{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T21:16:52Z","timestamp":1790630212814,"version":"4.1.0"},"reference-count":64,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2020,6,8]],"date-time":"2020-06-08T00:00:00Z","timestamp":1591574400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>During the last few years, the numbers of competitors in endurance and ultra-endurance sports modalities have increased significantly. This type of competition is an extreme challenge for athletes. Therefore, they have an increased the risk of developing medical and nutritional problems. The aim of the work is to estimate the incidence of nutrition-related adverse outcomes in endurance and ultra-endurance sports, considering the variables that influence them. A critical review was carried out based on the PubMed database, by means of a search strategy based on keywords separated by Boolean connectors. For all the results obtained in a period from 2008 to 2019, a series of inclusion\/exclusion criteria was applied to select only the studies that fitted the objective of the present study. Results and discussion: Of the 871 publications identified, 33 met the inclusion criteria. The adverse outcomes found included exercise-associated hyponatremia (EAH), heat stroke by exertion (EHS), gastrointestinal (GI) problems, dehydration, and hypothermia; the provision of misinformation to athletes about nutrient intake and hydration during competition was identified as the main cause. Conclusions: The main adverse outcomes in endurance and ultra-endurance sports modalities are EAH, GI inconveniences, and EHS. These problems can affect the performance and health status of the athlete during and post-competition. Several nutritional guidelines have been suggested that can prevent these adverse outcomes, and it is essential to individualize and adjust the nutritional intake and hydration status according to the characteristics of each competition.<\/jats:p>","DOI":"10.3390\/ijerph17114082","type":"journal-article","created":{"date-parts":[[2020,6,9]],"date-time":"2020-06-09T05:16:14Z","timestamp":1591679774000},"page":"4082","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":21,"title":["Nutrition-Related Adverse Outcomes in Endurance Sports Competitions: A Review of Incidence and Practical Recommendations"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9054-3858","authenticated-orcid":false,"given":"Jos\u00e9 Miguel","family":"Mart\u00ednez-Sanz","sequence":"first","affiliation":[{"name":"Departamento de Enfermer\u00eda, Grupo de Investigaci\u00f3n en Alimentaci\u00f3n y Nutrici\u00f3n (ALINUT), Facultad de Ciencias de la Salud, Universidad de Alicante, 03690 Alicante, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Fern\u00e1ndez Nu\u00f1ez","sequence":"additional","affiliation":[{"name":"Facultad de Ciencias de la Salud, Universidad de Alicante, 03690 Alicante, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8513-8986","authenticated-orcid":false,"given":"Isabel","family":"Sospedra","sequence":"additional","affiliation":[{"name":"Departamento de Enfermer\u00eda, Grupo de Investigaci\u00f3n en Alimentaci\u00f3n y Nutrici\u00f3n (ALINUT), Facultad de Ciencias de la Salud, Universidad de Alicante, 03690 Alicante, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4747-3465","authenticated-orcid":false,"given":"Alejandro","family":"Mart\u00ednez-Rodr\u00edguez","sequence":"additional","affiliation":[{"name":"Analytical Chemistry, Nutrition and Food Sciences Department, Sciences Faculty, University of Alicante, 03690 Alicante, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6891-391X","authenticated-orcid":false,"given":"Ra\u00fal","family":"Dom\u00ednguez","sequence":"additional","affiliation":[{"name":"Facultad de Ciencias de la Salud de la Universidad Isabel I, 09003 Burgos, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2222-6089","authenticated-orcid":false,"given":"Jos\u00e9 Antonio","family":"Gonz\u00e1lez-Jurado","sequence":"additional","affiliation":[{"name":"Facultad del Deporte, Universidad Pablo Olavide de Sevilla, 41013 Sevilla, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9022-6043","authenticated-orcid":false,"given":"Antonio J.","family":"S\u00e1nchez-Oliver","sequence":"additional","affiliation":[{"name":"Departamento de Motricidad Humana y Rendimiento Deportivo, Universidad de Sevilla, 41004 Sevilla, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,6,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1519\/JSC.0b013e31818b979a","article-title":"Effect of caffeine on sport-specific endurance performance: A systematic review","volume":"23","author":"Ganio","year":"2009","journal-title":"J. Strength Cond. Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1097\/00005768-200001000-00012","article-title":"Limiting factors for maximum oxygen uptake and determinants of endurance performance","volume":"32","author":"Bassett","year":"2000","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Dom\u00ednguez, R., Cuenca, E., Mat\u00e9-Mu\u00f1oz, J.L., Garca-Fern\u00e1ndez, P., Paya, N.S., Estevan, M.D.C.L., Veiga-Herreros, P., and Garnacho-Casta\u00f1o, M. (2017). Effects of beetroot juice supplementation on cardiorespiratory endurance in athletes. A systematic review. Nutrients, 9.","DOI":"10.3390\/nu9010043"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S340","DOI":"10.1249\/00005768-199209001-00007","article-title":"Training for endurance sport","volume":"24","author":"Pate","year":"1992","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"S91","DOI":"10.1080\/02640414.2011.610348","article-title":"Nutrition for endurance sports: Marathon, triathlon, and road cycling","volume":"29","author":"Jeukendrup","year":"2011","journal-title":"J. Sports Sci."},{"key":"ref_6","first-page":"549","article-title":"Bioenergetics and psychological profile of an ultra endurance walker","volume":"58","author":"Pedrinolla","year":"2017","journal-title":"J. Sports Med. Phys. Fit."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1249\/JSR.0b013e3182913c98","article-title":"Injury and illnesses prevention for ultramarathoners","volume":"12","author":"Krabak","year":"2013","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Six, C., Aboukais, S., Giron, S., D\u2019Oliveira, J.-C., Peloux-Petiot, F., Franke, F., Terrien, H., Dassonville, F., Deniau, J., and Ambert-Balay, K. (2016). Outbreak of diarrhoeal illness in participants in an obstacle adventure race, Alpes-Maritimes, France, June 2015. Eurosurveillance, 21.","DOI":"10.2807\/1560-7917.ES.2016.21.23.30253"},{"key":"ref_9","first-page":"35","article-title":"Medical and nutritional risk and dietary planning in mountaineering","volume":"28","author":"Urdampilleta","year":"2012","journal-title":"Eur. J. Hum. Mov."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"120","DOI":"10.14306\/renhyd.20.2.205","article-title":"Planificaci\u00f3n diet\u00e9tico-nutricional para llevar a cabo una Ultramarat\u00f3n, la Transvulcania: Informe de caso","volume":"20","year":"2016","journal-title":"Revista Espa\u00f1ola Nutrici\u00f3n Humana Diet\u00e9tica"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1249\/JSR.0000000000000344","article-title":"Management of suspected fluid balance issues in participants of wilderness endurance events","volume":"16","author":"Hoffman","year":"2017","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1097\/JSM.0000000000000144","article-title":"Incidence of exercise-associated hyponatremia and its association with nonosmotic stimuli of arginine vasopressin in the GNW100s ultra-endurance marathon","volume":"25","author":"Cairns","year":"2015","journal-title":"Clin. J. Sport Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1056\/NEJMc1510409","article-title":"Hyponatremia among triathletes in the ironman European Championship","volume":"374","author":"Danz","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Smith, R., Jones, N., Martin, D., and Kipps, C. (2016). \u2018Too much of a coincidence\u2019: Identical twins with exertional heatstroke in the same race. BMJ Case Rep., 2016.","DOI":"10.1136\/bcr-2015-212592"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"43","DOI":"10.4085\/1062-6050-445-16","article-title":"Fatal exertional heat stroke and american football players: The need for regional heat-safety guidelines","volume":"53","author":"Grundstein","year":"2018","journal-title":"J. Athl. Train."