Sports Essentials | How To Avoid ‘Bonking’ During a Marathon with Jennifer Smith, DPT

Podcast Transcript

John Horton:

Welcome to Sports Essentials, the athletic cousin of our popular Health Essentials Podcast. I'm John Horton, your co-host with Dr. Lauren Wichman.

How's it going today, doc?

Dr. Lauren Wichman:

John, it is fantastic, as always, to see you, and I am so excited for the conversation we have ahead of us.

John Horton:

Oh, and I am, too, because we are hitting a topic that I absolutely love chatting about as a runner. And it's the whole concept of bonking. And I know it's kind of a fun-sounding word, but anybody who's experienced it and kind of run headfirst into that wall knows it is not a fun place to be.

Dr. Lauren Wichman:

Absolutely. And I think I'm excited to not only dive into a little bit about what is it, but how can we help our listeners not hit the wall, get through their marathons performing at the best possible level that they want to and achieve those goals without hitting the wall.

John Horton:

And that's for any endurance thing. I know we're kind of focused on running, but it involves cycling. It involves ... you're in some soccer game that goes into multiple overtimes or something like that. It's something that affects anyone doing athletics.

Dr. Lauren Wichman:

Absolutely. I think making sure that any sport that's going to go … approach that one-and-a-half- to two-hour mark, which is a long competition or a practice, we need to make sure that we're doing all the right things because anybody can face this challenge here.

John Horton:

Well, and we have somebody with us today who really knows what they're talking about with it. So Dr. Wichman, I know you know her personally, so I'll let you do the introduction.

Dr. Lauren Wichman:

Jenny Smith is a fantastic resource for our patients here at Cleveland Clinic. She not only is an awesome runner herself, but she is a physical therapist here who has a special interest in runners. And I send so many of my patients who have an interest in running, I send them her way. So she can take a look at running forms. She can take a look at ways that we can prevent injury. And then, that has the added benefit of being able to talk through different race tips that she'll share with us today with those patients.

John Horton:

Dr. Wichman, I can't wait to hear these tips from Dr. Smith. So let's get to that starting line.

Dr. Lauren Wichman:

Let's do it.

John Horton:

Nice to see you again, Dr. Smith. Thanks for slowing down long enough to come in and chat with us.

Dr. Jenny Smith:

No problem. I'm happy to be here, and I'm excited to talk about this topic today.

John Horton:

We are, too. I've had this circled on the calendar for a long time.

Now, before we get started, Dr. Smith, I know you're a pretty accomplished runner. Congrats again on your Boston Marathon finish.

Dr. Jenny Smith:

Thank you.

John Horton:

But that being said, it sounds like you are also no stranger to hitting that proverbial wall that can pop up during any race or long run. If you're a runner, I know we all love sharing our war stories and the tales of misery. So if you can, tell us a little bit about your collision with that wall.

Dr. Jenny Smith:

Sure. I'm going to set the stage. This was my first marathon that I've ever done. Leading up to the marathon, I thought I was fueling appropriately, but I definitely now do twice as much fueling that I did that day. I did about a 20-miler in training. And literally like clockwork, I got to the 20-mile mark in my marathon, and I look over, my family's there, they're cheering me on, and I literally cannot go on any further. My legs are heavy. I start to feel that just huge amount of fatigue. And this is embarrassing to say, I remember yelling out to my brother saying, "Please run with me. I can't do this anymore." And sure enough, he jogged a couple miles, but the rest of those six miles were just slogging through, trying to kind of just put one foot over the other until I got to the finish line. And so I remember thinking to myself, "I want to do another marathon, but I don't want to do another marathon like that."

John Horton:

That is why you're here today because we don't want anybody to have to do a marathon like that. And we're going to kind of talk through some of the things that kind of happen when you bonk, why you bonk and better yet, how you can avoid it.

So I guess to get things going, we should define what “bonking” is, other than a really funny-sounding word.

Dr. Jenny Smith:

Yeah. I would say bonking is pretty synonymous in terms of runners with hitting that wall. It's the point of the race where you can almost think about your body is a car and the gas and fuel tank is on empty. So you are depleted of your fuel source. And for us, and as humans, it's glycogen. So we've either not fueled appropriately, didn't fuel during the race as we should have or started off way too fast to the point where our body couldn't keep up with what we were demanding it to do. So in kind of one word, it's depletion — depletion of energy, depletion of fuel and getting to that point where you are on empty.

John Horton:

Right. And glycogen, just throwing it out there, glycogen are kind of those little energy stores that you kind of have in your body for when you're going to ask a lot of it, correct?

Dr. Jenny Smith:

Mm-hmm. Yeah. Glycogen is that storage form of our carbohydrates that we take. We ingest it into our body, and then it gets stored as glycogen, and mostly in our muscles, but also in our liver. So that's kind of how we fuel up those areas before we go out and compete and race.

Dr. Lauren Wichman:

And if either of you are fans of one of my favorite TV shows, “Parks and Recreation,” I literally think of Andy Dwyer where he is like, "Did you know that the food you eat is energy?" And then he's karate chopping in the air and is like, "Look, that's spaghetti." I think in a sense, that is actually the case.

Dr. Jenny Smith:

Yes. Yeah. And it's simple. We overthink what we're eating. And in terms of carbs, it's sugar, sugar that we ... I mean, this is for some people before a race, this is their kind of cheat to eat whatever they want in the form of carbohydrates, to some extent, and to not feel bad about it because it's going to help them in the end.

John Horton:

Well, and I guess the main thing to kind of get into here is that you can do that storage and you have all this energy built up in you, but our bodies aren't necessarily built to just run 26.2 at a moment's notice. So when you're out there doing it, you run the risk of kind of running out of fuel unless you do certain things.

And before we get into all that, just want to get into a little bit, when you do bonk, let's go over some of the symptoms that kind of set in — how you're going to feel, what's going to happen. I know I've never done a full marathon like you, Dr. Smith. I've done halves. And I got to tell you, I have had that swimmy-headed feeling where you just feel like stuff's starting to leave you. So I don't know, maybe Dr. Smith, Dr. Wichman, walk us through a little bit as to what we're going to feel and how it's going to show up.

