The Mediterranean dietary pattern for optimising health and performance in competitive athletes: a narrative review.

Nutrition plays a key role in training for, and competing in, competitive sport, and is essential for reducing risk of injury and illness, recovering and adapting between bouts of activity, and enhancing performance. Consumption of a Mediterranean diet (MedDiet) has been demonstrated to reduce risk of various non-communicable diseases and increase longevity. Following the key principles of a MedDiet could also represent a useful framework for good nutrition in competitive athletes under most circumstances, with potential benefits for health and performance parameters. In this review, we discuss the potential effects of a MedDiet, or individual foods and compounds readily available in this dietary pattern, on oxidative stress and inflammation, injury and illness risk, vascular and cognitive function, and exercise performance in competitive athletes. We also highlight potential modifications which could be made to the MedDiet (whilst otherwise adhering to the key principles of this dietary pattern) in accordance with contemporary sports nutrition practices, to maximise health and performance effects. In addition, we discuss potential directions for future research.

Relationship between urinary nitrate concentrations and cognitive function in older adults: findings from the NHANES survey.

This study evaluated the association of urinary nitrate concentrations with cognition in older subjects enrolled in the NHANES study. We also explored whether associations between urinary nitrate and cognition were modified by cardiovascular risk, vitamin D status and vitamin C intake. Two NHANES cycles were merged (2011-2012 and 2013-2014) and a total of 1,015 adults aged 60-80 (69.4 ± 0.3) years were included. Cognition was assessed using the Word List Learning, Word List Recall, Animal Fluency and the Digit Symbol Substitution tests. Urinary nitrate was analysed using electrospray tandem mass spectrometry. Urinary nitrate concentrations were not associated with cognitive performance on any of the cognitive tests. Associations were also not significant in subjects at greater risk for cognitive impairment (i.e. high cardiovascular risk and non-optimal vitamin D status). Longitudinal analyses are needed to explore the associations of urinary nitrate concentrations with dietary nitrate intake and cognitive function.

Differences in circulating appetite-related hormone concentrations between younger and older adults: a systematic review and meta-analysis.

Ageing is associated with reduced appetite and energy intakes. However, the mechanisms underlying this phenomenon are not fully understood. This systematic review and meta-analysis quantified differences in circulating concentrations of appetite-related hormones between healthy older and younger adults. Six databases were searched through 12th June 2018 for studies that compared appetite-related hormone concentrations between older and younger adults. Data were pooled using random-effects meta-analysis and are presented as standardised mean difference (Hedges' g) with 95% confidence intervals (95% CI). Thirty-five studies were included involving 710 older adults (mean ± SD; age: 73 ± 5 years) and 713 younger adults (age: 28 ± 7 years). Compared with younger adults, older adults exhibited higher fasted and postprandial concentrations of the anorectic hormones cholecystokinin (Fasted: SMD 0.41 (95% CI 0.24, 0.57); p < 0.001. Postprandial: SMD 0.41 (0.20, 0.62); p < 0.001), leptin [Fasted: SMD 1.23 (0.15, 2.30); p = 0.025. Postprandial: SMD 0.62 (0.23, 1.01); p = 0.002] and insulin [Fasted: SMD 0.24 (- 0.02, 0.50); p = 0.073. Postprandial: SMD 0.16 (0.01, 0.32); p = 0.043]. Higher postprandial concentrations of peptide-YY were also observed in older adults compared with younger adults [SMD 0.31 (- 0.03, 0.65); p = 0.075]. Compared with younger adults, older adults had lower energy intakes [SMD - 0.98 (- 1.74, - 0.22); p = 0.011], and lower hunger perceptions in the fasted [SMD - 1.00 (- 1.54, - 0.46); p < 0.001] and postprandial states [SMD - 0.31, (- 0.64, 0.02); p = 0.064]. Higher circulating concentrations of insulin, leptin, cholecystokinin and peptide-YY accord with reduced appetite and energy intakes in healthy older adults. Interventions to reduce circulating levels of these hormones may be beneficial for combatting the anorexia of ageing.

Sex Differences in Performance and Pacing Strategies During Sprint Skiing.

