Nutritional Revolution Podcast

Can Your Medications Raise Heat Risk? Dr. Melani Kelly Breaks Down the Science

• Season 5 • Episode 164

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In episode #164 we discussed some important science around heat and performance with Dr. Melani Kelly:

  • The differences between heat exhaustion, heat injury, and heat stroke, and the role hydration and nutrition play in preventing them.
  • How certain medications can increase the risk of exertional heat illness, and how they can alter our physiological responses
  • Practical advice and strategies for athletes on preparing for and managing heat exposure during training and competition.

Melani Kelly is an Assistant Professor at Utah Valley University, where she teaches and mentors students in the Department of Exercise Science and Outdoor Recreation. She holds a PhD in Exercise Physiology from the University of Kansas, a MS in Sport and Exercise Sciences from West Texas A&M, and a BS in Athletic Training from Eastern Washington University. Dr. Kelly’s current research focuses on identifying exertional heat illness (EHI) risk factors and assessing kidney damage in 100-mile ultramarathon runners. Her work has highlighted various risk factors, including how mental health medications may increase EHI risk, and individualized gastrointestinal responses to limit damage and perceived symptoms experienced with physical activity

Please note that this podcast is created strictly for educational purposes and should never be used for medical diagnosis or treatment.

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Hello, everybody, and welcome back to the Nutritional Revolution podcast. Today we have for you guys Melanie Kelly, and she is an assistant professor at the Utah Valley University, where she teaches and mentors students in the Department of Exercise Science and Outdoor Recreation. She holds a PhD in exercise physio from the University of Kansas and a master's in sport and exercise science from West Texas A &M and a bachelor's in athletic training from Eastern Washington University. Dr. Kelly's current research focuses on identifying exertional heat illness, EHI, risk factors, and assessing kidney damage in 100-mile ultra marathon runners. Her work has highlighted various risk factors, including how mental health medications may increase exertional heat illness risk and individualized gastrointestinal responses to limit damage and perceived symptoms experienced with physical activity. This is the first of its kind for our podcast, and I found it extremely fascinating. And I think this knowledge needs to be shared and is very important. enjoy the episode, you guys. I certainly did. Hello, everybody, and welcome back to the Nutritional Revolution podcast. We have a first for you guys. We have Dr. Melanie Kelly here, and we're going to talk about some really unique stuff. I think it's unique. Maybe you're very used to Melanie, but thank you so much for joining us. I'm super excited to learn from you today. Thank you for having me. I'm excited. Yes, I'm excited. But as our listeners know, before we dive into all this fun information about heat illness, let's talk about your two truths and a lie. Try and stump me, break them down for me. Alright, um I'm gonna start with I was born in Minnesota. I grew up in Washington state and I have three brothers. Okay, these are all good ones. Born in Minnesota. But maybe you didn't like live in Minnesota because you don't have that like Minnesota accent. um Group in Washington State. Okay. Three brothers. to specify that. Most people will be like, wait, Washington, DC, or stay. Yeah. No, that's good. That's good. I actually am like, this is a really good stump one. I feel like maybe what I'm starting to get, I think a little bit better at our tutors and lie and detect the lie only because when people throw in numbers, because you said three brothers, it makes me think that maybe there is like two brothers or so I'm going to go with that as the lie. But because maybe there's some other number of brothers or maybe it's sisters. We will find out. at the end of the episode, so hang tight listeners. ah But before we dive in today, so we're going to be talking a bit about heat, uh exertional heat illness, right? E-H-I. And I'd love for you, before we kind of dive into it, to give us kind of a breakdown. What is, is there a difference between heat exhaustion, heat injury, heat stroke, heat illness? Can you break those down for us, Melanie? Yeah, I think the biggest thing too is like focusing more on the exertional side of it, right? So the activity component is where this focus or these definitions come from more than I think what you see in the news or maybe here on, you know, if you listen to the radio, there are ads now about passive or classic heat stroke, you know, don't leave your dog or your kids in the car. uh That would be your classic heat stroke with no exertion that can also occur, which is another medical emergency. But heat stroke is our most severe. So that would be our medical emergency. You need to cool them first. Transport Second is the motto for that one. I don't know the best way to word this other than I like to just say that you're basically in an instant pot cooking from the inside out but rapidly. So it's a very quick progression that would be your serious fatal one or could be fatal. Exertional heat exhaustion would be like, it's often attributed to people being not hydrated or not being used to the environment that they're exercising in and they're just physically exhausted at that point. So their heart rate and cardiovascular function can't keep up because they're already at a disadvantage often if they're not used to that environment. But it's not a medical emergency. Usually they can discontinue that exercise, rehydrate, sleep, and continue exercise the next day. um Whereas guess heat injury too would be... By definition, would be just that there's like an increase in the temperature or damage to a tissue or an organ. It doesn't necessarily mean that the condition of heat stroke or heat exhaustion is present, but that's just tissue or organ damage that can occur at a certain temperature. So when it gets too hot, yeah. Whoa. Okay. So what type of tissue? Not in our bullets, but yeah. Okay. Okay. Yes. Like, so you can have heat injury that's severe, definitely. So like the organs when they can't survive past a certain temperature, then they start to die or they can't function appropriately. So that could be heat injury isolated to a structure, I guess. versus heat stroke is like the entire body is having the instant pot reaction where it's an entire body reaction or pathological bad. I don't have the right words for it, but bad. you Yeah, yeah, no, that is helpful. Is there out of curiosity, do know, is there an organ that is like least heat tolerable compared to others? Do we see one kind of like tap out sooner? That's a good question. um think, especially with heat stroke and knowing that it's a medical emergency, part of the ways to differentiate is heat exhaustion, I'm going to give a number, but it doesn't necessarily mean that you have to have this threshold or this core temperature to diagnose, but they kind of use it as the threshold of 40.5 degrees Celsius. So often people with heat exhaustion will be below that 40.5 and they will be conscious and coherent. Whereas with heat stroke, the brain is being impacted with that cooking of the brain. Mmm. might not be the best when I say them this way, but when the brain starts to cook, we often see that threshold of we're at 40.5 or above, and we also have altered central nervous system function. So it's that alteration of not acting right in the head, essentially. And so the brain being susceptible, yeah. Yes, that makes a lot of sense. 