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Studies on Hyponatremia, Exercise and Hydration, Singapore Performance Edition

Updated: Apr 17

hyponatremia sweat rate tropical Singapore

This article focuses on studies and resources related to hyponatremia, specifically exercise associated hyponatremia (EAH). For general information on hyponatremia, please see the following article Singapore Hyponatremia Guidelines, Sports Safety in Singapore.

Click on the links in the studies below to be taken to the relevant papers. If you have other studies to share, let us have them in the Comments at bottom of page. Include the citation and/or PMID if possible.

Please note, these resources are shared for information purposes only. Always seek appropriate assistance for heat related medical situations; they can be life threatening. If you are considering changing your diet, exercise or lifestyle practices, please discuss plans with your primary medical practitioner before making any changes; especially if you are under treatment.

Hydrate, Sweat, Repeat


If you exercise in the heat, you might find these articles useful...


Studies on Hyponatremia

Barajas Galindo DE, Ruiz-Sánchez JG, Fernández Martínez A, de la Vega IR, Ferrer García JC, Ropero-Luis G, Ortolá Buigues A, Serrano Gotarredona J, Gómez Hoyos E. Consensus document on the management of hyponatraemia of the Acqua Group of the Spanish Society of Endocrinology and Nutrition. Endocrinol Diabetes Nutr (Engl Ed). 2023 Mar;70 Suppl 1:7-26. doi: 10.1016/j.endien.2022.11.006. Epub 2022 Nov 18. PMID: 36404266.

Miller NE, Rushlow D, Stacey SK. Diagnosis and Management of Sodium Disorders: Hyponatremia and Hypernatremia. Am Fam Physician. 2023 Nov;108(5):476-486. PMID: 37983699.

Johnson KB, Connolly CP, Cho SP, Miller TK, Sallis RE, Hiller WDB. Clinical presentation of exercise-associated hyponatremia in male and female IRONMAN® triathletes over three decades. Scand J Med Sci Sports. 2023 Sep;33(9):1841-1849. doi: 10.1111/sms.14401. Epub 2023 May 19. PMID: 37204065.

Sterns RH, Rondon-Berrios H, Adrogué HJ, Berl T, Burst V, Cohen DM, Christ-Crain M, Cuesta M, Decaux G, Emmett M, Garrahy A, Gankam-Kengne F, Hix JK, Hoorn EJ, Kamel KS, Madias NE, Peri A, Refardt J, Rosner MH, Sherlock M, Silver SM, Soupart A, Thompson CJ, Verbalis JG; PRONATREOUS Investigators. Treatment Guidelines for Hyponatremia: Stay the Course. Clin J Am Soc Nephrol. 2023 Jun 28;19(1):129–35. doi: 10.2215/CJN.0000000000000244. Epub ahead of print. PMID: 37379081; PMCID: PMC10843202.

Seal AD, Kavouras SA. A review of risk factors and prevention strategies for exercise associated hyponatremia. Auton Neurosci. 2022 Mar;238:102930. doi: 10.1016/j.autneu.2021.102930. Epub 2021 Dec 21. PMID: 35016044.

Rondon-Berrios H, Sterns RH. Hypertonic Saline for Hyponatremia: Meeting Goals and Avoiding Harm. Am J Kidney Dis. 2022 Jun;79(6):890-896. doi: 10.1053/j.ajkd.2021.07.020. Epub 2021 Sep 8. PMID: 34508830; PMCID: PMC10332848.


Klingert M, Nikolaidis PT, Weiss K, Thuany M, Chlíbková D, Knechtle B. Exercise-Associated Hyponatremia in Marathon Runners. J Clin Med. 2022 Nov 16;11(22):6775. doi: 10.3390/jcm11226775. PMID: 36431252; PMCID: PMC9699060.


Adrogué HJ, Tucker BM, Madias NE. Diagnosis and Management of Hyponatremia: A Review. JAMA. 2022 Jul 19;328(3):280-291. doi: 10.1001/jama.2022.11176. PMID: 35852524.

Bhasin-Chhabra B, Veitla V, Weinberg S, Koratala A. Demystifying hyponatremia: A clinical guide to evaluation and management. Nutr Clin Pract. 2022 Oct;37(5):1023-1032. doi: 10.1002/ncp.10907. Epub 2022 Aug 29. PMID: 36036229.

