Test Versus Test
Friday, May 31, 2013
Fasting Glucose: 89 mg/dl.
Glucose 1 hour after lunch: 108 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 112/73 mmHg, 67 bpm.
Exercise: 5.2 mile run.
When Tests Clash, Which One Is Right?
Here are two Google search-strings which seem to come at the same issue from opposite directions:
- "my a1c test shows i am not diabetic but my postprandial numbers show i am - go figure"
- "why is my glucose level normal and yet my hgb a1c at 6%"
A lot of people discover some kind of discrepancy (real or imagined) between their hemoglobin A1c test results and their glucose test results, and they want to know what the explanation for this can possibly be. (Naturally they are hoping it means they can ignore whichever test is giving them a less welcome indication of what is going on.)
A hemoglobin A1c test and a glucose test measure two very different things, and it is important for us to understand the distinction between them. Either sort of test might provide your doctor with a basis for diagnosing you with diabetes, but they aren't likely to cross the diagnostic threshold on the same day, so it is quite possible for them to appear to be in conflict, at least for a while.
First of all, let us face reality: the precise point at which diabetes is diagnosed is determined by arbitrary quantitative guidelines which have changed before and will probably change again. Any decision about where to draw the line is bound to reflect institutional politics (and, in the USA, the complicated relationship between the health-care industry and the insurance industry) more than it reflects biology. The line has to be drawn somewhere, and someone gets to decide where to draw that line. The person who gets to decide where to draw it isn't you or me. Let's not pretend that, once the line has been drawn, it has been magically transformed into a scientific fact rather than a bureaucratic compromise. Let's not become overly reverential of arbitrarily-chosen numbers.
Okay, with that disclaimer out of the way, let's compare what these two tests measure. The glucose test is a snapshot of what the glucose level in your blood was at a given time on a given day. But the glucose level in your blood is a constantly fluctuating quantity, so how do we extract any useful conclusions from it?
Generally blood glucose is tested in clearly-defined circumstances. The fasting test, which we take in the morning right after we wake up, happens after several hours of fasting and rest. At this point our blood sugar ought to have stabilized at its natural low point, and elevated blood sugar at that time is indicative of a problem.
The post-prandial test, which is taken after a meal, indicates how high our blood sugar goes in response to digesting food. The glucose peak usually occurs 50 to 60 minutes after eating, which is why I test after an hour, to see how high my peak gets. Most doctors these days tell people to test after two hours rather than one; I'm not sure what the rationale for that is, but probably doctors are concerned that in some people the peak is very prolonged. (In my case, the result is consistently lower after two hours, so I figure the main issue is to make sure the one-hour test isn't too high.)
The Oral Glucose Tolerance Test consists of a glucose test administered after a "glucose challenge" (usually in the form of 75 sickening grams of liquid glucose). It is taken for granted that your glucose will shoot up to an unusually high peak after something like that; the idea is to see how high that peak is. This test is used as a diagnostic test, in the hope that the glucose challenge will uncover a tendency toward post-prandial hyperglycemia which might otherwise be missed.
All these versions of the glucose test merely tell you what your glucose level was at a single moment in time. The trouble with that is it's hard to know what to make of one momentary position of a moving target. A glucose test might give a result which is not typical for you, if you're having an unusually good or bad day. So, if you think you know what your glucose test result is saying, how do you know that result doesn't reflect an unrepresentative moment?
That's where the hemoglobin A1c test comes in. It measures the glycation level (that is, the sugar-contamination level) of the hemoglobin in your red blood cells. Unwanted sugar accumulates on hemoglobin like rust. The more sugar your hemoglobin has been exposed to during the lifetime of your red blood cells (which last about three months before the body recycles them), the more glycated they will be. The result of the A1c test is regarded as a good basis for estimating average blood glucose levels during the previous three months.
So, we have glucose tests (which reflect a single moment) and hemoglobin A1c tests (which reflect overall trends over time). Each kind of test has its place. Glucose testing is far more useful in terms of day-to-day diabetes management; if you want to know how an allegedly low-glycemic food actually affects your blood glucose, a glucose test is the only way to find out. But if you want to know how good your diabetic control is throughout the 24-hour cycle (including all those times when you're not testing -- such as at 3 AM), the A1c test is the one that won't be fooled by short-term volatility.
If your A1c test result is better than your glucose test results, it probably means that you spike pretty high after a meal but you recover quickly, so your average blood sugar isn't too bad (at least so far!).
If your A1c test result is worse than your glucose test results (which is more common), it indicates that your blood sugar is probably going fairly high at times when you're not testing.
Also, for reasons which haven't been entirely figured out yet, the relationship between A1c result and average blood sugar seems to be somewhat different in different people. It appears that, in terms of assessing the health risk presented by diabetes, it is more realistic to believe high A1c results than lower glucose results.
Anyway, the relationship between these two kinds of test results is quite indirect, and in the earlier stages of diabetes they can seem to be sending contradictory messages.
Wednesday, May 29, 2013
Sorry -- out of town today, got home late, must go to bed, must sleep.
Thursday, May 30, 2013
Fasting Glucose: 91 mg/dl.
Glucose 1 hour after lunch: 131 mg/dl.
Weight: 191 pounds.
Blood pressure, resting pulse: 120/72 mmHg, 62 bpm.
Exercise: 5.4 mile run.
My Very Tense Day
Stress is one of those problems which is easy to talk about, and not so easy to do anything about. I know because this was a stressful day for me. It was one of those very special days we have at my company from time to time, when layoffs are occurring and everyone has to go into a meeting room with their supervisor to find out if they still have job or not.
It turns out I still do. Perhaps you're thinking: well, fine -- no problem! The stress should have gone away instantly! But stress doesn't seem to operate that way. I was still feeling a lot of tension long after the conference with my boss this morning. Some of my stress symptoms faded after that (the cold sweaty hands, for example), but I still felt very tense and anxious -- I seemed to feel my blood pressure rising, and a peculiar feeling in my shoulders and neck which I have learned to think of as a stress symptom (I can't describe it, I can only recognize it).
I tried to get rid of the feeling. At lunchtime I did the hardest run I could make time for -- a course with some brutally steep climbs. It made me feel only a little bit better, and the post-prandial result of 131 mg/dl after lunch seemed high for what I had eaten and the workout I had done. (Exercise tends to boost insulin sensitivity -- but stress tends to suppress it, and I think in this case stress won out, at least to some degree.)
I still felt very keyed up. Part of the reason was that I didn't yet know the fate of someone else I was partnering with on my current project. I was deeply afraid that they would get rid of him, and then I would somehow do everything he had been doing. To my surprise, that didn't happen either; by 3 PM I found out that he would still be working with me. But that didn't end the stress either.
I remembered that there was a blood-pressure machine in Building 2, and I figured I might as well stroll over there and see what kind of reading I got on it. The answer turned out to be 138/82. Not stratospheric, but higher than usual for me. After dinner, it would be down to 120/72, so I did manage to ratchet down my stress level eventually.
Exercise and rest breaks and breathing exercises help me reduce my stress level, but they certainly aren't magic cures; it's not as if they make the stress go away entirely. Once your body has been driven into a stress response, it's going to take some time for you to get over it, and we just have to live with that as best we can.
Type 2 Diabetes As A Label
I have suggested many times that "Type 2 Diabetes" might simply be the label we have chosen to give a collection of diseases which are similar in their impact on physiology but could have different causes (and might respond to different treatments). It turns out that I'm not alone in thinking this.
One diabetes specialist, Edwin Gale, has written an editorial in The Lancet arguing that "Type 2 diabetes is a disease in search of a definition. It has no hallmark clinical features, is generally diagnosed by default (no other cause for diabetes being evident), has very heterogeneous pathophysiological features, and varies widely between populations in clinical presentation and consequences".
In other words, if someone has elevated blood glucose, and we've established that they don't have Type 1 (that is, their pancreatic glucose production hasn't been killed off by an immune reaction), then they have diabetes caused by something other than that. And in that case, we say that they have "Type 2", as if we meant something specific by it instead of "not Type 1"!
Doctor Gale thinks using the term Type 2 diabetes implies that we are talking about a single disease with a single cause, for which there is a single best treatment. Which can't be the case, because Type 2 patients differ too much.
He proposes that doctors should refer to Type 2 diabetes by a more generalized term: idiopathic hyperglycemia. Your first reaction might be that this doesn't greatly clarify matters, but to a doctor it does. "Hyperglycemia" means "abnormally elevated blood glucose", and "idopathic" means "of unknown cause". His hope is that, if doctors use a very broad term such as this, instead of using a specific-sounding one such as Type 2, they will be constantly reminded that there might very well be different forms of this problem, requiring different therapeutic approaches.
I don't know if this kind of name change will ever happen, or will help if it does, but I have felt for years that the "Type 2" label created a false appearance of specificity. I'm glad to know that at least some diabetes experts agree.
How Long Can You Hold It?
Tuesday, May 28, 2013
Fasting Glucose: 84 mg/dl.
Glucose 1 hour after lunch: 109 mg/dl.
Weight: 191 pounds.
Blood pressure, resting pulse: 123/76 mmHg, 54 bpm.
Exercise: 4.1 mile run.
Your Urine Questions Answered!
A lot of the Google search strings I'm seeing lately are very urine-centric. Let me take up a few of them tonight...
- "peeing clear alot normal blood sugar"
- "peeing all the time low blood sugars"
- "cant stop peeing clear but no high blood sugar"
- "blood sugar is normal but urinating alot"
The word "diabetes" by itself refers to excessive urination (only "diabetes mellitus" means "frequent urination that is a consequence of elevated blood sugar"). Still, because "diabetes mellitus" is such a common problem, doctors usually truncate it to "diabetes", unless they intend to refer to some other source of urinary problem. This has resulted in some confusion, of course.
Because of the notorious linkage of polyuria (excessive urination) with diabetes mellitus, many people assume that only the latter can be the cause of the former. Therefore, they think it is mysterious or even paradoxical if they are non-diabetic (at least in their own opinion) yet still have to hit every rest-stop on the way to Los Angeles.
Well, diabetes mellitus is not the only disorder which might cause overproduction of urine. A pituitary disorder known as "diabetes insipidus" (which has nothing to do with elevated blood sugar) can also send you to the bathroom with embarrassing frequency. And so can a long list of other diseases -- disorders of the kidneys, disorders of the immune system, disorders of the endocrine system, and disorders of the everything else. Lupus erythematosus, aldosteronism, Sjogren's syndrome, interstitial nephritis, glomerulonephritis, hypokalemia, acromegaly, polycythemia, hypogonadism, hyperthyroidism, hypoxia, cirrhosis, hypovolemia, migraine... and many more! (Also there's this thing called pregnancy, which can do it to you as well.)
So, excessive urination is one of those symptoms which typically indicates one problem, but could also indicate a few dozen others. You can't just assume (on the basis of casual research) that you know what the explanation is. You have a consult an honest-to-goodness diagnostician about a symptom like that. To the doctor with you!
