Exercise Associated Hyponatremic Encephalopathy, Gatorade and the ACSM

[Russell Greene]

On August 6th Zyrees Oliver, a 17-year old with a 3.8 GPA, attended high school football practice in the 90-degree Georgia summer heat. Five days later, he died in the hospital.

But it wasn’t the heat that got him.

During practice, Zyrees complained of cramps. His aunt Dr. Tammy Chavis reports that he drank approximately 2 gallons of water, and two gallons of Gatorade. It’s not clear if his excessive drinking preceded or followed the cramps.

I am not sure if anyone precisely measured Zyrees’ fluid consumption, so take that 4 gallon figure with a healthy dose of electrolytes. And as of right now we don’t know the full story behind Zyrees’ death. Perhaps something in addition to over-hydration played a role. When the autopsy comes out, we’ll know more.

Nonetheless, the press reports that “Relatives said doctors told them Oliver suffered massive swelling around the brain from overhydration.” They also indicated that he had water intoxication (over-hydration). In other words, it sounds like Zyrees died from exercise associated hyponatremic encephalopathy (EAHE).

For more please visit:
http://therussells.crossfit.com/2014...ion-and-death/ (link is w/f safe)

[Jon Fuller]

Would also like to read a copy of the book.

[Alexander Granick]

I would like to read this book.

[Christopher Morris]

Originally Posted by Steven Wingo

Here is an unfortunate sporting death needing further investigation, occurring immediately following the conclusion of a half marathon. The potential causes are still wide open, but possible hyponatremia needs to be on the list to be considered.

http://www.weather.com/health/virgin...athon-20140318

Originally Posted by Christopher Morris

Early report on a death after the London marathon:

http://news.sky.com/story/1241957/ma...ondon-marathon (wfs)

Of course it's too soon to know the cause in this case. Since learning of EAHE, I'm always going to suspect it when seeing a story like this. I don't think EAHE overhydration deaths are in the forefront of general public knowledge enough. It's not the first thing suspected in media reports.

We've discussed two cases of death and long distance running in this thread. An update on Cameron Gallagher reports she died of an irregular heartbeat and dehydration caused by physical exertion. She did not die of EAHE. If she had died of EAHE, swelling in the brain would be apparent to the medical examiner.

http://wtvr.com/2014/07/14/cameron-g...ause-of-death/ (wfs)

I can't find any updated report on Robert Berry.

[Darryl Shaw]

Originally Posted by Russell Greene

On August 6th Zyrees Oliver, a 17-year old with a 3.8 GPA, attended high school football practice in the 90-degree Georgia summer heat. Five days later, he died in the hospital.

But it wasn’t the heat that got him.

During practice, Zyrees complained of cramps. His aunt Dr. Tammy Chavis reports that he drank approximately 2 gallons of water, and two gallons of Gatorade. It’s not clear if his excessive drinking preceded or followed the cramps.

I am not sure if anyone precisely measured Zyrees’ fluid consumption, so take that 4 gallon figure with a healthy dose of electrolytes. And as of right now we don’t know the full story behind Zyrees’ death. Perhaps something in addition to over-hydration played a role. When the autopsy comes out, we’ll know more.

Nonetheless, the press reports that “Relatives said doctors told them Oliver suffered massive swelling around the brain from overhydration.” They also indicated that he had water intoxication (over-hydration). In other words, it sounds like Zyrees died from exercise associated hyponatremic encephalopathy (EAHE).

For more please visit:
http://therussells.crossfit.com/2014...ion-and-death/ (link is w/f safe)

From your blog post -

Zyrees did not die from an unpredictable accident, or an act of nature. His death was a predictable consequence of excessive hydration and extreme hyponatremia. With the right hydration guidelines made public to all coaches and athletes, he may have survived today.

From the comments in your blog post -

Originally Posted by Russell Berger

A kid has died because of the perpetuation of a myth that was exposed over a decade ago. There is no excuse for NATA sitting around waiting for consensus before they change what are effectively life-threatening recommendations. If their organization is so ineffectively slow on issues of this magnitude, I suggest they disband and find something else to do."

Using a childs death to support your anti ACSM/Gatorade agenda is in really poor taste. Might I suggest you edit this post and remove this comment and wait until the autopsy results are known before exploiting this tragedy for your own (CrossFit's) aims?

[Christopher Morris]

I'm a little puzzled by your comments, Darryl. The way I understand it, they're using a child's death to avoid other preventable deaths. That doesn't seem in poor taste to me.

I also don't see that CrossFit HQ has much to gain from this campaign. They're encouraging good research, good recommendations, and safer hydration.

[Darryl Shaw]

Originally Posted by Christopher Morris

I'm a little puzzled by your comments, Darryl. The way I understand it, they're using a child's death to avoid other preventable deaths. That doesn't seem in poor taste to me.

I also don't see that CrossFit HQ has much to gain from this campaign. They're encouraging good research, good recommendations, and safer hydration.

While I am happy to support any campaign that highlights the risks of over-hydration it must be evidence based if it is to be taken seriously. Therefore, using this childs death to further this campaign before the cause of death has been established is simply indefensible, and I hope 'The Russells' have the decency to either edit their blog or remove that post until after the autopsy results are known.

[Christopher Morris]

Okay, I see your point. My comment before was to follow up on previous cases discussed in this thread, and it takes months for autopsy reports to come out. I fear that the media loses interest in a late autopsy report, but I do hope they follow up.

