Gatorade, Over-Hydration, and Death

zyrees-oliver
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).

Earlier this year CrossFit began an awareness campaign to spread the word about the dangers of over-drinking and EAHE. We are giving away up to 500 free copies of Tim Noakes’ history of hyponatremia, Waterlogged to anyone who asks in the CrossFit discussion board thread.

But why is it necessary to tell people not to drink too much water and Gatorade? Unlike soda or alcohol, excessive Gatorade-drinking simply isn’t fun. The press coverage of Olivers’ death suggests one reason why people are drinking too much: the information they’ve received from “experts.”

Take this coverage from News 4 Georgia, for instance. It reports that according to athletic trainer “Bryan Anderson preventing dehydration in the first place is key. He recommends athletes drink water throughout the day — rather than too much at once.”

This is strange. Anderson thinks that the key to preventing over-hydration, is preventing dehydration? It gets worse. Anderson recommends that athletes drink throughout the day,

“Not just scheduled water breaks … Also, you want to have scheduled water breaks in time off. So, for every 15 or 20 minutes, especially in the way we’re in the heat right now … it could be even as little as 10 to 15 minutes.”

It’s not fair to single out one athletic trainer, though. He’s probably just repeating what he’s been taught. The National Athletic Trainers’ Association (NATA) is “Gatorade-affiliated” according to Darren Rovell’s book First in Thirst.

It is not exactly clear to me what it means for medical professionals to be “affiliated” with a sugar-water brand, though I can guess. NATA’s website admits that Gatorade is a “Founding Sponsor.” How would NATA’s founding sponsor react to NATA’s members prescribing limits of maximum safe consumption on its marquee product?

The tie between commercial interests and hydration confusion isn’t just a CrossFit conjecture. The Washington Post reported,

“death from overhydration is rare but also preventable. You simply need to drink less. However, that is sometimes easier said than done with all the conflicting and often incorrect advice that exists about how much water you should consume after intense activity … The advice comes too late for Oliver, who had dreams of playing football in college.”

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. Now it’s our duty to prevent the next Zyrees from dying young. But if we leave it up to “experts” like Bryan Anderson and the Gatorade Sports Science Institute, will enough coaches and athletes learn to avoid over-hydration?

As a British Journal of Sports Medicine study reported, “Runners have a poor understanding of the physiological consequences of hydration behaviours that frequently reflect messages of advertising.” Tragically, “athletes” could easily replace “runners” in that sentence, with no loss of meaning.

Please join us in supporting Zyrees’ family as they bury their son.

19 comments

  1. Russell,

    Congrats, you have just stirred up a hornets nest that will bring a lot of traffic to your site. You are likely to get a lot of negative feedback and I hope that you allow it all to be posted in your comment section. Quite frankly you deserve the negative feedback. I am an athletic trainer and your post seems to put the NATA as a money first, safety second organization. To me that is absolutely absurd. Gatorade is a founding sponsor of the NATA, but I was never taught to drown my athletes in “2 gallons of water, and two gallons of Gatorade”. Your NATA is putting money before safety first tone is ironic, considering you are with Crossfit.

    Now, besides the attack on athletic trainers and the NATA, I agree with your science. We do over-hydrate, this is not an NATA thing though, this is a national problem, from the MDs to the Strength coaches to the lay person. Tim Noakes has provided us with excellent eye-opening material here. Waterlogged is a fantastic book. The science behind hyper-hydration is significant. I wrote an article very similar to this back in May http://stoneathleticmedicine.com/2014/05/the-hydration-nation-hyper-hydration-vs-dehydration/ and cite some decent studies. Please take a look.

    Go figure, I am an athletic trainer and my education has taught me that EAH and EAHE is a major concern. My athletic training based education taught me about over hydration. Great article on making us aware of EAH, EAHE, and over-hydration. Very poor in your selection to direct this young mans death to the NATA, the athletic trainer mentioned, and athletic trainers every where.

    • NATA guidelines for rehydration have failed to properly address the thread of hyponatremia. Here are a few excerpts from the NATA positions statement (http://www.nata.org/sites/default/files/FluidReplacementsForAthletes.pdf):

      “drink beyond thirst satiation or the typical few gulps.” 

