Human Limits

Brazil is slated to host the 2014 World Cup Soccer tournament and the 2016 Summer Olympics.  Currently the FIFA Confederations Cup soccer tournament is being held there as a sort of dry run for these big events and the festivities have been marked by massive public protests over “spending on stadiums” vs. basic public service.  The video below has gone viral and was posted a few weeks before the protests started.

click here for video

Mexico City 1968 and Denver 1976

The circumstances were different but there were large public protests including a massacre of about 40 protesters in early October of 1968 before the Mexico City Olympics.  Here is a link to BBC reporting from that time and also a more recent review of what happened in Mexico City.  In the early 1970s the people of Denver rejected public funding for the 1976 Winter Olympics, and the games were moved to Innsbruck, Austria. So, this is not the first time people have questioned the priorities associated with massive public spending on global sports extravaganzas.

Let Them Eat Stadiums?

Here is a link to an NYT op-ed piece entitled “Let Them Eat Soccer” with more on the situation in Brazil.  I have been to Brazil a couple of times.  It is a spectacular place poised to become a world power with world class people and capabilities in many areas.  However, it is marked by all sorts of problems related to corruption, extremely high levels of social inequality, and just plain growing pains.  In this context, is spending lavishly on stadiums a good idea?  Similar questions have been raised in the US about public subsidies for professional sports stadiums which seem a bit crazy since the owners of the big sports franchises are typically “billionaires”.  With people taking to the streets in Brazil and the ability of protests to go viral, I wonder what the long term effects will be on the ability of governments all over the world to subsidize stadiums.  The recent US Open Golf Tournament at Merion also shows that extravagant purpose built venues are not essential to great competition.  So, maybe there is a middle way.

The celebrity “Southern” cook Paula Deen was essentially fired by the Food Network for bad behavior including use of the N word.  In reading about this incident I ran across the picture below of loyal fans lined up outside her restaurant in Savannah, Georgia waiting to eat.  The N word aside, this photo is a perfect example of the obesity epidemic in America, and raises the question of how and why we celebrate people who promulgate too much of a good tasting thing.  Are there celebrity smoking and drinking advocates?  Are there celebrity drive too fast advocates?  Are there celebrity unsafe sex advocates?  Do these folks, if they exist, get their own TV shows?

Southern Cooking & The “Stroke Belt”

Diet matters and Southern Cooking and other unhealthy behaviors (smoking, inactivity, and obesity) have been implicated as causes of the so-called stroke belt which is shown in the first map below.  It shows a region of the country where strokes are an especially big problem and other markers of public health are typically low.  Obesity is also associated with about a 40% increase in health care costs that we all share one way of the other through health insurance premiums, taxes for programs like Medicare and Medicaid, or government disability payments.  The second map shows the impact of these behaviors on life expectancy.  The life expectancy data are confounded by things like poverty, race and education that seem to interact with all sorts of behavioral risk factors and determine who gets what disease and dies when.  Paradoxically the data in the second map also shows that there are areas of the country with life expectancy values that rival those seen in places like Scandinavia and even Japan.

Summary

I am not sure we need to become a country of food puritans, but I do think we need recognize that these problems are not going to go away unless we do something, and cleaning up the countries diet, especially in the stroke belt might be a good start.  The other interesting thing about the stroke belt is that it is a region of the country devoted to the rhetoric of “small government” and “individual responsibility”, but the data suggests that these philosophies are difficult for people to practice and that maybe Mayor Bloomberg is right.  Denial is typically not a good policy and it is never a smart policy.

In my last post I discussed the recent analysis of how physiologically “believable” key mountain climbs by noted riders in the Tour de France have been over the last 30 or so years.  The idea is doping likely contributed to some of the most unbelievable performances and that by analyzing power outputs, suspicious performances can be identified.    That having been said, it is interesting to note that the one hour record for cycling has hardly budged since 1972 when Eddie Merckx went just over 49.4 km at Mexico City.   People have gone much farther with exotic aero bikes, but the current record set in 2005 by Ondrej Sosenka is 49.7 km with a standard bike.  Sosenka had a number of doping violations that ultimately ended his career, so this record is suspect.  Merckx had issues with stimulants, but he rode in the pre-epo era and there is no evidence that I know of that he blood doped with traditional auto-transfusions.   So perhaps his one hour record sets the gold standard for what is physiologically possible in cycling without manipulating oxygen transport using epo or blood doping.

