Potential Long Term Health Effects of Ultrarunning with Nick Tiller PhD (2021) #195

Trail and Ultra Runners. What is going on? What's happening? Welcome to another episode of the Coupe Cast. As always, I am your humble host, coach Jason Coupe, and on the podcast today we have some big picture discussions lined up for you. It is all about the potential long term health problems, and keyword in that statement is potential of ultramarathon running and ultramarathon racing.

On the podcast today I have repeat offender again, nick Tiller, to talk about a recent review article that appeared in the Journal Sports Medicine, the lead author of which is Volker Scheer, who is part of the Ultra Sports Science Foundation. Nick was one of the coauthors on this paper and the title of it is potential long term health problems associated with ultra endurance running and narrative review. A link to that paper is going to be in the show notes, and this combined with two other factors. First off, this narrative that endurance exercise is either bad for your heart or bad for a certain organ seems to come around every few years. We talked about the last time that this narrative came around, kind of in the intro of this podcast. And the second thing, and more tragically recently, with a death that happened actually out on the marathon to sob course, we always need to keep these things in the back of our mind because ultimately we do ultramarathons for our own enjoyment, our own health and just simply as a recreational activity. Very few of the listeners out there are doing this professionally, and even amongst those professional athletes, they certainly do not want to do any of these activities at the potential keyword there again expense of their long term health. So I do think that it is important and also responsible for those people in the industry, including myself and including people like Nick to present the entire picture as we know it to date, based on what the science is actually saying. Do these types of activities, whether they're training or racing? Can they potentially have a negative impact on our long term health? So we explore all of that during the course of this podcast.

As always, it was a really fun conversation with Nick. You guys go and check out the show notes to this podcast. There are going to be a lot of links out there to some of Nick's work. You guys should go and check it out. We start out the conversation with a little bit of banter about the book which he was a scientific reviewer on and some other things that were going on, but I promise we get right into this paper within a couple of minutes. You guys will all enjoy it, I guarantee you. Here we go. I'm going to step right out of the way. Here's my conversation with Nick Tiller. So I found this hard copy of this book. Do you remember when this book came out? The hey, why Are Heart? Yeah, it's only a few years ago isn't it?

I think it was 2016. And, kind of. There's two reasons that I want to use it as a little bit of an intro and why it's still kind of vivid in my memory. First off, just as a personal connection, we use the same publisher, so the first edition of my book used the same publisher as this and for whatever reason these things kind of go it's just like everything else they go in cycles, right, it doesn't matter whether we're talking about a ketogenic diet or endurance is going to kill you.

It seems like every four or five years, this narrative starts to come back up and the combination of the fact that we have the same publisher in addition to that, just the title and I'll read the title for the people that are listening to the podcast version of this. It's called the hey, why Are Heart, which is by Chris Case, john Mandrola and Leonard Zinn. Leonard Zinn is a longtime cyclist who's had a huge footprint in cycling for a long, long time, and the first part of the subtitle, which I don't think people got passed, is how much to or sorry, how too much exercise can kill you comma, and then a line break and what you can do to protect your heart. And I think the way that you know it's obviously ordered provocatively because you got to sell books, right. You're presenting the negative first in this really provocative manner and then almost kind of surprised that the second part of that subtitle wasn't in smaller font just to like hide it even more. But the book kind of caught the endurance world by storm because it spoke to the entire endurance spectrum cyclist, runners, triathletes and it was right around the time where more ultra marathoning was starting to take off Once again, 2016, iron man was doing very well and cycling was still kind of doing very well at the time, and even on the cover they've got these images of all three of the different endurance disciplines across the front.

So it kind of spoke to everybody and what ended up the totality of the book is what I think is fairly balanced, meaning it does what the entirety of the subtitle actually says. It goes through how much too much exercise can be bad for your heart maybe not how it can kill you, but how it can be bad for your heart. And then also it gives you a lot of preventative takes on, even what to do when you go to the doctor's office, right, how to prepare yourself for a cardio, I'll just visit, and things like that. And so now here you go, four or five years later, right on cue, with you and your colleague Valkyler bringing the narrative up again. And so I want to know like, has like the lay media started to reach out to you to to get some takes on this, since it's kind of in the same, it's in the same vein?

Well, the difference here, of course, is that I don't have a book to sell, so in the title they have created a problem with the title itself.

They create a problem and then they're like well, here's the solution, you know. So they catastrophize in the whole thing and then and then providing a solution to it, which I think is, you know I sort of irresponsible, by understand why it's business. You've got to solve it, of course. And no, generally I haven't had too much negative feedback from the paper. When you do get negative feedback, it tends to come in the form of one of two logical fallacies it's either a false dichotomy or it's a slippery slope.

So what people generally say to you is well, okay, so let's just stop exercising and we'll just sit on the sofa and we'll all get cardiovascular disease. That will that make you happy, you know, which is obviously is slippery slope fallacy? But it's also presenting it as like well, either there's either we go, we go into ultra endurance running, which is the most extreme form of exercise that you can do, or you do nothing. And well, obviously that's that's a false equivalency, because there's a lot of space in the middle there where you can do, you know, recreational exercise. You can go out and run marathons and it's still not going to be as extreme as going out and running for 24 to 48 hours two to three times a year. But but you know I'm used to getting it in the next few people because I spend a lot of my time writing about, you know, tackling chiropractic and cup in people who are very zealot about these alternative therapies. So yeah, that stuff doesn't bother me.

But you know what we wanted to do with this paper and that's the different series that I'm not.

I don't get paid for writing these papers, so so not directly, not any form that I recognize but what we wanted to do was try to just get a very clear and elusive message across that, very broadly, exercises good for you, reduces the risk for all cause mortality, reduces risk of cardiovascular disease.

Being active, being physically active, doing it size is a good thing, but not all exercise is completely benign and actually, you know, I'm an ultra runner myself and I've been running ultra for nearly two decades, and as an ultra runner, I want to get more people running, I want to get more people participating in the sport, but I also want them to do it safely. I want to increase kind of the standard of medical support at the events and I want to improve longevity in the sport and to do that. It's no good, just burying our heads in the sand and pretending, like these, these things don't exist. It's important, it's better to have just an open discussion about the risks and the benefits and make a sensible approach going forwards. And that's how you improve, that's how you increase longevity in the sport.

