Run for Your Life

by Mark Cucuzzella

  Treating RED-S requires an adjustment to lifestyle that many find challenging. Once menstrual dysregulation has set in, it may take six to twelve months to restore healthy cycles, mainly by shifting gears from a state of physical overload and nutritional mismatch to a state of growth and repair. It’s a matter of choosing health over fitness. For all the benefits of running for women’s health, it’s important to beware that too much running can cause problems, too.

  To put it simply: eat healthfully and dial down the exercise. Bone remodeling and hormonal balance are keenly affected by the quality of one’s nutrition, and improvement will occur from efforts in the kitchen. It’s hard to get all the essential fats (especially omega-3s), amino acids, and B vitamins from a purely plant-based diet, so as a physician I don’t encourage athletes (especially those engaging in high-impact activities) to go vegetarian or vegan. These diets can work in response to specific medical conditions (fasting can, too, in some cases), but we all need the full spectrum of building blocks, especially when active. If they do it scrupulously, athletes can train and compete on a vegetarian-only diet, but it is not the norm. Matt Fitzgerald (The Endurance Diet) traveled the globe to study the diets of the best athletes in all endurance sports. He did not find a single vegan athlete. Perhaps tellingly, traditional cultures reserve the richest, most nutrient-dense foods for women of childbearing age.

  The stresses of life also stress your endocrine system. Find a trusted medical provider (an informed coach, trainer, sports nutritionist, or doctor) who can work with you through the recovery—especially someone who understands you and your commitment to sports.

  THINGS CHANGE, ESPECIALLY IN ADOLESCENCE

  For girls, the rapid changes that occur during adolescence don’t always favor endurance or fast running speeds, and it’s a time when many active young women ease away from sports. Fortunately, Title IX has helped to keep girls and women in the game.

  The adolescent female gains body weight not from overeating but as a result of surges in the spectrum of hormones that drive growth, body shape change, and essential fat storage. Adolescent boys are growing and putting on weight, too, but their testosterone-dominant hormones direct more of this weight into muscle mass. (They don’t grow because they are eating; they eat because they are growing.)

  In other words, females’ hormones prepare and reshape their bodies for childbirth, while males’ surges of testosterone and growth hormone shape and prepare them for more physical tasks. A twin brother and sister may grow up sharing the same diet and activities, and enter adolescence with similar body forms and athletic skills. But they emerge from high school with completely different physical attributes and body fat percentages.

  Peer pressure can be intense during adolescence, and young women are at risk for depression. This makes a simple activity such as running especially beneficial for overall health. During adolescence, physical activity is critical for the development of structural tissues such as bone, muscle, tendons, ligaments, and fascia. But it also enhances metabolism, brain function, mood, socialization, and quality of sleep. It even benefits the eyes, especially in this myopia-afflicted digital age. When you are running, your eyes strengthen by constantly changing focus between far, near, and peripheral distances—as contrasted with the rigidity of continual focus on a screen.

  Health consequences of relative energy deficiency in sport (RED-S) showing an expanded concept of the female athlete triad to acknowledge a wider range of outcomes and the application to male athletes.

  (*Psychological consequences can either precede RED-S or be the result of RED-S.)

  Relative energy deficiency in sport refers to impaired physiological function including (but not limited to) metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health.

  Different patterns of overuse injuries present in adolescent girls, too. As hips widen, foot and knee landing patterns can change, and knee valgus (the knee caving inward on landing) is all too common. “Runner’s knee” (a general term that refers to pain in the knee), IT band syndrome, and other maladies around the knee travel with knee valgus, and are especially common among adolescent women.

  CHANGING EXPECTATIONS WHEN EXPECTING

  In traditional cultures, and until modern times, pregnancy was viewed as part of the cycle of a healthy woman’s life. In many cultures still, women rarely change their activity levels in pregnancy. But when I began my medical career, restrictions during pregnancy (prescribed by white-coated “experts”) began to creep in. Women were discouraged from running.

  Few doctors noticed what is now becoming apparent: physically active women have better pregnancy outcomes. Fortunately, over the past couple of decades the experts have periodically relaxed earlier limitations on activity while pregnant. By 2018, we have finally agreed that it’s best to simply use good sense. In other words, if running makes you happy and healthy, keep running. Run your first hundred-mile race while pregnant? Probably not good sense.

  At the University of Colorado in the early 2000s, I worked in a wildly busy obstetrics fellowship for rural family physicians, delivering babies for mostly young Hispanic women. By and large, the mothers were healthy and enjoyed strong family support, and their labors and deliveries were mostly normal. Rarely did we need to intervene medically, and the C-section rate was in the single digits. In 2018, nearly a third of U.S. babies are now delivered by C-section.

  THE OTHER CHANGE OF LIFE

  Menopause presents its own challenges, in the form of depressed mood, fatigue, appetite changes, loss of desire, sleep disturbance, and a decline in youthful vitality. For decades, hormone replacement therapy (HRT) was routinely prescribed by doctors—until the Women’s Health Initiative linked HRT to a slightly elevated risk for breast cancer and cardiovascular events. Ever since, the search has been on for safer alternatives such as antidepressants and nutritional and herbal remedies—with mixed results. If you’re healthy, the increment of added risk from HRT may not be large, so evaluate your HRT options carefully with a trusted health care provider. Note that there’s no evidence that HRT improves running performance.

