Keeping It Simple

Friday, September 28, 2012

A Very Brief Blog Post

Sometimes you come home from work and do a blog post; sometimes you go to a party with a bunch of Irish musicians instead. The latter option is the one I went with tonight.

But I'm posting my numbers for the day anyway, lest you think I'm ashamed of them. 

Taking Precautions

Thursday, September 27, 2012

How Does Diabetes Harm Us?

The main problem with having the disease we call diabetes is that it makes us more likely to develop such diseases as... well, just about any other disease, it seems. We seldom read about a disease without learning that the disease in question is more common in people who have diabetes.

Take heart failure, for example. (The term doesn't refer to cessation of heartbeat -- that is "cardiac arrest". Heart failure means that the heart is still pumping, but isn't pumping strongly enough.) One recent study found that, of all the known risk factors for heart failure (smoking, diabetes, obesity, hypertension, and elevated LDL cholesterol), diabetes increased the risk the most, and by a wide margin.

Every time I read casual references to this or that disease being caused by diabetes, I want to ask "but why?". The authors of such comments almost never offer any explanation; diabetes simply puts you at risk for other diseases, and who knows what the mechanism is that increases the risk? And what does it matter anyway?

Well, I think it does matter how diabetes causes other diseases, because knowing how diabetes is causing a particular disease might arm us with useful information about how to prevent your diabetes from causing that other disease. The aim of diabetes treatment is not to control your diabetes without regard for how the treatment affects your health in general; the aim of diabetes treatment is to prevent diabetes from ruining your health. If there's more than one way to treat diabetes, you want to treat it in whatever way will minimize the risk that your diabetes will cause other health problems. And how do you figure that out, if you don't know how diabetes causes other health problems?

Concentrating specifically on Type 2 diabetes, there are two mechanisms I know of by which the disease triggers other diseases. One is hyperinsulinemia -- the process by which the pancreas tries to compensate for diminished insulin sensitivity by pumping out a chronic overdose of insulin. This is believed to have an inflammatory and damaging impact on arteries, leading to heart problems. The other mechanism is glycation -- the unwanted bonding of glucose to proteins, which occurs at an accelerated rate whenever blood sugar is high. As proteins have critical roles to play in tissues and organs throughout the body, mucking all of them up by sugar-coating them presumably can have harmful effects on just about every part of us.

The glycation problem can probably be dealt with by controlling blood glucose levels. But the hyperinsulinemia problem (which, by the way, can cause heart disease even when you're only "prediabetic") doesn't go away just because your blood sugar is under reasonably good control. What's actually keeping you under control may not be the diabetes meds you're taking -- it might be a combination of meds and hyperinsulinemia. If you want to prevent heart problems (which, needless to say, are considerably more common in diabetes patients), you need to be treating your diabetes in a way that reduces your need for insulin, so that the body doesn't have to produce excessive amounts of it.

Two good ways to reduce your need for insulin are to reduce the carbohydrate in your diet (so that insulin doesn't have as much sugar-storing work to do) and increase your sensitivity to insulin through exercise or weight loss (so that a smaller amount of insulin gets the job done).

I tend to see exercise as the most important of the things you can do about diabetes-related heart disease -- especially as exercise strengthens your cardiovascular system directly, so you would want to be doing it even if it didn't improve your insulin sensitivity. But since it does both, I call that a win-win scenario.

Balanced against all that, of course, is the stubborn fact that most people don't like exercise. How we solve that problem, I'm not quite sure.

Under The Desk

It was a lovely day, and no doubt that is why the worksite chose this morning to surprise us with an earthquake evacuation drill. We do this once a year, but we never know exactly when it's going to happen.

At first they announce on the loudspeakers that we're to pretend there's an earthquake, and we're supposed to crawl under our desks to take shelter from falling objects, "until the shaking stops". My rationale for not getting under the desk was that the shaking already had stopped. I certainly couldn't detect any. Embarrassment was the real motivation -- most people don't really do it, and I didn't want to be the only one dutifully hitting the deck. But the guy at the desk next to me actually did crawl under the desk, which ought to have given me social permission. Instead I accused him of showing off -- demonstrating that he was limber enough that he could crawl under the desk. I am, in fact, limber enough to crawl under the desk, but not limber enough to not hate crawling under the desk. I figure I'll really do it if there's really an earthquake.

Then they sounded the most loud and unpleasant alarm imaginable (think fingernails on a blackboard, amplified to such a degree that it would be pretty much impossible to stay in the building), and we all filed outdoors, standing around for a while on a beautiful fall morning, chatting and joking around. Kind of a party atmosphere. (Several hundred people are involved.) I quite enjoy these drills, actually -- once we're past the embarrassing instructions to crawl under the desk.  

I'm Feeling Spiteful Today

Wednesday, September 26, 2012

Short & Unsweet

Oh great, another article saying that self-monitoring of blood glucose by Type 2 diabetes patients who aren't using insulin is not useful enough to be worth doing. I was going to make a nuanced argument here, but let me just cut to the chase and say it plainly: I want every expert who makes this claim to die immediately and go to hell.

No doubt they also think that exercise and dietary restraint are useless, and for the very same reason: a lot of people who are told to do those things don't do them, or don't do them well. If a lot of people are bad at something, that means it's of no value, right? That's why there's no point in saving money or flossing your teeth, either.

Give & Take

Other news you can't use: further evidence has been found that castration makes men live longer. This conclusion is based on the records of Korea's Chosun Dynasty, records which shows that court eunuchs lived considerably longer than the fully-equipped monarchs they served.

Apparently men don't live as long as women because there is something about testosterone that reduces longevity. Whatever the specific disadvantage is (one theory is that high testosterone levels compromise the immune system), eunuchs don't have to deal with it, so they live longer. And it doesn't just seem longer, it actually is.

Oh, well. Life is full of trade-offs. And keep in mind that I'm merely mentioning a fact of interest -- I'm not making a recommendation here. 

The Joy Of Cooking Ever-Larger Things

There have been seven editions of The Joy of Cooking published (in 1936, 1946, 1951, 1963, 1975, 1997, and 2006). Professor Brian Wansink, a professor at Cornell, found 18 recipes which had appeared in all seven of those editions. However, later versions of those recipes did not use exactly the same ingredients as the 1936 original had done. Also, serving sizes (based on the number of servings stated for a given mass of ingredients) changed over the years.

In what direction did these things change? Well, you don't really need to ask, do you? You can already tell where this is going. Over the years, average calories per serving rose 63% (from 268 in 1936 to 436 seventy years later).

Yes, your grandmother made muffins, too -- but when she made a muffin, it wasn't big enough to use as furniture.

And Here's Why I'm Spiteful Today

The swelling has gone down, but I'm still hurting a bit from a nasty surprise that I received while eating lunch outdoors today: a yellow jacket (or, as Wikipedia would have it, "a predatory wasp of the genera Vespula or Dolichovespula") that was trying to steal a bite of my food got into my mouth and stung the inside of my upper lip.

It's enough to make you re-evaluate this whole eating-outdoors thing. Man, that hurts! And having a swollen lip all afternoon wasn't a lot of fun either. Apparently this is what the creature's barbed stinger (shown here inside its transparent sheath) looks like under a microscope:

And if that's not nasty enough for you, here's what the creature's hateful little face looks like:

Perhaps most annoying of all to me is this remark from the Wikipedia authors: "Despite having drawn the loathing of humans, yellow jackets are in fact important predators of pest insects."

Now, hold on a minute. I do not like the way the second clause of that sentence is offered as a contradiction of the first. The loathing of humans is well and truly earned by this unspeakable creature, and I don't care how important it might be as a predator of pest insects. I don't want to hear wasp apologists telling me about all the good things yellow jackets do, any more than I want to hear that Hitler loved his dog, or that doctors who want to take away my test strips give generously to the United Way charities. Bore me later, people; I am in no mood for that. No doubt that's why my systolic blood pressure is so much higher tonight than it was last night!

Kids & Calories

Tuesday, September 25, 2012

The School-Lunch Thing

"Parents know that their kids deserve all of the healthy and nutritious food they want." So says Representative Steve King, an Iowa Republican. 

I'm not sure I would describe that as an unquestionable truth which every parent "knows". In fact, some parents seem to be worried that the amount of food ("healthy" food or otherwise) that their children want is well in excess of requirements. The rising rates of childhood obesity, and even childhood Type 2 diabetes, suggest that parents who fear their children are overeating probably aren't imagining it.

