5th Thursday Update

October 30, 2014


Back to early sunsets!

We are about to abandon that peculiar ritual of societal self-deception known as Daylight Saving Time (or, as most of us mistakenly think it's called, Daylight Savings Time). Being unable to accept the cyclical variation in sunrise/sunset times throughout the year, we disguise it as best we can, by spending half the year lying about what time it is. But in a couple of days, we are going to stop doing that, and the early sunsets of winter will not be concealed from us. (Nor will the late sunrises of winter be made to seem later than they are.)

I make fun of DST not only because of the fundamental silliness of the idea, but because of its ragged implementation from region to region. Some countries observe it, and some don't. Those that do observe it don't all make the changeover on the same date. If you work remotely with teams in Europe and Asia, as I do, scheduling phone meetings becomes a terrible mess around this time of year.

Still, for all my ungrateful complaining about DST, I'm not above exploiting the practical advantages it does provide. Certainly I like to make use of the opportunity to go running after work, during the time of year when there's still enough daylight left after work to do that. My favorite time to go out for a run is the early evening -- starting before sunset and finishing before it gets dark. Tonight was my last opportunity to do that on a working day, and I made the most of it. It's hard for me to explain what it is about running at the end of the day that attracts me so much, except to say that the world looks beautiful to me at sunset in a way that it doesn't at any other time, and that's when I want to be outdoors.


The always-disappointing research news

Today I saw a health-news article with the intriguing headline "Sunshine may slow weight gain, diabetes onset, study suggests". This has nothing to do with Vitamin D, by the way (a substance which scientists are constantly announcing has beneficial effects which, upon further investigation, usually turn out to be highly questionable). The benefits in this case are linked to nitric oxide, another substance produced by the skin when it exposed to UV radiation from sunlight. Could going outdoors more often be the key to preventing weight gain and diabetes?

Well, maybe it could, if you're a rodent. Later in the article, we learn that the research was on mice -- creatures which are not only fur-covered, and therefore permanently sun-blocked, but are nocturnal to boot. What UV-induced production of nitric oxide does to mice is not necessarily relevant to human experience -- and in my opinion isn't likely to be.

Most of the research reports I look into are like this one, in that the headline makes promises which the report itself cannot fulfill. The headline essentially means "Here's Some Big Important News!", and the last few paragraphs essentially mean "But Here's Why This Might Be Total Bullshit!".

I shouldn't complain, really. In most sorts of literary advocacy (that is, writing which makes the case for a political, religious, or philosophical point of view), the author is under no obligation to acknowledge the weak points in his argument. Only scientists carry the burden of disclosing the reasons why their claims might ultimately turn out to be wrong. Scientists are only human, after all, and they must compete with other scientists for funding, so they do their very best to make the headline and the beginning of the article sound extremely promising, in the hope that you won't continue reading until the point where they admit that their conclusions are tentative and possibly wrong. But a scientist who presents conclusions triumphantly rather than tentatively, with no admission of possible weaknesses in the evidence or the argument, is regarded as a con artist. Scientists might not like admitting they could be wrong, but they are obligated to do so, and even obligated to specify the reasons why they might be wrong.

Maybe it wouldn't be a bad thing if political and religious blowhards were similarly obligated.

Anyway, my advice is never to judge research news by what is said in the first two-thirds of any report you read about it. Move down to the bottom of the article, where the obligatory admissions are made. If you haven't read the part of the article that says it might not be valid to draw conclusions about the effects of sunlight exposure on human health, based on what happens to nocturnal furry rodents that aren't usually exposed to sunlight... then you haven't read the important part of the article.

4th Thursday Update

October 23, 2014

I think it's time once again for me to try to answer some of the questions implicitly asked by recent Google searches that resulted in referrals to my blog.

"I'm t2 diabetes and use meth is that bad for me"

I think it might very well be bad for you. Diabetes is bad for you. Methamphetamine is bad for you. Does it seem probable that the combination of the two would not be bad for you?

There doesn't seem to be a lot of research on diabetes/meth interaction, but meth use has three effects which seemingly would make diabetes worse:

  1. Meth promotes glycation (unwanted bonding of sugars to proteins), which diabetes also promotes. Glycation leads (slowly) to all sorts of potential health problems. Whatever harm diabetes might be gradually and imperceptibly doing to your body will be intensified if you use meth.
  2. Meth impacts the immune system, triggering a chronic inflammatory response -- and one of the consequences of chronic inflammation is insulin resistance, which elevates blood sugar levels.
  3. Meth has a toxic effect on neurons (nerve cells), and people with diabetes already have enough to worry about in terms of neuropathy without taking neurotoxic drugs.

It's worth noting that these effects partially block the drug's action on the nervous system, so that habitual users need to take larger and larger doses of it to feel the same effect. That is probably why meth is unusually addictive.

