I'd noticed I was using a lot more insulin but figured it was because I'd cut down on my metformin. But when I went back up to 1 750 mg tablet a day of the Metformin I didn't see much improvement and my fasting bgs were creeping up again, so I started to wonder if my two month old vial of R was getting weak.
I'd been keeping the vial at room temperature after reading various places that it would keep at room temperature for many months and had used about half the vial. But my room has been quite warm of late, even with our feeble window air conditioner cranking at full blast down the hall, so it seemed like a good idea to buy a new vial.
Yesterday I'd stayed well over 110 mg/dl for hours after using 2 units of the old stuff on a conservatively estimated 16 grams at lunch (1 slice of "lite" rye bread with a reasonable serving of natural peanut butter), I tried 2 units of the new stuff today with the identical lunch.
Wham! I peaked at 99 an hour after eating and then went right back into the 80s, which "forced" me to eat half of a delicious peach for a snack 2 hours later to avoid hypoing. Five hours later I'm at a perfect 81!
So that answers that question of whether it's me or the insulin.
I'll be keeping the R in the fridge this time and testing with this reference meal from time to time to make sure it is still fine.
But at least I can be reassured that using insulin for a while hasn't somehow increased my need for insulin which had been a concern.
Thursday, July 27, 2006
Wednesday, July 26, 2006
Diabetics and Wound Healing, Alzheimers, Heart attack, etc.
You see these studies all the time that tell you cheery "facts" such as that diabetics are more likely to get heart attacks, Alzheimers, and have poor healing after wounds or surgery. Depressing, isn't it?
What they don't tell you is that the "diabetics" they are talking about are really "Diabetics with lousy blood sugar control". The diabetics in the studies that lead to these conclusions universally have A1cs of at least 7% and often more like 10% along with fasting blood sugars near 200 mg/dl (11 mmol/l).
Doctors all too frequently tell people with Type 2 diabetes that an A1c of 7% is "fine" and don't point out that an A1c that high almost guarantees neuropathy and early changes in the retina and kidneys leading, eventually, to disaster.
The 7% A1c target was originally established after the DCCT study found that people with Type 1 diabetes who achieved that A1c had far fewer complications than those whose A1cs were higher. (No study ever looked at what happened to complications if the A1cs were LOWER than 7%). But when they ran a similar study of Type 2s, the UKPDS, while they found that the 7% A1c resulted in fewer complications than higher ones, they also found that people with type 2 diabetes at the 7% A1c got far MORE complications than Type 1s had who had that same A1c. In short, an awful lot of people with Type 2 diabetes followed in the UKPDS study who kept their A1cs at 7% ended up with serious complications including retinopathy (med-speak for blindness).
The conclusion that should have been drawn from this is that people with Type 2 diabetes need to shoot for much lower A1cs than those with Type 1. Unfortunately, that isn't what happened. Most doctors still tell patients that 7% is a good A1c target that prevents complications and labs flag anything under 7% as "good control."
It isn't. Good control is control that gets you as close to normal numbers as is possible.
What is normal? There's some evidence that true normal is an A1c of 4.7%, a fasting of 83 mg/dl (4.6 mmol/L) and post-meal readings no higher than 120 mg/dl (6.7 mmol/l) within 2 hours of a meal. That's a tough target to meet and one that a lot of us can't reach. But the closer you can get to these numbers, the better off you will be.
Most people with Type 2 diabetes CAN get their A1cs into the 5% range with a combination of cutting way back on carbohydrates, taking insulin resistance drugs like Metformin, and if things are really out of control, insulin.
So when you see yet another study that tells you that because you have diabetes you are doomed to yet another nasty life-shortening condition, remind yourself it isn't some underlying condition causing these problems, it is high blood sugars, day after day, meal after meal. If you can bring your blood sugars down to normal, your risk for these conditions will drop to normal too!
What they don't tell you is that the "diabetics" they are talking about are really "Diabetics with lousy blood sugar control". The diabetics in the studies that lead to these conclusions universally have A1cs of at least 7% and often more like 10% along with fasting blood sugars near 200 mg/dl (11 mmol/l).
Doctors all too frequently tell people with Type 2 diabetes that an A1c of 7% is "fine" and don't point out that an A1c that high almost guarantees neuropathy and early changes in the retina and kidneys leading, eventually, to disaster.
