In the past few years, a large percentage of our reporting has looked at the relationship between the ACSM and its corporate sponsor, Gatorade. Specifically, we have covered how the ACSM allowed Gatorade funding to distort thermoregulatory science, creating the now-universal myth that dehydration contributes to heat injury in sports. We have also covered how the ACSM, Gatorade, and the Gatorade-funded National Athletic Trainers Association (NATA) published hydration guidelines recommending aggressive hydration strategies to combat this pretend disease (1,2,3,4,5,6,7,8,9,10,11,12).
Consequently, they created a real disease–Exercise-Associated Hyponatremia (EAH). Beginning in the 1990’s, the ACSM, NATA, and Gatorade instructed athletes to drink “as much as tolerable” (13), “beyond thirst satiation” (14), and “at least 40 oz. of fluid every hour” (15). Since then, roughly 20 athletes have died from EAH, including two high school football players. Greg Glassman’s 2014 comments summarize the significance of the problem:
“The consequences of this were the deaths of at least a dozen people, and serious injury to thousands of others. I believe that the Gatorade/ACSM cabal also has the distinction of having adversely affected sporting performance on a level the world has never seen before, and profit is and remains the singular motive”(16).
In May of 2015, Russ Greene and I attended the American College of Sports Medicine’s Annual Meeting in San Diego, California. On Wednesday of that week, we sat in on a lecture by Drs. Mitchell H. Rosner and Joseph G. Verbalis on the subject of exercise-associated hyponatremia. Also in the audience was Douglas Casa. Doug Casa is the Chief Executive Officer of the Gatorade-founded Korey Stringer Institute, and was the author of the 2000 NATA Fluid Replacement Position Statement. I’ve written before on this document, and noted that Casa’s fluid replacement recommendations are dangerously flawed (17). These recommendations were directly contradicted by Rosner and Verbalis during their lecture. Specifically, Rosner advised against any recommendation to drink beyond thirst satiation. At the end of the lecture, during the Q&A time, I brought this subject up.
Afterwards, Casa approached me and claimed his paper did not recommend athletes drink beyond thirst satiation. I pulled out my iPhone and showed him exactly where his 2000 paper does say this.
He looked at my phone, read his own words, and with a look of concern replied “Yeah, we should probably change that.” This was well over a year ago (18). Not only has the 2000 Fluid Replacement Position Statement never been updated, replaced, or revised, but five months after my interaction with Casa, he authored another NATA document–an updated Exertional Heat Illness Position Statement (19). Unbelievably, this paper actually cites the 2000 Position Statement that Casa acknowledged needed to be revised:
There is no longer any question that telling athletes to drink “beyond thirst satiation” is a dangerous recommendation based on the myth that dehydration causes heat injury. In fact, three months prior to the publication of Casa’s updated Heat Illness Position Statement, the Third International Exercise-Associated Hyponatremia Consensus Development Conference published a statement that directly contradicts the advice in Casa’s 2000 NATA Fluid Replacement Document (20):
The Consensus statement concludes with a recommendation that Casa and the Korey Stringer Institute have failed to acknowledge in any of their published recommendations: “The safest individualized hydration strategy before, during and immediately following exercise is to drink palatable fluids when thirsty.” The Korey Stringer Institute website even boldly claims, “Thirst develops once dehydration has already set in,” and, “Sensation of thirst works well only at rest.” These claims are made without citation, and dangerously contradict the latest consensus statement on EAH. Why have they not been revised?
To make matters worse, the Korey Stringer Institute’s website correctly notes that symptoms of EAH include “weakness, dizziness, headache, nausea, and/or vomiting” (21). This presents a problem for Casa’s 2000 NATA Fluid Replacement Position Statement, which conflates the symptoms of exercise-associated hyponatremia and dehydration.
The recommendation (in yellow) to “aggressively rehydrate orally” is exactly what doctors, coaches, and athletic trainers told Zyrees Oliver to do in 2014 (22). Oliver died of exercise-associated hyponatremic encephalopathy (EAHE) soon after. Regular readers will recall that in the same month, 17-year-old Walker Wilbanks collapsed during a game at Jackson Prep High School and died. His cause of death was later found to be EAH.
