http://thebostonphoenix.com/boston/news_features/other_stories/multipage/documents/02229150.htmRun for your life?
Researchers link heart trouble to marathoning, but runners stride on
BY NINA WILLDORF
TEST CASE: runners over age 40 should take stress tests before embarking on a marathon.
THIS MONDAY, more than 16,000 people will gather in Hopkinton, Massachusetts, pumped up on pasta, prepared to run 26.2 miles. At moments along the course, some will cry. Many will pee, mid-stride, through their shorts. And, according to some new research, a few may come awfully close to death.
Marathon runners have long been touted as poster children for physical fitness. For runners, crossing a marathon finish line is in many ways a rite of passage, a badge of courage, a coming of age. Their sinewy, muscled legs, their relentless drive, their dedicated eyes. Those protein-laden packets of goo they eat, for God’s sake. These folks are tough!
For years now, doctors have been saying that long-distance running batters the body. Runners are familiar with the obvious plagues of knee problems, shin splints, and bad backs, but new research points to the possibility of a far worse fate: death. Late last year, McLean Hospital released two studies indicating a possible connection between marathon running and increased risk of cardiac arrest. In the late 1990s, another researcher at Harvard found that exercise’s best health benefits come from the caloric equivalent of running a total of 20 miles per week — as opposed to 26.2 miles in one day.
It’s a rare marathoner who doesn’t experience an injury while training or during the race. In fact, the litany of distance-runner ills reads like a pharmaceutical drug company’s small print: may lead to stress fractures, lower-back pain, blood in the urine, repetitive-stress injuries, increased risk for eating disorders. But dropping dead — known in clinical terms as sudden cardiac arrest — is another story. Still, word of such serious health woes has yet to put the brakes on those hot to trot. Come Monday, they’ll stretch, they’ll line up — and they just may run their hearts out.
CERTAINLY, there’s such a thing as going too far — and many say a marathon qualifies. "It’s not natural for your body," advises Brian Fitzgerald, an athletic trainer and research-projects coordinator at Boston’s Children’s Hospital, who also sits on the Governor’s Committee on Physical Fitness. "There are road races — but marathons are going a little beyond."
While running has been shown to help prevent heart attacks over time, Arthur Siegel, director of Internal Medicine at McLean Hospital in Belmont, has conducted research showing that some distance runners put themselves at high risk. "There’s a paradox about exercise," he says. "It looks like the more you do, the better off you are. And that’s true, except, unfortunately, during the exercise itself." Siegel compares running to drinking. While a little alcohol may be good for the heart, too much of a good thing can lead to death — the returns diminish after a certain point. And docs are still trying to figure out what the magic number is.
Last October, in the American Journal of Cardiology, Siegel published two concurrent studies linking increased risk of heart-damaging events with long-distance running. Between 1996 and 2001, Siegel drew blood from 80 middle-aged male runners before, immediately following, and a day after the marathon. His findings showed that 24 hours after the race, the men, none of whom had any history of heart disease, exhibited early-stage signs of cardiac damage similar to those that appear during a heart attack.
(The American College of Cardiology recommends that runners over 40 take a stress test before embarking on a marathon. It is usually hidden or asymptomatic conditions that put long-distance runners at risk.)
Siegel explains that running a marathon causes injury to the skeletal muscles, which "sets off a cascade of inflammation in the body." Inflammation, normally a healthy bodily response that initiates muscular repair, also causes blood to thicken and clot. This secondary effect is good in the event of injury because it limits bleeding. But clotting and thickening of the blood can also occur in main arteries, interrupting normal heart function. Prolonged vigorous exercise can raise this normal clotting response to lethal levels, especially in those with a history of heart disease.
In addition, certain cardiac enzymes that show up during heart attacks are also present in some distance runners, a preliminary finding Siegel plans to explore further at Monday’s marathon. While the numbers of mid-marathon deaths are low — around one in 100,000 — Siegel says "sometimes the first symptom they have is a sudden death." But it’s also important to note, says Siegel, that because he tested men with an average age of 47, his findings may not have much bearing on younger heart-healthy runners. And, notes Charles Schulman, a cardiologist and assistant clinical professor at Harvard and the president of the American Running Association, while those enzymes may be elevated, that doesn’t mean the runners will necessarily suffer heart attacks. "These are not specific tests for heart damage," Schulman says. "[the doctors siegel studied] run the marathon, and they’re perfectly fine. We see them coming back."
Though unusual, marathon casualties do make the news from time to time; most famously, there were two at the 1994 New York City Marathon and another at the Boston Marathon Centennial in 1997. Given their medical knowledge of such events, cardiologists must balance cautioning those at risk with endorsing exercise, which is equally important for good health.
