June 6, 2017 link-a-dink

The idea that good diabetes care isn't strictly an obsessive quest for an A1c level of 7% or less is finally hitting the mainstream press. This article also touches on the very real dilemma that doctors and patients face: Do we use old, cheap drugs that are effective at lowering the hemoglobin A1c level, or do we use new, astonishingly expensive drugs that have better evidence of actually reducing death?

Most people will never understand my eating disorder. "I am six feet tall and between 180 and 190 pounds, depending on the month. I am by no means the picture of health or even particularly muscular-looking—not for someone who exercises this much, and definitely not compared to most of the men I see at my gym. Or maybe I am? That's the problem, or one of them: What I see when I look in the mirror doesn't correspond with reality. I see a fat piece of shit, and then I think to myself that it's time to punish my body for letting me down."

Do patients make mistakes during doctor visits because they're put in a position that forces them to rely on intuition and makes them vulnerable to biases? 

RIP Warner Blackburn: sadness at the Dirty Kanza

I finished the Dirty Kanza 200 yesterday, and I plan to write about the experience in detail. But for now, I want to mention Warner Blackburn, a man who died during the 50-mile race. He was given CPR on the course by a friend of mine and taken to the hospital, where he died of an apparent heart attack.

I suppose the most cyclist-y thing to say is that "Warner died doing what he loved" or some such crap. But I don't know that. I don't know that Warner even liked cycling. He left almost no trace on the internet. Maybe he was doing the DK 50 on a bet, or maybe he was trying to support a family member. My wife makes fun of me because I automatically assume that people in cycling and other outdoorsy pursuits are nice, even though I'm not the warmest cuddliest type around. So I'll say this: whether Warner liked cycling, or whether he was trying to support someone else, or whether he was trying to support a cool event for the local community, he went out on a high note. 

FWIW, for anyone thinking of starting exercising after a long period of physical inactivity, please take the Physical Activity Readiness Questionnaire first. It's a little too sensitive, meaning it may flag a few people who aren't that high risk, but if you have a "yes" anywhere on the form, it's worth talking to your doctor about before you go out and hit it too hard.

The 2016 Dirty Kanza 200: a look back

It's coming. The 2017 edition of the Dirty Kanza 200 is tomorrow, Saturday, June 3. I'm under-prepared. But I feel that way about every race I enter, as my notes from last year prove. Step into the time machine and travel back a year with me: 

I knew going into the 2016 Dirty Kanza 200 (my first attempt at the full distance) that I’d under-prepared. I’d done a few long-ish rides in the spring: several rides over 60 miles, a couple over 100 miles, including the local Wicked Wind 100. I’d even spent a few days at altitude, climbing hard in Santa Fe and Albuquerque, but the last day of it was complicated by a sticky bout of gastroenteritis. My vomiting wasn't from the exertion, but it might as well have been,  because climbing anything, at altitude or otherwise, has always been hard for me. I’d failed by a couple miles to summit Haleakala in February 2016. And I’d hardly started, let alone finished, Elrod’s Cirque in Winfield, thanks to an early mechanical on my coaster brake bike (I'd raced the Krazy Koasters division because of a chance of rain and a desire not to have my rear mech ripped off). So I’d given up hope on any real accomplishment at the DK other than finishing. There would be no real competition with my faster 40-something peers. I likely couldn’t sustain a pace to “beat the sun.” Finishing with a modest amount of suffering was my goal.

I felt like I needed to do some planning to make up for my lack of preparation. In the week leading up to the event, I tried to get on my bike for an easy-ish ride daily to keep my legs turned over without costing myself any rest. I strategized my food: I would eat protein at checkpoints and mostly carbs on the road. The protein would come in the form of Snickers bars and “PBJ Sushi” prepared by my daughter.

I would tear into a stockpile of stroopwafels on the road. Hydration would come in the form of water in a hydration pack and Skratch, a drink that has served me well in the past, in bottles. And even though the literature on it is sparse, I'm a fan of eating pickles at checkpoints, so I'd stocked up on those.

