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Cited by 25Thermoregulation and physiological responsesExercise and Physiological ResponsesSports Performance and Training

Nutrition-Related Adverse Outcomes in Endurance Sports Competitions: A Review of Incidence and Practical Recommendations

Open access
Martínez-Sanz, José Miguel, Fernández Nuñez, Ana, Sospedra, Isabel, Martínez-Rodríguez, Alejandro, Domínguez, Raúl, González-Jurado, José Antonio, Sánchez-Oliver, Antonio J.·2020·International Journal of Environmental Research and Public Health
DOI 10.3390/ijerph17114082PMC PMC7312487
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Abstract

During the last few years, the numbers of competitors in endurance and ultra-endurance sports modalities have increased significantly. This type of competition is an extreme challenge for athletes. Therefore, they have an increased the risk of developing medical and nutritional problems. The aim of the work is to estimate the incidence of nutrition-related adverse outcomes in endurance and ultra-endurance sports, considering the variables that influence them. A critical review was carried out based on the PubMed database, by means of a search strategy based on keywords separated by Boolean connectors. For all the results obtained in a period from 2008 to 2019, a series of inclusion/exclusion criteria was applied to select only the studies that fitted the objective of the present study. Results and discussion: Of the 871 publications identified, 33 met the inclusion criteria. The adverse outcomes found included exercise-associated hyponatremia (EAH), heat stroke by exertion (EHS), gastrointestinal (GI) problems, dehydration, and hypothermia; the provision of misinformation to athletes about nutrient intake and hydration during competition was identified as the main cause. Conclusions: The main adverse outcomes in endurance and ultra-endurance sports modalities are EAH, GI inconveniences, and EHS. These problems can affect the performance and health status of the athlete during and post-competition. Several nutritional guidelines have been suggested that can prevent these adverse outcomes, and it is essential to individualize and adjust the nutritional intake and hydration status according to the characteristics of each competition.

AI snapshot

Written from the paper’s full text.

TL;DR

This critical review of 33 studies covering 23,344 athletes found dehydration, exercise-associated hyponatremia (EAH), gastrointestinal (GI) problems, exertional heat stroke (EHS), and hypothermia (HT) are the main nutrition-related adverse outcomes in endurance and ultra-endurance competitions. Incidence varied by outcome and event, and the authors recommend individualized hydration/electrolyte strategies, acclimatization, and avoiding new foods or supplements during competition.

Key findings

  • From 871 identified publications, 33 met inclusion criteria (18 cohort studies, 11 case studies, 4 randomized clinical trials), with a total sample of 23,344 athletes; competitions included ultra-marathon (n = 8), marathon (n = 8), cycling (n = 6), Olympic distance triathlon (n = 3), hiking (n = 3), and others.
  • In cohort studies, incidence ranged from 6.4% (HT) to 20.4% (dehydration, DH); DH appeared in 392 of 1918 athletes, EAH in 10.3% (290/2829), GI problems in 9.4% (1302/13,852), and HT in 6.4% (13/202). No EHS cases were detected in cohort or clinical trial studies.
  • In clinical trials, DH appeared in 33.3% (10/30), GI problems in 16.7% (5/30), and EAH in 6.0% (14/233); no HT cases were detected. Among reported EAH cases, 6% were severe, 8% moderate, 86% mild or not clinically significant, and one had no severity information.
  • Other reported figures include EAH incidence of 6–18% in Ironman, 6–11.5% in mountain biking, and 15–30% in ultra-endurance running; HT average incidence of 1.7% across all included studies and approximately 1.5% in open-water swimming; and EHS estimated at 1 in every 1000 athletes. GI problems were reported in 30–70% of athletes in the introduction and 30–90% in the discussion.

