Potential Long Term Health Effects of Ultramarathon Running with Nick Tiller PhD | Koopcast Episode 98

trail and ultra runners what is going on what's happening welcome to another episode of the KoopCast as always i am your humble host coach Jason Koop and on the podcast today we have some big picture discussions lined up for you is all about the potential long-term health problems and key word in that statement is potential of ultra marathon running and ultra marathon 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 volkler sheer who is part of the ultra sports science foundation nick was one of the co-authors on this paper and the title of it is potential long-term health problems associated with ultra endurance running a 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 it seems to come around every few years we talk about the last time that this narrative came around uh kind of in the intro of this podcast and the second thing and more tragically uh 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 ultra marathons 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 is 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 i found this hard copy of this book do you remember when this book came out the haywire heart yeah it's only a few years ago wasn't it i think it was 2016 and um kind of there's two reasons that i

want to use it as an 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 uh we use the same publisher so the first edition of my book use the same publisher uh 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 you know endurance is going to kill you it seems like every four or five years this narrative starts to um starts to come back up and the combination of the the fact that we have the same publisher in addition to that just the title and i'll read the title for the the people that are that are listening to the podcast version of this it's called the haywire heart which is by chris case john mandrola and leonard zinn leonard zinn is a long time cyclist has 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 past 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 i'm almost kind of surprised that the second part of that subtitle was it in smaller uh smaller font just to like hide it even more but the the 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 was was still kind of doing very well at the time and even on the on the cover they've got that you know they've got this they've got these images of all three of the different endurance disciplines uh across the front so it kind of spoke to it kind of spoke to everybody and what ended up the totality of the book is what 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 cardiologist visit and things like that and so now here you go four or five years later right on cue with you and your colleague buckler 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 you're absolutely right in the title they have they create the problem with the title itself they create the problem and then they're like well here's the here's the solution yeah you know so they're catastrophizing the whole thing and then and then providing a solution to it which i think is you know it's a little irresponsible but i understand why

it's it's business and you've got to sell books of course and um no generally the i haven't had too much negative feedback from the paper that 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 will that make you happy you know which is obviously it's a slippery slope fallacy but it's also presenting it as like well either there's either we go we we go and do 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 it's still not going to be as extreme as going out and running for 24 24 to 48 hours two to three times a year but um but you know i'm used to getting it in the net from people because i spend a lot of my time writing about you know tackling chiropractic and cupping and people who are very zealot about these um alternative therapies so yeah that that stuff doesn't bother me but you know what we wanted to do with this paper and that's the difference here is that i'm not i don't get paid for writing these papers certainly certainly not directly not in 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 exercise is good

