International Journal of Sport Nutrition and Exercise Metabolism, 2014, 24, 460  -469

http://dx.doi.org/10.1123/ijsnem.2014-0008
© 2014 Human Kinetics, Inc.
www.IJSNEM-Journal.com
Consensus Statement

Nutrition, Illness, and Injury in Aquatic Sports

David B. Pyne, Evert A. Verhagen, and Margo Mountjoy

In this review, we outline key principles for prevention of injury and illness in aquatic sports, detail the
epidemiology of injury and illness in aquatic athletes at major international competitions and in training,
and examine the relevant scientific evidence on nutrients for reducing the risk of illness and injury. Aquatic
athletes are encouraged to consume a well-planned diet with sufficient calories, macronutrients (particularly
carbohydrate and protein), and micronutrients (particularly iron, zinc, and vitamins A, D, E, B6, and B12)
to maintain health and performance. Ingesting carbohydrate via sports drinks, gels, or sports foods during
prolonged training sessions is beneficial in maintaining energy availability. Studies of foods or supplements
containing plant polyphenols and selected strains of probiotic species are promising, but further research is
required. In terms of injury, intake of vitamin D, protein, and total caloric intake, in combination with treat-
ment and resistance training, promotes recovery back to full health and training.

Keywords: epidemiology, nutrition, swimming, infection, supplements, ergogenic aids

Aquatic coaches are obliged to use physically
challenging training programs to prepare their athletes
for high-level competitions. However, a high level of
exposure to training (and competition) can increase the
risk of illness or injury, limiting improvements in perfor-
mance. Sports science and sports medicine practitioners
who work with swimmers (and swimming coaches)
are seeking effective evidence-based interventions and
strategies to reduce the risk of injury and illness compro-
mising training and competitive performance. Although
the importance of illness and injuries and their impact
on performance is better understood nowadays by both
researchers and practitioners, there remains a lack of
quality information, particularly related to the importance
of nutrition and dietary practices.
Nutrient intake during everyday eating and around
swimming training and competition is a key factor
influencing immune function and risk of injury. Other
factors related to illness include the volume, intensity,
and load of exercise training; degree of exposure to
pathogens; underlying health and medical status of indi-
vidual athletes; lifestyle behaviors, including sleep and
recovery; and psychosocial issues related to training and
competition. Given the lack of specific research studies
on highly trained swimmers, it is necessary to look more
broadly at general nutrition, sports nutrition, and studies
Pyne is with the Dept. of Physiology, Australian Institute of
Sport, Canberra, Australia. Verhagen is with the Dept. of Public
and Occupational Health, VU University Medical Center,
Amsterdam, Netherlands. Mountjoy is with McMaster Uni-
versity Medical School, Ontario, Canada. Address author cor-
respondence to David B. Pyne at david.pyne@ausport.gov.au.
of athletes in other sports. A Medline search (November
2013) using nutrition as a search term yielded 325 hits
for swimming, but only seven for water polo, six for
long-distance swimming, five for diving, and two for
synchronized swimming.
Although the benefits of avoiding illness and injury
appear obvious, only one study has directly quantified
the effect of illness on international swimming perfor-
mance. A study of performances of Australian swimmers
showed that mild illness had only a trivial mean effect
on international performance by female swimmers and
a small harmful mean effect on that of male swimmers.
However, there were substantial chances of harm (and
benefit) for individual swimmers reporting symptoms
of illness (Pyne et al., 2005). More severe symptoms of
illness that require medical intervention and complete
cessation of training activities might have a larger effect
on competitive swimming performance. In this review, we
outline key principles of prevention for injury and illness
in aquatic sports, detail the epidemiology of injury and
illness of swimmers at major international competitions
and in training, examine relevant scientific evidence on
nutrients for reducing the risk of illness and injury, and
summarize practical recommendations for swimmers,
coaches, and practitioners.
Injury and Illness
Prevention Principles
A perennial issue is establishing a rigorous evidence-
based process for evaluating the effectiveness of training
and lifestyle interventions in sports. Differences in defini-
tions, terminology, and methodological approaches have
made comparisons of research studies difficult. Effective

460

prevention of injuries and illness does not happen by
itself and requires a systematic approach (Van Mechelen
et al., 1992).
