Reflections on fitness and health, long-haul COVID, choices, and consequences.
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I’ve often joked that if scientists proved running causes cancer, I would keep right on running. It’s a morbid way of making the point that health is very low on my list of reasons to run. Higher on this list are the sense of personal and familial identity running gives me (I started running with my father at age eleven), pure enjoyment of the activity itself, my passion for competition, the joy of improving, the many psychological benefits (stress management, confidence, sense of accomplishment, etc.), the hugely underrated pleasure of feeling fit even when not running, the forum it provides for creative exploration (mainly writing in my head), the spiritual quality that the running experience gained for me in adulthood, and, I’ll go ahead and toss in vanity as well.
Another, similar joke that I trot out with some regularity is a tongue-in-cheek vow to one day write a book titled Running Is Bad for You. The topic of injury provides the set-up for this wisecrack in most instances. Nearly all runners get hurt every now and again, and I am an especially injury-prone runner. Still, my joke is just that; I do not seriously believe that running is bad for one’s health.
Quite the contrary, in fact. Health is often defined in negative terms, as the absence of disease. I’ve never liked such definitions, preferring to define health positively, as vitality or aliveness. I am reminded here of Airman Dunbar’s definition of “old” in the novel Catch-22. “You’re inches away from death every time you go on a mission,” he says to a fellow pilot who has just objected to being called old. “How much older can you be at your age?” The way Dunbar sees it, oldness is proximity to death, hence one can be old at any age. Well, for me, health is the opposite: distance from death. More than being merely free of disease, health, in my view, is robustness, high functional capacity, firing on all cylinders.
From this perspective, fitness is essentially an enhancement of health. A person who can run a marathon is healthier than a person who can’t, and a person who can run a marathon in 3 hours is healthier than a person who can run a marathon in 4 hours. This perspective is not as radical as it might sound. Scientists have found that fitness measures such as aerobic capacity and muscle strength are among the strongest predictors of longevity in older people. More importantly, fitter older people not only are more likely to still be alive tomorrow but also tend to function better and feel better today.
The overlap between health and fitness is not absolute, however. Consider bone mineral density (BMD), a measure of bone health. Research has shown that people who run moderate amounts have higher BMD than people who don’t run, a benefit that is associated with a lower likelihood of fragility in old age. Beyond a certain point, though, running more stops increasing bone mineral density and in fact begins to undo some of the bone strengthening achieved by lesser amounts of running.
Then there’s immune function. All forms of aerobic exercise, including running, strengthen the immune system. But as many of us learned when the COVID-19 pandemic struck, exhaustive individual workouts (and races) temporarily suppress immune function, opening the door to viral and other pathogenic infections. Indeed, if for some strange reason you wanted to get sick, one of the best ways to do so would be to travel to and participate in a big city marathon, combining the temporary immunosuppression of running as hard as you can for a few hours with spending a lot of time in close quarters with other people on airplanes, in hotels and restaurants, and during the race itself.
My own last two viral infections were earned in precisely this way. In 2019 I came home from the Boston Marathon with a stomach flu. Though deeply unpleasant while it lasted, it didn’t last long. In fact, I missed only one day of training. But the 2020 Atlanta Marathon was another story. Five days after I returned to California from that event, I came down with what turned out to be the most severe and prolonged sickness I’ve ever experienced, losing an entire month to crushing fatigue, a violent and relentless dry cough, shortness of breath, and other symptoms.
And that was only the beginning. In October, after six months of restored health and rediscovered fitness, I started to go backward. The fatigue and shortness of breath returned, but other symptoms — including brain fog, erratic heart rate, and numbness in the extremities — were new. More than four months later, the worst of these symptoms are more severe than ever, and I’ve come to the conclusion that I am suffering from what is variously known as long COVID, long-haul COVID, and post-acute COVID-19 syndrome. Essentially, it’s a form of chronic fatigue syndrome, a condition that commonly strikes after a viral infection and in most cases never goes away.
