journal of research in health sciences

The Journal of Research in Health Sciences (JRHS) serves as the official publication of the School of Public Health at Hamadan University of Medical Sciences and is released on a quarterly basis. Since 2017, JRHS has transitioned to an electronic format.

JRHS is a rigorously peer-reviewed scientific journal with a multidisciplinary focus within the realm of public health. It welcomes contributions from diverse fields including Epidemiology, Biostatistics, Public Health, Occupational Health, Environmental Health, Health Education, and Preventive and Social Medicine.

It is important to note that we do not accept submissions related to clinical trials, animal studies, qualitative studies, health insurance, or hospital management. Additionally, we do not consider research findings from laboratory and chemical studies in the domains of ergonomics, occupational health, and environmental health for publication.

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JRHS  is indexed by:

Web of Science  – IF:  1.768

Emerging Sources Citation Index (ESCI)

PubMed Central (PMC)

Scopus    – CiteScore: 2.70

WHO-EMRO Index Medicus

Index Copernicus International

CABI (Centre for Agriculture and Biosciences International)

ISC (Islamic World Science Citation Center)

Iranian Magazine Database

SID (Scientific Information Database)

JRHS  is also approved by the  Iranian Committee on Publishing of Biomedical Journal  of the Ministry of Health and Medical Education.

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Research Methods in Medicine & Health Sciences

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• Description
• Aims and Scope
• Editorial Board
• Submission Guidelines

Research Methods in Medicine & Health Sciences is a peer reviewed journal, publishing rigorous research on established “gold standard” methods and new cutting edge research methods in the health sciences and clinical medicine. The journal is structured around the following sections: Research Concepts and Theory; Epidemiology and Study Design; Experimental Study Methodology; Observational Study Methodology: Systematic Review and Meta-analysis; Measurement Tools; Data Collection and Curation; Statistics and Data Analysis; Ethical and Legal Considerations in Research and Medicine; and Journalology. State- of-the art papers are selectively commissioned by expert Topic Editors for consideration in the journal and ad hoc submissions are also welcome. The journal will be built up over time to become a comprehensive resource for all relevant methods for medicine and health sciences written by experts in the field.

This Journal is a member of the Committee on Publication Ethics .

There are no fees payable to submit or publish in this Journal. Open Access options are available - see section 3.3 below.

This Journal recommends that authors follow the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals formulated by the International Committee of Medical Journal Editors (ICMJE).

Please read the guidelines below then visit the Journal’s submission site  https://mc.manuscriptcentral.com/rmm  to upload your manuscript. Please note that manuscripts not conforming to these guidelines may be returned. Remember you can log in to the submission site at any time to check on the progress of your paper through the peer review process.

Only manuscripts of sufficient quality that meet the aims and scope of Research Methods in Medicine & Health Sciences will be reviewed. 

Research Methods in Medicine & Health Sciences is freely available to view and has no article processing fees for authors. Accepted peer-reviewed articles are made freely available immediately upon publication, and are published under a Creative Commons license. For general information on open access at Sage please visit the Open Access page or view our Open Access FAQs .

As part of the submission process you will be required to warrant that you are submitting your original work, that you have the rights in the work, and that you have obtained and can supply all necessary permissions for the reproduction of any copyright works not owned by you, that you are submitting the work for first publication in the Journal and that it is not being considered for publication elsewhere and has not already been published elsewhere. Please see our guidelines on prior publication and note that Research Methods in Medicine & Health Sciences  does not accept submissions of papers that have been posted on pre-print servers .

• What do we publish? 1.1 Aims & Scope 1.2 Article types 1.3 Writing your paper
• Editorial policies 2.1 Peer review policy 2.2 Authorship 2.3 Acknowledgements 2.4 Funding 2.5 Declaration of conflicting interests 2.6 Research ethics and patient consent 2.7 Clinical Trials 2.8 Reporting guidelines 2.9 Research Data
• Publishing policies 3.1 Publication ethics 3.2 Contributor's publishing agreement 3.3 Open access and author archiving
• Preparing your manuscript 4.1 Formatting 4.2 Artwork, figures and other graphics 4.3 Supplemental material 4.4 Reference style 4.5 English language editing services
• Submitting your manuscript 5.1 ORCID 5.2 Information required for completing your submission 5.3 Permissions
• On acceptance and publication 6.1 Sage Production 6.2 Online First publication 6.3 Access to your published article 6.4 Promoting your article
• Further information 7.1 Appealing the publication decision

1. What do we publish?

1.1 Aims & Scope

Before submitting your manuscript to Research Methods in Medicine & Health Sciences , please ensure you have read the Aims & Scope .

1.2 Article Types

The Journal commissions papers on “gold standard” methods and cutting edge research methods. Research Methods in Medicine & Health Sciences accepts the following article types:

• Original Article
• Letter to the Editor

Please also include an abstract of no more than 250 words with your submission. 

1.3 Writing your paper

The Sage Author Gateway has some general advice and on  how to get published , plus links to further resources. Sage Author Services also offers authors a variety of ways to improve and enhance their article including English language editing, plagiarism detection, and video abstract and infographic preparation.

1.3.1 Make your article discoverable

For information and guidance on how to make your article more discoverable, visit our Gateway page on How to Help Readers Find Your Article Online .

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2. Editorial policies

2.1 Peer review policy

Research Methods in Medicine & Health Sciences operates a conventional single-blind reviewing policy in which the reviewer’s name is always concealed from the submitting author.   Research Methods in Medicine & Health Sciences is committed to delivering high quality, fast peer-review for your paper, and as such has partnered with Publons. Publons is a third party service that seeks to track, verify and give credit for peer review. Reviewers for Research Methods in Medicine & Health Sciences can opt in to Publons in order to claim their reviews or have them automatically verified and added to their reviewer profile. Reviewers claiming credit for their review will be associated with the relevant journal, but the article name, reviewer’s decision and the content of their review is not published on the site. For more information visit the Publons website.

The Editor or members of the Editorial Board may occasionally submit their own manuscripts for possible publication in the journal. In these cases, the peer review process will be managed by alternative members of the Board and the submitting Editor/Board member will have no involvement in the decision-making process. 

2.2 Authorship

Papers should only be submitted for consideration once consent is given by all contributing authors. Those submitting papers should carefully check that all those whose work contributed to the paper are acknowledged as contributing authors.  The list of authors should include all those who can legitimately claim authorship. This is all those who:

(i)    Made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of data, (ii)    Drafted the article or revised it critically for important intellectual content, (iii)    Approved the version to be published,  (iv)    Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

Authors should meet the conditions of all of the points above. When a large, multicentre group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript. These individuals should fully meet the criteria for authorship. 

Acquisition of funding, collection of data, or general supervision of the research group alone does not constitute authorship, although all contributors who do not meet the criteria for authorship should be listed in the Acknowledgments section. Please refer to the  International Committee of Medical Journal Editors (ICMJE) authorship guidelines for more information on authorship.

        Please note that AI chatbots, for example ChatGPT, should not be listed as authors. For more information see the policy on Use of ChatGPT and generative AI tools .

2.3 Acknowledgements

All contributors who do not meet the criteria for authorship should be listed in an Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, or a department chair who provided only general support.

Any acknowledgements should appear first at the end of your article prior to your Declaration of Conflicting Interests (if applicable), any notes and your References.

2.3.1 Writing assistance

Individuals who provided writing assistance, e.g. from a specialist communications company, do not qualify as authors and so should be included in the Acknowledgements section. Authors must disclose any writing assistance – including the individual’s name, company and level of input – and identify the entity that paid for this assistance. It is not necessary to disclose use of language polishing services.

2.4 Funding

Research Methods in Medicine & Health Sciences requires all authors to acknowledge their funding in a consistent fashion under a separate heading.  Please visit the Funding Acknowledgements page on the Sage Journal Author Gateway to confirm the format of the acknowledgment text in the event of funding, or state that: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

2.5 Declaration of conflicting interests

It is the policy of Research Methods in Medicine & Health Sciences to require a declaration of conflicting interests from all authors enabling a statement to be carried within the paginated pages of all published articles. 

Please ensure that a ‘Declaration of Conflicting Interests’ statement is included at the end of your manuscript, after any acknowledgements and prior to the references. If no conflict exists, please state that ‘The Author(s) declare(s) that there is no conflict of interest’. For guidance on conflict of interest statements, please see the ICMJE recommendations here .

2.6 Research ethics and patient consent

Medical research involving human subjects must be conducted according to the World Medical Association Declaration of Helsinki

Submitted manuscripts should conform to the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals , and all papers reporting animal and/or human studies must state in the methods section that the relevant Ethics Committee or Institutional Review Board provided (or waived) approval. Please ensure that you have provided the full name and institution of the review committee, in addition to the approval number.

For research articles, authors are also required to state in the methods section whether participants provided informed consent and whether the consent was written or verbal.

Information on informed consent to report individual cases or case series should be included in the manuscript text. A statement is required regarding whether written informed consent for patient information and images to be published was provided by the patient(s) or a legally authorized representative. Please do not submit the patient’s actual written informed consent with your article, as this in itself breaches the patient’s confidentiality. The Journal requests that you confirm to us, in writing, that you have obtained written informed consent but the written consent itself should be held by the authors/investigators themselves, for example in a patient’s hospital record. The confirmatory letter may be uploaded with your submission as a separate file.

Please also refer to the ICMJE Recommendations for the Protection of Research Participants  

2.7 Clinical trials

Research Methods in Medicine & Health Sciences  endorses the ICMJE requirement that clinical trials are registered in a WHO-approved public trials registry at or before the time of first patient enrolment. However, consistent with the AllTrials campaign , retrospectively registered trials will be considered if the justification for late registration is acceptable. The trial registry name and URL, and registration number must be included at the end of the abstract.

2.8 Reporting guidelines

The relevant EQUATOR Network reporting guidelines should be followed depending on the type of study. For example, all randomized controlled trials submitted for publication should include a completed CONSORT flow chart as a cited figure and the completed CONSORT checklist should be uploaded with your submission as a supplementary file. Systematic reviews and meta-analyses should include the completed PRISMA flow chart as a cited figure and the completed PRISMA checklist should be uploaded with your submission as a supplementary file. The EQUATOR wizard can help you identify the appropriate guideline. 

Other resources can be found at NLM’s Research Reporting Guidelines and Initiatives

2.9 Research Data

The journal is committed to facilitating openness, transparency and reproducibility of research, and has the following research data sharing policy. For more information, including FAQs please visit the Sage Research Data policy pages .

Subject to appropriate ethical and legal considerations, authors are encouraged to:

• share your research data in a relevant public data repository
• include a data availability statement linking to your data. If it is not possible to share your data, we encourage you to consider using the statement to explain why it cannot be shared.
• cite this data in your research

3. Publishing Policies

3.1 Publication ethics

Sage is committed to upholding the integrity of the academic record. We encourage authors to refer to the Committee on Publication Ethics’ International Standards for Authors and view the Publication Ethics page on the Sage Author Gateway .

3.1.1 Plagiarism

Research Methods in Medicine & Health Sciences and Sage take issues of copyright infringement, plagiarism or other breaches of best practice in publication very seriously. We seek to protect the rights of our authors and we always investigate claims of plagiarism or misuse of published articles. Equally, we seek to protect the reputation of the journal against malpractice. Submitted articles may be checked with duplication-checking software. Where an article, for example, is found to have plagiarised other work or included third-party copyright material without permission or with insufficient acknowledgement, or where the authorship of the article is contested, we reserve the right to take action including, but not limited to: publishing an erratum or corrigendum (correction); retracting the article; taking up the matter with the head of department or dean of the author's institution and/or relevant academic bodies or societies; or taking appropriate legal action.

3.1.2 Prior publication

If material has been previously published it is not generally acceptable for publication in a Sage journal. However, there are certain circumstances where previously published material can be considered for publication. Please refer to the guidance on the Sage Author Gateway or if in doubt, contact the Editor at the address given below.

3.2 Contributor's publishing agreement

Before publication, Sage requires the author as the rights holder to sign a Journal Contributor’s Publishing Agreement. Sage’s Journal Contributor’s Publishing Agreement is an exclusive licence agreement which means that the author retains copyright in the work but grants Sage the sole and exclusive right and licence to publish for the full legal term of copyright. Exceptions may exist where an assignment of copyright is required or preferred by a proprietor other than Sage. In this case copyright in the work will be assigned from the author to the society. For more information please visit the Sage Author Gateway .

3.3 Open access and author archiving

Research Methods in Medicine & Health Sciences  offers optional open access publishing via the Sage Choice programme and Open Access agreements, where authors can publish open access either discounted or free of charge depending on the agreement with Sage. Find out if your institution is participating by visiting Open Access Agreements at Sage . For more information on Open Access publishing options at Sage please visit Sage Open Access . For information on funding body compliance, and depositing your article in repositories, please visit Sage’s Author Archiving and Re-Use Guidelines and Publishing Policies .

4. Preparing your manuscript for submission

4.1 Formatting

The preferred format for your manuscript is Word. A Word template is available on the Manuscript Submission Guidelines page of our Author Gateway.

4.2 Artwork, figures and other graphics

For guidance on the preparation of illustrations, pictures and graphs in electronic format, please visit Sage’s Manuscript Submission Guidelines.

4.3 Supplemental material

This journal is able to host additional materials online (e.g. datasets, podcasts, videos, images etc.) alongside the full-text of the article. For more information please refer to our guidelines on submitting supplementary files .

4.4 Reference style

Research Methods in Medicine & Health Sciences adheres to the Sage Vancouver reference style. View the Sage Vancouver guidelines to ensure your manuscript conforms to this reference style.

If you use EndNote to manage references, you can download the Sage Vancouver EndNote output file

4.5 English language Editing Services

Authors seeking assistance with English language editing, translation, or figure and manuscript formatting to fit the journal’s specifications should consider using Sage Language Services . Visit Sage Language Services on our Journal Author Gateway for further information.

5. Submitting your manuscript

Journal of Information Technology is hosted on Sage Track, a web based online submission and peer review system powered by ScholarOne™ Manuscripts. Visit https://mc.manuscriptcentral.com/rmm to login and submit your article online.

IMPORTANT: Please check whether you already have an account in the system before trying to create a new one. If you have reviewed or authored for the journal in the past year it is likely that you will have had an account created.  For further guidance on submitting your manuscript online please visit ScholarOne Online Help.

As part of our commitment to ensuring an ethical, transparent and fair peer review process Sage is a supporting member of ORCID, the Open Researcher and Contributor ID . ORCID provides a unique and persistent digital identifier that distinguishes researchers from every other researcher, even those who share the same name, and, through integration in key research workflows such as manuscript and grant submission, supports automated linkages between researchers and their professional activities, ensuring that their work is recognized. 

The collection of ORCID IDs from corresponding authors is now part of the submission process of this journal. If you already have an ORCID ID you will be asked to associate that to your submission during the online submission process. We also strongly encourage all co-authors to link their ORCID ID to their accounts in our online peer review platforms. It takes seconds to do: click the link when prompted, sign into your ORCID account and our systems are automatically updated. Your ORCID ID will become part of your accepted publication’s metadata, making your work attributable to you and only you. Your ORCID ID is published with your article so that fellow researchers reading your work can link to your ORCID profile and from there link to your other publications.

If you do not already have an ORCID ID please follow this link to create one or visit our ORCID homepage to learn more.

5.2 Information required for completing your submission

You will be asked to provide contact details and academic affiliations for all co-authors via the submission system and identify who is to be the corresponding author. These details must match what appears on your manuscript. The affiliation listed in the manuscript should be the institution where the research was conducted. If an author has moved to a new institution since completing the research, the new affiliation can be included in a manuscript note at the end of the paper. At this stage please ensure you have included all the required statements and declarations and uploaded any additional supplementary files (including reporting guidelines where relevant).

5.3 Permissions

Please also ensure that you have obtained any necessary permission from copyright holders for reproducing any illustrations, tables, figures or lengthy quotations previously published elsewhere. For further information including guidance on fair dealing for criticism and review, please see the Copyright and Permissions page on the Sage Author Gateway .

6. On acceptance and publication

6.1 Sage Production

Your Sage Production Editor will keep you informed as to your article’s progress throughout the production process. Proofs will be made available to the corresponding author via our editing portal Sage Edit or by email, and corrections should be made directly or notified to us promptly. Authors are reminded to check their proofs carefully to confirm that all author information, including names, affiliations, sequence and contact details are correct, and that Funding and Conflict of Interest statements, if any, are accurate.

6.2 Online First publication

Online First allows final articles (completed and approved articles awaiting assignment to a future issue) to be published online prior to their inclusion in a journal issue, which significantly reduces the lead time between submission and publication. Visit the Sage Journals help page for more details, including how to cite Online First articles.

6.3 Access to your published article

Sage provides authors with online access to their final article.

6.4 Promoting your article

Publication is not the end of the process! You can help disseminate your paper and ensure it is as widely read and cited as possible. The Sage Author Gateway has numerous resources to help you promote your work. Visit the Promote Your Article page on the Gateway for tips and advice. In addition, Sage is partnered with Kudos, a free service that allows authors to explain, enrich, share, and measure the impact of their article. Find out how to maximise your article’s impact with Kudos .

7. Further information

Any correspondence, queries or additional requests for information on the manuscript submission process should be sent to the  Research Methods in Medicine & Health Sciences  editorial office as follows: 

Joel Gagnier, Editor-in-Chief: [email protected]  

7.1 Appealing the publication decision

Editors have very broad discretion in determining whether an article is an appropriate fit for their journal. Many manuscripts are declined with a very general statement of the rejection decision. These decisions are not eligible for formal appeal unless the author believes the decision to reject the manuscript was based on an error in the review of the article, in which case the author may appeal the decision by providing the Editor with a detailed written description of the error they believe occurred.

If an author believes the decision regarding their manuscript was affected by a publication ethics breach, the author may contact the publisher with a detailed written description of their concern, and information supporting the concern, at [email protected]  

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To order single issues of this journal, please contact SAGE Customer Services at 1-800-818-7243 / 1-805-583-9774 with details of the volume and issue you would like to purchase.

IMPACT FACTOR: 5.24 IFS 4,7 / UIF 3,8

ISSN 2523-1251 (Online) ISSN 2523-1243 (Print)

Journal of Research in Health Science

Journal of Research in Health Science is a multi-disciplinary, peer-reviewed international ISI journal for publication of novel ideas, the state-of-the-art research results and fundamental advances in all aspects of theoretical and applied topics in science and engineering including areas in natural and social sciences. The objective of the Journal of Research in Health Science is to serve a better understanding between the researchers and practitioners from academia and industry. The paper submitted to Journal of Research in Health Science should describe original and previously unpublished works, not currently under review by another conference, workshop or journal. However, authors can submit the extended version of conference papers. Papers for publication are selected through peer review to ensure originality, relevance, and readability. Upon preliminary evaluation by the Editorial Board, the papers are sent to two referees (experts in respective fields) for evaluation. The decision of the Editor-in-Chief to publish a paper in concurrence with referee(s) opinion is considered final.

Journal of Research in Health Science is indexed, refereed and peer reviewed journal, which is designed to publish research articles in, Medicine and Dentistry, Nursing and Health Professions, Pharmacology and Toxicology, Pharmaceutical Science, Veterinary Science, Veterinary Medicine etc.

Multidisciplinary Journal, Multidisciplinary Research Journal, Medical Journal

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Learn instructions, read latest articles, submit your article.

Address: HaYarden 2, Yashresh, Israel Phone: +972 3-972-7811

Journals published since June 2017 year. Issued Bimonthly the journal is published in electronic and printed form. The journal is an interdisciplinary journal is published entirely in the English, French, Russian languages.

The Journal invites original Research Papers, Review articles, Technical or Case reports and Short communications that are not published or not being considered for publication.

Journal of Qualitative Research in Health Science

Subject Area and Category

• Medicine (miscellaneous)
• Nursing (miscellaneous)
• Health (social science)

Kerman University of Medical Sciences

Publication type

Information.

How to publish in this journal

[email protected]

The set of journals have been ranked according to their SJR and divided into four equal groups, four quartiles. Q1 (green) comprises the quarter of the journals with the highest values, Q2 (yellow) the second highest values, Q3 (orange) the third highest values and Q4 (red) the lowest values.

The SJR is a size-independent prestige indicator that ranks journals by their 'average prestige per article'. It is based on the idea that 'all citations are not created equal'. SJR is a measure of scientific influence of journals that accounts for both the number of citations received by a journal and the importance or prestige of the journals where such citations come from It measures the scientific influence of the average article in a journal, it expresses how central to the global scientific discussion an average article of the journal is.

Evolution of the number of published documents. All types of documents are considered, including citable and non citable documents.

