I spoke today at the Intersections of Faith and Healing Conference in Salina, Kansas. Here are my slides.
SNAP stands for Supplemental Nutrition Assistance Program. It is used by about half of the Medicaid beneficiaries who qualify for it.
Previous warnings about small trials apply here, but in a study in The Lancet, investigators assigned women with mild reductions in iron storage (serum ferritin levels of ~25 ug/L or less) but not moderate or severe anemia to receive 60 mg ferrous sulfate every day for two weeks or every other day for 4 weeks. Then the investigators checked their fractional iron absorption and total iron absorption.
Two weeks following treatment, the alternate-day group had higher fractional iron absorption (22% vs. 16% ) AND total iron absorption (175 vs. 131 mg).
To make sure that this was an effect of timing and not just splitting the dose, a smaller group of women was then assigned randomly either 120 mg FeSO4 daily or 60 mg twice daily and the testing process was repeated. In this case, there was no difference between the two groups.
So what's the take-home? First, there is no benefit (*ahem*, small study) in dividing iron doses into twice daily. Second, it might be beneficial, at least in this specific patient population, to give the iron less often, but for a greater length of time. Mechanism unknown, at least to me. I have some concerns about every-other-day dosing. It seems like a good way to drive down adherence to therapy. But the effect is promising. In an astonishingly British-sounding editorial (the authors are straight from Downton Abbey casting), one states that the results "are likely to lead to a more felicitous means of administering this widely used therapy." Felicitous, in case you were born west of eight degrees longitude, means "well chosen or suited to the circumstances." Or "pleasing and fortunate." But the latter definition will seem strange to anyone who's ever tried to pass a ferrous sulfate-laced stool.
Speculation is that this is related to fear of traumatic encephalopathy and concussion. Speculation on my part is that this is the beginning of a slow decline in football in the non-deep-south.
Justin Moore, owner of an iPhone, agrees. Don't be a phoneworm.
Ok, only the body panels were soy plastic, but still. The everyday mechanical-chemical innovation of that part of history has been almost entirely replaced in our national mythos by software innovation. Kids don't seem to tinker as much as they used to.
Story from The First.
A UK writer catalogued chicken restaurants in the UK named after US states: "And after excluding Kentucky (for obvious reasons), I found 13 Tennessees, 6 Kansas, 4 Californias, 2 Floridas, and 1 each of a few others."
Story from The Gist.
Just an FYI. By the way, the image above is an ad for WrestleMania VI, a place I think we can all agree had its share of anabolic steroid use. Over 1/3 of the competitors are now dead, all of them prematurely.
There is no cheatin' spoon. There's only the big spoon and the little spoon, and your size ain't nothin' but a number:
1. “I love being big spoon but he’s so big I feel like a sloth just hanging onto a branch.”
2. “I’m always the big spoon! Because of the height difference, it makes me feel like I’m a rocket pack!”
3. “I feel like a koala when big spooning my boyfriend because he’s way taller.”
4. “I say if you think you’re going to sleep facing away from me you best be prepared for a koala on your back through the night.”
5. “My boyfriend is almost always the big spoon, although sometimes in the middle of the night I roll over to him and am his ‘jetpack.’ I love being the little spoon but it makes me anxious because sometimes I fart on him when I fall asleep.”
Bonus: “I prefer to lie face down and have my partner lie flat directly on top of me. The weight is so calming and eases my anxiety. Not spooning per se…maybe spatula-ing?”
How long until they have these in fast food places, too? Even Sonic has started modifying their kiosks to be more interactive. Big potential public health downside: More desserts ordered. Like 30% more.
Put another way: what's the free testosterone cutoff we should use for initiating treatment in potentially hypogonadal men?
Spoiler alert: maybe 70 pg/mL?
Background: a new paper from Anna Goldman, Shalender Bhasin, Frederick Wu, Meenakshi Krishna, Alvin M Matsumoto, and Ravi Jasuja lays out their thoughts on the state of the science in free testosterone measurement. This is important because we currently operate under a theory of "bioavailable testosterone." That is, we think that only testosterone that is unbound by proteins, the most important one called "Sex Hormone Binding Globulin," or SHBG, has any effect on the testosterone receptor. All the testosterone that's floating around attached to SHBG or other proteins is inert.