Wilbanks’ death was initially linked to over-hydration (23,24). His treating physician, Dr. Joe Pressler told press that “both before and during the game, Wilbanks drank Gatorade and Pedialyte, beverages with sodium concentrations that are higher than in water but lower than what is naturally found in the body” (25). Yet Dr. Pressler also made a series of bizarre and inaccurate statements that obfuscated the role of hydration in Wilbanks’ death. He characterized EAH as a loss of blood sodium rather than a dilution of blood sodium caused by over-hydration, and called Wilbanks’ death a “fluke” and a “freak” occurrence. In fact, Pressler specifically denied that Wilbanks’ death was related to fluid consumption: “It was in no way, a reflection of him being overhydrated, or under-hydrated. Walker did nothing wrong in preparation for this game. His coaches did nothing wrong in preparing him for this game…”
This explanation warrants serious suspicion. The Consensus Statement from the Third International Exercise-Associated Hyponatremia Consensus Development Conference states, “hyponatremia can result from loss of solutes (sodium, potassium), a relative excess of total body water or a combination of both. However, in most clinical scenarios, the driving force for the development of hyponatremia is a relative excess of total body water.”
Since the driving force in “most” EAH cases is over-hydration, Dr. Pressler should be able to provide evidence for his conclusion that over-hydration was not a factor in Wilbanks’ death. He does not. In fact, the Clarion-Ledger reported that Dr. Pressler “also said the player and coaches did everything correctly as they dealt with Wilbanks’ apparent overheating during the game” (26). This can only be interpreted to mean that Wilbanks’ EAH was initially misdiagnosed as a heat injury, and would have been treated per NATA guidelines with “aggressive rehydration.”
Even more suspicious, the Clarion-Ledger appears to have edited the headline of the story in which Dr. Pressler’s comments appear. The URL (http://www.clarionledger.com/story/prepsreport/2014/08/25/walker-wilbanks-cause-of-death-related-to-over-hydration/14598215/) contains a headline that no longer exists. The story, which appears to have been edited a day after its original publication, now carries the headline, “Doctor: Wilbanks’ death unpreventable, freak occurrence.” This story does not mention the word hydration once.
So I was not surprised to find out that one year after Wilbanks’ death, Douglas Casa of the Korey Stringer Institute visited his high school (27). The Clarion-Ledger reported that the visit was based on a “partnership” between the school and the Korey Stringer Institute and notes that Casa personally recommended the school install automated external defibrillators and hire a full-time certified athletic trainer. Over-hydration was not mentioned once in the article. The Clarion-Ledger also erroneously described Wilbanks’ cause of death (hyponatremia) as “a severe sodium deficiency.” The author of the article, Courtney Cronin, no longer works at the Clarion-Ledger. I emailed her and asked if she remembers who described Wilbanks’ cause of death to her in this way. Her response was “I believe I got that definition from the KSI or from Douglas Casa.”
In sum, here is the dilemma we face: A scientific consensus statement from the world’s foremost researchers says the best way for preventing excessive dehydration and deadly EAH is drinking according to thirst, not beyond or before. Doug Casa, NATA, and the Korey Stringer Institute directly contradict this information. Casa himself has admitted his 2000 statement was faulty when I pressed him in person, but it has never been revised and his recent papers continue to cite it.
Casa also personally visited the school of a young man who clearly died from a preventable case of EAH and is complicit in the obfuscation of his cause of death. It is worth noting that media coverage of Zyrees Oliver, who died the same month as Wilbanks explicitly linked his death to the four gallons of water and Gatorade he drank beforehand. His school received no visit from the Korey Stringer Institute. Was it because the former was poor and black while the later was affluent and white? I doubt it. Casa simply would not associate the Gatorade-founded Korey Stringer Institute with a death caused by overconsumption of Gatorade, even when his own published recommendations are likely to blame.
If Casa and his organizations had sufficient scientific evidence to counter the 2015 EAH Consensus Statement, they could defend their position on those grounds. As it stands, they have provided none and continue to cite outdated and dangerous guidelines without explanation. This does not mean there is no explanation for their apparent negligence. Casa, NATA, and the Korey Stringer Institute are all on Gatorade’s payroll. The 2015 EAH Consensus Statement was the first produced in the U.S. without Gatorade or Gatorade-proxy organizational involvement. It appears that for Casa, publishing safe and accurate hydration recommendations comes second to ensuring kids are buying plenty of his sponsor’s products.
