Hidden Poisons

Wednesday, October 31, 2012

Happy Halloween!

Ah, Halloween: the traditional day for explaining that the stories you have heard about people putting poison or injurious objects into Halloween candy are urban legends.

Apparently there isn't a case on record of anyone actually poisoning random strangers in this way. However, there have been a few murderers who have exploited the legends, so that they could kill a specific person and make it appear to be "yet another" case of random food-tampering. In Houston in 1974, a father-of-the-year candidate named Ronald Clark O'Bryan poisoned his heavily-insured son Timothy by putting cyanide in the boy's Halloween candy (and was later executed for it). In another case (in Detroit in 1970) a boy got into his uncle's heroin stash and poisoned himself with it; the family tried to protect the uncle by sprinkling heroin on the boy's Halloween candy and saying the heroin must have come from a random stranger. But the story as we usually hear about it -- wicked people handing out poisoned candy to the neighborhood children and waiting for the police detectives to show up the next day -- doesn't happen.

Of course, what we really ought to be worrying about is the harm that perfectly unadulterated Halloween candy can do. You can get the same result without the cyanide, if you're a little patient.


Trans Fats & Blood Sugar

A new study (or rather a review of existing studies) concludes that trans fats in the diet do not have an impact on blood sugar levels or insulin levels, as compared with a diet in which trans fats are replaced by other fats.

I was slightly surprised by this announcement -- not because I had thought trans fats affected blood sugar, but because I didn't think anyone else thought trans fats affected blood sugar, so I didn't know why anyone regarded it as a question that needed to be investigated.

Trans fats are created by saturating natural vegetable oils with hydrogen under high pressure; this twists the fat molecules out of their natural shape (that is what the word "trans" refers to), and one of the consequences of the alteration is that the oil will then remain solid at room temperature -- which is a desirable characteristic in many processed foods. Bending fat molecules out of shape does, however, raise concerns about health effects.

It doesn't seem likely that the health effects would relate to blood sugar. Digesting fat releases fatty acids, not glucose, into the bloodstream. Admittedly, the liver has the capacity to turn fatty acids into glucose later on (a process known as gluconeogenesis), but expecting the fat you eat (whether it's trans fat or natural fat) to spike your blood sugar is a bit unrealistic. Still, fat mebabolism is believed to play some kind of role in driving the development of Type 2 diabetes, so it isn't completely crazy to think that trans fats might trigger diabetes, and raise blood sugar in that way. The new study, however, does not support that idea. Apparently trans fats in the diet just don't affect blood sugar, so anyone who was worrying about that can stop now.

Which is not to say that trans fats are harmless. They have been known for decades to be strongly associated with heart disease, and the new study confirms that trans fats in the diet raise LDL ("bad") cholesterol and reduce HDL ("good") cholesterol.

Trans fats sort of flew under the radar for a long time; the public didn't hear about the health problems associated with them, and nutritional labels did not call out the trans fat content of processed foods. Then health activists started raising the alarm about them, and the government started to require clear labeling of trans fat content. The result has been a very large drop in trans fat consumption in the USA in recent years, partly because consumers started avoiding foods that contained trans fats, and partly because the food industry (now forced to come clean on what they were putting into foods) started backing off on including trans fats in their recipes. This trend may be part of the reason why cholesterol levels in the US population have been dropping of late (another part of the reason may be that half the population is being prescribed statin drugs).

I've been avoiding trans fats myself, but only to protect my arteries, not because I thought trans fats had an impact on glycemic control. Apart from that, I have pretty much stopped worrying about which kind of fats I'm consuming; my recent lipid test results seem to confirm that it doesn't really matter which sorts of fats are in my diet, so long as I'm still working out enough.

Question Time

Tuesday, October 30, 2012

Time Once Again For...

Users of search engines have questions about Type 2 diabetes, and I am willing to pretend to be able to answer them!

"Does a1c actually measure three months"

The only thing the hemoglobin A1c test actually measures is what percentage of the hemoglobin in your red blood cells is glycated (sugar-encrusted); all else is assumption. But the assumption (usually a reasonable assumption, but not always) is that, because red blood cells have a typical lifespan of about 90 days before they are recycled, the test result is affected by sugar levels in the blood over the past three months.

That description simplifies a complex situation, of course. Blood cells aren't all recycled at the same time, so on the day you take the test some of your red blood cells are 90 days old but most are younger than that, so if your blood sugar has changed much over the past 90 days, the test result is going to reflect more recent conditions better than it reflects conditions three months ago. A lot of the blood cells that were in your bloodstream 3 months ago are gone now, after all. On the other hand, even if your blood sugar went up recently, the younger cells have not had as much opportunity to become glycated, simply because they haven't been around very long.

Formulas that are used to convert the A1c test result into "estimated average glucose" rely on two assumptions which can be very wrong: that red blood cells are replaced at the same rate in everyone, and that the glycation rate (for a given level of blood sugar) is the same in everyone. Actually, both of those things vary (and the first of them can vary quite dramatically in people who are on hemodialysis). So we need to be a little in cautious about saying that the A1c test "measures" average blood glucose, when at most it provides a piece of evidence which we can use to estimate average glucose.

Anyway, your blood sugar level at any time in the last three months is bound to have some impact on your A1c result, but your blood sugar level during the most recent month has an especially strong impact.

"Does an a1ctest include blood sugars a week prior to the test"

Well, yes -- as described above, blood sugars during the three-month period preceding the test do have some kind of impact, and more recent blood sugar levels have a disproportionately large impact.

"How high can glycated hemoglobin get"

The more sugary your blood has been lately, the more of your hemoglobin is glycated. There isn't a theoretical limit to how high your glycated hemoglobin can get. I've heard of results above 14%, but I suppose others have gone higher. The higher you go, the more harmful it becomes, and the more likely it becomes that your excessive blood sugar will cause a problem that's severe enough to kill you. But I don't think there's a known upper limit, beyond which no man can go and survive to tell the tale.

"Does a normal a1c score indicate the absence of diabetes"

The short answer is "no", because if you control your diabetes well enough, you can stabilize your A1c result in the normal range, but you will still have "diabetes", in the sense of the word which most people use. They are thinking of diabetes as being something like Original Sin: it's still hanging over your head no matter what you do, and you probably deserve it. (That's not how I see, I'm merely acknowledging a social reality here.)

If you define diabetes simply as the state of having blood sugar levels that are abnormally elevated, then a normal A1c result would indicate that you're not diabetic currently. However, it wouldn't indicate that there's nothing going wrong with your endocrine system that might be trying to make you diabetic.

"Can I repair my cells so they absorb insulin better"

I'm guessing that the questioner meant "so they respond to insulin better, and absorb sugar more readily". Well, exercise tends to have that effect, at least if you do it often enough. Weight loss sometimes has the same effect.

"Do people urinate on themselves when their sugar drops"

Not that I've ever heard. If your blood sugar drops to a life-threatening low, I suppose you might wet your pants at that point. But I hardly think wet pants would be your greatest problem at that point.

"Do ants produce insulin"

Apparently not. Most of our animal pals can do it, and you have to get awfully far from humans on the evolutionary chart before you find creatures that don't produce insulin. But insects (including ants) are apparently different enough from us that they don't have an endocrine system, or at least not anything similar enough to our system that insulin would be produced by it.

Annual Checkup Time

Monday, October 29, 2012

Tom Goes To The Doctor

Today I went to my doctor's office for my annual physical. As usual I was nervous about it (will the lab results show something bad?), and this time I had more reason to worry than usual, because I was pretty sure my hemoglobin A1c result would be elevated compared to last year (when the result was 5.5%). I had a lot of trouble controlling my blood sugar during my two weeks in Ireland during August, and even after I got home, I was still getting higher numbers than I'd been accustomed to, for rather a long time. That trend, which extended into September, would be bound to have an impact, even though my glucose results this month have been better. So, I was sure my A1c result would be higher than usual this time. But how much higher? High enough to make my doctor think that I was losing control, and needed to be put on medications (or at least needed to see him more often than once a year)?

It turned out that the result was 5.8%. The lab I've been using defines the upper end of the normal range as 5.6%. It could have been worse, obviously, but I was sorry to see my first above-normal A1c result, after managing to hit the "normal" target consistently for almost twelve years.

My doctor put the thing in perspective:

My cholesterol results were normal, and quite similar to last year's results -- which is pretty funny, because my diet has changed significantly since then, and in a direction which many experts would have told me was sure to cause trouble. I have entirely given up on eating a mostly-vegetarian diet -- not because I think there is anything wrong with a vegetarian diet for most people, but because I have found it hard to avoid getting too many carbs for my system to handle on a vegetarian diet. Lately, with meat and dairy foods making up a much larger share of my diet, I have been getting much more saturated fat than before. People are still being told by seeming experts that saturated fat is the demon that will boost their serum cholesterol and clog their arteries, but the science behind that view was always shaky and seems to have collapsed of late. Still, despite evidence to the contrary, I was worried that my lab results would be worse this time, and provide support for the official opinion that high serum cholesterol comes from eating cheese omelets. Apparently it doesn't. Judging from my own medical history, my lipid test results are greatly affected by how much exercise I do, but not by how much fat (or what kind of fat) I have been eating.

