Monday, March 28, 2016

Testosterone; Why I Wouldn't Take It

Testosterone? Well who wouldn't want to take something that promises "strong bones, plenty of energy, sharper mind,......?

Maybe, like other cartoons, there's more fiction than truth.

Well, if it's been shown that "testosterone administration has been associated with development of acne, gynecomastia (breast development in males), peripheral edema, and polycythemia (abnormal increased concentration of hemoglobin in the blood)" maybe you'd want to rethink that decision to take testosterone supplementation.

3 double blind, placebo-controlled clinical trials evaluated a year of testosterone replacement in 790 men 65 or older with "moderately low serum testosterone concentrations."  The results were disappointing.  "Sexual function improved modestly, and there appeared to be marginal benefits in some areas of physical function and vitality as well."  

These are the findings published in the 3/14/2016 issue of The Medical Letter on Drugs and Therapeutics, a non-profit organization which takes an impartial look at new and not-so-new drugs as part of a continuing education program for physicians.  Previous studies have shown an association between testosterone replacement and cardiovascular disease as well as potentially with prostate cancer and an elevated serum PSA.  These three studies were unable to validate this but The Medical Letter closes with "the safety of testosterone replacement therapy remains unclear." 

Even though the participants in these studies were a little (or in some cases, a lot) older than the average reader, you'd expect them to have the most dramatic response if there were one.  But what about the reader who's heard that taking testosterone can improve athletic performance?  What if the salesman at the local supplement store promises vitality and youth "like back when you were college?"  For those patients with clinical low testosterone (hypogonadism - a disease) it can be of some benefit, but according to the Mayo Clinic web site, "It's unclear whether testosterone therapy would have any benefit for men who are otherwise healthy."

Mayo also points out that taking testosterone may 1) contribute to sleep apnea, 2) cause acne or other skin reactions, 3) limit sperm production and cause testicle shrinkage (shrinkage?!!) and increase your risk for DVT blood clots - see my recent blog on this subject .  They go on to point to one study where testosterone users increased muscle mass but didn't increase strength.

So, while the information on the street is that, all things being equal, you'd be a better athlete if you took this stuff, it's not supported by science and could actually cause you harm.

If you're interested, I did a piece on this last year, Testosterone. Don't Believe What You Hear! which can be found at .

Images 1,2 Google Images

Tuesday, March 22, 2016

DVT Blood Clots, Triathletes at Risk

“Don’t let the past remind us of what we are not now.”
                                                                                                 Suite Judy Blue Eyes; Crosby, Stills, Nash and Young

John Cobb, bike fitter extraordinaire, evaluates an IM age group chamipion

  It’s so easy to be hard on yourself when you under perform.  But is that fair?  Is it even accurate?  This can be a pretty rough sport, particularly when you are your own harshest critic, and you’re out for results, results, results!  I learned a long time ago that from one year to the next, any given race course can change dramatically.  Although the transition area and the bike and run courses are the same, there are many variables that you can neither control nor account for in a measurable fashion.  Sure, you know that the wind can significantly alter the face of the bike course but how about the way it changes the swim?  White caps, current, shifting of the buoys on their tethers, just to name a few of the variables which could slow your performance in a number ways. And that’s just one variable.

 So in May, at the post race party of your inaugural race of 2016, try to be aware of the host of variables that are really out of your control, but need to be taken into account to judge 2016 to any previous year. And as CSNY sing "Fear is the lock, and laughter the key to your heart."  See you at the post race party.

 Deep Vein Thrombosis (DVT), Why This is Important to You

 It’s Spring (yea!).  Summer’s coming, airline travel, extended car rides to races, and for those at risk the potential for formation of a blood clot, usually in one of the deep veins of the leg.  Sometimes these clots will dislodge, traveling through the venous system back to end up in one of the lungs in what’s known as a pulmonary embolus (PE). A PE can be a life ending event!

 One of the major risk factors is extended immobility, sitting in one position for a long time – like flying coast to coast – or some athletes with certain medical conditions, some medications, or those with recent trauma like a bike crash may be at increased risk.  Anytime blood flow is compromised or the vessel damaged, the risk is higher.  The list below, while certainly not all inclusive, gives you some idea as to the breadth conditions to consider when considering the potential for DVT:

                        Smoking                                  Oral contraceptives

                        Pregnancy                              Cancer

                        Previous DVT                         Recent Surgery or trauma

                        Obesity                                   Advancing age

                        Heart Disease

 So What Do We Do to limit Our “Exposure?”

 In short, the answer is by not staying immobile.  By moving your legs at regular intervals, walking the aisle of the plane, stopping the car at the occasional rest stop or restaurant. Even simply exercising in your seat be it calf raises, knee to chest, toe ups, etc.all help.   Avoid crossing your legs or ankles for extended intervals, avoid caffeine and alcohol to excess, and do your best to stay hydrated.

