Vicious cycle

Simon Morgan

doi:10.3399/bjgp16X686029

I spend a lot of time calculating cardiovascular risk. Perhaps that’s not unexpected, as a middle-aged male GP with a bunch of middle-aged male patients with often a little too much around their middle. Every day I faithfully trot out the Framingham Risk Calculator and plug in such patients’ parameters. Having just finished some home renovations, that grid of little coloured squares now always make me think of a Taubmans paint colour chart. It would definitely make for some arresting interior colour options. I can picture the glossy brochure — the new 5 Year Absolute Cardiovascular Risk indoor range, featuring ischaemic orange and lacuna red!

After discussing the percentage risk, I move onto lifestyle advice. Admittedly, nutrition isn’t my strong suit. I’m never sure whether carbs and fat are good or bad for you these days,¹^,² or whether chocolate really is one of the five food groups, so I tend not to dwell on the dietary discussion. I’m a bit more confident on motivational interviewing for physical activity and weight loss, so we usually have a yarn about incidental exercise. Occasionally I have a win — I recall one patient who returned after such a discussion and jubilantly reported that now when she makes a chocolate cake, she beats the eggs by hand. Small steps.

One of the stock bits of exercise advice I give to nearly all my patients (glowing Framingham green through to stroke scarlet) is to buy a pushbike and start cycling. I often ride to work and, in the absence of a garden shed at the practice, park my bike in the corner of my consulting room; unintentionally, it has been a great cardiovascular conversation starter. So much so, that I reckon every GP could leave a bicycle somewhere visible in the practice, cyclist or not, just to provoke a discussion on physical activity. That said, why stop at a bike — you could strategically lean a kayak against the waiting room wall or swap the examination couch for a weight bench, just to kick off the exercise dialogue.

But, alas, I have also discovered that promoting pedalling can be a vicious cycle. If you go down that road, prepare yourself for a rash of cycling dermopathies and ensure you bone up on bicycle-related musculoskeletal ailments (all puns definitely intended).

And the dislocations you may inadvertently facilitate are not only of the joints; there are social ones too. I now realise that my innocent advice has the potential to create a cyclopath; after one lap of the block, previously responsible parents start abandoning their children on Sunday mornings for long group rides, and endlessly obsess about the latest in carbon fibre technology. They can (and will) accurately estimate the gradient of any road to within a degree, and effortlessly sacrifice a night’s sleep to watch a rest stage of the Tour de France.

But the attraction to Lycra appears to be the biggest risk, seemingly a stronger addiction than nicotine. Over the years, I reckon I have spawned many new MAMILs (Middle Aged Men In Lycra), and induced not an insignificant number of VOMITs (Very Old Men In Tights). I don’t mind my patients wearing Lycra into the surgery, but when they follow me down the corridor in my slipstream and then pass me as we enter the consulting room with their arms in a victorious salute, it becomes a bit trying. I saw a patient recently who said that since taking up cycling he had developed a worrying lump in his groin. I tossed around differentials — a pudendal nerve palsy, dry sprocket, cyclothymia. However, the diagnosis became readily apparent when I examined him: ‘You have a harmless foam mass common in male cyclists, otherwise known as a Lycracoele. I am confident it will resolve once you take off your bike shorts.’

But the risk of Lycramania is worth taking for the cardiovascular benefits it gives. Absolutely.