4th Thursday Update

March 26, 2015

I started limping again, yesterday morning -- same pain in the right foot, in the same place. I thought it wasn't too bad, and I could run on it. So I ran yesterday. But it felt worse today. Experience has taught me that, in this situation, a long walk can make my sore foot feel better rather than worse. It seemed to work that way tonight -- I had a good hilly hike in the evening, and my foot felt better and better as the walk continued.

I hope it still feels better tomorrow. If not, I'll walk again instead of running. I can't give up exercise entirely for something like this, but the mild exercise of a hilly walk is probably the thing to do in the circumstances.

 


Diabetes prevalence: the non-medical factors

The trouble with using diabetes prevalence as an indicator of the state of public health (or as evidence for some theory of what is driving the diabetes "epidemic") is that diabetes prevalence is determined as much by politics (including the internal politics of the health care industry) as it is by anything that is happening to the health of actual human beings.

For example, suppose we change the diagnostic criteria or diagnostic methods which are currently used to justify a diabetes diagnosis. That will produce a dramatic overnight change in the number of people who "have diabetes", even though it does nothing to change anyone's health.

The current diagnostic test for diabetes is a fasting glucose test, and the current diagnostic threshold on that test is 126 mg/dl. It used to be 140, however, and when the threshold was reduced to 126, a whole lot of people "became diabetic" at once. Some doctors think it should be reduced further -- but there's a lot of opposition to that, because the number of people who will "become diabetic" if that change is made could be huge, and the health insurance industry doesn't want to deal with that.

Also, the fasting glucose test is clearly the wrong test to use for diabetes screening, because fasting glucose is often the last thing to go when people are losing control of blood sugar. A lot of "hidden" diabetes patients would be uncovered if the hemoglobin A1c test were used for screening instead. A few years ago, a Boston hospital tried an experiment in which it gave every patient who checked in an A1c test, and they discovered that a large fraction of the patients had undiagnosed diabetes (because they had managed to pass the fasting test on the few occasions when they'd taken it). The A1c test is certainly the way to go, but the health insurance industry is resisting this necessary change because they don't want "diabetes prevalence" to shoot up overnight.

And now another political factor is causing diabetes prevalence to go up -- at least in the 24 U.S. states that have expanded their Medicaid programs under the Affordable Care Act. Prevalence is up only a fraction of a percent in the 26 states which haven't expanded their Medicaid programs, because nobody in those states is getting medical care who couldn't get it before. But in the states which have expanded Medicaid, diabetes prevalence has increased by 23%. This dramatic difference can hardly indicate that the population is 23% sicker in the states with expanded Medicaid; clearly it indicates that a lot of diabetes cases are only diagnosed in people who can afford to see a doctor and be tested for it.

Also worth noting: average A1c levels in newly-diagnosed diabetes patients is a little lower in the states with expanded Medicaid programs. This probably indicates that, in those states, their diabetes is being discovered earlier. It should go without saying that discovering diabetes earlier is preferable (since getting blood sugar under control only gets harder if you wait), but that might not matter much to institutions that simply don't want to deal with diabetes at all, and don't want to have diabetes forced on their attention.

I mention all this mainly because reported diabetes rates over time are constantly being cited as evidence that this or that change in society (particularly in regard to which foods are popular) is making us diabetic. It might or might not be valid to do this. When bureaucratic and political decision-making can redefine millions of people as diabetic overnight, it might not be very meaningful to talk about what the diabetes rate is.

 


Hidden hypoglycemia

Apparently diabetes patients receiving treatment with insulin, or with glucose-lowering drugs, experience more hypoglycemic episodes than doctors had previously supposed, and this has a serious adverse health impact. This sad news was reported at the Diabetes UK Professional Conference. The conference chairman, David Russell-Jones (I'm not absolutely sure what lies behind the British hyphenated-name fetish, but I'm inclined to assume the worst) was quoted as follows: "What was quite novel here is that hypoglycemia in patients in hospitals is actually much more common... than one would expect from the randomized clinical-trial data. It leads to a greater length of stay and a huge health cost, and this is something that needs to be addressed."