Dr. Jenny Smith:

Sure. And I think the big thing here is, it varies from one person to another. And in addition to glycogen, our body also needs sodium and electrolytes and water and hydration. So there's multiple things on top of the glycogen that our body also uses for performance. So if some of those other things are running on empty, we might even experience a little bit different variety of symptoms.

But in general, I mean, you're looking at ... for me in my marathon, I had the hydration, I had the electrolytes. So my muscles weren't necessarily cramping, but they just felt like there were rocks on top of them. So it was that fatigue. And then what happens, the negative thoughts come into your system. So once your physical fatigue sets in, mental fatigue, emotional fatigue, you start thinking and, "Why did I do this? Why did I do this to myself, my body?" And it just becomes a vicious cycle.

On the flip side, though, if you're struggling with not only the fuel source, but you're also dehydrated and maybe you're going through hyponatremia — so the lowering of sodium in our body — you might have more kind of severe symptoms with the dehydration. So the dizziness, sometimes the loss of coordination, you feel like you can't go on. And that's why I would say it's really important with this podcast to bring up, there are some times that you should not push through that bonk or push through the wall, and then other times where you can. So it really depends on how severe your symptoms are and when it's something that you need to head to the medical tent and when you can kind of push through, which is a slippery slope. It's hard to know, and it's not a fine line either.

Dr. Lauren Wichman:

And I think, too, a couple thoughts that I have being on this podcast today, and in this conversation with two experienced runners like yourself, where I have not run a formal half-marathon or a marathon myself, but we take care of a lot of athletes that do love to be able to run these races, but also, too, we think about how these symptoms can kick in anywhere from when you've been pushing it to the limit from that 90- to 120-minute range. And the number of people where, if you have a soccer game that goes into overtime, you're hitting that mark. If you have those sprints that you've got to do and keep showing up on that line at the end of a two-day practice, bonking, I think, can happen, and hitting that wall can happen in multiple different sports. So this is very, very relevant conversation for so many people.

John Horton:

And Dr. Wichman, what are some of the things that we see? I know we've kind of mentioned just that mental fog that you get. What other symptoms are we going to start having when all those lights on the dashboard start going off for us?

Dr. Lauren Wichman:

Absolutely. I think you think about the mental and then the physical. So just like Dr. Smith was saying, whether it's extreme muscle fatigue, little bit of lightheadedness, dizziness, not feeling as sharp, you'll see it not only in that physical performance that may start to dip, but then also that mental performance, some of the decision-making on making a pass or not to anywhere from mentally being able to stay strong, like Dr. Smith was saying, and finish the race in front of you.

John Horton:

And obviously, I love how you mentioned this affects anybody doing athletic activity for a long time, any endurance sort of activity, this kind of comes into play. We're kind of focused on running today, and that's kind of where it's most talked about. So that's kind of why our focus is there.

Dr. Lauren Wichman:

Definitely.

John Horton:

Dr. Smith, when we were talking ahead of this, you told us, you shared one figure that just kind of blew me away, and it really kind of emphasized how important this is to talk about and kind of learn from each other so we can avoid bonking. And it's the number of marathon runners who actually hit that wall during a race. I don't want to steal your thunder, so drop that number on us.

Dr. Jenny Smith:

Yeah, sure. In a lot of the literature, when they talk about bonking, it's 2 in 5 runners will experience bonking or hitting the wall during a marathon. And what's interesting is, with some of this literature, when they go into the characteristics of the runner, they're finding out that it's much more common in our novice or inexperienced runners, or for me, as an example, my first time running a marathon. It's also a little bit more common in our recreational runners compared to our elites, just because you're going to be out on the course for a longer period of time, and that nutrition and getting that fueling and that mental capability in check as you go through is so important.

But yeah, 2 in 5, when we think about that, is a lot of the numbers of people that are stepping on that starting line for the marathon. So if we can prepare individuals for hitting that wall, and trying to at least kind of completely get through a marathon without hitting that wall, it's going to be so much better than you hit the wall in the race and now you have to try to pick up the pieces, get your fuel, slow down and do all of kind of the real-time management of it.

So I think if anything, out of this podcast, I want to try to give those tips of how we can avoid hitting that wall because it's just so much easier to prevent it than to have to accept it and then try to push through when you're in it. And from my own personal experience, no one wants to be in the wall, no one wants to be in it.

John Horton:

No. I think anyone who's been there knows that. So let's see what we can do to kind of cut down the crowd that's in the pain cave there.

Dr. Jenny Smith:

Sure.

John Horton:

So bonking avoidance, I guess, when we start talking about this, the work that goes into that starts way before you get to the finish line. So let's start on training and how we need to start the process there to have a really good race day.

Dr. Jenny Smith:

Sure. When I'm talking to a lot of my patients about preparation before a marathon, one of the most important things is not only preparing your muscles for the demand of that race, but almost preparing your gut for the fueling that you're going to need for the preparation of the carb-loading and the fueling on race day as well. So it's a combination piece of making sure that you're doing your long runs that are part of your training plan. For some individuals that I see that are injured, they never even thought about following a training plan. They just started running, and then they started increasing their mileage. And Dr. Wichman can probably agree, for my runners that come in, usually it's a load management issue that's caused their injury, or training just in a way that hasn't steadily built up what their muscle and cardiovascular system capabilities are.

So I would say, No. 1 is finding a training plan where you're going to be able to get by the end of it, a pace idea of where you want to start that race, because pacing and burning yourself out at the beginning, like so many runners do, is going to contribute to that wall.

John Horton:

[inaudible], yeah.

Dr. Jenny Smith:

Yes, yes. So I would say with training, it would include ... when I talk to people about their training — and it is quite variable because some people are everyday runners, some people like to run three times a week, but you want to get a long run in that steadily increases throughout your running. And even with that, sometimes when I have more experienced runners, I talk about, "Have you done some of those marathon pace miles?" So running that long run and several of those miles, you try out what your marathon pace would be like so that in the race, you know that that's something that you've already conquered. Mentally, you've been able to maintain it. And physically, you've been able to maintain it.

