Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, we're talking about preparing, training, and recovering from running marathons. It's marathon season. And joining me is Dr. Jaspal Singh. He's the Vice Chair of Strategy and Clinical Operations, and he's an Associate Professor within the Department of Rehabilitation Medicine at Weill Cornell Medicine. Dr. Singh, it's such a pleasure to have you join us. So, let's talk about marathons, because it's this season, but people train all-year round and then people are runners. So, how should beginners who want to start thinking about next year begin a training plan? What's the ideal duration for training before your first run?

Dr. Jaspal R. Singh: Yeah. Great questions, Melanie. Good to chat with you again. The phrase, it's a marathon, not a sprint. I mean, it's so applicable to more things than just running. It's how to run your life, how to live and work and be a father and husband, and someone who works at the hospital. So, that phrase is so relevant, because you can't just wake up and cram for a marathon like we used to do in high school and college. You could cram for a test. But the marathon's way different, and the reason for that is there have to be so many adaptations to your physical and even mental body to prepare for running a marathon, that it just takes time.

So, I got into running late in my life. My first marathon, when I was 42 years old, perhaps that's my midlife crisis. I could have bought a sports car or something like that, but I decided to run. And that's what I did, and I did a lot of research before running. Admittedly, I will tell you I could barely run a mile or two when I started my marathon running. I was big in the gym. I used to lift weights and do resistance training, but I was just never great at cardio. So, I did a lot of research. And what I found is that the minimum time required, if you're a beginner runner, or if you want to train for your first marathon, is about four to five months. I think four to five months really sets out a good trajectory, increasing your volume with every week, with every month, doing some strength training. But that's what I would budget. I would budget about four or five, maybe even six months to get yourself ready to run a marathon. And I will tell you this personally, I believe almost everyone can run a marathon. It sounds ridiculous, just the whole idea of running that far, but it's one step at a time. And if you get your body in shape, you can definitely do it.

Melanie Cole, MS: I couldn't definitely do it. I've walked a marathon. I did 26 miles in a day for one of these walks, I've actually done that a couple of times. But running it, I mean, it took me eight hours or I was going four miles an hour, three and a half. But I am one of those people that I couldn't run in high school, Dr. Singh. It hurt too much. But in any case, thank you for that answer. And are there specific health conditions that might make running a marathon unsafe? How would a person know if there's somebody who maybe shouldn't be running?

Dr. Jaspal R. Singh: That's always a good question to ask yourself and check in with your primary care doctors or general practitioners. And I think it's a good opportunity for most of us who don't regularly see a doctor, like I am a doctor and I'm probably a terrible patient. But when I started training for the marathon, I was like, "Maybe I should get things checked out. Maybe I should get my heart looked at and my cholesterol and diabetic levels. I'm Indian, South Asian, so we have high diabetes and heart disease in our culture." So, if you have conditions such as heart disease, such as asthma, maybe uncontrolled diabetes, even joint pains, which I think can be managed, I think having that all evaluated and just kind of looked at before you endeavor in this long four to five-month training program is a good idea. For the musculoskeletal injuries and the patients who suffer from joint pains and muscle aches, I think through training you can work through some of that with rest and recovery. But the big conditions, like I said, heart disease, asthma, diabetes, probably just get those looked at once to make sure you're safe to train for such an event.

Melanie Cole, MS: So, let's talk about some of the common injuries that marathon runners face. And I'd like you, Dr. Singh, to talk about injuries that long-time runners, chronic injuries that people face, but also new runners and what they should be on the lookout for as far as red flags, pain. "Oh, wow. I felt my knee today. I've never felt that before" or "My shin today, I've never felt that before." Speak about some of the common injuries that you see.

Dr. Jaspal R. Singh: When I started my marathon journeys, and like I said, I've done a lot of reading and research, and there's two schools of thought. There's one school that says marathon running is bad for you. People should not be running marathon and putting your body through such a rigorous effort and force. So, I took a deep dive into the research and looked at that, and it turns out actually marathon running isn't bad for you. People were concerned about scar tissue developing in the heart muscle, people were worried about developing arthritis. So many times that I hear it, even from my patients, "Oh my God, you're going to get arthritis because you're running a marathon."

