Essential Sports Nutrition


SIPE and Triathlon Swimming - what you need to know

A year ago, we experienced something incredibly scary as we had a coached athlete suffer from SIPE (Swimming induced pulmonary edema) during the swim portion of IM 70.3 St. George. Thankfully, he survived. Other triathletes, sadly, have not been so lucky. He is an experienced and fit triathlete so this was a big shock for us all. The water temp was in the low 60's and he was wearing a wetsuit. He didn't have a warm-up in the water. After entering the water, he started out with his effort and quickly felt tightness in his chest. He mentioned he felt a similar tightness (but not as severe) on the day before the race during a pre-race practice swim. He started to cough severely and noticed pink phlegm coming from his cough - he was able to get to a kayak to rest. He tried to swim to the next kayak but was getting weaker. He finally exited the water and went to medical. The med tent didn't take his BP after the event but he later followed up with his doctor. All was ok with his heart but we learned a few things from this.

"While the exact pathophysiology of SIPE remains uncertain, it is believed to be related to exertion, immersion in cold water, and overhydration. The body's normal response to exercise is to increase cardiac output to meet the increased oxygen demand. Although an increased cardiac output is known to cause pulmonary edema in racehorses, this increase is rarely enough to produce such an effect in humans. Cold-water immersion is instrumental in this process because the peripheral vasculature constricts to divert blood away from the extremities in an effort to maintain the core body temperature. This results in a central pooling of blood, leading to an increased preload, increased pulmonary artery pressure, and an increased cardiac output. The vasoconstriction also causes an increase in afterload, which leads to an increase in pulmonary vasculature resistance. The increased cardiac output from exertional activities coupled with an increased preload and afterload from immersion appear to be sufficient to rupture the pulmonary capillary membranes, thus resulting in pulmonary edema. In several documented cases of SIPE, it has been noted that the patients consumed anywhere from two to four liters of water in the hours leading up to their swim in an effort to remain well hydrated. It is believed that this degree of hydration led to a fluid overload that contributed to the onset of pulmonary edema by increasing the pulmonary capillary pressure. Patients may present with symptoms, such as cough, dyspnea, hemoptysis, tachypnea, and confusion with hypoxia, after exertional cold water activity such as swimming and scuba diving."

First off, triathletes need to take the swim portion seriously. This includes race day tactics and swim training preparation. Far too many triathletes don't train appropriately (or enough) to be prepared for the open water. For most developing triathlon swimmers, you need to learn how to swim at different intensities in the (with proper open water techniques), have more practice in the open water, know your abilities when you start the swim portion of the race and understand the demands of your swim course (ex. waves, currents, etc.).

We need every triathlon to offer a practice swim on the morning of the race. Not only does this provide a sport-specific warm-up but it gives athlete time to acclimate to the water and to adjust swim gear to the right fit/comfort. But to be honest, even when a practice swim is allowed, most triathletes don't take advantage of this practice swim because they don't want to be wet or they want to save their energy for the actual race. At IM 70.3 FL, there is a pool at the race venue. This year, I would guess there were no more than 50 total triathletes in that pool in the 90 minutes that the pool was open before the start of the race. You want to prepare your heart for the effort of the swim before you actually start swimming. 

I am strongly against the use of "boosters" before a race - caffeine, energy drinks, etc. There is so much anxiety and stress from swimming alone and the added stress on the heart is not worth it. Triathletes need to create a go-to warm-up strategy before the race - something that is familiar and well-practiced. This can help ease nerves and reduce anxiety. 
There's so much emphasis on sodium before a race that many athletes are overdoing it on pre-load and salt pills in an attempt to off-set the effects of dehydration. However, a hyper-hydration style beverage (or pills) may predispose an athlete to SIPE due to the potential of retaining excessive fluid. This will be worse if an athlete already has high blood pressure. SIPE is connected to a quick increase in blood pressure.  

