In the northeast we are at the tail end of summer.  Kids are back to school and temperatures are lower in the morning and evening, and very pleasant during the day hours with the occasional hot day.  It is just as important to stay hydrated this time of year and all year as it is during the summer.  It’s just easier to do so now.

Many don’t realize during the summer upon wakening they are in a mild state of dehydration.  Which makes sense, unless someone makes a conscious effort to wake up and drink water every once in awhile during the night.  Here are 4 reasons to make staying hydrated a priority year round:

1.  Cardiovascular health – dehydration lowers blood volume so the heart has to work a little harder to pump the lower amount of blood in the heart and get enough oxygen to the body’s cells.  Being dehydrated makes daily tasks as well as exercise more difficult.  Ever get to the top of a set of stairs and say ” wow that was especially hard today.”  Think before you tell yourself ( ” I’m outta shape” ) to figure out if you might be dehydrated.
2. Cool water keeps body temperature down – when in a dehydrated state body temperature will increase.  Your body releases heat by expanding blood vessels close to the surface of the skin.  During exercise this is why people’s faces or skin gets red.  The result is more blood flow and more heat released from your body into the air.  When dehydrated though it takes a higher temperature to trigger the expansion of blood vessels, so the body stays hotter longer.
3. Muscles and joints – water inside and outside of contracting muscles provides nutrients to muscles and helps lubricate joints to enhance performance during exercise.  Waking up for an early morning workout and not taking a beverage with you to drink along the way will have you in a deeper state of dehydration post workout.
4. Cleansing affect – kidneys need water to remove waste from body and excrete into urine.  Proper hydration can also prevent urinary tract infections and kidney stones from forming.

•  Courtesy of One Medical.

As an addendum, water doesn’t give our bodies everything all the time.  Electrolytes are lost and are essential for the body’s metabolic processes.  If you heard about the TB12 method ( Tom Brady) he talks about staying hydrated quite a bit.  If you watch games you’ll see him always drinking a bottle with a cloudy substance in it.  That is his electrolyte drink.  Potassium and magnesium are just two of the essential electrolytes our bodies lose or are deficient in on a daily basis.  Purelytes and Liquid I.V are two brands along with the TB12 brand of electrolytes that can provide your bodies with the adequate nutrients it needs for daily living as well as living an active lifestyle.  Stay away from Gatorade, Powerade and other older name brands.

It’s important to know that we do NOT get all the nutrients from the typical American diet.  Not even close.  I have no affiliation with those electrolyte companies, but feel it important to share the importance of staying hydrated on a daily basis, and it’s even more important if you are exercising 3-5 times per week.  Drinking when thirsty is the best way to stay on top of this!

Many of have experienced the core hammers to this point in our outdoor season.  We’ve stood and slammed utilizing our whole body.  When standing, the power comes from the amount of power your lower body puts into the ground.  The power is transferred from the ground, to the lower body through your midsection.  From here your mid section is creating a slingshot to help the arms deliver the hammer into the ground.

Now, think about this, what if we are sitting down?  How will the power come from the ground, through the torso and deliver to the arms?  Now your core muscles are more responsible for creating the power.  Making this option a great exercise to strengthen and shape your core.

We’ve only just begun using the hammers.  Take a look at this video from Yancy Culp on some other exercise options we’ve used, and will use in the very near future 🙂

 

Check us out for a free week trial in either our Newton locations or in Canton Ma.  Click here to get free trial

The fourth nor easter in the month of March is on it’s way, so it only seems appropriate to talk about the cold/snow mizer himself Wim Hof and the Wim Hof method.  Below is a snippet from his site about the cold therapy:

 

The first pillar of the wim hof method is the cold. The cold is your warm friend. Exposing your body to it in the right way starts a cascade of health benefits, including the buildup of brown adipose tissue and subsequent fat loss, reduced inflammation to facilitate a fortified immune system, balanced hormone levels, improved sleep quality, and the production of endorphins— the feel-good chemicals in the brain that naturally elevate your mood.

Learn more about his method by going to his website.  Embrace the cold, embrace the weather and reap all the benefits you possibly can.