This indicator counts the number of citations received by documents from a journal and divides them by the total number of documents published in that journal. The chart shows the evolution of the average number of times documents published in a journal in the past two, three and four years have been cited in the current year. The two years line is equivalent to journal impact factor ™ (Thomson Reuters) metric.

Evolution of the total number of citations and journal's self-citations received by a journal's published documents during the three previous years. Journal Self-citation is defined as the number of citation from a journal citing article to articles published by the same journal.

Evolution of the number of total citation per document and external citation per document (i.e. journal self-citations removed) received by a journal's published documents during the three previous years. External citations are calculated by subtracting the number of self-citations from the total number of citations received by the journal’s documents.

International Collaboration accounts for the articles that have been produced by researchers from several countries. The chart shows the ratio of a journal's documents signed by researchers from more than one country; that is including more than one country address.

Not every article in a journal is considered primary research and therefore "citable", this chart shows the ratio of a journal's articles including substantial research (research articles, conference papers and reviews) in three year windows vs. those documents other than research articles, reviews and conference papers.

Ratio of a journal's items, grouped in three years windows, that have been cited at least once vs. those not cited during the following year.

Evolution of the percentage of female authors.

Evolution of the number of documents cited by public policy documents according to Overton database.

Evoution of the number of documents related to Sustainable Development Goals defined by United Nations. Available from 2018 onwards.

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Nature Index  13 March 2024

Health sciences

More money is being spent on medical R&D than ever before, but with few new drugs to show for it. The race is on to find technological solutions that will speed up drug development and deliver better clinical outcomes. Nature Index Health Sciences 2024 highlights the people and projects that are bringing fresh perspectives to some of the most complex challenges in medicine and provides an in-depth look at how one country – the United States – is dominating the field. 

Features and comment

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A guide to the Nature Index

A description of the terminology and methodology used in this supplement, and a guide to the functionality that is available free online at natureindex.com.

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A new biosensor could mark a turning point in the struggle to identify an important, common and easily treatable condition.

A new injectable gel could seal wounds after cancer surgery

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A Review of Elite Athlete Evidence-Based Knowledge and Preparation for Competing in the Heat

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• Published: 17 May 2024

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• Chris J. Esh 1 , 2 ,
• Sarah Carter 3 ,
• Natalia Galan-Lopez 2 ,
• Frederic Garrandes 4 , 5 ,
• Stephane Bermon 4 , 5 ,
• Paolo Emilio Adami 4 , 5 ,
• Sebastien Racinais 6 ,
• Lewis James 2 ,
• Trent Stellingwerff 7 , 8 ,
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Elite athletes will compete in extreme heat more frequently as global land and sea temperatures increase, alongside more intense, frequent and longer duration heatwaves. Best practices to protect athlete health and performance during competition include heat acclimation/acclimatisation [(HA); i.e., long-term pre-competition preparation] complemented by pre-planned and practised cooling and hydration strategies (i.e., short-term interventions immediately before or during competition). This review explores elite athletes’ current behaviours and practices when preparing for competition in the heat and assesses the level of knowledge that has been exhibited by athletes and their practitioners in this space. Recommendations for future research, discussions of current best practices, and methods to improve translation of research into practice are provided. Available research focuses on small samples of elite endurance athletes during a selection of World Championship/Olympic/Paralympic events (~6% of competing athletes). While generally an increase in the adoption of evidence-based HA is seen chronologically from 2015 onwards, universal adoption is not seen. HA adoption is lowest in those who live/train in cold/temperate environments with cost and access to facilities/equipment being the most commonly reported barriers. Further research is required across the sporting landscape to fully characterise elite athlete behaviours and practices in these spaces. International federations and national governing bodies should continue their efforts to educate athletes and focus on regularly updated and reinvigorated release of evidence-based guidelines (in multiple germane languages) for competing in the heat, to increase the adoption of HA and other heat related best practice.

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Introduction

In the 2023 annual climate update the World Meteorological Organisation (WMO) estimated that global temperatures are likely (likelihood: 66%) to increase 1.5 °C above pre-industrial levels before 2027 [ 113 ]. Inevitably, this affects the sport landscape (an increasingly global industry estimated to be worth $700 billion by 2026 [ 111 ]). Indeed, Tokyo 2020 was the hottest Olympic [ 67 ] and Paralympic [ 64 ] games on record, and Paris (Olympic and Paralympic Games host, 2024), not typically considered a hot climate, could see temperatures regularly exceed 30 °C during the Games, or even reach 40 °C should a heat wave similar to that observed in 2022 occur [ 42 ]. Heatwaves are increasing in their frequency, intensity and duration [ 18 ], with maximum land [ 106 ] and sea [ 24 ] temperature records being regularly broken. The World Aquatics Championships (open water swimming events) in Fukuoka in July 2023 saw water temperatures of 25.8 °C to 28.2 °C in the Open Water Swim events. The World Athletics Championships in Budapest (August 2023) saw ambient temperatures and humidity exceed 35 °C and 90% respectively [wet bulb globe temperatures (WBGT) ranged from 21 to 29.5 °C (data provided via personal communication with World Athletics)], comparable to the Tokyo Olympic Games 2020. The forthcoming World Athletics Championships (Tokyo September 2025) and the Summer Olympic and Paralympic Games (Los Angeles July 2028) will be held in hot summer climates. For context, the hottest temperature recorded on earth (54.4 °C; July 2021) was reported in Death Valley, California, less than 200 miles (~322 km) from the Olympic and Paralympic site [ 23 ]. Elite athletes will inevitably be faced with extreme heat at future events given the increased frequency, length and severity of heatwaves seen and forecast. Concerningly, such extreme heat-related competition environments now occur at events, and within seasons, where such extreme weather conditions are historically rare, or have not been seen before (e.g., Race Walking World Championships Muscat March 2022, historical data predicted race temperatures of ~22 to ~26 °C but reached 31.3 °C [ 33 ]). For the purposes of this review elite athletes are those competing at Tier Four (Elite/International Level) and/or Tier Five (World Class) level of the Participant Classification Framework [ 61 ].

The increase in global temperatures, especially heatwaves, has substantial implications for public health, leading to significant increases in heat related fatalities (>60,000 deaths have been attributed to heat during the 2022 summer heat wave in Europe [ 9 ]) and overwhelmed health systems [ 58 ]. Similarly, hot environments have detrimental health and performance effects on individuals engaged in regular physical activity, from recreational to elite athletes [ 108 ]. In hot, compared to temperate, environments, significant exercise-mediated rises in core (Tc) and/or skin (Tsk) temperature (Tc: ~2–2.5 °C [ 25 ], Tsk: ~5 °C [ 69 ]) occur alongside concomitant plasma volume loss and dehydration, increasing physiological and perceptual strain [ 69 , 72 , 105 ]. These responses combine to negatively affect physical [ 36 , 69 ] and cognitive [ 57 , 101 ] performance in the heat. High Tc in this scenario is also associated with an increased risk of exertional heat illness (EHI) and the potentially fatal exertional heat stroke (EHS [ 71 ]). EHS will be diagnosed when an individual presents a Tc ≥ 40.5 °C and profound neuropsychological impairment (i.e., altered mental status [ 11 , 20 , 40 , 41 , 51 ]). Elite endurance training provides a health protective effect against EHS. For example, even temperate-based elite endurance training induces a partially heat acclimated phenotype [ 3 , 7 , 35 , 102 ] whilst elite endurance athletes who are heat acclimated/acclimatised can tolerate a Tc ≥ 41 °C without succumbing to EHS (i.e., no alteration in mental status [ 80 , 84 , 97 ]). Across various competition levels, intermittent sport athletes (386 individuals across 34 studies) have been observed to reach a peak Tc of 38.5 °C to 39.5 °C (24 of 34 studies included in a recent systematic review) and ≥ 39.5 °C (6 out of 34 studies [ 38 ]). Across intermittent and endurance sport competition and levels, 11.9% of athletes (1450 athletes from 49 studies) presented with a Tc ≥ 40 °C, with only 2.8% of these experiencing any EHI/EHS symptoms [ 91 ]. That said, it must be acknowledged that EHS can occur in any athlete, even within temperate environments, and this medical emergency remains one of the three leading causes of sudden death in sport [ 21 , 115 ].

Unprecedented and previously unseen action has been taken at recent World Athletics Championships (midnight race starts at the World Championships Doha 2019; 5000 m heats moved from morning to evening session at Budapest 2023), Olympic Games (Tokyo 2020: marathon and racewalks moved from Tokyo to Sapporo and women’s soccer final stadium and time changed) and the FIFA World Cup (Qatar 2022 was moved from summer to winter) in an attempt to avoid extreme heat. Of these actions not all were successful, for example WBGT reached 30.6 °C [ 80 ] at Sapporo, with similar conditions in Tokyo [ 99 ]. Thus, athletes can and should control their own preparation (i.e., implement heat mitigation strategies) as even sensible policy/logistical changes do not always elicit desired effects (i.e., the environment is not controllable). It is true that international federations in tandem with local organising committees must do their utmost to place athlete health at the forefront of decision-making regarding competition locations and timings alongside event logistics (e.g., appropriate medical tent set up, size and medical staff; emergency cooling equipment and expertise to perform cold water immersion; access to ice; enough wheelchairs and other athlete transports measures; evidence-informed heat-related policies, etc. [ 3 , 11 , 21 , 49 , 63 ]) in an a priori manner to optimise the environment for safe performance. That said, extreme weather conditions are becoming increasingly unpredictable and exceeding historical maximums [ 18 , 24 , 106 ]. Therefore, alongside an optimised performance environment (e.g., logistics, timings, and locations, etc.) supporting ‘thrive’ rather than ‘survive’ competition, within event day flexible policies are also required (e.g., timings and locations of events) which do not disadvantage athlete preparations (some of which may have been planned out for several years) or performance—an evidently challenging and multi-faceted space to get policy correct within. For example, only 6 women at the 2023 World Athletics Championships in Budapest ran under the Olympic Marathon standard of 2:26:50 in the extreme heat seen [race start (7 a.m.): 23 °C, 75% humidity WBGT: 22 °C, first finisher: 29 °C, 75% humidity, WBGT: 29 °C)], even though 34 women had personal best times better than the Olympic marathon standard. To reduce the impact of the heat, midnight races were organised at IAAF Doha 2019, but the conditions remained very difficult (max: 32.7 °C, 80.6% humidity, 30.6 °C WBGT [ 80 ]). Clearly, this space continues to evolve alongside the increased likelihood of competition in extreme heat [ 18 , 24 , 106 ]. The solutions rely on all stakeholders’ collaborating to deliver evidence-informed policy [ 3 , 11 , 21 , 49 , 63 ], education [ 4 , 33 ] and event-planning [ 81 ] related to competitions whilst athletes adopt gold-standard preparation [ 3 , 35 , 72 , 76 , 78 , 81 , 100 , 103 ] and are helped to overcome barriers they may experience (e.g., access to facilities and expertise [ 4 , 33 ]). Implementation of evidence-based practice as policy can impact the risk of EHI/EHS [ 27 , 49 ]. Where policies have been introduced that mandate heat acclimation/acclimatisation (HA) alongside physical activity in the heat guidelines (by government and/or athletic governing bodies) the risk of EHI can be reduced from 35 to 100% depending on environmental conditions [ 27 , 49 ].

Evidence-based optimal preparation for competition in the heat focuses on long- and/or short-term preparation strategies. Long-term preparation involves implementing a long-term HA strategy consisting of 10–14 days of consecutive passive and/or active heat exposures (for which there are a plethora of guidelines available [ 3 , 35 , 72 , 76 , 78 , 81 , 100 , 103 ]). From this point forward, HA will be used when referring to heat acclimation/acclimatisation in general, whereas heat acclimation [use of an artificial hot environment (e.g., heat chamber, sauna, hot baths, overdressing)] or heat acclimatisation [naturally hot environment (e.g., hot climate)] will be used when referring to a specific strategy. Short-term heat mitigation strategies should be complementary to (not instead of) long term HA; long term-HA strategies are by far the most health protective and performance enhancing compared to short-term interventions [ 35 ]. Short-term approaches can include implementing a pre-planned and practiced nutritional/hydration strategy [ 12 ] and pre and/or per-cooling techniques [ 2 , 98 , 100 ]. Therefore, it would appear prudent for those operating within the elite athlete space (e.g., researchers and practitioners) to be aware of how athletes are preparing to compete in hot environments and whether they are adopting evidence-based best practice when implementing any strategies aimed at alleviating the physiological and perceptual strain of competing in heat [ 4 , 33 ]. Understanding elite athlete knowledge of evidence-based practice and determining any barriers/challenges that prevent the adoption of these practices are also necessary to remain athlete centred and coach-/practitioner-led [ 4 , 33 ]. Such understanding can also inform governing body and federation driven educational initiatives and resources for their stakeholders. From this point forward, when referring to practitioners, this is inclusive of all members of an inter-disciplinary team that support an athlete (e.g., sports science/medicine staff, coaches, etc.).

Several comprehensive evidence-based guidelines (and consensus statements) outline the clear benefits of heat mitigation strategies to alleviate the impact of heat on athlete health and performance (i.e., peak performance can only occur when health is optimised), albeit the majority of which are practitioner and athletic performance-focused (including but not limited to [ 35 , 72 , 76 , 77 , 78 , 79 , 81 , 100 , 103 ]). However, only in the last decade has research investigated whether these guidelines are understood and/or implemented by elite athletes and/or their practitioners [ 6 , 33 , 74 , 80 , 85 ]. Therefore, it is the aim of this review to provide an overview of this research and outline the current state of elite athlete knowledge and adoption of evidence-based practice for competing in heat. In addition, this review will provide recommendations for best practice, future research, and what is required to improve the translation of research into practice among the elite athlete population.

This review will refer to several World Championship/Paralympic events with regularity and thus, these events will be referred to with abbreviations. The table below (Table  1 ) provides an overview of the key studies reviewed and the abbreviations used throughout this article.

Adoption of Heat Acclimation/Acclimatisation

HA is the optimal strategy to protect against the detrimental impact of heat on health and athletic performance [ 48 , 78 , 81 ]. The aim of implementing a HA strategy is to induce physiological adaptations (reduced resting and exercising heart rate, Tc and Tsk; increased sweat rate, decreased onset threshold for sweating, and increased blood and plasma volume [ 35 , 73 ]) that attenuate heat strain during exercise. Therefore, determining the level of adoption of a dedicated HA strategy among elite athletes prior to competition in heat is paramount to identifying whether evidence-based practice is being implemented. Investigating any barriers/challenges that may inhibit elite athletes from adopting HA and providing recommendations for innovative and efficient strategies to elicit heat adaptations should also be prioritised.

Limited evidence of elite athlete use of HA prior to competition exists and, to date, has mainly focused on elite endurance athletes at World Championships [ 33 , 74 , 80 , 85 ] with one study investigating HA adoption among paralympic athletes [ 6 ]. Table 2 provides an overview of the level of HA adoption at these championships where hot conditions were anticipated [temperatures across these competitions ranged from 19.5 to 32.7 °C (WBGT: 19.5 to 30.6 °C)]. In brief, the adoption of HA has increased since IAAF Beijing 2015 where 15% of surveyed athletes adopted a dedicated HA strategy [ 74 ] to 63% at IAAF Doha 2019 [ 80 ] (UCI Qatar 2016: 38% [ 85 ]; RWTC Muscat 2022: 57% [ 33 ]). Fifty-eight percent of paralympic athletes adopted a dedicated HA strategy, prior to the Tokyo Paralympics 2020; of those, only 45% had previously implemented a HA strategy at previous unspecified events [ 6 ]. This substantial increase in HA adoption from IAAF Beijing 2015 is likely due to increased education and awareness of evidence-based guidelines to protect athletes against the impairment of performance and risks posed to their health when competing in the heat.

Prior to IAAF Doha 2019, the IAAF [now World Athletics (WA)] released the ‘beat the heat’ pamphlet to all athletes, federations, and team doctors with similar initiatives implemented by the UCI, World Triathlon and the International Olympic Committee [(IOC) see Table  3 for full list]. Although, numbers of athletes/practitioners who read and/or specifically implemented the guidelines prior to these championships is unknown. Additionally, the majority of (if not all) educational material is published in English which, speculatively without specific data, may limit their impact within non-native English-speaking athletes, federations and/or those who have visual and intellectual disabilities. Significant media attention was paid to the extreme heat expected, alongside a plethora of research articles related to improving athletic performance in hot conditions in the build-up to IAAF Doha 2019 and the Tokyo 2020 Olympic and Paralympic Games (including but not limited to [ 13 , 40 , 46 , 68 ]). Indeed, the British Journal of Sports Medicine published an open access series of editorials specifically focusing on the preparation of athletes for the Tokyo 2020 Olympic and Paralympic Games (see Table  3 for full list).

The translation of evidence from a scientific journal to athlete practice is somewhat limited [ 31 ] and may be an example of why adoption of HA is not universal. Indeed, passive dissemination strategies (i.e., provision of information in booklets) is often ineffective (especially if not in the readers native language and/or for those with visual and intellectual impairments), active participation during the provision of guidelines increases their implementation [ 90 ]. Alongside more accessible and palatable content a ‘hands-on’ active approach to educating elite sport practitioners and athletes needs to be made available to improve translation of research to practice [ 31 , 90 ]. Combined, the increased attention and awareness of the impacts of competing in heat likely drove the increase in HA adoption from IAAF Beijing 2015 to IAAF Doha 2019. However, there was a small reduction (~6%) in HA adoption at the RWTC Muscat 2022 from IAAF Doha 2019 (3–4 years after the release of ‘beat the heat’). WA did not re-release the ‘beat the heat’ material from Doha 2019 prior to RWTC Muscat 2022, where 83% of athletes surveyed at RWTC Muscat 2022 were not aware of or had not read ‘beat the heat’ [ 33 ]. This, alongside less media attention and less extreme heat being anticipated, may have impacted the adoption of HA prior to RWTC Muscat 2022. Importantly, historical weather data suggested temperatures at these championships would be from 22.5 to 25.5 °C however, they reached up to 31.3 °C during the competition [ 33 ]. With the afore described increase in global temperatures and heatwaves, historical average weather data may be too low and athletes should be preparing for the record maximum temperatures in each location (even these are being regularly broken).

While it is encouraging to observe the increased adoption of HA in recent years, many athletes are still not adopting HA into practice. A self-reported survey of 55 elite athletes and 99 practitioners working with elite athletes identified a variety of significant barriers to adopting HA [ 4 ]. The cost (i.e., money required to live/train in a hot environment, or cost to access artificially hot environments) and access to facilities/equipment/expertise were the most commonly reported barriers to adopting HA [ 4 ], which were in agreement with HA adoption barriers reported at RWTC Muscat 2022 [ 33 ]. While funding may be seen as the most beneficial option to increase the adoption of HA, greater education (discussed in more detail below) of other possible low-cost and innovative strategies to achieve HA adaptations would likely increase the ability of athletes to achieve HA. For example, additional clothing [ 54 , 94 ], and post-exercise/training sauna and hot water immersion [ 22 , 37 , 60 ], or simply having a treadmill/bike inside a camping tent/greenhouse with heaters (see Fig.  1 —photos provided by author T. Stellingwerff), have proven effective in eliciting HA adaptations. Elite athletes may also struggle to implement a HA protocol within their training cycles [ 88 ]. In the build-up to major competitions athletes will generally complete a 4–6 week period of high volume/intensity training followed by a 1–2 week taper [ 88 ]. Adopting HA at the start of this intense block may lead to HA decay by the time of competition [ 28 ] and/or the quality of prescribed work being compromised [ 88 ]. HA during a taper or including heat exposures during the taper in a bid to re-induce adaptations that may have decayed [ 28 ] could (without careful consideration and prescription) disrupt the goals of the taper (i.e., reduced overall training load/stress) thus, adopting an evidence based ≥14 day HA protocol is challenging for the elite athlete and may be another barrier to its universal adoption [ 88 ]. The identified barriers to HA adoption [ 4 , 33 , 88 ] alongside the impact of the ‘beat the heat’ like material, highlights the importance of regular dissemination of the latest guidelines to athletes, national governing bodies, and practitioners to achieve universal adoption of HA prior to competing in heat.

