The three most common causes of death in children, suicide, vehicular accidents, and neoplasms, are approximately of equal incidence but suicides are increasing at an alarming rate.
While even the definition of the age of an individual considered to be a “child” varies in the literature, consensus to group statistics that aggregates age in bands of 5 years would suggest a population under 15 leading to the age range considered here 10 to 14 years inclusive.
Suicide requires that the individual executing it understand the concept of death. This appears to be the case generally for children older than 8 years old, and many of them are capable of planning, attempting and dying by suicide.
Deaths by suicide are generally under reported because of the associated stigma; this is particularly true of children with cause of death reported as accidents rather than suicide.
The following data on the death of children by suicide come from the Global Burden of Disease assembled by the Institute for Health Metrics and Evaluation at the University of Washington.
Death by Suicide: Male Children
Figure 1 Death by Suicide US Male Children
For male children ages 10 through and including 14 years old, Figure 1 indicates a recent sharp rise in the death rate by suicide. The most recent death rate is 15.6% from 2014 as reported by the National Center for Health Statistics. This compares to 6.2% in 2007 – a more than doubling the suicide rate in seven years.
Death by Suicide: Female Children
For female children in the US, the trend is similar as shown in Figure 2. In 2014, 13.4% of the cause of death was by suicide, up from 3.8% in 2007 – more than tripling the rate in seven years.
Figure 2 Death by Suicide US Female Children
Even disregarding outlier data, there is no doubt that suicide rates among our children is significantly on the rise.
Death by Vehicular Accidents: Males
Compare the cause of suicide death for male children to that of vehicular accidents, shown in Figure 3. Note that fortunately this cause of death is declining and in 2014 was 16.7%, similar to the rate of suicide.
Figure 3 Death by Vehicular Accidents of US Male Children
Death by Vehicular Accidents: Females
Figure 4 shows the death rate of females by vehicular accidents. Note that fortunately this cause of death is declining and in 2014 was 15.4%, similar to the rate of suicide.
Figure 4 Death by Vehicular Accidents in US Female Children
Other cause of death for US Children
Neoplasms cause about 15% of the deaths for male and female children in the US and appears to be rather steady over the past two decades.
Suicide rate shifting to younger age group
Figure 5 Suicide Rate by Age US Males 2000 – 2004
Figure 6 Suicide Rate by Age US Males 2010 – 2016
Figures 5 and 6 illustrate the suicide rate of US males for various ages in 2000 – 2004 compared to that in 2010 – 2016. In this rather short time interval, the most likely mean rate changed from about 25 to 15 years old. Data for females are very similar with the same approximate means for the two time intervals.
This is further indication of the crisis of suicides in our children.
 Mishara, B. L. (1998). Childhood conceptions of death and suicide: Empirical investigations and implications of suicide prevention. In D. De Leo, A. Schmidtke, & Diekstra, R. F. (Eds.), Suicide prevention: A holistic approach (pp. 111-119). Dordrecht: Kluwer Academic Publishers.
 Tishler, C. L., Reiss, N. S., & Rhodes, A. R. (2007). Suicidal behaviour in children younger than twelve: A diagnostic challenge for emergency department personnel. Academic Emergency Medicine, 14, 810-818.
 Crepeau-Hobson, F. (2010). The psychological autopsy and determination of child suicides: A survey of medical examiners. Archives of Suicide Research, 14, 24-34.
 Institute for Health Metrics and Evaluation (IHME). Causes of Death (COD) Data Visualization. Seattle, WA: IHME, University of Washington, 2017. Available from http://vizhub.healthdata.org/cod. (Accessed February 18, 2018)
by Richard Aiken MD PhD @rcaiken
Triathlon combines three sports into one sports competition. The three sports are: swimming, biking, and running – in that order and in immediate succession. There are various total distances for each of the three “splits”; basically Sprint, Olympic, and Ironman or Half Ironman. The distances are:
|Half Ironman 70.3
The triathlon is quickly gaining popularity in part because of the recognized benefits of cross training, namely that great overall fitness can be achieved while minimizing the likelihood of injury from concentration on just one sport.
With three sports rather than one, there is an increase in the necessary gear, both for training and for use during the competition. Resist the temptation to “go big” with expensive excess gear until it’s established that you are all-in with this sport; the gear won’t make a lot of difference at first.
