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  • Annie Bothma

THE MISSING PUZZLE PIECE

This is probably the most vulnerable and personal blog post I have ever written and shared with the world. It is easy for an outsider to judge or criticize me for what happened to me in 2022. However, without all the inside knowledge, you cannot make assumptions or accusations. For the majority of 2021 and 2022, I didn't know or understand what was happening in my body; in fact, I felt like I lost control.


How could I trust my body when it failed me at times when I needed to perform? It didn't make sense to me that I could no longer carry myself the distance, nor do the smallest tasks. In 2022, I had lost all trust in my body, and in this post I will share how after a year and a half of suffering I was finally able to restore that trust!



BACKGROUND

In September 2021, I was diagnosed with Central Diabetes Insipidus (CDI). This condition occurs when the body can't regulate how it handles fluids. The condition is caused by a hormonal abnormality, in my case, it is directly linked to my hypopituitarism and my body’s insufficient production of antidiuretic hormone (ADH). CDI is not related to type 1 or type 2 diabetes (also known as diabetes mellitus), but it does share some of the same signs and symptoms. The two main symptoms of CDI are extreme thirst (polydipsia) and frequent urination.

Before I got diagnosed and received treatment, I was chronically dehydrated and, as a result, my athletic performance suffered. The main reasons why dehydration has adverse effects on exercise performance are: reduction in blood volume, decreased skin blood flow, decreased sweat rate, decreased heat dissipation, increased core temperature, and an increased rate of muscle glycogen use. My blood pressure would drop and I would end up being dizzy and disorientated. I battled with the cold and often lost feeling in my hands and feet. I frequently fainted, during both training and races.

To manage my condition, I was prescribed a synthetic hormone called desmopressin acetate (DDAVP). This medication replaces the missing ADH, which is supposed to be secreted by my pituitary gland. Gradually my medication was increased with the goal to counteract the amount of fluids I was losing through urine, but it was now more concentrated than before. I was losing a lot of electrolytes, especially sodium.

To top it all off, after 10 years in athletics, I had never had a bone stress injury or a fracture. In fact, I was consistently doing marathon training for three years without getting an injury or niggle that took more than a day to recover.

This year, I suffered through four back-to-back bone stress injuries!


WHAT CHANGED?

How did I go from never having a bone stress injury before and not being injured for three years running the highest mileage I have ever done, doing the longest long runs of my running career, and completing the most intense sessions I could have ever imagined, to a series of bone stress injuries?

Let's backtrack to when the first cracks started to show...

In January 2022, I had a stress fracture in my left calcaneus. I spent 9 weeks doing non-impact or low-impact cross training activities, like aqua jogging, indoor cycling, and ElliptiGo. I also did a lot of strength training and rehab in the gym. I was able to start running pain-free and gradually increased my running distance. I was only able to sustain a quarter of the weekly mileage I used to breeze through.

During a run in April, I felt a sharp, debilitating pain in my back. I cut the run short and rested the next day. When the pain didn’t subside, I went for an MRI scan. Another stress fracture showed-up – this time in my sacrum!

I returned to non-impact and low-impact cross training activities, with minimal strength work this time. After six weeks I was able to very slowly return to running. But, my return was short-lived. After only 8 weeks of low-volume and minimal intensity running, I had a stress response in my right calcaneus.


Something didn’t make sense.

I was already being meticulous with my nutrition, to support my health and optimize athletic performance. I focused on getting sufficient calories and carbohydrates to stay in an energy balance and support my training. I have never done fasted training sessions or deliberately restricted my dietary intake. I increased my protein intake and was taking collagen daily to help facilitate a proper recovery and repair.

I abstained from running for another 6 weeks, and then started on an underwater-treadmill at 70% of my body weight. After only 5 sessions, each less than 30 minutes, I sustained yet another stress fracture, this time in my 4th metatarsal on the left foot.

Something really didn’t make sense!


I was suffering from hyponatremia.



THE WAKE-UP CALL

Every single blood test I did from December 2021 up until October 2022, pinned me as hyponatremic. My blood sodium levels were consistently around 120-30 mmol/L. Normal blood sodium is typically around 140-145 mmol/L. Symptomatic Hyponatremia can occur when the plasma sodium concentration rapidly drops to 130 mmol/L or less. Sustained low levels increases the risk of developing swelling of the brain (delusional encephalopathy) and accumulating extracellular fluid in the lungs (pulmonary edema). When plasma sodium falls below 120 mmol/L, the risk of a brain seizure, coma, and even death, increases.

I understood that hyponatremia was serious. I was adding salt to all my meals, drinking 1500-2000 mg of sodium through electrolyte tablets in my water, and later, even started taking a salt tablet with my meals, each containing 200 mg of sodium. Nothing was able to raise my levels back to normal. I suffered through the side effects of hyponatremia. I felt foggy and struggled to concentrate for long periods. I was always tired and I always had a headache. I was no longer able to keep up my cross-training intensity. Concentrating on my studies and work became increasingly difficult. I feared breaking more bones and felt extremely depressed, unable to participate in the sport I love so much.

