Late Bloomers

Tuesday, November 26, 2013

 


Taking up Exercise Late in Life

A lot of people assume that, if it's not exactly true that exercise is strictly for the young, it's definitely true that exercise is for older people only if they have been doing it ever since they were young. Taking it up after they're no longer young won't work.

Yeah, there are old people who exercise, and there are even old people who do tough endurance sports. Just looking around locally for evidence of this, I find that the results for last year's Napa Marathon show that nine of the runners who finished the 26.2-mile race were over 70. And I know that many of the stalwarts in the Santa Rosa Cycling Club -- the people who turn out reliably for long-distance rides -- are the retirees, who now spend a lot of their time on their bikes. But a lot of people would be tempted to assume that it's easy for them, because they've been doing this kind of thing all their lives, and their bodies have become adapted to it. If you've always been active, maybe you can stay active, but it wouldn't work for a sedentary person to try to become active late in life.

People don't base this assumption on evidence of any kind, they just think that certain human activities work that way. If you didn't start when you were young, it's too late. For example, everyone knows that if you didn't start playing the violin when you were a little kid, it's futile to take it up when you're an adult. (I took it up when I was 32.)

Even those who don't assume it's impossible to begin exercising after they are past their first youth might be inclined to assume that becoming active late in life wouldn't actually benefit their health, because it's "too late" by then for exercise to make a difference.

Well, it's always worth doing a little research into these matters, to see if the conventional wisdom matches up with the evidence. In this case, it apparently doesn't. Some researchers in England decided to conduct a study involving 3454 healthy people, average age 64 at the start of the study, in which their health was tracked over a period of 8 years to see who remained healthy (that is, free of chronic disease, physical impairment, and mental impairment), and who didn't. It turned out that active people were significantly more likely to be still healthy after 8 years than inactive people. Those who stayed active throughout the study were more than 7 times likelier to remain healthy than those who were inactive throughout. Even those who became active during the years of the study, but stayed active after that point, were more than 3 times likelier to remain healthy than those who remained inactive.

I was going to try to come up with something to say to wrap this up, but what else is there to say? The results seem to speak for themselves.

So if you're going to have a big holiday meal this week, do some exercise to make up for it a little. Apparently it's worth it, even if you're not young.

 


America and its 195 Imitators

Monday, November 25, 2013

 


Mexico in Trouble

Mexico, still reeling from having surpassed the USA as the fattest nation in the Americas (their obesity rate hit 32.8% in July, compared to our comparatively slender 31.8%), are now being urged to do something about the rapidly worsening cardiovascular health of their nation.

The Mexican Congress of Cardiology is currently meeting at Leon in the Mexican state of Guanajuato, and Dr. Enrique C. Morales Villegas is there to advocate a public-health intervention by the Mexican government. "I have proposed to the Mexican government that 18 year-olds should have obligatory measurements of glucose, cholesterol, blood pressure and body mass index, with repeat assessment every three years. Screening could be done in schools, shopping centers and other public places and if an abnormality is found a strategy should be in place to treat it. This would be easy and inexpensive and I am waiting for the government's response. The Mexican diet is more dangerous than fast food chains. It's a combination of fried food, junk food and soft drinks. The philosophy of life is around comfort. People eat too much and every day they watch 4 hours of TV, spend 2 hours at the computer and do less than 10 minutes of physical activity."

Whether the Mexican government can deal with this problem more effectively than it has dealt with the murder epidemic going on in their country is an open question, but it does seem as if action might be needed. Mortality from cardiovascular disease and diabetes in Mexico recently went up 9.5% in a single year (to 207,000, which may mean that the soft-drink makers are killing more people than the drug cartels are). Rates of diabetes, hypertension, high LDL cholesterol, and other indicators of cardiac risk are climbing fast.

It used to be said that Mexicans were comparatively healthy people until they relocated to the USA, at which point their habits changed. They abandoned traditional foods for snacks, gave up the customary walk after dinner, and started to spend hours sitting around. Apparently the Americanized lifestyle has worked its way back to Mexico itself, and these days the people there no longer need to emigrate to turn themselves into heart attacks waiting to happen.

I think we Americans were the canaries in the mine. We got there first with the modern lifestyle and its diseases; everyone in the rest of the world had their chance to make jokes about fat and unhealthy the Americans were. Unfortunately, now that the rest of the world is catching up to us, I think the impact will not be to make the whole world think about doing a lifestyle makeover; I'm afraid the impact will be to make it impossible for people to conceive that there's any other way to live (since nobody will be living any other way).

I'm not sure we Americans need to feel guilty about this, exactly (we didn't force other cultures to imitate us, they just decided to). But it's not a good thing.

 


Studies

And here's xkcd.com on the subject of new scientific studies:

 


Friday

Friday, November 22, 2013


After the Storm

Sorry I couldn't post anything yesterday, but it truly wasn't possible. High winds were whipping through the area last night, with branches flying about and trees falling and power lines being ripped loose. My immediate neighborhood (which never does well in high winds, because it's exposed on the top of a steep hill and there are a lot of tall trees to fall over) lost electrical power around 6:30 PM, and the power stayed out all night. But when the power failed initially, it shut itself on and off several times in a few seconds. These erratic power-spikes were significant, apparently, because in the morning I found that my DSL modem was completely dead and dark, and could not be coaxed back to life. So, I couldn't connect to the internet.

I bought a new DSL modem at Best Buy. It came with a CD ROM, and I assumed the manual was on it. Actually, when you put the CD in your hard drive, it tries to download the manual from the internet.

Now, think about that for a moment. The problem I'm trying to solve by buying this DSL modem is that I can't connect to the internet. And the manual for the product, which tells me what I have to do to configure it before it will connect to the internet, can be obtained only by connecting to the internet. I can see they really gave a lot of thought to how their customers would use this modem. I wonder if they make other consumer gizmos? Perhaps a microwave oven that can only be used on food that's already hot, or a dishwasher that only works on clean dishes? (Actually, I already have one of the latter, so maybe that's one of their products.)

I drove back to the office to download the manual from my office computer, and then take it home to do what was necessary to get the thing working.

And now it is working, and here I am! But it's still pretty windy, so I'd better write something and post it before I the power goes out again.