- “The ACSM Let Gatorade Distort Science”. THE RUSSELLS. 2014-02-20. Retrieved 2016-08-16.
- “Dehydration Myths, By Dr. Sandra Fowkes Godek”. THE RUSSELLS. 2014-08-28. Retrieved 2016-08-16.
- “ACSM on Hydration: Protecting Athletes or Corporate Sponsors?”. THE RUSSELLS. 2014-08-25. Retrieved 2016-08-16.
- “The National Athletic Trainers’ Association’s Moral and Academic Failure”. THE RUSSELLS. 2014-08-22. Retrieved 2016-08-16.
- “Gatorade, Over-Hydration, and Death”. THE RUSSELLS. 2014-08-21. Retrieved 2016-08-16.
- “No Excuses: Gatorade and Hyponatremia”. THE RUSSELLS. 2014-09-03. Retrieved 2016-08-16.
- “Athletes Don’t Just Die, By Jon Phillips”. THE RUSSELLS. 2014-10-15. Retrieved 2016-08-16.
- “ACSM President-Elect: Gatorade Does ‘Affect Objectivity’”. THE RUSSELLS. 2015-03-17. Retrieved 2016-08-16.
- “Gatorade’s Hydration Confessions”. THE RUSSELLS. 2015-05-04. Retrieved 2016-08-16.
- “Gatorade’s ‘Beat the Heat’: Based on a Lie”. THE RUSSELLS. 2015-06-12. Retrieved 2016-08-16.
- Bendory, David (2015-07-06). “Have Coca-Cola and PepsiCo Corrupted the Health Sciences? Part 1”. THE RUSSELLS. Retrieved 2016-08-16.
- “Stephanie Habif’s Mixify Hydration Advice: Willful Negligence?”. THE RUSSELLS. 2015-10-08. Retrieved 2016-08-16.
- Convertino, V. A.; Armstrong, L. E.; Coyle, E. F.; Mack, G. W.; Sawka, M. N.; Senay, L. C.; Sherman, W. M. (1996-01-01). “American College of Sports Medicine position stand. Exercise and fluid replacement”. Medicine and Science in Sports and Exercise. 28 (1): i–vii. ISSN 0195-9131. PMID 9303999.
- Casa, Douglas (June 2000). “National Athletic Trainers’ Association Position Statement: Fluid Replacement For Athletes” (PDF). Nata.org.
- Gatorade Advertisement, https://therussellsblogdotcom.files.wordpress.com/2015/05/40ounces-1.jpg
- “Exercise Associated Hyponatremic Encephalopathy, Gatorade and the ACSM – CrossFit Discussion Board”. board.crossfit.com. Retrieved 2016-08-16.
- “The National Athletic Trainers’ Association’s Moral and Academic Failure”. THE RUSSELLS. 2014-08-22. Retrieved 2016-08-16.
- “Russell Berger on Twitter”. Retrieved 2016-08-16.
- Hew-Butler, Tamara; Rosner, Mitchell H.; Fowkes-Godek, Sandra; Dugas, Jonathan P.; Hoffman, Martin D.; Lewis, Douglas P.; Maughan, Ronald J.; Miller, Kevin C.; Montain, Scott J. (2015-07-01). “Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015”. Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine. 25 (4): 303–320.
- “Hyponatremia | Korey Stringer Institute”. ksi.uconn.edu. Retrieved 2016-08-16.
- Cecil, Andréa Maria. “Deadly Myth”. Retrieved 2016-08-16.
- “Overhydration may have been factor in Mississippi football player’s death”. Retrieved 2016-08-17.
- “UMMC reaching out after death of high school football player – Mississippi Business Journal”. Mississippi Business Journal. 2014-09-12. Retrieved 2016-08-17.
- “Overhydration may have been factor in Mississippi football player’s death”. Reuters. 2014-08-26. Retrieved 2016-08-17.
- “Doctor: Wilbanks’ death unpreventable, freak occurrence”. Retrieved 2016-08-17.
- “Jackson Prep leading way in player safety initiatives”. Retrieved 2016-08-18.