Continuous Glucose Monitoring

If you are diabetic or heard enough about Continuous Glucose Monitoring from the media/friends already, you can skip this post completely. Emoji

Last time I went for a routine medical checkup/blood work, the numbers showed me as just reached pre-diabetic stage. If you are not familiar with this diagnosis, it is nothing too alarming, as millions of people all over the world live in this state for decades. The medical industry's guidance at this stage is to "just watch", meaning no medication or change in lifestyle required. They will keep testing once a year to see if we actually become diabetic, after which medications will be prescribed. To me, this doesn't make sense, since this is the time to dig into the data to see what changes we can make in our diet and exercise routine so that the A1C numbers don't continue to trend up. Though things like reducing weight, exercising more and eating less carbs will all help, since each individual's metabolism is different, getting lot more data about our particular body/food/exercise habits to see what we can easily to tweak to go back to normal state is what makes sense to me. 

To gather a lot of data, bought a Freestyle Libre CGM (Continuous Glucose Monitoring) system, that has a sensor that you attach to your body and a reader, using which you can read your blook glucose level in a second, whenever and as many times as you want. Till two weeks back, getting a CGM in the US usually required a doctor's prescription, whereas in other parts of the world, you can purchase one OTC (Over The Counter). The US FDA changed the rule couple of weeks back allowing OTC sales in US as well. Hopefully it will bring the price down. While there are a lot of models, types, version, the one I bought costs roughly $100 for the reader and $30 for the sensor that works for two weeks (exactly, to the minute). I got a second sensor, in case I mess up while putting on the first one. But it was easy to put on and so I have a spare one now, that someone else can use later. 

You can find a lot of details about CGM online, and in YouTube videos. But here are a few photos/video explaining what I did.

https://photos.app.goo.gl/2q2qfHiXDTfPAoLV7 

The Abbott Labs that sells this particular model wants you to create an account, and upload all the data to their cloud, so that they can analyze and give your results/recommendations. Since the EULA wants you to allow them to own/use the data however they want, forever, I felt uncomfortable and went through the painful process of entering all the data into a spreadsheet and doing the analysis myself. If you don't mind giving away your data, you can download apps available online, and use the provided USB cable to easily transfer the data to get the analysis done online. 

This reader also has the interface to take glucose blood test strips to provide you the reading, though I didn't use it myself. There are newer versions of the device, where using the Bluetooth interface, data can be directly transferred to your phone and then on to the cloud, etc. I intentionally used a low-tech version where the reading stays in the handheld reader, that is about the size of pager, with a very easy to use, single button interface.

The sensor actually measures the glucose levels in the Interstitial Fluid rather than in the blood hemoglobin but is considered pretty accurate, since the reader can use a formula to covert (i.e. estimate) it to blood glucose level. 

I took about 20 to 25 readings each day for the past two weeks and so have about 300 readings. The sensor you attach to your body does gather the glucose data continuously and so even if you don't read it so many times, when you do, it will transfer all the data to your reader. You can see it in the graphs the reader plots & shows you (see photos). But since the reader screen size is small, and since I wasn't transferring the data to the cloud, I am depending more on the 300 manual readings I took and recorded on a spreadsheet with notes on foot/activities. 

Observations made are applicable mainly to me, since that is the reason to go through this process is to get a better understanding of our own specific (i.e. one person) metabolism. Still, I am listing a few salient points I gathered, since these insights may be useful for others to follow or may indicate the value & surprise findings you derive by going through this exercise. I defined my "normal range" as 70 to 120 mg/dL.

- Eating a cup of plain white Raman noodles (without adding any vegetables, proteins, flavors, etc.) causes a glucose spike close to 200. I used this as a baseline to test couple of theories.

- Eating the same plain noodles, preceded by a small salad, flattens the spike, limiting it to about 150. 

- Eating the same plain noodles, followed by 20-25 minutes of moderate exercise (like brisk walking), flattens the spike, limiting it to about 150. 

- White rice eaten with Sambar/rasam/butter milk (typical south Indian lunch/dinner) causes a spike close to 200.

- Preceding the identical meal with a small salad keeps it under 150. 

- Alternately replacing white rice with cooked bulger wheat or brown rice eliminated the spike.

- Eating a small salad or protein, seems to coat/occupy your intestine preventing any subsequent carb/sugar coming in from causing a spike. 

