International Journal of Sport Nutrition and Exercise Metabolism, 2018, 28, 188-199

https://doi.org/10.1123/ijsnem.2017-0340
© 2018 Human Kinetics, Inc. SCHOLARLY REVIEW

Dietary Supplements for Health, Adaptation, and Recovery

in Athletes
Eric S. Rawson
Messiah College

Mary P. Miles
Montana State University

D. Enette Larson-Meyer
University of Wyoming

Some dietary supplements are recommended to athletes based on data that supports improved exercise performance. Other
dietary supplements are not ergogenic per se, but may improve health, adaptation to exercise, or recovery from injury, and so
could help athletes to train and/or compete more effectively. In this review, we describe several dietary supplements that may
improve health, exercise adaptation, or recovery. Creatine monohydrate may improve recovery from and adaptation to intense
training, recovery from periods of injury with extreme inactivity, cognitive processing, and reduce severity of or enhance
recovery from mild traumatic brain injury (mTBI). Omega 3-fatty acid supplementation may also reduce severity of or enhance
recovery from mTBI. Replenishment of vitamin D insufficiency or deficiency will likely improve some aspects of immune, bone,
and muscle health. Probiotic supplementation can reduce the incidence, duration, and severity of upper respiratory tract infection,
which may indirectly improve training or competitive performance. Preliminary data show that gelatin and/or collagen may
improve connective tissue health. Some anti-inflammatory supplements, such as curcumin or tart cherry juice, may reduce
inflammation and possibly delayed onset muscle soreness (DOMS). Beta-hydroxy beta-methylbutyrate (HMB) does not
consistently increase strength and/or lean mass or reduce markers of muscle damage, but more research on recovery from
injury that includes periods of extreme inactivity is needed. Several dietary supplements, including creatine monohydrate, omega
3-fatty acids, vitamin D, probiotics, gelatin, and curcumin/tart cherry juice could help athletes train and/or compete more
effectively.

Keywords: creatine, curcumin, gelatin, HMB, omega 3 fatty acids, probiotics, tart cherry juice, vitamin D

Several dietary supplements, including carbohydrate, caffeine, beta-hydroxy beta-methylbutyrate (HMB), omega-3 fatty acids,
creatine monohydrate, nitrate, beta-alanine, and sodium bicarbon- vitamin D, probiotics, gelatin, and anti-inflammatory supplements
ate, are well-established performance enhancers (see Peeling et al., such as curcumin or tart cherry juice. The potential benefits of these
2018). Additionally, the beneficial effects of protein on the adap- dietary supplements are summarized in Table 1.
tive response to exercise has been well studied (see Hector &
Phillips, 2018). Further, some supplements, such as caffeine and
carbohydrate, may augment both muscle and brain performance Creatine Monohydrate
(see Peeling et al., 2018). There is also research indicating that
Muscular Adaptations
some other dietary supplements may be valuable in enhancing
muscular adaptations to exercise, improving brain performance, The ingestion of the dietary supplement creatine monohydrate
decreasing delayed onset muscle soreness or pain, reducing injury (about 20 g/day for 5 days) increases muscle creatine by about
severity, enhancing recovery from injury, reducing gastrointestinal 20% (Harris et al., 1992; Hultman et al., 1996). Subsequently, the
problems, and decreasing respiratory tract infection illness load. performance of sports and exercises that rely heavily on creatine
For the most part, these effects are not ergogenic, but may help ath- and phosphorylcreatine to resynthesize adenosine triphosphate
letes to train and/or compete more effectively without performance (ATP) (e.g., <30 s, intense, repeated bouts) can be improved
impediments. These supplements include creatine monohydrate, (reviewed in Branch, 2003; Gualano et al., 2012; Rawson &
Volek, 2003). In addition to the well-established performance-
enhancing effects, creatine monohydrate also works through
Rawson is with the Department of Health, Nutrition, and Exercise Science, Messiah
College, Mechanicsburg, PA. Miles is with the Department of Health and Human
multiple mechanisms to enhance muscle recovery from intense
Development, Montana State University, Bozeman, MT. Larson-Meyer is with the exercise (reviewed in Heaton et al., 2017).
Nutrition & Exercise Laboratory, Department of Family and Consumer Sciences, Muscle phosphorylcreatine and glycogen can be depleted
University of Wyoming, Laramie, WY. Address author correspondence to Eric S. following intense exercise, but creatine supplementation can
Rawson at [email protected]. enhance replenishment of these fuel sources. Faster postexercise
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Table 1 Dietary Supplements for Health, Adaptation, and Recovery in Athletes
Dysfunction
With Potential Benefits of
Supplement/Nutrient Deficiency Deficiency Supplementation Comments
Creatine monohydrate: Low dietary No adverse Increased lean mass/strength; Well studied. Excellent safety profile.
