Mike Greenwood, PhD, CSCS*D
Lori Greenwood, PhD, ATC, LAT
Brian Leutholtz, PhD, FACSM
Exercise & Sport Nutrition Lab Center for Exercise, Nutrition & Preventive Health Research Baylor University
Reprinted with permission. This is available at http://www3.baylor.edu/HHPR/ESNL.
As active researchers in the area of exercise physiology, sport nutrition, strength and conditioning, and sports medicine, we would like to make the following comment and observations regarding the current controversy about the supposed link of ephedra supplementation to the tragic death of Baltimore Orioles pitcher Steve Bechler due to multiple organ failure, as a result of heat stroke, on Feb.17, 2003.
The Facts Regarding The Incident
Heat stroke fatalities are preventable if proper screening, conditioning, acclimatization, and precautions are employed to ensure that athletes train safely in hot and humid environments.
- The local coroner and members of Orioles management have suggested that Mr. Bechler's death was related and/or caused by the possible consumption of a dietary supplement containing the herb ephedra.
- These reports have caused a flurry of reports in the media questioning the safety of ephedra supplementation and calls to ban the use of ephedra in Major League Baseball and/or sale of ephedra in over the counter dietary supplements.
- At this point, toxicology reports have yet to confirm that Mr. Bechler had taken an ephedra supplement prior to practice.
- Clinical studies published in peer-reviewed journals have indicated that ephedrine and herbal ephedra supplementation can significantly promote weight loss with no major side effects in overweight but otherwise healthy individuals. There is also evidence that taking ephedra and caffeine during training may help promote greater fat loss. Most studies show that ephedra or ephedrine has no ergogenic benefit in and of itself. Claims that ephedra is a "performance enhancing substance" is not supported by the scientific literature. However, there is data showing that caffeine has ergogenic value and that there may be some ergogenic value of ingesting supplements that have ephedra and caffeine.
- Many over-the-counter medications (e.g., cold medications) contain ephedrine alkaloids (e.g., pseudoephedrine, etc.) at higher concentrations than found in nutritional supplements containing ephedra.
- Closer examination of contributing factors related to Mr. Bechler's death reveals that even if Mr. Bechler did consume the supplement, it was probably the least of the contributing factors leading to his death... and it may not have been a factor at all.
Bechler's Risk Factors For Heat Stroke
According to reports in the media, Mr. Bechler had the following risk factors for heat stroke:
- a prior history of heat illness episodes while in high school - which heightens the probability of reoccurring incidents;
- a family history of sudden death following exercise (his half-brother died of an aneurysm at the age of 20 after overheating from playing baseball);
- a history of hypertension and liver problems;
- he had not eaten solid food for a day or two, in an apparent attempt to lose weight;
- he was apparently not adequately acclimatized to training in the heat and humidity of South Florida;
- it appeared that he was wearing two or three layers of clothing during workouts, again, in an attempt to lose weight;
- he was overweight and did not have a high enough fitness level to make it through conditioning drills; and,
- he was allowed to exercise until he collapsed with a core temperature reportedly of 106Â° F before being removed from the field.
It has been extensively documented that untrained, overweight, and unacclimatized people who perform excessive exercise in heat/humidity are at great risk of heat illness and heat stroke... particularly if they have become dehydrated and are trying to lose weight quickly.
What Could Have Prevented This?
These pre-existing conditions raise serious questions as to the appropriate medical screening, conditioning, and supervision of Mr. Bechler participating in spring conditioning drills as follows:
Were team athletic trainers and conditioning specialists aware of Mr. Bechler's prior history of heat illness or stroke? If they were aware, why weren't additional exercise precautions taken to ensure that he was adequately trained, acclimatized, hydrated, and fed prior to his participation in intense conditioning drills?
- Media reports indicate that Mr. Bechler had a prior history of reporting to camp overweight and out of shape. If this is the case, was Mr. Bechler given appropriate training and dietary counseling and/or placed on a pre-camp conditioning and nutrition program to make sure he reported in good condition?
