Glucose Testing

Friday, November 30, 2012

I Dislike Testing & So Can You!

Yesterday I had a bad case of writer's block and finally, just before giving up and going to bed, admitted that I had nothing to say and no subject to discuss. Well, a reader suggested one: the realities of daily glucose testing. Not just how to do it and why to do it and how to interpret the results of it, but also how to make yourself do it even though it makes you talk like Gollum (we hates it, we hates it, we hates it forever!)

I can think of four reasons why people might not want to test their glucose.

The first three reasons are usually just a smokescreen, I think; the fourth reason is the real one. Paradoxically, it is also the main reason why you should be testing. Sometimes you want to be in a position to receive information even if there's a good chance it will be unwelcome information. When you are driving your car at night, you don't turn on your headlights because you expect them to show you a welcome sight; you turn them on because you know they might show you an unwelcome one. It isn't that you want there to be a downed tree in front of you on a narrow unlit road, but if something like that lies in your path, you want to be made aware of it. Glucose meters, like headlights and smoke detectors and burglar alarms, exist mainly for the purpose of giving us bad news, if there is any -- but we should try not to hold that against them. They're just doing their jobs.

But let's talk about what we want the meter to tell us, when the news is good. Being in the USA, I will be giving results in mg/dl -- if your meter measures in mmol/l, divide my results by 18 to get equivalent values (my 90 is your 5, in other words). In those units, what is a normal reading (for a fasting test, first thing in the morning, or for a post-prandial test, after a meal?)

Well, the definition of "normal" blood glucose has been evolving over the years -- in a downward direction. The normal range is sometimes called 70 to 110, or 70 to 100; my lab calls it 70 to 99. The typical, healthy, non-diabetic person wakes up with a fasting glucose level of about 82 on an average day, so that's what I think of as a truly normal result, and I'm happy when I can achieve it. Diabetes patients typically do not see fasting results in the low 80s, and they may not hit a more liberal "normal" target of 100 or 110 either, but that's what to aim for.

As for glucose levels after a meal, the truly normal person experiences a sharp rise in blood glucose after a meal, which peaks in 50 to 60 minutes, at a level of about 125 on average (although anything up to about 140 is usually considered normal). Glucose then drops again (almost as fast as it went up), settling back to the fasting level in 60 to 90 minutes. In patients with diabetes, of course, the peak after a meal is usually higher than 140, and often a great deal higher. Also, this exaggerated peak in diabetes patients tends to take a long time to subside. The is unfortunate, because at levels above 140 the excess concentration of glucose tends to have toxic, tissue-damaging effects -- and if this goes on too often and too long, the tissue damage accumulates faster than the body's maintenance processes can repair it. (That is what diabetes "complications" result from.)

When exactly should you make the post-prandial test? I have always done mine one hour after a meal (that was my doctor's original advice, way back in February of 2001), and although the fashion has changed (most people seem to test after two hours these days), I think the one-hour plan is better for me. That way I find out how high my peak is. People who test at two hours get a better sense than I do of how long their glucose remains high, but they're not finding out how high it goes. If I can keep my 1-hour peak within normal bounds, I don't have to worry so much about what happens after an hour. I have experimented enough with two-hour testing to realize that I usually drop pretty far between the one-hour point and the two-hour point, so I might as well concentrate on the one-hour point.

I like to get results reasonably close to what a non-diabetic person would get. So, I'm happiest when my fasting result is in the low 80s, reasonably content when it's under 95, and unhappy when it's over 95. So today's 99 made me unhappy. What do I do when I am unhappy about the result? I think about possible explanations for it, and try to make an adjustment in hopes of getting a better result next time. This morning's result was not too hard to account for: last night I'd had a late supper, and a comparatively high-carb supper, and I hadn't slept well. Those things don't help me.

My post-prandial result at lunchtime, on the other hand, was unusually low -- lower than the fasting result, in fact! This was all the more remarkable because I didn't have my usual lunchtime run (there was a heavy rainstorm going on outside). I don't know why that low result happened, but I've noticed that when I wake up with an unusually high fasting result, some sort of corrective mechanism gives me a lower post-prandial result later that day. I don't know the reason for that, but as it's not a problem I'm not anxious to investigate it. But if it had been a higher result, I would have thought about whether the meal had been too carb-heavy.

As for the problem of motivation -- that is, the problem of how to force yourself to do something which hurts your fingers and might hurt your feelings -- I guess one possibility as making sure your testing is purposeful. You want to gather what is known in Washington as "actionable intelligence" -- information that you can do something with. There's no point in turning on the headlights if you're not planning to steer the car. Collecting numbers and doing nothing with them is not only a waste of time but also kind of depressing. So you need to do something with the numbers you collect. You could record them in a journal and show your doctor the results. You could record them in a journal and show the results to nobody, but meditate on them yourself. You could blog about them daily, embarrassing yourself in front of a worldwide audience of millions (well, dozens more likely, but in principle anyone could see it). Or, you could simply use the numbers as daily reminder of what you need to do to steer those numbers in a more desirable direction. You can set goals, and gradually navigate in the direction of those goals.

A mistake many people make is to recoil in horror if their test results are not good, and give up immediately. If you aren't close to your goals, doesn't that mean your goals are hopelessly out of reach? Well, maybe they are, and maybe they're not, but even if you can't quite reach your goals, you can probably get close to them. There's a French saying that ideals are like stars: you can't reach them, but you can steer your ship by them. You'll be a lot better off as a diabetes patient if you aim for a goal, and get fairly close to it, than if you dream of a goal for a while and then give up. In terms of diabetes, or hand-grenades, "close" is often good enough.

At any rate, let's try not to have a bad attitude about our glucose meters, even if they insist on upsetting us with information we don't like to hear.

Blank Slate

Thursday, November 29, 2012


I have spent the last three hours trying to come up with a relevant topic to write about tonight, and now I've given up in despair. The well is dry, and that is that. Better luck tomorrow.

But I'm posting my numbers for the day, so you won't think I'm skipping the blog tonight just because I got bad numbers and don't want to admit it.

My hope is that tomorrow something interesting will happen that I can at least pretend is diabetes-related.

The Big Questions

Wednesday, November 28, 2012

I've noticed that the phrases people enter into their search engines (or at least the ones that result in references to this site) have settled into certain well defined categories, and within any given month I usually get several examples in each category. For example:


There are always searches from people who think they don't have diabetes and clearly do:

I don't know of any scenario under which non-diabetic people fail diabetes tests, or under which a non-diabetic person would ever see a blood glucose level of 360 mg/dl. I don't know what sugar level qualifies as "so high", but if it's well above the normal range, then that is the definition of diabetes, not a potential sign of it. And a hemoglobin A1c level of 7.5 not only indicates that the patient has diabetes, it also indicates that the patient's diabetes needs to be brought under better control.

A1c Confusion

There is always a lot of evidence out there that diabetes patients really don't understand what a hemoglobin A1c test is.

Hemoglobin A1c means that fraction of hemoglobin (a protein found in red blood cells) which has sugar bonded to it. It isn't "bad" in the sense that nobody should have any of it (everybody has some of it), but having more than the normal level (about 5%) indicates that "glycation" (the unwanted bonding of sugars to proteins) is going on at an accelerated rate. Accelerated glycation is bad because, if it continues a long time, it causes tissue damage all over the body, resulting in any of the four million or so health problems we call "diabetes complications". If the A1c is 7% or higher, that's definitely high enough to do serious harm over the long run, but just getting below 7% is not the same thing as achieving normality and avoiding all consequences; getting as close to 5% as possible is better.

