Just minutes a day

Remember the proliferation of exercise gadgets in the 1990s? You had the knee squeezer:

The sit-up machine: 

I don't see how this is better than a sit-up.

I don't see how this is better than a sit-up.

The aluminum pretzel:

I'm sensing a theme here...

I'm sensing a theme here...

And many, many others. What they all had in common (in addition to being highly inefficient ways to part you from your money) was their promise to turn you from "before" to "after" in some small period of time daily, usually under 30 minutes. 

Newsflash: doing anything--anything--physical for 30 minutes a day is going to help you out. It doesn't have to be a gymnastics routine. Hell, try doing push-ups, planks, and crunches for 30 minutes a day. It's a lot of work.


Both pictures are "after." Where can I buy those shorts? Rowrrr.

Both pictures are "after." Where can I buy those shorts? Rowrrr.

But that's all an aside. Here's the thing I'm really thinking of today: I’m not sure how may times I’ve had a parent or grandparent of young kids tell me how much physical activity he or she gets as a result of “chasing around a two-year old.” I’ve always been suspicious of the claim. Don’t get me wrong--parenting, especially at the toddler phase--is exhausting. But it tends to be exhausting in the way a stakeout is exhausting, mostly from monotony and sleep deprivation. It’s emotionally taxing because of the lingering self-doubt about the quality of your parenting and the everyday small decisions you fear will lead to some real harm if made improperly. Physically, it never seemed demanding at all with my two kids. There was some lifting, sure. But most of the parents I see in public with their kids are sitting somewhere gazing into their smartphones. It’s the kids who are doing all the physical activity. The parents are unlikely to take twenty steps in an hour, it seems. [note: none of this cynicism applies to daycare workers, most of whom really hustle]

Obviously I’m a little jaded. As I write this, I’m sitting in a fairly spectacular local park, taking part in a fundraiser. I can see eleven parents from my perch at a picnic table (at least I think they’re parents. They’re sitting adjacent to the playground with small children zipping between them. Oh, and there are 12 if you count me). Of the 12, twelve are either writing (that’s me), texting, or eating. Zero are interacting with children in any physical way. In an unusual turn of events, I’m actually primed for some moral superiority, since the kids and I got here by bicycle, in the #familypeleton, so I have the ~3.5 miles to the park and the 3.5 miles home on my side. That's enough self-congratulation for the day. My point is, being with your kids might bring you joy most of the time, but it won't bring you physical activity unless you do it self-consciously, just like any other activity. 

What got me thinking of this is the fact that I’ve had innumerable conversations with people about physical activity over the last decade in which one or both of us advocated for “Simple strategies to add physical activity to your routine!” These discussions were often irrationally enthusiastic about the awesomeness of parking at the far end of the parking lot, or substituting a rake for a leaf-blower, or using a whisk instead of an electric mixer. You get my drift, I hope. Here’s the problem: it’s almost all bunk. Desperate, depressing bunk. And I say this as the person who has on many occasions been on the giving end of this advice. Now, before Blue Zones fans come at me with pitchforks and torches (both good ways to “Add physical activity to your routine!”, by the way), let’s perform a little thought experiment.


Let’s imagine that you wake up from a routine surgical procedure to find a doctor solemnly standing over your bed.

“Justin, I have some bad news,” she says as she pulls up a chair. Your name is Justin in this dream, by the way.

“Your appendectomy went fine. You’re going to heal right up. But you had a rare complication of the anesthesia, and it appears you’re now paralyzed from the neck down. The good news [doctors always try to segue into the good news as quickly as possible, amiright?] is that you’re still able to breathe on your own, so you shouldn’t have any trouble talking, and you won’t need a ventilator.” As you try to shake off the last remains of the sleeping medicine, and as your spouse softly weeps at your side, the doctor goes on. “But you won’t be able to do any intentional physical activity beyond breathing, talking, smiling, and blinking.” She then explains that the condition is likely permanent, at least as permanent as you are.