Hyphenated or not, he's right: it does need to be addressed. And I feel as if I'm addressing it myself, in my own way.

If hypoglycemic episodes are a common and health-damaging consequence of diabetes treatments which rely on drugs to suppress glucose levels artificially, maybe more attention should be given to lifestyle-based approaches which do not cause hypoglycemic episodes.

I don't mean to be a radical or anything, but that's how it looks to me. Maybe working out, and cutting your carb intake, is a better solution than taking drugs (if you can make it work, anyway).

 


3rd Thursday Update

March 19, 2015

It was nice to be able to get to the state park after work, with enough daylight left to allow for a trail run. Maybe Daylight Saving Time is worth something after all.

 


The Huckabee thing

I've been asked to comment on Mike Huckabee, the preacher-turned-politician, who wants to be president of these United States. His unusual methods of campaign fund-raising include acting as a commercial spokesman for a rather questionable diabetes therapy.

Huckabee famously reversed his own diabetes by losing a great deal of weight, and the ads strongly suggest (without ever quite making it unmistakably clear) that he accomplished all this by adhering to the recommendations in the "Diabetes Solution Kit".

As you can see, a lot of people have said goodbye to diabetes (and said hello to solid colors), all as a result of doing what Mike Huckabee did.

Huckabee has admitted to reporters that what he actually did was lose weight by eating less food; he didn't take the supplements recommended by the Diabetes Solution Kit. He also says that he has cut his ties to the company selling the kit. He's been getting a lot of criticism for acting as snake-oil salesman, and it's been pointed out to him that grubbing for dollars in this way does not look "presidential". Which I guess is true, although I'm not at all sure that the dollars Huckabee took for these ads were the dirtiest dollars to find their way into a candidate's campaign fund this year. There's probably a limit to how much harmful influence supplement-mongers could have on the White House; at least, I find it hard to picture a scenario in which they would drag us into a war.

Supplements are strangely exempt from regulation by the Food and Drug Administration (perhaps because legislators couldn't agree on whether a supplement is a food or a drug), so it is legal to promote "cures" which haven't been shown to cure anything. The Diabetes Solution Kit apparently relies in part upon the rumored glucose-lowering effects of cinnamon -- a substance which had once looked promising in this regard, but hasn't stood up well to more thorough investigation. (The American Diabetes Association and the Canadian Diabetes Association say that supplements are not an effective diabetes treatment.)

I gathered as much information as my patience would permit on the Diabetes Solution Kit, and the impression I came away with is that it's an over-dramatic, long-winded, fear-mongering sales pitch for a regimen which boils down to "eat less carbohydrate and take these supplements". The former is useful and the latter will probably do no harm, but to claim that this plan is going to be enough to cure diabetes in four weeks seems irresponsible to me.

Anyway, it's a sales-pitch which seems so openly contemptuous of the audience's intelligence, you can't really feel sorry from anyone who's fooled by it and gets disappointed later. It's sort of like a "Nigerian letter" -- if you're conned by it, doesn't that mean you deserved to be?

Anyway, it looks to me as if the Diabetes Solution Kit is a mixture of common sense and woo-woo, packaged and presented as if it were a dramatic step forward which Big Pharma wants to suppress.

 


Net carbs

Processed-food makers want us to know that all carbohydrates are not created equal. It's true, up to a point. Some carbohydrates are not fully digestible, or not digestible at all, by humans. Cows and termites might be able to break down the cellulose in grass and wood into simple sugars, but we can't.

Sugar alcohols and "fiber" (a catch-all term for carbs we can't fully digest) affect human blood sugar less than one would expect from the total carbohydrate content. It is often suggested that we can subtract a portion of the carbohydrate total to account for the indigestibility of fiber and sugar alcohols. The usual formula, at least for fiber, is to subtract half the fiber grams from total carbohydrate (but only if the fiber count is 5 grams or more, for some reason).

