We all want to live as long as possible, but one of the realities is that there are so many chronic illnesses and things that we struggle with that even though we might live an extra couple of years, they may not be very functional years.

So we want to push the curve out of how long we live, but we also want those extra years to be as functional as possible.

Hello, this is the November 15, 2024 edition of the Tridoc Podcast.

I'm your host, Jeff Sankoff, the Tridoc an emergency physician, triathlon coach, and multiple Ironman finisher coming to you as always from beautiful sunny Denver, Colorado.

I know that I have spoken to you about how challenging it is to keep as many balls in the air as I do.

I also know that I'm not really alone in this endeavor.

Many of my listeners have incredibly rich, fulfilling, and very busy lives and have to balance their many responsibilities with their desire to train and race in whatever endurance sport that they are pursuing, just like I do.

Some of you are also coaches like me, and that adds just one more layer of complexity to the mix.

Staying on top of all of your athletes training plans and ensuring that you're there for all of them.

A smaller number still, and I'm guessing that to be maybe only a dozen or so, are also going to be podcasters, so only that really small subset will understand the final ball that's in the air, the one where you are coordinating interviews and content and production schedules.

Honestly, I don't know how you do it all, and I am pretty much myself making it up as I go along.

All this to say that I am amazed at the kind of mistake that I made.

Last episode isn't a more routine occurrence for those of you who actually listen to this part of the program.

When I do a brief monologue and introduce a segments on this episode, you likely caught the incredible gaffe that I made when I went on at some length introducing a medical mailbag segment that was in fact not the medical mailbag segment that was in the episode.

I know that personally, when I heard that I was pretty mortified.

But the reality is that once an episode goes out it's really hard to correct and so I had no choice but to leave it out there.

Gigantic error.

And all based on the fact that not a single person called me out on this.

I'm left to believe either that no one listens closely to this part of the program, or hopefully more likely that you're all just too kind to spend the effort to let me know.

And I'm really hoping it's the latter rather than the former.

At any rate, my excuse for this error is really quite simple.

I have a bunch of travel coming up that means I had to work on several episodes all at once in advance.

And in the effort to get three episodes done in a short timeframe, I I just got things mixed up and put the episode and put this episode's Medical Mailbag topic in the last episode's introduction.

I suppose that after 158 episodes it was bound to happen at some point.

Well, here's hoping that it will be at least another 158 before I make such a silly mistake again.

At any rate, you have my apologies if anyone was actually left confused.

I'm guessing you all figured it out, though my listeners are nothing if not pretty adaptable on the show today, the Medical Mailbag will not feature the discussion of collagen that I should have introduced last episode.

However, I promise that this time Juliette Hockman and I will answer a listener question about a fancy new device that leverages an old technology that I have discussed on the program once before.

According to their website, the Firefly is a revolutionary recovery device that speeds up the body's natural healing by increasing whole body blood flow.

It reduces recovery time and boosts performance.

End quote.

Now I know what you're thinking.

It sounds pretty awesome.

But is it true?

Well, we take a look at the evidence and that's coming up in just a couple of minutes later, I'm joined by a man with a strikingly similar resume to my own.

That is to say, he's a triathlete, a physician, and a podcaster.

Although Bobby dubois podcast is all about living well as we grow older, and his show Live Long and well with Dr.

Bobby looks at the various scientifically proven ways that we can maintain or even improve our quality of life as we age.

By leveraging what he refers to as scientific pillars, we talk about his multisport career, his podcast, and much more.

And that's coming up a little bit later on.

Before we get to all of that, I want to take a moment to thank all of my Patreon supporters of this podcast, including brand new subscriber Robert lynch, who decided that for about the price of a cup of coffee per month, they could all sign up to support this program and in doing so get access to bonus interviews and other segments that come out about every month or so.

The next of those episodes will be released next week and features an interview with professional triathlete and member of the Athletes Board of the PTO or professional triathletes organization.

Laura Siddle Laura helps me look forward to the 70.3 World Championships in New Zealand and gives her picks for the win on the professional men and women side.

That bonus episodes and others like it are available on a private feed for Robert and all of my other subscribers.

Plus for North American subscribers who sign up at the $10 per month level of support they receive a special thank you gift that I am showing right now on the YouTube channel in the form of this pretty cool Boko Tridoc podcast Running Hat.

It's very fashionable in fact.

For those of you who will be in Taup or Taupo, New Zealand this coming December, please do look me up.

I'm going to be bringing a few of these along and for the first I would say 10 of you who come and seek me out, I'll have one of these hats for you.

But another way to get them is to sign up at the $10 per month level as a Patreon supporter and I would be happy to send you one of these as part of my gratitude for supporting the podcast.

So become a supporter.

You can do so by heading over to my patreon site@patreon.com tridocpodcast you can see what is involved, maybe get access to this cool gift and certainly get access to all those bonus episodes.

And as always, I thank you in advance just for considering.

A reminder for those of you who are listening to the podcast, I hope that you will please leave a rating and a review wherever you get this podcast.

I swear those are incredibly helpful, immeasurably so to making the podcast better well known to others.

And if you're watching on YouTube, do me a favor, hit the like button and subscribe to the channel.

And now let's get on with the Medical Mailbag.

It is time for the Medical Mail Bag.

Juliet Hockman joins me from Hadrift in Oregon.

How are you Juliette?

I'm fine Jeff.

How are you?

If you are watching on YouTube this episode, you'll probably notice that in the next episode we're going to look very similar.

Maybe we'll change our hat and a sweatshirt or something.

The reason for that is because both Juliet and I are embarking on some exciting travels.

Where are you off to tomorrow?

Yes, tomorrow I am heading away for two and a half weeks.

