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PaE~.E':Tt~.~..~tt:DICI.~E t0. 316--323 t19811 "K P ¢ - +- D L- Effects of Marathon Running, Jogging, and Diet on _ _ Co, ro_na_ry Ris_k Fa~tor~ i,n Mid, d:!e_-Aged Me_n:~ ('ardh=c. R~.ltabi/italio~t Dt'l~to'lmettl. Melhndi.~t Ho.~'pita/. a~ttl D¢l}tO'tmt'nts ~/" (~lttl Phy.~ical Atr't/icitlt'. ~ Ol~hth,hmdogy attcl COIIllIIIIII~I)" Mcdit'i/re. Ultt[ Baylar C, Ih'~'c of .lh'dh'htt'. ttou.vtott. T('.rttx 770]0 Equal groups (N = 22) of middle-aged marathon r~ners, jokers, and inactive men we~ studied to dete~ine the possible effectof their activity levels and life-styles on coronary risk factors. The Ievel of physical activity ne~ssary to minimize corona~ risk was studied hy evaluating differences among the Ihree groups. Both active groups weighed less. had triceps skinfold fal. and higher NDL choleste~l levels than the inactive ~oup. Total cholesterol level was nol different among Ihe three groups, but ~he marathoners Md signifi- camly lower (riglyceride levels than the inactive men. Except for higher (;O.~ max and weekly miles run. lower resting heart rate. and percentage fat in the marathoners, no differ- ences were found between the maralhon runner~ and joggers. Dietary data showed that there were not significant dirferenc~s among the Ihre~ groups, except that the j0ggers consumed _ ...................................................... more dairy'produ~ts than-lhc.inactiyc g~oup, Maralhon runners-and joggers bolh app~ar4o ~.haye ]oweri(~sk~(aq~o~# for c0ron~try disease than inacti~ men. - " ~= : " .........................." TRooucTi0 : There ~s ~vidence-from ep~demiologic studiesthat habhual activity at an energy expenditure !eve!:_of-7.5 kcal/min?:offers protecti0~-from corgna.~ hea~ ~CHD) (14, 16. 17)._ Marathon runners and some.joggers exeFcise at this level and should exhibit lowered CHD risk ~f the protective effect is mediated throug~:a lowering of various risk factors as had been postulated by some researchers (2, 6.15). Froelicher and Oberman (7) critically reviewed early epidemiologic studies of exercise and CHD risk and found that lack of quantification of physical activity was a major fault of many of them. The lack of a gradient of exercise levels within the population chosen was also a major limiting factor in many reports. The recent increase in the popularity of marathon running among middle-aged males in this country affords the opportunity to study groups of individuals who va~ widely in physical activity levels, and for whom the amount of exercise can be easily quan- tified. If there is indeed a threshold level of physical activity required for lowering CHD risk. does it lie between the habitual exercise levels of the marathon runner and the jogger or between that of the jogger and the sedentary individual? The purpose of this study was to determine whether a significant difference would be found in various CHD risk factors among middle-aged male marathon runners. fitness joggers, and inactive su~iects. In addition, selected life-style and dietary [ 40 • Thi'~ rc,,¢urch ".,,'as supported in part by :7 grant from the Schwarz Fund. Houston. : To ~ ham reprint requests ~hotfld be addressed at Cardiac Rehabilitation Department 121E. The Melhndlst Ho~pilal. Texas M. edical Ccnler. Hou~lon. Tex. 77030. 316 ....... ~, ~91-74xY'8 I. 03031&08502.~/0 N~C~ ~IS MA~R~[ B~ BE PROTECTED ~ ~OP.YRIGHT ~W ~TLE 17 U. S. COD~ T105280138

