Nutritional Strategies for Optimizing Health, Sports Performance, and Recovery for Female Athletes and Other Physically Active Women: A Systematic Review

Systematic Review Nutritional Strategies for Optimizing Health, Sports Performance, and Recovery for Female Athletes and Other Physically Active Women: A Systematic Review Mar Larrosa 1 , Angel Gil-Izquierdo 2,3, �, Liliana Guadalupe Gonz� alez-Rodr � ıguez 1,4 , Mar � ıa Jos� e Mu~ noz Alf� erez 5 , Alejandro F. San Juan 6 , � Angela S� anchez-G� omez 7 , Natalia Calvo-Ayuso 8 , Juan Jos� e Ramos-� Alvarez 9 , Diego Fern� andez-L� azaro 10,11 , Ra� ul Lopez-Grueso 12 , Inmaculada L� opez-Le� on 13 , Javier Moreno-Lara 13 , Diego Dom � ınguez-Balmaseda 14 , Rom� an Illescas-Quiroga 15 , Eduardo Cuenca 16 , Teba L� opez 16 , Juan Jos� e Montoya 9 , Daiana Priscila Rodrigues-de-Souza 7,17 , Elena Carrillo-Alvarez 18 , Arturo Casado 19 , Bel� en Rodriguez-Do~ nate 20,21 , Mireia Porta-Oliva 22,23,24 , Catalina Santiago 14 , T� amara Iturriaga 14 , Beatriz De Lucas 14 , � Angela Garc � ıa Solaesa 25 , Mar � ıa del Pilar Montero-L� opez 26 , Elvira Ben � ıtez De Gracia 27 , Pablo Veiga-Herreros 27 , Alejandro Mu~ noz-L� opez 13 , Eva Orantes-Gonzalez 28 , Jos� e Carlos Barbero-Alvarez 29 , Ruth Cabeza-Ruiz 13 , � Angel Carnero-Diaz 30 , Isabel Sospedra 31 , Luis Miguel Fern� andez-Galv� an 32 , Jos� e Miguel Mart � ınez-Sanz 31 , Francisco Javier Mart � ın-Almena 25 , Margarita P� erez 6 , Eduardo J. Guerra-Hern� andez 33 , � Alvaro L� opez-Samanes 34 , Antonio Jes� us S� anchez-Oliver 13,35 , Ra� ul Dom � ınguez 13,35 1 Departamento de Nutrici� on y Ciencia de los Alimentos, Facultad de Farmacia, Universidad Complutense de Madrid, 28040 Madrid, Spain; 2 Research Group on Food and Nutrition (ALINUT), University of Alicante, 03690 Alicante, Spain; 3 Quality, Safety, and Bioactivity of Plant Foods Group, Department of Food Science and Technology, CEBAS-CSIC, University of Murcia, 30100 Murcia, Spain; 4 VALORNUT Research Group, Complutense University of Madrid, 28040 Madrid, Spain; 5 Department of Physiology (Faculty of Pharmacy, Cartuja University Campus), Institute of Nutrition and Food Technology “Jos� e Mataix”, University of Granada, 18071 Granada, Spain; 6 Department of Health and Human Performance, Faculty of Physical Activity and Sports Sciences (INEF), Universidad Polit� ecnica de Madrid, 28040 Madrid, Spain; 7 Departamento de Enfermer� ıa, Farmacolog� ıa y Fisioterapia, 14004 C� ordoba, Spain; 8 Departamento de Enfermer� ıa y Fisioterapia, Campus de Ponferrada, Universidad de Le� on, 24401 Ponferrada, Spain; 9 School of Sport Medicine, Department of Radiology, Rehabilitation and Physiotherapy, Complutense University Madrid, 28040 Madrid, Spain; 10 Department of Cellular Biology, Genetics, Histology and Pharmacology, Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; 11 Neurobiology Research Group, Faculty of Medicine, University of Valladolid, 47005 Valladolid, Spain; 12 Facultad de Ciencias de la Salud, Universidad Isabel I, 09003 Burgos, Spain; 13 Departamento de Motricidad Humana y Rendimiento Deportivo, University of Seville, 41013 Seville, Spain; 14 Facultad de Ciencias de la Actividad F � ısica, Deporte y Fisioterapia, Universidad Europea de Madrid, 28670 Villaviciosa de Od� on, Spain; 15 Departamento de Enfermer� ıa y Fisioterapia, University of Alcala, 28805 Alcal� a de Henares, Spain; 16 Academia de Guardias y Suboficiales de la Guardia Civil, 23440 Baeza, Spain; 17 Maimonides Biomedical Research Institute of C� ordoba (IMIBIC), 14004 C� ordoba, Spain; 18 Global Research on Wellbeing (GRoW) Research Group, Blanquerna School of Health Sciences, University Ramon Llull, 08025 Barcelona, Spain; 19 Centro de Investigaci� on en Ciencias del Deporte, Universidad Rey Juan Carlos, 28943 Fuenlabrada, Spain; 20 Comit� e Paral � ımpico Espa~ nol, 528040 Madrid, Spain; 21 Tu Gestor de Salud, 28001 Madrid, Spain; 22 Faculty of Food Technology, Autonomous University of Barcelona (UAB), Bellaterra, Spain; 23 FC Barcelona Medical Department, FC Barcelona, 08028 Barcelona, Spain; 24 Catalan School of Kinanthropometry, INEFC, 0838 Barcelona, Spain; 25 Faculty of Health Sciences, Catholic University of � Avila, 05005 � Avila, Spain; 26 Biology Department, Universidad Autonoma de Madrid, 28049 Madrid, Spain; 27 Facultad de Ciencias de la Salud, Universidad Alfonso X El Sabio, 28691 Villanueva de la Ca~ nada, Spain; 28 Department of Sports and Computer Science, Faculty of Sports, University of Pablo de Olavide, 41013 Seville, Spain; 29 University of Granada, Campus of Melilla, 52005 Melilla, Spain; 30 Departamento de Educaci� on F � ısica y Deportiva, University of Seville, 41013 Seville, Spain; 31 Nursing Department, Faculty of Health Sciences, University of Alicante, 03690 San Vicente del Raspeig, Spain; 32 LIFE Research Group, University Jaume I, 12071 Castell� on de la Plana, Spain; 33 Departamento de Nutrici� on y Bromatolog � ıa, Facultad de Farmacia, Universidad de Granada, 18011 Granada, Spain; 34 Faculty of Human and Social Sciences, Universidad Pontificia Comillas, 28049 Madrid, Spain; 35 Studies Research Group in Neuromuscular Responses (GEPREN), University of Lavras, 37203-202 Lavras, Brazil �Correspondence: � A. Gil-Izquierdo. Quality, Safety, and Bioactivity of Plant Foods Group, Department of Food Science and Technology, CEBAS-CSIC, Campus de Espinardo-25, 30100 Murcia, Spain. E-mail: [email protected]. © The Author(s) 2024. Published by Oxford University Press on behalf of the International Life Sciences Institute. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.1093/nutrit/nuae082 e1068 Nutrition Reviews V R Vol. 83(3):e1068–e1089 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 Context: Despite the progress toward gender equality in events like the Olympic Games and other institutionalized competitions, and the rising number of women engaging in physical exercise programs, scientific studies focused on establishing specific nutritional recommendations for female athletes and other physically active women are scarce. Objective: This systematic review aimed to compile the scientific evidence available for addressing the question “What dietary strategies, including dietary and supplementation approaches, can improve sports performance, recovery, and health status in female athletes and other physically active women?”Data Sources: The Pubmed, Web of Science, and Scopus databases were searched. Data Extraction: The review process involved a comprehensive search strategy using keywords connected by Boolean connectors. Data extracted from the selected studies included information on the number of participants and their characteristics related to sport practice, age, and menstrual function. Data Analysis: A total of 71 studies were included in this review: 17 focused on the analysis of dietary manipulation, and 54 focused on the effects of dietary supplementation. The total sample size was 1654 participants (32.5% categorized as competitive athletes, 30.7% as highly/moderately trained, and 37.2% as physically active/recreational athletes). The risk of bias was considered moderate, mainly for reasons such as a lack of access to the study protocol, insufficient description of how the hormonal phase during the menstrual cycle was controlled for, inadequate dietary control during the intervention, or a lack of blinding of the researchers. Conclusion: Diets with high carbohydrate (CHO) content enhance performance in activities that induce muscle glycogen depletion. In addition, preexercise meals with a high glycemic index or rich in CHOs increase CHO metabolism. Ingestion of 5–6 protein meals interspersed throughout the day, with each intake exceeding 25 g of protein favors anabolism of muscle proteins. Dietary supplements taken to enhance performance, such as caffeine, nitric oxide precursors, b-alanine, and certain sport foods supplements (such as CHOs, proteins, or their combination, and micronutrients in cases of nutritional deficiencies), may positively influence sports performance and/or the health status of female athletes and other physically active women. Systematic Review Registration: PROSPERO registration no. CRD480674. Key words: female athlete, sport nutrition, macronutrient, micronutrients, supplement. INTRODUCTION Physical exercise, aimed at promoting health, preventing injuries, improving physical performance, or for leisure is a significant phenomenon in society. For example, last year 57.3% of Spaniards reported engaging in regular physical exercise, and the gender gap has narrowed (63.1% of men vs 52.5% of women). Women’s participation in physical exercise and sport has increased by over 20% since 2010. 