Check out my monthly column at Endurance Corner. This month I describe some recent studies about endurance athletes and longevity.
Ironman and Heart Health: My Take on Things
For those of you who don’t already know him, let me introduce you to Dr. John Mandrola. You can read his musings at his Dr. John M Blog and follow along with his Twitter feed. John is a cardiologist in Lexington, Kentucky, who specializes in electrophysiology; he takes care of patients who have all sorts of abnormal heart rhythms, offering diagnosis and the entire spectrum of treatments available to these patients. He’s also a competitive cyclist and, at some point, was a triathlete, as well.
I particularly enjoy reading his Cycling Wednesday blog posts that are usually devoted to the “intersection” of medicine and cycling. These posts would be recommended reading for most athletes regardless of their sport. What I enjoy most about these blog posts are John’s skill at human observation, his ability and willingness to describe our follies (both physicians’ and athletes’), and his seeming general skepticism about many things. We often see things the same way.
The week before last, Dr. John wrote a blog piece entitled, “Is the Ironman triathlon heart-healthy?” Needless to say, this caught my eye. And, judging from the many comments I received afterwards, it caught the eye of a good many other triathletes as well. I also saw that there was a lively discussion on the Slowtwitch forum, with many triathletes weighing in on Dr. John’s thoughts and offering some personal accounts of various heart ailments as well. I also see that Dr. John received many replies and comments at his blog and felt obliged to issue “An Iron response….” at his blog a couple days after the original post.
Dr. John offered some important thoughts about endurance training and racing and their impact on heart health. These issues are important. His blog piece contained both opinion and fact. And, while it might be easy for me (as another medical professional) to see the difference, I can tell that many readers weren’t able to make that distinction. They got upset about some of the opinions and lost track of the facts. I thought I’d take a moment to separate out the opinions and facts–at least, as I see them–so that our readers might be in the best possible position to draw their own conclusions.
DR. JOHN’s OPINIONS
1. Ironman is the pinnacle of triathlon. No doubt, some people hold this opinion, but I’ll bet that many triathletes don’t. Olympic-distance (draft legal) racing is probably also a contender for being the pinnacle of our sport in many people’s eyes.
The participation rate for Ironman distance triathlon is relatively small. With about 25 Ironman-branded races worldwide each year and some number of other races of iron distance, the number of participants each year worldwide is probably less than 75,000. To put that into perspective, USA Triathlon recently reported that in the United States alone, there were 2.3 million triathlon participants in 2010. I’ve raced in 6 Ironman races over the past few years and each of those races held a pre-race dinner a couple nights before the race. At each of those dinners, 40-50% of the crowd stood up when the first-timers were introduced. With that statistic, it’s obvious that many Ironman participants are “one-and-done.”
2. Ironman triathlon….I don’t get it. Sure. Not everybody “gets it.” I could say the same for golf or tennis. To each, his own.
3. Heart healthier ideas: marathon or shorter running race, bicycle racing, shorter-than-Ironman triathlon. There is ample evidence that aerobic exercise produces long-lasting health benefits, including a longer life-expectancy. There has been speculation that, beyond some amount or intensity of exercise (or a combination of both), there might be some harm, including injury to the heart. I’m not aware of any credible studies, though, that address this issue in terms of the relative safety of 1 endurance sport over another….or race competition of 1 distance over another. In my view, it’s hard to imagine that half marathoners are somehow “heart healthier” than marathoners….or that half Ironman triathletes are somehow “heart healthier” than full Ironman triathletes. This issue about some threshold for harm remains unstudied….and therefore unsettled.
4. Can’t imagine riding for 5 hours continuously at 200 Watts. Obviously opinion. For me, it would be nearly 6 hours at 180 Watts. But BTW, I’m always willing to stop for a cookie break….on a training day OR at the race!
5. Long-term, low-intensity, ultra-endurance exercise (slogging, not racing) isn’t heart-healthy. Opinion. We know that long-term, low-intensity exercise IS heart-healthy. I’m not sure what qualifies for “ultra-endurance” and I’m not sure that “slogging” vs. “racing” makes a difference for the heart. Again, this issue simply hasn’t been studied.
