Marathoners, Get an EKG

Disclaimer: I am not a medical professional and do not have the credentials to provide medical treatment or advice.  This post is only my personal opinion based on my own experiences with medical tests and running.  It is not meant to be used as a guide for your own health decisions.  If you think you need an EKG or a similar procedure, please consult your personal care provider.

Getting into marathon shape is not easy, regardless of your weight, height or athletic history. Even once you make it to the finish line, you feel like your muscles are full of battery acid, ready to eat through your skin. You limp for days and wonder how you’ll ever manage to take another airborne step again. But one thing is certain: you’re likely to be in pretty good shape.

The buildup of mileage, the rush of oxygen and tearing up of muscle over the last four to six months have made you stronger. Your legs can carry you forward for hours, your resting heart beat has dropped a few beats per minute, and your body has become more energy efficient. There’s always one sign at every marathon emblazoned with some variation of the oft-quoted (but statistically unreliable) factoid that only 0.1% of the population has finished a marathon. We take that to heart, pun intended, because despite the noise and talk, we really are a minority.

The problem is that after many years of this, long-distance runners can fall into the trap of thinking they’re invincible. While the country (and increasingly the world) experiences public health and obesity crises, we stand somewhat apart, logging weekly miles and trying to eat right. Our reasons are diverse. We might have started training to lose weight, to challenge ourselves, or to carve out daily time to clear our minds. Whatever the cause, running between five and ten miles in one sitting is rarely a big deal to us.

But every so often the specter of doom rears its ugly head. I’m not talking about injuries – those happen to all of us and often enough that we know how to deal with most of them. I’m referring to the sobering fact that every so often, we are flooded with emails from friends and relatives all reminding us that someone died mid-race.

Long distance running is a unique sport. Few other sports allow thousands of amateur athletes to compete alongside the cream of the crop. Few other sports allow spectators to witness such incredible variance in performance over such a long period of time. We watch professional athletes on TV perform amazing feats, as they drop to the ground, heaving and sweating, but we never think they’re in any real danger. They are, after all, professionals. But that moment of security last a few minutes in a marathon as the elites and top 1% zip by. After that, it’s the throng of every-people, who run for fun or a sense of accomplishment.

The farther down the course you traverse, the more ragged everyone looks. The enthusiastic smiles of the first 10k become contorted in rictus grimaces, ebullient cheers are now hissed through gnashed teeth. As you watch people struggle to stay strong over such an unforgiving distance, it’s only natural to wonder whether the sport is good for them. And every so often, it seems like that question is given a dark answer.

First, the good news is that the numbers are on our side. If marathon running were truly bad for us, then we’d be seeing a lot more deaths. A recent Forbes article pins the likelihood of death from a marathon at 0.5 to 2 deaths for every 100,000 participants. While that is absolutely no comfort to the friends and family of the rare death, it does put the activity in perspective. For example, you are more likely to die while swimming, biking, playing football or even playing tennis and far more likely if you drive a car. Even with the boom that the sport is experiencing, deaths are very rare. A study published in the American Journal of Sports Medicine showed that despite the increase in participants from 2000 to 2009, the low incidence remains the same.

But the fact that they still happen sends a shiver down our spines, regardless of our PR ambitions. This year alone there have been deaths at the New York City Half Marathon, the London Marathon, the Shamrock Marathon in Virginia Beach and the Rock ‘n Roll Raleigh Half Marathon.  The fact that three of those examples were half marathons shows that the phenomenon is not limited to runners journeying 26.2 miles.

So why is it that some runners never cross the finish line? Dr. Peter McCullough from Dallas’ Baylor University Medical Center says that whenever a young, relatively fit person collapses mid-race, it’s most likely due to hypertrophic obstructive cardiomyopathy (HCM). This is a condition where the heart muscle or myocardium is thickened and thus restricts blood flow. The biggest issue with this condition is that it is asymptomatic, or difficult to detect until you’re having a cardiac episode.

But there is a way to detect if you have any abnormalities in the heart, including HCM, and that’s by getting screened. This is done via electrocardiogram (ECG or EKG), a device that measures the electrical activity of the heart. I went through the procedure in early May and it was completely painless. In addition to the EKG, I also underwent an ultrasound and a stress test, where I walked on an inclined treadmill with several electrodes attached to my chest. Every two minutes or so, the speed and incline increased until I was sweating bullets. During the ultrasound, I could see my heart expanding and contracting and each individual valve flapping effortlessly.

