Race Stronger Live Longer: A Physician's Guide to Wellness for Athletes

Preface

I still remember ever so vividly my first night on call on the cardiology ward of a large county medical center. I was responsible for so many patients that there was no way I could know each one of them very well. I never slept that night. Rather, I spent the entire evening studying the Washington Manual of Therapeutics, a go-to reference source of information, should a patient take a turn for the worse, or worse yet, suffer a cardiac arrest and a code blue need to be called to resuscitate him. Lucky for me, and even luckier for the patients, there was no disaster that night.

Back then, pretty much all I could do was alleviate pain, support the vital signs, and try to prevent the patient from deteriorating. This area of medicine was evolving, but even more troublesome was that the public was not making much progress in addressing healthier lifestyles.

Now, after over three decades in practice, I am proud to report that when a patient with an acute heart attack arrives at the emergency room, we are often able to abort that attack, and the patient has a good chance of walking out a few days later as though nothing had happened at all. For patients who recognize that they may be having a stroke and arrive at the hospital in a timely manner, we are also now able to aggressively evaluate and treat those patients. I have seen many patients who come to the ER with a severe stroke literally wake up before my eyes after a life-saving medication is given.

These significant strides forward must be supported with similar awareness in the community. Early grade school involvement to mandatory education in secondary schools could generate greater discussion and early lifestyle changes. Why do we have this epidemic of obesity in the United States? Is it apathy, a disregard for good health, a cultural disaster, or a result of a lack of education? As an instructor for the American Heart Association, I always incorporate issues of heart health and wellness in my classes. The medical community and the government must become more aggressive in educating the public on these issues of wellness.

My motivation for writing this book, therefore, must acknowledge all the patients and their families that I have interacted with. These patients have given me a greater sense of empathy, understanding, and now the impetus and direction for my next career of spreading wellness and healthy lifestyles to the community.

This book is intended to become a source of information for athletes and for the community at large with a desire to improve their quality of life over the long term. Throughout the development of this book, I have asked many friends for their input and criticism, and they have provided timely assistance. Gary has been my informal editor and given me lots of direction and suggestions. I also want to thank Sally and Bob, Ron, Bobby K., Lar-Dog, Lee and Cherie for all their valued support, Pam for the professional edit, and Ghislain for his design, layout, and conversion to e-book. And a mahalo nui loa to Kris for being my guide through the alphabet maze of things to do to get this manuscript to print. ♦

Introduction

Sudden death sometimes occurs in athletic events. According to a study in the American Journal for Sports Medicine, twenty-eight runners died during marathons between 2000 and 2009. Are you surprised at that statistic? In 2012, more than 529,000 runners finished a marathon in the United States and Canada. But it’s not just from marathons that athletes are dying. We are beginning to accumulate data showing that the swim segment of triathlons appears to be the riskiest for sudden death.

One of the first organized triathlons was held in San Diego on September 25, 1974. It was the brainchild of Jack Johnstone and he called it the Mission Bay Triathlon. The race consisted of a six-mile run followed by five miles of biking, then a five-hundred-yard swim in Mission Bay. Forty-six competitors toed the line that auspicious day. Today’s triathlon has morphed into varying distances, terrains, and, of course, locations.

The Sports & Fitness Industry Association (SFIA) has conducted surveys of the U.S. population inquiring as to what sports people participate in. In 2011, SFIA released findings that showed that more than one and a half million athletes participated in both on-road and off-road triathlon events. That’s a pretty impressive number. And the number of triathletes and races just keeps growing and growing.

Now, if you have never entered a triathlon, let me describe what generally happens. The first event is the swim. Typically, entrants will be grouped by age, and several age groups may start the swim at the same time. At times, and most notably in IRONMAN® races, there is a mass start. Here, more than two thousand athletes may crowd together waiting for the horn to blow signifying the start of the race. This might certainly be an overwhelming experience for the novice or the less-adept swimmer. You can imagine the adrenaline levels and the anxiety that this might provoke.

At the inaugural New York IRONMAN® (an IRONMAN® race consists of a 2.4-mile swim followed by a 112-mile bike, then a 26.2-mile run) in August 2012, a forty-three-year-old long-distance runner died after being in distress while swimming and being transported to a local hospital. In March 2013, a forty-six-year-old died during the swimming segment at the Escape from Alcatraz triathlon in San Francisco. In April 2013, a twenty-three-year-old male drowned during a water obstacle at a Tough Mudder event in West Virginia. These statistics pose important questions. Were these fatalities just flukes or coincidences, or were they somehow interrelated? Were they preventable? I doubt that any of these athletes considered that a cardiac arrest during the swim segment was even a possibility for them.

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An athlete who values and seeks wellness must also be concerned with issues of lifestyle, nutrition, longevity, and the overall quality of life. This requires an analysis of the state of fitness, an evaluation of cardiovascular risk factors, and an action plan to achieve that state of refined wellness. By doing so, athletes who seek wellness in their lives will reap the rewards of improved performance, along with an improved quality of life.

As athletes, we are naturally programmed to do everything within our power to make ourselves as competitive as possible. Whether we enhance our equipment, our training, or our nutrition, we are relentless in our quest to become stronger and faster and to achieve greater endurance and quicker recovery. We train regularly, often to complex schedules, and we might even have personal USA Triathlon-certified trainers to guide our workouts. In addition, we pay monthly dues for gym memberships, masters swim programs, and maybe even personal coaches.