But like any other hormone, testosterone's binding to SHBG or other proteins is affected by myriad causes, like obesity, other hormonal disorders, and other conditions or medications. Even the temperature at which it's measured. So guidelines from the Endocrine Society suggest measuring free testosterone levels in men whose total testosterone concentrations are low-ish and in men with conditions or medications that make total testosterone measurements less reliable (like obesity). But those same guidelines rely almost entirely on the total testosterone to determine who needs testosterone therapy. From their 2010 guideline:
The panelists disagreed on serum testosterone levels below which testosterone therapy should be offered to older men with symptoms. Depending on the severity of clinical manifestations, some panelists favored treating symptomatic older men with a testosterone level below the lower limit of normal for healthy young men [280–300 ng/dl (9.7–10.4 nmol/liter)]; others favored a level less than 200 ng/dl (6.9 nmol/liter). The panelists who favored treating men who had values less than 300 ng/dl were more influenced by the observation that men who have values below that level often have symptoms that might be attributable to low testosterone. The panelists who favored not treating unless the serum testosterone was as low as 200 ng/dl were more influenced by the lack of testosterone treatment effects in randomized clinical trials when subjects had pretreatment values of 300 ng/dl but suggestions of beneficial effects when the pretreatment values were closer to 200 ng/dl. The lack of definitive studies precludes an unequivocal recommendation and emphasizes the need for additional research. [emphasis mine]
No mention of the free testosterone in there. More research needed, they say. Well, Goldman et al have delivered it, in a way. They didn't do any new investigation, so far as I can tell, but they did review the existing literature pretty thoroughly and come up with a series of conjectures. The most important of these clinically is this (my words, not theirs):
Without a harmonized, replicable normal range between laboratories and methods, we cannot set a clinical threshold for free testosterone levels at which we should initiate treatment.
The authors point out that in a study by Le et al, only about a quarter of labs performing free testosterone assays would even confirm that they had performed validation studies on their assay. But seeking a clinically relevant answer, they go on to point out that In the Framingham Heart Study, the lower limit of the normal range for the calculated free testosterone for men between 19 and 40 (defined as the 2.5th %ile) was 70 pg/mL (242.7 pmol/L). They do not endorse this as a threshold. But given the lack of other published thresholds, I think it is at least a start.
One more point before I wrap up: whatever value you or your doctor use, whether it's free testosterone, bioavailable, or total, the number is only one piece of data. A free testosterone of 70 pg/mL in a young man with normal body hair, normal muscles, and a normal libido would not cause me to treat him. That same level in a man with a known pituitary issue, enlarging breasts, and fatigue would definitely cause me to treat him. And I tend not to recommend checks of testosterone in elderly men, even those with fatigue, unless they have other compelling evidence of hypogonadism. And my opinion is generally in line with that of the Endocrine Society:
We recommend against a general policy of offering testosterone therapy to all older men with low testosterone levels. (1|⊕○○○)
We suggest that clinicians consider offering testosterone therapy on an individualized basis to older men with low testosterone levels on more than one occasion and clinically significant symptoms of androgen deficiency, after explicit discussion of the uncertainty about the risks and benefits of testosterone therapy. (2|⊕○○○)
Why else do I hesitate to give testosterone? In a series of trials in JAMA and JAMA internal Medicine earlier this year, men aged 65 and older with a total testosterone level <275 ng/dL plus either sexual or physical dysfunction or reduced "vitality" were randomized to get either testosterone gel (lotion that absorbs through the skin) or placebo for 1 year. The men who got testosterone developed more coronary plaque than the men on placebo. (This may or may not mean anything; in other observational studies, the rate of heart problems was lower in men prescribed testosterone than in untreated men).
Importantly for the men who tend to come to me with suspected androgen deficiency, though, the men in these studies had no improvement in memory or other measures of brain function.
Testosterone did slightly improve bone density and bone strength compared with placebo. And testosterone seems to have improved the hemoglobin level (the weight of the oxygen-carrying protein in our blood) in anemic men by 1 g/dl more often than placebo did.
If all that sounds confusing, it's because it is. When I was an endocrine fellow, one of my faculty told me that in almost every case, if you don't know what to do, the correct path is to do nothing. So that's the direction I lean in borderline androgen deficiency cases, whether determined by total or free testosterone levels. I lean toward withholding therapy.
