On the Passing of an Ironman:

 Rishi was always there. And, with a smile.

My dear friend, Rishi Lalwani passed away on Sunday, 9^th July, 2023, at 9:30 am. I am still processing the shock and grief, over the loss of a friend and a gentleman. Rishi was always there for everyone; he was the classic 3 am friend, whether it was to party, or to go on a 4-hour cycle ride, both of which have been done. He was an integral part of the SoBo running and triathlon community, and it would be safe to say that Marine Drive won’t be the same without him. In a group of alpha males (and females), Rishi was unique – he trained as hard, if not harder than anyone around him, but somehow you never felt that competitive edge, when cycling or running alongside him. And before anyone pipes up – he was NOT overtraining. In fact, over the last year or so, his training volume was the lowest I have ever known it to be.

 

Rishi was always there. And, with a smile.

In the middle of a long run, it was not unusual for Rishi to suddenly up the tempo and leave us behind. We would wonder where he had disappeared, and would find him a kilometre ahead, at Worli, or at Chowpatty. He would be waiting for us with coconuts in his hands, all cut and ready to consume, so we could hydrate mid-run, without losing time. And for all you Garmin obsessed runners, you know what a big deal that is! Our good friend, Roopali Mehta, an ace runner and nutritionist was his regular running partner, who needs no introduction. Roopali stops for no one during her run, except for nature, which she often needs to. Rishi would specially carry a five-rupee coin, so she could use the Sulabh Sauchalyas along the way, and wait for her outside, every time.

 

Rishi was always there. And, with a smile.

Let’s rewind to my favourite Rishi-Simran story. Flashback to November, 2019, Antalya, Turkey, at the half Ironman triathlon. Rishi was known as the Ironman in our group, because of having done several ‘full Ironmans”. For the uninitiated, this consists of 3.8 km of sea swimming, 180 km of cycling, and 42.2 km of running, and yes, it’s all to be done back to back, with the idea being to spend as little time as possible in transition, between disciplines. Rishi trained his dear wife, Simran to participate in the triathlon, and here we were, all together in Turkey, for the event. He chaperoned her through the swim, and gallantly waited outside the ladies change area, for her to transition to the bike. A decent T1 (transition time), would be around 5 minutes, but after 15 minutes when she did not show up, he started getting worried, before madam finally appeared. It turned out that she spent the extra time, applying sun-block and getting prettied up for the next leg, as well as sharing cosmetics and skin-tips, with other triathletes! We must have narrated that story a hundred times, and each time, I could sense a mix of exasperation and joy in him, as we recalled that day. Their sweet daughter, Mallika was our official photographer during the trip, and the only adult present, might I add.

 

Rishi was always there. And, with a smile.

Rishi was a rare high-level athlete, who was always happy to run or cycle with those, much slower than him, and to give them company. If he saw you struggling mid-run, he would happily change his plan for the day, and give you the encouragement needed. His compassion extended off the field as well, till the very end. A week before his passing, when he was on a family holiday in Spain, they met an elderly couple in visible distress at Barcelona airport. It turned out, they had left their passport in the aircraft in their earlier flight, and were stranded.  At the cost of missing his own connection, he accompanied them to various counters of the airport, to make sure they were safe and sorted.

I was fortunate to have run with him alone, about ten days prior to that fateful Sunday. Usually, we have our entourage of Roopali, Krishna and the good lord, aka Saroosh, with us. Our conversations are never serious, but that day, serendipitously, we started talking about his life story. I learned how his first job was selling greeting cards, made by NGOs such, as CRY. He would buy bags of them from Mumbai and carry them to Pune, several times a week, where he would sell them to corporate clients. By chance, he landed up in the business of freight forwarding, in which he experienced great success, through sheer dint of hard work, and practical acumen. His was the classic story of landing up in Mumbai, with very little and making it big. I felt privileged to have had the good fortune of hearing it all from him, in great detail. When I met with Simran after the funeral, she narrated a string of random events, over the past two weeks, which somehow seemed to be him saying goodbye to the world.

The final run.

 On that fateful Sunday, I was running by myself and passed Rishi at Peddar Road, outside Jaslok Hospital, as I was heading north, and he was returning. Ordinarily, he would have turned around and joined me, but this time he just said, ‘see you at the end’. We did meet at NCPA, post-run, and indulged in our usual banter. This time the theme was the cruise he had just returned from, and we were ribbing him about it having been sponsored by his in-laws. Rishi was in vintage form, regaling us with stories about Ibiza, and how much fun the trip was, with his entire extended family there to celebrate his mother in-law’s 75^th birthday. He left for breakfast at KGC, after which he felt a bit queasy and ‘acidic’. He got home, and passed away within minutes, giving no chance for any emergency measures. He lived life on his terms, and lived it to the fullest. Unfortunately, like many great souls, he has left us too soon. He leaves behind a beautiful family; his wife Simran and two lovely children, Mallika and Jaan, who is aspiring to become a doctor.