Got a broken heart?  Then lift some weights and call your doctor in the morning.  Everybody LOVES doing aerobic training.  From running to spinning to cross training classes alike.  Feeling the heart rate elevate, lungs burn and sweat pour gives many the perception they are doing the best thing for health, heart and fitness.  This is true to some degree of course.  But research has shown that strength training can elicit some similar and some unique heart benefits that aerobics cannot.  Here are 4 of those benefits.

LOWER BLOOD PRESSURE

Research from Appalachian State shows strength training lowers blood pressure both in the shirt and long term.  Strength training increases blood flow throughout your whole body including limbs.  This gives the heart more places to push the blood flow thereby reducing pressure on arterial walls.

HIGHER HDL COUNT

Fatty substances such as triglycerides and cholesterol clog arteries leading to heart attacks and strokes.  Both cardiovascular and strength training exercise stand to reduce both these fatty substances in the blood stream.  Strength training not only helps reduce serum levels, but it also has shown to increase high density lipo-proteins known as ” good cholesterol.”  High HDL levels are associated with improved heart health.  A 2013 study demonstrated young men who lifted weights regularly had better functioning HDL compared to those who do not.

LESS FAT AROUND THE HEART

There are two kinds of fat, subcutaneous that sits right underneath the skin and visceral fat which surrounds organs, even the heart.  In a study done in 2015 strength training was shown to have a bigger impact on reducing visceral fat than aerobic exercise.  The study followed 10,500 men for a 12 year period who performed strength training for 20 minutes per day.  They were compared to a similar amount of men who performed cardiovascular training for the same amount of time.  The results were an increased metabolic rate leading to a decrease in visceral fat above what the cardiovascular group achieved.

SOUNDER SLEEP

Something I’ve been trying to get people to realize is that strength training will improve sleeping patterns.  My own experience has been restless and poor sleeping when performing aerobic training on a regular basis.  It’s just the opposite when I strength train though.  Sleep deprivation triggers inflammation that causes cellular damage to the cardiovascular system.  Poor sleep patterns are linked to poor insulin sensitivity, poor fat metabolism which increases visceral fat.  A study published in the Journal of Strength and Conditioning shows strength training improved sleep, a greater improvement was seen even more when performed in the evening.

In conclusion, our program is built around strength training.  Almost all the exercises we do involve using ” core” muscles either from a stability or strength stand point.  It’s designed this way because it really is the best way to train for lifelong fitness and heart health.  Happy Valentine’s Day everyone.  I hope you have some strength training planned to celebrate.

 

Five different, healthy recipes using pumpkin as an ingredient. It isn’t the end all be all as far as flavor or even nutrition, but for some reason it is really fun finding ways to consume the pumpkin! Here are 5 ways to get the flavor into your daily meal planning.

1. Pumpkin protein pancakes – that sounds good just saying it.

Ingredients:

1 cup canned pumpkin. ( make sure pumpkin is only ingredient)

2 scoops vanilla protein

1cup egg whites

1/4 cup coconut flour

1/4 cup unsweetened almond milk

1 tsp pumpkin pie spice

1/2 tsp cinnamon

4-6 scoops kal stevia

Directions:

Combine ingredients into food processor and cook on a skillet with a little coconut oil. Medium low temperature.

2. Vanilla, pumpkin and banana smoothie – another mouth watering name.

1-2 scoops vanilla protein powder (chocolate could also be used)

1-2 whole bananas

1/4-1/2 can of pumpkin puree, or use real pumpkin chunks purchased at Whole Foods.

1 tsp cinnamon

Add enough almond milk so it is higher than other ingredients combined in the blender. Blend until desired smoothness. Add less milk for a thicker smoothie. Great post workout or if you are in between meals looking to tide you over.

3. Pumpkin soup – Surprisingly good. There are many variations, this one is quick and easy.

Ingredients:

1 tablespoon olive oil

1 onion chopped

2lbs of pumpkin flesh chopped

1 carrot

3 sprigs fresh rosemary

4 cups chicken stock or vegetable stock

3 bay leaves

1 cup skim milk powder

Directions:

In a large saucepan heat olive oil and gently cook onion without browning, 3-4 minutes. Add pumpkin, carrot and rosemary and cook, stirring for 2-3 minutes. Add stock and bay leaves. Bring to a boil, cover and simmer for 12-15 minutes until vegetables are tender. Remove any rosemary stalks and bay leaves. Place 1/3 of the soup in a blender with 1/3 of the skim milk powder and puree. Pour into a large bowl. Repeat with the remaining soup and milk powder and pour back into saucepan, heat through and serve. Use vegetable stock for vegetarian friendly option.