Accelerated glycation also indicates that your blood sugar is too high, which most people imagine is the only reason we should take the test or care what the result is. Anything which drives blood sugar up on a chronic basis can result (indirectly) in a higher result on the A1c test, and factors which can drive it up include chronic stress, chronic infection, and chronic indulgence in sugar. But those factors have no measurable impact over the short term, so don't think that a bad day or a head cold or Thanksgiving dinner can "throw off" your test result. The A1c test is not something that can be thrown off, except by hemodialysis or something else which messes with your blood supply.

Doctor/Patient Communication Problems

Some search strings tell me that clear communication between doctors and patients is not universal.

Yeah, your doctor should say something if your A1c result is 7% or above -- but if you know enough to ask Google about this, you probably know enough to ask your doctor about it.

I don't believe for an instant that anyone's doctor ever said an A1c test result means the patient won't ever develop diabetes; everyone's A1c result is normal until it's not. A normal A1c result indicates that the patient isn't diabetic yet -- not that the patient is immune to diabetes.

Urine Confusion

I get a lot of urine questions which suggest that the subject is a mysterious one for many people.

Excessive urination is often an indication of diabetes that is getting out of control; extremely elevated blood sugar affects the kidneys in a way which causes excessive urine production.

However, it is sometimes possible for excessive urination to be caused by something other than diabetes. A pituitary problem known as "diabetes insipidus" can cause excessive urination without blood sugar being elevated. But you need to have that sort of thing checked out; Googling the subject is not good enough.

If a diabetic patient stops urinating, that is usually a good indication that the patient has been dead for a while. But if you have stopped urinating and you don't appear to be dead, call your doctor and report the phenomenon.

As for soda making urine sticky, I think adding soda to just about anything makes it sticky. Whether drinking soda makes urine sticky or not, I do not know -- but if it drives your blood sugar so high that the sugar gets dumped into your urine, than I imagine your urine will get stickier. I do have to wonder, though, how a properly brought-up person would become aware of this increase in stickiness.

Our Friends The Bugs

There's a special category of urine questions that relate to the behavior of social insects.

Sugary urine is a classic symptom of diabetes (specifically, a sign of out-of-control diabetes), but detecting it (in the days when chemical analysis tools had not yet been invented) was obviously not a job for the squeamish. Ancient doctors who did not wish to participate in a blind tasting could always turn to the insect world for assistance. However, it needs to be understood that watching someone's urine to see how much ants and bees like it is a somewhat imprecise basis on which to diagnose diabetes. Perhaps the patient has diabetes but it's not far enough out of control for it to please the bees. Perhaps the patient doesn't have diabetes but the ants are thirsty.

Attention, people who aren't living in ancient Rome: forget the goddam ants already! We have better tools now!

In Another Place

Here's something to put your place in the cosmos in perspective. Yesterday the Cassini spacecraft flew over the north pole of the enormous planet Saturn and took a few snapshots of a cyclone which is spinning there:

Here's a closeup of that little circlet at the center of it:

That little circlet is about 1200 miles across.

There, you see how small we and our troubles are?

Gastric Bypass & Frankensugar

Tuesday, November 27, 2012

The Gastric Bypass "Cure"

Gastric bypass weight-loss surgery has been getting a lot of unskeptical publicity as a miracle cure for Type 2 diabetes. I have been skeptical of it myself, mainly because of concerns that the surgery will "come undone" later and have to be repeated at intervals, leaving the patient as dependent on his surgeons as Michael Jackson apparently became after the nose-sharpening process went too far. It's still a little unclear how often that particular problem happens (it is a surprisingly unstudied issue; surgical procedures are approved as safe based on short-term results, usually without long-term follow-up).

However, we now know a little more about the long-term impact of the surgery on diabetes. A study conducted on 4,434 patients of the Kaiser Permanente HMO in northern California has found that although about two thirds of patients who have the surgery experience remission of diabetes, more than a third of those who do experience remission become diabetic again within five years after the surgery. If we add these temporary remissions to the non-remissions, the result is that 56% of diabetes patients who have gastric bypass surgery do not get a "cure" that lasts 5 years.

Now, a miracle cure that, in more than half of cases, either doesn't work or works for less than 5 years, is perhaps not a miracle cure as most people understand the term. Certainly it can be pointed out that a majority of patients get at least a temporary remission, which is better than no remission (and no remission is exactly what most patients get if they don't have the surgery). So, the surgery can hardly be called useless. Well, I'm not arguing that the surgery is useless, I'm arguing that it has been oversold as a miracle. For some people it is probably better to have it than not to have it, because a few years of normal blood sugar will benefit their health and quality of life more than the surgery harms it. However, you can't know how the surgery is going to turn out for you before you have it, so people facing a tough decision about whether or not to have the operation need to be given an honest presentation of the risks and benefits -- not miracle-talk.


HFCS and Diabetes

I imagine this is going to go on forever: studies suggesting that High Fructose Corn Syrup in processed foods is promoting obesity and/or diabetes, followed by objections that HFCS can't do that, because no one has demonstrated a metabolic mechanism which would cause HFCS to affect our health differently than cane sugar would.

The latest example is a study which finds that the rate of diabetes is 20% higher in countries where HFCS is widely used, even if you correct for other factors. Well, the limitations of this kind of study are almost too obvious to need pointing out: there's no way to correct for, or even discover, all of the factors that might make disease rates differ between two countries. We can't just assume that HFCS consumption is the only reason there's more diabetes in some countries than in others. It might be true, but we don't know that it is.

What interested me about this research was how much the rate of consumption of HFCS varies among countries where it is used. In Germany, annual per-person consumption of HFCS is 1 pound. In the USA is 55 pounds.

Fifty-five pounds. Americans are consuming 55 times as much HFCS as Germans. The disparity sounds almost impossibly extreme, but in America they sneak HFCS into almost everything; apparently in Germany they don't.

I'm still trying to wrap my mind around the idea that Americans are consuming a pound a week of HFCS -- in addition to whatever other kinds of sugar they're taking in! I can't believe this isn't affecting our health in some way.


The Shoulder Situation

I've been putting the ice bag on my shoulder a lot, and the inflammation seems to be subsiding -- I'm hurting considerably less today than I was yesterday. Still, I'm not going back to weight-lifting for a little while.


Thanksgiving & Recovery

Monday, November 26, 2012

Making Up for the Holiday

Apart from the all-but-inevitable weight gain, the big holiday weekend (which is mainly about feasting, after all) didn't have a bad effect on my numbers today. I had done my best to make up for the feasting with some tough, hilly running (14.5 miles over the last two days). But my attempt to cap the running with a resistance-training workout yesterday seemed to produce a bad effect. My right shoulder joint, which had been bothering me lately, really flared up while I was trying to sleep last night, and I got out of bed this morning with an arm that hurt when I tried to raise it, or when I swung the arm forward or back. When I went running at lunchtime, my arm hurt at first, until my shoulder either got used to the motion or the endorphins started masking the pain. I ended the day with my shoulder giving me less pain than it had this morning, but it was still pretty uncomfortable.

Okay, better take another break from the weight-training while I'm getting this healed. I'm doing what I know to do about this: ibuprofen, ice-bags, and physical-therapy exercises. I was worried about going to yoga tonight, but it turned out there wasn't anything there I couldn't do, and most of the poses felt as if they were helping my shoulder rather than hurting it. The strange thing was that, after doing all those difficult stretches and twists, the thing that hurt most was getting up off the floor when it was time to go home -- and fitting my arm into the sleeve of my jacket. Those things, rather than Adho Mukha Svanasana (the ever-popular "Downward-Facing Dog"), were the big challenges for the evening.

I wish my body didn't require so much maintenance. However, I guess living in an aging body is like living in an aging house: you just have to accept that there's going to be more repair-work to do in this place than there would be if you were living in something built more recently.


My Holiday Wish!

