Sausage Linkfest April 21, 2017

Like them or not, soda taxes seem to work. That is, they work to reduce sugar-sweetened beverage consumption. Time will tell if we can trace any health benefit back to them, like we did with trans fat bans. 

School shouldn't start before 8:30, say the sleep people.

Biking to work is associated with a 41% reduction in the risk of dying over five years. Biking was also associated with 45% lower rates of cancer and a 40% lower risk of dying of cancer. And, as has been noted here before, it's associated with having a shitload more money in your bank account.

Even short-term corticosteroid use is harmful, says a review in the BMJ, with accompanying coverage from the NYT. This is ironic, considering a very recent well-publicized study advocating for 10 mg of dexamethasone in place of antibiotics for sore throat. So a couple comments: first, even the "low-dose" steroids the BMJ article talks about constitute a potentially huge dose (20 mg daily). Second, 10 mg of dexamethasone is just a gigantic, chemotherapy-level dose. It is saved by the fact that dexamethasone has a half-life of only ~3 hours, so most of it is gone by the second day. But still...whatever happened to chicken soup and time for things to get better? *sigh* I guess dexamethasone isn't any worse than the cursed "Z-Pak" that urgent cares seem to hand out like Halloween candy. 

2. Social media is designed to be a time-suck*

*This is the third in what's turning into a series of posts. If you want the rant from the beginning, click here. 

Other than the intense junior-high-dance-level social anxiety, the things I most remember about my time on social media is that 1) my phone never seemed to shut up, no matter how fastidious I was about un-checking "notify" buttons in the settings, and 2) even if my phone wasn't buzzing, beeping, or flashing banner alerts at me, my mind was always subconsciously occupied in making sure that I was getting good wallpaper for my social media.  I was so busy worrying about tweeting of 'booking or 'gramming my life that I wasn't present. The social scientists call this and the related angst of seeing other people's fabulous posts "FOMO," for "fear of missing out." My mother more accurately called it, in the parlance of the 1970s, "Fear that somebody'll fart and you won't get the chance to smell it." How times change.

Here's the deal. As the Onion is wont to do, it perfectly captured the zeitgeist of 20-teens America. We accept constant intrusion into our lives because we've been told so many times that Silicon Valley is changing the world for the better that we've started to believe it:

And 3. (related) social media's goal is to take control of my life from me.

I didn't descend into the dark, lonely chasm of social media forever. At some point I realized that it's real purpose wasn't to help me or even to entertain me, unless you consider my juvenile efforts to use Facebook updates to relieve my own separation anxiety at the expense of my social anxiety. Social media, to paraphrase Jaron Lanier, was a way to avoid the closed door at bedtime, the empty room, the screaming vacuum of my isolated mind. But to draw attention on social media, I had to manufacture a version of myself that I thought people would like. By drawing me further from my true self and closer to the manufactured version of me I was putting out there for the sake of likes and re-tweets, social media's goal was to evolve a program that knew me better than I knew myself. The perfect social media platform would know what you really wanted, even if you were playing the game of trying to make yourself seem cooler than you really are. The sole purpose of this is to entice us with strategically placed alerts and rewards so that it can place ads in front of us. And yeah, I know that social media has been central to some very positive events in the past, like Tahrir Square. But I suspect that real action like that represents a tiny fraction of what comes from Twitter. The daily outrage is the more impotent, more common form of Twitter activity. 

The coders behind social media applications believe--with good evidence on their side--that you can't control your own behavior. They think you're manipulatable only by the clever use of algorithms and well-placed alerts on your smartphone. You know this isn't true. But to prove it, you have to break away.  Even still, after deleting essentially every social media app I've ever had (Strava is the exception) my hand is drawn to my iPhone like a professional baseball player's hand is drawn to his crotch.

Hi, little fella! Any re-tweets today?

I'm not alone. The average smartphone user checks his device 1,500 times a week. Add in the master social psychology of Silicon Valley and it becomes almost irresistable.

So I've developed a set of behaviors that I think have helped me take my life back:

1. I've deleted all social media accounts with the exception of Strava and LinkedIn.

2. I've turned off all notifications from Strava, and I have no app on my devices for LinkedIn. I've done my best to turn off all email notifications on LinkedIn, but they seem to trickle through every week or two, anyway.

3. Whenever possible, I leave my phone in the car or at home.

4. Whenever possible, I leave my phone in a face-down position.

5. I've turned off notifications for text messages. This may sound worrisome to anyone in the mood to text me, but the reality is that I still see my phone several times an hour for other reasons, so I have plenty of chances to see the little red dot on my message icon.

6. I keep my phone on sleep mode (that's the little moon in iOS; I'm sure other operating systems have a similar function) as much as I can. An advantage of non-traditional practice, I guess. No more pages in the wee hours of the night. 

My March WAMPO presentations

I was thrilled to get to speak to the Wichita Area Metropolitan Planning Organization about health effects of active transportation infrastructure. It was a great, receptive crowd. They gave me reason to hope for the future of a transportation system in which cars are a peripheral accessory and not the primary feature. 

Aaaaand I look a little like a wild-haired madman in the video, which I like. 

Richard Link-later April 18, 2017

Banning Trans Fats in NY reduced heart attacks by 6%. If this is true, it's astonishing. Researchers compared admission rates for the composite of myocardial infarction and stroke between New York counties implementing the ban in its eateries versus those that did not. The restricting counties showed an additional 6% drop in admissions relative to non-restricting counties after adjustment for an already-declining trend across the state. The difference became significant 3 years after implementation of the bans and benefitted men and women equally.

