Oddities

Friday, June 28, 2013

It was a pretty hot day for a noontime run, but these days it doesn't even occur to me to cancel a run for that. It wasn't easy, though, and I felt dizzy when I finished. Maybe I was a little dehydrated -- I didn't carry any water with me, because I thought a five-mile run was too short to require that. Maybe, in this heat, it wasn't too short after all.

I don't know why my glucose was up a bit today; the heat might have contributed to that. At least my blood pressure was low!

 


The Weirder Questions

Today I thought I'd take a look at some of the odder questions that have come to me by way of people's Google search strings...

"can you ever get an elevated a1c level and still have diabetes insipidus"

Can you catch a cold and still have tuberculosis?

A remarkable number of people seem to believe that you can only have one disease at a time, so any examination of one's symptoms must therefore point to one illness, not two.

As it happens, you can have two or more diseases simultaneously. You can even have two diseases with "diabetes" in their names simultaneously.

Strictly speaking, the word "diabetes" by itself only indicates a disease which causes excessive urination. If excessive blood sugar is involved, then it's not just diabetes, it's "diabetes mellitus" (the latter word implying that the urine which you are overproducing is honey-sweet). The pituitary disorder known as "diabetes insipidus" (the latter word implying a disappointing absence of flavor) produces excessive urine regardless of how high your blood sugar might be. And there is no law that says a person with diabetes insipidus cannot also develop diabetes mellitus (or the other way around). Having an elevated hemoglobin A1c test result indicates that you at least have diabetes mellitus. You might have diabetes insipidus, too. But do not assume that, if you do have diabetes insipidus, it means you don't have diabetes mellitus. Because the diseases are entirely unrelated, there's no reason why you couldn't have both. And it's hard to see how you could get a high A1c result and not have diabetes mellitus.

"i can't believe i have type 2 diabetes"

All right, don't believe it then. Demand further evidence. Have more tests done, even if you have to pay through the nose for them. But when the evidence comes in from the confirming tests, please take it seriously.

If you're going to manage diabetes at all well, the first step is to stop trying to fool yourself into thinking you don't have it.

Sometimes people "can't believe" they have Type 2 diabetes because they don't fit the profile of the "typical patient" which has been presented to them. They're not overweight, they're not sedentary, therefore they couldn't possibly have Type 2 diabetes! Well, guess what: not every patient with Type 2 meets the expected profile. I've met Type 2 patients who have always been active and fit; they think they're walking paradoxes because Type 2 patients supposedly aren't like that. Well, most Type 2 patients aren't like that, but a few are. Life is complicated; deal with it!

"i'm diabetic why do i have to push to pee"

I don't know. Diabetes only causes excessive urination when it gets out of control, and perhaps you're in pretty good control. If you're having trouble urinating, that's probably not a diabetes-related issue.

"bees attracted to those with low blood sugar"

Low blood sugar? I think you're a bit confused.

Bees and ants have been observed for many centuries to seek out the urine (not the person) of a diabetes patient, but this only happens when blood sugar gets high enough that it spills over into the urine.

"have they came out with a wonder drug for type 2 diabetes"

Wouldn't you have heard of it if they had?

There are plenty of drugs for Type 2, but they're not wonder drugs.

Actually, the closest thing to a wonder drug for Type 2 is one that you have heard of: exercise. It's hard to talk people into taking it, though.

"what to say if high levels of glucose were found in urine that was not mine"

Now, that is a cool question. It reminds me of a story that my nephew the cop likes to tell, about the way suspects react when he finds something of an illegal nature in their pockets. They look at him in surprise and say innocently, "oh, these are not my pants".

So now he sometimes begins his conversation with suspects on that very note: "Good evening, sir! Are those your pants?".

I assume what has happened here is that the questioner, forced to take a urine test for illegal drugs, and not feeling confident about passing it (the test, I mean), used artful trickery to substitute someone else's urine for his own. And now it turns out that this other person is diabetic! And he has to explain how all that sugar got in there instead of the cocaine. How very embarrassing!

I guess what you can say is that you have a binge-eating disorder and you ate an entire Boston cream pie before taking the test, and you're sure you can get your problem under control now that you've joined the support group, and they can repeat the test and this time you'll be normal.

And then join the support group -- but not the one for pie-eaters.

 


Blood, Sweat, & Tears

Thursday, June 27, 2013

A warm day (89 degrees), and humid by local standards (though not by any other standards; California is quite dry most of the time). A little challenging for a mid-day run, but I got through it! It was a sweaty run -- which turns out to be pertinent to my topic today.

 


Diabetic Sweat

I often review the Google search strings that have brought people here, and an astonishing number of them are about insects. Once people have heard reports to the effect that people with diabetes produce sugary urine which tends to attract insects, they can't get that image out of their minds, and every day people are running searches aimed at finding out if what they've heard about the ants and bees is true. Today I saw a search that read "do people that are diabetics have sweat that atracks bugs", which at least is a nice break from all the urine questions.

Well, as I've explained countless times before, it is true that people whose blood sugar gets above the "renal threshold" (somewhere in the range of 160 to 180 mg/dL), the kidneys can't fully retain it anymore, and glucose starts leaking into the urine. Since ancient times, this has been known to spark the interest of our six-legged friends. It's a pretty crude diagnostic indicator, however. If ants are taking an interest in your urine, they might be there for the water in it as much as for the glucose in it. So, if you want to find out what your glucose level is, you need to monitor your blood instead of monitoring insect behavior.

Unfortunately, monitoring your blood has a big drawback: you have to take blood samples. And a lot of people hate taking blood samples. Truth to tell, it doesn't hurt all that much (I can't believe anyone thinks it's as bad as flossing, which is my idea of a hateful chore). Still, a lot of people really can't stand it. For this reason, there have been a lot of attempts over the years to find a way to check glucose levels without actually collecting any blood. Couldn't our doctors give us a meter that would measure glucose in urine, or in tears, or in sweat?

Forget urine, please. It's a very imprecise measure of blood glucose, because your urine has been collecting in your bladder over an extended period, during which your blood glucose has been rising and falling. Urine glucose tends to be out of synchronization with blood glucose; it may be a better reflection of what was going on with your glucose than with what is going on.

Tears do reflect blood glucose levels, but apparently not with great accuracy. A few years ago I read about some contact lenses which were being tested, which changed color in response to glucose level changes. However, the lenses didn't measure precisely enough to do more than give you a warning of a dramatic high or low.

Glucose levels in sweat, however, do apparently correlate pretty well with glucose in blood. At least, so says this maddeningly vague report, which gives absolutely no numbers. (No other report I can find gives numbers either; how can anyone think vague adjectives and hand-waving are good enough when you're talking about measurement, of all subjects?)

Anyway, for the past seven years at least, researchers have been publishing reports suggesting that sweat-based glucose measurement is just around the corner, and that soon you will be able to have your glucose measured by having three probes stuck on your sweaty forearm by an even sweatier doctor:

There are technical reasons why three probes are needed which I won't go into; I'll just mention that this kind of measurement is tricky and potential sources of error need to be canceled out through the use of three probes.

Why don't we have this yet, if it's been tested successfully? My guess is that it can be tested successfully under ideal (and rather unrealistic) laboratory conditions, with knowledgeable experts doing the testing. It's probably not easy enough to do for patients to be able to get reliable results. And if it can only be used by trained professionals, then what's the point? The patient can't use it at home, and in the doctor's office a more accurate test (that is, a real blood glucose test) would almost certainly be used.

As for insects being attracted to sugary diabetic sweat, I'm sure it could happen, but as in the case of urine, they might be interested in the water content regardless of whether there's any sugar content. So if the bugs are bugging you, I doubt very much that it proves anything about the state of your glycemic control.

 


My Theme

Wednesday, June 26, 2013

 


Running In Five-Quarter Time

I did a long run at lunchtime today, and I was continuing to work on the running/breathing technique I wrote about on June 21, which I've been trying to adopt as a habit. As it requires you to (1) exhale during two footstrikes and inhale during the next three, and (2) avoid having the inhales start on the same foot twice in a row, the rhythm pattern is a little tricky. Over a very short time scale, the rhythm is irregular (because inhales last 50% longer than exhales), but over a slightly longer time scale there is a monotonous pattern. In other words, the rhythm is in 5/4 time... and there is a reason why popular music is almost never in 5/4 time instead of 4/4 time.

To keep myself on track with these alternating irregularities, I found myself (quite inadvertently) playing a simple theme in my head over and over. Maybe "theme" is too generous a description of it; let us say it is a recurring rhythmic figuration in G minor, in which an unvarying G (for the exhales) alternates with a longer D (or E-flat, or C) for the inhales:

(For what it's worth, the theme is played on cellos and basses in the orchestra of my brain.) Now, I'm surely not claiming this is a particularly inspired melody, but it's now drilled into my head and I can't seem to change it to anything else.

As this breathing technique does seem to make running less effortful for me, I'd like to continue doing it. But I sure hope I can get to the point that I don't need to have this maddening little melodic figure repeating endlessly in my mind the whole time. It would be nice to think of something else. Actually, it would be nice to think of nearly anything else.

It's possible that I'll be able to devise a better melody in 5/4 time which I can start playing in my head in place of this one. But it would have to be a very good melody indeed not to wear out its welcome; I run almost every day! It will be much better if I can learn to do this with no theme at all in my mind's ear.

I know it sounds as if I'm just joking about all this, but one of the most important (and most overlooked) aspects of creating an exercise program that works for you is the need to make it pleasant to do. If you're going to keep on doing it (and nobody, especially nobody with diabetes, can afford to let the exercise habit fall into dormancy), you have to find a way for it not to drive you crazy.

Unfortunately, exercise has a lot of ways to drive you crazy. At first (when you start working out after a long period of not doing so), it drives you crazy simply by being difficult and unpleasant to do. It makes you feel good afterward, of course, and that's great -- but it's hard to reap those post-exercise rewards, if the workout itself is so hard and uncomfortable for you that you just can't force yourself to go through with it.

That's one of the reasons why finding workout buddies, or joining an exercise class, can be so valuable for a lot of people. A little bit of peer pressure is always helpful in keeping yourself motivated. If you work out by yourself, who's going to know or care if you skipped a workout just because you were feeling lazy? But you know how unlikely it is that your exercise buddies, if you've got some, won't call you out if you try to pull something like that!

