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Effect of diet interventions, dietary supplements and

performance-enhancing substances on CrossFit-trained individuals’
performance: a systematic review of clinical studies

Marcus V.L. dos Santos Quaresma , Camila Guazzelli Marques ,

Fernanda Patti Nakamoto

PII: S0899-9007(20)30277-X
DOI: https://doi.org/10.1016/j.nut.2020.110994
Reference: NUT 110994

To appear in: Nutrition

Received date: 15 May 2020

Revised date: 3 August 2020
Accepted date: 8 August 2020

Please cite this article as: Marcus V.L. dos Santos Quaresma , Camila Guazzelli Marques ,
Fernanda Patti Nakamoto , Effect of diet interventions, dietary supplements and performance-
enhancing substances on CrossFit-trained individuals’ performance: a systematic review of clinical
studies, Nutrition (2020), doi: https://doi.org/10.1016/j.nut.2020.110994

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 Effect of diet interventions, dietary supplements and performance-enhancing substances on
CrossFit-trained individuals’ performance: a systematic review of clinical studies

Marcus V.L. dos Santos Quaresma, M.Sc.1, Camila Guazzelli Marques, Graduate.2, Fernanda Patti
Nakamoto, Ph.D.1

1 – Curso de Nutrição, Centro Universitário São Camilo, São Paulo, SP, Brasil.
2 – Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, SP, Brasil.
Authors' contribution: MVLSQ and CGM performed the bibliographic search. MVLSQ and FPN
wrote and corrected the article. FPN and CGM reviewed the bibliographic references. All authors
approved the final version of the article.

Correspondence author:
Marcus Vinicius Lucio dos Santos Quaresma
Avenida Nazaré, 1501, São Paulo – SP, Brazil.
marcus.santos.nutri@gmail.com
Tel.: +5511985020869
Abstract
CrossFit (CF) is characterized as a constantly varied high-intensity functional movement training
program, performed with little or no rest between bouts, combining strength and endurance
exercises, such as running, cycling, rowing, Olympic weightlifting, power weightlifting, and
gymnastic-type exercises. Several nutritional strategies are used to improve sports performance of
CF practitioners; however, most of them are empirical and lack scientific evidence. Thus, the aim of
this review was to determine the effect of diet intervention, dietary supplements, and performance-
enhancing substances in exercise-performance parameters of CF practitioners. MEDLINE/PubMed,
Web of Science, LILACS, SciELO, and Scopus databases were searched using specific Medical
Subject Headings and keywords for clinical studies which enrolled CF athletes in a diet, dietary
supplements, or performance-enhancing substances intervention. Athletic performance was
considered as the primary outcome. No other filters were applied. Including grey literature search, a
total of 217 studies and 2 abstracts were identified, however only 14 studies met the eligibility
criteria. Two studies evaluated the effect of caffeine supplementation on exercise performance and
performance parameters; five studies evaluated high or low carbohydrate effect on performance and
other parameters. One study verified the effect of multi-ingredient supplementation on CF-specific
performance and body composition. One study compared protein supplements intake on
performance and body composition. Two studies assessed the effect of green tea and (-)-epicatechin
on performance and other parameters. One study evaluated the effects of nitrate supplementation on
exercise performance. One study investigated the effect of betaine supplementation on body
composition and muscle performance. Finally, one study examined the effects of sodium
bicarbonate (SB) ingestion on exercise performance and aerobic capacity. Only sodium bicarbonate
(SB) supplementation improved CF performance. These outcomes may have been obtained due to
methodological limitations such as small sample size, lack of control over influencing variables,
short period of exercise intervention. Despite the popularity and growing evidence about the CF,
little is known about the relationship between performance-enhancing substances or dietary
interventions and CF performance. Given the lack of scientific evidence, new studies with potential
ergogenic supplements, good methodological model, and practical application are required.
Keywords: CrossFit. CrossFit-Training. Dietary Supplementation. Performance-Enhancing
Substances. Athletic Performance.
Background
CrossFit (CF) is characterized as a constantly varied high-intensity functional movement
training program, whose methodology is entirely empirical [1]. This type of exercise training has
been practiced to improve physical conditioning, as well as to reduce body fat, considering that the
intensity of training predisposes to negative energy balance [2]. CF is usually performed at high
intensity with little or no rest between bouts, combining strength and endurance exercises, such as
running, cycling, rowing, Olympic weightlifting, power weightlifting, and gymnastic-type exercises
[3]. Most practitioners seek fitness and health, but a significant amount engages in high level
competition, officially organized by CrossFit Games (games.crossfit.com).
These situations of high-intensity exercise may, however, precociously lead to fatigue and
increase the perception of tiredness. Furthermore, it is believed that, due to the high demand of
training and inadequate progressive load control, CF can increase risk of injuries, overreaching, and
overtraining [1].
In this scenario, although nutritional adjustments and ergogenic supplements are the target
of several studies related to physical exercise [4] in general, few studies have been conducted (i) to
determine the average intake of macronutrients and micronutrients by CF practitioners and (ii) to
determine the effect of ergogenic supplements on the CF performance. Considering the high
intensity [5] of CF, it is intuitively believed that the intake of carbohydrate (CHO) is essential to
maintain glycogen stores; however, practitioners commonly report undergoing diets with low CHO
levels or even ketogenic diet (KD) [6,7], even though the high demand for energy with insufficient
nutritional intake lead to conditions of low energy availability, known as relative energy deficiency
in sport (RED-S) [8]. Also, medium-chain triacylglycerol (MCT) supplementation has become very
common among CF practitioners, mainly before exercise, although several previous studies have
shown that there is no improvement in performance [9].
Therefore, the present review aimed to determine the effect of diet intervention, dietary
supplements, and performance-enhancing substances on exercise-performance parameters of CF
practitioners.

Methods
Study type
We followed the systematic review structure according to The Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) [10] and utilized the PICOS search approach
[11].

Eligibility criteria
 The present systematic review included randomized clinical trials or non-randomized
clinical trials that determined the effect of nutrition therapy, dietary supplements, and performance-
enhancing substances in young and adult CF athletes or CF practitioners. The PICOS approach was
utilized, including Medical Subject Headings, entry terms or keywords found in articles of the area.
Thus, we considered: Participants (CF Athletes); Intervention (Diet, Dietary Supplements or
Performance Enhancing Substances); Control (not applied); Outcome (Athletic Performance); and
study type (not applied). No language, publication date, or publication status restrictions were
imposed. We considered athletic performance as the primary outcome after different acute (hours-
minutes before the test) or chronic (days, weeks, or months) interventions. Other parameters
assessed in the studies were considered as secondary outcomes. Moreover, there were neither
exclusion criteria for study duration, dietary intervention, supplement type, dose, performance
outcome measurement, lack of placebo-controlled group, nor participant's sex, age, body mass,
sample size, or training status. Studies including animal models were excluded from the current
analysis.

Information sources
MEDLINE/PubMed, Web of Science, LILACS, SciELO, and Scopus databases were
consulted in this review. Moreover, we used gray literature through Google Scholar. The last search
was run on June twenty-third, 2020. In addition, we did manual search in websites of the area, using
the same keywords. No publication date filter was applied in any search.

Search strategy
A search for peer-reviewed literature of published articles (all clinical trials type), without
publication date restriction until June twenty-third, 2020 was conducted in MEDLINE, Web of
Science, LILACS, SciELO, and Scopus databases. MesH terms, entry terms, and keywords related
to CF, diet, dietary supplements, performance-enhancing substances, and exercise performance
were used. Full MEDLINE search strategy was adapted for the other databases. Gray literature
search was performed applying the same search terms in Google Scholar. There were no language
restrictions, although English search terms were used. Study type restrictions were not applied
during the search. The full search strategy is described in the supplementary material 1.

