5th Thursday Update

December 31, 2015


New Year's Eve

My last blog post of 2015! Every other "content creator" out there seems to feel that the occasion calls for a retrospective on the events of the year, but I'm not much inclined toward that sort of thing. I'm more involved in today than yesterday, generally speaking.

I had the afternoon off and the weather was brilliantly sunny, so I decided to do a long trail run. I hadn't done anything longer than six miles in a long time, and I wanted to make sure I was still capable of it.

The trails were beautiful -- the recent rains had caused green grass and moss to pop up everywhere. The trails were a little crowded today with runners, hikers, and mountain-bikers, taking advantage of the sunshine and the holiday. I imagine they'll be even more crowded tomorrow, as people test out their New Year's resolutions to get more exercise in 2016. (The gym will be crowded, too, but on the trails there will be more elbow room.)

I wasn't sure how long a run I was capable of doing today (especially as I went to party yesterday), but as I went along, I found that the steeper climbs didn't exhaust me too much, so I ended up doing a 9-mile route, and it wasn't that hard. I didn't feel beaten-up after I was done. The only problem was that it was a long time to be out in the cold, in light running-clothes, so I got a bit chilled. Now I'm experiencing the slightly feverish feeling that usually follows that sort of flirtation with hypothermia. It's actually a feeling I like, if it doesn't go too far. If it doesn't turn into the flu, I'm happy.

The age issue

In an old Monty Python sketch, a British admiral is giving an interview with a television reporter, and (without any prompting from the journalist) says: "and may I take this opportunity of emphasizing that there is no cannibalism in the British Navy..."

The point of the joke is that it is more alarming than reassuring to hear a vehement denial of something you hadn't suspected in the first place. Who would have thought there was a problem with cannibalism in the British Navy? And who wouldn't find it troubling if the British Navy suddenly felt the need to insist that there was no such problem?

There is always a credibility problem involved in protesting too much. Over-emphatic denials do more to create suspicion than to eliminate it. (That is why reporters everywhere say that you can't believe a rumor until it has been officially denied.)

Part of the reason we take alarm at exaggerated reassurance is that we're used to hearing it from dishonest people. When the promoter of an investment scheme claims that his plan is not just safe, it's "one thousand percent safe", the overstatement reminds us that nothing is even a hundred percent safe (and that you wouldn't call something one thousand percent safe unless it was utterly unsafe). Experience with these people has trained us to recognize denial of risk as a warning indicator of heightened risk (at least in retrospect, as in the case of that "unsinkable" vessel known as the Titanic).

I couldn't help being reminded of this when Donald Trump (reality TV star and presidential candidate) released a letter from his doctor describing the candidate's health as "astonishingly excellent":

The doctor in question, Harold N. Bornstein, is not only Trump's personal physician, but is also the son of Trump's former physician (apparently this is the sort of job you can inherit). Perhaps this long history of association with Trump accounts for the grandiloquent style of the letter, which concludes with the ringing words, "If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency."

The claim seems a little overstated, if Dr. Bornstein never gave Thomas Jefferson a checkup. Could it be that the good doctor is mischievous enough to be making his letter sound phony on purpose? Could he be pranking his patient, and deliberately undermining public confidence in his "astonishingly excellent" health? I thought so at first. But when I saw a photo of Dr. Bornstein, I realized he is much too serious a person to engage in any such shenanigans.

Well, actually, he looks like the sort of doctor that hipsters go to for a letter saying they have glaucoma. I'm not sure this guy could concentrate long enough to dream up a subtle way to prank his patient. So now I'm wondering if the prankster here is Trump himself. When you ask your wild-eyed doctor to publicly call your health "astonishingly excellent", aren't you pretty much having a laugh at the expense of the public? Maybe this is Trump's way of ridiculing people who worry about such things. (Nobody would ever accuse him of being too serious a person play games with this issue.)

The interesting thing about all this to me is that, until this letter was released, it had not occurred to me to suspect that Trump had a serious health problem and was concealing it. Not that I had regarded him as an exemplar of good health, exactly, but I hadn't thought he was falling apart, either. I simply hadn't thought about his health as an issue that needed to be considered by voters. I hadn't even thought about his age, let alone his health.