1 Additionally, at the international competitive level, the representation of women in the Olympic Games has risen from 34% in Atlanta 1996 to 48% in Tokyo 2020, and there is a commitment to achieve gender equality (ie, 50%) in Paris in 2024. 2 Boys and girls exhibit similar physical conditioning until adolescence, when sexual maturation causes divergence. Male gonads increase the synthesis of inhibin (a protein) and testosterone (a hormone), which together play a significant role in sex-based differences. 3 Testosterone stimulates a reduction in fat mass and an increase in muscle anabolism, 3 making muscle more responsive to hypertrophy and muscle fiber strength. 4 Girls, on the other hand, experience an increase in the production of 2 hormones: progesterone (only in the second post-ovulatory phase of the ovarian cycle and during pregnancy) and estradiol (which promotes fat accumulation in synergism with insulin). These hormonal differences result in adolescent and adult women having higher levels of adipose tissue, more noticeably in the Nutrition Reviews V R Vol. 83(3):e1068–e1089 e1069 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 chest and gluteo-femoral area. 3 Epstein et al 5 found there was 50% less muscle tissue in the upper limbs and 30% less in the lower limbs in women compared with men. Anthropometric and hormonal differences make male athletes stronger, more powerful, and faster in explosive efforts, resulting in differences of over 30% in the world records in the heaviest weightlifting categories. 3 However, in addition to hormonal differences, there are disparities between the sexes in mitochondrial function, substrate utilization, immune response, iron metabolism, thermoregulation, hydration, appetite control, energy availability, and endocrine function. 6 On the other hand, women have a higher proportion of type I muscle fibers and more favorable mitochondrial function, which could be advantageous in endurance and ultra-endurance sports. 7 This higher proportion of type I muscle fibers could explain the lower difference in muscle strength for lower limbs than for upper limbs. 8 Compared with men, women oxidize more lipids and fewer carbohydrates (CHOs) and amino acids at the same exercise intensity. 3 When comparing world records in swimming, there is a sex-based difference of 13.2% in the shortest distance (50 m) and of 5.7% in the longest distance (1500 m). 3 To establish the optimal training loads for and nutritional requirements of female athletes, it is essential to consider the many differences in this population during their reproductive years and throughout the menstrual cycle (MC). 9 During the first half of the MC (the follicular phase), estrogen levels progressively increase, reaching a peak that precedes the preovulatory phase, during which follicle-stimulating hormones and luteinizing hormones reach their highest levels. The second half of the MC (the luteal phase) is characterized by a decrease in estrogens to their lowest levels and an increase in progesterone levels; a second peak of estradiol levels occurs before a reduction at the end of the MC. 10 These hormonal variations throughout the MC can influence the female athlete’s metabolism. Estradiol promotes the bioavailability of fatty acids and lipolysis, while reducing the rate of gluconeogenesis, whereas progesterone: (i) decreases CHO sensitivity, mediated by IGF-1 in the muscle, and reduces liver glycogenolysis; and (ii) increases protein catabolism, with higher protein oxidation occurring both at rest and during exercise. 6 Over time, the hormonal response in the luteal phase diminishes, and during menopause the estradiol to progesterone ratio becomes imbalanced, resulting in insulin resistance and anabolic resistance in the muscle, decreased muscle mass and bone mineral density (BMD), and an increase in fat mass. 11 A well-planned diet can optimize health and the physical and cognitive performance of athletes. 12 Optimal strategies for sports nutrition include dietary manipulation and supplementation strategies. 13 Intrinsic characteristics of female athletes lead to specific responses to various training protocols and nutrition strategies, both of which can interact with the response and adaptions to physical exercise. However, it has recently been reported that only 6% of the studies focusing on the effects of CHO supplement strategies in athletes have included women in their sample populations. 14 Another study found that, among studies assessing with a high level of scientific rigor the effects of dietary supplements on response and adaptions to physical exercise, those with samples composed exclusively of women represented somewhere between 0% and 8%. 15 The present review is, to the authors’ knowledge, the first systematic review that has analyzed the effects of various nutritional and dietary strategies (including dietary manipulation and dietary supplementation) on performance, recovery, and health status parameters in female athletes and other physically active women. METHODS Protocol and registration This systematic review has been prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Supplementary Material S1). 16 The current protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (no. CRD480674). Literature search strategy A systematic literature search was conducted using the following databases: Pubmed, Scopus, and Web of Science, including all the results published between January 1, 2000 and July 3, 2023. The search strategy was restricted to studies published in English, Portuguese, or Spanish, excluding manuscripts published in other languages. The search was conducted using keywords connected by Boolean connectors. The search strategy used in the Pubmed and Scopus databases was as follows: (concept 1) Women OR female AND (concept 2) sport OR exercise OR athlet�OR “physical active�” AND (concept 3) nutri�OR micronutrients OR macronutrients OR aminoacids OR “ergogenic aid” OR CHO OR carbohydrates OR glucose OR lipids OR fats OR proteins OR minerals OR fiber OR vitamins OR Diet�OR probiotics OR prebiotics OR symbiotics�OR nutraceutic�OR “functional foods” OR supplement�OR “non-nutrient” OR phytochemical AND (concept 4) “health status” OR healthy OR “sport performance” OR conditioning OR “muscle performance” OR endurance OR strength OR speed OR agility e1070 Nutrition Reviews V R Vol. 83(3):e1068–e1089 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 OR “international concurrence” OR competition OR biochemical OR physiolog�OR contest OR “sport biomarker” OR DOMS OR “hormonal behaviour” OR “nutritional status” OR “bone health” OR hematolog� OR “oxidative stress” OR inflammat�OR microbio�. This search strategy was adapted for the Web of Science database. In Supplementary Material S2, the full search strategy used in the 3 databases can be found. Eligibility criteria The research question for this systematic review was: “What dietary strategies, including both dietary and supplementation approaches, can improve performance and/or health status in female athletes and other physically active women? In seeking to answer that question, inclusion criteria were established based on the PICOS criteria (see Table 1). 