EBT Heart Scan

The mail keeps coming in response to Ed Burke's heart attack. Here, a cyclist reports on a new type of scan that's being used in heart exams. Sounds promising, but RBR's medical advisor, Andy Pruitt, Ed.D., says it's not the final answer.

• Ed Burke's heart attack and the subsequent cardiac health discussions on this site motivated me to have a thorough annual physical. Like Ed, I have a family history of heart problems and an active road cycling regimen. Thus, I asked my physician to concentrate special attention on my cardiac health.
  
  My doctor suggested an EBT (electron beam tomography) heart scan as the most effective tool for analyzing the heart. His quote was, "If you undergo this test and everything looks good, I can practically guarantee that you will not drop dead of a heart attack during or after exercise."
  
  The EBT scan cost $475, but the procedure is seldom covered by insurance. My results were excellent, and the summary was provided immediately after the exam by a cardiologist in a one-on-one meeting. The entire process took 30 minutes.

The technology was amazing. The patient is only semi-enclosed (unlike an MRI), meaning claustrophobia is not a concern. The four-color photo scan shows specific detail of the heart and any calcium present in the arteries. The amount of calcium is apparently the most predictive element of heart trouble.

Based on my experience with this exam, and with the intention of riding for many more years, I would recommend the EBT. -- Gordon W.
 

• Andy Pruitt replies: I must sound a note of caution. EBT heart scan technology and result reliability is still in question. Its value is improving, but there is a reason that insurance companies don't cover it as experimental. At this point, most really good cardiologists use an EBT scan as just one piece of evidence. It is far from the gold standard.
  
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Should you have regular stress tests if you seem to be a fit and healthy cyclist? Read the point/counterpoint by two medical professionals, then decide.

Coronary Artery Disease

Here is a valuable account that tells us two things: (1) why you should never ignore telltale signs of potential heart trouble, and (2) how a consistent cycling program may save your life. For related material, see reader reaction to Ed Burke's heart attack, the new heart scan that helps determine coronary risk, and a debate over the value of stress tests.

• I've been active in outdoor pursuits all of my adult life and am now 58. For years I had been producing positive results on my treadmill stress tests. Because of my otherwise excellent fitness and asymptomatic response, the test results were called "false positives" and the usually prescribed angiogram, with its attendant risks, was deemed unnecessary.

I have a family history of heart disease and was being treated for hypertension. I have been well aware of the risk factors and have been able to effect those that were within my control, though a misspent youth in my 20s probably exacerbated the condition.

In 1999 I rode Paris-Brest-Paris, the classic 1,200-km ultramarathon event. It was around that time when I began to notice (or imagine?) some mild chest discomfort during the early stages of any competitive event or training ride. After 30 minutes the symptom would disappear and I would always finish strongly. This was diagnosed as everything from left ventricular hypertrophy ("athlete's heart") to exercise-induced asthma.

A year ago I came down with a recurring flu bug that kept me off the bike for nearly two months. When I did resume riding I experienced serious chest pain during exertion that could no longer be denied. I knew that I would continue to ignore these symptoms at my peril. I returned to my doctor who told me to park the bike. He ordered the angiogram.

The results were astounding. Of the three major arteries feeding the myocardium, two were 100% blocked and the other was passing only 10% of its capacity.

My doctors were obviously shocked and told me that many men with this much arterial blockage would already be dead.

I was alive, they concluded, because of the many thousands of commuting, training and touring miles I'd logged over the years that promoted the production of collateral vascularization, i.e., the formation of many smaller natural bypasses around the blocked arteries.

In July I underwent coronary artery bypass graft surgery. My hospitalization lasted five days and I was sent home feeling as though I'd been hit in the chest with a sledge hammer. Six weeks later I was back on the bike. In November my wife and I completed El Tour de Tucson.

Today I feel better than I have in years and am very happy to be alive. Next month I go in for another stress test which may indicate whether I will be able to randonneer again.

The moral of my story is that we must no longer believe that diet and aerobic exercise is the panacea that will prevent heart disease from occurring. If you've got even a moderate risk profile, regardless of how fit you feel:

1. Get regular checkups.

2. Take charge of you own health assertively.

3. Learn as much as you can about heart disease.

4. Take it seriously if you get a positive result on any heart test. Your life may depend on it. -- Tom H., BC, Canada

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Coronary Considerations

 

We all ride lots, we eat nutritiously, we try to keep body weight down, and we feel and look pretty fit.

 

But that doesn't guarantee we have healthy hearts.

 

Example 1:  Champion cyclist Joe Saling of New Jersey suffered a heart attack after finishing a criterium. He was 63 and had been competing for decades. He never dreamed he could have a blocked artery. Emergency surgery saved his life and he was able to race again.