      This is based on the idea that all dehydration, even voluntary dehydration in athletes is dangerous. This is simply false, as evidence by the ACSM’s 2007 backpedaling, in which they finally conceded that body-weight loss during performance is normal, and now suggest a 2% loss of bodyweight to be acceptable during performance. Teaching children to drink when they aren’t thirsty ignores the precision of the body’s thirst mechanism and is dangerous considering the threat of hyponatremia. 

      The only statement in the NATA publication about preventing hyperhydration and hyponatremia is this:

      “Dangerous hyperhydration is also a risk if athletes drink based on published recommendations and not according to individual needs”

      In other words, drink the way we (and others, like the ACSM) are recommending and you might die. The ethical failure here is in establishing a clear upper limit to the amount of fluid a person should ingest, something that would be done for any other substance known to be toxic in large doses. 

      The only mention of how to asses these “individual needs” in the position stand tell trainers to “check body weight (percentage of body weight change) before, during, and after exercise sessions to estimate fluid balance.” This so impractical for a high-school football team as to be absurd, and this would only tell you if someone was already possibly hyper-hydrated. It would also fail to give you data regarding blood sodium levels, meaning deadly hyponatremia would still be a possibility in some athletes who had consumed too much fluid. Hyponatremia is a significant risk not just in athletes who gain weight, but those who maintain it. In essence, this prescription is likely useless in preventing the condition.

      The NATA position stand overwhelmingly focuses on dehydration, fear of dehydration, and preventing dehydration by pushing fluid intake beyond thirst. I know of no athletes that have ever died from dehydration during football practice. If anyone on this thread can cite an example of this, please do. The NATA strategy of aggressive hydration is emphasized in the position stand when working with adolescents. To make these suggestions, and gloss over the known dangers of over-hydration is an ethical and scientific failure that needs to be explained. Considering that NATA is so closely tied to a multi-billion dollar company that sells sugar / electrolyte water (not surprisingly exactly what NATA recommends athletes drink) should raise suspicions. You should be just as interested in transparency between the NATA position authors and Gatorade as we are, rather than dismissing it with insults aimed at CrossFit.

  2. In my article, I too point to the very same position statement you cite here. I agree, it is dated. I also agree it is incorrect. However, to develop and publish consensus statement it takes an entire task force several years of research review to identify and select the appropriate RCT’s, SLR’s, and meta-analyses of high enough quality for inclusion. Once the evidence is definitive, a position statement can be made.

    Considering this was published in 2000, that means most research was done by a published by 1998 at the latest (check the articles references). Most of the data used for inclusion of the article was pulled from early – mid 1990’s. This is well before the science behind over-hydration and EAH or EAHE began getting published. The NATA did not knowingly overlook over-hydration for the sake of their partnership with Gatorade. They simply reported on the data and data to the contrary to over-hydration was non-existent and limited. They made a consensus statement based on the science available. To suggest otherwise is ignorance.

    I agree, what the NATA can do is revisit this position statement and to my knowledge this is something they are looking at. But as I mentioned above, these take time and this could still be three years away from publication. That said, they will report on the quality evidence available. There are significant dangers to both dehydration and over-hydration. Like msot things, it is not unequivocal.

    “Considering that NATA is so closely tied to a multi-billion dollar company that sells sugar / electrolyte water (not surprisingly exactly what NATA recommends athletes drink) should raise suspicions. You should be just as interested in transparency between the NATA position authors and Gatorade as we are, rather than dismissing it with insults aimed at CrossFit.”

    Considering the facts and the timeliness of the NATA’s position statement, I stand by the organization. I am confident the position statement was built of factual evidence available at that time. I’ll tweak your last statement “You should be just as interested in transparency between the NATA position authors and Gatorade as we are, rather than dismissing it with insults aimed at CrossFit.” Maybe, you should critically appraise the facts on why the NATA published that consensus state, rather than dismissing it with insults aimed at the the NATA and Athletic Trainers.

    • 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.

