Looking On The Bright Side!

Thursday, February 28, 2013

Can Diabetes Make Anything Better?

Health-wise, diabetes generally makes things worse, in a great variety of ways -- but is it unreasonable to wonder if the biochemical changes involved in diabetes might, somehow or other, make something better?

This is sort of like asking whether, despite everything we've heard about "water damage", there might be some part of your house that would actually be improved by flooding. There doesn't seem to be. It's not as if a flood is terrible for your flooring but fantastic for your stove.

And so it is, seemingly, with diabetes. The glycation (unwanted bonding of sugar to proteins) which occurs when blood sugar is elevated is not likely to result in an improvement in the way those proteins function. Proteins are complex molecules which function as tools, performing a huge variety of life-support functions in the body. The shape of a protein is critical to its proper functioning. Proteins aren't any more likely to function better once they are encrusted with sugar than a house-key is likely to fit a lock better once it has been dipped in epoxy. Therefore, the effect of diabetes on the body is to cause harm to proteins, and consequently (since all of the body's tissues and organs use proteins) to cause all sorts of harm to health.

It just isn't reasonable to expect that diabetes might accidentally produce a health advantage, to make up for the harm it more commonly does.

Still, is it possible that diabetes might confer an advantage somehow? For example, is it possible that diabetes might reduce the risk of cancer, even if it increases the risk of everything else?

When it comes to causes of death in the USA, your choices pretty much boil down to heart disease and cancer (after that it kind of trails off into paragliding accidents and killer bees), and most people who manage to avoid cancer do it by dying of heart disease first. Diabetes promotes heart disease, so it seemingly is possible that diabetes patients can hope to beat cancer through the simple expedient of having a heart attack first. This, however, is not most people's idea of a solution to the problem of cancer. And among people who don't die of heart attack, diabetes is generally thought to increase cancer risk rather than reduce it.

But are there exceptions to that discouraging rule? Is there any type of cancer for which the risk is reduced rather than increased by diabetes? Researchers from the Shiva Medical Center in Israel think they have found one! (Sorry, ladies, it's prostate cancer.) The researchers says that, over a period of 12.7 years, prostate cancer risk was reduced by 46% in men who had diabetes.

Odd as this claim sounds, it is not really new. Previous studies have found that prostate cancer risk is somehow reduced by diabetes; this is simply a larger study intended to confirm what the previous studies have found. But why would diabetes reduce prostate cancer risk? The lead researcher on the study has been quoted as follows: "Our findings emphasize the critical importance of sugar metabolism to the cancer cell, providing a clinical corollary to laboratory data. Modulation of glucose pathways is an area of very active research in cancer therapeutics. Exposing prostate cancer cells to 'a diabetic intracellular-environment' may be a new way to fight cancer."

I don't know why this effect would be specific to prostate cancer, but prostate cancer tends to be a slower-growing form of the disease, so perhaps prostate cancer cells find it especially hard to keep ahead of whatever diabetes does to inhibit them.

Of course, nothing about this research convinces me that having diabetes is good news after all. But it's nice to know that it maybe, kind of sort of, makes one thing better for diabetes patients.

Hey, even a broken clock is right twice a day.


The Sugar Menace!

Wednesday, February 27, 2013

Started the day at the dentist, where the hygienist said my gums were looking much better -- "awesome" in fact. Good: awesomeness is what we strive for in gum care.

The weather was perfect for a run (sunny, clear, beautiful, and around 60 degrees), so I did a long and scenic run. Nobody stopped by to tell me I was awesome, but you can't expect that twice in one day (or, for some of us, twice in one decade).


"Sugar Availability" & Diabetes Prevalence

Prevalence of Type 2 diabetes has risen enormously in recent years, but the increase has not been the same all over the world; some countries have a much bigger problem to deal with than others. PLOS One (the acronym stands for Public Library Of Science) has published a study which says that variations in diabetes prevalence in different countries is accounted for, at least partly, by variations in the amount of sugar in the diet of those countries. In fact, they found that sugar intake explained diabetes prevalence better than any other factor (including obesity and sedentary behavior). I have a funny feeling the sugar industry is not going to like this -- and at least one of the study authors is saying that's why they've been struggling for a long time to get this study published anywhere -- journal editors, according to Robert H. Lustig, don't like to publish research that will get them attacked by wealthy and powerful industries. (Lustig sees high sugar consumption as a major health threat, and has been campaigning hard to make the public aware of this.)

There can be little doubt that causation of Type 2 diabetes is a complicated thing, driven by a variety of factors (including genetics, diet, obesity, and physical activity levels). A statistical analysis of diabetes prevalence from country to country is seemingly going to present a somewhat blurry picture, no matter which of those factors you are concentrating on. For example, if we look at diabetes prevalence plotted against obesity prevalence:

These results seem to be scattered all over the place; although there is a rough general trend for diabetes rates to go up as obesity rates go up, there are a lot of exceptions sprinkled around. In other words, obesity is often, but not uniformly, associated with higher diabetes prevalence.

But if we look at diabetes prevalence plotted against sugar consumption, the association is more focused:

I still wouldn't describe that as a single straight line leading up and to the right. But apparently, of the factors that contribute to increased diabetes prevalence in a society, sugar consumption is the best predictor. Other foods don't show this kind of strong correlation, and neither does total caloric intake. Only sugar consumption yields that consistent a data plot.

The sugar industry will, of course, argue that there was bias in the selection of data which made sugar appear to be more strongly correlated with diabetes than it truly is. And that could be true; obviously at least one of the researchers involved (Lustig) feels pretty strongly that sugar is toxic, and if the researchers set out to blame diabetes on sugar consumption, they might have consciously or unconsciously cherry-picked data to support that conclusion. But anyone who wants to accuse them of that will need to prove their case.

We'll see!


Absolutism is Absolutely Dumb

Tuesday, February 26, 2013

"What sugar level does diabetes bad stuff happen?"

That question is one which seems to be very much on people's minds, judging from the searches people are running lately. Recent variations I've seen include "what a1c level will cause damage" and "with type 2 diabetes what is the highest sugar before you are endangered".

I realize that many people would like to imagine that they inhabit a world of absolutes, in which a given blood sugar level is harmless, but if it increases by 1% then you die. All you have to do is stay 1% under that second level, and no harm can come to you. So what exactly is that second level?

I must point out that this is generally not how the natural world works. Reality tends to include a lot of fine shadings of grey, and very few stark contrasts of black and white. It's a world of relativism, not absolutism. Health issues, in particular, tend to involve making judgment calls on how much risk you are willing to take on (versus how much curtailment of your natural desire sit around eating comfort foods you are willing to take on). There is no magic formula that gives you zero risk of developing health problems; instead there are known things you can do to reduce your risk of health problems. It's not likely that you are going to do every single thing it's possible to do to minimize your health risks, but you'll probably do whatever subset of them you feel you can do without making yourself miserable.

The fact that risk cannot be eliminated altogether does not mean (as some people seem to assume it means) that you might as well give up, and forget about trying to reduce your risk at all. For example, a recent Harvard study looked at the linkage between colorectal cancer and the lifestyle factors associated with it (lack of exercise and obesity). The study found that, in half of all colorectal cancers, the patient carries an unfortunate variant of the gene CTNNB1 -- and if you carry that gene, your risk is heightened regardless of whether you spend your weekend doing triathlons or sitting on the couch ordering pizzas. The other half of colorectal cancers occur in people without that gene -- and in those people, risk is determined by lifestyle.

Now, you can take the attitude that it isn't worth working out to prevent colorectal cancer, because half of the cancer cases that occur are of the type that cannot be prevented by working out. A statistician would not look at it that way; if there's something we can do about half of the total risk, then you do it. That is it isn't a sure thing is beside the point. Health maintenance isn't about sure things, it's about reducing risk where you can.

