Tiemeier et al.

Sports Medicine - Open (2024) 10:48 Sports Medicine - Open

https://doi.org/10.1186/s40798-024-00715-7

REVIEW ARTICLE Open Access

Ultra-Cycling– Past, Present, Future: A

Narrative Review
Lucas Tiemeier1, Pantelis T. Nikolaidis2, Daniela Chlíbková3, Matthias Wilhelm1, Mabliny Thuany4, Katja Weiss5 and
Beat Knechtle5,6*

Abstract
Background Ultra-endurance events are gaining popularity in multiple exercise disciplines, including cycling. With
increasing numbers of ultra-cycling events, aspects influencing participation and performance are of interest to the
cycling community.
Main body The aim of this narrative review was, therefore, to assess the types of races offered, the characteristics of
the cyclists, the fluid and energy balance during the race, the body mass changes after the race, and the parameters
that may enhance performance based on existing literature. A literature search was conducted in PubMed, Scopus,
and Google Scholar using the search terms ‘ultracycling’, ‘ultra cycling’, ‘ultra-cycling’, ‘ultra-endurance biking’, ‘ultra-
bikers’ and ‘prolonged cycling’. The search yielded 948 results, of which 111 were relevant for this review. The studies
were classified according to their research focus and the results were summarized. The results demonstrated changes
in physiological parameters, immunological and oxidative processes, as well as in fluid and energy balance. While the
individual race with the most published studies was the Race Across America, most races were conducted in Europe,
and a trend for an increase in European participants in international races was observed. Performance seems to be
affected by characteristics such as age and sex but not by anthropometric parameters such as skin fold thickness. The
optimum age for the top performance was around 40 years. Most participants in ultra-cycling events were male, but
the number of female athletes has been increasing over the past years. Female athletes are understudied due to their
later entry and less prominent participation in ultra-cycling races. A post-race energy deficit after ultra-cycling events
was observed.

Background
In Table 4 (see pdf ), please move the subheading'Psychological Ultra-endurance competitions are specific events extend-
aspects and sleep' down a row so that it is not an'orphan' at ing over an exceptionally long distance and time. They
the bottom of the page and is instead situated on the first are defined as distances longer than the classical mara-
row of the second page of the table. Please also note that the
subheading'Physiological function' has been incorrectly inserted thon and longer than 6 h in duration [1]. Ultra-endurance
in the row after'Psychological aspects and sleep'. Please delete events exist for different athletic disciplines, including
the'Physiological function' heading here and the empty row that running, cycling, and swimming [2]. Considering the
remains following its deletion.
duration of these events and the demanding preparation
Please make the heading'Sex as a Factor in Performance' the same
of athletes, ultra-endurance imposes extreme stress on
level/order of heading as the headings before and after it in the text
the human body, which justifies the scientific interest in
*Correspondence:
Beat Knechtle
this topic.
[email protected] Ultra-running events are defined as any race longer
Full list of author information is available at the end of the article than a marathon of 42.195 km for distance-limited events

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 2 of 18

Conclusion Future studies need to investigate the causes for the observed optimum race age around 40 years of age
as well as the optimum nutritional supply to close the observed energy gap under consideration of the individual race
lengths and conditions. Another research gap to be filled by future studies is the development of strategies to tackle
inflammatory processes during the race that may persist in the post-race period.
Key Points
• The optimal ultra-cycling race age is around 40 years.
• Performance-related factors were the most investigated topic of ultra-cycling studies.
• There is a lack of information about strategies to tackle inflammatory processes during ultra-cycling events.
Keywords ultra-cycling, Race across America, Endurance, Performance

and more than six hours for time-limited events [1] and self-supported bicycle race held in Europe is the Trans-
ultra-triathlons as any race longer than the Ironman- continental race, in which 4,000 km need to be covered
distance triathlon (3.8 km swimming, 180 km cycling and (https://www.transcontinental.cc/about). Nowadays, the
41.195 km running). In contrast, there is no compara- Silk Mountain Bike Race is considered the world’s hard-
tively precise definition of ultra-cycling. The Worldwide est mountain bike race, an unsupported race in the Kyr-
Ultracycling Association (WUCA) defines time-limited gyzstan mountains with a length of 1,155 miles (www.
cycling races as those encompassing a challenge of at silkmountainrace.com). The toughest winter races in the
least six hours duration [1–3], while distance-limited world are the Iditarod Trail Invitational race which takes
events must stretch over at least 125 miles (200 km) part in Alaska where the participants travel along the
and be completed in a single effort to be considered as historic Iditarod Trail on bicycle, foot, or skis (https://
an ultra-competition [3]. Thus, the definition of ultra- itialaska.com/iti-350) and the Arctic Circle Winter races
cycling is similar to that of ultra-running for time-limited in the fatbike category in the Finnish Lapland (http://
events, whereas it differs for distance-limited events due www.arcticraces.com). The world’s toughest mountain
to the faster nature of cycling compared to running. bike races are La Ruta de los Conquistadores in Costa
Such ultra-endurance events have gained increasing Rica with 29,000 feet of climbing over five mountain
popularity during the past 25 years due to the rise of ranges and a 12,000-foot volcano (http://www.racelaruta.
master athletes [4] and the participation of female ath- com) and the Trans Pyr in Spain involves eight days, 509
letes [2, 5]. Nowadays, ultra-cycling competitions are miles and over 66,601 feet of climbing (www.transpyr.
offered around the globe in varying time and distance com). Another mountain bike off-road ultra-cycling
formats [6]. Moreover, due to geographical differences event is the Cape Epic mountain bike race, which entails
between the countries in which such races take place, a 16,650 m elevation gain and 624 km. In comparison,
the elevation and distances above sea level vary as well the road race RAAM includes the longest elevation gain
[6]. Possibly the most famous road ultra-cycling event at with a 53,000 m climb along its course [8]. Among the
the moment is the Paris-Brest-Paris race [7]. The ‘Race world’s toughest mountain bike events, we can also list
Across America’ (RAAM) in the United States is cur- the Crocodile Trophy in Australia (eight days, 404 miles
rently the longest non-stop road ultra-cycling event [8]. and 13,000 m of elevation), the Yak Attack in the Himala-
It stretches over 4,800 km and has been taking place for yas (10 stages, 310 miles and 15,000 m of elevation), the
over 40 years [9, 10]. The Death Ride in the United States Iron Bike in Italy (seven stages, 435 miles, 22,000 m of
is a 103 miles long road race with 14,000 feet of eleva- overall climb) or the Tour d’Africa (90 stages, 7,450 miles,
tion (www.deathride.com) and ranks among the toughest 71,564 m of overall climb).
races in the world. The Transcontinental Race self-sup- Due to the increasing interest in participation in ultra-
ported ride across Europe with a distance of roughly cycling races, numerous studies have been published in
4,000 km, the Dragon Devil in Wales (320 km, almost recent years addressing various aspects of such races,
5,000 m of climbing), the Dirty Kanza XL (563 km, including the geographical differences between races,
4,500 m of elevation in Kansas), and the Mallorca 312 anthropometric characteristics of ultra-cycling partici-
(312 km, 5,050 m elevation) are also considered as some pants, age- and sex-related differences between cyclists
of the most challenging ultra-distance cycling races on [2, 11] and methods to describe heart rate, exercise inten-
the planet (www.redbull.com/mea-en/worlds-tough- sity and pacing [12–18]. In addition, research has been
est-endurance-cycling-events). The Great Divide (Tour conducted on nutritional considerations [19–21], water
Divide) is a mountain bike self-supported non-stop race and electrolyte disturbances during a race and rehydra-
with a 4,418 km distance from Canada to Mexico, the tion [20, 22, 23], hematological and biochemical param-
longest mountain bike race in the world. A non-stop and eters [22, 24, 25], factors impacting on the performance