40.5 in Fahrenheit, do we know what that is off the top of your head? Do you want me to convert it? yeah it's about 105. So 104.5 is what I might, I know I wrote it down but of course I meant to highlight it. Oh yeah, 40.5 is 104.9 so 105 degrees Fahrenheit, I know I forgot to highlight that one. I knew I needed to note it in Fahrenheit too. my Celsius to Fahrenheit conversions are not great. My kilos to pounds and my milliliters and ounces, I got that, but I'm still trying to work on my Fahrenheit to Celsius, vice versa. Yeah. Okay. Well, what got you interested in this type of research? um While I was working as an athletic trainer, so they say things like in the fall, I worked a lot of football, which I really enjoyed working football. I thought I was going to be a football athletic trainer for like the rest of my life. And it's funny to see where I am now, but at the time that I was working, they say like drop like flies. So that initial first two weeks when they're coming back, of course they didn't do their summer training. uh They're also trying to prove a point of I want to keep my scholarship or I want to be starting. So there's that emphasis, that peer pressure. So a lot of factors are going into it, but the dropping like flies days, no matter how much you warn them or educate them. um And a lot of people experiencing heat illnesses, they'll come in. And part of my curiosity was I really wanted to do for my dissertation, which I didn't end up doing because COVID, but was looking at alcohol hangover because a lot of people like to think that like the hangover causes dehydration. So that's what would set you up for having heat illness or heat stroke. Mmm. But in reality, it's probably more related to the GI distress that happens. So disrupting that barrier. like you talked about the organs that are more susceptible, like the stomach, when we change that blood flow with exercise onset, when it decreases, that temperature can also increase. And when we get what they refer to, like not the best way, but leaky gut, so to say. So when that barrier is disrupted and we get leakage into the systemic or the bloodstream, then we can have that inflammatory response. Mmm. throughout and it can kind of spiral that or kick that off, guess, so to say. Yeah, there's a lot that happens that works together against you in that type of setting, guess, so to say. Yeah. Yeah. So there is a specific study that we initially reached out to you about that I thought was very fascinating. And for our listeners, this is what I'm talking about. The first of our kind on our podcast, because you looked at medications implications on heat injury risk, correct? Yeah, so we've so part of my dissertation with this, like so when we pivoted from not being able to do that hangover stuff and looking at the GI responses, we did a survey with marching band artists. So we had over 1200 of them and we were just trying to identify risk factors in that population, which I never did marching band I can be the first to say that I complete disrespect for marching band, but I see how hard they are working now. I do see that one of the first studies we did at KU, we saw that their core temp is getting just as elevated as the football players on the field with some of them even needing treatment at that point. So that was pretty not good for them, obviously, but that was cool to see like the amount they're working, how hard they're working, that comparison to traditional type sports. But um throughout the survey, something that kind of showed up as a theme was different medications and correlation does not equal causation. So not to say that we directly measured this, but a lot of them that were citing previous exertional heat illness or that they had experienced it, they had also had associations with mental health medications. So I think that there was general associations with just taking a medication or a supplement, but when looking at what we actually had from the data, it ended up being the antidepressants, the antipsychotics, as well as the stimulants. And so that kind of just made me more curious about what are these drugs doing. So the curiosity is the mechanism of action, of course, and then how that can impact exercise. Yeah, wow. So marching band, mean, some of, I mean, they're all in a uniform that's usually, I mean, it's not providing probably a lot of ventilation. And then some of our, yeah, yeah. I remember one, so they got to where, at least where we were at, they had one game where they're allowed to wear what they called their fake khakis or their fakis. uh They got one game where they could wear their fakis, which they burned that, the first game that was supposed to be really hot, and then it ended up being even hotter for the next game. uh So they're in their uniforms and it's the wool blend and they're like half of their jackets are off. You can see their bibbers and they like got emails after from donors that we don't want to donate money if you're not going to wear the full uniform. And it's like, no, they were like dying on the in the stands at this point. They're just cooking. Yeah. So clothing does play a huge role in that too. Yeah. certainly. ah And then there are some of them are carrying like large heavy pieces of equipment. their instruments can be pretty large and I think about like breathing in general like you want to just take a break you can't you got to keep Right, yeah, blowing into that tuba or whatever. I didn't do any sort of instrument either, so flying off the cuff a little here, but trying to, you know, resonate. m so with that, how are you measuring core temperature with the band? With the first study we did, we had these little pills that they can take. And so it's just a core temp pill. They take it six hours before the event and it ends up in their small intestine and then you can walk up with a little