Study selection
Eligibility assessment was performed independently, in a duplicate standardized manner by
two reviewers (MVLSQ and CGM). Disagreements were resolved by discussion between the two
review authors; if no agreement could be reached, it was resolved by the third (FPN) author.
Data extraction
Data from the included studies were extracted by one review author (MVLSQ) and checked
by a second author (FPN). Disagreements were resolved by discussion between the two review
authors; if no agreement could be reached, it was resolved by a third author (CMM). Synthesis of
the results includes (1) authors and year, (2) study type, (3) size and characteristics of the sample,
(4) intervention (nutrition therapy, dietary supplements, performance-enhancing substances), (5)
control or placebo group, (6) dose, duration and frequency of the intervention, (7) exercise
performed, (8) primary outcome, (9) secondary outcome. Further details of the studies are described
in the supplementary material 2.

Quality assessment (risk of bias)

In order to ascertain the validity of eligible clinical trials, a pair of reviewers (MVLSQ and
FPN), working independently and with adequate reliability, determined the adequacy of
randomization, concealment of allocation, blinding of patients, providers, and researchers,
similarity of groups at baseline, dropout rate, adherence, avoidance or similarity of other
interventions, consistent implementation of valid measures to assess outcomes, power calculation,
prespecification of reported outcomes or analyzed subgroups, and intention-to-treat analysis,
employing Quality Assessment of Controlled Intervention Studies tool. Studies with no control
group were analyzed by the same pair of reviewers, employing Quality Assessment Tool for
Before-After (Pre-Post) Studies With No Control Group. Questions included in the assessment tools
were designed to help reviewers focus on the key concepts for evaluating a study's internal validity.
Both tools can be found at www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools.

Results
A total of 219 studies were identified in the full search for inclusion in the review. Twenty-
three studies were found in MEDLINE, 21 studies in Web of Science, 11 studies in LILACS, 6
studies in SciELO and 2 studies in Scopus. Concerning grey literature, 156 studies were found
through Google Scholar. After removing duplicates, 202 studies remained. Out of these, 183 studies
were discarded following abstract reading, because they did not meet eligibility criteria. After full
text detailed reading of the 19 remaining citations, 5 studies did not meet the inclusion criteria as
described. Therefore, 14 studies met the inclusion criteria and were included in the systematic
review. The steps for final selection of the studies are described in the PRISMA flow diagram
(Figure 1).
 Identification

Records identified through database Additional records identified

searching through other sources
(n = 63) (n = 156)

Records after duplicates removed

(n = 202 studies)
Screening

Records screened Records excluded

(n = 202) (n = 183)

Full-text articles assessed Full-text articles excluded,

Eligibility

for eligibility with reasons

(n = 19) (n = 5)
2 studies = not clinical
trial (cross-sectional)
2 studies = literature
Studies included in review
qualitative synthesis 1 study = retracted and
(n = 14) replaced
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n = 0)

Figure 1. Flow diagram of the search process

Participants and study general characteristics

Included studies (all 14) comprise 249 individuals, among which 99 are women (39.76%)
and 150 are men (60.24%), characterized by authors as physically active, CF practitioners, or CF
athletes. Mean age is 29.9 years and mean body mass index (BMI) is 25.31 kg/m2. Six studies are
randomized, double-blind, placebo-controlled, cross-over trials; one study is a randomized, double-
blind, placebo-controlled trial; one study is a randomized, double-blind trial; one study is a
randomized, placebo-controlled trial (blinding not informed); two studies are randomized,
controlled trials (blinding not informed); one study is a randomized, open-label, controlled, trial;
one study is a non-randomized, controlled, open-label trial; one study is a non-randomized, open-
label trial.
Studies were published between 2014 and 2020 (1 study in 2014; 2 studies in 2016; 2
studies in 2017; 2 studies in 2018; 3 studies in 2019; and 4 studies in 2020), carried out in different
countries: 9 in the United States of America, 3 in Poland, 1 in Italy, and 1 in Brazil. According to
the risk of bias analysis, 2 studies were classified as Good, 3 as Fair, and 9 as Poor. Risk of bias
details are described in the supplementary material 3.
Two studies (Fogaça et al., 2020 [12]; Stein; Ramirez; Heinrich, 2020 [13]) evaluated the
effect of caffeine supplementation on performance parameters. Five studies (Escobar; Morales;
Vandussenldorp, 2016 [14]; Gregory et al., 2017 [15]; Rountree et al., 2017 [16]; Kephart et al.,
2018 [6] and Durkalec-Michalski; Nowaczyk; Siedzik, 2019 [17]) assessed the impact of
carbohydrate (CHO) intake on different parameters. Three out of these five studies evaluated the
effect of the ketogenic diet on the oxidation rate of substrates (Durkalec-Michalski; Nowaczyk;
Siedzik, 2019 [17]), body composition, and performance (Kephart et al., 2018 [6]; Gregory et al.,
2017 [15]). Escobar; Morales; Vandusseldorp, 2016 [14] assessed the effect of increased CHO
intake on performance; Rountree et al. (2017) [16] evaluated the effect of CHO intake during
training on sports performance. One study (Outlaw et al., 2014 [18]) assessed the effects of a pre-
workout (extracts of pomegranate, tart cherry, green and black tea) and a post-workout (protein and
carbohydrate) supplement on CF-specific performance and body composition. One study (Banaszek
et al., 2019 [19]) compared whey protein with pea protein intake on performance and body
composition. Two studies assessed the effect of green tea and (-)-epicatechin on performance,
oxidative stress, antioxidant defense enzymes (Sadowska-Krepa et al., 2019 [20]), local
vasodilation following resistance exercise, and high-intensity exercise performance (Schwarz et al.,
2020 [21]). One study (Kramer et al., 2016 [22]) evaluated the effects of nitrate supplementation on
exercise performance. One study (Moro et al., 2020 [23]) investigated the effect of 6 weeks of
betaine supplementation on body composition and muscle performance during CF training; and One
study (Durkalec-Michalski et al., 2018 [24]) examined the effects of chronic, progressive-dose
sodium bicarbonate ingestion on CF performance and aerobic capacity (all results are shown in
table 1). More details about each of the 14 studies can be found below.

