2024 in Review Part 2 - Running 50 Miles is Easier Than Going to Work

 

Part 1 Here

Ok, so…By early 2024 I was 100% confident that my lasting symptoms were being driven by metabolic impairment of the brain. But knowing this and being able to do a lot about it are two different things. In the spring, I was offered an opportunity to change offices at work, from one of extreme tension and hostility to one that was far superior on both professional and interpersonal levels. And while this role was “better” by basically any metric you’d use to typically judge a job, it was also a bit more cognitively intensive.

To be clear…I was suffering on a daily basis in my previous role as well, but in a way that was often a touch more manageable. I could usually girt my teeth and continue to function in my day-to-day life, judiciously using leave (both personal leave and leave without pay) to manage the worst bits and sometimes string together stretches of days in which I felt nearly normal. This is how, for example, I was able to win a small trail race last fall after being away from work for almost 4 weeks in a 6 week stretch.

The new role, revolving around airspace and routing automation, wasn’t an extreme increase in workload in theory. But I also no longer had a boss fighting tooth and nail to shield me from fulfilling my job duties, as I had previously. I did a bit more work now - but having largely existed on a knife’s edge for so long anyway, this incremental increase in cognitive effort took a fairly extreme toll.

The most ironic part of all of this continues to be the fact that I can, at least when I feel well enough, continue to exercise at a high level without issue (and in fact, as I’ll discuss in part 3, its as important as anything in managing my condition). My brain doesn’t work but my body still does. To that end, despite barely running all spring, I was able to complete a 50 mile run in June of this year. I had been in Oklahoma City for 2.5 weeks for a very, very relaxed training course related to my new role and had just enough good health to exercise during most of my time there.

Nothing to do on the weekend was a good enough reason to drive to NW Arkansas for a 50 mile “backyard” style race. It followed the typical format of a backyard ultra – 4.1666 miles every hour on the hour – but instead of an endless race of attrition, it simply ended with a time raced on lap 12. So all told, a very easy way to get a 50 miler done in a bit over 11.5 hours. True to standard, I felt quite rough race morning and during the early laps, but improved considerably throughout and had an enjoyable experience overall.

That race was the end of the highlight reel though. Work has been too hard, and I’m not entirely sure my health hasn’t actually been slowly deteriorating as a result of the constant inflammatory stress that results from forcing my brain to do things it really can’t. The coping mechanisms over the summer were less than stellar – binge eating and alcohol (again, for reasons I’ll explain) both moderate symptoms enough to maintain some semblance of function. Not any kind of health, mind you, but enough function to work 25-30 hours a week while keeping the neurological complications on the right side of bedridden. Unsurprisingly, I gained about 10 pounds in 10 weeks employing this reactive strategy of brain energy management.

Meanwhile, I’d been fighting all year to find a doctor wiling to order the test (a PET scan of my brain) that I knew would prove the significant metabolic deficits driving my condition. I don’t really remember how many doctors I asked and how many times I was told no, even by doctors who seemed to agree right up until it was time to order the test. Finally, a neurologist at Johns Hopkins (one of I think 13 neurologists I’ve now seen) agreed to order the PET scan. Not that he necessarily wanted to - He was really just placating me and told me straight up that I was probably wrong about what the test results would show.

Well…as you can probably guess, I was not wrong. The PET scan confirmed impaired brain metabolism in the temporal, parietal, and frontal lobes, as well as parts of the limbic system, including the hippocampus. In short, a lot of my brain wasn’t working properly to produce energy. Unfortunately though, being right about the problem doesn’t do much to solve the problem. I could certainly be confident in my approach at least, which would now be a fair bit more diligent than briefly plugging holes with alcohol or excessive carb intake.

I finally this fall made the decision to commit long term to a strictly therapeutic ketogenic diet. I had been hesitant to make that change since successfully reintroducing fruit, but it seemed like an obvious best option moving forward. I’ll discuss more in the next section, but ketones are an alternatives source of brain fuel that can somewhat mitigate the negative effects of metabolic impairment without the obvious consequences of alcohol or binging on dried mango. My diet now consists of less animal protein, but more added fats such as tallow, butter, and heavy cream. I also consume a few servings of MCT oil daily as a source of additional fat, all as part of an effort to not only minimize carbs (like on a standard low-carb/keto diet) but to maximize fat ratio in an effort to drive ketones as high as practical.