My fondest wish for this joyous holiday season is that whoever started the media frenzy over "Black Friday" Christmas-shopping will die a painful death as soon as it can be conveniently arranged. Once upon a time I didn't think there could ever be a news story I wanted to hear about even less than I wanted to hear about happenings in the Middle East, but now I realize that depressing stories about people launching rockets at each other are downright cheery compared to depressing stories about shoppers fighting over sale merchandise. Attention news editors: you cannot force me to become interested in this subject.

If you live outside the United States, and don't have any idea what I'm referring to here, then you truly have something to be thankful for, even if you have no Thanksgiving holiday in your country.


Health-News Headline of the Day

Man, if you can't trust what you read on those web sites, where can you go for reliable information? I guess in the old days you'd join a local club for like-minded hobbyists. But do such clubs exist anymore? I hope those confusing and inaccurate websites have not put the old low-tech alternatives out of business. Sometimes you need the human touch.


Happy Thanksgiving

Wednesday, November 21, 2012

No real blog post tonight; I'm going to concentrate on getting prepared for Thanksgiving tomorrow. Good luck with balancing health against the social and gastronomic demands of the holiday!

Communication Problems

Tuesday, November 20, 2012


Oh, my goodness -- yesterday was World Toilet Day, and I overlooked it! And it was the 11th annual World Toilet Day, so it's not as if I hadn't been given enough time to get used to the idea. It sad to think the event came and went, and I didn't do a thing about it. At least, I didn't do anything about it as far as I know -- I'm not entirely sure how one celebrates World Toilet Day, so there's an outside chance that I actually did what was required. Maybe I didn't sit this one out after all.

I'll say one thing for the organizers of the event: they came up with a cute logo for it.

Actually, the idea is to do something about the fact that about a third of the world's population does not have access to a toilet. It's thought that improving sanitation anywhere is a good thing for humanity everywhere. Those microbes seem to have very little respect for international borders.


Words & Meanings

Although it's clear from various indications that communication between doctors and patients is very poor on average, it's not a problem with an easy solution, because much of the problem is related to what patients think they are hearing rather than to what doctors are actually saying. Patients place their own interpretations on what doctors tell them, and sometimes those interpretations are imaginative to say the least.

For one thing, patients who suffer harsh medical consequences, because they didn't do what the doctor ordered, are suing (sometimes successfully) on the grounds that the doctor wasn't forceful enough in explaining why the patient should do it. Doctors had been assuming that they were in the clear, so long as their records reflected the patient was told what to do, and didn't do it. It turns out that it can be a winning strategy in court for a patient to say "I didn't do what he said because he didn't make it clear enough to me why it was important -- I would have done it if I had realized it was a big deal".

Another problem area has to do with "informed consent". Agreeing to have a medical treatment performed isn't really valid if you didn't have a correct understanding of the risks and benefits involved. As it turns out, patients often have an extremely incorrect understanding of the risks and benefits involved -- not because their doctors misled them, but because they adopted their own very free interpretation of what the doctor said. A disturbing example of this was reported by the New England Journal of Medicine, in connection with chemotherapy for metastatic lung and colon cancer. Now, chemotherapy in such cases is palliative care. It cannot cure the disease; it is used only to delay death slightly and perhaps alleviate some symptoms. But it turns out that sizeable majorities of the people taking this treatment believe that there's a high probability it will cure them.

It seems as if there's an ethical problem here. I don't know how much chemotherapy costs in purely financial terms, but I know that the cost in terms of miserable side effects is very high indeed. Isn't it morally wrong to put patients through a treatment as difficult as that, if they think the probability of a cure is high and the doctor knows it's zero? Not that doctors are lying to patients about this, but if most patients are choosing to hear something the doctor didn't say, what can be done about the situation? Unfortunately, cancer patients as a class have been victimized by people pushing the idea that "positive thinking" will cure them -- which not only leads them to adopt delusional beliefs about what a palliative treatment can accomplish, but also leads them to blame themselves if the disease progresses in the expected way.

As I say, the problem seems insoluble. If patients are going to mentally convert any statement the doctor makes into something more in line with what the patient would prefer to hear, it's hard to see what doctors can do about it. It's a particularly difficult problem to solve in terms of Type 2 diabetes.

Take, for example, the term "pre-diabetes". To a doctor's way of thinking, "pre-diabetes" shouldn't be hard to interpret. It means, clearly, the condition that immediately precedes diabetes. A person who is about to develop diabetes is in pre-diabetic state -- just as a child who will soon be going to kindergarten is said to be a pre-schooler. Do the parents of pre-schoolers assume that the term means their child might possibly go to school some day, perhaps in 15 or 20 years? Well, that's how patients diagnosed with pre-diabetes interpret "pre": there is some slight risk that, in the distant future, diabetes may await them. But there's no immediate threat. Nothing to get excited about.

Arguably doctors are not to blame for this seemingly willful misinterpretation of their words. However, in the case of "pre-diabetes" (and probably in other cases too) doctors have surely had time by now to figure out that patients don't interpret what they're hearing correctly. Seemingly it is possible, and necessary, for doctors to offer a little bit of interpretive insight: "Here's what I expect to happen, based on what has happened to most of my patients diagnosed with pre-diabetes". Or perhaps "Here's what I expect the consequences will be if your HbA1c result remains above 7 much longer, based on what has happened to most of my patients in that situation". But, for all I know, doctors have been saying exactly that, and their patients have somehow been managing not to take it in.

Patients often complain that doctors don't listen, but we patients could probably benefit greatly by learning to listen better ourselves. And, when there's any room for doubt about how to interpret what the doctor said, we shouldn't seize on the interpretation which makes us most comfortable -- we should ask for clarification, or (if we miss that opportunity) do a little independent research. But asking for clarification is probably better, given the obstacles standing in the way of amateur health researchers seeking a straight answer. The internet provides us with a lot of nice things, but easily-located straight answers about health are not among them.


The Looming Holiday Season

Monday, November 19, 2012

Thanksgiving Thoughts

Uh-oh. It's time for all of us (at least all of us who live in the USA) to start gearing up for Thanksgiving. Only three more days left to lose 5 pounds to make up for what you'll gain at Thanksgiving dinner!

Many holidays tend to involve dietary excess, at least as an incidental element -- but Thanksgiving is different. On Thanksgiving, dietary excess is far from incidental, because there isn't much else going on, really. Thanksgiving is about dietary excess and very little else. Other holidays can involve pie, but on Thanksgiving pie is the point.

Thanksgiving is also the most active day of the American calendar in terms of domestic violence requiring police intervention. (I owe this information to my brother who works in law enforcement.) Christmas and New Year's Eve are comparatively tranquil, because the relatives who were going to get into a drunken brawl this year have already done it on Thanksgiving, and even if they're out of jail already, they're certainly not socializing with each other. But between New Year's Day and Thanksgiving (the fourth Thursday in November, in the USA), there is plenty of time for well-meaning relatives to try to bring about a family reconciliation. So, the combatants from last year are put into a crowded room together, plied with liquor, and left to express themselves about the outcome of the recent election. Result: police involvement. If you're a cop, it's a good night not to be working. But if you're a cop, it's not an easy night to arrange not to be working. A cop is about as likely to find himself free on Thanksgiving as a florist is on Mother's Day. (But my brother was able to get out of working this Thanksgiving through the simple expedient of having retired from the force.)

I was just reading one of those helpful articles about how diabetes patients can get through Thanksgiving safely without missing out on any of the fun. In other words, a stupid phony article by someone who would never dream of following any of this own advice (and, if he did follow it, would never be able to say that he hadn't missed out on any of the fun). It's all very well to say you can attend a Thanksgiving dinner and enjoy yourself so long as you don't indulge in high carb foods or alcohol, but it's sort of like saying you can enjoy attending an orgy so long as you're only there for the conversation.