Excess body fat is a major liability when exercising in hot/humid climates because it increases the insulation properties of the body which in turn reduces the amount of body heat that can be released through perspiration. Fatal heat strokes occur 3.5 more times in obese populations than any other population.
- Why didn't pre-participation medical screening identify the risk factors to heat stroke described above? Complete pre-participation exercise stress tests and/or fitness/sprint tests would have indicated that Mr. Bechler was not in sufficient physical condition to perform intense training. Further, that he was not adequately acclimatized to exercise in the heat. According to media reports, Orioles coaches knew that his conditioning was "not good".
If this is the case, then how was he allowed to participate in intense conditioning training? Medical screening should have also revealed a history of hypertension and liver problems. These are all contraindications to performing excessive exercise particularly in hot/humid environments.
- Where was the supervision to notice signs of heat illness in Mr. Bechler? Media reports indicate that he was dizzy, he was only able to perform 60% of the conditioning drills, and that he collapsed on the field. These are all signs and symptoms of heat intolerance and/or heat illness. It is the responsibility of athletic trainers and strength and conditioning specialists to make sure that athletes safely engage in physical activity. If athletes are showing signs of abnormal responses to exercise, it is the responsibility of coaches, team physicians, athletic trainers and/or strength and conditioning specialists to pull the athlete out of conditioning drills... not the athletes.
- Did the athletic trainers, team physicians, and/or strength and conditioning specialists know that Mr. Bechler evidently was not eating solid food? Training camp is not an appropriate time for athletes to diet. Allowing athletes to train when they are dehydrated and/or not well fed is dangerous. Athletes who report to camp overweight should be given proper nutritional counseling about safe and effective ways to lose weight.
- Team physicians , athletic trainers, and strength and conditioning coaches should know what supplements athletes are taking so they can counsel them about whether or not they are safe, legal, effective, and/or appropriate to take at a given time during training. In this case, a supplement bottle was purportedly found in Mr. Belcher's locker yet team officials were supposedly unaware of him taking supplements. This is troubling given that he had pre-existing medical conditions that were contraindicated for use of the purported supplement.
The Link To Ephedra Doesn't Make Sense!
The supposed link that ephedra supplementation caused or contributed to heat stroke does not make sense from a physiological standpoint for the following reasons:
Some of Mr. Bechler's teammates claimed that he usually took three supplement capsules (1.5 servings) in the morning. According to that product's label, that would have provided 30 mg of herbal ephedra. This is one third of the dose shown in long-term clinical trials to be safe.
- There is no scientific or medical evidence to indicate that ephedra/caffeine supplementation significantly increases thermal stress (increases core temperature 2-3 degrees above normal) during exercise, that it promotes dehydration, or increases the incidence of heat illness.
- The thermogenic effects of ephedra and caffeine are relatively small, typically increasing resting caloric expenditure by 5-10 kcals per hour. One oral dose of ephedra/caffeine usually lasts less than 3 hours. Therefore, the total caloric (i.e., heat) load would be 15 ... 30 calories in a 2-3 hour period following ingestion of one serving of an ephedra containing supplement. While this may be sufficient to promote a gradual weight loss (if one took 2-3 servings per day for 2-6 months), it would have minimal, if any, affects of core body temperature.
- In contrast, athletes commonly expend 600-1,200 kcals per hour during intense exercise or 1,800 ... 3,600 calories during an intense 3 hour practice. The thermal load of exercise generally increases core body temperature by 2-3 degrees when properly regulated.
- The primary way heat from exercise is dissipated is through evaporation of sweat. Exercise in humid environments decreases the ability of sweat to evaporate making it more difficult to regulate body temperature. When the humidity is very high (i.e., > 70%), sweat may not fully evaporate which increases susceptibility to heat disorders. Humidity is higher in morning and evening hours. This is the primary rationale why intense exercise should be avoided during humid conditions and/or additional precautions should be employed to supervise athletes training or performing in hot/humid environments.
- The media scare linking Mr. Bechler's heatstroke death with ephedra places emphasis on the unknown (pending toxicology results), and ignores known and obvious contributing factors already detailed here.
