You're Wrong, You're Wrong!

Thursday, March 28, 2012

I had to go running in the rain today, and you know what: I really didn't care. It just improved the quality of the hot shower afterward.

The Myth Business

Oh dear, the dLife mythbusters are at it again:

I have a bad attitude towards quizzes of this sort. First of all, they promote the idea that a situation full of ambiguities and contradictions can be reduced to simple dichotomy of true or false. (Usually at least one of the "myths" they claim to be debunking is arguably true.) And second, a myth is an idea which, although it may be entirely without foundation, is widely believed -- and quizzes of this sort usually offer, as examples of myths, things which nobody believes. "Two plus two equals six" is not a myth, although it's incorrect, because people never believed it in the first place. ("The earth is closer to the sun in the summer" is a better example of a myth, because the number of people who believe it exceeds the number of people who payed enough attention in school to know it's wrong.)

Okay, so I took the damned quiz, and as usual most of the questions are about things which are either obviously true or obviously false, and not the subject of any kind of popular mythology.

For example: "All fruits and veggies affect your blood sugar the same way. (True/False)". Do you know anyone who thinks this might be true?

Then we get to this: "Insulin makes you fat (True/False)". Immediately I could see that, although the statement is literally true, they wanted to me to click "True" so that they could tell me it isn't. I played along, and clicked "True". Then they show me this:

I can't believe they're publishing an answer as absurd (and flagrantly self-contradictory) as that. And by the way, the hyperlink in the last sentence was broken, so if it was meant to point to a more satisfactory answer, it didn't work.

Absorption of glucose into cells, and conversion of it into fat for long-term storage, is a process driven by insulin. If you aren't producing insulin, you're not storing fat. That is why unexplained weight loss (often despite high calorie intake) is typical of Type 1 diabetes patients before they are diagnosed and start receiving insulin treatments. It is also the reason that many weight-loss diets involve severe restriction of carbohydrates: the goal of such diets is to reduce insulin production, and thus reduce fat storage. Some Type 1 diabetes patients deliberately take less insulin than they need, simply because they can't bear to give up the slender physique that insulin insufficiency gives them. (I know whereof I speak; a member of my family used to do that, and died from it.) Even patients who are taking oral drugs which merely increase their insulin production or insulin sensitivity often find that such drugs reduce their blood sugar only at the price of pushing up their weight.

This is not to say that insulin is bad and we should try to live without it. I'm merely pointing out that insulin does, indeed, promote storage of body fat. It's silly to pretend that this is not an issue people must deal with.

And calling the whole issue a myth doesn't help people deal with it!



Wednesday, March 27, 2013

I thought I'd done pretty well carb-wise yesterday (and I did a hard run, too), so I assumed I would get a low fasting test this morning. However, last night I did pretty badly sleep-wise. I'm sure I didn't fall asleep until at least 2:30 AM. I think that's why my fasting result was a bit elevated today. I hope I do better in the sleep department tonight!

Should Diabetes Patients Avoid Fruit?

I like fruit, and I realize that it's considered "good for us" in a general way. It provides a certain amount of fiber, and a lot of vitamins, and also a lot of those colorful substances which are more tentatively thought to provide health benefits. Fruit appears to reduce inflammation, improve endothelial function, reduce cardiac risk, and reduce risk for certain kinds of cancer. However, because nearly all of the calories in fruit come from carbohydrate, I have tended to think of fruit as something I need to avoid. A lot of clinicians feel the same way, cautioning diabetes patients to limit their intake of fruit (and try to get their vitamins and fiber from the less sugary vegetables).

Is this caution excessive? Should diabetes patients be encouraged to include fruit in their diets? A recent Danish study tried to find out.

First of all, I should point out that it was a pretty small study, with only 63 participants, and it studied them for only 12 weeks. So, this study needs to be confirmed by others which studied more patients over a longer period. Anyway, the study divided a group of newly-diagnosed Type 2 diabetes patients into two groups, one of which ate more than twice as much fruit as the other.

The researchers found, perhaps surprisingly (surprisingly to me, anyway) that the high-fruit and low-fruit groups did not differ significantly in terms of glycemic control. And the high-fruit group did better rather than worse in terms of weight control.

Seemingly the moral of the story is that diabetes patients might was well make fruit a significant part of their diet, because it doesn't make glycemic control worse and in other areas it is beneficial.

However, I think we need to be cautious about applying the conclusions of one small, short-term Danish study to ourselves. The question to ask is not whether fruit causes glycemic-control problems for the average diabetic Dane, but whether it does so for us.

So, I'm willing to experiment with getting more fruit into my low-fruit diet, but I'm going to proceed cautiously. I want to see the effect of an orange on my post-prandial test results before I assume, based on this study, that oranges shouldn't be a problem for me.

I also plan to pay attention to the difference in sugar content between one kind of fruit and another. I looked up the numbers on some common fruits, and found large differences between them. (I was particularly startled to see how much difference there was between strawberries and kiwi fruit, as I have always thought of kiwi fruit essentially as a strawberry that happens to be green.) Anyway, here are the fruits I looked up, listed in order of increasing sugar content:

I guess the sensible thing to do, in terms of increasing my fruit intake, is to start with fruits from the top of the list, and see how it goes.

What's In A Name?

Tuesday, March 26, 2013

Research Trial Names Are Getting Really Weird

Medical research trials are big, expensive projects which often involve a lot of scientists at multiple universities, and are frequently referred to in other research papers. So, research trials need names. There has to be a handy label for them.

In my working world (the electronic equipment industry), product-development projects get names, too, but the names are quite arbitrary, and are intended to reveal nothing about what the project actually involves. Rightly so, of course: if you're getting ready to introduce a new product, the last thing you want to do is encourage the spread of rumors about what you're developing, so that your competitors can easily figure out what you're up to. So, projects are typically named after a geographic location, an athlete, a type of animal, or something of that sort. The names of military operations used to be as deliberately meaningless as that. If the enemy found out you were planning something called "Operation Overlord", they wouldn't be able to guess it meant "Guess what, guys: we're invading Europe, starting with an amphibious assault on the beaches of Normandy!". Similarly, there was no way to guess that "Operation Market Garden" was a plan for an airborne assault aimed at invading Germany by way of the Netherlands.

Nowadays, of course, the names of military operations are not arbitrary and meaningless anymore; these names are not only supposed to identify the operation but also to manipulate public opinion about it. Thus, America's 1989 invasion of Panama became "Operation Just Cause" (inviting jokes to the effect that "Operation Just Because" would have been more candid). The names of medical research trials seem to be jumping on that particular bandwagon.