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 3 of 18

(e.g., training status, fatigue and psychological parame- Using this search strategy, 948 studies were identified,
ters) [19, 26], and immunological and hormonal changes, with 93 results in PubMed, 21 results in Scopus, 101
in such a race [27, 28].. studies in SPORTDiscus, and 733 in Google Scholar. In
Google Scholar, the search term ‘ultra-endurance cycling’
Main Text yielded no results, while ‘prolonged cycling’ yielded
Aim 15,900 results and was therefore deemed too unspecific
To date, there is no comprehensive literature review and omitted from the Google Scholar search. Ten of the
available on this topic summarizing the findings of such 21 studies identified in Scopus were duplicates of stud-
studies on ultra-cycling. Therefore, the aim of the present ies that had been already identified in PubMed. All 97
narrative review was to provide an overview of the avail- studies identified in PubMed and all 21 studies identi-
able data and summarize the available information on fied in Scopus were also identified using Google Scholar.
ultra-cycling events and the participating cyclists. Topics All studies identified in SPORTDiscus had already been
of interest were geographic aspects of ultra-cycling races, identified in PubMed and GoogleScholar. Two of the
characteristics of ultra-cyclists, age and sex differences, studies found in Scopus were excluded, because one was
nutrition, fluid balance, body mass loss, and performance not available in either English or German, and the other
enhancement. The information provided can be useful was entirely off-topic.
for athletes and coaches to better delineate training strat-
egies for ultra-cycling events. Study Eligibility
In addition to relevant studies listed in these databases,
Methods an online search was conducted for ultra-cycling events
Database and search strategy A literature search was con- and road races around the world that meet the WUCA
ducted in three databases: Scopus (https://www.scopus. definition of ultra-cycling but may not have been identi-
com/home.uri), PubMed (https://pubmed.ncbi.nlm.nih. fied in the scholarly databases. Studies published in Eng-
gov/), SPORTDiscus (https://www.ebsco.com/products/ lish or German were considered. Studies focusing on a
research-databases/sportdiscus), and Google Scholar topic other than ultra-cycling were excluded, as were
(https://scholar.google.com/). The search terms used studies published in other languages. Studies reporting
were ‘ultracycling’, ‘ultra cycling’, ‘ultra-cycling’, ‘ultra- on triathlons, which typically entail a cycling distance of
endurance biking’, ‘ultra-bikers’ and ‘prolonged cycling’ 40 km (standard triathlon) or 180 km (Ironman), were
and the search was conducted on December 31st, 2022. excluded, but ultra-triathlons covering a cycling distance
of > 200 km in a single event were included, as these races
qualify as an ultra-cycling event according to the WUCA
Table 1 Studies identified in PubMed and Scopus categorized definition.
by area of interest Following the literature search, the relevant studies
Topic of interest Number of References identified in the three databases were categorized based
studies on their research focus according to the main topics
Geography/location 12 [9, 29–39] of interest of the present narrative review: geographic
Characteristics of ultra-cyclists 25 [2, 4, 9, 28, 33, aspects of ultra-cycling races, characteristics of ultra-
40–57] cyclists, age- and sex-differences, nutrition, fluid balance,
Age differences 8 [14, 30, 58–63] body mass loss, and performance enhancement (Table 1).
Sex differences 15 [23, 30, 38, 53, Several studies focused on two or more of the areas of
59, 62, 64–72]
interest and are therefore listed twice or more frequently
Nutrition 16 [73–90]
in each corresponding category of Table 1.
Fluid/mineral balance and rehydration 13 [23, 32,
91–101]
For each area of interest, the studies were accessed in
Body mass changes 14 [11, 22, 23, 27, full text, summarized, and the results compiled in the
43, 44, 56, 91, narrative review.
102–107]
Performance, physiology, hematological 41 [10, 13, 24, 26, Results
and biochemical parameters; thermo- 34–36, 52, 106, Race Locations and Geographical Aspects
regulatory and humoral responses, 108–139]
A total of 26 studies were identified in the search focus-
injury, and performance enhancement,
oxidative damage ing on a particular race or a particular location. These
Endocrine responses 4 [35, 119, 120, specific races and the countries in which they took place
140, 141] are summarized in Table 2.
Cardiac function, exercise intensity and 15 [12–18, 100,
pacing, power output, VO2max 142–148]

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 4 of 18

Table 2 Studies assessing races in different geographical regions not finishing the race [154]. Thus, the high rates of non-
Country Event Distance Reference finishers highlighted the demanding nature of ultra-
and
cycling races.
elevation
An overview of the participants in the identified pri-
USA RAAM 4,800 km, [9, 36, 90,
25,000 m 138, 139, mary studies is provided in Table 3, comparing cyclists’
elevation 149] characteristics such as age, sex, and training volume.
France and Paris-Brest-Paris and 600–720 km [46] Based on the existing literature incorporating the charac-
Switzerland RAAM qualifiers in teristics of ultra-cyclists, it appears that they are predom-
Switzerland inantly male and typically between 35 and 45 years old.
France Paris-Brest-Paris 1,230 km [141] Moreover, Swiss, German, and Scandinavian nationals
Spain Vuelta a España 3,431 km [15, 16, dominate in European races, whereas North American
142, 145]
cyclists are predominant in the RAAM [8, 31, 33, 40, 41,
France Tour de France 3,500 km [16, 26,
106, 128, 154]. Compared to other individual ultra-disciplines like
142, 145, running or swimming, ultra-cyclists are slightly younger,
146] have a slightly higher body mass index (BMI), and focus
France Paris-Roubaix 256,6 km [150] more on training volume than training intensity [44, 45].
Italy Giro d’Italia 3,448 km [100, 131,
132, 142] The Aspect of Age in Ultra-Cycling Performance
Italy Milano-Sanremo 294 km, [151]* Eight of the identified studies focused on the age of the
2,000 m
elevation
cyclists as a potential factor of ultra-cycling performance
Switzerland Swiss Cycling Marathon 720 km, [30, 32]
(Table 1). Allen et al. compiled a systematic review and
4,700 m meta-analysis on the age of elite athletes at the peak of
elevation their performance [58]. They also included two studies
Belgium Tour of Flanders 237 km [150, 152] on cycling events, one of which detailed the age of per-
Belgium E3 Saxo Bank Classic 203 km [150] formers at the ultra-cycling events Furnace Creek and
Belgium Liège-Bastogne-Liège 259 km [150] Swiss Cycling Marathon [154]. Allen et al. noted that the
Netherlands Amstel Gold 240 km [153]* top performers in ultra-cycling events were on average
Denmark - Italy Copenhagen-Palermo 3,000 km [63] 38 years old and thereby the oldest compared to the top
New Zealand K4 cycle race 387 km [89, 101] performers in all other assessed sports, including mara-
Note: USA (the United States) thon runners [58]. Knechtle et al. assessed whether the
*Race found by online search, no scientific study pertaining to results of this age of Ironman triathletes influences their performance
race was identified
and found that the younger athletes (18 to 40 years) were
significantly slower in the cycling component of the event
The Ultra-Cyclist compared to the older age groups (> 50 years), while they
Seventeen studies were identified that focused on the were faster in the running and swimming events and had
characteristics of ultra-cycling athletes (Table 3). In a shorter transition time [59].
the beginning of ultra-cycling competitions, most par- A potential reason for this observation could be that
ticipants were US nationals as the RAAM was the most the cycling performance declines relatively more slowly
competed in race [154]. With an increasing number of than the swimming performance [155]. Moreover, older
races taking place in Europe, the number of European athletes participating in ultra-races achieve a more even
participants in ultra-cycling races has also increased pacing compared to their younger competitors [59].
[154]. In a study investigating participation and perfor- Lepers et al. analyzed the performance of participants
mance trends in both an American qualifier (i.e., the Fur- in the Ironman Hawaii relative to their age at the time of
nace Creek 508) and a European qualifier for the RAAM competition [60]. Male and female finishers were catego-
(i.e., the Swiss Cycling Marathon) and the RAAM itself, rized by their age and the performance of the top ten fin-
the characteristics of the participants and their perfor- ishers in each group was evaluated over 15 years. During
mances were assessed [154]. Using a linear regression this period, a relative increase in athletes aged 40 years or
and variance analysis, it was shown that the races were older was observed, while a declining trend was noted for
very selective in terms of the number of racers participat- the age groups under 40 years. In addition, a trend was
ing and, ultimately, the resulting finishers. On average, noted towards a continuously improving performance of
∼ 41% of participants did not finish either the RAAM or the top finishers aged 45 years or older, and the sex differ-
the Furnace Creek 508, whereas ∼ 26% did not finish the ences in the top ten performers decreased with increas-
Swiss Cycling Marathon, with ∼ 26–40% of all starters ing age, in that the finishing times of the best ten male

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 5 of 18

Table 3 Characteristics of cyclists participating in ultra-cycling events

Event Year Participants References
Cycling events
Czech Championship 24-h 2013 Female winner, 46 years old, 15 years active, 12 finished ultra-races, 12 h training/week [40]
mountain biking race
Copenhagen-Palermo 2022 Comparison of two age groups (30 ± 5 years and 65 ± 6 years) in terms of metabolic and physi- [63]
ologic parameters
RAAM 2021 Male winner of RAAM, 75.2 h and 2,532 km completed as part of a team, average speed [139]
35.9 km/h, average power 210 W, average heart rate 121 bpm
RAAM qualifier in Switzer- 2007– Paris-Brest-Paris qualifier: mean age 45.2 years, BMI 24.2 kg/m2, higher training volume; RAAM [46]
land and Paris-Brest-Paris 2009 qualifier: mean age 41.4 years, BMI 23.4 kg/m2, higher training intensity
qualifier
RAAM 2018 (?) 4 female cyclists, 4 male cyclists, 7 male crew members, 1 female crew member, changes in physi- [9]
ological, psychological & perceptual parameters throughout the race in cyclists
Ötztal ultra-cycling race 1999 Single case study, male athlete, 36 years old, BMI 22 kg/m2, 12,000 km training in the year of the [49]
race
RAAM 2019 (?) Single case study, female non-athlete, training from sedentary lifestyle to ultra-event [28]
24 h time-limited, self- 2022 Single case study of the biophysical characteristics of a male ultra-cyclist with two world records [57]
paced road race events in ultra-cycling events
Cape Argus Cycling Tour 2012 Differences between mountain bikers and road cyclists in ultra-races in terms of motivation to [55]
and Cape Epic participate and behavior
Ultra-triathlons
Double, Triple, and Deca 1985 to Increase in overall number of finishers for Double (360 km cycling) and Triple (540 km cycling) [42]
Iron 2009 races, Deca (1,800 km cycling) finishers stable, women relatively slower than men with increasing
length
Triple Iron races vs. ultra- 2007– Cyclists participating in triple triathlons (540 km cycling) are younger, have a higher training [44]
marathon races 2009 volume, and have higher body mass than runners
Ironman and Triple Iron- 2007– Ironman participants vs. Triple Ironman (540 km cycling) participants, 49 different nationalities, [45]
man races 2009 ultra-athletes with higher BMI, shorter stature, and larger training volume
Double Iron ultra-triathlon 1985– European participants in ultra-triathlons (360 km cycling) have faster finishing times than North [50]
2010 American athletes
Ultra-triathlon races 1985– Influence of experience on performance in longer ultra-triathlons (360 km, 540 km, 900 km, or [47]
2014 1,800 km cycling)
Triple Iron ultra-triathlon 1988– Proportionally more of the female participants finished triple iron ultratriathlons (540 km cycling) [51]
races 2011 than of the male participants, race time decreased for men, increased for women
Ultra-triathlon race 30 years’ Two male athletes with 30 years’ experience in ultra-triathlon races (360–540 km cycling), > 60 [52]
time years of age, performance decline highest for running discipline
span
Ultra-triathlon race 1985– Fastest participants in ultra-triathlons (360 km, 540 km, 900 km, or 1,800 km cycling) are from [53]
2018 Germany, France, and Switzerland; few North Americans competing in European races; less time
for swimming and cycling, more time for running with increasing length of race