Blood sugar levels should not be seen in absolute terms; there is no way to be absolutely sure that the sugar in your blood won't do any harm to you, unless you eliminate sugar from your blood entirely (in which case you die from the total absence of the stuff). You need to have some sugar in your blood to survive, but sugar is a reactive substance which tends to form unwanted bonds with the proteins in your body tissues, and these unwanted bonds (known collectively as glycation) can have harmful effects. That is why the body recycles its proteins constantly -- to replace the older, already-glycated proteins with fresh, new, sugar-free proteins. The problem is that the protein recycling process can only keep up with the glycation process if the glycation rate within the body isn't abnormally high. Rising blood sugar accelerates the glycation process, and the result may be that the protein recycling rate can no longer keep up with the glycation rate. When that happens, a higher and higher percentage of your proteins become glycated (which interferes with their normal functioning and creates health problems). The damage is done very slowly and gradually, however, and it isn't really possible to look at anyone's health records and say definitely whether or not "the diabetes bad stuff" will happen.

We know what truly normal blood sugar looks like in non-diabetic people, on average: fasting tests in the low 80s (I'm talking in terms of mg/dl units), with brief excursions up to around 125 after a meal -- a pattern which results in A1c test results not too far above 5%. Diabetes patients are inevitably going to have higher blood sugar than that, on average, and the higher you get above the normal range, the higher your risk of "the diabetes bad stuff". The risk starts to get uncomfortably high as A1c test results approach 7%, which is why we are advised to stay under that threshold. That doesn't mean, of course, that there is no risk at 6.9% and terrible risk at 7.0%.

Going from 5.9% to 6.0% raises your risk a little tiny bit. Going from 6.0% to 6.1% raises your risk a tiny bit more. There is no place on the A1c result spectrum where zero risk suddenly turns into high risk. There is kind of cultural consensus within the medical profession that 7.0% is where the risk starts to become unacceptably high, but it's a judgment call, not an absolute.

My own feeling is that I should try to get as close to normal blood sugar levels, and normal risk levels, as I can, so that's what I aim for. Others can decide for themselves what they feel comfortable with, but they shouldn't assume that 7.0% represents hazard and 6.9% represents safety. Biochemistry isn't that black and white.



Monday, February 25, 2013

What we're having here in northern California, these days, is February as it should be (and so often is not, in other places). Winter is over, definitely, and everyone is getting outdoors and moving about. Which is a healthy thing.


Cell-Fate Conversion!

Biologists are starting to think they can monkey around with fate. The fate of pancreatic cells, anyway. In the movies, toying with fate tends to lead to big trouble, but researchers are hoping something good can come of it if they handle it right.

Different types of cells in the pancreas have different roles to play (different "fates", if you prefer), and the pancreatic cells that get the most attention, in terms of diabetes, are the "beta" cells; those are the ones that make your insulin supply. At least, that's what they ought to be doing, but if you have diabetes it's likely that they're not doing it, or not doing enough of it, because a disease process has interfered with their fate.

In the case of Type 1 diabetes, what interferes with the fate of the beta cells is an auto-immune reaction. That is, the body's immune system goes a little nuts, and attacks the body's own cells as if they were invading bacteria. In the case of Type 1 diabetes, the beta cells in the pancreas are the cells that get attacked. They may not be outright killed in the process, but enough damage is done to them that they're not producing insulin anymore.

In the case of Type 2 diabetes, there's no auto-immune reaction, but for whatever reason, a fair number of the pancreatic beta cells stop producing insulin. How and why that happens is a bit mysterious, but it may result from the toxic effect of chronically elevated blood sugar, which itself may result from diminished sensitivity to insulin.

One possible solution to this problem is transplantation of healthy beta cells into the pancreas. At least, it sounds like a solution. In the case of Type 1 diabetes patients, this approach would have to be combined with immunosuppression treatment, to make sure that the immune system doesn't knock out the new beta cells the same way it knocked out the old ones. But, in principle, it sounds as if transplantation of beta cells could work. The trick is producing a supply of healthy beta cells to transplant, by growing them from stem cells. Unfortunately, attempts at generating an adequate number of stem cells in this way has not been especially successful so far, and researchers are wondering if another solution might be better.

Now some researchers at the University of Pennsylvania think they have found such an alternative solution -- to change the "fate" of alpha cells in the pancreas, to make them function like beta cells.

This work revolves around the concept of "epigenetics" -- the various factors which don't affect which genes you have, but do affect which of your genes are expressed. What's in your DNA defines the biochemical toolbox that your body has to work with, but those tools can be activated or deactivated by environmental conditions (including the environment known as the womb, during fetal development). The DNA in a cell is wrapped around molecules known as "histones", and although the DNA contains the genes, the histones can influence which of those genes are expressed and which are not. In pancreatic beta cells, the histones activate the genes which produce insulin (the hormone which reduces blood sugar). But in pancreatic alpha cells, the histones activate the genes which produce glucagon (the hormone which increases blood sugar instead of reducing it). The histones in the nucleus of the cell are defining the "fate" of that cell, by determining which genes are expressed. So, if you have Type 2 diabetes, wouldn't it be better to interfere with the histones in a large number of alpha cells, so that those cells produce insulin instead of glucagon? If we can trick a enough alpha cells into behaving like beta cells, maybe we can beat diabetes!

The pancreatic cells in the picture below have been treated with a "histone methyltransferase inhibitor", to make some of them (the ones that look white) produce insulin instead of glucagon.

How well any of this would really work in a human patient, I do not know. But I mention the research for whatever it is worth. Some day we have the ability to change the "fate" of our pancreatic cells, so that more of them produce insulin.

Still, it's probably best if you don't hold your breath waiting for this to turn into a "cure" for diabetes. Don't stop going to the gym just yet.



Friday, February 22, 2013

Getting It Kind Of Right, Almost!

The American Board of Internal Medicine, or ABIM (an organization I'm not familiar with, but they sure sound important) has created something called the Choosing Wisely initiative. The main purpose of Choosing Wisely seems to be to persuade physicians in various specialties to stop ordering tests and prescribing treatments which are thought to be big wastes of time and money, at least by ABIM's various review panels.

I downloaded their big set of lists of things ABIM is recommending against, and scrolled through it nervously, looking to see if they are up to no good where diabetes patients are concerned. Was this another plot to take away our test strips, for example?

Well, no -- and diabetes treatments were mentioned less than I expected. And although the list of "Five Things Physicians and Patients Should Question" put together by the American Geriatrics Society included a specific recommendation regarding diabetes treatment, it seems to me that it contains a subtle sign of progress in the right direction:

"Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better. There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy."

What I find promising about that recommendation is that, throughout the first half of it, it doesn't just refer to tight glycemic control -- it refers specifically to using medications to achieve tight glycemic control. This distinction is usually overlooked; it is usually assumed that glycemic control is achievable only by means of medication, so it isn't necessary, when writing about glycemic control, to mention that it is heavy use of medication for glycemic control, and not glycemic control itself, which is associated with harmful consequences. And thus, quite absurdly, diabetes patients are given the impression that having normal blood sugar, or something close to it, is harmful (which always makes me wonder how all those people without diabetes are managing to survive).

To be sure, the authors of the list lose sight of this distinction half-way through, and the second half of the paragraph quoted above is written as if glycemic control itself, not drugs, were the problem. But it's kind of cool that they were capable, even temporarily, of not getting it wrong. This doesn't happen every day.

On the other hand, I'm not sure it's really asking too much to expect that the authors should be able to maintain their balance long enough to get through an entire paragraph. Is the journey really that long?


Rhythm Methods

Thursday, February 21, 2013

Frustrating! Yesterday I had a very solid workout, and a low-carb dinner (with a very low post-prandial test after it). I thought I had every reason to expect that my fasting result this morning would be down instead of up.

The culprit was probably my old demon: lack of sleep. Yesterday I was sleepy in the afternoon and evening, then wide awake at night. Reading at 2:30 in the morning, trying desperately to make myself as sleepy as I had been several hours earlier.

Maybe it's time for me to face up to who I really am: Count Dracula!


Circadian Rhythms & Insulin

Some researchers at Vanderbilt University have been finding out seemingly important things about the effect of circadian rhythms on obesity and health problems. But first: what is a circadian rhythm?

The Latin roots of "circadian" translate roughly as "around the day". A circadian rhythm is any biological process which follows a 24-hour cycle and also meets these criteria:

Anyway, it seems that disruption of circadian rhythms can promote obesity, diabetes, and heart disease -- and the reason for it is that insulin action is regulated by the body's circadian biological clock. For this reason, it isn't enough to consider what you eat: when you eat it matters, too!