17 Study selection Covidence systematic review software was employed for the screening and recording of decisions. As a part of this process, 2 authors (I.L.-L. and E.C.) independently reviewed all the titles and abstracts identified in the search in the 3 databases. These reviewers excluded all manuscripts that did not align with the objectives of this review. In a subsequent phase, another 2 authors (J.M.-L. and L.G-R.) thoroughly revised the full texts and checked whether the manuscript fulfilled all the inclusion criteria. During the first (title and abstract screening) and second phases (full-text review), a third reviewer (A.S.-G.) was consulted to assist in resolving any discrepancies. Finally, manuscripts that included only a probabilistic magnitude-based inference were removed. Data extraction Two authors (A.J.S.-O. and A.L.-S.) extracted data independently using the Covidence systematic review software (https://www.covidence.org/). Any discrepancy was resolved through discussion, and a third author (R. D.) was consulted if consensus was required. The information from each study that was included in the systematic review consisted of the following: •Sample (trained or competitive athletes and other physically active women): (i) the number of participants and their main characteristics related to their sport practice; (ii) age of participants •Menstrual function: (i) information about menstrual function (eumenorrheic, eumenorrheic, or menopause); (ii) information about possible control for the menstrual phase (follicular and luteal phases, with possible subdivisions of early, mid, or late phases in both the follicular and luteal phases) for the trials or assessment sessions •Experimental group (parallel groups study design) or experimental conditions (crossover study design): (i) definition of each experimental group/condition; (ii) sample size of each experimental group/condition •Intervention: (i) nomenclature of each intervention; (ii) characteristics of each experimental intervention; (iii) duration (acute: 1 day; days: <1 week; weeks: �1 week) •Outcomes: all the outcomes assessed related to performance and/or health status •Results: the outcomes specified for which statistical differences were found: (i) between experimental conditions (crossover study design); (ii) for the time of each group and in the interaction time-intervention (parallel groups study design). Risk-of-bias assessment For this systematic review, the modified Cochrane risk- of-bias for randomized trials tool (RoB 2) was used. 18 This scale, which is included in the Covidence tool, was employed to assess the potential risk of bias in each study. Based on the major domains of bias, the risks of bias were categorized as “low risk,” “unclear risk,” or “high risk.” Two authors (J.J.R.-A. and R.I.) conducted independent assessments of the quality of the studies and evaluated the risk of bias. Any disagreements between the reviewers were resolved by consultation with a third researcher (A.C.). The risk of bias was considered moderate, mainly for reasons such as a lack of access to the study protocol, insufficient description of how the hormonal phase during the menstrual cycle Table 1. PICOS Table for Inclusion of Studies Population (i) The sample must exclusively consist of women. (ii) The individuals within the sample should be explicitly referred to as “female athletes” in the manuscript or meet the criteria of being classified as “physically active” or exceeding the exercise recommendations of the American College of Sports Medicine (ACSM). Intervention Inclusion of a dietary/nutritional intervention that should involve the manipulation of a macronutrient, a micronutrient, water, and/or the use of supplements Comparison Inclusion of either a placebo or control group (parallel group study design) or experimental condition (crossover study design) Outcomes Any parameter related to sports performance and/or health status Study design Randomized controlled trials Nutrition Reviews V R Vol. 83(3):e1068–e1089 e1071 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 was controlled, inadequate dietary control during the intervention, or a lack of blinding of the researchers. RESULTS Literature search and study selection A flow diagram illustrating the article selection process is provided in Figure 1. Initially, a total of 3431 articles were identified, which were trimmed to 3169 articles after eliminating duplicates (n¼262). Subsequently, a total of 3169 titles and abstracts were screened. Of these, 99 full-text articles were identified as being potentially relevant to this study. However, 25 manuscripts did not fulfil the eligibility criteria. A total of 74 articles met all the inclusion criteria, but 3 were removed based on the statistical analysis used. Hence, 71 articles were finally included in this systematic review. Characteristics of the studies included in the systematic review Seventeen studies were focused on the analysis of dietary interventions: 7 of these studies had a parallel group design 18–25 and 11 had a crossover design. 26–36 The total sample size for these studies was 393 participants. Among them, 102 participants (26.0%) were categorized as competitive athletes, 65 were categorized as being highly or moderately trained (16.5%), and 226 (57.5%) were categorized as physically active or recreative athletes. Some studies 19,23,26–31,33 included a sample group consisting of eumenorrheic participants, although 1 of these studies did not control for MC variations during trials 30 ; 1 study specifically selected oligomenorrheic and amenorrheic women, 24 another was focused on menopause, 23 and the remaining studies did not control for menstrual function. Of the studies focused on dietary manipulations, 6 were focused on analyzing the effects of various levels of dietary CHO ingestion 26–28 or pre-exercise meals, 32 Records identified from: Databases (n = 3431) - PubMed (n = 994) - Web of Science (n = 2200) - Scopus (n = 237) Records removed before screening: Duplicate records removed (n = 262) Records marked as ineligible by automation tools (n = 0) Records removed for other reasons (n = 0) Records screened (n = 3169) Records excluded (n = 3070) Reports sought for retrieval (n = 99) Reports not retrieved (n = 0) Reports assessed for eligibility (n = 99) Reports excluded (n = 28) Reasons: - Wrong intervention (n = 2) - Wrong patients (n = 23) - Wrong statistical treatment (n = 3) Studies included in review (n = 71) Identification of studies via databases and registers Identification Screening Included Figure 1. PRISMA Flow Diagram e1072 Nutrition Reviews V R Vol. 83(3):e1068–e1089 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 including the impact of the glycemic index (GI), 30,31 on health or performance outcomes. Two studies specifically analyzed the effects of dietary manipulation on CHO bioavailability. 19,29 In relation to pre-exercise meals, 2 studies quantified the effect of calciumenriched meals, 34,35 while another quantified the effect of oatmeal ingestion. 36 The effect of a high-protein diet was assessed in 3 studies. 20–22 Other studies assessed the effects of a hyperenergetic diet, 24 a diet enriched in polyunsaturated fatty acids (PUFAs) in combination with resistance training, 23 or a high-antioxidant diet. 25 Another study evaluated the use of milk as a dietary source enhancing recovery. 33 A total of 53 studies were focused on the analysis of dietary supplement interventions. Regarding the type of experimental design, 20 adopted a parallel group design 37–56 and 30 followed a crossover design. 