As Simran told me, Rishi is in heaven and smiling at us. I actually imagine him on a stationary bike, coconut water in hand, and when it’s our turn, he will be there to welcome us. With a smile.

Rishi and Simran, Ironman, Turkey, Nov 2019

At Antalya, after the half-Ironman. Rishi is on the extreme right, in black

With Roopali and Simran at the 2023, Tata Mumbai Marathon

Surviving Corona In The Big City

 Let me begin with 3 disclaimers first:

• This article is aimed at an urban office-going, white collar demographic
• It represents my personal views on the subject, culled from the scientific and non-scientific reading I have done so far, and is meant to be a general guide on how to avoid catching the virus
• The information here is current as of Monday, 11^th September, 2020, 7:16 pm (yes, that’s how often our knowledge on the subject changes!)

How does the virus spread?

Clearly, to avoid catching it, you need to know how it spreads in the first place. The virus spreads mainly from person to person, through respiratory droplets. These are produced when an infected person coughs, sneezes, or talks. Through the droplets, the virus can fall on the mouths or noses of people who are nearby and may also be inhaled into the lungs. The closer you are to the person, higher the chances of the droplets falling on you. Recent research has also shown that it can be spread through aerosols, which are very tiny particles that can carry the virus. These have shown to be ‘alive’ for a period of up to 3 hours, leading to the fear of airborne transmission.

However, do keep in mind that your body’s innate immunity is always making an effort to fight the virus, and whether you get the infection will depend on the fight put up by the immune system, against the total amount of virus attacking you, also known as the viral load. Higher the viral load you are exposed to, higher is the chance of you catching the infection (distance and masks reduce the viral load).

 

What do we know for sure?

As was alluded to in the disclaimer, our knowledge of the virus is literally changing every day, but we know the most important ways of avoiding it, with a high degree of certainty.

 

1.       Physical distancing (I prefer this term to ‘social distancing’)

2.       Masks (any type, ranging from the N95 respirator to a simple home-made face covering)

3.       Hand hygiene

Conversely, we also know with a fair degree of certainty, the situations which put you at highest risk. This is summed up nicely by the Japanese health ministry as the 3 ‘Cs’.

1.       C- Closed spaces with poor ventilation

2.       C- Crowded places

3.       C- Close contact settings, such as conversations

 

Let’s look at some common daily scenarios we might face, and the best way to handle them:

What about going to office?

This is a tough one to answer. For a lot of people, there’s a limit to the work that can be done from home, and going to office, is a matter of economic necessity and survival. If you’re lucky enough to have your own cabin at work, then the risk is very low, even if it’s a small room and you have the air conditioning on. One important caveat is that it should be a stand-alone AC, since a common unit could potentially spread the virus from one area to another. Avoid having people come in frequently, and when they do, leave the door open for better circulation and keep the meeting time brief (with masks on, of course).

If you do not have your own cabin, then physical distancing is vital, and it would be best if you could maintain at least ten feet distance from someone next to you. Six feet is the ‘official’ recommended distance, but ten would be even better. Weather permitting, it would be good to have the windows open to allow ventilation. It goes without saying, that larger the room, the safer it is. In office settings, people often let their guard down while talking during lunch (one time, when you have to let your mask down), or around the water cooler.

 

But, how do I get to office, or elsewhere?

If you drive your own car, that’s the safest means of transport. And you don’t need to wear your mask, while you are by yourself in the car! On the other hand, travelling in a crowded train or bus is clearly the riskiest environment to be in.

Driver/Ola/Uber:

If you don’t drive yourself, make sure that both, the driver and you, have your mask on the whole time. I would also recommend leaving the windows down to allow free flow of air. I’ve noticed many private cab operators, having the driver’s seat cordoned off by a plastic curtain, which seems a fairly innovative way of reducing risk. Clearly, it would be best to be driven in your own car, but I don’t think you need to worry unduly about riding in a cab, if the proper precautions are taken. In addition to windows down and masking, I would advise sanitizing your hands once you are out of the vehicle.

 

Can I go to the Club?

Different clubs are slowly opening up their activities, and I’m happy to see that they’re doing it in a graded manner. Walking outdoors, and tennis have opened in most clubs and are relatively safe activities. Some have started other services, like take-out from restaurants as well as their hair salons. Most sports activities, where distance can be maintained are safe by themselves. Often, it’s the congregation after the activities, or in the dressing room, which are the problem. Closed room activities, such as billiards or card rooms, should definitely be avoided.

Exercising outdoors, whether at the club or elsewhere is generally safe and healthy, since exercise builds immunity. A big question that pops up, is whether to wear a mask or not- with a lot of misinformation being spread on whatsapp. It got to a point, where I wrote a blog (http://drcontractor.blogspot.com/2020/08/) on the subject, and will post just the take-home messages here.

