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El agua es el elemento constitutivo más importante del cuerpo humano. En sujetos adultos
jóvenes puede representarse hasta las dos terceras partes del peso corporal; así, en una
persona de 70 kilos de peso, el agua corporal total es de alrededor de 40 litros. El volumen de
agua corporal depende de una serie de factores, entre los cuales destacan el peso corporal, la
edad, el sexo y la presencia de mayor o menor cantidad de tejido adiposo. En el recién nacido, el
agua representa un 75% de su peso, pero existe una marcada tendencia a la reducción de ese
porcentaje con la edad, particularmente durante los diez primeros años de vida. En general, a
igual peso corporal, existe una menor proporción de agua en las mujeres que en los hombres.
Este hecho probablemente está relacionado con la mayor cantidad de grasa subcutánea de la
mujer. El tejido adiposo es él más bajo contenido en agua; por ello, el volumen total de agua
corporal es inversamente proporcional al grado de obesidad de los sujetos. De hecho, en los
sujetos obesos, el porcentaje de agua puede llegar a ser de tan sólo el 45% de su peso.
El porcentaje de agua varía sensiblemente de unos tejidos a otros y oscila entre el más del 80%
de los riñones y el 10% del tejido adiposo.
En el organismo existe un notable equilibrio entre los ingresos y pérdidas de agua. Este equilibrio
también alcanza a los solutos. El ingreso medio de agua en condiciones normales es de algo
más de 2 litros diarios entre ingerida en forma líquida, la contenida en los alimentos sólidos y la
pequeña cantidad que sintetiza como resultado del metabolismo de los hidratos de carbono. El
ingreso hídrico es muy variable en función de factores como las costumbres, la temperatura, el
clima, el ejercicio físico, etc.
Las pérdidas de agua se producen por diversas vías. En condiciones normales, la pérdida más
importante de agua se produce a través de la orina producida por el riñón (1.400ml). Otros
mecanismos importantes son la difusión a través de la piel, es decir, la llamada pérdida
insensible (350ml), pérdida por la respiración (350ml) y por las heces (100ml); sin embargo,
estas cantidades pueden verse aumentadas o disminuidas de forma muy considerable. El
volumen de orina aumenta de un escaso medio litro hasta varios litros en función de la mayor o
menor ingestión de líquido. La pérdida de agua por las heces aumenta varios litros en caso de
diarrea, y la sudoración, cuando se realiza ejercicio físico intenso o en el clima caluroso, puede
incrementarse extraordinariamente / hasta 1 o 2 l/h).
_ El líquido o compartimiento intracelular, que representa el 55% del total, y en el que tienen
lugar los fenómenos vitales.
Durante una hora de esfuerza intenso, por ejemplo, una persona de 70 kilos puede metabolizar
alrededor de 245 gramos de hidratos de carbono. Esto producirá alrededor de 146 mililitros de
agua. Durante el mismo período, no obstante, las pérdidas por el sudor pueden superar los 1.500
mililitros, aproximadamente diez veces más que la generada metabólicamente.
Sin embargo, el agua producida durante el metabolismo oxidativo ayuda a minimizar, aunque
sólo en un grado mínimo, la deshidratación que tiene lugar durante el ejercicio.
En general, la cantidad de sudor producido durante el ejercicio viene determinado por la
temperatura ambiental, el tamaño corporal y el ritmo metabólico.
Estos tres factores influyen en la acumulación de calor y en la temperatura del cuerpo. El calor
se transmite desde las áreas más calientes hacia las más frías, por lo que la pérdida de calor del
cuerpo se ve dificultada cuando la temperatura ambiental es alta. El tamaño del cuerpo es
importante, porque los individuos grandes generalmente necesitan más energía para hacer un
trabajo determinado, por lo que en general tienen ritmos metabólicos más altos y producen más
calor. Pero también tienen un área superficial más grande (piel) que permite una mayor
formación y evaporación del sudor.
Cuando la intensidad del ejercicio aumenta, también lo hace el ritmo metabólico. Esto
incrementa la producción de calor corporal y, en consecuencia, la sudoración. Para conservar el
agua durante el ejercicio, se reduce el flujo sanguíneo hacia los riñones en un intento de evitar la
deshidratación, pero, al igual que con el incremento de la producción de agua metabólica, esto
también puede ser suficiente. En condiciones extremas de ejercicio y de estrés debido al calor
ambiental, la sudoración y la evaporación respiratoria pueden producir pérdidas rápidas de hasta
2 o 3 litros de agua por hora.