receiver and it'll tell you their core temp. Obviously less invasive than our other options and easier, but if it's not in the right spot and they drink something, it can quickly change the temperature and you're like, okay, this isn't accurate. Okay. Yeah. So everything, every medical thing has its like potential outlier uh ranges. Yeah. Getting in the right spot. Interesting. So with that study, what did you find? I mean, you mentioned antidepressants, antipsychotics. What did you end up discovering with that research with it? was kind of just a paper to show us like the associations with it and that's what kind of led to like the rabbit hole of looking at different mechanisms of action. So since then I've presented at a couple of conferences with my advisor actually and we're hopefully going to be writing a review on this eventually but um it was interesting because and maybe my biggest motivator is like spite for a lot of things which you know it's it is what it is for that scenario but I also I had an opportunity to take a pharmacology class at the Med Center. Mm. And I was really excited to do that, I did not belong in that pro, like I did, I definitely did not belong in that class. It was like a uh third class in a series for the PharmD students. And I'm coming in without the first two. They were very kind to me to let me come in there. um But I remember we were talking about these medications, which kind of also helped like stem my interest in this was I had asked, they were talking about antidepressants specifically. And I said, what do we tell active populations? What are the warnings that we should give them? Because we're talking about a serious condition that can develop on an antidepressant, it's called serotonin syndrome, which is like that increasing in core temperature. It's not common, but it can be fatal, especially if you're taking more than one medication that may have an impact on the central nervous system. And so... I remember saying that question and being like, what are we warning our people? And she looked at me and maybe she just didn't want to entertain the question that day. She probably wanted to move on too, but I remember just being like, what do we warned? And she said something along the lines of, uh they're not exercising. And like in the back of my mind, I'm like, what? Like I have done so many pre-participation exams with athletes myself that are not only taking one of these medications, sometimes they're on like the combo of that medication, which is then in that mental health. or in the paper with marching band, we saw that there's so many people that are on medications that are actually like contraindicated. So they're reporting multiple drugs that like, if you're sitting in this class, they're not even supposed to be taking them together. And you're like, something's not adding up here. So now I'm just like, how can we warn people about different risks? Like even allergy medications, we don't think about changing our sweat rate, stuff like that. Yeah, they can have the same kind of action on So it's the cholinergic system, which induces sweating um and plays a role in those receptors. So it can inhibit or reduce the amount that we're sweating. then that would encourage more heat storage, so to say. So if you want. and stuff like that kind of allergy med? Yeah, I mean, it kind of depends on how long you've been taking it, like if you're adjusted to it as well, but like the it's just that it can have an anticholinergic effect. And so it can impact the sweating because the symptoms you're treating are to change the drainage or even like the mucus membrane stuff. And so that's where it can also take action elsewhere in the peripheral or out in the body as well. Wow, so fascinating. Okay, so why, so the serotonin, what did you call it, serotonin what in the brain? Syndrome, okay. Tell us more about that. that can develop with like, it's like a serotonin intoxication. So when we're taking an SSRI, would be one of your most common antidepressants prescribed. So selective serotonin reuptake inhibitor is what that stands for. So we're inhibiting the reuptake, which increases the concentration of serotonin. So we know it's associated with mood. Mm-hmm. But at the same time, we also know that more is not always better. And so in excess, like rare settings sometimes, or if you're taking it with another drug that can induce serotonin syndrome together, they might work together to have serotonin intoxication, which then can lead to uh that serotonin syndrome, which is pretty much present similar to heat stroke. So that hyperthermia can develop. uh You can also have like altered mental status at that point. It can impact pretty much any tissue that could be susceptible. Yeah. What is the mechanism there from so high serotonin concentration in the brain then causes elevation in core temperature while exerting yourselves because it's decreasing sweat rate? I don't think I have the information on what receptors it's working on specifically, but I do have some references that could be looked at too later. But it can cause the altered mental status and then it causes autonomic dysfunction and then neuromuscular abnormalities. So under the altered mental status, the more common signs or symptoms are agitation, confusion, anxiety, restlessness, potentially delirium and coma. So thinking of... The brain being just susceptible to an increase in temperature too, that's probably part of where that malfunction comes from. The autonomic dysfunction, so just our autonomic nervous system, so our parasympathetic versus our sympathetic branches. uh With this instance, with increasing things, it's going to be in relation to increasing blood pressure, so hypertension, potentially heart rate or tachycardia, and then that hyperthermia. So those can all kind of work hand in hand with the cardiovascular and thermoregulatory system working together. And if you're not sweating, in that setting, then your heat is being stored or trapped within, which Instant Pot example, guess. Yeah. This is so fascinating. And when someone is, again, most of our listeners are endurance athletes, but when someone's exerting themselves, runner, for example, aren't they producing serotonin? Isn't there kind of like, what is a runner's high? Is that a serotonin increase? think it's, I feel like I can picture the concept map at this point and I can't even think of the endogenous, the opioids that your brain makes too, would be part of that, like in Kethelan's, I don't even know if I'm saying that right, but that would be part of the runner's high. Like serotonin's I think associated too with the feel good and love is what I feel like a lot of people also associate it with. But. But any drug, I guess, that can alter a physiological function can just technically put you at a risk if you're not used to