First, the problem must be identified and described in
terms of incidence and severity. The objective of preven-
tion of this problem is theoretically simple and can be
summarized as removing the cause of injury or illness to
prevent its occurrence. The second step identifies the fac-
tors and mechanisms that play a part in the occurrence of
an injury or illness. The third step is to introduce measures
that are likely to reduce the future risk or severity of injury
or illness. These measures should be based on the etio-
logical factors and mechanisms identified in the second
step. Finally, the effectiveness of interventions must be
evaluated by repeating the first step, yielding a so-called
time-trend analysis of injury or illness patterns. However,
from an epidemiological standpoint, it is preferable to
evaluate the effect of preventive measures by means of a
randomized controlled trial. Unfortunately, randomized
controlled trials have only rarely been conducted in sports
injury and illness prevention studies, let alone on the topic
of nutrients and supplements. Most studies on this topic
have been conducted in settings other than swimming.
Accordingly, there is only limited scientific evidence
on the value of preventive approaches to nutrients and
supplements that can be directly applied to swimmers.
The underlying factors that lead to injury or illness
are multifactorial in nature and may differ among athletes
(Meeuwisse et al., 2007). Optimal prevention would
imply an individualized approach to tackling risks and
risk factors. At the elite level, an individual preventive
approach with detailed analysis of individual risk factors
is preferred. Any outcomes from (controlled) trials will
be based on group estimates. Evidence from research
studies alone should not be the foundation of effective
injury prevention programs but is complementary to
in-depth knowledge of an aquatic athlete’s health status.
This type of pragmatic preventive approach should aid in
the development and introduction of preventive measures
for specific injuries or illness.
Injury and Illness Prevalence
in the Aquatic Disciplines
The Fédération Internationale de Natation (FINA) began
conducting injury and illness surveillance with the study
of injuries in water polo in comparison with other team
sports during the 2004 Olympic Games (Junge et al.,
2006). The other disciplines of FINA, including swim-
ming, diving, marathon swimming, and synchronized
swimming, were added to the surveillance program in
the 2008 Olympic Games (Junge et al., 2009). FINA
conducted its first injury surveillance at the 2009 FINA
World Championships (Mountjoy et al., 2010). Illnesses
were also compared between aquatics and other Olympic
sports at the 2012 Olympic Games (Engebretsen et al.,
2013). FINA conducted its most recent injury and illness
surveillance during the 2013 FINA World Champion-
Illness and Injury in Aquatic Sports   461
ships, adding a retrospective survey of all athletes to
quantify the incidence and characteristics of preexisting
injuries (Mountjoy et al., in press).
In comparison with other team sports at the 2004
Olympic Games, water polo was safer than most other
team sports, ranking sixth out of eight for the relative
risk of injury. The total injury incidence was 12 injuries
per 1,000 player matches (Junge et al., 2006). A study
analyzing trends in water polo injuries in 2004, 2008, and
2009 showed that the overall injury incidence remained
steady; however, significant differences were found in
the incidence of gender-related injury (Mountjoy &
Junge, 2011).
In the 2008 Olympic Games, swimming (3.4%),
diving (2.1%), and synchronized swimming (1.9%) were
among the group of sports with the lowest injury rates in
comparison with other Olympic sports (mean injury rate
= 9.6%). Water polo (9.7%) had one of the highest rates
of in-competition injury and injury caused by contact.
Swimming showed a high incidence of training and
overuse injuries (Junge et al., 2009).
The 2009 FINA World Championships offered an
opportunity to study the health of the aquatic athletes
in more detail by including illness surveillance in the
protocol. The overall injury rate was 6.6%, with only
0.8% of all injuries resulting in time loss. The overall
illness rate was 7.1% with a 1.2% time loss. About half
(50%) of these illnesses affected the respiratory system,
and 20% affected the gastrointestinal system. Infection
was the leading cause (49%), followed by environmental
factors (28%; Mountjoy et al., 2010).
On average for all sports, the injury rate in the 2012
Olympic Games was 12.9% and the illness rate was 7.2%.
Swimming (5.4%) and diving (8.1%) were below the
mean injury rate risk; water polo (13%) and synchronized
swimming (14%) were higher. Diving had the highest
incidence of overuse injury, with 76% of all injuries
reported as having been caused by overuse. Synchronized
swimming had one of the highest illness rates, at 13% of
all athletes (Engebretsen et al., 2013).
A review of these surveillance studies showed that
the aquatic sports have a relatively low risk of new-onset
acute injuries during events. The most affected body loca-
tion for injury is the shoulder, and the rates of overuse
as a cause of injury in diving and swimming are high.
