Top Reads of 2013: Endurance Sports, Healthcare, and the Confluence of Both

I love to read and I read a lot, particularly content that pertains to endurance sports and healthcare.  Here are my top reads (articles and essays) from 2013.  I start by introducing something I that I think will be a hot button issue for years to come: the coming together of sport and medicine to improve performance. I then break out what I felt were the best pieces in each respective category.  Finally, I end my favorites reads of 2013 with a section bringing my two personal interests back together (and perhaps stretching the definition of healthcare just a bit).  Enjoy!

In 2013, the medicalization of aging and "performance enhancing therapies" became a heightened issue, raising questions about doping, rule-making, and the future of sport.  The following suite of articles provide a good look at what I feel will be the biggest issue in sport for years to come. 

• Men's use of Testosterone on the Rise: A look into the medicalization of getting older.
• Man and Superman: Is there such a thing as a 'level-playing-field' in sport?  Why are some things allowed and others not?
• U.S. Track's Unconventional Physician: Seems ironic that the prevalence of hypothyroidism is so much higher in certain groups of elite runners than other parts of the population.
• EPO vs. a Cortisone Injection and the Future of Sport: As science and technology improve, drawing the line between what's allowed in sport and what is not will only become harder and harder.

Top Endurance Sports Articles of 2013

• The six habits of highly effective Triathletes: A look at what some of the world's best do to manage the mental side of the game.
• Expert from the Sport's Gene: Why the 10,000 Hour Rule Doesn't Always Make Winners: Not nature or nurture, but nature providing the foundation to see how far nurture can take an athlete. Bottom line, nurture your nature!
• Training to Failure: Good Idea or Bad: The implications of "going to the well" or "seeing god" in workouts.
• A Conversation with Aries Merritt and Andreas Behm: Great insight into the training (i.e., life) of a world champion; uncovers everything from diet to underlying motivation to keep going.
• Eating Practices of the Best Endurance Athletes in the World: For endurance athletes considering a long-term low carb diet, this is a must read.

Top Healthcare Articles of 2013

• Life or Death Situation: A poignant essay examining the torturous complexity when textbooks become reality for a leading bioethicist who specializes in end-of-life autonomy.
• The Selling of Attention Deficit Disorder: Investigate reporting examining how major drug companies have used creative marketing tactics to exploit youth, parents, and teachers in the arguably unneeded rise of medicating ADHD.
• How Happiness Boosts the Immune System: Thorough report looking at the science of happiness and health and the virtuous cycle between the two; if you do what you love and love what you do, happiness will lead to health, and health promotes happiness.
• Physicians Learn to Ask About Exercise: Patients are conditioned to ask for the latest quick fix and docs are schooled to prescribe it, but perhaps that's changing in small pockets as exercise is being prescribed prior to traditional medication for select conditions.
• Uncomplicating Matters on the Way to Health: Take health into your own hands by focusing on the 3F's: feet (use them to move) fingers (don't use them for tobacco), and forks (eat food). 
• Diagnosis Human: A look into the medicalization of everything...is being human a disease?

The Confluence of Endurance Sports and Healthcare, Top Articles of 2013

• The Beautiful Adventure: A wonderful ode to fully living life, which is what health is all about in my opinion. "May the great mystery make sunrise in your heart." 
• How Exercise Can Calm Anxiety: Perhaps there is more of an underlying reason "endurance junkies" feel the need for 6 hours of solitude on a Sunday long ride. 
• Your Fat has a Brain, and It's Trying to Kill You:  More on the role of exercise as a potent treatment for so many metabolic disorders. "You could never design a drug better than exercise." 
• Inside the Endurance Conspiracy: Interview with Tony DeBoom on purpose, passion, and finding total health through always pursuing what makes him tick.

Iron Math: Calories and Why The Back Half of an IM Marathon Is So Damn Hard

I was recently trying to explain to someone that has little-to-no familiarity with endurance sports why the back half of an Ironman marathon is so hard.  In an attempt to put things in a more common and quantifiable language, I decided to frame my explanation in calories. I'd never thought through this on my own, and while the results certainly are not surprising, they illustrate why things tend to get so hard into the afternoon of an Ironman. Here is a summary of the conversation and the math.  Please note I'm not a scientist and a lot of this is based on assumptions, which in turn are based on various articles I've read; so while my analysis is far from precise, I am confident it is directionally correct.

Race Morning: Let's say I nail my carb-load and pre-race nutrition pretty well and start the race in a fully loaded state. I am going to call this having 2200 calories on board. I've seen a whole bunch of research that seems to center on a 'maxed out' carb load state between 2000-2800 calories, and given that I don't live in a lab, I think the lower end of the range most likely reflects my reality.