• 1.       Exercise improves your immunity, for which moderate-intensity exercise is best.
• 2.       When exercising outdoors, if you are able to maintain a 20 foot distance from others, it would be fine to let your mask (guard) down. When unable to maintain the distance, put it back on.
• 3.       Exercising with a mask, may lead to a greater subjective perception of effort, so you may need to reduce your exercise intensity.
• 4.       There are no ill effects of wearing a mask. If you feel uncomfortable while exercising with it, or have any serious health conditions, please speak to your doctor.

 

What about food delivery or other parcels arriving at home?

Currently there is no evidence that people can get infected by eating or handling food. However, people are afraid that the containers with food or any other delivery to the home, may be a source of spread of virus. For that to happen, an infected person needs to have ‘shed’ virus on the package, through sneezing on it, and you need to then touch the package (while the virus is still alive), and touch your mouth, nose or eyes, before you wash your hands. And, a sufficient amount of virus must be transmitted through this route for you to get the infection. While this is possible, it’s an unlikely route of transmission. However, it’s good practice to wash your hands after handling outside packages, to keep risk to a minimum.

 

Can I meet with family and friends?

This is the big one. Man is a social animal, and 'social distancing' can be crippling. Which, is why I dislike the phrase, but it's become part of our daily vocabulary. I prefer to call it physical distancing, which frankly is also a more accurate description. We have been deprived of the company of our loved ones for so long, and now that we are ‘allowed’ to meet, we shouldn’t let our guard down. But that’s exactly what happens, and I have observed this closely, including with my family. I think this is because of a subliminal belief that our near and dear ones, cannot pass on the virus to us. Sadly, this is far from the truth, and whether we like it or not, most of those infected would have caught it from those ‘nearest’ to them, pun intended.

Getting back to the question- it’s safe to meet, but you should not let your guard down. Avoid physical contact, and keep your masks on at all times. Most socializing also involves eating and drinking, at which point the mask has to be lowered, but at those times make sure there is adequate physical distance. And do keep in mind, that alcohol tends to loosen social inhibitions, and masks!

 

What’s your risk appetite?

I don’t think that many of us dwell on this, but on a daily basis we are taking decisions, which carry risk, which we subconsciously assess and decide whether to proceed or not. The simple act of crossing the road, walking in the rain, or even boiling water for tea carries an element of risk, which may not be as obvious as the risk involved in skydiving, bungee jumping or criticizing your wife’s cooking. And so, it is with our novel enemy, the Coronavirus. Apart from living completely by yourself in the wilderness with no human contact, every other situation carries the possibility of catching the virus. It’s a continuum of risk, ranging from minimal to very high, and you need to understand the relative risk of each activity and proceed as per your risk appetite. Each of the activities described above can be undertaken, but within each of them it’s important to be aware of the micro-environment, and keep your risk to a minimum. The BMJ- British Medical Journal published an excellent review article recently, titled –“Two metres or one: what is the evidence for physical distancing in covid-19?.” The table below, is from the article and grades your risk from low to high, in different daily situations.

Stay healthy, and stay safe. I will end by once again emphasizing, the best prevention strategy, whether you’re in a big city, or anywhere else in the world.  J

1.       Physical distancing (but socially connected)

2.       Masks 

3.       Hand hygiene

 Table from BMJ: 2020;370:m3223

Two metres or one: what is the evidence for physical distancing in

covid-19?: Nicholas Jones et al

BIBLIOGRAPHY:

 

https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Spread

https://coronavirus.medium.com/why-it-matters-how-much-virus-is-in-the-body-5a3998f8a323

https://www.health.harvard.edu/diseases-and-conditions/coronavirus-resource-center

https://www.bmj.com/content/370/bmj.m3223

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-how-is-covid-19-transmitted?gclid=EAIaIQobChMI--bQvILX6wIVRA4rCh3QrACgEAAYASAAEgIWvPD_BwE

TO MASK OR NOT TO MASK (DURING EXERCISE) IS THE QUESTION

In the year 2019, if someone had told you that a rectangular piece of cloth, which can barely cover your face, would become, not only the saviour of the world, the following year, but would also be a potent symbol of political division, within the United States, you would probably dismiss them, at best, and question their sanity, at worst.

But still, here we are in the middle of 2020, and that’s exactly what’s happened. This rectangular piece of cloth (which could be cotton, chiffon, silk, polyester, or the surgical variety of polypropylene), more correctly termed as a mask, is our defender-in-chief, against the dreaded coronavirus, technically known as SARS CoV-2, or better known as Covid-19. As we battle this pandemic, we have come to realise that it’s a virus like no other seen before, hence the term, ‘novel coronavirus’, and it’s proving that every day. With all the weight of scientists and doctors (and quacks and charlatans) of the world behind us, we still seem to be struggling to understand how it affects the body, and what’s the best way to contain and treat it.

