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When working with my patients I try to practice what we call evidenced based medicine.  In short, evidenced based medicine means using well conducted scientific studies to make medical decisions.  The current medical literature suggests that running does not lead to arthritis.  Konradsen conducted the landmark study that best addresses this issue in 1990.  After an average of 40 years of long distance running (12-24 miles per week), there was no increased chance of arthritis of the hip, knee, or ankle.  A recent German study in March 2004, pooled data from 13 different studies and found no evidence that running increases the risk of arthritis of the hip.  In the Annals of Internal Medicine October 1994, runners over age 50 had a 4.3 times lower risk of developing a disability than non-runners.  Runners were proven to be leaner, reported joint symptoms less frequently, took fewer medications, and had fewer medical problems.

What about the overweight runner? Another recent study showed that the chance of getting a hip or knee replacement is 35 times higher in the obese population. As our population becomes more overweight, I am convinced that any potential negative effect of repetitive impact to the joints from running is far outweighed by the health benefits and weight loss associated with running.

What about patients with previous injuries?  Patients who have had a traumatic knee injury, in particular, a torn anterior cruciate ligament (ACL), do appear to have an increased risk of arthritis.  However, the literature has not established a causal relationship between running and arthritis in these patients.  That fact is that people who have torn their ACL are at increased risk of developing arthritis.  However, there is no literature to support that this occurs at an increased rate comparedIn these athletes, long distance running may predispose them to arthritis.  Instead, these athletes should pursue non-impact sports such as cycling or swimming.  There is more controversy regarding patients who have had their meniscus removed (meniscectomy).  Early research suggested that patients who had open (not arthroscopic) total meniscectomy are at a high risk for developing arthritis and should avoid running.  However, a new study from the American Academy of Orthopaedic Surgeons showed that 15 years after arthroscopic partial meniscectomy, the patients who continued to run or play sports (such as basketball) had less arthritis and less knee pain.  Thus, I am now recommending that patients who have had an ACL tear or an open total meniscectomy avoid long distance running, and those who have not should pursue regular running.
As an orthopaedist, what do I do to prevent arthritis during my running career?  I train carefully and listen to my body.  I cross-train on the bicycle and in the pool.  When I have an injury (such as tendonitis), I use ice and rest until it starts to improve.  I also take a nutritional supplement, Cosamin DS, which contains glucosamine and chondroitin sulfate.  Glucosamine and chondroitin are nutrients that our body needs to make cartilage.  Unfortunately, the University of Maryland School of Pharmacy studied 15 different brands of glucosamine and chondroitin and found that 5 of them had no active ingredients.  Only Cosamin DS (made by Nutramax, available at Davidsons, Publix, Walgreens, Kash-n-Karry) contains enough ingredients in the correct formulation to be effective.   While I do not believe that Cosamin DS reverses arthritis, I do believe that it prevents inflammation and inhibits arthritis from progressing.
In conclusion, there is no good scientific evidence to suggest that running leads to arthritis.  There is a large body of evidence that proves that running has significant health benefits, most notably a substantial reduction in cardiovascular disease.  If you have never had a significant knee or hip injury, you should become a life-long runner.

As a new or novice runner or walker you may not be able to imagine how much friction can develop as our shirt or singlet rubs against our chest and nipples.  After all, most of us wear shirts throughout the day at work or home and don’t have to worry about chaffing.  What makes our long workouts or race day so different?  First is the distance – the more steps we take, the more times our shirt will rub against our chest.  In addition, during these longer workouts we will sweat a little more than we would on our normal training runs during the week.  Sweat is composed of water with salt and other electrolytes.  I’m sure everyone has seen someone with white crust around their face after a work out.  That white crust represents the salt and other electrolytes that were lost during the workout.  Just like the grit on a piece of sandpaper, the salt and other electrolytes excreted in our sweat are very abrasive to the skin.  These two elements work together to create the perfect storm that labeled me a rookie during my first marathon.

As a family medicine physician, I occasionally have to provide professional advice to a new mother on breast feeding.  You might ask yourself, what does breast feeding have to do with chaffing.  Ask any women who has breast fed a child and you will find your answer.  It should be noted that the skin around the nipple is not capable of forming calluses or “toughing” up.  This news is never very welcomed by the new mother.  We should learn a lesson from all the mothers out there – trying to suffer through chaffing hoping that your chest and nipples will get accustomed to the friction is a painless exercise in futility.  Prevention is the key to chaffing.  There are many tricks to avoid it..  The first and most commonly used method is covering the nipples with Band-Aids.  This is the method that I have found most successful.  There is even a company that developed a product called “nipguards” that are designed specifically for this purpose.  I prefer cheaper spot Band-Aids from your local drug store.  I typically buy the clear version so that I’m not embarrassed walking through the locker room at my exercise club after I’ve forgot to take them off.  The other commonly employed method for prevention is Vaseline or Body Glide.  I find that both of these are effective but can sometimes leave a yellowish tint to your running clothes.  However, I do find that they can be very effective in other areas that are prone to chaffing – between the thighs or under arms.  For women, I highly recommend being fitted for a proper running bra.  When I am standing in the finish line chute greeting all of the finishers I hope I don’t see any of those scarlet streaks.