57–86 The total sample size of these studies was 1261 participants. Among them, 436 women (34.6%) were categorized as competitive athletes, 476 were categorized as being highly or moderately trained (37.7%), and 349 (27.7%) were categorized as physically active or recreational athletes. Twelve studies 40,44,49,51,61,64,65,69,72,84,87,88 included a sample population of eumenorrheic participants. However, 3 of these studies did not control for MC variations in the trials. 64,73,74 One study selected specifically menopausal women, 89 and the other studies did not control for menstrual function. According to Maughan et al, 87 supplements can be classified into those used to prevent or treat deficiencies, those used as a practical source of energy and nutrients, and those used to directly or indirectly improve sports performance. In the present review, 6 studies 37–42 were classified as investigating the prevention or treatment of deficiencies: 3 studies analyzing the effects of iron supplementation, 37–39 including 1 investigating the effects of iron plus symbiotic supplementation 38 ; 1 study analyzing the effects of folic acid supplementation 40 ; and 2 studies on the isolated and combined effects of vitamins C and E. 41,42 We classified a total of 7 studies as investigating the effects of supplements used as a practical source of energy and nutrients 44–47,57,58 : 2 studies focused on the effect of a-lactalbumin 58 ; 3 studies focused on protein supplementation, 44–46 1 of them in combination with creatine 45 ; 1 study assessed the effects of various types of CHOs; 43 and 1 study compared the effects of supplementation with CHO vs supplementation with a combination of CHO and protein. 57 The majority (28) of the studies focused on dietary supplements directly aimed at improving performance. 48–52,59–78 Among these, 10 studies investigated the potential effects of caffeine on sports performance. 59–68 Five studies explored the effects of supplementation with nitric oxide (NO) precursors 72–76 and b-ala- nine, 50,51,88–90 and other supplements such as creatine, 48,49,70,71 p-synephrine, 69 sodium bicarbonate, 77 or multi-ingredient formulations. 52,78 Finally, 12 studies were undertaken to assess the effects of dietary supplements that might indirectly enhance performance. 53–56,86 In this category, colostrum bovine was the most studied supplement (4 studies), 80–83 with the remainder of the studies exploring the effects of other supplements such as fish oil, 54 probiotics, 53 curcumin, 85 avocado pulp, 79 Opuntia ficus indica, 84 tart cherry, 55 chromium picolinate, 56 and melatonin. 86 Summarized results of the studies based on the manipulation of diet In Supplementary Material S3, the characteristics and main results of the studies with interventions based on dietary manipulation are summarized. Among the studies that manipulated CHO ingestion in the diet, 1 study reported an increase in glycogen level pre-exercise, enhancement of CHO oxidation during exercise, and higher net glycogen consumption, leading to an improved result for time to exhaustion (TTE) above 80% VO 2max . 26 Another study reported a selective effect on CHO oxidation in the follicular phase of the MC. 28 In contrast, Dolins et al 27 did not find differences in scores on a high-intensity endurance test when comparing groups of participants with differing CHO content in their diets, and Wynne et al 32 did not find significant differences in participant performance with a higher CHO content in the meal previous to a simulated match, compared with a control group. Regarding GI, it has been reported that a high-GI dietary meal preexercise favors CHO oxidation at submaximal intensities. 30,31 Additionally, it has been reported that the intake of oatmeal with milk pre-exercise could diminish the level of reactive oxygen species (ROS) post-exer- cise, 36 and no gut discomfort or differences in performance were reported when compared with the effects of ingestion of a pre-exercise meal fortified in calcium. 34,35 Furthermore, a diet with very low CHO bioavailability (ie, a ketogenic diet), has been reported to positively influence body composition (reduction of percentage fat mass and increasing lean body mass), but not neuromuscular adaptations. Similar results were found when physically active participants undertook training in a fasted state. 29 Studies focused on a high-protein diet have not found an interaction between the duration of the intervention and performance variables, but they have confirmed that such a diet does not have a negative impact Nutrition Reviews V R Vol. 83(3):e1068–e1089 e1073 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 on health. 20,22 However, it has been reported that a high-protein diet (2.0 g/kg/day) has more beneficial effects than a low-protein diet (1.0 g/kg/day). 21 Similarly, it has been reported that a high-PUFA diet was associated with an increase in the cross-sectional area of muscle fibers, compared with a control diet. Other interventions, such as a high-antioxidant diet 25 or a hyperenergetic diet in athletes with oligomenorrhea and amenorrhea 24 have not yielded positive results. On the other hand, milk consumption (355 ml) ingested before sleep has been reported to influence the metabolic response at submaximal intensities, with a potentiation of CHO metabolism. 33 Summarized results of the studies based on the manipulation of dietary supplements The characteristics and main results of the studies with interventions based on dietary supplements are summarized in the Supplementary Materials, including supplements (i) for preventing and treating deficiencies (Supplementary Materials S4), (ii) as a practical form of energy and nutrients (Supplementary Materials S5), and (iii) for directly (Supplementary Materials S6) or (iv) indirectly improving performance (Supplementary Materials S7). Of the studies investigating dietary supplements for preventing or treating deficiencies, 3 studies that focused on iron supplementation reported a positive effect from this supplement in terms of increasing hemoglobin levels 38 and log serum ferritin 39 in competitive athletes. Additionally, a positive effect on total energy expenditure during 4-km time trials (TTs) was observed in iron-depleted rowers after iron supplementation. 38 These positive effects on the main iron metabolism indicators (ie, hemoglobin and soluble transferrin receptor) have also been observed in soldiers after an intensive training program, when they had been pretreated with iron supplementation. 37 Regarding vitamin supplementation, folic acid may be associated with a small enhancement of blood flow activity, 40 while vitamins with antioxidant effects, such as vitamins C and E, have failed to show enhancement of physical performance or facilitation of recovery post-exercise. 41,42 Regarding the use of supplements for supporting energy and nutrient bioavailability for physical exercise, it has been reported that CHO ingestion during the acute recovery phase post-exercise that induces muscle glycogen is effective for increasing performance in subsequent maximal efforts. 43 It has been reported that intake of a combination of CHO and protein during exercise could have more beneficial effects than intake of CHO alone, for TTE at 75% VO 2max after 3 hours of submaximal cycling. 57 Based on the results obtained from 3 studies, ingestion of egg (a natural form of protein supply) 44 and whey protein post-exercise at low dosages (from 15 to 25 g) 45,46 could be effective in improving both physical performance and body composition (in terms of increased lean body mass). In 2 studies conducted with a-lactalbumin supplementation, positive effects have been reported in competitive athletes regarding variables related to sleep quality 47,58 as well as endurance performance. 