Is there such a thing as TOO MUCH ENDURANCE TRAINING?

Introduction

After close to 30 years away from Queensland’s Gold Coast, I’ve returned to the beach to live and take up work as Professor and Head of Exercise and Sport Science at Bond University. I’ve also reconnected with a number of training buddies from the surf lifesaving and (very early) triathlon scenes. I’ve been amazed at how many of them have had heart-related issues. Indeed, three of them, including a former world champion age group triathlete, now have pacemakers inserted to keep their heart rates down and regular.

I’m just over 60 years of age now and am starting to think ‘will I be next?’. So I did some reading on what the research says about this relatively newly-discovered phenomenon that suggests too much high intensity endurance training over too many years may be pushing your luck when it comes to the ticker. I found that chronic exposure to high levels of endurance training over many years and at high intensities may lead to adverse cardiovascular outcomes in some people. These negative outcomes include loss of the benefit of living longer, atrial fibrillation, pathologic heart remodelling and even atherosclerosis or hardening of the arteries, something we always thought endurance exercise prevented. Let’s look at each in turn.

1. Too much strenuous exercise and competition over too long a period of time may lead to increased mortality. A study of 1098 joggers published in 2015 showed that, as expected, joggers who trained lightly or moderately had significantly improvements in mortality. However, those that trained strenuously had death rates similar to those of inactive non-joggers. This supports a classic study published in 2014 where 55, 137 people (13,016 runners and 42,121 controls) across all ages showed that moderate running reduced all-cause deaths by 30% and heart-related deaths by 45% but that in runners running six or more times a week or approximately more than three hours a week, these benefits were reduced.

2. Atrial fibrillation has consistently been shown to be associated with high levels of endurance exercise. Atrial fibrillation is a disturbance of the electrical activity of the heart. Sometimes it’s called arrhythmia or dysrhythmia but it’s always associated with an abnormal heart rhythm. It’s very common in older people and those with cardiovascular risk factors and disease. Now it seems to be appearing more commonly in some endurance athletes who do too much endurance training and competition over too many years. A meta-analysis (a review using statistical analysis of the outcomes of previous studies) is a very powerful piece of evidence in summarising research.  A meta-analysis of prior controlled studies published in 2009 showed the risk of atrial fibrillation on endurance athletes was five times higher of that of non-athletes with men being at greater risk than women. Confirming this finding, a 2013 study of 52,775 competitors in a mass cross-country skiing event followed 919 participants who suffered atrial fibrillation over many years and found those that competed more often and finished with the faster times were more at risk of arrhythmias.

3. Overdoing endurance exercise may lead to heart remodelling. In particular the right ventricle that pumps blood to the lungs appears to be the part of the heart most affected. It’s been suggested that repeated training of high intensity and extended endurance exercise may induce hardening of the right ventricle walls and reduced blood pumping ability of the blood from this heart chamber to the lungs.

4. Atherosclerosis or hardening of the arteries may be higher in endurance athletes undertaking consistently long training and competition. We’ve long known that physical activity reduces atherosclerosis which is the leading cause of heart-related morbidity and mortality in the developed world. Two studies, one in 2008 and the other in 2014, showed that older marathoners had similar levels of atherosclerosis to non-athletic controls, although family history, smoking history and other baseline measures relevant to heart disease were not collected. Some researchers suggest that the repeated stress on the coronary arteries may cause damage to the arteries. When combined with the increased amount of calcium in the blood following hard training or competition, the damage to the arteries may lead to the atherosclerosis.

The Bottom Line

I’m not trying to alarm masters athletes with this ever-increasing body of knowledge. I’m simply raising awareness. We are all different as a result of our genetics, our training and competition histories, our training patterns, and our lifestyles, all of which appear to affect our risk of cardiovascular issues. Based on current research it appears that long-term, high-intensity and long distance endurance training and competition may predispose some people to the above cardiovascular issues. If in doubt, do as I do. Speak with your family doctor about it, read about it, and maybe, as I now do as a result of lessons learnt from training mates, visit a cardiologist and get a yearly exercise stress test with echocardiography. These tests look at both the electrical and pumping and structural capacities of your heart. Indeed, I had one two days ago. I do have one risk factor – atrial (the collecting chambers of the heart) enlargement but it’s no different in size to last year. One of the other risk factors is elevated pulmonary artery pressure which appears normal in my case. I also know my other risk factors (blood lipids, blood pressure etc) are all good. Apart from these yearly tests I also treat my heart muscle as I would a swimming, cycling or running muscle. I don’t hammer it each day. I let it recover and rest. So far so good.

