Walking and Talking and Walking

Friday, August 30, 2013

During my continuing slow recovery, I'm trying to get exercise back into my life, but gradually. All I managed today was another evening walk, only this time a little faster and farther than yesterday. I walked around Spring Lake, which is pretty, and always has a lot of people walking around it. But here are also plenty of people of people running and cycling around it, too -- and I envied them, because they were feeling up to it and I wasn't.

I'm sure I'll get there by and by, but it feels like a long wait.

 


Fruit and Diabetes Risk

Eating certain foods is believed to increase the risk of developing Type 2 diabetes. White rice, for example, which is pretty close to being pure starch -- one is tempted to call it weapons-grade starch -- is thought to be especially hazardous in this regard.

But what about fruit? Is it as bad as white rice, because of the sugar in it, or is it better than that, because of the fiber and vitamins in it?

A Harvard-organized research project finds that some fruits can actually reduce the risk of diabetes. Blueberries, grapes, and apples are your best bets in this regard. But there's a catch: you need to eat the whole frut. Fruit juice -- which is almost pure sugar, with the fiber stripped away -- tends to increase your risk.

The actual risk reduction isn't exactly dramatic (about a 23% reduction) even with the fruits that tested best (blueberries). But at least blueberries don't increase your risk, which would have seemed plausible.

 


Walking the Talk

I've been reading a lot this year about research showing that sitting down for long periods (even if you get in a hard daily workout, during the hour or so that you're not sitting on your butt) is extremely harmful to health. But the problem seemed a little hard to solve, given the nature of the workplace.

A young business guru named Nilofer Merchant thinks she's found a solution to the problem: couldn't meetings, at least, take place while people were taking a walk? Here's her TED Talk on the subject. It's not a long video; see if she can convince you that this might work. She claims that "fresh air gives you fresh ideas". It sounds a little glib, and yet I can imagine there being some truth in that.

In some companies, this could be practical, at least for small meetings. Unfortunately, the meetings I go to are seldom local-only. There are usually people participating by phone from China or the UK. Other than taking a walk around the conference room, I think we'd usually be prevented from walking anywhere, because we usually need to say near the speaker-phone. Also, the meetings I go to tend to involve a lot of reference to graphs and block diagrams and flow charts. I'm working in an engineering culture, which places a premium on hard specifics (if engineers say that your presentation involved a lot of "hand-waving", they mean that they didn't believe a word you said). There are not a lot of meetings I go to which could be adequately conducted while strolling through the woods and fields.

Which is too bad, because I think I would like meetings a great deal more if they actually were run that way. And I'd be a lot better at staying awake during them. And apparently I'd be healthier for the experience.

I have heard of businesses which hold their meetings in conference rooms that have no chairs; the theory is that people are not so long-winded, and meetings don't drag on so long, when people have to stand up for them. I don't think it's as good as a walk in the fresh air, but it would be an improvement on the usual system.

 


An Evening Walk

Thursday, August 29, 2013

 


Trying to Get Moving Again

During my poison-oak ordeal (which improves daily, but only by small degrees) I haven't felt up to doing any kind of workout. I've kept my blood sugar within bounds by restricting carbs more than is usually necessary for me (I live in a world of salad right now), but this evening I felt that I had to do something. So I went for a walk around the neighborhood after dinner, looking at my surroundings lit up by the setting sun. It wasn't exactly strenuous, and it was only a couple of miles, but it was a start.

Of course, a walk after dinner is a healthy practice which we are all supposed to be doing anyway. It's traditional in many parts of the world; in fact, abandonment of that traditional practice has been suggested as one of the possible reasons why Mexicans tend to suffer a decline in health after relocating to the USA. And it did feel like a healthy thing to stroll down my woodsy lane to the main road.

That road is one of the few ways to get over a ridge that separates one part of Santa Rosa from the other, so it is heavily traveled most of the day. But it does calm down in the evening. There are remarkable views once you get to the top.

And the views are better at sunset, of course.

To the east: a sparsely-populated valley, with a sprinkling of rich people's houses accessorized with vineyards and stables.

To the west, the small downtown area, and the suburban neighborhoods surrounding it. Farther west, the evening fog spilling over the hills from the Pacific.

Also to the west: a glimpse of the red roof of the building I work in. I always like to see it from a long distance like this; it seems so innocent, so stress-free.

And I always like to finish a walk when the sun is disappearing and only the tops of the trees are lit.

Well, it was a nice walk. I'm not sure I would really call it exercise, but it's better than nothing, and it's a start. I can probably try a longer walk tomorrow, and work may way up to running again. As I continue my slow recovery from the poison-oak disaster, and my legs become less stiff and swollen, I ought to be able to do a little more each day.

I guess the important thing is for me to learn something useful from this mishap. Well, the obvious lesson is "don't get that close to poison oak again", but is there something more to learn?

Maybe the lesson is that it's still possible to keep diabetes under control even in extremely uncomfortable, unpleasant, and disruptive circumstances, if you're careful about what you do. But I shouldn't say that, in case tomorrow's glucose tests make a fool of me.

I guess it's time for me to recall that fable (which originated in ancient Persian poetry, but has become pan-national folklore), about a king who commanded a group of wise men to make for him a ring which would bear a single inscription that was sure to make him happy when times were sad, but was also sure to make him sad when times were happy. So they made him a ring engraved with the inscription, "This too shall pass".

 


One Pill Makes You Small!

Wednesday, August 28, 2013

Once again, my poison-oak-ravaged legs felt better than yesterday, but still not quite stabilized enough for exercise to seem feasible. Blood sugar still under control, but I'd better get myself back into workout-ready condition soon.

If you haven't had the poison-oak experience yourself, and it's hard for you to imagine how a mere rash could be bad enough to make someone who's used to daily exercise feel that he has to give it up for a while... well, thank your lucky stars that you're not in a position to understand this better!

 


Weight-Loss Drugs

An effective anti-obesity drug is pretty much the holy grail of pharmacology; if you can develop a pill that will make people lose weight, you can look forward to getting very, very rich. So a lot of people are trying to do it. The trouble is, anti-obesity drugs, like other drugs, need to demonstrate both safety and efficacy... and that's a hard combination to get right.

Most medications proposed as anti-obesity meds turn out not to work, and the few that do work keep turning out to be unsafe.

In the 1990s, a drug known as fen-phen (the combination drug fenfluramine/phentermine) was heavily marketed as a weight-loss medication. It was popular, and in fact it did seem to help people lose weight. Doctors worried about it, because an earlier, similar drug called aminorex had turned out to cause lung damage. Would fen-phen also cause lung damage? Not at all! Fen-phen caused heart damage. The FDA recommended withdrawal of the drug from the market in 1997; during the next eight years, lawsuits from people who had taken the drug added up to about 14 billion dollars' worth of liability.

Other anti-obesity drugs have come to grief in another way: they targeted a particular area in the hypothalamus (a part of the brain) associated with appetite control. Unfortunately, that same area of the hypothalamus also regulates mood; some people who took these drugs suppressed their mood along with their appetite, and became suicidal. Even anti-obesity drugs which have been approved by the FDA (such as Qsymia and Belviq) are not widely prescribed, because doctors are concerned about their side effects (and perhaps mindful of all those fen-phen lawsuits). This has sent researchers off on a search for a drug which works not simply by reducing appetite, but by disrupting the body's tendency to store fat.

In 2005, an experimental anti-cancer drug which was then known as CKD-732 was found to promote weight loss; since then, the pharmaceutical company Zafgen has been working on getting it approved as a treatment for obesity. They have high hopes for it, especially as it seems to be safe: it has so far not been shown to have the dangerous side-effects associated with other weight-loss meds. (Reality check: at one point fen-phen was also not known to have dangerous side-effects.)

The drug is now called "beloranib" (not such a big improvement on "CKD-732", if you ask me, but no one did), and it seems to do wonderful things. It is a MetAP2 inhibitor, which means that it blocks the functioning of the enzyme methionine aminopeptidase 2. That enzyme happens to be crucial to the production and usage of fatty acids within the body; blocking the enzyme causes weight loss, reduction of serum cholesterol, and other desirable changes. It seems to cause more weight loss in a shorter time than competing anti-obesity drugs, and without (so far as anybody knows yet) causing people to jump off buildings or suffer collapse of the heart valves. What's not to like?