 

Example 2:  Cycling physiologist Ed Burke of Colorado knew he had a family history of heart disease. Still he became a midlife convert to tough events such as Iditabike and the Leadville 100. He developed classic warning signs of heart trouble, but did not act on them. He suffered a fatal heart attack at age 53 on a noon ride.

 

Example 3:  Much-admired bike shop owner John Cuchessi died of an apparent heart attack during a weekly club ride near San Clemente, California. Cuchessi, called an "exceptional cyclist," suddenly veered from the road. Two nurses performed CPR until an ambulance arrived, but paramedics were unable to revive him. He was 54.

 

Charles Hall isn't nearly as well known in cycling as those 3 men. He's just a fit 50-year-old recreational rider in Madison, Alabama -- 5-foot-10 and a lean 160 pounds, working as a computer systems engineer. He'd read about Ed Burke on this page. Interesting, sad, but not pertinent, Hall thought.

 

Then something profound happened to Hall to make Burke's death very relevant. He opened up to RBR in newsletter issue No. 344 with a story he's allowing us to share. His life was saved. Others could be too.

 

The Heart of the Matter

By Charles Hall

 

I read your website's information on coronary artery disease a while back. I didn't think it applied to me. I was wrong.

 

About 3 weeks ago, I experienced moderate chest discomfort 5 minutes into a planned 30-mile ride. It didn't match the descriptions I remembered of heart problems, and after I eased up for about 15 minutes the pain went away and didn't return.

 

Two days later I had an exact repeat. Then again a couple of days after that. I went to my doctor, who thought it was nothing serious but scheduled a precautionary stress test. I had just passed my 50th birthday.

 

The stressed portion of the test went smoothly. My instructions were to keep going until I couldn't take another step, but the technicians weren't interested in my offer to go for a record so we quit after several speed/resistance increases. I had very mild chest discomfort mid-test, but my pulse, blood pressure and EKG were all fine.

 

That was a Friday. I was cleared to ride during the weekend and told to return Monday for the resting portion of the test.

 

Saturday's ride was a 50-mile (80-km) non-stop solo, and while I had more frequent chest discomfort, the intensity wasn't any greater than before.

 

Monday, everything changed.

 

After the stress test's resting portion, I was warned that my myocardiogram indicated irregularities and I should see a cardiologist. About an hour later I got the first big surprise.

 

The test, which included the injection of a tracer and electronic imaging to determine my heart's blood uptake, indicated reduced flow to the area supplied by the left anterior descending artery -- one of the 3 arteries supplying the heart.

 

The cardiologist expressed shock that I would have this condition. He said I could pay now with a heart catheterization or pay 4-5 months later with a heart attack. Based on the scan and my lack of symptoms, he estimated 70% arterial blockage.

 

A catheterization would show the exact location and extent of blockage. I had it on Thursday. The surprises continued. I was 99% blocked high in the LAD artery.

 

My lack of symptoms was explained by the excess heart capacity I'd built through years of cycling. It also meant that a lethal heart attack was probably going to be my first serious symptom.

 

A coronary stent was successfully placed to open the blockage, and I've been approved to return to riding in two weeks. There were no indications of heart damage. Given that I've been living on greatly reduced coronary blood flow, I've been told that my cycling performance should be better than it has been for some time.

 

I had all the body weight, blood pressure, diet and exercise factors on my side. I had no risk factors except for the one discovered in the blood work-ups during this incident: cholesterol. Without this lab work I never would have known.

 

My cholesterol level is two times higher than what's considered good health. In my case this is blamed on an inherited tendency, so reduction will have to come mainly through medication. There aren't huge diet or lifestyle improvements I can make.

 

Several things played a role in my survival. A big one was cycling. The same activity that made me fit enough to survive the ignorance of my high cholesterol also eventually gave me the warning signs to take action.

 

Looking back, during the second half of last year I lost enthusiasm for riding. It just became too hard, and I put it down to a busy personal schedule. After 3 months off the bike, I knew in January I needed to get started again. It was still hard, which I attributed to the layoff. Now I see this all in a new light.

 

My message? Biking is a good and healthful activity. We all know that. But just like you can't judge a book by its cover, you can't judge an athlete's coronary health by the way he or she looks. Check the inside stuff. And by all means pay attention to what your body is saying when you ride.

 

Live to bike. Bike to live.

 

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Ed. Note:  Here's a second report from Charles Hall about his progress.

 

Clark Kent's Stent

By Charles Hall

 

It's been 4 1/2 weeks since I received my coronary stent, and three weeks and 450 miles since I resumed cycling. I'm riding about 10% faster than before the stent, and logging about 50% more miles a week. Opening my artery didn't turn me into Superman, just a more fit Clark Kent.