- "average time between peeing for non diabetic"
Excessive urination is usually defined in terms of urine volume over time, not in terms of elapsed time between walks down the hall. The reason for this is that the feeling that we "have to go" is extremely subjective and is influenced by psychological and other factors; you might go twice as often as me without actually producing significantly more urine. (If you are pregnant, you might have to go more often simply because your bladder is now being crowded and compressed by the baby, and not because your are actually producing more urine than you did before.)
Exactly how much urine volume counts as excessive? I've found the numbers given differently in different places. The Merck Manual says >3 liters per day; NIH's MedlinePlus says >2.5 liters per day. To me even the latter figure seems like quite a lot, and I don't think I'd have to get above >2.5 liters before I'd start wondering what was up. I'd suggest that any striking increase above what you're used to producing is worth looking into.
- "if you are urinating a lot from diabetes will your urine be clear"
Probably so, but I would not read too much meaning into the color. If you are becoming dehydrated from excessive urination, your urine may become rather dark regardless of what else is going on, so a dark tint should probably not be taken as reassuring evidence that diabetes has nothing to do with it.
- "following diet now i am not peeing alot am i reversing the diabetes"
Urine productivity is not exactly a precise or reliable indicator of how high your blood sugar is. Probably your blood sugar isn't as elevated as it was before, if you're producing less urine than formerly, but that doesn't mean it's normal. If you want to know how well you're controlling your diabetes, you really have to test your blood. Your bathroom schedule doesn't answer the question.
- "normal blood sugar but urine is eaten by ants"
- "ants attracted to my urine is it diabetes"
- "can ants perch on my urine in the absence of diabetes"
- "when your urine attracts bees"
- "what does it mean if ants swarm your pee"
It's pretty clear to me that large numbers of people are fascinated by, if not downright obsessed by, the idea that they might be able to diagnose themselves as diabetic (or non-diabetic) by placing their urine in front of a kind of focus group in which the judges all have six legs each.
It ought to go without saying that this is an even less precise and reliable indicator of blood sugar than urine volume is. I don't know what insects might look for in a puddle of urine besides sugar, but surely water might be one, so if ants "eat" your urine, they might be quenching their thirst rather than satisfying their collective sweet-tooth.
Still, if ants really do "swarm your pee" (or "perch on your urine", which I have to admit is a beguiling mental image), it is worth getting your blood checked, just to see if you have a problem. I wouldn't give insects the final word on this. Most of them haven't even done pre-med, much less a full internship.
Craziness As A Tool;
& What A1c Means
Friday, May 24, 2013
Fasting Glucose: 90 mg/dl.
Glucose 1 hour after lunch: 108 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 125/72 mmHg, 59 bpm.
Exercise: Gym workout: strength-training & aerobic.
Be Aware, Ricepuller!
Sometimes I actually read the comments sections on YouTube videos, because some of them are written by clinically insane people and their thoughts are occasionally very original.
For example, there's this commentary on an interview with the movie director Werner Herzog:
"if you cannot heal the narcissistic psycho whoms perception does not differ between his toothbrush or his own daughter in an empathic way pushing out the least that would finaly draw a more or less likely faint association with human being is the best you can do. white ink is the worst choice to emphasize on white paper. the thread of being the one out of two most likely engaged in operating a 308winchester who does anything but touching a trigger? would be appropriate concerning my first point."
One thing that tells us is that not all insane people write in block capitals. Most do, however, including this person who was responding to a video about Japanese cooking:
"BE AWARE RICEPULLER, LPMPMMMNMIRROR, EICBOTTLE, 20NAILTOTOISE, SANDBOASNAKE,OWL-PEHENEGG,REDpyaz,TARMINDPULP,PALASHTREE,8METALHEATERSTATUE,DIPMONEY, LILIPUT, GLASS, BLACKTARMIND,Rs1-2.5-5-10-20-100,MILLIONDOLLARFAKECURRENCY, ANTIQUE, CAMEL RACE+SEX OF CHILDREN,ADV.NEWSPAPER-MOBILE ROBBERY,CHAINLINKSCHEME-RCM-EMBAYFOOL AND ALL RUMOURS OF WW W.RICE-PULLER.C OM & CALL SMUGLER GANG RAPER DISHONST CORRUPTED COMPUTER &TECHNOLOGY SPECIALIST ENGINEER? DIVESH BHATT 9 TO 12 PM"
At least we know when to call him.
Anyway, I was thinking that prose of this sort could be used as kind of non-invasive diabetes test. People who don't want to test their glucose because they hate pricking their fingers, but who nevertheless would like to have some kind of warning when they have got very far out of the normal range, could simply keep a card in their wallets with the paragraphs quoted above printed on it, and try reading it every few hours.
If it makes sense to you, report to the emergency room immediately. When they ask you what's wrong, hand them the card and say, "This really speaks to me."
Who Put the "A" In "A1c"?
Of all the confusions people tend to have about the Hemoglobin A1c test, you'd think the one they would be least worried about is where that name "A1c" comes from. And yet, if Google search strings are any indication, a lot of people are quite puzzled about this question. Why "A1c" and not "8Zf", or "pooziwinkle" for that matter? Seemingly they could have called it anything. So why did "A1c" seem like just the right name, to whatever committee of geeks managed to seize the naming rights on this thing?
Well, as biochemical science has gradually become more sophisticated over the years, it often has happened that a component of the blood which was originally assumed to be a single, uniform substance has turned out to exist in many different forms, with differences between them which were originally too subtle to be detected. Hemoglobin, a crucial protein found in blood, is an example of this phenomenon. The basic, common form of hemoglobin was just a starting point. As variations of it were discovered, they were given abbreviations. "Hemoglobin" was abbreviated "Hb"; if you are about to complain that "Hg" would have made more sense, be aware that Hg was already being used as the element symbol for mercury. (And if Hg seems like a pretty strange abbreviation for mercury, be aware that it comes from the Greek name for the substance, hydrargyrum -- literally water-silver.) The "subfractions" of hemoglobin (that is, the variations on the basic hemoglobin structure which can be distinguished because they differ in mass, charge, or other properties) were given letter designations. As more subfractions were discovered, the number of letter designations had to be expanded.
The most common form of hemoglobin turned out to be a specifically adult form of hemoglobin; babies are born with a different variety of the stuff, and as they grow up it is mostly replaced by the adult version (though adults continue to have a little bit of the newborn version along with it). These two variations on hemoglobin came to be called HbA (for "adult") and HbF (for "fetal").
However, that wasn't anywhere near the end of the story. HbA may have been the "adult" version, but it wasn't the only adult version. In some adults, especially if their ethnic background wasn't European, the HbA was combined with other variations which, as they were identified, were given other letters. So, we now know about the existence of HbB, and HbC, and so on up the alphabet. But the most common variant was designated HbS, because it was associated with "sickle cell" anemia.
Meanwhile, the common adult form known as HbA turned out to be divisible into many subfractions and sub-subfractions, which could be separated out from one another using various kinds of tests.
An especially interesting sub-subfraction of HbA was the one which happened to be designated HbA1c; this one was fairly easy to separate out from other forms of HbA because it had a different charge. And what else was different about HbA1c? It was "glycated" -- it had a glucose molecule bonded to it. Specifically, it has a glucose molecule bonded to "the N-terminal valine of the hemoglobin Beta chain" -- and we all know what a sensitive area that is, to have anything undesirable stuck to it! Man, when I have anything stuck to my N-terminal valine, I can't just think about somehting else and pretend nothing's wrong.
Because HbA1c was sugar-coated in this way, researches understood that the abundance of the HbA1c subfraction might be a good indicator of how sugary the blood has been lately. Subsequent investigations confirmed this. The abundance of HbA1c is now regarded as a reflection of average glycemic control over the past three months (red blood cells are recycled after three months, so the test doesn't reflect conditions farther back).
There are some complicated problems involved in all these variations on hemoglobin, which different people have in different amounts. This may be the reason that different people with seemingly similar levels of glycemic control can get different results on an HbA1c test. Ideally, patients should be tested to see exactly which forms of hemoglobin they have, and in what proportions, because this might be a necessary first step toward interpreting HbA1c test results reliably.
For now, that level of sophistication is not being applied. Most of us take an HbA1c test and hope that the kind of hemoglobin we have is close enough to the standard model for the standard interpretation of the test results to be valid.
Finally: An Approved Test!
Thursday, May 23, 2013
Fasting Glucose: 85 mg/dl.
Glucose 1 hour after lunch: 103 mg/dl.
Weight: 189 pounds.
Blood pressure, resting pulse: 120/72 mmHg, 57 bpm.
Exercise: 5.2 mile run.
A1c Testing As A Diagnostic Tool
The FDA has finally approved the hemoglobin A1c test -- or at least one version of the A1c test -- for use as a tool to diagnose diabetes. The test and lab equipment which the US Food and Drug Administration has endorsed for this purpose is the "Cobas Integra 800 Tina-quant HbA1cDx Assay", made by Roche.
Immediately you're thinking: wait a minute. Haven't doctors been using the A1c test in this way for years? Well, if you want to drag reality into this, yes, a lot of them have been. But, strictly speaking, they're not supposed to. Official medical organizations of various kinds have been slow to give their blessing to the A1c test as a diagnostic tool, and many doctors diagnose diabetes using oral glucose tolerance tests and fasting glucose tests... for reasons which are not entirely clear, at least to this exasperated spectator. Blood glucose concentration is a notoriously volatile quantity, and glucose tests are notoriously prone to missing diabetes, perhaps because patients often fast stringently before a lab test (and on no other day of the year). The glucose tolerance test is somewhat more reliable, because at least it challenges the patient with a sudden large intake of sugar. But glucose tolerance is also volatile, and the patient might be tested on a day when their system is more ready than on most days to take on a challenge.
The whole point of the hemoglobin A1c test is that it is not volatile. What happened the day before the test has almost no impact on the result. The A1c result (a measure of how much of the hemoglobin in your blood has been "glycated", or sugar-encrusted) reflects average conditions in your blood over a period of about three months before the test was taken. In other words, the test assesses the impact of steady, accumulated sugar-encrustation on your proteins; it cannot be thrown off significantly by your having a good day or a bad say. It is, therefore, the test least likely to miss diabetes if you have it.
The reasons why it has not already been universally adopted as the standard diagnostic test for diabetes are unclear, at least to me, but it may be partly because there are various ways to conduct an A1c test, and the FDA has never evaluated any of them as being accurate enough to rely upon for diagnostic purposes. Well, now the FDA has authorized Roche to advertise their A1c test as an FDA-approved diagnostic test for diabetes. Presumably the FDA will endorse other tests eventually, and the Roche version happens to be the one they approved first.
I think that the understanding of the A1c test as an accumulative test, which cannot be thrown off by a brief fluctuation, is not universal. In search strings I see in my website statistics, I find a lot of A1c questions which indicate that people have no idea how the test works. Lots of people ask whether "stress" can make the test read high (only if stress makes your blood sugar go up, and this happens to you often), or whether taking insulin on the morning of the test is all right (hard to imagine how it could have any measurable effect).
