No, Running Isn’t a Silver Bullet for Health

This article originally appeared on Trail Runner

I got a surprise when I visited the doctor this summer.

It was a routine physical, the kind that's good to have even if you're young and seem healthy and if you have insurance that covers it. (Thankfully, mine does.) At the end was a standard blood draw to look for anything that was off. I walked out with a cotton ball taped to the inside of my elbow and didn't think about it for a few days.

But then my doctor emailed. One of the things they'd tested for--which I'd never heard of--was called hemoglobin A1C. There's a more complicated definition of A1C, but basically, it measures how much glucose was attached to the hemoglobin in your bloodstream in the past few months, measured as the average percentage of your blood that was glucose. It measures your diabetes risk.

The doctor emailed to tell me my A1C was 5.7 percent. The ideal range is below 5.6 percent. In no uncertain terms, this made me pre-diabetic, even if just barely.

This news flummoxed me a bit. I've been running (or cycling or Nordic skiing) basically year-round for 20-plus years. I watch what I eat--I'm vegetarian, try to avoid processed foods, and would give my nutrition a solid B+. And I'm only 36! This is all to say: I don't appear to fit the bill of someone who would normally be at risk of diabetes.

I went in for a follow-up the next week, where I asked: "How can I get this number down?"

"Stop smoking," the doctor said, deadpan. (She knew my history well by now.) "Take up exercising."

"But seriously."

"It could be a lot of things," she continued. "It could be genetics. It could be that your diet isn't as good as you think, just because you look healthy."

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Exercise Doesn't Make You Immune

The doctor's main point was this: You can be young. You can be super fit. You can be outside of every "risk group" on paper--but your risk isn't zero. It's never zero. Young, fit athletes are certainly at lower risk for chronic issues like heart disease, diabetes, and cancer than their sedentary counterparts, but that doesn't make us immune, not by a long shot.

"Exercise is the most magical, incredible therapy we have for overall health and longevity," says Dr. David Hinchman, a cardiologist and co-founder of the High Desert Heart & Vascular Group in Boise, Idaho. Hinchman is also an incredible endurance athlete, cycling and Nordic skiing year-round. "But exercise doesn't eliminate the risks of disease," he continues. "It just dilutes their potency."

My goal here isn't to sow fear or cynicism. You don't need to give up your favorite foods, and you should definitely keep running--more on that later. This is a PSA that, while running is a huge step toward a long, healthy life, it's not a silver bullet. I'll use my own life to illustrate that below. First, we'll do a quick primer on heart disease and diabetes--two of the big chronic diseases that tend to affect Americans--then we'll dive into the factors (other than exercise) that can affect your risk and what you can do about them if you're in the danger zone.

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Heart Disease

Back before, I was a fit runner under 40 who was surprised he could be prediabetic; I was a fit runner under 30 who was surprised his cholesterol could be so high.

But how high? 350 mg per deciliter (mg/dL) of blood, with an LDL score nearing 200. That's dangerous territory--most clinicians recommend your total blood cholesterol level stay below 200 mg/dL, with LDL remaining below 100.

Basically, I was walking around with motor oil in my veins, and that meant I was at risk for a heart attack or stroke down the road.

"Over time, exposure to high cholesterol levels causes buildup of plaque on the wall of your coronary arteries, which give blood flow to the heart," says Hinchman. "When a plaque ruptures or builds into a complete blockage, it blocks the blood flow, and your heart muscle starts to die. That's a heart attack."

And just because I had a few decades (hopefully) to right the ship before it was an emergency didn't mean I should dilly-dally.

"The risk is cumulative," Hinchman continues. "The longer your arteries are exposed to high levels of cholesterol, the more plaque you can build up."

That's why, at the age of 22, I was prescribed simvastatin-a medium-intensity drug that reduces the amount of cholesterol produced by my liver. It didn't make for the sexiest bio line in the dating apps, nor did my upgrade at age 29 to atorvastatin-a high-intensity drug they give you when the lighter stuff still isn't cutting it. (My numbers went down but were still too high.)

Heart disease is the leading cause of death in the U.S., outpacing cancer. And most of it is chronic-coronary artery disease caused by atherosclerosis, the name of the aforementioned buildup of plaque in the arteries. That's distinct from things like hypertrophic cardiomyopathy, which can cause sudden cardiac death in young, otherwise healthy athletes.

Hinchman also noted the risk to long-term endurance athletes of a condition called atrial fibrillation (AF), an irregular heart rhythm that can cause blood clots in the heart and lead to stroke. But he says the risk is one of a few that's only elevated if you exercise a ton-think professional Nordic skier levels of training intensity and duration-and even then, the evidence is limited.

