Don't be a statistic!

Yesterday, I was perusing articles online, and one grabbed my attention--the subject was that athletes are not immune to hypertension. Without repeating all of the details, the net conclusion was that studies on athletes involving the risk of high blood pressure have been poorly done, and not well documented, but that statistically, it appears that athletes have the possibility of developing unhealthy blood pressure independent of their activity level.  The conclusion makes sense--if you work out all the time, it does not give you carte blanche to eat nothing but fried food and desserts while smoking and drinking a fifth of vodka every day.

What concerned me was some of the comments to this article--and one in particular from a guy who was obviously a medical doctor of some sort.  He stressed that his recommendation was for everyone to take in no more than 2300 mg of sodium per day.

About a decade ago, I was diagnosed with a heart condition, called a patent foramen ovale with atrial septal aneurysm (PFO w/ASA), and was simultaneously misdiagnosed with hypertension. The PFO w/ASA is a topic for another post--but right now, I think it's important to point out the missteps that the medical community made in relation to my misdiagnosis.

First and foremost, blood pressure readings were taken on me that indicated that I had borderline high blood pressure, measuring anywhere from 130/85 to 150/95.  These numbers, standing without context, are enough for pretty much anyone to suspect that there is a problem. But context is something that appears to have lost traction in today's slam-bam-thank-you-mam 5 minute visit with a medical professional.  I was placed on blood pressure medication, and my numbers came down...way down.  Frankly, I think that I could barely move.  I lost the ability to exercise effectively--running become next to impossible, and I wound up having to move down a couple of lanes at masters swimming.  It was my own conclusion that a drug that prevented me from working on things to improve cardiovascular fitness was probably not the right answer, and I stopped taking the blood pressure medication. I did, however, heed the advice of the doctors to watch out for "excessive sodium intake" and began watching my diet for these things while training for and (barely) completing my first marathon.

In the years that would follow, I would successfully complete two ironman triathlons, along with a number of other things, take off a minor amount of weight, and have wildly fluctuating blood pressure readings.  All the while, I would watch for dietary consumption of sodium, but know that to complete an ironman triathlon, supplementing electrolyte intake was important.  People collapse on the course due to sodium depletion routinely--so routinely that seeing someone hooked up to an IV in a medical tent is an expected part of the race.

I developed wicked headaches after most of my long distance training sessions.  Common knowledge was that I must have been dehydrated, and I would talk to people (other athletes, my GP, one of the several cardiologists I saw, and a nephrologist) about this, and explain that my urine was clear, and a universally puzzled look would come across their faces and the conversation would end. It was not until I started working with my current triathlon coach (Joanna Zeiger) that we got to the bottom of this.

I raced a half marathon one day, and did not do as well as I would have liked. My muscles seized on the finish line and I couldn't move for a period of several minutes. This passed--and I went home and somewhere during this process texted Joanna my result, the fact of my headache, and that I seized up on the finish line, and that I was in no condition to talk to her.  She was persistent (not out of the norm for Joanna), and eventually got through to me that she thought that I was low in sodium.  She had no idea at the time what I had been through regarding the whole mess with my heart condition and the recommendations from doctors to limit my sodium intake. In desperation, I conceded to try consuming what would wind up being three cans of V-8, with a little water to wash it down (that's right--36 ounces of the stuff, containing nearly 3 grams of sodium). The effect was rapid--over the course of a couple of hours my headache would disappear, my mood would improve, and I would feel like the adverse affects of the half marathon never occurred in the first place. In the past, once a post workout headache would occur, it would stick with me for the rest of the day, and only relent with the passage of time, generally until the next day.  So, this change was dramatic.

The fact of the matter is that physicians are trained to act based on statistics--the vast majority of patients that they see with a high blood pressure reading are sedentary and they do not exercise at all, let alone to the point that triathletes do.  The recommendation of no more than 2300 mg of sodium per day holds true for a very large percentage of the population, so they're going to be right probably 99% of the time.  The problem is that endurance athletes are the statistical anomaly in their day to day operations.

• Endurance athletes sweat (a lot).  It's not uncommon for me to lose, and subsequently replace, 5 pounds of water weight a day while training.  Each pound of sweat lost contains, on average 1.5 grams of sodium.  Simple math reveals that 7.5 grams of sodium lost is much more than the 2.3 grams of dietary sodium recommended as a maximum.
• Athletes tend to have more muscular arms.  It turns out that most nurses, and some doctors, are unaware how much the wrong size blood pressure cuff can affect a blood pressure reading.  Switching to the "fat-people cuff" revealed that my blood pressure is within the norm for the population.  Too small of a cuff crushes the blood vessels in the arm, creating a situation where an accurate reading is impossible.
• Athletes tend to get workouts in all the time...and those workouts can cause increases in blood pressure that last for hours, often spiking that blood pressure reading during your office visit.
• Some doctors have a problem with a god complex.  One cardiologist I saw would not even let me finish a question about how much I sweat and how to deal with that while limiting sodium intake.  In retrospect, it would have been best if I had never gone back to see this guy again.
• Low blood sodium is much more dangerous than high blood sodium is, with risks including hyponatremia, brain swelling, loss of muscle coordination, and potentially the risk of fatal fluid buildup in the pericardium.  It is possible that the heart palpitations I have experienced in the past are the result of insufficient sodium in my bloodstream.
• A lot of pills sold as electrolyte supplements do not contain enough sodium to be effective.  Before my collapse at that half marathon, I was using Endurolytes (80 mg of sodium per pill) and not taking enough of them.  Since then, I have switched to SaltStick (215 mg of sodium per pill) and now take 4 per hour while running (or more if very hot).

The simple fact of the matter is that today's medical industry does not adequately address the needs of the athlete, and it does so for very good reason.  The endurance athlete is the 1% of the clients that they see, and they're going to be right much more often by ignoring them.  I have to remind my doctor during my annual physical to use the large blood pressure cuff, that I worked out a couple of hours beforehand, and that in the past week I've sweat out approximately 15 liters of fluid. Nobody is going to fix this problem with modern medicine, but with the right knowledge at your disposal, you can probably avoid becoming a victim of it.