Infectious illnesses of the respiratory and gastrointesti-
nal systems also cause significant health concerns. This
finding is consistent with experience in other elite sports
(Spence et al., 2007). Knowledge of these trends in injury
and illness patterns in aquatic sports enables effective
prevention planning. The role of nutritional interventions
for illness prevention and injury prevention and recovery
warrant further development.
For example, asthma is a common airway disease
present in the general population (Elers et al., 2011).
A swimming program for asthmatic children has been
shown to improve respiratory function and decrease the
severity of asthma symptoms (Wang & Hung, 2009).
The incidence of asthma in aquatic athletes at the 2008
462  Pyne et al.
Olympic Games was higher than in all other sport disci-
plines except for triathlon. Synchronized swimming has
the highest incidence of asthma of all aquatic sports at
21%, followed by swimming at 19.3% (average 7.2%;
unpublished Therapeutic Use Exemption data, IOC Medi-
cal Commission data). Antioxidant supplementation has
proved effective in ameliorating asthma symptoms in
nonathletes (Scott et al., 2013), and this approach may
be worthwhile for swimmers.
Review of Scientific Evidence
for Nutrients
A well-planned diet rich in nutrients is needed to main-
tain a robust immune system with sufficient capacity to
tolerate the demands of training and competition. A swim-
mer’s diet should be sufficient to meet the underlying
energy, carbohydrate (CHO), protein, and micronutrient
requirements (Gleeson, 2013; Nieman, 2008) because
energy availability has been demonstrated to be a key
performance limiter in swimming speed (Vanheest et
al., 2014). However, imbalanced nutrition in top-level
swimmers is not uncommon (Kabasakalis et al., 2007).
Younger swimmers who are maturing physically have
additional dietary requirements to facilitate growth. Given
that inadequate nutrition affects almost all aspects of the
immune system, a well-planned diet is important (Gunzer
et al., 2012). The most challenging energy demands for
all aquatic athletes are the extended periods of training in
the months before major competitions, such as a national
championship or an international competition (FINA
World Championships or Olympic Games). High-volume
and high-intensity pool-based training generally charac-
terize precompetition periods. Clinical trials or properly
conducted randomized trials are difficult to conduct with
elite athletes, including swimmers, and therefore research
on dietary practices and nutritional supplements is some-
what inconclusive (Romeo et al., 2010).
Caloric Intake
Aquatic athletes may experience insufficient caloric
intake either voluntarily when trying to manipulate
body shape and composition or involuntarily in the face
of physically demanding training. Although the aquatic
disciplines may not have the body weight restrictions
faced by athletes in other sports that emphasize leanness,
some athletes experience energy and nutrient deficits.
This situation is more relevant to synchronized swimming
and diving, two sports in which the importance of aes-
thetic appearance is more prominent. The consequences
of inadequate caloric intake may include compromised
nutritional status, fatigue, dehydration, delayed growth,
impaired tissue repair and immune function (Montero
et al., 2002), menstrual dysfunction (Thein-Nissenbaum
et al., 2011), higher psychological stress and risk of ill-
ness (Hagmar et al., 2013), and increased risk of injury
(Thein-Nissenbaum et al., 2011).
A wide range of personal, lifestyle, cultural, socio-
economic, and religious factors can influence caloric
intake. In the past decade, a concerted effort has been
made to describe and manage dietary arrangements of
Muslim athletes (including swimmers) during Ramadan,
in which there must be abstinence from food and fluid
intake from dawn to sunset for 1 month. Experienced elite
Muslim athletes are able to maintain their usual training
load during Ramadan without decrements in measures
of fitness and with only minimal adverse effects (Mujuka
et al., 2010). In addition to the provision of energy and
specific nutrients, another issue is the effect of abstinence
on inflammatory and immunological measures. However,
it appears that athletes can train intensely during Rama-
dan without placing undue stress on the immune system
(Chaouachi et al., 2009).
Swimmers who voluntarily restrict caloric intake
may invoke adverse effects on immunoglobulin and
complement, both of which are key protein components
of the innate immune system. An experimental group
of athletes combining exercise and dietary restriction
to invoke a mean weight loss of 2.8 kg exhibited small
decreases in salivary immunoglobulin G and M and
complement C3 concentrations 7 days after competition
(Umeda et al., 2004). Although acute changes were small,
the potential cumulative change over time might have
more substantial effects on the immune system, thereby
increasing the risk of illness. A study of female athletes in
training showed that iron, vitamin B1, and niacin intake
were positively correlated with immunoglobulin G levels
(Kim et al., 2002).
