The man who ate 25 eggs per day: What does this case really tell us?

Many readers of this blog have probably heard about the case of the man who ate approximately 25 eggs (20 to 30) per day for over 15 years (probably well over), was almost 90 years old (88) when the case was published in the prestigious The New England Journal of Medicine, and was in surprisingly good health ().

The case was authored by the late Dr. Fred Kern, Jr., a widely published lipid researcher after whom the Kern Lipid Conference is named (). One of Kern’s research interests was bile, a bitter-tasting fluid produced by the liver (and stored in the gallbladder) that helps with the digestion of lipids in the small intestine. He frames the man’s case in terms of a compensatory adaptation tied to bile secretion, arguing that this man was rather unique in his ability to deal with a lethal daily dose of dietary cholesterol.

Kern seemed to believe that dietary cholesterol was harmful, but that this man was somehow “immune” to it. This is ironic, because often this case is presented as evidence against the hypothesis that dietary cholesterol can be harmful. The table below shows the general nutrient content of the man’s daily diet of eggs. The numbers in this and other tables are based on data from Nutritiondata.com (), in some cases triangulated with other data. The 5.3 g of cholesterol in the table (i.e., 5,300 mg) is 1,775 percent the daily value recommended by the Institute of Medicine of the U.S. National Academy of Sciences ().

As you can see, the man was on a very low carbohydrate diet with a high daily intake of fat and protein. The man is described as an: “… 88-year-old man who lived in a retirement community [and] complained only of loneliness since his wife's death. He was an articulate, well-educated elderly man, healthy except for an extremely poor memory without other specific neurologic deficits … His general health had been excellent, without notable symptoms. He had mild constipation.”

The description does not suggest inherited high longevity: “His weight had been constant at 82 to 86 kg (height, 1.87 m). He had no history (according to the patient and his personal physician of 15 years) of heart disease, stroke, or kidney disease … The patient had never smoked and never drank excessively. His father died of unknown causes at the age of 40, and his mother died at 76 … He kept a careful record, egg by egg, of the number ingested each day …”

The table below shows the fat content of the man’s daily diet of eggs. With over 14 g of omega-6 fat intake every day, this man was probably close to or in “industrial seed oils territory” (), as far as daily omega-6 fat intake is concerned. And the intake of omega-3 fats, at less than 1 g, was not nearly enough to balance it. However, here is a relevant fact – this man was not consuming any industrial seed oils. He liked his eggs soft-boiled, which is why the numbers in this post refer to boiled eggs.

This man weighed between 82 to 86 kg, which is about 180 to 190 lbs. His height was 1.87 m, or about 6 ft 1 in. Therefore his body mass index varied between approximately 23 and 25, which is in the normal range. In other words, this person was not even close to obese during the many years he consumed 25 eggs or so per day. In the comments section of a previous post, on the sharp increase in obesity since the 1980s (), several readers argued that the sharp increase in obesity was very likely caused by an increase in omega-6 fat consumption.

I am open to the idea that industrialized omega-6 fats played a role in the sharp increase in obesity observed since the 1980s. When it comes to omega-6 fat consumption in general, including that in “more natural” foods (e.g., poultry and eggs), I am more skeptical. Still, it is quite possible that a diet high in omega-6 fats in general is unhealthy primarily if it is devoid of other nutrients. This man’s overall diet might have been protective not because of what he was not eating, but because of what he was eating.

The current debates pitting one diet against another often revolve around the ability of one diet or another to eliminate or reduce the intake of a “bad thing” (e.g., cholesterol, saturated fat, carbohydrates). Perhaps the discussion should be more focused on, or at least not completely ignore, what one diet or another include as protective factors. This would help better explain “odd findings”, such as the lowest-mortality body mass index of 26 in urban populations (). It would also help better explain “surprising cases”; such as this 25-eggs-a-day man’s, vegetarian-vegan “ageless woman” Annette Larkins’s (), and the decidedly carnivore De Vany couple’s ().

The table below shows the vitamin content of the man’s daily diet of eggs. The vitamin K2 content provided by Nutritiondata.com was incorrect; I had to get what seems to be the right number by triangulating values taken from various publications. And here we see something interesting. This man was consuming approximately the equivalent in vitamin K2 that one would get by eating 4 ounces of foie gras () every day. Foie gras, the fatty liver of overfed geese, is the richest known animal source of vitamin K2. This man’s diet was also high in vitamin A, which is believed to act synergistically with vitamin K2 – see Chris Masterjohn’s article on Weston Price’s “activator X” ().

Kern argued that the very high intake of dietary cholesterol led to a sharp increase in bile secretion, as the body tried to “get rid” of cholesterol (which is used in the synthesis of bile). However, the increased bile secretion might have been also been due to the high fat content of this man’s diet, since one of the main functions of bile is digestion of fats. Whatever the case may be, increased bile secretion leads to increased absorption of fat-soluble vitamins, and vitamins K2 and A are fat-soluble vitamins that seem to be protective against cardiovascular disease, cancer and other degenerative diseases.

Finally, the table below shows the mineral content of the man’s daily diet of eggs. As you can see, this man consumed 550 percent the officially recommended daily intake of selenium. This intake was slightly lower than the 400 micrograms per day purported to cause selenosis in adults (). Similarly to vitamins K2 and A, selenium seems to be protective against cardiovascular disease, cancer and other degenerative diseases. This man’s diet was also rich in phosphorus, needed for healthy teeth and bones.

Not too many people live to be 88 years of age; many fewer reach that age in fairly good health. The country with the highest average life expectancy in the world at the time of this writing is Japan, with a life expectancy of about 82 years (79 for men, and 86 for women). Those who think that they need a high HDL cholesterol and a low LDL cholesterol to be in good health, and thus live long lives, may be surprised at this man’s lipid profile: “The patient's plasma lipid levels were normal: total cholesterol, 5.18 mmol per liter (200 mg per deciliter); LDL, 3.68 mmol per liter (142 mg per deciliter); and HDL, 1.17 mmol per liter (45 mg per deciliter). The ratio of LDL to HDL cholesterol was 3.15.”