Most of the screening was, to be completely honest, a fun ego stroke. The majority of the patients that walk into the doctor’s practice were there because they had a problem and not for some peace of mind. Since HCM is a largely unfelt heart condition, I wanted to make sure I wasn’t that one unfortunate runner among the masses. After all, the most common fatalities occur in men in their 30s, albeit those with pre-existing, undiagnosed heart abnormalities.

It would seem somewhat reasonable to suggest then, that you too should get screened. If you are a serial marathoner, an ultrarunner or someone who routinely logs over 30 miles a week in the sport, it wouldn’t be unwise to take a look at your heart, especially if you experience any sort of chest pain or pressure during a run or if you have a family history of HCM.  Some might even say that routine checkups should be compulsory.  However, the American Heart Association has oddly not recommended mass screening. Their reasons have to do with resource allocation and logistics – there are simply many more health issues to tackle that take more lives and there are far too many active, athletic people in the United States to warrant that many EKGs (it’s also suggested that it would cut into cardiologists’ profit margins if widespread EKGs achieved economies of scale).

“The cardiac community is divided on this,” says Dr. McCullough. “But I fall in the camp where I think that everyone involved in serious athletics should have a echocardiogram, just like every woman who gets pregnant has two or three ultrasounds.”  Source

I agree completely. If you have the incentive (you are a serial marathoner or an ultrarunner) and the opportunity (you have decent health insurance), then by all means, get screened and run calm.

Are We Running in a Bubble?

Are We Running in a Bubble?
Putting too much of our hearts into the sport.

I love to run. 

It’s more than a simple declaration of fact.  It’s a mantra, a lifestyle, a reason to get out the door and chase a new PR, train for a grueling race or simply enjoy the wind through your sleeves.  It gets blood pumping, helps maintain my weight and afterward gives me an invigorating feeling.  Even after notably intense runs, I rarely go home and regret having logged another run for the records.  I’ve been running consistently for about four years and still haven’t lost my passion for it.  If habits are formed three months at a time, then running has reached the level of eating lunch or waking up.  It’s part of my daily routine now and I can’t imagine what would get me to abscise it from my being.

Because running isn’t just about the physical act itself.  There’s an entire culture that has exploded around it in recent decades, creating an amazingly supportive and inspirational community that soon becomes part of every serious runner.  You can’t buy a pair of shoes without overhearing a conversation about a local race or toe the line at a big-city marathon and not see T-shirts for other races that will soon earn a spot on your bucket list.  It can be all-consuming and truly addictive.  Once you dip your toes into this wonderful fitness land, you won’t want out.  And why would you?  The vast majority of runners started out like you, uncertain, slow and possibly over-injured and are eager to offer tips, advice and even themselves as running partners.

For some runners, a half marathon is enough.  They train for months, hammer out 13.1 miles and stop the clock with what feels like their last breath, content with having finished what they started.  Others go for the marathon, finish, and never go back.  But then there are people like me, who like to return to the distance to expand their limits, be that in speed or distance.  To do that, conventional wisdom, elites and many training plans offer a lot of advice, but a lot of it hinges on adding mileage.

Run more.

So we do just that.  If people much faster than us are routinely hammering out 60-90 miles a week, then they must be onto something.  But the vast majority of “normal” people would laugh at the idea of running 60 miles a month.  We’re the weird ones and we’ve been told that many times, from the first time we announced that we wanted to run the equivalent of a $40 cab ride for fun.  How many of us have heard from our friends or family that we’re doing damage to our bodies by running this much?  We scoff at the idea and assuage their concerns without sounding condescending.  But it doesn’t stop there.

How many times have we gone to doctors with running-related injuries only to be told to stop running?  We decide that this quack just doesn’t get it and that he must be wrong.  So we seek second opinions, preferably from a doctor who is also a runner in hopes of hearing something else.  If that doesn’t work, then we scour the internet for an article or, heaven forbid, a forum that will tell us that everything is alright and that soon enough, we’ll be back to running as if nothing had happened.

And that’s when I start asking myself that nagging question that we try to avoid: are we running in a bubble?

marathon-logThe short answer is absolutely, we definitely are.  Incredibly involved and supportive communities that revolve around a singularly unique experience are, in a way, bubbles by definition.  It takes a lot to crack into it; it doesn’t happen by simply buying running shoes.  But my question is more about the way many runners ignore the outside signals and any evidence that goes against the benefits of long-distance running.  We refuse to take seriously anyone or any article that cautions us from running too far or too often.  Are we clamping our hands to our ears whenever anyone says that running marathons is bad for our bodies because we’re convinced it’s actually good, or because we don’t want to pick away at our convictions regardless of potential evidence?