- Eating 1.5 slices of toasted whole wheat bread OR just one cup of south Indian rava uppuma caused a sharp spike. I think white bread would have caused even a bigger spike. 

- I tried all types of food (Mexican, Italian pasta, pizza, black coffee, coffee with milk & sugar, fruit smoothie, pistachio nuts), different type of exercise (walk, jog, weights, stretches/sit-ups) and took readings to see how/what I can optimize to prevent spikes.

There are articles like this one that argues why common public should NOT do CGM, and how spikes after eating different food is quite normal, as long as the glucose level comes down on its own in the following hour. I do understand those points and my levels do come down. Still, being an engineer, I prefer & tend to measure, analyze, debug and fix issues before they become a crisis. I am hoping to use the collected data to modify my diet & exercise routines to see if I can go back to being normal (instead of pre-diabetic) next time I go for a checkup. If I can do that, I'd have gotten my money's worth, and this process will be in line with my goal of living a healthy life as long as I can without resorting to chronic daily medication just to lead a normal life. Will tell you how it goes after 6 months or 1 year. 

If you are already an expert and have pointes for me, drop me a note.  

Book Review: Chip War by Chris Miller

This book titled Chip War - The fight for the world's most critical technology by Chris Miller came out in late 2022 and became a best seller quickly garnering a lot attention. Since I keep yapping about semiconductors all the time, many friends, including my own team members who have read the book kept asking me if I had read it. Since I am slow reader, who still haven't learned to skim through a book perfunctorily, I remained reluctant to pick it up. I thought it may not have a lot of new material for me to learn, as we have been living this history for the past few decades. But the noise about the book was getting deafening, with our own CEO interviewing the author, and various news media outlets incessantly talking about it. So, decided to pick it up from the local library. While I should honestly say there wasn't a ton of new information for the semiconductor industry oldies like myself, I thoroughly enjoyed the read. It felt similar to watching a good movie you liked for the second time! If you are not in the semiconductor industry, I will highly recommend this book as the material is written in an extremely accessible prose covering lucidly not only the old history but the current status and how critical this technology is for the entire world.

Author is not an industry expert but an academic, who teaches international history. Since he has taken the time and put in the effort to grok a lot of material, conducted a ton of firsthand interviews, the story arc has come out very well, bearing his international history background as the overarching signature. Most of the individual chapters are only 4, 5 pages long, while the total book spans a respectable 350 pages. Starting from cold war days, the invention of integrated circuits, book chronicles how this technology originally invented in the US, was taken over by countries like Japan in the 80's forcing companies to reinvent themselves. There are several stories and personalities from Intel since it is a quintessential part of the world's chip industry history. While in the late 80's it looked like US has totally lost the leadership, US companies managed to out invent everyone else, bringing the leadership back to the US for couple of decades. But the subsequent developments, such as the emergence of TSMC that prints chips for most of the world, has reshaped the world and this market. Countries like Russia and China see the importance of being a leader in this domain from both military and civilian national requirements but haven't succeeded in becoming serious players so far, despite a lot of government push, deluge of subsidies and even industrial espionage. While most people in the world think of chips as some commodity similar to potato chips (i.e. fungible, gets produced somewhere and used somewhere, without the locations mattering much), the pandemic that resulted in chip shortage that brought things like automobile production lines to a halt, helped the world realize how smoothly this supply chain has been running in the background.

Though US controls many choke points such as high-end chip design software, currently the manufacturing prowess to produce the most advanced chips sit with TSMC and Samsung. Our company Intel Corp is trying to catch up, working with companies like ASML that manufacture the machines needed to make these cutting-edge chips. Building each generation machines and factories costing literally tens of billions of dollars involving extreme specialization makes this cutthroat competitive world a difficult one to survive. Just take a look at this one short video our company has put out to see how complex the technology is. If you pay attention to the process of generating the UV light that doesn't exist naturally, you will see why the effort we need to go through and the technology that need to work flawlessly to print the next gen microchips is truly mind boggling. If you don't ask. "Are you kidding me? Is this for real?", you weren't paying attention. 

While I am tempted to write a lot more, I am trying to keep this short and will highly encourage those who are not working in the field of semiconductors to reach this book to understand the breadth and importance of this field. Same recommendation for new young engineers in this field as well! 

