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Fluid and electrolyte supplementation for exercise heat stress1–4

Michael N Sawka and Scott J Montain

ABSTRACT During exercise in the heat, sweat output often at the beginning of exercise but incurs hyphohydration (a body
exceeds water intake, resulting in a body water deficit (hypohy- water deficit) over a prolonged period. Hypohydrated persons who
dration) and electrolyte losses. Because daily water losses can be exercise in the heat will incur significant adverse effects (9). Hypo-
substantial, persons need to emphasize drinking during exercise hydration increases physiologic strain, decreases exercise perfor-
as well as at meals. For persons consuming a normal diet, elec- mance, and negates the thermoregulatory advantages conferred by
trolyte supplementation is not warranted except perhaps during high aerobic fitness (10, 11) and heat acclimation (10, 12). If stren-
the first few days of heat exposure. Aerobic exercise is likely to uous exercise is performed by hypohydrated persons, the medical
be adversely affected by heat stress and hypohydration; the consequences can be devastating (13, 14).

Downloaded from ajcn.nutrition.org by guest on June 25, 2013
warmer the climate the greater the potential for performance We review human fluid and electrolyte balance relative to
decrements. Hypohydration increases heat storage and reduces a their effects on temperature regulation and exercise performance
person’s ability to tolerate heat strain. The increased heat storage in the heat. In addition, needs for research on fluids and elec-
is mediated by a lower sweating rate (evaporative heat loss) and trolytes will be discussed for 3 special populations: cystic fibro-
reduced skin blood flow (dry heat loss) for a given core temper- sis patients, older persons, and persons with spinal cord injuries.
ature. Heat-acclimated persons need to pay particular attention
to fluid replacement because heat acclimation increases sweat
losses, and hypohydration negates the thermoregulatory advan- FLUID AND ELECTROLYTE BALANCE
tages conferred by acclimation. It has been suggested that hyper- To support the contraction of skeletal muscles, physical exercise
hydration (increased total body water) may reduce physiologic routinely increases total body metabolism to 5–15 times the resting
strain during exercise heat stress, but data supporting that notion rate. Approximately 70–90% of this energy is released as heat,
are not robust. Research is recommended for 3 populations with which needs to be dissipated to achieve body heat balance. The rel-
fluid and electrolyte balance problems: older adults, cystic fibro- ative contributions of evaporative and dry (radiative and conduc-
sis patients, and persons with spinal cord injuries. Am J Clin tive) heat exchange to total heat loss vary according to climatic
Nutr 2000;72(suppl):564S–72S. conditions (15). In hot climates, a substantial volume of body water
may be lost via sweating to enable evaporative cooling (7).
KEY WORDS Skin blood flow, cystic fibrosis, dehydration, In addition to climatic conditions, clothing and exercise inten-
fluid redistribution, hypohydration, hyperhydration, older adults, sity influence the sweating rate (15, 16). Residents of desert cli-
spinal cord injury, sweating, thermoregulation mates often have sweating rates of 0.3–1.2 L/h while performing
occupational activities (17). Clothing may be a major concern;
persons wearing protective garments often have sweating rates of
INTRODUCTION 1–2 L/h while performing light-intensity exercise (18). For ath-
Water and electrolyte balance are critical for the function of letes performing high-intensity exercise in the heat, sweating
all organs and, indeed, for maintaining health in general (1, 2). rates of 1.0–2.5 L/h are common. Expected sweating rates from
Water provides the medium for biochemical reactions within cell running in different climatic conditions are shown in Figure 1
tissues and is essential for maintaining an adequate blood vol- (7). The influence of climate and amount of physical activity on
ume and thus the integrity of the cardiovascular system. The
ability of the body to redistribute water within its fluid compart-
ments provides a reservoir to minimize the effects of water
1
deficit. Each body water compartment contains electrolytes, the From the Thermal and Mountain Medicine Division, US Army Research
concentration and composition of which are critical for moving Institute of Environmental Medicine, Natick, MA.
2
Presented at the workshop Role of Dietary Supplements for Physically
fluid between intracellular and extracellular compartments and
Active People, held in Bethesda, MD, June 3–4, 1996.
for maintaining membrane electrochemical potentials. 3
The views, opinions, and findings contained in this report are those of the
Physical exercise and heat stress cause both fluid and electrolyte authors and should not be construed as an official Department of Army posi-
imbalances that need to be corrected (3–6). Generally, persons tion or decision, unless so designated by other official documentation.
dehydrate during exercise in the heat because of the unavailability 4
Address reprint requests to MN Sawka, Thermal and Mountain Medicine
of fluids or a mismatch between thirst and water requirements (7, Division, US Army Research Institute of Environmental Medicine, Kansas
8). In these instances, the person is euhydrated (normally hydrated) Street, Natick, MA 01760-5007.