I guess the question that still needs to be asked is: does that enzyme MetAP2 do anything else besides regulate the production and usage of fatty acids? If it does anything else, suppressing it chemically might turn out to have unforeseen consequences. That's why drug approvals take so long. It can take a while for it to become clear that a new drug causes people to become constipated, drive into trees, or talk about dipthongs in mixed company. Maybe beloranib will continue to seem like a miracle cure for obesity even after more is known about it. I'm not sure I'd bet on it -- but Zafgen clearly is, so I'd advise them to get to work on finding a better name for the stuff by the time they're offering it for sale.

 


Taste Buds

Tuesday, August 27, 2013

My poison-oak nightmare continues, but I guess it was about two or three percent less nightmarish today. There were times, scattered throughout the day, when an entire minute would go by when I wasn't thinking about the fiery, ugly, itchy rash on my legs. I was going to say "unbearably itchy", but it's not really unbearable -- it's just unignorable. I can take it; what I wish was that I could stop thinking about it.

After a long day at the office of constant physical discomfort, I still didn't feel capable of intensifying the discomfort by attempting exercise after I got home.

I hope I'll feel up to it soon, though. My blood sugar is still within bounds, but that won't last if I can't get back to working out soon.

 


I Have Taste Buds Where?

The headline "Gut taste mechanisms are abnormal in diabetes sufferers" caught me by surprise. What on earth would "gut taste mechanisms" be? And what would abnormal ones be like?

Well, it turns out that we don't just have taste buds on our tongues. We also have them in our intestines. They are there not for the purpose of giving us a sense of what our food tastes like on the way out of us rather than on the way into us (not that I'm complaining, mind you), but for the purpose of giving our body an idea of how much carbohydrate we're taking in. Armed with this information, the body is able to respond appropriately. That's how it's supposed to work, anyway. "In his study, Dr Young compared healthy adults with type 2 diabetic adults. He found that the control of sweet taste receptors in the intestine of the healthy adults enabled their bodies to effectively regulate glucose intake 30 minutes after exposure to glucose. However, abnormalities in the diabetic adults resulted in more rapid glucose uptake."

According the researchers at the University of Adelaide (in Australia), these taste buds tend to fall down on the job when they are located in the intestines of diabetes patients. "When sweet taste receptors in the intestine detect glucose, they trigger a response that may regulate the way glucose is absorbed by the intestine. Our studies show that in diabetes patients, the glucose is absorbed more rapidly and in greater quantities than in healthy adults. This shows that diabetes is not just a disorder of the pancreas and of insulin -- the gut plays a bigger role than researchers have previously considered. This is because the body's own management of glucose uptake may rely on the actions of sweet taste receptors, and these appear to be abnormally controlled in people with type 2 diabetes."

Of course this leaves unanswered the big question: how does this "gut taste" regulatory mechanism work in non-diabetic people, and how does it fail in diabetic people?

You know what the answer to that one is as well as I do. "More research" is needed!

 


Down with the Immune System!

Monday, August 26, 2013

 


My Poison Oak Adventure

I am now wishing that I hadn't agreed to particpate in the trail-clearing activity on August 16th, because it has now become tragically clear that the work exposed me heavily to our friend Toxicodendron diversilobum, better known as western poison oak:

That's the green version; it's actually in its red phase now:

Most typically it's a bit of both:

Just be glad that I'm only showing pictures of the plant's leaves, instead of showing you pictures of what they can do to you.

Poison oak (like poison ivy and poison sumac) exudes an oily resin containing urushiol. I am told on good authority that urishiol is made of "unsaturated congeners of 3-heptadecylcatechol with up to three double bonds in an unbranched C17 side chain". So you see the problem!

In humans (or in most humans), urushiol triggers an immune-system reaction which results in contact dermatitis -- inflammation of the skin. "Contact dermatitis" seems like an awfully mild term for the effect that poison oak actually has on human skin: a ferocious red rash with hives and blisters and an itching sensation so intense that it dominates your consciousness day and night; thinking about anything else becomes difficult, and dropping off to sleep becomes nearly impossible.

Contact dermatitis associated with poison oak is an allergic reaction; not everyone suffers from it, because not everyone's immune system is sensitive to it. I had never suffered from it before. Unfortunately, exposure can cause you to develop the allergy even if you had always thought you were one of the lucky ones. If you were already allergic before an exposure, the rash develops early (within 48 hours). If you are newly allergic, the rash can take more than a week to develop, and the delay will encourage you to think your time in the woods had no consequences. I thought exactly that, when I didn't develop a rash within a few days of my trail-clearing volunteer work. I hadn't done the research to learn that, for novices, the rash takes a lot longer to develop.

Well, by last Friday a rash was starting to develop on my right calf (I had, I'm sorry to say, been wearing shorts during the trail-clearing work -- it was hot and I was dumb.) By Saturday it was getting bad, and my left leg as also affected. On Sunday it was almost unbearable. Today it was unspeakable, and in the afternoon I called my doctor to report my appalling symptoms. He told me that, however appalling they might be, they are par for the course. He prescribed an ointment for me that is stronger than the cortisone creams you can buy off the shelf, and he suggested that I take an anti-histamine to help me sleep. But he also said that I pretty much have to wait this out for 10 to 15 days. The very worst of it will soon be over, but it's still going to be ugly and uncomfortable for several days.

This experience is really beginning to make me resent my immune system. Yeah, I know, people with failing immune systems (due to AIDS or other medical issues) soon have reason to wish they had their old immune systems back. But still! Deer and most other animals can eat poison oak without suffering any ill effects from the urushiol in it, so the ridiculously intense human allergy to the stuff seems awfully stupid and pointless. It doesn't even benefit the plant, much less the humans.

But, of course, my immune system isn't the only thing I'm resenting now. There's nothing like intense, nagging physical discomfort for making you resent anything and everything. Today was a warm day, and I kept seeing people walking around in shorts; I found myself hating them for their healthy skin. How dare they taunt me like this with their rash-free legs? At least I'm able to recognize this sort of thinking as irrational. It's a little too reminiscent of the diabetes patients who yammer on about the "anger" they feel over being diabetic.

Of course, I am very curious about how my poison oak adventure will affect diabetes management. Inflammation tends to promote insulin resistance; with such severe inflammation going on in my legs right now, will I be getting high glucose numbers? Today's numbers weren't bad, but I won't be surprised if that changes over the next few days.

Running, or even extensive walking, was more than I could handle today, but I can't just stop exercising altogether for however long it takes for this situation to improve. I'm going to start walking, at least, as soon as I can.

After I got home from work and applied the new ointment, and took an anti-biotic, I was actually able to get enough relief to be able to take a nice nap. It's a big step in the right direction...

 


Let's Define Our Terms!

Friday, August 23, 2013

 


Still a Diabetic?

When a simple question seems strangely difficult to answer, often the reason for the difficulty is that we're not sure what is meant by the question. Defining the terms of the question more clearly is often all it takes to make it answerable.

For example: if a tree falls in the forest, when there's nobody around to hear it, does it still make a sound?

The reason that question seems difficult is that we haven't made clear what we mean by "sound". If sound means longitudinal waves of pressure variation in the air, then a tree falling in the forest is going to make a sound, regardless of whether anyone is around to hear it. If sound means the subjective sensory experience which those waves produce when they stimulate human eardrums, then a falling tree doesn't make a sound unless somebody is present to have that sensory experience. (However, most animals can perceive sound waves, even if they don't perceive them quite the way humans do -- so if we broaden our definition of "sound" to include what mice and birds experience, the falling tree is almost sure to make a sound.)

What brings this to mind is a question from a reader: "If I control my sugar am I still a diabetic?". It sounds like a pretty simple, straightforward question, and yet there's no answer I could give to it which wouldn't be arguably wrong. A lot depends on what we think it means to say that someone is "a diabetic". (And by the way, I am aware that using "diabetic" as a noun to identify a human being is widely regarded as offensive. Treating adjectives as nouns, and nouns as adjectives, is a traditional marker of hate speech, as in "a Jew lawyer". But I'm putting that aside for now.)

