Journal of the american medical athletic association - Volume 30, Number 1 Spring 2017
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Journal of the
American Medical Athletic Association
Volume 30, Number 1
Spring 2017
My Journey FOUNDER
Ronald M. Lawrence, MD, PhD
BOARD OF DIRECTORS
Over the past 15 years I have been privileged to lead a group of some of best leaders Cathy Fieseler, MD, President
Charles L. Schulman, MD, Immediate Past-President
in running and sports medicine where our annual meeting takes place at the Boston Douglas J. Casa, PhD, ATC, FACSM
Marathon. We were known as the “Medical Joggers” back in the 70s and our members S. Mark Courtney, PA-C
helped bring medical care and oversight to the greatest marathon in the world. We had Mark Cucuzzella, MD, FAAP
over 700 bandit runners one year back when “Bandit Runners” were as welcome to Ronald S. Dubin, MD
Ronald M. Lawrence, MD, PhD,
Boylston Street as Boston’s Billy Rodgers crossing the finish line first. Today’s “Medical Member Emeritus
Joggers” are known as the medical runners and professionals of AMAA. In conjunc- Noel D. Nequin, MD, FACSM, FAACVPR,
tion with our parent organization, the American Running Association (ARA) who were Member Emeritus
the “National Joggers” back in running boom #1, we have a budding cause in youth COL Francis G. O’Connor, MD, FACSM
Chris Troyanos, ATC
fitness—the National RUN A MILE DAYs campaign (www.runamile.org).
I will be leaving AMAA the end of June. I’m going to stay active in the RUN A MILE HONORARY DIRECTORS
Marv Adner, MD
effort and hopefully create a documentary on some great stories from across America. Judi Babb
I also want to speak publicly on ways we can beat cancer and live a second life. In the Walter M. Bortz II, MD
January/February issue of Running & FitNews, I shared my story of what it has been like Ken Cooper, MD
to be diagnosed with melanoma (three times) and the journey I have taken over the past EXECUTIVE DIRECTOR
few years. I now share this you in my final writing of “Front of the Pack.” David Watt
MANAGING EDITOR
Barbara Baldwin, MPH
BOOK REVIEW EDITOR
Cancer was not new to me. I first confronted it when I was 26—it was melanoma. In Paul J. Kiell, MD
February 1983 I had no idea what the word melanoma meant other than anything ending
TALKING ABOUT TRAINING EDITOR
with “oma” was not good. I managed to survive that encounter, but it led to leaving the Navy Douglas F. Munch, PhD
and starting a second career. Speed ahead to 2010 and a second melanoma is found. Was I
CONTRIBUTING WRITER
a bit complacent after 26 years? Sure, but I had charged ahead and thought that my surgeon Jeff Venables
had gotten ahead of things. Well, this time, cancer decided to take a different path, just like
MEETING COORDINATORS
going on a run. And once again, like in 1984, I had to find a way to get ahead and defeat the Judi Babb
melanoma cancer cells. Barbara Baldwin, MPH
It was just prior to the EDITORIAL ADVISORY BOARD
2014 Boston Marathon Brian B. Adams, MD
when I felt a hard mar- Donald B. Ardell, PhD
ble-like ball in my left Robert Bice, Jr., MD, FACS
Paul E. Casinelli, MD
upper shoulder. It was George M. Dallam, PhD
just above the surgical Edward R. Feller, MD
site of my 2010 mela- Lawrence A. Golding, PhD, FACSM
noma excision. My mind Steven J. Karageanes, DO
John M. Levey, MD
raced. Could the cancer Steve Morrow, DDS
have spread to an un- Douglas L. Noordsy, MD
known or unforeseen Edward R. Sauter, MD, PhD
lymph node? In 2010, I Walter R. Thompson, PhD
had surgery to excise the The American Medical Athletic Association (AMAA),
area around the site of the melanoma lesion. It was not pretty. In fact later that summer, my professional division of the American Running Association,
was founded in 1969 by Ronald M. Lawrence, MD, PhD,
then 5-year-old nephew saw me and asked what happened to my arm? I said, “Shark bite.” to educate and motivate fellow physicians to disseminate
It made him step back in awe. information about exercise and nutrition to their patients,
I knew that surgery was going to be the best step at the time to get ahead. One aspect of thereby enhancing their quality of life.
The AMAA Journal is a peer-reviewed publication.
that surgery was to inject nuclear dye at the original cancer site and see where it would go Opinions expressed in the AMAA Journal are not necessarily
inside my lymphatic system. This procedure is called the “sentinel node.” In my case, the endorsed by AMAA.
Address editorial, membership, advertising and change
melanoma cells followed a less traveled path. On that day, I was both anxious and pissed. of address information to AMAA, 4405 East-West Highway,
I had not been vigilant checking all areas around my left shoulder, yet I was told that I was Suite 405, Bethesda, MD 20814-4535, TEL: 301-913-9517,
“free and clear.” I had no scheduled visits to see the surgical oncologist or an oncologist. FAX: 301-913-9520, E-mail: amaa@americanrunning.org,
www.amaasportsmed.org.
That was a medical mistake that angered me that day in 2014. I kept thinking, “Could we
stay ahead?” (Just like running a race, you want to stay ahead of your competitors to win; in
continued on page 7
2 AMAA Journal Spring 2017
AMAA PREMIER MEMBERS
The American Medical Athletic Association wishes to thank those
members who have contributed to the organization beyond their
annual dues. This list reflects membership upgrades received
from June 1, 2016 to June 1, 2017.