Time to go back to The Song of the Cell by Siddhartha Mukherjee that I am only halfway through! 

Book Review: Outlive by Peter Attia

This book titled "Outlive - The Science and Art of Longevity" came out just last year (2023) and seems to be making waves. My friend Sanjay Padubidri recommended it and so picked up a copy from our local public library. Since it is a fairly new book, it came on a two week loan, instead of the usual 3 week period. Though at 410 pages, it looked like a big book, it was an easy read and yes, it could have been shorter in length, like this book review. 

Attia is a practicing physician and has written this book with Bill Gifford, though pretty much every line is written in first person singular mode. Classifying and giving names to everything is a common practice in the US these days. In that tradition, he starts off discussing medicine as Version 1.0 (medieval practices like blood letting, etc.), 2.0 (current version that focuses on issues after they show up) and 3.0 (where a lot of treatment is preventative). Then spends a lot of pages talking about the "the four horsemen" of ailments that pain us as we age, viz. metabolic issues like diabetes, heart health issues, cancer and neurological issues like Alzheimer's. Second half of the book dives into measuring everything possible, finetuning our routines (in eating, exercising, sleeping) to prevent or delay these ailments from slowing us down, so that we can "Outlive" them into a happy, healthy old age. 

Books gets into the details of each area (e.g. functions of various genes, enzymes, hormones) and also adds a lot of personal stories about patients he treated, how he was so ignorant and over the decades learned his lessons and so on. While these makes it all very easy to read as there is not a lot of difficult concepts that you need to remember, it also feels like very many pages could have been eliminated, including sections meant for his humble bragging. On the positive side, certainly liked the fact that he is not pushing any one wonder drug or diet or practice that will solve everything but is evangelizing a comprehensive approach of moderation on multiple fronts (diet, sleeping, exercising, taking needed medication). The overall takeaways are presented in an easy to remember fashion and so it is worth a read, though it may not be necessary to buy and keep a copy. Last round of annual check up I had showed me as mildly pre-diabetic. Based on what Sanjay was telling and this book is suggesting, thinking of getting a CGM (Continuous Glucose Monitor) for a month or two to get a lot of data. This should help me tweak whatever I can in diet/exercise to continue my general goal of living a healthy happy life as long as I can, without having to take chronic medication. Will see how it goes. Looks like many such "lifestyle gurus", he is also making an industry out of this with a website where he is posting videos, podcast, book, patient sessions, etc. Though there is nothing wrong with any of that, it reminded me of another writer mildly making fun of an Indian Swamiji pushing spiritualism, who has established an equivalent of a mega church that takes Mastercard and Visa for their services! 

Enathu Naadaga Vaazhkkai

For my non-Tamil speaking friends, this email's subject line might have sounded odd. It is because it is the transliterated title of an old Tamil book. It means something like "My Life in Drama" as in stage plays. It can also be understood as "My Fake Life". Pun is certainly intended by the author. Thought will write a note about this Tamil book, for many interesting reasons. 

I came across this book in an article I was reading on the Tamil magazine website solvanam.com. Since it sounded interesting and is readily available to download as a public domain PDF version, started reading it. This is supposedly an autobiography written by a legend in Tamil stage plays, called T.K.Shanmugam, who lived from 1012 to 1973. You can read a quick excerpt about him at 

https://en.wikipedia.org/wiki/T._K._Shanmugam

It was written/published more than 50 years back and appears to be based extensively on the daily diary he had kept. So, it read more like a series of diary updates rather than a cohesive thesis or a well put together story. Every couple of paragraphs or page had a subsection title, as each one talked about a particular event or activity, without too much of a continuation from one subsection to the next. After a few pages I was getting a little tired with the flow and the prose. But then realized I actually need to step back to understand the overall ideas in the book on my own, rather than depending on what the author is saying page by page. Once this realization set in, I started enjoying the read. 

I was intrigued to note that even after using English as my first language for the past 3+ decades, I could read a book in Tamil much faster than I can one in English. Granted this book is certainly light reading, compared to something like Francis Fukuyama's Political Order and Political Decay. Still, this book is more than 560 pages long and I was able to read it in 2-3 days. You can either say my Tamil is still much better than English or perhaps my English will never improve to be any good till the end of my life.  

