Monday, November 21, 2016

The Flame Broiled Doctor, Episode 3: Do You Smell What The Doc Is Cooking?


Episode 3 is up! Transcript after the jump.

Welcome back to the Flame Broiled Doctor podcast series! I'm Dr. Frank Warsh, the Flame Broiled Doctor, and you can reach me on my website at drwarsh.blogspot.com, tweet me @drwarsh, or leave a comment on SoundCloud where this podcast is hosted.

Okay, so today's episode is going to center on something that's been a guilty pleasure of mine for over thirty years, and that's professional wrestling. I can vividly remember the first time I ever watched it. I was at a friend's house in January of 1987, and he put on Maple Leaf Wrestling, which was just a Canadian re-title of the syndicated WWF Superstars show. I watched it just out of the corner of my eye, flipping through a comic book and not really caring one way or the other...until they aired this interview segment with Hulk Hogan, Rowdy Roddy Piper, and Andre the Giant, characters I recognized from the Hulk Hogan's Rock n' Wrestling Saturday morning cartoon. Really, I picked a hell of an time to pay attention, because it turns out this was the opening chapter in what might still be the most famous angle in the company's history, the feud between Hulk Hogan and Andre the Giant through Wrestlemania 3 and 4. Point is, I was hooked in a flash, and even now I subscribe to the WWE Network to watch new and classic events with my family all the time.

So that's the when and how I got hooked, but what about the what and why? Why, as an adult with a medical degree and a Master's in Public Health, do I still watch something that so many people sneer at, and what is it about pro wrestling that I enjoy so much? Every fan is going to have their own reasons. For some, it's their favorite character - "Macho Man" Randy Savage, Dwayne "The Rock" Johnson, "Stone Cold" Steve Austin - these are phenomenal all-around entertainers. For others it's the "violent athleticism", provided you're able to suspend your disbelief that what you're watching is choreographed with a predetermined outcome. The need to suspend your disbelief - and it's 100% necessary to enjoy pro wrestling - doesn't come to everybody. Some people can't get over that, and I get it. Millions of people can't sit through comic book movies, which are more or less the same thing as pro wrestling - grown men wearing spandex in staged fights. Tastes differ, understood.

Personally, there are two things I really enjoy about pro wrestling, and this is only my opinion. First, there is no form of live entertainment I can think of with the same kind of interaction between performer and fan. There is no other spectacle you can watch or attend, make as much noise as you want, cheering or booing...not only is it instigated and encouraged by the performer, but the good ones will feed off that energy and throw it back at you. Second, if you're capable of suspending your disbelief, pro wrestling done right delivers all the hype, drama, and intensity people love about sport, parceled reliably into 15-30 minute blocks of time. Boxing sometimes gets there, but rarely. A marquee tennis match can run well over four hours, and will still be filled with double faults, shanked balls, and TV time outs.

Okay, but this is a health-and-medicine podcast, so it's my duty to make this episode about health and medicine. With that in mind, I decided to look up what the medical literature - the stuff not written by lifelong fans - has to say about pro wrestling. It turns out, there wasn't all that much. There's a ton of medical research about amateur and Olympic wrestling, and a growing body of knowledge around martial arts, mixed martial arts, and other combat sports, but the professionals get the short end of the stick. What medical researchers do have to say about pro wrestling, though, falls into one of two categories: what pro wrestling does to the performers, and what watching pro wrestling can do to its fans' attitudes and behaviors.