Innovative low-cost strategy to induce HA adaptations (photos submitted by author T.Stellingwerff). Cycle ergometer and treadmill inside camping tents in a home garage with heaters (NB: athletes implementing these HA strategies should be supervised by qualified personnel at all times with tent temperature, thermal sensation and heart rate continually monitored. Ideally, body temperature measurement tools should also be used to avoid adverse health outcomes)

To date, there are minimal data on the specific HA strategies athletes use (e.g., acclimation vs. acclimatisation) and the specific HA protocols implemented (e.g., environmental temperatures, self-regulated vs. fixed intensity exercise). Heat acclimatisation (natural hot environment) appears to be most popular with elite endurance athletes, 59% (41% heat acclimation, IAAF Doha 2019 [ 80 ]) and 60% (32% heat acclimation, 8% combined HA, RWTC Muscat 2022 [ 33 ]). Heat acclimatisation was also most prevalent amongst paralympic athletes prior to the Paralympics Tokyo 2020 (51% vs. 16% acclimation [ 6 ]). Such data likely reflects a finding from Galan-Lopez et al. [ 33 ] where athletes who adopted a dedicated HA strategy were more likely to live/train in a hot climate, whereas those who live/train in cold/temperate climates have identified greater barriers to the adoption of HA compared to their counterparts from hot climates ([ 4 , 33 ] specific data are provided and discussed in detail below). Greater specificity should be reported within the literature, as most studies do not report the breakdown of duration (i.e., number of days), exercise protocol (e.g., fixed vs. self-regulated work rate), or environmental characteristics (i.e., temperature, humidity) used. Only Galan-Lopez et al. [ 33 ] determined the specifics of HA protocols, with 62% of the athletes who adopted HA using self-regulated exercise intensities compared to 23% who used a fixed intensity. Ninety three percent of athletes who adopted heat acclimation used a fixed environmental temperature (mean ambient temperature: 31.5 °C) compared to an incremental temperature rise across the protocol (7% [ 33 ]). An observational study by Carr et al. [ 19 ] followed 6 Olympic racewalkers through their preparation for the Tokyo 2020 Olympic Games. These athletes completed an intermittent incremental heat acclimation protocol (1–2 treadmill sessions per week) over 3 months. This was followed by 18 days of heat acclimatisation during a team camp one month prior to the Tokyo 2020 Olympic Games [mean temperature range of training sessions: 23 °C, 71.4% relative humidity (RH) to 24.3 °C, 67.4% RH, mean maximal temperature: 27.3 °C, 89.4% RH (i.e., similar weather conditions to Tokyo), training intensity and duration varied across these sessions [ 19 ]]. Similarly, real-world HA practices in elite race-walking athletes have been described and include the use of combined outdoor and indoor HA training [ 97 ], and combined outdoor HA training and passive hot-water immersion [ 96 ]. While data of this nature are insightful, it is challenging to obtain this level of detail from elite athletes via a survey. In addition, Tc and/or other physiological data (e.g., heart rate, sweat rate) were not collected [ 19 ], and have not been collected elsewhere prior to world championship events [ 6 , 33 , 74 , 80 , 85 ] to objectively assess the physiological adaptations of the adopted HA strategies. Although, in-competition Tc/Tsk, performance and illness EHI/EHS presentation offer insight into the success of adopted self-reported HA strategies (e.g., Table  2 citations).

Current evidence of the adoption of HA mainly exists amongst elite endurance athletes prior to World Championships, Olympic and Paralympic competitions. However, these are not the only sporting events held in hot environments or the only elite athletes who benefit from adopting HA. Considerable research efforts are required to gauge the adoption of HA across the sports landscape and determine whether athletes are preparing(ed) to compete in the heat. Including and not limited to youth and master’s athletes whose thermoregulatory systems may be compromised compared to the elite adult athletes [ 65 , 104 ]. International federations [e.g., World Athletics, International Olympic Committee (IOC), International Paralympic Committee (IPC)] and national governing bodies remain central advocates and educators to ensure that HA is universally adopted amongst elite athletes. Specific research into Paralympic athletes is also essential, given those with spinal cord injuries are at greater risk of EHS [ 34 ], and yet there is only one study to date investigating the adoption of heat preparation strategies prior to competition in this population [ 6 ].

Adoption of Heat Acclimation/Acclimatisation and the Impact on Performance and Medical Events

It is unlikely that an elite athlete will adopt any training method into their practice without understanding if it will improve their ability to perform in competition. At IAAF Doha 2019, athletes who had adopted HA finished better than those who did not (mean finishing position: 18th HA vs. 28th non-HA, P  = 0.009) although, the relative performance in terms of percentage difference from an athlete’s own personal best (PB) time was not different (112.6% of PB time for HA vs. 113.3% non-HA [ 80 ]). Of those who undertook HA, only 19% did not finish (DNF) vs. 30% who did not HA, although this was not statistically significant [ 80 ]. In addition, the adoption of HA influenced physiological responses, with those undertaking HA having a lower race start Tc (− 0.2 °C, not statistically significant but potentially physiologically meaningful [ 105 ]) and lower in-race peak Tc (− 0.4 °C, statistically significant [ 80 ]). The potential to lower peak Tc by 0.4 °C over a race in hot conditions may mean the difference between competing for the win or experiencing EHI/EHS, especially given the regularity with which athletes (elite and recreational) reach and exceed a Tc of 40 °C, even in cool environments (see Table  4 ). Prior to RWTC Muscat 2022 the four surveyed athletes that achieved a medal had all adopted a dedicated HA strategy prior to the championships, and of the 15 surveyed athletes who finished within the top 10 in their race, 80% had adopted a specific HA strategy for the event [ 33 ].

Of the Australian racewalking athletes from Carr et al. [ 19 ], two improved their PB, two finished in the top 10 and the maximum performance decrement of the six athletes was 8.9% of their PB, which is within the expected range of performance decrement when performing in the heat (6%–16% or 0.3% to 0.4% for every 1 °C WBGT outside of 7.5–15 °C [ 22 , 55 ]). This suggests the adopted HA strategies successfully induced physiological adaptations, although, confirmatory objective physiological (e.g., heart/sweat rate and plasma volume changes) data are not available. There are a multitude of studies that have observed a positive impact of HA on exercise performance in the laboratory (summarised in this meta-analysis [ 105 ]) and current evidence of in-competition performance, albeit limited by the small number of studies, suggests that this translates to elite level competition [ 19 , 33 , 80 ].

Performance is likely the key desired outcome for athletes, but for race organisers and international federations the health/safety of the athletes is of primary importance. Experiencing symptoms and clinical diagnosis of EHI is prevalent among elite athletes (outlined in Table  5 [ 6 , 33 , 74 , 80 , 85 ]) perhaps reflective, in part, of the lack of HA adoption observed. Studies have reported the number of previous incidents of EHI/EHS among their sample but have not associated this with previous adoption of HA [1.6% of surveyed athletes at Beijing 2015 [ 74 ], three cases of EHI (specifically, heat exhaustion) were recorded at UCI Qatar 2016 [ 85 ] and 21% of Paralympic athletes surveyed experienced symptoms of EHI [ 6 ]]. At IAAF Doha 2019, 32% of surveyed athletes who did not adopt HA experienced a heat related medical event compared to only 19% of those who did HA prior to the event although, not statistically significant ( P  ≥ 0.179 [ 80 ]). Female athletes experienced a higher prevalence of an in-race medical event compared to males (32% vs. 17%, respectively, P  < 0.001) during the marathon, however, the environmental conditions during the respective marathons were considerably different (female race WBGT: 29.6 °C, male race WBGT: 23.5 °C) and likely explains this finding [ 80 ]. No differences between males and females were observed during the racewalk races (male and female races were run simultaneously, P  = 0.597 [ 80 ]). Lower incidence of medical events in those that adopted HA is again indicative that the adopted HA strategies successfully induced physiological adaptations that reduced, but did not eradicate, medical events during competition in heat. It must also be noted that during real-world competition there are many factors that may have impacted the outcomes in these athletes (e.g., appropriate pacing strategy, cooling/hydration plan, non-heat related illness, etc.). More detailed data are required to determine with certainty if physiological adaptations have been induced and resulted in improved health and performance. Figure  2 provides an overview of current practice by elite athletes and the impacts on performance and medical events.

Adoption of HA in Elite Athletes: An overview of the literature that has assessed the adoption of HA in elite athletes, what influences the adoption of HA and the barriers to adopting HA that athletes experience. The content within this figure is derived from data within the following publications: Périard et al. [ 74 ], Racinais et al. [ 85 ], Racinais et al. [ 80 ], Galan-Lopez et al. [ 33 ], Alkemade et al. [ 6 ]. HA heat acclimation/acclimatisation, DNF did not finish, Tc core temperature

Effect of Climate and Biological Sex-Based Differences on the Adoption of Heat Acclimation/Acclimatisation

The climate an athlete lives and trains in may impact the adoption of HA to prepare for hot competitions however, data are scarce. Studies have assessed home continent and HA adoption; however, this is not indicative of any specific climate/conditions an athlete trained in [ 6 , 74 ]. Alkemade et al. [ 6 ] observed that Paralympic athletes from Oceania were more likely to have adopted HA at prior events, but no differences were observed prior to the Paralympics Tokyo 2020. However, Galan-Lopez et al. [ 33 ] observed that, paradoxically, only 44% of athletes from a cold/temperate environment (self-reported) adopted an intentional HA strategy, compared to 82% from a hot climate. Importantly, this finding is linked to the barriers to HA identified by athletes and practitioners. The most common barrier to HA adoption among those residing in cold/temperate climates is accessibility of hot environments (52% vs. 37% from a hot climate [ 4 ] and 49% vs. 27% from hot [ 33 ] of surveyed athletes) and cost of implementing HA (up to 45% vs. 35% from hot [ 4 , 33 ]). It should be noted that specific costs of implementing HA have not been identified, so it is not fully clear whether these high costs are real or perceived. These findings suggest that those residing in cold/temperate climates need greater support in adopting HA strategies. Where funding is not available, education is essential to increasing the adoption of HA (i.e., awareness of low cost and effective alternative HA strategies [ 22 , 37 , 54 , 60 , 94 ]).

The impact of biological sex differences on the adoption of HA has received more attention than climate within this context. Females [20%, males: 11.6% ( P  = 0.045)] were more likely to have trained in the heat at IAAF Beijing 2015 [ 74 ], and at UCI Qatar 2016 [ 85 ], there was a significant effect of biological sex on the adoption of HA. Specifically, more males (30%) than females (8%) did not implement any form of heat training [ P  < 0.05, UCI Qatar 2016 [ 85 ]]. In contrast, HA adoption was higher among males (63%, female: 46%) at RWTC Muscat 2022, although not statistically significant [ 33 ]. Alkemade et al. [ 6 ] observed that male Paralympic athletes were more likely to have adopted a HA strategy prior to past events but prior to the Paralympics Tokyo 2020 no differences between sexes were identified. Adoption of HA was not significantly different between sexes [56% and 68% (male vs. female not specified)] at IAAF Doha 2019 [ 80 ].

Findings are somewhat inconclusive in determining a specific impact of biological sex on the self-selected adoption of HA prior to major championships, due to limited available data/sample size. Significantly more research is required to determine any impact of sex on the adoption of HA prior to competition. Additionally, debate exists surrounding the timescale of male vs. female adaptation to the heat [ 47 , 110 ]. Some evidence suggests that short (i.e., 5 day) HA protocols are likely insufficient for females to obtain physiological adaptations that are beneficial for health/performance [ 39 , 50 , 62 , 109 , 116 ] however, the limited data in females make specific conclusions difficult [ 47 ]. Thus, the continued comparison of elite male and female athlete real-world heat-based practices are warranted. Similarly, more data are required across the sport landscape to determine with greater certainty if and/or how living/training in a cold/temperate environment impacts an athlete’s ability to adopt HA. From the current data, international federations and governing bodies should make a concerted effort to support those from a cold/temperate environment to be able to adopt HA into their practice, whether this is through education or funding.

Knowledge of Heat Related Best Practice

Knowledge of athletes and practitioners can be assessed in multiple ways. Including but not limited to self-reported survey questions and/or interviews that directly evaluate knowledge, and observe current practice (i.e., training/competition preparation) to determine whether evidence-based guidelines are followed. For example, to achieve full HA adaptations ≥14 consecutive days of heat exposure for at least 60 min where Tc ≥ 38.5 °C, combined with high skin temperature and profuse sweating, are required [ 35 , 73 , 78 ]. Shorter HA protocols (minimum 5 days of heat exposure) can elicit some physiological adaptations and performance benefits [ 35 , 44 , 112 ]. Athletes that implement a dedicated HA strategy for ≥5 days are indicative of some/appropriate knowledge of HA best practice (and of course have the time, environment and/or facilities to do this).

Currently, there is limited comparability between research studies given the surveys that have been implemented to assess athlete knowledge lack standardisation, thus, the key findings are conveyed descriptively here. Alabdulwahed et al. [ 4 ] determined elite athletes and practitioners’ knowledge and use of heat adaptation practices via an online self-reported survey. Athletes had less heat related best practice knowledge than practitioners, and although both populations exhibited greater knowledge of appropriate nutritional strategies for training/competing in the heat, greater education is still required [ 4 ]. Perceived performance decrement in hot conditions was ~30% (median) among both athletes and practitioners, considerably higher than the reported 6% to 16% and 0.3% to 0.4% per degree of WBGT from the optimal 7.5 °C to 15 °C in the literature [ 22 , 55 ]; with a range of ~ 5% to 50% in perceived performance decrement highlighting a highly varied level of knowledge. The median number of days athletes/practitioners believed were needed to achieve full HA was ~ 15 days, which suggests appropriate knowledge of HA adaptations; however, the large range of responses (from 3 to 30 days) does not support this [ 4 , 33 ]. When rating the effectiveness of HA to offset heat induced performance decrements, athletes most commonly (38%) selected that HA was ‘moderately effective’ compared to 49% of practitioners who perceived it as ‘extremely/most effective’ [ 4 ]. Interestingly, both athletes and practitioners perceived cooling strategies, pre (58% and 60%, respectively) and mid-cooling (66% and 74%, respectively), to have good efficacy in reducing heat induced performance decrements. This is reflected in current practice where 50%–80% of athletes have pre-planned cooling strategies across competitions (discussed in depth below [ 74 , 83 , 85 ]). Athletes and practitioners had limited knowledge of safe Tc during exercise with biologically implausible Tc’s (range of 25 °C to 45 °C) being reported as a ‘safe’ Tc to attain during exercise [ 4 ]. Measuring Tc during training/competition was considered to be important (53% to 74% of surveyed athletes reported it as important) yet, 75% to 91% of those surveyed reported not having measured Tc previously [ 4 ], similarly 77% of those at the RWTC Muscat 2022 had never measured Tc [ 33 ]. These data highlight that knowledge of evidence-based practice does not always translate to the adoption of best practice [ 4 ]. Finally, only 35% of athletes at RWTC Muscat 2022 were aware of what WBGT is [ 33 ], suggesting athletes may be unaware of the magnitude by which ambient conditions may impact their health and performance.

Not all research assessing elite athlete preparation for competition in heat has directly assessed athlete or practitioner knowledge. However, the low adoption of HA in these studies may infer that a significant proportion of athletes may not be aware of the importance/benefits of adopting HA and/or how to induce beneficial HA adaptations prior to competition in the heat, or face significant barriers that prevent its adoption [ 6 , 33 , 74 , 80 , 85 ]. Given the events studied are World Championship and Paralympic events and are generally considered the pinnacle of an athlete’s career, it would be expected that athletes would prioritise preparation for these events to achieve the highest place finish possible. Furthermore, national federations likely provide greater financial support to athletes competing at these events and it can be assumed that these competitions represent maximal adoption of HA in comparison to events of lesser standing. Those who did adopt a dedicated HA strategy prior to events did so for between 5 and 30 days, indicative of athletes implementing short to long-term HA [ 6 , 33 , 74 , 80 , 85 ]. At RWTC Muscat 2022, 57% undertook self-reported HA for > 10 days, suggesting an attempt to elicit fuller HA adaptations [ 33 ]; however, this is speculative.

Effect of Climate and Biological Sex-Based Differences on Knowledge of Heat Related Best Practice

The climate that an athlete lives/trains in has limited impact on knowledge of heat related practice. Alabdulwahed et al. [ 4 ] observed minimal differences in knowledge between athletes residing in hot compared with cold/temperate climates. Seventy eight percent of surveyed athletes/practitioners from a cold/temperate climate (hot: 57%) identified pre-cooling as the most effective strategy for reducing performance decrements induced by hot conditions, suggesting limited knowledge among athletes/practitioners from both climates. Biological sex differences in knowledge were not assessed within this study [ 4 ]. Galan-Lopez et al. [ 33 ] saw no impact of climate on knowledge but there were differences between sexes. A comparison between men and women showed that 83% of females vs. 55% of males did not know what WBGT was, 42% of females vs. 14% of males were more likely to report not knowing the maximum environmental conditions expected at the RWTC Muscat 2022, and only 8% females vs. 31% males reported having measured Tc in training/competition previously.

Based on current evidence, knowledge of heat related practice appears to be limited among elite athletes. International federations and national governing bodies must remain central advocates for the implementation of concerted efforts to improve knowledge among their athletes, practitioners and stakeholders. More informed/educated athletes are likely to adopt evidence-based practice that will benefit themselves (i.e., improved performance in the heat) and race organisers (i.e., fewer medical events). It is unclear whether the educational material provided by the IAAF prior to IAAF Doha 2019 drove the increase in the adoption of HA (amid substantial media and scientific attention given to the conditions); however, regular release of such material with updated recommendations (and in multiple languages) should be encouraged. In the short-term, based on the limited available data, female athletes may require increased educational focus given they have exhibited less knowledge in this area than male athletes.

Adoption of Hydration and Cooling Strategies

Hydration [ 5 , 32 , 72 ] and cooling strategies alone [ 14 , 16 ] are effective in alleviating heat strain and improving athletic performance in hot conditions, but evidence suggests they should be complementary to the adoption of HA [ 100 ]. Hydration investigations during competition have focused on pre-planned fluid intake (namely water) and supplementation with carbohydrates and electrolytes. The prevalence of a pre-planned fluid intake strategy is generally high among elite athletes (≥80%), as is electrolyte and carbohydrate supplementation [ 74 , 83 , 85 ]. Adoption of a pre-planned fluid intake is considerably higher than that of HA and likely a reflection of athlete and practitioner knowledge, and reduced barriers to adoption of short-term heat mitigation strategies compared with HA. Alabdulwahed et al. [ 4 ] found that athletes and practitioners had superior knowledge of nutrition and hydration strategies compared to HA, and their self-reported practice was aligned with consensus recommendations for training and competing in the heat [ 78 ]. The use of a pre-planned fluid intake strategy and the volume of fluid varies depending on the event, due to a combination of competition rules (i.e., fluids not permitted), event duration, event temperatures, and ease of fluid intake during events (i.e., pace/speed of athlete during a race and frequency of aid stations [ 59 ]). Up to ~38% of track athletes (13.6% sprints, 37.8 middle distance, 23.4% long distance runners and 0% decathlon/heptathlon) at IAAF Beijing 2015 did not plan to consume any fluids during their competition [inclusive of warm-up/cool down [ 74 ]]. Time trialists (~45 min event) during UCI Qatar 2016 (65%–70%) planned to drink less than 0.5 L compared to the road race [~3 (female) to 6 (male) hour race) athletes who planned to drink over 2 L [90% [ 85 ]]. The event an athlete competed in impacted planned fluid composition with up to 54% of time trialists and ~70% of road race athletes at UCI Qatar 2016 planning to supplement their fluid with carbohydrates or electrolytes [ 85 ]. The attention given to heat prior to IAAF Doha 2019 and release of ‘beat the heat’ educational material likely reflects the high prevalence (93%) of athletes having a pre-planned hydration strategy with high use of electrolyte (83%) and carbohydrate (81%) supplementation [ 83 ]. Competition event (likely due to duration and race day weather conditions) still impacted fluid consumption, 82% of 50 km racewalk athletes reported planned consumption of over 2 L compared to 41% of 20 km racewalkers and marathon runners [ 83 ]. Only 30% of Paralympic athletes planned to consume fluids with electrolytes and 16% with carbohydrates. The rate of electrolyte/carbohydrate supplementation is likely due to the sample covering all Paralympic athletes and not only endurance-based events [ 6 ]. Hypohydration (reduced body water), equivalent to a body mass loss of 2%–3%, decreases plasma volume and increases cardiovascular strain when exercising in the heat, which may be detrimental to performance [ 45 , 66 ]. Elite athletes have been observed to experience severe hypohydration in competition and can still produce world class performances [ 10 ]. While this apparent tolerance is not well understood, it does seem that some ‘habituation’ to hypohydration may be possible [ 30 ] and elite athletes (due to their high absolute work rates and prolonged training) would likely regularly experience hypohydration in training and competition. Nonetheless, hypohydration is reported to exacerbate heat [ 89 ] and cardiovascular [ 1 ] strain and impair performance, even when athletes are blinded to their hydration status [ 32 ]. Fluid ingestion is also an effective measure to attenuate Tc rise during endurance performance [ 5 ]. The adoption of pre-planned hydration strategies and generally appropriate consumption levels by elite athletes suggests that they implement evidence-based guidelines when competing in the heat.

