Links for Friday, December 1, 2017: vegan NBA, and I think I want an epidural

NBA players are going vegan for performance

When I was young and still athletic enough not to have confronted the fact that I'd never play competetive sports beyond high school, the trend for high-level basketball players was to bulk up. Larry Johnson from UNLV and later the Charlotte Hornets was the prototype:

The dress adds ten pounds. But he was still a big guy. The thought was that huge guys could just push around and get to the basket. It fit the style of play in the NBA at the time: isolate one player with the ball and let him go one-on-one, then fight like crazy for the rebound. 

But now that the style of play has become much more collaborative, with passing and quick cuts valued over banging, players are trying to slim down.

Some are even calling it "skinny ball."

How are they slimming down? For many, it's by giving up meat and dairy.

"[Kyrie's] had great energy all year," Boston coach Brad Stevens says of Irving. "The nutrition side is huge."

The only other player with more clutch points than Irving this season? That would be Damian Lillard, who—you don't say!—went vegan this offseason, too, dropping almost 10 pounds in the process.

"I wanted to eat cleaner," Lillard told The Oregonian this offseason. "Also I want to play lighter this year and be easier on my joints and feet. I'm getting older, you know what I mean?"

Irving and Lillard aren't the only ones. Wilson Chandler, Al Jefferson, Garrett Temple, Enes Kanter, JaVale McGee and Jahlil Okafor have all made the switch to a vegan or vegetarian diet in the past year or so. For the uninitiated, vegans don't eat animals or animal-derived products like eggs or milk. A vegetarian can order the omelette with cheese; a vegan goes for the oatmeal with soy milk.

The rise of plant-based diets in the NBA follows a worldwide uptick in meat-free meals. According to research firm GlobalData's report, 6 percent of U.S. consumers identify as vegan, up from just 1 percent in 2014. In the United Kingdom, veganism rose by 350 percent from 2006 to 2016, largely from the country's younger demographics.

I think, therefore I am getting the G@##$%*&d epidural

This essay goes pretty far astray from the usual metabolic, physical activity, and food-oriented material I like to post, but it's so funny that I couldn't help but share it. 

An anesthesiology professor told me once in medical school that if doctors allowed the kind of pain women feel in childbirth in any other medical procedure, they'd be sued. That statement reduces the delivery of a child to something simpler than what it really is. But, the idea that women achieve some special womanhood status for having put themselves through an unnecessarily painful delivery is absurd, and Rebecca Schuman does a great job exposing that absurdity:

It was all right, though — my books had a plan. That plan involved laboring at home until the baby crowned. If, said my books, I had to bend the truth to my obstetrician, Dr. Holtzbrink, about when my water broke so that I could stay home longer, so be it. It was better than risking a hundred totally unnecessary interventions, all of which would beget other interventions, and culminate in the worst possible nightmare. No, not a birth complication, worse: a Cesarean. An alarming number of the narratives in the midwifery books were cautionary tales from hospitals, full of pushy MDs and C-sections that resulted in not having really given birth.

Collaborative practice agreements from the physician's perspective

Many thanks to Dr. Spurlock for helping us out. 

You wanna do the Dirty Kanza 200? Here’s how.

You may have heard that the new lottery for the Dirty Kanza opens Friday and continues from December 1st - December 16th, 2017. This replaces the old system that was in a sense a lottery of its own, run through the steaming-hot servers at bikereg.com. That's not me picking on bikereg.com. They have a great service. What I mean is that the volume of people applying to race through their site in past years overwhelmed the site, and I think a certain amount of luck went into whose ones and zeros penetrated the server to get a spot in the race.

Anyhoo, I thought today might be a good time to share some of my experience with the DK and what I think makes for a successful day. Warning: what follows is advice for people like me who perform in the vast middle of the range of abilities on a bicycle:

Based on my performance, it is obviously not for people who expect to be on the pointy end of the race. If you're one of those, you can find good advice from folks like Ted King, Rebecca Rusch, Allison Tetrick, and Dan Hughes.

And I'll likely update this post as I remember more. So if you see something embarrassing here the first time you read this, hopefully it's gone by the time you come back. 