Swim: For the hour and change (and a bit of change in my case) it takes to swim 2.4 miles, I am going to assume I burn 700 calories. Thus, I'll finish the swim with 1500 calories on board which probably explains why I feel so good getting on the bike!

Bike: Based on an accurate power meter reading, I'm fairly certain I burn 700 calories an hour while riding. I am consuming 450 calories an hour of straight carbohydrate.  I am going to be generous and assume I'm actually absorbing 400 of those calories (research here says the upper limit of absorption per hour is 100 grams of CHO, or 400 calories, so this is a very aggressive estimate, but it's also a nice round number).  So, 700-400 = 300 calories net burn in every hour.  My IM bike took a bit under 5 hours, which means I had a net loss of 1500 calories (300x5) on the bike, so I'll finish the bike even.  Not ideal for starting a marathon (just think about starting an open marathon after eating a low-carb diet for 3 days), but not terrible either, which explains why most (myself included) feel pretty good in those first few miles of the run.

Run: Now this won't be as accurate as the power meter data from the bike, but running at between 7:50-8:30 pace (my range this last IM) and in fairly hot conditions, I'll estimate a burn of about 800 calories per hour. Between sips of sports-drink at aid stations and energy gels, I probably consume around 250-300 calories an hour on the run...so I'll call it 275, and this is all carbohydrate.  Let's say I absorb 250 of these calories (again, super generous, but keeping numbers round).  With this burn and replacement, I'm running a net deficit of 550 calories an hour.  Here is how that shakes out over the course of the run:

• 1 hour (7.5 miles) 550 calorie hole
• 2 hours (15 miles) 1100 calorie hole
• 3 hours (21.5 miles in, I've slowed down a bit) 1650 calorie hole
• 3-3.5 hours (to race finish) the hole grows to 2200 calories as it is becoming harder to take down anything, and the time it takes to absorb carbohydrate becomes greater than the remaining time left in the race.

Like I said in opening, this should not be surprising; the back half of an IM marathon is hard! But I do find this back-of-the-envelope analysis a nice and straight forward way to understand why most start to feel a big drop-off in overall energy around mile 13-15.

A few notes: This model assumes a lot, including that 100% of energy during the race is coming from carbohydrate stores.  I'm sure (because I've seen Alan Couzens' charts) that some of the burn is coming from fat, but probably a pretty minimal amount at the watts I'm riding (200-215) and pace I'm running (7:50-8:30).  Also, every individual is different in their metabolism and the strain that respective pacing places on their energy systems; so while this cannot be applied with any precision, from a thematic standpoint, this story holds true for any athlete that is "racing hard," whatever his or her hard might mean in watts, pace, etc.

What this means to me: I think Mirinda Carfrae said it best on the recent NBC Ironman special.  When asked what is going through her mind during the run, she simply said "Eat. Drink. Run."   The IM marathon is a beast with fangs, and all energy should be used on running, and if not running, making sure you eat and drink. Carfrae nailed it, and she is a total killer, and I have a mini-crush on her because of it (sorry Caitlin).

Final interesting thing: This type of approach to thinking about the IM marathon explains why when top-end professional's blow up, they often end up walking or DNFing, whereas for many age-groupers, at "blow-up point" the run turns into a jog which turns into a shuffle.  For the former, with body fat % that is extremely low, there isn't a lot of fat on board so literally the tank becomes empty and the car stops.  For age-groupers, even the pretty lean (e.g,. 7% body fat and up) there is enough usable body fat on board to fuel the end of the run, just at a significantly reduced pace.

The Slowest Generation and Cultural Impact on Competition

A recent editorial in the Wall Street Journal entitled The Slowest Generation examined a trend of slower finishing times in endurance events, going on to suggest that this is a bad thing rooted in a cultural shift in the way that younger generations approach competition.   The author says "races are turning into parades," and that "performance related apathy" among younger generations is the culprit.  He even suggests this could be underlying why the US hasn't won an Olympic Marathon medal since 2004.

I think it is hard to make snapshot judgments about a racer (and thus a race in totality) by looking at time alone, and it's certainly not slow finishing times that worry me about an apathetic generation when it comes to sport.  If a finishing time is slow but it is the result of an individual giving it his or her all, than that is the most honorable thing that an athlete can do.  What does worry me is when people would rather be apathetic (even going as far as to shun the whole notion of competition during a race) because it is easier to do that than to give an earnest effort and risk/expose oneself to failure. If you make a joke out of something, you can't fail. I do agree with the author of the WSJ piece that there is an increase in this attitude toward races, it is more prevalent in younger generations, and it is a sad and worrisome cultural reflection...especially because I'm afraid it expands well beyond sport. I'm not sure how vast the issue is, and I certainly don't know what to do about it...but I agree it is real.