Newer, novel (and astonishingly expensive) diabetes drugs seem to have lower hypoglycemia, heart, and death risk than good old insulin: even though this study had a lot of warts (industry-funded, retrospective, yada yada), I'm having a harder and harder time justifying the addition of insulin to high-risk patients' regimens.

"My V-steam cost $50, which is a lot to pay for sitting over hot vapor. Is your money well spent on this stuff? It depends on what you’re looking for."

It's a "fear social media" bonanza! First up was Hidden Brain on the dangers of curating your social media presence to look universally positive:

And then (and then!) Ezra Klein, a journalist I've heard my fair share of thoughts from in regards to how social media doesn't make him happy, interviewed Cal Newport about his notoriously fuddy-duddy views on social media, which I'll cover briefly in the very near future on this very blog.

I was asked recently to name a book that changed my life. The book I chose was Cal Newport’s “Deep Work,” and for the most literal of reasons: it’s changed how I lived my life. Particularly, it’s led me to stop scheduling morning meetings, and to preserve that time for more sustained, creative work. Which is all to say that I’m a bit obsessed with Newport’s work right now, and especially his account of how the digital environment we inhabit is training us out of concentration and into distraction in ways that are bad for us, bad for our work, and ultimately bad for the world. Most of the conversations on this podcast are how to think about things differently. This one is too, but it’s more importantly about how to do things differently, and why you should do them differently. We discuss: -How Newport defines depth when it comes to work -Why the information revolution boosted productivity up until the 2000s, but then stagnated -What he thinks is problematic about the constant accessibility of technologies like email, Slack, and other communication tools -His perspective about how we’re still in an early age of the internet, and what looking back at periods like the Industrial Revolution can teach us about using new technology to work smarter -How to take productive breaks, rather than flicking through email and Facebook and Twitter -How “flow work” and deep work overlap, and how they’re distinct from each other -Why he consumes and produces information more slowly and more traditionally—through newspapers and radio, and why that might benefit people who work in the knowledge economy -His vision of the workplace of the future I hope you get as much out of Newport’s ideas as I have. Books: -Jaron Lanier, “You Are Not A Gadget” and “Who Will Own The Future" -Douglas Rushkoff’s “Throwing Rocks at the Google Bus”

For past thoughts on social media, check here and here.

And PS--I mean fuddy-duddy in the most admiring, sincere way, obviously.

Go to church, you heathens, and adopt a perspective of abundance

I can remember one time in my life that I've asked God for help. I'm not proud of that fact. There were surely other times that I can't remember right now. I think my privileged life has something to do with it; I just haven't had that many chances to suffer.

It was in my senior year of cross country. I was running my hometown meet. 

Bowl cuts forever.

High school cross country races are a relatively anonymous affair. They don't draw big crowds, because people don't want to drive two hours to watch a twenty-minute race. So being at home was a big deal. I wanted to give the home crowd what it wanted, I guess, so I foolishly tried to keep pace with a kid from Liberal who was much, much faster than me. The race was 5k (3.1 miles), and at about 2.5k I knew I was in trouble. I figured I could limp home and still finish in the top ten (and I think I did, but I can't prove it). But to do so would mean going to a very dark place. I made promises to God that day, and I ran one of my fastest times: 16:59; not world-class, I know, but fast for me. If God had anything to do with it, I haven't remotely repaid the favor.

But I digress. This post isn't about my religion, or lack thereof. I attend church, but I'm not what any religious person would call a believer. Some of it boils down to the fact that I'm a bit of a skeptic in general and even more of a hermit. I'm simply more comfortable being alone than being in crowds. But being alone isn't good for me. So off to church I go most Sundays, wife and kids leading the way. And I frequently get something out of it, in spite of my smoldering skepticism. Take a couple Sundays ago, toward the start of Lent: our pastor brought up Nicodemus, the Pharisee who visits Jesus one night and serves up a big steaming pile of skepticism:

Nicodemus, in John 3:1-3:15, gets to play Scottie Pippen to Jesus's Michael Jordan.

Later on he reminds the rest of the Sanhedrin that the law mandates that a person be heard before he's judged, and later he helps embalm Jesus's body. And even later on, a group of newly-freed slaves founded a badass frontier town in his name in northwest Kansas. (which they only managed to hang onto with the help of some Osage, but that's another story)

Nicodemus deserves some credit here for asking Jesus questions about his radical philosophy. And the answer Jesus gives boils down to this: See your world through the lens of abundance, not scarcity. I think this philosophy applies to all of us. We're genetically programmed to cram high-fat, high-salt, high-sugar food into our mouths and lie on the couch because we evolved in an environment where calories were hard to come by, and where it took a helluvalotta work to extract them. But we also developed brains capable of rational thought, and now here we sit in an environment of caloric abundance, not scarcity. What we're programmed to seek now destroys us. It's as if we need water to survive, but we're being pulled into the center of a sucking whirlpool, being submerged in water that in excess quantity has become toxic. We're drowning. 

Through a lens of scarcity, we are compelled to hoard calories and stuff them in our bodies as quickly as we can. And we're similarly compelled to preserve those calories by kicking back in a La-Z-Boy. But our evolved brains tell us that we don't need to do this. Through a lens of abundance, the path toward happiness doesn't pass through a cheeseburger. 

Roadblock.