58 Regarding supplements for enhancing performance, the most important finding is that 9 out of 10 studies analyzing the effectiveness of caffeine (at dosages ranging from 3 to 6 mg/kg of caffeine administered 45 to 60 minutes pre-exercise) have reported an ergogenic effect for at least one of the assessed physical variables, 59–62,64–68 especially in explosive and high-intensity efforts. Regarding the MC, the 2 studies published have reported an ergogenic effect from caffeine ingested during both the early and late follicular phases, 59,60 but 1 of the studies did not find statistically significant differences in the luteal phase. 61 Similarly, greater effects of caffeine have been observed in the morning, 66 while the ergogenic effects appear similar at dosages ranging from 3 to 6 mg/kg, 67 with no additional efficacy reported after combining with CHO mouth rinsing. 68 However, 1 study reported a negative effect of caffeine on sleep post-supplementation. 64 Regarding NO precursors, a study performed with elite hockey players failed to show enhancement in physical conditioning in a simulated match after beetroot juice supplementation (BRJ). 74 However, the other 4 studies conducted in physically active or moderately trained women reported ergogenic effects of BRJ 72,73 and citrulline malate 75,76 in explosive and high-intensity efforts. Regarding alkalizing supplements, an acute study using supplementation with sodium bicarbonate (NaHCO− 3) found there was increased pH and NaHCO− 3 in the blood of elite water polo squad players, but it was not effective in enhancing performance outputs in a simulated match. 77 Three out of the 4 studies conducted using b-alanine as a supplement reported an ergogenic effect on physical performance, including endurance, 51 high-intensity efforts, 50,75 and explosive effort. 75 Regarding creatine supplementation, a study of less than 1 week of supplementation duration failed to show an incremental improvement in physical performance, 49 while longer studies reported effects on body composition, including an increase in body mass and/or lean body mass, with 70 or without 71 concurrent increases in physical performance. When creatine supplementation was combined with plyometric training, a greater effect was observed compared with only plyometric training. 48 e1074 Nutrition Reviews V R Vol. 83(3):e1068–e1089 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 Other studies have reported conflicting results regarding the effectiveness of multi-ingredients supplements, 52,78 and 1 study has reported non-ergogenic effects of p-synephrine. 69 Regarding dietary supplements with a potential indirect effect on improving performance, colostrum bovine supplement has been assessed in 4 studies conducted on high-level athletes. 80–83 One of these studies reported that this supplement had a positive effect on plasma buffer capacity in elite women rowers, 82 and a second study in the same sport reported increased mechanical work done and performance in a 4-minute rowing TT. 83 The other 2 studies, focused on inflammatory and iron metabolism markers, reported that colostrum bovine supplement had an ameliorating effect on the inflammatory response to exercise: a reduction in IL-6 81 and creatine kinase in 1 study, and an increase in IL-10 80 in the other, post-exercise. Other effects on the inflammatory response post-exercise have been investigated in a further 3 studies: increased performance was associated with some supplements (eg, curcumin supplementation was associated with increased VO 2max –), 85 but not with other supplements, such as fish oil 54 or Opuntia ficus indica. 84 Additionally, ergogenics effects have been reported for both the probiotic DE111 53 and tart cherry. 55 In this way, probiotic DE111 53 increased strength andinduce to a reduction of body fat mass while tart cherry supplementation 55 induce to higher neuromuscular function in physically active women. 53 The intake of avocado pulp has been shown to enhance recovery post-exercise. 79 Conversely, other supplements such as chromium picolinate 56 and melatonin 86 have not demonstrated similar effects. Risk-of-bias assessment Overall, the experiments exhibited “unclear” risk of bias. Our assessments predominantly indicated unclear risk of bias for 55 studies (77%), while 12 studies fell into the category of high risk (17%) and 4 studies (5%) exhibited a low risk of bias (see Supplementary Material S8). This was primarily due to a lack of reporting of protocols prior to the trials. Without this issue, the majority of interventions would have scored a low risk of bias. Among the 71 RCTs, 10 studies had an unclear risk of bias related to lack of a dietary control group; 40 studies were assessed as having risk of bias related to absence of information about controlling for MC phase; 25 studies were assessed as having risk of bias related to a lack of information on the protocols; finally, 17 studies were assessed as having risk of bias related to the blinding of researchers. Generally, the studies scored better (were assessed as having “low risk”) on items related to deviations from the intended interventions, missing outcome data, and participant randomization. DISCUSSION The first finding of this systematic review was that there is a very small number of studies that have been undertaken focused on optimizing health, performance, and recovery in female athletes and other physically active women, relative to the number of studies focused on male athletes. Thus, dietary strategy recommendations based on scientific evidence for women 13,87,91–93 are currently overshadowed by those available for physically active men athletes. The second important finding was that only 22 studies (31%) (including 2 studies with menopausal/oligomenorrheic/amenorrheic athletes) considered the MC when undertaking trials, and only 4 studies compared the effects of various nutritional interventions at different phases of the MC. Due to the limitations of the available data, the current dietary recommendations for female athletes (including those discussed in the present systematic review) may have limited biological validity and applicability in physically active women and female athletes. 15 The American College of Sports Medicine declared that the benefits of dietary supplements should be considered as an adjunct to a well-designed nutritional plan, as a possible optimizing complement. 13 The dietary recommendations for female athletes, however, represent a starting point in new lines of research that may provide information about the physiological effects of dietary manipulation and supplementation, and the best way to apply dietary manipulation and supplementation, within the framework of female physiology and adapted to the various sports disciplines. Nevertheless, 76% of the studies included in the present systematic review assessed the effects of dietary supplements. Effects of various types of dietary manipulation in female athletes In the 1970s, a pioneering study established a direct relationship between fatigue, as determined by TTE running at an intensity of approximately 80% VO 2max in both continuous and intermittent procedures, and the complete depletion of muscle glycogen stores. 94 In a subsequent study, a dual relationship was established: (i) higher CHO content in the diet resulted in higher muscle glycogen content; (ii) higher pre-exercise muscle glycogen content improved performance for TTE running at approximately 80% VO 2max . 95 These studies are of considerable importance, as their findings showed the benefit of increasing the CHO content of an athlete’s diet. In fact, the initial recommendations for an athlete’s Nutrition Reviews V R Vol. 83(3):e1068–e1089 e1075 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 nutrition prioritized the establishment of a high-CHO (HCHO) diet. Athletes were advised to increase their CHO consumption based on their energy cost of training or competition, environmental factors, and sex (with men requiring a higher amount of CHO than women). 