A surprising amount of the effort involved in maintaining the exercise habit over the long haul is mental effort. You have to keep inventing ways to trick yourself into doing it, or to trick yourself into thinking it's really not that tough. It takes a fair amount of imagination and creativity to keep at it, and to keep fine-tuning it to meet your physical needs (in terms of diabetes management, and health management) and to meet your psychological needs (in terms of keeping at it no matter how much you wish you could stop).

You have to find your theme -- the theme that will carry you through for now, and keep you going. It might be a really stupid theme at first, but perhaps you can find a better one later!

 


Follow-Up

Tuesday, June 25, 2013

The gloomy weather continued today -- the rain never stopped. I tried waiting it out -- putting off my usual lunchtime run till evening, but the rain just got heavier instead of stopping. I didn't want to have two gym workouts in a row, so finally I bit the bullet and ran in the rain.

My biggest problem with running in the rain is that, when my clothes get heavily water-logged, they really start chafing me. I made it a fairly short run, and I applied BodyGlide carefully beforehand. Fortunately, I got by with it this time -- no raw patches, no howling in the hot shower afterward. (The hot shower, by the way, is the only good thing about running in the rain.)

I am continuing to experiment with the breathing technique for running which I wrote about in last Friday's blog post. It doesn't invigorate quite so much when you're running in the rain as it does under more pleasing circumstances, but it does seem to be a good thing to do. The problem is that, so far at least, I have to think about it constantly to make it happen, and I'd rather have my mind available to me for my own use. But maybe with enough practice I can learn to do it without thinking about it.

 


More Questions From A Reader

Last Wednesday I featured some questions from a reader who has been struggling to obtain any clear information from doctors about whether she is pre-diabetic, or diabetic, or exactly what she's dealing with, and I did my best to give answers. She sent me some follow-up information (including the information that she lives in the UK, which means that I ought to translate my measurement units for her -- the measurement units favored in America are unfamiliar in Europe). Anyway, I'll once again quote her comments and questions in blue, and respond to them in black.

Well, I have some numbers for you now. I did also take your advice and go and get myself a blood glucose meter. I have to say looking both at my medical records and my meter readings I'm still clueless. I hope you will be able to shed some light. I do apologise if these are not American values and if you have to 'translate ' them. First of all the Glucose Tolerance Test I had in 2010 came back at a fasting level of 4.9 mmol/L followed by 11.9 mmol/L at one hour later and 11.3 mmol/L at two hours later. A follow up fasting serum glucose also in 2010 came back at 3.9 mmol/L which of course led my doctor to conclude I was not a diabetic.

Okay, that Oral Glucose Tolerance Test (OGTT) would have equated in these parts to 88 mg/dL for the fasting test, 214 for the 1-hour result, and 203 for the 2-hour result. Your fasting level was normal. But, assuming this was the usual 75-gram oral glucose dose, normal at the 1-hour point would be 200, not 214. And normal at the 2-hour point would be 140, not 203. To be above 140 after two hours is usually regarded as an indication of "prediabetes", and to be above 200 after two hours is usually regarded as an indication of diabetes -- even though many doctors don't regard the OGTT as a definitive basis for diagnosing the patient as diabetic. The follow up test (3.9 mmol/L) translates in my units to 70 mg/dl, which is not only normal towards the low end of the normal range; this seems to have reassured your doctor that your OGTT was a false alarm. However, it might have been an indication that your blood glucose level is volatile and subject to wide swings.

The first A1c test I had, which was actually in 2011, came back at 5.8% with an estimated average glucose of 6.6mmol/L. I then had no further tests until the A1c in November 2012 which came back at 6.2 mmol/L.

My lab defines the normal range on their A1c test as extending only up to 5.6%; a result of 5.8% is pushing the limit of normal even if it's not seen as over the limit. But you'd have to hit 6.5% to meet the diagnostic criteria for diabetes, so I imagine your doctor thought that adopting a wait-and-see attitude was the right thing to do.

I just got my blood glucose meter today. I was out and actually feeling pretty bad; shaky, confused, like I needed desperately to eat. So I got the meter home and checked my glucose which was not bad I think at 4.4 mmol/L! So what is going on? I ate a meal with a fair bit of carbohydrate as I wanted to see what would happen, I had salad with crab and some seeded bread with a little butter and I also drank apple juice which is kind of a blood sugar nightmare. Anyway, an hour later I was at 7.8 mmol/L and two hours later at 9.0 mmol/L which seems very high when I multiply it by 18 to get the American value. Did I do that right?

Your initial value of 4.4 translates to 79 mg/dL (normal); why you felt bad at that level is an issue I'll get to a little later. Your 1-hour postprandial of 7.8 translates to 140, which is somewhat higher than what a typical healthy non-diabetic person would get, but is not terrible. Your 2-hour postprandial result of 9.0 translates to 162 -- which is more worrisome, because you seemingly should have gone down rather than up between the 1-hour point and the 2-hour point. To be above 140 after two hours is considered excessively high. The truly normal response to a meal is a sharp rise (to about 125 mg/dl, not 140) in about an hour, followed by a steep decline. You experienced a prolonged peak which was still going up a bit at the 2-hour mark. Your OGTT result also showed a 2-hour result which was not significantly lower than the 1-hour result. The impression I'm getting here is that, although your glucose is normal after a long-enough fast, you tend to experience a postprandial glucose spike which is higher than normal and is also unusually prolonged. It sounds as if, when your endocrine system is hit with too big a dose of carbohydrate (whether in the form of oral glucose or apple juice), it doesn't handle the challenge all that well. Further experimentation may reveal to you how many grams of carbohydrate in a meal you can get away with, and not trigger a long-lasting glucose spike of this sort.

I really don't know what to make of all this. It doesn't look great but it also doesn't look diabetic I think? I don't know why I feel so bad and like I have low blood sugar when actually it isn't that low. But my glucose does also seem to shoot up pretty high after I eat. I will test again before I go to bed and again in morning, just to get a picture. Can you please comment on these values? Thank you.

Let me let you in on a secret about "the shakes" -- that is, the unpleasant symptoms of hypoglycemia. It is amazing how strong those feeling can be, how desperate they can make us feel. You may find yourself having such a panicky feeling (about your imminent death from low blood glucose) that it might seem to you as if eating an entire wedding cake would not be an excessive response to the emergency. And yet, these terribly upsetting sensations are not necessarily triggered by an excessively low level of blood glucose! What triggers the symptoms of hypoglycemia is not the actual level of your blood glucose, but rather the rate at which it is falling! People whose blood sugar used to be chronically high, but are starting to get it under control, often find that they have episodes of the shakes when their actual glucose level is normal, or even a bit elevated, but is nevertheless lower than typical for them, or is falling at a steep rate. It sounds as if you tend to have high, prolonged blood-sugar spikes, because your endocrine system doesn't correct a high promptly -- but when it finally does correct the high, it does so rapidly and gives you the shakes. Exactly why this would be the case for you, I don't know, but whatever the explanation is for your personal patterns, it is worth doing enough testing to get a good idea of what your patterns are. Perhaps you can find a way of eating, or a way of coordinating meals with exercise, which reduces this tendency toward sharp upswings and downswings.

You also wrote that you suspected I have other underlying conditions which may be driving the insulin resistance. I do also have under active thyroid for which I take daily medication and a condition called Polycystic Ovary Syndrome which is strongly correlated with diabetes. So you were very perceptive there!

Maybe I was perceptive; more likely I took the most reasonable guess! I am aware that a lot of diabetes patients also have hypothyroidism and/or PCOS, but unfortunately I have not studied those conditions enough to have any useful insights into how they interact with diabetes. Whether they play any role in driving these upswings and downswings in blood glucose which you seem to be experiencing, I don't know, but it seems like a topic worth delving into.

Anyway, you seem to have an unusually volatile glycemic profile, for whatever reason -- with overlong spikes after a meal, followed eventually by a rapid drop which makes you hypoglycemic (or at least feel hypoglycemic). I think it would be worth experimenting to see if there is a carbohydrate limit which, if a meal doesn't exceed it, protects you from an excessive spike after a meal (and the shakes later on). Some diabetes patients do better with meals that are smaller but more frequent, and you might possibly be one of those patients. Experiment and find out!

 


A Little Bit Dreary

Monday, June 24, 2013

Yesterday the weather was gloomy (threatening rain) and today was gloomier (delivering rain). Not that it was raining all that hard today, but rain in late June counts as bizarre weather in these parts. I found myself unable even to consider going out and running in it at lunchtime. I decided to do a gym workout after work instead. And when I got to the gym, the place was overcrowded with other people who had presumably also decided to do that instead of exercising outdoors today.

The trick to maintaining the exercise habit is not necessarily to just go ahead with your workout plan regardless of circumstances; the trick is to adapt your workout plan to the circumstances, so that you still end up exercising somehow, even if you're not exercising when and where and how you thought you would when you got up this morning.

 


Infection & A1c

A lot of people that Google refers to my site have been entering search strings such as "can infections affect your a1c" and "if my fasting blood sugar is 150 can it be that high because of a viral infection".

The potential connection between infection and elevated blood glucose is not entirely imaginary, but people exaggerate it so much that I think we have to call this wishful thinking.

There can be a connection -- not a very direct connection, but a connection -- between infection and elevated blood glucose. We shouldn't overstate the significance of this connection, though, and we certainly shouldn't use it as an excuse to dismiss unwelcome test results.

Infections of any sort can produce an inflammatory response, which tends to reduce your sensitivity to insulin. Obviously any reduction in your insulin sensitivity tends to lead to some elevation of blood glucose levels. Chronic infection is especially likely to have an impact in this area. Inflammation of the gums from periodontal disease is known to promote insulin resistance (hence the association between periodontal disease and Type 2 diabetes). And other conditions which tend to promote diabetes (including obesity and sleep deprivation) may promote diabetes specifically because they trigger some kind of inflammatory response.

A lot of people have heard about the impact of infections and inflammation on diabetes. But they interpret this impact wrongly! What a lot of patients don't seem to understand about this issue is that, if they have an infection and their A1c test result or blood glucose result is high, this is not a case of the infection "throwing off" and falsely elevating the test result. This is a case of the infection having a harmful impact on what the test is measuring.

In other words, don't think "my tests look bad, that's not for real; I just had an infection, that's all". Any number of factors could drive your test results up, but if that happens, you need to concentrate on bringing them back down, instead of concentrating on finding excuses to believe they aren't "really" up at all. Look, you need to face it: they're really up.