And that's really what I appreciated about this paper, first and foremost, is that it was balanced. We can't stick our heads in the sand and say, oh, everything is good and it's all unicorns and rainbows and there's no risks associated with anything. You have to be realistic about the risks and then the potential tradeoffs that you get for training as hard, as a lot of the athletes that are in this space have to train and I've always looked at things through a 10 year lens. If you can do things in 10 years down the line they're not positive. You should go ahead and do them. They might be negative for like a week or a month or maybe even maybe even a year in some cases, but if you can do things, you put content out there. In this case, right, training, interventions or whatever that are net positive over long periods of time. That's what I think is true ambassadorship within the sport, which is what people like yourself or in leadership positions should always aspire to do. So so let's dig into it.

You guys took assist kind of what I would, what I would describe as a system by system approach, very scientific, right.

We're going to take the whole body and we're going to look at all of these individual components and say, okay, here's how things are effective by ultramarathon training, here's how this system is affected by ultramarathon training, here's how this system is affected by ultramarathon training. And then you took what I thought was a really unique approach where you looked at I hate to say the word special populations, but just like different populations that might be understudied, and pointed out some differences within those populations group. But let's look at the system by systems approach first. Right, when you and we're going to bring it all back together at the end because I think there's a good synopsis that we need that we would be remiss to mention that that health is far beyond one system or another, and that's going back to the title potential long term health problems, right, which we need to be mindful of. So when you look at each one of those systems, like in your reviewing the literature, which ones kind of stuck out to you that, okay, these things are more affected by ultramarathon training than the other ones?

Yeah, and we took this approach in the paper because I think it helps scientists to sometimes create those arbitrary abstractions, to think of it as in different body systems. You're absolutely right that actually the body is an organism and all of these different body systems work synergistically and I think it's always better to look at how these different systems overlap and intersect. We talk about cardiopulmonary function, for example, how the heart and the circulatory system and the lungs kind of work together as this sort of single unit. But actually the way that one system functions will have implications for all of the others. But I think when you're looking at the research it's certainly easier just to split it up and kind of create that arbitrary sort of boundary.

And the other thing that you mentioned which I just want to touch on very quickly is we were very pointed about using the term potential in the title and we went back and forth and what is it to wordy whatever?

But actually including the word potential in there and we use, we litter it throughout the manuscript because these are potentially these are not guaranteed maladaptations that all people are going to experience, these are potential long term implications for some people.

So I think that was really important to just touch upon quickly. So in terms of which ones jump out more prominently, it's certainly the cardiovascular system, respiratory to a lesser extent and perhaps renal as well, but the one that the main one that people are concerned about and this is probably why the book you mentioned was so popular is because cardiovascular system, the heart and the blood vessels are really important role in the body. The circulatory system literally keeps us alive, once blood and oxygen to the various tissues, and if that system, in fact if anyone in the systems systems fail, you got a problem. The cardiovascular system, the heart and blood vessels really do kind of strike us as one of the more kind of prominent systems that is so crucial for life. So when we look at the long term implications, maladaptations in the cardiovascular system, particularly in the heart, seem to be more prominent in the literature and there's more literature in that area as well. So I think that's why it's possible to write on a book on this subject.

And what always strikes me when I look at this is the proportion of endurance. Athletes will kind of scale it down from ultramarathon athletes, but endurance athletes that present to some sort of abnormal heart structure and it's on the order of 50% and more, and I think that's why it gets so much attention is that when you line up a bunch of people and you start doing measurements and scans and things like that on their heart very specifically the endurance athletes as a consequence of their training, their hearts just look differently and those differences are what could potentially to use your word and I just looked it up 22 times in the paper, by the way, so that's over one per page so potentially could cause problems. What people are going to want to know is this is an impossible question to ask, but it's my job to ask it what's the threshold? Where's the threshold where things might cause more harm than good, specifically with a heart, when we're looking at training and the potential for that training to manifest itself in some sort of cardiac problem?

Well, see, this is the million dollar question, and this is what I find so fascinating about this topic, and it's not been explored enough. We need to kind of really zone in on answering this question, because the key question that we have to answer is is it the high volume training that does the potential damage to the cardiovascular system primarily, or is it the physiological stress strain of periodic racing that does the damage?

And that's a really important question that the moment we can't answer. There was a really fantastic study published by Ben Levine's group in the last year or so. Have you spoken to Ben?

Not, since I had him on the podcast. No, I want to bring him back to talk about stuff like this though. So the long-time listeners remember had been Levine on to talk about potential cardiac complications from contracting COVID, based on a study that they did primarily in NCAA athletes. So that's the reference point there that Nick was talking about.

He's a great guy and a world-renowned cardiologist and his group published this study looking at more than 2,000 extreme exercises, and they did this long-term follow-up and a really comprehensive cardiovascular assessment that echoes echocardiography, which is basically getting ultrasound images of the heart to look at the structure and function, and they looked at coronary artery calcium, which is calcified deposits in the blood vessels that actually supply the heart with blood, the heart itself, and, as I said, they looked at over 2,000 extreme exercises. Now, these are not ultra-injurious athletes and they're not professional athletes. They just love exercise and they do something similar upwards of 30 hours a week, which is a lot of exercise, I think. Even for most auto runners, 30 hours a week would probably be happy enough to satisfy all of your training requirements, and so they do a lot of exercise, and what?

they found was actually that there was no greater risk of cardiovascular disease and no greater risk of mortality in this group in a fairly long-term follow-up. Now, this is great news because it means that in theory, you can do a lot of exercise upwards of 30 hours a week and it's not going to have negative implications on morbidity and mortality. But this is the problem. This is the problem that we have is that with ultra-running it's a different scenario, because you're not just doing a very high-volume training, you're also going out a couple of times a year and you're running for a day or two days. I mean, from your athletes, how many times a year do they typically race?

Three, maybe four.

OK. So let's say, somewhere between two and four times a year they're going out and they're racing at least for 12 hours. Maybe 24 hours could be 48 hours, and that's you know. Think about a typical 100-mile race like UTMB, for example. So it's 10,000 meters of a cent. It's a very, very hard race. The good athletes will still take 30 hours to finish our race. You know the elites do it in. I mean, what's the record now?