The names of research trials are usually acronyms for the description of a study ("NHANES" for "National Health and Nutrition Examination Survey", for example), but these days, almost invariably, the acronyms just happen to spell a recognizable word or phrase, and the word or phrase chosen is typically something which sounds cute, catchy, and positive.

Thus we have such research trials as HOPE (Heart Outcomes Prevention Evaluation) and CALM (Candesartan And Lisinopril Microalbuminuria study). But it gets a great deal more contrived than that, and the search for appealing acronyms can become a bit competitive: there are two research trials called AMIGO, two more called ADOPT, and no less than four called ADVANCE. (Which does rather raise the question of what good the name does, if it doesn't distinguish one research trial from all others.)

Some of these names are pretty nakedly propagandistic, especially those which seem to exist for the purpose of boosting sales of a drug. Thus we have COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation), IDEAL (Incremental Decrease in clinical Endpoints through Aggressive Lipid lowering), and TRIUMPH (Tilarginine Acetate Injection in a randomized international study In Unstable MI Patients witH cardiogenic shock). Notice that some of these acronyms play pretty fast and loose with the actual initials of the phrases they supposedly stand for; notice also how strongly they hint at the desired outcome of the study! When you can't tell a research report from a marketing brochure, something is probably wrong.

Some of these names seem to pursue cuteness a little more single-mindedly than I think is wise. Do you really want to do a study of "Acute Myocardial Infarction With Hyperoxemic Therapy" just so that you can call it AMIHOT? When the name of your study suggests the online nickname of a 13-year-old who is not destined for good things, something is probably wrong. And would a serious researcher concoct "Prophylactic Amiodarone for the Prevention of Arrhythmias that Begin Early After Revascularization" just for the sake of being able to call it PAPABEAR? It does make one wonder if the people involved in these decisions are grownups.

Which brings us up to the study I read about today. It looked at a population of older Mexican-American residents of northern California, and found that, at least in this particular population, Type 2 diabetes is associated with an increased risk of dementia. Well, okay: Type 2 diabetes is associated with an increased risk of everything else one can imagine going wrong in a human life, including paper cuts and disappointing theatergoing experiences, so why shouldn't dementia be on the list?

But what seems noteworthy about this report is the name of the study in which the participating patients were enrolled: the Sacramento Area Latino Study on Aging. Also known as... SALSA.

Did they have to? Could they really not resist calling it that? I mean... exactly how drunk were they?


Doctor Fitness; Dementia Risk

Monday, March 25, 2013

Yesterday was pretty sedentary -- even though I did a difficult, hilly, 5.3-mile run. Apart from that I spent rather a lot of time sitting down (and had a fairly generous intake of carbs, too, come to think of it), so I shouldn't be surprised to have a fasting test above my target zone today. Well, I hope I do better tomorrow!

Fit Doctors Promote Fitness

I've written before about studies indicating that doctors who are of normal weight themselves are likely to counsel overweight patients on the dangers of obesity, while obese doctors are likely to avoid the subject. Researches are free to invent whatever explanations for this phenomenon they wish to, but it seems pretty obvious to me that doctors, like everyone else, dread being seen as hypocrites (and perhaps being called out on it, which would seem to be the natural reaction to expect from anyone who is being told by a fat person to lose weight).

Well, apparently there is a similar phenomenon operating in regard to fitness. Which doctors are most likely to recommend regular exercise to their patients? Doctors who exercise regularly. Which doctors are least likely to recommend regular exercise to their patients? Doctors who don't exercise. Wow, who saw that coming?

It is thought (probably reasonably) that patients are more likely to take up exercise if the doctor who recommends it has personal anecdotes to share about participating in footraces, bike rallies, and the like. Just as it's easier to take dietary advice seriously when it comes from someone who isn't fat, it's probably easier to take fitness advice from somebody who works out.


Blood Pressure & Alzheimer's

I hadn't realized there was a connection between high blood pressure and Alzheimer's disease, but apparently there is one -- or at least there can be, for people who are unlucky in their genes.

Alzheimer's disease is caused by (or at least very strongly associated with) amyloid plaques deposited in the brain, and the amyloid deposition rate is higher in some people than others. In patients who carry an unlucky gene variant known as APOE Epsilon 4 (we don't traffic in Greek letters here at Not Medicated Yet, so I'm not going to render that properly), the rate of amyloid deposition tends to be high, and the risk of Alzheimer's disease is elevated accordingly. However, according to a new study, there is something we can do about this -- because the risk is greatly ameliorated in patients with normal blood pressure (or whose tendency to high blood pressure is brought under good control). The real problem is not the APOE Epsilon 4 gene -- the real problem is the combination of that gene with high blood pressure.

I don't know whether or not I carry that bad gene, and I imagine it's not cheap to find an answer to that particular question. But I guess the take-away message is that having the gene isn't all that bad -- so long as you keep your blood pressure under control!

But perhaps you're thinking, "What if I later find out I don't have that bad gene? Won't it mean I controlled my blood pressure for nothing?". Actually, controlling your blood pressure is a good idea anyway (because it protects you against heart attacks and strokes -- both of which diabetes patients are prone to), and it may be that controlling blood pressure reduces Alzheimer's risk even in people who don't carry that gene. (Lacking that gene doesn't mean your Alzheimer's risk is zero, just that it's lower!)


Give Or Take 120,000,000 Years!

Friday, March 22, 2013

In general I'm not an admirer of the Daylight Saving Time concept, but I have to admit that it is pretty nice to have enough daylight left in the early evening to start a long trail-run without having to worry about being stuck in the middle of the spooky woods as darkness falls. The sun was still well above the horizon when I finished.

Glucose Meters & The Age Of The Universe

One thing that people who don't understand science like to tell you about science is that scientists are constantly changing their minds about everything, and what's indisputably true this year will be rejected as obvious nonsense next year.

The reason people like to think science is like this is that science sometimes tells them things they don't want to hear. A lot of people feel the need for an emotional defense against science, hence their eagerness to believe that science is just a series of intellectual fads which are discarded the moment they are no longer fashionable. If that is the case, then obviously we don't have to listen to scientists when they tell us things we wish they weren't telling us. Therefore, people love to pounce on any story about scientists which seems to confirm the idea that they're always changing their minds.