and female performers became more and more similar shorter distances. An explanation of this finding might be
over the course of time. the accumulation of training and sport experience allow-
Nikolaidis et al. assessed the age of peak performance ing the participation in longer races for older athletes.
of men and women participating in an ultra-distance Pozzi et al. investigated the age of peak performance of
duathlon, the Powerman Zofingen [61]. To do so, the participants in a 24-hour ultra-cycling event in Switzer-
authors divided the participants into age groups of five land over a 10-year period [156]. It was observed that the
years and measured the effect of age on race time and on age of peak performance did not significantly change for
the type of race (short versus long version). The results male athletes over this period, but significantly decreased
showed that age affected the performance times in both for females and for the overall participant pool. In turn,
the short and the long races, with younger athletes (25 to the achieved cycling distance was reduced with the
29 years) completing the race significantly faster than the increasing age of the athlete, and a significant effect of
oldest athletes (70 to 74 years). Of note, the age of peak age on the performance was noted. The most successful
performance in the longer run (33 years) was higher than participants were between 35 and 39 years old. Zingg et
that in the shorter version (22 years) of the race, indi- al. focused on the influence of age on the performance of
cating that the older athletes performed well at a higher participants in the Swiss Cycling Marathon and observed
age in longer endurance competitions compared to the

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 6 of 18

similar ages of the top performers, with an average of 35 55.5% of female participants in the Deca Iron ultra-tri-
years for men and 38 years for women [30]. athlons completed the race, while 82.9% of male partici-
The focus of a study by Wundersitz et al. was the physi- pants finished these races.
ological parameters during an ultra-cycling race relative For all three races, women took longer to complete
to the age of the athletes [14]. The main outcome was the race. Comparing the best performance times of
the incidence of cardiac arrhythmias after the race. The male and female participants, women required 21.2%
results showed an overall increase in the incidence of more time than men to complete the cycling compo-
cardiac arrhythmias, a decrease in aortic valve maximum nent of Double Iron ultra-triathlons, 23% more time than
velocity, and a slower mitral valve deceleration time. The men to complete the cycling component of Triple Iron
incidence of cardiac arrhythmias was highest in the older ultra-triathlons, and 19.4% more time to complete the
age groups (45 years or older), rendering this group par- cycling component of Deca Iron ultra-triathlons. These
ticularly susceptible to cardiovascular events during an sex-related differences in performance times could be
ultra-cycling race. explained by anthropometric differences, e.g., the higher
Frandsen et al. conducted a 15-day intervention in fat mass and lower skeletal muscle mass of women com-
which cyclists completed 3000 km over a time period of pared to men.
15 days [63]. Before and after the intervention, VO2max, In contrast to the observation of these studies that the
lipid parameters (resting plasma fatty acids, low density participation of female athletes in ultra-races increases,
lipoprotein (LDL)-cholesterol, CD36, fatty acid binding Rüst et al. observed that the number of male participants
protein/FABP), proteins involved in glucose metabo- in Triple Iron ultra-triathlons significantly increased
lism (glucose transporter 4/GLUT4, SNAP23), and reac- over a 13-year period, while that of female participants
tive oxygen species production were compared between remained stable [51]. Moreover, in contrast to the study
younger (average age = 30 years) and older (average on the Norseman Xtreme race, the sex gap in terms of the
age = 65 years) participants. The results demonstrated finishing time increased over time from 10 to 42%. The
that the adaptive response of younger cyclists was supe- authors speculated that this may be due to a diminished
rior to that of older cyclists. Older cyclists exhibited importance of the finishing time for women due to social
impaired adaptation of their cardiovascular function factors.
due to the decreased adaptive response of metabolic Lepers and Stapley investigated the issue of sex differ-
parameters. ences in performance of participants in ultra-races and
Summarizing the studies on the influence of age on summarized the sex performance gap as 10% [4]. They
performance in ultra-cycling events, it can be concluded identified physiological differences between men and
that the highest performance is achieved in the mid- women as potential factors influencing this performance
to late thirties, and that the finishing time decreases gap, including the larger VO2max of men, lower body fat,
from the age of 40 years secondary to increased cardiac greater muscle mass, and a greater hemoglobin concen-
arrhythmia and decreased adaptation. In light of this tration [4]. The authors noted that due to these physiolog-
observed decline in performance, metabolic and physi- ical differences, biological factors are not responsible for
ological problems occur more frequently in cyclists aged the observed change in performance over time, i.e., the
40 or older, which likely contributes to a slower finishing observed changes in the differences between women and
time. men. They identified age as a potential factor to increase
the sex gap, because less women participate in ultra-
Sex as a Factor in Performance races in the higher age groups and, hence, fewer regular
A total of 15 studies were identified that focused on sex competitors are found among the female participators.
differences between cyclists participating in ultra-cycling Moreover, social factors may have prevented female par-
events. ticipants from achieving their peak performance.
Knechtle et al. analyzed the participants in Double, Scheer assessed participation trends in different ultra-
Triple, and Deca Iron ultra-triathlons over 25 years and races and identified an overall low participation of female
found an overall decrease in the speed of female racers athletes in ultra-cycling events, ranging between three
with increasing length of the race, which was not the case and 11% [2]. It was noted, based on the existing research,
for male participants [42]. The number of female partici- that the proportion of females participating in ultra-
pants increased steadily from the first race held in 1985. cycling event is lower than in ultra-marathon running
The finish rate was higher for women than for men in events [2]. In conclusion, sex-related differences in both
the Double and Triple Iron ultra-triathlons, with 79.6% the participation rates and performance in ultra-cycling
of men and 84.7% of women finishing the Double Iron events have been noted.
ultra-triathlons and 71.7% of men and 77.0% of women
finishing the Triple Iron ultra-triathlons. In turn, only

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 7 of 18

Fluid and Electrolyte Balance and Rehydration was compared to consumption of a pre-defined amount
Twelve studies were identified in the literature search of liquids in terms of the participants’ performance [93].
that focused on fluid and electrolyte balance and rehy- Three studies on endurance cycling events were included
dration during an ultra-cycling event. Hyponatremia in the analysis, and while none of these studies focused
is defined as a sodium serum level below 135 mmol/l. on ultra-races, an overall beneficial effect of liquid intake
Sodium serum levels below 120 mmol/l can cause neu- on pacing was noted, while an effect on performance
rological symptoms due to cerebral edema [157]. When was only observed for prescribed drinking and not for
sodium serum levels decrease below 110–115 mmol/l, ad libitum intake [165–167]. It remains to be determined
respiratory failure due to cardiopulmonary decompen- whether similar effects of the fluid intake can be observed
sation may occur [158]. Different etiologies have been for ultra-races. One study by Gauckler et al. investigated
described for hyponatremia, including side effects of cer- whether the drinking pattern during ultra-cycling races
tain pharmaceuticals and systemic causes [159]. In terms has effects on the incidence of edema [92]. A correla-
of sporting events, hyponatremia correlates with sodium tion between fluid intake pattern during the race and the
loss throughout a race, and this phenomenon is called occurrence of kidney-related symptoms, occurring in
exercise-associated hyponatremia (EAH) [160]. EAH two-thirds of the participants, was determined. In this
occurs in intense training or competition with prolonged context, drinking as much as possible was positively cor-
intense exertion for four to six hours or longer and is thus related with the incidence of kidney-related problems
a concern for athletes participating in ultra-events [161]. and edema, while drinking according to the need based
Before EAH was conceptualized, athletes were gener- on the environmental conditions during a race showed a
ally recommended not to drink during an exercise, which negative correlation with kidney-related symptoms and
led to hypernatremia [162]. Consequently, the American edema. These findings point towards an advantage of
College of Sports Medicine unfortunately recommended controlled fluid intake during an ultra-cycling event to
drinking as much as possible during exercise to offset prevent occurrence of limb swelling.
hyponatremia, thereby increasing the incidence of EAH Chlíbková et al. assessed the hydration status of ultra-
in athletes due to fluid overload [162, 163]. In order to cyclists participating in mountain bike races [23]. While
find a balance between hypo- and hypernatremia, fluid no changes in lower limb volume were observed after the
intake before, during, and after a race should be moni- race, the plasma urea level as an indicator of kidney func-
tored to reach an optimum hydration status [164]. tion and water conservation negatively correlated with
The literature search identified 11 studies focusing on the ranking of the participants in the race, but this cor-
fluid and electrolyte balance and rehydration during an relation was only significant for male participants.
ultra-cycling event. Moyen et al. conducted a study to Armstrong et al. determined the body water of par-
determine the effect of the hydration status of partici- ticipants in an ultra-cycling event of 164 km length [91].
pants in ultra-cycling events on their pain and mood [97]. The authors determined that changes in body mass and
They observed that throughout a race, fatigue, thirst, body water during the event were correlated but were
pain, thermal sensation, and exertion increased, while not equivalent. However, body mass loss was concluded
tension and vigor decreased. A comparison of dehydrated to be a suitable measurement to determine water loss
participants with those not suffering from dehydration during such an event and may serve as a basis for fluid
showed that dehydration led to a stronger sensation of replenishment.
fatigue and pain at the beginning and in the middle of the In terms of hyponatremia during ultra-races, four stud-
race, whereas the hydration status did not affect any of ies were identified focusing on sodium levels during and
the parameters after the race. Overall, dehydration was after ultra-races. Knechtle et al. reviewed available data
linked to more pain, fatigue, thirst, and thermal sensation on the prevalence of hyponatremia and the associated
compared to euhydration, while there was no significant clinical presentation and found evidence for a higher
effect of urine-specific gravity on the mood stage. prevalence of hyponatremia in triathletes with increas-
Black et al. assessed the fluid balance of ultracyclists ing duration of the event (Ironman versus Triple Iron
participating in a 387-km race by analyzing blood and ultra-triathlon) [95, 98]. Moreover, a link between EAH
urine samples before and after the race [101]. Low blood and fluid overload was noted. In races where cycling was
sodium concentrations of 135 mmol/L were measured the only discipline, the prevalence of EAH appeared to be
after the race, while dehydration only affected 2 of the 18 lower than in races combining multiple disciplines [95,
participants. The authors concluded that hyponatremia 99].
rather than dehydration is an issue that needs to be con-
sidered in the context of fluid balance of ultracyclists. Nutrition, Energy Expenditure, and Performance
In a meta-analysis by Goulet and Hoffman, the effect The literature search revealed 18 studies dealing with
of an ad libitum fluid intake during endurance events nutrition during an ultra-cycling event. These articles