Naturally swimming requires a swimsuit but triathletes wear “trisuits” suitable for all three events, including a “tush cush” (padding of the “sit bones” areas of contact with the bike seat known as the saddle). They are very form fitting to minimize drag. Everyone wears swim googles of course; you will want several pair for various lighting conditions. Get used to wearing a swim cap as these are required in competition and usually color coded based on your “seeding” or for other reasons, for example, bright colors so you can be seen in open water; the cap is useful for keeping hair from tangling up with the swim googles.
The bike may be the most expensive single gear element. If you have a bike, use that for initial training and competition. I have competed in road races with a mountain bike – the kind with thick stubby tires and a shock system that ate up pedal accelerations; the appreciation from fellow competitors was worth the mechanical disadvantage. Some hardcore bikers will compete with “fixies”, bikes with only one gear.
But the best biker in the world riding a child’s tricycle would be beaten out every time by a 12-year-old riding a two-wheeler so the bike does matter. I bought used Chris Lieto’s Trek 9.9 Equinox TriBike; Chris used this bike in the 2009 Ironman finals in Kona and had the best bike split. I also crashed it twice using aero bars and too-heavy clipped setting. One of those accidents tore up my left shoulder requires extensive surgery and halted my training for the better part of a year. So use the bike you have and gradually work up to the better bikes.
I don’t train very much on the roads where there are cars because it is too dangerous. 90% of my training is indoors; I will train on a course that a triathlon competition is to be held though. I usually video and GPS record it, then practice the course through Kinobike software. More on that later.
Besides the bike itself, there will be other accessories. The helmet is important obviously. You might want to splurge a bit here as only reputable brands have shells that won’t split apart of crush with impact. And they say that it should be replaced every 3 or 4 years as the foam-type structure breaks down with time. So if you have an old helmet in the garage, you might want to consider an upgrade. Gloves will be appreciated after about 10 miles of biking (tip: don’t grip too hard – only use the muscles that directly drive you forward). You will almost always want to wear sunglasses – even on cloudy days, clear glasses avoid insects or debris from ruining your ride.
The run is relatively gearless. For endurance running lightweight shoes are popular; I use Saucony Kinvaras. My dermatologist is an endurance runner and advises me to never train without a cover for the arms and legs (I’ve had some pre-cancerous lesions removed periodically). Therefore, I train outdoors with a thin opaque compression-type baselayer on top and bottom. I like too how one can throw some water on it and it cools down as the water evaporates.
By the way, I minimize the run training outdoors because of the pounding the pavement element is very tough on the joints. Yes, running indoors (track or treadmill) can be boring but see “other accessories” below.
Although it may be obvious, let me begin by stating that the main element of training is regular, and I mean everyday, activity. Occasional workouts will not hack it in the endurance world. The key is to vary the workouts (swim, bike, run) and supplement with core strength and flexibility workouts, sometimes called “prehab” workouts – muscular support for the three sports to avoid injuries that require rehab.
Social support from like-minded individuals is great and I recommend joining Strava (free) and encourage “friends” you may not ever meet them but you can find some with commonalities. About 50% of the followers on Strava are bikers, maybe 30 % runners, and the rest combination athletes, including triathletes.
In order to motivate and improve the workouts you do, monitoring is very useful. You can go very deeply into this and, like buying gear, probably should gradually ramp this up. Most everyone initially monitors weight and for good reason 1 pound of excess weight (fat) will slow you down about 1%. Once you are really a serious triathlete, keeping weight on becomes more of a consideration. Once you are training for a competition, it’s not a great time to try to lose weight because partial starvation (more calories out per day than in) makes training more difficult.
Unless you are lucky enough to live near open water in which swimming is allowed, you will train in a poor, typically 25 meters long. Many of the inland triathlons use pools for the swim leg. Some think this is easier than open swimming but personally I prefer the buoyancy of ocean swimming – as long as there are not heavy waves. Turning in a pool efficiently is tricky. It is too easy to essentially brake every 25 meters; the key is to not lose the momentum and use the legs to spring off the end of the pool – this can be a powerful boost. I find flip turns are particularly challenging (I was practicing these in a small pool onboard the Pride of America cruise ship, hit my knee on a submerged ledge there for edge-of-pool-leg danglers, and wore crutches for the remainder of my cruise, missing run-swim training on Kuai. That would have made training on 4 Hawaiian Islands in one week).