4. Rosemary pumpkin hummus – Hungry yet?

Ingredients:

1 can (15 oz) chick peas

1/2 cup pumpkin puree

1 garlic clove

1 tablespoon of rosemary minced

1/2 tsp cumin

juice of 1/2 of lemon

5 tablespoons extra virgin olive oil (more for a smoother, creamier result)

salt and pepper to taste

Directions:

In a food processor combine all of ingredients except olive oil and pulse until coarsely chopped. Slowly add olive oil in small increments until hummus is desired consistency. Serve with pita chips and carrot sticks.

5. Pumpkin turkey chili – may not sound as tantilizing as the others, but it is really good.

Ingredients:

1 tablespoon extra virgin olive oil

1 chopped onion

1/2 cup chopped green bell pepper

1/2 cup chopped yellow bell pepper

1 clove of garlic minced

1 lb ground turkey

1 (14.5 oz) can diced tomatoes

2 cups pumpkin puree

1 1/2 tablespoons of chili powder

1/2 teaspoon ground black pepper

1 dash salt

1/2 cup shredded cheese

1/2 cup sour cream

Heat oil in large skillet over medium heat, saute the onion, green and yellow pepper, and garlic until tender. Stir in turkey and cook until evenly brown. Drain and mix in tomatoes and the pumpkin. Season with chili powder, salt and pepper. Reduce heat to low, cover and simmer 20 minutes. Serve topped with low fat sour cream.

Why you need them?  Probiotics aid in absorption of nutrients.  They ensure your body can absorb vitamins, minerals, and proteins from foods.  They also affect the number of neurotransmitters produced in the gut which impact mood, motivation and cognitive function.

Fat loss – a Japanese study found that by increasing probiotics for four weeks participants lost an average of 8.2 percent body fat.  Researchers believe probiotics aid in burning body fat by raising metabolism and ant-inflammatory signal called ” adiponectin” that improves the body’s ability to burn fat.

Detoxification – Probiotics displace harmful bacteria and improve the body’s ability to eliminate waste products and foreign compounds.

So, probiotics are indeed important!

Honorable mention list:

Magnesium -Magnesium is a mineral that is often overlooked and it is affects more than 300 processes in the body.  So, when a body is deficient it can feel as if it is falling apart!

Why you need it?  the quality of soil in the U.S has dropped, combine this with the increase in processed food consumption and we have a huge increase in magnesium deficiency among the American population.  In 1900 the avg daily consumption of magnesium in one’s diet was 500 mg/day.  Today the average is well below the RDA at 225 mg/day.

•  Magnesium has a calming effect on the nervous system reducing stress and leading to restful sleep.
• Seratonin is dependent on magnesium.  Magnesium supplementation is a natural way to get seratonin levels up without having to use anti depressants.
• Magnesium is key for healthy blood sugar levels.
• Magnesium deficiency sends nervous system into overdrive leading to increased stress and high blood pressure.
• Exercise increases need for magnesium by 10-20% due to sweat, stress management, fighting inflammation and allowing the body to clear cortisol( stress  hormone).

How to take it:

Scientists recommend 10 mg/kg/body weight.  Look for magnesium bound to any of the following:  citrate, malate, glycinate, threonate, taurate, fumarate or crotate.  Best results come from different forms in different doses.  Example:  take magnesium glycinate after a workout and then a blended magnesium at subsequent meals.

RESOURCES:

1.  http://main.poliquingroup.com/ArticlesMultimedia/Articles/Article/1500/Top_Five_Supplements_Everyone_Should_Take.aspx

The nutrition world, like the fitness world, runs on a pendulum swing.

Carbs are bad
Now carbs aren’t bad
Low fat is better
Low fat is bad
Eat more protein
Don’t eat too much protein

What is a person to do?  Which is the best route for success?  It all comes back to ” everything in moderation.”  Completely eliminating carbs might work for awhile but not forever.  The human body needs (good) carbohydrates to function.  Not doughnuts and pop tarts.  Red blood cells are made from healthy carbohydrates like green leafy vegetables, sweet potatoes and fresh, raw fruits. Glucose, which is carbohydrate that has been broken down to enter a human’s bloodstream for utilization, is the main fuel source for the brain.  Take away carbohydrates from one’s diet and, you’ve heard of the term “brain fog” right??

