My remarks from the Wichita Business Coalition on Health Care's Obesity Forum this morning

Thanks for inviting me to kick off this very important event. Let’s start with a healthy dose of intellectual honesty. Obesity is a disease. It has arguably been so since the beginning of time, but it was made official in this country in 1985 when the National Institutes of Health issued a statement following its Consensus Development Conference on Obesity. This was followed by the report of the World Health Organization’s Consultation on Obesity and then the report of a committee of the Institute of Medicine, now known as the Health and Medicine Division of the National Academy of Sciences. Finally, the American Medical Association in 2013. Obesity is a disease because it is a “definite, morbid process with characteristic symptoms which affects the entire body; and has a known pathology and prognosis.” Obesity shouldn’t need this label in order to be taken seriously. Whether we--our institutions and organizations--pay for obesity treatment should ultimately depend more on what outcomes we value and the cost of achieving those outcomes. That is, the material inputs and outputs of the process, not our opinions of the people or behaviors that lead to them. A materialist versus spiritualist argument. I recently spoke at the Chronic Disease Alliance of Kansas meeting. Some of you were there. I made the argument that even if you are a spiritualist by nature, if you’re interested in medicine or public health, you must invest in a materialist point of view. That means you have to provide evidence for your assertions. How does this little philosophical cul-de-sac apply to obesity? Because I would argue that in spite of ample evidence and the label of disease applied by the NIH, the National Academy of Sciences, the AMA, and others, we don’t treat obesity in this country as a disease.

Think of what happens if you have, say, osteoarthritis of the knee. If you go to the doctor complaining of knee pain that fits the pattern of knee osteoarthritis, within some small confidence interval, you’ll get the same treatment regardless of what doctor you visit: x-rays to confirm the diagnosis, then some initial combination of anti-inflammatory drugs plus or minus strength training or physical therapy; then possibly an injection of hyaluronate or another agent; then a surgical procedure. All backed by some degree of clinical evidence as to their efficacy, with a set of professional guidelines that dictate the order and intensity in which they’re used.

And treatment for the disease--osteoarthritis still--is not limited to the clinical environment. We live under a robust set of laws, regulations, and expectations surrounding the humane treatment of people with osteoarthritis: handicapped parking stalls, construction standards around accessibility (curb cuts and whatnot). Furthermore, an enormous industry exists which caters to osteoarthritic people’s needs: handrails, higher toilets, special bathtubs, purpose-designed kitchen utensils, and others. For all its imperfections, this set of guidelines and expectations has the hallmarks of science: organization of knowledge, adaptability, the ability and willingness to change as evidence evolves.

But what happens if a patient goes to see his or her doctor for obesity? Even if the patient is lucky enough to encounter a doctor that considers obesity a disease and not a personal character failing, no such predictability exists. Doctor one may prescribes meal replacements, a la Nutrisystem, Weight Watchers, or dozens of competitors. Doctor two recommends avoiding “carbs.” (once called Atkins, now called paleo or ketogenic diet; it never goes away, we just change the name every ten years or so to convince people to avoid whole grains, the single most protective dietary component against diabetes) Doctor three prescribes phentermine, or if the patient is lucky, one of the drugs actually approved by the FDA for weight loss, all of which are exorbitantly expensive and modestly effective. Doctor four recommends the Diabetes Prevention Program. Doctor five recommends bariatric surgery. Doctor six recommends probiotics or another microbiome-directed treatment.

When the patient leaves the doctors office, she enters a built environment designed to be maximally obesogenic. Four-lane arterial roads replacing walkable, bikeable streets, even though we know beyond certainty that trips taken by car, rather than by bike, foot, or public transportation, are perfectly, directly related to the obesity rate in any community. And the amount of money any community spends on car-related transportation is perfectly aligned with obesity rates. Our patient pays sales taxes on obesogenic foods (red meat, refined carbohydrates, sugared beverages, and fats) at exactly the same rate as protective, high-fiber, unprocessed fruits, vegetables, and whole grains, in spite of evidence that Pigovian taxation, in which unhealthy foods are taxed at a rate equal to their the social cost and healthy foods are subsidized, has a powerful effect. Similarly, crop insurance and subsidy programs--in whatever form they take--favor meat and dairy production over fruits and vegetables.

When a peer gets cancer, we offer words of encouragement and give her rides to the doctor. We judge those with obesity and say they’re getting what they deserve for their weakness and sloth. We consider people who are competent, functioning members of society to be somehow constitutionally flawed and subject them to various levels of social discrimination. Obesity, along with intelligence, seems to be one of the final acceptable targets of discrimination; we casually make jokes about fat people and stupid people with none of the anxiety that accompanies insensitive remarks about race or sexual orientation. This is surely short-lived; over 80 million people in the U.S. have an I.Q. less than 90, and over 100 million are obese by body mass index criteria. These are groups large enough to fight back.