I intended to pack light on the road. Previous finishers had convinced me to treat the race like four 50-mile races strung back-to-back, and this seemed to make the likelihood of needing bulky provisions fairly low. So there would be no tangle bag, feed bag, or extra bottle mounts. Just my trusty, rusty steel Ritchey Swiss Cross, me, and the hydration pack. My wife, the Chief of Sunscreen Police, would tend to keeping me unburnt with ample sunscreen at each checkpoint.

I’m not a 100% glove-wearer, but for the sake of decreased hand fatigue I would wear them for the DK. I would, as a lifelong heavy sweater, wear a Halo sweat cap under my helmet to keep the sweat out of my eyes. The cap would earn me extra points from the Sunscreen Police for keeping my forehead and scalp covered.

Effort-wise, I planned to keep my heart rate around 130 beats per minute, a pace that my home experimentation showed my should 1) be sustainable for a very long time, and 2) get me to a ~14 mph average, depending on the roughness and grades of the roads.

I checked in and went to the riders' meeting, ate a huge Mexican dinner downtown, then retired to the hotel room to make sure all my gear was in order. After being awakened by a 3 am rumble of thunder and the sound of heavy rain, I slept fitfully the rest of the night and woke up early. I ate the complimentary breakfast at the hotel, then skedaddled downtown and lined up to start near the 15-hour sign. I was later getting to the starting line than I’d intended, and I’d walked my bike the three blocks from our parking spot to the start. So as the countdown began, I looked down and saw that my chain was off the front chainring. I unstraddled the bike to put the chain on and, thank God, noticed that my front cantilever brake’s (I’m old school like that) straddle cable hadn’t been re-attached after taking my bike off the rack.

Look closely at the chain and wonder to yourself how this bonehead expects to be able to move the bike down the road. 

Look closely at the chain and wonder to yourself how this bonehead expects to be able to move the bike down the road. 

So as the leaders rolled out, I took a deep breath and re-attached the cable. I rolled out five seconds behind schedule and, relieved to find myself moving on a functioning bike, I forgot to his “start” on my Garmin until I was a half-mile or so down the road. It started without trouble, though, and the route popped right up.

South we rolled out of town, on a mixture of old-timey brick streets (“Kansas cobbles,” as they say) and pavement. The previous night’s thunderstorm had wetted the street. I was unsure how far outside town the storm had reached. As soon as the group hit the first right turn onto dirt roads south of town, order descended into chaos. Riders were charging through mud and standing water, and within two miles of town, they were already paying the price with broken derailleurs and clogged cogsets. Dozens of riders were in the ditches, working furiously on their bikes. Many of their days had ended 12 hours early.

I rode gingerly through the mud, watching my derailleur closely to try to keep from breaking it off (I've sacrificed more than one rear derailleur to the mud in my day). I had to stop pedaling at one point as a rock positioned itself perfectly between the chain and the pulleys and flipped the mechanism up behind the dropout. I was millimeters from suffering my own early abandon. But with a little caution and a lot of luck, I made it to the point outside town where the mud transitioned into gravel, and I was off. 

Lucky socks, only partially caked in mud at this point.

Lucky socks, only partially caked in mud at this point.

The first checkpoint at Madison High School was challenging in that you had to follow a little spur road to get there, and since the riders were still fairly bunched at this point, it was hard to find my support crew. But after a quick phone call, I found her by the road. 

I used a water bottle to try to rinse the mud out of my chain and cassette. Then, after a quick refill of water bottles and pockets, a couple pickles, a Coke, and a Snickers, I was on my way.

That's not cake batter on my face. It's sunscreen, applied by the Chief. 

That's not cake batter on my face. It's sunscreen, applied by the Chief. 

My apologies to the guy on the Open U.P. bike that passed me at about mile 85. As soon as we turned north into the headwind, I wheel-sucked him for several miles, then passed him as soon as the route turned east and out of the headwind. He didn’t seem flattered by my (sincere) compliment of his bike, and I don’t blame him.

Not the guy on the Open U.P. But a nice guy, as I remember. 

Not the guy on the Open U.P. But a nice guy, as I remember. 