 


Abe's Update

Remember Abe Ramos? I did a profile of him a little over three years ago, describing his diabetes adventure, and his determination to manage his diabetes without depending on prescription drugs to do the heavy lifting for him. Perhaps you've absorbed enough of the prevailing medical pessimism about diabetes management to assume that he's screwed it all up by now, and lost control of his blood sugar. Not so, skeptical reader!

I heard from him yesterday: "Had my annual physical last week and just got my test results in and other than my wife, you were the next person I thought of! A1C of 5.1,cholesterol good, etc. I just made my 5 year anniversary of being medication free!!!!"

So there you have it: other people can do this. I'm not unique in succeeding at this; there are other people besides me. Maybe you'd never hear about them if you didn't hear about them from me, but they exist.

Congratulations, Abe -- keep it up!

 


American Health Care

Here's a picture worth a thousand words: the relationship between how much a country spends on health care per person and how long people live in that country. For most countries there is a clear relationship between the two (a rising arc of life expectancy for countries that invest more in health care), with one notable outlier.

Yeah, that's us way over on the right. Americans, who pay more for their health care than anybody else, die younger than people in most developed countries. Make of that what you will, but you're going to have a hard time making a case that this graph shows we're doing everything right when it comes to keeping ourselves healthy.

 


Is that your pancreas or are you just glad to see me?

Transferring beta cells from the pancreas to the eye might seem like a strange idea to you -- and that's because it is a strange idea. But some Swedish researchers think this strange idea is worth pursuing, according to the tragically-named scientific journal PNAS.

The beta cells in your pancreas are important because they create your insulin supply, and it would be useful to diabetes researchers to be able to keep a watch on the beta cells and see how they respond to changing conditions (and especially how they respond to medications). But the trouble with beta cells is that they're in a very inaccessible place. The pancreas is about as well-concealed a location as there is in the entire human body; it's terribly difficult for doctors to get to the pancreas, or figure out what's going on in there. (This is why pancreatic cancer has such a low survival rate -- it's hard for doctors to see that anything bad is happening there until it's wildly out of control.)

Well, the Swedish researchers have found a way to keep an eye on beta cells. "What we've done is made the cells optically accessible by grafting a small number of 'reporter islets' into the eyes of mice, which allows us to monitor the activity of the pancreas just by looking into the eye... We're now able to really study the insulin-producing beta-cells in detail in a way that wasn't possible before... The Islets of Langerhans can be visualised repeatedly over a period of several months, and our work shows that during this time, functional and morphological changes occur in them that are identical to those occurring in the pancreas."

It's not entirely clear to me from the article whether the idea is simply to use this trick in animal studies of drug effects, or if the researchers want to transfer beta cells into the eyeballs of human diabetes patients, so that changes in their beta cells can be visually tracked.

If this is going to be done in humans, I hope we don't find out later that the researchers have simply found a way to give people pancreatic cancer in their eyes, of all places.

Maybe this research will lead us to something useful. Maybe it won't. In any case, I hope it isn't just used as a means of searching for the next billion-dollar drug. It would be nice if this research could add to our fundamental understanding of how diabetes works.

 


Dealing with the Unpredictable

Wednesday, November 20, 2013

 


My Surprising Day

Okay, so yesterday's surprise test result was 106 in the morning -- definitely above my comfort zone for a fasting result, and yet I couldn't see any reason why it should have been unusually high. Today's fasting result was much preferable. But then tonight's post-prandial result was inexplicably low.

I like to think of my blood sugar as controllable and predictable to a very large degree. I know the factors that affect it. If I get an unusually high or low result, it ought to make sense to me in terms of what I've eaten lately, and what my exercise schedule has been like lately, and so on.

That is true more often than it's untrue, but fluctuations in blood sugar can sometimes be impossible to account for in terms of any factors which I can directly control or directly observe. Every once in a while I've tried doing everything the same way on two consecutive days (same meals, same workout, same schedule), and the test results are not always similar on both days. Blood sugar is a variable phenomenon, and some of the factors which cause it to vary are outside of our awareness.

For a patient with Type 2 diabetes, the wild card is insulin sensitivity, which is generally lower in Type 2 patients, but which has a strong tendency to fluctuate in response to various factors. Unfortunately, only some of the factors which have an impact on insulin sensitivity are controllable.

Exercise tends to increase insulin sensitivity, which is why I make it the cornerstone of my system of glycemic control. Other factors have a tendency to reduce insulin sensitivity. One of them is dehydration (which means that prolonged exercise in hot weather can become counterproductive if you don't replace the water you're losing). But probably the most important factor which reduces insulin sensitivity is inflammation -- which can proceed from a variety of causes.

A lot of different things can trigger an inflammatory response which suppresses insulin sensitivity. Having an infection is one (including the low-grade chronic infection associated with periodontal disease). Obesity can trigger an inflammatory response as well -- in fact, it may be that obesity's association with diabetes is mainly because of that inflammatory response, more than because of any other impact that obesity has directly. Another great promoter of the inflammatory response is stress (and its associated stress hormones, adrenaline and cortisol). The association between sleep-deprivation and diabetes might be that people who aren't getting enough sleep are releasing a lot of stress hormones as a result, and this is promoting inflammation, which in turn impairs insulin sensitivity.

Clearly, if a variety of things (some of which fluctuate in a way which you can't control) are going to have an impact on your insulin sensitivity, then unpredictable daily variations in glycemic control are going to occur. Therefore, your glucose test results will not always make sense to you; they will rise and fall for no understandable reason. Since you can't tell what your cortisol level is at any given time, you can't be expected to understand what's going on when it increases.

That doesn't mean you should give up on the idea of glycemic control. There are things you can do in a general way to reduce the factors that impair insulin sensitivity. One thing you can do, which most people don't think of, is look after your teeth -- or rather your gums. Periodontal disease is a common inflammatory condition which can make glycemic control a lot harder to achieve. I guess my mind is on the subject because I had a dental appointment this morning (I have them pretty often because I have a history of trouble in that area). This time things were looking good; my dentist and his hygienist both told me gums were looking much improved, and there was nothing wrong on the X-rays. Okay, so I'm doing okay on that particular front. But I don't have a handle on everything that can impact my insulin sensitivity, so some of what goes on with my blood sugar is unpredictable.

When you get surprised by your blood sugar, you have to step back and take the long view. If what's happening on average is in the right range, you can relax a little about the surprises that happen on a day-to-day basis. The trick is not to relax about everything, even when the long-term trend is not good.