In any case, this drug's effects on the body seem to magnify the impact of diabetes, so I would say that meth should not be a diabetes patient's drug of choice. Try a class of Zinfandel instead, and see how that goes. (I'm an old-fashioned guy, and I like drugs that have been around long enough for the human species to have adapted to them.)


"blood sugar is 92 after meals but still feel dizzy shaky confused"

It is possible to feel dizzy, shaky, and confused for reasons unrelated to your blood sugar level. Watching the evening news can be enough, sometimes -- especially if the news channel you're watching is trying to drum up national hysteria over an infectious disease which has, so far, killed fewer Americans than have been married to Kim Kardashian. Anyway, if you feel this way often, and you can't see a clear connection to hypoglycemia, than maybe you should ask your doctor what else might be causing the problem.

But let's assume that the symptoms you report do relate to blood sugar levels. Here's a fact that doesn't get mentioned enough: the feelings we associate with hypoglycemia are not necessarily triggered by blood sugar being low in absolute terms. What really triggers those feelings is an unusually rapid decline in blood sugar. 92 mg/dl is not low enough to be called hypoglycemia, but if you dropped from 132 to 92 in a short enough time, you would get the shakes anyway.

And it's quite possible that you did drop from 132 to 92 in a short time. 92 may not be hypoglycemia, but it's low for a post-prandial reading (most non-diabetic people experience a peak of about 125 after a meal, and most diabetic people get a peak higher than that). Perhaps your reading of 92 was taken at a point when you were sliding down the other side of a glucose peak which had been substantially higher ten minutes before you tested; perhaps what made you feel shaky was the rapid rate of decline. If you are taking insulin or other glucose-lowering meds, you might be overdoing the meds a little.

Sometimes you can get this sort of effect from exercise, too, especially if you're not accustomed to exercising regularly. Also, if you're getting your blood sugar under control after an extended period of poor control, your body may over-react to being in a lower range than it is used to. Time tends to take care of this problem; it might even be seen as a sign that you're making progress. But if medication is involved, the problem might be that you haven't got your dosages right yet, or aren't eating enough for the dosages you're taking.


"what would happen if insulin wasn't discovered"

History has already run that experiment for us, because for many years insulin was undiscovered and was not available as a treatment for Type 1 ("juvenile") diabetes. Type 2 patients usually have other options, but if you have Type 1, insulin is the only treatment that works. What happened, during the time when insulin remained undiscovered, was that people with juvenile diabetes tended to have short lifespans. Diabetic kids typically wasted away and died before reaching adulthood.

The discovery of insulin, and the implementation of it as a diabetes therapy in the 1920s, seemed like a miracle at the time. Suddenly it was possible for diabetic kids to grow up and lead adult lives.

Of course, if insulin wasn't discovered, scientists wouldn't have been able to figure out how to develop any treatments for Type 2 diabetes, either. The drugs and lifestyle modifications that are available for Type 2 are generally designed either to increase productivity of insulin, or to increase sensitivity to insulin (so that less of it is needed).

So, I guess the complete answer is that if insulin wasn't discovered, everyone with any kind of diabetes would be screwed.


"what if my glucose is 325 and I am pregnant"

325 mg/dl is abnormally high for anyone, at any time, and if you're pregnant, a glucose level this high could have more impact on your baby than it has on you. Elevated blood glucose in the mother's bloodstream seems to have the effect of over-nourishing the baby. The typical result is a baby with an abnormally high birth weight, but the consequences don't end there: children who had to spend their first nine months exposed to high glucose levels face a heightened risk of developing diabetes (and possibly other problems) later on. So, for the sake of having a healthy baby, talk to your doctor about how to maintain better glycemic control than this during the duration of the pregnancy. 325 is simply too high to be safe.

Many women who were not diabetic before pregnancy become diabetic during pregnancy (that's why an Oral Glucose Tolerance Test is commonly given to pregnant women, to check for evidence that this is happening). "Gestational" diabetes may or may not end once the pregnancy is over, but women who were temporarily diabetic during pregnancy face a heightened risk of becoming chronically diabetic later in life, so it's definitely an issue to keep an eye on, even after you think it's all over.

It may be that gestational diabetes is really no different than Type 2 diabetes, except that women who are already predisposed to develop Type 2 later in life get a kind of "sneak preview" of it earlier in life, when the physical changes caused by pregnancy put a lot of extra strain on the endocrine system. A lot of people who are unlucky in their genes spend their adult lives fighting off diabetes without knowing it: as they gradually lose their sensitivity to insulin, their endocrine systems pump out more and more extra insulin to compensate for (and hide) the problem. Somewhere along the way, the body gets into an overstressed or weakened state and the underlying problem can no longer be hidden. Perhaps pregnancy puts enough strain on the system to force the hidden problem into the spotlight, years before it would otherwise have been detected. The end of pregnancy may allow the problem to slink back into the shadows again -- at least for a while -- but that doesn't mean the problem has gone away.


