Time, said Auden, will say nothing but I told you so. Time also gives one the opportunity to brood – darkly – on so many of the idiocies out there in the ever-expanding world of health information. So here, in no particular order, what’s been making me especially cranky:
Monster under the bed roams city streets
Diabetes, the latest health scourge to hit the news, is now a City of Vancouver problem, at least according to a headline in a throw-away newspaper I threw away,
“Vancouver to track and attack diabetes”. With what, one idly wonders. Bicycle spokes dropped on those bicycle lanes? Pointed sticks? Stern warnings? Nothing so mundane it turns out. This, apparently is part of some international initiative (a word that sets my teeth on edge) and creme de la creme cities like Houston, Mexico City, Copenhagen, Shanghai and Tianjin (where?) are on board, tracking “people at risk of diabetes” as part of a campaign to promote “healthier cities”. Curiouser and curiouser. Who knew cities were sentient and could get sick.
So the plan is – what? Skulk behind anyone leaving Starbucks with a large, frothy coffee? Tap anyone who seems a bit plump on the shoulder and read them the health riot act? (Honestly officer, it’s this outfit. Makes me look fat.)Someone with the unlikely title of managing director of social policy at, one assumes, the City of Vancouver will start “consultations” with Vancouver Coastal Health and – wait for it – Novo Nordisk, the sponsor of this demented plan.
Of course. Silly us, not to have realized a drug company had to be involved.
Novo Nordisk, a nominally Danish but probably multinational drug company almost exclusively manufactures diabetes drugs (oral hypoglycemics) as well some types of insulin. (The old insulin by the way, the non-patent-able kind that came from animal pancreases and was easily tolerated isn’t around any more at least on this continent. Banting, bless him, donated his discovery to the people of the world; he didn’t believe anyone should benefit financially from diabetes. Unfortunately he had no way of knowing that by the late 20th century pretty much anything could be “property”: manufactured and sold, up to and including a person’s genome.)
This diabetes sneak attack has already started up in Houston where they “mapped” various areas (for what one wonders) and went door to door to “educate” people about diabetes. Then, if their numbers don’t match some ideal level no doubt they need some of Novo Nordisk’s boffo drugs. (This class of drugs, by the bye, doesn’t tend to have a long shelf life as they usually are fairly toxic to the liver and quite a few of them have come and gone.) These hapless people will be told to get their fasting glucose and A1C* checked and down the rabbit hole they will go. We will all go.
These days after all it has nothing to do with the actual human being who may be in there somewhere but about the numbers. (There’s an American drug ad that doesn’t even pretend it’s about anything but “bringing your numbers down”.) I suppose racial profiling could play a part as well, given that, statistically, people of South Asian, Hispanic, Asian and First Nations background may be at greater “risk” – whatever that means.
What few people realize is that this ostensible epidemic of type 2 diabetes sweeping the world has much to do with the continual lowering of inclusion criteria. A few decades ago “normal” glucose levels were around ten. Now they’re about half that. For people over 50 the latter number is especially problematic as close to half of us, as we age, tend to have somewhat higher levels of glucose and if you think about it, it simply makes no sense that a physiologic change that affects close to half the population in a particular demographic is a pathology. It’s what’s called, um, normal.
As for me, if anybody tries to corner me and talk to me about my diabetes risk, I plan to run shrieking into oncoming traffic. At least that’s a risk that makes sense.
Fight them on the Beaches
In that previous story what initially struck me was the term “attack”. As though a glucose level that could potentially be problematic was some kind of enemy – not some fluctuating number based on a myriad factors ranging from weight to diet to sleep. A number that moves up and down depending on the time of day and a host of other factors.
Physiology is dynamic, not that you’d ever know it these days given how mesmerized we are with the numbers.
Oliver Sacks, RIP
Someone who understood the complexities of physiology – and stood up for clinical knowledge and patient narratives – was Oliver Sacks., who died last August.
Physician, author, eccentric and host of oddball characteristics, Sacks wrote some amazing books (Migraine, The Man who Mistook his Wife for a Hat, An Anthropologist from Mars, A Leg too Few are some of the ones I enjoyed reading. Apologies if I got the titles slightly wrong as I’m quoting from memory). Most important, his writing reminded us of the diversity and variation(s) there are between us; not simply the similarities that clinical trials, statistical averages and guidelines exploit. Sick or well we’re all different and, to paraphrase Hippocrates and Osler and other famous sorts, medically the person with the disease matters as much as the disease. Or ought to. Alas, the trajectory of modern medicine whether it’s so-called preventive care, apps or genetics has a tendency to iron out those differences and push us towards some mythical average or “normal” that few of us come close to.