It's all very well to say that a diabetic is someone who has diabetes, but what exactly does "diabetes" mean? Diabetes can be defined in many ways. Originally it merely referred to excessive urinary output (polyuria is the general term for that now). "Diabetes" came to be given qualifiers such as "mellitus" and "insipidus", to refer to more specific conditions which can cause polyuria.

But when the term "diabetes" is used by itself, "diabetes mellitus" is usually assumed to be the meaning. Diabetes mellitus refers to elevated blood glucose (which can produce the symptom of polyuria, but is not the only possible cause of that symptom). Strictly speaking, to be diabetic merely means to have abnormally high blood glucose,for whatever reason and for whatever duration. Strictly speaking, all it takes to be non-diabetic is to have normal blood glucose now (even if it was high yesterday and will be high again tomorrow). So, you must have had abnormally high glucose to be diagnosed as diabetic in the first place, but if you have got your glucose worked all the way back down to the normal range again, then you're no longer diabetic.

However, I hasten to add that most people (including most doctors) are not speaking that strictly. When they use the word diabetic, they don't just mean "your glucose is high right now, but who knows what tomorrow may bring?". They mean "you have an endocrine disorder which is (1) giving you chronically elevated glucose, (2) is not curable, and (3) is going to get worse over time". The fact that you have got your glucose worked down to the normal range may strike them as commendable, but it isn't going to convince them that you are no longer "a diabetic", because they think the status of being "a diabetic" is permanent, not temporary. Right now, your glucose may be normal, but you have an underlying condition which is going to keep trying to make your glucose abnormally high, and you'll be fighting that problem for the rest of your life.

It has always struck me as a shame that there is no generally-accepted medical term for people who have normalized their blood sugar following a diabetes diagnosis. Not having a word for something is often a way of denying that it exists, and it is always worth questioning the motives behind that kind of denial. If doctors had a way to talk about those who have done what's necessary, maybe they would be better able to encourage other patients to do what's necessary. It's hard to offer people encouragement if your professional jargon pretty much defines success out of existence.

I guess the next puzzle I should take on is: if you are surprised and upset by a high glucose test result, and there's no one there to hear you saying "Oh, shit!!!!", did that high result really happen?

 


Inaccurate Glucose Meters

Thursday, August 22, 2013

 


Give or Take 20%

Next month the Food and Drug Administration will participate in a Maryland meeting put together by the Diabetes Technology Society aimed at doing something about glucose meter accuracy.

You see, even though the FDA's standards for glucose meter accuracy are extremely lax ("In order to be approved, 95% of all measurements of a glucose testing system must be within 20% of reference values at or above 75 mg/dL and within 15 mg/dL below 75 mg/dL"), a lot of meters fall below even those crappy standards. It turns out that, once a meter system is approved by the FDA, the meter manufacturers often transfer manufacturing of their meters to third-world countries, and quality standards are relaxed further: "About a third of the devices that had met FDA standards and were licensed for sale in the United States were no longer meeting those standards once they were in real-life use. Most of these less accurate meters are manufactured outside the United States and sold at lower cost than the name brands."

It's bad enough to realize that the FDA considers it okay for a meter to be no closer to the correct answer than plus or minus 20%; it's downright creepy to realize that a third of meters don't even get that close.

So far, my own meter brand (OneTouch) has matched up well enough with lab results for me to feel reasonably confident that the information I'm getting from my glucose tests is pretty close to right. Consumer Reports also says that OneTouch meters are among the most accurate available to patients. But experiments with other meters (including two that were sent to me unsolicited, clearly with the intention of getting me locked in to buying test strips for them) did seem to confirm that there's a lot of very bad measurement hardware out there on the market, perhaps approved by the FDA on the basis of a prototype which was nothing like what's being sold now.

As health insurers have developed increasingly draconian policies about reimbursement for test strips, patients (who must shoulder most or all of the financial burden for such supplies) are increasingly turning to the cheapest stuff they can get their hands on. And some insurers that still do reimburse for test strips will do so only if you buy the cheapest ones, which aren't accurate.

This is what happens to medicine when the health-care industry is run primarily by accountants and secondarily by lawyers, with doctors occasionally allowed to offer an opinion if they don't get too uppity about it.

The FDA says that, despite appearances, it really does care about glucose meter accuracy. Here's an FDA official (Alberto Guttierez): "Glucose meters have always been a priority for the FDA. This is an area that's complex, where lots of things happen... It's always been high on our list." By "always", I assume he means since 1976, when the FDA began licensing glucose meters. Here it is only 37 years later, and they're thinking of addressing the problem already! I'm glad they didn't wait.

By the way, I'm curious: could Alberto Guttierez name some medical topics which don't qualify as "an area that's complex, where lots of things happen"? It seems to me that any issue related to health, or even to biology in general, is inevitably going to involve complexity and lots of things happening. And measuring the amount of glucose in a sample does not seem like the most complex issue that science has taken on during the last 37 years. Your cell phone knows where you are, where you're going, and what you're likely to buy when you get there; I'm not sure glucose measurement is as quixotic a technical problem as we're being asked to believe.

 


Hallucinations: Are They For You?

Wednesday, August 21, 2013

I don't think my lunch today was any lower in carbs than my dinner last night was, but I got a post-prandial glucose result of 104 after it, compared to 141 after dinner last night. The difference: a hard lunchtime workout today, versus no lunchtime workout yesterday.

Exercise isn't the only variable that could have played a role, of course, but it's an important one, and sometimes we need to be reminded of that.

 


Hallucinogens

Psilocybin, a substance produced by about 200 species of mushrooms (mostly those of the genus Psilocybe) causes people to experience hallucinations of various kinds. When ingested, psyilocybin is converted into another compound called psilocin, and psilocin is apparently what causes the hallucinations.

Most "recreational" drugs operate by overstimulating cell receptors which are designed to respond (more moderately) to some naturally-occurring compound in the blood. Opiates, for example, mimic (and greatly exaggerate) the effect of naturally-occurring hormones in the blood known as endorphins. It has been claimed (I don't know how accurately) that the psilocin compound (which the body converts psilocybin into) mimics a naturally-occurring ingredient in human blood, which some people have more of than others.

If that is true, then I certainly am one of the people who have more of the substance that psilocin mimics than the average person does. Even without consuming mushrooms of the genus Psilocybe, I have an imagination which is already about as vivid as I can stand. Intensifying it is the last thing I need; I'm a hair's breadth away form hallucination at the the best of times. And that is why I cannot rejoice in the news that hallucinogenic drugs are apparently not bad for people, and may even improve their mental health.

I'm glad to know that people who dabble in hallucinogens are not, contrary to government-sponsored legends, giving themselves schizophrenia or other disorders, and may in fact be preventing the development of the same. But it's not something I can deal with, or am even especially curious about.

Coffee and wine pretty much cover it, if you ask me.

 


Again with the Urine!

The Google search strings I've been tracking lately seem to include a lot of variations on this one: "if im not urinating that much does that mean my diabetes is under control?".

No, it doesn't mean that.

It does mean that your diabetes isn't as far out of control as it could be; that comfort you may keep. But the truth of the matter is that the blood glucose doesn't start leaking through the filtering apparatus of the kidneys, and into your urine, until your blood glucose reaches a concentration of about 160 mg/dl. You can be below that threshold and still have abnormally high blood glucose. Non-diabetic people don't usually go much higher than 125 mg/dl even at the peak level which occurs an hour after a meal.

You don't have to hit 160 to have a problem with glycemic control. Therefore, don't assume that everything's fine so long as your urine isn't attracting bees yet.

 


Dealing With Bad Days

Tuesday, August 20, 2013

 


I Don't Have Time for This!

Advice about how to manage Type 2 diabetes often leaves out one of the most important elements: "be a rich guy with time on your hands". My theory is that anyone can manage Type 2 diabetes successfully if he doesn't have to do anything else. The test of diabetes management is to do what's necessary even when you don't have time to deal with it.