An example of this is the news that astronomers have been wrong about the age of the universe. New data coming in from the Planck spacecraft say that the universe is older than previously thought!

Those wacky scientists! Who knows how old they'll say the universe is the next time they send up a spacecraft to gather data! Why don't they just admit that they have no idea how old the universe is?

However, if you look into the details behind this, a very different story begins to emerge.

The previous estimate of the age of the universe was based on data gathered by an earlier spacecraft known as WMAP.

For both spacecraft, the mission was to scan the sky at a microwave frequency that captures the "echo" of the Big Bang. The point is to create from this a mapping of the early distribution of matter in the universe, at a time shortly after the Big Bang had occurred.

Even at this early stage in our universe's existence, matter was not evenly distributed -- it was "lumpy", and the lumps turned into galaxies. Studying the distribution of matter in the early universe is important in creating an accurate estimate of the universe's age. But the accuracy of the estimate is going to be limited by the accuracy of the data you can gather.

The previous estimate of the age of the universe, based on the data from the WMAP spacecraft, was 13.73 billion years. The new estimate, based on the data from the Planck spacecraft (which has better measurement technology and can give a more accurate figure) is 13.82 billion years.

Does this mean that up till now scientists have been "wrong"? Well, allow me to point out that the difference between 13.73 and 13.82 is not all that dramatic in relative terms. More significantly, the old estimate was not precisely 13.73 billion. It was 13.73 billion plus or minus 0.12 billion. In other words, the actual estimate was that the age of the universe was "somewhere between 13.61 billion years and 13.85 billion years", not "13.73 billion years". And the new figure is within that range! It's not in the middle of the range; it's near the top. But it's within that range. In other words, the new result refines the precision of the earlier estimate, but does not contradict it.

If astronomers had been saying that the age of the universe was 13.73 billion years, and then started saying they'd made a mistake and it was really 6000 years, we would be justified in saying that scientists are fickle and you can't take seriously anything they say. But when they replace "13.61 to 13.85" with "13.82", they haven't contradicted themselves, they have simply become more precise.

This kind of thing happens surprisingly often. Scientists refine an estimate, and the news is announced in the popular press as if it were a dramatic reversal. Scientists abandon an idea which had only been tentatively suggested in the first place, and the news is announced as if it were some kind of scandal.

Science is a process of gradually closing in on accuracy; along the way you have to settle for approximations. And approximations are useful.

A lot of diabetes patients find it disturbing that glucose meters give only approximate values. They don't have excellent "repeatability" -- meaning that a glucose meter measuring the same blood sample repeatedly will yield a series of answers which fluctuate above and below the actual value. Those fluctuating values will average out to something very close to the actual value, but still! If you repeat a test and find that it said 104 the first time and 95 the second time, how do you know what to believe? (Well, you could believe that the real answer is probably somewhere between 95 and 104. And that's close enough to be useful to someone trying to achieve reasonably normal glycemic control.)

I, too, would like my meter to be absolutely accurate and repeatable, but I know that's not going to happen. It isn't reasonable to expect results as accurate as a medical lab would get, using equipment cheap enough for home use. Yes, it would be nice to have absolute precision in glucose measurements, but we have to settle for approximations instead. And that's not really so bad. If astronomers can cope with having only approximations for the age of the universe, I can cope with having only approximations for my glucose levels.


Just Checking!

Thursday, March 21, 2013

Who Needs To Test?

Here's an interesting question, asked implicitly by someone who entered the following Google string: "should i measure my blood sugar levels even if i am not diabetic?".

I'm sure that, to some people, this seems like a silly question. Of course you shouldn't measure your blood sugar levels if you aren't diabetic. What on earth would be the point? Why check your blood sugar if you're not having a problem with your blood sugar?

However, the question is actually a little less silly than it seems. For one thing, how do you know that you're not having a problem with your blood sugar? Hyperglycemia has no symptoms until it gets severe, so if you aren't checking your blood sugar regularly, you have no way of knowing what is going on with it. Also, it is pretty standard human behavior to check on things which, so far as we know, are not going wrong at the moment.

A man walking out of a restaurant bathroom might check to make sure his zipper is up, even if he doesn't really think he left his pants unzipped, and even if he is very much in the habit of zipping up his pants before stepping away from the urinal. Why does he check on this, when he knows the risk is low? Because the risk/benefit analysis favors it. The risk of his pants being unzipped may be low, but on the other hand, the inconvenience of checking his zipper is also low, while the potential embarrassment of walking out into a crowded restaurant with unzipped pants is high. The outcome of this (admittedly unconscious) analysis is that he checks his zipper.

We do this kind of thing all the time. "Do I have my keys?" is a question many of us look into several times a day, even if it's only a matter of quickly patting a pocket or reaching into a purse. The verification process is easy and quick, and it relieves anxiety. (It also is an excellent thing to do as you go out your front door in the morning, especially if you do it before you lock that door.) When something is easy to check, and has potentially serious consequences if it has gone wrong, we check pretty frequently, even if the actual risk that it has gone wrong is pretty low.

When it comes to health care, the risk/benefit analysis tends to be skewed a bit differently. Checking what's going on chemically in your bloodstream tends to be inconvenient and costly. If it's a lab test, you have to get your doctor to order the test, and you have to go to the lab to have a blood sample taken, and you have to pay whatever they're charging for this. This is not like patting your pockets to make sure you've got your keys. You and your doctor and your health insurer are not going to go through all this every day. You will get this kind of test when (1) there is some indication of a problem which needs to be checked out, or (2) a specified time period (typically a year) has elapsed since the basics were last looked at.

Checking your blood sugar is a little easier; certainly it's a lot easier than it used to be. Glucose testers are pretty affordable. But you only get one use out of a test strip, and they cost more than a dollar each -- a cost which your health insurance company is unlikely to help you pay for if you don't have diabetes (or even, these days, if you do). Also, you have to prick your finger, which bothers a lot of people. Also, as the timing of these tests is significant, the proper time to do the test may come up when you're in a business meeting, or sitting at a restaurant table, or in some other situation where testing your blood in front of alarmed bystanders is not something you wish to do. So, blood sugar testing is not something that most people are going to undertake casually, unless they already have a good reason to suspect that something is amiss.

Which is unfortunate, really. As with cancer, Type 2 diabetes is best detected early, before things have got too far out of control. The sooner you start trying to regain control of your blood sugar, the likelier you are to succeed at it. But most people don't know the problem is developing until it has already become pretty serious.

