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)

Circling the parking lot = circling the drain

A couple weeks ago, I spent some time in a YMCA parking lot to do the Wichita Area Metropolitan Planning Organization's bike/pedestrian count. I was in a pretty rural area, and the bike/ped traffic was light. It gave me a chance to watch the steady stream of cars in and out of the lot, though. The Y was rocking, which made me happy, but I couldn't help but wonder about the goals of the people in the cars screeching in and out of the driveway.

A woman who worked in the office of a YMCA recently told me that one of the biggest safety issues the organization deals with is parking lot safety for pedestrians. So many people circle the parking lot in their fancy gas-powered wheelchairs during busy times that pedestrians crossing the lot were in danger of being run over.

This is not the kind of wheelchair I'm talking about. I might respect someone who circled the health club parking lot in this rig. By the way, there was a third dog riding on the scooter. Respect. This must have been a logistical nightmare to get out the door. 

This is not the kind of wheelchair I'm talking about. I might respect someone who circled the health club parking lot in this rig. By the way, there was a third dog riding on the scooter. Respect. This must have been a logistical nightmare to get out the door. 

She was talking about people circling the lot, mind you, so that they could walk the minimum distance to get into the building and walk...on a treadmill. Or ride a stationary bike or something. 

This problem is a bit of a throwback for me. I remember as a kid, when the remote controls for TVs were still mostly up-and-down affairs (hit the up arrow to scroll upward through channels, hit the down arrow to go the other way; ditto volume), I would, out of habit, walk all over the room looking for the remote so I could change the channel on the TV. I would walk multiples of the distance it would have taken me to simply get off the couch and walk to the TV and push a button. But like the Kodak people who couldn't imagine a world without film, I couldn't imagine a world without the satisfying weight of that remote, with its sleek aluminum Sony case, in my hand. 

Is there a name for this particular brand of self-defeating convenience? I've stretched Google's abilities to the limit and I can't identify one. But it clearly pre-dates modern technology. And don't get me wrong. I've ridden, and continue to ride, an absurd number of miles in cars. But I've felt like an asshole for almost all of those miles that didn't involve traveling outside of town. 

But back to parking. Scott Wadle of the City of WIchita likes to say that there's no such thing as free parking. While he means that we all subsidize the space that cars take up whether we mean to or not, I think of it in more cosmic terms. All that space could be used for something else. And the physical activity it would take us to park in vertical garages and walk to our destination, or the slightly greater physical activity it would take for us to bike to work would be a small price to pay to get green space and health back. An optimist's view of the coming autonomous fancy gas-powered wheelchairs is that we'll need far less parking, thus opening up more and more space for commerce and for public use. A pessimist's view is that we'll eventually transition to a WALL-E situation in which your autonomous gas-powered wheelchair picks you up at your door to deposit you in front of the door to your office, at which point a smaller, more Segway-inspired motorized device takes you to your desk. Where you sit. All day. 

I'm not going to talk about "productivity" or "optimization" here. There are plenty of places to get a dose of that perspective. But just consider this when it comes to the YMCA or your local health club: grinding away on a treadmill for 30 minutes a day after driving an oversize luxury wheelchair to the building is not my idea of freedom. It's a chore. But if I turn that chore into the choice to walk or ride by the health club while I watch all the wheelchair circle: that choice makes me unspeakably happy.

You can't use drugs to "prevent" diabetes

Big, big disclosure here: I am a paid consultant for a CDC grant that aims in part to increase use of the Diabetes Prevention Program. So there. Read on.

Good to see you again, Mrs. D. You mind if I call you Mrs. D? Thanks. Reminds me of "Mrs. C" on Happy Days. You know, she was the only one with the cojones to call the Fonz "Arthur." So you can see the resemblance.

I'm glad you asked about the recent study that showed a medicine called "liraglutide" (brand names Victoza or Saxenda) "prevented" diabetes. You're a smart person, so you read some of the fine print in the study, and you know that ~2200 patients, most of them obese, were randomly given a daily shot of placebo or a daily shot of liraglutide, a chemical that mimics a gut hormone to trick the pancreas into producing more insulin. Liraglutide has the side effect of making people feel fuller sooner after eating. Doctors call this "early satiety." The tricky vocabulary's how we make so much money.

All of the patients had elevated blood sugars, but not so elevated that they could be labeled "diabetic." They were "pre-diabetic" in the current nomenclature, just like you. It means the same thing as "impaired fasting glucose" or "impaired glucose tolerance." The study set out to prove that liraglutide could "prevent" the onset of diabetes. Now you're probably wondering: If I'm taking a diabetes drug, what's the point of having "prevented" diabetes?

And you're on to something, Mrs. D. This is an absurd question at face value, but it keeps getting tested, mostly by drug companies. Not surprisingly, in most cases people getting the diabetes drug were less likely than those getting a placebo pill or shot to have their blood sugars rise high enough to be diagnosed with diabetes.