Nuestro cuerpo pierde más agua que electrólitos cuando estamos sudando intensamente. Esto
eleva la presión osmótica de nuestros fluidos corporales: nuestros electrólitos se concentra más.
Por esto, la necesidad de electrólitos, porque únicamente reponiendo agua pueden volver estos
últimos a sus concentraciones normales. Pero, ¿cómo sabe el cuerpo cuándo es necesario esto?
SED
Cuando tenemos sed, bebemos. El hipotálamo regula la sensación de sed. Éste activa la sed
cuando la presión osmótica del plasma aumenta. Desgraciadamente, el mecanismo de la sed del
cuerpo no mide con precisión el estado de deshidratación del mismo. No sentimos sed hasta
mucho después de que se ha iniciado la deshidratación. Incluso cuando estamos deshidratados,
puede que deseemos fluidos a intervalos intermitentes.
El mecanismo de control de la sed no se conoce del todo. Cuando se les permite beber agua
según les dicta su sed, las personas pueden necesitar entre uno y dos días para reemplazar
completamente el agua perdida por sudoración intensa. Por el contrario, los perros y los burros
llegan a beber hasta un 10% de su peso corporal total en los primeros minutos transcurridos
desde la finalización del ejercicio o de la exposición al calor y reemplazar toda el agua perdida.
Debido a nuestra lenta forma de reemplazar el agua corporal, y a fin de impedir la deshidratación
crónica, aconsejamos beber más fluidos de los que nos indica nuestra sed. Dada la mayor
pérdida de agua durante el ejercicio, es imperativo que la ingestión de agua de los deportistas
sea suficiente para satisfacer sus necesidades corporales y es esencial que se rehidraten
durante y después de la sensación de ejercicio.
Cuando los sujetos se deshidratan durante varias horas de carrera sobre una cinta ergométrica
en ambiente caluroso ( 40 ºC) sin reposición de fluidos, su ritmo cardíaco se incrementa de
forma sostenida durante el transcurso del ejercicio. Cuando se les impide tomar fluidos, los
sujetos se agotan y no pueden completar las seis horas de carrera. La ingestión de cantidades
de agua o de una solución salina iguales a sus pérdidas de peso previene la deshidratación y
mantiene más su ritmo cardíaco. Incluso fluidos calientes ( de temperatura cercana a la del
cuerpo) proporcionan cierta protección contra el sobrecalentamiento, pero los fluidos fríos
favorecen el enfriamiento del cuerpo, porque algo del calor profundo del cuerpo se usa para
calentar bebidas frías hasta la temperatura corporal.
Los efectos adversos producidos por la pérdida de sudor se compensan en parte con la ingesta
de líquidos.
Para evitar los efectos adversos de la pérdida de líquidos, sobre todo cuando la actividad física
sea de larga duración y se lleve a cabo en ambientes calurosos, se recomienda beber 400
centímetros cúbicos una media hora antes de realizar el ejercicio. Una vez comenzada la
actividad se recomienda ingerir 150 mililitros cada quince minutos de una solución de polímeros
de glucosa al 4 o 6%, aunque el deportista no tenga sensación de sed. Cuando el ambiente es
húmedo y caluroso, la prioridad es la hidratación; deben ingerirse 300 centímetros cúbicos de
agua desde el comienzo del ejercicio y, pasada una hora u hora y media de ejercicio, polímeros
de glucosa al 3 o 7% cada 15 minutos.
La frecuencia de los problemas asociados a niveles bajos de sodio en las pruebas de larga
distancia es muy elevada. Un trabajo realizado el pasado año con practicantes de triatlón (
combinación de carrera de fondo con ciclismo y natación) arrojó un índice de incidencia del 18%.
El estudio mostró además que las mujeres acusan más este problema y desarrollan una
sintomatología más severa que los varones.