We kept a nice tailwind from the north as we rolled toward Eureka. Some of the last few miles into town were even downhill, which felt great. By Eureka, the crowd had thinned, and I found my wife-slash-support crew easily this time. My chain was in dire need of lube by this point, so after the usual refills and a quick application of lube to the drivetrain I was on my way. Very uneventful stop.

Miles 100 through 120-ish were OK. I was riding either with the same tailwind we’d had all morning, or I was riding with a brisk but tolerable left-to-right crosswind. But the heat was starting to rise; blue mirages started to appear on the roads ahead. I actually saw a vulture circling. The heat and dry wind started to take their toll on my hydration somewhere around mile 120. That was about when I peed for the last time all day. Somewhere around mile 140 I took my last drink of Skratch (from a water bottle) or water (from my hydration pack). Then I entered a dark place. A dark, cotton-mouthed place. A wrestling match with a bicycle in a field of heated talcum powder. My tires rolled over a flattened, dry snake carcass. I was temporarily relieved by a four-wheeler driving dude hanging out water bottles at about mile 143. He limited me to one bottle, which was reasonable, and I poured it into my own bottle, thanked him profusely (I may have offered him a kidney. Things get fuzzy here), and took advantage of a descent eastward.

I descended a couple hundred vertical feet and drank half my bottle in one long pull. Then a river crossing came with advice from some volunteers who suggested that I ride through the foot or so of water instead of walking. I did as they said, and the cold water splashing up against my feet and legs felt incredible. It felt so good that I briefly considered stopping and sitting in it, but I didn’t like the idea of a wet-diaper chamois for the next two hours, so I pedaled on. Foolishly, maybe, I ate a melted Snickers bar and drank the rest of my charity water in the next mile or so.

It was about here that the cramps suddenly worsened. I had felt a familiar twinge in my right calf a couple of times, but it hadn’t progressed into a full-on cramp. I can’t explain the timing, since I’d just had some water, but once my dehydration intersected at just the right place with my muscle fatigue, and once I had spent some time going into the wind, a cramp seized my right inner thigh, then the left. I’ve done enough distance cycling to know this feeling. Stopping does not help. Stopping may make the cramping worse. There is something therapeutic about the forced circular motion of your feet. I embraced the therapy and kept turning the pedals.

Somewhere in through here I passed a guy in a green Salsa kit. Having forgotten the exact location of Checkpoint Three, I asked him where to look for it, mileage-wise. He good-naturedly told me mile 161 (we were at about mile 150 at this point), and I thanked him and moved on. My cramps spread into both calves. I became sufficiently desperate for water that when I saw one of the hundreds of inadvertently jettisoned water bottles on the route, I stopped, reversed course for 100 feet, and picked it up. Finding only ~10 ml of sticky, red, backwash-laced liquid inside, I sighed, dropped the bottle, and turned back north into the wind. By the way, a big shout-out to King cages here. The ability of everyday aluminum or composite cages to hold on to bottles in such bumpy conditions is overestimated, because in races such as this you see hundreds of bottles on the road or trail in the first ten miles, let alone the remaining 195. The most dramatic places are at the bottoms of hills, where full bottles have been bounced from cages. So Kudos to King cages.

Anyway: I was tired and thirsty and crampy. I wanted a drink of water. I rode by a restored foursquare house with outbuildings, a well-maintained flower garden, and some cattle pens. I turned into the driveway, laid down the Ritchey, and knocked on the door. No answer. I walked toward the outbuildings and called out. No response. About then, the guy with the Salsa kit followed me into the yard. I told him I didn’t think anyone was home. We agreed that the homeowners surely wouldn’t mind us using an outside hydrant. But we tried two, with no luck. The water was shut off to both. I cursed, rode toward a stock tank to make sure I wasn’t missing a hydrant, and failing to find one, rode on.