for you reduces the risk for all cause mortality reduces risk of cardiovascular disease being active being physically active doing exercise 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 ultras for nearly two decades and as an ultra runner i want to get more people running i want to get more people participating in this 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 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 trade-offs that you get for training as hard as a lot of the athletes that are in this space have 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 net positive you should go ahead and do them they might be net 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 is 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 a system 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 uh system is affected by ultramarathon training and then you took uh what i thought was a really unique approach where you looked at uh i hate to say the word special populations but just like different populations that might be understudied um and pointed out some differences uh within those uh within 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 uh 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 what 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 you know we talk about cardiopulmonary function for example you know how the the 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 it 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 and kind of create that arbitrary um 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 yeah and we went back and forth and whether it is a two wordy whatever but whatever but actually including the word potential in there and we use we litter it throughout the manuscript because these are potential 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 uh respiratory to a to a lesser extent and perhaps renal as well but the one the main one that people are concerned about and this is probably why the the book you mentioned was so popular is because cardiovascular system the heart and the blood vessels have a really important role in the body you know the the circulatory system literally keeps us alive pumps blood and oxygen to the various tissues and if that system failed in fact if any one of the systems systems failed you've got a problem the cardiovascular system you know the heart and blood vessels really do kind of strike us as one of the more kind of um 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 uh 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 what always strikes me when i look at this is the proportion of of endurance athletes we'll kind of scale it down from ultra marathon athletes but endurance athletes that present 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 you know 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 in those in those in that in 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 that's over one per page so potentially could 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 the 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 and it's not been explored enough we need to kind of really zone in on answering this question because the 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 at the moment we can't answer there was a really fantastic study published by ben levine's group um in the last year or so have you have you spoken to ben not since not since i had him on the podcast no i want to bring him back i want to bring him back to talk about stuff like this though so so the long-time listeners remember i 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 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 this long-term follow-up and a really comprehensive cardiovascular assessment they did 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 kind of calcified deposits in the uh in the blood vessels that actually supply the heart with blood than the heart itself and as i said they they looked at over 2 000 extreme exercises now these are not ultra endurance athletes and they're not professional athletes they just love exercise and they do something up something like upwards of 30 hours a week oh okay which is which is which is a lot of exercise i think even for most ultra runners yeah you know 30 hours a week would probably be enough to satisfy all of your training requirements and so they do a lot of exercise 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 you know upwards of 30 hours a week and it's not going to have negative implications on morbidity and mortality but this is 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 of training you're also going out a couple of times a year and you're running for a day or two days i mean how you know from your athletes how many times a year do they typically race three maybe four okay so 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 like a typical 100 mile race like UTMB for example so it's 10 000 meters of ascent it's a very very hard race to good athletes will still take 30 hours to finish that 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 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 their right mind is going to think well that that's going to be good for you there's there's got this 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 seven hundred milers this year alone that's an awful lot of racing and particularly you know the hundred mile races are at the definitely at the extreme end of the spectrum most ultra runners probably won't race hundred milers and if they do they won't do them very often and uh 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 uh she's 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 it 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 with 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 exercisers 30 hours a week which i agree that's a lot of training that's like iron man professional iron man level training and they're not finding any issues with their cardiovascular system with their cardiac system however so if 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 there's kind of another thought there's another line of thought around this as well which kind of follows that similar deductive path okay 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 in 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 okay 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 is the logical answer right yeah sure and it's really difficult to do because ultra endurance sport and 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 forward at all i mean we had this wonderful string of studies

back in sort of 2009 2010 and 11 from andre lagersh's group and uh i mean i've got some of the papers up here which we cited in our review yeah the gersh's group and uh jessica scott with keith george and rob shaven those guys and they did this great string of studies looking at you know fairly small sample sizes but looking at the the cardiovascular implications of competing in either an ultramarathon or ultra triathlon which was ironman and you know finally looking at it mechanistically and looking at what are the structural and functional changes that occur pre to post race and what are the follow-up you know if you do a follow-up a week later do the do these kind of acute perturbations come back to baseline and generally they do but we haven't done a lot of really good work on it since then and there were a lot of unanswered questions so you know for example that this study in particular that was published back in 2008 and again this is from audrey gersh's group and they took 26 athletes who had done an ironman triathlon and they took some blood samples pre and post and they looked at these biomarkers of cardiac damage it's kind of debated whether the markers really reflect cardiac damage but but it's kind of like troponins and bnp 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 had returned to baseline so they had 26 athletes and they looked at left ventricular and right ventricular function and they looked at these biomarkers in the bloods and pretty much everything had returned to baseline a week after the event which is which is great news except in one athlete where right ventricular dysfunction had persisted even one week after the event now actually there was only one line in the in the paper you know they don't really explore it in any in any sufficient detail and it's easy to just kind of gloss over that that one athlete that 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 iron man you know a couple of months later or does the third iron man 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 stimulation so they're obviously not recovering as quickly so with repeated stimuli is this the individual that is you know one in 25 who is going to potentially uh you know exhibit with these these cardiovascular abnormalities after a decade of of training and racing and that's we've got to do more

