Monday, August 24, 2015

Marathon Training Update from Dr. Brandon Larkin; "Choose Your Own Adventure--The Long Run of Doom!"

Do you remember the “Choose Your Own Adventure” book series?  Huge in my life as a child.  I read every one of them.  Several times.  (That was the point, you know.)

Just in case you were not a purveyor of children’s literature in the eighties and have no idea what I’m talking about, CYOA was a collection of books in which you determined the plot.  The stories started out harmless—a regular kid having a regular day.  Heck, it could have been you.  In fact, it was you!  Some crazy sequence would occur and you were smack dab in the middle of a volcano.  And you drove the plot—“Choose option 1 to hike up the stairs to get away from the smoldering lava, turn to page 25.” Or choose option 2 to jump over the liquid fire, turn to page 44.”  Eventually you’d either win the day….or get killed.  But the beauty part was that if you got killed, you just start over and make a different pivotal decision.  And if you were in a pinch, you could just peek ahead and look for “THE END” on your chosen page, then flip back because those two words were pretty much a death sentence.  But you would only do that if you were a big ol’ cheater.

So let’s play “Choose Your Own Adventure—Long Run of Doom”

You’re on a 16-miler around the hills of beautiful Queeny Park.  It’s beautiful scenery, but as usual, it’s hot and humid.  Kind of like running in the Mekong Delta.  (See what I did there?)

You’re half way around your fourth four-mile loop, and your running buddy, Suzi, is starting to sag a little.  She’s been cramping for the last couple of miles, but now she’s starting to get dizzy and confused, and she’s throwing up.  She looks rough.

Do you:

1: Start pushing fluids.  She’s been drinking the whole run, but it’s hot and she’s sweating something fierce.  It must be dehydration.

2: Try these salt tabs you bought last week.  And how about an ambulance?

Suzi’s been drinking Nuun and Gatorade non-stop for two hours, so more salt probably isn’t the answer.  She needs more fluids, right?

You choose option 1.  (Just do it.  The story works better that way.)


Nice job. Some friend you are.


Fortunately, especially for Suzi, I’m going to let you turn back and choose option 2.  But wait, why does she need salt? You would have thought she would have had plenty of salt from the sports drinks.  Turns out you were wrong. 

Suzi is suffering from exercise-associated hyponatremia (EAH).  Because of the steamy forecast, she prehydrated all day yesterday and this morning with water and sports drinks.  This caused the concentration of sodium in her blood to decrease and the continuous drinking during the run made it even lower—dangerously low. 

So where did Suzi (and you—you’re not off the hook yet) go wrong?  She followed the dogma of overhydration.  The one that tells athletes to drink and drink and drink.  And then drink some more.  Gotta keep hydrated to replace the fluids lost by sweat, right?  And that means drinking like a fish, right?

Well, wrong.  In fact, too much water during exercise can be incredibly dangerous.  And even replacing fluids with an electrolyte containing beverage like Gatorade or Nuun isn’t safe.  These sports drinks are more dilute than your blood, so they’re considered “hypotonic.”  That means that drinking them will not increase the sodium concentration in your blood.  Rather, it makes things worse.

Too much water or sports beverages over an extended period can cause hyponatremia, or low sodium concentration in the blood.  We replace lost fluids when we drink it, but not enough of the sodium is replaced, and the blood in our body becomes diluted. Hyponatremia can be incredibly dangerous, even deadly. 

So there needs to be a balance, but do we really know how much to drink and what to drink and when to drink it during a prolonged bout of exercise?

Fortunately, new guidelines about this topic are hot off the presses, having been published in the July 2015 issue of the Clinical Journal of Sports Medicine.  It’s an 18-page article that I’m going to distill down into one sentence for you. (It’s OK.  I like reading this stuff. You’re welcome.)

Lean closer. Here it is: “Drink when you get thirsty.” 