I tend to disregard age insofar as it is humanly possible to do it. I don't try to guess how old other people are (and, if forced to, I tend to guess very inaccurately). I pretend that all adults are simply that: adults, with no age in particular. I act as if we're all contemporaries and grew up watching the same TV shows. I'm not trying to award myself credit for high-mindedness here: I only take this attitude as a defensive stratagem. Not thinking about anyone else's age is a trick that helps me avoid thinking about my own age. It's a bargain I make with the rest of humanity: I won't notice you're getting older, and I expect you not to notice that I'm getting older.

My attempt not to notice age is often stymied by celebrities. Famous people, people I have been aware of all my life, people I think of as more or less young (since they were young within my lifetime) have a tendency to disappear from view for long periods and then show up again looking shockingly older. I haven't seen them in a while, and suddenly there they are, on a talk show or on stage at the Oscars, looking twice their age... until I do the math and realize that they look exactly their age. In the case of certain celebrities, you can dismiss the changes as merely the effects of drug abuse, but not every celebrity is Keith Richards. Even the healthier ones have clearly become old. Oh, look: there's George Takei (young Mr. Sulu on the original Star Trek), making his Broadway debut... at age 78. And there's John Cleese (who can forget his long-limbed acrobatics in the "Ministry of Silly Walks" sketch?) chatting on television... about his hip-replacement surgery. If people are present in our regular lives, they are around us often enough that the changes in them occur too gradually to have any shock value. Celebrities, however, drop out of view periodically, and they stay out of view long enough to cause alarm when we see them again. Celebrities after a certain age begin to be all about "milestone" events: a beloved TV show has its 40-year anniversary; glamour queens become grandmothers; Beatles die. These developments put famous faces back in front of the camera, only to reveal their wrinkles (or, more sadly, to reveal the desperate means by which their wrinkles were eliminated).

It's a bit different with Trump -- partly because he is one celebrity who has never dropped out of view for very long. When you are in the business of being famous for being famous, you can't risk being out of the spotlight, and he never has been. Anyway, he is a politician now, and politicians are regarded a bit differently, in regard to age, than other celebrities. We may worry that they're too old to be running things, but we are just as likely to worry that they are too young to be running things.

We worry that a young president will be naive, impulsive, and easily manipulated by people exercising power behind the scenes. We worry that an elderly president will be develop dementia and order a missile strike on Narnia. (The oldest president so far, Ronald Reagan, supposedly didn't develop Alzheimer's disease until after he was out of office, but experts analyzing his increasingly vague and repetitive language in press conferences think they've found evidence that the cognitive decline began much earlier.) The desirable age range for national leadership, at least in the minds of voters, is rather narrow: ideally, most American voters don't want their president to be much younger than 50 or much older than 60. The timing doesn't usually work out quite so neatly for an individual politician's career, of course, so a lot of presidential candidates are inevitably going to fall outside the ideal age range, and voters are going to have to decide if it matters.

I had not realized how old Donald Trump was until recently, nor had I thought about it much. I usually think about politicians in terms of their politics, not their age. But it's hard to ignore age this time, because this election's large assortment of potential candidates is dominated by people who seem to be worryingly old for a presidential run. If we ignore such improbable candidates as Bernie Sanders, Trump is the oldest of them (well into his 70th year on inauguration day) -- but many of the others are not very far behind him. Hillary Clinton will be 69, for example, and although I realize women have a natural advantage in terms of longevity, I'm not sure that means they avoid cognitive decline longer.

I suspect that the two parties will eventually offer me a choice between two candidates who are both too old to run for president, which will leave me free to vote on their policy positions and ignore (as best I can) my concerns about what will happen when someone with access to the launch codes enters the repetitive-anecdote phase of life.

The election of Barack Obama made me feel a little indignant, at first, because I now needed to live, for the first time in my life, under a president who was younger than myself. I had always assumed it was part of the deal that a president would never be younger than me. Now, as we approach the end of Obama's second term, I find myself feeling, for the first time in my life, that it might actually be a problem for the president to be very much older than me.

Of course, if one of the younger candidates in this race wins, I'll have the comfort of knowing that at least they are not young in spirit: most of them want to return America to the 1850s. So, in one way or another, this election will be a return to form: the president will make me feel like a comparative newcomer to the planet!


3rd Thursday Update

December 17, 2015

It's been a frantic week for me. I've been desperately trying get a complicated project done before the company shuts down for the Christmas holiday next week. I've also been preparing for the big performance of Christmas music at work tomorrow morning. (And it is a big performance. What used to be a small strolling band, when I started this thing up 20 years ago, has now grown into something like an orchestra and chorus, with 17 instrumentalists and 6 singers.) I've been putting in extra hours and experiencing a lot of extra stress. Assuming I get it all done tomorrow, I'm promising myself a big workout to get my nervous system into healthier shape.