If we assume that this man is at least somewhat representative of the human species, and not a major exception as Kern argued, this case tells us that a diet of 25 eggs per day followed by over 15 years may actually be healthy for humans. Such diet has the following features:

- It is very high in dietary cholesterol.

- It involves a high intake of omega-6 fats from animal sources, with none coming from industrial seed oils.

- It involves a high overall intake of fats, including saturated fats.

- It is fairly high in protein, all of which from animal sources.

- It is a very low carbohydrate diet, with no sugar in it.

- It is a nutritious diet, rich in vitamins K2 and A, as well as in selenium and phosphorus.

This man ate 25 eggs per day apparently due to an obsession tied to mental problems. Repeated attempts at changing his behavior were unsuccessful. He said: “Eating these eggs ruins my life, but I can't help it.”

UCI uphold USADA findings - surprised?

Could have gone either way. . .

On Monday, as scheduled, the UCI held a press conference to announce it would recognize the reasoned decision submitted by USADA and not appeal to the CAS.  Honestly, based on the UCI's history, it was 50/50.  I don't think any one who follows the sport would have been surprised had they chosen to appeal the decision up to CAS.  Yes, many big sponsors had already "endorsed" the decision by sacking Armstrong, but again given the UCI's past behavior it was plausible they could appeal.  Perhaps they realised they had no choice but to uphold the decision, perhaps there was pressure from somewhere else like IOC (unlikely, but we don't know), but whatever the reason, they chose wisely in our opinion.  It does not redeem them by any stretch, and they should still be removed and replaced by new leadership, but that is the topic of another post!

We have been sharing links and comments on our Facebook page, so if you have not visited, check there for some discussion and links.  Our page is a great way to keep the info and discussion rolling when we don't have exhaustive hours to spend digesting the data ourselves and synthesizing a post, which is most of the time these days.

Exploring the USADA case

So I had some time Monday night during an exam to pore over some of the documents from the USADA case.  If you visit the USADA website, you might see why it took them over month to produce the evidence to the UCI---it must have taken them that long just to upload all the files.  Kidding aside, though, it is an absolute mountain of detailed information and evidence.  

Especially relevant to this week's news, though, is the correspondence between UCI President Pat McQuaid and the USADA.  Recall that McQaid first stated at the outset that the UCI would stay out and let the USADA proceed with their investigation. . .only to change his tune later and challenge the organisation's jurisdiction. . .only to take another about face and now validate the findings and decision by USADA.  It's farcical that the president of a global sporting organisation behaves like this, and that as late September 17, still was challenging the jurisdiction USADA had over Armstrong.

It's a rule violation, not an illegal activity

A common argument that keeps coming up from supporters is that there is no "evidence" to support the sanction, or cries that the information provided by USADA hardly passed for evidence.  This is amusing since witness testimony contributes to the body of evidence in legal cases, so I don't think that argument really works.

But more importantly, we have to be clear that USADA did not evaluate whether or not Armstrong broke a law.  Instead, they evaluated whether or not he broke a rule, specifically as outlined in the rule books for cycling and triathlon during the years in question.  Whether or not Armstrong is charged with a crime in the United States remains to be seen.  Currently people are murmuring about the possibility of a perjury charge, since on at least one occasion during the SCA hearings he testified under oath.  Can a prosecutor prove he lied?  We don't know---that is not our area here, you have to visit our sister site The Law of Sport to read about that.

No human rights, constitutional rights, or any other rights have been violated.  USADA operated within its responsibilities as an anti-doping organisation.  And for anyone whose doping paradigm is still stuck in last century, sanctioning athletes in the absence of an "analytical finding" is entirely acceptable, and in this case Armstrong is just another athlete on the growing list of those who have in fact been sanctioned without ever testing positive (officially).  

So don't bemoan the process.  If you want to support him as a cancer survivor, please do.  By some accounts it's a near miracle he survived such an advanced case of cancer that had spread throughout his body.  But it has now become patently obvious that at least since 1998, all of his cycling success was achieved by breaking the rules.  Was the era fraught with doping?  Absolutely, and the UCI more than anyone else is to blame for t hat.  But that does not make it ok that anyone broke the rules.  And worse, he and his foundation benefited immensely as a direct result of his sporting success, which was fraudulent.  His net worth is estimated upwards of $125 million, and does anyone reading think it would be that high had he not won seven tours?

Be informed:  read the USADA documents

The information there is sometimes old, most of the time revealing, and always interesting.  If you are a cycling fan or want to have all the facts to form your own informed opinion, we suggest you wade through them.  Due to the volume there is likely to be more analysis of them in time as people can consume and digest all the info there.

For now, visit our Facebook page to follow the comments and links we post there (and please "Like" us if you have not already, that's social currency for us!).

Jonathan

Sponsors overboard & a guest post on legalized doping, the Armstrong dilemma

It's not about the evidence: Sponsors retreat, and a guest post on legalizing doping, amnesty and more

It began with the swoosh, as Nike issued a statement yesterday saying that in the face of "seemingly (emphasis mine) insurmountable evidence that Lance Armstrong participated in doping and misled Nike for more than a decade", they were making the "sad" decision to end their association with him.  Then followed a host of his long-time supporters - RadioShack, Anheuser-Busch, Giro, and most recently, Trek bicycles.  Armstrong also stepped down as chairman of his LiveStrong foundation, though he remains on its board, and both Nike and Trek have pledged their continued support for the foundation, if not for its founder.  