Instead, the path gently curves around that cheeseburger through something more sensible. Ultimately, you're happier if you skip the cheeseburger and eat something you won't regret later. This isn't a matter of deprivation. This is a matter of titrating our cheeseburger intake, just like we adjust our amount of driving or spending or physical activity, to achieve the maximum amount of happiness. 

From a perspective of scarcity, your neighbor's new car induces a twinge of jealousy. But from a perspective of abundance, you can see the year's salary you saved by driving your perfectly good ten year-old car as a reward for the regular 30-minute walks or 10-minute bike rides to the grocery store. A perspective of abundance sees these walks not as a chore, but as a choice. Or better, an opportunity. And if that opportunity coincides with, as writer Florence Williams calls it, a reversal in your "slow telomeric death march" (I'm paraphrasing), all the better. 

So back to church. Economist Jonathan Gruber from MIT has written about the effect of religion on well-being, and his thoughts were recollected in J.D. Vance's Hillbilly Elegy. Not only are people who go to church healthier and happier, but the effect seems to be causative. That is, church attendance seems to have caused people to be healthier and happier, not just that healthier and happier people tend to go to church more. To a skeptic, or to an *ahem*, coastal elite, there is a reasonable assumption that this personal benefit comes at a societal cost, since people who go to church are less tolerant than people who don't. And when it comes to some specifics like gay marriage, that's true. But for many other things, like immigration, religious people are much more likely to be tolerant if they're a regular church goer than if they identify as religious but stay home on Sundays. 

As Easter dawns, I'm sitting in western Kansas wondering what it is about the morning ritual of church that makes people healthier. My religious half says that recognition of a higher power comes with benefits: I scratch God's back, he scratches mine. But my scientific half says that it's not the religion that's doing the trick. It's probably the community that matters. The act of putting the needs of a group of people before your own surely causes some reapportionment of the mixture of good and evil humors that make up our sense of well-being. So if church or temple or mosque isn't your thing, join the PTA. Or volunteer at a soup kitchen a couple times a month. Or help with your community's health assessment. Do pedestrian/bike counts on the public paths when they're looking for volunteers. Volunteer at Boy Scout camp. Whatever your church becomes, do the duties it requires from a perspective of abundance. 

You might live longer. You might be happier.

Happy Easter!

Have a linkboy, not a poolboy April 10, 2017

Most of us eat chocolate bunnies ears-first. Better to not eat them at all, but...

The FDA has given clearance to 23andMe to perform genetic testing for ten diseases. The links are theirs, not mine:

• Parkinson’s disease,
• Alzheimer’s disease,
• Celiac disease, a disorder resulting in the inability to digest gluten that everyone thinks they have; maybe this will set their minds at ease,
• Alpha-1 antitrypsin deficiency, a disorder that causes your lungs and liver to literally digest themselves,
• Early-onset primary dystonia, a movement disorder,
• Factor XI deficiency, a blood clotting disorder,
• Gaucher disease type 1, an organ and tissue disorder in which white blood cells get abnormal sphingolipid deposits,
• Glucose-6-Phosphate Dehydrogenase deficiency, also known as G6PD, a condition that makes red blood cells fragile,
• Hereditary hemochromatosis, a disorder of iron metabolism that leads to excess iron build-up,
• Hereditary thrombophilia, a blood clotting disorder

Vitamin D supplementation probably doesn't prevent heart disease. After all the vitamin D promise (hype?) in the oughts, it's one negative trial after another nowadays.

Big swings in weight may be associated with increased risk of heart attack and stroke. I'm skeptical of the result, but if true, this is yet another way you can improve your chances of a long, healthy life. Eat good foods, get yourself around under human power, get some sleep, and watch your weight hit a natural level for your body. If you're very heavy or having complications of your extra weight, think about bariatric surgery. No need to have your weight swing back and forth 50 pounds a year for the rest of your life. 

Re-link-uishment April 6, 2017

Genetically modified organisms are safe to eat. Period. Anyone who tells you otherwise is misinterpreting the data or deliberately misleading you. But food safety is only part of the picture. Some uncertainty remains about the safety of the organisms to the environment. Agricultural monoculture, with hundreds of acres repeatedly planted to one, two, or three crops, is surely a bad idea. Reducing pesticide use with GMO crops is surely a good idea, but it has the specter of downstream effects that may currently be unknown hanging over it.  

Would Silicon Valley rather make death less likely or life better? Evidence seems to point to #1; most social media and apps turn out to be tools for either wasting our precious time or toys for rich people. 

Is it foolish for a woman to cycle alone across the Middle East? It is stories like this that make me miss social media. But not enough to go back to it.

Levothyroxine didn't make older people with subclinical hypothyroidism feel any better in an RCT. Huh.

Switching poorly controlled people with type 1 diabetes to an insulin pump before "optimizing" their diabetes education may not be helpful. The training only took five days, and at 24 months, both groups (pumpers vs. educated) had similar reductions in their HbA1c level. "These results do not support a policy of providing insulin pumps to adults with poor glycemic control until the effects of training on participants' level of engagement in intensive self management have been determined." How to determine their level of engagement seems to be the bugaboo, then. 

Guest post! The Archetype of 21st Century Medicine, by Stephanie Shirey, MS1

The popular narrative of medicine models that of a comic book hero or heroine—angst, turmoil, followed by a close save as the champion swoops in at the last minute to save the day. It is this story line that drives many of us into a career in medicine, feeling the pull to be the knight in shining armor. We as health care providers want to affect a tangible change in each of our patients lives. However, in the progress we have made in pharmaceutical and technological advances in the last 75 years the opportunities for these bold interventions have become less and less frequent.

