Journal of the
American Medical Athletic Association
Volume 29, Number 1
Spring 2016
Back to Boston…and Furthering Knowledge
Although by the time you read this, AMAA’s 45th Annual Sports Medicine Symposium at
the Boston Marathon will be in the recent past, I still feel the need to comment on my excitement about the anticipation of renewing professional relationships and friendships at this
annual event. And I know, as always, the race will be challenging and exhaustive; however, it
is also rewarding in so many ways, calling for a repeat performance year after year. It truly
is a life experience!
Every year I also look forward to attend the American Medical Athletic Association’s
two-day symposium, which never disappoints. The speakers, many of whom are the most
respected physicians in the country, always seem to provide a myriad of thought-provoking,
inquiry-driven, and science-based lectures. From what I have seen, the program this year
is following suit with a stellar line-up of speakers and interesting topics. But don’t fret if
you missed the event this year because the next issue of the AMAA Journal will highlight the
Boston weekend in a special summer color issue, including a wonderful spread of photos,
summaries of the weekend, a list of AMAA finishers, and articles from symposium speakers.
(And next year you can join us!)
Speaking of the AMAA Journal, I would like to take this opportunity to remind our readership that this publication is your journal. Among its published offerings that are both
informative and educational are original papers related to the medical aspects of sports,
nutrition, exercise, fitness, and running.
To fulfill the goal of providing a member journal that continues to interest you and increase your knowledge base, we seek input from our colleagues as well as our readers. We
encourage your support and participation by asking for article submissions that will not only
add to our current profiles but also introduce new areas of interest to readers. You can view
the guidelines for submitting articles on page 11 of this journal or go to www.amaasportsmed.org/amaa_journal.htm.
We have also created a short survey to help assess the publication content and
determine new topic areas to consider. Please participate in this survey by going to
https://www.surveymonkey.com/r/RK5SSK6.
Let’s all remember that the journal is our resource for learning and for furthering and
enjoying aspects of the professional world that we share. The intellectual camaraderie within
our community is wholesome and the journal is a way to link us and help share worthwhile
topics of sports medicine throughout the year.
Thank you for being a member of AMAA, and for being an AMAA Journal reader.
Stay the course!
Kathleen Russo, MD
Editor in Chief, AMAA Journal
FOUNDER
Ronald M. Lawrence, MD, PhD
BOARD OF DIRECTORS
Cathy Fieseler, MD, President
Charles L. Schulman, MD, Immediate Past-President
Douglas J. Casa, PhD, ATC, FACSM
S. Mark Courtney, PA-C
Mark Cucuzzella, MD, FAAP
Ronald S. Dubin, MD
Ronald M. Lawrence, MD, PhD,
Member Emeritus
Noel D. Nequin, MD, FACSM, FAACVPR,
Member Emeritus
COL Francis G. O’Connor, MD, FACSM
Kathleen Russo, MD
Chris Troyanos, ATC
HONORARY DIRECTORS
Marv Adner, MD
Judi Babb
Walter M. Bortz II, MD
Ken Cooper, MD
EXECUTIVE DIRECTOR
David Watt
EDITOR-IN-CHIEF
Kathleen Russo, MD
MANAGING EDITOR
Barbara Baldwin, MPH
BOOK REVIEW EDITOR
Paul J. Kiell, MD
TALKING ABOUT TRAINING EDITOR
Douglas F. Munch, PhD
CONTRIBUTING WRITER
Jeff Venables
MEETING COORDINATORS
Judi Babb
Barbara Baldwin, MPH
EDITORIAL ADVISORY BOARD
Brian B. Adams, MD
Donald B. Ardell, PhD
Robert Bice, Jr., MD, FACS
Paul E. Casinelli, MD
George M. Dallam, PhD
Edward R. Feller, MD
Lawrence A. Golding, PhD, FACSM
Steven J. Karageanes, DO
John M. Levey, MD
Steve Morrow, DDS
Douglas L. Noordsy, MD
Edward R. Sauter, MD, PhD
Walter R. Thompson, PhD
Bruce Wilk, PT, OCS
The American Medical Athletic Association (AMAA),
professional division of the American Running Association,
was founded in 1969 by Ronald M. Lawrence, MD, PhD,
to educate and motivate fellow physicians to disseminate
information about exercise and nutrition to their patients,
thereby enhancing their quality of life.
The AMAA Journal is a peer-reviewed publication.
Opinions expressed in the AMAA Journal are not necessarily
endorsed by AMAA.
Address editorial, membership, advertising and change
of address information to AMAA, 4405 East-West Highway,
Suite 405, Bethesda, MD 20814-4535, TEL: 301-913-9517,
FAX: 301-913-9520, E-mail: [email protected],
www.amaasportsmed.org.
2
AMAA Journal Spring 2016
Message from the President . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Can Endurance Athletes Perform Well with a Very Low
Carbohydrate Diet? (Part I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Richard Wood, PhD
Talking About Training:
High-Intensity Interval Training versus Traditional Continuous
Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Fred L. Miller III, PhD, ACSM-HFS, CSCS
Experience Tells Us:
Endurance Sport Can Mimic Phases of Life: An Interview with
Zola Budd Pieterse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Douglas F. Munch, PhD
Guidelines for Submitting Articles to the AMAA Journal . . . . .11
Book Review:
Injury-Free Running: How to Build Strength,
Improve Form, and Treat/Prevent Injuries . . . . . . . . . . . . . . . .12
Cathy Fieseler, MD
Member Profile:
Natalie Stavas, MD: Putting Lives in Balance with the
Transformative Power of Running . . . . . . . . . . . . . . . . . . . . . . .13
Jeff Venables
A Call for Research Input on Kidney Stones . . . . . . . . . . . . . . .15
AMAA Journal Spring 2016
3
Message
from the
President
As I write this, the Boston Marathon is
quickly approaching. Most readers of the
AMAA Journal know that the American
Medical Athletic Association (AMAA) hosts
an outstanding symposium in conjunction
with this particular marathon, but many
may not be aware that the AMAA also hosts
symposiums in conjunction with the Marine
Corps Marathon and in Dallas. The meeting in Dallas, which is in its infancy, was
held the weekend of the Dallas Marathon
(December) its inaugural year. This year,
the meeting was held the weekend of the
Cowtown Marathon in late February. The
Dallas meeting is hosted by Baylor Institute
for Rehabilitation and has featured several
sensational speakers; during the inaugural year, Dr. Ken Cooper introduced us to
Orville Rogers, a (now) 98-year-old running marvel with multiple world records to
his credit.
The meeting at the Marine Corps
Marathon is entering its 25th year. COL
Francis G. O’Connor, MD, has done an outstanding job serving as the director of the
meeting since its early days. Exciting news
for this meeting is an agreement between the
AMAA and MedStar Georgetown University
Hospital/MedStar Sports Medicine. The
meeting will now be held at Georgetown
University Hospital (my alma mater).
Attendees who are not running the marathon
have the opportunity to work with the top notch
crew in the medical tent, if desired.
The AMAA symposium in Boston is our flagship event, and it seems to get better every year.
Many outstanding speakers have presented a
myriad of topics at this meeting; many of these
lectures have addressed current hot topics in
medicine and exercise. We are pleased to have
a few of the speakers from this year’s event contribute to this issue of the journal. Dr. Richard
Wood wrote an informative article on his area of
expertise, Zola Budd Pieterse was interviewed by
Talking About Training Editor Dr. Doug Munch,
and Dr. Natalie Stavas is the featured AMAA
4
Cathy Fieseler, MD, and Bill Borowski, ATC, at
the Dallas meeting on February 27. Bill has been
instrumental in facilitating the partnership between
AMAA and the Baylor Institute for Rehabilitation.
Member in our Member Profile section. We appreciate the efforts of these speakers; taking the
time to write an article in addition to preparing a
lecture certainly earns a gold star.
Richard J. Wood, PhD, is the department
head of the School of Public Health and Health
Sciences at the University of Massachusetts,
Amherst. His lecture in Boston, “Can Distance
Runners Perform Well Without the Traditional
High Carb Eating Pattern?”, addresses some
thought provoking questions. Endurance athletes
have long used the excuse of needing carbohydrates for their food indulgences,
but what is that second dessert doing to
your overall health, never mind athletic
performance? Is a high carbohydrate diet
necessary for optimal performance in endurance events? And what happens when
you reduce carbohydrate intake and force
the body into habitual ketosis?
