Hyponatraemia

Stephen Burns

Environmental Exercise Physiology

SS3111

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 Overview
• Introduction
• Hyponatraemia –definition and prevalence
• Hyponatraemia – Singapore
• Performance and hypohydration in race conditions
• Summary
• Recommended reading

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Hyponatraemia – definition and prevalence

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 What is hyponatraemia?
• Excessive consumption of water or fluids
low in sodium before or during exercise can
lead to hyponatraemia.

• Defined as a serum sodium concentration

<135 mmol/L.

• Severe hyponatraemia can be defined as

serum sodium concentration <120 mmol/L.

From: Exercise Physiology: Energy, Nutrition and Human

Performance. McArdle WD, Katch FI, Katch VL 7th Edition, 2010.
Lippincott Williams and Wilkins.

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 Symptoms and risks?
• Exercise associated hyponatraemia (EAH) can be
symptomatic or asymptomatic.

• Athletes with symptomatic EAH can present with

mild, non-specific symptoms (e.g. light-
headedness, nausea) but typically present with
headache, vomiting, and/or altered mental status
(confusion, seizure) resulting from cerebral
edema.

• Symptoms associated with EAH are due to

osmotic-induced shifts of water into the
intracellular compartment.

• In the confined space of the cranium these water From: Exercise Physiology: Energy, Nutrition and Human
shifts into the central nervous system lead to Performance. McArdle WD, Katch FI, Katch VL 7th Edition, 2010.
cellular edema and increases in intracranial Lippincott Williams and Wilkins.
pressure which in the extreme can lead to death. 6
 Prevalence of hyponatraemia
• From a sample of 488 individuals in the
Boston Marathon, the percentage with
hyponatraemia has been recorded at
13% (serum sodium concentration <135
mmol/L).

• Those experiencing critical

hyponatraemia has been recorded as
0.6% (serum sodium <120 mmol/L).

Dr. Cynthia Lucero

From: Almond et al, New England Journal of Medicine,
2002 Boston
352:1550-1556, 2005. Marathon.
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 Factors associated with hyponatraemia

From: Almond et al, New England Journal of Medicine, 352:1550-1556, 2005.

• Hyponatraemia was associated with weight gain, consumption of >3 L of fluid during the race, drinking
fluids every mile, and a racing time of >4 hours.

• It is unclear why low and high BMI are associated with hyponatraemia – low BMI because smaller runners
may drink more in proportion to larger runner, high BMI because larger runners may lose less water
through evaporation (sweat) as a result of a lower ratio of surface area to volume.
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Hyponatraemia – Singapore

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 Singapore: North Face 100km trail running
race 2009

• Many runners lost more than

the 2% of body mass
recommended in position
stands by many scientific
associations.

• However, a substantial
proportion of runners gained
weight during these races.

From: Dr. Lee Kai Wei Jason. DSO National Laboratories, Singapore. Personal communication.
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 Standard Chartered Singapore Marathon 2009

• 40% of marathon runners lost

more than the 2% of body
mass recommended.

• 4% of runners gained weight.

• Are there performance or

health detriments associated
with these changes?

From: Dr. Lee Kai Wei Jason. DSO National Laboratories, Singapore. Personal communication.

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 Standard Chartered Singapore Marathon
2009: Serum sodium levels

• Three cases of mild

hyponatraemia found with
marathon running.

• Symptoms of hyponatraemia
are similar to those associated
with heat exertion – how are
these individuals treated?

From: Dr. Lee Kai Wei Jason. DSO National Laboratories, Singapore. Personal communication.

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Published data – Adidas Sundown Marathon 2009

• Three of eight runners (37.5%) admitted to medical

tent were cases of hyponatraemia.

• ~7-8% of runners are gaining body mass in these

runs.

Lee et al, International Journal of Sports Medicine, 32:297-302, 2011

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 Exercise-Associated Hyponatraemia (EAH)
Statement

• “Given that excessive fluid consumption

is a primary etiologic factor in EAH,
using the innate thirst mechanism to
guide fluid consumption is a strategy
that should limit drinking in excess and
developing hyponatremia while
providing sufficient fluid to prevent
excessive dehydration.”