November is a great time for me and my husband to travel.

I am going to the UK first to see family in England and Scotland and then my husband and I are biking in Spain for a week before we return to England again for a few more days.

So really looking forward to getting out of Dodge.

Sounds just awesome.

Yeah.

So that is.

And where are you going?

Dodge.

Amazing.

So my family, over Thanksgiving week, we will be heading to French Polynesia.

We'll be scuba diving on a couple of the atolls, Rangaroa and Fakarava, to be specific.

My wife and I have been down there.

We dove Rangaro once before and it's spectacular.

And wanted to take the kids down.

And we had not had a chance to go to Fakarava, which is another one that we've heard is really great.

So we are very much looking forward to that.

And that will take place.

I actually come back from that, have a week and then off to New Zealand for world.

Yeah, I know it's.

We're gonna.

We're gonna have to record the probably four podcasts out from now to.

Yeah, we'll have a few episodes to get it all in, but we're going to record two of them back to back here.

They will publish, of course, a couple of weeks apart.

And I the episode that just.

We're recording this on November 2nd and the episode that came out November 1st, in the monologue, I erroneously, instead of introducing the subject of collagen, introduced the subject of tonight's medical mail bag.

And I was like, yeah, it's one of those things where after it publishes, it's such a.

It's a huge endeavor to edit them, to change the podcast once it's out.

And I just let it go.

So I was like, I was.

I felt so ridiculous as I'm listening to the monologue and I hear myself talking about the subject of tonight of this episode's medical mailbag in the last episode.

Anyways.

Oh, that's funny.

What are we going to be talking about?

So this question or query comes to us from a couple of our younger athletes.

It is a product called Firefly Recovery, which makes great claims in terms of being an incredibly convenient device that generates small electrical pulses to stimulate nerve function.

That and it claims it help with recovery.

It claims to help with blood flow, it claims to help with oxygen delivery, nutrient delivery, et cetera.

And unlike sort of its predecessors, which involve pads and wires and other things like that, which are very unwieldy, this one is extremely easy to strap on and go to make some pretty big claims, even bigger than some of its more clunky predecessors.

So what did you and your team find out about Firefly Recovery?

This was a rabbit hole for a firefly.

It was an interesting endeavor and it was Nina Takeshima who did the work on finding the literature for this and she did a terrific job.

She came up with just some amazing papers that I think really help put some perspective on this.

And just to go back to some of those claims, Firefly has a lot of the red flags that I've spoken about in the past.

If you ever go to a website for one of these companies and you see some of these things on their website, you should always be a little bit wary.

And they have a very flashy website, lots of animation on there, lots of endorsements by athletes, high profile athletes, Olympians, various professional athletes from all kinds of sports, and then just a ton of really bold claims.

One of them being that by putting this little device over your shin and letting it stimulate your perineal nerve, that's a nerve that comes down the side of your leg just below the knee, and when stimulated, it causes your lower leg to twitch and your foot to twitch.

Basically their claims are that by doing this you can improve blood flow in the area.

Although they make it seem like it's whole body blood flow by 400%.

And it's pretty crazy.

That's like a waterfall of blood working through euphoria.

I know.

So immediately I, yeah, I was pretty skeptical.

And they do, to their credit, list some science on their website, but we found a lot more.

And just to give some background.

So the corporation that makes the Firefly actually started by making a.

The exact same device, but they made it for the purposes of being used in hospital on patients who'd had surgery.

And it was called the Gecko.

G E K O the Gecko.

And it's exactly the same.

It's this sort of.

It looks like a sort of oversized bandaid and instead of having a gauze in the middle, it's got this disc in the middle.

And that disc is what holds the battery.

And it powers these two electrodes that are in either side of the adhesive pads that wrap around the leg and it sends a little current across that basically then stimulates a nerve that causes these muscles to contract.

And the whole reason that this was developed as the get go was for patients who are in hospital and have had an operation are going to be bedridden.

They are at great risk for developing blood clots post surgery.

This has been a major problem in hospital for decades.

And we've come up with a lot of different ways to try and mitigate the danger from this.

Because if the clot forms, it can break off and go to the lung and Cause what's called a pulmonary embolism.

And that's a really significant problem for patients.

So there have been.

We use blood thinners like heparin.

Often that's introduced in any patient who's had surgery.

We start giving them heparin almost right away to try and prevent blood clotting.

We put on pneumatic compression boots and pneumatic compression, not pneumatic, but compression stockings to try and improve venous return from the legs.

And the boots are very similar to Normatex, but they don't cover the whole leg like a Normatec does.

They really just cover the calves.

And the stockings are very powerful elastic stockings to try and reduce pooling of blood, because those clots happen when you have any degree of pooling of blood within the veins.

So the gecko was developed because we know that when we walk, even though our feet are dependent by gravity, the contraction of the muscles in the legs, the feet, the calves, and everything else causes the muscles to contract around the veins that are running through those legs and squeezes the blood out of the veins back towards the heart.

So the developers of the gecko thought, if we can make the muscles contract involuntarily so the person doesn't have to be thinking about doing this consciously, maybe we can improve blood flow into the veins.

And indeed, there are some studies on the gecko that suggest that this does happen.

If you put the gecko on patients who have had surgery, you can improve blood flow in the veins of the legs pretty significantly.

However, it's never been shown, at least in that we could find.

We were not able to find any clinical studies that showed that doing so actually decreased the incidence of blood clot formation.

It makes sense that it probably would.

And the company actually received a couple of different design awards for their work in this area.

But to date, there have been no clinical studies that show that it does actually decrease the incidence of blood clots.

Still promising and interesting.

One of the other medical studies that was done on the get go is where this 400% number that we mentioned a little bit earlier comes from.