One evening in October, it overwhelmed my body. My head was pounding and my world grew darker. I felt like everything was spinning. Like I was floating and then it just went black. I woke up in the middle of the night, my face covered in my own spit. My head and face felt swollen and my body too heavy to move. I fought against the feeling of fatigue, but ultimately I gave in and just closed my eyes again.

I suffered a seizure...



THE IMPACT OF CHRONIC HYPONATREMIA ON BONE METABOLISM

I started doing research on bone health. I listened to the IOPN’s Podcast WE DO SCIENCE, with Prof Craig Sale on Athlete Bone Health. I listened carefully to Dr. Laurent Bannock and Prof. Craig Sale discussing the important factors when it comes to preventing bone stress injuries and/or the development of osteopenia or osteoporosis. The next day, I downloaded the research paper that was referenced in the podcast – Nutrition and Athlete Bone Health, by Craig Sale, Kirsty Jayne Elliott-Sale (2019) – and eagerly started reading.

I read it over and over; finally, I found the missing puzzle piece!

I finally understood what was actually happening in my body! It finally made sense why I was getting repeated bone-stress injuries.

As I was reading, my eyes grew wider…

“ In line with this, there is also the possibility that the challenge to fluid and sodium homeostasis that would occur under these circumstances might influence bone metabolism and health. This, to our knowledge, has not been directly or well studied in relation to the athlete, but there is some suggestion from the osteoporosis focussed literature suggesting that bone might be negatively affected by hyponatremia. Verbalis et al. [83] examined the effects of using a syndrome of inappropriate antidiuretic hormone secretion rodent model to show that 3 months of hyponatremia (~ 30% compared with normonatremia significantly reduced the BMD of excised femurs and reduced both trabecular and cortical bone, purportedly via an increase in bone resorption and a decrease in bone formation. The same paper also reported on a cross sectional analysis of human adults from the Third National Health and Nutrition Examination Survey, showing that mild hyponatremia was associated with significantly increased odds of osteoporosis, in line with the rodent data presented. This might be explained by novel sodium signaling mechanisms in osteoclasts resulting in the release of sodium from bone stores during prolonged hyponatremia [84].” (Sale, 2019)

Suddenly, I realized my CDI medication was putting me in a state of hyponatremia! As a result of my inappropriate ADH dosage my body was losing all the important minerals needed to maintain and build strong bones. I knew I needed to be on medication to manage my condition, thus not being chronically dehydrated, but I also knew that I needed to get my sodium levels back to normal as soon as possible.

I felt overwhelmed, realizing the damage that the medication has done to my body and that my suffering could have been prevented. Yet, I felt excited. Could this be the answer to turning my situation around? After several months of pain, I finally saw a way out of this dark hole.

I immediately booked an appointment with my endocrinologist. He was alarmed after hearing the news, seeing the latest blood results and just how low my blood sodium levels had dropped. He advised that the dose was too high. Being chronically hyponatremic was not only detrimental to my bone health, but it was also life-threatening!

“Annie, if we don’t adjust the dose right now, you are not only going to continue breaking bones, but you are going to die!”

He adjusted my dosage and for the following few weeks I had to go for weekly blood tests to monitor my sodium and hydration levels. At the beginning of November, I was finally able to start running again without pain. I had only been doing short easy runs for 4 weeks when I received the opportunity to go run at the South African Cross Country Trials where the world cross country team were to be selected to represent the country in 2023 at the IAAF World Cross Country in Australia.

I decided to risk it and booked my ticket to go run at the trials. I knew I wasn’t ready to compete at my best, but I still wanted to give myself the opportunity to race again. With limited fitness, I managed to squeeze my way onto the team coming 4th. I felt intense gratitude for making my third World Cross Country Team after everything I had to overcome this year.

I throw my arms up in the air like I won the race. I feel like crying. I can’t believe it. I made the team. I am going to the world cross championships in Australia! After all those months of living in a fog, feeling confused and not understanding what was happening in my body. I had lost all trust in my athletic ability and thought I would never be able to compete at the same level as before. There were even times when I thought I would never be able to run again, let alone compete at a national or world championship. Overwhelmed by gratitude I walk off the course. I FINALLY HAVE MY BODY BACK!


REFLECTION

This incident taught me an extremely valuable lesson as a professional athlete, but also as a practitioner. Knowledge is power. If you can understand what is going on you can help and equip yourself to make better choices in the future. In my case, discovering what was going on in my body saved my life! Furthermore, it made me realize you should be a student of your body and a student of life. You should always ask questions, and never stop learning or growing! You should take responsibility for your body and situation. Others aren’t always going to be there to help figure things out; sometimes you need to be able to help yourself and in the process you will be able to help others in the future!

This incident has forced me to delve deeper into the research of bone metabolism and how to prevent bone stress injuries in athletes. It taught me about the delicate fluid

and sodium balance that exists in the body and how hyponatremia can be just as dangerous as dehydration. Most importantly, it taught me to not simply accept

things the way they are. I will strive to always ask questions, research, learn, and grow. I will now try to encourage every athlete I coach or help with their nutrition to be curious about their situation and to take responsibility for their body and life.


- Annie

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