Cassia Campos Arthur*

nutricionistacassiacampos@gmail.com

Evelyn Suene Maia de Assis**

evelynmaia9@yahoo.com.br

Yves Ferreira Porto Pereira+

yves.porto@yahoo.com.br

Marcos Daniel Motta Drummond++

zangmarcos@gmail.com

*Nutricionista do Minas Tênis Clube

Graduada em Nutrição pela Universidade Federal de Juiz de Fora

Graduada em Educação Física pela Universidade Federal de Minas Gerais

Pós graduada em Nutrição Clínica e Desportiva

Pós graduada em Nutrição Esportiva Funcional

**Nutricionista, formada pela Universidade Federal de Minas Gerais

Pós graduada em Nutrição Esportiva: ênfase em alimentação e suplementação

Faculdade Cidade Verde - Paraná

Mestre em Ciências do Esporte, na Escola de Educação Física, Fisioterapia

e Terapia Ocupacional (EEFFTO-UFMG)

Nutricionista voluntária do Centro de Treinamento Esportivo

da Universidade Federal de Minas Gerais (CTE-UFMG)

Membro do Laboratório de Nutrição e Treinamento Esportivo

da Universidade Federal de Minas Gerais (LAN/UFMG)

+Possui graduação em Educação Física

pelo Centro Universitário de Belo Horizonte

Membro do Laboratório de Nutrição e Treinamento Esportivo (LAN/UFMG)

++Doutor em Ciências do Esporte (UFMG)

Mestre em Ciências do Esporte (UFMG)

Possui Especialização em Fisiologia do Exercício (UVA)

Graduação em Nutrição (UNI-BH) e graduação em Educação Física (UFMG)

Atualmente é professor do curso de graduação em Educação Física

da Universidade Federal de Minas Gerais (UFMG)

Professor e orientador na pós-graduação stricto sensu

em Ciências do Esporte da UFMG

Coordenador do Laboratório de Nutrição

e Treinamento Esportivo (LAN) da UFMG

Supervisor e nutricionista

do Centro de Treinamento Esportivo (CTE) da UFMG

(Brasil)

Reception: 07/04/2023 - Acceptance: 11/08/2023

1st Review: 10/03/2023 - 2nd Review: 11/05/2023

Accessible document. Law N° 26.653. WCAG 2.0

Suggested reference: Arthur, C.C., Assis, E.S.M. de, Pereira, Y.F.P, & Drummond, M.D.M. (2024). Effects of Carbohydrate Mouth Rinse on Gastrointestinal Disorders in Triathletes. Lecturas: Educación Física y Deportes, 28(308), 102-115. https://doi.org/10.46642/efd.v28i308.7107

 

Abstract

    In long-term efforts, such as triathlon, the requirement for carbohydrate intake can also work as an ergogenic strategy. However, the literature has reported and recorded gastrointestinal discomfort by athletes during the race when performing this practice, which can compromise performance. Mouth rinses with carbohydrates, followed by the disposal (spitting) of the solution, is a strategy to maintain performance, without generating side effects. Therefore, this study aimed to verify the potential side effects of carbohydrate mouth rinse in triathlon athletes during cycling practice. Twelve trained male - triathletes were subjected to two experimental situations, in which they have completed 1.5 km of swimming, followed by 40 km of cycling, within the shortest time possible and self-regulated intensity (time trial test). Throughout the cycling, blindly and crossed-wise, the volunteers rinsed their mouths using a bolus of 25 ml of 0% CHO placebo solution and 16% CHO (maltodextrin) solution, for each 12.5% of the distance to be covered. A gastrointestinal symptoms questionnaire was answered at the end of the 40 km cycling. Only one volunteer (8.33%) reported discomfort, while 91.66% of them presented no type of symptoms according to the CHO rinse protocol. Therefore, carbohydrate mouth rinse presents no gastrointestinal side effects during long-term exertion.

    Keywords: Nutrition. Carbohydrates. Gastrointestinal disorders. Triathlon.