Although a wetsuit can be to blame, many triathletes feel more comfortable swimming in a wetsuit due to the buoyancy. However, triathletes need to practice in the wetsuit (at race intensities) to ensure it's the right fit (and race intensities are realistic). Gerry Rodrigues did a great discussion on his Tower 26 podcast on finding the right wetsuit. 

Things to consider: 

  • Many athletes go into races overly hydrated - an increase in body fluid is not a good thing. 
  • Abrupt cold water exposure and/or compression of the wetsuit can push fluids to the core. I advise athletes to use a bottle of water to pour down the wetsuit and try to get wet before the race so the water is not a shock to the body when you can't warm-up in the water. 
  • Athletes who already have high BP can experience a further increase in BP at the race start - causing fluid in the lungs (similar to flash pulmonary edema). 
  • Interestingly, even though research has shown cardiac issues among elite athletes, I will generalize and say that swimming related deaths appear more common in the less experienced and in males. Instead of making assumptions of the risk of death in the triathlon swim, it would be beneficial if we could better understand more about the background of the athlete who passed away. For example, did this person have a preexisting heart condition, was she/he wearing a wetsuit for the first time, is she/he on any medications/drugs, what was the nutrition like on race day morning, was she/he stressed before the race, what type of training did she/he do on race week, etc.? This additional information may help us further prevent or reduce the risk of future triathlon swimming deaths. 

What can we do to reduce the risk:

  • Start slow in the water - give yourself time to warm-up and get breathing under control before taking your first stroke. 
  • No more than 30 ounce water on race morning.
  • Get a medical exam (as comprehensive as possible) before a race (or before training for a race). 
  • Fuel and hydrate appropriately - don't restrict, don't overdo it either. 
  • Take training and racing very seriously. Long distance triathlon should not be seen as the new "marathon" but as an extreme endurance event that comes with great risk. 
  • Choose races appropriately - consider the water temperature, water environment (ex. chop, current, etc.) and how you will prepare for your open water swim (can you do practice swims in similar conditions)?
  • Test out your wetsuit several times in advance - in the pool and open water. 
  • Take your health (and swimming ability) seriously. 

Additional reading:
Triathlon swim deaths
Diagnosis review
Risk factors


DEXA Body Composition Testing - Review (and results)

Several weeks ago I was contacted via email by someone from a company who asked if I was interested in receiving a complimentary DEXA Scan (along with Karel) in return of a review. As you may know, I am not a fan of the scale and I never weigh myself. Considering all that makes up your body, your body weight can’t accurately be told by a number on the bathroom or BMI scale. But this doesn't stop far too many athletes from daily or weekly scale weighing - often feeling like the scale runs or ruins the day.

A DEXA Scan is a reliable, gold-standard way to precisely measure body composition (I discussed this in my book Essential Sports Nutrition). DEXA stands for dual energy x-ray absorptiometry.  More than just a weight, a DEXA Scan tells you what you are made up of - muscle, fat and bone. You can see muscle asymmetry, visceral fat and bone density.

For the athlete with excessive body fat, weight loss may improve health and sport performance. However to pressure from society, coaches and social media, it’s not uncommon for many athletes to have body image struggles, feeling like the body should always look differently. Because many athletes resort to unsafe weight loss methods and strategies when feeling “fat”, the first step in a weight loss program is to gather baseline information of your current body composition – what are you made of? Your bathroom scale does not tell you what you are made of - it only tells you a number.

Understanding body composition 
Your body weight is made of two parts: body fat and lean body mass.

Body fat can be divided into two types; essential fat and storage fat. Essential fat is stored in organs, like the heart, lungs, spleen, kidneys, intestines and liver, as well as in muscle tissue, the central nervous system and bone marrow. Although a small amount stored in the body, the body requires this type of fat for bodily processes. Essential fat is very important for your overall health. Women have more essential fat than men for child-bearing purposes. Essential fat is also needed for hormone related functions.