It's like 22 hours or something like that. 22 something, yeah, 22.

So the elites are taking basically a day to get around this course. For everyone else it's closer to 30 or 40 hours. You do that two to three times a year for a decade or two decades. Nobody really is, you know, in the right mind, is going to think, well, that that's going to be good for you. There's got to. It's intuitive to think that going out and doing that, that kind of really extreme physical activity, is going to have some kind of maladaptation. And it appears that if you do, if you engage in these really extreme exercise behaviors, that might not necessarily be the problem. But what could be causing the long-term cardiovascular implications? It could be the fact that you're going out two to three times a year and you're exercising for a day or longer. I mean, I saw this girl on social media. I won't name her, but she's got something like 10,000 followers on Instagram and her thing is that she races really really frequently and I think the last time I checked she's clocked up six or 700 miles this year alone.

That's an awful lot of racing, and particularly, you know, the 100 mile races are definitely at the extreme end of the spectrum. Most ultra runners probably won't race 100 miles, and if they do, they won't do them very often, and so you have to think a lot of people like that, for whatever reason they're doing it for, maybe they just like the attention. She's not an elite athlete, so she's not getting sponsorship. Maybe at some point she can monetize the 10,000 followers that she has. But the point is that is not somebody who is racing sensibly, and I'm concerned about her longevity in the sport because I think intuitively that it's the periodic stress of racing that could be doing damage, rather than the training itself.

Yeah, that's an interesting piece of deductive logic and it kind of comes out. Let me just like synopsize that a little bit for the listeners right? So, based on the Levine study, they're taking all of these chronic exercises, 30 exercises, 30 hours a week, which I agree, that's a lot of training, that's like Ironman, professional Ironman level training, and they're not finding any issues with their cardiovascular system, with their cardiac system. However, so if it's not the high volume training that could potentially cause problems, it could be these repeated doses of overload in the form of races that could cause that. And there's another line of thought around this as well, which kind of follows that similar deductive path.

Ok, if it's not chronic endurance training, even very high volumes of chronic endurance training, it's something that you're doing repeatedly, that's over. And the other thought process is high intensity training. So if you do high intensity training once a week, twice a week, over the period of 20 years, that high intensity training over that period of time, because it's so far over, has the potential to cause cardiac issues as well. But it's always interesting how these things kind of come back to. Ok, we're going to rule this out, we're going to rule this out, we're going to rule this out, and the thing that's left over is the logical answer, right?

Yeah, sure, and it's really difficult to do, because ultra endurance for an ultra running more specifically, it's only really been studied for the last 30, 40 years, which sounds like a long time, but the human physiology has been around for an awful lot longer and we're really just starting to scratch beneath the surface and, unfortunately, a lot of the research that we have in ultra endurance sport isn't that good, it's not very mechanistic, it's kind of just publishing stuff for the sake of publishing and it doesn't really advance the field for wood at all.

I mean, we had this wonderful string of studies back in 2009, 2010, and 11 from Andrele Gersh, his group, and I mean I've got some of the papers up here which we've cited in our review.

Yeah, the Gersh's group and Jessica Scott with Keith George and Rob Schaefer and those guys, and they did this great string of studies looking at fairly small sample sizes but looking at the cardiovascular implications of competing in either an ultramarathon or ultra triathlon, which was Ironman, and looking at it mechanistically and looking at what are the structural and functional changes that occur pre-depose race and what are the follow-up. If you do a follow-up a week later, do these kind of acute perturbations come back to baseline and generally they do. But we have done a lot of really good work on it since then and there are a lot of unanswered questions. So, for example, this study in particular was published back in 2008. And again, this is from Audre Gersh's group and they took 26 athletes who had done an Ironman triathlon and they took some blood samples pre-imposed and they looked at these biomarkers of cardiac damage.

It's kind of debated whether the markers really reflect cardiac damage, but it's kind of like trochanins and BMP and so forth. And they did some echocardiography as well and what they found was that when they did a follow-up, which was a week after the event, all variables have returned to baseline. So they had 26 athletes and they looked at left ventricular and right ventricular function and they looked at these biomarkers and the blood and pretty much everything had returned to baseline a week after the event, which is great news, except in one athlete where right ventricle dysfunction had persisted even one week after the event. Now I see there's only one line in the paper. They don't really explore it in any sufficient detail and it's easy to just kind of gloss over that that one athlete, that one individual is clearly more susceptible to these acute kind of cardiac dysfunction and so if this athlete then goes away and does another?

Ironman a couple of months later or does a third Ironman in a given year? Are they more susceptible to these long-term maladaptations? Because clearly in this one individual everyone else has recovered back to baseline within a week of the race, but one week later this one individual is still exhibiting some kind of dysfunction. So they're obviously not recovering as quickly. So, with repeated stimuli, is this the individual that is, one in 25 who is going to potentially exhibit with these cardiovascular abnormalities after a decade of training and racing? And that's what we've got to do more work in that area as well, to kind of pull out the ones who are potentially more susceptible.

And it makes sense that you see those things show up in races as opposed to training. Because if you think about a training bout, even the hardest training bout that you could design, it's not that much different from whatever your baseline physiological output is. If you think about homeostasis, you're not moving up and down the homeostasis ladder all that much in any one single training bout. But a race, particularly Ironman, particularly Ultramarathon, you're moving way up the ladder from a homeostasis standpoint. So the potential for disruption in any one singular system is always greater or greatest when you're doing that the most.

Well, think about the race duration. A typical marathon runner and this is kind of if you're not looking at ultra endurance sport. The next peg down, if you like, is marathon running. You go out and train for marathon. Even if you're not a league, you might still go and run 20 miles, 22 miles. If you're running your first marathon, it's recommended or you're the coach, you tell me if you disagree it's recommended probably going to at least 20 to 22 miles.

So you get to go ahead. That's the formula. That's the point. Yeah, it's the cliche formula.

That's the cliche. That's the one that I'm most familiar with because I'm not a coach. But OK, but still, you're going to try and you can get close to the distance. Ok, you could argue that that last 10K is what does the damage. But OK, even worst case scenario, you go out and you might do 18 miles, 20, 22 miles, even if you do the full distance. The fact that you can go out and practice the full distance is a merit. When do you ever go out and practice running for 24 hours? You don't do it because the physiological strain is so great it will have a knock-on effect on all of your training. It's impossible to really condition your body to go out and run for 24 hours or go and run for 100 miles, and that's the discrepancy that we're looking at.

