The Effects of Multi-Day vs. Single Pre-exercise Nitrate Supplement Dosing on Simulated Cycling Time Trial Performance and Skeletal Muscle Oxygenation

Nutritional Ergogenic Aids in Cycling: A Systematic Review

This systematic review aimed to evaluate the effectiveness of the independent or combined use of nutritional ergogenic aids belonging to Group A of the ABCD classification by the Australian Institute of Sport (AIS) in the context of cycling (caffeine, creatine, sodium bicarbonate, beta-alanine, nitrates, and glycerol). A comprehensive search was carried out using three databases: PubMed, Scopus, and Web of Science. All the databases were searched for Randomized Controlled Trials or crossover design studies assessing the effects of supplementation on cycling performance in comparison with placebos in healthy adults. The methodological quality of each study was evaluated using the Physiotherapy Evidence Database scale. Thirty-six articles involving 701 participants were included in this review, examining supplementation with caffeine (n = 5), creatine (n = 2), sodium bicarbonate (n = 6), beta-alanine (n = 3), and nitrates (n = 8). Additionally, supplemental combinations of caffeine and creatine (n = 3), caffeine and sodium bicarbonate (n = 3), caffeine and nitrates (n = 1), creatine and sodium bicarbonate (n = 1), and sodium bicarbonate and beta-alanine (n = 4) were analyzed. A benefit for cyclists' athletic performnce was found when consuming a caffeine supplement, and a potential positive effect was noted after the consumption of sodium bicarbonate, as well as after the combination of caffeine and creatine. However, no statistically significant effects were identified for the remaining supplements, whether administered individually or in combination.

Muscle Oximetry in Sports Science: An Updated Systematic Review

BACKGROUND

In the last 5 years since our last systematic review, a significant number of articles have been published on the technical aspects of muscle near-infrared spectroscopy (NIRS), the interpretation of the signals and the benefits of using the NIRS technique to measure the physiological status of muscles and to determine the workload of working muscles.

OBJECTIVES

Considering the consistent number of studies on the application of muscle oximetry in sports science published over the last 5 years, the objectives of this updated systematic review were to highlight the applications of muscle oximetry in the assessment of skeletal muscle oxidative performance in sports activities and to emphasize how this technology has been applied to exercise and training over the last 5 years. In addition, some recent instrumental developments will be briefly summarized.

METHODS

Preferred Reporting Items for Systematic Reviews guidelines were followed in a systematic fashion to search, appraise and synthesize existing literature on this topic. Electronic databases such as Scopus, MEDLINE/PubMed and SPORTDiscus were searched from March 2017 up to March 2023. Potential inclusions were screened against eligibility criteria relating to recreationally trained to elite athletes, with or without training programmes, who must have assessed physiological variables monitored by commercial oximeters or NIRS instrumentation.

RESULTS

Of the identified records, 191 studies regrouping 3435 participants, met the eligibility criteria. This systematic review highlighted a number of key findings in 37 domains of sport activities. Overall, NIRS information can be used as a meaningful marker of skeletal muscle oxidative capacity and can become one of the primary monitoring tools in practice in conjunction with, or in comparison with, heart rate or mechanical power indices in diverse exercise contexts and across different types of training and interventions.

CONCLUSIONS

Although the feasibility and success of the use of muscle oximetry in sports science is well documented, there is still a need for further instrumental development to overcome current instrumental limitations. Longitudinal studies are urgently needed to strengthen the benefits of using muscle oximetry in sports science.

The effects of nitrate ingestion on high-intensity endurance time-trial performance: A systematic review and meta-analysis

Background/Objective

Dietary nitrate ingestion extends endurance capacity, but data supporting endurance time-trial performance are unclear. This systematic review and meta-analysis evaluated the evidence for dietary nitrate supplementation to improve high-intensity endurance time-trial performance over 5-30 min on the premise that nitrate may alleviate peripheral fatigue over shorter durations.

Methods

A systematic literature search and data extraction was carried out following PRISMA guidelines and the PICOS framework within five databases: PubMed, ProQuest, ScienceDirect, Scopus and SPORTDiscus. Search terms used were: (nitrate OR nitrite OR beetroot) AND (high intensity OR all out) AND (time trial or total work done) AND performance.