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 8 of 18

could broadly be divided into four focus areas: energy 5 kg of body mass he lost during the race were due to
expenditure/energy balance during a race [73, 74, 78, 79, protein (muscle) or fat metabolism.
83, 84, 90, 168], nutritional behaviour/food intake during A comparison of different types of ultra-endurance
a race [75, 77, 86, 89], the influence of nutrition on the events revealed that cycling and triathlon races induce
performance [80, 82, 85, 141], and the breakdown of indi- an approximately three times higher energy deficit com-
vidual nutrients [76, 81]. pared with ultra-endurance running events [84]. In sum-
mary, ultra-cycling events lead to an energy deficit due
Energy Expenditure/Energy Balance to the discrepancy in energy intake and the extended
Barrero et al. conducted an analysis of the energy bal- energy expenditure. The optimum nutritional supply to
ance of ultra-endurance triathletes by assessing both close this energy gap has yet to be determined and must
the energy of the food and fluids consumed during the be adapted to the individual race lengths and conditions.
Extreme Man Salou-Costa Daurada triathlon in Spain
and the expended energy according to heart rate, oxygen Influence of Nutrition on Performance
consumption, and body composition [73]. All partici- In a study by Goedecke et al., the effect of supplying
pants were male and had been recreationally participat- athletes during an experimental ultra-cycling race with
ing for at least three years in ultra-endurance events. The a drink containing either carbohydrates alone or carbo-
average energy intake amounted to 3,643 kcal, while the hydrates and medium-chain triglycerides on their per-
average energy expenditure was 11,009 kcal, demonstrat- formance [80]. The idea for this trial stemmed from the
ing a significant energy deficit during the race. It was also hypothesis that in the later stages of such races, when gly-
observed that the athletes consumed significantly more cogen stores are depleted, lipids may serve as alternative
macronutrients, solid foods, and fluids during the cycling energy sources. Eight male athletes participated in two
stage of the race than during the running stage. Body trials in which one of the solutions was consumed. Per-
mass significantly decreased, which was be primarily formance was determined as the time to complete 75 kJ
attributed to the loss of total body water. A similar energy and 200 kJ trials. Both performance measures decreased
deficit was observed by Bescós et al., conducting a case significantly more when the solution contained carbo-
study on a single cyclist participating in a 24-hour-ultra- hydrates and medium-chain triglycerides compared to
cycling event [74]. The athlete was male and predomi- carbohydrates alone. The reason for these performance
nantly consumed during the race solid foods rather than differences could be the gastrointestinal symptoms and
sports drinks, with a total energy intake of 5,571 kcal. The delayed gastric emptying experienced after medium-
energy deficit amounted to 9,915 kcal, which was suppos- chain triglyceride consumption and the resultant heart
edly met by endogenous fuel stores. These values were rate increase early in the race. The overall fat content of
similar to the energy expenditure determined for elite the diet was a focus of a study by Rowlands and Hopkins,
Ironman athletes of 9,626 kcal per race [83]. who compared the effect of a diet with a high fat content
Enqvist et al. assessed the energy expenditure of ath- (70% of the total energy from fat) on the performance of
letes participating in a 800 km-adventure race with a competitive male ultra-cyclists with that of a diet with a
cycling component by determining their heart rate and high carbohydrate content (70% of the total energy from
oxygen intake [78]. The average energy expenditure was carbohydrates) [85]. The diets were consumed for two
80,000 kcal, with a range of 64,000 to 114,000 kcal during weeks prior to the experimental race. Performance in
the 5-day race. During an ultra-cycling race, an energy the ultra-cycling event was measured during a 100 km
expenditure ranging from 10,557 kcal to 44,521 kcal was time trial. A trend was observed towards a better perfor-
determined in five recreational athletes [79]. mance in the high-fat diet group compared to the high-
Hulton et al. determined the energy expenditure of carbohydrate diet group (4% improvement in time and
cyclists participating in the RAAM [90]. The average 11.4% improvement in power output), but the difference
energy expenditure amounted to 43,401 kcal and the lacked statistical significance. Nonetheless, the difference
daily energy expenditure to an average of 6,420 kcal. may have been statistically significant if the effect of both
Based on the daily food and fluid intake, an energy deficit diets on performance had been compared in an ultra-
of 13,878 kcal was observed. A case report by Knechtle et endurance event.
al. also focused on the energy intake and energy expen- The effect of carbohydrate supplementation in com-
diture of a cyclist participating in the RAAM [168]. The parison with protein supplementation was assessed by
cyclist consumed 96,124 kcal in the course of the race, Koopman et al., who focused on the protein turnover
with 75.2% of these calories consumed as carbohy- during an experimental ultra-endurance race with 2.5-
drates. The energy deficiency after the race amounted hour bouts of cycling and intermittent one-hour running
to 83,526 kcal., while it was not determined whether the phases [82]. Two trials were conducted in which the same
subjects consumed either a carbohydrate solution or a

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 9 of 18

solution that contained both carbohydrates and protein common post-race foods were vegetables, cheese, and
hydrolysate. Protein turnover was measured by injecting meat [87].
amino acid isotope tracers. Supplementing the drink with Wilson et al. performed an analysis of the types of sac-
protein hydrolysate resulted in an increased protein flux, charides contained in the carbohydrates consumed dur-
protein synthesis rate, and whole-body protein oxidation ing an ultra-triathlon race [86]. Saccharide content was
compared to the drink containing carbohydrates only. either measured by liquid chromatography or based on
Individual amino acid analysis revealed differences in the the values reported in the US Department of Agricul-
measurements of protein turnover, which in turn means ture Database. The proportions of glucose, fructose, and
that an effect of supplementation on protein metabolism sucrose were calculated from 80 different consumed
depends on the composition of the protein hydrolysate. foods, and amounted to a median of 64%, 50%, and 10%
These results also demonstrate that protein supplementa- of total carbohydrates, respectively.
tion induces protein metabolism more than carbohydrate Black et al. conducted a study on the energy intake of
supplementation and may therefore enhance perfor- cyclists participating in a 384-km ultraendurance race
mance during an ultra-endurance race. [89]. The cyclists reported their food and fluid intake
Geesmann et al. evaluated the effect of energy balance after the race and the nutrient composition of the con-
of cyclists during an 1230-km ultracycling event on the sumed food and drinks was assessed. The results dem-
release of hormones that are involved in metabolism onstrated an inverse correlation between the completion
[141]. They discovered that several metabolic hormones, time and energy intake, as well as a correlation between
including leptin and testosterone, were suppressed and carbohydrate and fat intake and completion time. The
remained suppressed for a 12-h-period following the end authors concluded that the energy requirement during
of the race. The suppression of insulin-like growth fac- such an ultraendurance event should be met with a high
tor-1 correlated with the energy deficit during the race energy intake during the race in order to achieve the opti-
[141]. mal performance.