When you put these electrodes on, you actually cause some vasodilation in the area where the electrodes are, and it's the vasodilation specifically of these tiny little perforating micro vessels.

And so what ends up happening is where the electrodes are located, you end up increasing the perfusion of the microvasculature by about 400%.

But it's very localized.

It's not widespread.

It's not.

It's not particularly distal to the area.

It seems to be located primarily where the electrodes and where the electrical activity is.

Now, that's all great for medical patients, but what about athletes?

Because that's really what we're interested in.

So there have been several studies on this.

And I first want to just refer because, Juliette, you were saying that you have one of these devices.

I do.

I have one of those little off of Amazon E Stim machines with the two pads and the wires.

And initially it was to help with my glute and my hamstring.

But honestly, the whole process of getting it all hooked up was so cumbersome that I didn't use it very much.

I still have it.

Yeah.

And the acronym for this is nmes, although it goes by various.

ESTIM is another one.

Electrical stimulator.

ME S is neuromuscular electrical stimulation.

The idea behind this, it's been used for quite a long time, but it's really gained popularity in athletics over the last, I would say, decade or so.

I actually reviewed this technology pretty early on.

I'll have to go.

I'll put the link to the original episode where I reviewed this in the show notes.

But I talked about it because I had been asked about it by a couple of different people because it was really getting a lot of play in social media at one point from a couple of manufacturers who I think are no longer in the market for this.

But basically, you put these electrodes on your leg, you turn the machine up and your leg starts twitching.

And the promises that were being made were that, number one, you were almost exercising without exercising, and you could actually build muscle strength and endurance.

That's rubbish.

Yeah, that is complete rubbish.

That is not happening.

The second thing, and you see the funny ones are like the abs, when.

It'S on your abs, the military.

Look at all these jackals that I got.

It's so funny.

Yeah.

You see a lot of these guys who are already with their six packs and they put them on the six pack and they make.

It's like they didn't get like that from the East End, but whatever.

And then the other thing you hear is this recovery issue is that doing this somehow promotes blood flow in the area and allows for improved recovery.

And that's basically what the recovery firefly is leveraging on.

It's that same idea that putting this thing on your leg, causing the twitching in the lower leg is going to improve blood return from the area to wash away evil humors, but also improve blood flow to the area because Your muscles are active.

The advantage of the Firefly, or the Recovery Firefly over the traditional devices are exactly as you said, Juliette.

These.

The Firefly is super portable, super easy to put on and take off, and unfortunately disposable.

So not exactly environmentally friendly.

And we'll get to that a little bit later on when we talk about some of the drawbacks of this device.

But let's just talk about the literature, because there is quite a bit of literature, not necessarily on the Firefly itself, but on these kinds of devices.

A study from 2014 looked at the impact of neuromuscular electrical stimulation on recovery after intensive muscle damaging maximal speed training in professional team sports players.

This looked at rugby and soccer players, otherwise known in the rest of the world as football.

Exactly.

And basically they were able to show that if they used neuromuscular electrical stimulation for eight hours post training, they actually found that, oh, at 24 hours, perceived soreness seemed to be much better and they seemed to have some improved peak power output in terms of jumping and sprinting.

Sounds potentially interesting.

The problem is that this study is like many other studies that have been done on neuromuscular electrical stimulation.

And they were all compiled in an excellent systematic review that was done in 2014 by an author named Malone.

Neuromuscular electrical stimulation during recovery from exercise.

A systematic review.

And what he pointed out in this study is that like the previous study I just talked about, or are all kinds of problems with studies on neuromuscular electrical stimulation.

The major two problems are there's actually three problems.

So number one, there's no standardized protocol for this stuff.

So you heard that in the first study I mentioned eight hours, they had to sit for eight hours with these stimulator on their legs.

Now, with the Firefly, you can actually just walk around with this thing on your leg, but the battery life is only four hours.

You wouldn't really get eight hours.

That being said, these guys in that first paper were sitting there with those bulky devices.

They weren't doing anything else.

They were just sitting there for eight hours with this electrical stimulator on.

That's not something that most people are going to be able to do or willing to do.

So the protocols for these things are all over the place.

The second problem is almost every single one of these studies, like we talked about when we talked about collagen, are sponsored by the makers of these devices.

So there is an inherent bias in the authors.

They are obviously going to publish to papers that are positive.

They are obviously going to have a rationale to find positive results and the negative studies are probably going to get buried.

With that being said.

Oh, and then the last problem with these studies is they're not blinded.

And for obvious reasons, like you can.

When we talk about blinding, what we're talking about is that the person, the subjects who are part of the research, they don't know if they're getting the treatment or the control.

You're obviously going to know.

I was going to say, how can you not?

Right.

Yeah.

How can you not know?

So in this case, this is one of these kinds of things where you absolutely are going to know.

So the major findings of this systematic review, which was an excellent systematic review, it really pointed out some of the major problems, was that essentially these devices seem to result in people feeling like maybe they're getting a benefit subjectively, but objectively, the measures of performance never seem to show any major benefits.

And I think that Malone, the author of this article, he wrote.

I'm just going to read because he wrote a really nice quote here.

He wrote, although the beneficial effects of neuromuscular electrical stimulation on subjective measures of pain and feelings of well being should not be discounted and may provide some justification for use in some populations, the lack of evidence regarding its effect on actual athletic performance is likely the most important factor to consider for athletic populations.

And I think for you and me and for the people we're talking to, that's really the most important thing.

And I've said this before, listen, normatex, the evidence is pretty clear.

They don't actually make you perform better, but man, do they make you feel better.

They really feel good.

Yep.

Yep.

And I think in the end, the firefly is probably gonna end up being something similar.