Sticky proteins are up to no good!

Sometimes, when I read a report on medical research, the thing that really catches my attention is not the author's main point, but something that is mentioned casually, in passing, as if it were too well-known or too unimportant to be emphasized.

An article I read today appeared under the headline, "Antibiotic resistance could help find drugs for some of the most intractable diseases".

What caught my eye was not the discussion of antibiotic resistance, but this sentence: "Amyloid diseases such as Parkinson's, Alzheimer's and type-2 diabetes pose a particular problem for drug designers because they do not present a clear target structure to aim at."

Wait a minute -- Type 2 diabetes is an amyloid disease?

I knew that amyloids were undesirable substances which formed deposits (plaques) in the brain tissue of Alzheimer's patients. I hadn't heard that Parkinson's involved a similar problem, though it sounded superficially plausible. But Type 2 diabetes? I hadn't heard that amyloids played a role there. (Or, if I had heard that, I'd forgotten it -- which would indicate I've got some amyloid issues of my own to deal with.) So what are amyloids exactly, and what do they have to do with Type 2 diabetes?

Amyloids are proteins that have "issues". Proteins in general consist of amino acids linked to form a long chain, but the chain is folded up like origami to give each protein a unique shape (and therefore a unique way of interacting with other molecules -- it is the shape of a protein in its folded form which makes it function in a particular way). Unfortunately, if a protein bends in the wrong places, it takes on a shape which gives it undesirable characteristics. An amyloid is a protein which, because of how it is folded, tends to "aggregate" -- it's sticky, it tends to form deposits, and the deposits are hard to get rid of because amyloid is insoluble -- it doesn't dissolve. Diseases such as Alzheimer's are incurable because we don't have any way of dissolving the amyloid deposits -- once the patient has them, they remain in place, and they just build up further. The only hope of curing Alzheimer's is to find a drug that is capable of dissolving the amyloid deposits from a patient's brain tissue somehow. But developing a drug that can do that is not going to be easy. It's very difficult even to study amyloids, because they tend to be inextricably bound up with other molecules; they're not floating around free to be examined and experimented upon. They get lost in the crowd. So how do you do drug research on how to fight amyloids?

Well, somebody has an idea how to do that now, based on studies of antibiotic resistance. It seems that when bacteria develop resistance to an antibiotic, they do it by attacking the molecules of the antibiotic -- they produce an enzyme which breaks the antibiotic down. Now researchers are experimenting with anti-antibiotics, by grafting an amyloid-producing gene onto enzymes which normally cause antibiotics to break down. Those enzymes get smothered by the amyloids, so that they can't do their job. You might say that the researchers are trying to give Alzheimer's to an antibiotic, gumming it up so that it can't function properly.

And what the hell is the point of doing that, you ask?

A fair question. The researchers aren't trying to declare war on antibiotics. They're doing something more complex, and more interesting.

The point of the research is:

Look, I know this is a complicated story to follow -- it's like a spy novel about double-agents who turn out to be double-double agents. I guess the bottom line is that molecules can have complex adversarial relationships with one another, and that researchers are hoping to turn this fact to their advantage, because it gives them an easy way to test a substance which might be useful against amyloid deposits and the diseases they cause.

However, this still leaves unanswered the question of greatest interest to me: what do amyloid deposits have to do with Type 2 diabetes? I thought Type 2 had to do with insulin resistance, not amyloids.

Well, insulin resistance has a quite lot to do with Type 2, and it even has quite a lot to do with the role of amyloids in Type 2, as we shall see.

Insulin resistance (a diminished sensitivity of the body's cells to the hormone insulin) causes the body to compensate for the problem by pumping out abnormally large amounts of insulin. This "hyperinsulinemia" has long been known to be harmful to human health (for one thing, all that extra insulin has an inflammatory effect on blood vessel walls, and that kind of chronic inflammation promotes arterial disease). But apparently over-production of insulin has another harmful effect which wasn't understood until comparatively recently.