The roles we play as healthcare providers are quickly evolving as more long-term health concerns make their way to the forefront: 36.7 million people worldwide are living with HIV/AIDS, 422 million patients have diabetes, and it is estimated that 17.3 million people die each year due to heart disease. These pandemics just scratch the surface of the innumerable chronic diseases the must be managed to improve health care delivery, and not a single one of them has an answer that can be delivered with a finite, distinct procedure or medication. Medicine can no longer be practiced on the basis of short appointments with a high-tech fix, or even a yearly check-up.

Now that American patients are (for now) able to seek care without the fear of being dropped from their insurance carrier, health care providers are able to address much more than the issues that give quantity of life, but can now start chipping away at the barriers restricting quality of life. In Dr. Atul Gawande’s article “The Heroism of Incremental Care” he explores just what mystical powers providers in generalist and primary care specialties harness in order to reduce long-term morbidity and mortality while simultaneously improving a patient’s day-to-day living.

Each of the providers Dr. Gawande spends time with knows the value and skill set they possess is vital to their patients’ well-being. Yet, in a compensation survey conducted in 2016, these physicians are rewarded at half the rate of their proceduralist or interventionalist counterparts. Not only are these “incrementalist” physicians making substantially less money, but their access to the funds for appropriate medical staff and equipment is woefully lacking. Just how is a doctor supposed to provide adequate care for her patients’ diverse needs, many of which reflect the patients’ status as part of a very high-risk population, when the office is unable to afford a nurse to coordinate referrals, or to purchase lab equipment allowing them more real-time knowledge of their patient’s progress? America is in desperate need of a health care and insurance system that allows primary care providers access to the same resources that their interventionalist counterparts have. Medicine is facing a new frontier of chronic disease management and we must evolve our approaches if our patients are going to survive it.

Postscript, by Justin Moore: I *ahem* roll in a pretty important crowd sometimes:

Atul likes the right hand over the left. I'm a left-over-right guy. Dr. Williams prefers to have her hand on Atul himself. 

How else can you crank up the bass?

Having taken a bold stand against the onslaught of low-value data, I'm inspired to voice related opinions. If you've read much here at all, you already know that I believe that good health, like a good life, is achieved deliberately. Your time is precious and it's worth something. Your money is precious and shouldn't be mindlessly wasted on trivial crap. Moving through space under your own power prolongs your life, saves you money, and will help prolong humanity's life on planet Earth. And so on.

You may wonder why I don't just put these opinions in a Facebook page or Twitter feed. I'm glad you asked. Pictures like the one at the top of this page (taken by a young Stanley Kubrick, fyi) are plastered all over the internet with snarky memes like "All this technology sure is making us antisocial!"

But that take on a picture of people reading the newspaper fundamentally misses the point of the experience these people are having. To illustrate what I'm saying, it might be best for me to tell my own social media story:

Over the last few years, but not always simultaneously, I had accounts with Facebook, Snapchat, Twitter, Google Plus, Doximity, Pinterest, Instagram, LinkedIn, Sermo, and probably several other social media platforms that I can't remember now. I still have a LinkedIn page, but I tend to think of Linked in as social media that doesn't even try to tempt me. If you spend enough time on my LinkedIn page, you might see a moth fly by, or a tumbleweed ramble across the page. So I'll give it a pass. But the rest of those accounts are gone. Over the next few posts I'm going to try to tell you why:

1. Social media is expensive

The value of your life isn't simply a matter of how many checks you write versus how many checks you cash. So the next time you download a "free" social media app, think of what it's costing you. The developers are betting on their ability to get you to pay in privacy and time, mostly for the sake of being able to stick cleverly disguised paid advertising in front of you. The average American spends three hours (!) a day on social media, 50 minutes on Facebook alone, more than the average two-way bike commute (which is a habit that actually makes you money, along with making you happier, healthier). So if it helps to put a monetary value on all that time (the equivalent of 6 years and three months of your life over the next fifty years), let's do a little thought experiment: at the current federal minimum wage of $7.25 (good Lord, I hope you're making more than that), that three hours a day equals $5,655 a year you're paying for the privilege of being on social media. And that only includes weekdays. If you include Saturday and Sunday, you're giving up $7,917 a year. And that astonishingly huge amount of money doesn't even account for what would happen if you worked a part-time job those three hours and put that money into some safe, reasonable investment vehicle and let it sit. It makes whatever the people in that train above paid for those newspapers seem pretty reasonable, right?

But it's not just the raw amount of time. In my social media heyday, I put an excessive amount of energy into tending to my online doppelgänger. I blush in shame now at the thought of what I must have missed out on by spending parties and nights out sweating for the next post, tweet, or 'gram. And for what? The little dopamine rush I got with every retweet was tiny in comparison to the feeling I get with good, old-fashioned excitement or awe. I wondered what all that energy could have done if it'd been redirected away from the construction of my online fictional persona and toward making my true self better. So I stopped. I stopped because of the opportunity cost of three hours a day, sure. But I also stopped because I'm not someone who's good with a one-liner; my mind needs time to work. 

And that's what this little shout into the void is about. My pledge here is to take some time to think things through (turning up my own "bass," I guess) so that I know I've spent more time writing and thinking about a post than it will take you to read it. So even if none of you read this, the process will have somehow improved me. 

There. Better already.