As you let this news settle over you, what will you miss? Will you miss your thighmaster or ab cruncher or aluminum pretzel time? I hope not. But if so, that's cool. Will you miss mowing the lawn? Maybe, if you’re one of the guys Lowe’s advertises to in the springtime. Will you miss using a whisk? Well, I guess, insofar as you’ll miss cooking in general. (note: Julia Child has a great old clip in which she talks about how normal cooking should lead to the cook getting sweaty. It’s awesome. You should look for it. I'd link it, but I can't find it, and I'm in a hurry.) But I’m willing to wager that the walk across a shimmering, sweaty, oil-stained parking lot upon which you’ve intentionally parked your automobile far, far from the entrance to the big box store is something that approximately zero percent of us would miss. Zero percent of responders to this scenario would miss running a vacuum cleaner, or washing their tile floor by hand, or any of the 1,000 other “strategies” I’ve heard in this regard.

What would you miss? Dancing with family at weddings, maybe. The spray of water on your face as you waterski. I’d desperately, achingly, miss my morning cycling route that takes me through the sunrise in summertime and through a crystal wonderland in the winter. I know this because I've been sick lately, and I fear the cold air would make me sicker. I’d miss the bike ride to school with my kids. I’d miss the competent, reassuring thud of a frisbee into my outstretched hand. I’d miss the brace of cool water against my face the first time I dive into a pool in the springtime. I’d miss...nothing at all related to parking.

Here’s my point: Movement isn’t just a utilitarian product of 85 million years of evolution. It isn’t just a means of getting from point A to point B. It is a source of joy. So, sure, park at the edge of the Target parking lot. But even better, leave your car at home and find joy in the 30-minute bike ride or hour walk to the store because it brings you joy, is good for the planet, and it saves you money. Instead of burying your face in your smartphone while your kids play, take pleasure in helping your kids hunt fireflies or throw snowballs or walk around the neighborhood for 30 minutes in the evening. Take a big step, not a small one. Move because it makes you feel good, not because it adds steps to your FitBit.


On this day in 1980 recombinant insulin was first given to an American.

From The Louisville Courier-Journal: 

WICHITA, Kan. Synthetic human insulin was injected into a 37-year-old Wichita homemaker yesterday at the start of the first long-term study of the new. product. Sandy Atherton, a recently diagnosed diabetic, became the first diabetic., to receive the insulin, which is made with recombinant DNA. She led a test group of five patients. They received the insulin from Dr. Richard A. Guthrie of the University of Kansas School of Medicine-Wichita. A total of 50 patients eventually will take part in the test. A smaller evaluation was done in Europe on healthy people earlier this year. Guthrie said the product is identical to insulin produced in the human body but lacks the impurities of insulin' extracted from cattle and swine pancreases. An. estimated 1 million American diabetics need daily insulin shots to stayalive. The disease is caused by a deficiency of insulin, the hormone-like substance that controls the level of sugar in the blood. A few diabetics become severely allergic to impurities in regular insulin and their allergic reactions can even be fatal, Guthrie said. The recombinant DNA insulin, made by Ell Lilly and Co. in Indianapolis, was developed in 1978 by Gen-entech Inc. of Calif. Scientists took the gene for human insulin and inserted it into bacteria, causing the bacteria to become like tiny factories manufacturing the vital hormone. However, biosynthetic insulin is not the only non-human source of pure human insulin. A Danish firm recently announced a new process that makes human insulin out of pork insulin by changing its chemical structure. 

Are friends for hire a solution to loneliness?

Just out of college, one of my friends quit his good-paying, stable job at a big midwestern company to start a "jack of all trades" handyman business. He and another of our college friends mowed lawns, rebuilt decks damaged by tornadoes, repaired drywall, fixed sprinkler systems, and did other odd jobs. General handyman stuff. 

One day he was called to a house to change light bulbs. This was a common call; it was easier for people to call him than to get their own ladder and defy death above a stairwell. When he finished, the elderly lady who'd called him offered him a glass of water and a seat while she paid the bill. 