 

My leg strength is pretty good, but I have some ground to make up on endurance and aerobic conditioning. That seems to be where my blockage held me back.

 

I'm writing this after a follow-up visit with my personal physician. Everything looks good. My resting heart rate is down 10 bpm to 52.

 

I asked the doctor what I could've done differently to avoid developing the condition. He said not much, aside from getting my cholesterol checked earlier (triglycerides 232 mg/dL, LDL 181, and HDL 43 the week before the stent was inserted).

 

The doctor also said that acting on my symptoms instead of ignoring them was the critical thing.

 

If a person is asymptomatic for coronary artery disease, medicine today does not have a simple, definitive test to reveal it. Lots of research is going into understanding the relationships between cholesterol levels, arterial inflammation and artery disease. Someday we'll have better answers.

 

For now, we need to note symptoms of problems. And during my most recent 3 weeks of riding, I've realized I missed some personal indicators. My body was telling me things I wasn't hearing until it spoke loudly and urgently.

 

Three things stand out most:

• I can climb again.  Two months ago, I would grab for ever lower gears and grind up hills that are now just a training challenge. I'm relearning technique and gear selection, but hills no longer mean suffering.
   

• Longer rides don't leave me exhausted.  My routine includes a nonstop solo ride of 60+ miles once a week. Last year it would leave me worthless for the rest of the day. Now I feel nicely recovered after a shower, a short rest, and some food.
   

• Riding in the heat doesn't sap my energy.   I rode in temperatures in the low 90's (34C) recently. Alabama's summer heat is just not the factor it's been in recent years.

I was oblivious to the deterioration in my physical ability during the past year or 2. The differences since the stent are striking. There has been an immediate and marked improvement in my climbing, recovery and heat tolerance. My experience indicates that these are good barometers of health, and if there's an unexpected and consistent decline in them, an explanation should be sought.

 

Keeping a cycling diary (long advocated by RBR) can be a way to spot negative trends. By noting how you feel during rides, your times on certain climbs or courses and your recovery, you'll have a way to judge physical performance -- and potentially the state of your heart's health -- as months go by. 

 

I have an appointment with my cardiologist in July. My goal is to be at 1,000 miles (1,600 km) post-stent by then. I'll write another update following his exam and evaluation.

 

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Climbing Strength

In newsletter issue No. 61, Coach Fred Matheny said that a winter spent on the leg-press machine won't automatically produce greater climbing strength. Here's another take on this issue.

• I read Fred's comments with interest. As a long-time cycling coach and personal trainer here in Berkeley, the issue all comes down to specificity: We get precisely what we train for and nothing more.

If you want to be a good climber, you must climb steep hills. Absolute leg strength has little or no bearing on climbing ability. I do not know if great climbers of the past like Fuente, Van Impe, Alban, Winnen and so on ever even saw the inside of a weight room, yet they could outclimb any bodybuilder who could leg press 1,000 pounds with ease.

On a climb, you must be able to move your own bodyweight -- and the bike's weight -- against inertia. This is an entirely different enterprise from moving dead weight up and down a fixed path.

The two best ways I know to become a better climber are:

1. Lose weight, as this is the single biggest inhibitor to successful climbing.

2.  Train like mad on steep hills one or two days per week.

By steep, I mean a gradient greater than 8% for three miles or more. Needless to say, this is not terribly fun or easy, but it's a superb way to get used to working the deep muscles of the thighs, hips and low back. No other exercise can approximate this type of work. -- Tom S.

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Ashamed in the Gym

In newsletter issue No. 75, Coach Fred Matheny gave advice to a roadie named Patrick, who felt embarrassed to be lifting light weights while surrounded by hulking strong guys in the gym. It looks like other roadies have dealt with this concern, too.

• I used to feel the same as Patrick at the gym, but that stopped once I started telling myself that I would easily blow away any of these guys in a century ride! I picture myself laying down the gauntlet after they start snickering as I walk by. Actually, that's never happened. Most of the people are friendly and seem to respect me for showing up every week as I do. -- Joe
  
   

• As a classic mesomorph, I've never felt Patrick's shame (except when climbing). I have a skinny buddy, however, who says he's happy at the gym. He says he finds comfort knowing he can kick any musclehead's butt in a sprint. Not that they'd show up. That's another of his observations. He has the courage to graze on their turf, but he has yet to see one of them at the start of a ride. -- Richard R.
  