Intervention characteristics
Fogaça et al. (2020)[12] evaluated the effects of acute caffeine supplementation (6 mg/kg
body mass) on workout performance, power, markers of muscle damage, and soreness in trained CF
men. Caffeine supplementation had no influence on CF workout performance compared to placebo
group (PLA). Countermovement jump (CMJ) test and hand grip strength also did not differ between
treatments. CAF group showed higher glucose concentration compared to PLA in post workout.
Creatine kinase (CK) and high-sensitivity C-reactive protein (CRP) activity did not differ between
groups in post or 24 h post workout. Likewise, no differences were found between treatments in
delayed-onset muscle soreness (DOMS) and ratings of perceived exertion (RPE). Therefore, authors
found no changes after acute caffeine supplementation in any analyzed parameter. Stein, Ramirez,
Heinrich (2020)[13] determined the effects of caffeine supplementation (5mg/kg; 1h prior to
exercise) on CF performance for a 20-min muscular endurance workout of as many rounds as
possible (AMRAP) of 5 pull-ups, 10 push-ups, and 15 air squats (CF benchmark "Cindy").
Considering the total number of repetitions performed in 20 minutes, no significant differences
were found between caffeine and placebo conditions. Therefore, caffeine supplementation did not
improve performance of CF practitioners.
Gregory et al. (2017)[15] determined the effects of a low-carbohydrate ketogenic diet
(LCKD) on body composition and performance after 6-weeks of CF training. It was observed that
the LCKD group significantly decreased body weight, BMI, percentage body fat (%BF), and fat
body mass (FBM) compared to the control group. Both groups significantly decreased total workout
performance time, with no significant difference between groups. Moreover, no significant
differences in vertical jump and standing long jump were found between or within groups, when
analyzed separately. For both groups combined, author observed significant overall change in
vertical jump and significant improvement when looking at these power tests together. Authors
suggest that adhering to a LCKD and CF practice can lead to weight loss and improved body
composition, without negatively affecting lean body mass (LBM), strength, or power performance.
Durkalec-Michalski; Nowaczyk; Siedzik (2019)[17] determined the effects of a 4-week
ketogenic diet (KD) on oxidation rates of energy substrates in twenty two CF-trained athletes.
Authors observed that both women and men increased the rate of fat oxidation (g·min−1·kgFFM−1)
and the percentage contribution of fat oxidation to the energy yield at KD compared to customary
diet (CD) testing. In women, the contribution of CHO to energy metabolism was significantly lower
at KD compared to CD testing, but the rate of CHO oxidation was unchanged. In men, the rate of
CHO oxidation and the contribution of CHO oxidation to energy metabolism during the KD testing
was lower compared to CD testing. However, parameters of sports performance were not analyzed
in this study. No control group was included in this study. Therefore, it cannot be assumed that this
nutritional intervention improves physical capacity. It suggests, though, that regarding metabolic
adaptation, the result was positive. In a longer intervention, Kephart et al. (2019) [6] determined the
effects of a 12-week KD on body composition, metabolic, and performance parameters in
participants who trained recreationally at a local CF facility. Authors found significant decrease in
body mass and fat mass in KD group. However, since the data of food intake in the control group
are not presented, it is not possible to affirm weight loss is an exclusive consequence of CHO
restriction. Resting energy expenditure and respiratory quotient did not differ between groups.
Regarding performance parameters, no changes were observed following strength/power tests of
one-repetition maximum (1-RM) back-squat, 1-RM power-clean, push-ups, 400-m run). Finally, no
changes were observed in fasting glucose, HDL cholesterol, and triglycerides levels between
groups, although LDL cholesterol increased in KD group (114.1  16.2 to 153.9  27.4 mg/dL).
Escobar; Morales; Vandusseldorp (2016) [14] determined the effects of a high CHO intake
on CF performance in strength trained individuals. Both groups consumed, over five days, <6g of
CHO/kg/day. At days 6, 7, and 8, CHO group subjects were instructed to increase consumption to
6-8g of CHO/kg/day. Control group subjects maintained previous intake (<6g of CHO/ kg/day). At
days 1, 5, and 9, "Rahoi" CF workout (a 12-minute workout of AMRAP of 12 box jumps, 6
thrusters, and 6 bar-facing burpees) was performed. Mean O2, mean respiratory exchange ratio,
pre, 4 minutes, 8 minutes, and immediately post (12 minutes) blood lactate concentration measured
during "Rahoi" were not influenced by the experimental intervention. The number of complete
repetitions increased significantly in both groups (CHO group: 139.2  28 to 154.4  29; control
group: 132.2  23.8 to 137.9  24.9), with no difference between the groups. However, although
there is no significant difference, CHO group displayed a 15.2 repetition increase (+ 10.9%) on day
9, compared to 5.7 (+ 4.2%) displayed by the control group. It is especially relevant in CF
competition, since the higher number of repetitions in a specific duration bout can define the
winner. It brings encouraging information, leading towards further investigation with more
participants and analysis of other parameters.
Rountree et al. (2017) [16] investigate the performance impact of CHO ingestion during
high-intensity exercise sessions in CF-trained men. The CHO supplement was a 6%
sucrose/dextrose solution. Participants received 16 grams of CHO in ~ 250 mL of fluid over 30
minutes during the supplementation trial. Beverages containing a 6% CHO solution in 41.6 mL of
water were provided immediately prior to the warm-up, prior to the initiation of round one of ―Fight
Gone Bad Five‖ (FGBF) benchmark workout, and during the one-minute rest breaks after rounds 1–
4, for a total of six ingestions. FGBF consists of 5 rounds of 5 minutes (1 minute for each exercise,
respectively: wall ball throw, sumo deadlift high pull, box jump, push press, and rowing
ergometry), in which as many repetitions of each exercise as possible within the minute are
performed. No differences were observed for total work between CHO and PLA trials. As a result,
authors did not find any performance improvement with CHO supplementation.
 In an open label randomized study, Outlaw et al. (2014) [18] assessed the effects of a pre-
and a post-workout supplement on CF-specific performance and body composition, following 6
weeks of CF training. Anthropometric and performance parameters ( O2max, Wingate peak (WPP)
and mean power (WMP), sport-specific Workouts of the Day (WOD) (WOD1: 500 m row, 40 wall
balls, 30 push-ups, 20 box jumps, 10 thrusters for time; WOD2: 15 minutes to complete a one-time
800 m run, followed by as many rounds as possible (AMRAP) of 5 burpees, 10 Kettlebell swings,
and 15 air squats) were assessed at weeks 0 and 6. Thirty minutes before each training session,
participants of the supplement group received 19 g of a pre-workout drink (extracts of pomegranate,
tart cherry, green and black tea). Immediately after each training session, they received a post-
workout protein and carbohydrate supplement. The control group consumed only water one hour
before or after workouts. According to authors' 95% Confidence Intervals and Magnitude
Inferences analysis, O2 max, Wingate peak power, and WOD2 results revealed that the pre/post
supplements were likely beneficial. No time × group interactions for body composition, Wingate
mean power, or WOD1 were found. Authors did not inform the number of subjects in each group,
baseline information of height, or BMI.
Banaszek et al. (2019) [19] compared the effects of consuming whey protein and pea protein
on body composition and performance, following 8-weeks of high-intensity functional training
(HIFT - 4 training sessions per week). Participants consumed 24 g of either whey (n = 8) or pea (n
= 7) protein before and after exercise on training days and in-between meals on non-training days.
Performance parameters assessed were 6-second isometric mid-thigh pull, 1-RM back squat, 1-RM
deadlift, WOD 1 (400 m run, 50 sit ups, 400 m run, 40 box jumps, 400 m run, 30 kettle bell swings,
400 m run, 20 wall balls, 400 m run, and 10 thrusters, in this order, as fast as possible), and WOD 2
(maximum distance row using a row ergometer). No significant differences were found in body
composition within or between groups after the intervention. The same results were observed in the
performance tests, except for significant improvements in muscular strength for 1-RM back squat
and 1-RM deadlift (for both groups; no difference between groups). Authors suggest that whey and
pea proteins promote similar strength, performance, body composition, and muscular adaptations
following 8-weeks of CF training. Unfortunately, no placebo-controlled group was included.
Sadowska-Krępa et al. (2019) [20] conducted a pilot study to determine the effects of a six-
week daily green tea extract (GTE) supplementation on blood antioxidant status, serum brain-
derived neurotrophic factor (BDNF) levels, and on aerobic capacity in male CF practitioners.
Training sessions comprised a warm-up, took about 50 minutes and finished with an intense
stretching of the whole body, in a five-day-on and two-day-off pattern schedule. The influence of
CF training on aerobic capacity was assessed based on incremental cycle ergometer testing prior to
the intervention (1st trial) and after the 6-week training period (2nd trial). No significant differences
were recorded among assayed measures such as Catalase (CAT), Glutathione Peroxidase (GPx),
and Glutathione Reductase (GR). Significantly higher SOD activity was recorded at rest and post-
exercise in both studied groups (PLA and GTE) in the 2nd trial compared to the corresponding
values in the 1st trial. Moreover, in the 1st trial, SOD activity significantly increased post-1 h of
recovery in the PLA group compared to the resting values. Levels of ferric reducing ability of
plasma (FRAP) and Thiobarbituric acid (TBARS) increased in the 2nd trial compared to the 1st trial
in both groups, with no difference between groups. Regarding BDNF levels, a significant increase
was observed only in the PLA group, immediately after exercise and post 1 h of recovery,
compared to values recorded at rest. Concerning aerobic performance, no significant intergroup
differences regarding peak O2max were found in the second trial.
Schwarz et al. (2020) [21] determined the effects of acute (-)-epicatechin ingestion on
brachial artery dilation and markers of nitric oxide synthesis in response to resistance exercise
(study 1) and on high-intensity exercise performance (study 2). Since study 1 was not related do
CF, only study 2 was included in this review. Experimental protocol involved a double-blind,
placebo-controlled, randomized-balanced, crossover design. Participants performed the 15.5 CF
Open Workout (27 rowing kilocalories followed by 27 barbell thrusters; 21 rowing kilocalories
followed by 21 barbell thrusters; 15 rowing kilocalories followed by 15 barbell thrusters; 9 rowing
kilocalories followed by 9 barbell thrusters) in 3 separated occasions. Supplementation consisted of
100 mg of 98% pure (-)-epicatechin, twice a day, for 2 days before testing sessions 2 and 3, plus
200 mg with water 60-90 minutes before completing these sessions. No significant difference was
observed for time to complete the workout between testing sessions.
Kramer et al. (2016) [22] analyzed the effects of six-day nitrate supplementation (8 mmol
potassium nitrate in capsules/day) on performance parameters. Subjects performed isokinetic and
isometric extension and flexion strength tests, 30-second Wingate test, two-kilometer rowing
ergometer time trial, and "Grace" CF workout (30 clean-and-jerk repetitions, as fast as possible).
For the Wingate test, there was a significant increase in peak power following nitrate
supplementation within nitrate supplementation group. There were no differences from pre- to post-
treatment nor between interventions for any other strength power or endurance variable, including
"Grace" CF workout performance.
Moro et al (2020) [23] investigated the effect of a 6-week betaine supplementation on body
composition and muscle performance in 29 male and female CF practitioners. In a randomized,
double-blind, placebo-controlled design, volunteers received a total of 2.5g of betaine supplement
or placebo (1.25g in the morning, 1,25g half an hour before training session), keeping the same time
of ingestion in rest days. The 2-3 training sessions per week were typical CF workouts (high
intensity with minimal or absent rest periods between bouts). No significant differences were found
between groups regarding body composition, strength (3-RM back squat), aerobic performance (2
km rowing test), or anaerobic capacity (Bergeron Beep test).
Finally, Durkalec-Michalski et al (2018) [24] examined the effects of chronic, progressive-
dose sodium bicarbonate (NaHCO3 - SB) ingestion on CF-like performance and aerobic capacity. In
a randomized, double-blind, placebo-controlled, cross-over trial, 21 participants ingested either up
to 150 mg/kg of SB or placebo, in a progressive-dose regimen (days 1-2: 37.5 mg/kg; days 3-4: 75
mg/kg; days 5-7: 112.5 mg/kg; days 8-10: 150 mg/kg), for 10 days, with a 14-day washout period.
Before and after each trial, an incremental cycling test (ICT) and CF workout Fight Gone Bad
(FGB) (the same as described for FGBF, but consisting of 3 rounds only). Overall FGB
performance (total number of repetitions of all exercises in all 3 rounds) post intervention was 3.1%
higher in SB group (SBpost) when compared to placebo group (PLApost). In ICT, SBpost resting
pyruvate concentration, resting CK activity, time to ventilatory threshold (VT), workload at VT,
and heart rate at VT were also higher when compared to PLApost. No significant alterations in
blood lactate were found.
 Table 1. Summary of the studies included in the review
Study
Author (Year) Sample size and characteristics Intervention Control Dose, Duration and Frequency Exercise performed Primary outcome Secondary outcome
Type
Fogaça et al. R Sample size: CAF PLA: CAF: Testing:  Workout performance  CK
2020) DB 9 men supplementation microcrystalline 6 mg/kg-1 body mass with 150 mL of 1. CrossFit Workout  Muscle power  CRP
12] PLA-C cellulose water 5 sets: 1 rep of snatch from the block (80% of  Muscle strength  DOMS
CR Sample characteristic: 1RM) + 2 min rest between sets  RPE
7-day CF experience: 2 ± 0.3 years PLA: 3 sets: 5 rep of touch-and-go snatches (75% of
washout A: 28 ± 2 years 6 mg/kg-1 body mass 1RM) + 90 s rest
H: 175.3 ± 3.2 cm 3 sets: 60 s of isometric weighted plank (11.4
BM: 78.7 ± 3.2 kg Acute: 60 min prior to exercise kg) + 90 s rest
BMI: 25.5 ± 0.4 kg/m2 5-min recovery interval
% BF: 16.9 ± 1.7 Endurance conditioning: 10 min of AMRAP
LBM: 61.2 ± 3.0 kg of 30 double-unders and 15 power snatches
(34 kg)
2. CMJ on force platform to measure
maximum height jump
3. Handgrip strength measured with dominant
hand (average of three attempts)
Stein; Ramirez; R Sample size: CAF PLA: biotin CAF: Testing:  "Cindy" CF workout  RPE
Heinrich (2020) DB 20 men supplementation 5 mg/kg-1 body mass "Cindy" CF workout: AMRAP in 20 min of performance
13] PLA-C five pull-ups, 10 push-ups, and 15 air squats
CR Sample characteristic: PLA: 300 g
7-day CF experience: 3.7 ± 2.9 years
washout A: 26.7 ± 6.2 years Acute: 60 min prior to exercise
H: 178.6 ± 4.8 cm
BM: 84.0 ± 9.7 kg
BMI: 26.3 ± 2.5 kg/m2
% BF: 19.3 ± 3.4
Escobar; Morales; R Sample size: CHO C CHO: Testing:  "Rahoi" CF workout  O 2  RER
Vandusseldorp CON 18 participants (11 women / 7 men) supplementation (n = 9) Intake from < 6 g/kg-1 body Day 1: "Rahoi" CF workout (12 min: AMRAP (repetitions completed)  [La]
2016) (n=9) mass/day to 6-8 g/kg-1 body mass/d of 12 Box Jumps, 6 Thrusters, 6 Bar-Facing
14] Sample characteristic: Pre CHO (g·kgBM·day−1): Burpees)
Strength and conditioning experience: of 3.37 ± 1.27 Day 5: "Rahoi" CF workout
≥ 3 training sessions/week for ≥ 1 year Intervention CHO (g·kgBM·day−1): Day 9: "Rahoi" CF workout
11 women: 6.30 ± 0.537
A: 22.9 ± 2.8 years Training:
H: 164.5 ± 5.4 cm C: Day 6: ―120107‖ CF workout (fixed
BM: 61.1 ± 5.5 kg Maintained their current intake of < workload; 10 rounds of 15 deadlift, 15 push-
7 men: 6 g/kg-1 body mass/day ups)
A: 26.1 ± 10.2 years Day 7: ―Sean‖ CF workout (fixed workload;
H: 178.7 ± 8.1 cm Pre CHO (g·kgBM·day−1): 10 rounds of 11 chest-to-bar pull-ups, 22 front
BM: 77.2 ± 8.8 kg 3.73 ± 1.21 squats)
C CHO (g·kgBM·day):
3.13 ± 1.02 Days 2, 3, 4, and 8: rest d