My work schedule was difficult today. I couldn't do my lunchtime run, and I couldn't do an early-evening workout either, because I had a meeting that kept me at work till 7 PM, and then I had an errand to run downtown. By the time all that was squared away, I was too hungry to work out, so I had to have dinner first -- even though I knew that would mean I'd have to work out quite late (working out right after a meal is a pretty awful idea). So I waited an hour after dinner and did a post-prandial glucose test (getting a 141, which is higher than I'm comfortable with; the reason for it, no doubt, was that I'd skipped my mid-day run). Then I was, in theory, free to go work out.

Here's where the difficulty arose: I really, really didn't feel like working out tonight. By now it was getting to be too late for the gym, so I'd have to run in the neighborhood -- my spooky, woodsy, poorly-lit neighborhood, in the dark, with who knows what animals bounding out of the bushes at me. I have seldom been so keenly tempted to skip a workout.

I used to struggle on a daily basis with the urge to skip a workout "just this once". Now that I'm pretty firmly established in a habit pattern (lunchtime runs on the weekdays, a long hike or trail-run on Sunday), it's usually pretty easy for me to do what I'm supposed to do, without having to fight an internal battle over it. But when I feel the pressure of other obligations, and there just doesn't seem to be time to pay attention to diabetes management, it's still awfully tempting to take the easy way out. Not that it makes life easy in the long run, of course, but tonight it would have been mighty convenient to say "I don't have time for this".

Once I finally got started on my run, I actually rather enjoyed it. No creepy encounters with wild animals; that was nice. And I did cross paths with one neighbor out for a walk, so I didn't have to feel like an isolated crazy person doing what no one else would dream of doing. After the run and a hot shower, my blood pressure was strikingly low (101/65).

So I guess the day ended well enough, but it wasn't a fun time all the way, and I hope tomorrow goes better. I don't want to have my willpower tested constantly.

 


Pruning the Old Inbox

It is a great convenience, sometimes, to buy things, reserve things, register for things, and research things online. The trouble is that doing any of that often places you in a long-term electronic relationship with some energetic organization which has a perpetual urge to communicate with you -- and never becomes discouraged, no matter how firmly you ignore them. If this behavior had a sexual motive we would call it stalking. Unfortunately, financial stalking is not recognized as an offense, so it's probably futile to seek a restraining order.

My e-mail inbox today included such gems as "Your Weekly Mix from TicketWeb" (I bought a concert ticket through them once, because it was the only way to buy it, and they're never going to let me forget it) and "Bike to School Blowouts!" from a bicycle store which, I swear, I never bought anything from in my life. And an online music store from which I bought some fiddle strings a few months ago sent me a passive-aggressive message headed "We Miss You". But the highlight of the day's haul was from MedPage Today. Its enticing subject line reads, "Visual Quiz -- Diagnose the Lesion".

Who could resist such a charming offer?

The message shows me a very ugly picture of a very raw patch on a man's face (which you should thank me for not sharing with you), gives me a little detail about the reported symptoms and history, and invites me to guess whether the correct diagnosis would be Histoplasmosis, New World Cutaneous Leishmaniasis, Tinea Corporis, or Sporotrichosis. I never told these people I was a doctor, but they seem to have put me down for one, based on the topics I was using their web site to gather information on, and now they are offering me all sorts of professional brain-teasers and opportunities to sound off on my patients. I have resisted the temptation, at least so far, to tell them that I have only one patient and he's a pain in the ass.

I think it's time to start making a serious attempt it getting my name off most of the mailing lists I'm on.

 


What Else is Wrong?

Monday, August 19, 2013

Yesterday I hiked up the same trail that I had helped clear on Friday. A pleasant hike, but I ended up wishing I had taken some "before" pictures of the trail. All I could do now was take "after" pictures of how clean and clear the trail looks now, with nothing to compare them to. However, because the trail was not littered with the corpses of the people who had participated in the big mountain-bike race on Saturday, I have to assume that our trail-clearing operation on Friday made things safer for everybody.

My right shoulder is holding up okay. I still feel some residual soreness from the flare-up in my rotator cuff a few weeks ago, but the trail-clearing project doesn't seem to have made it any worse.

 


Dementia Revisited

It was only a few weeks ago that I was reporting on a study which said that, contrary to earlier reports, diabetes was not associated with a significant increase in the risk of dementia.

Well, I knew that happy situation could not last. Doctors are so much in the habit of blaming diabetes for everything short of a tsunami that can go wrong in life, they are certainly not going to let diabetes off the hook for dementia without a struggle. So, I was not surprised to see a report in The Lancet on the "risk score for prediction of 10 year dementia risk in individuals with type 2 diabetes".

What did the researchers find about the risk for dementia in diabetes patients? Well, mainly they found that the risk varied enormously. The risk of developing dementia over a 10-year period could be as low as 5.3% or as high as 73.3%.

And what determined whether a diabetes patient has a low risk or a high risk? Well, this seemed to be determined mainly by what else was wrong with them, besides merely having been diagnosed as diabetic. Other problems that correlated with dementia were "microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education". (I am unable to tell from the abstract whether the authors really mean that being educated increases the risk of dementia, or whether they mean that a deficiency of education increases the risk.)

The health problems that correlate with heightened dementia risk are numerous, and although diabetes increases your risk of many of them (particularly "education" -- there's nothing like diabetes for getting a person to do uncharacteristic amounts of homework) -- the extremely wide range of dementia risk suggests that diabetes itself is not a very important part of the problem. What matters is what else is going wrong.

So, I don't think this study really does anything to contradict the earlier one, which found that diabetes by itself was not a cause of dementia. What increases your risk of dementia is a general breakdown of health. (And getting educated, apparently.) Avoid those two things, and your risk is fairly low!

Admittedly, you have to manage diabetes pretty carefully if you want to prevent it from giving you "complications" such as cardiovascular disease and bachelor's degrees. But if you can accomplish that, your not facing a big risk of dementia simply because you have diabetes.

 


Sweating for a Cause

Friday, August 16, 2013

 


A Different Sort of Workout

The company I work for, and three other local technology companies, work together to sponsor environmental work projects from time to time, usually on a Friday afternoon. Employees of the company contribute an afternoon of their time doing some kind of environmental work, somewhere in the county. When I've volunteered for the program in the past, I have done such things as cleaning litter off beaches, eradicating invasive plants in parks and open-space areas, and digging flood-control channels.

There was a project scheduled for today, which involved doing trail-maintenance at Annadel State Park, under the guidance of the Sonoma County Trails Council. The park is not only under-funded but very close to non-funded, and is in constant danger of being shut down. The park only has functional trails because the SCTC's armies of volunteers come in on weekends to maintain them.

Since I use that park all the time (practically every weekend I do a long hike or trail-run in there), I felt as if I owed the SCTC a little bit of practical assistance. So I signed up to be a volunteer this afternoon. I was a little nervous about it, though, because of the recent flare-up of inflammation in my right shoulder. Could I do the work without driving myself into a relapse?

Well, at this point, I don't truly know the answer to that question, because if what I did this afternoon hurt me, I probably won't find that out for a day or two. All I can say is that my shoulder felt all right during the work, and feels okay now.

It was a big volunteer group; I think there were about 30 of us. Our project today consisted of clearing brush and branches from a somewhat overgrown stretch of trail which is going to figure prominently, tomorrow morning, in a big mountain-bike race through the park. My understanding is that the race is going to draw in mountain bikers form all over the state. As I happen to have hiked on that stretch of trail just last Sunday, I was pretty aware of what the problem was: because of the way brush was encroaching on the trail, there were places where there was no clear line-of-sight -- people using the trail couldn't see what was even a short distance ahead of them. On Sunday I witnessed a scary incident in which a a mountain-biker nearly slammed into a horse that he hadn't realized was just ahead of him. Our mission today was to make that stretch of trail safer, by cutting away branches that were reaching into the trail and blocking the view.

It was pretty hard work (and it was a warm day), and it was an effort simply to climb up to where our work needed to be done. So I didn't see any reason why this activity shouldn't count as my workout for the day.

While we were working, several mountain-bikers came down the trail (a lot of them were probably out-of-town race-participants checking out the race route); it was nice that most of them called out thanks to us for working to clear the trail they would be using.