¿ Por qué descienden de golpe los niveles sanguíneos de sodio en estos corredores? Durante
un ejercicio extenuante, el flujo sanguíneo se desvía desde el tracto gastrointestinal a los
músculos. De esta forma, la mayor parte del agua ingerida queda “ secuestrada “ en el tubo
digestivo y no llega a la sangre. En el momento en que cesa el ejercicio físico ( por ejemplo, al
terminar una carrera ciclista) se produce un paso brusco de agua del aparato digestivo a la
sangre, lo que hace disminuir la natremia. Esta situación de déficit de sodio desencadena un
edema pulmonar.
El consumo de antiinflamatorios, una práctica frecuente entre deportistas, es otro de los riesgos
sobre el que se debe llamar la atención.
EL CASO DE KELLY BARRETT
Hace año y medio una corredora moría en un hospital de Chicago tres días después de competir
en la maratón de la ciudad, una de las más prestigiosas del mundo. Kelly Barrett tenía cuarenta y
tres años y participaba por segunda vez en un maratón. Kelly no consiguió llegar a la meta: se
desplomó cuando sólo faltaban cuatro kilómetros para el final. Días después, la autopista reveló
que la causa de su muerte se encontraba en la fatal convergencia de tres factores: arterias
coronarias congénitamente estrechas, arritmias y un exceso de ingestión de agua durante la
carrera. Esta última circunstancia, unida a la pérdida de sales debido a la sudoración, tuvo como
consecuencia un descenso brusco e irreversible de los niveles de sodio en sangre.
El caso tuvo una gran transcendencia en Estados Unidos y consiguió concienciar a los
corredores de maratón de que en las carreras no hay que beber sólo agua. Para mantener unos
niveles adecuados de sales minerales en sangre es necesario tomar bebidas isotónicas o
completar la ingestión de agua con frutas como la naranja ( habitual en los puestos de
avituallamiento ).
Como consejo personal, recomiendo sinceramente que en la práctica deportiva, sin ninguna
exclusión, con la aprobación del médico deportivo correspondiente, el deportista se acostumbra
a beber agua Vichy Catalán mezclada con Font d’Or y con Ginseng. Hablo por experiencia
personal, sólo es un consejo y se debe beber según las circunstancias deportivas de reposo,
competición y comida.
2.18. - PHYSIOLOGICAL BASES OF WATER BALANCE.
THIRST AND THE PRACTICE OF SPORTS
By Manuel Vitoria Ortiz
Head Professor of Physical Education and Sports Medicine,
Faculty of Medicine of the Basque Country University (UPV-EHU)
And member of the Basque Academy of Gastronomy.
In the 1972 Tour of Spain, I acted as official physician and was in charge of antidoping testing
during the tour. This circumstance gave me the opportunity to start up a good friendship with the
great Belgian champion Eddy Mercks (winner of that tour), which was soon developed into a
fantastic personal relationship. A result of that friendship he confided certain secrets to me,
ranging from his religious beliefs to anything having to do with medical aspects of sports. One of
these secrets was the following:
“Doctor, in cycling you have to suffer, and this is measured by your ability to avoid drinking water
both during training and competition.”
I had been told the same by Domingo Perurena, another great Spanish cyclist, who demonstrated
this to me by putting it into practice in the professional World Championship of 1974 in Montreal,
which I attended as a doctor for the Spanish Cycling Federation. When he was on his third lap
around the circuit, I offered him a bottle of fresh water and on seeing it he crossed over to the
other side of the road to avoid yielding to the temptation and looked towards the public so as not
to see me.
The subject of the need to drink fluids during the practice of sports requires a debate between
physicians, athletes and their coaches, in the light of our knowledge of sports physiology and
measurements. I think that the times have changed and today’s athletes know they must drink
fluids, know what the basic drinks are and are aware of need to avoid excess. They know how to
control their food and drink, both during periods of competition and rest. If we add to this the
variety of sports played nowadays and the different ages and sex of those who participate in
them, we will come to positive conclusions that reject the eating principles followed by elite
athletes not so long ago. What, when and how much should a soccer player, a marathon runner,
a fencer, a swimmer, a long-distance skier, a boxer, an archer, an athlete participating in a 100-
kilometer race, an ultra-long-distance runner who runs the 24-hour Coslada race with swollen
hands and parched lips (the Asturian José Manuel García completed 128 kilometers in this race)
or a long-distance specialist (such as Alfredo Uría, 1,000-mile world record holder, who spent a
dozen days running 120 to 130 kilometers daily on an athletics track in Baracaldo) “Winning is
pain.” Should all drink the same and the same amount? Answers are very varied, without going
into considerations about countries, eating habits, heat or cold, etc.