Cooling strategies have been widely adopted by elite athletes with an increase being observed in more recent competitions. From 52% of surveyed athletes at IAAF Beijing 2015 [ 74 ] to as much as 96% of time trialists at UCI Qatar 2016 (road race athletes: 74% [ 85 ], 80% IAAF Doha 2019 [ 83 ], 77% Paralympics Tokyo 2020 [ 6 ]). Cooling methods have varied greatly across studies with a high prevalence of ice vest use [ 83 ]. Mid-cooling (i.e., cooling during an event) has not been widely investigated, only at IAAF Doha 2019 and the Paralympics Tokyo 2020. Ninety-three percent (IAAF Doha 2019) and 88% (Paralympics Tokyo 2020) of surveyed athletes intended to implement a mid-cooling strategy [ 6 , 83 ]. Ninety-nine percent of those who had a planned pre-cooling strategy at IAAF Doha 2019 also had a planned mid-cooling strategy, and the predominant strategies were cold water dousing (65%) and cold water ingestion (52% [ 83 ]). This increased use of cooling strategies is representative of athletes perceived effectiveness of the strategy, having most commonly ranked pre- and mid-cooling as the most effective strategies to reduce the detrimental impact of heat stress on performance [ 4 ]. The prevalence of pre-planned cooling strategies among elite athletes is representative of the ease with which they can be applied in practice and suggests knowledge of evidence-based guidelines.

Hydration and cooling strategies are highly prevalent in elite athletes competing in the heat and there has been an increased prevalence since IAAF Beijing 2015 (see Fig.  3 for what is currently implemented by athletes in practice). The level with which hydration and cooling strategies have been adopted by athletes is significantly higher than HA, likely due to superior knowledge of, and logistical ease of employing these strategies compared to implementing and undertaking a HA regimen across several days/weeks. It would be of interest to determine the specifics of cooling strategies adopted by athletes, to date, only details of whether a cooling strategy will be used and which strategy (e.g., ice-vest, cold water ingestion) an athlete might adopt have been evaluated. Understanding differences in sport specific use of cooling strategies [ 2 ] and the duration, timing and aggressiveness of cooling interventions would help to determine whether evidence-based recommendations are being adopted [e.g., not inducing shivering, cool Tc and warm periphery (muscle temperature) as outlined by Taylor et al. [ 100 ]].

Nutrition, Hydration, and Cooling: An overview of the acute race day strategies implemented by elite athletes, what influences the strategy used and recommendations for athletes and practitioners. The content within this figure is derived from data within the following publications: Périard et al. [ 74 ], Racinais et al. [ 85 ], Racinais et al. [ 80 ], Galan-Lopez et al. [ 33 ], Alkemade et al. [ 6 ]

Effect of Climate and Biological Sex-Based Differences on Hydration and Cooling Strategy Adoption

The impact of the climate an athlete lives/trains has not been investigated for hydration and cooling strategies to date. However, Racinais et al. [ 83 ] noted that of the eight African based runners who completed their questionnaire two declared they planned no fluid intake [also observed in African runners previously [ 10 ]) and, perhaps consequently, these two athletes finished in the bottom 50% of finishers. African runners also had significantly higher body mass losses (− 3.9% vs. − 2.0%) compared to other athletes ( P  = 0.001 [ 83 ]). Sex-based differences have been observed within the hydration and cooling data [ 74 , 83 ]. Females were less likely to supplement their fluid consumption with electrolyte or carbohydrates at IAAF Beijing 2015 [ 74 ]. Females’ planned use of electrolytes (72%; men: 91%; P  = 0.029) and carbohydrate (67%; men: 93%; P  = 0.003) was significantly lower than their male counterparts at IAAF Doha 2019 [ 83 ]. Forty two percent (females) and 52% (males) planned a pre-cooling strategy at IAAF Beijing 2015 [ 74 ] however, at UCI Qatar 2016 96% of females planned to adopt a pre-cooling strategy prior to the road race compared to 57% of males (use among team/individual time trialists was not different between sexes [ 85 ]). The use of a pre- or mid-cooling strategy at IAAF Doha 2019 was not different between sexes other than higher (31%) adoption of pre-cooling via ice-slurry in females (males: 13% [ 83 ]). The sample of data in this space are limited, and further investigation is warranted to provide a greater understanding of hydration strategies between sexes.

Recommendations for Best Practice, Future Research and the Translation of Research into Practice

The recommendations were initially outlined by authors CE and LT and whenever possible align with existing consensus, meta-analysis, reviews and best-practices (as extensively cited above). Refinement and consensus between authors was reached via three rounds of author revisions (all authors). Further in-depth validation was sought from authors SR and TS. These recommendations are realised through a combination of best practice guidelines and author experience (including but not limited to: elite sport practitioners, elite sport researchers/scientists, elite sport clinicians and medical doctors, and members of international federations/governing bodies) within elite sport. Figure 4 provides an overview of these recommendations.

Recommendations: An overview of best practice recommendations, what research should focus on in the future and how to improve the adoption of these recommendations. These recommendations are realised through a combination of best practice guidelines and author experience within elite sport. Tc core temperature, Tsk skin temperature, HA heat acclimation/acclimatisation, IF international federation, NGB national governing body

Best Practice

HA is optimal to improve performance and protect health when competing in the heat. To achieve HA at least 10–14 consecutive days of active heat exposure (using a natural or artificial environment), where Tc is ≥38.5 °C, Tsk is ~35 °C with an increase in skin blood flow and profuse sweating is induced for at least 60 min, should be adopted in environmental conditions that are similar to or exceed the expected conditions (i.e., historical peak temperature/humidity) of the competition location [ 3 , 35 , 72 , 76 , 78 , 81 , 100 , 103 ]. Elite athlete training schedules may not allow for this type of regimen thus, they should look to complement specific HA training with the following two recommendations.

Where exercise in a hot environment is not achievable, post-exercise sauna (≥ 80 °C) or hot water immersion (≥40 °C) for 20–40 min [ 22 , 37 , 60 ] or wearing additional clothing during training [ 54 , 94 ] should be adopted to induce HA adaptations (NB: tolerance to these HA strategies should be built up gradually over time ideally, supervised by qualified personnel and monitored using body temperature measurement tools to avoid adverse health outcomes). An additional benefit of this approach is ‘quality’ preservation of the ‘active’ sport-specific part of the training session.

Pre-cooling strategies should be complementary to HA (but not replace) and focus on the physical and perceptual reduction of Tc and deep body tissue temperatures while maintaining a warm activated periphery (i.e., muscle temperature) to facilitate initial competition performance capacity [ 100 ]. If the periphery is cooled too much pre-competition (i.e., to the point of shivering), a disruption in peripheral to central feedback processes can occur at race onset which, until a relative equilibrium is reached, compromises pacing (athletes and coaches should plan for this within their adopted pacing strategies). CWI for 10–15 min at 10–15 °C is the most efficacious pre-cooling strategy to reduce body tissue temperature yet is often incompatible with practice [ 100 ]. Alternative albeit less effective (in terms of body tissue temperature reduction) methods include ice-vests/towels and ice slurry/cold water ingestion which have good practice-compatibility [ 14 , 16 ]. Mid-competition cooling, ideally adopted in a complimentary manner to both HA and pre-cooling, should focus on reducing the rate of rise in Tc and favourably altering body tissue and Tsk perceptions [ 100 ]. Ice cold water ingestion at regular intervals during competition, ice hats/towels and menthol spray are mid-competition cooling strategies observed to provide an ergogenic effect [ 14 , 16 , 95 ]. Importantly, an individualised approach to cooling should be adopted and thoroughly practised in training to ensure tolerance, avoid negative consequences (e.g., gastrointestinal issues, altered pacing, shivering) and ensure optimal implementation prior to and during competition [ 100 ].

Hydration strategies should be complementary to HA and pre-/mid-cooling approaches. Athletes should be euhydrated prior to competition and hydration strategies should begin in the days leading up to competition [ 45 ]. Competition day strategies should begin several hours before the start of competition to allow for fluid absorption and urination to return to normal. In-competition strategies should plan for fluid intake to, if possible, avoid significant dehydration (body mass losses of >2%) accruing during competition, but it must be acknowledged that in some settings this may not be possible [ 45 , 66 ]. Fluids may consist of electrolyte and/or carbohydrate solutions, although carbohydrate intake in particular, needs to be well planned to ensure carbohydrate intake is appropriate (i.e., not too little or too much). All strategies should be individualised and specific to the competition with thorough planning and repeated practise during training to avoid negative performance effects (e.g., gastrointestinal disturbances, hyponatraemia) during competition [ 45 ].

Take a holistic approach to assessing heat-based best practice within elite athletes linking the levels of adoption of HA, use of cooling and hydration strategies to self-reported knowledge and their execution to objectively measurable outcomes (e.g., the impact on performance and medical events). Investigation with large samples of competition fields is imperative (i.e., only 6% of athletes competing at the competitions in this review were surveyed, Table  1 ) and the research must be expanded from the current endurance athletes across other types of sports, sport modes and athletes’ performance levels.

Research should focus on capturing the athlete voice and identifying: (1) those unable to undertake HA and determine the barriers faced in adopting HA and how these can be overcome; (2) where athletes obtain their knowledge (e.g., practitioners, medical teams) of heat-based practice; and (3) individual differences and perceptions of the necessity for adopting dedicated HA training (e.g., individuals from a hot climate may perceive they are already/always HA and do not need to adopt HA).

Practitioners (e.g., medical team, coaches) have an instrumental role in knowledge translation and adoption of heat mitigation strategies thus, assessing their knowledge and where they obtain their knowledge provide insight to the results seen in athletes.

Translation of Research into Practice

International federations and national governing bodies must remain central advocates and educators of evidence-based practice with regular (not only prior to major championships) dissemination of updated and evidence-based educational materials, to all stakeholders including the athletes. Efforts should be made to deliver content in multiple languages and be accessible for athletes who may be visually impaired or have intellectual disabilities. Deploying strategies for active education (i.e., more than simply disseminating material) of evidence-based practice is likely required to observe an increase in the adoption of evidence-based practice among athletes [ 31 , 90 ].

Specific focus should be given to athletes from cold/temperate climates with innovative strategies to HA, given that these athletes are seen to be considerably less likely to adopt HA due to actual and/or perceived barriers faced accessing facilities and hot environments to live/train [ 4 , 33 ].

Education surrounding evidence-based hydration and cooling guidelines should be implemented to ensure athletes implement best practice and are ideally prepared for their event. Particularly for female athlete populations who have demonstrated sub-optimal practices compared to males which may be, in part, due to a lack of knowledge [ 33 , 83 ].

Conclusions

Long term HA (i.e., ≥10 days) is by far the most health protective and performance enhancing strategy to mitigate the impacts of heat compared to short/medium term HA. Cooling and hydration strategies should complement and not be used instead of HA and strategies should be individualised and well-practised. The adoption of HA among elite athletes prior to competition in the heat appears to be increasing, however, is not universal. Provision of easily digestible educational materials with alternative low cost, innovative and implementable HA strategies appear to be paramount to increasing the adoption of HA. Materials of this nature are needed most by those from cold/temperate climates who have been shown to be the least likely to adopt a HA strategy and face the most significant barriers to its implementation. There is wide use of cooling and hydration strategies by elite athletes competing in heat, likely due to the ease of implementation compared to HA. Educational materials should also include evidence-based guidelines that ensure athletes are optimally prepared for competition. Importantly, a one size fits all approach should be avoided. Materials must cater for sport and sex specific differences ensuring Paralympic athlete specific challenges (i.e., altered thermoregulation) are accounted for. Finally, research is required on large competition samples across the sporting landscape to determine how elite athletes outside of World Championship/Olympic/Paralympic endurance events prepare to compete in the heat.

Data Availability

Adams WM, Ferraro EM, Huggins RA, Casa DJ. Influence of body mass loss on changes in heart rate during exercise in the heat: a systematic review. J Strength Cond Res. 2014;28(8):2380–9.

Article   PubMed   Google Scholar  

Adams WM, Hosokawa Y, Casa DJ. Body-cooling paradigm in sport: maximizing safety and performance during competition. J Sport Rehabil. 2016;25(4):382–94.

Adams WM, Hosokawa Y, Casa DJ, Périard JD, Racinais S, Wingo JE, Yeargin SW, Scarneo-Miller SE, Kerr ZY, Belval LN, Alosa D, Csillan D, Labella C, Walker L. Roundtable on preseason heat safety in secondary school athletics: heat acclimatization. J Athl Train. 2021;56(4):352–61.

Article   PubMed   PubMed Central   Google Scholar  

Alabdulwahed S, Galan-Lopez N, Hill T, James LJ, Chrismas BCR, Racinais S, Stellingwerff T, Leal DV, Hausen M, Chamari K, Fullagar HHK, Esh C, Taylor L. Heat adaptation and nutrition practices: athlete and practitioner knowledge and use. Int J Sports Physiol Perform. 2022;17(7):1011–24.

Alhadad SB, Tan PMS, Lee JKW. Efficacy of heat mitigation strategies on core temperature and endurance exercise: a meta-analysis. Front Physiol. 2019;10:71.

Alkemade P, Daanen HAM, Janssen TWJ, Broad E, Goosey-Tolfrey VL, Ibusuki T, Kneepkens H, Périard JD, Eijsvogels TMH. Heat preparedness and exertional heat illness in Paralympic athletes: a Tokyo 2020 survey. Temperature (Austin). 2023;10(2):264–75.

Armstrong LE, Maresh CM. The induction and decay of heat acclimatisation in trained athletes. Sports Med. 1991;12(5):302–12.

Article   CAS   PubMed   Google Scholar  

Aughey RJ, Goodman CA, Mckenna MJ. Greater chance of high core temperatures with modified pacing strategy during team sport in the heat. J Sci Med Sport. 2014;17:113–8.

Ballester J, Quijal-Zamorano M, Mendez Turrubiates RF, Pegenaute F, Herrmann FR, Robine JM, Basagana X, Tonne C, Anto JM, Achebak H. Heat-related mortality in Europe during the summer of 2022. Nat Med. 2023;29(7):1857–66.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Beis LY, Wright-Whyte M, Fudge B, Noakes T, Pitsiladis YP. Drinking behaviors of elite male runners during marathon competition. Clin J Sport Med. 2012;22(3):254–61.

Belval LN, Casa DJ, Adams WM, Chiampas GT, Holschen JC, Hosokawa Y, Jardine J, Kane SF, Labotz M, Lemieux RS. Consensus statement-prehospital care of exertional heat stroke. Prehosp Emerg. 2018;22(3):392–7.

Article   Google Scholar  

Belval LN, Hosokawa Y, Casa DJ, Adams WM, Armstrong LE, Baker LB, Burke L, Cheuvront S, Chiampas G, Gonzalez-Alonso J, Huggins RA, Kavouras SA, Lee EC, Mcdermott BP, Miller K, Schlader Z, Sims S, Stearns RL, Troyanos C, Wingo J. Practical hydration solutions for sports. Nutrients. 2019;11(7):1550.

Bermon S, Adami PE. Meteorological risks in Doha 2019 Athletics World Championships: health considerations from organizers. Front Sports Act Living. 2019;1:58.

Bongers CC, Hopman MT, Eijsvogels TM. Cooling interventions for athletes: an overview of effectiveness, physiological mechanisms, and practical considerations. Temperature (Austin). 2017;4(1):60–78.

Bongers CC, Thijssen DH, Veltmeijer MT, Hopman MT, Eijsvogels TM. Precooling and percooling (cooling during exercise) both improve performance in the heat: a meta-analytical review. Br J Sports Med. 2015;49(6):377–84.

Bongers C, Ten Haaf DSM, Ravanelli N, Eijsvogels TMH, Hopman MTE. Core temperature and sweating in men and women during a 15-km race in cool conditions. Int J Sports Physiol Perform. 2020;15:1–6.

Google Scholar  

Byrne C, Lee JK, Chew SA, Lim CL, Tan EY. Continuous thermoregulatory responses to mass-participation distance running in heat. Med Sci Sports Exerc. 2006;38:803–10.

Capon A, Jay O, Ebi K, Lo S. Heat and health: a forthcoming Lancet Series. Lancet. 2019;394(1098):551–2.

Carr AJ, Vallance BS, Rothwell J, Rea AE, Burke LM, Guy JH. Competing in hot conditions at the Tokyo Olympic Games: preparation strategies used by Australian Race Walkers. Front Physiol. 2022;13:836858.

Casa DJ, Demartini JK, Bergeron MF, Csillan D, Eichner ER, Lopez RM, Ferrara MS, Miller KC, O’connor F, Sawka MN. National Athletic Trainers’ Association position statement: exertional heat illnesses. J Athl Train. 2015;50(9):986–1000.

Casa DJ, Hosokawa Y, Belval LN, Adams WM, Stearns RL. Preventing death from exertional heat stroke—the long road from evidence to policy. Kinesiol Rev. 2017;6(1):99–109.

Casadio JR, Kilding AE, Cotter JD, Laursen PB. From lab to real world: heat acclimation considerations for elite athletes. Sports Med . 2017;47(8):1467–76.

Chen S, Komatsu S. Plant proteomic research 4.0: frontiers in stress resilience. Int J Mol Sci. 2021;22(24):13362.

Cheng L, Abraham J, Trenberth KE, Fasullo J, Boyer T, Locarnini R, Zhang B, Yu F, Wan L, Chen X, Song X, Liu Y, Mann ME, Reseghetti F, Simoncelli S, Gouretski V, Chen G, Mishonov A, Reagan J, Zhu J. Upper ocean temperatures hit record high in 2020. Adv Atmos Sci. 2021;38:523–30.

Cheuvront SN, Kenefick RW, Montain SJ, Sawka MN. Mechanisms of aerobic performance impairment with heat stress and dehydration. J Appl Physiol. 2010;1985(109):1989–95.

Christensen CL, Ruhling RO. Thermoregulatory responses during a marathon. A case study of a woman runner. Br J Sports Med. 1980;14:131–2.

Cooper ER, Grundstein AJ, Miles JD, Ferrara MS, Curry P, Casa DJ, Hosokawa Y. Heat policy revision for Georgia high school football practices based on data-driven research. J Athl Train. 2020;55(7):673–81.

Daanen HAM, Racinais S, Périard JD. Heat acclimation decay and re-induction: a systematic review and meta-analysis. Sports Med. 2018;48(2):409–30.

Duffield R, Coutts AJ, Quinn J. Core temperature responses and match running performance during intermittent-sprint exercise competition in warm conditions. J Strength Cond Res. 2009;23:1238–44.

Fleming J, James LJ. Repeated familiarisation with hypohydration attenuates the performance decrement caused by hypohydration during treadmill running. Appl Physiol Nutr Metab. 2014;39(2):124–9.

Fullagar HHK, Mccall A, Impellizzeri FM, Favero T, Coutts AJ. The translation of sport science research to the field: a current opinion and overview on the perceptions of practitioners, researchers and coaches. Sports Med. 2019;49(12):1817–24.

Funnell MP, Mears SA, Bergin-Taylor K, James LJ. Blinded and unblinded hypohydration similarly impair cycling time trial performance in the heat in trained cyclists. J Appl Physiol. 2019;1985(126):870–9.

Galan-Lopez N, Esh C, Vaz Leal D, Gandini S, Lucas R, Garrandes F, Bermon S, Adami P, Kajeniene A, Hosokawa Y, Chrismas B, Stevens C, Taylor L. Heat preparation and knowledge at the world athletics race walking team Championships Muscat 2022. Int J Sports Physiol Perform. 2023;18(8):813–24.

Gee CM, Lacroix MA, Stellingwerff T, Gavel EH, Logan-Sprenger HM, West CR. Physiological considerations to support podium performance in para-athletes. Front Rehabil Sci. 2021;2:732342.

Gibson OR, James CA, Mee JA, Willmott AGB, Turner G, Hayes M, Maxwell NS. Heat alleviation strategies for athletic performance: a review and practitioner guidelines. Temperature (Austin). 2020;7:3–36.

Girard O, Brocherie F, Bishop DJ. Sprint performance under heat stress: a review. Scand J Med Sci Sports. 2015;25(Suppl 1):79–89.

Heathcote SL, Hassmen P, Zhou S, Stevens CJ. Passive heating: reviewing practical heat acclimation strategies for endurance athletes. Front Physiol. 2018;9:1851.

Henderson MJ, Grandou C, Chrismas BCR, Coutts AJ, Impellizzeri FM, Taylor L. Core body temperatures in intermittent sports: a systematic review. Sports Med. 2023;53(11):2147–70.