The 7% A1c target was originally established after the DCCT study found that people with Type 1 diabetes who achieved that A1c had far fewer complications than those whose A1cs were higher. (No study ever looked at what happened to complications if the A1cs were LOWER than 7%). But when they ran a similar study of Type 2s, the UKPDS, while they found that the 7% A1c resulted in fewer complications than higher ones, they also found that people with type 2 diabetes at the 7% A1c got far MORE complications than Type 1s had who had that same A1c. In short, an awful lot of people with Type 2 diabetes followed in the UKPDS study who kept their A1cs at 7% ended up with serious complications including retinopathy (med-speak for blindness).
The conclusion that should have been drawn from this is that people with Type 2 diabetes need to shoot for much lower A1cs than those with Type 1. Unfortunately, that isn't what happened. Most doctors still tell patients that 7% is a good A1c target that prevents complications and labs flag anything under 7% as "good control."
It isn't. Good control is control that gets you as close to normal numbers as is possible.
What is normal? There's some evidence that true normal is an A1c of 4.7%, a fasting of 83 mg/dl (4.6 mmol/L) and post-meal readings no higher than 120 mg/dl (6.7 mmol/l) within 2 hours of a meal. That's a tough target to meet and one that a lot of us can't reach. But the closer you can get to these numbers, the better off you will be.
Most people with Type 2 diabetes CAN get their A1cs into the 5% range with a combination of cutting way back on carbohydrates, taking insulin resistance drugs like Metformin, and if things are really out of control, insulin.
So when you see yet another study that tells you that because you have diabetes you are doomed to yet another nasty life-shortening condition, remind yourself it isn't some underlying condition causing these problems, it is high blood sugars, day after day, meal after meal. If you can bring your blood sugars down to normal, your risk for these conditions will drop to normal too!
Wednesday, July 19, 2006
PREFER - This Idiotically Designed Study will Set Back Diabetes Treatment for Years
Diabetes in Control reported this week on a study presented at the ADA conference this past June that could going to cause a lot of people to go blind and lose kidneys and toes.
[2006 American Diabetes Association Scientific Sessions : Liebl A et al. "Biphasic Insulin Aspart 30 (BIAsp30), Insulin Detemir (IDet) and Insulin Aspart (IAsp) Allow Patients with Type 2 Diabetes To Reach A1C Target: The PREFER Study" Presented June 11, 2006 Bretzel RG et al. "Equivalence of Basal Insulin Glargine vs Prandial Insulin Lispro for Glucose Control in Type 2 Diabetes Patients on Oral Agents - Results of the APOLLO Study" Presented June 12, 2006]
In brief, the study concludes that there is no reason for people with type 2 to use bolus insulin as the results of using a basal alone is comparable to a bolus/basal regime.
Why is this so dangerous? Because of the way the study was designed. What it really proved is that patients who don't use enough bolus insulin to control blood sugars will get little improvement from using bolus insulin. That's because the post-meal target in this study was 180 mg/dl, a level guaranteed to promote neuropathy in everyone and retinopathy in a lot of people with type 2. (Details of why can be found at Research Connecting Organ Damage with Blood Sugar Level)
This is, of course, the level the ADA has been pushing for years. One that the American College of Clinical Endocrinologists (AACE) has abandonned, because it is far too high.
Not only that, but the patients in this study were taken off ALL oral drugs, which of course meant that their insulin resistance went WAY up, making control that much harder.
The tragic thing is that insurers are likely to seize on this as a reason to deny coverage for bolus insulin to people with Type 2 diabetes.
Why doesn't ANYONE in the medical establishment get it that people with Type 2 deserve treatment that gives them NORMAL blood sugars, not those that ensure that most of them will suffer horribly for years?
[2006 American Diabetes Association Scientific Sessions : Liebl A et al. "Biphasic Insulin Aspart 30 (BIAsp30), Insulin Detemir (IDet) and Insulin Aspart (IAsp) Allow Patients with Type 2 Diabetes To Reach A1C Target: The PREFER Study" Presented June 11, 2006 Bretzel RG et al. "Equivalence of Basal Insulin Glargine vs Prandial Insulin Lispro for Glucose Control in Type 2 Diabetes Patients on Oral Agents - Results of the APOLLO Study" Presented June 12, 2006]
In brief, the study concludes that there is no reason for people with type 2 to use bolus insulin as the results of using a basal alone is comparable to a bolus/basal regime.