The only bad news is that I'm due for a screening colonoscopy, and need to make an appointment with Dr. Hornberger for that, even though I find his family name a disturbingly rough-edged one for a doctor working in that particular speciality. Should I seek a different, less scary-sounding gastroenterologist? There's another doctor in the same office, named Faust... but I'm not sure that sounds a lot more promising (especially considering that "faust" is German for "fist"). None of the other local possibilities sounded all that gentle either. Oh well, what's in a name?


Just Can't Blog Today

Friday, October 26, 2012

I went to a funeral today that was quite far out of town, and it pretty well threw off my schedule. I had to make today a rest day; I'll work out tomorrow instead. And blogging I'll need to put off till next week.


How Much Is Enough?

Thursday, October 25, 2012

Exercise: The Optimal Range

Exercise is known to have a mental health benefit -- a benefit usually defined, in the arcane language of clinical psychologists, as "not feeling like crap" (although we laymen tend to speak of reduced rates of anxiety and depression). But how much exercise is the right amount?

A study conducted by universities in New York and Korea looked into this question, and concluded that the optimal amount of exercise (specifically with regard to mental health benefits) is 2.5 to 7.5 hours per week. It is perhaps not surprising that people who get less than 2.5 hours of exercise per week tend to have more anxiety and depression than people in the optimal range. But why would the benefits start to trail off as you get above 7.5 hours? Why would people doing a lot more than 7.5 hours of exercise per week have more mental health problems than people who are doing 7.5 hours?

First of all, the study does not actually show that, above the optimal range, exercise is the cause of whatever problems people are having. The arrow of causation may actually be pointing the other direction: some people who suffer from anxiety and depression, and are aware that exercise relieves these problems, are consciously "self-medicating" with exercise -- and those who are having more serious problems with anxiety and depression may go overboard. In fact, exercise may become a compulsive, addictive behavior which they feel they "must" do but don't enjoy doing.

Any kind of behavior which people feel enslaved to -- even if they started doing it in order to feel better -- is likely to make them feel bad in the long run. Also, if they are spending a lot more than 7.5 hours a week doing it, it is probably conflicting with other life activities which they ought to be spending more time on -- activities which cannot be neglected without making life less rewarding. So, it's possible that doing extreme exercise doesn't cause mental health problems, but people doing extreme exercise are often doing it to specifically to combat mental health problems.

I exercise a lot, so I wondered if I was perhaps above the optimal range. I decided to try to estimate my weekly exercise, and see where I am on the spectrum.

My lunchtime workouts on weekdays typically last 40 to 60 minutes; I'm guessing 50 minutes would be a good average. Okay, that accounts for 250 minutes of exercise.

On the weekends I usually do a long trail-run in the state park; that typically lasts 90 to 130 minutes; let's call that an average of 110 minutes. Which brings my total up to 360.

I do two, sometimes three, resistance-training workouts a week, but they're not very long. I'll count that as an average of 80 minutes a week. Which brings my weekly total up to 440 minutes.

Okay, that amounts to 7.3 hours. So I'm near the upper end of the optimal range (7.5 hours), but I'm not exceeding it. I've exceeded it in the past, while training for marathons, but I haven't done a marathon in a while now and I'm not at all sure I'm ever going to do another. So, unless something changes, I am pretty solidly established in the upper reaches of the optimal range.

But is it a problem that I'm exercising because I feel that I have to? Diabetes rather than mental health is the main reason that I feel I have to, but mental health plays a role in it too, and there's no question that my brain has a bias towards anxiety and depression which exercise greatly alleviates. Is there something pathological, at least in a psychological sense, about my exercise program? I can only say that it doesn't feel that way to me.

Anyway, the feeling that I "have to" exercise or "need to" exercise doesn't feel especially oppressive to me, and I don't think I'm exercising more and more over time to get my needs met. In other words: this ain't cocaine.



Wednesday, October 24, 2012

My Biased Morning Ritual

I have a doctor's appointment next week, and I needed to go to the lab early this morning to have some blood drawn for it. I got up much earlier than usual, and my fasting result at the time was 84. But more than an hour passed before my blood sample was actually collected, and right after that I tested it myself, and this time it read 92. I always like to do that, to compare the accuracy of my meter (a OneTouch UltraSmart) against whatever the lab result turns out to be. So far, it's never been off by more than a few points, but take it from me (as someone who works in the test & measurement industry): you can't assume that measurement equipment is still accurate just because it was accurate a year ago. You need to do the occasional reality check.

Whenever I get an unusually high reading from my meter, the first thought that pops into my mind is that the meter might be wrong. Glucose meters (or rather their test strips) have poor "repeatability", meaning that repeated measurements on the same sample give variable answers. Some readings are a bit high, others a bit low. The errors average out over time, but any individual result could be off -- and it could be off by rather a lot, since the accuracy specifications for meters are not exactly tight. It's legal to sell a glucose meter which is only accurate within plus or minus 20%. Mine seems to do a lot better than that, but it's always worth confirming that it's still on track. Because there is always a possibility that something could go wrong with a meter, it isn't nutty to wonder if your meter has a problem when you get an unusual result. However, if you think your meter has a problem, the next step is to check it out, not to adopt a policy of assuming that unusual results are erroneous.

The sad truth is that I never suspect my meter of having a problem when it shows me the results I want to see. It could be wrong then, too, but that thought doesn't cross my mind. This is what is known in science as "confirmation bias". Any kind of measurement could be wrong (with a result that is too high or too low), but we only question the accuracy of a measurement when the result is not what we wanted. If a scientist's lab equipment is yielding the expected or desired measurement result, it is assumed to be valid data. If it is yielding results which are neither expected nor wanted, it is assumed to be questionable data, and the equipment is given a thorough going-over. The data is equally likely to be erroneous in either of those cases, but only errors in the undesirable direction are investigated.

Confirmation bias is a huge problem in science, and some rather strange stories have resulted from it. A famous one involves Robert Milikan, the physicist who measured (a little inaccurately, it later turned out) the charge on an electron in 1909. The physicist Richard Feynman summarized the subsequent (embarrassing) history thusly: "Millikan measured the charge on an electron by an experiment with falling oil drops, and got an answer which we now know not to be quite right. It's a little bit off because he had the incorrect value for the viscosity of air. It's interesting to look at the history of measurements of the charge of an electron, after Millikan. If you plot them as a function of time, you find that one is a little bit bigger than Millikan's, and the next one's a little bit bigger than that, and the next one's a little bit bigger than that, until finally they settle down to a number which is higher. Why didn't they discover the new number was higher right away? It's a thing that scientists are ashamed of -- this history -- because it's apparent that people did things like this: When they got a number that was too high above Millikan's, they thought something must be wrong -- and they would look for and find a reason why something might be wrong. When they got a number close to Millikan's value they didn't look so hard. And so they eliminated the numbers that were too far off, and did other things like that."

The same thing goes on in medical science, and probably a lot more often, not only because there is more money at stake, but because the realities of health are not as hard-edged as the realities of physics, and there is more room for interpretation in any experiment. If you have a set of data which supports your hypothesis and another set of data which undermines it, which set of data are you going investigate and find an excuse to throw out? If you conduct a meta-analysis which combines the results from many studies, and you are deciding which studies to include, are you not going to try harder to find reasons to leave out those studies which aren't backing you up?

It is very hard to fight confirmation bias; we need to force ourselves to remain aware of it. Whenever you are tempted to assume that a worse-than-expected test result is erroneous, ask yourself if you would be equally suspicious of the result if it were, to the same degree, better than expected.


Other Data

Here's xkcd on "Drama":


Short Post Today

Tuesday, October 23, 2012


Strange test results today: fasting test unusually high, post-prandial test unusually low -- and both were 99 mg/dl. I'm having a hard time accounting for this. Some days I just get odd results.


Reducing A1c

Some encouraging news out of the Swedish National Diabetes Registry: reducing your Hemoglobin A1c result really does get results, and in one of the areas where diabetes patients are most interested in getting results: not dying.

The study looked at patients who had poorly controlled diabetes (average A1c 7.8%) as of 5 years ago. Some of these patients were able to bring their A1c down and keep it down; others were not. The study compared the morbidity and mortality rates in the improved group (average A1c 7.0% after five years) and the unimproved group (average A1c 8.4% after five years).

Over the five-year period, patients in the improved group were 33% less likely to develop cardiovascular disease, and 41% less likely to die from any cause, than the patients in the unimproved group.

So there you have it: it's worth doing.


