Those in the medical arena are better equipped than many to understand the marvels of the human body, exactly what it’s capable of and how far its limits can be stretched. But where did the ‘insanity’ of the marathon begin?

There is arguably no greater test of human endurance than the marathon. The race is superhumanly physical, surprisingly strategic and – quite often – overwhelmingly emotional. It is one of the only events where the accomplishments of the professionals are just as celebrated as the efforts of the amateurs. Every year, more than 100,000 people around the world run the 41.195km, pushing their bodies to the limit in the name of physical fitness, personal growth and, in some cases, raising money for charity.

Indeed, just making it to the starting line calls for months of training, dietary changes and mental psyching-up. According to seasoned marathon runner and cosmetic physician Dr Peter Muzikants, deciding to undertake a first marathon, after racing in shorter distances and half marathons, often calls for extraordinary circumstances to fuel the external and internal motivation required to train and prepare both physically and mentally.

“I’d already been doing half marathons and shorter distances. Then, in the year 2000 when we had the Sydney Olympic Games, they organised a marathon to run along the exact same course as the Olympians and to finish in the stadium. That’s when I decided to step up and complete the full thing,” he says. “Since then, I’ve done around 10 or so marathons.”

Dr Muzikants isn’t the only one. The popularity of marathon running is well and truly on the rise. Recent research from Jens Jakob Andersen from Copenhagen Business School and has found a global increase of 13 percent in marathon participation between 2009 and 2014. In Australia alone, there has been an 84 percent growth in the same time period.

The history of the marathon

The marathon originated in ancient Greece. The distance comes from the legend of Pheidippides, the Greek messenger from 49 BC who ran from the Battle of Marathon (in which he also fought) to tell the people of Athens that the invading Persians had been defeated. After running the entire distance without stopping, Pheidippides burst into the assembly announcing “we have won” and – legend has it – collapsed and died immediately.

The journey of Pheidippides from Marathon to Athens can take several routes, and the actual distance Pheidippides ran – somewhere between 21.4 miles and 25.6 miles – is not known for certain.

When the Olympics were revived in 1896 in Athens, organisers saw the marathon as a way to celebrate Ancient Greece and generate more publicity around the inaugural Modern-Day Olympics. The winner of this first Olympic marathon was a Greek water-carrier who finished the run in 2 hours, 58 minutes and 50 seconds.

The physiology of marathon running

Marathons are arguably one of the greatest tests of human endurance. One just has to consider how long it takes the body to return to normal following a marathon to fully understand the level of stress running 26.2 miles can inflict on the body.

Dehydration, muscle fatigue, cellular damage, sodium imbalance, a compromised immune system and urinating blood are all potential consequences of marathon running.

Troponin increases are also relatively common among marathon finishers. The molecule, released from the heart tissue, can reach levels in the blood typically diagnostic for acute myocardial infarction, according to a study, by Fortescue et al (2007), published in the journal Annals of Emergency Medicine.

This study analysed the blood of 482 runners at the finish line of the Boston Marathon. The results showed that most runners (68 percent) had some degree of post- race troponin increase and 11 percent had significant increases (troponin T > or = 0.075 ng/mL or troponin I > or = 0.5 ng/mL).

The report states that marathon inexperience and younger age appears to be associated with troponin increases, whereas race duration and the presence of traditional cardiovascular risk factors are not.

As for myoglobinuria, this is commonly linked to extreme exertion and muscle destruction, while sodium imbalance is usually a result of consuming an inappropriate quantity of water, disrupting the body’s sodium concentration.

Hitting the wall

‘Hitting the wall’ is the phrase used to describe the event when the body moves from burning glucose to burning fat, usually around the 30km mark. It occurs due to the near- complete depletion of carbohydrate stores in the leg muscles and liver and, according to a study by Benjamin Rapport (2010) published in PLOS Computational Biology, results in a “drastic, abrupt and painful decrease in performance”.

“I’ve seen mates of mine fall apart, and it’s not a pretty sight,” says Dr Muzikants. “I’ve always finished strongly, and in relatively good condition and that’s to do with both luck and preparation. I’ve seen virtual spasms, severe muscle cramps and extreme nausea in those who have ‘hit the wall’. The possibility is always in the back of my mind.”

More than two in five runners report ‘hitting the wall’, and there are a number of factors involved in determining an individual’s level of risk. Rapport (2010) found these factors include muscle mass distribution, liver and muscle glycogen densities and running speed. The report goes on to say that recent research suggests the primary risk factors for ‘hitting the wall’ are male gender, running a maximum of 20 miles or less during training and psychologically ‘expecting’ to hit the wall.