Why is this so dangerous? Because of the way the study was designed. What it really proved is that patients who don't use enough bolus insulin to control blood sugars will get little improvement from using bolus insulin. That's because the post-meal target in this study was 180 mg/dl, a level guaranteed to promote neuropathy in everyone and retinopathy in a lot of people with type 2. (Details of why can be found at Research Connecting Organ Damage with Blood Sugar Level)
This is, of course, the level the ADA has been pushing for years. One that the American College of Clinical Endocrinologists (AACE) has abandonned, because it is far too high.
Not only that, but the patients in this study were taken off ALL oral drugs, which of course meant that their insulin resistance went WAY up, making control that much harder.
The tragic thing is that insurers are likely to seize on this as a reason to deny coverage for bolus insulin to people with Type 2 diabetes.
Why doesn't ANYONE in the medical establishment get it that people with Type 2 deserve treatment that gives them NORMAL blood sugars, not those that ensure that most of them will suffer horribly for years?
Tuesday, July 18, 2006
Off Metformin for a Week.
I've been having a problem with mild nausea for several weeks, so I figured I better cut back on the metformin before going to the doctor and getting put through the whole misery of having tubes stuffed up various orifices, just to make sure the nauseous isn't a side effect of the Met.
I hadn't had a problem with metformin causing stomach problems in the past, but the endo told me last week she had another patient who developed the same problem after a couple years on metformin, had the expensive work up, and then found out the problem WAS from the drug.
So this is day 3 with no metformin, and boy am I hating it.
All my nice insulin dosages are now off because the Metformin drops me at least 20 mg/dl. So instead of being in the 80s this morning after my very low carb breakfast-- 4 grams--I was in the 100-110 range instead, and stayed there until my lunch injection. At dinner I saw a nasty spike though I'd done a bit more than usual hoping to cover it. And since it takes a few weeks for metformin to washout of the body, it's going to keep getting worse as time goes on.
Naturally, this would be he day that The World's Nicest Man brought me home an eclair from the Black Sheep Deli in Amherst, which is something I only get once every couple blue moons. It is almost my birthday and this is a pastry worth shortening your life for. I haven't had one for months and they don't keep, so I'd dosed the insulin with it in mind. But with that spike 90 minutes after dinner, no eclair for me, at least not until I'm back at a reasonable level.
Guess I better go see the doc and hope it's a treatable ulcer, though treating an ulcer when you can't take salicylates may be interesting, too. That said, the tummy is a lot happier without the metformin. Damn!
I hadn't had a problem with metformin causing stomach problems in the past, but the endo told me last week she had another patient who developed the same problem after a couple years on metformin, had the expensive work up, and then found out the problem WAS from the drug.
So this is day 3 with no metformin, and boy am I hating it.
All my nice insulin dosages are now off because the Metformin drops me at least 20 mg/dl. So instead of being in the 80s this morning after my very low carb breakfast-- 4 grams--I was in the 100-110 range instead, and stayed there until my lunch injection. At dinner I saw a nasty spike though I'd done a bit more than usual hoping to cover it. And since it takes a few weeks for metformin to washout of the body, it's going to keep getting worse as time goes on.
Naturally, this would be he day that The World's Nicest Man brought me home an eclair from the Black Sheep Deli in Amherst, which is something I only get once every couple blue moons. It is almost my birthday and this is a pastry worth shortening your life for. I haven't had one for months and they don't keep, so I'd dosed the insulin with it in mind. But with that spike 90 minutes after dinner, no eclair for me, at least not until I'm back at a reasonable level.
Guess I better go see the doc and hope it's a treatable ulcer, though treating an ulcer when you can't take salicylates may be interesting, too. That said, the tummy is a lot happier without the metformin. Damn!
Saturday, July 15, 2006
Figured out Comments - and Comments on the Comments
Apologies to those of you who posted comments that never appeared. I didn't realize I had to approve each one. They're visible now.
A few thoughts in response to the comments.
1. Re A1c: I controlled with diet for many years before starting insulin. I did not find the A1c a good guide at all, because my diabetes was characterized by very high post-meal readings, but near normal fasting values. As a result, my A1cs were often only slightly elevated while my blood sugar, for many hours a day, was high enough to do significant damage. This, it turns out is a common pattern among women who die of heart attacks. I've got some pointers to the Rancho Bernardo study that discovered this pattern on the "What they Don't Tell You About Diabetes" site.
