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Death by Firearms Increasing for Youth


Richard Aiken MD PhD @rcaiken

Cause of death by firearms is becoming more likely at younger ages in the United States.

The following data on the homicides by firearms [1] come from the Global Burden of Disease assembled by the Institute for Health Metrics and Evaluation at the University of Washington.


Males in the United States.

death homicides firearms 80 - 84 males US

In the interval 1980 – 1984, the most likely age for death by firearms was the mid to late twenties.  Since that time, the rates have shift toward younger ages.  The following graph indicates homicide death by firearms in the more recent interval 2010 – 2016.

Death by Firearm Homicide 2010 - 2016 males

More currently, then, the most likely age for death by firearm is about 15 years old, roughly 10 years younger than that 30 years ago.

[1] Institute for Health Metrics and Evaluation (IHME). Causes of Death (COD) Data Visualization. Seattle, WA: IHME, University of Washington, 2017. Available from (Accessed February 18, 2018)



Death by Suicide of US Children in Epidemic Rates

by Richard Aiken MD PhD @rcaiken


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[1], and many of them are capable of planning, attempting and dying by suicide[2].

Deaths by suicide are generally under reported because of the associated stigma; this is particularly true of children[3] with cause of death reported as accidents rather than suicide.

The following data on the death of children by suicide[4] 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

suicide males US 10 - 14

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.

suic females US 10-14

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.

veh male 10-14

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.

veh death female 10-14

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

suicde age male 2000

Figure 5 Suicide Rate by Age US Males 2000 – 2004

suic age male 2010

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.



[1] 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.

[2] 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.

[3] Crepeau-Hobson, F. (2010). The psychological autopsy and determination of child suicides: A survey of medical examiners. Archives of Suicide Research, 14, 24-34.

[4] Institute for Health Metrics and Evaluation (IHME). Causes of Death (COD) Data Visualization. Seattle, WA: IHME, University of Washington, 2017. Available from (Accessed February 18, 2018)



Triathlon for Beginers

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:

Sprint 750 m
(0.47 mi)
20 km
(12 mi)
5 km
(3.1 mi)
Olympic 1.5 km
(0.93 mi)
40 km
(25 mi)
10 km
(6.2 mi)


Half Ironman 70.3 1.9 km
(1.2 mi)
90 km
(56 mi)
21.1 km
(13.1 mi)
Ironman 140.6 3.9 km
(2.4 mi)
181 km
(112 mi)
42.2 km
(26.2 mi)

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 bikeelements 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




You likely are magnesium deficient


At the risk of sounding reductionist, there does appear to be an insufficient intake of magnesium by most Americans.  The latest data indicates that 68% of Americans do not consume the recommended daily intake of magnesium (420 mg per day) and 19% of Americans do not consume even half the government’s recommended daily intake of magnesium[1].


Would a serious whole-food varied-plant diet provide adequate magnesium?  Maybe.  But thinking of by-gone millennia in which greens were the food of choice (and spring water/ rain water the only beverage) does raise some doubts.  As an example, consider spinach and oat bran, both considered good sources of magnesium.


A dose of 30 grams (one cup) of spinach minus the 27.4 grams of water content has 23.7 mg of magnesium; 96 grams of oats (one and a half cups) minus 2 grams of water has 96 mg of magnesium.  But on a per calorie basis spinach has 3.4 mg magnesium compared to 0.45 mg for oats.  On a per dry weight comparison spinach has 3.4 mg/g of magnesium compared to 1.7 mg/g for oats.  That’s more than five times the magnesium content in spinach compared to oats.


Magnesium, one of the most essential minerals in the human body, is a co-factor in more than 600 known enzymatic reactions[2]. Magnesium is widely connected with brain biochemistry and, as a result, a deficiency is associated with a variety of neuromuscular and psychiatric symptoms such as depression, psychosis, agitation and irritability, headaches, seizures, muscular weakness, anxiety, insomnia, fatigue, confusion and cognitive changes; this is reversible with restoration of sufficient magnesium levels[3].


The diets of those clinically depressed is correlated with low intake of magnesium; research indicates an inverse relationship between dietary magnesium content and depressive symptoms[4].  Suicidal depression particularly appears to be related to magnesium insufficiency; for example[5], data indicate that magnesium concentration in cerebrospinal fluid was low in patients with history of suicidal behavior[6].


The take-home here is to eat your greens.  A magnesium level may be useful as an initial clinical workup for psychiatric symptoms. If your magnesium level is verified to be low and there are accompanying psychiatric symptoms, your provider may choose to add a supplement of 600 – 800 mg per day of any of the various forms of magnesium available (except magnesium oxide, which is not bioavailable).


[1] King, D. E., Mainous, A. G., Geesey, M. E., & Woolson, R. F. (2005). Dietary Magnesium and C-reactive Protein Levels. Journal of the American College of Nutrition, 24(3), 166-171. doi:10.1080/ 07315724. 2005.10719461.


[2] Kantak, K. M. (1988). Magnesium deficiency alters aggressive behavior and catecholamine function. Behavioral Neuroscience, 102(2), 304-311. doi:10.1037//0735-7044.102.2.304.

[3] Papadopol V, Tuchendria E, Palamaru I: Magnesium and some psychological features in two groups of pupils (magnesium and psychic features) (2001). Magnes Res, 14, 27–32.

[4] Jacka, F. N., Overland, S., Stewart, R., Tell, G. S., Bjelland, I., & Mykletun, A. (2009). Association between magnesium intake and depression and anxiety in community-dwelling adults: The Hordaland Health Study. Australian and New Zealand Journal of Psychiatry, 43(1), 45-52. doi:10.1080/00048670802534408.

[5] Banki, C. M., Arató, M., & Kilts, C. D. (1986). Aminergic Studies and Cerebrospinal Fluid Cations in Suicide. Ann NY Acad Sci Annals of the New York Academy of Sciences, 487(1 Psychobiology), 221-230. doi:10.1111/j.1749-6632.1986.tb27901.x.

[6] Banki, C. M., Vojnik, M., Papp, Z., Balla, K. Z., & Arató, M. (1985). Cerebrospinal fluid magnesium and calcium related to amine metabolites, diagnosis, and suicide attempts. Biological Psychiatry, 20(2), 163-171. doi:10.1016/0006-3223(85)90076-9.