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1080\/02701367.2017.1342201","article-title":"Top 10 research questions related to preventing sudden death in sport and physical activity","volume":"88","author":"Katch","year":"2017","journal-title":"Res. Q. Exerc. Sport"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1249\/JSR.0000000000000244","article-title":"A tale of two heat strokes: A comparative case study","volume":"15","author":"Stearns","year":"2016","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1177\/1941738116630542","article-title":"Exercise in the cold: Preventing and managing hypothermia and frostbite injury","volume":"8","author":"Fudge","year":"2016","journal-title":"Sports Health"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1434","DOI":"10.1152\/jappl.1995.79.5.1434","article-title":"Control of thermoregulatory sweating is altered by hydration level and exercise intensity","volume":"79","author":"Montain","year":"1995","journal-title":"J. Appl. Physiol."},{"key":"ref_20","unstructured":"Whitney, E.N., and Rolfes, S.R. (2008). Understanding Nutrition, Thomson\/Wadsworth."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1249\/JSR.0b013e318249c311","article-title":"Upper gastrointestinal issues in athletes","volume":"11","author":"Waterman","year":"2012","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"S79","DOI":"10.1007\/s40279-014-0153-2","article-title":"Gastrointestinal complaints during exercise: Prevalence, etiology, and nutritional recommendations","volume":"44","author":"Burini","year":"2014","journal-title":"Sports Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1097\/MOG.0000000000000322","article-title":"Runner\u2019s diarrhea: What is it, what causes it, and how can it be prevented?","volume":"33","year":"2017","journal-title":"Curr. Opin. Gastroenterol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2176","DOI":"10.1017\/S0950268817001017","article-title":"Outbreak of diarrhoea among participants of a triathlon and a duathlon on 12 July 2015 in Utrecht, The Netherlands","volume":"145","author":"Parkkali","year":"2017","journal-title":"Epidemiol. Infect."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1016\/j.wem.2016.12.002","article-title":"An assessment of diarrhea among long-distance backpackers in the Sierra Nevada","volume":"28","author":"Meyer","year":"2017","journal-title":"Wilderness Environ. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1123\/ijsnem.2016-0053","article-title":"High prevalence of dehydration and inadequate nutritional knowledge among University and Club level athletes","volume":"27","author":"Magee","year":"2017","journal-title":"Int. J. Sport Nutr. Exerc. Metab."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1089\/ham.2015.0110","article-title":"Results of a Prospective Observational Study on Mountaineering Emergencies in Western Alps: Mind your head","volume":"17","author":"Brustia","year":"2016","journal-title":"High Alt. Med. Biol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"173","DOI":"10.4077\/CJP.2016.BAE391","article-title":"Pre- and post-race hydration status in hyponatremic and non-hyponatremic ultra-endurance athletes","volume":"59","author":"Rosemann","year":"2016","journal-title":"Chin. J. Physiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1017\/S1049023X15005555","article-title":"Mandatory rest stops improve athlete safety during event medical coverage for ultramarathons","volume":"31","author":"Joslin","year":"2016","journal-title":"Prehosp. Disaster Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/02640414.2015.1012104","article-title":"Gastrointestinal distress is common during a 161-km ultramarathon","volume":"33","author":"Stuempfle","year":"2015","journal-title":"J. Sports Sci."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"784","DOI":"10.1249\/MSS.0b013e31827985a8","article-title":"Exercise-associated hyponatremia and hydration status in 161-km ultramarathoners","volume":"45","author":"Hoffman","year":"2013","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"147","DOI":"10.4077\/CJP.2012.BAA010","article-title":"Higher prevalence of exercise-associated hyponatremia in triple iron ultra-triathletes than reported for ironman triathletes","volume":"55","year":"2012","journal-title":"Chin. J. Physiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1017\/S0950268812000817","article-title":"Gastrointestinal disease outbreaks in cycling events: Are preventive measures effective?","volume":"141","author":"Mexia","year":"2012","journal-title":"Epidemiol. Infect."