96 For decades, CHOs have played an important role in the dietary and nutritional interventions and planning for athletes. Over time, various recommendations for CHO intake have been established, based on the type and duration of training and competition. In recent years, there has been a growing interest in the application of CHO manipulation strategies as part of nutritional prioritization and as a key element of training planning. Examples of such strategies are HCHO or low- CHO diets, fasting, or GI-based diets. These strategies have been relatively understudied in female athletes. Glycemic index is a term used to classify dietary sources of CHO, based on the rate at which blood glucose level is increased after ingestion, compared with the rate after ingesting glucose. 97 A study was conducted by Stevenson et al 30 in 8 active and eumenorrheic women. They compared the effects of pre-exercise mixed meals containing CHOs with either a high GI (HGI) or a low GI (LGI) on substrate utilization during rest and exercise. A breakfast was provided 3 hours prior to exercise, including 2 g of CHOs per kilogram of fat mass, with the GI for one group being 78 (HGI) and that of the other group being 44 (LGI). Their results demonstrated that GI can influence substrate oxidation during subsequent exercise: there was a higher rate of fat oxidation in the group that ingested a LGI breakfast. In addition, GI was found to have a significant effect on hyperglycemia and hyperinsulinemia response (higher in HGI than LGI) during the postprandial period in women. One of the studies included in this systematic review confirmed this pioneering finding in the field of sports nutrition. Walker et al 26 found that 3 days following a HCHO diet, followed by 3 days with a large volume of training while following a mixed diet (48% of energy provided by CHO), during the luteal phase, increased muscle glycogen content before exercise in comparison with a mixed diet alone in female endurance athletes. Furthermore, the HCHO diet induced a metabolic response characterized by an increased respiratory exchange ratio (RER), increased rate of CHO oxidation, higher blood lactate concentration, and an extended TTE at an intensity of above 80–82% VO 2max . These results substantiate for women the previously reported relationship established for male athletes between the CHO content of the diet and fatigue in efforts where glycogen depletion is a limiting factor of fatigue. 94,95 In another study, Dolins et al 27 analyzed the effect of diets with different CHO content (3 vs 5 vs 8 g/kg/ day) on TTE at an intensity of 90% VO 2max in female endurance cyclists. They did not report differences in the metabolic response, measured as either RER or in performance. The absence of change in the metabolic response being detected in that study is expected, because the intensity used (upper second ventilatory threshold) can only be sustained through CHO metabolism. 98 The intensity of the effort was modulating the metabolic response more significantly than the muscle glycogen content was. The relatively short duration of the effort (�4 minutes) meant that glycogen availability was not a limiting factor for performance. In fact, these results could be in agreement with the findings of McLay et al, 28 who investigated muscle glycogen levels pre-exercise (following ingestion of 8.4 vs 5.2 g/kg/day of CHO) and found a subsequent increase in the rate of CHO utilization during submaximal exercise in moderately trained female cyclists (at intensities of between 45% and 75% VO 2max ). The McLay et al 28 study did not demonstrate a statistical significant enhancement of performance in the time taken to cover a 16-km TT, although 6 out of 8 participants showed an improvement in performance after ingesting a HCHO diet. Their study validated 2 hypotheses: (i) HCHO diets increase muscle glycogen and the metabolic use of CHO as a fuel source, and (ii) an increase in muscle glycogen content after a HCHO diet is not effective in improving performance in trials characterized by a lack of depletion of muscle glycogen content. They found that neither the metabolic nor the physical response differed between the midfollicular and midluteal phases; however, the most important finding was that HCHO diets do not increase performance during physical efforts where there is an insufficient capacity for depletion of muscle glycogen stores in female athletes. Zeng et al 36 investigated the influence of CHO ingestion in the meal preceding exercise and reported a positive effect of including oatmeal (1 g/kg) combined with milk, in comparison with only milk. There was an increase in blood glucose during high-intensity interval training (HIIT) and a reduction in ROS post-exercise. These effects may be attributed to greater glycogen availability during exercise, which could reduce metabolic stress in the acute recovery period post-exercise. Oatmeal is a dietary source enriched in CHO with a low GI (LGI). Two different studies have reported the effects of an isocaloric breakfast (2 g/kg/day) consumed 3 hours pre-exercise, comparing the effects of LGI and HGI meals. 30,31 In one of these studies, which involved 7 physically active women, the HGI meal resulted in an increase in blood glucose and insulin levels pre-exercise, with a trend towards increased CHO metabolism. 31 The e1076 Nutrition Reviews V R Vol. 83(3):e1068–e1089 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 procedure, Glenn et al 88 reported an increased TTE at 120% VO 2max after a single dose of 1.6g of b-alanine. In long-term protocols, Smith et al 51 reported an interaction between time and supplementation for the effect on body composition and RPE after 4weeks of ingesting 4.8 g/day of b-alanine, but not for VO 2max or VT1. Thus, it is important to note that changes in VO 2max in trained athletes are limited and require at least an 8week training period. The positive effect reported for RPE could reflect an enhanced training capacity in the participants, especially during interval training, due to a higher buffer capacity. In fact, this superior capacity for training could explain the enhancements observed in a consecutive 60seconds of CMJs and a running-based anaerobic print test (RAST) in combination with plyometric training vs plyometric training alone. However, these effects have not been detected in other tests with lower demands in terms of glycolytic metabolism, as in 20-m sprints or in a single CMJ in women soccer players. In agreement with their results, Glenn et al 89 reported mean power and total work done during the last third of a set of 50 maximal isokinetic leg extensions, an effort with significant glycolytic demands. The reduction in pH occurring as a consequence of increased glycolytic activity inhibits phosphofructokinase activity, 137 hampering the glycolytic pathway and affecting muscle contraction by influencing competition between calcium and hydrogen ions at the troponinbinding site. 138 b-alanine increases carnosine levels, facilitating the transport of calcium from the sarcoplasmic reticulum to the myoplasm, promoting more crossbridging and potentially faster muscle contraction. Carnosine also acts as a buffer, capturing hydrogen ions and transporting them to the extracellular space. 139 Given that women present lower levels of muscular carnosine compared with men 140 and, considering the results of the studies included in this systematic review, it is plausible to state that female athletes and physically active women are likely to benefit from the ergogenic effects of b-alanine. Regarding NaHCO− 3, only 1 article met the inclusion criteria. 