564S Am J Clin Nutr 2000;72(suppl):564S–72S. Printed in USA. © 2000 American Society for Clinical Nutrition

and osmolality 0. Sodium and chloride are primarily responsible for the Except for the first several days of heat exposure. As a result. with temperature they measured the animals’ body water. Hypohydration reduces the gastric emptying rate of ingested fluids during exercise in the heat (29. adults will dehydrate by 2–8% BWL. Because adipose tissue is 10% water but muscle tissue is 75% water. heat- by matching fluid consumption with sweat loss. 26. plasma. and that of magnesium. The water contained in body tissues is distributed between the FIGURE 1.5 mmol/L) (21). intracellular and extracellular fluid spaces. hydration. These researchers sodium by active transport. acclimated persons have lower sodium concentrations mated persons hypohydrated to various degrees are shown in in sweat (> 50% reduction) for any specific sweating rate (22). Thus. 40% of the water deficit was from 10–70 mmol/L) and varies by diet. Correspondingly. Figure 4 (33). muscle water and glycogen content parallel each other. 24). By virtue of having more dilute sweat. 30).2–1. 28). As a result. 14% from viscera. sweating rate. who have a smaller reduction supplementation is not needed (25). 20). Sweat glands reabsorb Neither the brain nor liver lost significant water. some dehydration is likely to occur during exercise in the heat. which mobilizes fluid from supplementation is not necessary because normal dietary the intracellular to the extracellular space to enable defense of sodium intake will cover the sweat losses (3. muscle. unless forced hydration is stressed. but the ability to reabsorb sweat concluded that hypohydration redistributes water largely from sodium does not increase with the sweating rate. 17). 22). maturation. trained athletes have rela- tively greater total body water than their sedentary counterparts by virtue of a smaller percentage body fat and a higher concen- tration of skeletal muscle glycogen. 27). ad libitum water intake during exercise in the heat results in an incomplete replacement of body water losses (Figure 3. that of calcium. Plasma volume decreases 0. . In addition. 20). calcium. Nose et al (32) determined the distribution daily fluid requirements is shown in Figure 2 (19. when taking fluids is stimulated by consuming food (4. 0. Humans will usually fully rehydrate at meals. and magnesium present in smaller amounts. and degree of heat acclimation (21. thirst is not perceived until a per. Because there is free fluid exchange.3–2 mmol/L). 1 mmol/L (range tion to the amount of fluid loss. probably because of the osmotic pressure exerted by glycogen granules within the muscle’s sarcoplasm (31). fluid from the intracellular space. thus. hypohydration mediated by sweating will influ- ence each fluid space. Water constitutes 45–70% of body weight (1). This concept is illus- contains vitamins. 5). active persons need to stress drinking at meals to avoid persistent hypohydration. Daily in the rat of body water loss among the fluid spaces as well as requirements for sedentary to very active persons range from among different body organs. hypohydration must be avoided water deficit (36). An approximation of hourly sweating rates as a function of climate and running speed (7). Because heat acclimation improves the ability to reabsorb Resting plasma volume and osmolality values for heat-accli- sodium. Neufer et al (29). vitamin trated by heat-acclimated persons. This is difficult acclimated persons have additional solutes remaining within the because thirst is not a good indicator of body water require. for example. Forty-one potassium. Although sweat plasma volume in hypohydrated persons. electrolyte elevated plasma osmolality (34. found a reduction of 20–25% in the gastric emptying rate when their subjects were hypohydrated (5% body weight) that was related to increased core temperature. at high the intracellular and extracellular spaces of muscle and skin as a sweating rates the concentration of sodium increases (15). 26. Sweat-induced hypohydration will decrease The potassium concentration in sweat averages 5 mmol/L plasma volume and increase plasma osmotic pressure in propor- (range: 3–15 mmol/L). their concentrations are low.8 mmol/L (range because it provides the precursor fluid for sweat. and 14% from bone. Sex. they thermally dehydrated rats by 2–4 L/d in temperate climates and from 4–10 L/d in hot climates. beginning FIGURE 2. 2013 Sodium chloride is the primary electrolyte in sweat. son has incurred a water deficit of 2% body weight loss (BWL) (17.org by guest on June 25. thus. percent of the water deficit was intracellular and 59% was extra- The sodium concentration in sweat averages 35 mmol/L (range: cellular. in plasma volume than do unacclimated persons for a given body During exercise in the heat. and aging do not appear increases because sweat is ordinarily hypotonic relative to to affect sweat electrolyte concentrations markedly (23. 30% from skin. the average male (75 kg) has 45 L of water (about 60% of body weight). During situations of stress and prolonged high sweat loss. FLUID AND ELECTROLYTE SUPPLEMENTATION 565S important not only to minimize hypohydration but also to maxi- mize the bioavailability of the ingested fluids. In terms of organs. Influence of climatic temperature and daily metabolic fluid intake during the early stages of exercise heat stress is rate on daily fluid requirements (19. 35). Thus. 10% BWL and after the animals regained their normal core Downloaded from ajcn. 17). In general. extracellular space to exert an osmotic pressure and redistribute ments (17.nutrition. way of maintaining blood volume. a person’s total body water varies by body composition (1).

with a much greater ratio of plasma work” for occupational tasks but “moderate work” for athletes) loss to body water loss than in either exercise. plays an important role in the reduced exercise performance mediated by a body water deficit. tion on maximal aerobic power and physical work capacity (33). Inc. PA). 5000-. TBW. Diuretic-induced hypohydration generally results in an et al (17). 38). moderate-intensity exercise (43–45). work output was decreased by 50%. A substantial volume of blood could be redirected to the skin and thus be Persons who use diuretics for medical purposes or to reduce removed from the effective central circulation and be unavailable their body weight are at increased risk of hypohydration because to perfuse the skeletal muscles (47. and a 2. . During maximal exercise. For example. Persons who tion (water deficit) during ad libitum drinking by heat-acclimated per. It appears that the thermoregulatory system. the superficial skin veins reflexively dilate to increase cutaneous blood flow and volume. For euhydrated persons. climatic heat stress alone decreases maximal aerobic power by 7% (46). perhaps via increased body tempera- tures. 40). Philadel. Several investigators reported a ten- dency for reduced cardiac output when subjects are hypohydrated during short-term. 37. maximal aerobic power reportedly letes.566S SAWKA AND MONTAIN volume and cardiac output. Hoechst-Roussel. The physical work capacity for aerobic exercise of progressive intensity is decreased when a person is hypohydrated (33).org by guest on June 25. Relatively less intracellular fluid is lost after (49). Hypohyration resulted in much larger decrements of phys- ical work capacity in hot than in temperate climates. output and therefore oxygen delivery during maximal exercise. Lederle Laboratories. were experienced together. 2013 of solutes. viscosity-mediated increased FIGURE 4. Climatic heat stress reduced submaximal work output at all diuretic administration because there is no extracellular solute hydration levels. and the reduction is larger with increasing water deficits. Hypohydration also impairs endurance performance in ath- In temperate climates. It is not surprising that climatic heat stress potentiates the hypohydration-mediated reduction in maximal aerobic power and physical work capacity for progressive-intensity exercise.or heat-induced was assumed. Relation between sweating rate and voluntary dehydra. both climatic heat diuretics increase urine formation and generally result in the loss stress and hypohydration can act independently to limit cardiac Downloaded from ajcn. carbonic anhydrase The effects of hypohydration and air temperature on submaxi- inhibitors (eg. Physi- cal work capacity has been shown to be decreased by marginal (1–2% BWL) water deficits that do not alter maximal aerobic power (37. Diuril. The redirection of blood flow to the cutaneous vasculature could decrease maximal aerobic power by 1) reducing the portion of cardiac output that perfuses contracting muscles or 2) decreasing the effective central blood volume and central venous pressure. Diamox Parenteral. A metabolic rate of 650 W (which represents “hard isoosmotic hypovolemia. total body water. be hypovolemic and still have to perfuse simultaneously the cuta- neous vasculature and contracting skeletal muscles. mal work output are illustrated in Figure 5. thereby reducing venous return and cardiac output. decreased blood volume increases blood viscosity and can reduce venous return. water deficits of 2–4% BWL were reported by Craig and Cummings (39) to cause a large reduction in maximal aerobic power. Armstrong et al (40) had athletes compete in 1500-. however. Data from this study indi- cate a disproportionately larger decrease in maximal aerobic power with an increased magnitude of body water deficit. In hot climates. if these events Numerous studies have examined the influence of hypohydra. with an air temperature of 43 C and low humidity hypohydration. FIGURE 3. decreases when hypohydration reaches or exceeds 3% BWL (10. and 10 000-m races when euhydrated and when hypohydrated. Thus. Merck & Co. West Point. Hypohydration is associated with decreased blood (plasma) volume during both rest and exercise (41.5% BWL (compared with euhy- EXERCISE PERFORMANCE dration) reduced work output by the same amount. Commonly used diuretics include thiazides (eg. heat stress and hypohydration were additive (17).nutrition. Somerville. the work output decrements from excess to stimulate redistribution of body water. exposure to 43 C reduced work output by 25% (compared with temperate conditions). In the heat. In addition. Lasix. Body water loss effects on plasma osmolality and plasma resistance and reduced cardiac filling could decrease both stroke volume (PV) in heat-acclimated persons (33). and furosemide (eg. 48). research conducted > 50 y ago in the California desert by Adolph NJ). A reduced maximal cardiac output might be the physiologic mechanism by which hypohydration decreases a person’s maximal aerobic power and physical work capacity for progressive-inten- sity exercise. which draws on phia). are hypohydrated and encounter environmental heat stress would sons in the desert (17). 42).