work in that area as well to to kind of pull out the ones who are potentially more susceptible and it 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 right if you think about homeostasis right you're not removing you're not moving up and down the homeostasis ladder all that much in any one single training bout but a race race particularly iron man particularly ultra marathon 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 when when you're doing that the most well think about the race the race duration okay typical marathon runner and this is kind of if you're not looking at ultra endurance sport but the kind of the next peg down if you like is marathon running you go out and train for marathon even if you're not elite you might you might still go and run 20 miles 22 miles if you're running your first marathon it's recommended well you're the coach you tell me if you disagree it's recommended probably go and do at least 20 to 22 miles so you get it go ahead that's that's the formula that's the put 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 okay but but still you you're going to try and you can get close to the distance okay you could argue that that last 10k is what does the damage but okay even 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 met 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 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 it's it that's one of the things that makes ultra marathon so fascinating so okay we've got the we've got the cardiac system right and there's this we're not going to come up with any like brilliant answers here but i want to give people information to where they can actually kind of track things down and i think looking at things post-race might be a good way to to to start to do that what are the other like 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 or or repeated ultra marathon training so i think the respiratory system is another one that for which there is potential for long-term mal adaptations probably the 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 probably not greater for ultra than you would expect for other types of endurance training so that so when you when you compete in a in

any given ultra race and you see similar kind of responses for marathon but it's it's kind of exacerbated in ultra we see this 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'd see similar responses if you were to do a triathlon or a marathon and for the for the most part these these changes are not clinically significant in most people okay so you'd get this significant reduction but it's not 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 there 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 starting from a lower exactly they're starting from a lower baseline so if you have somebody with below average you know below average baseline function and then they drop by 20 percent they're now getting into this kind of region where we might be a little bit concerned from a clinical perspective but most marathoners

if they don't have a pre-existing respiratory disorder like exercise induced asthma or kind of regular asthma and you know most of the time they don't have you know COPD there are some COPD athletes but for the most part if you have chronic obstructive pulmonary disorder you're not going to be in you're not going to be running marathons and doing triathlons for most people it's not clinically meaningful but what i will say about that is it's always if you're unsure or if you're if you're competing in your first ultra it's always a good idea to maybe go and get screened 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 burnt 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 up a mountain or when you're you know traipsing through the desert because you know medical assistance as good as it is in most of these races if you are halfway up a mountain you don't want to start having some kind of um you know some 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 but to kind of finally answer 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 the stress and strain that causes inflammation in the airways and this can happen whether or not you have asthma 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 uh 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 i'm repeated 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 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 quite rightly say it's the duration 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 suggests that the prevalence rates of exercise induced asthma are probably not

higher in ultra runners than they are in 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 ultra runners prevalence of about 11 olympic athletes you're looking at 20 something like this we've got very limited data the only data we have on this is uh was a survey done by um marty hoffman and they looked at over 1200 ultra marathon runners and self-reported prevalence of exercise induced asthma was about 11 percent you have to take those data with a pinch of salt because it's self-report and you could argue either way you know individuals who who respond to these types of surveys maybe they have you know 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 you know so it can kind of swing both ways yeah that data that data has been brought up when the tu e controversy with inhalers at the olympic level right because the diff the discrepancy between the number of olympic level endurance athletes that have asthma right and are applying for a therapeutic use exemption to use usually it's a you know usually it's some sort of inhaler to to to treat that as so much higher than than the general population or even when you subsect the general population into like recreational endurance runners people kind of look at that and