All of this led to some interesting e-mail traffic and a discussion about what is physiologically believable in running.  This is harder to guesstimate because unlike cycling, measuring the actual mechanical work done and power generated during running is very challenging.  It is also harder to link running performances to estimates of oxygen consumption.   However, one can ask what the best performance ever is in the pre blood-doping/EPO era was, use it as a baseline and then go from there.   This is reasonable at some level because by the 1960s people were training as hard as they do now, and lab data from that time suggests the record holders then were comparable to today’s top performers.  Additionally, the first real suspicions of blood doping emerged with Lasse Viren in 1972 and 1976.  Here is an example using men’s marathon and 10,000m performances:

• Derek Clayton ran 2:08:33 in 1969 and his best for 10k was relatively slow 28:45 (likely on dirt).   In that era the fast 5,000 and 10,000m runners did not move up to the marathon that often, and if they did it was at the end of their careers.  There was no real money to be made running and the races (except for Boston and the Olympics) were pretty low profile.  Clayton’s record lasted 12 years until shortly after the big city/big money marathons started and top track runners “moved up”.   So people with 10k PRs faster than Clayton started to run the marathon and they started to run more of them at the peak of their careers.

• The fastest 10k time on dirt is 27:39 by Ron Clarke in 1965.  If you figure a synthetic track is worth 2-3% then Clarke might have run ~27:00 on a synthetic track.  This time is equal to about a 2:04 for the marathon if you plug it into one of the better race conversion calculators.  Clarke ran his 27:39 alone and like Jim Ryun’s 3:51:1 mile on dirt there was not a pacer.  Both would have run faster in a real race with a pacer.

• There are about 50 people who have broken 27:00 for 10,000m, the fastest time since drug testing got “better” over the last 5 or so years is about 26:45.  Many of the rest of the best times are from the mid-90s to about 2005 when epo was endemic.  Bjarne Riis used epo in the 1993 Tour de France and it is hard to imagine that the runners were far behind.  There is also evidence that the East Africans are not as clean as widely believed, and throughout this period they had managers and trainers from the same parts of Europe noted for doping in cycling.

• So it looks like a human might be able to run 26:45 with limited suspicion of doping and that works out to about a 2:03:03 estimated marathon.   If 26:30 is possible without drugs you get 2:01:54.  26:20 gets you 2:01:08. The race conversion calculators are not perfect but they are pretty good and most of them (plus an old point table system from the early 70s that I have a hard copy of) give relatively convergent estimates.

• You can do a similar analysis (with a dirt track conversion factor) for the mile, 3000m and 5000m and the records from the middle 60s look very similar to those up to about 1990.  Also the best performances since about 2008-10 (when drug testing got better) are slower than the current records and perhaps closer to the pre-doping values.

Ultimately, who knows which runner has been doing what over the last 20 or so years?  Who ran what race clean, who doped, and who was clean all of the time and who doped all of the time.   However, like the hour ride for Merckx, there is no evidence that the current elite runners are physiologically better than people from an earlier era when techniques to manipulate oxygen transport for a competitive edge were not available.

The recent and controversial AMA decision to categorize obesity as a disease has a raised a number of questions and discussion points.  I thought I would cover a few here to help readers sort through the issue on their own.

Definition of Disease

Below is an extended quote from the wiki definition of disease.  It is similar to other definitions I found and if you link to the site there is a pretty comprehensive discussion of the concept of disease and related things like “disorder” or syndrome.  Based on the blurb below obesity certainly seems to fit many of the definitions of a disease.  One interesting recent observation is that if you track obesity in social groups it moves through them with a pattern that looks a lot like the way infectious disease moves through a population.

“A disease is an abnormal condition that affects the body of an organism. It is often construed as a medical condition associated with specific symptoms and signs.[1] It may be caused by factors originally from an external source, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune diseases. In humans, “disease” is often used more broadly to refer to any condition that causes pain, dysfunction, distress, social problems, or death to the person afflicted, or similar problems for those in contact with the person. In this broader sense, it sometimes includes injuries, disabilities, disorders, syndromes, infections, isolated symptoms, deviant behaviors, and atypical variations of structure and function, while in other contexts and for other purposes these may be considered distinguishable categories. Diseases usually affect people not only physically, but also emotionally, as contracting and living with many diseases can alter one’s perspective on life, and their personality.”

Defining Obesity

BMI or body mass index has emerged as a favored definition of obesity.  This definition is probably OK when thinking about groups or populations of people but does not always tell you much about an individual.  There can be “normal weight” people with a lot body fat and health problems, and there can be heavy people with lots of muscle mass and very little body fat.   Then there is the problem of distribution of fat.  Visceral fat or “belly fat” is worse for your health than fat in your lower extremities. When I started medical school in the early 80s fat was seen mostly as a tissue that simply stored excess energy, but in the last 20 or so years it turns out that some fat cells secrete all sorts of biologically active substances that wreak havoc on the blood vessels, heart, liver, pancreas, skeletal muscle and brain.  One critical thing to note is the physically active “fat people” are largely protected from some or most of these problems

What Does Disease “Status” Do?