 

Resumo

    A ingestão de carboidratos se configura como uma interessante estratégia ergogênica, durante esforços de longa duração, como o Triatlon. Entretanto, desconfortos gastrointestinais são bastante comuns ao se realizar essa prática, o que pode comprometer o desempenho do atleta. O enxágue bucal com carboidratos, seguido do descarte (cuspida) da solução, pode ser uma estratégia para manutenção do desempenho, sem a ocorrência de efeitos colaterais. Dessa maneira, o objetivo do presente estudo foi verificar possíveis efeitos colaterais do enxágue bucal com carboidrato, no ciclismo, em atletas de triathlon. Doze homens, triatletas treinados, foram submetidos a 2 situações experimentais, nas quais eles deveriam completar 1,5 km de natação, seguidos de 40 km de ciclismo, com o menor tempo possível e intensidade autorregulada (teste contrarrelógio). Ao longo do ciclismo, de forma cega e cruzada, os voluntários enxaguaram a boca com um bolus de 25 ml de solução placebo 0% de CHO ou solução com 16% de CHO (maltodextrina), a cada 12,5% da distância a ser percorrida. Um questionário de sintomas gastrointestinais foi respondido ao final dos 40 km de ciclismo. Apenas 1 voluntário (8,33%) relatou desconforto, enquanto 91,66% não apresentaram nenhum tipo de sintomas no protocolo de enxágue com CHO. Portanto, no presente estudo, o enxágue bucal com carboidrato não apresentou efeitos colaterais gastrointestinais quando utilizado durante esforço de longa duração.

    Unitermos: Nutrição. Carboidratos. Distúrbios gastrointestinais. Triatlo.

 

Resumen

    La ingesta de carbohidratos es una estrategia ergogénica interesante durante esfuerzos de larga duración, como el Triatlón. Sin embargo, las molestias gastrointestinales son bastante comunes al realizar esta práctica, lo que puede comprometer el rendimiento del deportista. Enjuagarse la boca con carbohidratos y luego desechar (escupir) la solución, puede ser una estrategia para mantener el rendimiento, sin que se produzcan efectos secundarios. Por tanto, el objetivo del presente estudio fue verificar los posibles efectos secundarios del enjuague bucal con carbohidratos, durante el ciclismo, en deportistas de triatlón. Doce hombres, triatletas entrenados, fueron sometidos a 2 situaciones experimentales, en las que debían completar 1,5 km de natación, seguido de 40 km de ciclismo, en el menor tiempo posible y con una intensidad autorregulada (prueba contrarreloj). Durante todo el ciclismo, de forma ciega y cruzada, los voluntarios se enjuagaron la boca con un bol de 25 ml de una solución placebo con 0% CHO o una solución con 16% CHO (maltodextrina), cada 12,5% de la recorrido a ser recorrida. Se completó un cuestionario de síntomas gastrointestinales al final de los 40 km de ciclismo. Sólo 1 voluntario (8,33%) refirió molestias, mientras que el 91,66% no experimentó ningún tipo de síntoma durante el protocolo de enjuague con CHO. Por lo tanto, en el presente estudio, el enjuague bucal con carbohidratos no presentó efectos secundarios gastrointestinales cuando se usó durante esfuerzos prolongados.

    Palabras clave: Nutrición. Carbohidratos. Desórdenes gastrointestinales. Triatlón.

 

Lecturas: Educación Física y Deportes, Vol. 28, Núm. 308, Ene. (2024)

---

 

Introduction 

 

    Triathlon is a sport that involves three activities of continuous effort (Sareban et al., 2016). This sport is contested over six different distances: Sprint or Short; Olympic or Standard; Long distance; Mixed Relay; Half-Ironman, and the Ironman (CBTRI, 2020). The effectiveness of triathlon performance is linked to maintaining high rates of energy expended for long hours, without damages that could lower the athlete’s performance (O'Toole, Douglas & Hiller, 1989). The effort involved in the training and competition of this modality requires a high mobilization of energy substrates, such as lipids and carbohydrates. In this sense, the availability of carbohydrates is a limiting factor of performance, due to the reduced hepatic glycogen stores of the active muscles (Fontan, & Amadio, 2015). Thus, carbohydrate depletion (CHO) might be a cause of lower performance and increased feelings of tiredness (fatigue), along with dehydration. (Jeukendrup, Jentjens, & Moseley, 2005)