Nutritional Behaviour/Food Intake Individual Nutrients

Bescós et al. studied the nutritional intake of male Two studies assessed changes in the metabolism of indi-
cyclists during a 24-hour-relay race in Barcelona [75]. vidual nutrients during ultra-endurance events. Borgen-
While the athletes were encouraged to consume primar- vik et al. determined the amino acid metabolism of male
ily carbohydrates before the race to fill their endogenous participants in an adventure race and during post-race
glycogen stores, they were allowed to consume any food recovery [76]. They discovered that the plasma con-
of their choice during the race. They consumed mostly centration of glutamine, glycine, lysine, serine, threo-
carbohydrate-rich foods and drinks during the event, nine, and valine was diminished by the race, while the
with individual variations in the in-race intakes of protein concentration of tyrosine, phenylalanine and gluta-
and lipids. The intakes of sodium and caffeine increased mate increased. In the muscle, only lysine significantly
towards the later stages of the race. decreased. The post-exercise levels of branched-chain
Chlíbková et al. determined the nutritional intake amino acids correlated with the glycogen content of the
of ultra-cyclists before, during, and after a 24 h-ultra- muscle, indicating a potential protein breakdown during
cycling race [77]. Two-thirds of the athletes followed a the race due to depleted glycogen stores. No significant
diet rich in carbohydrates before the race, while the other decreases in the amino acid levels were observed during
third observed a protein- or fat-rich diet regimen. During the recovery phase.
the race, the athletes consumed 56 different foods and 16 Konopka et al. analyzed protein synthesis in the skel-
different drinks. The most common foods were bananas, etal muscle during the ColoradoTrail Race, an ultra-
apples, oranges, raisins, pineapple, melon, chicken, bread, endurance mountain bike race, and compared the data
noodles, rice, biscuits, energy and muesli bars, cheese, to a control situation without normal activity [81]. The
chocolate, tomatoes, and dried fruits, while the most authors discovered that protein synthesis in the skeletal
common drink was an isotonic sport drink followed by muscle was increased during the race, and indices of cel-
water. After the race, the food patterns were like the in- lular energetic stress increased.
race pattern, with the most common foods being bread, Summarizing the results of studies focusing on nutri-
noodles, rice, bananas, chicken, tomatoes, and cheese. tion during ultra-cycling events, it becomes obvious that
The most common beverage was water. In a study assess- there is a lack of studies on the nutritional behaviour and
ing the nutritional habits of participants in the RAAM, energy expenditure of female athletes, as all the studies
similar foods were identified as in-race energy suppliers, were conducted with male athletes. Moreover, the ques-
primarily bananas, chicken, and bread [87]. The most tion remains whether nutrients other than carbohydrates
could enhance performance, particularly during the later

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 10 of 18

stages of the race. At present, it remains unclear whether of 1 kg, a decrease in fat mass by 0.8 kg, and a decrease in
in-race triglyceride or protein supplements can contrib- muscle mass by 0.9 kg [104]. In contrast, an assessment
ute to a faster race time. of eight athletes participating in the Deca Iron Triathlon
showed no significant loss in body mass [103]. Losses of
Changes in Body Mass skeletal muscle mass (1.1 kg) and fat mass (0.9 kg) were
The literature search retrieved 14 studies focusing on like the losses observed in the case study [104].
changes in body mass during an ultra-cycling race. A correlation between the intensity of the race and the
Bischof et al. determined anthropometric parameters body composition changes was noted in a study assess-
of cyclists participating in the Swiss Cycling Marathon ing body mass and composition changes of participants
[102]. Anthropometric measurements included skin- in the Triple Iron ultra-triathlon in Germany 2006 [105].
fold thickness, limb circumferences, and body mass. Body mass, limb circumferences, skinfold thicknesses,
The relative proportion of body fat and muscle mass was fat and muscle mass, and body fat percentage were mea-
calculated from these measurements. The anthropo- sured before and after the race. A significant decrease
metric measurements were repeated at multiple check- in body mass of 3.9% was noted, as well as a decrease in
points throughout the race. The results demonstrated a limb circumferences for all body parts except the thigh
mean decrease in body mass by 1.5 kg and a decrease in and the chest. There was no significant change in skeletal
fat mass of 1.5 kg. Skeletal muscle mass and estimated muscle mass, yet both the BMI and the relative propor-
body water did not significantly change during the race. tion of body fat decreased significantly. Along with these
Decreases in skinfold thickness were noted for all mea- observations, no decrease in skeletal muscle mass was
sured limbs, with the abdominal skinfold thickness neg- observed in participants in the Swiss Cycling Marathon
atively correlating with the cycling speed. A potential [11]. Anthropometric measurements were conducted
explanation for these changes includes the degradation before and after the race. Body mass decreased by 1.7 kg
of subcutaneous adipose tissue in the body parts that and fat mass by 1.4 kg, while total body water and skeletal
are used most during an ultra-cycling event, such as the muscle mass showed no significant changes. The changes
thigh and the pectoral muscles. in body mass and fat mass correlated significantly, as did
Chlíbková et al. aimed at determining the changes in the changes in body mass and total body water changes.
body composition of ultra-cyclists during two 24-hour In a review assessing the changes in anthropometric
races [23]. Anthropometric measurements included skin- measurements during ultra-endurance races, decreases
fold measurements, limb circumferences, fat and muscle in all assessed skinfolds (pectoral, mid-axilla, triceps,
mass, body mass, as well as body water. Moreover, the subscapular, abdominal, suprailiacal, thigh, and calf )
changes in foot volume were assessed by plethysmog- were noted for ultra-endurance cyclists [43].
raphy to determine the presence of edema. Changes Valenti et al. assessed whether participation in a
in body mass correlated negatively with the distance 4,400 km ultra-cycling race (NorthCape4000) impacts
covered during the race and positively with their over- on body composition and metabolic parameters involved
all ranking. The ranking also correlated positively with in myogenesis [27]. They conducted bioelectrical imped-
changes in fat mass and negatively with fluid intake. The ance analyses and dual energy x-ray absorptiometry to
absolute changes in body mass and fat and muscle mass measure body composition before and after the race and
were calculated separately for male and female partici- determined the level of myogenic progenitor cells indi-
pants. Male participants lost an average of 2.0 kg of body rectly by the level of the transcription factors required for
mass, 1.4 kg of fat mass, and 1.4% of body fat. Skeletal this process. Fat mass, visceral adipose tissue, and truncal
muscle mass did not decrease significantly. Female par- fat significantly decreased after the race, while lean mass
ticipants lost 0.9 kg of body mass during the race, 1.2 kg significantly increased [27]. The expression of transcrip-
of fat mass, and 2.7% of body fat, while no significant tion factors involved in myogenesis was elevated after the
changes in skeletal muscle mass were observed. No sig- race.
nificant changes in the foot volume were noted in either
men or women. The higher changes in the body mass of Performance, Injury, and Performance Enhancement
men compared to women could be explained by the fact Forty-one studies were filtered from the search results
that men had a higher body mass to start with, that they that focused on factors influencing performance in an
completed the race faster, and that men utilize intramyo- ultra-cycling race. Five themes pertaining to their influ-
cellular lipids more than women [169, 170]. ence on performance were identified: physiological,
Knechtle et al. conducted several studies and on body demographic and anthropometric parameters, pacing
mass and body composition changes during ultra-endur- strategies, injury and inflammation, and psychological
ance events [11, 104, 105]. A case study of a participant of aspects of sleep. These themes and the respective stud-
a Deca Iron Triathlon revealed a decrease in body mass ies are presented in Table 4. In terms of the physiological

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 11 of 18

Table 4 Factors influencing performance in ultra-cycling or mixed ultra-endurance events

Race characteristics Performance indicator Outcome Refer-
ence
Physiological function
8.5 h, 105 km wilder- Respiratory function pre- and post- Decrease in oxygen saturation, forced expiratory volume, forced vital capac- [123]
ness race race, race completion in one athlete ity, potential airflow obstruction, no obvious respiratory symptoms, race
completed
Ultra-cycling event heart rate, cycling power, speed, 861.6 km completed, average power = 210 W, average heart rate = 121 bpm, [139]
distance greater power during daytime
RAAM VO2max, lactate, power pyramidal training intensity distribution-based training only marginally [138]
increases performance
Ultra-triathlon Performance, heart rate, oxygen con- Lower heart rate during cycling leg than during swimming leg, race time [108]
sumption relative to race intensity associated with difference in oxygen consumption and heart rate between
running and swimming, but not cycling legs
24 h-ultra-cycling Physiological performance-related Relative power output positively correlated with covered distance and veloc- [13]
relay race parameters and influence of team size ity; no higher average intensity observed relative to number of participants
Transcontinental Heart rate and performance of a Decrease in heart rate to mid-race, increase towards the end, effect of tem- [110]
Race 5 single athlete perature and sleep quality on performance
Experimental 24-h Physiological parameters during Initial increase (up to 6 h) in heart rate during cycling leg, then decreased, oxy- [121]
race with running, mixed endurance race gen consumption increased up to 6 h and remained high until the end
cycling, and kayaking
Demographic and anthropometric parameters
Ironman Triathlon, Predictors of performance, finish time Influence of sex, age, experience, and performance in cycling and running [115]
Ultra-triathlon legs on finish time
Double and Triple Performance changes in two athletes 0.19% and 1.12% performance decline in cycling per year, largest declines in [52]
Iron ultra-triathlons over three decades running discipline
Triple Iron Influence of anthropometric variables No significant correlation between anthropometric parameters and finish [114]
Ultra-triathlon and split times for each discipline on time, performance in running and cycling, but not swimming, influences
performance finish time
RAAM Differences between finishers and Anthropometric differences observed, finishers have lower BMI, lower [127]
non-finishers percentage of body fat, and lower thigh and upper arm circumference than
non-finishers, but anthropometric measurements not related to finish time
Pacing
RAAM Influence of pacing on performance Decrease in performance with increasing age and altitude changes, top finish- [10]
over five year-period ers started faster, had higher peak speeds, and maintained speed longer
24-h ultra-cycling Influence of pacing on performance Wind speed, temperature influence performance, pacing with beneficial [116]
event impact on top performance
Swissultra Pacing strategies in different multi- Race distance affects running, but not cycling performance in multi-stage [12]
stage ultra-triathlon events events, pacing strategies affected by race distance
Injury and inflammation
Ultra-cycling races Shermer’s Neck in ultra-cyclists Incident Shermer’s neck in ultra-cycling races after 800 km, prevention by [109]
stretching and chin support
Ultraman Florida Inflammatory markers pre- and post- Increase in C-reactive protein, no change in interleukins 6 and 10, positive [124]
Triathlon race, finish time correlation between interleukin 10 levels and finish time
24-h-mountain bike Intake of anti-inflammatory medica- 10% of participants used anti-inflammatory medication during the race, [111]
race tion before, during, and after the race mostly ibuprofen, users were significantly older than non-users
Experimental cycling Effect of anti-oxidant consumption on Changes in endogenous oxidant and anti-oxidant processes during the test, [112]
test with triathletes performance dietary anti-oxidants effective against exercise-induced oxidative stress
and marathon
runners
Hotter’N Hell Inflammatory markers pre- and post- Increase in pro- and anti-inflammatory cytokines, shorter self-pacing associ- [119]
Hundred race, influence of pacing strategies on ated with higher anti-inflammatory cytokine concentration
these markers
Hotter’N Hell Immunological and hormonal Testosterone decreased, growth hormone, cortisol, interleukin 6 increased, [120]
Hundred changes during a race in hot climate cortisol and growth hormone levels higher in fastest compared to slowest
and influence on performance participant
Southern Traverse Influence of heart rate, immunologi- Heart rates declined up to mid-race and then remained stable, leukocyte [118]
Adventure Race cal parameters on performance plasma concentrations and plasma volume increased
Psychological aspects and sleep