56). subjects (2%) and 15 of 70 nondrinking subjects (21%) suffered hypohydration reduces both effector heat loss responses for a exhaustion from heat strain during an attempted 8-h desert walk. found that it took hypohydration (5% BWL) on core temperature responses in the the rowers an average of 22 s longer to complete the task when same persons when unacclimated and when acclimated are they were hypohydrated than when they were euhydrated.5 km/h [ambient temperature (Ta) 38 C] and either drank Hypohydration impairs both dry and evaporative heat loss (or. but more important. dry bulb temperature. soldiers induced by hypohydration was greater in heat-acclimated than in attempted endurance (2–23 h) walks in the California desert at unacclimated persons. which decreased plasma volume by 11%. For the 7% hypohydration experiments. Hypohydration reduced tolerance time from 121 to 55 min. and 7% BWL. relative humidity = 20%) and power. 55). responses when subjects were euhydrated. More recently. BWL. 2013 Running performance was impaired at all distances but more in Hypohydration not only elevates core temperature responses the longer races (5% for the 5000 and 10 000 m) than in the but also negates the core temperature advantages conferred by shortest race (3% for the 1500 m). hypohydration increases the incidence of exhaustion from heat strain. A critical deficit of 1% of body weight elevates core temperature during exer- cise (54). Clearly. water ad libitum or refrained from drinking. db. The magnitude of core Hypohydration (2% BWL) was achieved by diuretic administra. age point of body weight lost (17.1 to 0. so that different combinations of salt and water. relative humidity = 20%) environment when euhydrated and when hypohydrated by 3%. Thus. high aerobic fitness and heat acclimation (10–12). even when hypohydration is associated with no change in 140-min walk in a hot (Ta = 38 C) environment while ingesting sweating rate. 9. 4–6. 57). the core temperature penalty in the heat. · weight loss) during exercise heat stress (33). To address whether hypohydration alters physiologic toler- ance to heat strain. there is a concomitant graded elevation of core temperature during exercise FIGURE 5. In research conducted by Adolph et al (17). These investigators if the air is warmer than the skin. These findings suggest that hypohydration not only impairs exercise perfor- mance but also reduces physiologic tolerance to heat strain. Ladell (51) had subjects attempt a ever. sweating rates at a given metabolic rate in the heat (60). 6 subjects discontinued after completing only 64 min (mean). who exam. Relation between the elevation in core temperature tion in either a euhydrated or hypohydrated (8% of total body (above euhydration) and hypohydration (measured as percentage body water) state. when they were hypo- Surprisingly. hypohydration reduced average power by 5%. TEMPERATURE REGULATION Hypohydration increases core temperature responses during exercise in temperate (11. 53) and hot (12. In shown in Figure 7 (12). it reduced the core temperature a person could tolerate (the core temperature at heat exhaustion was 0. . 7. The experiments were designed so that the com. All 8 subjects completed the euhydration and 3% hypohydration experiments. Exhaustion from heat strain occurred in 9 of 12 (75%) experiments when subjects received neither water nor salt and 3 of 41 (7%) experiments when subjects received only water. The effects of ined simulated 2000-m rowing performance. temperature elevation ranges from 0. Sawka et al (52) had subjects walk to exhaus. Burge et al (50). Sawka et al (41) had subjects attempt lengthy treadmill walks (25% of maximal oxygen uptake for 140 min) in a hot-dry (Ta = 49 C. As the magnitude of water deficit increases. How- About a decade later. FLUID AND ELECTROLYTE SUPPLEMENTATION 567S exercise intensity (47% of maximal oxygen uptake) would not allow thermal equilibrium. given core temperature (36).4 degrees lower in the hypohydrated state). hypohydration is usu- The magnitude of hypohydration was not provided in either set ally associated with either reduced or unchanged whole-body of experiments. In Figure 8. 55. few investigators have documented the effects of hydrated. 41) climates.23 C for every percent- tion (furosemide). and 7 of 8 completed the 5% hypohydration experiments. dehydration aggravates dry reported that 1 of 59 (2%) soldiers who drank and 11 of 70 heat gain) (6. FIGURE 6. Relations between body water loss and core submaximal work output (17). Acclimation lowered core temperature addition. the core temperature is usually elevated. As shown. VO2max. maximal aerobic bined environment (Ta = 49 C. body weight loss from dehydration.org by guest on June 25. 5%. temperature elevations reported by studies that examined several water deficits are shown in Figure 6 (33). In addition. (58) and skin blood flow responses (59) to hypohydration (5% In subsequent experiments. Downloaded from ajcn. 41. they reported that 1 of 59 drinking BWL) during exercise in the heat are illustrated. and heat exhaustion would eventually occur. the local sweating response (16%) who did not drink suffered exhaustion from heat strain. similar core temperature responses were observed for hypohydration on physiologic tolerance to submaximal exercise both acclimation states.nutrition. Effects of hydration level and climatic temperature on heat stress (41.

