No one has linked caffeine to either case (or most others). The amount against which the medical directors group cautions — equivalent to two cups of home-brewed coffee, or one cup plus two caffeinated energy gels — would not raise flags in an autopsy.
Physicians believe multiple factors come together at a particular time in a particular way to stress a diseased cardiovascular system (more common in racers over 40) or push a previously unidentified abnormality beyond the breaking point (in competitors under 35).
The notion that caffeine might be an invisible trigger came up at an International Marathon Medical Directors Association meeting in Barcelona, Spain, in 2010.
“What we all were trying to put together was why people were dropping at the ‘X spot,’?” said Lewis G. Maharam, chairman of the group, referring to the term he coined for the first place where runners can see the finish line. The pattern was so clear, he said, that he would locate the spot before events that he oversaw, mark it with chalk, and order paramedics to stand beside it.
“The presumption is that when you first see the finish line,” Maharam said, there’s a “?‘Wow, I can finish,’ and then a rush of adrenaline to the heart” and a sprint to the end.
The group discussed research that showed caffeine temporarily increases blood pressure and decreases blood flow to the heart during exercise for reasons that are unclear. But other studies have found that regularly consuming moderate amounts of caffeine may protect the cardiovascular system. Regular exercise certainly does.
They also recounted their experiences over years of interviewing runners who had been resuscitated.
“Almost every one of them had done energy drinks or multiple cups of coffee,” Maharam said.
“We believe that it is a no-brainer to ask runners to limit caffeine on race morning,” Maharam said. The group also recommends taking one baby aspirin to prevent clots that can lead to a heart attack.
The group’s other recommendations, such as discussing plans for a race with your doctor at an annual physical and drinking what you need for thirst but not overdoing it, are more critical and are supported by more evidence.
Jeffrey Lee, 21, of Cerritos, Calif., collapsed and died just after crossing the finish line in Philadelphia’s half-marathon in November. The University of Pennsylvania senior was believed to be in excellent health and had run races before, although his brother has said this was the longest.
Chris Gleason, 40, a lawyer from Clifton Park, N.Y., had completed three Ironman triathlons and three marathons and was on track to meet his goal of a three-hour Philadelphia Marathon when he collapsed about a quarter-mile before the end.
“He was the healthiest guy I had ever known,” said his widow, Jennyfer. She said he might have had a small coffee and used Hammer Nutrition products, some of which may have contained caffeine, but would not have done anything out of the ordinary that morning. She said she had not heard cautions about caffeine.
The Philadelphia Medical Examiner’s Office attributed both deaths to cardiomyopathy, an often-asymptomatic thickening of the heart muscle that can disrupt heart rhythms. It is the most frequent cause of sudden cardiac death in young athletes.
Aaron L. Baggish, associate director of the cardiovascular performance program at Massachusetts General Hospital, said caffeine could pose a risk for someone who is not used to it, consumes a lot, and also has a heart problem. But he said the blanket recommendation goes too far.
“Caffeine is used by many, many, many endurance athletes,” he said, and even several cups of coffee would be metabolized in an hour or so, well before marathon runners reach the spot where deaths occur.
“Nothing that I’ve ever seen in any of my research suggests that caffeine is the problem,” Baggish said.
Twenty-eight years ago, the running death of fitness guru Jim Fixx, the best-known proponent of running for health, led to widespread fears about running safety. David S. Siscovick, a professor of medicine at the University of Washington, was lead author of a paper three months later that analyzed the combined risks and benefits of vigorous exercise.
It found that men were more likely to die during strenuous exercise than at other times but that regular high levels of activity lowered the risk of death. At greatest risk would be non-runners out for a hard run.
Because multiple factors are probably involved in a sudden death, he said, a link to caffeine or any other source is hard to prove: “There may be triggers. And vulnerabilities to triggers.”
Caffeine comes from many sources. A 16-ounce coffee can exceed the marathon medical directors’ recommended maximum of 200mg. Two Excedrin caplets deliver a dose of 130mg. One Carb-BOOM! energy gel has 50mg.
Deaths of even experienced competitors are not limited to marathons. A 29-year-old teacher and black belt in the Korean martial art of tang soo do died after crossing the Broad Street Run’s 10-mile finish line in 2007. A 45-year-old plumbing supervisor collapsed and died midway through his fifth running of the race in 1998.
“I don’t think it matters by distance per se,” said Bruce Adams, medical director of the Marine Corps Marathon.
Adams, a member of the international committee that wrote the caffeine guidelines, said the stimulant may pose greater risks to less-experienced runners who are more likely to register for Broad Street than for a marathon.
“My general advice would be, ‘Run like you trained,’?” he said — at the same pace (no dash at the end), and with the same amount of water (no reason to drink at every station).
Contact Don Sapatkin at 215-854-2617 or email@example.com.
Guidelines for Competitors
To reduce the risks of sudden death, the International Marathon Medical Directors Association recommends:
Training: Besides sufficient training, participants should have a goal and race plan to match their training and fitness level.
Physical: Discuss exercise plans, goals, and intensity with your doctor annually.
Baby aspirin: Consume 81 mg aspirin on the morning of a run or walk of 10K or more unless there is a medical reason not to.
Caffeine: Consume less than 200 mg before and during a 10K or more.
Sports drinks: Only use a sports drink during a workout of 10K or more.
Fluids:Drink for thirst.
NSAIDs: Avoid nonsteroidal anti-inflammatory drugs during a 10K or more.
Salt: Consume salt during a 10K unless there is a medical reason not to.
Last mile: Maintain your pace or slow down; do not sprint to the end unless you practiced it in training.