OLYMPIAN ($250) Walter M. Bortz, II ±
Mary C. Boyce Brad Carmines
Julius S. Brecht Steven D. Coffman
Charles (Scott) Clark David Cooper
Harry Daniell James Culpepper
Ronald Dubin Michael DeMauro
Edmond G. Feuille, Jr. Michael S. Doyle
Cathy Fieseler *± Thomas Easley Message from the President . . . . . . . . . . . . . 4
Wade Gaasch Robert Erickson
Scott Glickman Joseph M. Gaffney Introduction to the IIRM. . . . . . . . . . . . . . . . . 5
Fawwaz Hamati John Geren Chris Troyanos, ATC and
Jeffrey Hawkins John W. Gilpin
Stuart Weiss, MD, FACEP, FAAP
Patrick J. Hogan Bernard Gitler
John Howick Jeff Godin
Timothy Lepore Lisa Griffin Can Endurance Athletes Perform Well
Francene Mason Arnold Greene with a Very Low Carbohydrate Diet?
John McAuliffe Steven Grufferman (Part 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Steve Morrow *± Kevin R. Haley Laura Christoph, PhD and
Terry Murphy Michael Hamrock Emily Miele, MS, ACSM HFS
Peter Oroszlan Beverly Handy
Daniel Pereles Dexter Handy Running with Music. . . . . . . . . . . . . . . . . . . 13
Richard Prokesch David Jack Jasmin C. Hutchinson, PhD
Robert Sanders C. Douglas Johnstone
Charles L. Schulman Allan Katz Talking About Training:
Robert Sholl Brian Y. Kim Practical Implementations of HIIT . . . . . . . 16
Michael Solinger Andrew King Miller III, PhD, ACSM EP-C, CSCS
Philip Zitello J. Mark Lawson
Steven Wynder Robert B. Lee In Memoriam:
Frank Massari, Jr. Bruce R. Wilk, PT, OCS . . . . . . . . . . . . . . . . . 18
PATRON ($150) Ronald H. Miller
Larry Boies, Jr. Robert P. Nirschl
Phil Filbrandt Member Profile: William O. Roberts, MD
Floyd Okada ± Life at the intersection of family
Lawrence Frank Mark Rubenstein
Susan Harding Hawkins practice and sports medicine . . . . . . . . . . . 19
Bill Snyder Jeff Venables
Tristram C. Kruger Ralph Sulser
Franklin G. Mason Greg Thorgaard
Jim Skibo J. Michael Ward
SUPPORTER ($100) Clay Whiting
Sal Barbera Valerie Zughaib
Matthew Barnes Bruce R. Worley
Christianne Bishop
* Contributions surpass Olympian level
± Life Member making contribution at the level of Premier Member
Funds from this program have helped to support NATIONAL RUN
A MILE DAYS, an annual campaign promoted by the AMAA and the
American Running Association (ARA) to encourage elementary
and middle school age children to become more active.
3 AMAA Journal Spring 2017
Message
from the
To All of our Faithful President aimed at education and research into the issues
surrounding the death of its namesake, Matthew
AMAA Members, Good. He passed away in June of the same
It has been a rollercoaster ride for the year while running a half marathon for charity.
American Medical Athletic Association (AMAA) Matthew collapsed of heat-related illness only 1K
Loughborough University
since early fall 2016. As you know, we did not from the race finish; he was 32.
• Electronic version of the AMAA Journal, to
receive charity entries for the 2017 Boston The IIRM has various membership cat-
be expanded in content delivered by sports
Marathon and the likelihood that we could be egories, including multiple event, single event,
medicine experts
awarded entries in the future was bleak due individual and even one offered through an MGF
to a change in policies by the Boston Athletic grant. You, of course, will become an “individual
The IIRM will also continue to offer sports
Association. We submitted a solid proposal last member.”
medicine symposiums, including the Marine
summer; however, it appears selection is now There is so much wonderful history with
Corps Marathon meeting to be held on October
based on location and the ability of the char- AMAA, especially at the Boston Marathon, and we
20 and 21 in conjunction with MedStar Sports
ity to positively impact the Greater Boston area. will strive to maintain the integrity of its mission.
Medicine. Also, IIRM Executive Director Chris
These criteria make it very difficult for AMAA to Although, at this time, there is no definite plan to
Troyanos, ATC, has been working toward of-
compete. hold a meeting at the 2018 Boston Marathon, this
fering continuing education credit through the
Because the Boston charity entries provided may be subject to change. We will certainly keep
IIRM online videos. We’ll keep you posted as this
the main source of funding for the American you posted as we get closer to the fall months.
exciting opportunity evolves!
Running Association and its professional arm Fear not as we enter this “brave new
The IIRM and AMAA have a lot in com-
AMAA, we started to experience a downward world”…I view this merger as an opportunity to
mon—ensuring the safety of participants in
spiral. Our pursuits of alternate funding sources open new and exciting doors, and to encourage
races, promoting health and wellness through ex-
were unsuccessful and, as a result, the board growth of the organization. It has been my privi-
ercise, and improving athletic performance with
decided to entertain other opportunities to con- lege to serve as your president for the past four
state-of-the-art information. In reality, the two or-
tinue the mission of the organization. years and I look forward to continuing our re-
ganizations have run parallel courses for several
The International Institute for Race Medicine lationship through my involvement on the IIRM
years, so a merger to save AMAA makes sense.
(IIRM), formerly the American Road Race Medical executive board for years to come.
To give you a brief history of the IIRM, it was
Society (ARRMS), stepped in and offered to as- If you have any questions or would like to
originally founded under the American Running
similate AMAA. Over a span of six months, the two learn about participation in IIRM committees,
Association (2003) as the American Road Race
executive boards engaged in lengthy discussions to please contact Barbara Baldwin at bbaldwin@
Medical Society by Twin Cities Marathon Medical
not only work out details of an assimilation but also racemedicine.org or call 240-271-1657.