We track the yards we swim and the miles we bike and run. With our GPS devices, we track the calories we expend per workout and our average output of watts. You may have made a recent purchase this year to add to that already high-tech bike that may be locked up in your garage. At the 2012 Hawaii IRONMAN® World Championship, it was estimated that more than five million dollars’ worth of bikes and equipment were in the transition area (the area where the athletes will get their bikes once out of the swim).

Will all of this equipment make us more competitive athletes? Possibly, but even with that high-end carbon-fiber bike, we may not reach our true potential without a plan for overall wellness. I am referring to eating a healthy diet, maintaining an ideal body weight, reducing cardiovascular risk factors, and keeping a positive mental approach as we target that finish line.

We are so concerned with excelling within our age groups that we may not be concerned with overall wellness. Rather, we maintain a tunnel-vision approach to improving our performances, and maybe even our lifestyles. Do you know what your cholesterol level is or what your blood pressure is? If we talk the talk, then we must walk the walk. You should know how an improved nutrition plan can improve your lipid profile, your blood pressure, and your longevity.

My interest in wellness dates back as long as I can recall. Being an emergency medicine physician for more than thirty-five years, and having treated more than one hundred thousand patients, I have observed generations of health and wellness. I have seen one-hundred-year-old patients who swear that they are still active because they ate red meat and drank whiskey every day. Then there are patients who are forty and look tired and well-worn.

Can we chalk it up to genetics, or has something else influenced how these patients have aged? Your mother and father might be ninety-five years young, still active, and living independently, but does this mean that you will follow in their impressive footsteps? You might think it’s set in stone, but to improve your odds of greater longevity and quality of life, I want to introduce to you a new perspective on health and wellness. While physical fitness is necessary for being successful at the races, it is only one element within the Circle of Wellness, which will enable you to achieve overall wellness.

What is wellness and why should we be concerned about it?

The World Health Organization defines wellness as, A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity¹. For me, wellness is balancing how you live your life and how you respond to what life brings your way.

It’s not easy achieving this balance. Wellness is a continually moving target, a dynamic process that presents you with choices and awaits your decisions. How you aim for this target is up to you.

The Circle of Wellness includes many factors, such as setting goals, developing a fitness plan, evaluating your nutrition, recognizing the mental commitment needed to be successful, and educating yourself and others about risk factors that could affect your health and that of your family.

My triathlon career dates back to the 1980s, when I was introduced to this great sport by a team known as Your Name Here. My first triathlon was the USTS San Clemente, an Olympic distance race (.9-mile swim followed by a twenty-five-mile bike, then a 6.2-mile run) that was very popular back then. On the morning of the race, I was so nervous that I did not complain about the cold water, even though I swam without a wetsuit. My bike was a Nishiki ten-speed with no aero bars, race wheels, or clips. I ran in generic Nikes, and I had a terrific time out there. I was convinced that I had become a triathlete after I accomplished this combination of events and crossed the finish line without vomiting, collapsing, or getting injured.

USA Triathlon (USAT, the national governing body for triathlon) recently released a study looking at fatalities in triathlon. They determined that the rate was about one fatality per seventy-five thousand participants. This rate was not significantly different than the rate for marathons. The report concluded with a list of recommendations to help athletes become more aware of the signs of cardiac disease, and it also discussed medical testing. I will review this later, because I believe this to be invaluable information for every athlete.

As an athlete, do you think that this concept of wellness is just what happens to you when you train for twenty hours a week? Do you believe that because you run thirty miles a week and have a resting heart rate of fifty that you have minimal risk of developing heart disease? Congratulations on completing a hard workout swimming five thousand yards, or a tough, fifty-mile bike ride followed by a six-mile run. But does this mean that you will outlive people who do not exercise? I am here to tell you that this perception is wrong.

I will provide suggestions for better nutrition during your training and racing. Keep in mind that the basics for nutrition for an athlete are broad, and each individual will have to fine-tune these suggestions for daily training and for racing. I will provide you with personal observations along with formulas and charts comparing sports nutritionals on the market today. There is little science proving that one method or nutritional is superior to another. You will ultimately have to make that decision for yourself. I will provide you with reference tables that compare calories, electrolytes, carbohydrates, protein, fat, and fiber in common nutritionals on the market. I will also discuss common issues, including dehydration, heat acclimation, and hyponatremia. I will relate my own experiences and reference articles regarding these common conditions, in the hopes of helping you improve your nutrition on and off the racecourse.

For more than thirty years, I have competed in well over forty triathlons, including ten IRONMAN® races. Along the way, I have experienced many of the injuries of overtraining, and I have felt the disappointments of racing, from getting an unexpected flat during the bike segment to experiencing nearly intractable vomiting and dehydration. I have sustained and rehabilitated myself through many injuries, and I have always managed somehow to cross the finish line.

During times of stress and duress while training and racing, I decided to mentally log how I would need to adapt my nutrition to improve my performance. And over the years, I have researched and personally experimented with various foods and supplements, counting calories, fiber, electrolytes, carbohydrates, protein, and fats—you name it, and I looked into it.

For the record, all these years of data collection did provide one glaring result. There is no one formula that is applicable to every athlete. What is absolutely important is that you respect the need for an informed approach to your nutrition, mental well-being, and training.

It does not matter if you are a runner, a mountain biker, or a triathlete. Hopefully, you will derive some benefit from the knowledge I will present to you. Your own target formula of nutrition for training and racing may be very close to mine, and I will provide you with suggestions on how to customize this for yourself.

The anecdotal stories preceding each chapter may enlighten you