Weekend Potpourri - Six weeks to Chicago

I don't know if many have noticed, but now that the oppressive summer heat has given way to cooler and milder weather, it can only mean one thing - fall marathon season is fast approaching! As of this writing, there are only six training weeks left before "Marathon Weekend" on 10/9-10/10 commences. In honor of this occasion (and frankly because I have too much material to cover in not so much time and space), I present to you running highlights from my past week in six points:

1. Running/Training Update - This was a peak week of training for me. After rocking out a tough tempo run Tuesday, track work on Thursday and a 20 mile long run today (as a pacer), I'm on my way to a 70+ mile training week, which is a new mileage PR for me. Yet despite all that, I'm still relatively healthy with minimal pain, soreness or tightness to report. I have really taken to heart the old adage of running slow runs slow so you can run the faster runs fast and it has really worked well for me. I have two hard weeks of hard training left and a 24 hour relay race in mid-September before the taper. I can hardly wait.


2. Running Relays - Speaking of relays, did you know that I'm running the Reach the Beach Relay next month? I'll be running with Team Saucony as part of a 12-person team that will cover a distance of 200 miles in 24 hours. Judging from the insane fun I had at Ragnar NY back in July, I am expecting much the same in this one. And since I've had one relay race under my belt, I'll be more experienced and be more prepared to run my best in this race. I'm so excited to run with this crew. Woohoo!


3. Running Podcast - A week ago, my friends Jason and Ray at "Geeks in Running Shoes" invited me on their podcast to talk running, hydration, and injuries. Apparently, it has gotten rave reviews from many so far so I wanted to make sure my bloggy friends get a chance to listen too. You can download the show from ITunes or directly from the site here. I promise lots of laughter, some nonsense and a bit of medical knowledge too! If you listen, be sure to leave some feedback for us. Thanks!
   


4. Running Strides - As a followup to my last post where I spoke about using a faster and shorter stride to gain speed and improve running form, my friend Pete L forwarded me this article from Runner's World detailing a research study where it was confirmed that this was true. The study showed that increasing turnover and taking shorter strides does indeed lead to runners landing closer to their center of mass and reducing energy absorption on joints. As the researchers concluded from their study, "Our findings demonstrate that subtle changes in step rate can reduce the energy absorption required of the lower extremity joints, which may prove beneficial in the prevention and treatment of running injuries." (Thanks Peter!) Those who are interested in transitioning to minimalist/barefoot running and those who are looking to improve their performance should pay close attention.


5. Running Shoes - Meanwhile, Pete L, the running shoe guru himself also wrote up a splendid review of the Saucony Kinvara and how the shoe resembles a gateway drug for the minimalist running. I have been running races and long runs in my Kinvaras and have felt great in them. My take on them is that although they are not strictly minimalist per se, they are by far the shoes with the lowest heel drop I've ever worn. They are lightweight (7.7 oz) and feel extremely comfortable on my feet. I am already on my second pair and will most likely run my fall marathons in them.


6. Running Marathons - Speaking of marathons, I posed this question to the twitternation earlier this week - If you were to receive a full ride to run just one single marathon, which would you choose? Out of 20+ people, the top three vote-getters were London, Great Wall, and Antartica. Interesting. I'm now opening the survey up to the masses - What say you blogger people?

Have a great weekend everyone! I hope the final days of summer are kind to you and you are all rocking those workouts!

Running: Physiologically SpeakingThe Trouble with P.T.

As a runner and as an M.D., I get asked a lot of questions about the body as it relates to running. Why can’t I lose as much weight running marathons now as I did when I used to run track? (Your appetite and corresponding metabolism isn’t the same.) Why can I run faster with less effort during the winter as supposed to summer? (Your evaporative powers are maximized in the cold dry air.) What is the best way to take GU during a race? (A little at a time over a long distance to prevent sudden spikes in blood sugar and insulin levels.) In general, I welcome questions because they allow me the opportunity to apply what I know about human physiology to the sport of running. Most of the time, the answers are pretty obvious to me. Sometimes, I have no clue what people are asking and have to defer to my sports medicine or orthopedic colleagues/friends for their clinical advice and acumen. Rarely, one of my running buddies will tell me about what their P.T. told them about some injury they have and I have to do a double-take. Say that again. My P.T. told me that my hip/knee/groin/ankle/foot pain is caused by x,y, and z and recommended that I do these specific exercises. Really? Hmmm, okay, I don’t mean to insult your intelligence, buddy, but that makes as much sense as me going to the local drugstore and asking the sales clerk behind the counter which of these 1000 vitamins and supplements is going to cure my sinus infection!

The truth of the matter is that a lot of people, runners included, do not understand the qualifications or job description of a physical therapist and get in trouble when they seek out their trusty PT to diagnose and treat any and all injuries. This edition of “Running: Physiologically Speaking” is meant to educate my running friends so they are a bit more informed about how the evaluation, diagnosis, and management of sports injuries are supposed to work and who is qualified and licensed to do what job. I understand that many do not understand how different components of the healthcare system are supposed to work, so hopefully this will help shed a little light into the situation for you.