Zola Budd Pieterse, an elite endurance athlete, gained world recognition
as a teenage phenomenon who broke the
world record for 5000m at age 17 years.
Unfortunately, most people will remember
her as the barefoot runner involved in Mary
Decker’s fall in the 1984 Olympic 3000m.
She had a great career despite this event; in
2012, she competed in one of the world’s
most famous ultramarathons, Comrades,
and finished as the first senior female and
seventh overall female. All of the scientific
data in the world pales in comparison to
the personal experience someone such as
Zola can share.
I would like to invite all of our readers
to attend one or more of the symposiums
hosted by the AMAA. These meetings have
always been enlightening; I have changed
my lifestyle (vegan) and medical practice as
a result of information I learned from the
expert speakers. The meetings are a great
place to network with active health care
providers from all over the country. You don’t
have to run a marathon to attend these meetings;
come for the education and fun.
And, as always, we appreciate feedback from
AMAA members. If you would like to recommend
meeting topics, speakers, or simply have suggestions to enhance our/your symposiums, please
write to [email protected].
Keep Running.
Cathy Fieseler, MD
AMAA Journal Spring 2016
Can Endurance Athletes Perform Well with a Very
Low Carbohydrate Diet? (Part I)
Introduction
Nutrition for endurance athletes has long been
centered on carbohydrate consumption. Whether
looking at pre- and post-competition nutrition, or
looking at nutritional patterns over the course of a
training year, most recommendations include a diet
based predominantly on carbohydrate (1,2). The
resurgence in popularity of low carbohydrate diets
in the early 2000s centered mostly upon weight loss
and the management of disease. Though there were
limited data available at that time, there have since
been hundreds of studies supporting the efficacy
of low carbohydrate diets for weight loss and for
managing chronic disease, most specifically type
2 diabetes. Low carbohydrate diets consistently
and predictably reduce fasting and postprandial
triglycerides and often lead to increases in HDLcholesterol along with favorable changes in lipid
particle profile (3). Due to these types of findings,
there are recent calls for changes in the Dietary
Guidelines for Americans (4,5), citing, among many
other factors, that basing the diet on carbohydrate
may be predisposing many people to obesity and
the related comorbidities.
Panning over to the subset of our population
that is endurance athletes, at first glance it
may seem counterintuitive to even consider a
low carbohydrate diet. First, just about every
recommendation available to endurance athletes
over the past several decades has the majority
of kilocalories coming from carbohydrate.
Consuming a low carbohydrate diet would go
completely against almost every recommendation
in print. Second, endurance athletes are probably
thought to be some of the people at the lowest
risk for obesity and type 2 diabetes.
Though interconnected, the topics of guidelines
for health and performance and the effects of dietary
pattern on treating metabolic disease are not the
focus of this paper. This paper is about performance.
Ultimately, the question to be answered is “can an
endurance athlete perform well while consuming a
very low carbohydrate diet”?
Defining low carbohydrate diet
Table 1 was created based on several sources
(6,7). No single, widely-accepted definition
of a low carbohydrate diet exists. Regardless,
restriction of carbohydrate is probably better
depicted on a continuum with thresholds for
various degrees of restriction.
AMAA Journal Spring 2016
generally takes 2-4 days. The ketone formation is
a result of accelerated fat utilization; the pathways
of lipolysis, fatty acid transport, and beta oxidation
are all increased (7). The result of increases in
By Richard Wood, PhD these pathways is an elevated amount of acetyl-CoA
being available for oxidation in the Krebs Cycle.
Acetyl-CoA enters the Krebs cycle by combining with
oxaloacetate to form citrate. This match between
Acetyl-CoA and oxaloacetate occurs on a 1:1 basis.
When the generation of Acetyl-CoA
exceeds the capacity of oxaloacetate,
Table 1
the Acetyl-CoA is then diverted to the
Reference
Percent of
Grams of
synthesis of ketone bodies, Figure 1B,
Term
kcal from CHO
CHO / day
which include β-hydroxybutyrate,
Western Diet
~50
≥250
acetoacetate, and acetone. Ketone
Reduced Carbohydrate
25-40
125-200
generation occurs mostly in the liver
Low Carbohydrate
10-25
50-125
in the mitochondrial matrix. Blood
Very Low Carbohydrate
ketone levels reach approximately 1-3
/ Ketogenic
<10
<50
mmol/L during a ketogenic diet (vs
approximately 0.1 mmol/L under a
typical habitual diet), an environment
Given the lack of any widely-accepted
often
referred
to as “physiological ketosis” (10).
definition, when reviewing literature germane
During
these
conditions, cells dependent on
to low carbohydrate diets, it is important to
glycolysis
(ex:
red
blood cells) use glucose derived
understand what participants actually ate.
from
gluconeogesis,
the precursors for which
As our group reported previously, literature
are
glycerol,
lactate,
and
glucogenic amino acids.
examining low carbohydrate diets ranges from
Ketones
spare
the
use
of
amino
acids and glucose,
carbohydrate intakes of 5-40% of total kcal (8).
being
used
as
a
fuel
source
for many tissues,
That range could have a difference of hundreds
including
the
brain
(11).
of grams of carbohydrate per day. If the typical
Interestingly, reducing dietary carbohydrate
American is eating approximately 50% of their
imposes
many of the same metabolic effects of
kilocalories from carbohydrate, then eating 40%
starvation
(12-14), yet people are not actually
of kilocalories from carbohydrate is a form of
starving.
restriction, but would have very different effects
The pathway of ketogenesis is also highly
on physiology as compared to a diet with 10% of
upregulated
in the presence of very low levels of
kilocalories from carbohydrate.
insulin, as seen in type 1 diabetes. An important
note is that ketone levels seen diabetic ketoacidosis
Ketones and ketoadaptation
A “ketogenic” diet or a “very low carbohydrate are > 25 mmol/L, which exceeds levels seen during
diet” is the intake pattern with the fewest dietary starvation or with the consumption of low levels
carbohydrates consumed. Most evidence supports of dietary carbohydrate 3-4 fold, and is known as
that the intake of fewer than 50 grams/day of “pathological ketosis” due to effects on the blood
dietary carbohydrate leads to the production of pH (10). When people are consuming a ketogenic
measurable amounts of
ketones (7,9). Figures
1A and 1B depict how
ketogenesis becomes
upregulated
when
switching from habitual
diet (Figure 1A) to a
ketogenic diet (Figure
1B). Ketogenesis begins
when liver glycogen
becomes reduced, as
is seen in either fasting
or low consumption of
dietary carbohydrate.
With adoption of a
very low carbohydrate
diet, the onset of
traceable
ketones
continued on page 6
Figure 1A. Metabolism during habitual diet
5
continued from page 5
diet, urinary ketones are often measured as a metric
of compliance (15), given that consumption of
more than 50 grams of carbohydrate per day almost
instantly results in ketone levels being reduced to
below traceable levels.
Typically, when people are consuming a
ketogenic diet they would consume unlimited
quantities of fish, meat, poultry, and eggs, cheese,
and non-starchy vegetables, with limited quantities
of starch vegetables as well as nuts and berries.
There are no limits on type or quantity of dietary
fats or dietary cholesterol. People would avoid
cereal, bread, pasta, rice, desserts, many fruits,
and all fruit juices and soft drinks (16). The
carbohydrate present in the diet is residual, and
mostly from the vegetable intake. The diet is not
necessarily a “high protein” diet (generally 2035% of kilocalories); the diet is based on fat,
and proper care should be taken for adequate
fat intake. Furthermore, mineral intake is also
an important consideration, with particular focus
on sodium and potassium since an inadequate
intake of these minerals is more likely on a very
low carbohydrate diet (6,17). There are a number
of resources available with detailed examples of
dietary plans, recipes, etc. (7,10,18,19). As
carbohydrate intake increases, but remains below
average intake, the type of carbohydrate restriction
can be categorized as in Table 1.
Generally, when people eat carbohydrate, they
use carbohydrate as a predominant source for fuel.