Creatine is a naturally creatine intake clinical or enhanced recovery from intense A small increase in body mass is
occurring nutrient, consumed (e.g., vegan, performance exercise (faster PCr and glycogen common with supplementation. This
in the diet, and synthesized in vegetarian, or findings with resynthesis); enhanced adaptive may be relevant for sports with weight
the body. Recommended low meat eater) dietary-induced response to exercise via increased classes/restrictions or where increased
supplement dose is 20 g/day decreases deficiency. growth factor/gene expression, body mass may decrease performance.
for 5 days followed by 3 to muscle and increased intracellular water; Not known if improved cognitive
5 g/day to increase and blood muscle reduced symptoms of or enhanced processing translates into improved
maintain elevated body creatine recovery from muscle damaging athletic performance.
creatine levels (Harris et al., concentrations. exercise (e.g., DOMS); enhanced
1992; Hultman et al., 1996). recovery from disuse, immobili-
zation, or extreme inactivity such
as after injury; improved cognitive
processing; decreased risk/
enhanced recovery from mTBI.
Beta-hydroxy Beta- N/A/ N/A Enhanced lean mass, strength, Cannot be confidently recommended
methylbutyrate (HMB): and adaptation to exercise via to athletes. Effects may be no more
HMB is a metabolite of the decreased muscle protein effective than adhering to the current
amino acid leucine. breakdown; reduced symptoms protein intake recommendations. May
Manufacturer recommended of or enhanced recovery from prove useful in rehabilitation where
dosage is 3 g/day (Rowlands muscle damaging exercise there may be periods of extreme
& Thomson, 2009; Sanchez- (e.g., decreased DOMS). inactivity, but few data are available.
Martinez et al., 2017).
Vitamin D: An essential Insufficiency/ Blunted adapted Improved adaptive response to RDA 600 IU/d; identify deficiencies
fat-soluble vitamin. Skin deficiency has to response to exercise; decreased incidence, through blood work, consult with a
exposure to sunlight accounts been identified exercise likely; duration, and severity of URTI; physician and sport nutritionist, and
for 90% of the source of in athletes from increased URTI; decreased stress fractures. take corrective actions in insufficient/
vitamin D. recreational increased injury, deficient athletes with changes in
through stress fractures. lifestyle, food intake, and possibly
professional supplementation; indiscriminate
levels vitamin D supplementation for athletes
especially, but is not advised; compensatory response
not exclusively, to high-dose supplementation possible
when access to (e.g., decreased PTH), but not well
sunlight is studied.
limited
Omega 3-fatty acids: Dose Not described Not described Improved cognitive processing; Not known if improved cognitive
most commonly studied is in athletes. in athletes. decreased risk/enhanced recovery processing translates into improved
about 2 g/day (Jeromson from mTBI; reduced symptoms athletic performance; few data on
et al., 2015; Mickleborough, of or enhanced recovery from mTBI, but animal data and two case
2013). muscle damaging exercise studies show that the structural damage
(e.g., DOMS). and cognitive decline associated with
mTBI are reduced/attenuated with
omega-3 fatty acid; benefits to muscle
damage are not a consistent finding; low
risk but unclear if supplementation
should be pursued by athletes, in lieu of
including fatty fish in the diet as a
source of omega-3 fatty acids.
Probiotics: Effective dosing N/A N/A Decreased severity or duration Modest benefits to athletes prone to
regimens of 109 to 4 × 1010 of gastrointestinal problems; GIT problems or traveling to regions in
CFU for 4 to 21 weeks in decreased incidence, duration, which GIT problems are more likely;
duration (Pyne et al., 2015). and severity of URTI. most studies report reduced incidence,
duration, and severity of URTI in
athlete; many different probiotic
supplements have been studied, so
specific recommendations and
conclusions are difficult to ascertain;
supplementation needs to begin well
ahead of competition.
(continued)

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190 Rawson, Miles, and Larson-Meyer

Table 1 (continued)
Dysfunction
With Potential Benefits of
Supplement/Nutrient Deficiency Deficiency Supplementation Comments
Gelatin and vitamin C/ N/A N/A Increased collagen production, Gelatin and collagen supplements
collagen: Recommended thickened cartilage, decreased appear to be low risk; few data are
dose of gelatin is 5 to 15 g knee pain. available; functional benefits, recovery
gelatin w/50 mg vitamin C from injury, and effects in elite athletes
(Shaw et al., 2017). are not known.
Collagen hydrolysate dose is
about 10 g/day (Clark et al.,
2008; McAlindon et al.,
2011).
Anti-inflammatory N/A N/A Anti-inflammatory effects; Reduced DOMS may be important in
supplements: Curcumin is a reduced symptoms of or enhanced sports where soreness might impair
constituent of the spice recovery from muscle damaging performance in a subsequent bout of
turmeric, and supplements exercise (e.g., decreased DOMS). exercise; benefits may be sport/training
are often ingested at a dose specific; more research needs to be
of about 5 g/day (McFarlin conducted before these compounds
et al., 2016; Nicol et al., could be recommended to athletes.
2015).
Tart cherry juice is ingested
at a dose of about 8 to 12 oz.
(1 oz. if concentrate) twice/
day for 4 to 5 days before an
athletic event or for 2 to
3 days afterwards to promote
recovery (Bell et al., 2014,
Coelho Rabello Lima et al.,
2015).