Suppose my friend, Joe Blow, is a newbie runner, who all of a sudden, while out running a long run one day, experiences a sharp shooting pain in the back of his ankle. He stops his run and limps home. Maybe he does the right thing and ices, compresses, and elevates. Maybe he doesn’t. Either way, he feels better the next day. There is no pain. He is happy. He trots out and tries his long run again (after all, he knows he can’t ever miss a long run if he’s “in marathon training”…no way!) Same thing happens again. This time he can barely make it past first mile before the pain cripples him. Crap! He goes home, all dejected. He repeats the same pattern for the rest of the week, but it doesn’t get better. He finally reluctantly calls his runner doctor friend, me, and I advice him to find a sports medicine doctor (or orthopedist) near his home. He goes, gets an X-ray and gets his diagnosis: tiabilis-posterior tendonitis. Treatment: Pain meds, no running, and 4-8 weeks of PT. Not the worst news in the world, but he isn’t so thrilled with the no running part. Still, he wants to get back to the road as soon as possible (after all, he has a marathon to train for!) so he does as he’s told. He finds a good PT, goes to all the sessions, but at the end of the two months, something’s still not quite right. His pain, which started at the back of his ankle has migrated somewhat to the bottom of his feet. His PT tells him he just needs more time, his muscles feel tight and he’s willing to continue the therapy for another 4-8 weeks without a prescription. I advise him to go back to the sports medicine doc and be re-examined. He wants to believe PT guy because he’s been seeing him for 8 weeks and figures he knows him pretty well by now and doesn’t want to go through the hassle of booking another appointment and getting more tests. On the other hand, he isn’t sure if he really needs the PT or if it’s really working. What should he do? What would you do? Are you one of those who’s perpetually in PT, or one of those who seems to have more of a relationship with PT and trust him/her more than practically anyone else you know? If you are, or think you are, or know someone who you think might be, please read on.

First of all, let me start by saying that I think physical therapy, in all its many forms, is necessary and important in injury healing and prevention. When properly done for the appropriate injury by the right qualified person, it is indispensable in helping patients recover fully from any muscle, tendon, or ligament damage they may have sustained as a result of trauma, accident or injury. I myself had to utilize their services when I suffered a clavicular fracture last winter and lost some mobility in my rotator cuff. The caveat though is that the right physical therapy must be tailored for the right injury for the right patient. It must be prescribed by a licensed medical professional (usually someone with an M.D. degree) after a thorough physical examination of the injury and evaluation with lab tests or imaging studies. A physical therapist is not qualified to perform these diagnostic tasks. They, the ones who are licensed anyway, have gone through physical therapy school, not medical school. Their main responsibility is to develop a treatment protocol (for a finite period of time, usually in the order of a few weeks to a few months) once a definitive diagnosis has been established. Coming up with the right diagnosis for the injury is not part of their job description, nor should it be. In fact, after the prescribed amount of PT is over, the patient should return to the physician who ordered the PT for a re-examination to determine if PT was successful and produced the desired effect. If not, the patient should be re-evaluated to determine whether there is some other underlying problem or to pursue whether other therapeutic options would be more appropriate. The answer is never to repeat the same set of PT exercises if they didn’t work or work well enough the first time. Is this distinction clear? I always hear of runners and other athletes who go to the same PT year after year, rehabbing the same injury the same way over and over, without the supervision of an M.D. and it frustrates me to no end. In my mind, the situation is similar to the people who goes to the local pharmacy to seek recommendations there on how to treat every disease and symptom they come across. Nothing very good ever comes out of those stories.

I hope this was a helpful discussion for some of you. Again, I’m not trying to knock the field of physical therapy or the people that perform them. Heck, I have friends who are in that line of work! However, I think it is important for everyone to know what the limits and responsibilities of their line of work. As someone who’s been on both sides of the provider/patient equation, I think it is to everyone’s benefit that we don’t overstep our boundaries and do or say things that although well-intentioned may end up hurting others in the process.

As always, comments, stories, and questions, welcome. Hope you all are having a fine day. Get out there and run, if you can. Class dismissed!

Running: Physiologically SpeakingMarathon Deaths – Why The Men?

Late last night, while soaking my feet and licking my wounds after 18 grueling miles in the cold, wind, and rain – my last long run before the NYC Marathon – I came across some disturbing news with an interesting followup question posted on the NY Flyers running forum that left me a bit shocked, a little intrigued, and slightly apprehensive about racing 26.2 miles in a couple of weeks. Apparently, at the Detroit Marathon yesterday, three men, ages 26, 36, and 65, collapsed and died for no apparent reason (other than the fact that they were running a half marathon). No doubt this is indeed sad news for all of us who are passionate about the sport and thoughts and prayers go out to the families of those who were personally affected by this tragedy, but one general question that my fellow club member and I share in response to these untimely deaths is this: Why are they all men? In other words, are men more susceptible to dying in half/full marathons than women? Is this mere coincidence or is there some scientific justification for these unfortunate events? (For the rest of this discussion, for simplification, I will refer to them as marathoners and the incidents as marathon deaths even if their unfortunate passing occurred on or around the half marathon course.)

In the spirit of raising public awareness and reminding myself as well as the running community about the inherent danger of endurance running, I will use this edition of Running: Physiologically Speaking to discuss why marathon deaths occur predominantly in men (and not in women). Hopefully, this will be somewhat educational for everyone involved.

Before I begin, I would like to throw out a couple of disclaimers.

1. The death of a runner in the middle or right after a half or full marathon is an exceedingly rare event. Estimates vary but it is reported that 0.8 deaths occur per 100,000 runners. Considering that even the most popular marathons (like New York) do not exceed 40,000 participants, to have three people die in a single race is infinitely rare.

