Regimented Sodium Replacement vs Ad Lib Consumption of High Sodium Fluids in NFL Players Arthur Bartolozzi, MD Pennsylvania Hospital, Philadelphia PA Sandra.

Regimented Sodium Regimented Sodium Replacement Replacement

vsvsAd Lib Consumption Ad Lib Consumption

of High Sodium Fluidsof High Sodium Fluidsin NFL Playersin NFL Players

Regimented Sodium Regimented Sodium Replacement Replacement

vsvsAd Lib Consumption Ad Lib Consumption

of High Sodium Fluidsof High Sodium Fluidsin NFL Playersin NFL Players

Arthur Bartolozzi, MD Pennsylvania Hospital, Arthur Bartolozzi, MD Pennsylvania Hospital, Philadelphia PAPhiladelphia PA

Sandra Fowkes Godek, PhD West Chester UniversitySandra Fowkes Godek, PhD West Chester University

C Peduzzi, ATC, S Condon, ATC, R Burkholder, ATC C Peduzzi, ATC, S Condon, ATC, R Burkholder, ATC

Philadelphia EaglesPhiladelphia Eagles

Arthur Bartolozzi, MD Pennsylvania Hospital, Arthur Bartolozzi, MD Pennsylvania Hospital, Philadelphia PAPhiladelphia PA

Sandra Fowkes Godek, PhD West Chester UniversitySandra Fowkes Godek, PhD West Chester University

C Peduzzi, ATC, S Condon, ATC, R Burkholder, ATC C Peduzzi, ATC, S Condon, ATC, R Burkholder, ATC

Philadelphia EaglesPhiladelphia Eagles

The HEAT Institute of West Chester UniversityThe HEAT Institute of West Chester UniversityThe HEAT Institute of West Chester UniversityThe HEAT Institute of West Chester University

BackgroundBackgroundBackgroundBackgroundWe previously reported that We previously reported that

hypovolemic hyponatremia occurs in hypovolemic hyponatremia occurs in un-supplemented college and un-supplemented college and professional football (NFL) players professional football (NFL) players Fowkes Godek S, Bartolozzi AR. Changes in blood electrolytes and plasma volume in NFL Fowkes Godek S, Bartolozzi AR. Changes in blood electrolytes and plasma volume in NFL

football players during pre-season training. football players during pre-season training. Athl Train Sports Health CareAthl Train Sports Health Care. 2009;1(6):259-. 2009;1(6):259-

266266

We subsequently supplemented NFL We subsequently supplemented NFL players with Rehydralyte and pickle players with Rehydralyte and pickle juice and successfully maintained fluid juice and successfully maintained fluid balancebalance

We previously reported that We previously reported that hypovolemic hyponatremia occurs in hypovolemic hyponatremia occurs in un-supplemented college and un-supplemented college and professional football (NFL) players professional football (NFL) players Fowkes Godek S, Bartolozzi AR. Changes in blood electrolytes and plasma volume in NFL Fowkes Godek S, Bartolozzi AR. Changes in blood electrolytes and plasma volume in NFL

football players during pre-season training. football players during pre-season training. Athl Train Sports Health CareAthl Train Sports Health Care. 2009;1(6):259-. 2009;1(6):259-

266266

We subsequently supplemented NFL We subsequently supplemented NFL players with Rehydralyte and pickle players with Rehydralyte and pickle juice and successfully maintained fluid juice and successfully maintained fluid balancebalance

BackgroundBackgroundBackgroundBackgroundPrevious field research indicates that Previous field research indicates that

sodium replacement helps maintain sodium sodium replacement helps maintain sodium balance, plasma volume and body weight in balance, plasma volume and body weight in football players during pre-season. football players during pre-season.

It is unclear whether It is unclear whether ad libitumad libitum

consumption of high sodium fluids consumption of high sodium fluids maintains sodium and fluid balance as well maintains sodium and fluid balance as well as athlete specific sodium replacement as athlete specific sodium replacement using high sodium fluids and sodium using high sodium fluids and sodium capsules. capsules.

Previous field research indicates that Previous field research indicates that sodium replacement helps maintain sodium sodium replacement helps maintain sodium balance, plasma volume and body weight in balance, plasma volume and body weight in football players during pre-season. football players during pre-season.

It is unclear whether It is unclear whether ad libitumad libitum

consumption of high sodium fluids consumption of high sodium fluids maintains sodium and fluid balance as well maintains sodium and fluid balance as well as athlete specific sodium replacement as athlete specific sodium replacement using high sodium fluids and sodium using high sodium fluids and sodium capsules. capsules.

MethodsMethodsMethodsMethodsThe supplementation protocol The supplementation protocol

took place during the first 10 took place during the first 10 days of preseason training days of preseason training campcamp

We measured We measured • blood electrolytesblood electrolytes• urine osmolalityurine osmolality• changes in plasma volume (% ∆PV) changes in plasma volume (% ∆PV) • body mass (% ∆mass)body mass (% ∆mass)

The supplementation protocol The supplementation protocol took place during the first 10 took place during the first 10 days of preseason training days of preseason training campcamp

We measured We measured • blood electrolytesblood electrolytes• urine osmolalityurine osmolality• changes in plasma volume (% ∆PV) changes in plasma volume (% ∆PV) • body mass (% ∆mass)body mass (% ∆mass)

MethodsMethodsMethodsMethods

We hypothesized that We hypothesized that FluidsFluids would not maintain blood would not maintain blood sodium or increase PV sodium or increase PV compared to compared to Capsules Capsules plus fluid plus fluid replacement.replacement.

We hypothesized that We hypothesized that FluidsFluids would not maintain blood would not maintain blood sodium or increase PV sodium or increase PV compared to compared to Capsules Capsules plus fluid plus fluid replacement.replacement.

MethodsMethodsMethodsMethods Change in plasma Change in plasma

volumes was volumes was calculated from calculated from Hct and HbHct and Hb

Electrolytes were Electrolytes were measure by ion-measure by ion-selective electrodeselective electrode

Osmolality was Osmolality was measured by measured by freezing point freezing point depressiondepression

Change in plasma Change in plasma volumes was volumes was calculated from calculated from Hct and HbHct and Hb

Electrolytes were Electrolytes were measure by ion-measure by ion-selective electrodeselective electrode

Osmolality was Osmolality was measured by measured by freezing point freezing point depressiondepression

Design and Design and SettingSettingDesign and Design and SettingSetting

Observational Observational cohort studycohort study

Study conducted Study conducted during during consecutive consecutive preseason preseason training camps of training camps of one NFL team. one NFL team. • Year1 = Year1 = capsulescapsules • Year2 = Year2 = fluidsfluids

Observational Observational cohort studycohort study

Study conducted Study conducted during during consecutive consecutive preseason preseason training camps of training camps of one NFL team. one NFL team. • Year1 = Year1 = capsulescapsules • Year2 = Year2 = fluidsfluids

SubjectsSubjectsSubjectsSubjects Eleven NFL players Eleven NFL players

volunteered volunteered • 6 players participated 6 players participated

in both years and in both years and • the other 5 were the other 5 were

physically matchedphysically matched

• Ht = 187 ± 5cm,Ht = 187 ± 5cm,• Mass = 113.4 ± 17kgMass = 113.4 ± 17kg• BSA = 2.38 ± 0.17mBSA = 2.38 ± 0.17m22

Eleven NFL players Eleven NFL players volunteered volunteered • 6 players participated 6 players participated

in both years and in both years and • the other 5 were the other 5 were

physically matchedphysically matched

• Ht = 187 ± 5cm,Ht = 187 ± 5cm,• Mass = 113.4 ± 17kgMass = 113.4 ± 17kg• BSA = 2.38 ± 0.17mBSA = 2.38 ± 0.17m22

InterventionsInterventionsInterventionsInterventionsBoth years the players had 15 practices Both years the players had 15 practices

the first 9 days of campthe first 9 days of campYear 1: Year 1: CapsulesCapsules - players consumed - players consumed

sodium containing fluids and salt sodium containing fluids and salt capsules at meals in amounts equal to capsules at meals in amounts equal to 50% of daily sweat sodium losses50% of daily sweat sodium losses

Year 2: Year 2: Fluids Fluids - players were - players were encouraged to consume sodium encouraged to consume sodium containing fluid (458 mg to 1.1 g∙lcontaining fluid (458 mg to 1.1 g∙l-1-1))ad libitumad libitum but but were not instructedwere not instructed on on specifically what to drinkspecifically what to drink

Both years the players had 15 practices Both years the players had 15 practices the first 9 days of campthe first 9 days of camp

Year 1: Year 1: CapsulesCapsules - players consumed - players consumed sodium containing fluids and salt sodium containing fluids and salt capsules at meals in amounts equal to capsules at meals in amounts equal to 50% of daily sweat sodium losses50% of daily sweat sodium losses

Year 2: Year 2: Fluids Fluids - players were - players were encouraged to consume sodium encouraged to consume sodium containing fluid (458 mg to 1.1 g∙lcontaining fluid (458 mg to 1.1 g∙l-1-1))ad libitumad libitum but but were not instructedwere not instructed on on specifically what to drinkspecifically what to drink

MethodsMethodsMethodsMethods

Blood samples for baseline Blood samples for baseline measures were obtained when measures were obtained when players reported to camp and players reported to camp and prior to the morning practice on prior to the morning practice on Days 3, 5 and 10Days 3, 5 and 10

Blood samples for baseline Blood samples for baseline measures were obtained when measures were obtained when players reported to camp and players reported to camp and prior to the morning practice on prior to the morning practice on Days 3, 5 and 10Days 3, 5 and 10

MethodsMethodsMethodsMethodsBaseline mass was recorded after Baseline mass was recorded after

urine samples ensured euhydrationurine samples ensured euhydration

• CapsulesCapsules osmolality 637 ± 304 osmolality 637 ± 304 mOsm∙kgmOsm∙kg-1-1

• FluidsFluids osmolality 725 ± 301 osmolality 725 ± 301 mOsm∙kgmOsm∙kg-1-1

• CapsulesCapsules USG 1.018 ± .008 USG 1.018 ± .008 • FluidsFluids USG 1.018 ± .009 USG 1.018 ± .009

Baseline mass was recorded after Baseline mass was recorded after urine samples ensured euhydrationurine samples ensured euhydration

• CapsulesCapsules osmolality 637 ± 304 osmolality 637 ± 304 mOsm∙kgmOsm∙kg-1-1

• FluidsFluids osmolality 725 ± 301 osmolality 725 ± 301 mOsm∙kgmOsm∙kg-1-1

• CapsulesCapsules USG 1.018 ± .008 USG 1.018 ± .008 • FluidsFluids USG 1.018 ± .009 USG 1.018 ± .009

Data AnalysisData AnalysisData AnalysisData Analysis

Dependent Variables:Dependent Variables:• %∆PV%∆PV• %∆mass %∆mass • blood sodiumblood sodium• potassium and chloridepotassium and chloride

Two-way ANOVA with repeated Two-way ANOVA with repeated measures and correlated t-testsmeasures and correlated t-tests

Dependent Variables:Dependent Variables:• %∆PV%∆PV• %∆mass %∆mass • blood sodiumblood sodium• potassium and chloridepotassium and chloride

Two-way ANOVA with repeated Two-way ANOVA with repeated measures and correlated t-testsmeasures and correlated t-tests

ResultsResultsResultsResultsMean WBGT during Mean WBGT during

practices for days practices for days

1- 9 were not 1- 9 were not

different different

• CapsulesCapsules 25 ± 3.5ºC25 ± 3.5ºC • Fluids Fluids 25.5 ± 3.1ºC25.5 ± 3.1ºC

Mean WBGT during Mean WBGT during

practices for days practices for days

1- 9 were not 1- 9 were not

different different

• CapsulesCapsules 25 ± 3.5ºC25 ± 3.5ºC • Fluids Fluids 25.5 ± 3.1ºC25.5 ± 3.1ºC

Results - Results - SoduimSoduimResults - Results - SoduimSoduim

Sodium was lower on Sodium was lower on

Days 3 and 5 in Days 3 and 5 in

FluidsFluids versus versus CapsulesCapsules• 137.8 ± 1.4 vs 140.6 ± 137.8 ± 1.4 vs 140.6 ±

1.5mmol∙l1.5mmol∙l-1-1

P = 0.004P = 0.004

CapsulesCapsules group sodium group sodium remained unchangedremained unchanged

FluidsFluids group returned to group returned to baseline at day 10baseline at day 10

Sodium was lower on Sodium was lower on

Days 3 and 5 in Days 3 and 5 in

FluidsFluids versus versus CapsulesCapsules• 137.8 ± 1.4 vs 140.6 ± 137.8 ± 1.4 vs 140.6 ±

1.5mmol∙l1.5mmol∙l-1-1

P = 0.004P = 0.004

CapsulesCapsules group sodium group sodium remained unchangedremained unchanged

FluidsFluids group returned to group returned to baseline at day 10baseline at day 10

Results - Results - ChlorideChlorideResults - Results - ChlorideChloride

Fluids group was Fluids group was lower from lower from baseline on days baseline on days 3 and 5 and 3 and 5 and returned to returned to baseline at day 10baseline at day 10

p = 0.05p = 0.05

Capsules group Capsules group statistically statistically unchangedunchanged

Fluids group was Fluids group was lower from lower from baseline on days baseline on days 3 and 5 and 3 and 5 and returned to returned to baseline at day 10baseline at day 10

p = 0.05p = 0.05

Capsules group Capsules group statistically statistically unchangedunchanged

Results - Results - PotassiumPotassiumResults - Results - PotassiumPotassium

Both groups Both groups decrease from decrease from baseline at day 3baseline at day 3

p < 0.01p < 0.01

Capsules group Capsules group increased above increased above baseline by day 5baseline by day 5

p < 0.01p < 0.01

Both groups Both groups increased to above increased to above baseline by day 10baseline by day 10

Both groups Both groups decrease from decrease from baseline at day 3baseline at day 3

p < 0.01p < 0.01

Capsules group Capsules group increased above increased above baseline by day 5baseline by day 5

p < 0.01p < 0.01

Both groups Both groups increased to above increased to above baseline by day 10baseline by day 10

3.8

4

4.2

4.4

4.6

4.8

5

Baseline Day 3 Day 5 Day 10

Mm

ol/l

CapsulesFluids

3.8

4

4.2

4.4

4.6

4.8

5

Baseline Day 3 Day 5 Day 10

Mm

ol/l

CapsulesFluids

4.94.94.94.9

Results - Plasma Results - Plasma

VolumeVolume

Results - Plasma Results - Plasma

VolumeVolumeCapsules group PV Capsules group PV increased increased • 11% by day 3, 11% by day 3, • 12.4% by day 5 12.4% by day 5 • remained at 9.3% remained at 9.3%

elevated by day 10 elevated by day 10 over baselineover baseline

Fluids group PVFluids group PV• Decreased -0.6% on Decreased -0.6% on

day 3day 3• Significantly lower Significantly lower

than capsules group than capsules group on day 3on day 3

Capsules group PV Capsules group PV increased increased • 11% by day 3, 11% by day 3, • 12.4% by day 5 12.4% by day 5 • remained at 9.3% remained at 9.3%

elevated by day 10 elevated by day 10 over baselineover baseline

Fluids group PVFluids group PV• Decreased -0.6% on Decreased -0.6% on

day 3day 3• Significantly lower Significantly lower

than capsules group than capsules group on day 3on day 3

11%11%11%11%12.4%12.4%12.4%12.4%

9.3%9.3%9.3%9.3%

Results – Body Results – Body MassMassResults – Body Results – Body MassMass

No differences No differences were found for were found for % ∆ mass. % ∆ mass.

No differences No differences were found for were found for % ∆ mass. % ∆ mass.

ConclusionsConclusionsConclusionsConclusionsSodium and chloride remained constant Sodium and chloride remained constant

during the first 10 days of preseason in during the first 10 days of preseason in NFL players who replaced 50% of their NFL players who replaced 50% of their daily sweat sodiumdaily sweat sodium losses using a losses using a regimented dosing with sodium regimented dosing with sodium capsules and fluid replacementcapsules and fluid replacement

In players using In players using ad libidumad libidum fluid fluid replacement, sodium and chloride replacement, sodium and chloride dropped below baseline at days 3 and 5dropped below baseline at days 3 and 5

Sodium and chloride remained constant Sodium and chloride remained constant during the first 10 days of preseason in during the first 10 days of preseason in NFL players who replaced 50% of their NFL players who replaced 50% of their daily sweat sodiumdaily sweat sodium losses using a losses using a regimented dosing with sodium regimented dosing with sodium capsules and fluid replacementcapsules and fluid replacement

In players using In players using ad libidumad libidum fluid fluid replacement, sodium and chloride replacement, sodium and chloride dropped below baseline at days 3 and 5dropped below baseline at days 3 and 5

ConclusionsConclusionsConclusionsConclusions% ∆PV was higher on day 3 in % ∆PV was higher on day 3 in

the the CapsulesCapsules group and group and remained elevated while PV did remained elevated while PV did not increase until day 5 in the not increase until day 5 in the FluidsFluids group group

Elevated blood potassium levels Elevated blood potassium levels occurred in both groupsoccurred in both groups

% ∆PV was higher on day 3 in % ∆PV was higher on day 3 in the the CapsulesCapsules group and group and remained elevated while PV did remained elevated while PV did not increase until day 5 in the not increase until day 5 in the FluidsFluids group group

Elevated blood potassium levels Elevated blood potassium levels occurred in both groupsoccurred in both groups

DiscussionDiscussionDiscussionDiscussionOur results support the use of Our results support the use of

individualized dry sodium individualized dry sodium replacement along with sodium replacement along with sodium containing fluids during training containing fluids during training camp as superior to camp as superior to ad libidumad libidum intake of high sodium fluids as intake of high sodium fluids as a fluid replacement strategya fluid replacement strategy

Our results support the use of Our results support the use of individualized dry sodium individualized dry sodium replacement along with sodium replacement along with sodium containing fluids during training containing fluids during training camp as superior to camp as superior to ad libidumad libidum intake of high sodium fluids as intake of high sodium fluids as a fluid replacement strategya fluid replacement strategy

DiscussionDiscussionDiscussionDiscussionPlasma volume increase is Plasma volume increase is

supported by pill augmentation supported by pill augmentation of sodium replacement and the of sodium replacement and the delay in plasma volume delay in plasma volume increase using increase using ad libidumad libidum replacement may be clinically replacement may be clinically relevant and may affect relevant and may affect performanceperformance

Plasma volume increase is Plasma volume increase is supported by pill augmentation supported by pill augmentation of sodium replacement and the of sodium replacement and the delay in plasma volume delay in plasma volume increase using increase using ad libidumad libidum replacement may be clinically replacement may be clinically relevant and may affect relevant and may affect performanceperformance

What specific replacement do each of these athletes need?

●Sweat rates are different●Sweat sodium is different●What is the effect on

performance

●Sweat rates are different●Sweat sodium is different●What is the effect on

performance

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