I read a study once, conducted at a hospital in Boston, which involved giving the A1c test to everyone who checked into the hospital, regardless of why they checked in and regardless of whether they were thought to be at risk for diabetes. The results was that quite a large number of them had undiagnosed diabetes, because they still hadn't failed a blood glucose test. A year later, many of them still hadn't been diagnosed, because they still hadn't failed a blood glucose test. That's a pretty creepy consequence of not using the A1c test as a diagnostic tool: a lot of people end up being diagnosed late, after the disease has had a lot of opportunity, over the course of a year or more, to cause trouble.
The sooner you find out you have diabetes, the sooner you can do something about it, and the more likely it is that you can do something about it which will work. If the A1c test gives us our best shot at uncovering a hidden case of diabetes, then I am glad that the FDA is finally authorizing the A1c test for this purpose.
Wednesday, May 22, 2013
Fasting Glucose: 96 mg/dl.
Glucose 1 hour after lunch: 104 mg/dl.
Weight: 189 pounds.
Blood pressure, resting pulse: 117/71 mmHg, 64 bpm.
Exercise: 5.4 mile run.
I didn't like getting a fasting result over 95, so I made sure I did a challenging, hilly run at lunchtime, and had a low-carb lunch afterward. The outcome was a post-prandial test result of only 104.
It isn't about steering the ship in a straight line, it's about making the right course-corrections.
What Is Borderline Diabetes?
I see a lot of Google search strings in my site statistics which suggest people are very curious about that mysterious twilight zone, that no-man's-land, between normal glycemia and diabetes, known as "borderline diabetes" (or sometimes "prediabetes"). What goes on in that forbidden territory -- and if you stumble into it, can you hope to stumble back out?
- "what does borderline diabetic mellitus mean"
- "what is a borderline a1c score"
- "once a1c level reaches 6.2 can it return to normal"
- "does one a1c result over 6.0 mean you're a diabetic"
Some of this anxiety arises from "reification" -- the tendency to treat a purely abstract, statistically-defined concept as if it were an actual object existing in the world.
The most famous, and probably most successful, example of reification to date is "IQ". This rough assessment of a child's rate of learning compared to peers (invented for use as a screening tool to identify children with dyslexia) has become transformed, as if by magic, into a permanent biological limitation on adults. It is assumed to determine which individuals (or, to be more candid about it than is customary, which ethnic groups) are worthy. IQ has figured significantly, but largely behind the scenes, in the current political battles over immigration reform (the idea is that we mustn't let in the sort of people who tend to have low IQs). So successful has the reification of IQ become that most educated people, even if they think IQ scores shouldn't determine who has human rights, nevertheless take it for granted that IQ is an actual, existing thing, and that everybody's got one, and that their children will inherit it. Seldom has a concept so questionable triumphed so completely.
Other things which seem to be examples of reification are the inflation rate and unemployment rate -- both of which are related to actual phenomena, but both of which are defined and redefined constantly, through processes which are more or less political in nature. (How many of the people who aren't working count as "unemployed"? Somebody other than you gets to decide that.) Most of us are aware of these limitations, yet we talk about these numbers as if they were concrete objects whose existence could not be doubted.
"Borderline diabetes" and "prediabetes" (and, in a way, Type 2 diabetes in general) are reifications: mathematical abstractions which, by convention, we talk about as if they were actual objects.
The concept of "borderline" diabetes seems to me an especially unhelpful example of reification. The idea is that, if you're going to define diabetes as abnormally elevated blood sugar, then you have to decide how much abnormally elevated blood sugar it takes to qualify for a diabetes diagnosis. That magic number is chosen arbitrarily, and has changed before, and may change again. But until you hit that magic number, you remain (supposedly) on the borderline, not quite normal and not quite diabetic. This implies that the difference between borderline diabetes and honest-to-goodness diabetes is a difference in kind, not a difference in degree. And that isn't remotely possible.
It would be a miraculous coincidence if borderline diabetes and diabetes were separate diseases with separate causes, yet everyone who had the former disease eventually got cured of it, on the same day that he developed the latter disease. Who could possibly buy this story? It is perfectly obvious that borderline diabetes is simply the name that has been given to an early stage of Type 2 diabetes.
By the time your endocrine system is having any kind of detectable difficulty in keeping your blood glucose levels within normal bounds, it is clear that something is going wrong with glycemic regulation in your body, and diabetes is the catch-all term we apply to such a problem. The potential causes of this problem haven't been thoroughly explored, but once the problem has developed to the point that evidence of it is detectable, it tends to be pretty well established as a persistent personal characteristic. One can manage it -- but one cannot stop managing it. You will not necessarily remain "diabetic" forever; you certainly might be able to regain a normal or nearly-normal range of glycemia. But maintaining that happy state of affairs is going to demand care and effort for the rest of your life. You now know that your body, left to its own devices, has a tendency to become diabetic -- and you must constantly steer it away from that default destination.
The conventional diagnosis points for a diabetes diagnosis are a hemoglobin A1c result of 6.5 or a fasting glucose test of 126 mg/dl, but that doesn't mean elevated results which haven't quite reached those diagnosis points should be regarded as anything other than diabetes -- diabetes identified at an early stage, and therefore diabetes unusually susceptible to being brought under control -- but diabetes all the same.
Allergies & Ignorance
Tuesday, May 21, 2013
Fasting Glucose: 91 mg/dl.
Glucose 1 hour after lunch: 113 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 114/72 mmHg, 57 bpm.
Exercise: 4.6 mile run.
Allergies: Looking On The Bright Side
It was warm but windy day, and after I returned from my daily run my eyes were irritated just enough to remind me that the wind was really stirring up the pollen out there. But my eyes weren't that irritated -- for example, I wasn't finding it intolerable to wear my contact lenses. And it dawned on me how much better things are now for me, in one area of my health.
I live in Sonoma County, California, which is said to be one of the great allergy capitals of the U.S., especially in terms of the variety of pollens represented. Whatever kind of pollen you're allergic to, your odds of finding it here are excellent. Which is potentially a problem for me, as I have suffered from spring allergies since I was a young child.
When I was eight, my allergies took the form of asthma serious enough to hospitalize me for a couple of weeks. A long treatment with injected allergens greatly reduced the impact of my asthma in subsequent years. The less alarming, but very annoying, allergy symptoms affecting my eyes were more persistent.
It was after I moved to Sonoma County that I was diagnosed with diabetes and started my exercise program (which I have been doing steadily for 12 years now). As most of my exercise has been done outdoors (running, cycling, or hiking), I have logged a lot more hours outdoors than I ever used to before I was diabetic. And the result seems to have been a gradual diminishment of allergy symptoms, season after season. I still take Claritin (or rather generic Loratadine, which costs less) during my problem period (April through mid-June), but I'm really not having a lot of allergy trouble anymore. A few bad days here and there -- but by "bad days" I mean swollen eyes, not heavy wheezing. I can still run. I can run up steep hills, even. I may not be loving it, but I can do it.
Apparently all this outdoor exercise has caused my body to become gradually acclimated to the pollens that are blowing around out there, and over time I react to them less and less.
We are so used to thinking of health that can only get worse, never better, over the years. We need to appreciate any improvement we can manage to make.
Are They Dumbing It Down Enough?
A JAMA article looked into the readability of patient education materials from various medical specialties, and concluded that they aren't easy enough to read. Their assumption was that such materials need to be written at a sixth-grade level, at least for American patients, who can't handle anything more intellectually challenging than that. Alas, most patient education materials haven't been dumbed-down to that level!
And here I was, thinking most patient education materials are dumbed-down too much as it is. Look, health involves biology, and biology is complicated! There is a reason why endocrine disorders were not covered in "Fun With Dick And Jane". There is a reason why Mister Rogers never turned encouragingly to the camera and said, "Can you say hyperinsulinemia, boys and girls? Yes, I thought you could!". By the time we're in a position to have to manage our Type 2 diabetes, we ought to be great big boys and girls who don't run screaming from the room when we encounter an unfamiliar technical term which can be Googled in seconds if we don't know what it means.
I'm inclined to feel that presenting technical information in dumbed-down form is nearly always self-defeating, because the simplified version usually doesn't make any sense, and therefore is neither convincing nor memorable. Instead of deciding that technical concepts can never be understood by the reader, the right approach (as I see it) is to take the time to explain those concepts. My readers seem to understand what I'm telling them. Admittedly, my readers are self-selecting and those who don't understand what I'm telling them will probably move on. But I can't help feeling that it's better to explain complicated issues than to dismiss them as unexplainable, and hand the reader something which is simple (yay!) but largely false.
I am sometimes obliged to face the fact that, without intending it, I have been oversimplifying matters myself. Every time biologists take a closer look at a seemingly simple issue, such as what effect insulin has on cells, they discover immense complexity underlying the generalizations. Some researchers in Australia decided to take a closer look at what effect insulin has on just one type of cell (adipocytes, or fat-storage cells). They uncovered amazing levels of complexity in this. The cells contain thousands of different proteins, and they have regulatory interactions with one another using various processes, one of which is called "phosphorylation" -- that is, phosphate molecules are grafted onto proteins at special sites, to convey information or alter the functioning of the protein. The researchers identified 37,248 phosphorylation sites, on 5,705 different proteins, within these cells. Of those sites, 5,587 changed in response to insulin stimulating the cell!
So, in just one type of cell, insulin triggers changes in more than five thousand different proteins.
You can't discuss processes as complex as this without resorting to some degree of simplification. I admit that. But there have to be some limits to how far you are willing to push the simplification process. "Fun With Dick And Jane" is pushing it too far.
If Americans can't read at an adult level, the solution is not to write medical information on a child's level. Perhaps Americans can listen at an adult level. If the problem is literacy, the patient education materials should be in audio or video form. But I still cling to the belief that people can understand a complicated idea, even when it's described in writing, if it is described by a patient person who actually cares about being understood and is interested in what he's writing about. I like to think of that as my advantage over the people who are writing dumbed-down crap because they don't think patients deserve (or at least can handle) anything better.
Patents & Parties
Monday, May 20, 2013
Fasting Glucose: 94 mg/dl.
Glucose 1 hour after lunch: 128 mg/dl.
Weight: 189 pounds.
Blood pressure, resting pulse: 113/73 mmHg, 58 bpm.
Exercise: 5.2 mile run at lunchtime; yoga class in the evening.
Another Unfinished Tale
It's becoming a whole new literary genre for me: articles which I don't read past the intriguing opening line, because I fear that reading further would only ruin it: "SAN DIEGO, California — Not every man wants a bit of cow grafted to his penis, but hundreds of patients have found the experience satisfying, a new study shows."
If, for some reason, you want more detail than this ("just how much of the cow are we talking about?"), the answer is here.
Patents On Genes
The insanity that is American intellectual-property law has reached some kind of absurdist extreme with the notion that genes can be patented.
News flash: genes existed before biologists knew anything about them. Nobody invented genes. Living organisms have had them for a few billion years now. The idea that a gene can be anyone's "property" is a joke -- and not a very good one. Maybe you can win a prize for discovering it, but if you think you own it, there is something seriously wrong with you.