Director and AMAA Life Member Bill Roberts,
to ensure that the AMAA membership stayed intact MD (profiled in this issue of the AMAA Journal).
with worthwhile member benefits and familiar Sincerely,
Its purpose was to serve the road racing commu-
faces/voices in management. We were successful nity in North America as an educational resource
in meeting these goals by having Barbara Baldwin, Cathy Fieseler, MD
and medical leader for road races from the 5K
MPH, continue as the membership director (I will AMAA President/IIRM Executive Board Member
up through ultra distances. Dr. Roberts had
be joining the IIRM executive board) and offering envisioned that ARRMS would serve all medi-
a slew of educational opportunities for members. cal professionals who work and/or volunteer at
As of July 1, all AMAA members will become any size road race with a mission to educate the
IIRM members and will have access to the running industry, race organizers, and the pub-
password-protected area of the website (www. lic about medical issues that impact the sport of
racemedicine.org). Access allows you the ability running and road racing.
to view: The organization then took on an interna-
tional focus and was renamed the International
• Multiple educational videos—with more on Institute for Race Medicine. This occurred fol-
the way—covering topics relevant to race/ lowing the development of a partnership with the
running medicine (17 sports medicine lec- United Kingdom-based Matthew Good Foundation
tures, plus 10 short videos on medical race (MFG) to provide education worldwide to the
care logistics) medical communities who serve runners. The
• Comprehensive 92-page medical manual foundation, based in East Yorkshire, England,
developed by experts from the IIRM and was created in July 2011 with its initial project
4 AMAA Journal Spring 2017
Dear AMAA Members, provide you expanded member benefits and con-
tinuing education opportunities.
The last few months have brought sev- We will also make sure that our efforts and
eral changes to the American Medical Athletic interactions with all members are supportive and
Association—some have been disappointing collaborative. To help with this transition and
such as the loss of Boston Marathon charity en- to give you some continuity, we will be adding
tries, but many have brought great promise for AMAA President Cathy Fieseler, MD, to the IIRM
the future with opportunity for growth. As the Executive Board and AMAA Programs Director
executive director of the International Institute and Membership Coordinator Barbara Baldwin,
for Race Medicine (IIRM), I am delighted to MPH, will become the IIRM Executive Assistant As the executive director
welcome all current AMAA members as IIRM in- and Membership Director. Both of these out-
dividual members; together we will expand our standing professionals will not only add to the
of the International
learning experiences and work to promote run- IIRM mission and brand, they will also ensure Institute for Race
ning medicine. that AMAA members have a voice—a voice that Medicine (IIRM), I am
Since its inception in 2004, originally as the we hope you will use in the coming months to
American Road Race Medical Society (ARRMS), provide input. We also welcome you to take part delighted to welcome all
the IIRM has had a similar focus and mission as in any activities or groups created to facilitate current AMAA members
AMAA with one of its goals including the provi- our mission.
sion of quality education to those interested in In closing, I also want to say a few words
as IIRM individual
the field of endurance medicine. As we combine about AMAA Executive Director Dave Watt whom members; together
the AMAA and IIRM memberships, we will con- I have known and worked with since he took the
tinue to pursue this goal and strive to provide
we will expand our
position in 2002. With his support, the AMAA al-
more educational opportunities for those inter- lowed our organization (then ARRMS) to grow learning experiences
ested in this niche of sports medicine. and flourish under the AMAA banner. That sup- and work to promote
Over the years, we have found that the road port is something I will never forget. I told Dave
race industry lacks a central source for its medi- that IIRM will continue supporting his mission; running medicine.
cal guidelines or standards of care. When it comes I cannot think of a better way to honor Dave’s
to providing medical care to millions of runners, efforts and achievements.
proven medical protocols and coordination are I hope you will take the time to review the
in high demand. It is the goal of the IIRM to be- outline on page 6 of this journal showing IIRM
come that source of information. We do not want developments and future plans, as well as our
to dictate the types and levels of care provided at website (www.racemedicine.org). Comments
endurance events, we just want to be a reputable or suggestions can be sent to Barbara Baldwin
resource for medically-proven options and a fo- at bbaldwin@racemedicine.org. Growth of the
rum for informed discussion. This will allow for organization depends on collaboration between
additional growth in our area of expertise. the IIRM board and members and mutual sup-
As you review our website (www.race- port of all those involved.
medicine.org), you will see that we have built We look forward to an exciting and produc-
the educational section on a comprehensive tive future!
distance learning platform; additional video
presentations, medical protocols, and other Sincerely,
website programs will be added over time. You
will also notice that we have taken impressive Chris Troyanos, ATC
steps to widen our reach within the international Medical Coordinator, Boston Marathon
medical community, including awarding grants Executive Director, IIRM
for complimentary one-year IIRM memberships troyanos@racemedicine.org
to qualifying events worldwide.
The IIRM Executive Board is working hard to
ensure a smooth transition as we begin to take
responsibility of the AMAA membership and your
needs over the next few months. We hope to earn
your trust and support with our commitment to
continued on page 6
5 AMAA Journal Spring 2017
continued from page 5
Dear AMAA Members,
On behalf of the International Institute for Race
Recent IIRM Developments • Five to 10 educational videos will be add-
Medicine’s Board of Directors, I am excited to
• On January 1, we hired Barbara Baldwin, ed to the IIRM video library on the website
welcome you as new individual members of the or-
MPH, as the part-time executive assistant (password-protected) by the end of 2017.
ganization. Through the hard work of the current
and membership director. This will move • We will add a blog to the website to help
AMAA leadership, IIRM Executive Director Chris
to full-time as of July 1. promote dialog within our industry as we
Troyanos, and the IIRM Board of Directors, we
• We developed partnerships with road race examine some of the challenges we face.