Daniele DO, Wilkerson T. Update: Exertional hyponatremia, active component, U.S. Armed Forces, 2006-2021. MSMR. 2022 Apr 1;29(4):21-26. PMID: 35608522.


Martin-Grace J, Tomkins M, O'Reilly MW, Thompson CJ, Sherlock M. Approach to the Patient: Hyponatremia and the Syndrome of Inappropriate Antidiuresis (SIAD). J Clin Endocrinol Metab. 2022 Jul 14;107(8):2362-2376. doi: 10.1210/clinem/dgac245. PMID: 35511757; PMCID: PMC9282351.

Lecina M, Castellar-Otín C, López-Laval I, Carrasco Páez L, Pradas F. Acute Kidney Injury and Hyponatremia in Ultra-Trail Racing: A Systematic Review. Medicina (Kaunas). 2022 Apr 21;58(5):569. doi: 10.3390/medicina58050569. PMID: 35629986; PMCID: PMC9146822.

Kheetan M, Ogu I, Shapiro JI, Khitan ZJ. Acute and Chronic Hyponatremia. Front Med (Lausanne). 2021 Aug 3;8:693738. doi: 10.3389/fmed.2021.693738. PMID: 34414205; PMCID: PMC8369240.

Rangan GK, Dorani N, Zhang MM, Abu-Zarour L, Lau HC, Munt A, Chandra AN, Saravanabavan S, Rangan A, Zhang JQJ, Howell M, Wong AT. Clinical characteristics and outcomes of hyponatraemia associated with oral water intake in adults: a systematic review. BMJ Open. 2021 Dec 9;11(12):e046539. doi: 10.1136/bmjopen-2020-046539. PMID: 34887267; PMCID: PMC8663108.

Lipman GS, Burns P, Phillips C, Jensen J, Little C, Jurkiewicz C, Jarrett B, Walker A, Mansfield N, Krabak BJ. Effect of Sodium Supplements and Climate on Dysnatremia During Ultramarathon Running. Clin J Sport Med. 2021 Nov 1;31(6):e327-e334. doi: 10.1097/JSM.0000000000000832. PMID: 32097177.


Rosner MH. EXERCISE-ASSOCIATED HYPONATREMIA. Trans Am Clin Climatol Assoc. 2019;130:76-87. PMID: 31516170; PMCID: PMC6735969.

Nolte HW, Nolte K, Hew-Butler T. Ad libitum water consumption prevents exercise-associated hyponatremia and protects against dehydration in soldiers performing a 40-km route-march. Mil Med Res. 2019 Jan 25;6(1):1. doi: 10.1186/s40779-019-0192-y. PMID: 30678725; PMCID: PMC6346586.

Bennett BL, Hew-Butler T, Rosner MH, Myers T, Lipman GS. Wilderness Medical Society Clinical Practice Guidelines for the Management of Exercise-Associated Hyponatremia: 2019 Update. Wilderness Environ Med. 2020 Mar;31(1):50-62. doi: 10.1016/j.wem.2019.11.003. Epub 2020 Feb 8. PMID: 32044213.

Hoffman MD. Predicted Risk for Exacerbation of Exercise-Associated Hyponatremia from Indiscriminate Postrace Intravenous Hydration of Ultramarathon Runners. J Emerg Med. 2019 Feb;56(2):177-184. doi: 10.1016/j.jemermed.2018.10.026. Epub 2018 Dec 10. PMID: 30545731.


Knechtle B, Chlíbková D, Papadopoulou S, Mantzorou M, Rosemann T, Nikolaidis PT. Exercise-Associated Hyponatremia in Endurance and Ultra-Endurance Performance-Aspects of Sex, Race Location, Ambient Temperature, Sports Discipline, and Length of Performance: A Narrative Review. Medicina (Kaunas). 2019 Aug 26;55(9):537. doi: 10.3390/medicina55090537. PMID: 31455034; PMCID: PMC6780610.

Hew-Butler T. Exercise-Associated Hyponatremia. Front Horm Res. 2019;52:178-189. doi: 10.1159/000493247. Epub 2019 Jan 15. PMID: 32097926.

