This study aimed to investigate the potential differences in the health status of recreational half-marathoners, marathoners/ultra-marathoners, and 10-km runners. Mental health, BW and BMI, the prevalence of chronic diseases and hypersensitivity reactions, medication and supplement intake, smoking habits, food choice from ingredients to be avoided or desired, and regular or routine health checkups were measured and compared between the study groups. The main findings were (1) that while no association between race distance and seven health dimensions were found, “chronic diseases and hypersensitivity reactions” had a significant association with race distance, and (2) compared to 10-km and marathon/ultra-marathon runners, half-marathoners showed a tendency towards better scores in six out of eight dimensions of health (BW/BMI, mental health, chronic diseases and hypersensitivity reactions, medication intake, smoking habits, and health care utilization) with an average score of 77.1%; the half-marathon distance was found to contribute best to the overall health status among endurance runners.

Interestingly, only 8% of half-marathon runners and 10% of the overall sample reported “sport for health” as the basic assignment to a sports area, while “sport for leisure” (54% of total participants, 64% of half-marathoners) and “sport for performance” (36% of total participants, 28% of half-marathon runners) were ranked higher. “Hobby” and “health” with 34% and 19% of total participants, respectively, were ranked highest among other initial motives for running, with no considerable difference between the study groups. The number of completed races shows that endurance athletes in the present study are not novices but rather active in recreational (not professional) running. It has been shown that recreational participation in running activities could affect some health-related findings⁴⁹, which could be linked to the participants’ slight emphasis on specific personal achievements versus the joy of running (53% vs. 47%) as the main goal to participate in running events. Consistent with the present findings, it has been reported that “the joy of running races” was a top reason, and “winning” was identified as an unimportant reason to participate in running events⁴. Although “health” was the second-highest ranked reason among the seven motivations for running, it could be considered as the 1^st rank (by 44%) when pooled with two other health-related motivations (BW loss and maintenance). This finding is consistent with the literature available, with the main underlying intention probably being to achieve the advantageous effects and pronounced benefits associated with health^1,4, especially for long-term adherence to running activity^4,50. Running is expected to be a powerful strategy in the prevention of diseases, promotion of health, and maintenance of a good state of health, especially in elderly populations with an age of ≥ 50 years⁵⁰.

BW and BMI

Four out of five endurance runners in this study were found to have a BW that corresponds to a healthy BMI_NORM. Half-marathoners most often matched the BMI_NORM and consequently had higher health scores compared to marathoners/ultra-marathoners and 10-km runners. However, 10-km runners were found to have lower BW than half- to ultra-marathoners, nicely matching their reports where BW loss was ranked 2nd highest motivation to start running. In addition, the higher score of 10-km runners in food choices compared to runners over longer distances could be partially associated with the existing findings regarding their trend toward having a lower BW. Another justification could be the higher number of vegan runners in 10-km compared to half-marathon and marathon/ultra-marathon groups in the present study.

About 25% of runners in the present study stated BW management (loss: 18%, and maintenance: 7%) as the reason to start running. However, the half-marathoners seem to established a good balance between running-induced energy required and dietary intake, as they reported least often a decrease in BW due to a change in their diet. These findings emphasize the significance of BW control strategies for endurance runners as dietary changes potentially cause unintended BW loss^29,51, and adherence to appropriate nutrition strategies for sustainable BW management is highly advised to endurance runners²⁹. Although the lower BMI and being leaner were found to be associated with increased endurance running performance⁵², and training/competing in longer race distances correlates with a decrease in BW and body fat⁵³, evidence excludes marathon runners or ultra-endurance athletes from this fact^54,55. This is consistent with the present findings where marathon/ultra-marathon runners had a slight but non-significant higher BMI. The higher BMI of ultra-marathon runners compared to shorter distance endurance runners might be due to the lower importance of running speed in long-distance compared to shorter distance runs. In general, however, reports from the successful runners over 10-km and marathon distance indicate that an optimal BMI for health and performance was found to be between 19 and 20 kg/m²⁵⁶. The vegan diet was shown to effectively reduce BW and particularly body fat^57,58, with favorable effects on running performance, if planed appropriately⁵⁹. Consistently, previous data from our laboratory show that vegan endurance runners are significantly leaner than omnivores (64 kg vs. 68 kg), contributing to their overall state of health with the highest health score (69%)¹⁰.

Mental health

While most participants were not suffering from mental stress, half-marathoners reported lower perception of pressure and stress compared to 10-km runners and marathoners/ultra-marathoners. In line with the present findings, it has been found that endurance running leads to stress reduction, a better mood, and higher resilience to psychological pressure and anxiety^43,60. However, data in terms of the appropriate amount of physical activity in order to maximize these positive effects while avoiding negative effects is sparse. Too little exercise does not evoke beneficial effects, but too much exercise (defined as overtraining) can cause the perception of stress⁶⁰. Half-marathon allows performance to increase within a short period of time, which provides the feeling of success³⁸. These characteristics are supposed to lead to a certain degree of life satisfaction and thus a resilience to stress and pressure perception⁴³.