Here's where the lines get blurred.  Drawing a clear distinction between Armstrong and Livestrong requires setting aside the foundations on which Livestrong was built.  Livestrong may deserve continued support, of course, and one would not want to undermine the work it has done for awareness and to support those with cancer (but not research, I have to point out), but the corporate backing of Livestrong independent of Armstrong is the sponsorship equivalent of a front.  Armstrong's continued presence on the board and the 'shared DNA' between him and Livestrong means that any corporate backer will never fully separate itself from the athlete, whose success has now been shown to everyone to be built on cheating, lying and intimidation.

There's also the reality that Nike and co had little alternative than to make a move to distance themselves from Armstrong.  It was the only move left on the chessboard for them.  Sadly, it wasn't the details and 1000 pages of evidence in the USADA report that prompted yesterday's procession of abandonments, but the growing resentment and backlash from the public towards, in particular, Nike and Oakley.  Telling as it may be, it is unsurprising that companies are more concerned with the opinions held by their consumer markets than with the "trivial" matter of breaking the rules of sport to sell more product, and yesterday was a good illustration of this.  It would be oversimplifying it to say that for the likes of Nike, it is a simple question of "Will we sell more product with or without Lance Armstrong?"  Brands consider more than just profit and loss, and brand equity has an unquantifiable component to it.   However, on both the P&L basis, and the brand equity, some time in the last week, the balance has tilted in favor of the "without", hence their action.  Continuing the association with Armstrong produced a net downside, and so we should not be too quick to commend the sponsors' actions yesterday.

Then there are the very clear and direct allegations that the sponsors were not merely ignorant, but complicit in what USADA called the "most sophisticated, professionalized and successful doping program that sport has ever seen".  Nike were alleged to contribute to pay-offs to the UCI to bury doping offences (as per Kathy Lemond's affadavit) and other sponsors are alleged to have spoken openly about doping or harshly condemned those who opposed the Armstrong myth (Trek's statement included no apology to Lemond).  Whether yesterday's retreat spares them the scrutiny to confirm these allegations (made for example by David Walsh, and we've seen that he is worth paying attention to) remains to be seen.

Stepping back to be mindful of the big picture once again, it is interesting to consider how this impacts on the UCI.  Once Nike acted, other sponsors were compelled to follow suit - you could hardly be the minnow sponsor remaining steadfast in support while the big ones are jumping ship.  Does the UCI decision change in any way as a result?  It's difficult to see that yesterday directly impacts on them, but it does emphasize once again how deep the issue was, and just how dramatically inadequate UCI leadership was during this period.

And on an even larger scale is the question about why Armstrong is so squarely the center of attention when it is becoming clearer and clearer that the entire sport had this problem?  That is a question which is addressed in the guest article below.  Written by Dr John McGowan, who is the Academic Director of the Department of Applied Psychology at Canterbury Christ Church University in Kent, it tackles the following three questions:

1. Should we offer amnesty to convicted dopers?
2. Should doping be legalized?
3. Why does Lance Armstrong provoke such particular ire?

Dr McGowan emailed me a few weeks ago to request this piece, and given my own time constraints, and my desire to hear views from outside, this seemed an excellent opportunity to host our first "guest post" on the site.  It's something I hope to do much more often in the future, provided articles contribute value and fall within the scope of the site.  As some of you may know, I spent two years working in sports sponsorship and business, and the big-picture, strategic thinking where commercial interests intersect with sports performance and science is a particular interest.  So the last week has been enthralling, if only to see how reactions have swung, and why.

Dr McGowan's piece, unedited, touches on some of the themes, including the legalization of doping argument, and how to police sport better in the future.

Ross

Lance Armstrong: It's not about the doping (Dr John McGowan)

As the time approaches for cycling chiefs to decide if they accept the recent rulings of the US Anti-Doping Agency, I’ve been wondering what to think about Lance Armstrong. Clearly many feel the evidence of rule-breaking, cover-up and intimidation is so overwhelming it’s high time he got his comeuppance. Despite everything though, he still has his partisans. Interestingly however, even some of them don’t care if he was doper. As commentator Gary Imlach commented,“an argument about Lance Armstrong is almost a faith-based matter”.

Amid the storm of claim and counter-claim one piece in particular caught my attention. On a site called Practical Ethics, Julian Savulescu and Bennett Foddy (both of Oxford University) argue that the prevalence of performance-enhancing drugs is such that there need to be important changes in cycling (and perhaps other sports too). However, unlike USADA and the majority of journalistic opinion, their prescription is that, instead of punishing rule-violators andtightening testing, we should be offering amnesty to drug-takers and relaxingthe rules on doping.

The Practical Ethics article raises issues of justice, liberty and expectations of public figures: evidence that cycling can be about a lot more than skinny guys pedalling up hills (though I’m personally quite fond of that bit). Specifically their piece poses three interesting questions: should we offer amnesties to those caught doping, and should we have more liberal rules? And why, when so many others are implicated, does Lance Armstrong provoke such particular ire?

Is a doping amnesty a good idea?

This isn’t something only advocated by those sympathetic to doping. The rationale was outlined in a Scientific American article a few years ago (text-only version here) by Michael Shermer. To lower drug use in cycling he suggested a first step would be to,

“Grant immunity for all athletes pre-2008... Immunity will enable retired athletes to work with governing bodies and anti-doping agencies for improving the... system.”

The benefits of dopers confessing, and telling the authorities how they did it, are envisaged as bolstering a post-amnesty regime of more stringent testing and harsher punishments. While there is evidence that the last two elements are effective, the question of amnesties is more difficult. The motives to conceal doping (financial or retaining your reputation) still likely to be very strong. Unless you were already being investigated, hanging on to your palmarès might not necessarily provide an incentive to fess up. 

A second problem is the seriousness with which people take the message, “I know we said we meant it last time but this time we reallymean it.” Behavioural psychology would suggest that such intermittent reinforcement of rule breaking (by getting off) might make giving the finger to authority more rather than less tempting. It’s also worth considering where an amnesty would leave those who did try and play within the rules. While it’s probably unrealistic to think that they might be awarded titles stripped from others, it does seem somewhat unfair on them that some people would get the slate wiped clean.