The dehydration and cramping, combined with forced physical exertion, had the effect of inducing an attitude of introspection and retrospection. Introspection regarding the choices I have made. Have I spent my days meaningfully? Have I wasted them? Have I taken my days for granted, or as a gift? This is not the thought of a dying or starving person. This wasn't a Jack London short story or the Revenant; my cell phone was in my empty hydration pack, after all, on airplane mode. Even though the cell coverage in rural Kansas is spotty, I could surely have thrown down a pin and had help within an hour or so. Retrospection for past bicycle-related follies, like the time I was stuck above 11,000 feet outside Angel Fire, New Mexico, out of water, with a wrecked bike, and forced to drink from a stock tank out of desperation, my reward of moisture having outweighed my risk of diarrhea from a mountain stream pathogen. I wasn't there yet.

A couple miles up the road I came across another farmhouse, and after following the same procedure as with house, number one, with largely the same results, I found a hydrant that yielded a trickle. I filled a bottle, dropped it, and spilled ~90 percent of the water, filled it again, dropped it again and spilled ~50%, and gave up. Mi amigo en Salsa was waiting for me to finish. I rolled back onto the road, back into the dust, back into the routine of pedaling and breathing, cramping and pedaling. The solitude of the Dirty Kanza is surprising. Nine hundred riders start, and for the first 50 miles you feel like you’re part of a swarm of ants. Then the group gets spread out, and by the time you hit the third checkpoint, there are times you can’t see another rider. It’s just you and the grass and the rocks and the sun and the wind.

A word on the people of Emporia, Madison, Eureka, and the surrounding areas of Greenwood, Chase, and Lyon counties: they have embraced this event. When I started spending a reasonable amount of time on the roads on bikes in the early 1990s, cycling, even mountain biking, carried a bit of a trashy, conceited euro patina that seemed to turn outsiders off. And this was right after LeMond won the Tour de France for the third time. I can’t imagine what the atmosphere in small towns was like before “LeMan” made cycling more familiar to a mainstream audience. Maybe it’s the gravel scene itself or maybe it’s a move toward everyone, rural, urban, athlete, or otherwise, being more accepting of cyclists in general, but I encountered nothing but smiles, waves, and courtesy in my fifteen-plus hours and 200-plus miles of the DK. On two separate occasions, a diesel truck--long the natural enemy of the cyclist--passed me with an outstretched arm ringing a cowbell.

With the encouragement of the locals I rolled on into Eureka, caked in salt, feeling completely fatigued. I used the lawn chair my wife had brought for the first time all day. I aired up the tires on my trusty Ritchey and sat both of us in the shade. I plugged in the external battery to my Garmin just in time to avoid it going completely dead, and I sat. Then I sat some more. I didn't keep time, but looking at the splits on my race, I suspect I was there for at least 30 minutes. I eventually resigned myself to needing to get back on the bike. I checked my hydration pack and my two bottles. I felt through the left pocket of my jersey to confirm it was full of goo and stroopwafels, and I rolled out. Slowly. 

Cockiness gone. Replaced by salt oozing from my skin, iguana-style.

Cockiness gone. Replaced by salt oozing from my skin, iguana-style.

I tried to concentrate on things other than the discomfort: the constant crunch of gravel, interrupted only occasionally by the soft whoosh of knobby tires on rain-softened clay or the splash of a water crossing. The chatter of grass in the first two hours had given way to the soft sway of adolescent corn stalks in the 13th and 14th hours. I concentrated on keeping my breathing low and steady.

It was a while until I was able to get on top of my cramps, but I eventually did. At about mile 170 my Garmin, with the external battery plugged in, gave me the “turn off in 15 seconds” warning. I X-ed it out, but then It did the same thing twice more until, at mile 199-ish, I missed the warning and let it shut off. I panicked al little because, 1) I didn’t want to lose the data (few classes of athletes, I suspect, are as paranoid as cyclists in regards to losing proof of their effort), and 2) I didn’t know the route from memory. I didn’t want to try to navigate home by cue sheet in the dark. The red flashing taillight I’d been following had dropped me or become otherwise invisible. I was too proud to wait for a follower to catch me. Fortunately, when I hit the power button, the Garmin lit back to life just as it had gone to sleep. I unplugged the external battery and tucked the cord away. I double-checked my headlight and taillight and put my head down.