   

• Two thoughts about cyclists vs. bodybuilders: (1) Most bodybuilders concentrate on their upper body. As a cyclist, when you do leg presses, you'll probably use more weight than the hulks. (2) I join the various exercise classes at my gym. The "Body Pump" class is especially helpful for me. It uses lower weights and higher reps, typically a hundred or so. This is what I need as an endurance cyclist. Also, with 95% females, the view is more pleasurable! -- Dan C.
  
   

• When I'm doing bench presses with an empty bar, I'm laughing my weenie biceps off at those steroid infused apes. After I'm done, I'll spend hours having fun under the sun on my bike. All they have to look forward to is another day in that dingy weight room! I'm much more fit than they'll ever be, and my spandex still gets honks and whistles from women half my age. Ashamed? The joke's on them! -- Bill R.
  
   

• We'll see who laughs last. The ripped, pumped lifters, if they don't do the necessary aerobic work, only look fit. They are far less fit than they look. They might be "built," but they aren't "in shape." -- Jim C.
  
   

• I felt the same way as Patrick until I took my road bike into the weight room one day. After the hulksters found out that I was a cyclist, they started asking me questions on how to improve endurance, breathing, etc. After that, I was The Man. -- Enrique B.
  
   

• Hey, Patrick, don't feel ashamed in the gym. I'm one of those big bodybuilders. I just started cycling in the late summer and have a long way to go to be in the same league as most road bikers.

Those big guys and strong women do not think anything about how much you lift. We all had to start somewhere, and everyone started with an empty bar. We don't look down on someone who may or may not be as strong or can't lift as much. All bodybuilders and power lifters see where you are and they respect you for trying to improve yourself.

Take the time to talk to these men and women. You will find that they are good people and will help you with any questions you have. Just like when I started riding, no one looked down on me. All the riders I talk to are very supportive and recognize I'm a beginner and not a strong rider. Go back to the gym with the goal to improve yourself. -- Kyle B.

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Hip Replacement

In newsletter issue No. 48, Coach Fred Matheny asked for personal experiences with joint replacement surgery. We received several positive stories. First, one about hips, then two about knees.

• I'm a 58-year-old cyclist. I had a hip replacement six years ago after an altercation with a car whilst riding in a time trial at the Australian masters championships.

Recovery was quite fast. I was allowed in the pool once the wound had healed, and this allowed me to exercise quite a bit. As soon as I was comfortable, I was on the home trainer with no load and the saddle down a bit, increasing steadily till I was finally back on the road.

Later that year I won two stages plus my age group in the masters Tour of New Caledonia. I have continued racing, as my surgeon says that it's a lifestyle thing, but "Please stay upright!"

Possibly the hardest thing was having to back down a level from where I was. However, normal cycling you can do forever. Don't be scared to gear down and go for it.

If someone needs a hip replacement, I would recommend it every time. It's worth it just to get rid of the pain and get on with your life. On the bike it's great -- not as good as the original but pretty damn close.

I just newly subscribed to your newsletter. It's a great effort. Keep up the good work. -- John M.

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Knee Replacement

• I was not quite 42 when I had my left knee replaced 3 1/2 years ago. An injury forced the issue. I had to try it in order to ride again -- or engage in any athletic activity, for that matter.

I'm very pleased with the result. I was back on the bike in 3 months and back to pre-injury condition within a year. My quadriceps returned and I have yet to experience the aching, swelling and excruciating pain caused by 20 years of osteoarthritis.

I haven't achieved normal flexion range and do not feel comfortable with long rides (60+ miles) or daily training. I think my power is greater than ever, though, now that I'm pedaling with 2 legs instead of 1 1/2. -- Steve R.
 

• I had both knees replaced just before I turned 65. I started riding a recumbent about 6 weeks later and my mountain bike a week after that. Less than 4 months after the operation, I did an 80-mile ride. Two months later, I did 340 miles in 6 days. I finished the year with about 3,700 miles and I'm going strong this year, too.

I am thoroughly pleased with the results. No water on the knee or stiffness the next day. I was told my titanium knees will last over 30 years, so I'm not worried about wearing them out. -- Bob S.

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Numb Hands

In newsletter issue No. 120, Coach Fred Matheny gave seven solutions to a roadie suffering a common malady -- hand numbness while riding. This prompted subscriber feedback pointing to possible causes and solutions we usually don't think about. First, the original Q & A.

Q:  After about 30 minutes of riding, my hands get so numb and tingly that I can't shift gears. My handlebar is level with the saddle. Can you help? -- David W.

Coach Fred Replies:  You've already done one key thing to prevent hand numbness -- raise the handlebar. Doing so stops you from putting excessive weight on your hands that compresses nerves and blood vessels. So there must be another cause. Here are some suggestions to help you sleuth out the problem:

• Move your hands frequently. Switch your grip from the hoods to the drops to the flats next to the stem, then back again. Don't leave your hands in one place long enough for tingling to develop.
   