The only other “intervention” so to speak remains the same as always – exercise as much as possible. Exercise increases metabolic activity in the brain. The more I exercise, and the longer each session is, the better I tend to feel. Days in which I fail to exercise before work are almost uniformly worse than when I do, and carry with them a high risk of failing to make it through the day. It certainly took a few weeks for the exercise to begin normalizing – while I had previously spent long stretches of time eating zero carbs on a pure carnivore diet, it was when my health was generally too poor to exercise anyway. A commitment to an approximately zero carb diet in the context of training and exercise was largely unchartered territory.

Where am I now? Ketosis is roughly as effective as binge eating and alcohol at mitigating extreme symptom presentation. The big difference is that its much healthier overall, and indeed I’ve now reversed most of the weight I gained gorging over the summer. Unfortunately, being roughly as effective still means I’m not well enough to get through the work week. I do manage to exercise most days, especially if I run in the mornings early in the week, although it often falls apart in concert with my struggles at work. I still spend quite a bit of time in pain, with sleep problems, numbness, and dizziness permeating most of my days. I do think the ketosis blunts this to a degree, of course, and so “catastrophic” episodes that leave me briefly bedridden and unable to run for a week at a time are less frequent than they otherwise may be.

I’m continuing to try to combine deep ketosis with frequent exercise to the best of my ability, while limiting cognitive strain where I’m able (It’s taken a very long time to write this for largely that reason). Beyond that, though, there’s very little to be done. There is no medical treatment for impaired brain metabolism (part of the reason some doctors wouldn’t order the test) and no particular reason to be confident this will ever get better after all this time. In fact, impaired brain metabolism is a hallmark characteristic of Alzheimer’s, Parkinson’s, and other neurodegenerative diseases. In a more “normal” patient, such findings would generally be expected to continue degrading over time and would likely foretell progressive impairment and damage to the brain and nervous system.

In part 3, I’ll explain why I don’t think that worrying forecast necessarily applies to me and discuss brain metabolism more broadly in the context of my condition. 

Part 3 Here

2024 In Review, Part 1 - A New Paradigm of Brain Dysfunction

Its been a while

In fact its been a good solid year since I’ve written anything here about my health and life journey. Part of that is because things have been fairly dynamic, and part of that is because things have been fairly difficult.

While everything I’ve previously discussed about my health has been through the lens of autoimmune issues, it was already becoming increasingly clear a year or more ago that the situation had been evolving and that an updated paradigm was warranted. While the autoimmune issues were very real – you don’t just test positive for every marker of Lupus without an autoimmune problem – and the likely root cause of my overall condition, my symptoms were becoming increasingly decoupled from acute immune triggers. This had been the case since at least mid-2023, after my second week+ long fast. By this point, I had fasted for a week on two occasions, for 3-5 days on several more, and for 36-48 hours probably dozens of times. I had adhered for long stretches to a pure carnivore diet, and only gently introduced the (theoretically) safest non-carnivore options like organic fruit and honey. To my knowledge, this is the only evidence-based approach to seriously fighting autoimmune disease and, one way or another, I had largely moved past these issues by the end of 2023.

What was also clear, however, is that I wasn’t healthy. In retrospect, I was still struggling to totally move on from the autoimmune paradigm and was sometimes shoehorning symptom triggers into that myopic view when it wasn’t warranted. To make things worse, the realization that the resolution of autoimmune markers and reduction in autoimmune triggers weren’t going to portend a full-scale return to health was fairly demoralizing. That can all be seen by simply looking back one year, at some musings that I’m not overly proud to have written.

What I knew very clearly at the time but was not fully exploring was that I struggled quite a bit at work. And this was despite the fact that my work was, um…..not particularly challenging. Bluntly and briefly, I was under the supervision of a boss who put her greatest efforts into ensuring that as much work as possible was shunted away from our department. It was a boring, uncomfortable work environment, but certainly not a busy one. Still, I did enough work to know that my symptoms were exacerbated and magnified by the effort. Conversely, symptoms diminished whenever I was away, and able to fully rest my cognitive faculties.