"How much would it cost to have you here weekly?" she asked. Again, this wasn't an uncommon request. Many people kept him on retainer and had him come by periodically to do little jobs. My friend eased into his spiel about the packages he had available, and what services were available at each price point. 

"No, no," she said. "How much would you charge just to come by and talk?"

I don't know what happened after this. Every time I heard him tell the story it ended there with all of us groaning about how sad it all was. How sad that an old lady was so lonely that she was willing to give money for company. The reason I bring the story up at all now is that I just read "How to Hire Fake Friends and Family" by Roc Morin in The Atlantic. 

"[Ishii Yuichi]'s 8-year-old company, Family Romance, provides professional actors to fill any role in the personal lives of clients. With a burgeoning staff of 800 or so actors, ranging from infants to the elderly, the organization prides itself on being able to provide a surrogate for almost any conceivable situation."

Some details are heart-wrenching: single moms hiring men to pose as Dad so they aren't discriminated against. Some of them are creepy: one of those single moms has never broken it to her daughter that Yuichi isn't her real dad after eight years. Some of them are downright strange, like this example of surrogacy that seems right out of an Uday and Qusay tale:

"Usually, I accompany a salaryman who made a mistake. I take the identity of the salaryman myself, then I apologize profusely for his mistake. Have you seen the way we say sorry? You go have to down on your hands and knees on the floor. Your hands have to tremble. So, my client is there standing off to the side—the one who actually made the mistake—and I’m prostrate on the floor writhing around, and the boss is there red-faced as he hurls down abuse from above."

Because of the "Romance" in the company name, I suppose, and to head off the inevitable comparison to prostitution, no, Yuichi and his workers do not provide sex. He claims that they aren't even allowed any physical contact besides hand-holding.

I've written several times in the short life of this blog about the dangers of loneliness. I've spoken about it even more. So this post isn't meant to poke fun at the sometimes bizarre social norms like this that crop up in Japan. They may only be bizarre to my western eye. After all, much of what we do in medicine, particularly in palliation, boils down to the act of being present for a person. And sometimes that's the hardest thing of all. My friend didn't take the lady's money for his company. But even if he had, I think we could argue he'd earned it. 

In the words of Yuichi himself, "It feels like work to care for a real person."


Those people look scared, don't they? Hard to blame them. I bet you're scared, too, if you're somewhere below a "1" on the Double Arrow Metabolism Wellness Index. I don't blame you. I've been there. You creep up on middle age and watch a couple close friends or family members get sick or die, you get a little disgusted with what you do for a living, you start to search for meaning. But you also can't help but cushion the hard bedrock of that dread and regret with things: donuts or steaks or a new car or a bigger house because "you can't take it with you."

But those things won't make you happy. You know what makes people happy? Mastering something. Autonomy. Friendship. Not stuff. Think of the courage on display at the average grade-school talent show. The kids have just begun to feel self-conscious, but it hasn't yet shaded out the old-fashioned fear of separation from the safe anonymity of the crowd. But they get up there and show a skill they've practiced, and they walk of the stage smiling. That's what it feels like to take control of your life. 

I know this sounds angry. But it's not. It's just honest. It's honest to what I believe are essential truths. Happiness runs along a path that you set, not a path that the big pharma companies or the food companies sets for you. So with the New Year creeping up on you, what are you going to do? Make another New Year's resolution to do some meaningless thing like "just park as far from the door of Wal-Mart as you can"? 


I'm an anti-incrementalist. The proper advice, if delivered by a physician being intellectually honest (that's me) about what would be best for a patient looking to be healthier and happier would not be to park further from the Wal-Mart entrance, but would go something like this: Leave the car at home. Don't go to Wal-Mart at all. But if you do, walk there, bike there, or bus there. The trip will be good for your body and your mind, and the lack of a fancy gas-powered wheelchair will keep you from buying a bunch of crap you don't need and spending money you'd be better off saving. And that will keep you from worrying about retirement or working extra hours (or years) at a job you don't like to pay for all the crap you just bought.

