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The Science Of Hydration

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=The science of hydration for exercise is complex and controversial. While dehydration can cause problems, the real risk is [[Hyponatremia]] where the level of sodium in the blood is too low. The science shows that sodium losses increase exponentially with sweat rate, so exercise in the heat can result in extreme levels of sodium loss. For a simpler look at hydration, see [[Practical Hydration]].= Introduction ==The advice given to runners on hydration has changed over time and looks set to continue to change. There are competing forces at work - sports drink manufacturers, event organizers (often sponsored by the manufacturers) and scientists (some also sponsored by the manufacturers). One thing is clear about hydration - it is important. Incorrect hydration can lead to impaired performance, and in extreme cases, death. A condition related to dehydration is [[Hyponatremia]], which is where the sodium (salt) level in the blood becomes too dilute. This is a dangerous condition that has killed a number of runners. This entry is a follow on to [[Practical Hydration]] which should be read first. == Effects of dehydration ==Everyone knows While it's commonly believed that even small levels of dehydration is bad. But how bad? Current impacts performance, the research indicates that some level of real world performance is not impacted by dehydration (up to 34%) does not impact performance, or impacts performance much less than expected of body weight<ref name="Goulet2012"/><ref name="ref7Goulet2011"/>. (Dehydration Greater levels of 5% does dehydration will impact performance <ref name="ref11González-Alonso-1995"/>.) This may While authorities have recommended aggressive drinking<ref name="Convertino-1996"/>, these guidelines are now recognized as erroneous<ref name="WallWatson2013"/>, though they are still promoted by the beverage industry<ref name="beverageWWW"/>. =Dehydration and Body Weight =A common method of calculating dehydration is simply from body weight. While it's true that an athlete's weight loss during exercise will be due predominantly from water, this is not the same as dehydration, nor does it necessarily imply this weight needs to the fact that be restored quickly though drinking. This is because a carbohydrate (glycogen[[Glycogen]]) is stored with water, in the ratio of about 1g glycogen [[Glycogen]] to 2.5g water <ref name="ref8Nilsson-1973"/>. This means that 2000 calories of glycogen [[Glycogen]] depletion that are likely to occur in marathon distance runs would result in about 4lb weight loss /2Kg [[Weight Loss]] with no reduction in hydration (2000Kcal/4=500g glycogen [[Glycogen]] + 1250g water = 1750g). In practice To restore the weight lost in endurance exercise the Glycogen reserves must also be restored, something that may take days. Even moving from a high carbohydrate to high fat diet can see 6lb weight loss[[Weight Loss]] from [[Glycogen]] depletion.=Sodium Intake and Rehydration=Several studies have shown that drinks containing sodium provide better rehydration by reducing urine output. * Consuming drinks with 61 mmol/l (~1/2 teaspoon salt per quart/liter) reduced urine output and improved hydration when compared with 23 mmol/l (~1/4 teaspoon salt per quart/liter)<ref name="Shirreffs-1996"/>* When comparing drinks with 2, 26, 52 and 100 mmol/l, urine output was inversely proportional to sodium concentration, and the 2 & 26 mmol/l cases resulting in dehydrated subjects after 5.5 hours, believed where the others were rehydrated<ref name="Maughan-1995"/>. (These cases are roughly equal to be glycogen + water depletion , 1/4, 1/2, 3/4 teaspoon of salt per quart/liter.)* Drinks containing 0.45g salt/100ml reduced urine output and improved hydration<ref name="ref8Nose-1988"/>. (0.45g/100ml is about 1/10 teaspoon of salt per quart/liter.)== Salt Sodium loss through sweat ==The amount of salt that is lost through sweating varies a lot. It varies from individual to individual, and for an individual it will vary depending on fitness and heat acclimation <ref name="ref9"/>. This means that you may have to experiment with your salt intake, both during and after exercise. Anecdotal tip==Anatomy of Sweating==[[File: If your skin is crusty with salt after a run, you are probably someone who sweats out a lot Sweat Gland.jpg|right|thumb|500px|A drawing of saltthe sweat gland. (C=clear cells, D=dark cells, IC=Sodium Loss Table=Intracellular canaliculi, M=Myoepitherial cell, Mc=Mitochondria. )]]{| {{table}} | alignHumans have 2-4 million sweat glands over nearly their whole body surface, and though each is tiny, together they weigh as much as a kidney (~100g)<ref name="centerFitzpatrick" style/>. Sweat glands are most numerous on the soles of the feet. Sweat is produced in two steps<ref name="backgroundFitzpatrick"/>:#f0f0f0;"A coil generates an ultra-filtrated fluid. This fluid has the same sodium concentration (isotonic) as the blood.# The fluid travels from the coil up the sweat duct which reabsorbs sodium and chloride (but not [[Potassium|'''Source'''potassium]]). This reabsorption is via active transportation (i.e. it requires energy from ATP). The [[Glycogen]] stored in the sweat glands will only support the reabsorption for less than 10 min., so the energy is predominantly supplied by the blood. Glucose is the preferred energy source, though [[Lactate]] and pyruvate can also be used. Fatty acids, ketones, and amino acids are very poorly used. The reabsorption process also acidifies the final sweat.| alignThe rate of sweat production depends on the local skin temperature and core body temperature. A rise in the localized skin temperature will produce an increased sweat rate within 60 seconds<ref name="centerFitzpatrick" style/>.=="background:#f0f0f0;"|'''Sodium - mmol per liter'''| alignLoss Table="center" style="background:#f0f0f0;"|'''The table below is based on the research showing that sweat sodium concentration increases with sweat rate. The table below is for a runner who is 174cm/70inches high and weighs 60Kg/132lbs, but you can create a customized chart at [[Sodium - grams per Loss]]. To check your sweat rate, simply weigh yourself before and after a run. Dropping 1 Kg or 2.2 pounds equates to 1 liter'''of sweating. (Obviously you need to adjust for any fluid intake and avoid urination.) {| alignclass="centerwikitable" style! ! ! colspan="background:#f0f0f0;3"|'''Sodium - grams per pintHeat Acclimated'''| align! colspan="center" style="background:#f0f0f0;3"|'''Salt Heat Non- grams per pintAcclimated'''