And then with those long runs, just like any type of training, like Dr. Wichman had said, we have to fuel, we have to recover from our training, and we need to make sure that our strategies for recovery are set, like sleeping, stress management, making sure — and I always talk to my runners, "Hey, did you fuel during your long run? Did you make sure that you were trying some of those gels that you're planning to do on marathon day in the long run?" And I know for myself, sometimes gels are expensive. So I feel like I kind of am a little bit cheap when I'm like, "Oh, I took one maybe every 45 minutes," even though, in race day, I'm taking it 25 to 30 minutes. So it's really important, if we can, to prepare not only how we run, how we train, but also how we fuel and recover at that same time.

Dr. Lauren Wichman:

And I say, too, I think you hit on so many different great points there, Jenny, that I think we'll be able to dive into and make sure that we hit. And I think one that I wanted to make sure that we emphasize was the difference between not only just distance, because I think people a lot of times think, "Oh, I have to make sure I can just run to that distance," but also practicing the pace in which you're going to do it.

And then the other piece that I think of, too, and I'd love to get your perspective on, would be, obviously, running becomes a big part of our training, but what about the cross-training piece, the strength training piece? Tapping into your expertise as a PT here I think would be super beneficial to hear about.

Dr. Jenny Smith:

Sure. I would say if there's one thing that I want every runner to do, it would be to strength train.

John Horton:

Everybody's just out there pounding out miles and not hitting the weights.

Dr. Jenny Smith:

Yes, yes. And there are very few professional athletes that can get away with it. But for every mere mortal runner that's out there, if we want a performance cheat code and a way that we can kind of run a little bit less mileage and have a little bit less injury, injury capabilities, we want to make sure that we're strength training — specifically the muscles that we're using with running. So that's something where a runner will come in and I'll ask them what they're doing for their cross-training, and a lot of times, they'll say, "Well, I have the outdoor sidewalk I'm running." That's what they do. There's nothing else that they do, and they wonder why they're injured. If I could have everyone strength trained twice a week — and I don't mean strength training the upper body because I'll also have patients that come in and they're like, "I do strength training. I do my biceps, my triceps, my chest press."

John Horton:

You got to look good in that tank top.

Dr. Jenny Smith:

They say, "Running is my strength training for my legs." And that's completely false. Your strength training for your legs is building up your calves' endurance and capabilities, your glutes, your quads, your hamstrings. I think that's something that's such a missing piece for just the everyday runner.

I think it's improving, and now more than ever, since I've been working with runners for over a decade, people are coming in and they're saying, "I've done a little bit more strength training." But it's a great way to challenge your cardiovascular system in a little bit different way to build up your power.

And in general, from a bone health standpoint, our bones get bored with just the same direction loading. We don't build up as much, and especially for our female runners, as much of that bone density that we can get from heavy strength training. So for a multitude of reasons, you can do so many different ways of cross-training, but if there's at least one that people add in, it would be strength work.

John Horton:

So Dr. Smith, if you do that, if you focus on building up some of those other muscles, the non-running muscles that are just around there, will that kind of have a ripple effect and help you then on race day to maybe help you get through that wall and get past a little bit, just because you're kind of strengthening your entire system and it all kind of works together to kind of push you to the finish line?

Dr. Jenny Smith:

Definitely, definitely. And for not only the physical piece, but also for the mental piece. I know I'm not someone that loves getting into the gym and doing some weighted squats and stuff like that. I like it more than I used to, but it's something that because of the, "Oh, I'm pushing this in a different way," then when I'm racing, I'm like, "Oh, I've done 10 harder things than this little couple steps that I just took." It's the same thing as with this strength training or cross-training or even the variety of different training runs that you can do that are going to be pushing your intensity or your power in different ways, variety is good. Variety is very good. If there's another take-home message, is, you want to be exercising with a variety even if you love to run. You can still put that in there.

Dr. Lauren Wichman:

And what I tell people, too, a lot of times is, resistance training improves muscle strength, and that muscle strength is going to improve your running form, that running form, improvements in the running form, improve the running economy, which then uses less of that glycogen, which, as we were talking about before, we want to try to conserve to make sure that we have enough to get through the wall so then we don't ever hit it. And so strength training can be a big part of that.

John Horton:

Let me ask you this. As we talk about strength training, if you run, we all become addicted to the miles. We have our little watches, we keep track of it. So you want to hit your 30-mile week, your 50-mile week. I've run with a lot of people who do 100 miles a week. In your opinion, I guess, would you sometimes be better off to let some of those miles go and just get a good strength training workout in?

Dr. Jenny Smith:

100%. And I've told patients this as well where they ... I feel like especially with marathoners, and I can say this because I'm one of them, we're very type A personality where we want to — it's almost like that checklist. You want to check the box that you hit what you were supposed to do.

John Horton:

…yep, goals for the month, goals for the week, all that.

Dr. Jenny Smith:

Yes, goals for the months. So it's really hard to let some of those miles go. So what I've talked to patients about, and I've really finally started listening to my own advice, which is, hey, if I can choose, if I've got 20 minutes and I'm either going to go for maybe a couple more miles or if I'm going to go in and get my strength training done, I have to pick the strength training because that's what's going to give me more bang for my buck in that shortened amount of time.

John Horton:

Everyone's going to hear that, "Hit the snooze button," Dr. Smith's advice.

Dr. Jenny Smith:

To a certain extent. To a certain extent.

Dr. Lauren Wichman:

One of my research collaborators, Stacy Sims, she is a huge advocate in resistance training for women, and she actually recommends that you call your resistance training time ... she's like, "Schedule it as a meeting. Because we tend to not break meetings. But if it's an extracurricular, you might push it off, you might push it off. This is important. This needs to be designated a meeting."

Dr. Jenny Smith:

Yes. No, that's fantastic. Because a lot of times, we're talking about maybe 20- to 30-minute segments that you have of time within your day that you just have to do it, and it's just-

Dr. Lauren Wichman:

You can make a difference.

Dr. Jenny Smith:

Yeah. I make my kids breakfast. They're kind of doing something. I'm like, "Mommy's going downstairs and just lifting with her hex bar, OK? I'll check in and see how you guys are doing." You just make the time. And when you make the time, it happens.

John Horton:

So obviously, strength training is important. But if you're running a marathon, you're going to have to get a couple miles in here and there. It is part of the plan. So Dr. Smith, walk us through what do those long runs do? And how are they going to, I guess, help you not bonk on race day?