Don't test the thyroids of generic obese children, says Choosing Wisely
The endocrine section American Academy of Pediatrics has listed its five "Choosing Wisely" tests to avoid. TSH levels in obese kids is one of them. I completely, completely agree. But telling a mom or dad that is equivalent to malpractice in their eyes. It really illustrates one of the central problems with the way we practice medicine: order the test, make mom happy, keep the family as patients, but cost the system some extra money that could be better spent on something else. Refuse the test and you make mom unhappy (sometimes very unhappy), you lose the family as patients, and the family simply goes somewhere else with a provider that will comply with their wishes. Sure, you can have a prolonged conversation with the family about why you're not doing it, but the cost of physician time exceeds the cost of the lab test pretty quickly. Whew. OK. Rant concluded.
The title of "Blade Runner" comes from an obscure physician-penned novel about a future dystopian society that has eugenics as the core of its national healthcare strategy.
It follows the adventures of a young man known as Billy Gimp and his partner in crime, Doc, as they navigate a health-care dystopia. It’s the near future, and eugenics has become a guiding American philosophy. Universal health care has been enacted, but in order to cull the herd of the weak, the “Health Control laws”—enforced by the office of a draconian “Secretary of Health Control”—dictate that anyone who wants medical care must undergo sterilization first. As a result, a system of black-market health care has emerged in which suppliers obtain medical equipment, doctors use it to illegally heal those who don’t want to be sterilized, and there are people who covertly transport the equipment to the doctors. Since that equipment often includes scalpels and other instruments of incision, the transporters are known as “bladerunners.” Et voilà, the origin of a term that went on to change sci-fi.
The name Blade Runner actually came not from the story itself, but from the title of a nearly incomprehensible adaptation by William S. Burroughs, The Blade Runner: a Movie.
The team delved into whether ride-hailing affected crash rates in four cities: Las Vegas, Portland, Ore., Reno, Nev., and San Antonio, Texas — American cities in which Uber, the nation's largest ride-sharing company, launched, ceased, then resumed operations. And the results were mixed. Crashes involving alcohol decreased as Uber resumed services in Portland and San Antonio, but not Reno. And in no case did Uber's resumption of service result in fewer total injury crashes or serious crashes overall.
It's easy to look at this kind of story and be really, really disappointed. But I think it's just further proof that changing human behavior is complex. It is not a matter of greater knowledge = better decisions. If it were, the smoking rate and the rate of texting while driving would both be nearly zero. I'm optimistic for ride sharing and autonomous vehicles' role in reducing drunk driving deaths.
Citi bikes have so penetrated New York City that over 50% of peak-hour taxi trips would be faster if taken by Citi bike.
See graphic above. No word on how the bikes compare to ride sharing, though. This statistic kills me. But then again, I'm from the least congested city in America.
I spend a lot of time talking about cycling here, and it's generated quite a few questions about recommended products. I'm by no means an expert in cycling. But I have enough experience to have developed some opinions. I've even tried to curate those opinions to match the coming cooler weather. And over time, I'd like to expand it to include some of the other things we work with a lot, like medical equipment and software. But cycling's it for now.
So take the recommendations or leave them. But first, go to our new recommended products page at the top of the screen and take a look. If you have other stuff you think is great, let me know. We'll try it out and, if we like it, it'll end up on the page with your name attached for posterity.
A couple weeks ago, I spent some time in a YMCA parking lot to do the Wichita Area Metropolitan Planning Organization's bike/pedestrian count. I was in a pretty rural area, and the bike/ped traffic was light. It gave me a chance to watch the steady stream of cars in and out of the lot, though. The Y was rocking, which made me happy, but I couldn't help but wonder about the goals of the people in the cars screeching in and out of the driveway.
A woman who worked in the office of a YMCA recently told me that one of the biggest safety issues the organization deals with is parking lot safety for pedestrians. So many people circle the parking lot in their fancy gas-powered wheelchairs during busy times that pedestrians crossing the lot were in danger of being run over.
She was talking about people circling the lot, mind you, so that they could walk the minimum distance to get into the building and walk...on a treadmill. Or ride a stationary bike or something.
This problem is a bit of a throwback for me. I remember as a kid, when the remote controls for TVs were still mostly up-and-down affairs (hit the up arrow to scroll upward through channels, hit the down arrow to go the other way; ditto volume), I would, out of habit, walk all over the room looking for the remote so I could change the channel on the TV. I would walk multiples of the distance it would have taken me to simply get off the couch and walk to the TV and push a button. But like the Kodak people who couldn't imagine a world without film, I couldn't imagine a world without the satisfying weight of that remote, with its sleek aluminum Sony case, in my hand.