Viewed by an outsider, this set of circumstances does not resemble science. This is not the end result of a materialist view of the world. It resembles religion: a cultural system of competing behaviors, world views, and ethics that relate humanity’s problems not to the laws of the universe, but to supernatural elements. This elevation of the spiritual realm above the material realm is perfectly fine on Sunday mornings. I’m not here to make an anti-religion argument. Religion and spiritualism are vital in mobilizing public passion and opinion. NIH director Francis Collins, who discovered the gene mutation responsible for cystic fibrosis and later directed the Human Genome Project, is an evangelical Christian who advocates that religious belief can not only be reconciled with acceptance of scientific evidence, but that spirituality is vital to the responsible advancement of science. But spiritual thought in the absence of material evidence is unacceptable in the pursuit of a public health solution.

So how should we handle obesity as a health problem? As Kansans, we’re lucky to have perhaps the best model in our collective memories. We have Samuel Crumbine, early 20th century Dodge City physician who revolutionized the treatment of tuberculosis and other infectious diseases. At the outset of Dr. Crumbine’s career, infections were the leading cause of death by far and were dealt with in a quasi-spiritual manner. The consumption of tuberculosis was seen as God’s wrath. But Dr. Crumbine applied common sense strategies to limit the spread of the disease. He helped established sanitaria for tuberculosis patients, to isolate them from the public until they were no longer contagious. He spearheaded laws against spitting on the sidewalk (remember the bricks?), against shared drinking cups (you have him, indirectly, to thank for the modern bubbler-style drinking fountain), and against shared towels in public bathrooms. He advocated for fly-swatting campaigns. And all the while, he still promoted medical interventions for people already infected. Better antibiotics were developed. The entire specialty of cardiothoracic surgery grew not out of a need for coronary artery bypass grafting, but out of the need to drain tuberculous abscesses from the chests of infected patients.

When applied to obesity, I’m aware that lines blur. Calling something a disease moves individuals across a gauzy barrier between personhood and patienthood. You’re a person up until you’re labeled with a disease, then you’re a patient. The label inherently causes the patient to adopt a role in which he or she is excused from responsibility for his/her condition. This is healthy and appropriate; we know that the vast majority of lung cancers are caused by cigarette smoking, but we do not argue that smokers should be denied treatment. And the label creates an obligation for treatment that many obese people may not want. Roxane Gay and others have argued eloquently against the over-medicalization of body weight. And if this process (labeling of a disease, applying that label to people) entails an obligation for treatment, who will consent to pay the costs for that treatment? This social negotiation is just as big a part of what we need to address as any specific decision on the appropriateness or order of interventions.

I’m no Samuel Crumbine. I don’t even have a mustache. But if I channel Dr. Crumbine, I can see continued progress starting today. I can see the further development of a bike and pedestrian infrastructure, sensible parking policies, and street design that encourages higher density development with widely available green spaces. This can be partnered with local laws and regulations, a more sensible crop subsidy program, and a food tax system that encourages the production and consumption of quality foods over obesogenic foods. For patients who choose to seek help from their doctor, I can see a set of community-wide standards that promote a practical, stepwise approach to treatment that incorporates dietary and behavioral interventions alongside policies that make proven drug and surgical interventions more affordable. I can advocate for the development of a unified, science-based approach to obesity, motivated by spirituality but guided by material evidence.

Disclaimer: Health ICT was also a presenter, and the Forum was supported through a grant offered by the National Alliance of Healthcare Purchaser Coalitions and Novo Nordisk.

I'm changing the way I talk about walking

I spend a lot of time trying to convince people to be more physically active. I spend time on top of that trying to convince people that we should change the built environment, parking policies, and traffic laws to allow people to be more physically active.

One of my old standby stories is of a person who's spent most of his life sitting on the couch watching TV. He goes in for a routine operation, has a catastrophic adverse event, and ends up paralyzed as a result. When he wakes up the surgeon and the anesthesiologist gather to tell him the bad news. The first question out of this man's mouth, a man who has not walked further than from the bed to the bathroom, the bathroom to the kitchen, the kitchen to the sofa, or the car to his office cubicle in years, is this: "When will I walk again?"

I've even posted the story here from time to time

My point with the story has always been to get people to approach the world from a perspective of abundance. Don't take for granted the gifts you have today. Our bodies were designed by millions of years of evolution to move bipedally. If we forsake that, we end up less healthy and less happy. 

But yesterday I listened to Enter the Exos, a new-ish episode in Rose Eveleth's always thoughtful series Flash Forward. 

In the episode, Rose spends a predictable amount of time talking about the possibility that robotic exoskeletons, or even powered clothing, will make us faster, stronger, and less prone to injury:

 I'm talking about the one on the left.

I'm talking about the one on the left.

But she spends an even greater amount of time talking with people with various disabilities about their perception of exoskeletons. This is the part that got me. William Peace, blogger of Bad Cripple, has this to say

Your typical bipedal person exposed to a barrage of misleading news stories is led to believe all paralyzed people share one goal in life--walking. Please cue the soaring inspirational music accompanied by the brave and noble young man or woman struggling to walk surrounded by health care professionals, computer scientists, and engineers who share the same ritualized ideal. 