Results

Twenty-four studies were included. Fifteen studies applied an acute supplementation strategy (4.1 mmol-15.2 mmol serving on one day), eight chronic supplementation (4.0 mmol-13.0 mmol per day over 3-15 days), and one applied both acute and chronic supplementation (8.0 mmol on one day and over 15 days). Standardised mean difference for time-trial ranging from 5 to 30 min showed an overall trivial effect in favour of nitrate (Hedges'g = 0.15, 95% CI -0.00 to 0.31, Z = 1.95, p = 0.05). Subgroup analysis revealed a small, borderline effect in favour of chronic nitrate intervention (Hedges'g = 0.30, 95% CI -0.00 to 0.59, Z = 1.94, p = 0.05), and a non-significant effect for acute nitrate intervention (Hedges'g = 0.10, 95% CI -0.08 to 0.28, Z = 1.11, p = 0.27).

Conclusion

Chronic nitrate supplementation improves time-trial performance ranging from 5 to 30 min.

Effects of Dietary Nitrate Supplementation on Performance and Muscle Oxygenation during Resistance Exercise in Men

The purpose of the current study was to assess the effects of acute and short-term nitrate (NO3−)-rich beetroot juice (BR) supplementation on performance outcomes and muscle oxygenation during bench press and back squat exercise. Fourteen recreationally active males were assigned in a randomized, double-blind, crossover design to supplement for 4 days in two conditions: (1) NO3−-depleted beetroot juice (PL; 0.10 mmol NO3− per day) and (2) BR (11.8 mmol NO3− per day). On days 1 and 4 of the supplementation periods, participants completed 2 sets of 2 × 70%1RM interspersed by 2 min of recovery, followed by one set of repetitions-to-failure (RTF) at 60%1RM for the determination of muscular power, velocity, and endurance. Quadriceps and pectoralis major tissue saturation index (TSI) were measured throughout exercise. Plasma [NO3−] and nitrite ([NO2−]) were higher after 1 and 4 days of supplementation with BR compared to PL (p < 0.05). Quadriceps and pectoralis major TSI were not different between conditions (p > 0.05). The number of RTF in bench press was 5% greater after acute BR ingestion compared to PL (PL: 23 ± 4 vs. BR: 24 ± 5, p < 0.05). There were no differences between BR and PL for RTF for back squat or power and velocity for back squat or bench press (p > 0.05). These data improve understanding on the ergogenic potential of BR supplementation during resistance exercise.

Effects of Nitrate Supplementation on Exercise Performance in Humans: A Narrative Review

Nitrates have become increasingly popular for their potential role as an ergogenic aid. The purpose of this article was to review the current scientific evidence of nitrate supplementation on human performance. The current recommendation of nitrate supplementation is discussed, as well as possible health complications associated with nitrate intake for athletes, and dietary strategies of covering nitrate needs through sufficient intake of nitrate-rich foods alone are presented. Pubmed, Scopus, and Web of Science were searched for articles on the effects of nitrate supplementation in humans. Nitrates are an effective ergogenic aid when taken acutely or chronically in the range of ~5-16.8 mmol (~300-1041 mg) 2-3 h before exercise and primarily in the case of exercise duration of ~10-17 min in less trained individuals (VO2max < 65 mL/kg/min). Nitrate needs are most likely meet by ingesting approximately 250-500 g of leafy and root vegetables per day; however, dietary supplements might represent a more convenient and accurate way of covering an athlete's nitrate needs. Athletes should refrain from mouthwash usage when nitrate supplementation benefits are desired. Future research should focus on the potential beneficial effects of nitrate supplementation on brain function, possible negative impacts of chronic nitrate supplementation through different nitrate sources, and the effectiveness of nitrate supplementation on strength and high-intensity intermittent exercise.

The effects of dietary nitrate supplementation on endurance exercise performance and cardiorespiratory measures in healthy adults: a systematic review and meta-analysis

BACKGROUND

Nitrate supplementation is thought to improve performance in endurance sports.

OBJECTIVE

To meta-analyze studies evaluating the effect of nitrate supplementation on endurance sports performance among adults.

DATA SOURCES

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science and CINAHL without language restrictions.