Much remains unknown about long COVID, but one thing we do know is that it disproportionately affects people who were relatively young (at 49, I’m pretty typical age-wise) and healthy before they got sick. Some doctors and researchers speculate that long-haulers are victims of an excessive immune response to the virus. If this is the case, then my being a runner might have hurt me in two distinct ways with respect to COVID. As noted, a temporary weakening of immune defenses resulting from running a marathon opened the door for the virus to claim my body in the first place. But having a strong immune system overall as a result of running might then have caused the unending overreaction that I’ve been living with for several months, with no end in sight.
Then there’s the heart. We’ve all been told that running is good for the heart, and it is — except when it isn’t. In the early 2000’s, there began to emerge evidence of an association between years of heavy endurance training and calcification of the coronary arteries, a contributor to heart disease. Subsequent research has revealed that only a fraction of athletes are susceptible to this effect of training; that the type of plaque seen in athletes tends to be more stable, hence less harmful, than the type commonly seen in sedentary individuals; and that runners and other endurance athletes with significant plaque buildup in the coronary arteries are less likely to suffer heart attacks than nonathletes of the same age and sex. Still, those plaques aren’t a good thing and are rightly regarded as a toll taken on the body by years of physical stress.
Among the many medical tests I’ve undergone since my long-haul symptoms set in was an exercise stress test, which is a standard tool for assessing heart health. Although I performed well in this test in most respects, the cardiologist saw a red flag in the EKG that caused him to order an angiogram, where a dye is injected into the bloodstream to determine whether there are any blocked arteries. In my case, no blockages were found, but my calcium score was quite high — above the diagnostic threshold for heart disease.
It takes years for plaques the size of mine to develop. Hence, they could not have been caused by COVID. It is possible, however, that the virus did accelerate their growth. That’s because COVID-19 is known to damage blood vessels, and damaged blood vessels become sticky, trapping calcium particles and other junk that would normally pass through the bloodstream unabated. I’ll never know for sure, but it is conceivable that a lot of the plaque buildup in my arteries occurred during the six months between my recovery from the virus and my descent into long-hauling, when I was training and racing hard with lingering blood vessel damage.
I’m not trying to scare you. I’m merely using personal examples to make the point that, although there is a large degree of overlap between fitness and health, they are not quite the same thing, and there are instances in which the pursuit of fitness can come at the cost of health.
My overarching advice to my fellow runners on this subject is that you base your decisions on a full understanding of the potential risks. If I could rewind my athletic journey 25 years, I would choose to train just as hard and to race just as often as I did the first time around, because for me, the adventures I had and the personal evolution I experienced through this journey were well worth the toll taken on my body. But you might make a different choice in my shoes, and that’s okay — just make it consciously.
There are also specific measures you can take to attenuate the health risks associated with pursuing fitness. Injuries are an ineradicable part of our sport, and they’re also not the end of the world when they do happen, so I don’t recommend being overcautious in your training for the sake of preventing injuries. But there’s a lot you can do to reduce injury risk while continuing to train hard — avoiding abrupt increases in training load, listening to your body, etc. — and if you do all of these things consistently, you can have it both ways, for the most part.
Similarly, with respect to infectious disease risk, one way to protect yourself is to avoid doing hard workouts and races that temporarily weaken immune defenses. But this, of course, amounts to giving up on your competitive ambitions. An alternative is to go ahead and train and race hard while taking practical measures to protect yourself, including keeping up on your vaccinations, washing your hands frequently, avoiding close contact with others to the degree it’s possible, and wearing a face covering as appropriate.
Finally, regarding heart health, I want to underscore that training hard and racing often will not automatically put you where I find myself today. Unknown factors appear to predispose some individuals and not others to develop calcium deposits as a result of strenuous habitual exercise. I think it’s also important to highlight the fact that, even if you do end up where I am, you won’t necessarily face an elevated risk of heart attack or have to stop running. I myself have stopped running not because the doctors told me to (they didn’t) but rather in the hope that doing so might accelerate the healing of my blood vessels. Maintaining a healthy diet and getting regular checkups on your heart health will help you further minimize this particular risk.
Running means different things to different runners. We’re not all meant to travel the same course in our running journeys. But the one thing every runner should want is to look back on their journey without regrets. I certainly have none, and I want this to be true for you too.