"how does urination flush glucose"

It doesn't, really. Not nearly as much as people think, anyway.

Most people know that people with excessively high blood glucose tend to excrete glucose in their urine. Most people assume this means the body is using the urinary tract as a relief valve, to flush all that excess glucose out of the bloodstream and return the blood glucose level to normal. That's not really what happens. Glucose doesn't pass from the blood to the urine because the body is trying to make that happen, in order to correct for excess blood sugar.

Glycosuria (glucose in the urine) occurs not because some kind of glucose-excreting mechanism has been activated, but because a glucose-retaining mechanism has been overwhelmed. Glucose is not supposed to pass into the urine, and when that does happen, it isn't by design.

The reason we need kidneys is that various metabolic processes generate chemical waste-products within the blood, and these need to be eliminated. For example, when you digest protein, some toxic nitrogen compounds (such as ammonia and urea) are left over, and these can't be allowed to build up to harmful levels in the blood. That is why the kidneys are constantly filtering the blood supply, using an extremely sophisticated sorting mechanism to throw undesirable compounds out in the urine -- while returning desirable compounds to the bloodstream. One of the desirable compounds which the kidneys are designed not to throw out is glucose.

Glucose is a precious source of energy, and the body does not waste it (because the body is programmed to defend itself against any possibility of starvation). The body either burns glucose as fuel, or places it in the muscle cells to burn it later, or places it in fat cells and turns it into fat for long-term energy storage. Simply discarding the glucose is not an acceptable option, even when glucose is superabundant.

Therefore, the kidneys do their best to return to the bloodstream all of the glucose that passes through them. Normally, they do return all of it. However, when the glucose level in the blood gets above a value known as the "renal threshold" (usually about 160 mg/dl, at least in adults), the kidneys are no longer able to return all of it to the blood stream -- some of it leaks out into the urine.

This leakage of glucose into the urine is not sufficient to "flush" excess glucose out of the body and normalize blood sugar. At least, it isn't enough when nature is allowed to take its course. There are diabetes drugs now being introduced (such as dapagliflozin) which are designed to impair the kidney's ability to return glucose to the bloodstream. In effect, such drugs lower the renal threshold, so that a lot of glucose leaks out into the urine even when blood sugar is not extremely high. Such drugs can reduce blood sugar to normal levels, or near-normal levels. But, of course, there are side-effects to deal with -- including the possibility that having very sugary urine will promote urinary tract infections. I haven't ever had a urinary tract infection myself, but I hear they're not a lot of fun, so I hope the researchers are able to prevent the drugs from having that effect.

However, if you're not taking drugs to lower your renal threshold, your kidneys are not going to be able to do anything that could be fairly described as flushing the excess glucose out of your system.


"why is blood sugar high when i wake up"

I was wondering that myself, this morning. I didn't think I'd overindulged in carbs last night, and I didn't see why my fasting test should be as high as 98. My fasting test had been 85 yesterday, under conditions seemingly more sinful.

However, your fasting test doesn't necessarily reflect what you had for dinner the night before. It has more to do with what your liver has been up to while you were sleeping through the night.

During the daytime, your blood sugar level is influenced mainly by whatever food you take in (and whatever physical activity you engage in). But your fasting test follows a long period during which you were asleep. During that time, your digestive tract wass not contributing any glucose to your bloodstream -- and exercise was not subtracting any glucose from your bloodstream, either. During that prolonged fast, your liver took over the task of making sure your blood was supplied with glucose, by releasing stored sugar into the bloodstream whenever you seemed to be getting low.

Unfortunately, the glucose released by your liver during the night may be a little too much -- and if you have diabetes, the mechanism that is supposed to correct for that isn't working as well as it should be.

The endocrine system does not work like a thermostat, releasing a hormone that raises blood sugar when you're too low, and later on releasing a hormone that reduces blood sugar when you get too high. The endocrine system actually works by releasing both hormones at once, but adjusting the ratio between them to fine-tune the glucose level. Unfortunately, if you have diabetes, the glucose-raising hormone (glucagon) is working just fine, but the glucose-reducing hormone (insulin) isn't, so the system is out of balance, and is biased towards high blood sugar.

So, when you wake up with elevated blood sugar, it's because your liver (which was trying to protect you from hypoglycemia) released a little too much stored glucose during the night, and your endocrine system wasn't able to correct for that. (No doubt it tried to correct for that, by releasing insulin, but it wasn't able to produce enough insulin, or your muscle cells weren't responsive enough to insulin for the corrective action to work perfectly.)