For all these reasons many of us might struggle with an amnesty. It’s worth noting that the governing body of cycling have recently come to the same conclusion, though perhaps for different reasons. There is evidence though that sometimes humans let an aversiontounfairness get in the way of bigger gains. It could be a reluctance that’s worth getting over though. It might be in all our interests us all to bail out people in negative equity though it may feel like rewarding those who borrowed irresponsibly. We use amnesties and lenient sentences in criminal trials all the time to produce (hopefully) wider benefits. It may stick in the throat but it’s often worth trying to swallow.

Of course the discussion so far has been about amnesty as a tool to stop doping. If you would be happy with more liberal rules, amnesties may be less problematic. Why wouldn’t you have an amnesty if you decided doping was OK?

Should doping rules be relaxed?

It’s worth bearing in mind that simply prohibiting something society is concerned about is not always the best way to control its use. For example, the effects of  laws prohibiting recreational drugs have often had mixed results, especially when it comes to regulating safe supplies. There is also the issue of personal liberty. In cycling, arguments for the rights of athletes to take what they want in order to perform go back at least to the great Italian champion FaustoCoppi.

Savulescu and Foddy (also see this more detailed paper) use these arguments to call into question several principles underlying the World Anti-Doping Agency Code. In particular they challenge: 

• the idea that anti-doping measures will ever have a significant impact, 
• the view that competition enhanced by pharmacology is not desirable, and 
• the principle that curbing doping means fairer and safer sport.

These areas have been discussed extensively in other postings. In particular, regular readers will have some knowledge of advances in anti-doping paradigms and might conclude that Savulescu and Foddy are overly pessimistic about tackling the issue. So let’s say we can have an impact on doping. Maybe not eliminate it but certainly achieve reductions. Should we try?

On Savulescu and Foddy’s second challenge (to the illegitimacy of doped competition) it’s often pointed out that drugs may affect competitors differently. This might distort contests that many feel should be based primarily on biological potential and training. This issue is perhaps a matter of taste. A vision of the human body as a kind of laboratory-cum-Formula 1 car competing with the aid of the most cutting-edge science (including pharmaceuticals) might appeal to some but repel others. If it does seem a bit WWE for your taste it may be worth thinking why.

If you can accept such a vision of sport, what about fairness and safety? Inequalities related to wealth, diet and demographic factors are legion and it’s naive indeed to suggest that eliminating doping automatically equals fair sport. However, introducing more liberal rules, especially related to a potentially expensive commodity, would seem very likely to skew the playing field even more in favour of the wealthy. Still, there was a time when having a coach was seen as an unfair advantage so I guess it’s possible that I’m just being like the old duffers who were snooty to Harold Abrahams in Chariots of Fire.

As with fairness, it may be rather simplistic to insist that doping-free sport eliminates risks. Elite sport in particular can reward all sorts of risk-taking, but opening the door to more drug use again seems to potentially worsen the problem. For this author at least it’s this issue of safety that finally leads to a parting of ways with Savulescu and Foddy. I’m not sure I can get comfortable with a sport where a legitimate route to winning is for young athletes to push the limits of pharmaceutical assistance. Should I be comfortable with sport that encourage pushing the limits in other ways? Perhaps not. But that doesn’t mean I want to open another avenue of risk. There is the possibility of improving safety with medical supervision, but a glance at the motley collection of doping medics who populate recent sport memoirs leaves me a little low on confidence that this would help.

The involvement of those dubious doctors, though, highlights a counter-argument and brings us back to the issue of illegality itself compromising safety. As with recreational drugs, if a substance is permitted there may be a greater incentive to improve its safety (rather than at present where the emphasis is on undetectability), and for people of greater integrity to become involved in its supervision. In the end the issue pivots on whether you can argue convincingly enough that, as in the case of something like heroin, prohibition actively contributes to the risks via dodgy suppliers, unsafe drugs or badly controlled administration. If someone could make this case might it change things?

Why Lance Armstrong?

“Wear yellow for Armstrong? Fucked if I will. Wear it for Fignon? In a heartbeat.”

@festinagirl

Though they didn’t broach this subject explicitly, Savulescu and Foddy’s arguments did get me thinking about why many seem to have such particularly negative feelings about the man formerly known as winner of seven Tours de France. The New Yorker’s Michael Specter, author of a famous profile in 2002, recently pronounced that now Armstrong “is nothing”. Really? Nothing? While there's a case for doping being outside the rules, there are clearly far greater wrongs in the world. Though it’s tempting to see dopers as simply cheats who take unfair advantage, the experiences of athletes suggest a far more complicated picture than baddies who did and goodies who resisted. But, as the quote from the estimable Festina Girl suggests, we seem disinclined to cut Armstrong slack even compared to other admitted dopers. 

Here are three possible explanations for why we are so down on Lance. One thing they have in common is that none of them suggest the main problem is simply taking performance-enhancing drugs. To coin a phrase: it’s not about the doping.

1. Unlike many others, Armstrong hasn’t admitted fault and asked for forgiveness: a well trodden path for celebrity transgressors. Instead he has doubled down on a career of denials and cast himself as a victim of unfair accusations. This may satisfy the loyalists but seems guaranteed to infuriate everyone else. Of course the potential consequences for him go far beyond annoyance. Potential litigationover sponsorship deals and prize money are looming large. Doping is one thing but clearly lying is quite another. (My addition: as is the possibility of perjury charges considering that some of these lies have happened under oath)

2. Armstrong has behaved very badly towards anyone who has threatened him: a major element of the USADA case . Of course there is no rule that sporting champions have to be nice. Many famously seem not to be. Few however have been as publically contemptuous of their doubters as Armstrong after the 2005 Tour de France (“I’m sorry that you can’t dream big”).  Whatever you think of revelations from disgruntled ex-friends, statements like this are asking for schadenfreude.