Owen McGuinness of Vanderbilt University says, "People have suspected that our cells' response to insulin had a circadian cycle, but we are the first to have actually measured it. The master clock in the central nervous system drives the cycle and insulin response follows."

The 24-hour cycle is (or at least is intended by nature to be) divided into an inactive/fasting phase (night-time in humans, daytime in mice) and an active/feeding phase (daytime in humans, night-time in mice). Mouse studies of variations in insulin sensitivity shows that cellular sensitivity to insulin is heightened during the active/feeding phase, and reduced during the inactive/fasting phase. During the active/feeding phase, when insulin sensitivity is highest, the cells use glucose for energy; during the inactive/fasting phase, when insulin sensitivity is lowest, the cells convert glucose into fat and store it.

Mouse studies show that feeding during what should be the inactive/fasting phase promote insulin resistance, and consequently promote obesity, heart disease, and diabetes.

The researchers think the same thing happens in humans, and that this explains the higher rates of obesity and diabetes among night-shift workers: they are active (and probably feeding) during what should be the inactive/fasting phase of the circadian rhythm.

The researchers say that what people need is a long fasting period after dinner and before breakfast. Even if you're a shift worker (or a blogger) and awake late, you still shouldn't be eating then, because that's just when your body is insulin-resistant and programmed to store fat.


The Big Questions

Wednesday, February 20, 2013

Bad News For The Universe!

How's this for an alarmist headline: "Higgs Data Suggest Universe Has A Finite Lifespan". The universe is in trouble, it seems.

Last year, physicists using the Large Hadron Collider discovered the much-sought-after particle known as the Higgs boson. This particle, long thought to exist for purely theoretical reasons but never detected before 2012, is seen as an important key to a lot of Big Questions in physics, such as why particles have mass and whether or not the universe is stable enough to go on forever. The measurable properties of the Higgs boson would tell us, in effect, whether the universe is here for keeps.

Unfortunately, the measurable properties of the Higgs boson seem to be telling physicists that the universe is not here for keeps. As physicist Joseph Lykken says, "If you use all the physics that we know now and you do what you think is a straightforward calculation, it's bad news... This calculation tells you that many tens of billions of years from now, there'll be a catastrophe. A little bubble of what you might think of as an 'alternative' universe will appear somewhere and then it will expand out and destroy us."

The silver lining here is that, if the catastrophe Lykken is forecasting will occur tens of billions of years from now, none of us will be around to see it. The sun is projected to run out of hydrogen fuel, and burn out, in a mere 4.5 billion years. And the larger universe, finite thought its lifespan may be, will continue to exist long after our solar system has gone cold and dark.

So, if you want to worry, worry about something else!


The Google search strings lately have been indicating to me that diabetes patients are asking the Big Questions these days...

"do i legally have to see a doctor for diabetes"

An intriguing question, assuming it was asked by an American, given that American society is so much more focused on denying people health care than with forcing it on them! But perhaps we are the sort of society which denies health care only to those people who want it, and provides it only to those who don't want it.

Given the seriousness of the health threat which diabetes can represent, it seems paradoxical for anyone with diabetes to worry primarily about being obliged to see a doctor. What might lie behind that concern? A fear of needles, and an assumption that going to the doctor for your diabetes leads to your having to give yourself shots? Or perhaps a fear of losing a job, because diabetes might be seen as a handicap in that line of work?

So far as I know, going to a doctor is never a legal requirement. I behave as if it were, sometimes. I have taken it for granted, for example, that when my doctor said it was time for me to schedule a colonoscopy, I had to go ahead and schedule it whether I felt like it or not (and who, in human history, ever felt like doing that?). I was startled to learn, from asking my friends, how many adults I know whose doctors have been trying to get them to schedule a colonoscopy, without success. Apparently your doctor can't call the police on you, and have you dragged off to the endoscopy center.

So I'm pretty sure the answer to the question is "no"!

"is diabetes still harmful if your a1c stays within range"

In terms of "diabetic complications" such as kidney disease, neuropathy, and retinopathy (problems related directly to the harmful effect of elevated blood sugar on easily-damaged tissues), diabetes is not harmful if your hemoglobin A1c results remain normal. However, keeping your A1c normal doesn't necessarily protect you from the cardiovascular harm which can be caused by compensatory hyperinsulinemia (abnormally high insulin levels, as a compensation for reduced insulin sensitivity). If you want to do something to prevent those sorts of problems, you have to do a lot of exercise, too.

"is there a 0% for hemoglobin a1c"

No. To get 0% you'd have to have no glucose in your bloodstream for three months or so, and miraculously survive that experience. That's not how human physiology works.

"can having a sugar low of 24 kill you"

Yes, but deaths from extreme hypoglycemia are pretty rare. When hypoglycemia kills, it's typically because the person suffering from the low was driving a motor vehicle when he lost consciousness.

"is a blood sugar of 325 too high and what can happen"

Yes, it is too high, and what can happen is pretty much "everything". 325 mg/dl is extreme hyperglycemia, which has damaging effects on tissues and organs throughout the body; if it continues long enough, it leads to very serious health problems. Especially common consequences are kidney failure, blindness, chronic pain from nerve damage, and circulatory problems leading to untreatable infections in the extremities (and ultimately leading to amputations).

"if a1c is high does it always means diabetes"

If there's something other than diabetes which can cause your hemoglobin A1c result to be abnormally high, I haven't seen it mentioned in the literature. Unless the lab result is simply wrong (the result of a procedural error of some kind), elevated A1c equals chronically elevated blood glucose -- and the medical term for chronically elevated blood glucose is "diabetes mellitus".

"what should my sugar be high in the morning if i'm not diabetic"

What makes you think you're not diabetic? There's no reason for your sugar to be high in the morning if you're not diabetic. Of course, you haven't defined "high", but if it's above 125 mg/dl, that's considered diagnostic of diabetes. If it's not quite that high yet, then you're not quite diabetic yet, but the underlying mechanism that's elevating your blood sugar is the same, regardless of whether it has yet brought you to the diagnostic threshold.

"can a1c rise significantly in 3 months"

Sure. Why not? If your blood sugar levels have been rising significantly during those three months, then the red blood cells collected at the end of those three months will be significantly more sugar-coated than the red blood cells collected for your previous A1c test.

"a1c trigger for insulin"

Doctors make their own decisions about how high your hemoglobin A1c result needs to get before they prescribe insulin shots. But it's generally agreed that A1c results should be kept below 7.0%, and if that isn't happening without insulin, doctors will naturally want to consider making it happen with insulin.

"why are a1c tests all over the place"

Because your blood glucose is all over the place? That would be one explanation.

If you're on hemodialysis, however, be aware that that treatment can distort the results of an A1c test. (But it tends to create false low readings, not false high readings -- if your A1c result is higher than you like it to be, dialysis treatment is not likely to be the reason.)


Hey John Barleycorn

Tuesday, February 19, 2013

The hike yesterday, and possibly the trail-run the day before, left me with a sore ankle. That, combined with the rainy weather today, convinced me to work out at the gym instead. I didn't think anything as percussive as running on pavement was going to encourage my ankle to get over whatever is troubling it. It's starting to feel better now, though, so maybe running tomorrow will be okay. The run is supposed to be over by then, too.


This Low-Glycemic Mystery Grain Walks Into A Bar...

Okay, so I open up the e-mail inbox this morning, and I've got a message from dLife Foodstuff with the subject line "Best Whole Grain for Diabetes", and it leads me to one of those chirpy little slide-shows promoting some food as a real treasure for anyone who is trying to keep diabetes under control.

And already I'm getting annoyed. I don't know who decided to translate "whole grains aren't quite as bad for people with diabetes as refined grains are" into "whole grains are good for people with diabetes", but it was a very irresponsible thing to do and I seriously question their motives.

However, I figured I should actually step through the slide show, and make sure I wasn't being unfair in thinking that it must be dangerously misleading propaganda for some grain or other.