When carbohydrate is not available, or ingested
carbohydrate is present in insufficient amounts to
meet fuel demands, reliance for energy shifts to
fat (20). When people switch from a habitual diet
to a ketogenic diet, the predominant fuel source
becomes fat. The transition from relying largely on
carbohydrate to relying on fat and ketones for fuel is
referred to as “ketoadaptation,” and the process of
ketoadaptation has been known for some time with
documentation of the concept more than 130 years
ago (10). Ketoadaptation involves the upregulation
of enzymes in pathways utilizing ketones and
fatty acids for fuel, and takes from one to four
weeks (6,10,17). Whether or not an individual is
ketoadapted is a very important consideration when
evaluating performance measures.
Evidence supporting low carbohydrate
intake in endurance athletes
The energy demands for endurance athletes
have been depicted elsewhere. Briefly, the
predominant source for ATP while exercising
below the lactate threshold is fat but the degree
to which fat is used varies between individuals.
The majority of any competitive endurance event
is spent at intensities below the lactate threshold.
As people become more trained, they are able to
complete more work at a given exercise intensity,
and the more individuals are able to rely on fat as
the primary energy source, the more they are able
to conserve glucose. Ultimately, becoming the best
“fat burner” possible is probably, in theory, an
excellent way to approach the energetics goals of
an endurance athlete. As is eloquently described
by Volek and Phinney (19), we have VASTLY more
fat energy stored in our bodies than carbohydrate
(20 fold or more), so it is unfortunate that any
endurance athlete could experience a “bonk”
with an incredible fuel reserve still present.
Considerable evidence exists to support the
use of ketogenic diets in endurance athletes. One
of the earliest studies done was by Phinney et al
in 1980 (12). Participants were not endurance
athletes, but moderately obese sedentary adults
(n=6) who underwent an in-patient, proteinsupplemented (1.2 g/kg/d) fast for six weeks,
and no exercise training occurred during the
treatment period. Exercise capacity, as measured
by VO2max, was measured at baseline and week
six. Since weight loss was an average of 10.6 kg
by week six, the amount of weight lost by each
participant was placed in a backpack and worn
by the participant at the
post-testing. VO2max
was unchanged from
baseline to week six.
Two very interesting
findings
emerged.
In addition to the
VO2max
testing,
participants completed
an endurance test to
exhaustion at baseline
and week six and had
a muscle biopsy taken
before and after the
endurance exercise
test to measure muscle
glycogen. Time to
exhaustion was 155%
longer at week six as compared to baseline;
however, it is important to note that exercise
intensity at the post test (60±1%) was completed
at a significantly lower percentage of VO2max as
compared to the baseline test (75±3%). The
pre-exercise muscle glycogen at week six was
32% lower at week six than at baseline. However,
at baseline, muscle glycogen decreased by 15%
after the endurance test, whereas at week six,
muscle glycogen remained virtually unchanged
(-2%). Secondly, the respiratory quotient (RQ;
indicator of fuel utilization) values decreased
significantly during the endurance exercise
test at week six when compared to baseline,
indicating an increased reliance on lipid. The
robust change in fat utilization and glycogen
sparing are very interesting in this early study,
but a number of factors limit these findings.
To address limitations of the 1980 study,
Phinney et al. (14) then recruited five highlytrained cyclists who were fed a eucaloric ketogenic
(<20 grams carbohydrate per day) diet for four
weeks, while maintaining their training routine.
VO2max and exercise time to exhaustion at 6264% of VO2max was unchanged from baseline to
week four. However, the RQ dropped significantly
from baseline to week four, which corresponded
to an average fat oxidation of 1.5 grams per
minute (21). That finding is extremely significant
since the upper limit of fat oxidation is thought to
be approximately 1.0 gram per minute in people
eating a mixed diet (22). Glucose oxidation was
three times lower at week four than at baseline.
Furthermore, muscle glycogen utilization was
four times lower during exercise to exhaustion
at week four when compared to baseline (14).
These results indicate that a ketogenic diet led
endurance athletes to significantly increase fat
oxidation capacity and more effectively spare
glucose, with no decrement in performance.
Using a crossover design, Zajac (23) examined
the effects of a four-week ketogenic diet on aerobic
performance measures in eight trained off-road
cyclists. Compared to a mixed diet, the ketogenic
diet led to increased fat utilization during
exercise, as well as increases in relative VO2max
and increased oxygen consumption at the lactate
threshold. Importantly, these changes in oxygen
consumption and relative capacity were explained
by the changes in body weight that accompanied
the ketogenic diet. The maximum work load and
the work done at the lactate threshold were higher
after the mixed diet as compared to the ketogenic
diet. These data support the use of a ketogenic
diet during lower to moderate intensity, higher
volume endurance exercise, but limitations may
exist during maximal-effort attempts or sustained,
higher intensity training. Others have also reported
similar findings of increased capacity for fat
oxidation after a low carbohydrate diet (24-26).
Figure 1B. Ketogenisis during a very low carbohydrate diet
6
AMAA Journal Spring 2016
One of the limitations of the studies done
on ketogenic diets is that they are of a relatively
short term (i.e. only a matter of weeks).
Recently, Volek et al. (21) reported on the
Fat Adapted Substrate use in Trained Elite
Runners (FASTER) study, which was designed
to examine the metabolic differences between
competitive ultra-marathoners and ironmandistance triathletes consuming low carbohydrate
and high carbohydrate diets. Participants were
matched for anthropometrics and competition
characteristics. Participants underwent two days
of testing; on the first day testing was completed
to determine VO2max and peak fat oxidation. On
the second day participants completed a threehour treadmill run at 64% of their VO2max. The
low carbohydrate group had been consuming
less than 10% of kilocalories from carbohydrate
for 9-36 months, whereas the high carbohydrate
group had been consuming approximately 59%
of kilocalories from carbohydrate for at least
six months. The primary finding was that peak
fat oxidation was 2.3 times higher in the low
carbohydrate group as compared to the high
carbohydrate group. Interestingly, the peak fat
oxidation in the low carbohydrate group ranged
from 1.15 to 1.74 grams per minute, and every
subject in that group had a value that exceeded
the highest value in the high carbohydrate group
(0.4-0.87 grams per minute). The total energy
used during the endurance run were not different
between groups, but the low carbohydrate group
had a much higher contribution from fat (88%)
compared to the high carbohydrate group
(56%). These results confirm earlier findings
by Phinney et al. (14) in terms of maximum
fat utilization values after adaptation to a very
low carbohydrate diet, and further support the
evidence that adopting a very low carbohydrate
diet significantly increases the reliance on fat
while performing endurance exercise.
More work has also been done examining
the sedentary, obese population than with
endurance athletes. The findings are similar in
that a ketogenic diet increases fat oxidation and
either no change (27) or an increase in VO2max
(28) as compared to a high-carbohydrate diet.
Not all studies are in agreement about the effects
of a ketogenic diet on endurance exercise
performance (29). Due to methodological and
subject differences, changes in body weight, and
the importance of ketoadaptation, considerable
additional work is necessary in this area to
improve upon the understanding of the ketogenic
diet as related to exercise performance.
Conclusion
High carbohydrate diets increase muscle
glycogen and have been shown to improve
performance, but also increase the rate of
AMAA Journal Spring 2016
carbohydrate use during exercise. Since we
have a limited ability to store carbohydrate,
sources must be regularly replenished during
endurance training and competition. The
potential for endurance athletes to switch to
becoming preferential and efficient fat users can
be realized through the adoption of a ketogenic
diet. Research is still somewhat limited, but
anecdotal accounts are increasingly common.
Nutrition is a very individualized subject; the
aforementioned evidence supports ketogenic
diets as an option for some endurance athletes.
Adoption of a ketogenic diet must be done with
care, and proper resources should be consulted
(19). Of particular importance are sodium
and potassium intake, moderating protein
intake, and optimizing fat intake. Furthermore,
a period of ketoadaptation is critical and
should be accounted for in any training/
competition periodization planning. Although
the safety of ketogenic diets has been shown
through a considerable body of research and
clinical application, concern about side effects
for competitive athletes still exist, including
dehydration and kidney stones (23), and should
be considered on an individual basis by athletes.