Yeah, that's one of the things that makes ultramarathon so fascinating. So, ok, we've got the cardiac system and we're not going to come up with any brilliant answers here, but I want to give people information to where they can actually track things down, and I think looking at things post-race might be a good way to start to do that. What are the other heavy hitter physiological systems or organs that, once you pour through the literature, are just more susceptible to long-term health implications from either repeated racing or repeated ultramarathon training?

So I think the respiratory system is another one for which there is potential for long-term health implications.

Probably for the most part, as far as we know at the moment in terms of the respiratory system, the negative aspects of long-term training, of racing, are probably not greater for ultra than you would expect for other types of endurance training.

So when you complete in any given ultra race and you see similar kind of responses for marathon, but it's kind of exacerbated in ultra we see this acute drop in lung function. So when we say lung function we're talking about lung capacity, the amount of air that an individual can move in and out of the lungs in a given breath, and also peak flows, how quickly the air can be expelled from the lungs. These are all kind of very basic, superficial measures of lung function and all of these things drop by somewhere between 15 and 25% immediately post-race. You see similar responses if you were to do a triathlon or a marathon and for the most part these changes are not clinically significant in most people. So you'd get this significant reduction but in most people it's not clinically meaningful.

Now there is a caveat to that that if you have a pre-existing respiratory disorder, if you have asthma or if you have baseline function that is below average, then they could be clinical manifestations for somebody who then goes out and does an ultra endurance race.

Because they're starting lower and then they get dropped down. They're starting from a lower baseline.

Exactly. They're starting from a lower baseline. So if you have somebody with below average baseline function and then they drop by 20%, they're now getting into this kind of region where we might be a little bit concerned from a clinical perspective. But most marathon runners if they don't have a pre-existing respiratory disorder like exercise induced asthma or kind of regular asthma, and most of the time they don't have COPD. There are some COPD athletes but for the most part if you have chronic obstructive pulmonary disorder you're not going to be running marathons and doing triathlons. Most people it's not clinically meaningful.

But what I will say about that is if you're unsure or if you're competing in your first ultra it's always a good idea to maybe go and get a screen.

Go and get your respiratory function screen Because it's an easy test to do.

It's basic spirometry.

And a lot of these ultra races they're extreme in distance, they're extreme in duration.

A lot of the time you're competing in extreme environments and you don't want to find out for the very first time that you have a pre-existing respiratory disorder when you're halfway out of the mountain or when you're traipsing through the desert, because medical assistance, as good as it is in most of these races, if you are halfway out of the mountain you don't want to start having some kind of distressing respiratory symptoms that could have been avoided. So if you are competing in your very first race, it's always a good idea to make sure that you don't have any pre-existing conditions. Last, to kind of finally ask your question with the respiratory system, the main thing that we're looking at is kind of long-term damage to the airways. So this is the stress and strain that causes inflammation in the airways and this can happen whether or not you have asphalop, and this can occur just through high-volume training, particularly in cold and dry conditions. When you dehydrate the airways it causes an inflammatory response and in the long-term studies show that this can cause kind of damage and remodeling of the airways.

But this is more volume-dependent, I guess, is what you're kind of getting at right Long-term, repeatedly breathing in dry air over long periods of time, that might cause some type of remodeling of the airways that could have a negative consequence.

It's particularly with endurance-type exercise because of the high ventilation rates. So whenever you're doing an exercise where the ventilation rates are kind of going to be relatively high and or for a prolonged period of time and, as you said, you're quite rightly saying it's the duration, it seems to be the issue. So this is what we refer to as exercise-induced asthma or sometimes called exercise-induced bronchoconstriction. The highest prevalence rates are in cross-country skiers because they have very high ventilation rates long periods of time but it's in very cold, dry conditions that dehydrate the airways and causes this inflammatory response.

The very limited dates that we have at the moment suggest that the prevalence rates of exercise-induced asthma are probably not higher in orcheron as than they are in the rest of the population, maybe very slightly higher, but certainly not as high, anywhere near as high as what you see in Olympic athletes. So we're talking about in orcheron as prevalence about 11% Olympic athletes. You're looking at 20%, something like this. We've got very limited data. The only data that we have on this was a survey done by Marty Hoffman and they looked at over 1,200 orcheron marathon runners and self-reported prevalence of exercise-induced asthma was about 11%. You have to take those data with a picture of self because it's self-report and you could argue either way. Individuals who respond to these types of surveys maybe they have, maybe they're responding because they are less healthy and they want people to know that they're less healthy, or maybe they're happy to respond because they're more healthy. So it can kind of swing both ways.

Yeah, that data has been brought up in the TUE controversy with inhalers at the Olympic level, because the discrepancy between the number of Olympic level endurance athletes that have asthma and are applying for a therapeutic use exemption to usually it's some sort of inhaler to treat that is so much higher than the general population. Or even when you sub-sec the general population into recreational endurance runners, people kind of look at that and they get the skeptical snake eye and think that something's a right. But interesting that the highest prevalence is in cross-country skiers, which makes all the sense in the world. They're doing the highest volume in the driest conditions.

Yeah, and also anytime you're doing this endurance type exercise in an environment that could irritate the airways. So if you exercise in an area with high pollution, that can have a negative effect as well. Climate change is real, folks, and it can have a downstream negative effects if you're doing very high volume training. I haven't been in California for a little while heading back there soon, but during wildfire season they're like maybe don't exercise outside because it's not going to have a positive effect.

In fact, they've done some studies recently on this. It's absolutely fascinating that the long-term effects of exercising in a high-polluted area could have more damage and actually may offset the beneficial effects of doing the exercise in the first place. So it's like, okay, finding a gym during COVID is going to be tough. That's why treadmill sales have gone through the roof.

Yeah, exactly All those indoor exercise equipment. Okay, anything else on the respiratory equipment. I'm going to dodge the UTMB health policy question with you. By the way, we're going to handle that in the podcast Later. I've done. A lot of people are listening and wanting me to ask that question. We're not going to cover that here. But anything else on the respiratory system or if you just want to go off on the UTMB health policy, you're more than welcome to Well, all I would say about it is that I absolutely support the fact that it banned the use of NSE.