Colourful, thoughtful clinicians like Sacks have become vanishingly rare. Perhaps it was Sacks own differences – Jewish, gay, former biker and user of psychoactive drugs, gefilte fish aficionado – that made him realize just how much one’s personal history and narrative played into one’s physiology. Or just how vital it is for clinicians to listen as well as talk.
Dem bones, dem bones
L’esprit de l’escalier is a French phrase referring to all the pithy remarks one ought to have made but which only come to mind some hours later. Usually as one’s interlocutor is long gone.
So, to the pleasant woman who came up to me after my CAIS (Canadian Association of Independent Scholars) talk last year to ask about vitamin supplements, more specifically calcium, what I omitted to mention was that calcium is not a vitamin, it’s a mineral. An element, if one wants to be pedantic, Ca+ (20 on the Periodic Table). Hence, the “elemental calcium’ you can buy in the drug store.
The notion that we all need to take calcium supplements for our bones is based on somewhat simplistic notion, namely that simply ingesting this mineral will somehow magically increase bone density which we are told we are losing at an alarming rate, especially if we are women over 50. Clever advertising ably preys on our fears of “weak” bones, metaphors being what they are.
Bone is an amazing substance. It is dynamic – the collagen demineralizes and then degrades even as other cells (in sync) remineralize the collagen that has just .. diminished for want of a better word. It ebbs and flows (how else could a broken bone heal?) to achieve a balance; a balance that alters with age. When we are young/growing bone builds to its apex, in our twenties. It then plateaus for a time then, as we pass age 35 or thereabouts we gradually lose bone density. This is what we used to realize was normal development. And the bone in your body differs in form, hardness and elasticity depending on where it is and what it does – the vertebrae in your spine and the long bones in your body are of a different consistency and respond to changes in pressure differently than the ribs or the wrist.
The calcium/Vit D directive has become so engrained however that most people believe what they are doing is somehow maintaining or feeding their bones with supplementation.
But our endocrine system monitors the blood level of calcium and maintains it at our personal set point. One that is different for each person. This means that taking in more calcium is generally pointless as it simply cannot be absorbed. To quote Nortin Hadler, an MD, in his book, The Last Well Person, “If the blood calcium level trends down, vitamin D is converted to an active metabolite, which makes the intestinal absorption of calcium more efficient and vice versa”. More is not better; it’s useless. And potentially harmful as calcium can deposit in joints and other bits. As for vitamin D, it too has a set point that differs in each person; too large doses can build up and become toxic. So, those generic amounts you’re advised to take may or may not apply to you. Probably don’t in fact.
We tend to think that the supplements we take as a kind of top-up to diet, like adding oil to a car or salt to soup. Our bones rely on calcium so we basically assume that bone density is improved by taking supplemental calcium. And since our bones contain calcium, and as we get older our bones become less dense, we should “supplement”. It’s a mechanistic form of thinking about the body, one that took off after the Industrial Revolution when an “engineering mentality” took hold about physiology (in anthropologist Margaret Locke’s term). It certainly doesn’t hurt that the nice people at Bayer (who are taking over the world and now sell everything from vitamins to glucose meters) continually tell us we should. Alas, physiology is rarely so cut and dried and our understanding of how bone (or anything else) works remains primitive.
The real advantage of dietary calcium is when we are young and our bones are developing (in our teens). Unfortunately, short of building a time machine and going back in time there’s not much we can do to reverse the bone mass we accrued before our twenties.
So for now the basics of health remain the same as they were in decades past. Relax, eat well, exercise and stop stressing out about supplements. Most important: stop listening to all that bogus advice out there. If all we do is obsess about our health, our diets, our bodies – well, we won’t actually live any longer but it sure will seem that way.
*A1C is a measure of a red blood cell that is said to provide a “snapshot” of your glucose levels over the previous three months. It’s rather elegant but is still a correlation. A good one to be sure but correlation is not, as we all know, causation.