Methods

  • A critical review was conducted using PubMed, with a search strategy based on MeSH descriptors, entry terms, and [tiab] terms. Inclusion criteria were human studies on adverse outcomes in endurance/ultra-endurance athletes during competitions, cohort studies/case studies/clinical trials, English or Spanish, published 2008–2019; reviews, non-human studies, and non-endurance sports were excluded.
  • Two researchers independently screened titles and abstracts, accessing full texts when in doubt. Of 871 publications identified, 6 duplicates were removed, leaving 865 screened and 33 included.
  • Data extracted included study authors/year, objective, sample, sport competition, adverse outcomes, incidence, causes, and conclusions. Incidence was calculated in cohort studies where the total population was described.

Limitations

  • The paper states that available evidence for HT is limited and mechanisms of swimming-related cardiac arrhythmias are not clearly defined; it also notes limited published results for GI diarrhea and that EAH signs/symptoms are nonspecific and can be confused with EHS, GI symptoms, and hypoglycemia.
  • Evident from the text: this is a critical review limited to PubMed and 2008–2019, with no meta-analysis or formal risk-of-bias/quality appraisal described, and incidence estimates are drawn from heterogeneous study designs and only cohorts with total population described.
  • Evident from the text: no EHS cases were detected in the included cohort and clinical trial studies, so EHS incidence estimates rely on other cited sources rather than the reviewed incidence data.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3390/ijerph17114082

Cites

Statistics

Nothing to recompute.

Claims the paper makes

0 of 74 cited sources checked · 0 supported · 0 flagged

  • Findingreasoning

    The main adverse outcomes in endurance and ultra-endurance sports modalities are EAH, GI inconveniences, and EHS.

    “Conclusions: The main adverse outcomes in endurance and ultra-endurance sports modalities are EAH, GI inconveniences, and EHS.”
    Quote in the paperSubstantial claim
  • Findingown data

    In clinical trial studies, EAH appeared in 14 of 233 (6.0%).

    “and EAH with 14 cases of 233 (6.0%).”
    Quote in the paperNot a substantial claim
  • Findingown data

    In cohort studies, EAH incidence was 10.3% (290 cases of 2829).

    “followed by EAH with an incidence of 10.3% (290 cases of 2829)”
    Quote in the paperNot a substantial claim
  • Findingcitation

    EAH incidence rates of 6-11.5% were reported in mountain biking events.

    “6–11.5% in mountain biking events [28,43]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [28] Rosemann, 2016, Pre- and post-race hydration status in hyponatremic and non-hyponatremic ultra-endurance athletes, Chin. J. Physiol. source

      Not checked in the free run.

    • cites [43] Knechtle, 2011, Prevalence of exercise-associated hyponatremia in male ultraendurance athletes, Clin. J. Sport Med. source

      Not checked in the free run.

  • Findingcitation

    EAH incidence rates of 15-30% were reported in ultra-endurance running races.

    “15–30% in ultra- endurance running races [34,36]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [34] Hoffman, 2012, Hyponatremia in the 2009 161-km Western States Endurance Run, Int. J. Sports Physiol. Perform. source

      Not checked in the free run.

    • cites [36] Bruso, 2010, Rhabdomyolysis and Hyponatremia: A cluster of five cases at the 161-km 2009 Western States Endurance Run, Wilderness Environ. Med. source

      Not checked in the free run.

  • May combine two claims. 25
  • Classified as probably not a substantial claim. 19

  • May combine two claims.

    Findingown data

    The adverse outcomes found in the reviewed studies included exercise-associated hyponatremia (EAH), heat stroke by exertion (EHS), gastrointestinal (GI) problems, dehydration, and hypothermia.

    “The adverse outcomes found included exercise-associated hyponatremia (EAH), heat stroke by exertion (EHS), gastrointestinal (GI) problems, dehydration, and hypothermia; the provision of misinformation to athletes about nutrient intake and hydration during competition was identified as the main cause.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The main adverse outcomes in competitions of endurance and ultra-endurance are dehydration (DH), followed by EAH and GI alterations or diseases.

    “The main adverse outcomes in competitions of endurance and ultra- endurance are DH, followed by EAH and GI alterations or diseases.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The review identified 33 studies meeting inclusion criteria from 871 publications.