you know they get the skeptical snake eye and think that's that something's a right but interesting that that the highest prevalency 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 airway so if you exercise in an area with high pollution you know that can have a negative effect as well you know climate change is real folks and it can have a you know downstream negative effects if you're doing very high volume training you know 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 it's not going to have a positive effect on in fact they've done some studies recently on this it's absolutely fascinating that the the long-term effects of exercising in a highly polluted area could 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 covet is going to be tough you know that's that's why treadmill sales have gone through the roof yeah exactly all those indoor all those indoor exercise equipment um 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 down 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'll say about all i will say about it is that i absolutely support the fact that they've banned the use of ns i think we'll talk about nsets and you know allergies it's something slightly different it comes into play when we're talking about renal issues that's the other thing that we can touch on very briefly is the potential for long-term uh renal problems because this is something that's more prevalent potentially in ultra endurance sport because of the stress that you're putting the renal system under and banning nsets is a fantastic move because there is more than enough data now to show that nsets have this really negative consequence on on the way that the renal system functions basically blocks prostaglandins which which restrict blood flow to the renal system and when you're doing an ultra we've segued nice you know smoothly seamlessly it's all good renal function but uh you know when when you do an ultra race and particularly the really long ultras and this is why ultra is just 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 you know and everything in between but uh when you when you do an ultra you're 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 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 hypernatremia 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 n sets on top of that that that increases the renal stress then you have this kind of cocktail of ingredients that that it's very easy to see why acute kidney dysfunction is 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 of 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 this ultra marathon 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 n sets are present and there it's an exponentially weighted equation at that point right it's not linearly 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 you know there are a lot of medical directors out there and i we should spend some more some more time on this because this 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 that's their almost kind of like nightmare uh 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 and every ultra marathoner 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 consequence of those of those things two or three years down the line and this is an instance where when you're taking nsets 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 you know 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 renal system as you say it's it's not an organ system that that seems to regenerate as as perfectly as optimally as you would like if there is some kind of you know 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 that we didn't mention but very briefly pulmonary edema or extravascular lung water is a common response to strenuous exercise we see it very frequently after marathon and after 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 get left ventricle hypertrophy this is a normal response to endurance training left heart gets bigger and stronger can pump more blood out with with each contraction but the right ventricle

seems to maybe not repair itself quite as effectively the the long-term implications seem to be more pronounced in the right ventricle 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 for the listeners are stay hydrated and don't take nsads they're really that absolutely really that simple yeah pretty much yeah obviously don't over drink drink the right amount of fluid for you and if you're serious about your ultra running you should know what that is and don't take nsads there's a reason you know i fully support that the fact that they banned nsads i hope other organizations follow suits i'm not so sure about the banning of analgesics altogether i understand why they've done it they don't want people masking symptoms masking pain there's issues with that but nsads there's no debate there we should we should differentiate between the two colloquially so nsads would be something like aleve or advil ibuprofen naproxen 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 yeah avoid aspirins avoid any kind of nsaid the uh colloquial names are different in in europe and and in the us so i'll take your word for that in the in the europe it's like ibuprofen is uh it's the most common nsaid so you want to avoid answers analgesics like tylenol in

europe it's paracetamol it's the same stuff and uh these are just analgesics these are just just pills usually pills or capsules that mask the pain the yeah so the difference and i think that we should point this out the difference is the nsads 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 if you've got enough experience you'll know when there's a 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're dosed up on you know cocodomol or you know other other types of analgesics you know opioids and analgesics whereas an nsads are um as we've said non-steroid anti-inflammatory drugs they're all they're anti-inflammatories which is the key thing and they work 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 uh uh draw bag or something like that and i'm crewing 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 for 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 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 it's an incense no question okay we'll put that one to bed um okay last topic is in the paper you you you and your uh co-authors uh good friend volkler took some time to point out some what's different between different populations and specifically with female athletes and and and masters 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 masters 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 in that and just hitting your peak as well if you look at the data you know most your peak performance in races between 50 and 100 miles probably going to occur in your mid-40s yeah and so you you guys drew the line you guys drew the line at 35 right which is you know people draw a line at 35 40 45 or whatever what what specifically though do masters 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 there's two basic scenarios that you that you can look at the first one is a masters athletes so somebody over 35 but typically and this could be somebody over 40 or over 50 who's having