E.FF~EC~TS OF RUNNING ON' C,~RONARY RISK FA_CTORS ~3 [7 habits of these three groups were compared in order to determine if differences in these factors infiuenced CHD risk factors. ....................... _. ~_ ......... : - ..... ~T~O:~: .... . : ........ Fo~y-four h~alth.~ men ~g~d 4t to 6i ye~.~s w-ere studied in orde~to determine the long-term effects of running or jogging on CHD risk ~actors or the develop- merit of ove~ CHD symptoms. Twenty-two of the men had completed a 42.2-km marathon run within a year of the current testing sessions and regularly trained by running or jogging more than 30 miles a week. Another 22 subjects jogged a minimum of 2 miles, 3 days per week. A group of 22 relatively inactive men in the same age range were randomly selected [rom among ~ubjects who had volun- teered for a research project involving dieta~ modification for reduction of blood lipid' levels. These me~ were healthy, with no known blood lipid abnormalities and were not necessarily ove~eight. They were normally active men who may have played golf or tennis or engaged in calisthenics occasionally, but who were not on a regular endurance exercise program. These subjects were tested prior to any dietary teaching or modification. ........ Th.e-runners andjoggersseported ~o the-hospiltal on twoseparate occasions with ~:=:- :at least one week between visitsLA~-the first ~i~it, in the early morning following a -.-- 12- to 15-hourfast, blood .w.as.drawn for lipld.determinations, and Weight, bl6od pressure,'and skinfold measurementswere taken. Sabjects completed diet,-life- ..... style.,- b.nd anxie2~, questiffnnaires diJ~'ihg the fi~.St part o~-ihe second-visit. A- .... sonal:health history and z family history ofCHD.or rlskfactors'were-also obtained at this visit, Laboratory determination of maximal oxygen uptake (t;'O= max) using an open circuit gas analysis method was then performed on the runners and joggers. The test involved a continuous treadmill-running protocol (13). The inac- - rive inertalso reported to the laboratory on tWO occasions and the same mea- surements were made except the anxiety scale. Treadmill testing was done using the Bruce protocol with I)'O.., max estimated from endurance time (20). The personal history included questions concerning present or past incidence or complaint of chest pain, hypertension, and smoking habits. The family history quest.ionnaire was designed to determine if blood relatives (parents, siblings, aunts, uncles, grandparents) had early cardiovascular disease, stroke, hyperten- sion. hyperlipidemia, or cardiovascular surgery. The diet questionnaire was a self-reporting instrument for indicating how many servings ot'eac'h of 25 foods or food groups subjects ate in a specified time period. • _ The questionnaire has previously been described in detail and the rationale for its use has been discussed I I0). Specific data obtained included: weight and height, plasma total cholesterol and triglycerides. HDL (high-density lipoprotein) cholesterol, sklnfold thickness at the triceps, resting heart rate, and resting blood pressure. Cholesterol and triglyceride values were assessed using the facilities and methods of the Lipid Research Clinics (12). Factors related to anxiety and tension in the runners and joggers were obtained from the Anxiety Scale Questionnaire (ASQ} of the Institute of Personality and Ability Testing (IPAT) ~11). The ASQ was developed as a means of obtaining clinical anxiety intbrmation in a rapid, objective, and standard manner. Raw TI05280139

318 HARTUNG, FARGE, AND MITCHELL scores are standardized by using a formula based on the known mean and standard deviation. The ASQ is a brief (40 item) instrument to measure anxiety in a stan- dardized and nonstressful manner. The five factors are Apprehensiveness (12 items), Tension (I0 items), Socially Uncontrolled (8 items), Instability (6 items), mulas were used to reduce raw scores to standard scores. Tests for reliability of the ASQ based on internal consistency are repoaed to range from 0.78 to 0.92. Descriptive statistics were computed for all physiological and biochemical vari- .ables: an analysis of valance for the difference between means was calculated among the groups. The Scheffe post hoc test (22) was used ifl case of a significant F ratio to test differences between all pairs of treatment means. The health histow and family history data were compared using a X~ test for significance among the groups. RESULTS • Table I shows that the active groups did not differ from each other or th~ inactive group in age or height. The marathon group.had a significantly lower triceps skinfold thickness and both active groups weighed less than the inactive m~.