You don't want to over-react to fluctuations, but you don't want to ignore them either. It's not an easy balance to strike, but that is the task at hand. Somehow or other, you need to learn how to deal with the unpredictable.

 


Another Failed Prediction

My surprising day wasn't as surprising as that of the "psychic" charlatan Sylvia Browne, who is in the embarrassing position of not being alive today. She died very much as she had lived: inaccurately. Up to now, her best known error was appearing on television with the mother of a missing child (Amanda Berry) and telling her that her daughter was dead (actually, Berry was alive, and still is). But Browne also predicted her own death, which she said was not to happen until she was 88. She died yesterday, at age 77.

People who like to believe stupid things will surely say: okay, she was a little inaccurate about when it would happen, but at least she was right in saying that she would die. Strange as it may seem, people who are determined to believe in psychic powers are willing to redefine them on the fly, to whatever degree is needed, to make them seem at least slightly valid. Given that amount of wishful thinking, predicting something that can't not happen is all it takes to impress some people.

Here's my own prediction: that the idea of psychic powers will never go away. The supply of people who like to believe stupid things is inexhaustible, and the money that can be made from those people is too tempting, and too easily obtained from them, to be ignored.

 


Activity and Diabetes Risk

Tuesday, November 19, 2013

Yikes! 106 is not the kind of fasting result I like to see! And I don't understand why it was that high, either. I had dinner late last night (after getting home from my yoga class), but I didn't think I overdid the carbs. Oh well, let's see if it's any better tomorrow -- if not, think of something to change!

That's pretty much the whole story of diabetes management: get a result you don't like, see if you can figure out why it happened, try for a better result next time -- and if you don't get a better result next time, think of something you can change. That's my process, anyway. Some people use a different process which goes: get a result you don't like, get depressed, give up. (It has the virtue of simplicity, but there are drawbacks to it.)

 


What's Your LTPA Category?

Medical researchers are fond of acronyms, and as a result I spend a lot of time on the web looking them up to see what they stand for. However, because medical researchers aren't the only people who are fond of acronyms, I sometimes have to dig through a lot of different definitions for a given one before I find anything relevant. Tonight, I was trying to find out what "LTPA" was (since it was being reported to influence the risk of diabetes).

Actually, by mistake I originally searched on LPTA rather than LTPA, and got such results as "Laser Percutaneous Transluminal Angioplasty" and "Licensed Physical Therapy Assistant", not to mention the less plausible "Lowest Price Technically Acceptable" and "Lower Paper Tray Assembly". But when I got the spelling right, I found "Leisure Time Physical Activity" and I knew I was on the right track.

Leisure time physical activity is what you and I know as "exercise". Bear that in mind.

Anyway, I Diabetologia has published a study which looked at Finnish men of a certain age (in their early 70s, on average) who had formerly been elite athletes. The idea was to see if their athletic background gave them a different risk profile for diabetes than men who did not have that kind of background. I was interested in this because some studies have recently suggested that very intense exercise can do more harm than good in the long run, at least by some measures. Was this study going to show that seriously competitive athletes were at a disadvantage when it came to diabetes risk, or would it show that athletes fared better instead of worse?

It turned out that former athletes have a lower risk of becoming diabetic later in life than most people. Risk was reduced by 32% in former elite athletes generally, but by a whopping 61% in patients who had been involved in endurance sports rather than power sports. (Distance runners, in other words, were the best-protected against diabetes.)

But the researchers also looked into how physically active these former athletes are now. They sorted the men into LTPA categories (based on how much energy they are burning off due to physical activity per day). Here's the distribution:

That is, more of the former athletes were in the second-highest category of physical activity, but the overall distribution was fairly random. However, things look a lot less random when the men who developed diabetes are sorted into LTPA categories. Diabetes prevalence is, rather dramatically, highest in those who are least active today, and lowest in those who are most active today.

So, the moral is that it helps to have been an elite athlete in your youth, but it still matters a lot what you have been up to lately. Perhaps the reason that former elite athletes do better in general is that, according to the first of the two bar graphs, a lot of former elite athletes remain active later in life, and reap the benefits of that.

You might think that all of this talk about diabetes risk is a rather academic (that is, pointless) issue for anyone who already has developed diabetes. Why should we care, if we've already made that transition?

I think we should care because whatever tends to promote diabetes for those who don't have it probably also makes diabetes worse for those who already do. I pay a lot of attention to factors which are found to increase the risk of diabetes, because I take it for granted that they also increase the severity of diabetes once it is present.

So I keep exercising.

 


Autumnal Thoughts

Monday, November 18, 2013

I don't like seeing fasting results above 95, but yesterday was a day of indulgence -- including dinner at a really good Mexican restaurant -- so I shouldn't be too surprised. My post-prandial result after lunch was good, though.

And I wasn't nearly as stiff and sore at my yoga class tonight as I was last time. That's always nice to see!

 


Okay: Fall Exists!

I was beginning to wonder if fall was ever going to arrive, but I think it's here. It was chilly this morning, and rain is forecast for tonight (80% chance) and tomorrow (100% chance). Maybe tomorrow will be a gym workout for me, rather than an outdoor run.

On Saturday I took a walk at Spring Lake in the late afternoon, and found subtle signs of the season everywhere.

"Fall color" is a decidedly muted phenomenon in California (where it doesn't get cold enough at night to bring out the tints in the foliage), but if you look around you can find a few traces of it.

People taking walks in the area were putting on sweatshirts and even light jackets -- which, in these parts, is how you know that the change of seasons is starting to get serious.

Another sign of the season was that it was staring to get dark by the time I made it around the lake.

But it was worth it, to see the dramatic rise of the full moon over the ridgeline.

Fall can be one of the best times of year for outdoor exercise, provided you're dressed right for it. The trouble is that it's hard to be sure if you're dressed right for it -- it's pretty easy to find yourself out there on the trail, wearing too many layers or not enough of them. Still, exercising in cool weather can be very refreshing, and it makes for a great hot-shower experience afterwards.

But I have to admit that exercising in the rain is not my favorite approach, so if the forecast is right about tomorrow, I'll probably be doing my exercise at the health club.

 


Don't Talk Backwards

I'm surprised how often health headlines give a misleading impression of the news they are summarizing. Sometimes the headline says the opposite of what it should. Such was the case, I thought, with "Cardiovascular Complications Diabetes Associated With Physical Activity" in Science Daily.