something of a midlife crisis and they've probably some of them have never exercised before they give up smoking and they start doing ultra running and this is uh this is a recipe for disaster because there may be pre-existing you know 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 you know 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 you've scouted it out and you're taking the run you know the appropriate steps to minimize your risk so those are kind of the two types of masters athletes and as you've said kind of the the average age of an ultra runner is probably somewhere between 35 and 55 and 55 and there was a great paper published by b nestle and nicolaitis back in 2018 physiology and pathic 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 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 uh 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 masters athletes 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 partly 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 high level training or not and kind of the fundamental the 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 those things that you pick that you can pick up from previous training patterns with the 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 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 a whole lot different yeah and there's this this is ongoing debate with regards to screening and ben levine is kind of he's a you know he's he's really kind of prominent in those debates and i won't you know get myself in hot water by making a stance you know on either side of the fence but i think if there isn't the the base very briefly is what we can't do is just advocate widespread screening for everybody because we don't have the infrastructure we don't you know is the economic burden of that is is going to be unrealistic and it may not be necessary it could cause more harm than good in some respects but i think if an argument can be made for screening it's more more likely to be in masters athletes or people who other other high-risk groups so if you have somebody who is an older athlete and we you know we're not talking about you know masters over 35 we're talking about somebody who's maybe in their you know 40s 50s you know 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 you know there's there's some really interesting we can call it preliminary data because it's in small samples the data for you know really nice study hit much in 2011 um but uh greg white was involved with and what they essentially found was they did some cardiac mris in 12 lifelong uh ultra marathon and ultra marathon runners so they've been doing this for a number of

decades and what they found was that um that the prevalence of myocardial scarring so myocardial fibrosis was about 50 so they found considerable amounts of my myocardial fibrosis in six out of the 12 12 athletes when you compare that to aged match age match controls who weren't lifelong ultra runners prevalence was like zero maybe you know borderline one out of 12 so it's only 12 subjects but if you can make an argument for doing screening in 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 is the word that you use potentially caused by the racing over that long period of time right those extreme perturbations in away from baseline that the racing actually causes that that might actually it'd be interesting to to compare those groups right the people who've just chronically trained that's almost ben 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 what we really what we really need is this a longitude or a large epidemiological study that looks at a thousand veteran or lifelong ultra runners and just does a bunch of cardiac mris yeah and just looks at what's going on because at the moment we've only got studies either self-reported data or small samples like this one which is

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 uh earlier it's it this arrow keeps get all the indicators keep pointing to the same arrow over the last four years that any endurance athlete and in particular ultra marathon 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 and i think it reinforces the 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 as opposed to men i kind of summarized the section for you and i wanted you to do it so now 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 uh you know people who are competing in 10k races 1500 runners female runners they 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 the physiological functioning in males and females so this idea of relative energy deficiency in um in sport or reds 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 concentration and this kind of the synergy between the two we need to look at this and consider this more carefully in in female athletes so we everyone knows about the female athlete triad how always they should and if you're a female athlete you should definitely know about the female athlete triad but 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 or calorie balance and this idea