Dr. Jenny Smith:

Sure. The long run helps you in a multitude of ways. Number one, it allows you to practice maybe the routine that you might need to do for race day. So for that maybe last long run that someone does, I have them use their race shoes if they can. I have them use their race clothing just so they feel really comfortable with it. I have them try to set out and do the race fuel. It's like their dress rehearsal for the run. So beyond kind of the cardiovascular benefit, because, again, training over those ... usually most marathon training plans are about 16 to 20 weeks. You're building up your aerobic capacity, and it allows you to kind of be able to utilize that glycogen a little bit more efficiently as you get these long runs in and build them up. But at the same time, then you've got the confidence of the dress rehearsal, of making sure that everything that you've done during that long run can be the same way that you do it during race day.

John Horton:

Are you training your body to, I guess, parse out that glycogen a little bit slower or just make more efficient use of it?

Dr. Jenny Smith:

I think Dr. Wichman can probably kind of even give a little bit more of an in-depth answer here, but I would say it would be more of the efficiency piece of how our muscle stores are able to utilize it in a quicker manner and then bring more into work. So I don't know, what else would you add to it?

Dr. Lauren Wichman:

No, totally. I think it's all part of that thinking about VO2 max and lactate threshold and kind of working on maximizing some of those numbers. It's more so working on our training there, which ultimately if we can optimize that, then that helps to perfect in a way that use of the glycogen, for sure.

John Horton:

We'll have to come back and have a whole VO2 max conversation. So I got to say, I have nerded out over that. And it's like, it's fun to watch.

Dr. Jenny Smith:

Yeah, that's where, in addition to ... I've had a whole slew of athletes where we talk about threshold workouts and how the threshold is the way … it's the point at which our lactate is at that fine point of where our body can't get rid of it as much as the accumulation happens. So that's kind of the sweet spot. But you can only do it for so many miles of the workout for the week because your body also needs that long-duration run. So to your point, in terms of the long run, the long run can be utilized for a couple different ways. If it's more of that easy long run, that's where you're going to just get that aerobic capability of, one, going the distance, getting your glycogen stores ready for the long distance. But when we talk about VO2 max and threshold and more of those interval or tempo workouts, those are also important because that's going to help with the efficiency of the system, because it's going to put more stress on our system of how we have to utilize that glycogen. So having that happy medium of both is really good.

John Horton:

So we've covered kind of get the strength training in, which most runners don't think about. So emphasize the importance of that, your long runs. And I think with long runs then, we kind of get into the whole notion of planning out your route to race day...

John Horton:

So we've covered kind of get the strength training in, which most runners don't think about. So emphasize the importance of that, your long runs. And I think with long runs then, we kind of get into the whole notion of planning out your route to race day. And it sounds like there's a lot of importance in that. And Dr. Wichman, I'm guessing we're talking runners here, but I'm thinking for any athlete, there's a certain amount of, you got to put the prep in, you got to know exactly what you're training for to make sure your body is ready for what you're going to ask of it.

Dr. Lauren Wichman:

Absolutely. I think understanding a little bit about the course that you're about to run or the conditions that you may face can really prepare what your prep is going to look like, but then also what the experience is going to look like on that day. A lot of times, we'll have people, we'll recommend, "Make sure that you familiarize yourself with the course. Know, OK, what are the hills on this course look like? How much of that training do we need to make sure that you include in your prep?"

John Horton:

Dr. Smith, I'm pretty sure you knew Heartbreak Hill was coming and exactly when it was going to hit when you were running Boston.

Dr. Jenny Smith:

100%. I think the tough thing with that course in particular is that there was a lot more downhill in the first half, which is tricky because everyone wants to go a lot faster out. But you have to prepare for the fact that miles 16 to 21 are filled with a ton of uphills that are going to really put the work on your calves, your hamstrings in a way that they're already fatigued and then they have to push through.

So one strategy that I utilized for that was making sure that I knew where those hills were coming and then where I was going to get my fuel. So I was really thankful to have my husband, my son, and my parents there. And so during one of the miles, they were ready to give me some carbohydrate, an electrolyte drink and a gel pack that I was ready to take so I could supplement that with some of the course nutrition and fueling. And then it was a great way to have that camaraderie where I'm like, "OK, this is coming up. At least I'll know that there's going to be tons of fans screaming for me and we're all going to be in this together as runners that are going to hit it."

But then once I got up to the Heartbreak Hill, I knew that even though there was some slight inclines, it was literally, no pun intended, downhill from there. So I think knowing that gave me that mental kind of extra cheat that "Hey, if I get through this, I'm doing good. I can keep going." So knowing the course, knowing what kind of course nutrition and fuel that's on it is going to be so important for all the athletes that are doing upcoming races, because then you know what other kind of either things that you have to be prepared for, have spectators ready to hand to you, or knowing that, "Hey, I'm OK. I know that every mile, I have the option to get something to drink or have the option to get some type of fuel. Or maybe I don't have the option, so I need to make sure that I'm preparing myself for this." So it's as easy as just going onto that course website, looking up the course, and then looking up every kind of marathon or half-marathon will say where their medical tents are at, where they're having their kind of fueling, how often the fueling's happening. Just get prepared and give yourself that peace of mind, is always my kind of-

John Horton:

I study those like crazy ahead of a race because I want to know exactly what I can expect to get my fluids in, where they hand out the gels, all of that stuff. And there's nothing worse than when you're at a race and it's not where it's supposed to be. Whereas I've had it and it's like, "Oh good God, man, this is right when I thought I was going to get this drink and it's not there." That can get really tough. So I know it's important to keep everything flowing.

Dr. Lauren Wichman:

And I know both of you have even mentioned, too, whether you drive the course the day before, if you're coming in from out of town or you're local, trying to make sure you can visualize that and even find certain landmarks. So if you're like, "OK, mile 10 has this, mile 15 has that," and then you can keep your eye out for it. So it kind of motivates you to look for that thing, look for that thing that keeps you moving, in addition to family and adoring fans, of course.

Dr. Jenny Smith:

I would say, too, the other thing for some of these bigger races that you might want to watch for is pacers. So there will be individuals that will be running at certain paces and their job is to be consistent at that pace. So if you've noticed during some of your long runs that you're trying, you think that you're running at a certain pace and that you just have a really difficult time doing that, usually at the expo of the marathon, you'll be able to find that pace team and discuss with them like, "Hey, I think I need to find if there's a pacer that's going to be doing this type of minute mile. Can I go with them?" And usually it's a really easy way.