Storage fat (the more familiar fat) consists of fat accumulation in adipose tissue. Subcutaneous fat helps to protect the skeletal structure and to conserve body heat. Visceral fat (or abdominal fat) lies just beneath the skin surface. An excessive amount of visceral fat has been linked to health issues. It's important to know your android fat level and gynoid fat level (and ratio) for metabolic health. Gynoid fat storage (pear shape) is common in women as this fat is stored primarily around the hips and thighs. This storage is often seen as healthy for child bearing. Android fat (apple shape) is stored in the midsection, predominately in the abdomen, but can be also be found in the chest and upper arms. This type of fat is consistently shown to place people at a higher risk of heart disease, diabetes, hormonal issues and more. Knowing the distribution of fat in your body can be helpful to monitor health risks and to minimize health issues later in life. Because a DEXA scan measures different types of fat in every region of your body (even your head!), the ratio of android to gynoid fat (A/G ratio) is something to monitor. You want this ratio below 1.0.

Lean body mass is everything that is not fat. Your bathroom scale doesn't know how much of your body is lean vs. fat. For example, your scale doesn't tell you the weight of your bones, organs, muscles, fluid, ligaments and tendons. More so, if your body composition is changing, your weight won't tell you why it's changing - is it more/less fluid, more/less muscle, more/less fat, more/less bone?

When we think of words like lean, fat or overweight, what do those words really mean? For example, according to a height and weight table, I may be classified as normal weight (but on the high end), but this table doesn't take into account my muscle mass and bone density. And although excess body fat can have an impact on your overall health, you do need body fat for important bodily functions.

If you are concerned or interested in your body composition, I highly encourage you to ditch the scale and get a DEXA scan. The DEXA Scan website will help you find the nearest location (and pricing) to get your body composition tested. Although not every center with a DEXA scan is listed on this website, it's a good starting place. The average price of a DEXA scan varies from $50-150 (on average). I'd say that's extremely reasonable, considering all the information you receive and the ease of the test. It only takes ~6-8 minutes for the machine to run the scan on you - while laying down - and you immediately get your results right after the test.

Because a DEXA scan tells you a tremendous amount of information about your body composition, here are some practical applications from the analysis of your body composition:
  • If you feel the need to change your body composition, you should know exactly what you are made of before attempting to change your diet or exercise regime. And because you can't target your fat loss or spot reduce, even if you try to build muscle or reduce body fat, repeated testing (ex. every 3 months) can show you trends over time after establishing a baseline - particularly, how your body composition has changed over time. This will also emphasize the fact that healthy and sustainable body composition changes can not be quickly achieved, especially through extreme exercise or strict eating methods. Far too many athletes overexercise and undereat for the reasons of wanting to weigh less to perform better. If you are serious about changing your body composition, you need a very specific program/approach that will help you achieve your goals (ex. decrease body fat, increasing muscle) without compromising your health, performance and quality of life. And because body composition changes don't guarantee performance improvements, your primary focus for changing body composition should be for health reasons - not aesthetics. 
  • Although a DEXA scan is not a bone density exam, it does give you a general overview of your bone strength. As an athlete, you should be very concerned about this number. A high bone density (higher Z-score), means strong, healthy bones. Interestingly, a DEXA scan may tell you about  imbalances, that may have resulted in (or predispose you to) an injury. This information may help your PT/trainer better understand the exercises that you need to be doing to rehab appropriately (after an injury) or to reduce the risk of an injury. For example, in the DEXA scan, you can see the difference between your right side and left side bone density. A large imbalance may indicate a muscle imbalance from a past muscle injury or an injury waiting to happen.
  • Body weight is a sensitive topic and many athletes are trying to avoid the scale for that reason. I agree - the scale is not a good indicator of your self-worth, athletic talents or overall health. Because poor body image can lead to obsessive behaviors (ex. eating/exercising), a DEXA scan may give you reassurance and satisfaction that your body is actually in great health. I feel there's something extremely powerful in knowing exactly what you are made of - it also shows you how incredible your body is because of all that it's made of. Plus, if you have recently gained or lost weight, you want to be assured that it's the "right" kind of weight. For example, you could avoid carbohydrates for a few days and lose a lot of water weight. Your weight may be lower but your weight loss likely didn't come from fat. 
Karel and I found this experience to be very enlightening. We never obsess about our weight/body image and our eating habits are not regimented or strict. The information we received from our scans was more about knowing what we are made of, instead of feeling like we need to use this information to make changes. We don't plan on making any changes with our diet (or training) to change our body composition for we are both healthy, performing well and enjoy our current style of eating/training. Plus, we feel our body composition  naturally changes throughout the season based on our ability to adapt to training stress and recover between sessions. We also know that serious health issues can occur from getting too lean (the body gets weaker, not faster). And seeing that it's only June and we still have over three more months of Ironman specific training, we don't want to jeopardize our health in favor of attempting a leaner body composition.