The notion that I was suffering from impaired brain metabolism was something in which I became increasingly confident over the winter. While specific foods didn’t trigger acute symptom onset like they used to, I could still manipulate symptoms by, for example, binge eating, which would preclude symptom onset in part or entirely. Exercise helped considerably as well, as I was often barely able to shuffle out the door before eventually finding improved health over the course of multiple hours of walk-jogging at an easy effort. These factors, combined with the obvious acute distress that accompanied mental effort either at work or home, largely cemented my new metabolic paradigm of neurological dysfunction.

However, the final nail in the coffin, so to speak, didn’t come until the first weekend in February. I flew to Las Vegas to spend a long weekend with my family, and frankly I felt like shit. I struggled mightily with pain and numbness on the flight, and the plan my wife and I had to show up early for a day of hiking ended with her leaving me behind to hike on her own. After a full week of work, I wasn’t in sufficient neurological health to function at a normal human level.

But, after a couple days wandering around the strip with alcohol in my hand, that had changed considerably. To be clear, this wasn’t some Hangover-esque degree of debauchery. I just simply sipped alcohol (largely not caring how it might affect my symptoms) for most of a couple consecutive days and felt really quite good. As I progressed from shaking in the trailhead parking lot to feeling as well as I had in months, I finally confirmed with certainty the metabolic damage to my brain and abandoned any remnants of the autoimmune paradigm for good.

The reason I was able to do this is because alcohol is, for all intents and purposes, a brain fuel. The traditional notion is that the brain only uses glucose for energy, but this isn’t really true (much more on this in a later post). The brain can also use, among other substrates, alcohol. So while I had once again wrecked my body all week by straining my brain in an energy-deficient state, I had followed it with a relaxed weekend of frequently available energy flowing from large cans of hard seltzer. While the obvious overall health implications still apply, in this case my brain and nervous system were recovering thanks specifically to an uncommonly available energy flow.

I’ll write specifically amount impaired brain metabolism and its consequences in part 3, but for now its enough to know that I had confidently assessed the major problem I was still dealing with. The arduous duel tasks of demonstrating it and dealing with it will comprise part 2.

Part 2 Here, Part 3 Here

Excessive Running Doesn't Kill You the Way Some People Seemingly Wish it Did

 

A paper was published recently in the British Journal of Sports Medicine that sought to examine the longevity of extremely serious endurance athletes, motivated largely by the persistent undercurrent of thought that too much extreme exercise may in fact be harmful, especially for one’s heart. The cohort chosen for this study was an interesting one – the first 200 people to ever run a sub-4 minute mile.¹ The idea here is obvious – these men clearly existed on the very edge of human aerobic exertion for some amount of time and did so long enough ago to have now reached advanced age or death.

While this is an interesting study, the results aren’t necessarily what I’m here to talk about. This really just serves as a jumping off point for the broader topic of “excessive” endurance exercise and mortality, something that pops up in the news every year or two as concerns over the potential cardiovascular harm of serious endurance training are regurgitated anew. Its something I’ve been meaning to write about for a while, so…here we go.

Oh right, the results – the researchers found these world-class milers lived an average of 4.7 years beyond their predicted life expectancy. They didn’t catalogue or analyze cause of death, but did note that among the 7 individuals who died young – before the age of 55 – six died of traumatic causes and one of pancreatic cancer. Not a catastrophic heart among them. But like I said, that isn’t the point of this post. There’s a lot we don’t know about these athletes’ lives, or about their exercise habits later in life, and so we can’t really draw sweeping conclusions. We can, at least, be sure that world-class levels of training and performance in early adulthood did not negatively impact the lifespan of these men relative to the general population.

This isn’t an entirely novel exploration either. A similar, larger study of past Tour de France participants also found significant decreases in all-cause and cardiovascular mortality in later life.² While again we can’t “prove” a lot from this, the fact that elite middle distance running and elite endurance cycling both fail to negatively impact lifespan is certainly credible evidence against the notion that such activity is overwhelmingly damaging to health.