Certain unusual circumstances might make your A1c test read lower than it should (hemodialysis and blood donation are two possibilities), but I don't there's any circumstance which could make your results look higher than they really are.

If your test results say that your blood sugar has been elevated lately, and you know or suspect that you've had an infection lately, don't assume that you can ignore the elevated blood sugar because of the infection. Getting the infection under control would be a good idea (if you have inflamed gums, see a dentist), but in the meantime, monitor the blood sugar situation carefully!

As a general rule, be suspicious of your own motivation whenever your preferred interpretation of a mystery is the one which lets you off the hook for something you'd rather not face.

 


Unfocused Friday

Friday, June 21 2013

Ah, the Summer Solstice! The day that the sun reaches its maximum axial tilt toward the sun (23 degrees, 26 minutes). The day that so many newspapers declare, for no logical reason, to be "the official first day of summer".

If summer means anything at all, it means the warmest three-month period of the year wherever you find yourself. In most areas, or anyway in my area, that period begins before the solstice, so the media announcements about "the first day of summer" invariably come at least a few weeks after the first heat wave.

This may be the "longest day" of the year, but that doesn't mean we had the latest sunset of the year. Next Wednesday the sunset will come a minute later. But the day will be shorter, because the sunrise will be two minutes later, for a total loss of one minute of daylight. These things are subtle. I wonder how the Mayans succeeded as well as they did with it.

 


Simple Trick

The people at Runner's World have been trying pretty hard to get me to buy this book:

They send me messages making a lot of claims about how the book will teach me how to breathe properly while running, to achieve greater efficiency and avoid running injuries.

I wondered how any method of breathing while running could be elaborate enough to require an entire book to explain it. On the other hand, I am always ready (for good reason) to believe that my running style is all wrong and is causing me to be needlessly slow (and needlessly sore afterwards).

So, I went to Amazon to check the customer reviews. Some liked it, but one was bitter enough to catch my attention: "Here's the entire book: belly breath in for three steps then exhale for two. If you're working hard make it 2:1. Oh, and here are some couch to 5k type training plans. Seriously, that's it. It goes into a whole bunch of new-agey reasons why you don't want to always exhale when the same foot hits, but I have to tell ya, I'm no metronome so that would average itself out over time. If you think that's enough reason to throw some money at Amazon, go for it, but you've been warned."

This discouraged me from investing in a book which apparently consisted mostly of elaborate justifications for an extremely simple recommendation. But I thought the recommendation might be worth checking out. So, on my lunchtime run today, I tried out this simple formula of deep-abdominal inhaling during three footstrikes, and exhaling during two.

Of course it took some getting used to, and it was easy to fall out of the pattern. But using this technique had some interesting effects. For one thing, I really was faster, as measured by the clock; this breathing method did seem to oxygenate me and energize me better than whatever unconscious thing I was doing before. Also, I've been combating soreness in the left hip, groin, and gluteus muscle while running, and this method made it feel better -- normal even. Also, I felt better during the run. Also, I felt much more of an endorphin after-effect; I was high all afternoon. And my blood pressure was unusually low later in the evening.

The only downside is that I had to concentrate on my breathing the whole time I was running, instead of daydreaming as I usually do. I didn't get bored this time, but I might after a while. So we'll have to see if this method is right for me in the long term. But all the effects were positive.

Since the method seems to work so well for me, I suppose I should feel guilty that I didn't buy the book which recommends it. But when the idea is that short and simple, maybe you don't have the right to expand it into book form and expect people to pay for it.

 


The End Of An Era

The Food Network is dropping Paula Deen, because of the scandal about her use of racial insults and her benign view of the south's history of slavery. Well, okay, if they think she's bad for their brand, obviously they can drop her, and obviously she should have known better.

But telling people to make a bread pudding out of Krispy Kreme donuts and add a pound of powdered sugar to it -- while she was already secretly diabetic herself -- that was okay?

It seems that she adds as much sugar to her vision of life in the antebellum south as she does to anything else; she seems to think slavery was a much nicer institution than northerners realize. Who could possibly take offense at such views? People are so sensitive these days!

Well, at least she's managed to make sure she'll be remembered for something besides dietary excess. Now people on Twitter are competing with each other to make up the ideal racially-charged name for a Paula Deen recipe. (The funniest one I've seen so far was called "Ku Klux Klams".)

But I suppose we shouldn't count her out. Yes, she'll be a walking punchline for a few months, but people have made comebacks in less promising circumstances. I doubt we have seen the last of her!

 


Huh? What?

Sometimes I read about a medical study and am at a loss to figure out what the take-away message is supposed to be.

A study has found that men who took a drug called finasteride as a treatment for baldness, and quit taking it because it caused sexual dysfunction, and whose sexual dysfunction persisted for months after they stopped taking the drug... those men experienced a long-lasting decrease in alcohol intake, because they had a reduced tolerance for alcohol and had problems with hangovers.

If somebody is thinking of promoting finasteride as a treatment for alcoholism in men, they're going to have a hard time selling it, if the drug only has that effect in cases where it also causes long-lasting impotence.

 


Free Lunch Fantasies

Thursday, June 20, 2013

 


Magic Shortcuts

Throughout history, people have looked for ways to get something for nothing. And no wonder! We must live within the real world, which means that we must live with limitations which often stand as barriers between ourselves and the things we want. This is highly frustrating. We can't help thinking that maybe there's some way to trick the world into giving us what we want -- and preferably giving it to us for free!

Out of this deluded yearning for a free lunch, mankind has developed all kinds of dopey schemes to hoodwink nature into handing over the goods. These schemes have included love potions, perpetual-youth potions, cures for incurable illnesses, alchemy (a sorcerous art which aimed at creating gold out of cheaper ingredients), and all sorts of attempts to find an inexhaustible source of cheap energy (ranging from perpetual motion machines to, more recently, "cold fusion").

But this yearning for an easier way to get what we want probably finds its finest expression in the search for an easy way to lose weight. Diet-book authors have been making money for decades by holding out to us the hope that, somewhere out there, somebody has found a weight-loss method that isn't maddeningly difficult. And a lot of people like to think that they've hit upon a scheme that would work.

People who climb Mount Everest or explore the arctic tend to lose body weight, because their bodies burn up a lot of calories simply maintaining body temperature. I have heard seriously-intended proposals that the way to lose weight is to spend a winter with your furnace turned off and your warm coat left in the closet. Yeah; sounds totally practical.

What brings all this to mind is a search term which somebody Googled recently (with a resulting link to my blog). The search term was: "if my blood sugars are high how many calories am i urinating out per day".

Well, there's a case of somebody looking on the bright side! My blood sugar is out of control, but at least maybe this will help me lose a few pounds.

Believe it or not, I was actually going to try to arrive at a serious answer to this question. I thought it wouldn't be that hard to calculate, if I could find enough information about how much glucose is in urine for a given amount of glucose in the blood, and also enough information about typical urine volumes in people with glycosuria (sugary urine). Unfortunately, I wasn't able to find enough information to come up with even a rough estimate.

However, we need to be realistic here. The sugar in the urine of people with high blood sugar might be sufficient to attract bees, but that doesn't mean a large volume of sugar is being expelled from the body. High blood sugar does result in glucose leaking through the kidneys and into the urine, but this isn't a case of the kidneys deliberately expelling excess blood sugar to protect you. The kidneys try to retain blood sugar instead of letting it pass through into the urine, but when blood sugar gets somewhere above 160 to 180 mg/dl, the kidneys can't hold onto all of it, and some of it ends up in the urine. That is why sweet urine has always been the classic telltale sign of diabetes. Still, I don't think the amount of sugar loss through the kidneys is so large that anybody can expect to lose weight that way.

It's true that untreated patients with Type 1 diabetes, who have lost the ability to produce insulin, tend to lose weight. But I think the reason for that isn't that they're pissing the calories away; the reason for their weight loss is that their cells can't absorb sugar and do anything with it (including turn it into fat); for energy, the cells need to burn whatever fuel they have already absorbed -- and they thin themselves down in the process.

Even if extremely high blood sugar did result in weight loss through urinary excretion of unburned calories, it wouldn't be a weight-loss method worth pursuing, because of the damaging impact of that high blood sugar in other regards.

We need to be on guard against this kind of thinking. It's too tempting. And con artists know that it is!

 


Patients Being Kept In The Dark

Wednesday,June 19, 2013

 


A Reader's Dilemma

A lot of people who have Type 2 diabetes, or "prediabetes", or who fear they have one of those conditions, report to me that their doctors don't tell them anything clear or useful about such matters.

Recently a reader who is (apparently) pre-diabetic, and fears that she may have crossed the line into diabetes already, wrote to me expressing her frustration about the lack of guidance, or even basic communication, that she's been getting from her doctor. I invited her to send me a list of her unanswered questions, so that I could take a shot at answering them. She tried, and found that it was hard to boil the whole complicated situation down to a simple list of questions. What she came up with was more of a narrative, with some questions embedded in it. Well, let me present that narrative (in blue), interrupted periodically by my answers (in black).

I will tell you that what I feel I most lack right now is support. I just have so much confusion also about what my status actually is and what I should be doing about it. I gather from my little bit of research online that diabetes is a serious illness and one I should be trying to fend off at all costs but I have not been told this by any medical practitioner that I have seen.

I suppose the medical practitioners involved would protest that there are thousands of diseases a patient might get, and they haven't got time to warn you against all of them. My answer would be: if you haven't got time to mention all of them, concentrate on the ones that are both common and preventable. Diabetes is very common, and apparently more preventable than most common diseases are.

I was told approximately five years ago that I had insulin resistance, 'only slight' I was informed and I was prescribed Metformin. Unfortunately Metformin did not agree with me and so I was taken off it and that was that.

I suppose the plan was that the metformin treatment would prevent your insulin resistance from pushing you all the way into a diabetic state, at least for a while. But when it turned out that (like a lot of people) you don't tolerate metformin well, your doctor switched to Plan B, which in this case was "do nothing and hope for the best". There are, however, a couple of other things to be done about insulin resistance. First of all, exercise temporarily restores at least some of your lost sensitivity to insulin, and although the improvement gradually subsides over the next couple of days, exercising regularly prevents it from subsiding too far. Also, if body fat is what's driving your insulin resistance (and often, but not always, it is), losing weight has the potential to restore at least some of your lost sensitivity to insulin (and often, but not always, it does). Also worth pointing out: insulin resistance isn't a problem just because it leads to diabetes. Insulin resistance is bad for your cardiovascular health even if it never makes you diabetic. Your body tries to compensate for lost insulin sensitivity by generating abnormally large amounts of insulin -- which is apparently bad for your arteries. Insulin resistance, all by itself, increases your risk of coronary heart disease, so it's worth improving your insulin sensitivity even if you're not diabetic.