Abbreviations: CFU = colony forming units; DOMS = delayed onset muscle soreness; GIT = gastrointestinal tract; mTBI = mild traumatic brain injury; PCr = phosphoryl-
creatine; PTH = parathyroid hormone; RDA = recommended dietary allowance; URTI = upper respiratory tract illness.

phosphorylcreatine resynthesis may improve recovery from an cell survival (Safdar et al., 2008). Some of these effects may be
acute bout of sprint type exercise, or during repeated bouts of modulated by increased intramuscular water (Deminice et al.,
sprints, which mimics the stop and go, intermittent nature of many 2016), which can inhibit protein breakdown and RNA degrada-
sports. Consequently, this could improve exercise performance in tion, and stimulate protein, DNA, and RNA synthesis (Berneis
subsequent bout(s) a few minutes later (Greenhaff et al., 1994; et al., 1999; Häussinger et al., 1993).
Yquel et al., 2002). Also, simultaneous creatine and carbohydrate Rawson et al. (2017) recently reviewed the effects of creatine
loading further increases glycogen resynthesis (12%) (Nelson et al., monohydrate supplementation on markers of exercise-induced
2001), with 82% of this increase occurring during the first 24 hr muscle damage and found that of 15 studies, eight reported no
(Roberts et al., 2016) (reviewed in Volek & Rawson, 2004). This effect (positive or negative), while seven showed favorable out-
could enhance the performance of a subsequent bout of exercise comes following stressful exercise. Beneficial effects were noted in
occurring hours or days later. the form of decreased postexercise muscle serum proteins (e.g.,
It is unlikely that creatine improves the adaptive response to creatine kinase [CK] and lactate dehydrogenase [LDH]), improved
exercise through direct effects on muscle protein synthesis (MPS) postexercise recovery of strength/force, attenuated postexercise
or muscle protein breakdown (MPB) (Louis, Poortmans, Francaux, increase in delayed onset muscle soreness (DOMS) or decrease
Berre et al., 2003; Louis, Poortmans, Francaux, Hultman et al., in range of motion, and decreased postexercise inflammatory
2003), although one group found that creatine decreased plasma markers (e.g., prostaglandin-E2 [PGE2], tumor necrosis factor-α
leucine rate of appearance and leucine oxidation (Parise et al., [TNF-α], interferon-α [INF-α], interleukin-1-β [IL1-β], c-reactive
2001). However, it appears that creatine could enhance the adap- protein [CRP]). These benefits, which were noted across various
tive response by modulating increased expression of growth resistance and endurance exercise challenges, indicate creatine may
factors (e.g., myogenin, MRF-4, insulin-like growth factor I play a role in reducing muscle damage and inflammation.
and II [IGF-I and IGF-II]; Burke et al., 2008; Deldicque et al.,
2005; Willoughby & Rosene, 2001, 2003). Further, creatine Recovery from Disuse/Immobilization
supplementation plus resistance training increases satellite cell
number and myonuclei concentration more than resistance train- Along with decreases in muscle mass and function, muscle creatine
ing alone (Olsen et al., 2006). Increasing muscle creatine content decreases as much as 24% during periods of extreme inactivity,
through supplementation increases expression of multiple genes such as during immobilization (MacDougall, Ward, Sale, & Sutton,
associated with adaptive processes, including: osmosensing, cyto- 1977). Consequently, maintaining or increasing muscle creatine
skeleton remodeling, GLUT4 translocation, glycogen and protein with supplementation during periods of inactivity or recovery
synthesis, satellite cell proliferation and differentiation, DNA from injury may prove advantageous. Seven studies of the effects
replication and repair, mRNA processing and transcription, and of creatine supplementation during immobilization have been
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 Supplements for Health, Adaptation, and Recovery 191

published, with some positive findings, including: (a) better main- β-Hydroxy β-Methylbutyrate (HMB)
tenance of muscle mass/cross sectional area, strength, and muscle
endurance; (b) maintenance of or increase in muscle creatine; HMB is ingested in the diet and is a metabolite of leucine.
(c) maintenance of or increased GLUT4; (d) increased muscle Animal research indicates that HMB can increase body mass in
glycogen; and (e) increased growth factor (MRF4) expression slaughter animals (reviewed in Szczesniak et al., 2015). As a
(Derave et al., 2003; Fransen et al., 2015; Hespel et al., 2001; supplement for humans, HMB is marketed as an anticatabolic
Johnston et al., 2009; Op ‘t Eijnde et al., 2001). These studies are nutrient that decreases protein breakdown; a dose of about 3 g/
difficult to compare as they had different outcomes, were of day has been recommended. Potential mechanisms underlying
different durations (1–10 weeks), investigated different limbs anticatabolic effects include decreased protein breakdown
(arm vs. leg), and some were exercise training studies. Although through reduced expression of components of the ubiquitin
positive effects were not found in every outcome of each study proteasome pathway, increased protein synthesis through phos-
(Backx et al., 2017; Eijnde et al., 2005), it appears that creatine phorylation of mammalian target rapamycin (mTOR) substrates
supplements may play a role in recovery from disuse. and phosphorylation of eukaryotic initiation factor (eIF2),
increased cholesterol synthesis, increased growth hormone
and IGF I mRNA, increased proliferation and differentiation
Brain of satellite cells, and inhibited apoptosis (reviewed in Szczesniak
A small amount of creatine is manufactured and stored in the brain et al., 2015). However, these potential benefits may be just as
where it is used for ATP production. Brain creatine can be easily obtained with ingestion of leucine or whey protein, which
increased with creatine supplementation (about 10%), and this increase muscle protein synthesis and anabolic signaling
increase may lead to improvements in cognitive processing (re- (Wilkinson et al., 2013).