That makes it sound as if physical activity causes, or at least is linked to, diabetes complications. The opposite is true, however; they should have said that diabetes complications are associated with the lack of physical activity, because that is what the referenced study actually found. The original report from the European Society of Cardiology, had a less misleading headline: "Cardiovascular complications of type 2 diabetes associated with levels of physical activity". This was study of cardiovascular complications specifically, and the conclusion was pretty stark: "Notably, those with low levels of physical activity had a 70% greater risk of cardiovascular death than those with higher levels."

Well, golly, what have I been telling you all along?

 


Hurting Versus Not Hurting:
Which Is Better?

Thursday, November 14, 2013

 


Enjoy Your Body While You're In It!

I have let myself get a bit distracted from certain body-maintenance issues in the past few weeks. I didn't go to my usual Monday night yoga class this week, because I had an evening medical appointment -- and I had also missed the same yoga class two weeks earlier because of a late meeting at work. Could that be why I've been feeling unusually stiff and sore this week?

It's funny how the most trivial actions we perform daily tend to put us on notice that we haven't been doing proper body maintenance. For me, this week, it's been the act of putting on my pants in the morning. I've been finding that stepping into my pants is not quite the effortless gesture it used to be. I have to think about where I'm going to standing and what I'm going to be leaning against.

When a simple action (which you are used to performing quite unconsciously) suddenly requires a strategy, that's a sign that you have neglected the issue of body-maintenance and are paying a price for it.

My yoga class was exceptionally hard for me tonight. We weren't doing anything all that difficult, but suddenly a lot of it was painfully difficult. The main problem-area was my lower back -- which used to be a huge problem for me, but hasn't been bothering me very much since I started using yoga to stretch my poor spine out. Now it's bothering me again.

A lot of things could be contributing to my current stiff-and-sore condition, but probably the biggest issue is simply that I'm getting older, and as you get older it become much harder to get away with things. The body becomes increasingly unforgiving of any neglect, or any needless stress.

I had a bit of a discussion with my doctor about this kind of thing on Monday. He had found that his usual physical position during his office visits with patients (seated with his right elbow resting on the counter beside him) was wreaking havoc on his right shoulder, and he'd been forced to train himself not to do it.

All sorts of postures and other physical habits can place unhealthy stress on our bodies, and it may take a long time for that stress to manifest itself as pain or inflexibility. But when the evidence of harm comes in, we need to react to it, and do what we can to correct the situation.

My Monday night yoga class has been my general solution to body-maintenance problems, but it's not a useful solution if I don't do it regularly. I guess I need to set aside more time for this kind of thing.

I admit that yoga (and tai chi, and pilates, and other body-maintenance disciplines) are not necessarily the most thrilling ways to spend an hour, and it's easy to say "forget it, I'm too busy for that today". Unfortunately, pain always has time for us, no matter how busy we are. Keeping the body flexible and pain-free is just one of those things that has to be done, whether we get a kick out of the process or not.

I don't think of yoga as something that helps me with diabetes management in any direct way. But it helps me keep the machine going, and that is definitely necessary for diabetes management. And when I don't do it, it comes back to haunt me!

 


Bones Matter

Wednesday, November 13, 2013

Rather amazing running weather we're having. Here it is mid-November, we've had no rain (and none is forecast), and today was sunny and in the 70s. The fall foliage is out there -- mostly on the ground at this point. When I go out running at lunchtime, I'm ploughing through great colorful drifts of them, crunch crunch crunch. I'm enjoying it while I can. Eventually the weather will make outdoor exercise a little less comfortable (at least I assume it will, but it is starting to look as if we've got a drought on our hands, so I don't think I'll have a lot of precipitation to deal with).

 


Keep an Eye on Your Bones

Oh, great -- one more thing for diabetes patients to worry about. We needed one, right? Anyway, it looks as if diabetes can undermine your bone strength.

The Mayo Clinic site has reported on a study (hidden behind a paywall at the Journal of Bone and Mineral Research) which looked into the question of increased bone-fracture rates in diabetes patients. Specifically, the researchers looked at post-menopausal women, as that is a population segment with a high rate of osteoporosis (that is, porous bones -- which can set you up for very debilitating injuries such as hip fractures).

What the researchers expected to find was that diabetes tended to promote osteoporosis. They expected to see lower bone density in diabetic women. What they found was a little different than that, but not more encouraging. They found that diabetic women had higher rates of bone fractures than non-diabetic women even if they had normal bone density! Examination of the bones of diabetic women found that their bones had reduced material strength, even if their bones were not porous, or low in density, or marked by any visible abnormality in their microstructure. "The study showed that diabetic women with lower bone material strength had also experienced higher levels of hyperglycemia over the previous 10 years, suggesting potential detrimental effects of poor glucose control on bone quality." The obvious question (why were their bones less strong, if they weren't porous or low in density?) is apparently not answered, or perhaps even asked, by this investigation.

But anyway, there's your bad news for the day: diabetes is associated with a weakening of bones which is not the same as osteoporosis but has the same painful and crippling effects.

I feel like it's my job to come up with a silver lining here, as my site aims to be non-depressing. Here are the two that come to mind:

  1. The weakening of bones is apparently driven by hyperglycemia. Keeping your blood sugar under control is protective. Some diabetes complications (especially the very dangerous complication known as coronary heart disease) are not much mitigated by maintaining good control. But maintaining good glycemic control appears to be a useful countermeasure against this particular problem.
  2. Vigorous physical exercise tends to strengthen the bones, so you can probably counteract the bone-weakening effects of diabetes at your local gym. (Weight training is particularly useful in this regard.)

So, anyway, do your best to look out for your bones. You never know when you might need them.

 


The Cause (or the Causes)

Tuesday, November 12, 2013

 


Cause of Diabetes Found: "Being Alive"

For a long time the big mystery about Type 2 diabetes was that nobody knew what caused it. These days, the mystery is that every researcher who looks into the question discovers a different cause for the condition. Every week, new genes, new proteins, and new aspects of fat metabolism are shown by some research study or other to be the cause. Apparently everything causes Type 2 diabetes. Being alive on planet earth may well be all it takes.