We'll talk about NSE and allergies. It's something slightly different. It comes in the same way when we're talking about renal issues. That's the other thing that we can touch on very briefly. It's the potential for long-term renal problems, because this is something that's more prevalent, potentially an ultra-endurance sport, because of the stress that you're putting the renal system under. And banning NSE is a fantastic move because there is more than enough data now to show that NSE has this really negative consequence on whether the renal system functions Basically blocks across the glandins which restrict blood flow to the renal system.

And when you're doing an ultra with sequad smoothly, seamlessly, it's a renal function. But when you do an ultra race, and particularly the really long ultras and this is why ultras is such a crazy sport, because you say marathon to somebody and everybody knows the marathon is 26, 26.2 miles, 42.2 kilometers, an ultra can be six hours or it can be 46 hours and everything in between. But when you do an ultra, you're really stressing the renal system because anytime you restrict blood flow to the renal system, you're potentially causing inflammation and then downstream damage. So it's the prolonged nature of the event which causes redirection of blood flow to the exercising muscles. It's the fact that a lot of these races are done in the heat, sometimes at altitude, so that has implications as well. You become chronically dehydrated and people don't take in enough fluid. There's the risk of potential risk of hyponutrivia, you know, not taking in enough electrolytes, and that's a whole separate podcast.

I'm sure you've talked about that before and you know, when you pile incense on top of that that increases the renal stress. Then you have this kind of cocktail of ingredients. That is very easy to see why acute kidney dysfunction is kind of so common in ultra endurance sport. Now, for the most part it's benign and it doesn't have clinical manifestations mostly, and really you know, catastrophic renal injury during an ultra race is very rare. That's really important to say. What we don't yet know is if you have repeated injury with the renal system, even a low grade injury, whether that can cause chronic renal scarring, chronic scarring of the kidneys, and how that can kind of manifest in renal dysfunction in the long term. That's the thing that we don't yet know.

And I always like to point this out that these are things that are greater than the sum of their parts, right? So you do the Soltramarathon and, yes, it's a really long duration event, your kidneys are under a lot of stress just from the stress of the event, and then you add on high temperature, and then you add on dehydration, and then you add on the stress that the NSAIDs are present, and there it's an exponentially weighted equation. At that point, right, it's not linear. It's not linear. It's not one plus one equals two. It's like two squared, or two to the fourth power, or two to the sixth power, and so on and so forth with all these things.

And there are a lot of medical directors out there and we should spend some more time on this, because this, I think, is a big, big problem. There are a lot of medical directors out there that that's what they're preparing for. They're preparing for acute kidney injuries and people with renal failure to come in, and what are they going to do with them? Right? I mean, that's their almost kind of like nightmare situation where they have to treat those people out in the field or try to transport them to a hospital as quickly as possible, and not only the kind of.

The short-term consequences of that, I think, are things that athletes need to be wary of. But the long-term consequences of repeatedly doing that, because it's an organ that doesn't repair itself very well, is, I think, also underappreciated with endurance athletes, because we have in races, in particular in every ultramarathon or that's listening to this has, this mindset of I want to do whatever it takes to get to the next aid station, to finish this race, to get a 24-hour belt buckle, and they're not thinking about things that they're doing and the consequences of those things two or three years down the line. And this is an instance where when you're taking NSAIDs, particularly during a race, or you're repeatedly damaging your kidneys in some other form or fashion during the race, that might have long-term consequences, specifically because it's not like a musculoskeletal injury where you take two months off or you take four weeks off and it repairs itself. This is something where the regeneration and the repair is low, if not non-existent in a lot of cases.

And I think anytime you have the potential for a maladaptive response, then you have the potential for long-term implications. So with the real system as you say, it's not an organ system that seems to regenerate as perfectly, as optimally as you would like If there is some kind of acute renal injury, then the risk that you're not going to come completely back up the baseline is always going to be there. With the respiratory system, it's more that the unknown is kind of pulmonary edema, which is something that we didn't mention. But very briefly, pulmonary edema or extravascular lung water is a common response to strenuous exercise. You see it very frequently after the marathon and after the ultra. It seems to be relatively benign in most cases. But again, if you have this repeated stimuli and you repeatedly experience pulmonary edema, what are the long-term implications of that?

And with the cardiovascular system, it seems to be more right ventricle function. Left ventricle seems to adapt pretty well, yet left ventricular hypertrophy. This is a normal response to endurance training. The heart gets bigger and stronger, can pump more blood out with each contraction, but the right ventricle seems to maybe not repair itself quite as effectively. The long-term implications seem to be more pronounced in the right pinch pull. So you're absolutely right. The renal system is one of those organ systems that doesn't seem to bounce back quite as effectively after an acute injury

.

So the take-home for the listeners are stay hydrated and don't take NSAIDs. Really that simple. Absolutely Really that simple.

Yeah, pretty much. Obviously, don't over-drink the right amount of fluid for you, and if you're serious about your ulteran, you should know what that is.

And don't take NSAIDs.

There's a reason, you know. I fully support that, the fact that they're banned NSAIDs. I hope other organizations follow suit. I'm not so sure about banning a ban on G6 altogether. I understand why they've done it. They don't want people masking symptoms, masking pain. There's issues with that. But NSAIDs there's no debate there.

We should differentiate between the two colloquially. So NSAIDs would be something like Aleve or Advil, ibuprofen, aproxen, and then analgesic would be Tylenol and aspirin, always kind of like floats in between the categories. I've never even gotten that.

Yeah, aspirin, I believe, is an NSAID. It's a blood thinner as well. Avoid aspirin, avoid any kind of NSAID. The colloquial names are different in Europe and in the US, so I'll take your word for that. In the Europe, it's like Ibuprofen is the most common NSAID, so you want to avoid NSAIDs. Analgesics like Tylenol in Europe is paracetamol. It's the same stuff and these are just analgesics. These are just pills, usually pills or capsules that mask the pain.

Yeah, so the difference and I think that we should point this out the difference is the NSAIDs are affecting the renal system and the analgesics have the potential to mask pain, which just makes you run through a musculoskeletal injury or some sort of other injury when you would not have otherwise.