77 That study reported a positive effect of NaHCO− 3 in regulating blood pH, but did not find a significant improvement in mean sprint times in a 59-minute simulated match in an elite water polo squad. Future studies should investigate the effect of NaHCO− 3 supplementation in female athletes, since the ingestion of NaHCO− 3 increases blood pH, facilitating the buffering of excess hydrogen ions in the blood, delaying accumulation of hydrogen ions within muscle fibers and leading to increased glycolytic metabolism during efforts. In addition, these future studies should adhere to the recommended dose (200–400 mg/kg) in combination with a small CHO-rich meal (1.5g/kg) 2–2.5 hours before exercise to minimize gastrointestinal symptoms. 87 Creatine is considered one of the most effective supplements in the sports world141; however, its effectiveness in women has been largely overlooked until now. In this review, 4 studies conducted with creatine supplementation met the inclusion criteria. In elite female soccer players, supplementation with 20 g/day of creatine for 6 days increased body mass; however, overall, it did not improve performance in agility tasks. 70 In a similar study, the effects of a 6-week plyometric training and creatine supplementation intervention on maximal-intensity and endurance performance in women soccer players showed that both placebo and creatine plyometric training groups showed improved performance in jumps, sprints, repeated sprinting, endurance, and change-of-direction speed, and that creatine did not impact on these parameters. 48 The study of Brooks et al 71 investigated the effects of 0.1 g/kg/day creatine supplementation for 6 weeks on body composition, performance, and cognitive function of female collegiate dancers. Creatine significantly impacted body composition by increasing total body water, lean mass (kilogram), and lower appendicular lean mass, but not the percentage of lean mass. No effects were detected in performance or cognitive function. 71 Only 1 study considered the phase of the MC in relation to the effect of creatine supplementation in women. The study investigated the effects of 20 g/day of creatine supplementation for 5 days on performance and hormone levels in recreationally active women. During the luteal phase, sprint performance and recovery were significantly reduced in both groups, indicating that perhaps this phase of the MC would be the most appropriate for supplementation. However, creatine supplementation had no effect on heart rate variability (HRV), fatigue index, sprint performance, or recovery. Creatine is a naturally occurring compound in the body, being stored primarily in the muscles and used for quick bursts of energy during high-intensity activities. Creatine supplementation has been shown to increase the body’s creatine phosphate stores, leading to enhanced performance in short-duration, high-intensity activities like sprints and jumps. 142 The effects of creatine supplementation in women are multifaceted and influenced by various factors, including the type of physical activity, the training regimen, and hormonal fluctuations. The need for more comprehensive research that considers these variables and has higher sample sizes is evident if we are to better understand the nuanced relationship between creatine and athletic performance in females. A fourth category of dietary supplements includes those that may indirectly improve physical performance by supporting the athlete’s health status, promoting a more suitable body composition, or enhancing the ability Nutrition Reviews V R Vol. 83(3):e1068–e1089 e1083 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 to train hard, recover fast, or avoid sport injuries. 91 Within this category, bovine colostrum stands out as the most-studied dietary supplement for women, with a total of 4 studies. 80–83 Bovine colostrum is a type of milk produced by cows during the first few days after giving birth. It contains a high concentration of mitogenic hormones and growth factors, which have been shown to increase the synthesis of skeletal muscle protein. 143 Two studies investigated the effect of bovine colostrum on buffer capacity in female rowers, with different results. 82,83 In the first study, supplementation with 40 g/day of protein from bovine colostrum for 9 weeks increased buffer capacity, 82 whereas in a second study 83 it did not. Neither study detected any effect on sporting performance. The discrepancy in these results may be due to the small sample size (less than 10 women in each study) and/or to the lack of detailed characterization of the colostrum composition. Two other studies investigated long-term (6 months) supplementation with 3.2 g/day of bovine colostrum on the immune system, iron homeostasis, oxidative stress, and inflammation, 80,81 in women basketball players. Of all the parameters analyzed in relation to the immune system (IL-1-alpha, IL-2, IL-10, IL-13, TNF, IgG), supplementation only showed an effect on IL-10 levels (an increase compared with the control group), indicating a potential anti-inflammatory effect. Bovine colostrum supplementation was able to decrease muscle damage, as lower postexercise CKMM levels were detected in the colostrumsupplemented group. 81 The findings in relation to oxidative stress, inflammation, and iron homeostasis are also rather limited. Changes were only detected in the lipid peroxidation marker (TBARS) and in IL-6 levels, which were lower post-exercise in the supplemented group. 80 Higher transferrin and lactoferrin values were found in the post-exercise stage after supplementation, which indicates that bovine colostrum may have an effect on iron homeostasis, which is of great importance for the female athlete. The results of the studies included in this systematic review suggest that supplementation with bovine colostrum could reduce oxidative stress and inflammation through the presence of antioxidants, such as lactoferrin and caseins, which protect against free radical damage. In addition, bovine colostrum can modulate the inflammatory response and iron levels in the body, which may contribute to its beneficial effects. Some studies included in the systematic review have evaluated the effects of various interventions based on the consumption of certain foods or supplements containing nutrients, bioactive compounds, or probiotics in female athletes. 55,84 For example, the consumption of foods such as Opuntia ficus indica juice, which is rich in minerals, vitamins, proline, glutamine, taurine, and betalains, was shown to be associated with a statistically significant reduction in exercise-induced oxidative stress parameters, contributing to an accelerated recovery time. 84 Furthermore, in a study conducted by Brown et al, 55 supplementation with Montmorency tart cherry concentrate, which is rich in flavonoids and anthocyanins, was shown to be associated with an improvement in recovery after CMJ performance compared with the control group. Moreover, supplementation with avocado pulp (high in phenolic acids, flavonoids, and oleic acid) prior to exercise was associated with improved recovery after exercise in metrics of heart rate, systolic blood pressure, HRV, and skin conductance. 79 Conversely, the study performed by Livolsi et al, 56 which evaluated the effect of supplementation with chromium picolinate on muscular strength and body composition, found no significant benefits. On the other hand, probiotics purportedly show promise of beneficial effects in terms of recovery post-exercise, decreased muscle soreness, and decreased levels of markers of muscle damage. 