If you get something out of the firefly, it makes you feel good.

I don't think that should be discounted.

Just don't think it's going to actually be doing anything for you and making you perform any better, because it seems pretty clear that it's not going to.

And there's a lot of fluff pieces out there.

We came across a fluff piece in a runner's magazine titled, is this the best recovery device for runners yet?

You could imagine what they had to say.

There's not a whole lot.

We found several other papers and I think one of the things we found was this is a good one.

Passive Recovery Strategies after Exercise.

A narrative literature review of the current evidence.

And this came out in 21.

And basically what this study said is it looked at neuromuscular electrical stimulation and it compared it to passive recovery in the form of just rest, massage and then active recovery in terms of just light exercise.

And it found pretty clearly there was no difference.

You did better actually with active recovery than you did with anything else.

Right.

What do you tell your athletes?

They've had a race, they've done something.

Do you like?

There were this came up actually in the Tri Doc podcast Facebook group just this week.

Somebody asked about the value of recovery days and what do you or being actually rest days.

So what do you tell your athletes?

It depends a little bit athlete to athlete and certainly age and experience and just number of miles on the body has a lot to do with it.

So I wouldn't want to say blanket statement, but in general I think, and you probably agree, big fan of active recovery.

Taking a day off every week or taking really regular days off just doesn't seem to have a whole lot of benefit regardless of who you are.

And so yes, a day off from time to time, but for the most part, if you are recovering from an event or even just recovering in the larger training cycle, better to go and do something.

And that might be something really light, a really light jog, a really easy spin, ride to the coffee shop, stop, have some coffee, ride back, or do some very light functional strength or something like that, or easy swim.

There's a lot of ways to move your body without putting stress on it.

And at the end of the day your body is going to come out feeling better.

And had you just sat around and.

Watched YouTube all day, I totally agree.

I think that movement getting the blood flowing, it doesn't have to be high intensity, it certainly doesn't have to be high impact.

It's just getting the blood flowing.

And I allude to it all the time.

Clearing out these evil humors is the way to go.

And while I think that there is the theory that neuromuscular electrical stimulation can help do that for people, I don't think there's any substitute for just getting out there and actually doing something activity wise.

Because while the recovery Firefly is going to work on your leg, below your knee and certainly small muscle groups, there I am getting out and walking, getting out and spinning on your bike, you're gonna be working much bigger muscles and allowing for a significant improvement in blood flow.

I do want to mention the price.

You can, yeah, you can get like neuromuscular electrical stimulators.

You can get them.

They're not terribly expensive.

Very cheap on Amazon.

Yeah, yeah.

But the Firefly's benefit is that it's so portable and it comes in this tiny little package.

But the problem is, it's not cheap.

You're paying for that.

Afford.

You're paying for that portability.

It's $99 for the starter pack, and that is four straps.

Yeah.

And there's single use, remember, one on each leg, right?

Yeah, Single use.

Right.

Now you can use them.

I got the sense you can peel them off and put them back on.

I'm not entirely sure how you would preserve the adhesive.

They have four hours of battery life, so I don't know how long people wear these things.

The one use I could think of these is if you have a long flight.

So if you were in Kona and you had a long flight back to wherever home was.

We know that racing puts.

So I mentioned blood clots earlier, and the three things that lead to blood clots are stasis.

So blood pooling in the legs, vascular injury, which is something that can happen just because of our running a marathon.

You can get these little micro injuries to the vessel walls and then hypercoagulability.

Hypercoagulability is the predilection for forming clots.

Now, we don't see that in most people, most healthy athletes, but if you become dehydrated, as people often do on an airplane, that concentrates your clotting factors and actually can lead to a slight increase in coagulation.

So being on an airplane for a long flight is one of those things that actually, we know is associated with the formation of blood clots, even in healthy individuals.

And so I always tell people after a race, that's the time to put on these pressure clothes on your lower leg, stuff like that.

And you could certainly make an argument.

Again, there's no evidence that shows that the gecko device or the firefly device prevent clots, but I don't see a reason it would hurt.

So if you wanted to use it for that reason, if you could sleep through it and could tolerate the continuous twitching, I don't know that it would be for me, but.

Or you could get a $20 pair of compression socks and with stripes and put those on that you could use.

Frequently that you could use multiple times.

Yeah, Yeah.

I can't really.

I can't really say that this is a device that I would think very seriously about.

Yeah, I mean, it sounds like it's.

It's similar to a lot of the other products that we review, which is it's not going to hurt you.

It's.

But it's not going to necessarily help you.

And the price tag might be a deterrent.

Am I right?

Yeah.

Yeah.

I think that's succinct.

And definitely I wish I could.

I always feel like I'm naysaying or poo, pooing everything, but the reality is that a lot of these devices are out there.

I think this was developed as a medical device.

And when you develop a medical device like this, you have to jump through a lot of hurdles to get it approved to be used as a medical device.

You don't have to jump through any hurdles to get athletes to be able to use it.

And so if you are the manufacturer of this thing, it makes good business sense to try and find another consumer market.

Population.

Yeah, consumer market.

So I understand why it would be marketed to athletes this way.

And as I told Nina when we were talking about this, when we were discussing the papers that she found and just talking about the website, you have to be very careful with athlete endorsements.

Athlete endorsements don't mean they actually believe it.

They don't mean they actually benefit from it.

Doesn't even mean they actually use it.

All it means is they're going getting a paycheck to tell you that they like it.

So it's something you have to remember.

All right.

Juliet and I are going to take a brief pause, but for you, it's going to feel like weeks.

Change our sweatshirts.

Yeah, exactly.

This has been another interesting segment of the Medical Mailbag.

And Juliet, thanks for being here.

If you have a question you would like for us to answer, I hope that you will consider sending it in.

