Medical Research at Western States: “Reuniting the soul with the body.”
For more than 40 years, medical research activity has played an important role at the Western States Endurance Run. One of the three pillars of the Western States’ vision statement is a focus on ultrarunning research. WSER’s late Medical Director, Dr. Robert Lind, welcomed and encouraged researchers from throughout the country and the world to come to WSER and study its runners. One of the earliest studies to establish a connection between the body’s release of endorphins and physical activity was conducted at WSER in 1981 by Dr. Walter Bortz of Stanford University. Since 2006, over 100 research publications or abstracts in human performance have been produced by researchers from throughout the world based on studies conducted on WSER runners. No other ultrarunning race in the world has been connected to more research studies than WSER.
The Beginnings:
For more than 30 years, the Western States 100-mile Endurance Run medical team was headed by Dr. Robert Lind, an emergency room physician from nearby Roseville, Calif.
Lind, in his mid-70s with a distinguished shock of white hair, a ready smile, and dark eyes that twinkled with a keen intellectual curiosity, had been associated with the race from its inception in 1974 when Gordy Ainsleigh made history and finished the historic race route in less than 24 hours along with the horses of the Tevis Cup.
From the very beginning, Lind knew he was bearing witness to a unique and wonderful experimental opportunity. Though no one asked him to, Lind took to creating a maze of charts and graphs, recording every fluctuation in weight, blood pressure, and core temperature of every runner entered in Western States. He quizzed the race’s runners about their fluid and food intake. He asked them about their mental well-being as they entered the race, and what it was like during and after. He queried them on their past medical history, wondering if they had experienced dizziness or chest pains as they prepared for the run. Several middle-aged runners, including Dick Collins, a beloved race director and ultramarathoner from Northern California, had participated in the run following heart surgery. Lind saw their participation not only as notable, but natural and noble, as the heart was at its essence a muscle, one that could, even with some previous damage, be re-trained and re-conditioned for exacting tests like running 100 miles. “It’s a pretty simple calculation, actually,” Lind said. “Walking, running, or crawling, the bottom line is, you want to get to Auburn.”
At the finish line Lind’s thoughtful gaze was always upon the run’s finishers. Or, as he put it, he was there as both doctor and documenter, “To see if their soul had separated from their body. You know they were OK again when the soul had reunited with their body, and they could look you in the eye with clarity and hope again.”
His garage at home was filled with spreadsheets, hand-written roadmaps of the route the bodies of each and every runner who ever competed at Western States had taken over the Sierra to the finish line at Auburn. As the summer turned to fall and into winter, Lind would pore over the data filling the many shoeboxes in his Roseville garage, looking for recurring frequencies and tendencies. With the advent of blood sampling data at the run, Lind was presented with even more information from the race’s finish line. Even with this valuable information, Lind knew that it was dangerous to over-generalize. Every runner was different, every runner was unique, every runner’s innermost engine was slightly different than the rest. It was the way that the race required a special mixture of the soul and the body – heart and muscle – that fascinated Lind. And it was his yearning for a better insight into that special crucible – the inevitable separation of the soul and the body as the race’s pressures mounted, and their subsequent reunification miles later as the runner found balance for the two conflicting powers, finally yoking body and soul to the task at hand – that kept bringing Lind back to the race each year. He was too humble a man to believe the words, but they were true: No one had a better understanding of the physical and the psychic test of Western States than Bob Lind.
Dr. Lind set the standard for Western States’ medical research- a standard that continues today. It is no exaggeration to say that some of the most important medical research on endurance athletes ever done has been conducted by researchers at Western States.
Dr. Walter Bortz, at the urging and invite of Bob Lind, conducted the first official medical study at Western States in 1981. The race’s remoteness and inaccessibility challenged Bortz’s ingenuity to even conduct the study in a scientifically relevant manner.
Bortz, who was already a nationally known figure for his research into exercise and aging, was determined to discover at Western States if there really was tangible, scientific proof of an ephemeral phenomenon known as “runner’s high.” So he lugged a refrigerated medical centrifuge up a long hill into the tiny former mining community of Michigan Bluff, located at the race’s 55.7-mile mark.