Excessively Flimsy Evidence

Ok, so the point isn’t to talk about this one study. The point instead is to push back against the creeping notion that excessive endurance training leads to elevated risk of early cardiovascular death. That claim has percolated for upwards of 15 years or more now, largely thanks to the efforts of two cardiologists – James O’Keefe and Carl Lavie. They’ve worked together on a number of papers that frequently make headlines by claiming that excessive running just might kill you. A selection -

·       “Running too fast, too far, and for too many years may speed one’s progress towards the finish line of life”³

·       “Chronic excessive endurance exercise might adversely impact CV health”⁴

·       “Cardiac overuse injury may be associated with more ominous outcomes, including threatening cardiac arrhythmias, accelerated coronary plaque formation, premature aging of the heart, myocardial fibrosis, plaque rupture and acute coronary thrombosis, and even sudden cardiac death”⁵

·       “It is common, in our experience, that mothers tend to urge their offspring not to do marathons and other extreme endurance events. Just as we would all be better off if we heeded our mothers’ advice to eat fruits and vegetables, we would likely do well to not make a habit out of doing marathons”⁶

 

Their position is clear – running very much or very hard is likely to impact your heart in a negative way, which in turn places you at risk of early death. Which….sounds very scary right? Of course it does – you don’t want to accidently run too much and suddenly drop dead because of it. And these guys don’t really beat around the bush. They tell you, and make national news for telling you, that you are playing with fire and placing your health in danger if you run too much.

-------------------------------

You can probably guess what happens next – I look at some of their papers and tell you that their claims are mostly baseless nonsense.

Lets start with a paper titled “Dose of Jogging and Long-Term Mortality: The Copenhagen City Heart Study,” that divides people by volume and frequency of running and tracks deaths over a decade.⁷ The premise is simple enough – the researchers grabbed about 1,000 people from the larger Copenhagen City Heart Study and surveyed their running habits, ultimately breaking them up into the following groups by running status: Sedentary, Light, Moderate, and Strenuous. After 10 years, when counting up the number of deaths, they found that “strenuous joggers have a mortality rate not statistically different from that of the sedentary group.”

There you have it, apparently – Running far and/or frequently is just as bad as not running at all. If you want to be healthy, jog only a small amount and don’t risk damaging your heart. But, of course, this is all ridiculous bullshit. For at least a couple reasons. Deaths are as follows:

 

  

Notice that the actual death rates differ remarkably. 30 percent of the sedentary group died during the follow up. But it wasn’t (specifically) because they were sedentary, although that surely didn’t help. Its because they were in their 60s, on average, when the study began. Meanwhile, there were only 2 total deaths in the much smaller strenuous running group. And it’s the nature of this group that’s such a major problem, for a couple of reasons.

The first is that with a sample size this small, the 2 deaths are essentially “random.” A change of one death in either direction massively changes the outcome. If there had been 3 deaths instead of 2, we might have been subject to headlines about running killing more people than smoking. You simply can’t get any kind of precise number in a tiny population. 

However, this first problem is extremely minor compared to the second – There is no effort made in this study to assess cause of death. They acknowledge as much, somehow blaming that problem on the number of deaths they recorded – “The small number of deaths in each group made it impossible to report different causes of deaths.”

I have no idea why this should make it impossible to report cause of death, but I have no problem whatsoever levying an accusation as to why they’d claim it to be impossible - Its impossible for them to report cause of death because in order to demonstrate that running increases cardiovascular mortality, you need runners to die of cardiac-related causes. And that probably never happened.

Recall that the sedentary group began this study at an average age of 61. The strenuous running group? They were only 38, on average, at the study’s outset (to be clear, they do adjust for the age difference). Which does help explain the low mortality rate, but also helps us make educated guesses about the cause of these 2 deaths (since the researchers won’t tell us). The most common cause of death, by a wide margin, for a person in the 35-44 age group is by accident. In fact, individuals in this age range are some 3.5 times more likely to die by accident, homicide, or suicide than they are by “diseases of the heart,” which account for only about 12% of deaths.⁸ So, knowing literally nothing else about these people except that they died and were most likely in their early 40s, we can estimate that there’s about a 77% chance neither of them died from “diseases of the heart.” 

And that’s why the researchers didn’t attempt to report cause of death. Because the entire point of this paper is only to fabricate “evidence” to support the notion that too much running promotes fatal cardiac consequences. In order to demonstrate that this happens, first you need to demonstrate that running “causes” people to die. And you can only do that by grabbing a very small sample size, hoping at least 2 of them randomly die (again, only random 1 death would have torpedoed their analysis), and then ignoring actual cause of death in order that you may theorize it must be due to cardiac complications. This entire paper pushes the narrative that running is bad for your heart because exactly 2 people (2 people!!) died in what, statistically speaking, was far more likely to be a car crash.