3rd Thursday Update

October 16, 2014


Sour wine & diabetes

People have known for a mighty long time that exposing wine to air for too long will cause it to turn into something else -- something which isn't as good as wine, perhaps, but does have its uses. This transformed substance was known to the French as vin aigre (sour wine), and from that we get the English word "vinegar". The Italians called it aceto, and from that we derive the name of the essential ingredient in the stuff: acetic acid.

Vinegar is formed by certain bacteria (ever-present in our environment) which convert alcohol to acetic acid. Vinegar consists essentially of acetic acid and water, with traces of other substances which give it flavor. Vinegar is used as a mildly acidic condiment, as a medium for pickling vegetables, and as a cleaner. It has also been used as a folk remedy for various ailments... but so has everything else. Does vinegar actually have any potential health benefits which stand up to examination?

Well, it does have one property which is bound to make it interesting in terms of diabetes management: acetic acid inhibits the action of enzymes present in the mouth, esophagus, and stomach -- enzymes which are used in digesting carbohydrates (especially starch).

I was amused to find some alternative-medicine websites complaining that this inhibition of digestive enzymes makes vinegar harmful rather than helpful; they were writing on the assumption that the most efficient possible digestion is always desirable. Well, if you're on the edge of starvation, digestive efficiency certainly counts for something, but if you're living in the overfed First World, and especially if you have Type 2 diabetes, it might actually be better for you not to extract every last gram of carbohydrate from your meals.

It is all very well to say that acetic acid inhibits carbohydrate digestion in a test tube, but does it have that effect in living bodies? Apparently it does. The studies that have been done on the issue (mostly very small studies, unfortunately) show that the impact of a meal on the blood-glucose levels of insulin-resistant test subjects can be cut (perhaps by about 30%) simply by including some vinegar in the meal, without reducing the carbohydrate content.

The mechanics of this are not too hard to understand. Because the acetic acid inhibits the enzymes which should be breaking down carbohydrate in the stomach, the carbohydrate is not digested as fast as it normally would be. This has two important consequences: (1) glucose, as a product of carbohydrate digestion, doesn't flow into the bloodstream as fast as it otherwise would, and (2) some portion of the carbohydrate is not digested in the stomach at all, and doesn't get turned into blood glucose; instead it as passed along to the lower digestive tract, where bacteria consume it instead. These two effects combine to reduce the magnitude of the glucose spike which follows the meal.

The mechanism of action described above implies that vinegar would limit the short-term glycemic impact of a given meal, but would not have a lasting effect, such as reducing the fasting glucose level the next morning. And yet, for reasons unknown, it appears that vinegar consumed before bedtime can indeed result in reduced fasting glucose the following morning. At least, one small study found that this was the case. The effect could hardly be called dramatic, but there was a measurable improvement (for some people, fasting glucose was 6% lower with vinegar than without it). Another study found that insulin sensitivity can also be improved by vinegar, although the reasons for this are not clear.

So, there's a fair amount of data supporting the idea that vinegar is helpful to people with Type 2 diabetes. But, as a practical matter, how do you go about consuming more vinegar? The most obvious solution is vinegar-based dressings on salads or vegetables, but that works better in an actual meal; for those looking to consume some vinegar at bedtime, in hopes of improving their fasting tests the next day, it's harder to think of a good solution. A sour pickle might serve the purpose, but it's not everyone's idea of a midnight snack. Nobody wants to swig vinegar straight (nor should they: undiluted, its acidity can irritate the esophagus). You have to combine the vinegar with something. One reader described to me a bedtime regimen which has been working for her: two spoonfuls of vinegar mixed into some Crystal Lite fruit punch. She says this typically brings her fasting level down 10 points. I can't promise that it will have the same effect on you, but I pass it along as something you might want to experiment with.

Actually, that caution applies to just about any suggestions I ever make here: don't take my word for it! Experiment and see if what I'm suggesting actually helps you. We are all different, and what works for one diabetes patient might not work for another. The great thing about glucose meters is that they give us an opportunity to find out, on a day to day basis, whether what we're doing is working for us or not.

As I've said before, when you have diabetes, you are your own Science Fair project, and you want to get a good grade on it. Make sure you're keeping an eye on the data, and noticing any trends in it. If vinegar really does improve your test results, it shouldn't take too long to find some evidence of that.


About that diabetes "cure" in the news

Last week there was some pretty extravagant press coverage of a stem-cell research breakthrough at Harvard University which was presented as a diabetes cure. What happened was that the researchers were able to use human embryonic stem cells to grow insulin-producing cells "in vitro" (in test tubes), and these cells actually functioned properly "in vivo" (when transplanted into the bodies of diabetic mice). The cells produced insulin as needed, and brought down the rodents' blood sugar.

This therapy would obviously be aimed at Type 1 patients (who can't produce insulin on their own), although it might also be useful to some Type 2 patients who have lost much of their insulin-producing capacity.