Robert C Oh, Bryan Malave, Justin D Chaltry, Collapse in the Heat – From Overhydration to the Emergency Room – Three Cases of Exercise-Associated Hyponatremia Associated with Exertional Heat Illness, Military Medicine, Volume 183, Issue 3-4, March-April 2018, Pages e225–e228,

Hew-Butler T, Loi V, Pani A, Rosner MH. Exercise-Associated Hyponatremia: 2017 Update. Front Med (Lausanne). 2017 Mar 3;4:21. doi: 10.3389/fmed.2017.00021. PMID: 28316971; PMCID: PMC5334560.

Tan DW, Yap SH, Wang M, Fan PW, Teo YS, Krishnasamy P, Krishna L, Hew-Butler T, Lee JK. Body Mass Changes Across a Variety of Running Race Distances in the Tropics. Sports Med Open. 2016 Jul 19;2(1):26. doi: 10.1186/s40798-016-0050-3. PMID: 27478761; PMCID: PMC4951505.

Tan DW, Yap SH, Wang M, Fan PW, Teo YS, Krishnasamy P, Krishna L, Hew-Butler T, Lee JK. Body Mass Changes Across a Variety of Running Race Distances in the Tropics. Sports Med Open. 2016 Jul 19;2(1):26. doi: 10.1186/s40798-016-0050-3. PMID: 27478761; PMCID: PMC4951505.

Weismann D, Schneider A, Höybye C. Clinical aspects of symptomatic hyponatremia. Endocr Connect. 2016 Sep;5(5):R35-R43. doi: 10.1530/EC-16-0046. Epub 2016 Sep 8. PMID: 27609587; PMCID: PMC5314806.


Hew-Butler T, Rosner MH, Fowkes-Godek S, Dugas JP, Hoffman MD, Lewis DP, Maughan RJ, Miller KC, Montain SJ, Rehrer NJ, Roberts WO, Rogers IR, Siegel AJ, Stuempfle KJ, Winger JM, Verbalis JG. Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Br J Sports Med. 2015 Nov;49(22):1432-46. doi: 10.1136/bjsports-2015-095004. Epub 2015 Jul 30. PMID: 26227507.

Rondon-Berrios H, Berl T. Mild Chronic Hyponatremia in the Ambulatory Setting: Significance and Management. Clin J Am Soc Nephrol. 2015 Dec 7;10(12):2268-78. doi: 10.2215/CJN.00170115. Epub 2015 Jun 24. PMID: 26109207; PMCID: PMC4670756.

Nolte HW, Hew-Butler T, Noakes TD, Duvenage CS. Exercise-associated hyponatremic encephalopathy and exertional heatstroke in a soldier: High rates of fluid intake during exercise caused rather than prevented a fatal outcome. Phys Sportsmed. 2015 Feb;43(1):93-8. doi: 10.1080/00913847.2015.1001714. Epub 2015 Jan 14. PMID: 25586818.

Lee JK, Nio AQ, Ang WH, Johnson C, Aziz AR, Lim CL, Hew-Butler T. First reported cases of exercise-associated hyponatremia in Asia. Int J Sports Med. 2011 Apr;32(4):297-302. doi: 10.1055/s-0030-1269929. Epub 2011 Jan 26. PMID: 21271498.

Mohseni M, Silvers S, McNeil R, Diehl N, Vadeboncoeur T, Taylor W, Shapiro S, Roth J, Mahoney S. Prevalence of hyponatremia, renal dysfunction, and other electrolyte abnormalities among runners before and after completing a marathon or half marathon. Sports Health. 2011 Mar;3(2):145-51. doi: 10.1177/1941738111400561. PMID: 23016001; PMCID: PMC3445140.


Related Studies

Pałka, T.; Rydzik, Ł.; Koteja, P.M.; Piotrowska, A.; Bagińska, M.; Ambroży, T.; Angelova-Igova, B.; Javdaneh, N.; Wiecha, S.; Filip-Stachnik, A.; et al. Effect of Various Hydration Strategies on Work Intensity and Selected Physiological Indices in Young Male Athletes during Prolonged Physical Exercise at High Ambient Temperatures. J. Clin. Med. 2024, 13, 982.

Wijering LAJ, Cotter JD, Rehrer NJ. A randomized, cross-over trial assessing effects of beverage sodium concentration on plasma sodium concentration and plasma volume during prolonged exercise in the heat. Eur J Appl Physiol. 2023 Jan;123(1):81-89. doi: 10.1007/s00421-022-05025-y. Epub 2022 Sep 29. PMID: 36173481; PMCID: PMC9813217.