1. Prepare your body

You're going to know whether or not you're in the race by early January. Don't wait until then to start preparing. I think it's possible to get in good enough shape in five months to complete the ride; don't get me wrong. But if you want to really enjoy the day of the DK and feel confident about finishing, I think more preparation than that is probably needed. One of the hardest things about the ride is just the act of being on a bike for 12 hours or more. Not many of us do that routinely. So my routine is something like 8-10 hours a week in the months leading up to springtime. Since hills are hard to come by here in Kansas, I make sure 3 hours per week are intervals. I don't do anything fancy. I don't have an interval timer. One day a week I go to my favorite road/crit loop, pictured below, and I ride laps for an hour. At three spots on the map, each one of them 1/8 to 1/4 mile long, I sprint. If you don't have a nice tidy loop like this, just pick out landmarks ahead of you 300-400 meters and sprint to them a few times an hour on your usual rides a couple days a week. After each sprint, or just pick out a landmark a few hundred meters ahead of you and sprint to it. Rest a couple minutes and do it again.

That's the loop around Botanica in Wichita. 

The next best thing to do to prepare yourself is to ride a couple hard gravel races ahead of time if you can. Here in Wichita, I like the Rage Against the Chainring series. The races are short, about 50 miles each, but that's okay. The DK200 itself is really just four 50-mile races stacked up in a day.

And--this is really important--make sure you go for at least a couple of very long rides before the big day. Like at least 3-4 hour rides. This isn't for cardiovascular or leg fitness as much as it is to see if your shoulders, back, and butt can handle long stretches on your bike. If you have trouble on these rides, be sure to get your fit checked out (see #2 below). 

Practice your hydration strategy. Again (dead horse alert), you probably go on rides without thinking much of food or water all the time. This is not one of those times. I'm a legendary sweater (I'm sweating just typing this), so I know my fluid needs are above the norm. I take that into account in my preparation. After intentionally riding long distances on some warm days, I came up with a strategy is to fill two large bidons with Skratch. I like Skratch because it doesn’t upset my stomach like more sugary drinks do. Preferably one of the bottles is insulated to stay cool. I drink it second. On top of this, I wear a one-liter hydration pack that’s just water. I found I could easily drink all three on a typical 50-60 mile ride.

Food-wise, you need mostly carbs, with a touch of protein thrown in. Don't make this complicated. Even as a physician, I get bored with talk of "nutrients." Use trial and error. My experimenting taught me that, even though I'm disgusted by gels, I needed to eat one gel every hour on long days like the DK. As they say, strawberry goo forever. Between every gel that I manage to choke down, I eat a snack-size Payday. After some experimentation with other bars, I found I liked them because they didn't melt in my jersey pocket. So if you're doing the math at home, that's eating every 30 minutes. It's not scientific. It's just what I've found my stomach can handle. 

2. Pimp your ride

This seems obvious, but in the weeks leading up to the race, make sure your bike works. You'll be amazed how many clickety-clackety derailleurs you hear on the course. This advice extends from the grips or bar tape to the tires to the drivetrain. That little click or loose spoke is annoying on a commute or a two-hour ride, but it’s potentially catastrophic on a 15-hour ride over rocky gravel roads. If your bike needs tuned up, do it a week or two ahead of the race so the cables have a chance to stretch before the big day.

Do you need anything new on your bike? Well, I'd at least consider new tires if yours are more than a year old. You'll wanna replace those old, squeaky brake pads with new ones, since the descents in the DK can be fast and hairy.

Really consider a GPS. I know they're expensive, and my goal here isn't to convince everyone to spend a bunch of money on their bike. But pre-loading the route makes it soooo much easier and nicer to stay on course, especially during the times you find yourself all alone. And occasionally someone gets asked for their GPS data to prove she finished the course and can't provide it. Don't be that person. 

3. Race day

Don't overdress. Kansas can still be a little chilly early in the morning in early June, but don't let it fool you. It'll be hot later in the day. That 80 or 90 degrees later on is what you should dress for, not the 50 or 60 that morning.

Have a plan for support during the race. If past is prologue, you'll have a color-coded spot to seek out in the parking areas of the checkpoints:

But the crowds are huge, so have a plan for your support to flag you down, or have a plan for where to find them within your designated area. I like the idea of having a flag flying to look for.

That's Colby Reynolds, past DK Half-Pint finisher and my badass 2017 Crew Chief. (other crew included wife and kids)

Have some other food handy with your crew. The DK is many things. For that one day, it's a license to eat. I hit the bananas and pickles at the rest stops, along with a bottle of Coke (I drink bug juice exactly one day a year, and it invariably keeps me from sleeping that night). Cut the ends off your Payday bar wrappers. They can be hard to get out of the package.

Take care of your butt. I know, I know: you ride a lot. But you don't ride 200 wet, dusty, sweaty miles in a day very often. I've used Chamois Butt'r and Deez Nutz, and I honestly can't tell them apart. They both work. I use a lot more Chamois Butt'r because they sponsor the DK along with some other local races here, and I want to reward them for their support. Use the stuff liberally. Apply a little at each checkpoint if you're unsure. This last year I forgot to re-apply at the third checkpoint, and by the time I hit Emporia, my perineum was a white-hot glowing ember.