I haven't been able to find satisfyingly persuasive information about the validity of all this. I suspect that the formula of "subtract half the fiber" is a compromise, reflecting the variable digestibility of different kinds of fiber under different conditions (perhaps the digestibility of the fiber depends, to some degree, on how the food is cooked, or on what else is in it). Anyway, processed food manufacturers have been pushing the "net carbs" concept on their product labels. I bought a loaf of flax-seed bread recently which said, in very large letters on the wrapping, that each slice only provides only 6.5 grams of net carbs per slice, based on the low carb count and high fiber count. Probably they're telling the truth about that; the bread tastes like drywall and doesn't spike my blood sugar. I had two pieces of it with lunch today and only went up to 113 mg/dl an hour later. I can't say it made for the sandwich of my dreams, but on the evidence of my meter result, I'd have to say that the "net carb" claim seems to have a legitimate basis.

However, it's worth noting that the government does not regulate "net carbs" claims, and there is no officially enforced definition of the term. In theory, companies can say just about anything regarding this this and get away with it. So, I would recommend against making too much of "net carbs" numbers promoted by food companies.

Also, I would recommend against making too much of the small difference, in this regard, between one food and another. People with diabetes are constantly being told to eat whole-wheat bread, as if the slight increase in the fiber content of whole-wheat bread was going to make a huge difference. A glance at the nutritional label (or at your glucose meter) should be enough to tell you that th difference is not as large as you've been led to expect!

 


2nd Thursday Update

March 12, 2015

No, I didn't gain five pounds since last week. I had a physical exam yesterday, and the scale in my doctor's office gave a result so much higher than the result from bathroom scale, I decided I'd better replace my bathroom scale with one which measures more accurately. Tragically, I was able to find one!

I suppose I shouldn't have become a health blogger in the first place, if I didn't want to embarrass myself publicly.

 


Fourteen years later

I didn't celebrate it, or even think about it at the time, but last month was the 14th anniversary of my diabetes diagnosis. I was 43 then; I'm 57 now. Soon to be 58. Maybe it's time for some ruminations on diabetes management as a long-term proposition.

I guess the first point worth noting is that I'm still able to maintain normal blood sugar levels without medication, fourteen years after diagnosis. This is a surprising fact. The conventional wisdom says the non-medicated approach to diabetes management only works temporarily, and even in exceptional cases it can't be made to work for more than ten years. But, in my case, it has worked for fourteen years. Could it be that the conventional wisdom is needlessly pessimistic?

Yesterday I had a physical exam, and a review of my latest lab work. Here's my hemoglobin A1c test result:

As you can see, I'm within the normal range. I don't mean normal for somebody who has diabetes, I mean normal for somebody who doesn't.

The rest of my test values were very good as well. Th only area on my lab report where I fell just slightly short was HDL ("good") cholesterol -- shown in red here because my value is outside the normal range:

The normal HDL range is anything over 40 mg/dL, and my result was 40 exactly. Obviously I didn't miss the target by much! In any case, HDL is considered "good" because it counteracts the plaque-forming action of "bad" cholesterol; therefore, the less non-HDL cholesterol you have, the less HDL cholesterol is needed to counteract it. My "bad" cholesterol is low, so I don't need a lot of HDL to offset its effects. The ratio of total cholesterol to HDL is supposed to be less than 5, and my ratio was only 3.7, so I'm well within the normal range there. Also, my triglycerides are extraordinarily low -- less than a third of the value defining the top of the normal range.

So, I don't have an excess of sugar in my bloodstream, and I don't have an excess of fat in my bloodstream either. Those two things together point to a reduced risk of cardiovascular disease -- rather than the heightened risk which is more typical of diabetes patients.