Hertig BA, Belding HS, Kraning KK, Batterton DL, Smith CR, Sargent F 2nd. Artificial acclimatization of women to heat. J Appl Physiol. 1963;18(2):383–6.

Hosokawa Y, Casa DJ, Racinais S. Translating evidence-based practice to clinical practice in Tokyo 2020: how to diagnose and manage exertional heat stroke. Br J Sports Med. 2020;54(15):883–4.

Hosokawa Y, Racinais S, Akama T, Zideman D, Budgett R, Casa DJ, Bermon S, Grundstein AJ, Pitsiladis YP, Schobersberger W. Prehospital management of exertional heat stroke at sports competitions: international Olympic Committee adverse weather impact expert working group for the Olympic Games Tokyo 2020. Br J Sports Med. 2021;55(24):1405–10.

Ibebuchi CC, Abu I-O. Characterization of temperature regimes in Western Europe, as regards the summer 2022 Western European heat wave. Clim Dyn. 2023;61:3707–20.

Ihsan M, Périard JD, Racinais S. How to integrate recovery during heat acclimation. 2021;55:185–6.

James CA, Richardson AJ, Watt PW, Willmott AG, Gibson OR, Maxwell NS. Short-term heat acclimation improves the determinants of endurance performance and 5-km running performance in the heat. Appl Physiol Nutr Metab. 2017;42(3):285–94.

James LJ, Funnell MP, James RM, Mears SA. Does hypohydration really impair endurance performance? Methodological considerations for interpreting hydration research. Sports Med. 2019;49(Suppl 2):103–14.

Kakamu T, Wada K, Smith DR, Endo S, Fukushima T. Preventing heat illness in the anticipated hot climate of the Tokyo 2020 Summer Olympic Games. Environ Health Prev Med. 2017;22(1):68.

Kelly MK, Bowe SJ, Jardine WT, Condo D, Guy JH, Snow RJ, Carr AJ. Heat adaptation for females: a systematic review and meta-analysis of physiological adaptations and exercise performance in the heat. Sports Med. 2023;53(7):1395–421.

Kerr Z, Register-Mihalik J, Pryor R. The effect of the National Athletic Trainers’ Association Inter-Association Task Force (NATA-IATF) preseason heat acclimatization guidelines on high school football preseason exertional heat illness rates. J Athl Train. 2018;53:S72.

Kerr ZY, Register-Mihalik JK, Pryor RR, Pierpoint LA, Scarneo SE, Adams WM, Kucera KL, Casa DJ, Marshall SW. The association between mandated preseason heat acclimatization guidelines and exertional heat illness during preseason high school American football practices. Environ Health Perspect. 2019;127(4):47003.

Kirby NV, Lucas SJE, Lucas RAI. Nine-, but not four-days heat acclimation improves self-paced endurance performance in females. Front Physiol. 2019;10:539.

Laitano O, Leon LR, Roberts WO, Sawka MN. Controversies in exertional heat stroke diagnosis, prevention, and treatment. J Appl Physiol. 2019;1985(127):1338–48.

Laursen PB, Suriano R, Quod MJ, Lee H, Abbiss CR, Nosaka K, Martin DT, Bishop D. Core temperature and hydration status during an Ironman triathlon. Br J Sports Med. 2006;40:320–5.

Lee JK, Nio AQ, Lim CL, Teo EY, Byrne C. Thermoregulation, pacing and fluid balance during mass participation distance running in a warm and humid environment. Eur J Appl Physiol. 2010;109:887–98.

Lundby C, Svendsen IS, Urianstad T, Hansen J, Ronnestad BR. Training wearing thermal clothing and training in hot ambient conditions are equally effective methods of heat acclimation. J Sci Med Sport. 2021;24(8):763–7.

Mantzios K, Ioannou LG, Panagiotaki Z, Ziaka S, Périard JD, Racinais S, Nybo L, Flouris AD. Effects of weather parameters on endurance running performance: discipline-specific analysis of 1258 races. Med Sci Sports Exerc. 2022;54(1):153–61.

Maron MB, Wagner JA, Horvath SM. Thermoregulatory responses during competitive marathon running. J Appl Physiol Respir Environ Exerc Physiol. 1977;42:909–14.

CAS   PubMed   Google Scholar  

Martin K, Mcleod E, Périard J, Rattray B, Keegan R, Pyne DB. The impact of environmental stress on cognitive performance: a systematic review. Hum Factors. 2019;61(8):1205–46.

Mason H, King CJ, Peden EA, Franklin CR. Systematic review of the impact of heatwaves on health service demand in Australia. BMC Health Serv Res. 2022;22(1):960.

Mccubbin AJ, Allanson BA, Caldwell Odgers JN, Cort MM, Costa RJS, Cox GR, Crawshay ST, Desbrow B, Freney EG, Gaskell SK, Hughes D, Irwin C, Jay O, Lalor BJ, Ross MLR, Shaw G, Périard JD, Burke LM. Sports dietitians Australia position statement: nutrition for exercise in hot environments. Int J Sport Nutr Exerc Metab. 2020;30(1):83–98.

Mcintyre RD, Zurawlew MJ, Oliver SJ, Cox AT, Mee JA, Walsh NP. A comparison of heat acclimation by post-exercise hot water immersion and exercise in the heat. J Sci Med Sport. 2021;24(8):729–34.

Mckay AKA, Stellingwerff T, Smith ES, Martin DT, Mujika I, Goosey-Tolfrey VL, Sheppard J, Burke LM. Defining training and performance caliber: a participant classification framework. Int J Sports Physiol Perform. 2022;17(2):317–31.

Mee JA, Gibson OR, Doust J, Maxwell NS. A comparison of males and females’ temporal patterning to short- and long-term heat acclimation. Scand J Med Sci Sports. 2015;25(Suppl 1):250–8.

Miller KC, Casa DJ, Adams WM, Hosokawa Y, Cates J, Emrich C, Fitzpatrick T, Hopper M, Jardine JF, Labotz M, Lopez RM, O’connor F, Smith MS. Roundtable on preseason heat safety in secondary school athletics: prehospital care of patients with exertional heat stroke. J Athl Train. 2021;56(4):372–82.

Millet GP, Hosokawa Y, Sandbakk O, Girard O. Editorial: Tokyo 2020 Olympic and paralympic games: specificities, novelties and lessons learned. Front Sports Act Living. 2022;4:1026769.

Millyard A, Layden JD, Pyne DB, Edwards AM, Bloxham SR. Impairments to thermoregulation in the elderly during heat exposure events. Gerontol Geriatr Med. 2020;6:2333721420932432.

Murray B. Hydration and physical performance. J Am Coll Nutr. 2007;26(Suppl 5):542S–548S.

Nakamura M, Naito T, Saito T, Takahashi A, Muraishi K, Hakamada N, Otomo M, Iizuka S, Nakamura D, Takahashi H. Case report: countermeasures against heat and coronavirus for Japanese athletes at the Tokyo 2020 olympics and paralympic games. Front Sports Act Living. 2022;4: 878022.

Notley SR, Racinais S, Kenny GP. Do sex differences in thermoregulation pose a concern for female athletes preparing for the Tokyo Olympics? Br J Sports Med. 2021;55(6):298–9.

Nybo L, Rasmussen P, Sawka MN. Performance in the heat-physiological factors of importance for hyperthermia-induced fatigue. Compr Physiol. 2014;4(2):657–89.

Ozgunen KT, Kurdak SS, Maughan RJ, Zeren C, Korkmaz S, Yazici Z, Ersoz G, Shirreffs SM, Binnet MS, Dvorak J. Effect of hot environmental conditions on physical activity patterns and temperature response of football players. Scand J Med Sci Sports. 2010;20(Suppl 3):140–7.

Périard JD, Degroot D, Jay O. Exertional heat stroke in sport and the military: epidemiology and mitigation. Exp Physiol. 2022;107(10):1111–21.

Périard JD, Eijsvogels TMH, Daanen HAM. Exercise under heat stress: thermoregulation, hydration, performance implications, and mitigation strategies. Physiol Rev. 2021;101(4):1873–979.

Périard JD, Racinais S, Sawka MN. Adaptations and mechanisms of human heat acclimation: applications for competitive athletes and sports. Scand J Med Sci Sports. 2015;25(Suppl 1):20–38.

Périard JD, Racinais S, Timpka T, Dahlström Ö, Spreco A, Jacobsson J, Bargoria V, Halje K, Alonso J-M. Strategies and factors associated with preparing for competing in the heat: a cohort study at the 2015 IAAF World Athletics Championships. Br J Sports Med. 2017;51:264–70.

Periard JD, Wilson MG, Tebeck ST, Gilmore JB, Stanley J, Girard O. Influence of the thermal environment on work rate and physiological strain during a UCI World tour multistage cycling race. Med Sci Sports Exerc. 2023;55:32–45.

Pryor JL, Johnson EC, Roberts WO, Pryor RR. Application of evidence-based recommendations for heat acclimation: Individual and team sport perspectives. Temperature (Austin). 2019;6(1):37–49.

Pugh LG, Corbett JL, Johnson RH. Rectal temperatures, weight losses, and sweat rates in marathon running. J Appl Physiol. 1967;23:347–52.

Racinais S, Alonso JM, Coutts AJ, Flouris AD, Girard O, Gonzalez-Alonso J, Hausswirth C, Jay O, Lee JK, Mitchell N, Nassis GP, Nybo L, Pluim BM, Roelands B, Sawka MN, Wingo J, Périard JD. Consensus recommendations on training and competing in the heat. Br J Sports Med. 2015;49(18):1164–73.

Racinais S, Casa D, Brocherie F, Ihsan M. Translating science into practice: the perspective of the Doha 2019 IAAF world championships in the heat. Front Sports Act Living. 2019;1:39.

Racinais S, Havenith G, Aylwin P, Ihsan M, Taylor L, Adami PE, Adamuz MC, Alhammoud M, Alonso JM, Bouscaren N, Buitrago S, Cardinale M, Van Dyk N, Esh CJ, Gomez-Ezeiza J, Garrandes F, Holtzhausen L, Labidi M, Lange G, Lloyd A, Moussay S, Mtibaa K, Townsend N, Wilson MG, Bermon S. 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. Br J Sports Med. 2022;56(8):439–45.

Racinais S, Hosokawa Y, Akama T, Bermon S, Bigard X, Casa DJ, Grundstein A, Jay O, Massey A, Migliorini S, Mountjoy M, Nikolic N, Pitsiladis YP, Schobersberger W, Steinacker JM, Yamasawa F, Zideman DA, Engebretsen L, Budgett R. IOC consensus statement on recommendations and regulations for sport events in the heat. Br J Sports Med. 2023;57(1):8–25.

Racinais S, Ihsan M. Why should I test my athletes in the heat several months before Tokyo 2020? Br J Sports Med. 2020;54:700–1.

Racinais S, Ihsan M, Taylor L, Cardinale M, Adami PE, Alonso JM, Bouscaren N, Buitrago S, Esh CJ, Gomez-Ezeiza J, Garrandes F, Havenith G, Labidi M, Lange G, Lloyd A, Moussay S, Mtibaa K, Townsend N, Wilson MG, Bermon S. Hydration and cooling in elite athletes: relationship with performance, body mass loss and body temperatures during the Doha 2019 IAAF World Athletics Championships. Br J Sports Med. 2021;55(23):1335–41.

Racinais S, Moussay S, Nichols D, Travers G, Belfekih T, Schumacher YO, Périard JD. Core temperature up to 41.5 °C during the UCI road cycling World Championships in the heat. Br J Sports Med. 2019;53(7):426–9.

Racinais S, Nichols D, Travers G, Moussay S, Belfekih T, Farooq A, Schumacher YO, Périard JD. Health status, heat preparation strategies and medical events among elite cyclists who competed in the heat at the 2016 UCI Road World Cycling Championships in Qatar. Br J Sports Med. 2020;54(16):1003–7.

Racinais S, Périard JD. Benefits of heat re-acclimation in the lead-up to the Tokyo Olympics. Br J Sports Med. 2020;54:945–6.

Sandford GN, Stellingwerff T, Koehle MS. Ozone pollution: a ‘hidden’ environmental layer for athletes preparing for the Tokyo 2020 Olympics & Paralympics. Br J Sports Med. 2021;55:189–90.

Saunders PU, Garvican-Lewis LA, Chapman RF, Périard JD. Special environments: altitude and heat. Int J Sport Nutr Exerc Metab. 2019;29(2):210–9.

Sawka MN, Cheuvront SN, Kenefick RW. Hypohydration and human performance: impact of environment and physiological mechanisms. Sports Med. 2015;45(Suppl 1):S51-60.

Schipper K, Bakker M, De Wit M, Ket JC, Abma TA. Strategies for disseminating recommendations or guidelines to patients: a systematic review. Implement Sci. 2016;11(1):82.

Singh G, Bennett K, Taylor L, Stevens C. Core body temperature responses during competitive sporting events: a narrative review. Biol Sport. 2023;40(4):1003–17.

Singh NR, Denissen EC, Mckune AJ, Peters EM. Intestinal temperature, heart rate, and hydration status in multiday trail runners. Clin J Sport Med 2012;22:311–8.

Stephenson BT, Hoekstra SP, Tolfrey K, Goosey-Tolfrey VL. High thermoregulatory strain during competitive paratriathlon racing in the heat. Int J Sports Physiol Perform. 2020;15:231–7.

Stevens CJ, Heathcote SL, Plews DJ, Laursen PB, Taylor L. Effect of two-weeks endurance training wearing additional clothing in a temperate outdoor environment on performance and physiology in the heat. Temperature (Austin). 2018;5(3):267–75.

Stevens CJ, Mauger AR, Hassmèn P, Taylor L. Endurance performance is influenced by perceptions of pain and temperature: theory, applications and safety considerations. Sports Med. 2018;48(3):525–37.

Stevens CJ, Ross ML, Carr AJ, Vallance B, Best R, Urwin C, Périard JD, Burke L. Postexercise hot-water immersion does not further enhance heat adaptation or performance in endurance athletes training in a hot environment. Int J Sports Physiol Perform. 2020;16(4):480–8.

Stevens CJ, Ross ML, Périard JD, Vallance BS, Burke LM. Core temperature responses to elite racewalking competition. Int J Sports Physiol Perform. 2020;15(6):892–5.

Stevens CJ, Taylor L, Dascombe BJ. Cooling during exercise: an overlooked strategy for enhancing endurance performance in the heat . Sports Med. 2017;47(5):829–41

Sugawara M, Manabe Y, Yamasawa F, Hosokawa Y. Athlete medical services at the marathon and race walking events during Tokyo 2020 olympics. Front Sports Act Living. 2022;4:872475.

Taylor L, Carter S, Stellingwerff T. Cooling at Tokyo 2020: the why and how for endurance and team sport athletes. Br J Sports Med. 2020;54(21):1243–5.

Taylor L, Watkins SL, Marshall H, Dascombe BJ, Foster J. The impact of different environmental conditions on cognitive function: a focused review. Front Physiol. 2015;6:372.

PubMed   Google Scholar  

Taylor NA. Eccrine sweat glands. Adaptations to physical training and heat acclimation. Sports Med. 1986;3(6):387–97.

Taylor NA. Human heat adaptation. Compr Physiol. 2011;4(1):325–65.

Topham TH, Smallcombe JW, Clark B, Brown HA, Telford RD, Jay O, Périard JD. Influence of sex and biological maturation on the sudomotor response to exercise-heat stress: are girls disadvantaged? Am J Physiol Regul Integr Comp Physiol. 2022;323(2):R161–8.

Tyler CJ, Reeve T, Hodges GJ, Cheung SS. The effects of heat adaptation on physiology, perception and exercise performance in the heat: a meta-analysis. Sports Med. 2016;46(11):1699–724.

Van Daalen KR, Romanello M, Rocklov J, Semenza JC, Tonne C, Markandya A, Dasandi N, Jankin S, Achebak H, Ballester J, Bechara H, Callaghan MW, Chambers J, Dasgupta S, Drummond P, Farooq Z, Gasparyan O, Gonzalez-Reviriego N, Hamilton I, Hanninen R, Kazmierczak A, Kendrovski V, Kennard H, Kiesewetter G, Lloyd SJ, Lotto Batista M, Martinez-Urtaza J, Mila C, Minx JC, Nieuwenhuijsen M, Palamarchuk J, Quijal-Zamorano M, Robinson EJZ, Scamman D, Schmoll O, Sewe MO, Sjodin H, Sofiev M, Solaraju-Murali B, Springmann M, Trinanes J, Anto JM, Nilsson M, Lowe R. The 2022 Europe report of the Lancet Countdown on health and climate change: towards a climate resilient future. Lancet Public Health. 2022;7(11):e942–65.

Veltmeijer MT, Eijsvogels TM, Thijssen DH, Hopman MT. Incidence and predictors of exertional hyperthermia after a 15-km road race in cool environmental conditions. J Sci Med Sport 2015;18:333–7.

Wald A, Demorest S. Race to beat the heat: climate change impacts physical activity. J Nurse Pract. 2022;18(4):388–94.

Weinman KP, Slabochova Z, Bernauer EM, Morimoto T, Sargent F 2nd. Reactions of men and women to repeated exposure to humid heat. J Appl Physiol. 1967;22(3):533–8.

Wickham KA, Wallace PJ, Cheung SS. Sex differences in the physiological adaptations to heat acclimation: a state-of-the-art review. Eur J Appl Physiol. 2021;121(2):353–67.

Wilby RL, Orr M, Depledge D, Giulianotti R, Havenith G, Kenyon JA, Matthews TKR, Mears SA, Mullan DJ, Taylor L. The impacts of sport emissions on climate: measurement, mitigation, and making a difference. Ann N Y Acad Sci. 2023;1519(1):20–33.

Willmott AGB, Hayes M, Waldock KAM, Relf RL, Watkins ER, James CA, Gibson OR, Smeeton NJ, Richardson AJ, Watt PW, Maxwell NS. Short-term heat acclimation prior to a multi-day desert ultra-marathon improves physiological and psychological responses without compromising immune status. J Sports Sci. 2017;35(22):2249–56.

WMO. WMO Global Annual to Decadal Climate Update (Target years: 2023–2027). 2023. https://library.wmo.int/index.php?lvl=notice_display&id=22272#.ZGS-wnZBxD . Accessed 17 May 2023.

Wyndham CH, Strydom NB. The danger of an inadequate water intake during marathon running. S Afr Med J. 1969;43:893–6.

Yankelson L, Sadeh B, Gershovitz L, Werthein J, Heller K, Halpern P, Halkin A, Adler A, Steinvil A, Viskin S. Life-threatening events during endurance sports: is heat stroke more prevalent than arrhythmic death? J Am Coll Cardiol. 2014;64(5):463–9.

Yanovich R, Ketko I, Charkoudian N. Sex differences in human thermoregulation: relevance for 2020 and beyond. Physiology (Bethesda). 2020;35(3):177–84.

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Esh, C.J., Carter, S., Galan-Lopez, N. et al. A Review of Elite Athlete Evidence-Based Knowledge and Preparation for Competing in the Heat. J. of SCI. IN SPORT AND EXERCISE (2024). https://doi.org/10.1007/s42978-024-00283-y

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Global research trend and hotspot in the low FODMAP diet: a bibliometric analysis

• Cheng Xu 1 , 2 ,
• Zhen Song 2 ,
• Jing-yi Hu 1 ,
• Chong-chao Li 2 &
• Hong Shen 1  

Journal of Health, Population and Nutrition volume  43 , Article number:  63 ( 2024 ) Cite this article

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The low FODMAP diet is the most recommended dietary intervention for the clinical management of IBS symptoms.

Bibliometrics analysis provides a comprehensive perspective and direction on global research trend and hotspot in the low FODMAP diet research.

The restriction stage of the low FODMAP diet is superior to other dietary therapies for IBS in terms of symptom response, but it has a negative impact on the abundance of gut Bifidobacteria and diet quality.

Identification of biomarkers to predict response to the low FODMAP diet has become the current research hotspot.

Large, well-designed clinical research studies are needed in the future to investigate the long-term efficacy and safety of the low FODMAP diet, including FODMAP reintroduction and personalization stages.

According to national guidelines, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) is a second-line therapy option for irritable bowel syndrome (IBS) and improves functional intestinal symptoms. Numerous noteworthy results have been published in this field over the past fifteen years. This study aims to analyze the global research trend and hotspot of the low FODMAP diet research, and provide a comprehensive perspective and direction for researchers.

The Science Citation Index-Expanded of the Web of Science Core Collection (WoSCC) was used to identify low FODMAP diet-related articles and reviews. Three bibliometric programs (CiteSpace, VOSviewer, Scimago Graphic) were utilized to analyze and visualize the annual publications, authors, countries, institutions, journals, citations, and keywords.