Is there a name for this particular brand of self-defeating convenience? I've stretched Google's abilities to the limit and I can't identify one. But it clearly pre-dates modern technology. And don't get me wrong. I've ridden, and continue to ride, an absurd number of miles in cars. But I've felt like an asshole for almost all of those miles that didn't involve traveling outside of town.
But back to parking. Scott Wadle of the City of WIchita likes to say that there's no such thing as free parking. While he means that we all subsidize the space that cars take up whether we mean to or not, I think of it in more cosmic terms. All that space could be used for something else. And the physical activity it would take us to park in vertical garages and walk to our destination, or the slightly greater physical activity it would take for us to bike to work would be a small price to pay to get green space and health back. An optimist's view of the coming autonomous fancy gas-powered wheelchairs is that we'll need far less parking, thus opening up more and more space for commerce and for public use. A pessimist's view is that we'll eventually transition to a WALL-E situation in which your autonomous gas-powered wheelchair picks you up at your door to deposit you in front of the door to your office, at which point a smaller, more Segway-inspired motorized device takes you to your desk. Where you sit. All day.
I'm not going to talk about "productivity" or "optimization" here. There are plenty of places to get a dose of that perspective. But just consider this when it comes to the YMCA or your local health club: grinding away on a treadmill for 30 minutes a day after driving an oversize luxury wheelchair to the building is not my idea of freedom. It's a chore. But if I turn that chore into the choice to walk or ride by the health club while I watch all the wheelchair circle: that choice makes me unspeakably happy.
Unsatisfied with limiting itself to its whopperCoin cryptocurrency, Burger king Russia is complaining that Pennywise the dancing clown gives McDonald's an unfair advantage.
What? There's no way any kid ever has confused Pennywise with the modern-day Ronald McDonald. The Willard Scott version, maybe:
But Willard's been out of the burger bidness for a while now.
See also: Whoppercoin
That's my take. Atul Gawande (disclosure: I'm a big fan) takes his surgical mind to the problem and, as usual, illuminates the complexity of the issue. What if we had a system that allowed trash to back up into the streets if people didn't buy exorbitantly expensive "garbage insurance?" I suspect we'd move toward a system like what we have now: mostly affordable, in many cases government-subsidized trash collection. Healthcare could follow a similar model.
When I was a resident in the early oughts, vitamin D was the hottest thing going. We thought we were going to fix or prevent sooooo many problems by optimizing people's levels. Unfortunately, almost no intervention with vitamin D has proven successful. Vitamin D levels instead serve as kind of a generic marker of unwellness. Repleting those levels does not in and of itself fix the unwellness, though.
Phrases to Avoid:
Chocolaty...Made with chocolate...Chocolate liquor...Vegetable oil...Butter oil...Artificial sweeteners...Milk substitutes...PGPR...Vanillin...Distributed by...Product of.
(link from marginal revolution)
This will distract from their naked butter churning over spring break.
First things first: I've never done a triathlon. I swim like a St. Bernard. But I've done a lot of endurance bike racing, and I've been at more than one event with a death, the most recent the 2017 Dirty Kanza. So I was interested that in the latest Annals of Internal Medicine, investigators looked into a sudden death database to identify 135 race-related deaths and cardiac arrests in American triathlons between 1985 and 2016. Interestingly, right at two-thirds of deaths and arrests happened in the swim part of races, which usually comes first, before the bike and run. The editorialists spend a lot of energy trying to link swimming to some special form of stress from cold water or other factors that might be extra-dangerous. But to me, the swimming link seems consistent with the finding that in autopsies, about half of subjects had cardiovascular abnormalities, most often old-fashioned atherosclerotic disease. Swimming caught most of these people simply because it was the first event. Had running or cycling come first, I suspect one of them might have been the death leader. I'm not convinced by their observation that most marathoners die toward the end of races; anyone who's seen the scrum at the beginning of a triathlon knows that it's inherently different than the often walking pace seen at the start of a marathon:
85% of victims were male, but I'm not sure the significance of that number, since >60% of participants (at least in pro Ironman races) are male:
And if you look at total Ironman competitors, the distribution of sex comes much closer to the death/cardiac arrest statistics:
But sex aside, we're forced to see that cardiac arrest and death are not rare among triathletes. Between 2006 and 2016, their incidence was 1.74 per 100,000 participants in the study. The risk of death increased with increasing age, unsurprisingly. Don't let this dissuade you from being more active. The benefits of physical activity far, far outweigh the risks in almost everyone. If you're inactive now and thinking of becoming active, or if you're active now and thinking of doing really hard-core things like triathlon, consider taking the American College of Sports Medicine's new-ish algorithm to your doctor and talking it over before you hit it really hard:
We don't know how really weird stuff like performance enhancing drugs effects this. My suspicion is that it's not good.