viewed in Gualano et al., 2016; Rae & Broer, 2015; Rawson & If HMB is anticatabolic, it could improve training adaptations
Venezia, 2011). Most studies demonstrate an improvement in by decreasing muscle damage or protein breakdown. The effects of
cognitive processing following creatine supplementation, but these HMB supplementation on markers of muscle damage and resis-
studies are difficult to compare due to differences in supplementa- tance training adaptations in lean mass and strength have been well
tion protocols (dose: 2.5 to 20 g/day; duration: days to weeks), reviewed (Fitschen, Wilson, Wilson, & Wilund, 2013; Molfino,
populations (old vs. young; vegan vs. meat-eaters), subject state Gioia, Rossi Fanelli, & Muscaritoli, 2013; Zanchi et al., 2011).
(e.g., rested vs. sleep deprived), and cognitive processing outcomes While early research and a meta-analysis concluded that HMB
(reviewed in Gualano et al., 2016; Rae & Broer, 2015; Rawson & supplementation both increased lean mass and decreased muscle
Venezia, 2011). Also, attempts to translate “improved cognitive damage (Nissen & Sharp, 2003; Nissen et al., 1996), these con-
processing” to athletes and athletic performance are few. One clusions have not stood the test of time. In two meta-analyses, it
group compared the effects of acute ingestion of creatine, caffeine, was concluded that HMB supplementation had inconsequential or
or placebo on a rugby skill passing test in 10 sleep-deprived pro- trivial effects on strength and fat free mass, especially in trained
fessional rugby backs (Cook et al., 2011). Both creatine and competitive athletes, and that effects on muscle damage (based on
caffeine attenuated the decrease in skill performance caused by blood creatine kinase levels) were unclear (Rowlands & Thomson,
the sleep deprivation, indicating a potential role for creatine in 2009; Sanchez-Martinez et al., 2017). Unfortunately, data on HMB
improving sport performance through the brain. supplementation are discrepant and difficult to interpret due to
clustering of data sources (i.e., positive studies from the same/
similar labs) and reliance on nonspecific markers of muscle damage
Concussion (Mild Traumatic Brain Injury) (e.g., creatine kinase) (Decombaz et al., 2003). Additionally, in
Following a mTBI, brain creatine decreases (Vagnozzi et al., 2013) some instances, potential conflicts of interest were not fully dis-
and there is a hypometabolic state. These challenges to energy closed (Editor, 2003).
status could be mitigated through creatine supplementation The recent publication of several studies on HMB-free acid
(Barrett et al., 2014; Dean et al., 2017). Additionally, multiple (HMB-FA) supplementation where implausible anabolic drug-
other changes, including membrane disruption, calcium influx, like gains in strength, power, and fat free mass, and reductions in
nerve damage, mitochondrial dysfunction, oxidative stress, and muscle damage were reported (Lowery et al., 2016; Wilson et al.,
inflammation, that could make the brain vulnerable to further 2013; Wilson et al., 2014) has further complicated interpretation
injury, could potentially be offset with creatine supplementation of the HMB literature. These findings have been challenged by
(Barrett et al., 2014; Dean et al., 2017). Animal data indicate that other researchers (Gentles & Phillips, 2017; Phillips et al., 2017),
creatine supplementation, prior to traumatic brain injury, can de- but, at this time, the authors have not responded. HMB appears to
crease damage up to 50% (Sullivan et al., 2000). Indirectly, the have some biologic activity in humans that may aid in muscular
potential benefits of creatine supplementation on mTBI are sup- adaptations from exercise, but it is doubtful that effects are as
ported by the data of Turner et al. (2015), who showed improved powerful as some studies have shown. Perhaps, HMB (reviewed
cognitive processing in humans during oxygen deprivation, which in Wu et al., 2015), like creatine monohydrate (reviewed in
mirrors some of the effects of mTBI. Data on creatine supplemen- Gualano et al., 2012; Gualano et al., 2016), is of benefit for
tation and mTBI are limited to two open-label trials in children, but patient populations or sarcopenic older adults. Unlike creatine
there were improvements in cognition, communication, self-care, monohydrate, HMB cannot be confidently recommended to
personality, and behavior, and decreased headaches, dizziness, and athletes, as the effects may not be more effective than adhering
fatigue (Sakellaris et al., 2006, 2008). The potential benefits of to the current protein intake recommendations. HMB may prove
creatine supplementation on reducing the severity of or enhancing useful in rehabilitation where there may be periods of extreme
recovery from mTBI need to be further studied, and although the inactivity, as Deutz and others (2013) showed better preservation
data are not conclusive, athletes ingesting creatine for muscular of lean mass in older adults ingesting HMB during 10 days of
benefits may receive benefits to the brain as well. bed rest.