• Change your grip. Hold the bar in a way that limits pressure on the center of the heel of your hand. That's where you're most susceptible to numbing nerve compression.
   

• Pad your hands and/or handlebar. Sometimes wearing gel gloves or putting gel padding under the handlebar tape will stop numbness by softening pressure and damping vibration.
   

• Check your saddle angle. If the nose is tilted down, it can cause you to slide forward. This puts extra weight on your hands and stresses your arms and shoulders, too.
   

• Consider aero bars. When using them, all hand pressure is relieved. Weight is borne by your forearms.
   

• Consider changing shifters. Some riders do better with bar-end or down-tube shifters rather than integrated brake/shift levers. When you have to move your hands to shift, pressure is automatically relieved.
   

• Get a hand exam. Numbness in just 30 minutes of riding is unusual. If it also persists long after rides, check with a physician to rule out an underlying cause.

Roadie Feedback

• Neck position can affect your hands. I have an old neck injury from a bike/dog crash, and when my neck is extended back, my hands and fingers tingle and go numb. Raising my handlebar and occasionally lowering my head while riding so that my neck is in a straight line with my spine helps relieve the pressure. -- Peech K.
  
   

• I suffer from numbness in my right hand and have found that neck and shoulder stiffness are what cause it. Massages have significantly increased my ability to ride without numbness. -- Rick K.
  
   

• Be aware of  the possibility of a nerve problem at the base of the neck. An existing problem here can be aggravated when the head is held up as during cycling. This position can irritate a bundle of nerves called the brachial plexus, which provides messages down the arms and into the hands.

I have found that about 80% of the people that come in complaining of carpal tunnel symptoms, many of them cyclists, have this problem in their neck, known as a spinal subluxation. We have a success rate of greater than 90% when this is the case. There are some people who don't respond and may require more invasive procedures, such as surgery.

If any RBR readers are suffering from hand numbness and would like to be evaluated, they should consult a chiropractor in their area who specializes in correcting spinal subluxations. -- Dr. Dan Curriden
 

• If you ride with a backpack and suffer numb hands, the straps pressing on the nerves in your neck and shoulders may be the reason. I changed from a 15-pound backpack to front panniers for my commute and my chronic numbness disappeared. -- Arnie S.

• Check your fore-aft saddle position. Numb hands commonly result from too much weight on your hands. Sliding the saddle back can center your weight over your cranks and take weight off your hands. You may have to get a seatpost with more setback or a saddle with longer rails. And you may also need to counterbalance the increased saddle setback with a shorter stem to maintain the right reach. In my case, heavy shoulders necessitated a custom frame with a 72-degree seat-tube angle to keep my weight off my hands. -- Eric E.
  
  [Ed. note: We caution against altering saddle position for this or any reason if it moves you out of your ideal knee-over-pedal relationship. First try the numerous other solutions for numb hands.]

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Dialing 911

In newsletter Nos. 16 and 35, we mentioned the value of riding with a cell phone to call for help if you or a riding partner becomes injured or sick. Good advice, and here's some more.

• I never ride without a phone now. But when my friend went down last year and lost consciousness, I forgot that on a cell phone 911 doesn't necessarily get picked up in the same town you're calling from.

I kept repeating the intersection and, in my hysteria as my friend started to go out, I didn't realize that the person on the other end didn't know what town I was in.

Because 911 could get answered far from where you are, you need to get transferred to a local service. -- Mark O.
 

• Any cell phone, even one not active with a number, can be used to call 911. So, if you have an old phone lying around and not in service, charge it up and take it with you on rides. It could be invaluable. -- Joe S.
   

• Before you rely on an out-of-service cell phone for emergencies, double check with your local 911 service to make sure it'll work for them. Don't call 911 and declare "false alarm" -- enough little old ladies with their cats stuck in a tree do that. Ask someone at the office. -- John D.
   

• Have the folks at your friendly cell phone kiosk make your out-of-service phone "generic." Then you can place outgoing calls on a pay-as-you-go basis using a credit card (not a phone calling card). It's pricey, but cheaper than paying a monthly service fee if you only use the phone for emergencies. No one will be able to call you, but who needs a ringing phone when you're enjoying one of the best activities life offers? -- Bob T.
   

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Gloves for Cold Rain

In newsletter issue No. 83, we asked for recommendations on gloves that will keep hands dry enough and warm enough for comfort in cold rain. Here are the real-world responses that poured in.

• Use large rubber dishwashing gloves over your normal winter cycling gloves. Secure them around your wrist with an elastic band or duct tape. -- John R.
   