There is so much to unpack there. I walk, and I like doing it, so I've always thought that other people without the ability would want it. And maybe they would, if the technology were developed that could be applied to people with all kinds of disabilities (cerebral palsy is a lot different than spinal cord injury is a lot different than post-polio, etc). But bipeds like me have a hard time imagining that someone wouldn't want to get closer to the way I move, just like people with normal hearing are mystified by deaf culture. When I put myself in the position of someone who is in a wheelchair or needs another assistive device, I can see and hear the condescension in my words.

So I'm changing my pitch. I'm going to lean more on the "move through space" message and delete the "walking" part. I plan to work harder on the infrastructure message, with curb cuts and tactile crosswalks and protected walking lanes and a hundred other easy fixes that make life better not only for differently abled people, but for people who can walk and bike without difficulty like me.

And I'm going back to my perspective of abundance: we don't have functioning exoskeletons or other sexy fixes for paralysis or weakness yet, but we're all cyborgs already. Most of us carry a device in our pocket that literally has the world's knowledge at our fingertips. We should harness that technology to find safer routes for human-powered transportation of all kinds. And people who can't walk have a 235 year history of constantly improving wheelchair technology whose potential could be unleashed with a little more attention paid to the way we design our environment and laws.

Pedal powered vehicles are some of the best parts of the Air and Space Museum

The post about Skylab's probable clipless pedals was fun to write. But the sweet 70's leisure suit vibe of the Skylab ergometer couldn’t touch the wood-wheeled elegance of this bike, one of five (5!) surviving bikes built in Dayton by the Wright brothers. Tim Moore, the author of Gironimo!, who completed one of history‘s hardest Giro d’Italia courses on a wood-rimmed bike from the teens, would kill for this bad boy:


Its price in 1898 was $42.50. The inflation calculator from the Bureau of Labor Statistics indicates that  this works out to a little over $1000 in 2018 money:

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Since the calculator only goes back to 1913,  I assume we can tack on a few bucks, although I think inflation was pretty low at that point in time. And knowing that this bike, the St. Clair, was Wright Cycles' mid-range model below the Van Cleave, it’s at least in the price ballpark of modern day bikes.

Here's the St. Clair with the original Wright Flyer in the background:


That’s the actual bike next to the actual airplane that flew at Kitty Hawk in December 1903. The Wright Flyer is five years newer than the St. Clair. That's what I call A-U-T-H-E-N-T-I-C-I-T-Y. It will not surprise you to know that I was more excited about the bicycle. And not because the Wright Flyer has been re-skinned twice since it flew.

Lucky for me, just around the corner was the Gossamer Condor to merge my interests:  


To explain the significance of this Saran-wrapped beauty, you have to step back a few years. In 1959, the Kremer Prize was established by London’s Aeronautical Society. The rules were simple: a human-powered plane had take off by itself (no catapults allowed) and climb to an altitude of ten feet to clear a marker. Then the plane had to make a 180° left turn, travel to another marker a half-mile away, and make a 180° right turn before clearing the same ten-foot marker prior to landing:

This was a beast of a challenge, and not just because it pre-dated the metric system. Even the strongest cyclists (who, I'm guessing, aren't the best pilots in most cases) can only sustain about half a horsepower for any meaningful amount of time on a good day. Which means that any human-powered aircraft has to be really, really light. It also introduces a chicken-and-egg paradox: is it easier to teach a cyclist to fly, or is it easier to train a pilot to generate the necessary wattage to keep the fragile plane aloft? Gossamer Condor builder Paul MacCready tried it both ways. First, his son Tyler flew the Condor because of his small size and his experience flying hang gliders. Then, racing against what they thought was a Japanese team with a balsa-and-paper plane, MacCready hired professional cyclist (and onetime US National Team member and 1989 contestant in the Human-Powered Vehicle Race across America) Greg Miller as pilot. Greg proceeded to set the world record for man-powered flight in the Condor, but he reportedly couldn't negotiate the Kremer course and crashed in a later test flight (see the video below). When Greg had to go to Europe to race, MacCready found Bryan Allen, an avid amateur cyclist and hang-glider (and now scientist at Jet Propulsion Lab), to do the penultimate Kremer test:

The Flight of the Gossamer Condor, of which this clip is an excerpt, won an Academy Award for Documentary Short Subject in 1978.

Let's geek out over the similarities and differences in the Wright Flyer and the Gossamer Condor:

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Did Skylab have early clipless pedals?

In case my newfound e-bike fandom didn't give it away, I made a quick trip to Washington D.C., last week. We hit the Smithsonian museums hard, and it was worth every minute. But the most entertaining elements for me by far were the pedal powered equipment. Here's the bicycle ergometer from Skylab:

 You know this is my personal photo by the fuzziness and poor composition. 

You know this is my personal photo by the fuzziness and poor composition.

I can't embed the video here, but take another look at Pete's mounting of the bike. He clearly works to get his feet situated in some kind of clip or strap before he starts pedaling. I tried to find schematics, but I can't find the contractor for the bike. The orbital workshop itself was built by McDonnell Douglas (right):

And while there were early, proto-clipless pedals around for cycling, this was at least a decade before Look pedals debuted at the Tour de France (see Greg winning Worlds in Look clipless below in 1989; Sean Kelly and Dimitri Konyshev are still rocking clips and straps):


Look at those handlebars! 