Water is the major constituent of the human body. In young adult subjects it can account for as
much as two-thirds of total body weight; thus, total body water in a person weighing 70 kilograms
is about 40 liters. The volume of body water depends on a series of factors, of which the most
important are body weight, age, sex, and the presence of a greater or lesser amount of fat tissue.
In the newborn, water comprises 75% of body weight, but there is a marked trend for a reduction
in this percentage with age, particularly during the first ten years of life. For individuals of equal
body weight, there is generally a lower proportion of water in women than in men. This is
probably related to the greater amount of subcutaneous fat in women. Fat tissue has the lowest
water content; thus, total body water is inversely proportional to the degree of obesity of the
subjects. In fact, in obese subjects, the percentage of water can be as low as only 45% of their
weight.
The percentage of water varies widely from one tissue to another and ranges from over 80% in
the kidneys to 10% in fat tissue.
The body maintains a remarkable balance between water intake and losses. This balance also
involves solutes. The average intake of water under normal conditions is a little more than 2 liters
daily between the water ingested in liquid form, that contained in solid foods and the small
amount produced as a result of the carbohydrate metabolism. Water intake is highly variable
depending on factors such as habits, temperature, climate, physical exercise, etc.
Water losses occur through various routes. Under normal conditions, the largest water loss is
produced through the urine secreted by the kidney (1,400 ml). Other important mechanisms are
evaporation via the skin, i.e., so-called insensible water losses (350 ml), losses from the
respiratory tract (350 ml) and losses in the feces (100 ml); these amounts, however, may be
considerably increased or decreased under certain circumstances. Urine volume increases from
as little as half a liter up to several liters depending on the amount of fluid intake. Water losses in
the feces increase by several liters in the case of diarrhea, and losses from sweating during
vigorous physical exertion or in a hot climate can increase dramatically (up to 1 or 2 l/h).
For physical activity and exercise to occur, the intervention of the body’s skeletal muscle is
indispensable. But, proper functioning of muscle cells requires that homeostasis or a constant
internal environment be maintained, even during vigorous prolonged exercise (increases in
extraction of oxygen by muscle of up to 50% and even 100% have been reported in some cases).
This maintenance of a constant balanced composition of the internal environment during physical
exercise has been called “homeokinetics” by some authors. This constitutes an enormous
challenge for the blood circulation and especially for the blood or blood tissue, since any changes
in the composition or properties of the intracellular and extracellular fluids can cause the
processes necessary for cell functioning to be diminished or even interrupted.
In the phylogenetic evolution of species, the first unicellular organisms were transformed into
multicellular organisms by surrounding themselves with a space, the extracellular space, which
cushioned fluctuations in the environment, even if only slowly. When the first living organisms
abandoned the sea, they had an intracellular composition (rich in potassium and poor in sodium)
that was identical to that of the early sea, and an extracellular composition that recalls that of the
sea today (rich in sodium and poor in potassium). During this evolution from the sea to the land,
organisms brought their water with them, such that, in the specific case of man, 70% of body
composition in males is water (this percentage is lower in the obese and in women because the
latter accumulate more fat in certain zones of the body). These differences are due to the fact that
the water content of an organism is inversely proportional to its fat tissue content. Based on this,
a constant relationship has been established between total body water weight and fat free body
weight (or lean body mass), such that, in a 70-kilogram adult, total water weight comprises 72%
of lean body mass.
The composition of the human body, though constant, is not uniformly distributed; cellular
organization requires the existence of different spaces with differing chemical, anatomical and
functional properties. These include:
_ The intracellular compartment or fluid, which accounts for 55% of total fluid, and is where vital
processes take place.
_ The extracellular compartment or fluid, which accounts for 45% of total fluid. Within it, several
subcompartments are distinguished such as the interstitial fluid, the intravascular or plasma fluid
and others in smaller amounts. The fluid in blood tissue is constantly exchanged with interstitial
and intracellular fluid through the permeable capillary walls, allowing the free passage of all
substances in the blood (except certain plasma proteins and blood cells). This is one of the most
important functions of the blood, since it contributes decisively to maintaining a constant internal
environment, both under basal conditions and during physical activity.