However, what we do know for sure, is that the best ways to keep it at bay, are:

1.       Physical distancing (I prefer this term to ‘social distancing’)

2.       Masks (any type, ranging from the N95 respirator to a simple home-made face covering)

3.       Hand hygiene

 

Exercise and Immunity:

Regular exercise has been shown to boost immunity. Having a stronger immunity is clearly an asset at a time like this. However, this is not a case of ‘more is always better.’ Research has shown that exercise and immunity have a ‘J-shaped relationship’, which means that the best immunity is attained with moderate levels of exercise. Not exercising at all, and excessive exercise lead to lowered immunity as compared to moderate exercise. Do keep in mind, that the terms moderate and excessive are relative. If you have been exercising, prior to the start of the lockdown, please continue to do so at your usual levels, but do not increase it dramatically. If you haven’t been exercising it might be a good time to start a moderate program, such as brisk walking or cycling.

 

 Exercise and Masks:

When exercising indoors, in your own home, you certainly do not need to wear a mask. The recommendations will be focussed on outdoor exercise. In general, the risk of viral transmission is significantly lower outdoors, than indoors, which is a great advantage to start with. But do keep in mind when exercising outdoors, especially at higher intensities, the risk of aerosols and droplets (which contain the virus) travelling further due to heavy breathing, or the wind is theoretically much higher, than when a person is standing still.

 

Intensity matters:

For most people, wearing a mask is uncomfortable at first, especially during exercise. But like with most things, with a bit of practice one gets used to it. While doing low or moderate intensity exercise, such as brisk walking, wearing a mask should not be uncomfortable, but when you start increasing the intensity, the degree of discomfort might increase. When exercising with a mask, your perception of effort tends to increase, which means you might need to reduce your intensity to feel the same level of effort you feel, without a mask.

 

Distance matters, even more:

If you are lucky enough to stay in an area where you can exercise outdoors, with no one around you, then it would be fine to exercise without a mask. Most guidelines recommend you stay 6 feet away from those around you (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html). However, during exercise, I would suggest increasing that distance, since, as explained above, the droplets may travel further. There is no specific cut-off that has been scientifically proven, but out of abundant caution, I would recommend trying to maintain a distance of 20 feet. Now, I know that’s not possible for most people living in crowded cities, so here is my practical suggestion. Try and exercise using routes, and timings, such that you come across the least number of people. Have your mask around your neck, or ears, and lower it when no one is around you. When passing through an area, where you cannot maintain the required distance, raise the mask and cover your nose and mouth. You can lower it again, when clear of people.

 

What about carbon dioxide poisoning?

There have been reports in the social media, from various parts of the world regarding people collapsing due to exercising with face masks, and blaming it on carbon dioxide poisoning due to ‘rebreathing’ the air. There is no scientific evidence to support this. Masks are designed to allow the flow of air in both directions. Surgeons and other healthcare workers, have been wearing masks since decades, without any ill effects. Yes, sometimes one does feel a sense of suffocation if not used to it- in that case, it’s fine to simply uncover your face and mouth for a few breaths, till you feel better. Here are links to two good articles on the subject.(https://www.forbes.com/sites/marshallshepherd/2020/07/01/debunking-2-myths-toxic-coronavirus-masks-and-breathing-warms-the-climate/#3b2d907a30f4; 

https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/debunked-myths-about-face-masks)

One word of caution here – those with pre-existing respiratory and cardiac conditions may feel a greater subjective sense of discomfort, with a mask and need to adjust their activity accordingly. Actually, this can apply to others, too. If you are feeling uncomfortable exercising with a mask, reduce your exercise intensity and see how it feels. If you feel better, that’s great, if not, stop exercising and have a word with your doctor.

 

Take-home messages:

1.       Masks, physical distancing and hand hygiene are proven strategies to prevent the spread of coronavirus.

2.       Exercise improves your immunity, for which moderate-intensity exercise is best.

3.       When exercising outdoors, if you are able to maintain a 20 foot distance from others, it would be fine to let your mask (guard) down. When unable to maintain the distance, put it back on.

4.       Exercising with a mask, may lead to a greater subjective perception of effort, so you may need to reduce your exercise intensity.

5.       There are no ill effects of wearing a mask. If you feel uncomfortable while exercising with it, or have any serious health conditions, please speak to your doctor.

Can one cigarette a day cause a heart attack or stroke?

Moderation is the key to long-term success, is a line I often use with my patients (and try and apply to my life too). However, there is one area, where moderation does not work, and that's for smoking. Most smokers accept that they have a problem, but are so addicted to the habit that, when I counsel them to quit, they will try and rationalize with me (and themselves) how a cigarette once in a while won’t hurt them. They also try to convince me that since they were smoking 15 cigarettes a day earlier, wouldn’t it be okay if they cut it down to five cigarettes a day. My answer to them is a well-rehearsed one, since I have said it a hundred times. I tell them, it’s like asking me whether it’s better to jump off the fifteenth floor of a building, or jump off the fifth floor! They usually get the message.