The effects of hypohydration on cardiovascular responses to exercise have been investigated by several researchers (70. 81–83) but have not addressed exercise performance. Both the singular and combined effects of plasma hyperosmo- Downloaded from ajcn. venous return.nutrition. by hypohydration reduces skin blood flow for a given core tempera. person is hypohydrated (60). Other studies reported that acute unloading of atrial 84. the control condition represented hypohydration showed that hypohydration-mediated hypovolemia increases rather than euhydration) (33). As body temperature increases during exercise. which thermoregulation in the heat. thereby improving exercise performance. Fortney (76–78) during exercise but have yielded disparate results on et al (69) provided a rationale as to why an isoosmotic hypohydra. which is associated with increased cuta. infusion) have usually reported decreased cardiovascular strain ture and thus the potential for dry heat exchange (67. theorizing that Studies that attenuated plasma hyperosmolality during exercise hypovolemia might reduce cardiac preload and alter the activity of heat stress generally have reported improved heat dissipation atrial baroreceptors. 73–75). a reduced atrial filling pressure might modify neural Many studies have examined the effects of hyperhydration on information to the hypothalamic thermoregulatory centers. the sweating rate for a given core temperature is lower when a and thus cardiac output decrease below euhydration values. Hyperhydration (greater than normal body water) has been sug- Changes in plasma osmolality may relate to tonicity changes in the gested to improve thermoregulation and exercise heat performance extracellular fluid that bathes the hypothalamic neurons (61–63). 48). During submaximal exercise with little heat strain.org by guest on June 25. As a result of decreased blood volume and blood displacement to cutaneous vascular beds. Some investigators reported lower plasma norepinephrine. 5% body weight loss) persons neous vasodilation occurs and the superficial veins become more both before (UA) and after (HA) being heat acclimated. Isotonic Studies in which blood volume was directly expanded (eg. heat strain of exercise by expanding blood volume and reducing Isotonic hypohydration alone can impair heat loss and increase blood tonicity. 72). thus decreasing venous resistance and pressure (15). 2013 lality and hypovolemia have been suggested as mediating the HYPERHYDRATION reduced heat loss response during exercise heat stress (36). during hypohy- dration a decreased blood volume reduces central venous pres- sure (73) and cardiac filling. several studies (83. The theory was sitive and osmosensitive. Gonzalez-Alonso et al (70) problems (eg.568S SAWKA AND MONTAIN pressure (physiologic technique to unload cardiopulmonary barore- ceptors) impairs heat loss and increases core temperature (71. heat stress. Also. core temperatures during exercise after hyperhydration (83–87). preoptic. but cardiac output does not usually change from what is seen in a euhydrated state (43–45). Thus. compliant. (58. heat dissipation (77–79) and exercise heat performance (79. 89). mus. hypo- hydration elicits an increase in heart rate and decrease in stroke volume. 90) reported higher sweating rates with hyperhydration. dration might benefit exercise performance arose from observation anterior hypothalamic neurons are present that are both thermosen. The combi- nation of exercise with heat strain results in competition between the central and peripheral circulations for a limited blood volume FIGURE 7. central venous pressure. 88. which have afferent input to the hypothala. core temperature during exercise heat exposure (66–68). 80). Such data suggest a central interaction that expanding body water might reduce the cardiovascular and between thermoregulation and body water regulation (65). neous vascular resistance and reduced blood flow during exercise but other researchers did not (75. cuta- euhydrated (EU) and hypohydrated (hypo. Core temperature responses during exercise heat stress in (47. which reduces stroke volume and requires a compensatory increase in heart rate (75). tion might reduce skin blood flow and sweating rate. 69). In all baroreceptors during exercise with periods of lower-body negative studies. of the adverse consequences of hypohydration. but most suffer from serious design control skin blood flow and sweating. . Local sweating rate and forearm skin blood flow (FBF) response data for euhydrated (Eu) () and hypohydrated () [5% body weight loss (BWL)] persons during exercise heat stress. above that achieved with hypohydration. Apparently. The idea that hyperhy- Silva and Boulant (64) showed that in rat brain slices. heart rate was lower during exercise with hyperhydration FIGURE 8.

8. In a study by Blyth and Burt (95). They have high sweating rates and very high sweat sodium significantly less of the water load than did those consuming chloride losses that are not abated by heat acclimation (100). In addition. and reduced poten- The mechanisms responsible for the lower exercise core tem. because of the high sweat solute losses. glycerol hyperhydration produced a higher sweating rate and substantially lower core temperature (0. Riedesel et al (92) were the first to report that ness. tial to dissipate body heat (96–98). For one trial. and thirst sensation and fluid improve heat dissipation during the exercise period. fluid intakes were plotted against thirst sensation. In water alone. 85. Often. reported that expansion Downloaded from ajcn. the first to report the effects of hyperhydration on per- formance during exercise heat stress. 99). and in the other 2 trials subjects ingested fluid as well as do their healthy counterparts (99). fluid ingestion was restricted to patients are forced to drink. Other stud. Together. 