Healthy carbohydrates are essential for rebuilding broken down muscle tissue and replenishing energy systems through a process called glycogen re-synthesis.  So, if the body is deprived of them for an extended period of time while on an exercise program then muscles won’t rebuild, metabolism won’t increase and body fat will be gained instead of lost.  Carbohydrates aid in the transport of protein to the broken down muscle cell sites.  Without carbohydrates, less of the protein that is consumed will get utilized for muscle repair.

The best and simplest way to implement carb cycling for losing body fat is to break down your days down into two categories:

1.  Training days: big and small.
2.  Non training days.

TRAINING DAYS

A higher carbohydrate intake is required on training days.  The bigger muscles in the body are the legs and upper back.  Exercises such as squats, row variations, pull ups, dead  lifts are all exercises that create a large metabolic demand.  Dragging heavy sleds, heavy dumb bell or kettlebell carries are also examples of exercises that create a very large metabolic demand.  So on days that these exercises are utilized the carbohydrate intake can be higher.

BIG TRAINING DAYS  

A good guideline for carb intake for fat loss on a big training day would be to consume .25 grams of carbohydrate per pound of body weight.  So, someone who weighs 200 lbs should consume 50 grams on a big training day.  Use high glycemic carbohydrate for the first post workout meal like bananas, mangoes and rice.  For the second post workout meal use low glycemic carbohydrates like green leafy vegetables, blueberries, sweet potatoes.

For the third meal post workout if there is one ( depends on what time exercise is completed) stick to just protein with a healthy fat source.

SMALL TRAINING DAYS

Same exact rules apply as above with big training days EXCEPT for cutting the carbohydrate consumption in half.  Using the above example of the 200 lb person would mean 25 grams post workout in the first two meals.  Small training days are days where smaller muscle groups are trained.  For example some do a body part split routine where one day is dedicated to just biceps and triceps.  This type or workout won’t demand as much as training heavy with legs, upper back or chest.  A shorter workout will also require a lower carbohydrate intake.

NON TRAINING DAYS

On non training days stick to protein and fats with only trace carbohydrates from green leafy vegetables.  Good fat sources are almonds, almond butter, macadamia nuts, coconut and olive oils.  Proteins are proteins.

SAMPLE SCHEDULE

A sample day meal plan can look like the following.  This is based on early morning exercisers, as that is what we all are.

5:45 am Workout

First meal: 7:00 am (roughly) Post workout meal – protein smoothie with berries, protein powder and any liquid you desire.  This is the best time to drink or consume something ” high glycemic.”  So, your smoothie liquid could be orange or apple juice or any of the milks.  Bananas, cherries and other high glycemic fruits would be best consumed post workout if you at all.

Example 1:  3/4 – 1 cup frozen bananas, chocolate protein, , almond or coconut milk. Preferably almond milk due to a lower fat content, fat slows down absorption and ideally you want quick delivery of nutrients post workout.  Any other time of day it is a great source of nutrition though.
Example 2:  1/2 cup frozen blueberries, 1/2 cup frozen mango or banana, almond milk as a liquid or juice.  (Don’t go crazy with juice)

Second meal:  Lean protein source with sweet potatoes or brown rice.

Remaining meals:  As previously stated fats and proteins with vegetables being the main carbohydrate source.

Example 1:  grilled hamburger with 1/2 avocado, edamame beans, handful of salad greens.  With olive oil and a dash of sea or pink Himalayan salt

Example 2: chicken, beef or seafood stir fry.  No rice or noodles of any kind.

Consuming the right kind of carbohydrates in the right amounts at the right times are the 3 keys to weight loss success.  However this will only work if a regular strength training program, high intensity interval training program or a combination of the two (what we do) is being followed consistently.  Swimsuit body here we come!

Here is a great workout that can be done in the office in just four short minutes.  It’s short enough that there won’t be too much perspiration, yet long and challenging enough to be effective.  One round would be the minimum amount.  If time allows it try for multiple rounds throughout the day, in the office…

 

It’s back, the body transformation to jump start the bathing suit body preparation for anyone!  The first 2 weeks are free starting Monday May 1st.  The rest of May will be prorated once you decide to continue.  The program includes the following:

Metabolic strength training

Fat loss conditining

**Bonus**

Full meal plan including:

Weekly meal plans

Weekly shopping lists

Recipe manual

Dining out guide

Start now, look and feel great by Memorial Day!