|-

|Blood'''Sweat Rate'''|'''Sweat Rate'''|140'''Sweat Concentration'''|[[Sodium Loss]]|3.2[[Sodium Loss]]|'''Sweat Concentration'''|1.5[[Sodium Loss]]||3.9[[Sodium Loss]]

|-

|Sweat of un-acclimated, unfit'''(l/hr)'''|'''(mg/cm2/min)'''|80'''(mmol/l)'''|'''(mg/hr)'''|1.8'''(tsp/hr)'''|'''(mmol/l)'''|0.9'''(mg/hr)'''||2.2'''(tsp/hr)'''

|-

|Sweat of un-acclimated, fit'''0.5'''|'''0.49'''|6022|249|0.1.4| 31|355|0.7||1.72

|-

|Sweat of acclimated, fit'''1'''|'''0.98'''|4032|732|0.93| 46|1044|0.4|-| '''1.5'''| '''1.47'''| 43| 1450| 0.6| 61| 2066| 0.9|-|'''2'''|'''1.96'''| 53| 2402| 1| 75| 3423| 1.5|-| '''2.5'''| '''2.45'''| 63| 3589| 1.5| 90| 5113| 2.2

|}

This table is based on the research quoted below showing a linear relationship between sweat rate and sweat sodium concentration. ==Sodium Loss and Sweat Rate==The concentration of sodium in sweat depends on the sweat rate. This is believed to be because the sweat is released with a high sodium concentration, then the sodium is reabsorbed before it reaches the surface. The faster the sweating, the less chance for reabsorption. [[File:Sweat Rate Sodium Concentration - adjusted.jpg|none|thumb|400px|Sweat rate and sodium concentration<ref name="Buono-2008"/>, adjusted using the formula for regional patch collection<ref name="Baker-2009"/>.]]===Converting per-area sweat rates to whole body sweat rates===We can convert from per-area sweat rates to whole body sweat rates by using a [http://www.halls.md/body-surface-area/bsa.htm Body Surface Area Calculator]. For example, a 135 pound, 70 inch high person has a skin surface area of 1.74 m², which is 17,400 cm². Therefore 1 mg/cm²/min is 17,400 mg/min, or 17.4 g/min or 1,044 g/hour, or 1 liter/hour. ==Sodium Loss and Fitness==While some sources suggest that increased fitness reduces the sodium concentration in sweat research<ref name="Hamouti-2011"/> shows this is not the case. For both trained and untrained individuals sodium concentration depends mainly on sweat rate. In fact, for a given relative intensity (% of [[VO2max|V̇O₂max]]) trained individuals will be performing a greater absolute work rate and therefore have a greater sweat rate and sodium concentration.[[File:Sodium Source Tablein sweat trained and untrained.jpg|none|thumb|400px|Sweat sodium concentration against sweating rate, showing for three different work intensities and for trained and untrained individuals. Note that this data is not adjusted for regional patch collection, so the rates are too high and should be scaled by 0.67.]]==Sodium Loss and Heat Acclimation==A study<ref name="Buono-2007"/> shows that the sodium concentration of sweat is reduced by [[Heat Acclimation Training]]. The study used three bouts of 30 min. of exercise in environmental chamber with 10 min. of rest between each bout.[[File:Sweat Rate Sodium Concentration for heat adaptation - adjusted.jpg|none|thumb|400px|Sweat sodium concentration against sweating rate, before and after 10 days of heat acclimation training, adjusted using the formula for regional patch collection<ref name="Baker-2009"/>.]]