About the time I entered Emporia city limits, a couple guys caught me, then we caught a couple more, all of which led to a nice little rotating group for a mile or two. I was able to tuck in and go fast for a while, all while getting some rest, what with the draft and the intermittent pavement. Sweet Lord, the pavement. There’s not much, but the few miles of pavement mix in give you needed relief. The feel of pavement after 200 miles of gravel, mud, grass, and water is soooo good. Think of pushing a shopping cart across rough parking-lot tarmac, then hitting the smooth linoleum of the grocery store. It was like that. Only better because, see, in the Dirty Kanza 200, you’ve earned that smooth feeling.

But then, with some complacency setting in on my part, we missed a right turn by about 100 feet. I swore at myself, turned the bike around, and made the turn. I was getting impatient at this point, so when we finally made the turn and regrouped, I abandoned the (admittedly thrilling) nocturnal paceline and went to the front. After a minute or so I realized that the paceline was intact, but was no longer rotating. I was driving. In a fit of hypoglycemic, hypoxic grandiosity, I actually thought to myself, “I’m going to drive this train home.” Those who have spent any time with me on the road know the absurdity of this thought. But on I pedaled until I saw a stop sign and approaching car lights from the south.

“Car left!” I called out in the usual cyclist parlance, and I braked for the sign. My compatriots in the paceline, maybe feeling a bit hypoglycemic/hypoxic themselves, didn’t even pause.

“I think we’re good,” I heard one of them say, and they cheerfully blasted through the stop sign as the approaching car slowed. I waved, sensed that the car was going to wait for us, and got back on the pedals.

The final couple miles of pavement up the final climb through Emporia State then downward toward the chute with cowbells in my ears made me feel like Superman.

That guy looks so happy to be off his bike. 

That guy looks so happy to be off his bike. 

I took 20 minutes for photo ops and a beer. When I got back to the hotel, I showered and fell almost immediately into bed. Then I immediately got back up to walk off a cramp in my foot. Then I laid back down and felt the beginnings of a chill. My mind settled into sleep, but I didn’t feel the familiar, reassuring drift toward family or childhood memories. I felt the sudden, intermittent jerks of fever dreams, of heat and thirst and middle-school rejection. The jerks woke me, and I had to get out of bed from time to time to stretch a cramp or to go to the bathroom. The trips to the bathroom were welcome. I hadn’t urinated for 12 hours before, so even though urination burned a little and my bladder never felt empty, and even though I would discover the next morning that my urine was a burnt orange color, it felt reassuring to know my kidneys were back in business. After each urination I would fall back to sleep and feel the suffocating heat on my face. Adjustment of the hotel’s A/C did not help. I briefly feared that I'd picked up a bug, or contracted old-timey "dust pneumonia." (after this kind of effort, your mind may not work exactly right. But by the next morning, though, all was well. 

Why ride a bike for 15 hours? Doesn’t the law of diminishing returns start to apply? Well, no. The 14th hour on a bike is only slightly like the first hour. And to experience the change from giddy excitement to cautious anticipation to pained determination, to experience the camaraderie first with enthusiastic pace-leaders, then hopeful bike-pushers, then finally determined, steel-faced stragglers, you need to have those middle hours from two to 14. You need to feel that first tug of a cramp in your right calf progress to an annoying knot, then you need to wax nostalgic for the cramp once it’s gone.

About 48 hours after the ride, my butt was back to normal. No more numbness. The soreness in my legs reminded me of the four hours of cramps I’d had; cramps bad enough to notice, but not bad enough to limit me, really. My hands, counterintuitively, were weak enough that it was hard to write longhand. My pinkies were numb. My neck, shoulders, and back were surprisingly unaffected, considering my lower back gave me some trouble during the ride. 

Meeting these aches and pains was inevitable once I’d made the decision to do the Dirty Kanza 200. But they were a small price to pay for the rest of the experience: the view of waving, chattering grass, long vistas, natural water crossings and bridges. The comaraderie. The encouragement of the locals, with their ringing cowbells in the dark and the Emporia State students cheering us on as we rolled through campus.

People who don’t ride bikes, like people who’ve never been in love, think that the middle and the end must be the same, too. But if you last long enough, if you push through those initial bumps and slips, you find out that the middle and the end are what you were really looking for. And you know what? After the soreness was gone, I actually missed it. But I know where to find it again: tomorrow, June 3, 2017 in Emporia, Kansas.