2. Just because you are young, not male, or can run five minute miles does not mean you are without risk. There are many exceptions to the rule and not everything I will explain later pertains to everyone. So check with your own personal doctor to review your own individual risk factors before training for or participating in any endurance event. Likewise do not use anything I write as medical advice because it is not intended as such. You have all been forewarned.

Now that we’ve dealt with the pleasantries, let’s delve into a discussion of why it is so much more likely to read and hear about men dying in marathons than women. I will make some general statements about marathon runners using statistics gathered from the runners of the Detroit Marathon to illustrate my point. To make my arguments valid, two basic assumptions have to be made. The first is that marathon deaths are cardiovascular in nature or result from an acute coronary or cardiac event. Historically, cardiac problems are the most common identifiable cause of sudden death in marathon runners. Recently, it has also been recognized that troponin and other cardiac enzymes that represent myocardial injury are elevated during and immediately after a marathon (link). For the purposes of this discussion, we will ignore deaths that result from other causes. The other assumption we have to make is that the runners who ran and finished the Detroit Marathon is somewhat representative of marathon runners in general. As you will see from the data, although the numbers are small in comparison to other major marathons, the actual breakdown in percentages and established trends are not that significantly different.

Here is the chart showing the breakdown of all the finishers of the 2009 Detroit Marathon by age and sex.

Fact #1 – The most populous age group was men between 40-44 and women between 25-29. In general, older men and younger women represent the majority of marathoners. Whatever your theories are for why this is true, this trend is typical of most long distance races.

Fact #2 – Older men are statistically more at risk for major cardiovascular events than women. According to the Heart Disease & Stroke Statistics published by the American Heart Association, which you can read here, the average annual rates of first major cardiovascular events rise from 3 per 1000 men at ages 35-44 to 74 per 1000 at ages 85-94. For women, comparable rates occur 10 years later in life. The gap narrows with advancing age. Likewise, if you look at a representative graph of heart attack hospitalizations in New York State in 2000-2005, as depicted here, you can appreciate the fact that acute cardiac events start early and occur more frequently in men. (Although these statistics do not pertain specifically to athletes, I am using the data to illustrate a general trend so the actual numbers is not particularly significant in this discussion...)

Fact #3 – Women, compared to men, are very unlikely to suffer acute cardiac events until after menopause. This epidemiologic observation can be explained by the fact that physiologic estrogen has been proven to be cardioprotective. That is the reason why, as we saw in the Heart Disease & Stroke Statistics, cardiovascular risk do not rise substantially in women until beyond the age of 44. This cardioprotective property of estrogen is one of the reasons why hormone replacement therapy should be considered for most postmenopausal women.

So now, if we go back and revisit the demographic data gathered from finishers of the Detroit Marathon, we see something interesting. Notice how the majority of male marathon runners are above the age of 35 when the risk of acute cardiac events becomes substantial and begins to rise. However, when we look at the corresponding female runners, the majority of them are below the age of 40 or 45, which is the age cutoff when their risk of acute cardiac events rises. This means, essentially, that the men who most commonly run marathons are also the most at risk to suffer an acute cardiac event while the women who most commonly run marathons are much younger and have much lower risk. No wonder why you hardly ever hear of women collapsing and dying during marathons. It just doesn’t happen, as proven by the statistics and explained by medical science. (*I realize that the 29-year-old man who died during the Detroit Marathon is outside the range of appreciable risk for men, but I'm treating this case as exception to the rule...)

But even beyond these reasons, I can think of two other possible explanations for the disparity of mortality rates between male and female marathoners. One is the simple fact that men in general (and I include myself in this) do not care as much or pay as close attention to their health as their female counterparts. Study after study have shown that men visit doctors less frequently, engage in fewer preventive practices, and are less knowledgeable about their own medical history than their female counterparts. It is not surprising then that more men in general die younger and have a shorter life span than women. The importance of screening tests and regular scheduled visits to your doctor cannot be overemphasized, whether you are a veteran marathon runner or not.

Finally, I think the false bravado of the general male ego may also contribute at times to our own demise. Consider the newbie runner who thinks he can run a marathon without having run farther than a few miles in training. He is probably carrying a Y chromosome. Or the runner who is at mile 21, slogging on, refusing to acknowledge the sharp stabbing pain in his chest that is growing more intense with every step. He is also likely to take his bathroom break standing up. Finally, there is the runner who just finished the marathon and is getting congratulated left and right by friends and family. He feels tremendous pressure on his left chest with pain radiating down his left arm. How likely would this person be to voice concern if he were male vs if she were female?

In conclusion, you may ask, “Is there a take home message to all of this?” I think the most important message I want to leave you with is not to assume that you are healthy and well just because you train for and run marathons. Running does not automatically give you the right to ignore your health. Be knowledgeable. Visit your doctor and find out what risk factors you have and discuss your concerns with him/her so you can be an active participant in your own care. Because, outside of psychic powers or a fortune teller who can predict the future with 100% accuracy, taking control of your own health and well-being is the best guarantee you have to living a long, productive and healthy life – on and off the marathon course.

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As a reminder, I am still missing a few questions to complete my list of 20 Questions about Me…so please feel free to ask away (even if you have already asked a question!). You can drop them in here or in the comments to the last post. I’ll start providing answers in the next post. Thanks for playing.