According to Dr Muzikants, there are several tricks of the trade to help with a successful – and healthy – race finish. Part of this is keeping hydrated during the race, and trying to boost glycogen levels with glucose drinks and gels.

“I have tried various things that friends have suggested. When I first started, I would take flat Coca Cola along with me during the race, which is high in sugar, caffeine, electrolytes, potassium and sodium,’ Dr Muzikants explains. ‘Recently, I’ve given this away. Now, I take water and one electrolyte drink along the route. Mostly, I drink water.

Indeed the nuances of preparing for a marathon, as well as ways to recover from the event, can be very specific, and very personal also. Carbohydrate loading is a common technique to boost glycogen stores before the race, in a bid to prevent their complete depletion during the event.

“In the two to three days directly before a race, I cut out vegetables and start ‘carb loading’ with pastas and breads,” Dr Muzikants explains. “On the day before a race, I’m on a high-carb diet, drinking sugar drinks to increase glycogen stores in the body and reducing any fiber to avoid runner diarrhoea.”

“At the end of the race, I take electrolytes immediately and keep drinking fluids. In the days following, I return to a normal diet, adding fruits and vegetables and often some meat,” Dr Muzikants adds.

“I also wear pressure, recovery pants for a week day and night to reduce soreness and aching following a marathon.”


Physiologically, the main indicative factors for performance during marathon running are maximal oxygen uptake (VO2), the oxygen cost of running (also referred to as the running economy) and the fractional utilisation of VO2 at marathon race pace, as found in a study by Sjodin Svedenhag (1985), published in the Journal of Sports Medicine.

Together, these factors “can almost entirely explain the variation in marathon performance,” the report states. They also contribute to the anaerobic threshold and can help delay the fatigue associated with hitting the wall.

Training is the number-one way to optimise oxygen uptake and boost the running economy, according to the authors.

So how much training is needed before a marathon, and how much is too much? “I never run the full marathon distance during training,” Dr Muzikants says. “In two to three hours I might try to do 30km, as there’s no point stretching the body too much. Bear in mind, it takes the body around a month or more to recover from a run of over 30km.”

“It’s important to train consistently, and build up to two hours running plus, but it’s not necessary to do the full distance until the event day,” he adds.

However, finding time to run two to three hours can be difficult in a busy schedule. “Fitting long runs into a busy schedule is one of the hardest things I find with marathon running,” Dr Muzikants says.

“But getting up at 4am or 5am in the morning to fit in a two to three hour run once or twice a week means you’re buggered for the rest of the day, but in a good way. Even though you’re tired, you’re happy you’ve achieved something.”

But, why?

For the fun, of course. As insane as it might seem, Dr Muzikants says running 42.195km is rewarding, both physically and mentally, and can keep you motivated for future events. It’s also, as he explains, the perfect excuse to travel.

“The feeling of finishing a marathon is euphoric, even though you’re in pain,” Dr Muzikants says. “But the training is also enjoyable – the medical industry can be competitive in some ways, and running forms a good outlet for this stress. Going for a run can be therapeutic, relaxing and meditative, and lets you ‘switch work off’.”

“Physically, you obviously reap the benefits of being quite fit: you can work longer hours, you’re mentally more alert, and decision- making is easier,” he adds. “If ever I feel bogged down about things, or can’t decide on something, I look forward to going for a run to find some clarity.”

For those contemplating running a marathon, whether it’s a first venture into running or if it’s a step up from other distances, Dr Muzikants has some “words from the wise” to help in the preparation.

“Allow yourself a good loading time, and spend three to four months building up a good running base,” he says. “At first, don’t worry about sprints and interval training, just do the distances to build up stamina.”

“The goal for a first marathon shouldn’t be anything to do with time – you just want to finish in a good condition, not staggering home and never wanting to do it again,” Dr Muzikants adds. “The second and third time round, you can focus on timing. The most important thing? You want to be able to enjoy yourself.”

What happens to your body when you run a marathon

  • You’ll lose 2-5kg through lost fluid over the course of a marathon.
  • The number of calories used to run a marathon is around 2,800.
  • You’ll have sharper hearing – training for a marathon improves circulation to the ear, which provides a greater supply of nutrients to help preserve hearing.
  • You’ll most likely lose a toenail – clipping toenails short can limit the friction within your trainers, but it’s almost inevitable given that the average runner takes 32,000 strides during a marathon.

