Fluid Recommendations for our Runners and Walkers

Runners Underestimate Fluid Needs

Too much is dangerous!!


Lewis G. Maharam, M.D., FACSM

aka Marathon Doc aka Rock 'N' Roll Doc aka Country Music Doc

Medical Director, New York Road Runners Club, New York City Marathon, NYC Triathlon, Suzuki Rock 'n' Roll Marathon, Country Music Marathon, Carlsbad 5000,

And Rock 'N' Roll Half Marathon

President, Greater New York Regional Chapter, American College of Sports Medicine

Chairman, Board of Governors, International Marathon Medical Directors Association

When the weather is steamy or your athlete’s body is down a quart and the workout is far from over, it's a bad time to begin wondering if you've had enough to drink lately. Every obviously needs to drink. Not drinking may lead to early fatigue or heat illness. But, encouraging the slower runners/walkers in marathon races to drink “as much as possible” is the incorrect treatment for the wrong group of athletes, since it is precisely this group of athletes who are at essentially no risk of developing heatstroke due to their low rate of heat production during exercise. It is the elite athletes who experience the greatest risk of heatstroke due to their much larger rate of heat production. Even they tend not to develop heat stroke despite drinking very little during such races, because they vary their pace according to existing conditions, delivering extraordinarily quick performance times in cooler weather and slowing the pace appropriately during hot summertime competitions such as occurs with major world championships.

So, when coaching your athletes, please remind them to drink not too much and not too little! Too far either way and they can get into trouble! For simple re-hydration on an average day, water does the job; however, sports drinks have made the issue more complicated than that. As Medical Director of several marathons as well as the New York Road Runners, I credit the research evidence that says the sugar and salt in those sports drinks form an "active pump" that gets more water into the body faster than the unassisted process - simple diffusion of water. The additional salt is advantageous to help hold onto water and maintain proper blood sodium levels. Practice with fluid replacement drinks is essential. Don't do anything new on race day that hasn’t been practiced with is the golden rule of marathon medicine!.

Here are some practical tips for advising your athletes how much to drink both during training periods and on race day:

 Fluids on Race Day

Water and sports drinks provide individuals with fluid, by far the most important nutrient a body needs to finish a marathon healthy! Follow these recommendations and your athletes will prevent dehydration! BUT DON’T OVER-DRINK! Remember, too much is as bad as too little. Use urine color as a guide (see below):

bulletDrink about 16 ounces of fluid 1-2 hours before the race.
bulletDrink another 16 ounces of fluid in the hour before the race.
bulletHave your athlete check their urine ½ hour before the race…if clear to dark yellow…the athlete is well prehydrated…if dark and concentrated…drink more fluids! 
bullet During the race drink no more than 1 cup (8-10 ounces) of fluid every 15-20 minutes along the way - that does not mean a cup at EVERY water station. Water/Sports Drink stations are usually located throughout the course at closer intervals than it is healthy to drink. Don’t be afraid of skipping a station; there are more stations ahead. 

Too Much Fluid IS Harmful

Most athletes understand the importance of drinking fluids, but some don't understand that drinking too much can be harmful as well. It is your job as a coach to drive home this point. Overhydrating can lead to a dangerous condition known as hyponatremia (low blood sodium). Marathoners out on the course for long periods (usually 4 hours or more), losing lots of sodium in sweat, are at risk. Overzealous drinkers who drink lots of water in the days prior to the race and then stop at every fluid station along the course also may risk hyponatremia. This condition can lead to nausea, fatigue, vomiting, weakness, sleepiness, changes in sensorium and in the most severe instances, seizures, coma and death.

To avoid hyponatremia have your athletes follow these easy guidelines:

bulletFollow the fluid recommendations. 
bulletTell them to try not to drink more than they sweat. 
bulletInclude pretzels or a salted bagel in their pre-race meal. 
bulletFavor a sports drink that has some sodium in it over water which has none. 
bulletIn the days before the race, add salt to their foods (provided that they don't have high blood pressure or their doctor has restricted their salt intake). 
bulletEat salted pretzels during the last half of the race. 
bulletHave them carry a small salt packet with them, and during the last half of the race, if they feel that they have been sweating a lot or that it’s a warm/hot day, consume that single packet. Do NOT use salt tablets which concentrated form may cause stomach ulcerations; salt packets from a fast food vender are safer!
bulletAfter the race, drink a sports drink which has sodium in it and eat some pretzels or a salted bagel.

Pain Relievers may add to the problem!

Recent medical research has shown that non-steroidal anti-inflammatories (NSAIDs) like Advil, Motrin, Aleve, ibuprofen, naproxen, etc. may be harmful to marathon runners’ kidney function; acetaminophen (Tylenol) has been shown to be safe. These NSAIDs are thought to increase the possibility of hyponatremia while running a marathon due to their decreasing blood flow to the kidney and interfering with a hormone that helps the body retain salt. Therefore, it is recommended that on marathon day (specifically, beginning midnight before your athletes run) they do not use anything but acetaminophen (Tylenol) if needed until after they have finished the race, are able to drink without any nausea or vomiting, and have urinated once a clear to clear-yellow urine. Then, an NSAID would be of benefit in preventing post-marathon muscle soreness.


Help for coaches

You are not alone out there. If you have any questions about these recommendations or any other health related issue, please call Craig Schmidt at Risk Management (914-821-8961) or me (212-765-5763). What our runners/walkers are doing is wonderful. It is always easy to recruit a medical team when Team in Training has a significant number of runners do to the wonderful cause these athletes are supporting. But we need to keep them healthy so that they will spread the word as well as do it again themselves! We are here to help. We can only be as good for you as you let us be. We look forward to healthy athletic year!


Dr. Lewis G. Maharam can be contacted at 24 West 57th Street; 6th Floor, New York, NY 10019. Telephone: 212-765-5763 E-mail: nysportsmd@aol.com



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