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 12 of 18

Table 4 (continued)
Race characteristics Performance indicator Outcome Refer-
ence
Physiological function
Ultra-cycling race Effect of intermittent naps on In-race naps decrease performance, low body fat and duration per training [117]
performance unit increase performance
5 h timed race with Impact of mental workload on Mental workload, quantified by EEG theta power, heart rate variability, and [137]
ultra-cyclists performance psychomotor vigilance, does not affect performance in a staged ultra-cycling
race
10 km simulated Sleep patterns of an ultra-cyclists Sleep duration reduced during the race, slow-wave sleep increased [136]
Road to Camarón before, during, and after the race
race
RAAM Impact on in-race emotions Individual differences in emotional stage, fatigue and negative or positive [36]
(Brunel Mood Scale) and sleep on emotions may enhance or diminish performance depending on personal
performance optimal emotional state, fluctuation of emotions throughout the race

function, the findings were inconsistent in terms of taking anti-inflammatory medication during the race, yet
the heart rate changes during the race, with an ini- it remains unclear to what extent such an intake can pre-
tial decrease observed in one study [110] and an initial vent inflammatory processes during and after the race.
increase observed in another study [121]. Male sex cor- The optimum fluid and nutrient intake before, during,
related positively with a better finish time [115], while and after the race is associated with the total body water
anthropometric measurements were not associated with and, hence, the hydration status and energy balance of
performance [114, 127]. the athlete. The best strategy to prevent hyponatremia of
In-race changes in inflammatory markers such as cyto- ultra-cyclists remains to be determined. EAH appears to
kines were observed in several studies [35, 112, 118–120, be less of an issue for ultra-cyclists than for other ultra-
124]. Oxidative changes induced by exercise could be athletes, potentially due to a more efficient control of
modified by the dietary consumption of antioxidants fluid intake during a race, but the reason for these dif-
[112], and inflammation was counter-balanced by taking ferences has yet to be clarified. Another open question
anti-inflammatory medication [111]. Taking naps during regarding hyponatremia in ultra-cycling is the apparent
an extended race resulted in a diminished performance lack of severe neurological consequences in hypona-
in terms of the finish time [117]. Emotions experienced tremic ultra-cyclists despite critically low sodium levels
during the course of an extended race could exert both [171].
a stimulating and impairing effect on the performance, It appears that many ultra-cyclists already focus on
depending on the emotional state and the perceived emo- maximizing their glycogen stores before the race and
tional optimum state of the individual cyclist [36]. consuming carbohydrate- and protein-rich foods before
and after it, yet an energy deficit is frequently observed.
Discussion Therefore, future studies should focus on the best
The present review aimed at assessing the current lit- nutritional preparation for an ultra-cycling event. The
erature about ultra-cycling races. The results showed observed energy deficit may be due to the fact that nutri-
that the popularity of these events has been consis- ent oxidation exceeds nutrient transport in the gut, and
tently increasing in recent years, with races being mainly hence, enhancing transport capacity of intestinal trans-
offered in North America, Latin America, and Europe. porters may be an approach to diminish this deficit. It
While men dominate all races in terms of their propor- seems that carbohydrates are the most efficient nutrient
tion of the participants, the number of female cyclists is for energy supply, with no benefit of pre- or in-race tri-
increasing. glyceride supplementation being observed.
Due to the later entry of women in such events, the The available data on body composition indicate that
available studies assess predominantly male athletes an ultra-cycling event leads to decreases in body mass
and, hence, there is a lack of knowledge on female ath- and fat mass, while skeletal muscle mass does not appear
letes pertaining to their anthropometric measurements, to significantly change. Nonetheless, study results differ,
their immunological and physiological parameters dur- with decreases in muscle mass observed in some studies
ing a race, and the factors influencing their perfor- [103, 104] and no changes in total body water observed
mance. The studies revealed changes in inflammatory in studies with a loss in body mass [11]. Body mass losses
and oxidative processes during an ultra-cycling race, occur as a consequence of ultra-cycling events, and these
which could impact performance. In particular, losses are higher in men than in women. These changes
older athletes try to compensate for such changes by are putatively mostly due to the in-race degradation of

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 13 of 18

lipids stored intramyocellularly or in the subcutane- athletes, as these aspects were identified as research gaps
ous tissue. Potential explanations could be that men and in this review. Topics that warrant further investigation
women exhibit distinct changes in body mass, and that include the causes for an optimum age of peak perfor-
the anthropometry of athletes differs between individual mance around 40 years and the optimum nutritional
sports and combined races such as triathletes. Therefore, supply to close the observed energy gap under consider-
depending on the participants that are studied, different ation of the specific race lengths and climate conditions.
outcomes in terms of body mass changes and composi- Another research gap to be closed by future studies is the
tion may be expected. It is worthwhile investigating in development of strategies to tackle inflammatory pro-
future studies if and why skeletal muscle mass appears to cesses during the race that may persist in the post-race
be unaltered by ultra-endurance exercise, and whether period.
the loss in body mass is solely attributable to the loss in
Abbreviations
total body water. BMI body mass index
It must be acknowledged that there is no clear trend EAH exercise-associated hyponatremia
for consistently observed differences between the sexes, FABP fatty acid binding protein
GLUT4 glucose transporter 4
as studies found conflicting results. This may be due to a LDL low density lipoprotein
lack of comparability between these studies or the races RAAM Race Across America
described therein. Several open questions regarding the WUCA Worldwide Ultracycling Association

role of sex in race performance remain, including the Acknowledgements

observed differences in the peak performance age and the not applicable.
reasons for a comparatively lower performance improve-
Authors’ Contributions
ment of participating women. Lucas Tiemeier collected all studies and drafted the manuscript, Pantelis T.
Topics that warrant further investigation are the causes Nikolaidis, Daniela Chlíbková, Matthias Wilhelm, Mabliny Thuany, Katja Weiss,
for the optimum race age around 40 years of age. Judging and Beat Knechtle helped in drafting the manuscript. All authors read and
approved the final manuscript.
from other sports, one would expect that younger cyclists
would have a greater physical fitness and, hence, would Funding
have an advantage over the 40-year-olds. Nonetheless, not applicable.

experience might be a relevant factor for an optimum Data Availability

performance and could outweigh potential advantages not applicable.
of a younger age. In addition, the mitochondrial vol-
ume may reach an optimum in middle-aged athletes as Declarations
demonstrated in animal studies [172]. This in turn could
Ethics approval and consent to participate
lead to diminished mitochondrial function and oxidative not applicable.
capacity to process nutrients, and be linked to a decrease
in muscle mass and sarcopenia [173]. Moreover, it has Consent for publication
not applicable.
been suggested that the accumulated experience leads to
a reset of central fatigue [174]. Competing Interests
Research gaps pertaining to influencing factors on not applicable.

performance in ultra-cycling races are interventions to Author details

tackle inflammatory processes during the race that may 1
Centre for Rehabilitation & Sports Medicine, Bern University Hospital,
persist in the post-race period. Moreover, the currently Inselspital, University of Bern, Bern, Switzerland
2
School of Health and Caring Sciences, University of West Attica, Athens,
available studies on physiological function are difficult Greece
to compare, because different race durations and inten- 3
Centre of Sports Activities, Brno University of Technology, 61669 Brno,
sities were assessed, mostly with only a few participants. Czech Republic
4
Faculty of Sports, University of Porto, Porto, Portugal
In order to fully understand heart rate and oxygen con- 5
Institute of Primary Care, University of Zurich, Zurich, Switzerland
sumption changes during ultra-cycling races, the inten- 6
Medbase St. Gallen Am Vadianplatz, Vadianstrasse 26, 9001 St. Gallen,
sity and the number of participants must be considered. Switzerland