6. The occurrence of fatalities during Ironman triathlong might entice others to participate. Perhaps. I suppose anything is possible, but I haven’t encountered that motivation. It’s important to remember that the small number of fatalities at triathlon races have occurred in races of all distances and the victims have spanned a large age range and ability level–from novice to veteran triathlete. In truth, most triathlon race fatalities have occurred in shorter-than-Ironman races.
THE IMPORTANT FACTS
1. Ironman triathletes are focused. True. Regardless of the particular hobby, anybody who spends 10-20 hours per week doing something is focused.
2. Daily exercise is good. Irrefutable fact.
3. Athletes are more likely to die of sudden cardiac death (SCD) during exercise (or competition) than non-athletes (who don’t exercise). Fact. SCD is not related solely to triathlon, though. A recent study of SCD in the general adult population showed that this occurs in (decreasing order of incidence) cycling, jogging, soccer, hiking, swimming, basketball, rugby, tennis, diving, judo, handball, alpine skiing, table tennis, and body building, among other sports. Cycling accounted for almost one third of the SCD events. Although most of the triathlon race-related deaths have occurred during the swim portion of the race, in the general population SCD while swimming accounts for only about 4% of the total number of episodes. On balance, though, the health benefits of exercise appear to far outweigh the small risk of SCD.
4. Endurance athletes are more likely than non-athletes to develop atrial arrhythmias. Fact. There is overwhelming evidence for this. Many references are included in Dr. John’s second blog post. This issue hasn’t been well studied in triathletes, but there’s no reason to think that triathletes are immune. The influences of exercise duration and/or intensity on the development of these arrhythmias need further study.
5. Scarring in the heart has been found in long-term endurance athletes (and laboratory rats). True. I wrote about the recent studies in a column at Endurance Corner. It’s important to remember, though, that scarring was only found in veterans of many, many marathons….and the clinical significance (if any) has not yet been determined. For now, there is no evidence that the scarring led to a shorter life or was associated with other heart problems in these runners, but these observations merit further study.
6. Heart damage can be detected after an endurance race. True. Studies have shown elevated levels of cardiac enzymes (indicating heart cell damage) in the bloodstream and altered (diminished) heart function by echocardiogram in athletes immediately after running and triathlon events. These abnormalities have not been shown to persist and so their significance (if any) is not clear. Some authorities have speculated that repeated episodes may be harmful.
ONE UNTRUTH
1. Sudden cardiac death (SCD) is “not uncommon” during triathlons. This simply isn’t true. SCD is actually a rare event at triathlons. There is a single report on this issue that showed SCD to occur at a rate of approximately 1 per 65,000 participants. USA Triathlon is convening a Taskforce to examine this issue in further detail and I’m certain that additional information may be reported in the coming months. To give this issue some context, it was reported earlier this year that the rate of SCD among NCAA athletes (in all sports) was approximately 1 per 45,000 athletes per year.
DR. JOHN’s SUGGESTED ACTIVITIES
Let me finish by saying that Dr. John’s list of 7 suggested activities at the end of his first blog piece are great ideas. I need to work on #2, #3, and #6. I’ll report back.
1. Swim a fast and smooth 400-yard individual medley (100 yards each of the butterfly, back, breast, and freestyle strokes
2. Ride a criterium bicycle race
3. Train to knock 1 minute off your best 10 km run time
4. Complete an Olympic-distance triathlon
5. Try touching your toes without bending at the knees
6. Write a blog without a grammatical error
7. Sit still long enough to read a book
In the Medical News: Sports-Related Sudden Death in the General Population
In a scientific article published online earlier this week by Circulation, Eloi Marijon and colleagues at the Paris Cardiovascular Center reported on “Sports-Related Sudden Death in the General Population.”
In recent years there has been a focus on sudden cardiac death (SCD) that occurs in young athletes who are participants in organized and/or competitive sports. There has been much less attention paid to SCD that occurs in athletes (of all ages) who are not part of organized or competitive sports–those who are undertaking so-called recreational sporting activities. The investigators have studied the issue of SCD in this second, much larger group of athletes.