I think I may volunteer in the future for other SCTC trail-clearing projects. It's highly likely that, in your community, there are organizations looking for volunteers to do physical work of this sort from time to time; if you're looking for a different kind of workout -- one that feels a little more purposeful than running on a treadmill -- it might be worth checking out.

 


Not an Addiction?

Oh, no! A new brain-imaging study says that sex-addiction may not be a real addiction after all!

Well, gosh, if you can't believe in sex addiction, what can you believe in?

Well, to be honest, I always did think "sex-addict" was an awfully fancy term for guys who have sex with astonishing frequency. "Liars" is what we used to call them in my day.

 


Risk

And finally, a much-needed reality check from XKCD, which we should keep in mind whenever a given situation increases the risk of something by such-and-such percent:

 


Diabetes & its Optional Accessories

Thursday, August 15, 2013

Both glucose tests were higher today than I thought they should have been, all things considered. But I often think that. And I never complain when my tests are lower than I expected, do I? That's the trouble with reality: it is what it is, regardless of whether it's what you expected. Physicists are working on the problem, but if they've made any progress I haven't heard about it.

I've been getting unusually low blood-pressure readings this week, but I'm not sure why. I think I've been working harder at my lunchtime running workouts, mainly because a running buddy who was out with an injury is running with me again, and I'm focused on keeping up with him. Maybe that's the explanation, but it's hard to be sure. I don't think less stress is the explanation, because I don't think I'm having less of that.

 


I'm sure you'll be as stunned as I was to discover that the combination of diabetes and ESRD (end-stage renal disease, which means your kidneys are going bye-bye) makes you more likely to have a "cardiovascular event" (heart attack, stroke, congestive heart failure) than if you had diabetes without ESRD, or ESRD without diabetes. Either problem by itself increases your risk considerably. But having both problems at once is even worse!

The grimmest stats are the ones for heart attack: diabetes alone increases the risk by a factor of 1.7, ESRD alone increases the risk by a factor of 2.7, and the combination of the two increases the risk by a factor of 5.2. More than five times the normal risk of heart attack if you have both problems!

And here I was thinking that having two diseases was no riskier than having one!

Well, it always seems funny to me when people conduct elaborate research to confirm the obvious. But I guess it's worth doing, just for the sake of those occasions when what seems obviously true turns out not to be. And in the case of this particular research, even though it's not surprising that having two diseases is worse than having one, we might as well find out how much worse it is, and we wouldn't know that if nobody did the research.

I do have to draw the line, though, at some research I read once which found that having two bad knees was worse, from the standpoint of disability, than having one bad knee. (And how much worse was it? Twice as bad! Who knew?)

However, what can we do with the information that having both diabetes and failing kidneys is a bad thing?

To me, what's worth paying attention to here is that the thing we can't do anything about (the mere status of having been diagnosed with diabetes) is a risk factor for cardiovascular events... but not nearly as big a risk as having diabetes combined with other problems. And you don't have to have those other problems too, just because you have diabetes, even though a lot of people with diabetes develop those other problems.

The depressing stories and statistics you come across, about unpleasant things happening to diabetes patients, are mostly not happening to people who have diabetes and nothing else. Most of those people have other problems which, with a little luck and a lot of effort, you can do something about. If you manage your diabetes well enough, it won't drive you into kidney failure and hypertension and dyslipidemia.

Diabetes you're stuck with... but those problems you can probably opt out of, if you put your mind to it.

 


Amusing and Interesting Things

Wednesday, August 14, 2013

Today I ran the same route as yesterday, and I ran it at a slower pace, and yet I felt as if I was working a lot harder. The difference was that it was about ten degrees hotter today. These things matter...

 


Bad Beginnings

This is just for entertainment purposes, but for all I know you might like entertainment.

I was a fan, at first, of the Bulwer-Lytton fiction contest. Named for the wordy Victorian novelist of "It was a dark and stormy night" fame, the contest invites people every year to write the worst possible opening line of a novel. Sadly, the contest judges began the bad habit of awarding the prizes to extremely long run-on sentences that weren't really all that funny, or all that plausible as examples of unintended bad writing. I always ended up feeling that terse entries that did not win (example: "Just beyond the narrows the river widens") were funnier than the rambling entries that did. I was pleased when the rival Lyttle Lytton contest was set up, which restricts the length of its entries, and awards the prizes to examples which sound as if they are accidentally awful rather than cunningly so.

Some of my own favorite entries follow...

 

"This is a mystery about a murder I committed."

"Deep space. The silence of the void. Shh."

"Maria's flossing was now complete."

"Madison was a shy, awkward, inwardly beautiful teenaged girl just like you."

"It was a beautiful night, and the full moon glew like it had never glown before."

"Tuesday. Africa. Lion o’clock."

"Emperor Wu liked cake, but not exploding cake!"

"He, from a physical stature, was short."

"Six o'clock comes early, and so does death."

"PEWPEW — Lasers! — PEWPEWPEW!"

"Agent Jeffrey’s trained eyes rolled carefully around the room, taking in the sights and sounds."

"Michael had always wanted to lactate."

"The pain wouldn't stop, and Vern still had three cats left."

"'Crime,' declared the police captain, 'is everywhere, crime, crime!'"

"Now, you're all aware of my vocal campaign against the global slave trade, so what I am about to confess may raise a few eyebrows."

"It was the best of times, it was the worst of times; I know that's a contradiction but bear with me."

"'Handful of Meat' was, unfortunately, more than just the name of Carl's band."

 


A (Healthy) Diet

A study reported in JAMA looked at chronic kidney disease (CKD) in Type 2 diabetes patients, to see what effect diet had on the problem. The rather oddly worded statement of the study's objective reads: "To examine the association between (healthy) diet, alcohol, protein, and sodium intake, and incidence or progression of CKD among individuals with type 2 diabetes." Perhaps the parentheses around "healthy" are something akin to finger-quotes, and are intended to acknowledge the rather unsettled state of opinion on what "healthy" means in regard to diet. In this case, a healthy diet meant one which was rich in fruits and vegetables, low or moderate in alcohol, and also limited in animal protein and sodium (both have long been thought to cause or aggravate CKD).

What did the researchers find? That the fruits and vegetables and moderate drinking all significantly reduced the risk of CKD and mortality. However, reductions in animal protein and sodium did not seem to make much difference.

So there you have it! Sodium is the new alcohol.

 


Counting the Costs

Tuesday, August 13, 2013

 


Oh, dear: it turns out that, in addition to whatever else is wrong with it, diabetes is expensive!

At least according to this report, being diagnosed with Type 2 diabetes will eventually cost you $85,500 on average. But the lifetime cost is higher if you are diagnosed earlier than the average patient. For a man diagnosed with diabetes between the ages of 25 and 44, the cost is $124,700. The cost is a bit higher for a woman diagnosed at the same age ($130,800), but I don't know whether that's because women live longer than men, or because of the mysterious process which makes women's clothing more expensive than men's. (I'm told.)

A fair amount of the cost of diabetes comes from direct treatment of diabetes itself (testing supplies, medications, extra doctor visits), but a little more than half of it comes from "treating complications such as kidney disease, nerve damage, eye damage, heart disease, amputations, and stroke". (Okay, I get it; I'm all cheered up now.)

Well, so far at least, I don't seem to be fitting this pattern. Like all newly-diagnosed diabetes patients, I was originally put on a more frequent schedule of doctor's-office visits than non-diabetic patients are on. However, after I got a certain number of normal A1c test results in a row, my doctor put me back on the once-a-year plan. So doctor visits aren't causing me to spend any extra money.

I'm not taking any meds, so there's no expenditure there. I do have to spend money on testing -- mostly on test strips. There's also the once-a-year hemoglobin A1c test.

You could argue it's dishonest to say that I have no medication costs, since I'm using exercise as my medicine. Perhaps the money I spend on running shoes, workout clothes, sun-block, and suchlike things ought to come under the heading of medication costs. And, for all I know, I spend more money on these things than I would on meds (although it's hard to say that with confidence, since I would probably be on at least five meds by now if I hadn't started my exercise program).