METHODS

We included studies that: 1) compared nitrate supplementation with placebo; 2) enrolled adults engaging in an endurance-based activity; and 3) reported a performance measure or surrogate physiologic outcome. We evaluated risk of bias using the Cochrane Collaboration tool and pooled data with a random-effects model. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate confidence in estimates.

RESULTS

We included 73 studies (n = 1061). Nitrate supplementation improved power output (MD 4.6 watts, P < 0.0001), time to exhaustion (MD 25.3 s, P < 0.00001), and distance travelled (MD 163.7 m, P = 0.03). We found no significant difference on perceived exertion, time trial performance and work done. Nitrate supplementation decreased VO₂ (MD - 0.04 L/min, P < 0.00001) but had no significant effect on VO_2max or blood lactate levels.

CONCLUSION

The available evidence suggests that dietary nitrate supplementation benefits performance-related outcomes for endurance sports.

Dietary and Ergogenic Supplementation to Improve Elite Soccer Players' Performance

BACKGROUND

Soccer is an extremely competitive sport, where the most match important moments can be defined in detail. Use of ergogenic supplements can be crucial to improve the performance of a high-performance athlete. Therefore, knowing which ergogenic supplements are important for soccer players can be an interesting strategy to maintain high level in this sport until final and decisive moments of the match. In addition, other supplements, such as dietary supplements, have been studied and increasingly referenced in the scientific literature. But, what if ergogenic supplements were combined with dietary supplements? This review brings some recommendations to improve performance of soccer athletes on the field through dietary and/or ergogenic supplements that can be used simultaneously.

SUMMARY

Soccer is a competitive sport, where the match important moments can be defined in detail. Thus, use of ergogenic supplements covered in this review can improve performance of elite soccer players maintaining high level in the match until final moments, such as creatine 3-5 g day-1, caffeine 3-6 mg kg-1 BW around 60 min before the match, sodium bicarbonate 0.1-0.4 g kg-1 BW starting from 30 to 180 min before the match, β-alanine 3.2 and 6.4 g day-1 provided in the sustained-release tablets divided into 4 times a day, and nitrate-rich beetroot juice 60 g in 200 mL of water (6 mmol of NO3- L) around 120 min before match or training, including a combination possible with taurine 50 mg kg-1 BW day-1, citrulline 1.2-3.4 g day-1, and arginine 1.2-6 g day-1. Key Messages: Soccer athletes can combine ergogenic and dietary supplements to improve their performance on the field. The ergogenic and dietary supplements used in a scientifically recommended dose did not demonstrate relevant side effects. The use of various evidence-based supplements can add up to further improvement in the performance of the elite soccer players.

Beetroot supplementation in women enjoying exercise together (BEE SWEET): Rationale, design and methods

Background

Postmenopausal women exhibit higher rates of disability and cardiovascular disease (CVD) with aging compared to men. Whereas habitual exercise training is a known strategy to enhance physiologic function in men and premenopausal women, exercise-related adaptations are often modest in postmenopausal women. We propose dietary nitrate (beetroot juice) administered prior to exercise training may be a feasible approach to improve mobility and cardio-metabolic health outcomes in postmenopausal women.

Methods

Our randomized, placebo-controlled study aims to determine preliminary effects sizes for changes in functional mobility and endothelium-dependent vasodilation across three study arms: exercise only (EX), exercise + placebo (EX + PL), and exercise + beetroot (EX + BR). Thirty-six postmenopausal women are recruited in small cohorts wherein group exercise is implemented to facilitate social support and adherence to an 8-week training progression. Participants are randomized to one of three study arms (n = 12 per group) following baseline assessments. Post-intervention assessments are used to determine pre-post changes in outcome measures including distance covered during a 6 min walk test, walking economy, muscle speed and power, and endothelial-dependent vasodilation as determined by flow-mediated dilation. Measures of feasibility include recruitment, retention, adherence to exercise prescription, perceived exercise session difficulty, and adverse event rates.

Discussion

Evidence-based, translational strategies are needed to optimize exercise training-related adaptations in postmenopausal women. Findings will inform larger randomized clinical trials to determine if pre-exercise consumption of beetroot juice is an efficacious strategy to promote mobility and attenuate CVD disease risk.