Hew-Butler et al, Clinical Journal of Sport Medicine, 25:303-320, 2015 14

 Heat illnesses do occur in the heat
• US Army: 5,246 soldiers hospitalized and 37 deaths
due to heat illnesses in 22 year period.

• 61% of hospitalizations due to heat

exhaustion/syncope, followed by heat stroke (18%),
and heat cramps (8%).

• Mortality rate was 0.3 per 100,000 soldier year during

22-yr period.

• Heat stroke – 17% were associated with dehydration,

25% had rhabdomyolysis, 13% had acute renal failure.
6% of all heat stroke cases presented with all three.

• Hyponatraemia hospitalisations were low and have

remained relatively constant at ~1 case per 100,000
soldiers per year.
Cater III et al, Medicine and Science in Sports and Exercise,
37:1338-1344, 2005
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 Risk in Singapore?
• Is heat illness or hyponatraemia the greater concern in Singapore?

• Which carries the greater risk?

• Does fluid intake really help prevent heat illnesses?

From: Channel News Asia

CFC Dave Lee: 19 y
Benjamin Sim: 16 y

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Performance and hypohydration in race
conditions

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 Dehydration and impairment of performance?
Kenefick, Sports Medicine, 48(S1):S31-S37, 2018
• Most laboratory studies indicate
an impairment in endurance
performance with exercise
performed in a dehydrated state.
Note: Data are from review of 34 endurance
exercise/dehydration studies. Fractions above
bars represent the number of significant
observations out of total observations for each
level of dehydration. 41 out of 60 studies
showed impaired performance with
dehydration ≥2%.
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 Body weight change and marathon performance?

• However, in real-life many runners and

other athletes complete endurance races
successfully with body mass losses well in
excess of 2%.

Note: Level of post-race dehydration vs. average

running speed and finishing time for 42 km when
drinking ad libitum.
Kenefick, Sports Medicine, 48(S1):S31-S37, 2018
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 Elite performance?
• Body mass loss of 10 winners and 1 second
place individual in 13 major men’s city
marathons were on average 8.8%.

• Haile Gebrselassie who won the 2009 Dubai

marathon had a body mass loss of 9%.

• Average total drink duration during these

races was 26 secs (range 1.6 – 50.7 secs).

• This does not necessarily mean that

exercise-induced body weight loss is
ergogenic, but that the maintenance of body
weight <2% is not critical to performance
Beis et al, Clinical Journal of Sport Medicine, 22:254-261, 2012 during endurance events.

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 Body weight change and marathon performance?

Zouhal et al., British Journal of Sports Medicine, 45:1101-1105, 2011

• In cool conditions (9-16°C) with moderate humidity (60-82%), the degree of body weight loss was linearly
related to 42 km race finishing time in the 2009 Mont-Saint Michel Marathon.

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 Body weight change, rectal temperature and
triathlon?
Group 1 Group 2 Group 3 Note:
Mean Mean Mean Group 1: weight loss >5%
Rectal temperature (°C) 37.5 37.7 37.6 Group 2: weight loss 3.5-4.5%
Group 3: weight loss 3% to
Swimming (mins) 68.2 67.4 70.0 weight gain of 3%
Cycling (mins) 384.5 386.8 383.5
Running (mins) 279.5 273.9 278.6
Overall race time (mins) 739.2 741.8 741.9
• In a 224 km Ironman triathlon in South
Africa in 2000 and 2001 there was a weak
inverse association between temperature
and percentage weight loss.

• However, temperatures from 15.6-23.9°C

during these races and humidity averaged
65%.
Sharwood et al., British Journal of Sports Medicine, 38:718-724, 2004 22
 Laboratory studies - external validity?

Cotter et al., Extreme Physiology & Medicine, 3:18, 2014

• There are criticisms surrounding ecological validity for laboratory-based studies.