Fast forward a few years and I was told that a Glucose Tolerance Test I had came back abnormal. An A1c test was ordered to confirm and my doctor told me I did not have diabetes but instead had a 'glucose intolerance' but 'no real problem with sugar'. Again I went on my way.

I would be curious to know what the actual numbers were, but I assume the situation was that your results on both tests indicated that your blood sugar was elevated above the normal range, but not far enough above the normal range to meet the diagnostic criteria for diabetes. Doctors don't seem to have any general agreement about what they are supposed to tell patients who are in this particular twilight zone. And, of course, the patients have no idea what to make of what little they are told. If you had been tested for pregnancy instead of diabetes, and the doctor said that your non-pregnancy was somewhat impaired but you had 'no real problem with baby', I imagine you would have insisted upon a clearer answer than that. We see pregnancy as an either/or proposition: you are or you're not, even though we know that pregnancy proceeds from an invisible stage to an impossible-to-overlook stage. Diabetes isn't seen that way; its early stages are usually not called diabetes, and they are not explained to patients with any great clarity. The sad thing about all this vague hemming and hawing in the early stages is that the early stages are the best time to try do something about the situation. If doctors continue dithering until the window of opportunity closes, patients miss their best chance to get healthy. Why do doctors take this approach to diabetes? They don't take this approach to early-stage cancer, after all; nobody is told to go home and report back in whenever the tumor spreads.

Then in November 2012 I had another A1c test which came back at 6.2 which I was told was 'normal and nothing to be concerned about'. Whatever that may mean. I did ask if I was Pre-Diabetic and my doctor's answer was 'probably'.

The "normal" ranges for various lab tests have tended to become more stringent in recent years; in the past, the normal range for the A1c test has sometimes been defined as going all the way up to 6.0 (but never as high as 6.2, so far as I know). My lab now lists the upper limit of the normal range for its A1c test as 5.6. A result of 6.2 is not "normal and nothing to be concerned about". It is somewhat elevated, and it indicates that your endocrine system is having trouble maintaining normal glycemic levels, even if it hasn't lost control entirely. Hence your doctor's use of the word "prediabetic". (Why he had to muddy an already-vague term by qualifying it with "probably", I don't know.)

Here I am in June 2013 and I am not feeling great. Right now as I write this my vision is blurry, I feel 'foggy' in my mind if you can understand that. I have no energy lately, zero. I am scared to go out because recently I have taken to becoming weak, shaky and in desperate need of sugar at inconvenient times. I fear that I may have crossed over in to full blown diabetes.

These are non-trivial symptoms. I understand mental fog -- it's more or less my normal state -- but the other problems you report sound serious and need to be checked out. They could have various possible causes. All of them could indicate abnormal blood sugar, but the blurry vision sounds like high blood sugar, and the weak-and-shaky episodes sound like low blood sugar. Maybe you are experiencing rather wild up and down swings in blood sugar levels. Whatever is actually driving these bad feelings, they are obviously having a severe impact on your quality of life, and they need to be investigated. I would advise you to make an appointment as soon as you can. And while you're waiting for your appointment, I would advise you to go down to the drugstore and get an affordable glucose meter (such as the OneTouch Ultra Mini) and some test strips, and find out what sort of blood sugar excursions you are actually experiencing. A fasting test (first thing in the morning, no breakfast first) should give a non-diabetic person a result no higher than 99 mg/dl, and anything above 125 is considered diagnostic of diabetes. How high does a non-diabetic person go after eating a meal? Typically about 125 mg/dl after an hour; anything above 150 is worrisome. Try testing at those times, and see what you get. Also try testing whenever you're having an episode of feeling weak and shaky. Write down these results (and the circumstances for each one), and report them to your doctor.

Tom, is it possible that my A1c level of 6.2 could have shot up since last November so quickly?

Yes, it's possible there was a big increase since November. Diabetes does not necessarily develop slowly. It can get pretty far out of control in a fairly short time, especially if it is being triggered by some other health problem that you don't even know you have. Maybe you have developed some kind of infection or other source of inflammation which has made your insulin resistance worse than it used to be (dental problems can be enough!). Maybe you have developed sleep apnea, or some kind of auto-immune problem. It sounds as if you're feeling pretty low; maybe there's something else going on here that's making you ill and is also intensifying your insulin resistance. Or maybe it's simpler than that: your endocrine system tried as hard as it could, for as long as it could, to keep you from becoming diabetic, and it finally lost the fight.

Of course this all begs the question, have I seen a doctor lately and yes I have. I recently moved and have joined a new practice. As part of the initial blood tests, I was told my 'sugar levels were high' and I was advised to have them checked again soon. This was in February of this year. Other than that, no real concern was shown.

This is what comes of a medical philosophy which says that diabetes is something that you treat with prescription drugs. The doctor can't start writing prescriptions until the patient reaches the diagnostic threshold (usually defined as 126 mg/dl fasting glucose, or 6.5% A1c), so there's nothing for the doctor to do but wait until you reach that threshold. There's plenty that the patient could be doing, of course, but it sometimes doesn't occur to the doctor to mention that -- especially if the doctor has decided to assume that you wouldn't actually do it anyway. Doctors tend to be very pessimistic about patient compliance. (I'm sure doctors would say that their pessimism is born of experience; I would suggest that some of their experience is born of their pessimism, because their low expectations of patients tend to become a self-fulfilling prophecy).

I have moved again and will have a new doctor within the coming weeks. I will of course request a new A1c.

Good -- I hope the new doctor is a little more communicative and a little more interested in giving you useful guidance. Do request the A1c test, and do report both your current symptoms and whatever glucose test results you can gather.

My point in telling you all of this is to show what I feel has been a real lack of information given to me by the medical profession. Maybe this is unfair of me but I really wish someone had told me how serious this all was years ago.

I agree that your doctors should have told you more than they did. Still, a lot of information about the seriousness of diabetes as a public health issue has been out there in the popular news media lately. In fact, I would say that the "diabetes epidemic", and the "obesity epidemic" which is generally assumed to be responsible for it, have been the most heavily covered health-related stories in the news during the past five to ten years. (What is Michelle Obama's big cause? Fighting childhood obesity, largely as a means of preventing diabetes.) It almost seems as if a person could not escape being informed about the seriousness of diabetes. However, I say that as someone who has had diabetes for the past twelve years, so when diabetes is mentioned in the news I always notice it. A lot of people don't notice it; they tune out when diabetes makes the news. Perhaps you filter out news about diabetes the same way I filter out news about the Middle East, and for the same reason: you think it's an unpleasant subject and you're hoping it won't affect you directly. Well, unfortunately, it sounds as if diabetes is going to be affecting you directly, so you can't tune out reports from the war zone any more. Admittedly, a lot of the diabetes information offered in popular media is of low quality (if anyone tries to convince you that "whole grain" bread is automatically diabetes-friendly, stop listening to that person -- it's only slightly less bad than white bread). Who should you listen to, then? I guess me, but nobody's a hundred percent reliable on a subject this tricky, so shop around.

If I have questions they are what should I do now? What changes should I make? How can I help myself?

The reason I'm suggesting that you get a glucose meter is that, when you are able to collect data, you are able to operate with some autonomy, instead of just passively following instructions and hoping it does some good eventually. You can experiment. Instead of waiting to be told whether it's okay to eat a bowl of oatmeal or not, you can eat a bowl of oatmeal, test your glucose afterward, and decide (based on the result) whether or not your system handled it well enough to justify you in trying that again. If you keep track of the circumstances surrounding each test, you will eventually see patterns emerge, and you will understand how different foods (and portion sizes) affect your blood glucose; you will also understand how exercise, hydration, sleep, and other issues affect your glucose. And once you understand those things, you will know what to do -- you won't have to wait for someone else to tell you. You'll be control of the situation (at least to a degree); you'll be making decisions and taking action, and then looking at the results to determine whether or not your decisions and actions were the right ones. You'll be constantly making adjustments, pushing your results in the direction you want them to go. You'll be steering the ship, instead of watching helplessly as it drifts into the rocks. When you get a glucose test result you don't like, instead of getting depressed about it, you'll think about what you're going to change today so that you get a better result tomorrow. Ideally, you would like to get the kind of glucose profile that a very healthy non-diabetic person typically gets (fasting results in the low 80s, with post-meal spikes to about 125), but these ideal values are just aiming points -- you try to get closer and closer to them, without necessarily expecting to get all the way there. When I was diagnosed, my doctor told me to try to keep my fasting tests under 110 and my post-meal tests under 150, but I try to do better than that, and most of the time I can. Anyway, the way to help yourself is to test, see if you like the results, and decide what adjustment you're going to make (mainly to your meal plan or your exercise schedule) if you didn't like the results. Keep doing that, and you will gradually steer yourself into a better situation.

Am I Pre-Diabetic and what does that mean?

Apparently you are, or were, prediabetic, and there's a chance you're just plain diabetic now. Who knows what prediabetic really means; it's a pretty vague term. It more or less means "not quite diabetic yet, but getting there". In practice, it means elevated blood glucose that isn't elevated enough to qualify as diabetes. I think of it as an early stage of diabetes. Actually, I think of it as the stage of diabetes during which you have your best opportunity to get it under control if you take action.

Like you, I would prefer to stay unmedicated. Metformin, as I have said, is a no go and insulin, well, the thought of being insulin dependant is scary to me.

When you were taking metformin you came up against the difference between an ideal drug (which creates a single, desirable change in your body) and a real drug (which usually creates a tangle of changes, some of them desirable and some of them not). We can never be quite sure that we know all the effects a drug is going to have. And it's not nice to have your health become dependent on a medication, especially if it's expensive or if there's a reason (such as the necessity of injecting it) why you don't like taking it. All in all, it's best to avoid taking a drug if we can manage to solve our health problems without it. Medications are particularly burdensome for diabetes patients, who typically end up taking more and more additional drugs over time, and dealing with all the side-effects and costs involved. And yet, for some diabetes patients, it's possible to do as well or better without the drugs. Nobody can tell you in advance whether or not it will be possible in your case; the thing to do is try as hard as you can to make it happen. If you truly give it your best shot and you still can't get acceptable results, you will need to be medicated to some degree. But that won't mean it wasn't worth trying. The things you need to do to try to normalize your blood sugar without drugs (regular exercise, weight loss if appropriate, limitations on carbohydrate intake) are the things you still have to do to stay healthy with diabetes, even if you are taking the drugs. You have to do this stuff anyway, drugs or no drugs, so you might as well try to do it so well that drugs aren't required.

