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Exercise is good for the heart… but is there a limit?

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Exercise is good for the heart… but is there a limit?
by: Dr André La Gerche


There is no doubt that moderate exercise is good for you. Exercise reduces your risk of heart attacks, stroke, diabetes and some cancers. The promotion of exercise as a positive and powerful health intervention has never been more important given the explosive increase that we are seeing in disease states which are related to under-activity such as obesity and diabetes. In proportion to its importance, I should spend the next 10 pages discussing the need for all people to undertake moderate exercise but I will instead discuss the relatively small amount that we know about the benefits of exercise in the amounts commonly performed by competitive endurance athletes. There are few studies which adequately address this topic and this is somewhat surprising given the massive increase in endurance sport participation over the past few decades.

From the viewpoint of a keen athlete, I would like to first address the “who cares?” factor. The lay press and medical journals like to focus on the stats. Do athletes live a year longer or a year less? Are they 0.1% more or less likely to suddenly die of a heart attack? These are important scientific questions but will the answers influence my decision as to whether I go running in the forest this Sunday? All athletes know that their motivations for sport practice are not based on statistics but from the immediate satisfaction that comes from it. You are more likely to be killed by a car when riding than you are of dying of a heart attack and yet cyclists do not spend all of their cycling hours avoiding this risk on a wind trainer.

On the other hand, my job is to assess athletes who have developed heart problems and so the question as to whether sport may have contributed becomes important. With current evidence, I would not advise that any level of exercise is unhealthy. At the same time, I think that it is important to recognize that some things remain unanswered.

What is strenuous exercise?

Here is the first major problem with the medical literature. Numerous studies report improved health outcomes as a result of regular strenuous exercise. For example, in a widely quoted study (Blair et al., 1989) longer overall survival was attributed to “high levels of fitness” but it was also concluded that these benefits may not be seen in those performing exercise above a level of 10 metabolic equivalents (METS). So, what is 10 METS? This is the equivalent of exercising at an oxygen consumption of 35 ml/kg/min which is about 50% intensity for a well-trained athlete, jogging, riding a bike at 20km/h etc. Put simply, it is way below that which competitive athletes do in training on a regular basis. This same problem is true of nearly all of the large studies that have assessed exercise benefit – they all set maximal exercise at a level way below that appropriate for athletes. Thus, the current evidence base can be summarized as follows:


Figure 1: The benefit of exercise is likely to extend to high levels of exercise but is there a point where the benefits start to plateau or even reverse? Note, however, that it is unlikely that any level of exercise will increase risk to the level of a sedentary person.

It is likely that the benefits of exercise extend beyond the fairly conservative range which has been studied but the controversy involves whether there is a point where ‘extreme’ amounts of exercise may increase the risk of some heart problems.

There are some well-conducted studies from Scandinavia which have looked at health outcomes in ex-Olympic athletes and the results have been very reassuring (Sarna, Sahi, Koskenvuo, & Kaprio, 1993) Olympic athletes live longer and develop fewer health complaints. However, they are also wealthier, smoke and drink less and are likely to have better diets etc. – all of which may account for the differences in health that were reported. Thus, whilst it seems clear that being an athlete is healthy, these studies do not enable analysis as to whether benefits are due to lifestyle factors, exercise, or a combination of both.

What evidence is there to suggest that extreme exercise may have unwanted effects on the heart?

Exercise causes heart enlargement
Greater amounts of exercise (at least 3 hours/week) are associated with “re-building” of the heart. This is of benefit for the athlete because a larger heart enables more blood to be pumped during exercise. The more blood that is pumped the greater the amount of oxygen that gets to the muscles for use.

Mostly the heart enlargement that occurs is quite mild and goes away completely if the athlete stops training. This is called ‘physiological remodeling’ and simply reflects enlargement of the muscle just as your biceps enlarge with curls.