      • Jose' Rivera

        Russell, I’m also a certified athletic trainer and director of an educational program. I have been an ATC for over 30 years, and an educator for almost 20. What Josh is trying to communicate to you is that the NATAs affiliation with Gatorade does not in any way influence what we teach, or how we practice. To accuse an entire organization and it’s professionals of being partially responsible for this, and assume that the relationship between the NATA and Gatorade influences our behavior regardless of health outcomes is an insult and irresponsible journalism. Did you poll ATCs on their practices in preventing dehydration? or on whether or not the Gatorade organization has any influence on our practice? Do you have any clue as to whether your assumptions regarding the influence of the Gatorade sponsorship on our practice are in any way valid? The answer is a resounding NO. A responsible journalist does not print conjectures that were arrived at due to lack of information on the culture of an organization. Did you find out how many lives ATCs have saved, all the positives that come from having a certified athletic trainer watching over young athletes on a daily basis. The NATA position statement, like position statements in many other sports medicine organizations, needs to be revised. And not just this position statement. Practice follows the evidence, as more evidence is gathered, changes must occur, and position statements are revised all the time. The position statement was written with evidence from the 90s, and influenced by the history of the overwhelming number of cases of dehydration related illnesses at the time. Historically, heat illnesses due to dehydration and high body temperatures has been a major focus precisely because of the many dehydration related emergencies and deaths that were happening at the time. Being that EAH has historically been very rare in comparison to cases of dehydration, the position statement written in 2000 is reflective of that. The position statement is dated and as research is printed, position statements are revised based on that printed research. That’s how it works, and like Josh tried to tell you, any book, any position statement, always lags behind because they are written based on the printed evidence at the time. And the research often appears on print long after it has been completed. Your attempt at making the NATA the villain is misplaced and based on ignorance, you owe us an apology for being so irresponsible.

      • You said: “What Josh is trying to communicate to you is that the NATAs affiliation with Gatorade does not in any way influence what we teach, or how we practice. To accuse an entire organization and it’s professionals of being partially responsible for this, and assume that the relationship between the NATA and Gatorade influences our behavior regardless of health outcomes is an insult and irresponsible journalism.”

        I’m glad you have such faith in NATA, but the abysmal failure of your organization to address the dangers of over hydration is best explained by corruption. Ignorance and inefficiency don’t have the same explanatory power. This is insulting, but insulting to NATA’s members and the athletes of the world. My responsibility as a journalist is to ask for transparency when I see evidence of possible corruption. NATA’s responsibility is to provide transparency regarding the relationships between Gatorade funding, grants, and favors, and NATA authors. Not surprisingly, the author of this 2000 position statement, Casa, has since benefited enormously from Gatorade, which appears to have contributed millions to his foundation. but don’t take my word for it, Dr. Fowkes-Godek said this in a comment above yours: 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. She works in this field and likely knows far more about this subject, and NATA than either of us.

        You also said: “The position statement was written with evidence from the 90s, and influenced by the history of the overwhelming number of cases of dehydration related illnesses at the time.”

        The body of evidence indicating that EAHE was caused by over hydration was available in the 1980’s and the countries that lead this research implemented restrictions on fluid availability in endurance events. The results were an immediate drop in death from EAHE. There is simply no excuse for NATA being 20 years behind. If they are this ineffective as leaders of the fitness industry, I again must suggest they disband.

        Historically, heat illnesses due to dehydration and high body temperatures has been a major focus precisely because of the many dehydration related emergencies and deaths that were happening at the time. Being that EAH has historically been very rare in comparison to cases of dehydration, the position statement written in 2000 is reflective of that.

        EAH didn’t exist until the 1981, when the first documented case occurred. Since then it has skyrocketed in prevalence, as the ACSM / GSSI / NATA recommendations began pushing aggressive hydration strategies. Please find me an example of athletes dying from dehydration prior to the 1980’s. The myth that this was epidemic has no support in the literature I’ve reviewed. Dehydration is a natural process of competing in endurance events, and the belief that heat stroke is caused by dehydration is also unsupported, as has been pointed out by Tim Noakes and others (http://www.medscape.com/viewarticle/576841_3). The “yeah our advice killed people but look how many people we saved” defense has no basis in history or science.

      • I’m sure they won’t, considering the primary author of the 2000 NATA position stand, Casa, has his research and foundation funded by Gatorade… but that’s just a coincidence I’m sure.

  3. 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.