Running: Physiologically SpeakingEffects of Blood Donation on Athletic Performance

Earlier today, Ari over at Run Ansky Run asked me a question about donating blood and running that I found rather intriguing. So instead of writing a long drawn out e-mail or comment that might seem rather inappropriate for such a simple question, I’ve decided to answer it here in an attempt to educate the masses who might be similarly interested in the topic.

He asks – Laminator, I gave blood today and I am scheduled for speedwork tomorrow. Is is OK for me to do an intense workout, such as speedwork, 24 hours after giving blood?

First off, on behalf of those that may need your blood for whatever reason, thank you for donating. As every health professional knows, there’s a shortage of blood in the NYS Blood Bank right now so every little bit helps.

Now to tackle your question on more than a cursory level, let us review the physiologic effects of giving blood. Typically, 450cc of fresh blood is removed during a standard round of blood donation. This blood that is taken away is composed of multiple different fractions – packed red cells, white cells, and plasma. Of particular interest to the athlete are the red blood cells (RBCs) which are responsible for oxygen transport and delivery (via hemoglobin) and plasma which makes up the bulk of a given volume of blood. According to different studies, plasma volume drops 7-15% after standard blood donation, but returns to normal levels within 12-24 hours (depending on the rate of oral rehydration after the donation). RBCs on the other hand can take up to 3-4 weeks to return to normal levels (the production of RBC production in the bone marrow is a slow and tedious process). So although the initial recovery is relatively quick (within 24 hours), there will a noticeable drop in maximal performance for at least two weeks after. Because of this, some coaches of competitive runners will discourage their athletes from giving blood in season or during peak training.

So, my advice to you, my dear friend, is to hydrate liberally immediately after the blood donation to replenish your plasma volume as quickly as possible. Stack up on your vitamins (Iron & B12) if you are into supplements. Try to decrease the level of your physical exertion for at least 24 hours to allow for adequate physical recovery. If you are going to run or engage in exercise, limit the effort to a moderate intensity level and keep an eye out for signs of physical decompensation (such as dizziness, lightheadedness, nausea, extreme fatigue, etc). Listen to your body and stop immediately if you should experience any of these symptoms. As is, you will find that your heart rate is a bit higher and the effort a bit harder to maintain than you are used to even just running at a slow pace so be careful out there (especially in this hot and humid weather).

Thanks for the question. For those who want to read more information from a more authoratative source than I (including how some elite athletes use this technique in reverse to booster their performance on race day), check out this article.

Happy running all!

HIT vs ET: A Scientific Review

Sometime late last week, my partner-in-running-crime Frayed Laces, asked me to review her latest running science report on the benefit of long endurance training vs short interval workouts in increasing aerobic capacity. Since I am a passionate runner, a medical scientist and somewhat of an Alberto Salazar to her Kara Goucher (okay the last one is a bit of a stretch, but work with me here people…) I will oblige her request and share with you all my scientific opinions on her piece.

For all who haven’t done so, please read my review on the physiologic differences of interval training, tempo workouts, and long runs because what is to follow will be somewhat of a continuation on that theme. First of all, let me start by saying that I agree with FL’s general assessment of the NY Time’s report. The physiologic benefit of HIT (high intensity training) vs ET (endurance training) is oversimplified in their review. On the protein level, the rise in PGC-1a seems rather short after HIT compared to ET. The peak levels (as she has shown) is indeed lower as well, even if the difference may not be statistically different. It is also impossible to extrapolate the changes in concentration of one protein level as the cause/effect of training as we know that it is sometimes not the quantitative effect but a qualitative effect on protein-protein interaction that affects muscle performance.

On the macroscopic level, I surmise that HIT/ET produces some qualitative differences on running economy that may be not measured in their simple rat/human experiments. As I explained in my initial review, I surmise that HIT is similar to going at max speed for a short time, while ET allows the oxygen delivery system to become more adapt at sustaining top efficiency for a much longer period. In the span of a 30-minute test or some other short-term measure, both parties can have similar benefits but if you extended the test and asked the subjects to bike/workout at equivalent time/effort to a marathon, I surmise that there would be a clear difference in their exercise physiology. (Maybe that’s why the study clearly state that they’ve never tested their hypotheses on runners…)

In the end, I think although there is clearly some crossover benefit, specificity training is clearly the best way to prepare for an event. Short distance runners should clearly concentrate their efforts on the track while marathon runners should stick to their consistent long runs. Clearly though, it helps for each to train in the other’s shoes every once in a while.

Thanks to F.L. for bringing forth this interesting topic for discussion!

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I spent the entire weekend packing and completely missed my long run. So instead of amassing 36 or 38 miles for the week, I got stuck at a pitiful 28 miles. Total suckiness. But at least I'm almost all packed up! Moving day is just 2 days away! Will provide some pictures of my new crib once it's a bit more presentable. Hope everyone had a great weekend!

Running: Physiologically SpeakingWhy Am I Peeing Blood After My Long Run?

Oops, it happened again, today, to a running friend after she ran 12 miles. Something weird. Something unexpected. And yeah, it freaked the living daylights out of her.

The first time it happened to a friend, I was there, with F.L., when she came out of the bathroom right after the Boston Marathon. She was somewhat freaked as well.

In both circumstances, I happened to be at the right place at the right time and luckily, I miraculously did not fall asleep when they covered this topic in medical school. Go me! On the other hand, I wonder how much running-related medical information I must have missed out on because I used to sleep through all the lectures. Damn, if only I knew I’d be a runner way back when…

Lam, stay on topic, so what is thing that happened to F.L. and your running friend? They both started peeing blood right after their runs. I thought it was obvious from the post title.

