Marathoners Warned About Too Much Water

By GINA KOLATA
Copyright 2005 New York Times

Dr. Lewis G. Maharam, the medical director for the New York City Marathon and marathons in San Diego, Phoenix, Nashville and Virginia Beach, said he was taking every opportunity this year to educate runners about the biggest threat to their lives on race day - drinking too much water.

He knows the danger: in their zeal to avoid becoming dehydrated, runners may end up drinking so much that they dilute their blood. Water rushes into cells, including cells of the brain. The swollen brain cells press against the skull, and the result can be fatal. The resulting condition is known as hyponatremia - too much water.

"There are no reported cases of dehydration causing death in the history of world running," Maharam said. "But there are plenty of cases of people dying of hyponatremia."

No one knows how many have died, said Dr. Arthur Siegel, the chief of internal medicine at McLean Hospital in Belmont, Mass., and the designated hyponatremia team leader for recent Boston Marathons. But he said that perhaps a dozen hyponatremia deaths had been recognized, according to informal communications among doctors at recent marathons.

So this year, for the first time, the participant handbook for runners in the Nov. 6 New York City Marathon tells them how much to drink - no more than eight ounces of water every 20 minutes.

Maharam also makes sure the message is delivered via television shows that feature news about the marathon. He makes an announcement at the start of the marathon about how much to drink. And there will be a flier in the goody bags telling each runner, once again, of the dangers of drinking too much.

Even though Gatorade is one of the sponsors and the race features Gatorade's new sports drink, Gatorade Endurance Formula, Maharam said that sports drinks were no better than water. Eight ounces of fluid every 20 minutes is plenty.

But it is a message that is not always heard. Last year, one percent of the more than 35,000 New York City marathoners developed hyponatremia, Maharam said, and although that is a smaller toll than in other cities' marathons, doctors say every one of those life-threatening medical emergencies could have been avoided.

To make matters worse, medical treatments for hyponatremia are often disastrous. Some doctors mistakenly think the runner is dehydrated and give intravenous fluids.

The extent of the problem may go far beyond the number of runners who have been hospitalized for it. A recent study of runners in the 2002 Boston Marathon found that 13 percent who finished the race had hyponatremia. And those were runners who thought they were fine and were just participating in a study. If such a runner continued to drink after the marathon, perhaps thinking that feelings of nausea and malaise were due to dehydration, the runner could end up with seizures or slip into a coma, doctors say.

That is what happened to Mark Robinson, a 27-year-old computer programmer from West Roxbury, Mass., who sees his story as a cautionary tale.

The day of the 2004 Boston Marathon dawned unusually hot. The race was on April 19, but the temperature was projected to reach nearly 90 degrees. Robinson was concerned. It was his first marathon, he had been training for six months, and he wanted to run it in four hours or less. "I sweat a lot," he said. With weather like that, he worried he might become dehydrated. So he tried to make sure he drank enough.

"I drank more than a gallon of water before the race, and then at every rest stop I would stop and have a couple of drinks of water," he said. He was on pace until Mile 19 when, suddenly, he felt nauseous and his legs began to cramp. He forced himself to continue, but by Mile 23 he could no longer run. "I tried to power-walk it in," Robinson said.

His parents met him at the finish line, bringing water. He drank two quarts, but he felt worse than ever. Not only was he vomiting and having diarrhea, Robinson said, but "I felt spacey, out of it, almost like I was on drugs."

His parents got a wheelchair and took him to the medical tent, where the person doing triage at the entrance asked if he could stand on his own. He could. He said he was told, "We have people here who are lying down," and was sent away. His parents helped him walk to the subway and took him to their home in Wayland, Mass. All the while, Robinson was drinking water and drinking Gatorade and vomiting.

Robinson said: "I felt completely mentally out of it. It was a strange sensation. Deep down, I knew something really, really wasn't right. It was like a feeling of impending doom. My father wanted me to take a bath, but I didn't want to be alone. I looked at my dad and he was talking and his mouth was kind of going," but, Robinson said, he could no longer hear what his father was saying.

Suddenly, Robinson screamed, leaped into the air, and fell down on his shoulder, breaking it. He lay on the floor, unconscious and no longer breathing.

His mother called 911 and a helicopter arrived. On the flight to Boston Medical Center, Robinson received intravenous fluids; the medical team thought he was dehydrated.

He ended up in a coma, on life support, and woke up four days later. His problem? Hyponatremia - poisoned by drinking too much water.

Robinson still runs, but much shorter distances. "I'll never run a long race again," he said. And forget marathons, he added. "My wife would never give me permission," he said.

Dr. Paul Thompson, a cardiologist, a marathon runner and a director of the Athletes' Heart program at Hartford Hospital, said: "Everyone's been told to drink water, drink water, drink water. Water companies want you to drink water like a fish. Then you dilute your blood and your brain starts to swell. You have healthy people running marathons and dying. Has the word gotten out? No."

Even now, more than a year later, Robinson says he is still shaken from his near-death experience after the Boston Marathon. "You would never, ever think that water could kill you," he said.

The Distance Runner's Diet

What to eat and drink in your next running race

by Hal Higdon, Copyright © Hal Higdon Communications

Good nutrition--both before the race and during--is critical if you hope to excel in any running race. When you run long distances, your energy requirements increase. In an article on endurance exercise in The Physician and Sportsmedicine, Walter R. Frontera, M.D. and Richard P. Adams, Ph.D., comment, "During sustained exercise such as marathon running, total body energy requirements increase 10 to 20 times above resting values." Runners need to eat more of the proper foods to fuel their muscles. They also need to drink more, particularly in warm weather.

At a sports nutrition seminar in connection with the 1992 US Olympic Marathon Trials in Columbus, Ohio, Linda Houtkooper, Ph.D. a registered dietitian at the University of Arizona, made clear that endurance athletes in particular should get most of their calories from carbohydrates.

No argument there. The only problem is that with 35,000 items in the supermarket, marathon runners sometimes need help determining which foods are highest in carbohydrates. Unless you plan to eat spaghetti three meals a day (and even pasta contains 14 percent protein and 4 percent fat), you may need to start reading labels.

Dr. Houtkooper explained that the body requires at least 40 nutrients that are classified into six nutritional components: proteins, carbohydrates, fats, vitamins, minerals, and water. "These nutrients cannot be made in the body, and so must be supplied from solid or liquid foods." She listed six categories that form the fundamentals of a nutritionally adequate food selection plan: fruits, vegetables, grains/legumes, lean meats, low-fat milk products, and fats/sweets (in descending order of importance).

Concentrate on carbohydrates

The recommendations for a healthy diet suggest 15 to 20 percent proteins, 30 percent fat and 50 to 55 percent carbohydrates. But all carbohydrates aren't created alike. There are simple and complex carbohydrates. Simple carbohydrates include sugar, honey, jam, and any food such as sweets and soft drinks that get most of its calories from sugar. Nutritionists recommend that these simple carbohydrates make up only 10 percent of your diet. It's complex carbohydrates you should concentrate on--the starch in plant foods--which include fruits, vegetables, bread, pasta, and legumes.

Endurance athletes in particular benefit from fuel-efficient complex carbohydrates because of the extra calories burned each day. You need to aim for even more total carbohydrates than the suggested 50 percent. You can eat (in fact, may need to eat) more total calories without worrying about weight gain. The average runner training for a half marathon and running 20 to 25 miles a week probably needs a daily caloric intake near 2,500 to maintain muscle glycogen stores. As your mileage climbs beyond that, you need to eat more and more food, not less. In all honesty, this is why a lot of runners run, and why they train for marathons. Their common motto is, "I love to eat."

Some people seeking to finish their first marathon, however, are more than 15 pounds overweight--or they think they are. So they also attempt to lose some additional weight by dieting. To a certain extent, this isn't a bad idea, assuming you choose your diet prudently. Those who choose a fad diet that lowers carbohydrate intake make a major mistake. That's because most fad diets fail to provide enough energy for endurance activities. Stay away from the so-called "Zone," "Adkins," or "40-30-30" diets Their emphasis on low carbohydrates is merely a short-term fix to losing weight.

You don't need to patronize Italian restaurants to ensure an adequate supply of complex carbohydrates. I sometimes choose a Chinese restaurant, because rice is also high in carbohydrates. And Nancy Clark, R.D. director of nutrition services for SportsMedicine Brookline in Boston, and author of Nancy Clark's Sports Nutrition Guidebook, points out that you can get plenty of carbos in most American restaurants. If you eat soup (such as minestrone, bean, rice, or noodle), potatoes, breads, and vegetables along with your main dish, and maybe grab a piece of apple cobbler off the dessert tray, you can end up eating more carbohydrates than fats or protein.

Carbohydrates are particularly important the night before your race, and even before your long runs or walks leading up to your race. That's one reason why a lot of endurance races offer "pasta parties" the night before. Be sure to drink plenty of fluids the day before the race, but stay away from diuretics that contain alcohol or caffeine. It's also a good idea to top off your fuel tank with a light carbo snack before going to bed. You also might consider rising early on race day so you can have a light, pre-race meal. Toast or a bagel washed down with orange juice and maybe one cup of coffee works well 2 or 3 hours before the race start--but practice this routine before your long training workouts to make sure this doesn't upset your stomach.

Learning to drink

Once the race starts, hydration becomes important, particularly if it is a warm day. Drink, drink, drink. Do this during your long workouts in practice too. Not only will drinking fluids make your weekend long workouts more comfortable, but it also will teach you how to drink and how often to drink. Drinking while you run is not an instinctive technique; you need to practice to do it properly.

No tennis player would start a match without practicing lobs; no golfer would think a game complete without learning how to pitch from a sand trap. And no runner should enter a half marathon without figuring out how and when to drink.

Drinking while running definitely is not easy. Unless you grasp the cup carefully, you can spill half the contents on the ground. If you gulp too quickly, you can spend the next mile coughing and gasping. If you dawdle at aid stations, you can waste precious seconds. And if you gulp down a replacement drink you aren't used to, it might make you nauseous.

Drinking on the run is a science--and so you need to practice. Do this during your training runs, particularly your long training runs.

Drinking on the run is necessary for survival. Here's why. During exercise, the body usually produces more heat than you can get rid of by sweating. A marathoner's body temperature gradually rises 3 or 4 degrees to 102 degrees Fahrenheit, an efficient level for energy utilization. At this point, your air-conditioning system is in synch with the environment and you perform well. If the weather is too hot or too humid, or you become dehydrated--resulting in a drop in sweat production--the body's temperature can soar to dangerous levels. Your muscles will not perform efficiently at temperatures that are too high (over 104), so that will slow you down. This is an important defense mechanism, because if you fail to sweat and your core temperature rises past 108, you may suffer heatstroke, a potentially serious problem that can cause headaches and dizziness, and in extreme cases convulsions, unconsciousness, and death.

So drink up--but don't drink too much or too often, otherwise you'll waste time waiting to use the portable toilets along the course. You have to learn how to drink properly, and that's why you need to practice drinking during your long workouts.

Tips for staying cool

What strategies can runners use to avoid problems on hot days? Here are some training trips for proper hydration:

1. Drink before running. Drink adequately and drink often up until two hours before the start. Excess body water will be passed as urine before you start to run. Two hours before, however, stop drinking otherwise you'll be ducking into the bushes.

2. Drink while you run. Just before the gun sounds, you can start drinking again. Once you're moving, you'll sweat off any excess liquid before it reaches your kidneys. You also need to drink frequently while training, especially during warm weather. You'll run faster and recover sooner. Carry a water bottle if necessary.

3. Walk to drink. Don't try to gulp it down while running through the aid stations. You'll be able to drink more if you stop or at least walk. You'll lose less time than you think. I once ran a 2:29 marathon walking through every aid station on a hot day.

4. Drink after running. Drink as soon as you stop, but even after your initial thirst is quenched, you still need to keep drinking. One sign of your hydration level is to check your urine. Clear urine is a sign of good hydration.

5. Don't overestimate your ability. Realize that you can't run as fast when it's warm. Don't expect to set a Personal Record, and don't be afraid to bail out early (at least start slowing down) when you're starting to overheat.

Adapted from Hal Higdon's Marathon: The Ultimate Training Guide.