You could email me@tridocloud.com you could drop your question into the Tridoc podcast Facebook group.

I hope that if you're not a member, you will search for it on Facebook, answers the three easy questions to be admitted and I will gain you admittance.

You can join the conversation, ask your questions there, and who knows, maybe you'll hear it answered here on the Medical Mailbag in an upcoming episode.

Juliette, thanks for being here.

You're welcome.

You and I will be right back to answer another question.

And for everybody else, they'll hear us in another couple of weeks.

Yeah.

Woo.

My guest on the podcast today is Bobby Dubois.

Bobby is a physician who trained at Harvard in Johns Hopkins and finished a residency in internal medicine at Harbor UCLA.

He's also a scientist with more than 180 published peer review articles on what does and does not work in healthcare.

If that wasn't enough, he has co founded several companies that work to improve the care that patients receive, ran a think tank in Washington D.C.

and has competed in durance sports for several decades, including completing 15 marathons, four full and 13 half ironman distance events.

Bobby now has moved on to have a new and growing podcast called Live Long and well with Dr.

Bobby, which is focused on wellness and longevity.

He also has a ranch and a ranch bed and breakfast in Texas where he invites guests to join him to focus on these six pillars for longevity, exercise, sleep, nutrition, mind, body harmony, exposure to heat and cold, and social relationships.

Recently, Bobby went and completed the swim run Casco Bay, which is one of the Otolo, I think I'm getting that right, Otolo events.

And he is going to join me to talk about all of these things if we can compress it into a half an hour or so.

Bobby Dubois, thank you so much for joining me on the Tridoc podcast.

It's a pleasure to have you here.

It's great to be here.

Thanks for including me and I look forward to the discussion.

Yeah.

Let's start first and foremost with your most recent accomplishment, the swim run that you did in Casco Bay up in Maine.

I have heard a lot about these events that people have done and they are growing in popularity.

Tell me what got you interested in doing that and how did it go?

It's a unique event, started in Europe and the one here in Portland, Maine, you basically swim from island to island.

So you start on an island, run to the other side, jump in the water, swim to the next island, get out, run to the other end of the island, and so on and so forth.

All the while you're tethered to your partner, which is my brother, and it's a hoot and a half.

I was reflecting on the fact that going to a long distance event by airplane, if you were doing a triathlon, is a major logistic challenge.

Of all the gear you gotta bring with you for the swim run, I was able to put everything in a rollerboard, all my equipment, including my clothes, for a week and off I went.

So it's a very different experience and it's really a lot of fun.

And although it's competitive for some people, most people are there just to have a great time, which we did.

And what are we talking about in terms of distances?

How much swimming, how much running?

What was the longest swim?

What was the longest run?

Yeah, we did what's called the sprint course.

Took us about three hours.

We had five swims and six runs.

I think it is total of eight miles of running.

And two miles of swimming.

And the longest run was probably three and a half miles of running.

And the longest swim, I think, was about 900 meters.

The long course is probably about twice that.

So that was a lot more for them.

And given that I'm 68, my brother's 70, we decided, I think the sprint course was just fine for us.

Was the long course just two laps of what you did, or it was a completely different.

No, they get more islands and more venues and it's a hoot.

It's a technical process.

It's an eco race.

So you carry everything with you.

So you wear your shoes while you're swimming and you get to pull buoy and paddles to help you with the drag.

And then of course, while you're running, you get to carry your pull buoy and your paddles and you get a little cup.

You carry that with you.

And there's some hydration stations.

And what's remarkable if people haven't done swim run is that doing a long course triathlon, you're beating your body up hour after hour.

And the next day you definitely feel it.

Because every time you get tired on the run, you jump in cold water, and then every time you're tired of being in the water, you get out and get to run.

It's remarkably mild on your body and the next day you really don't feel like you've really killed yourself.

So it's a wonderful kind of side benefit.

Are you swimming in a wetsuit?

They have something called the swim run wetsuit, which looks like bike shorts on the bottom and a simple wetsuit top shorts, short sleeves on the top, so it's thin enough to run in.

And of course, the bike shirts are very easy to run in.

You typically pull a zipper down so you can breathe a little easier, but the water's 60 degrees.

It can be 50 degrees depending upon what race you do.

So you do need something to keep you warm.

I don't have a lot of fat content, so definitely is helpful to have a little bit of a wetsuit.

And you said you're wearing your shoes when you swim, so you're not.

Yes.

Presumably you're not wearing like actual running shoes.

They're trail running shoes, but you get ones that drain really well.

If anybody's done long races that you could be running a marathon in the rain, then after the first 10 minutes of being drenched.

Yeah, it doesn't really matter.

You know, your feet are wet, they're not getting any wetter.

So it's the same thing.

Very few blisters.

I certainly didn't get any.

And then what about nutrition?

I imagine you have to carry that in your dry bag.

You get to carry everything.

Sometimes they'll have some gels at one or two of the water stations but we brought our stuff with us.

So you stuff it down through your wetsuit, up you up the legs on your.

The bike, short part of things and you carry it along again.

We were only at it for three hours so it was a limited amount of nutrition we had to worry about.

That was going to be.

My next question was about water because obviously you can't be carrying water for that amount of time.

So there's water stations now that they do for you that they get.

They have some big giant water things that you stop and grab some water and off you go.

That's great.

It sounds like a really fantastic event.

Now we know the unfortunate reality of triathlon is that when deaths occur, they happen during the swim.

And here's an event that has a lot more swimming that's really spread out.

How do they manage the safety on the water and did you hear of any bad things happening?

Not necessarily a death, but people having to be pulled from the race, from the water?

It's a great question.

The swims are all monitored with kayakers or jet skiers.