In total, 843 documents related to the low FODMAP diet research were published in 227 journals by 3,343 authors in 1,233 institutions from 59 countries. The United States, which was the most engaged nation in international collaboration, had the largest annual production and the fastest growth. The most productive organization was Monash University, and the most fruitful researcher was Gibson PR. Nutrients ranked first in terms of the number of published documents. The article “A diet low in FODMAPs reduces symptoms of irritable bowel syndrome” (Halmos EP, 2014) received the most co-citations. Keywords that appear frequently in the literature mainly involve two main aspects: the clinical efficacy evaluation and mechanism exploration of the low FODMAP diet. The term “gut microbiota” stands out as the most prominent keyword among the burst keywords that have remained prevalent till date.

The restriction stage of the low FODMAP diet is superior to other dietary therapies for IBS in terms of symptom response, but it has a negative impact on the abundance of gut Bifidobacteria and diet quality. Identification of biomarkers to predict response to the low FODMAP diet is of great interest and has become the current research hotspot.

Introduction

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) are a category of possibly poorly digested and absorbed but fermentable carbohydrates that can cause gastrointestinal discomfort in some people. Professor Gibson PR initially introduced the concept of the low FODMAP diet in 2005 for the prevention and treatment of Crohn’s disease [ 1 ], but the main focus of research quickly shifted to irritable bowel syndrome (IBS). IBS is a functional bowel disorder, mainly manifested by abdominal pain and bloating, accompanied by changes in bowel habits and/or abnormal stool characteristics [ 2 ]. The low FODMAP diet caused a short-term clinical response in 50–80% of IBS patients [ 3 ], and meta-analyses revealed that the diet was superior to other dietary therapies in terms of improving abdominal pain, bloating or distension, and bowel habits [ 4 ]. The low FODMAP diet was recommended as second-line therapy by national guidelines in United States [ 5 , 6 ] and the United Kingdom [ 7 , 8 ], and was perhaps the most evidence-based dietary intervention for IBS [ 5 ]. The low FODMAP diet is a therapeutic approach that includes an initial phase of restricting high FODMAP foods, followed by a systematic reintroduction process to evaluate an individual’s tolerance to different FODMAP categories. This step-wise approach ultimately leads to the development of a personalized diet plan tailored to each individual’s specific needs and tolerances [ 9 ].

Over the past fifteen years, there has been a significant increase in published studies on the low FODMAP diet. With such rapid growth, it becomes essential to adopt new approaches to review and interpret research trends. Bibliometrics, which combines mathematics, statistics, and philology, provides a multidimensional quantitative analysis and evaluation of literature, enabling a comprehensive understanding of the current state, potential development trend, and hotspot in a research area [ 10 , 11 ]. To date, no bibliometric analysis has been conducted to assess the global research trend and hotspot in the low FODMAP diet. This study aims to address the following research questions by providing a comprehensive analysis through the examination of pertinent data collected from previous research related to low FODMAP diet research (Table ​ 1 ).

Data collection

The Science Citation Index-Expanded of the Web of Science Core Collection (WoSCC) database was utilized for the search. Two authors independently conducted and verified all searches on July 1, 2023, to ensure accuracy and eliminate bias resulting from database upgrades. The search strategy was as follows: TS= (“FODMAP*” OR “Fermentable, poorly absorbed, short-chain carbohydrates” OR “Fermentable oligosaccharides, disaccharides, monosaccharides and polyols”). Taking into account the constant updating of the database, we conducted a secondary search on April 13, 2024 to integrate the results of recently published studies that met the criteria. The search encompassed the entire time range from the establishment of the database to April 13, 2024, and was limited to publications written in English. Articles and review articles related to the low FODMAP diet that could be correctly identified using bibliometric tools were included in the bibliometric analysis. The detailed search plan and data filtering procedure are displayed in Fig.  1 .

Flowchart for data collection and bibliometric analysis

• Bibliometric analysis

The full record and cited references of all literature obtained from WoSCC were downloaded in TXT format [ 12 ]. The TXT files were then imported into CiteSpace (V6.3 R1 Advanced), VOSviewer (V1.6.19), and Scimago Graphica (V1.0.40) for further analysis [ 13 , 14 , 15 ].

CiteSpace, VOSviewer, and Scimago Graphica are commonly used bibliometric and visualization software platforms [ 16 ]. CiteSpace is a Java program created by Professor Chaomei Chen to analyze and visualize trends and patterns in scientific publications [ 17 ]. In this study, CiteSpace was used for dual-map overlap analysis of journals, document co-citation analysis, and keyword-related analysis and visualization. VOSviewer, a Java-based bibliometric mapping application developed by Leiden University, excelled in processing extensive bibliometric maps based on network data and presenting scientific information [ 18 ]. VOSviewer was utilized for co-occurrence analysis, identifying patterns among countries, institutions, authors, journals, and keywords. Scimago Graphica is an application designed to analyze and visualize data. Scimago Graphica was used to produce collaboration and geographic distribution maps of publications.

Annual growth trend of publications

A total of 843 publications related to the low FODMAP diet were identified through our search strategy, including 474 articles (56.23%) and 369 review articles (43.77%). The annual number of publications is displayed in Fig.  2 . The number of publications in the early stage (2007–2012) remained small, with less than 10 publications per year. The subsequent four-year period (2013–2016) exhibited a steady growth pattern, with the annual publication count consistently exceeding twenty. Between 2017 and 2022, there was a considerable increase in the number of publications in this area, indicating that research on the low FODMAP diet has gained worldwide attention. However, there was a slight decline in the number of articles published in 2023. In general, judging from the fitting curve, the number of publications in this field will continue to grow steadily in the future.

The number of annual research publications and growth trend related to low FODMAP diet research

Distribution of countries and institutions

In total, 1,233 institutions from 59 different countries participated in the research of the low FODMAP diet. Table  2 lists the top 10 productive countries for scientific research. Most publications were produced in the United States (210, 24.91%), followed by Australia (155, 18.39%), the United Kingdom (120, 14.23%), Italy (105, 12.46%), and Canada (53, 6.29%). The United States had the highest annual output and the fastest growth, gradually overtaking Australia, which once maintained its leading position in the field. The United States was the most active country in international cooperation (Fig.  3 A), and Australia and the United Kingdom had the most common cooperation with the United States (Fig.  3 B and C). The top 10 productive institutions are listed in Table  2 , with Monash University (99, 11.71%) in Australia ranking first, followed by King’s College London (39, 4.63%), La Trobe University (23, 2.73%), and Guy’s and St Thomas’ NHS Foundation Trust (21, 2.49%). The cooperation between institutions is depicted in Fig.  3 D, with Monash University serving as the center of inter-institutional cooperation.

( A ) Network map of the collaboration analysis of the low FODMAP diet research among countries, export of results from VOSviewer. Each node represents a country. The size of the node is proportional to the number of documents published. The lines between nodes represent cooperation between countries. ( B ) Visualization map of international collaboration generated by Scimago Graphica. The size of the node represents the number of publications, and the color and thickness of the line represents the strength of cooperation between countries. ( C ) Map of geographical distribution of publications generated by Scimago Graphica. The size of the node represents the number of publications, and the color and thickness of the line represents the strength of cooperation between countries. ( D ) Network map of the collaboration analysis of the low FODMAP diet research among institutions, export of results from VOSviewer. Each node represents an institution. The size of the node is proportional to the number of documents published. The lines between nodes represent cooperation between institutions

Core author’s distribution and co-authorship network

In all, 3,343 authors contributed to research on the low FODMAP diet. Table S1 lists the top 10 authors in terms of publications and co-citations. The top three authors based on the number of publications were Gibson PR (65, 7.71%), Muir JG (44, 5.22%), and Whelan K (29, 3.44%). The network visualization map offers vivid details of cooperative interactions, aiding in the identification of possible partnerships (Fig.  4 A). In terms of co-citations, Staudacher HM had the most citations, reaching 909, followed by Halmos EP (711), and Gibson PR (607). Co-citation relationships occur when two publications are jointly cited by a third citation publication [ 19 ]. The network visualization of the relationship between co-cited authors is displayed in Fig.  4 B. Four of the top 10 productive authors were among the top 10 co-cited authors (Gibson PR, Staudacher HM, Biesiekierski JR, and Barrett JS).

Analysis of journals and co-cited journals

Publications related to the low FODMAP diet research were found in 227 journals. The top 10 productive journals and co-cited journals related to the low FODMAP diet research are listed in Table  3 . As shown in Fig.  4 C, Nutrients had the greatest volume with 140 documents (14.61%), followed by Neurogastroenterology and Motility (32, 3.80%), Journal of Gastroenterology and Hepatology (31, 3.68%), and Alimentary Pharmacology & Therapeutics (24, 2.85%). The frequency of co-citations, which indicates a journal’s substantial effect on a certain topic, is a key indicator of its influence. When ranked by co-citations, the top three journals were Gastroenterology (4174), American Journal of Gastroenterology (3166), and Gut (2642). The network visualization of co-cited journals is shown in Fig.  4 D. Among the top 10 co-cited journals, 40% were in the United Kingdom and 30% were in the United States. Additionally, 90% of these journals belonged to the Q1 or Q2 JCR division. The topical distribution of academic journals is depicted in the dual-map overlay of journals (Fig.  4 E). The colored paths show the citation relationships, with the citing journals on the left and the cited journals on the right. As shown, the low FODMAP diet research was mainly published in journals about “medicine, medical, clinical” subjects, and the documents cited by these studies were mostly published in journals related to “environmental, toxicology, nutrition”, “molecular, biology, genetics” or “health, nursing, medicine subjects”.

( A ) Network map of the collaboration analysis of low FODMAP diet research among core authors, export of results from VOSviewer. Each node represents an author. The size of the node is proportional to the number of documents published. ( B ) Network map of the co-cited authors related to low FODMAP diet research, export of results from VOSviewer. The size of the node is proportional to the number of citations. ( C ) Network map of the academic journals publishing low FODMAP diet research, export of results from VOSviewer. Each node represents a journal. The size of the node is proportional to the number of documents published. The colors represent the average year of publications (blue: earlier, yellow: later). ( D ) Network map of the co-cited journals publishing low FODMAP diet research, export of results from VOSviewer. The size of the node is proportional to the number of citations. ( E ) A dual-map overlap of journals publishing low FODMAP diet research, export of results from CiteSpace. The left side is the citing journal, the right side is the cited journal, and the longer transverse width of the ellipse indicates more documents in the relevant journal

Analysis of document co-citation

A total of 28,797 references were cited in the 843 included documents. Table  4 lists the top 10 highly co-cited documents related to research on the low FODMAP diet, all of which were clinical trials investigating the clinical efficacy of this therapy. The most highly co-cited document, authored by Halmos EP, received 217 citations. Among the top 10 highly co-cited documents, Halmos EP and Staudacher HM each had two documents. All of the top 10 highly co-cited documents were published in JCR Q1 or Q2 journals, with four of them published in Gastroenterology and two in Gut .

Analysis of keywords co-occurrence and topics trending

Keywords play a crucial role in revealing the primary themes of an academic publication. Fig.  5 A depicts the co-occurrence analysis of keywords, and Table S2 lists the top 20 keywords by frequency. Among the 459 keywords originating from the 843 included documents, the three most frequently used keywords were “irritable bowel syndrome” (529), “low FODMAP diet” (314), and “gastrointestinal symptoms” (216). The clustering visual analysis map delineates four principal research topics within the realm of low FODMAP diet, encompassing clinical trials, mechanisms, efficacy and safety, and efficacy comparison (Fig. 5 B).

The hierarchical cluster labeling method was employed to identify keywords most relevant to research on the low FODMAP diet. As shown in Fig.  5 C, these keywords were grouped into ten clusters, primarily focusing on evaluating the clinical efficacy (#0 irritable bowel syndrome, #3 ulcerative colitis, #4 quality of life, #6 symptoms, #7 inflammatory bowel disease) and exploring the mechanisms (#1 chronic pain, #2 nutrition, #9 gas production, #8 lactose malabsorption) of the low FODMAP diet. The clustering timeline view combines cluster analysis with time slice analysis to provide a clear depiction of the distribution and trend of keywords over time.

Keyword burst detection is a technique for detecting topics trending and current hotspot. The top 25 keywords with the strongest burst strength related to the low FODMAP diet research from 2007 to 2024 are presented in Fig.  5 D. Prior to 2012, there was a significant emergence of burst keywords such as “fructose malabsorption”, “lactose malabsorption”, and “common Australian vegetables”. Subsequently, from the period of 2013 to 2021, keywords like “gastrointestinal symptoms”, “placebo-controlled trial”, and “healthy subjects” exhibited a high burst strength. The recent burst in keywords such as “gut microbiota” (with a burst strength of 5.94), “mediterranean diet” (with a burst strength of 5.31), “disorders of gut brain interaction” (with a burst strength of 4.14), “carbohydrate diet” (with a burst strength of 4.05), and “scale” (with a burst strength of 3.16) reflects the emerging trends in the low FODMAP diet research. Among these keywords, “gut microbiota” stands out with the highest burst strength, signifying its position as the research hotspot in this field.

( A ) Temporal view of keywords co-occurrence generated by VOSviewer. Each node represents a keyword. The size of each node is proportional to the frequency of occurrence. The colors represent the average year of keyword occurrence (blue: earlier, yellow: later). ( B ) Clustering visual analysis map of keywords generated by VOSviewer. The size of each node is proportional to the frequency of occurrence. Nodes of different colors form separate clusters, each representing distinct research directions. ( C ) Timeline view of keywords co-occurrence generated by CiteSpace. Each node represents a keyword. The node size, indicative of occurrence frequency, correlates with the sum of their sizes along the yearly ring line. The links between keywords indicate co-occurrence, where deep blue signifies earlier appearances, deep red represents later ones, and overlapping colors denote occurrences in corresponding years. ( D ) Keywords with the strongest burst strength related to low FODMAP diet research during the period of 2007–2024. The burst period is represented by the red section on the blue timeline, export of results from CiteSpace

General information

The low FODMAP diet has gained significant attention in recent years within the scientific literature. This article presents the first study to utilize the bibliometric method for analyzing documents related to low FODMAP diet research, employing mathematical statistics and visual analysis to identify development trend and research hotspot based on data information.

Over the past fifteen years, there has been an increase in research related to the low FODMAP diet. Dietary therapy has become an important part of multidisciplinary intestinal disease management, evolving from a virtually non-existent position in the mid-20th century to one oriented on patient care and now plays an essential role in providing treatment [ 20 , 21 ]. Furthermore, the increasing research on the low FODMAP diet can be attributed to its value in controlling functional gastrointestinal symptoms, particularly in IBS. It is currently considered the most evidence-based dietary intervention for IBS [ 5 ], and has been recommended as a second-line herapy option for IBS [ 8 , 22 , 23 ]. The increase in studies demonstrates the prospective future for the low FODMAP diet research and requires greater focus and in-depth investigation.

The United States has emerged as the leading country in terms of publications in the field of low FODMAP diet research. This is unsurprising considering its academic funding and economic growth [ 24 ]. In addition to the United States, Australia, and the United Kingdom have published more than 100 documents related to the low FODMAP diet research, reflecting the fact that current studies are based on western dietary patterns. Among institutions, Monash University in Australia had the most publications worldwide. The study team from Monash University, a pioneer in this field, was the first to propose and develop the low FODMAP diet [ 1 ]. The United States and Australia exhibit the highest level of cooperation, which is unsurprising considering the United States’ significant output and Australia’s role as the initiator of low FODMAP diet research. The cooperation between the European region, represented by the United Kingdom, and the United States or Australia should not be ignored. In general, the research on the low FODMAP diet is a domain of global cooperation, so it is very important to strengthen institutional and international collaboration to promote the sustainable development of this field.

The number of publications represents the author’s contribution to the research field, and the number of citations reflects the author’s influence. Among the authors who contributed to the research of the low FODMAP diet from 2007 to 2024, Gibson PR from Monash University published the most documents. Gibson PR’s research team has been at the forefront of investigating the mechanisms and clinical aspects of this therapy. Staudacher HM from Deakin University is the most co-cited author in this field, focusing on researching the impact of the low FODMAP diet on gut microbiota, and relevant research literature has been widely cited [ 25 , 26 ]. Gibson PR, Staudacher HM, Biesiekierski JR, and Barrett JS are among the top 10 authors in terms of both published documents and citations, indicating their extensive scientific output and significant influence.

Analysis of journal publishing volume and journal co-citations can demonstrate their contributions to the field, and researchers can utilize these results to identify appropriate journals for submission. Among the 227 journals that have published low FODMAP diet research, Nutrients stands out with the highest number of publications, totaling 140. Nutrients is an international journal focused on nutrition and human health, and its considerable influence in the low FODMAP diet research field is noteworthy. It has emerged as a prominent platform for the dissemination of the latest and most extensive research in this area. Besides, documents published in Gastroenterology occupied the highest citation. As the official journal of the American Gastroenterological Association, Gastroenterology holds a prestigious position within the field of gastrointestinal diseases, demonstrating that some high-level and influential journals value the low FODMAP diet research. The results of the dual-map overlap of journals revealed that the majority of low FODMAP diet research was published in “medicine, medical, clinical” journals, and the cited literature was mostly published in “environmental, toxicology, nutrition”, “molecular, biology, genetics” or “health, nursing, medicine” journals, indicating that the research in this field was mainly focused on clinical trials and translational medicine research.

Knowledge base

Highly cited publications serve as indicators of the research hotspot within the field, and analyzing the cited references provides insights into the knowledge base of the field. Notably, the top 10 highly co-cited documents are all randomized controlled trials (RCTs) of the low FODMAP diet, serving as reliable reference resources for future research in this area. The first RCT of the low FODMAP diet found that after 4 weeks of restriction of fermentable carbohydrates, it significantly relieved the symptoms of IBS compared to a habitual diet [ 25 ]. Subsequent studies have consistently confirmed the efficacy of the low FODMAP diet. Most of these studies demonstrated that the low FODMAP diet had a positive effect on IBS symptoms compared to habitual diets [ 27 ], typical diets [ 28 , 29 ], a high FODMAP diet [ 30 ], or a sham diet [ 26 ], and several studies found its equivalent treatment efficacy to standard dietary advice [ 31 ] or general dietary guidelines [ 32 ]. However, the quality of evidence was rated as low due to potential bias stemming from a lack of double-blinding and inadequate reporting of suboptimal adverse events [ 4 ]. It is important to note that while the efficacy of the low FODMAP diet is considered “low quality evidence” according to GRADE criteria, it is recognized that dietary interventions rarely meet the criteria for “high quality evidence” used to evaluate pharmaceutical trials [ 33 ]. Several management guidelines have still recommended the use of this diet as a primary or secondary treatment for IBS [ 6 , 34 ].

Diet exerts a significant influence on the human gut microbiota [ 35 , 36 ], and the low FODMAP diet is no exception. Several studies among the top 10 highly co-cited documents have reported a relative reduction in total bacterial abundance due to FODMAP restriction, including a decrease in gut microbes typically linked with health, such as Bifidobacterium [ 25 , 26 , 37 ]. The first RCT of the low FODMAP diet showed a decrease in the proportion and concentration of luminal Bifidobacteria compared to a habitual diet [ 25 ]. Similarly, two other RCTs demonstrated a lower absolute abundance of Bifidobacteria in the low FODMAP diet compared to a placebo diet [ 26 , 37 ]. In contrast, another RCT did not observe a decrease in Bifidobacteria with the low FODMAP diet, but rather found an increase in the Bifidobacteriaceae family and certain species within the family Lachnospiraceae when following a high FODMAP diet [ 30 ]. The consistent finding of reduced Bifidobacteria abundance due to the low FODMAP diet raises concerns about potential adverse consequences, although the health effects of lower Bifidobacteria resulting from this diet remain unknown. In the long term, the adverse effects on luminal Bifidobacteria levels caused by FODMAP restriction can be effectively restored through FODMAP personalization [ 38 ], emphasizing the essential role played by the reintroduction and personalization stages in the low FODMAP diet [ 39 ]. However, further rigorous clinical trials are still necessary to establish the long-term efficacy and safety of the low FODMAP diet.

Research trend and hotpot

Visualized analysis of keywords reveals the evolution of high-frequency keywords and shows the development path of the low FODMAP diet. After clustering, we obtained 10 clustering labels that encompassed two primary aspects: the evaluation of clinical efficacy (#0 irritable bowel syndrome, #2 ulcerative colitis, #4 functional dyspepsia, #5 children, #6 celiac disease, #7 dietary interventions, #8 diet quality) and the exploration of mechanisms (#0 gas production, #2 colonic fermentation, #9 bifidobacteria) related to the low FODMAP diet.