Carbohydrate
CHO plays a key role in maintaining energy availability
during training and competition, but also in homeostatic
control of the hormonal and immune systems. It is well
established that consuming CHO before and during
exercise can attenuate the increases in glucocorticoid
stress hormones such as cortisol. A swimmer training or
competing in a CHO-depleted state may evoke a greater
increase in the concentration of stress hormones and
larger perturbation of key immune functions that may
predispose them to illness (Gleeson & Bishop, 2000).
A meta-analysis of 66 placebo-controlled or cross-over
trials of nutritional interventions in athletes indicated the
most effective choice was consumption of more than 6%
CHO during prolonged exercise (Gunzer et al., 2012).
Consuming 30–60 g of CHO/hr-1 using sports drinks,
gels, or other sports foods during exercise should attenu-
ate rises in stress hormones such as cortisol and limit
the degree of exercise-induced immune depression. A
6-day CHO-rich diet (12 g CHO/kg body mass-1/day-1)
during intensive exercise training maintained higher
pretraining salivary immunoglobulin A concentrations
and stabilized blood glucose concentration better than a
control self-selected diet (Costa et al., 2005). Swimmers
can be prone to fluctuating levels and higher variability in
salivary immunoglobulin A concentration, which might

reduce the level of protection against pathogenic agents
at mucosal surfaces of the respiratory tract (Francis et
al., 2005). Maintenance of glucose levels during training
should attenuate cortisol release and reduce the risk of
exercise-induced immunosuppressive effects. Finally,
CHO supplementation can also reduce the symptoms of
overtraining or overreaching (Halson et al., 2004) that
sometimes accompany illness during periods of intensive
work. Decreased endocrine responsiveness to exercise
may be implicated in the decreased performance and
increased mood disturbance characteristic of overtraining.
Protein
In the general population, moderate to severe deficiencies
in dietary protein and selected micronutrients can lead to
immune dysfunction and clinical consequences. Healthy
aquatic athletes undertaking regular training and physical
activity are unlikely to be suffering from protein malnu-
trition. However, a high-protein diet (3 g/kg-1 protein/
day-1) might reduce the incidence of respiratory illness
in at-risk athletes during periods of high-intensity train-
ing (Witard et al., 2013). Studies have investigated the
benefits of coingestion of protein and CHO particularly
in the recovery period after strenuous training or com-
petition (Beelen et al., 2010). Coingestion of protein and
amino acids does not seem to further increase muscle
glycogen synthesis rates when CHO intake exceeds 1.2
g/kg-1/hr-1. However, from a practical point of view, it is
not always feasible to ingest such large amounts of CHO.
The combined ingestion of a small amount of protein
(0.2–0.4 g/kg-1/hr-1) with some CHO (0.8 g/kg-1/hr-1)
stimulates endogenous insulin release and yields similar
muscle glycogen-repletion rates as ingestion of 1.2 g/
kg-1/hr-1 CHO (Beelen et al., 2010). Studies are needed
to investigate the immunological benefits of coingestion
of protein and CHO.
Bovine colostrum supplementation could be a useful
nutritional countermeasure to enhance (or maintain)
immune function and reduce the risk of upper respira-
tory tract infection (URTI). Daily supplementation with
bovine colostrum for several weeks can maintain intesti-
nal barrier integrity and immune function and reduce the
chances of URTI in athletes undertaking heavy training
(Davison, 2012). The purported mechanisms are likely to
relate in part to small bioactive components that survive
digestion and are biologically available after consump-
tion. One study investigating the effects of 12 weeks of
colostrum supplementation showed a 79% increase in
salivary immunoglobulin A concentration (Crooks et
al., 2006).
Another dietary issue is celiac disease, with increas-
ing diagnoses and public awareness in both the general
community and sporting populations. Celiac disease
occurs when the immune system reacts abnormally to
gluten (a protein found in wheat, rye, and barley), causing
damage to the small bowel. Celiac disease is not uncom-
mon, with a prevalence of about 1 in 100 in the general
community. Sports medicine practitioners working with
Illness and Injury in Aquatic Sports   463
swimmers should be alert to the possibility of celiac dis-
ease and familiar with the appropriate tests and diagnostic
procedures (Mancini et al., 2011). The cornerstone of
management of celiac disease is a gluten-free diet under
the direction of a dietitian. Dietary issues related to celiac
disease include poor absorption of iron, vitamin D, and
calcium. There are substantial educational resources
available for athletes on maintaining a gluten-free diet.