However, in more extreme endurance exercise, the heart enlargement can be dramatic (see figure below) and it may not resolve when the athlete stops training. For example, in a study of nearly 150 Tour de France riders (Abergel et al., 2004), hearts size was greatly increased and, when studied 3 years later, the riders’ hearts were larger still. In a recent study from Switzerland (Baldesberger et al., 2008), ex-professional cyclists had persisting enlargement of the heart despite having retired from sport 30+ years earlier. This would suggest that something other than simple muscle enlargement was occurring because otherwise it would have returned to normal size once the load of exercise ceased. This might not seem a big deal but there are only a few things in the heart – muscle, the connective tissues which hold the muscle in place and the electrics of the heart. If there is an increase in the connective tissue part then it can interfere with muscle or electric function. Therefore, the failure of heart size to return to normal MAY be a cause for concern.


Figure 2: Comparison of the heart size in two 23 year olds – a non-athlete and a young professional cyclist. Note the 10cm marker as a reference. The non-athlete’s heart is approximately 15 x 12cm vs. 25 x 18 for the athlete!

Enlargement of the heart in athletes may cause scarring
This is a very contentious statement and not at all proven. As stated above, the heart enlargement is mostly due to ‘hypertrophy’ (enlargement) of the muscle fibres themselves but there is some suggestion that the connective tissue may also increase following extreme training. This connective tissue is also called ‘scar tissue’ and it has the potential to cause heart rhythm problems. It is very difficult to be certain about whether extreme exercise can cause scar because it is usually only diagnosed under the microscope on heart muscle tissue. As you can imagine, this is hard to get. We are therefore left with reports of single cases or small groups of athletes in which scar was found (La Gerche et al., 2010; Mottram et al., 2004; Whyte et al., 2008) and these do not provide definitive answers.

In one recent high profile case, Ryan Shay died during the 2008 US marathon trials and the cause of this death was never established. His autopsy result was stated as “Cardiac arrhythmia due to cardiac hypertrophy with patchy fibrosis of undetermined etiology. Natural causes.” In other words, he had heart muscle enlargement (completely expected for an elite athlete) with small areas of scar (definitely abnormal in athletes) and the conclusion…natural causes. It is surprising that this finding did not stimulate debate as to why a fit young athlete had patches of scar in his heart. Was exercise the cause? We do not know. But, we will never know if the question is not asked. This is shaky ground, however, because a balance has to be struck between investigating issues such as these and yet not creating disproportionate hysteria within the media and wider community. We must always remember that the death of a young athlete is very, very rare.

Some heart rhythm problems are more common in athletes
There are multiple types of heart rhythm problems (arrhythmias) which range from completely safe through to life threatening. As far as we know, exercise does NOT cause an increase in life threatening arrhythmias. However, there is increasing evidence that some benign arrhythmias are more common. This is well summarized in a review by Lluis Mont (Mont, 2010) for those who are interested and is beyond the scope of the discussion here. However, please remember that these are “nuisance arrhythmias” rather than life threatening ones.


This is a lot of information and may well seem somewhat confusing. I will try to summarise all of this information in some simple points.

– Mild and moderate exercise provides considerable health benefits to everyone
– Prolonged, intense exercise (such as the levels practiced by competitive athletes) is also likely to be safe but it has not been well studied.
– There are a number of questions which remain unanswered
– Can exercise cause small amounts of heart muscle scar?
– Why do arrhythmias occur in some athletes?
– Why are some athletes at risk (a very, very small number), how can we identify them early and how can we prevent these problems?
Remember, the scale of any potential issues related to sport are miniscule against the massive benefits of exercise.

To continue reading this interesting article by Dr André La Gerche with some Q&A please click here 


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Text by Rod Cedaro (M. App. Sc.) Consultant Exercise Physiologist ACC Accredited Level III Triathlon Coach (DUNCAN)

In TMSM (a magazine I write for) I’ve often sung the praises of riding indoors on trainers as a means of taking your cycling to another level.

In fact, here in Brisbane where we run our two Activ Tri-Group sessions at our indoor cycling facility (see: as (i) it is easier to keep a group of varying ability levels together and safe and (ii) because the improvement we’ve seen from riding on the computrainers are substantially more than we could have hoped for by sending athletes out to do their sessions on the road. So that begs the question can treadmill running be to running what the computrainer is to cycling?