Turkey dressing, mashed potatoes, and pumpkin pie are part of the Thanksgiving deal. In fact, they're the main part of the deal. You can skip them, or you can participate in Thanksgiving; you must choose. And as for attending a big family event and not having anything to drink -- well, let's say no more about that. Some authors write about the real world (I hope I am one of those), and some authors write about an imaginary one. It seems to me that, if you are going to write an article claiming that diabetes patients can participate fully in Thanksgiving without missing out on anything significant, you should identify yourself as a fantasy author... along with Jeffrey Brown, author of a book of life-lessons derived from the parenting experience of Darth Vader.

Thanksgiving is what it is. We must deal with it the best we can, but I don't think there's much point in pretending that we can sail through it without being affected by it. Like the fast-food industry, it looms large in our existence, and it is bound to have an impact. The most we can do is limit that impact.


All About Rates

Friday, November, 2012

Diabetes Epidemiology

The trouble with claiming, as so many people do, that diabetes is "a genetic disease" is that the genetic diseases tend not to have epidemics. You don't see a sudden, localized spike in hemophilia cases, for example. Evolution doesn't work fast enough to cause gene frequencies to change strikingly within a single generation. Prevalence of diabetes in the USA, on the other hand, has changed strikingly within a single generation.

The CDC (Centers for Disease Control) has (or have?) looked at diabetes prevalence in the USA, at 5-year intervals since 1995. The changes between 1995 and 2010 show a much more striking increase than could possibly be explained by genetic change.

During that 15-year period, diabetes prevalence in the USA increased from 4.5% to 8.2%. In other words, diabetes prevalence went up by 82.2%. That was the average increase, for the nation as a whole; comparing prevalence on a state-by-state basis, we find that the increase was much worse in some states (especially in the south). The highest prevalence (11.7%) was in Mississippi. But Oklahoma may soon catch up, as Oklahoma has been experiencing an extraordinary rate of growth in diabetes prevalence (up 226.7% since 1995!).

As it is not very likely that the gene-frequency for polymorphisms associated with diabetes has gone up 226.7% in Oklahoma during a 15-year period (while going up only 27.1% in Vermont), one has to assume that there is something about the way people are living that is causing diabetes prevalence to increase. As regional variations in diabetes rates keep remarkably in step with regional variations in the rates of obesity and consumption of sugary soft drinks, it may not be too hard to figure out what's going on here. But whatever else we do, let's not pretend that this is not going on.


Birthin' Babies

How's this for a scary headline: "Amish Cesarean Delivery Rate Supports Low-tech Approach". I was almost unwilling to read the article that went with it, fearing that I was going to learn more than I wanted to about a subculture in which obstetric surgery involves simple farm tools. I mean, a back-to-basics approach to life can have a certain sentimental appeal, and all that, but when I look about myself in my doctor's examining room I don't want to see a maul or a butter churn sitting around in there.

It turns out that what the article actually says is that, in Amish communities, where the emphasis is on natural childbirth except in emergencies, women have far fewer cesarean deliveries than women do in the rest of American society (3.8% versus 32.9% and rising), and apparently this approach isn't noticeably less safe for them.

Of course, Amish communities probably have a lower prevalence of malpractice lawyers, too. It is thought that fear of lawsuits is soon going to drive the cesarean rate above 50%. If there is anything even slightly unusual going on with a pregnancy, the woman's doctor pretty much has to go for the cesarean option, because otherwise it can be made to appear, in court the following year, that any other option was unsafe. Until US courts and juries can get over the idea that, if a child is born with two heads, it's the obstetrician's fault, I don't think the rest of America is going to be taking the Amish approach.


Going Too Far

Thursday, November 15, 2012

Going Crazy With Insulin

Somebody entered this question as a Google search request: "how can i have normal a1c with hyperinsulinemia". The question implies that there is a paradox here -- as if it should seemingly be impossible to have both a normal hemoglobin A1c result and hyperinsulinemia. My answer would be that this is getting it backwards: you don't have a normal A1c despite having hyperinsulinemia; you probably have a normal A1c because of having hyperinsulinemia.

Hyperinsulinemia means having abnormally high levels of insulin in your blood. It is an adaptive response to declining insulin sensitivity. In people with Type 2 diabetes, the body's cells (most critically, muscle cells) become less responsive to insulin than they used to be. It is as if the cells have become "deaf" to insulin's message -- so the body has to start "shouting" that message, by pumping out abnormally large quantities of insulin.

Hyperinsulinemia acts not only to correct the problem of declining insulin sensitivity, but to conceal it. So long as the insulin overdose your body is producing is sufficient to compensate, your blood sugar (and hence your hemoglobin A1c result) remain within the normal range. It's only when the body is pushed to the limit of its insulin-producing capacity, and it can no longer generate enough extra insulin to compensate for loss of sensitivity to the stuff, that your blood sugar starts to rise and you develop a problem that is detectable on standard lab tests. But that doesn't mean that everything was fine until that point was reached. This adaptive response (hyperinsulinemia as a corrective mechanism for declining insulin sensitivity) is a problem in and of itself (usually referred to as "metabolic syndrome" or "syndrome X"), because hyperinsulinemia has an inflammatory effect on blood vessel walls and promotes arterial disease. Strange as it sounds, diabetes can give you a heart attack before your doctor can tell you have diabetes. Even if it hasn't raised your blood sugar yet, metabolic syndrome can be a very dangerous thing.

Because excessive insulin levels can be harmful, writers on health topics ought to be more cautious in saying that a patient in a particular situation "needs" more insulin because he isn't producing "enough" of it. Often this doesn't mean the patient isn't producing a amount of insulin -- instead it means that the patient isn't able to produce a big enough overdose of insulin to compensate for loss of sensitivity to insulin. That's a very different thing. Medical therapies which aim to treat diabetes by causing the patient to generate extra insulin are solving one problem by creating another. Maybe the tradeoff is a good one, in some situations, but the nature of the tradeoff should not be concealed. Patients should not be misled into thinking that an overdose is a normal dose, especially when an overdose of the hormone in question is known to cause heart disease.


Nyuk Nyuk!

This handsome fellow... Scott DesJarlais, the Tennessee congressman who is strongly opposed to abortion except in cases where the mother is carrying his own unwanted baby -- a circumstance which arises more often than you might suppose. DesJarlais is a doctor, and has a history of philandering with both hospital workers and his own patients. He has never quite got the hang of birth control, despite what seem like abundant opportunities to practice, so he has found it repeatedly necessary to pressure the women in his life to "get this solved" by means of a procedure which he doesn't think should be available to pregnant women who are not pregnant by him. Various other weird and unpleasant details are coming to light about him; most of them were revealed before last week's election but he won anyway. Tennessee must be an interesting place.

Anyway, I've been trying to figure out for weeks why he looks familiar to me, but now I think I've got it. I'm surprised it took me so long.

My problem is that I didn't recognize him out of context. Without Moe and Larry at his side, I just couldn't place him.


Common & Uncommon Problems

Wednesday, November 14, 2012

When You're Limping Along

We tend to assume that the medical problems we hear about most often are the ones that cause the most trouble, but it is not always so. For example, there has been a little more attention given lately to the bacterial infection known as MRSA than there used to be, but it's still not exactly a household word, and I would venture that most of us, if asked, would guess that MRSA kills fewer Americans than AIDS does (not so, apparently). A health problem can be both common and severe without receiving a lot of publicity, and this can cause confusion -- even about other diseases.

For example, I used to wonder why the coronary arteries (that is, the arteries that supply blood to heart muscles) are so uniquely vulnerable to being clogged with cholesterol and blocked up by blood clots (resulting in CHD, or coronary heart disease). Why doesn't this happen to arteries that serve the other parts of the body, I wondered?