There has always been concern about the behavioral consequences of kids' exposure to violence in the media. Given that the action of pro wrestling is inherently violent, and at times has been tasteless as well, it's no surprise it would be a subject of interest to public health and pediatrics researchers. A review of the literature around TV and kids' health in the year 2000 - so this is before YouTube, before console-based online gaming - found that kids watch a lot of TV. Pro wrestling was considered kid-oriented entertainment through the first half of the 1990s (it went adult-oriented in 1996). Like other forms of supposedly kid-friendly entertainment, pro wrestling has five times the number of violent acts per hour as adult-oriented programming. And like cartoon characters, pro wrestlers don't suffer the ordinary consequences of violent acts, which can be highly misleading to young kids. As someone who's done martial arts, I can attest to the fact that when you're slammed into the ground and don't know how to land, you will not hop back up and dare your opponent to come at you again...you will stay on the ground and groan, then hope you avoid passing out as you're taken for medical attention. The net effect is that watching TV violence like pro wrestling does make kids more aggressive, more tolerant of aggression, somewhat more sexist (and this is before the "Attitude" era), and desensitized to violence. The researchers also expressed concern that, as cartoonish as pro wrestling could be, there was the possibility that the excess violence was creating what they termed the "Mean World Syndrome" in young viewers: an impression that the world was colder and more dangerous than it really is.

Pro wrestling underwent a radical shift in the late 1990s, towards an edgier, adult-oriented form of entertainment. Some of the stuff from this time period ranged between tasteless to just plain stupid: "Viagra on a pole" matches, wrestlers cast as porn stars or pimps, and in the most infamous example longtime fans will recall, attempting to find the fun in necrophilia...yes, somebody thought it would be funny for a wrestler to pretend to fuck a corpse. Medical researchers understandably took a harder look at the effects of pro wrestling on youth, this time with teens and young adults rather than kids. What did they find?

A survey of teens in North Carolina, conducted during the absolute peak of pro wrestling's popularity in 1999, found that watching it was associated with violent behavior, in particular being involved in a fight on a date. The community surveyed had some pretty eye-popping numbers for violent behaviors to begin with: 20% of females and over a third of males reported being in fights that year, and about one in five from either group committed acts of property damage. Oddly, the strongest association was found with young women watching pro wrestling, in what you could even call a dose-response relationship. These women were more than twice as likely to pick a fight on a date as the men, and the more wrestling they watched, the more likely they were to pick a fight.

A broader national survey in the U.S. in 2001 added to the body of research. It was a historically shaky time for pro wrestling, because its popularity among youth looked to be in freefall. Less than half the proportion of youth reported having watched wrestling as compared with the 1999 survey. That's not an irrelevant point, because if fewer young people are watching overall, there's necessarily less of a public health concern. Still, the researchers found that watching pro wrestling was associated with higher odds of risky and dangerous behaviors, including cigarette smoking, threatening someone with a weapon, and having unprotected sex. Of note, the one finding researchers couldn't explain was that watching wrestling was associated with reduced alcohol consumption.

A couple of things. Even though both of the surveys were pretty well done, and did the necessary adjustments for confounding factors like income and race, they're not cause-and-effect studies. It could be that people more prone to violence and high-risk behaviors simply enjoy pro wrestling more than people that aren't prone to violence or high-risk behavior. In that instance, pro wrestling might just be an indicator of how a young person might be more likely to behave.

The other thing worth noting is that the research is from a point in time when the on-screen product was adult oriented, which is no longer the case. Yes, pro wrestlers now perform many more dangerous stunts than they used to, such as being slammed through tables or bouncing off ladders. Stunts have essentially replaced "blading" in pro wrestling - wherein the wrestler makes a relatively harmess razor-blade cut across his own forehead to look like he's bleeding large volumes - so the program is now devoid of blood. And the sexual content is long gone, with women wrestlers provided screen time and accolades on par with all but the top male stars. In other words, the notion that watching pro wrestling makes the viewer more likely to act dangerously, particularly towards women, needs to be researched in light of the changed nature of the TV product.

That's the audience, but what about the performers? Pro wrestling is a very risky career path. The most comprehensive study, published in 2014, looked at 557 male wrestlers - 495 living, 62 dead - that had started their careers between 1985 and 2011. Pro wrestlers have nearly three times the odds of dying prematurely than men in the same age groups. It's probably no surprise to hear that drug overdoses are horrifically common among pro wrestlers. Drug overdose accounted for 18% of pro wrestler deaths, with wrestlers having more than 100 times the odds of men their own age of death by overdose. Wrestlers also have six times the odds of dying from cancer, though the data wasn't robust enough to figure out if a certain type of cancer is disproportionately to blame.