Walk to the store with a list of items that you settled upon after appropriately scolding yourself for almost falling into the consumerist trap that purveyors of early-twenty-first century crap want to snare you in. Use the list to buy those things, then walk out and walk home. Or bike or bus. If you don't think you can get home with the amount of groceries you need, get on Craigslist and buy a bike trailer.

Here's one that I found in ten seconds that you could undoubtedly have for $50 or less (or one tank of gas for the adult Tonka Toy)

Here's one that I found in ten seconds that you could undoubtedly have for $50 or less (or one tank of gas for the adult Tonka Toy)

My rig on a day when my kids had let their hedonic adaptation get the best of them and hadn't ridden to school. I delivered their bikes so they could ride home. 

My rig on a day when my kids had let their hedonic adaptation get the best of them and hadn't ridden to school. I delivered their bikes so they could ride home. 

Do you live too far from Wal-Mart or Super Target to walk, bike, or bus? Find a closer store. Chances are it's smaller, and they'll work harder for your business. Can't find one at all? Move. Move to the smallest house you can find that's within human-powered range of your job, a grocery store, and a park or university campus. The average new home in 1950 was under 1000 square feet (and the average family aimed for six people under that roof).

There. There's one item for your 2018 resolution. What else can we come up with that will make you happier?

1. Delete your social media accounts. If that's too drastic, delete the apps off your phone and make yourself go to the website. That's all the incrementalism you'll get from me. 

2. Go through your email inbox and unsubscribe to every non-essential mailing list. Modern email managers make this easy. This includes all the "discounts." They're a scam. Do you think you'd be sad if you didn't get your daily discount flier from Bed Bath and Beyond? 

3. Stop between the mailbox and the house every night and recycle every piece of mail that isn't a bill or a letter from a loved one or a magazine that you're actually looking forward to reading.

4. Stop reading this blog. Go hug a kid and offer to take her outside to play frisbee or go for a bike ride or memorize lines of Shakespeare together or pitch a tent.

5. Decide what you want to get good at and work toward mastering it. Enroll in lessons. Set aside time for practice. Now that your fifty minutes of daily Facebooking is freed up, you'll have more than enough time.

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

NBA players are going vegan for performance

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

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

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

Some are even calling it "skinny ball."


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

"[Kyrie's] had great energy all year," Boston coach Brad Stevens says of Irving. "The nutrition side is huge."
The only other player with more clutch points than Irving this season? That would be Damian Lillard, who—you don't say!—went vegan this offseason, too, dropping almost 10 pounds in the process.
"I wanted to eat cleaner," Lillard told The Oregonian this offseason. "Also I want to play lighter this year and be easier on my joints and feet. I'm getting older, you know what I mean?"
Irving and Lillard aren't the only ones. Wilson Chandler, Al Jefferson, Garrett Temple, Enes Kanter, JaVale McGee and Jahlil Okafor have all made the switch to a vegan or vegetarian diet in the past year or so. For the uninitiated, vegans don't eat animals or animal-derived products like eggs or milk. A vegetarian can order the omelette with cheese; a vegan goes for the oatmeal with soy milk.
The rise of plant-based diets in the NBA follows a worldwide uptick in meat-free meals. According to research firm GlobalData's report, 6 percent of U.S. consumers identify as vegan, up from just 1 percent in 2014. In the United Kingdom, veganism rose by 350 percent from 2006 to 2016, largely from the country's younger demographics.

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

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

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

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


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

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

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

Screen Shot 2017-11-29 at 9.47.51 PM.png

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

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

1. Prepare your body


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

That's the loop around Botanica in Wichita. 

That's the loop around Botanica in Wichita. 

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

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

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

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

2. Pimp your ride

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

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

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

3. Race day

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


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


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

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

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 I

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

5. The finish line

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

12. Patch kit.

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

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

15. Multi-tool. See above. 

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

17. Extra shift cable. See above. 

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

19. Glasses cleaner and rags.

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

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

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

23. Tire levers.

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

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

26. Gloves.

27. Lawn chair.

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

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

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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 the fam. Look for me on the tandem. See you there!