This large, observational study examined the experience in France between 2005 and 2010. The experience included 169,742,000 age specific person-years of follow-up. The investigators considered 2 separate groups:
1. Young athletes, ages 10-35, who were competitive athletes, and
2. Athletes, ages 10-75, who were participants in recreational sporting activities (cycling, jogging, soccer, hiking, swimming, basketball, and others).
Overall, the incidence of SCD was 4.6 per million population per year (860 events total). While a small number of SCD events (50) were observed in the first group, approximately 94% of the SCD events occurred in the group of recreational athletes. If the same statistics were applied to the United States population, we might expect upwards of 4250 cases of SCD among recreational athletes each year.
In the group of recreational athletes with SCD, only 11.7% had a known history of cardiovascular disease or had more than 1 classic risk factor for coronary heart disease. The majority of victims in this group were regular exercisers.
The exact cause of death among the victims was determined for only a minority (24.7%) of the group. If a cause of death was identified, it was cardiac-related in 98%.
The vast majority (93%) of SCD events were witnessed, but bystander CPR was provided in only one third of cases. Survival among the athletes with SCD was very much dependent upon prompt CPR and defibrillation.
SUMMARY
The frequency of SCD among recreational athletes is probably much higher than previously thought. This issue deserves and probably will receive additional investigation. The information provided by this report should prompt or renew discussion about the availability of CPR and defibrillation (AED’s) at venues where recreational athletes participate in their sports.
In the Medical Journals: Athlete’s Heart and Cardiovasclar Care of the Athlete
In last week’s edition of the American Heart Association’s (AHA) medical journal, Circulation, Aaron Baggish and Malissa Wood contributed a review article entitled, “Athlete’s Heart and Cardiovascular Care of the Athlete: Scientific and Clinical Update.” This is the most concise, current review of this topic I have seen and I would recommend this article to those of you with a medical or physiology background.
Over time, I’ll try to put up some posts here at the blog that cover, in layman’s terms, some of the important topics covered in this article.
Six Tips for Athletes to Reduce the Cost of Preventive Medical Care
Readers here at the blog will know that I’ve recommended that adult athletes have a doctor….and that they visit the doctor annually. This sort of medical care falls under the category of preventive care or wellness care. You’ll also know that I’ve recommended cardiac screening evaluations that might include an ECG or echocardiogram.
When I talk to athletes about this issue, it seems that one of the most common barriers is the cost. No doubt, medical care is expensive. Moreover, many young adult athletes have medical insurance plans with high deductibles….or no medical insurance coverage at all.
My friend and professional triathlete, Jusitn Daerr, recently wrote an article entitled, “I’m Young, I’m Fit, What Could Happen?” at EnduranceCorner about his experience with a new-patient office visit and cardiac screening evaluation. I’d encourage you to read his piece. His situation and thoughts are typical for young adult athletes.
Today, I thought I’d offer 6 tips for athletes to help reduce the expense of preventive medical care:
1. Know the price (as best you can)
It may actually be difficult to know (ahead of time) the cost of medical services you might need, but it’s worth your effort to try to find out. Your doctor’s office can readily tell you the typical charges for a new patient or established patient visit. Keep in mind that a follow-up visit often costs much less because the doctor doesn’t need to spend as much time getting to know you after the initial visit. You might feel reluctant talking to the doctor about the costs of any visit, but he/she will probably be very happy to answer questions that you might have.
Your doctor or his/her office staff should also be able to find for you the costs for any laboratory or other diagnostic testing that is recommended. It’s important to realize that your doctor may establish the fee schedule if the test is done in his/her office, but won’t have any part in setting the charges if the test(s) are performed at a hospital or other facility. Nevertheless, the doctor’s staff can help you track down the costs of most any test that is recommended.
Your doctor and his/her office staff can also provide some “local knowledge” about options for where to go for a particular test. Since each facility will have a different fee schedule, it can pay off to do some research about the charges at different facilities that offer the test(s) that you need. Don’t be afraid to ask.