Conditions were anything but controlled, with the temperatures soaring near 100 degrees. There was no guarantee that all of the runners involved in the study would even make it to Michigan Bluff. “It was a herculean technological victory just getting the centrifuge in place for the experiment,” remembered Bortz, a past president of the American Geriatric Society, longtime Clinical Associate Professor of Medicine at Stanford University.
Bortz remembered the day in Michigan Bluff as a flurry of activity. Hundreds of other runners, crew members, aid station personnel and spectators who had gathered there on that hot afternoon, saw a gray-haired man, his scholarly, patrician face squarely set with intensity, hustling back and forth from exhausted runners who had just given him blood samples, to a refrigerated medical centrifuge tucked away in one of the few shady spots across the street from the Michigan Bluff aid station.
Weeks later, as the samples were analyzed in the human performance laboratories of Stanford, the results were remarkable. A phenomenon known as “runner’s high” had been believed to occur during strenuous exercise, when a runner would cross a certain vigorous, intense level of exercise that would activate endorphin production by the pituitary gland and the hypothalamus in the brain. A single study had linked exercise to the production of endorphins; the blood samples taken at Michigan Bluff confirmed the earlier study’s finding. “It was the second study ever to show that physical exercise produced endorphins,” Bortz said. “Who would’ve thought that these Western States runners, all of whom were in the middle of a tremendously taxing effort, were producing so many endorphins?
“But to me, that was only the beginning.”
On the heels of the endorphin study, Bortz recruited about a dozen Western States runners for another test. He took them to the cardiac catheterization lab at Stanford Medical School, where the runners underwent coronary arteriograms.
“I was in the cath lab during the first one, and when the dye was injected, I thought we had killed our friend … his artery was so huge,” Bortz said. “But as it turned out, he wasn’t the only one. All of their arteries were huge.”
Like the endorphin study, Bortz had no idea what he would ultimately find, nor did he foresee the impact it would have on future cardiac studies. “Our study of the 12 Western States runners really helped prove that the health and size of the coronary arteries are a key cardiac benefit,” Bortz said. “In other words, who gives a shit what your cholesterol is, if your arteries are only an inch and a half apart and your heart is screaming for oxygen? Running isn’t a complete cure-all, but it certainly is a sturdy barrier against heart disease.”
The article, authored by Bortz and several other cardiology colleagues from Stanford was entitled “Coronary Artery Size in Ultra-Marathon Runners,” and it appeared in the medical journal Circulation. It remains one of the most referenced articles in the world for any article that addresses coronary health.
Dr. David Niemann, director of the Appalachian State University Human Performance Laboratory and a professor in Appalachian State’s Department of Health, Leisure and Exercise Science, began his association with the race in 2001.
Bob Lind, always in search of new exercise physiology research, came upon one of the more than 200 peer-reviewed journal articles written by Niemann. The late 1990s had not been kind to the health of some of the pioneering Western States runners. The run’s first two over-50 finishers, Peter Mattei and Dr. Ralph Paffenbarger, had experiences extreme health conditions. Peter Mattei died in 1998 and Ralph Paffenbarger had suffered two major heart attacks. Dick Collins, a beloved race director and ultra runner in northern California who had run more than 200 ultras and nearly 150 marathons, passed away in 1997 at age 64 from heart failure.
Lind, concerned that ultrarunners were following their bliss to the detriment of their health, found Niemann’s article fascinating. Niemann, who was himself a veteran of more than 50 marathons, had conducted a ground-breaking study of more than 2,300 runners in the Los Angeles Marathon in 1987. He found that the odds of contracting a cold or flu-like symptoms following the marathon were six times greater than for the average runner who hadn’t run a marathon. “This was exciting because it seemed to indicate that there was a real connection between strenuous training and illness,” Lind said. Lind contacted Niemann at his Boone, N.C., office, and the two struck up an immediate friendship.