have forged a path forward bringing the best parts
organizations such as AIMS (Association
What our Future Holds of both organizations together to form a stronger,
of International Marathons and Distance larger organization that will serve our membership
• The IIRM plans to host four medical
Races), Running USA, and the Road and endurance sports for many years to come. As
seminars per year. We believe that such a
Runners Club of America. Chris has laid out in his letter to you in this issue,
“traveling road show” not only helps us
• The Matthew Good Foundation provided there are many exciting projects in the works. I
promote the IIRM brand, but also ensures
a grant to allow 100 endurance events to invite you to become active members of IIRM.
our mission is moving forward. For each
join the IIRM for one year. We always welcome our members’ feedback and
seminar, we plan to develop a strong part-
• We added a comprehensive medical man- suggestions—your input is vital to help guide the
nership with the local marathon to ensure
ual to the IIRM website. organization in the best direction.
all volunteers and public safety support
• A post-race reporting tool was added to As the chairman of your board, I would en-
systems have access to state-of-the-art
the site. Information collected with this joy hearing from you. Send me your comments,
knowledge for road race medicine. Plans
tool will support future research within suggestions or just a note to say hello. I can be
to hold seminars in Europe and Asia will
our industry. reached at sweiss@racemedicine.org.
be added over time as we strive to also
Coming Soon meet goals for our international mission. Welcome to the IIRM!
• We are working with the Marine Corps • We will continue to develop a strong continu-
Warmest regards,
Marathon and MedStar Sports Medicine ing education program through our online
to hold a comprehensive medical sympo- medical content and live medical seminars,
Stuart Weiss, MD, FACEP, FAAP
sium in October 2017 and 2018 (this is with a future goal to offer online continuing
Chairman, IIRM Board of Directors
a continuation of the AMAA symposium education opportunities. We believe this will
held in conjunction with the marathon). greatly enhance the IIRM member experience
• The AMAA Journal will become an IIRM as a valuable added benefit.
publication and will be shared electroni-
cally with all members.
YOU CAN STILL RUN THE 2017 SOLD-OUT
MARINE CORPS MARATHON
Register for only $25 and then fundraise for a total of $425 (or donate the fee yourself) to
receive the following benefits:
• Guaranteed race entry (will be required to pay the $160 entry fee to the Marine Corps
Marathon)
• Customized online fundraising page through CrowdRise
• Complimentary registration for one individual to the IIRM’s Sports Medicine Symposium at
the Marine Corps Marathon ($200 value)*
• Complimentary one-year individual membership in the International Institute for Race
Medicine ($75 value)*
*transferable to another individual
If you are interested in running the Marine Corps Marathon or know someone else who would
like to run, contact Barbara Baldwin, MPH, at bbaldwin@racemedicine.org.
6 AMAA Journal Spring 2017
continued from page 2
cancer’s case, the race to win is critical to
beating cancer). I went in for surgery and
had my entire left armpit lymph nodes re-
moved. All the nodes were negative, good
news. The one piece of news that jarred me,
though, came from the radiology oncolo-
gist. He said that while the other nodes were
negative, the primary node that was positive
(cancer) had broken through its wall lining.
Now I was fighting the odds of staying ahead
of the cancer cells’ moves.
I was on the way to the Penn Relays in
late April 2015, one week after the Boston
Marathon weekend. I got a call from the
radiology lab where I had gone for a CT.
Something was small yet visible on my liver.
Now my heart was racing. I called my on-
cologist and we talked about possibilities. It
could be a non-lesion or it could be a me-
tastasized melanoma lesion. It was the latter.
My path ahead was not full of roses. I did
not hear many great outcomes. This is when
I called out for help. My friend Bill and wife
Debbie went to work and started research-
ing the advancements that were occurring in
fighting advanced melanoma (I did not like
using the term “stage” for where I was clini-
cally with cancer). All I was hearing from
my then-oncologist was that we could see who were “BRAF WILD” (remember I talked of calm. These people were here to help me.
if I was genetically pre-disposed for a type about a test for a mutated BRAF gene). We all They were upbeat and talked about how the
of mutated gene—the BRAF gene. It turns met, Debbie my wife and Bill. Looking over trial would work. Downsides were discussed
out that about half of melanoma patients are things, it appeared there were options that along with side effects. What remained was
BRAF positive, meaning they have the mutat- my oncologist was not offering nor even men- the upbeat and positive nature of this team.
ed BRAF gene. A new immunotherapy drug tioned to me in our meetings. Time was ripe I know it may sound whoey, but I felt like I
was available for those patients who were for a summit meeting. In fact the doctors had belonged. That day the #2 oncologist for the
BRAF positive. In my case, I was in the other their own meeting ahead of meeting with us. melanoma team told me I was accepted into
half——BRAF negative, or what I would It was their “tumor board.” They told us that the trial. In just a week, after some blood
later hear as being BRAF WILD. it was their opinion that I should start taking tests were performed and a follow-up scan,
Quick layman’s talk on immunotherapy the immunotherapy drug Prembrolimab, al- I could start treatment.
drugs and their remarkable effect: these though it was not a great match for me. The Onto the phase of infusion….and no
drugs can halt a T-cell inhibitor and un- three of us were a bit perplexed. Fortunately chemo! I came up with my own suspense
leash the ability of your immune system to another “new to the team” oncologist agreed imagery for what the dual immunotherapy
go beyond the T-1 inhibitor and find the to talk to us privately. He had come to this drugs were hoped to do. The drugs were the
melanoma cells and lesions. (Pardon me if team from Georgetown University Hospital’s magic potion that allowed the “wild wolves,”
I have screwed up the medical terminology Lombardi Cancer Clinic. In the discussion, (aka, the “super cancer fighters”) to go
and description.) Bill brought up the clinical trial that involved bounding throughout my body and seek, en-
It is now early May and I feel directionless. two immunotherapy drugs, Nivolumab and compass, and destroy all melanoma lesions
Yet my team—let me emphasize the point of Ipilumumab. This oncologist had just come and cells. Sounds like a video game, right?