Furthermore, this is the only paper I can find in which O’Keefe or Lavie actually produce data to support their argument, although of course I’m using the term “support” in only the loosest possible sense. They do occasionally reference other pieces of data, but only in ridiculous and hyperbolic ways. For example, the claim that “considerable evidence has established the link between high levels of physical activity and all-cause and cardiovascular disease-specific mortality” is seemingly only supported by findings that higher levels of exercise fail to reduce (but not increase!) cardiovascular deaths in patients that previously suffered a heart attack.^9,10

 

Excessive Bullshitting

We aren’t done. Lets now consider another paper O’Keefe and friends wrote a few years later, in part about how the previous paper helps prove excess exercise to be detrimental to health. This paper begins by claiming the following:

 

“Middle-aged and older individuals engaging in excessive strenuous endurance exercise appear to be at increased risk for a variety of adverse effects—mostly CV in nature”¹¹

Which is a claim indeed. And a claim that is, ostensibly, well-supported – the authors attach 18 unique references to this claim. That’s a lot! That makes the claim seem more credible! That’s probably why they included so many! And listen, I won’t claim to be entirely innocent of the same tactic. I’ve added more references than necessary at times because more studies confirming the same finding add weight to said finding. But the huge, major, overwhelming difference between me and these clowns is that when I cite 18 references, all 18 of them are absolutely going to support the statement I’m making. On the other hand, among our 18 studies cited here, apparently demonstrating that strenuous exercise increases CV risk, is one that reaches the following conclusion:

 

“We observed a benefit threshold at approximately 3 to 5 times the recommended leisure time physical activity minimum and no excess risk at 10 or more times the minimum”¹²

 

And another that found “excessive” vigorous exercisers in fact die the least:

 

“Among people reporting any activity, there was an inverse dose-response relationship between proportion of vigorous activity and mortality. Our findings suggest that vigorous activities should be endorsed in clinical and public health activity guidelines to maximize the population benefits of physical activity.”¹³

 

And another that found that…

 

“In the analyses of change in running behaviors and mortality, persistent runners had the most significant benefits”¹⁴

 

And here’s a fourth!

 

“Higher levels of physical activity were associated with greater gains in life expectancy”¹⁵

 

So that’s 4 studies that find “excessive” exercise to be at least as, if not more, healthy than moderate levels, yet all 4 are cited as evidence that excess running has the power to kill. There’s a fifth paper I can’t access behind a paywall, and then 13 additional papers authored at least in part by O’Keefe, Lavie, or both, in which they repeatedly cite their own theories as basis for the next paper in a circular logic kind of way. This is a time-honored tradition for these gentleman, who over the course of some 15 years have created a catalogue of essays on the theoretical dangers of running that cite greater and greater numbers of their previous musings, each paper counting as an additional “evidence” about the potential harm of excessive running.

All these papers do, for the most part, is repeat each other and reference themselves back and forth in order to increase the volume of papers that suggest the same thing. They will, of course, throw in scary bits about exactly what it is that’s killing you when you run too much, like sudden cardiac death (SCD). And here’s the thing – SCD is, unfortunately, real. Something like 1 in 100,000 marathon or Ironman participants will simply drop dead. Some people are going to be unlucky. Occasionally, some person with an underlying heart condition may die during great physical exertion. However, the notion that SCD is proof of running’s cardiac destruction is ridiculous, particularly when the risk of SCD during a particular bout of physical activity is as much as 30 times lower in the most physically active individuals vs. their sedentary counterparts.¹⁶

 

Excessive Risks?

Are there any real risks that I’m thus far underselling? Maybe…The most legitimate and most commonly cited as a cause of SCD is probably atrial fibrillation or other arrhythmias developing from extreme endurance training. One of O’Keefe and Lavie’s many papers on the dangers of running includes the following graph:

And such arrhythmias do in fact seem more common among extreme endurance athletes later in life, although (as suggested by those massive uncertainty lines), this isn’t a particularly consistent finding. Beyond that, its difficult to figure out what such an increase would even mean. I can’t find any studies, for example, that show elevated rates of arrythmias among endurance athletes and then also track mortality and CVD data for years to assess potential negative consequences of those arrythmias. It’s possible that arrhythmias could increase while still remaining benign in nature.