People who are known to be at high risk of developing Type 2 diabetes (because of family history, or US citizenship, or some such reason) probably should check their blood sugar on a routine basis. Maybe not daily... but would weekly testing be asking too much, in the case of people who are at risk?

My own diabetes wasn't detected until a blood test I took for an annual physical twelve years ago showed a fasting level of 174. I acted quickly and got it under control within a few months, but I still think I would have been better off to know what was going wrong some months before I actually did.

So, I think that, at least if you are facing a high risk of Type 2 diabetes, you probably should be testing your blood sugar once in a while, even if you haven't been diagnosed with it yet. The sooner you find out, the better.

And it's not as if the risk is low! Type 2 diabetes is now a common disease, and is becoming more common every day. The risk (at least if you have risk factors weighing down on you) is high enough to justify checking, even if our available methods of checking are not yet as effortless as patting your pockets.


Exercise & Soda

Wednesday, March 20, 2013

How's Your QOL?

I've been known to point out that exercise improves glycemic control and reduces cardiac risk. But apart from such comparatively minor advantages as Not Dying, can exercise offer us anything of real value? Can exercise improve our Quality Of Life, or QOL as I understand it's called?

Don't get me wrong: Not Dying is a pretty big deal, and I'm sure we should all care about it a lot more than we do. But QOL is a bigger deal, let's face it. It's all very well to be non-dead, but a lot of us look for other things in life, such as being physically functioning, or not being in pain. Some researchers decided to find out if exercise made a difference to QOL, at least in Type 2 patients. They did it by gathering together some patients with Type 2 diabetes, and assigning them to one of three exercise programs (aerobics, resistance training, or both). Naturally there was also a control group which was not assigned to any exercise program, so that each exercise program could be compared to no exercise program.

It turns out (surprise, surprise) that all three exercise programs caused significant improvements in QOL, compared to no exercise program.

Resistance training produced the greatest improvement in terms of bodily pain. Aerobic training (or the combination) produced the greatest improvement in terms of physical functioning. The combination produced the greatest gains in terms of vitality and mental health.

So, to improve your QOL (and I assume you're all about improving your QOL), your best bet is to combine aerobic and resistance training.


Sugary Death!

How's this for an attention-grabbing headline: "Sugary Drinks May Explain 180,000 Death Worldwide Each Year".

That's from an epidemiologic study which tries to estimate the human cost of our ever-increasing consumption of sugary soft drinks. This breaks down as 132,000 deaths from diabetes, 44,000 from cardiovascular disease, and the rest from cancer. Of course, to buy these numbers, you have to accept the researchers' assumptions about how closely sugary drinks link up with obesity, and how well obesity links up with diabetes and cardiovascular disease and cancer. That's a lot of assuming. But it sounds as if the world could afford to cut back considerably on the sweet fizzies.


Frequently Asked Questions

Tuesday, March 19, 2013

The search phrases that lead people to this site mostly fall into four categories:

Here are some recent examples from each category...

Questions About Urine

If you are seeking ways to slow down your production of urine, that means you are not "borderline" diabetic. If your blood sugar isn't pretty far out of control, it's not going to make you visit the bathroom abnormally often. Of course, there can be other reasons why someone might be urinating excessively; there's a pituitary disorder that can cause excessive urination even in people who don't have abnormally high blood glucose. But if you don't have something like that, excessive urination usually results form excessive blood glucose.

Excessive urination is a symptom of out-of-control diabetes, not a symptom of diabetes regardless of blood sugar levels. It's only when your blood sugar gets well above normal that the kidneys start leaking it into the urine (which, owing to osmotic pressure, results in an increased flow of fluid into the bladder).

This can happen, but it's not entirely good news: it's an indication of kidney disease. Sugar in the blood is supposed to be "reabsorbed" in the kidneys, meaning that it goes back into the bloodstream instead of passing into the urine. Sugary urine indicates either that your blood sugar is too high for your kidneys to be able to reabsorb all of it, or that your kidneys aren't working properly. If you're not diabetic, then it sounds as if you need to have your kidneys checked out.

Pretty much the same as peeing without diabetes, I'd say. It comes from the same place, anyway. But it might happen more often, if your blood sugar isn't under good control.

Questions About Insects & Urine

It probably means you live in ancient Greece, because that's how they diagnosed diabetes in those days. The diagnostic technology has improved since then, however, so I would suggest you find a more reliable method of determining whether or not you are diabetic.

Only after it has already left your bladder, I hope.

Maybe, but as I said, we have better ways to determine such things now.

I guess ants must have pretty low standards, if that's what they're attracted to. I'd never heard of this particular connection, or alleged connection, and I'm hoping to hear less about it in the future.

Questions About The A1c Test

Only if the infection goes on for a long time. Chronic infections (periodontal disease, for example) can cause you to be in a persistent state of inflammation, which results in a loss of insulin sensitivity, which results in elevated blood sugar, which results in a high A1c test result. But please realize that this is not a case of infection "invalidating" the test and causing it to show an "inaccurate" result. If an infection causes your A1c result to rise, it does so by causing your blood glucose level to rise first.

Questions About Getting 6.2% On The A1c Test

For reasons which are not clear to me, I get far more questions about A1c results of 6.2% than I do about any other sort of A1c result. Mainly, people want to know if they should be concerned about having an A1c result of 6.2%, or if 6.2% is normal.

6.2% is slightly above normal. The upper limit of the "normal" range is sometimes described as 6% (although my lab calls it 5.8%). Being above normal, but not all the way up to 6.5% (the diagnosis point for diabetes) is usually described as "prediabetes". Prediabetes is indeed something to worry about, because it really is just a stage in the development of diabetes. (It's like describing the first trimester as prepregnancy.) The blood sugar level that will give you an A1c result of 6.2% is not particularly harmful in and of itself, but it indicates that your endocrine system is starting to lose the battle to control your blood sugar, so it's not a good sign. If you got an A1c result of 6.2%, you should go work on reducing your blood glucose level -- because at that point it's going to be comparatively easy to do accomplish it. The longer you wait, the harder it gets!


People Who Have Been There

Monday, March 18, 2013

Learning From Your Diabetes Peers

After five years of doing this diabetes blog, I am still half-expecting to get in big trouble over it. Is somebody (or some professional organization) going to accuse me of practicing medicine without a license? Other diabetes bloggers have been threatened with legal action, for giving advice to those who write to them. I try to sprinkle a fair number of I-am-not-a-doctor disclaimers around, but apparently that doesn't buy you anything legally.

