by Erin Stokes, ND
“Whatever the event, nutrition plays a major role in the achievement of various factors that will see a runner or walker take the starting line in the best possible form .”
In our holistic practices, we’ll invariably have the opportunity to work with runners, some of whom are high-level, competitive athletes, and others who are recreational runners.
In both cases, there is sound advice we can offer patients that is based on recent research.
Healthy Fat Intake for Runners
The best place to start with supporting runners is without question offering specific nutrition tips. Runners always want to know more about what and when to eat. We all know that you need the right fuel to move efficiently, but what about the relationship between food and injury prevalence? A study in the Journal of the International Society of Sports Nutrition attempted to determine the relationship between dietary fat intake and lower extremity injury in adult female runners. Eighty-six female runners, who were running a minimum of 20 miles per week, completed a food frequency questionnaire. The findings showed that, “Over half the runners in this study sustained a running-related injury in the year following their initial assessment. These injured runners consumed a diet significantly lower in total fat and lower in percentage of total energy from fat.”
In fact, it is now known that not consuming enough fat can have a major impact on runners’ health and performance. Furthermore, a major issue facing many runners today is simply consuming enough caloric energy overall.
Female Athlete Triad
There is a well-documented susceptibility of female athletes, and runners, in particular, to negative health effects of exercise in the face of inadequate nutrition. In this case, female runners chronically under-consuming calories are at considerable risk for multiple issues, including amenorrhea and stress fractures. At one time, this syndrome was thought to be related to a decreased total body fat percentage, but it has now been found to be an issue of inadequate energy intake through the diet. And one that must be corrected for runners to have both health and performance over the long-term.
Known as the “Female Athlete Triad,” it was originally classified as a presentation of combined disordered eating, amenorrhea and osteoporosis. It has since been re-defined in order to help a large number of female athletes who were on the road to major clinical problems.
Since it was found that the recognition of this issue was low by physicians and trainers alike, there has been a new definition put in place since 2007. This new definition not only aimed to create a greater understanding of the issue (only ⅔ of physicians in one study were even familiar with it), but also widened the net to catch the many patients who were slipping through the cracks.
To fix this, the American College of Sports Medicine in 2007 stated the Female Athlete Triad was “a three-disorder spectra involving energy availability (EA), menstrual function, and bone health.” However, it was also noted that not all three criteria needed to be present.
“Sustained low EA associated with the Triad can impair health and wellness, causing medical complications that can impact the skeletal, endocrine, cardiovascular , reproductive, and central nervous systems… ranging from a healthy status to subclinical and clinical endpoints.”
Studies have also found that lack of knowledge regarding inadequate energy intake is widespread throughout athletics, including coaches, trainers and athletes.
Strategies around this issue include making both patients as well as their athletic support teams aware of the problem. If any of these symptoms are present, making sure that energy intake is adequate to meet the demand of athletes, in general, and runners, in particular, is critical. Possible disordered eating patterns should be addressed with proper clinical support when necessary. Failure to address this issue in female runners can lead to lifelong endocrine and bone health issues as well as other health problems.
Discussing Fat Burning, Weight, Performance and Health: Helping Patients Get the Best of Both Worlds
The other question that we get as natural providers with regard to runners is on the flip side of the coin, i.e. “how do I as a patient run to lose weight?” Correct nutritional strategies need to be addressed, as well as the reasons why patients want to lose weight. Is it to look better, feel better, or be healthier? All of these can and should be accomplished, but as we’ve seen, it shouldn’t be one at the expense of the other.
The good news is that recent research has shone a light on strategies to help such patients lose weight and improve performance while running, which, at the same time, minimize the strains involved in excess training. The key is to avoid what has now been described as “the black hole” of training. For most recreational runners, and even a majority of competitive athletes, a run consists of a set time period that is filled mainly with higher intensity running. Not an all-out sprint, but enough to feel like we are really working hard and getting our heart rate up.
However, recent research by exercise physiologist Stephen Seiler and colleagues has shown that that is not the best approach. What they found was that running at a rate slightly below maximal effort, the pace that happens to be used by most runners, was an inefficient and possibly harmful strategy.
Dr. Seiler was recently featured in a piece for the lay public in Outside magazine explaining it this way:
“‘The ‘black hole’ is Seiler’s term for a nightmare training zone that can be hard to resist—an enjoyable, moderately taxing workout intensity that falls somewhere between a piece-of-cake recovery pace and a hellishly intense interval session. It’s vigorous but not aerobically painful—which is why so many athletes are sucked into its vortex.” 
Dr. Seiler discovered this concept by looking at elite athletes, so many of whom had structured their training as a mix of slow, low intensity efforts combined with a few bouts of very high-intensity work. To see why this approach seemed to work better, he set up a study comparing this type of running workout strategy to the more common type of efforts, where most training days are filled with moderately high-intensity running.
It turns out his original observations about the training strategies of elite athletes was a good hunch. The group of runners who spent five months training in primarily low-intensity efforts outperformed the higher intensity group, as long as the low-intensity group had just enough high-intensity work sprinkled into the mix.
And while all of this research has been coming out only in the last ten years, there are theories as to why this is the case. Among the reasons for this effect are that athletes may have better recovery by avoiding excess moderate- to high-intensity running, improved form through lower intensity efforts, and potentially better metabolic effects by staying well under the lactic acid threshold.
That’s right, lower intensity efforts are better at burning fat relative to carbohydrate. At highest-intensity efforts, fuel is shifted to carbohydrate sources. And it just so happens that the “black hole” of training, where we feel like we are putting in a really good effort for our run, is just underneath the lactic acid threshold, where carbohydrate metabolism takes over as a predominant fuel source.
So, if patients really want to feel better, look better, and get the best results out of their runs this summer, make sure they get both their training and nutrition sorted out. Many of the regular runners that we see in our practices are the “type A” achiever types, who will be as strict as possible in every avenue to get the results they want. Clinicians can help by directing these patients to slow down in every aspect and focus on achieving their goals the right way.
This includes eating a balanced diet with enough healthy fats, carbohydrates and proteins to support their bodies through their training. Also, advise them to focus their workouts on a mix of good, high-intensity efforts with a lot of high-quality movement as a running base. And, in keeping with our creed as doctors to first do no harm, make sure that runners aren’t creating health issues for themselves as they look to improve their health and performance.
 Kristen E Gerlach, Harold W Burton, Joan M Dorn, John J Leddy and Peter J Horvath. Fat intake and injury in female runners. Journal of the International Society of Sports Nutrition. 2008 5:1
 Curry EM et al. Female Athlete Triad Awareness Among Multispecialty Physicians Sports Med Open. 2015; 1(1): 38.