Well, actually, it does happen to the arteries that serve the other parts of the body, I later found out. It happens to the arteries serving the brain (thus causing ischemic strokes). Well, yeah, I'd heard about that. But what about the more distant reaches of the body -- the leg muscles, for example? Why doesn't it happen to the arteries that take blood all the way down there? Well, actually, it does happen to the arteries that serve the more distant reaches of the body. This problem is called PAD (peripheral artery disease); when the muscles are not getting sufficient blood flow, the insufficiency manifests in various ways -- typically as "claudification", a disabling muscle pain which develops when the muscle is used. The literal meaning of claudification is "limping", and people who suffer from it find that they can only walk a short distance before their leg muscles hurt too much to continue.

But why doesn't PAD happen more often? Heart attacks happen all the time, after all -- why isn't PAD and "claudification" and the rest of it as common as CHD and heart attacks and all the rest of it? Well, here's the interesting part: you may not hear as much about PAD as you do about CHD, but that doesn't mean it's less of a problem. It turns out that America spent $3 billion on medical interventions for CHD in 2011, but $4 billion on medical interventions for PAD! And I imagine it is almost needless to say that diabetes patients suffer disproportionately from PAD, as they suffer disproportionately from everything else that medical science has made up a Latin name for.

Well, if PAD is so common and we're spending so much money on it, perhaps it's worth asking what is the best way to treat PAD. The common treatment for it is surgical "revascularization", obviously not a low-cost solution. Could there be cheaper alternatives that would work as well? It turns out that "a program of supervised exercise for 30 minutes, twice a week, was as effective as endovascular revascularization in terms of functional outcomes and quality of life in patients with intermittent claudification", or so the American Heart Association was informed last week. This was the conclusion of a study which followed patients over a 7-year period and found the benefits to be lasting.

The catch (and you knew there was going to be one, didn't you?) is that, even though exercise is already recognized as a first-choice treatment, and is even recommended to physicians as a first-choice treatment in many clinical guidelines, doctors seldom prescribe a supervised exercise program to their PAD patients, at least in the USA. Why not? Because it isn't reimbursed by insurance companies.


What Number Do You Like?

Tuesday, November 13, 2012

Continuing Recovery

Today I ran the same route at lunchtime as I did yesterday, but notably faster, because I was feeling more fully recovered from the virus I caught last week. Also, this time I had a running buddy with me to keep up with, and yesterday I was running alone.

My sore shoulder is still pretty sore, though. I decided not to risk doing any resistance-training tonight. Just continuing the shoulder-rotations, to free that up.


Crazy-Talk About Gestational Diabetes!

The professional world of obstetrics is in a bit of a tizzy right now about GDM (Gestational Diabetes Mellitus), which means diabetes triggered by pregnancy. There seems to be a lot of it about. And a lot of pregnant women whose glucose is elevated, but not elevated enough for them to be diagnosed with GDM, experience abnormalities in their pregnancies, such as "fetal macrosomia" (meaning your baby's too big). Should the diagnostic criteria for GDM be expanded, to include these women as well? Some experts are saying "No!". Or perhaps more accurately, "Oh my God no! Please, please, no! No, no, no!!!!!".

The problem, you see, is that if the diagnostic criteria for GDM are expanded to include these women, then a lot more women will be diagnosed with GDM. Well, duh -- of course that's what would happen! Why is that an argument against expanding the diagnostic criteria? Because our heath care system is not equipped to deal with the presumed consequences. According to articles appearing in obstetrics journals, the current prevalence of GDM (it occurs in something like 5% of pregnancies) would more than triple under proposed changes in diagnostic criteria, and the primary health care system does not have anything like the resources needed to take that hit.

The reason I call this crazy-talk is that it demonstrates the degree to which diagnostic criteria for diabetes of any kind have come to reflect political and bureaucratic realities rather than medical science. How do we arrive at the best possible definition for a disease? By asking the accountants and lawyers and insurance executives what the fallout would be for the industry if we defined it in a particular way. For a doctor to diagnose diabetes, in the USA at least, is something like a pilot declaring an in-flight emergency: you know it's going to have a lot of bureaucratic consequences (and that you'll never hear the end of them), so you don't want to do it until you have to. In principle, all these people creating those bureaucratic consequences could lessen the burden, and take a more nuanced approach which acknowledge that there are levels of diabetes (just as their are levels of emergency). But no, that's not how it works. Any diagnosis of any kind of diabetes has major consequences for medical care (and expensive consequences), so we need to define the disease in such a way as to minimize the number of people who will be diagnosed with it.

This is specifically an American problem. In America, for a pregnant woman to be diagnosed with GDM, she must fail more than one OGTT (Oral Glucose Tolerance Test). First there is a 50-gram test; a failing result would be blood glucose of 140 mg/dl after one hour. Having failed that, she must then take a 100-gram OGTT; in this case the failing criteria are 180 mg/dl after one hour, 155 after two hours, 144 after three hours (she must fail at least two out of those three to be diagnosed).

In other countries, the diagnostic process is simpler and catches more cases of GDM. In 2010 the International Association of Diabetes and Pregnancy Study Groups proposed that the American diagnostic system be simplified to bring it in line with international standards. Their proposal: just one 75-gram OGTT, with a failing result defined as 180 mg/dl after 1 hour or 152 after two hours. Diagnosis would be triggered by a failure of just one of those two measurements, or by a fasting glucose reading above 91 mg/dl.

The concern, of course, is that a lot of American women couldn't pass this test, hence the expected flood of new GDM cases -- and the resulting panicky warnings that we must not bring American diagnostic practice in line with international standards.

It seems to me that there are more interesting questions to ask than "how will the health care system be impacted?". One is: if American women will really have a GDM rate of nearly 18% if America adopts international diagnostic standards, what is going on with women in other countries? Do they have an 18% GDM rate? If they don't, but American women do, then maybe there's a medical problem (not a political problem, not a financial problem, not an industry problem -- a medical problem) which urgently needs looking into.

Another question worth asking: is there some way we could adjust the way our health care system reacts to a GDM diagnosis, so that the treatment women get is appropriate to the severity of the problem in their particular case? Maybe adopting international diagnostic criteria wouldn't seem so prohibitively costly if we didn't over-react to the consequences.

Whenever diagnostic criteria are discussed in this way (with industry considerations always emphasized over medical considerations), I am reminded of a joke about a psychologist who was studying the impact of people's career choices on their mathematical reasoning. He does this simply by interviewing people in different professions, and asking them "How much is two plus two?".

He asks an engineer, who says "four point zero".

He asks a mathematician, who says "It depends on what base you're using, but in base-ten numbers the answer is four."

He asks a lawyer, who says "How much do you want it to be?".

How many pregnant women have GDM? 5%? 18%? Well, how women do you want to have GDM?

Medicine: sort of an art, sort of a science, mainly a business!


Much Less Sick!

Monday, November 12, 2012

State Of Refurbishment

I spent an exceedingly dull weekend getting over the cold I caught late last week; I didn't get out of the house much, and I did only a very minimal amount of exercise. But I wasn't exactly at death's door, and I feel a lot better now.

On other physical fronts: one step forward, one step back. My lower back problem is pretty much recovered, but now the capsulitis problem in my right shoulder is flaring up on me. Well, I got over the back problem, presumably I can get over the shoulder problem. I guess, once you're past a certain age, there's always some part of the body that needs some repair work. Just like a house of a certain age. (Maybe even the same age.) Well, it's a little challenging, but it's better than being dead.

My yoga teacher was talking tonight about her oldest yoga student -- who just turned 97. She was around for the very first Veteran's Day -- before it was even called Veteran's Day. She's still doing yoga. I guess I'd better keep at it...


Fasting & The Lipids Test

Here's something I've always wondered, and always intend to ask my doctor, and always forget to ask my doctor: is fasting necessary for a lipids test (that is, a test for cholesterol and triglycerides in the blood)?