So why would a member of Congress take a stand for the let-'em-eat-as-much-as-they-want plan? Well, this gets complicated -- and, needless to say, political. Rep. King is objecting to Michelle Obama's campaign against childhood obesity, and is taking aim at a related USDA rule change affecting the school lunch program. USDA Secretary Tom Vilsack has issued guidelines which limit the number of calories in school lunches. Rep. King is having none of this: he thinks there should be no limits on calories in school lunches, and in response he has introduced legislation (H.R. 6418, which he calls the No Hungry Kids Act) to overturn the new USDA guidelines. King argues that obesity in some children is no reason for the government to put all children on a diet.

Is it a diet, though? It is perhaps worth specifying what those new USDA guidelines are: 

These don't seem, at first glance, like starvation rations. It looks as if the values were chosen so as to limit lunchtime calories to something like a third of daily requirements, on the assumption that breakfast and lunch will provide the other two-thirds (and then some, perhaps -- but who knows?).

However: children, like adults, vary in their caloric needs; for some kids, especially active kids, the USDA limits would probably bring those lunch calories down to less than a third of daily requirements. If so, do the USDA limits essentially put some children on a weight loss diet? 

Here we start to get into the murky subject of what purpose the school lunch program is really meant to serve. Is the idea to ensure that children suffering poverty or neglect get at least one square meal every schoolday? If that's the goal, maybe each lunch served should provide more than a third of daily calorie requirements (but how much more?). Or is the program actually meant to provide a dependable revenue stream to those who provide the food to the schools? If that's the goal, any movement in the direction of smaller lunches is clearly a threat to said providers.

Another question to think about: what portion of daily calories should we expect a lunch to provide? Should it be as much as a third? More than a third? In some countries, the mid-day meal is the main meal of the day, and supper is a notably lighter affair, but in America it tends to be the other way around. Aren't kids likely to go home to a big supper? (Not if their families are too poor to provide one.)

We are used to thinking that America has a bigger problem with overfed children than with underfed children, so it does seem a bit odd to oppose calorie limits on school lunches. I am quite ready to assume that Rep. King is motivated by political opportunism rather than concern for hungry children. Still, a case could be made that, even if childhood obesity is a more common problem now than childhood malnutrition, the school lunch program can do a lot more to help the underfed children than the overfed ones. With the caloric limits removed, overweight kids still have the option (in principle) of eating less -- but if the caloric limits are left in place, underweight kids do not have the option of eating more.

Oh, well. For decades the school lunch program has been ground zero for strange political symbolism (remember that Reagan-era flap about the program defining ketchup as a vegetable?). I see this as more of the same -- one more opportunity to be reminded of Ambrose Bierce's definition of politics: "a strife of interests masquerading as a contest of principles". At least these periodic episodes of craziness give us a reason to think about why, exactly, we have a school lunch program, and what the program's main goal ought to be. It looks to me as if we haven't figured that out yet, but here's another opportunity to do so.

In theory, the problem of overfed children is more in need of solving, but I can't help feeling more sympathetic to the underfed ones. It's hard to say for sure who should win this fight.

Runners & Drug Lords

Monday, September 24, 2012

Distance Running

I am signed up to run a half-marathon race on October 14, which means that I need to get some long practice runs done between now and then, to get my body ready for the challenge. I do run a lot, obviously... but maybe it would be more accurate to say that I run often. Recently I have had very few runs that were much longer than five miles.

A half-marathon is 13.1 miles. Which, in case you haven't tried it yourself, is a pretty long way to go. Running 5-milers doesn't really get you into shape for that kind of challenge. Between now and race day, I need to make room in my weekends for some endurance runs.

Yesterday we had exceptionally fine weather (sunny, calm, only slightly warm), and I thought it was a good opportunity to head over to the state park and do a long trail run. The route I chose was a little over 12 miles, so it was almost as long as the race will be, and on far steeper terrain besides. 

After taking a bad fall on those same trails in July, and ending up with a left hand that was sore for weeks, I was nervous about the possibility of doing the same thing again. The result was that I didn't enjoy the scenery in the park as much as I would like to. I pretty much kept my eyes glued to the trail, watching out for rocks and roots that might be sticking up to trip me. I had a vague peripheral awareness that I was in the woods on a beautiful day, but other than that I might as well have been on an unusually dirty treadmill. It wasn't quite the nature-fix I tend to crave on the weekends, but it was adequate. 

Almost the whole way through the run, I happened to be following the same route as two guys on mountain bikes, and I more or less stayed with them the whole way. The climbs were steep enough that running them was faster than riding them, so I would pass them going up a hill, and then they would pass me going down it. This happened several times over. It was odd to be paired up with them for several miles in this way; we even had a little bit of dialogue while passing one another. Nothing heavy. No politics or anything.

I'm glad to report that I wasn't exhausted or sore after the run, and I didn't get hypoglycemic either, so that bodes well for the half-marathon. The only real problem was chafing under my arms, mainly from the straps holding my Camelback water bag on. There's nothing quite like raw chafed skin to get your attention when you step into the hot shower afterwards. Yowwww!

The long run yesterday didn't take so much out of me that I couldn't run at lunchtime today. However, the minute I walked into yoga class tonight, my teacher knew I was a little worn down. It's pretty hard to fool her...

Big Pharma: Worse Than We Thought

I have certainly taken the opportunity in my blog, more than once, to deplore the sorry state of drug-related medical research, with financial interests exerting every kind of inappropriate influence on how research is conducted, interpreted, published, and presented to the general public. But if you thought I was cynical about the drug business, you haven't read Ben Goldacre.

Ben Goldacre (author of the much-acclaimed Bad Science) is a British doctor, psychiatrist, popular science writer, and self-described "nerd evangelist" who likes to expose quackery of all kinds. He has a new book coming out called Bad Pharma: How drug companies mislead doctors and harm patients. The Guardian has published a preview which lays out some specifics about Goladacre's own experience of prescribing a drug for his patients, only to discover later that the evidence shows the drug is ineffective and sometimes harmful -- but that this evidence had been suppressed.

How can such a thing happen? According to Goldacre, "Drugs are tested by their manufacturers, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques that exaggerate the benefits."

He offers a specific example: "Reboxetine is a drug I have prescribed. Other drugs had done nothing for my patient, so we wanted to try something new. I'd read the trial data before I wrote the prescription, and found only well-designed, fair tests, with overwhelmingly positive results. Reboxetine was better than a placebo, and as good as any other antidepressant in head-to-head comparisons. It's approved for use by the Medicines and Healthcare products Regulatory Agency (the MHRA), which governs all drugs in the UK. Millions of doses are prescribed every year, around the world. Reboxetine was clearly a safe and effective treatment. The patient and I discussed the evidence briefly, and agreed it was the right treatment to try next. I signed a prescription."

All of the information he'd been given about Reboxetine was crap. "In October 2010, a group of researchers was finally able to bring together all the data that had ever been collected on reboxetine, both from trials that were published and from those that had never appeared in academic papers. When all this trial data was put together, it produced a shocking picture."

Several studies were conducted on the drug. Most of the data showed it wasn't effective. Only the atypical data showing it was effective ever got published. Most data showed the drug produced undesirable side-effects; only the atypical data showing it didn't produce undesirable side-effects got published.

"I did everything a doctor is supposed to do. I read all the papers, I critically appraised them, I understood them, I discussed them with the patient and we made a decision together, based on the evidence. In the published data, reboxetine was a safe and effective drug. In reality, it was no better than a sugar pill and, worse, it does more harm than good. As a doctor, I did something that, on the balance of all the evidence, harmed my patient, simply because unflattering data was left unpublished."

Incidentally, the drug has not been taken off the market, even though it is known to be ineffective and sometimes harmful.

I'm trying to see the silver lining here, but it's hard to spot. 

Why This Brownie?

Friday, September 21, 2012

What "Sugar Free" Means (If Anything)

The people at dLife sent me an e-mail this morning, with links to diabetes-related features on their web site which they think I ought to see.

One of them is a recipe for Blackberry Brownie Torte. The listed source of the recipe is Smuckers. Three of the ingredients (the Blackberry Jam, the Chocolate Fudge Brownie Mix, and the Hot Fudge Topping) are described as "Sugar Free". The recipe is said to make 10 servings -- a point on which I reserve the right to remain skeptical. However, assuming that someone makes this recipe and really does divide it into 10 parts, one of those 10 parts provides 36 grams of carbohydrate, according to the nutritional analysis presented. These brownies are 77% carbohydrate.

The recipe does not say that these brownies are low-carb... but neither does it say that they are medium-carb, high-carb, or anything else. There is no commentary at all which would explain why this recipe is being offered on a diabetes site, or why it is being cited in an e-mail promoting another article on the site called "Taking Care of Prediabetes". Probably the idea was that other brownies are higher in carbohydrates than this one is, so if you can't resist having a brownie, better to have this one than another. But none of that is actually stated.