Hot, And Not

Monday, October 22, 2012

Ugliness And Science

Your interpretation of what follows may depend, to some degree, on how good-looking you think this man is, so make up your mind about that first:

I'll offer no opinion of my own, because I don't want to influence your judgment. But anyway, the man the picture is Dario Maestripieri, a behavioral biologist who specializes in primate behavior. He is Professor of Comparative Human Development, Evolutionary Biology, and Neurobiology at The University of Chicago. He recently attended a scientific conference, and updated his Facebook page to share the following thoughts with the world: "My impression of the Conference of the Society for Neuroscience in New Orleans. There are thousands of people at the conference and an unusually high concentration of unattractive women. The super model types are completely absent. What is going on? Are unattractive women particularly attracted to neuroscience? Are beautiful women particularly uninterested in the brain? No offense to anyone."

Well, it's a good thing he added "No offense to anyone" at the end. People are so hypersensitive these days that, without such a disclaimer, someone might have become annoyed with the professor. In fact, a few people were annoyed anyway, even with the disclaimer included. Women pursuing careers in neuroscience have gone so far as to suggest that their scientific careers are being judged and influenced (by Maestripieri and others like him) on a basis unrelated to the merit of their work.

Not being a woman scientist, I think I had better leave the sexism aspect of the story to those more familiar with the practical implications for academic life and careers. But the professor's public meditations on the absence of "super model types" at neuroscience conferences do raise a few other issues. One is that, if Maestripieri has been able to have a distinguished career in his field (and he has, having published such seminal works as the 2009 paper "Gender differences in financial risk aversion and career choices are affected by testosterone" and "Early experience affects the intergenerational transmission of infant abuse in rhesus monkeys"), then maybe studying "primate behavior" isn't as hard as we might have supposed. I mean, he seems to be an idiot, and it hasn't held him back. Is it fair to say that pretty much anyone can get a job at the University of Chicago? Or has Maestripieri succeeded because of some personal advantage that doesn't meet the eye? (It certainly seems conceivable that, in studying primate behavior, he already had a leg up, so to speak.)

I suspect one of the reasons that super model types don't show up in large numbers at neuroscience conferences is that super model types are more interested in being super models. Even those few super model types who are interested in becoming neuroscientists may find that it takes a long time to become one of those, and by the time they make it, they are already too old to meet Maestripieri's standards. (But, to be fair, the professor did not specify his beauty criteria, and for all we know age is not a disqualifier, so long as the candidate achieves adequate levels of hotness in other regards.)

What interests me about the academic mini-scandal touched off by this professorial ape is that it serves as a splendid warning against the logical fallacy known as the "argument from authority". This is an error of reasoning in which a conclusion is held to be true or at least probable because it is being advocated by some expert who has been judged to be right about other matters. The problem with this approach is that it rests on assumptions which we know, from good historical evidence, to be unjustified. We cannot assume that an expert who has been right some of the time is right all of the time. We cannot assume that an expert who has been brilliant in solving one problem will be brilliant in solving other problems. We cannot assume that an expert who has exhibited sound judgment in one area is not an absolute crackpot in other areas.

The biographies of geniuses tend to reveal that they were geniuses in some areas and fools in other areas. Isaac Newton's achievements in physics, mathematics, and optics have been called miraculous, but he devoted more of his time to alchemy and other superstitious nonsense than to real science. More modern scientists have sometimes tended to cap a brilliant career with some kind of embarrassing descent into kookery (for example, William Shockley's downward arc from physicist and semiconductor pioneer to "racist and biological ignoramus", as one science historian described him). The pattern is too strong to be ignored: brilliant people tend to be brilliant only within a restricted range of their activities. Invoking the name of a distinguished scientist as a reason for accepting an idea is worthless. A scientific idea is worth something only if it can be validated under stringent conditions -- no matter what big name in the field has proposed or endorsed that idea. Too many big names in every field have turned out to be lunatics and fools outside one narrow area of competence.

The field of medical research has certainly not been free of seeming rationalists who are in fact obsessed with pushing some crackpot theory or other, and are willing to do bad science to carry their point. Patients who are trying to keep up with what the scientists have to say about health issues have to take a very skeptical view of any idea which seems plausible simply because it comes from a plausible-sounding source. Every idea has to stand on its own merits, no matter whose idea it was originally or who has jumped on the bandwagon since then. Can the idea stand up to scrutiny from skeptical and fully independent observers? If not, it's junk.

One final note: in light of the number of wrinkles visible in the the professor's face, I would like it to be noted for the record that he is seven years younger than I am. But then, the comparison is unfair, as I'm a technical writer, and that is a field to which attractive people have always been disproportionately drawn. Everyone knows that.


Hard Questions

Friday, October 19, 2012

Restless Nights & Morning Highs

A fasting result of 99 is higher than I consider acceptable, and it seemed a trifle unfair to get that this morning, based on my diet and exercise specifics the day before. But unfortunately I'd had another night of insufficient sleep, and that is probably what pushed up my glucose. Today I went to the drug store and picked up some melatonin tablets (I had run out). We'll see if that helps me get sleepy instead of alert at midnight.

I tested my glucose after breakfast this time, to see if the post-prandial result was unusually high. It was only 113, quite normal. I tend to get better post-prandials after breakfast than after any other meal, even though breakfast tends to be my highest-carb meal of the day. I seem to be able to handle carbs better in the morning than later in the day, which is strange, because for a lot of diabetes patients it's the other way around. I don't know why I'm different in that regard, I just know that I am.

Know your patterns, whatever they are! I think a lot of diabetes patients go astray by following advice which applies to some people but not to them.


"does it matters how much sugar you intake to get diabetes"

That question (a Google search request that showed up in my results) presumably comes from someone who is wondering whether or not excessive sugar consumption can directly cause diabetes. It sounds like a perfectly reasonable question, and a perfectly simple one, yet it is a surprisingly difficult question to answer.

There is a certain crude plausibility about the idea that a disease characterized by a breakdown of the body's sugar-regulation mechanism would be caused by excessive intake of sugar. However, attempts at uncovering good evidence for such a scenario in actual patients have not been very successful so far.

The evidence connecting weight gain with the subsequent development of Type 2 diabetes is strong, but so far nobody has been able to demonstrate that (1) gaining weight specifically from eating too much sugar causes diabetes, but (2) gaining weight from eating too much fat does not. It's not an easy issue to investigate, because you need to look at people's dietary habits over a long period of time, and you have to assume that what they are telling you they ate is what they actually ate. Also, you have to identify people who eat a lot of sugar and people who eat little or no sugar, and make a comparison between them. This has proved very hard to do.

You could argue that America has been conducting a vast experiment along those lines in recent years; sugar consumption has gone way up (largely due to the heavy use of high-fructose corn syrup in soft drinks and processed foods), and the regions of the country where sugar consumption has increased the most are also the regions where the rates of obesity and diabetes have increased the most. Still, this is too complex a situation to be analyzed as if it were a controlled experiment. (Sugar consumption isn't the only aspect of life that has changed in recent years, after all; something other than sugar consumption could be driving our public health problems.) Until we start raising people in cages, I'm not sure we're ever going to have the quality of evidence it would take to show convincingly that eating too much sugar (but not eating too much fat) is a direct cause of diabetes.

While we're waiting for evidence we may never have, we can at least think about possible causal mechanisms. Exactly how would eating too much sugar cause diabetes?

Well, one possible answer is that excess sugar consumption causes diabetes indirectly, simply by causing weight gain. Obesity (at least in genetically susceptible individuals) tends to degrade insulin sensitivity, eventually resulting in Type 2 diabetes. The current epidemic of "diabesity" could be the result of nothing more than the extra calories which have been added to the American diet by the HFCS industry in recent years. Many, many foods we eat today are higher in calories than equivalent foods a generation ago, and added sugar accounts for a lot of that difference. It could be that sugar-driven obesity is no more likely to cause diabetes than any other kind of obesity, but sugar-driven obesity is the kind we're familiar with because the food industry has been sneaking HFCS -- and not olive oil -- into everything we eat and drink.

If increased calorie consumption is the causal mechanism, then sugar is no worse than fat or protein in terms of triggering diabetes, and the way to avoid triggering diabetes is to eat less of whatever it is you're eating now.

However, it is possible that sugar has a more specific and more sinister role to play in triggering diabetes. Sugar is different from fat or protein in that consuming sugar provokes a strong insulin response: the beta cells in your pancreas are obliged to pump out a large dose of insulin whenever you take in sugar (or starch, which is essentially sugar presented in slightly different packaging). If your sensitivity to insulin is declining, then the insulin response to sugar has to be even bigger.

If your diet includes a lot of sugar, then your beta cells are routinely turning out mega-doses of insulin. The question is, can they keep on doing that forever? Or do the beta cells "burn out" due to overuse, and go into decline? Insulin productivity typically declines over time in Type 2 diabetes patients, and in some cases the decline begins early and precedes the diabetes diagnosis. Might it be the actual cause of the disease in such cases? And might the decline in insulin productivity be the result of beta cells being burned out by the pressure that a sugary diet is putting on them?