3. I suspect the main reason for the strength of reaction is to do with what Armstrong has received from cycling: wealth, fame and status far greater than any other cyclist. This makes him vulnerable to the “Tiger Woods Effect”. During Wood’s sex-scandal a few years back the question arose of whether his behaviour would compromise his standing and, crucially, his endorsement contracts. Surely we were beyond holding a man’s private indiscretions against him? The business journalist James Surowieki  suggested that actually Woods was in line for some big losses. The reason was the way he was perceived in the public mind: as mentally tough and possessing almost superhuman discipline. It turned out that, when confronted with a line of blonde cuties throwing themselves at his feet, he was actually just like most other guys. Tiger had effectively undermined his own brand.

(My addition: in sponsorship, a fundamental concept is that of 'transferred attributes', in that the attributes of the sponsored athlete are meant to be transferred, in the mind of the consumer, to the product.  Endorsement relies in part on the (false) perception that it's the Wilson tennis racket, or Adidas boots, that make Federer or Messi so talented.  Puma must be fast because Bolt is.  Drinking Red Bull must be cool because Felix Baumgartner skydives from outer space, and so on.  When Nike invested in "hope" and "courage" and "hard work" of the Armstrong story, the most damaging thing imaginable would be to introduce "deceit", "immorality" and "short cuts".  For this reason, their endorsement fails anyway.  Remember when Paula Radcliffe failed to finish the 2004 Olympic Marathon?  It damaged sponsors because their association with her was on going the distance, and not quitting.  Clearly, some transgressions are worse than others, notwithstanding that some are just downright illegal)

So what is (or was) Lance’s public image? Cancer survivor, ferocious competitor and charity campaigner are all well established. I’d go further and suggest the essence of brand Armstrong is actually hero. How does being a hero square up not only with doping, but also with deceit? Throw in the actions of a bully, and the strain between the emerging picture and the brand reaches breaking point. Something has to give and his hero status looks unlikely to withstand such an onslaught. Where this leaves his charitable foundation is something else again.

Another way to look at it though is to consider the possibility that Armstrong is not quite as reprehensible as all that. It could be that we are seeing (as Tyler Hamilton and others have suggested) someone trapped inside a lie that’s too big for easy escape and driven by fear. Fear of failing, of discovery, of loss of the esteem which some still have. How would most people deal with that? How would you? Armstrong’s public stance of studied (or pretend) indifference is quite agonising to watch. It may be that that he is simply an ordinary person, albeit in extraordinary circumstances, with weaknesses and flaws like the rest of us. And this is the heart of his problem: if you’re Lance Armstrong, the journey to just being an ordinary guy is a long, long way down.

Dr John McGowan

Year/Academic Director,

Department of Applied Psychology

Canterbury Christ Church University

Kent

TN3 0TG

The steep obesity increase in the USA in the 1980s: In a sense, it reflects a major success story

Obesity rates have increased in the USA over the years, but the steep increase starting around the 1980s is unusual. Wang and Beydoun do a good job at discussing this puzzling phenomenon (), and a blog post by Discover Magazine provides a graph (see below) that clear illustrates it ().

What is the reason for this?

You may be tempted to point at increases in calorie intake and/or changes in macronutrient composition, but neither can explain this sharp increase in obesity in the 1980s. The differences in calorie intake and macronutrient composition are simply not large enough to fully account for such a steep increase. And the data is actually full of oddities.

For example, an article by Austin and colleagues (which ironically blames calorie consumption for the obesity epidemic) suggests that obese men in a NHANES (2005–2006) sample consumed only 2.2 percent more calories per day on average than normal weight men in a NHANES I (1971–1975) sample ().

So, what could be the main reason for the steep increase in obesity prevalence since the 1980s?

The first clue comes from an interesting observation. If you age-adjust obesity trends (by controlling for age), you end up with a much less steep increase. The steep increase in the graph above is based on raw, unadjusted numbers. There is a higher prevalence of obesity among older people (no surprise here). And older people are people that have survived longer than younger people. (Don’t be too quick to say “duh” just yet.)

This age-obesity connection also reflects an interesting difference between humans living “in the wild” and those who do not, which becomes more striking when we compare hunter-gatherers with modern urbanites. Adult hunter-gatherers, unlike modern urbanites, do not gain weight as they age; they actually lose weight (, ).

Modern urbanites gain a significant amount of weight, usually as body fat, particularly after age 40. The table below, from an article by Flegal and colleagues, illustrates this pattern quite clearly (). Obesity prevalence tends to be highest between ages 40-59 in men; and this has been happening since the 1960s, with the exception of the most recent period listed (1999-2000).

In the 1999-2000 period obesity prevalence in men peaked in the 60-74 age range. Why? With progress in medicine, it is likely that more obese people in that age range survived (however miserably) in the 1999-2000 period. Obesity prevalence overall tends to be highest between ages 40-74 in women, which is a wider range than in men. Keep in mind that women tend to also live longer than men.

Because age seems to be associated with obesity prevalence among urbanites, it would be reasonable to look for a factor that significantly increased survival rates as one of the main reasons for the steep increase in the prevalence of obesity in the USA in the 1980s. If significantly more people were surviving beyond age 40 in the 1980s and beyond, this would help explain the steep increase in obesity prevalence. People don’t die immediately after they become obese; obesity is a “disease” that first and foremost impairs quality of life for many years before it kills.

Now look at the graph below, from an article by Armstrong and colleagues (). It shows a significant decrease in mortality from infectious diseases in the USA since 1900, reaching a minimum point between 1950 and 1960 (possibly 1955), and remaining low afterwards. (The spike in 1918 is due to the influenza pandemic.) At the same time, mortality from non-infectious diseases remains relatively stable over the same period, leading to a similar decrease in overall mortality.