It turns out that the grain in question (called "The Low GI Grain" on Slide 1) is barley. And boy do the folks at dLife have a high opinion of the stuff! "Nutty in flavor, springy and slightly chewy in texture, barley is an ancient grain that's new again. Get a load of its nutritional content and glycemic index ranking (the lowest!), and you'll want to have some on hand at all times. Different barley preparations can have a delicious place at breakfast, lunch, dinner, and, surprise, even dessert (just swap out half of a recipe's regular flour for the same amount of barley flour)."

Gosh, do you think they like it? But it's puzzling to me that they say barley's glycemic index is "the lowest" without giving a value. I assume they mean it has the lowest glycemic index of any grain, because some foods (grapefruit, for instance) have a lower glycemic index than barley does. Barley does have a bit more fiber in it than most grains do, so the carbs in it are digested comparatively slowly, and this gives it a lower index than other grains. But not that much lower, for crying out loud! The Harvard health site gives pearled barley a glycemic index of 28 and wheat kernels a glycemic index of 30; hardly a difference of night and day. And the fact that barley converts to blood sugar more slowly than another grains doesn't mean it yields less blood sugar altogether; barley is still a high-carbohydrate food and its total glycemic load is significant no matter what the "glycemic index" suggests.

This is what drives me crazy about dumbed-down happy-talk news for diabetes patients. We're told that barley is (to a degree not specified) better for us in terms of glycemic impact, and then, without any quantitative comparisons being made, we're told that we will "want to have some on hand at all times". We're encouraged to use barley flour to replace half the regular flour in dessert recipes, and left to assume that the resulting dessert will be rendered diabetes-safe by that substitution.

The overselling continues from there. Slide 2 says that "Barley's high fiber content makes it a diabetes superfood", and claims that half a cup of cooked barley provides 8 grams of fiber. At least we've finally been given quantitative information. But is that information right? Not according to my sources, which say barley provides 6 grams of fiber per cup, not 8 grams per half-cup:

And notice what else a cup of cooked barley provides: 44 grams of carbohydrate. You ought to use the term "diabetes superfood" cautiously, it seems to me, when you're talking about a food that provides more than 40 grams of carbohydrate per serving (only partially offset by fiber). Even if you subtract all the fiber from the carb total, that leaves barley with a significantly greater total glycemic load than 12 ounces of Coca-Cola.

Other grains are also carb-dense, and they usually provide less fiber than barley does. But is barley really so much better? I compared the data for a cup of barley to a cup of oatmeal...

...and to a cup of Cream of Wheat:

It seems to me that the total glycemic impact is higher for the barley than it is for the oats or the wheat. So tell me again, why is barley a diabetes superfood?

Slides 3 through 9 are about nothing more than how to cook barley and how to substitute it for rice and other grains in various recipes. Nothing much is said about how these recipes might impact a diabetes patient's blood sugar, but the impression created by these kitchen hints is that they represent good healthy practices for diabetes patients.

Finally, on the last slide, we get a dose of reality-based thinking: "Barley has the lowest glycemic index and glycemic load of all the grains tested to date; however, that doesn't make it a low carb food. You still have to count every last carbohydrate -- and test, test, test, after you eat. Portion control matters." There follow some nutritional specifics on barley, again not matching the data I've seen reported elsewhere.

Well, if you ask me, the reality-check on the last slide is too little, too late. You don't get to gush for nine pages about how great barley is for diabetes patients (who should have some on hand at all times), and then quietly hint on the last page that everything you've said so far is extremely misleading if not outright fraudulent.

This kind of thing has got to stop.

Presidents' Day

Monday, February 18, 2013

The Presidents, And Their Day

Today is Presidents' Day, and I'm spelling it that way for a reason. Putting the apostrophe after the "s" signifies that the noun is both possessive and plural -- after all, the holiday refers to other presidents besides the original honoree, George Washington. If you spell it as President's Day, then only one president is honored. Not that we have a superabundance of presidents deserving of honors, but we're trying to be fair about this. (Fair in the Washington DC sense of the term, that is, by which I mean that merit isn't a consideration.)

The first president to impact my life was Eisenhower; I remember being resentful, at the age of three, because he came on television to announce a war or something, interrupting the TV show I was watching at the time. I didn't like the look of him. He reminded me unpleasantly of Mr. Clean, the mysterious figure who showed up on the labels of cleaning products. I found Mr. Clean a little menacing (not as menacing as the Jolly Green Giant, but not someone I wanted to encounter, either). To have a president who was even a little like Mr. Clean was worrisome, especially as my understanding of the president's role was that he was granted the authority to interrupt my favorite TV shows -- a privilege which he abused, in my opinion.

I'm not sure that my view of the presidency has evolved as much, since then, as it probably ought to have. But anyway, today is President's Day, and I didn't have to go into the office, so I decided to devote my afternoon to a hike in the hills. I didn't feel like going for a run, as I'd gone an 8-mile trail run the day before; I thought a hike would suit my body a little better today.

After yesterday's spectacular weather (more like May than February), today was cool and a bit cloudy, with a possibility of rain in the forecast, so I was slightly worried that I might come home from the hike shivering and wet, but I put on a jacket and hoped for the best.

It's an oddity of this part of the country that winter is the greenest season of the year.

The trails were steep enough to seem, in places, a little closer to mountain-climbing than walking, so I felt that the hike counted as a real workout.

The whole thing took about 2 hours. My lower back was feeling a bit sore during the hike, and at the end of it my right ankle was feeling sore as well. But I knew I was going to yoga class in the evening, so I would soon be loosening up whatever I was stiffening up on the trail. I'll risk the poison so long as I know I've got the antidote handy.


Diet Sodas Cause Diabetes?

Lots of studies associate sugary soft drinks with increased risk of Type 2 diabetes. That makes sense. But sugar-free soft drinks? Some studies show that artificially sweetened soft drinks have the same problem. Which doesn't make sense, seemingly.

A new study from France confirms the increased diabetes risk associated with both sugary and sugar-free soft drinks -- and, unless I'm misreading their rather dense style of summarizing the results, the risk is actually higher in those who drink the sugar-free soft drinks. Medscape's gloss on the study suggests vaguely that "there are some biologically plausible mechanisms" by which artificially sweetened beverages might increase diabetes risk, but does not list those plausible mechanism. The only possibility Medscape mentions (that those who are already at risk of diabetes, because of a tendency towards obesity, may be exactly the same people who are most likely to drink diet sodas) is rejected as unlikely by the study authors. They think diet sodas actually do something to people which sets them up to be more vulnerable to developing diabetes, and this needs to be investigated. (It sounds like a headline in The Onion: "More Research Is Needed, Say Researchers Seeking Research Grant".)

I have read some speculations about artificial sweeteners fooling the endocrine system into releasing more insulin than is needed, thus promoting fat storage and ultimately leading to obesity (and secondarily diabetes). I don't know if it really works that way, but it is, as they say, biologically plausible. At least to a non-endocrinologist such as myself (for all I know, the idea might be considered laughably unlikely by experts).

As the actual research paper is placed behind a $40 firewall on line, I have to rely on the abstract and on others' commentary on the paper. (That's how it is with most research, even if the research was already funded by taxpayers such as myself.) It would nice not to have to rely on fragmentary reports and biased opinions to try to piece to together what researchers have actually found. I don't know if I'll live to see it, though!



Friday, February 15, 2013

Stuff Falling Out Of The Sky

It's been a busy day for astronomy. Just when all the world's most easily-worried people were fretting about the flyby of the 50-meter-wide asteroid 2012 DA14 (come on, folks, it was known in advance that the thing was going to miss us by 17,000 miles), an unrelated cosmic collision occurred.

A smaller object, probably about one-tenth the size of the asteroid, entered earth's atmosphere above Western Russia, traveling at about 30,000 miles an hour. It superheated almost instantly, and exploded high in the atmosphere, becoming briefly brighter in the sky than the sun. The object seems to have caused no harm in its actual landing (the larger pieces of it are thought to have crashed through the ice of a frozen lake), but the mid-air explosion caused a powerful shock wave which damaged buildings (especially windows), and sent hundreds of people to the hospital, injured by flying glass. When those kinds of velocities and releases of energy are involved, an object doesn't have to hit you to hurt you.