Chronic: 3 d
Gregory et al. R Sample size: LCKD Regular diet LCKD: Training characteristics: Within both groups: LCKD:
2017) CON 27 participants (22 women / 5 men) (n = 12) (n = 15) Carbohydrate 4 CF training sessions per w ↓ Total CF performance test time ↓ Weight
15] intake restriction to < 50 g/d ↑ Vertical jump ↓ BMI
Sample characteristic: Testing: ↑ ertical jump + standing long ↓ % BF
CF experience: non-elite CF subjects C: 1. Power Test: jump ↓ FM
A: 34.58 ± 9.26 years Usual dietary intake Vertical & Standing Long Jump  LBM
H: 169.01 ± 9.44 cm 2. CF Performance Test:  Vertical jump and standing
 BM: 74.55 ± 13.58 kg Chronic: 6 w 500-meter row long jump
BMI: 25.91 ± 2.88 kg/m2 40 body weight squats
% BF: 32.11 ± 7.53 30 abdominal m at sit-ups
LBM: 48.46 ± 10.46 kg 20 hand release push-ups
FBM: 23.06 ± 6.98 kg 10 pull-ups
Rountree et al. R Sample size: CHO PLA CHO: Testing:  "FGBF" CF workout -
2017) DB 8 men supplementation 6% sucrose/dextrose solution (16 g ―Fight Gone Bad Five‖ (FGBF) CF workout: performance
16] PLA-C of CHO in ~ 250 mL of fluid over 30 5 rounds of as many repetitions of each
CR Sample characteristic: min) exercise as possible:
7-day Training experience: Resistance training 1 min wall ball throw (3.05 m target; 9 kg); 1
washout  6 months / CF training  3 months PLA: min sumo deadlift high-pulls (34 kg); 1 min
A: 22 ± 1.8 years non-caloric beverage containing box jumps (50.8 cm); 1 min push presses (34
H: 177 ± 7 cm sucralose and aspartame kg) + 1 min rowing ergometry (max kcal)
BM: 81.3 ± 7.2 kg No rest between exercises
Acute: xxx One-minute break between rounds
Total exercise task time: 30 min
Kephart et al. OL Sample size: KD C Only the KD participants Testing:  1-RM squat Within CF group:
2018) CON 12 participants (3 women / 9 men) (n = 7) (n = 5) completed food logs 1. Strength/power test (1-RM back-squat, 1-  1-RM power clean  BM
6] RM power-clean, max rep push-ups, 400-m  Max rep pushups  FM
Sample characteristic: Energy intake (kcal/d): run)  400 m run  Dual-arm lean mass
Exercise background: strength:mass ratio Baseline = 2499 ± 350 2. IRT  Dual-leg lean mass
≥ 1.00 (1-RM back squat) 3 months = 1948 ± 293  V. Lateralis
KD: CHO (g/d): tickcness
A: 32 ± 3 years Baseline = 164 ± 32  REE
H: 1.71 ± 0.08 m 3 months = 15 ± 3
 RQ
BM: 82.7 ± 8.2 kg Lipids (g/d):
 O2 peak
% BF: 24.6 ± 2.2 Baseline = 154 ± 40
C: 3 months = 170 ± 25  Glucose
A: 29 ± 3 years Protein (g/d)  HDL-C
H: 1.70 ± 0.03 m Baseline = 114 ± 10  LDL-C
BM: 76.9 ± 5.5 kg 3 months = 89 ± 20  Triglycerides
% BF: 20.6 ± 4.7
Durkalec- OL Sample size: KD CD pre-KD KD: Training characteristics: - Women and Men:
Michalski; 22 participants (11 women / 11 men) (n = 22) (n = 22) Energy intake (kcal): A minimum of 4 CF training sessions per w  Rate of fat oxidation
Nowaczyk; Siedzik Male: 2659 ± 273  % contribution of fat
2019) Sample characteristic: Customized diet Female: 2955 ± 265 Testing: oxidation to the energy
17] CF experience:  4 CF workouts/week performed before CHO (g·kgBM·day−1): ICT yield
for  2 years the intervention was Male: 0.5 ± 0.1  Contribution of CHO to
A: 29.5 ± 4.4 years considered as a Female: 0.4 ± 0.1 energy metabolism
H: 172 ± 8 cm control group Lipids (g·kgBM·day−1):  O2max
BM: 71.1 ± 12.8 kg Male: 3.8 ± 0.5 Men:
O2max: 45.8 ± 7.5 mL·min− 1 kg− 1 Female: 3.2 ± 0.6  Rate of CHO oxidation
Protein (g·kgBM·day−1):
Male: 1.9 ± 0.2
Female: 1.7 ± 0.2