Received: 19 February 2023 / Accepted: 6 April 2024

Conclusions
In conclusion, literature on ultra-cycling races is com-
paratively scarce, yet certain aspects, such as the types
of athletes and fluid balance/hyponatremia have been References
investigated. Future studies should primarily focus on 1. Zaryski C, Smith DJ. Training principles and issues for ultra-endurance
the energy balance, the occurrence and consequences of athletes. Curr Sports Med Rep. 2005;4(3):165–70. https://doi.org/10.1097/01.
csmr.0000306201.49315.73. Epub 2005/05/24.
inflammatory and oxidative processes, and the female

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 14 of 18

2. Scheer V. Participation Trends of Ultra Endurance Events. Sports medicine 23. Chlíbková D, Knechtle B, Rosemann TJ, Žákovská A, Tomášková I, Shortall M, et
and arthroscopy review. 2019;27(1):3–7. Epub 2019/01/03. https://doi. al. Changes in foot volume, body composition, and hydration status in male
org/10.1097/jsa.0000000000000198. PubMed PMID: 30601393. and female 24-hour ultra-mountain bikers. J Int Soc Sports Nutr. 2014;11:12.
3. WUCA. What is ultracycling? 2022 [15.07.2022]. https://www.ultracycling. 24. Valenzuela PL, Foster C, Lucía A, de la Villa P. Performance and physiologi-
com/what-ultracycling. cal analysis of 500 km non-stop cycling: a case study. Res Sports Med.
4. Lepers R, Stapley PJ. Master athletes are extending the limits of human endur- 2018;26(2):222–9. PubMed PMID: 29359592.
ance. Front Physiol. 2016;7:613. https://doi.org/10.3389/fphys.2016.00613. 25. Wirnitzer KC, Faulhaber M. Hemoglobin and hematocrit during an 8 day
Epub 2016/12/27. mountainbike race: a field study. J Sports Sci Med. 2007;6(2):265–6.
5. da Fonseca-Engelhardt K, Knechtle B, Rüst CA, Knechtle P, Lepers R, Rose- Epub 2007/01/01. PubMed PMID: 24137084; PubMed Central PMCID:
mann T. Participation and performance trends in ultra-endurance running PMCPMC3786250.
races under extreme conditions - ‘Spartathlon’ versus ‘Badwater’. Extrem 26. Lucia A, Hoyos J, Chicharro JL. Physiology of professional road cycling. Sports
Physiol Med. 2013;2(1):15. https://doi.org/10.1186/2046-7648-2-15. PubMed Med. 2001;31(5):325–37. https://doi.org/10.2165/00007256-200131050-
PMID: 23848985. 00004. Epub 2001/05/12.
6. WUCA. World Ultracycling Association Race. Calendar 2022 [10. October 27. Valenti MT, Braggio M, Minoia A, Dorelli G, Bertacco J, Bertoldo F, et al. Effects
2022]. https://www.ultracycling.com/calendar. of a 4400 km ultra-cycling non-competitive race and related training on
7. Apidura. Paris-Brest-Paris: Everything You Need to Know body composition and circulating progenitors differentiation. J Transl Med.
2022 [11.07.2022]. https://www.apidura.com/journal/ 2022;20(1):397. https://doi.org/10.1186/s12967-022-03591-5. Epub 20220904.
paris-brest-paris-everything-you-need-to-know/. 28. Guex K, Wicht S, Besson C, Degache F, Gojanovic B, Gremion G. From
8. RAAM. Race across America 2022 [11.07.2022]. https://www.raamrace.org/ sedentary and physical inactive behaviours to an Ultra Cycling race: a mixed-
about. method case report. Int J Environ Res Public Health. 2020;17(2). https://doi.
9. Guex K, Serain E, Gremion G, Besson C, Faiss R, Majo J, et al. Participating in org/10.3390/ijerph17020502. PubMed PMID: 31941104; PubMed Central
the race across AMerica in a team of eight cyclists: do not neglect Crew Prep- PMCID: PMCPMC7014053. Epub 2020/01/17.
aration. Open Access J Sports Med. 2019;10:161–9. https://doi.org/10.2147/ 29. Knechtle B, Rüst CA, Rosemann TJ, Martin N. 33 ironman triathlons in 33
oajsm.S219124. Epub 2019/12/07. days–a case study. Springerplus. 2014;3.
10. Heidenfelder A, Rosemann T, Rüst CA, Knechtle B. Pacing strategies of Ultracy- 30. Zingg M, Knechtle B, Rüst CA, Rosemann T, Lepers R. Age and gender
clists in the race across AMerica. Int J Sports Physiol Perform. 2016;11(3):319– difference in non-drafting ultra-endurance cycling performance - the
27. https://doi.org/10.1123/ijspp.2015-0051. Epub 2015/07/29. ‘Swiss Cycling Marathon’. Extrem Physiol Med. 2013;2(1):18. https://doi.
11. Knechtle B, Wirth A, Knechtle P, Rosemann T. An ultra-cycling race leads to no org/10.1186/2046-7648-2-18. Epub 2013/07/16.
decrease in skeletal muscle mass. Int J Sports Med. 2009;30(3):163–7. https:// 31. Rüst CA, Knechtle B, Rosemann T, Lepers R. Men cross America faster than
doi.org/10.1055/s-0028-1104585. Epub 2009/02/10. women–the Race across America from 1982 to 2012. Int J Sports Physiol
12. Weiss K, Sousa CV, Thuany M, Cuk I, Nikolaidis PT, Knechtle B. Differences in Perform. 2013;8(6):611–7. https://doi.org/10.1123/ijspp.8.6.611. Epub
pacing during cycling and running in ultra-triathlons - the example of ‘Swis- 2013/02/26.
sultra’. Eur Rev Med Pharmacol Sci. 2022;26(14):4959–68. Epub 2022/08/03. 32. Rüst CA, Knechtle B, Knechtle P, Rosemann T. No case of exercise-associated
doi: 10.26355/eurrev_202207_29281. PubMed PMID: 35916791. hyponatraemia in top male ultra-endurance cyclists: the ‘Swiss Cycling
13. Bescós R, Rodríguez FA, Iglesias X, Knechtle B, Benítez A, Marina M, et al. Marathon’. Eur J Appl Physiol. 2012;112(2):689– 97. Epub 2011/06/10. https://
Physiological demands of cyclists during an ultra-endurance relay race: a field doi.org/10.1007/s00421-011-2024-y. PubMed PMID: 21656229.
study report. Chin J Physiol. 2011;54(5):339–46. Epub 2011/12/06. PubMed 33. Rüst CA, Bragazzi NL, Signori A, Stiefel M, Rosemann TJ, Knechtle B. Nation
PMID: 22135913. related participation and performance trends in ‘Norseman Xtreme Triathlon’
14. Wundersitz D, Williamson J, Nadurata V, Nolan K, Lavie C, Kingsley M. The from 2006 to 2014. Springerplus. 2015;4.
impact of a 21-day ultra-endurance ride on the heart in young, adult and 34. Nikolaidis PT, Chtourou H, Ramirez-Campillo R, Villiger E, Rosemann T,
older adult recreational cyclists. Int J Cardiol. 2019;286:137–42. https://doi. Knechtle B. The Combined Effect of Aging and Performance Level on Pacing
org/10.1016/j.ijcard.2019.03.016. Epub 2019/03/25. PubMed PMID: 30904280. in Duathlon - the ITU Powerman Long Distance Duathlon World champion-
15. Earnest CP, Jurca R, Church TS, Chicharro JL, Hoyos J, Lucia A. Relation ships. Front Psychol. 2019;10:296. https://doi.org/10.3389/fpsyg.2019.00296.
between physical exertion and heart rate variability characteristics in profes- Epub 2019/03/06.
sional cyclists during the Tour of Spain. Br J Sports Med. 2004;38(5):568–75. 35. Luk H-Y, McKenzie AL, Duplanty AA, Budnar RG, Levitt DE, Fernandez A, et al.
https://doi.org/10.1136/bjsm.2003.005140. Epub 2004/09/25. Leukocyte subset changes in response to a 164-km road cycle ride in a hot
16. Lucia A, Hoyos J, Santalla A, Earnest C, Chicharro JL. Tour De France versus environment. Int J Exerc Sci. 2016;9:34–46.
Vuelta a España: which is harder? Med Sci Sports Exerc. 2003;35(5):872–8. 36. Lahart I, Lane A, Hulton A, Williams K, Godfrey RJ, Pedlar C, et al. Challenges
https://doi.org/10.1249/01.Mss.0000064999.82036.B4. Epub 2003/05/17. in maintaining emotion regulation in a sleep and energy deprived State
17. Padilla S, Mujika I, Santisteban J, Impellizzeri FM, Goiriena JJ. Exercise intensity Induced by the 4800Km Ultra-endurance Bicycle race; the race across
and load during uphill cycling in professional 3-week races. Eur J Appl AMerica (RAAM). J Sports Sci Med. 2013;12:481–8.
Physiol. 2008;102(4):431–8. https://doi.org/10.1007/s00421-007-0602-9. 37. Knechtle B, Wirth A, Knechtle P, Rüst CA, Rosemann TJ. A comparison of
PubMed PMID: 17978835. Ultra-endurance cyclists in a qualifying Ultra-cycling Race for Paris-Brest-
18. Neumayr G, Pfister R, Mitterbauer G, Gaenzer H, Sturm W, Hoertnagl H. Heart Paris and Race across America—Swiss Cycling Marathon. Percept Mot Skills.
rate response to ultraendurance cycling. Br J Sports Med. 2003;37(1):89–90. 2012;114:110–96.
https://doi.org/10.1136/bjsm.37.1.89. Epub 2003/01/28. 38. Knechtle B, Nikolaidis PT. Sex differences in pacing during ‘Ultraman Hawaii’.
19. Linderman J, Demchak T, Dallas J, Buckworth J. Ultra-endurance cycling: a PeerJ. 2016;4:e2509. 10.7717. Epub 2016/10/06.
field study of human performance during a12-hour moutain bike race. J 39. Knechtle B, Knechtle P, Andonie JL, Kohler G. Influence of anthropometry
Exerc Physiol Online. 2003;6:14–23. on race performance in extreme endurance triathletes: World Challenge
20. Geesmann B, Mester J, Koehler K. Energy balance, macronutrient intake, Deca Iron Triathlon 2006. Br J Sports Med. 2007;41(10):644–8. https://doi.
and hydration status during a 1,230 km ultra-endurance bike marathon. org/10.1136/bjsm.2006.035014. discussion 8. Epub 2007/06/09.
Int J Sport Nutr Exerc Metab. 2014;24(5):497–506. https://doi.org/10.1123/ 40. Chlíbková D, Rosemann TJ, Knechtle B, Nikolaidis PT, Žákovská A, Sudi K.
ijsnem.2013-0169. Epub 2014/03/29. Description of three female 24-h Ultra-endurance Race winners in various
21. May GC, Doherty AR, Smeaton AF, Warrington GD. Correlating multimodal Weather conditions and disciplines. Chin J Physiol. 2017;60(4):231–41.
physical sensor information with biological analysis in ultra endur- 41. Gallmann D, Knechtle B, Rüst CA, Rosemann T, Lepers R. Elite triathletes in
ance cycling. Sens (Basel). 2010;10(8):7216–35. https://doi.org/10.3390/ ‘Ironman Hawaii’ get older but faster. Age (Dordr). 2014;36(1):407–16. https://
s100807216. Epub 2010/01/01. doi.org/10.1007/s11357-013-9534-y. Epub 2013/04/18.
22. Stuempfle KJ, Lehmann DR, Case HS, Hughes SL, Evans D. Change in serum 42. Knechtle B, Knechtle P, Lepers R. Participation and performance trends in
sodium concentration during a cold weather ultradistance race. Clin J Sport ultra-triathlons from 1985 to 2009. Scand J Med Sci Sports. 2011;21(6):e82-90.
Med. 2003;13(3):171–5. https://doi.org/10.1097/00042752-200305000-00008. Epub 2010/07/16. https://doi.org/10.1111/j.1600-0838.2010.01160.x. PubMed
Epub 2003/06/07. PMID: 20626703.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 15 of 18

