A Marathon induced depression

Feb 5, 2020

This is an abridged version of an article that was originally published in FSN Magazine in November 2017…

This is the case of a formerly robust 32-year-old female investment banker, whose health declined after completing her fifth marathon. The case study was presented at the recent IHCAN Functional Sports Nutrition conference in London. It will demonstrate the application of the functional medicine model in identifying the root cause of the patient’s poor health. Additional tools used with this model are the time-line, and the ATM’s (antecedents, triggers and mediators).

It will demonstrate the application of the functional medicine model in identifying the root cause of the patient’s poor health. Additional tools used with this model are the time-line, and the ATM’s (antecedents, triggers and mediators).
When presenting case studies, we need to be mindful that all cases are individual and there may not be one standard treatment protocol for similar cases. Despite the fact that this patient improved following my treatment, I cannot guarantee that this was induced solely down to my interventions. Although we would love to think that it was!

Background: This patient presented at my clinic in February 2016 with depression and chronic fatigue like symptoms, that had begun to appear shortly after becoming unwell during the latter stages of her fifth marathon in May 2015. The marathon was clearly the trigger for her current condition.
She had gone to her GP in June 2015, still feeling unwell, and had subsequent blood tests completed, which all come back normal. Her GP suggested post-viral fatigue, triggered by the marathon, which would eventually clear up. Under the circumstances; good advice.
Her symptoms continued, however, and by December 2015, she presented back at the
GP, where a diagnosis of possible depression was discussed. Treatment options, which included medication, were suggested by the GP. The patient chose not to go down this route and subsequently came to see me for an alternative treatment plan.

The timeline tells the story… One of our best investigative tools is the timeline: a chronological and detailed case history allows potential clues to be plotted out. With the patient being so healthy up until the marathon, it was clear that the action of running such an event was the key to understanding her current symptoms. I theorised that her gastrointestinal tract suffered significant trauma on the day and that the continued consequences of the marathon were still mediating her current condition.

I worked through her timeline, from pre- and post-birth (antecedents) right up to the point when the marathon finished and I applied scientific rationale at various points on the timeline, which may have relevance to the case.
My patient came from very healthy parents and grandparents, who were all still alive. She was born by C-section and bottle-fed, factors that may have increased her risk of microbiome and immune related concerns, when matched against normal delivery and breast feeding in early life. She had some recurrent otitis media (for around five years), which was treated with antibiotics; again, suggestive of possible microbiome, gastrointestinal (GI) and immune dysfunction. Additionally, it has been shown that one course of antibiotics can change the microbiome for at least one year in duration.

The only time she started to see GI symptoms was when she started to take up regular running and competing in marathon events. Endurance events, running in particular, can create a ‘perfect storm’ of events for trouble in the GI tract.

The day of the event… On the eve of the marathon, my patient consumed a meal that was higher in refined carbohydrates and saturated fats than she would normally have eaten. She also drank more alcohol than she would normally drink and I propose that these actions may have contributed to increased GI inflammation and to an increased risk of intestinal permeability. She was, however, well-hydrated before going to bed and felt great on the morning of the event.

In the first hour of the race, she felt great and was on target for a quick time. In her second hour, however, she started to experience some GI discomfort and noted that the weather had become much warmer. Her symptoms worsened and to counteract this, she slowed her pace rather than lose control of her bowels. By the third hour, her pace had slowed considerably, mainly in an attempt to prevent having a bowel movement. Despite this slowing of her pace, she managed a time that was within one minute of her previous personal best.
Immediately after the race, she was in significant GI distress and needed the bathroom. Following a forceful evacuation, she felt somewhat better.

My theory and working hypothesis….My theory? The marathon had induced an inflammatory cascade; i.e. a cytokine storm. The resulting effects created increased permeability of the GI tract, allowing higher than normal levels of gram-negative bacteria to enter the body, carrying lipopolysaccharides. The increase in lipopolysaccharides created endotoxemia and stimulated a cytokine response that continued to mediate her symptoms. A response that mirrored the results of Jenkendrop et al on competing triathletes. she was back at her hotel room several hours later, she had become very fatigued and feverish and took some non-steroidal anti- inflammatories (NSAIDs) to relieve these symptoms. Did these NSAIDs aggravate an already highly irritated and inflamed GI tract? Despite the medication, she continued to experience fever and flu-like symptoms throughout the night. These symptoms had begun to ease by the morning, by which time the effects of muscle soreness had started to develop.

My interventions…After discussing the findings with my patient, she indicated that she would like to do as much with real food as possible and then to use supplementation. Homemade fermented foods, such as sauerkraut and yogurt, therefore became staples in her diet.
My past experiences with supplemental regimes have taught me to go slow and titrate up gently over a few weeks. Many patients find large doses of multiple supplements too much to tolerate early on and with my patient, we were using foods first. The supplement choices used were mixed ingredients to support GI mucosal repair, and a reduction in inflammation.
Are supplements the answer? No, but they are one part of the recovery. We should not be ‘green pharmacists’, replacing a pill for an ill with a supplement for an ill. We need to do much better; we have to treat the whole of our patient’s life. For example, getting her to engage more with friends and family was good socio-genomics – there is plenty of evidence to show how this can enhance health and mood. Using simple and very low-level exercise to engage her more with the outside world was a step forward to reducing the social isolation that can occur with high levels of cytokines. We agreed not to do any significant ground reaction activities.

If you would like to know more about how Functional Medicine could help you, please get in touch.