I am 39, overweight and a non-exerciser. Reading your website has made me understand the importance of exercise. So I am about to start an exercise regime, I have removed refined sugars from my diet. Will this be enough?

Exercise is critical; you definitely need it. Whether it turns out to be enough is not something anyone can predict. If you're not used to exercise, and not feeling terribly confident about your ability to do it, it can be helpful to start small and gradually build up the intensity or duration. If a mile is what you can handle today, do a mile -- with the understanding that you'll try 1.1 mile next time, and keep on raising the ante. If you can find exercise buddies (ideally people who are just a little bit fitter than you, so that they'll challenge you without leaving you entirely in the dust), that can be a good way to stay motivated. Joining an exercise class is good too. But if you're not feeling comfortable yet about exercising with others, you can always go it alone. Regarding refined sugars, it's not a bad idea to avoid them, but bear in mind that starch (as in bread, rice, potatoes, pasta, cereal) is essentially the same as sugar; it tastes different, because of the way the sugar molecules in it are bonded together, but minutes after you swallow starch it breaks down into sugar, so there really isn't all that much difference between eating a mound of rice on your plate and eating a similarly-sized pile of sugar cubes. So, don't get too fixated on "sugar" as a separate category -- carbohydrates in general will spike your blood glucose within an hour after you swallow them. The real problem with refined sugar is the way they sneak it into processed foods, making them higher in carbohydrate than you would expect. For example, dried fruit (which is sweet enough to begin with) is often infused with high-fructose corn syrup; it doesn't occur to most consumers to think that any sugar has been added to dried fruit, but there you are.

I really would just appreciate your viewpoint on all this, maybe some of it sounds familiar to you?

Yes, it sound pretty familiar, all right -- although you seem to have been stuck with doctors with more than their share of communication problems. If your new doctor isn't much better, do what you can to learn from other sources.

I hope this was helpful, or at least more helpful than what you've been offered so far -- which doesn't seem to be a very high bar to get over!

 


Irresistible Offer Of The Day

Here's an e-mail message I received today; who could be skeptical of a message so thoughtfully expressed?

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I've got a touch of "hair baldness" myself, so even if I don't invest in the company, I ought to look into their modern applications!

 


Who's Guiding The Guidelines?

Tuesday, June 18, 2013

 


Bone-Chilling Announcement Of The Day

From the Centers for Disease Control and Prevention:

"Unintended pregnancy rates remain high in the United States; approximately 50% of all pregnancies are unintended, with higher proportions among adolescent and young women, women who are racial/ethnic minorities, and women with lower levels of education and income."

But it does sort of make sense of certain otherwise-puzzling aspects of American life. Half the population consist of unwanted children. Suddenly it all comes into focus!

 


More On The AACE Guidelines

The AACE Comprehensive Diabetes Algorithm, which I said some disrespectful things about when it was released in April, has come in for some additional criticism from someone in a better position than I am to have his criticisms taken seriously. That would be Jerry Avorn, who happens to be a professor of medicine (and at a school I've heard of -- it's called Harvard). His criticisms were published as an opinion piece in the New York Times.

Dr. Avorn seems to take a jaundiced view of the new treatment guidelines: "The AACE's latest guidelines elevate many second- or third-line drugs to more prominent positions in the prescribing hierarchy, rivaling once uncontested go-to medications like metformin, an inexpensive generic. They also emphasize the riskiness of established treatments like insulin and glipizide, which now carry yellow warning labels in the AACE summary. Several of the now promoted drugs are expensive newcomers that lack the track records of clinical effectiveness and safety held by the older, potentially displaced treatments. The changes were made, ostensibly, to give physicians more treatment choices for their patients. But there is also concern that they could have been influenced by another factor: the manufacturers of some of these new drugs financially supported the development of the guidelines, and many of the authors are paid consultants to some of those companies."

Dr. Avorn argues that this is a common failing of treatment guidelines: who knows what the real motive was for the decisions that some guideline committee made? "The nation's $325 billion prescription-drug market offers an enormous incentive to develop and disseminate information lauding the presumed virtues of costly new medications, but there is much less muscle behind efforts to encourage the use of established, off-patent drugs, even when the weight of evidence and experience recommends them."

And if there is much less muscle promoting older generic drugs, imagine how little muscle there is promoting exercise.

The AACE is not taking Avorn's criticisms lying down; they have issued a statement which is intended to refute him; how successfully it does so is a matter of opinion. I'm a bit dubious about it. Exactly how reassured do they expect me to be when I read a statement such as "There was no direct industry funding for the development of these AACE guidelines."?

No direct industry funding? All right! So long as it was indirect!

It's always worrisome when science crosses paths with commerce. Money talks -- actually, it tends rather to scream -- and this makes it hard to assess the credibility of the reports we get. I'm sure that yesterday's report in JAMA, on how red meat in the diet increases the risk of Type 2 diabetes, will be vigorously challenged. That's fine, up to a point, because scientific ideas are supposed to be vigorously challenged. But if the vigorous challenges are the result of vigorous funding from the beef industry, I might not be so ready to believe that they are valid.

Good science is about careful elimination of sources of bias, and what could be a greater source of bias than financial self-interest? Whenever researchers and doctors who have any kind of financial relationship (however "indirect") with parties who stand to win or lose by the outcome of a report or guideline, they should not act put-upon when people question their objectivity. People in those situations are guilty until proven innocent, and ought to understand that.

 


Alternative [Reality] Medicine

Monday, June 17, 2013

 


Skepticism & The Legend Of The Ulcer

Here's a classic skeptic's joke:

Q: What do they call "alternative medicine" that has actually been shown to work?
A: "Medicine".

The point, of course, is that you wouldn't need to call it "alternative" if the evidence showed it to be effective. Alternative medicine means medicine for which supporting evidence is lacking. You can, if you like, assume that, although such evidence hasn't been gathered yet, it soon will be. You can even assume, if you like, that such evidence could be gathered, but it never will be, because pharmaceutical companies are conspiring to suppress an effective treatment which could put them out of business. Well, that's one possibility, but we have to consider other possibilities -- including the possibility that these conspiracy stories about villains suppressing medical breakthroughs are simply being made up by people trying to legitimize quackery.

Alternative medicine advocates like to tell stories about how the medical research establishment laughs off any new ideas which don't fit its preconceptions. And there is one particular story which they love to cite: the story of Helicobacter pylori and peptic ulcers. A legend has grown up around this, and it is offered routinely as a cautionary tale about doctors and scientists arrogantly rejecting an unconventional hypothesis, even though it was right.

The story began in 1983, when two Australian medical researchers (Robin Warren and Barry Marshall) reported in Lancet an unusual bacterium living below the mucus layer in the stomach lining. According to the legend, the two researchers argued that this bacterium was the cause of peptic ulcers, but the entire medical establishment laughed at them and ignored their work -- and continued to ignore it for 13 years, after which time it suddenly become clear that Helicobacter pylori was indeed the cause of peptic ulcers, and could be treated with antibiotics -- which meant that people with peptic ulcers experienced 13 years of needless suffering, simply because the medical establishment wouldn't listen to any idea which did fit with what they'd been taught in medical school.

The actual history of the case matches up very poorly with the legend, however. Warren and Marshall originally proposed a connection between the bacterium and gastritis (not ulcers), and tentatively at that. They found the bacterium in patients with gastritis and not in those without it, and suggested that the bacterium might be causing the gastritis. Later they associated the bacterium with ulcers as well, for the same reason. Yes, their proposal was received with skepticism at first -- which was entirely appropriate. All proposed scientific ideas are supposed to be received with skepticism.

Skepticism doesn't mean irrational denial, it means an unwillingness to accept unproved claims. The Australian researchers were not "laughed at", and their proposal was not "ignored", but scientists wanted to see better evidence than Warren and Marshall had come up with so far. And there were reasons to doubt that they had it right. Warren and Marshall had found Helicobacter pylori only in patients with gastritis or ulcers, but other researchers found the bacterium in patients who had neither of those problems. It is all very well to say that a bacterium is found in people with a particular disease, but that doesn't prove the bacterium causes the disease -- especially if some people have the bacterium without the disease! To add to the difficulty, there were special technical problems which made it hard to test for Helicobacter pylori in the stomach lining, so data was hard to gather.

Also, it is not true that there was no treatment available for people with peptic ulcers before Warren and Marshall proved that antibiotics would cure the problem. Peptic ulcers, for all the discomfort involved, were usually not dangerous, and they were treatable even without antibiotics, so it's not as if there was a medical emergency going on while a hidebound medical establishment stood in the way of progress. If you're going to introduce a new way of treating a disease, based on a new understanding of what causes the disease, then you have to show that your approach is both more effective and safer than the treatments available now. There's no reason for doctors to rush to adopt a new approach which hasn't yet been shown to be an improvement.

It took a long time to gather solid enough evidence to support what Warren and Marshall has proposed, but during the time that evidence was being gathered, scientists and doctors became more and more interested in the hypothesis as more and more data came in supporting it.

It was about 10, not 13 years, before Helicobacter pylori was fully accepted as the cause of ulcers. Researchers were eventually convinced that, even though the bacterium was sometimes present in patients without ulcers, it was always present in those who did have ulcers; the bacterium caused the problem, even though it caused the problem in only some of the people carrying it. The standard treatment for ulcers became an antibiotic designed to rid the patient of Helicobacter pylori.

So, pretty much every element of the legend is incorrect. Warren and Marshall were not laughed at -- they were taken seriously. We just need to remember that, in the world of science, the way to take someone seriously is to say, "Let me see your evidence", and wait as long as it takes for satisfactory evidence to be produced.

In the world of alternative medicine, the way to take someone seriously is to say, "Wow! I bet you're right!".

The latter approach has the benefit of immediate gratification; the former approach has the benefit of finding out, eventually, whether or not something is true. Not everyone cares about that, of course, so it's good to know that alternative medicine is out there to fill that market niche.