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

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

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

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

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

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

The last of the iron lungs

Get your kids vaccinated for polio, folks.

Germany has banned smartwatches for kids

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

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

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

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

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

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


Links for Wednesday, November 15, 2017: the new definition of hypertension, preventing bike accidents by driving, podcast brain-fry, and webside manner

Your new definition of hypertension is....130/90 mmHg

I remember an anthropologist in college making fun of an economist, saying the economists never changed the questions on tests, only the answers. This seems like that. But the guideline includes more organizations than I can shake a stick at:


So it has consensus going for it, I guess. And I like that it makes HTN treatment more like cholesterol treatment: initiation and targets are linked to 10-year vascular disease risk, which can be calculated here.

With a risk >/=10%, you get drugs if your BP is 130/80 mmHg or above. With a risk <10%, and you get lifestyle management alone. Everyone gets drugs at 140/90 mmHg:

HTN algorithm.PNG

"90 percent of bike accidents could be prevented by buying a car like a normal person."

I LOL'ed. 

Are podcasts frying my brain? Are they worse than silence?

I'm on board for recommendations on sleep. If we could get by with less sleep than ~7-8 hours, I figure Mother Nature would have mutated the need out of us long ago. But even though I'm a social media skeptic, I just can't quite bring myself to think that podcasts are bad for me. Maybe I love them too much. But humans are social animals, and in many cases we're put in situations where social interaction just isn't practical. Podcasts fill some of that gap for me. And I agree that the reason podcasts light up people's brains on fMRI is because fMRI is so boring to begin with:

“One of the problems you have in MRI experiments is oftentimes they are very boring,” Gallant said on Freakonomics. “If you put somebody in an MRI scanner, which is a very uncomfortable place to be, and then you flash a word at them every five seconds for an hour, they get bored out of their skull.”

To me, an apt, potentially enlightening, comparison is podcast listening versus phone calls. We know that even hands-free phone calls for drivers radically decrease the quality of driving. Listening to music is associated with no such risk, and neither is talking to a passenger in the car. So is driving while podcasting (DWP) more like hands-free driving, or is it more like driving with music? If you're futzing around with your device trying to find a podcast you like, it's clearly dangerous. That's one reason I absolutely despise Apple's new podcast app, which won't just play podcasts in series like the old app did. I have to pull over to start a new podcast if I'm in the gas-powered wheelchair. But if you don't need to touch your device to play the sound, it seems more like music. On the other hand, podcasts can't shut up when the traffic gets bad or warn you you're about to hit somebody like a passenger can. Sigh. I don't know if I'm talking myself into something or out of something at this point. 

We need to teach medical students "webside" manner

I've done a fair amount of telemedicine, all with Vigilias. (I think I was the first doc to ever see a patient on their platform). The practice is closer to in-person medicine than you think. But there are some tricks, as the article points out:

"It sounds strange, but when you're on camera all your actions are magnified," Krupinski says. Sitting six feet away from your doctor, in person, you might not mind or notice her slouching, fidgeting, or gesticulating. But a webcam's intimate vantage point augments these actions in ways that patients can find distracting or off-putting. "You take a sip of coffee and your mug takes up the whole screen, and all they hear is the sound of you slurping," she says. "Or you turn away to make a note, and now all your patient sees is your shoulder. Maybe you disappear from the frame entirely."

And this one is the hardest to get used to:

To appear as though they're making eye contact, clinicians are taught to look not at the patient on their screen, but directly into their device's webcam.

I had other little quirks in my telemedicine days: I had to move my studio to the basement because of complaints about the neighbor's dog barking in the background. And at the beginning I only "dressed" from the waist up, since patients would never see me below the waist. But I found that it made me self-conscious. I needed to have some kind of uniform on to feel like a doctor. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(paywall, but the abstract is free)

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