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1123\/ijspp.7.1.6","article-title":"Hyponatremia in the 2009 161-km Western States Endurance Run","volume":"7","author":"Hoffman","year":"2012","journal-title":"Int. J. Sports Physiol. Perform."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1123\/ijspp.6.1.25","article-title":"Factors related to successful completion of a 161-km ultramarathon","volume":"6","author":"Hoffman","year":"2011","journal-title":"Int. J. Sports Physiol. Perform."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1016\/j.wem.2010.06.012","article-title":"Rhabdomyolysis and Hyponatremia: A cluster of five cases at the 161-km 2009 Western States Endurance Run","volume":"21","author":"Bruso","year":"2010","journal-title":"Wilderness Environ. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1704","DOI":"10.1017\/S0950268810001561","article-title":"Using the internet for rapid investigation of an outbreak of diarrhoeal illness in mountain bikers","volume":"138","author":"Griffiths","year":"2010","journal-title":"Epidemiol. Infect."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1136\/bjsm.2009.059535","article-title":"The incidence of exercise-associated hyponatraemia in the London marathon","volume":"45","author":"Kipps","year":"2009","journal-title":"Br. J. Sports Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1186\/s12970-015-0091-x","article-title":"Rhabdomyolysis and exercise-associated hyponatremia in ultra-bikers and ultra-runners","volume":"12","author":"Knechtle","year":"2015","journal-title":"J. Int. Soc. Sports Nutr."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1123\/ijsnem.2016-0135","article-title":"Exertional hyponatremia and serum sodium change during ultraendurance cycling","volume":"27","author":"Armstrong","year":"2017","journal-title":"Int. J. Sport Nutr. Exerc. Metab."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1080\/15438627.2016.1202831","article-title":"Hydration assessment among marathoners using urine specific gravity and bioelectrical impedance analysis","volume":"24","author":"Cutrufello","year":"2016","journal-title":"Res. Sports Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1080\/15438627.2016.1191491","article-title":"The influence of hydration state on thermoregulation during a 161-km ultramarathon","volume":"24","author":"Valentino","year":"2016","journal-title":"Res. Sports Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1097\/JSM.0b013e31820cb021","article-title":"Prevalence of exercise-associated hyponatremia in male ultraendurance athletes","volume":"21","author":"Knechtle","year":"2011","journal-title":"Clin. J. Sport Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"854","DOI":"10.1111\/sms.12676","article-title":"Successful out-of-hospital therapy for heatstroke in three marathon runners with a novel core body cooling device: CAERvest \u00ae","volume":"26","author":"Gomm","year":"2016","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Carvalho, A.S., Rodeia, S.C., Silvestre, J., and P\u00f3voa, P. (2016). Exertional heat stroke and acute liver failure: A late dysfunction. BMJ Case Rep., 2016.","DOI":"10.1136\/bcr-2016-214434"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"785","DOI":"10.1249\/MSS.0000000000000847","article-title":"Recurrent heat stroke in a runner: Race simulation testing for return to activity","volume":"48","author":"Roberts","year":"2016","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1016\/j.wem.2015.03.001","article-title":"Hiker fatality from severe hyponatremia in Grand Canyon National Park","volume":"26","author":"Myers","year":"2015","journal-title":"Wilderness Environ. Med."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"813.e1","DOI":"10.1016\/j.ajem.2013.12.041","article-title":"A near-fatal case of exercise-associated hyponatremia","volume":"32","author":"Severac","year":"2014","journal-title":"Am. J. Emerg. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"456","DOI":"10.3109\/10903127.2013.864357","article-title":"Recognition and treatment of exertional heat illness at a Marathon Race","volume":"18","author":"Hostler","year":"2014","journal-title":"Prehosp. Emerg. Care"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/j.wem.2009.12.003","article-title":"Detection and management of hypothermia at a large outdoor endurance event in the United Kingdom","volume":"21","author":"Bhangu","year":"2010","journal-title":"Wilderness Environ. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1590\/S1807-59322009000400014","article-title":"Risk of hypothermia in a New Olympic Event: The 10-km marathon swim","volume":"64","author":"Castro","year":"2009","journal-title":"Clinics"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1193","DOI":"10.1249\/MSS.0b013e31816a7155","article-title":"Heatstroke during endurance exercise: Is there evidence for excessive endothermy?","volume":"40","author":"Rae","year":"2008","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1097\/JSM.0000000000000221","article-title":"Statement of the third international exercise-associated hyponatremia consensus development conference, Carlsbad, California, 2015","volume":"25","author":"Rosner","year":"2015","journal-title":"Clin. J. Sport Med."},{"key":"ref_54","first-page":"377","article-title":"American College of Sports Medicine position stand. Exercise and fluid replacement","volume":"39","author":"Sawka","year":"2007","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_55","unstructured":"Dom\u00ednguez, R., Mata-Ordo\u00f1ez, F., and S\u00e1nchez-Oliver, A.J. (2017). Nutrici\u00f3n Deportiva Aplicada: Gu\u00eda para Optimizar el Rendimiento, ICB Editores."},{"key":"ref_56","first-page":"339","article-title":"Nontraumatic medical emergencies in mountain rescues","volume":"29","year":"2017","journal-title":"Emergencias"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1097\/JSM.0000000000000052","article-title":"Analyses of Helsinki 2012 European Athletics Championships injury and illness surveillance to discuss elite athletes risk factors","volume":"24","author":"Edouard","year":"2014","journal-title":"Clin. J. Sport Med."},{"key":"ref_58","doi-asserted-by":"crossref","unstructured":"Ordo\u00f1ez, F.M., Valenzuela, P.L., Gimenez, J., Tur, C., Ferreria, D., Dom\u00ednguez, R., S\u00e1nchez-Oliver, A., and Sanz, J.M.M. (2019). Carbohydrate availability and physical performance: Physiological overview and practical recommendations. Nutrients, 11.","DOI":"10.3390\/nu11051084"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"982","DOI":"10.1001\/jama.2015.0958","article-title":"Irritable bowel syndrome","volume":"313","author":"Chey","year":"2015","journal-title":"JAMA"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1123\/ijsnem.2013-0247","article-title":"Exploring the popularity, experiences, and beliefs surrounding gluten-free diets in Nonceliac athletes","volume":"25","author":"Lis","year":"2015","journal-title":"Int. J. Sport Nutr. Exerc. Metab."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"986","DOI":"10.4085\/1062-6050-50.9.07","article-title":"National athletic trainers\u2019 association position statement: Exertional heat illnesses","volume":"50","author":"Casa","year":"2015","journal-title":"J. Athl. Train."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.wem.2015.09.009","article-title":"Medical evaluation for exposure extremes: Heat","volume":"26","author":"Pryor","year":"2015","journal-title":"Wilderness Environ. Med."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"1360","DOI":"10.1136\/bjsports-2015-094722","article-title":"Hypothesised mechanisms of swimming-related death: A systematic review","volume":"50","author":"Asplund","year":"2016","journal-title":"Br. J. Sports Med."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1053\/ajem.2000.16313","article-title":"Hypothermia and afterdrop following open water swimming: The Alcatraz\/San Francisco swim study","volume":"18","author":"Nuckton","year":"2000","journal-title":"Am. J. Emerg. Med."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/11\/4082\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:36:39Z","timestamp":1760175399000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/11\/4082"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,8]]},"references-count":64,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2020,6]]}},"alternative-id":["ijerph17114082"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17114082","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,6,8]]}}}