Reasonable people can disagree about how low-carb a recipe has to be before it can reasonably be offered to diabetes patients, but if the recipe is for a dessert (in other words, something that will surely be consumed as an extra treat, on top of whatever actual meals someone is planning to eat), then there ought to be some kind of discussion of a potential problem: this is brownie is mostly carbohydrate.

It may seem surprising that the recipe is full of "Sugar Free" ingredients, yet the recipe made from those ingredients is 77% carbohydrate. I looked up the nutritional facts on the various ingredients, to see where those carbs were coming from:

I think a lot of people (including, it seems, a lot of people offering recipes to diabetes patients) are making far too much of the phrase "sugar free". The distinction between sugars and other carbohydrates is mostly pointless. For purposes of citations on nutritional labels, "carbohydrate" and "sugar" are two very different things. For purposes of digestion, they most certainly are not.

A "carbohydrate" may not be a "sugar" while it's still located in the brownie, but once it's located in you, it's either sugar or it's about to be sugar in a few minutes. Pretending that sugar is a menace and other carbs aren't is pretty silly, given that all carbs that aren't called sugars are made of sugars and are broken down into sugars again as soon as you digest them.

Put it this way: if you want to, you can invent a special word for bullets that haven't been fired yet... but if you try to use that distinction to imply that as-yet-unfired bullets are no threat to anyone, you're not an honest person. I think there's something dishonest going on with a lot of the "diabetes-friendly" recipes we see so much of. 

Of course, maybe I just have a bad attitude because I know that, if I made those brownies, I would probably eat three or four of them.  

Big Challenges!

Thursday, September 20, 2012

Mission Impossible: Reducing American Obesity

Oh dear: another team of researchers has gathered data to answer the question "Are Americans too fat?". And you'll never guess what answer they came up with!

The new report (encouragingly entitled "F as in Fat: How Obesity Threatens America's Future 2012") comes from the Robert Wood Johnson Foundation and Trust For America's Future. And the answer they came up with, in case the suspense is killing you, is that yes, Americans are too fat.

They took the current rising trend in the prevalence of obesity, and projected it forward in time to see how many Americans will be obese in the year 2030 if the trend doesn't change. (2030 sounds like a very remote future, until you do the subtraction and notice that it's only 18 years away.)

Their projection is that, by 2030, all 50 states could have obesity rates above 44%, and 13 of the 50 states could have obesity rates above 60%. (Mississippi would lead with 66.7%, and Colorado would be the slimmest with 44.8%)

How does that compare to the current situation? Well, the current spread reaches from 34.9% in Mississippi to 20.7% in Colorado. So the projected increase is very large -- which suggests that obesity rates have been rising very fast. (And they have been.) The usual consequences are noted: 68 million Americans with hypertension, 27 million with chronic heart disease, 25 million with Type 2 diabetes. The study authors make a number of bold predictions about how these disease rates could be slashed if Americans could achieve a 5% reduction in Body Mass Index.

Jeff Levi of the Trust For America's Future offers hope that this is a solvable problem: "We know a lot more about how to prevent obesity than we did 10 years ago", he lies.

What makes people say things like this in public? Every fact cited in the TFAF's own study proves that we definitely do not know a lot more about how to prevent obesity than we did 10 years ago. (The examples he cites of this hard-won new knowledge are pathetically familiar: schools should provide more sporting activity and more fresh fruits and vegetables. Yeah, that will turn the situation around in no time.)

If there's anything we know for sure, it's that we haven't yet hit on the right way to prevent obesity. If we had, the obesity rate would be falling instead of climbing. Can we please, for heaven's sake, stop pretending that we've got this problem figured out already, when it's so screamingly obvious that we haven't?

The Monster Behind Me

I found this image, thought it was funny, and forwarded it to my running buddies at work. 

One of them said that, for him, the T-rex chasing him was the half-marathon we all signed up to do on October 14.

Yeah, I guess it's a cause for concern. October 14 is not that far away. I'd better make sure I get a really long run in this weekend. Time to get in training for the race!

Choices, Consequences

Wednesday, September 19, 2012

Questionable Lunch Choice

I did an unusually difficult lunchtime run today (extremely hilly, and more than 5 miles). After the run, I was feeling very hungry, and nothing in the cafeteria appealed to me except for something which was too carb-heavy (a small plate of ravioli). I rationalized it (I'd just done a hard run, after all; surely I could handle some extra carbs, couldn't I?). An hour later my blood glucose was 141.

My doctor's guidance was only to keep it under 150 after meals, but 125 is more like what "normal" looks like, so I try to hold myself to a stricter standard -- and by that stricter standard, 141 is too high. The solution seems obvious: listen to the part of your brain that says any lunch that includes pasta is too high in carbs, whether you've just had a hard run or not. Unfortunately, when you're hungry, that part of your brain is not always the part that's talking loudest.

Autism & Genetics

Scientists say that genetic testing can evaluate the risk of an infant's later developing autism. The accuracy claimed so far is only 70%; perhaps testing can be made more accurate that that.

However, if scientists are already able to do even that well, then autism is clearly a geneticially-driven disease. It's not caused by vaccination, and the anti-vax idiots can find some other issue to waste their time on. Something equally stupid, in all likelihood, but perhaps something less dangerous to society at large.

I enjoy the 19th century's literature and art, but have no desire to bring back its epidemics.  

Comparing Runners & Non-Runners

Since I run so often, I was interested to discover that some researchers at the Stanford School of Medicine did a long-term study (reported in 2008) in which a 538 people who belonged to a running club were compared to 423 people (initially healthy people) who didn't run. Their health was tracked over a 21-year period to see how their subsequent health histories compared. Did running make a difference?

Well, in terms of not dying, it certainly made a difference:

The probability of survival was higher in the runners (the magenta trace) than in the non-runners (the blue trace), and the gap became gradually wider over the years. No two ways about how to interpret that.

Perhaps more significant than the survival statistics were the statistics on disability levels. Quality of life is probably a bigger issue than simple longevity -- most of us don't want extra years because we want to experience more pain and helplessness, after all. To be alive is nice, but to be alive with your bones and joints working properly is a lot nicer. So I was glad to see that disability levels for the runners (in blue this time, not magenta) were consistently lower -- and, once again, the gap increased with the years.

Maybe there's nothing else that needs to be said about this. Not tonight, anyway! I haven't been sleeping well of late, and sleeplessness certainly does not benefit me.

Where Your Fat Is

Tuesday, September 18, 2012

Visceral Matters

Most people know that Type 2 diabetes is associated with obesity; not everyone knows that it is associated with a particular kind of obesity. "Visceral" fat (fat immediately surrounding the intestines) is the type of fat that ups your risk of becoming diabetic. Being overweight by itself is not the issue; carrying your excess weight mainly in the abdomen is the issue. "Pear-shaped" people whose excess weight is concentrated lower down tend not to be the ones who develop diabetes.

I found some photographs which I could use to illustrate what visceral fat is, in case I haven't described it vividly enough, but then I decided that it would kinder not to do so.

A study reported in JAMA today confirms this; the study's authors found that the risk of Type 2 diabetes is independently associated with visceral fat, and also with insulin resistance, but not associated with "general adiposity" (being fat, but without a concentration of fat in the abdomen).

The authors seem to have no views on why this should be so. What makes excess visceral fat so different from excess fat elsewhere? It appears (from other research, anyway) that visceral fat behaves a little like an endocrine gland, exchanging chemical signals with the digestive tract. Perhaps a buildup of excess visceral fat is a cause (or effect) of something going haywire in whatever control mechanism is supposed to be functioning there.

The new study seems to do more than confirm what has been said for years about visceral fat and diabetes (one apparently causes the other; nobody understand how). However, a particular detail jumps out at me: the mention of insulin resistance increasing the risk that the patient will later develop Type 2 diabetes. Isn't that like saying the presence of bullets inside the body increases the risk that the patient will later die from gunshot wounds? The relationship between visceral fat and diabetes might be a little murky, but the relationship between insulin resistance and diabetes seems considerably more straightforward than that.

By the way, nobody is suggesting (so far) that you can cure diabetes by distributing your body fat differently in some way. Despite what you've heard about ab exercises supposedly burning abdominal fat preferentially, the body seems to concentrate fat where it chooses to, regardless of what you try to do about it. You have to work with the body you have; there's no use getting angry.

Last Rose Of Summer Feared Dead!

Summer really is ending, I guess. This morning, sadly, I got out of bed and realized that it was cold enough for me to have to turn on the furnace (otherwise I wouldn't have been able to get out of the shower). And when I went running at noon today, I put on long-sleeved shirt! Always a sad day when things like that happen.