The Effect of Dietary Nitrate Supplementation on Isokinetic Torque in Adults: A Systematic Review and Meta-Analysis

Dietary nitrate (NO3-) supplementation, which can enhance performance in exercise settings involving repeated high-intensity efforts, has been linked to improved skeletal muscle contractile function. Although muscular strength is an important component of explosive movements and sport-specific skills, few studies have quantified indices of muscular strength following NO3- supplementation, particularly isokinetic assessments at different angular velocities. We performed a systematic review and meta-analysis to determine whether dietary NO3- supplementation improves peak torque, as assessed by the gold standard method of isokinetic dynamometry, and if this effect was linked to the angular velocity imposed during the assessment. Dialnet, Directory of Open Access Journals, MEDLINE, PubMed, SciELO, Scopus, and SPORTDiscus were searched for articles using the following search strategy: (nitrate OR beet*) AND (supplement* OR nutr* OR diet*) AND (isokinetic OR strength OR "resistance exercise" OR "resistance training" OR "muscular power"). The meta-analysis of data from 5 studies with 60 participants revealed an overall effect size of -0.01 for the effect of nitrate supplementation on isokinetic peak torque, whereas trivial effect sizes ranging from -0.11 to 0.16 were observed for independent velocity-specific (90°/s, 180°/s, 270°/s, and 360°/s) isokinetic peak torque. Four of the five studies indicated that dietary NO3- supplementation is not likely to influence voluntary knee extensor isokinetic torque across a variety of angular velocities. These results suggest that NO3- supplementation does not influence isokinetic peak torque, but further work is required to elucidate the potential of NO3- supplementation to influence other indices of muscular strength, given the dearth of experimental evidence on this topic.

Effects of Dietary Nitrates on Time Trial Performance in Athletes with Different Training Status: Systematic Review

Much research has been done in sports nutrition in recent years as the demand for performance-enhancing substances increases. Higher intake of nitrates from the diet can increase the bioavailability of nitric oxide (NO) via the nitrate-nitrite-NO pathway. Nevertheless, the increased availability of NO does not always lead to improved performance in some individuals. This review aims to evaluate the relationship between the athlete's training status and the change in time trial performance after increased dietary nitrate intake. Articles indexed by Scopus and PubMed published from 2015 to 2019 were reviewed. Thirteen articles met the eligibility criteria: clinical trial studies on healthy participants with different training status (according to VO_2max), conducting time trial tests after dietary nitrate supplementation. The PRISMA guidelines were followed to process the review. We found a statistically significant relationship between VO_2max and ergogenicity in time trial performance using one-way ANOVA (p = 0.001) in less-trained athletes (VO₂ < 55 mL/kg/min). A strong positive correlation was observed in experimental situations using a chronic supplementation protocol but not in acute protocol situations. In the context of our results and recent histological observations of muscle fibres, there might be a fibre-type specific role in nitric oxide production and, therefore, supplement of ergogenicity.

Dietary Nitrate Supplementation and Exercise-Related Performance

Over the last decade, there has been a growing interest in the utility of nitrate (NO3^-) supplementation to improve exercise-related performance. After consumption, dietary NO3^- can be reduced to nitric oxide, a free radical gas involved in numerous physiological actions including blood vessel vasodilation, mitochondrial respiration, and skeletal muscle contractile function. Emerging evidence indicates that dietary NO3^- supplementation has a small but nevertheless significant beneficial effect on endurance performance through the combined effects of enhanced tissue oxygenation and metabolic efficiency in active skeletal muscle. There is further evidence to suggest that dietary NO3^- exerts a direct influence on contractile mechanisms within the skeletal muscle through alterations in calcium availability and sensitivity. Response heterogeneity and sizeable variability in the nitrate content of beetroot juice products influence the effectiveness of dietary NO3^- for exercise performance, and so dosing and product quality, as well as training history, sex, and individual-specific characteristics, should be considered.

Higher doses of a green tea-based supplement increase post-exercise blood flow following an acute resistance exercise bout in recreationally resistance-trained college-aged men

BACKGROUND

There are animal data suggesting green tea can enhance blood flow. However, human data are lacking. Thus, the purpose of this study was to examine the acute effects of low and high doses of a green tea-based supplement (GBS) on brachial artery blood flow before and following a resistance exercise bout.

METHODS

In this, double-blinded placebo-controlled trial, college-aged males (n = 18) who self-reported recreationally resistance training for the previous 6 ± 3 years were assigned to one of two studies including a low (300 mg serving) (n = 9) or high dose (600 mg serving) (n = 8; 1 drop) GBS study. During testing sessions, participants reported to the laboratory following an overnight fast and rested in a supine position for 15 min. Thereafter, baseline measurements for resting heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), brachial artery diameter (BAD) and blood flow (BBF) were obtained (PRE). Participants then consumed either their respective GBS dose or a similar placebo dose (microcrystalline cellulose) in a supine resting state. HR, SBP, DBP, BAD and BBF were measured 45 min after placebo or GBS ingestion (PRE2). Participants were then placed in a recumbent position and performed 4 sets of 10 arm curl repetitions using an 11 kg dumbbell. Participants returned to a supine position and HR, SBP, DBP, BAD and BBF were obtained within the first 3 min following exercise (POST), 15 min after exercise (15POST), and 45 min after exercise (45POST). Participants returned to the laboratory 24-48 h later to repeat the same protocol with either GBS or the placebo depending on randomization. Two-way (supplement x time) repeated measures ANOVAs were used to compare dependent variables between testing sessions for Study 1 (300 mg of GBS and placebo) and Study 2 (600 mg of GBS and placebo), and statistical significance was set at p < 0.05. No statistical comparisons were made between studies.

RESULTS

As expected, exercise increased BAD and BBF compared to resting baseline measured irrespective of supplementation. In addition, BAD and BBF did not differ between GBS and placebo at any time point after exercise in Study 1. In study 2, however, 600 mg GBS increased baseline-normalized BBF at immediately post exercise compared to placebo (placebo = 211 ± 155% increase, GBS = 349 ± 156% increase; p = 0.012) but not BAD.

CONCLUSIONS

These data suggest a higher dose of GBS can enhance localized blood flow acutely following a resistance exercise bout. However, the long-term implications of these data are unclear, and more well-powered studies are needed to validate efficacy and elucidate potential mechanisms.

Could intramuscular storage of dietary nitrate contribute to its ergogenic effect? A mini-review

Extensive research performed over the past 10 years has resulted in dietary nitrate being considered a nutritional supplement that can improve exercise performance. However, there is still limited insight in the metabolic fate of dietary nitrate following the appearance of nitrate and nitrite in the circulation. Recent observations in humans suggest the storage of nitrate in skeletal muscle tissue. This short review discusses the possibility of nitrate being stored and utilized in human skeletal muscle tissue, and why confirming this may increase our understanding of how the nitrate-nitrite-NO pathway improves exercise performance. Further insight in skeletal muscle nitrate storage and metabolism may provide answers to current gaps in knowledge, such as the ergogenic benefit of acute vs multiday dietary nitrate supplementation, as well as the suggested muscle fiber-type specific effects on exercise performance. In this mini-review, specific questions that need further exploration are also discussed.

Influence of Equimolar Doses of Beetroot Juice and Sodium Nitrate on Time Trial Performance in Handcycling

This study aimed to investigate the influence of a single dose of either beetroot juice (BR) or sodium nitrate (NIT) on performance in a 10 km handcycling time trial (TT) in able-bodied individuals and paracyclists. In total, 14 able-bodied individuals [mean ± SD; age: 28 ± 7 years, height: 183 ± 5 cm, body mass (BM): 82 ± 9 kg, peak oxygen consumption (VO_2peak): 33.9 ± 4.2 mL/min/kg] and eight paracyclists (age: 40 ± 11 years, height: 176 ± 9cm, BM: 65 ± 9 kg, VO_2peak: 38.6 ± 10.5 mL/min/kg) participated in the study. All participants had to perform three TT on different days, receiving either 6 mmol nitrate as BR or NIT or water as a placebo. Time-to-complete the TT, power output (PO), as well as oxygen uptake (VO₂) were measured. No significant differences in time-to-complete the TT were found between the three interventions in able-bodied individuals (p = 0.80) or in paracyclists (p = 0.61). Furthermore, VO₂ was not significantly changed after the ingestion of BR or NIT in either group (p < 0.05). The PO to VO₂ ratio was significantly higher in some kilometers of the TT in able-bodied individuals (p < 0.05). The ingestion of BR or NIT did not increase handcycling performance in able-bodied individuals or in paracyclists.