It's also significant that two studies of neuropathy in people with non-diabetic blood sugars found no correlation between incidence of neuropathy and A1c, but a clear relationship between 2 hour glucose tolerance test result and neuropathy. So here too, post-prandial levels are much more indicative of early damage than A1c. All this is documented at the "At what blood sugar level does organ damage occur" page on the phlaunt.com site.
Finally, just this week, Diabetes in Control reported that the ADA is now saying that an A1c of 5.8% indicates a possibility of diabetes and should be screened. My endo told me that in her experience 5.7% is almost always diabetic! But most family doctors won't even mention diabetes until you are nearing 7%!
2. Byetta: I have heard very good things about Byetta, most notably from someone with a very similar kind of diabetes to what I have who is getting excellent results. However, I have a long history of getting bad side effects, some permanent, with common drugs, so I felt it would be smart to wait until there was more data available on Byetta use, long term. Since my current regimen is working very well, there's no hurry.
3. What if Exubera turns out not to harm lungs. Is it great then? No. Not unless they can come up with a dosing mechanism that allows finer titration. As I told the Business Week editor, I often dial in my dose to 1/2 a unit. An bolus insulin delivery system that has 3 units as the smallest increment is going to be useless for anyone who is insulin sensitive. Beyond that, since 2 mg isn't the same effective dose as 2 times 1 mg, according to what I've read, even an IR type 2 is going to have trouble figuring out how to match this stuff to meals.
There's a buccal insulin in the pipeline (absorbed via the cheek membrane) that would not have the lung issues and might be more easily dosed. That could be helpful. But we'll have to see what it really does. I don't trust any of the PR you read before the drug company has to put together something that has legal standing. And even there, I've read enough Prescribing Information to see the statistical tricks they pull to make their product look more effective than it is!
A few thoughts in response to the comments.
1. Re A1c: I controlled with diet for many years before starting insulin. I did not find the A1c a good guide at all, because my diabetes was characterized by very high post-meal readings, but near normal fasting values. As a result, my A1cs were often only slightly elevated while my blood sugar, for many hours a day, was high enough to do significant damage. This, it turns out is a common pattern among women who die of heart attacks. I've got some pointers to the Rancho Bernardo study that discovered this pattern on the "What they Don't Tell You About Diabetes" site.
It's also significant that two studies of neuropathy in people with non-diabetic blood sugars found no correlation between incidence of neuropathy and A1c, but a clear relationship between 2 hour glucose tolerance test result and neuropathy. So here too, post-prandial levels are much more indicative of early damage than A1c. All this is documented at the "At what blood sugar level does organ damage occur" page on the phlaunt.com site.
Finally, just this week, Diabetes in Control reported that the ADA is now saying that an A1c of 5.8% indicates a possibility of diabetes and should be screened. My endo told me that in her experience 5.7% is almost always diabetic! But most family doctors won't even mention diabetes until you are nearing 7%!
2. Byetta: I have heard very good things about Byetta, most notably from someone with a very similar kind of diabetes to what I have who is getting excellent results. However, I have a long history of getting bad side effects, some permanent, with common drugs, so I felt it would be smart to wait until there was more data available on Byetta use, long term. Since my current regimen is working very well, there's no hurry.
3. What if Exubera turns out not to harm lungs. Is it great then? No. Not unless they can come up with a dosing mechanism that allows finer titration. As I told the Business Week editor, I often dial in my dose to 1/2 a unit. An bolus insulin delivery system that has 3 units as the smallest increment is going to be useless for anyone who is insulin sensitive. Beyond that, since 2 mg isn't the same effective dose as 2 times 1 mg, according to what I've read, even an IR type 2 is going to have trouble figuring out how to match this stuff to meals.
There's a buccal insulin in the pipeline (absorbed via the cheek membrane) that would not have the lung issues and might be more easily dosed. That could be helpful. But we'll have to see what it really does. I don't trust any of the PR you read before the drug company has to put together something that has legal standing. And even there, I've read enough Prescribing Information to see the statistical tricks they pull to make their product look more effective than it is!