As far as that goes, make sure you wear your best shorts for the DK. 

Ride with a goal in mind. If you have a heart rate monitor, set a goal HR and try to stick to it. Ditto power if you have a power meter. Speed is an unreliable indicator of effort in gravel races. Even former pros run lower speeds than you'd expect.

17.9 mph ain't no joke, but it's not what World Tour guys are used to riding, either. 

It can be very seductive to fall in with a group going ten percent faster than you're comfortable early on in the race. But you're gonna be out there for 12 hours or more. Going faster than is comfortable early on is a recipe for suffering later.

Don't try to win the race on the descents. Every year I've done the DK I've seen people have horrendous, ass-over-teakettle crashes on rocky jeep road descents. Jim warns everyone about it every year, and it still happens. And even if you don't crash, the risk of getting a flat tire going 45 mph down a rocky path is high. Be careful. 

This was the result of stupidity on firm, level ground, not a descent. But there were no witnesses I

5. The finish line

Sign your name on the DK Poster. This is mandatory:

Enjoy sitting on something--anything--that isn't a bike seat. 

Feel prepared to enter the lottery? Here's a checklist of what you may need for the DK:

1. Four to eight large water bottles (preferably half uninsulated, half insulated)

2. Hydration pack: If you're a light sweater, you may be able to get by without this, but it's risky in my opinion.

3. A dozen snack-size Payday candy bars. I eat one of these an hour (alternating with gels).

4. A dozen gels (pick your favorite flavored goo and eat one an hour). Alternate, minimally tested choice: Ted's Untapped Maple syrup.

5. Skratch. I use it in my water bottles and keep my hydration pack filled with water.

6. Three gallons of water (for refilling said hydration pack and bidons)

7. six-pack of Coca-Cola. Long races are the only time I allow myself bug juice. Old-fashioned Coke, with its caffeine buzz and high sugar content, is hard to beat at checkpoints.

8. Pickles and bananas. The data on pickles for cramp prevention is light and inconsistent, but the salt tastes great on a hot day. The bananas are bland and smooth enough to still taste good at the end of the day.

9. Sunscreen. Don't even try to go without it.

10. Butt lube. I like Chamois Butt'r. Have enough on hand to re-apply at every checkpoint.

11. Three extra inner tubes. This goes whether you're running tubeless or with tubes (I've done it both ways, and I can't say one is dramatically better than the other).

12. Patch kit.

13. Chain breaker. I hear stories of broken derailleurs every year, and if you can't shorten your chain your day is done. Get one that has an attached multi-tool or carry a multi-tool separately.

14. Extra chain link. Make sure you get one that matches the size of your chain, i.e., 10-, 11-, or 12-speeds.

15. Multi-tool. See above. 

16. Extra brake cable if you have cable-pull brakes. This isn't to carry with you, but it's nice to have at a pit stop if things go wrong. 

17. Extra shift cable. See above. 

18. Chain lube. When you lube your butt, lube your chain. I like wax-based lubes because they're less finicky about wet or dry conditions. 

19. Glasses cleaner and rags.

20. Extra water to clean your bike at checkpoints in case of heavy mud. 

21. Mini-pump (or a frame pump if you're old school).

22. Three CO2 cartridges (one for every spare tube).

23. Tire levers.

24. Headlight, fully charged (so bring your charger).

25. Taillight, fully charged (so bring your charger). 

26. Gloves.

27. Lawn chair.

28. Three moist towels folded inside plastic zip-loc bags. They'll be nice and warm when you take them out to wipe off your face between stages. 

29. GPS. I know this sounds like a techie ad for unnecessary doo-dads. And yes, the race organizers do a good job with cue sheets. But having the course loaded onto your GPS is so much nicer. And later, you'll have the GPS data to use to brag to friends. And you'll be able to turn off your phone. Phone reception is non-existent for much of the course, anyway. 

And do bring your helmet, jersey, shorts, socks and shoes. That goes without saying. 

I won't be in the DK200 this year. I'm planning on doing the 25 mile ride with the fam. Look for me on the tandem. See you there!

Strava's global exercise heatmap is addictive

Take a good long look at Strava's global exercise heatmap

Just here in Wichita, there are so many hidden little gems. I'm not much of a runner anymore, but love the 400 meter tracks:

That's the Friends University track near the center. To the left is the Mayberry Middle School track. 