Immediately I wondered whether the researchers had overlooked something obvious: Type 1 diabetes is an auto-immune disease. The reason Type 1 patients lack the ability to produce insulin is that their immune systems have become "allergic" to insulin-producing cells, and have destroyed them. What's to stop the immune system from attacking the new cells as soon as they are transplanted?

The researchers have thought of a way around that problem: the transplanted cells can be placed within a porous enclosure that functions like a teabag: the insulin that the cells produce can flow out of the bag, but immune-system cells can't get inside the bag to damage the transplanted cells. I'm not sure how many teabags you would need to have implanted in you, or where they would go, but I guess we'll find out more about that when they researchers get finished with the mice, and start scaling up the therapy for use in humans.

The researchers are very excited about what they've accomplished, and are describing the breakthrough in such extravagant language that I'm wondering if they are rather over-selling this. But it could very well turn out that this is a hugely important development in the treatment of Type 1, if not of Type 2.


2nd Thursday Update

October 9, 2014


Recovery Mode

Yesterday I finished a very difficult project at work -- one which I am almost surprised I was able to complete on time. Over the course of the project, the scope of work expanded by about 75%, while the allocated man-hours shrank by about the same percentage. It was stressing me out quite a bit.

So, anyway, the project is done and I'm taking some time off work to recover my equilibrium a little. Today I went to the state park for a nice long trail-run, figuring that some time spent working out amongst the trees might help relax me.

It did, or anyway it helped me make some progress. I've still got some relaxing to do.

I don't know exactly why a hard workout relieves stress, but it does. Any time you're in a situation where you're overscheduled and under pressure, and you feel as if you can't possibly make time for exercise -- that's when you need exercise the most. Don't think of a workout as time robbed from the important tasks you need to get done; think of it as the method you're using to ensure you are relaxed enough to do those important tasks well.


Which foods are okay if you're diabetic?

A reader of my blog who finds diet the most confusing aspect of managing Type 2 diabetes asked me for a list of foods that are "unequivocally acceptable". Hmmmm. It sounds like a simple question, but I think it needs a complicated answer.

Diet certainly is the most confusing aspect of managing Type 2 diabetes. But then, diet is the most confusing aspect of human health in general. It seems to me that the current state of human knowledge on the subject of nutrition is mighty shaky. I wouldn't apply to it William Goldman's famous comment on moviemaking ("Nobody knows anything"), but certainly we don't know much.

The reason we don't know much is that we can't perform proper scientific experiments. That is, we can't raise people in cages like lab rats, controlling every aspect of what they eat and how much of it they eat, and controlling all their other behavior as well, so that we can make a really rigorous comparison between different kinds of diets. And if we could do all that, we would have to keep doing it for decades, in order to identify all the long-term effects of a particular diet.

Nutritional science can get some idea of the differences between diets, but all conclusions have to be tentative, because there are a lot of uncontrolled variables involved. If one country has a higher rate of heart disease than another, and the one with the lower heart disease rate also consumes more parsley, we cannot simply conclude from this that parsley prevents heart disease. Maybe the populations of the two countries differ in something other than parsley consumption. What if the real issue is simply a genetic difference between two ethnic groups? Or a difference in lifestyle or stress level?

Also worth keeping mind: individuals vary. Even if a given diet is best for the average person... what if you're not the average person?

Because nutritional studies tend to produce murky data, with differently-conducted studies yielding different results, people are free to latch onto any diet they like, and announce smugly that the science backs it up. It's not a lie, really: for just about any diet, some of the science supports it. Decide which diet you like, and you'll probably find at least one study that says you're right. So then you can adopt that diet, hope for the best, and see how you do over the long haul.

It appears that human beings can be healthy on a variety of diets. Unfortunately, the diet which has become the international standard in modern societies is apparently not one that works well for most people; when poorer countries adopt the first-world diet, they start developing "diseases of affluence" such as heart disease and diabetes. Why, exactly? Well, I'm afraid that's controversial still. Depending on whom you believe, the reason the modern diet is unhealthy is that we consume too much refined carbohydrate, too much protein (or anyway too much animal protein), too much saturated fat, too much trans fat, or perhaps simply too much food. Data can be found to reinforce, or undermine, any of those ideas.

My own opinion of what constitutes "a healthy diet" tends to fluctuate over time, and I'm never really certain about it. However, when it comes to dealing with the specific challenge of diabetes management, I am a little more confident in my views.

It's all about carbohydrate!

There is very little doubt about what the biggest nutritional issue is in terms of blood sugar management: the amount of carbohydrate in the meal. That is the issue to focus on. Look at nutritional labels on processed foods, and look up nutritional data on unlabeled foods (an online source for nutritional data is http://nutritiondata.self.com).

The spike in blood sugar which follows a meal is driven largely by digestion of carbohydrate. Your body can make sugar out of protein and fat, but it's a slow and gradual process; it doesn't suddenly flood your bloodstream with sugar. Digesting carbohydrate does suddenly flood your bloodstream with sugar.