Swimming in a triathlon is different because there is minimal use of the legs (other than the end-of-pool thrust). This is because the other two sports are very leg-oriented, so one saves the legs in the swim. Yes there may be some movement to assist with timing and body rotation but the extra speed from heavy leg work is minimal; it is much better to save the legs for the real work.
The swim is the most feared of the three sports and the reason why many people do not venture into the triathlon. This is interesting because no one wins a triathlon because of their swimming prowess. The time difference of the best and worst of the swimmers is not THAT different. This is not the case for the bike and particularly the run. Most races are won or lost in the run.
For bike training, as previously mentioned, I use an indoor system. It’s true that certain elements of the bike experience are only present in an outdoor ride (bumps, traffic, wind, flats), the main idea behind training is to develop getting oxygen to the slow and fast twitch muscle fibers. I have my tribike attached to a Wahoo Kickr base that when connected to various software very closely reproduces the conditions of the simulated ride: uphill and downhills are pretty exact and require gear switching just like the real deal. I have a fan and a large television monitor directly in front of the bike. There are a lot of software out there for training. For serious but gradual training I like TrainerRoad; this gives training tip after tip while the terrain varies.
For more enjoyable software Kinomap is my favorite (I have a library of my own recorded rides too, like with my daughter); it incorporates Strava segments – competition around the globe with virtual bikers and recently live competitions. I also use Rouvy for the high definition professional and vast variety of rides. I used to also enjoy Zwift in which one just joins into an arbitrary position of a whole world race; it’s cool to be challenged by an actual person who comes up on your six to pass but you step it up and out pedal the challenger. It is a little pricy though, so I stick with the aforementioned sotware.
Training should involve doing biking then running, so called “bricks” because after a long ride your legs feel like bricks but then you have to run on them. You have to experience it to really understand. This is where training and pacing helps so much.
I previously mentioned my philosophy on the run – I prefer indoors with surfaces that give a little but you’ve got to take it to the real surfaces too. If your weight and age are right, outside running is great. If the weather is poor or it is dark, take it indoors if you can. When I was younger, I thought it cool to run in the rain at night (at least I did it on an outdoor track), but now I think it is just dangerous.
The idea with training is choosing, say, three competitions during the season, the most important one, the second, and the third. Your training should be oriented toward number one but number two and three can be thought of as “training competitions”.
You might even look several years down the line and have in mind long term improvement. A friend of mine (Ed Wolfgram of Washington University) had the ultimate long-term plan: starting from essentially scratch with no training background in his late forties, decided to be a triathlete and win the Ironman world championship at Kona. I’m not joking. This was a 25 year plan. In 2004, he finished first in the 70 – 74 year age group to win the world championship Ironman
Get the free software program called TrainingPeaks. This can be connected to various running and biking apps to record activities and, with the premium version you can analyze the gajebies out of your performances. You can also plan days or months of training with the app.
Some triathletes like to train based on heart rate zone; some like cadence; others power output. Still others just train according to their feeling at the time. I use heart rate as I find that I get gassed out if I am in too high a heart rate zone for very long.
But these data require data gathering instruments. Heart rate can be recoded at the wrist with various watches but I think it is generally agreed that this is only accurate while one is at rest, hardly useful for training. That means wearing a chest strap. Various software and watches require different chest straps. I recently went ahead and purchased the ultimate triathlon watch – the Garmin 935 with triathlon chest strap and another even more accurate chest strap for the water. Yes, it is possible to monitor the heart rate, pace, distance, stroke rate and efficiency of the swim. Heart rate is taken in real time but not displayed on the watch – it is downloaded after you are out of the water, but the other parameters are on the watch during the swim.
The Garmin 935 helps also monitor precisely bike cadence (if you have a device on the bike), power (if you have a device on the bike – these are expensive), run cadence, vertical oscillation, stride length – it goes on and on, including Heart Rate Variability (HRV), a measure of your stress level and when to ramp-up or ramp down exercise.
Generally, monitoring helps to put more effort where it helps performance and is quite motivating to see the difference and progress from many hours of hard work.
Whole food varied-plant diet – see my Neurodietetics, Chapter 13 on exercise. Tip: Beet juice 1 hour before heavy training increase ability to get oxygen into the muscles. Keep well-hydrated.