At Wichita State University's Cessna Stadium, you can make out lines going up and down the bleachers, especially on the west (left) side. 

And the trails along the river are well-represented, no doubt thanks in part to BikeShareICT:

As are the mountain bike trails at Miller's Meadow (RIP):

And Air Capital Memorial Park: 

For giggles, I found my childhood home in western Kansas. I'm not the only person who's recorded activity there, but I'm one of few. This isn't a surprise considering how few people live there:

Thanksgiving extravaganza! Links for Wednesday, November 22, 2017

17th century food was fibrous, bland, and surprisingly good for you (if you could get enough of it)

This is not to say that their food tasted bad, necessarily. But it was clearly very simple, and very starch-heavy. From China to Europe to sub-Saharan Africa, gruels and stews made out of staple grains or legumes were the daily fare. Italian farmers weren't eating eggplant parmesan or spaghetti with meatballs. They were typically eating either boiled beans or grains, day after day after day.

First mind-blowing passage from this post:

One example: I didn't realize until recently that broccoli, Brussels sprouts, cauliflower, kale, cabbage, and collard greens are all technically the same species, Brassica oleracea. The substantial differences between these sub-species are all due to patient intervention by human farmers over millennia. Many of these changes are surprisingly recent. Early versions of cauliflower may have been mentioned by Pliny and medieval Muslim botanists, but as late as 1600, a French author was writing that cauli-fiori "as the Italians call it" was "still rather rare in France." Likewise, Brussels sprouts don't appear to have become widely cultivated until the Renaissance.

Selective breeding and pollination (the original GMOs) have radically altered what our food looks like. See this picture of fruit from the link. Look closely at the watermelons in the right lower corner. They look nothing like the pink, juicy, almost seedless beasts we see in the grocery store circa 2017:

"as time went by, a dish tended to become sweeter, spicer, and more complicated."

We paid for that sweeter, spicier food, and not just in our waistbands. The Columbian Exchange brought diseases to immunologically naive people and turned people in to chattel. The English didn't have bad teeth til sugar came along. 

Eat up.

You'll only gain 0.8 pounds this holiday season. But if you do that every year you get fat

We overestimate our own weight gain a lot over the holidays:

When Jack Yanovski and his colleagues began their study of 200 National Institutes of Health employees, they were responding to a media environment that frequently cited holiday weight gain averages of 5 to 10 pounds. But they found their subjects gained an average of only 0.8 pounds between mid-November and early January, and that those same subjects overestimated their own weight gain by a factor of 4.

But then we don't lose the modest weight that we do gain, and after a couple decades we're in trouble:

 A 2014 review of six different studies found an average holiday weight gain of 1 pound. A 2017 summary of the research found similar results. Just 1 pound — but a significant pound because research also suggests that it could account for most (if not all) of our average annual weight gain. “Yup, it’s small,” said Dale Schoeller, professor emeritus of nutritional sciences at University of Wisconsin-Madison and author of the 2014 review paper. “But because it’s a large percentage, it’s not unimportant.” Schoeller calculates total annual weight gain by comparing the average weight of a 20-year-old in 1960 to the average weight of a 60-year-old in 2000. By his calculation, Americans gain about 0.8 pounds a year. Over the course of 20 years’ worth of Thanksgivings, he pointed out, it can start to add up.

Links for Tuesday, November 21, 2017: more on the new HTN guideline, Gymnastics coaches throwing robot shade, the last iron lungs, Germany bans smartwatches, and Raymond Chandler hated US healthcare

Thoughtful post on the new HTN guideline by Dr. Allen Brett

Representative quote: "Consider, for example, a healthy white 65-year-old male nonsmoker with a BP of 130/80 mm Hg, total cholesterol level of 160 mg/dL, HDL cholesterol of 60 mg/dL, LDL cholesterol of 80 mg/dL, and fasting blood glucose of 80 mg/dL — all favorable numbers. The calculator estimates his 10-year CV risk to be 10.1%, making him eligible for BP-lowering medication under the new guideline. To my knowledge, no compelling evidence exists to support drug therapy for this person."

A gymnastics coach says the Boston Dynamics robot flip was a 3.5/5.0

'In a back salto, says Mazloum, “you want to be able to go as high as you can, and you want to be able to land as close to where you take off as possible.” To do that, the gymnast has to squat, throw her arms up by her ears so her body is a straight line (in gymnast-speak, opening the shoulder angle and the hip), then contract into a “closed” position again. By these standards, Atlas’ trick is “not the cleanest flip,” explains Mazloum.