So, I can say pretty confidently looking at the meta analysis, looking at the systematic reviews that that's not true. If you train properly, if you ramp up your volume slowly and judiciously, you can safely train for marathon and avoid injuries and prevent complications down the road. The most common things that I see, and we're in the season, September, October, November, leading up to the New York City marathon where injuries happen because these last few weeks or the last month is when the training volume really increases. We're talking about late double digit mile runs, so 18-mile runs, 20-mile training runs. And without rest and without proper cross-training, a lot of injuries occur. So, what I see in my clinic are the most common things; knee pain, which is patellofemoral arthritis, or patellofemoral overuse syndrome, runner's knee; shin splints, hopefully not stress fractures in the foot, and then things in the lower body like your IT band, which is sitting on the outside of your leg, or your glute muscle, your buttock muscle, you get soreness.

And I believe, and just based on what the data shows as well, the most common reason for most of these injuries to occur is you aren't resting enough, or you're running too much, and you aren't doing the requisite resistance and cross-training, because those muscles that are really useful and support your gait that allow you to minimize injury. So, lower extremity things are the most common things we see and we just tell patients, you know, back off the running for a little while, work on strength training, work on resistance and slowly get back into it.

Melanie Cole, MS: I think you made the major point here is the cross-training, because we've seen injuries, you and I in the field over the years of sports-specific training for anything really, youth sports, tennis, soccer, whatever it is, sports-specific. But for marathon runners and specifically runners, boy, some are so dedicated that that's all they do and try and run through that chronic pain when that's not always the best idea. Do you have some advice for that chronic pain as far as wrapping? Because, you know, you see them out there with their knee wraps on or their ankle wraps and then even shoes, Dr. Singh, because they can make a world of difference. I can go walk five miles and come back and feel, "Oh God, my knee hurts or the arch of my foot hurts." I put my new shoes on, do the same thing the next day, and I don't feel anything.

Dr. Jaspal R. Singh: When thinking about training for a marathon and the whole idea of running 26.2 miles, it's pretty scary. It's daunting. So, beginner runners, I was guilty of this also, all you think about is the run. "I have to make that distance. I have to be able to run for whatever, three, four, five, six hours. And you focus on that, and you forget about all the other supportive muscles, like your core muscles, like your quads, your hamstrings, your glutes. So, by doing the cross-training, things like swimming, or cycling, yoga, Pilates, core work, all those things are going to support you in preventing injuries in the long run. Now, we all have different body habituses. We all have different shaped feet. We all have different length of legs and hips and things like that. So, not every shoe is going to fit the same person.

The technologies in shoes has developed and exploded over the last five, 10 years, and you might want to run out and get a brand new trainer with a carbon plate, because they say it's going to make you faster. Yeah, it's going to make the really fast, elite marathon runnies a little bit faster. But for 99% of us who are kind of recreational runners, the carbon plate is probably going to do us more harm than benefit, because there's no cushion. You really need that cushion. Like I said, you're running 26 miles. You're going to be on your feet for hours and hours pounding, pounding the pavement. So, getting yourself something with a really thick cushion. And again, the technology out there is fantastic between New Balance and Brooks and Asics. But getting something that will give you some cushion is going to reduce the ground impact force with every heel strike that goes from your ankle to your knee to your hip to your spine. People get back pain all the time with running and they wonder why. It's because these forces are being transmitted up from the ground. So, preparing yourself with those exercises is helpful. K taping and wrapping can sometimes position joints that are a little bit out of alignment that can also prevent injuries. But really, focus on what's worked. Focus on stretching, focus on strengthening, and then obviously do the aerobics and cardio to get your mileage up to speed.

Melanie Cole, MS: This is so informative, Dr. Singh. So, let's think about the mental aspect, because for me, and you said anybody can really do it. I think I could, but it is the mental block, really. I know I can go distance. The running part has that mental block for me. And I'd like you to speak about your own experience, how you got past that, and the people that are really good at marathons, how do they prepare themselves mentally for not only the marathon itself, but the training that goes with it?

Dr. Jaspal R. Singh: I'm not a professional runner. I'm going to put that out there already. I'm a good researcher, so I can read a lot of books and articles on how to mentally prepare. But I'll tell you, the first year I ran it, and this is my fourth year now, marathons four and five this year, the first year I remember doing one of those long runs, 18 or so miles, and coming back and just being kind of defeated, thinking, "Oh my God, I have to run eight more miles for the actual marathon." It was kind of depressing and I felt defeated until you start realizing that marathon training, just like anything else, is one step at a time. And I tell my kids this, I tell patients when I see them in the office about weight loss and getting back to their activities. Everything in life happens with one small step. So if you start thinking about 26.2 miles on day one, yes, it's going to be tough to visualize that goal and maintain that positive self-talk. So, one step at a time is what I tell patients, at a time is what I tell myself. And that's how dreams are accomplished, right? I mean, anything you set your heart out to accomplish, whether it's a weight loss goal, whether it's a fitness goal, whether it's a finance goal, whatever it is, even at work to get a promotion, it must come with one small step at a time.