I always have fasted for a lipids test in the past -- but that was only because, whenever my doctor has ordered a lipids test, he has also ordered a glucose test as well, and a glucose test definitely does require fasting, so I've always had to fast anyway. I have never known whether fasting would be required if I were taking the lipids test alone.

Apparently fasting is required for a lipids test, or at least has been required so far -- but that requirement could be dropped soon. A new study finds no evidence that patients get significantly different results depending on whether they are measured in a fasting state or a non-fasting state.

I still am left wondering exactly how volatile lipids test results are -- if you change your diet, do you have to be on the diet for two days, two weeks, or two months before your lipids panel results change much? But the whole issue is starting to look silly to me, because my diet changed a lot during the months leading up to my most recent lipids test, and the results were very similar to what I've seen before. My lipids results have been normal, and remarkably stable, throughout several years of dietary changes. The constant in all this has been my exercise program, and I tend to think that matters more than what I eat for dinner.

The recent change in my diet, in case I haven't explained this before, was a movement away from vegetarian or mostly-vegetarian meals, and toward meals that included more meat and dairy. The reason for the change was simply that I was finding that meatless eating was making it too hard to control carbohydrate consumption. In recent months my diet has included a lot more saturated fat than it used to; this change seems to have had no significant impact on cholesterol or triglycerides in my lipids results.

I guess there's one dietary factor which has been stable for me, regardless of what else was changing in my diet: I've been avoiding trans fats for years. Actually, most Americans have been doing that -- trans fat consumption is way down, and this is thought to account (at least in part) for a recent drop in cholesterol in the general population. So maybe there's a factor worth looking into, if you haven't been avoiding trans fats. But I still think exercise is the biggest issue of all.



Friday, November 9, 2012

That Thing That's Going Around

A big international training event has been going on at work this week, and we have scores of field engineers from all over Europe and Asia spending several days here. In other words, we are having a global respiratory-virus convention, and everyone is sharing in the fun. I realized last night that I was coming down with it myself, and I was realizing it even more vividly today.

I wasn't feeling so bad that I saw a need to stay home from work; apart from a mild sore throat, fatigue, and that vaguely unpleasant feeling that a mild viral infection gives you, I wasn't really feeling disabled by it. I was a little hesitant about running outdoors at lunchtime, especially as it was cold outside. It's a dilemma I often face when I get a virus that isn't disabling enough to make a workout clearly impossible: if you are pretty sure that you can do a workout, but you're not sure if you should do it, how do you decide?

What I instinctively want to do when I'm coming down with something is to go home, lay in a stock of comfort foods, curl up with a good book under six or seven blankets, and wait patiently for nature to take its course. Years so I tended to yield to that instinct, and I have to say that it usually seemed to have the effect of making me sicker. In more recent years I tend to fight that instinct; I try to keep up with normal activities, including exercise, unless I feel absolutely incapable of doing so. There's no way for me to be sure that this is the right approach, but I seem to get better results that way. So, today I went for the run (and found it difficult, but nowhere close to impossible). And I'm doing at least a brief blog tonight, instead of crawling into bed immediately.

But I'm not going to push myself too hard. I'm going to try to get some extra sleep tonight, and hope that this thing won't get any worse. I hate to blow my weekend on anything as boring as being sick.

And I'd better be cautious with the comfort foods. A viral infection tends to suppress insulin sensitivity, so it becomes harder to keep glucose levels down.


Taking My Time

Thursday, November 8, 2012

Time Warp!

The cartoonist Randall Munroe...

...reports this "Odd Temporal Milestone": The first Star Trek episode aired closer in time to the ratification of the 19th Amendment (which gave women in the US the right to vote) than to today.

I'm damned if I can explain why that seems so uncanny to me, but I suppose it has something to do with the fact that I remember watching the 1966 television premiere of Star Trek when I was 9 years old (so obviously it couldn't have been all that long ago), whereas the 19th Amendment was ratified in 1920, which was seven years before my parents were born (so obviously it is ancient history, and I imagine most of what we know about that period comes from analyzing bone fragments).

But Munroe's math checks out, alas. It does put my life-experience into perspective, I guess. Too much perspective, really. I'd like to preserve a sharper distinction between ancient things (which happened before my birth) and modern things (which happened after my birth). Sometimes that can't be done.


Accommodating An Injury

My back is feeling better, or at least better than it did on Monday, and I even decided that I was okay to go back to resistance training. So, I went to the gym after work and did weights. Didn't hurt my back.

Still, I don't want to push it. I decided not to participate in a volunteer activity tomorrow. A few times a year, employees at my company volunteer half a day to go work on an environmental cleanup project. The actual work involved varies, but it's almost always hard on the back whatever it is. Tomorrow's activity will involve cleaning up damage to a city park, caused by an overflowing creek during a recent storm. I was actually tempted to sign up for it, especially as they're short of volunteers this time and pleading for more help, but sometimes you have to be realistic. Doing stoop labor just when my sore back is starting to feel better would not be the action of a rational being.

In general, my mantra in regard to a physically challenging activity (these days, at least) is "don't be a baby about it". Go ahead and do it. Sometimes that instinct to say yes has to be moderated. It can be a useful instinct, of course; it helps me avoid becoming sedentary by helping me resist the temptation to do nothing at all. But there have to be limits imposed on it. You can't just sign on to everything that is proposed to you.

When I'm pretty sure that a proposed activity is going to leave me seriously hurting for several days, I have to say no.

Still, it is a difficult thing to judge. If you don't keep telling yourself not to be a baby, aren't you pretty likely to keep finding excuses never to get off the couch again for the rest of your natural life?



Wednesday, November 7, 2012

Numbers Matter

Now that the election is over, and we don't have to keep listening to "experts" presenting reckless fantasies (with no known evidentiary support) of how they think it will come out, XKCD offers some insight:

Yes, numbers do matter, but a lot of people hate them despite that. In fact, some people hate them because of that.

The big problem with numbers, at least as compared with reckless fantasies, is that they often don't tell us what we want to hear. That's why most of us are prepared to dismiss any number which seems to point toward facts which we wish were otherwise.

For political pundits, it's okay to do that. Most of them have appallingly poor track records in terms of making accurate election forecasts -- but nobody holds that against them. Their fans don't watch them to get an accurate analysis of what is going on, but rather to get a reliable influx of wishful thinking which happens to match their own. It doesn't matter that the pundit was wrong about who was going to win -- it was quietly understood that his prediction of who would win was really a statement about who should win, and in that regard his fans think he called it right. The failure of his prediction of a Romney landslide will hardly alienate those who feel that there ought to have been a Romney landslide.

Political punditry hardly matters in this world (it's only entertainment, after all). But I'm guessing that, behind closed doors, the political campaigns have analysts who are tracking the data more seriously, and trying to figure out what is actually going on, not what the campaigns wish was going on. In most areas of life that aren't just about entertainment, it matters whether the things we think are true or untrue, and numbers do tend to be the test of what's true and what isn't. It can be dangerous to disregard numbers. We always want to do it, though, don't we?

Diabetes management is all about numbers, whether we like it or not. Diabetes itself is all about numbers. It's defined numerically. A certain quantity of glucose in the bloodstream is required, but it's harmful to have too much (>125 mg/dl on a fasting test equals diabetes, and so does >6.4% on a hemoglobin A1c test). And the amount of glucose in the bloodstream is determined by the ratio between the quantities of two hormones (and modified further by the relative cellular sensitivity to those hormones). It's all numbers, really. And we manage the situation by measuring those numbers, and doing what we can to influence those numbers, and get the ratios right. That's all we've got to work with, really. Numbers continue to be the best system for determining which of two things is larger.

I am quite resigned to the idea that, in order to control my diabetes, I have to pay attention to numbers, and respect numbers, and believe that what they're telling me is significant regardless of whether it is welcome news.