Insulin is made by the beta cells in the pancreas. When the beta cells produce insulin, they also product along with it a substance known as IAPP, or Islet Amyloid Polypeptide (sometimes called Amelyin), which in its normal form has effects similar to insulin. However, the volume of IAPP produced is much greater than the amount of insulin produced along with it, and when insulin production is magnified to compensate for insulin resistance, IAPP production is hugely magnified. Also, when beta cell is making a lot of IAPP, it first has to make a lot of a precursor compound known as ProIAPP. When abnormal amounts of ProIAPP are produced, they tend to leak out of the beta cell.

Well, wouldn't you know it! ProIAPP has the kind of mis-folded protein chain which makes it "aggregate" -- it's sticky, and it tends to gum up the works. Specifically, when it leaks out of a beta cell, it tends to bind up the cell with other nearby cells, and smother the cells within a sticky, non-functional mass. And then the beta cells start dying (cell death is known as apoptosis). The process is illustrated below.

Unlike Type 1 patients, whose beta cells are almost entirely wiped out by their own immune system, Type 2 patients lose some fraction of their beta cells as an indirect consequence of producing too much insulin (and therefore producing too much of the amyloid protein ProIAPP as a byproduct).

I see all this as confirmation of what I had been thinking all along: the key to managing diabetes is to combat insulin resistance. If you don't, you're forcing your body to produce more insulin than it should have to (and more amyloid than it can handle). The famous "progression" of Type 2 diabetes, which most people accept as a mysterious but inescapable disaster heading their way, is probably nothing more than a gradual buildup of damage within the pancreas, as a result of amyloids leaking out of the beta cells. If you don't force your beta cells to produce more insulin than they should have to, they won't be leaking amyloids and damaging other beta cells in the vicinity.

Insulin sensitivity is the key here -- or so it seems to me, at any rate. I've heard people argue that insulin sensitivity isn't the real issue in Type 2 -- that falling insulin production in the pancreas is what matters. However, now that we know more about what is causing insulin production to fail in the pancreas, it sure looks as if the failure is an indirect consequence of over-production of insulin earlier. Yes, amyloids play a role in diabetes, but apparently the amyloids wouldn't be there if falling insulin sensitivity hadn't forced the beta-cells to over-produce insulin, and leak out amyloids as a result. The key to success in diabetes management is to maximize your insulin sensitivity.

And the best way to maximize your insulin sensitivity is to exercise. So, like it or not, we have to do the exercise! I'm not in a good position to say that today, because I didn't have a workout today. But once I get my final project work delivered tomorrow, I can get back to my proper routine.

My spell-checker didn't recognize the word "origami", which I used earlier. It's the Japanese art of folding paper to create elaborate shapes. My spell-checker suggested that the correct spelling of the word I had in mind might be "orgasm", but I don't know -- I'm just not feeling it.


2nd Thursday Update

December 10, 2015

Last week I was dealing with a serious flare-up of lower back pain, which was making it difficult to get into and out of such things as my bed, my clothing, and my car. By Sunday I was feeling significant improvement, and I was able to go to my yoga class on Monday (although, as I expected, the standing forward bends were beyond me). I'm quite a lot better now. I was able do a hilly run of more than five miles today.

I guess he trick now is to prevent the next such episode. I'm reading a book on chronic pain and how to prevent it, which one of my coworkers recommended because it helped him with the same problem.

It's all about preventing the bad thing, isn't it?


Correlation and Causation

In science classes we were sternly reminded that correlation and causation are two different things. Correlation is any kind of noticeable pattern in the way two variables relate to one another. For example, lung cancer, a formerly rare disease, became increasingly common as tobacco-smoking became increasingly common. Another example: beer sales supposedly increase as unemployment rises, and decrease as unemployment falls.

It is always tempting to jump to the conclusion that one of the correlated factors is the cause of the other. Obviously smoking causes lung cancer, if the disease went from rare to common once large numbers of people started smoking! However, there's a problem with this kind of thinking: the increase in the smoking rate was not necessarily the only thing that changed about the world during the time the lung cancer rate was going up. The increase in disease prevalence could have been caused by something else. You'd have to make an effort to account for other possible factors, if you wanted to conclude with any confidence that smoking was the culprit. Also, you'd need to explain how smoking could cause the disease -- what was the mechanism of causation?