Friday, July 14, 2006
Why a "mere blogger" knows more about new treatments that her doctor
It all comes down to time. I have it, my busy endocrinologist does not.
So I read weekly newsletters like "Diabetes in Control", I scan health news posted in online edition of the NYtimes and on the Google News site every day, and when I see something about a new diabetes treatment or drug, I check the newsgroups and bulletin boards to see what people who are using the drug have to say.
That's why I'd noticed, months before my endocrinologist did, that the people reporting the biggest weight loss successes with Byetta were those who had been having problems controlling their eating (a problem I don't have.)
When she suggested that I try Byetta 6 months ago, I'd pointed out that I don't eat very much and certainly didn't want to lose weight and that the people who were happiest with Byetta were those who were eating a lot less now that they were taking the drug. Just yesterday at my appointment, when I asked the endo how her patients were doing on Byetta, she said, "I'm finding it's working best for the people who had problems with overeating."
When Levemir came out in the U.S., I looked to see what people in the U.K. who had been using it for years had to say. I also read the prescribing information very carefully. As a result I knew that it was not the 24 hour basal that the manufacturers would like you to believe it is. And, for that matter, that neither is Lantus for people taking type 1 rather than type 2 sized doses!
When I was looking to improve my control last year and checked out Avandia, I read the prescribing information, and then posted online asking people about their experiences with it. I got an earful! Dozens of people reported that it had caused edema and weight gain. I read an article online about an eye doctor who gave a speech at a conference linking Avandia to macular edema almost a YEAR before that news finally made it to mainstream medical news organs. I gave it a try, but when I swelled up like a tic and started having daily headaches, I ditched it immediately, though my family doctor who had prescribed it insisted that his other patients who took it had no problem with edema!
Most recently, when I was looking at Amaryl I checked out the whole story behind the increased incidence of heart attacks in people taking sulonylurea drugs. This is cited in a bold print warning in the Amaryl prescribing information. When I mentioned this to my endocrinologist, she told me she was not aware that there was a link between sulfonylureas and increased heart attacks nor did she know about the warning in the Amaryl prescribing information.
These are just a few examples of how the educated patient, who has the time to study up on their condition may be way ahead of the busy doctor whose continuing education consists of occasional drug-company sponsored junkets.
Fortunately, I'm not alone in doing this. Scan alt.support.diabetes via Google Groups, or read http://www.diabetes-book.com/cgi-bin/yabb2/YaBB.pl and you'll find lots of other people with diabetes doing the same thing. That's because with diabetes, the consequences of settling for average care instead of the right care can be early death, lost limbs, dead kidneys, and blindness.
If busy professionals would have more respect for the experience and knowledge of educated patients, the rest of their patients would probably be better off!
So I read weekly newsletters like "Diabetes in Control", I scan health news posted in online edition of the NYtimes and on the Google News site every day, and when I see something about a new diabetes treatment or drug, I check the newsgroups and bulletin boards to see what people who are using the drug have to say.
That's why I'd noticed, months before my endocrinologist did, that the people reporting the biggest weight loss successes with Byetta were those who had been having problems controlling their eating (a problem I don't have.)
When she suggested that I try Byetta 6 months ago, I'd pointed out that I don't eat very much and certainly didn't want to lose weight and that the people who were happiest with Byetta were those who were eating a lot less now that they were taking the drug. Just yesterday at my appointment, when I asked the endo how her patients were doing on Byetta, she said, "I'm finding it's working best for the people who had problems with overeating."
When Levemir came out in the U.S., I looked to see what people in the U.K. who had been using it for years had to say. I also read the prescribing information very carefully. As a result I knew that it was not the 24 hour basal that the manufacturers would like you to believe it is. And, for that matter, that neither is Lantus for people taking type 1 rather than type 2 sized doses!
When I was looking to improve my control last year and checked out Avandia, I read the prescribing information, and then posted online asking people about their experiences with it. I got an earful! Dozens of people reported that it had caused edema and weight gain. I read an article online about an eye doctor who gave a speech at a conference linking Avandia to macular edema almost a YEAR before that news finally made it to mainstream medical news organs. I gave it a try, but when I swelled up like a tic and started having daily headaches, I ditched it immediately, though my family doctor who had prescribed it insisted that his other patients who took it had no problem with edema!