I know with the Chicago Marathon that I did in the fall, they had multiple pacers for the same time in a lot of the different corrals. So even if you were in corral A versus B, they had a pacer that was still running a similar time just because of the amount of people that were running it. So that's always another quick tip to just watch for, especially if you're worried about hitting that pace or maybe you don't want to look down at your watch. Because sometimes our watches can be a little bit difficult, especially when we're running in different cities where the buildings aren't letting us really see what our actual pace is at. So always just good thing to look out for that.

John Horton:

Yeah, pacers should wear capes because they're like heroes when you're out there on the course. And I also find most of the time wherever you go and they have pacers, those are usually locals, too.

Dr. Jenny Smith:

Oh, yeah.

John Horton:

So everything we've been talking about as far as how the course is laid out, where the hills are, things like that, they know that. And I know they'll talk you through it like, "Hey, listen, this mile's going to be a little bit faster, because I'm saving it because I know we're going to have the hill right after it." And they start prepping you for exactly what's going to come. So they can give you gobs of information.

Dr. Jenny Smith:

100%.

John Horton:

So I feel like, as we've been talking here, we were kind of like all the work you have to do in advance of the race. And through our running through this, we've kind of run all the way to the starting line. So it seems like we're kind of at a spot where we should start focusing on race day itself and race weekend, maybe.

Dr. Jenny Smith:

Sure. Sure.

John Horton:

And the one thing I know everybody hears about is carb-loading. It is the pasta lovers amongst us. It's the most glorious time. So Dr. Wichman, Dr. Smith, tell us what we're doing for our body right then as far as building that energy supply and getting it ready to go.

Dr. Jenny Smith:

Yeah. I would say it definitely takes work to build that energy supply over more than just one day. So I think a lot of newer runners think about, "Oh, I got a pasta dinner the night before. I'm ready to go," but it starts even well before that. So typically, for a carb-load, we're looking at about two to three days of building up those glycogen stores. And I always choose more of the three-day carb-load because I just can't take as many carbs in for a day just because my stomach just doesn't handle it well. But yeah, in the research, we're looking at anywhere from 8 to 12 grams of carbohydrate per kilogram per day. So for me being about 58 kilograms, I was looking always for those three days, 460 grams of carbs, which seems like, "Wow, that sounds great," but it's actually a job to carb-load, to get those stores where they need to be. It's a little bit tough.

Dr. Lauren Wichman:

Dr. Smith, like you said, I think you really do have to work at it and plan that out. What kinds of foods are you finding not only help you achieve those marks, but then also seem to be well tolerated because you want to be feeling your best in a few days?

Dr. Jenny Smith:

The biggest thing is avoiding the fat, fatty, oily, kind of fast food, fried food type of stuff. Really focusing on just strictly carbs, sugars. What I started doing more for this last marathon was smoothies. So a lot of fruit smoothies where with one smoothie, I could get 65 grams of carbs in, which is a great start. Or even I would have an orange juice for breakfast or maple syrup on my pancakes. So it doesn't mean ... this is something that, in general, isn't always looked at as healthy foods, but it's strict sugars, carbohydrate food.

So with those carbohydrates, things that aren't necessarily filled with fiber is what we want to go for because fiber tends to fill us up a little bit more. It can cause a little bit more of that digestive issue. More of just the simple carbs. So we're talking breads, bagels, pretzels, smoothies, juices, Gatorade Endurance®, any type of sports drinks that you want to add into it, the pastas, the white rice. There's a lot of different options. I even know people that'll just say, "I ate a whole pizza last night and it was mostly crust." And I'm like, "Awesome job." That sounds like a great carb-loading option.

John Horton:

It almost makes running the marathon worth it at that point.

Dr. Jenny Smith:

Yeah. Or if you're my husband and you don't have to run the marathon but you get to carb-load with me, that's even better. At least so he says.

John Horton:

It's good to have a carb buddy.

Dr. Jenny Smith:

Oh, yeah. Oh, yeah. So that's more of the loading beforehand.

Dr. Lauren Wichman:

And I think, too, going back to the theme we were talking about before, too, making sure that trying some of these foods, if you're like, "OK, what's going to be my weekend meal?" If you want to try some of those things before some of your long runs, those dress-rehearsal runs, and make sure, "OK, this sat well. I tolerated this," lets you feel like, "OK, this is going to be a good setup going forward."

Dr. Jenny Smith:

100%.

John Horton:

Yeah, you don't want to be experimenting the day before the race with some new type of pasta or new anything. You want to make sure it's a meal that you've had plenty of times before so you know how your stomach feels with it and how your body responds.

Dr. Jenny Smith:

Yes, nothing new on race day.

Dr. Lauren Wichman:

So I think that's a perfect description and picture of what that weekend leading up to it looks like. What about the morning of the race, right before the race? How do you recommend people approach that, Dr. Smith?

Dr. Jenny Smith:

So that's also something that's really important to know when your race starts. So that goes into really looking up the course. Because sometimes, like the Boston Marathon, I think my starting time was about 10:45. But with the different marathons that are local, it could be 7:00, 7:30. So it really does change where you need to adjust your fueling. And this is something where, too, if I have someone that's really worried about it, I always say, "Hey, we've got some great dietitians at the Cleveland Clinic where I want you to really work with them on individualizing this plan based on what your body does well with." But just in general, I would say typically you want to wake up a little bit earlier before your race anyway and get a decent amount of carbs. And then typically, right before the race goes off, I start with my first gel or carbohydrate. That's usually about 10 to 15 minutes before race time just so I get the complete finish of it.

So in general, you don't want to feel bloated necessarily, but you should feel fairly full. Something that I'll tell my runners is because they get really nervous or they get worried. So they go to the starting line and they're hungry. You should never toe the line and be hungry because you're going to be really struggling then through the next several miles that are about to come. So feeling full in a good way.