You know, the other big thing about running and the running community is that it's so encouraging out there. You know, I train in Central Park a lot in New York and everyone is encouraging you. If they see you walking, you don't know these people. They're all strangers, but they clap for you and they say, "You can do it. The finish line is right around the corner." And I think the philosophy is because in marathon world or in running world, there's kind of an understanding that there's room at the finish line for everyone. So rather than competing less with one another, we encourage each other more. And just having that community of runners has really helped me stay positive, stay confident. But that's my mental approach. My mental approach is you're going to have bad days. You're going to have a bad training run where you can't run 10 or 12 miles or one mile, and you're going to have good training runs. But if you're running uphill, there's a downhill right around the corner is another kind of saying that I go with. And that's what propels me and pushes me to finish this goal.

Melanie Cole, MS: That's so cool. Now, Dr. Singh, one of the things that goes along with those rest days that the chronic overuse and cross-training we're talking about, the recognition of injuries, and the proper footwear, all of those things comes nutrition. Now, we used to, you know, only talk about when I was in graduate school and exercise phys, it was like, we talked about carbo loading and the night before and all of those things. I'd like you to speak now about nutritional practices for marathon runners as they're training, and then how their diet should change leading up to the race. What role about hydration? Obviously, we know so much more than we used to. And I even add in a little stuff about your electrolyte balance and those beverages, energy gels, any of those things.

Dr. Jaspal R. Singh: One thing I want to stress about injuries versus pain during training is to really recognize the difference. Because when you are training for a marathon, when you are putting in this amount of weeks of running and cross-training and stretching, you're going to be sore. So, there is normal soreness. And normal soreness is usually bilateral, so you'll feel it maybe on both sides. You might feel it a little bit more on one side. It usually resolves after a few days. And that's all normal, and expect that to happen. What you want to be worried about is when you feel something sharp, or it's localized pain. It's tender to palpation, it might get worse with activities, there's swelling, there's redness. Now, these are injuries where you might want to modify your activities, so that if an injury is brewing, you can kind of mitigate it and halt the progressions quickly so you can get back to your activities. So, just a little caveat on normal soreness versus real injuries and things like that.

Now, nutrition is critical. And just like during the marathon training, it's important to experiment with different types of gels and gummy chews and water and electrolyte drinks during your training runs, so that when you're actually running the marathon, you're not doing anything new. That's a huge mantra in marathon training, is don't do anything new the day of the race. It should all have been practiced multiple, multiple times, and choreographed throughout the process so that everything is very familiar. So, nutrition is key. You know, without lean muscle mass and all the strength training and resistance training, your muscles cannot propel you forward. So, having a diet that's rich in complex carbohydrates, having a diet that's high in protein. I talk a lot about protein on my newsletters. And a lot of people don't take in enough protein, especially those with dietary restrictions, whether they're vegan or vegetarian. You must supplement it so that you can achieve between a gram or a gram and a half per pound of body weight to build that lean muscle to propel you forward. So, having that diet throughout your training is very important.

The carbo loading is interesting. When I was in high school, the mantra or the thought was, "Yeah, just eat a big pasta the night before a race." And really, it's not sufficient enough. You need a couple of days for your muscles to rebuild these glycogen stores, because glycogen is the fuel that's going to get you through the marathon. Most of our glycogen in our body is held in our liver and our muscles, so rebuilding those glyco stores, those carbohydrate stores for three to four days will be helpful. So, a few days before the marathon, start eating potatoes and complex carbs and pastas and breads, so that you are well-replenished during the race.

Electrolytes and hydration are key too. You know, Gatorade is a really famous drink that was started in Florida. And basically, what they did was they looked at sweat. There was actually an interesting study they did at the medical university. They looked at the content of sweat and said, "What are people losing when they're training?" It was for the University of Florida football team. And they found that it was a lot of sodium and potassium and magnesium. And that's how they formed this drink called Gatorade. It's the University of Florida Gators. That's what's in there. They made a sweeter obviously, and now they have G0 without sugar. But replenishing those electrolytes, replenishing calories during your run, you must practice that so that on the race day you don't hit that famous wall and you don't finish it at 20 miles. But maintaining electrolytes, maintaining hydration are very, very important.