  4. Pingback: The National Athletic Trainers’ Association’s Moral and Academic failure | THE RUSSELLS

  5. David Powell

    Before you start throwing the NATA and ACSM under the bus, let’s look at the hydration plan. According to the NATA position statement that has been cited, this young appears to have ingested almost 4 times the recommended amount of fluid. If he indeed ingested water and sports drink, then he should not have had “water intoxication” or hypotremia since he also ingested electrolytes. The NATA position statement recommends; ” 0.5-0.6 L of fluid 2-3 hours before activity, 0.2 -0.3 L 20 min before, and 0.2-0.3 L every 10-20 minutes during activity”. If my calculations are correct, someone would only be ingesting a maximum of 4.5 L of fluid before or during activity, or 1.17 gal. This young man ingested almost 4 times that amount. It is not the NATA, ACSM, or other similar body that should be chastised for their recommendations.
    Any accidental death is tragic, but how does a young man ingest that much fluid before, during, and probably after practice. I guess we will find out when everything is finished being investigated.

  6. David. I think the volume is irrelevant and the very fact that any amount is recommended by guidelines is imprudent. It’s kind of like the old “drink eight 8oz glasses of water a day” beyond everything else that you drink. This would certainly not approach the fluid needs of a 300 lb football player but would make a child hyponatremic. The most glaring misconception in your post has to do with your belief (that is shared by the majority of people) which is that he should not have had “water intoxication” if he indeed ingested a sports drink (because it has electrolytes). When it comes to causing a fatal drop in serum sodium (water intoxication) Gatorade is exactly the same as water and ABSOLUTELY CANNOT prevent HYPONATREMIA. Here’s why. Hyponatremia is when blood (serum) sodium drops below the normal level of 135 to 145 mmol/l. Our body defends this range aggressively but please know that the upper range (above 145 mmol/l , which is usually caused by dehydration or hypohydration) is well tolerated and will never kill an athlete. Whereas the lower range, below 135 mmol/l, is caused by over drinking which is not well tolerated and at its worst is fatal as we know from Zyree’s case. Let me present some numbers that are not new but reflect what physiologists and medical doctors have known for decades. Water has a sodium concentration of 0 mmol/l, Gatorade has a sodium concentration of 19 mmol/l, sweat has a sodium concentration of 55 mmol/l, although the range is tremendous (10 to over 100 mmol/l), blood has a sodium concentration of 140 mmol/l, and full saline has a sodium concentration of 140 mmol/l (it is the only thing out there that is isotonic, in other words, has the same sodium concentration as blood). So to nicely correct anyone who thinks that Gatorade is not hypotonic (because it has electrolytes) and therefore can prevent hyponatremia, I simply ask them to review the numbers. 19 mmol/l versus 140mmol/l?? Over drinking Gatorade has the exact same effect as over consuming water when it comes to hyponatremia. Drinking saline is unpalatable and causes fluid to be drawn into the gut, but IV saline works quite well. This is evidence based medicine at its best. Just ask the NFL sports medicine staffs. Gatorade hates it when numbers are shown. I wonder why?? You know those commercials where athletes are sweating colored sweat??? False marketing at it’s best.

  7. OK he was cramping for weeks before something else is lurking in the darkness of this story.
    A little something else we must keep in mind http://www.sicklecelldisease.org/index.cfm?page=sickle-cell-trait-athletics
    I picked this reference because it also talks about “Crossfit’s Dirty little secret” Rhabdo ( I am not pointing a finger, cause it does happen, though very rare in a normal population, under properly supervised training sessions). While any death/injury during training or competition is unacceptable, the quest for better performance pushes all athletes to a point that may cause damage, I think this is part of the crossfit athletes motto, and any athletes for that matter, so we can agree on something. If you are going to continue to go out of your way to blame the NATA, ACSM and NSCA, XXXX.org then at some point you need to take a good look at crossfit corporate, it’s injury rate status, and their ability to sweep it and other issues under the carpet. Yes things happen but why, and shouldn’t the organization correct things. Same basic concept, organization puts out info, the public gets hold of it and messes it up. That is american culture in a nut shell.
    On the flip side of the over-hydration issue you point to is that performance is preserved by “proper hydration” (that is a loaded term). But, a drop as little as 2% body mass reduces performance and puts you at a high risk of heat related illnesses. Even a 300lb lineman would need less than a gallon to replace lost fluids. Double that loss it still only amounts to about about 1.5 gallons (taken OVER TIME). But at that loss I am more concerned with cooling the core temperature than hydration (http://www.humankinetics.com/excerpts/excerpts/dehydration-and-its-effects-on-performance) sorry to lazy to dig up the research articles. Your nemesis Dr. Kreamer spoke of this about 10 years ago at a conference where he was referencing marathons in heat. I paraphrase, “Dunk them in an ice bath reduce core temp as fast as possible worry about shock and fluid replacement later”.
    I think as this particular case develops there is more than he drank 4 gallons of fluid causing his death, or that any organization is responsible for something that clearly oversteps the bounds of sanity is even more ludicrous. Otherwise Crossfit is clearly responsible for any injury that occurs while someone is crossfitting either at an affiliate or elsewhere.