Yeah, for sure, and I think if you have most runners, again, if you've got an osteocisperience, you'll know when there's a niggle because you've been running for 20 hours and your leg hurts and when there's a pain in your leg because you've torn something. You would hope that people would know the difference, but it's much harder to detect that very fine line if you do stuff on. You know cacodum or other types of analgesics I hope you have analgesics Whereas NSAIDs are, as we've said, non-steroid anti-inflammatory drugs. They're anti-inflammatories, which is the key thing. I mean, we're working in a very different way, so it's important to draw a line in the sand and separate those two things.

I always. My rule is I think I mentioned this on this podcast before if I find ibuprofen or naproxen or leave or whatever in an athlete's draw bag or something like that and I'm current for them I just throw in the trash.

Yeah, don't give them the option.

No, I don't give them the option.

Yeah and I know Some people are saving from themselves.

Well, it's just like. Well, I just need this just in case I'm like, no, you don't, yeah, no, you don't. I don't want to take the risk, I don't want it over my head, there's no excuse.

I think there is more of a lucid argument for basic analgesics yeah, but NSAIDs no question.

Okay, we'll put that one to bed, okay. Last topic is in the paper you and your co-authors good friend Volkler took some time to point out some what's different between different populations and specifically with female athletes and master's athletes, that there might be certain considerations that those groups need to take into consideration when they are looking at their long-term health. We'll talk with the master's athletes first, because that's pretty much everybody in ultra-running. I mean, come on, you look at the demographics, everybody's over 45. I'm about to be over 45 in a couple years, so I'm going to get in that group as well.

Volkler, if you look at the data, most of your peak performance in races between 50 and 100 miles is probably going to occur in your mid-40s.

Yeah, so you guys drew the line at 35, right, which is, people draw a line at 35, 40, 45 or whatever. What specifically do master's athletes need to look at that could potentially cause issues for their long-term health when they're training or racing ultra-marathons?

Well, there's two basic scenarios that you can look at. The first one is a master's athlete, so somebody over 35, but typically this could be somebody over 40 or over 50, who's having something of a mid-life crisis, and some of them have never exercised before they give up smoking and they start doing ultra-running. And this is a recipe for disaster, because there may be pre-existing conditions that maybe haven't manifested, they're not conditioned, and that they basically jump in at the deep end and it's kind of asking for trouble. And so that's kind of one scenario you're looking at. The other scenario is somebody who started running ultra at a kind of a much younger age maybe somewhere between 20 and 30, and they've been running for 20 to 30 years. And in those people, because they've been endurance training for such a long period of time everything that we've been discussing for the last 45 minutes there is the potential for chronic maladaptations in a small subset of people. So you just need to take precautions to make sure that you don't fall into that subset and if you do, you've scouted it out and you're taking the appropriate steps to minimize your risk.

So those are kind of the two types of master's athletes and, as you've said, kind of the average age of an ultra runner is probably somewhere between 35 and 55.

And there was a great paper published by B Nestle and Nicolides back in 2018, physiology and Pathetic Physiology and Ultra Running. And one of the things they did right at the start, they produced a bunch of tables and looked at the average age of peak performance in the different race distances. What we basically find is that, from the shorter races of 50K, the average age of peak performance is like 35 years old, and then, as you go through the higher distances, you get up to 100 miles, the age of peak performance is like up to mid 40s. So did your age of peak performance increases concurrent with the race distance.

You know it's interesting when you mention those two different types of master's athletes Because in my coaching practice the first couple of years of coaching athletes in either one of those groups looks markedly different. I could have a 40 year old that comes into ultra running from no exercise background bull ride. I had this guy who was a professional bull rider for many, many years and then he came into running and was not. He did not use endurance as part of his bull riding training, which is probably part of his problem. That's another story. But his training looks markedly different than the 40 year old that has 20 years of endurance running experience. Whether it's high level training or not, and kind of. The fundamental way that they're different is in the first category. The 40 year old that doesn't have that type of experience is.

You're just checking a lot of boxes at the beginning, like are they good candidates for training? You don't know what their training strengths and weaknesses are. So all of those things that you pick up from previous training patterns with the latter group that has all that training history you don't have. So you're guessing a lot more. So you've got to put these checks and balances in the beginning. From the first place. They might do the same overall mileage, but the architecture and the way that you're analyzing the training I've always found is a whole lot different.

Yeah, and there's this ongoing debate with regards to screening, and Mimolavine is kind of prominent in those debates and I won't get myself in hot water by making a stance on the side of the fence. But I think if there is a bit, the base is, very briefly, what we can't do is just advocate widespread screening for everybody Because we don't have the infrastructure. The economic burden of that is going to be unrealistic and it may not be necessary. It could cause more harm and good in some respects. But I think if an argument can be made for screening, it's more likely to be in masters, athletes or people who are the other high risk groups.

So if you have somebody who is an older athlete and we're not talking about masters over 35, we're talking about somebody who's maybe in there In the 40s, 50s, maybe late 40s, 50s, who's never done an ultra before, it might be sensible to have a full health screening before you go and do your first ultra. And at the other end of the spectrum, there's some really interesting we can call it preliminary data because it's in small samples the data for a really nice study published in 2011 that Greg White was involved with, and what they essentially found was they did some cardiac MRIs in 12 lifelong ultra marathon and ultra marathon runners. So they've been doing this for a number of decades. What they found was that the prevalence of myocardial scarring, so myocardial fibrosis, was about 50%. So they found considerable amounts of myocardial fibrosis in six out of the 12 athletes. When you compare that to aged match controls, who weren't lifelong ultra runners, prevalence was like zero, maybe borderline one out of 12.

So it's only 12 subjects.

But if you can make an argument for doing screening in ultra runners, maybe it's in those people that have been doing it their whole lives and maybe over a higher risk of myocardial fibrosis.

Well, as we talked about earlier, that's more, maybe more likely. What was the word that you use? Potentially caused by the racing over that long period of time? Right, those extreme perturbations in our way from baseline that the racing actually causes? That might actually be interesting to compare those groups, right? The people who've just chronically trained that's almost been Levine's earlier study that you mentioned earlier Trained for 30 hours a week and didn't do any racing, or trained for 30 hours a week and did do the racing. What is the incident rate between those two groups? That'd be a cool.