It may well be that there are two different ways for insulin productivity to decline. In some patients, it declines because glucotoxicity (that is, the toxic effect of excessive blood glucose) is killing off or weakening beta cells. In some patients, it declines because the beta cells have been pushed too hard to make extra insulin, and they have burned out as a result. In those patients, it seems as if a sugary diet might well be capable of triggering diabetes.

Unfortunately, it is still pretty unclear whether or not beta cells actually "burn out" from overuse. Some experts say they do, some experts say they don't, and most experts say they might. Take your pick.

Because it is at least possible that beta cells can be worn down by the strain of producing extra insulin (and because excessive insulin is harmful to the arteries), I don't tend to see overproduction of insulin as a desirable goal or a perfect solution to the problem of Type 2 diabetes. If you ask me, the long-term goal of diabetes management is not to produce more insulin, but to need less.


Runners, Sitters, And Runners Who Sit

Thursday, October 18, 2012

Race Pictures

When you participate in a big organized footrace, they usually have photographers stationed somewhere along the course, and at the finish line, to snap a few candid photos of you as you go by. These will be posted on line a few days later, so that the world can study your awkward gait, puffing cheeks, and despairing eyes. The photographers are hoping you will order expensive prints of these images, but in my case they are usually hoping in vain. I did order a coffee mug with a race picture on it once, but most of these photos are not exactly keepers.

However, I do check them out. I don't hold out any hope that these pictures will make me look like a star athlete, or even like a competent runner; I look at them because I'm curious. It's my opportunity to see how sweat-soaked and clingy a shirt can get, and to find out what new oddities of posture I have added to my repertoire without realizing it. Also, I find it interesting to compare the pictures of me taken mid-race to the pictures taken of me at the end, to see the visible toll that the miles took on me. It is usually pretty obvious that I'm a lot less serene crossing the finish line than I was six or seven miles earlier.

Here are two examples from the half-marathon race on Sunday. In the first one I'm looking pretty relaxed and comfortable...

...and perhaps a tiny bit less so as I approach the finish line (mile 13, in other words). Well, I've certainly looked worse than that at the finish line.

Now, about those sunglasses. Why was I wearing them, you ask, when it was obviously a foggy morning? Well, I thought I would need them when the morning fog burned off and we finished the race running into the dazzling sun. Well, the sun dazzled, all right, but not until after the race was over. I didn't it was going to be that way when the race was starting, and I needed to choose either to have the sunglasses or not have them. Anyway, wearing contact lenses makes my eyes hypersensitive to light, so I usually wear sunglasses outdoors in the daytime, even if it's not sunny.


The Perils Of Sitting

Lately I have been reading a lot of health studies which redefine "sedentary lifestyle" so that, to my surprise and dismay, it includes my own lifestyle.

Apparently you don't get off the hook for being sedentary just because you work out daily and there are pictures of you on line participating in endurance races. You are still sedentary (and have elevated health risks for that reason) if a large share of your daily schedule is consumed by prolonged episodes of sitting. In other words, a desk job is not bad for you because people in the habit of sitting around don't go to the gym after work -- it's bad for you because sitting is harmful, in and of itself, even if you do go to the gym after work.

That, at least is the conclusion of researchers at the University of Leicester, who report that long periods of sitting increase a person's risk of diabetes, heart disease, and death. (I have heard that the risk of death is actually 100% no matter what you do, but I guess they mean the risk of dying earlier than the average person would.) Anyway, the harmful impact of lengthy sit-downs is said to be independent of helpful impact of exercise taken at other times.

The researchers recommend that long periods of sitting should be interrupted with walking-around breaks. Stand-up desks can also be helpful, or so I'm told; I've never used one. Maybe I should start.


Exercise Motivation

Wednesday, October 17, 2012

How Do You Do It?

"How do you stay so consistently motivated to exercise?" asks a reader who has been exercising, but has apparently been finding the habit hard to maintain.

Well, maintaining the habit certainly is challenging, and I'm not going to pretend it's not. Exercising is hard -- or at least it's a lot harder than not exercising -- and the first five minutes of it (when your body is switching over from one fuel-burning mode to another) can feel unpleasant enough to make you feel strongly that curling up with a good book would be a far better way to spend the hour. Putting on your running shoes and heading to the park, when life is clearly so much better right here on the sofa, can be an extraordinarily difficult thing to talk yourself into. I certainly remember evenings when I finally dragged myself to the gym after an hour or two of agonizing inner debate. It's always so easy to think of excuses why, this time, we shouldn't have to do it. It's been a hard day! How can we possibly be expected to exercise when we're feeling so tired, so stressed-out, so not-in-the-mood? But if you cave in to those feelings every time you experience them, you will never exercise at all.

I've shared my meditations on this topic before, but maybe I'm about due to talk about it once again. Probably it's impossible to say too much about this issue; it may be the single most important issue facing anyone who is trying to manage Type 2 diabetes.

Below I'll offer some thoughts on what seem to me like the most significant factors that can help you stay on track with exercise.


Peer Pressure

We are tribal creatures, we humans, and almost anything is a lot easier to do if your peers are doing it too. That is why it is important to have exercise buddies. That might mean joining a running club or cycling club in your area; it might mean teaming up with a friend or two who share your need to get in shape (and perhaps also share your difficulty in staying motivated). But I would strongly suggest that at least some of your exercise should not be a solo act down at the gym; some of it should be a social activity.

After diagnosis I started to do distance cycling, simply because a friend of mine was doing a lot of that at the time and I let him talk me into participating. Later I started running on my lunch hour, and teamed up with some of my co-workers who also do that. A decade later we're still doing that.

When exercise is a social activity, it seems natural to do it, and you don't really question it. In fact, you start to forget that everyone doesn't do it. Somewhere along the way I started to forget that everyone in town isn't aware of when the next marathon or century-ride is happening in the area -- just as, after learning to play the fiddle, I started forgetting that not everyone is a musician and lots of people show up at a party without an instrument case.

Also, when exercise is a social activity, you get a lot of gentle promptings to do more of it. At work I'm always getting little e-mails from co-workers: Are you running today? Meet me at the flagpole at 11:45. Are you doing the Harvest Run this weekend? How about the Healdsburg Half-Marathon? Trust me, I'm not likely to drift out of the exercise habit because nobody is reminding me to do it.


Long Habit

Any often-repeated activity can become habitual, but an activity which causes you no effort or strain is going to be pretty easy to turn into a habit; a challenging activity which makes you feel (at least for the first five minutes) as if it's going to make you throw up -- turning that one into a habit is going to take some time. It could take a year -- or two -- or maybe three -- of regular exercise to make you feel so hooked on it that not exercising seems like more of a strain, or more uncomfortable, than exercising does. The way I think of it is that skipping a planned workout should make you feel uncomfortable, in much the same way that heading to the office in the morning without having taken your morning shower would make you feel uncomfortable. But it can take a long time to reach that state, so while you're waiting to get there, you need to use whatever tricks you can to force yourself to stay on track. That's one of the things that peer pressure can help you deal with.


Putting It On Record

I would hesitate to recommend doing a daily blog in which you describe your exercise activities to anyone (including your doctor) who cares to check up on you -- now that I know how much more difficult it is to do that than many people imagine. But there could be some value in keeping a record of your exercise, even if it's not published on the web and even if you are the only person who ever sees it. One reason it could become valuable is that, if you keep a record not only of your exercise but also of your blood sugar and blood pressure, you may start to see patterns emerge which help you understand how exercise affects your health. Data of this kind, properly evaluated, can be a good motivator. I've always tried to evaluate my test results carefully on any day, and (if they're not so good) think about possible ways to make them better next time. Exercise is, of course, one of the best ways to get your results headed in the right direction.

And, of course, if the records you are keeping actually are being seen by other people, that can put just enough pressure on you to make sure your exercise record doesn't make you look like a wimp. I know that I was always glad to be able to boast about running full marathons, when I was still doing those occasionally. I don't think I'm going to do more of them, just because the trauma/benefit ratio is high, but half-marathons are fairly easy for me -- and being able to say that publicly is as strong a motivator for staying active as anything else is.



Hard exercise causes the body to release its own home-grown opioids, known as "endorphins" (the term translates roughly as inner morphine). Endorphins make you feel good, the way narcotic drugs do, but unlike narcotics they are actually designed to fit the body's endorphin receptors perfectly, so that endorphins don't cause the problems associated with narcotics (which crudely overstimulate those receptors, with undesirable consequences). Admittedly, the endorphin high is a bit more subtle than what a street dealer might be able to arrange for you, but subtler is better in this department, so long as you're paying attention. Since I usually run at lunchtime, I'm always aware of how much better I feel in the afternoon than I did in the morning. Sometimes, when there's a stressful issue to be dealt with at the office, I deliberately postpone dealing with it until the afternoon, when I know I'll be feeling more relaxed.