Jardine WT, Aisbett B, Kelly MK, Burke LM, Ross ML, Condo D, Périard JD, Carr AJ. The Effect of Pre-Exercise Hyperhydration on Exercise Performance, Physiological Outcomes and Gastrointestinal Symptoms: A Systematic Review. Sports Med. 2023 Nov;53(11):2111-2134. doi: 10.1007/s40279-023-01885-2. Epub 2023 Jul 25. PMID: 37490269; PMCID: PMC10587316.

Ly NQ, Hamstra-Wright KL, Horswill CA. Post-Exercise Rehydration in Athletes: Effects of Sodium and Carbohydrate in Commercial Hydration Beverages. Nutrients. 2023 Nov 12;15(22):4759. doi: 10.3390/nu15224759. PMID: 38004153; PMCID: PMC10674530.

Veniamakis E, Kaplanis G, Voulgaris P, Nikolaidis PT. Effects of Sodium Intake on Health and Performance in Endurance and Ultra-Endurance Sports. Int J Environ Res Public Health. 2022 Mar 19;19(6):3651. doi: 10.3390/ijerph19063651. PMID: 35329337; PMCID: PMC8955583.

Surapongchai J, Saengsirisuwan V, Rollo I, Randell RK, Nithitsuttibuta K, Sainiyom P, Leow CHW, Lee JKW. Hydration Status, Fluid Intake, Sweat Rate, and Sweat Sodium Concentration in Recreational Tropical Native Runners. Nutrients. 2021 Apr 20;13(4):1374. doi: 10.3390/nu13041374. PMID: 33923890; PMCID: PMC8072971.

Fan PW, Burns SF, Lee JKW. Efficacy of Ingesting an Oral Rehydration Solution after Exercise on Fluid Balance and Endurance Performance. Nutrients. 2020 Dec 15;12(12):3826. doi: 10.3390/nu12123826. Erratum in: Nutrients. 2021 Oct 28;13(11): PMID: 33333771; PMCID: PMC7765193.

Nolte HW, Nolte K, Hew-Butler T. Ad libitum water consumption prevents exercise-associated hyponatremia and protects against dehydration in soldiers performing a 40-km route-march. Mil Med Res. 2019 Jan 25;6(1):1. doi: 10.1186/s40779-019-0192-y. PMID: 30678725; PMCID: PMC6346586.

Kenefick RW. Drinking Strategies: Planned Drinking Versus Drinking to Thirst. Sports Med. 2018 Mar;48(Suppl 1):31-37. doi: 10.1007/s40279-017-0844-6. PMID: 29368181; PMCID: PMC5790864.

Tyler CJ, Reeve T, Hodges GJ, Cheung SS. The Effects of Heat Adaptation on Physiology, Perception and Exercise Performance in the Heat: A Meta-Analysis. Sports Med. 2016 Nov;46(11):1699-1724. doi: 10.1007/s40279-016-0538-5. Erratum in: Sports Med. 2016 Nov;46(11):1771. PMID: 27106556.

Nolte HW, Nolte K, van der Meulen J. Total Body Water, Electrolyte, and Thermoregulatory Responses to Ad Libitum Water Replacement Using Two Different Water Delivery Systems During a 19-km Route March. J Strength Cond Res. 2015 Nov;29 Suppl 11:S88-93. doi: 10.1519/JSC.0000000000001028. PMID: 26506205.

Johannsen NM, Lind E, King DS, Sharp RL. Effect of preexercise electrolyte ingestion on fluid balance in men and women. Med Sci Sports Exerc. 2009 Nov;41(11):2017-25. doi: 10.1249/MSS.0b013e3181a82940. PMID: 19812516.



Weather and Heat Stress. Singapore provides live heat stress information, stay up-to-date here.

Learn about Singapore's Heat Resilience and Performance Centre (HRPC) at the Yong Loo Lin School of Medicine, NUS Medicine.

From the USA, The Warrior Heat- and Exertion-Related Events Collaborative (WHEC) Heat Illness Resources  WHEC is a multidisciplinary advisory group focused on developing and implementing procedures to help providers, service members and civilians prevent and treat heat-related illnesses and injuries. WHEC works in collaboration with the Army Heat Center (Fort Moore, GA) and the Uniformed Services University's Multidisciplinary Case Review Committee.

Hyponatremia Singapore

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