It doesn't seem unreasonable to me that a process as complex as glycemic regulation might fail in more than one way. As I've said many times before, the term "Type 2 diabetes" is probably a category of diseases rather than a disease; any failure (or partial failure) of the glycemic regulatory system that isn't caused by an autoimmune reaction knocking out the beta cells in the pancreas is categorized as Type 2. But "Type 2" basically means "all forms of diabetes that aren't Type 1". We shouldn't be surprised to learn that more than one problem might impair glycemic regulation.

Still, the sheer number of proposed causes for Type 2 is a disconcerting. It's only Tuesday, and already I've learned about two more of them this week. One of them is acidic foods in the diet, and the other is improper "clumping" of certain proteins.

The one about acidic foods comes from a French study of 60,000 women which found that "higher overall acidity of the diet, regardless of the individual foods making up that diet, increases the risk of type 2 diabetes". The theory behind this is that "increasing acidosis can reduce the ability of insulin to bind at appropriate receptors in the body, and reduce insulin sensitivity".

The catch is that foods can be "acidogenic" regardless of whether they are acidic in the form they are eaten; some acidic foods (such as fruits) contain "alkaline precursors which neutralise the acidity", so they end up reducing acidity in the body even if they are acidic when swallowed. So how do we know which foods are "acidogenic"? The study authors make it pretty clear that they are talking about animal proteins. Eat more meat, and you increase your diabetes risk.

Immediately you're wondering if the study authors are vegetarians looking for an excuse to promote vegetarianism. We can't rule that out, of course, but I assume that if they're wrong about this, subsequent research will debunk their claims. Meanwhile, if your appetite for details about this study is insatiable, you can download the full report in all its glory here.

The theory about protein clumping comes from research at the University of Wisconsin. The idea is that insulin production in the pancreas is impaired in Type 2 patients because a protein called amylin clumps together in an undesirable way around the beta cells in the pancreas and forms destructive plaques. This occurs in some animal species but not in others, because the structure of the amylin protein varies from species to species. This is thought to be the explanation of why cats and humans develop Type 2 diabetes, but dogs and rats don't. The researchers in Wisconsin have identified a specific section of the amylin known (for good reasons, I am sure) as "the floppy FGAIL region", which determines whether or not the amylin is going to clump together and form a harmful plaque. They think that zeroing in on the floppy FGAIL region will eventually enable them to develop drugs which target that region, and prevent the floppy bit from becoming rigid. And there you go: Type 2 diabetes prevented!

I suppose it is hardly necessary to point out that this is extremely preliminary information, probably years away from practical applications. But there it is for whatever it's worth: yet another instance of somebody discovering The Cause Of Type 2 Diabetes.

 


Common Sense in the Kitchen

Speaking of floppy bits, here's some practical advice which you will be sorry if you disregard! Don't claim that I didn't pass along any practical tips to you today:

I don't want to be hearing about any such shenanigans from my readers. The kitchen is a difficult enough venue for diabetes patients as it is; you don't need to be adding any needless complications. (And if you can't resist, don't offer me any of your Pop Tarts when I come to visit.)

 


Seeing the Doctor

Monday, November 11, 2013

I don't like seeing fasting test results above 95, but I guess the 100 fasting result I got this morning isn't so surprising, because yesterday I indulged in some high-calorie, high-carb foods while I was wine-tasting and picnicking at the local vineyards. After my low-carb dinner tonight, the post-prandial result was not significantly higher than my fasting test had been.

I think that, every once in a while, people who are managing diabetes just have to drop their guard and eat and drink what they want to, especially at events such as picnics and holiday parties. The trick is to reel it back in the next day, and get yourself back in the zone where you need to be.

 


Annual Physical

I had already had the lab work for my annual physical done a couple of weeks ago, and the results were normal -- or, as my doctor put it, awesome. (When you're a diabetes patient, "normal" pretty much equals "awesome".) But you do actually have to show up in the examining room and do the dignity-shedding thing as well. Until somebody with an MD has given your prostate a handshake, you can't really say that you've had your annual checkup.

So we did all that (no problems were discovered in the process -- my prostate is, if not awesome exactly, at least perfectly fine). But the indignities didn't really take up too much of the visit -- and it was a surprisingly long visit, despite all I hear about how much doctors are under pressure to minimize the time spent with patients. So we spent a lot of time on seemingly non-urgent "maintenance" issues -- especially the challenges of staying active over the years, as the body's natural tendency to slow down with time comes into conflict with our best intentions. My doctor seems confident that I'll manage to do what needs to be done, even if it becomes a tiny bit harder to accomplish every year.

In fact, after so many years of good results, he is thinking that in another year or so he will take "diabetes" off my problem list in his records. This has no actual consequences from an insurance perspective, or any other perspective really, except that it might mean he'd stop doing hemoglobin A1c tests on me, until he saw some other indication that I was losing control. He said this doesn't happen often (he's only had a couple of other opportunities to take a patient out of the diabetic category, so even as a symbolic formality it's significant).

Much as I appreciate that symbolic formality, I told him I thought the annual A1c test was an important guidepost for me, and I'd like to continue doing that test. He said this was a reasonable attitude to take, and if it was important to me he'd continue to order them.

But there can't be many diabetes patients who are told by their doctors that maybe there's no need to track A1c result any more. So I'll gloat on that fact for a while, even if I still want to collect that data for my own purposes.

In short, I have the right to continue being concerned -- but I also have the right to be smug as well! It's what you might call the best of both worlds.

 


Blots

Friday, November 8, 2013

I took a chance on lunch today: a mushroom soup not made by me (I had no way of knowing how much flour or potato-starch might have been put in it to give it that thick consistency) and a Fuyu persimmon (which I assumed was no worse than an apple in terms of sugar content, although subsequent research has shown that I was quite wrong about that). After a long and hilly lunchtime run, I figured I could probably handle those things. Wrong! My post-prandial glucose at the one-hour point was 157 mg/dL, which is well above my comfort zone (and also above my doctor's comfort zone, even though he is less strict than I am in such matters). I decided I'd better test again after two hours (which is when most people test anyway), and got a much more comforting 104.

I guess that's why I think the one-hour interval I usually stick to is a better choice; your post-prandial glucose is likely to be at its actual high point after an hour, and you might as well know how bad things are getting at the high point, even if you'd much rather see how things look after the high point is past.

I still like a Fuyu persimmon better than I like an apple, but that doesn't mean a Fuyu persimmon likes me. Maybe I could handle eating half of one, but apparently eating a full Fuyu persimmon is not a good plan for me. (I doubt that the soup was the main culprit today.)