Personally I believe, like cycling on a computrainer, running on a treadmill can be an excellent “adjunct” to road running, but as is the case with riding, running on a treadmill should not be used to completely replace road, trail or track running sessions.

Rod Cedaro 1

I’ve often had athletes comment that running on a treadmill feels somewhat “easier” than running at the same pace than running over the ground. How can this be? If you’re running 4.00/km on the road you’re running 15kph, surely, if you stoke a treadmill up to the same speed you’ll be doing the same sort of work, or will you……….

When you run on a treadmill the ground (or rather belt) is being pulled underneath your feet and there’s no wind resistance, whilst when you’re running outdoors you literally have to lift and pull yourself over the ground and deal with air resistance. You don’t think that the air resistance is a factor? Just like drafting on the bike, running in another athlete’s slipstream pays big dividends, more than faster you go, in fact at an elite level on a 400 metre track during a 5-10km race the advantage of “sitting on” has been calculated by the boffins to be in the order of about 1 second per 400.

Think about that, over the 25 laps almost half a minute improvement for your 10km for the same effort by simply drafting a slightly faster runner – hence why at major track meets and major international marathons they employ “rabbits” to take the favourites through the first 2/3 to 3/4 of an event.

Rod Cedaro

Anyway back to our treadmill question. Running on a treadmill, along the flat is indeed “easier” than running at the equivalent pace outdoors, but, as you will see, this too can have its advantages. So how you can simulate running outdoors on the treadmill to make up for the air resistance and having the belt moving under you, rather than you moving over the ground? Simple, stick the treadmill on a slight incline – 1.5-2% will suffice. You will then find that the speed on the treadmill and what you experience outside over the ground will be similar.

So why not do all of your running on the treadmill? After all, it is indoors, in a controlled environment, there are no potholes to worry about twisting an ankle in, etc. The fact is that running all of your training on the treadmill is “too” repetitive and can lead to overuse injuries.

When you run outdoors you are constantly having the make minor adjustments in your foot plant and running gait to negotiate the ever changing terrain and surfaces you travel over. No two steps are the same; this is not the case with the treadmill.

Secondly, until relatively recent times treadmills didn’t have a lot of “give” in their decks, so athletes who did considerable amounts of their training on the treadmill (landing in the same manner over and over again countless times) often experienced stress fractures and the like. This is certainly also true of runners who spend the vast majority of their time running on the road (asphalt) or worse still concrete footpaths, however when running outdoors the athlete always has the option to run on softer surfaces like nature-strips and golf courses to lower the impact shock.

To their credit, treadmill manufacturers have recognised this shortcoming in their products and a number of manufacturers have made remarkable advances in treadmill deck design resulting in a much gentler run for the user. Unfortunately they haven’t (and to my way of thinking) wont, be able to get over the issues of every step being pretty much identical to the last and hence increasing the possibility of overuse injuries.

So is it worthwhile using a treadmill? Absolutely! A treadmill can be a valuable adjunct to your training when:

(a) You are trying to teach an athlete to run at “tempo” – in other words a consistent regular rhythm. Set the treadmill at 12kph and the speed won’t vary and the athlete will follow suit. Ask that same athlete to run 120 second per 400 metre lap (i.e. 12kph) after lap on a track and chances are the speed will be all over the place. Given that the most “efficient” way to run a race is even paced through the first phase of the run and then kicking for home, treadmills can be most valuable in this instance.

(b) When you’re doing some “over-speed” work. Swim coaches have long known that cardiovascular fitness, strength, etc. is only part of the answer to developing speed, the other part is “feel” or for those of you more technically minded out there – neuromuscular firing patterns. Swim coaches achieve this by literally pulling/towing swimmers through the water faster than they are capable of swimming. This gives the swimmer the “feel” of swimming at a higher velocity so that they can endeavour to achieve that same sensation when training/racing by reproducing similar muscular firing patterns. The same applies to a runner. If out on the road you are limited to turning your legs over at 20kph, a treadmill, where your legs are being “dragged through” by the belt can be stoked up to 20.5kph to teach the nerves that innervate your muscles to fire appropriately. Sure you can also achieve this outside by running DOWN a gentle gradient, but this changes your gait more so and greatly increases the chance of injury.