2013 of blood volume (by 450–500 mL) increased simulated time trial performance by 10% (81 compared with 90 min). FLUID AND ELECTROLYTE SUPPLEMENTATION 569S water (21. and persons who men during exercise heat stress and the relation between drinking behav- ior and thirst sensation. they tolerate the consumed 5. Ninety minutes after this hyperhydration period.3 compared with 16. much of the fluid overload is hydration on thermoregulation in this group. older adults (> 55 y) have reduced thirst tion might reduce the thermal and cardiovascular strain of exercise. both groups were before exercise. exercise per se did not exacerbate the difference that existed exercise heat stress.5% BWL. cystic fibrosis patients have suppressed thirst sensations Lyons et al (90) studied whether glycerol-mediated hyperhy. reported greater exercise sweating rates when sub. Research from our own laboratory has failed to show any thermoregulatory advan- tages of either water or glycerol hyperhydration during exercise heat stress (93. Compared with drinking water alone. the subjects began exercise. by having subjects overdrink water or take water-electrolyte adding solute to stimulate thirst (2)] to optimize fluid and elec- solutions. 90). these factors cause large body stress. suffer a high incidence of heat injury or ill- glycerol (91. have suffered a spinal cord injury all have unique problems associated with fluid and electrolyte balance during exercise heat stress. RESEARCH NEEDS FIGURE 9. they have the hyperhydrated. More recently. a multisystem disorder that alters retention can be achieved with an aqueous solution containing sweat gland function. 94). persons with cystic fibrosis. however. therefore. the 2 groups jects were hyperhydrated (84. but the difference in average time to exhaustion (17. Thus. subjects ran to exhaustion in a hot climate (49 C) when normally hydrated and when hyperhydrated by drinking 2 L of fluid 30 min before exercise. Research issues include the testing of strategies [eg. Several older persons experience when fluid homeostasis is challenged studies reported that overdrinking before exercise lowers body (96) is illustrated in Figure 9 from the research of Mack et al core temperature before exercise (84.9 min) was not statistically significant. Subjects completed 3 trials in which they exercised in a water deficits during exercise heat stress (99). these findings support the notion that hyperhydra. groups. sensation. However. This observation is important in light of hyperhydration may improve heat dissipation during exercise the reduced ability of older persons to conserve water and elec- heat stress.4 mL/kg body wt. older persons have a reduced (87) found that sweating began earlier when subjects were thirst sensation. when matched ies. If cystic fibrosis hot (42 C) climate. Few studies have examined whether hyperhydration improves exercise performance or heat tolerance. which reduce the osmotic dration improves thermoregulatory responses to exercise heat drive for thirst (2. Together. For example. (65–78 y) persons for thirst sensation and fluid intake during ies. these approaches have resulted in only transients trolyte replacement in these populations and the effects of hypo- expansions of body water. Grucza et al drank the same amounts. Subjective thirst sensation of younger () and older () Older adults. Research . Hyperhydration. In addition. 92). additional research is needed on all 3 of these (33). apparently did not hypohydrated by 2. during exercise. Those investigators compared younger (18–28 y) and older to the energy cost of warming the ingested fluid. probably because of fluid or electrolyte imbalances (99.nutrition. rapidly excreted (91). Thirteen of 18 subjects ran longer when hyperhydrated. After this perturbation. trolytes in their kidneys when challenged by body water Although many studies have tried to induce hyperhydration deficits.4 mL/kg) with or without a bolus of glycerol (1 g/kg). less ability to concentrate urine. but for a given thirst sensation. In these stud. after hyperhydration with a glycerol solution.org by guest on June 25. intakes were lower in the older group. however. 85). Luetkemeier and Thomas (80). The reduced thirst sensation peratures in the hyperhydrated state remain unclear.7 C) than did control conditions and water hyperhydration. but this is likely due (98). who examined whether hyperv- olemia improved cycling performance. Evidence has accrued that greater fluid Persons with cystic fibrosis. The findings of these last 4 studies suggest that same drinking behavior. subjects excreted 100). glycerol ingestion increased fluid retention by 30%. addition.

J Appl Physiol 1971. Coyle EF. Sawka MN. 9. but data 22. 1990:1–38. sis after exercise. 1996:187–214. Effects of ingesting cal function and exercise performance. Armstrong LE. Together. Nutritional needs in hot environments: application AJ. Vol- 5. KY: Armored Force Medical Research Laboratory. sweat output often exceeds water intake.570S SAWKA AND MONTAIN should focus on developing fluid-electrolyte strategies to stimu. eds. The consequences of spinal tion and exercise: effects of heat acclimation. Francesconi RN. Carmel. 19. ed. Engell DB. 1988:227–66. Washington. Work performance after dehy- late thirst and minimize voluntary dehydration in this population. gender. In: Das B. 26. Bean. Mack GW. American College of untary dehydration and electrolyte losses during prolonged exercise Sports Medicine position stand: exercise and fluid replacement. London: Taylor & Francis. Limitations of heat tolerance. Hubbard RW. Fluid replacement and heat stress. Nose H. Maughan RJ. Naman RK. ment. In: Pandolf KB. Hales JRS.24:776–81. Eur J Appl Physiol 1982. tective systems during exercise in the heat.70:1490–4. the higher and more complete the cord injury. carbohydrate beverages during exercise in the heat. Vol 3. Sawka MN. Sils IV.55:1147–53. Hubbard RW. 1989. Thirst and fluid intake following graded hypohydration levels in for military personnel in field operations. Sargent F 2nd. The water deficit in industrial ergonomics and safety II. eds.57:868–73. Med Sci Sports Exerc 1992.1:24–7. Francesconi RP. in the heat. dration: effects of physical conditioning and heat acclimatization. thirst sensation. Neufer PD.55:507–12. 1994:195–214. these factors lead to a reduced ability to ther- 15. Brouns F. Washington. Determination of water and salt cise tasks are likely to be adversely affected by hypohydration requirements for desert operations. 7. Nadel ER.30:708–12. Fluid replacement and heat reduces a person’s ability to tolerate heat strain. Thermoregulatory responses moregulate during exercise heat stress (105). noninvasive 157–85. Pandolf KB. Physiological consequences of hypohydration: exercise 32. Perspectives in exercise science and sports medicine. Cadarette BS. Armstrong LE. IN: Benchmark Press. 