Email gregg@greggsmithfitness.com or call 617-968-5539 to register.

There was time long. long ago when people who were outside running on the street for exercise were considered weird. The running ” boom” started back in the 70’s with runners taking to the streets with socks pulled up to the knees, head and wrist bands and short shorts.  The running fashion boom hadn’t come yet.  Jim Fixx is the author of ” The Complete Book of Running” and is also credited with two big revolutions in history.  The first being  starting the fitness revolution back in the 70’s.  Fixx also created awareness to the potential dangers of running when he died in 1984 while out on his daily run in Vermont.  So, he is a pioneer on both ends of the running spectrum.  Fixx’s father died of a heart attack as well at a much younger age.  Fixx was also a heavy smoker prior to picking up running.  Many believe these factors have more to do with Fixx’s death than running.  Is sudden cardiac death the exception or the rule when it comes to running many miles per week?

Jim Fixx

Over the past 35 years the number of Americans participating annually in a marathon has risen 20 fold. (1)  Sudden cardiac death (SCD) among marathoners is rare, about 1 incident per 100,000 runners. (2)  As the number of participants increase each year so does the absolute mortality rates.  Meaning more runners are having sudden cardiac events, but the per participant rate has stayed the same.  Many of the SCD’s are caused by underlying cardiovascular diseases.  The final 1 mile of the marathon accounts for 50% of the SCD’s during the race.(3)

Triathlon’s SCD statistics are double that of marathon runners.  The cause is both SCD’s and drowning during the swim portion of the race.(4)  The benefits of moderate, physical activity far outweigh the potential risks for individuals and society.  It’s important to know the risks and how the body responds to any kind of training, especially any training that is considered extreme such as long duration endurance events.  Strength training changes the size and structure of skeletal muscle.  Body builders participate in extreme training for their sport, competition.  Therefore extreme changes are made to  skeletal muscle as a result.  The heart is made up of cardiac muscle tissue.  It’s an organ that is composed of mostly muscle tissue.  If this organ made of muscle is put on an extreme cardiovascular training protocol, then there is the potential for extreme structural changes.

Structural changes

Cardiac out put at rest is approximately 5 liters a minute on average.  Cardiac output is the measure of blood pumped through the heart out to the body.  During vigorous exercise cardiac output on average can increase up to 25 liters of blood per minute.(5)  Daily long duration endurance exercise causes dilation of both the right atria and right ventricle of the heart.(6)  The chambers are stretching out and then within hours after exercise they return to their normal shape and size.   Repeating this over and over for a very long period of time can predispose an individual to permanent structural changes to the heart. Right atria and ventricle that are always overstretched and dilated can lead to myocardial scarring in the cardiac muscle tissue.    Scarring is dense, fibrous, less pliable muscle tissue.  Myocardial scarring is seen in patients who have had myocardial infarctions, more commonly known as heart attacks.  To draw a parallel think about replacing skeletal muscle in the lower body and lower back with stiffer, less pliable muscle tissue.  The joints that those muscles rely on will lose function and mobility.  Sustained loss of function and mobility leads to bigger problems like joint injury.

Coronary artery changes

A study done on 108 veteran, German, marathon runners  compared the coronary artery structure of the runners to non runners.  Researchers found a greater atherosclerotic burden in the marathon runners which was measured by coronary artery calcium scores.(7)  The higher level of calcium on the inside of arterial walls indicates a higher level of arterial wall hardening.  Arteriosclerosis by definition is a hardening of the arterial walls.  During follow up testing of the subjects in this study the adverse cardiovascular event rates of these marathoners measured similar to those in a population with congenital heart disease, those with heart deformities from birth.(8) So the hearts of these runners were in no better shape than those with congenital heart disease.

