It is well established that carbohydrate drinks can enhance sport performance, however an athlete may not even need to drink the fluid to experience a benefit on performance. Sounds very strange right? Take a look at my write up below on my systematic review I carried out as part of my masters in Dietetics. I wanted to find out how a carbohydrate mouth rinse affected resistance training performance.
This is most likely going to be the most formal article I will write on the blog, However I wanted to keep it an acceptable reading time so it is not a complete overview, It is really just the key points...
Background of the intervention
Athletes and coaches are continuously searching for ways to enhance performance and improve recovery. This is often achieved with the use of ergogenic aids; techniques or substances that are used to enhance performance (Silver, 2001). This can include pharmacology, sports psychology, devices and of particular interest for this review, nutrition (Silver, 2001).
Carbohydrate mouth rinsing (CMR) to potentially enhance exercise performance was first observed in Carter et al. (2004) innovative study on cyclists. The positive effect on performance within this 60-minute laboratory-based time-trial led the researchers to believe that the mechanism in which carbohydrates generate an ergogenic effect in shorter duration exercise (<1h) is different to that of prolonged durations (>2h). Glycogen depletion significantly impairs performance (Noakes, 2000). Increasing carbohydrate (CHO) availability will spare liver glycogen and maintain the high CHO oxidation levels required to sustain high-intensity performance (Cermak and van Loon, 2013). CHO daily recommendations are considerably higher in athletes who participate in this longer duration activity. A review update by the international society of sports nutrition suggests up to 8-10g of CHOs/per kg of body weight per day when partaking in high-intensity exercise, 3-6 hours per day (Kerksick et al., 2018). Furthermore, for events lasting >2.5 hours, ingesting 60-70g CHO/hour, and up to 90g if tolerable on the digestion system have been proposed during activity (Burke et al., 2011). Research suggests that CHO can oxidise at 1-1.5g per minute in these conditions; therefore, intra-workout CHOs are essential for performance outcomes (Burke, Hawley, Wong and Jeukendrup 2011). Failure to meet CHO demands can result in increased fatigue, reduced work capacity and impaired concentration, all potentially deleterious to performance (Jeukendrup, Jentjens and Moseley, 2005; Getzin, Milner and Harkins, 2017). In contrast, within the first hour of exercise, CHO oxidation is estimated at 5-15g. This amount of CHO is likely to be insufficient for any meaningful enhancements in performance (Jeukendrup, Brouns, Wagenmakers and Saris, 1997). Therefore, in short duration activity, it has been proposed that a neurological mechanism is present. Authors such as Chambers, Bridge and Jones (2009), Devenney, Collins and Shortall (2016) and James, Ritchie, Rollo and James (2017) postulate that CHOs enhance activation of the cerebral structures. Magnetic resonance imaging showcases increased activity within the insula/frontal operculum, orbitofrontal cortex and striatum regions of the brain. These areas are associated with increased feelings of reward and motivation (Chambers, Bridge and Jones, 2009). Increases in situational motivation can enhance sporting performance (Gillet, Vallerand, Amoura and Baldes, 2010).
Carter et al. (2004) conducted the first investigation on CMR. The CMR protocol usually consists of a solution that has a CHO concentration of at least 6% rinsed around the oral cavity for 5-10 seconds before spitting out. The use of a mouth rinse treatment removes CHO oxidation as an influence on performance and instead initiates response through a central action via oral receptors within the mouth (Carter, Jeukendrup and Jones, 2004).
Several studies have shown positive effects in shorter duration (<1hr) exercise (Ataide-Silva et al., 2016; Bastos-Silva et al., 2016; Rollo, Williams and Nevill, 2011; Lane, Bird, Burke and Hawley, 2013; Baltazar-Martins and Del Coso, 2019) and in sprinting performance (Philips, Kavaliauskas and Grant, 2014; Beaven et al., 2013; Simpson et al., 2017; Chong, Guelfi and Fournier, 2014).