Background: It is illegal to pay for sperm donations in America's hat.
"What Canada should do is legalize compensation for renewable bodily fluids in our own country. It would be the morally right thing to do. It would help make and save more lives, without harming anybody.
Until we realize our mistake, we need you Americans to keep rolling up your sleeves and unzipping your pants not just for the sake of lucre, but also for the sake of the thousands of current and future Canadians whose lives depend on you."
Bottom line up front (BLUF): Over 4.0 years of accelerometer use, total sedentary time was associated with an increased risk of dying. Not only that, but the longer the usual sedentary bout, the higher the risk of dying (roughly double for the highest quartile). This study is encouraging, in a way: you don't have to move that much to really affect your risk, you just have to move often. But this doesn't apply to you, dear reader, since you ride your bike to the grocery store and forsake social media. Don't you?
If you live in a disadvantaged neighborhood, the usual risk factors for heart disease probably underestimate your risk.
BLUF: In a group of patients from the Cleveland Clinic, the Pooled Cohort Equations Risk Model, or PCERM of the American College of Cardiology and American Heart Association underpredicted vascular disease risk in patients from disadvantaged communities (those with a high "Neighborhood Disadvantage Index," or NDI). For a patient from a disadvantaged community, the model only achieved a "concordance index," a measure of how well it predicts vascular disease, of 0.70. In Affluent communities, on the other hand, the concordance index was 0.80. That doesn't sound like a huge difference, but the NDI was much more powerful at predicting variation between census tracts than was the PCERM tool itself.
"The seventh month of the lunar calendar is called Ghost Month, when the gate of the underworld is said to open and people prepare offerings for the dead.
People have refrained from offering bananas, plums, pears and pineapples, because the fruits’ names sound like they are inviting ghosts in Hoklo (also known as Taiwanese), the market’s Fu-te Temple (福德宮) chairman Lin Lai-fa (林來發) said.
In Hoklo pronunciation, banana sounds like “inviting” (tsio), plum like “you” (li), pear like “come” (lai) and pineapple like “prosperity” or “more” (ong), the combination of which sounds like an invitation for ghosts to stay in someone’s home."
Whatever, Taiwanese Agricultural and Food Agency. I've seen a Dragon Fruit. That thing's bound to attract demons.
Anyone who wants a baby should be able to have one, and I'm glad we have thoughtful, careful reproductive endocrinologists and urologists working on the problem. But I think as we rocket toward 10 billion people on planet Earth, calling it a crisis is probably premature.
What would possess a person to think that inserting jade eggs (those are actual egg-shaped pieces of stone, mind you) into her vagina would make her feel better? I have two theories: first, stories are more powerful than data. Local Wichita public health dynamo Becky Tuttle says that stories are "data with soul," but that's only part of the story. People like the illusion of certainty where there is only doubt. I think that's what quacks have always offered.
Confession: medical school turned me into an heroic Diet Coke drinker in the late '90s. /at first it was just because I needed a reliable source of caffeine to keep me awake, but later it became more of a habit. It may even have had some religious undertones. Short story author Amy Parker once called it "the national beverage," and it was true for me. Every drink felt like a sip of America herself. But in February, after a bout of severe insomnia, I decided to give up caffeine altogether (it helped). It was only by coincidence that 1) data had started to accumulate that diet drinks were certainly not a panacea, and might even be bad for us, and 2) most other artificially sweetened beverages taste the way I imagine ground Smurf would taste. So I mostly gave them up, too. I've probably had 5-10 caffeine-free diet drinks since, and unless someone can produce evidence that they're not bad for me, I'm done forever. Mostly.
I picked up a copy of We Have Always Lived in the Castle by Shirley Jackson last week at the library:
It is a Gothic masterwork, and the speculation it allows around the psychopathology of Merricat and the townsfolk who hate her and her sister and uncle is irresistible.