What we really need is this longitude or a large epidemiological study that looks at a thousand veteran or lifelong ultra runners and just starts a bunch of cardiac MRIs and just looks at what's going on, because at the moment we've only got studies in the self-reported data or small samples like this one, which is interesting, doesn't really get to the root of the question.

Okay, last group Female athletes. Ironically enough, before I actually reached out to you to set this podcast up, I wrote an article about this earlier. This arrow keeps. All the indicators keep pointing to this same arrow over the last four years that any endurance athlete, and in particular, ultra marathon female athletes, need to be extremely cognizant of their total energy availability. And one of the one of the great and for any female athletes out there.

If you don't want to read this whole paper, go and read section 6.3 in this paper because it will point this, this aspect, out very clearly. It'll take you two minutes to read. It reinforces the concept very well that female athletes tend to have. They tend to be more susceptible and tend to have higher negative consequences or more severe negative consequences to low energy availability as opposed to men. I kind of summarized the section for you and I wanted you to do it. I don't know where to go. So, nick, like you, take it over, like, like. Why, like? Why is this the case and what do we actually see within the ultra, the female, ultra marathon population, of why this becomes a big issue?

Well, this is an ongoing problem, not just in, as you'd expect, it's, not just in ultra sport, but in any kind of endurance sport. You can look at you know people competing in 10k races, 1500 million runners, female runners. They are at a high risk of suffering the same problems. The reason why it is potentially more of an issue in ultra is because of the extremely high mileage and the high exercise durations, so the the energy expenditure is much more likely to exceed the energy intake. So anytime you have kind of even short periods of insufficient energy intake, it can affect physiological functioning in males and females. So this idea of relative energy deficiency in in sport or rents for its syndrome, it affects males and females because anytime that you have insufficient energy intake affects your ability to recover. The reason that it has more prominent effects in females is because of the interaction of energy intake with bone health and menstrual cycle. Okay, and that's kind of the key difference between males and females. So it does affect both groups, but because of the downstream effects the energy intake has on basically the concentrations and this kind of the synergy between the two. So we need to look at this and consider this more carefully in female athletes. So we've. Everyone knows about the female athlete triad, her orders they should, and if you're a female athlete you should definitely know about the female athlete tribe.

This is kind of this idea that there is this interplay between three important components of a triangle.

The first one is, as we've said, energy intake, or calorie balance, and this idea that if you're burning a lot of calories through your training and through your competing, you need to make sure that you get insufficient calories to fuel basic metabolic function, to fuel recovery. If you're not getting in enough calories, you'll know that because you'll start losing weight. Specifically, you'll start losing body fat, and sometimes that is a deliberate decision that somebody's made to get leaner and sometimes it's inadvertent. They're just not thinking carefully enough about their energy intake and they end up losing weight. The other, the second kind of component of that triangle, is bone health and, more specifically, bone mineral density. Bone mineral density is affected by the third prong in that triangle, which is estrogen concentration. So if you have an amenorrhea athlete, that's going to have more profound effects on estrogen concentrations and if you have insufficient energy intake, that's going to affect your estrogen concentrations and that puts the athlete at an increased risk of poor bone health and, in turn, stress, fractures and other musculoskeletal injuries.

Well, and then when you think about it from like a really practical training standpoint, one of the features of ultramarathon training are these big swings in volume. When you look at it on a day-to-day basis or even a three-day rolling basis, right, you might go out and run an hour for your easy run and then three, four, five, six hours for a long run. And you don't see that in other endurance sports. Maybe you could say you see that in like Ironman triathlon where they're doing those longer bricks that get into the three or four hour range. But ultramarathon is really unique in that that the energy expenditure that you're that is specifically from the activity can be 3x, 4x, 6x, sometimes even 10x from your normal baseline.

And for athletes to get a fix on the energy intake that they need to consume to cover for that maybe not within the day, maybe over a two or three day rolling period is a hard thing to. It becomes really problematic to get a fix on and the athletes that are really pushing that at the edge then become susceptible to this week over week chronic energy deficit. That then wrecks havoc on their entire system and that's one of the reasons that, from a practical standpoint, I leave a lot of these fasted and carbohydrate or sorry, fat oxidation strategies just on the table. Because if you can't get energy balance right fundamentally, why would you try any of these advanced interventions to like further? You know, kind of like that could potentially further perpetuate those problems.

What is the benefit to risk ratio Exactly?

What is the benefit of, you know, nailing a keto or low carb diet or you know, any other fat diet or taking a particular supplement, when actually the potential risks of getting that wrong, particularly if you've got a very, very high, you know mileage output?

As you said, you need to, first and foremost, focus on the biggest challenge, the biggest nutritional challenge the ultra-ronus phase is getting sufficient calories. We had a three hour chat about this last year sometime. But that's the thing to focus on first. And you know, when you look at the prevalence of stress, fracture, injuries, it is higher in ultra-ronus because of the high volume and if you look at the average numbers, depending on the report, it's somewhere between 5% and 10% on average overall, but it's like 20% in females and that's because they are at a higher risk group. And as we wrote in the paper very succinctly at the end of that section, is failure to consider these differences in the design of female specific training programs may have a negative impact on athlete longevity and that's what we've got to avoid, particularly in these potentially high risk groups.

Very succinct right there. So, above all else, make sure you have adequate energy intake to cover the output. We talked about this last time on the podcast. You're an advocate for using heart rate based training to get a fix on how much caloric expenditure you're actually going through. The intake side is always more problematic, though, and the registered dietitians. I'm going to speak for them because I have a lot of those colleagues. They pull their hair out because of the reporting becomes so problematic. But I just tell athletes, you got to try. Download an app there's, you know, five or six of them out there work with a registered dietitian and just get a close fix on it, because the education is going to. The education in of itself is going to raise the level of your knowledge, and that you're just, you're just putting up more armor at that point for your training. Your training is going to be more effective and you're less likely to experience any of these negative side effects just by going through that educational process.