My most recent hemoglobin A1c test was up from last year's (5.8% instead of 5.5%); I expected an increase, based on the problems I had in August and part of September, but I was still unhappy about it and I want to get it back down where it belongs. I'm not going to pretend to myself that the A1c result was erroneous or insignificant. It's when you don't like a number that it's most significant and deserves the most attention from you.

My lunch today was probably too high-carb, and my most-prandial result of 136 after lunch was higher than usual for me; I had to take that seriously, as something to correct. So I had a low-carb dinner, the post-prandial result after that was only 94. Mission accomplished, then. But you only accomplish the mission if you take it seriously. And you only take the mission seriously if you take numbers seriously. We may not love numbers, but they matter.


Elections And Other Problems

Tuesday, November 6, 2012

Election Day

As if fitting a workout into my day were not challenging enough, today I had to fit voting in as well. Voting in the morning was out -- I had an early meeting at work. After some dithering, I decided to skip my lunchtime run and go vote at noon. In the evening I was going to go to the gym, and combine aerobics and resistance training -- however, my sore back (although improved since yesterday) made me think I'm not ready to weights yet. So I settled on going for a night-time run, in the spooky darkness.

It turned out to be just a little spookier than I was ready for. At one point, when I was running along a very dark road with thick trees and bushes to the side of me, something large suddenly and noisily came bursting out of the underbrush at me. It turned out to be a deer, fortunately, rather than a mountain lion. It bolted in front of me ran and across the road, and as there were no paramedics to use a defibrillator on me, I recovered from the heart attack through sheer willpower, and continued with the run.

Then I got home, took a shower, checked the election results, and found a hopelessly garbled phone message waiting for me (and I mean garbled so severely that I couldn't even recognize the voice, much less make out the words). But based on whom it was from, I am pretty sure that I was supposed to meet my friends downtown for beer night, and forgot the engagement. Elections days are hard on me, and election nights are harder...


"how does peeing a lot get rid of calories"

It doesn't. It gets rid of water. If you have uncontrolled diabetes and sugar is leaking into your urine, to that extent you are getting rid of some calories, but it's not something you want to have happening.

"blood sugar levels in the 60s wont kill you"

No, they won't; you're right. (I assume we're talking about measurements in mg/dl.) But slipping down into the 50s is more serious; you may start losing a few brain cells when that happens, so try not to spend too much time below 60.

"a1c test is 4.5 but there is glucose in urine"

Then you either have an inaccurate A1c test result or a problem other than diabetes that is causing glucose to show up in your urine. Get thy kidneys checked out; something weird is happening here!

"does a person who is type diabetic have to be medicated"

Type what? Type 1? Type 2? If you have Type 1, you have to be medicated, because your pancreas isn't making insulin. If you have Type 2, you might or might not need to be medicated, depending on what level of control you are able to achieve without meds.

"at what level of your a1c do you need to medicate"

My doctor told me last week that the trigger point for him, at least in my case, would be 7%. My situation isn't the typical one. Most diabetes patients are already on medications, and reaching that trigger point at 7% would probably cause their doctors to prescribe more meds, or different ones.

"how to bring down your hemoglobin a1c for non diabetic"

Why do you need to bring it down if you're non-diabetic? Isn't it down already? If it's high, but you haven't been diagnosed with diabetes, it seems as if the medical bureaucracy just hasn't caught up yet with what is happening to you.

The best ways to bring down your A1c are (1) to boost your insulin sensitivity, primarily through exercise, and (2) to reduce the amount of glucose that is entering your bloodstream, by limiting your carbohydrate intake.

"if your a1c is 6.2 what is your average"

Presumably you mean "what is your average glucose level". Well, going by the standard conversion formula...

(28.7 x HbA1c) - 46.7 = eAG in mg/dl

...a hemoglobin A1c result of 6.2% equates to an eAG (estimated average glucose) of 131 mg/dl (or 7.3 mmol/l). The conversion formula rests on two assumptions: that your rate of red blood cell replacement is not unusually high or low, and that your rate of glycation for a given glucose level is not unusually high or low. Because both of those characteristics vary from person to person, the assumptions underlying the formula could be wrong, which is why we call it estimated average glucose and not measured average glucose.

"is fasting glucose scores 128mg/dl a bad score"

Yes. 100 is considered "elevated", and 126 is considered "diabetic".

"is a1c of 6.2 bad"

That sort of depends on whether or not you have already been diagnosed as diabetic. If you have, 6.2 indicates better-than-average success in controlling the disease; it's above normal, but not by a very wide margin. (Labs vary on this, but mine calls anything below 5.7 normal.) It's best to get your A1c result down to a truly normal level if you can, but if you're not far above normal, you'll probably do pretty well.

If you haven't already been diagnosed with diabetes, 6.2 is not so good. It's below the diagnosis point for diabetes (which is 6.5), but it's above normal, and getting above normal is a trend which tends to intensify over time. A result of 6.2 says that your endocrine system is losing its grip on glycemic control, even if it hasn't failed badly enough yet for the situation to be called diabetes. This twilight-zone situation is called "pre-diabetes", which patients think is a doctor's way of saying "There's a slight risk that you might become diabetic a few decades down the road", when in fact it is a doctor's way of saying "I can't call you diabetic yet, but I know I'll have to, and probably pretty soon".

"will normal urine attract bugs"

Possibly, if they're thirsty and have low standards. I wouldn't put it past them. Insects do a lot of things that you wouldn't do (at least, I'm going to assume that you have none of the mate-devouring tendencies that are so regrettably commonplace among insects and spiders). But I suppose you ask about this because you've heard that insects are especially drawn to urine from persons with diabetes, and you wish to be reassured that any popularity your own urine has gained within the arthropod community is explainable in some other way. Well, let me put it this way: over the past 3000 years, mankind has made a lot of progress on proper diagnostic tools, and we no longer try to detect diabetes by watching ants. If you suspect you might have diabetes, either because your urine draws a swarm of creepy-crawlies or for some other reason, have your blood sugar checked by one of the more high-tech methods that are available today.

"why does muccle milk make my pee like sugar"

I can't help wondering how you established that your pee is like sugar, and in what sense it is like sugar. (Is it white and granular?) In any case, if you have uncontrolled diabetes, any carbs you take in are likely to result in a blood-sugar high tide, which then leaks into your urine. The product sold as "Muscle Milk" comes in various flavors, with varying amounts of carbohydrate. None of them are sugar-bombs exactly, but some of them contain 18 grams of carbohydrate per serving, and if your diabetes is poorly controlled, that might be enough to spike you.

Of Back-Attacks & Heart-Attacks

Monday, November 5, 2012

My Aching Back

I usually do a yoga class on Monday night, which I see primarily as an opportunity to refurbish whatever parts of my body I traumatized on the weekend. Last week, because of a schedule conflict, I missed my yoga class -- which meant that I did nothing to repair whatever I had done to myself during an 8.3 mile trail-run on the preceding Sunday. The spine-gods have punishing me ever since, with painful spasms in my lower back. I'm okay sitting or lying down, and I'm okay standing up -- but making a transition between those states is a painful and difficult business. This is a problem that flares up for me occasionally; I have a slightly herniated disk, and every once in a while it decides to remind me that it's there, even though it's asymptomatic most of the time. Today, putting on my pants was a little challenging, and if I dropped something on the floor, I told myself that maybe it was fine for it to stay right where I dropped it for a day or two.

But tonight it was time to go back to yoga class, and I knew it wasn't going to be easy. Some of the poses I couldn't do properly -- particularly the Uttanasana pose, which in theory looks something like this:

Not that I can do it as well as that guy even on my best days, but I can do it. Tonight, however, I looked more like this:

Well, at least I was doing something. I am a great disbeliever in the popular assumption that resting up is the best remedy for a hurting body-part. I think it's generally a better approach to use that body part, to the extent you can do it without hurting yourself further. Anyway, the yoga-class tonight wasn't a miracle cure, but I think I did myself some good with it, and that my back will be at least a little better tomorrow than it was today. (Not that I was totally crippled today. I did a really tough run at lunchtime, and my back could handle that. It's getting into my car that I have a problem with.)