    “The number of publications identified was 871. After eliminate duplicate articles (n = 6), 865 articles were identified for this review, of which only 33 (18 cohort-study articles, 11 case studies, and 4 randomized clinical trials) remained after applying thee exclusion criteria (see Figure 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    From all reported EAH cases, 6% were classified as severe, 8% as moderate, 86% were mild or not clinically significant, and for one case no information about severity was reported.

    “from all the cases reported, only 6% were classified as severe, 8% as moderate, 86% were mild or not clinically significant and for one case no information about its severity was reported.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among the adverse outcomes observed in the different studies were GI diseases or alterations (n = 7), EHS (n = 7), HT (n = 3), EAH (n = 13), and DH (n = 5).

    “Among the adverse outcomes observed in the different studies were GI diseases or alterations (n = 7), EHS (n = 7), HT (n = 3), and alterations related to the hydration status of the athletes: EAH (n = 13) and DH (n = 5).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among the GI alterations found were nausea, vomiting, diarrhea, stomach/abdominal pain, cramps, and GI hemorrhages.

    “Among the GI alterations we find nausea, vomiting, diarrhea, stomach/abdominal pain, cramps, and GI hemorrhages.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    These conditions affect not only performance, but also the health of participants.

    “(2) these conditions affect not only performance, but also the health of participants”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    EAH can be prevented and treated if it is detected quickly and appropriate measures are taken, avoiding complications and side effects that in extreme cases can lead to death.

    “The appearance of EAH can be prevented and treated if it is detected quickly and appropriate measures are taken, thus avoiding the complications and side effects that, in extreme cases, can lead to death [13].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Danz, 2016, Hyponatremia among triathletes in the ironman European Championship, N. Engl. J. Med. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    EHS is one of the first three causes of sudden death in sports.

    “being a potentially dangerous condition for the athletes and one of the first three causes of sudden death in sports [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Stearns, 2016, A tale of two heat strokes: A comparative case study, Curr. Sports Med. Rep. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Dehydration diminishes the ability to dissipate body heat, and correct fluid reposition during exercise could diminish a possible EHS associated with exercise.

    “Therefore, the dehydration diminish the ability to dissipate body heat and a correct fluid reposition during exercise could diminish a possible EHS associated to exercise [19].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] Montain, 1995, Control of thermoregulatory sweating is altered by hydration level and exercise intensity, J. Appl. Physiol. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Dehydration is caused by inadequate fluid intake and/or a significant loss of body fluid through sweat.

    “Dehydration (DH) is the problem of greatest concern to date, being caused by inadequate fluid intake and/or a significant loss of body fluid through sweat [10].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] 2016, Planificación dietético-nutricional para llevar a cabo una Ultramaratón, la Transvulcania: Informe de caso, Revista Española Nutrición Humana Dietética source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Studies suggest that between 30 and 70% of athletes experience gastrointestinal problems during competition.

    “In general, studies suggest that between 30 and 70% of athletes experience gastrointestinal problems during competition [21].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Waterman, 2012, Upper gastrointestinal issues in athletes, Curr. Sports Med. Rep. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In some environments overhydration is almost as frequent as dehydration and is a key stimulus for the development of symptomatic exercise-associated hyponatremia (EAH).

    “However, it should be noted that in some environments overhydration is almost as frequent, being a key stimulus for the development of symptomatic hyponatremia associated with exercise (EAH) [11]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Hoffman, 2017, Management of suspected fluid balance issues in participants of wilderness endurance events, Curr. Sports Med. Rep. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Even in cold weather the active body still sweats and needs fluids, and warm fluids or fluids at room temperature can help protect against hypothermia.

    “Likewise, even in cold weather the active body still sweats and needs fluids, and warm fluids or at room temperature can help to protect against hypothermia [20].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Whitney, E.N., and Rolfes, S.R. (2008). Understanding Nutrition, Thomson/Wadsworth.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationnone given

    Several nutritional guidelines have been suggested that can prevent these adverse outcomes.

    “Several nutritional guidelines have been suggested that can prevent these adverse outcomes, and it is essential to individualize and adjust the nutritional intake and hydration status according to the characteristics of each competition.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Most gastrointestinal symptoms during exercise are mild and do not carry any health risks, but hemorrhagic gastritis or intestinal ischemia can be serious medical problems.