When you hear about some berry or herb which is supposedly much more effective against diabetes than anything else you've hear about, the question to ask yourself is this: "Do I really care whether this is true or not?". If the answer is "No", then go for it! But if the answer is "Yes, I care if this is true or not", then you can always say, "Let me see your evidence".

 


The Occasional Moment of Sanity

Thursday, June 13, 2013

It was sunny and warm, but not too warm, and it occurred to me that I haven't yet taken advantage of the late sunsets this time of year, and gone for an after-work trail run. I used to do that once a week during the summers, and I've more or less got out of the habit, mainly because the people I used to do it with gave it up. But there isn't any reason I can't do it by myself, so I went.

While climbing the steeper hills, I decided that it was a little warmer than I had thought it was before I started running. Still, it wasn't bad. The park was beautiful, and full of mountain-bikers and runners. Most of the runners were kids from the local cross-country teams, who made me feel pretty old and feeble by comparison. But it's not their fault they're young, is it?

 


No Patents On Genes

The Supreme Court ruled today that a patent on a naturally-occurring gene is not valid. Artificially created genes can be patented, but not the ones that nature was already making; Myriad Genetics cannot claim that the BRCA1 and BRCA2 genes are its intellectual property.

Well, good. Because if a corporation can seize legal ownership over a natural phenomenon, there's really no limit to how far the madness can go. The idea of granting a patent on, say, fire to whichever company has the best-financed legal team is a little scary to contemplate. If the court allowed Myriad Genetics the right to claim that they own two naturally-occurring genes, presumably it would allow them to claim ownership of other naturally-occurring molecular structures within the human body. I don't think we would want to see what would happen to the price of insulin if Myriad Genetics was allowed exclusive rights to it. We certainly know what happened to the price of genetic testing for the BRCA1 and BRCA2 genes when Myriad Genetics was the only provider of the test.

The legal decision seems to be a commendable, and refreshing, re-engagement with the Real World on the part of our Supreme Court justices, but news coverage of the story don't seem to give the court much credit for acknowledging the freaking obvious. Some commentators on the decision stress its possible bad effects: perhaps genetics companies won't do basic genetics research any more, if they know they can't patent the genes they're studying. Well, most of that basic research is actually being publicly financed, so if I'm helping support the research with my taxes, I feel as if the information that comes out of it should be freely available, and certainly should not become (for some corporation) the gift that keeps on giving.

The maddening thing about intellectual property law is that so much of patent and copyright income goes to people and institutions that made zero intellectual contribution to the work they are claiming to own. Patents and copyrights are mostly commodities, and creative lawyering is the only kind of creativity they involve. Case in point: Warner/Chappell, the publishing arm of the Warner Music Group, makes an estimated $2 million a year on licensing fees for a song which is often used in movies. That song? "Happy Birthday To You". Written by Patty and Mildred Hill in 1893 (but originally called "Good Morning To All" -- the birthday-themed lyrics arose through the folk process). The melody is 120 years old, and the longest-surviving of the two sisters who wrote the original song has been dead for 67 years. But it's still worth $2 million a year to Warner/Chappell. And think what Warner/Chappell could get away with if today's court decision had gone differently! They wouldn't have to limit themselves to claiming ownership of "Happy Birthday To You". They could claim ownership of birthdays in general. And perhaps Time itself! Every time you got a year older you'd have to pay them a fee! Can anyone seriously think it's a shame that the court didn't pave the way for that?

 


A Better Beta-Cell Transplant?

If you're not able to produce insulin, or at least not enough of it, because you don't have enough functioning beta cells in your pancreas, one solution (at least in theory) is to get some healthy beta cells transplanted into you. It is possible to harvest beta cells from a recently deceased person. The hitch is that you don't get all that many healthy beta cells from one cadaver, and they don't want to reproduce.

Researchers at Washington University in St. Louis think they have found a way to solve this problem. "Until now, there didn't seem to be a way to reliably make the limited supply of human beta cells proliferate in the laboratory and remain functional. We have not only found a technique to make the cells willing to multiply, we've done it in a way that preserves their ability to make insulin."

Unfortunately, there is a very scary potential issue hanging over any technique that stimulates cells to multiply. What if the technique turns some of the beta cells cancerous? Not exactly the sort of thing you want to have transplanted into you. And pancreatic cancer is one of the most difficult cancers to treat, too. The researchers say they found no sign that this was a problem with the beta cells in their experiments. But it may take a while to reassure the FDA (and me, for that matter) on that point!

 


The Average-Patient Problem

Wednesday, June 12, 2013

 


Do We Matter As People?

Diabetes researchers like to do studies supposedly proving that regular glucose monitoring in diabetes patients who aren't insulin-dependent isn't worth the trouble and expense -- because the average diabetes patient doesn't do better that way.

It's an easy thing to prove, if that's what you want to prove. The average diabetes patient can be counted on to screw up just about anything, so of course the average diabetes patient screws that up, too.

This sad reality doesn't make the same impression on me that it makes on insurance companies and medical guilds, because I think the cornerstone of diabetes management is not being like the average diabetes patient. Find out what the average diabetes patient does, and do something else -- that's pretty much my diabetes-management philosophy in a nutshell.

If you're doing diabetes management right, then by definition you are not doing what the average patient does, and studies demonstrating what happens to the average diabetes patient will not take your story into account.

Another way to put it is: if you're not typical, you don't matter. Medical studies don't reflect your experience, so treatment guidelines don't reflect your potential for success. It is assumed that you will fail, and in exactly the same way that the average diabetes patient fails.

I suspect it is also assumed that you deserve to fail in exactly the same way that the average diabetes patient fails, but this part of the conventional wisdom is not expressed openly.

A new study has found that "intensive glucose monitoring" (which in this case meant four glucose tests a day) does make Type 2 diabetes patients with "well-controlled" diabetes do better. But, on average, it only makes them do a little better. As the improvement in HbA1c scores is not much better than .1% on average, the study authors wonder if this small improvement is worth pursuing.

What occurs to me is that, if the improvement was small on average, then presumably for some patients the improvement was large, and for some patients it was tiny or non-existent. The take-away message can't be that this isn't worth it because the improvement was small for the average patient. The message is that this is worth it for some patients, and doctors should be allowed to encourage and empower those patients who have demonstrated that, for them, it's making a large difference.

To argue that exceptionally committed patients shouldn't have the tools they need to succeed, because such tools are wasted on the average patient, seems clearly wrong to me. To design a one-size-fits-all approach to diabetes management because it makes sense in terms of the average patient's experience is like prescribing penicillin to 100% of patients because the average patient is not allergic to it.

And, so far as I know, doctors aren't taking that attitude about penicillin allergies.

 


Reward Withdrawal

Tuesday, June 11, 2013

 


My Sugar Doesn't Work!

Insulin resistance -- the mysterious loss of cellular sensitivity to insulin, which is common if not universal in Type 2 diabetes -- seems to promote overeating and weight gain somehow. Animal studies show this clearly, and it certainly appears to be true of humans. The development of insulin resistance (often before blood sugar actually rises to diabetic levels) causes problems with appetite control, and typically ushers in a period of rapid weight gain.

The exact reasons for this have never been clear, and (given how complicated are insulin's effects on the body) it might well be true that insulin resistance interferes with appetite regulation in more than one way. Well, it seems that at least one of those ways has been identified.

Researchers at Stony Brook University reported yesterday that insulin resistance interferes with the response of pleasure centers in the brain which are supposed to reward us for eating.

Their study involved positron emission tomography (PET scans, that is) of the brains of people who drank sugary (or artificially sweetened) liquids, to see how the brain responded to actual sugar. Some of the test subjects were insulin-resistant and had appetite-control problems; the idea was to see if the brains of insulin-resistant people responded differently to sugar intake.

The test method involved a synthetic compound called raclopride, which binds to dopamine receptors in the brain. (Dopamine is a neurotransmitter which the brain's reward system uses to make us feel good when we do what the brain wants us to do.) By tagging the raclopride with a radioisotope (Carbon 11), the researchers were able to capture binding activity at dopamine receptor sites, and make the feel-good chemical secretions visible on a PET scan:

What the researchers found, by comparing the PET scans of insulin-resistant people with those of insulin-sensitive people, was that "those who were insulin-resistant and had signs of disorderly eating were found to have remarkably lower natural dopamine release in response to glucose ingestion when compared with the insulin-sensitive control subjects".

In other words, insulin-sensitive people are rewarded with a generous release of dopamine when they eat sugar; those who have lost a significant amount of insulin sensitivity are much less rewarded for it by the brain. And, since insulin-resistant people start out as insulin-sensitive people, they experience this change as a dramatic withdrawal of a pleasure they had become used to. The natural consequence of this change may be an overpowering urge to eat more, in order to receive the reward which is no longer being provided.

For what it's worth, all of this seems plausible in light of my own experience. We talk as if we eat when we're hungry, but I have to admit that I often feel a powerful urge to eat which I cannot claim is actually accompanied by a feeling of hunger; the feeling isn't really coming from my stomach at all. It's coming from somewhere else -- or rather it's coming from absolutely everywhere, which is probably just another way of saying it's coming from my brain.

I'm not sure that knowing about this mechanism tells us anything useful about how to combat it, but I doubt that knowledge is ever entirely useless.

 


Osmosis Is Not Your Friend

Monday, June 10, 2013

Volatile weather over the weekend: very hot on Saturday, then overcast and chilly on Sunday, with a lengthy electrical storm that started around midnight and went on for about three hours. So, I didn't get a lot of sleep last night. If I lived somewhere else I probably could have slept through it without too much trouble, but thunderstorms are so uncommon around here that you feel like you can't afford to miss the show.

Apparently it wasn't as good a show as it should have been: someone in my yoga class, who grew up in South America, pronounced it "very weak" and said it wasn't even a proper thunderstorm at all, by his standards. He went on to detail how much more dangerous lightning is in South America, how large and prominent are the lightning rods in people's houses, and how everyone wears rubber-soled shoes, even at home, to isolate themselves electrically from the ground, because otherwise they'll get "fried". If he was trying to stir feelings of envy in me, he didn't quite succeed. I'm trying to be content with whatever lame examples we get here of nature's high-voltage fury.

An educational note: in French, "voltage" is spelled "tension"; if you hear power-lines referred to as "high-tension wires", that's where that comes from. But no doubt they're also under tension in our sense.

 


Death By Soy Sauce

Last week the Journal of Emergency Medicine reported on a 19-year-old man whose friends brought him in to a Virginia hospital; he was comatose and exhibiting "seizure-like activity". Although he nearly died, the doctors were able to save him once they were able to discover the root cause: soy sauce.