Now, some believe that this strategy is a sure path to dehydration, but based on the research, we know that the thirst sensation is a finely tuned mechanism for maintaining normal fluid concentration.  It does a pretty good job of protecting against excessive dehydration.  And while controversial, most of the research supports that mild levels of dehydration (up to 2-3% of body weight) are tolerable and don’t overly affect performance.  The only concern here is in extreme environments or with especially aggressive prolonged activities that may lead to rapid dehydration.  In these cases, drinking to thirst may not be enough.  But situations like this are pretty rare.  (Think ultramarathons and Ironman Kona.)

If you want to be a little more scientific about it, pre- and post-exercise weights are a good way to determine the total amount of fluid to replace.  The goal should be to replace enough fluid to maintain a consistent weight or to come in a little less after exercise.  You should NEVER weigh more.  This method is relatively involved, as we don’t often have a scale readily available after completion of a run.  And it doesn’t account for the weight of the non-fluid nutritionals you put in your body during a long run or of the, ahem, other substances that leave your body during pit stops.  (Insert your favorite poop joke here.)

If you’re technologically inclined, there are apps into which you can feed the ambient temperature and humidity, your weight, and other important data to get a handle on your fluid requirements.

But here’s the deal.

Your body already does this.  Really well.  Without wifi.  The body is filled with receptors that monitor your fluid volume and electrolyte concentrations—in real time.  And these receptors give constant feedback to your brain about the situation on the ground.

And you know what it does when your internal fluids start to drop too low?  Your body, supercomputer that it is, says to your brain, “Hey! You know that water bottle sloshing around on that belt down there?  Use it, dummy.”

Your body makes you feel thirsty, so you drink.  And that’s that.  If you drink according to thirst, you stay hydrated in a safe way. 

So if our buddy Suzi had just been drinking when she was thirsty and not freaked out about the heat, we wouldn’t be in this mess.  (So, let’s blame her.)

Now, I mentioned salt supplements as an option above.  A quick note: Salt supplements can help replace depleted sodium.  In fact, oral sodium is the treatment for hyponatremia out in the field before an affected athlete can get to the hospital.  Studies recommend 4 bouillon cubes in a half-cup of water for anyone exhibiting signs of mild EAH. (Yum.) 

What they don’t recommend is more sports drinks.  The benefit of the sodium in these beverages is far outweighed by the volume of fluid it takes to deliver it when you drink.  So Gatorade isn’t going to fix anything.  And if you still overdrink while you’re taking salt supplements, you can still get EAH.

At any rate, overhydrating by constantly drinking during a prolonged bout of exercise increases the risk of hyponatremia and is potentially disasterous.  So stop doing it.  Drink when you’re thirsty.  And don’t forget to pack your bouillon.

Suzi will thank you.

THE END, for real. 

Tuesday, August 11, 2015

Straight from the trenches! Dr. Brandon Larkin talks marathon training and the "Platoon-St. Charles" in this week's #trainingtuesday blog!

Humans are tribal animals. They seek others for support and survival, especially in times of great stress.  That’s why groups of people who live through trauma together tend to be bound to each other for life.  They’ve shared the same horrible experiences and feel as though only those who were there with them can truly understand the emotional toll.  We see this during famine and wartime.  And we saw it this past weekend on the harsh burning trails of the St. Charles Riverfront.

I have never been in the military, and I’ve never faced a situation in which my life was truly in danger. But I’ve seen a lot of war movies, so I’m pretty sure that makes me an expert on the interpersonal relationships of a basic military unit.

Welcome to Platoon—St. Charles.

Let me set the scene.  While war takes soldiers to some of the harshest terrain in the world—the jungles of Vietnam or the dusty deserts of Iraq—our environment was almost just as treacherous.  In striking similarity to the Mekong Delta, the weather at the start of this 17-mile run was 75 degrees with 83% humidity.  5 brave souls headed northeast on the rocky Katy Trail along the Missouri River.  Not all five would make it back.

The cast of characters is usually pretty much the same, whether in the movies or, I’m assuming, in true wartime conflict.  So let me introduce you to our players—the 9:30 minute/mile pace group.  During my weekend long runs, these folks are the ones with which I spill blood, sweat, and tears on the pavement as the miles tick by.