I also need to say that the key paper I used to inform this article concluded by stating: At present, there remain no definitive data that support practitioners to advise against ‘excess’exercise in healthy athletes and recreational exercisers engaged in high level and extreme doses of physical and athletic activity. Stay active for life!

Bibliography

 

To Multivitamin or Not to Multivitamin?

Introduction

About 30% of adults in the western world take a multivitamin. Multis alone make up about 40% of all vitamin and mineral supplement sales. However, research evidence supporting the use of multis is mixed at best with recent large population studies reporting no association between use of multis and better cardiovascular or brain health, and only modest cancer protection. In contrast, one 2011 study, the Iowa Women’s Health Study, showed an increased risk of death in women who took multis.

I’m aware of these ‘fors’ and ‘againsts’ and have for year taken a daily multivitamin (and Flaxseed oil – source of Omega 3, 6 and 9). I eat very healthily with plenty of natural cereals, 5 servings of vegetables a day and at least 3-4 serves of fruit a day. However, I’m also very active exercising 1-2 hours a day. My belief is that despite eating a nutritious and well-balanced diet, my multi a day might cover my butt with any dietary deficiencies I may have in vitamins and minerals.

Recently I found a great discussion paper in a journal where four experts from Tufts University in the USA discussed their thoughts on use of multivitamins. One was a professor and director of an antioxidant research laboratory, one a professor of nutrition and contractor to the Office of Dietary Supplements in the USA, one a professor of nutrition science and director of a cardiovascular nutrition laboratory, and the other a professor and director of a vitamin and cancer lab. Collectively, world leaders in the field I feel!

What were the main points raised?

  1. Multis are not harmful and help fill the inadequacies in the average requirements for vitamins D, E and K and minerals magnesium and potassium that about 60% of Americans fail to meet. Moreover, about 40% of them fall short on vitamins A and C. Why are this happening? Because sadly people aren’t eating fruit, vegetables and whole grains where collectively all these great vitamins and minerals are found. In general masters athletes like us tend to be well-educated and eat well. So maybe we don’t need multis if we are eating natural foods and not hammering the junk food and take-aways!
  2.  Not every person needs a multi.Some examples where they might be needed include:
    • the very old and / or frail who don’t eat a lot
    • people with disease or illness who may not eat well
    • athletes who train hard and / or long and are not getting enough energy intake in a day so are losing weight
  3. People who might need supplements such as iron or calcium supplements should be taking these supplements and not a multi. The belief that a multi contains enough of a particular vitamin is wrong. In general, the amount of any one vitamin and/or mineral in a multi is not enough to make up for a problem a particular individual may have. This is where a dietician or doctors input is critical.
  4. If you are shown to have an inadequacy in a vitamin or mineral look for a natural food solution rather than a pill. For example, the intake of the mineral calcium and vitamin D is often found to be inadequate in older people, especially in post-menopausal women who don’t get much sun, including older female athletes. So is low-fat greek yoghurt or increasing your dairy intake a better option? These experts think so!
  5. What about the 2011 study that said women who take multis are at higher risk of death than those that don’t? This study has not been supported by other studies since. Moreover, it did not tightly control for other factors that may have contributed to deaths such as smoking, obesity and pre-existing illness. The consensus at present is that taking multis does not increase how long we live but equally it does no harm either. A recent study called The Physician’s Health Study II tested a complete multivitamin in 15,000 men and actually found a reduction in cancer incidence in those men who took multis. They also controlled for confounding variables like smoking.
  6. Taking too much of a vitamin does not appear to be an issue. Except taking too much vitamin A which has been linked to bone loss.
  7. Bottom line is to personalise your intake of vitamins and minerals based on your nutritional intakes, health status and exercise habits. While a multi may not do any harm, they have small amounts of everything and may miss something you as an individual may need. Chat with your doctor or dietician is my suggestion.

