Links for Tuesday, August 21, 2018: patients love good news. And weed. Patients love weed.

Patients liked a blood pressure app better because it was inaccurate

If I were to pick a single study that wraps all my angst about medicine up into a tidy bow, it would be this one:

"...user enjoyment and likelihood of future BP monitoring were negatively associated with higher-than-expected reported systolic BP. These data suggest reassuring app results from an inaccurate BP-measuring app may have improved user experience, which may have led to more positive user reviews and greater sales."

A better writer could hold forth on how doctors (and devices?) are so bad at giving negative but meaningful information to patients that patients simply avoid the process altogether, leading patients to seek a relationship with their doctors that more resembles that between a shaman and a subject than that of a modern, informed, dynamic doctor-patient exchange of information.

*head explodes*

Dr. Robert Badgett, on seeing this study, reminded me of a quote by Voltaire:

"The art of medicine consists in amusing the patient while nature cures the disease."

I certainly feel like I'm in the entertainment business some days.

With wider availability of cannabis comes wider use and wider abuse

"Public-health experts worry about the increasingly potent options available, and the striking number of constant users. 'Cannabis is potentially a real public-health problem,' said Mark A. R. Kleiman, a professor of public policy at New York University. 'It wasn’t obvious to me 25 years ago, when 9 percent of self-reported cannabis users over the last month reported daily or near-daily use. I always was prepared to say, ‘No, it’s not a very abusable drug. Nine percent of anybody will do something stupid.’ But that number is now [something like] 40 percent."

I knew guys in college who were stereotypical "potheads," and I think my bias at the time was that all but a few of them would be reined in by the relative difficulty of getting the drug (not that it was difficult). Now that the reins are off, we're stuck addressing possible solutions to the problem. This is not an argument for going back to hard-core criminalization. As Annie Lowrey points out, the US still arrests more people for marijuana offenses than it does for all violent crimes combined. That seems, shall we say, excessive. 

I've had several Impossible Burgers. They're amazing

A few years ago I made a choice to eat very little meat. Everyone who comes to a this dietary decision gets there for one of several reasons. For some, it's a matter of animal welfare. For me, it was the impact of excessive meat intake on my personal health: meat, particularly red meat and processed meat like bacon, has been linked to increased risk of heart disease, cancer, and other diseases. Plus, beef in particular is astonishingly carbon-intensive; were people to forgo only red meat in favor of beans (while, mind you, continuing to eat pork and poultry), the U.S. would come very near Paris Accord carbon emissions goals, all without a change in driving habits or other energy production from fossil fuels, and without a change in efficiency. 

Giving up meat for me was astonishingly easy. I don't miss it. Were you to ask me to give up sweeteners, we'd have a problem. I like desserts more than I should, and despite my frequent screeds against bug juice, I have an occasional caffeine-free Diet Coke. But no meat? No problemo. Part of the reason for this is that we've had a big increase in the availability of meat substitutes in the past decade or so. This doesn't affect me so much as it affects people who eat with me. I can make meals that are almost meat that I can serve to carnivorous friends and family without feeling like I'm depriving them of anything. But hamburgers, the quintessential American food, have been a problem. I've tried multiple veggie patties and black bean patties. They're all mostly okay, but they're no substitute for real meat. You have to have in your mind that you're not eating a hamburger to enjoy them. You tell yourself, "This is a good veggie burger," but you can never convince yourself that you're eating a real-for-real hamburger.

Then I heard about Impossible Foods and their bleeding vegan hamburgers. I was intrigued, but there was no place near home for me to try one. But last summer I was in Houston a week or two before Hurricane Harvey. We found a Hopdoddy just west of Rice Stadium:

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This was directly adjacent to Rice's semi-famous 1/3 mile "Bike Track," whose popularity I assume is at least partly due to the apocalyptic artillery-grade roughness of the surrounding streets. Hopdoddy was pushing the Impossible Burger hard:

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But that didn't mean they didn't have the customary pile o' beef in their kitchen:

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And it didn't mean that when I ordered on the waitress wouldn't say I was "brave." But when it arrived, so far, so good:

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My burger looked like a million bucks. But I didn't get a chance to find out if my burger bled; it was well-done:

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Impossible Burger has the look and feel of beef. It has the mouthfeel of beef. It just does. For all intents and purposes from the consumer end, this is beef. I tried a bite of my son's regular patty for a taste test. I'm a bit of an unreliable witness here; my enthusiasm for meatless foods taints my impression of these things. But honestly, the only difference was that his real burger was saltier. I suspect Impossible keeps the salt content lower to avoid dryness.