"Normal" CVD Risk

One of the biggest reasons diabetes is a problem is that it increases your risk of cardiovascular disease, or CVD as the pros call it. CVD basically means clogged arteries, and the life-threatening "events" (such as heart attacks and ischemic strokes) that can occur when arteries aren't flowing freely enough to get blood where it is needed.

Anything that increases your risk of CVD is a threat to your longevity, so doctors pay a lot of attention to the various risk factors for CVD, such as smoking and high cholesterol. And diabetes, naturally (because diabetes increases the risk of everything.)

But these risk factors (including diabetes) act as multipliers of the normal CVD risk. No matter how healthy and fit you are, you have a nonzero risk of CVD. You could end up having a heart attack which leaves your doctor and everyone who knows you scratching their heads. How could he have a coronary, when he was doing everything right? But it turns out that doing everything right is no guarantee against CVD. Good health habits can only work your risk down to the "normal" level. But what exactly is the normal level?

It turns out that the normal level is pretty damned high. According to a rather disheartening new study, even people with zero risk factors for CVD face about a 30% risk of developing it sometime after the age of 45. To be sure, the risk for the average person is much higher (60% for men, 55% for women), but 30% does seem like rather a lot of risk for someone who wasn't smoking and exercised regularly and kept his cholesterol level in the normal range.

However, we might as well face reality here: CVD is an extremely common cause of death in human beings. Basically, it is what kills us if cancer doesn't. I know this because I used to work at a title insurance company, and this led to my reading a whole lot of death certificates. CVD (that is, heart attacks and strokes) and cancer were the two possibilities. Not very many people managed to die of anything else.

Maybe the more important question is not how big the risk is of developing CVD at some point in our lives (especially if cancer is the delightful alternative); maybe the more important question is when we are likely to develop CVD. It turns out that, when people with zero risk factors develop CVD, it tends to happen 8 to 14 years later than it does in people with 2 risk factors.

So it's all about reducing risk (not eliminating it), and delaying problems (not preventing them from ever occurring). But if you think about it for a moment, everything to do with medicine and health is about that. I don't know anybody whose health insurance plan includes an immortality option. We do the best we can, and try to last as long as we can.


Fasting, And Lasting

Friday, November 1, 2012

Fasting Tests

Ack! Fasting test above 100! My first reaction in these situations is always to think that it's not fair, there's no reason why my fasting test this morning should be significantly higher than yesterday's. But then I remembered that I had a later-than-usual supper last night, after I got back from the gym, and it was a higher-carb meal supper than usual for me.

Lately, when I get a higher-than-usual fasting test in the morning, I've been doing my post-prandial test after breakfast rather than lunch or dinner, to see if the elevation is continuing through the morning. I usually find that it isn't -- the test after breakfast is usually good under these circumstances. Today it was only 110 after breakfast. Breakfast is my most carbohydrate-rich meal of the day, but also the meal that gives me the least trouble with glycemic control.

Speaking of fasting tests: I had mentioned earlier that I like to compare my glucose meter against the lab, when I go in for blood work. Last Wednesday I got up early, tested my fasting glucose at 84, went to the lab, had blood drawn, and then tested myself again, getting a result of 92 this time. So what glucose level did the lab measure, in between my readings of 84 and 92? It turned out to be 86. I conclude from this (and from previous comparisons, which were even closer) that my meter is pretty accurate. (It's a OneTouch UltraSmart, in case you're ShoppingForMeters.)


Dementia Prevention

While we're all busy worrying about dementia (aren't we?), researchers are collecting evidence to suggest that there's something that can help us reduce the risk of that problem. It turns out that exercise (you knew I was going to drag that into it, didn't you?) seems to be able to reduce the risk of dementia significantly, even in the case of people who are thought to be at heightened risk of dementia because they have "white matter changes", or WMC.

The European "LADIS" study found that regular exercise cut in half the rate of vascular dementia in at-risk patients. The mechanism by which exercise accomplishes that is unidentified so far; possible explanations for the exercise effect include "improved cerebral blood flow, reduced vascular risk factors, decreased secretion of stress hormones, and enhanced endothelial function". At any rate, it seems that physical exercise is good for your brain.

But what about mental exercise? What about all those crossword puzzles people have been doing lately to ward off dementia? Well, maybe those things help, but another study which looked at the effects of physical exercise on the brains of elderly people suggests that physical exercise helps more. The study found that high levels of physical activity were associated with "less brain atrophy, higher volumes of gray matter, and less damage to white matter". But high levels of socially or mentally stimulating leisure activities were not associated with these benefits. You can still do the crossword puzzles... but then head down to the park.


Another Reason Sitting Is Bad

Thursday, November 1, 2012

Take Breaks!

I have been hearing a lot of reports lately to the effect that uninterrupted periods of sitting (even in people who exercise regularly, when they're not chained to their desks) have harmful health effects. Well, here's a rather startling result from a study which looked into this phenomenon: average blood glucose is elevated significantly on days when you have long periods of uninterrupted sitting, as compared to days on which you get up for a brief walk around every 20 minutes:

Insulin levels showed exactly the same effect: they were elevated in the same way on days that included long uninterrupted sitting.

I was going to write at greater length about this, but I have to get up and walk around.


Tell-Tale Signs That You're Losing It

I should never read anything about any kind of mental disease, because I always end up thinking that I've got a case of it myself. Most mental diseases are defined in terms of faults that everyone suffers from, at least to a degree, from time to time. For example, it's very easy to persuade yourself that you are starting to develop Alzheimer's disease; we all have memory lapses (don't we?), and because these tend to grow more frequent as we get along in years, it's easy to spot that trend and make too much of it. Of course, Alzheimer's is the one that everybody fears they have. The trouble is, I don't stop there. If it's been written about, I have probably given serious consideration to the possibility that I'm developing it.

For example, where is the dividing line between having a lively imagination and being schizophrenic -- and how close am I to that line? Admittedly, the only mental experiences I've had that approached the condition of schizophrenia occurred when I was very short of sleep and was dozing off in the daytime. Under those circumstances, I've been known to have mild hallucinatory sensations, including "hearing voices". I guess that the difference between me and a schizophrenia patient is that these hallucinatory sensations always seemed to be exactly that. I never thought they were in any sense real. I never thought demons were ordering me to kill the giant penguin next to me, or anything like that (which is why you'll find no nun-assaults on my record). What bothered me about such experiences wasn't that I thought these perceptions were genuine; the problem was that I didn't understand why these clearly artificial thoughts were entering my head without my wanting them to be there. Yes, I realize that those "hallucinations" were what, in more appropriate sleeping conditions, would be called dreams. But if I'm sleepy enough I can start to have dreams while still being slightly aware of my surroundings, and that co-existence of dreaming with conscious perception was the creepy part, the do-I-have-schizophrenia part.

Well, now I've got a new reason to worry about schizophrenia. Some researchers in the UK have found that a simple test which tracks eye movements can identify schizophrenia patients with remarkable reliability. Apparently schizophrenia patients have difficulty (for reasons which are unclear) with tracking a moving object, or staring fixedly at a stationary object. Their eyes move in a recognizably abnormal pattern when they try to do these things. If I have schizophrenia, an expert can discover that about me by monitoring my eye movements.

I hope no experts spring this test on me, perhaps exclaiming "Look at that truck going by!" and then watching my eyeballs to see what patterns emerge. If it ever happens, though, I imagine the expert will say, "Don't worry, you don't have schizophrenia. Just Alzheimer's."


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