First, invest in a good pair of running or walking shoes that have been properly fitted for you and your unique foot type. Every time your foot strikes the ground, forces equal to 4-5 times your body weight must be absorbed by your body; most notably, your bones, muscles, tendons, and ligaments. Your shoes are you first line of defense in absorbing these forces. It’s important to ensure that your shoes provide the support and cushioning you need to protect your body from the impact of running and walking. I highly recommend seeing a running or walking shoe expert before you begin your training program. There are several stores in Columbus that specialize in running and walking shoes.

Walk before you run!   I recommend a 5-10 minute warm-up walk before running followed by a cool-down walk. This allows for increased blood flow through the muscles you will be using during your workout. Some studies have shown that this is a very effective means of reducing the risk of injury. In the beginning if you can’t run continuously for the entire time take walking breaks and start running again when you feel up to it.

Frequency – begin running / walking at least three times a week.   Gradually increase the frequency of you workouts to 4-5 times per week. Don’t workout two days in a row for the first six weeks.  Give your muscles and bones a chance to adapt to the new training program

Duration – when starting out, run for a specified period of time, not a distance.  Your running program should be designed to gradually increase the time you spend on your feet, rather than the distance. I recommend starting with 20 minutes and gradually increasing to 40-60 minutes. Avoid drastic increases in your program. I typically recommend increasing by no more than 10% per week. For example, if you ran or walked for a total of forty minutes one week, don’t increase by more than four minutes the following week.

Intensity – don’t focus on getting faster until you have reached your frequency and duration goals. Be patient!  Increasing your intensity while increasing your frequency and duration will lead to injuries. Don’t be in a hurry to enter a local road race no matter how much your friends and family pressure you.
Make it fun and find a friend or family member to train with.  Camaraderie during a workout can make the time more enjoyable. It’s also helpful to run or walk with someone to judge how fast you are going. If you can’t talk to the person next to you then you need to slow down. In addition, knowing that someone else is counting on you helps to ensure you will stick with training schedule. Consider joining a training program. Columbus offers several different training groups that meet on different days and in various locations throughout the city. I happen to be a coach within the MIT – Marathoner in Training program. MIT is one of the largest marathon and half marathon training programs in the country with nearly 700 members. The program has successfully coached thousands of runners and walkers across the finish line of their goal race.

The greatest challenge of training for a marathon or half marathon is not finishing the race but making it to the starting line uninjured and well rested. Hopefully this information will greatly reduce your chances of incurring an injury along the way. Good luck and we’ll see you at the finish!

Do you have any written info you could forward to me about diluting/not diluting Gatorade and/or the use of gels with Gatorade?  I train with a club in Indianapolis but both of our main coaches are very “old school” and use nothing but water and don’t have much knowledge about using Gatorade, diluting it, or using with gels.

ANSWER

I would strongly suggest you never ever dilute Gatorade, that is not the way the product is intended to be used.  Gatorade is a 6% carbohydrate solution, and that is not by accident.  We know from a tremendous amount of research on hydration and gastric fluid emptying that the ideal concentration for carbohydrate solutions to leave the gut most rapidly is between 6% and 8%. (As a related aside, Powerade is a 6.5% carbohydrate solution and Accelerade is a 7% carbohydrate solution.).  You want the carbohydrate that is in these beverages to leave the gut as rapidly as possible so it can be in the bloodstream where it can then be utilized by your working skeletal muscle cells to allow you to run.

Additionally, Gatorade has electrolytes (sodium and potassium), which your body absolutely requires if your exercise session exceeds 60 minutes.  Your sweat contains electrolytes and if you do not replenish those during your run you greatly increase your likelihood of cramping later in a race, which it sounds like you experienced.

My advice is to take Gatorade at every aid station during your marathon, even the early ones, from mile 1 on.  The only exception to this would be if it is an aid station where you ingest a GU, or some other gel pack.  If you take a gel make sure to swallow it with water, not Gatorade, as you do not need the additional carbohydrate or electrolytes due to the composition of the gel pack.

Finally, make sure you practice your runs with Gatorade and gels if that is your race plan.  If you are not used to doing this in your long runs it is not a good idea to make the race your first experience with Gatorade or gels.

Best Wishes,

Dr. Devor

Steven T. Devor, Ph.D., FACSM

QUESTION

Dr. Devor,
Lately my running workouts with the group have been feeling a lot harder, and I think it might be related to my eating.  I am confused by what to eat before my workout.  My stomach is sensitive and is easily upset by too much food.  Also what about carbohydrates and protein before exercise, or should I eat mostly fat before a workout?  Is there any difference if I am going to be weight lifting or running.