Even though I didn't choose it with the intention of kicking off any kind of Halloween-y creepy reading list, now that I've started The Handmaid's Tale by Margaret Atwood, it seems I've inadvertently waded into Gothic waters. Atwood is incredible, but I'm in the mood for something a little more straightforward. So I've made it official: my next book will be It by Stephen King. I was a voracious King reader as a high-schooler. And a copy of Salem's Lot I found in a call room nightstand once got me through a snowy, slow call night as a resident. I left the book there when I finished, and I have wondered many times since how many residents at Deaconess Medical Center have found that same book and killed a couple hours with it. I know, I know, that King is hardly literary. His is not necessarily the kind of reading that increases empathy, but since It is currently crushing it (see what I did there?) at the box office and in critical reviews, it's time.
Assuming I can get through It's 900+ pages in the next few weeks, what other creepy-crawly books should I attack before All Hallow's Eve?
Sherry Turkle from the MIT Media Lab talks about the frequency she hears people say they'd "rather text than talk." People say they feel less vulnerable when they text than they feel in a face-to-face conversation. I agree. I feel less vulnerable texting, too.
So don't be a phone worm. When I was in medical school in the late '90s, I remember classmates making fun of a woman in our class who was pathologically attached to her cell phone. We'd all just learned the word "pathologic," and our family members were already asking us for medical advice, so we all felt comfortable making the diagnosis. Anyway, hers was the phone that would ring its Nokia ringtone multiple times a day to interrupt class back when this was still a novel occurrence:
In the year 2017, I'm not sure she'd even hit the average cell phone use. Recently, at my kids' gymnastics lesson, I was flanked by two women on cell phones. The first one sat to my right, bouncing off my shoulder as she sat. I forgave her for this, because she couldn't see me past the smartphone glued to her left ear. Then she proceeded to scream intermittently at two kids who were not in the gymnastics class, all while never removing the phone from her ear. I didn't blame the kids for being wound up; it was after school, and they were stuck in a building watching a sister when they would've undoubtedly preferred to be outside on the playground. But she couldn't be bothered to interrupt what seemed like a very non-urgent conversation.
I moved to a quieter place, sacrificing my chair for the floor. Then, three feet away, a second person started talking at full voice on her cell phone, telling the unfortunate listener on the other end repeatedly how pissed she'd been earlier in the day. Keep in mind, it was sunny and 66 degrees outside. Either person stepping outside to take her call would have been healthful and humane. But both women, insofar as my amateur observational skills could tell, sat in the middle of a crowded room and talked on their phones for the duration of the one-hour practice, save for the intermittent screaming at their kids. One child actually begged lady number two not to talk on the phone anymore, and was told to "zip it." A third man, who I assume was also a parent, broke his phone conversation only to tell a toddler to "stop fucking around." The toddler did not heed his instruction, and the man was soon sufficiently lost in his talking and texting to allow, shall we say, ample f'ing around, toddler-style.
Sherry Turkle doesn't get into this directly in the brief video above, but this is all consistent with her observations that technology is killing social skills. We collectively show decreased empathy and a decreased ability for self-reflection. A big part of my job is handling sometimes delicate negotiations within clinics or within medical systems or between payers and doctors. In those situations, vulnerability is key. If the interested parties can't look one another in the eye and feel insecure and feel like their decisions impact the other people around the table, we get nowhere.
Don't get me wrong. I've taken my share of calls and texts in crowds. But I've felt like an asshole almost every time. So to keep from being a hypocrite, I've set my phone to no alerts for messages or emails, and I frequently put it on sleep mode, meaning it won't ring unless an immediate family member or neighbor calls (I figure the neighbors have the best view of my house burning down). And though I've occasionally feared that this would kill my productivity, I'm fairly certain now that it does the opposite. I'm more productive the more time I spend apart from my device. People think email is urgent, for example. According to psychologist Dan Ariely, it's not. Yuval Noah Harari, author of some incredible work including Sapiens, meditates for two hours a day. And the astonishingly productive computer scientist and self-help writer Cal Newport is "indifferent" to his smartphone, still subscribes to paper newspapers, and only upgraded from a flip phone because his wife guilted him into it when they had their first baby.