This has not stopped corporations from claiming ownership of genes, and there can be a lot of money in doing that, if you pick the right genes. Myriad Genetics picked the right genes (called BRCA1 and BRCA2); defects in these genes greatly magnify the risk of certain cancers, particularly breast and prostate cancer. Angelina Jolie, after testing positive for the dreaded BRCA2 defect, recently had a precautionary mastectomy, and there has been tremendous publicity about this -- much to the delight of Myriad Genetics, which holds the patent on the gene in question. If you want to be tested for that gene, you have to pay whatever Myriad Genetics wants you to pay for the test, because nobody else is offering it. And guess what? The test is expensive! Who would think that would happen, in the absence of competition? Yet it did. Getting yourself tested for the BRCA2 gene will run you $3000 to $4000. Angelina Jolie can afford that. Can you? Oh, really? Well, too bad.
So far, Myriad Genetics has not sued any breast cancer patients for reproducing unauthorized copies of "their" gene, but I guess that will be Phase 2. For right now, Myriad Genetics is trying to defend its patent at the Supreme Court level. Angelina Jolie's announcement triggered a jump in Myriad Genetics' stock price, and may very well help their court case; a health activist named Mike Adams accused her of acting as a hired gun for the company. I'm not sure she's that hard up for money, but it would not astonish me that the company might be helping fan the flames of publicity for their own purposes.
Anyway, it seems to me that understanding genetic variants is so crucial to treating many disease (diabetes certainly included) that we cannot afford to be granting ownership of them to whatever corporation has the best lawyers. "Ownership" is not supposed to consist of arrogance plus a legal team.
Nobody owns genes. And if the Supreme Court says otherwise, we'll know that they're even more senile than they appear.
I went to a really good party on Saturday, with a bunch of Irish musicians. Food and snacks first, but by around 8:30 we were gathered in a big circle in the big living-room, playing away. And having more wine. And playing more tunes. And having more wine. And continuing in this mode for another five hours or more. Time has no meaning at a good music session. You notice a few people leaving, and you look at your watch and think, my goodness, we're not much short of 2 AM, maybe it's almost time to go home. (And I didn't drive home, by the way -- my hosts live about a third of a mile from me, and their parties are so good that I like to take advantage of the fact that I'm staggering distance from their place.)
Well, I'm here to tell you that there are easier things in this world than to get up, the morning after a big party like that, and go for a 5.3 mile run on extremely steep hills. But I did it.
You don't have to give up everything for diabetes, but you have to be very aware of the tradeoffs you're making to balance the requirements of staying alive against the need to have something to stay alive for.
Sat-Fats & Fraidy-Cats
Friday, May 17, 2013
Fasting Glucose: 95 mg/dl.
Glucose 1 hour after lunch: 119 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 117/73 mmHg, 62 bpm.
Exercise: 5.2 mile run.
What Links Saturated Fat & Heart Disease?
There's a saying that, when it comes to potential risks to human health and safety, science can issue an indictment but cannot dismiss the charges.
Once suspicion has fallen on something as possibly dangerous (electromagnetic fields from power lines cause leukemia! vaccinations cause autism!), it doesn't really matter whether later, more thorough investigations find no such cause-and-effect relationship. Once people have experienced a fear response, they don't let go of it. They simply develop new rationalizations for clinging to the old fears. The studies that found no danger must have been bought and paid for by evildoers among us who don't want us to know the shocking truth about power lines and vaccinations! Anyone who doesn't buy our conspiracy theory must be part of the conspiracy!
Because that tendency to cling to a fear response is so strong, it can take a very long time to dethrone a this-thing-causes-that-problem claim, once it has become widely accepted.
For decades now, we have been told that saturated fat in the diet is bad for us, because it promotes high serum cholesterol, which promotes arterial plaques, which promote coronary heart disease. If you had a heart attack, it's because you ate too much saturated fat.
The evidence for this was never very strong, and certainly never very direct, and promoters of the idea seem to have prevailed more through superior skill at academic politics than for any other reason. Scientists have been pointing out this problem for many years, but the situation has not changed much, at least in terms of anything visible to the general public. We are still being urged, constantly, to cut saturated fat from out diets to keep our hearts healthy. And our definition of a "healthy" food is still, after all these years, any food which contains little or no saturated fat (even if that food is loaded with starch, which is probably what we ought to be cutting, even if we don't have diabetes).
The case against saturated fat has been based on two correlations:
- High dietary saturated fat correlates with high serum cholesterol (especially if you cherry-pick the studies you look at, to maximize this effect).
- High serum cholesterol correlates with high risk of coronary heart disease.
The assumption has been that the first of these correlations directly drives the second. We can eliminate the middle-man, and assume that high dietary saturated fat is the cause of coronary heart disease.
An article in Advances in Nutrition by Glen D. Lawrence argues that these assumptions don't stand up very well under close examination. Lawrence states that "the meager effect that saturated fats have on serum cholesterol levels when modest but adequate amounts of polyunsaturated oils are included in the diet, and the lack of any clear evidence that saturated fats are promoting any of the conditions that can be attributed to PUFA, makes one wonder how saturated fats got such a bad reputation in the health literature." My goodness.
I should mention that PUFA means poly-unsaturated fatty acids, which differ from saturated fats in terms of how their carbon atoms are bound together (and I absolutely refuse to go into the details). Apparently having the wrong kind of PUFAs in your blood can be harmful, and it is beginning to look as if that is a much more worrisome issue, in terms of heart disease, than saturated fat, which has been forced very unfairly to take the blame for problems which it may not be playing any role in causing. Lawrence argues that PUFAs and carbohydrates are more likely to be the real culprits.
"Various aldehydes produced in the oxidation of PUFAs, as well as sugars, are known to initiate or augment several diseases, such as cancer, inflammation, asthma, type 2 diabetes, atherosclerosis, and endothelial dysfunction. Saturated fats per se may not be responsible for many of the adverse health effects with which they have been associated; instead, oxidation of PUFAs in those foods may be the cause of any associations that have been found. Consequently, the dietary recommendations to restrict saturated fats in the diet should be revised... It is time to reevaluate the dietary recommendations that focus on lowering serum cholesterol and to use a more holistic approach to dietary policy."
Of course, this argument doesn't leave us with any clear, simple rules about what to eat and what not to eat. But it does suggest that, whatever we do about potential dietary causes of heart disease, cutting saturated fat does not seem to be especially useful, and we need to move on from dietary recommendations based on alarmist conclusions drawn from weak evidence.
Some Brief Reports
Thursday, May 16, 2013
Fasting Glucose: 87 mg/dl.
Glucose 1 hour after lunch: 103 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 118/71 mmHg, 58 bpm.
Exercise: 4.1 mile run.
Another Statin Side-Effect!
I've heard about statin drugs (for cholesterol) causing various sorts of problems, but here's a new one, as reported by John Thyfault, associate professor of nutrition and exercise physiology at the University of Missouri:
"Fitness has proven to be the most significant predictor of longevity and health because it protects people from a variety of chronic diseases. Daily physical activity is needed to maintain or improve fitness, and thus improve health outcomes. However, if patients start exercising and taking statins at the same time, it seems that statins block the ability of exercise to improve their fitness levels."
Terrific. You put people on a drug which they might be able to stop taking, if their exercise program goes well... and the drug prevents their exercise program from going well.
I'm sure this is Wall Street's idea of a happy ending, but I'm not sure it's mine.
Another Fitness Benefit!
A study of lung cancer and colorectal cancer in middle-aged men found that cardiorespiratory fitness reduced both the risk of developing these cancers and the risk of dying from them if they did develop.
So it's not just about controlling diabetes and preventing heart attacks.
Another Marijuana Study!
Cannabis smokers have better glucose control, less insulin-resistance, higher levels of HDL ("good") cholesterol, and even (despite what you've heard) smaller waist circumference than those who have never smoked it, or have quit smoking it. This according to an article and editorial in the American Journal of Medicine. Can marijuana really prevent or treat diabetes? If so, how does it work? Most important of all, can the ingredient which produces this therapeutic effect be isolated and sold separately from the actual weed, in a form which is (1) more expensive and (2) doesn't make people feel good?
America wants to know!
The Salt Of The Earth
Wednesday, May 15, 2013
Fasting Glucose: 83 mg/dl.
Glucose 1 hour after lunch: 130 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 120/69 mmHg, 56 bpm.
Exercise: 5.4 mile run.
Is Salt The Enemy?
About 20% of people are "salt-responders", meaning that their blood pressure goes up as dietary sodium (the problematic element in salt compounds) goes up.
So what we do about this? Well, one possible approach would be to figure out which people are salt-responders, and advise them to limit their salt intake in order to avoid hypertension. This is pretty much how we handle such issues as peanut allergies and celiac disease. We don't tell the population as a whole to eliminate peanuts and wheat from their diets (that's no easy task, after all); we identify the people who have a problem with those foods and tell them to avoid such foods.
We don't take this approach to the salt-responders among us. Unfortunately, there doesn't seem to be any simple test to determine whether you're a salt-responder or not. It would be hard to figure out who the salt-responders are, and concentrate on changing their diet. So, a lot of public-health organizations have been taking the easy way out: advising everyone to curtail sodium consumption. The advantage of this approach is that it catches all the salt-responders. The disadvantage is that it involves asking 80% of the population to stop eating the foods that taste good to them, for no reason whatsoever.
We need a certain amount of dietary sodium to maintain good health, and it isn't necessarily easy to obtain as much of it as we need, if we're living in a state of nature. Therefore, nature has designed us to crave the salty taste of sodium-rich foods, and eat them voraciously whenever they come our way. To satisfy that craving, we humans have found ways to redesign our environment, so that it is more sodium-rich than anything nature would provide. We gather salt (by mining salt-deposits or evaporating seawater), and then we refine it, sell it, and put it in every food product that we hope to sell at a profit. Restaurants and processed-food companies know better than to sell foods that are low in sodium and therefore too bland to appeal to customers. Also, some types of foods (such as breads) are hard to make at all in a low-sodium version (salt serves as a moderator of the rising process).
The medical associations who want to reduce the incidence of hypertension think it's all very simple: everyone should resign themselves to eating bland foods for the rest of their lives. So what if this ruins one of the major pleasures of life for most people, and gives them no benefit in return?
The American Heart Association wants Americans to restrict their sodium intake to 1500 mg per day. To give you some idea of what that means, imagine that at breakfast you have two slices of whole wheat toast with butter, and one of those tiny 5.5-ounce cans of V8 juice. You have already consumed 46% of your sodium allowance for the whole day, according to the American Heart Association. Clearly, restricting sodium to the degree the AHA recommends is not going to be easy.
From time to time, some maverick medical organization points out what is wrong with asking the population as a whole to restrict sodium intake for the sake of a minority within that population. This enrages the anti-sodium crusaders, of course. The latest example of this phenomenon is a report from the Institute Of Medicine, which was tasked by the Centers for Disease Control with assessing the effectiveness of sodium-restriction in preventing disease. Their conclusion: high sodium consumption correlates with disease, but restricting sodium as low as 1500 mg/day is going too far, because it doesn't seem to reduce disease risk any better than a more reasonable limit of 2300 mg/day. The AHA is upset about this, of course.