Ketogenic diets are becoming well-known
among trainers and athletes. Part II of this
series will discuss the practical aspects of a
ketogenic diet. It will include issues such as
implementation, monitoring, and possible side
effects when used as part of an overall endurance
training program.
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22.Venables MC et al. Determinants of fat oxidation during
exercise in healthy men and women: a cross-sectional
study. J Appl Physiol 2005; 98(1): 160-7.
23. Zajac A et al.The effects of a ketogenic diet on exercise
metabolism and physical performance in off-road cyclists.
Nutrients 2014; 6: 2493-2508.
24. Burke LM et al.Adaptations to short-term high-fat
diet persist during exercise despite high carbohydrate
availability. MSSE 2002; 34(1): 83-91.
25. Lambert EV et al. High-fat versus habitual diet prior to
carbohydrate loading. Effects on exercise metabolism and
cycling performance. Int J Sports Nutrition Exerc Metab
2001; 11: 209-225.
26. Helge JW et al. Fat utilization during exercise:
adaptation to a fat-rich diet increases utilization of plasma
fatty acids and very low density lipoprotein-triacylglycerol
in humans. J Physiol 2001; 15: 1009-20.
27. Brinkworth GD et al. Effects of a low carbohydrate
weight loss diet on exercise capacity and tolerance in
obese subjects. Obesity 2009; 17(10): 1916-23.
28.Wycherley TP et al. Long-term effects of a very lowcarbohydrate weight loss diet on exercise capacity and
tolerance in overweight and obese adults. J Am Coll Nutr
2014; 33(4): 267-73.
29.White AM et al. Blood ketones and directly related to
fatigue and perceived effort during exercise in overweight
adults adhering to low-carbohydrate diets for weight loss:
a pilot study. J Am Dietetic Assoc 2007; 107(10): 1792-6.
Dr. Richard Wood is an associate professor
of exercise science at Springfield College in
Springfield, Massachusetts, where his research
interests focus on how dietary changes impact
chronic metabolic disease and sport performance.
Dr. Wood was a speaker at the AMAA’s 45th annual
Sports Medicine Symposium at the Boston
Marathon (2016) in April. His website focuses
on helping people understand nutrition and can
be found at www.drrichwood.com. He is an avid
hockey player and youth coach.
10. Paoli A et al.The ketogenic diet and sport:A possible
marriage? Exerc Sport Sci Rev 2015; 43(3): 153-62.
11. Cahill GF. Fuel metabolism in starvation. Annu Rev
Nutr 2006; 26: 1-22.
12. Phinney SD et al. Capacity for moderate exercise in
7
HIIT may be a great alternative to traditional
continuous training in improving cardiovascular
health and fitness. HIIT takes considerably less
time and several studies have reported similar
and in some cases greater improvements
compared to traditional continuous training.
Furthermore, musculoskeletal injuries are
no more common in groups performing HIIT
By Fred L. Miller III, PhD, ACSM-HFS, CSCS compared to other forms of exercise (14).
However, numerous long term (>8 weeks)
Have you looked around recently in restaurants health and fitness measures (6,9). Some of studies have shown lasting health and fitness
or shopping malls? In today’s society, most adults these improvements include larger stroke benefits following traditional continuous
are overweight and underactive. According to volume (8), increased VO2max (3), increased training and very few, if any, have reported long
the Centers for Disease Control and Prevention oxidative enzyme levels (1), greater glucose term effects of HIIT. Furthermore, potential
(CDC), 69% of U.S. adults are overweight and control (16), and decreased body mass index dropout due to reported lower enjoyment in
about 35% of those are clinically obese (13). (BMI) (16). Although both training types lead high intensity interval training leaves traditional
Furthermore, the 2011 National Health Interview to improvements, several studies have reported training more favorable.
When prescribing HIIT or any form of training
Survey (NHIS) reported only 20.6% of adults greater improvements in cardiorespiratory
it
is
important to define intensity in practical
met both the aerobic and muscle-strengthening health and fitness following HIIT compared to
terms.
Most HIIT programs recommend the
guidelines and less than half (48.4%) met just traditional continuous exercise. For example,
“high-intensity”
bout to be at least 90% of
the aerobic activity guidelines (2). The current a meta-analysis of 10 studies (18) reported
one’s maximum aerobic
guidelines recommend adults accumulate at greater improvement in
capacity. Normally, aerobic
least 150 minutes of moderate intensity (64 to cardiorespiratory
fitness
capacity is based on one’s
RPE
(Borg)
Scale
76% Heart Rate Max [HRmax]) or 75 minutes of following
HIIT
versus
VO2max. The problem with
vigorous (77 to 95% HRmax) aerobic activity per moderate intensity continuous
0 Nothing at all
using VO2max is most people
week to achieve health benefits (5).
exercise (19.4% vs. 10.3%),
1 Very, very light
don’t understand it and/or
It is well-known that regular aerobic exercise 10% greater improvements in
2
Very
light
have access to the equipment
improves cardiovascular health (11,12); stroke volume following HIIT
3Moderate
necessary to determine it. A
however, most adults still do not engage in the versus long, slow distance
popular alternative to using
4
Somewhat
hard
recommended levels of exercise. Numerous studies training (8), and greater
VO2max as an assessment of
5Hard
have concluded the number one reason for not VO2max
improvements
aerobic capacity is heat rate
6
exercising is “I don’t have time” (7,17). Given the (15% vs. 9%) following a
max (HRmax). When using
7 Really hard
time constraints most people feel as a barrier to HIIT program versus doing
HRmax, though, one should
exercise participation and the high prevalence of continuous aerobic training
8
use 95% as the minimum
overweight and physical inactivity in today’s society, (3). Furthermore, Perry
9 Extremely hard
“high intensity” since 95%
would an exercise prescription requiring less time and colleagues (2008)
10 Maximal Exertion
HRmax is equivalent to 90%
with the same benefits as the traditional moderate- reported higher fat and lower
VO2max. For example, if a
intensity continuous training be an answer?
carbohydrate oxidation after
person performs a HRmax
High Intensity Interval Training (HIIT) is just 6 weeks of HIIT (15). For
assessment
and
that
person’s HR max is 170
characterized by repeated bursts of high-intensity, those with a scientific bent, the metabolic value
bpm
(beats
per
minute),
then 95% of 170 (.95 x
short duration exercise separated by periods of of this technique is to train the mitochondria
170)
equals
161.5
bpm.
Therefore, this person
low-intensity exercise. The high-intensity bouts to burn fat efficiently through the process of
would
want
to
exercise
at
161.5 bpm or higher
typically range from 10 seconds to 4 minutes oxidative phosphorylation in the TCA cycle.
during
the
“high-intensity”
bout of HIIT. The
followed by lower intensity recovery period
Given that many studies have shown HIIT
problem
with
this
method
is
most people don’t
ranging from 10 seconds up to 8 minutes. The leading to similar and in some instances better
know
how
to
determine
his
or
her HRmax. So,
high-intensity bout is often an “all-out” effort improvements short term (2-8 weeks) in
a
solution
to
this
problem
is
using
a well-known
or at a target intensity of at least 90% of one’s health and fitness gains compared to traditional
Haskell
and
Fox
equation
to
predict
estimated
maximal aerobic capacity (95% of HRmax). The continuous training, and that HIIT takes less
HRmax.
This
equation
is
as
follows:
HRmax =
low-intensity is typically an “easy” effort or around time, one may deem HIIT the way to go. However,
220
age.
For
example,
a
50
year
old’s
predicted
60% of one’s aerobic capacity (75% of HRmax). HIIT may have lower adherence. For example,
HRmax
would
be
170
(220
50
=
170).
Once
The total time commitment (excluding warm-up a major finding of Foster and colleagues (4)
you
know
the
person’s
HRmax,
then
you
can
and cool-down) is normally 4 to 20 minutes.
comparing three training groups (two HIIT
calculate
95%
of
that
person’s
HRmax.
For
the
Traditional continuous training normally and one steady-state) found exercise enjoyment
50
year
old,
95%
of
170
equals
161.5
bpm.
consists of a steady-state, non-stop (normally lowest in the most intense training group.