Last month, a study was published in the BMJ (British Medical Journal) which underscored this point. (Click here for study abstract). Researchers looked at studies from 1946 to 2015, and found that smoking one cigarette a day was associated with a 48% to 74%  increase in the risk of coronary heart disease (CHD) in men, a 57% to 119% increase in CHD risk for women, and a roughly 30% increase in the risk of stroke for both men and women.

The conclusions of the study, were:

Smoking only about one cigarette per day carries a risk of developing coronary heart disease and stroke much greater than expected: around half that for people who smoke 20 per day. No safe level of smoking exists for cardiovascular disease. Smokers should aim to quit instead of cutting down to significantly reduce their risk of these two common major disorders.

Benefits of quitting:

It’s never too late to quit smoking. It does not matter how long you’ve been smoking, the moment you quit your risk starts dropping. In fact, the benefits start from the minute you extinguish your last cigarette. Within the first hour your heart rate and blood pressure drop and the carbon monoxide level in your blood returns to normal. Over time your risk for heart attack, stroke and cancer starts dropping steadily towards that of a non-smoker. Of course, this information should not be used by you as a license to continue smoking with the thought that you will give it up one day in the future and recover all of your lost health. Remember, once there is build-up of plaque in your arteries, it can lead to a heart attack any time it ruptures. Smoking is one of the key factors that can precipitate plaque rupture, which is why even one cigarette can be harmful in the setting of blockages. It’s similar to standing on the edge of a cliff. Even a slight push may be enough to topple you over; in the same way, one cigarette may be the final straw that broke the camel’s back (no, not the cigarette brand, Camel).

Last para excerpted from my book, The Heart Truth 

HOW TO RUN A MARATHON IN LESS THAN 3 HOURS AND 40 MIN (3:40)

Let me begin with two disclaimers: I ran the 2018 Tata Mumbai Marathon on Jan 21, in 3:40:01, which is 2 seconds above the sub 3:40, in the title. Secondly, the title is worded in this manner, since it’s a ‘search term’, often typed into Google, and allows people to find articles, such as this. By no means, do I purport to be a guru of guiding people below specific timing goals, after having done it only once in my life (thus far…).

In January 2017, I completed the Mumbai Marathon in 3:54 hours, clocking the exact same time as I had done the previous year, and was quite disappointed. By itself the time was respectable, but I wasn’t elated, since my training was in tune with a better run, and I was injury-free. After the ritual download of my Garmin data, I noticed a strange pattern in both runs (2016 and 2017)- there was a dramatic drop in pace, post 32 km (20 miles). It didn’t need me to look at data to figure that out, since I had clearly suffered for the last 10 k on both runs, but what surprised me was the extent of the drop. In both instances, I was cruising along at an average pace of 5:15 min/km, till 32 km and then wham- the pace dropped by more than a minute per km after that. I’m embarrassed to say, that the obvious, didn’t strike me, which is that I’d hit the proverbial wall. It needed my friend Daniel Vaz, who’s an experienced running coach, to point it out to me.

After the 2017 run, I decided to take an off-season from running (which sounds unnecessarily grand, considering I didn’t have too much of a season to begin with), which extended till the end of August. I knew I had 4.5 months before the next marathon, and decided to go in with a better plan than the previous years, which would mostly centre around not bonking (a more colourful term for ‘hitting the wall’), in the last 10 km. I’m not going to bore you with the weekly mileage details, but want to highlight the key points, which I felt worked for me.

Finish line picture- at the 2017 Mumbai Marathon - with my daughter

1.       Make a plan and stick to it

I know that this is stating the obvious, but it shocks me as to how many runners train for the marathon, without a plan. All marathon training plans, should be based on gradual progression of running volume, and should include the following 3 components.

a.       The long run-This is the foundation of the training program, and refers to distances ranging from 12-35 km, in gradual progression and is done at a comfortable pace, which is usually 30-60 seconds slower than race pace. I ran my long runs at 5:45 min/km, since my goal was to complete the marathon sub 3:45, a pace of 5:15 min/km.

b.      Interval training-running distances between 400-1600 m, at close to all-out pace helps increase your VO2 max (your aerobic power), and gets you used to sustaining a fast pace at the end of your long runs, even when the muscles and spirit are flagging. My goal was to run 400 m in 1 min 40 secs, and the longer intervals, at multiples of that.

c.       Easy runs- as the name implies, these are done at a relaxed pace, a couple of times a week, to build mileage in your legs.

In addition to these, there are tempo runs, race pace runs, and fartleks, but the idea is not to get into the nitty-gritty of the plan, but just to outline it.