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192 Rawson, Miles, and Larson-Meyer

Omega-3 Fatty Acids ultraviolet B (UVB) rays in sunlight (Hossein-nezhad & Holick,
2013). Synthesis of vitamin D in skin cells, however, is dependent
Omega-3 polyunsaturated fatty acids are essential fatty acids that on factors including time of day of exposure, season, latitude, cloud
are consumed in the diet and concentrated in foods such as cover, smog, skin pigmentation, skin area exposed, sunscreen
cold-water fatty fish and fish oils. Fish oil and, in particular, coverage, and age. Cutaneous vitamin D is not synthesized during
eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), the winter at latitudes greater than ∼33° north or south because
supplements have been studied for their effects on brain and insufficient UVB photons reach the earth’s surface during these
cardiovascular health, muscular performance, and recovery from months (Hossein-nezhad & Holick, 2013).
injury (reviewed in Barrett et al., 2014; Erdman et al., 2011; Although there is disagreement over appropriate cut points
Jeromson et al., 2015; Mickleborough, 2013; Tipton, 2015). of serum concentrations of 25-hydroxyvitamin D (the marker of
EPA and DHA are important cell membrane components in brain vitamin D status), commonly used cut points define deficient as
and muscle, and it is possible that altering the lipid content of a serum 25 hydroxyvitamin D of <50 nmol/L, insufficient as
the membrane through dietary consumption of omega-3 fatty acids <75 nmol/L, sufficient as >75 nmol/L, and optimal as 100 to
can alter membrane function. Cognitive improvements following 250 nmol/L (Larson-Meyer, 2015). Using these or similar cut
DHA/EPA supplementation have been noted in several studies points, it appears that many athletes are insufficient or deficient
with populations ranging from healthy older adults, to those with at various times of the year (Halliday et al., 2011; Larson-Meyer,
mild cognitive impairment, to Alzheimer’s patients (reviewed in 2015), including those who live in sunny environments close to the
Barrett et al., 2014). It is not known if omega-3 fatty acid equator (Hamilton et al., 2010). Some data on elite and professional
supplementation would improve cognitive processing in elite athletes also show a high percentage of deficiency and insufficiency
athletes, or how/if this would translate into improved athletic (Allison, Close et al., 2015; Allison, Farooq et al., 2015; Close,
performance. Results from animal studies strongly suggest that Leckey et al., 2013; Close, Russell et al., 2013; Fishman et al.,
omega-3 fatty acid supplementation before or after mTBI reduces 2016; Maroon et al., 2015; Morton et al., 2012; Owens et al., 2017).
structural damage and subsequently attenuates the expected de- The data on the effects of vitamin D supplementation on
cline in cognitive function (reviewed in Barrett et al., 2014; muscle function have been described as equivocal, with discre-
Erdman et al., 2011; Tipton, 2015). With the exception of two pancies in research in part caused by differences in baseline
case studies, which showed improvements from supplementation 25-hydroxyvitamin D concentrations prior to supplementation
(Lewis et al., 2013; Roberts et al., 2016), it is not known how (Close et al., 2016). For example, Close, Russell, et al. (2013)
these data translate to humans, but large, double-blind, placebo- showed improved sprint time and vertical jump height following
controlled trials are currently underway (clinicaltrials.gov vitamin D supplementation in deficient athletes, but a separate
NCT101903525, NCT01814527). study showed no effect of supplementation on strength (Owens
Omega-3 fatty acid supplementation can increase MPS in et al., 2014). Owens and colleagues (2015) recently demonstrated
response to hyperaminoacidemia or hyperinsulinemia (Smith et al., that vitamin D supplementation (6 weeks; 4,000 IU/day) improved
2011a, 2011b), although this increase may not occur in the presence recovery of posteccentric exercise peak torque in vitamin D insuf-
of recommended postexercise protein intake (30 g) (McGlory et al., ficient men and increased in vitro myotube hypertrophy. These data
2016). Recently, Gravina et al. (2017) showed improved perfor- strongly suggest a role for adequate vitamin D in the adaptive
mance on the YO-YO test of anaerobic endurance, but no increase process to intense exercise. Whether vitamin D supplementation is
in strength, speed, or power in soccer players following 4 weeks of necessary for adequate adaptive effects likely depends on the
omega-3 fatty acid consumption, indicating minimal functional athletes’ vitamin D status at the initiation of supplementation.