The reason I keep writing this blog is that I think there is a need for diabetes patients (and people hoping not to become diabetes patients) to receive advice from diabetes patients, not just from doctors. Peer-to-peer advice is simply different from professional advice, and in some situations it can fill major gaps.

For whatever reason, technical expertise correlates with poor communication skills. Engineers, scientists, and doctors tend to be very good at understanding ideas, and very poor at expressing them clearly to anybody else. The stereotype of the professor who goes to the blackboard and writes A, but says B (and actually means C) -- that's rally not so far from the truth. Of course, this is only a tendency, not a rule. Many doctors are perfectly capable to communicating clearly. But how much time are they given in which to do it? Office visits are time-constrained. If the economic imperative is to get you out of that examining room before 15 minutes have expired, regardless of whether your questions have been answered, then it's pretty likely that some of your questions are going to go unanswered. Showing up with your questions already written down on a notepad is helpful, of course, but even if you do that it's quite possible to emerge from the doctor's office feeling that your questions were addressed but not really answered.

I've lately had a bit of vicarious education on this subject, by trying to help my father understand some very complicated instructions from his doctors in regard to the various medications he's on. More than one doctor is involved, so he's had conversations with them, and e-mails from them, and written instructions that come with the meds, and suggestions from the pharmacists as well. There is no consistency to any of this. An attempt to ask one of the doctors a clarifying question via e-mail yielded a condescending suggestion that we re-read the written instructions, which is a strange way to answer a complaint that the written instructions are unclear. If I could be put in touch with patients who had been on a regime of medication similar to my father's, I would certainly like to hear what they had to say about their experience. Sometimes you really need to hear from patients, not just doctors.

It seems to me that diabetes is a disease which would benefit greatly from patient-to-patient input. It's a common disease (millions of us have it), and it's a remarkably complicated disease, so doctors don't really have enough time with patients to be able to explain it adequately. Most significant of all, it is inevitably a self-managed disease, with the patient carrying the burden of daily data-gathering and daily decision-making. No doctor who doesn't have diabetes is going to know what it's actually like to live with it.

This was just my personal opinion, at least until today, but now I've discovered that there is actually some research data which seems to back me up.

Annals of Family Medicine has published a study entitled "Impact of Peer Health Coaching on Glycemic Control in Low-Income Patients With Diabetes: A Randomized Controlled Trial". The study compared diabetes patients given the usual treatment with patients who were coached by a diabetes patient who met with them at regular intervals, by phone and sometimes in person. Result: better glycemic control. The patients with peer coaches experienced, on average, a drop in their hemoglobin A1c results of 1.07% (compared to 0.30% for the patients who didn't get peer coaches).

I feel totally vindicated by this! But, admittedly, nobody has done a study (so far) comparing glycemic control between readers and non-readers of my blog. I guess that's the next step in science's march forward.


Gentleman Doctors & Lady Doctors & Kidneys

Thursday, March 14, 2013

Today was pretty much the same formula as yesterday: busy at lunchtime, couldn't run then. Ran after work. Came home and had a low-carb dinner, followed by a low post-prandial test result. Well, if it ain't broke, don't fix it.

I still think running at lunchtime is a better plan for me, if only because it makes me feel good in the second half of my workday. But this sunset-run thing isn't so bad, with the sun setting this late and the weather this comfortable.


Death & The Female Doctor

These days a lot of primary care physicians are women, which means that enough people have female PCPs for comparisons to be made between health outcomes of patients with female doctors and patients with male doctors.

Do patients with female doctors visit the doctor less often, or have worse mortality statistics than patients with male doctors? Researchers did a study to find out.

And the answer was: no.

If you have a female doctor, you're as likely to make an office visit -- and also as likely to die -- as anyone else is. No doubt there are good doctors and bad doctors, but the difference does not seem to be related to what's in their pants.

So, if you've been worrying about that... stop.


Kidneys & Blood Sugar

Google recently linked to this site when somebody entered the search phrase: "will you have high blood sugar if something's wrong with your kidneys".

That would make a lot more sense if it said "will something go wrong with your kidneys if you have high blood sugar", because excessive blood sugar can do harm to your kidneys, but diseased kidneys cannot cause you to have excessive blood sugar.

Glycation (the unwanted bonding of glucose to proteins, which happens at an accelerated rate if you have abnormally high blood sugar) is especially harmful to structures within the human body which involve very tiny blood vessels; as a result, the eyes and kidneys are especially vulnerable to the impact of high blood sugar. (Retinopathy and kidney failure are, therefore, distressingly common among diabetes patients.)

But it doesn't work the other way around. Your kidneys can't give you high blood sugar. Your kidneys do have a slight connection to blood sugar, in the sense that they are supposed to prevent the sugar in your blood from leaking out into your urine (but they can't do it when your blood sugar is extremely high, which is why sugar in the urine is an indication of excessive sugar in the blood). But in that case your kidneys are slightly reducing your blood sugar, not raising it. There doesn't seem to be anything your kidneys can do to raise your blood sugar. (Your liver can do that, but that's a story for another day.)


Repairing Proteins, Muscles, & Shoulders

Wednesday, March 13, 2013

I was in an all-day training class at work today, and didn't have enough time for a lunchtime run. But now we're in Daylight Saving Time again, so I had enough daylight left after work to go for a long run.

And right after that I went home and had a dinner that was pretty low-carb, hence the unusually low post-prandial result of 94.


Modern Medical Research: The Abbreviated Version

It seems as if most of the medical research going on nowadays is like the research reported in this story, with a few details changed. There's a protein called HNF-4-alpha, and it regulates gene expression in the liver and pancreas, and people with a rare form of diabetes known as MODY-1 have a mutated form of that protein. So now scientists have mapped out the structure of the HNF-4-alpha protein. It is Y-shaped, and the mutated area of it is the notch of the Y. Which means that notch is a potentially a "druggable site".

So the researchers are hoping they can craft some molecule that will fit into that notch and reshape the protein to function normally. And a new drug is born!

The researchers are also hoping, though they don't mention it, that whatever newly crafted molecule they come up with will not also fit into a notch in some other protein which doesn't need reshaping... with terrible consequences.