it. ah And so, like with serotonin syndrome, you would probably know if you have something like this before you even tried to, I would hope that you recognize the warning signs, I guess, before you would go into having serotonin syndrome and trying to exercise. You probably wouldn't feel like exercising because you're gonna feel like death in that scenario. For lack of a better word. yeah. And so you're saying from the marching band study of 1200 participants, it's correlation, not causation that you're. m we can't directly link anything but what we saw the most was in relation to those medications and then outside of medications it was poor nutritional habits. They did identify quite a few eating disorder type or disordered eating type pattern stuff and in that setting it's kind of similar to traditional sport but there's that concern about weight and you know the show must go on you're on display at all times so there was a lot of mention of like laxative use or that they felt pressure to lose weight. We don't have obviously confirmation of diagnosis, but things reported like I've been diagnosed with an eating disorder or I think I have an eating disorder were also asked about. So there was a lot that showed up with like poor nutritional habits as well. So does it go hand in hand with the mental health disorder, which you can also talk about. Some of those can be diagnosed in an eating disorder type setting. It's kind of tough to know what exactly may be promoting this more than anything, but Mm-hmm. Yeah. to see all the risks with medications after that. Totally. Yeah, that is really fascinating. So from an athletic lens, I mean, how should athletes be potentially approaching their medications when they know they're going to be exposed to the heat? um I think the biggest thing is like, especially if they're not used to the heat, right? Like there's already kind of a disadvantage if you're not used to the environment that you're gonna be exercising in. And if you have the opportunity to acclimatize the best that you can, that would obviously be ideal. uh But if not, also have you been taking the medication for a long enough time to know how you respond to it? Would be part of it. Have you had a conversation maybe with your healthcare provider like... Hopefully, I hope for everybody to have a healthcare provider that they feel comfortable talking to. But that may also be another conversation of maybe I need a new healthcare provider if I can't have these conversations, if they don't even want to entertain the thought of me exercising on these medications. Because it should definitely go hand in hand with them, and it's a very individual thing. What else are you taking? What are the risks of the condition that you might be taking that medication for? But as an individual, you can also look up your drug. Look up the medication that you're taking and It's a lot of Googling. It might be your own homework. I also have resources in one of the articles that I'll share that's like drugs.com. I know, so simple. Drugs.com, type your drug in and it will give you the mechanism of action. It will give you side effects or adverse effects. And while you may not be experiencing those, the other thing you can do is pay attention. try to get to know how you feel when you're not on the medication, when you start that medication, is there anything that's changed? Can you document that? Can you kind of make your own little journal? See if there's any patterns that arise. um And like with stimulants, if you get prescribed a stimulant in winter, you may think that you're good and then you go to the heat and you don't even think twice about the fact that the side effect of like reducing your perception of fatigue, right? So now you can work harder, but you're not even heat acclimatized and it might push you past that level of when you should stop exercise. Right, right. What would be an example of a stimulant medication? Like what people get prescribed for ADHD so like the amphetamines or Ritalin or Adderall Methylphenidate is another one Like the general recommendation is to try to avoid stimulant use for exercise definitely And they say that if you're take a stimulant, hopefully it's the extended release There's kind of the association of abusing stimulants, especially the the short-acting ones or the ones that aren't extended release Mm-hmm. right before activities. So there's also lot of monitoring and banning in certain sports. So that would be another thing to also pay attention to is that a drug that you can even take uh in relation to whatever organization that you're working with. It is banned by like WADA, the World Anti-Doping Agency, um unless you have certain documentation. So obviously being aware of those risks if you are competing at that level. m But yeah, it's hard because it's so individual. But just trial and error. are you used to that environment? Have you taken this medication before? Have you recognized these symptoms? Before or after medication use, you may want to play with dosing. There are some drugs that may have an accommodation. So actually in 2024 maybe, recently, the American Medical Society, the sports medicine physician statement that they had come out, they actually did say there's no direct evidence to show that. ADHD medication or stimulants cause exertional heat illness, but based on theory we know that there's an association with increasing that risk. So we caution not taking stimulants during the heat, especially if you're not used to the heat. I know I mentioned, sorry go ahead. I was gonna say, I know I mentioned that it just reduces like your fatigue perception. And so like that's a big thing, right? If you can't recognize that, then you can push past the warning signs potentially. Yeah, yeah, that certainly makes sense. And then where would something like em over the counter meds, like any NSAIDs, do they play into any of this? I mean, insets in general, like I think that people, the misconception with that is like that they think that they can reduce their fever by taking it or like reduce their temperature just by taking it preventatively. usually when you're taking a medication for that, it's in relation to the reset of your hypothalamus at that point or the thermostat of the body at that point. So when you have a fever, it's going to be elevated. And so that onset of sweating will be at a later time point, so heat storage can happen quicker if you're exercising with a fever. But reducing the fever with a medication doesn't necessarily stop you from experiencing symptoms either. It might actually make you more susceptible to developing exertional heat illness too during the exercise, but like, insects specifically are known to potentially cause GI disruption, like distress and disruption of the barrier. which obviously if you're having symptoms like