Maybe that’s obvious. But why? They both had E.I.H.

What’s E.I.H.? Is that the name of a new designer steroid for performance enhancement? No, no, no. E.I.H. stands for exercise induced hematuria. It is the appearance of blood in the urine (gross or microscopic) occurring after a period of intense exercise in people who have no other evidence of kidney or urinary tract disease. It goes away with rest.

Are there any associated symptoms? No. The key feature of E.I.H. that separates it from everything else is that it occurs in the absence of any disease. As such it is completely asymptomatic, well aside from the residual muscle soreness as a result of the intense exercise of course.

How long does it usually last? It usually resolves within 24-48 hours.

What if it doesn’t? If the hematuria persists beyond 72 hours or you’re having other symptoms, such as pain or fever, then you’re not dealing with E.I.H. and should get checked out by a doctor. It could be a urinary tract infection that requires antibiotics or rhabdomyolysis that may lead to kidney failure or something else.

Why causes E.I.H.? No one really knows. One theory is that constant jarring of the bladder wall during exercise causes bleeding and leakage of blood into the urine. Another more physiologic theory is that when there is intense vasoconstriction of blood vessels into the kidney during prolonged exercise, some of the cells responsible for filtered the blood inside the kidney can die from ischemia and get filtered into the urine. Usually, this slight alteration in kidney function is reversible and not of any clinical consequence, but in cases where the kidneys are already artificially clamped down (as is the case after ibuprofen ingestion…hint, hint...) the effect can be multiplied and result in some degree of kidney ischemia and kidney failure.

How common is E.I.H.? Statistics vary, but according to some studies, about 20-30% of runners were found to have some degree of hematuria after a marathon. Most cases are microscopic though, which means they are not visible to the naked eye.

Is it preventable? Because no one knows what brings it on, no one knows how it can be prevented. There is general consensus though that dehydration plays a key role, so make sure you drink plenty of fluids before, during, and after your runs if you don’t want to see red in your pee.

Where can I go to learn more about this? You can read about it here and here. Someone also wrote a blog post about it here.

Hope you all learned something today. From now on, no more freaking out if you see a little blood in your pee after a long run, you hear? Good. Class dismissed.

Running: Physiologically SpeakingThe Marathon and Hormones Edition

At times during the day, when I’m busy attending to patient affairs and practicing clinical medicine, I sometimes feel as if I’m Clark Kent, because hidden behind my long white coat and the stethoscope that adorns my shoulders like a Christmas ornament is a speed-crazed super runner that is unknown to anyone within the confines of the hospital. This suits me just fine because contrary to what someone might think, when I’m at work, I generally do not like to think about running because not only does it distract attention away from the patient at hand, but also because no one could or would understand my passion for it anyway. So as a general rule, running and clinical medicine don’t mix, at least for me.

But like they teach all the students in medical school, patients don’t read textbooks and there are exceptions to every rule. True to form, every once in a while, especially when I’m at the peak of marathon training, some running thoughts inexplicably force their way into my head even as I’m seeing patients and dealing with issues that have nothing to do with running. Below is a sampling of the random thoughts that flowed through my head this week as I was working. Some of it will be beneficial to you all, some not very much so. Read ‘em at your own risk.

Weighing In

Some kid came in early last week for evaluation of poor weight gain. He was a scrawny looking prebuscent kid who’s only abnormality I found after performing all the necessary tests, was having O.C.D. parents. As I was explaining to both mom and dad that their boy didn’t have malaria or parasites living within him, the boy said something that completely surprised me. “I’m okay. I’m not weak, or sick, or anything. I work out everyday. I can probably bench-press the doctor if I wanted to.” It would have been funny if it wasn’t so blatantly obvious. After some mild chuckling and further assurance that everything was indeed fine, I shooed the whole family out of my office and went to weigh myself. Sure enough, another 3 pounds lost since the beginning of the month. All together that makes 10 since the beginning of January! No wonder the kid picked up on it. I was turning into a stick figure faster than Haile Gebrselassie running a marathon!

Okay, I know for most of the population, this would be a cause for celebration, but for me, this is anything but since I’m already underweight for my size as it is. Unlike most everyone who have problems losing weight, I find it extremely difficult to keep the pounds that I have. Marathon training I’ve found is the worse for me since I tend to eat less even as I’m running more. Friends and patients have asked me how I lose weight so easily and I reply by asking them how they gain weight so easily (No I don't, but I so want to!). Last month, I was in contact with a nutritionist in my department who advocated many small meals for me throughout the day instead of the three large ones I’ve habitually consumed. It worked for a while, until I couldn’t find time anymore to have my seven meals and so now, instead of the three big meals that I started out with, I’m having only about three small snacks a day. So not good.

I’m hoping to get back to eating more regularly and eating healthy and gaining back my 10 pounds after the marathon. Ideally I want to gain 20, but that’s as likely as me running a 2:30 marathon so yeah, maybe in the next lifetime. I’m saying after the marathon too not because I think I want to keep my weight down to maintain top efficiency for the big race (as some friends have suggested), but rather it is because I think it’ll take me not running for an extended period to gain the weight back. It is not funny how many times I’ve wished that some of the obese kids I see in clinic everyday could just lend me an extra twenty pounds or so…

A Cure For Childhood Obesity

Speaking of obesity, Mr. Petes at Runner Write wrote an interesting article last week on how to solve the traffic problems in big cities like New York. He proposes the elimination of roads for cars and the construction of running routes to encourage people to run to work everyday. Not only so, but instead of parking lots, there’d be showers and lockers for each employee to change and clean up after their run.