A meteor strike on this scale happens fairly often -- it will probably be one to five years before the next one -- but most of them plunge into the ocean without attracting any attention, or strike land so far from cities that they have little effect on the human population. The Russian meteor landed close enough (or at least exploded close enough) to inhabited regions that its shock wave caused human injuries.

This meteor was captured by an extraordinary number of video cameras. The explanation for this oddity turns out to be the same explanation that applies to a lot of other phenomena in Russia: corruption. People there feel so vulnerable to being set up for phony criminal charges (by police or judges hoping to extort money from them) that they tend to carry around video cameras, and set up video cameras in their cars; they are constantly collecting exculpatory evidence of their own lives. In the process, they accidentally collect a lot of evidence of other things. That's why so many horrifying videos of traffic accidents come from Russia: the cameras are always rolling there. So, when a meteor strike happens in Russia, it's not going to go unfilmed.

And in case you were wondering if the meteor was actually a piece that had broken off the asteroid that missed us today -- the meteor wasn't traveling in the right direction for that to be the case. Its arriving on the same day as the asteroid flyby was a meaningless coincidence. But if you want to read a meaning into it, I know I can't stop you. There are few forces in nature more powerful than the human urge to invest meaning (and always meaning relevant to humans) in whatever accidental things happen in nature, at any time, and in any place. That urge is not a healthy thing (it leads people into idiotic and dangerous assumptions with alarming frequency), but I am beginning to doubt that we will ever overcome it. Which is too bad, because our tendency to parrot the notion that "everything happens for reason", without thinking it through, is a not only stupid but harmful.

Everything does not happen for a reason, at least if you think of a "reason" as being something other than the laws of physics. People develop diseases all the time, usually because of nothing more than meaningless bad luck. Such things are as random as meteor strikes. If you want to suggest, in reference to someone who has developed a disease, that this happened to them "for a reason" (that is, they deserved it), go ahead and suggest that. And may you be punished for saying it, as painfully as fate, at its most cruelly ironic, can arrange!



Thursday, February 14, 2013

Inadvertent Hydration Experiment

Last night I wrote about hydration -- or rather dehydration -- and its effect on blood sugar levels. I have started wondering whether some of my more unexpected variations in blood glucose reflected variations in hydration level.

The issue is seemingly less significant in the winter, when we are sweating much less even during prolonged outdoor exercise. In the summer, even a comparatively short run can cause me to lose a few pounds of water weight; in the winter, even a comparatively long run will cause only a slight loss of water weight.

Last night I tried to make sure I was well hydrated before going to bed, and my fasting test this morning was 86 (compared to 99 the morning before). Maybe significant, maybe not. But today's run was pretty long (5.4 miles) and extremely hilly, and on top of that, the weather today was exceptionally warm for February:

So, after a stretch of cold (or at least cool) weather, I did a challenging run today in rather warm, sunny weather. I certainly was sweating a lot during the run. I got back to the office, had what I considered a light lunch, and got a post-prandial test result of 135. Not especially high for someone with Type 2 diabetes, but I expected the combination of a heavy workout and a light lunch would give me a post-prandial result under 120. 135 seemed a little high for the circumstances. Could dehydration from the run be an issue? I hadn't had very much to drink at lunch after the run. And when I got home, I found that I'd lost four or five pounds, obviously from water loss. I made an effort to rehydrate myself, and after dinner I got a result of 117, which was more in line with expectations.

Of course, it's always risky to read too much into test results from one occasion. But I think today I might have lived out an example of the dehydration scenario that I wrote about last night. I didn't think of it as a scenario that was likely to play out in February, but if the weather is unusually warm in February we must adapt to that. Apparently, after the run, I was a bit dehydrated, so my blood volume after lunch was lower, my blood glucose was less diluted, than they would otherwise have been.


Diabetic Impotence

I was going to discuss this article on the "Pathophysiology of Diabetic Erectile Dysfunction", I guess as a sort of Valentine's Day observance, but my efforts at developing an understandable summary of it have been unavailing so far. This is some of the densest writing on health issues I have encountered to date.

For example, here is the explanation, offered by the authors, of how erections normally work:

"Penile erection is the result of relaxation of smooth muscle in the cavernous body and associated blood vessels. Smooth muscle relaxation is mediated primarily by nitric oxide (NO), which is a gaseous and labile mediator, yet one of the most potent endogenous smooth muscle relaxants. NO is synthesized by neuronal NO synthase (nNOS) in the autonomic postganglionic parasympathetic nerves (nitrergic nerves) and by endothelial nitric oxide synthase in the endothelium lining the blood vessels and cavernosal sinusoids. Nerve impulses in response to sexual stimulus are carried from the spinal cord to the hypogastric plexus where the cell bodies of the nitrergic nerves are located. Once activated, the nitrergic neurones within the hypogastric plexus transmit action potential through their axons to the penile vasculature. These nitrergic axons then release high quantities of NO on to the nearby smooth muscle cells. NO diffuses rapidly into the smooth muscle cells, causing relaxation by increasing the intracellular concentrations of cGMP. The relaxation of the cavernosal and arterial smooth muscle results in an increase in blood flow into the penis. In turn, this causes shear stress on the endothelial lining, which promotes phosphorylation and prolonged activation of endothelial nitric oxide synthase leading to long-lasting release of NO from the endothelium to maintain the smooth muscle relaxation. As the intracavernosal pressure reaches the level of the systemic arterial blood pressure, the subtunical venules are compressed, which results in a rigid erection."

Yes, it's just that simple! This turgid prose (sorry, but what else can I call it?) has pretty well defeated me. Maybe I can analyze and summarize this article at a later point; so far, my reading of it is (1) that diabetes causes erectile dysfunction because it does, and (2) that it's important for us to get diabetes under control as soon as possible if we want to avoid experiencing that problem. (And it's a pretty common problem: about half of men who get diagnosed with diabetes develop erectile dysfunction within ten years.)


Sugar-Water, and Water

Wednesday, February 13, 2013

Another one of those odd days when my post-prandial test result is lower than my fasting test result. Dinner was low-carb, so it's not too surprising to get a low post-prandial result. But last night's dinner was pretty low-carb too, so I was hoping to get a lower fasting result this morning.

Well, these things are never easy to predict. Maybe I'll do better tomorrow.


Mountain Dew For Breakfast!

The people who make Mountain Dew say that there are plenty of people out there (young people, anyway) who don't like coffee or tea -- but are nevertheless eager to drink something in the morning that provides a caffeine kick. Enter "Kickstart"!

Kickstart hasn't actually been introduced yet, but it will be later this month, and it is reported to be a "sparkling juice beverage" which provides 20 g of carbs, 170 mg of sodium, and 92 mg of caffeine (slightly less than a cup of coffee, but more than a cup of tea). This particular sparkling juice beverage contains 5% real fruit juice, so if you're wondering what "sparkling juice beverage" means, it means "a can of carbonated sugar-water".

To the soda industry, I'm sure the situation is clear: we've identified a period of the day during which most people aren't drinking soda! This problem must be solved!

Apparently it will be solved, by the end of February. But solving one problem often creates another...


Hydration & Blood Glucose

It used to be said, in reference to industrial pollution, that "the solution to pollution is dilution" -- which basically meant dumping pollutants into the ocean and assuming that the ocean was big enough to dilute those pollutants so thoroughly that they wouldn't do any harm. There turn out to be a few problems with making this work, however. Pollutants often accumulate in a limited area instead of diffusing endlessly across the seven seas; also, once pollutants get into the food chain, the "biological magnification" process gets started, and pollutants become increasingly concentrated in the bodies of fish that humans use for food.

Still, the basic concept of making a troublesome substance less harmful by diluting it in a lot of water does have some merit.

Which brings me to the subject of blood sugar. We need to remind ourselves that the test result we get from a glucose meter is actually a ratio: mg/dl means milligrams of glucose per deciliter of blood. It isn't a measure of how much glucose is in your body; it's a measure of how much glucose (in milligrams) is present in a deciliter (about 3 ounces) of your blood. In other words, it's a measure of how concentrated (or how diluted) the glucose is in your blood.