This is what post-prandial glucose testing is for: it gives us an opportunity to find out if our ideas about which foods we can handle are true or false.

 


The Test

Today's birthday boy is the Swiss psychiatrist Hermann Rorschach, inventor of the ink-blot test, born this day 129 years ago.

As a young man Rorschach was torn between potential careers in art and psychiatry. He was so fond of making inkblot images as a boy that his schoolboy nickname was "klecks" (German for inkblot). He is remembered today mainly as the creator of a personality test in which people are asked to say what they "see" in a standardized set of inkblots.

Rorschach is also remembered as being better-looking than the other pioneers of psychiatry. What a lot of people claim to "see" when they look at photographs of him is "Brad Pitt".

Anyway, Rorschach's famous inkblot test consists of a series of ten symmetrical inkblots. Rorschach experimented with several hundred inkblot images, and settled eventually on the ten images that he found were most likely to evoke a specific response from patients asked to say what they "saw" in them.

A couple of them are bats, although a lot of people claim to see them as butterflies, because someone had warned them that psychiatrists think you're weird if you see a bat, even when they're showing you a bat. But they're bats, people, let's stop playing games!

One of them is a picture of two wizards high-fiving each other...

And another depicts a couple of headwaiters quarrelling over which of them has the more stylish bowling bag.

The other pictures are a little harder to interpret, but psychiatrists who use the test are pretty sure they reveal a lot about how we see our mothers, our fathers, and sex. This picture of an animal-skin rug, for example, is supposed to be the sexiest of the lot.

Perhaps you'd like to be left alone with that one for a while. And perhaps not. There is always the possibility that the psychiatrists who have read so much into this test and people's reactions to it are casting a brighter light on themselves than they are on anyone else.

What interests me about this test is that Rorschach himself doubted that it could be useful as a personality test. His intention was to use it as a screening test for schizophrenia. He had found that people with schizophrenia gave strikingly different answers on this test than anybody else did. I'm not sure what they saw where everyone else saw a bat (or pretended to see a butterfly), but apparently it was different enough that Rorschach thought this could be a quick and easy way to identify schizophrenics. He did not think it would reveal variations of personality within the non-schizophrenic population. Unfortunately, he died at the age of 37, and years later others took over the test and decided that they could use it to judge people.

That's pretty much the history of psychological testing in a nutshell: someone invents a test to screen for a particular problem, and then other people go nuts with it and decide it reveals everything about everyone. Binet intended his "IQ" test for a very limited (and benevolent) purpose: it was a screening tool for identifying schoolchildren with learning disabilities, so that students who needed special help could receive it before they fell too far behind in school. He never intended it as a measure of adult mental capacity, still less as the cultural weapon it later became.

We need to beware of our own tendency to see test data as conveying a meaning beyond anything that is actually being measured by it. I'm collecting medical data on myself all the time, and obviously I take test data seriously. But I try to remind myself frequently of what a test measures and what it doesn't measure. I try not to get carried away.

I love the Sherlock Holmes stories, but I can't read a description of Holmes examining the stains on man's hat, and announcing that the hat's owner is obviously a retired military surgeon whose wife no longer loves him, without thinking that Holmes is jumping to conclusions. Let us learn what we can from the data that is available to us, but let us not lose sight of the limitations of that data.

 


If You're Very Young at Heart

Thursday, November 7, 2013

Beautiful fall weather, sunny and clear and slightly warm. May it continue!

 


Why Is Diabetes so Bad for the Heart?

One of the reasons why I think lifestyle changes (and particularly exercise) are crucial for diabetes management, no matter what medications you might be taking, is that diabetes has a detrimental effect on heart health -- and this seems to be true even if (by means of medication) you bring blood glucose, lipids, and blood pressure under control. There is still an added cardiac risk if you have diabetes, even if your lab numbers relevant to cardiac health look good. You have to do more to strengthen your heart than avoid the kind of lab results that tend to weaken it. And when it comes to strengthening your heart, there is nothing quite like exercise.

But a crucial question remains: why does diabetes undermine heart health? What is the mechanism for the harm that occurs?

A partial answer seems to emerging from research going on at the University of Texas Medical Branch. Diabetes activates an enzyme known as protein kinase C, or PKC for short. PKC is a protein that regulates other proteins. The PKC activation caused by diabetes has strange effects on the proteins in heart muscle. Apparently the effect is to cause "mechanisms of the heart to behave as though it were still an embryo". Adult heart muscle thinks it is fetal heart muscle, and exhibits inappropriate growth of fibrous tissue that clogs the heart and makes its pumping inefficient. The result is "heart failure" (which means weak pumping action, not cessation of heartbeat, but is a very serious condition).

What's not clear from the research (at least not clear to me from the full paper) is how diabetes activates PKC, with the result that an adult heart thinks it's an embryonic heart. Unless I misunderstand the paper (always a possibility) the researchers don't understand this either; they have simply noticed that diabetes activates PKC somehow or other, so they've studied the results of that activation.

It seems to me that the most useful thing for the researchers to do is pursue a full understanding how diabetes activates PKC. Maybe there's something that could be done to prevent that?

Anyway, I'm hoping that my daily exercise is doing a better job of strengthening my heart muscle than PKC is of infantilizing it.

 


By the way, I resisted strong temptation tonight: I did not allow the spell-checker to change "kinase" to "kinks". Kinks may occasionally play a role in heart trouble, but that's not our theme tonight.

 


Blueberries

Wednesday, November 6, 2013

I swear there's no sensible reason why my fasting glucose should have been up this morning. Well, sometimes fasting glucose does not follow sensible rules.

 


Fruit and the Diabetes Patient

We all know that fruit is supposed to be "good for us", and that fruits contain not only vitamins but a variety of other compounds that are supposed to provide this or that health benefit. A diet rich in fruits correlates well with good cardiac health, for example. And yet, in terms of macronutrients, fruits provide little besides sugar (and fruit juices are even worse in this regard, being highly concentrated sugar, with fiber largely eliminated). Don't fruits spike your blood glucose too much to be considered "healthy" for anyone managing diabetes?

Well, some fruits do that, at least in my experience. I have largely given up on bananas for that reason. (To console myself for the loss, I have decided to focus on a creepy fact: a Brazilian spider species that is sometimes accidentally imported on bunches of bananas is reputed to have the deadliest venom in all spiderdom.) But some fruits carry less of a glycemic payload than others, and might qualify as practical health-foods for diabetes patients.