An important point about carbohydrate which you could easily overlook, because a lot of people are trying to hide it from you, is that all carbohydrates are, in essence, sugar. The carbs that are in the form of fairly simple sugar molecules, and therefore taste sweet and hit the bloodstream within 15 minutes after we swallow them, are the ones we call sugar. When the sugar molecules are linked into long chains, they don't taste sweet and they take 30 minutes or more to hit the bloodstream; we call them "starch" or "complex carbohydrates". When the sugar molecules are linked up in ways which make them difficult or impossible for the human digestive tract to break down, we call them "fiber".

Far too much is made of the distinction between "sugar" and "starch". The latter turns into the former so quickly that, for all practical purposes, it's a distinction without a difference. Eating four ounces of starch does not differ in any significant way from eating four ounces of sugar.

The distinction between sugar and fiber is more meaningful, but it is not as absolute as we're often led to believe. Apparently some carbs classified as fiber are not indigestible, they are merely digested slowly or inefficiently. You can't subtract all of the fiber grams from the total carbohydrate grams; the usual rule is to subtract half of them. If a given food provides 20 grams of total carbohydrate, and 6 grams of fiber, the effective carb total (in terms of impact on blood sugar) is 17 grams, not 14.

Anyway, my advice in terms of evaluating a food's glycemic impact is to look at total carbohydrate grams minus half the fiber grams -- and ignore the "sugar" listing as a pointless distraction. The main significance of the fat and protein grams is that these nutrients tend to slow down digestion; if the carbohydrate is combined with a lot of fat and protein, your blood sugar won't be hit quite as hard as it would if the fat and protein weren't there. A pure carbohydrate snack is likely to give you a bigger spike than something more balanced. Don't rely too much on this principle, however: the fact that a chocolate bar has fat in it doesn't mean the carbs in it don't count.

You can do your own research on your own favorite foods, but here are some that I looked up.

Most green vegetables are good bets:

Food Amount Carb, Fiber (g) Protein (g) Fat (g) Cal
Spinach 1 cup (30 g) 1, 1 1 0 7
Kale 1 cup (67 g) 7, 1 2 0 33
Brussels Sprouts 3 sprouts (63 g) 3, 3 3 0 24
Cabbage 1 cup (109 g) 2, 0 1 0 13
Cucumber 1/2 cup (52 g) 2, 0 0 0 8
Asparagus 1 cup (134 g) 5, 3 3 0 27
Summer Squash (zucchini) 1 cup (124 g) 4, 1 2 0 20
"Spaghetti" squash 1 cup (101 g) 7, 0 1 1 31

Other vegetables can have substantial carbohydrate content, sometimes significantly reduced by a high fiber content, and sometimes not. (Avocados are a special case: fairly high in carbs, but the carbs are mainly fiber; very high in calories because of the hefty fat content.)

Food Amount Carb, Fiber (g) Protein (g) Fat (g) Cal
Avocado 1 cup (230 g) 20, 16 5 35 384
Peas 1 cup (134 g) 18, 6 7 1 103
Winter squash (butternut, acorn) 1 cup (140) g 16, 3 1 0 63
Carrots 1 cup (128 g) 12, 4 1 0 52
Turnips 1 cup (156 g) 8, 3 1 0 34

Beans tend to be high in carbs, fiber, and protein (and low in fat).

Food Amount Carb, Fiber (g) Protein (g) Fat (g) Cal
Black Beans 1 cup (172 g) 41, 15 15 1 227
Pinto Beans 1 cup (240) 37, 11 12 2 206
Lima Beans 1 cup (188 g) 39, 13 15 1 216
Lentils 1 cup (198 g) 40, 16 18 1 230

Nuts and seeds tend to be high in everything; proceed with caution.

Food Amount Carb, Fiber (g) Protein (g) Fat (g) Cal
Almonds 1 cup (95 g) 21, 12 20 47 546
Walnuts 1 cup (125 g) 12, 9 30 74 773
Pumpkin Seeds 1 cup (64 g) 34, 0 12 12 285
Dry Roasted Mixed Nuts 1 cup (137 g) 35, 12 24 70 814

Fruits tend to be sugary, but there is a surprisingly wide range of variation, so you'll need to do your research:

Food Amount Carb, Fiber (g) Protein (g) Fat (g) Cal
Navel orange 1 cup (165 g) 21, 4 2 0 81
Banana 1 cup (225 g) 51, 6 2 1 200
Apple 1 cup (110 g) 14, 1 0 0 63
Blueberries 1 cup (148 g) 21, 4 4 0 84
Lemon 1 fruit 12, 5 1 0 22

Potatoes and grains are pretty bad in terms of glycemic management: they mostly consist of carbohydrate, and not much of that in fiber form. You have to be careful with how much of these foods you consume. (It's interesting to see that rice is by no means the worst offender; I had been wondering how Asia managed to have, until recently, low diabetes prevalence despite all that rice consumption.)