When proper treatment options are not available, infectious diseases kill disproportionately at ages 15 and under (). Someone who was 15 years old in the USA in 1955 would have been 40 years old in 1980, if he or she survived. Had this person been obese, this would have been just in time to contribute to the steep increase in obesity trends in the USA. This increase would be cumulative; if this person were to live to the age of 70, he or she would be contributing to the obesity statistics up to 2010.

Americans are clearly eating more, particularly highly palatable industrialized foods whose calorie-to-nutrient ratio is high. Americans are also less physically active. But one of the fundamental reasons for the sharp increase in obesity rates in the USA since the early 1980s is that Americans have been surviving beyond age 40 in significantly greater numbers.

This is due to the success of modern medicine and public health initiatives in dealing with infectious diseases.

PS: It is important to point out that this post is not about the increase in American obesity in general over the years, but rather about the sharp increase in obesity since the early 1980s. A few alternative hypotheses have been proposed in the comments section, of which one seems to have been favored by various readers: a significant increase in consumption of linoleic acid (not to be confused with linolenic acid) since the early 1980s.

USADA Reasoned Decision

USADA's reasoned decision: The evidence 

At the bottom of this post, you'll find the 202-page Reasoned Decision that was released by the US Anti Doping Agency today.  A long read, but a comprehensive summary of USADA's investigation into what their chief Travis Tygart described in an earlier statement as a system "professionally designed to groom and pressure athletes to use dangerous drugs, to evade detection, to ensure its secrecy and ultimately gain an unfair competitive advantage through superior doping practices".  He further referred to the US Postal run scheme as "a program organized by individuals who thought they were above the rules and who still play a major and active role in sport today"

Strong words, and below you'll be able to read the 202-basis for them.  You'll find the witness testimonies of 15 former team-mates (no doubt you have already seen statements from George Hincapie and Michael Barry, Levi Leipheimer and the Slipstream team that includes Danielson, Vandevelde and Zabriskie confessing their doping), as well as emails, financial statements, scientific data and lab test results.

I confess that I haven't yet gotten through the document, but only scanned it.  I may be reading well into the night, and probably tomorrow.  But it'll be here for a while, so do take your time.  In fact, you should probably look at this USADA document as the sequel to Tyler Hamilton and Daniel Coyle's book - print it out, and read it as if it were a dryer, more factual and detailed version of that particular expose.

Also, if you're following the story on Twitter, then there are a few people who I'd highly recommend for the short, sharp and accurate insights on this story as it continues to develop.  They are, in no particular order:

Shane Stokes, David Walsh, NY Velocity, UCI Overlord, cycletard, The Race Radio, Edward Pickering, David Epstein, Bonnie Ford, Joe Lindsey, Juliet Macur and of course, when he comments on this latest story, Paul Kimmage

The links below contain the Twitter handles for these people - they won't miss a thing in the coming days (whereas I might!):

Essential Twitter accounts 1

Essential Twitter accounts 2

And final thought on the day's evidence and events:

Hincapie and co are today being hailed for coming out and telling the truth.  And I agree that this is a day of progress for the sport.  Tyler Hamilton himself described it as "a big step for the future of our sport".

But at the same time, I would allow for the possibility of some ambivalent feelings about these statements.  I think back to the now famous occasion where Paul Kimmage challenged Armstrong in a press conference and Armstrong brutally cut him down, using cancer as his weapon. Seated alongside him was Hincapie. This was representative of the entire system for many years - these were all men who were silent, wealthy as a result of their complicity in the cheating, and witness to the destruction of many innocent people and careers, until they were pushed into a legal corner and then testified.

The counterpoint to that, of course, is that they were in an incredibly difficult position during their careers, and I've often said that I am grateful at my lack of cycling ability, because it meant I never faced the choices you will read about in the statements of Hincapie and co. (in particular, Zabriskie makes mention of being "cornered" and "succumbing to the pressure).  I can completely empathize with the difficulty of that choice - it is the common theme in all their testimonies, and it is the reason that I would not be too hard on those who were a silent part of this culture but who have now eventually spoken out.

So rather than condemn the (late) whistleblowers, let's celebrate even more those who DID speak BEFORE they had to.  As some of those names above have already mentioned on Twitter, let's use this moment to celebrate those who were courageous and outspoken from the start.  Those who had their reputations smeared by the bullying tactics of Armstrong PR because they dared to go against the grain of cycling's doping culture.  Those who were slandered and marginalized for standing up to the dishonesty, and who often retired from their sport because their position in it became untenable, often at Armstrong's hand.

Let's think then of Betsy and Frankie Andreu, David Walsh, Paul Kimmage, Emma O'Reilly, Andy Hampsten, Scott Mercier, Darren Baker, Christophe Bassons, and all the others who spoke first, or walked away.  Theirs is the example to praise, and today is a day to celebrate them.

There is a 202-page document to be read, so I'll leave it there.

Enjoy the read.

Ross

Reasoned Decision

Chicago 2012: Live splits and thoughts

Chicago 2012:  Tsegaye Kebede breaks course record with 2:04:38

Tsegaye Kebede has won the 2012 Chicago Marathon in a course record time of 2:04:38, taking just under a minute off Moses Mosop's one-year old record.  It also puts Kebede exactly one minute outside the world record, and he led home a field that saw the top five all set PBs (of course, one was a debutant, and the fourth hadn't finished a marathon until today)

Here are your top 5:

1.  Tsegaye Kebede - 2:04:38
2.  Feyisa Lelisa - 2:04:52
3.  Tilahun Regassa - 2:05:26
4.  Sammy Kitwara - 2:05:53
5.  Wesley Korir - 2:06:13

So, three Ethiopians on the podium, and the first time in many years that a Kenyan has not won, let alone not even finished on the podium.

Kebede was the class act of the day, and was its aggressor.  He went to the front shortly after halfway, while the pacemakers were still there, and you could see him straining to go.