So there's people to help you.

What makes swim run interesting is that in Casco Bay, Maine you get four foot tide differences and so depending upon whether the tide is going in out or it's a slack tide, you're contending with current.

We were fortunate that we didn't have to deal with any major currents, but some people do and they do pull people out of the water.

If you're getting drifting into the ferry lane.

Didn't happen for us.

I don't think it happened for anybody this time.

But they certainly warned us.

Aim right.

We don't want to have to drag you off the course if you're in the ferry lane.

Yeah, I just thinking about the logistics for the race organizers.

Just monitoring that many swims just sounds really challenging.

I imagine they must roll it up so that as the competitors move from island to island they probably don't need to monitor some of the swims and they can just reallocate their resources.

But wow, that's something else.

It's quite an impressive event and congratulations for doing that.

Do you think you will do another one in the future?

Definitely.

I've got the Waco 70.3 traditional triathlon in October.

So that's my Next fun event.

But do you think you'll do other swim run events?

Oh, absolutely.

They're just fun.

There's no such thing as a PR because every race is different.

Even doing the same race two years in a row, you're in the woods, they may tweak where you're running.

Depending upon how the current is.

What used to be a swim could be a run.

So you're just out there having fun.

Some people obviously are trying to win, are.

And you get.

Everybody makes a team name.

So you're tethered to your partner.

So we were called two old men named Papa since we're both grandparents and we both are called Papa by our grandkids.

So it's a hoot and a half.

And yes, I think as long as we're able to, we'll continue to do one a year.

Are you tethered during the run or just during the swim?

You don't have to be tethered during the run, and we do disconnect because we don't want to trip.

But when you're in the water, you're asking about safety.

And one of the safety items is you're connected to your partner, so you never get too far away.

And if one of you has trouble, the other is right there and knows about it.

Because now all of a sudden, you're dragging somebody.

How long is that tether?

It's about six or so feet.

But you try to stay really close on the swim so you can draft, which sometimes works and sometimes not.

And sometimes you get tangled up in the bungee cord.

It's all part of kind of the whole experience.

Yeah.

Yeah.

I'm sure you probably have to figure in the first one or two swims, just try to figure out how that cord is going to exactly interfere and how to make it work.

That's really fascinating.

That definitely sounds like something I would be interested in trying at some point in the future because it really does sound like an interesting event.

Let's talk a little bit about what you have been doing with your podcast, because I think there's a lot of overlap between what you're doing and with what I do on my podcast.

So tell us a little bit about the podcast you're doing.

Live long and with Dr.

Bobby.

What.

Where did it come from?

What is the focus of it, and what are the kinds of things you discuss.

As you mentioned, I'm a physician and a scientist, and my career really focused on what actually works to help patients and what is really things that patients might get or do that doesn't help.

Who needs back surgery and which patients is it going to help and which are not?

And what's the evidence that supports that or doesn't support it?

Here's a new expensive medication.

Which patients should get it and which patients actually don't need it.

And I've had this passion for thinking about healthcare from a policy standpoint and doing right by as many patients as we can, spending money wisely so people get what they want.

And over the years I just got more and more focused, not just on health for myself, but issues of longevity and wellness.

And so over the last few years, I just pivoted from just thinking about sort of surgical types of things that patients might receive or expensive medications to what would allow us to live long and well.

And there are separate areas.

Living long.

We all want to live as long as possible, but one of the realities is that there are so many chronic illnesses and things that we struggle with that even though we might live an extra couple of years, they may not be very functional years.

So we want to push the curve out of how long we live, but we also want those extra years to be as functional as possible.

And certainly your audience knows how important exercise is, but there are many other aspects and we call them the six pillars that you mentioned, like sleep and nutrition and all the rest that help us do that.

And I think where the synergy is great with what you're doing is that you take an extremely evidence focused approach on the topic of performance and performance for Ironman triathletes.

What I've done is really take the same approach, but apply it not just to the performance in a race, but in essence, the performance in our lives?

How can we, being age 40, 50, 60, have a life ahead of us that we're not stuck in a chair with aches and pains as we get older?

And what is the evidence that it works?

I talk about the six pillars.

I'm about to do my next recording on the topic of eight glasses of water a day.

Truth or urban myth?

And it's fascinating.

I just love diving into topics like this or your morning coffee.

Is it a good idea or a really bad idea?

Or what nutritional supplements actually work?

And which can you save your money on?

So these are the types of topics that I get excited about and the listeners seem to as well.

And it's just a lot, just a lot of fun.

I just.

My latest one was on.

It was stimulated by our concern about our president and mental decline and concerns about that.

And I basically said, okay, what aspects of mental decline might be preventable and what can listeners do to actually prevent that?

And it turns out that 40% of the risk of cognitive decline is preventable through exercise, through dealing with hearing loss, through social connections.

And so that's what I talk about.

Things that are tangible, evidence based and will help people live long.

And.

Well, I just, I know it's a sort of a takeoff on Star Trek, but it really encapsulates all the things that I hope people can experience.

Oh, it is, it's a huge, it's a huge area of interest for so many people, especially as our population gets older and gets older with more resources.

People are very focused on this idea of not just living longer, but living longer.

Well, as you said.

And I subscribe to, for example, a stock investing service that is always sending me these informationals that talk about different companies to consider investing.

And there's all these themes.

We've just started a whole new theme on this whole idea of longevity.

And the person who is sending the advice on this stuff is promoting companies that sell just the most outrageous things that are not at all backed by science, it's all about Mikey likes it stuff.

But you could see how these companies are performing and they're performing well because just like the products I review in my podcast, people are easily persuaded by slick advertising and promises of results that are clearly not in keeping with reality.