• The Assos Isotex winter gloves are good for me down to 45F degrees, rain or dry. Below that, I add polypro glove liners. -- Dave K.
   

• SealSkinz work for me in Seattle down to about 30F degrees. -- Reid W.
   

• SealSkinz keep my hands almost too warm. They are waterproof. I got mine for $29.95 through REI's internet site. -- Terry M.
   

• Wear latex surgical gloves inside full-finger winter gloves. The latex doesn't breathe, but it does save your hands from getting cold. -- Mark O., Frank G., Carl K.
   

• Try Sharkskins gloves used by kayakers. -- Ron K.
   

• For cold and wet commuting, I wear neoprene gloves with silk glove liners. Silk insulates well even when damp. -- Bob E.
   

• Fleece gloves from Manzella keep my hands reasonably comfortable down to about 45F degrees in wet Pacific Northwest weather. -- Terry Z.
   

• Three-pocket "lobster" mitts work well in temps in the low 20s. Even if hands get wet with sweat, they remain warm. But these mitts are actually too warm when it's warm enough to rain. -- Steve W.
   

• Outdoor Research makes a Gore-Tex lobster shell that weighs about 50 grams per pair. -- Kevin H.
   

• I wear Gore-Tex Windstopper overmitts over regular cycling gloves in cool weather, over the cycling gloves with polypro glove liners in cooler weather, and over winter gloves in cold weather. The mitts are so light you don't notice them, and I don't have any problem gripping anything. -- Mary Lynn M.
   

• The Performance "Legend" gloves were a great solution, but they aren't offered anymore. They had Thinsulate lined with Gore-Tex under a nylon shell. They even had padded palms and terry on the back for wiping nose drip. -- Rich H.
   

• Cannondale's Gore-Tex gloves keep hands warm and dry for at least an hour in Seattle's wet winter. -- D.V.
   

• Pearl Izumi's polyester winter gloves have leather palms and list polyurethane as one of the components. I've had to wring them out because they were soaked, but my hands stayed warm, though wet. They seem to have some property akin to wool that keeps you warm even when wet. -- Mike I.
   

• For warm hands in the rain, wool will retain heat when wet. You can usually buy good wool gloves with rubber or leather grippers on the fingers and palm at hardware stores, western wear stores, camping stores, surplus stores and some bike shops. In fact, if you aren't wearing wool socks, gloves and jersey in the rainy months, you are going to get chilled quite fast. -- Aaro H.

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Dental Dangers

• I always enjoy your newsletter and I buy your eBooks. Often there are recommendations to use sports drinks during rides.
  
  The value of sports drinks in replenishing the body's physiological needs is well documented. However, as a practicing dentist, I have seen more than a few cases of terrible, destructive, rampant tooth decay from the sugar in these drinks. (Also from soda, energy bars, candy, dried fruit, etc.)
  
  Sometimes the decay is preceded by increasing tooth sensitivity, but, as is often the case with dental caries, generally there are no warning signs or symptoms. Whenever one's teeth have repeated or extended contact time with sugar, they are extra-vulnerable to this upsetting (and potentially expensive!) problem.
  
  For myself (and what I recommend for my patients), I drink only plain water while I ride, supplemented with sodium, potassium and magnesium pills or foods (bananas, orange juice, Mag-Ox 400 tablets, etc.) before, during breaks, and/or after riding. Orange juice has too much sugar, too, but I rinse well and wash it down with plain water.
  
  If you must use a sugared sports drink or the like, I'd recommend extra-thorough brushing and flossing ASAP after riding, plus using supplemental fluoride (over-the-counter rinses and/or prescription brush-on formulations). -- Dan Sullivan, DDS
  
   

• While I agree with Dr. Sullivan that the sugar in the food and drinks consumed by cyclists is a potential problem, I think he may be a bit too cautious.
  
  I say this because as a practicing endodontist, I have seen cyclists as root canal patients and can't remember any whose problems were likely attributable to energy foods.
  
  The three main features of dietary sugar exposure as it applies to caries (the name of the disease) are concentration of the sugar, frequency of exposure, and duration of exposure.
  
  Sugary energy drinks should be kept as dilute as reasonably possible, and perhaps rinsed out of the mouth with water at frequent intervals. Not much can be done about frequency, as regular consumption is necessary for continuous riding. However, a water rinse should go a long way towards preventing a problem. This applies to the duration of sugar exposure as well.
  
  Solid foods present another problem -- duration of exposure owing to the texture of the food. Bananas have a fair amount of sugar in them, and they may stick between teeth. Worse are raisins and other dried fruits. Energy bars... 'nuf said!
  