And again, same thing the morning of. Really simple carbohydrates. So it could mean a little bit of just toast with a banana, and then you've got your electrolyte and your carbohydrate-filled drink. This is also a perfect time to just bring in the fact that caffeine can be helpful in terms of athletic performance. So it's something where a lot of runners will have their coffee. I always have two glasses of probably some caffeinated tea in the morning just to kind of get ready to go. And then during the race, that caffeine, to a certain level, can be really helpful, but it's also something you got to practice this before race day. But yeah, so electrolytes, you're fueling, your potential caffeine. And then just making sure, we're all runners here, making sure that you can go to the bathroom before you hit the starting line so you're ready to go.

John Horton:

The coffee helps with that, too.

Dr. Jenny Smith:

And the coffee and caffeine help with that, too. So it's a win-win.

John Horton:

It does. So I'd say, when we were talking before, everything you laid out kind of hits what I do ahead of the race. I've always been a toast and honey guy, banana, coffee, all of that, a little Gatorade. The fueling during the race, I have to say the tips that you were saying, I realized that I have not been, I guess, taking care of my needs throughout the race. And I think I always make the mistake of maybe waiting too long to start putting some energy back in for my body to use. So walk us through that process as we're out running that course, how often we should be hitting gels, making sure you get that back in.

Dr. Jenny Smith:

Yeah, no, that's a great question. In general, originally, the number was 30 to 60 grams of carb per hour. But what we're finding out with all this new research and what we're getting out of our own bodies and with these professional athletes that I would say the goal would be to aim more towards the 50 to 60 or even higher grams of carbs per hour, which, if you look at most gels, they're going to be around 22 to 25 grams of carbs in a gel. That'd be something where you're taking that every 25 to 30 minutes.

So for me running, let's say my marathon time was just under 3:30, I'm taking, throughout that run, one gel at the beginning and then an additional six or seven on course. On top of maybe the Gatorade Endurance that they had on the course, that's also going to give me a little bit more top off and some other things that I'm taking. So it's a lot, and that's why we have to train our stomachs for it. But yeah, in general, upwards of over 50 grams of carbs per hour. And we want to make sure that we don't just chug something or take something that has a ton of carbs in it all at once. We have to slowly and gradually work it into our system. And that's why a lot of people like to do it every 25 to 30 minutes.

John Horton:

But in doing that, too, with what you said, if I'm doing my goo math right with what you said is in one of those packs, you're looking at maybe two packs every half hour or so that you might want to put down?

Dr. Jenny Smith:

Potentially, if your body can handle it. I mean, we've seen from some of the professional athletes, they're hitting 80 to 100 grams of carbs per hour. But it really depends on what you need. I know for me right now, I've never, knock on wood, thrown up during an endurance race or marathon. And so I haven't tried to push it past six or seven on my stomach in addition to some other fueling. But in general, I would love to probably be able to see if I could push it a little bit more because we're finding out that it's helping performance and helping that ability to push past the wall.

John Horton:

And is the whole key there that, as you kind of replenish, I mean, you don't want your tank to get empty, it sounds like. You always want to make sure ... OK, I'm one of those, I let my car, that tank gets down to where it's on E and it says I got three miles to go. If you're running, that's not the way you want to do it, right?

Dr. Jenny Smith:

100%. And I would say, too, when I talk to my runners, I had a conversation with one that she was still battling injury and I knew that there was probably a recovery piece, a fueling piece, a part of it. And she's like, "I just feel ravenous after I finish all my long runs." And I'm like, "Yeah, that's because you're hungry because you're not fueling your body for the run before, during, and after." You shouldn't feel like you need to eat everything in sight right after a marathon or a long run. And then the reason for that is because you've been consistently putting stuff in your stomach as fuel.

John Horton:

Well, that's a great tip, because I wouldn't think of that when you get done, you think, "Oh, I just should naturally be hungry." But it sounds like if you're famished, you should look at that as a sign that maybe you need to re-look at, I guess, your energy process during your run and up it a little bit to make sure then that when you finish, you're not that emptied out.

Dr. Jenny Smith:

And that same rule of thumb goes for your hydration as well. So if you're noticing it's mile 17 and you are so thirsty, it's a little bit too late for you to start really building on that. I would say you probably should have built up your hydration, one, during your carb-loading because that's going to help our body store the carbs a little bit better, but also leading up and during the race, consistently getting some of those water and Gatorade options on the course or whatever option that there is. So I would say, too, with hydration, with fueling, sometimes if you start noticing that you need more, you probably didn't prepare yourself enough for it. Which is tough because sometimes, depending on the environmental factors of the race, it's easier to get dehydrated, or because it's so hot and humid out, it's easier to feel like you didn't get enough sodium.

And again, we haven't talked about sodium yet, but for those individuals that are sweaty, just with all their athletics, or tend to be really salty sweaters, you really need to be getting those electrolytes and sodium in during your long runs to see how your body does. I remember one run that I did. This was, I think, during a previous marathon. I used a new gel that didn't have any sodium in it. And I got done with the run. And my other gels usually had sodium, so I never had an issue. I had the worst calf cramps after that run until I realized, "Oh my gosh, the gel that I was taking for multiple times during this last run gave me zero sodium whatsoever." So another thing, always, too, if you have a gel that you're using, make sure that it has the sodium that you need.

And there's a lot of resources that you can look at in terms of figuring out what your sweat rate is and how much potential sodium that you lose within that sweat rate just based on what you see on your skin. If you notice you get done with an activity and you have white all over your skin, you're probably a pretty salty sweater.

John Horton:

I've been told I sweat like crazy. I'd be in that super sweater category. And I think that as we're talking about bonking avoidance here, this kind of goes right into the whole adapting to the conditions. Because we all know you want race day to be a perfect maybe 40-some degrees and the weather's great and it's overcast, the sun beating down on you. That is not always the way it happens. And we've all had those races where it's 30 degrees warmer than what you wanted. And I know that can take a toll on you. So how does that factor into the whole hitting the wall, when it might reach you, and what you need to do to avoid it?

Dr. Jenny Smith:

Sure. I would say you might have to increase your carb-loading and your fueling if you know that race day is going to be a little bit more hot or humid. You also are going to have to adjust your initial pacing. So if your marathon pace going out was supposed to be at an 8-minute mile, there's a good chance that you're probably going to want to start a little bit more conservatively just so that you don't hit that wall sooner. So I feel like that's the biggest answer to your question.