that if you're burning a lot of calories through your training and through your through your competing you need to make sure that you get in sufficient calories to 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 that 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 concentrations if you have an amenorrhea athlete that's going to have more profound effects on estrogen concentrations and if you 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 um you know muscular speeds and injuries well and then when you think about it from like a really practical training standpoint one of the one of the features of ultra marathon 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 ultra marathon 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 two or three day rolling period is is a hard thing to it it becomes really problematic to get a fix on and the athletes that are really pushing that at the edge then become susceptible susceptible to this week over week chronic energy deficit that then kind of 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 and and carbohydrate ox 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's the benefit to risk ratio right exactly what is the benefit of you know nailing a keto or a 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've said you need to first and foremost focus on the the biggest challenge the biggest nutritional challenge challenge ultra runners face is getting sufficient calories i mean you know we had a three-hour chat about this last last year sometime but but that's the thing to focus on first and you know when you look at the the prevalence of stress fracture injuries it is higher in ultra runners because it's a high volume and in if you look at the average numbers depending on the report it's somewhere between five and ten percent on average overall but it's like 20 percent in females and that's because they are at a higher they're a higher risk group and as we wrote in the paper um 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 high risk 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 many how much caloric expenditure you're actually going through the intake side is always problematic more problematic though and the registered dietitians i'm going to speak for them because i have a lot of those 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 registered dietitian and just get a close fix on it because the education is going to the education in and of itself is going to raise the level of your knowledge and that you're just are 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 fitter 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 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 uh 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 it's not that simple you can't just put on a pair of runners and and just go and and run your body into the ground because you'll you'll do it for six months and then you'll have

you know 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 yeah this was awesome nick uh i'm gonna obviously leave a link to the paper uh in the show notes you cleverly put up your author copy i noticed what's the deal with that does it get like blocked the official copy gets blocked for a certain amount of time but then you can upload a a previous author copy or something that's how i got that was 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 springer we'll see we'll see anyway so a link to it will be in the show notes it's a 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 um debunking that you have been doing uh since the olympics ended on all of these different areas so 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 is it was it in triathlon magazine or triathlete magazine yeah that was an interview uh i did with susan lack who's editor just become editor of triathlon magazine and um board is it triathlete magazine and uh and she's kind of done a great expose on some of the pseudoscience

that's so pervasive in health and sport and i've i've done a whole bunch of stuff since the olympics i wrote an article in the conversation which got lots of feedback or all positive negative from people who like cupping and chiropractic and other you know bullshit alternative remedies but you know everyone else thought it was a great article and then i did a talk for the skeptical inquiring 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 it's i think the talk is pseudoscience in exercise and sport and it's like a 45 minute lecture with a q a at the end and i really go to town on kind of the the um yeah exact pseudoscience in exercise and sport because we're dealing with it all the time if there was one to answer your question if there was one that i i really that frustrated me more than the others it'd probably be something like chiropractic or cupping chiropractic probably more so because um chiropractic somehow has kind of smuggled its way snuck its way into mainstream practice and a lot of people go and see chiropractors without realizing that it's a complementary and alternative medicine you know that they think it's mainstream part of mainstream practice but it's actually it's a very you know it's a very um niche alternative and when you actually look you know i'm a scientist and i i don't i never apologize for the truth i i always point my nose in the direction that the evidence suggests because that's the strength of science right we don't we don't look at anecdote 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 and with chiropractic when you look at the evidence there's loads of research on it the 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 and it's so freaking popular and people if they have back problems and neck problems and headaches and uh you know they're suffering from stress and anxiety they often go and see a chiropractor and 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 you know manipulated somebody's neck and and um you know broken the neck or caused a stroke or some other kind of catastrophic injury and um you know when when you talk about alternative therapies you you you've got to talk about the risk to benefit ratio which which which is what you've got to do for all right any kind of intervention risk to benefit now with actual medical treatments that you know have proven efficacy the physician you know 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 and the risk just can't be justified so it's just for me it's it's mind-boggling to see how popular it is the and um yeah but you're sorry for starting me off that's why hey man i wanted to get you at least give one good rant i know you're good for more than that but one good one will satiate my my uh 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 long-time 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 or doesn't actually say about about what that will actually do that that difference how wide that chasm is has always been one of my biggest frustrations as well so i feel you're i feel you're paid to that area i'm gonna link up uh uh in the show notes to all of those different interviews and things like that so 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 will just do that for three hours hey my pleasure that's a lot of fun thank you all right folks there you have it there you go that wraps up another episode of the KoopCast

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 out these questions and you run with them and you know the science so well and you 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 KoopCast 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 of 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