  I believe that unless a rider is doing multiple back-to-back all-day rides, normal flossing and brushing should be sufficient to maintain dental health. Rampant caries are probably due to more factors than just sugar consumed on the bike. Certainly any rider who finds his or her dental health changing for the worse should see the dentist and discuss the options. -- Steve Weeks, DDS
   

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Acid Reflux Solutions

We've ridden with Scott Stinnett, M.D., of Siloam Springs, AR, at several cycling camps. As a long-distance rider, he's well aware of the digestive difficulties that can strike as food goes down and miles pile up. Here, he shares his recommendations for modern medicines that may prevent abdominal pain and burning acid reflux. Most are prescription drugs, so check with your doctor. Others are coming onto the OTC market.

• Initially, I recommend trying either Nexium 40 mg or Aciphex 20 mg. These could be taken once or twice daily.

Similar drugs are Prevacid 30 mg and Protonix 40 mg.

The next round would be Carafate 1 gm up to four times daily. The above four drugs stop acid secretion in the stomach while Carafate will protect the stomach lining from irritation and has absolutely no systemic effects.

Round three would be Reglan, which helps with motility in the GI tract. It has serious neurological side effects, especially if taken over long periods (months). It may also cause drowsiness. But taken in small doses, Reglan may help keep the gut going on 300K brevets, double centuries and longer.

Pepcid, Zantac and Tagamet could be helpful, and they are available without a prescription. But they are far less effective than Nexium and the others.

-- Scott Stinnett, M.D.

• Is there a place for an acid reflux suggestion from a long-distance-riding nutritionist?
  
  I frequently recommend and use dried pineapple on long rides. It's not only a good source of carbs but the "acid" in pineapple actually acts in reverse to what you'd expect and will neutralize the bounce-back acid in the stomach. Pineapple also comes equipped with enzymes to help digest whatever is causing the acid reflux.
  
  Also note that the minerals in good electrolyte replacement drinks will serve as natural buffers as long as we remember to stay hydrated. -- Peg B.
   

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Another Way to Ride PBP

Ed Pavelka’s story in newsletter issue No. 108 about his 67-hour ride in the 773-mile Paris-Brest-Paris randonnee resulted in several e-mails about his approach to the event. The writers pointed out that there is an entirely different way to do PBP -- not to try for a low time but simply to reach the finish. Here's one roadie's story.

• I've enjoyed following Ed's progress on his training and completion of Paris-Brest-Paris. And by Ed's own admission he is a very competitive rider who did not train almost 9,000 miles to just finish without getting a good time. However, there is a whole aspect of PBP that Ed is overlooking in his articles.
  
  I am a long-distance cyclist who is in his mid 50s and has been riding for 12 years. I really enjoy the challenge of long rides. The problem is, I'm not very good at them. 
  
  I've read the books, worked on training techniques and have improved over the years despite the fact I'm getting older. However, the bottom line is that I just don't have the natural physical abilities to ride and climb as well as Ed and many of the other strong riders. I'm with those who are well behind, the ones that make you wonder, "Are these guys going to make it?"

But I'm also a two-time PBP ancien [official finisher], having completed the '99 and '03 events.

For riders like me, just getting through it is the challenge. Both of my rides have been in the 88-89-hour range, so you see I am not burning up the road. And I definitely don't fit in the category of those who take the whole 90 hours but get lots of sleep and long naps. In both of my PBPs I only managed 5 hours of sleep. That is close to what Ed got but I was out there a day and a half longer.

In the back of the pack there are hundreds -- no, probably thousands -- of riders like me. People who are exhausted, sleep-deprived and struggling to stay within the time limit. Since the majority of the participants are in this category, we also have the added complications of dealing with huge crowds at the controls, cafeterias, sleep areas, etc.

This is what I consider the true PBP experience: An average rider, a guy or gal with a normal office or factory job who only trains on weekends but is willing to accept the challenge of this great event and has the determination to complete it, no matter what.

I am truly proud of my two PBP finishes. To my non-cycling friends I'm some sort of wonder. However, when I talk to riders and mention I did PBP, the first thing they ask is my time. When I indicate it took 88-90 hours, the reaction is often that that's no big deal, anyone can do that. They don't realize that just completing it, no matter what the time, is an incredible feat. Those who have only read about PBP and never done it don't have a clue how difficult it is.

You have a great forum at RBR. It would be nice to use it to encourage cyclists of all levels to consider PBP. While everyone who attempts it must work hard to pull it off, not everyone needs to be the caliber of Ed or Lon Haldeman or similar riders. Let your readers know that even the slow, back-of-the-pack person can enjoy the experience of PBP. It is not just for the cycling elite. -- Mike A.
 