Source:  Should you take a multivitamin? Four Tufts experts tackle the multi-billion-dollar question, Tufts University Health & Nutrition Letter Sept. 2015.

 

Popular Diets and Athletes – Promises, Premises, Pros and Cons!

Introduction

Athletes young and old like diets that promise improved sport performance, reduced body fat, increased muscle mass and improved health. Training mates, social media, TV documentaries and the popular press are abuzz with the latest diet fads or lifestyle plan and what they can do for us as athletes. A recent review by a Professor of Nutrition from the USA examined the premise, promises, pros and cons of four popular diets currently doing the rounds - the Raw Food Diet, the Gluten-Free Diet, the Fast Diet and the Paleo Diet. Here is what she came up.

How do they Rank as Diets?

For the last four years, US News and World Report ranks the best diets from best (ranking 1) to worst (ranking 32) using a nationally recognised panel of experts and specific criteria. Table 1 below shows how the Raw Food Diet, the Fast Diet and the Paleo Diet rank in the eight categories examined.

Table 1: Ranking of the popular diets 2014 (1 = best diet; 32 = worst diet). The gluten-free diet was not ranked but information is available here.

Category

Raw Food Diet

Fast Diet

Paleo Diet

Best overall diet

29

28

31

Best weight-loss diet

2

20

32

Best diabetes diet

23

25

31

Best heart-healthy diet

21

26

31

Best healthy eating diet

31

28

29

Easiest diet to follow

32

18

27

Best plant-based diet

11

Not ranked

Not ranked

Let’s take a look at the four diets in turn and see what the science says about these diest when it comes to athletes and sport performance.