Sarah:  “The Commander” AKA “Coach”
Sarah serves as the leader of the cadre, both logistically and inspirationally.  She’s an experienced marathoner and knows how to get the most from her men.  And women.  And while she’s the spiritual leader of the crew, she is prone to operational errors, like losing track of the correct course or forgetting gear that is vital to mission success—like her pacing watch.

Lisa: “The Grizzled Veteran”
With over 25 years of distance running under her belt, Lisa does things her own way.  And she’s respected for it.  She doesn’t have patience for things like “rules” and “schedules.” If you don’t like how she does things, too bad.  She’s been around too long to take any lip from you, Buster.  “Good luck, kid.  See you on the other side.”

Leslie: “Pancake”
Whether it’s a distraction technique or simply a quirky preoccupation, Leslie’s the one always talking about food.  Pancakes for breakfast after the run.  New restaurant for dinner that night.  She forces you to fantasize about the comforts of home while you’re trudging through the hell of war.  Or in this case, marathon training.  Think Bubba in Forrest Gump.

Brent: The “Go On Without Me” Guy
Brent sweats.  A lot.  Hydration in these high heat, high humidity situations is always a concern.  As the temperature rises, Brent starts to drift behind.  But as a good soldier, he doesn’t want his personal struggles to jeopardize the success of the mission.  So he urges us forward, often at his own peril.  There’s always this guy in the movies.

Me: “Pollyanna”
I try to stay positive, even in the face of massive hardship.  “C’mon guys! It’s a character building exercise!  We’re fine!”  In the movies, this guy usually gets killed in the first 30 minutes.  Sometimes by his own men.

So we set out on our mission.  It’s hot. It’s sticky.  There are a lot of miles ahead of us.  And for the first half of the run, we’re okay.

Me: “C’mon guys! It’s not that bad.  The sun isn’t even blazing yet.”

Assorted grumbles.

Brent’s already sweat through his shirt.  We’re a half a mile in.

At our first stop for provisions around mile 8, some of the squad starts to show cracks.

Lisa: “I’m not going out all the way for the second loop, whipper-snappers.  I’ve done this enough.  I don’t want to get out too far and get in trouble.  It’s about the effort, not the mileage.”

Doubt starts to creep in.  The crafty veteran has made her play.  She’s got a point.  Should we follow? She’s knows her stuff and she’s got a feeling.  Who am I to not trust it?  But Sarah’s in charge.  Follow the chain of command.

Now we set out toward the southwest.  The trail is crowded now.  The carnage is immense.  Marathon and half marathon trainees are littering the path.  Few are smiling.  Most show no emotion.  Steely determination? Or dehydration induced disorientation?

I should mention that at our resupply stop we picked up a new character—Rachel.  Rachel commands another squad, but she’s now running with us.  I can only assume all of her men have become casualties.  She plays the cinematic part of the new leader who takes over after the original one gets killed or wounded or sent back home due to mental breakdown.  Sarah’s still with us, but she doesn’t really seem to be truly “with” us.  We’re all scared.  Rachel tries to pick up morale.

Rachel: “Alright guys, we’re almost there.  Just a few more miles.  Oh, and by the way, I’m knocking off early.  I put enough miles in already earlier this morning.”

Dang it.  That didn’t help.

Brent starts to sag.  He hasn’t spoken since mile 9.  Lisa turns back for basecamp.

Lisa: “Good luck kid.  See you on the other side.” 

We urge Brent to a forward position.

Brent: “I’m no good, man.  Go on without me.”


Brent: “I’m only going to bring you guys down.  You have to go on!”

Brent softly, quietly, turns back and heads to basecamp.  We don’t go after him.

Now we’re down to three and our plus one, until Rachel mysteriously disappears for a few miles.  Captured? Worse? Just kinda tired of all the running?

We’re down to three.  We’re in bad shape.  No one is talking.  Except Leslie.

Leslie: “Pancakes.”

Rachel reappears.  Is she a double agent?  She’s got pep in her step now.  Is that even really Rachel?  I’m not well.

We reach basecamp.  Rachel bugs out with a smile.  I’ve never trusted her.  

We get a visual on Lisa (feet in the ice bath chomping on a cigar—total veteran move) and Brent (in the ice bath, surrounded by medics with two large bore IVs dropping liters of fluids into his thirsty veins).