Once they dropped off, Kebede had free reign and open road, and he took both, going to the front and winding the pace up.  Halfway was reached in a relatively slow 62:53 (the talk was of a 62-min target), but then Kebede cranked it up.  From 25km he ran a 14:29 split, and followed that up with a 14:19 split to take him to 35km.

That meant he covered those 10km in 28:48, and it was enough to destroy the field, with one exception - Lilesa.  The Ethiopian was the last man standing with Kebede, and so with 5km to go, the race resembled the epic 2010 battle that saw Kebede and Wanjiru duel together in a race that resembled a track cycling race, such were the surges and counter-surges.  On that occasion, the two were locked together until the last straight, and Wanjiru broke Kebede for the win.

That didn't happen today - Kebede was too strong.  Lilesa showed at the front for a while, but with about 4km to go, he dropped behind Kebede.  That was a temporary move, because at around 40km, he was gapped, and the tiny Ethiopian, who many consider unlucky to have missed out on the Olympic Games in London, showed his major marathon credentials, to move away and claim an ultimately comfortable victory.

Behind him, as mentioned, PBs for Lilesa, Regussa (a super fast debut, though not quite as quick as Kimetto last week in Berlin), Kitwara and Korir.  The USA's Dathan Ritzenhein also ran a PB, finishing in 2:07:47 for ninth place.

Below is the race, as it happened.  You'll see 5km splits, overall times and the odd comment.  It also shows how the early pace was slow, perhaps because it was a little too cold (4C or 40F at the start), and that they were never ahead of Mosop's course record until 40km.  Below the splits are my comments as the race unfolded.

New York remains as the final marathon of the Majors, though Frankfurt may yet have a say in the ranking lists.  Join us for those in coming weeks!

Live split graph

Women's race

The women's race produced a spectacular finish, as Atsede Baysa of Ethiopia raced side by side against Rita Jeptoo of Kenya, ultimately winning by less than a second.

Baysa's winning time of 2:22:04 is not spectacular, but the finish was.  Baysa has run three marathons this year, and according to the best commentator of the day, Tim Hutchings, has made a habit of running three or four marathons a year.  She has won Paris twice, and had a PB of 2:22:04 coming in (she equalled it today), but her recent form didn't point to her as the likely winner.

The pace was consistent throughout - 10km in 34min projected a 2:23:28, then halfway was reached in 1:11:15 (2:22:30 projected), and so it remained pretty steady, a race of attrition as early leaders fell away.  There was no decisive move, though the 10km from 30km to 40km were covered in 33:30, the fastest of the race.  That was when the east Africans made their presence felt, and the Russians who had led early were relegated to outside the top 3.  First among them would be Liliya Shobukhova, who was bidding for her fourth straight Chicago victory, but ultimately came up short in fourth place, 55 seconds down on the winner.

The other spectacular thing about the women's race is just how bad the commentary was from out on course.  Joan Benoit Samuelson was on the route, and she first crowned Maria Konovalova of Russia as the champion after only 10km.  Then by halfway, she declared the Shobukhova had the race under control.  By 25km, Lucy Kabuu was your winner, and of course by 40km, it was Jeptoo.  Her voice tremored with excitement as she urged the runners to "run" and "use your arms", and made the race difficult to watch with the sound on.  It was as though she's never watched a marathon before, let alone won some really big ones.

As it happened...

40km

The pace may have slowed (14:40 for the last 5km), but it's still much faster than Mosop last year at the same stage, and the result is that having been behind course record pace all the way, Kebede is now well under it - his 1:58:02 at 40km puts him 31s ahead of Mosop at the same stage last year.

Kebede has also dropped Lilesa, and running from the front, is on the way to the Chicago title, in a course record, and possibly the fastest time in the world this year, though that may be just out of reach.

38km

It's down to two - Kebede and Lilesa responded to Regassa's surge, and it was enough to drop Kitwara, and so now Kebede finds himself in familiar territory - driving the pace in the final 5km of the Chicago Marathon.  This time, there is no Sammy Wanjiru, but rather countryman Feyisa Lilesa.

Who decides to have a weather report at the 39km of a marathon?  Unbelievable...

35km

The last 5km in 14:19, and so now it really is spectacular!  The last 10km have been covered in 28:48.  That's very aggressive, and it explains why the lead group has been thinned to only four.

Three Ethiopians vs one Kenyan, and that Kenyan in Sammy Kitwara.  Regassa surged just after 35km, so the race is now really on.

And astonishingly, they are doing an interview with a dignitary, and then a weather report, and now a post-race interview.  The mind boggles...

33km

The race has come nicely to a boil now - Kebede started it at 28km, and the damage is now becoming clearly.  The group was eleven when Kebede went to the front, it thinned to 7 or 8 at 30km, and now, at about 33km, it's down to five.

And now it's four, as last year's second-placer Wesley Korir (also Boston champ this year) is just beginning to drop off.  Sammy Kitwara is there, he of the sub-59 min half marathon and that's a big dangerman for the Kebede and the Ethiopians - any sub 59 min guy is always an exciting proposition in the marathon.  Feyisa Lilesa is still there, and so is Tilahun Regassa.  Tony Reavis thinks it is four Ethiopians, but of course Kitwara makes it one Kenyan vs three Ethiopians.

Speaking of bad commentary, Joan Benoit Samuelson is doing an appalling job on the women's race.  After about 8km, she basically awarded the victory to Konovalova, then by 15km it was Shobhukova, and now, at 30km, Lucy Kabuu is your winner.  You'd think she's never run (or seen) a marathon before...from the uncontrolled excitement in her voice, she's clearly never been trained as a commentator either.

30km

Tsegay Kebede, he of the epic duel of 2012 with Sammy Wanjiru, has gone to the front at about 28km, and is now either the undesignated pacemaker or is feeling so strong that he's willing to front run for the final 14km.  It definitely got more aggressive - not decisively, because only two men have dropped off as a result, but the lead group (which I make ten large) is definitely being stretched and the 'casualties' will become clearer within the next ten minutes.  Kebede was of course the major omission from Ethiopia's Olympic team, and perhaps has a point to prove.