53 Toohey et al 53 investigated the effect of Bacillus subtilis supplementation and found that probiotic consumption in combination with post-workout nutrition had no effect on either physical performance or hypertrophy; however, it may improve body composition by reducing body fat percentage. Supplementation with fish oil (6 g/day) for 3 weeks has not been shown to increase physical performance in 5 maximum isokinetic extensions, but it positively influenced parameters related to muscle damage and inflammation, such as myoglobin and TNF-a. 54 The only study that assessed the effect of curcumin supplementation reported a positive influence of 500 mg/day of Curcuma longa L supplementation on inflammatory parameters and biomarkers of muscle damage, and an improvement in VO 2max . 85 Currently, all of these supplements are categorized as being supported by a low level of scientific evidence. 87,91,92 The limited number of studies on them published to date suggests there is a need to conduct studies in female athletes and other physically active women on possible beneficial effects of the supplements categorized in this group. In addition, future studies should take into account the potential variation in responses to supplements among women, considering factors such as age, fitness level, and individual differences, which may significantly influence outcomes. This is the first systematic review that has analyzed the findings regarding the effects of dietary manipulations and dietary supplementation on performance, recovery, and health status parameters in female athletes and other physically active women. The review has some limitations, related to the number and heterogeneity of the studies and their overall assessment as having “unclear” risk of bias. The first limitation, the limited number of studies analyzing the effects of dietary strategies on performance and health status in female athletes and other physically active women, is amplified by considerable heterogeneity in the e1084 Nutrition Reviews V R Vol. 83(3):e1068–e1089 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 types of interventions in the studies, the very limited information provided about control for menstrual function in adult athletes in the studies, and the minimal amount of research that has been conducted on menopausal and oligomenorrheic/amenorrheic athletes. The most important limitation is related to the detection of only 4 studies (5% of the studies included in the review) exhibited a low risk of bias. Further research in the female population is vital, including longitudinal studies to evaluate the long-term effects of dietary strategies on the performance and health of female athletes and other physically active women. CONCLUSIONS The number of studies analyzing the effects of dietary strategies on performance and health status in female athletes and other physically active women is very limited. This is concomitant with large heterogeneity in the types of interventions of the available studies, very limited information about the influence of the menstrual function, and minimal research on populations including menopausal and oligomenorrheic/amenorrheic athletes. In addition, research on dietary supplements and their effectiveness has been more prevalent than research on dietary interventions in female athletes. Further research is clearly needed on dietary strategies for female physically active women and female athletes. Furthermore, longitudinal studies evaluating the longterm effects of dietary strategies on the performance and health of female athletes are essential. Regarding dietary interventions, we can conclude that HCHO diets influence energy metabolism, potentiating CHO metabolism during exercise and favoring recovery. However, HCHO diets only enhance physical performance in efforts that deplete muscle glycogen. In athletes with a HCHO diet, higher consumption of CHO in preexercise meals and dietary sources with a HGI increase CHO metabolism but have not been shown to improve physical performance. A calcium-rich dairy-based meal may have a positive effect on BMD without increasing gut discomfort. Dietary intake approaching the upper limit of the general recommended protein intake for athletes (1.2–2.0 g/kg/day), distributed over 5 to 6 meals throughout the day, with each meal containing at least 25 g of protein of high quality, may be optimal for ensuring training adaptations. At the same time, ensuring the PUFA-n3 content of the diet is above 500 g weekly of fish or seafood is recommended, and maintainance of an n-6/n-3 ratio below 2 should be considered. Dietary supplements should be considered within an integral dietary plan for female athletes. It is crucial to review possible nutritional deficiencies, focusing on the most prevalent deficiencies (iron, calcium, vitamin C, folic acid, and vitamin B12). Iron status should be frequently reviewed, because iron supplementation may enhance performance even in the case of ID without anemia status. Under normal conditions, there is no evidence for a beneficial effect from intake amounts higher than the RDA. Sports foods can be beneficial for female athletes, especially in situations where there is limited access to foods. CHO supplements are effective for recovery after exercise involving consecutive efforts, and their ingestion with protein could have an added benefit compared with the intake of CHO alone. Whey protein at doses of 0.25–0.3 g/kg immediately post-exercise has been associated with improvement in physical performance and body composition (increasing lean body mass and reducing body fat percentage) in response to a resistance training program. The current data suggests that the use of supplements such as caffeine, precursors of NO, and b-alanine are associated with ergogenic effects in physically active females, specifically in non-elite athletes. The use of other supplements, such as creatine, sodium bicarbonate, a-lactalbumin, fish oil, bovine colostrum, probiotics (DE111), curcumin, and avocado pulp, require more extensive studies, because the existing data, while suggesting a possible effect, are not sufficient to justify recommending their use in female athletes. This review underscores the importance of promoting educational initiatives aimed at raising awareness among female athletes and other physically active women about the importance of nutritional intake and its impact on performance and health. It is imperative that further genderspecific research is conducted to bridge the existing knowledge gaps regarding how dietary manipulation and supplements may impact men and women differently. Author Contributions R.D., A.S.-G., R.C.-R., A.M.-L., and A.S.-G. were responsible for the project administration. M.L., A.G.-I., L.G.G.-R., D.F.-L., A.J.S.-O., and R.D. conceptualized the study. A.S.-G., I.L.-L., and E.C. screened the titles and abstracts. A.S.-G., J.M.-L., and L.G.G.-R. assessed the eligibility of the studies. R.D., A.J.S.-O., and A.L.-S. extracted data from the included studies. J.J.R.-A., R.I.- Q., A.C.-D., and A.S.-G. analyzed the risk of bias of the included studies. M.L., A.G.-I., L.G.G.-R., M.J.M.A., A. F.S.J., N.C.-A., R.L.-G., P.V.-H., E.O.-G., J.C.B.-A., I.S., L.M.F.-G., J.M.M.-S., F.J.M.-A., M.P., E.J.G.-H., A.L.-S., A.J.S.-O., and R.D. wrote the original draft. A.S.-G., J.J. R.-A., D.F.-L., I.L.-L., J.M.-L., D.D.-B., R.IQ., E.C., T.L., J.J.M., D.P.R.-d.-S., E.C.-A., A.C., B.R.-D., M.P.-O., C. S., T.I., B.D.L., A.G.S., M.P.M.-L., E.B.D.G., A.M.-L., R. C.-R., and A.C.-D. wrote, reviewed and edited the manuscript. All authors reviewed and provided comments on the manuscript. All authors approved the final manuscript. Nutrition Reviews V R Vol. 83(3):e1068–e1089 e1085 Downloaded from https://academic.oup.com/nutritionreviews/article/83/3/e1068/7712679 by Sevilla Psych Lib B21 user on 24 February 2025 Supplementary Material Supplementary Material is available at Nutrition Reviews online. 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