Grave Concerns

Most days, on my noontime run, I don't worry about dying.

Sure, my HDL ("good" cholesterol), which should be well over 50, is down in the basement (mid-30s), next to the late Tim Russert's. And my grandfather had his first heart attack in his 50s. And some people consider me a Type A personality. And I'm at an age, 62, where I've got decidedly fewer birthdays ahead of me than behind.

But my daily run offers so many pleasant distractions. I can check out my neighbors' gardens. Work through personal problems, consider a marathon, or simply enjoy the satisfaction of another workout in the bank. Running also taps deep into the brain's complex circuits—I never know what's going to pop into my head, the creative or the humdrum. (Notes to self: Start work on new book. Don't forget to pick up laundry.)

Still, a somber thought does intrude from time to time. I might remember the Saturday phone call I got almost 25 years ago. The speaker said he was a reporter for CBS Radio. He wanted a comment about Jim Fixx, whose best-selling 1977 book had done much to popularize running. "No problem," I replied. "He's such a great guy. Smart, humble, and hardworking, and I've never met anyone who appreciates running more than Jim does."

The reporter cut me off. "Maybe you haven't heard," he said. "Fixx passed away yesterday afternoon. He was running down a road in Vermont."

And then there was that tense moment last November when Ryan Hall faced the press after his magnificent victory in the USA Men's Olympic Marathon Trials in Central Park. "This was a dream come true for me, but first I want to offer my thoughts and prayers to Ryan Shay's family," he said. Moments later New York Road Runners CEO Mary Wittenberg stepped to the microphone, her face pale: "We have absolutely tragic news—Ryan Shay passed away this morning." Shay, just 28, was the first world-class marathoner to die from a heart attack while competing.

Last fall was a tough time for those of us who believe running makes us healthier. The day after Shay's death, Matthew Hardy, 50, died of an apparent heart attack an hour or two after finishing the ING New York City Marathon in 4:48:21. A month earlier, Chad Schieber, 35, who'd been diagnosed with a heart defect (mitral-valve prolapse), had died in the unusually hot Chicago Marathon. These stories often get more attention than those of the race winners. And they always raise the question: If running is so damn healthy, why do runners keep dropping dead in their tracks? Statistically speaking, a handful of runners will die in a marathon this year—the vast majority from heart attacks (the others from heatstroke or hyponatremia). Is running—as the alarmists and cynics often suggest—a dangerous activity?

To find out, I visited the world's leading heart and exercise experts, reviewed stacks of medical research about exercise and death risks, and consulted with the statisticians who work in this field. I learned the reassuring truth that running and other vigorous exercise does dramatically lower mortality risks. But I also learned that there are surprising paradoxes, and no guarantees. Every workout is a bit of a crap shoot. Fortunately, if you run smart and fully informed, you should be able to keep going for a long, long time.

Exercise matters

Fitness researcher Steven Blair is a bit of a fuddy-duddy. You notice this right away from the pristine condition of his house and landscaping in Columbia, S.C. When I arrive for a 7 a.m. run in mid-May, Blair is brushing a coat of dust from his porch banisters. Blair strives for order, clarity, and meaning in his life and work, traits that have helped make him arguably the world's leading exercise epidemiologist.

At 69, Blair doesn't look like most of the lifelong runners I know. He's as round as a beach ball, with a trim gray beard. Blair figures he has run 70,000 miles in the last 40 years, including 18 marathons, with a best of 3:28 at Napa Valley. But the miles haven't chased away the weight. He's gained 30 pounds through his midlife years, largely around the waist, and now carries 195 pounds on a 5-feet-5 frame. He knows this is disconcerting to new acquaintances who expect a pencil-thin fitness fanatic. He often describes himself as "short, fat,and bald," in part because he has a self-deprecating sense of humor and in part to emphasize that not everyone is born lean and mean.

Our workout begins with a two-block walk in the leafy Shandon neighborhood where he lives. Then Blair breaks into a smooth jog—about 11 minutes per mile. Every minute or two, he exchanges greetings with another runner, cyclist, or dog-walker. "I do this run most mornings of the week," he says. "I still consider myself a runner,although I'm not sure my neighbors agree. They probably can't tell if I'm running or walking."