Since the typical daily sodium intake for an American adult is 3400 mg/day, it seems to me that AHA should perhaps aim for a more realistic goal of 2300 mg/day, and give up on the plainly ridiculous goal of 1500 mg/day.
I know that hypertension is common among Type 2 diabetes patients and, if present, magnifies the health risks involved in being diabetic. Seemingly that might argue for greater sodium restrictions among diabetes patients than in other people. But, for heaven's sake -- are Type 2 diabetes patients not making enough sacrifices at the dinner table already? If we're having our stir-fry without the noodles, don't ask us to omit the soy-sauce as well: it's asking too damned much! Certainly it's asking too much if we are able to control blood pressure by other means.
What these health-promoting organizations often fail to consider is that, if you define healthy living as a state of permanent unrelieved deprivation, people tend to give up on it. This is a much more serious issue than they seem to want to know.
Off The Grid!
Tuesday, May 14, 2013
Fasting Glucose: 90 mg/dl.
Glucose 1 hour after lunch: 125 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 119/82 mmHg, 55 bpm.
Exercise: Gym workout: strength training and aerobic.
Patients On The Lam
I see a fair number of Google searches in my site statistics that are of this type:
- "can i get diabetes medican without going to the doctor"
- "if your told you have diabetes mellitus and never go back to doctor what can happen"
These are patients who obviously fear going to the doctor, but probably not in the sense that they have iatrophobia (a powerful and surprisingly common fear of medical treatment of any kind). I think they fear the consequences of becoming a diabetes patient. There is a lot of anxiety, at least in the United States, about becoming identified (to the "system") as a patient with a serious chronic disease.
I think the feeling that Americans have about out health care system is that it divides everyone into two categories: the desirables (who have money but no diseases) and the undesirables (who have diseases but no money). To be identified as a diabetes patient is to be identified as an undesirable. Anyone who follows the news at all knows that diabetes is being presented to the public as (1) an optional lifestyle disease which, if you have it, is your own damned fault, and (2) a hopeless incurable illness which takes longer to kill you than is convenient to society, which knows it will get stuck (one way or another) with the cost of your long final journey through the health care system.
So, a lot of Americans who know or suspect that they have diabetes want to find out if there is some way for them to go it alone. Can they deal with diabetes independently of the health care system? Can they go "off the grid"?
I think the American health care industry ought to be a little worried about the increasing tendency of Americans to see the industry not as a system set up to help them stay healthy but as a system set up to punish them for being ill.
When I was something like 12 years old, my family was going to a family gathering at which we were expecting to meet a distant relation who was serving in the U.S. Army. He was home on leave from the war in Viet Nam. And before we arrived there, my parents gave all of us, but particularly my older brother, a stern lecture about the importance of not saying a word to him about the war, or asking him any questions about it, or offering any opinions about it. Even at the time, I recognized this warning as deeply significant. Had this scene played out a generation earlier, it certainly would not have occurred to a family meeting a soldier home on leave from World War II to declare the war an unmentionable subject, to be awkwardly ignored. But Viet Nam was a different kind of war. You couldn't talk about it at the dinner table. It was a dirty topic; nice people didn't discuss it. I've always remembered that incident whenever our government has been trying to crank up the war machine. It seems like a reasonable litmus test for any proposed war: are we going to be able to talk about this one at family gatherings? If not, maybe we shouldn't get involved. It seems unfair to send soldiers to a war which, when they are home on leave, will be ruled unmentionable by their relatives.
Surely there has to be a similar kind of significance that diabetes is starting to be seen by a lot of people as a dirty little secret, to be hidden from the authorities, lied about, and coped with on a purely amateur basis. That can't be an indication that the system is working well.
Is Your Doctor A Pusher?
Monday, May 13, 2013
Fasting Glucose: 97 mg/dl.
Glucose 1 hour after lunch: 127 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 112/74 mmHg, 56 bpm.
Exercise: 5.2 mile run at lunchtime; yoga class in the evening.
I was disappointed not to get a lower fasting result today, after doing a very hilly 8-mile trail run yesterday. But I was super-hungry after the run and probably took in too many carbs at dinner.
I'm being bothered by some lower abdominal muscle soreness while running; I talked to my yoga teacher about it tonight and she suggested some things to try. Okay, I'll try 'em. I can't afford to get myself into a situation where running hurts too much to let me continue with it. I'm not at that point; I can still run. I just don't want to let the soreness get worse, and bench me. As my two running buddies at work are both sidelined by muscle injuries, and have been for a long while, I realize how hard it can be to recover from such problems if they get seriously painful.
Checking Your Doctor
A friend sent me a link to a Pro Publica report on irresponsible prescription practices by doctors (specifically related to older patients receiving drugs under the Medicare prescription drug plan). Apparently some doctors have been indiscriminately prescribing psychotropic drugs and narcotics to elderly patients who probably shouldn't be getting them because they are "potentially harmful, disorienting, or addictive". Some prescription drugs that are legal are nevertheless marked with "black box" warnings indicating which patients probably shouldn't get them, and apparently some doctors ignore such warnings and prescribe them inappropriately, especially to older patients.
There is an online tool you can use to find out whether your own doctor is involved in any such chicanery. I suspect that using this tool properly requires a more sophisticated understanding of the realities of medical practice than I possess. In other words, even if anything in my own doctor's record looked a little suspicious, I think I would need to do a lot of careful research before I would be justified in concluding that I had found some kind of smoking gun.
What would make my doctor's record look suspicious? Apparently, one warning sign is that your doctor's prescription pattern is very different from that of the average doctor in the same specialty. The results for my own doctor indicated that he is strikingly middle-of-the-road, writing prescriptions that are extremely typical for doctors who specialize in family medicine. His list of most-prescribed medications, in order of descending frequency, was as follows:
- SIMVASTATIN (elevated-cholesterol treatment)
- LISINOPRIL (hypertension treatment)
- METFORMIN (diabetes treatment)
- LEVOTHYROXINE SODIUM (hypothyroidism treatment)
- OMEPRAZOLE (gastric reflux treatment)
- AMLODIPINE BESYLATE (hypertension treatment)
- HYDROCHLOROTHIAZIDE (hypertension treatment)
- BENAZEPRIL HCL (hypertension treatment)
- LIPITOR (elevated-cholesterol treatment)
These are some of the most commonly-prescribed medications out there -- particularly for elderly patients (and 71% of his Medicare patients are over 64). So, nothing odd here; none of these drugs are in the category of potentially-hazardous narcotics or psychotropics.
The report indicates that 23% of his Medicare patients had been given at least one prescription for narcotics. Is that lot? Apparently it's on the low side of typical, if I am interpreting the report correctly.
Although my doctor writes a lot of prescriptions (at least where his elderly patients are concerned) for cholesterol drugs, hypertension drugs, and diabetes drugs, he is not pushing any of these things on me, and in fact I'm taking none of them. (For a long time he was prescribing Monopril, a very similar drug to Lisinopril, for blood pressure, but he told me I could drop it after I started my exercise program). So, it appears that he doesn't push pills if the patient is willing to try another approach.
Bottom line: no medical scandal here. I didn't expect there to be. But if you're wondering if your own doctor is engaging in questionable prescription practices, I guess this is how you find out.
Not Doing It Wrong
Friday, May 10, 2013
Fasting Glucose: 91 mg/dl.
Glucose 1 hour after dinner: 108 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 114/71 mmHg, 52 bpm.
Exercise: 5.2 mile run.
The Only Stir-Fry Recipe You Will Ever Need
Slate.com has a recipe series with the encouraging title "You're Doing It Wrong", in which it is explained that various popular dishes are commonly prepared in a way which makes us wonder how they became popular. We are then told how to stop doing it wrong.
As you might expect, a lot of dishes analyzed in this series are not especially diabetes-friendly, but stir-fry! There's a diabetes-friendly dish if ever there was one! All you have to do, to modify a stir-fry recipe and make it diabetes-friendly, is to omit the final step ("serve atop a mound of rice or noodles the size of a throw-pillow").
So, I was interested in the article on stir-fry by L.V. Anderson. Anderson's take on the big problem with stir-fry seems to zero in on my own problem, historically, with stir fry: most people include way too many ingredients, and especially way too many kinds of vegetables, in their stir-fry, and then they try to cook all of it at once. As the ingredients don't cook at the same rate, including a wide variety of ingredients in your recipe results in a lot of ingredients being overcooked and perhaps some being undercooked. Therefore, simplicity is the key to a good stir-fry. Specifically, you want one kind of protein (meat, poultry fish, tofu) and one kind of vegetable. If one kind of vegetable seems too limited a palette to you, add one kind of mushroom. Also needed:
Cooking oil (obviously).
- A tablespoon of grated ginger.
- 2 garlic cloves minced or mashed.
- A minced chile pepper (seeded, unless you're tough).
A sauce consisting of:
- Something sweet (such as a tablespoon of mirin, a sweet Japanese rice-wine, or perhaps an improvised mixture of a teaspoon of honey and two teaspoons of water).
- Something salty (such as two tablespoons of shoyu, tamari, soy sauce, or Thai fish sauce).
And that's pretty much it. For the ginger, by the way, the best approach is to buy a big clunky root of the stuff, keep it in your freezer, and use a grater to shave off a little of it when needed.
Okay, so here's the procedure:
- Cut the protein into bite-sized pieces and stir-fry it in a wok or deep skillet in hot oil. Season it with salt and pepper, get it cooked, get it browned, and empty it onto a plate.
- Add a little more oil to the pan and cook the aromatics (ginger, garlic, chile) for a minute, adding salt and pepper while stirring.
- Add the vegetables and stir-fry until just tender.
- Put the protein back in the pan with the vegetables and add the sauce ingredients. Stir-fry briefly until the sauce thickens.
- Serve over rice or noodles, except omit the rice or noodles, because you've got diabetes, remember?
And there you go. I've tried this with tofu and asparagus, and with chicken and broccoli, and tonight with shrimp and bok choy (in this case I used fish sauce to replace the shoyu I used the other times). All of these versions were good, and none of them gave me high post-prandial glucose readings. So, I can recommend this approach with a clear conscience.
How Do You Solve A Problem Like Diabetes?
Thursday, May 9, 2013
Fasting Glucose: 88 mg/dl.
Glucose 1 hour after dinner: 114 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 108/73 mmHg, 62 bpm.
Exercise: Short bike-commute; aerobic workout in the gym.
Ah, first Thursday in May: Bike To Work Day! Which would be fine, if it weren't also Bike Home From Work Day; that is the hard part for me. I live about a mile and a half from work, but work is downhill. I have to make a very steep 500-foot climb on the way home, and I arrive at my front door looking as sweaty and shaking and wrecked as if I'd been to San Francisco and back.
I don't know if I have what it takes to do that again tomorrow; we'll see.