    “Most gastrointestinal symptoms during exercise are mild and do not carry any health risks, but hemorrhagic gastritis or intestinal ischemia can be serious medical problems [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Burini, 2014, Gastrointestinal complaints during exercise: Prevalence, etiology, and nutritional recommendations, Sports Med. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Some GI problems are serious and affect the performance of athletes.

    “Some of these GI problems are serious and affect the performance of athletes [23].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] 2017, Runner’s diarrhea: What is it, what causes it, and how can it be prevented?, Curr. Opin. Gastroenterol. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    The incidence of DH may reflect limited opportunities for the ingestion of fluid during competition and/or a lack of knowledge regarding the nutritional requirements and fluid consumption by athletes.

    “The incidence of DH may also reflect limited opportunities for the ingestion of fluid during competition and/or a lack of knowledge regarding the nutritional requirements of and fluid consumption by athletes [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Magee, 2017, High prevalence of dehydration and inadequate nutritional knowledge among University and Club level athletes, Int. J. Sport Nutr. Exerc. Metab. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The causes that contribute to the development of some of these risks are of multifactorial origin, although some cause-effect relationships have been established.

    “The analysis of the results obtained showed that the causes that contribute to the development of some of these risks are of multifactorial origin, although some cause-effect relationships have been established.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    12.8% of the rescues of mountain athletes in the province of Aragon, Spain, are for GI problems.

    “12.8% of the rescues of mountain athletes in the province of Aragon, Spain, are for these reasons [56].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] 2017, Nontraumatic medical emergencies in mountain rescues, Emergencias

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Inadequate guidelines on the nutritional needs of each athlete, added to the introduction of food or supplements that the athlete has not previously consumed, can cause discomfort and GI diseases.

    “Inadequate guidelines on the nutritional needs of each athlete, added to the introduction of food or supplements that the athlete has not previously consumed, can cause discomfort and GI diseases.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Risk factors identified for the development of EAH include female sex, alcohol consumption, excess of fluid replacement, weight gain during exercise, low body weight, slow running performance, and inexperience in endurance events.

    “The risk factors that have been identified regarding the development of EAH include: female sex, alcohol consumption, excess of fluid replacement, weight gain during exercise, low body weight, slow running performance and inexperience in endurance events [12].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Cairns, 2015, Incidence of exercise-associated hyponatremia and its association with nonosmotic stimuli of arginine vasopressin in the GNW100s ultra-endurance marathon, Clin. J. Sport Med. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    If acclimatization appropriate to the conditions in which the competition takes place is not performed, this increases the risk of suffering from EHS and HT.

    “In addition, if acclimatization appropriate to the conditions in which the competition takes place is not performed, this increases the risk of suffering from EHS and HT (Figure 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Between 30 and 90% of endurance and ultra-endurance runners may suffer one or more GI problem(s) that affect their performance and may determine whether or not they finish the competition.

    “Between 30 and 90% of such athletes may suffer one or more GI problem(s) [23,33] that affect(s) their performance and, therefore, may determine whether or not the athletes finish the competition [23].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [23] 2017, Runner’s diarrhea: What is it, what causes it, and how can it be prevented?, Curr. Opin. Gastroenterol. source

      Not checked in the free run.

    • cites [33] Mexia, 2012, Gastrointestinal disease outbreaks in cycling events: Are preventive measures effective?, Epidemiol. Infect. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The most common complaints of the upper gastrointestinal tract include heartburn, nausea, abdominal cramps, vomiting, epigastric pain, and diarrhea.

    “The most common complaints of the upper gastrointestinal tract include heartburn, nausea, abdominal cramps, vomiting, epigastric pain, and diarrhea. Each of these symptoms may be present in multiple disease states at different levels of severity [23].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] 2017, Runner’s diarrhea: What is it, what causes it, and how can it be prevented?, Curr. Opin. Gastroenterol. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A sufficient amount of carbohydrates should be ingested to ensure the recovery of glycogen stores; this may vary between 5 and 12 g/kg body weight/day depending on the athlete and the physical activity performed.