~The marath~n~grbup was rffnh~nga-mean 0f~70 ~m perwe~k~and th~ jogging-. group 28.6 km per~e;k. However; there was not a significant difference between "- grorps With ~espect to the numbereryears tha~ ~he Subjects had~een ~nni~g~ There. were few_~dstiqally s~igo~ficant physio[ogicai differen.ce~_ between_ the. ................... ma~thon~and jogging groups fTable 2) except in tho~e variables related to differ- -en~:-in-acti vity:l~eI,The m~r~-fi0n group had~a-qower me~h~esting he~ raie than either thejogg[ng or inactive groups. than the joggers, and higher in both active groups than the inactive. Maximum heart rates were not significantly different for the ma~thon and jogging groups and resting blood pressure showed no difference among the three groups. The three groups were not significantly different with respect to mean total cholesterol (Table 3) but both the runners and joggers had significantly higher HDL cholesterol levels than the inactive men. The ratio of HD~total cholesterol was also higher for both active groups than for the inactive groups. Triglycedde TABLE DESCRIPTION OF Marathon IM) Joggin8 (J) Inactive tl) (,v = 22) IN = 22) (N = 22) P Age (years) 48.2 ~- 4.8" 48.7 = 5.4 48.3 "- 5.6 NS Weight (kg) 72.4 -- 8.8 76.2 = 8.7 86,0 "~ 11.9 <0.001 M. J < I Height (era) 179.2 -'- 6.2 178.3 -'- 5.2 178.3 -'- 5.5 NS "Triceps skin- 8.4 = 3.0 9.5 '" 3.3 12.5 ~ 6.5 <0.01 M, J < I fold ~mrnt Distance run 3.644 = 1.20£1 !.488 = 878 <0.001 M > J per year Ikrnl Values are mean = SD. T105280140

EFFECTS OF RUNNING ON CORONARY RISK FACTORS P 319 Resting HR 54.4 = 9.9" 62.4 _ 12,5 67.7 = 8.8 <0.05 VO~ max 57,2 = 7.6 49.2 ± 6.0 42.5 = tmlJkg- mint Max HR 173.8 -~ 9.0 173.3 -,- 10.2 173.1 = 11.3 NS SBP(mm Hg) 121.6 = 13.2 127.9 -,- 13.6 119.6 = 12.5 NS DBP(mm Hg) 78.6 _~ 7,1 80..5 ~.- 8.7 " 77.3 = 8.1 NS " Values are means zSD. ~ Estimated from treadmill time. levels were significantly lower in the mar,~thon group than the inactive group, with the joggers' value between the two, but not significantly different from either. . There were no significant differences among the groups of various personal (history_ of hype .r.-_t.e_ns!on;-c hest~ pai_n_)~a_ nd:-familial (stroke~;.:lil~id ~tisorde/-s,~ca-rdia6 surgery, MI) CHD risk indicators, including present cigarette smoking habits as assessed by t.he?~z method, The~mea-/i number of cigarefies smoked within ~h-e _g~-oups was_S..l_.:~:_0_5~ an~d l.!4~.e_L _dgy_ by. !he inact!ye,__Ljggging, and ma~thgn groups, respectively. The marathiSh~i'sandjoggers webd:~ibt ~significantlydiff~rent-in. total tedsionor- anxiety as measured by the IPAT scale. A mean raw score of 23.6 for the joggers and 23.7 for the marathon groups places both in the 40th percentile of anxiety level. Bc;th groups combined were found to score near the population mean for overt anxiety (12.6 for the joggers and 13.3 for the marathoners) and lowerthan the population mean for covert anxiety (1 I.i for the joggers and 10.3 for the marathoners). The ASQ mean standardized score of 5.04 for the entire group (marathoners having a mean of 4.96 and joggers, 5. 