The greater the concentration of glucose within a given volume of blood, the higher the rate of glycation (undesirable bonding of glucose to proteins). The higher the rate of glycation, the higher the risk of diabetes-related health problems. So, a lower concentration of glucose is generally better -- which, to look at it another way, means that a higher dilution of glucose is better. Even if the total amount of glucose in your bloodstream doesn't change, you will get a higher glucose reading if your blood volume goes down (because the glucose becomes less diluted), and a lower glucose reading if your blood volume goes up (because the glucose becomes more diluted).

I'm not suggesting that you start getting blood transfusions in order to see lower glucose test results. However, there is another issue besides blood transfusions (or blood loss) which affects your blood volume. That issue is, of course, hydration.

I can say from experience that endurance sports (such as marathons and 100-mile bike rides) which result in dehydration can also result in a temporary elevation of glucose test results. Part of this effect is the result of diminished insulin sensitivity caused by dehydration, but part of it is simply that, when you are dehydrated, your blood volume is lower and whatever glucose is in your blood supply is more concentrated. Rehydrating yourself causes that glucose to be more diluted, so your test results come down.

Let's be clear: I'm not suggesting that you drank massive amounts of water just to bring your glucose down. Excessive water-drinking can cause serious problems (it doesn't just dilute the glucose in your blood; it also dilutes the salts in your blood, perhaps to the point that the nervous system is adversely affected -- and that is not something to mess with). What I am saying is that being dehydrated (which a lot of people frequently are, without realizing it) tends to elevate blood glucose. Making sure you're taking in plenty of fluids makes sense, especially when you're trying to keep blood glucose under control.

The next time you get a high glucose result which seems unexpected and even rather unfair under the circumstances, ask yourself: have I been getting enough water to drink today? Dehydration could be driving your glucose up. It's an issue to consider, anyway!


Keeping It Going

Tuesday, February 12, 2013

A Runner Retires From Racing

An important focus of my exercise program is simply to find a way to keep doing it, despite the injuries which we all get from time to time, and the aches and pains and infirmities that tend to crowd into people's lives as they age.

Still, no matter how carefully we try to keep ourselves limber and strong, there comes a time when an athlete realizes he is just too old and tired to continue in his sport. Apparently the distance-runner Fauja Singh has reached that point. He is planning to retire from racing after finishing an event in Hong Kong at the end of this month.

That isn't even a current photo of him, by the way; it's seven years out of date. Today he is 101 years old, and approaching 102 fast.

Not that Singh is planning to become entirely sedentary; he says he will continue his practice of walking 4 hours a day, to serve as an example for others. And he told an interviewer "I will keep running to inspire the masses. Running is my life and I really would not have stopped competing if I had not crossed the age of 100." He's giving up racing, not moving.

Singh (a Londoner, but originally from India) didn't even take up running until he was 89; he was simply looking for something to do during the day. Since then he has completed 7 full marathons and countless shorter races. Naturally, people often ask him what advice he can offer on how to enjoy a healthy and vigorous old age. He has offered some nuggets of wisdom:

He also mentions a meeting of elderly people he attended: "One day they asked us to raise our hands if we do not take medicine or tablets. Out of 50 people I was the only one to raise my hand and say that I have never taken medicine. We all sometimes get ill but I just take porridge and simple food to aid my recovery!" So there you have it. He is healthy because of what he does, not because of what his pharmacist does.


The Special-Occasion Problem

Monday, February 11, 2013

Banquet Recovery

I knew my fasting test would be up a bit this morning, because I was at a banquet last night, but I am pleased to note that, after getting in a good hilly run at lunchtime, my post-prandial test was just barely higher than the fasting test had been.

I might as well tell you about the banquet. It was a Burns Supper -- a uniquely Scottish social event which is centered around the poetry and songs of the great Scottish poet Robert Burns (1759-1796), who wrote "Auld Lang Syne" and is the originator of that famous line about what often happens to "the best-laid schemes o' mice an' men".

Scottish expatriates and descendants all over the globe hold Burns suppers, on Burns's birthday (January 25th) if it's convenient, or near it, as in our case. It's an event that involves a lot of feasting and toasting, but also a lot of Scottish history and poetry and music.

This particular Burns Supper was held at an old Victorian house in Healdsburg, California, which has become a Bed & Breakfast. I was playing music for the event with some Scottish musician friends.

I also got to participate in the poetry reading. Specifically, I gave the traditional "Toast to the Immortal Memory of Robert Burns", which is usually a mini-lecture about the life and works of the poet; my version was in the form of a poem. But my main contribution to the evening, as I saw it, was playing my fiddle in the musical interludes.

An odd thing happened while were away from our seats at the table to play some tunes: dessert was served to everyone else, and we were seemingly overlooked. I had mixed feelings about this. On the one hand, it seemed unfair to the musicians, and on the other hand I realized that I certainly didn't need a dessert, so it was all for the best that they didn't give me one. Then, later in the evening, the kitchen staff realized their mistake and put a bowl of trifle in front of me. Did I indignantly push it away? Did I offer it to someone else who might like seconds? No, I did not. I found a way to rationalize eating it (I'd done a long trail-run earlier in the day; wasn't I entitled to dessert?). I knew it wasn't the right thing to do. When I got out of bed this morning and went to the bathroom to get my glucose meter out of the drawer, I knew that dessert was going to be saying "Good Morning!" to me when I read the result. It was higher than I like it to be (102), though it certainly could have been worse (and certainly would have been worse, if I hadn't done that long trail-run).

If you have diabetes, one issue never goes away: the conflict between your awareness of the restraint you ought to be practicing and your desire to participate fully in life's celebratory events the same way everyone else does. If nobody else at the banquet is leaving their trifle untasted, and if no one else at the banquet is refusing to taste more than a spoonful of the mashed potatoes on their plate... it's pretty hard to persuade yourself that you have to do those things. (And, of course, it doesn't help if you're at an event that involves drinking toasts all evening.)

I think you have to allow yourself a certain degree of license on festive occasions, simply to avoid going stark raving mad, but life can become pretty full of festive occasions if you let it. There's always a reason to declare that today is special...

Well, I struggle with that just like everyone else does.


More Searching Questions

Thursday, February 7, 2013

It was raining when I got to work this morning, and I thought this might not be a day for running outside. But by 9:30 the clouds parted; there was brilliant sunshine, and the cool breeze made the air feel as if it had more oxygen in it than usual. So, instead of skipping my lunchtime run, I treated myself to an extra-long one. I'm not saying that ironically, by the way; it actually did feel like a treat rather than an ordeal. For some reason, I'm very impatient while exercising in the gym, and very patient while exercising outdoors. Thirty minutes on a treadmill seems like a long run to me; ninety minutes on the trail does not.


I am looking over some recent questions (implicit questions anyway) that have come my way in the form of internet search terms that the folks at Google thought my site might be relevant to. As usual, these questions reveal widespread confusion about the hemoglobin A1c test, and widespread preoccupation with urine...

"do all labs report a1c results as percentages"

All labs measure hemoglobin A1c as a percentage, but they often omit the "%" sign when reporting the test results. This is because the health care industry is aware that most people don't really understand the A1c test, and the industry wants to change that situation, so that nobody understands it. So they omit mentioning that the result is a percentage, and they tell people that the test "measures" average blood sugar, which it doesn't. (Average blood sugar influences the test result, but the relationship between the two is complicated; one can use the A1c result to estimate what average blood sugar has been lately, but to call that a "measurement" would, in another context, be pretty close to scientific fraud.)

The hemoglobin A1c test analyzes the hemoglobin in your red blood cells to find out what percentage of it is "glycated" (sugar-encrusted). The glycated fraction of your hemoglobin is identified as the subtype "A1c" (it's just an arbitrary label for that variety of hemoglobin.)

The test is of interest mainly because it indicates the glycation rate (that is, the rate at which unwanted sugar bonding is affecting the proteins in your body). The glycation rate matters because accelerated glycation (which occurs when blood sugar is abnormally high) causes health problems which we usually think of as "complications" of diabetes. The higher the glycation rate, the worse the risk of such health problems. The lower your A1c, the lower your glycation rate, and the lower your risk. So, if you have diabetes, you want to work your A1c down to normal level, or at least a non-harmful level -- and the way to do that is to control your blood sugar as well as you can.