  Are there any risks of running during menopause, and later? Not in particular. You can expect mostly benefits, with no side effects or increased risks. But it’s important to remain aware of RED-S and osteopenia, and work your way into a training program gradually. Distance running sensations Colleen De Reuck, Zola Budd, Joan Benoit Samuelson, and Meghan Arbogast continue to rewrite the understanding of what can be done after age fifty.

  TAKIN’ CARE O’ BUSY-NESS

  Running coach and author Elinor Fish has struggled with occasional fatigue, particularly as a parent. “As I get older and life seems to move ever faster, filled with more pressures and worries, fatigue issues arise more frequently. This can make it hard to run consistently, and at times has been so severe that it was all I could do to get through the workweek—in order to spend the entire weekend in bed. My poor husband had no idea how to help me.

  “In response, I began to research stress. I was shocked to learn how profoundly stress affects the body and contributes to chronic health issues. I’m especially sensitive to this because I have an autoimmune condition that flares terribly when my stress levels rise.”

  Once Elinor started to actively manage her stress, she said, her vitality and desire to run began to return. Now many women runners who are facing the challenges of demanding jobs and family lives come to her with their stories of stress-induced and fatigue-related health problems. “Their busy schedules have left them with little time for self-care, including activities that relax the mind and restore their energy,” Elinor said. “This is significant because women physically respond to stress differently than men do.”

  Elinor’s experience aligns with that of Arianna Huffington, who in her book Thrive explains that women are paying a higher price than men for their participation in a wor
kforce fueled by stress, sleep deprivation, and burnout.

  THE MAGIC OF TWO FEET OFF THE GROUND

  Is all of this running a good thing? Why do millions of women around the world take to running, and even endure injuries to keep doing it? Why not just walk, cycle, swim, train on an elliptical, or just squat repeatedly throughout the day?

  My wife’s cousin Meaghan Cusack exemplifies how our need for full mobility and body movement—of the kind that running provides—is ingrained in our DNA.

  Meaghan describes her youth as not very athletic. “I dreaded the day in gym when we filed outside for the mile run. It was only four laps around the school, but it felt like a marathon.” At the age of ten, she developed a pain in her ankle in gymnastics, and limped around for several weeks. Multiple ankle X-rays showed nothing. A few months later, she noticed a lump near her knee, and was diagnosed with osteosarcoma, an aggressive form of bone cancer.

  More than two years of chemotherapy, relapses, and failed attempts at joint salvage finally came to a conclusion when doctors found that the cancer had spread to her lungs. It meant another year of chemotherapy.

  Her leg had been valiantly trying to heal in the midst of it all, but the final year of chemo was the last straw. Her father was in tears when the doctor pulled up the X-ray of her lower leg. The bone was nearly gone, and they knew it would never heal. Two days later, the hospital room filled with family and friends who prayed over her as she was wheeled into surgery to amputate her leg above the knee.

  Meaghan never allowed the disability to limit her goals. After graduating from college, she went on to get a master’s and a Ph.D., while learning to walk on various prostheses and competing in cycling events. But she never ran. Until, that is, she met a prosthetist who asked her if she would ever want to try running again.

  “I was hesitant at first,” she said, “but he gave me a prosthetic running foot, and I took it home to try. Starting in the hallway of my building, I cautiously planted one foot in front of the other, then gradually lengthened my stride and increased my pace.” Now she’s hooked on 5K races.

  What was Meaghan reexperiencing, after more than eleven years, that compels her (like others) to continue running?

  “I felt I was flying,” she said simply. “Both feet were in the air at the same time.”

  That’s precisely what’s happening in joyous midstride, when both feet are airborne (whether you have two original feet or not). “My trainer had to tell me to slow down,” she added. “He saw that I risked burning out.”

  Slowing down can be hard when you suddenly realize that you were born to fly.

  Meaghan Cusack out “flying”

  Ultra runner Sara Davidson challenges herself—and the trail.

  DRILLS

  Knee valgus and noncontact ACL injuries tend to occur more commonly among women. The drills related to single-leg strength, balance, and foot and hip control are foundational, and are described in other chapters:

  Single-leg stance

  Single-leg run drill

  Proper squats

  Box jumps, done correctly

  Regarding nutrition, women in particular might want to note this dietary advice:

  Eat plenty of iron-rich foods (iron is lost during menstrual cycles). Red meat has the most bioavailable iron.

  Get adequate vitamin D from food and sunlight, for bone strength. Check your level. Optimal is greater than 50 ng/mL.

  Foods with vitamin K and K2 are essential for hormonal function (quality meat, seafood, eggs, leafy greens, and full-fat dairy). Don’t be afraid of high-quality organ meats, and eating “tip to tail,” as traditional cultures do, and look for dark, leafy greens such as spinach, kale, chard, and broccoli. These contain fat-soluble vitamins, so they work better in combination with butter, olive oil, eggs, dairy, and meat than they do separately.