Purpose: This study aimed to compare performance and pacing strategies between elite male and female cross-country skiers during a sprint competition on snow using the skating technique. Methods: Twenty male and 14 female skiers completed an individual time-trial prolog (TT) and three head-to-head races (quarter, semi, and final) on the same 1,572-m course, which was divided into flat, uphill and downhill sections. Section-specific speeds, choice of sub-technique (i.e., gear), cycle characteristics, heart rate and post-race blood lactate concentration were monitored. Power output was estimated for the different sections during the TT, while metabolic demand was estimated for two uphill camera sections and the final 50-m flat camera section. Results: Average speed during the four races was ∼12.5% faster for males than females (P < 0.001), while speeds on the flat, uphill and downhill sections were ∼11, 18, and 9% faster for the males than females (all P < 0.001 for terrain, sex, and interaction). Differences in uphill TT speed between the sexes were associated with different sub-technique preferences, with males using a higher gear more frequently than females (P < 0.05). The estimated metabolic demand relative to maximal oxygen uptake ( V ˙ O2max) was similar for both sexes during the two uphill camera sections (∼129% of V ˙ O2max) and for the final 50-m flat section (∼153% of V ˙ O2max). Relative power output during the TT was 18% higher for males compared to females (P < 0.001) and was highly variable along the course for both sexes (coefficient of variation [CV] between sections 4-9 was 53%), while the same variation in heart rate was low (CV was ∼3%). The head-to-head races were ∼2.4% faster than the TT for both sexes and most race winners (61%) were positioned first already after 30 m of the race. No sex differences were observed during any of the races for heart rate or blood lactate concentration. Conclusion: The average sex difference in sprint skiing performance was ∼12.5%, with varying differences for terrain-specific speeds. Moreover, females skied relatively slower uphill (at a lower gear) and thereby elicited more variation in their speed profiles compared to the males.

Commercially available compression garments or electrical stimulation do not enhance recovery following a sprint competition in elite cross-country skiers.

This study investigated whether commercially available compression garments (COMP) exerting a moderate level of pressure and/or neuromuscular electrical stimulation (NMES) accelerate recovery following a cross-country sprint skiing competition compared with a control group (CON) consisting of active recovery only. Twenty-one senior (12 males, 9 females) and 11 junior (6 males, 5 females) Swedish national team skiers performed an outdoor sprint skiing competition involving four sprints lasting ∼3-4 min. Before the competition, skiers were matched by sex and skiing level (senior versus junior) and randomly assigned to COMP (n = 11), NMES (n = 11) or CON (n = 10). Creatine kinase (CK), urea, countermovement jump (CMJ) height, and perceived muscle pain were measured before and 8, 20, 44 and 68 h after competition. Neither COMP nor NMES promoted the recovery of blood biomarkers, CMJ or perceived pain post-competition compared with CON (all P > .05). When grouping all 32 participants, urea and perceived muscle pain increased from baseline, peaking at 8 h (standardised mean difference (SMD), [95% confidence intervals (CIs)]): 2.8 [2.3, 3.2]) and 44 h (odds ratio [95% CI]: 3.3 [2.1, 5.1]) post-competition, respectively. Additionally, CMJ was lower than baseline 44 and 68 h post-competition in both males and females (P < .05). CK increased from baseline in males, peaking at 44 h (SMD: 1.4 [-0.4, 0.9]), but was decreased in females at 20 h post-competition (SMD: -0.8 [-1.4, -0.2]). In conclusion, cross-country sprint skiing induced symptoms of exercise-induced muscle damage peaking 8-44 h post-competition. However, neither COMP nor NMES promoted physiological or perceptual recovery compared with CON.

Physiological and performance effects of nitrate supplementation during roller-skiing in normoxia and normobaric hypoxia.