June 2, 2017 links to skim

Michael Bliss, author of The Discovery of Insulin, has died. RIP. I read his book while I was an endocrine fellow, overlapping, ironically, with a trip to Toronto for the Endocrine Society conference. His work was accessible, non-academic, and revealing.

“Family-based weight loss therapy sessions worked just as well whether children attended or not, as long as their parents did,” researchers found in a “two-arm trial” that included “150 overweight or obese children ages 8 to 12 and their parents.” Parents, your work with your children matters a lot. 

Whole-body vibration may be as effective as exercise in mice. Color me skeptical. I first heard of vibration for metabolic disease in a presentation by an astronaut in college in the nineties. And, in spite of the plethora of machines available claiming to vibrate you to better health, the science just doesn't seem to have advanced that much. I'll skip my vibration sessions for the time being. 

2. Social media is a set of common platforms to draw out our worst tendencies

(note: this is a continuation of a rant from a couple weeks ago)

I know it's absurd for me to be talking about "social media" as though it's some homogenous monolith. I'm sure aficionados could tell me the subtle differences between platforms the way a sommelier could tell me the difference between a Malbec and a Cabernet. But at the end of the day, those are just two varieties of red wines, and like them, Instagram and Twitter are more similar than they are different. And one of their similarities is they tend to bring out the worst in us.

Before my departure from social media, I saw people on Facebook joining or "liking" pages devoted to searing hatred of immigrants. These same people in some cases had testified at deportation hearings for undocumented family friends. What was it about the choice architecture of that "like" button that made the sort-of-evil decision the easy one? 

This isn't that different from the other happiness-draining things our consumerist society throws at us with the promise that we'll be happier if we use them. Tobacco, junk food, and social media all want the same thing from you: they want to take away your control over your life, health, and happiness. But while we've made strides to combat tobacco and junk food, like smoke-free laws and taxes on bug juice, we seem stuck in a self-sustaining vortex that tells us that more connection, more technology, will solve our problems instead of creating new ones. If a drug hit the market and prompted some of the behaviors that we see with social media, would we applaud it?

And the children. The children. We're training our kids to avoid boredom at all costs. How many kids have you seen dialed into a phone at a restaurant? How many staring into a screen at a playground? How many being beseeched to turn down their phones while at a restaurant or basketball game?

These are not behaviors that any of us are proud of. Were you to point them out to the very people exhibiting them, they would be ashamed, right after they got done telling you off and posting on Facebook about what a jerk they just ran into at the restaurant. But pride aside, there is probably real harm being done here. I'm frankly suspicious of any claim that the fake news on social media swayed the last US Presidential election, but it certainly didn't lead to a more erudite, informed electorate, either. But a kid who sits at a restaurant with earbuds in, staring at a screen, is being trained that boredom is unacceptable. What will happen to this person the first time he's confronted with a situation that requires delayed gratification or an attention span? 

So even though I'm a bit of an anti-incrementalist, I'm hoping to see just a series of small ticks in mobile/social media use. Comedian Chris Rock is having fans lock up their phones at his shows. Jack White has been doing it for a while now. I don't think these guys are doing it out of general fuddy-duddyness; they're trying to bring out the best in their audiences and to make sure everyone has a shared experience. Schools, historically afraid of parent backlash to less-than-100-percent-available kids, are even in on the act, establishing "phone free zones" with the same technology Chris Rock is using. 

The weakest link-fest April 27, 2017

Man, Kottke.org has been on fire lately with health-related videos and links. Above is a sweet demo of four ways to put roads on diets to reduce congestion and increase safety. 

And then there's this little micro-documentary on a guy who tries to do a DIY-style fecal (and skin and nasal) microbiota transplant. This definitely falls outside the guidelines for the procedure. 

And finally, the story of a science writer who turned a Seinfeld episode into a "case report" for an open-access journal and got it published. I've linked Kottke's page because he does such a good job of explaining it and has all the relevant links. The chief complaint and history (but minimal physical examination) are here: