The National Athletic Trainers’ Association’s Moral and Academic Failure

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We recently published this article on the death of Zyrees Oliver, presumably from exercise-associated hyponatremic encephalopathy, induced by overhydration. In that post, we questioned the motives of The National Athletic Trainers’ Association (NATA), which continues to support erroneous hydration recommendations, the likes of which seem to have lead to Zyrees’ death. The connection between NATA’s dangerous hydration stance and it’s financial founding by Gatorade is even more suspicious. This suspicion was shared by one of our readers, Sandra Fowkes Godek, Professor in the Department of Sports Medicine at West Chester University. As she puts it,

“The very thought of EAH and EAHE finding it’s way into the sport of football … 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.” 

To begin with, NATA’s guidelines for rehydration have failed to properly address hyponatremia, a deadly condition caused by excessive fluid intake (source). Here are a few excerpts from the NATA positions statement:

Notice the intended goal of having athletes “drink beyond thirst satiation…”

This concept has roots in the 1996 American College of Sports Medicine position stand on Exercise and fluid replacement, which stated that athletes would only be safe to exercise if they drank “as much as tolerable.” Dr. Timothy Noakes has criticized these guidelines extensively, explaining that they “failed to emphasize the established finding that the overconsumption of sodium-poor fluids during exercise could have fatal consequences”(source).

It is worth noting that the ACSM’s only two “platinum” sponsors are Gatorade and the Gatorade Sports Science Institute (GSSI).

While the ACSM quietly removed this language from their guidelines by omitting it from their 2007 Position Stand (after a number of high-profile deaths in marathon runners from hyponatremia), The NATA has kept it.

Presumably, this advice is based on the idea that all dehydration, even voluntary dehydration is dangerous for athletes. This is simply false, as is evidenced by the ACSM’s 2007 backpedaling, in which they concede that bodyweight loss during performance is normal, and now suggest that 2% loss of bodyweight in athletes is acceptable. Teaching athletes to drink when they aren’t thirsty ignores the body’s thirst mechanism and is dangerous considering the significant risk from hyponatremia.

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

Read that one more time: “Dangerous hyperhydration is also a risk if athletes drink based on published recommendations and not according to individual needs”

In other words, if you drink the way NATA (and others, like the ACSM) are recommending, you may die. The ethical failure here is not 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.

The NATA position stand’s only mention of how to assess these “individual needs” tells trainers to “check body weight (percentage of body weight change) before, during, and after exercise sessions to estimate fluid balance.” The ACSM’s 2007 position stand makes similar suggestions. While it is true that weight gain during exercise is a warning sign of over hydration, so is maintaining weight (source). Measuring weight of players during every water break is also so impractical for a high-school football team as to be absurd.

EAHA, an illness unknown until 1981, is no longer a problem for only for endurance athletes.

EAHA, an illness unknown until 1981, is no longer a problem for only for endurance athletes.

The NATA position stand overwhelmingly focuses on dehydration, fear of dehydration, and preventing dehydration by pushing fluid intake beyond thirst. I personally know of zero athletes that have died from sport-related dehydration, especially during football. If anyone reading this can inform me of an exception, please do.

The NATA strategy of aggressive hydration is emphasized in the position stand when working with adolescents, whose smaller bodies may make them more susceptible to hyponatremia. To make these suggestions, and gloss over the known dangers of over-hydration is a moral and scientific failure that needs to be explained. The fact 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) raises suspicions.

A young man died because of the perpetuation of hydration myth by a recognized authority in heath and fitness. NATA’s stated mission is to “…enhance the quality of health care provided by certified athletic trainers and to advance the athletic training profession.” If this is true, then there is no excuse for NATA failing to change inaccurate and life-threatening guidelines that were exposed as such in the 1980’s. Dr. Godek said it best in a recent comment on Facebook:

“It’s time for the athletic training profession to step up and take some responsibility for propagating the myths like “dehydration causes exertional heat stroke”, ” drink before you are thirsty”, ” If you are thirsty you are already dehydrated”, and start taking an active role in passing along the correct facts to our athletes, coaches, parents and colleagues.”

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