The weird part is that I actually like fall better than I like summer, yet I always feel sad when summer ends. It's some kind of conditioned response: I know we're supposed to feel sorry that summer is over, so I do. However, my daily runs are always more pleasant after the weather cools off, so I'll get used to this soon.

Exercising outdoors makes you more sensitive to the seasons, but also quicker to adapt to them.

Sugar Abuse In NY

Monday, September 17, 2012

Sugary Drinks: Size Matters!

The New York Board of Health met last week, and voted 8 to 0 in favor of Mayor Bloomberg's proposed ban on selling super-sized sugary drinks. 

However, it needs to be pointed out that the New York Board of Health has a limited scope of authority: only a business which must pass inspections by the board is really affected by the new rule. A movie theater would be blocked from selling you a soda larger than 16 ounces, but a convenience store would not be.

In other words, the 7-Eleven stores (eager promoters of gigantic soda sizes) can continue to sell Coca-Cola in the sizes outlined below (along with the sugar payload of each):

(The numbers come from the Sugar Stacks website -- and obviously are unthinkable as "serving sizes" for a diabetic person, or even for a non-diabetic person who would like to remain a non-diabetic person.)

All members of the Board of Health were appointed by Mayor Bloomberg, and the ban was his idea, so the board's approval is not too surprising. Neither is it surprising that a lot of people who happen not to be the mayor are hostile to the idea, or see it as silly. Even those who like the idea in principle feel that the New York implementation of it is an inconsistent mess, with loopholes that you could drive a truck through. Milkshakes are exempt from size limits, no matter how sugary they may be. And although you can't buy a 32-ounce coke in a movie theater, you can easily buy two 16-ounce cokes in a movie theater, no questions asked.

Just as Prohibition did not prevent anyone who wanted to get drunk from doing so, the new ban will not prevent anyone who wants to overdose on sugar from doing so. The ban is little more than a symbolic gesture -- so what's the point of it?

Of course, one could ask, with equal justice: what's the point of opposing it? The soda industry is spending a lot of money on fighting the soda ban. Why bother, if it won't change anything?

No doubt the soda industry is concerned that this particular symbolic gesture will change something. 7-Eleven has normalized the idea of drinking sugar by the bucketload, and this has helped the industry sell more product. If the city government of New York makes a point of reminding the public that drinking 32 ounces of Coca Cola at once (and therefore consuming 91 grams of sugar at once) is not normal -- is in fact weird and unhealthy -- it's entirely possible that at least some people will reduce their intake of sugary drinks. Maybe a lot of people will. If this scenario plays out, how can the soda industry not be at risk of having their sales shrink instead of growing?

The soda industry likes to point out that they are not the only source of calories in anybody's diet. That's true as far as it goes, but the enormous growth in consumption of sweetened soft drinks has certainly been an important contributor of extra calories to almost everybody's diet. The U.S. obesity maps show a remarkably consistent overlap between regions where soda consumption is highest and regions where obesity is highest. And it's not as if Coca Cola contributes something else to anyone's nutritional needs; take out the sugar and there's nothing else to speak of. Sugary drinks are the emptiest of empty calories, and for a lot of people those calories don't even count, because they imagine that only solid food is significant in terms of calorie intake.

I guess my bottom line is that the New York ban on supersized sugary drinks is silly, inconsistent, hopelessly impractical, and very probably the wise thing to do... even if some would prefer a different path to enlightenment.        


Friday, September 14, 2012

Having A Job

A research study published last month looked into the question of whether diabetes patients do better if they are employed than if they are unemployed.

You will be amazed to learn the answer: they do better if they are employed!

Actually, the study only looked at the connection between employment status and compliance with prescribed medication. People who have jobs are somewhat likelier to take their meds than people who don't.

The authors say that it isn't just a matter of having health insurance or not having it: "It is linked to bigger issues such as being employed, periods of joblessness or a personal financial strain."

Right. Got it. People who have jobs are likelier to take meds than people who don't have jobs, probably because they are likelier to be able to pay for them.

Having A Locker

At the health club I belong to, I have never had my own private locker. There are smaller lockers available there for free, but the electronic combination locks on a great many of them are broken (an issue which the health club management seems to be invincibly opposed to addressing). So, every time I go there, I have to hunt around for a locker that isn't being used and doesn't have a non-functioning lock either.

Then I heard that it doesn't cost as much as I had thought to reserve your own private locker. So I signed up for one. Locker 161 belongs to me and nobody else!

How much difference does this really make? We'll see. The locker is bigger than the free ones I've been using, and I can leave things in it (such as gym shoes and shaving accessories) so that I don't have to be transporting them back and forth. And I don't have the irritation factor of needing to hunt down a free and functional locker every time I go there.

Whether or not these minor conveniences will actually result in my going there more often, I don't know, but it may help. During the summer my exercise is mainly outdoors, and I only go to the health club to use weights -- two or three times a week, in other words. (But maybe it will now start to be three times a week more often than it's two times a week?) Once we get into the rainy part of the year, I'll have a reason to do my aerobic workouts there too, some of the time, and an improved locker situation will make that a more attractive option.

In terms of sticking to an exercise program, minor conveniences can become surprisingly important; they may make the difference between doing a workout and not doing it. The important thing is to learn to recognize what makes a practical difference for you, and act on that knowledge.

Acquired Immaturity

Thursday, September 13, 2012

Backward Beta Cells

Why does insulin production decrease in Type 2 diabetes patients?

We know why it decreases in Type 1 diabetes patients -- the immune system goes haywire, and attacks the beta cells in the pancreas (the cells which produce most of our insulin supply). But in Type 2 diabetes, there isn't an immune reaction of this type. Something else is causing the problem.

The leading hypothesis up to now has been "glucotoxicity" -- elevated blood glucose (presumably caused, at first, by loss of sensitivity to insulin) kills beta cells, and therefore leads to a loss of production of insulin. A vicious cycle results: the higher your blood glucose gets, the less insulin you can produce to control it.

The problem with this hypothesis is that investigators never find enough dead beta cells in the pancreas to account for the size of the drop in insulin production. The pancreas of a Type 2 patient ought to be a battlefield, littered with the corpses of formerly-healthy beta cells.... but this is not what researchers have been finding. Apparently something else is going on that cuts insulin productivity. 

A new study from the Columbia University Medical Center proposes a different explanation: the beta cells are not actually killed -- instead they revert to a precursor cell type which is not able to produce insulin. It's a little bit as if adult humans reverted to a pre-adolescent state and lost the capacity for sexual reproduction.

What would cause beta cells to revert to a precursor, non-insulin-producing state? Apparently, various kinds of physiological stress can trigger this reaction (and elevated blood glucose counts as physiologic stress in this regard).

Now, you might think: what difference does it make whether elevated blood glucose actually kills the beta cells, or causes them to revert to a more infantile (and incapable) form? Well, if beta cells are actually killed, they're gone (and the body replaces them only very slowly). But if beta cells merely convert to an immature form -- maybe they can convert right back to the mature form, and start functioning normally again.

Everyone but me is thinking in terms of creating a drug which forces beta cells to convert back to the mature form. I, of course, am wondering if a change of habits can bring about that conversion without chemical help! 

Incontrovertible Proof!

An article published in Pediatrics recently says that, contrary to popular belief, overweight children eat less than normal-weight children, not more. This conclusion is based entirely on how much the overweight children said they ate.

In other news: a study of politicians reveals that they love their families, their home towns, and their country more than normal people do.

And even more news which will astound you: premiums for employer-sponsored health insurance are climbing faster than employee's wages are. And here I was, thinking we were all getting a free ride on this!

My Dental Visit

Okay, I had the root-planing done on the other side of my mouth today, so I'm all done with that for now (hopefully for years). It was a little easier to get through than last time. But I'm not sure I'll ever be a fan of this procedure, so I guess I'd better do a fantastic job on the brushing and flossing, to make sure I don't need this again soon. Gum inflammation is no advantage when it comes to diabetes management.

Noisy Claims & Quiet Retractions

Wednesday, September 12, 2012

Accentuating The Positive

As we saw so recently in the case of a very unrevealing study of organic food, a health research project sometimes receives media attention wildly out of proportion to any conclusions it supports. When the study is refuted or weakened by later research, however, the journalists who called attention to the original study (and exaggerated its significance) seldom call attention to its subsequent debunking.

This journalistic phenomenon was studied recently by Francois Gonon and colleagues at the University of Bordeaux. They began with 47 papers on ADHD published in the 1990s, and selected the ten papers which had been most echoed in newspaper articles.

Of these ten widely-reported studies, six were largely or entirely refuted; a seventh was weakened; an eighth was neither refuted nor confirmed, but "its main conclusion seems unlikely". Not a hugely impressive batting average.

