technical writer by trade, so I'm not easily intimidated by impenetrable-looking prose.

No, when I'm put off by the research literature, it's usually because the researchers have chosen to look into an issue that seems to me like a dry well.

For example, I don't much enjoy reading about the latest tests of the latest diabetes drugs, because the story is always the same. Somebody is pushing a new drug, and it has been shown to be an "effective" treatment for Type 2 diabetes (in the sense that it produces better lab results), but there's a slight hitch in that the drug seems to increase, rather than decrease, the risk of serious health problems which we thought a diabetes treatment was supposed to prevent. This scenario plays out terribly often, and reading about it doesn't greatly excite me. Oh, look, another research team just learned that messing with the endocrine system can have unintended consequences! Whoever could have seen that coming?

Another type of research I dislike reading is the kind that boils down to: changes in the way people live nowadays have resulted in a greatly increased risk of diabetes and other health problems -- but we mustn't question those changes, or try to reverse them.

The recent research on shift work promoting diabetes falls into this category. Earlier research had seemed to suggest that shift work only promoted diabetes because it promoted obesity, but more recent, larger studies find that, even if you correct for obesity, people who do shift work still have a heightened diabetes risk, and the heightening of risk gets worse the longer you go on doing shift work. The factors thought to be significant are disruption of sleep patterns, dietary patterns, and exercise habits.

But researchers who have looked into this problem seem to consider it unthinkable that we might try to do anything about it directly. "We are increasingly residing in a '24/7' society; thus, the option to eradicate shift working is not realistic."

So there you have it: society is changing in a way which makes people sick, but society doesn't have any choice but to go along with that change. Why doesn't it? Because it just doesn't, that's all. If we want to do something about this problem, we can't do it by addressing the root cause. We need to find a work-around solution. Perhaps that new drug (which seems to increase, rather than decrease, the risk of serious health problems which we thought a diabetes treatment was supposed to prevent) is the solution we're looking for!

Maybe society really is helpless to fight its own unhealthy trends, but if that is the case, I'm not sure that this kind of research has much point. I read this stuff, because I sort of feel as if it's my duty. But it's not a duty I enjoy. 

Following this kind of issue is like following what's going on the Middle East: you know that a good citizen is expected to take an interest in this issue, but you also know that you'll hear about nothing but depressing problems that can't be solved.

Maybe I can work out a deal with myself where I only read about this stuff on Mondays. 

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