That's the tricky thing about drug development: you want the drug to change one little thing within the body's fantastically complex interactive network of genetic molecules and signaling molecules. But it's awfully hard to change just one little thing within an interactive network. That's why, for any medication, side effects are the rule rather than the exception. With luck, the side effects will turn out to be minor and tolerable, or at least rare, but it takes a lot of time and effort to establish all that with any confidence, so drug development doesn't happen quickly. Even after a drug has been approved, problems may surface later (such as high rates of cancer, heart attack, or kidney failure in people taking the drug over a long period). Hence the sensible policy (or at least my sensible policy, and my doctor's) of avoiding medication unless it's actually necessary. Where a non-medicated approach works as well or better, go with the non-medicated approach.


Resistance Training & Older Type 2 Patients

Speaking of non-medicated approaches that work, a study of resistance training in older adults finds that such training reduces insulin resistance and hemoglobin A1c. The improvement is reported to be comparable in magnitude to the addition of a second diabetes drug (such as a sulfonylurea) to metformin treatment.

This makes me feel a bit guilty, as I've been avoiding resistance training lately as I try to recover more fully from the rotator-cuff pain I've been having in my right shoulder. The shoulder problem keeps getting better and then coming back, in irregular cycles. I think I just need to increase the number of times a day I do physical-therapy exercises on that shoulder, to get a more decisive recovery. After all, my left shoulder, which used to be much worse than my right shoulder is, feels fine now, because I did the physical therapy routine often enough for long enough. I'll get there with the right shoulder, somehow!


A Bitter Non-Pill

Tuesday, March 12, 2013

Ugly Awful Vegetable May Help!

Here's a nice headline: "Bitter melon juice activates cellular energy sensor AMP-activated protein kinase causing apoptotic death of human pancreatic carcinoma cells". That's the title of a study which suggests it is possible to fight pancreatic cancer (an all-but-invincible disease) with the juice of the bitter melon.

Bitter melon has long been used in Chinese medicine, and has been found to boost insulin sensitivity in people with Type 2 diabetes. And now it looks as if it has a therapeutic effect on pancreatic cancer, too. It's useful stuff, therefore, and I guess it would pretty much have to be, as the bitter flavor (said to resemble an unripe persimmon) is hard to tolerate for people who didn't grow up eating it -- and you probably didn't, if you grew up outside Asia. And, if that is not enough to discourage you, bitter melons look like this:

Oh, good: a warty monstrosity that tastes as bad as it looks! Who could resist giving it a try?

Well, so far, I've resisted giving it a try. Late last year I went so far as to buy one at a Chinese market, thinking I could persuade myself to use it in a stir fry, but I never managed to get up the nerve before it went bad (although what "bad" means, in connection with a vegetable that looks like that when it's in its prime, is a little hard to say). I haven't made another attempt since then.

Still, for those who can get past the alien appearance and bitter flavor of the vegetable, it can be useful to diabetes patients. (It is a staple food in Okinawa -- and that is a place famous for the longevity of its citizens, which suggests that bitter melon is at least harmless, and possibly helpful, in that regard.) Suggestions I have heard for taming the bitterness include salting and/or parboiling the melon before using it in a recipe. Also, you're supposed to scrape the seeds out of the middle of the thing (and, in many Asian recipes, fill it with ground pork). I suppose that heavy drinking might help, too.

But how does bitter melon do whatever it does? Well, in terms of boosting insulin sensitivity, four compounds that have been found in bitter melon are known to activate an enzyme known as AMP-activated protein kinase, or AMPK for short. AMPK acts within muscle cells to mobilize the glucose transporters which, when the cell is stimulated by insulin, drag glucose from the bloodstream into the cell interior. The more transporters are mobilized, the better the cell responds to insulin, so an increase in AMPK is effectively an increase in insulin sensitivity. Exercise activates AMPK also; that is at least part of the reason why exercise is an effective therapy for Type 2 diabetes. Exercise has other beneficial effects as well, so eating bitter melon to boost your insulin sensitivity is not a real replacement of exercise. The melon does, however, duplicate one of the useful effects of exercise. And for people whose poor health or disabilities make exercise difficult, bitter melon might conceivably serve as a (partial) exercise substitute.

But what about the cancer connection? It seems that activating AMPK also has the effect of restricting the ability of pancreatic cancer cells to metabolize glucose -- which means that those cancer cells become energy-starved and die. Now, here is the point at which the story gets very confusing. Up till now, everyone has been saying that AMPK acts to facilitate (not restrict) glucose metabolism, at least in muscle cells. Why would it do the opposite in pancreatic cancer cells? Is there something I'm missing here? Yes, probably! But nobody is likely to fill me in.)

Mouse studies also suggest that bitter melon is useful in preventing, not just treating, pancreatic cancer. So, it seems as if this is an important food, and I may just have to bite the bullet and eat some of it.


Glycemic Control, & Also Sausages

Monday, March 11, 2013

The Golden Mean

In a lot of problem situations, you want to beware of over-reacting just as much as you want to beware of under-reacting. But is diabetes one of those situations? Some doctors think it is.

The American College of Cardiology has been holding its 2013 Scientific Sessions in San Francisco, and one presentation given there says that the risk of heart failure in diabetes patients is increased by out-of-control blood sugar, but is also increased by aggressively controlled blood sugar. According to this study, the safest hemoglobin A1c range to aim for, at least in terms of heart failure risk, is 6% to 6.9%. Going higher than that is worse. But going lower than that is also worse, apparently.

Why is it worse, though? Healthy non-diabetic people are below 6% all the time, and it's not giving them heart failure. Why is it harmful for people with diabetes to go below 6%?

The answer, obviously, is that it's not being below 6% that's a problem -- the real problem is the things diabetes patients might do to get below 6%.

Helen Parry, the presenter in San Francisco, was asked how tight glycemic might increase the risk of heart failure. Her quoted reply: "It's probably multifactorial. First, there's a possibility these people are on a lot of antihyperglycemics — they are on insulin and sulfonylureas — and we know that these are associated with development of heart failure. Aside from the drug effects, we know that hyperglycemia is bad for the heart and increases mortality, so it may be that even in those whose [mean] HbA1c is around 5.5%, these are also the people who are more susceptible to acute hyperglycemic events." I can't help noticing that her answer is not confined to why tight glycemic control increases the risk of heart failure -- it seems to be about why diabetes in general increases the risk of heart failure.

Certainly diabetes is a huge risk factor for heart failure -- making your risk roughly seven times higher, if the Framingham study does not mislead. But have scientists examined that risk factor, to determine how much of it is accounted for by the side effects of diabetes drugs, and how much of it is due solely to having diabetes?

I don't know the answer to that one, but I'd sure like to know, because I'm not using drugs to control my blood sugar, and I'd like to know if heart failure is something I need to worry about, or not.