But the failure of those studies to hold up was not given the same level of publicity as the original, confident-sounding reports. Newspaper articles about the original research studies outnumbered articles about their subsequent debunking by a margin of nearly 5 to 1.

Gonon and colleagues suggest that this "represents a major cause of distortion in health science communication". It's hard to see how they could be wrong about that.

The real question is how to solve the problem. False or questionable claims made by political candidates do receive a certain amount of fact-checking scrutiny; news outlets have started to realize that they aren't doing their jobs if they simply quote what a candidate said without trying to find out if it's true. They have started to realize that they are supposed to be, to some degree, analysts rather than stenographers. Perhaps they can be persuaded that this responsibility exists not just in relation to candidates making questionable claims, but also in relation to scientists making questionable claims.

However, the problem may run a little deeper than I am suggesting. In reporting on scientific studies, journalists almost never report what the study authors actually said, and leave it at that. They usually come up with a summary which does not even resemble what the authors actually said. Many media summaries of that organic food study misrepresented the findings so completely that you almost have to wonder who put them up to it. It's hard for me to believe that such a large number of journalists and editors innocently missed the point in the same way on the same day.

More Dental Fun

Last Thursday I went in to the dentists's office for "root planing" treatment on all the teeth on the left side of my mouth. Tomorrow morning I go in to have the same thing done on the right side. Then I'll be finished with the process, and hopefully won't have to go through it again, at least for several years.

I'm hoping it will be easier for me this time, simply because I know what to expect. And supposedly my teeth are in better shape on the right side, so it should go a little quicker.

I don't know why the teeth on the right side of my mouth would be in better shape. I'm right-handed, though; I wonder if that somehow leads to my brushing better on that side? Golly, this asymmetry opens up all sorts of surreal possibilities. For glucose tests, I always use the fingers of my right hand (because I'm a fiddler -- no time to explain). But what if my glucose levels are different on the left side of my body? Maybe testing on my right hand yields misleading results...

Things You Don't Forget

Tuesday, September 11, 2012

About Paul Ryan's Marathon Time

It can be very frustrating when there's a story in the news that relates to an unusual personal interest or experience of yours: the minute you hear about it, you realize that most people won't understand it the way you do.

It doesn't often happen that a political news story is broken by Runner's World, of all publications, but it did happen on August 31. Vice presidential candidate Paul Ryan boasted in an interview of having run a marathon in under 3 hours ("two hours fifty-something", to quote him). The marathon in question took place in Minnesota in 1990, and before committing himself to this boast, Ryan should perhaps have thought for a moment about how easy it is to check into these things, and about how likely it was that America's marathon runners would do the minimal homework required to find out that Ryan's actual finish time was a little over 4 hours. Runner's World was first out of the gate with this information, to give credit where it's due, but there was really no possibility of such a claim going unchecked.

I knew, as soon as I heard about this story, that most non-runners would say: "For heaven's sake, the race was years ago! Anybody could make a mistake like that." Well, say that if you want to. Just don't try saying it to marathon runners -- because those are the people who could not make a mistake like that.

What you need to understand, if you haven't ever run a marathon, is that marathon-runners take their finish times very, very seriously (even if they pretend not to, and very few of them even bother pretending not to). It doesn't matter whether their times are under three hours (Ryan's claim) or over fours (Ryan's reality -- and my own); marathon runners care about their finish times. You think baseball fans are obsessed with sports statistics? Forget it -- marathon runners put them to shame. There is no such thing as someone who has run a marathon (no matter how long ago) and cannot recall his finish time a good deal more accurately than Ryan did. There is no such creature as a marathon runner who took over four hours to finish but thinks it was under three. I would sooner believe that a woman can't remember whether or not she's ever given birth. There are some things people don't forget, and the experience of running a marathon is one of them.

Ryan has received a lot of personal publicity as the fittest member of congress -- which is perhaps not the most competitive field around, but he seems to have enjoyed the attention, and I can only assume that he got hooked on it, and couldn't resist grabbing for more credit than he was due.

Whatever Ryan's motivation was for saying what he said, don't try to convince a marathon runner that Ryan didn't know he was lying!

Running Buddies

Although others at work sometimes join us, there are only two fellow employees that I run with regularly at lunchtime. We've been doing this for years now. Along the way we have gradually made our runs more challenging, and have often talked each other into taking on challenges (including distance races, and ultimately full marathons) which we probably never would have attempted if we hadn't had anyone to train with.

I notice that there are other groups of employees at work who exercise together more or less the way we do. Runners, walkers, cyclists, soccer players, basketball players, softball players. Like us, a lot of these people have been working out together for several years. It makes it easier for them to get through the day; it cuts stress, and probably makes them more effective at their jobs, which is one of the reasons the company does not discourage it.

I recommend this approach strongly to anyone who wants to start a regular exercise program. It's just a lot easier to stick to the program when there is a social element to it. If you're on your own, it's so easy to skip a workout: who's going to know anyway? If you work out with other people, any skipped workout is going to be on your permanent record, and is going to open you up to teasing. So you show up and do it, instead of wimping out every time you feel like it. Eventually you just become accustomed to the idea that your workout is part of your daily routine, and you don't even feel especially tempted to skip it.

The regularity of the workouts -- and the regularity of the social partners involved -- also tend to give you a sense of long-term history that is interesting. Today we came upon a large patch of smooth, soft mud to the side of the road, with various animal tracks meandering across it. We stopped to examine them, trying to identify the animals involved. Raccoon? Too big for that. Is this other one from a deer? Could that one be a bobcat? All of this reminded me of the time, a few years ago, on that very spot, when we spotted an animal in the distance, and just as I realized that it was indeed a mountain lion, one of my running buddies terrified and infuriated me by yelling "Here, kitty kitty kitty!" at the very moment when I was desperately wanting to keep a low profile. (I still haven't killed him for that, but I'm not promising that I never will.) The nostalgia rush I got from that today was pretty intense. It happens to me a lot when I'm out running. One run reminds me of another one from years before. We've signed up to run a half-marathon next month, and that will remind me of other such races I've run over the years.

If you want to keep exercising over the long haul, you want to make your workouts a little more interesting than spending half an hour on the exercise bike with no one to to talk to. The solution: workout buddies. Find some. 

Why People Move To California

Here's the forecast for the coming week:

I don't know that this totally makes up for the cost of living here, but it's a start.

How Little We Know

Monday, September 10, 2012

Hidden Things

The sun had a major fit on August 31 -- although the more correct term for it is "coronal mass ejection". A huge arc of hot gas rose over the solar surface and suddenly exploded, flinging hundreds of millions of tons of matter into space at a speed of about 900 miles per second.

To get a better idea of the scale of the explosion, here's a picture of it with the earth's size painted in for comparison.

The event was almost unimaginably large and powerful. And yet, were you even aware it happened? That gigantic spray of particles was aimed more at Venus than at Earth; apart from some especially good displays of the aurora borealis later on, there was no significant impact on our own planet. Most people didn't even hear about it.

It is possible, when conditions are just right (or rather just wrong) for a solar event of this type to have a significant impact on us, mainly by disrupting telecommunication, damaging satellites, and possibly damaging electrical transmission lines. It doesn't happen often, though. Most of the time, a coronal mass ejection has no visible effects here on earth. Unless you share my interest in astronomy, and tend to keep up with the latest explosion-on-the-sun news, you probably remain blissfully ignorant of a lot of titanic events.

Sometimes there is no connection at all between the scale or intenstity of an event and our awareness of that event. Huge, dramatic things can easily pass unnoticed -- at least until they catch up with us, and cause some kind of trouble that affects us in a personal way.

That is the way it is with human health. Certain kinds of health problems produce immediate symptoms which are easy to notice, and often easy to interpret (although the number of unrelated diseases that cause "flu-like symptoms" does seem a little excessive to me).

A lot of serious health problems, unfortunately, don't produce symptoms at all -- at least in the early stages, when recognizing the symptoms would put you in a position to do something useful about the problem.

Both Type 2 diabetes and its most dangerous fellow-traveler (arterial blockage) often produce no early warning signs of any kind. People might not know anything is amiss, until they wake up in the emergency room and don't like the looks on the faces of the ER staff who are hovering over them. It would have been helpful to know something was going wrong before things got to that point, but often people don't know that.

Even if you know the score -- you've been diagnosed, you've got the lab results, you're testing your blood glucose and blood pressure regularly, and you feel as if you're pretty much on top of the situation -- you may be in a state of frustration or anxiety about the things you don't know and can't find out for yourself. You might find out later -- at an annual physical, for example -- but until then you're in suspense.