Out like a lion links for March 31, 2017

What happens when diagnosis is automated? From the always excellent Siddhartha Mukherjee. Spoiler alert: some good things, some bad things. Reminiscent of the discussion of genomic diagnosis from a few days ago.

UK grocer Tesco has struck a deal to give ALL unsold food to charity, which temporarily restores my hope for the future of humanity.

Aaaaand there it went. Hope is gone: Bodegraven, Netherlands, has installed LED traffic lights on the sidewalk at pedestrian crossings so that phone worms can’t miss them even if they are staring open-mouthed their smartphone screens.

Linque dump March 29, 2017

Whaaa? Joakim Noah was suspended for using an androgen receptor modulator, and he don't care who knows it. The science of these is fascinating. LGD-4033 is one of several new-ish compounds designed to stimulate the anabolic effect (think muscles) of the androgen receptor without tickling the androgenic effects (think beards and penises). It will not surprise you to know that they are meant for treating muscle-wasting diseases and not NBA players with bad haircuts in career downturns. 

When CVS stopped selling cigarettes, it dropped the smoking rate by 1% in the states CVS operates in. “It shows that responsible behavior by a pharmacy has public health benefits for the whole population,” Stanton Glantz said...

Is it more dangerous to be a black pedestrian in the US than it is to be a white pedestrian? "...when the women were in the middle of the road, cars in the high-income area with the faster, wider road were seven times less likely to yield to the black pedestrian than the white pedestrian."

There are at least 79 rare genetic syndromes that have obesity as a feature. This finding underscores the likelihood that in the future, much diagnostic work will be done genomically and not clinically. Real-life paper here. 

Crank up the bass

I remember signing up for my first email address. I was a freshman in college (jbmm@ksu.edu, I think), and right after I got the email address I signed up for an exercise physiology listserv at the request of a professor. I was embarrassed that I was so taken with the idea of email. I checked it once or twice a day (on dial-up!), and even that frequency felt decadent. But in spite of my relatively frequent chekcing, within days the fresh new-account smell was gone and my inbox was crammed with hundreds of emails from people whose email addresses seemed threatening and strange. I felt a choking sensation. What was I missing if I didn't get to all of them? Was there some valuable nugget on the Krebs cycle in there that I needed to know for the exam, or worse, for my future career? That listserv bugged me for the rest of the semester until I finally de-listed. I'm not sure I ever learned anything from it, but in retrospect it was about a thousand times more manageable (and useful) than Facebook. 

In The Nature Fix, writer Florence Williams seems to make a repeated point about the speed at which we all receive data now. Compared with the trickle of data we all took in even a couple decades ago, each of our personal data streams is now a firehose. Out in the wild, though, data comes at us slowly, at a rate that two million years of human evolution have attuned us to. Surrounded by chirping phones, incessant email alerts, and the background noise of nonstop television and radio, we're knocked out of sync. And as we bump along out of the groove that nature designed for us, we ignore those around us and make bad decisions.

The idea fits nicely with Jaron Lanier's idea of "treble" versus "bass." He uses the example of George W. Bush's Wikipedia page to illustrate this. When left to their devices, Wikipedians circa 2008 were so rapid with edits as to be destructive to the page. This is Jaron's "treble." Is this what direct democracy would look like? Lanier wonders. I dunno. I hope not. Wikipedia solved the problem by limiting the number of edits a single user could make to a page. Or, as Jaron would say it, they turned up the bass. The process worked for Wikipedia, and I bet it would work for many of us, too.

So, for your health (and for an intentional move up the Double Arrow Metabolism Wellness Index), I'm challenging you to turn down the treble in your life. I'm a notorious anti-incrementalist, so go big. Here's a suggestion: go to the settings on your phone and disable notifications for the apps that are most insistent on your attention. Better yet, delete the apps altogether. The next time you're in an elevator for a ten-second ride, resist the temptation to pull your device out of your pocket. Think instead. Think about how lucky you are to have a piece of glass with all the world's knowledge inside of it in your pocket. Then think of how lucky you are to have been born with a brain that lets you decide when and where to use it. 

The next time you go to an event, like your daughter's soccer game or your son's piano recital, leave your phone at home. If you drive to the event, leave it in the car. Or better yet, if you ride your bike to the event, leave your phone in the pannier of your bike. It'll be safe there, I promise. (If you skateboard to the event, leave your phone at home. A skateboard is a terrible place to store your phone.) 

The handling is good, but there's zero trunk space.

If you're afraid you'll miss out on a thought while you're apart from your accessory brain, take a pen and paper with you to jot things down while you're there. Maybe someone will see you taking notes and be so taken with the idea that they'll strike up a conversation with you. 

Wouldn't that be nice?

Spring has sprung link dump March 27, 2017

Men today have weaker grips than their fathers. From my own study of this topic (n=1), I've known this since I was a wee little boy.

Drinking fruit juice (aka "all-natural bug juice") is associated with weight gain in young kids.

You'll soon be able to use your smartphone to 1) access the masturbation superhighway*, and 2) do a semen analysis on the results. *the internet, of course. But not this little corner of it.

Link dump March 20, 2017

Everything old is new again. Whole-body vibration may improve metabolism in mice. I fully expect vintage vita-masters to become the new hot thing on eBay:

Click here if you wanna buy this baby. Time's running out!

People without diabetes are wearing continuous glucose monitors (CGM) for reasons I completely fail to understand. 