161 places the group within the normal limits of anxiety. The authors of'the ASQ ( 111 consider scores of 1-3 to be low anxiety (5 of the current samplel, 4-7 to be average anxiety 05 of the current samplel, and 8 or higher to be high anxiety (4 of the sample). Factors relating to the dietary habits of the three groups were compared, with no statistically significant differences noted except tbr greater consumption of TABLE 3 PLASMA LIPIDS AND LtPOPRO'I'EIN IN ACTIVE AND INACTIVE GROUP~ Marathon Jogging Inactive (N = 22) (N = 221 (N = 22) P Total cholesterot' 195.6 ¢ 35 204.3 _- 38 213.4 : 33 NS Triglyeerides~ 87.4 = 39 103.6 = 54 146.6 = 86 <0,01 M < 1 HDL cholesterol" 69.3 = 19 61.5 = 28 38.4 = 12 <0,001 M. J .-:-I HDLtotal cholesterol 0.36:0.13 0.31 = 0.II 0.18 ± 0.07 <0.001 bl.J > l • ' Values'are mg,.dl, mean = SD. T105280141

320 HARTUNG. FARGE. AND MITCHELL dairy products in the.jogging group th.an in the inactive group (Table 4). Consump- tion of alcoholic beverages was not significantly different among the groups, in the marathon group, only ~ admitted to drinking an average of more than 21 d:~!nk, s per week_, wh!!&23%, of !he ie__gg~ers d_ ra:n_k_ this .~a~tftty of._~oholie b~ever- DISCUSSION Bonanno and Lies (.~) have reported significant reduction of systolic blood pressure in hypertensive subjects and a decrease in serum trigtyceride concentra- tion in middle-aged males, following a 12-week exercise program. Except for improvement in physical fitness, no other changes in major coronary risk factors were found to result from the program. Other Studies have shfwn that significant changes in body composition (18. 2 I), and perhaps in other risk factor elements, may take a longer period of time or a program with more frequent exercise ses- sions. A longitudinal study of male executives at the NASA Johnson Spacecraft Cen- ter (15) indicated that exercise intervention reduced CHD risk over a 6-year period in each of three age cohorts. The authors, however, were unable to determine whichJndividual risk factors, presumably the muitl-variate CHD r~sk-. . ~-.-Ma.ximal oxygen uptake values for the active:groupS were~much higher than w_ould be expected in a sample ~f sedentary- men of the same age:-These values-. ......... were,-in fact; higher tlhan would-be expected inmen classi~ied-ih good cardio~,a~- cular fitness .with a mean age 29 years youngerthan the-pres_ent sample~(1)._ vaiues for 12~3.~ max in the mara_thoners compared favorably with values found by Pbllock and others (19) in champion track athletes of the same age range. Esti- mated I;'O.., max for the inactive" gronp indicate that they were probably above average in endurance fitness for their age ( The energy expenditure during training was estimated to average 14.4 kcal/min for the marathon group, a total expenditt~re of approximately 763 kcai for an average daily training run lasting 53 rain. For the jogging group, the training TABLE 4 Portion M.'trathtmers Joggers inactive size ~.V = 221 I,V = 221 t,~,~ = 221 P Red me;=t 3 oz 5.8 = 4.?' 5.2 "- 4.4 8.2 = 6.2 NS Proces.~d meat Varlet. 4.3 = 4.3 3.5 = 3.3 4.3 = 2.4 NS Poultry 3 oz 1.9 "- 1.4 1.8 = 1.4 2.3 "" 2.7 NS Fi~.h 3 or. I.P. = 1.6 1,6 = I,.6 1.4 = 1.2 NS Eggs lined 3 5 : 4.2 3.4 = 3.3 ]..0 = 2.4 NS Dairy prt~ducts Varies 19.7 _ I I.S 22.9 = It.0 13~6 ---. 8.6 <0.05 J > t" Sugar. tick,errs Varic~ 13.1 = -11,6 7.4 = 7."~ 16.1 -~ la.7 N5 Sol't drink~ 12 oz 6.5 = 9.9 9.7 "- 16.6 6.6 _- 9.3 NS Aleuhol 1.5 oz R.7 = 9.4 9.9 = 10.6 II..'; "" 15.9 " Values arc mean servings per v, eek = SD. T!05280142