 

    Therefore, the practice of triathlon demands the supplementation of this energetic nutrient during training sessions and long-term races (Bennemann et al., 2018). In triathlon, the most appropriate timing for supplementation is usually during cycling, because, in this phase, the supplement becomes more readily available and supplementation easier to manage (Jeukendrup, Jentjens, & Moseley, 2005). Still, supplementation in cycling extends to running, thus involving greater difficulties for food ingestion, either solid or liquid, which may influence performance positively at the end of training or competition. (Jeukendrup, Jentjens, & Moseley, 2005)

 

    However, during long exercises, lasting more than four hours, one of the most serious problems concerning supplementation and carbohydrate intake is the imbalance of gastrointestinal (GI) functions (Jeukendrup, 2011). There is a high prevalence of these complaints among triathletes when ingesting liquids and solid or diluted carbohydrates, such as nausea, intestinal cramps, epigastric pain, vomiting, and diarrhea (Strock, Cottrell, & Lohman, 2006). Burke et al. (2005) reported that three runners participating in the study complained of GI discomfort in the carbohydrate gel trial, impairing performance in the half marathon. In turn, Sareban et al. (2016) reported that two athletes refused to ingest the carbohydrate gel provided for consumption during the race due to their usual discomfort when ingesting this supplement during cycling.

 

    Given the reports of difficulties and discomforts of GI, studies have focused on carbohydrate mouth rinse as a potential substitute for the intake of this macronutrient (Brietzke et al., 2019; Chambers et al., 2009; Fuentes-Barría et al., 2020; Loureiro et al., 2020; Pomportes, & Brisswalter, 2020; Prata et al., 2020). Jeukendrup (2013) describes that this resource, possibly ergogenic, might be an alternative form to CHO supplementation for sports practices for generating neither discomfort nor GI disorders. The underlying mechanisms that promote the expected ergogenic effect may not be metabolic, but rather at the level of the central nervous system (Jeukendrup, 2011). There is evidence associating carbohydrates in the mouth with increased neural activity in various regions of the brain (Chambers et al., 2009; Smeets et al., 2007; Gant, Stinear, & Byblow, 2010). Sensory receptors in the mouth and pharynx are activated by the presence and ingestion of food (Konturek et al., 2004; Kringelbach, 2004; Zafra, Molino, & Puerto, 2006). This sensory information affects voluntary motor behavior, as well as initiating early digestive reflexes (Simon et al., 2006; Zafra, Molino, & Puerto, 2006). Thus, despite exerting ergogenic motor and psychic effects, consequently influencing performance, these responses can also generate GI disorders like carbohydrate intake. In addition, sustained rinsing for several seconds (i.e., 20 seconds) can disrupt the ventilatory cycle, resulting in some type of discomfort.

 

    No studies were found investigating potential occurrences of gastrointestinal disorders for this practice in triathlon. Thus, carbohydrate mouth rinse is a promising ergogenic resource, but there is a gap in the literature regarding verifying its safety concerning GI disorders, especially in triathlon. Thus, this study aimed to verify whether the use of carbohydrate mouth rinse can generate GI discomfort during cycling, in trained triathlon athletes. The hypothesis is that mouth rinse with carbohydrates causes no GI disorders.

 

Methods 

 

Sample characterization 

 

    The sample consisted of a total of 12 triathlon athletes (72.82 ± 7.21 kg; 1.75 ± 0.06 meters; 29.91 ± 8.10 years; mean body fat percentage of 12.50 ± 5.4%). The sample size was defined by convenience. After 60 days of dissemination in clubs, training centers, and academies, all volunteers who met the following inclusion criteria were recruited: composing the category of male triathlon athletes, having at least twelve months of experience in the sport, and participating in competitions of the modality in the Olympic distance. Volunteers would be excluded automatically from the study if they were injured throughout the study period, altered their normal diet, or started any type of supplementation; however, none of these were the case.

