Too Much of a Good Thing?
Since I have been seeing a lot of marathoners getting injured in their preparation, I thought I might put this blog out as food for thought. Don't let this discourage you from your goal, but this should help you keep your health in perspective. If you are reading my blog it is likely that you are an exercise enthusiast; you hit the treadmill in the morning and crush the weights in the gym, or at least you intend to. I have a tendency to become quite addicted to working out and love the endorphin rush that comes with intense exercise. I overreach now and then to blast through plateaus. Sometimes that overreaching even becomes overtraining with fatigue, disordered sleep, weakness, and pain. Nevertheless, despite the occasional setback, I work around my injuries, take breaks when needed, and use dietary supplements to recover faster.
We are told that exercise is good for the heart, the brain, and the soul. That being said, many studies substantiate the metabolic dysfunction that occurs with a sedentary lifestyle and the shorter life span that goes along with it. Exercise can increase longevity, decrease the risk of diabetes and heart disease, and even alleviate symptoms of depression. With all the benefits that come with exercise is it even possible that we can do too much? Indeed, new research suggests that there may be such a thing as doing too much exercise for our own good. In fact, research suggests that those who we once thought as the fittest of the fit, marathoners, are in fact no less likely to die of heart disease than the average couch potato. Sound a little farfetched? Let’s look at the whole story.
This story really starts in early recorded history. In 490 B.C., Phidippides, a 40 year old courier ran many miles from a battle in Marathon to Athens to proclaim that the Greeks had won. As I am about to turn 40, I feel the pain this must have created. Upon uttering his proclamation he collapsed and died (1). Fast forward to the 1970’s when physicians began proclaiming that if you can run a marathon you could be impervious to death from coronary artery disease (2). How we as an educated society made the leap from Phidippides’ death after his epic journey to the immortality of marathon runners has always baffled me. Have you ever been to the tent at the finishing line of a marathon? It is a disaster scene; hot, red swollen knees, people collapsing, people carrying bodies, others plainly just passing out. Although the death count at most marathons is only up to 1 in 100,000 participants, it is definitely not easy on the body and research suggests that this repeated stress over years exacts a toll.
Chronic extreme exercise appears to cause structural damage to the heart that may be a sign of repeated insults, injury, and scarring. This wear and tear offsets the cardiovascular benefits of moderate exercise. Studies show that even vigorous exercise for up to 40 minutes per day can reduce mortality by almost 40% (3). Beyond 45 minutes no further benefit is conferred by vigorous exercise on the heart, at least statistically. Interestingly, light to moderate activity proportionately lowers mortality risk to times of up to 110 minutes. It can be inferred from the data that those who train with high intensities over long periods of time are interested in something other than their longevity. For instance, Darren Miller, the international channel swimmer from Pittsburgh (https://www.darren-miller.com), isn’t swimming to lengthen his own life; he is saving the life of kids through the Children’s Foundation.
So what is it about long lasting, 1 to 2 hour, vigorous intensity endurance training that causes damage to the heart? When training at high intensities, such as distance running, blood has to be returned to the heart and pumped out at rates up to 5 to 7 times resting levels. As blood returns from the leg veins at this rate the right ventricle of the heart which accepts the venous blood is overstretched. This overstretching is much like doing an extra heavy eccentric bicep curl (the contraction on the way down). If you have tried “eccentrics” in the gym you understand the damage it causes to the muscle as the next day you are so sore you can barely comb your hair. Just as markers of muscle damage rise in the blood with eccentric exercise, high intensity endurance exercise causes an elevation of blood markers for heart muscle damage (4). Although those markers return to normal after about 1 week, damage to the heart wall has occurred and healed. How often can the heart go through such stress?