However, there is a counter-argument to be made against the idea of counting exercise as a treatment cost: you'd need to do it anyway, whether you had diabetes or not. The only real choice is between exercising because you have diabetes and exercising because you don't want to have diabetes. After all, we don't usually count food as a treatment cost, even though there's a medical problem you're sure to get if you don't eat.

Maybe the real difference between exercise and diabetes drugs is that you can't even pretend to be taking metformin for the sake of the high-spirited fun it brings to your life.

 


Absolute & Relative

Monday, August 12, 2013


Let's say you study 1000 people who drink coffee and 1000 people who don't, and during the time you're studying these people, 44 of the coffee drinkers develop cancer and 22 of the coffee abstainers develop cancer. How are your finding reported? "Coffee Doubles Cancer Risk".

Suppose that, in this study, 2 of the 1000 coffee drinkers develop cancer, and 1 of the 1000 coffee abstainers develops cancer. How are your findings reported? "Coffee Doubles Cancer Risk".

There is a striking tendency, in public reporting of health research, to emphasize relative risk very strongly, and to de-emphasize absolute risk to such a degree that it is almost a secret. When we read a report claiming that such-and-such a circumstance increased the risk of such-and-such a disease two-fold, four-fold, or eight-fold, we really have scan the fine print pretty carefully to find out what the actual numbers are. If the absolute risk is 2 out of 1000 instead of 1 out of 1000, I might be willing to live with that, but if the absolute numbers are higher, I might be more concerned. The authors of the research try pretty hard to discourage me from making that kind of practical analysis, however.

No doubt the concern is, at least in part, that people won't take a heightened risk seriously if even the heightened risk sounds low. If you admit that a significant number of smokers don't get lung cancer, you'll only encourage a lot of irresponsible people to take a chance on smoking, because it looks as if they have a fair shot at being one of the lucky ones.

I mention all this because, in my efforts to find out how much I'm at risk of developing the heart-rhythm problem known as atrial fibrillation (as a consequence of my exercise program), I'm uncovering a fair amount of information about relative risk, and very little information about absolute risk.

The reports I've seen so far give various estimates of how much "endurance exercise" increases the risk of atrial fibrillation (or "AF", as doctors call it). Depending on which study you believe, the risk might be increased by a factor of two -- or maybe by a factor of five, or even eight! Probably the reason these estimate vary so widely is that different people have different ideas about what counts as "endurance exercise", and people who run marathons frequently may have a higher risk of AF than people who think a five-mile run is about as much as anyone really needs for a workout. The consensus among researchers seems to be pretty strong that people who do long or intense workouts regularly have a higher risk of AF than sedentary people. But what is the base-level risk if you don't exercise, and how bad does it get if you do endurance exercise?

One study (if I'm not misinterpreting its carefully-obscured results) showed that the base risk was 0.7% and endurance exercise raised it to 4.9%. That's a big increase in relative terms, I realize, but if even the heightened risk isn't quite 1 out of 20, maybe the heightened risk is still not as bad as the other risks sedentary people face.

After all, it means very little to compare exercise to non-exercise in terms of just one risk, when we know that many other health risks are affected by exercise. How does the 1 in 20 risk of AF associated with endurance exercise compare to other risks (perhaps larger risks?) associated with not doing endurance exercise?

I'm still pretty far from reaching a conclusion about AF risk and exercise. While I'm trying to sort this out, I have been continuing my experiments with long walks as a substitute for running. I did a hike in the state park yesterday (6.7 miles) along a route I have usually run in the past. It takes longer, but it is theoretically less hard on the body. The strange thing is that I'm having problems with sore muscles and blisters which I didn't have when running the route instead of walking it! I'm becoming more an more aware over time that any activity your body isn't used to -- even an activity seemingly easier than the ones it is used to -- is going to have consequences. (But I guess that's what yoga classes are for.)

 


Immortal People Suck!

Thursday, August 8, 2013

 


Would You Live Forever?

We usually think of science fiction and opera as very separate things, but there is at least one opera which qualifies as science fiction, and I saw an excellent production of it in San Francisco several years ago: "The Makropulos Case" by Leos Janacek. The opera doesn't feature any space travelers, and it doesn't feature any robots either (although Karel Capek, the Czech author of the play that the opera is based on, coined the word "robot" in another one of his plays). For most of its length, the opera gives the audience no clue that it's science fiction. But science fiction is any kind of literature that looks at the impact of scientific discoveries or technological innovations on human life, and by that standard "The Makropulos Case" qualifies.

The story is centered around a Prague legal office in the present day (which, when the opera was composed, meant 1925), and around a legal battle between two families that has been dragging on for nearly a century. A young woman named Emilia Marty shows up at the law office inquiring about that old legal case, and knowing a suspicious amount of specific information about it. There is a missing will in the case, and she seems to know where it is -- and she is, for some reason, desperate to get her hands on another paper that is attached to that will.

As the opera goes on, the more we find out about Emilia Marty, the more mysterious she becomes. An old man is convinced he had an affair with her in Spain, only Emilia Marty was then going by the name Eugenia Montez (hmmmm, same initials). His story couldn't be true, because it happened 50 years ago, and she's still young. But the weird part is that she seems to remember this affair too. Further information arises about a historical chain of other women with the initials E.M. ("Ellian MacGregor" and "Ekaterina Myshkin", for example), all of whom seem to be very much the same person as this Emilia Marty character, even though they lived over a span of many generations and lived in different countries.

Well, as you can imagine, the explanation is quite simple when we finally get it: Emilia Marty is over 300 years old. She was born Elina Makropulos. Her father, an alchemist, tasked with creating an immortality potion for Emperor Rudolph II, and ordered to test its safety on his own daughter first, went to jail when she took the potion and fell into a coma. But eventually she awoke, and has remained young ever since. Because society makes no accommodations for immortal individuals, she has kept her immortal condition a secret. She has led an extremely peculiar personal life. Every few decades (whenever her failure to age starts to arouse suspicion that she has been engaging in witchcraft or something), she has to keep changing identities, and starting a new life someplace else. She can't get married and settle down; instead she has had a long series of relationships with men which she knows won't last. It's clear in the opera that she has become cold, uncaring, and rather bored. Nothing seems to mean much to her, least of all the men she occasionally goes to bed with to get something she wants from them. She's pretty unpleasant all around. Not only is she not making other people happy, she doesn't seem to be able to make herself happy.

Nevertheless, she wants this bizarre life to continue. The old paper she's scheming to get hold of is the formula for her father's potion. It turns out that the stuff is only good for 300 years, and it's starting to wear off; she needs another dose.

In the end, she does manage to lay her hands on her father's formula. But, in the opera's remarkable last scene, when she walks on the stage looking suddenly old, and she realizes she will die if she doesn't take the potion immediately, she decides not too. She has lived too long. She has been disrupting other people's lives, and not enjoying her own. It's time to quit. She hands the formula to another woman, who sets fire to it. (In the production I saw, there was a beautifully timed final moment, when all the lights went out in the theater, and the stage was lit only by the old parchment going up in flames.)

The philosopher Bernard Williams featured this opera, or rather the play it was based on, in a famous essay entitled "The Makropulos Case: Reflections on the Tedium of Immortality", in which he argued that the sad story of Elina Makropulos has a lot of truth in it. "From facts about human desire and happiness and what a human life is, it follows... that immortality would be, where it conceivable at all, intolerable". Williams argued that Elina Makropulos's descent into cold indifference and boredom was not peculiar to her; it is what any of us would have come to, sooner or later, in her situation. An endless life is a meaningless life. That life is limited is what gives it value.

Williams may be right, although it seems to me that Elina Makropulos's biggest problem wasn't that she was immortal, but rather that everyone else wasn't. There was no way for her to fit into the life of anyone else in her society. If she hadn't felt obliged to move on every decade or two, maybe she would have learned to enjoy life a little more. Of course, even if she were exceptionally lucky in her search for love, you do have to wonder whether she'd have found anyone she could have stayed happy with for 300 years. (Well, at least she would have had plenty of time to shop around. Immortals can afford to be choosy.)

I guess I'm torn between the impulse to agree with Williams (most of us would probably stop caring about life after a few centuries of it) and the impulse to suspect that this is sour-grapes thinking. Are we quick to denigrate immortality simply because we know we can't have it?