Stories Left Unfinished
Sometimes I read the beginning of a news story, and I decide immediately that I don't want to continue past the first paragraph, because the opening of the tale fires my imagination so strongly, without giving me much specific information, that I know the rest of the story will only turn out to be a letdown compared to what's swirling in my brain.
Such a news story is this one:
"There was a terrible, sulfurous smell, like rotten eggs, and a tremendous pressure against my chest," Paul Templer said, recalling the moment he realized he had been swallowed by a hippopotamus."
Immediately I'm wondering how a man could realize he had been swallowed by a hippopotamus, as opposed to knowing damned well he was being swallowed by a hippopotamus. It doesn't sound like the sort of problem you would become conscious of belatedly, after you'd been a bit bored and inattentive for a while.
As for the rotten-egg odor, I'm not claiming that I wouldn't notice it, under the alarming circumstances described... but I'm not sure it would be the first thing I'd mention, any more than I'd start with the poor lighting or the lack of furniture.
Well, I'm sure all my questions would be answered satisfactorily, if I read the rest of the article. But somehow I prefer leaving my questions unanswered in this case. I'm content to know that somebody, somewhere, was swallowed by a hippopotamus. And it took him a while to become aware of it. And when he did become aware of it, his first thought was that he didn't care for the atmosphere in there.
At least somebody knows how to keep things in perspective; I'm not so good at that myself.
But if you must know what actually happened, the rest of the story I left unfinished is here.
At work today there was a "webinar" (a seminar conducted online) for all interested employees, on the subject of "Living Well With Type 2 Diabetes". I doubted very much I would learn anything new from it (such presentations are usually geared toward the newly-diagnosed and uninformed), but I figured as long as they were putting the thing on, I might as check it out, and see what they had to say.
I was braced for it to be infuriating in the usual ways, but I ended up being so distracted by a technical problem that I didn't notice the annoying aspects of the presentation as much as I might have. The webinar was supposed to be interactive: you could type in questions during the presentation, and they would be displayed on the screen, and the presenters would answer them. There was something wrong with my hookup to the website; I could see and hear everything that was presented, and I could see the questions other people typed in, but my questions were not accepted and were not displayed, and nobody answered them. Which is too bad because, as you can imagine, my questions were better than the ones that did get answered.
The presentation itself wasn't so bad on the whole; most of what was said was true or a reasonable approximation of the truth. Some things (such as the claim that the hemoglobin A1c test "measures" average blood sugar) struck me as not very reasonable approximations of the truth, but I guess I can see why they thought being truthful about that one would take too long, in a presentation which aimed to cover all of Type 2 diabetes in an hour (which obviously can't be done without resorting to oversimplifications of this sort).
More worrisome was their list of "effective care measures":
"Care measures" doesn't mean "treatments", because only two of the seven items listed are treatments, but what does it mean? The other five items are diagnostic tests. I couldn't help noticing that blood pressure medications and cholesterol medications are mentioned, but exercise isn't. But diabetes medications aren't listed either. What is this list, exactly? The individual items are discussed in some detail, but the big picture goes missing, I think.
There was a section of the presentation on nutrition, and predictably it was the low point; the presenter took what seemed to me a wildly unrealistic attitude toward the issue of carbohydrate intake. "There are no 'good' or 'bad' foods", she said, and suggested a carbohydrate intake of 45 to 75 g per meal, with no mention of the need to use glucose test results to confirm that you really can handle that kind of carbohydrate intake. A handout provided said, "Each day, try to eat a variety of healthy foods like: grains, whole grain breads and cereals, pasta and rice, starchy vegetables (like corn, potatoes or yams)." Other, less problematic, foods were eventually listed as well, but what kind of loony would put that many starch-bombs at the head of a list of "healthy foods" which diabetes patients should sample a variety of each day?
Exercise was eventually covered in some detail, and at least one of the reasons for doing it was mentioned. So I can't say they ignored the subject; they just didn't give it the kind of emphasis I think it merits.
Well, I can't expect to get everything I want out of a presentation like this, and certainly this one could have been worse. But I hate to see wasted potential. The basic concept of diabetes management as I understand it (the principle of judging your daily health practices against test results, and making adjustments to find what works for you) was absent. It could have been covered, even though there was only an hour available for the whole presentation -- and covering it would have been worth more than anything else that was covered. Better that than listening to a lot of the usual blather about whole grains!
Does This Seem High To You?
Wednesday, May 8, 2013
Fasting Glucose: 84 mg/dl.
Glucose 1 hour after dinner: 111 mg/dl.
Weight: 191 pounds.
Blood pressure, resting pulse: 109/74 mmHg, 55 bpm.
Exercise: 5.1 mile run.
I just found out that April was Stress Awareness Month, and what did I do about it? Absolutely nothing!!!
I can't talk about it right now, I'm too upset!
Non-Diabetics With High Blood Sugar
Sometimes I see a group of suspiciously similar search phrases in my website stats, and I wonder if they all were entered by the same anxious person, trying to investigate the same worrisome issue. Here's a recent example of three searches which seemingly could have come from the same person:
- "bs shot to 212 after dinner"
- "high intake of carb reading of sugar test of 212 and im not diabetic"
- "i had a glucose reading of 212 about 3 hours after dinner does that mean im diabetic"
Okay, somebody out there who thinks he's non-diabetic (presumably because no one has yet told him otherwise) tested his blood sugar one evening after dinner, out of curiosity, and got a 212 result (presumably in mg/dL). It sounds high to him, and now he wants to be assured that it isn't as bad as it looks.
Who knows what that statement about "high intake of carb" really means -- did he eat a club sandwich? Did he eat most of a large pizza, and then have a banana split for dessert?
Even if it was the latter, 212 sounds mighty high for a post-prandial result, whether it was three hours after dinner or only one hour.
Let's put it this way: I'm twelve years into the diabetes journey, and my result after dinner tonight was 111. If I had got 212 instead I would have been in a panic. (And my dinner tonight wasn't as low-carb as last night's; there was even some fruit involved.) Sometimes it amazes me, as a diabetes patient, to hear people who claim to be non-diabetic seek reassurance that there is nothing wrong with them getting results which, if I had got them, would have made me soil my pants.
This happens to me more often than you would think (not the part about the pants, the part about what people say). Sometimes acquaintances ask me to test them, because they're idly curious (for no reason at all, you understand) about whether there's any possibility they might be becoming diabetic themselves. And I test them, and they get a result which would alarm me if I (the diabetes patient in this scenario, let us remind ourselves!) ever saw a result that bad. And I tell them so, and then they shrug it off and pretend that none of this ever happened.
A person who is truly non-diabetic typically goes up to a blood glucose level of about 125 mg/dL, an hour or less after a meal, and the carbohydrate content of that meal shouldn't have too much of an impact on the result, because a non-diabetic body can keep things under reasonable control regardless of what's in a meal.
As someone who does have diabetes, I try to get results which are as close as possible to the results I would get if I didn't have diabetes. It seems like a sensible approach to me. But it seems pretty strange (and funny in an unpleasant kind of way) when people who claim to be non-diabetic make up their minds to be satisfied with results which, if I got them, would give me a seizure.
Weight & Glucose & Green Tea
Tuesday, May 7, 2013
Fasting Glucose: 86 mg/dl.
Glucose 1 hour after dinner: 96 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 111/74 mmHg, 66 bpm.
Exercise: 5.2 mile run; resistance-training at the gym.
My shoulder wasn't feeling bad, so I decided to do some weights this evening. It didn't seem to bother my shoulder; I hope that still holds true tomorrow morning.
As always, after weight-training, I find that my blood pressure is lower than usual and my heart rate is higher than usual. I have decided to assume that, on balance, that's good.
My dinner was very low carb; that explains the low post-prandial number.
Body Weight and A1c Results
Yesterday Google referred someone to me who had entered the search term: "why wouldn't glycated hemoglobin change after weight loss".
To which my answer would be: why would it change after weight loss?
The glycated hemoglobin test (also known as the hemoglobin A1c test, because the glycated fraction of your hemoglobin is identified as "A1c") does not measure your weight. It does not measure your average blood sugar either, despite what you've been told. It examines your hemoglobin (a protein in your red blood cells) to see what percentage of that protein is "glycated" (sugar-coated as a result of prolonged exposure to glucose circulating in the bloodstream).
Because the rate of hemoglobin glycation rises when blood sugar rises, a higher percentage of glycated hemoglobin indicates that blood sugar has been higher on average lately; a lower percentage of glycated hemoglobin indicates the opposite. A formula has been developed for turning the A1c result into "eAG" (estimated average glucose)...
(A1c X 28.7) - 46.7 = eAG in mg/dl
.... but bear in mind that this formula takes for granted that the glycation rate, for a given glucose level, is the same in all individuals -- and we know that isn't so. So "eAG" is an estimate, not a measurement (and not a terribly accurate estimate for some people). The only thing the test actually measures is glycated hemoglobin; the rest is only an inference.
Anyway, why would weight loss cause the A1c result to change?
Obesity tends to cause (or at least can cause, in people with Type 2 diabetes) a loss of sensitivity to insulin, which in turn causes excessive amounts of glucose to build up in the bloodstream,... which in turn causes the glycation rate to go up... which in turn leads to higher results on the hemoglobin A1c. That's a pretty indirect chain of causation, and there's plenty of room for individual variation there.
Weight loss can (but doesn't always) cause individuals to regain their lost insulin sensitivity (some of it, anyway). If your A1c result is high, and you lose weight, you may eventually see a reduction in your A1c result. There is no guarantee, however. Maybe your insulin sensitivity is so profoundly compromised that losing weight doesn't make enough of a difference to give you noticeably better A1c results. Exercise is a more reliable way to boost insulin sensitivity; weight loss sometimes does it, and sometimes doesn't.
Anyway, if you've lost weight, congratulations, but don't count on that alone to bring your glycated hemoglobin down. You may need to do more than lose weight to make that happen.
For a long time, green tea has been seen as having some kind of therapeutic effect in terms of controlling weight and blood sugar. Attempts to study this effect have yielded mixed results, with some studies saying it's helpful and others saying it isn't.
Lately scientists have identified the therapeutic ingredient in green tea as a set of compounds called "gallated catechins", and a new study investigates how these substances operate.
Apparently gallated catechins, at least when they are within the intestinal tract, inhibit the intestinal walls from absorbing sugars and fats. Clearly that has potential usefulness in preventing excessive weight and excessive blood sugar. However! When the gallated catechins themselves cross through the intestinal wall into the bloodstream, they start having a contrary effect, increasing insulin resistance and promoting obesity and weight gain. So, the gallated catechins do good things in one place, and bad things elsewhere.
But what if you could force the gallated catechins to stay in the intestinal tract, where they have a desirable impact instead of an undesirable one? The researchers found that they could achieve that (at least in mice) by binding the gallated catechins with "a non-toxic resin, polyethylene glycol", which prevented the stuff from being absorbed and entering the bloodstream. In mice, at least, this approach seems to work: the gallated catechins stay within the intestinal tract, and they lead to a reduction in both obesity and insulin resistance. If the gallated catechins are not bound with the resin, they enter the bloodstream and their good effects are canceled out. If they are bound with the resin, their good effects are not canceled out.