 

    Initially, all participants were instructed regarding the indispensable information concerning the research protocol follow-up, both verbally and written, as well as the objectives and procedures of the research methodology. Finally, the participants were instructed to sign the Free and Informed Consent Form, in which they assumed to collaborate voluntarily in the study. This study was approved by the Research Ethics Committee of the Federal University of Minas Gerais (protocol: 52927621.0.0000.5149).

 

    The participants of the study sample were typified concerning total body mass through the Welmy Digital Scale (Welmy® Indústria e Comércio Ltda., Brazil), which has an accuracy of 0.02 kg. Height was measured using a stadiometer coupled to a digital scale of 0.5 cm. Body fat percentage was calculated following the seven-fold skinfold protocol of Jackson & Pollock (1978) using the Lange adipometer (Lange Skinfold Caliper®, USA).

 

Experimental design 

 

    This research is a crossover, randomized, and blinded study with volunteers covering a total distance set at 40 km. Since the aim was to verify the side effects of carbohydrate mouth rinse in triathlon, all volunteers completed 1.5 km of swimming before cycling. Thus, the Olympic distances were repeated to simulate a real competition. Immediately after swimming, the athletes started the tests on the bike, with a transition period of five minutes between activities, without ingesting any type of food or supplementation. Partial times along the 1.5 km swimming course were recorded at each arrival in the pool so that the volunteers maintained a pace; therefore, they had to adjust to complete the distance without significant difference. (Sareban et al., 2016)

 

    The collection took place during the pre-season. All volunteers were instructed to remain with the same usual and individual habits of food and sleep, as well as to avoid any type of physical activity during the 24 hours preceding the experimental sessions. Mouth rinse was performed during cycling -indicated in the literature as the most adequate time for such (Jeukendrup, Jentjens, & Moseley, 2005; Vitale, & Getzin, 2019), and each volunteer performed the test on their bicycle, affixed to a training roller (Computrainer). Each volunteer was present at the collection site three times for the experimental sessions that comprised the study, with an interval of seven days.

 

    Weight, height (Welmy® digital scale), and skinfolds were measured in the first session,. In the second and third sessions, the athletes were instructed to perform 1.5 km of swimming, followed by covering 40 km of cycling (Carter, Jeukendrup, & Jones, 2004), with the administration of mouth rinse. The experimental research was carried out under two situations of mouth rinse, containing carbohydrates or placebo, with bolus administration, for each 12.5% of the mileage traveled, of 25 ml of solution. (Devenney et al., 2016)

 

    The experimental conditions were randomly tested by lottery. Then, a random number list was generated using online software (https://www.random.org/sequences/, Dublin, Ireland). Blinding and randomization were performed by a person who was not directly involved in data collection. At the end of each cycle of administration of the solutions, the volunteers answered a questionnaire on side effects to assess whether there was GI discomfort, comparing mouth rinse with placebo and carbohydrates. Figure 1 represents the experimental study design.

 

Source: Authors

 

    During data collection, one hour before exercise, all participants were instructed to eat a standardized meal adapted to their routines, rich in carbohydrates and low in fiber, fats, and proteins. Consuming these foods before physical exercise predisposes to the occurrence of GI symptoms (Lira et al., 2008). They were also instructed neither to consume alcoholic beverages nor any type of ergogenic resource during the research.

 

Mouth rinse protocol 

 

    Each participant received, for every 12.5% of the total distance covered (40 km), 25 ml of two solutions, as follows: rinse with placebo (0% CHO) and rinse with carbohydrate (16% CHO). Upon receiving the solution, the volunteer should pass it through the entire oral cavity for five seconds and discard it immediately afterward in the specific container. (Carter et al., 2004)

 

    We used a type of sweetener containing 0% carbohydrate and zero calories for the placebo (Stevita Soul ®), and maltodextrin for the CHO scenario, containing 16%, approximately 4 grams of the macronutrient in question (Devenney et al., 2016). Maltodextrin was used as a carbohydrate source for the CHO rinse scenario. It is a partially hydrolyzed starch that is colorless when dissolved in water, thus having no marked sweet taste. (Carter et al., 2004)

 

    For the blinding of the volunteers, a comparative test of flavors was performed before starting the study. In the first experimental session, the volunteers themselves tried rinsing with the substances alternately and saying what it was, with no hits. Thus, we can ensure that the participants were not able to determine the solutions. During the research, they were offered the substances in opaque plastic cups to avoid identification of differences in the color of the mixtures, thus characterizing a blind procedure. For randomization, we chose to store the substances in bags unknown to the researcher so that there would be neither familiarization nor identification of any of the substances chosen on the day of collection.