It’s no secret that a lot of us are caught in a positive feedback loop.  I read books like Born to Run (Christopher McDougall) and Running on Empty (Marshall Ulrich) that talk about superhuman athletes capable of amazing running feats.  I read blogs like Jeff’s Run Factory and Danielle’s T-Rex Runner who knock out marathons and ultras with as much frequency as eating breakfast.  I’ve even committed to running ultras with Otter, the tacit agreement being that we’ll push each other through the challenges come what may.  It doesn’t stop with me though; I pay the attitude forward.   With so much to draw on, it’s impossible to avoid getting enveloped by the gung-ho attitude that anything is possible as long as you can put one foot in front of the other.

But where does that stop?

I earned my current marathon PR of 3:23 by running between 30 and 40 miles a week.  That weekly training load was both challenging and sustainable.  But I knew that if I was serious about running ultras, I’d have to kick that up a bit.  If push comes to kick in the back and I decide to one day run 100 miles, I’d have to inflate the weekly mileage even more.  And the question returns:

Where does it stop?

If you turn to the running community and fellow trail-blazers, you might hear things like “Never!”  Those with a little less zeal might tell you to listen to your body.  But you’ll also hear very often that humans were meant to run long and nay-sayers just don’t understand.  There certainly is no shortage of awe-inspiring stories that showcase these enduring themes front and center.  After all, what better representation of the triumph of the human spirit than running hundreds of miles?  But as a reasonable person, there does come a point where I have to step outside of this wicking fabric bubble and ask the awful question that nobody wants to hear:

What if we’re wrong?

Running in my first ultra -- journeying past the conventional marathon and into the unknown.

Running in my first ultra — journeying past the conventional marathon and into the unknown.

By now you’re probably asking yourself a different question.  Why the sudden, borderline apostasy?  What happened to shake my faith in the common axiom that all woes are cured by going for a run?  After all, the sport has become an essential part of who I am, so why would I question it?  The answer has to do with the intense polarization of the world’s discussion space.  Thanks to the internet, everyone has an opinion on everything and can find a website to back it up in some way.  The more we stay in these echo chambers, the more entrenched we become in our beliefs.  Very soon, we almost become shackled to them, lest we give in to our opponents.

It becomes less about thoughtful, analytical thinking and more about scoring points.

I therefore could not consider myself a reasonable person without at least entertaining the idea that there is such thing as excessive running.  Despite the outcry from the faithful, it’s a necessary inquiry.  After all, our sport is extreme by definition.  There’s a reason it’s called long distance running and part of it is because it defies the age-old saying that everything should be done in moderation.  The term “exercise addiction” is routinely thrown around when discussing marathoners, although the vast majority of us discard it completely because we don’t believe it negatively affects our relationships (and to be fair, in my case, it rarely does).  Plus, why make a problem out of something that is largely considered a good thing?  Few parents will ever worry about their children exercising too much like they would if they had the same issue with junk food, pornography or cocaine.

But it could be a problem and not just from an addiction standpoint.  It seems that every other day we get a new study from a reputable health center saying that marathon running is bad for the heart.  Studying the effects of long distance running on the heart has become the new daily glass of wine.  For every study that suggests that marathons are deleterious to the heart, there’s another that says otherwise.  Even the running man theory posited in Born to Run that suggests that the human body was evolutionarily engineered to run long distances is a very new idea.  Tantalizing yes, but very new and relatively untested.  But every time one of these cautionary articles comes up, we either avoid reading it altogether, or manage to find something wrong with the study to keep from worrying about our monthly marathon schedules.

Take, for example, a recent story in the New York Times about barefoot running.  Chris McDougall’s bestseller pushed barefoot running into popular culture and has spawned a faithful following.  But given the billions of dollars generated by the running shoe industry, it’s no surprise that there has been much debate on the merits of going shoeless.  However, the article did point out the shocking fact that, somehow, heel-striking is the more efficient and economical stride style and “by a considerable margin.”  I was an instant skeptic – if suddenly heel striking is the recommended landing strategy, flying against everything I had read on the topic, then what’s next?  Avoid drinking water on hot days?  Holding your breath during intervals increases endurance?  A gallon of heavy cream three hours before a race guarantees a PR?