CD:
Energy (kcal):
Male: 2485 ± 279
Female: 2645 ± 289
CHO (g·kgBM·day−1):
Male: 4.7 ± 1.5
Female: 3.6 ± 0.9
Lipids (g·kgBM·day−1):
Male: 1.7 ± 0.4
Female:1.3 ± 0.3
 Protein (g·kgBM·day−1):
Men: 1.8 ± 0.4
Women: 1.6 ± 0.2
Outlaw et al. R Sample size: Pre-workout C Pre-workout supplement: 2 Workouts of the Day (WOD1 and WOD2) Likely beneficial: WOD2 Likely beneficial:
2014) CON 29 participants (13 women / 16 men) Supplementation 19 g (Pomegranate Fruit Extract, WOD1: performance O2max
18] OL Tart Cherry Extract, Beet Root 500 m row, 40 wall balls, 30 push-ups, 20 box  WOD1 performance Wingate peak power
Sample characteristic: Post-workout Extract, Green Tea Extract, and jumps, and 10 thrusters  Wingate mean
CF experience:  at least 3 CF supplement Black Tea Extract) power
workouts/week for  6 months 20 min rest  Body composition
A: 31.87 ± 7.61 years Sample was not Post-workout supplement:
BM: 78.68 ± 16.45 kg described for Women: 1 serving; 20 g protein; 40 g WOD2:
% BF: 21.97 ± 9.02 groups carbohydrate + 8–10 oz of water 800 m run
Men: servings; 40 g protein; 80 g AMRAP of 5 burpees, 10 Kettlebell swings,
carbohydrate + 16–20 oz of water and 15 air squats within 15 min

C: Aerobic capacity testing:

Only water consumption 1 hour O2max graded exercise test
before and 1 hour; after each CF
workout Anaerobic capacity testing:
Wingate power test
Banaszek et al. R Sample size: WP group - WP group: Testing:  IMTP PF  BM
2019) DB 15 participants (7 women / 8 men) (n = 7; 4 men/ 3 WP composition: 120 kcal, 1.2 g 6-s isometric mid-thigh pull  IMTP RFD 250 m  % BF
19] women) FAT, 1.4 g CHO, 24.4 g PRO  WOD 1 performance  Rectus femoris
Sample characteristic: 1RM: back squat and deadlift exercises  WOD 2 performance thickness
HIFT experience:  at least 3 CF PP group WP energy intake: 2287.8 ± 704.8 Within both groups:  Vastus lateralis
workouts/week for  6 months (n = 8; 4 men / 4 kcal/d WOD1 (as fast as possible): 400 m run, 50 sit ↑ 1-RM back squat thickness
7 women: women) Protein intake: 150.7 ± 40.9 g/d ups, 400 m run, 40 box jumps (men: 24‖ box; ↑ 1-RM deadlift
A: 38.9 ± 10.9 years CHO intake: 191.6 ± 60.4 g/d women: 20‖ for), 400 m run, 30 kettle bell
H: 1.7 ± 0.10 m Fat intake: 88.7 ± 29.6 g/d swings (men: 24.1 kg for; women: 15.9 kg),
BM: 73.3 ± 10.5 kg 400 m run, 20 wall balls (men: 9.1 kg to a 10’
8 men: PP group: target; women: 6.4 kg to a 9’ target), 400 m
A: 38.6 ± 12.7 years PP composition: 110 kcal, 1.2 g run, and 10 thrusters (men: 43.2 kg; women:
H: 1.8 ± 0.1m FAT, 1g CHO, 24.5g PRO 29.5 kg); 5-min rest period
BM: 87.7 ± 15.8 kg
PP energy intake: 1888.1 ± 295.8 WOD2: max distance row
kcal
Protein intake: 129.9 ± 32.1 g/d Training:
CHO intake: 165.8 ± 39.1 g/d 8w
Fat intake: 66.52 ± 17.7 g/d 4 CF workout sessions/w (strength training
session, followed by a metabolic
Chronic: xxxx conditioning)
Sadowska-Krępa R Sample size: GTE PLA GTE: Testing: -  O2max
et al. (2019) PLA-C 16 men supplementation (n = 8) 245 mg polyphenols (200 mg ICT  CAT
20] (n = 8) catechins: 137 mg epigallocatechin-  GPx
Sample characteristic: 3-galate + caffeine < 4 mg, Training:  GR
CF experience: involved in CF training microcrystalline cellulose, and 6-w CF program based on the CF training  SOD (within GTE
GTE group: magnesium stearate) guide (5-d-on and 2-d-off pattern) group)
A: 22.0 ± 1.1 years  FRAP (within both
H: 181.6 ± 6.2 m groups)
BM: 77.6 ± 6.4 kg PLA:  TBARS (within PLA
PLA group: Microcrystalline cellulose,
group)
A: 23.1 ± 1.7 years magnesium stearate, and
H: 180.0 ± 8.3 m maltodextrin
BM: 80.1 ± 11.5 kg
Chronic: 6 w, 2 capsules, 1x/d
Schwarz et al. R Sample size: (-)-EPI PLA (-)-Epicatechin: 15.5 CF Open Workout (3x) separated by 5-7  Time to complete  Total serum
2020) DB 2nd study: 11 participants (6 women / 5 supplement 100 mg of 98% pure (-)-epicatechin d: 27-21-15-9 rowing kcal and barbell 15.5 CF Open Workout nitrate/nitrite
21] PLA-C men) 2x/d, for 2 d before testing sessions thruster’s rep ↑ brachial artery diameter
CR 2 and 3 + 200 mg with water 60-90 post-exercise and 30 min
5 to 7- Sample characteristic: min before completing these sessions post-exercise (within both
day CF experience:  6 months; successfully groups)
washout performed 15.5 CrossFit® Open PLA:
Workout before Cellulose
A: 26.4 ± 4.8 years
H: 1.72 ± 0.09 m
BM: 75.1 ± 15.6 kg
BMI: 25.4 ± 4.0 kg/m2
Kramer et al. R Sample size: Nitrate PLA Nitrate: Testing:  "Grace" CF workout -
2016) DB 12 men supplementation 8 mmol·d−1 potassium nitrate (2 x 4 Strength test: isokinetic and isometric performance
22] PLA-C mmol capsules, 1 in the morning, 1 extension and flexion (on a dynamometer)  Isometric Ext.60°
CR Sample characteristic: in the evening) Wingate test  Isometric Flex. 60°
10-day Exercise experience:  3 CF 2 km rowing ergometer TT  Isokinetic Ext. 60°·s−1
washout workouts/week for  4 months PLA: "Grace" CF workout: 30 clean-and-jerk  Isokinetic Flex. 60°·s−1
A: 23 ± 5 years 8 mmol·d−1 nitrate free potassium repetitions using 61.37 kg, as fast as possible  Isokinetic Ext. 180°·s−1
H: 175.9 ± 7.4 cm chloride (2 x 4 mmol capsules, 1 in
 Isokinetic Flex. 180°·s−1
BM: 82.7 ± 13.5 kg the morning, 1 in the evening)
 2 km TT
FFM: 70.6 ± 7.2 kg
Chronic: 6 d  Wingate Mean
% FFM: 86.1 ± 5.7
 Wingate Peak within Nitrate
FM: 12.1 ± 7.8 kg
group
% FM: 13.9 ± 5.7
O2Peak: 48.5 ± 7.0 (ml·kg-1·min−1)
Moro et al. (2020) R Sample size: Betaine PLA Betaine: Testing:  Strength  FM
23] DB 29 participants (14 women / 15 men) supplement (n = 15) 1.25 g in 8 g of microcrystalline Leg muscular strength test:  Aerobic performance  FFM
PLA-C (n = 14) cellulose in ~ 100 mL of water (2x/d) 3-RM during a back-squat exercise  Anaerobic capacity
Sample characteristic:
CF experience:  2 times weekly for  6 PLA: 5 min rest
months Microcrystalline cellulose in ~ 100
A: 35.11 ± 8.27 years mL of water (2x/d) Aerobic performance test:
BM: 72.03 ± 10.51 kg 2 km rowing
BMI: 24.18 ± 2.02 kg/m2
15 min rest
Chronic: xxx
Anaerobic capacity test:
Bergeron Beep (7 thrusters, 7 pull-ups, and 7
burpees in less than one min and rest for the
remainder of that min) until the participant
was unable to complete a full round

CF training sessions:
2-3x/w
~ 60 min/session: warm-up (~10 min) + skill
technique workout (~ 10-15 min) + strength or
conditioning workout (~ 30 min) + mobility
and cool down exercises (~ 5–10 min)
Durkalec- R Sample size: Sodium PLA Sodium bicarbonate: ICT: ↑ Overall FGB performance ↑ Time to VT
Michalski et al. DB 21 participants (9 women / 12 men) bicarbonate (n = 9) Unmarked disk-shaped tablets (1 g Fight Gone Bad (FGB): 3 rounds of as many ↑ Workload at VT
2018) PLA-C (n = 12) SB) + at least 250 mL of water repetitions of each exercise as possible: 1 min ↑ Heart rate at VT
24] CR Sample characteristic: days 1-2: 37.5 mg·kg-1 wall ball shots; 1 min sumo deadlift high- ↑ pre-ICT [Pa] post
14-day CF experience:  4x/week ( 3x/week days 3-4: 75 mg·kg-1 pulls; 1 min box jumps; 1 min push presses; 1 intervention
washout CF sessions), for  2 years days 5-7: 112.5 mg·kg-1 min rowing ergometry (max kcal) ↑ pre-ICT CK activity
A: 32 ± 5 years days 8-10: 150 mg·kg-1 No rest between exercises post intervention
One-min break between rounds
 H: 174 ± 8 cm PLA: Total FGB workout time: 17 min  ICT [La]
BM: 73.0 ± 14.0 kgSB; 73.2 ± 13.8 kgPLA Tablet maltodextrin with NaCl
FFM: 58.4 ± 13.4 kgSB; 59.3 ± 13.7 3 evenly split doses/d:
kgPLA Training days: morning, evening, 1.5
FBM: 13.6 ± 4.9 kgSB; 13.9 ± 4.9 kgPLA h before session;
Rest d: morning, afternoon, evening