Take, for example, a study examining previous finishers of the 90km Vasaloppet ski race. The researchers demonstrated that future arrythmias were more likely in older participants and those who completed more editions of the race, while being lowest among the slowest finishers. They did not, however, “observe higher incidence of sudden cardiac death with higher number of completed races or finishing time,” although this only considered Vasaloppet finishers and not the general population.¹⁷ Meanwhile, a second study on largely the same population of finishers demonstrated significant reductions in death and cardiovascular complications relative to the general populations – With a trend towards greatest reductions among the oldest competitors and those who had finished the greatest number of races. There’s just no good evidence that any increase in arrythmias among endurance athletes translates to tangible mortality risk.¹⁸

 

Conclusion

So…will running a bunch place you at increased risk for future cardiovascular complications or death? Probably not. We can say a couple things with pretty high confidence. One, that the most extreme levels of endurance training and racing inarguably improve cardiovascular health and future health outcomes. Two, that those extreme levels of training probably offer little to no additional health benefit vs. more moderate levels. We can say with somewhat less confidence that you may be placing yourself at increased risk for future arrhythmias by training at high volume and intensities. We can’t really say with any confidence at all if those arrhythmias would translate into any tangible consequence.

So, no, I don’t deny the possibility that sudden cardiac death or arrythmias could result from extreme levels of endurance training. But there is no data whatsoever that suggests this risk translates into negative consequences on a population level. Serious endurance athletes, by and large, are healthier than and live longer than most other people. To any degree that negative cardiac complications occur, they occur only at the margins. They occur only as statistical noise, that does little to limit the greatly increased cardiac/cardiovascular health of persistent life-long endurance athletes.

For my own two cents, given the dearth of evidence linking extreme endurance competition to cardiac complications, I’d wager an unfortunate soul is a lot more likely to discover or exacerbate an underlying heart condition during extreme exercise than they are to breed a new one (but, unlike certain others, I’m willing to admit this is largely conjecture on my part). I’d also venture a guess that, to whatever degree future cardiac complications may arise in this population, that they may be just as well linked to the “anything goes” sugar-guzzling mindset that permeates much of both elite and recreational endurance pursuits. If I were offering candid advice, it would be that there are no real downsides to avoiding the underlying dietary drivers of cardiovascular disease – sugar, seed oils, grains – or ensuring easy training is indeed sufficiently easy (we perhaps agree here, as O’Keefe uses the hilariously arbitrary pace of 10 minutes/mile as slow enough to be safe).

I can’t say what will happen to your heart if you train your ass off for the next 15 years. What I can say, unequivocally, is that people who train their ass off for years on end absolutely live longer and suffer fewer cardiovascular complications than the average person. And there’s some important nuance there – people typically don’t train their asses off for health reasons. Even if there were a tangible argument for moderating, maybe half a year of expected lifespan, I don’t think most serious athletes would be interested in making that trade.

And they shouldn’t have to. The claim that “running too fast, too far, and for too many years may speed one’s progress towards the finish line of life” is not only highly irresponsible but is in fact an outright fabrication. When literally zero of the first 200 sub-4 milers die of early cardiovascular complications, when Tour de France cyclists outlive the general population by years, when no evidence has ever, ever, ever demonstrated an increase in early death among highly competitive endurance athletes (and when “great” maximal oxygen consumption is associated much longer lifespan than “good” oxygen consumption¹⁹)…Statements like these exist beyond the realm of conjecture or hypothesis. They, instead, are fantasy.

I won’t claim to know that there is literally no risk when one engages in extreme endurance competition, but I will certainly accuse O’Keefe and Lavie of fabricating evidence to push the narrative that it may kill you. Not only do they use twisted data to support their agenda, they support their narrative with evidence that is entirely contrary to their claims. This is not a mistake, or a misrepresentation, or a small stretching of the truth on their end. It is a lie, an outright fabrication. It is not something fit to be print in an academic journal, and it is not something a respectable journalist should be engaged in promoting. It is a scare tactic, for reasons still not clear to me. But they have a clear agenda, and they have proven time and time again that they will lie to promote it.

While I must, as always, stress that this is not medical advice (you should probably see a doctor if your heart is doing something weird...), it is absolutely a claim that these fearmongers are stoking baseless fear for reasons unknown, and a steadfast opinion that you should probably just go ahead and relax and head out for that run. 