Fat
The immune system is sensitive to both fat intake and
prolonged and intense exercise. A low-fat diet may com-
promise the immune system, whereas a higher fat diet
may yield improvements, although the clinical effects
remain unclear. Some athletes may consciously modify
eating behaviors and consume as many as 25% fewer
calories than actual energy requirements, leading to low
intakes of some essential micronutrients and fats. Lipids
are powerful mediators of the immune system and may
play in a role in modulating the immunosuppressive
effects of strenuous exercise. A low-fat, high-CHO diet
(i.e., of total calories, 15% fat, 65% CHO, and 20%
protein) can increase proinflammatory and decrease
anti-inflammatory cytokines, depress antioxidants, and
negatively affect blood lipoprotein ratios (Venkatraman et
al., 2000). Increasing total caloric intake by 25% to match
energy expenditure and increasing dietary fat intake to
32% appears to reverse the negative effects of a low-fat
diet on immune function and lipoprotein levels. Increas-
ing the dietary fat intake of athletes to about 40% while
maintaining caloric intake equal to expenditure does not
negatively affect immune competency or blood lipopro-
teins, whereas it improves endurance exercise perfor-
mance at 60%–80% of VO2max in cyclists, soldiers, and
runners (Venkatraman et al., 2000). Studies are needed
to determine whether the beneficial effects of higher fat
diets in athletes, including long-distance and open-water
swimmers, reduces the rate of common illnesses.
The effect of fish oil supplementation on the immune
responses of elite swimmers was investigated in a random-
ized placebo-controlled trial. Swimmers received either
fish oil capsules containing omega-3 long-chain polyun-
saturated fatty acids or placebo for 6 weeks (Andrade et
al., 2007). Fish oil elicited an increase in omega-3 fatty
acids, a decrease in arachidonic omega-6 fatty acids in
plasma, and reduced production of interferon gamma by
cultured cells. A reduction in the production of tumor
necrosis factor alpha was observed in both groups. Fish
oil was able to attenuate the exercise-induced increases in
prostaglandin E2. It appears that fish oil supplementation
can influence exercise-associated immune responses in
competitive swimmers.
Vitamins and Minerals
Despite the popularity of vitamin and mineral supplemen-
tation in both the general and sporting communities, the
evidence of beneficial effects is limited, and the results
464  Pyne et al.
of relevant studies are often inconsistent (Gunzer et al.,
2012). Most studies have indicated that vitamin and
mineral concentrations are not usually a problem among
athletes—notable exceptions may be calcium and iron in
some female athletes. The clinical and performance issues
associated with disordered eating in female adolescent
swimmers may affect nutrient levels and body composi-
tion. Adolescent swimmers presenting with disordered
eating had lower protein consumption and lower calcium
intake than healthy eaters (da Costa et al., 2013). Subop-
timal intake of vitamins and minerals can have a negative
impact on health because vitamins A, D, E, B6, and B12
have important roles in immune function (Gleeson, 2013).
The issue of vitamin C supplementation remains
controversial. The authoritative Cochrane Reviews
concluded that the failure of vitamin C supplementation
to reduce the incidence of common colds in the general
population indicates that routine high-dose prophylaxis
is not justified (Hemilä & Chalker, 2013). However, in
individuals exposed to brief periods of severe physical
exercise, akin to the training and racing demands of
elite swimmers, vitamin C supplementation could be
worthwhile. Closer inspection of experimental evidence
has indicated that vitamin C supplementation (1 g/day-1)
might be beneficial in reducing the duration and sever-
ity, but not the frequency, of URTIs in male adolescent
swimmers (Constantini et al., 2011).
The influence of vitamin D status on a variety of
health and performance measures is a topical issue in
the sporting community. A study of 225 endurance ath-
letes during a 4-month winter period was undertaken to
address this question (He et al., 2013). Low vitamin D
status was associated with lower proinflammatory cyto-
kine production by monocytes and lymphocytes. The
proportion of subjects who presented with symptoms of
URTI in the vitamin D–deficient group (plasma 25[OH]
D < 30 nmol/L-1) during the study period was substan-
tially higher than in the optimal vitamin D group (>120
nmol/L-1). Low vitamin D status could be an important
determinant of URTI risk in endurance athletes. Mucosal
as well as systemic immunity could be enhanced via
vitamin D–dependent mechanisms.