I don't especially like suspense. Movie scenes in which someone is slowly exploring a dimly-lit basement -- while we wait for the axe-murderer to come leaping out of some dark corner -- are generally not my favorite movie scenes. Actually, I should put it more strongly: I hate suspense, and I am quick to resent anyone who seems to be subjecting me to it needlessly. If I could change anything about the way our health-care system treats its customers, I would probably start with suspense-reduction rather than expense-reduction.

This is one of my great failings as a diabetes patient, of course. I ought to just do the best I can and not worry about things invisible to me, but the truth is that I am always worrying about things invisibile to me. Waiting for bad news (by which I mean "waiting for news which could conceivably turn out to be bad news") is almost absurdly hard for me. At the moment I am fretting about the hemoglobin A1c test which I expect to be taking in October -- and which I fear will be seriously impacted by my troubles with glycemic control during August. I am also fretting about the colonoscopy which will probably happen later in the fall. Does worrying about these things help me? Definitely not. Can I knock it off, then? Theoretically yes, but so far I haven't been able to.

Perhaps my real problem is that I have too much imagination. I am too aware that dramatic things can be happening without my being aware of them. If the sun blew up entirely, we wouldn't know it for more than 8 minutes -- so for all I know it happened 7 minutes ago!

Doctors have a word for this: hypochondria.

When Junk Isn't Junk

Friday, September 7, 2012


I didn't want or expect a fasting result above 95 this morning -- I was hoping I had put that sort of thing behind me after recovering from my vacation. Get back to work on it, Tom.

At least my post-prandial result this afternoon was good.

Junk DNA & The ENCODE Project

I have never been a believer in "junk DNA". The notion that only a tiny amount of our DNA consists of functional genes, while the rest is genetic gibberish and serves no purpose at all, has never seemed plausible to me. I figured that the rest of our DNA must be there to do things that we simply haven't figured out yet.

And it turns out that I was right. Geneticists are finally starting to discover what all that supposedly purposeless "junk DNA" is there for. This makes me feel smug -- which is, of course, a great feeling.

The notion of "junk DNA" arose from early studies of how genes work. The DNA molecule is shaped like a spiral-staircase, with each "step" consisting of a pair of chemical bases bonded together. Because the bases are of four types and can occur in any order, the base-pairs can serve as "letters" spelling out a coded message.

The purpose of the code (at least, the purpose that scientists found easiest to figure out initially) was to give our cells instructions on how to assemble a protein. A given sequence of base-pairs was called a "gene" if it contained the instruction for creating a specific protein. The body builds and regulates its tissues using these proteins, so obviously the genes for creating proteins play a very important role. About 21,000 different genes have been identified, each playing its own specific role in the protein-making process.

However, those genes account for only 1% of the total genetic code! The remaining base-pairs do not code for a protein. So what are they there for? They don't seem to do anything. For this reason, they came to be called "junk DNA".

Well, if junk DNA doesn't do anything, why do we have it? Above all, why do we have so much of it? Nature tends to erode rather than expand needless features, as in the case of cave-dwelling fish gradually losing their eyesight and even their eyes. A few patches of meaningless DNA code, here and there, might not do any harm, and therefore might linger on for a long time, but it's hard to see how we could get into a situation where 99% of our DNA consists of biochemical rubbish.

It's also hard to see how vast stretches of meaningless code could be truly harmless: after all, if our DNA is mostly random junk, doesn't that increase the risk that some of it is also cancer-causing junk? You would think natural selection would eliminate DNA which is not only useless but hazardous -- or at least would reduce it to well below the 99% level!

I can accept that biology sometimes fails to eliminate a non-functional feature, so long as it's harmless -- as in the case of male nipples. But if men had 200 nipples rather than two, I think it would be reasonable to assume that nature would not be so extravagant with them, unless they served some purpose.

Ever since I first heard about junk DNA, I figured this concept was simply a misunderstanding on the part of the geneticists. Probably they were looking for DNA sequences that code for proteins -- on the assumption that this is what DNA is for -- and they were too quick to dismiss as "junk" any DNA sequences which didn't code for proteins.

However, once they realized that 99% of all DNA is junk by this definition, they should have paused to think about whether they had defined the purpose of DNA much too narrowly. A visitor from Mars who had never seen a book before, and who was first confronted with a book in the form of an algebra text, might conclude that the purpose of books is to teach the earthlings how to do math. But that visitor, upon exploring a library in which most of the books were not about mathematics, would probably start to wonder if maybe books had other purposes as well. (And if he didn't wonder that, we might reasonably conclude that the red planet had not sent us one of its smarter Martians.)

Fortunately, not all geneticists were willing to dismiss DNA sequences which didn't code for proteins as junk. In 2003, a large research project was launched to investigate the "other 99%" of DNA, to see if it perhaps it actually did something. The project is called ENCODE (a somewhat strained acronym for Encyclopedia of DNA Elements).

What has ENCODE discovered so far? Well, for one thing, at least 80% of that 99% of DNA does perform a biological function: it serves as an extremely complex control mechanism. The "junk" DNA may not consist of genes, but it is in charge of running the genes. It sends transcription factors and regulatory factors swarming up and down the DNA strand, turning genes on and off, and intensifying or weakening their effects. Genes would be useless without the so-called junk DNA, because it is the junk DNA which regulates the "expression" of those genes. Far from being inert, the junk DNA is in charge.

This discovery solves (or at least offers hope of solving) some persistent mysteries about how genes affect our health. For example, why do people carrying the gene for a disease sometimes not get it -- and why do people carrying the gene which protects against a disease sometimes get it anyway? (This even happens to identical twins -- one of whom may develop a genetically-driven cancer while the other remains free of it). Confusions and complexities of this sort become less mysterious, once we know that the "junk DNA" regulatory system may be turning bad genes -- or good ones -- on and off. Knowing which genes you have doesn't tell you what your health future will be, if the outcome is ultimately determined by how this newly-discovered regulatory system activates and deactivates your genes.

Clearly all this is pertinent to Type 2 diabetes. The disease is associated with many different genes, but not one of them can definitely determine whether you will become diabetic or not. And the disease is also associated with excess weight and insufficient exercise. So what's going on there? Can it be that the gene-regulating functions of the "junk DNA" system are responsive to lifestyle factors -- and may activate your diabetes-related genes, if you develop the wrong habits?

Clearly, the discovery that junk DNA is not really junk adds a new layer of complexity to our understanding of genetics, and it may take a long time before we know anything medically useful about how this gene-regulating system actually works.

But it shows that I was right all along about junk DNA, and for me that's more important than anything else. So thank you, geneticists! You certainly took your time about validating my opinion, but better late than never.      

Questions, Questions

Thursday, September 6, 2012

Dental Fun

I felt a little cheated at the dentist today -- the receptionist had told me that, if I moved my appointment to today at 7 AM, they would have enough time to "get it all done at once". Turns out that what she meant by "it all" was the left side of my mouth. After ninety minutes of root-planing work on me, the job was only half done, and I have to come back in a few weeks for the other side.

In terms of pain, it wasn't nearly as bad as I expected -- but I can't help being extremely tense and unhappy in a dentist's chair, and ninety minutes in that state is a rather long time. I'll be glad to get the other half over with!

My comments below, on search strings that caused Google to send people here. As always, some of questions are clearly from people who are hoping to be told that their troubling lab results might be wrong.

"does clotting affect a1c results"

The blood sample submitted to a laboratory for a hemoglobin A1c may be clotted, but the lab has procedures for dealing with that; if they treat a clotted sample appropriately, they can still get a valid test result from it. It's not as if they're going to be fooled into giving false results because your sample is more clotted than somebody else's.

"could an infection raise you a1c reading"

Maybe -- if the infection goes on for a long, long time.

Chronic infections (such as periodontitis, which is the issue I was trying to deal with at the dentist's office today) produce an inflammatory response; this can have the effect of reducing your insulin sensitivity, which in turn can elevate your blood sugar, which in turn can elevate your hemoglobin A1c result.

A short-term infection isn't likely to have an impact on an A1c test, however.

"i have high glucose in urine but normal a1c"

Shouldn't your doctor be giving you a bit of feedback about this? There are a few (rare) conditions besides diabetes which can cause sugar to be present in the urine, but your doctor needs to be figuring which of those conditions you have.

If you have independently discovered that you have glucose in your urine (using urine test strips, or perhaps tempting the bees), and you are assuming that an A1c test which wasn't recent is still valid, the explanation might be that your blood sugar has gone up a lot since the last time you had an A1c test -- and if you redid the A1c today, it wouldn't be normal any longer.

"what if a diabetic is medicated and still has high glucose"

Then that patient has discovered the best-kept secret about diabetes management: that diabetes medications by themselves are not enough to give most patients with Type 2 diabetes good control of blood sugar.