Blair, who holds a doctorate in physical education, returned to Columbia two years ago after 22 years at the groundbreaking Cooper Aerobics Center in Dallas,first as a researcher but eventually as CEO. He was the guy who did the work that helped Kenneth H. Cooper spread the word about the health benefits of exercise. Now a professor in the Arnold School of Public Health at the University of South Carolina, Blair continues his research while arguing at every opportunity that America's public health could be improved, and its medical bills reduced, if everyone would just get up and get moving for 30 minutes a day. He's got the studies to prove it, too—hundreds of them. Blair has also held leadership positions on committees of the American Heart Association and the American College of Sports Medicine. "Steve's probably our most famous faculty member," another University of South Carolina professor told me.

An exercise epidemiologist looks for connections between exercise habits and health outcomes, such as heart disease, stroke, diabetes, and high blood pressure. The going is tough, because it's difficult to conduct controlled experiments. People aren't mice; you can't lock them in cages for weeks on end and force them onto an exercise wheel. Most epidemiologists resort to questionnaires to quantify human behavior, a dicey prospect, since most people underestimate how much they eat (Ben & Jerry's—not much!) and overestimate how much they exercise (At least five or six times per week). Yeah, right!

All of Blair's subjects, in contrast, have actually visited the Cooper clinic and taken a treadmill stress test, running to exhaustion. Years and even decades later, the same subjects are polled to determine their health. Some will be fit as a fiddle, some won't. Some will have died. Epidemiologists love dead people. You just can't find a medical condition more clearly defined than death. "I give Ken Cooper a lot of credit," Blair says. "He realized from the very beginning that we had to put our treadmill tests into a database, so we could follow these people and see what happens to them."

Over the last 30 years, more than 80,000 subjects, male and female, have been poked, prodded, and treadmill-tested at the Cooper Center. Every year, Blair and colleagues issue a handful of new reports that slice and dice the data, officially known as the Aerobics Center Longitudinal Study. The results are eye-popping. In general, the most-fit subjects have heart-disease death rates 50 percent lower than the least fit. They're also much less likely to have strokes, or to develop diabetes or high blood pressure.They have a lower incidence of many cancers. And now, in the latest and most startling development, they are showing lower risk for senile dementia and diseases like Alzheimer's.

It's crucial to note that these "most fit" individuals are not super athletes. They're not the winners of the Boston and New York City marathons. Most exercise the equivalent of 15 to 25 miles of running per week at about 10 minutes per mile. Other studies have produced results that reinforce the ACLS research. Exercise doesn't just feel good and provide a mental break from our overstressed lives; it also produces measurable health benefits. "Our data probably show the strongest association between fitness and various health outcomes,"says Blair. "That's because our treadmill tests come closer to the truth about someone's fitness than questionnaire studies."

Blair admits that if he were 30 pounds lighter, he would be healthier and would need fewer meds to control his cholesterol and blood pressure. While he has never had a heart attack, he has had angioplasty and heart-bypass surgery to clear clogged arteries. "I do what I can," he says. "If it weren't for my fitness, I might have needed the surgery 10 years earlier."

Reams of research have shown that excess body fat increases mortality rates, but Blair is banking on his morning runs to protect him. His own findings offer much hope. Evidence from the ACLS indicates that the fit-but-fat are nearly as healthy as the fit-of-normal-weight. In other words, regular exercise offsets many of the dangers of being overweight. For that reason, Blair believes American public-health leaders should stop screeching from the rooftops about obesity and instead switch their message to the benefits of exercise. "When you look at me, you can tell I'm surprised and delighted by the fit-fat finding," says Blair. "But the point is, we're losing the obesity battle. So let's try something else. Let's focus on fitness."

Notwithstanding all the studies, Blair and other fitness proponents realize there are no guarantees. Heart attack rates inevitably climb with increasing age. Exercise is recommended, but it isn't a cure. There are no cures for heart disease. Blair knows he's just one errant heartbeat away from a newspaper headline: "Fitness expert dies on the run." The first sentence of the story almost always includes the word "ironically," as if Blair and friends believe running will help them live forever. They don't. They know the facts: Everyone dies, and some die while running.