The present study examined the effects of acute nitrate (NO3-) supplementation ingested in the form of concentrated beetroot juice on cross-country roller-ski performance in normoxia (N) and normobaric hypoxia (H). Eight competitive cross-country skiers (five males: age 22 ± 3 years, V·O2max 71.5 ± 4.7 mL kg-1·min-1; three females: age 21 ± 1 years, V·O2max 58.4 ± 2.5 mL kg-1·min-1) were supplemented with a single dose of NO3--rich beetroot juice (BRJ, ∼13 mmol NO3-) or a NO3--depleted placebo (PL, ∼0 mmol NO3-) and performed 2 x 6-min submaximal exercise bouts and a 1000-m time-trial (TT) on a treadmill in N (20.9% O2) or H (16.8% O2). The four experimental trials were presented in a randomised, counter-balanced order. Plasma NO3- and nitrite concentrations were significantly higher following BRJ compared to PL (both p < 0.001). However, respiratory variables, heart rate, blood lactate concentration, ratings of perceived exertion, and near-infrared spectroscopy-derived measures of muscle tissue oxygenation during submaximal exercise were not significantly different between BRJ and PL (all p > 0.05). Likewise, time to complete the TT was unaffected by supplementation in both N and H (p > 0.05). In conclusion, an acute dose of ∼13 mmol NO3- does not affect physiological or performance responses to submaximal or maximal treadmill roller-skiing in competitive cross-country skiers exercising in N and H.

"Beet-ing" the Mountain: A Review of the Physiological and Performance Effects of Dietary Nitrate Supplementation at Simulated and Terrestrial Altitude.

Exposure to altitude results in multiple physiological consequences. These include, but are not limited to, a reduced maximal oxygen consumption, drop in arterial oxygen saturation, and increase in muscle metabolic perturbations at a fixed sub-maximal work rate. Exercise capacity during fixed work rate or incremental exercise and time-trial performance are also impaired at altitude relative to sea level. Recently, dietary nitrate (NO3-) supplementation has attracted considerable interest as a nutritional aid during altitude exposure. In this review, we summarise and critically evaluate the physiological and performance effects of dietary NO3- supplementation during exposure to simulated and terrestrial altitude. Previous investigations at simulated altitude indicate that NO3- supplementation may reduce the oxygen cost of exercise, elevate arterial and tissue oxygen saturation, improve muscle metabolic function, and enhance exercise capacity/performance. Conversely, current evidence suggests that NO3- supplementation does not augment the training response at simulated altitude. Few studies have evaluated the effects of NO3- at terrestrial altitude. Current evidence indicates potential improvements in endothelial function at terrestrial altitude following NO3- supplementation. No effects of NO3- supplementation have been observed on oxygen consumption or arterial oxygen saturation at terrestrial altitude, although further research is warranted. Limitations of the present body of literature are discussed, and directions for future research are provided.

Dietary nitrate supplementation enhances short but not longer duration running time-trial performance.

PURPOSE: This study evaluated the effects of dietary nitrate (NO3-) supplementation on physiological functioning and exercise performance in trained runners/triathletes conducting short and longer-distance treadmill running time-trials (TT). METHOD: Eight trained male runners or triathletes completed four exercise performance tests comprising a 10 min warm up followed by either a 1500 or 10,000 m treadmill TT. Exercise performance tests were preceded 3 h before the exercise by supplementation with either 140 ml concentrated nitrate-rich (~12.5 mmol nitrate) (BRJ) or nitrate-deplete (~0.01 mmol nitrate) (PLA) beetroot juice. RESULTS: BRJ supplementation significantly elevated plasma [NO2-] (P < 0.05). Resting blood pressure and exercise [Formula: see text] were not significantly different between BRJ and PLA (P > 0.05). However, post-exercise blood [lactate] was significantly greater in BRJ following the 1500 m TT (6.6 ± 1.2 vs. 6.1 ± 1.5 mM; P < 0.05), but not significantly different between conditions in the 10,000 m TT (P > 0.05). Performance in the 1500 m TT was significantly faster in BRJ vs. PLA (319.6 ± 36.2 vs. 325.7 ± 38.8 s; P < 0.05). Conversely, there was no significant difference in 10,000 m TT performance between conditions (2643.1 ± 324. 1 vs. 2649.9 ± 319.8 s, P > 0.05). CONCLUSION: Acute BRJ supplementation significantly enhanced 1500 m, but not 10,000 m TT performance. These findings suggest that BRJ might be ergogenic during shorter distance TTs which allow for a high work rate, but not during longer distance TTs, completed at a lower work rate.