Myron Rolle, former All-American defensive back for Florida State, will enter a neurosurgery residency in July. This counters the frequent narrative of the under-performing college football player, and further counters the infrequent college football player who makes a big deal out of his intentions for medical/graduate school and never follows through. See also John Urschel, NFL offensive lineman and badass MIT mathematics grad student. 

Delta Dental has shockingly good data on what your kid's tooth is worth to the Tooth Fairy. Spoiler alert: $4.66: 

The combination of good drugs and cheap, immersive technology is driving millenial men away from even seeking work. "It is not always clear when gaming is the refuge of the trapped and when it is the trap." But see also, "A life spent buried in video games, scraping by on meagre pay from irregular work or dependent on others, might seem empty and sad. Whether it is emptier and sadder than one spent buried in finance, accumulating points during long hours at the office while neglecting other aspect of life, is a matter of perspective."

Howard County, Maryland reduced consumption of bug juice by 20% without a soda tax. 

March 23, 2017 links

NBA players play better on the road now because they get more sleep, among other proposed factors. Why do they get more sleep, you ask? They find their, *ahem* "dates" on social media instead of by going to clubs. You should get more sleep, too. But probably not this way.

Direct-to-consumer advertising is astonishingly effective at getting men testosterone prescriptions, many of them without even being tested (!).

Cycling in Kansas doesn't suck

I woke up this morning sound of mind, but less sound of body. My throat was sore. And I needed to help family members get going and yada, yada, yada I didn't make it to the start of this morning's race in Cheney. 

So after lunch, when I felt better, I decided to stave off the self-pity by going for a bike ride. I put on stretchy shorts and clippy shoes and a styrofoam helmet and filled three water bottles. Did I mention I took Thin Mints? (that's right. And I capitalized their name on purpose)

I took Thin Mints. They happen to be my favorite cookie made by our favorite all-female paramilitary child army (was that redundant?), and they appear mysteriously in our house this time of year. But even though Girl Scout cookies are no longer the trans-fat laced nightmare they once were, they're still pretty bad. Not the best choice. So I made a deal with myself that I could have a cookie every 30 minutes of my ride. I can usually cover around fifty miles in three hours,  so that equalled six cookies (including my celebratory ride-is-over cookie). Because sugary minty serendipity, that's the number of cookies left in the sleeve I was holding in my sweaty little hand.

So off I went.

The slight wind was out of the east and slightly south, so I headed west so I could have the wind at my sort-of back on the way home. I got a slight puncture to my rear tire around ten miles in, and it sprayed my left calf with a worrisome amount of sealant, but then the leak stopped. I breathed a sigh of relief. Around fifteen miles in, the pavement changed to pea gravel.

Warning heeded.

And a few miles after that, the pea gravel got pretty thick. My teeth got rattled a little by the washboard.

I got my teeth back in their rightful places and took attendance with my tongue. Then, having no real destination, I pedaled by the Prairie Rose Chuckwagon, known for singing cowboys and paper plates buckling under the weight of barbecue and coleslaw. This was accidental, which made it cool.

Actually, that's not fair. These guys are pretty cool with or without the element of surprise:

As I rode by the 'Chuckwagon, the road turned from pea gravel to chert (you'd know what that meant if you read PrairyErth, you philistine).

No cattle out today, silently chewing cud and waiting for death. 

Energized by the sight of Thomas Etheredge's former lair, I cranked on.

Even the pictures lean to the right in Kansas.

When I turned north, the prairie grass had been burned along the west side of the road for a couple miles.

And when I turned back west a couple miles later, new wheat (aka futurebread) was growing on land that had probably been burnt in the last couple years.

It was unseasonably warm out, so I had to turn on the A/C.

Ladies.

Four Thin Mints in, I saw this tiny house I'd never noticed before.

The wheels might give the reason for its elusiveness away.

The road turned gradually back to pavement.

*the transition to tarmac was actually intermixed with dead squirrels.

**there was also a dead badger, but I couldn't retrieve the phone quickly enough to take a terrified snapshot before I pedaled away in horror.

And I dove back into the suburbs and made my way back home. 

FYI: South-central Kansas is kind of flat. Behold 948 feet of climbing in 50 miles. 

At the end of the ride, my bike, like a good horse, looked like it was ready to do it all over again.

Soon, mi amigo. Soon.

A little under three hours, and my self-pity had been stopped before it got a chance to start.

I thought about taking a picture of the Thin Mint wrapper, now empty. But that seemed gross. 

Leprechaun link-a-dink March 17, 2017

From Bike Snob NYC:

This video "...articulates the relationship Americans have with cars better than perhaps anything else I've ever seen...  Really, this video has everything, included but not limited to:
--"American" car ostensibly with all-terrain capability [ed: note that you could get almost anywhere with a car worth less than $10,000 that burned 1/3 the gas and didn't fetishize obsolete 1940s-era technology. Or at least you could get stuck in the snow for a lot less money];
--Driver completely unable to utilize this all-terrain capability [ed: see above] due to his complete ignorance with regard to the nature of traction and gravity;
--Road rage [ed: completely avoidable had he just taken off walking down the street. In the seven minutes of his tantrum, he easily could have covered a half-mile or more, which gets close to the most common length of a car trip in the US];
--Grown man throwing an obscenity-laden temper tantrum in front of a private residence in clear view and earshot of children [ed: errrrr...glass houses for me].
Yes, it's quite satisfying to see someone's faith in their lavish purchase get completely shattered, though it's horrifying to consider this represents the state of mind of many of the drivers with whom you "share" the road."