diarrhea or vomiting, then we're also contributing to things like um fluid loss. So you're dehydrating yourself on top of that. Knowing with, I think it's antidepressants, specifically the SSRIs are more associated with this one, but it is that the increase for a GI bleed is also there if you're taking insets with the SSRI as well. So it's another thing you can learn from, healthcare provider, right? And if it's not even your primary healthcare provider, you can talk to the prescribing pharmacist. I know that that's also kind of awkward when they're like really busy and they're like, do you need to see that? And it doesn't feel like a welcoming environment. At the same time, it's your health. Like we also have to look past that, I don't know, like embarrassment that I think that we all kind of feel when we're standing there like, okay, I'm just going to go like, and try to ask the questions to advocate to take care of ourselves is one of the biggest things, definitely. Yeah, yeah, certainly. So if someone were maybe not having a fever, but they had knee pain and they're taking an EDCED during a race or just before a race, is there possible implications there with like core temperature management and heat illness? It's probably like if you're taking it, might help with the pain that they're experiencing. But at the same time, I think of another risk. I guess the AT in me is like, are you masking pain to exercise? Are we going to delay the healing process in that scenario too? Yeah, it kind of depends on the reason, but it's probably not going to impact your core temp. Likely that's going to be in relation to potentially environment, the attire that you're wearing, the physical fitness of the individual. what's the intensity of the exercise, um and then that risk associated with GI distress. I think the more that you take NSAIDs, the more likely you are to be resilient or accommodate them and less likely to have symptoms probably, but the risks are probably higher if you're taking them on an empty stomach or if you're not hydrated. And then if you take them while you're exercising and you don't take it with food or fluids, it might also lead to more irritation of the GI tract. Mm-hmm. I guess my biggest thing is cautioning or try to restrict the amount of insides or medications that you have to use during exercise if you can. Yeah. And for our listeners that aren't familiar with what NSAIDs are examples, can you give us a couple examples? INSED stands for the non-steroidal anti-inflammatory drugs. So that would be like your ibuprofen. If you over the counter, ibuprofen, I guess would be your generic name of it. But you can also buy like, I feel like I'm blanking on drug names now, Aleve or Advil as well. Yeah, naproxen sodium is one of them as well. So a lot of those over the counter anti-inflammatories. The other is because outside of INSEDs are like really ibuprofen is the most common probably example would be Tylenol or acetaminophen which would be indicated for reducing fever more than ibuprofen would. Ibuprofen would be more specific to muscle pain. Mm-hmm. That makes me think too. So, okay, so Tylenol. So you mentioned the like reducing the temperature set point and Tylenol reducing fever. Does that help if someone is, could it help in any way? Like if someone is racing or is it going to hurt to bring? as what I've read is that, because I remember when I first also started even learning what exertional heat illnesses were, thought why can't people just take Tylenol or ibuprofen and prevent it? That just seems so simple if it has that action. uh But it's not quite as simple as that and it doesn't directly... reduce the temperature while exercising. So I know that there's been a few studies that have been done and I don't know the names of them off the top of my head, but I can provide some of those sources too in relation to trying to see if you can blunt the core temperature response by taking that before exercise and I don't think that there was any success with that, yeah. Yeah, because in endurance sport, right, there's this constant battle of like, trying to, you know, maintain your hydration and not become so dehydrated. And then your temperature gets elevated and then your stomach gets upset and then you can't feel her, you know, it's um so yeah, very interesting. I know there was an ultra runner recently who I think just broke like a record. And he like did a breakdown of what he was healing with and he said, He's like, I don't necessarily recommend this, but I think he was taking, I forget if it was an NSAID or Tylenol, but he was taking like multiple of it throughout a hundred mile race, like during. I haven't gotten into our own data yet either with that, but we have like, we've started going to the ultra races and we've been to the Bear 100 a couple of times now and hopefully we'll get to go back. But the number of times that they document taking a medication during the race and it's always either Tylenol or ibuprofen is mind blowing. We have definitely not analyzed that yet. We are, we're analyzing kidney biomarkers with that as well, but We got to finish that first before we even look at stats at this point. um But yeah, no, they take a lot of those medications, but what we do also know in that ultramarathon population is kidney disease is more prevalent. And part of the reason why we were even, I guess, welcome at coming to this race was because the race director had mentioned experiencing kidney failure himself. uh And it's hard because it's like, We want to, like, I think about how people go to races, they go to the expo, they see these new things, and they're like, oh, well, if so-and-so's doing that, I want to do that, or I want to just try this out. And it's like, race day is not the day to try things out. See if that was a problem. Another, like, another thing that you can do is trying to eat during exercise, if you are going to take medications, right? But did you eat during your training cycle to know that you're not going to cause GI distress? Is it a food that you can tolerate? And like, coming back to those basics is always kind of what this... What this is, this is boring side of things, is did you sleep, did you eat, are you hydrated? Yeah, yeah, yeah, so important. OK, so from like a screening lens, if we do have some uh clinicians and other researchers listening, em but if there's a clinician who's doing a screening for an endurance athlete before a hot event, are there three questions about meds or mental health history that would be important to cover for the athlete or any labs even that they should be looking at? specifically about labs for all of the medications or if there's any that are I guess required. I do think that lithium is a drug that's not commonly prescribed in athletes, but if you are an athletic person there are recommendations