Major clinical outcomes of nutrology management and the endocannabinoid system in the performance of paralympic athletes: a systematic review
Authors: Medeiros Vitor Bezerra de , Lima Kennya Medeiros Lopes de Barros , Magalhães Ana Gabriela de , Borges Laís Martins , Santos Karlla Gabrielly Claudino , Mélo Neto Leonardo Honório de Andrade , Lopes Hugo Menezes , Araujo Jeffeson Alexandre Azevedo de , Pereira Netto Diego , Dall’orto Brysa Freitas , Campos Nicole Velasco 
Published: September 2024

Introduction: In the Paralympic sports scenario, recent research suggests that the connection between nutrients and the intestinal microbiota may play an important role in athlete health and performance. Exercise-induced extracellular vesicles (exosomes and microRNAs) have emerged as potential mediators of muscle crosstalk. Furthermore, clinical studies suggest that cannabidiol (CBD) may be useful for athletes due to its anti-inflammatory, analgesic, anxiolytic, and neuroprotective properties and its influence on the sleep-wake cycle. As a corollary of this, a series of implications of cannabidiol in gene expression processes modulated by microRNAs are being evidenced, impacting the immune and inflammatory systems in athletes. Objective: This study aimed to present the main clinical outcomes of nutritional management and the endocannabinoid system in the performance of Paralympic athletes through a systematic review. Methods: The systematic review rules of the PRISMA Platform were followed. The search was realized from June to July 2024 in the Scopus, PubMed, Science Direct, Scielo, and Google Scholar databases. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: 135 articles were found. A total of 28 articles were evaluated and 25 were included in this systematic review. Considering the Cochrane tool for risk of bias, the overall assessment resulted in 18 studies with a high risk of bias and 25 studies that did not meet GRADE and AMSTAR-2. Most of the studies presented homogeneity in their results, with X2 = 87.5% >50%. It was concluded that Paralympic athletes should feed, train, and utilize the entire supraorganism, including the intestinal microbiota, implementing gut-centered dietary strategies to achieve optimal performance. Current evidence suggests that the gut microbiota may contribute to sports performance through the production of nutritional metabolites (short-chain fatty acids, secondary bile acids), influence on gastrointestinal physiology (nutrient absorption), and immune modulation (inhibition of pathogens). Intake of adequate dietary fiber, a variety of protein sources, and emphasis on unsaturated fats, especially ɷ-3 fatty acids, as well as supplementation with pre-, pro-, and synbiotics, have shown promising results in optimizing the health of Paralympic athletes and with potential beneficial effects on performance. Furthermore, there is preliminary evidence supporting the anti-inflammatory, neuroprotective, analgesic, and anxiolytic actions of cannabidiol and the possibility that it may protect against gastrointestinal damage associated with inflammation and promote the healing of traumatic skeletal injuries. A specific repertoire of microRNAs regulated by cannabinoids in resting (vigilant) and lipopolysaccharide-activated microglia has been identified. The modulated microRNAs and their target genes are controlled by TLR, Nrf2, and Notch cross-talk and are involved in immune response, cell cycle regulation, cellular stress, and redox homeostasis.