Astronauts Charles C. "Pete" Conrad Jr. (seen space-cycling above), Paul J. Weitz, Joseph Kerwin, (Scientist; I love that Skylab missions included people simply and officially dubbed "Scientists."), Alan L. Bean, Jack R. Lousma, Owen K. Garriott (Scientist), Gerald P. Carr, William R. Pogue, and Edward G. Gibson (Scientist) undoubtedly knocked out some Zwift-style mileage on that baby. 

Legend has it that the bike was rated to 300 watts, but it could really only get to about 270 watts reliably. I have no idea why. But 270 W is no joke.

All the exercise was intended to prevent muscle atrophy. Since astronauts are in microgravity, their muscles don't get the same routine, day-by-day work that yours get just in the process of sitting and standing. The data that came back from Skylab was fascinating: cardiac output was down 30% (mostly from a 50% reduction in stroke volume; heart rates actually went up) upon the astronauts' return to earth. Peripheral vascular resistance was up, presumably to keep the blood pressure up with such a big drop in output (mean arterial pressure didn't change). No matter how long the astronauts stayed on Skylab (approximately 1 month, 2 months, or 3 months), they returned to normal within 30 days of landing. 

I wondered if the same shoes that allowed them to clip into the floor allowed them to clip into the pedals. Skylab had a bungee cord system that was designed to strap the astronauts down. Here it is being used with the "treadmill" (really just a piece of teflon-coated metal) on the third mission (left).

But Pete's not wearing the bungee harness in the photo, so he must be clipped in. I can't find a good source, but the shoes were definitely up to the challenge, even if it took a little duct tape:


Even though I'm not much of a runner myself, I'll admit that the bike looks like less fun than Skylab's famous "exercise wheel," or as I prefer to call it, the "Zero Gravity Stripper Pole":

I tried Jump Bikes. Now I think e-bikes may be the future of commuting.

I'd never been on an e-bike before I went to Washington, D.C., last week. I've seen a lot of them. I thought they looked goofy: the giant downtube, or the giant hub on the wheel providing power:

And I'm consistently annoyed by the gas-powered "Whizzer" style bikes that people ride on the bike paths in Wichita, blowing blue smoke and making noise.

So I was a skeptic. E-bikes seemed lazy and ugly. They seemed to fill a niche that didn't really exist: why not just buy a moped or scooter? But just before I left for D.C. I saw reports that Uber, the beleaguered ride share company, had bought Jump, a dockless e-bike share company that is only in a few markets (D.C., San Jose, and San Francisco). Uber riders have been able to book JUMP bikes via the Uber app since January 2018. For the time being, JUMP’s app will continue to exist, but I suspect they'll eventually be completely integrated into the Uber app. When I got off the train to my hotel, sure enough, I saw one. The bikes are aesthetically pleasing, with their little aerodynamic basket in front: 

 The Jump is on the other side of the fat (phat?) downtube. 

The Jump is on the other side of the fat (phat?) downtube. 

Dockless bike shares are controversial among a certain set of people, who complain about the possiblity of "abandoned" bikes littering cities. This has naturally and appropriately drawn sarcastic scorn from critics of car culture, who point out that cars themselves are mostly "dockless":

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Uber's motivation for buying up Jump was apparently that a big fraction of Uber's trips are very short (maybe under 3 miles). And since the demographic that would tend to use the bikes is at smartphone saturation (for better or for worse), it makes sense for Uber to try to divert those rides to e-bikes, where the company wouldn't have to divert 80% of revenue toward drivers (because the "driver" of the e-bike is you, and you're paying for it. Get it?).

So, needing to entertain myself for a couple hours, I tried one. Step one was to download the app, just like Zagster and a million other such companies. 


Obviously, I tried a few other sharing services while I was there, too. All those apps on my phone? That's not even all of them I could have put on there. I know I missed D.C. Insider, Ofo, Mobike, and Capital Bikeshare (I used Capital Bikeshare, but you don't need the app to do it). There may have been others. D.C. is to bike/scooter share what the Idaho panhandle was to anti-government militias in the '90s. 

 Ofo trying to capture the Blind Melon revivalist market.

Ofo trying to capture the Blind Melon revivalist market.

And that's not even counting the scooters.

Once the app was downloaded, I got an account number emailed to me, and I chose a PIN. The same email warned me to "start slowly to get familiar with its boost." 

I scoffed. Please. I've ridden a million bikes. I've ridden almost as many motorcycles. I know power.

Next was checking out the bike. The app tells you that you can either walk up to a bike and check it out, or reserve one through the app. No need in my case, since I was standing by the bike. But in case I couldn't find a bike right away, I could have held one for up to 20 minutes ahead of time, with the knowledge that the clock would start ticking once the reservation was made (if I didn't make it to the bike in time, the reservation would cancel automatically).

Next, I needed to actually rent the bike. I was instructed to enter my account number and PIN using the keypad on the back of the bike, then to remove the U-lock and slip it into the two holster loops on the left:

 This is actually from the end of the ride, since I was too big a bonehead to remember to photo it up front. FYI: The solar panel only powers the electronics.