Three of us set out for the last sortie—Sarah, Leslie, and myself.

Me: “It could always be worse!”

I’m pretty sure sniper fire just misses me.  I assume it’s from a friendly.

Me: “Okay.  This kind of stinks.”

No response.  We’ve hit “The Zone.”

In times of great stress, one often looks to his comrades to survive.  But sometimes he is forced to draw on his own strength to persevere.  The three of us had arrived at that point.  That’s “The Zone.” We had done all we could to help each other.  It was do or die.  Or call on the cell phone to get picked up and driven to the end of the trail in a car.

So as we limped back into basecamp, beaten and exhausted, there was no joy in finishing.  We had lost some good men. And women.  And while it was true that they were technically at camp stretching and drinking water and seemingly doing pretty okay, we knew we would never forget them or the sacrifices they made.  

We left a little of our childhood on the trail that day.  We were no longer the innocent runners we started as.  We did horrible things.  We left Brent behind.  You never leave a man behind.  But we did.  We had seen things that could not be unseen.  We saw some guy with both nipples bleeding through his shirt.  So I’m serious here.  

But we now were bonded together for life.  We had lived through that traumatic August morning, and come out stronger on the other side.

There was only one thing left to do.


Tuesday, August 4, 2015

Hot, Hot, Hot! Great tips for running and training in the St. Louis August Heat from Dr. Larkin

Hot, Hot, Hot.

My goodness it's hot in St. Louis in August!  We got away with a little bit of a cooler summer with all this rain and milder temperatures, but this weekend's run was what I like to call a "Character Building Exercise."

I am now training for my third marathon.  For each of them, I have trained with the Fleet Feet Training team.  It's a nice setup, as they are able to customize your training schedule based on your experience and goals.  My training encompasses a few weekday runs on my own, then a group long run on Saturday mornings.  These will range from 11 to 21 miles during training.  

This past weekend, to remind you, was pretty darn warm.  And humid.  Swampy, even.  But, 15 miles lie ahead of us, so we set out from the St. Peters City Center heading northeast.  And by 5 miles in, I looked as though I had jumped into a swimming pool along the way.  Much of the course was in full sun, and by 8 AM, it was like running in a greenhouse.  Except without the pleasant floral aroma.  Not even close to pleasant floral aromas.

So a few notes for running in the heat.  (Yeah, a teaching moment!)  

Look for these symptoms:

·         Cramps
·         Chills
·         Dark urine
·         Dizziness
·         Dry mouth
·         Weakness
·         Thirst
·         Headaches
·         Nausea and vomiting
·         Confusion

To prevent heat illness, stay hydrated before, during and after exercise.  Light, loose clothing should be worn and skin should be exposed as much as possible.  Train appropriately to be ready for the heat, usually starting with short, low intensity workouts that may gradually increase over 7-14 days.  This allows the body to get used to the conditions safely. Consider altering your workouts when heat and humidity are high

Hydration is the most important way to prevent heat illness.  Drink at least 16 ounces of water one hour prior to exercise.  During exercise, continue to drink regularly, about 4-8 ounces every 15-20 minutes.   If a run lasts longer than one hour, a drink containing carbohydrates and electrolytes should be used.  Most sports drinks will do the trick.  Otherwise, plain water is fine.

If you see any signs of heat illness in you or your running partners, you may be dealing with a life-threatening emergency.  Do not hesitate to call for an ambulance early on if somebody seems to be in trouble.  While you are waiting, get him or her to a shaded area.  Placing ice bags or cold towels around the neck, armpits, and groin will help.  Provide cool beverages if possible.  Act quickly, as these interventions may save someone’s life.

Hopefully, we won’t have many more runs like last weekend.  But if you do happen to see sweaty footprints on the pavement, it’s probably me.   (That’s right, I sweat through my shoes.  It was hot!)

Sunday, August 2, 2015

Nash-Vegas!! An update on marathon training from Dr. Brandon Larkin!


