Do sex differences in thermoregulation pose a concern for female athletes preparing for the Tokyo Olympics?

A century of exercise physiology: concepts that ignited the study of human thermoregulation. Part 4: evolution, thermal adaptation and unsupported theories of thermoregulation

This review is the final contribution to a four-part, historical series on human exercise physiology in thermally stressful conditions. The series opened with reminders of the principles governing heat exchange and an overview of our contemporary understanding of thermoregulation (Part 1). We then reviewed the development of physiological measurements (Part 2) used to reveal the autonomic processes at work during heat and cold stresses. Next, we re-examined thermal-stress tolerance and intolerance, and critiqued the indices of thermal stress and strain (Part 3). Herein, we describe the evolutionary steps that endowed humans with a unique potential to tolerate endurance activity in the heat, and we examine how those attributes can be enhanced during thermal adaptation. The first of our ancestors to qualify as an athlete was Homo erectus, who were hairless, sweating specialists with eccrine sweat glands covering almost their entire body surface. Homo sapiens were skilful behavioural thermoregulators, which preserved their resource-wasteful, autonomic thermoeffectors (shivering and sweating) for more stressful encounters. Following emigration, they regularly experienced heat and cold stress, to which they acclimatised and developed less powerful (habituated) effector responses when those stresses were re-encountered. We critique hypotheses that linked thermoregulatory differences to ancestry. By exploring short-term heat and cold acclimation, we reveal sweat hypersecretion and powerful shivering to be protective, transitional stages en route to more complete thermal adaptation (habituation). To conclude this historical series, we examine some of the concepts and hypotheses of thermoregulation during exercise that did not withstand the tests of time.

A century of exercise physiology: concepts that ignited the study of human thermoregulation. Part 3: Heat and cold tolerance during exercise

In this third installment of our four-part historical series, we evaluate contributions that shaped our understanding of heat and cold stress during occupational and athletic pursuits. Our first topic concerns how we tolerate, and sometimes fail to tolerate, exercise-heat stress. By 1900, physical activity with clothing- and climate-induced evaporative impediments led to an extraordinarily high incidence of heat stroke within the military. Fortunately, deep-body temperatures > 40 °C were not always fatal. Thirty years later, water immersion and patient treatments mimicking sweat evaporation were found to be effective, with the adage of cool first, transport later being adopted. We gradually acquired an understanding of thermoeffector function during heat storage, and learned about challenges to other regulatory mechanisms. In our second topic, we explore cold tolerance and intolerance. By the 1930s, hypothermia was known to reduce cutaneous circulation, particularly at the extremities, conserving body heat. Cold-induced vasodilatation hindered heat conservation, but it was protective. Increased metabolic heat production followed, driven by shivering and non-shivering thermogenesis, even during exercise and work. Physical endurance and shivering could both be compromised by hypoglycaemia. Later, treatments for hypothermia and cold injuries were refined, and the thermal after-drop was explained. In our final topic, we critique the numerous indices developed in attempts to numerically rate hot and cold stresses. The criteria for an effective thermal stress index were established by the 1930s. However, few indices satisfied those requirements, either then or now, and the surviving indices, including the unvalidated Wet-Bulb Globe-Thermometer index, do not fully predict thermal strain.

Quantifying Exercise Heat Acclimatisation in Athletes and Military Personnel: A Systematic Review and Meta-analysis

BACKGROUND

Athletes and military personnel are often expected to compete and work in hot and/or humid environments, where decrements in performance and an increased risk of exertional heat illness are prevalent. A physiological strategy for reducing the adverse effects of heat stress is to acclimatise to the heat.

OBJECTIVE

The aim of this systematic review was to quantify the effects of relocating to a hotter climate to undergo heat acclimatisation in athletes and military personnel.

ELIGIBILITY CRITERIA

Studies investigating the effects of heat acclimatisation in non-acclimatised athletes and military personnel via relocation to a hot climate for < 6 weeks were included.

DATA SOURCES

MEDLINE, SPORTDiscus, CINAHL Plus with Full Text and Scopus were searched from inception to June 2022.

RISK OF BIAS

A modified version of the McMaster critical review form was utilised independently by two authors to assess the risk of bias.

DATA SYNTHESIS

A Bayesian multi-level meta-analysis was conducted on five outcome measures, including resting core temperature and heart rate, the change in core temperature and heart rate during a heat response test and sweat rate. Wet-bulb globe temperature (WBGT), daily training duration and protocol length were used as predictor variables. Along with posterior means and 90% credible intervals (CrI), the probability of direction (Pd) was calculated.