I ask Blair why he continues to run almost every day. "It's a habit," he says. "It's one of the most pleasant parts of my day. I've done thousands of runs in different places around the world, and there were only one or two times when I didn't feel better afterward. Running makes me feel good. That's reason enough."

The heart-health connection

In their studies, Steve Blair and all modern exercise epidemiologists have built on the work of Jeremy Morris and Ralph Paffenbarger, the pioneering giants in the field. More recently, Paul Williams has expanded our knowledge of serious exercisers by using Runner's World readers to build his database. Williams's National Runners Health Study was launched in these pages in 1991. While all the studies have reached similar conclusions—regular exercise provides significant health benefits—each has made interesting and unique contributions of its own.

Great Britain's Morris spent the WWII years as an army doctor in India and Burma. His first big exercise study ("Coronary heart disease and the physical activity of work," The Lancet, 1953) investigated the different heart-health outcomes of London transport workers-the bus drivers who sat on their arses all day versus the ticket-takers who walked up 600 stairs a day on London's double-decker buses. Result: The ticket-takers suffered 30 percent fewer heart attacks, and their attacks were less severe.

Later, in his 27-year career as England's director of the Medical Research Council's Social Medicine Unit, Morris realized that physical activity had disappeard from most jobs. Everyone sat at a desk all day long. He decided to begin looking at "leisure-time exercise" and its impact on heart health. He followed 17,000 male civil servants between the ages of 40 and 64, and discovered that those who frequently burned about 450 calories per hour in exercise (roughly equivalent to an easy four-mile run) had only one-third the heart attacks of those who had little or no exercise. He concluded that "vigorous exercise is a natural defense of the body, with a protective effect on the aging heart against ischemia and its consequences." In 1996, Morris received the International Olympic Committee's first award for excellence in sport sciences, an honor he shared with Ralph Paffenbarger.

Paffenbarger grew up in Columbus, Ohio, and received a bachelor's degree from Ohio State before taking a doctorate in public health at Johns Hopkins in 1954. He later taught at Berkeley, Stanford, and Harvard, concentrating on the relationships between exercise and health. In his early work with San Francisco longshoremen, Paffenbarger showed that those with the most arduous jobs, the cargo handlers, had heart-attack death rates significantly lower than those with desk jobs.

In 1960, Paff, as he was widely known, helped create the influential Harvard Alumni Study, which produced and continues to yield valuable information about physical activity and health. Among its most important findings: that student sports participation at the collegiate level yields no long-term health benefits, but adult exercise does. Paff also found that while health benefits begin to slow beyond 1,000 exercise calories burned per week (approximately 10 miles of running), the benefit curve doesn't flatten. You still get more benefit at 20 miles per week and beyond, particularly if you do some harder workouts.

Paff was so impressed by his own findings that, after a previously sedentary life, he took up running in 1967 at age 45. In the next 25 years, he ran 151 marathons and ultras, including 22 Boston Marathons (5:05 his first; 2:44 his best). In 1977, he became, at age 54, the oldest-yet finisher of the Western States 100-miler, in 28:36, persuading Western States organizers to extend the cut-off time to 30 hours. One of the great unsung heroes of the running boom, Paff died on July 9, 2007, at age 84.

Most epidemiologists struggle to find subjects who burn more than 2,000 calories a week in exercise. Paul Williams, Ph.D., has made his mark by exploring the health outcomes of serious runners, some of whom exceed two or three times that amount in their weekly training. From his results, he insists on a simple but important message: More is better.Other exercise epidemiologists don't disagree; they just think Williams is mostly irrelevant, since so few Americans are willing to exercise as much as Runner's World readers. These scientists point out that the biggest public health benefits come from getting more people to simply walk a few miles a week.

This doesn't discourage Williams. In one 1997 study of 8,283 male runners, he compared those running more than 50 miles a week with those running less than 10. The high-mileage guys were 2.5 times as likely to have heart-protective levels of HDL, the "good" cholesterol, and 50 percent less likely to suffer from high blood pressure. Just six months ago in the Journal of Hypertension, Williams updated his information on running mileage and high blood pressure, now using data from more than 24,000 male runners. He looked at runners doing more than 25 miles a week versus those doing less than five. Depending on age, the higher-mileage runners had a 57 to 80 percent lower rate of high blood pressure, a major contributor to disease and death.