2. Time your medical care to your advantage
By its very nature, preventive care is not urgent or emergent. Office visits and laboratory or other diagnostic testing can be scheduled at your convenience. You should take advantage of that opportunity.
Many athletes will have a medical insurance plan with an annual deductibe….a dollar amount that you must pay fully out of pocket before the “real” insurance coverage kicks in. In recent years, it has become common for plans to have deductible amounts of $500 to $1000 or more. Since preventive care often costs far less than this amount, the cost of that preventive care is often totally out-of-pocket.
If you are somebody who has various medical expenses throughout the year (that add up over time), be sure to schedule your preventive care at a time during the year when you will get the best insurance coverage. This could mean delaying that care until later in the year, once your annual deductible is already met. By doing this, you might enjoy considerable cost savings for your preventive care needs.
3. Find health fairs that offer needed services
Local health fairs are a great oportunity to find some of the preventive services you need….either FREE or at a greatly reduced price. But you have to be willing to do some homework to find these health fairs….and work with your doctor to plan for using the health fairs to get needed test(s).
Justin Daerr brought to my attention a great offering in the Colorado front range area. There is a multi-city, continuing health fair sponsored by 9News. Examples of services that can be obtained at a tremendous cost saings include: blood chemistry (blood tests), blood counts (blood test), blood pressure, bone health screening, breast exam, eye health screening, diabetes screening (fingerstick), hearing tests, lung function test, pap smear, sleep apnea screening, and many others. With a variety of offerings, you could choose WHEN and WHERE to get any needed screening tests….and the results could be forwarded to your doctor for review.
This is just one example. Your doctor’s office can often help you to locate suitable offerings in your area. Keep in mind, too, that in February, during Heart Month, many health organizations sponsor health fairs that are very specific to the heart and cardiovascular systems. It’s often possible to find fairs that offer free ECG’s, heart exams, and exams/testing for peripheral arterial disease of the extremities and neck. It’s not usunual to be able to get $100’s to $1000+ of free services if you plan ahead.
4. Use your HSA if you have a high-deductible medical insurance plan
By law, individuals with high-deductible medical insurance plans may contribute pre-tax dollars (up to $3,050 for an individual in 2011) to a Health Savings Account (HSA) that can then be used to pay for necessary medical expenses. By planning ahead for your preventive care needs, you could make the necessary contribution to your HSA and pay for your preventive care with pre-tax dollars (getting you a “discount” of whatever your tax rate would ordinarily be).
Since preventive care can typically be an out-of-pocket expense, the use of your HSA for this purpose is a no-brainer.
5. Use your employer-based flexible spending account if it’s available
Many large employers offer a flexible spending account as part of their benefits package. Like an HSA, the flexible spending account allows for contribution to the account of pre-tax dollars that are deducted from your paycheck each pay period. The money accumulates in your account until you spend it on qualified expenses. Virtually all preventive medical care and any diagnostic testing recommended by your doctor would be eligible.
Unlike the HSA, however, money in the flexible spending account “goes away” if it is not spent by the end of each calendar year (plus, perhaps a small grace period). As a result, it requires special attention and forethought on your part to make an appropriate contribution choice….and then to spend the money before the end of the year. Even with these burdens, though, the flexible spending account is a terrific way to pay for your preventive care needs with pre-tax dollars (getting you a “discount” of whatever your tax rate might be).
6. Take advantage of wellness benefits of your insurance plan
Lastly, be aware that many employer-based health insurance plans offer some sort of wellness benefit. With the newly passed health care reform package, these wellness benefits will be more and more common in insurance plans, going forward.
As an example, I’ll share some of the details of the wellness benefit offered through my own personal employer-based Blue Cross insurance plan. If I enroll (by answering an online questionnaire at the start of the year), I can get up to $1000 in covered wellness services without paying a cent out-of-pocket. The plan prescribes the eligible, covered services by age group for the plan’s participants.
I hope that these 6 suggestions are helpful. A little bit of knowledge can help an athlete get the most for their health care dollar!