[Christopher Morris]

Here are a few things I've learned from Tim Noakes' book Waterlogged so far:

- those who die from EAHE have a metabolic disfunction caused by genetics
- our bodies are extremely efficient at storing and processing salt
- most cases of heat stroke are not due to dehydration.

Genetic disfunction
Pages 4-5 (beginning with the last paragraph on 4) describe the metabolism of EAHE. Exercise/profuse sweat and overhydration are conflicting signals to the body. Which signal wins determines if overhydration will kill you.

Exercise/profuse sweat causes:
- reduction in total body water
- increased sodium concentrations
- kidneys retain water and excrete sodium

The book goes on at length about how a loss of 2-3% body weight due to sweat has been the norm in endurance sports, and up to 6% can be within tolerance without heat injury.

Overhydration causes:
- fluid loss through kidneys

The amount of fluid the kidneys excrete is controlled by antidiuretic hormone (ADH). Some people have Syndrome of Inappropriate ADH (SIADH), which the book calls a genetic disfunction. The ADH signal is telling the kidneys to retain water when it should be excreting water (as in times of overhydration). You don't really know if you are genetically disposed to ADH malfunction, EAHE, and death until you overhydrate. Better not to overhydrate either way.

Even without genetic SIADH, I wonder if you could die of EAHE in certain conditions (low to moderate exercise, overhydration, cool damp weather), or would appropriate kidney function keep you safe? The state of exercise with enough intensity to produce excessive sweat also tends to diminish the desire to drink; the book cites circumstances where runners won a marathon without drinking at all during the race. If you're jogging at a slow to moderate pace and can stomach drinking 40 oz. per hour, you're don't need that much fluid.

Salt

Hydration science in question says we are at risk of dehydration and heat injury if we don't intake more salt and other electrolytes during exercise. The book counters that this thinking is flawed because of misunderstanding about how our bodies store and use salt, and also the connection between dehydration and heat injury.

The first three pages of chapter 4 blew my mind on the history of salt. Later the book cites studies where salt intake and sweat loss are measured for a long period of time. There were days that subjects lost more in salt that the took in, proving that the body is highly efficient at storing salt for later use. The details about this provided by the book really cast doubt on any urgent need for any salt intake during a relatively short exersion (like a two and a half hour marathon).

Heat injury not connected to dehydration

From page 160: "Most cases of heatstroke occur within 60 minutes of the start of exercise... 'Dangerous dehydration,' a term favored by some scientists working with the sports drink industry, could not have been a factor, since such dehydration requires at least 3 hours to develop." This case is made by citing multiple studies.

So if dehydration is not connected to heat injury, and our bodies are actually very efficient at storing and using salt, then the need for immediate and continuous electrolyte hydration is in question.

As I continue to make my way through the book I still have questions.
Is drinking a hypertonic fluid helpful in exercise and EAHE? We know that a hypertonic IV fluid of 3% sodium is helpful in EAHE, but I wonder about digestion's effect on hypertonics and if they're actually helpful.

If we follow the "Drink when you're thirsty," guideline, will that have any effect on the development of kidney stones? Kidney stones may be more a function of diet and overhydration is meant to overcome a poor diet in kidney stone prevention.

[Russell Greene]

If you have received your copy of Waterlogged then you may be familiar with Dr. Sandra Fowkes Godek. She has a blurb on the back cover and her research is cited throughout the book. Dr. Godek's resume is available here, but some of the highlights are she is Director of the HEAT Institute at West Chester University and she works with NFL, NHL, and college teams on electrolyte balance and hydration. And she has worked as a reviewer for both the ACSM and NATA. In other words, she is one of the world's foremost experts on sports hydration and standard hydration guidelines.

Our work caught the attention of Dr. Godek last week. She posted the following comment to TheRussells.CrossFit.com. I have since been in contact with both Dr. Godek and Zyrees Oliver's family. You can read more of Dr. Godek's thoughts on this tragedy on her Facebook page . She is also working on an article. Stay tuned. This is just beginning.

I am so sorry I have been out of the loop since posting nearly continuously on FB last week about Zyree’s unfortunate and completely preventable tragic death due to over-drinking. The HEAT Institute at West Chester University has actually been deep in extensive data collection on this very issue (fluid and electrolyte balance) in collegiate football players (which is by the way who we are talking about – football players).

The very thought of EAH and EAHE finding it’s way into the sport of football (there was another death of a high school player from CA a few years ago and a case study of an NFL player hospitalized for EAH as well) is mind-boggling and can only be explained by the constant reminder from the media and marketing giants, who do sponsor NATA and ACSM, with millions if not billions of dollars. Any athletic trainer who doesn’t believe that NATA and it’s leaders and “experts” on this issue (who have a very close “affiliation” with the sports drink industry) is not at all biased by that “affiliation” is terribly naive.

I invite those skeptics on this issue to do some close background checking to see how may of the original authors of the NATA position statement on fluid replacement, and for that matter the one on exertional heat illness have direct ties (paid or “research supported”) by Gatorade/PepsiCo or in the past the Quaker Oats company. Beware however – if you don’t want certain expert names to appear on your list, don’t dig too deep!!!

My biggest issue is how much the sports drink industry has influenced the publication of “pseudo-science” papers and the outright censorship of others that might question the “drink ahead of thirst”, “drink beyond thirst” dogma that has existed for several decades. Might I add – Tim Noakes began warning sports medicine professional about the problems related to overdrinking long before 1998. His first paper about hyponatremia was published in 1981. Not by chance – Gatorade and the GSSI would never think to acknowledge that this might be a problem – even decades later.


(links are w/f safe)