Chronic: 10 d
Legend: R = randomized; DB = double-blind; PLA-C = placebo-controlled; CR = crossover trial; CON = controlled; OL = open label; n = sample size; CF = CrossFit; HIFT = high-intensity functional training; A = age; H = height; BM = body
mass; BMI = body mass index; % BF = percentage body fat; LBM = lean body mass; FBM = fat body mass; FFM = fat-free mass; % FFM = percentage fat-free mass; FM = fat mass; % FM = percentage fat mass; O2max = maximal oxygen
uptake; CAF = caffeine; PLA = placebo; C = control; LCKD = low-carbohydrate ketogenic diet; KD = ketogenic diet; CD = customary diet; WP = whey protein; PP = pea protein; GTE = green tea extract; (-)-EPI = (-)- epicatechin; SB = sodium
bicarbonate; CHO = Carbohydrate; FAT = fat; PRO = protein; mg/kg = milligram per kilogram; mL = milliliter(s); g = microgram(s); kg = kilogram(s); g = grams; mg = milligram(s); km = kilometer(s); m = meter(s); cm = centimeter(s); d =
day(s); w = week(s); h = hour(s); min = minute(s); s = second(s); kcal = kilocalories; Oz = Ounces; NaCl = sodium chloride; RM = repetition maximum; rep = repetition(s); CMJ = Countermovement jump; max = maximum; ICT = incremental
cycling test; IRT = incremental running test; WOD = Workout of the Day; FGB = Fight Gone Bad; FGBF = Fight Gone Bad Five; IMTP = Isometric Mid-thigh Pull; CK = Creatine kinase; CRP = high-sensitivity C-reactive protein; DOMS =
delayed-onset muscle soreness; RPE = ratings of perceived exertion; 2 peak = peak oxygen uptake; AMRAP = As many rounds as possible; TT = time-trial; PF = peak force; RFD = Rate of Force Development; Ext. = extension; Flex. = flexion;
La] = lactate; [Pa] = pyruvate; REE = resting energy expenditure; RQ = respiratory quotient; RER = respiratory exchange ratio; VT = ventilatory threshold; HDL-c = high-density lipoprotein cholesterol; LDL-c = low-density lipoprotein
cholesterol; CAT = Catalase; GPx = Glutathione Peroxidase; SOD = superoxide dismutase; FRAP = total antioxidant capacity; TBARS = thiobarbituric acid; ↔ = without change;  = increased;  = decreased;  = bigger or equal; < = smaller; ~ =
approximately.
Discussion
CF has become popular due to its dynamism, socialization, increased physical fitness,
increased muscle strength, and reduced body fat [2,25]. Therefore, it is common to have an interest
in maximizing sports performance through nutritional strategies. The official website
(https://www.crossfit.com/essentials) affirms that the CF stimulus - constantly varied high-intensity
functional movement coupled with meat and vegetables, nuts and seeds, some fruit, little starch, and
no sugar - prepares the body for the demands of a healthy, functional, independent life and provides
a hedge against chronic disease and incapacity.
It is imperative that one take caution when associating nutritional strategies and performance
improvement in CF. Although scientific information on consumption of macronutrients,
micronutrients, and nutritional supplements to improve exercise performance is robust [4,26–28],
extrapolating to CF seems to be intuitive.
Exploring the information assembled in this review, we could determine that only sodium
bicarbonate (SB) supplementation improved CF performance. Interestingly, despite previous
positive exercise-evidence with caffeine supplementation [29,30] and carbohydrates intake [31], no
study showed any improvement in CF performance. Finally, it is possible to note that studies
concerning other types of intervention have weak theoretical premises, once previously evaluated
groups (sportsmen or athletes) did not display improvement in exercise performance [26].
At least in part, these outcomes may have been obtained due to methodological limitations
(small sample size, lack of control over influencing variables, short period of exercise intervention,
and others). Therefore, it is notable that despite the popularity and growing evidence about the
sport, little is known about the relationship between performance-enhancing substances or dietary
interventions and CF performance. Figure 2 illustrates the proposed interventions, potential
mechanisms of action and results found.
Figure 2. Nutritional interventions already tested at CF. Legend: ↑ = Increase;  = No changes;
 = Decrease; H+ = Hydrogen; Ca2+ = Calcium; WOD = Workout of the Day. This figure was
created using images from Servier Medical Art Commons Attribution 3.0 Unported License.
(http://smart.servier.com). Servier Medical Art by Servier is licensed under a Creative Commons
Attribution 3.0 Unported License.

Sodium bicarbonate supplementation

Durkalec-Michalski et al. (2018) [24], evaluated the effects of split SB supplementation (35
to 150mg / kg) for ten days. Authors found an improvement of ~ 6% in performance, in agreement
with previous studies. Furthermore, although the doses tested in the study are considered small [32],
it showed a satisfying result for CF athletes. The effects of intense physical exercise, such as CF
workouts, on peripheral fatigue, are well known [33]. Muscle contraction is believed to occur
through the hydrolysis of adenosine triphosphate (ATP). The release of hydrogen ions (H+) in this
reaction rises faster in high-intensity exercises, which are highly dependent on glucose oxidation
(glycolysis). The accumulation of H+ reduces muscle pH, increasing intracellular acidosis. This is
one of many factors contributing to the perception of fatigue due to inhibition of key enzymes in
energy metabolism [34]. Researchers have extensively determined the role of SB during high
intensity exercise [35], being considered one of the few ergogenic supplements by the International
Olympic Committee [26]. Bicarbonate (HCO3-) increases blood pH and augments the efflux of
lactate and H+ from muscle cells to the blood circulation, improving muscular enzymatic
environment and sports performance [36]. Despite positive results in the present study, more
information is needed to elucidate the positive effects of SB in CF context, including different
subjects' levels, other kinds of workouts, among others.

Caffeine supplementation
Studies with caffeine supplementation on CF [12,13] have not shown positive results.
Several studies discuss genotypic limitations that prevent caffeine from exerting its ergogenic
effects [37], and it is also believed that the effects (when positive) are higher in men compared to
women [38]. Moreover, Pickering & Kiely (2018) suggest the inter-individual variation in caffeine
ergogenicity [39]. Although many studies show the positive effects of caffeine supplementation in
different types of sports [30,40], little is known about these effects in CF. In the study of Fogaça et
al. (2019) [12], the sample is small (n = 9) and volunteers are categorized as intermediate level CF
practitioners. The subjects had an average consumption of 0.46 (0.06 - 0.63) mg of caffeine per
week. Stein; Ramirez, and Heinrich (2020) [13] included subjects with only  6 months CF
experience in their study and daily caffeine intake was 288.3  287.5 mg/day. It is argued that the
effects of caffeine supplementation may differ according to the level of training of the subject.
Some studies suggest that more trained subjects are more responsive to caffeine [41,42] although it
is not consensual [43,44]. The effect of caffeine supplementation on sports performance includes
endurance and strength exercises [30]. Several systematic reviews and published meta-analyses
support that caffeine can improve performance in endurance sports, strength sports, muscular
endurance, vertical jump height, speed during running, cycling, or rowing [40,45–48]. All of these
movements are observed in CF, which may suggest the positive effects of caffeine supplementation.

Low-carbohydrate and ketogenic diet

CF workouts range from 5 minutes or less to 30-45 minutes (in rare cases, longer). A typical
CF training session consists of 3 parts: warm-up (~ 5-10 minutes), skill technique workout (~ 15–20
minutes), and the WOD (abbreviation for Workout of the Day, generally characterized by a strength
or conditioning high intensity workout (~ 20-40 minutes). These sessions are competition-based and
scored based, requiring the athlete’s ability to complete a set amount of work as fast as possible or
to complete as much work as possible within a given period. Babiash et al. (2016) [49] found that
CF increases heart rate averaging ~ 90% of maximum heart rate and aerobic intensities averaging ~
85% O2 max, as well as it is believed that due to the intensity of training, muscle glycogen levels
fall rapidly [50,51]. Based on this glycogen decrease, it is believed that CHO intake is essential for
carrying out the practice, since the glycogen stores can determine the ergogenic capacity [52].
However, as a more interesting result, we found that studies with a ketogenic diet [6,15,17] or that
used CHO as an intervention [14,16] did not worsen or improve performance, respectively. The
lack of glycogen levels assessment and failure to control food intake stand out as limitations of the
studies mentioned above. Although Low-Carb diet or KD may potentiate signaling pathways to
increase the fat oxidation [53,54], studies suggest that, chronically, these interventions may be
harmful to high intensity exercise, for impairing, by pyruvate dehydrogenase kinase-4, the pyruvate
dehydrogenase complex [55–57].
CF practice is expected to contribute to body fat reduction due to its high energy demand.
This contribution should be more expressive when associated with a decrease in total energy intake
[2]. Kephart et al. (2018) [6] found a reduction in fat mass after three months of a KD. Considering
that food intake data for the control group were not described, it seems probable that this effect was
due to the caloric restriction imposed by the abrupt decrease in CHO intake, showing the necessity
of more controlled studies. Likewise, Gregory et al. (2017) [15] found similar results in
performance between control and Low-Carb diet. The control group had a reduction in time
(seconds) of -41.20 ± 43.17 and the LCKD group of -55.08 ± 44.29. Significant difference was
observed only within group, not between groups. Thus, it is not possible to consider the superiority
of the Low-Carb diet. Furthermore, positive effects observed in fat mass of LCKD group (-2.83 ±
1.77 kg) vs. control group (-0.06 ± 1.12 kg) (p <0.001) can be attributed to its the lower energy,
since an average reduction of 115 and 334 kcal can be observed in weeks 4 and 6, respectively.
Although not statistically significant, this amount of calorie reduction is enough to cause weight
loss [58]. Furthermore, it is worth mentioning that the composition of macronutrients in the diet
does not seem to be the determining factor for weight loss [59].