I thought this was a brilliant idea, but thought it could be further extended down to children commuting to school. Instead of school buses picking up kids everyday, we can have coaches lead walking and running groups to school every morning. Given the lack of physical education and playground time in schools these days (most of the kids I see on average report only 2 gym sessions in school per week), they need all the exercise they can get. Traveling to school on one’s two feet (like they do in other parts of the world) would be a pivotal start. I’m sure the rates of childhood obesity would plummet if we could somehow implement that strategy.

Menstruation and Marathons

I don’t know if many of you know, but as part of my job description, I help young women deal with their menstrual problems on a daily basis. Whether it is a problem of frequency, irregularity or pain, I’m often the one that’s called upon to perform the detective work necessary to determine if there’s a hormonal basis for the abnormality. Most of the time, within the first fifteen minutes of the interview, I can tell that the issue is psychological or social and not hormonal. Yet I still find myself listening to the stories, hoping to nail down the root cause of the concern. In a perverse sort of way, I find the menstrual cycle very intellectually stimulating, similar in many respects to a marathon training cycle. The interplay of the rise and fall of different hormones at different times within the menstrual cycle parallels the synchronous nature in which different types of runs complement each other in a marathon training program. Not only so, but just as emotional stress can create havoc in a woman’s inherent cycle, so too can physical or psychological stress interfere with the success of marathon training.

Exercise May Be Dangerous During Pregnancy

I don’t want people to freak out over this because it is only one paper, and it’s from Europe no less. (Apologies to Xenia and whoever reads this from across the pond) According to this study (pages 12-13 here), exercise, even as little as 30 minutes per day, can dramatically increase the risk of pre-eclampsia during pregnancy. Really? Now I’ve already spoken to several colleagues about this, and they seem to think that this study only applies to a selective population that is already at high risk but still I am at least a little worried. More confirmatory studies are on the way.

I guess if this were proven true, it’d be just one more excuse to be lazy...considering you are pregnant of course. So from now on, if I hear that a female runner all of a sudden loses motivation and is sitting on the couch all day eating Doritos, rumors are going to start to fly. Just sayin’.

Hormone Doctor or Performance Enhancement Guru

Almost on a weekly basis, one of my patients, or their parents will ask if stopping some medication that I’ve prescribed for them previously will interfere with their athletic performance. Most of the time, I’m somewhat perplexed by the question because enhancing performance on the court or the ball field or track was never discussed as a potential positive side effect when starting the medication in the first place. And then it hit me late last week, as I was working at the office while ordering the Boston Marathon jacket online. Because I’m a hormone doctor, practically every medication I prescribe can be considered performance-enhancing. Seriously. Almost every single one. A partial list of common medications I write for include testosterone, estrogen, androstenedione, insulin, growth hormone, and IGF-1, and every single one has been banned by the I.O.C. and M.L.B. I wrote a tongue-in-cheek essay on this when the Mitchell report came out a couple years back, but I seriously hadn’t realize how prevalent my involvement in this arena was, or could be. So in essence I could be called a performance enhancing guru and be responsible for a whole generation of dopers out there. This is somewhat of a frightening proposition.

On the flip side, I wonder if people are getting suspicious of me running such great times recently. After all, I might not be so “clean” either. As I’m writing this, I’m wondering how long it would take for the Boston Marathon race officials to e-mail or call and ask me for a urine sample. If they don’t, and I end up running a sub-3 in three weeks, I wonder if I can voluntarily drop trough right at the finish line and ask the race officials to take my pee and run some tests. I’m sure they’d appreciate the honesty.

That’s all from me today folks. Can you tell I’ve got marathon fever up in the head? Hope you all are enjoying your weekend. I’ll be back later to recap the week of marathon training, which will the last for me before the taper. Wahoo!

Running: Physiologically SpeakingFive Easy Steps to Better Nutrition

When it comes to my ramblings about running, those who’ve been around these parts know that I usually don’t delve into the subsidiary topics such as fueling and nutrition. I know there are many running bloggers out there that are both knowledgeable and skilled in this arena so I figured I’d leave the advice and the recipes to them. After all, I spend so much of my blog space talking about running and marathon training that I feel I would not do the topic justice if I were to cover it sporadically. As such, even if nutritional counseling is part of my daily responsibilities as an obesity specialist, up to now, I’ve resisted all temptation to talk about my attitudes/advice concerning nutrition in this blog.

That all changed last week when I saw two patients in the clinic back-to-back and found myself giving the same exact speech to both families. The odd thing was that they would appear for all the world to be completely different in every appreciable way. One was a morbidly obese teenage girl who was seeing me because all her previous attempts at weight loss has been unsuccessful. The other was a muscular teenage boy, very active in school sports, who was seeing me for an underactive thyroid condition, but mid-interview, asked if he needed nutritional supplements because he felt groggy after early morning football practice. As I was explaining to both patients and their parents some key principles of proper nutrition, I was quite shocked to find that most of what I had to say was completely foreign to them. Seriously? And both of them had been to countless other professionals, such as trainers and nutritionists, before coming to me.