In summary, hemokinetic regulations are carried out in blood tissue by intervening in endocrine
regulation, osmotic pressure and water balance regulation, thermal regulation, ion balance and
pH or acid-base balance, and regulation of arterial pressure and volemia.
Based on the above, it can be seen that hematological responses and adaptations to exercise are
closely linked to respiratory, nutritional, excretory and immune functions as well as hormonal
regulation. These adaptations are of particular importance in aerobic endurance exercises.
Given that oxygen is transported primarily by hemoglobin, it is obvious that the number of red
blood cells and the concentration of hemoglobin will be determinants of the amount of oxygen
that reaches the muscle during physical activity. This fact has been clearly demonstrated by the
reduction in physical endurance seen in subjects in whom part of their blood was drawn.
WATER BALANCE DURING EXERCISE
Water loss is accelerated during exercise. The ability of our body to endure the heat generated
during exercise depends primarily on the formation and evaporation of sweat.
When the temperature of our body rises, sweating increases in an attempt to prevent
overheating. But, at the same time, more water is produced during exercise due to the increase in
oxidative metabolism. Unfortunately, the amount produced, even during the most strenuous
exertion, has only a small impact on the dehydration resulting from profuse sweating.
In an hour of strenuous exertion, for example, a 70-kilogram person can metabolize about 245
grams of carbohydrate. This will produce about 146 milliliters of water. In the same period,
however, the losses from sweating can exceed 1,500 milliliters, approximately ten times more
than the amount generated metabolically.
Nevertheless, the water produced during oxidative metabolism helps to reduce, even if only to a
minimal degree, the dehydration that occurs during exercise.
In general, the amount of sweat produced during exercise is determined by ambient temperature,
body size and metabolic rate.
These three factors influence the accumulation of heat and the temperature of the body. Heat is
transmitted from hotter to cooler areas, which is why loss of body heat is more difficult when the
ambient temperature is high. Body size is important because large individuals generally require
more energy to perform a specific task, and so generally have higher metabolic rates and
produce more heat. But they also have a larger surface area (skin) which allows greater formation
and evaporation of sweat.
When the intensity of exercise increases, so does the metabolic rate. This increases the
production of heat by the body and, hence, sweating. To preserve water during exercise, blood
flow is reduced to the kidneys in an attempt to avoid dehydration, but, as in the case of increased
metabolic production of water, this may also be insufficient. Under extreme conditions of exercise
and stress due to ambient heat, sweating and evaporation can cause rapid losses of up to 2 or 3
liters of water per hour.
Our body losses more water than electrolytes when we sweat profusely. This raises the osmotic
pressure of our body fluids, our electrolytes become more concentrated. For this reason,
electrolytes are needed; because only by replacing water can they return to their normal
concentrations. But, how does our body know when this is needed?
THIRST
When we are thirsty, we drink. The hypothalamus regulates the sensation of thirst. The
hypothalamus activates the thirst mechanism when the osmotic pressure of plasma increases.
Unfortunately, the body’s thirst mechanism does not measure precisely the state of dehydration
of the body. We do not feel thirst until long after dehydration has started. Even when we are
dehydrated, we may only desire fluids at intermittent intervals.
The mechanism controlling thirst is not fully understood. When allowed to drink water according
to their thirst, humans may need from one to two days to completely replace the water lost from
profuse sweating. In contrast, dogs and donkeys can drink as much as 10% of their total body
weight within the first few minutes after exercise or exposure to heat, and replace all the water
lost. Because our body replaces water slowly, we recommend drinking more fluids than the
amount indicated by our thirst to prevent chronic dehydration. Because of the greater loss of
water during exercise, it is imperative that athletes drink enough water to cover their bodily
requirements and it is essential that they rehydrate themselves both during and after exercise.
Drinking fluids during the performance of prolonged exercise, especially in hot weather, has
obvious benefits. Ingestion of water will minimize dehydration, increases in body temperature and
cardiovascular stress.