out there for um undergoing testing to make sure that the blood level of the lithium isn't increasing because sweating can increase the concentration of the lithium in your blood. Right? yeah. specific example I know and I don't think that that's commonly prescribed to active people without undergoing testing or it shouldn't be. I don't want to say it isn't because I don't know. But I guess labs, yeah, that would be one example that I have for those. also just asking them in general, so what we do in athletic training is a pre-participation exam. And that's where you collect, do they have any medical conditions? Are they taking any medications? A couple of other questions you might want to ask would be, you ever experienced heat illness before? That's one of your top predictors if you may experience heat illness again is you've had it in the past. It doesn't mean that you're doomed but um it may be a warning about that. So I mean like number one is do you have any chronic medical conditions or do you have any medical conditions? I guess could be your first question, your second question, are you taking any medications? Whether that's over-the-counter or prescription. um And then I guess lastly, how long, like if they say yes to the medications, it might be a follow-up of like how long have you been taking it, have you worked out in this environment or at this intensity on these medications before might be a good starting place. Do you did you see it all with the survey um with the marching band? Were was there any uh change in heat illness if they've been on it longer versus a shorter duration of time? That's one thing we would like to look into in the future, but because it was just a one-time survey, we don't know necessarily how long they were on it. We didn't even know we were going to get that much medication information. Yeah. That was definitely after starting the analysis, like I could have never guessed that there would have been that many medications being taken. And not only a lot of the articles talk about like monotherapy, so just taking one prescription, but there's also a lot of individuals that are actually prescribed more than one. And not only are they taking more than one medication, they're taking different from different providers. So did their providers even talk to each other about why they're on two different medications or did they review the history? uh And at a patient level, I guess that comes back to like, do you are you actually telling your provider that you're taking these supplements or these medications? Or do you just expect them to know things and then don't mention it? Yikes, yeah, yeah. Well, you mentioned the drugs.com piece, right? Where people like listeners can go and search and see if they're anything they're on is increasing or worsening the absorption or effects of the other medication. So check that for sure and definitely talk to your doctors. is definitely a good one. Or PubMed, I know has some on there as well. Or like the NIH Stat Pearls, those are some of the easier ones to read. They do have each class of these medications on there too. Nice. We will definitely link all those below for the listeners so you guys can check those out. You mentioned heat acclimation or climatization. Is that a suggestion for someone while they're on the medication to be on the medication and prep themselves in a manner for the heat before they do the event or the marching band game in the heat? Yeah, I mean like probably anybody going to an environment that's new. If they can, like definitely acclimatize or acclimate to that uh environment that they're going to. It's like similar to if you have a race and you know it's at altitude or you know it's in a different time zone. If you can train at those times or try to train limited periods of time in higher elevation, right? Like you would take that if you can. It may not be the best opportunity or if you can... if you have the resources and the money to show up early somewhere to also do that and get familiar. But it usually takes between 10 to 14 days to appropriately or fully acclimatize to an environment. And that is with that daily exposure, not including rest days, essentially. There's lots of different ways that you can go about getting used to the environment. But in the heat, it'd be, in general, not even taking a recommendation. Gradually introduce and remember that that new stressor is stressing your body's ability to keep you healthy and maintain the exercise. But then when you add a medication, you might want to be even more gradual with that introduction. Okay, and then is there an increased hydration and or sodium need for these individuals? There has been some information that's come out about like the SSRIs specifically. There was a few of them that in the first three weeks they may be at a higher risk of developing hyponatremia and it's kind of hand in hand with like an increased thirst. So they have the increased thirst and then they're getting hyponatremic and basically their urine is clear in that scenario and they're excessively peeing more than they want to for sure. But usually after about three weeks is when they would see that kind of settle out. It's also a matter of, that's why I guess I mentioned earlier, how long have you been taking the medication? And so in that instance, not only how long have you been taking it, are you used to it? Have you figured out a way to overcome if you are peeing excessively, have you added more sodium to your diet potentially? Or if you have darker urine on a medication, are you drinking more water in that scenario? Right. Okay. That makes sense. And then are there cooling strategies you recommend if someone is on one of these medications and they're starting to feel maybe some of those earlier symptoms come on? Um, that one was, okay, I did kind of have a, I forgot to ask this question too, like, so when you say cooling, is this like when you're talking about like, like during the activity, like they put on a cooling vest and then they... Yeah, that or sipping something really cold or water on their head, are any of those like effective mechanisms for that population? I don't know if it, see that's the thing is it's so hard to know because a lot of the data that we have in general is from like the classic or that passive heat stroke. like when heat waves happen in an elderly populations. And so now we're kind of just extrapolating over to, well, if there's a risk in that setting, right? Like we would assume that there's a risk in those that are exercising potentially. Yeah. So I don't know. Yeah, I don't know if there are any that would be beneficial for those medications, but I know that. It's also dependent upon the individual and the activity, because you don't want to cool down too much to the point where then you don't feel ready