Sunday, February 25, 2018

Eating Disorders and Triathletes, Close to Home?

National Eating Disorder Awareness Week 
starts today.  Their website notes: 
"Our theme this year is Let's Get Real and our goal is to expand the conversation and highlight stories we don't often hear. Our culture has complicated relationships with food, exercise, and appearance.
30 million Americans will struggle with a full-blown eating disorder and millions more will battle food and body image issues that have untold negative impacts on their lives.
But because of stigma and old stereotypes, many people don't get the support they deserve. Join the conversation and help us raise awareness, bust myths, get people screened, and start journeys to healing."


One local athlete confided in me a couple years ago that, when growing up, she was one of those with an eating issue, "and it was a real problem getting over."  She says they called her "chicken legs," and it bothered her greatly.  But get over it she did.  Susequently, she blossomed since!  She was able to turn this liabilty as a youth into a significant asset as a now adult long course triathlete.  (I can see you're jealous already.  Me too, actually.)  She has a little better control of what makes it off her plate into her mouth, perfect awareness and motivation that those in this sport try so dilgently to attain. 


While touring colleges with my daughter a while back, I found this posted on the wall of the infirmary of a mid west university:

                                                            Staggering Facts...

  • 54% of women would rather be hit by a truck than be fat (Martin, 2007)
  • If mannequins were women, they would not be able to bear children.
  • Research shows that just 3-5 minutes of engaging in fat talk substantially increases body dissatisfaction (Stice, 2003)
  • Four out of ten Americans either suffered or have known someone who has suffered an eating disorder (NEDA, 2005)
  • As many as 20 million females are battling an eating disorder such as bulimia or anorexia. Millions more are battling binge eating. (Crowther, J. H., et al. 1992)
  • Most fashion models are thinner than 98% of most women.
  • 81% of ten year olds are afraid of being fat (Martin, 2007)
  • 25% of American men and 45% of American women are on a diet on any given day (Smolak, L., 1996)
While I cannot speak for the reproducibility of these "statistics" you get the point.  Eating disorders are serious business and triathletes are neither excluded nor immune. Even celebrities like Paula Abdul, Justine Bateman, Karen Carpenter, Susan Dey, Tracey Gold, Princess Di, and Joan Rivers have experienced an eating disorder.  EDs have the highest mortality of any of the mental illnesses.  In fact, 20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart disease.  But, according to the South Carolina Dept of Mental Health only one person in ten with an eating disorder ever receives treatment.

If you're reading this blog it's because you're interested in triathlon performance.  Compiling a complete piece on eating disorders is beyond the scope of this blog but suffice it to say that it's a serious issue with endurance athletes and can have a negative influence on their performance.

Casa Palmora is a clinic in California that specializes in those patients with ED.  In their advertising they point toward a number of famous athletes who've suffered with eating irregularities including 9 time Olympic Gold Medalist Nadia Comenechi and Bahne Rabe, a winner of 8 Olympic Gold Medals in rowing who also suffered from anorexia which would ultimately contribute to his early death.

Others you'd know include tennis player Zina Garrison, skater Nancy Kerrigan, jockey Laffit Pincay, gymnast Cathy Johnson, etc.  A quick check of PubMed notes a study by DiGioacchmo et al. of 583 triathletes  where 39% of the females and 23% of the males scored below the mid point on a standardized test to construct Calorie Control.  "All of the subjects indicated dissatisfaction with their body mass index (BMI). The study participants revealed attempts to reduce body weight by means of energy restriction, severe limitation of food groups and excessive exercise...  "The triathlon seems to be a sport that is susceptible to a higher prevalence of disordered eating," noted this study. 

Nancy Clark, RD says that, "Athletes with eating disorders tend to be very talented, hardworking people who ache inside and fail to see their strengths.  Something inside them says they should always be working or studying or exercising.  Taking time to hang out and chat with others makes them feel guilty.  They need to learn being "human" - like the  rest of us - is more attainable than being "perfect." That said, I would predict that many of you reading this right now understand that need to be doing, doing something, and doing it right now.  Right?
So whether you are talking bulimia, anorexia, etc. in most cases they can be both treated and prevented.  We define eating disorder generally as an "obsession with food and weight that harms a person's well being."  The cause is incompletely understood, and although initially it may start with a preoccupation with food and weight, this is a multifaceted affliction. Societal pressure for "thin is in" or "you can never be too thin or too tan," excess stress or needing to have the feeling of being "in control" all contribute.