Here’s Mazloum’s critique: Atlas didn’t quite get to that open position, “so it didn’t really get the full vertical that we look for. That’s why it went backwards a little bit.”'

The last of the iron lungs

Get your kids vaccinated for polio, folks.

Germany has banned smartwatches for kids

If I understand this correctly, it is not because smartwatches cause kids to be distracted monsters (although I don't doubt that that statement is at least a little bit true). The decision stems from the capability of bad guys to hack in and monitor the location of little Dick and Jane:

You have to wonder who thought attaching a low-cost, internet-enabled microphone and a GPS tracker to a kid would be a good idea in the first place. Almost none of the companies offering these “toys” implement reasonable security standards, nor do they typically promise that the data they collect—from your children—won’t be used be used for marketing purposes. If there ever was a time to actually sit down and read the terms and conditions, this was it.

Get your shit together, parents.

Asking parents to destroy them might be a bit of an overreaction, though.

Raymond Chandler paints a dark picture of American healthcare in a newly-discovered story

The title, "It’s All Right – He Only Died," sounds like the title of a video residencies would show interns to convince them that quality improvement and patient safety are part of their job.

The doctor who turned away the patient, Chandler writes, had “disgrace[d] himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long-acquired skill might help or save”.

Madonna was framed in Body of Evidence. It's super hard to kill somebody with sex.

In the 1993 "erotic thriller" (everyone's favorite kind of thriller) Body of Evidence, Rebecca Carlson, played by Madonna, is taken to court for murder. Specifically, she's accused of having had rough or aggressive sex with a series of older rich men in order to cause their deaths. One survivor even says that she ended their relationship after he had heart surgery that made him healthier. Minor spoiler alert: she testifies on her own behalf and is eventually acquitted.

But her attorney, who she's been having rough sex with (natch), sneaks to her house after the trial and finds her with the doctor of one of her victims. The doc has coached her in how to kill men with sex. She taunts the doctor, who she's also been having sex with (natch), about how she can get him to do anything because of her world-class bedroom skills. When she tells him to get lost, he flies into a rage, eventually shoots her, and she falls out a window. I think there was some wrassling between the doctor and the lawyer in there somewhere. Aaaaaaaaand scene. At least that's how I remember it. I also remember some candle wax early in the movie, but I don't think it applies to the point I'm about to make. 

In a brand-new research letter in JACC (paywalled and not indexed by pubmed as of this writing), investigators studied 4557 cases of sudden cardiac arrest in or around Portland, Oregon, area between 2002 and 2015. Did I mention that Body of Evidence was set in Portland? Because it was. The mean age of the men was 65 years, which is prime Carlson Country, too.

They found that far less than <1% of cardiac arrest cases were linked to sex (34/4557, for an incidence of 0.28 per 100,000 adults per year). In 18 cases, the arrest occurred during sex. In 15, it was right after, and in one, the timing could not be determined. Only 1/3 of the people who had sex-associated cardiac arrests had any kind of bystander CPR. That's a hallmark of Rebecca Carlson if I've ever seen one. Also in the Rebecca Carlson tradition: almost 95% (32/24) of the sex-related cardiac arrests happened in men. The likelihood of a history of heart failure or heart disease was the same in sex-related and non-sex-related arrests. But men who had sex-associated arrests were on average five years younger than the non-sex-associated arrests. They were slightly more likely to be African-American, too. They note that an autopsy study in Germany came up with slightly higher risk, at around 0.2% of cases linked to sex.

So women: have all the high-intensity sex you want. You're safe. Men: If you're willing to roll the dice on your own personal Rebecca Carlson, the die is probably 100-sided, and you only die if it lands on the 100. Proceed accordingly. 

Should young, healthy people with type 1 diabetes take statins?

I encountered this question a couple months ago in a consult and intended to blog about it then, but relatively little trial data was available. I would have essentially been giving my own off-the-cuff opinion. That's very unsatisfying to me, and probably to the reader.

As background: we tend to think of type 1 diabetes as more a need for hormone replacement (insulin) than as a disease state requiring the complex management that type 2 diabetes requires. That is to say that type 1 diabetes, for all the unpleasantness it causes for people, is easier on the blood vessels as a general rule than type 2 diabetes. The ADA has a statement in its guideline that "For patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy." It's a category C recommendation, meaning it's mostly opinion and has a less-than-spectacular evidence base. It also doesn't differentiate between type 1 and type 2 diabetes. Similarly, a joint statement by the ADA and the AHA states that "Adults with T1DM who have abnormal lipids and additional risk factors for CVD (eg, hypertension, obesity, or smoking) who have not developed CVD should be treated with statins." Both statements argue against the routine use of statins in young healthy type 1 diabetics.