As I was coming home from work that day, it occurred to me that I should write about this, not because what I have to say is so earth-shattering or brilliant, but because it is so basic, and would help both those who are trying to lose weight and those who are looking to improve their athletic performance. Again, dear readers, the list that follows is not comprehensive, but serves to just highlight some basics for those who have no idea where to start. I hope they will be useful to you and will inspire you to look elsewhere for more information.

My Five Easy Steps to Better Nutrition

1. Always eat breakfast – This is by far the most frequent faux pas among dieters and athletes alike. In my opinion, breakfast is the MOST IMPORTANT meal of the day. That is because your body has been in starvation mode while you’ve been sleeping through the night. When you awake, all your hormones are reved up to help your body physiologically get ready for the day. It is in desperate need of some energy to fuel this transition. (That’s why that cup of joe feels so good in the morning!) If you skip that meal, then you are essentially asking the body to use alternative sources of fuel (by breaking down muscle for example) for energy since the glucose/glycogen stores from the previous meal has long been depleted by this point. (It is well known that those who don’t eat prior to early morning workouts bonk earlier and suffer more injuries than those who do.) Also, because the body adapts amazingly well to your eating habits, when you skip meals, you will feel more hungry during the infrequent meals that you do eat, and will tend to store more of those meals as fat to be used in the early morning. (That’s why those who don’t eat breakfast can’t lose weight or maintain their weight loss for very long.) So for both the athlete and the dieter, it is imperative that they both eat a small breakfast to reach their goals.
2. Have smaller and more frequent meals – The current recommendation is 6 to 7 small meals folks, not the standard three big meals that we knew and love when we were kids. This is due to the fact that when we eat, insulin is secreted in proportion to the meal size. So the bigger the meal, the higher the insulin level. High insulin levels are generally not good because it enhances lipogenesis (or the deposition of fat cells). Not only so, but it is also a culprit behind hypertension, high cholesterol and a myriad of other problems. When you eat smaller but more frequent meals, you keep insulin levels somewhat low and in a narrow range, which helps your body adapt to metabolic changes and handle energy demands more rapidly and more efficiently.
3. Chew your food and eat slowly – Aside from the obvious enjoyment of the food that you’re eating, another reason to take your time to chew, eat, and drink is because stretch signals from the stomach (carried on slower nerve fibers) take a good 5-10 minutes to generate a feeling of satiety in the brain. What this means is that if you eat at a pace that is faster than what the brain can process, you will still be eating when the stomach is already full. This is one situation that can be avoided if we allow the time to chew, swallow and digest our food fully before proceeding to the next bite.
4. Skip the juice/Avoid liquid calories – Except in specific circumstances, such as during or after a hard workout, it is generally a good idea to skip the juice. These empty liquid calories do not offer any nutritional benefits and can sabotage any well-intentioned diet very quickly. Stick to the diet stuff if you must.
5. Avoid eating around stress/Be calm when you eat – I like this one because it makes perfect hormonal sense. When your body is stressed, again there is a surge of hormones (think flight-or-fight response) that is preparing the body for a physical or psychological battle. These hormones, just like we saw in the early morning, is helping the body cope by absorbing more of the food and storing it as fat. (It’s not a coincidence that at times of extreme stress, we often feel the most hungry.) This tendency to overeat is also in response to elevated cortisol levels which is the inherent stress hormone for the body. If you can find a calm setting for a meal, you not only will eat less and eat more comfortably, but will absorb less of what you eat as fat as well.

That’s it. Hope all my knowledgeable and fine readers are already abiding by these basic principles. If so, then pass this advice along to someone else who needs it. God knows how many people there are out there who just need a little guidance to improve their health and their lives.

If you have questions for me, or have other clinical questions related to running, training, or nutrition, drop me a line. Au revoir for now!

[FYI – For those who are new and never read the first installment of Running: Physiologically Speaking, you should check it out. It was pretty well received and convinced me to continue the series…albeit nine months later! Okay, my bad. Still, it might be educational if you’ve ever had a headache after a long run on a hot sunny day…]

Running: Physiologically SpeakingThe Danger of Rapid Rehydration

Now that I’ve recovered from my own running troubles, I’d like to help the running community by discussing a common problem I’ve heard some runners complain about after their long runs. I’m also including this as my contribution for this week’s Take It and Run Thursdays series on "Running In The Heat" because it has to deal with dehydration and rehydration, which as we all know, is all too common in the summertime. So sit back, grab your favorite margarita, tequila, or whatever alcoholic or non-alcoholic beverage strikes your fancy, and prepared to be educated…


THE PROBLEM

Has this ever happened to you?

It's a bright and sunny day and you're out running. It took a while to find your stride, but now that you found it, you feel like you could run forever. You feel relaxed, floating in a sea of endogenous opioids and running a comfortable pace when suddenly you realize the water bottle you're carrying has less than a sip left. You know you should slow down and turn left towards home at the next intersection, but heck, it took you so long to get to this happy place that you'd like to stay just a little while longer so even before you realize it you're turning right for another 5-mile loop around town. Four miles into this second trip, you're out of water, sweating bullets, and starting to feel a little delirious. Your lips are dry and your skin is flushed. You're still feeling pretty good about the 5 "extra" miles you’re putting in, but not so much about the dehydration. Luckily, you're less than a mile away from home, and because you rather get there sooner rather than later, you bust it all the way home. When you finally get there, you proceed to drink up everything in sight. Within 15 minutes, you've downed 16oz of water, 16oz of gatorade, and the quart size container of chocolate milk intended for your kindergartener when he comes home from school. Feeling as if you've somewhat rehydrated, you change out of your stinky clothes, take a shower, and proceed back to the kitchen intending to carbo-reload. Five minutes later, the sandwich is made, you're sitting down to eat, but you're no longer hungry. Instead, you feel nauseous and have a splitting headache. It takes all of your energy to take a few small bites before you head back upstairs to put your head down. Before drifting off, you review the events of the last two hours in an effort to figure out how you ended up this way...