“team”— yes, my team had come up with from the melanoma team at Georgetown. I That is what I hoped would happen. Based
options that sounded futuristic and poten- asked him the one question that few others on the initial results in the first two phases
tially a miracle cure. No oncologist likes to would answer, “What would you do if in my of the clinical trial, the duo of Nivo and Ipilu
use that “C” word when it comes to defeating position?” were out there unlocking the wild wolves in
cancer. Bill, however, had uncovered through Three days later I had an appointment over 60% of cases, and that percentage was
his research on Pubmed.org that there were at the Lombardi Clinic at Georgetown rising. Now it was my time. Infusion is done
highly successful clinical trials involving other University Hospital. The three of us went in similar way to chemo. The main differ-
immunotherapy drugs. The good news was to the appointment with the clinical trial ence is immunotherapy is not poison. Also,
that these drugs were working on patients team. The very first thing I felt was a sense
continued on page 8
7 AMAA Journal Spring 2017
continued from page 7
I did not get a “port.” My first infusion was
in mid-June. The plan was to have four infu-
sion dates of the dual immunotherapy drugs.
The protocol involved coming in every week
for blood work. Everything went fine. A week
later, all was normal. I was still running and
felt good.
It was now August and I had had my third
infusion. One thing had happened on my
neck. An obvious lymph node that had been
enlarged and was considered cancerous
had disappeared—”gonzo.” I was a couple
weeks out from my fourth and final infusion.
We had planned a vacation to Cape Cod with
a rental home. On the way to the house I
started feeling exhausted, a plain case of
no energy. On day two of vacation it be-
came worse. I felt like a big sloth just sitting
there. We call the on-call oncologist fellow
and I was advised to go to the local ER. It
turns out that in Falmouth, Massachusetts, The CT scans confirmed it: my cancer was beating cancers like melanoma with immu-
they were holding their biggest event of the stagnated and the lesions appeared to be notherapy drugs will have success in other
year, the Falmouth Road Race. The hospital shrinking or surrounded. (Previous biop- cancers. You are seeing transferable use in
was semi-deserted when I arrived. Most of sies on similar patients earlier in the trial treatment against lung cancer. I knew it as
the ER staff had worked the event and only showed dead tissue surrounded by immune Nivolumab or Nivo. On TV it is Opdivo.
the basic crew was there. Next thing I know, cells and material.) Good—actually, really This story does not define me. It has
after having a chest x-ray and CT, I am be- great—news! It appeared that the immune opened a door to a second chance at life.
ing admitted. It was a Sunday night and I am system had found the cancer lesions and For all of you who have endured cancer and
miserable. It turns out I had had the first cells and was attacking or had attacked and continue to battle it today, I offer you hope.
major side effect of the dual immunother- defeated the cancer. Could this be a cure? I feel blessed to have a VERY supportive
apy drugs. My endocrine system had been I am now at the two-year mark. This is the wife and family—my wife Debbie and our
overwhelmed. The wild wolves can attack time that a couple of melanoma oncologists kids Alex and “creative rocker” Jeffrey.
things at-will that are not cancerous. So it initially felt was a good marker for survival. Thanks to all my AMAA friends and sup-
went with my pituitary, thyroid, and adrenal Nothing is guaranteed. Yet the most experi- porters. We all have 26.2 journeys in us.
glands. Now came the powerful steroids to enced of the oncologists who have worked
right my system. on defeating melanoma for decades are now Best Regards,
It’s September and I had started the dual smiling. Dr. Atkins, the lead oncologist on
infusion treatments in early to mid-June. It melanoma at Lombardi, sent out invitations Dave Watt
was time for scans. I also found out that the in March 2016 to come attend a “Melanoma ARA/AMAA Executive Director
oncology team felt the fourth dual infusion Survivors Luncheon.” Anytime a cancer pa-
would be overkill. In addition, the clini- tient receives an invitation that says you are
cal trial director at Bristol-Myers-Squibb a “survivor,” please do attend. Since that
removed me from the trial due to my side day, I keep battling side effects that have
effects. I wanted “back in.” Through this been tough yet somewhat tolerable. I am not
period of misery in the hospital and good back to running….yet. I may never be able
results visually of my neck lymph node, my to play golf again due to shoulder deteriora-
lead oncologist and the team felt that they’d tion caused by the wild wolves. Still, it’s a
see a stable or shrinking scene on my liver. miracle. I am convinced that the success in
8 AMAA Journal Spring 2017
How Can Endurance Athletes Perform Well with
a Very Low Carbohydrate Diet? (Part 2)
Laura Christoph, PhD and Emily Miele, MS, ACSM HFS
Introduction “ketogenic.” Though definitions for these terms
Traditionally, dietary recommendations for can vary between sources, Richard Wood, PhD,
endurance athletes are founded on the notion has previously compiled the respective ranges of
that muscle glycogen content and blood glucose kilocalorie percentages from carbohydrate as well
levels are the most crucial factors in evading as grams of carbohydrate per day for each diet (9).
fatigue and performing at one’s highest potential Among these diets, a reduced carbohydrate diet
(1). These recommendations are based on typically involves the least amount of restriction,
evidence that carbohydrate sources, specifically while a low carbohydrate diet calls for a greater
muscle glycogen, are of critical importance in reduction in carbohydrate intake, and a ketogenic The human body stores
providing energy during exercise (2). Therefore, diet is the most restrictive; requiring a reduction in
the rationale behind most sport nutrition carbohydrate to less than 50g per day. A ketogenic at least 20 times more
guidelines is to prevent muscle glycogen from diet involves a significant amount of knowledge,
getting too low, which would essentially exhaust commitment, and planning for an individual to
energy as fat than it does
a predominant energy source. In order to successfully adhere to the requirements. Like any as carbohydrate; thus,
maintain optimal glycogen content, endurance dietary practice, a ketogenic diet will produce
athletes are traditionally advised to consume high different results for each individual and may not avoiding a reliance on
levels of carbohydrate in their diet in addition to be optimal for some endurance athletes. In this
carbohydrate supplementation before, during, paper, we present strategies to implement the
carbohydrate for energy
and after athletic events (3). ketogenic diet on an individual basis including how is intuitively logical.