But a recent study from the New England Journal helps us with the question of statins in kids, and throws in ACE inhibitors for good measure. Investigators led by M. Loredana Marcovecchio and Scott T. Chiesa randomized 443 kids between 10 and 16 years with type 1 diabetes and urine albumin-to-creatinine ratios in the upper third of "normal" to some combination of ACE inhibitor, statin, and placebo. Creatinine is a consistently excreted product of muscle metabolism that serves as a nice comparator for other things the kidney excretes. So even if you drink a lot of water and dilute the amount of albumin in your urine, we can look at it compared to the similarly diluted creatinine and see if you're excreting too much.

Anyway: the investigators used a 2 x 2 trial design, meaning that there were ultimately four groups: placebo-placebo, placebo-ACEi, placebo-statin, and ACEi-statin. The statin was atorvastatin 10 mg daily, and the ACEi was quinapril 10 mg daily (after titration). They were most interested in the change in albumin excretion (that is, how much protein spilled through the kidneys into the urine). They assessed this according to that same measure, the albumin-to-creatinine ratio in the urine, from three early-morning urine samples obtained every 6 months over about two and a half years. They also looked at secondary outcomes like the new development of microalbuminuria (that is, the new appearance of protein in the urine), worsening of eye disease, changes in kidney function, blood lipid levels, and measures of cardiovascular risk. For the cardiovascular risk, they did ultrasounds of the carotids to measure the thickness of the vessels (carotid intima–media thickness) and measured levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine in the blood. Both of these are generic markers of vascular risk.

After an average of 2.6 years, no benefits were found within the ACEi group, the statin group, or the ACEi+statin group compared to placebo. Unsurprisingly, the ACEi group had a much lower incidence of new microalbuminuria, but "in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94)." Also unsurprisingly, the use of statins resulted in lower cholesterol levels (including, unfortunately, HDL). But neither drug had significant effects on carotid intima–media thickness, C-reactive protein, kidney function, or progression of eye disease.

So we can take away from this small-ish study that, at least in a short amount of time in pretty healthy twelve-year-olds (the subjects were excluded if they had genetically bad lipid levels; the participants' average A1c was ~8.3% and their average blood pressure was 116/65 mmHg), there was no benefit to statins or ace inhibitors. This study will influence my recommendations to patients and other docs in the future. The kicker, naturally, is that many young people with type 1 diabetes have imperfect blood sugar control. What about those who can't get their diabetes controlled? It's a tougher call in that case, and this study didn't address it. 

Links for Tuesday, November 7, 2017: hacking the genome, ammonia in the NFL, and community health workers for hypertension

Body hacker Josiah Zayner wants us all to use CRISPR to modify our bodies

And give ourselves cancer. I think he forgot the cancer part. From author Rowan Jacobsen:

"Let’s be clear: don’t try this at home! Although hundreds of gene-therapy trials are under way, and many experts believe they will eventually transform almost every aspect of human health, few have been proven safe. When you start scrambling your DNA, very bad things can happen. You can get cancer. Your immune system can attack the unfamiliar DNA, as happened when an 18-year-old with a rare metabolic disorder died during a University of Pennsylvania gene-therapy trial in 1999."

You may recall a link I posted to this guy giving himself a DIY fecal transplant. I'll give him an A+ for marketing. You can't beat the name Gut Hack:

NFL players have decided (not recently, it seems) that inhaling ammonia is performance-enhancing

Instead of something sinister, though, what the widespread use of smelling salts really reveals is the increasingly bizarre culture created by the NFL's (win-at-all-costs pressure cooker. Extreme parity, the minuscule margin of error, the constant threat of injury and million-dollar stakes all push players to exploit any shortcut, no matter how weird, gross or pitiful. More than a century ago in major league baseball, players like Hall of Fame pitcher Pud Galvin thought consuming ground-up monkey testicles was the answer (seriously). A decade ago, football found deer antler spray. Now it's smelling salts.

Not coke, but smelling salts in a cup. I think I would actually prefer ground-up monkey testicles.

More evidence that community health workers improve the care of certain patient populations

(paywall, but the abstract is free)

The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001).