When subjects become dehydrated after several hours running on a treadmill ergometer in a hot
environment (40 ºC) without fluid replacement, their heart rate shows a sustained increase over
the course of exercising. When they are prevented from drinking fluids, the subjects become
exhausted and cannot complete the six hours of running. Ingestion of amounts of water or a
saline solution equal to weight losses prevents dehydration and preserves their heart rate better.
Even hot fluids (close to body temperature) provide a certain degree of protection against
overheating, but cold fluids favor cooling of the body, because part of the deep body heat is used
to warm the cold drinks to body temperature.
As we have just seen, an increase in body temperature occurs during physical activity, which is
related to the intensity of the exercise. The amount of heat produced by a muscle during activity
can be one hundred times greater than at rest. In these conditions, the primary mechanism to
eliminate heat is to produce sweat for its subsequent evaporation.
Sweat contains water and the same electrolytes as plasma and tissue fluids, although in different
proportions. In trained individuals, the mechanism of sweating is triggered earlier and their sweat
is poorer in electrolytes. In addition, these subject have a better redistribution of fluid losses in the
different compartments (plasma, intracellular, and interstitial), as well as a higher capacity to store
heat in the body. These adaptations help athletes to reduce hyperthermia, but increase the risk of
dehydration. Losses from sweat equivalent to 4 or 5% of body weight are associated with a
decrease in work capacity of approximately 30%.
The adverse effects caused by losses from sweating are partially compensated by the intake of
fluids.
To avoid adverse effects from fluid loss, especially when physical activity is prolonged or carried
out in hot environments, it is recommended to drink 400 cubic centimeters half an hour before
performing exercise. Once exercise has begun, it is recommended to ingest 150 milliliters every
fifteen minutes of a 4% or 6% glucose polymer solution, even if the athlete has no sensation of
thirst. In a hot and humid environment, hydration is the priority; 300 cubic centimeters of water
should be ingested from the start of exercise and, after an hour or an hour and a half of exercise,
a 3% or 7% glucose polymer solution every 15 minutes.
Hydration of an athlete should not be restricted to ingestion of water. Replacing mineral salts lost
via sweating is extremely important when hyponatremia (lack of sodium in the blood) is
experienced by marathon runners, as they can suffer pulmonary edema resulting not from a
cardiac cause but associated with hyponatremic encephalopathy.
The frequency of problems associated with low sodium levels in long-distance races is very high.
A study carried out last year on participants in a triathlon (a combination of a long-distance race
with cycling and swimming) yielded an incidence rate of 18%. The study also showed that women
are more affected by this problem and develop more severe symptoms than men.
Why do sodium blood levels drop suddenly in these runners? During exhausting exercise, blood
flow is diverted from the gastrointestinal tract to muscles. As a result, most of the water ingested
remains “sequestered” in the digestive tube and does not reach the blood. When physical
exercise ceases (e.g., at the end of cycling race), water passes abruptly from the digestive tract
to the blood, thereby reducing natremia. This situation of sodium deficiency triggers pulmonary
edema.
The use of anti-inflammatory drugs, a common practice among athletes, is another of the risks
which deserves further attention.
A year and a half ago, a women runner died in a Chicago hospital three days after competing in
the city’s marathon, one of the most prestigious in the world. Kelly Barrett was forty-three years
old and this was the second time she participated in a marathon. Kelly didn’t reach the finish line:
she collapsed when she was only four kilometers from the end. Days later, the autopsy revealed
that the cause of her death was a fatal convergence of three factors: congenitally narrow
coronary arteries, arrhythmias and an excessive intake of water during the race. This latter
circumstance, combined with the loss of salts due to sweating, resulted in an abrupt and
irreversible fall in blood sodium levels.
The case had great impact in the United States and was successful in making marathon runners
aware that they should not drink only water during the races. To maintain adequate levels of
mineral salts in the blood, runner need to drink isotonic beverages or complete ingestion of water
with fruits such as oranges (usually found at drinks stations).
My personal advice is to sincerely recommend that during the practice of sports, with no
exclusions, and subject to the approval of their sports physician, athletes acquire the habit of
drinking Vichy Catalán mineral water mixed with Font d’Or water and ginseng. I speak from
personal experience, this is only a recommendation and one should drink according to the
circumstances of the sports event in terms of rest, competition and food intake.