Protein supplementation
Still regarding body composition, Banaszek et al. (2019) [19] aimed to compare the effects
of whey protein and pea protein on the body composition of CF practitioners. The authors found no
difference after the intervention period. These findings are in agreement with other studies that
compared similar interventions [60]. In addition, despite the possible heterogeneity of the amino
acid composition of different protein supplements, it is believed that reaching adequate amounts of
protein per day (~ 1.6g / kg/day), associated with strength training, results in the increase of fat-free
mass [61]. Considering protein intake to improve performance, studies appear to be controversial
and the effect of protein appears to be uncertain [62].

Green-tea and (-)- Epicatechin supplementation

 The study published by Sadowska-Krepa et al. (2019) [20] aimed to determine the effects of
GTE on performance parameters, antioxidant defense enzymes, and oxidative stress markers. The
authors did not see an improvement in exercise performance, observing only an increase in SOD in
the GTE group. Other studies did not show exercise performance improvement with green tea
supplementation [63], even though enhancements in the antioxidant defense system were found
[64]. Machado et al. (2018) [65] found that GTE was able to reduce CK and TBARS levels, besides
showing positive results on neuromuscular parameters. However, evidence for exercise
performance improvement is still scarce. Schwarz et al. (2020) [21] determined the effect of (-)-
epicatechin supplementation on performance. This polyphenol is present in various foods, such as
grapes, green tea, and apples, and it is studied for increasing vasodilation through the increase of
nitric oxide [66]. Despite, comparing subjects who consumed PLA supplement and subjects who
consumed (-)- epicatechin, authors did not observe any difference in the time to complete the
performed CF workout. Although possible positive effects observed in an animal model [67],
studies suggest negative effects on aerobic adaptations in humans [68].

Betaine supplementation
More recently, Moro et al. (2020) [23] determined the effects of betaine supplementation on
CF athletes' performance. Some evidence suggest that betaine may improve muscle function [69],
mainly due to its role in the methylation process, which can be speculated for creatine and carnitine
synthesis [70,71]. Therefore, it is suggested that betaine may contribute to muscle strength increase
[72,73]. However, authors did not identify positive effects on leg muscular strength or on
performance. Taking into account that other studies have not found positive effects on athletic
performance, [74,75] betaine does not appear to be an advantageous nutritional supplement for
athletes.

Nitrate supplementation
Kramer et al. (2016) [22] tested the effects of nitrate supplementation (not in beetroot juice)
on exercise performance parameters and found no positive effects, except for enhanced Wingate
peak power within supplementation group. Systematic reviews have shown that effects of nitrate
supplementation depend on the type of physical exercise. McMahon et al. (2017) [76] suggest that
nitrate supplementation is likely to elicit positive outcome when testing endurance exercise
capacity, whereas supplementation is less likely to be useful for time-trial performance (typical
exercise model proposed by CF). Van De Walle & Vukovich (2018) [77] showed that nitrate
supplementation increases tolerance and efficiency to high-intensity constant and maximal
incremental exercise, which may increase exercise performance. Doses ranging from 5 to 9 mmol
of nitrate seem to be the most effective and can be taken as either a single bolus or as multiple doses
(up to 15 days). Even though supplementation characteristics in this study [22] is in accordance to
this recommendation, evidence on CF performance is still scarce.

Multi-ingredient supplementation
Outlaw et al. (2014) [18] determined the effect of multi-ingredient supplementation on
O2max, Wingate peak power, and WOD-performance of CF practitioners. Thirty minutes before
the training sessions, participants consumed a supplement contained Pomegranate Fruit Extract,
Tart Cherry Extract, Beet Root Extract, Green Tea Extract, and Black Tea Extract. This
combination should be rich in phytochemicals, nitrate, epicatechin, and caffeine. In addition, after
the same sessions, subjects consumed whey protein and carbohydrate supplement. Simultaneously,
control group was required to consume only water one hour before and one hour after each CF
workout. Subjects were also instructed to refrain from taking any performance-enhancing dietary
supplements throughout the study. Authors analyzed results using magnitude inferences, a method
proposed to investigate meaningfulness and practical importance, as outlined by Hopkins et al.
(2009) [78]. This method is criticized by the scientific community for inflating type 1 error (reject
the null hypothesis when, in fact, you should accept it) [79,80]. Moreover, in the present study,
authors themselves point out a significant limitation, the absence of a placebo-controlled group,
impairing extrapolation of the findings. Taking all this information into account, authors reported
that O2 max, Wingate peak power, and WOD2 performance results revealed that the pre/post
supplements were likely beneficial.

Final considerations and perspectives

In CF, practitioners often adopt several strategies such as supplementation of medium-chain
triacylglycerol, isolated amino acids, or buffering supplements (beta-alanine and sodium
bicarbonate), as well as restrictive diets (paleolithic or ketogenic diet), believing that it will increase
their exercise performance. Nevertheless, these practices lack scientific evidence to be supported.
Such a popular and well-known modality as CF raises a few hypotheses on performance-enhancing
substances or dietary intervention, which could be targets for future investigation.
Although published studies with caffeine supplementation have not determined a positive
effect on CF performance so far, new studies should be carried out including analyses of volunteers
genotypic profile, among other important variables. In addition, it is intuitive to believe that
carbohydrate intake, especially before practice, should be encouraged. The high intensity of CF can
contribute to the increase in glucose uptake by skeletal muscle for rapid ATP resynthesis. Also,
considering its high intensity, one should consider adapting the intake of antioxidant vitamins and
minerals, since such enhanced oxidative stress and inflammation can cause cellular damage [81],
especially when the intake of micronutrients is inadequate. It could also be suggested that
interventions capable of preventing skeletal muscle H+ accumulation (such as beta-alanine [82–84])
and supplements with an effect on muscle strength (such as creatine [85,86]) could contribute to
CF performance improvement, due to its high intensity.
Finally, we concluded that only sodium bicarbonate supplementation increased CF-trained
athletes' performance. Given that most studies included in this review display high risk of bias,
according to our analysis, new studies with potential ergogenic supplements, good methodological
model (internal validity), and practical application (external validity) are required. It should be
considered that the influence of any performance-enhancing substances or dietary intervention will
depend on the type of exercise performed on the day, because some may be more intense, while
others may be less intense, focusing on technique, for instance. Thus, some can be characterized as
aerobic exercise while others are clearly focused on strength. Due to the dynamism and frequent
exchange of energetic substrates for ATP formation, CF seems to be a peculiar form of training that
deserves further studies to elucidate the lack of scientific evidence.

Disclosure statement
All authors approved the final manuscript, and none has any conflict of interest.

Financial support
We did not have any financial support.

Acknowledgment
We appreciate the privilege of staying at home during the COVID-19 pandemic to study, write and
collaborate, even if in a simple way, with the science of nutrition and physical exercise.
We would like to thank both reviewers for the valuable comments, which significantly contributed
to improve our study.
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Declaration of interests

☒ The authors declare that they have no known competing financial interests or personal
relationships that could have appeared to influence the work reported in this paper.

☐The authors declare the following financial interests/personal relationships which may be considered as
potential competing interests:

Financial support

We did not have any financial support.