==Sodium Loss and Skin Temperature==A study<ref name="Shamsuddin-2005"/> of sweating great sodium concentration for different temperatures has shown that sodium reabsorption is greater at high temperatures. Unfortunately the units used in this study are not comparable with other studies. The mechanism behind this is unclear, but the implication is that the sodium concentration of sweat in cooler weather may be higher than expected from the above studies. [[File:Sweat Rate Sodium Concentration for skin temperatures.jpg|none|thumb|400px|Sweat sodium concentration against sweating great, shown for two different skin temperatures.]]=Sodium Retention=The human body has mechanisms to try to maintaining its sodium balance. Greater sodium intake results in the excess being excreted in the sweat and urine. Conversly, restricted sodium intake will result in a reduction of the sodium concentration of the sweat<ref name="CONN-1946"/>. This reduction in the sodium concentration occurs at all sweating rates, but the relationship between sodium concentration and sweat rate remains a straight line<ref name="Sigal-1968"/>. So at any given sweat rate, a restricted sodium intake will result in less sodium in the sweat. However, even on a restricted sodium intake, the more you sweat, the greater the sodium concentration. Comparing the maximum sodium concentration of sweat between a salt intake of 500mg/day and 20,000mg/day, the low salt intake reduced the sodium concentration by 30-48%<ref name="Sigal-1968"/>. [[File:SodiumIntakeSweatConcentration.jpg|none|thumb|500px|The effect of high (20,000mg/day NaCL) and low (500mg/day NaCL) on the sodium concentration of sweat at various sweat rates<ref name="Sigal-1968"/>. Three subjects were put on the diet for a week, then tested for five days while remaining on that diet. The two tests were separated by a month.]]=Sodium Intake=

Below are some sample sources of Sodium, with the concentrations defined.

{| {{table}} | alignclass="centerwikitable" style="background:#f0f0f0;"|'''! Source'''| align="center" style="background:#f0f0f0;"|'''! Sodium - mmol per liter'''| align="center" style="background:#f0f0f0;"|'''! Sodium - grams per liter'''| align="center" style="background:#f0f0f0;"|'''! Sodium - grams per pint'''| align="center" style="background:#f0f0f0;"|'''! Salt - grams per pint'''

|-

|Gatorade||18||0.4||0.2||0.5

|-

|Water + 1/4 Teaspoon salt per quart||27||0.6||0.3||0.75

|-

|Gatorade+ 1/4 Teaspoon salt per quart||45||1.0||0.5||1.2

|-

|S-Caps + 8oz water*||65||1.4||0.7||1.7

|-

|Salt Stick + 8oz Water||38||0.84||0.4||0.98

|-

|Salt Stick + 16oz Water||19||0.42||0.2||0.49

|}

 Note: S-Caps does not specify the amount of fluid to take with each capsule, but does mention 'at least one cup', so this ratio is used. The per-pint and per-liter equivalents assumes assume a constant ratio of one capsule per 8oz of water. See also [[Comparison of Gels]]. ===Examples=Example Sodium Losses==