We already know that in addition to diminished athletic performance, physical problems can effect the heart, kidneys, GI tract, and lead to menstrual irregularities as well as dry, scaly skin.

For the person with an eating disorder, accepting the fact that treatment is in order may the single hardest step.  Occasionally inpatient hospitalization is required.  Significant counseling of the patient, spouse and family can all contribute to the potential for success.  The Internet is rife with help like the National Eating Disorder Association whose sole goal is to aid those in need by specialized, individually oriented care hopefully pointing to a successful outcome.  They are careful to address both the medical and nutritional components as well as assisting in securing insurance company coverage when needed.

In summary, this is a common, destructive disorder and if this blog leads to just one person seeking assistance, it will be my most successful writing to date.  Help a friend!

Credits:  NEDA
              Google images
              Denison University Health and Counseling Center

Sunday, February 18, 2018

Atrial Fibrillation, Afib or AF, in the Endurance Athlete

"Don't call for your surgeon, even he says it's late.  It's not your lungs this time but your heart holds your fate."          Manfred Mann

Although it might be somewhat surprising, the single most popular piece I've written here, and mind you this is a triathlon oriented blog, was on pills.  Antihypertensives to be specific; medication for blood pressure control.  So this issue will expand on that writing that addressed rapid heart rates in general and review a very commonly seen abnormal rhythm called atrial fibrillation also written AF or Afib. More people than you would guess have this issue, particularly those in the sport for decades.

Usually the heart beat is regular and labeled normal sinus rhythm, NSR.  But in Afib, the ventricles, or major pumping chambers, receive a rapid, erratic signal and pump at a varying, irregular rate.  Although some can have AF and be symptom free, others can experience chest pain, dizziness, fainting, or be intolerant to exercise,etc. They can be at a 7-8 times increased risk of suffering a stroke.

The diagnosis is made after obtaining a history, physical exam and EKG.  Occasionally an echo cardiogram or blood work are also indicated.  Then, one would search for the underlying cause to choose treatment options.  Interestingly, a common cause is dehydration.  Also found can be an over active thyroid, hypertension, certain types of lung disease, diabetes, excessive alcohol consumption, etc. although finding no definite cause is quite common.  If the diagnosis is in doubt, the patient can be fit for a monitor which continuously records the EKG for 24 hours or longer. Once this diagnosis is made, the goal of treatment is to restore the heart rate back to a normal level and diminish the risk of stroke.  Often this is more of a challenge than the patient (athlete) would like.

Medically, a number of medications are available for stroke prevention including aspirin, warfarin and the newer (read more expensive - and to be fair, much more user friendly) agents.  When addressing the abnormal rhythm, various meds are available and, when ineffective catheter ablation may be offered.  This is catheterizing the heart, usually through one of vessels in the leg, and attempting to both locate and destroy the tracks along which the abnormal electric signal travels.  As you might imagine, it's a big deal!  I found an on line ad for the Cleveland Clinic where they advertise having performed more than 1200 ablations for AF last year with success.

I've read various posts over the years on various tri forums, readers echoing the disappointment that their medical issues not only limit their ability to train but race as well.   One athlete with significant AF summed it up this way, "I am not letting it take over my life, but it ****ing sucks that I can no longer participate at the level in endurance sports that I had been able to achieve with 20 years involvement in one sport or another (running, cycling and tris).  I even dropped out of IMLP since I knew I couldn't train for the race in my condition."  (I really feel for this guy and I know you do too.)

So, if you've recently been given the news that you have AFib and it requires treatment, research it out, get as much information as you can, and do what you and your physician think is best for you.


"No One Said It Would Be A Piece Of Cake?"
This hand written note was tied to a sign at about the one mile mark of the bike in Kona in October.  A mile later there was one that read, "Cake?  We have an App for that!"  And a mile get the picture.  Isn't it nice that on days when we occasionally feel isolated and exhausted, that we have friends and family to remind us that they're still there, and they care.  Make sure you thank them every day.                                 