How do you help your listeners sift through the.

Because let's face it, yours and my budget is nowhere close to the slick advertising budgets that a lot of these products and companies have.

How do you help people cut through that and help them understand to make the good decisions?

It's the fundamental question you're asking.

I have the benefits or liabilities of not being an expert in any of these areas.

So when I reviewed the information about cognitive decline, one of the popular things now are these brain games, these websites, the Lumosity or all these other ones.

And they tout that they of course can help you to maintain your cognitive function over time.

Because my career hasn't been focused on cognitive decline.

I don't go at this with a sort of a pony in the race.

What I do come at it is a really good ability to look at the evidence and say whether it's compelling or it's not compelling.

People will tout supplements or diets that will help your brain health.

When you look at the randomized trials, they don't show any benefit.

So I review the work and I share it with people.

As a curator of the Evidence, and hopefully it affects how they think about it.

The brain games, some of the older ones definitely don't appear to work.

Doing crossword puzzles, yes, it will help you get older and do crossword puzzles better, but that's not what we're after.

What we're after is, does doing the crossword puzzle help me remember somebody's phone number or somebody that I meet in the market?

And the answer is that most of this stuff doesn't generalize.

You gain that skill, but you don't really gain anything else.

Now, there's some new brain games that have some interesting data that might be promising.

So when I talked through the issues, I said, here are 10 things you can do that the evidence supports that will help you reduce the risk of cognitive decline.

Oh, by the way, here's some stuff that doesn't work, and the evidence is pretty clear about that.

And then here's some stuff we really don't know.

So if you want to try it, but we really don't know if it's going to help you or not.

And that's the approach I do to really all of these types of topics.

I looked at sun protection.

We as triathletes are out in the sun all the time.

So what actually works?

Do you need the fancy stuff or just the regular stuff?

And what will help you to avoid skin cancer and skin aging?

And the data, unfortunately, isn't as strong as we would like it to be.

So I try to review it, share it with people, and by and large, people seem to like.

But I'm sharing.

I'm a little bit disappointed that my morning routine of playing all the New York Times word games is not going to help me avoid the inevitable mental decline.

But I'm going to keep playing them anyways, because maybe when, yeah, maybe when I'm 80, I'll finally be able to get connections on the first try every single time.

We'll see.

There you go.

I think that what you described with those brain games is just this classic example of there's a theory that people can understand.

Hey, play these games.

They will make your brain sharper.

That just makes sense.

And then what the advertisers do is they put the cart before the horse.

They say, oh, you understand that theory?

So we're going to tell you that this is going to prevent your mental decline.

But they don't have any evidence or research to actually support that.

They're just telling people that because it intuitively makes sense to the people who are listening.

And so they all get on board and they're more than happy to pony up with their hard earned cash dollars in the hopes that what they're being told is the truth.

And it's often backed by pseudoscience or pseudoscientists.

And yeah, I see the exact same thing in endurance sport and all kinds of things being marketed to triathletes.

So it's refreshing to see that somebody else is doing the same thing for life things and not just for endurance sport things.

I want to ask about one of the pillars that you talk about is heat cold.

I think people have heard about that a lot.

There is that very famous.

I think he's from Iceland, the guy who talks about the cold water swims and sitting in.

That's him.

That has led to deaths by people who have taken it to the extreme.

But we do know that there is some science to support what he is talking about.

So if you could give us your overview of what heat cold means in terms of that pillar that you're talking about and how people can leverage it to improve their quality of life and improve their longevity.

Absolutely.

And if folks are interested, I do have an episode just on exposure to heat and cold.

So heat and cold has been around forever, not a surprise, for thousands of years.

The Romans would sit in their hot baths and it was a great social thing and people did it.

And the folks in the far north would do a sauna and then roll around in the snow.

So this has been around for a very, very long time.

You could then say it's been around a long time.

It must work.

I'm.

That doesn't work for me in terms of that's not the evidence I'm looking for.

So I divided into the two categories, exposure to heat and exposure to cold.

The exposure to heat has been studied for a fair bit of time and pretty rigorously now.

Just so your audience understands, the ideal approach is to randomize people.

All right, here's 10,000 people.

You're going to do asana three times a week.

And we're going to see what happens over 30 years.

And this other group, you're not going to do asana.

You can't do a randomized trial like that.

It just isn't going to happen.

What often happens are observational studies.

And they follow people who do saunas.

They then ask the question, how often do they get strokes, heart attack, die, cognitive decline?

And then they compare that with people who don't have saunas and they find that the people who do saunas do much better on all those measures.

And there's a dose response, meaning the more often you do the sauna, the better off you are.

The longer you're in the sauna, the better off you are.

And the problem with all of that is the confounders.

Because people will say, yeah, the only people who can do a sauna are people who have free time or people who have the money to do a sauna.

So you're really not measuring sauna, you're measuring all these other things.

And people scratch their head and say, yeah, that's a good point.

So there's a series of studies that were done in Finland which show all these benefits.

And so then the question is, why Finland?

It turns out there's probably one sauna for every two people in Finland.

It's not a measure of wealth.

Every apartment building has saunas.

You sign up for them and you enjoy them.

It's part of the culture.

So when they actually look at people who do a lot or do very little sauna, they're actually looking at the sauna itself, more likely than other things like education or free time.

Those have been very compelling and it's been duplicated elsewhere.

I actually do believe.

And there's theory behind why asana might help.

It causes the body to produce certain shock proteins, as you were alluding to.

I don't put much stock in theory.

Everybody's got a theory.

They've tested it in mice or yeast or test tubes and I could care less.

I want to know what's been done in humans and does it work?

So on the sauna side, I feel like we actually have pretty good data.

On the cold plunge side, the data is new and it's not very rich.