So here's a challenge for this week: Go outside your phone (comfort) zone. The next time you're standing in line waiting for something to happen, or watching your kids jump on the trampoline, or between innings at a softball game, or waiting for a movie to start, leave your phone in your pocket. Better yet, take it to whatever vehicle brought you to the game (except your skateboard; skateboards are a bad place to store a phone). It'll be hard to do, but you have the strength. Concentrate on your breathing. Once you've safely stowed the phone away, look at the others around you. You might have to work for some eye contact, because they probably aren't following the same rules you are. While you're gyrating around trying to get them to look at you, think about their stories. It'll give you something to ask them about. If they won't talk to you, make like Yuval Harari and make this time your meditation. If you're not the meditative sort, think about what you want to accomplish with the rest of the day. Make a mental plan. For a few minutes, don't be a phone drone.
Ever wonder where to find a little library near your house? My 10-year old did. She found the answer at Little Locator.
If so, bravo, Mr. Secretary. With Rigoberto Uran's podium at the 2017 Tour de France, things are looking up for one of only two American-sponsored teams in the UCI peleton.
I've never traveled to China, but my hunch is that the bikes being scattered all over Beijing have a lot more to do with 1) a lot of people in a small space, and 2) the Wild West unregulated atmosphere of bike shares there:
In many cities, the supply of bicycles far exceeds demand, bringing chaos to sidewalks, bus stops and intersections and prompting grumbles that excessive competitiveness — seen as a national trait — is spoiling a good thing. In Shanghai, where officials have struggled to maintain order, there is now one shared bike for every 16 people, according to government statistics.
In some places, the authorities have confiscated tens of thousands of bicycles and imposed parking restrictions. News outlets have documented the waste with astounding images of mountains of candy-colored bicycles, each hue representing a different bike-share company.
For reasons I can't figure out, Swiss law allows use of only mealworm larvae, house crickets and migratory locusts. But apparently they taste fine:
The burger itself has little white specks of rice inside with traces of carrot, paprika, chili powder and pepper. After a hesitant bite, the main flavors that come out are the spices. The texture is curious, a bit like a meaty falafel with a crunch. An aftertaste lingered — but maybe that was just my subconscious playing tricks.
Sales are apparently brisk in a very limited release so far.
Marion Nestle points out what we already know about the PURE Study (that's Prospective Urban Rural Epidemiology): Fruits, veggies, and legumes are good for us.
And refined carbohydrates and sugar are bad. The study's "high fat" diet didn't even approach the amount of fat that most of us eat (18-30% versus 35% in the US), so it's impossible to really say what the study proved in regards to fat intake.
Text below, in case you want to avoid reading the grisly details of a murdered family:
The second-most-prevalent obsession is food. Longo says he actually has two photo collections: nude women and gourmet cuisine. His letters to me are filled with food cravings: "a salt bagel with a full plain cream cheese schmeer from Einstein or Brueggers — toasted, of course"; "a cinnabon with a good cup of coffee"; "a pizza"; "honey-dripping baklava." To make the institutional meals more palatable, the men sometimes hold death-row dinner parties. Several inmates will pass their trays down the row to one cell — frequently, to Longo's. He'll combine all the food together, add commissary-bought items like hot sauce, peppers, and shredded cheese, then rebuild the plates "Cadillac style," as it's called, and send the trays back.
How all this plays into the choice of a last meal, I don't know.
I cannot find data on bottled water, but considering that most of it is packaged in plastic, I suspect it's no better. Why does this matter? Well, besides the ick factor, plastics have a notorious reputation in the endocrinology world as "endocrine disruptors," meaning that they exert a hormone-like effect on tissues. The most notorious chemical within plastics with this effect is bisphenol A, which among other effects acts as an estrogen mimic.
Answer: Books by the Foot, mostly.
I grew up about twenty miles outside of a small town. So small that the addition of something like a Chili's would really set the place on fire. I still remember when we got a Wal-Mart and when we got a McDonald's. I can't say that either of those were great for the town on balance. I suppose they offered some low- to mid-range jobs, salary-wise. My mom had one of them at Wal-Mart for years. But no one that I know of ever felt the kind of devotion to either place that's described in the hard-core Chili's trainers in this article:
For the right kind of new person, though, Chili's is the righest kind of place. Her story echoes Sara's, which echoes everyone else's at their level: She was pursuing a different path (grad school for criminal justice), but kept being drawn back to Chili's, where she realized she was happiest. She was searching for something and found it there. For Nikki, now, it has grown into pure purpose. "I live and breathe for this company," she says. "This is totally what I was supposed to do. This is what makes me tick everyday. Everything I do is with Chili's. This is not a job for me—this is my life."