20 to 60 minutes) activity (e.g., cycling, running, Less enjoyment could potentially lead to lower Therefore, it would be recommended the 50
swimming) that is challenging, but at a manageable compliance, thus making HIIT less than ideal for year old aim for a heart rate of 161.5 bpm or
pace, normally between 50 to 70% of one’s maximal the long-term. Although, some data suggest high- higher during the “high-intensity” bout of HIIT.
A good alternative to relying on heart rate
aerobic capacity (65% to 80% HRmax).
intensity, lower frequency exercise leads to better
to
assess
intensity during HIIT is using a rate of
Both HIIT and traditional continuous adherence when compared to low-intensity,
perceived
exertion (RPE) scale. An RPE scale
training have been shown to improve several higher-frequency training (10).
High-Intensity Interval Training versus
Traditional Continuous Training
8
AMAA Journal Spring 2016
may be easier and more appropriate for some. A
perceived exertion scale is a subjective measure
of how hard you feel you are working out. There
are a variety of RPE scales. A common and
simple RPE is the Borg CR10 scale, which uses
a simple scale of 0 to 10. A zero is equivalent
to “no exertion at all” or “rest” and a 10 is
“maximum exertion.” When using this scale for
HIIT, I suggest working at an exertion of 7 (really
hard) to 9 (extremely hard) during the “highintensity” bout and between a 2 (very light) to 3
(moderate) during the “recovery” bout.
Deciding if and when to recommend HIIT
can be challenging. To make the decision easier,
I suggest gathering information about the person
interested in improving one’s cardiovascular
health/fitness. For example, let’s pretend John
asks you if he should include HIIT in his weekly
workouts? Your simple answer may be, “Go for
it!” or “Don’t do it!” I advise against these simple
responses and, instead, suggest that you ask him
certain questions before responding. Then, based
on his answers, you can decide if he should
include HIIT workouts and, if so, how often. A
few important questions I would ask include,
“Why do you want to perform HIIT? What are your
fitness/health goals? How much time do you have
to workout? Have you been exercising regularly?”
And “Oh, by the way, how old are you?”
Let’s say John’s answers to your questions
are, “I heard HIIT is an effective way to improve
one’s health and takes less time than traditional
continuous training. My goals are to lose 5 lbs
and to run a half-marathon. I have up to an hour
per day, five days per week to work out. I have
not been exercising regularly (my last workout
was two years ago). I am 35 years old.” Based
on John’s answers, I would tell him to avoid
HIIT workouts for the first three weeks and then
during the fourth week replace one traditional
continuous workout with HIIT and see how it
goes. Depending on the outcome, I may have
him perform up to two HIIT workouts per week
but no more. This is mainly based on his goals,
which indicate the need for more traditional
continuous training. When working with anyone,
I recommend you gather enough information
about that person before telling them whether
HIIT is appropriate. In addition, when making
that decision try to remember that any exercise
program (with or without HIIT) should focus
on being safe and avoiding injury, helping one
reach his/her goals, and ultimately encouraging
a lifelong commitment.
As a professor of exercise science and a
distance runner, I am often asked by students,
colleagues, friends, and family what is the best
way to train? Many times this question is in
reference to training for a 5K, half marathon,
or a marathon, but the question could easily be
AMAA Journal Spring 2016
about other sports (e.g., cycling and swimming),
which would include an answer applying similar
general training principles. Sometimes though,
this question is related to weight loss, fitness,
and/or general health. As many readers of this
journal can attest, the answer to their question
is complex. In simple terms, I typically tell them
to eat healthy, eat less, get 7 to 8 hours of sleep
per night, be more active, and exercise regularly.
This simple response, however, isn’t enough for
most people. Many people, perhaps including
you or individuals you work with, need more
details. What I have shared above about HIIT
versus traditional continuous training is simple,
but a good starting point for you to determine for
yourself if HIIT or traditional continuous training
is more appropriate for you, your clients/patients,
and/or your friends. As you likely know, deciding
to include HIIT depends on many factors such as
one’s goals, motivation level, exercise background,
available time to exercise, one’s age, and more.
For myself, I do more traditional training than
HIIT, mainly because of my experience with both
and because my focus is on performing well in
half marathons and marathons.
Which do you prefer? Have you tried both
training types? What are your experiences with
HIIT versus traditional training? Feel free to
email me your thoughts and/or experiences
to [email protected]. Bottom line—eat
healthy and stay active!
Effects of high intensity interval training vs steady state
training on aerobic and anaerobic capacity. J Sports Sci
Med 2015; (14)747-755.
Dr. Fred Miller III, Associate Professor of
Exercise Science at Anderson University, is a
long-time distance runner who has completed
over 500 races ranging in distance from
the 5K to the Marathon. He has completed
19 marathons (18 of those under 3 hours),
winning the October 2015 Indianapolis
Marathon in 2:41. He is an American College of
Sports Medicine Certified Exercise Physiologist
(ACSM C-EP) and a National Strength and
Conditioning Association Certified Strength
and Conditioning Specialist (NSCA-CSCS). He
is currently training for his 20th marathon,
with the goal of running a personal best.
13. National Center for Health Statistics (NCHS). United
States, 2014, Centers for Disease Control and Prevention
(CDC): Hyattsville, MD. Retrieved from http://www.cdc.
gov/nchs/fastats/obesity-overweight.htm.
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Short-term sprint inverval vesus tradional endurace
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RA, Ekelund U, Katzmarzyk PT, Blair SN. Comparisons
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High-intensity aerobic interval training increases fat and
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B, Schuette J,Tuuri A, Doberstein S, and Porcari J.The
9
Endurance Sport Can
Mimic Phases of Life:
An Interview with
Zola Budd Pieterse
By Douglas F. Munch, PhD
with Zola Budd Pieterse
Endurance athletes may go through different
phases with their sports. Some start out
competitively and remain so for many years.
Others train for the enjoyment, mental peace
or release, others for serious fitness, and still
others may evolve into the competitive elements
over time. Many endurance athletes may enjoy
all of the above to one extent of another, while
some evolve through different phases as their life
changes through the years. Zola Budd’s running
career has been complicated. She is recognized
for world records, controversy, misfortune, but
few know about her painful personal losses, one
of which may have driven her to be an unwitting
world champion. In talking with Zola Budd, I
found that her running experience has been an
evolution through many different phases, which
today includes a perspective about coaching and
training young athletes.
Experience
Tells Us
DFM: How do you view your running today?
DFM: When did you start running?
ZBP: I started running at school in Bloemfontein,
South Africa, because we were forced to do a
sport and I was useless at anything else, as I swam
like a rock and had no ball sense whatsoever.
I decidedly took to running like a fish to water
and really loved doing it. I enjoyed the feeling
of running, the experience of just being in the
moment, the autumn leaves underneath your feet
and the smell of fresh green grass in spring. So, I
got hooked to the sport at an early age.
DFM: Was competition always a part of your
running in the early days?
ZBP: When I was fourteen years old, my sister
suddenly passed away and I put all my energy
into running. The more I ran, the better I felt and
the better I performed. Soon I was hooked into
the goal-driven and outcome-based narrative of
competitive running. The better I ran, the more
this narrative was confirmed and the more other
people around me bought into it as well. This
trend continued to grow and finally consumed my
life in such a way that the sum of my humanness
was graded by my running performance. The sad
thing about this, I should take care to note, is
that I bought into this impression completely.
10
of running. When I ran for Great Britain in 1984
I felt like I had to perform because of all the
pressures of money, sponsorships, races, etc.
It was then that I felt I had lost control of my
running and life.
When I was seriously injured in 1986 and could
not compete for a year or two, I had to rethink my
whole attitude to running. I was left in a vacuum
of not knowing who I was and what I wanted to do
with my life. I learned at a very young age the truth
about finding my own answers to life―that is, by
setting my own goals regardless of the opinions of
others. This adjustment in thought process forced
me to retrain my brain and make a complete
paradigm shift, and helped me see myself merely
as a participant, and not a competitor.
Thirty-five years later I still love running and
am actively involved in running and sharing my
experiences. I feel very strongly about running
with passion.
Zola Budd Pieterse racing to first place (1:21:15)
in the women’s division of the Myrtle Beach Mini
Marathon on October 20, 2013.
DFM: You grew up loving to run with your sister.
As your speed increased, when did competitive
running become outcome based narrative
[winning races] for you?