2.       Nutrition matters

As described above, I have had two experiences, of what I consider ‘hitting the wall’, and they weren’t pleasant. The feeling I had at that time was one where my legs seemed fine, breathing seemed fine, but I just felt that there wasn’t any ‘energy’ in the body to move it forward. That made me go back to the drawing board and look at how much carbohydrate I needed to supplement during the run. Yes, I still use old fashioned carbs, since they are the primary source of energy during running. Over the past few years, theories abound on getting to teach your body to be a better fat oxidizer, since theoretically fat in the form of stored triglycerides is a limitless source of energy. On the other hand, stored glycogen is good for about 2,000 cal worth of exercise, roughly translating to 20 miles or 32 km. The bulk of the data at present, still supports the use of carbs as a ‘performance fuel’, and I’m sticking to it, till there is different evidence.

My strategy consisted of getting in about 45 gm of carbs per hour of running, divided between a sports drink and supplemental carbs in the form of ‘gummy sweets’, since I find the taste of gels hard to handle after the first two. As I approached the 32 km mark, I was psychologically getting prepared to get slammed, but luckily it didn’t happen, and I do believe that the nutrition and fuelling strategy worked.

3.       Think less about your ‘self’….to improve yourself

This is a quote I’ve taken from the book, Peak Performance, by Brad Stulberg and Steve Magness. I read the book after my last marathon and found it full of insight, not only to improve running performance, but also to lead a better life. I highly recommend it to everyone.  Let me explain what this headline meant in relation to my race. My long time running partner, Cyrus Mehta, was on song this year. He needed to run 3:40 to qualify for the Boston marathon, in his age category. Now, for those of you who are running nerds, you’ll know what a big deal a BQ (Boston qualifying) is. For the past few months, I’ve been convinced and trying to convince Cyrus, that this would be a cinch for him this year, given his level of preparation. I was as keen on him getting that time, as I was in getting a 3:45. As usual, Cy took off like a rocket and I didn’t see him till just before the sea link. On the link, I kept looking at my Garmin (well, unfortunately I keep looking at it all the time), and wanted to finish the first half in 1:48, so that Cy had a great springboard to achieve the BQ. The time I had set for myself, was actually 1:50. Cyrus is a much stronger runner than me, so when he overtook me at the 26 km mark, I didn’t make an attempt to keep up. Well, to cut a long story short, thanks to pacing him, I had enough time in the bank to complete it in 3:40, even though my goal was a full five minutes longer.

Post-script: runners tend to be obsessive about their ‘timing’ and I’m no different. I tried to behave myself this year and promised to look down less at my Garmin. And what was the result- I didn’t look at it for the last km, and finished two seconds over a sub-3:40 time. Yes, I know it sounds ridiculous, to even talk about it, considering I bettered my previous best by more than 14 mins, but hey, if you’ve read the whole article thus far, you’re probably in the same category. On that note, I’m signing off. Have a great running year, and wave if we cross paths on the road. 

Last km of this year's run

From L to R - Deepankar,Deepa (podium finisher), myself, Cyrus, Rox the Boss, and Ali

The Medical Profession has Lost its Allure. Yet its ability to touch lives is unmatched.

This is an article I wrote for Outlook Magazine (July 1, 2013) on the medical profession. I have copied it below, and here is the link to the original article:
http://www.outlookindia.com/article.aspx?286234

Lighter Medicine Chests

The medical profession has lost its allure. Yet its ability to touch lives is unmatched.

“My daughter just topped her entrance exams, but thank God, she does not want to be a doctor.” Coming from anyone, this may sound a bit strange, but when it’s spoken by one of the most successful physicians in the city, one really needs to sit up and take notice. When I heard my close friend utter these words over a Sunday evening coffee, my curiosity was aroused. His reasoning was quite simple—he had spent the better part of his life studying medicine, from graduation to post-graduation to super-specialisation, and by the time he was truly ready for practice, he was on the wrong side of forty.

Even then, to be successful was a str­uggle, esp­ecially since he decided to pursue the ethical route. On the other hand, he pointed to our friends who had made their first million before 30, and were in semi-retirement on their 40th birthday, since they pursued a career in fin­­ance. But, I argued, what about all the good you are doing and the gratitude you get from pat­ients? Isn’t that the best benefit of a noble pro­fession? “Nobility does not pay my bills”, was his pat reply.

Around the time I completed my 12th grade, the brightest took up medicine or engineering, irrespective of aptitude. Thankfully, that has cha­nged, and stu­dents have more options. Over time, the glamour and prestige of medicine has diminis­hed; no more is it the automatic cho­ice of top students. Partly, it’s due to the red­­u­ced ava­ilability of ‘merit’ seats in gov­ernment colleges and increasing fees in private institutions. Con­stantly changing policies on the duration of com­pulsory rural service, as well as adm­ission to post-graduate courses, make it even less attractive. Post-graduate courses in spe­­ci­alisations, such as radiology, can cost upwa­rds of one crore rupees, and make sense only to those who have a business in the field or intend turning it into a business (and then we wonder about ethics!).