The heart and our metabolic physiology hasn’t evolved as much as technology has in the past 100,000 years. Our Paleolithic ancestors would hunt down their prey with stone tools in short bursts of energy over relatively short distances. They experienced regular bouts of famine and survival of the fittest prevailed. This led to evolution of human physiology capable of storing fat more easily and conserving energy when hunting. Then came the cultivation of wheat and carbohydrate as overly abundant energy sources. Humans are then able to expend energy over longer bouts of time. However, the environmental pressures to evolve are erased by technology that allowed life expectancy to grow beyond early mating years. In other words our hearts were designed for short bursts of energy for 30-50 minutes, not 2-3 hours. These high volume episodes of vigorous activity have been proven to damage the heart’s muscle fibers with microtears, inflammation, and scarring (5). Relatively recent research demonstrated that heart disease patients treated with 30 or 60 minutes of vigorous exercise sessions better improved arterial stiffness and had less oxidant stress with 30 minutes versus worsening of both conditions with the 60 minute sessions (6).
The most disturbing research about the detrimental effects of extreme endurance training has been presented in recent literature. Cardiologists evaluated the amount of plaque formation in the hearts of marathoners that had completed at least 25 marathons over 25 years and what they found was surprising (1). What they found was that the marathoners had 60% more coronary plaque formation than their sedentary counterparts of the same age. In addition, irregular heart rhythms, even life threatening ones, can be found in aging endurance athletes in the absence of any significant coronary disease(7). It is encouraging however, that rat models of long-term endurance training and cardiac fibrosis have demonstrated reversibility of the arrhythmias and structural changes in the heart with discontinuation of the intense training (8).
In March of 2012, the author of the best-seller Born to Run, Micah True died at age 58 while running in the wilderness of southwest New Mexico. He was an advocate of long distance running and was known to run between 25 and 100 miles per day! At his autopsy his heart demonstrated chronic inflammation, thickening of the heart walls, and focal thickening of the coronary arteries with mild plaque formation. O’Keefe and colleagues have recently described this appropriately as ‘Phidippides cardiomyopathy’ (1). These scientists have also quoted a well-known contemporary of Phidippides in ancient Greece, Hippocrates-the father of medicine:
“The right amount of nourishment and exercise, not too much, not too little, is the safest way to health”
The main point of this blog is to follow a principle that I like to live by, “everything in moderation, including moderation”. The medical literature overwhelmingly supports the health benefits of an active lifestyle over living a couch potato life. As long as there are competitions in the world (forever) athletes will try to outperform others. In that context, one must throw moderation out the window and go all out. In doing so, that athlete will inflict stress on their body that they will have to cope with and recover from. If they don’t allow their body to recover, it will lead to injury. Just as one’s muscles get weaker with overtraining with weights, the heart can be overtrained with excessive high intensity endurance exercise. The science presented here suggests that once you have attained your endurance training goals or competitive success you should return to moderation and let your heart heal. Said another way, don’t run faster to the pearly gates, because you just might win that race.
O’Keefe JH, et al. Potential adverse cardiovascular effects from excessive endurance exercise. Mayo Clinic Proc 2012;87:587-95
Bassler TJ. Marathon running and immunity to atherosclerosis. Ann N Y Acad Sci 1977;301:579-92
Wen CP, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011;378:1244-53
Ector J, et al. Reduced right ventricular ejection fraction in endurance athletes presenting with ventricular arrhythmias: a quantitative angiographic assessment. Eur Heart J 2007;28:345-53
La GA, et al. Exercise-induced right ventricular dysfunction and structural remodeling in endurance athletes. Eur Heart J 2012;33:998-1006
Michaelides AP, et al. Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease. Heart 2011;97:832-7
Patil HR, et al. Cardiovascular damage resulting from chronic excessive endurance exercise. Mo Med 2012;109:312-21
Benito B, et al. Cardiac arrythmogenic remodeling in a rat model of long-term intensive exercise training. Circulation 2011;123:13-229) Autopsy report Micah True; http://extremelongevity.net/wp-content/uploads/2401-12AutRpt.pdf