A particularly promising fruit in this regard is the blueberry.

Actually, you probably have a pretty good idea of what blueberries look like, but I think I need to include a photo of actual blueberries to underline the point out that blueberries don't look like this:

Sad to say, the "blueberries" inserted into pastries sold as "blueberry muffins" are typically not blueberries at all, but artificially colored sugar-blobs. So, please understand that I'm talking about blueberries, not "blueberries".

Anyway, blueberries have less of a tendency to spike your blood sugar than most fruits. A 5-ounce serving of raw blueberries provides about 21 grams of carbohydrate, of which 4 grams is fiber, and as fruits go it has a comparatively modest glycemic impact. And blueberries seem to provide advantages to make up for the sugar in them.

Researchers report that "Wild blueberries are a rich source of phytochemicals called polyphenols, which have been reported by a growing number of studies to exert a wide array of protective health benefits. A new study by researchers at the University of Maine adds to this growing body of evidence. This new research, published today in the journal Applied Physiology, Nutrition, and Metabolism, shows that regular long-term wild blueberry diets may help improve or prevent pathologies associated with the metabolic syndrome, including cardiovascular disease and diabetes."

The research in question relates to the obese Zucker rat, an animal which is seen as a good model of the human metabolic syndrome which produces Type 2 diabetes. I'm not absolutely sure what the Zucker rat looks like, as my Google searches for it yielded results as disparate as this...

...and this:

I assume the first of those two pictures is more relevant, as he certainly seems more obese. Anyway, the research on obese Zucker rats found that "Obese Zucker rats exhibited a reduced vasoconstrictor response to Phe and an exaggerated vasorelaxant response to Ach. The [wild blueberry] diet partially restored Phe-induced constrictor responses and attenuated Ach-induced relaxant responses... In conclusion, [wild blueberry] consumption altered the biomechanical properties of the [obese Zucker rat] aorta by partially restoring the impaired Phe-induced constrictor responses and attenuating the exaggerated response to Ach-induced vasorelaxation." So you see. I'm only reading tea-leaves here, but all the indications are that the changes induced by blueberry consumption in the obese Zucker rats are thought to be good changes.

So there you are: blueberries are good for you, and good for your heart! The catch is that the rats in the study were eating a lot of blueberries, equivalent to a human eating 2 cups of them per day. You're probably not going to do that, and I'm not suggesting that you should. But it does appear that blueberries offer health benefits, and if you can tolerate them (in terms of their impact on your blood sugar) it seems like blueberries are a good fruit for you to include in your diet.

The catch is that you really have to do enough experimentation with your glucose meter to be pretty confident about how well your endocrine system handles what amount of blueberries. You can't adopt a rule as simple as "I read on some guy's blog that blueberries are good for people with diabetes, so I'll eat as many of them as I want as often as I want". That, alas, is not how diabetes management works.

 


Thoughts on DST and the OGTT

Tuesday, November 5, 2013

 


Thought for the Day

Daylight Saving Time is like painting an exterior wall by holding a paint-brush in a fixed position and moving the house back and forth against it.

I mean, if people wanted to get up earlier in the summer, they seemingly could. We don't have to get the whole population to agree to spend several months of every year lying about what time it is, just to make that happen.

Part of my annoyance with the whole program is that it is not universally adopted. Some countries use it, many don't (partly because it's pointless if you're near the equator), and even those countries that use it do not necessarily make their time changeovers on the same date. So, the system is hellishly confusing if you work in an international business (I do, and scheduling phone meetings with overseas collaborators is hard enough as it is, without throwing in uncoordinated time changes).

I'm surprised that the people who invented Daylight Saving Time were content just to monkey with our perception of time. To help conceal from us the changes that summer brings, why didn't they also arrange for 20 degrees to be subtracted from all temperature readings? On a certain Saturday night each year, the evening news anchors could remind us not to forget to put out our summer thermometers.

And during the winter holidays, they could subtract 10 pounds from body weight measurements! I should think that would be a popular idea, in the aftermath of the Christmas-party season. Who wouldn't give up Daylight Saving Time in exchange for Daylight Losing Weight?

 


Screening for Gestational Diabetes

Every once in a while some medical society proposes a medical screening policy with I had thought was already a well-established practice. For example, the Endocrine Society has issued a Clinical Practice Guideline recommending universal diabetes testing (using the Oral Glucose Tolerance Test, or OGTT) for all pregnant women.

You mean this hasn't already been happening? Every woman I know whose been pregnant in recent years has had to take the OGTT, and some have been startled to find that they didn't pass it. Gestational diabetes is extremely common (supposedly almost a fifth of pregnant women experience it). I thought universal screening was already the rule. But maybe the pregnant women I've known had better health insurance than a lot of women do.

Is there any substantial difference between gestational diabetes and Type 2? Women who become temporarily diabetic during pregnancy very often develop Type 2 later on; it's highly likely that the women who experience gestational diabetes are simply those who happen to have a genetic predisposition to Type 2, and the rapid weight-gain (or other physical changes) associated with a pregnancy brings the problem to the surface. Their bodies get the problem under control for a while after the pregnancy is over, but it is still lying in wait. (This version of events is merely plausible, not proved -- it could be that gestational diabetes is different from Type 2 in some way that has not been identified.)

Even if gestational diabetes is purely temporary, it does have an impact while it lasts. In particular, chronic high blood sugar "overfeeds" the fetus, so women with gestational diabetes tend to have very big babies. I can't say for sure, not having given birth myself, but I bet that's not a good thing. So, considering how common the problem is, I would certainly tend to agree that a diabetes screening test for pregnant women ought to be the norm. The only drawback is that the OGTT involves swallowing 75 grams of glucose at once, which can be a bit nauseating, and early pregnancy is a time when anything that tends to cause nausea has got to be a very tough sell. I'm not the one who has to sell it to pregnant women, though, so I say go for it!

 


A Mystery Solved

Monday, November 4, 2013

Pretty nice weather for my lunchtime run today -- sunny and clear, slightly warm, and breezy. The falling autumn leaves were blowing about (yes, we do have them in California -- they're just not as colorful, because it doesn't get cold enough at night for the more dramatic shades to emerge). Our fall weather is very comfortable for running. I'll enjoy it while I can.