This is actually from the end of the ride, since I was too big a bonehead to remember to photo it up front. FYI: The solar panel only powers the electronics.

Then I was to adjust the seat height to one that works best for you. This was a little complicated because, as a #bikesharerenegade who often lets his kids ride bike shares with him, I needed to adjust the seat several times for my kids and me. I was not reassured that Jump bikes use the same janky, slippy clamp and post as virtually every other bike share:


Then: "Test your brakes. And get ready for the smiles." Oh, I was ready:

 That goofy smile is system-delivered. Tan lines are an upgrade. 

That goofy smile is system-delivered. Tan lines are an upgrade. 

The jump bikes have a threaded bottom bracket. Yay! 


A spring keeps the front wheel from flopping around.

We headed for the proving ground, Rock Creek Park:

 This is from the bottom of the park, looking up north and east.

This is from the bottom of the park, looking up north and east.

That gentle upslope you see is no joke. It's actually a pretty legit climb, a little over a quarter mile at a near-seven percent grade. It would easily qualify as the biggest hill in Wichita were you to transport it 1500 miles west: 

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We coasted down the hill without really even pedaling, then turned back uphill. And wow. When you step on the pedals, the bike really jumps. I immediately regretted my initial scoffiness. It was legit, even a little unnerving the first time. When my daughter did it, she couldn't help but laugh with delight at the acceleration. That same eleven year-old daughter of average athleticism absolutely hammered this hill on the Jump Bike. I should have timed her, because I legitimately think she would have been in Queen of the Mountain range, thanks to the e-bike boost. My friendly neighborhood wattage calculator, assuming 75 watts from my daughter, gives me this (the Jump Bikes generate 250 watts, according to WikiPedia):

Screen Shot 2018-05-13 at 11.02.51 AM.png

The bikes have three speeds, courtesy of Sturmey-Archer:


But honestly, you don't need the bottom two unless you want to climb Quintana-style. Even a modestly fit rider can crush hills on this thing.

The bike was cheap: $2 to rent, which buys 30 minutes, or 11 miles at 250 watts:

Screen Shot 2018-05-13 at 11.08.06 AM.png

That's enough to get me halfway across Wichita. If you go over 30 minutes, you're $0.07/minute for additional use. If you run out of pedal assist power, you can note that when you end the rental and Jump will "take care of it from there," which I assume means swap out the battery. If you leave the service area of the bikes, you're warned that you might get charged a fee for retrieval. This is dirt cheap; about half what it costs over time to ride a scooter share (yep, they have those in DC too). This leads me to my final point on e-bikes, and potentially e-bike shares: they're the future. They're the future because they're so democratic. They're cheap, and almost anyone with even rudimentary bike skills and basic fitness can ride one. My mom is in her seventies and has not been on a bike since her teens, I suspect. But she could easily pedal an e-bike 20 miles in an hour or so. And if she couldn't, it probably wouldn't be because of leg, lung, or heart fatigue. It would be a matter of regaining some basic bike handling skills and butt toughness. 

A full charge gets you about 30 miles of range, just slightly below what my Chevy Volt gets on a charge. I drive said Chevy Volt because I can travel the vast majority of miles I travel under electric power. The reason I drive a Volt instead of, say, a Nissan Leaf is because I like the insurance policy of a gas engine behind the electric battery. If I go beyond the 40-ish miles the battery gives me I can get another 240 miles from the gas engine. The beauty of e-bikes is that I’m that insurance policy. If the battery quits, there’s a couple hundred watts of human power on the pedals to get me home. 

The advantage of the "e" in e-bikes is mostly sweat. Or lack thereof. Jump bikes make me think a future garage may have not two cars, but a car and an e-bike. The e-bike will be adjustable so that the bike can be used by multiple members of the family:

 The lovely and talented Tracy Williams, MD.

The lovely and talented Tracy Williams, MD.

The bike could be shared like the car was. But the cost of owning the bike would be essentially zero compared to the cost of a fancy gas-powered wheelchair. And you can criticize the decreased work of riding an e-bike versus an unmotorized bike, but riding an e-bike is still a helluva lot more exercise than piloting a gas-powered wheelchair. And it gets you out to interact with humanity in a non-fist-shaking, non-furious way. Ever see somebody on an e-bike with road rage? Me neither. It goes fast enough, relatively sweat-free, to get you places in a reasonable amount of time, but not so fast that it turns you into a raving lunatic at every 20-second delay for a crosswalk or light. 

At the end of our test session, we locked the bike back to a rack:


Biggest criticism? That U-lock is tough to get in place if the space is tight. You have to wrassle a really heavy bike around to get the tines on the lock to line up with the holes through the frame and wheel. It's tough. A much better design would be like Zagster's here in Wichita:


I don't think security would be an issue, since 1) the bikes are tanks, and 2) they're tracked with GPS. The Jump bike automatically ends your ride when the lock is put in place, though, which is nice. To incentivize people to put the bikes back where they'll be easy use (and presumably easy for the Jump folks to pick up and charge), they offer $1 credit for returning any bike parked outside of a virtual fenced-in "hub" back to a hub. Try as I might, I cannot find a map for these. 