I'm about to get really, really snarky, Mrs. D, but before I do, it's important that I make this point: the prevention of diabetes is actually a HUGE deal, and not only because diabetes remains the number one cause of blindness, kidney dialysis, and foot amputation in the United States. It is astonishingly expensive. Of the $3.2 trillion (!) that Americans spend on health care annually, diabetes directly accounts for $101.4 billion, making it officially the most expensive disease in America. If you can prevent people from advancing from the just-a-little-abnormal-sugars "pre-diabetes" to old-fashioned diabetes, you save about $12,000 per year in expenses. Now, that's insurance company money, but we all pay for it in premiums.

This is where your insurance premiums are going.

This is where your insurance premiums are going.

And as I've pointed out before, a big chunk of that extra spending isn't insurance money at all; it's coming out of your pocket in the form of co-pays and whatnot. And it's not much better for the Medicare crowd, who we all pay for in taxes:

So let's perform a quick thought experiment. You came to see me because you weren't feeling your best, and I checked a blood sugar on a hunch, and it's slightly elevated at 106 mg/dl. That's in that pre-diabetic range I've been talking about.

Bummer.

Now, we've got some options here. But let's say I tell you that the best way to keep yourself from becoming diabetic is to inject yourself with 10 units of insulin every night before bed. That way, your blood sugars will go back to normal, and we can both wash our hands of the whole issue. Great, right? We've prevented a case of diabetes! Your blood sugars are normal, after all.

BUT YOU'RE ON A DIABETES DRUG NOW!

Of course we haven't prevented a case of diabetes! We've just put you on a diabetes drug that has (predictably) lowered your blood glucose levels. The entire assertion that we've prevented anything is as laughable as the assertion that we could "prevent" a diagnosis of hypertension by putting you on blood pressure medications.

To make the situation even more ridiculous with liraglutide, it costs a fortune: over $3,000 a month for the 3 mg dose! If you wanna know where that extra $12k a year is going, I think we're hot on the trail. Think what else we could do with that amount of money. And if you for some reason think the idea of "preventing" diabetes by taking a diabetes drug isn't patently absurd, it works only modestly better than metformin, a drug that can easily be obtained for $3-4 per month.

But the final insult, Mrs. D, is that liraglutide worked barely better in its study than a program called the "Diabetes Prevention Program," or "DPP." In the liraglutide study, roughly 2% of people receiving the drug went on to have blood sugars high enough to be diabetic in three years, versus 6% of people getting placebo, for what we call an 80% "relative risk reduction." (Drug companies love using relative risk because it makes the numbers sound so much more impressive) In the original version of the Diabetes Prevention Program, 4.8% of people getting counseling on diet and lifestyle by a coach went on to be diabetic, versus 11% getting placebo, for a 58% relative risk reduction. The numbers for both groups in the DPP were higher, which I blame on an older participant population.

The cost of the Diabetes Prevention Program? $429 per year. So you might not be surprised to know that in 2016, when CMS was debating whether to allow Medicare to cover the DPP, the Pharmaceutical Research and Manufacturers of America (PhRMA) fought against it, saying that twenty years of evidence was only "preliminary." They do. Not. Care. About your health or the seemingly inevitable transformation of America into a single, enormous insurance company that also happens to field a Navy. And we should all remember that back when insulin was discovered, the University of Toronto held the patent for insulin to keep any single company from exploiting the drug for unreasonable profit. How times have changed.

Okay. Deep, cleansing breaths. I'm calming down. Liraglutide is a good medicine for diabetes. It helps keep sugars down, it helps with weight loss, and it may even help prevent heart attacks. In diabetics, that is. But you're not diabetic, and you don't have to become diabetic, and all drugs come with a cost, financially and otherwise. I think we can agree that diabetes is expensive enough; we shouldn't use drugs to "prevent" it that are even more expensive than the disease itself.

So, Mrs. D. You'd be a great candidate for the DPP. But even if you weren't, do you know what the DPP asks of its participants? 150 minutes a week of physical activity and some dietary modifications to allow you to lose around 7% of your body weight. Let's think about what that might look like. The average bike commute in this country is around 19 minutes one-way. Do that five days a week, and you're at 190 minutes already! And that doesn't even count trips to the grocery store! And if you stop drinking insect bait and cut out the foods that aren't really foods:

If you cut those out from your diet and start eating most of your food from the produce aisle or from the canned fruits and vegetables aisle, don't you think that 7% weight loss sounds pretty modest? I bet you'd blow it out of the water. 

And besides, do you really want to cross that grim threshold from "person" to "patient?" Because the first time you put the needle of that Saxenda pen into your skin, that's what you'll have done. You'll have moved the wrong direction on the Double Arrow Metabolism Wellness Index. You'll have gone from a person with agency, someone who takes medicines to feel better or live longer, to someone who has yielded control to a chemical--a $30,000 a year chemical--to do something you could have done better yourself. You'll have succumbed to a philosophy of better living through chemistry.