So, is there a silver lining amidst all this gloom? There certainly is. At the risk of delivering a cliche, I must admit that the look of hope on a pat­ient’s face as you hold their hand, or the joy on a relative’s face when you tell them that their loved one is out of danger, is worth all the money in the world. As doctors, we have the ability to touch people’s lives as no other profession can.If you join medicine for money, then you are in the wrong profession. Before you point to all the doctors that drive BMWs, do remember that those are a minuscule fraction. Medical practice in India is such that 80 per cent of all the work (especially surgeries) is done by 20 per cent of the doctors.  Those few are certainly well off, but the average doctor will earn far less than his com­patriots in other parts of the world, even in relative terms. The reason is that healthcare in India is relatively inexpensive. With changing eco­­nomics, people are comfortable spending Rs 10,000 or more on beauty treatments, but begr­udge a doctor his Rs 1,500 consultation fees.

Of course, all doctors are not angels floating around, waiting to dart down and provide their healing touch. The reality is that malpractice does exist and often medical decisions and opinions are not carried out in the patients’ best inte­rest. However, in spite of all its pitfalls and dubious practices, the medical profession retains a touch of nobility that is worth preserving. Just make sure, you don’t enter it to get that BMW.

RISK OF DEATH DURING MARATHON RUNNING

Legend has is that a Greek soldier by the name of Pheidippides, ran from the plains of Marathon to Athens, to announce that the Greeks had just defeated the Persians, in 490 BC.  The distance he ran was 42.2 kilometers, which has then become the official distance of a ‘marathon’.  Legend also has it that after announcing the victory, he collapsed and died.  2500 years later on February 24, 2013 a brave citizen of Bombay ran the half marathon in Thane, and at the end of the race he proudly collected his medal.  After receiving his coveted prize, like Pheidippides, he too collapsed and died, despite intense efforts to revive him by the doctors present there.

Historians contested this version of Pheidippides, and in fact later discovered that he had run well over 450 km, over a ten day spell and was instrumental in saving the battle for the Greeks.  Unfortunately, for our Bombay Braveheart (I am not naming him, in respect for privacy), and his family his death is undisputed, and I extend my deepest sympathies to his family and friends.

As is to be expected, this running death has created grave concern within the running fraternity of Mumbai, of which I consider myself an integral part (both, as a runner and as the Medical Director of the Standard Chartered Mumbai Marathon).  In the media, and in the running community I have encountered polarized views on the risks of long distance running.  One view is that exercise in general, and running in particular is extremely healthy, and therefore cannot be harmful by any means.  The opposite view is that running is dangerous and if one wants to exercise, nothing beats a leisurely walk.  In my opinion, neither of these views is absolutely true, since this is a complex topic and needs a deeper understanding rather than knee-jerk one-liners.  The purpose of this article is to try and shed some more light on the risk associated with marathon running.

Before we begin, I would like to clarify that this article is not about the benefits and risk of exercise in general.  The health benefits of exercise have been unequivocally established, and these benefits very clearly outweigh the risks.  Also, this article deals with running  half and full marathons, and not distances beyond that.  There is new literature emerging on the cardiovascular effects of ultramarathons, which can be discussed separately.

DEATH DURING LONG DISTANCE RACES: THE NUMBERS

In 2012, a study was published in the New England Journal of Medicine, titled ‘Cardiac Arrest during Long-Distance Running Races’. This looked at the incidence of cardiac arrests in marathon and half-marathon races in the United States from 2000 to 2010, and included 10.9 million runners.  In that entire period there were 59 sudden cardiac arrests, of which 42 were fatal.

Sudden cardiac arrest occurs when the heart suddenly and unexpectedly stops beating. When this happens, blood flow to the brain and other vital organs stops, and can lead to death if not treated within minutes.  In fact, this year at the SCMM marathon we had a sudden cardiac arrest, and due to a combination of luck and medical preparedness we were able to save the runner (for more on that, read here: http://drcontractor.blogspot.in/2013/01/a-miracle-on-race-day.html).

The following is the information we learned from the Cardiac Arrest study:

1. Cardiovascular disease accounted for the majority of these cardiac arrests and deaths
2. The incidence of arrests was significantly higher during full-marathons than half-marathons, and was higher among men than women
3. The incidence rate of cardiac arrest during half and full marathons was 1 per 184,00 runners
4. The incidence rate of death during half and full marathons was 1 per 259,000 runners
5. The commonest cause of death was hypertrophic cardiomyopathy

According to official figures, about 10 deaths take place on the Mumbai suburban railway network each day, and approximately 7 million commuters travel each day. This translates into 1 death per 700,000 commuters. In other words, the risk of dying during marathon running is a little more than double that of taking a ride on the Mumbai local trains!  I know this is not a fair or scientific comparison, and I do not mean to trivialize even a single death, but the idea is to put the risk in perspective, which in absolute terms is very low.

 

WHAT CAUSES THESE ARRESTS AND DEATHS?