The author TKS had joined a company when he was just 5 years old and had started performing. He has written about his life as a traveling performer and subsequently as a theater company owner, spanning 50 years from pre-independence British colony India days to the post-independence Republic of India years. Similar to traveling circus groups that were popular during the first half of the 20th century in the US, there were these theater groups that were popular in India, particularly in the southern state of Tamil Nadu. Each one of these companies had a long name something like Madurai Saraswati Ghana Vinoda Nadaga Sabah. Many companies had the Madurai prefix, which refers to a famous temple town in Southern India that was historically known for poetry, literature and theater. They felt it gave them an aura of credibility, irrespective of whether they are originally from Madurai or not! 

Each group probably consisted of close to about 100 people, that constituted of actors, musicians, stage designers, organizers, accountants, cooks, managers and so on. Owners who invested money, traveled with the group and managed day-to-day affairs or employed managers and stayed in their home bases. These groups used to put together a play that could be based on one of the Indian mythologies (such as The Ramayanam, Mahabharatham or a subplot from one such mythology), or based on historically popular brave Indian kings & queens or based on contemporary societal issues that were on the forefront in those days. These groups are often called "Boys Company". Many even had that term in their company names. It actually indicated that most of the actors in these companies were 10- to 20-year-old boys. It is amazing to realize that 12, 13-year-old boys memorized hundreds of pages of dialogues and songs and then performed as full-fledged actors on these theater productions, playing both male and female roles. The tutors in the company used to teach them how to sing and act. Newbies will start performing small roles and depending upon their abilities, graduate to bigger roles, finally ending up with the lead roles on multiple plays. They are often required to memorize lines (author refers to "lines" as "paadam" in Tamil, which means "lesson") for both hero and heroine roles as they may be required to switch roles depending upon the play/company/actor availability & requirements! Those who play female roles routinely used to grow long hair to make the makeup part easier to complete. While they did employ few women actresses, since keeping young women in payroll and taking them around had its own complications and safety issues, they preferred men (or actually boys) playing female roles.

Similar to circus companies in the US in those days, these companies used to move from one town to another every few weeks. Once a town is picked, they will find a stage for which they will pay rent, find a big house where most of the company members would stay (this is referred to as company house) and start practicing. Food will be cooked and provided by the company to all the employees on a daily basis. These stage plays will start around 9:30 p.m. and we'll go on till 2:00, 3:00 a.m. in the morning, thus lasting about 5 to 6 hours or even more! It is common for these young actors to even sleep in between and then wake up to return to the stage to finish off performing their roles. Shows will not be held on weekends but more on weekdays. Audience used to finish their work and then head over to these temporary theaters to see these elaborate shows. 

There were a lot of very intriguing and interesting facts that are sprinkled around the book. For example, it was customary to print notices with interesting hook lines, exclaiming why a particular character that is part of the play is laughing or crying and encouraging people to come and see the show to find out the answers. When the company TKS belonged to moved into a small town (circa 1923), they were told that in that town there are no printing presses to print anything and so it is not a practice to distribute notices to advertise the play. The author TKS being a 11-year-old boy, was afraid to ask the elders in the company as to how else would they advertise the play in that town. But he subsequently comes to know that outside the building where the show was being performed, half a mile away, there was a marked location to explode loud firecrackers. Around 7:00 p.m. they would explode 3 firecrackers that would send out loud booms, heard by people in the nearby towns and villages in the next 5-to-10-mile radius. This will serve as an advertisement and notification that a drama company is in town performing plays. Hearing these loud booms, people will walk over or come in small carriages to the location, buy the ticket and watch the play that runs through the night. 

In the early days, there was no electricity. So, they used what are called Petromax lights. Since even these are expensive, they used to have just 4 such lights. One in front of the theater, one in the back where actors were putting on make-up and two on the stage to light the stage up. That's all the lighting they had for the big production! Author talks about difficulties they had walking from company house to the building where the show was taking place in the dark, in unpaved village mud paths, worried about animals or snakes attacking them! Usually, one elder in the company will carry a lantern and lead the walk, while everyone else will just follow that person walking in the dark. Sometimes plays used to be staged in the middle of the ground, with people sitting around (like amphitheater) as well. As the decades passed by, they moved on to more solid stages, electric lighting and lot of stagecraft involving electricity, elaborate pulley systems to show mythological characters flying, floating on clouds and so on. It was also customary to stop the play before the final scene, to allow local patrons/village heads to come and give presents (like gold medals) to the actors and then continuing with the last scene to complete the play. Picture of the book's cover page shows TKS with four different looks. He is in the middle with glasses, performing as the Hindu God Krishna on the left, as a king/warrior and as a female Tamil poetess named Avvaiyaar on the right. Since his performance in this role was so spectacular and the play was such a big success, he was given the title "Avvai" and so was known as "Avvai Shanmugam". 