Schwartz et al reported (8) on a US cohort study of long-term marathon runners, defined as individuals who completed at least 25 marathons over the previous 25 years, and found higher than expected levels of CAC and calcified coronary plaque volume. That study, utilizing computed tomographic coronary angiography, found that the long-term marathoners had significantly more calcified plaque volume than sedentary controls.  Think about that finding for a second.  Runners who have run 25 marathons having more arterial plaque build up than sedentary people.  Tall, lean, sinewy athletes with the capability of running for hours a day having greater signs of heart damage than couch potatoes.  Lastly, In a case report, Goel et al (9) observed a 49-year-old marathoner who had significant obstructions in all 3 major epicardial coronary arteries without associated risk factors and who generated protracted oxidative stress with prolonged running.  Usually blockages in arteries are accompanied by the following symptoms:

1.  Chest pain.
2. Shortness of breath.
3. Heart palpitations.
4. Weakness and/or dizziness.
5. Nausea.
6. Sweating.

The fact that this 49 year old case study had no signs of his arterial obstruction makes him a ticking time bomb.  Oxidative stress is caused by free radicals in the body and are a result from constant stress put on the body through life stressors or through self induced stress such as, excessive exercise.  Free radicals rust the cells of the body.  Similar to when an apple has been cut and left out in the air, it turns brown from the oxygen.  The body’s cells can rust too from excessive exposure to free radicals.

Athletic Heart Syndrome– AHS (10) is associated with structural changes that occur during consistent, long duration, endurance exercise.  Athlete’s heart is a normal response by the heart to exercise stressors such as long duration aerobics.  It is considered benign but can hide a more serious condition.  Most people don’t realize they have an ” athletic heart” until they find out through being examined for something else.  Specific test need to be done to identify it.  Athletes with AHS show three common signs.

1.  Bradycardia – slower than normal heart beat, around 40-60 beats per minute.
2. Cardiomegaly – the state of an enlarged heart.  Which wouldn’t be known to the athlete unless seen on an ECG or chest X-ray.
3. Cardiac hypertrophy – the thickening of the walls of the heart, specifically the left ventricle.  Detected via EKG or can be heard through a stethoscope.

Left ventricular hypertrophy (LVH) is a benefit from exercise, a big benefit.  When the wall of the left ventricle is thickened through exercise it’s ability to pump more blood per pump increases.  Therefore the heart is more efficient and it doesn’t have to beat as often as less conditioned hearts.

Who needs to be concerned?

Highly competitive athletes performing 5 hours or more of aerobic exercise and competing in multiple long duration events per year are at the highest risk.  This is a result of both higher volume and intensity.  This leads to the heart being exposed to more oxidative stress and more time the chambers of the heart are dilated which will then lead to the chambers being more stretched out or expanded permanently causing the structural changes highlighted above.  There is also a direct link to excessive endurance exercise like marathon training and stiffer less pliable coronary arteries.

Recreational exercisers who are performing 5 or more hours of aerobic exercise are at a lower risk than highly competitive athletes competing for money and prizes.  Highly competitive, professional endurance athletes exercise at a higher intensity than the recreational exerciser and in general are performing a much higher weekly volume of training.  And keep in mind the odds of someone suffering an event while running is 1 in 100,000 as mentioned in the introduction.

Lowest risk exercisers are those who do less than 5 hours of long duration aerobic exercise per week.  It’s clear that with aerobic exercise, more isn’t necessarily better.  The research clearly demonstrates that60 minutes or more of aerobic exercise led to more aortic and aterial stiffness.  30 minutes or less showed little to no stiffness.  The science today is pointing to shorter duration, higher intense bouts of exercise followed by active or passive recovery for fitness and fat loss gains.  This is a good thing.  Shorter duration means less chance of SCD, less chance of overuse injury, and similar if not better cardiovascular benefits as long as the intensity is increased.

 

In conclusion, exercise can impact someone’s life dramatically for the better.  It is important for a motivated exerciser to know how his/her body will respond both in the short and long term.  Our bodies are always changing in response to what we do to them and what we put in them.  It’s a daily chemical experiment that should be taken seriously and with the right knowledge behind the lifestyle choices.  The old saying ” everything in moderation” certainly applies to exercise.  A complete program should include some form of cardiovascular training, strength training, flexibility, mobility and nutrition.  If any one of those components is emphasized over the other there will be an imbalance in total health.

Resources:

1.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

2.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2991639/

3.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

4.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

5.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

6.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

7.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

8.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

9.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/

10.  https://en.wikipedia.org/wiki/Athletic_heart_syndrome