"i'm diabetic can i give blood"

Here are the Red Cross guidelines on this issue:

"Diabetes mellitus: Acceptable two weeks after starting insulin.
Medications to lower your glucose level do not disqualify you from donating. Those who since 1980, received an injection of bovine (beef) insulin made from cattle from the United Kingdom are not eligible to donate. This requirement is related to concerns about variant CJD, or 'mad cow' disease."

Apart from that, you're in the clear. I have often wondered what they do if you donate them a pint that has a very high sugar content, but it may be that this simply isn't much of an issue, as that pint will be diluted in the rest of the recipient's blood supply, and unless the patient is also diabetic they won't be much affected. Anyway, a patient who is getting a transfusion probably has bigger issues to worry about than that.

"my hemoglobin is 6.2. am i at risk of becoming diabetic"

Yes. Labs disagree slightly about where the upper limit of "normal" is on an A1c test, but 6.2 is certainly above normal. You only have to get to 6.5 before the A1c alone is enough evidence for a diagnosis of diabetes. If you're at 6.2, you are certainly heading for 6.5, and will probably get there pretty soon if you don't take corrective action.

You don't want to wait for an "official" diagnosis of diabetes before you start doing something about the problem -- and if you didn't have that problem, you wouldn't be at 6.2 in the first place.

"post prandial glucose is 186 after eating quinoa pasta"

186 after a meal is too high, but I'm guessing that the subtext here is "those bastards told me that quinoa was a different sort of grain and it wouldn't elevate my blood sugar!".

Well, maybe you would have gone to 206 instead of 186 if it had been wheat pasta. Quinoa might be a little better than wheat, and whole wheat might be a little better than refined wheat, but if you count on the difference to be large in such cases, you are setting yourself up for a disappointment.

At least you tested to see if it really worked -- sad to say, a lot of diabetes patients just follow popular advice about eating brown rice instead of white rice, and take it for granted that this is effective.

"what does a1c of 7.3 mean"

It means that 7.3% of the hemoglobin in your red blood cells is encrusted with sugar. Or, to put it another way, it means that you are diabetic and your diabetes is not under very good control. Blood that sugary does harm to you, over the long term. You need to bring that down.

That Organic-Food Study

Wednesday, September 5, 2012

Meta-Analysis: The Cuisinart Of Data!

I'm starting to wonder if it might be a good idea to pass a law against publishing meta-analysis studies.

A meta-analysis is a study in which you don't do any original research or gather any new data -- you just review a bunch of studies that were published before on a given topic, and slice-and-dice the data from those studies in order to support a grand conclusion which you put into a press release; soon the public is being told that you proved something important. You may not actually have proved it, and in fact your published study might have very little to do with the thing you supposedly proved -- but what does that matter? The public is told on the evening news that you proved something important.

There are a lot of problems with this approach. One of them is that the studies you have selected used various different methods of assembling test subjects, gathering data, and interpreting the meaning of that data. What does it really mean to combine data from studies that really didn't collect the same kind of data?

The biggest problem with a meta-analysis, however, is the selection process. Which studies do you include? If you are actually out to prove a particular point, you can easily select studies that support the point you are making, and exclude studies that don't support the point you are making. You can always invent criteria for inclusion which just happen to favor the studies you want to include, to protect yourself from a charge of cherry-picking the data. This problem becomes especially serious when the study is looking into a subject about which there is intense controversy. Who gets to decide which studies can be included in a study of the health effects of vegetarian diets, or low-carb diets, or heavily-marketed prescription meds? Often, when a study receives a lot of media attention, subsequent investigation reveals that a lot of questionable decisions were made about what sort of data to include.

And then there is the hidden selectivity known as "publication bias". Studies which yield negative results generally don't get published -- which means that studies which claim positive results (legitimately or not) are over-represented in any meta-analysis. If there's a rumor that cell phones cause cancer, and ten studies look for evidence of the connection, but only two of them find such a connection, those are the two that get published. A meta-analysis inevitably excludes most of the data which doesn't confirm the idea being studied, because most non-confirming data never sees the light of day.

Meta-analysis studies are often pretty obviously the work of someone with an axe to grind, and it is often possible to uncover strong evidence of bias in their selection of data, or in their presentation of its statistical significance. Always watch out for impressive conclusions drawn from unimpressive numbers. (One much-publicized study earlier this year, involving 15,600 subjects, claimed to have shown that the children of gay parents had more social and emotional problems than other kids. Of those 15,600 subjects, how many had been raised by a gay couple? Two.)

Because it is so easy to use a meta-analysis to support a conclusion reached in advance, a meta-analysis pretty much needs to be judged guilty of bias -- or even fraud -- until proved innocent. We have to look at who is paying for the study, and who is promoting it, and who is proclaiming what it supposedly proves, and what prejudices (and concealed motives) may be involved.

Which brings us to the meta-analysis published yesterday by the Annals of Internal Medicine, which supposedly shows that organic foods are no safer or healthier than other foods. That's how the popular press is summarizing the study, anyway. Arguably, that is not the fault of the study authors, who are notably more temperate than their interpreters: "The published literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods. Consumption of organic foods may reduce exposure to pesticide residues and antibiotic-resistant bacteria."

Huh? If, by "more nutritious", we mean "containing more macronutrients, vitamins, and minerals", I'm not sure that was a claim that many people were making for organic foods in the first place. So if the published literature "lacks strong evidence" for that idea, it isn't exactly a game-changing revelation.

I had been assuming that reduced exposure to pesticide residues and antibiotic-resistant bacteria was, in fact, the whole point of the organic-food movement -- and the study says that this claim, which people have been making for organic foods, "may" be valid.

In short: we have no strong evidence in favor of claims that people weren't making for organic food, but the claims people were making for organic food may be valid.

How this gets translated into "we proved that organic food is a stupid waste of time!" is a little unclear, but the translation has certainly been made, and that is how the major media outlets have played the story.

I don't have an axe to grind here myself, as I don't have any consistent attitude about the issue of organic food. Sometimes I buy it, and often I don't. The problem is that I have no idea whether the food offered as "organic" in grocery stores is actually any different than other food sold in the same store. (I'm a little more confident at a farmer's market, but not 100% confident.) It does seem likely to me that it would be better to have less exposure to the pesticides, antibiotics, growth-hormones, and other dubious chemical tools of the factory-farm industry. But I'm hardly a fanatic about this issue, and in fact I often ignore it.

Is it possible that the authors of this study -- or at least the people who pushed it into the media spotlight -- are a little fanatical about this issue? Note this curious detail about the disclosure statements in the published article: "Primary Funding Source: None."

What do you mean, "none"? You're saying this was volunteer work?

I mean, come on, guys. Somebody was behind this.   

Fun At The Dentist Tomorrow

I start my day early tomorrow, with 90 minutes of "root planing" (a rather aggressive and invasive cleaning process, needed to treat or prevent periodontal disease), which I am not looking forward to.

Apparently some of us are simply cursed -- by unfortunate mouth chemistry, or some other problem -- with a tendency toward gum disease, which no amount of flossing can defeat. I try my best to keep the problem under control, but every once in a while I have to get this treatment. It's actually been several years since the last time I went through it, so I guess you could argue that I've had a pretty good run, and should stop whining. Okay: whining over.

Your Body: Should You Move It?

Tuesday, September 4, 2012

Some Lifestyle Studies

A few articles I read today reported on research showing health benefits of physical activity.

One study at the University of Texas found that fitness in middle age leads to reduced incidence of chronic disease later in life -- in fact, those with the lowest fitness level in middle age had almost double the rate of chronic disease later on than did those with the highest fitness level in middle age. According to the study authors, physical activity "likely represents an important determinant of healthy aging".

A German study found that a fitness program which was based at the workplace rather than a clinic had impressive success at cutting down the rates of smoking, hypertension, and metabolic syndrome.  One of the study authors is quoted as saying that "the workplace is the ideal setting for primary and secondary prevention, because there we can get access to all patients at risk" (which is a nice demonstration of professional naivete: an intervention in the workplace doesn't give you access to "all patients"; it gives you access to patients who have jobs).

Another study finds that going for a walk after a meal (an established custom in Mexico and some other countries) has the effect of cutting post-prandial increases in blood glucose -- cutting them by half, in healthy patients, and cutting them even more in patients with Type 1 diabetes. This interested me, because I have read about research showing that Mexican immigrants to the USA suffer a strongly elevated rate of diabetes and other chronic disease after they get here. The suspected reason for this decline in health is that healthy customs which a family formerly practiced in Mexico may disappear once they are living in the USA. Apparently Mexican families tend to stop going out for walks together after dinner, after they've lived here a while. It's a little hard for me to believe that Mexican families abandon this custom (considering how many Mexican families I see walking around Spring Lake in the evening), but perhaps I'm only seeing the more recent arrivals, who haven't abandoned it yet. At any rate, it appears that there is a penalty for abandoning it, and they ought to reconsider.