With those environmental changes, you're probably going to hit the wall sooner unless you're proactive about it, which means pacing, being a little bit more forceful about getting the electrolytes in, the hydration in, and then also carb-loading and fueling maybe a little bit more frequently throughout that race. That's going to at least help.

Mentaly, heat is heat, right? But if we can feel better in general pushing through that heat, there's a good chance that you'll be able to push that wall further and further from happening.

John Horton:

To me, heat is a four-letter word, but it's-

Dr. Jenny Smith:

…or that. Or that. Yeah.

John Horton:

Yeah.

Dr. Lauren Wichman:

I think one of the things, too, as a team doc who's covered these endurance races before, you never forget the patients that you do see that ... something we touched on a little bit earlier, there's a difference between the wall and a serious medical concern. And the patients that do come into our tent with exertional heat stroke symptoms, they're completely out of it. Their internal body temperature is 108 degrees-plus, and they've got to get dunked in the cold tub in order to make sure that their organs don't go into complete dysfunction and failure. That is a very serious concern. That is not something that, obviously, we can just push through. However, by doing all these things that Dr. Smith said and trying to be as prepared as we can, that also comes into not only trying to prevent bonking but preventing serious medical concerns.

John Horton:

Dr. Wichman, what would you say then with that? Because we've all seen videos of runners, marathon runners. You're getting to the end and, I mean, they're just falling over. And I know I've been at races where people go down near you, and it can be scary. You realize when you're doing this, kind of the demands that you are putting on your body. So I guess, when do you need to like, "Hey, I need to shut it down. I need to go into the medical tent. I need to get some attention"?

Dr. Lauren Wichman:

It's a hard question. It's a hard line to try to make sure that you're not going past. I mean, I think you always do run into those people that cross the finish line and then collapse. And that's more due to a circulation-type thing. And if they're coherent, you get them seated, you lift their legs up, they're answering all your questions and all that stuff, that usually is like, "OK, they're going to be just fine. They just need a little bit of rest, a little bit of ... get that blood flowing back to their head, and they're good to go."

On the flip side, it's the people where, especially if you've got a running buddy that doesn't seem like they are making any sense, that's usually one of the things where I get really concerned. They're staggering down. You'll see people sometimes, too, they're staggering down that final stretch. They are somebody, as the medical staff, we're keeping a close, close eye on to see, "Are they going to make it?" Obviously, the last thing we want to do is have to go in and intervene on somebody that we want to make sure that they finish this thing that they have put so much work into. But at the same time, we want to make sure that everybody's doing it in a safe way.

So those are the red flags, not physically able to stay upright, not seeming like themselves. Those are the really big red flags for us that get people over to the tent ASAP.

Dr. Jenny Smith:

And I was going to say, too, just as a runner who has seen people having issues, you can know when someone's cramping up because they're grimacing. They're like, "Ah, I got to get this leg over." They don't have the loss of coordination or they're not breathing well. They're making this, "I'm getting through it. This quad isn't moving." It's almost like you get it and you're like, "Yeah, keep going, but I'm going to go past you a little bit," versus someone's falling down. And I feel like, as every runner, it's kind of our duty to check on them, make sure they're OK. I mean, with running as a sport, we, unfortunately, see this where there's cardiac arrests and there's a lot of unfortunate events that can happen. I mean, even with the recent Pittsburgh Marathon, they had nearly 30 people that they had to transport to the hospital after the race or during the race.

So it's not that kind of unlikely that that could happen. So it's really, like Dr. Wichman said, recognizing the people around you. And I think, really, as a runner, similar when someone's not talking, they are basically doing the loss of coordination, that type of stuff. That's almost where they got to be pushed into medical. They can't keep pushing. But as a personality of a runner, I know that we don't want to stop. That means that we're giving up.

John Horton:

No. There's an embracing of the pain. Yeah.

Dr. Jenny Smith:

Yes.

John Horton:

Yeah.

Dr. Jenny Smith:

So yeah, it's hard to know what is pain and what's a medical emergency. But I feel like that's where Dr. Wichman's the expert, along with a lot of these medical directors of races that really are able to find that difference versus just some of us that are just a part of it.

John Horton:

One last thing with bonking avoidance, and I think we've kind of touched on it throughout, but I want to make sure we really emphasize it a little bit, is the importance of pacing. And I know that's something I have always struggled with. The whole negative split concept of a race is something that has eluded me a lot. I probably tend to go out a little hot and then try to hang on for as long as possible, which is probably not the best training recommendation out there.

Dr. Smith, talk to us a little bit about the importance of pacing and how, I guess, setting the right pace can maybe prevent you from bonking when you hit those later miles.

Dr. Jenny Smith:

Sure. I mean, it's crucial. Now, I say that with the fact that I've done eight marathons, I have never done one with a negative split. The closest I've gotten was 90 seconds between the first half and the second half, and that was my personal record marathon. So that right there just tells you the closer that you can get the first half and the second half together, the more successful you'll most likely be. If we look at the world record that was recently set at the London Marathon, the first half was in an hour. The second half was more in 59. He did negative split. So that's-

John Horton:

…hour and 30 and 59 minutes, which is still just mind-blowing that anybody's running that fast in the second half of a marathon.

Dr. Jenny Smith:

And that's a professional runner that it works for, but it also works for recreational runners. And so you're 100% right, where we have to figure out what's the right pace. And sometimes, it's really hard and you kind of have to just try to figure it out.

It also depends on what the course is like. So in general, the runs that you do leading up to race day should help you figure that out. For example, I had given the marathon pace long run, where some of those miles that you do at what you think your marathon pace should be like is a great option.

There's also marathon predictor workouts that you can potentially do. Some of them have a little bit more validity than others. And then a lot of people will use their different watches and devices to see what their predicted time is based on that. Overall, what I'll say ... because I have my own device that sometimes I use and it way underpredicted what I was capable of. So I would say use all of those predictor workouts with a little bit of a grain of salt.

You also want to go into just basically how you're feeling at the beginning. I would always say that the easiest thing to do is run slower than you think you can handle. That first 5K, when you go out of the gate, you should be holding yourself back. Because you-

John Horton:

…oh, that's so hard.