The feel-good benefits of exercise will only keep you on the exercise track if you pay attention to them, and sensitize yourself to the issue of how you feel at different times, and why. It can be useful to think of a workout in terms of you want to feel after it, not during it -- if you look at it that way, a more challenging workout may start to seem like a more attractive option. The nap I took after the half-marathon on Sunday felt amazing, for example. A walk around the block won't do that for you.

What We Know We Should Do
& What We Do

Tuesday, October 16, 2012

Sleep And Diabetes

It has been known for many years that sleep deprivation is associated with elevated blood sugar (patients who develop sleep apnea are at extremely high risk of developing Type 2 diabetes -- and guess how I happened to find that out). What hasn't been clear is why sleep, or the lack of it, would have anything to do with elevated blood sugar. What mechanism is involved here?

A new study (and unfortunately a very small one, with only 7 individuals participating) seems to have uncovered a significant clue: people who weren't getting enough sleep (only 4.5 hours in bed per night, in this study, for four nights in a row) experienced a 30% decline in their sensitivity to insulin. At least, they suffered that effect in abdominal fat cells, which is the specific tissue that was tested in this experiment; the assumption is that other types of cells probably lose sensitivity to insulin as well, when sleep is insufficient.

To be sure, even if this were a much larger study which gathered data on thousands of patients under a broader range of circumstances, the result would still go only a very short distance toward solving the mysteries of sleep and health. We still don't really understand what sleep is for, and we still don't know how or why insulin sensitivity declines in people who aren't getting enough sleep. However, this study does challenge a fairly well-established assumption about sleep (that we need it mainly to perform restorative cleanup work on the central nervous system). Apparently sleep serves other purposes as well, some of which have to do with metabolism and the endocrine system.

Sleep is a difficult issue for me, and always will be. I've worked through the apnea problem pretty well, but I have other demons. The two main problems are: (1) my personal sleep rhythm is all wrong; I tend to become very alert late at night when I should be sleeping, and very sleepy early in the afternoon when I should be alert, and (2) I actually rather dislike sleep, or at least resent having to do it, and I resist it mentally. My brain is never more feverishly active than when I know perfectly well that I ought to be nodding off if I know what's good for me. I have struggled with these problems all my life, and I guess I always will.

I didn't sleep well last night; maybe that's why I got a higher than usual fasting test this morning. Another possible reason is that I had a late supper after yoga class last night. But sleep probably mattered more. I'm going to try very hard to get more sleep tonight and see if I get rewarded with a lower fasting result in the morning. We'll see how it works out!


Fungal Meningitis By The Numbers

These are the latest facts and figures I could find:

I've talked to a few people who survived meningitis, and they say people shouldn't imagine that, so long as it doesn't kill you, it's like getting the flu or something. Apparently it can be extraordinarily painful and debilitating, and recovery from it is a very slow and difficult process.

Maybe we should take this kind of thing sort of seriously, you know what I mean? Maybe there should be some quality control or something.


Balancing Act

Monday, October 15, 2012

Race Report

I ran the half-marathon yesterday, and although my finish time was slow (2 hours 18 minutes; one of my running buddies from work finished in under 2 hours), my relaxed pace had one big advantage over my previous experiences of running half-marathons: I felt good all the way through the race. I didn't get sore and exhausted during the last couple of miles. I felt good afterwards, too. I did need a nap afterwards, but that was mainly because I'd got up at 5 AM for the race, which started just before sunrise. Later in the day I was up and around and doing things. I went to play music with friends (and none of them said anything like "Are you okay? You look exhausted!"). Today I could feel that I'd had an endurance run the day before, but I wouldn't exactly say I was feeling stiff and sore. I was able to go running at lunchtime, and although I was a little slower than I normally would be on that route, it wasn't bad. So maybe a relaxed pace was the right approach for me. I'm not doing this to win medals, after all.


Diabetes & "Dumping"

"Have you ever heard the term dumping in connection with diabetes?", a reader was wondering.

Why, yes, I have! Let me give you some background on this subject.

Most people assume that sugar only gets into the bloodstream as a direct result of digestion. That is, if you haven't eaten anything during the last three or four hours, no sugar is being added to your bloodstream. Whatever sugar is in your blood has been kicking around in there ever since you digested your last meal.

Well, if that is an accurate description, it raises an interesting question: why aren't we all dead? Going to bed at night, and not eating anything at all until we wake up the next morning, seemingly should result in severe (and probably life-threatening) hypoglycemia during the night. Generally this doesn't happen. And some people even discover, upon consulting their glucose meter in the morning, that their blood sugar is actually higher than it was when they went to bed the night before, even though they have had nothing to eat for 10 or 12 hours. Clearly there is more to the story than meets the eye. Even when we are asleep, the body consumes blood sugar constantly, using it as fuel to keep such basic equipment as the brain, heart, and liver powered-up and functioning. If blood sugar doesn't diminish (and sometimes increases) during a long fast, despite this constant consumption of the stuff, then obviously there must be sugar flowing into the bloodstream from some source other than the digestive tract, to keep the blood sugar level from dropping dangerously low.

That alternative source of sugar is the liver, an organ which is capable of storing a supply of sugar (during times when digestion is adding a lot of it to the bloodstream), and doling it out later whenever it is needed.

But how does the liver know that it's time to start releasing some of its stored sugar into the blood? Well, first the body has to detect that blood sugar is getting low. How that happens is not terribly clear, but researchers have reported that there are specialized neurons in the brain which detect blood sugar levels, so presumably the brain issues a warning message to the endocrine system as blood sugar starts to fall below the normal range, and orders the pancreas to do something about it.

The pancreas contains both "beta" cells, which produce the hormone insulin, and "alpha" cells, which produce the hormone glucagon. These two hormones have opposite effects. Insulin tends to push the blood sugar level down (by ordering cells to start absorbing sugar from the bloodstream), while glucagon tends to push the blood sugar level up (by ordering the liver to release some of its stored sugar into the bloodstream). The endocrine system doesn't just crudely alternate between these two hormones (turning one on and the other off), because that would cause blood sugar to swing violently between high and low. What happens is that the endocrine system adjusts the ratio between these hormones (more glucagon than insulin when sugar is low, more insulin than glucagon when sugars is high).

But there's another important difference between the alpha and beta cells: in diabetes patients, the beta cells are either weakened (in Type 2 patients) or entirely destroyed (in Type 1 patients) -- but the alpha cells are doing just fine. In other words, we have a regulatory system which operates by fine-tuning the ratio between two hormones with opposing effects. And, if you have diabetes, one side of this system is broken, and the other side is not. It's like being a tightrope-walker who is carrying a long horizontal pole for balance, but one end of the thing has a sack of bowling-balls tied to it. It's hard to avoid leaning too far to one side, under the circumstances.

The resulting imbalance means that, in diabetes patients, the regulatory system tends to under-react to a high, and over-react to a low. When your blood sugar is dropping to the bottom of the normal range, your pancreas releases an enthusiastic blast of glucagon which unfortunately is not compensated for by a normal level of insulin. Result: your liver releases a bunch of sugar, and the amount it releases is too much for your system to cope with. You wake up in the morning with a blood sugar level which seems completely unreasonable to you, given that you were lower than that the night before and you haven't eaten anything since. This excessive release of sugar by the liver is often referred to as "dumping" (or "a liver dump").

The term is probably a little misleading. The impression people have is that the liver is releasing far more sugar than a non-diabetic person's liver would. I don't think that's necessarily the case; the real problem seems to be that the amount of sugar the liver releases is too much for your system to deal with (a non-diabetic person could probably handle it).

You're thinking, "All that's very interesting, but what exactly can I do about any of this?".

Well, there isn't an easy fix I know of that will make this issue go away for anybody with diabetes. But increasing your sensitivity to insulin tends to restore the balance to this out-of-balance situation, and exercise helps enormously with that.

Technical Difficulties, Please Stand By

Friday, October 12, 2012

I regret that Thursday's blog wasn't posted until Friday night, but I'm dealing with a file-corruption problem that is preventing me from using my usual HTML editor. At the moment I'm working around that problem by using far more primitive tools. Just what I need: something to make blogging more time-consuming than it already was! I'll try to get a real blog post up on Monday, if I'm still functional after the half-marathon on Sunday.


Very Very Small Workouts

Thursday, October 11, 2012

Scheduling Exercise

Another day which presented great difficulties in the way of fitting a workout into it -- and once again I had to fall back on an evening visit to the gym. My gym workouts are less intense than outdoor running is, so I usually don't do two gym workouts on successive days. But it may be appropriate this time, because I have a half-marathon race on Sunday and I need to dial it back a little before then. Also, my right leg was a bit sore on Tuesday and I want to give whatever that problem was a little healing time before the race. But really, the main reason I didn't run at lunchtime today or yesterday was that I just couldn't find time for it.