The bottom line, according to the researchers, is that "dietary green tea extract and polyethylene glycol alleviated body weight gain and insulin resistance in diabetic and high-fat mice, thus ameliorating glucose intolerance. Therefore the green tea extract and polyethylene glycol complex may be a preventative and therapeutic tool for obesity and obesity-related type 2 diabetes without too much concern about side effects."
Why would there not be too much concern about side effect? Because they said so, that's why. And also because polyethylene glycol is already used in medicines. It's usually used in laxatives, though, so there's at least one side effect I would be looking out for. We'll see!
Life In The Stroke Belt
Monday, May 6, 2013
Fasting Glucose: 86 mg/dl.
Glucose 1 hour after lunch: 120 mg/dl.
Weight: 191 pounds.
Blood pressure, resting pulse: 113/74 mmHg, 54 bpm.
Exercise: 4.1 mile run at lunchtime, yoga class in the evening.
Stroke Risk & Diabetes
I had always heard that the risk of stroke is higher if you have diabetes. But how much higher? A recent study tried to quantify that.
Apparently diabetes increases the risk of stroke quite a lot -- but increases it more if you're under 65. Specifically, your stroke risk, as a diabetes patient, is 12 times as high if you're under 65, but only 2.7 times as high if you're over 65.
Immediately you're thinking, "That doesn't make any sense! Stroke risk is higher in old people! How can the risk be worse before you're 65 than afterward?"
The study didn't find that anyone's stroke risk goes down after 65. What they found was that the difference in stroke risk between diabetic and non-diabetic people became smaller after age 65. Stroke risk, and the risk of having problems which contribute to stroke risk, increase after age 65. Younger people have very little stroke risk and very few factors which magnify that low risk; diabetes is the biggest risk factor that's common in people under 65, so diabetes stands out in the risk figures. In older people, other stroke risk factors come into play, so diabetes just becomes one risk factor among many, and its contribution to total risk does not stand out so much.
In other words, if you have diabetes and you make it to 65 without having a stroke, that doesn't mean your stroke risk just went down. It means that your total risk from all causes has become large enough that the risk contributed by diabetes alone is now smaller in comparison.
But how much actual risk is there? The statistics I found were for fatal strokes, not strokes in general, but those stats vary enormously from region to region in the USA -- from 35 annual deaths per 100,000 to 198 per 100,000:
Note the concentrations of stroke deaths in the southeastern "stroke belt", which by an extraordinary coincidence is also the USA's diabetes belt, obesity belt, and sugary-drinks belt. Anyway, if some regions have 198 stroke deaths per year rather than 35, and diabetes multiplies your risk by 12, it's a safe bet that diabetes is what's driving a lot of those deaths.
You might be tempted to think that even the worst rate (198 per 100,000) isn't that bad. Well, keep in mind that that's only the stroke death rate; a lot of people survive a stroke (although often with disabling consequences). Also, it's only the rate per year; if you're planning to live multiple years, be aware that the risk keeps piling up.
By the way, the risk ratios from the study which I quoted earlier were for white patients. There were some puzzling differences in the results for black patients: diabetes seems to cause a lesser increase in stroke rate in those patients (the risk multiplier for black patients under 65 was 5.2 instead of 12). However, this doesn't mean black patients have fewer strokes (they have more, actually). Apparently it means that black patients under 65 already had other risk factors besides diabetes (hypertension, for example), so the impact of diabetes wasn't as dominant in the mix as it was for white patients under 65.
Oh, wait a minute -- I just remembered that it's my job to try to counteract the gloom-and-doom version of what diabetes is about. What silver lining can I find here?
Well, as always with ugly-sounding diabetes statistics, we need to keep in mind that those statistics reflect the average diabetes patient, who -- let us be frank here, ladies and gentlemen -- is not doing everything possible to control diabetes or mitigate the health risks associated with it. (Is the average patient exercising six days a week, I ask myself? Probably not, but I am.)
I'm pretty sure that a lower risk is faced by a patient who is doing more about the problem than the average patient is doing about it. And even at its worst, the added stroke risk for diabetes patients doesn't add up to anything like certainty that you're going to have a stroke because you're diabetic. It might happen, but it's likelier not to -- especially if you're doing something to prevent it, such as staying active and keeping your blood pressure under reasonable control.
Nobody has zero risk. The goal isn't to eliminate risk (that's impractical, obviously) but to reduce it. Some of us have to live with more risk for certain things than others do. I live in coastal California, so I face a greater risk from earthquakes and wildfires than other people do. But perhaps those people, because of where they live, face risks that I don't, from ice storms, or tornadoes, or hurricanes, or depression brought on by living in a very uninteresting place.
We all have to face some risk. And we all have to do our best to manage it.
Friday, May 3, 2013
Fasting Glucose: 82 mg/dl.
Glucose 1 hour after lunch: 132 mg/dl.
Weight: 190 pounds.
Blood pressure, resting pulse: 114/73 mmHg, 52 bpm.
Exercise: 4.6 mile run.
Little Tiny Things
Is this the next big diabetes therapy?
These are nano-particles -- tiny man-made particles, less than a micrometer in diameter -- which can be injected into the bloodstream. They have been rather cunningly designed so that they gradually release insulin, but not at a constant rate: they release it at higher rates when blood sugar is high, and at lower rates when blood sugar is low. Eventually the nanoparticles run out of insulin, of course. Does that mean the bloodstream continues to be littered with now-useless particles? No, the particles are biodegradable; they dissolve within the blood eventually. Experiments in which the nano-particles were injected into diabetic mice showed that the treatment was effective: it allowed the mice to maintain normal blood-glucose levels for over a week without a repeat injection. ("Normal" was in this case defined as <200 mg/dL, which is not my idea of normal; maybe it's normal for mice, but it's also possible that the researchers redefined "normal" so as to make their treatment sound more effective than it was -- so I hope we'll hear more about that detail in the near future.)
Anyway, this isn't a new drug; it's a new (and more sophisticated) way of delivering an old drug. The fact that the nanoparticles keep working for several days (so that injections don't need to be as frequent) is the obvious advantage. Other slow-release drugs (such as Victoza) which don't require frequent injections exist already, however, so the nano-particle approach will have to show that it's more effective and/or more safe than competing therapies.
I am not making any assumptions about possible risks and unintended consequences which might be involved in injecting man-made particles into the bloodstream. Maybe this is a good idea, and maybe it isn't. I don't think I want to be one of the "early adopters". But I'll be interested in hearing what happens, over extended periods, to patients who go this route.
Thursday, May 2, 2013
Fasting Glucose: 84 mg/dl.
Glucose 2 hours after lunch: 106 mg/dl.
Weight: 189 pounds.
Blood pressure, resting pulse: 121/71 mmHg, 59 bpm.
Exercise: 5.2 mile run.
More Fan Mail...
...this time from a more distant locale. And this time my correspondent (Neil by name) doesn't just have praise to give -- he's a question that needs answering:
"Just to say that I have read your website and find its positive message very useful.
To give a little background on myself: I am a UK expat living in Abu Dhabi. After going for a medical for a new job I found that I was diabetic. I had shocking figures! I had a fasting glucose of about 253 and an A1c of 10.6. My cholesterol was high and so were my triglyceride levels.
The doctor here has put me on 2000mg of Metformin and a statin. As my figures were so bad I was happy to take it as something needed to be done quickly ( I am lucky not to have any noticeable side effects from this).
However, like yourself I wanted to do something about it so i have started exercising and have changed my diet alongside the drugs. My BMI is now 26 and I think I will achieve 25 soon. I am now managing reasonable evening post- prandial figures at the one and two hour mark of maximum 130 and usually less than 110 according to my meter. This is after about 1 month and I am going for a follow up in a few weeks and hope that this is reflected in my A1c test.
The problem for me is my morning levels. This morning I was 119 and an hour after eating breakfast (2 eggs & one slice of granary bread) it was 150! Previously I had tested after 2 hours and this had dropped to 137 but I am far from happy about this.
Have you come across this yourself to any degree? It is frustrating that simply sleeping raises my glucose levels! I am hoping as time goes on I can still improve on this situation without additional medication. I am well aware you are not a health professional and of course will speak to my doctor (or should I say healthcare team LOL) when I see him but I just wondered if it may make an interesting topic for your blog. Sorry if you have covered this already but I couldn't find it if it was there.
Keep up the good work and thank you for the positive outlook. I am worried enough as it is without more doom and gloom!"
No doubt I've covered the dawn phenomenon before, but like Neil, I can't find where I did, so I'll just cover it again. And who knows? Maybe I'll do a better job of it this time.
A lot of Type 2 patients find it extremely frustrating -- and confusing as well -- that fasting levels can be harder to bring under control than post-prandial levels. To see their blood glucose level go up rather than down after 8 to 12 hours without food seems to them not only maddeningly unfair but also highly mysterious. How does that happen?
Well, to get a slightly better grasp of the causes of morning highs, you need to begin by letting go of the idea that any glucose that shows up in your bloodstream must have got there by being released from the digestive tract. That is not the case. If your bloodstream is a sink, there are two faucets, not one, that can pour glucose into it. One of those faucets, the one we usually are conscious of, is the digestive tract. The other faucet is the liver, and we need to be a little more conscious of that one, even though we don't have much control over it. We should at least be aware of what, in general, it is doing.
One of the important jobs which is performed by the liver is to protect you from hypoglycemia between meals, by storing up glucose (during periods when glucose levels are normal or elevated) and releasing a little of it later (during periods when glucose levels are low). If it wasn't for the liver, you'd have to keep snacking continuously, day and night, at just the right rate of consumption, in order to maintain a continuing flow of glucose into your bloodstream, so that you never ran low. With a liver, you don't have to do that. You can have long fasts between meals. You can even go to sleep for several hours, without running out of glucose and dying of hypoglycemia at 3 AM, because the liver releases enough glucose during the night to prevent that.
By the way, the liver obtains its glucose stores not only by absorbing glucose from the bloodstream but also by converting fat from the bloodstream into glucose -- this conversion process is called gluconeogenesis. (Fat cells work the same trick in reverse, by absorbing glucose from the blood and converting it into fat.) Anyway, because the liver has two different ways of building up and storing glucose, it isn't likely to run out.
I don't want to create the impression that the liver just automatically secretes glucose all night, at whatever rate it feels like doing so. Obviously the process needs regulation, so that the liver doesn't release more glucose than you need, or less glucose than you need. I'm sure you won't be surprised to hear that this regulatory process is complicated. I'm sure you'll be even less surprised to hear that, if you have Type 2 diabetes, this regulatory process does not work as well as it ought to.