benefits. Omega-3 fatty acids have anti-inflammatory properties and In addition to muscle function, vitamin D supplementation
so could play a role in recovery from intense exercise, particularly may also be important for reducing risk of upper respiratory tract
if there is a large eccentric component. This concept is supported infections and stress fractures. These factors compromise an
by studies where eccentric-exercise-induced DOMS was reduced athlete’s ability to train and compete. Studies in athletes (Cox et al.,
following supplementation (Jouris et al., 2011), but this has not 2008; He, Aw Yong, Walsh, & Gleeson, 2016), military personnel
been shown in every case (Gray et al., 2014). (Laaksi et al., 2007), and the general population (Berry et al., 2011;
Concerns of fish oil or omega-3 fatty acid consumption Ginde et al., 2009; Sabetta et al., 2010) have reported negative
would include heavy metal contaminants, bleeding, digestive associations between vitamin D status and incidences of upper
problems, and increased low density lipoprotein (reviewed in respiratory tract illness (URTI). One study in college athletes found
Erdman et al., 2011; Mickleborough, 2013). Additionally, since that serum 25(OH)D concentrations over the winter and spring
there are not sufficient data to indicate that decreased dietary or were negatively associated with documented frequency of acute
body levels of omega-3 fatty acids cause functional impairments, it URTI (Halliday et al., 2011). The breakpoint for contracting a
is unclear if supplementation should be pursued by athletes, instead single episode occurred at ∼95 nmol/l such that all athletes with
of including fatty fish in the diet as a source of omega-3 fatty acids. concentrations lower than this breakpoint experienced one or more
episodes of illness, whereas those with higher concentrations had
Vitamin D one or fewer episodes. A similar study in endurance athletes
reported that a greater proportion of athletes who maintained serum
Although vitamin D is most associated with bone health, the 25(OH)D concentrations of <30 nmol/L presented with URTI
presence of vitamin D receptors throughout the body, including symptoms over this time point. The fewest symptoms were re-
in skeletal muscle, indicate a role in other tissues. The recom- ported in those with 25(OH)D concentrations >120 nmol/L (He,
mended daily allowance (RDA) for vitamin D in the United States Handzlik, et al., 2013). Athletes with low vitamin D concentrations
and Canada is 600 IU/day, but vitamin D is also synthesized also experienced a higher number of days with upper respira-
endogenously. In fact, required amounts of vitamin D can be tory symptoms and higher symptom-severity scores. Although
obtained entirely from synthesis in the skin via exposure to the additional studies are needed to confirm the effectiveness of
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correcting low vitamin D concentrations through supplementation, typically fall within the range of 109 to 4 × 1010 CFU for 4 to
a recent randomized, placebo-controlled study in university ath- 21 weeks in duration (Pyne et al., 2015). The convention for
letes found that 14-weeks of supplementation with 5,000 IU per naming bacteria is Species strain (e.g., Lactobacillus rhamnosus
day of vitamin D3 during winter training significantly increased [L. rhamnosus]). A variety of strains within the Lactobacillus,
salivary secretion rates of immune factors, namely cathelicidin and Bifidobacterium, and, less frequently, the Streptococcus species are
secretory immunoglobulin A (He, Fraser, et al., 2016). Concerning used as probiotics. These bacteria are Gram-positive (do not
stress fractures, a study in Finnish military recruits found that stress contain endotoxin).
fracture risk was 3.6 times higher in those with low vitamin D status Strenuous and prolonged exercise place stresses on the GIT
(serum 25[OH]D concentrations <12 nmol/L) (Ruohola et al., that increase the likelihood of discomfort, abdominal cramping,
2006). Further, a randomized, double-blind trial in US female acid reflux (heartburn), nausea, vomiting, diarrhea, and leakiness of
naval recruits found that supplementation (800 IU of vitamin D3 the gut that may allow endotoxemia to occur (de Oliveira et al.,
plus 2,000 mg calcium/day) reduced stress fracture incidence by 2014). Splanchnic hypoperfusion leading to ischemia in the gut is
20% (Lappe et al., 2008). Again, while additional studies are accepted as a principle cause, with additional contributions from
needed, vitamin D supplementation may have an impact on nutritional, mechanical (e.g., jarring), and genetic influences that
reducing stress fracture risk. make some individuals more susceptible than others (de Oliveira
Based on the number of deficient athletes, it seems that sup- et al., 2014). Probiotic support to increase resilience of the GIT
plementation is warranted in many athletes. Ideally, the supple- against ischemia is of interest to athletes, particularly for those in
mental dose should be dependent on current status, but some prolonged endurance events that have the greatest occurrence of
experts recommend upwards of 2,000 IU of vitamin D3/day GIT problems that impair or stop performance. The proposed
(Holick et al., 2011). Owens and colleagues (2017) reported that mechanism by which probiotics prevent GIT problems stemming
elite athletes given high doses of vitamin D (12 weeks; 35,000 or from ischemia are related to improvement in the mucosal and
70,000 IU/week) increased serum 25-hydroxyvitamin D, but also epithelial barriers preventing a ‘leaky gut’ and in production of
decreased parathyroid hormone (PTH), indicating compensatory anti-inflammatory mediators. Probiotics do not eliminate hypoper-
changes. Thus, it is prudent to first identify deficiencies through fusion of the GIT, thus moderate reduction in severity and duration
blood work (see Larson-Meyer et al., 2018), then consult with a of gastrointestinal symptoms and exercise-induced endotoxemia
physician and/or sport nutritionist, and finally take corrective are the best outcomes that might be expected in clinical trials.
actions in insufficient/deficient athletes with changes in lifestyle To this end, a number of clinical trials have measured small to
and supplementation as needed. More research on the conse- moderate decreases in severity or duration of gastrointestinal
quences of high-dose, longer-term vitamin D supplementation is problems attributed to use of L. rhamnosus, L. fermentum, and
encouraged, but indiscriminate high-dose vitamin D supplementa- two different multi-strain probiotics (Haywood et al., 2014;
tion for athletes is not advised. Kekkonen et al., 2007; Shing et al., 2014; West et al., 2011).