 While some DVT’s are silent, others yield swelling in one leg, sometimes both, even redness on occasion. Symptoms of a PE are not so subtle, heralded by chest pain, acute onset shortness of breath, even a pink frothy sputum in some cases.

 But, if we follow these simple tips we reduce our chances of DVT.  That said, if you think you or one of your fellow travelers has a clot, seek medical help immediately.  It could easily be the difference between life and death.

Thursday, March 17, 2016

Where Have You Gone Joe DiMaggio? Medical Advice for Triathlon

"My doctor gave me two weeks to live.  I hope they're in August."

                                                                                                   R. Shakes

I'm asked regularly for medical advice by the folks in my swim group, family and friends, even people I don't know all that well: How do I feel about this diet or that one? My shoulder hurts, what do you think? What do I know about a particular medication?  My grandmother in Savannah says her back hurts. Do I think she needs to see the doctor? That kind of thing.
These same people are usually disappointed when I don't share their enthusiasm about the newest way of eating, or fad cleanse in the world of health.  Under the guise of you get what you pay for, it's probably not the wisest - and in some cases safest thing - (see to try and do anything other than provide superficial care for your own family or friends.  And don't you know that they quickly see my doubting Thomas approach, even when they consider the current symptoms serious. "Do know what people are most afraid of?" asks Sean Connery in the movie Finding Forester.  "That which they don't understand."  So my experience dealing with matters of sickness and wellness pushes me back into the realm of the complexities of medicine.  "Well, it may not be so simple."

When you have an ache, a pain, or some type of symptom, it may not be easy correlate it to a single system or single easy explanation. "Do you think I have something wrong with my neck?  Or maybe my shoulder?  Or maybe it's infected?  Could it be cancer" Nobody wants to hear the "C" word!  So despite the incredible pace of technological advances, even Science Friday on NPR, being a physician is still about taking what he/she is told and coming up with a hypothesis or theory. An educated guess. 

So for the concerned, educated, goal oriented triathlete interested in performance improvement, health maintenance, and still having time in the schedule to tuck the kids in at night, the answer is prevention.  There's a great deal known, evidence based data, upon which to make several basic tenants on which to balance your prevention strategy but given our chosen sport, laid upon a probable already full life, many don't follow the obvious.  In fact, if you ask them, they often respond, "I know, I know.  I just don't have time."  So at the risk of being boringly repetitious, here is your game plan:

Sleep: even though we're in the midst of March Madness, pretty important here in ACC land where our local college, UVA, is a #1 seed, please, set the alarm for that morning work out and when it's bed's bed time.  Get the ball score in the morning.  Coach Joe Friel writes that "regardless of age, most of us are capable of achieving a great deal more than we even imagine is possible."  But we need sleep, "for growth and rejuvenation of the human body." 

Eat Well: There are an infinite number of dietary choices from Mediterranean to Paleo to whatever.  Do what's right for you.  But if you incorporate the thoughts of Michael Pollan into it you can't help but succeed. "Eat food. Not too much. Mostly plants." But we're triathletes and we need rules.  Pollan has many, like "If it's a plant eat it.  If it was made in a plant, don't." Or, it's not food if it arrived through the window of your car."  He suggests that the "not too much" recommendation is particularly hard for Americans and I'll bet you hear him loud and clear.  Pollan suggests we buy smaller glasses and plates. Your servings will actually seem larger.  We do this at the Post house.  "Try not to eat alone" as it will make you slow down a bit and really enjoy the meal more.  You can google Pollan for more if you wish.

Flu Shot/Tetanus Booster: Part of the prevention theme.  I know an athlete bitten by a bat on a morning run...and he argued about  whether or not he needed to update his tetanus status. Seriously?  As Nike says, Just Do It.

Be thankful: You are lucky to be doing this.  Honestly, just look around at those who won't or can't do what you do on a daily basis.  The simple act of an early morning run through the woods, easy to take for granted, but when you consider the lives of the disabled or elderly who have no possibility of replicating this time of joy in your day, it should make you grateful.

Help your body help you improve: You spend so much mental and physical energy getting faster you can't help but be a successful athlete.  The human body can survive the good, your next race, and the bad as Rolling Stone member Keith Richards has shown us for decades.  I'll leave you with two thoughts on him, the first from NYT writer Timothy Egan - one of my favorites.  If you don't follow him on Twitter you should - and the second from the old reliable Onion.
First Egan.   The cadaverous Keith Richards, at the age of 72, is a living testament to how much self-abuse — heroin, tobacco, alcohol and sleep deprivation — one man can endure. After the apocalypse, goes the old joke, only Richards and cockroaches will remain.
Or, from the Onion 3//15/16

Keith Richards' Housekeeper Has Braced Herself For Finding Dead Body Every Day Since 1976

Thank you.