The glucose regulatory system is controlled mainly by the hormone insulin (which stimulates cells throughout the body to leach glucose out of the blood, thus bringing blood glucose levels down). But there are also counter-regulatory hormones which undermine the effects of insulin. The main one is glucagon, which stimulates the liver to release its stored glucose into the bloodstream, thus raising the blood glucose level instead of reducing it. There are other hormones which, in one way or another, nullify the glucose-lowering effects of insulin. These include epinephrine, growth hormone, and cortisol. The body (or rather its endocrine system) can use all of those counter-regulatory hormones to reduce or eliminate the impact of insulin.
Now, another idea which many people may have (and which they need to let go of) is that the endocrine system simply switches off insulin production when blood sugar is low, and switches on production of glucagon and the other counter-regulatory hormones. That is apparently not how it works (and it would be a crude and unstable way for the endocrine system to operate, if you think about it). The way the endocrine system really operates is to release at least a little of all these hormones at once; it adjusts the blood glucose level by adjusting the ratio between the regulatory and counter-regulatory hormones, to keep things balanced -- like a tightrope walker carrying a long horizontal beam, and tilting it just slightly to one side or the other to make adjustments. Hanging a twenty-pound weight on one end of that beam and not the other would not help the tightrope walker stay balanced, would it? And that's what diabetes is like: an overbalance on one side. The insulin regulatory side of the beam isn't working properly; the counter-regulatory side of the beam is working just fine. Of course you're going to lean too far to one side!
In all of us, whether we have diabetes or not, the endocrine system uses the counter-regulatory hormones to protect us from hypoglycemia, and just before sunrise it starts to ramp up the counter-regulatory hormones, to prepare your body for the exertions of the day to come. If you're not diabetic, this isn't a problem, because those counter-regulatory hormones are being balanced out by insulin, so things don't go too far. Your morning blood glucose level does not rise above the normal range. But if you have diabetes, things aren't so neatly balanced. Either you don't produce a normal amount of insulin, or your cells don't have a normal amount of sensitivity to it. So, the endocrine system's routine release of counter-regulatory hormones (somewhere between 2 AM and 4 AM) is too strong; it overwhelms the capacity of your insulin supply to counter-balance it.
This is the maddening "dawn phenomenon", and it results in people waking up with higher blood glucose than they had when they went to bed.
There is a similar, but not quite identical, problem called the Somogyi effect, in which you experience a hypoglycemic episode while sleeping, and the endocrine system over-corrects for it, by releasing too big a dose of counter-regulatory hormones. It sounds as if there's not much difference between the dawn phenomenon and the Somogyi effect, but there is actually a pretty important difference: the Somogyi effect occurs only if you experience hypoglycemia while sleeping, while the dawn phenomenon occurs as a result of perfectly routine releases of counter-regulatory hormones in the wee hours. You might deal with your morning highs differently if you know they're caused by the Somogyi effect. (Finding that out won't be easy, unless you have Continuous Glucose Monitoring equipment; without CGM you'll have to do a lot of experiments involving waking up and testing at three in the morning.)
If you're on insulin or oral diabetes meds, you may need to talk to your doctor about when and how much of these things you're taking. It could be that your morning highs reflect a less-than-optimal medication schedule.
People who get high fasting numbers are often advised to avoid eating anything (especially anything with carbohydrate in it) after dinner. This helps some people. It doesn't help everyone. If you're experiencing the Somogyi effect rather than the dawn phenomenon, and the morning highs are being triggered as over-reactions to hypoglycemia, taking an extra-long fast might only make the problem worse. Another correspondent who was frustrated by morning highs reported to me that taking a light snack (maybe 15 g of carbs) before bed actually reduced his morning glucose levels; apparently the Somogyi effect, not the dawn phenomenon, was a bigger issue for him.
My own experience has been the opposite: for me, eating after dinner produces higher fasting results the next morning. So apparently I have a bigger problem with the dawn phenomenon than with the Somogyi effect. This isn't too surprising, as I don't become hypoglycemic often -- presumably because I'm not taking diabetes meds.
Because it is so hard to find out what is really going on with your endocrine system (most of us have no data on how much insulin or glucagon we are producing), I think the best approach to the problem of morning highs is to try different things and see what effects they have on morning results in your case. The prolonged-fast approach is probably the first thing to try, as it probably applies to more people. If that doesn't work, try the midnight-snack approach (but don't persist in it if it doesn't help -- generally speaking it's not a great idea).
Another thing to keep in mind: if you keep active, and maintain good post-prandial glucose control, your frustratingly high morning results may gradually come down over time, as your body adapts to the healthier habits you're cultivating. I can't promise that will happen, but it can. Insulin sensitivity, and even insulin productivity, can probably improve (slowly) if you stay on track. If you can make that happen, morning highs may eventually become less and less of a problem.
Yay Yesterday, Boo Today!
Wednesday, May 1, 2013
Fasting Glucose: 86 mg/dl.
Glucose 2 hours after dinner: 111 mg/dl.
Weight: 189 pounds.
Blood pressure, resting pulse: 125/76 mmHg, 54 bpm.
Exercise: 5.5 mile run.
I do get fan mail now and then, though I usually don't publish it here. But if people are not only expressing thanks for the information or inspiration I've provided, but are also telling me that it helped them make major progress, then I figure I ought to share that. I don't want readers to think I'm the only one who has been able to achieve any health improvement following a diabetes diagnosis -- other people have done that, too, and it's important to get the word out about them.
So here's what I heard yesterday from Ben in Alabama (or, as he suggests I identify him, "Ben from Alabama....surviving and thriving a real life!!!!"):
"I just want to thank you for providing your website to the world. I found it while desperately searching for answers to questions that seemingly no one could or would answer for me. Some answers were confusing. The biggest thing you did for me was convince me to START exercising. I used to be very athletic and active, but have been very sedentary the last 20 years. The concept of exercise as medicine really hit home with me. I seemed to be getting worse as I was taking more medicine. Eating more, gaining more weight and A1c results of course getting worse. I was diagnosed in November 2011. My triglyceride level was 1911 !!!! I weighed 270 plus pounds at 5'11" and had just turned 44 yrs old the week before. My A1c was 10.7, cholesterol was 321, fasting BG was 235. On another note, my father died 36 yrs ago from a stroke at the age of 46. So, all of this really hit home with me and scared me.
So I turned to my doctor with open arms and an open mind. I wanted help. I got medicine and nothing else. After another year of following his rules, and being a sheep, my results weren't much better and I felt worse. That's when I discovered your website. Thank you Thank you Thank you!!!!!!! Your info and inspiration got me moving in the right direction.
In the last 64 days I have lost 55 lbs and my A1c is at 6.5 (I'm not done yet) and my avg fasting BG is in the mid 80's to mid 90's. I also work rotating night/day shifts (4weeks days/ 2weeks nights) which adds to my challenges. But I will persevere. I was up to 2 metformin (500 mg each) in the AM and 2 in the PM a couple of months ago.
I am now only taking half of a metformin pill (250 mg) in the morning. I plan on eliminating that soon. The best thing you did for me was to help me see my way back to exercising. I now ride a recumbent bike a minimum of 10 miles a day while randomly adjusting the tension. I have done as much as 60 miles on a Saturday (once). I average about 12 miles a day now pretty much. Eating much healthier.
At 215 lbs now and plan to continue to 190 ish. I think I should get around a 5.8 on my A1c at my next appt., which is June 10th. So, I have 40 days or so to improve on my 6.5 A1c. I know that I have been lengthy but I want you to know that I will forever be indebted to you. I know I did the work but you put me on the right path and your personal story inspires me daily. THANK YOU !!!!!!! Good luck to you in your future also."
Left-Handed Compliment Department
I can always count on my eye-doctor for light-hearted conversation that seems cheerful and congratulatory, but ends up leaving me feeling wounded because it encapsulates so much of the prevailing medical pessimism about diabetes regardless of circumstances.
Every year, when I go in for my eye exam, he starts out by asking me general health questions, and he always wants to know if I'm still controlling my diabetes without medications. One of these conversations, five years ago, gave me the name of this website, when he expressed the question this way: "And you're still controlling your diabetes with exercise? You're not medicated yet?"
I could have slapped him for that "yet". Does he ask his other patients if they're divorced yet, or unemployed yet?
He asked more or less the same question today, and when I said yes (which should have been superfluous in the first place, as I'd just filled out a form for him indicating I was taking no diabetes drugs) he offered me one of the most left-handed of all the compliments I've ever received: "Well, it's good that your able to do that... for now, even if not for the long haul".
Many possible retorts occurred to me. I could have tried something short-and-sweet: "I figure I've got more years ahead of me than you do, pal!". I could have tried something elaborate-and-bitter: "I've been doing this for twelve years. It's the same story every time I come in here. Once again, the eye scans you just took showed no sign of the kind of damage to blood vessels that you told me you expect to see in diabetes patients. I'm not on any diabetes meds. So far, my approach is still working. Do you think maybe you could lighten up on the gloom-and-doom until further notice? When I fail at this, you can say 'I told you so' if you like. But until that happens, why don't you shut your goddamned mouth before I shut it for you?".
What I actually said, of course, was nothing.
That is the way we diabetes patients live, of course. For all our fantasizing about throwing social caution aside, and expressing our anger fully, we let people say these things to us all the time, and we don't react. Looking on the bright side, there's less homicide this way, but there is also a price to be paid. Essentially, we are encouraging them in their complacent belief that this sort of thing is acceptable.
I once had to go on a business trip to Georgia, meeting with various federal government employees, and as people joined and departed the meeting, we came to a moment when it was only white people in the room. And immediately the guy running the meeting tells me an extremely crude racial joke. I wish I could tell you that I said what I was thinking (which was that I couldn't believe I had just flown 2000 miles to listen to this juvenile horseshit), but the truth is that I said nothing of the kind. Not that I pretended to be amused, or even tried to conceal my discomfort; maybe that was enough (he didn't try that again during my visit), but perhaps a stronger reaction would have been better, because then the message he would have learned was "don't tell racial jokes" rather than "don't tell racial jokes to this stuck-up guy from California".
Maybe I let the side down again, today. I don't know how healthcare professionals are going to come to understand that ritualized pessimism about diabetes patients is destructive, if diabetes patients don't bust them on it once in a while.
"NOT MEDICATED YET"
Reading the Stats
What this is about
I am going to use this space to report on my daily process of staying healthy -- what I'm doing, and what results I'm getting, and how I interpret the connection between the two.
I am not trying to taunt anybody, by reporting better results than they are getting themselves. I'm doing this to provide encouragement, not irritation.
Regardless of what your own health situation is now, you can probably pick up some useful ideas by tracking what I'm doing, and seeing what the results are. I don't mean that you should do whatever I do, or that imitating my behavior will get you the same results I get. We all have to figure out what works for us. Let's just say that I'm giving you an example of some things to try, and they might help. If they don't, try something else!
One word of warning: I sometimes participate in endurance sporting events (including "century" bike rides and the occasional marathon), but please don't assume that you would have to participate in extreme sports to get the kind of results I'm getting. Most of the year I'm not working out nearly that hard, and I still get very good results. For some people, vigorous walking may be enough. (But if it isn't in your case, don't cling to the idea that it ought to be enough -- do whatever it takes to get good results!)