Here is a recap of our body composition analysis from the Lovelace Family Medicine Center in Prosperity, SC. 


Age: 42
Weight (weighed with shoes and clothes on, I feel this should have been a naked weight): 145.0 lb
Height (shoes on - I feel they should have taken our shoes off): 67.5 inches
Body fat percentage: 12.4%
Android: 13%
Gynoid: 13.6%
Android/Gynoid ratio: .96 

L Arm: 10.7% fat
R Arm: 11.3% fat
L leg: 12.9% fat
R leg: 12.2% fat
Head: 21.7%
Z score: 0.1
T score: 0.1
(a score of -1.0 or above is normal bone density. A score between -1.0 and -2.5 means low bone density or osteopenia and -2.5--4 is osteoporosis. A T-score is your bone density compared to what is normally expected in a healthy young adult of your sex. Your Z-score is the number of standard deviations above or below what's normally expected for someone of your sex, age, weight, ethnic or racial origin). 

L Arm: 0.950 BMD (bone mineral density, the amount of bone mineral in bone tissue)
R Arm: 0.997 BMD
L Ribs: 0.736 BMD
R Ribs: 0.639 BMD
T Spine: 0.887 BMD
L Spine: 1.093 BMD
Pelvis: 1.205 BMD
L Leg: 1.251 BMD
R Leg: 1.254 BMD

Age: 37
Weight (weighed with shoes and clothes on, I feel this should have been a naked weight): 114.0 lb
Height (shoes on - I feel they should have taken our shoes off but I'll take the height increase :): 61.5 inches
Body fat percentage: 17.1%
Android: 13.9%
Gynoid: 23.2%
Android/Gynoid ratio: .60 

L Arm: 16.5% fat
R Arm: 14.3% fat
L leg: 21.3% fat
R leg: 19.5% fat
Head: 21.3%
Z score: 0.5
T score: 0.8
(a score of -1.0 or above is normal bone density. A score between -1.0 and -2.5 means low bone density or osteopenia and -2.5--4 is osteoporosis.)
L Arm: 0.794 BMD (bone mineral density, the amount of bone mineral in bone tissue)
R Arm: 0.842 BMD
L Ribs: 0.571 BMD
R Ribs: 0.632 BMD
T Spine: 0.966 BMD
L Spine: 1.212 BMD
Pelvis: 1.078 BMD
L Leg: 1.128 BMD
R Leg: 1.148 BMD

Although athletes tend to have lower body fat percentages, extremely low body fat can pose health issues - for men and women. When it comes to seeing where you stack-up with your body composition compared to someone else, be mindful that your body is unique. We must keep in mind that there an extreme variability of body shapes, sizes, heights, bone structure, genetics, weight and fat and muscle distributions. No two bodies are the same so it's not worth comparing your body composition (or image) to that of another athlete. Two athletes, each with 15% body fat can look extremely different. You can also be very fit at different body fat percentages. You can also be extremely lean but in poor health. This is why it's also important to never assume that weight loss will result in performance gains. Through DEXA testing, you can see how your body is put together and what you are made of. It's up to you if you want to do anything with that information.