Here are some hypothetical examples

 * Adam, a fit, heat acclimatized runner, weighs himself before and after his four hour run and the difference is 8 pounds, which is roughly equivalent to 8 pints /4 liters of sweat. We Based on 1 liter/hour of sweating we estimate that Adam has lost 0.4 grams of sodium per pint, for a total of 3.2 grams of sodium, which is 8 grams of salt or about 1.3 2 teaspoons. * Bob, a fit, but is not heat acclimatized runner, weighs himself before and after his run and the difference is 10 losses 9 pounds, which is roughly equivalent to 10 in three hours (9 pints of /4.5 liters). From the sweat. We rate we estimate that Bob has lost 0.7 grams of sodium per pint, for a total of 7 grams of sodium, which is 17 grams of salt or about 3 teaspoons.* Charlie, a fit, but not heat acclimatized runner, weighs himself before and after his run and the difference is 8 pounds, which is roughly equivalent to 8 pints of sweat. Charlie had also consumed 80 ounces of Gatorade on the run. This gives an estimate of 8+5=13 pints of sweat. At 0.7 grams of sodium per pint, that’s a total of 9 grams of sodium, which is 23 grams of salt or about 4 teaspoons3. The Gatorade provided approximately 1 gram of sodium, or a 1/2 teaspoon. * For the next run, Charlie changes his drink to add 1/4 teaspoon of extra salt to his Gatorade. He sweats and drinks the same amounts as the previous run. This time, his drink provides him with 4.7 grams of salt, or 3/4 teaspoon of saltteaspoons.  ===Sodium Loss Sweat Rates While Running=== 

Sweat rates in male runners have been measured in the range from 0.75-2.23 in winter to 0.99-2.55 in the summer (Liters per hour)<ref name="acsm"/>. At the low end, we can imagine a fit runner finishing a 3-hour marathon in winter and sweating only 2.25 Liters. Assuming they are also heat acclimated, they would only lose 2 grams of sodium, which is 5 grams of salt, less than a teaspoon. On the other end of the scale, a fit, but unacclimatized runner completing a 5 hour marathon in summer would sweat out nearly 13 Liters, 18 grams of sodium, which is 45 grams of salt or more than 7 teaspoons.

 

There is a table showing a range of values at [[Sodium Loss]].

 == Hyponatremia ==[[Hyponatremia]] is where the sodium (salt) levels becomes in the blood become too dilute. Initial The symptoms of mild hyponatremia tend to be a gain in weight and a general swelling and 'puffiness', most noticeable in the hands. More However, mild Hyponatremia may have no clinical symptoms, or just weakness, dizziness, headache, nausea/vomiting, but more severe Hyponatremia is likely to have symptoms are caused by a swelling of the brain (cerebral edema) , including nauseaaltered mental status, seizures, pulmonary edema, vomitingcoma, headache and malaise death<ref name="ref10RosnerKirven2006"/>.  == HypERnatremia - the opposite of HypOnatremia ==Generally, Hypernatremia (too much sodium in the blood) seems to be a result of dehydration rather than excessive salt intake <ref name="ref17Kratz-2005"/>. It should be noted that taking [[Electrolyte Capsules]] bypasses the body's taste. This sense of taste seems to reflect our body's internal sensors; our desire for salty foods reflects our salt requirements. == Salt and High Blood Pressure ==If you have high blood pressure, you may need to be careful with your salt intake. There is evidence that increased salt intake can increase blood pressure <ref name="ref4"/>. If , and the common recommendation is to restrict your salt intake if you have high blood pressure, discuss these issues with your doctor. If your doctor is not an athleteHowever, I would highly recommend changing to one a recent study<ref name="Stolarz-Skrzypek-2011"/> has shown that is. If you don't know what reducing your salt intake may increase your blood pressure is, get risk of a heart attack rather than lower it checked. (For more on the health risks of low salt diets see http://www.drmirkin.com/public/ezine050811.html As an aside, if you have low blood pressure, which I do, increasing your salt intake can really help.) == Caffeine and Alcohol ==The scientific evidence shows that caffeine [[Caffeine]] is generally not a diuretic <ref name="ref5Graham-1998"/><ref name="ref14"/><ref name="ref15Falk-1990"/>. Previous studies have shown that if you don't normally take caffeine [[Caffeine]] and then get a large dose, there is some diuretic effect. However normal intakes of caffeine [[Caffeine]] by non-users and use by regular users is not a diuretic <ref name="ref16Maughan-2003"/>. (If you urinate more because you drink a 20oz Latte, it is because of the 20oz of fluid, not the caffeine[[Caffeine]].)=Alcohol =Alcohol is a diuretic due to the suppression of vasopressin secretion<ref name="ROBERTS-1963"/><ref name="RubiniKleeman1955"/>, and the volume of urine produced is another story; drinking anything stronger than 2% will cause dehydration. Because alcohol takes 36 hours proportional to clear the bodyalcohol consumed<ref name="Eggleton-1942"/>. However, it should the diuretic effect of alcohol may be avoided for 48 hours before you wish to avoid impaired performancereduced when consumed when suffering from post-exercise dehydration. A study looked at consuming water or an alcoholic beverage of 1%, 2%, and 4% after 1 hour of moderate exercise<ref name="ref5Shirreffs-1997"/>. The study found that urine production tended to increase with alcohol content, but the difference was not statistically significant. The alcohol tended to reduce the rate of recovery for both blood and plasma volume, though tendency was only statistically significant at 4%. In summary, alcoholic beverages of up to 2% appear to have little impact on rehydration rate compared with the equivalent volume of water, but 4% beverages tend to delay recovery. == Cramps ==

The evidence for hydration and electrolyte status causing [[Cramps]] is somewhat ambiguous, but supplementing your electrolyte intake may help.

== Blisters and black toe nails ==Dehydration reduces body weight, which can reduce the size of your feet. This in turn changes the fit of your shoes[[Shoes]], causing blisters. [[Hyponatremia ]] can cause swelling, which increases the size of your feet and can cause blisters. Both conditions can also increase the chance of black toe nails.  ==Sodium and Water in the Body<ref name="CLINC"/>==Approximately 60% of the human body weight is water, though this varies primarily with body fat as adipose (fat) tissue contains a lower percentage of water. Total Body Water (TBW) can be divided up into <ref name="CLINC"/>:

* Intracellular fluid (ICF) which is 40% of body weight

* Extracellular fluid (ECF) which is the other 20% of body weight

** plasma Plasma is 25% of ECF/5% body weight** interstitial Interstitial fluid which is 75% of ECF/15% of body weight, typically 11 Liters/22 pints. The volume of extracellular fluid is typically 15 liters in a 70 kg human, and the 50 grams of sodium it contains is about 90% of the body's total sodium content.==Symptoms of Dehydration=These symptoms are for the general public<ref name="CLINC"/>==These symptoms are for the general public, and there is evidence<ref name="SYMPT"/> that they may not apply to athletes suffering from mild dehydration.{| {{table}}| alignclass="centerwikitable" style="background:#f0f0f0;"|'''! symptom'''| align="center" style="background:#f0f0f0;"|'''! mild dehdration dehydration (3-5% body weight)'''| align="center" style="background:#f0f0f0;"|'''! Moderate dehdration dehydration (6-9% body weight)'''| align="center" style="background:#f0f0f0;"|'''! Severe dehdration dehydration (>10% body weight)'''

|-

| Level of consciousness||Alert ||Lethargic ||Obtunded

|-

| Capillary Refill||2 seconds||2-4 seconds||>4 seconds

|-

| Blood Pressure||Normal||Normal supine, lower standing||lower

|-

| Skin Turgor||Normal||Slow||Tenting

|-

| Eyes||Normal||Sunken||Very Sunken

|}

   == References ==

<references>

<ref name="RosnerKirven2006">M. H. Rosner, J. Kirven, Exercise-Associated Hyponatremia, Clinical Journal of the American Society of Nephrology, volume 2, issue 1, 2006, pages 151–161, ISSN [http://www.worldcat.org/issn/1555-9041 1555-9041], doi [http://dx.doi.org/10.2215/CJN.02730806 10.2215/CJN.02730806]</ref>