For many more tips, see my Facebook page Triathlon https://www.facebook.com/Triathlon-414878148562206/
by R. Aiken MD PhD @rcaiken
Flaxseed helps lower cholesterol, lowers blood pressure, is anti-inflammatory, has good anti-oxidants, and fiber. It is the single most neuroprotective food; oh yes, then there is the omega-3 content.
There is no doubt that this food is an excellent source of essential omega-3 fats in the form of alpha-linolenic acid, the basic building block to other omega-3s – eicosapentaenoic acid and docosahexaenoic acid. Omega-3, and a proper omega-3 to omega-6 ratio, is important in mental wellness and recovery from psychiatric disorders.
But flaxseed offers more than just the ideal omega-3 source; it contains many polyphenolic compounds such as phenolic acids, flavonoids and lignans along with vitamins C and E. One study found that flaxseed significantly decreased chronic stress (cortisol) levels, indicating a possible synergistic effect between omega-3 fatty acid and polyphenols. Other components such as a flaxseed lignan (a phytoestrogen compound called secoisolariciresinol) has been shown to have possible applications in post-menopausal depression.
Studies of flaxseed oil supplementation have indicated a good tolerance even in the pediatric population where one study indicated its effectiveness in child bipolar disorder.
I recommend a daily intake of one to three tablespoons of ground flax, each tablespoon of which contains about 30 calories, 2.5 grams fat, 2 grams fiber, and 1.5 grams protein. Be sure to grind the flaxseeds as the fine seeds with their hard shell will likely just pass on through the gut otherwise. Flaxseeds can be ground in a coffee bean grinder and the ground powder added to grains, salads, beans – practically any dish for a little texture.
Note that the shelf life of the oily seeds is limited unless kept in an airtight container in the fridge or freezer. Ground flaxseeds or flax meal should be kept in the freezer; at room temperature and exposed to air, use the ground seeds within one week. Smell the flax – if it has a strong odor such as fishy smell, it may be rancid. A taste test should reveal a mild nutty flavor – if bitter or sour that also may be a signal that it is rancid.
For these reasons, chia seeds, rich in antioxidants and omega-3 PUFAs may be preferable to some.
 Oomah, B. D., Kenaschuk, E. O., & Mazza, G. (1995). Phenolic Acids in Flaxseed. J. Agric. Food Chem. Journal of Agricultural and Food Chemistry, 43(8), 2016-2019. doi:10.1021/jf00056a011.
 Bidlack, W. W. (1999). Functional Foods: Biochemical and Processing Aspects, G. Mazza, ed. Lancaster, PA: Technomic Publishing Co., Inc., 437 pp, 1998. Journal of the American College of Nutrition, 18(6), 640-641. doi:10.1080/07315724.1999.10718899.
 Naveen, S., Siddalingaswamy, M., Singsit, D., & Khanum, F. (2013). Anti-depressive effect of polyphenols and omega-3 fatty acid from pomegranate peel and flax seed in mice exposed to chronic mild stress. Psychiatry Clin Neurosci Psychiatry and Clinical Neurosciences, 67(7), 501-508. doi:10.1111/pcn.12100.
 Wang, Y., Xu, Z., Yang, D., Yao, H., Ku, B., Ma, X., . . . Cai, S. (2012). The antidepressant effect of secoisolariciresinol, a lignan-type phytoestrogen constituent of flaxseed, on ovariectomized mice. Journal of Natural Medicines,67(1), 222-227. doi:10.1007/s11418-012-0655-x.
 Gracious, B. L., Chirieac, M. C., Costescu, S., Finucane, T. L., Youngstrom, E. A., & Hibbeln, J. R. (2010). Randomized, placebo-controlled trial of flax oil in pediatric bipolar disorder. Bipolar Disorders, 12(2), 142-154. doi:10.1111/j.1399-5618.2010.00799.x.
 A very convenient way to have ground flax ready to serve is provided by Carrington Farms Organic Ground Milled Flax Seeds, two tablespoon packets sealed and lasting without refrigeration about one year.
Certain wild cereals, or grasses, contain edible components in their grain, botanically a type of fruit. Grains are small, hard, dry seeds, with or without attached hulls.
Some argue that from an evolutionary standpoint, grains are a relatively new addition to our diets and therefore should be excluded.