Melanie Cole, MS: It's true. And it's interesting how things have changed from what we've learned, but that Gatorade story, that was really cool. I did not know that. So now, let's talk about day of. You talked about nutrition and mental preparation, day of the race. Get in there. Layers, I mean it might be chilly in the morning, get hot after 10 miles, 15 miles. I'm somebody who sweats a lot, so the layers, I wouldn't even probably start with those, but a lot of people would need to do that. So, I'd like you to speak of day of and then recovery, the next day and dealing with all of that.

Dr. Jaspal R. Singh: I think the mental preparation aspect of marathon running is super important, especially the couple days leading up to the actual race day. So, day of really depends on where you're running, what the anticipated climate and weather look like. I'm actually running Berlin soon in a couple weeks and then New York City six weeks after that. And the weather's going to be about the same. They say it starts about 55 or so degrees in the morning, but you're waiting in those starting corrals for a long time. You could be there, especially for New York, you could be there for an hour, a couple hours. So, you want to stay warm. So wearing a sweatshirt that you can discard, wearing some sweatpants that you can get rid of at the start of the race, or help with just so your muscles don't get tight and crampy. And then, as the race proceeds, you can start removing some of these layers. I am someone where my hands get a little cold so I like gloves, but my arms and legs stay warm so I don't need long sleeves or pants. But preparing yourself in terms of clothing is very, very important.

And then also, lay out everything. Lay out your bib, affix it to your shirt, get your socks, your shoes, your gels, your water bottles, your hydration packs. Get all that ready because the last thing you want to do is stress yourself out in the morning. You want to shower, you want to have your breakfast that you've been training with. Whether it's a bagel with peanut butter, whether it's a banana, whether it's a cup of coffee, have all that ready, don't experiment with it, so that you're mentally prepared to make your way to the starting corral.

And then, once you're in the starting corral, like I said, you're going to be there 30-40 minutes, maybe even longer, start doing some warm-ups. You don't want to do significant static stretching, like holding a pose. There's a lot of research that says keeping your muscles a little bit tight actually improves performance. The same is true for marathon running. Just some dynamic stretching, getting the blood flow in those certain areas. You're going to have a lot of time to warm up. I mean, it is four or five hours, six hours of running sometimes, So, you're going to warm up throughout the race. And then, sticking with your game plan, saying when am I going to hit my first gel, where are the water stations, kind of review the course, are there hills that I should prepare for, and then what's the finish line looks like, and just visualize that. It's all about mental visualization. What does it feel like? What is it going to look like when I cross that finish line? And kind of take yourself there, and I think that will help you finish.

Melanie Cole, MS: Final thoughts, Dr. Singh, best advice about planning, training, preparing for a marathon. What do you want listeners to take away from this that can really help to motivate them?

Dr. Jaspal R. Singh: I think this has been an incredible journey for me. Like I said, I got into running late in my life, early 40s. I have found nothing but benefits as a "runner." Obviously, the health and fitness benefits. My good cholesterol is really good. My resting heart rate is much lower. I actually have asthma, and I don't use my medications anymore. The mental aspect of it, just knowing that you can set a goal and accomplish it, it's so meaningful. I think there's a sense of personal achievement, that it's tough to conceptualize until you're in there and kind of doing it and saying, "Oh my God, what did I just accomplish?" It's great for my mental health and stress. I live in New York City. Kids, family, work, you know, things get stressful, and it's a great way to release endorphins. It's a great way to improve mental clarity. I actually don't listen to anything. I don't listen to music. I used to listen to some audio books, but now it's just me and my thoughts and my footsteps and looking at the cadence. So, that's really helped me in my mental health.

The sense of community, like I mentioned, is tremendous. Runners motivate you. They support you. It's a social outlet. There's a saying in marathon running, if you want to go fast, go alone, go by yourself. But if you want to go far, go together. And I think that mantra can be used in so many things with family members, with work, and things like that.

I know for my kids, it's been nice to see them. I feel like I'm setting an example. My son, anytime he sees someone running, he's always like, "Daddy's marathon runner. I'm going to run a marathon with you." So, I think that would be amazing if one day I can run a marathon with my kids. But enjoy the process. It's all about forming new habits, setting out the process so that you visualize what you want to do every step of the way. And I go back to everything in life happens with one step at a time. And if you kind of live your life by that, who knows what you can accomplish and who knows what you can achieve.

Melanie Cole, MS: Thank you so much, Dr. Singh. What a great guest you are. So much quality information to help people motivate and get started if this is really something that they've always wanted to do. And your story is very inspiring. And I do hope that you get to run with your kids one day because how cool would that be?

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