ZBP: I think I subconsciously tried to make up
for my sister’s death by being a good runner. My
mom and dad traveled to meets with me and we
were a resemblance of a family again. The better
I ran, the more I could rescue us as a family.
DFM: Were you driven to win races or did you
continue to run just for the sake of running? Was
world class competition just a consequence of
loving to run?
ZBP: I never set out to run world records or
win championships. It was just a consequence
ZBP: Today, I look at myself as a survivor of “the
competitive-narrative syndrome.” It took a great
deal of torment and soul-searching to reach the
point where I could truly say and believe that this
moment in time is exactly where I want to be, that
this is what I want to do with my running, and that
my running moment is now, and not lost somewhere
in the past. My attitude today, in essence, consists of
the attitude of, whatever the outcome may be, the
result is good enough for me.
I sometimes still find myself trying to justify my
lack of athletic performance and competitiveness
to others who are still caught up in the “competitive
narrative.” I regularly have to re-affirm my own
standpoint, as it is easy to get hooked and pulled
into the “competitive narrative syndrome” when
talking to other athletes.
DFM: When did you begin coaching and what do
you enjoy about it now?
ZBP: I have always been involved in some sort of
coaching. I coached some high school runners in
South Africa and loved it. Currently I am coaching
at Coastal Carolina University in Myrtle Beach,
South Carolina. I enjoy running with the college
runners and to add some meaning to the highly
outcome-based formula of Division 1 running.
DFM: What are your concerns for young runners?
ZBP: My main concern is that they run because
their parents want them to run, or the coach
pressures them or because of scholarships.
Believe me; none of the above are going to
motivate you to become a dedicated runner.
Intrinsic motivation is the key and that needs a
AMAA Journal Spring 2016
few chapters to describe and explain. I fear for
the “take away,” “throw away” society we live in;
it is not conducive to a healthy lifestyle.
I believe running is a tool to enhance and enrich
your life on a physical, psychological, and spiritual
level. If coaches cannot address this holistic
principle in their coaching, athletes will get hurt. A
coach’s performance is measured by more than just
the performance outcomes of their athletes.
DFM: What advice would you give to young runners?
ZBP: If I could pass on any information to new
young runners from the long, steep journey I
have ran (and even crawled, at times), it would
be to push the “competitive narrative syndrome”
aside, and to encourage young athletes to write
their own story in a personal meaning-driven way.
This, I feel, would be the greatest contribution
to not only an athlete’s performance, but the
longevity of their running career, as well.
DFM: At what point should young runners
consider competition?
ZBP: Competition is good at any age. I am not
against competition. I would recommend that
parents should make sure that it is the child who
wants to do it and not them or the coaches.
Competing is conducive to good
performance, dedication, hard work and all the
easy roll-off-the –tongue “lingua” motivators
use. I agree with this, but only if it is the athlete’s
choice. Competition becomes negative when it is
outcome based and is not seen as part of your
development and learning process. Competing
becomes negative when the fear of losing
controls your participation. Attitude towards
competition is what should be coached!
DFM: What would you advise athletes about how
to keep competition in perspective and “healthy”?
that I won, but rather the training with friends
and I am so thankful that I am still able to run
and enjoy the silent healing of our sport.
Zola Budd Pieterse continues to be a
middle and long distance runner. In 1984,
Zola competed in the Olympic Games for Great
Britain and then again in 1992 for South Africa,
both at 3000 meters. She held the world record
in the women’s 5000 meters in 1984 and 1985.
Zola was also a world champion cross country
runner. Now she runs mainly for pleasure…
and occasional competition. Zola presented a
lecture on “A Holistic Approach to Running”
at the AMAA’s 45th Annual Sports Medicine
Symposium at the Boston Marathon and was
one of the special guests at the AMAA’s Pasta
Party held each year before the marathon.
ZBP: The best advice is not to take yourself
so seriously. The friendships and learning
experiences as well as spiritual and psychological
development through the process of competing
is far more valuable than any gold medal you can
ever win. My fondest memories are not of races
Guidelines for Submitting Articles to the AMAA Journal
The AMAA Journal publishes original
papers related to the medical aspects of
sports, exercise, and fitness. Our goal is
to assist physicians and other health care
professionals in caring for active patients,
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training programs for all patients. The journal
also speaks directly to the physician and
health care professional, who may benefit
themselves from the information provided.
Manuscripts are considered on the condition
that they are contributed solely to the AMAA
Journal at the time of submission. Reprints are
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Research articles should be between 1,500
and 2,500 words in length. Manuscripts should
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The authors’ full names, degrees, and
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as well as contact information.
References should be cited in numerical order
in the text in parenthesis and listed in the same
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AMAA Journal Spring 2016
formatted as shown in the following examples:
Journal Reference: Holmes MD, et al.
Physical activity and survival after breast cancer
diagnosis. JAMA 2005; 293(20):2479-2486.
Book Reference: Bandura A. Social
Foundations of Thought and Action: A Social
Cognitive Theory. Englewood Cliffs, NJ: PrenticeHall, 1986.
Pharmaceuticals: Generic names of drugs
and other products should be used, unless use of
a particular brand is relevant to patient outcome.
Review Process: Articles that meet the
editors’ initial criteria are then reviewed by
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article. Authors are notified when we receive a
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we accept the manuscript, reject it, or request a
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Editing: Articles will be edited to conform
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_________________________________
Contributing to Special Sections
Talking About Training: This column is
a contemporary forum covering training issues
ranging from philosophies to methodologies,
psychology to physiology and nutrition, and
sports medicine to electronic tools while
incorporating concepts of life long fitness and
wellness for a broad range of sport (800-1,600
words). To submit an article for this section,
contact Talking About Training Editor Douglas
F. Munch, PhD, at [email protected].
Experience Tells Us: Educational articles
based on clinical or training experience
(800-1,600 words). To submit an article
for this section, contact Barbara Baldwin at
[email protected].
AMAA Member Profile: Written by
Running & FitNews Editor Jeff Venables,
this feature focuses on an AMAA member’s
contribution to sports medicine, as well as
their personal history (800-1,600 words). If
you would like to nominate an AMAA member
to be profiled for this section, please contact
Jeff Venables at [email protected].
Book Reviews: Short articles reviewing
new books or books that may be of particular
interest to the AMAA audience (600-800
words). Contact Book Review Editor Paul
Kiell, MD, at [email protected] regarding
books to review.
Letters to the Editor: Letters that refer
to articles published in the AMAA Journal or
regarding AMAA events. If you have a letter to
submit to the Editor-in-Chief, please contact
Kathi Russo, MD, at [email protected].
11
BOOK REVIEW
Injury-Free Running: How to Build Strength,
Improve Form, and Treat/Prevent Injuries
By Dr. Thomas C. Michaud
Paperback, 214 pp, Newton Biomechanics, MA, 2013
Reviewed by Cathy Fieseler, MD
Injury-Free Running is a well-written and
thought-provoking book for runners of all
abilities. Dr. Michaud is a chiropractor who has
cared for numerous runners for several decades
and brings his wealth of experience to this book.
There are numerous illustrations throughout
the book to help the reader understand each
concept and exercise that is described.
The initial premise of the book is that man
(woman) was not born to run; otherwise the
injury rates would not be so high. Basic running
anatomy and the evolution of the biped running
man are covered in the first two chapters. Then
you get to the “meat” of the book.
Dr. Michaud eschews the concept that there is
a perfect gait or a perfect shoe. He recommends
against use of NSAIDs for most musculoskeletal
injuries in runners. And he backs up all of his
work and recommendations with numerous
references at the end of each chapter.
Basic gait mechanics are reviewed. Each
phase of the walking and running gait is
described in detail, providing the reader with
a good understanding of this process and
allowing the reader to understand how some
injuries occur and how adjustments in gait can
help accommodate for anatomic variants that
may otherwise create problems for a runner.
He further elaborates on the most efficient gait
to remain injury-free. This is not a “one size fits
all” formula but rather he presents the effect of
running speed and anatomic variants on impact
forces and mechanics. In addition to discussing
how various foot strike patterns impact the body,
he discusses ways to improve form. The gait
mechanics chapters include exercises to help
improve running form.