Links for Thursday, November 2, 2017: Why Amsterdam works for bikes, dirty mustaches, dockless bike sharing, weird fertility quotes, and menstrual synchrony

Norman Garrick, author of one of my favorite papers on the built environment's effect on health, on why Amsterdam is so good for bikes:

1. All streets are bike streets

2. Separated cycle tracks, not bike lanes

3. When possible, go completely car free

4. Two speeds, both slow

5. Stress-free intersections

That favorite paper? Right here: Community design, street networks, and public health

“A French scientist caused a sensation in 1907 when he recounted an experiment showing that the lips of a woman kissed by a mustached man were polluted with tuberculosis and diphtheria bacteria as well as food particles and a hair from a spider’s leg.”

Is dockless bike sharing the next Uber?

FWIW, I hate the "Uber for ...." thing. But I'm told that it's interesting shorthand for investors. The part of this article I'm fascinated by is the "dockless" part. To my reading, dockless bike stations eliminate so many of the traditional obstacles of traditional bike shares. Less permitting, less infrastructure, less up front expense. I even wonder if they're the way that small- to medium-sized towns get into the bike share game. But you can't just ignore the city governments:

'Technically the dockless companies can enter a market without asking permission. They only need to leave some bikes around the city, and anyone with the app can start riding. But since bikes are portable and can be left anywhere, they’re vulnerable. An unhappy city regulator could round them up and haul them away at any time. “[This is] ask permission, not forgiveness,” Jordan says, reversing a popular Silicon Valley mantra. “It’s not like Lyft, where the cars are moving around, or Airbnb, where you don’t publish the address.”'

The fertility business is booming, especially on the sperm donor side

Up front: I'm totally, 100% on board with whatever fertility treatments people need to receive in order to reproduce. But there are soooo many weird quotes in this:

"Want your sperm donor to have a B.A. in political science? Want your egg donor to love animals? Want the genes of a Division I athlete? All of these are possible. Prospective parents overwhelmed by all the choices can leave it to the heavens and pick a donor by astrological sign."

and:

'The Seattle Sperm Bank categorizes its donors into three popular categories: “top athletes,” “physicians, dentists and medical residents,” and “musicians.”'

But some of the quotes from donors are heartbreakingly sweet:

'The donor said she was a “homebody” who loves taking pictures and being with family on the beach. Her personal goals, she wrote, include being “the best possible mom I can be for my children. I want to be ‘present’ when I am with them and invest into their lives. . . . I want my life to matter.”'

Here is the original Nature paper describing the synchronization of women's menstrual cycles

 

The Gingerbread Man: an iStory

“You should go as the Gingerbread Man,” she said. “I'll be the fox!”

“It's kind of played out, isn't it? Women as foxes?” I replied.

She glanced at my leg. “Well, I could go as the old lady or the farmer. But you have to be the Gingerbread Man.”

“You could be Little Red Riding Hood and I could be the Big Bad Wolf,” I offered.

“Meh. It just wouldn't be the same. Don't you think this would be fun? You never want to have any fun with this. Shouldn't we take advantage?” She looked down at me again.

I didn't bother to offer Hansel and Gretel.

On Halloween I wore a brown shirt and pinned up the right leg of my brown pants. I left my prosthetic leg at home. I left my crutches home, too, so I leaned on her all night. When we got home, I was just under a quarter gone.

Links for Thursday, October 26, 2017: walkability and city growth, eating alone is bad for you, BMX is back, and diet avocados

Is wichita's poor walkability holding it back economically?

From the Chung Report: 

Our respondents believed Wichita is fairly inaccessible on foot, with 77.4 percent saying they either disagreed or strongly disagreed to the idea that Wichita is walkable. This means this aspect of Wichita likely won't attract millennials over other cities that are more progressive when it comes to transportation. And our peers do seem to be more progressive.

WalkScore.com, a website that determines walkability and bikeability for U.S. cities, calls Wichita a "car-dependent city," which means most errands require a car. Cities with scores of 70 to 89 are considered very walkable while scores of 90 to 100 are a "walker's paradise." Wichita scored a 35 on walkability and a 44 on bike infrastructure, meaning the city has minimal bike infrastructure. This same site gave Des Moines and Omaha walk scores of 45 and Cleveland a walk score of 60.

These trends aren't going unnoticed. Advocacy groups like Bike Walk Wichita (disclosure: I'm on the board) have made tremendous progress in getting more attention paid to walkability and bikeability over the last decade (including a bike share and dozens of miles of new bike lanes and paths). But clearly there is work to be done. 

Eating alone may increase your risk of metabolic syndrome

Metabolic syndrome, FYI, is a catch-all term for people at risk of developing diabetes and heart disease. It's a constellation of extra weight around your waist, higher-than-normal blood sugars, abnormal triglyceride levels in the blood, and higher-than-normal blood pressures. A few observations about this study: we've known for a while that being alone in general is bad for you. Like, 30% increased risk of dying on any given day bad. So it's not a surprise that eating alone is associated with risk. But is it any different than being alone in general? I don't think the authors make that case. 