I couldn’t help but think, was this study funded by Nike?  Flexfilm manufacturers?  How much money did Big Heelstrike’s lobbyists have?  But the point was that there was a study that disproved or somewhat dismantled something I thought was sacred.  And then I got to thinking: so much of the wisdom and advice around running is anecdotal or speculative.  The more you read about discoveries in the sport, the more you realize how little we know about it.  In fact, steak used to be the recommended meal the night before a race before carbohydrates became every runner’s preferred gorge.  Overhydration was prescribed until runners in medical tents unwittingly discovered hyponatremia.  And now there’s an article that says heel striking is the way to go.

For better or worse, we’re all different.  Every single serious list of tips comes with the requisite note that silver bullets don’t exist and what works for some won’t work for others.  Some love pickle juice, others swear by mustard packets.  For every runner that has their own meticulous electrolyte concoction there’s another who survives just fine on water.  For many aspects of running, we are fine making the right choices on our own, adopting what works for us and shelving what keeps us from our goals.  If you throw up after eating a sport bean, then maybe those aren’t right for you.  If you feel water sloshing around your stomach, try drinking at longer intervals on your next long run.

But what about what we can’t immediately see or feel?

A friend of mine sent me an article from the Wall Street Journal that debunks the idea that long-distance running guarantees excellent health.  It cites the buildup of coronary plaque and a condition called atrial fibrillation among others, saying that whatever health benefits we earn by running can become harmful past a certain distance.  Oddly enough, that number was very specific: 7.1 kilometers (4.4 miles) a day.  Once again, my instinct was to downplay it and insist that running was great and running long was greater.  But I’m not a scientist or a doctor.  How can I be so sure?

The sad truth is that, at the moment, we don’t know anything for sure.  There are people who smoke like the Deepwater Horizon and eat nothing but bacon well into their 80s.  If you search hard enough (or maybe just fire out one quick Google search) you might find a group of chain smokers who can cite studies showing that smoking can actually increase your life expectancy.  So what’s a serial marathoner to do with all these conflicting studies about heart tissue damage?

Stop running.  Just kidding.  Can you imagine that?

Pay attention to your body.  It has happened on more than one occasion, mostly when running fast in very warm conditions, that I’ll feel a cramp in my chest.  At that point, I always stop running and hydrate, most likely ending the run for the day.  Any sort of cramp in your chest is your body telling you to take it easy.  Even if it’s not serious, I’d rather assume the worst than poke the beast.

Research.  Read reputable studies on the matter and find out if anyone in your family has had a problem with heart disease.

Get yourself checked out.  The majority of deaths that occur during marathons stems from undiscovered heart conditions that were aggravated during exercise.  While it’s not cheap, an electrocardiogram (EKG) can tell you if you have any issues with your heart.  It can tell you if you’re developing symptoms for heart disease, if you have inflammation or any other abnormalities.

Play it safe.  There is the possibility that the study the Wall Street Journal cites is correct and that running past 30 miles a week is legitimately dangerous for our hearts.  In this case, we could pay Pascal’s Wager and simply keep our weekly limit to 30 miles to avoid pissing off the running gods.

All worries aside, marathons are on our side, at least for the short term.  In the ten years between 2000 and 2009, there were over 3.7 million marathon finishers (not individual people as I’m sure the study didn’t account for serial marathoners).  Of those, there were 28 reported deaths, 22 men and 6 women.  In other words, the chance of suffering a fatal heart attack during a marathon is so miniscule it might as well be negligible.

As for potential damage to our hearts, a lot of cases involve people with abnormal heart conditions that also happened to be marathoners.  In those cases, marathoning didn’t necessarily cause the condition, but it potentially made it worse.  The overall point is that it happens and many of us inside the running bubble are too quick to ignore it.  We get so caught up in the sport’s fervor and passion that we close our minds to outside, often contrarian opinions.  Our friends and family call us crazy and we embrace it like a compliment but if a doctor does the same, we feel like it’s a slight on our culture.  What we should be doing is asking why.

These thoughts aren’t meant to be a buzzkill, but an invitation to think objectively about the sport that we love so much.  I often complain that our ability to be open-minded about crucial topics (fiscal policy, the existence of god, the best condiment, etc.) is a thing of the past, so I owe it to myself to take a step back and wonder whether our marathon hedonism is worth it.  Part of it also has to do with my summer ultra training schedule, which is rarely a walk in the clouds.  But onwards I will continue with my regimen because I love the sport, the community, and yes, the bubble.  I just think that we should pop it every now and then to make sure we’re not doing any lasting damage.

Lastly, I’d love to hear from you about this.

Are there any interesting related articles that you have read recently that can shine more light on the situation?  Where do you draw the line?  How much is “too much”?  Do you think we were made to run extremely long distances?