The increasing number of literature within CMR has led to several narrative and systematic reviews (Rollo and Williams, 2011; Jeukendrup, 2013; Chambers, Bridge and Jones, 2009; de Ataide e Silva et al., 2013; Peart, 2017; Brietzke et al., 2018). However, to the best of our knowledge, there are no reviews on CMR with resistance training (RT). Much of the focus on CHO intake in sports nutrition is within endurance training. CHOs ergogenic benefits have been recognised since pioneering research by Gordon and colleagues (1925) in the Boston marathon. Subjects who consumed simple sugars prior and during the event displayed higher blood glucose levels upon completion. Later, more sophisticated research by Hermansen, Hultman and Saltin (1967) discovered that increased dietary intake of CHO before events led to improved performances. This later became known as carbohydrate loading, a term that would become synonymous with sports nutrition (Sedlock, 2008). More recently, research is underway on a CHO periodisation protocol where athletes purposefully train with low CHO availability to enhance training-induced adaptations. Diligently planned periods of fasting and lowered CHO intakes may improve the bodies storage of glycogen (Impey et al., 2018). High amounts of CHOs are reintroduced before intense training sessions (generally closer to competition) and race day. This strategy is known as 'train low, race high' (Impey et al., 2018). It is unlikely that CHOs within RT will have such a significant impact as longer duration endurance due to the metabolic disadvantage. However, motivation is linked to greater performance outcomes (Chantal, Guay, Dobreva-Martinova, and Vallerand, 1996). Furthermore, research suggests the previously mentioned reward centres of the brain lower perceptions of exertion and displeasure during exercise (Chambers, Bridge and Jones, 2009; Backhouse, Ali, Biddle and Williams, 2007; Backhouse, Bishop, Biddle and Williams, 2005). CHOs may lower ratings of perceived exertion (RPE), which is well correlated with exercise intensity (Noble et al., 1983). An athlete may be able to complete more workload at similar feelings of effort if RPE is reduced. Furthermore, feelings of displeasure are a deterrent to long term adherence to exercise (Ekkekakis, Parfitt and Petruzzello, 2011; Farland et al., 2015).
High glycemic CHOs are typically used for mouth rinsing studies, e.g. glucose, sucrose, maltodextrin as they have rapid absorption rates (Schulte, Avena and Gearhardt, 2015). Nutritional status may affect performance outcomes in CMR studies. It is hypothesised that being in a fasted state for the intervention improves outcomes (Brietzke et al., 2019). However, studies have still shown significant effects in unfasted populations (Lane, Bird, Burke and Hawley, 2013; Murray et al., 2018). The effects may not be as pronounced because exposure to CHOs in a fasted state further increase regions in the brain associated with motivation and reward (Haase, Cerf-Ducastel and Murphy, 2009).
The majority of CMR interventions employ a rinse period of 5-10 seconds. Only three studies are known to employ a 10 second rinse period; All with significant results (Chambers, Bridge and Jones, 2009; Sinclair et al., 2013; Fares and Kayser, 2011). Sinclair's study observed improved performance outcomes in a 10-second mouth rinse compared to a 5-second in a 1hr time trial, which suggests the possibility of a dose-response relationship.
The concentration of the CHO drink generally falls in between 6-10% osmolality, with the majority of studies using 6%. Two studies have compared different solution concentrations (Ispoglou et al., 2015; Kulaksız et al., 2016). No differences were observed between 3,4,6 and 8% solutions. In addition, Kulaksız et al. (2016) subjects were in a fasted state which heightens neural responses to CHO. However, no dose relationship was discovered.
Resistance Training
Resistance training (RT) is a crucial aspect of many athletes training regime. It stimulates athletic development and performance enhancement (Suarez et al., 2019) as well as preventing the likelihood of injury, making an athlete more durable to the stressors experienced over the competitive season (Zwolski, Quatman-Yates and Paterno, 2017). Periodised training plans can be structured to focus on different athletic qualities. The attributes that require focused attention will be individual to each athlete's circumstances (Bompa and Buzzichelli, 2018). Common qualities generally trained within RT include muscular strength, power and endurance (Hass, Feigenbaum and Franklin, 2001). Additionally, RT is of paramount importance to those seeking body compositional changes (Giessing, Eichmann, Steele and Fisher, 2016; Grgic et al., 2018). RT is used by many athletes to promote a hypertrophic stimulus (increased skeletal muscle size). This is essential in sports such as bodybuilding and powerlifting; where higher levels of fat-free mass strongly correlate with performance (Helms, Aragon and Fitschen, 2015; Ye et al., 2013). Sprinters of a high level have also demonstrated increased levels of hypertrophy in the hip and knee flexors and extensors (Handsfield et al., 2016). Hypertrophy, when applied correctly, can be advantageous for a wide variety of athletes (Hornsby et al., 2018). Alternatively, if an athlete is required to lose bodyweight, RT helps minimise the loss of skeletal muscle tissue (Hunter et al., 2008). There are many different considerations in the subscription of RT programs: Training intensity or % of 1RM), rest intervals between sets, exercise selection, tempo, frequency of sessions, exercise order within sessions, volume and how many reps from failure, (commonly known as reps in reserve).