Iron status and immune function can be impaired in
various clinical conditions such as chronic inflammation
and obesity. Iron is necessary for proper functioning of
both the innate and the adaptive immune systems (Dao
& Meydani, 2013). A study of healthy adolescent Greek
swimmers reported substantial fluctuations of iron status
during a training season but no significant differences in
iron status or performance between iron-supplemented
and nonsupplemented swimmers (Tsalis et al., 2004). In
females, iron lost during the menstrual cycle could con-
tribute to fatigue, illness, and performance decrements
that can occur with a heavy period. However, screening
for hematological and iron-related abnormalities in male
athletes has a relatively low yield, and testing of both
males and females is best performed on clinical grounds
(Fallon, 2004).
There are conflicting recommendations on the use of
zinc supplements for athletes, and no specific studies with
swimmers. Zinc administered at a dose of 75–100 mg/
day-1 within 24 hr of the onset of symptoms can reduce
the duration of the common cold in healthy individuals
(Singh & Das, 2013). For this reason, some practitioners
support the use of zinc lozenges as part of an early inter-
vention approach. Evidence for prophylactic use of zinc
is lacking, and further studies are required. The purported
side effects of zinc supplementation in some individuals
include nausea, vomiting, diarrhea, metallic taste, and
kidney and stomach problems; a health care professional
should be consulted if these symptoms occur.
Amino Acids
Reduced glutathione can remove damaging reactive
oxygen species such as hydrogen peroxide. Amino acid
supplementation could increase intracellular glutamate
and cysteine that consequently enhance concentra-
tions of reduced glutathione (Newsholme et al., 2011).
Branched-chain amino acid supplementation can reverse
the reduction in serum glutamine concentration that
occurs after prolonged exercise. Glutamine is the most
abundant amino acid in the body and has a range of physi-
ological roles, including with immune cells. A decrease
in plasma glutamine can increase the risk of illness or
infection mediated by lymphocyte responses and induc-
tion of cytokines, such as interleukin-1 and interleukin-2,
tumor necrosis factor, and interferon gamma (Bassit et
al., 2000). This study of illness in triathletes showed that
those consuming branched-chain amino acid supplements
(Bassit et al., 2000) were less likely to report illness.
However, despite the purported benefits of glutamine,
it is difficult to unconditionally recommend glutamine
supplements for athletes (Newsholme et al., 2011).
Plant Polyphenols
Plant polyphenols such as quercetin are strong antioxidant
and anti-inflammatory agents and exert antipathogenic
and immunoregulatory influences. Studies on quercetin
supplementation in athletes are suggestive of benefits in
postexercise inflammation, oxidative stress, and immune
dysfunction and reduction in rates of illness. Quercetin
combined with other polyphenols and food components
(e.g., green tea extract, isoquercetin, and fish oil) can
induce substantial reductions in markers of inflammation
and oxidative stress. Consumption of plant flavonoids,
antioxidants, and omega-3 fatty acids elicited health
benefits derived primarily through increased plasma
antioxidant activity (McAnulty et al., 2011). A recent
study examined the effect of a flavonoid-rich juice con-
taining citrus juices and common vegetables on markers
of inflammation, oxidative stress, and immunity in elite
swimmers (Knab et al., 2013). Sprint and middle-distance
swimmers had a small chronic elevation in markers of
oxidative stress, exhibited minimal posttraining pertur-

bations in biomarkers, and received no apparent benefit
from the juice apart from the underlying nutrient intake.
Further work is required to establish clear guidelines for
using combinations of supplements involving flavonols
and flavonoid-rich juices.
Probiotics
Probiotics are live microorganisms that are present in
some dairy foods and nutritional supplements that may
prevent or limit the effects of various illnesses and infec-
tions. Probiotics complement the normal gastrointestinal
flora and offer a practical means of enhancing gut and
immune function (West et al., 2009). These bacteria are
integral to the ontogeny and regulation of the human
immune system, protection against infection, and mainte-
nance of intestinal homeostasis. Some swimmers present
with gut symptoms such as nausea, bloating, cramping,
pain, and diarrhea. A small number of studies of highly
active individuals have indicated modest clinical benefits
of probiotics in terms of reduced frequency, severity,
or duration of both respiratory and gastrointestinal ill-
nesses (Pyne et al., 2013). To date, no studies have been
published on probiotic supplementations with swimmers.