Speaking of McDonalds, the burger place occupies a special place in the communities in which it's found (I'd say serves, but I'm not there yet):
In Sulfur Springs, Texas, in the late morning, Lew Mannon, 76, and Gerald Pinkham, 78, were sitting alone at a table, the last of the morning regulars to leave. She was needling him about politics. (“I like to tease the men who come, get them all riled up, tell them they just don’t want a female as president.”) Both are retired, Gerald from working for an airfreight company, and Lew after 28 years as a bank teller.
When I asked Lew about her life, she started to tear up, stopped for a second, and composed herself. “Life is hard. Very hard. Seven years ago I lost my husband to leukemia. Then three years ago I lost one of my sons. Health complications from diabetes. When my son died, I had nobody to help me, emotionally, except this community here. Gerald lost his wife three years ago, and we have helped support each other through that.”
She stopped again, unable to speak from tears. After a moment of silence: “I look composed on the outside. Many of us do. But I struggle a lot on the inside. This community here gives me the support to get by.”
When I was in second grade, I got to have my birthday in McDonald's. It was noteworthy for a couple reasons: first, birthday parties were always a little touch-and-go with me, since my birthday so often fell dead-center in corn harvest; and second, because I was the first person in my class to have his party at the new McDonald's in town. I remember it all: the faux-wood bent booths, the paper hats, the Happy Meal toys.
I was so excited to leave school to take my friends there that my mom tried to slow my down and I fell on the cement and tore my jeans. I didn't even care.
"Radiology has become commoditized over the years," Kelley says. "People don't want interaction with a radiologist, they just want a piece of paper that says what the CT shows."
That little click you just heard was another tiny domino falling in the decline of football. I've said before that the NFL was one thing, but it's such a small, relatively well-paid population that it doesn't mean much. Once concern starts spreading upstream into college, high school, and beyond, football is in trouble.
In my neighborhood we've experimented with our version of Kibbutzing: we used to have a monthly (or so) breakfast where everyone in the neighborhood was invited to a single house for pancakes, breakfast burritos, etc. Like so much in life, though, it was overtaken by other Saturday morning chores. It's hard for even a breakfast burrito to compete with kids' soccer, the Home Depot, and volunteer duties. It's time to resurrect our Kibbutz.
Caitlin brings up the possibility of this having been a placebo effect. I agree. It's hard to find clinical trial data on meldonium in English; almost all the trials are published in Russian:
And there are no systematic reviews. Wolfgang Schobersberger, Tobias Dünnwald, Günther Gmeiner, and Cornelia Blank wrote a nice narrative review (paywalled) on meldonium's transition to a performance-enhancing drug, though. The take-home from their article is right in the abstract:
The benefit of taking meldonium in view of performance enhancement in athletes is quite speculative, and is discussed without sound scientific evidence.
A few years ago, a stem cell clinic opened here in Kansas, with surprising fanfare. IIRC, they convinced the Governor and even Kansas State Head Football Coach Bill Snyder to attend a grand opening. Coach Snyder is even in a video on their website. Not long after, I reached out to the docs in the clinic through their website to ask to talk about the evidence they were using to justify their treatment regimens. I never got a response. That clinic is not on the list, as far as I can see, of clinics that have been contacted by the FDA.
I'm skeptical. And I suspect the downstream effects of blocking FSH, which aren't completely known yet, might be worse than an extra 15 pounds.
I hope I'm not being burned by fake news here.
When I read the words in EB White's Once More to the Lake, I ache. His description of the smell of wood, the feel of the water, and the schedule set by the sun gives me a completely unearned sense of nostalgia. Most of my summer (and adult) trips to the lake have been marked by the anodyne scent of an RV air conditioner and the coconut-tainted slip and slide of sunscreen. But I ache for microwaved biscuits and gravy and cheese sandwiches and kool-aid. I can smell the fishy water covering the sandstone shore of Wilson Reservoir. I can see the treeless lunar landscape.
So this is your permission from me--not that you were seeking it--to engage in a Great American Pastime and head to the lake for Labor Day. Do it before the McMansions obliterate any of the charm that EB White talked about:
Do it even though, unlike him, you won't be able to spend a month there. Do it because someday you'll wonder what you've done with your life, and the answer of "I took my [kids/wife/husband/friends/enemies] to the lake once in a while, and we had fun and made memories" is better than "I got high and played a lot of video games."