10. Eur J Appl Physiol for exercise in hot weather. Influence of acclimatization on sweat sodium supporting that notion are not robust (110). Young A. eds. Environmental issues that influence intake of replace- environments (51). technologies to measure total body water and hydration status 16. WB. Pandolf KB. Sawka MN. New York: Intersciences. 30. New York: Oxford University Press. Exerc 1986. Morimoto T. ed. 1996: A final research need is the development of rapid. addressed water and electrolyte requirements. Bar-Or O. Blatteis CM.33:1019–29. (Report no. Med Sci Sports eds. 1. Quigley MD. Maller O. The effects of exercise and heat on vitamin require- 2. Montain SJ. Goldman RF. Adolph EF.56:765–70. Body fluid responses and hypohydration during exercise. New York: Oxford University Press. The increased stress. ed. Clarkson PM. environ- thermoregulation during hypohydration for this population. eds. motor and sudomotor adjustments) over large areas of skin (106) 13. 1947. Sawka MN. Human ences in physiological reactions to thermal stress. Fort Knox. Med Sci Sports Exerc 1996. Young AJ. 14. 27. Szlyk PC. Bass DE. et al. Predicting sweat loss response (108). 8. environment and clothing. DC: National Academy Press. Blatteis CM. Fluid replacement strategies cise: effects of heat stress and hypohydration. Convertino VA. Army Sci Conf Proc 1982. concentration. Wall PT. Physiology of man in the desert. pro. Toner MM. Effects of body water loss on physiologi. Nelson N. Indianapolis: Cooper Publishing Group. Neufer PD.18:568–75. Slabochova Z. Sawka MN. Matthew WT. ed. Sawka MN. Sawka MN. Latzka WA. Lamb DR. Hubbard RW. fluid compartments of tissues under thermal dehydration in the rat. Allan JR. Hubbard RW. Pandolf KB. Greenleaf JE. Levine L. Heat—sweat—dehydration—rehydration: a praxis ori- skin blood flow for a given core temperature. The magnitude of and the hypohydration response to exercise-heat stress. 31. 2013 18.org by guest on June 25. may reduce thermal strain during exercise in the heat. Gonzalez RR. 48:83–96. sweating. extremes. J Appl Physiol performance physiology and environmental medicine at terrestrial 1967. Handbook of physiology. Sawka MN. Marriott BM. In: Gisolfi CV. In: Marriott BM. Downloaded from ajcn. Water as a tactical weapon: a doctrine for preventing and the isolation of thermal receptors throughout the body (107).58:433–9. Sawka MN. ed. Athletic Therapy Today 1996. Toner MM. Iampietro PF. 1996:285–355. et al. In: Marriott BM. Aviat Space Environ Med 1985. some sweating can occur over the insen. Body fluid balance during heat stress in ments. 29. 1994. Associates. lowers both intracellular and extracellular volume and also 1990:897–904. J Appl Physiol 1983. the greater the 12. and involuntary Hypohydration does not impair skeletal muscle glycogen resynthe- dehydration.28:i–vii. 23. Sweat elec- trolyte loss during exercise in the heat: effects of gender and matu- REFERENCES ration. 28. Greenleaf JE. Sawka MN. DC: National Academy Press. Wenger CB. Environ Med 1984. heat casualties. Aerobic exer. 11. Section 4. Cadarette BS. humans. ogy. 24. 17. Distribution of water losses among performance and thermoregulation. Hypohydration increases heat storage and ment beverages. 1943.24:645–56. 1993. Problem: thirst. Buskirk ER. J Appl Physiol 1991. New York: Oxford University Press. J Sports Sci 1991. In: Fregly MJ. Levine L. Washington. Aviat Space impairment is related to the level and completeness of the lesion. Sawka MN. Persons with spinal cord injury have an impaired ability to J Appl Physiol 1958. Sandick BL.12:189–94. 2-6. Hypohydra- thermoregulatory impairment (105). drinking behavior.22:526–32. Aerobic fitness thermoregulate during heat stress (101–104). Heigenhauser GJF. . Advances ducing a body water deficit (hypohydration). Section sate skin. Med Sci Sports Exerc 1992. DC: National humans. but it is sparse and not synchronous with sensate skin 4. MacDougall D. Shapiro Y. Academy Press. measure deficits as small as 5% of total body water. Washington. Young 4. SUMMARY Physiologic strain associated with wearing toxic-environment pro- During exercise. During heat exposure. Gaffin SL. mental physiology. DC: National Academy Press. Pandolf KB. Valid methods are needed that have enough resolution to to exercise.40:229–36. Environmental physiol.9:143–52. Hyperhydration ented approach. Med Sci Sports Exerc 1992. Voluntary dehydra- 3. Research has not to acute exercise-heat stress and heat acclimation. J Appl Physiol 1984. and environ- cord injury are loss of sympathetic control of heat loss (via vaso.) (109). potentially more so at higher exercise intensities in warm 20. Matthew WT. Physiol Behav 1987. Handbook of physiology. Quigley M. Wilson CG. Jpn J Physiol 1983. Kregel KC.2:125–39. or Blatteis CM. Sex differ- heat stress. Sawka MN. 25. tion and alliesthesia for water. 24:657–70. Pandolf KB. heat storage is mediated by a reduced sweating rate and lower 21.nutrition. In: Fregly MJ. Marriott BM. Nutritional needs in hot environments. Meyer F. In: Fregly MJ. Ogura K. Gisolfi CV. 1993:137–71. Gastric emptying during exer- 6. Owen MD. results in plasma hypertonicity and hypovolemia. Pandolf KB. Morimoto T. Drolet L. Eichna LW.

42. Blatteis CM. Heat tolerance fol- maximal exercise after dehydration and rehydration in high school lowing diuretic induced dehydration. Critz JB. Strydom NB. water deficit on physiological responses during heat stress. J Appl Physiol 1990. The effects of different levels of cise-heat exposure. Nazar K. vascular resistance during exercise. Shi XR. 76. Sproles CB. Proppe DW. Downloaded from ajcn. eds.49:715–21. Sawka MN. Greenleaf JE. of saline infusion on body temperature and endurance during heavy 55.19:1125–32. Wilk Physiol 1995.39:1491–7. Greenleaf JE. Body fluid balance during exer. and metabolic function following dehydration and rehydration. Hubbard RW. Wenger CB. Francesconi RP. Magder S. exercise. Boca Raton. 66. dehy. Sawka MN. J Appl Physiol 1985.65:1827–32. Below PR.org by guest on June 25.11:177–80. Elizondo RS. Ladell WSS. Exercise stroke volume relative 52. upon thermoregulation responses to exercise in the heat. New York: Oxford University Press. Greenleaf CJ. J Appl Physiol 1980. Nousiainen U. Eur Physiol 1981. Fink WJ. Grande F. Rutt R. Gonzalez RR. B. J Appl Physiol 1988. 