Are triathlons dangerous?

First things first: I've never done a triathlon. I swim like a St. Bernard. But I've done a lot of endurance bike racing, and I've been at more than one event with a death, the most recent the 2017 Dirty Kanza. So I was interested that in the latest Annals of Internal Medicine, investigators looked into a sudden death database to identify 135 race-related deaths and cardiac arrests in American triathlons between 1985 and 2016. Interestingly, right at two-thirds of deaths and arrests happened in the swim part of races, which usually comes first, before the bike and run. The editorialists spend a lot of energy trying to link swimming to some special form of stress from cold water or other factors that might be extra-dangerous. But to me, the swimming link seems consistent with the finding that in autopsies, about half of subjects had cardiovascular abnormalities, most often old-fashioned atherosclerotic disease. Swimming caught most of these people simply because it was the first event. Had running or cycling come first, I suspect one of them might have been the death leader. I'm not convinced by their observation that most marathoners die toward the end of races; anyone who's seen the scrum at the beginning of a triathlon knows that it's inherently different than the often walking pace seen at the start of a marathon: 

From http://www.zwemza.com/?p=5515, triathletes tempting fate. 

85% of victims were male, but I'm not sure the significance of that number, since >60% of participants (at least in pro Ironman races) are male:

From https://www.outsideonline.com/1964906/fight-gender-equality-ironman

And if you look at total Ironman competitors, the distribution of sex comes much closer to the death/cardiac arrest statistics:

But sex aside, we're forced to see that cardiac arrest and death are not rare among triathletes. Between 2006 and 2016, their incidence was 1.74 per 100,000 participants in the study. The risk of death increased with increasing age, unsurprisingly. Don't let this dissuade you from being more active. The benefits of physical activity far, far outweigh the risks in almost everyone. If you're inactive now and thinking of becoming active, or if you're active now and thinking of doing really hard-core things like triathlon, consider taking the American College of Sports Medicine's new-ish algorithm to your doctor and talking it over before you hit it really hard:

We don't know how really weird stuff like performance enhancing drugs effects this. My suspicion is that it's not good. 

Links to health for Wednesday, August 9, 2017: Laennec and his stethoscope, rich people love endurance sports, the health of elite athletes, and mythical drug expiration dates

After Rene Laennec invented the stethoscope, he encouraged other doctors to make their own.

This is reminiscent of the way Banting and Best handled insulin: 

"...the first “sale” of insulin was for just $3 (Canadian), not for a vial, but the very intellectual property of the drug itself. Frederick Banting, Charles Best, and James Collip, the team that first discovered and refined insulin therapy, agreed to receive $1 each in exchange for giving their patent rights to the Board of Governors of the University of Toronto in 1923.

This was a bold move, and not without controversy at the time, according to an article posted by the University of Toronto Centre for Innovation Law and Policy. At the turn of the 20th century, it was considered beneath scientists and universities to patent medical innovation at all. However, Banting and company believed that they needed to patent their formulation of insulin to stop pharmaceutical companies from rushing to patent an inferior, less potent form of the drug. The university immediately gave pharmaceutical companies the right to manufacture insulin, royalty-free, and to improve upon the formulation and patent any subsequent improvements."

If only we saw such responsibility and modesty from drug manufacturers now.

But back to Laennec: it is strange that we continue to venerate the stethoscope 200 years after its invention, especially when we have rapidly evolving, already far superior equipment in the form of handheld ultrasound. As the folks at 99 percent invisible note, docs no longer routinely carry reflex hammers or pinwheels, but they still overwhelmingly carry stethoscopes. I do not. You can't auscultate an adrenal tumor, you know what I'm saying? Bedside ultrasounds are the future, period. They'll just reach full market penetration sooner in the US than in developing countries.

Why do rich people love endurance sports?

Brad Stulberg pontificates on why endurance sports are so popular among high-income people. 

"...data collected in 2015 by USA Triathlon shows that the median income for triathletes is $126,000, with about 80 percent either working in white-collar jobs—professions such medicine, law, and accounting—or currently enrolled as students."

Once upon a time, and still for a shrinking older population, golf was the sport that signaled wealth. But now, with the fuzziness that surrounds the measurement of effectiveness in the knowledge economy, endurance sports give white-collar workers a simple, quantitative way to measure progress. You run/swim/bike/ski faster or slower than you did the last time, period. And the pain doesn't hurt (pun intended):

“By flooding the consciousness with gnawing unpleasantness, pain provides a temporary relief from the burdens of self-awareness,” write the researchers. “When leaving marks and wounds, pain helps consumers create the story of a fulfilled life. In a context of decreased physicality, [obstacle course races] play a major role in selling pain to the saturated selves of knowledge workers, who use pain as a way to simultaneously escape reflexivity and craft their life narrative.” 

Link from marginalrevolution.com

Related: Are elite athletes healthy?

Answer: it's complicated.

The myth of drug expiration dates

A pharmacist finds a cache of drugs, unopened, all 30-40 years past their expiration date. He has them tested by a toxicologist. The result? All of the drugs--all of them--are still useable.

Congressman Earl Blumenauer (and his sweet bow tie) wants to reform the Farm Bill

Link from foodpolitics.com