Salt and water before stepping on stage: the risks

Manipulations with water and salt in the final days before a show became part of bodybuilding “folklore” long ago. The editorial team broke down how the body reacts to such experiments, what complications are described in the medical literature and why diuretics are a separate zone of heightened danger.

Why athletes manipulate salt and water

The last week before a bodybuilding and fitness competition — the so-called “peak week” — is traditionally surrounded by rituals. Among the most common are “water loading” followed by a sharp restriction of fluids, complete removal of salt from the diet a few days before the show and, in extreme cases, taking diuretics. The goal is to remove water from under the skin so that the muscles look denser and more defined.

A survey of natural bodybuilders conducted by Chappell and Simper (2018) showed that a significant share of participants use manipulations with water and sodium, although the methods vary greatly and are often passed on “by word of mouth.” The scientific basis for most such protocols is weak or absent.

The problem is that the body has powerful mechanisms for maintaining the water-salt balance. An attempt to “outsmart” the kidneys and the hormonal system over a few days often produces the opposite effect: the muscles lose fullness, the skin becomes “flat,” and well-being worsens on the very day of the show.

In this article the editorial team focuses on the risks: what happens physiologically with a sharp restriction of water and salt, what complications are described in the medical literature and why diuretics are a separate, far more dangerous story.

Physiology: why the body “fights” restriction

The body keeps the sodium concentration in plasma within a narrow corridor. When water intake drops sharply, the pituitary gland releases antidiuretic hormone (ADH, vasopressin), and the kidneys begin to concentrate the urine and retain water. When sodium intake falls, the renin-angiotensin-aldosterone system is activated: aldosterone forces the kidneys to retain sodium and at the same time excrete potassium.

This is exactly where the paradox of peak week lies. A person removes salt to “get rid of water,” and the body responds by raising aldosterone and retaining sodium. If on the final day the salt is brought back or the athlete eats salty food, part of the fluid can be quickly retained — and not necessarily where it was wanted.

Water loading followed by restriction is based on the idea that the kidneys will “get used to” excreting a lot of fluid and will keep doing so after fluid intake is cut. Some short-term effect is indeed possible, but it is accompanied by a loss of electrolytes in the urine, and in combination with a low salt content in the diet — by the risk of their deficiency.

It is also important to understand that more than half the volume of muscle tissue is water. Excessive dehydration reduces not only subcutaneous fluid but also intracellular fluid, so the muscles lose the volume and “fullness” for the sake of which the whole thing was started.

The main health risks

Even without drugs, the combination of a low-calorie diet, fluid restriction and giving up salt burdens the cardiovascular system and the kidneys. An athlete at the final stage of preparation usually has minimal glycogen stores, a low body-fat percentage and chronic fatigue, so the compensatory capacities are reduced.

Hyponatremia deserves separate attention. The consensus on exercise-associated hyponatremia (Hew-Butler et al., 2015) emphasizes that the main cause is excessive water intake relative to losses. The scenario in which an athlete drinks large volumes of fluid and at the same time removes salt theoretically raises this risk. Severe hyponatremia can cause brain swelling and is life-threatening.

Disturbances in potassium and magnesium levels are dangerous for the heart. Even moderate hypokalemia against the background of an energy deficit and high adrenaline before a show can provoke arrhythmias. That is exactly why descriptions of severe complications in bodybuilders often feature electrolyte disturbances.

It is also significant that all these conditions develop over hours to days, and an athlete stressed before a competition tends to write symptoms off as nerves. Leg cramps, palpitations and dizziness are not a “normal part of peak week” but a signal to stop.

Diuretics: a separate category of danger

Diuretic drugs (loop, thiazide, potassium-sparing) are prescription medicines for treating heart failure, hypertension and edema. In sport they fall under section S5 of the WADA Prohibited List as “diuretics and masking agents,” meaning they are banned in all sports and at all times.

The danger of diuretics in the context of peak week lies in the fact that they remove fluid and electrolytes much faster and in larger volumes than an “ordinary” body is capable of. Loop diuretics can cause a pronounced loss of potassium, sodium and magnesium, while potassium-sparing ones, on the contrary, can cause a dangerous rise in potassium. Both scenarios threaten arrhythmia.

The medical and sports press has described cases of severe complications and deaths of bodybuilders that involved diuretics against the background of harsh fluid restriction. The editorial team provides no schemes for their use and stresses: the independent use of these drugs for cosmetic purposes is a serious risk to life.

In addition, diuretics cause a sharp drop in plasma volume, which, combined with posing (which raises intrathoracic pressure) and the heat under the stage lights, creates conditions for fainting and collapse on stage.

• banned by WADA at all times (section S5);
• can cause both a deficiency and an excess of potassium;
• raise the risk of acute kidney injury;
• do not provide a guaranteed aesthetic effect.

What evidence-based recommendations say

A review by Helms, Aragon and Fitschen (2014) on the preparation of natural bodybuilders concluded that aggressive manipulations with water and electrolytes lack a sufficient evidence base and carry risks, so the authors advised caution. A later review by Escalante and colleagues (2021), devoted specifically to peak week, emphasizes that the leading role is played by the condition achieved by the time of the show and by carbohydrate management, not by extreme fluid manipulations.

An evidence-based approach assumes that the athlete does the main work on definition over the weeks and months of preparation. If a week before the competition the body-fat percentage is still too high, no tricks with water will fix it — they will only add risk.

Moderate corrections — for example, keeping the athlete’s usual salt level without sharp jumps, controlling fiber to reduce bloating, rehearsing a “trial” peak week in advance — are considered much safer. The key word here is “usual”: sharp changes in either direction give the least predictable result.

Any plans to restrict fluids for athletes with heart or kidney disease, or those taking medications that affect electrolytes, should be discussed with a doctor. Before a competition it is useful to have the results of recent electrolyte and creatinine tests.

And finally, an important organizational point: the athlete should not be alone on the day of the competition. A companion who knows the signs of dehydration and hyponatremia can call for medical help in time.

Editorial conclusions

A sharp restriction of water and salt before stepping on stage triggers compensatory reactions of the body that often nullify the expected aesthetic effect. Instead, the risk of dehydration, electrolyte disturbances, arrhythmias and fainting rises.

Diuretics are prescription drugs banned by WADA, and their cosmetic use is associated with severe complications up to and including fatal cases.

Evidence-based reviews advise relying on quality preparation and a moderate peak week without extreme manipulations.

Related topics on our blog: carbohydrate loading before a competition, electrolytes in sport and nutrition during cutting.

References

1. Chappell AJ, Simper TN. Nutritional peak week and competition day strategies of competitive natural bodybuilders. Sports (Basel). 2018;6(4):126.
2. Escalante G, Stevenson SW, Barakat C, Aragon AA, Schoenfeld BJ. Peak week recommendations for bodybuilders: an evidence based approach. BMC Sports Sci Med Rehabil. 2021;13:68.
3. Helms ER, Aragon AA, Fitschen PJ. Evidence-based recommendations for natural bodybuilding contest preparation: nutrition and supplementation. J Int Soc Sports Nutr. 2014;11:20.
4. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med. 2015;25(4):303–320.
5. Sterns RH. Disorders of plasma sodium — causes, consequences, and correction. N Engl J Med. 2015;372(1):55–65.
6. World Anti-Doping Agency. The World Anti-Doping Code: International Standard — Prohibited List (section S5: Diuretics and masking agents). Montreal: WADA; чинна редакція.