The longevity of the long distance runner, part 3: Cardiac Outcomes

After examining the anecdotal evidence provided by elderly marathoners and then grappling with some of the basic science underlying longevity in recent posts, it is time to attempt to draw some practical conclusions about what can be done to optimise longevity as a runner.   While the unfolding science of the molecular mechanisms by which our bodies respond to wear and tear offers intriguing prospects of identifying strategies for promoting heathy aging, there are at this stage more questions than answers. However we each live only once and if we want to optimise our chances of running fluently in old age, we must make the most of the evidence that is currently available. Despite the uncertainties, the evolving science provides a framework for weighing up the value of the lessons that might be drawn from the anecdotes.

But it is necessary to be aware of the pitfalls if we are too simplistic in our interpretation of the science. For example, at first sight the fact that catabolic hormones such as cortisol promote the break-down of body tissues to provide fuel for energy generation in stressful situations, suggests that avoiding sustained elevation of cortisol is likely to promote longevity. Indeed this conclusion might be valid in some circumstances, but it is not a universal rule. The strategy that is most successful for promoting longevity in animals is a calorie restricted diet. This works for creatures as diverse as worms, fish, rodents and dogs, and there is some evidence for health benefits in primates. The mechanisms by which it achieves its benefits include an increase in resistance to oxidative damage to tissues by virtue of more resilient mitochondrial membranes. However calorie restriction is stressful and promotes long term elevation of cortisol. It appears that animals actually need at a least a moderate level of ongoing stress to encourage heathy adaptation. The goal is achieving balance between stressful stimuli and adaptive responses.   The balance point depends on individual circumstances, and is likely to shift as we grow older.

The nature of training

The basic principle of athletic training is stressing the body in order to encourage it to grow stronger. One of the key mechanisms by which this is achieved is inflammation, a process by which damage to tissues generates a cascade of responses mediated by chemical messenger molecules that circulate in the blood stream, triggering repair and strengthening but also leaving a trail of debris.

There is abundant evidence that running increases life expectancy. In a 21 year follow-up study of elderly runners Chakravarty and colleagues at Stanford University found that continuing to run into the seventh and eighth decades has continuing benefits for both life expectancy and reduction of disability. Death rates were less in runners than in controls not only for cardiovascular causes, but also other causes, including cancer, neurological disorders and infections. Nonetheless, unsurprisingly, Chakravarty reported that although the increase in disability with age was substantially less in runners than in non-runners, the runners did nonetheless suffer increasing disability over the follow-up period. This is of course what would be expected if the processes by which training strengthens the body also leave a trail of debris.

If our goal is to increase not only life expectancy but also to achieve healthy aging and longevity as runners, we need to look more closely at the mechanisms by which running damages tissues. Ensuring longevity as a runner requires training in a manner that ensures that the accumulation of debris is minimised.

Healthy aging is a process affecting all parts of the body. Nonetheless, for the runner, the cardiovascular system, musculoskeletal system, nervous systems and endocrine systems are of special importance. There is a large body of evidence about how these systems age and about both the beneficial and the damaging effects of running on these systems.   I will examine the evidence regarding cardiovascular system in this post, and draw some tentative conclusions about how we might train to achieve healthy aging of the heart. In my next post I will examine the evidence regarding the musculo skeletal system, for which much more detailed information about cellular mechanism is available due to the feasibility of tissue biopsy. This will allow us to extend and consolidate the conclusions regarding optimal training for maximizing longevity as a runner.    In the final posts in this series I will turn my attention to the nervous and endocrine systems, and speculate about the way in which optimal training might impact upon health aging of those crucial systems.

Cardiovascular changes

Running produces both short term and long term changes in the cardiovascular system, some beneficial, some potentially harmful. I have discussed many of these changes in several previous blog posts (e.g. ‘The athletes heart’; ‘Inflammation, heart-rhythms, training-effects and overtraining’; ‘Endurance training and heart health, revisited’) and will present a brief overview here.