to exercise. But if it's something that you've trained with, might be like the cooling vest is what I think of making people feel better. Sometimes if you can lower your core temp, if you have that time. But I don't know how, like what the parameters of what the temperature of that has to be or how long you have to wear that to even see a decrease in core temp. Yeah, yeah. And on that note, too, out of curiosity with your research in this area, um there's obviously come out these like different wearable sensors that they say are telling you your core temp, but it's actually just attached to your skin, which is like more accurate of your skin temperature. Can you tell us a little bit about those? I know I'm going to say everybody's favorite word, I'm sure. But the most accurate way to get a core temperature would be taking a rectal thermometer or rectal temperature. That would be your gold standard. The other option is esophageal to get an actual true core temperature because you need to know what the temperature of the organs is. um And so if you don't know what the temperature of the organ is and you're getting like a skin, so if it's like a ring or a watch that's telling you your temperature like you just mentioned, right, like that's definitely going to be more skin related but it could also be impacted by environment if you do like armpit or forehead right and they were just sweating or they also cooler than they're likely cooler than what their core will be. Unfortunately nobody has been able to figure out the equation for predicting what the skin or peripheral temperature is to be able to take a guess on what the core is. And that's why it's so hard like I know I said the 40.5 or 105 degrees but you don't want people to also rely on that number as if, well, they're only at 104, but they're altered central nervous system. They can't have heat stroke. So it's kind of that diagnostic criteria that goes together, I guess. I wouldn't say with that, I don't even know where, yeah, I forgot where I was supposed to go with that answer. that'll make sense. I just think, yeah, that's important to be shared because some of these sensors, yeah, are saying it's telling you a core temperature and it's like you're saying it's not. Yeah, you'd be more likely to like underdiagnose in that setting if you don't have the true core temp because you'd think that it's lower, it might not be heat stroke or like I know that there was a paper that came out recently talking about like EMS responses and by the time that they've gotten to somebody that has collapsed like on the sidewalk like sure they may be getting a heat from the ground as well especially if it's asphalt but they've probably already started the cooling process. They're no longer exerting themselves so is their core temperature even going to reflect? what it was when they collapsed is another concern. So in those instances when somebody does have, especially with like collapse and you don't know and they're overheating, sometimes it's better safe than sorry if you can cool first, transport second, because you know that people will survive and they're less likely to have like permanent consequences to the organs or like multi-organ failure if they're cooled within that 30 minutes is what they've shown. Wow. OK, within 30 minutes. Interesting. OK, so on that note, so when something goes wrong and someone is experiencing exertional heat stroke or illness, you mentioned cool first. How are they being cooled? What's the recommended way to cool somebody? um If you can, cold water immersion. Like an ice cap, essentially. um We use like, I feel like we go to the tractor supply and get like the feeding troughs that you can just put their core in, essentially. Yeah, but as soon as you can, as soon as you recognize or if that's your suspicion, it's an immediate, get their core into cold water immediately. um Once they've cooled, if you can, because you would do continuous um rectal formometry, usually it's just a... flexible thermistor, you'll plug it in when they're in there and you can pull them out when they, I want to say it's 103 to 102.5, it depends on if they're getting better or not. You can go off of the core temp to pull them out or you can pull them out when they start to shiver. But hopefully you can continuously monitor. Once they've been cooled then you can have them transported to go have labs done and see if there's any other damage that occurred at the same time. Yeah, just depends on how long the Instant Pot got to go. Yeah, yeah. So in like an endurance setting, uh ultra runners like out on a trail somewhere in a race and they don't have access to an ice bath. Are they trying? I mean, a cold ice like snow ice river could be obviously an option. But I've heard different things about different locations on the body that can help cool faster. Is there any thought or conversation there if they have access like ice packs? Are there certain certain locations they should put them or? water on certain parts of the body, any recommendations there? I mean if they don't have like cold water immersion, anything that they can do at that point to try to cool would be ideal. I know that like some papers recommend doing like the armpits and the groin, but also if you can just cover the core as well. If you can put on their back, if you can also rotate it, if you can, if you have towels and you can go dip it in the snowy ice water, if that's available, rotate the towels, put those over them. Once they heat up, go dip them back in the cold water again. um they use, like in the military setting they have essentially body bags that they use and they zip them up with ice and water in them. Obviously that's something you would need to have with you for that to work out but um whatever you can do to cool would be ideal and if you don't necessarily have anything to cool if you can at least put them in the shade and try to get them out of that environment as quick as possible to get them to a cooling point that would obviously be ideal. Hopefully you can recognize warning signs before they would go into complete collapse. uh It's not the most, but it's It's one way to remember like that central nervous system alteration. It's not the most like appropriate. So understand if it needs to be edited out too, but like thinking about it from like the perspective of central nervous system alteration, if they're not acting right in the head or they're being somewhat of a dickhead, which would be disoriented, irritable, combative and confused. Okay. Okay. Yeah. right in the head. Maybe they're disoriented, irritable, combative, confused, suspect potentially that they might have exertional heat stroke and don't let them continue activity. But if they're also acting that way, they may not even listen to you. They may become more combative. So are you prepared