Earlier this year, a Swedish industrial designer named Joakim Christoffersson was strugging with the issue of finding room in his overscheduled life to work out. He made a joke to the effect that maybe his bathroom should have an exercise machine in it, so they he could use it for a few minutes whenever he went in there. Then it occurred to him was that the solution to his problem might be to develop simple, brief exercises which could be performed in commonplace situations which don't demand our full attention -- for example, when you are sitting in your car waiting for a red light to turn green, or waiting in line at the coffee bar, why not do a little bit of muscle-flexing and tendon-stretching?

Thus was born the website Nano Workout ("A healthy lifestyle without breaking a sweat"), which offers tips on how to fit tiny bouts of not-very-vigorous exercise into the dullest moments of your day.

By the way, tech people should probably stop assuming that everyone knows what "nano" means. It comes from the Greek word nanos ("dwarf"), and it is used as a prefix in the metric system to signify "one billionth of", as in "nanosecond". But it is also used more broadly to mean "extremely small" -- which does seem to be the right word for the workouts described on the site, including these:

The Nano Workout site does have a certain amount of charm; I'll give it that. And I can't be absolutely sure that Mr. Christoffersson isn't intending it as a joke. However, he has given interviews in which he says such things as: "All of the workouts work just as well as any other exercise in a gym or aerobic class. Some of them might be a bit odd but they all serve their purpose". Maybe, but what is their purpose?

It seems to me that claiming "toothbrush squats" work as well as any other exercise in a gym is probably overstating the case by a wide margin, but I guess we can't really say how well any exercise "works" until we have defined what we expect it to do for us. And that expectation may be very different for diabetes patients than it is for the population as a whole.

In terms of boosting insulin sensitivity, so that blood sugar is kept within bounds without medication, I find that I need to do a lot more exercise, and much more intense exercise, than anything described on the Nano Workouts site. If I tried to get the amount and intensity of exercise that I require while I was simultaneously driving or shopping, the whole thing would probably end in police involvement.

I was worrying that my last two workouts were pretty minimal, because they were gym workouts rather than outdoor running. The idea that doing neck stretches at the dinner table "works just as well" as running 4 miles does not seem remotely plausible to me, at least in terms of my own needs.

Admittedly, it would be better for people to do Nano Workouts than zero workouts, so if the site is persuading people to do at least some exercise, when they formerly were doing none, I guess it's a good development. But I am not sure anyone should be promoting the potentially dangerous concept of "a healthy lifestyle without breaking a sweat". Sometimes sweat needs breaking.

Exercise Intensity

Wednesday, October 10, 2012


I had a very difficult schedule today, partly because I was going to be playing music at an office party in the evening, and I had to rehearse for it at lunchtime, which meant that I couldn't exercise then, which meant that I had to squeeze in a visit to the gym before the party...

Sometimes diabetes is about time management than it's about anything else.

The music at the party went well enough, even though I felt we were under-prepared (two people that I have hardly ever played with were involved, and there was no opportunity to rehearse with them, or even discuss a playlist, before today). I was feeling more than the usual amount of performance anxiety, so I'm glad to have the assignment done. My blood pressure reading tonight was good, but that was because I measured it after the performance and not before!


The intensity of a particular form of exercise is sometimes rated in terms of the number of calories it burns per hour, but there is another (perhaps more meaningful) measure of exercise intensity known as a MET. This stands for Metabolic Equivalent of Task, which is a strange choice of words if you ask me. But the idea is fairly simple: lying in bed and doing nothing is 1 MET. More energetic activities are rated as multiples of that.

In other words, 4 METs means that an activity uses 4 times as much energy as lying still.

A large table of MET ratings for various activities, known as the Compendium of Physical Activities Tracking Guide, was been put together by the Arnold School of Public Health Prevention Research Center at the University of South Carolina. It's a rather thorough survey of things which people spend time doing, perhaps in the belief that they are burning a lot of calories in the process. The compendium invites them to compare their favorite physical activities with lying in bed, to see if those two things really are as far apart on the METs scale as one might think.

Sweeping the floor counts as 3.3 METs (mopping or vacuuming is a touch more vigorous, at 3.5).

Cooking dinner: 2.0 METs. (But if your food prep included butchering an animal, that's a big 6.0!)

Ironing clothes: 2.3.

Repairing an automobile or aircraft is generally 3.0 (but 4.0 for body work).

As lying in bed counts as 1.0 MET, how about other motionless activities? Well, sitting still watching television is also 1.0 MET. So is meditation, or even sitting still while talking on the phone.

Can anything be less than 1.0? Just one thing: if you are lying in bed and you fall asleep, you drop from 1.0 to 0.9. And I think it goes even lower than that if you die.

Some yard activities:

Some musical activities:

Some on-the-job tasks I would not be good at:

Some tasks which I suspect should not have been given the same rating, but were:

Some athletic activities:

Download the file I linked to above; it's interesting stuff, even if you reserve the right to be a little skeptical of some of the ratings.

Getting Rid Of It

Tuesday, October 9, 2012

"can you get rid of diabetes if its in your genes"

This was a question somebody did a Google search on yesterday, resulting in a reference to this site. Brief as it is, this question raises three troublesome issues. The only one that is easy to address is the missing apostrophe in the word it's. (Probably this is one of those people who uses an apostrophe in a plural, where it doesn't belong, but not in a contraction, where it does.) Okay, one out of three issues dealt with! The others are harder.

"Get rid of diabetes" is an interesting way of putting it. Most people say "cure", not "get rid of", and when they say that it touches off an argument about whether it is socially acceptable to question the dogma about diabetes being incurable, and a subsidiary argument about what the word "cure" actually means. Is "get rid of" any less likely to spark controversy?

The other issue is the notion of diabetes being "in your genes". To what degree is that a valid description of the relationship between genetics and diabetes?

Strictly speaking, a "cure" is a treatment. However, most people think it means a treatment which causes a disease condition to go away -- completely and forever.

Strictly speaking, "diabetes" is elevated blood glucose, regardless of cause or severity or duration. However, most people think it means one of the specific diseases which causes elevated blood glucose. Most people also think that (with the exception of "gestational" diabetes, which is experienced during pregnancy) anything called diabetes is a permanent condition.

Of course, gestational diabetes is very likely Type 2 diabetes -- which is famously incurable. Women who experience it are "at risk of developing Type 2 diabetes later on", probably because they've already had it. In other words, gestational diabetes is probably the first visible manifestation of a problem which was present before pregnancy and will still be present after pregnancy. Perhaps the physical stress (or simply the weight gain) of pregnancy is enough to cause the endocrine system to lose, for a while, its ability to keep the problem hidden -- an ability which it regains after the baby is born, but may lose again later on (at which point we call it Type 2 instead of gestational diabetes). Apparently a variety of factors can cause this hidden-in-the-background problem to manifest itself as elevated glucose, and those factors have a tendency to accumulate with age, so the probability of being diagnosed with diabetes rises over time. 

There isn't "a gene for" Type 2 diabetes; there are lots of genes which play some kind of role in increasing your risk of developing it. Depending on how many of those genes you have, your vulnerability to losing control of your blood glucose may be high or low. But even if it's high, it won't necessarily happen, unless some particular stress or problem or bad habit challenges your endocrine system a little too much.

In other words, symptomatic "diabetes" can come and go, even if the hidden problem that is driving it is constantly present. The question is, can we make it "go"? Can we get rid of it?

My own experience suggests that it's possible, at least in some cases, to drive your blood glucose down to non-diabetic levels and hold it there for an extended period. To call that "getting rid of diabetes" is probably saying too much, because the underlying problem is still present and will drive you back up to diabetic levels once again as soon as you stop fighting it.

But the idea that, if diabetes is in your genes, resistance is futile and you might as well give up the fight -- that I cannot accept!   

Pressed For Time

Monday, October 8, 2012

The Weekend

Very little went according to plan for me today or tonight, so I'm short of time, and can't come up with any profound insights about diabetes at the moment. So I'll just tell you what I was up to over the weekend.

Last week was Fleet Week in San Francisco, and my brother and his wife were staying for the weekend at the Cavallo Point resort, at the northern end of the Golden Gate Bridge, and hosting a picnic from which we could watch an airshow over the bay which included the Blue Angels.

People gathered early to set up chairs where they could get a good view.

Angel Island in the background there.

Blue Angels entering the Golden Gate.

The Blue Angels did a lot of low and loud formation flying, sometimes directely over our heads...

...or right over the beach...

...or right over town.

That was Saturday -- my non-exercise day (although hiking up into the Marin Headlands to take pictures of the bridge did involve some exertion).

Sunday was my last chance for a long run before the half-marathon on October 14, so I went to the state park and ran a 9.3 mile route. The race will be 3.8 miles longer than that, but not half as hilly as my trail-run was, so I think my recent long runs on the weekends have helped me get ready for the race. (Ready to finish it, anyway!)