However, in the L. fermentum trial, benefits were lower in female
Probiotics participants, and the decrease in severity was accompanied by a
two-fold greater increase in the number of and duration of less-
Microbes in the gut influence gastrointestinal tract (GIT) functions, severe symptoms in male participants for the probiotic compared to
the immune system, and metabolite production in a variety of ways placebo group. The latter was proposed to be part of the adaptive
that exert influence on exercise. The GIT microbiome primarily response to probiotic colonization. Using a biomarker of gut
consists of a diverse array of bacterial species, each of which permeability, a supporting clinical trial demonstrated that multi-
interacts with the host in a unique way. This influence ranges from strain probiotic reduced leakiness of the GIT as an underlying cause
beneficial, to neutral, to pathogenic or opportunistic, and the net of GIT distress (Lamprecht et al., 2012). Upon reviewing the
effect of the GIT microbiome is a function of the combined effects evidence, Pyne et al. (2015) reached the reasonable conclusion
of many different strains and their relative abundance. By defini- that athletes prone to GIT problems, or traveling to regions in
tion, probiotics are strains of bacteria that can maintain viability which GIT problems are more likely, may benefit modestly from
in supplement form for oral ingestion, survive the acidic gastric the above probiotics, but supplementation needs to begin well
environment, adhere and colonize in the GIT, antagonize patho- ahead of competitions and more research is needed before pro-
genic bacteria, and provide health benefit(s) to the host (athlete) biotics are recommended with confidence.
(West et al., 2009). There are dozens of bacterial strains used as Modulation of the immune system to increase defenses against
probiotics, particularly those that produce lactic acid, but each URTIs is the potential benefit of probiotics for athletes that has
strain is unique with respect to how it responds to and affects the been most extensively researched. As a major gateway for patho-
GIT milieu, the GIT, the immune system components within the gen entry, the GIT is heavily protected by the immune system.
GIT, and all downstream systems of the body. Thus, it is important Two-way communication between the immune system and the
to be specific about effects of each specific probiotic strain or GIT microbiome impacts immune defenses throughout the body.
combination of strains and not to generalize effects of one probiotic Probiotics have been shown to enhance innate immunity (first line
to all probiotics. Research regarding athletes has been undertaken of defense) by upregulating immunoglobulins, antimicrobial pro-
to evaluate the efficacy of probiotic supplementation to (a) prevent teins, phagocytic activity, and natural killer cell activity, and also
or relieve GIT problems during exercise, (b) reduce the impact of to enhance acquired immunity by improving antigen presentation
URTIs, and (c) improve endurance performance. and function of T and B lymphocytes to neutralize pathogens
While there is a variety of bacteria that have been used as and virally-infected cells (Bermon et al., 2015; Pyne et al., 2015).
probiotics in clinical studies in athletes, there is more consistency This is of particular importance to athletes because exercise may
in the dosage and duration generally needed to produce benefits. increase susceptibility to URTI by decreasing sIgA, decreasing
A single bacterium is a colony-forming unit (CFU) and dosages cell-mediated immunity by decreasing type 1 T lymphs to make
are expressed using this common terminology. Dosing regimens recurrent infections more likely, and glucocorticoid suppression of
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monocyte/macrophage antigen presentation and T lymphocytes resistance, high-force eccentric, running, and cycling exercise
(Lancaster et al., 2004; Martin et al., 2009). (reviewed in Bell et al., 2014; Coelho Rabello Lima et al.,
The majority of placebo-controlled clinical trials assessing the 2015). There are concerns that blunting inflammation may impair
efficacy of probiotics for reducing incidence, duration, and severity the adaptive response to exercise training. However, at times, such
of URTI in athletes report beneficial outcomes, however, many as when there are multiple competitions in a brief period of time,
different probiotics have been used and the differences in trial faster recovery of strength or decreased soreness may be more
protocols and outcome measures complicates the drawing of more valued by the athlete than adaptation (Bell et al., 2014). Thus, it
specific conclusions. Pyne et al. (2015) have provided an excellent appears that curcumin and tart cherry juice may offer some benefits
summary of 15 clinical trials through 2014 in which 10 of 13 to athletes, although these benefits may be sport/training specific,
studies reported favorable changes in immune and inflammatory and more research needs to be conducted before they could be
markers, and six of seven studies reporting clinical outcomes for recommended to athletes.