71. and Thermoregulatory and blood responses during exercise at graded temperature on neurons in preoptic tissue slices. Levine L. Human tolerance to heat strain during exercise: influence 77. Thomas EL. 1902–8. performance. Mora-Rodriguez R.34:569–79. Acta Physiol Scand 79. Ekblom B. Thermoregulation and body fluids: role of blood vol- mance in the heat. 1984. Hypothalamic neurons regulating body temperature. 34.26:503–9. 51. Craig EN. Young AJ. Francesconi RP. Section 1984. Rowell LB. J Appl Physiol 1995. Allen TE. Influence of graded dehydration on hyper.47:1–7. Nadel ER. submaximal exercise after dehydration and rehydration. dration. 60. Jpn J Physiol 1990. In: dehydration on competitive running performance. Extracellular loss regimen practiced by college wrestlers. Silva NL. 37.25:1358–64. and exercise-induced hypohydration. responses to exercise in man on restricted food and water intake. eds. ume on sweating rate and body fluids in exercising humans. J Appl Physiol 1988. Sawka MN. Prediction modeling of physiological responses and human perfor- 73. J Appl Physiol 1990. Effect of acute alter- Med Phys Fitness 1976. J Appl Physiol 1985. Influence of diuretic-. Am J Physiol 1989. Handbook of physiology. Role of cardiopulmonary baroreflexes 49. wrestlers. Morimoto K. J Appl Physiol 1992. Circulatory and thermal regulations during exercise. Boulant JA. Luetkemeier MJ. Bove JR. Valeri CR. Smith DP.43:627. Effect 1970. 1955. Cadarette BS. ations of blood volume on circulatory performance in humans. Handbook of physiology.40:165–79.127:11–46.257:R311–6. acute plasma volume expansion on altering exercise-heat perfor- 54. 67. Quigley MD. Effects of J Appl Physiol 1959. Brain Res Bull 1988. Francesconi RP. Horstman DH. Circulatory responses to Proc 1980. Effect of hydration state on cir- mance of men working in hot and humid environments. Physiological effects of a weight 61.56:91–6. 75. J Sports 68.68: 1992.24:643–4. Gaddis GM. Eur J Appl Physiol 1983.73:1340–50. Montain SJ. Hermansen L. Buskirk ER. thermia and cardiovascular drift during exercise. J Appl Physiol 1989. Hypervolemia and cycling time trial 1992. Senay LC Jr. J Appl Physiol 1968. 1979. Nadel ER. 1996:143–61. Hopper MK. Muza SR. . Coyle EF. Sawka MN. Effects of osmotic pressure. Gut ance: exercise and sport. fluid bal. Effect of central blood volume decrease 48.16:98–105. Inoue T. 1984. to plasma-volume expansion. 57. Fortney SM. J Appl 35. Stroschein LA. Gonzalez RR. Tankersley CG. Pan. Payne WR. 74. Weltman A. Med Sci Sports 1977. Drolet LL. Fed 44. Rasmussen IB. Control of thermoregulatory sweating during exercise in and diuretic dehydration. 39. Dehydration and muscular work. Nose H. Boulant JA.21:670–4. sweating is altered by hydration level and exercise intensity.9:159–63. Pan- trolyte changes after prolonged bicycle exercise.79:475–83.64:404–8. 59. Pimental NA. 1968. Stoklosa J. J Appl 45. Pandolf KB. J Appl ence of heat stress and acclimation on maximal aerobic power. 64. New York: Oxford University Press. Influ. Am J Physiol 1980. 69. Fed Proc In: Fregley MJ. Dennis RC. Young AJ. Age and hypohydration independently influence the peripheral vascular response to heat stress. Current concepts concerning thirst. Pandolf KB. 58. view.79:1487–96. regulation during exercise dehydration in man. Nadel ER. Bonnesen A. Hyde DE. Neufer PD. Cummings EG. 56. dogs.79:1434–9.252:1165–9. 72.53:294–8. Pandolf KB. Mack GW. J Appl 62. osmotic and cardiovascular signals on preoptic and anterial 1984. Puhl SM. Costill DL. Comput Biol Med 1986. dolf KB. Hori T. Young AJ. Young AJ.57:1018–23. Coyle EF. Sawka MN. Med Sci Sports Exerc 1994. Cardiovascular adjustments to heat stress. Armstrong LE. Kozlowski S.22:229–34. The effects of water and salt intake upon the perfor. FL: CRC Press. Sawka MN. passive heating dolf KB. Ahonen E. Morimoto T. eds.51:303–12. Mack G. Wenger CB. Gonzalez-Alonso J. Levy RD. Sawka MN. 1986. Knowlton RG. Francesconi RP. and fluid replacement: overview. Influence of diuretic-induced 63. Med Sci Sports Fregly MJ. Convergence of and vascular fluid shifts during exercise in the heat. Puhl SM.17:456–61. Exerc 1985. Med Sci Sports Exerc hyperosmolality and body temperature during physical exercise in 1990. Nakashima T. Koga A. Nielsen B. Fortney SM.16:319–29. Latzka WA. New York: Oxford University Press. Human circulation: regulation during physical stress. Sawka MN. Coyle EF.nutrition. J Appl Physiol hydration level and body fluids on exercise performance in the heat. Sawka MN. J Appl Physiol 80.69:609–16. Allen TE. Section 4. In: Buskirk ER. FLUID AND ELECTROLYTE SUPPLEMENTATION 571S 33. 40. Differential effects of sauna-.8:239–43. Greenleaf JE.73:368–75. 1996:215–43.66:2799–804. Fink W.14:194–8. Young AJ. Senay LC Jr. Carey MF. hypothalamic neurons in the rat. Wenger CB. JAMA 1984. saline infusion during exercise on thermal and circulatory regula- 53. Rowing performance.25:149–52. Nadel ER. Bove JR. Am J Physiol hypohydration levels. Pandolf KB. Body fluid bal. Body temperature tions. Taylor HL. Turlejska E. Pandolf KB. Sawka MN. [K+]. Costill DL. Med Sci Sports Exerc Turner NL. Holdsworth LD. J Appl Physiol thermal. responses to repeated bouts of prolonged running. 78. Circulatory response to submaximal and maximal exercise Physiol 1981. Webster S. the heat.59:1394–401. J Physiol culatory and thermal regulations. Sawka MN. Latzka WA. Marliss EB. Blatteis CM. Relationship of evaporative rates to serum [Na+]. Kenney WL. Smith DP. Claremont AD. Deschamps A. Coggan AR. Caldwell JE. Sawka MN. Miller DK. Nose H. Kiyohama T. Hemodynamic response to sub. Latzka WA. 4. Nadel ER. 38. Kubica R. 1996:105–25. Newswanger DL. J Appl Physiol 1964. 70. Nadel ER. Med Sci Sports 1976.239:R180–3. after thermal dehydration. Monagle JE. Acta Physiol Pol 1983. Control of thermoregulatory and osmolarity in acute heat stress. during dynamic exercise. glucose. J Appl Physiol 1979. Med Sci Sports Med Sci Sports Exerc 1993. Montain SJ. Temperature mance. Saltin B. 50. Relationship between plasma volume reduction and plasma elec. Cosio MG. Montain SJ. Johnson JM. Temperature regulation and hypohydration: a singular Physiol 1966. 36.51:1594–600.20:879–85. ume and central venous pressure. 2013 41. Byrd RJ.50:292–8. Burge CM.26:95–102. Effect of of hydration. 43. Van Handel P.247:R335–45. Fortney SM. Effect of blood vol- 46. Dehy- dration reduces cardiac output and increases systemic and cutaneous 47. Hydration 65. Thermal and circulatory ance.