Final thoughts....we found this process informative. I saw this as a wonderful opportunity to see how strong and healthy my body is in the inside and to see what I am really made of. Because athletes can become so overly focused on body image, make sure you are spending your energy in the right place - to become a stronger, healthier and better athlete. Performance gains don't come quickly and you should never make assumptions that lean = fit. Strive to be in great health and don't tie your happiness, confidence and self-worth to an image or body composition.

If you are interested in getting your body composition tested, you can use this link, DEXA Scan, to find your nearest location. 

I was not paid to write this post and all thoughts/feedback are my own. In return of this blog post, I received two complimentary DEXA Scan tests at a location of my choice. The closest location per the DEXA Scan website was ~90 minutes away. The test was performed on June 4th, 2019. 


5 weeks until IM Canada - update

This isn't my first rodeo of training for an Ironman but life has presented me with an incredible opportunity to take my training up a notch with the professional guidance of my coach, Cait Snow (with the JD crew). Having already qualified for the Ironman World Championship at IMWI last September, this upcoming Ironman is an opportunity for me to remember what it's like to race an Ironman. While I have processed-driven goals for the race (which are keeping me motivated, patient and disciplined with my training), I have no time goals. With ~8,000 feet of elevation gained on the bike and unpredictable weather, my goal is to simply put together a race with the fitness that I've accumulated over the past 8 months and to cross the finish line feeling like I made good decisions for all 140.6 miles.

With my 15th Ironman distance triathlon approaching in just 41 days, I thought this would be a good time to share some feedback on this Ironman journey.

My health is the most important thing to me. Therefore, in order to ensure that my health isn't compromised by my training, I keep the communication going with my coach. She knows when I'm predicting my menstrual cycle each month, I leave detailed feedback on my execution of the workout, weather and any niggles/concerns in Training Peaks for every workout and if I have a concern, I text or email her. I also don't neglect the things that I can do between training sessions to ensure that I can perform well and recover well between sessions. I sleep between 8-9 hours a night, I eat before every training session, I use sport nutrition for every training session, I have some type of recovery snack/meal after every training session. I've learned that I can not neglect daily mobility so I make sure to spend at least 5-10 minutes before every run workout on mobility and strength for my hips/glutes and I spend 5-10 minutes on hip exercises from my PT before bed. I try to get a massage once a month but sometimes it's twice if I am feeling extra tight - prehab is worth the investment over rehab. I've also had several dry needling sessions which I feel really helps my tight spots. There's nothing magic or secret about keeping my body in good health - it's just the daily decisions that add up to optimal health  - otherwise, when these little things are neglected, health becomes compromised. I still get my period on a monthly basis, I have not been sick in well over a decade and I haven't had an injury since 2013. I have my share of niggles but in knowing my body, I've managed to keep something minor from turning into something major. This comes with experience as in the past, I wasn't so good at listening to my body. I feel extremely fit, healthy and strong. I do love this feeling but I know it takes a lot of work, commitment and effort and it's not something I take for granted. I constantly remind myself that I only have today - tomorrow is not guaranteed.

Nothing has changed here. I'm still a lacto-ovo vegetarian (been one for the past 27 years) and my diet consists primarily of real food. With the more frequent training and longer training sessions, I don't see my diet as Breakfast, Lunch, Dinner and snacks between but instead, I'm constantly focused on eating to keep my calories up. I incorporate more processed foods like granola, pretzels, salty chips and fig newtons as they are more energy dense foods to compliment the many nutrient dense foods in my diet. I'm a great water drinker, I salt my food and I don't believe in off-limit food. I don't weigh myself or worry about what I look like but instead, I'm focused on how my body performs so food is my nourishment and fuel. Some meals are thrown together pretty quickly but I still enjoy cooking on a daily basis.

