The blog is dead, long live the feed!

For curated links on research for management, control, and possible remission of type 2 diabetes mellitus, please see:

• current @T2DRemission on Twitter
• archive Michael.Massing on Pinboard

Pending further developments,these posts will remain online; each represents my best understanding as of the time of publication. Posts are subject to review as science, clinical practice, and my thinking (e.g., about reliance on dietary animal protein) evolve.

Here and elsewhere, read critically. Your life and wellbeing depend on it.

what they don't say (enough)

Are there "gaps" in what you hear and read about diabetes? An online survey for people affected by the disease(s) is gathering "missing" information to incorporate into educational videos.*

Distortions and omissions in the diabetes discourse are a recurring theme here - usually how:

• Medical research is dominated and distorted by deep-pocketed industrial interests.
• Standards for self care and even for diagnosis are shockingly - it is no exaggeration to say fatally - inadequate.

My top-of-mind short list for the biggest diabetes information gaps includes: 

• Diabetes is complicated. Volumes of research produce inconclusive and contradictory results.
• Diabetes-related research may be badly reported, or just plain bad.
• Evaluating research, assessing risks and benefits, and devising a working strategy for self care are not helped by the cognitive deficits, depression, and fatigue associated with blood sugar highs and lows.
• Drugs used to treat diabetes and/or its comorbidities may increase the risk of death or morbidity, including onset of diabetes itself and incidence of comorbidities. 
• Blacks, Hispanics, American Indians, and Pacific Islanders are known to be at higher risk for developing diabetes. Less discussed are the risks conferred by a range of circumstances: socioeconomic status, stress, sleep, inadequate health literacy and education, location, and exposure to plastics and to environmental pollution. These factors often trump genetics; they can increase diabetes incidence and/or worsen outcomes.
• Lack of professional consensus, balky insurance plans, and physicians' disregard of patient-reported data may all interfere with getting adequate testing supplies to carry out tight glucose control.

In short, diabetes usually cannot be resolved by, as one pharmaceutical company shamelessly touts, "simple changes."

Of course, those of us with type 2 diabetes have it "easy." Those with type 1 can match all of the above point for point (with some variation) besides being burdened with:

• fewer treatment options 
• a more painstaking, invasive, and wearying—and typically decades longer—self-care routine
• immediate and potentially mortal risks that can come from monitoring and treatment errors

Cheery thoughts for a sunny winter's day! Well, they asked.

Good heath and good luck,

M.

*The survey is sponsored by wegohealth, a platform for online "health activists"; they will donate to diabetes organizations based on survey participation to promote the survey. I don't know much about the sponsors, but they are asking the right questions.

normal? really?

Here's a secret. When it comes to blood glucose levels, nobody knows what "normal" means.

As noted before, medical research finds increased incidence and risk of diabetic comorbidities or "complications" (late-stage symptoms) correlating with blood sugar levels currently deemed "pre-diabetic" or even normal.

We know this more precisely now, yet it's nothing new. The correlation of elevated blood glucose with morbidity and mortality is long-established; it informs our current definition of normal as fasting blood glucose under 100 mg/dL, although in an entirely inadequate way.

As long ago as 1980, impaired glucose tolerance (defined as blood sugar levels of 96 mg/dL or greater after a clinically-administered "challenge" of 50 g oral glucose), roughly doubled risk of death due to coronary heart disease.

In short, that level of post-challenge glucose intolerance, several points within today's "normal" fasting range, kills people. Quibbling over the additional 25 mg/dL that distinguish the "pre-diabetic" from the diabetic seems as useful as speculating over how many angels can dance on the head of a pin.

more on the risks of current norms

p.s. I was recently surprised to find an untapped prescription for glucose test strips, and was able to get it extended. I'm gathering new data on my own progress and setbacks, and should be able to publish them soon. I shall also finally incorporate into the data the standards for normoglycemia that have been tightened - obviously to my mind not enough - since my original intervention in 2003.

back on track

I'm returning to the plan from 2003. I've been losing about three pounds a month since March.

I also finally got some pharmacy issues sorted out, and have glucose meter test strips again. Early results are good:

• Most results are in the normal range, less than 100 mg/dL glucose.
• I am still subject to some version of the "dawn phenomenon", with morning fasting readings around 120.
• On the other hand, I may have responded "non-diabetically" to a big dish of ice cream right as I started testing, with a 2-hour postprandial reading of 128. (But see below. And no, big dishes of ice cream are not part of the plan.)

Separating meals by a minimum of four hours is critically important for these results.

In the next series of tests, I need to get a better idea of where my postrprandial peak falls. I know it's longer than two hours, probably closer to three. With that done, I'll post more detailed results.