What triggered me to bring all this up was a report from the Pew Research Center on American attitudes regarding "radical life extension". Do people want to see the average human lifespan extended to over 100, or even over 120, if this becomes possible?

It turns out that people have very mixed feelings about this. The average figure people give as the ideal lifespan is 90, not 120, and a lot of people say that they wouldn't sign on to a treatment designed to extend life beyond that (although they assume most other people would!).

Why the surprising lack of enthusiasm for extreme life extension? There seem to be a lot of reasons. I don't think too many people worry about ending up like Elina Makropulos, engaging in endless identity changes and joyless bed-hopping. But a lot of people worry that life extension means being "kept" alive rather than living, and probably leading an existence dominated by health problems and disabilities.

People like the idea of living longer in principle... but they worry a lot about what it would amount to in practice. They're taking a wait and see attitude, until they know how things will seem to them later on.

I guess none of us can really know, until somebody actually puts Elina Makropulos's immortality formula into our hands, whether we would burn the thing or head straight to the pharmacy with it.


Question Time!

Wednesday, August 7, 2013

 


I try to keep a close eye on the questions people have been asking Google (and which Google has suggested my site may be able to answer). I think there is a prevailing trend toward weirdness in these questions, just lately, but I'll do my best to address them anyway.


"can something other than diabetes cause the pancreas to fool you into thinking you have diabetes?"

It's a little hard for me to untangle the mental process that led to the formation of this question. How exactly would the pancreas fool you into thinking you have diabetes?

If you are losing control of your blood sugar, and your pancreas is somehow involved in what's happening, I doubt very much that your pancreas is playing the role of the artful trickster. It's not as if that rascally gland is playing games with you, hoodwinking you into thinking you've got diabetes when it's really tennis elbow.

Although this question seems pretty bizarre, it fits well enough into a genre of search questions I see frequently: questions from people who have some reason to think they have diabetes, but would prefer to believe it's all a misunderstanding, and are searching for potential scenarios in which it turns out the doctor was wrong and this is something odd which looks like diabetes but isn't.

Sad to say, medical situations that look like diabetes tend to be diabetes. There just aren't a lot of ways to seem diabetic and not be diabetic.

 


"how fast will a glucagon kill you if injected with high blood sugar?"

Great. Another question from a would-be murderer who wants to use diabetes as an untraceable murder weapon.

As I've pointed out before, diabetes may be dangerous but it's the least reliable way of killing anybody imaginable. Try cuticle scissors, if you want to be original, but diabetes is not the kind of murder weapon a person can count on.

Glucagon is, in effect, anti-insulin. It is a hormone which drives blood sugar up rather than down, so an injection of the stuff, especially when your blood sugar is high already, seems hazardous and inadvisable. But I don't think any diabetes expert on earth could calculate a specific dosage of glucagon that would necessarily be fatal, or calculate how fast it might kill someone.

If I read a murder mystery which featured this scenario, I would strongly suspect that the author had invented the technical details for the sake of the story. It's just not that simple.

 


"how does one determine good or bad a1c test?"

The lab that does your A1c test is supposed to tell you what the "reference range" or "normal range" for the test is. For my lab's version of the test, the reference range extends up to 5.6%, and anything above that is considered elevated.

The diagnosis point for diabetes is usually defined as 6.5%, so if you're above the reference range but not as high as 6.5%, you're sort of in a no-man's-land (or the land of "prediabetes", if you prefer).

It's best to be in the normal range, obviously. If you have diabetes, you may not be able to control your blood glucose well enough to be in the reference range -- but you want to be as close to it as you can get.

Most doctors tell diabetes patients to keep their A1c test results below 7.0% if at all possible, because above that point the risk of "complications" starts to climb steeply.

 


"quantity of hemoglobin and its impact on the a1c test?"

Low hemoglobin (from blood loss or other causes) can, according to the Mayo Clinic, cause your hemoglobin A1c test results to be misleadingly low. However, I don't know of any formula you can apply to "correct for" this bias. If you have low hemoglobin, or think you do, there is a possibility that your glycemic control is not as good as the A1c test result seems to suggest.

 


"why does my a1c come out higher than my average glucose percentage?"

Perhaps because your true average glucose level isn't as low as you are imagining it is. How many times per hour do you test your glucose, after all?

But the formula linking the A1c test result with average glucose is based on all sorts of assumptions which might not apply in your case. That formula is only rough rule of thumb, not to be taken too seriously.

 


"what happen if you are diabetic and lose your mine?"

Well, if you lose your mine, you're just going to have to purchase your ores on the open market like the rest of us (try the New York Mercantile Exchange, or the London Metal Exchange). But that's true whether you have diabetes or not.

 


Moderation

Tuesday, August 6, 2013

 


Lazy Lunch

I usually run at lunchtime, but I found that difficult to arrange today, and I put off my workout till the late afternoon. So, when I had lunch, I knew my system would need to process whatever carbs were in that lunch, without benefit of the boost in insulin sensitivity which my mid-day workout normally provides. I choose what looked like a low-carb lunch (a salad with roast chicken on top) but under the chicken was a layer of pecans that were very much candied pecans. Perhaps you're thinking I could have left those uneaten, but I left out an important detail: they were good.

Anyway, I didn't think these heavily-glazed pecans were so numerous that they really made the salad add up to a high-carb lunch. On the other hand, not having exercised in 24 hours might make my system less able to handle that sugary glaze that was on those pecans. So how high would I go after lunch?

It turned out that I went to 127. Not bad, and not really above the normal glycemic profile for a non-diabetic person. But yesterday I had lunch after a hard run, and after as lunch which was probably higher in carbs than what I had today, my test result was only 109.

I realize, of course, that it's best not to read too much into a single glucose test, because it's so hard to know for sure that some extraneous issue (including the variability of test strips) isn't creating a misleading impression. And yet, I can't help analyzing individual test results and reaching some kind of conclusion about what those results mean. I've made up my mind that my after-lunch test result today, while not excessively high, was nevertheless a little higher than it would have been if I had had a workout first.

 


Walk, Don't Run?

Now that I've started to pay attention to the issue of exercise intensity (and the possibility that more intense exercise might not be better exercise), I'm starting to find studies suggesting that walking is as good as running, and perhaps (in some situations) better.

For example, this report from the American Heart Association says that walking seems to be as effective as running (or better) in preventing hypertension, diabetes, high cholesterol, and coronary heart disease. Another report from Imperial College in London makes similar claims for the benefits of walking.

Of course, these are studies looking into the effectiveness of exercise as prevention. It may be that, when it's too late for prevention and you already have diabetes, more strenuous exercise may best for controlling, as opposed to preventing, Type 2 diabetes.

I'm still feeling my way through this question, obviously. I'll let you know if I come to any definite conclusions.

 


All Over The Map

Monday, August 5, 2013

 


When You Don't Know What To Think

For several months now, my two regular running buddies at work have been hors de combat (that means either "out of action" or "militant appetizer"; I'll nail that down later if I have time). Each of them has some kind of slow-to-heal sports injury -- one in the knee, the other in the hips. Mike, who is the one with the knee injury, tried running again last month, found that it still caused him pain, and went back to resting up. But today he decided to try running again, with me. We met at our usual place, and took off for our usual Monday route.

We both enjoyed the experience -- him more than me, I'm pretty sure, because he seemed downright delighted to be running again after a long layoff. But the experience as a whole really brought home to me how little opportunity I've had, so far this year, to run with anyone else. Our pace wasn't fast, but even so, it was faster than I'm used to, because when I run by myself I automatically slow down, and I had definitely formed the habit of running at a very slow pace. Today, struggling to keep pace with a runner who's faster than me (even when he's recovering from an injury and trying not to push himself too hard), I found myself working a lot harder than I have been in recent months. My finish time was much shorter than it has been for that route in a long time.

Obviously, running faster than I'm currently used to was hard work. But, despite the difficulty, I actually enjoyed the run more than I usually do -- partly because I had someone to talk to this time, but also, I think, because the physical difficulty of the run was triggering my body to release more endorphins. I got the runner's high that I had lately ceased to notice, and that high continued for some hours after the run -- I was feeling it all afternoon at the office.