In the medium term (over time scale of weeks) regular training leads to an increase in blood volume. This increases venous return to the heart. The stretching of the heart muscle leads to more forceful contraction and a greater stroke volume. The cardiac output for a given heart rate is increased. Resting heart rate decreases and the heart rate required to run at a particular sub-maximal pace decreases.

In the longer term, the heart muscle is remodelled, with an increase in overall volume and in thickness of the ventricular walls. This condition is known as ‘athletes heart’. The mechanism is mediated by the intra-cellular signalling pathway that engages an enzyme known as Akt, which promotes growth of both muscle cells and capillaries. This is usually regarded as a benign physiological adaptation. The enlargement of the heart that accompanies pathological conditions such as high blood pressure or obstruction of the heart valves is also mediated by the Akt signalling pathway, but in contrast to the benign enlargement of the athlete’s heart, the Akt signalling is accompanied by inhibition of a growth factor required for the development of capillaries. Thus, in the athlete’s heart the enlargement is accompanied by adequate development of a blood supply to the heart muscle, whereas in pathological conditions the blood supply is usually inadequate.

However, in some athletes the enlargement might have adverse effects. There is compelling evidence that endurance runners with a long history of substantial training have an increased risk of disturbances of heart rhythm, including both ‘supra-ventricular’ disturbances such as atrial fibrillation, and potentially more lethal ventricular disturbances. The cause of these rhythm disturbances is not fully established but it is probable that the re-modelling of the heart muscle in a way that alters electrical conduction pathways plays a role.  It is likely that residual fibrosis at sites where damaged muscle has been repaired also plays a role by producing local irritability of the cardiac muscle cells leading them to fire spontaneously.

During intense prolonged exercise the strength of ventricular contraction, especially that of the right ventricle, is diminished, a condition known as Exercise-Induced Right Ventricular Dysfunction. If the exercise is sufficiently intense and prolonged, cardiac enzymes can be detected in the bloodstream, indicating a least temporary structural damage to heart muscle.

In a study of forty highly trained athletes competing in events ranging from marathon to iron-man triathlon, LaGerche and colleagues from Melbourne found transient weakening of the right ventricle immediately after the event. This was more severe the longer the duration of the event. The transient weakness returned near to normal within a week. However in 5 of the athletes, there was evidence of long term fibrosis of the ventricular septum, indicating chronic damage. Those with evidence suggesting long term damage had an average age of 43 and had been competing for an average of 20 years. Those without evidence of chronic damage had an average age of 35 and had been competing for an average of 8 years.   The evidence suggests that duration of endurance competition is a strong predictor of chronic damage.

Although an enlarged athlete’s heart usually has a much better blood supply than the enlarged heart associated with high blood pressure or obstruction of the heart valves, there is disconcerting but controversial evidence of excessive calcification of the arteries in at least some athletes, especially in males in who run marathons over period of many years. The mechanism is uncertain, though sustained inflammation is a plausible mechanism.

Effects of the amount and type of training

Although an overwhelming mass of evidence demonstrates that runners have a longer life expectancy and in particular, a lower risk of death from heart attack or heart failure than sedentary individuals, several large epidemiological studies raise the possibility that adverse health effects (especially cardiac events) tend to be a little more frequent in those who engage in a large amount of exercise than in those who exercise moderately. The US Aerobic Longitudinal Study examined the associations of running with all-cause and cardiovascular mortality risks in 55,137 adults, aged 18 to 100 years (mean age 44 years) over an average period of 15 years and found a marked decreased in both cardiac and all-cause mortality in runners compared with non-runners, but the reduction in mortality was a little less in those training 6 or more times per week compared with those training 1-5 times per week. The Copenhagen City Heart Study followed 1,098 healthy joggers and 3,950 healthy non-joggers for a period of 12 years and found that 1 to 2.4 hours of jogging per week was associated with the lowest mortality. These ‘moderate’ joggers had a mortality hazard ratio of 0.29 compared with sedentary non-joggers.