Anatomic variants such as arch height,
leg length discrepancy, and flexibility issues
are discussed in detail along with exercises
and other measures that can help an athlete
continue running. The impact of strength
deficits is emphasized. Numerous stretching and
strengthening exercises are provided to help a
runner become more injury resistant.
An entire chapter is devoted to selecting the
12
After years of taking care of athletes, it’s great to
find a book that summarizes numerous studies
that have been published and relates them to the
care of runners. The treatment of a specific injury
is just one small piece of the puzzle; determining
the cause of the injury to prevent the dreaded
and oh-so-common re-injury is critical. Finding
and addressing strength/flexibility deficits and
anatomic variants that may predispose to injury
is even better.
All runners will benefit from the information
presented in this book. The information is
presented so that anyone can understand it,
albeit with possible reference to the first chapter
on running anatomy for the non-medical reader.
I highly recommend this book.
best running shoe for an individual. The pros and
cons of each style of shoe are presented, along
with information regarding the most appropriate
shoe for a runner based on anatomy, running
speed, and history of injuries.
The final chapter is dedicated to treatment
protocols for 25 common running-related injuries.
The anatomy and presenting symptoms of each
injury are outlined followed by treatment protocols
that can be easily initiated by anyone. As expected,
recommendations are provided when seeking
evaluation by a medical professional is warranted.
I read this book after hearing Dr. Michaud
speak at our Boston symposium in 2015 and
began incorporating some of the treatment
protocols into my clinical practice. I keep the
book nearby as a reference for my patients. I read
the book again before writing this review and
have gleaned even more information which is so
important in caring for runners. The references
that are provided at the end of each chapter are
great resources for additional information on
any of the topics that are concisely yet thoroughly
presented in the book.
As a sports medicine physician, I have read
numerous books and articles (professional and
general public) on running and running injuries.
AMAA President Cathy Fieseler, MD, is the
director of primary care sports medicine at
the Trinity Mother Frances Health System
in Tyler, Texas, and the team physician for
the University of Texas. She is also a regular
contributor to Running Times/Runner’s World,
national instructor for Team in Training, and
a marathoner and ultra-marathoner.
From Dr. Fieseler’s description of this
book, it sounds like it meets particular
needs that our members may not even
realize they need.
Runners often overlook practicing their
technique. This is in contrast to some other
sports, such as swimming, where technique
is paramount. Technique modifications
may prevent injury. For example, how do
you land? Is it on the heel or at forefoot
level? When I was a runner it seemed I was
always running between injuries. Shoes
were important but deciding which style
would be best for me was always a problem.
I imagine there is a lot to study in
this book, and it is beneficial for the
runner to do just that, particularly if
sidelined with a running-related injury.
–Paul Kiell, MD, Book Review Editor
AMAA Journal Spring 2016
Member Profile:
Natalie Stavas, MD
Putting Lives in Balance
with the Transformative
Power of Running
By Jeff Venables
In farm country of the sort just outside
Lincoln, Nebraska, neighborhood blocks are
big and, like much of the state’s borders not
defined by the rolling contours of the Missouri
River, perfectly square. It was along these streets
in the 1980s that Natalie Stavas learned to run.
A “hyper” child of two healthcare providers—
Maureen, an RN, and Joseph, a physician and
lifetime AMAA member beginning in 2001—
seven-year-old Natalie was prescribed daily runs
around the block in the pre-ADHD diagnostic
era to expend her abundant energy and help her
become more relaxed and focused after school.
“My parents observed that if I got some sort
of exercise I would be able to do my homework
better,” she recalls. Soon enough Natalie noticed
this too, and thinking nothing of completing
the four miles that these country block runs
were, the girl under age ten became a lifelong
lover of running, and a little later equally
passionate about pediatric healthcare. “I never
was really treated [with medication] for my
hyperactivity and inattention, but running made
me productive, happier, and more efficient,”
she says. This lesson sticks with her wherever
she goes, and today has especially profound
implications for her career.
Trauma, pediatrics, and public health
Natalie Stavas, MD, is a physician at the
Children’s Hospital of Philadelphia, where she
is currently pursuing fellowship training in
Child Abuse Pediatrics while obtaining a Master
of Science in Health Policy Research at the
University of Pennsylvania. Her focus is on how
to better protect high-risk kids, heal traumatized
ones, and decrease youth violence.
One area of keen interest within this greater
pursuit is the growing body of research on just
how impactful exercise is on the developing
AMAA Journal Spring 2016
brain. Equally important to her is the emerging
field of exercise as an incredibly effective
therapeutic tool for treating traumatized brains,
or “how running can reverse the effects of an
adverse childhood.” This is in fact the topic
that Dr. Stavas’ presented at the 2016 AMAA
symposium in Boston.
Natalie continued running—now marathons—
as a pleasurable and indispensable part of her
stress management during nursing school, from
which she emerged in 2003 and enjoyed what she
calls a “short but fabulous” four-year career as a
pediatric critical care and ER nurse.
She attended medical school at the University
of Nebraska Medical Center, and performed her
residency in Pediatrics in Boston as part of the
Boston Combined Residency Program. Until
recently she was an instructor in Pediatrics
at Harvard Medical School. It was during her
residency in 2013 that Natalie became aware of
a study published by the international children’s
aid group UNICEF that, after looking at an array
of mental and physical attributes and metrics
that included behavior problems and other
data, ranked the U.S. dead last among developed
countries in children’s health.
To understand where we are headed as a
nation, of course, we must look carefully at
the health status of our nation’s children. That
among the world’s wealthiest nations the U.S.
raises the unhealthiest kids shocked her. “Here
we are in the richest country in the world and
we have the unhealthiest children; I thought, we
have to do something,” she says.
It didn’t take long to discover that innercity sedentarism plus poor dietary options and
choices were major causes of the problem.
Natalie wondered almost whether we were losing
sight of “what it is to be human”—indeed, human
thriving, or life in balance, is a greater theme that
keeps coming up for Stavas, underscoring what
is ultimately important to her and helping her
follow the trail wherever it leads next.
“We are a medication nation,” she says. “We
want to cure behavior, disease, unhappiness,
and everything else with pills. That’s not the right
way to care for things. We can do better than just
medicate people.”
Adding sugar to the fight
Stavas, who will be 35 in June, got immediately
involved in the movement to combat obesity in
American children, in particular in Massachusetts
by taking on the sugary, sweetened beverage
industry known more colloquially as Big Soda.
As evidence has mounted that the empty
calories from soft drinks are the primary
source of added sugar in the American diet,
many health experts have been critical of the
business practices of companies like Coca-Cola
and PepsiCo, which they say deliberately market
to children and low-income parents while
continued on page 14
Natalie Stavas, MD, surrounded by Sole Train participants, a program where
underserved Boston middle and high schoolers are mentored to run the Boston
Half-Marathon.
13
continued from page 13
profiteering in schools with vending machines.
When you consider that just one extra
12-ounce can of a typical sweetened beverage a
day can add on 15 pounds in a year, the problem
with these beverages is thrust into high relief.
From 2011 to 2013, Stavas served on the
Obesity Prevention and Treatment Committee
of the Massachusetts Chapter of the American
Academy of Pediatrics. And in a campaign
aimed at passing legislation to rid the absurd
tax exemption in Massachusetts on sugary,
sweetened beverages, she testified before the
Massachusetts State Legislature and helped write
two House bills, including provisions that would
take that lost tax revenue and put it into the
creation of physical and health education classes
in schools. The bills failed to pass.
In the U.S., we too often want things fast,
tasty, sweet, supersized, and cheap. Still, in
Massachusetts and elsewhere, toothpaste is taxed
as if it were an optional commodity rather than an
essential item in the home, but a two-liter bottle
of soda is not taxed. “I just think that it so crazy,”
says Stavas, pointing out that the soda lobby
is obviously a powerful special interest group
warping the system away from common-sense
legislation. “We thought this is super low-hanging
fruit because here we are in a progressive state.”
As Natalie points out, “Kids don’t understand
that their decisions now are going to affect
their lives down the road.” Enticing them with
juices and soda courts diabetes, hypertension,
and obesity later. “To a lot of us this is common
sense,” she says, “It’s just so hard to get it
translated into actionable policy change.”
Youth out of whack
On April 15, 2013, Natalie’s perception of the
problems facing young people broadened forever.