More recently, research studies investigating to determine whether or not the ketogenic diet is a
the effect of carbohydrate restriction on endurance good fit for an athlete, macro- and micronutrient
performance have increased in number, and guidelines and considerations, as well as strategies
a subset of elite endurance athletes are eating for transitioning to the ketogenic diet. The intent
low carbohydrate diets (4). To many, it may of this paper is to provide guidance on how to
appear counterintuitive to restrict carbohydrate implement a ketogenic diet for endurance athletes
consumption when large amounts of energy are with the intent to better inform those professionals
needed for the repetitive muscular contractions who advise them.
involved in endurance athletics. However, the key
to carbohydrate restriction for athletes is to reduce Ketoadaptation
the body’s reliance on carbohydrate for energy and It is important to note that becoming
increase the capacity to metabolize fat—an energy more efficient at fat utilization does not occur
source that is both more available and more efficient immediately upon beginning a ketogenic diet.
(5). This can be accomplished by consuming a diet Within 2-4 days of the diet, ketones will usually
high in fat and very low in carbohydrate (4,6). The be detectable in urine as a marker of increased
human body stores at least 20 times more energy as fatty acid oxidation and reduced carbohydrate
fat than it does as carbohydrate (7); thus, avoiding metabolism (10). Reagent strips for urinalysis
a reliance on carbohydrate for energy is intuitively are available over the counter and allow for
logical. By utilizing fat as one’s predominant energy easy tracking of one’s status in ketogenesis
source during endurance exercise, athletes have by indicating the ketone level in the urine.
been able to maintain a higher level of performance During ketogenesis, in the presence of low liver
for a longer duration, without the need for glycogen; Acetyl CoA, the product of fatty acid
exogenous carbohydrate supplementation, by oxidation, is used to form ketone bodies, or
“sparing” glycogen for later use (8). An overview ketones. Ketones can then be used for energy
of evidence supporting low carbohydrate intake in production by skeletal muscle as well as the
endurance athletes has previously been presented brain (11). However, it takes at least one week
in Part I to this paper (9). and possibly up to four weeks for an individual
There are multiple terms used to describe to be able to utilize ketones efficiently for the
dietary carbohydrate restriction that vary with metabolic production of energy (12). This
respect to the extent of restriction required. These transition period is termed “ketoadaptation” and
terms include “reduced carbohydrate,” “low has been covered in detail in Part I (9). When
carbohydrate,” and “very low carbohydrate” or continued on page 10
9 AMAA Journal Spring 2017
The ketogenic diet can be a great fit for a variety of athletes,
specifically those in weight monitoring sports where a
weigh in or lean physique is encouraged, and endurance
sports where efficient metabolism is an advantage.
an individual is in the ketoadaptation phase, consuming carbohydrate during a competitive glucose production through gluconeogenesis,
performance decrements often occur while the endurance event, ketogenic athletes can rely which raises blood sugar and stimulates insulin
body adjusts to using fat and ketones for energy. on their fat oxidation efficiency and supplement production, knocking the athlete out of ketosis
Timing, which is discussed in a subsequent with glucose to fuel the TCA cycle as they work (10). Consuming a reduced carbohydrate,
section of this paper, is therefore a crucial at intensities close to VO2max for optimal moderate protein, and high fat diet is important
consideration for athletes seeking to begin a performance. in order to maintain ketosis (9).
ketogenic diet. Weight loss diets that focus on carbohydrate
Health Benefits for the Athlete reduction and encourage increased protein
Athletic Performance Benefits The ketogenic diet protocol also removes a and fat intake have been shown to be higher
The ketogenic diet can be a great fit for a variety number of major digestive tract irritants such in micronutrient content than other dietary
of athletes, specifically those in weight monitoring as grains, legumes, and high fructose foods due approaches (25). However, there are some
sports where a weigh in or lean physique is to its restrictive nature, which may be beneficial vitamins and minerals of concern to note with
encouraged, and endurance sports where efficient for runners who experience the water retaining a ketogenic diet including magnesium, sodium,
metabolism is an advantage. The decrease in effect of 6-carbon molecules in the gut, often zinc, and copper.
water retention resulting from low carbohydrate leading to exercise-induced irritable bowel Magnesium is likely to be suboptimal in
diets can be helpful for athletes who participate syndrome (IBS). IBS is a common issue in those a typical American diet and is also depleted
in weight class sports (13), especially females participating in endurance sports, especially through sweat during exercise (26).
of childbearing age, whose monthly hormonal running, which can impede performance by Supplements have not been shown to improve
fluctuations often result in water weight gain (14). leading to nutrient malabsorption, dehydration athletic performance, but may be helpful for
Furthermore, athletes who participate in sports in and physical discomfort (19). Research those at risk of deficiency (27). Ensuring the diet
which leanness and lightness are advantageous shows that IBS symptoms may be alleviated by is high in magnesium rich foods such as leafy
such as distance running, cycling and triathlon, eliminating short chain carbohydrates through greens, fish, nuts, and avocados (28), as well as
may find that the appetite suppressing effects (15- the FODMAP (fermentable oligosaccharides, considering a magnesium supplement if the RDA
17) of lower carbohydrate, moderate protein and disaccharides, monosaccharides, and polyols) is not achieved (27), may be helpful for athletes
high fat diets are advantageous to maintaining diet (20), and preliminary studies show promise beginning a ketogenic diet. This is especially a
optimal body composition. for athletes with GI distress (21). Therefore, the concern in those who experience magnesium
The fat adaptation that results from a ketogenic diet, which is naturally low in most deficiency symptoms such as muscle twitching
ketogenic diet protocol may also be helpful to FODMAPs, may be helpful for athletes with IBS. and muscle spasms.