Updated 5/14/18 with a picture of the Sturmey-Archer shifter.

Re-post: You wanna do the Dirty Kanza 200? Here’s how.

If you're one of the lucky ones from last winter's lottery, you're a month out from the 2018 Dirty Kanza as of today. Maybe you're nervous about preparing. Well, since I'm a completely mediocre cyclist (see: painful, sunburnt non-finishing of last weekend's Open Range 200k) and I've still managed to complete two Dirty Kanza 200s, I thought I'd share again 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:

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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.

1. Prepare your body


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 recommended routine is something like 8-10 hours a week in the months leading up to springtime. Too late for that now, I know. But you still have some time to build fitness. Since hills are hard to come by here in central Kansas (not to worry, there's a crapload of climbing in the DK itself; see the profile below), 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. 

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 [not really]), 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

Screen Shot 2017-11-29 at 9.57.43 PM.png

This seems obvious, but between now and 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)

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. 

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, thank heavens.

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

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. 

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

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. Reapply at checkpoints, too. 

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, fully charged (so bring your charger). 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 your phone will drain its battery trying to find a signal.

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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 my son. Look for me at the finish line. See you there!

Replacing a worn-out bike tire makes you feel thrifty and badass


I love the way road tires wear down to a flat shape right before the rubber wears through to the casing. That flat spot tells you you've put in some time on the bike. You've covered ground that would really show up on the map. You've gone from point A to point B. Or more likely, from point A to point A many times.



The last few hundred miles before the wear finally breaks through are super-suspenseful. Kind of like waiting for a kidney stone to pass, but without the pain. And then one morning you're innocently getting the bike of the rack for a morning ride, and your fingers run over the rough of a torn blister in the tire:

 If you're in the U.K., I guess I mean "tyre."

If you're in the U.K., I guess I mean "tyre."

And then you get to replace the tire with a nice, round, new one:

 Old meets new.

Old meets new.

Then a quick pump up to 95 lbs, and you've gone from flat-top to round-top:

 I'm more of the 80 kg variety.

I'm more of the 80 kg variety.

 Ahhhh. That's better. 

Ahhhh. That's better. 

Continentals are great. They look euro-sophisticated, with the dark gumwalls that haven't changed since forever and the "Hand-Made in Germany" that you wish was true but you know probably isn't. They set onto the bead with a satisfying "pop." And the gator hardshells are almost flat-proof. It took a stray decking screw to puncture the last one that flatted out on me.

 Not that kind of goat. Side note: Awwww!

Not that kind of goat. Side note: Awwww!

I hear grumbling from people like the Velominati that they "don't corner well," and blah blah blah. Listen: south-central Kansas is goat head country.


 This kind of goat. Side note: Ouch!

This kind of goat. Side note: Ouch!



I'm not going out there with some lightweight, flimsy-ass tire or (gasp) tubulars just so I can walk my bike home. 






And you feel like you've really extracted your money's worth when you throw the old tire away, or recycle it, or turn it into a monkey habitat.

 Or is that a lemur? Could be a lemur. 

Or is that a lemur? Could be a lemur. 

I don't think you get this kind of satisfaction with many other sports. You can't really wait for running shoes to wear out like this without putting yourself at risk of injury. Ditto tires on motorcycles or gas-powered wheelchairs. (though to be fair, if I lived somewhere with hills or technical roads, I wouldn't run my tires as long as I do)

How to break up with your phone, Double Arrow Metabolism edition, Days 25-29

This is it. Was it. My last week in Catherine's tutelage. It wasn't a great week, phone-wise. The NCAA Tournament was a meltdown of epic proportions, with upsets every day, and I couldn't help but hit refresh on the ESPN website (but not the app; I learned that buzz-filled lesson long ago) a couple times an hour for score updates. We even had the tournament here in Wichita, complete with artisanal basketball folk art:

 The geometry of the stripes is wrong, but I like where the artist's head is at. 

The geometry of the stripes is wrong, but I like where the artist's head is at. 

For Day 25, she told me to Clean Up the Rest of my Digital Life. Step one: unsubscribe from email lists that don't interest me. I actually did this a few years ago. I was prompted to do it by my former employer's excessive institutional email habits. The university collectively never met an email it didn't like. Need safety training? Email. Leftovers from Grand Rounds available? Email. But Catherine's reminder was a good way to re-examine my inbox and hit the delete button on the bottom of a few emails. It felt good, like electronic spring cleaning. 

Step two was to save myself from the tyranny of my inbox. As an aside, I've seen screenshots of people's unread email badges, and I don't know how they sleep at night:

 Honestly, either read the emails or disable the badge.  *cold shiver*

Honestly, either read the emails or disable the badge.

*cold shiver*

Catherine recommended apps to help me prioritize email senders, but I feel like I do this pretty well already, and after my less-than-great experiences with Freedom and Moment, I'm not excited about adding new software. So instead, I decided to set a 6 pm hard stop on email checking. It's not hard to do, since I don't have an email alert on my phone, and the little red badge doesn't show up when I have an unread email.