Clinical research on the low FODMAP diet has mostly focused on its efficacy in IBS, which has been discussed in the previous sections. However, it is exciting to explore the potential efficacy of the low FODMAP diet for diseases other than IBS. More and more research data supported the use of the low FODMAP diet in conditions such as inflammatory bowel disease [ 40 , 41 ], functional dyspepsia [ 42 , 43 , 44 ], and celiac disease [ 45 ], etc. The low FOAMAP diet can assist in symptom management of a variety of diseases, which is thought to be related to the underlying pathological mechanism of FODMAP’s involvement in visceral hypersensitivity [ 46 ]. While encouraging, larger and more rigorously designed clinical trials evaluating the long-term effects of the low FODMAP diet are needed to evaluate its efficacy and safety in clinical practice.

The low FODMAP diet is the most recommended dietary intervention for managing of IBS symptoms, but faces challenges in dietary therapy development. In addition to its impact on gut microbiota mentioned above, the low FODMAP diet may also affect nutrition intake and diet quality. Patients with IBS were reported to have lower calcium intakes than those who followed a regular diet after following the low FODMAP diet for 4 weeks [ 25 ], as well as lower calorie, carbohydrate, and fiber intakes when compared to those following the diet recommended by the National Institute for Health and Care Excellence [ 32 ]. While the implementation of the low FODMAP diet was observed to reduce several micronutrients, most of these reductions were not significant after adjusting for energy intake, except for riboflavin [ 47 ]. An RCT of 130 individuals revealed that the low FODMAP diet had higher intakes of vitamin B 12 and selenium than the sham diet and more intakes of vitamin B 12 than a habitual diet, but decreased diet quality compared with the habitual control diet [ 48 ]. The reintroduction and personalization of FODMAP can be a solution to the nutritional deficiency that can occur with FODMAP restriction [ 49 ]. Besides, several attempts have been made to include dietary supplements to enhance the nutritional value of the diet, with specific supplements showing additional symptomatic benefits compared to FODMAP restriction alone [ 50 , 51 ]. Clinicians and dietitians should provide guidance to optimize nutrient intake, maintain diet quality and enhance patient adherence [ 52 , 53 ].

The low FODMAP diet may improve gastrointestinal symptoms through various mechanisms, and further research on mechanisms may broader its clinical application. FODMAP malabsorption leads to intestinal fermentation, gas production, and an increase in osmotic pressure, which stimulate mechano- and chemoreceptors, resulting in pain, decreased gastrointestinal motility, flatulence, and bloating [ 43 ]. However, a study using MRI showed that after consuming fermentable carbohydrates, IBS patients and healthy controls had comparable levels of gas and bowel distension, which suggested that the colonic hypersensitivity to distension, rather than the excess of gas, was the underlying cause of symptoms in IBS patients [ 54 ]. A recent finding has revealed that the low FODMAP diet can alter visceral hypersensitivity by increasing colon microcirculation perfusion and decreasing the expression of vascular endothelial-derived growth factor [ 55 ]. Another hypothesized mechanism by which FODMAPs cause gastrointestinal symptoms is related to increased histamine. It has been reported that IBS patients have increased urinary histamine levels and the low FODMAP diet can decrease histamine levels [ 30 ]. The cause of the histamine elevation has not been identified, as it may derive from dietary sources, or be produced by colonic mast cells or intestinal microbiota [ 56 ]. In addition, a decrease in the inflammatory cytokines interleukin (IL)-6 and IL-8 have been reported in IBS patients following the low FODMAP diet [ 57 ]. Therefore, the low FODMAP diet may improve gastrointestinal symptoms by regulating mucosal barrier and proinflammatory factors.

Keyword burst is regarded as a key indicator of trend and hotspot in a research field. The period prior to 2012 witnessed the burst of keywords such as “fructose malabsorption”, “lactose malabsorption”, and “common Australian vegetables”, which served as markers of the formulation and development of new concept within the field. Subsequently, spanning from 2013 to 2021, burst keywords like “gastrointestinal symptoms”, “placebo controlled trial”, and “healthy subjects” indicated a substantial surge in clinical trials performed during this timeframe to assess the effects of the low FODMAP diet. Burst keyword that has persisted until now can be regarded as the forefront of the low FODMAP diet research. The low FODMAP diet can improve the clinical condition in 50-80% of IBS patients [ 3 ]. In other words, 20–50% of individuals do not respond to the low FODMAP diet. Therefore, research on identifying biomarkers to predict response to the low FODMAP diet has become a prominent topic. Predicting responses to the low FODMAP diet based on fecal bacteria profiles is an emerging research field. The fecal microbiota has been analyzed by a “GA-map Dysbiosis Test” to create a “Dysbiosis Index” score, which provides a numerical score indicating how an individual’s bacterial composition compares to a healthy reference population, with some bacteria having higher abundance than others, including Bacteroides stercoris , Acinetobacter , Pseudomonas , and genus Desulfitispora [ 58 ]. Children with IBS who responded to the low FODMAP diet had a higher abundance of certain bacteria at baseline, such as Bacteroides , Ruminococcaceae , and Faecalibacterium prausnitzii , which are known to have great saccharolytic metabolic capacity [ 29 , 59 ]. Moreover, a recent study stratified IBS patients based on gut microbiota species and metabolic genetic characteristics, identifying two distinct microbiota profiles for IBS pathogenic-like and IBS health-like subtypes [ 60 ]. Patients with IBS pathogenic-like subtypes had a greater clinical response to the low FODMAP diet than those with IBS health-like subtypes [ 60 ]. However, a recent finding showed that the fecal microbiota did not predict response to the low FODMAP diet, and supported the distinction between the low FODMAP diet responders and non-responders based on fecal metabolites [ 61 ]. A previous study also used fecal volatile organic compounds at baseline to predict the response of IBS patients to the low FODMAP diet with 97% accuracy [ 62 ]. As a low-cost and non-invasive method, fecal volatile organic compounds profiling can be used to predict whether IBS patients would respond to the low FODMAP diet, but it still has to be verified by a large prospective cohort. The research on predictors of response to the low FODMAP diet is currently a hotspot, with preliminary evidence supporting the use of fecal microbiota or fecal metabolites. However, these methods need to be tested in larger external validation populations.

Strengths and limitations

To our knowledge, this study is the first to comprehensively summarize and analyze the knowledge base, research trend and current hotspot of the low FODMAP diet research using bibliometrics. Compared with traditional literature reviews, a bibliometric analysis based on bibliometrics tools (CiteSpace, VOSviewer, Scimago Graphic) can provide a relatively comprehensive and objective presentation of the data to better describe and visualize the research trend and hotspot. However, it is important to acknowledge that this study has inherent limitations due to the use of bibliometric analysis. First, the WOSCC database is still being updated, and some of the updated documents were not included in our study, so the results could not fully reflect the situation of the documents published in 2024. Second, the documents included in our study may not be complete. On the one hand, we only focused on data from the WoSCC database since CiteSpace can only analyze and visualize co-citation maps of data retrieved from this database. This selection was made due to the unavailability of co-citation analysis support on other significant search engines such as PubMed, Embase, and Ovid. On the other hand, due to the uniformity of data extraction, only published English literature was searched, and some bias was introduced. Nevertheless, considering the authority of the WoSCC database and the widespread use of English as the predominant international language, we consider this study still effectively portrays the overall situation in this field. Third, since citations to documents take time to accumulate, their amount does not accurately reflect the influence of the documents. Early published literature may receive more citations, while newer high-quality publications may require more time to accumulate citations.

This research is the first bibliometric analysis to summarize and visualize the development of the low FODMAP diet research, and explore the research trend and hotspot in this field. The gradual increase in published documents over the past fifteen years suggests that this field is receiving more attention from researchers. The research in this area has mainly focused on the evaluation of clinical efficacy and exploration of the mechanism of the low FODMAP diet in the treatment of IBS. The restriction stage of the low FODMAP diet is superior to other dietary therapies for IBS in terms of symptom response, but it has a detrimental influence on the abundance of gut Bifidobacteria and diet quality. Identification of biomarkers to predict response to the low FODMAP diet is of great interest and has become the current research hotspot. To provide higher levels of clinical evidence, large, well-designed clinical research studies are needed in the future to investigate the long-term efficacy and safety of the low FODMAP diet, including FODMAP reintroduction and personalization stages. We hope that this study will aid researchers in better comprehending the general trends in this field and can offer direction for further study.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols

• Irritable bowel syndrome

Web of Science Core Collection

Randomized controlled trials

Interleukin

Gibson PR, Shepherd SJ. Personal view: food for thought–western lifestyle and susceptibility to Crohn’s disease. The FODMAP hypothesis. Aliment Pharmacol Ther. 2005;21(12):1399–409. https://doi.org/10.1111/j.1365-2036.2005.02506.x .

Article   CAS   PubMed   Google Scholar  

Enck P, Aziz Q, Barbara G, Farmer AD, Fukudo S, Mayer EA, et al. Irritable bowel syndrome. Nat Rev Dis Primers. 2016;2:16014. https://doi.org/10.1038/nrdp.2016.14 .

Article   PubMed   PubMed Central   Google Scholar  

Staudacher HM, Whelan K. The low FODMAP diet: recent advances in understanding its mechanisms and efficacy in IBS. Gut. 2017;66(8):1517–27. https://doi.org/10.1136/gutjnl-2017-313750 .

Black CJ, Staudacher HM, Ford AC. Efficacy of a low FODMAP diet in irritable bowel syndrome: systematic review and network meta-analysis. Gut. 2022;71(6):1117–26. https://doi.org/10.1136/gutjnl-2021-325214 .

Chey WD, Hashash JG, Manning L, Chang L. AGA clinical practice update on the role of Diet in Irritable Bowel Syndrome. Expert Rev Gastroenterol. 2022;162(6):1737–45. https://doi.org/10.1053/j.gastro.2021.12.248 .

Article   Google Scholar  

Lacy BE, Pimentel M, Brenner DM, Chey WD, Keefer LA, Long MD, et al. ACG Clinical Guideline: management of irritable bowel syndrome. Am J Gastroenterol. 2021;116(1):17–44. https://doi.org/10.14309/ajg.0000000000001036 .

McKenzie YA, Alder A, Anderson W, Wills A, Goddard L, Gulia P, et al. British Dietetic Association evidence-based guidelines for the dietary management of irritable bowel syndrome in adults. J Hum Nutr Diet. 2012;25(3):260–74. https://doi.org/10.1111/j.1365-277X.2012.01242.x .

McKenzie YA, Bowyer RK, Leach H, Gulia P, Horobin J, O’Sullivan NA, et al. British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update). J Hum Nutr Diet. 2016;29(5):549–75. https://doi.org/10.1111/jhn.12385 .

Whelan K, Martin LD, Staudacher HM, Lomer MCE. The low FODMAP diet in the management of irritable bowel syndrome: an evidence-based review of FODMAP restriction, reintroduction and personalisation in clinical practice. J Hum Nutr Diet. 2018;31(2):239–55. https://doi.org/10.1111/jhn.12530 .

Chen C, Dubin R, Kim MC. Emerging trends and new developments in regenerative medicine: a scientometric update (2000–2014). Expert Opin Biol Ther. 2014;14(9):1295–317. https://doi.org/10.1517/14712598.2014.920813 .

Article   PubMed   Google Scholar  

Agarwal A, Durairajanayagam D, Tatagari S, Esteves SC, Harlev A, Henkel R, et al. Bibliometrics: tracking research impact by selecting the appropriate metrics. Asian J Androl. 2016;18(2):296–309. https://doi.org/10.4103/1008-682x.171582 .

Wang X, Liu H, Li W, Xiao H. Bibliometric analysis of functional dyspepsia research trends over the past 20 years. Front Public Health. 2022;10:1019110. https://doi.org/10.3389/fpubh.2022.1019110 .

Li Y, Zhou Y, Wang L, Lin X, Mao M, Yin S, et al. Emerging trends and hotspots in the links between the gut microbiota and MAFLD from 2002 to 2021: a bibliometric analysis. Front Endocrinol (Lausanne). 2022;13:990953. https://doi.org/10.3389/fendo.2022.990953 .

Zyoud SH, Shakhshir M, Abushanab AS, Koni A, Shahwan M, Jairoun AA, et al. Bibliometric mapping of the landscape and structure of nutrition and depression research: visualization analysis. J Health Popul Nutr. 2023;42(1):33. https://doi.org/10.1186/s41043-023-00378-2 .

Wan Y, Shen J, Ouyang J, Dong P, Hong Y, Liang L, et al. Bibliometric and visual analysis of neutrophil extracellular traps from 2004 to 2022. Front Immunol. 2022;13:1025861. https://doi.org/10.3389/fimmu.2022.1025861 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Xu C, Jiang R, Liu JY. Emerging trends and hot spots in subacute thyroiditis research from 2001 to 2022: a bibliometric analysis. Front Endocrinol (Lausanne). 2023;14:1144465. https://doi.org/10.3389/fendo.2023.1144465 .

Chen C, CiteSpace II. Detecting and visualizing emerging trends and transient patterns in scientific literature. J Am Soc Inf Sci. 2006;57(3):359–77. https://doi.org/10.1002/asi.20317 .

van Eck NJ, Waltman L. Software survey: VOSviewer, a computer program for bibliometric mapping. Scientometrics. 2010;84(2):523–38. https://doi.org/10.1007/s11192-009-0146-3 .

Trujillo CM, Long TM. Document co-citation analysis to enhance transdisciplinary research. Sci Adv. 2018;4(1):e1701130. https://doi.org/10.1126/sciadv.1701130 .

Fitzpatrick JA, Melton SL, Yao CK, Gibson PR, Halmos EP. Dietary management of adults with IBD - the emerging role of dietary therapy. Nat Rev Gastroenterol Hepatol. 2022;19(10):652–69. https://doi.org/10.1038/s41575-022-00619-5 .

Moayyedi P, Simrén M, Bercik P. Evidence-based and mechanistic insights into exclusion diets for IBS. Nat Rev Gastroenterol Hepatol. 2020;17(7):406–13. https://doi.org/10.1038/s41575-020-0270-3 .

Mansueto P, Seidita A, D’Alcamo A, Carroccio A. Role of FODMAPs in patients with irritable bowel syndrome. Nutr Clin Pract. 2015;30(5):665–82. https://doi.org/10.1177/0884533615569886 .

Gibson PR. The evidence base for efficacy of the low FODMAP diet in irritable bowel syndrome: is it ready for prime time as a first-line therapy? J Gastroenterol Hepatol. 2017;32(Suppl 1):32–5. https://doi.org/10.1111/jgh.13693 .

Zhao SX, Yu S, Tan AM, Xu X, Yu H. Global pattern of science funding in economics. Scientometrics.109(1):463–79. https://doi.org/10.1007/s11192-016-1961-y .

Staudacher HM, Lomer MC, Anderson JL, Barrett JS, Muir JG, Irving PM, et al. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr. 2012;142(8):1510–8. https://doi.org/10.3945/jn.112.159285 .

Staudacher HM, Lomer MCE, Farquharson FM, Louis P, Fava F, Franciosi E, et al. A Diet Low in FODMAPs reduces symptoms in patients with irritable bowel syndrome and a Probiotic restores Bifidobacterium species: a Randomized Controlled Trial. Gastroenterology. 2017;153(4):936–47. https://doi.org/10.1053/j.gastro.2017.06.010 .

Harvie RM, Chisholm AW, Bisanz JE, Burton JP, Herbison P, Schultz K, et al. Long-term irritable bowel syndrome symptom control with reintroduction of selected FODMAPs. World J Gastroenterol. 2017;23(25):4632–43. https://doi.org/10.3748/wjg.v23.i25.4632 .

Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014;146(1):67–e75. https://doi.org/10.1053/j.gastro.2013.09.046 .

Chumpitazi BP, Cope JL, Hollister EB, Tsai CM, McMeans AR, Luna RA, et al. Randomised clinical trial: gut microbiome biomarkers are associated with clinical response to a low FODMAP diet in children with the irritable bowel syndrome. Aliment Pharmacol Ther. 2015;42(4):418–27. https://doi.org/10.1111/apt.13286 .

McIntosh K, Reed DE, Schneider T, Dang F, Keshteli AH, De Palma G, et al. FODMAPs alter symptoms and the metabolome of patients with IBS: a randomised controlled trial. Gut. 2017;66(7):1241–51. https://doi.org/10.1136/gutjnl-2015-311339 .

Böhn L, Störsrud S, Liljebo T, Collin L, Lindfors P, Törnblom H, et al. Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 2015;149(6):1399–407. https://doi.org/10.1053/j.gastro.2015.07.054 .

Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A randomized controlled trial comparing the low FODMAP Diet vs. modified NICE guidelines in US adults with IBS-D. Am J Gastroenterol. 2016;111(12):1824–32. https://doi.org/10.1038/ajg.2016.434 .

Yao CK, Gibson PR, Shepherd SJ. Design of clinical trials evaluating dietary interventions in patients with functional gastrointestinal disorders. Am J Gastroenterol. 2013;108(5):748–58. https://doi.org/10.1038/ajg.2013.77 .

Vasant DH, Paine PA, Black CJ, Houghton LA, Everitt HA, Corsetti M, et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut. 2021;70(7):1214–40. https://doi.org/10.1136/gutjnl-2021-324598 .

Wu GD, Chen J, Hoffmann C, Bittinger K, Chen YY, Keilbaugh SA, et al. Linking long-term dietary patterns with gut microbial enterotypes. Science. 2011;334(6052):105–8. https://doi.org/10.1126/science.1208344 .

Rothschild D, Weissbrod O, Barkan E, Kurilshikov A, Korem T, Zeevi D, et al. Environment dominates over host genetics in shaping human gut microbiota. Nature. 2018;555(7695):210–5. https://doi.org/10.1038/nature25973 .

Halmos EP, Christophersen CT, Bird AR, Shepherd SJ, Gibson PR, Muir JG. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut. 2015;64(1):93–100. https://doi.org/10.1136/gutjnl-2014-307264 .

Staudacher HM, Rossi M, Kaminski T, Dimidi E, Ralph FSE, Wilson B, et al. Long-term personalized low FODMAP diet improves symptoms and maintains luminal Bifidobacteria abundance in irritable bowel syndrome. Neurogastroenterol Motil. 2022;34(4):e14241. https://doi.org/10.1111/nmo.14241 .

Lomer MCE. The low FODMAP diet in clinical practice: where are we and what are the long-term considerations? Proc Nutr Soc. 2023;1–11. https://doi.org/10.1017/s0029665123003579 .

Gearry RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR. Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease-a pilot study. J Crohns Colitis. 2009;3(1):8–14. https://doi.org/10.1016/j.crohns.2008.09.004 .

Prince AC, Myers CE, Joyce T, Irving P, Lomer M, Whelan K. Fermentable carbohydrate restriction (low FODMAP Diet) in clinical practice improves functional gastrointestinal symptoms in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2016;22(5):1129–36. https://doi.org/10.1097/mib.0000000000000708 .

Black CJ, Paine PA, Agrawal A, Aziz I, Eugenicos MP, Houghton LA, et al. British Society of Gastroenterology guidelines on the management of functional dyspepsia. Gut. 2022;71(9):1697–723. https://doi.org/10.1136/gutjnl-2022-327737 .

Popa SL, Dumitrascu DI, Pop C, Surdea-Blaga T, Ismaiel A, Chiarioni G, et al. Exclusion Diets Funct Dyspepsia Nutrients. 2022;14(10). https://doi.org/10.3390/nu14102057 .

Rettura F, Lambiase C, Grosso A, Rossi A, Tedeschi R, Ceccarelli L, et al. Role of Low-FODMAP diet in functional dyspepsia: why, when, and to whom. Best Pract Res Clin Gastroenterol. 2023;62–3. https://doi.org/10.1016/j.bpg.2023.101831 .

van Megen F, Skodje GI, Lergenmuller S, Zühlke S, Aabakken L, Veierød MB, et al. A low FODMAP Diet reduces symptoms in treated celiac patients with ongoing Symptoms-A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2022;20(10):2258–66. https://doi.org/10.1016/j.cgh.2022.01.011 .

Biesiekierski JR, Tuck CJ. Low FODMAP diet beyond IBS: evidence for use in other conditions. Curr Opin Pharmacol. 2022. https://doi.org/10.1016/j.coph.2022.102208 .

Eswaran S, Dolan RD, Ball SC, Jackson K, Chey W. The impact of a 4-Week Low-FODMAP and mNICE Diet on Nutrient Intake in a sample of US adults with irritable bowel syndrome with Diarrhea. J Acad Nutr Diet. 2020;120(4):641–9. https://doi.org/10.1016/j.jand.2019.03.003 .