The two most common causes of death found during this study, as well as others looking at exercise and acute cardiovascular events were:

1. Hypertrophic cardiomyopathy
2. Atherosclerotic coronary artery diseases (blockages in the arteries)

Hypertrophic cardiomyopathy (HCM) has been defined as a primary disease of the myocardium (the muscle of the heart) in which a portion of the myocardium is hypertrophied (thickened) without any obvious cause (source: Wikipedia).

It has been well established that among young individuals, less than 30 years of age, HCM and other birth related (congenital) abnormalities are the main cause of cardiovascular events.

It was also thought that in athletes over the age of 30, atherosclerotic coronary artery disease (which is just the scientific way of saying ‘blockages in the heart arteries’) is the most frequent cause of cardiac arrest and death.  Vigorous exertion was thought to lead to rupture of the blockage, leading to clot formation, which leads to an abnormal heart rhythm knows as ventricular fibrillation and ultimately death.

The surprising finding in the New England study was that HCM was also the leading cause of death in the population studied during the ten years of marathon running, including the older runners.  Several of the deaths were due to a combination of HCM and blockages in the arteries.

OTHER CAUSES OF DEATH:

Besides the cardiovascular causes, hyponatremia (low sodium level in the blood), and hyperthermia accounted for a total of about 10 percent of the deaths.  These remain important concerns during long distance running but are not common causes of death.

WHAT CAN BE DONE TO REDUCE RISK?

This is clearly the most important question at the end of it all.  In my opinion, risk can be reduced by taking care of the following:

1. Pre-participation health check
2. Paying heed to warning signs
3. Sensible and appropriate training programs
4. Medical facilities available during races

Pre-Participation health check:

Before you read any further, it is important to acknowledge that the human body is an extremely complex organism.  There is no definite testing protocol which can completely rule out risk, which is why you occasionally have the scenario of someone suffering an attack, even though they recently passed their medical evaluation with flying colours. Having said that, these are the tests I recommend, and the reason for each:

1. ECG: this is certainly not a perfect test, but is a great starting point to give a basic indication of your heart function. It’s a great test to pick up HCM
2. Fasting sugar, lipid profile, blood pressure, body mass index and weight circumference: all of these will give an indication of your ‘cardiac risk profile’.
3. Stress test: one can debate the necessity of a stress test, but I would recommend it for two reasons.  It’s a great indicator of your cardiovascular fitness, if nothing else and may indicate the presence of blockages in your arteries.  One can criticize it for two reasons too: blockages show up on the stress test only when they reach a certain size and are ‘obstructive’ to the flow of blood. Often, there are smaller plaques which are the ones that actually rupture and cause the attack. Also, stress tests often show up ‘false positive’ tests, wherein no abnormality exists even though the test is abnormal (for some strange reason, doctors call it ‘positive’ when it is abnormal).  Let the physician conducting the test know that you are a marathon runner and to allow you to carry out the test till you reach maximal fatigue.
4. 2 D- echo: this is a great test to assess  heart valve functioning, and the pumping capacity of your heart muscles. It’s also a great test to rule out HCM. It is relatively expensive, and if you are younger and asymptomatic I guess it would be fine to just do a simple ECG.

The most important part of the evaluation is to consult with a physician who ‘understands’ exercise and the kind of program you hope to embark upon.  In addition to the above tests, your medical and family history is vital.  Data from individual tests do not have as much meaning as the combined risk profile.

Warning Signs:

Several studies have shown that individuals who experienced cardiac events during exercise, often had mild warning signs and symptoms, which they or their physician chose to ignore.  The most common of these, which occurred a week before their arrest were (as reported by friends and families):

1. Chest pain
2. Increasing fatigue
3. Indigestion / heartburn /gastrointestinal symptoms
4. Excessive breathlessness
5. Ear or neck pain

Appropriate training programs:

All exercise programs should be progressed gradually.  Most arrests and deaths occur in individuals who participate without adequate preparation or those who ramp up their training exponentially.  At the end of vigorous physical exertion it is important to cool down appropriately (something which most of us, including myself do not do), since reduced blood supply to the heart may be exacerbated by abrupt cessation of activity.  This is the reason that runners often collapse immediately after finishing an intense race.

Medical facilities on race day:

It goes without saying that adequate medical facilities should be available during long distance runs, especially those exceeding 10 km.  In addition to medical facilities, I personally feel that every runner should take it upon himself or herself to learn the technique of CPR (cardiopulmonary resuscitation). In the event of a cardiac arrest, good CPR can be life-saving.

TAKE-HOME MESSAGE:

Long distance running can be a safe and enjoyable sport with considerable health benefits.  There is a small amount of risk involved which can be kept to a  minimum by making sure you undergo a ‘running-specific’ health check, train sensibly and pay heed to warning signs and symptoms should they occur.

References:

1. Cardiac Arrest Duing Long-distance Running Races. Kim et al, NEJM 2012;366:130-140

2. Exercise and Acute Cardiovascular Events: American Heart Association Scientific Statement: Circulation 2007;115:2358-2368