I hope I'll have something more relevant to talk about tomorrow! 


Friday, October 5, 2012

Why Would You Make This Choice?

The following is not my own work, but the child who turned in this assignment is writing very much in the spirit of certain test answers which I remember committing to paper in my own day.

I had little patience with dumb questionnaires then, and I can't say I have a lot more of it now. Why do people always ask the wrong question?

It happens in other spheres as well... opinion surveys, presidential debates, celebrity interviews. Come on, question-askers: if you only get to ask a limited number of questions, don't let any of them be stupid ones.

Other Questions

Here are four questions (not necessarily dumb questions, just questions) taken from Google searches that yielded references to my site. 

"if i feel flushed does that mean my blood sugar is too high"

If you feel flushed, your blood sugar could be too high. Or too low. Or just right. Feeling flushed isn't a reliable indicator of blood sugar level. Unfortunately, no feeling is a reliable indicator of blood sugar level.

It is much easier to sense a low than a high, but the signs of a low are many and varied (for me, the main symptoms are weakness, shaking, sudden hunger, and nervousness that threatens to become panic -- other people experience other symptoms).

A high is something you usually can't feel at all, unless it's an extreme high, but even in that case it's hard to predict exactly what your symptoms will be, and most of the possibilities are symptoms (such as fatigue and headache) which could be caused by other conditions as well.

If you have reason to think you have high blood sugar, you need to get hold of a home glucose monitor. They're not that expensive, and you might as well know what's up. Trying to figure out what your blood sugar level is based on how you feel is a losing game.

"is 160 blood glucouse 2 hrs after dinner a bad reading for me"

I don't know if it's an unusually bad reading in terms of what you usually get, but it's not a good reading. A truly normal glycemic profile shows a modest spike (up to about 125 mg/dl on average) an hour after a meal, and the reason it's called a "spike" is that it goes down as rapidly as it went up, so it would certainly be under 125 at the 2-hour point. Of course, if you have diabetes, you probably can't achieve a truly normal glycemic profile (although I try to aim for that myself); still, if you're still as high as 160 mg/dl after 2 hours have gone by, that's something to worry about, or rather something to correct.

"Glucotoxicity" (the destructive tendency of high blood sugar) starts to manifest itself somewhere around the 140 mg/dl level, so staying as far below that level as you can, as often as you can, is the goal.

"is 325 high on a diabetic"

It's high on a diabetic, and it's high on anyone else. 325 mg/dl is a very high blood sugar level. Any time you're that high, you can take it for granted that tissues throughout your body are being injured. Glucose has a tendency to gum up the works by cementing itself onto proteins; this damage can be undone by the body's protein recycling process, but if your blood sugar is too high, the damage builds up faster than the recycling process can correct it. At 325 mg/dl, the damage is building up much faster than the recycling process can correct it.

"can sugar spikes in diabetics cause you to pee alot"

Whether it is a "spike" or a chronically elevated level, high blood sugar has an odd effect on the kidneys. Normally the kidneys work to retain sugar within the blood supply rather than excreting it, but once the sugar level gets too high, the kidneys can no longer prevent sugar from spilling out of the blood and into the urine. And when the sugar flows into the urine, water flows with it (because of osmotic pressure -- don't ask), so your bladder fills with urine faster. The higher your blood sugar gets, and the longer it stays high, the stronger the impact on urination.


Why Screen?

Thursday, October 4, 2012

Up A Bit

I thought my fasting test and post-lunch test were both higher than they "should" have been. Well, if something or other was pushing me up today, it seems to have leveled off by dinnertime. We'll see what happens tomorrow.

The heat wave is most definitely over now -- though I doubt the cool weather had anything to do with it.

Screening Not Worth It, Supposedly

A study in England, reported in The Lancet, compared medical practices which made a special effort to screen high-risk patients for diabetes with practices which did not do this, to see if there was a difference in patient mortality over a 10-year period. There wasn't. Patients died at the same rate whether they were screened for diabetes or not. Apparently, having your diabetes detected early because you were screened for it doesn't buy you anything in terms of 10-year survival.

Most deaths in the study period were from cancer, but even deaths due to diabetes and cardiovascular disease weren't less common in the practices that screened for diabetes than in practices that didn't.

The study authors puzzle over possible explanations for this disappointing result. One suggestion is that, because these medical practices were in comparatively affluent areas, the patients were getting regular enough medical care that their diabetes did not go undetected for very long, even if no special screening program was in place for it. The screening didn't buy these patients much time, but it would have been more advantageous to people with less frequent access to a doctor.

I would like to suggest another possible reason for the lack of difference in mortality. The patients in the screened practices were given either "routine treatment" (= drugs) or "intensive multifactorial treatment" (= more drugs). The main effect of the screening process was to get patients signed up a bit earlier for one of two modes of treatment which both have poor success rates.

If nearly all diabetes patients get essentially the same kind of treatment (that is, drugs that don't work very well over the long haul), we shouldn't be surprised that experimenting with minor variations on the usual pattern never seems to result in a major difference in survival rates.

Suppose that your usual headache remedy is hot tea, but you're looking for a more effective treatment. Do you think you'll do much better if you alter your tea-drinking schedule, or switch your blend from English Breakfast to Earl Grey? My guess would be that you'd have to make a bigger change than that. If tea isn't getting the job done for you, you might have to look beyond tea. I think diabetes patients need to look beyond drugs. 

The main reason for screening, it seems to me, is that catching diabetes at a comparatively early stage in its development gives you your best chance of being able to control it without drugs. If you catch it early but don't try to control it without drugs, screening will not have benefited you when all is said and done  -- but I think that means you squandered the benefit, not that the benefit wasn't there.

Risks & Benefits

Wednesday, October 3, 2012

An Iatrogenic Menace

Do you worry about your glabella?

How about your nasolabial folds? Fretting about those, are you?

These turn out to be two naturally-occuring features of the human face -- features which some people hate.

The glabella is the area above the nose and between the eyebrows. Creases in the skin tend to appear on either side of the glabella, where it meets the -- what is the term? -- the superciliary ridges above the eyes. These creases are sometimes called "worry lines" or "frown lines". Presidential candidate Mitt Romney supplies us with an example:

The nasolabial folds are larger creases in the skin which extend from the sides of the nose downward and outward to the corners of the mouth. They are sometimes called "laugh lines" or "smile lines". Mr. Romney's opponent doesn't seem to have much of a glabella, but he makes up for it with an outstanding pair of nasolabial folds that are a gift to political cartoonists:

Apparently a lot of people really, really hate to see these creases when they look in the mirror. Why? Well, because they are features of the human face which tend to become more prominent with age, and I don't need to tell you how our society feels about anything that is associated with age. If older people have more of it than younger people do (with the exception of money), it is a bad thing, and needs to be eliminated -- surgically if possible.

So a lot of people have a type of cosmetic surgery done in which some kind of filler (possibly "autologous fat", meaning fat moved from one part of the body to the other) is injected into these creases to fill them out and make them less prominent. A slight problem with this procedure is that it might make you go blind.

Huh? I realize that "do that and you'll go blind" is a warning likely to raise a snicker nowadays, if only because that warning has been issued dishonestly in the past, to discourage another type of behavior (without much effect, although most of us decided to do only enough of it to need glasses). But apparently it is possible for these fillers, after injection into facial creases, to wander a bit, and end up in places they weren't supposed to go. The result: "iatrogenic retinal artery occlusion". Let me translate: the word iatrogenic refers to any medical problem which is caused by medical treatment; the medical problem here is blockage of the arteries which furnish the retina of the eye with its blood supply. This blockage is painful, and the damage it causes to eyesight is typically permanent.

At least, that is the problem that was reported by a group of medical researchers in South Korea, where a lot of young women are having this cosmetic procedure done. The researchers looked at 12 patients who suffered sudden vision loss after receiving the facial injections. At this point in the evening I'm getting tired of translating medical terms, so I'll leave you to decode this one on your own: "Two patients who had received fat injections in the glabella sustained a cerebral fat embolism leading to brain infarction, potentially by way of the anastomosis between the angular and ophthalmic arteries." So you see.

American cosmetic surgeons are expressing surprise at reports of this research; they say they haven't been seeing this problem, and assume it must be very rare. They wonder if there's a particular reason why multiple cases of this are turning up in South Korea. Well, it could be that the procedure is done differently there; it could also be that the surgery is more popular there, so even "rare" problems are bound to turn up more often.

It seems to me that potential blindness is an awfully high price to pay for the privilege of having your face scraped clean of any signs of character or feeling. But the blank and brainless look of the fashion model...

...has been defined for us as an ideal of beauty, and many women feel that they have no choice but to chase that ideal. If makeup alone will get the job done, fine, but if it takes surgery to achieve that android look, then it takes surgery. Because this is what a woman's face is supposed to look like. And a man's face as well, some people think. 