In a normal, healthy person, the glycation rate is low enough that the glycated fraction of hemoglobin is stabilized at about 5%. Diabetes, by raising blood sugar, increases the glycation rate, so in diabetes patients the glycated fraction of hemoglobin tends to be above 6%. Sometimes a lot more than 6%. The higher it gets, the greater the risk of health problems such as blindness and kidney disease.

Anyway, the result is always a percentage, even if the lab report doesn't say so.

"can artery blockage alter a1c results"

My goodness, people sure can get imaginative when they're looking for an excuse to dismiss an unfavorable A1c test result as being incorrect.

An arterial blockage might limit the flow rate of blood within a particular part of the body, but I have a mighty hard time imagining how it could cause the hemoglobin in your blood to seem more (or less) sugar-coated than it really is.

Nice try, though!

"new studies showing a1c below 6% not healthy"

I rather doubt that; pretty much every health non-diabetic person has an A1c below 6%.

What you're probably thinking of is studies which seem to show that aggressive drug treatment to bring down a diabetes patient's A1c to near-normal levels usually causes more problems than it solves.

Such studies do not, of course, indicate that having an A1c below 6% is bad for you -- at most they show that intense drug therapy is bad for you. If a study finds that it's bad to lose weight by cutting your legs off, the takeaway message is not that weight loss is unhealthy no matter how you do it.

"how to raise your a1c"

Does it ever happen that anyone needs to do this?

Drinking sugary soft-drinks would be one way to accomplish it, if you needed to. Pasta helps, too.

"What is difference between diabetes mellitus and diabetes insipidus and why are they both called diabetes"

An ancient physician (Aretaeus, whose practice was in Alexandria) coined the term "diabetes" for excessive discharge of urine. The precise Greek etymology is a little confused; the Greek root for the term (diabainein) has been variously translated, but it certainly refers, in its modest and metaphorical way, to urination. If you have diabetes mellitus, the excessive urine you're producing is sugary ("mellitus" means "honey-like"). If you have diabetes insipidus, th excessive urine you're producing is not sugary ("insipidus" means "lacking flavor"). The former condition is caused by excessive blood sugar; the latter condition is caused by a pituitary disorder. Both conditions result, or at least can result, in excessive urination, which is why both are called "diabetes". Because diabetes mellitus is more common than diabetes inspidius, the time-saving use of the word "diabetes" by itself is assumed to refer specifically to diabetes mellitus.

"diabetics and peeing blood"

Hematuria (blood in the urine) can be caused by a variety of problems in the kidneys, bladder, or prostate. It doesn't directly relate to diabetes.

"how low does my suger number gotta be so it wont show in urine"

Here we have the Lance Armstrong approach to diabetes management: the issue is not what's going on, but whether you can conceal what's going on.

Sugar in the urine is relevant to diabetes only in that it is a warning sign that you have diabetes (or that your diabetes is getting out of control). Sugar in your urine does no harm in itself, and the goal of diabetes management is not to improve your urine quality.

When blood is filtered through your kidneys, the sugar in it is returned to the blood supply, instead of being allowed to pass through the nephrons into your urine. At least, that's that goes on when your blood sugar level is normal and your kidneys are working fine.

As blood sugar levels rise above normal, eventually you reach the "renal glucose threshold" -- the point at which there is too much sugar in the blood for your kidneys to recapture all of it. Some of it leaks into your urine, and your urine starts to have a measurable sugar content. That threshold varies from person to person. In most healthy adults, it is around 160 to 180 mg/dl, and so long as their blood sugar is lower than that they don't pass any sugar into the urine. However, the threshold can be significantly lower than that. In children, and in pregnant women, it is often below 126 mg/dl. Kidney disease can cause it to go even lower. But, in most people, the threshold isn't any lower than 160, so if you keep your blood sugar below 160, you probably won't pass sugar into your urine. That doesn't mean 159 mg/dl is a perfectly normal and harmless level. It isn't your urine that determines whether or not diabetes harms you.

"if i had diabetes with low blood sugur would i still be peeing alot"

Probably not, unless your excessive urination was caused by something other than your diabetes.

"if you drink a lot of bee you produce a lot of urine. why"

I'm guessing they meant "beer", not "bee". But I'm surprised they needed help with this.

Drinking a lot of beer results in a lot of urine because beer is mostly water (taking in a lot of water produces a lot of urine) and because beer contains alcohol (which is a diuretic -- that is, it tends to stimulate urine production).

Still, drinking a lot of beer is better than drinking a lot of bee. Ask anyone who has tried both.


Mental Fitness

Wednesday, February 6, 2013

It was a higher-carb lunch than usual; unsurprisingly, I got a higher post-prandial glucose result than usual (141 mg/dl). Still within my doctor's guidelines, but higher than I like to see. I keep thinking I can get away with things, so I need to come up against the blunt reality of glucose test results to remind me of how things really work. That's why testing is necessary for me; in principle I know what I should do, but as a practical matter I have to be nudged periodically into doing it.

An Unusual Exercise Benefit

Apparently exercise can help protect us against more problems than heart disease and diabetes complications: a new study finds that physical fitness is inversely related to the risk of dementia. That is, people with high levels of physical fitness have a significantly lower risk of dementia in old age (from Alzheimer's disease or other causes) than people with low levels of physical fitness. And the fittter you are, the greater the benefit. If we treat the risk faced by people with the lowest fitness levels as a baseline, the risk faced by the people with medium fitness levels was 79% of that, and the risk faced by the people with the highest fitness levels was 64% of that.

Yeah, I know: we've all heard that crossword puzzles help with this. Well, fine, do the crossword puzzles -- but exercise too: it seems to help more.

Now, some people might be inclined to assume that the reason fitness reduces dementia risk is that it reduces stroke risk. Interestingly, the new study found that the fitness advantage (in reducing dementia risk) applied just as well to people who had not suffered strokes as to people who had suffered strokes. Whatever exercise does to prevent dementia in old age, it isn't just a matter of stroke avoidance. There is something inherent in exercise which wards off dementia; we just haven't found out what it is yet.

The study authors say that, although the ideal situation is to become fit at a young age and stay fit throughout life, it's never too late to start; people who adopt an exercise program in middle age benefit as well.

The authors of another study are claiming that the benefits of exercise can be obtained with three short workouts a week instead of five longer ones -- provided that those three short workouts are at a very high level of intensity. Well, that sounds great in principle (stay fit while devoting only 90 minutes a week to exercise!), but don't commit yourself to that program before you have done enough experimentation to find out what exercise at a very high level of intensity feels like. You might find out that five hours a week of jogging isn't as hard on you as 90 minutes a week of crazy-intense workouts. I mean, give it a try if you're interested, but make sure that you don't end up using it as a convenient rationalization for doing less exercise without making it more intense exercise.


Pesticides & Diabetes

Tuesday, February 5, 2013

Cause Of Diabetes #7641!

Exposure to certain pesticides magnifies the risk of developing Type 2 diabetes. At least, that's what researchers at the University of Granada (in Spain) say, and I guess they must be right, because they are young and photogenic:

On the other hand, the crest that represents their university is hideous, so maybe they're wrong after all:

I am, of course, joking about evaluating the scientists and their college based on imagery, but it's a joke with a point: imagery is about as good a basis as any for evaluating a scientific report which hasn't been confirmed by anyone else yet. Either you buy it or you don't... and very probably you're going to buy it for reasons that aren't relevant. For example, you might buy it because you're personally inclined to blame human health problems on environmental contaminants -- or you might refuse to buy it because you're personally involved in the pesticide industry, or in an agricultural industry which uses those pesticides. Often a scientific idea makes sense to us primarily because it harmonizes well with opinions we already hold... but that, of course, is not a sensible basis on which to accept or reject a scientific idea. That would be as silly as accepting or rejecting a scientific idea on the basis of what the scientists look like.