Not surprisingly, Marvin Adner, medical director of the Boston Marathon, leans in favor of running — though he doesn’t deny the risks. "You’re at higher risk for heart attack when you’re running. And when you’re not running, you’re at a lower risk," explains Adner, who adds nonchalantly that he’s had "a few friends" die from running. "In the long run, it’s more value than harm — but some people die doing it."
Another frightening threat to distance runners has emerged in recent years: hyponatremia, a condition that occurs when runners drink too much water. Siegel, who’s in the process of studying the illness, calls it "water-intoxication syndrome." As a result of over-hydrating — which can happen at races in hot climates — the balance of salt and water in runners’ bodies’ gets out of whack, and the concentration of sodium in their blood falls too low, causing an electrolyte disorder. The result? Brain swelling and, in some cases, seizure. Certainly, hyponatremia doesn’t pose as much of a threat in Boston in April as it does in a place like Houston during the summer, when temperatures soar and runners chug water, but doctors will be keeping an eye out for signs of the condition come Monday.
Although, in the end, maintaining adequate electrolyte balance — not just regulating water intake — is most important in preventing conditions such as cardiac arrhythmia.
Marathon running had a portentous start. The 26.2-mile race gets its name from a run taken by an ancient Greek messenger named Phidippides from Marathon to Athens to warn of approaching Persian ships. After finishing the run — which followed days of other lengthy message deliveries — he reportedly dropped dead, after uttering the proclamation, "Rejoice."
Rejoice, indeed. Worldwide, marathons have become a cause for mass celebration, especially in Boston, where a holiday is spent cheering on the throng of sweaty runners. The Boston Marathon, held by the Boston Athletic Association, has been run annually (except 1918) on Patriots’ Day since 1897. In addition to this year’s 16,830 registered participants, organizers anticipate a "fair share of bandits," or unregistered runners, jumping into the course.
Most agree that running can be a tremendous form of exercise. Studies abound pointing to the high-intensity workout's physical boons. In 2000, the American Journal of Hypertension hailed running's effect on lowering blood pressure. The year before that, the American Journal of Public Health reported a link between running and reduced health problems in the obese and overweight. It’s even been reported that regular runners can count on an increased life expectancy of two to seven years. Run an hour, goes the conventional wisdom, add two hours to your life.
Harvard School of Public Health’s Ralph Paffenbarger tracked Harvard alumni over a period of about 40 years. His data showed that exercisers get the most benefit from an energy expenditure equaling approximately 20 miles of running per week, which cuts stroke risk in half and lowers the risk of death from heart disease. But it’s unclear whether adding to that mileage also adds to the benefits; Paffenbarger didn’t test marathoners, and the tests that have been done, like Siegel’s, have not been promising.
HARD-CORE RUNNERS’ response to all the bad news? See you at the finish line.
Runners are a peculiar breed. I should know, because I was one. Training for a marathon involves getting up early, running until late, and lacing up the sneaks six out of seven days each week — for months on end. Running becomes your life, your social center, your number-one priority. Kerry Roche, 25, can tell you that. The Quincy resident is training with five girlfriends to run the Boston Marathon — their first. "We’re boring people," she tells me. "It’s all we talk about."
Bob Fitzgerald, the editor of New England Runner magazine, says that people train for marathons for one of three reasons: it’s what their peer group is doing, they’re trying to lose weight, or they’re looking to lead a healthier lifestyle.
For me, call it boredom. I started training for a marathon in the summer of 2000 for lack of anything better to do. I’d just moved to Boston, knew very few people, and even less about the city. So I ran. And ran and ran. With nothing better to do in the evenings, on weekends, whenever — I ran. I quickly became one of those runners who scoffs at the Walkman, who runs deftly with water bottles and Gatorade in tow, who knows the perfect spot in a sneaker to hide a key.
I soon found a community of runners. We’d jog in place for a few, talk about how much distance we were doing, what injuries we were nursing that day, and how much more we had to go.
Most of my new ragtag running mates were training for something. In hard-core running circles, there is, unsurprisingly, a densely layered status system. The DC marathon (Marine Corps) is considered wimpy. The Providence one (Ocean State), which I was training for, is good for first-timers, i.e., pretty wimpy. New York is above those. And as for the Boston — well, wooo-ey — that’s for the hard-core.
Injuries were par for the course. I had mine mid-training, when I took a bad fall one night, tripping over a coat hanger in the middle of Comm Ave, and skidding down the asphalt. I dug the rocks out of my knee in time to meet my friend Patrick, who was training for the DC marathon — and the next week I was running again. Call it Marathon Madness. Marathon Macho. Whatever; I just wanted to get back out there. I was losing time on my finely calibrated training schedule.