  1.  Raw Food Diet. These diets are frequently vegan diets but can include raw meats, cheeses and milk. Raw foods are defined as never having been heated to greater than 115 degrees F (46 degrees C), never processed, microwaved, irradiated, genetically-modified, or treated with herbicides or pesticides. Premise: Proponents say raw foods are healthier because cooking destroys most of the vitamins and minerals and phytonutrients in foods. Cooking also destroys the enzymes in raw foods which the proponents say are important for good health. Promises: The marketers of this diet say it promotes weight loss, ‘detoxifies’ the body (what does that really mean?), prevents and reverses diabetes, and improves energy levels. Pros: The Raw Diet is rich in fruit and vegetables and thus high in vitamins and minerals. It’s also high in fibre and phytonutrients, low in sugar, salt and fat. It’s great for losing weight as those who use it eat about half their normal energy intake but feel full. Cons: It’s hard to follow and meal preparation can take a long time. Eating out can be hard as even vegetarian meals are usually cooked. Contrary to the proponents who say cooking can destroy vitamin, minerals and other nutrients some foods are more bioavaliable when cooked. These include lycopene in tomatoes. Other vegetables that deliver more nutrients when cooked include kale, carrots, spinach, mushrooms, asparagus, cabbage and peppers. Cooking meat improves digestibility and destroys some pathogens. What about Raw Foods and Athletes? The biggest concern with raw food diets is getting enough energy to train and recover. The other major issue is how to get enough protein so important for muscle repair and growth. Finally, for female athletes, especially older female athletes, raw food diets have been shown to compromise bone mineral density. Research has shown that athletes who consume raw food diest may have shortfall of calcium, iron and vitamin B12 so supplementation may be needed.
  2. Gluten-Free Diet. When current number 1 tennis player Novak Djokovic claimed his ranking was due to this diet, athletes jumped on board. This diet is critical for for the health of people with celiac disease, an autoimmune disease that damages the small bowel and is triggered when gluten is eaten. Gluten is a protein found in wheat, barley, rye and oats and their associated products. This condition effects 1 in 133 americans and 1 in 70 Australians. Recently, researchers have shown some people suffer from nonceliac gluten insensitivity may also benefit from this diet. The food industry has jumped onto this desire to eat gluten-free foods even though people these people don’t have celiac disease or nonceliac gluten sensitivity! Premise: Gluten cannot be digested by a small percentage of the population and thus be eliminated from the diet for good health in those people. Promises: For people with celiac disease or nonceliac gluten sensitivity the diet promises weight loss and good health. Pros: Eliminating gluten found in wheat, rye, barley, oats and semolina and spelt improves symptoms (diarrhoea, constipation, nausea, vomiting, flatulence, cramping, bloating, abdominal pain and others) in these people. Alternative carbohydrate and thus energy-providing alternatives for these individuals include rice, corn, quinoa, millet, potatoes and tapioca. Cons: Athletes without gluten intolerance may be restricting variety and energy-rich options in their diet. Their is NO evidence that a gluten-free diet will enhance weight loss, indeed it may lead to weight gaingiven many gluten-free products coantain higher amounts of fat, sugar and energy than gluten-containing foods. Are we being conned is the question with research from suggesting the biggest market in gluten-free products is in those without celiac disease or nonceliac gluten sensitivity? What about the Gluten-Free Diet and Athletes? Athletes on this diet may not get enough of the important energy-producing carbohydrates to fuel training and competition. Gluten-free products may often contain a lot of sugar and fat not suited to performance in training and racing. Athletes who suffer from celiac disease or nonceliac gluten sensitivity should work with a sports dietitian. Gluten-free does not mean healthier athletes.
  3. The Fast Diet: Doctor and journalist Michael Mosley recently introduced this diet that suggests intermittent fasting two days a week when males should eat 600 calories on those days and females 500 calories. Premise: This 5:2 diet (5 days normal diet, 2 fasting) can lead to weight loss and reduce the risk of chronic disease. Promises: Weight loss and protection against cardiovascular disease and cancer. Pros: The reduction in calories on the fasting days (usually spread over the week) does lead to weight loss if energy intake is held constant on the other 5 days. Some research also suggests mood enhancement on the fasting days as well as reduction in rheumatoid arthritis sysmptoms. Cons: Research is yet to show weight loss or reduction in disease symptoms with intermittent fasting. This diet is also not recommended for pregnant or lactating women or people with diabetes. For athletes, the biggest issue is not getting enough energy for training. What about the Fast Diet and Athletes? Athletes in training need carbohydrate, protein and fat to meet training demands, especially hard training. If wanting to use this diet, fast on rest or low volume/intensity days.
  4. The Paleo Diet. This was the most ‘googled’ diet search term in 2013! The paleo diet is ‘cross-promoted’ by CrossFit, one of the many new crazes to hit the fitness industry! The basis of the diet is to eat meat and vegetables, nuts and seeds, some fruit, little starch and no sugar. Premise: Modern consumerism has seen us move towards processed foods. Returning to the diet of our caveman ancsetors will restore health and reduce the incodence of chronic disease. Promises: The diet promises weight loss, improved health, preventaion of modern chronic diseases, and an eating plan better matched to our biology. Pros: It encourages the eating of lean protein-rich foods such as wild game, grass-fed beef and fish. These foods are loer in saturated fats than most farm-raised protein-rich foods. The diet also encourages the eating of greeh and non-starchy vegetables, fruit, nuts and the plant-based oils from olives, coconut and grapeseed. The diet is also high in dietary fibre and low in sugar and salt. Cons: It’s not asy to find totally organic foods including wild game. These foods are also relatively expensive. The diet also criticizes the use of foods that come from modern agriculture including wheat, oats and barley, legumes and nuts. Some of these foods are also enriched or fortified with nutrients such as iron, niacin, thiamin and riboflavin that are needed for energy production pathways and thus important for athletes. What about the Paleo Diet and Athletes? Avoiding grains, dairy foods and starchy vegetables make it hard for athletes, especially endurance and team sport or internmittent sport athletes (tennis, squash) to get the all-important carbohydrates and nutrients they need for energy production. Female athletes may also miss out on their calcium needs, especially if pregnant or lactating.