Individuals who ate alone 2 or more times per day in their dataset were more likely to live alone, were more likely to be unmarried, and were more likely to skip meals. Interestingly, alone eaters ate out less, which is generally considered a good behavior. Women who ate alone ≥2 times per day were 29% more likely to have metabolic syndrome than women who didn't eat alone. But once they accounted for other factors, like XXXXX, the assocation went away, statistically-speaking. Eating alone two or more times a day was associated with a 45% increased risk for abdominal obesity and a 64% increase for metabolic syndrome in men. This was especially true in men without spouse. The men without a spouse were 300% more likely to have metabolic syndrome, while married men were only 48% more likely to have metabolic syndrome.

BMX is "back"

(it never left) Link posted here because I like the video. 

Someone created "diet" avocados and I just want to die

My disgust with this isn't related to the specter of GMOs or hybrid crops. I'm actually generally in favor of both (see the Hawaiian papaya story to understand why). I just find the idea of taking a food that is perfectly good for you in its native state and monkeying with it to make it "diet" depressing. Avocados aren't a wonder food, and their trendiness will eventually fade. But they're fine the way they are. Their high fat content has never hurt anyone, and it might even make you feel full longer. So for heaven's sake. Eat a normal avocado. Don't fall for this. 

Links for Wednesday, October 25, 2017: Leonardo and the aortic valve, e-bike smackdown in NYC, candy corn is disgusting but interesting, and McDonalds takes phones away

Leonardo da Vinci understood the anatomy and physiology of the heart better than the physicians of his day

He made wax molds of the aortic valve.

Based on zero deaths reported from e-bicycles, NYC mayor Bill DeBlasio is outlawing them. Super. 

He says not to worry, deliveries by car (responsible for 70 deaths in NYC so far in 2017) will still be available. I'm as skeptical of e-bikes as any long-time cyclist (mopeds and golf carts on the local bike paths cause me to mumble horrible things under my breath), but this is bananas. They should stay on the streets. They're smaller, slower, and infinitely safer to their surroundings than cars.

Candy corn, aka clown droppings, explained

Candy corn is disgusting. But this article is delicious. 

McDonald's is experimenting with locking up phoneworms' devices

My grouchy side says "Your pocket is just as good a place as the Fun Zone locker." My realistic side says that most of us lack the self-control to ignore a device that's in our pocket:

According to a survey of 302 parents conducted by McDonald's in Singapore, most (98%) say they use their mobile device whenever they're with family and more than two-thirds of them admitted using smartphones during meals. Most parents also said their kids use their phone during family time.

How do we engage physicians in quality improvement? Not with money or guilt

I was asked to give input to the Kansas 1422 in-person meeting last week. I couldn't make it in person because of another speaking engagement, but I recorded some thoughts. Enjoy!

Your ticket buys a whole seat, but you'll only need the edge

I'm in Reno County talking about the future of healthcare in Kansas on Tuesday, October 23 at the Sand Hills Event Center. Beeee theeeeeerrre!

Good neighboring is good medicine. I'm certain of it.

I spoke today at the Intersections of Faith and Healing Conference in Salina, Kansas. Here are my slides. 

Links for Monday, October 16, 2017: SNAP to keep seniors home, every-other-day iron, high school football's decline

SNAP is a good way to keep senior citizens out of the hospital. 

SNAP stands for Supplemental Nutrition Assistance Program. It is used by about half of the Medicaid beneficiaries who qualify for it. 

In certain iron-deficient women, it might be better to take iron every other day. 

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.

Kansas is among states where high school football participation is down more than 10 percent. 

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.

Congrats to Allen County, Kansas on its 2017 RWJF Culture of Health Prize. 

Jony Ive, designer of the iPhone, says we use our iPhones too much.

Justin Moore, owner of an iPhone, agrees. Don't be a phoneworm. 

Links for Friday, October 13, 2017: Ford's soy-plastic car and US-themed UK chicken shacks

Henry Ford and George Washington Carver (!) once collaborated to build a plastic car made from soy.

Those are soy fibers. Images from the Henry Ford Museum.

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.

Links for Tuesday, October 10, 2017: anabolic steroids are terrible for you, spoon for health, and tabletop devices in restaurants

Anabolic steroids are terrible for your heart.

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. 

Spooning, on the other hand, is the good stuff.

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?”

Tabletop devices in casual dining restaurants aren't going anywhere soon.

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.

What do we do with a free testosterone?

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.