So the sauna data, they follow people for 20 or 30 years and that's great.

There's no long term data on cold plunge and the benefits of it.

What there are very short term studies and as people may know, dopamine is a happy hormone.

And when you have dopamine surgeries, then people feel happy and people are aware of runner's highs, which is releasing certain chemicals in the brain.

So what we do appear to know is that in the short term, jumping in a cold plunge for a couple of minutes will raise your dopamine levels a lot.

And they don't just raise for 10 minutes, they remain elevated for hours.

So people do feel better and feel happier for hours and hours after a cold plunge.

What we don't know is does that help you live long?

Now the WIM HOF stuff is there's a whole lot of sort of question about what he does and how he does it.

He is probably a genetic mutant that he is able to sustain what he is able to sustain.

And measuring things in his body are very interesting.

Like he'll say my inflammation goes down, but it's not clear if that will benefit anybody else and where people have gotten into serious trouble and died by following his breathing technique.

So he couples a hyperventilation approach with cold exposure and he'll swim under the ice or do things like that.

And unfortunately, when you hyperventilate, you blow off CO2, which reduces your feeling of needing to take a breath.

And so people actually will hold their breath too long and they can die because of that in the cold water.

So again, we knew more about sauna than cold plunge.

I we do have a cold plunge tank at the ranch that I enjoy and our guests enjoy.

But I'm not claiming long term benefit, but it sure as heck makes you feel better.

Yeah, and I remember seeing a piece on Nova of all things, the PBS show many years ago, this goes back a long time and looking at this Scandinavian practice of going from the hot sauna and jumping in a cold winter lake.

And there was this thought that, oh, this was really great for health and everything else.

But man, when they measured things like blood pressure and the effect that had on blood pressure going from the hot, where you're very vasodilated and then jumping into this cold water where the immediate impact was to have all your blood vessels constrict and it just caused a blood pressure spike that was very dramatic.

And how that potentially could result in health effects, but again, not really well studied at alternating hot cold.

And it remains an area of interest and an area that I think probably does have some interesting health effects.

Probably positive, but yeah, certainly no reason not to do these things.

But to do so carefully and not to do any of those breathing things.

Of the other five pillars, obviously I believe exercise, sleep, nutrition, very important.

Just quickly Mind body harmony.

What does that refer to and how do you encourage people pursue that?

Mind body harmony are the collection of activities that might range from yoga, meditation, qigong or simple breath practices.

You can do five minutes of controlled breathing in certain ways and there's lots of stuff on the web if you want to watch videos of how to do it.

And it has been shown to lower blood pressure, lower stress hormones, help your sleep.

It really can be highly leveraging.

So it's something that I try to incorporate.

I have a meditation practice, but even just being out in nature now, I'm not quite sure whether you get the same benefit by running in nature because we're so focused on the athletic part of it.

But just taking a stroll in nature and just looking around you has been shown to change what happens in your brain, in your amygdala and other parts of your brain.

So I think it's very helpful.

I'm very big on what's called the N of 1 trial.

I'm focused on studies, and studies generally compare two different groups and they give you an average.

On average, this makes a difference.

That may be true, but for some people they get a lot of benefit and for other people they may get no benefit.

What really matters is what helps you.

So when we were talking about sauna, one of the things that helps sleep and data has shown this is exposure to heat.

Before you go to bed, maybe an hour before bed, take a hot shower, do a sauna.

It tends to vasodilate you and that actually leads to your body temperature falling over time.

And that's very promoting of good sleep, longer sleep and more quality sleep.

But I can't tell you whether it's going to work for you.

But it's so simple.

Many of us have Oura rings or Apple watches that monitor our sleep.

Or you can do a simple questionnaire in the morning, how many hours did I sleep and do I feel refreshed and was I lying awake at night and all that kind of thing.

So I recommend doing an N of one study for a week.

Monitor your baseline sleep and then for the next week, say, I'm going to do a hot shower before bed or a sauna if I have access to it.

And then I'm going to measure it again for the next week.

If it helps, wonderful.

If it doesn't help, you've learned that for you, whatever it is, doesn't help people.

Doctors say, oh, you have high blood pressure, you must reduce salt in your diet.

It turns out 25% of people in the United States are not salt sensitive.

They can have all the salt they want, won't change their blood pressure.

The only way you're going to know if you fit into that is to test it.

So for all of these things, I talked about how to do the tests in yourself and figure out what matters and do what matters for you and stop the stuff that doesn't.

Yeah.

I talk frequently about how the research is really population based and how it doesn't necessarily predict anything for any one individual and how important it is.

Exactly how important it is to remember that if you feel like something is working for you, then I'm not here to tell you not to do something.

I'm here only to tell you what the research shows for the population.

Bobby, this has been a fascinating conversation and I look forward to listening to more of the episodes of your podcast where we can hear even more interesting insights, revelations and research on all kinds of things related to longevity, growing older with a higher quality of life.

If you want to know more about where to find Bobby's podcast, a link will be in the show notes.

I encourage you to have a listen.

I think it's a quite entertaining and informative show.

Bobby, thank you so much for being here.

I really enjoyed the conversation.

I look forward to chatting with you again in the future about other interesting topics and perhaps having you back to discuss some more of the research that you find on your own show.

Wonderful.

Thanks so much for having me sing.

The top of my lungs Arms entwined in yours I'm singing all the songs.

Hi, my name is Justin Rayfield and I'm a proud Patreon supporter of the Tridoc Podcast, the only show that's more addictive than carbs before a long work produced and edited by the one and only Jeff St, along with this dynamic duo of interns, Coet Rhodes and Nina Takashima, who are so amazing they make superheroes look like they're on a coffee break.

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