Giving school kids fruits and vegetables and restricting their access to bug juice may make them live longer, healthier lives. Go figure. But previous reservations about unpublished conference presentations apply. 

Letting a kid stare blankly at a piece of glass with moving colors and pictures on it for three hours a day is associated with increased fat mass and increased insulin resistance. Good to know. But the fact that 2-3 hours of screen time was in most markers better than 1-2 hours makes me suspicious of any neat, tidy linear relationship between screen time and bad metabolic markers.

In the spirit of people giving up on weight loss, overweight moms may underestimate the weight of their own kids.

A man lived alone for 27 years in the Maine backwoods. "...he did not follow any formal religion; he was not protesting modern society; he produced no artwork or philosophical treatise. He never took a photograph or wrote a sentence; not a single person knew where he was. His back was fully turned to the world. There was no clear reason for what he chose to do." This is not a recommended life strategy. Side note: this story was written by Michael Finkel, known to me as the Jonah Hill character in True Story.

Climate change is already affecting our health, says a consortium of eleven medical societies. Popular Science has a take. Among their findings and vulnerable groups:

• Extreme heat is adversely affecting people with chronic conditions, outdoor workers, student athletes, and people lacking air conditioning
• Air pollution from increased smog, wildfires, and pollen is detrimental to people with asthma and chronic lung conditions
• Increased geographic range of disease-carrying ticks and mosquitoes threatens anyone who spends time outdoors
• Contaminated food and water puts children, seniors, the poor, and people with weakened immune systems at risk

How to be a stoic

From the New Yorker, Elif Batuman wrote a short piece on how she discovered stoicism:

When a cabdriver lied about a route, or a shopkeeper shortchanged me, I felt that it was my fault, for speaking Turkish with an accent, or for being part of an élite. And, if I pretended not to notice these slights, wasn’t I proving that I really was a disengaged, privileged oppressor? Epictetus shook me from these thoughts with this simple exercise: “Starting with things of little value—a bit of spilled oil, a little stolen wine—repeat to yourself: ‘For such a small price, I buy tranquillity.’ ”

My mind tends to go to images of monks in brown robes standing in the rain when I think of stoicism, but I think this is a really, really helpful frame of mind. It's complementary to the strategy of remembering what you have control over right now.

Linkfest March 15, 2017

Watch a professional cyclist's carbon wheel melt before your very eyes:

Some people think going gluten-free may be risky for diabetes. Hmmm. Gluten-free diets are, for the most part, a waste of time and effort unless you have celiac disease. And whole grain intake is generally associated with a decreased risk of diabetes, which is consistent with the alleged findings of this study. And this paper (not yet published) comes from Harvard, which gives it a certain cachet, but I'm always skeptical of big, splashy pronouncements like this when they're made ahead of publication. Too many of these studies end up having fatal flaws.

Bikes now officially outnumber cars in Copenhagen. "When Copenhagen first began manually counting cars and bikes in 1970, there were 351,133 cars and 100,071 bikes on the roads—a ratio of about 3.5 to 1. That's important, because it means not only are more people riding—about 150 percent more over 46 years—but also, fewer people are driving."

How the world's heaviest man lost it all. "The only thing that gave him comfort in life was food. It was a drug of abuse, freely available, heavily marketed."

Is loneliness the biggest threat to middle-aged men? Well, Vivek Murthy is definitely qualified to say so, and I think we're self-isolating ourselves with suburban homes and gadgets, but "biggest" is a stretch when we still have tobacco and obesity/diabetes to contend with...

Big pharma is very nervous about possible Trump FDA deregulation. This one cuts both ways. On one hand, I'm afraid that ineffective drugs are going to start coming to market if deregulation goes too far. On the other hand, any deregulation that is opposed by big pharma is inherently attractive.

The ADA 2017 Standards of Care in Diabetes are out. "To help providers identify those patients who would benefit from prevention efforts, new text was added emphasizing the importance of screening for prediabetes using an assessment tool or informal assessment of risk factors and performing a diagnostic test when appropriate." It's a start.

You can't use drugs to "prevent" diabetes

Big, big disclosure here: I am a paid consultant for a CDC grant that aims in part to increase use of the Diabetes Prevention Program. So there. Read on.

Good to see you again, Mrs. D. You mind if I call you Mrs. D? Thanks. Reminds me of "Mrs. C" on Happy Days. You know, she was the only one with the cojones to call the Fonz "Arthur." So you can see the resemblance.

I'm glad you asked about the recent study that showed a medicine called "liraglutide" (brand names Victoza or Saxenda) "prevented" diabetes. You're a smart person, so you read some of the fine print in the study, and you know that ~2200 patients, most of them obese, were randomly given a daily shot of placebo or a daily shot of liraglutide, a chemical that mimics a gut hormone to trick the pancreas into producing more insulin. Liraglutide has the side effect of making people feel fuller sooner after eating. Doctors call this "early satiety." The tricky vocabulary's how we make so much money.

All of the patients had elevated blood sugars, but not so elevated that they could be labeled "diabetic." They were "pre-diabetic" in the current nomenclature, just like you. It means the same thing as "impaired fasting glucose" or "impaired glucose tolerance." The study set out to prove that liraglutide could "prevent" the onset of diabetes. Now you're probably wondering: If I'm taking a diabetes drug, what's the point of having "prevented" diabetes?

And you're on to something, Mrs. D. This is an absurd question at face value, but it keeps getting tested, mostly by drug companies. Not surprisingly, in most cases people getting the diabetes drug were less likely than those getting a placebo pill or shot to have their blood sugars rise high enough to be diagnosed with diabetes.