Even if you found some statistical evidence suggesting people who wore red clothing had more strokes, you'd still need to explain how red clothing caused strokes before anybody would believe that the connection was more than a coincidence. Statisticians often find startlingly close correlations between two variables which clearly have nothing to do with one another. A remarkable example is the divorce rate in Maine, which apparently rises and falls in lockstep with fluctuations in the rate at which Americans consume margarine. At least, it did that from 2000 to 2009, and a statistician publicized this to demonstrate how perfect a false correlation can look on a chart. To look at the picture below, you'd swear that divorce simply has to be margarine-related -- the pattern is too consistent.

But wait a minute: the figures for margarine consumption are nationwide; why does it only correlate with the divorce rate in Maine, and not, say, Florida? Also, how exactly would consuming more or less margarine lead to a higher or lower risk of marital breakdown? (Also, look a the X-axis on the left: the total range of fluctuation in the divorce rate is only from 4.1% to 5%, so if margarine is having an impact, it's a mighty small impact.) Another question worth pondering: why should we assume that margarine consumption is causing marital troubles, when it could just as easily be that marital troubles drive people to eat more margarine? It's much too easy to assume, when we think we've found a cause-and-effect relationship, that A is causing B and not the other way around. In short: you almost can't be too suspicious when someone is presenting a correlation as evidence that Factor A caused Problem B.

Even when we have reason to think the correlation is more than a coincidence, we still have to figure out exactly what the connection is between the two factors. Assuming it really is true that beer sales track the unemployment rate, what would account for that trend? Depressed and anxious unemployed people drinking more to drown their sorrows? People who formerly drank wine switching to beer because they're out of work and beer is cheaper? Some other reason we haven't thought of yet?

When I read about this or that health problem being more common in people with diabetes (and it seems as if correlations of this type are reported almost daily -- apparently everything that can go wrong with the human body is more common in people with diabetes), I try not to over-react. Which, sometimes, is not easy.

The natural reaction, if you have diabetes and you read that diabetes patients are more likely than other people to have their heads fall off, is to think: I'm doomed! My head is going to fall off!

But you have to put that reaction on hold while you ask some pertinent questions. How often does anybody's head fall off? How much more often does that happen to people with diabetes? And what sort of diabetes patients have their heads fall off? If my risk of having my head fall off only increases from .0000001% .0000002% if I have diabetes, and the diabetes patients who experience head loss also have a bunch of other health problems I don't have, and they have much worse lab results than mine, and they exercise a lot less than I do, then maybe this whole head-falling-off scenario isn't something I need to lose sleep over.

I haven't actually read a study so far (knock on wood) that claims diabetes correlates with an increased risk of head loss. But I did read one today which said diabetes correlates with an increased risk of tooth loss, which to my mind is only a smaller-scale version of the same thing.

The CDC (the Centers for Disease Control and Prevention, that is) has (have?) published a 40-year study on tooth loss among adults with and without diabetes. This study looked at "dentate" people (I should explain that you are dentate if you have any teeth in your head -- and one tooth is all it takes to qualify) and examined the rate at which they lost teeth over the years. The study compared the rate of tooth loss in people with and without diabetes. And, of course, people with diabetes lost more teeth. Because there was a lot of differences between races, the results were shown separately for blacks, whites, and Hispanics (color-coding is used in the graphs to differentiate ethnic cohorts).

The rather busy graph below compares the number of missing teeth for people of different ages. Unsurprisingly, the graph rises with increasing age. But the solid lines, representing people with diabetes, clearly rise more steeply than the dotted-line (meaning non-diabetic) equivalents. At any age, people with diabetes have lost more teeth than non-diabetic people of the same age.

Another graph shows the trend over the years in how the overall populations of diabetic and non-diabetic people are doing in terms of tooth loss. There was a striking improvement during the last three decades of the 20th century; things have leveled off since. But all along, the pattern has been for diabetic populations to have more missing teeth than non-diabetic populations.

Mexican Americans seem, at least in the second chart, to lose fewer teeth than whites, but the reasons for this are apparently unclear to the study authors. Blacks lose more teeth than whites, and the reason for this is thought to be that they have less access to dental care (though the evidence on this is from a study that came out the same year as the first Star Wars movie; things conceivably have changed since then). Anyway, for all groups, the rate of tooth loss is clearly worse in people with diabetes -- about 50% worse.

Why might that be? The study authors point to evidence that people with diabetes have poorer dental hygiene, receive dental care less often, and have poorer health habits overall than people without diabetes. However, they also make a revealing remark in passing about "the bidirectional relationship between diabetes and periodontal disease". This refers to research suggesting that dental problems can be a cause rather than a result of diabetes.