Images 1, 2 Google images

Sunday, March 13, 2016

OK, Training's Getting Old, Where's Spring?

"It's getting to the point where I'm no fun anymore."
                                        Crosby, Stills, Nash and Young

"...were hung by the chimney with care, in hopes that St. Nicholas soon would be there."

The Ironman athlete above hangs his "blue bike bag" 15 hours before the gun.

Michael Phelps was asked if he would trade an Olympic medal to improve his golf game. "I'd give up a bronze to shoot under 70," Phelps said. "I don't know about (the golds). I worked too hard for them."


It may be time to lead by example

March is a hard time of year to train for those of us in the colder climates.  It takes commitment, perseverance and strength.  Training when you may not really feel like it, or don't have the longer term goal of the racing season clearly in sight.  Even though triathlon produces close and lasting friendships with training partners, the difficulty associated with "maintaining an even strain" as was said in The Right Stuff can be awfully challenging.  I was reminded of a motivational page I'd read a few years ago by sports psychologist Dr. Keith Bell and thought that reproducing it at this time of year might be especially beneficial. The steady efforts of sticking to your ATP here will pay off measurably right around the racing season corner.

"...if your aspirations are high and you act consistently to try to attain them, you sometimes risk straining your friendships.

It's a discouraging dilemma.  And, it would be nice if it weren't that way.  But the fact remains that some of your friends may not have the drive and dedication you do.  Or, they may not share your high goals.  Then, your friends may try subtly coax you into their less hard working ways. It's not that they are intentionally trying to drag you down.  They just don't want to look bad next to you. So, they invite you to join in their rebellion, confusion, bad habits, or low level of aspiration.

You need not reject your friends, but neither do you have to give up your goals to join the crowd and the fun.  If it's hard to do your thing while they are doing theirs, talk to them about it.  Don't scold them for their actions, but ask for their acceptance and encouragement in your quest to reach the top.

And encourage your teammates.  Pay attention to a job well done by them in practice. Encourage them to strive for more.  How you act and what you say to your teammates is contagious and has a way of coming back to you.

Set a norm and get after it: to challenge yourself and others.  Don't let the norm become an avoidance of effort.  Don't make it "cool" or "in" to goof off.

Remember your goals.  And protect them. Take good care of them. You may have to.  Others may not have the same goals."

In short, this time of year proves why you have what it takes to be a winner, a leader, the strongest in the group! 


One of the benefits of triathlon.....


Phelps quote, Sports Illustrated, 3/4/2013
Dr. Keith Bell, Psychology for Swimmers, 1980

Sunday, March 6, 2016

Your Dog Just Bit a Lawyer!

A patriotic looking Tim O'Donnell in 2013

 We're slower bikers than we used to be.  Or maybe the dogs have gotten faster.  Either way, a dog's teeth pierced my buddy's ankle skin a while back when we were cycling on a quiet Sunday morning not that far from Thomas Jefferson's home, Monticello.  

We saw the house where the dog ran back to and Mike, big local trial lawyer in these parts and Kona vet, slowly turned his bike around, pedaled a couple revs and coasted to the mailbox at the end of the dog's driveway.  Subsequently coming to a stop, leaning on their mailbox, he made this big production of pulling out a pen and paper from his fanny pack. He should have been nominated for an Emmy.  He  knew he was being watched from inside the home.   

Still sitting on his bike he leaned over the side of the mailbox to carefully, ever-so-slowly, read and copied the owners name and address onto the paper for "later use."  The front door opened slightly and a woman appeared.  Mike glanced up from his writing, looked her right in the eye, and in his strong lawyer-scary voice told her "Your dog just bit a lawyer!"

We then rode south about 100 feet to tend the the bite marks, and very slowly, a huge man in a blue pick up pulled up behind us, almost silently, and got out. Clad in blue bib overalls only pulled halfway up. (He'd also neglected to put on shoes or a shirt.)  One look at his face told you that 3 minutes earlier he was pillow hugging for sure.  He'd been ordered to fix this. "You boys alright?" he questioned.  Despite his fearsome size and shape, Mike knew "I had him!"

It turned out that Mike's ankle was not the first two-wheeled morsel the dog had tasted and they'd already been reported the animal control folks.  Although the owner was "real sorry," this was a common place to ride, and for all bikers in the future, we turned him.   The animal was found to be disease free luckily.  The last time we rode down that way we saw a nice, new, shiny chain link fence around the yard.  Score 1 for triathletes!