The AMA decision does not do anything right away other than make a statement and raise a bunch of questions:

• Will disease status increase public awareness of obesity as a medical problem?  My guess is that most people are probably already aware that obesity is a problem.
• Will disease change medical practice and encourage more Drs. to discuss the issue with patients?  Should things like exercise and physical activity be a vital sign?
• Will disease status influence the way insurance covers certain treatments like gastric bypass?  Some plans do, some don’t and here is link to a nice opinion piece on that topic.  What happens if the insurance plans that political leaders get cover it but not the plans the rest of us have?
• Will disease status limit the use of sin taxes and incentive plans linked to weight loss by governments and insurance companies?
• Will disease status encourage people to take more or less responsibility for their own behavior?  Obesity is a lot more than a few bad genes “making us fat”.  In fact genetics likely plays a minor role for most people and the big increase in average body in the US over the last couple of generations has occurred faster than any genetic changes that might explain it.  For the vast majority of us it is all about the environment and our behavior.

Our Obesogenic World!

We live in a high calorie low physical activity world primed to make us all fat.  At some level it is amazing that anyone remains normal weight.  The lessons from improved traffic safety and smoking rates over the last 50 plus years tell us that these big public health problems require structural changes in society as well as changes in individual behavior and so-called “choice”.    Where to start with the obesity problem: Sugar and fat taxes or other policies designed to reduce calorie consumption and increase healthy food choices?  Walking and biking friendly urban planning?  Safe streets to encourage getting outside in all neighborhoods?  More PE and better nutrition at school?  Financial incentives via health insurance plans?  Limiting our own screen time and that of our kids?  Drs. and nurses communicating more about the problem with patients with easier referrals to diet and exercise programs?  The short answer is all of the above.

With the Tour de France set to start at the end of June, Major League Baseball in mid-season and international track and field winding up it, seems like a good time to review a few developments in the world of doping.  Where to start?

Baseball

The big doping news in baseball center around reports (starting last winter) that a Miami “clinic” was providing performance enhancing drugs to a number of high profile players.   Major League Baseball has obtained the records from the clinic and is considering action including the suspension of a large number of players.  The take home messages from this story include:

• Drug testing, both the tests and the way they are administered, remain beatable.
• High profile cases are frequently more about paper and financial trails than testing.
• Baseball seems to be taking this more seriously than in the past.

Track & Field

In April there were reports that some high profile distance runners were being treated with thyroid hormone “replacement” therapy.  Here is a link to a thoughtful analysis by the Science of Sport blog.  It raises a number of questions about therapeutic exemptions for athletes with real medical conditions.  The other big issue here is that if heavy training and competition alters key hormone levels should the athletes be permitted to use supplemental doses to get their levels back to “normal”.   This is a slippery slope and could lead to a situation where upper limits of normal for hormone levels and hematocrit are established and “doping” up to that level is allowed.  Perhaps the biological playing field would be level but what about individual variation and the challenge of working with what you have?  At some level this might already be happening with the use of low dose doping programs designed to fly under the testing radar.  For those of you wanting a deeper dive on this topic the links above are excellent and cover a lot of ground.

Cycling

A colleague sent me a link to a Velo News (the bible of Cycling) article on a new analysis of power outputs on iconic Tour de France mountain climbs.  The data come from a number of top cyclists over the last ~30 years and provides a color coded index of suspicion related to who might have been doping on what climb when.   The idea is that if you know a rider’s power output in watts/kg you can make reasonable estimates of oxygen consumption and that some of these power outputs would require people to be working at VO₂max for prolonged periods of time, at altitude, at the end of long rides with multiple climbs.  This is a collection of circumstances that seems physiologically unlikely at best.   The article is an interesting read and here is a link to the full analysis being published as a one time magazine and also a podcast interview with the author.

Summary

At one level the news is depressing and it appears that doping goes on more or less unchecked with ever more sophisticated “work arounds” to beat the testing.  At another level perhaps the testing, analysis and detective work are getting good enough to keep the lid on things to some extent.  This has been likened to having enough speed limit enforcement on the highways to keep most drivers close to the speed limit.  Perhaps this is the best we can hope for given the money and fame at stake in professional sports.

In my last post I made the point that no one should be that surprised that the government is collecting all sorts of electronic data and using it to try to detect and track suspicious activity by potential terrorists.  The revelation that a low level security contractor was responsible for the leaks and what to do about them and him has generated all sorts of debate.   That having been said, this whole incident makes me think about the post World War 2 “Red Scare” and the emergence of the so-called national security state after World War 2.  One of the justifications for the national security state is and was that “no one wants another Pearl Harbor”.