EFFECTS OF RUNNING ON CORONARY RISK. FACrORS energy expenditure w.ns only 302 kcal/day based on approximately 12.[ kca]/min for a mean d~fly run of 3J rain. The mnr~[honers w~r~ expending npproximn[ely 4,~2.8. kca~¢:ek..and~ .~he j~gge~s,. 1,8t2 kca[. in vigorous physical activity. We o.nt~ modcPa~el~ ~i'goTous activity (<7.5 kca~min). Ac~-ording to Pafl~nbarger al. { 16), a tow total weekly expenditure of energy (< 2,~ kcaVweek) in walking. climbing stairs, and sports play may be related to increased risk of coronary heart disease. The active subjects in the present study had been running or jogging lbr several years (75% for more than 6 years). This figure did not differ between the two groups and may account for the fact that~e smoking was less common in these groups than in the general population. Many of the former smokers reported that they stopped smoking ciga~ttes at the time or shortly after they began to exercise regularly, which su~ the idea that smoking and running or jog- ging are not usually compatible habits. Runners and joggers seem to possess anxiety levels which do not substantially differ from the general population. Other studies have noted that runners have -.-personality-tr~iits-whicla..areosignificantly different from.other:normal.groups.19) :_-:The :lmu~ tr~gly~erid¢ ~an/.i high HDL cholesterol coacent(ations ~6 groups, and their:high ratio of HDL to total cholesterol (0.31 and 0.36) indicate=a lowered risk_for CHD (4, 8). Data from the Framingham Hea~ Study {8) indicate that HDE~holesterol--levelsin the .range found in runners andjoggers-inthe~ presenc study:.re~91~g~.in_appr0~imately a 5~;~ decrease in theincidence_pf-~_Hp as compafed.w.i[h normal HDL concentrations such as exhibited by the i!3ac_tive group. ..... Since there is some indication that body fat stores or plasma triglyceride levels -influence HDL-cholesterol, we tested this hypothesis in a previous-study Groups of inactive men of similar body weight and triglyceride level still had significantly lower HDL than marathon runners :rod joggers. Active subjects may adopt habits or a life-style which promote overall health. Proper sleep habits, regular meals, moderate drinking, maintenance of normal weight, and cessation of smoking, in addition to exercise, may lead to less illness and increased longevity (2). The similar dietary habits of the current sample do not support Cooper's observation (5) that habitual running leads to dietary modifica- tions. Comparisons of dietary differences among larger active and inactive groups cot:tfirm this finding (10). The fact that significant differences were not found for many variables between the jogging and marathon group indicates that the threshold level of physical activity necessary to promote reduction of risk factors probably lies between the activity levels of the jogging group and the inactive population. A middle-aged man may not, then, have to become a marathon runner in order to obtain benefi- cial physiological and biochemical alterations which indicate a reduction in risk of coronary heart disease. It is of course possible that men may choose to run or jog habitually because of different physiological or biochemical makeups which are genetic and. therefore. exist before starting exercise training. The work of Paffenbarger et al. t 16}, how- T!05280143

]22 HARTUNG. FARGE, AND MITCHELL ever, shows that college athletes were not protected from heart disease unless - they continued to exercise or resumed exercise training later in lifc.~ SUMMARY AND CONCLUSIONS The following conclusions can be drawn, from the results obtained~[n this study: -['a~h¢~'_ ,a~..'~h'o~:ru~n'_e_x~ ~h~,'g;n'~fiea_~l~' h~h~a_'c:r~:h~¢ ca~ of CHD than the joggers: (b) in this sample, higher HDL cholesterol was as- sociated with ~nning and.jogging: (c) .runners and joggers were not different from inactive men in qualitative dieta~ habits: (d) both active groups were avenge, relative to the degree of anxiety and tension under which they live: (e} the level of physical activity necessary to reduce CHD risk probably lies between that of the joggers and inactive men. We~believe that such a level of physical activity can be effectively attained without undue expenditure of time pc money. Therefore, duction of CHD risk is perhaps more within the reach of most individuals than h~ been pc¢viously thought. REFERENCES t. Am¢rican Haa~ Association (Committee on Exe~is,). "" Exercise Testing and T~inin~ o~ Appav ently Healthy Individuals: A Handbook for Physicians." American Haa~ ~ss~iation. New :1: : " ::2,:BellOC. N, D. Relationship of heMth practices and mortality, Prer Med:=2:-67:gl'=f1973|: -- -~ " --:- : . ..3_~ ~0_nanno, ~. A.