Sunday, February 11, 2018

Xrays, MRIs, Cat Scans: When do You Need What

"How long can you stay fresh in that can?" The cowardly lion on first introduction to the tin man.

                                                                          Bert Lahr in the Wizard of Oz

A former patient of mine, upon being told that an MRI was the next step in diagnosing what was thought to be a rotator cuff tear, wanted to know how long he's have to be stuffed "into that can?"

 A big arm of the American Academy of Orthopedic Surgeons, the AAOS, is education.  People don't always know the differences between these studies, what they show - and as importantly what they don't show - so I've reproduced this to eliminate that lack of understanding.

X-rays, CT Scans and MRIs

Diagnostic imaging techniques help narrow the causes of an injury or illness and ensure that the diagnosis is accurate. These techniques include X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI).

These imaging tools let your doctor "see" inside your body to get a "picture" of your bones, organs, muscles, tendons, nerves, and cartilage. This is a way the doctor can determine if there are any abnormalities.


X-rays (radiographs) are the most common and widely available diagnostic imaging technique. Even if you also need more sophisticated tests, you will probably get an X-ray first.

The part of your body being pictured is positioned between the X-ray machine and photographic film. You have to hold still while the machine briefly sends electromagnetic waves (radiation) through your body, exposing the film to reflect your internal structure. The level of radiation exposure from X-rays is not harmful, but your doctor will take special precautions if you are pregnant.

Bones, tumors and other dense matter appear white or light because they absorb the radiation. Less dense soft tissues and breaks in bone let radiation pass through, making these parts look darker on the X-ray film. Sometimes, to make certain organs stand out in the picture, you are asked given barium sulfate or a dye.

You will probably be X-rayed from several angles. If you have a fracture in one limb, your doctor may want a comparison X-ray of your uninjured limb. Your X-ray session will probably be finished in about 10 minutes. The images are ready quickly.

X-rays may not show as much detail as an image produced using newer, more powerful techniques, but they're much cheaper, and if they reveal the diagnosis save the patient both money and x-ray exposure

Computed Tomography (CT, or cat scan to many)

Computed tomography (CT) is a modern imaging tool that combines X-rays with computer technology to produce a more detailed, cross-sectional image of your body. A CT scan lets your doctor see the size, shape, and position of structures that are deep inside your body, such as organs, tissues, or tumors. Tell your doctor if you are pregnant before undergoing a CT scan.

You lie as motionless as possible on a table that slides into the center of the cylinder-like CT scanner. The process is painless. An X-ray tube slowly rotates around you, taking many pictures from all directions. A computer combines the images to produce a clear, two-dimensional view on a television screen.

You may need a CT scan if you have a problem with a small, bony structure or if you have severe trauma to the brain, spinal cord, chest, abdomen, or pelvis. As with a regular X-ray, sometimes you may be given barium sulfate or a dye to make certain parts of your body show up better.

A CT scan costs more and takes more time than a regular X-ray, and it is not always available in small hospitals and rural areas.

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) is another modern diagnostic imaging technique that produces cross-sectional images of your body. Unlike CT scans, MRI works without radiation. The MRI tool uses magnetic fields and a sophisticated computer to take high-resolution pictures of your bones and soft tissues. Tell your doctor if you have implants, metal clips, or other metal objects in your body before you undergo an MRI scan.

You lie as motionless as possible on a table that slides into the tube-shaped MRI scanner. The MRI creates a magnetic field around you and then pulses radio waves to the area of your body to be pictured. The radio waves cause your tissues to resonate.

A computer records the rate at which your body's various parts (tendons, ligaments, nerves, etc.) give off these vibrations, and translates the data into a detailed, two-dimensional picture. You will not feel any pain while undergoing an MRI, but the machine may be noisy.

An MRI may help your doctor to diagnose your torn knee ligaments and cartilage, torn rotator cuffs, herniated disks, hip and pelvic problems, and other problems. An MRI may take 30 to 90 minutes. It is not available at all hospitals.

Part of the take home here that each technique has it's strength and although many will walk into their doctor's office wondering "if I need a scan," depending on the presumed diagnosis, other tests, like plain x-rays to quantify arthritis of the hip, may in many cases be superior to some kind of a scan.

Sunday, February 4, 2018

Racing at Night, Your First Ironman. Yep, Easily Could be You.