Since these were the 1920s, 30s and 40s, the growth of this industry is quite closely tied up with Indian freedom fighting movement to get freedom from the British, promoting societal values such as women's education, widow's remarriage and so on. Author write with so much of exuberance about seeing national leaders & freedom fighters such as Gandhi, Nehru, Rajaji, singing in front of them, interacting with many others. Since motion pictures were also showing up to compete in the entertainment realm, these companies, actors, and owners were often involved in producing movies based on their plays. In many years/towns, collections for the shows used to be so bad that they need to frequently move to find greener pastures or switch shows from one to the next within a day to try to make more money. If the movies they produced were successful, they plowed the profits back into these productions. Many of the political parties in Tamil Nadu having understood the power of this mode of mass communication, routinely used this medium to promote their ideas and principles. Many of the show authors subsequently became political leaders, and Chief Ministers of the state. Since one division of the political party considered themselves as rationalists who were atheists, they were often opposed to productions based on Indian mythologies with Hindu Gods. Still the drama companies and the atheist politicians got along, tolerating each other as they were also often staging plays that tried to push the society in the right direction that they both could agree on.

It was amusing to see practically every name the author mentions (as actors, musicians, writers, tutors, supporters, that would run into hundreds) has their caste name listed as the name's suffix. This was very common in those days and was practically a mark of respect, though it sounds so anachronistic today! Another amusing thing I noted about the names were the double initial. In the state of Tamil Nadu in India, there is no concept of family name. Each one is given a name (my name was Sundararajan) that will be preceded by the first letter of the father's given name (in my case Vedantham) as the person's initial (and so my name in school certificates were V. Sundararajan). Occasionally my classmates (or even my Dad) used to have two initials, referring to their hometown, etc. My Dad's official name is A.D.Vedantham, where A refers to the town where he grew up in (Ariyakudi) and D refers to my paternal grandfather (Desigan). In my school days, out of 30, 40 kids in my class, usually a couple will have two letter initials. But practically every person this author refers to (including himself) had two initials! 

There is so much more to write, such as the ease with which TKS and three of his brothers, learned different languages to bring in plays from other languages in India, how they wrote down occasional English dialogs in Tamil, memorized and delivered them precisely earning kudos, so many jokes (someone's hair piece coming off exposing the boy playing girl), dangers (stage props falling down occasionally injuring actors), difficulties (local mafia asking for a cut in collection without which they won't let the production go on), the immensely satisfying literary (Shakespeare like) Tamil poetry and songs they wrote/sang, new drama conferences they conducted and prizes they instituted to nurture the trade and so on. I was also amazed to hear that each show they put together was done only after receiving proper written permission from the author and for each show performed, they provided royalty to the author. This is especially impressive, since Indian movie stories were often copied from Hollywood or other places without any copyright attribution in the 1980's, which is getting corrected now, since anything produced anywhere in the world is visible everywhere else. 

When I was growing up, movies had mostly taken over and so stage productions had dwindled and morphed considerably. I have seen many live historical/mythological/contemporary productions. But they used to be just one show performed with the support of a local cultural association, not a 25 or 50 day runs conducted by the show's own company. In the 80's these shows became mostly contemporary comedies that were cheaper to produce. These are still on since there is no Broadway type shows permanently being staged in India though different Indian states still have smaller production houses staging plays. But I do fondly remember couple of big historical productions of this kind I have seen in the late 1970's that were really impressive with their elaborate costumes, sets and magic tricks performed on the stage (e.g. to show a ghost, they will have smoke going up on the stage, on which they will show slides or projection of a ghost, etc.). 

Write back about equivalent practices/shows/customs you grew up with or have heard of during the last century wherever you live.