Most recently, when I was looking at Amaryl I checked out the whole story behind the increased incidence of heart attacks in people taking sulonylurea drugs. This is cited in a bold print warning in the Amaryl prescribing information. When I mentioned this to my endocrinologist, she told me she was not aware that there was a link between sulfonylureas and increased heart attacks nor did she know about the warning in the Amaryl prescribing information.
These are just a few examples of how the educated patient, who has the time to study up on their condition may be way ahead of the busy doctor whose continuing education consists of occasional drug-company sponsored junkets.
Fortunately, I'm not alone in doing this. Scan alt.support.diabetes via Google Groups, or read http://www.diabetes-book.com/cgi-bin/yabb2/YaBB.pl and you'll find lots of other people with diabetes doing the same thing. That's because with diabetes, the consequences of settling for average care instead of the right care can be early death, lost limbs, dead kidneys, and blindness.
If busy professionals would have more respect for the experience and knowledge of educated patients, the rest of their patients would probably be better off!
Wednesday, July 12, 2006
Study: Exercise decreases Insulin Resistance but does not improve blood sugar control
The "study of the day" reported by Diabtes in Control involved two groups of people with "mild" type 2 diabetes. One group exercised, the other exercised and took a drug, Acarbose, which is sold in the U.S. as Precose.
What it found was this: while exercise reduced insulin resistance in the group using exercise alone, as measured by various laboratory techniques, it made no difference in blood sugar control as measured by the A1c. Adding Acarbose improved both IR and blood sugar control.
Lost in the way the article is presented is the more important message here: that the usual advice to exercise your way out of diabetes is not going to do much for you unless you cut way down on your carb intake. I took Acarbose for years and as long as I had some second phase insulin response left, it pretty much acted like cutting 15 grams of carb out of a meal. Unfortunately, as my second phase weakened, Acarbose started to simply postpone the blood sugar spike, not eliminate it. This sounds great, but it's main side effect which is socially catastrophic gas for anyone who eats anything near a "normal" amount of carbs, make it unlikely to ever gain much public acceptance.
But getting back to the study: Since 99.5% of doctors will tell anyone with diabetes that if they only exercised more they'd get better control, this is an extremely important finding. Reducing your Insulin Resistance in a way that makes lab instruments happy but doesn't lower A1c is not going to do much for your health.
My feeling has long been that exercise is oversold as a diabetes remedy. My blood sugar deteriorated significantly during the year when I went to the gym almost every day. I ended up with pretty muscles, lousy blood sugar and repetitive stress injury in my feet from the treadmill which eventually made it harder to do any exercise at all.
There certainly are reasons to do exercise--improving strength, endurance, and cardiac capacity--but exercise is not the miracle cure for diabetes people think it is. Studies also show it doesn't do much for obesity unless it accompanies a rigid, long-term diet.
Try telling that to the people selling gym memberships!
What it found was this: while exercise reduced insulin resistance in the group using exercise alone, as measured by various laboratory techniques, it made no difference in blood sugar control as measured by the A1c. Adding Acarbose improved both IR and blood sugar control.
Lost in the way the article is presented is the more important message here: that the usual advice to exercise your way out of diabetes is not going to do much for you unless you cut way down on your carb intake. I took Acarbose for years and as long as I had some second phase insulin response left, it pretty much acted like cutting 15 grams of carb out of a meal. Unfortunately, as my second phase weakened, Acarbose started to simply postpone the blood sugar spike, not eliminate it. This sounds great, but it's main side effect which is socially catastrophic gas for anyone who eats anything near a "normal" amount of carbs, make it unlikely to ever gain much public acceptance.
But getting back to the study: Since 99.5% of doctors will tell anyone with diabetes that if they only exercised more they'd get better control, this is an extremely important finding. Reducing your Insulin Resistance in a way that makes lab instruments happy but doesn't lower A1c is not going to do much for your health.
My feeling has long been that exercise is oversold as a diabetes remedy. My blood sugar deteriorated significantly during the year when I went to the gym almost every day. I ended up with pretty muscles, lousy blood sugar and repetitive stress injury in my feet from the treadmill which eventually made it harder to do any exercise at all.
There certainly are reasons to do exercise--improving strength, endurance, and cardiac capacity--but exercise is not the miracle cure for diabetes people think it is. Studies also show it doesn't do much for obesity unless it accompanies a rigid, long-term diet.
Try telling that to the people selling gym memberships!
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