Isotonic contractions (dynamic constant external resistance) are most frequently used in RT settings (Garber et al., 2011) and are therefore of particular interest within this study. Only isotonic contractions will be included within the scope of this review to maintain external validity.
How the intervention might work
Athletes embarking on a RT program must apply principles of progression and overload. Whatever the athletes' goal, a well-designed program should apply intensities and volumes that provide a stimulus for adaptation. One method to monitor the stimulus applied within the training is volume. This can be expressed as the number of repetitions x weight lifted (kg), an easy and accepted method to quantify training workload (Schoenfeld and Grgic, 2017). This tonnage can be monitored in each session, weekly and throughout the macrocycle. The volumes an individual performs should increase progressively as he/she becomes adapted to the current stimulus (Baechle and Earle, 2015). Too little stimulus and no adaptations will occur, too much stimulus can lead to overreaching, and if prolonged, overtraining. Increases in training volume have a direct relationship up to a point. Therefore it can be advantageous for an athlete to reach maximum recoverable volume in some stages in the program.
CMR rinsing seems to attenuate fatigue after multiple sets (Jensen, Stellingwerff and Klimstra, 2015), therefore making it possible for the athlete to complete more workload in a session. When incorporated over a more extended period may increase physical adaptations to training as long as recovery is adequate.
The ease of having a CMR to improve RT performance may be an attractive option for athletes. Adequate concentrations of CHOs are present in commercially bought isotonic drinks. Popular UK brand Lucozade contains 6.3-6.6g (6.3-6.6%) CHO within 100ml within their isotonic range (Lucozade Sport, 2020)
Why is this review important?
The ease of use for a potential benefit in performance. Popular UK brand Lucozade contains 6.3-6.6g (6.3-6.6%) CHO within 100ml within their isotonic range (Lucozade Sport, 2020). So no need for any fancy concoctions, You can pop to your local shop and purchase this isotonic drink.
Administration of CHOs is very easy in a resistance training setting due to rest interval between sets
Athletes who suffer from GI distress when consuming simple carbohydrates (This is a very common issue for athletes)
Athletes who are currently reducing body weight - ingestion of large amounts of CHOs may not be manageable due to energy restriction.
No review of CMR in mouth rinsing has been undertaken
Inclusion criteria:
Randomised control trials
Carbohydrate mouth rinse interventions to test volume and strength in resistance training
Studies in healthy humans
Isotonic resistance exercise
No date limits
No language limits
Exclusion criteria:
Animal studies
Studies that did not test for strength and/or volume in resistance exercises
Articles which investigated isometric or isokinetic exercises
Articles which tested dynamic, open-chain kinetic exercises, emphasising mostly muscular power with no constant external resistance (sprints or jumps)
Studies that combined CMR with other ingredients
Studies that combined cardiovascular training with resistance training
Studies that used cardiovascular training as pre-fatigue
Grey literature
Non-peer-reviewed publications
Results
The flow chart below shows the process I went through. From initial search to selecting my final papers
After a couple weeks of sifting through the papers I narrowed it down to 7 papers that fit my inclusion criteria.
Participants
95 participants (80 male, 15 female)
19-30 years old
Minimum training age ranged from 6 months to 2 years
Exercise modalities
4 studies used mixture of upper and lower exercises - 3 studies used upper only
4 studies tested muscular endurance/total load volume - 3 used muscular endurance and TLV only
4 used a mixture of free weights and machine based resistance and 3 used solely free weights
12 different exercises were used across the 7 studies with bench press being the most frequent (everybody loves a bench press)!
Sets ranged from 1 to 24
In 6 studies all sets were taken to failure (24 sets to failure sounds like absolute hell!)
6 studies based the ‘working weight’ off of a % of 1RM. Ranging from 40 - 80% 1RM
2 studies employed a tempo - 2 second eccentric and eccentric). The other 5 studies did not use tempo
All 1rm attempts had 3 minute rest times between attempts
Nutritional status
Studies ranged from pre exercise meal 90 minutes before testing to overnight fasting. 11 hours was the longest ‘fast’ before testing
if you are interested in the specifics of the CHO rinse protocol, take a look at the table below.
If you are interested in some of the stats of the 7 studies that fit my inclusion criteria then take a look at the tables below.