Next was a suggestion to use folders to keep myself sane. Catherine had some very specific advice in this regard. One piece was to make a "needs response" folder. But that's what I use my inbox for. Anything still sitting in there is unresolved. I move resolved emails that I want to keep to topic-specific folders and keep a to-do list on Wunderlist (with alerts/notifications turned off, natch). So I didn't change anything.

Then Catherine recommended setting up a "commerce" email for the Amazons and Zappos of the world, so that those emails wouldn't come to my main address. Nope. I actually like getting shipping updates from those companies in my inbox, and I fastidiously unsubscribe to any lists that don't deal with those. I'm not interested in sales, because I rarely buy anything that I don't need pretty quickly.

She followed this advice with instructions to set up a VIP list on my phone and email so that I'm sure to get emails from important people. Good idea, and done. 

Next I was instructed to set up a "Justin_Important" email to alert people who emailed me on vacation that if it was really important, they could send an email to the "Justin_Important" address and I would get back to them. But honestly, it seemed impersonal, and I'd rather have some email pile up while I'm on vacation than put people off. Maybe that makes me soft. So I didn't do it, but I will continue to use auto-respond emails when I'm out of town to let people know I'm not immediately available. 

Catherine gave me some instructions to use for social media, but I was like, "What? I haven't had a social media app on this phone for years. Get outta here."

We're in the home stretch (Day 25 was labor-intensive). Catherine told me to activate drive mode for my phone, which I did with the last big iOS update and which I love. Then she told me to unlink accounts I might be using for log-ins. I don't have many (or any) of these, but if I did, the recent Cambridge Analytica mess would've scared me off them a lot faster and harder than Catherine ever could.

Day 26 was my day to Check My Checking. What Catherine means is, when I reach for my phone, I'm supposed to ask myself, "What's the best thing that could happen? What's the likelihood of this?" The idea is that mindlessly checking my phone has a much higher risk of making me sad than of making me happy. It's a good strategy, and it reminded me to stop mindlessly clicking through the news websites whose bookmarks I deleted a couple weeks ago, but whose URLs I still have locked in. Day 26 reminded me of one of my college roommates who is now a college professor. He publishes a lot, and the work and focus required to do this makes his mornings pretty valuable. So he has a rule to never check his email before 12 pm, because there is a very high chance of there being something in his inbox that will ruin his day. 

Day 27, Catherine reminded me to perform some Digital Sabbath Life Hacks. That is, come up with some ways to separate myself from my phone periodically. I can't do a day a week like she suggests, or probably even a day a month. My income is just too tightly bound to phone availability, probably like many of yours. But I tried three-hour breaks, and I liked it. Catherine took Day 28 to remind me of The Seven Phone Habits of Highly Effective People, which was a nice review of the strategies we'd gone through in the last few weeks. 

Day 29, Catherine told me to set a monthly reminder to evaluate my phone usage. Wunderlist to the rescue:


How to break up with your phone, Double Arrow Metabolism edition, Day 24

Today's the day Catherine tells me I need to Manage My Invitations. At first I thought she meant calendar invitations. But she means invitations from my brain

She seems to be getting back to mindfulness. Okay. But the more actionable advice for today comes from one of the quotes she includes in her book, in which a person relates the feeling of discovering that she was reaching for her phone out of habit, not necessity, and that if she pauses and asks herself what she needs from the phone, she discovers she needs nothing. So she puts it down. I think I'm at that point. 

How to break up with your phone, Double Arrow Metabolism edition, days 20-23

Well. That did not go well. My Saturday was fine. I raced in the first race of the Rage Against the Chainring series, and finished 16/55 in the "B" race, about as good a result as I could have hoped for:

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I spent precious little time on my phone Saturday, but I can't prove it since I deleted Moment over the weekend. I just couldn't handle the notifications, and I couldn't justify having the app without having it remind me to stay off my phone. So it's gonzo. 

Sunday, though, was tough. I started strong and left my phone in an inconspicuous place, and I did well staying away from it through the morning and early afternoon. I did fun things with real people, per Catherine's instructions. I didn't even get any Rubicon consults. Come evening, though, the seeding for the NCAA men's basketball tournament came down the tracks like a locomotive. And I just. Couldn't. Stop. Myself. from looking to see where my beloved Kansas State Wildcats ended up. I didn't even consciously cheat. I just walked by my phone and casually picked it up and tuned into the NCAA website:

 Answer: on a collision course with a first-weekend exit. 

Answer: on a collision course with a first-weekend exit. 

And once I'd peeked to see where the 'Cats were, I couldn't resist looking to see where the rest of the Big XII ended up, and then where Wichita State was seeded, and then a bunch of posts on The Ringer and ESPN about how easy the Xavier/UNC bracket was. I killed an hour, easy. On a day I was supposed to be phone-free. Sigh. 

But yesterday (Monday) was a new day. It was the first day of My New Relationship with my phone. Catherine told me to answer a series of questions she calls "See/Think/Feel/Wonder."