to? Yeah. The nice thing is I've been Because my mentor at the University of Kansas, she works at the Heat Deck at the Boston Marathon. So I've been able to go and volunteer since 2018 now. So the last few years I've been able to be on the Heat Deck. My first year there was the year that Des Linden won. And so it was the hypothermia year. I remember we set up the Heat Deck, had a tub ready to go with the ice and water in it, just one, and then it was like, we don't even need this at this point. gosh. We're just transforming over into another segment of the ICU to hypothermia. But at Austin, we have the tubs ready to go. We've got the rectal thermometers on the table, ready to core temp anybody that's suspected. And as soon as it's been recognized, once you get the core temp, if it's at a level in their altered central nervous system, you just throw them in the tub. You have a lot more people to obviously help you in that scenario. um But yeah, it's really unfortunate when you get a combative athlete and you're alone. yeah, yeah, yeah, sounds tough. Sounds tough. ah It just makes me think of like a cranky old man or something. And he's just like, yeah. Yeah, tough. Yeah. Yeah, tough cookies out there. OK, well, I certainly want to be mindful of your time here. So we'll do let's see here. I just want to see which ones we want to cover. um this is an interesting one. How do we know if there's any influence on recovery after the Medicaid, like back to back trainings or racing? like a race on a Saturday and a Sunday or a stage race and medications implications on how they're recovering if there's been any heat stuff. That's a good question. em Even without medications, know that heat can be cumulative. So if they're not prioritizing their own recovery in general, like being in the heat repetitively without appropriate recovery or refueling, rehydrating strategies can make you more susceptible to heat illness. em And if you're not trained in that environment, you're already at a disadvantage from the perspective of the increased physiological strain. And then you're taking a medication that also alters your physiological function or ability to function. Hmm. so I would assume that the priority prioritization of the simple things like eating, hydrating are probably a little bit higher for individuals that are taking medications if they're also working out in the heat on a repetitive basis. Just a guess though. Yeah. Like if they're taking those anti-cholinergic drugs that are impeding sweating, or potentially reducing sweating, they may want to pay more attention to their hydration status. is just in general with that, also monitor their own core temperature. it, I guess, let me say one other thing, I guess, would be sleep. Are they sleeping? Because sleep can also lead to an increase in your core temp before even exercising. Especially if you're getting sick, but you can change your core temp and the ability to thermoregulate if you have a reduction in your sleep. so, that's why I'm like, the basics, like we gotta go back to the basics. Are we in a prime spot to even work out regardless if we're on a medication or are we setting ourselves up for more potential risks associated with that exercise? That's interesting. And then of course, then there's gotta be literature on women like in their luteal phase of their menstrual cycle when their core temperature is slightly elevated and then they're on SSRIs and then they race in the heat. Then what's happening? I am very curious about what's happening in females, but I don't have those answers either. Another drug that actually has come up recently that a few people have mentioned to me, which I didn't think much about, but it makes sense, is the acne medications. Because if you're blocking the follicles, you would be changing probably the sweat rate too. I haven't looked as much into any of that mechanism of action stuff, but just thinking about it probably impacts your ability to sweat as well. Yeah, that's really interesting. I didn't know about the sleep thing. That's fascinating. um OK, quick myth busting lightning round and then we're to find out what your tutors can rely. um OK, so antidepressants automatically mean you can't race in the heat. True or false? As long as you take them regularly and know what you're doing. Don't take them the first day of racing. Right, um NSAIDs keep your core temperature lower. True or false? box. If you felt overheated once, you're always, you'll always be heat intolerant. True or false? We we broke the thermostat and it's on now forever. I think, think it's false. You can also backtrack when you experience that and see, was there a trigger to this? Did I not sleep well last night? Do I have GI symptoms? Do I? Lots of things, yeah. Lots of things. OK, so I'm going to jump back to your two truths and lie. And then we're going to find out where people can find you and follow you and get all those good nuggets. OK, so you said you were born in Minnesota. You grew up in Washington state and then you have three brothers. I thought the three brothers was a lie. Is that. I got it. Yes, I am getting good at this. OK. don't know what to say for this, but maybe it'll throw her off if I say Minnesota and Washington. Do you have any brothers or do you have sisters? Oh, OK, nice. Yes, that's a good one. You did get there. then so you're born in Minnesota, but when did you mean? Did you move to Washington? How old were you? ah Before I recall, I was a baby, so I was born basically in Canada in International Falls, Minnesota and then grew up in Washington State. uh And where are you zooming in from today? Utah. OK. That's right. Yes. Yeah. Awesome. All right. OK. Well, where can our listeners find you, follow your research, all that good stuff? I'm not on social media so I will be disappointed from that perspective but I guess I have I somewhat used my research gate. My Google Scholar I do try to keep updated because that helps me update my own CV that I have to keep up to date that I forget about. So yeah I don't have a lot of places to be followed but that would be I guess the two that you could search for this stuff or if you send me an email I will reply. Perfect, yes. And then in the ultra bare data, that's gonna be coming out when do you think? um Hopefully we will be getting that out this spring. So we've got one more biomarker to analyze and then we'll have four biomarkers on the kidneys and we have all their nutrition info that they self-reported and medication use. So I'm really excited to start looking at that stuff. Yeah. I would look forward to that. perfect. Awesome. Well, thank you so much for joining us, Melanie. This has been awesome. Yeah, thank you for having me. Bam.

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Kyla Channell, MS

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