 


How Metformin Works

The diabetes drug metformin has been around for an awfully long time. It belongs to a class of drugs known as the biguanides, which were originally isolated from a plant long used in folk medicine: Galeta officinalis, also known as goat's rue and (somewhat more encouragingly) French lilac. I mean, if you were naming that, would you rather call it "goat's rue" or "French lilac"? (If you chose the former, marketing is not the right field for your skill set.) Anyway, the plant in question was known to reduce the blood glucose levels of rabbits that ate it, and subsequent research showed that it could have the same effect on diabetic humans.

The specific compound now called metformin specifically was identified in the 1920s, and developed as a diabetes drug in the 1950s. So it's been around a long time, and has become a cheap "generic" drug. Naturally, the pharmaceutical industry has been trying hard to replace it with something else that's a lot more expensive and profitable, but they've been having a really hard time creating anything that's any more effective or has less harmful side-effects. The main side-effect of metformin is gastrointestinal distress (diarrhea, cramps, nausea, vomiting, and increased flatulence); those don't sound like the kind of features that you want to highlight in the product brochure, but most drugs competing with metformin cause side-effects that are more dangerous than that, which is why metformin is still very widely prescribed. In fact, metformin is thought to be the most widely prescribed diabetes drug there is (48 million prescriptions for it were recorded in 2010).

Given the popularity and longevity of the drug, it's a little weird that doctors have never had a very good understanding of how it works. They were aware that metformin somehow discouraged the liver from releasing too much stored sugar into the bloodstream (a common problem in people with Type 2 diabetes), but how this miracle was accomplished was unclear for a long time.

That is, it was clear until this month. Researchers at McMaster University (it's in Ontario, Canada; the fact that their website is so shy about mentioning that they're Canadian should have been enough to let me know what country they're probably in) believe that they have figured out how metformin works. I guess the title of their paper tells all: "Single phosphorylation sites in Acc1 and Acc2 regulate lipid homeostasis and the insulin-sensitizing effects of metformin".

Well, perhaps that doesn't tell the whole story for everyone. But it turns out that "It indicates the way metformin works isn't by directly reducing sugar metabolism, but instead by acting to reduce fat in the liver, which then allows insulin to work better". In other words, insulin is supposed to send a message to the liver ("release less glucose, please"), but in Type 2 patients, the message doesn't get through, because fat in the liver makes the liver deaf to insulin's message. Metformin overcomes this problem, at least to some extent; it combats the development of fats in the liver which interfere with the liver's response to insulin.

I don't know that this research really solves the mystery of how metformin works, but it does seem to move us a little closer to understanding the biological realities involved. I still don't want to take metformin before I really have to (as a consumer, the concept of buying diarrhea, even at a bargain price, holds little appeal for me), but I suppose it's a positive thing that we now know more about how this drug functions within a human body (or at least within a lab-rat's body!).


Indestructible People!

Friday, November 1, 2013

I was out of town last night and couldn't do a blog post. Now it's Friday and I don't feel like doing one, but I'll see if I can come up with something.

 


Would it Kill You?

One of my favorite New Yorker cartoons ever:

A lot of people's questions about health seem to boil down to, "Will this kill me?". I suspect a lot of people assume anything which doesn't cause immediate death is harmless. When I look over the Google searches that have yielded a link to my site, they seem to be very focused on problems that will kill them, and kill them right away; problems that will harm them in a non-fatal way are not worried about nearly as much. Here are some typical diabetes-related searches:

  • "will it kill you if blood sugar stays high"
  • "can too much sugar kill a diabetic"
  • "can you kill a diabetic with too much sugar"
  • "how long does a low blood sugar take to kill"
  • "how does high blood sugar kill you"

Many of those questions sound as if they were written by someone who is planning to murder a family member but is still in the research phase; however, we will ignore that. What other pattern emerges from these inquiries? It strikes me that there is a lack of curiosity here about what excessive blood sugar might do to your health besides killing you.

I think people have learned to sort health problems into two categories: (1) problems that are immediately fatal, and (2) problems that aren't worth worrying about.

Certain medical innovations (such as vaccines, antibiotics, and blood transfusions) have gone a long way toward eliminating certain serious health threats which used to be a constant worry for people. The change this has made in human life is so complete that it is now difficult for us to understand the mental atmosphere which 19th-century artists lived in. It strikes us as melodramatic that characters in the novels of Jane Austin and Charles Dickens, no matter how young and healthy, are always at risk of contracting some mysterious, life-threatening fever (as if such risks were not commonplace in their day). It strikes us as morbid that the composer Gustav Mahler was so preoccupied with the death of children (as if the childhood deaths of Mahler's own brother and daughter had not given him a reason to brood on the topic). We live in a different world now. We think of early death as a freakish occurrence -- the sort of thing that happens in old movies but not in life, or at least in our lives. We think any medical problem is fixable, so long as you make it to the emergency room before it kills you.

Accordingly, we tend to think that staying healthy means identifying the problems that are immediately fatal, and dealing with those. Everything else is pointless to worry about, because a doctor can always fix it later. For the most part, we're indestructible.

I don't think that's a good way to look at this, however, particularly if you're managing diabetes. Considering how serious an illness diabetes is, not many people die of it directly. The number of people who die simply because their blood sugar got too high is pretty small. If diabetes is going to do you in, it's far more likely to happen because your diabetes promoted the development of heart disease or kidney disease.

And anyway, I think we need to avoid thinking that the only problem we need to be concerned about in connection with diabetes is that it might kill us, directly or indirectly. Diabetes can have a huge impact on quality of life, and it can have that impact many years before we die. The nonfatal "complications" of diabetes can be quite serious in terms of the way they impact your life. Without killing you, diabetes can attack your eyesight, and it can damage your nerves in a way which causes chronic pain and other problems. I usually try not to dwell upon such things, but I'm mentioning them here because I want to argue vigorously against the apparently commonplace assumption that what doesn't kill you makes you stronger. When it comes to diabetes, what doesn't kill you often makes you feel awful, unless you do something about it.

I think all diabetes patients need to avoid the mindset (seemingly common to huge numbers of people) which says that you only have to do something about a problem if it's going to kill you. You need to do something about a problem if it's going to make you miserable, too.

I guess that's why I'm not content to settle for test results that are "pretty good for a guy with diabetes"; I want results that are "normal". In other words, I am not content with results which won't kill me; I want results which won't cause me other problems either!

 



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