 

Effort protocol 

 

    In swimming and cycling, the participants were instructed to perform the practices under self-regulation of the intensities (Carter et al., 2004). Between the two modalities, no type of food intake was allowed, either food or food supplement. The water intake of the athletes during the test was ad libitum throughout the effort on the bike. During cycling, the training roller app (Computrainer, Racermate, USA) generated informative data on the time and distance traveled. The laboratory conditions were maintained (air-conditioned environment) in all situations and for all volunteers, not being performed any type of external incentive, either music or conversation, throughout the effort, thus providing only the information of the distance already completed.

 

Side effects questionnaire 

 

    The questionnaire was applied immediately after cycling to verify the two scenarios of mouth rinse (placebo and CHO). As in Sareban et al. (2016), the volunteers were asked if they felt any kind of GI discomfort, and the questions were part of the side effects questionnaire for common GI symptoms and could be answered with “yes” or “no”. The questionnaire proposed by Sareban et al. (2016) contains questions about the sensation of bloating, flatulence, need for defecation, stomach colic, and diarrhea, among others (in which they could answer any other type of symptom they were feeling at the time or had felt throughout the test). The questionnaire was filled out by professionals who participated in the research and were trained to perform the questions directly, without inducing any type of response.

 

Statistical analysis 

 

    The analysis of the perception of GI side effects was performed descriptively based on percentage, mean, and standard deviation. The data for statistical analyses was assessed on the JAMOVI software (version 2.3) [Computer Software].

 

Results 

 

    As to side effects, in both experimental conditions - rinse with carbohydrates and placebo -, 100% of the answers discarded the occurrence of any type of GI discomfort. The questions covered “bloating”, “flatulence”, “need for bowel movement”, “stomach cramps”, “diarrhea”, and “other symptoms”. However, one volunteer (8.33%) reported “abdominal pain” in the option “other for the placebo rinse scenario” and “mild intestinal discomfort” for the carbohydrate rinse scenario, while none of the other volunteers (91.66%) reported any occurrences concerning these parameters. Table 1 presents these results.

 

Athlete

Bloating

Flatulence

Need for bowel movement

Stomach cramps

Diarrhea

Other symptoms

Placeb

Carb

Placeb

Carb

Placeb

Carb

Placeb

Carb

Placeb

Carb

Placeb

Carb

1

No

No

No

No

No

No

No

No

No

No

No

No

2

No

No

No

No

No

No

No

No

No

No

No

No

3

No

No

No

No

No

No

No

No

No

No

No

No

4

No

No

No

No

No

No

No

No

No

No

No

No

5

No

No

No

No

No

No

No

No

No

No

No

No

6

No

No

No

No

No

No

No

No

No

No

No

No

7

No

No

No

No

No

No

No

No

No

No

Abdominal pain

Mild intestinal discomfort

8

No

No

No

No

No

No

No

No

No

No

No

No

9

No

No

No

No

No

No

No

No

No

No

No

No

10

No

No

No

No

No

No

No

No

No

No

No

No

11

No

No

No

No

No

No

No

No

No

No

No

No

12

No

No

No

No

No

No

No

No

No

No

No

No

Source: Authors

 

Discussion 

 

    This study aimed to investigate the occurrence of side effects (GI discomforts) in triathletes performing carbohydrate mouth rinses in a cycling session after swimming. We hypothesized that mouth rinses with carbohydrates would not cause GI discomfort. The results demonstrated a low occurrence of perceived side effects. Thus, our hypothesis was confirmed.