I have some new ideas about the elevated waking readings - sleep apnea has been ruled out - and hope to be able to score some more strips to test those soon.

p.s. I've updated the dataset download page with PDFs of some input and outcome overviews.

eye risk before diagnosis

A recent study proposes new thresholds for predicting risk of diabetic retinopathy. Using more precise gradation in the "good control" or "prediabetic" range than comparable earlier research, Massin et al. found the following correlations among 700 French volunteers studied for ten years, and were confident in proposing them as predictive:

HbA1c %	fasting plasma glucose mg/dL	predicted retinopathy
6.0	—	6.0%
—	108	8.4%
—	116	14.0%
6.5	—	14.8%

The takeaway? A difference in the range of half a percentage point of HbA1c, or 8 mg/dL of fasting plasma glucose, roughly doubles one's risk of potentially blinding retinopathy, from about one in 15 to one in 7. This risk correlation held even among subjects who did not develop diabetes, as currently defined, over the course of the study, retaining their diagnosis of "impaired fasting glucose".
The current diagnostic threshold for diabetes is an HbA1c of 6.5, the highest value in the proposed predictive model. Since the diagnostic threshold in terms of fasting blood glucose is 126 mg/dL, the remaining values are well below the threshold, in the so-called "prediabetic" range. Normoglycemic, neither diabetic nor prediabetic, is currently defined (at the upper end) as under 100 mg/dL fasting glucose or under 5.7% HbA1c.
I have two reasons for highlighting this study:

• Absent a risk of going hypoglycemic—into dangerously low blood glucose levels—there is a compelling argument for driving blood glucose levels down even if you are being told, as people in the "prediabetic" range often are, that they have "good control". A level of control that may double my risk of blindness doesn't seem to me to have much good about it. (Type 1 diabetics or others considered to be at higher risk for "going hypo" may want to check with their care team about the extent to which tight control might mitigate both short- and long-term risks.)
• If diabetes is a progressive, degenerative, debilitating, and potentially fatal disease with multiple comorbidities—it is—and if "prediabetes" is an independent mortality risk whose defining numbers successfully predict so-called "complications", or more precisely late-stage symptoms, of diabetes—it is and they do—why on Earth is the diabetic establishment still sugar-coating the reality of this disease by mucking around with terms like "prediabetes"? When will medicine catch up with science and lower the diagnostic threshold? It has done so before, and can do so again. Come the day!

source: Massin P et al. Archives of Ophthalmology, 2011: 129(2): 188-195

slip-sliding away

I like to keep my eye on the feeds here. Each has its own value.

Diabetes Self-Management works as a go-to site for the newly-diagnosed and long-term managers alike. I follow it primarily for the regular bloggers, and especially for David Spero's examination of questions not satisfactorily answered by current medical and diabetic orthodoxy. His savaging of the distorted reporting of one phase of the landmark ACCORD drug-treatment trial—including outrageously harmful comments by medical experts—stands as a cautionary tale against believing what you read in even respected sources in the popular press.

What caught my eye today was Eric Lagergren's Intake Accountability. I knew from the title I had to read it.

I've briefly mentioned "backsliding" out of remission, my current attempts to restore self-preservative sanity to my diet, and the need for diabetics to "meter" their food intake as rigorously as they monitor their blood glucose levels. Lagergren nails the process by which this discipline can fall apart. I wish him and all of you success in restoring or maintaining the necessary accountability.

And I remind myself that my own success will depend on more than wishing.

(Thanks to jlesage via Delicious.com for directing me to this invaluable site!)

medicine's blind spots

When I was hospitalized with a MRSA infection, I was seeing doctors and other health specialists, not counting the ward nurses, literally by the dozen. I needed surgery on my foot to clear out an infection there, and my lungs were also infected, showing “cavitary lesions” (basically holes, which for the most part filled in again after treatment). It was not clear at first that the infections were the same, since the necessary intervening pathways—the blood and the heart—showed no infection by the time the lung damage was found. So I was talking to orthopedic surgeons, cardio and infectious specialists, pulmonologists, practitioners from my primary care team, and doubtless others I can’t remember; San Francisco General Hospital seemed to stint no resources in a multidisciplinary approach to figuring out what was wrong with me and how to fix it.
Among all these doctors, one stands out: Dr. X checked in with me regularly, often several times a day. He made sure I was getting all the information that I needed from the various teams. He explained how the thinking of the teams was progressing, where there was consensus and where uncertainty. Uniquely among the doctors, he repeatedly encouraged me

remission? cure? control?

2003/12/16 "Looks to me like you're not diabetic anymore."
—my Kaiser Permanente doctor

Wow. I didn't think they were allowed to say that. Nor that any doctor would ever say, as mine did later in the same conversation, "You've cured yourself."

As I've learned since, only the first of these statements is true. Being "not diabetic anymore" can serve, with certain caveats, as an attainable goal in diabetes control. This is what I, along with more and more lay people and professionals, call remission.