Chronic disease and hypersensitivity reactions

The present study revealed a significant difference between the race distance groups and the dimension, “chronic diseases and hypersensitive reactions”, most beneficially contributing to the half-marathoners’ state of health. Recreational endurance running is well accepted, having various health effects with robust evidence for regular running to add benefits in aerobic, metabolic, and cardiovascular function at rest. Consistent with the study findings, running has beneficial influences on the prevention of chronic and cardio-metabolic diseases, including but not limited to coronary heart disease, stroke, hypertension, diabetes mellitus type 2, and hypercholesterolemia, mainly via increasing cardiorespiratory fitness as a strong predictor for morbidity and mortality^8,9,12,15. This is in line with another finding from the present study, where race distance was found to have a significant association with chronic diseases and hypersensitivity reactions. These exercise-induced advantageous effects are based on various mechanisms, such as adaptations to the cardiorespiratory and cardio-metabolic system (e.g., changes in the musculoskeletal system and heart muscle cells, increased maximal oxygen uptake), modifications in hormonal response and enzymatic activity, the activation of both inflammatory response and detoxification processes, the involvement of pathways associated to immune response, lipid transport and coagulation, and further genetic adaptions^38,61.

The present findings could be influenced by the distribution of diet types, particularly vegetarians and vegans, among the endurance runners. It has been reported that appropriately planned vegetarian and vegan diets are healthful and nutritionally adequate even for athletes and provide health benefits for the prevention and treatment of cardio-metabolic disorders and certain diseases such as ischemic heart disease, type 2 diabetes, hypertension, inflammatory problems, and some types of cancer^47,62. More specifically, the higher prevalence of plant diets together with the null association between race distance and the incidence of allergies in the present study is in line with the available data on the protective effects of fruits and vegetables on the incidence of food allergies, including allergic asthma¹⁸ as well as the lower prevalence of allergies in vegan endurance runners (20%) compared to omnivores (32%) and vegetarians (36%)¹⁰. Despite the null association between the occurrence of food intolerances and race distance in the present study, gastrointestinal complaints due to food intolerances are common among endurance runners⁶³, probably caused by subclinical food sensitivities that occur during vigorous exercise⁶⁴.

Medication intake

Medication intake in the form of contraceptives was lower with a statistical trend (p = 0.051) in marathoners/ultra-marathoners compared to half-marathoners and 10-km runners. This finding, however, could be explained by a sex-based bias as there were fewer females (38%) among marathoners/ultra-marathoners than in half-marathoners (55%) and 10-km runners (74%). Indeed, 85% of those who reported an intake of thyroid hormones were women, and 100% of those who reported an intake of other hormones than thyroid medication were women who reported the intake of contraceptives. However, there was no association between sex and the dimension “medication intake” when runners were pooled for the MANOVA. As a well-established fact associated with the present findings, women suffer more often from hypothyroidism than men⁶⁵, and importantly, more than 100 million women worldwide use contraceptive pills to avoid undesired pregnancies⁶⁶. Although there were no associations between race distance and the intake of any medication, race distance had a considerable association (score range 0.82–0.86) with medication intake. However, as the majority of distance runners (84–87%) reported no medication intake, caution must be considered when interpreting the present limited data concerning the intake of non-contraceptives medications across different subgroups of distance runners.

Smoking habits

A low rate of smoking (< 2%) was found in endurance runners across all race distances. Consistently, data indicate that smoking prevalence is usually quite low among endurance runners⁶⁷. This can be justified by undesired performance limitations due to smoking⁶⁸ and the health-consciousness of athletes in general⁶⁹. On the other hand, adhering to regular physical exercise, particularly endurance running, can be an effective way to prevent people from smoking or even help in smoking cessation by reducing cessation-related mood symptoms, cigarette cravings, and withdrawal symptoms among temporarily abstinent smokers⁶⁸. In the present study, there was no association between smoking habits and race distance, but half-marathoners showed a better score in this dimension. While no comparable data are available in the literature, evidence has found a positive association between smoking quitters and running activity in terms of weekly training mileage⁶⁷.