URTI report decreased incidence, duration, and or severity with
probiotic supplementation. Trials published more recently follow a
similar pattern with decreased (∼half) incidence, duration (∼2 days
Summary
shorter), and severity (fewer symptoms) of URTI (Michalickova In this review, several dietary supplements are described that can
et al., 2016; Strasser et al., 2016). An additional trial was unable to potentially play a role in health, exercise adaptation, and/or recov-
distinguish placebo and probiotic treatments because of unexpect- ery for athletes. As summarized in Table 1, creatine monohydrate,
edly low incidence of URTI in both groups (Gleeson et al., 2016). vitamin D, omega 3-fatty acids, probiotics, gelatin/collagen, and
The different probiotic formulations used across these studies are certain anti-inflammatory supplements can influence cellular and
too numerous to list, so for the sake of brevity, we conclude here tissue health, resilience, and repair in ways that may help athletes
that there are many probiotics that may decrease the negative maintain health, adapt to exercise, and increase the quality and
impact on training or competition caused by URTI. quantity of their training. Creatine monohydrate could be recom-
More research is needed to establish whether probiotics im- mended for promoting recovery from, and muscular adaptations to,
prove performance. There is some evidence that lowering GIT intense training; recovery from periods of injury that result in
permeability may have contributed to a longer time to fatigue while extreme inactivity; cognitive processing; and reducing severity of
exercising in the heat (Shing et al., 2014). The only other study to or enhancing recovery from mTBI. Vitamin D insufficiency or
evaluate performance found no improvement in a short-duration, deficiency appears common, and the benefits of replenishment with
high-intensity exercise bout without heat stress with probiotic supplementation likely improve some aspects of muscle function.
compared to placebo treatment (Cox et al., 2008). However, athletes should seek a blood test and guidance from a
physician to confirm inadequate vitamin D status, and then guid-
ance from a nutrition professional regarding supplementation.
Gelatin and Collagen There are several potential benefits of Omega fat supplementation
Much of the research on nutrition and the adaptive response to on skeletal muscle, but more research needs to be conducted. Like
exercise focuses on dietary supplements that affect skeletal muscle creatine monohydrate, omega 3-fatty acid may reduce severity of or
tissue, MPS, and MPB. However, nutritional interventions that enhance recovery from mTBI. At this time, a recommendation for
could benefit connective tissue proteins would valuable as well fatty fish consumption, which would include increased intake of
(reviewed in Baar, 2017). Shaw et al. (2017) showed the combi- omega 3-fatty acids, protein, vitamins, and minerals, may be more
nation of exercise plus a gelatin/vitamin C supplement (15 g appropriate for athletes than a recommendation for fish oil sup-
gelatin plus 50 mg vitamin C) increased collagen production plementation. The majority of placebo-controlled clinical trials
in vitro, and amino terminal propeptide (PINP) in the blood. show that probiotic supplementation can reduce the incidence,
Collagen hydrolysate supplementation (about 10 g/day) has been duration, and severity of URTI in athletes. It is difficult to make
shown to thicken cartilage in osteoarthritis patients (McAlindon more specific recommendations, as many different probiotic sup-
et al., 2011), and decrease knee pain in athletes (Clark et al., 2008). plements were used in these studies. However, it is likely that there
These studies suggest a benefit of gelatin plus vitamin C and/or are several probiotic supplements that can improve training or
collagen supplementation, but data on functional benefits in elite competitive performance by decreasing the negative effects caused
by URTI and/or GIT problems. A small amount of literature exists
athletes, such as performance changes or recovery from injury,
that demonstrates a benefit of gelatin and/or collagen on connective
are not available.
tissue health. As adverse effects from gelatin/collagen supplements
appear low, at worst, these supplements are just an inexpensive
Anti-Inflammatory Supplements source of amino acids, so the benefits of supplementation outweigh
the risks. Anti-inflammatory supplements, such as curcumin and
A constituent of the spice turmeric, curcumin supplements are often tart cherry juice, show promise in their ability to reduce markers
ingested for anti-inflammatory effects at a dose of about 5 g/day. of muscle damage and/or inflammation. However, it is unknown
Potentially, these supplements could be used to decrease muscle if these effects can enhance recovery in elite athletes or affect
damage or DOMS in athletes. Some groups have noted reductions subsequent performance. HMB cannot be recommended at this
in DOMS, CK, and inflammatory cytokines (e.g., TNF-α, IL-8) time, but more research on recovery of muscle injury during
following eccentric contraction induced muscle damage (McFarlin periods of extreme inactivity is needed.
et al., 2016; Nicol et al., 2015). However, similar protective effects
of curcumin and reductions in inflammatory makers (e.g., no effect
Acknowledgments
on IL-6, IL-1, IL-10, or CRP) were not seen following endurance
exercise (Sciberras et al., 2015). Tart cherry juice has been shown Manuscript preparation and editing was undertaken by ESR, MPM, and
to decrease muscle damage and inflammatory markers following DELM. All authors approved the final version of the paper.
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 Supplements for Health, Adaptation, and Recovery 195

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