The extended quotes below come from the CIA website and are comments that President Eisenhower made at a news conference following the Soviet downing an American spy plane in May of 1960.  Eisenhower was a great man who understood the limits of military power and coined the phrase the military industrial complex warning about the perils of the national security state.  Here is video of Eisenhower’s farewell speech on January 17, 1961.   It seems to me that many of the issues he warned about in this speech and also discussed after the U-2 incident are still with us, and much of what he warned about has come to pass.  One question stemming for the tracking program is just how much tracking should we tolerate based on the concept of “no one wants another 9/11”.   I don’t have an answer for this complex question but it is certainly something that we all need to discuss and consider when we think about the kind of country and world we want to live in.

click to watch

 Excerpts of Ike’s Comments About the U-2 Incident

 “I HAVE MADE SOME NOTES FROM which I want to talk to you about this U-2 incident. . . .

“The first point is this: the need for intelligence-gathering activities.”

“No one wants another Pearl Harbor. This means that we must have knowledge of military forces and preparations around the world, especially those capable of massive surprise attacks.”

“Secrecy in the Soviet Union makes this essential. . . .”

” . . . ever since the beginning of my administration I have issued directives to gather, in every feasible way, the information required to protect the United States and the free world against surprise attack and to enable them to make effective preparations for defense.”

“My second point: the nature of intelligence-gathering activities.”

“These have a special and secret character. They are, so to speak, `below the surface’ activities.”

“They are secret because they must circumvent measures designed by other countries to protect secrecy of military preparations.”

“They are divorced from the regular visible agencies of government which stay clear of operational involvement in specified detailed activities.”

“These elements operate under broad directives to seek and gather intelligence short of the use of force–with operations supervised by responsible officials within this area of secret activities. . . .”

“These activities have their own rules and methods of concealment which seek to mislead and obscure– . . .”

“Third point: how should we view all of this activity?”

“It is a distasteful but vital necessity.”

“We prefer and work for a different kind of world–and a different way of obtaining the information essential to confidence and effective deterrents. Open societies; in the day of present weapons, are the only answer. . . .”

“My final point is that we must not be distracted from the real issues of the day by what is an incident of a symptom of the world situation today.”

click here for video

The news over the last couple of weeks that the National Security Agency is routinely tracking all sorts of electronic communications as part of the “War on Terror” has gotten a lot of attention.  It has raised concerns about government as big brother, privacy, and when the government is justified in “following” people.  This is part of a big data mining effort trying to figure who potential “bad guys” are communicating with and then connect the dots associated with their networks to prevent acts of terror.   The idea is that monitoring so-called metadata can provide all sorts of information and in fact tell you a lot about a person or group of people.

Thoughts About Tracking?

Last March I asked “Who is Tracking You?” and pointed out many of the issues associated with all of the data that is floating around out there.  In light of that post, I guess I am not surprised by the fact the Federal Government is casting a wide net on communications metadata.  A so-called “total information awareness” program emerged just after 9/11 and was widely criticized.  The program was thought to have been canceled but appears to have been merely “rebranded”.  So here are a few observations related to our lives in the era of big data:

•  Any data that can be mined will be mined.

• All data is fundamentally mineable.  Even data that was not created digitally can be digitized and then mined.  This has happened with pre-digital books and magazines as part of text mining, and provided information about social change based on how word use changes with time.  For example the use of the word “women” has increased dramatically since the 1970s.

• There are four fundamental kinds of snooping:

1. The Gladys Kravitz on steroids effect or just plain snooping by someone with access to a database.  Here is a link about someone targeting women via Minnesota driver’s license data.
2. The dog ate my homework….this happens when a lap top or thumb drive with things like medical or banking records are lost.
3. Hacking by criminals looking to make money.
4. Governments, businesses or even political campaigns looking to mix and match data for some reason.

• Some data is part of crumbs or footprints we leave behind doing various transactions or just living in an electronic world.  Some is data that is intentionally gathered for example when the cashier asks for your phone number when you check out of certain stores (your phone number can be linked to all sorts of things).  Some is data that is passively collected and can be used later like video surveillance tapes.  As the Boston bombing shows getting information out of images can also be crowd sourced.  The final way personal data becomes available is via what we voluntarily disclose on social media as part of the societal phenomenon of Oprahization.

• The final point is that who knows where the government ends and the big IT and communications companies begin.  None of this happened without the collaboration of the big companies.  How hard did they fight to not give up the data?  When electronic copies of the internal corporate memos are leaked (one of the positives of all of this) it will be interesting to wade through the doublespeak and see just how willingly the big boys collaborated with the Feds.

End of Privacy?

I guess the overwhelming conclusion is that we have entered the “end of privacy” era.  We are all addicted to the convenience and efficiency of the electronic world and I doubt that for most of us there will be any going back.  Our Oprahized world suggests that a lot of people are embracing a world with no privacy.