By 30km, the aggression has produced the expected increase in pace, but again, nothing too spectacular - 14:29 for the last 5km, so that's very fast.  But compare the 14:18 that Mutai ran when he surged at 30km in Berlin last week, and you see why there are still eight or nine in that group.

25km

The pace has slowed a little - 14:54 for the last 5km.  Kebede is showing strongly at the front, but all the major players, Kenyan and Ethiopian, are still there.

Halfway

1:02:53 through the half-marathon, and so they are on schedule for a sub-2:06, and it may well get considerably faster.  They are ahead of course record schedule, for what that is worth, because the big changes will come after 30km.

20km

Weather update - light winds, and a temperature of 40F (4C).  The commentators and weather lady say it is ideal for marathon running.  It's actually too cold, especially if you are running at 20km/h.  That explains why the pace is fast without being sensational.

At 20km, it's 59:40. The pace has been remarkably consistent, with very little variation, but now it has really been ramped up - that was 14:44 for the last 5km, and it brings them to within 5 seconds of Mosop's time last year.  What will determine whether they can get back to the course record is how the attacks come and whether they are too aggressive.  As Geoffrey Mutai showed in Berlin, too big a surge at around 30km can become costly to overall time, even though it may win the tactical race.  Should be intriguing once we get to 30km, because at this pace, there'll be ten left once the pacemakers drop off.

15km

Two mile splits from the interval were 4:45 and 4:50, so the pace remains at around 3min/km.  The last 5km were covered in 14:58, so still nothing spectacular, but the pace has been remarkably constant, as the graph shows.  A group of 15 in the lead.

10km

The 10km mark has just been reached - 29:58, so a small increase in speed.  The last 5km were covered in 14:54, and it brings them onto a 2:06:27 pace.  At this stage, they're 41s behind the time that Makau ran on route to his record in Berlin, but they are closer to Mosop's 2012 course record - the gap there is 17 seconds.

5km

The first mile was done outside 5 miles, which was very slow.  It then sped up with a 4:42 second mile, but the time to 5km was slow - 15:04, which projecs a 2:07:09.  I think it's safe to say that the pace will ramp up.  The conditions were thought to be ideal, but it's now being reported that it may be too cold.

For comparison's sake, the image belows shows the 5km split times for the world record (left column) and the current Chicago Marathon course record (Mosop from last year).

View more videos at: http://nbcchicago.com.

Ross

The anatomy of a VAP test report

The vertical auto profile (VAP) test is an enhanced lipid profile test. It has been proposed, chiefly by the company Atherotech (), as a more complete test that relies on direct measurement of previously calculated lipid measures. The VAP test is particularly known for providing direct measurements of LDL cholesterol, instead of calculating them through equations ().

At the time of this writing, a typical VAP test report would provide direct measures of the cholesterol content of LDL, Lp(a), IDL, HDL, and VLDL particles. It would also provide additional measures referred to as secondary risk factors, notably particle density patterns and apolipoprotein concentrations. Finally, it would provide a customized risk summary and some basic recommendations for treatment. Below is the top part of a typical VAP test report (from Atherotech), showing measures of the cholesterol content of various particles. LDL cholesterol is combined for four particle subtypes, the small-dense subtypes 4 and 3, and the large-buoyant subtypes 2 and 1. A breakdown by LDL particle subtype is provided later in the VAP report.

In the table above, HDL cholesterol is categorized in two subtypes, the small-dense subtype 2, and the large-buoyant subtype 3. Interestingly, most of the HDL cholesterol in the table is supposedly of the least protective subtype, which seems to be a common finding in the general population. VLDL cholesterol is categorized in a similar way. IDL stands for intermediate-density lipoprotein; this is essentially a VLDL particle that has given off some of its content, particularly its triglyceride (or fat) cargo, but still remains in circulation.

Lp(a) is a special subtype of the LDL particle that is purported to be associated with markedly atherogenic factors. Mainstream medicine generally considers Lp(a) particles themselves to be atherogenic, which is highly debatable. Among other things, cardiovascular disease (CVD) risk and Lp(a) concentration follow a J-curve pattern, and Lp(a)’s range of variation in humans is very large. A blog post by Peter (Hyperlipid) has a figure right at the top that illustrates the former J-curve assertion (). The latter fact, related to range of variation, generally leads to a rather wide normal distribution of Lp(a) concentrations in most populations; meaning that a large number of individuals tend to fall outside Lp(a)’s optimal range and still have a low risk of developing CVD.

Below is the middle part of a typical VAP report, showing secondary risk factors, such as particle density patterns and apolipoprotein concentrations. LDL particle pattern A is considered to be the most protective, supposedly because large-buoyant LDL particles are less likely to penetrate the endothelial gaps, which are about 25 nm in diameter. Apolipoproteins are proteins that bind to fats for their transport in lipoproteins, to be used by various tissues for energy; free fatty acids also need to bind to proteins, notably albumin, to be transported to tissues for use as energy. Redundant particles and processes are everywhere in the human body!

Below is the bottom part of a typical VAP report, providing a risk summary and some basic recommendations. One of the recommendations is “to lower” the LDL target from 130mg/dL to 100mg/dL due to the presence of the checked emerging risk factors on the right, under “Considerations”. What that usually means in practice is a recommendation to take drugs, especially statins, to reduce LDL cholesterol levels. A recent post here and the discussion under it suggest that this would be a highly questionable recommendation in the vast majority of cases ().

What do I think about VAP tests? I think that they are useful in that they provide a lot more information about one’s lipids than standard lipid profiles, and more information is better than less. On the other hand, I think that people should be very careful about what they do with that information. There are even more direct tests that I would recommend before a decision to take drugs is made (, ), if that decision is ever made at all.