Runners are an interesting breed.  They are typically a pretty obsessive group, and that’s even worse during marathon training season.  It’s raining?  The training schedule says I gotta run.  Blazing sun and 105 degree heat index? Yep, I’ll just take a little more water.  But I gotta run.

Missing a group long run while out of town on vacation with the family?  13 miles?  Hmmm.  I can make that work.  The schedule says…..

We’ll leave our jobs and our house and our real life responsibilities to take a vacation, but we can’t neglect that run.  So this past weekend my wife (thankfully an accomplished marathoner in her own right, so she gets it) and I loaded the kids into the Family Truckster, heading southeast toward Nashville, Tennessee. 

Already, the 13 miler was on my mind—driving on the highway will do that. “I could totally run to the next exit if we ran out of gas.  It’s not that far.”  But my incessant thoughts didn’t last long.

Now if you have been to Nashville, you undoubtedly know the force that is “Hot Chicken.”  Worshipped around the city and celebrated on national television, hot chicken is just that—fried chicken prepared to varying degrees of spiciness.  And just for good measure, the flagship of the hot chicken armada, Hattie B’s, dumps spicy fried chicken grease on the bird as a final step in its preparation.

My insistence on trying local cuisine while traveling is just as strong as my desire to complete every run during training season as scheduled, regardless of location.

This turned out to be a mistake.  Hot chicken does not make for a good pre-run late dinner.  Nor does the local microbrew consumed to extinguish the fire.  But when in Nashville….

Still licking the spicy from my fingers, I returned to the hotel and planted the computer on the bed to map my route for early the next morning.  Nashville has a nice greenway trail system that runs into downtown that I could pick up just a couple of miles from the front lobby of the sprawling Gaylord Opryland Hotel.  

So here’s the plan: Up with the sun, knock out 13 miles and meet the family to refill the gut with biscuits and sausage at a highly Yelp! rated breakfast spot downtown.  What could go wrong?  I mapped the entire route, sent it to my phone, and clicked off the light. And that little access road that didn’t seem to connect all the way on Google Maps?  It’s fine! I crossed checked it with satellite imagery and it goes through—pavement the whole way!  No problemo! Nighty night.  Ooh, that was an interesting tummy rumble.

Passing the Opryland Hotel and the adjoining Opry Mills Mall consumed darn close to two miles of the run.  The complex is really a shining monument to commercialism and capitalism.  But would it kill them to have the doors to the restroom open at 6 in the morning?

Having made it past the Mills and now a stone’s throw from the greenway along the Cumberland River, I hit that little questionable spot on the map.  And while my satellite reconnaissance was correct—it was a through road—I neglected to notice the ten foot high locked gate surrounded by barbed wire lined fencing during my research.

So I started thinking about options to get to the trail:
  1. Climb it.  Sure the gate and fence are there for a reason.  And the barbed wire.  And what’s that strange car doing parked a few yards away?  I don’t want to break a leg this early in training.  And who am I kidding?  I wouldn’t make it to the top, much less over it.
  2. Quit.  It’s only one run.  It’s not going well anyway.  This is a sign.  And that hot chicken is starting to become a serious concern.  Oh, and YOU’RE ON VACATION!
  3. 7 loops around the Opryland/Mills complex.  But once this mall opens, people will happily run me down looking for ridiculous deals.
  4. Consult the map.  I can still get there, but I have to run on a highway.  But just for a half mile or so.  Tempting, but….
  5. Head back to the room, grab the car, and drive to the trail.  With no car, the family can’t meet me downtown.  OK, I’ll just do an out and back and we can hit breakfast together when I’m finished.  It’ll be a bit of a pause in my run to get there, but it’s better than snagging my Achilles on razor wire or being shot for trespassing. Bingo!  And there’s a bathroom in my hotel room!  Everything’s falling into place!

So I head back, and as it turns out, the rest of the run was perfect.  It was a beautiful trail with a pedestrian bridge crossing of the Cumberland River.  Lots of friendly runners and cyclists.  A few deer.  Just what I was hoping for, minus the little detour.  Long run—check.

The biscuits tasted a little sweeter later that morning.  Probably because they were topped with success and perseverance.  And extra honey, you know, for the effort.