Heat Adaptation for Females: A Systematic Review and Meta-Analysis of Physiological Adaptations and Exercise Performance in the Heat
Authors: Kelly Monica K. , Bowe Steven J. , Jardine William T. , Condo Dominique , Guy Joshua H. , Snow Rodney J. , Carr Amelia J. 
Published: May 2023

Abstract
Background
Heat adaptation regimes are used to prepare athletes for exercise in hot conditions to limit a decrement in exercise performance. However, the heat adaptation literature mostly focuses on males, and consequently, current heat adaptation guidelines may not be optimal for females when accounting for the biological and phenotypical differences between sexes.

Objectives
We aimed to examine: (1) the effects of heat adaptation on physiological adaptations in females; (2) the impact of heat adaptation on performance test outcomes in the heat; and (3) the impact of various moderators, including duration (minutes and/or days), total heat dose (°C.min), exercise intensity (kcal.min−1), total energy expended (kcal), frequency of heat exposures and training status on the physiological adaptations in the heat.

Methods
SPORTDiscus, MEDLINE Complete and Embase databases were searched to December 2022. Random-effects meta-analyses for resting and exercise core temperature, skin temperature, heart rate, sweat rate, plasma volume and performance tests in the heat were completed using Stata Statistical Software: Release 17. Sub-group meta-analyses were performed to explore the effect of duration, total heat dose, exercise intensity, total energy expended, frequency of heat exposure and training status on resting and exercise core temperature, skin temperature, heart rate and sweat rate. An explorative meta-regression was conducted to determine the effects of physiological adaptations on performance test outcomes in the heat following heat adaptation.

Results
Thirty studies were included in the systematic review; 22 studies were meta-analysed. After heat adaptation, a reduction in resting core temperature (effect size [ES] =  − 0.45; 95% confidence interval [CI] − 0.69, − 0.22; p < 0.001), exercise core temperature (ES =  − 0.81; 95% CI − 1.01, − 0.60; p < 0.001), skin temperature (ES =  − 0.64; 95% CI − 0.79, − 0.48; p < 0.001), heart rate (ES =  − 0.60; 95% CI − 0.74, − 0.45; p < 0.001) and an increase in sweat rate (ES = 0.53; 95% CI 0.21, 0.85; p = 0.001) were identified in females. There was no change in plasma volume (ES = − 0.03; 95% CI − 0.31, 0.25; p = 0.835), whilst performance test outcomes were improved following heat adaptation (ES = 1.00; 95% CI 0.56, 1.45; p < 0.001). Across all moderators, physiological adaptations were more consistently observed following durations of 451–900 min and/or 8–14 days, exercise intensity ≥ 3.5 kcal.min−1, total energy expended ≥ 3038 kcal, consecutive (daily) frequency and total heat dose ≥ 23,000 °C.min. The magnitude of change in performance test outcomes in the heat was associated with a reduction in heart rate following heat adaptation (standardised mean difference =  − 10 beats.min−1; 95% CI − 19, − 1; p = 0.031).

Conclusions
Heat adaptation regimes induce physiological adaptations beneficial to thermoregulation and performance test outcomes in the heat in females. Sport coaches and applied sport practitioners can utilise the framework developed in this review to design and implement heat adaptation strategies for females.