Anyway, what the scientists are reporting is that "persistent organic pollutants" (which tend to accumulate in the body) are strongly associated with Type 2 diabetes. For example, people with higher concentrations of DDE (a relic of exposure to the pesticide DDT) are four times as likely as other people to develop Type 2 diabetes.

What's intriguing about this report is that it seems to make sense of the real (but somewhat erratic) association between obesity and Type 2 diabetes: persistent organic pollutants tend to accumulate in body fat, so people carrying extra body fat are likely to be carrying an extra burden of pollutants. But exposure to those pollutants also varies from individual to individual, so obesity isn't the only factor determining how much of a given pollutant will be inside you. Therefore, obesity and Type 2 diabetes are linked, but not quite consistently; there will always be fat people who don't become diabetic and thin people who do.

Of course, no one has yet figured out how pesticides cause Type 2 diabetes, if indeed they do. The new research represents a promising lead for scientists to investigate. The first step (the easy one) is to confirm the connection between pesticides and diabetes; the second step (the hard one) is to determine the nature of that connection. I'm not going to hold my breath waiting for a clear explanation of what the Spanish researchers discovered, but it's certainly worth following the story to see where it leads.

Where stories like this usually lead is nowhere, of course. But I'll be interested to see if anything comes of it.


Superbowl Sunday

Monday, February 4, 2013

You Don't Have To Watch

On Superbowl Sunday I'm always interested in gathering evidence that life goes on despite The Big Game. There are certain events and entertainments in American life which, supposedly, the entire population is so wrapped up in that life is halted in its tracks for a little while. The Superbowl is one of those events. It has gradually developed into a party occasion: essentially an excuse to drink enough that you don't notice how many snacks you're eating. America probably doesn't need an occasion like that, so soon after the winter holidays. But whether we need it or not, a lot of us find it to be inescapable, even if we're not football fans, because everyone tells us it's really about the liquor and the nachos and the halftime show and even the TV commercials. There's a football game involved in it somewhere, but that is incidental. Being uninterested in the game itself is not an adequate reason to skip the event.

I have always disliked the idea of things becoming socially obligatory for no good reason. (I remember, as a child, having "fashion" explained to me, and being outraged by the very idea of it -- a feeling which has not receded much during the intervening years.) So, I tend to be a contrarian: when I'm told that everyone else likes something, I immediately begin to suspect that there must be something wrong with it. I'm not absolutely consistent about this, I have to admit: you won't find me manning a lonely outpost of opposition to guacamole, for example; its popularity has not been enough to convince me that it has nothing going for it.

Still, I am a bit of a holdout against Superbowl Sunday and the high-calorie ceremonies which honor it. When that particular Sunday rolls around, I like to leave the house and hunt for evidence that other people are out there in the real world, doing things.

When I left the house yesterday, looking for signs of life away from the Superbowl broadcast, I must admit I found that American life away from the Superbowl broadcast does not go on quite so busily as it might on other occasions. For example, I found it easier to snag a parking space near the trailhead than I would have on a more typical Sunday afternoon with good weather. All the same, people were outdoors, moving under their own bodily power. I encountered a fair number of cyclists, runners, and hikers on the trails. I even saw people out on the street, while I was driving to and from the park, walking around as if there wasn't something far more important happening on network television.

Anyway, I still cling to my skepticism that "everyone" is really into what we're told "everyone" is into. Of course I'm not arguing that people shouldn't attend Superbowl parties; I'm merely suggesting that preferring to do something else on a sunny Sunday afternoon is okay, too.

Unhealthy Baby Boomers

A report from JAMA Internal Medicine says that "baby boomers" generally have worse health than their parents did. I had always thought that "the baby boom generation" was an extremely vague term for the increase in the American birth rate after World War II, but JAMA thinks it has a more precise definition: if you were born during the period stretching from 1946 to 1964, you're a boomer. (In other words, I'm part of the baby boom generation myself, even though I was born in 1957 and I had thought of the boomers as those who were a few years ahead of me.)

Some aspects of the JAMA report definitely cry out for skeptical inquiry; for one thing, an important issue in the report was how well the patients themselves assessed their own health. Baby boomers tended to give themselves low marks for the quality to their own health, at least compared to the generation that preceded them -- but couldn't that be an indication that baby boomers are not less healthy than their parents, but rather more inclined to complain?

However, the study also looked at more objective criteria for judging the patient's medical condition, and found that the boomer generation has higher rates of obesity, diabetes, cholesterol problems, and hypertension than their parents' generation did. Maybe, instead of focusing on the supposed egocentricity of the baby boomer generation, we should focus on figuring out the real reason why they're having so much more trouble with their health than their parents did. One possible explanation, I'm guessing, is that their parents' generation didn't go to Superbowl Sunday parties; naturally they had fewer health problems!

Trickle-Down Diabetics

(Good Heavens, Readers, Is Your Curiosity About Urine Insatiable?)

Friday, February 1, 2013

I get a lot of questions about urine and diabetes. Well, actually, that's not quite true; what happens is that Google gets a lot of questions about urine and diabetes, and refers them to my site. Sometimes, when I review the search strings that brought people here, I am astounded at how many of them are about making water.

Some of these questions are from people who are puzzled about the diabetes/urine connection:

The last of those questions is the key to the whole diabetes/urine situation. As blood flows through your kidneys, some ingredients of the blood are supposed to be re-absorbed, so that they are retained in the blood supply instead of being dumped out into the urinary tract. Glucose is one of the ingredients that is supposed to be re-absorbed by the kidneys. However, if your blood glucose level is extremely high, the kidneys can't re-absorb all of it, so some of it passes into the urine. When this happens, osmotic pressure causes a greater volume of water to pass into the urine along with the glucose, and this increased fluid volume results in abnormally frequent urination. The higher your glucose goes, the more urine you produce.

Other questioners have noticed that frequent urination doesn't always mean high blood glucose:

Diabetes mellitus isn't the only condition which can cause the symptom of frequent urination; for example, a pituitary disorder called diabetes insipidus causes frequent urination without high blood glucose. That's why diabetes mellitus is not (in modern times) diagnosed on the basis of what's going on with your urine. However, when your doctor is investigating the symptom of frequent urination, diabetes mellitus is the likeliest suspect.

Others seem to have confused expectations about urine color:

If you are producing an excessive flow of urine because (as a result of high blood glucose) more water than usual is passing into your urine, it's only to be expected that the extra-watery urine that results will be extra-clear in color.

Some people seem to be mistakenly assuming that, if extremely high blood glucose can result in sugary urine, non-sugary urine ought to be a guarantee of normal blood glucose levels -- and it is therefore strange if anyone without sugary urine should get a high result on a hemoglobin A1c result:

Blood glucose can be elevated enough to give you a high result on an A1c test (and do harm to your health) without being elevated enough to produce sugary urine.

Some questioners are a little confused about the real health significance of sugary urine:

The reason to be concerned about sugary urine isn't that sugar in the urine does any harm; the reason to be concerned about sugary urine is that it's a warning sign of sugary blood. The way to "get glucose outta my urine" is to get the sugar in your blood under control.

And here's someone who is even more confused:

Frequent urination may be an inconvenience, but it isn't the real problem here, and your goal shouldn't be to "stop pissing" (the time to stop doing that is after you die). Your goal should be to get your blood sugar under control. It should never be high enough to have that effect on your bathroom habits. Don't think in terms of trying to make life easier when it's that high; think in terms of preventing it from getting that high.

But most of the diabetes/urine questions I get are really diabetes/urine/insect questions:

There's something that fascinates people about hearing that doctors in ancient times (we're talking pre-Biblical times) recognized diabetes by the way urine of diabetes patients attracted ants and bees. However, this is a somewhat imprecise diagnostic tool, as insects are interested in other things besides sugar (water, for one), so there might be various reasons why insects would take an interest in your urine. Or your bathroom. Or your panties.

Really, folks, the connection between urine and diabetes is not much more than a historical curiosity these days; we now have better ways of telling how high your blood glucose is.

Finally, a bonus question, blessedly unrelated to urine:

If you have just been doing what, sir? I don't even know where that train of thought was heading, but if that was the station it started from, then the answer is yes. Worry!

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