I'm about to get really, really snarky, Mrs. D, but before I do, it's important that I make this point: the prevention of diabetes is actually a HUGE deal, and not only because diabetes remains the number one cause of blindness, kidney dialysis, and foot amputation in the United States. It is astonishingly expensive. Of the $3.2 trillion (!) that Americans spend on health care annually, diabetes directly accounts for $101.4 billion, making it officially the most expensive disease in America. If you can prevent people from advancing from the just-a-little-abnormal-sugars "pre-diabetes" to old-fashioned diabetes, you save about $12,000 per year in expenses. Now, that's insurance company money, but we all pay for it in premiums.

This is where your insurance premiums are going.

And as I've pointed out before, a big chunk of that extra spending isn't insurance money at all; it's coming out of your pocket in the form of co-pays and whatnot. And it's not much better for the Medicare crowd, who we all pay for in taxes:

So let's perform a quick thought experiment. You came to see me because you weren't feeling your best, and I checked a blood sugar on a hunch, and it's slightly elevated at 106 mg/dl. That's in that pre-diabetic range I've been talking about.

Bummer.

Now, we've got some options here. But let's say I tell you that the best way to keep yourself from becoming diabetic is to inject yourself with 10 units of insulin every night before bed. That way, your blood sugars will go back to normal, and we can both wash our hands of the whole issue. Great, right? We've prevented a case of diabetes! Your blood sugars are normal, after all.

BUT YOU'RE ON A DIABETES DRUG NOW!

Of course we haven't prevented a case of diabetes! We've just put you on a diabetes drug that has (predictably) lowered your blood glucose levels. The entire assertion that we've prevented anything is as laughable as the assertion that we could "prevent" a diagnosis of hypertension by putting you on blood pressure medications.

To make the situation even more ridiculous with liraglutide, it costs a fortune: over $3,000 a month for the 3 mg dose! If you wanna know where that extra $12k a year is going, I think we're hot on the trail. Think what else we could do with that amount of money. And if you for some reason think the idea of "preventing" diabetes by taking a diabetes drug isn't patently absurd, it works only modestly better than metformin, a drug that can easily be obtained for $3-4 per month.

But the final insult, Mrs. D, is that liraglutide worked barely better in its study than a program called the "Diabetes Prevention Program," or "DPP." In the liraglutide study, roughly 2% of people receiving the drug went on to have blood sugars high enough to be diabetic in three years, versus 6% of people getting placebo, for what we call an 80% "relative risk reduction." (Drug companies love using relative risk because it makes the numbers sound so much more impressive) In the original version of the Diabetes Prevention Program, 4.8% of people getting counseling on diet and lifestyle by a coach went on to be diabetic, versus 11% getting placebo, for a 58% relative risk reduction. The numbers for both groups in the DPP were higher, which I blame on an older participant population.

The cost of the Diabetes Prevention Program? $429 per year. So you might not be surprised to know that in 2016, when CMS was debating whether to allow Medicare to cover the DPP, the Pharmaceutical Research and Manufacturers of America (PhRMA) fought against it, saying that twenty years of evidence was only "preliminary." They do. Not. Care. About your health or the seemingly inevitable transformation of America into a single, enormous insurance company that also happens to field a Navy. And we should all remember that back when insulin was discovered, the University of Toronto held the patent for insulin to keep any single company from exploiting the drug for unreasonable profit. How times have changed.

Okay. Deep, cleansing breaths. I'm calming down. Liraglutide is a good medicine for diabetes. It helps keep sugars down, it helps with weight loss, and it may even help prevent heart attacks. In diabetics, that is. But you're not diabetic, and you don't have to become diabetic, and all drugs come with a cost, financially and otherwise. I think we can agree that diabetes is expensive enough; we shouldn't use drugs to "prevent" it that are even more expensive than the disease itself.

So, Mrs. D. You'd be a great candidate for the DPP. But even if you weren't, do you know what the DPP asks of its participants? 150 minutes a week of physical activity and some dietary modifications to allow you to lose around 7% of your body weight. Let's think about what that might look like. The average bike commute in this country is around 19 minutes one-way. Do that five days a week, and you're at 190 minutes already! And that doesn't even count trips to the grocery store! And if you stop drinking insect bait and cut out the foods that aren't really foods:

If you cut those out from your diet and start eating most of your food from the produce aisle or from the canned fruits and vegetables aisle, don't you think that 7% weight loss sounds pretty modest? I bet you'd blow it out of the water. 

And besides, do you really want to cross that grim threshold from "person" to "patient?" Because the first time you put the needle of that Saxenda pen into your skin, that's what you'll have done. You'll have moved the wrong direction on the Double Arrow Metabolism Wellness Index. You'll have gone from a person with agency, someone who takes medicines to feel better or live longer, to someone who has yielded control to a chemical--a $30,000 a year chemical--to do something you could have done better yourself. You'll have succumbed to a philosophy of better living through chemistry.

Maybe Du Pont doesn't deserve this.

Or do you want to be the person who SAVES thousands of dollars per year by ditching the fancy gas-powered wheelchair so you can propel yourself through space with your own legs and feet and by eating real foods you made with your own hands and eating them when you want, the way you want, and in the quantities you want? Do you want to live by a philosophy of self-determination, where you know that every healthy, happy day you live from now on was of your own making? 

If that life is what you want, then don't try to prevent diabetes with drugs. It can't be done.