endurance athletes for a more practical reason: There are additional health benefits to becoming Americans typically consume plenty of sodium
because athletes on the ketogenic diet experience fat adapted that reach above and beyond sports (28); however, ketogenic athletes may be at risk
increased metabolic efficiency, it may be less performance. For instance, the American College for sodium deficiency. Carbohydrate restriction
important to consume as much exogenous fuel of Sports Medicine (22) recommends that athletes causes water weight loss and sodium depletion
during training and racing (8). Furthermore, consume 30-60g of sugar per hour for 1.5-2 hour (29), leading to decreased plasma volume, and
if the exogenous fuel consumed is composed events and up to 90g per hour for events lasting consequently, a decrease in blood pressure (28)
of fat rather than carbohydrate, athletes can longer than 2 hours. If athletes are consuming which increases the need for sodium intake.
take in over twice as many kilocalories for the sports gels and drinks at this volume, their overall Furthermore, major sources of sodium in the
same amount of weight carried, as fat contains added sugar intake may be of health concern due typical American diet are highly processed food
nine kilocalories per gram while carbohydrates to tooth decay (23). Products that have alternative and packaged high carbohydrate foods (28),
contain only four kilocalories per gram. This can fuel sources, such as Generation UCAN, have been so elimination of these contribute to decreased
be highly beneficial in an extreme endurance developed for fat adapted athletes, and can provide intake. Athletes might consider adding chicken
event in which an athlete needs to carry all of his an exogenous fuel for endurance sport that holds broth, table salt, eggs, cheese, and salted nuts and
or her own fuel. blood glucose levels steady (24) without having the seeds to their daily intake in order to meet sodium
On the other hand, some athletes might negative impact on dental health. needs (see Figure 1 on page 12).
choose to train on a ketogenic diet but take Zinc is another nutrient of concern for low
in carbohydrate during an endurance event, Nutrients of Concern carbohydrate athletes, but adequate intake can
using carbohydrate as a performance enhancer. Athletes must learn how to moderate be achieved through careful diet planning (30).
Athletes on a ketogenic diet have been shown macronutrient intake and address potential Zinc is important for immune function, cell
to maintain relatively normal glycogen stores micronutrient deficiencies when they begin division, growth and development; however,
even with low carbohydrate intake (4), but may a ketogenic diet. First off, in order to stay in supplementation is discouraged due to possible
benefit from additional exogenous carbohydrate ketosis, athletes must be careful of excessive deregulation of copper (31), another nutrient of
sources during high intensity activity (18). By protein intake. High protein intake leads to concern for ketogenic athletes. Foods such as
10 AMAA Journal Spring 2017Preliminary studies and work with individual
athletes show promise that this dietary approach can
be beneficial for the athletes in weight-monitoring
and ultra-endurance sports.
beef, poultry, and pork are important sources for athletes. Long-term effects are unknown, 14. White CP, Hitchcock CL, Vigna YM, Prior JC. Fluid
retention over the menstrual cycle: 1-year data from the
of zinc (28). Zinc and copper intake can be and athletes looking to transition to a ketogenic prospective ovulation cohort. Obstet Gynecol Int J. 2011;
balanced by coupling animal protein intake with diet should do so under a doctor’s supervision. Article ID 138451.
nut and seed consumption. Nevertheless, preliminary studies and work with 15. Westerterp-Plantenga MS, Nieuwenhuizen A, Tome D,
Soenen S, Westerterp KR. Dietary protein, weight loss,
individual athletes show promise that this dietary and weight maintenance. Ann Rev Nutr. 2009;29:21–41.
Transitioning to a Ketogenic Diet approach can be beneficial for the athletes 16. Veldhorst M, Smeets A, Soenen, S, Hochstenbach-
The approach to implementing a ketogenic in weight-monitoring and ultra-endurance Waelen A, Hursel R, et al. Protein-induced satiety: effects
and mechanisms of different proteins. Physiol Behav.
diet may vary depending on the athlete. Some may sports. Individuals willing to experiment with 2008;94: 300–307.
transition to a low carbohydrate diet by gradually a nontraditional diet approach for training and 17. Johnstone AM, Horgan GW, Murison SD, Bremner DM,
replacing high carbohydrate choices with sources racing may find that the ketogenic diet protocol Lobley GE. Effects of a high-protein ketogenic diet on
hunger, appetite, and weight loss in obese men feeding
of dietary fat in a methodical approach over a results in optimal body composition and ad libitum. Amer J Clin Nutr. 2008;87:44–55.
few weeks or months, while others may choose increased sports performance. 18. Zajac A, Poprzecki S, Maszczyk A, Czuba M, Michalczyk
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11 AMAA Journal Spring 2017Sample Meal Plan, Figure 1.