<ref name="CLINC">Clinical Studies in Fluid and Electrolyte Balance</ref>

  <ref name="SYMPT">J. McGarvey, J. Thompson, C. Hanna, T. D. Noakes, J. Stewart, D. Speedy, Sensitivity and specificity of clinical signs for assessment of dehydration in endurance athleteshttp://bjsm.bmj.com/content/early/2010/04/22/bjsm., British Journal of Sports Medicine, volume 44, issue 10, 2008.053249.abstract</ref> <ref name="ref5">Caffeine dehydration : Caffeine and alcohol - just how dehydrating are they?, pages 716–719, ISSN [http://www.pponlineworldcat.co.ukorg/encycissn/caffeine0306-dehydration.htm http://www.pponline.co.uk/encyc/caffeine3674 0306-dehydration.htm3674]</ref> <ref name="ref6">Muscle Cramps : No link between hydration and cramps, doi [http://wwwdx.pponlinedoi.co.ukorg/encyc/muscle-cramps10.htm http:1136//wwwbjsm.pponline2008.co053249 10.uk1136/encyc/muscle-crampsbjsm.2008.htm053249]</ref> <ref name="ref7Nilsson-1973">Hydration - fluid intake advice and tips[http://wwwLH.pponlineNilsson, Liver glycogen content in man in the postabsorptive state.co.uk/encyc/hydration, Scand J Clin Lab Invest, volume 32, issue 4, pages 317-fluid-intake-advice-and-tips-40789 http://www.pponline.co.uk/encyc/hydration-fluid-intake-advice-and-tips-40789]</ref> <ref name="ref8">The Relation Of Glycogen To Water Storage In The Liver23, Dec 1973, PMID [http://www.jbcncbi.org/cgi/reprint/96/2/367nlm.pdf http://wwwnih.jbc.orggov/cgipubmed/reprint/96/2/367.pdf4771101 4771101]</ref> <ref name="ref9González-Alonso-1995">Cracking the Code on Hydration[http://wwwJ.active.com/cycling/Articles/CrackingGonzález-the-Code-on-Hydration.htm http://wwwAlonso, R.active.com/cycling/Articles/CrackingMora-the-Code-on-HydrationRodríguez, PR.htm]</ref> <ref name="ref10">Hyponatremia[http://enBelow, EF.wikipedia.org/wiki/Hyponatremia http://en.wikipedia.org/wiki/Hyponatremia]</ref> <ref name="ref11">Coyle, Dehydration reduces cardiac output and increases systemic and cutaneous vascular resistance during exercise[http://www.edb.utexas.edu/coyle/pdf%20library/%286329%20Dehydration%20reduces%20cardiac%20output%20&%20increases%20systemic%20&%20cutaneous%20vascular%20resistance%20during%20exercise,%20J%20Appl%20Physiol%2079J Appl Physiol (1985), volume 79, issue 5,%201487pages 1487-96,%201995.pdf Nov 1995, PMID [http://www.edbncbi.utexasnlm.edunih.gov/coylepubmed/pdf%20library/%2863%29%20Dehydration%20reduces%20cardiac%20output%20&%20increases%20systemic%20&%20cutaneous%20vascular%20resistance%20during%20exercise,%20J%20Appl%20Physiol%2079,%201487-96,%201995.pdf8594004 8594004]</ref>   <ref name="ref14Graham-1998">TE. Graham, E. Hibbert, P. Sathasivam, Metabolic and exercise endurance effects of coffee and caffeine ingestion[http://jap.physiology.org/cgi/content/full/, J Appl Physiol (1985), volume 85/, issue 3/, pages 883 -9, Sep 1998, PMID [http://japwww.physiologyncbi.orgnlm.nih.gov/cgi/contentpubmed/full/85/3/8839729561 9729561]</ref> <ref name="ref15Falk-1990">B. Falk, R. Burstein, J. Rosenblum, Y. Shapiro, E. Zylber-Katz, N. Bashan, Effects of caffeine ingestion on body fluid balance and thermoregulation during exercise., Can J Physiol Pharmacol, volume 68, issue 7, pages 889-92, Jul 1990, PMID [http://www.ncbi.nlm.nih.gov/pubmed/2383801 http://www.ncbi.nlm.nih.gov/pubmed/2383801]</ref> <ref name="ref16Maughan-2003">RJ. Maughan, J. Griffin, Caffeine ingestion and fluid balance: a review., J Hum Nutr Diet, volume 16, issue 6, pages 411-20, Dec 2003, PMID [http://ptwww.wkhealthncbi.com/pt/re/jhnd/abstractnlm.00009862-200312000-00004nih.htm;jsessionid=KNhWhGQSZnXhY11p2f7qnnmn1Q7z376shvhsK7hTWDLVGQhWpGGJ%21811725889%21181195628%218091%21-1 http:gov/pubmed/pt.wkhealth.com/pt/re/jhnd/abstract.00009862-200312000-00004.htm;jsessionid=KNhWhGQSZnXhY11p2f7qnnmn1Q7z376shvhsK7hTWDLVGQhWpGGJ!811725889!181195628!8091!-119774754 19774754]</ref> <ref name="ref17Kratz-2005">A. Kratz, AJ. Siegel, JG. Verbalis, MM. Adner, T. Shirey, E. Lee-Lewandrowski, KB. Lewandrowski, Sodium Status status of Collapsed Marathon Runnerscollapsed marathon runners., Arch Pathol Lab Med, volume 129, issue 2, pages 227-30, Feb 2005, doi [http://arpadx.allenpressdoi.comorg/arpaonline/?request=get-document&doi=10.1043%2F1543/1543-2165%282005%29129%3C227(2005)129<227:SSOCMR%3E2>2.0.CO%3B2 http://arpa.allenpress.com/arpaonline/?request=get-document&doi=;2 10.1043%2F1543/1543-2165%282005%29129%3C227(2005)129<227:SSOCMR%3E2>2.0.CO%3B2;2], PMID [http://www.ncbi.nlm.nih.gov/pubmed/15679427 15679427]</ref> 

