● Lithium

● Diuretics
● Beta blockers
● Ethanol

Not all commonly available supplements are associated with an increased risk of
heat illness, however, those with sympathomimetic properties can be problematic
[32]. A systematic review of 10 studies concluded that there is no evidence to
support the notion that creatine supplementation impairs an athlete's ability to
dissipate heat or disturbs their fluid balance [32]. (See "Nutritional and non-
medication supplements permitted for performance enhancement".)

Data from the United States military confirms the role of the risk factors for EHI
listed above and has identified several other factors, including [11,33-35]:
● Asian/Pacific Islander ethnicity
● Raised in a temperate climate (ie, higher incidence of EHI among recruits from
Northern states)
● Male sex

Nevertheless, approximately 50 percent of EHI cases during basic training occur in

recruits without these risk factors [13,36]. According to observational data, an
episode of EHI sustained during basic training does not increase the risk for further
episodes [37]. Retrospective studies of military cases of EHI report an association
between EHI and increased long-term mortality from organ failure (kidney, heart,
liver) [38]. However, such studies are limited in that the timing and types of
treatment for EHS were not considered, nor were individual risk factors.

THERMOREGULATION IN THE HEAT

Regulation of body temperature — Body temperature is regulated in the preoptic

nucleus of the anterior hypothalamus, which carefully maintains a core
temperature of 37°C±1° (98.6˚F±1.8°). The pathophysiology of heat illness is
discussed separately. (See "Nonexertional (classic) heat stroke in adults", section on
'Pathophysiology'.)

While the human body has remarkable resilience against cold, it can tolerate only
minor temperature elevations above normal (4.5°C, 9°F) without developing
systemic dysfunction, which ultimately leads to multiorgan failure and death if body
temperature cannot be lowered. Accordingly, the human body has multiple
mechanisms to dissipate heat [30,39,40]:
● Evaporation occurs when water vaporizes from the skin and respiratory tract.
This is the body's most effective mechanism for dissipating excess heat and is
the primary means for athletes exercising in hot environments.
● Radiation is the emission of electromagnetic heat waves. This energy transfer
does not require direct contact or air motion.
● Convection is the transfer of heat to a gas or liquid moving over the body.
Heat transfer occurs when the gas or liquid is colder than the body.
● Conduction is direct heat transfer to an adjacent, cooler object.

During exercise, the human body acts to dissipate the excess heat generated by
skeletal muscle. This requires an intact cardiovascular system that uses blood to
transfer heat from the body core to the skin, where the mechanisms for dissipating
heat can take effect. During high heat loads, blood flow to the skin increases
manyfold to facilitate conduction, convection, and radiation. However, these
mechanisms become ineffective when the ambient temperature is higher than the
body's core temperature.

Environmental conditions also affect evaporative cooling. A water vapor pressure

gradient must exist for sweat to evaporate and release heat into the environment.
In high humidity (relative humidity >75 percent), evaporation becomes ineffective
for transferring heat. Thus, in hot and humid conditions, athletes become
susceptible to exertional heat illness (EHI).

Limitations on heat dissipation in hot and humid weather are exacerbated during
intense exercise by a finite supply of blood that must fulfill multiple functions,
including meeting the metabolic demands of active skeletal muscle and
transporting heat to the skin surface for cooling. Further complicating matters is
the dehydration that develops in most individuals during intense exercise in the
heat, which decreases plasma volume.

Studies suggest that during intense exercise in the heat, for every one percent of
body mass lost from dehydration, there is a concomitant increase in core body
temperature of 0.22°C (0.4°F) [41-45]. In other words, other factors being equal, an
athlete who lost only 1 percent of body mass from dehydration during intense
exercise in the heat would be 1°C cooler compared with a teammate who lost 6
percent of body mass. This would equate to a temperature difference of
approximately 39°C (102°F) versus 40°C (104°F) at the end of a training session.

A number of additional factors influence the rate at which a person's core body
temperature rises during vigorous activity, including fitness level, degree of
acclimatization to heat, clothing/equipment, and physiologic response (eg, degree
of tachycardia) [43].

Compensated and uncompensated heat stress — Heat stress refers to the

environmental and host conditions that increase body temperature. Heat stress is
further categorized as compensated or uncompensated. Heat strain is the
physiological and psychological consequence of heat stress. Severe heat strain is
associated with a decline in athletic performance and increases the risk for EHI
[30,46,47].

During exercise, the body elevates its temperature in response to the increase in
metabolic heat production; a modest rise in temperature is thought to represent a
favorable adjustment that optimizes physiologic functions [39]. With compensated
heat stress, the body achieves a new steady-state core temperature that is
proportional to the increased metabolic rate and available means for dissipating
heat. Studies in runners describe exercise-induced hyperthermia, including athletes
completing events successfully with significantly elevated core temperatures
[48,49].

Uncompensated heat stress (UCHS) results when cooling capacity is exceeded and
the athlete cannot maintain a steady temperature. Continued exertion in the
setting of UCHS increases heat retention, causing a progressive rise in core body
temperature and increasing the risk for severe heat illness [47,50].

Thermotolerance and acclimatization — Tolerance of extreme heat and humidity

depends upon a number of functional, acquired, and congenital factors, of which
acclimatization is of great importance [39,51-53]. (See 'Risk factors' above.)

Acclimatization is the body's ability to improve its response and tolerance of heat
stress over time, and it is the most important factor determining how well an
athlete withstands extreme heat. Thus, allowing sufficient time and using optimal
training strategies that enable athletes to acclimatize is critical for improving
performance and mitigating the risk for EHI. Observational studies have found that
the first week of athletic practice in high heat and humidity is the period of greatest
risk for developing EHI [3,50,54]. Acclimatization requires at least one to two weeks.
However, any improved tolerance of heat stress generally dissipates within two to
three weeks of returning to a more temperate environment [30,50]. The attached
tables provide guidelines for acclimatization ( table 3 and table 4).

The major physiologic adjustments that occur during heat and humidity
acclimatization include [50]:
● Plasma volume expansion
● Improved cutaneous blood flow
● Lower threshold for initiation of sweating
● Increased sweat output
● Lower salt concentration in sweat
● Lower skin and core temperatures for a standard exercise

These adaptations allow for better dissipation of heat during exercise and limit
increases in body temperature compared to athletes who have not acclimatized.

DETERMINING RISK

It is important to consider environmental and individual factors when assessing the

risk for exertional heat illness (EHI). A method for assessing the environment is
described here, while individual risk factors are described above. (See 'Risk factors'
above.)

Wet bulb globe temperature (WBGT) and other heat indices — One clinical tool
commonly used to determine the overall environmental heat load is the WBGT. This
index was developed by the military to calculate heat stress, thereby enabling
commanders to make adjustments in physical activity and fluid requirements in
order to maximize performance [50]. The index is employed in the civilian setting to
adjust athletic workload (eg, work-to-rest ratios, intensity of exercise, equipment,
hydration breaks). In extreme circumstances, the WBGT may serve as the basis for
cancelling activities ( table 5) [55]. (See "Exertional heat illness in adolescents and
adults: Management and prevention", section on 'Prevention of exertional heat
illness'.)