While at work one day, I did some Web searches to see how much good I was doing myself, as I absentmindedly squeezed my newly bulging quads. I came across some studies that didn’t quite fall in line with what I was expecting. There was talk of permanent bone damage, ills caused by dehydration, bad, bad things.
What? How could this be? Running was healthy! It had even compelled me to stop smoking, after years of deceiving myself that I merely enjoyed the Occasional Social Cigarette.
I defiantly shrugged off the bad tidings. I was so close to my marathon date, and I wasn’t going to stop for anything, especially something as vague and amorphous as bone damage. I mean, come on, that doesn’t happen to regularly exercising twentysomethings. Please. The only thing that was going to stop me at this point was a real, blood-oozing, painful injury. Not some potential future event.
Besides, by this point, my parents were flying out from San Francisco to cheer me on — my dad, especially, gushing with pride in his athletically inclined daughter. Like reading Ulysses or putting on an ambitious dinner party, running this marathon had become a personal test, a marker of how well I’d adjusted to my new city. Running unscathed would prove even more to myself. And somehow, despite clocking 40 miles a week at my peak, I miraculously got through training with all my limbs, muscles, and ligaments intact — although I’d lost my training buddy to a knee injury.
The race itself was something of a blur. Hopping up and down before the start, I remember being nervous about getting a bad stomachache, which induced a bad stomachache. I was concerned about things like warmth, food, hydration, peeing. I was not thinking about things like bone damage, seizure, cardiac arrest.
Pumped up, we launched to the tune of "Who Let the Dogs Out." Here’s how it went: I ran. And that’s pretty much all I remember. At a few points, I remember seeing my parents pass off peanut-butter sandwiches as I tossed them my long-sleeve shirt. I chatted with people running next to me. I mainly focused on putting one foot in front of another. Making it the next few miles — to a water station. Finding a building to dive behind for a quick pee.
I crossed the finish line in Providence, numb in the limbs, my head weighing me down, sucking madly on candy a fellow runner dug out of his shorts, and crying. I wasn’t sad. It was just the only physical response I had left. There had been laughter, there had been lots of groaning, and there had been, yes, some singing to myself.
Finishing the race felt like what I imagine giving birth to be — incredibly painful, but somehow compelling enough to repeat. You want to drop, and then (hello, endorphins; what pain?) — you want to do it all again. The pain was vaguely gratifying, even. My medal. "So, what’s next ... Boston?" asked a friend over a post-marathon pub lunch in Providence. "Hell, yeah!" I enthused, mentally planning my new regimen.
I haven’t run more than a handful of miles since: now, my left knee starts screaming by Mile Two. Sadly, my marathon madness ended at that finish line in Providence. If that hadn’t happened, there’s a good chance I would be out there on Monday too.
CALL IT ADDICTION — many do. "It’s pretty safe to say that I’m addicted to running," says Allison Lombardi, 24, who’s flying in from California to run the Boston Marathon. "If I don’t run one day or a couple days in a row, I get pretty antsy, and I feel pretty yucky."
Lombardi has had shin splints for eight years. Over the course of her running career, which has included running track and cross-country on athletic scholarship for the University of California at Berkeley, she’s also experienced a stress fracture in her foot. "I’ll be laying in bed at night and I’ll start to feel pains in my shins and stuff and I’ll be like, ‘This probably isn’t a good sign.’"
"I can see where a doctor would say that [running a marathon] is not the best thing for your body," she adds. "It’s not like you run and you feel great. You feel like crap for a week afterwards. The whole next day you’re walking like an old lady. I couldn’t climb any stairs for a day."
By his count, Boston Marathon medical director Marvin Adner has run 50 marathons. He doesn’t run them anymore because his knee hurts him. Arthur Siegel, who calls himself "marathon-friendly," ran the Boston Marathon every year for 20 years, starting in the 1970s. He calls Boston the "Holy Grail, a badge, a rite of passage." He stopped, he says, because "it just got to be more than my body could handle."
On the flip side, Children’s Hospital’s Brian Fitzgerald has never run a marathon. "Run it?" he snorts. "It’s a long way to drive. You kidding me? I’ll catch them as they fall across the finish line."
And fall they do. Of the scene in the triage tent at the finish line in Boston, Adner says, "Ever seen ER?" Siegel also works in the tent. "People can get delirious," he says. "They can need IV fluids."
There are wheelchairs, people collapsed, blood, says Adner. "The [injured runners] look like they’re dying. They’re just tired. But with fluids and rest and cooling, they get better really quickly." He adds, "It’s fun."
And talk of death, seizure, even permanent skeletal damage isn’t compelling enough to dampen the enthusiasm of many a distance runner. "I think I’ll probably do it as long as I can," says Lombardi. "As long as my body lets me."
She knows it hurts. She ices away. But she’s not going to stop. Runners ready?