Processed Meats & You

For a long time it was stated in a very general way that meat consumption correlated with serious diseases such as cancer and heart disease. I was content to leave it at that, when I was trying to control blood sugar with a vegetarian approach to diet. Once I decided that my vegetarian diet was too high-carb for me, I became more interested in knowing whether some meats were more dangerous than others.

Lately, there have been more studies trying to differentiate the health impact of different kinds of meat, to see where the real risk lies. Apparently, the risky meats are processed meats -- bacon and sausage, for example. This study found that processed meats had "a moderate positive association" with cancer and cardiovascular disease. Why? Well, it's anyone's guess at this point. Is it because processed meats provide more fat? More cholesterol? More salt? More creepy additives? (They do provide more of all of those things -- the questions is which of those things does the harm.) Don't worry about it, though, because I'm sure the American Sausage Advisory Board (or whatever the processed-meat lobby calls itself) will soon sponsor a study showing that there's no problem here.



Thursday, March 7, 2013

Ouch! After yesterday's fasting test of 87, I thought I was back on track. But yesterday's fasting test came the morning after an early dinner and a good night's sleep. This morning's test came after a late dinner and not enough sleep. High fasting glucose is, very often, the cost of being sleep-deprived. So, the fasting test of 101 this morning is not entirely inexplicable.

At least the post-prandial test today was good...


Diabetes Is Expensive!

The American Diabetes Association has issued a report saying that diabetes is costing the country money. Lots and lots of money, it seems.

The basics:

All right, so diabetes is costing America a lot of money and, with diabetes prevalence way up, it's going to cost America even more money in the near future. What can we do about it?

Although the report does mention better treatment as a possible way to contain diabetes-related costs, the general consensus seems to be that prevention is the best option. Okay. Good luck with that!


How Low Are My Carbs

The great thing about the term "low carb" is that it really has no definition. To diabetes patients it has a very reassuring sound; they assume that any food described as "low carb" contains too little carbohydrate to push their blood sugar above normal levels. For them, "low carb" means "don't worry about it".

However, the meaning of "low carb" is very different to someone who is promoting a particular food to diabetes patients. All they mean by it is that it contains less carbohydrate than some foods they could mention. For them, "low carb" means "could be worse".

These two definitions of low carb seem to collide in a slide show presentation on dLife which I saw today. The link inviting me to look at the presentation said "Best Low Carb Budget Foods". However, when I followed the link, the presentation that came up was now labeled simply as "Budget Foods". So are they low carb, or not? Here's the list:

Eggs and tuna and vegetables are low-carb; I think most people would agree on that.

But beans? They're lower in carbs than rice, I agree, but not so devoid of carbs that diabetes patients don't have to be concerned about glycemic impact. And sweet potatoes? Not as high-carb as some potatoes, but a long way from carb-free. I like these foods, but I've found that, when consumed in satisfying quantities, they do have a substantial impact on my blood glucose. I don't see them as low carb; I see them as "could be worse".

And fruit? Since when is fruit low carb? Almost all the calories in fruit come from carbohydrate.

And oatmeal? Is this a joke? At least the notes on the slide show come clean here: "Oatmeal is not low carb, but it's higher in fiber than breadcrumbs and quite inexpensive as well". If it's not low carb, what is it doing on what has been promoted as a list of low carb budget foods? And how much does it matter that oatmeal is higher in fiber than breadcrumbs? We're definitely in the valley of "could be worse" here.

I think we may need to pass a law that says no one can describe a food as low carb unless they also make clear whether they are using it in the "don't worry about it" sense or in the "could be worse" sense. People usually guess it's the former, when in fact it's usually the latter.


Serving Sizes!

If you've been looking for a way to ensure that you're not loading more than the proper "serving sizes" onto your plate, help is available:

Never fear: the Meal Measure is here!


On The Loose

Wednesday, March 6, 2013

He Could Be Anywhere!

Now that I have been writing this diabetes blog for five years, I have become increasingly aware that there is very little I can say about the subject that I haven't said already, and to avoid repeating myself endlessly I am always on the lookout for inspiration. My first resort is to look over the latest research, but that is becoming a bit of a dry well. Most diabetes research these days is not about gaining an understanding of diabetes, but rather about gaining funding for more research. By uncovering some new gene or some new hormone interaction, researchers create the impression that a "promising drug target" has been found and will lead to the next billion-dollar patent, if only the researchers get more grants. (The pharmaceutical companies are aware that most of this is hype, or even fiction, and are a bit angry about it actually, but it's the game they created and they have no choice but to keep playing it.) Anyway, I dutifully report on this stuff, but I know that most of it isn't going to change anything. So what else is there?

I also like to look over the Google search phrases that have led people to my site, just to see what kind of questions (and extreme confusions) people have about diabetes. Often those things give me ideas that I can expand upon. But today I found a search phrase that really stopped me in my tracks: "he's a type 2 impotent diabetic who left me and never returned".

Wow. It sounds like a literary contest: your challenge is to write a short story for which the opening line is "he's a type 2 impotent diabetic who left me and never returned". My goodness, the possibilities!

I picture this is as a scene from a hard-boiled detective story. The stunningly beautiful redhead with the haunted expression and the peculiar scar on her chin takes a seat in the office of the world-weary private eye, and that's the line she opens with. Her man is gone, and she wants him tracked down. Does she really want him back, though -- this impotent diabetic who left her and never returned? Or does she want something else? Revenge, perhaps? Or something of monetary value? Did he take something more from her than her heart? Should the detective trust her? (Clearly not.) Should the detective seduce her? (Clearly yes, if we want this story to sell.) But where does it all lead? Who else gets involved in this tangled plot before it leads to a terrible standoff between drug dealers and corrupt cops on the roof of the Dorothy Chandler Pavilion?

However, I have to assume that this search phrase did not arise as a result of a literary contest. Someone must have entered those words into the Google search window for a reason. But what could the reason possibly have been?

Under what circumstances would any human being open up a Google window and type "he's a type 2 impotent diabetic who left me and never returned"? Why would you run a search on that, and what on earth would you expect to find by running it? (Your ex-husband?)

Maybe what really worries me about this search phrase is that Google clearly thought that, whatever this person was looking for, my site was where they would find it.

Well, they're wrong. I'm not harboring any impotent diabetics on the lam here, folks. Look for him somewhere else!


Why Does It Happen?