Cardiovascular disease is the #1 killer, though, with wrestlers having 15 times the odds of dying prematurely from it as their fans from the same age group. There are a few contributors to that statistic. Anabolic steroids - testosterone supplements to build muscle - are known to raise cholesterol and accelerate the process of arteries getting clogged. Anti-inflammatory pain killers that wrestlers almost certainly take in high doses like Advil or Aleve can cause blood pressure to go up and reduce blood flow to the kidneys. But it looks like obesity is the biggest player here. The classic measure of obesity, BMI or body mass index, doesn't work all that well in very muscular people, but when the researchers looked at both BMI and absolute body weight, it's clear that excess weight is bad for pro wrestlers. Odds of cardiovascular disease and death increase dramatically with each successive category of obesity, and deceased wrestlers were on average 40 pounds heavier than surviving ones.

Where there might be more cause for concern, though, is with wrestlers suffering head injuries. With the physical intensity of wrestling matches having jumped dramatically since the 1980s, we can count on seeing more and more cases of head trauma, and everything that entails. There was one paper that looked at a series of Japanese female wrestlers, none of them terribly large women, with head injuries. Among 18 women with reported head injuries, three of them reported retrograde amnesia, or loss of memory from before the injury. One woman even had a brief loss of consciousness. When some of these women were taken to the ER, one was diagnosed with swelling within the brain, and another with a collection of blood inside the brain called a subdural hematoma. Both of these women needed extended stays in hospital, despite presenting with relatively minor and non-specific symptoms like headache and nausea.

Like other contact sports, though, the major long-term risks associated with head injuries in wrestling aren't acute, but chronic. Here we need to look at the most sordid stain on the history of pro wrestling, the murder-suicide of Canadian Chris Benoit and his wife and son in 2007. This was very big news at the time, and brought a ton of media attention, most of it focused around drug use in pro wrestling, especially anabolic steroids. Sure enough, the autopsy results came back showing Benoit had been taking testosterone supplements, as well as opioid pain killers and a minor tranquilizer called alprazolam or Xanax. For those not familiar with Xanax, it's a drug in the benzodiazepine family that includes Ativan and Valium.

Here's what you might not have heard about Chris Benoit's death. Before the body was sent for cremation, a request was made by Christopher Nowinski - a former WWE wrestler himself who's now an advocate around concussion-induced brain injury - to obtain Benoit's brain for analysis. The results of the brain examination were published in the Journal of Forensic Nursing by Dr. Bennet Omalu. If that name sounds familiar, he's the forensic pathologist portrayed by Will Smith in the movie Concussion, who investigated NFL players with chronic and severe brain damage. Benoit's behavior reflected the same sort of brain damage that the NFL players Omalu had examined suffered from, and indeed, that's precisely what the pathology revealed.

Chris Benoit wrestled an incredibly intense physical style, with obvious blows to the head coming multiple times in every match, even before factoring in stunt-heavy ladder matches or head injuries from simple mistakes. What's worrisome is that he was far from the only wrestler that performed (or still performs) that way. It takes years for symptoms to manifest, and the diagnosis so far can only be confirmed at autopsy. As a fan, and a doctor, I can only hope that none of these performers, and especially not their loved ones, ever suffers the same fate.

So if you stayed with me this far, congratulations! You are as up-to-date on the world of pro wrestling as it matters to doctors and nurses as anyone, and have my permission to throw these facts and figures at your friends that wouldn't invest the time. If you'd like to hear more on this or another topic, or just want to send some feedback or say hi, leave a comment on SoundCloud or hit the Subscribe button, visit my blog at drwarsh.blogspot.com, or tweet me @drwarsh.

Next time (I hope): my personal experiences with burnout as a doctor, and some news on how you can read far more about me than a human being probably should. I'm Dr. Frank Warsh, the Flame Broiled Doctor, and thanks for listening!

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