Estimating indicator weights for the motor health of pre-school-aged children: an integrated-methods approach.

Armed conflict constitutes one of the most physiologically severe environmental stressors to which human populations are chronically exposed., Since 2022, the geographic scope of active armed conflict has expanded substantially across multiple regions, collectively placing tens of millions of individuals under conditions of chronic threat exposure. The participation of athletes in high-level competition while residing in an active war zone constitutes one of the most extreme and understudied physiological situations in sports science. Unlike classical overtraining or isolated psychological stress, this condition simultaneously combines three mutually reinforcing biological stressors: a chronic life-threatening stress that maximally activates neuroendocrine systems,, an intense physical training-program maintaining permanently high hormonal demand, and severe sleep deprivation that destroys the biological architecture essential for recovery., Conflict exposure activates the hypothalamic-pituitary-adrenal (HPA) axis, leading to sustained cortisol elevation, amygdala hyperactivation, and prefrontal cortex suppression, together with hypervigilance states that profoundly disrupt sleep onset and maintenance., As noted in the literature, among the hormonal changes induced by sleep loss, there is an increase in cortisol and corticosterone secretion, and a reduction in testosterone and insulin-like growth factor-1 (IGF-1), favoring the establishment of a highly proteolytic environment.,, Although conflict-related stress has been extensively studied in military and civilian trauma populations, its implications for athlete recovery and performance remain insufficiently examined. Physical activity and sport participation surveys across the Eastern Mediterranean Region (EMR) nevertheless document an established athletic infrastructure within these populations, indicating that many athletes continue to train and compete under conditions of acute and chronic conflict exposure that conventional periodization and recovery models do not adequately accommodate. This review is written with several audiences in mind. Sports scientists and chronobiologists will find a mechanistic framework for studying environments where multiple stressors overlap. Sports medicine physicians and other healthcare providers can use the candidate monitoring markers and intervention targets to track and support athletes affected by conflict. For coaches and performance support staff, the framework informs training load and recovery decisions when athletes train under threat. Athletes themselves may use it to make sense of their own symptoms and to adopt simple self-management steps, such as filtering nighttime alerts or napping at strategic times. It also speaks to sport governing bodies and policy-makers, whose scheduling and welfare provisions have yet to accommodate the demands of religious observance during active conflict. A mechanistically distinct stressor may further compound this neuroendocrine burden. In active conflict-affected regions, athletes rely on continuous digital communication for security monitoring while simultaneously being subject to state-broadcast emergency acoustic alert systems, including missile warning sirens, civil defense broadcasts, and military public-address notifications that deliver sudden, high-intensity acoustic stimuli during nocturnal recovery windows., These systems produce neurobiologically distinct effects from those generated by voluntary recreational device use., They precipitate acute sympathetic-adrenomedullary activation, force complete arousal from sleep, mandate behavioral evacuation or shelter-seeking responses that extend wakefulness by 30 to 90 minutes or more per episode, and condition a generalized acoustic hypervigilance such that all subsequent auditory stimuli acquire threat-signal properties through associative learning., This pathway, designated here as conflict-specific acoustic hypervigilance (CSAH), is mechanistically and clinically distinct from the voluntary, behaviorally mediated pathway of behavioral digital sleep fragmentation (DSF-B), which includes notification-driven micro-arousals and pre-sleep blue-light exposure from recreational screen use., Conflating these two pathways may mischaracterize the primary mechanism operative in conflict-zone athletes, underestimate the physiological severity of the condition, and misidentify appropriate intervention targets. For athletes in conflict-affected Muslim-majority nations, a concurrent religious observance introduces distinct physiological demands: approximately two billion Muslims observe Ramadan annually, abstaining from all food and fluid intake between dawn () and sunset () for 29 to 30 consecutive days. For competitive athletes, this observance entails sustained daytime caloric restriction, progressive hypohydration, and temporally structured meal timing that coincides with ongoing training and competition demands. Meta-analytic