What is Hyponatremia? (hi-PO-na-tree-mee-uh)
Table salt, sodium chloride, is lost in sweat and urine and replaced by food. The sodium part (of sodium chloride) is vitally necessary for such body functions as muscle contraction and transmission of signals along nerves. The average American diet has more than enough sodium to keep these functions going… for most people.

The body has excellent adaptation mechanisms in the kidney, sweat glands, and blood vessels that maintain blood sodium levels in a very tight range of about 135-145 meq/L. Going much outside this range means trouble. So the maintaince system is very efficient. Ultra endurance events challenge this efficient survival mechanism.

Imagine your body is a glass of salt water. Poor out (sweat) some of this water. Replace it with tap water. This glass (your body) is now low in sodium compared to the original glass. This low blood sodium or hyponatremia can be tolerated for a brief period of time. But do this for 4-12 hours or more, and potentially dangerous symptoms result. In fact 30% of Hawaii IM finishers are hyponatremic.

Sweat contains 2-3.5 grams of sodium per liter. (The more trained you are, the more dilute your sweat, the better your body can conserve salt.) Triathletes can easily sweat more than 1 liter per hour during training. In a 12-hour race, that could mean 24-42 grams of salt lost. Replacing with only water causes hyponatremia.

Aspirin, ibuprofen, and other anti-inflammatory that tri racers frequently pop, interfere with kidney function and contribute to the development of hyponatremia. Under tough conditions you need your kidneys need to function at 100%.

Symptoms of Hyponatremia
Blood sodium levels below 125 produce symptoms. You’re probably familiar with the symptoms of hyponatremia: nausea, muscle cramps, and irritability. At this point many athletes think they’re dehydrated and drink more water, making the problem worse. In the past, the medical tent at races would treat these symptoms with intravenous fluids. The American College of Sports Medicine now calls such practice the “dehydration myth.” These early symptoms should be treated with salty foods and some sports drink.

More severe symptoms include seizure and coma. Of course if your training buddy has these symptoms, get him to medical attention immediately. The medical team will likely go with intravenous HYPERnatremic (high salt) solutions to rapidly elevate serum sodium level to a “safe” level of 120-130 in a few hours, followed by a gradual increase to normal over the next few days. Entirely too many athletes have died of hyponatremia.

Prevention of Hyponatremia
No clear-cut recommendations work for all. So I stress that you know your sodium needs prior to race day. Practice your hydration, eating and salt strategy during training. In general, events more than 3 hours require sodium from sports drinks. When going more than 5 hours (ultras, IMs) salty foods are necessary. Most authorities and I recommend against salt tablets (unless your very experienced with them) which may give you too much salt.

Get used to reading FDA labels. Remember training removes 2-3.5 grams of sodium per hour. Do not try to replace all of this during your workout. Rather increase sodium intake for several days prior to a long event. Then shoot to get about 1 gram of sodium an hour during training. This will keep you out of trouble. The ideal training food has both sodium and carbs. Here are a few favorites:

Serving Sodium (mg) Fat (gm) Carbs (gm)
Gatorade 8 oz 110 0 14
Exceed 8 oz 50 0 17
Salted pretzel 10 reg size 300-500 0-1 19-22
Fat free saltine 5 crackers 130 0 11

Other great choices are chicken noodle soup (a must at IM), pickles, and tomato juice. The exact amount of sodium varies among brands.

Recommendations
1. Increase sodium intake by 10-20 grams per day for a few days before the event.
2. Use a sodium containing sports drink when going for a long time.
3. Shoot to get one gram of sodium per hour during the event.
4. Weigh yourself before and after training. Drink enough sports drink to keep the numbers the same.
5. Avoid aspirin, ibuprofen, and other anti-inflammatories.
6. Discourage the practice of “drinking the maximal amount of water that can be tolerated.”

Don’t get rid of your saltshaker, know your needs, eat well, drink the right fluids, and go like hell.

It’s the Olympic motto. In a world where athletic events are won by hundredths of a second and competitors do almost anything to win, athletes of all levels explore ergogenic aids (substances that improve athletic performance). The Tour riders and Richmond runners are no exception. Legality is a concern. Governing board policies echoe that of USOC (Olympic Committee). This article is not saying that ergogenic aids are bad and don’t you dare touch them. Rather, I realize that you are trying to learn about and use what’s effective and safe… so here’s what you need to know.

Water
Duuuugh. Drink fluids. By the time you feel thirsty, you’ve already lost 1% of your fluid volume and 3% of your strength. It’s legal, free and effective. But don’t go overboard, or you’ll get water intoxication: hyponatrimia.

Carbohydrates
Carbos are the body’s main source of quickly available fuel. Loading carbohydrates for 2-4 days prior to a race improves performance if the event is more than 2 hours long. Drinking carb-containing fluids during the event has been found to IMPROVE PERFORMANCE in marathons and longer races.