Now, I'm not trying to promote alarm over soy sauce as a dangerous substance. After all, the young man did drink a quart it (on a dare from his friends), and even those who are very partial to soy sauce, and use it generously, are pretty unlikely ever to down a quart of the stuff. Unless you are an exceedingly dopey Virginian with unusually awful friends, nothing like this is likely to happen to you.

But it is an interesting question: why would drinking a quart of soy sauce send you into a coma, give you seizures, and nearly kill you?

The short answer is that soy sauce is an extremely salty substance; a quart of it contains more than a third of a pound of salt. Drinking it in such a ridiculously large amount caused the salt level of the young man's blood to become extremely high (196 mmol/L, which apparently is a higher level than anyone has ever survived without brain damage).

This condition of extra-salty blood is called hypernatremia. The doctors were able to save him simply by getting a great deal of water into him in a hurry (6 liters in a 30-minute period), thus diluting the salt in his blood and flushing it out of his system. Within 5 hours, his sodium level was all the way down to normal. By reducing the salt concentration of the patient's blood in a hurry, they were not only able to save the patient's life, they were able to avoid permanent damage to his nervous system. It was a close shave, though: even after the man's sodium level was normalized, he remained in a coma for three days, and brain function took several more days to return completely to normal (or to whatever passes for normal in the sort of guy who lets his friends talk him into drinking a quart of soy sauce).

So, salty blood was the problem. But of course this answer only raises a further question: why would having unusually salty blood be so dangerous?

Here we get into a peculiar phenomenon known as osmosis. Most people have only the vaguest notion of what osmosis actually is; we sometimes speak of learning things "by osmosis", meaning that some kinds of knowledge are simply absorbed as a result of being around people who have and use that kind of knowledge. In other words, we think osmosis has something to do with flow, leakage, absorption, and that kind of thing. And it does have to do with those things, but it's more specific than that.

Osmosis in general relates to something dissolved in a solution -- any solution -- but for all practical purposes we can assume here that it refers to salt dissolved in water. Further, it has to do with what happens when the water comes up against a barrier that is "selectively permeable", so that water can flow through it but the salt (or whatever else is dissolved in the water) can't flow through it.

Here's an illustration of the process: the U-shaped tube on the left below has water with salt dissolved in it (the red dots represent the salt). At the bottom of the U is a selectively permeable membrane; water can flow through it but salt can't. And in this case, the water on the left side of the membrane has more salt in it.

For reasons we aren't going to go into here, nature wants to equalize this unequal situation: nature wants the water on both sides of the membrane to be equally salty. In fact, this inequality is referred to as "osmotic pressure" because of nature's impulse to even things out. If the salt molecules could pass through the membrane, enough of them would do so to equalize the saltiness. But they can't. Only water can pass through the membrane. So nature equalizes the osmotic pressure another way: enough water flows from the right side of the membrane to the left side of it to equalize the saltiness. Now there's no osmotic pressure, because the saltiness is equalized. But now there is more water on the left side of the membrane, as shown on the right side of the picture. Osmotic pressure makes saltiness equal by making water volume unequal. (In practice this means that water flows toward salt.) This is a pretty useful trick if you are a tree, and you want water to flow out of the soil into your roots and up your trunk. (You knew trees had to be hoisting water up somehow; now you know that osmotic pressure is what does the heavy lifting in the plant world.)

Selectively permeable membranes can be made artificially, but in nature they exist mainly in living tissues. In particular, cell membranes tend to be permeable to water, but not to the salt and other substances that are dissolved in the water (as in the case of human blood). So, water from your bloodstream can flow in and out of your cells, but other things can't flow in and out unless special arrangements have been made for chemical transport (as in the case of the GLUT4 transporters which drag glucose into cells, at least when properly stimulated by insulin).

So what happens when your blood becomes unusually salty, so that the salt is more concentrated on the outside of your cells than it is on the inside? Well, this creates osmotic pressure, and water flows out of the cells and into the bloodstream (water flows toward salt). The opposite happens if the blood is less salty than the inside of the cell; in that case water flows into the cells, not out. Obviously, if either process goes too far, it can be bad for the cells. In the ideal state, called the "isotonic" state, saltiness inside and outside the cells is equal, and the cells themselves contain the normal amount of water. But if osmotic pressure causes too much water to flow out of the cells, they become squashed (as illustrated on the left below), and if too much water flows into the cells, they can become swollen (as on the right below) -- and either of those states can be harmful to the cells.

I don't mean to create the impression that the cell is deliberately expelling or absorbing water in hopes of equalizing the osmotic pressure. This isn't a goal-oriented activity, it's just a physical phenomenon. It occurs in non-living materials as well. If the cells were doing it on purpose, we would have a right to complain that the cells ought to knock it off with the osmosis, in situations when it's not helping. And often osmosis creates problems for living tissues, so it would be nice if cells could knock it off sometimes. But they can't; the osmosis still goes on even in situations where it's dangerous to survival. I'm sure snails and slugs would be happy to be able to stop osmosis, because then you couldn't kill them just by pouring salt on them, thus forcing the water out of their cells. And sometimes we humans can be pretty vulnerable to osmosis ourselves.

The soy-sauce-guzzling 19-year hero of our story made his blood so salty that osmotic pressure caused his cells to empty themselves of water and become squashed; brain cells are especially vulnerable to this kind of rough treatment, hence the coma and convulsions and near-death experience. A salt overdose is a very dangerous thing (it was a common enough suicide method in ancient China).

But high blood salt (hypernatremia) has an evil twin: low blood salt (hyponatremia). This can happen to endurance athletes who sweat heavily and drink large amounts of water during an event. It famously happened to a participant in a stunt sponsored by a Sacramento radio station in 2007, in which contestants had to drink large volumes of water while holding their urine as long as possible. One of the contestants, a 28-year-old woman named Jennifer Strange, suffered a painful death as a result. What killed her? Osmotic pressure: her cells, and particularly the very vulnerable brain cells, were so much saltier than her blood that water flowed into them and they swelled to bursting. Obviously osmotic pressure is a powerful force, not to be trifled with.

Osmotic pressure also plays a role in diabetes. As I mentioned earlier, osmosis is not specific to salt in the blood; anything dissolved in the blood, including glucose, is relevant here. When blood sugar gets out of control, glucose begins leaking through membranes in the kidney which are normally not supposed to pass the stuff. As concentrated glucose accumulates on the outside of the membrane, osmotic pressure causes an excessive flow of water through the same membrane (in this case, water flows toward sugar instead of flowing toward salt). The result is the sudden increase in urine volume which has always been the most easily-recognized symptom of diabetes.

Osmotic pressure also plays a minor role in forcing at least a little glucose into cells which aren't absorbing it because they are insulin-resistant or because no insulin is being produced. This effect is not large enough to solve the problem of diabetes, but without this effect diabetes would presumably be even worse.

No doubt there are some areas in which you are greatly helped by osmosis, even if you're not a tree, but in a lot of cases osmosis is simply an oddity of physics, and a potentially dangerous one. Anyway, I think it's worth knowing about.


No Time!

Friday, June 7, 2013

Sorry, no time to come up with a substantial blog post tonight. But here's something: a thoughtful cartoon from XKCD:

Nothing is easier than killing cancer cells in a Petri dish. There are a million ways to do it. Change the temperature, dribble in a bit of bleach or ammonia or vinegar, or just leave the cover off the dish and let it dry out. Or use a handgun; that works too.

The problem is that nearly anything you did to kill cancer cells in a Petri dish would also kill any non-cancerous cells in the Petri dish! What would be of some practical value is to find a way to kill only cancerous cells and leave the non-cancerous ones alone. It is precisely because cancer chemotherapy does not make that kind of strict distinction that cancer treatment is so hard on the patient: it kills off cancer cells, sure -- but it also kills off a lot of cells that aren't cancerous, and that you still need.

When medical research triumphs are announced, it is always a good idea to check out the fine print, and see if the new therapy being heralded as a game-changer has actually been shown to be effective and safe inside a living human body. It's always nice to know that something good can be made to happen inside a dish or a lab-rat, but it's a lot nicer to know that it can be made to happen inside a person without doing that person any collateral harm.

 


My Strange Thursday

Thursday, June 6, 2013

 


Crisis On The Run!

I had an unusual adventure while I was out running at lunchtime. I was running through a quiet suburban neighborhood when an old man flagged me down from his driveway and asked for help. He said his wife had fallen down in the garden and he couldn't help her get up. Obviously I couldn't refuse, so I followed him around the house to the back yard... but the whole time I was very worried that I might do more harm than good. I had no training as an emergency responder, and I really wished he was calling in the professionals instead.

We found his wife lying in a flower bed on very uneven ground. It was hard to know where to stand for stability. She was facing away from us and she didn't answer immediately when her husband spoke to her, so I was afraid she was unconscious. But then, as if she'd been dozing, she began having a somewhat faltering conversation.

I asked her if she had any injuries; she said no -- she wasn't hurt, she just couldn't get to her feet. She said she hadn't fainted, she had just had become "suddenly tired". I thought, what if this is a heart attack, or a stroke, or an asthma attack? If I manage to get her to her feet, is she going to keel over again, and hurt herself worse?

I tried lifting her up and couldn't quite do it -- she seemed entirely limp at first. She certainly didn't seem to be contributing any energy to the effort. Her husband was standing back, as if he had decided that the paramedic was here now, and he could leave everything to me. I asked him to help me by taking her hands and pulling up as I lifted from under her arms. Between us we got her standing up, but she was very unsteady on her feet and I had great difficulty guiding her as she tottered down out of that flower bed and onto level ground. However, once she was there, she seemed to experience a miraculous cure, and suddenly become stable and relaxed. She looked okay, and seemed quite convinced that the episode was all over now.

They thanked me for the assistance and I continued with my run -- but before I left, I strongly suggested that she call her doctor to report this incident. Her husband mentioned that she'd had pneumonia twice in recent months, as if today's little problem was just a lingering after-effect of that. I picked up the impression that they were both reluctant to seek professional help for this, probably for fear of medical costs. I can understand that; I've heard of people getting billed for short ambulance rides at such steep rates as to suggest a helicopter had airlifted them out of Yosemite. Nobody wants to call an ambulance these days, if they don't absolutely have to. I understand that.