 As for the rest of the story that day, we cleansed the bite with everything that was in my water bottle. I really tried to remove as much of the dog's saliva from the wounds as possible.  We then put some Neosporin on it and a dressing.  (OK, OK, I'm a surgeon, I ride prepared for this kind of thing.  (And allergic reactions, and road rash, and...)  We rode home so Mike could further irrigate the wounds.   As soon as we were back in cell phone range, I called my doctor wife, gave her the facts and the dog's house address in case the headlines in the next day's paper included "Bikers Shot South of Town" so she'd know where to start the search.  

 Although you're concerned about infection, rabies - although unlikely - is more of a concern. I had a bat land on my head once while running - I know, I know - a what?  Although I felt the sharp claws as it landed on my skull cap, the skin wasn't broken and I wasn't bitten.  Bats are known rabies carriers also.  The difference here is that with the dog, it can be observed for any signs of illness, it's inoculation status is known, as is it's physical location.  None are true with the bat.

 We've been vaccinating dogs in this country for over seventy years and this has reduced the number of documented cases of rabies to less than 5 annually.  Internationally, however, upwards of 50,000 deaths occur each year from rabid animals, probably more. In the U.S. when we think rabies we think skunks, racoons, foxes, and as mentioned, bats. A bat's bite can be missed, particularly by children. If one is found in the home, particularly a home with access to sleeping children, it should be caught for later examination.

 In short, although dogs chase us repeatedly, and there are some roads we avoid simply due to canine presence, should you be bitten do the following:

1) Cleanse the wound as best you can immediately

2) Seek medical evaluation that day

3) Identify the animal and inform local animal control

 As noted above, very few die from this disease. But if you need the post-exposure rabies prophylaxis (series of shots), they are neither painless nor cheap. In other words, forget about those new aero wheels!

But when that new law office opens up down the street, why not swing by one afternoon and see if he/she rides.   It could be right handy one day!

Thursday, March 3, 2016

Why You'll Finish Your First Ironman

Seconds away from hearing "You are an Ironman!"

Completion of 140.6 miles of racing takes many things.  Among them is belief.  Belief that you’ve put in enough training, the right kind of training, that Mother Nature won’t have it out for you like at IMAZ recently serving up a cold and rainy day. "But I've never done one of these, how do I know I'll cross the line to "You are an Ironman?" you wonder.

A full 17%* of USAT registered athletes are just like you, 140.6 racers, and they all had to do their first one.  Like you, they showed up on race morning with the belief that, with a little luck, they could do this thing.  They believed.
Here’s an example.  I was backpacking with our daughter in Sequoia National Park a couple years ago, 15 miles from civilization.  As we were putting finishing touches on packing up for the hike back out, bidding adieu to the other family that had shared the campsite with us the previous night, their Mom mentioned that somehow she’d lost her wedding ring “like a complete idiot, I washed my hands in the river 2 miles back and put the ring in my pocket for some stupid reason.”  She was certain that she’d never see it again, “but if perhaps you see it, could you pick it up?”  Seriously ?  Millions of acres of park land and I’m going to find a dropped wedding ring?  I told her I’d give it a try knowing that she was SOL as far as this ring went holding little hope inside that it would be seen by mankind again.

But if there’s one thing I’m good at, very good at actually, it’s finding things. My wife’s car keys, that misplaced earring, that kind of lost item.  I don’t know why, maybe it’s chromosomal.  I enjoy the challenge of doing something others cannot and I’m very patient.  Sort of like your iron distance event coming up.
So rather than hike at a break-neck pace like our girls, I took my time as we headed downhill out of Hamilton Lakes.  After about half an hour of absolute concentration staring at the rocks and plants about my feet, under, and around every possible crevice seeing nothing other than more rocks and plants, I thought I noticed a hint of grey.  But aren’t wedding rings gold?  Mine is.  My brothers is.  It was just that this was something different.  Maybe it was a tent grommet, or portion of some tarp in the distant past.  As I bent over to retrieve it I saw that indeed it was a ring.  A ring with initials engraved in it, the object of my search!
I’m not sure why but I’d had the forethought to get the woman’s mailing address.  Subconsciously cocky that I’d find it? Yes, you may be right.  But you’re going to the start line of your first Iron distance race, you have to have more than just a little confidence that you’re going to succeed at the challenge of doing something that others cannot.  You have to have at least a touch of “attitude.” I mailed it back to her Michigan address when we got home.  Lucky me.  Lucky her.

So in the hours before your first Ironman, review in your mind the effort expended to get there, the personal and family sacrifice that permitted you a shot at becoming an Ironman.  Remind yourself that you have 17 full hours to finish this thing and that the goal, the only goal mind you, is finishing.  Be nice if the first stop after crossing the finish line wasn’t the medical tent too!  Start off slow and ease back as they say.  Believe.