But closer look at the evidence reveals a potentially informative detail. In a study of heart health of over a million women, Miranda Armstrong and her co-investigators from Oxford  found that among obese women, those who did a large amount of exercise suffered more heart problems than those who did a moderate amount. However, in contrast, among the women who had a Body Mass Index less than 25, those doing a large amount of exercise had fewer heart problems than those doing a moderate amount of exercise.   This suggests that if there is a risk in doing a large amount of exercise, it is mainly confined to those for whom the exercise is excessively stressful due to other risk factors that shift the balance towards harm rather than benefit.

Although the evidence from the large epidemiological studies remains a topic of debate because of issues such as possible bias in participant selection and the relatively small numbers of individuals in the category who take a very large amount of exercise, I think the balance of evidence does indicate that at least some individuals who take a large amount of exercise do have an increased risk of death, including death form cardiac events, within a given time period.   In my opinion, the important question is what determines which individuals will be harmed by a large amount of exercise, and whether there are ways in which we can minimise the risk of harm.

There is evidence that adequate prior training can protect against damage.   Neilan and colleagues studied non-elite marathoners runners completing the Boston Marathon and reported that right ventricle weakness was more pronounced in those who had trained less than 35 miles per week compared with those who had trained more than 45 miles per week.   The logical conclusion from studies such as the Oxford study of obese female runners and Neilan’s study of marathoners is that running in a manner that exceeds the individual’s current ability to cope with the stress increases the risk of damage.   This in turn suggests that building up gradually in a manner that ensures that training sessions are never excessively stressful is likely to be the safest approach.

Furthermore, it is likely that lack of adequate prior training or obesity are not the only factors that impair the ability to cope with the stress of demanding training and racing. Following a very demanding marathon or ultra-marathon, the evidence of damage remains detectable for a period of weeks. It is plausible that demanding training when the heart is in a weakened state will compound the damage. It is widely accepted in practice that recovery following intense racing or heavy training is crucial, but unfortunately there is relatively little scientific evidence addressing the question of whether or not the adverse cardiac effects of intense exercise resolve during a recovery period, or conversely, whether the adverse effects are compounded by repeated bouts of exercise.   We must therefore turn to evidence from studies of rats.

Benito and colleagues exercised rats on a treadmill for 60 minutes at a quite vigorous pace of 60 cm/s (achieved after 2 weeks of progressive training) 5 days per week for a total of 4 weeks, 8 weeks or 16 weeks. For a rat, 16 weeks of life is roughly equivalent to 10 years for a human. During the first 8 weeks there was relatively little evidence of damage, but prominent signs of damage emerged between 8 and 16 weeks. After the 16 weeks of exercise, the rats exhibited hypertrophy of the left ventricle and also the reduced function of the right ventricle, similar to the findings reported in humans. Furthermore the rats had marked deposits of collagen in the right ventricle, and messenger RNA and protein expression characteristic of fibrosis in both atria and the right ventricle. The exercised rats had an increased susceptibility to induction of ventricular arrhythmias. A sub-group of the rats were examined after an 8 week recovery period following the 16 weeks of exercise. Although the increased weight of the heart had not fully returned to normal level, all of the fibrotic changes that had been observed after 16 weeks of exercise had returned to the normal level observed in sedentary control rats. Thus, at least in rats, the adverse potentially arrhythmigenic changes produced by intense exercise over a 16 week period appear to be reversible after an adequate recovery period.    Thus the best available scientific evidence does support the accepted principle that recovery following intense racing or heavy training is crucial.

CardiacOutcomes

Proposed cardiac outcomes of long-term training. The size of the ellipses indicates cardiac fitness at each stage; colour indicates balance between recovery (blue) and stress (red)

In summary, the evidence regarding the cardiovascular effects of running suggests the following guidelines for healthy aging and longevity as a runner:

  • Continuing to run regularly, at least into the seventh and eight decades decreases risk of death and disability.
  • Training volume should be built up gradually.
  • Adequate recovery after demanding events, such as a marathon (or indeed, even after heavy training sessions) is likely to be crucial.