Nutritional Recommendations
for Injury and Illness Prevention
Illness Prevention
Illness prevention strategies center on limiting pathogen
exposure, managing underlying medical issues, managing
training load, and a variety of lifestyle and behavioral
factors such as sleep, psychological issues, and nutrition
(Gleeson, 2000; Pyne et al., 2000). Limiting pathogen
exposure in the aquatic environment is important given
evidence of water quality issues in swimming pools
(McCann et al., 2013; Sanborn & Takaro, 2013) and
freshwater and marine (Arnold et al., 2013) environ-
ments. Other factors influencing the risk of illness include
season, with a higher risk of URTIs in winter months
(Hellard et al., 2011).
In terms of nutrition, athletes should consume a
well-balanced diet with sufficient calories, macronutri-
ents (particularly CHO and protein), and micronutrients
(particularly iron, zinc, and vitamins A, D, E, B6, and
B12) to maintain health and performance. Ingesting
CHO via drinks, gels, or sports foods during prolonged
training sessions is beneficial. Recent nutritional studies
have indicated benefits in consuming foods or supple-
ments containing plant polyphenols and selected strains
of probiotic species. Given the limited support from qual-
ity scientific studies for micronutrient supplementation,
using a single nutrient may not be as effective as using a
mixture of several nutritional supplements.
One perennial discussion point is whether the nutri-
ent value and digestive processes of natural foods are
Illness and Injury in Aquatic Sports   465
preferred over consumption of commercially available
nutritional supplements. Regular consumption of natural
foods such as fruits and vegetables is seen as an impor-
tant contributor to a healthy diet (Lamprecht, 2012).
Plant foods are rich sources of vitamins, minerals, and
phytochemicals. A deficit of these micronutrients could
exacerbate inflammatory states, decrease immunity,
increase susceptibility to injury, and prolong recovery
from intensive training and competition. A combination
of a well-balanced diet of natural foods and additional
nutritional supplements on the basis of expert advice
from a dietitian or nutritionist is possibly the preferred
approach.
Aquatic athletes need to be careful about sourc-
ing and using nutritional supplements and ergogenic
acids taken for dietary reasons or for convenience or
to maintain or boost the immune system. Not all ath-
letes need supplements. Many top-level athletes take
no supplements at all, including successful Olympic
and World Championship swimmers. These swimmers
pride themselves on a high-performance diet, a good
training ethic, and good sleep. Supplements should
be taken only when swimmers are having difficulty
meeting energy and nutritional requirements with their
everyday diet. It is prudent action to avoid supplement
companies involved in network marketing who are likely
motivated by drivers other than training and competi-
tive performance. It is difficult to absolutely guarantee
the safety or legality of supplements, and swimmers
should only use products from reputable companies and
avoid supplements whose source or origin is uncertain.
Supplements may contain World Anti-Doping Agency–
prohibited contaminants that may trigger an adverse
analytical finding during antidoping testing. Swimmers
seeking nutritional information should be encouraged
and reminded to seek expert medical opinion from a
sports medicine practitioner or a registered dietician
or nutritionist.
Long-term planning by organizations, teams, or
individual swimmers should include a yearly sports
medicine consultation, periodic contact with a sports
dietician, review of primary and secondary vaccina-
tion schedules, advice on insect avoidance and malaria
prevention, review of allergy and asthmatic conditions,
establishment of a medical network, and management
of team and travel logistics. Vitamin C and zinc supple-
ments can be a useful addition to a so-called illness
prevention or “sick pack” provided to some swimmers
before long-haul travel, training camps, and major
competitions (Hanstad et al., 2011). There should be a
review or debriefing session after competition involv-
ing medical, scientific, and management staff; a writ-
ten report of the medical events of the season, main
competition, or both; referral of athletes experiencing
long-term or recurrent or persistent illness for medical
review; input from the dietician or nutritionist on team
and individual swimmer issues; and early preparations
for the following season.
466  Pyne et al.
Injury Prevention
An approach to injury prevention through nutrition fol-
lows a similar approach to that for illness prevention.
Given that injuries are mainly due to mechanical stress
and subsequent inadequate adaption of the musculoskel-
etal system, the role of nutrition in the onset of injury may
appear trivial. However, at the elite level training loads
are of such demand that appropriate levels of nutrients
are required to provide the body with the building blocks
to recover. Unfortunately, studies on the role of nutrition
in the prevention of the onset of injury are in general
lacking. Consequently, the potential role of nutrition
in the prevention of injury has not been well described
(Thein-Nissenbaum et al., 2011).