Dr. Jenny Smith:

And it's so hard. It's so hard.

John Horton:

…you're so excited. Then there's crowds. Everybody's cheering. Those loud cowbells are going.

Dr. Jenny Smith:

Surrounded. And even with that, people still run out too fast. But if you don't hold yourself back, you're going to be in a lot of pain. So one thing I think we had hit on earlier this week was how, when individuals pace, sometimes they think about, "Oh, I'm banking the time so that I can slow down later in the race." You don't want to think like you're banking the time. You want to think about how you're going to be keeping your fuel and your energy so that you can excel at the end of the race, not survive at the end of the race. And I think that's something that usually comes with experience with running. And that's why, like I said, with bonking, it's much more common in our novice or our first-time marathoners.

John Horton:

Or stubborn ones like myself, because I still run into that trouble because I go out to ... I think I start out at the pace where I want to run, but maybe not where I'm at. And that's often a problem.

When we're talking about setting that slower pace, I think some of it is just accepting that that slower pace is OK. And I know we did a whole podcast a while back with Dr. Singh talking about slow running and how there's really a lot of benefit to it. It sounds like when you're in these races that there is a little bit of a tactical approach there where if you go a little slow early, you're going to have a little more for later.

Dr. Jenny Smith:

100%, yes. And for runners that are trying to get a fairly competitive time, that slow pace, it might not be your easy recovery marathon training pace. It's a slow pace for what race pace would be like. And that's where we get into the nitty-gritty details of just training plans and stuff like that. But for some runners, slow running is just 100% what they shoot for the marathon because their goal is to finish in maybe six hours or seven hours and they're just trying to hold on for that pace as long as they can go. Whereas other runners might have to be a little bit more strategic and say, "OK, even though my easy runs were done at a 9-minute mile pace for my overall training recovery, once race pace hits, my race pace is at an 8-minute mile. For me, I got to start at 8:15, just a teeny bit slower, so that by the later miles, I can see if I can get into a 7:55 by the end." So it just really varies depending on what your own personal goals are.

And that's why, too, I always tell when I have a patient coming in and they're like, "Jenny, I'm training for my first marathon," I try to tell them, "Enjoy it. Experience it. Don't put any specific major goals on this first one because this is the first time that you're going to experience what this feels like, which probably toward the end is not going to feel good. So if you just lower those expectations for the first one, you kind of have that experience under your belt, you can build on some other kind of higher-achieving goals for the next time." So I feel like that helps a little bit settle expectations.

John Horton:

Well, I feel like we're getting close to the finish line here. So I guess, before we say our goodbyes, let's give folks just a few actionable tips. There's a couple things they're going to take away from this that are the absolute priorities, what would they be? And Dr. Wichman, why don't you start us off there, and then Dr. Smith, give us your marathon expertise and take us to the end.

Dr. Lauren Wichman:

I would say, number one, everything we talked about in terms of preparation being key is so important. Making sure that you have the right training program. That's where I see so many people coming into my office with injuries, is because their training program isn't optimized. They're putting too much stress, too much load on miles that maybe they aren't necessarily ready for yet. Adding in the cross-training, like strength training we talked about, can also be key. And making sure that you've got the nutrition right and the course down pat, that preparation is going to set you up for success.

Dr. Jenny Smith:

Yeah. And I would just add to that in a few words, you want to be going to the line healthy and maybe a little bit undertrained, but not injured. I would say if there's one big takeaway here because of the preparation, focusing on recovery, strength training, even if it means you have to lower your mileage a little bit, you are going to that line healthy because you've been taking care of your body.

And then because of your excellent carb-load, getting in the fuel sources that you need, focusing on sleep the night before and the proper mindset, you're going to feel confident once you get to that starting line. And then, once it comes to race time, execute that fueling plan and those course goals. Keep some type of happy mantra. And it could change from marathon to marathon. Or some gratitude miles. My last six miles of one of my marathons, I dedicated it to a person.

So when I was in that pain cave where all I wanted to think about how bad I was hurting, I was like, "Oh, this is my dad's mile," all the good things, "He wants me to finish this. He wants me to do this." It just was a huge mental kind of help to get me through. I mean, you've done all the work at this point, you're toeing the line, embrace it, enjoy it, and just appreciate the fact that you get to be there and you get to do it because not many people can. So I'd say that's kind of the last couple words and hopefully motivational speech that I would give.

John Horton:

Wow. That's a great motivational speech. I got to tell you, I am ready now to just run right through that wall the next time I'm out there.

So Dr. Smith, thank you again for coming in. This has been a fabulous chat. I've learned a lot during it. And I know things that I know will help me the next time I'm in one of those runs and I'm getting past that 90-minute mark and starting to struggle. So thank you so much.

Dr. Jenny Smith:

No problem. This has been great. Thanks, guys, for having me.

John Horton:

Dr. Wichman, all I can say is wow. I've run like 40-plus half-marathons. And after talking with Dr. Smith, I realized there's a lot I still need to learn. And I know I picked up a bunch of tips from that that are going to help me the next time I sign up for a race.

Dr. Lauren Wichman:

I think that a lot of our listeners hopefully learned a little something, too, right? A lot of times, we'll think of the episode of “The Office” where Michael is eating his fettuccine alfredo right before the race and we've learned that's probably not the approach to take to make sure that you're fueled and ready to hit the road.

John Horton:

Well, and that whole concept of bonking, I mean, we've all kind of been there. When you're on that run and you feel empty, your body's got no energy left, but it sounds like there are ways we can address that and make sure that we take care of our body so we have enough fuel to kind of reach that finish line.

Dr. Lauren Wichman:

Absolutely. I think we talked about the preparation and how key that can be, and then also the mindset and the approach to have on race day, adapting to different conditions that you might have to face or trying to hold back and make sure you're not caught up with everybody that gets you shooting right out the gates. It was a great conversation.

John Horton:

So let me tell you, did we convince you to sign up for a half-marathon?

Dr. Lauren Wichman:

I don't know. I mean, you might get me to throw on some tennis shoes and try this out.

John Horton:

We'll see. Maybe we'll talk about that on another podcast and we will lay out how to get that program started.

Dr. Lauren Wichman:

Right, right. That'd be perfect.

John Horton:

Well, if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Till next time, play hard and be well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.