Supplement intake and performance-enhancing substances

The most commonly reported supplement by the runners was vitamin D. Several studies have detected a huge difference between required and real vitamin D intake in athletes worldwide^70,71. In addition to dietary intake, athletes’ vitamin D level depends on skin color, training day-time, indoor/outdoor training, and geographic location⁷¹. Although supplement intake was not associated with race distance, it was found to have high scores (score range 0.88–0.92) among race distance groups, with a slight predominance in 10-km runners. However, the prevalence of intake was generally low, reflected by high health scores across all race distance subgroups. Compared with the highest rate of supplement intake reported by half-marathoners (16%), a recent study reported that 30% of female and 40.2% of male endurance runners consume supplements in order to enhance performance⁷². Although few studies have yet compared different groups of endurance runners regarding the patterns of supplement intake⁷³, it has been well-documented that endurance athletes use supplements to a greater extent than non-endurance athletes⁷⁴, probably due to the higher exercise-induced nutritional requirements associated with long-time training, competition, and recovery⁷⁵. Reports from a recent study on elite track and field athletes indicated that distance runners have a significantly higher prevalence in supplemental micronutrient but not macronutrient intake when compared to runners in other track and field disciplines⁷⁶. Moreover, there is some evidence for an increasing problem of doping among elite endurance runners⁷⁷. However, as the participants in the present study were mostly recreational runners, they may have different choices of dietary supplements, which could be associated with their different goals for engaging in training and competition compared to elite athletes⁴⁹. In addition, findings from the present study regarding the participants’ attitudes towards food choices characterize them as being health-conscious, so they might have been aware of potential detrimental effects of risky performance-enhancing substances. In general, despite the fact that the beneficial effects of many supplements on the promotion of health, prevention of chronic disease, and enhancement of athletic performance remain unclear⁷⁸, it is well-established that these products significantly contribute to the nutrient requirements of athletes^78,79,80.

Food choice

The present study showed that food choice was not associated with race distance, but the runners over the 10-km distance reported choosing food in order to avoid white flour, sweets, and nibbles more often than half to ultra-marathoners. This is even reflected by their higher score for food choice (72% vs. 67% and 65%) along with their motivation for choosing food based on health-promoting and health-maintaining reasons. However, caution must be warranted while interpreting the findings, as the higher score of 10-km runners in food choice could be potentially associated with their lower BMI among the study groups. Although the majority of the runners in this study reported following a mixed diet, 59% of 10-km and 56% of half-marathon runners reported following vegetarian/vegan diets, which were recently found to add most advantageous benefits to the runners’ state of health mainly due to maximizing favorable food choice behaviors in endurance runners¹⁰. The imbalanced distribution of vegans in the 10-km group (compared to the overall groups) might explain, in part, the highest scores for both supplement intake and food choice, as vegans are known to be more health-conscious and thus take special care and compensate for potential deficiencies considering critical nutrients such as vitamin B₁₂^10,59,81. Considering a health-related food choice to get desired ingredients by a specific choice of healthy and health-maintaining items, most participants reported health-conscious behavior across all race distance subgroups. This finding was in line with available literature^2,69, where athletes were characterized as being health-conscious, particularly with regard to food choice¹⁰.

Healthcare utilization

Overall, most athletes reported seeing a doctor at least once a year and making use of regular health checkups. These findings were consistent with the previous literature⁸² and emphasize the fact that regular and sustainable physical activity can diminish morbidity rates and thus the necessity for doctor consultations⁸³. The endurance runners of the present study were found to have a good balance between healthy physical activity and vigorous exercise, which could be advantageous for gaining the desired health effects², and importantly for the avoidance of the detrimental consequences of overtraining following excessive running or training activities. In the present study, there was a statistically significant association between race distance and age. Interestingly, and although being older than runners over other distances, marathoners/ultra-marathoners had a low score for regular and routine health checkups, indicating disadvantageous contribution to overall health from weak healthcare utilization.

Limitations, strengths, and future perspectives

There are limitations worth mentioning. The present study shares with others the limitations of the cross-sectional design. The fact that the findings relied on self-reported records should be considered as the primary limitation since under- and over-reporting are potentially prevalent in self-reported data. However, this effect was compensated by using control questions. Also, the high intrinsic motivation of the participants could be consequential to increase the accuracy of their answers to provide a high quality of the data set. The operationalization of state of health as a latent variable (domain scores) should also be considered as a statistical limitation. Nonetheless, the health score was identified as a meaningful tool to assess the health status. In this regard, however, retrospective rating of the cross-sectional design might raise misunderstandings about the associations between health-related variables and race distance, and thus, caution must be warranted in the representativeness of the present findings. Moreover, the sex-based imbalance in the study groups (particularly the higher number of males in the marathon/ultra-marathon group and females in the 10-km group) could be influential on the health-related findings, as females are well-known to be more health-conscious than males considering favorable habits and healthy lifestyles (e.g., physical activity, alcohol/nicotine, plant-based diets). Nevertheless, the data contribute to the growing scientific interest and knowledge in health-related consequences of endurance exercise for distance running in particular, and can be taken as a step towards broadening the body of evidence in the field.

Although it is well-established that endurance running offers various health benefits, the body of science is still contradictory considering both quantity and quality of running activity that enables obtaining the maximum beneficial health effects and preventing the minimum undesired or adverse effects. Therefore, specific knowledge about the interconnectedness of running distance (in training and racing) and health can provide a better basis for athletes, coaches, physicians, and specialists to optimize health-related training and racing strategies. Thus, the results might be useful for different populations by providing such knowledge to aid the decision of an active and healthy lifestyle, with regular involvement in running training, and also to advise individuals to run for sustainable health outcomes. Even at community and public health levels, health authorities can use this information to support policies towards investing in running programs that promote sustainable running training strategies.