 

    As suggested by Oliveira, & Burini (2014), there is no macromolecule intake, and the digestive systems responsible for good or bad digestion of food are not used. Therefore, this study found that the mouth rinse with carbohydrates is not responsible for generating GI discomfort. However, such a scenario might also be linked to the volunteer’s motivation, who unconsciously expects that the protocol has some ergogenic effect, thus disregarding the feeling of discomfort (Carlino, & Benedetti, 2016; Clark et al., 2000; Hurst et al., 2017; Raglin et al., 2020). Furthermore, the intake of other foods before the test might have interfered with the identification of GI symptoms at the time of the test. In this case, intestinal disorders already present before the test would not be altered by the mouth rinse protocol, either carbohydrate or placebo.

 

    Several studies have found that carbohydrate mouth rinses improved performance, time, power, number of repetitions, distance, and jumps. None of these factors were assessed herein (Hartley et al., 2022). Like our results, no side or deleterious effects were reported in these studies resulting from the use of such potential ergogenic resource. However, none of them specifically assessed the occurrence of GI discomforts caused by carbohydrate mouth rinse, nor did they associate the possible discomforts generated with physical performance. Such a factor limits the discussion of the results and indicates the need for further studies on the subject.

 

    Burke et al. (2011), Carter, Jeukendrup, & Jones (2004), and Vitale, & Getzin (2019) suggest that the central nervous system (CNS) benefits from the presence of carbohydrates in the oral cavity, whether sweet or not, through brain receptors that promote a greater sense of reward, well-being, improved exercise rhythm, hence improving physical performance.

 

    Podlogar, & Wallis (2022) suggest that one of the ergogenic mechanisms of carbohydrate mouth rinse would be the uptake of carbohydrates detected in the oral cavity, causing activation of brain regions that stimulate the CNS and are responsible for improving physical performance. Likewise, Best et al. (2021) demonstrate that although the mechanisms responsible for the ergogenic response to mouth rinse with CHO should be further investigated, it is believed that oral receptors present in the mouth are stimulated by CHO molecules that pass through the oral cavity and promote such CNS activation. Such neural stimulation would develop ergogenic physiological and psychological responses to exercise. Likewise, Baltazar-Martins, & Del Coso (2019) corroborate that rinsing the mouth with carbohydrates during exercise could exert an effect on the CNS through the receptors found in the oral cavity (mouth and tongue),in addition to reducing effort perception and promoting a sense of well-being. Their study also hypothesized that oral receptors would stimulate the brain reward center directly, which would generate a “central impulse” to improve performance, even if the individual is low in liver or muscle glycogen. Vitale, & Getzin (2019) suggest that such stimulation of receptor cells happens in the reward centers in the brain located in the anterior cingulate cortex, ventral striatum region, and frontal orbital cortex. (Vitale, & Getzin, 2019)

 

    Carter, Jeukendrup, & Jones (2004), Jeukendrup, & Chambers (2010) describe robust evidence that when physical activity lasts for between 45-75 minutes, carbohydrate mouth rinse does not have its ergogenic effect promoted by metabolic mechanisms. This occurs mainly because rinsing is involved with active processes of ergogenicity through the central nervous system, thus being responsible for improving performance by 2-3% (Jeukendrup, & Chambers, 2010). Considering the reports about GI disorders when ingesting food and drink during exertion, further studies should associate potential central neural responses with physical and sports performance, as well as potential side effects.

 

    This work has a differentiated methodological design that includes rinse interventions in active triathletes, with and without carbohydrates, in the triathlon cycling modality. This is also innovative since only a few of the studies found have associated mouth rinse with carbohydrates in triathlon.

 

    The sample size, selected by convenience, is a limitation of this study. In addition, since our research involved no control over water or food intake, the potential neural response was not investigated, which would attest to the effect of mouth rinse, associating the relationship between the ergogenic effect promoted by carbohydrate mouth rinse and the CNS. Finally, it is also worth mentioning the lack of running modality at the end of the test, which would represent the triathlon event in full.

 

Conclusion 

 

    According to these results, mouth rinses with CHO show a low occurrence of side effects of GI disorders and can be a safe supplementation alternative for long-duration efforts.

 

References 

 

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Lecturas: Educación Física y Deportes, Vol. 28, Núm. 308, Ene. (2024)