As I mentioned earlier, we need to be cautions about saying A caused B without checking to see if B could have caused A. Periodontal disease (a chronic inflammation of the gums, and a common cause of tooth loss) has the same effect as other chronic inflammatory conditions: it suppresses insulin sensitivity, raises blood glucose, and is a recognized risk factor for Type 2 diabetes. At least some of the correlation between tooth loss and diabetes may be attributed to the simple fact that a lot of the diabetes patients in the study became diabetic as a result of having periodontal disease.

So how upset should I be getting about any of this?

I have known all along that I have a problem with periodontal disease -- I am a champion plaque-former, and I have to get my teeth cleaned more often most people. I have also had to have some special treatments under the gum-line a few times, when it looked as if I was losing ground.

When I squint at the chart for my age and race, it looks as if being diabetic should have cost me perhaps one tooth by this point (the diabetic and non-diabetic results don't diverge too sharply at my age). And I haven't lost any teeth yet, which seems to put me ahead of the non-diabetic people in the study, much less the diabetic ones.

So, the bottom line on the tooth-loss thing is that diabetes is associated with tooth loss for various reasons, some known and some mysterious -- but the estimated added risk for me is not terribly dramatic, and so far I haven't seen even a small effect from it. I know that periodontal disease is a problem for me, and puts me at risk for tooth loss -- but I'm doing something about it, and so far it's working. You can't scare me, CDC!

So, I'm going to go back to worrying if my head is going to fall off.


1st Thursday Update

December 3, 2015


Holding it all together

Although I did survive the Thanksgiving holiday, I can't exactly claim to be doing great this week. A problem of mine which first surfaced 32 years ago (a slightly herniated spinal disk) still flares up once in a while, causing me painful back-spasms and inflexibility. On Sunday it came roaring back, all at once, while I was doing nothing more strenuous than standing in my kitchen making coffee. I'm still fairly functional -- I can work -- but simple things such as getting dressed, getting out of a car, or getting up from a chair are absurdly difficult, because they involve some kind of painful transition between one position and another. (Sitting is okay, and standing is okay, but getting from one to the other -- yikes!)

I'm doing what has worked for me before: ice, ibuprofen, certain kinds of physical therapy that can be self-administered, and patience. As of tonight my back is feeling significantly improved, but this sort of problem is always worst in the morning and improves with daily activity, so I can't count on the improvement still being present tomorrow morning. I'm fairly hopeful, though, that I'm past the worst of it. Also, an office-mate who's had the same back-problem recommended to me a book on the subject that had helped him ("Pain Free" by Pete Egoscue); I got hold of it and just started doing an exercise from the book which I'm told is very helpful. It involves sitting up straight, on the edge of a chair, and repeatedly squeezing a pillow between your knees. (Yes, I know it doesn't sound as if that would use your lower back muscles, but when you have this kind of problem you find out the hard way that everything uses your lower back muscles.)

Because I never know how long an episode of this kind is going to persist, I can't just rest up until it's over. For one thing, inactivity prolongs the problem (it could be the problem happened in the first place because I was doing too much sitting during the week leading up to the flare-up (including a lot of driving on Thanksgiving, and a lot of time at the computer since then). For another thing, I rely on exercise too much for blood glucose control to become purely sedentary for several days. Being diabetic makes it a lot more difficult to get through these episodes when your body is hating you and you are hating it right back.

I knew I couldn't handle going outside for a run (my usual, and preferred, form of a workout), but I've found an aerobic exercise machine at the gym which I can use without overstraining my sore back. Earlier in the week I did 30-minute workouts on it, but tonight I did a full hour just to see if I could handle it. (I could, although I did have a couple of brief back-spasms toward the end.) Still, this kind of exercise is less strenuous than a real run, and I figured I wasn't getting as much of a boost in insulin-sensitivity as I do from my usual outdoor workouts. So, to make allowances for the lower-intensity exercise, I've been cutting carbs more than usual. My low post-prandial glucose result after lunch today (96 mg/dl!) is not quite as impressive as it might seem, because it was a very low-carb lunch. If I'd had bread with it, the result would probably have been a lot higher; I knew that this wasn't a week when I could have bread and get away with it.