Tuesday, March 5, 2013

Fat & Inflammation

Chronic inflammation has long been thought to play a role in the development of Type 2 diabetes, apparently because inflammation tends to degrade insulin sensitivity. Conditions as seemingly unrelated to blood sugar as periodontal disease have been found to be associated with heightened risk of Type 2 diabetes; if you have chronically inflamed gums (and I should mention that this is a problem I've been battling most of my life), the inflammatory response is setting you up to become diabetic.

Obesity also increases the diabetes risk, and you might think that obesity has nothing to do with inflammation... and yet it does. When you are carrying excess weight, you may develop inflammation in your fat tissue -- as if your fat cells were infected. When this happens, you are at risk for Type 2 diabetes.

But why, exactly? Researchers have been trying for a long time to figure out why obesity has anything to do with inflammation.

Well, it seems as if they've figured out at least part of the picture. Fat cells were once thought of as little more than storage jars for chemical energy; sugar went into them, and got turned into fat, and was saved for a rainy day, but that was supposedly all that happened; the cells didn't do anything. However, it turns out that fat cells are more active and sophisticated than previously thought. They exchange chemical signals with other cells. In particular, they exchange signals with the cells of the immune system; hence the problem with inflammation.

For reasons not yet understood, fat cells (adipocytes) respond to obesity by sending out a chemical distress signal known as major histocompatibility complex II, or MHCII. This is normally a signal indicating a viral or bacterial infection, and it jolts the immune system into action. When the fat cell sends out MHCII (and also leptin) in response to weight gain, this triggers the immune system's CD4 T-cells to release interferon gamma, which drives the inflammatory response, and converts M2 macrophages to their infection-fighting M1 form. Here's a pretty illustration of the process that accompanied the original research paper:

And here's the dumbed-down version that ScienceDaily came up with (if you ask me it adds embarrassment without adding clarity, but to each his own):

What the researchers haven't found yet is an explanation for why the fat cells would respond in this way to weight gain. What is the point of triggering inflammation as a response to obesity, especially if it creates new problems (such as diabetes) without solving an old one? That's the bit nobody understands yet.

What the researchers do understand is that they've found a new "drug target" -- if they can develop a drug which prevents the fat cells of obese people from generating MHCII, then they've got a drug that seemingly would prevent obesity from causing diabetes (without the patient losing any weight). How much they can charge people for a drug which prevents a disease they haven't got yet, I don't know. But medical research these days is all about finding drug targets, so that's just where researchers' minds go first. I'm more interested in the larger questions, though, so I hope those larger questions won't be entirely ignored.

My guess is that, if we ever do get the answer to the riddle, we are not going to find out that the fat cells respond to obesity by triggering an inflammatory response in order to achieve some particular goal. In a state of nature, obesity usually isn't common enough for the body to need a special strategy for dealing with it. Maybe the fat cells release MHCII when they are overfilled with fat, simply as an accidental byproduct of the way they function chemically. It doesn't necessarily mean anything; for all we know it just happens. Like a lot of other things in nature, it may happen simply because there isn't anything going on that will stop it from happening.

But if it turns out that it happens for an identifiable reason, I will be very curious to know what it is!


The Curious & The Confused

Monday, March 4, 2013

Unusual Diabetes Questions

When I review the internet searches which led Google to refer people here, I sometimes worry about the extent of people's confusion about very basic concepts involved in diabetes.

How about this, for example: "diabetic patient blood drop is attracted to ants"? I'd say that a drop of blood, whether it's from someone with diabetes or not, isn't going to be attracted to anything. It's possible that ants might be attracted to the drop of blood, though, if the blood is sugary enough. What we more typically hear about is ants being attracted to a diabetes patient's urine. (If blood sugar is seriously elevated, a lot of the sugar will pass through the kidneys and make the patient's urine sugary.) But, to reiterate, neither the blood nor the urine is attracted to the ants; it's the other way around.

And here's a seemingly related question, perhaps crafted by the same person: "when you start peeing glucose is it alot or just some drops". Huh? There isn't a special bladder that's just for glucose. If your kidneys are allowing glucose to be excreted (because there is too much glucose in your blood for the kidneys to re-absorb all of it), it goes into the same bladder as everything else that your kidneys release. The glucose is dissolved in your regular urinary output, not delivered separately. And, when your urine is sugary, you are going to produce a greater volume of it, because this causes an increase in osmotic pressure and therefore an increased fluid flow rate. Anyway, you're not going to be peeing drops of pure glucose from a separate spigot. So, get that image out of your head. (If you can, now!)

However, sometimes the questions people ask are a bit more thoughtful: "if blood sugar gets too low what mechanism restores it to normal". The reason hypoglycemia (at least if it's not medication-induced) is usually not life-threatening is that the body does have a pretty good mechanism for correcting the problem. When blood sugar gets too low, the pancreas releases a hormone called glucagon, which is more or less the opposite of insulin: it causes blood sugar to rise rather than fall, mainly by stimulating the liver to release some of the sugar stored in it. Without this mechanism to protect us, we would be at high risk every night of dying in our sleep from hypoglycemia. However, as with any safety mechanism, there's a potential for the mechanism to go too far, or not far enough, in correcting the problem. When it goes too far, you wake up in the morning with a high fasting glucose level, seemingly for no good reason. When it doesn't go far enough, you feel pretty awful: weak, shaky, clammy, anxious, and suddenly starving.

Here's a question that seems almost like a moral dilemma: "what to do when a diabetic is normally high but drops and is incoherent". You can feel the symptoms of hypoglycemia without being truly hypoglycemic, simply because your blood sugar is lower than it usually is, or dropping faster than it usually does. But if someone with falling blood sugar is actually becoming incoherent from it, my guess is he's seriously low and need an intervention. If he's not too far gone to understand you, offer him something sweet -- and pretty much wave it in his face. Here's hoping he responds. A friend of mine experienced a severe hypoglycemic episode once, and became not only incoherent but combative as well. This problem was ultimately solved when the space aliens who had crashed through his bedroom wall (actually they were fire-fighters who had walked through the bedroom doorway) held him down; his wife was then able to squirt a little cake-frosting into his mouth from a pastry tube, whereupon he suddenly became docile (and hungry for more of that lovely cake-frosting). I guess the moral is to address the issue as well as you can, and as soon as you can, while it is still possible for someone without previous wrestling experience to intervene. (Insulin, and sometimes other diabetes meds, can bring about a low this severe by overwhelming the protective mechanism I described earlier.)


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