Undoubtedly grains have existed for many millennia, but the problem with harvesting had been that first of all these grains must be separated from the inedible grasses, requiring some winnowing process. Secondly, the wild grains usually shatter when ripe, dispersing the seeds, making collection difficult. Then the tiny hard grains would have to be further processed to avail digestion. Thus, patches of such grains in the wild may not have been favored by hominids until at least primitive hand tools were used and present near sites of grain-containing grasses.
Nevertheless, grains were apparently consumed well before animal domestication 10,000 years ago.
For example, a large amount of starch granules has been found on the surfaces of Middle Stone Age stone tools from Mozambique, showing that early Homo sapiens relied on grass seeds starting at least 105,000 years ago, including those of sorghum grasses. That’s more than 5000 generations ago.
Of course if one has celiac disease, gluten intolerance, a food allergy or sensitivity to grains, grains should be avoided.
Grains for brains (as well as other organs)
Whole grain includes dark bread, whole-grain breakfast cereal, popcorn, oats, bran, brown rice, bran, and many other examples.
Whole-grain foods contain fiber, vitamins, magnesium and other minerals, phenolic compounds and other phytonutrients, which may have favorable effects on health by lowering serum lipids and blood pressure, improving glucose levels, insulin metabolism and endothelial function, as well as alleviating oxidative stress and inflammation.
A meta-analysis of 15 cohort studies with nearly a half million participants revealed that whole grain intake was associated with a reduced risk of vascular disease.
There is an association between dietary whole grain intake and mortality; two large prospective studies of more than one hundred thousand participants indicated a significant life extension independent of other dietary and lifestyle factors.
The effect was pronounced up to one-half serving per day after which there was a leveling off. This is shown in the figure below, taken from the Wu et al. aforementioned article, where the mortality risk is plotted against servings of whole grain.
Relative Mortality Risk v. Whole Grain Intake
 Mercader, J. (2009), Mozambican Grass Seed Consumption During the Middle Stone Age, Science, 326.
 Anderson, J. W. (2003). Whole grains protect against atherosclerotic cardiovascular disease. Proceedings of the Nutrition Society, 62(01), 135-142. doi:10.1079/pns2002222.
 Tang, G., Wang, D., Long, J., Yang, F., & Si, L. (2015). Meta-Analysis of the Association Between Whole Grain Intake and Coronary Heart Disease Risk. The American Journal of Cardiology, 115(5), 625-629.
 Wu, H., Flint, A. J., Qi, Q., Dam, R. M., Sampson, L. A., Rimm, E. B., . . . Sun, Q. (2015). Association Between Dietary Whole Grain Intake and Risk of Mortality.JAMA Internal Medicine JAMA Intern Med, 175(3), 373.
by R Aiken MD PhD @rcaiken
Nutritional yeast has a nutty, cheesy flavor and is often used to emulate cheese, thicken sauces and dressings, and to provide an additional boost of nutrients, particularly B vitamins, folates, thiamine, riboflavin, niacin, selenium and zinc. It is a complete source of essential amino acids.
Impressive research exists that supports a positive effect of nutritional yeast on stress and related immune function resulting, for example, in a decrease for the susceptibility to the common cold. Beta glucan fiber, found in baker’s, brewer’s and nutritional yeast, helps to maintain our body’s defense against pathogens. And this is extended to improvement in mood states, related to immune vitality and emotional vitality.
For endurance athletes who place significant stress on their bodies, regular ingestion of this substance is recommended.
Keep a container of nutritional yeast on your countertop and regularly, even daily, use about one heaping tablespoon (4 grams) on a variety of foods.
 Auinger, A., Riede, L., Bothe, G., Busch, R., & Gruenwald, J. (2013). Yeast (1,3)-(1,6)-beta-glucan helps to maintain the body’s defence against pathogens: A double-blind, randomized, placebo-controlled, multicentric study in healthy subjects. European Journal of Nutrition, 52(8), 1913-1918. doi:10.1007/s00394-013-0492-z.
 Talbott, S. M., & Talbott, J. A. (2012). Baker’s Yeast Beta-Glucan Supplement Reduces Upper Respiratory Symptoms and Improves Mood State in Stressed Women. Journal of the American College of Nutrition, 31(4), 295-300. doi:10.1080/07315724.2012.10720441.