ANSWER

Thanks for your question.  As I have discussed many times in my talks to the group, eating before training or a race is crucial to enhance your performance and make you feel better while running or doing other exercise.  It is important to get the right combination of foods in your pre-exercise meal.  As your question indicates, I believe the confusion is still mainly with what to eat before exercise.  Should it be carbohydrate, protein, fat, or some combination; that is what I will address.  I can also offer you some suggestions for your sensitive stomach with regard to pre-exercise meals, and help with your confusion about protein before a workout as well.

The bottom line is this:  when you eat carbohydrate rich foods prior to exercise you will not only perform better but also feel much better during your workout.  Carbohydrate is the preferred fuel for your body during exercise, and is the only fuel your brain and motor nerves are able to utilize as fuel.  In spite of all the claims, misinformation, and the idea of “fat burning zone”, it is a fact based upon a significant amount of very well done scientific research in my lab and others, that the percentage of fat burned during exercise is NEVER greater than the percentage of carbohydrate that is burned.

I believe this is where the confusion comes from and where the the idea of a “fat burning zone” came from.  Do you burn more fat as fuel at lower intensities of exercise compared with higher intensities of exercise?  Yes.  However, and this is the important part, the percentage of fat that is burned is NEVER greater than the percentage of carbohydrate that is burned. For example, even when you are exercising at approximately 50% of your VO2max, which for most people is walking quickly (roughly 4.0 mph on a treadmill with a 0% grade), we are still burning approximately 60% carbohydrate and only 40% fat.  For most people when they are exercising, they are at a significantly higher intensity than 50% of their VO2max.  Consequently the amount of carbohydrate they are burning is increased well beyond what is being burned at the 50% of VO2max intensity.  So the whole idea of a “fat burning zone”, is simply not true and is extremely misleading for many people.  Further, it is precisely why it is so critical to have adequate carbohydrate in your diet if you are engaged in regular physical activity.

While it is true that when you exercise on an empty stomach it permits your body to burn more fat, this does not typically translate to a reduction in body fat (i.e., stored calories).  When the body must utilize fat for fuel during exercise (because no carbohydrate is available), it requires you to work out at a lower intensity, and that means that you are burning fewer calories per minute of exercise.  To really burn excess body fat (once again:  stored calories), you need to exercise at a higher intensity.  When you have supplied your body with adequate carbohydrate you will use that food to power your exercise, and that means you will be able to burn more calories per minute of exercise. When carbohydrate is not available, your intensity drops, both physically and mentally, and exercise on an empty stomach generally feels much harder.  So, choose a satisfying meal or snack, but keep the high calorie additions to a minimum if you are trying to lose body fat.  Allow 30 – 60 minutes to digest the food and then hit a high intensity workout.  Try these lower calorie, carbohydrate-rich foods to fuel your workouts:  Unsweetened cereal with skim milk and fruit, or whole wheat toast with light spread of almond butter and preserves, or maybe a low-fat yogurt-fruit mix.

Since your stomach is sensitive and frequently gets upset, I would suggest you go with low fiber and low fat foods before exercise.  Try to eat at least one hour before you exercise and skip high fiber cereals and peanut butter.  Fiber and fat take much longer to digest and are therefore in your stomach longer and cause it to work harder, not what you want if your stomach is already sensitive before you exercise.  You want the food that you eat before a workout to be digested and out of your gut when you start exercise.  I would try a banana, whole wheat English muffin or bagel, and perhaps some low-fat yogurt.

As important as carbohydrate is to fuel your aerobic exercise, it is equally as important before you do your resistance training to fuel your skeletal muscles for the lifting they are about to do.  Another well entrenched myth and bit of misinformation that exists for many people is that you need to ingest pre-exercise protein to fuel your resistance training workouts.  Once again, this is simply not true.  Most resistance training is very high intensity exercise, especially when you are being pushed by a personal trainer or a workout partner.  Just as with aerobic activity, the higher the intensity of exercise, the greater the percentage of carbohydrate that is required to work your hardest and get the most from your weight training session.  If your carbohydrate availability is low, you will lose physical energy and mental focus and your workout will suffer.  Proteins are very complicated molecules, and your body will never choose them to fuel exercise, unless your carbohydrate and fat storage is completely depleted.  It requires a significant amount of energy to simply break down proteins we ingest, and so they become a very inefficient way to fuel exercise.  Protein is an absolutely essential part of your diet for many reasons, but it is not used to fuel exercise.

To get the most benefit from your weight training focus on consuming adequate protein AFTER your workout when your skeletal muscles are in need of the protein for repair and growth.  I suggest post workout meals of lean cuts of chicken and turkey, salmon, nuts and nut butters, and Greek yogurt.  Beans and legumes are also great sources of protein as well as fiber and carbohydrate.  If you are a vegetarian or vegan athlete, you can consume adequate protein by incorporating soy products such as tofu, tempeh, and seitan into your diet.

Best wishes for your continued training success.

Dr. Devor