RESULTS

Eighteen articles from twelve independent studies were included. Fourteen articles (nine studies) provided data for the meta-analyses. Whilst accounting for WBGT, daily training duration and protocol length, population estimates indicated a reduction in resting core temperature and heart rate of - 0.19 °C [90% CrI: - 0.41 to 0.05, Pd = 91%] and - 6 beats·min-1 [90% CrI: - 16 to 5, Pd = 83%], respectively. Furthermore, the rise in core temperature and heart rate during a heat response test were attenuated by - 0.24 °C [90% CrI: - 0.67 to 0.20, Pd = 85%] and - 7 beats·min-1 [90% CrI: - 18 to 4, Pd = 87%]. Changes in sweat rate were conflicting (0.01 L·h-1 [90% CrI: - 0.38 to 0.40, Pd = 53%]), primarily due to two studies demonstrating a reduction in sweat rate following heat acclimatisation.

CONCLUSIONS

Data from athletes and military personnel relocating to a hotter climate were consistent with a reduction in resting core temperature and heart rate, in addition to an attenuated rise in core temperature and heart rate during an exercise-based heat response test. An increase in sweat rate is also attainable, with the extent of these adaptations dependent on WBGT, daily training duration and protocol length.

PROSPERO REGISTRATION

CRD42022337761.

Treating exertional heat stroke: Limited understanding of the female response to cold water immersion

According to an expansive body of research and best practice statements, whole-body cold water immersion is the gold standard treatment for exertional heat stroke. However, as this founding evidence was predominantly drawn from males, the current guidelines for treatment are being applied to women without validation. Given the recognised differences in thermal responses experienced by men and women, all-encompassing exertional heat stroke treatment advice may not effectively protect both sexes. In fact, recent evidence suggests that hyperthermic women cool faster than hyperthermic men during cold water immersion. This raises the question of whether overcooling is risked if the present guidelines are followed. The current mini-review examined the literature on women's response to cold water immersion as a treatment for exertional heat stroke and aimed to clarify whether the current guidelines have appropriately considered research investigating women. The potential implications of applying these guidelines to women were also discussed.

Association between thermal responses, medical events, performance, heat acclimation and health status in male and female elite athletes during the 2019 Doha World Athletics Championships

Purpose

To determine associations between thermal responses, medical events, performance, heat acclimation and health status during a World Athletics Championships in hot-humid conditions.

Methods

From 305 marathon and race-walk starters, 83 completed a preparticipation questionnaire on health and acclimation. Core (T_core; ingestible pill) and skin (T_skin; thermal camera) temperatures were measured in-competition in 56 and 107 athletes, respectively. 70 in-race medical events were analysed retrospectively. Performance (% personal best) and did not finish (DNF) were extracted from official results.

Results

Peak T_core during competition reached 39.6°C±0.6°C (maximum 41.1°C). T_skin decreased from 32.2°C±1.3°C to 31.0°C±1.4°C during the races (p<0.001). T_core was not related to DNF (25% of starters) or medical events (p≥0.150), whereas T_skin, T_skin rate of decrease and T_core-to-T_skin gradient were (p≤0.029). A third of the athletes reported symptoms in the 10 days preceding the event, mainly insomnia, diarrhoea and stomach pain, with diarrhoea (9% of athletes) increasing the risk of in-race medical events (71% vs 17%, p<0.001). Athletes (63%) who performed 5–30 days heat acclimation before the competition: ranked better (18±13 vs 28±13, p=0.009), displayed a lower peak T_core (39.4°C±0.4°C vs 39.8°C±0.7°C, p=0.044) and larger in-race decrease in T_skin (−1.4°C±1.0°C vs −0.9°C±1.2°C, p=0.060), than non-acclimated athletes. Although not significant, they also showed lower DNF (19% vs 30%, p=0.273) and medical events (19% vs 32%, p=0.179).

Conclusion

T_skin, T_skin rate of decrease and T_core-to-T_skin gradient were important indicators of heat tolerance. While heat-acclimated athletes ranked better, recent diarrhoea represented a significant risk factor for DNF and in-race medical events.