I'm glad to see more and more studies looking into, and confirming, the health benefits of exercise. Maybe eventually people will start to realize that this stuff matters.

The Walnut Issue

A lot of people have a big problem with vocal music that is sung in a foreign language. Whether it is an Italian aria, a French chanson, or a Gaelic ballad from the Isle of Skye, the listener familiar with none of these languages can have only a rough idea of what the text means, from hurriedly skimming a synopsis or an awful translation (and nearly all translations of vocal music are awful -- nothing is less translatable than lyric verse). To me, though, this lack of clarity is not a disadvantage. Like candle-light, lyrics in an unfamiliar language invite us to use our imaginations to fill in the details we can't perceive directly. The result is something better, or at least more interesting, than clarity ever could be. Often I prefer not to understand lyrics completely. Sometimes it's even fine with me not to have anything better than a vague idea what the singer might be singing about. (Especially when it's a singer who can produce a high B-flat like this one .)

I have lately begun to apply this principle to news from the world of medical research. When the title of an article has obviously been designed to be startling and a bit puzzling, so that you will be compelled to read the article and find out what story could possibly lie behind that headline... I am sometimes perfectly content to read the headline alone and move on -- leaving the mystery unsolved.

Such was the case with one of the headlines I read today: "Walnuts Appear to Improve Semen Quality in Healthy Men". Read the article if you want to, but I'm not bothering with it. Others might insist upon knowing how "quality" is judged in this context, and how quality is affected in men who are not healthy, and why walnuts, of all things, would be relevant here (or why it would occur to anyone to look for such a connection in the first place).  Not me. I'm quite willing to take in the headline and leave it at that.

The only worrisome aspect of the story is that walnuts are my least favorite variety of nut. I'm not sure that the implied quality-control issue is one that I want to dwell on.   

Back In The Saddle

Monday, September 3, 2012

On Blogging Again After A Month Off

I was sorely tempted to use the Labor Day holiday as an excuse to delay my return to blogging, but Labor Day isn't celebrated everywhere, and anyway I said I'd be back on Monday. Also, my numbers were good today, and it was good to have a chance to report good numbers.

My numbers were certainly nothing to boast about during my trip to Ireland -- and even after I got home, I had an extremely hard time getting my fasting results under 100 (or even under 110, a lot of them time). My fasting result today (83) was the third in a row that was under 95, and was also the lowest I've seen in a good while, so I'm starting to feel relieved that my problems with glycemic control during and after my vacation are apparently not permanent.

I have some doubts about seeing a fasting result as low as 83 tomorrow, because I indulged in a barbecue earlier this evening. The dinner itself was scrupulously low-carb (meat and green vegetables), but I drank two beers with it, so we'll see what impact that has.

I have to admit that, after I got home from Ireland and found that my glucose levels did not immediately start falling back down to where they had been, I was pretty alarmed. Had I finally lost it? Had some switch flipped inside me, which would make it impossible for me to control my glucose in the future without drugs?

I think I have never shaken off my fear of the doomsday scenario which is so often (and so irresponsibly) presented to diabetes patients who want to achieve glycemic control through lifestyle changes: "Diet and exercise work for a few years and then they stop working, and when they stop working there's nothing you can do about it". Although the doomsday scenario is usually not any more specific than "a few years", I have seen it claimed that the absolute maximum you can hope for is ten years. I've gone eleven and a half years, so by now I should have the courage of my convictions, and should not think "This is it -- the game is over and I've lost!" every time I have a setback. The sad truth is that I think exactly that, every time.

Anyway, I'm glad to have had a long break from blogging, and glad that I didn't have to resume the practice until I started getting some non-embarrassing results. But anyway -- I'm back!

Travel & Diabetic Control

Why, exactly, does travel make diabetic control so difficult? There are a lot of factors involved, clearly.

For me, the sheer disruption of flying from California to Ireland was a major issue. My sleep was seriously compromised, obviously, and added to that was the stress involved in being ill-treated by the airline. Our flight to Newark was late, and they knew they had several Ireland-bound passengers on the late plane who had to go about half a mile to reach the gate for the connecting flight. By running (dangerously) through a crowded terminal, we managed to get there, as if by a miracle, just before the stated departure time... but they had closed the gate and didn't want to let us board. We yelled, screamed, cursed, pounded on locked doors, bared our teeth, and generally acted like wild animals until they let us on the plane. Experienced travelers tell me this is what you have to do, these days. "Air rage" used to be a pathology; now it is simply the minimum effort you have to make in order to get the airline's attention. You have to give them a dead-eyed look which says, "I was thinking about suing you, but now I'm not sure that's the right approach, because killing you is looking like a much more attractive option at the moment." Well, our undignified display of ferocity worked, and they let us get on the plane. But we paid a pretty high price in physical stress for the experience, and I'm sure that had an effect on me.

Perhaps you have already sensed that I'm not a good traveler. Your intuition is correct: I'm not. When I am an airline passenger, I never feel like I am a "customer" -- I am a hostage (except that hostages usually get more leg-room). And this feeling does not entirely leave me when I arrive at -- and eventually exit! -- the destination airport. Simply to be away from home, and in an unfamiliar environment (where nothing works the way it does at home) is enough to stress me out. Example: for someone accustomed to the California notion of what the word "road" means, a journey by car through rural Ireland is not likely to be a relaxing experience.

Still, if we want to visit places that have great advantages over the place we are used to (in Ireland those advantages include a beautiful landscape combined with friendlier and more culturally-accomplished people than you are going to meet just about anywhere else), then the stressful side of travel is simply the price we have to pay. (It's because I can't always persuade myself to pay that price that I don't travel very often.)

Another thing that travel can greatly interfere with, for anyone controlling diabetes through lifestyle, is exercise. I addressed that issue as soon as I could. At the first place we stayed (as houseguests of the great Irish fiddler Martin Hayes , whom we knew from studying with him during his visits to California) I found a little-traveled backroad and made a routine of running on it every morning before breakfast:

I wasn't getting as much exercise as I get at home -- my runs in Ireland were usually just 3 to 4 miles -- but I figured it was enough to meet minimum requirements.

Sleep is a problem, too, if only because it takes such a long time to recover from jet-lag. I certainly did a lot of therapeutic napping in the afternoons, to try to make up for it, but there's only so much you can do to correct a problem like that.

The biggest problem throughout the trip, of course, was food. Regarding the nutritional aspect of my hostage ordeal in the air-travel gulag, the less said the better. But being away from home almost inevitably makes it harder to stick to any kind of nutritional principles. I was eating at restaurants and pubs quite a lot -- and having mounds of highly tempting carbs placed in front of me three times a day. Ireland is a place where a restaurant may choose to supplement the salmon you ordered with three servings of potatoes, prepared three different ways (all of them good). And let's not forget the breads they put in front of you, too.

My problem is that I really crave bread and potatoes, and I can hardly keep my hands off them when they are placed within easy reach. At home, I am able to show a certain amount of backbone in terms of not buying lots of high-carb foods at the grocery store; but this steely determination doesn't last long when a waiter sets them down right in front of me. The friends I was traveling with eventually became my carb-cops and started moving these temptations out of my reach, but on the whole I have to admit that my dietary discipline during most of the trip must have been pretty poor, otherwise my numbers would not have started climbing. At home, I hate to see a fasting result above 95; in Ireland I had several in the 110-120 range, and was very unhappy about it -- although I realize that a lot of people with Type 2 diabetes would be happy to get results that low. To me, they were high; I guess a lot depends on what you're used to, and what you've defined as good enough for you.

So here's my summary of the effects of long-distance travel on glycemic control, and the possible ways to mitigate said effects:

Maybe my real solution to all of the above problems can be summed up in two words: travel infrequently!

Catching Up On The Health Headlines

This just in from The Onion :



Getting Back

Saturday, September 1, 2012

I'm back from my journey (primarily a musical journey) to Ireland, and I'm trying very hard to work myself into the proper mental state to take up blogging about diabetes again. It's been awfully nice to spend a whole month not doing that, but all good things must come to an end, and I guess it's time to get back on the horse.

But for today I'm not going to do anything besides showing you a few of the several hundred photos I took while I was in Ireland. It was a kind of research project to see how many shades of green there actually are in the world. Quite a few, it turns out...


















All right -- that was easy enough. Monday I'll get back to the more difficult part of the assignment...


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