Conclusion

All weight loss diets such as these four will help you lose weight, especially in the short term. However, like all fad diets like these, research has shown that longer term people almost invariably return to their normal or slightly modified diet. If you are an athlete who trains regularly, my advice is to ensure you work with an accredited sports dietitian to ensure you are getting the energy and nutrients you need to train and perform. They can also advise you as to the ‘ideal’ weight for you and your sport or event. Finally, I’d like to finish with a quote from a recent article on diet fad that appeared in the Journal of the American Medical Association. For me it says it all: “the ongoing diet debate exposes the public to mixed messages…..that heavily reinforces a fad diet industry that derives billions of dollars from a nation that is not getting healthier”. The solution is not the latest and greatest fad diet but a well-balanced diet that focuses on your training needs, your body weight, your gender and your age. For the most-detailed discussion on nutritional needs of the masters athlete, see Chapter 16 of my book The Masters Athlete. Chapter 17 of the same book also presents the only scientifically-based chapter I have seen on Weight Control and the Masters Athlete.

Sources: 1. Rosenbloom, C. (2014). Popular diets and athletes. Nutrition Today, 49(5): 244-248. 2. Pagoto, S. and Applehans, B. (2013). A call for an end to the diet debates. Journal of the American Medical Association, 310(7): 8687-8688.

 

Shoulder Pain – What are the Risk Factors in Masters Swimmers?

Introduction

Many years ago when I was a 35 year old young buck, I had a conversation with a couple of Miami Masters legends, John Crisp and Geoff Ross. Both were well into their 50’s and to me were ‘old’. They were hard and consistent trainers who’d been swimming competitively in surf and masters swimming since before I was born.

The chat was about swimmer’s shoulder. To highlight how bad they can be, Geoff pulled a plastic bottle out of his coat pocket and showed us a bone fragment that had been chopped off one his shoulders. He warned me to look after the shoulders or end up having an operation just like him. That op forced him out of the water for a few months then many more months of rehab to get his shoulders back to being able to handle the grind of training and competing again.

So what are the risk factors associated with shoulder pain in swimmers? Some recent research that included swimmers young and old examined the physical characteristics and training variables that can lead to shoulder pain or disability.

The Research

This American study examined differences between swimmers with and without shoulder pain. The researchers had 236 competitive female swimmers between the ages 8 and 77 years of age complete the Penn Shoulder Score test (a test of shoulder pain and discomfort) with the Sports/Performing Arts Module plus a range of other physical tests including core (tummy) endurance (how long the swimmers could hold a side bridge), range of motion (flexibility) around the shoulder tests, range of shoulder muscle strength tests, muscle (pectoralis minor) length tests, and scapular motion tests. Height, weight, years of swimming, hours of swim training per week, prior shoulder injuries and involvement in other sports were also surveyed.

The swimmers were grouped into four groups:

  1. 8-11 years (n=42)
  2. 12-14 years (n=43)
  3. 15-19 years (n=84) (High school swimmers)
  4. 23-77 years (n=67) (Masters swimmers)

And the age groups compared and contrasted using various statistical methods.

The Results

Nine (21.4%) swimmers aged 8 to 11 years, 8 (18.6%) swimmers aged 12 to 14 years, 19 (22.6%) high school swimmers, and 13 (19.4%) masters swimmers had shoulder pain and disability. High school swimmers were the most symptomatic. Differences that were found in 2 or more age groups between athletes with and without shoulder pain and disability included greater number of years of training and number of swim training hours per week, a higher incidence of previous traumatic injury and patient-rated shoulder instability, and reduced participation in another sport (cross-training) in the symptomatic groups. Reduced shoulder flexion motion, weakness of the middle trapezius muscle and internal rotation, shorter pectoralis minor and latissimus muscle, participation in water polo, and decreased core endurance were found in symptomatic females in individual age groups including the masters swimmers. Breathing pattern, stroke preferences or use of paddles did not have any influence on shoulder pain or disability in the masters swimmers. Previous shoulder damage such as dislocation or fracture was related to shoulder pain in the masters swimmers.

So What?

The results of this study strongly support the need for stretching of the chest and posterior shoulder muscles, strengthening of all the muscles of the shoulder joint, and development of the core abdominal muscle strength and endurance.

The results also highlight that masters swimmers should get along to a sports physiotherapist and get screened if they have any history of prior shoulder injuries, are experiencing shoulder pain, or feel any instability in their shoulders.

Chapter 12 (Injury prevention and management for the masters athlete) of my book The Masters Athlete details the key principles of injury prevention and treatment while Chapter 7 (Strength and power training for the masters athlete) and Chapter 9 (Developing flexibility in masters athletes) present what science says are the ways to develop these qualities in masters swimmers.