I wish I could give a typical training week but my training varies each week. I do a lot of repeated workouts that are familiar and sometimes there will be a minor tweak in distance or effort. Most of my workouts are at or below threshold and if the workout is intense, it's typically short in duration for the interval/workout. So in other words, I don't find my training as "too hard" to complete. The biggest thing is training through fatigue. This requires me to be constantly in-tune with my body and to also trust the training that my coach has planned for me. There are easy sessions built in so I make sure to keep these sessions easy so I can go hard when needed. I am not a slave to my metrics so I use them for guidance. Most of all, training is fun for me. It's an escape from my busy life and I remind myself that training is something I "get" to do - not have to do. When I train, I love it. I feel grateful and thankful for what my body can do and I constantly remind myself that I am in charge of the workout and what I can do during the workout. I try to make everything training session a productive one - not defined by metrics or distance completed but I try to finish each session feeling like I executed the best that I could on the day. My training is challenging but not so much that I am so smashed that I can't function in life. It's actually been a lot of fun to push myself to new limits and I feel my coach really cares about my health and joy for sport so it's a nice mix of workouts that I like and workouts that I need.
I do a lot of frequency with my training (2-3 sessions a day), I have 3 scheduled strength sessions a week that I can do any day during the week (I try to do them on my hard days of training to keep the easy sessions easy), I run three days in a row but never run more than 5 runs a week), I do a lot of brick runs, my longest run so far has been 79 minutes, I swim a lot (4 days a week) and I bike a lot (like - a lot!). My longest bike has been 5 hours.

I have been averaging around 20 hours a week of training for the past two months and the break down typically looks like the following (for reference, here was my last week of training):
-22:18 hours of training
-4:34 hours of swimming (19,390 yards)
-11:50 hours of cycling (191 miles)
-4:28 hours of running (33.7 miles)
-1:15 hours of strength

Life with Karel is always entertaining but we certainly have our ups and downs when we both train for the same events. The ups include having great workouts and sharing them with each other, being able to train together (mostly biking outside as we often have different swim and run workouts and Karel is too speedy on the run for me to hang along) and to live an active lifestyle together. We hold each other accountable and support one another. The lows include having an off-workout, working through a niggle and feeling overwhelmed with a lot on the daily plate. But the highs absolutely outweigh the lows. There's a lot of communication between us so that we both know how the other is feeling and the upcoming training, day of work and other to-do's that need to get done. There's a great sense of teamwork in our relationship as oppose to you or I need to do this. Campy still gets a ton of attention with lots of walks. We try to include Campy in our training sessions, even if that means one of us walking Campy around Furman when the other one swims or finishing a run workout with a Campy walk. But once our workout is over and we chat about the highs and the lows, it's back to normal life. I try not to bring my training life into my work life so once a workout is over, it's behind me and I focus on the present without dwelling what's in my past. I feel like our training is really working for us and we both see it as something good in our life. We both communicate with our coach to make sure training makes sense - this also helps our relationship so that training fits into our life. For example, next week is our endurance training camp so our training will take a backseat for 4 days so that we have enough mental and physical energy for our campers.

Life is busy. Although I put a lot on my daily plate, I try to not overload myself so that I can still have some downtime - even if that means an hour of watching TV before bed between 8-9pm. I turn off "work" in the evening so I can go to sleep with a clear mind, while getting excited about another day of life. Right now I am working on two books (just finished one and writing the second one) but I actually love the combination of training and writing (writing a book is much more demanding that Ironman training!) as it keeps me focused and structured. I still have several nutrition consults throughout the week, coaching athletes and other work obligations for Trimarni so I think of my job(s) as flexible but non-stop. I work 7 days a week. For example, I had my long ride on Friday (5 hours). I woke up before 6am, worked for two hours on the computer, did my ride, worked for another 3 hours, and then went for my evening swim. Over the weekend, I had about six hours of training but worked on the computer for about 12 hours. I am not complaining as I look forward to every day of the life I created. I make sure when I am doing something, I am 100% focused and present. So when I train, it's all about training. When I write/work, I don't think about training. Most of all, training is a compliment to my life - it's not something that takes over my life. It has it's place and I feel my training makes living that much more fun and meaningful.