<ref name="acsm">http://journals.lww.com/acsm-msse/_layouts/oaks.journals/ImageView.aspx?k=acsm-msse:2007:02000:00022&i=TT2

</ref>

 

<ref name="ref4">Micronutrient Information Center - Sodium

[http://lpi.oregonstate.edu/infocenter/minerals/sodium/ http://lpi.oregonstate.edu/infocenter/minerals/sodium/]

</ref>

<ref name="Stolarz-Skrzypek-2011">K. Stolarz-Skrzypek, T. Kuznetsova, L. Thijs, V. Tikhonoff, J. Seidlerová, T. Richart, Y. Jin, A. Olszanecka, S. Malyutina, Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion., JAMA, volume 305, issue 17, pages 1777-85, May 2011, doi [http://dx.doi.org/10.1001/jama.2011.574 10.1001/jama.2011.574], PMID [http://www.ncbi.nlm.nih.gov/pubmed/21540421 21540421]</ref><ref name="Buono-2008">MJ. Buono, R. Claros, T. Deboer, J. Wong, Na+ secretion rate increases proportionally more than the Na+ reabsorption rate with increases in sweat rate., J Appl Physiol (1985), volume 105, issue 4, pages 1044-8, Oct 2008, doi [http://dx.doi.org/10.1152/japplphysiol.90503.2008 10.1152/japplphysiol.90503.2008], PMID [http://www.ncbi.nlm.nih.gov/pubmed/18653750 18653750]</ref><ref name="Hamouti-2011">N. Hamouti, J. Del Coso, JF. Ortega, R. 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