Maintaining a flexible approach -- adjusting your habits to adapt to altered conditions -- counts for a lot in diabetes management. I think a lot of people with diabetes make the mistake of finding something that works, and then assuming that (1) it works under all circumstances, and (2) it's the only thing that works, so if you can't do that, you can't do anything. Good diabetes management is about recognizing when circumstances have changed, and figuring out what you can do to adjust to those circumstances. It's always tempting, when you're in physical distress, to give up on doing anything. You have to take the trouble to figure out what you can still do, and do it.

I hope I'm feeling more energetic tomorrow, because at lunchtime I need to lead a rehearsal for our annual Christmas music at the office, and it's going to be a big, complicated ensemble. This year we have 2 flutes, 2 violins, 2 string basses, 2 guitars, 2 trumpets, 2 trombones, 1 horn, 1 clarinet, 1 percussionist, 4 singers, and possibly some other string players (children of employees who may participate). I'm almost anxious about the musical force I've unleashed here. I've been organizing this Christmas band at work for 20 years now, but the band has never been this big before. At least the size of the thing will help the players relax: when the ensemble is that large, you're not so worried about your mistakes being noticed!


Stopping hummus!

Presidential candidate Ben Carson, speaking at the Republican Jewish Coalition today, said that "Obama doesn't even have a plan to defeat hummus".

The crowd tittered -- Jews tend to know what hummus is. They also tend to know what Hamas is, and even how to pronounce it. It's highly likely that Carson was trying to say Hamas. However, if he really was accusing the president of having no plan to defeat hummus, then I guess we need to brace ourselves: the Diet Wars are going to be heating up in 2016!


What causes diabetes? (Two new answers.)

The simplest answer to "What causes diabetes?" is "everything". Not many months go by without some researching finding some gene or enzyme that is supposedly the real, underlying cause of the condition. Today I read about two more.

One explanation is that diabetes (or rather Type 2 diabetes, the common form) is caused by a buildup of fat (specifically, triglycerides) in the pancreas. This comes out of a study of the effect of weight loss (from bariatric surgery or other methods) on triglycerides in the pancreas. The researches say that the relationship between total weight loss and loss of pancreatic fat is different for diabetes patients than for other people, and the nature of this difference suggests that pancreatic fat is a cause of diabetes -- or else that being diabetic is a cause of excess pancreatic fat. I'm not sure I grasp the significance of this finding -- but it doesn't sound as if the researchers involved get it either, so I don't feel too bad about my confusion. Anyway: Type 2 diabetes apparently has some sort of connection to pancreatic fat. I'm sure the next step will be for pharmaceutical companies to try to invent a drug which reduces pancreatic fat, in the hope that this will prevent or cure diabetes.

The other explanation for diabetes (this time Type 1) is "gene-folding". Invisibly tiny though a single cell is, the tightly-wrapped strand of DNA in the nucleus of a cell would, if you pulled it out straight, be two meters long. The coiling of DNA to make it fit within a cell involves countless folds, and apparently it matters where these folds occur, because the proximity of a gene to a fold can affect how that gene is activated and deactivated. Apparently, a DNA strand which folds at the wrong place can derail gene expression, and this type of problem is now implicated in various auto-immune diseases, including Type 1 diabetes and arthritis.

I'm not sure what can be done about it, if your DNA folds in the wrong places and interferes with the expression of nearby genes in some undesirable way. But I'm sure somebody is now hard at work on a drug that will make your DNA fold differently. I'm not going to be the first to take that drug, but no doubt it is on the way.


Your mileage may vary!

A lot of people with Type 2 diabetes, especially if they are newly diagnosed, decide to go on a "diabetic diet", and then become highly confused when they discover that nobody knows what a "diabetic diet" is -- or rather, everyone knows, and they all disagree, which for all practical purposes is the same thing as nobody knowing.

The problem is that people are variable in their response to foods. There is probably no approach to "diabetic dieting" that hasn't worked for someone, somewhere. But if you want to find out if it works for you, you'll have to try it and monitor your results. If it works for you, it doesn't matter that it doesn't work for me. (Or, if it doesn't work for you, it doesn't matter that it works for me.)

A study I read today found that glycemic response to different foods varies enormously between individuals. The example illustrated below shows the results from two different patients, one who is spiked by cookies but not by a banana, and one who is spiked by a banana but not by cookies:

The study authors conclude that diet need to be individually tailored to reflect the individual's response to different foods. (What they meant, of course, was that I'm right: you need to figure out what works for you, and forget about whether it works for somebody else.)


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