Sex Differences in Endurance Running

In recent years, there has been a significant expansion in female participation in endurance (road and trail) running. The often reported sex differences in maximal oxygen uptake (VO_2max) are not the only differences between sexes during prolonged running. The aim of this narrative review was thus to discuss sex differences in running biomechanics, economy (both in fatigue and non-fatigue conditions), substrate utilization, muscle tissue characteristics (including ultrastructural muscle damage), neuromuscular fatigue, thermoregulation and pacing strategies. Although males and females do not differ in terms of running economy or endurance (i.e. percentage VO_2max sustained), sex-specificities exist in running biomechanics (e.g. females have greater non-sagittal hip and knee joint motion compared to males) that can be partly explained by anatomical (e.g. wider pelvis, larger femur-tibia angle, shorter lower limb length relative to total height in females) differences. Compared to males, females also show greater proportional area of type I fibres, are more able to use fatty acids and preserve carbohydrates during prolonged exercise, demonstrate a more even pacing strategy and less fatigue following endurance running exercise. These differences confer an advantage to females in ultra-endurance performance, but other factors (e.g. lower O₂ carrying capacity, greater body fat percentage) counterbalance these potential advantages, making females outperforming males a rare exception. The present literature review also highlights the lack of sex comparison in studies investigating running biomechanics in fatigue conditions and during the recovery process.

A Mixed-Method Approach of Pre-Cooling Enhances High-Intensity Running Performance in the Heat

We investigated whether single or combined methods of pre-cooling could affect high-intensity exercise performance in a hot environment. Seven male athletes were subjected to four experimental conditions for 30 min in a randomised order. The four experimental conditions were: 1) wearing a vest cooled to a temperature of 4 ℃ (Vest), 2) consuming a beverage cooled to a temperature of 4 ℃ (Beverage), 3) simultaneous usage of vest and consumption of beverage (Mix), and 4) the control trial without pre-cooling (CON). Following those experimental conditions, they exercised at a speed of 80% VO₂max until exhaustion in the heat (38.1 ± 0.6 ℃, 55.3 ± 0.3% RH). Heart rate (HR), rectal temperature (T_core), skin temperature (T_skin), sweat loss (SL), urine specific gravity (USG), levels of sodium (Na⁺) and potassium (K⁺), rating of perceived exertion (RPE), thermal sensation (TS), and levels of blood lactic acid ([Bla]) were monitored. Performance was improved using the mixed pre-cooling strategy (648.43 ± 77.53 s, p = 0.016) compared to CON (509.14 ± 54.57 s). T_core after pre-cooling was not different (Mix: 37.01 ± 0.27 ℃, Vest: 37.19 ± 0.33 ℃, Beverage: 37.03 ± 0.35 ℃) in all cooling conditions compared to those of CON (37.31 ±0.29 ℃). A similar T_core values was achieved at exhaustion in all trials (from 38.10 ℃ to 39.00 ℃). No difference in the level of USG was observed between the conditions. Our findings suggest that pre-cooling with a combination of cold vest usage and cold fluid intake can improve performance in the heat.

Hydration and cooling in elite athletes: relationship with performance, body mass loss and body temperatures during the Doha 2019 IAAF World Athletics Championships

Purpose

To characterise hydration, cooling, body mass loss, and core (T_core) and skin (T_sk) temperatures during World Athletics Championships in hot-humid conditions.

Methods

Marathon and race-walk (20 km and 50 km) athletes (n=83, 36 women) completed a pre-race questionnaire. Pre-race and post-race body weight (n=74), T_core (n=56) and T_sk (n=49; thermography) were measured.

Results

Most athletes (93%) had a pre-planned drinking strategy (electrolytes (83%), carbohydrates (81%)) while ice slurry was less common (11%; p<0.001). More men than women relied on electrolytes and carbohydrates (91%–93% vs 67%–72%, p≤0.029). Drinking strategies were based on personal experience (91%) rather than external sources (p<0.001). Most athletes (80%) planned pre-cooling (ice vests (53%), cold towels (45%), neck collars (21%) and ice slurry (21%)) and/or mid-cooling (93%; head/face dousing (65%) and cold water ingestion (52%)). Menthol usage was negligible (1%–2%). Pre-race T_core was lower in athletes using ice vests (37.5°C±0.4°C vs 37.8°C±0.3°C, p=0.024). T_core (pre-race 37.7°C±0.3°C, post-race 39.6°C±0.6°C) was independent of event, ranking or performance (p≥0.225). Pre-race T_sk was correlated with faster race completion (r=0.32, p=0.046) and was higher in non-finishers (did not finish (DNF); 33.8°C±0.9°C vs 32.6°C±1.4°C, p=0.017). Body mass loss was higher in men than women (−2.8±1.5% vs −1.3±1.6%, p<0.001), although not associated with performance.

Conclusion

Most athletes’ hydration strategies were pre-planned based on personal experience. Ice vests were the most adopted pre-cooling strategy and the only one minimising T_core, suggesting that event organisers should be cognisant of logistics (ie, freezers). Dehydration was moderate and unrelated to performance. Pre-race T_sk was related to performance and DNF, suggesting that T_sk modulation should be incorporated into pre-race strategies.