Regardless of your abilities or expectations, you may find your first attempt at the 140.6 mile distance a really big bite, more than you'd ever planned or imagined.  It's not uncommon for the sun to cross the horizon at sunset before you cross the line an Ironman.

Ironman South Africa
Each of us has some idea of what to expect when we strap on those swim goggles, follow a whole herd of nervous newbies just like us, each with some idea of what's right around the corner of our first IM.  But most are wrong, underestimating the effort required by, in some cases, a fantastic amount.  It's like the practice of medicine in this way.  When, as a first year medical student taking Physical Diagnosis, you are learning to be an investigator, a pathfinder, what's wrong with the patient in front of me and how can I ask the best questions to help figure this out?

Part of the questioning frequently comes to alcohol, a touchy subject for many, where the student inquires as to the amount this patient consumes.  Before writing the response down and entering it in the medical record, the student is advised by the crusty mentor to think if that answer fits the situation or if it's considerably less than the truth.  While this is the exception rather than the rule, suffice it to say that there are misperceptions in both the newbie triathlete's expecations of the first IM as well as for some of us when revealing our alcohol consumption.*

So regardless of prior marathon experience, distance swims performed, local Labor Day century bikes rides in the logbook, most underestimate the effort that will be expended that day or the time to expend it.  They also fail to appreciate that the weatherman has a big influence here and the effect a warm day will have to knock the wind out of their sails.  And their legs.  One example would be local athlete Emily, a skilled competitor and Ironman finisher, who finished a recent 70.3 effort where the temperature reached the high 80's, and a half mary course where the only shade provided are the occasional telephone wires across the road.  It was hot!  "That may have been the hardest thing I've ever done!  Maybe harder than the full distance under cooler conditions," she observed.

All of the above leads us to the object of this piece that while you may not finish during daylight hours, you will finish!  Honest.  It's just going to take a different kind of effort than you may have planned while putting in laps at the fitness center.  First off, you'll have plenty of company.  There's a really good chance that you'll have to walk during the run.  Some of us nearly all of it. And there will be at least one racer if not more who will be there right with you.  With the same ultimate goal, finishing before the ultimate time cut off.  It's a pretty simple calculation to determine the required pace.  But be forewarned. Ironman is nothing if not a rule following organization. (A local VA race billed itself a "Double Ironman" until a cease and desist order was received from WTC instructing them not to.)  I have seen athletes who are mere seconds past the swim, bike and finish time cut off who are DQ'd.  Don't be surprised, they really have to draw the line somewhere, no pun intended, so do your pace calculation with room to spare just in case.

If your run course has aid stations "approximately every mile" and you can maintain just under a 15 minute per mile walking pace, you'll hit four miles per hour with a few seconds at each aid station to stock up. (Remember this though, that with decreased effort - not running - you'll have different fluid and electrolyte needs.  Less obviously, over-drinking can lead to hyponatremia, a serious medical condition that you need to be aware of for both you and you new walking friends.  As the sun sets, you will probably be given a light stick to hang from your clothing or some do well as a necklace that can be seen from front and back.  This could be important as the entirety of the course may not be closed both ways to vehicular traffic and you don't want to get squashed.

Lastly, when you finally do make it to the finish line chute, unlike the 7 hour marathon finisher, IM race fans do hang around to cheer you on those final yards. From experience, you feel a little sheepish, you've been at this a long time.  You're a little embarrassed, like maybe you should be carrying a spear and shield or something, but the second you cross that line, it all goes away.  Mission accomplished!  You're an Ironman with a big medal around your neck to prove it.  A month from now, a year from now, no one is going to ask about your pace at the nineteen mile mark, they'll just be in awe that you're an Ironman finisher.  Like Judy and John Collins, the ones who thought up this crazy thing say, "Swim 2.4 miles, bike 112 miles, run a marathon, and brag for the rest of your life."

And don't forget to shake the hands of your new found walking buddies.  They're Ironman finishers too.  But do it humbly.

Sunset on the Big Island, earlier than most people think!
*We just finished no-alcohol January 3.0 where a big group of triathletes went alcohol-free for the month.  Easy for some, quite the challenge for a few!  But huge grins on that latter group who showed that with a little help from your triathlon peers, you can accomplish most anything!