  8. George

    “The volume is irrelevant.” Really? So therefore, according to that argument, any amount of fluid ingestion at all is going to start killing thousands of high school football players around the world. All of my athletes should start dropping any second, correct? Because if the “volume is irrelevant” than all fluid consumption must therefore be fatal.

    I have been a certified athletic trainer for 15 years. I use position statements, personal experience, common sense, and evidence based practice to treat my athletes. And I will keep pushing water and sport drinks because in 15 years, I’ve had multiple incidents of athletes requiring IV fluids for treatment of DEHYDRATION, and multiple football players who could not finish a game because of muscle cramps most likely due to DEHYDRATION, and have had NO athletes suffer from ANY symptoms of hyponatremia or overhydration except for vomiting when they drank too much too quickly and it upset their stomach.

    Now, if my professional practice was with endurance athletes instead of high school athletes, my recommendations to them would be different. But I advise based on who I am responsible for, and the risks I see in their behavior. And I’m not sure if anyone from a Crossfit platform has a leg to stand on when it comes to responsible health care recommendations for athletes, or a right to criticize ANYONE about health care.

  9. John Weatherly

    This may seem to be a small and insignificant detail but I noticed Blaney Performance spelled Dr. Kraemer’s name wrong in his post. Dr. Godek seems to be a person concerned with details and has the research to back up her statements. She seems to be the expert on this issue.

  10. Sandra Fowkes Godek, PhD, ATC

    Two key points here to comment on. First of all- I have absolutely no affiliation with CrossFit and as far as I’m concerned this could be anyone’s blog. I do appreciate the fact that CrossFit was not afraid to that on this issue. Could it be that they are not sponsored by the sports drink industry? It’s really irrelevant to me. There’s that word. The reason why the volume consumed is irrelevant in these cases is because any volume of water or Gatorade (as they are the same when we talk about hyponatremia) that dilutes blood sodium at all is a volume consumed well after the drive to drink has gone. What you obviously don’t understand is the considerable variation is both sweat rate (especially between small females and large male, but even within the sport of football) and sweat sodium concentration. Again, I need to try to show you with math. If a football player sweats at 3 liters per hour (average for a lineman) and has a high but common sweat sodium concentration of 90 mmol/l, then it doesn’t take any more than simply drinking enough Gatorade to replace all of his sweat loses (as NATA suggests) to make him hyponatremic. To make it more simple, he loses 6.2 grams of sodium per hour and replaces (with Gatorade) 1.3 grams of sodium per hour. So you do the math, in a 3hr game that’s 18.6 grams of sodium lost and 3.9 grams gained by drinking enough Gatorade to replace the volume of sweat that he lost. This will most certainly cause a drop in his blood sodium (hyponatremia). I suspect you do have more cases of hyponatremia than you realize but you would need an expensive analyzer to know for sure. I am also certain that you often diagnose these players with the dreaded illness calls “Dehydration”. Getting back to the main point, the actual volume is irrelevant because of the individual variability that exists. Having 15 years experience is great but might I suggest you read some of these pertinent research articles of real football players (collegiate and NFL) practicing in real football practice outside in the heat that I’ve published in your professional journal (JAT). The reason that you have to give IV’s is not because they haven’t drunk enough, it’s because they have drunk TOO much. The athletes like I described above simply cannot put the lost sodium back drinking hypotonic fluid. The only thing that is isotonic is saline which is terribly unpalatable and would cause water to be drawn into the stomach which is counter productive, and most of the sodium would be quickly excreted. IV’s work great because if you infuse two bags of full saline you put back 6.6 grams of sodium directly into the blood stream, so of course it works. We have known for years that IV sodium replacement is the best way to go in many of these players. Gatorade does not want you to know the math, they just want you to push more of their product on your players, and in the process they are contributing to these EAHE deaths. Most certainly.

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