  If pregnant, you will become more prone to insulin resistance, so don’t overload on simple (processed) carbohydrates. If your body is craving a certain food, you are likely missing something essential, and may benefit from consulting with a nutritionist or medical provider. Eating nutrient-poor foods rarely curbs these cravings, so chuck the junk!

  If you have any unexplained symptoms, especially if neurological, check your B12 status. Optimal is greater than 500 pg/mL.

  And destress. As Elinor notes above, women can find a place of joy and grace in running. Talk a friend into joining you for a short run.

  CHAPTER 16

  Young at Heart

  Our growing softness, our increasing lack of physical fitness, is a menace to our security. We do not want in the United States a nation of spectators. We want a nation of participants in the vigorous life. This is not a matter which can be settled, of course, from Washington. It is really a matter which starts with each individual family.

  —PRESIDENT JOHN F. KENNEDY, Conference on Physical Fitness of Youth, 1961

  Kids today are under house arrest.

  —UNKNOWN

  Play as if your life depends on it.

  —FRANK FORENCICH

  MYTH: Thanks to superior nutrition and training, today’s youth are healthier than at any point in history.

  FACT: Children today are a minute slower in the mile run than children of thirty years ago, and more than a third are overweight or obese.

  In America, we have built an entire culture around elite youth sports. Children and teens are groomed to excel, and selected youth are channeled into specializing in a single sport, often in order to chase the elusive goal of a college scholarship.

  This parental preoccupation with excellence isn’t healthy for kids. By nature, most children are motivated by a love of play, and they should be allowed and encouraged to define their own level of involvement in sports. When parents confine themselves to offering support and a place to play (and setting inspiring examples, themselves), they see better results than when they prod and push and challenge. The most significant influence on a child’s level of physical activity is the parent’s level of physical activity.

  THERE’S NO SURE APP FOR THAT

  It would seem, judging by our fascination with sporting events (and the piles of money lavished on professional teams), that American kids are fitness-crazed, and from an early age. The reality is very different. The total number of children engaged in daily exercise, formal or informal, is low and declining. In 2016 the Sports & Fitness Industry Association determined that the number of youth aged six to twelve who were active through sports on a regular basis fell to 26.6 percent—continuing a slide from 30.2 percent in 2008. The quality of the exercise is declining, too, such that the modest amount of exercise each child gets may not be contributing a lot to overall health.

  This isn’t due to lack of awareness. Most of us know that exercise is good, yet we’ve been gradually, insidiously sidelining regular activity for kids. Funding for physical education and fitness programs in schools has consistently been cut, and only about a quarter of children engage in physical activity outside of school. Poor nutrition, lack of recreational opportunity, and excessive computer and smartphone time all may be contributing to declining leisure time activity. The American Medical Association and other sources clearly state that decreased physical activity plays a critical role in the increase in obesity, morbidity, and chronic diseases among youth. Some observers rationalize that the incidence of obesity has plateaued in the past few years—though at a very high level. This ongoing epidemic doesn’t need to be stabilized. It needs to be reversed. Data from 2017 unfortunately show childhood obesity is still on the rise.

  A HEFTY DEFENSE CHALLENGE

  Obesity and poor fitness are the biggest contributors to a startling statistic. According to 2017 Pentagon data, 24 million young Americans between the ages of seventeen and twenty-
four—71 percent of the people of that age group—are ineligible to serve in the United States military. This is especially distressing when we consider President Kennedy’s concern, expressed a half century ago, about the poor physical condition of the country’s youth. Indeed, the first warning call was sounded in the late 1950s, when it was discovered that 58 percent of American children were unable to pass a basic fitness test. Fewer than 9 percent of Europeans failed the same test. President Eisenhower, and later Kennedy, saw the problem and took action.

  Kennedy recalled that Theodore Roosevelt had required Marine officers to march fifty miles in three days, and in 1963 he challenged the commander of the Marines to see if his troops were in comparable shape to those of the early 1900s. Bobby Kennedy attracted media attention when he walked fifty miles from Great Falls to Harpers Ferry on the C&O Canal towpath—in a pair of oxfords, in freezing conditions—and made it in under eighteen hours. The fifty-mile challenge became a national craze, drawing in housewives, students, scouts, seniors, soldiers, and everyday citizens. The JFK 50 Mile was born out of this movement, and the route overlaps part of our annual Freedom’s Run marathon, which starts in Harpers Ferry, West Virginia.

  A STATE WITH SOME WEIGHT

  Changes in diet and lifestyle have impacted not only personal performance and the conditioning of our armed forces. Increasingly, young people in general are at risk from diseases that can diminish the quality, productivity, and length of their lives. The CDC estimates that 75 percent of health care dollars are spent on chronic diseases that could be prevented. In 2011, they report, chronic diseases comprised seven of the top ten causes of death, and 86 percent of all health care spending was for people with chronic medical conditions. (End-of-life care is no small portion of this.)