In short, no bad news yesterday. Fourteen years into my diabetes adventure I've still got things under control. My doctor said he doesn't see me as having well-controlled diabetes -- he sees me as not having diabetes at all. He's taken diabetes off the "problem list" in my medical records. I don't know that this will make the insurance industry forget that I was diagnosed with diabetes in 2001, but maybe they'll decide that the original diagnosis was a mistake. (It wasn't, though, in case you're thinking the same thing: my fasting glucose was 174 at the time.)

However, I had to confess to my doctor that achieving all this is harder work than it used to be. The machine runs down, you know? My body is not getting with the program as readily as it once did. The amount of carbohydrate I can get away with in a meal is lower than it used to be; I have to be more careful about my meal choices. And, considering how dependent I am on exercise to boost my insulin-sensitivity, wear and tear on the body over time is a significant issue. I am more often having days when I think a lengthy workout (or an especially intense one) is what I need, but it's not what my body is feeling ready to perform.

These days I always seem to be coping with low-level injury to one part of the body or another. For example, on Saturday I went trail-running, and seemingly nothing hurt afterwards. Sunday was a rest day. Monday morning I woke up with a sore right foot, and was limping around everywhere. I didn't think I could run, so I went to the gym and used the stair-climber for my workout. On Tuesday, while walking down a flight of stairs at work, I got a burning pain shooting up my left ankle. Great! Now both feet hurt. I applied ice-bags and took Ibuprofen. I didn't think I could do any serious workout at all, so I went for a 2-mile walk as a substitute, hoping that it would loosen my feet up instead of making them more stiff and sore. Fortunately, that worked, and on Wednesday I was able to go for a six-mile run without ill effects. Problem solved, seemingly... and yet I'm sure something else will flare up soon. My left hip, perhaps, or my right knee. Or maybe some really painful lower-back spasms -- haven't had those in a while! As I get older, the intervals between these episodes of injury seem to get shorter and shorter. My body seems to become more and more vulnerable to minor trauma, whether from exercise or from work habits or from bad posture.

For the time being I can cope with all this -- it is simply normal aging, after all, and exactly what I should be expecting -- but a day will come when I will need to re-think my exercise regimen. I will probably have to find a gentler way to work out. My doctor suggested lap-swimming as a possibility -- it makes sense, and I know that a lot of injured runners fall back on it. But as I don't especially like swimming (or cold water generally), I'll hold of on it until it becomes a necessity.

The other issue we discussed was my increasing tendency toward weight-gain over time. Blood-sugar control I can manage, even if I'm working harder at it than I used to, but weight control seems to be much harder than before. A likely reason is that, even though my exercise program continues, I'm increasingly sedentary the rest of the time, so I'm burning fewer calories but still eating the same amount.

I can make an effort to spend less time sitting, but I think I'll also have to find a way to get calorie consumption down. I think I'm going to have to fall back on the tried-and-true method of writing down everything I eat. It's not something I like doing, but I know that keeping a record can be enough, all by itself, to make me eat less.

Anyway, I guess my overall message is that you can continue managing diabetes without meds over the long haul -- but to make it work, you need to be aware of the ways in which your body changes over the years, and you need to be willing to adapt your approach as necessary, and keep working at it even when the going gets tough. Which it will!

 


The state of research today

 


1st Thursday Update

March 5, 2015

 


Statins and diabetes

Statin drugs (very widely prescribed for purposes of lowering blood cholesterol) are known to increase the risk of diabetes, but so far it has looked as if the increase in risk is comparatively modest (10% to 22%, depending on the study). A new, larger study from Finland says that the increase in risk is actually larger than that: about 46%. Apparently the problem is that statin use causes reductions in insulin production and also in insulin sensitivity (in other words, taking a statin drug causes you to need more insulin, at the same time that it's causing you to produce less of it). The reductions in insulin production and insulin sensitivity are not extreme (12% and 24%, respectively), but taken together they could certainly push someone who is close to becoming diabetic over that edge.