Unfortunately, these media reports may mislead some to conclude that simply prohibiting athletes from taking ephedra supplements will eliminate the risk of heat fatalities.
Instead, we should be stressing the importance of properly educating athletes, coaches and athletic trainers about the risks of training in hot and humid environments when participants are poorly conditioned, have not acclimatized to the heat and humidity, have engaged in dehydration practices, have medical histories that should have raised warning flags, and have not been sufficiently supervised.
The tragedy is that if Mr. Bechler had been properly screened and conditioned; if he had acclimatized properly to high heat and humidity conditions; if he had been adequately supervised; and if he had been properly educated about diet, weight loss, and the use of dietary supplements, he may be alive today.
In our view, this is another example of poor supervision and screening of athletes and not an issue of inappropriate use of a dietary supplement.
Tips to Prevent Heat Illness and Stroke in Athletes
Conduct a comprehensive medical examination to examine past history and risk factors to heat illness.
Make sure the athlete is adequately trained to participate in high intensity exercise prior to the start of conditioning.
Acclimatize the athlete to training in hot/humid environments by beginning with brief and low intensity exercise sessions and progressing up to longer and more intense training sessions during the first few days of training.
Make sure the athlete is eating a healthy and nutritious diet and is well-hydrated prior to the start of each practice.
Monitor ambient environmental conditions (temperature, humidity, heat index, etc) and adjust workout intensity, duration, and frequency as necessary to reduce risk to athletes.
Monitor pre- and post practice weight changes. Ingest 3 cups of water or sports drink for every pound lost during practice.
Do not allow athletes who lost more than 3% of their body weight to practice again until their weight is up to acceptable ranges.
Do not allow athletes to wear excessive clothing which can impede sweat evaporation and therefore reduce cooling.
Provide frequent and planned water/sports drink breaks during practice. Ensure that the athlete drinks 1-2 cups of water or sports drink every 15-20 minutes during exercise in the heat/humidity.
Watch for signs of heat illness including cramping, dry mouth, fatigue, dizziness, loss of concentration, palor, vomiting, cessation of sweating, dry and hot skin, and inability to maintain exercise workloads.
Do not excessively train athletes in hot/humid environments. The higher the intensity of training, the greater amount of heat produced. This means that if it is very hot/humid, practices should be rescheduled and/or involve less intense training. Athletes should be pulled from conditioning drills if they are unable to perform them and not allowed to train until they collapse.
Provide appropriate medical supervision at a supervisor to athlete ratio that will allow signs and symptoms of heat illness to be immediately recognized.
Provide prompt medical care when signs are observed of abnormal responses to exercise in the heat.
Have emergency procedures well defined so that prompt medical attention can be provided in the event heat illness is observed.
Get the FACTS about the safety of ephedra at EphedraFacts.com.
Prof. Richard Kreider, a specialist in exercise physiology and sport nutrition, is chairman of the Department of Health, Human Performance and Recreation at Baylor University. He founded the Exercise & Sport Nutrition Lab and the Center for Exercise, Nutrition, and Preventive Health Research.
Prof. Mike Greenwood, a specialist in strength and conditioning and former NCAA Division I Baseball Coach, is Professor of Musculoskeletal Physiology and Nutrition in the Department of Health, Human Performance and Recreation at Baylor University.
Prof. Lori Greenwood, a certified athletic trainer and sports medicine specialist, is Associate Professor and Director of the Graduate Athletic Training and Sports Medicine Program in the Department of Health, Human Performance and Recreation at Baylor University.
Prof. Brian Leutholtz, a specialist in clinical exercise physiology, exercise assessment and programming, sport nutrition, and weight loss, is a Visiting Professor in the Department of Health, Human Performance and Recreation at Baylor University.
* The comments provided above represent the scientific opinions of the authors and do not necessarily reflect those of Baylor University and/or professional organizations that the authors may belong. Publication of this position statement on Bodybuilding.com does not mean that their lab, the coauthors, or the professional organizations they represent endorse the content, articles, or products sold on Bodybuilding.com.