Eating a mixture of carbs and protein within 2 hours of an endurance workout helps rebuild glycogen stores and decrease breakdown of the muscles used in the workout. This means you RECOVER FASTER.

O2
Yes that’s right. Oxygen is a tremendous ergogenic aid. It’s free, legal and very effective. So use it to your benefit. At the beginning of a climb, take a few slow deep BREATHS. This will “saturate” your blood with O2.

Keep your red blood cell (RBC) count up, i.e.; DON’T BE ANEMIC. Since RBCs carry oxygen to working muscle, more RBCs mean more O2… you go faster. If you think you might be anemic, consult your Sports Medicine health care provider for a simple blood test and appropriate dietary recommendations.

Beta agonists
O2 is good… is more O2 better? This brings us to the use and abuse of prescription medication to dilate the airways in the lungs. Most beta agonists are USAT illegal. But remember ANYTHING IS LEGAL WITH A PRESCRIPTION. The most common of these medications is albuterol. In fact, you probably have a training buddy who carries and puffs an albuterol inhaler during workouts.

In the 2004 OLYMPICS, more than half the triathletes HAD PERSCRIPTION beta agonists for “asthma.” If you believe all these elite athletes have asthma, then I have a bridge to sell you.
So does albuterol work? It does. Not only does it increase O2 to the lungs, but it also has an “upper” effect by increasing you heart rate. Enter bad side effect: dangerously high heart rate, causing irregular heartbeats.

Other Legal Prescription Meds
Thyroid supplementation can up your metabolism, thereby helping you get leaner and faster. Ask your Sports Med provider if this might be good for you.

Some prescription anti-depressants (like Zoloft) work by increasing you serotonin levels. The result is higher pain tolerance and better concentration during very long (> 5 hour) workouts and races. This is an effective, legal, relatively safe strategy for runners.

Caffeine
Runners know it works… but how? First of all it is a brain stimulant, which helps concentration during long, tough workouts. But moreover, it helps METABOLIZE FAT, from the stores, to the blood and into energy. This helps conserve muscle glycogen stores. Sounds too good? Maybe

Too much caffeine will cause tremors, and make you nervous, DEHYDRATED, and unable to sleep. The ergogenic dose is 250-500mg (about 24 oz of java or 8 sodas).

Stimulants
You’ve seen these on bottle labels: ephedrine, pseudoephedrine, phenylpropanolamine, herbal ephedrine, and ma huang. They all increase metabolism, energy, and endurance while decreasing appetite and perceived exertion. In all regular users they cause hypertension. In regular and occasional users they cause (potentially LETHAL) IRREGULAR HEARTBEATS. This lethal potential is even higher when stimulants are combined with caffeine. Ephedrine and its cousins are responsible for the DEATHS of scores of athletes.

Creatine
You ingest it in beef and fish; your body makes up for any dietary deficits by PRODUCING IT in you liver, kidneys, and pancreas. So what’s all the hype about getting more creatine?

Flash-back: high school biology
Working muscles use ATP. Used ATP becomes ADP. Creatine does the job of turning “used” ADP back to the “fresh” ATP. Increasing muscle creatine means faster regeneration of ATP.

This helps improve performance only in sports that require BRIEF (<10 seconds) repeated bouts of all out exertion (swinging a bat, jumping to a lay up). Since repeated 10 second bouts of exhaustion are not what running is about, creatine supplementation will NOT HELP you. Plus, creatine use results in a 3% weight gain of water. This might even slow you down.

Human Growth Hormone (hGH)
Hope for hGH to rejuvenate older athletes like the “fountain of youth” faded about a decade ago. Studies showed that the laboratory made drug is not as effective as the real thing that young bodies produce naturally. In older patients (>75 years old) hGH does help lose body fat; however, it does not increase strength, endurance, or concentration. Although there is no test to detect its use, it is illegal.

DHEA
Dehydroepiandrosterone is a precursor of other hormones. In other words, in everyone’s liver the body normally converts DHEA to the ergogenic hormone, testosterone, as well as to the feminizing hormone, estrogen. Does this same conversion happen with DHEA that arrives in pill form in the stomach? We know that in men on DHEA, estrogen (but not testosterone) levels are increased. Women taking the supplement DO INCREASE their testosterone levels, but NOT THEIR STRENGTH and endurance. DHEA is illegal, probably NOT EFFECTIVE, and can produce all the bad side effects associated with anabolic steroids (below).

Anabolic Steroids (AS)
Suffice it to say, in the worst-case scenario, AS cause tendon ruptures, irreversible psychosis, and liver CANCER. They are illegal in nearly every sport organization and very dangerous. Just say no.

There you have it. Eat right; drink plenty of fluids; go like hell.