And, of course, if you already have Type 2 diabetes, taking a drug which compromises your insulin production and insulin sensitivity will certainly make it harder to keep your blood sugar under control.

Having said all that, the researchers certainly are not recommending that everyone stop taking statins. For many patients, the cardiovascular risk associated with out-of-control cholesterol is a bigger threat than an increased risk of becoming diabetic (or increased difficulty in managing existing diabetes). Doctors are going to have to make case-by-case judgment calls on this, and very likely the new evidence will not produce any kind of dramatic turnaround in the rate of statin use. I just hope it will restrain the enthusiasm which a lot of doctors seem to have for statins. I know four people whose doctors pushed statins on them very aggressively, even though they reacted badly to the drugs and felt miserable while taking them. There are other things we can do about cholesterol, and in the case of a diabetic or pre-diabetic patient there are probably better things to do.

 


The rat pack

Until today I never thought of rats as having grandparents, but of course they obviously must. Which is a good thing, because if you're going to do research on certain issues related to chronic metabolic diseases, such as diabetes, you want to do multi-generational studies to see if there are any patterns of inheritance for such diseases. Fortunately, it doesn't take all that long to do a multi-generational study, if it's a study of rats. So, researchers have been taking a look at grandparent rats and their grandkids, to see what they can find out about disease inheritance. By the way, it turns out that young rats are not kids, they're "pups". (It's been a big day for me -- not only did I find out that rats have grandparents, I found out that they have pups, too.)

The research I read about today was so strange that I'm amazed anyone even thought of trying it. (But I'm also amazed that anyone thought of trying to make cheese, wine, or chocolate, and we wouldn't want those things not to have happened.) The study was related to low-birthweight babies (or pups, I should say), and the health problems they develop later -- which become inheritable for subsequent generations.

The researchers employed a technique called IUGR (intrauterine growth restriction). That is, they deliberately created a batch of low-birthweight rats by means of a surgical procedure on pregnant females (they choked off uterine arteries to limit the supply of nutrients to the fetus). They then tracked the health histories of the low-birthweight rats, over a couple of generations.

Exactly what they found is difficult to tell from the material that I was able to see (a terse and unrevealing abstract, plus press summaries that are enthusiastic and unclear). But it appears that being born underweight (because you didn't absorb enough nutrition in the womb) causes certain changes in gene expression which then become inheritable traits; the low-birthweight tendency can be passed on from either the male or female parent. Also passed on, along with this tendency toward low birthweight, is a tendency to develop metabolic syndrome (the set of physical changes which leads to diabetes). Can dietary changes correct this inherited problem? Apparently not, at least for the low-birthweight tendency, but apparently so, for the metabolic syndrome associated with it.

But I'm not sure how much any of this is applicable to human health. We're talking about generations of rats, not generations of humans, and there might turn out to be some differences worth mentioning.

 


Sad and nervous mice

Diabetes is associated with high rates of anxiety and depression -- and not just because managing diabetes is a pain in the ass, since patients with other, similarly burdensome health problems don't show those same high rates of anxiety and depression. So there must be something about having diabetes which produces those effects on mood.

Researchers at the Joslin Diabetes Center think they've found the explanation, and it turns out to be insulin resistance in the brain.

They genetically modified mice to make their brains insensitive to insulin, and later made studies of their brain tissue. They found that the insulin-resistant mice had reduced levels of a neurotransmitter (dopamine); this deficiency is known to be linked to anxiety and depression. The mice also exhibited behaviors suggestive of anxiety and depression.

I'm not sure what sort of behaviors a mouse exhibits which would be suggestive of anxiety and depression, but maybe the mice looked sort of like this:

Anyway, now that we know insulin resistance triggers anxiety and depression, what can we do about it?

Well, exercise would be one thing -- it is known to combat insulin resistance, and it is also known to relieve anxiety and depression. Now at least we have a plausible explanation for the connection between those seemingly unrelated things.

 



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