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Diabetes

I got some slightly reassuring news about my high A1C from Dr. Sherwin D'Souza, himself a trail runner and Medical Director at St. Luke's Clinic-Idaho Endocrinology and the Humphreys Diabetes Center in Boise.

"You can't look at the A1C in isolation," he told me. "You have to look at it in conjunction with your fasting blood sugars. A lot of factors go into diagnosing diabetes."

Then, the less-reassuring news. "When we see a young, active adult with a high A1C out of nowhere, it could mean they have a variant of Type 1 diabetes," he explained. Type 1 is the kind you can't control through lifestyle factors.

Let's back up. In a healthy person, the pancreas secretes a hormone called insulin, which converts food to energy and helps store that energy for later. When you eat food, your blood sugars rise, and your pancreas releases insulin, which harnesses all that sugar and brings your glucose back to a normal range.

In Type 1 diabetics, the pancreas simply doesn't make insulin. This tends to arise in younger patients and has nothing to do with lifestyle.It's just a draw of the genetic short straw.

We'll focus more on Type 2 diabetes here. In that case, your pancreas still creates insulin, but your body becomes resistant to it. Your pancreas overcompensates by creating too much insulin, but that makes it tired, and, over time, it can't keep up. Without the negating effect of insulin, your blood sugars rise. If left untreated, unregulated blood sugars can result in a coma and death.

Type 2 is far more controllable through lifestyle factors and accounts for about 90 percent of diabetes cases in the U.S.--hardly surprising given our largely sedentary lifestyle.

My A1C score was only barely on the high side-5.6 percent and below is normal, while 5.7-6.4 percent is prediabetic. For blood sugars, 99 mg/dL or lower is normal, while 100-125 mg/dL is prediabetic. In that range, you can still reverse those numbers-but if you cross over to 6.5 percent and 126 mg/dL, you've got diabetes, and it's permanent.

The good news is you can control your risk of both heart disease and diabetes through diet and exercise-to an extent. But you have to get ahead of both of them.

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Genetics Play an Outsized Role

"We can't outrun our genetics," D'Souza says. "Genetic factors play a huge role; more than 70 percent of cholesterol is made in our liver. [The other] 30 percent we control in our diet."

My genes almost certainly play a role in my lifelong battle with high cholesterol. I do pretty much everything within reason to control the lifestyle factors and still need pharmaceutical intervention. Heart disease runs rampant in my family, too, particularly on my mom's side, where, up until a generation ago, the men had a habit of dying before they turned 50 for heart-related reasons.

"We've identified some genetic mutations with, for example, PCSK9 [a gene that codes an enzyme crucial to LDL cholesterol regulation]where someone's LDL is just extremely high, like 400," Hinchman says. "And we've seen the reverse mutation where their LDL is extremely low, like two or three, and they're living a normal, functional life."

"Basically, genetics make it too variable or individual, and it's impossible to tell just by how much someone exercises or how fit they are what their risk profile is," he says.

That's equally the case with diabetes," D'Souza says. "If you have a family member who's had diabetes, you're automatically at risk."

D'Souza and Hinchman both noted an additional genetic heart disease risk called lipoprotein (a). Basically, Lp(a), as it's known, can cause plaque buildup in the arteries, elevating your risk of heart attack or aortic stenosis without giving you high cholesterol as a warning sign.

"We don't have a treatment for it, but one should be here soon," D'Souza says. "It's worth testing for this because if you have it, we can be more aggressive in controlling other risk factors."

Hinchman confirmed his practice is currently doing clinical research on Lp(a) treatments. "It's worth checking your Lp(a) once during your lifetime," he says.

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Diet

A funny thing happened in my early 30s: a handful of my most active friends started reporting that they'd learned their cholesterol was high. The common thread? All of them still ate like they were 22. Pizza, burgers, ice cream, beer. You name it. The old adage that "if the furnace is hot enough, it'll burn anything" rang true. That was, until it didn't.

I surmised that maybe the 30s was when those worlds collide when we are young enough to pass as conventionally super "fit," comparable to younger versions of ourselves, but where we are old enough that a poor diet and other habits can start coming home to roost.

"I know when I go on a long run, I think I can eat whatever I want. I'm so hungry and have burned so many calories," D'Souza says. "But just because your weight is under control doesn't mean you aren't at risk like anyone else."