    “A sufficient amount of carbohydrates should be ingested to ensure the recovery of glycogen stores; this may vary between 5 and 12 g/kg body weight/day depending on the athlete and the physical activity performed [5,58].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [5] Jeukendrup, 2011, Nutrition for endurance sports: Marathon, triathlon, and road cycling, J. Sports Sci. source

      Not checked in the free run.

    • cites [58] Ordoñez, F.M., Valenzuela, P.L., Gimenez, J., Tur, C., Ferreria, D., Domínguez, R., Sánchez-Oliver, A., and Sanz, J.M.M. (2019). Carbohydrate availability and physical performance: Physiological overview and practical recommendations. Nutrients, 11. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    EHS can be due to the production of metabolic heat (internal heat) and/or an overload of environmental heat (external heat), and occurs when the thermoregulatory system is disabled due to excessive heat production or inhibition of heat loss (i.e., a decreased sweating response).

    “EHS can be due to the production of metabolic heat (internal heat) and/or an overload of environmental heat (external heat), and occurs when the thermoregulatory system is disabled due to excessive heat production or inhibition of heat loss (i.e., a decreased sweating response) [45,61]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [45] Carvalho, A.S., Rodeia, S.C., Silvestre, J., and Póvoa, P. (2016). Exertional heat stroke and acute liver failure: A late dysfunction. BMJ Case Rep., 2016. source

      Not checked in the free run.

    • cites [61] Casa, 2015, National athletic trainers’ association position statement: Exertional heat illnesses, J. Athl. Train. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In cold waters, rectal temperature can continue to fall after the swimming stage, and relative humidity during subsequent cycling can trigger a greater fall in body temperature and a deterioration in performance.

    “In cold waters, the rectal temperature can continue to fall even after the end of the swimming stage; this, together with the relative humidity that the athletes experience when subsequently continuing with the triathlon bike stage, can trigger a greater fall in body temperature and a deterioration in the performance of the athletes [64].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64] Nuckton, 2000, Hypothermia and afterdrop following open water swimming: The Alcatraz/San Francisco swim study, Am. J. Emerg. Med. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There is a theoretical relationship between body water balance and the development of cardiac arrhythmias.

    “Although the mechanisms of cardiac arrhythmias are not clearly defined, there is a theoretical relationship between body water balance and their development [63].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [63] Asplund, 2016, Hypothesised mechanisms of swimming-related death: A systematic review, Br. J. Sports Med. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Prior acclimatization to the weather conditions of the competition and an adequate hydro-electrolyte balance reduce the risk of DH and therefore the risk of suffering from EAH.

    “Athletes participating in endurance and ultra-endurance competitions should keep in mind that both prior acclimatization to the weather conditions of the competition and an adequate hydro-electrolyte balance reduce the risk of DH and therefore the risk of suffering from EAH”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    DH is a predisposing factor in the development of EAH.

    “(4) DH is a predisposing factor in the development of EAH.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In cold weather, the active body still sweats and needs fluids.

    “At nutritional level because in cold weather the active body still sweats and needs fluids”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Whitney, E.N., and Rolfes, S.R. (2008). Understanding Nutrition, Thomson/Wadsworth.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    HT, as a non-traumatic medical pathology related to the environment, accounts for 68.9% of the rescues of mountain athletes.

    “It has been reported that HT, as a non-traumatic medical pathology related to the environment, accounts for 68.9% of the rescues of mountain athletes [56].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] 2017, Nontraumatic medical emergencies in mountain rescues, Emergencias

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    HT is not limited to sports involving swimming races; it also occurs in other sports such as mountaineering and mountain races, where high altitude causes a descent in temperature and increases the probability of HT.

    “but it is not limited to sports involving swimming races, it also occurs in other sports such as mountaineering and mountain races, in which high altitude causes a descent in temperature and increases the probability that athletes suffer this condition [27].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Brustia, 2016, Results of a Prospective Observational Study on Mountaineering Emergencies in Western Alps: Mind your head, High Alt. Med. Biol. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Adequate pre-competition preparation is a fundamental part of the avoidance of DH.