This rather complicates the recent evolution of my thoughts about what my exercise program ought to be like.

Recent research linking endurance exercise with heart-rhythm problems (especially atrial fibrillation) has led me to wonder if there's a way for me achieve the same advantages (in regard to glycemic control) from exercise which is less strenuous -- such as hiking. Since the flareup of my shoulder problem last week, I have been using long walks as a substitute for running, so far with good results in terms of glucose control. However, those long walks were made practical by my doing them after work, or on days off from work. That approach is seemingly not sustainable, or not easily sustainable -- a walking workout that is equivalent in effectiveness to a running workout is going to take more time.

I have not by any means read enough about the heart-rhythm consequences of hard exercise to be sure that I need to be seeking a less intense kind of workout. It's quite possible that I'll decide this is a change I need to make. Still, today's reminder of how much better I feel when I have a workout that really challenges by strength and stamina... that's something I won't be setting aside too casually.

I guess a crucial factor in the decision will be figuring out exactly how intense are the workouts of people who tend to develop heart-rhythm problems from exercise; it may well turn out that the people who get into trouble are working out a lot harder than I ever have in my life. If that is the case, I may decide that, just because a workout seems hard to me, that doesn't mean it counts as hard exercise. Maybe people who work out no harder than I do are pretty unlikely to suffer cardiac consequences. If this heart-rhythm thing is mainly a concern from people who run ultra-marathons and compete in the Tour de France, I'm probably okay to do whatever works for me.

At the moment, my thoughts are all over the map; I hope I can find some focus pretty soon!

 



Contradictions

Friday, August 2, 2013

The improvement in my shoulder continues! In fact, I have already developed a tendency to forget about the problem; I have to remind myself to do the physical therapy exercises -- even though they're pretty easy to do now.

That's the problem with this kind of inflamed-joint problem -- the minute it stops hurting, you forget that you still have an issue to manage, and it will soon be hurting again if you don't do what's required.

More hiking today -- I'm still trying to figure out if forms of exercise that are less hard on the body can work for me. Not that this hike was easy. I was checking out a new open-space park south of town, which turned out to be more hilly than I expected. There were nice views, but you had to work pretty hard to get up to them!

 


Damned If You Do/Don't

Today I saw two health articles, one raising the alarm about doctors not "intensifying" diabetes treatment soon enough, and the other raising the alarm about "intensive" diabetes treatment causing heart attacks.

One report is entitled Clinical Inertia in People With Type 2 Diabetes, and although inertia, strictly speaking, simply means a tendency not to change, it clearly has a pejorative connotation. Doctors should not be inert! They should take action immediately, when they find that their patients with Type 2 diabetes are not meeting their goals! There should be "treatment intensification", meaning more drugs -- both insulin and oral diabetes drugs (OADs). But the researchers find instead that "There are delays in treatment intensification in people with type 2 diabetes despite suboptimal glycemic control. A substantial proportion of people remain in poor glycemic control for several years before intensification with OADs and insulin."

Unfortunately, one of the consequences of "treatment intensification" is that patients will experience a lot of episodes of hypoglycemia. We could, of course, take the attitude these lows, however unpleasant they might be to experience, are simply the price one must pay for improved glycemic control. So long as they don't kill you, what does it matter?

Well, it matters if these hypoglycemic episodes set you up for severe consequences down the road. And a new report in BMJ says that they appear to do just that: "In summary, results from this meta-analysis suggest that severe hypoglycaemia is associated with approximately twice the risk of cardiovascular disease. Furthermore, a bias analysis indicates that the observed association between severe hypoglycaemia and cardiovascular disease may not be entirely due to confounding by comorbid severe illness. The findings support the notion that avoiding severe hypoglycaemia may be important to prevent cardiovascular disease in people with type 2 diabetes."

Twice the risk of cardiovascular disease? Haven't drugs been banned for doing less harm than that? And are we really supposed to be upset that doctors don't resort quickly enough to "treatment intensification" which increases the risk of cardiovascular disease?

I continue to be amazed at how easily some people overlook a fundamental irony in diabetes treatment: cardiovascular disease is the most dangerous consequence of diabetes, yet most diabetes patients receive treatments which increase cardiovascular risk instead of reducing it. The conventional wisdom about how to treat diabetes seems to be getting closer and closer to the classic definition of fanaticism: redoubling your effort after you have forgotten your goal.

 


Staying Flexible

Thursday, August 1, 2013

The shoulder problem I mentioned earlier (painful inflammation in the rotator cuff) started on Monday, was worse on Tuesday, and was bad enough on Wednesday that I decided to take today off work and concentrate on healing up. I was afraid, based on the way things had been going, that it would be so bad when I woke up this morning, I would be seriously disabled.

To my surprise, there was considerable improvement this morning. For one thing, I had actually slept through the night -- I hadn't been awoken by pain every 15 minutes. I got out of bed (without difficulty) and also found that getting dressed, getting in my car, and other routine activities were all reasonably comfortable experiences now. The pain I had been feeling whenever I lifted my arm even a few inches was now very much faded; I was aware of it but not grimacing over it.

I could do the shoulder rotation exercises that the physical therapist taught me once again -- not entirely comfortably or smoothly, but without significant pain. Which means I now have to do them pretty often, to get the shoulder joint back in the groove.

Because I had the day off, I had time to do a pretty long workout -- a 6.8 mile hike. It didn't bother my shoulder -- if anything the hike seemed to be therapeutic.

I hope this recovery continues on the rapid track it seems to be following!

 


Whatever Works!

When I started this diabetes adventure, I was 44. I'm 56 now. Has anything changed?

I was guided from the first by the simple principle, "do whatever works". This implied that, if whatever I was doing stopped working, I would need to make a change at that point. But that implication was pretty easy to forget about; I found myself getting pretty comfortable with what I was doing, because it kept working. I began to feel that I had definitely figured out what worked, or at least what worked for me. I was aware, in an abstract sort of way, that what worked for me at one age might not work for me at a later age. Still, when your basic approach works over a period of years, you start to be convinced that you're doing everything right, and you don't need to pay much attention to alternative solutions that other people are using.

Not that I haven't been experimental in some areas. Certainly in terms of diet, I have tried a lot of different approaches. I tried being a pretty strict vegetarian for a long time, but eventually I gave up on that -- not because I found meatless meals unsatisfying, but because I was finding it very hard to put together meatless meals which were not too high in carbohydrates for my purposes. In my experiments with different approaches to diet, I was finding that I could make various diets work, provided that I did plenty of exercise. And I tried to get fit enough to do endurance events, such as marathon races and "century" bike rides (100-milers).

Lately I've been wondering if the endurance sports aren't overkill -- particularly as I'm seeing my exercise buddies succumbing to sports injuries and being forced to take long breaks from exercising at all. I've become increasingly focused on trying to avoid sports injuries myself, and increasingly worried about whether endurance sports create so much wear and tear on the body that they end up being counterproductive.

Some of my readers have lately been directing my attention to emerging evidence that endurance sports ultimately increase your risk of certain health problems, especially atrial fibrillation (a heart-rhythm disorder which not only makes your heart weak and inefficient, but can also promote strokes). I have not yet researched that topic enough to have reached any conclusion about whether endurance workouts do more harm than good (if they dramatically cut the risk of a heart attack and only mildly increase the risk of stroke, they might still be a good tradeoff).

While I'm still trying to figure it out, though, I am trying to get myself into a more flexible frame of mind about the issue. If I find evidence that my approach needs to change, I need to be mentally prepared to do what is necessary.

For right now, simply as an experiment, I am trying to see if walking rather than running can work for me, at least if the walk is a long one. It's a good time to experiment, because my inflamed shoulder-joint is making me think that less physically jarring workouts are probably best while I'm trying to solve that problem. Also, I have time for long walks now -- at least I did yesterday in the evening, because the sunsets are still coming pretty late, and today in the afternoon, because I took the day off work. The trick will be to see if I can make milder exercise work when I'm more pressed for time.

Anyway, I need to keep my mind open to other possible ways of keeping my blood sugar under control. I shouldn't let myself get so stuck on what worked 12 years ago that I'm unable to experiment enough to find out what other approaches might work for me now.

 



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