Staudacher HM, Ralph FSE, Irving PM, Whelan K, Lomer MCE. Nutrient intake, Diet Quality, and Diet Diversity in Irritable Bowel Syndrome and the impact of the low FODMAP Diet. J Acad Nutr Diet. 2020;120(4):535–47. https://doi.org/10.1016/j.jand.2019.01.017 .

O’Keeffe M, Jansen C, Martin L, Williams M, Seamark L, Staudacher HM, et al. Long-term impact of the low-FODMAP diet on gastrointestinal symptoms, dietary intake, patient acceptability, and healthcare utilization in irritable bowel syndrome. Neurogastroenterol Motil. 2018;30(1). https://doi.org/10.1111/nmo.13154 .

Erickson J, Korczak R, Wang Q, Slavin J. Gastrointestinal tolerance of low FODMAP oral nutrition supplements in healthy human subjects: a randomized controlled trial. Nutr J. 2017;16(1):35. https://doi.org/10.1186/s12937-017-0256-3 .

So D, Yao CK, Ardalan ZS, Thwaites PA, Kalantar-Zadeh K, Gibson PR, et al. Supplementing Dietary fibers with a low FODMAP Diet in Irritable Bowel Syndrome: a randomized controlled crossover trial. Clin Gastroenterol Hepatol. 2022;20(9):2112–20. https://doi.org/10.1016/j.cgh.2021.12.016 .

Whigham L, Joyce T, Harper G, Irving PM, Staudacher HM, Whelan K, et al. Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome. J Hum Nutr Diet. 2015;28(6):687–96. https://doi.org/10.1111/jhn.12318 .

Wilson B, Cox SR, Whelan K. Challenges of the low FODMAP diet for managing irritable bowel syndrome and approaches to their minimisation and mitigation. Proc Nutr Soc. 2021;80(1):19–28. https://doi.org/10.1017/s0029665120006990 .

Major G, Pritchard S, Murray K, Alappadan JP, Hoad CL, Marciani L, et al. Colon hypersensitivity to Distension, Rather Than Excessive Gas production, produces carbohydrate-related symptoms in individuals with irritable bowel syndrome. Gastroenterology. 2017;152(1):124–33. https://doi.org/10.1053/j.gastro.2016.09.062 .

Hu C, Yan C, Wu Y, Tao E, Guo R, Zhu Z, et al. Low FODMAP Diet relieves visceral hypersensitivity and is Associated with changes in Colonic Microcirculation in Water Avoidance mice Model. Nutrients. 2023;15(5). https://doi.org/10.3390/nu15051155 .

De Palma G, Bercik P. Long-term personalized low FODMAP diet in IBS. Neurogastroenterol Motil. 2022;34(4):e14356. https://doi.org/10.1111/nmo.14356 .

Hustoft TN, Hausken T, Ystad SO, Valeur J, Brokstad K, Hatlebakk JG, et al. Effects of varying dietary content of fermentable short-chain carbohydrates on symptoms, fecal microenvironment, and cytokine profiles in patients with irritable bowel syndrome. Neurogastroenterol Motil. 2017;29(4). https://doi.org/10.1111/nmo.12969 .

Valeur J, Småstuen MC, Knudsen T, Lied GA, Røseth AG. Exploring gut microbiota composition as an Indicator of clinical response to Dietary FODMAP restriction in patients with irritable bowel syndrome. Dig Dis Sci. 2018;63(2):429–36. https://doi.org/10.1007/s10620-017-4893-3 .

Chumpitazi BP, Hollister EB, Oezguen N, Tsai CM, McMeans AR, Luna RA, et al. Gut microbiota influences low fermentable substrate diet efficacy in children with irritable bowel syndrome. Gut Microbes. 2014;5(2):165–75. https://doi.org/10.4161/gmic.27923 .

Vervier K, Moss S, Kumar N, Adoum A, Barne M, Browne H, et al. Two microbiota subtypes identified in irritable bowel syndrome with distinct responses to the low FODMAP diet. Gut. 2022;71(9):1821–30. https://doi.org/10.1136/gutjnl-2021-325177 .

Wilson B, Kanno T, Slater R, Rossi M, Irving PM, Lomer MC, et al. Faecal and urine metabolites, but not gut microbiota, may predict response to low FODMAP diet in irritable bowel syndrome. Aliment Pharmacol Ther. 2023;58(4):404–16. https://doi.org/10.1111/apt.17609 .

Rossi M, Aggio R, Staudacher HM, Lomer MC, Lindsay JO, Irving P, et al. Volatile Organic compounds in Feces Associate with response to Dietary intervention in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2018;16(3):385–91. https://doi.org/10.1016/j.cgh.2017.09.055 .

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The study was supported by the project of Jiangsu Province Traditional Chinese medicine digestive disease medical innovation center [grant number CXZX202208].

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Xu, C., Song, Z., Hu, Jy. et al. Global research trend and hotspot in the low FODMAP diet: a bibliometric analysis. J Health Popul Nutr 43 , 63 (2024). https://doi.org/10.1186/s41043-024-00567-7

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In a study recently published in Nature Communications on March 28, 2024, researchers from Tokyo Medical and Dental University (TMDU) found a way to achieve this by improving upon a widely used animal model to study periodontitis.

Studying periodontitis directly in humans is challenging. As a result, scientists often resort to animal models for preclinical research. For instance, the "mouse ligature-induced periodontitis model," since its inception in 2012, has enabled researchers to study the cellular mechanisms underlying this condition. Simply put, with this model, periodontal disease is artificially induced by ligating silk threads onto the molars of mice models, which induces plaque accumulation. While convenient and effective, this model, however, fails to capture the complete picture of periodontitis. "Even though the periodontal tissue is composed of gingiva, periodontal ligament, alveolar bone, and cementum, analyses are usually performed exclusively on gingival samples due to technical and quantitative limitations," remarks lead author Mr. Anhao Liu. "This sampling strategy limits the conclusions that may be drawn from these studies, so methods that allow for the simultaneous analysis of all tissue components are needed."

To address this limitation, the research team developed a modified ligature-induced periodontitis model. Instead of the classic single ligature, they used a triple ligature approach on the upper left molar of male mice. This strategy expanded the range of bone loss without causing severe bone destruction around the second molar, increasing the yield of the different types of periodontal tissue. "We isolated the three main tissue types and evaluated the RNA yield between the two models. The results showed that the triple-ligature model effectively increased the yield, achieving four times the yield of normal peri-root tissue and supporting the high-resolution analysis of different tissue types," explains senior author Dr. Mikihito Hayashi.

After confirming the efficacy of their modified model, the researchers proceeded to investigate the effects of periodontitis on gene expression among the different tissue types over time, focusing on genes related to inflammation and osteoclast differentiation. One of their main findings was that the expression of the Il1rl1 gene was markedly higher in peri-root tissue five days after ligation. This gene encodes the protein ST2 in both receptor and decoy isoform, which binds to a cytokine called IL-33 that is involved in inflammatory and immunoregulation processes.

To gain further insights into the role of this gene, the team induced periodontitis in genetically modified mice that lacked the Il1rl1 or Il33 genes. These mice exhibited accelerated inflammatory bone destruction, highlighting the protective role of the IL-33/ST2 pathway. Further analysis of cells containing the ST2 protein in its receptor form, mST2, revealed that most of them were of macrophage lineage. "Macrophages are typically classified into two main types, pro-inflammatory and anti-inflammatory, based on their activation process. We found that mST2-expressing cells were unique in that they expressed some markers of both types of macrophages simultaneously," comments senior author Dr. Takanori Iwata. "These cells were present in the peri-root tissue before inflammation was triggered, so we named them 'periodontal tissue-resident macrophages.'"

Together, the findings of this study showcase the power of this modified animal model to study the full scope of periodontitis in greater detail, right down to the biomolecular level. "We suggest the possibility that a novel IL-33/ST2 molecular pathway regulating inflammation and bone destruction in periodontal disease, alongside specific macrophages in peri-root tissue, is deeply involved in periodontal disease. This will hopefully lead to the development of new treatment strategies and prevention methods," concludes senior author Dr. Tomoki Nakashima.

• Bone and Spine
• Biotechnology and Bioengineering
• Microbiology
• Periodontal disease
• Adipose tissue
• House mouse
• Biological tissue
• Blood vessel
• Global climate model

Story Source:

Materials provided by Tokyo Medical and Dental University . Note: Content may be edited for style and length.

Journal Reference :

• Anhao Liu, Mikihito Hayashi, Yujin Ohsugi, Sayaka Katagiri, Shizuo Akira, Takanori Iwata, Tomoki Nakashima. The IL-33/ST2 axis is protective against acute inflammation during the course of periodontitis . Nature Communications , 2024; 15 (1) DOI: 10.1038/s41467-024-46746-2

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Are We Talking Too Much About Mental Health?

Recent studies cast doubt on whether large-scale mental health interventions are making young people better. Some even suggest they can have a negative effect.

By Ellen Barry

In recent years, mental health has become a central subject in childhood and adolescence. Teenagers narrate their psychiatric diagnosis and treatment on TikTok and Instagram. School systems, alarmed by rising levels of distress and self-harm, are introducing preventive coursework in emotional self-regulation and mindfulness.

Now, some researchers warn that we are in danger of overdoing it. Mental health awareness campaigns, they argue, help some young people identify disorders that badly need treatment — but they have a negative effect on others, leading them to over-interpret their symptoms and see themselves as more troubled than they are.

The researchers point to unexpected results in trials of school-based mental health interventions in the United Kingdom and Australia: Students who underwent training in the basics of mindfulness , cognitive behavioral therapy and dialectical behavior therapy did not emerge healthier than peers who did not participate, and some were worse off, at least for a while.

And new research from the United States shows that among young people, “self-labeling” as having depression or anxiety is associated with poor coping skills, like avoidance or rumination.

In a paper published last year , two research psychologists at the University of Oxford, Lucy Foulkes and Jack Andrews, coined the term “prevalence inflation” — driven by the reporting of mild or transient symptoms as mental health disorders — and suggested that awareness campaigns were contributing to it.

“It’s creating this message that teenagers are vulnerable, they’re likely to have problems, and the solution is to outsource them to a professional,” said Dr. Foulkes, a Prudence Trust Research Fellow in Oxford’s department of experimental psychology, who has written two books on mental health and adolescence.

Until high-quality research has clarified these unexpected negative effects, they argue, school systems should proceed cautiously with large-scale mental health interventions.

“It’s not that we need to go back to square one, but it’s that we need to press pause and reroute potentially,” Dr. Foulkes said. “It’s possible that something very well-intended has overshot a bit and needs to be brought back in.”

This remains a minority view among specialists in adolescent mental health, who mostly agree that the far more urgent problem is lack of access to treatment.

About 60 percent of young Americans with severe depression receive no treatment, according to Mental Health America, a nonprofit research group. In crisis, desperate families fall back on emergency rooms, where teens often remain for days before a psychiatric bed opens up. There is good reason to embrace a preventive approach, teaching schoolchildren basic skills that might forestall crises later, experts say.

Dr. Foulkes said she understood that her argument runs counter to that consensus, and when she began to present it, she braced for a backlash. To her surprise, she said, many educators reached out to express quiet agreement.

“There’s definitely a fear about being the one to say it,” she said.

A deflating result

In the summer of 2022, the results of a landmark study on mindfulness training in British classrooms landed — like a lead balloon.

The trial, My Resilience in Adolescence, or MYRIAD, was ambitious, meticulous and expansive, following about 28,000 teenagers over eight years. It had been launched in a glow of optimism that the practice would pay off, improving the students’ mental health outcomes in later years.

Half of the teenagers were trained by their teachers to direct their attention to the present moment — breathing, physical sensations or everyday activities — in 10 lessons of 30 to 50 minutes apiece.

The results were disappointing . The authors reported “no support for our hypothesis” that mindfulness training would improve students’ mental health. In fact, students at highest risk for mental health problems did somewhat worse after receiving the training, the authors concluded.

But by the end of the eight-year project, “mindfulness is already embedded in a lot of schools, and there are already organizations making money from selling this program to schools,” said Dr. Foulkes, who had assisted on the study as a postdoctoral research associate. “And it’s very difficult to get the scientific message out there.”

Why, one might ask, would a mental health program do harm?

Researchers in the study speculated that the training programs “bring awareness to upsetting thoughts,” encouraging students to sit with darker feelings, but without providing solutions, especially for societal problems like racism or poverty. They also found that the students didn’t enjoy the sessions and didn’t practice at home.

Another explanation is that mindfulness training could encourage “co-rumination,” the kind of long, unresolved group discussion that churns up problems without finding solutions.

As the MYRIAD results were being analyzed, Dr. Andrews led an evaluation of Climate Schools, an Australian intervention based on the principles of cognitive behavioral therapy, in which students observed cartoon characters navigating mental health concerns and then answered questions about practices to improve mental health.

Here, too, he found negative effects. Students who had taken the course reported higher levels of depression and anxiety symptoms six months and 12 months later.

Co-rumination appears to be higher in girls, who tend to come into the program more distressed, as well as more attuned to their friends, he said. “It might be,” he said, “that they kind of get together and make things a little bit worse for each other.”

Dr. Andrews, a Wellcome Trust research fellow, has since joined an effort to improve Climate Schools by addressing negative effects. And he has concluded that schools should slow down until “we know the evidence base a bit more.” Sometimes, he said, “doing nothing is better than doing something.”

The awareness paradox

One problem with mental health awareness, some research suggests, is that it may not help to put a label to your symptoms.

Isaac Ahuvia, a doctoral candidate at Stony Brook University, recently tested this in a study of 1,423 college students . Twenty-two percent “self-labeled” as having depression, telling researchers “I am depressed” or “I have depression,” but 39 percent met the diagnostic criteria for depression.

He found that the students who self-labeled felt that they had less control over depression and were more likely to catastrophize and less likely to respond to distress by putting their difficulties in perspective, compared with peers who had similar depression symptoms.

Jessica L. Schleider, a co-author of the self-labeling study, said this was no surprise. People who self-label “appear to be viewing depression as a biological inevitability,” she said. “People who don’t view emotions as malleable, view them as set and stuck and uncontrollable, tend to cope less well because they don’t see a point to trying.”

But Dr. Schleider, an associate professor of medical social sciences at Northwestern University and the director of the university’s Lab for Scalable Mental Health, pushed back on the prevalence inflation hypothesis. She disagreed with the claim that students are overdiagnosing themselves, noting that Mr. Ahuvia’s findings suggest otherwise.

Awareness campaigns are bound to have multiple effects, helping some students and not others. And ultimately, she argued, the priority for public health should be reaching young people in the most distress.

“The urgency of the mental health crisis is so clear,” she said. “In the partnerships that I have, the emphasis is on the kids truly struggling right now who have nothing — we need to help them — more so than a possible risk for a subset of kids who aren’t really struggling.”

Maybe, she said, we need to look beyond the “universal, school-assembly-style approach,” to targeted, light-touch interventions, which research has shown can be effective at decreasing anxiety and conduct disorders, especially in younger children.

“There is a risk of throwing the baby out with the bathwater,” Dr. Schleider said. “The response can’t be ‘Forget all of it.’ It should be ‘What about this intervention was unhelpful?’”

Other researchers echoed her concern, pointing to studies that show that on average, students benefit from social and emotional learning courses.

One of the largest, a 2023 meta-analysis of 252 classroom programs in 53 countries, found that students who participated performed better academically, displayed better social skills and had lower levels of emotional distress or behavioral problems. In that context, negative effects in a handful of trials appear modest, the researchers said.

“We clearly have not figured out how to do them yet, but I can’t imagine any population-based intervention that the field got right the first time,” said Dr. Andrew J. Gerber, the president and medical director of Silver Hill Hospital and a practicing child and adolescent psychiatrist.

“Really, if you think about almost everything we do in schools, we don’t have great evidence for it working,” he added. “That doesn’t mean we don’t do it. It just means that we’re constantly thinking about ways to improve it.”

‘We want everyone to have it’

These debates are taking place a long way away from classrooms, where mental health curriculums are increasingly commonplace.

Allyson Kangisser, a counselor at Woodsdale Elementary School in Wheeling, W.Va., said the focus in her school is on basic coping skills. In the early grades, students are asked, “What things can you do to take care of yourself when you’re having big feelings?”

Starting in third grade, they take on more complex material, such as watching cartoon characters to distinguish transient stress from chronic conditions like depression. “We’re not trying to have them diagnose themselves,” Ms. Kangisser said. “We are saying, what do you feel — this one? Or this one?”

At the school’s sixth annual mental health fair last month, Woodsdale students walked through a giant inflatable brain, its lobes neatly labeled. They did yoga stretches and talked about regulating their emotions. Ms. Kangisser said the event is valuable precisely because it is universal, so troubled children are not singled out.

“The mental health fair, everybody does it,” she said. “It’s not ‘You need it, and you don’t.’ We want everyone to have it, because you just never know.”

By the time the students reach college, they will have absorbed enormous amounts of information about mental health — from school, but also from social media and from one another.

Dr. Jessica Gold, chief wellness officer for the University of Tennessee system, said the college students she sees are recognizably different — more comfortable speaking about their emotions and more willing to be vulnerable. They also overuse diagnostic terms and have the self-assurance to question a psychiatrist’s judgment.

“It’s sort of a double-edged sword,” she said. “We want people to talk about this more, but we don’t want that to lead to overdiagnosis or incorrect diagnosis or overtreatment. We want it to lead to normalizing of having feelings.”

Lucy Kim, a Yale senior who has lobbied for better mental health support on campus, described the prevalence inflation hypothesis as “disheartening, dismissive and potentially dangerous,” providing another way to discount the experiences of young people.

“As a college student, I see a generation of young people around me impacted by a depth and breadth of loneliness, exhaustion and disillusionment suggestive of a malaise that goes deeper than the general vicissitudes of life,” said Ms. Kim, 23.

Overdiagnosis does happen, she said, and so does glorification of mental health disorders. But stigma and barriers to treatment remain the bigger problem. “I can confidently say I have never heard anyone respond to disclosures of depression with ‘That’s so cool, I wish I had that, too,’” she said.

Ellen Barry is a reporter covering mental health for The Times. More about Ellen Barry

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Researchers hope to bridge gap in care and treatment for heart disease in women

R esearchers at the Ludeman Family Center for Women's Health Research published a paper in the Journal for Women's Health Research that calls attention to how doctors can better diagnose and treat coronary heart disease (CHD) in women—particularly when it comes to the diagnosis of a heart attack.

"CHD manifests differently in women than in men, which results in different symptoms and responses to treatments," said the paper's lead author Stacy Trent, MD, MPH, a researcher at the Ludeman Family Center for Women's Health Research on the University of Colorado Anschutz Medical Campus.

CHD is commonly underdiagnosed and undertreated in women, leading to a higher mortality rate in women than in men.

"Current standards of care at many hospitals and emergency rooms are directed towards symptoms that are more common in men, increasing the chances for women to be misdiagnosed, and delaying proper and life-changing care," Trent adds.

In an effort to treat women more effectively, the American Heart Association/American College of Cardiology added a section to their Guideline for the Evaluation of Chest Pain focused on the "uniqueness" of chest pain in women.

In the paper, Trent and her team identify key elements in the new section that have the most potential to help catch and treat heart disease in women more quickly and effectively.

"I hope that health care providers can reference our paper to help diagnose and treat CHD in women," Trent said.

The paper goes into detail about the below recommendations related to the guidelines.

• Doctors should consider both the similarities and differences of symptoms by sex—keeping in mind that women are more likely to have chest pain and other symptoms like shortness of breath or nausea.
• They should use high-sensitivity troponins interpreted with sex-specific cutoffs to diagnose a heart attack. Sex-specific thresholds have been shown to decrease false negatives in females and decrease false positives in males.
• As well as use evidence-based clinical decision pathways to risk stratify patients. The use of sex-specific high-sensitivity troponin cutoffs may minimize misclassification in women and is an indirect way to add sex to risk stratification scores.

This research comes on the heels of President Biden's Executive Order to advance women's health research to ensure women get the answers they need when it comes to their health, including cardiovascular disease.

"We believe a big step for closing the gap right now in care for women is to shine a light on ways that clinicians can better address sex specific symptoms and treatments," senior author Amy Huebschmann, MD, MSc, the Ludeman Center's lead scientist.

The paper's authors conclude by urging organizational change leaders to push forward and make the necessary changes to ensure CHD is recognized and treated appropriately in all patients.

More information: Stacy A. Trent et al, Toward Personalized and Equitable Chest Pain Pathways: Considerations Related to Sex and Gender Differences, Journal of Women's Health (2024). DOI: 10.1089/jwh.2024.0242

Provided by CU Anschutz Medical Campus