• Thank you for printing Mike's letter. I, too, finished PBP -- about midway between Ed's and Mike's times -- and enjoyed myself immensely, a large part of which included the stops in bars at night for coffee and talk with other riders, for pastry at a few of the bakeries in the many towns we went through, for water and food with the locals along the roads in the middle of the night, and the new friends from foreign countries that I made.

For me, these are the experiences I will long remember, not my time or how little or long I slept. Next time I will even opt for the 90-hour group to allow myself more time for the whole experience.

Glad to hear that Ed will once again break his rule not to ride the same event twice! I look forward to following his reports in 2007. -- David N.

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High Brake Levers

In newsletter issue No. 110, Coach Fred Matheny gave several reasons why pro road racers might be putting their brake levers higher on the curve of the handlebar. In issue No. 111, we printed reader feedback and posted a photo to illustrate the new position. Here we have a reader’s reaction to the picture, and then more opinions on this surprisingly hot issue.

• Tyler’s Levers

I, too, noticed the high-lever positions on several bikes while watching the Tour de France this year. My initial reaction was, "Aha! They've finally figured out what I've been doing for years!"

My other comment is that perhaps the photo of Tyler Hamilton is not the best example, since he may have adopted that position to compensate for riding with a broken collarbone. Eh? -- Tom H., British Columbia

[Good point, Tom. Several other readers made it, too. Tyler’s levers are quite high in the photo, so we used it to show the position, not to make any point about him personally. We checked some shots of his bike before the collarbone fracture. His levers were higher than traditional then, too, but it appears he raised them even more after his injury.]
 

• Goofy Position

I have considered the goofy, upward-pointing lever phenomenon myself this spring and summer, and my answer, which I had until now kept to myself, was the same as yours: frames are too small, bars are too low and the only way to ride on the hoods is to jack them up as high as possible. 

See two sources for confirmation of this: any Rivendell literature on sizing and position, or any photo of a pro racer from the 1930s through the early ‘90s. You'll rarely see more than a "fistful" of seatpost sticking out of the frame. Or try setting up a modern-style bike with an older seatpost. Impossible. Keep up the good work. -- D.D.
 

• Not About Style

Ed and Fred, I'm disappointed in you. You turned the brake lever issue into a speculative free-for-all complete with predictable brand bashing, and your readers are no closer to understanding why we raise brake levers.

While Coach Fred's point about frame sizing is certainly a valid consideration, this is not about style. This is a biomechanical issue, not an emotional one.

My experience has shown that riders with low hoods typically ride with a kyphosic back position because they are leaning to reach their hoods and typically have weak core muscles.

High hoods allow for a comfortable hand and wrist position, forearms resting on the bar, bent, aerodynamic elbows, usually a lordosic back position with hips tilted forward, which means maximum utilization of critical core strength, which translates into delayed lactic accumulation in the primary muscles and far greater output of power, especially on climbs.

My brake hoods have been high for 38 years, which corresponds to my level of experience in cycling. In that period I have been a member of three Olympic teams, amassed 18 national championships, 14 of which were on the road, and 7 of those in elite-level competition. 

I position an average of 10 riders per week. My coaching staff's clients have won 144 national titles, 14 world titles and one Olympic Gold.

Guys, we know our stuff. Stop the speculation and share the opinions of myself, Andy Pruitt and Max Testa. Do your readers a favor, get real scientific facts. -- John Howard
 

• Ergonomic Benefit

As an Ergonomic Expert, I will confirm that the higher position of the brake levers is more "neutral," as we say in the ergo world. Bending the hand toward the little finger (ulnar deviation) makes the carpal tunnel in the wrist smaller, thereby increasing pressure on the median nerve. Constant pressure in this area is called carpal tunnel syndrome.

Symptoms that you are compressing the median nerve are numbness and/or tingling in the index, middle, and the inside of the ring fingers. If you look at the new position in the photo, you can see that the new position would result in less bending of the wrist. -- Diane E.
 

• Looking Cool, Feeling Better

I run Campy Chorus levers on a 38-cm Cinelli anatomic bar. For a few months, my shoulders were aching because I had a flat/slightly forward ramp with my levers.

Wanting to be cool like the Europeans (and because Phil and Paul were commenting on it during the Tour on OLN), I mounted my levers further up. What a difference! It’s a much more comfortable hand position for climbing, and there’s more room for my hands underneath the levers when I'm in the drops. -- Mary T.
 

• Comfort for Touring

I've been riding with my hoods in this "controversial" position on randonneur-bend bars for over 30 years. I'm a tourist, and it is simply more comfortable for long hours in the saddle. Speed isn't my issue, enjoyment is. -- Rusty