~ and LiFs. J. Ei EffeCts of physical traini.~g 0t! cpr~9~ar_z r.i_slc factors.-Amer: J. . C~=rdiol. 33, 760-764 (1974): : 4. Castelli. W. P.. Doyle. J.T:,Gordoa:T~,Hames, C. G.. Hj0nland; M. T.. f-lu~ley. S. B., Kagan." .......... g~Tand Zukel. W. J., HDLch~l~te~[~dd other lipids in coronary h~~disea---~se: The coo~- ..... : :~- ~i~.eJipoprot¢in phenotyping stu~y=~:r~,~datioa 55, 767-772 (19~.. 5. Cooper. K. H. "'The Aerob[cs Way." M. Evans & Co.. New York. 1977. 6. Fox. S., M. llI.. Naughton..J, P,, andGorman., P, A. Physiea activity and cardiovascul~ health:. 1. Potential for p~vention of corona~ hta~ disease and possible mechanism. Mud. Concepts Cordiot'asc. Dis. 41, 17-20 (1972). 7. £roelicher,V. F,. andOberman. A. Analysisofepidemiologic studiesofphy~ical[nactivity asHsk factor for corona~ a~ew disease. Prt,,L,. C~¢nl~ot'(L~('. D[.~. IS, 41-65 (1972). 8. Gordon. T.. Castelli, W. P., Hjo~land. M. C.. Kennel. W. B.. and Dawber. T. R. High density lipoprotein as a protective factor against coronary hea~ disease: The F~mingham Study,Amer. J. Med. 62. 707-714 H977). 9. Ha~ung. G. H.. and Farge. E. J. Personality and physiological t~its in middle-aged runners and oggers. J. Gerontol. 32. 3~1-348 ~ 197~. 10. HaRung, G. H.. Foreyt. J. P.. Mitchell. R. E.. Vlasek. !.. and Gotto. A. M. Relation of diet to high-density-lipoprotein cholesterol in midd~e-aged ma~thon runners, joggers, and inactive men. i~ett. EnA, l. J. Med. 302, 357-361 t1980). I I. Krug. E.. Schei*r, l. H,. and Cattell, R. B. "Handbook for IPAT Anxiety Scale." Institute for Personality and Ability Testing. Champaign. Ill.. 1976. I2. "'Manual of Laboratory Methods." Lipid Research Clinics Program. University of Noah Carolina. Chapel Hill. 1972, 13. McArdle. W. D., Ketch. F, I.. and Peehar. G. S. Comparison of continuous and dimontinuous treadmill and bicycle test for max f'O:..tled. SH..$p¢,r~) 5. 136- t~ (1973L 14, Morris. J. N.. Adam. C., Chav¢. S. P. W.. Sirey, C.. Epslein. L.. and Sheehan. D. ~. Vigorous exemi~e in leisure-time and the incidence of coronary heart disease. L~mcet 1,333-339 t 1973L 15. Owen, C.. Prior. B.. Beard. E., and Jackson. A. Longitudinal evaluation of an exercise prescri~ lion intervention prog~m on corona~" hea~ disease risk. 3fed. $t'i. ,$p¢)r~d tO. 3~ { 1978) {Abq~ctL Tt05280144

EFFECTS OF RUNNING ON CORONARY RISK ~ACI'OR$ 323 16. PalTenbarger, R. $.. It., Wing, A. L.. and Hyde. R. T. Physical ac~ivily as un index ul'heurl ri~k in college alumni. Amcr. ~. I~pidcmi,~L 1~)8. 1~1 - 17~ 17. Pal'fenb~er. R, S., and H~lle, W. E. Work acliv~)' ~md cor~nary h~rl mo~;dily. No, 19~L .I. " - capacity, cardiovascular-~un~tion~ and bod,y uompo~ki~ o~" ndul~ men. M,~..~ci..~p,~rL~ 70- 74 (1969). 19. Pollock. M. L.. Miller. H. S.. and Wilmor¢, J. Physiolog=cal characlcristics or'champion Ameri- can track ~=hleces 40 to 75 years oF age. J. G<,rrm~d. 29. 64~-649 (1~4). 20. Pollock, M. L.. Bohannon, E. L., Cooper, K, H., Ayers. J. 1.. Ward, A., White, S. R., and Linn¢~d, A. C. A compara[ive analysis or" lbur protocols tbr maximal treadmill s[ress testing. ~m=,r. H¢,r~r~ J. 92, 39-46 (1976). ZI. Skinner, ], D,. Holloszy, J. O.. and Cureton. T. K. E~ects of a program of endurance eXerci~¢on physical work. Amcr. J. C<ir<lir~L 14. 747~752 H964). 22. Winer. ~B. J., "'Statistical Principles in Experimental Design.'" McGraw-Hill, New York. ~.. I ! ; T!05280145