The two worked together to secure research funding from two unlikely sources: Gatorade and the Department of Defense. Like the Western States researchers before him, Niemann could not believe his good fortune in implementing the series of studies that would stretch over the next few years of Western States. “Western States is the ideal field condition for this type of study,” he said in “Marathon and Beyond.” Tellingly, and somewhat ominously, he said, there were probably more similarities than differences between the stresses of Western States and the stresses of the battlefield. “The Pentagon supplies us with some of our funding because the military uses the information we’re gathering to help soldiers on the battlefield,” Niemann said. “From a physical and mental standpoint, participating in an endurance event like the Western States 100 is very comparable to being in a wartime situation. The stresses on the body are much the same.”
Niemann and his team of Appalachian State researchers, post-doctoral students, and graduate students became as much a part of the Western States landscape as the soaring peaks of the Sierra or the dreaded canyons from 2002-2006. On the Friday before the race, they would professionally and quietly take samples from volunteer competitors’ blood and saliva. On race day, a la Walter Bortz some 20 years earlier, they could be found at Michigan Bluff, waiting in the shade to draw mid-race blood. At the finish line, they would somehow find a way to gently coax the last bits of saliva from the dehydrated mouths of the race’s finishers, and as well, convince them that yet another blood draw could not be nearly as painful – or as dangerous – as the previous 24 or 30 hours of running non-stop through portions of wild country.
The Western States “lab” proved not only realistic, but productive. In several studies, Niemann and his team were able to mark and identify several key physiological occurrences that provide an important bridge in understanding the connection between strenuous exercise and illness. The studies, Niemann said, “have shown repeatedly that the immune system does suffer suppression during heavy exercise bouts.” A 2003 article in the International Journal of Sports Medicine by Niemann and his colleagues found that “about 1 in 4 runners (at Western States) reported upper respiratory tract infection during the 2 weeks post-race.” Compared to his L.A. Marathon findings in 1987, where about 1 in 6 runners reported suffering cold or flu-like symptoms, the article seemed to be further proof that 100-mile races not only demanded more of a runner’s muscular system, they also seemed to reach deeply into a runner’s immune system as well. Further Western States studies made other key linkages and provided informed insight into the prevailing “best practices” seen in ultras throughout the country. For example, many ultra runners beginning in the late 1990s, in an effort to stave off muscle soreness in the latter stages of races, had begun to gobble high doses of non-steroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen or Advil. Niemann and his team found that such a practice can actually be harmful to the immune system, increasing the oxidative stress on runners.
Taken together, the Niemann studies helped validate an uneasy feeling Western States competitors had had for many years. Although for many it could prove to be an experience of a lifetime, Western States wasn’t without inherent risks – risks that each runner had to personally weigh before deciding to compete in the race. “The immune system studies did establish a clear cause and effect around what an exhausting effort can do to the body’s internal systems,” said Tim Twietmeyer, the race’s only 25-time finisher. “The immune system studies show that it’s a very difficult thing to put your body through such extreme paces. There’s still a lot of research to be done, but the studies that have been done really point to the fact that for many years, Western States has been way ahead of the curve for providing the endurance world with some pretty timely and important human performance research.
The next step: Dr. Martin Hoffman
WITH BOB LIND’S RETIREMENT from Western States medical duties in 2005, the void left was understandably large. Rather than replace Lind, the race’s board of trustees took a different direction. Marty Hoffman, M.D., the respected chief of physical mobility and rehabilitation for the Veteran’s Administration of Northern California and professor of clinical physical mobility and rehabilitation at UC-Davis, was the natural choice to helm Western States’ research efforts. Hoffman, in his early 50s, had been an ultramarathoner and trail runner for more than 20 years. A formal Medical Research Committee was formed under Hoffman’s direction in 2006. The group’s charge was four-fold: 1) assure proper human studies requirements were being met with each future research project; 2) expand future funding opportunities; 3) promote greater quality and publishable research from the event; 4) propose specific lines of research. The group worked quickly, enacting a formalized submission proposal process, with the underlying directive that the race had, and would continue, to acknowledge and encourage applied, clinical and behavioral research associated with the event.