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 Ecologically valid laboratory studies
• Cyclists were dehydrated -3% in body
mass during 2 hours of submaximal
exercise and then blinded to the extent
of rehydration during a saline infusion.

• There was no difference in subsequent

25 km time trial performance in the
heat with real-life wind speeds (32
km/h) when they were fully rehydrated
compared with -3% or -2% dehydration
even though rectal temperatures were
greater in the -3% condition.

Wall et al., British Journal of Sports Medicine, 49:1077-1083, 2015

• Wind speed may play an important role
in skin temperature cooling.

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 Adaptation to hypohydration?
• Familiarisation to hypohydration (four successive
session of 2% hypohydration) may nullify
impairments in performance (treadmill running)
without diminishing cardiovascular strain.

Note: 10 recreationally active males ran for 45 mins

Cotter et al., Extreme Physiology & Medicine, 3:18, 2014 citing at 75% VO2max followed by a 5 km time trial. Data
Fleming & James, Appl Physiol Nutr & Metab, 39:124-129, show difference between euhydration and
2013.
hypohydration before and after habituation.

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 Overall performance
• Meta-analysis of five articles with 13 effects
found that during cycling in ‘real world’
laboratory conditions, exercise-induced
dehydration did not alter cycling time trial
performance and drinking to thirst was
associated with an increase in time trial
performance compared with drinking above or
below thirst.

• Real world conditions included: (i)

hypohydration induced during and not before
exercise; (ii) fluid replacement given orally; (iii)
equal amounts of carbohydrate given in both
conditions; (iv) exercise completed in
Goulet, British Journal of Sports Medicine, 45:1149-1156, 2011
compensable heat stress; and (v) time-trial
protocols with known end-points.

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 Ecologically valid vs. non-valid protocols
• Endurance performance during
ecologically valid (time-trial exercise) vs
non-valid (clamped intensity exercise).

• Data suggests that exercise-induced

dehydration ≤4% does not impair
performance in ecologically valid
studies.

• However, during clamped intensity

exercise performance is impaired with
dehydration ≥1.75%.

Goulet, British Journal of Sports Medicine, 47:679-686, 2013

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 Too much versus too little?

• Both over consumption and

inadequate consumption of fluids
(water) are associated with acute
and chronic health risks for athletes
and may impair performance.

• Individuals working with athletes

should provide reasonable
guidelines related to fluid intake
that do not endanger health.

Cotter et al., Extreme Physiology & Medicine, 3:18, 2014

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 Polarised debate – drink to body mass or drink to
thirst?

Cohen, BMJ, 345:e4737, 2012 Heneghan et al., BMJ, 345:e4797, 2012

Emeritus Professor Timothy Noakes

Exercise Science and Sports Medicine
University of Cape Town, South Africa
http://www.youtube.com/watch?v=8dFlV-Rn1yw

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 Summary
• Excessive consumption of water or fluids low in sodium before or during exercise can lead to
hyponatraemia.

• A significant number of individuals competing in distance races may be at risk of developing

hyponatraemia, including in Singapore.

• Hyponatraemia during marathon running is associated with weight gain, consumption of >3 L of
fluid during a race, drinking fluids every mile, and a racing time of >4 hours.

• Whilst many laboratory studies indicate an impairment in endurance performance with exercise
performed in a dehydrated state that is not the case in real-life racing or in ecologically valid
laboratory studies. It is important to recognize that many of these studies are not always
conducted in hot and humid conditions.

• There is vigorous debate about whether exercising individuals should drink to thirst or to body
mass.
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 Recommended reading
• Exercise Physiology: Energy, Nutrition and Human Performance. McArdle WD, Katch FI,
Katch VL 8th Edition, 2015. Lippincott Williams and Wilkins. Chapter 25: Exercise and
Thermal Stress. Pgs. 615-642.

• Exercise Physiology: Theory and Application to Fitness and Performance. Powers SK, Howley
WT. 8th Edition, 2012. McGraw-Hill. Chapter 12: Temperature Regulation. Pgs.261-280.

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