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• W4385416192 abstract "INTRODUCTION Since the landmark discovery that a brief 3-d supplementation period of sodium nitrate can reduce the oxygen cost of submaximal exercise (1), numerous studies have investigated the effects of nitrate supplementation, and many systematic reviews and meta-analyses show that it can benefit exercise performance and capacity (2,3). However, despite overall evidence in favor of its use as an ergogenic aid (2,3), a substantial proportion of the existing literature shows no benefit of nitrate supplementation on exercise performance and capacity-related outcomes (2), which suggests the existence of a substantial variation in response to its use. Many factors that can influence the ergogenicity of nitrate have been proposed, but perhaps one of the most interesting, albeit seldom investigated, is biological sex (2). In agreement with this notion, the results of two recent meta-analytic studies suggest that, although nitrate exerts a positive effect in men, its supplementation does not seem to benefit female performance, even in the face of evidence suggesting that women have a greater reduction of nitrate to nitrite than men (2–4). Nonetheless, some caution is needed in concluding that women do not benefit from nitrate supplementation; the small number of studies conducted exclusively with female participants (n = 6) and their heterogeneity in important methodological aspects (such as practices that control oral microbiota diversity, ingestion strategies, and exercise conditions) may have contributed to the lack of effect for women in these meta-analyses (2,3). Therefore, it is possible that these results are just a reflection of the small and limited literature on the ergogenic effect of nitrate in women. NITRATE SUPPLEMENTATION IN EXERCISE Although there is extensive research investigating the effects of dietary nitrate in men, women are clearly underrepresented in research on nitrate supplementation (5). Recently published data showed that, of 126 studies investigating the effect of nitrate on performance outcomes, 21 included at least one woman as part of a mixed-sex cohort disregarding the potential influence of sexual dimorphisms, only 7 were conducted exclusively with female participants, 3 conducted some subanalysis on men versus women, and only 1 study specifically compared nitrate supplementation between men and women (5). Regarding the available literature on the ergogenic effect of nitrate in women, most experimental studies have not found positive results with its use (6–11), although there is some evidence suggesting that nitrate may improve exercise performance in female athletes (12–14). Importantly, based on the meta-analysis by Silva et al. (3), the absence of any ergogenic benefit from nitrate supplementation in most of these studies may be due to methodological aspects and not sex differences per se. These specific factors include not accounting for ovarian hormone status (including menstrual cycle phase and hormonal contraceptive use) and factors that may modulate nitrate supplementation’s effectiveness. Although it is possible that the effects of nitrate are less apparent in women (15), there is currently insufficient evidence to affirm that nitrate supplementation is not, or is less, effective in women for exercise performance. The comprehensive systematic review and meta-analysis recently published by Silva et al. (3) provided evidence that factors such as oral hygiene practices, dose ingested, timing of supplementation, source of nitrate, and exercise duration may moderate the effectiveness of nitrate supplementation. Specifically, the results suggest that, despite an overall ergogenic effect, there seems to be no benefit from nitrate ingestion in studies that do not control for antibacterial mouthwash use, use acute doses ≤4.9 mmol or ≥15 mmol and chronic doses ≤4.9 mmol or ≥10 mmol, perform supplementation <150 min before the performance test, supplement with nitrate salts, and utilize exercises with duration ≤120s or >600 s (3). Given this, it seems that nitrate supplementation may be especially effective in the absence of the use of antibacterial mouthwash, and preferably other practices that reduce oral microbiota diversity (e.g., using antibacterial toothpaste, tongue scraping, chewing gum), when performed with 5.0–9.9 mmol nitrate from vegetables, beetroot gel, or beetroot juice provided at least 150 min before exercise tasks lasting 120–600 s (3); there is also the possibility that dietary nitrate may be ergogenic in continuous exercise lasting up to approximately 30 min (16). Based on this evidence, most studies that have investigated the ergogenic effect of nitrate in women have at least one suboptimal methodological aspect that may have contributed to a lack of benefit (3). PROPOSED RESEARCH AGENDA To determine whether female athletes can benefit from nitrate supplementation, conducting more experimental studies with female participants using optimal study designs should be a priority (3,15). It is imperative that studies that aim to establish whether nitrate supplementation is effective or not to improve exercise performance in women are well designed and create the “ideal” environment in which an ergogenic effect is most likely (Fig. 1). Considering that nitrate supplementation is usually performed in an acute or short-term manner, and that its washout time seems to be relatively short (<24 h) (17), we advise that future research on the topic preferably be characterized by a placebo-controlled, crossover, double-blind, and randomized study design. Meta-analytical data based on 123 studies and 243 outcomes suggest that studies should use a supplementation strategy providing 5.0–9.9 mmol of nitrate, using beetroot juice as a vehicle (because of the large evidence base showing positive effects of beetroot juice and its potentially superior effects to nitrate salts), ingested ≥150 min before an exercise test lasting 120–600 s (3). Given recent evidence suggesting that practices that affect oral microbiota diversity (e.g., antibacterial mouthwash or toothpaste) may reduce or even eliminate the ergogenic effect of nitrate (3), studies should control the use of these practices. In theory, based on previous work, this design would provide the greatest likelihood of demonstrating an ergogenic effect and could serve as a platform to determine the efficacy of nitrate in women. Study designs incorporating the aforementioned guidelines may wish to include a men-only group to confirm, or refute, the efficacy of the intervention (because they are based on meta-analytical data of numerous studies performed primarily in men) and to determine whether sex differences in the response to nitrate supplementation exist. Such research will probably provide the strongest evidence regarding the existence or not of sex differences to the ergogenic effects of nitrate. Because of possible sex differences in the conversion of nitrate to nitrite (4), when feasible, investigations should measure plasma and muscle nitrate and nitrite responses after supplementation because they may explain any potential performance changes.Figure 1: Key points for future studies investigating whether female athletes may benefit from dietary nitrate supplementation. *For research conducted to determine whether sex differences in the response to nitrate supplementation exist.Because monophasic oral contraceptive (OC) users have low and stable endogenous ovarian hormonal profiles coupled with consistent daily supplementation of exogenous ethinyl-estradiol and progestin, it might be interesting for future research on nitrate supplementation in women to compare its effect between users of these contraceptives and a men-only group to determine whether there are inherent physiological differences (e.g., differences in fiber type proportion and skeletal muscle capillarization) that may lead to distinct performance responses after nitrate supplementation between women and men without being influenced by fluctuating hormone levels. This would also be relevant to a large proportion of the female population; some data suggest that almost 50% of elite female athletes use hormonal contraceptives and about 70% of them use monophasic OC (18). Studies should recruit OC users who have been taking the pill for ≥3 months, with the main tests preferably occurring between the 7th and 21st days of the pill-taking period to ensure ovarian hormone levels (both endogenous and exogenous) are stable (19). Another important factor to consider is the potential influence of cyclical ovarian hormones on various biological systems and exercise performance (19,20). Research should determine whether the menstrual cycle phase alters the response to nitrate supplementation through intraindividual comparisons of the effects observed between two or more of the phases established by Elliott-Sale et al. (19), because there are indications that variations in ovarian hormones, specifically estradiol levels, across the cycle may influence the bioavailability of nitric oxide, as well as nitrite and nitrate concentrations, which may infer differences in the responsiveness to nitrate supplementation (21). Besides exercise performance metrics, studies could also measure the effect on resting blood pressure to complement any investigation of between-phase differences in response to nitrate ingestion. To prevent major changes in ovarian hormones between conditions, main tests (nitrate and placebo) in each phase should be separated by 48 to 72 h or be performed in separate menstrual cycles (particularly in the case of very short phases such as phases 2 and 3). It is essential that studies controlling for menstrual cycle phase define each phase based on hormonal profiles verified by blood analysis, as proposed by Elliott-Sale et al. (19). Such studies are likely to provide the strongest evidence regarding the efficacy of nitrate supplementation for female athletes across the menstrual cycle. Comparisons could also be made to an OC-user group to determine how responses might differ because of OC use. It is important that future studies on nitrate supplementation continue to account for ovarian hormone status, in particular menstrual cycle phase or OC use (19), given that these profiles are likely to represent the majority of women. Furthermore, because there is evidence, mainly from studies in men, suggesting that individuals with high aerobic capacity (maximal oxygen consumption ≥65 mL·kg−1·min−1) may not benefit from nitrate (2,3), it would be relevant for studies to compare its effect in groups of women with different aerobic capacities to establish whether maximal oxygen consumption has a similar influence on the ergogenic effects of nitrate in women and whether any threshold might differentiate those who might benefit from those who might not. CONCLUSIONS In view of the small, limited, and somewhat conflicting literature on the ergogenic effect of dietary nitrate in women, there is currently insufficient evidence to draw conclusions about the efficacy of its supplementation for female athletes. To determine whether women can benefit or not from nitrate supplementation, it is essential that future studies are well designed and create an optimal environment in which to elicit an ergogenic effect of nitrate (Fig. 1). Until such well-designed research exists, professionals working with female athletes are advised to be cautious when recommending nitrate supplementation, preferably testing in repeated simulated performance trials during training to be clear that the athlete is not susceptible to experiencing side effects (e.g., mild gastrointestinal problems) and to verify if nitrate can provide some ergogenic benefits. Once this is accomplished and the absence of side effects and any performance benefits from nitrate supplementation are consistently observed, the athlete should consider its use in competition." @default.
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• W4385416192 title "Directions for Future Studies to Determine Dietary Nitrate Efficacy in Female Athletes" @default.
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