In short order, Hoffman helped produce two historical analyses of the race’s results, focusing on factors that affect performance – age, gender, temperature on race day. Hoffman’s findings: the proportion of women at Western States continues to grow (from the race’s first female finisher, Pat Smythe in 1978, to today, where nearly one quarter of all competitors each year are women).
“Although compared to marathons and road races, where participation is nearly 50/50 male/female, 100-mile trail races have a way to go,” Hoffman said.
One of the more intriguing findings Hoffman found in 2007, and which has come to pass today, was that as more talented female runners gravitated to ultras, the top-five female finishers at Western States are, on average, running faster each year than their top-five male counterparts. “They’re gradually catching the men,” Hoffman said of the women. “Especially since 1980, the women are getting faster. In 1980, they were 25 percent slower; (in 2007), they’re under 20 percent slower … it’s been a good development for the race.”
“People may find this interesting, but this statistical foundation is not the end point,” Hoffman said. “Even with all of the studies that have come before us – and they were all very interesting, and very helpful – we are still in the process of moving forward in producing information that can be directly applied to the individual who might run the race, or who is training or racing any 100-miler, for that matter.”
During the time, Dr. Hoffman, working with the medical directors, first Dr. Lisa Bliss and then Dr. Bob Weiss, also recognized the dangers of hyponatremia (low blood sodium levels) in ultrarunners. At large road marathons, runners have died from hyponatremia. At WSER, while fortunately no runners have passed away, there were a number of runners who were critically ill and ended up in the ICU. Dr. Hoffman and his research efforts helped runners and medical teams identify the underlying causes of hyponatremia, improved recognition of they signs and symptoms of hyponatremia, and finally, improved treatment protocols that helped saved runner’s lives.
Western States Research in the last 10 years
In 2016, Dr. Hoffman stepped down as research director, and the WSER board chose Dr. John Diana, a respected Northern California orthopedist and ultra runner, and WSER finisher. Dr. Diana shifted the WSER research team’s focus to bringing in external researchers rather than “internally” conducting research. This philosophical change helped expand WSER research into areas such as the gut microbiome, visual alterations, and metabolomics. It was also during this time that WSER started the Western States Health and Athletics Conference (WHAM), resurrecting a meeting that helped to spread the newest research on ultrarunning that Dr. Hoffman organized years earlier.
In 2022, after a successful 6 years with Dr. Diana, Dr. Emily Kraus and Dr. Megan Roche, who had both previously conducted several key WSER medical research studies, were named co-research directors. At the time, Dr. Kraus and Dr. Roche were working closely together at Stanford University School of Medicine, with Dr. Kraus as Dr. Roche’s PhD research advisor. The appointment of Drs. Kraus and Roche was historic for a race that has long valued its history – it was the first time female doctors had been chosen to lead the run’s medical research enterprise. During their time, they continued to bring in outside researchers while also conducting valuable research focusing on bone health and relative energy deficiency syndrome (REDS), with a particular focus on the health of female runners.
In 2025, Dr. Tamara “Tami” Hew-Butler was announced as the next research director for WSER
Dr. Hew Bulter brings an impressive array of professional achievements as a clinician and scientist, having been published extensively in some of the world’s most crucial exercise science journals. Dr. Hew-Butler was the lead author and organizer of three International Exercise-Associated Hyponatremia Consensus Guidelines and previously received two WSER research grants as Principal Investigator (PI), which in turn generated 18 scientific publications.
Hew-Butler, who is a Fellow of the American College of Sports Medicine, is a recently retired Associate Professor at Wayne State University in Detroit, Michigan. Previously, she was an Associate Professor at Oakland University in Rochester, Michigan, as well as a Research Assistant Professor at Arizona State University. She received her Doctor of Podiatric Medicine degree from Temple University, and has been a clinician for more than three decades. She received her Ph.D. in exercise science from the University of Cape Town, South Africa.
Under Dr. Hew Butler’s leadership and with the assistance of the WSER research committee and board, Western States has a strong commitment to continue to be the leader in ultrarunning research. Our goals are to increase our research budget and continue to perform research at WSER that helps get as many runners to the finish line as safely as possible.