Well, people think they just have to go out and train, get the miles in, and that's the most important thing. But that's like one piece of the puzzle Because, as you well know, training doesn't make you fit. Recovering from training makes you fitter, and people forget this time and time again. So you go and put the miles in, but then you've got to think. You've got to put equal effort, equal time and effort into your nutrition and getting that right, and equal time and effort again into other aspects of your recovery, like your sleep. And you've got to do that again, thinking about your mental health, because you're so having physical health if you don't have mental health right. So you've got to try and balance all of these things and it's they're all equally important parts of a very complex equation that you're trying to balance. And, yeah, it's not easy, but you've got to put in the time and think about all of these different balls that you're trying to juggle 100%.

It's not just about the running right.

I wish it were, but it's not that simple. You can't just put on a pair of runners and just go and run your body into the ground, because you'll do it for six months and then you'll have a year off from injury.

Yeah, usually it's. It's the duration, right, it's the duration that catches up with people, usually six months a year, maybe two years. You can kind of get away with those bad practices, but then eventually they kind of catch up with you.

If there's a weakness, if there's a weak link in somewhere along that process, it will be exploited and exposed by ultra endurance training

.

This was awesome, nick. I'm going to obviously leave a link to the paper in the show notes. You cleverly put up your author copy. I noticed. What's the deal with that? Does it get, like blocked, if the official copy gets blocked for a certain amount of time but then you can upload a previous author copy or something? That's how.

I got to hold it. That was inadvertent. Maybe it's like it's free for a month or something, I don't know. Don't tell the people. At spring We'll see.

Anyway, a link to it will be in the show notes. It's great paper. Thank you for doing it. I'd be remiss not to go back and forth with you just a little bit on some of the debunking that you have been doing since the Olympics ended, on all of these different areas. Pick your favorite one that you just want to go on a little bit of a tangent. I know I'm putting you on the spot right now, but you just came out with an article. Was it in Triathlon Magazine or Triathlete Magazine?

Yeah, that was an interview I did with Susan Lac, who's editor she's just become editor of Triathlon Magazine and Porter's at Triathlete Magazine.

Yeah, Triathlete Magazine.

She's done a great expose on some of the pseudo science that's so pervasive in health and sport. I've done a whole bunch of stuff since the Olympics. I wrote an article in the conversation which got lots of feedback all positive, negative from people who like cupping and chiropractic and other bullshit alternative remedies. Everyone else thought it was a great article. Then I did a talk for Skeptical Inquirer Magazine which you can find. I tweeted it a couple of times but it's on YouTube If you look up Center for Inquiry and I think the talk is pseudo science in exercise and sport.

It's like a 45-minute lecture with a Q&A at the end. I really go to town on the exact pseudo science in exercise and sport because we're dealing with all the science. To answer your question, if there was one that I really they're frustrated me more than the others, it'd probably be something like chiropractic or cupping Chiropractic. Probably more so because chiropractic somehow has kind of smuggled its way, snuck its way into mainstream practice. A lot of people go and see chiropractors without realizing that it's a complementary and alternative medicine. They think it's part of mainstream practice but it's actually a very niche alternative when you actually look. I'm a scientist and I never apologize for the truth. I always point my nose in the direction that the evidence suggests, because that's the strength of science.

We don't look at Haneck, though we're not really interested in the it worked for me argument, that kind of defense. What we look at is high quality, controlled studies that are designed to minimize bias and to try and get to the truth of the matter With chiropractic. When you look at the evidence there's loads of research on it. The disparity between the claims that are made for chiropractic and the evidence in support of those claims is as big for chiropractic as it is for anything.

Chiropractic doesn't work at all for almost anything. It's so freaking popular People, if they have back problems and neck problems and headaches and they're suffering from stress and anxiety, they often go and see a chiropractor. There are lots and lots of case reports far too many to mention, unfortunately of chiropractic related deaths where people have been killed by a chiropractor who's kind of manipulated somebody's neck and broken the neck or cost of stroke or some other kind of catastrophic injury. When you talk about alternative therapies, you've got to talk about the risk to benefit ratio, which is what you've got to do for all any kind of intervention risk to benefit With actual medical treatments that have proven efficacy.

The physician, the primary care provider, will make a judgment on the relative risks and the relative benefits. But with alternative medicine the benefit hinges on placebo. The only potential benefit of chiropractic is a placebo effect. The risk just can't be justified For me. It's mind-boggling to see how popular it is. But you're sorry for starting me off.

That's why I wanted to get you at least one good rant. I know you're good for more than that, but one good one will satiate my needs for now. The discrepancy between the claims and what the science says about the intervention or the treatment or whatever that has always been one of my longtime frustrations with anything. Nutritional supplements is another big area that you can talk about, where the discrepancy between what this nutritional company is going to claim that their product does versus what the research will say or doesn't actually say about what that will actually do that difference, how wide that chasm is, has always been one of my biggest frustrations as well. I feel you're paid to that area. I'm going to link up in the show notes to all of those different interviews and things like that. If people are curious they want to hear any more of Nick's rants, they can go and check those links out. Thank you, my friend. I appreciate it. We'll have you back on and maybe we'll just do that for three hours.

Hey, my pleasure. That was a lot of fun, thank you.

All right, folks, there you have it. There you go.

That wraps up another episode of the Coupecast. Once again, thanks to Nick for coming back on the podcast for your third time. You make my job really easy because I can just throw all these questions and you run with them and you know the science so well and it's just incredibly relatable to the audience. Hope everybody had fun listening to this episode of the podcast.

We are closing in on almost 100 episodes of the Coupecast. I can hardly believe it. Maybe I'll do something special for the 100th episode. You guys will just have to wait with bated breath. But that gives me a chance to say I appreciate everybody who has tuned in every single week to these podcasts. These podcasts have come to you advertisement and sponsorship free.

That was a commitment that I made to the audience and I made to myself from the onset of that podcast. I've honored that commitment for nearly two years to date, right now, and the reason I do that is to make the information that is contained within all these podcasts as unbiased and unadulterated as possible. So you can help the podcast out by sharing it with your friends, family, your running partners, your colleagues, whoever you think would benefit from this information. Just go ahead, pass the link along to them. You can also leave a rating or review on Apple podcasts. I almost said iTunes Apple podcasts. Those mean a lot to me as well and helps the podcast get exposure. But, most importantly, I just appreciate people tuning in. I love seeing you guys out on trail and hearing feedback when I get out into the community or online. So I do appreciate the heck out of each and every one of you and, as always, we will see you out on the trails.