Meal Description Food Items Amount Calories Protein g Fat g Net Carb g Mg mg Zn mg Sodium mg
BREAKFAST:
3 poached eggs, Egg, whole, cooked, poached 3 large 214 19 14 1 18 1.94 446
1 avocado sliced, 6 oz Avocados, raw, California 1 fruit (without
coffee blended with Beverages, coffee, brewed, skin and seed) 227 3 21 3 39 0.92 11
1 Tbsp coconut oil breakfast blend 6 ounces 4 1 0 0 7 0.04 2
Oil, coconut 1 tbsp 121 0 14 0 0 0 0
SNACK:
2 stalks celery with Celery, raw 2 stalk, small
(5” long) 34g 5 0 0 1 4 0.04 27
2 Tbsp peanut butter Peanut butter, chunk style,
with salt 2 tbsp 188 8 16 4 51 0.89 156
LUNCH:
6 oz canned salmon over Fish, salmon, pink, canned,
total can contents 6 ounces 219 33 8 0 51 1.29 685
1 cup spinach tossed in spinach, raw 2 cups 14 2 0 1 47 0.32 47
with 2 Tbsp Olive oil Oil, olive, salad or cooking 2 tbsp 238 0 28 0 0 0 0
SNACK:
1 cup cucumber slices and Cucumber, with peel, raw 1 cup slices 16 1 0 3 14 0.21 2
1 oz almonds and 1 cup Nuts, almonds, dry roasted,
chicken broth with salt added 1 ounce 170 6 14.9 3 79 0.94 141
Soup, chicken broth,
ready-to-serve 1 cup 15 2 1 1 2 0.17 924
DINNER:
Beef burger topped with Beef patty, 20% fat, broiled 6 ounces 460 44 30 0 34 10.62 128
1 oz cheddar and 1/4 cup Cheese, cheddar 1 ounce 115 6 9 1 8 1.02 183
sliced tomatoes Tomatoes, red, ripe, raw, 1/4 cup sliced 8 1 0 1 5 0.08 2
year-round average
TOTALS 2014 126 159.9 19 359 18.48 2754
(25% total (70% total (Running with Music
By Jasmin C. Hutchinson, PhD
Take a look around you the next time you
lace up at the gym, hit a local running path, or
toe the line at a road race. More often than not
you’ll see runners tuning into a personal beat.
While some running purists recoil at the idea
of listening to music while running, a growing
subculture of runners wouldn’t dream of taking
a single step without their pulsating playlists.
Case in point, there was uproar in 2007 when
the USATF banned the use of portable music
devices in its sanctioned events* and many chose
to flaunt the rules; “I dare them to find the iPod
on me,” said Richie Sais, 46, a police officer in
Suffolk County, New York, before running the
Marine Corps Marathon as he clipped his iPod
Shuffle under his shirt (1).
Of course, moving to the beat isn’t anything
new, but recent technological advances have
facilitated this marriage between music and
movement. As portable listening devices have © 123RF
become smaller, increasingly dependable,
to a beat during running, a process known as a variety of exercise modalities (9), intensities
and more affordable we have seen a veritable
auditory-motor synchronization, helps regulate (10), age groups (11), and fitness levels (12).
explosion in the use of music by runners and
and maintain pace, and can improve running Feeling states and motivation are closely related
other exercisers. Similarly, over the last 20
economy (5). Finally, appropriately selected constructs; put in simple terms, how we feel
years, there has been a dramatic increase in
post-run music can enhance recovery, facilitating about something directs our motivation toward
empirical research on the psychological and
the return of runners’ internal systems, such it. Running intensities that are associated with
psychophysical effects of music in sport and
as heart rate and blood pressure, to the pre- significant cardiorespiratory gains can induce
exercise settings. Insights gleaned from this
workout state (6). feelings of fatigue and negative affect, which
body of work will be outlined below, together
can act as a deterrent to continued participation
with a brief overview of the mechanisms by
Optimizing Arousal and Affective Valence and impact negatively on motivation levels
which music might exert an effect during sport
Music can be used as either a sedative or a (3). Therefore, interventions that improve the
and exercise, and a series of evidence based
stimulant to engender the optimal arousal state running experience, such as music, are likely
applied recommendations. Future papers in
prior to and during a run. Research has broadly to have a positive impact on motivation and
this series will explore in greater detail the
supported the assumption that stimulative music adherence, particularly among novice runners.
varied underlying mechanisms by which music
increases psychomotor arousal, while soft or Researchers have attempted to tease out which
influences running performance.
sedative music decreases arousal and facilitates particular aspects of music influence emotional
relaxation. Music may also influence arousal if states in listeners. Two key elements are tempo
Overview of Research Findings
it evokes an extra-musical association that either and mode (major or minor key). “Happy music”
The benefits of music listening in a sport or
inspires physical activity or promotes relaxation is characterized by fast tempo and major mode,
exercise setting are numerous, and have each
(7). A classic example of a piece of music with whereas sad music is typically played in slow
received strong empirical support. Prior to a
highly arousing extra-musical associations would tempo and minor mode (13). Faster tempo music
run, music can enhance emotional state and
be Survivor’s Eye of the Tiger, from the Rocky also leads to enhanced psycho-motor arousal.
motivation, allowing runners to find their optimal
movie series. Many athletes harness the arousal Several studies have shown increased activation
arousal “zone” and priming the various bodily
regulatory qualities of music to help get them of the sympathetic nervous system—the system
systems for action (2). During a run, music can
“in the zone” before competition. A well-known responsible for priming the body for action—
function as a distractor, drawing attention away
example is Olympic swimmer Michael Phelps, with higher tempo music. Conversely, listening to
from feelings of pain and fatigue (3). Music is
who listens to music until the last possible moment sedative music can lead to decreased heart rate,
also known to increase the release of feel-good
before competition. “It helps me to relax and get respiration rate, and blood pressure, indicating an
chemicals in the brain, such as dopamine and
into my own little world” says Phelps (8). increase in parasympathetic activity (14).
opioids, that may enhance feeling state, dull pain,
Mood responses and feeling states during The role of music in the affective response
and delay fatigue (4). Moreover, synchronizing
exercise tend to be more positive under music to exercise is complex. Perhaps more than
compared to no-music conditions (3). This any other stimulus, music has the ability to
* USATF later amended the ban and it now applies only
to those vying for prizes in championships effect has been found consistently and across invoke powerful images and feelings. Music is
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