My next post will examine the evidence regarding the effects of training on the musculoskeletal system, and will both consolidate and extend these conclusions.

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7 Responses to “The longevity of the long distance runner, part 3: Cardiac Outcomes”

  1. Ewen Says:

    Thanks again Canute. That was an interesting finding about the stress caused by exercising with a high BMI. I think about that when I see ads for ‘The Biggest Loser’ on TV! It seems that keeping exercise as stress-free as possible is the way to go. Perhaps the inherent stress of racing and hard sessions (intervals etc) can be reduced by ‘running by feel’ and not battling with the watch to achieve goal splits and paces?

    On a different subject, I’ve come across a book – “Thrive: The Vegan Nutrition Guide to Optimal Performance in Sports and Life” which promises good health by adopting this diet. Do you have any thoughts or do you know of any research on vegan athletes?

    • canute1 Says:

      Ewen

      Thanks for your comment. As you are aware the issue of diet has been one of the major topics of debate in the athletic community for over the past decade. The evidence demonstrates that there are no simple answers, though almost certainly nutrition is of major importance. In my previous posts on nutrition I have come down in favour of a Mediterranean diet which includes a relatively high proportion of vegetables, fish and nuts. This is partly based on evidence from studies of large populations, and partly on what our current understanding of the mechanisms of body strengthening, maintenance and repair indicate that the human body needs. In general, vegetables are a good source of the micro-nutrients that we require (at least in small quantities) to promote a healthy response to inflammation. A substantial proportion of vegetables in the diet is almost certainly good for an athlete. The converse question of whether animal sources of protein (at least in moderate amounts) are actually harmful is less easy to answer.

      The currently available, but limited, scientific evidence comparing athletic performance in vegetarians with that in omnivores indicate that predominately vegetarian-based diet does not either improve nor hinder performance in athletes. This was the conclusion reached by a fairly rigorous review of the evidence by Craddock and colleagues (from Wollongong) published in the International Journal of Sport Nutrition, Exercise and Metabolism last November. However they were only able to find 8 studies that met the criteria for inclusion in their analysis.

      As for a vegan diet, I think the rigorous evidence is even more sparse, though there are several prominent ultra-marathoners, including Scott Jurek, who demonstrate that it is possible to be a champion ultra-runner on a vegan diet.

  2. padraigjapan Says:

    Thanks again for another fascinating paper. I really enjoy and get great benefit from your work as I head towards my 6th decade.

    Have you considered the benefits of regularly measuring Heart Rate Variability (HRV) to gauge recovery from stressful exercise and do you think it is useful?

    • canute1 Says:

      Padraig
      Thanks for your comment I consider HRV is useful when interpreted in conjunction with other relevant variables reflecting stress and response to training.

      A few years ago I measured RMSSD in a standard manner every morning but did not find it was consistent enough to employ as the primary guide to adjusting training load. However, on one occasion, I found that it was very helpful in determining what was going on during an episode of serious over-reaching.

      I no longer measure HRV daily because I do not consider the consistency of the information is good enough to justify the required standard daily routine. Nonetheless, I do measure RMSSD during a period of quiet relaxation before a sub-maximal test which I perform weekly to monitor response to training. (I consider the HR during a specified sub-maximal load in a good measure of aerobic fitness). I use the combined information from RMSSD, resting HR, HR during submaximal exercise and sense of well-being (energy, enthusiasm, mood) to estimate how stressed I am, and I adjust training load accordingly

  3. Bob Says:

    I’m sure there’s many factors at play when it relates to “moderate jogging.” Moderate joggers are moderate in other ways as well. Moderate diet. Moderate alcohol. Most serious runners I know do not eat properly and their extreme training also goes hand in hand with other extremes. They frequently drink a lot and eat a lot, with little concern about what they put in their stomachs.

    • canute1 Says:

      Bob, Thanks for your comment. I agree there are many factors in play. In the fifth article in this series (The longevity of the long-distance runner, part V: ‘whole body mechanisms’) which I will post within the next few days, I will place some emphasis on interaction between multiple life-style factors

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