As for the relationship between "performance related apathy" and US Olympic Marathon medals, I think the author is way off the mark. I've been fortunate enough to spend time with elite endurance athletes in Olympic Development Programs, and 'apathy' or a lackluster attitude toward competition are polar opposites to what goes on in those environments.  A bunch of new-age hipsters drinking beer and purposefully going slow in a color run has *absolutely nothing* to do with what is going on in Colorado Springs, Eugene Oregon, Ann Arbor Michigan, etc., etc.

EPO vs. a Cortisone Injection and the Future of Sport

Between Lance Armstrong’s fall from grace, doping accusations against baseball’s Alex Rodriguez, and a flurry of recent reports suggesting testosterone use in the NFL, it’s clear that cheating is a significant issue in modern sport, and unfortunately, likely more pervasive than most think. This isn't just in the professional ranks either; more and more amateur athletes are getting popped for doping in marathons, triathlons, and cycling events.  

I finally got around to reading Malcolm Gladwell's latest in the New Yorker; a predictably well-written essay raising questions about a 'level playing field' in sport and what it means to cheat. While I highly recommend reading the full article, the basic premise is to question why sport allows some advantages, both pre-determined and technologically driven (i.e., individuals with obscure genetics, cortisone shorts, Tommy-Jon surgery, Lasic, etc.), while disallowing others (i.e., EPO, blood transfusions, testosterone therapy).  The article prompted me to think about how/why these lines are drawn, and what it means for the future of sports.


For instance, what would happen if EPO (i.e., blood doping) or some new equivalent of it became as 'safe' as a cortisone shot? The situation gets real murky. Both are mechanisms allowing an athlete to train and compete harder than their own physiology would let them...so why allow one but not the other? Who is to say that inflammation induced by going too hard is much different than a reduction in hematocrit levels induced by going too hard? Both are the body’s natural processes of telling an athlete to back-off. The former uses pain as a signal (cleared by a cortisone shot) and the latter causing massive fatigue (fought with EPO). 


The downstream enforcement of cheating should be simple: if an athlete breaks a rule, regardless of his/her rationale, genetic baseline, etc., it is cheating, and the athlete must face that respective sport's penalty for breaking the rule. Things get more complicated further upstream, where decisions about what is and is not allowed are made, a process that will only get more complex as science and technology improve and athletes experiment with new ways of enhancing their bodies and minds. It used to be that pretty reliable guidelines could be used: if taking a certain substance had a great chance of harming an athlete, that substance would be banned. But with continual progress in the lab, it is extremely likely there will be an increasing number of substances and medical interventions that improve performance with minimal to no adverse health effects.  

Things get even more convoluted when athletes present with a legitimate clinical diagnosis, but one that may have been contributed to or caused by excessive training. My favorite example is the 43-year-old amateur triathlete who trains 20 hours a week on top of a highly demanding job and three young kids. He starts to feel fatigued all the time (who wouldn't), and goes to the doctor where a blood work-up shows his testosterone values are clinically low. Should he be able to start on testosterone therapy -- the recommended medical action -- even though if he reduced training by 50% his lab values would probably return to normal? Should the governing bodies of triathlon count on physicians to screen for "endurance training" when deciding how to treat these disorders? Is it up to the sport to do this? The questions are endless. 

This isn't just an issue for amateurs. Many elite endurance athletes are treated for hypothyroidism, a trend especially documented in elite runners. It seems an unlikely coincidence that the prevalence of hypothyroidism just happens to be so much higher in those that run for a living versus the general population. A recent article in the Wall Street Journal profiles a physician whose patient panel is dominated by professional runners, suggesting that perhaps it's something about the relentless training and physical stress inherent to their programs that causes hypothyroidism. So should treating this medical condition be considered cheating? And if it is, then what to do with someone who has underlying hypothyroidism unrelated to training? How to delineate between the two? Again, there are more questions than answers.


I could go on and on with examples, and they will only grow with continued progress in sports science, medicine and technology. In order to prevent an ‘anything goes’ circus in sports, it is extremely important that the governing bodies critically examine the process for deciding what constitutes cheating. It is a complex discussion and one that should be frequently revisited. No doubt, endless questions will be raised; the answers to which will define the future of athletic competition.