In other words, the furnace might burn the calories of that pizza or pint of ice cream, but the gunk that causes health issues down the road--saturated fat, high-fructose corn syrup, etc.--can linger, the same as if you were sedentary.

D'Souza says the foods we often use to fuel ourselves in training and racing can be some of the worst offenders."I've heard of people running ultras fueled by stuff like soda and processed meats," he says. "Obviously, that's not a normal situation, but if you're training a ton and using simple sugars and processed foods to fuel it, that can add up."

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Is There Such a Thing as Too Much Exercise?

That begs the question: though exercise might be the best prevention for a lot of chronic diseases, is there a point where the returns diminish or even backfire a bit?

If, say, I go for a three-hour long run, I might be starting the day with up to 100 grams of sugar in the form of gels and sports drinks. And that's before I eat whatever I feel entitled to the rest of the day, which, as D'Souza noted, probably won't paint a picture of perfect health.

"The official recommendation is usually around three hours of cardiovascular exercise a week," D'Souza says. "That's just for general health and not for athletic performance, of course. In terms of pure health, more exercise probably won't hurt, but it won't necessarily help. And if it's causing you to eat junk, that's a downside to consider.

Hinchman is slightly more bullish on the benefits of exercise. "If you're really fit, you're going to get away with more," he says. "You'll be a lot more resilient when faced with the same risk factors sedentary people face. Maybe for that reason, V02 max is one of the better predictors of longevity we have."Still, he reiterates, "Exercise doesn't eliminate the risks."

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What Can We Do?

First, it's probably good to assess whether you're at risk for diabetes and heart disease. If you're not, congrats!

If anyone in your family has had diabetes or died of a heart attack, there's a good chance you're genetically inclined toward those risks. But even if they haven't or don't have adequate information, it's worth it to get your bloodwork done. If your numbers are on the high side, work with your doctor on a path forward. It might include medication or diet modifications.

If you're concerned and want to modify your diet, Hinchman and D'Souza both offer some broad, low-hanging solutions. And I know this can get tricky; disordered eating and body dysmorphia are an epidemic all their own in endurance sports. Preoccupation with "healthy," "proper," or "clean" eating can manifest as orthorexia, a full-blown eating disorder. And D'Souza and Hinchman both led by acknowledging that athletes need to fuel themselves first and foremost, following the adage "eat enough, always." Ideally, athletes will work with a registered dietitian to dial in their nutritional needs.

Both D'Souza and Hinchman point toward the "Mediterranean diet"--lots of nuts, lean proteins, fruits, and vegetables with minimal processing--as something consistently tied to longevity. That diet is often associated with moderate amounts of red wine, but Hinchman says there's probably little or no benefit to alcohol.

"That doesn't mean you need to follow this or that diet," he clarifies. "I've had very healthy patients who are athletes who are keto, who are plant-based, or who are more moderate all-around. You can be an unhealthy vegan if you eat only processed food, or you can be a very healthy vegan if you eat lots of fruits, vegetables, and legumes."

Regarding diabetes, D'Souza says limiting processed foods is the easiest, biggest step you can take, especially those with added sugars. He says high-fructose corn syrup is especially nefarious. Athletes with specific health needs should work with an expert to determine the best mid-run fuel for them.

As for those post-long run cravings? Take small steps you can sustain rather than making big lifestyle changes you'll abandon in short order.

"If you want something sweet, try going for some fruit instead of ice cream," D'Souza says. "But I get it. I love ice cream, and we can't deprive ourselves of the thing we love. Just make sure you eat it in moderation."

As with pizza and ice cream, D'Souza says you don't have to cut out alcohol if you enjoy it and can drink it responsibly. "Just use it in moderation, like everything."

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It can be frustrating to think you can do everything right and still be at risk of chronic diseases more typically associated with a sedentary lifestyle. But that certainly doesn't mean you should give up. Take it from me. A few years ago, I had a stroke due to a heart defect. I was active as heck and controlling my cholesterol with medication and bam! I got t-boned by something I didn't even know I should be watching out for.

This goes to show there are too many risks out there to worry about them all, all the time. The best we can do is control the things in our power and still seek out joy where we're able. Even if it didn't affect my health, I'd still run.-Why? Because I love it. But there's been a tangible upside, too. That appointment when my A1C came back high? My cholesterol at that appointment was down to 144-a new PR.

As for the stroke, I almost certainly bounced back from it quicker than I would have if I had been sedentary or if I smoked. Health isn't black and white-there's a big sliding scale. So keep doing what you can. Keep living your life. Hopefully, we'll all be able to do it for a long time to come.

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