Effects of Interventions
Out of seven studies, three reported significantly positive results. Some studies had multiple outcomes that fit the inclusion criteria. Twenty-five outcomes were included within the seven studies. Five outcomes were reported as having a significant positive effect.
Primary Outcomes
Muscular Endurance
Of the six studies that assessed muscular endurance, two trials reported positive significance. Fifteen total outcomes were recorded, three of which displayed a positive result.
Total Load Volume
Of the five studies that assessed TLV as an outcome, two had positive findings. Overall, seven outcomes were assessed with two significantly positive.
Secondary Outcomes
One Repetition Maximum
Of the three studies that tested one repetition maximum, no studies reported a positive result.
Subgroup Analysis
Nutritional Status
Out of the three studies that reported improvements in performance, two included an overnight fast of at least 8 hours (Decimoni 2018). One study that did not employ overnight fasting of at least 8 hours had significantly positive results (Bastos-Silva 2019).
Exercise Type
Of the three studies that reported a positive result in muscular endurance and TLV, two studies employed a mixture of upper and lower body, and one study used upper body only. Two positive studies utilised a tempo; one did not.
Two of the positive studies employed multiple sets, whereas one did not.
Sets to failure were utilised in all three positive studies.
Mouth Rinse
Of the three studies that reported a positive result – one utilised a single mouth rinse, and two studies utilised more than one rinse – all positive studies used maltodextrin as the CHO mouth rinse source.
Discussion
(A very brief run through of some of the key points)
All sets were taken to failure in positive studies
The increased feelings of motivation and drive may alleviate feelings of discomfort from training to failure.
2 out of the 3 studies include multiple sets (10+) with sessions lasted in excess of 25 minutes.
In contrast Bastos- Silva 2019 observed positive results in a protocol that had one set. Differences were 80% of 1RM was used for muscular endurance sets. Higher than all other studies. Higher %s are correlated with increased perceived exertion. This study also used a tempo which controls initial velocity. It has been hypothesised not allowing for a tempo on the lift can induce more fatigue as initial repetitions are completed using more force than without CMR. This is observed in research by Beaven et al. (2013) who tested CMR on sprint cycle performance. Five sets of 6-second sprints were performed following CMR. It was observed that the CMR group had greater power in the first set; however, had an inability to maintain power over the remaining sets compared to control. This can be controlled for if a tempo is employed during muscular endurance to failure. This steady cadence makes sure all reps have similar power output ensuring the participant will not fatigue early from initial higher power output. Only two studies required a tempo out of the seven analysed in this review and both had significantly positive outcomes.
Osmolarity of CHO had no effect on outcomes
Amount of mouth rinses had no effect on performance
2 out of 3 studies employed a overnight fast for > 8 hours
CMR offers a small to medium effect size within the positive studies.
Changes in 1RM bench may be difficult to detect with smaller effect sizes.
A study by Ritti-Dias and colleagues 2011 found that 1RM can differ up to 7.4% over 3 separate testing sessions. Can also be lower for upto 72 hours after testing due to fatigue. All 1RM studies had 1RM test - retest within this fatiguing time frame.
Meaningful adaptations occur in strength and hypertrophy over weeks and months. A long term study that tests volume or strength over a longer period of time may be warranted. Small to medium effect sizes acutely may transfer to large effect sizes over time.
Limitations
Absence of meta analysis
No grey literature
Only isotonic movements
Not including RPEs as a secondary outcome
Not having a team to overlook search strategy, risk of bias, to reduce possible errors.
Conclusion
This review shows mixed results for the efficacy of a CMR to improve RT performance. The use of CMR to enhance muscular endurance and TLV acutely, shows some promise. CMR does not seem to improve performance in the 1RM. From the results of this study, it appears CMR has a greater effect during higher volume sessions (10+ sets) with sets taken to volitional failure or if sets to failure are at a higher intensity (80%+ of 1RM). Athletes may experience greater effects from CMR when they have fasted for 8+ hours. Overall the effectiveness of CMR mouth rinse in RT settings are inconclusive.
Practical Application
Whilst results are inconclusive; it may still be a potential ergogenic aid for athletes and coaches to consider. It is cost-effective and easy to administer. The mouth rinse can be a commercially bought isotonic beverage. This mouth rinsing option may be an alternative to ingestion for athletes who experience gastrointestinal distress. Additionally, athletes who are restricting energy intake may benefit from this protocol. The athlete should mouth rinse 25-100ml of CHO sports drink for 10 seconds before expelling. This should be done immediately before the working set of the first exercise and potentially midway through the session
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