Over the past few weeks, I've read similar accounts from many running friends out in the blogosphere. So, what is the problem here? Why is it so common to be totally wiped and exhausted a few hours after a hard run in the afternoon? Most people would blame dehydration as the root of all evil. Well, I'm here to tell you that although the lack of fluids is a contributing factor, it is actually the replenishment of the lost fluids that is really the culprit. More specifically, it is the rapid rate of fluid intake that we runners take post-run that is most responsible. You heard it right folks. Rehydration can sometimes cause more problems than dehydration.

THE CAUSE

In order to understand why rapid rehydration is such a problem, we need to go over some priniciples of human physiology. If you remember back to high school biology, we learned that chemical particles, just like people, always tend to move from an area of high concentration to an area of low concentration unless prevented from doing so by an outside force. This is referred to as the process of diffusion. Water, in a similar fashion, will always move from an area of high to low pressure. The technical term for the diffusion of water across a selectively permeable surface (such as a cell membrane) is osmosis. Now, because all the molecules and electrolytes found within the human body exists in solution with water at different concentrations, there is constant pressure for both molecules and water to move across cell membranes (in opposite directions) so that the final concentration of solute over water would be equal on both sides of the cell membrane. This pressure for solutes to move across a membrane along a concentration gradient is termed diffusion pressure, while the pressure for water to move along its concentration gradient is similarly termed osmotic pressure.

Now, let’s observe what happens to the brain and the rest of the body during the process of rapid dehydration, as can occur in the middle of a long run on a hot day. We tend to lose a lot of electrolytes and water in the periphery in the form of sweat when we run. Most of these electrolytes and water are drawn from fluids found outside of cells (technically, blood and the interstitial space). Inside the cells, the concentration of water and electrolytes are kept relatively constant by the protection offered by the cell membrane. At some point however, as the dehydration gets worse, the osmotic pressure becomes too great for the cell membrane to handle and water is eventually drawn from inside cells (called the intracellular space) as well. As more and more water is lost from cells through the circulation to the environment as sweat, cells lose their volume and shrink. As they shrink, they also lose the capacity to function normally. In order to prevent this process from happening at the level of the brain, where maintaining a critical water concentration is vitally important for nerve conduction and other high level processes to take place, it has the special ability to generate free osmotically active molecules, called free osmoles, which allows it to negate some of the water pressure exerted on by the periphery. Essentially what happens then, is that as more water is lost in the circulation, the more osmoles are generated in the brain to balance the solute/water concentration. That way, water is drawn away only from the periphery and not from the brain, where centrally processes can continue to function normally.

This unique adaptive ability of the brain to generate free osmoles in the face of dehydration is not without consequence however. The most important side effect, for the purposes of this discussion, is that once these osmoles are generated, they take a very long time to go away. This important principle comes into play in the rehydration phase, after the long run. When we rehydrate, we are refilling our body with a large quantity of water (and electrolytes). And because the brain hasn’t yet had a chance to decompose the free osmoles, there is a high residual osmotic pressure for water to move intracellularly (which is no longer compensated by the osmotic pressure for water to move outside the cells since the periphery is now water replete, and not dehydrated.) As a result, water is drawn into brain cells as fast as it is consumed in the periphery and the cells swell up. Unfortunately, the brain handles water intoxication much worse than it does with water deprivation. As a result, brain function goes haywire and you end up with a splitting headache. By the way, this is actually the same mechanism by which people die from severe hyponatremia (as caused by too much water consumption and too little solute consumption) during marathons.

THE SOLUTION

The recommendation I’m proposing is the same recommendation that is used to treat patients suffering from severe dehydration in the emergency room. The key to rehydration is to replace HALF of the fluid deficit in the first 2-4 hours and the REST over the next 12-24 hours. This means that if you estimated that you lost about 16 ounces of water in your long run, you shouldn’t gulp down two 8-oz bottles of Gatorade before you hit the showers. Instead you should have one bottle and wait for about an hour or so before you have the second one slowly with your post-race meal. The slow rehydration allows the brain to eliminate some of the free osmoles that are no longer needed and the rest of the body to readjust gradually from a dehydrated state back to normal.

This slow rehydration technique is more important for small-framed individuals and people who tend to sweat a lot when they exercise because they will have more fluid shifts during their dehydration and rehydration phase. Also, because these central osmoles are generated only with moderate to severe dehydration, these guidelines are much more applicable for those who participant in long endurance training events than those that exercise for shorter periods of time.


Hope you all find this little dissertation on the physiologic consequences of rapid rehydration useful. Please feel free to ask any questions. Let me know if this was all too confusing to follow. I’m thinking I’d like to post some other physiology lectures on running in the future so if there are any burning questions that you want answered, I’ll take suggestions for those too.

Okay, hope you all learned something today. Class dismissed!