Well, I feel the same way about surgery as I do about prescription medications: because they always involve some risk, you don't resort to them unless there's a compelling reason to do it. If the risk involved is a painful blockage leading to permanent blindness, I don't think that "I'm tired of looking like an earthling" qualifies as a compelling reason to take that risk -- but I guess other people feel differently. And enough women have assured me that I have no idea how much pressure they are under to look a certain way, that I guess I shouldn't assume such decisions are made frivolously.

Cutting A Deal

Tuesday, October 2, 2012

The Heat Wave Continues!

102 degrees today. This is getting ridiculous. This is not October as we know it. I did a lunchtime run despite the heat, but I certainly didn't maintain a brisk pace. 

An Offer You Can't Refuse

When I was a young child, there was a company called Pacific Finance which constantly ran television commercials offering to help you pay off all your debts... by becoming even more indebted to Pacific Finance. They could lend you the money you needed to pay off all your creditors, and then you could gradually pay off that big loan with a very small monthly payment. (Because those monthly payments were so reassuringly low, I assume that they either got a lot bigger later or they took 99 years to pay off.)

Anyway, the commercials always began with the same opening line from the narrator with the booming voice: "DO YOU HAVE DEBT WORRIES?".

At least, that was what I later realized the opening line was. But I was so inexperienced in life that I didn't recognize the word "debt", and I actually had no understanding of what sort of business Pacific Finance was in. As a child, I thought the line was: "DO YOU HAVE DEATH WORRIES?". And I thought that the charts showing the very low monthly payments represented the price you needed to pay if you wanted to avoid dying.

In a part of my childish brain I did wonder how Pacific Finance came to have any authority over death, and any capacity to hold it at bay. The world was so mysterious to me, though, that it didn't seem beyond the realm of possibility, and that wasn't my main reaction anyway. My main reaction was to wonder why anyone would ever choose to die, when you could so easily avoid it by making a two-figure monthly payment to Pacific Finance. You'd have to be insane not to fork over the pittance demanded, if that was all you needed to do to get rid of your DEATH WORRIES. How could anyone possibly be so cheap that they would refuse to hand over the money, and remain alive?

Well, I eventually came to realize my error. Pacific Finance was only claiming to get people out of debt, not out of death. (I don't know if they actually did either of those things, but they only claimed to be able to do one of them.)

Imagine my disappointment, when I found out that there isn't actually any outfit from which you can purchase immortality at reasonable monthly rates! It's a little embarrassing to think that, even when I was in first grade, I could have thought such bargains might be negotiated somewhere.

However, today I learned about a deal which is surely the next best thing. There may not be a way to eliminate your risk of death in exchange for low monthly payments, but it turns out that there is a way to substantially reduce your risk of death, for free.

An analysis of data from the Swedish National Diabetes Register found that patients with Type 2 diabetes significantly reduced their risk of death and cardiovascular disease if they exercised. Furthermore, patients who were not exercising at the beginning of a five-year study period reduced their risk of death during that period by almost two-thirds if they started exercising and kept at it.

So there you go. Maybe it still seems like a more attractive deal to reduce risk your risk of death to zero by writing a monthly check, and not exercise at all. But that deal isn't available, and this one is.

The "Thing" Thing

Monday, October 1, 2012

October Heat Wave!

Well, here's something you don't expect on the first day of October: the temperature today reached 100 degrees. My lunchtime run was extra-challenging. In fact, the last hill-climb was a killer and left me feeling a little dazed and unsteady after I finished.

Sunday was hot, too, and I did a longer run then (a trail-run of 9.3 miles). I think running in the heat is something you can get used to in the middle of summer, but when the autumn leaves are already falling and the days have been cooling down, a sudden heat wave can catch your body unprepared. Oh, well -- I'm sure this won't last.


Let me talk a little about reification, which could be loosely but unhelpfully translated as thing-making.

Reification is a logical fallacy (sometimes called the fallacy of misplaced concreteness) in which an abstract idea is mistakenly regarded as if it were a real, solid entity. To reify an idea is to transform it into a thing -- an object or phenomenon of the real world, not just a mental construct.

The classic example of reification is IQ, which started out as a method of screening schoolchildren for dyslexia. It was nothing more than a rough way of comparing rates of classroom learning. A low score meant that a child might have a learning disability, and should be checked out to see what was going wrong. That was all; IQ had only a limited significance in regard to schoolchildren, and it meant nothing at all in regard to the adult population.

And yet, people insisted on reifying IQ. The result is that we now think of adults as possessing some mysterious feature of the brain, some thing, called an IQ, which is permanent and unchangeable and follows them throughout their lives, determining what they can and cannot accomplish.

To speak of an adult as having an IQ at all is an absurdity, but it's an absurdity which almost no one ever notices or points out. Most adults think of themselves as having a specific IQ, and even if they're not sure what numerical value to put to it, they assume that they could find out what it is, by "having their IQ tested". In other words, they think IQ is like cholesterol: it's an actual thing, and someone in a white coat could measure it for them. The difference is that cholesterol levels can change over time; we think of IQ as a fixed quantity which each of us is stuck with forever, like a family curse. It's easy to overlook the craziness of this kind of talk, because by the time you have reified an abstract idea into a presumed concrete entity, you have already stopped thinking about what the idea means. Reification marks the death of thought.

Reification probably has a lot to answer for in regard to the popular understanding of diabetes. We have stopped thinking about what diabetes is. We only think about who has it. It's a stigma more than anything else. Patients are agonizing over the question of whether or not they really have diabetes, and doctors are agonizing over the question of how diabetes should be defined, screened for, and diagnosed. Most of what people say about all this suggests that they have reified diabetes -- it has become a thing, an entity.

In fact, diabetes is a vague term which can be applied to almost any kind of fault (mild or severe, permanent or temporary) in the glycemic regulatory system. But that's not how we see it. We have reified that vague concept into a single, permanent, unchanging, incurable medical monster. This leaves the patient population divided into those who definitely have it (and therefore see themselves as doomed) and those who don't definitely have it (and therefore see themselves as invulnerable to the problem). A subtle, complex physiological phenomenon which is very much a matter of degree has been reified into a simple, absolute, all-or-nothing proposition.

Blood glucose levels fluctuate -- in everyone -- but the fluctuations are supposed to stay within a limited range of "normal" values. To be above that range, at least part of the time, is to be "diabetic". But once we have said that, we must define exactly what the normal range is, and how far one has to be above it (and in what circumstances) before one is branded forever as "having diabetes". Because we have reified diabetes, we have also politicized it. Like that imaginary "IQ" thing which supposedly follows us through life, a diagnosis of diabetes is a black mark that we can never erase from our permanent record. Patients, doctors, and health insurers all have a stake in determining who gets that black mark and when, and the wrangling that goes on over this issue seems a lot more like political in-fighting than medicine.

The Google search phrases that have resulted in references to this site seem to reveal a pattern of rigid and unimaginative thinking, of the sort that is bound to occur when a subject has been reified. "Does one high A1c test mean I am diabetic?", asks one patient, clearly hoping to be told "no".

What one high A1c test tells you is that an abnormally high percentage of your hemoglobin is sugar-encrusted, and that wouldn't happen unless your blood glucose level had been elevated during at least part of the 90-day period preceding the test. Knowing this certainly gives you a problem to solve (allowing your blood glucose level to remain elevated is harmful, so you have to do something about it). But that specific issue -- elevated glucose -- is what matters, and although "diabetic" is indeed the word used to describe anyone with elevated glucose, it would be a lot more useful to concentrate on correcting the problem than to quibble about whether and when that is the correct word to use -- especially if you're planning to give up if the answer is "yes" and celebrate with a pizza if the answer is "no".

Suppose that high A1c test result was 6.4% -- just below the diagnostic threshold for diabetes. If you're told that 6.4% doesn't make you diabetic, you're going to think nothing is seriously wrong. But something damned well is wrong, because nobody who doesn't have a serious defect in his glycemic regulatory system is going to get that result. On the other hand, if the result is 6.5% and you're told this does make you diabetic, you may over-react in the other direction, deciding that your endocrine system is totally out of control and you can't do anything to change that. I call that a counter-productive way to look at the situation. And it's pretty ridiculous to pretend that the difference between 6.4% and 6.5% glycated hemoglobin is the difference between "no problem" and "no hope".

I don't know how to solve the problem of reification and how it distorts our thinking about diabetes, but maybe it will help a little if we at least acknowledge that the problem exists.

Pointless Anecdote

I can't claim this tale is relevant to anything, I just like it and felt like sharing it.

Two film composers from Hollywood's golden age, Max Steiner and Erich Wolfgang Korngold, were friends but also rivals. One day, Steiner playfully asked Korngold: "Can you explain why it is that, over the years, my music is getting better and better, and yours is getting worse and worse?"

To which Korngold replied without hesitation: "It's because you've been stealing from me, and I've been stealing from you."

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