What did I observe (see) about myself and my behavior and emotions during my twenty-four-hour trial separation?

When I actually managed to keep away from my phone, say before and after the hours of 4-6 pm CST, I felt great. I did meaningful work around the house, I asked my kids questions, and I did the laundry in silence (sans podcast). I was a better person than I am with my phone distracting me. 

What do these observations make me think about? When I reflect back on my experience, what thoughts come into my mind?

I feel like, even after three weeks of conscious effort and months or years of half-assed behavior modification before that, I still have work to do. 

Now that i've made it through the Trial Separation, how do i feel about my phone itself, as well as my relationship with it?

I still feel like my phone is very, very valuable for specific tasks, like my to-do list, my calendar, and podcasts. And being a phone, of course, And texting, to a smaller extent. But the rest of my phone is an elaborately designed distraction device. It is definitely expendable for large swaths of the day. 

Now that I've completed the Trial Separation and begun to deeply observe my relationship with my phone, what do I wonder? What questions do I have? What do I want to know more about? What would I like to investigate further or look into more?

I wonder if I could really go back to having just a home phone and a paper planner, or if I could at least revert to a flip phone. I know it would cause me to carry a paper planner around, which would be a drag, but I already carry a notebook and pen most places, so it wouldn't be a big deal. I'd miss being able to coordinate my calendar with my wife. I'd miss getting my kids' school calendars automatically through Google on my phone. I'd like to investigate more how I could handle those issues through my work computer. 

What was the hardest part?

Finding the results of NCAA tournament bracket seeding in a house with no cable subscription, obviously. 

What was the best part?

I had several Beyblade battles with my son without the threat of phone interruptions. 

What surprised me?

I was surprised that I fell back into phone use so easily. It really disappointed me that I was so weak.

What did I learn from the experience that I can use once my official breakup is over?

If I really want to stay away from the device, it needs to be in a different room. It's that bad.

Day 23, Tuesday, today, was to Phast. Catherine said to pick a time today to take at least a half-hour break when my phone would be either unavailable or turned off. This was easy. I knew I had a couple high-level tasks to complete this morning before going to lunch and then going to KUSM-Wichita to teach at one pm. So I silenced my phone at 10 am and stuck it in my briefcase. I used a desktop computer to order Chipotle for carry-out. Then I sat down and ground out a couple hours' work on the use of the Diabetes Prevention Program for osteoarthritic pain. It felt great to work without interruption or distraction from my phone and to have something to show for the morning. 

How to break up with your phone, Double Arrow Metabolism edition, Days 18 and 19

Day 18 is to Meditate. Spoiler alert: I didn't do it. I know meditation brings many people a lot of joy and meaning. I know that some very high-functioning, productive people like Yuval Harari swear by it. I know some good evidence (albeit tainted by low adherence rates) exists for its practice. 

Here's the thing: I hate it. Every time I've tried meditation, on my own or in groups, I've heard a voice inside my head yelling "You're wasting your life. You're wasting your life. YOU'RE WASTING YOUR LIFE," over and over. I don't think that counts as an insight.

 There is one exception. I have trouble going to sleep at night. It's not a new problem. Once upon a time, someone taught me to repeat a mantra to myself as I lie in bed. I take a deep breath and think to myself, "I'm relaxing my feet, I'm letting go." I exhale and do my best to completely relax my feet. Then I take another breath and think to myself, "I'm relaxing my calves, I'm letting go." I exhale and relax my calves. And so on, until I'm either asleep or to the top of my head. It works. But I don't think true meditation is supposed to put me to sleep.

And since the entire reason I'm trying to break up with my phone is to stop wasting my life in a different way, I refuse to meditate. And I damn sure refuse to download a "meditation app." Using my phone, which I'm trying to free myself of, to engage in an alternative activity that also makes me feel bad is what they call a "double whammy" in my neck of the woods. No thanks.

So on to Day 19: Prepare for Your Trial Separation. Catherine tells me to identify what it is I'll be taking a break from. She recommends going screen-free, including movies, computers, and television. I'm not sure I want to do it. My kids loooooove going to movies, and A Wrinkle in Time just came out, and I'm not sure I want to miss seeing it with them. Plus, Catherine says to make plans for fun things to do. So I'm making plans to see a movie.

Then I'm supposed to tell people what I'm doing and get them on board. This is actually pretty easy. I don't want to be obnoxious about this. My goal here isn't to make people think I'm superior. And I suspect people who can't get ahold of me will just call my wife. She recommends setting a phone greeting to let people know I'm phone-free, but I don't think I'll need it. I don't have a landline, so I can't forward calls. 

Preparing with hard-copy instructions is next. I have a bike race Saturday that I'll be using my Garmin to navigate. No phone needed. But Sunday, I'm expecting no travel. So I shouldn't need a map.

Catherine says to carry a pen and paper for a "to-phone" list once I'm done. I've already started doing this, so I'm set. 

Podcasts: those are gonna be hard. I'm not sure how I'll brush my teeth without the sweet, sweet, honey-filled timbre of Mike Pesca's voice in my ear. But I'm committed to giving it a shot.