Food Amount Carb, Fiber (g) Protein (g) Fat (g) Cal
Potato (baked) 1 large (299 g) 63, 7 7 0 278
Quinoa 1 cup (185 g) 39, 5 8 4 222
Buckwheat 1 cup (120 g) 85, 12 15 4 402
Whole Wheat 1 cup (120 g) 87, 15 16 2 407
Rye 1 cup (128 g) 88, 29 18 3 415
Rice 1 cup (158 g) 45, 1 4 0 205

Most animal foods (beef, chicken, fish) provide protein and fat, with no significant carbohydrate content. You might have other reasons to limit these foods, but they have little glycemic impact. They are not much of an issue in terms of diabetes. Dairy products are an exception, however: milk is sugary. A cup of whole milk provides 13 grams of carbohydrate, and no fiber. In estimating the carbohydrate content of your breakfast, don't ignore the carbs in milk and cheese.



Perhaps you're wondering how any of this information can be applied in a useful way to day-to-day living with diabetes. Well, the nutritional data is a starting point rather than an end point: you use it inform your experimental process. Instead of hoping to be told by someone in a white coat which foods are "good" (that is, eat as much as you want of them) and which foods are "bad" (that is, never eat them at all), you need to figure out how much carbohydrate your system can tolerate without producing an abnormally high blood sugar spike after the meal. You need to find out which foods tend to spike you, and then find out (through experimentation) how large a serving of that food you can get away with. You may find that a small scoop of rice is something your system can handle, but more than that is a really bad idea. This sort of experimentation is a lot more useful if you go into it with enough data to support you in deciding what to try.

Foods which contain little or no carbohydrate (such as meats and green vegetables) are the foods that you want your diet to emphasize. But it's hard to live without the more problematic foods, so you're better off limiting them than shunning them. It isn't about declaring some foods innocent and some foods evil, and then taking a vow never to touch the latter. The "evil" foods are so ubiquitous in our food culture that you can't simply part company with them and never think about them again. You need to establish by experiment how well your system can handle those foods -- and then live within the boundaries that your experiments establish.

You won't always get it right. For dinner tonight I had chili that was not made by me. There was hominy in it, which is a high-carb grain food, and I figured I could handle it because I'd just run 8 miles and I was starving. I hoped I'd get by with it, but at the same time I was aware that I'd probably taken in more carbohydrate than was good for me. An hour after eating, my blood glucose reading was 149 -- higher than I'm comfortable going. I checked again at the two-hour point, and by then I was down to 82. Apparently I pushed my system a little far, but after a while it got things under control, perhaps enabled by the long trail-run, which had revved up my insulin sensitivity. If I hadn't just worked out, who knows how much higher I might have gone?

You can never hope to get these things perfectly right... but the better informed you are, the more often your guesses will turn out to be correct.


1st Thursday Update

October 2, 2014

At this time of year, the sun sets one to two minutes earlier each day (6:52 PM as of today). In other words, it is fast approaching the time when fitting in a run after work, but before it gets dark, will be impossible. I'm continuing to take the opportunity while I still can.

Sunset is my favorite time of day to run, especially when it's been hot (it was in the 90s today, strange as that may sound for October). It's nice to start out the run while the sun is still up and the air is still warm, and then feel the world cooling off as the sunlight reduces down to a brilliant orange glow on the hillsides. I finished the run after the sun was down but it wasn't dark yet. That's my idea of a perfectly timed workout. (I realize that some people think sunrise is a better time to work out, but I'm content to take their word for it.)


Needle Phobia

I'm used to hearing elaborate names for phobias. Here's the start of a list of hundreds of them:

It's fun to look over such lists, because they include so many fears of things most of us wouldn't imagine could be sources of fear. "Pogonophobes", for example, are afraid of beards. Surely there's a limit to how much harm a beard could do to anyone.

But then there are clinical names for fears which don't sound all that unreasonable. Why make "taphephobia" a named disorder, for example? Clinicians should probably worry less about people who are afraid of being buried alive, and worry more about people who aren't.

Anyway, with such a marvelous vocabulary available to describe every fear you can imagine, and several fears that you might never have imagined ("siderophobia" is the fear of stars, and "coprostasophobia" is the fear of constipation), I'm a little disappointed to learn the fear of needles is simply called "needle phobia".

Fancier names for it have been proposed, but psychiatrists couldn't agree on which one to select. "Aichmophobia", "belonephobia", and "enetophobia" are all possibilities, but apparently they also refer more generally to sharp or pointed objects, and finally the experts gave up and settled on "needle phobia" by default.