But getting "suddenly tired" to the point that you find yourself lying in a flower bed and unable to get back to your feet? To me that sounds like something more than fatigue. It was a sunny day, but the temperature was only about 70 degrees, and the garden was shady, so I hardly think it was any kind of heat-related illness. Her breathing seemed too normal for it to be asthma. She had sounded a little sleepy and out of it when I first got there, but she conversed normally; it didn't seem like a stroke. She didn't seem to be in pain. She was sweatier than I expected from the weather, but that could have been from whatever gardening work she had been doing. But her listlessness when we were trying to stand her up, and her unsteadiness when I was walking her out of the flower bed, made her seem seriously disabled to me, at least for a minute.

But then she was suddenly, dramatically better, and I don't know how to make sense out of something like that. Maybe her doctor won't know what to make of it either, but I think her doctor ought to know it happened, so I hope she makes that phone call.

I guess this is one of the odd results of doing so much outdoor exercise: I'm out there in the real world, encountering the kind of stuff that goes on out there. Some of it is a little alarming!

 


Preventing Diabetic Vascular Damage

Diabetes is strongly associated with cardiovascular problems in general, and atherosclerosis in particular, but the reasons for this have never been clear.

Now researchers at Lund University in Sweden say they have identified a causal mechanism: a protein known as NFAT, which is activated when blood sugar is high. Somehow or other, NFAT causes or accelerates the hardening and constriction of arterial walls. The researchers were able to halt development of arterial damage in diabetic mice, by treating the mice with a substance which prevents formation of NFAT in blood vessels.

The substance (not so far identified) which prevents formation of NFAT does not suppress formation of NFAT in other tissues besides blood vessels, so it is hoped that this substance is narrowly-enough focused that it won't turn out to have a bunch of undesirable side-effects. Time will tell!

Of course, if a pharmaceutical treatment grows out of this research, everyone with diabetes will be told that they should take it, and keep taking it forever. It sounds like a real goldmine. No wonder researchers are excited about this!

 



Watch For Dogma!

Wednesday, June 5, 2013

At the gym tonight I used some weight-machines I had been avoiding for a long time (such as chest-press machines) because they had been hurting my sore right shoulder too much. Lately my shoulder had been feeling improved enough that I thought it would be worth a try. It didn't bother me, or at least it didn't bother me half as much as it used to. So maybe I'm good to go, on that front. But if my shoulder is sore again tomorrow, I'll know I wasn't really ready for that after all.

That's the trouble with these sorts of injuries: the only way to find out if you're healed enough to resume the exercise that caused trouble before is to resume that exercise, and see if it causes trouble this time.

Running felt better today; I think I'm healing in that regard as well.

 


Myths Die Hard

Myths about scientific issues can be terribly hard to get rid of. High-school science textbooks are notorious for repeating whatever was in the previous textbook, whether it's scientifically valid or not. And popular wisdom about various practical issues has more lives than a cat. Bad scientific ideas are particularly tenacious if they have some kind of basis which sounds sensible if you don't examine it too closely.

For more than forty years, people have been telling each other that fluorescent lights should be left on continuously (not turned off when no one is in the room). This strangely persistent notion is based on two claims: (1) that the "inrush current", which is required every time you turn on a fluorescent light, burns more energy turning the light back on than you saved during the time it was off, and (2) that turning fluorescent lights on and off frequently reduces their lifespan. Upon closer consideration, these claims don't hold up. That inrush current doesn't last long enough to use much energy, so the light only has to be off for about 5 seconds before turning it off has saved more energy than it will take to turn it back on. As for the lifespan of fluorescent lights, it isn't measured in terms of days elapsed before replacement; it's measured in terms of hours of operation. Whatever you gain in "lifespan" by not turning the lights on and off frequently is lost because you're leaving them on for hours! The bottom line is: if you turn fluorescent lights off whenever the room is going to be unoccupied for more than a few minutes, you'll use less energy and you'll go longer between replacements.

A more dramatic example of persistent mythology is the sort of advice people are routinely offered about how to survive a tornado. For example, opening the doors and windows of a house is widely believed to protect the structure, by allowing inside pressure and outside pressure to equalize. However, what really causes damage in these situations isn't unequal pressure -- it's the stress on the building caused by air moving very fast in constantly-changing directions. Opening up a house to this air movement only adds to the stress on it, so it does more harm than good. (You doubt me? Check out this video demonstration!) But I'm sure that people in Oklahoma dealing with the killer tornadoes currently raging there are still being told to open doors and windows. Most people have no idea that the evidence says this is bad advice.

Most people also have no idea how questionable is the long-enduring assumption that dietary saturated fat is the cause of coronary heart disease. People are still being routinely advised to avoid saturated fat as if it were asbestos or plutonium, even though a lot of research says saturated fat isn't the problem.

A new study looked at the results of an intervention to replace "unhealthy" saturated fat in the diet with "healthy" Omega-6 linoleic acid. The study participants were 458 men, aged 30 to 59 years, who had experienced a "recent coronary event". The result? The "healthy" fat provided no health benefit, and the men who got it had a higher death rate (from heart disease, and from other causes) than men who continued eating the "unhealthy" fat.

But if you go to any health website, I can practically guarantee you'll be told that saturated fat is what causes heart disease. And that you should open the doors and windows during a tornado. And that leaving your fluorescent lights on will save energy.

 


The Barcode Of Truth

Tuesday, June 4, 2013

How's that for a narrow glycemic range: a fasting test of 95, and later a post-prandial test of only 96! It makes sense, though. The fasting test result was higher than I thought it ought to have been. In reaction to that, I did a very hard run at lunchtime, and then had a fairly low-carb lunch. I figured I'd get a pretty low post-prandial value, though I admit 96 was lower than I expected.

 


Baby Bags!

Researchers in Zambia report that tiny premature babies can be effectively protected from hypothermia by putting them in plastic bags.

However, there's something you need to be careful about: only the part of them that's below the neck goes inside the bag. If you screw this up, it won't be because I didn't warn you. Some people may think I give advice recklessly, but actually I try to be pretty careful about it.

 


Lying About Groceries

One of the big problems with studies that examine the health impact of lifestyle, particularly in regard to diet, is that people know enough about what doctors consider "healthy" choices to lie about the choices they actually make. Perhaps "lie" is too strong a word in some cases, but at a minimum people tend to have a subconscious tendency to report a sanitized summary of what they've been doing. They hardly ever eat pizza, for example. Everyone hardly ever eats pizza. And yet, somehow, the pizza companies stay in business.

A Dartmouth lifestyle study tried to get around this inherent defensive bias in self-reporting, by studying households over long periods and using a barcode readings to track their purchases. Instead of asking people how much salami they buy, ask the barcode reader.

The study is of special interest because it looked at how purchasing patterns changed after someone in the household was diagnosed with diabetes. Purchases of sugary colas declined in such households -- but this trend was offset, and overcompensated, by increases in purchases of fatty, salty snacks, and even sugary foods such as ice cream and cookies. (And many diabetes patients make a big, meaningless distinction between foods full of "sugar" and foods full of starch -- which is basically sugar traveling under another name.)

Health-conscious people, with or without diabetes, tended to avoid demonized snacks (no fried pork rinds for them!), but indulged so heavily in foods popularly perceived as "healthy" (such as yogurt) that their caloric intake was higher rather than lower on balance.

The study mainly gives us a peek into the never-ending conflict between what people think they ought to be eating and what they actually want to be eating. But it does suggest certain issues that people are confused about, including the assumption that "fat free" means "good for you", and the assumption that "sugar free" means "sugar free".

All you have to do to convert a sugar-free potato chip into sugar is eat it.

But that's depressing, so don't think about that. Think about how cool sunsets look from orbit!

 


Body Stuff

Monday, June 3, 2013

 


The Body In Question

I'm not sure this is relevant to anything, even symbolically, but yesterday afternoon two children playing in a neighborhood park found the dead body of a woman face-down in a creek. And the place where they found the body is right along a running route that I take from my workplace on a routine basis. As the woman had been missing since Thursday, I presumably ran right past her body, because I did run that route on Friday. Not that I would have seen it, because I don't get close enough to the creekbed to have seen anything. But still, I was there, and completely unaware of the situation.

I didn't necessarily run past "the scene of the crime", because there might not have been a crime involved. The cause of death is unclear; the police saw no obvious signs of foul play, and the coroner and toxicologist haven't weighed in on the matter yet. Even if she was murdered, she may have been murdered elsewhere, and her body dumped in the creek.

Suppose it was a suicide, though. I can't see how suicide can be considered wrong, but it does create an etiquette problem. How do you want your body to be found, and by whom? Presumably you don't want it to be found by two children who came to a neighborhood park for a birthday party, and decided to explore the creek, as happened in this case. If this was a suicide case, it was also a case of someone doing suicide wrong. I can sort of understand why suicidal people don't always think to show consideration for other people (such as the person driving the bus or train they jumped in front of, or the cop they forced to return fire), but really, folks, this isn't the right way to do things. Coming to the end of your life is no excuse for bad manners. The time to abandon concern for others is immediately after you're dead, not immediately before.

I guess the weird irony that's getting to me about this situation is that I go by that scene of death on a routine basis, when I'm running from my workplace at lunchtime, as part of my therapeutic exercise program -- in other words, the only reason I'm ever there at all is to avoid dying. But somebody else went there (intentionally or not) to die.

 


The Body In Pain

I've been dealing for a few weeks now with some muscle pain while running, in the left gluteus muscle. Mainly I've been dealing with it by waiting for it to get better, but I decided late last week to see if there was some way for me to address the problem more directly. I started using a Thera Cane deep-tissue massager. It's a hard green plastic device that makes it possible to put a lot of focused pressure on one spot on the body -- often a spot which is hard to reach. The device looks like this:

On Thursday I started trying to use that to deal with the pain I've been feeling lately. But the problem was that I only have one Thera Cane, and I've been keeping it at work (to use after lunchtime workouts) rather than at home. So on Friday I decided to order a second one for home use, and today the Amazon people obligingly delivered another one to my front porch.

So far, the Thera Cane treatment seems to be helping -- I'm still aware that the muscle is sore, but it has been hurting less while I'm running. Yesterday I managed to do an 8-mile trail-run, and it didn't bother me much. Today's run bothered me less. I'm cautiously optimistic that, if I keep on giving the sore muscle frequent deep-tissue massages, I can get rid of this nagging problem.

I can't really afford to let myself get so stiff and sore that I can't keep exercising. So, I need to find a way to keep doing what's necessary.

 


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