If you thought running a marathon was enough…
Q and A with Dr Gavin Sandercoe, Ironman triathlete

How did you first become involved in Ironman triathlon?

I got into triathlon at the end of my first year of plastic surgery training. I was pudgy and unfit, but had done a bit of running and swimming and biking in the past.

marathonI was discussing the Women’s 2004 Olympics Triathlon with a consultant. I said that the distances seemed achievable, and was told: “Dr Sandercoe, I don’t think you have the physique of a triathlete.”

My consultant was right, but I decided to take up the gauntlet and change my life. Throughout my training as a plastic surgeon, I trained and raced for sprint and Olympic distance races. In reality, I could not train for any races longer than this with the hours required as a trainee plastic surgeon.

As I entered my final year, I got used to even less sleep to create time for studying. I had been warned about the possibility of post-exam depression when trainee plastic surgeons get past their final exam. Once I found out that I had passed, I decided to channel that time and energy into completing an Ironman. It was a ridiculous aim at the time, and my wife questioned my sanity, but sometimes the best way to find out what you can do is to commit to something beyond your comfort level and make it work.

I’m not a gifted athlete. Although I was a reasonable swimmer at school, I was a ‘back of the pack’ runner, and had never ridden a road bike until I was 30! I was one of the guys that made up the numbers on the school rugby and weekend AFL teams, but spent a lot of time warming the benches.

I now race mostly because it gives me a target to train for. I want to maintain a healthy weight and be a good example to my children (and keep up with them as they get older). Prior to finding triathlon, I tried to exercise for different goals, all with minimal success. If I have a race on, I will train hard to meet my goals.

What was the attraction of Ironman triathlons over the standard distance?

The appropriate analogy in car engines is to compare diesel and rotary engines. Olympic-length racing is about red-lining for as long as you can before you burst. Ironman is more about finding a rhythm that is just beyond your comfort zone, and holding that until the finish line.

Ironman holds a unique appeal of “Swim 2.4 miles, Bike 112 miles, Run 26.2 miles, and then brag for the rest of your life”. Like deciding to run a marathon, it is an accomplishment that your family and friends understand and respect.

To be honest, I enjoy racing Half Ironman distance the most. It is a 1.9km swim, 90km ride, 21.1 (half marathon) run. The training is a lot friendlier for a family, and race day is a balance between red-lining and managing fatigue/nutrition.

Is it true you have completed five Ironman Triathlons?

Yes. I completed Ironman Busselton in 2007, 2009 and 2010. I also raced China in 2009 and Melbourne in 2014.

What’s been your favourite race?

That is such a hard question to answer. I am most proud of my Ironman races in China in 2009 and Melbourne in 2014. Melbourne 2014 is my fastest Ironman time, and China was an insanely hard race.

It was a unique cultural experience riding through traditional villages and running through the local markets. The temperatures peaked at 45 ̊C and about a quarter of the field (and half of my friends) did not finish due to dehydration and heat stroke. The medical tent at the finish line looked like something from M*A*S*H.

My favourite races are the Half Ironman (70.3) Races in Hawaii and the Philippines (Cebu). The Hawaiian 70.3 is a great swim, a ride along the famous Queen K highway up to Hawi and back, and then a solid run through the Kona Golf Courses. It is also in early June, so a great time to have a break from Sydney winters, so I have done this race three times.

I have only raced the Cebu 70.3 once, but it’s now my favourite race. The swim is over an amazing coral reef, an interesting bike course with a good road surface, but a hot and humid run. The support from the local crowds is insane – it is like what you see in the Tour De France, and an amazing experience in triathlon.

How do you taper before a race?

This is really opening a can of worms. Carbohydrate loading works on the idea that if you fill your muscles with carbohydrates before a race, you will perform better. I believe that the evidence on nutrition has changed a lot in the past decade. My normal diet is a bit light on processed carbohydrates – I try to avoid bread and pasta. I loosen those guidelines a bit in the few days before a race. The most important thing to me in the two to three days before a race is reducing the amount of fibre in my diet – no one wants to need a toilet stop (or a toilet accident) during a race.

The few days before a race is a bundle of nerves checking and double-checking things (mostly the bike), as well as trying to get a few race-pace, but short, sessions in to keep the muscles firing, not getting sunburnt, and trying to stretch, roll, massage. Focusing on the task ahead and thinking about the downtime and rewards afterwards and how much I will enjoy a deserved break are great motivators.