Effect of Dietary Nitrate Supplementation on Swimming Performance in Trained Swimmers.

Nitrate supplementation appears to be most ergogenic when oxygen availability is restricted and subsequently may be particularly beneficial for swimming performance due to the breath-hold element of this sport. This represents the first investigation of nitrate supplementation and swimming time-trial (TT) performance. In a randomized double-blind repeated-measures crossover study, ten (5 male, 5 female) trained swimmers ingested 140ml nitrate-rich (~12.5mmol nitrate) or nitrate-depleted (~0.01mmol nitrate) beetroot juice. Three hours later, subjects completed a maximal effort swim TT comprising 168m (8 × 21m lengths) backstroke. Preexercise fractional exhaled nitric oxide concentration was significantly elevated with nitrate compared with placebo, Mean (SD): 17 (9) vs. 7 (3)p.p.b., p = .008. Nitrate supplementation had a likely trivial effect on overall swim TT performance (mean difference 1.22s; 90% CI -0.18-2.6s; 0.93%; p = .144; d = 0.13; unlikely beneficial (22.6%), likely trivial (77.2%), most unlikely negative (0.2%)). The effects of nitrate supplementation during the first half of the TT were trivial (mean difference 0.29s; 90% CI -0.94-1.5s; 0.46%; p = .678; d = 0.05), but there was a possible beneficial effect of nitrate supplementation during the second half of the TT (mean difference 0.93s; 90% CI 0.13-1.70s; 1.36%; p = .062; d = 0.24; possibly beneficial (63.5%), possibly trivial (36.3%), most unlikely negative (0.2%)). The duration and speed of underwater swimming within the performance did not differ between nitrate and placebo (both p > .30). Nitrate supplementation increased nitric oxide bioavailability but did not benefit short-distance swimming performance or the underwater phases of the TT. Further investigation into the effects of nitrate supplementation during the second half of performance tests may be warranted.

Dietary nitrate supplementation enhances high-intensity running performance in moderate normobaric hypoxia, independent of aerobic fitness.

Nitrate-rich beetroot juice (BRJ) increases plasma nitrite concentrations, lowers the oxygen cost (V⋅O2) of steady-state exercise and improves exercise performance in sedentary and moderately-trained, but rarely in well-trained individuals exercising at sea-level. BRJ supplementation may be more effective in a hypoxic environment, where the reduction of nitrite into nitric oxide (NO) is potentiated, such that well-trained and less well-trained individuals may derive a similar ergogenic effect. We conducted a randomised, counterbalanced, double-blind placebo controlled trial to determine the effects of BRJ on treadmill running performance in moderate normobaric hypoxia (equivalent to 2500 m altitude) in participants with a range of aerobic fitness levels. Twelve healthy males (V⋅O2max ranging from 47.1 to 76.8 ml kg(-1) min(-1)) ingested 138 ml concentrated BRJ (∼15.2 mmol nitrate) or a nitrate-deplete placebo (PLA) (∼0.2 mmol nitrate). Three hours later, participants completed steady-state moderate intensity running, and a 1500 m time-trial (TT) in a normobaric hypoxic chamber (FIO2 âˆ¼ 15%). Plasma nitrite concentration was significantly greater following BRJ versus PLA 1 h post supplementation, and remained higher in BRJ throughout the testing session (p < 0.01). Average V⋅O2 was significantly lower (BRJ: 18.4 ± 2.0, PLA: 20.4 ± 12.6 ml kg(-1) min(-1); p = 0.002), whilst arterial oxygen saturation (SpO2) was significantly greater (BRJ: 88.4 ± 2.7, PLA: 86.5 ± 3.3%; p < 0.001) following BRJ. BRJ improved TT performance in all 12 participants by an average of 3.2% (BRJ: 331.1 ± 45.3 vs. PL: 341.9 ± 46.1 s; p < 0.001). There was no apparent relationship between aerobic fitness and the improvement in performance following BRJ (r(2) = 0.05, p > 0.05). These findings suggests that a high nitrate dose in the form of a BRJ supplement may improve running performance in individuals with a range of aerobic fitness levels conducting moderate and high-intensity exercise in a normobaric hypoxic environment.