 

 

1.           Foulkes S, Hewitt D, Skow R, et al. Outrunning the grim reaper: longevity of the first 200 sub-4 min mile male runners. Br J Sports Med. Published online May 6, 2024. doi:10.1136/bjsports-2024-108386

2.           Marijon E, Tafflet M, Antero-Jacquemin J, et al. Mortality of French participants in the Tour de France (1947–2012). European Heart Journal. 2013;34(40):3145-3150. doi:10.1093/eurheartj/eht347

3.           O’Keefe JH, Lavie CJ. Run for your life … at a comfortable speed and not too far. Heart. 2013;99(8):516-519. doi:10.1136/heartjnl-2012-302886

4.           O’Keefe EL, Torres-Acosta N, O’Keefe JH, Lavie CJ. Training for Longevity: The Reverse J-Curve for Exercise. Mo Med. 2020;117(4):355-361.

5.           O’Keefe JH, Franklin B, Lavie CJ. Exercising for Health and Longevity vs Peak Performance: Different Regimens for Different Goals. Mayo Clinic Proceedings. 2014;89(9):1171-1175. doi:10.1016/j.mayocp.2014.07.007

6.           Bhatti SK, O’Keefe JH, Hagan JC, Lavie CJ. The Lady Doth Protest Too Much, Methinks. Mo Med. 2013;110(1):17-20.

7.           Schnohr P, O ’Keefe James H., Marott JL, Lange P, Jensen GB. Dose of Jogging and Long-Term Mortality. Journal of the American College of Cardiology. 2015;65(5):411-419. doi:10.1016/j.jacc.2014.11.023

8.           nvsr70-09-tables-508.pdf. Accessed May 28, 2024. https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-09-tables-508.pdf

9.           Lavie CJ, Lee D chul, Sui X, et al. Effects of Running on Chronic Diseases and Cardiovascular and All-Cause Mortality. Mayo Clinic Proceedings. 2015;90(11):1541-1552. doi:10.1016/j.mayocp.2015.08.001

10.         Williams PT, Thompson PD. Increased Cardiovascular Disease Mortality Associated With Excessive Exercise in Heart Attack Survivors. Mayo Clinic Proceedings. 2014;89(9):1187-1194. doi:10.1016/j.mayocp.2014.05.006

11.         O’Keefe JH, O’Keefe EL, Lavie CJ. The Goldilocks Zone for Exercise: Not Too Little, Not Too Much. Mo Med. 2018;115(2):98-105.

12.         Arem H, Moore SC, Patel A, et al. Leisure Time Physical Activity and Mortality: A Detailed Pooled Analysis of the Dose-Response Relationship. JAMA Internal Medicine. 2015;175(6):959-967. doi:10.1001/jamainternmed.2015.0533

13.         Gebel K, Ding D, Chey T, Stamatakis E, Brown WJ, Bauman AE. Effect of Moderate to Vigorous Physical Activity on All-Cause Mortality in Middle-aged and Older Australians. JAMA Internal Medicine. 2015;175(6):970-977. doi:10.1001/jamainternmed.2015.0541

14.         Lee D chul, Pate RR, Lavie CJ, Sui X, Church TS, Blair SN. Leisure-Time Running Reduces All-Cause and Cardiovascular Mortality Risk. Journal of the American College of Cardiology. 2014;64(5):472-481. doi:10.1016/j.jacc.2014.04.058

15.         Moore SC, Patel AV, Matthews CE, et al. Leisure Time Physical Activity of Moderate to Vigorous Intensity and Mortality: A Large Pooled Cohort Analysis. PLOS Medicine. 2012;9(11):e1001335. doi:10.1371/journal.pmed.1001335

16.         Out of Hospital Sudden Cardiac Death Among Physically Active and Inactive Married Persons Younger than 65 Years in Slovenia Out of Hospital Sudden Cardiac Death Among Physically Active and Inactive Married Persons Younger than 65 Years in Slovenia. Accessed May 28, 2024. https://www.researchgate.net/publication/265532052_Out_of_Hospital_Sudden_Cardiac_Death_Among_Physically_Active_and_Inactive_Married_Persons_Younger_than_65_Years_in_Slovenia_Out_of_Hospital_Sudden_Cardiac_Death_Among_Physically_Active_and_Inactive_Ma

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