Chronic high-dose beetroot juice supplementation improves time trial performance of well-trained cyclists in normoxia and hypoxia

Dietary nitrate (NO₃^-) supplementation via beetroot juice (BR) is known to improve endurance performance in untrained and moderately trained individuals. However, conflicting results exist in well-trained individuals. Evidence suggests that the effects of NO₃^- are augmented during conditions of reduced oxygen availability (e.g., hypoxia), thereby increasing the probability of performance improvements for well-trained athletes in hypoxia vs. normoxia. This randomized, double-blinded, counterbalanced-crossover study examined the effects of 7 days of BR supplementation with 12.4 mmol NO₃^- per day on 10-km cycling time trial (TT) performance in 12 well-trained cyclists in normoxia (N) and normobaric hypoxia (H). Linear mixed models for repeated measures revealed increases in plasma NO₃^- and NO₂^- after supplementation with BR (both p < 0.001). Further, TT performance increased with BR supplementation (∼1.6%, p < 0.05), with no difference between normoxia and hypoxia (p = 0.92). For respiratory variables there were significant effects of supplementation on VO₂ (p < 0.05) and VE (p < 0.05) such that average VO₂ and VE during the TT increased with BR, with no difference between normoxia and hypoxia (p ≥ 0.86). We found no effect of supplementation on heart rate, oxygen saturation or muscle oxygenation during the TT. Our results provide new evidence that chronic high-dose NO₃^- supplementation improves cycling performance of well-trained cyclists in both normoxia and hypoxia.

Short-Term Effects of a Ready-to-Drink Pre-Workout Beverage on Exercise Performance and Recovery

In a double-blind, randomized and crossover manner, 25 resistance-trained participants ingested a placebo (PLA) beverage containing 12 g of dextrose and a beverage (RTD) containing caffeine (200 mg), β-alanine (2.1 g), arginine nitrate (1.3 g), niacin (65 mg), folic acid (325 mcg), and Vitamin B12 (45 mcg) for 7-days, separated by a 7-10-day. On day 1 and 6, participants donated a fasting blood sample and completed a side-effects questionnaire (SEQ), hemodynamic challenge test, 1-RM and muscular endurance tests (3 × 10 repetitions at 70% of 1-RM with the last set to failure on the bench press (BP) and leg press (LP)) followed by ingesting the assigned beverage. After 15 min, participants repeated the hemodynamic test, 1-RM tests, and performed a repetition to fatigue (RtF) test at 70% of 1-RM, followed by completing the SEQ. On day 2 and 7, participants donated a fasting blood sample, completed the SEQ, ingested the assigned beverage, rested 30 min, and performed a 4 km cycling time-trial (TT). Data were analyzed by univariate, multivariate, and repeated measures general linear models (GLM), adjusted for gender and relative caffeine intake. Data are presented as mean change (95% CI). An overall multivariate time × treatment interaction was observed on strength performance variables (p = 0.01). Acute RTD ingestion better maintained LP 1-RM (PLA: -0.285 (-0.49, -0.08); RTD: 0.23 (-0.50, 0.18) kg/kg_FFM, p = 0.30); increased LP RtF (PLA: -2.60 (-6.8, 1.6); RTD: 4.00 (-0.2, 8.2) repetitions, p = 0.031); increased BP lifting volume (PLA: 0.001 (-0.13, 0.16); RTD: 0.03 (0.02, 0.04) kg/kg_FFM, p = 0.007); and, increased total lifting volume (PLA: -13.12 (-36.9, 10.5); RTD: 21.06 (-2.7, 44.8) kg/kg_FFM, p = 0.046). Short-term RTD ingestion maintained baseline LP 1-RM (PLA: -0.412 (-0.08, -0.07); RTD: 0.16 (-0.50, 0.18) kg/kg_FFM, p = 0.30); LP RtF (PLA: 0.12 (-3.0, 3.2); RTD: 3.6 (0.5, 6.7) repetitions, p = 0.116); and, LP lifting volume (PLA: 3.64 (-8.8, 16.1); RTD: 16.25 (3.8, 28.7) kg/kg_FFM, p = 0.157) to a greater degree than PLA. No significant differences were observed between treatments in cycling TT performance, hemodynamic assessment, fasting blood panels, or self-reported side effects.