Maybe Du Pont doesn't deserve this.

Maybe Du Pont doesn't deserve this.

Or do you want to be the person who SAVES thousands of dollars per year by ditching the fancy gas-powered wheelchair so you can propel yourself through space with your own legs and feet and by eating real foods you made with your own hands and eating them when you want, the way you want, and in the quantities you want? Do you want to live by a philosophy of self-determination, where you know that every healthy, happy day you live from now on was of your own making? 

If that life is what you want, then don't try to prevent diabetes with drugs. It can't be done. 

What the hell is water?

There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says, "Morning, boys. How's the water?" And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, "What the hell is water?"

-David Foster Wallace

 

I don't know exactly what the late, great DFW meant by this. Tragically, he's not around to tell us. But what I think he meant is that the most important realities are often the ones that are the hardest to detect. And to continue to borrow DFW's analogy, most of us paddle forward as best we can without ever feeling the flow of water against us, pushing us back, keeping us from reaching our potential. That rush of water consists of a lot of things, but most of them are visible if you look closely.

I’m a physician, as you might have deduced by the initials after my name. And physicians by training are supposed to notice the things that others don't. But most of us don't, and I've been more guilty of this than anyone in the past. See, I'm an endocrinologist. That’s a specialist in metabolic and hormonal disorders (think disorders of the pituitary, thyroid, and adrenal glands; and osteoporosis and diabetes and whatnot). You’d think that an endocrinologist is a person particularly well-trained to help patients escape the vortex of fancy motorized wheelchairs, faux-foodtime-sucking devices, and all the other things pulling us under.

But that’s not at all what I was trained to do. In fact, I found during my career as an academic endocrinologist that instead of getting people safely to shore, I was often quickening or deepening the vortex that my patients were swimming in. In 15-minute office visits, I’d prescribe drugs that cost thousands of dollars and have trite, brief (in case the 15-minute visit didn’t give it away) conversations about what they could do with their weight, or their fatigue, or their sadness. The visits cost me 15 minutes, that is. They cost my patients a lot more. A lot more.

I was doing my best, obsessing over the things I could measure or manipulate, like blood sugars, cholesterol, blood pressure, and weight. All those are important. Don’t let anything you read here convince you otherwise. But I was swimming in the vortex myself. I simply paddled forward in the water I was trained to swim in, comfortably moving myself from today into tomorrow, spending the loads of money I made on things that didn’t make me happy and working extra hours to pay them off. I drove like a maniac between two clinics and four hospitals, often putting almost 100 miles a day on my car. The vortex deepened. The extra hours ate into time that I should have spent doing things I loved, like chasing my kids or riding my bike, so I weighed thirty pounds more than I wanted to. The water sped up. And then my blood sugars--one of those things I prided myself on controlling--started going up. And then I started getting really unhappy and resentful at work. I was swimming as hard as I could, but spiraling. What I couldn’t detect was that I and my patients needed to become people again.

What’s that? My patients weren’t people? What am I, a veterinarian?

P. henrylawsoni  can out-wrestle  A. woodhousii  any day of the week.

P. henrylawsoni can out-wrestle A. woodhousii any day of the week.

What I mean is, that once a person crosses that gauzy threshold from the waiting room to the exam room, he experiences a transition from personhood to patienthood. And patients are bad swimmers. Let me illustrate. Most of us, whether we’ve thought about it or not, exist somewhere on this spectrum:

  1. I feel great. I’m as healthy as I can be, and I’m intentionally doing things daily to improve my health.
  2. I’m healthy, but mostly by accident.
  3. I’m not sick, but I don’t feel good. I’m always stressed out.
  4. I have one or two health problems that I manage pretty well, but I’m broke.
  5. I have a few health problems that I struggle to manage, I’m broke, and I’m working a second job to pay medical expenses.
  6. I have been hospitalized one or more times in the last year for chronic health problems, and I can’t work.
  7. I’m in a nursing home or assisted living because I can’t take care of myself anymore.
  8. I am dying.

The thing about this spectrum is that the strategy for moving up on it depends on where you start, and it’s never a straight line. If you’re one of the unfortunates at #7 or #8 that our system most definitely calls patients, my thoughts are with you. If you are at #5 or #6, your strategy for moving up may involve a lot of pharmaceutical help. I have opinions, at least metabolically speaking, on what that help might look like. But if you’re at #4 or above, and you’re working on getting to #1, the path to get there may meander through the local pharmacy for a bit, but most of the path is outside in the sunshine and fresh air. The path most definitely does not intersect with your couch.

So by reading this blog, if you’ll bear with me, you’re going to learn to feel the water around you, and you're going to get the skills to map out your own path out of the evil vortex. I intend to be completely honest and transparent about what I know and what I’m not so sure about. There’ll be philosophical stuff, like what a good partner in health ought to offer. There may even be diversions into seemingly unrelated topics, like pop culture, the weather, or my favorite, cycling. If I haven’t scared you off yet, come back for the next post.