Take me through what happens during the actual race?

The race usually starts with a mass swim start. There are 2,000 or more athletes on a beach,marathon3 all of us are a bunch of nerves, waiting for the gun to go off. The first five to 10 minutes is frantic – arms and legs everywhere. Everyone gets a bit beaten up, but the field thins out in the first 10-15 minutes. Everyone gets into a rhythm and gets through the swim. We then change from swimming gear into our bike gear (transition) and get on our bikes. The bike course is where some athletes put out more than they can cope with – they start the bike strong and then fade during the day. Transition 2 is where athletes change from their bike gear into run gear. It often takes a few minutes to get the legs used to running after being on a bike for 180km. Some wisdom that was passed on to me is that the race begins at the half-way mark of the marathon. I agree completely. It is ok to keep your legs turning over for a while after starting the run, but it all gets hard about two hours in, and then the training and grit shows.

Have you ever ‘hit the wall’?

My first three Ironman races finished with me walking the last few hours. In retrospect, this may have been inadequate training. Hitting the wall or ‘bonking’ is a situation where the
athlete is competing at the pace they planned, and then the wheels fall off or a piano drops on their back. This happened to me in my PB race in Melbourne. I started cramping during some uphill sections at about the 30km mark, but managed to change pace and get some salt tablets in.

I slowed my pace a fraction and mentally gave up my race goal but knew I was still in PB territory. I made a conscious decision to slow down or walk through each aid station to ensure that I got enough calories and sodium in. At the last aid station (only 2km from the finish) I walked through to get in some Gatorade and Coke and then really battled to get my legs firing again. I felt awful, but I kept plodding one foot in front of the other. It took about 5 minutes for the sugar and salt to get absorbed and for my legs to feel ready to go.

Luckily this coincided with going past a shop front filled with cheering spectators (mostly drinking beer). I got my thoughts together and pushed towards the finish line. I’m happy that I left nothing in the tank, and that my PB was the best that I could do on the day.

Do you do anything special to help the recovery process?

My recovery is usually a hot shower and dinner with my support crew (family and friends). If I can get a massage, that helps. The next few days is always a bit tender, but the recovery seems to get easier as I have done more races. I usually take a week or two off, and then get back into training for the next race. Any longer than a month off and I find that I have lost some strength or fitness that I need to work to regain.

How would you say that running marathons has changed you – both physically and mentally?

Racing triathlon and marathons has definitely changed my body composition. I’m only a few kilos lighter than I was when I started in 2004, but I’m definitely carrying a lot less fat. It has also made me a lot more mentally tough, and able to persevere when life is a bit less rosy.

Do you have any tips for peers who are interested in triathlon? Your biggest obstacles are the excuses that you create. If you want to give it a go, work out how to make the rest of your life fit around it. If you enjoy the process and feeling of accomplishment, then you know it is worth the sacrifices that you’ve made. If it is not for you, at least you’ve given it a go.

For people that are thinking of going to a longer distance race, the only things you need to do are to find time for the longer training sessions, and learn what works for you in terms of pacing and race nutrition.

How do you find time to train?

The two biggest secrets are enough support and timing. I tend to drag family and friends into anything that I am doing. That helps create an enormous support network. I encourage everyone that if I can do it, so can they! Once I started in triathlon, my wife, father, siblings and my anaesthetist followed. My Dad had run a few marathons when I was little, but followed my lead into triathlon and a few years ago was ranked 2nd for his age group for the Half Ironman distance! My wife had to do triathlon training just so she could see me on weekends!

For a while, parental and sibling support was enough to help manage the family, but my wife marathonand I now rely an au-pairs so that we can both train and the children can be supervised. Our kids are also used to waking up and coming downstairs and we’ll be training on our bikes, so they grab a book or do some colouring in until we are finished and we have breakfast together.

I have tried to set up my life to minimise wasted time. My home, office, and main operating hospital are all within walking distance of each other. Aside from my days doing reconstructive surgery in the public hospital, I rarely have to spend more than 10 minutes per day in the car.

A general rule for having a busy career and balancing triathlon or running training is to embrace 5am! The end of the day can be more pleasant to train, but things often build up and get in the road and prevent the afternoon session. It also means being in bed by 10pm for me – others might cope with less sleep, but there is a high correlation between going to bed late and hitting that snooze button and missing a morning session.

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