It's ironic that needle phobia lacks a proper Latin or Greek label of its own, because it is one of the commonest phobias out there. And one of the most reasonable, too. Let's face it: being punctured by a needle hurts. Maybe not a lot; it depends on the type of needle and where you're injecting it, but it does hurt. And, as with most phobias, common or uncommon, there's more involved in needle phobia than a rational awareness of consequences. For a lot of people, a needle symbolizes a personal threat -- a threat of being invaded, violated, abused.

For diabetes patients, needles symbolize a threat of another kind: a progression from a mild state of ill health to a severe one.

I'm talking mostly about Type 2 patients. For Type 1 patients, who aren't making any significant amount of insulin themselves, there really aren't any alternatives besides injecting it, so if they're needle-phobic they have no choice but to overcome it. The situation is more complicated for Type 2 patients, who (depending on how much insulin their bodies make, and how sensitive to insulin they are) may very well be able to control their blood sugar without insulin. Unfortunately, the condition often progresses, so that Type 2 patients who formerly didn't need insulin are advised by their doctors that they need it now, or will need it soon. Patients do not tend to see this as good news, and they do their best to resist and delay. Many doctors see it as a serious problem that so many Type 2 patients postpone the transition to insulin injections. I'm not sure they have a very accurate sense of why their patients put up so much resistance, though.

For many Type 2 patients, taking their first insulin shot seems like a very gloomy rite of passage. It is as if they had just sat down in the wheelchair they're going to be using from now on. The transition to insulin use carries such a grim symbolic weight for people that they put it off for as long as they can.

We all want to feel like people rather than patients, and apart from being bed-ridden, nothing makes people feel like patients more than having to take regular injections. In many people's minds, the transition is stark: so long as you haven't started taking insulin yet, diabetes hasn't beaten you yet; your first injection means that, in some sense, the battle is over and you lost. I'm not surprised that people fear and resist crossing that frontier. (I am, however, surprised that this important psychological issue isn't better understood within the medical profession.)

Because needle phobia, at least among Type 2 patients, is as much about sorrowful symbolism as it is about pain, I'm not sure that it will be possible to get patients to make the transition to insulin earlier simply by making shots less painful or less frequent. But pharmaceutical companies are betting a lot of money that it is possible.

It's quite a gamble. The Danish drug company Novo Nordisk is trying to develop a kind of long-acting insulin, known as LAI287, which only needs to be injected once a week. The thinking is that even the most needle-phobic patients can surely put up with insulin shots if they don't have to do it more than four or five times a month.

If I am right about the true reason a lot of patients postpone the transition to insulin, making the shots a once-a-week chore might not change patients' attitudes as much as Novo Nordisk is hoping.

In any cases, financial analysts are concerned that the odds are against LAI287 winning regulatory approval. You don't have to be a doctor to see that there's got to be something a bit weird and risky about an insulin shot that works for a whole week. How do they make that happen? Insulin usually breaks down fairly quickly within the body.

Actually, any hormone breaks down fairly quickly within the body, because the way hormones are supposed to work is that, after they stimulate a hormone receptor on a cell, the cell then latches onto the hormone and dissolves it. When hormones are used, they are used up. A lot of drugs function as hormone analogs: they are similar enough to given hormone to stimulate a hormone receptor. But if the cell isn't able to break down the hormone, it become reusable and has a stronger impact than the hormone it is imitating. Opium-based narcotics work this way: they resemble natural endorphins, and stimulate endorphin receptors -- but because they are hard to break down, they overstimulate the receptors -- and this leads to addiction.

LAI287 is not really insulin; it is a molecule designed to be enough like insulin to stimulate insulin receptors, but not enough like insulin for cells to be able to break it down. It continues to circulate in the bloodstream, stimulating more cells. After a week, enough of it has finally broken down that you need another shot.

What seems riskiest to me about this scheme is that, for a week, that patient's circulating insulin level is going to be fairly high, even during times when the patient's blood sugar is low. Wouldn't this cause a serious risk of hypoglycemic episodes?

I suppose that is why Novo Nordisk is planning to use LAI287 as a drug for Type 2 patients but not Type 1 patients. Because Type 1 patients have no other sources of insulin, having a constant high dose of the stuff would be too risky. But for Type 2 patients, insulin is only used to supplement whatever amount of insulin the body is producing on its own; if LAI287 is only part of the mix, not the patient's sole source of insulin, then perhaps a safe minimum dosage of it can be used, and its impact on the total insulin supply won't be too dramatic.

Still, it sounds like a risky thing to me -- not only medically, but as a business speculation.

I'm sure patients who do take insulin shots would rather do it once a week than several times a day. But I don't know that this is going to entice very many people to make that psychologically burdensome transition from non-insulin use to insulin use.

I, too, am trying to put off taking insulin shots as long as possible. But I'm also trying to put off taking pills as long as possible, so my own needle phobia is a long way from being put to the test.


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