Stavas was approaching the finish line of her
fifth Boston Marathon when suddenly the second
of the two bombs exploded that day went off just
blocks from her. She ran directly into the chaos,
jumping a barricade and explaining her medical
credentials to a police officer near the scene.
After arriving at the site, the one-time emergency
room RN began administering CPR, applying
tourniquets, and triaging the wounded. In 2014,
she was named Bostonian of the Year by Boston
Globe Magazine as the result of her brave actions.
In the weeks that followed the marathon, she
fixated on the psychographic of the two brothers
in incomprehension and frustration. “The people
who planted these bombs,” she says, “one was
barely 18. I was really, profoundly struck by what
went wrong in their lives that they felt the need to
be so violent and destructive. I wanted to start to
understand how we prevent violence in general,
violence in cities and violence in children—
14
as well as how we help children who have
been exposed to violence.” The problem had
expanded into youth mental health. Natalie says,
“I joined Sole Train to try to find some answers.”
Turning destructive impulses into
constructive ones
Boston-based Sole Train is a non-profit
organization focused on creating safe, supportive
exercise environments and mentoring for city
kids often stuck in “exercise deserts”—Natalie’s
corollary term to go with the “food deserts” the
obesity movement have identified as a challenge
to healthy eating. She recalls her childhood in
Nebraska, where it was safe to run outside, and
so she did. In many U.S. cities, safe public parks
and other adequate, readily available spaces for
exercise are the exception, not the rule.
Sole Train works with Boston’s underserved
middle and high schools to improve kids’
physical and mental well-being through closely
mentored running. The personal goal-setting the
program encourages, rather than competition,
is the key as Natalie sees it. Indeed, there is
research on how previously sedentary kids may
use a strategy of “not trying” to “look cool”
and dismiss competition in gym class for what
is really fear of failure. In this way, exercise is
sometimes anathematized in underserved urban
school culture, precisely where and when in a
child’s life it is needed most.
Sole Train tries to improve the health of
urban communities by helping kids realize their
full potential and learn to function with team
spirit against a common, shared goal—most
often, finishing a race. As such, Stavas points
out that the program “mentors with rather than
at,” meaning Sole Train mentors run and sweat
right alongside their young charges, discussing
the challenges at hand and literally being there
at every turn. This style of mentorship is a far cry
from the once prevalent “history coach” teaching
PE with the beer belly and the whistle around his
neck, yelling at students from the sidelines.
Stavas vividly describes the amazing
transformative power running can have on the
kids. “They start out angry or bouncing off the
walls, and then they start running,” she explains.
“The muscles in their face begin to relax. They
start to have reasonable conversations about
their life, their goals.” She is currently working
on a book that fully explores this deeply
transformative power.
“We tell them, we’re going to give you a pair
of shoes and you’re going to run the Boston
Half Marathon.” Yes, she finished Boston this
year alongside one boy with whom she has
been training since 2013. He completed a halfmarathon in 1:32:00. But at first, he had looked
at her with what Natalie calls “the ‘impossible’
mindset—many of the kids are just not used
to achieving things.” The boy had been a foster
child and at one point homeless. In this way, Sole
Train invites these children, adolescents, and
teenagers, perhaps for the first time in their lives,
to contemplate the extraordinary.
A national vision
Currently Dr. Stavas is helping in the
Philadelphia area in tandem with her child
abuse fellowship at The Children’s Hospital
of Philadelphia and masters program at the
University of Pennsylvania. She served as the
medical advisor for the Appalachian Mountain
Club, which is committed to improving
children’s health by getting them outside. She has
also worked with the non-profit organizations
Students Run Philly and Girls on the Run.
To Natalie, running should play a central
role in how we care for our kids; it was after
all how she was positively influenced, and in her
view it is how we should positively influence their
developing brains. She wants to see mentorships
in running implemented across the U.S., and
emboldened by research-backed science, help
develop their curricula.
Helping kids swap bad goals for good ones is
becoming her life’s work—at least this chapter
of it. Stavas hopes to use her masters to advance
research that has been following the thread of
causality backward, from improving nutrition
and increasing exercise to annihilating the
psychological barriers to achievement more
generally, to ultimately disrupting the path
to despair and violence too many kids have
experienced or witnessed already.
To take a traumatic event and render its
negative impact powerless by finding meaning in
it, or growth out of its very roots, and ultimately
turning it into an opportunity—this is something
Natalie Stavas knows all too well how to do, as
when that second bomb went off and she first
leapt into action. She hasn’t stopped since.
Jeff Venables is the editor of Running & FitNews
and a regular contributor to the AMAA Journal.
AMAA Journal Spring 2016
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 April 1, 2015 to April 1, 2016.
OLYMPIAN ($250)
Elisabeth Beyer Nolen
Christianne Bishop
Mary C. Boyce
Christopher Bullock
Todd Daniels
Ronald Dubin*
A. Christine Emler
Cathy Fieseler*±
Robert Frimmel
John W. Gilpin
Jeffrey Hawkins
Patrick J. Hogan
John Howick
Francene Mason
George Morris
Steve Morrow*±
Robert A. Niedbala*±
Peter Oroszlan
William Paronish
Daniel Pereles
Frank J. Rodriguez, Jr.
James Salisbury
Charles L. Schulman*
Dave Sealy
Robert Sholl
Matthew L. Smith
Joseph L. Verdirame
Joel B. Weber
Philip Zitello
PATRON ($150)
Terry Murphy
Robert Erickson II
John Hagan III
Susan Harding Hawkins
Robert Janigian, Jr.
Daniel Lieberman
Laura R. Ment
Don G. Nelson
Michael W. Moats
* Contributions surpass Olympian level
SUPPORTER ($100)
Bill Borowski
Richard Bosshardt
Thomas Boud
Richard G. Bowling±
William Braswell
Julius S. Brecht
James Bristol
Brad Carmines
Charles (Scott) Clark
Steven D. Coffman
Edgar L. Cortes
James Culpepper
Kathleen Doughney
Michael S. Doyle
Edmond G. Feuille
Joseph M. Gaffney
John Geren
Bernard Gitler
Arnold G. Greene
Michael Hamrock
Beverly Handy
Dexter Handy
John W. Houri
Allan Katz
Jeffrey T. Kirchner
Howard M. Marker
Franklin G. Mason±
Frank Massari, Jr.
John McAuliffe
Peter Mendel
Crystal Neel
Mark Rubenstein
Robert A. Sabo
Lann Salyard Woehrle
William Simmons
Charles H. Stubin
Greg Thorgaard
Toussaint G. Toole
Stewart Turner
J. Michael Ward
Clay Whiting
John Zinkel
± Life Member making contribution at the level of Premier Member
To become an AMAA Premier Member, please go to www.amaasportsmed.org and click on “Join AMAA.” The funds from this program help support the
AMAA running medicine awareness campaigns and the American Running Association’s signature national outreach campaign event National Run A
Mile Days held annually in May.
Evaluation of the Relationship between
Distance Running and Renal Stone Formation
AMAA Member Dr. Stanley Zaslau, a urologist at West Virginia University, is requesting
your help with a research survey he is conducting of both males and females who are
long distance runners and who may be prone to developing or have had a history of renal
stones The purpose of this study is to learn more about the possible relationship between
long distance running and the formation of renal stones. Please consider participating by
completing an anonymous online survey which includes questions regarding background
information, running/training information, methods of hydration, running injuries, and renal
stone information. Dr. Zaslau and his colleagues will then review the results and report the
findings in the AMAA Journal.
Survey link: https://www.surveymonkey.com/s/GVDQF9R
AMAA Journal Spring 2016
15
Join us on October 28, 2016 for the
AMAA’s 25th Annual Sports Medicine Symposium
at the Marine Corps Marathon™
Presented by the American Medical Athletic Association and MedStar
Sports Medicine and held in conjunction with the Marine Corps Marathon
and Uniformed Services University Consortium for Health and Military
Performance (CHAMP).
New location in 2016! Cross the Potomac River to MedStar Georgetown
University Hospital.
Visit www.amaasportsmed.org for additional information.
AMAA and MedStar Sports Medicine are pleased to announce a three-year partnership
supporting this sports medicine symposium.