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I liked the one I ate so much that I convinced my then-ten year-old daughter, a notorious carnivore, to try one. She will eat veggie patties, begrudgingly, the way somebody who's tasted whole milk will settle for almond milk on her cereal if they don't have a choice. But after tasting mine, she was enthusiastic to get her own. And she's had several since.

The primary ingredients are wheat, coconut oil, potatoes, and heme. Heme is part of the molecule that carries oxygen in your bloodstream: "hemoglobin." Impossible gets its heme in the form of soy "leghemoglobin." Their website says they chose it because of taste and lack of allergenicity. I suppose this means people won't get a rash if they eat it. Not that I knew hemoglobin allergies were a big problem.

If you're the anti-GMO type (I'm most certainly not), beware that Impossible's leghemoglobin is produced by a genetically modified yeast. But it is 100% vegan. It's not gluten-free, which is a bummer for the small fraction of the population with celiac disease. For the remaining 99% of us, it's neither here nor there. Impossible burger patties are kosher.  Halal are anticipated later this year.

My second Impossible Burger was in Washington, D.C., for a work trip. My daughter's, ironically, came with bacon:

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My wife's medium-rare (not ordered that way, but delivered that way) patty gave us a chance to taste the heme without the searing. It definitely loses something. The seared heme is important: 

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I tried to convince my daughter that the tater tots were also "Impossible," but that since they were naturally made of potatoes the impossible factor was figuring out how to make them out of animals. She didn't buy it: 

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Impossible Burgers are now served in more than 1,500 restaurants. Since April, White Castle has been selling Impossible Sliders for just $1.99. After trying Impossible Burgers myself, I'm convinced that meat production in the way we've been practicing it for the past 100 years has an expiration date. We simply won't tolerate the health and environmental consequences of it when we have alternatives that are this good. I'm not here to tell you that Impossible Burgers represent any kind of achievement. Quite the contrary: as good as they are, they're just the beginning. Meatless "meat" is the worst today that it ever will be. It will only get better from here. Next phase vegetarian chicken? Faux eggs? Faux seafood

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:

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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:

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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:  

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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:

https://hackaday.com/2015/01/27/retrotechtacular-the-gossamer-condor/

https://hackaday.com/2015/01/27/retrotechtacular-the-gossamer-condor/

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. 

 
https://www.flickr.com/photos/nasa2explore/11456762794

https://www.flickr.com/photos/nasa2explore/11456762794

 
http://spaceref.com/nasa-hack-space/skylab-shoe-fashion---with-duct-tape.html

http://spaceref.com/nasa-hack-space/skylab-shoe-fashion---with-duct-tape.html

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):

https://www.cxmagazine.com/greg-lemond-echelon-dirt-gran-fondo-hood-river

https://www.cxmagazine.com/greg-lemond-echelon-dirt-gran-fondo-hood-river

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https://starchild.gsfc.nasa.gov/docs/StarChild/space_level2/conrad_bicycle.html

https://starchild.gsfc.nasa.gov/docs/StarChild/space_level2/conrad_bicycle.html

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:

https://lsda.jsc.nasa.gov/Mission/miss/40

https://lsda.jsc.nasa.gov/Mission/miss/40

800px-The_Skylab_Orbital_Workshop_Experiment_Area_7030269.jpg

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:

electricbike.com

electricbike.com

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.

ebay.com

ebay.com

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. 

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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. 

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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:

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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! 

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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):

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

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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:

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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:

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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:

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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

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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

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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.

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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:

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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:

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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

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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)