84. Distribution of impaired cutaneous vasomotor and core temperature. Kenney WL. In: Hollozsy 95. O’Brien C.76:1615–23. Baltimore: Williams & in high ambient temperatures. ed. hormonal. Montain SJ. thirst and renal osmoregulation. Sawka MN. Henke KG. 1995:305–51. Gillen CM. Hay JA. Freund PR. Rowell LB. MN. Body fluid and temperature regulation as a function of lality on control of blood flow and sweating. Binkhorst RA. Meuli LE. Baker-Fulco CJ. Wilkins. 65:1082–6. Chick TW. Res Q Exerc Sport 1932.83:860–6. 99. Libert JP. et al. Fowler SR. J Appl Physiol 1998. Influence of body water and blood volume on stress. age. Hyperhydration: ther.15:195–200. Sawka MN. In: Hales hyperhydrated men during physical exercise. et al. Langhans GW. Oeseburg B. Med Sci Sports Exerc 1999. moregulatory effects during compensable exercise-heat stress. Med Sci exercise in the heat. Voluntary dehydration and heat intolerance in cystic fibrosis. Bar-Or O. Hyperhydration Physiol 1984. during hypohydration and hyperhydration. Attia M. Kahn JM. 267–70. Sports Exerc 1990. Exercise temperature regulation in man in persons with paraplegia to prolonged arm exercise and thermal stress. Young AJ.30: 104. Lyons TP. Physiol 1978. Thermoregulatory set-point in paraplegia. Hyperhydration: toler. Heat acclimation in cystic in exercising man during dehydration and hyperhydration with fibrosis. Sawka Physiol 1997. Edwards RJ. thermoregulation during exercise. 108. . Effects of changes in plasma volume and osmolarity on 98. 85.3:301–7. Montain SJ. Fennessy PA. Thermal physiology. Thermal exercise.90: Nadel ER. Brengelmann GL.56:603–7. Glycerol hyperhydration: 1974. Scherzer H. A 31P MRS study. Hansen G. 83.83:11–8. Bove JR. J Appl Physiol 1988. 1987. Thermoregulation 100. Bioimpedance 93.nutrition. Gass GC. J Physiol (Paris) 1988. Cardiovascular responses 88. with glycerol solutions. upper body exercise: able-bodied and spinal cord injured. Exercise and sport sciences reviews. Gisolfi CV. renal. MacDougall JD. Montain SJ. Engel P. Bass DE. 107. sudomotor function in paraplegic man. Nadel E. 2013 tal vs. J Appl Physiol 1994. Downloaded from ajcn. Ward DS. Halar E. Jorgensen SO. Med Sci Sports 1974. Pandolf KB.56:1104–9. adults. Harrison MH. J Appl Physiol 1987. Coyle EF. and vascular fluid responses. eds. Attenuated skin 79:2069–77. Sedlock DA.25:577–83. 101. Jolesz FA. Zientara GP. Al-Qattan K. Scand J Clin Lab Invest 91. Candas V. Methylcholine-activated eccrine sweat tonicity as factors in the regulation of body temperature. induced hyperhydration prior to exercise in the heat on sweating and 106. Orenstein DM. Sawka MN. Riedesel ML.339:696–9. and circulatory responses during prolonged exercise at different lev- 105. Intravascular volume and 97. J Appl Physiol 1988. Smith SA. Latzka WA. Hopman MT. Sawka MN. Kozlowski S. New York: Raven Press. Exercise in older 57:1688–95. Fitzgerald PI. Latzka WA. Szczypaczewska M. Blimkie CJ. Gisolfi CV. Castle BL. Matott RP. Med Sci 90. Indianapolis: Cooper Publishing.84:1889–94. 103. blood flow response to hyperthermia in paraplegic men.22:477–83.org by guest on June 25. 82. J Appl 92. thermoregulation and exercise performance in the heat. Freund BJ. J Appl Physiol 1965. et al.21:S132–40. assessment of hypohydration. Effects of glycerol- Sports Exerc 1989. Latzka WA. Nadel ER. 96. Brandenberger G. Temperature regulation during els of hydration.31:1466–71. Copping JR. Montain SJ. Camp EM. water and saline. Normell LA. Med Sci Sports Exerc 1990. Lancet 1992.84:1858–64. Nielsen B.6:108–13. Riedesel ML. Thermal effects of prolonged treadmill adjustments to prolonged exercise in paraplegic women. Allen DY. Sagot JC. Engel P. J Appl Physiol 1971. Rectal and rec- 847–53. Kenney WL. J Appl Physiol 1995. Sawka MN. Fortney SM. 87. Nielsen E.44:69–75. J Appl gland density and output as a function of age. Mack GW.20: WM. Effect of water balance on ability to perform JO. Young AJ. 1999:167–218. Acta Physiol Scand 1974. Greenleaf JE. Moroff SV.22:629–35. Peake GT. Nielsen B. esophageal temperatures in paraplegic men during prolonged 89. In: Lamb DR. Grucza R.63:2262–8. Green CG.57:408–12. Effects of overhydration on man’s physio. 1984:79–82. Hypohydration effects on skeletal muscle performance and 94.138:25–41. Thermoregulation in 102. Gwinn TH. Weseman CA. Eur J Appl Physiol JRS. Nadel ER. J Appl Physiol 1984. Wilson logical responses to work in the heat.572S SAWKA AND MONTAIN 81. ance and cardiovascular effects during uncompensable exercise-heat 110. J Appl Physiol 1998. Circulatory and thermal 86. J Appl 109. Knowlton RG. ed. Med Sci Sports Exerc 1993. Body fluid balance in dehydrated healthy older men: 725–30. Int J Biometeorol 1971. Burt JJ. metabolism.64:2265–71. Effect of hyperosmo. Wenger CB. J Appl Physiol 1984. Blyth CS.