    “These data suggest that a fundamental part of the avoidance of DH is an adequate pre-competition preparation”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The diagnostic signs of EHS are collapse, aggressiveness and irritability, confusion, convulsions, and alterations of consciousness.

    “The diagnostic signs of EHS are collapse, aggressiveness and irritability, confusion, convulsions, and alterations of consciousness [61]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [61] Casa, 2015, National athletic trainers’ association position statement: Exertional heat illnesses, J. Athl. Train. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    To prevent athletes from suffering from EHS, they must undergo a previous protocol of acclimatization to the conditions in which the competition will take place.

    “(6) to prevent athletes from suffering from EHS, they must undergo a previous protocol of acclimatization to the conditions in which the competition will take place”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Inadequate acclimatization and dehydration/hypohydration (DH) are the main causes of EHS.

    “Based on the analysis of the different studies found, inadequate acclimatization and the DH of athletes can be suggested as the main causes of this adverse outcome.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    EHS has an estimated incidence of 1 in every 1000 athletes.

    “It has an estimated incidence of 1 in every 1000 athletes [62]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [62] Pryor, 2015, Medical evaluation for exposure extremes: Heat, Wilderness Environ. Med. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationcitation

    Good strategies of fluid management before, during, and after exercise could contribute to prevent hypothermia.

    “so good strategies of fluid management before, during, and after exercise could contribute to prevent hypothermia [20].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Whitney, E.N., and Rolfes, S.R. (2008). Understanding Nutrition, Thomson/Wadsworth.

      Not checked in the free run.

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References 66 · Cited by 25

Authors
Martínez-Sanz, J. M., Fernández Nuñez, A., Sospedra, I., Martínez-Rodríguez, A., Domínguez, R., González-Jurado, J. A., & Sánchez-Oliver, A. J.
Affiliations
  • Departamento de Enfermería, Grupo de Investigación en Alimentación y Nutrición (ALINUT), Facultad de Ciencias de la Salud, Universidad de Alicante, 03690 Alicante, Spain
  • Facultad de Ciencias de la Salud, Universidad de Alicante, 03690 Alicante, Spain
  • University of Alicante (ES)
  • Universidad Isabel I (ES)
  • Universidad Pablo de Olavide (ES)
  • Universidad de Sevilla (ES)
Corresponding author
González-Jurado, José Antonio
ORCID
Venue
International Journal of Environmental Research and Public Health
Publisher
MDPI AG
Published
2020-06-08
Volume
17
Issue
11
Pages
4082
ISSN
1660-4601 (ISSN-L)
DOI
10.3390/ijerph17114082
PMC
PMC7312487
OpenAlex
W3033826617
Semantic Scholar
8b66b72bdab83ad2a146d78371aba3febd85572d
Cited by
25
References
66
Citations by year
2026: 1 · 2025: 5 · 2024: 3 · 2023: 9 · 2022: 2 · 2021: 4 · 2020: 1
FWCI
0.51
Type
journal article
Language
en
Open access
Licence
Locations
  • International Journal of Environmental Research and Public Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (publishedVersion, cc-by-nc-nd)
  • RePEc: Research Papers in Economics (submittedVersion)
  • LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (submittedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • Deposito de Investigacion Universidad de Sevilla (University of Seville) (submittedVersion, cc-by-nc-nd)
  • Repositorio Institucional de la Universidad de Alicante (Universidad de Alicante) (submittedVersion, cc-by)
Topics
  • Health Sciences › Medicine › Physiology › Thermoregulation and physiological responses
  • Health Sciences › Medicine › Rehabilitation › Exercise and Physiological Responses
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
Keywords
endurance sports, ultra-endurance sports, exercise-associated hyponatremia, heatstroke, gastrointestinal problems, dehydration, hypothermia, nutrient intake, personalized nutrition, incidence, prevention recommendations
MeSH terms
Humans, Nutritional Status, Physical Endurance, Sports, Incidence, Athletes

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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