(c) Technique modification. Stick a treadmill in front of a mirror, point out the technical faults of someone whilst they are running and immediately, by watching themselves in the mirror and gaining instant feedback, they can modify their style and quickly improve their efficiency and ultimately their performance.

(d) Safety. If you’re in a strange location on business, you don’t know your way around the streets or the streets are chocked with car fumes, seeking refuge in a hotel health club or local gymnasium and jumping on the treadmill can ensure you still get that all important training session in.

Rod Cedaro 2


In short, used wisely and not exclusively, treadmill running has the potential to help lift your running prowess to the next level – consider it as another training option, but remember, mentally, you’ll likely have a tougher time dealing with the monotony of the treadmill. I can go out on a road/trail run and have two hours slip by easily, get me on a treadmill and I’m looking at my watch every 3 minutes and 24 seconds wishing the session to be over! It’s easier to distract yourself when running outside. The bottom line, as you get closer to competition be specific, try to train outside as much as possible to prepare for race conditions.

Rod Cedaro


Danny Green announces his comeback bout on the 19th August 2015

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Rod Cedaro_Danny Green

Rod Cedaro (right) from the Ultra Group of Companies catches up with former world boxing champion Danny Green at the announcement of his comeback bout, after a 33 month hiatus against Slovakian, Tamas Kovacs at Melbourne’s Hi-Sense Arena on August 19th, 2015.

The 42-year-old announced the fight, his first since 2012, at Crown Casino in Melbourne on Wednesday, with the bout to take place at Hisense Arena on August 19.

Green said that he would have his hands full with the light heavyweight, who has a professional record of 26 wins and one loss, but has maintained his fighting weight since his last bout and still has a burning passion for the sport.



Rod Cedaro – Low GI Carbohydrates for Runners

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Rod Cedaro – Low GI Carbohydrates for Runners

As an athlete, it is crucial to ensure that you are getting the right balance for all of your meals. Part of that is making sure that your diet incorporates sufficient energy sources to enure maximum performance. Carbohydrates are an important source of energy and the best type are those that have a low GI which will release glucose more slowly and steadily over time. Foods are given a GI number according to their effect on blood glucose levels and those with a lower GI number have a more steady impact:

Rod CedaroRod Cedaro, Altitude Services

5 Inspirational Triathletes

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5 Inspirational Triathletes

There are so many athletes and triathletes that inspire us to work harder, perform better and push ourselves to the limit. There is always something to learn from those that have worked hard to achieve their goals. Here are 5 excellent triathletes that have pushed themselves to the limit and gained outstanding and worthy success throughout their careers:


Erin Baker

Erin Baker

Erin Baker – Hailing from New Zealand, Erin is considered one of the best female triathletes of all time, winning a total of 104 out of the 121 races she joined.

Rod Cedaro - Dave Scott

Dave Scott

Dave Scott- he is a  6 time winner of the Ironman World Championship, holding the joint men’s record and is the first person ever inducted in the Ironman Hall of Fame.

Paula Newby-Fraser

Paula Newby-Fraser

Paula Newby-Fraser – she has won the Ironman World Championship 8 times, winning won 24 Ironman races overall between 1986 and 2002, later competing in ultra marathons.

Craig Alexander

Craig Alexander

Craig Alexander – Australian Craig is the 2008, 2009 & 2011 Ironman Triathlon World Champion and currently the course record holder.

Mark Allen 1995 Ironman Triathlon World Championship

Mark Allen

Mark Allen – is joint holder of the mens record of 6 wins of the Ironman World Championship and winner of the ITU World Championships in 1989.

By Rod Cedaro