The best-described relationship between injury and
nutritional status is that of vitamin D. Vitamin D is neces-
sary for adequate bone health (Holick, 2004). It is plausible
that suboptimal vitamin D status increases the risk not only
of susceptibility to common URTIs and other illnesses but
also of overuse and inflammatory injuries. The latter types
of injuries are predominantly those suffered by aquatic
athletes. Athletes participating in indoor sports, including
aquatic sports, have been reported to have lower circulating
vitamin D in the fall than athletes participating in outdoor
sports (Halliday et al., 2011). These findings suggest that
aquatic athletes are at increased risk for vitamin D insuf-
ficiency and deficiency and can have lower bone mineral
density (Mudd et al., 2007). Although a full link between
vitamin D insufficiency and injury has not been established
as yet, studies of healthy individuals have indicated that
vitamin D correlates positively with bone mineral density
(Bischoff-Ferrari et al., 2006; Välimäki et al., 2004). Other
studies have highlighted the causal link between low bone
mineral density and the risk of stress fractures in athletes
(Myburgh et al., 1990). Given these risks, adequate vitamin
D levels are recommended to prevent injury in aquatic
sports (Lewis et al., 2013). Care should be taken especially
during fall and winter. It should be noted that vitamin D
is limited in the general food supply. Only a few food
products—including oily fish—naturally contain vitamin
D. Other products that are fortified to contain additional
vitamin D include milk, some fruit juices, margarine, and
ready-to-eat cereals (Calvo et al., 2004). Additional intake
of these foods and products by aquatic athletes is recom-
mended, with additional supplemental intake during fall
and winter.
It only seems logical and sensible that inadequate
caloric intake may impair tissue repair (Montero et al.,
2002). The question, however, of which type of calories
are required to optimize tissue recovery remains unan-
swered. Also, the timing of caloric intake, the amount of
(additional) caloric intake, and the form of intake require
further study. A plethora of studies have looked at such
questions from a performance perspective, that is, how
to optimize functional recovery and training adaptation.
Yet, the viewpoint of actual tissue repair and injury risk
has mostly been neglected. As such, future studies are
required on this specific topic.
A final consideration is the importance of nutrition
when recovering from injury. Nutrient intake is important
in wound healing and facilitating tissue repair in response
to injury. Caloric intake might need adjustment if the ath-
lete is not expending as much energy as usual when fully
fit and in normal training and competition (Tipton 2013).
Immobilization results in muscle loss resulting from
increased periods of negative muscle protein balance as a
function of decreased basal muscle protein synthesis and
resistance to anabolic stimuli such as protein ingestion.
Resistance exercise during the rehabilitation phase will
increase muscle protein synthesis and restore sensitivity
to anabolic stimuli. After initial injury management and
treatment, the intake of protein and energy must be suf-
ficient to support muscle growth.
Summary
• Aquatic athletes in all disciplines (i.e., swimming,
water polo, synchronized swimming, diving, and
open-water swimming) should benefit from a well-
balanced diet to reduce the risk of illness and injury
and promote rapid recovery back to full health and
fitness.
• Evidence from experimental studies should always
complement practical and clinical experience and
in-depth knowledge of an aquatic athlete’s health
status.
• Athletes should consume a well-balanced diet with
sufficient calories, macronutrients (particularly CHO
and protein), and micronutrients (particularly iron,
zinc, and vitamins A, D, E, B6, and B12) to maintain
health and performance.
• Evidence is emerging for the benefits of ingesting
foods and supplements rich in polyphenols (flavo-
noids) and probiotics. More studies are required
that evaluate the effectiveness of these nutrients and
supplements in various sports-specific settings across
the aquatic disciplines.
• Nutritional considerations for promoting tissue
repair after injury center on overall caloric and
protein intake. Vitamin D and ensuring balanced
energy availability could be useful in a prophylactic
approach to reduce the risk of injury (particularly
related to bone health) and promote recovery from
tissue damage.
• Aquatic athletes should have regular interaction with
a sports dietician to develop and review specific
nutritional strategies around training and competi-
tion. Particular care should be made around the
selection, purchase, and consumption of supplements
and ergogenic aids to limit the risk of contaminants
and illegal substances.
Acknowledgments
The authors have no conflicts of interest to declare.

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