Better to be safe than sorry when it comes to being able to swim for life.

Source: Tate, A. and others (2012). Risk factors associated with shoulder pain and disability across the lifespan of competitive swimmers.  Journal of Athletic Training, 47(2): 149-158.

Risks and Benefits of Cycling – What Does the Research Say?

Introduction

Despite cycling being one of the largest participant activities in the world, little research has been undertaken on the health risks and benefits of cycling. What research has been done tells us that in the USA in 2011 there were over one million non-fatal cyclist injuries and 675 deaths reported. Major contributors to the deaths were lack of helmet use and use of alcohol. Of fatally-injured cyclists, 25% had blood alcohol levels at or above 0.08%, 67-85% were not wearing helmets, and 38% were riding between the hours of 6pm and midnight. While we know cycling has the potential for both serious traumatic and overuse injuries, the health benefits of our sport far outweigh these risks. Here is an American study that describes both the health risks and benefits of cycling.

The Research

5,818 cyclists completed an online survey that examined their demographics, cycling behaviours, injuries and medical conditions. 5,600 were over the age of 18 years and 4,792 met the study’s definition of being a cyclist – cycling on average more than twice a week for recreation or competition. The average age was 43.7±11.8 years. (range 18-85 years) and they rode on average 9.2 hours per week and had been cycling for 19.6 years. 81.7% were males and 18.3% females. 94.6% rode road bikes and 60.1% raced regularly.

The Results

Importantly, the survey participants reported that, after starting cycling, there were reductions in:

  1. obesity (76.2% of participants)
  2. cholesterol (66.1%)
  3. hypertension (50%)
  4. asthma (58.7%)
  5. smoking (86%)
  6. substance abuse (76%)
  7. There were decreased reports of all mental health diseases reported.

However, the results also showed that the cyclists in the survey reported a dramatic 310% increase in urologic disease with 62.3% of the cyclists reporting issues related to prostate enlargement, erectile dysfunction and prostate cancer.

The majority of injuries were taken care of by the cyclist with no effect on their ability to continue with their job or activities of daily living. There were also increases in musculoskeletal complaints with hand pain and numbness increasing by 420% since starting cycling. Abrasions were the most common injury (53%). The most injured body parts were the pelvis/hip (15.5%), knee (14.8%), and shoulder (13.6%). Interestingly, 60% of injuries occurred on the road of which 25% occurred during competition, mainly during crits (51.3%). Out of competition injuries were the result of colliding with an obstacle (26%), another rider (20%), cars (13%), with 19% due to issues related to train tracks, ice and gravel. At least 7.0% reported the use of performance-enhancing drugs with the use increasing as the level of competitor increased from recreational to professional.

 The So What?

While the results of the online survey might be questioned because it relied on self-reporting from the cyclists, the outcomes from this large survey strongly suggest the health benefits of cycling far outweigh the health risks. Cyclists report reduced obesity, cholesterol, diabetes, asthma and hypertension. The study showed only 1.6% of the cyclists has coronary artery disease while the normal population has figures of 7%.

The 310% increase in urologic diseases is expected given that cycling is a recognised but rarely discussed risk factor for uro-genital health. Bike saddles design, wearing knicks with padding as well as ensuring good bike fit can help reduce the pressure on the area between the genitals and anus. The high incidence of hand pain and numbness can be reduced by wearing gloves with a padded area on the palm as can padded handlebars and shifting hand positions regularly.

Bottom line is to keep riding but ensure you take every opportunity to ride safe by wearing a helmet and padding in all the right spots, have a good bike fit, and ride safe in terms of when and where you ride and who you ride with.

For a detailed discussion based on research evidence, check out three chapters in my book The Masters Athlete:

  1. Chapter 12 (Injury prevention and amanagemnt for the masters athlete)
  2. Chapter 13 (Overtraining in the masters athlete)
  3. Chapter 14 (Staying healthy and illness-free)

They are available as pdf’s too.

 Source: Greve, M. and others (2014). Health conditions and injury patterns in avid US cyclists. International SportMed Journal, 15(3): 245-254.