43. Knechtle B. Relationship of anthropometric and training characteristics with 63. Frandsen J, Sahl RE, Rømer T, Hansen MT, Nielsen AB, Lie-Olesen MM, et al.
race performance in endurance and ultra-endurance athletes. Asian J Sports Extreme duration exercise affects old and younger men differently. Acta
Med. 2014;5(2):73–90. Epub 2015/04/04. PubMed PMID: 25834701; PubMed Physiol (Oxf ). 2022;235(3):e13816. https://doi.org/10.1111/apha.13816. Epub
Central PMCID: PMCPMC4374609. 2022/03/30.
44. Knechtle B, Knechtle P, Rosemann T. Similarity of anthropometric mea- 64. Gloor RU, Knechtle B, Knechtle P, Rüst CA, Haupt S, Rosemann T, et al.
sures for male ultra-triathletes and ultra-runners. Percept Mot Skills. Sex-related trends in participation and performance in the ‘Swiss Bike
2010;111(3):805–18. https://doi.org/10.2466/05.25.Pms.111.6.805-818. Epub Masters’ from 1994–2012. Percept Mot Skills. 2013;116(2):640–54. https://doi.
2011/02/16. org/10.2466/30.PMS.116.2.640-654.
45. Knechtle B, Knechtle P, Rüst C, Rosemann T. A comparison of anthropometric 65. Knechtle B, Zingg MA, Rosemann TJ, Rüst CA. Sex difference in top perform-
and training characteristics of Ironman triathletes and Triple Iron ultra-triath- ers from Ironman to double deca iron ultra-triathlon. Open Access J Sports
letes. J Sports Sci. 2011;29:1373–80. https://doi.org/10.1080/02640414.2011.5 Med. 2014;5:159–72.
87442. 66. Nikolaidis PT, Villiger E, Vancini RL, Rosemann T, Knechtle B. The Effect of
46. Knechtle B, Wirth A, Knechtle P, Rüst CA, Rosemann T. A comparison of Sex and Performance Level on Pacing in Duathlon. Sports (Basel). 2018;6(4).
ultra-endurance cyclists in a qualifying ultra-cycling race for Paris-Brest- Epub 2018/11/28. https://doi.org/10.3390/sports6040152. PubMed PMID:
Paris and Race Across America-Swiss cycling marathon. Percept Mot Skills. 30477088; PubMed Central PMCID: PMCPMC6315520.
2012;114(1):96–110. https://doi.org/10.2466/05.Pms.114.1.96-110. Epub 67. Rüst CA, Knechtle B, Knechtle P, Rosemann T, Lepers R. Sex differences in
2012/05/16. Ultra-triathlon performance at increasing Race Distance. Percept Mot Skills.
47. Knechtle B, Zingg MA, Rosemann T, Rüst CA. The aspect of experience in 2013;116(2):690–706. https://doi.org/10.2466/30.06.PMS.116.2.690-706.
ultra-triathlon races. Springerplus. 2015;4(1):278. https://doi.org/10.1186/ 68. Rüst CA, Rosemann T, Knechtle B. Performance and sex difference in ultra-
s40064-015-1050-3. triathlon performance from Ironman to double Deca Iron ultra-triathlon
48. Stiefel M, Knechtle B, Lepers R. Master triathletes have not reached limits in between 1978 and 2013. Springerplus [Internet] 2014. 2014;3:219.
their Ironman triathlon performance. Scand J Med Sci Sports. 2014;24. 69. Rüst CA, Rosemann T, Lepers R, Knechtle B. Gender difference in cycling
49. Neumayr G, Gänzer H, Sturm W, Pfister R, Mitterbauer G, Hörtnagl H. Physi- speed and age of winning performers in ultra-cycling - the 508-mile furnace
ological effects of an Ultra-cycle ride in an amateur Athlete - A Case Report. J Creek from 1983 to 2012. J Sports Sci. 2015;33(2):198–210. PubMed PMID:
Sports Sci Med. 2002;1:20–6. 24993112.
50. Rüst CA, Knechtle B, Knechtle P, Lepers R, Rosemann TJ, Onywera V. European 70. Salihu L, Rüst CA, Rosemann T, Knechtle B. Sex Difference in Draft-Legal Ultra-
athletes dominate performances in double Iron ultra-triathlons– A retrospec- Distance Events - A Comparison between Ultra-Swimming and Ultra-Cycling.
tive data analysis from 1985 to 2010. Eur J Sport Sci. 2014;14:S39 - S50. Chin J Physiol. 2016;59(2):87–99. Epub 2016/04/16. https://doi.org/10.4077/
51. Rüst CA, Knechtle B, Knechtle P, Rosemann TJ, Lepers R. Participation and cjp.2016.Bae373. PubMed PMID: 27080464.
performance trends in Triple Iron Ultra-triathlon– a cross-sectional and longi- 71. Baumgartner S, Sousa CV, Nikolaidis PT, Knechtle B. Can the Performance
tudinal data analysis. Asian J Sports Med. 2012;3:145–52. Gap between Women and Men be Reduced in Ultra-Cycling? Int J Environ
52. Sousa CV, Knechtle B, Nikolaidis PT. Longitudinal Performance Analysis in Res Public Health. 2020;17(7). Epub 2020/04/11. https://doi.org/10.3390/
Ultra-Triathlon of the World’s 2 Best Master Triathletes. Int J Sports Physiol ijerph17072521. PubMed PMID: 32272640; PubMed Central PMCID:
Perform. 2020:1–5. PMCPMC7177769.
53. Sousa CV, Nikolaidis PT, Knechtle B. Ultra-triathlon—Pacing, performance 72. Scholz H, Sousa CV, Baumgartner S, Rosemann T, Knechtle B. Changes in
trends, the role of nationality, and sex differences in finishers and non- sex difference in Time-Limited Ultra-cycling races from 6 hours to 24 hours.
finishers. Scand J Med Sci Sports. 2020;30(3):556–63. https://doi.org/10.1111/ Medicina. 2021;57(9):923. https://doi.org/10.3390/medicina57090923.
sms.13598. PubMed PMID.
54. Mavromati M, Kriemadis A, Gkatsis G, Psiloutsikou M, Koronios K. Motiva- 73. Barrero A, Erola P, Bescós R. Energy balance of triathletes during an ultra-
tion and high performance sports events: an exploratory investigation of endurance event. Nutrients. 2014;7(1):209–22. Epub 2015/01/07. doi:
the motives underlying repeated participation. Int J Sport Manage Mark. 10.3390/nu7010209. PubMed PMID: 25558906; PubMed Central PMCID:
2019;19:35. https://doi.org/10.1504/IJSMM.2019.10018016. PMCPMC4303834.
55. Kruger M, Saayman M. How do mountain bikers and road cyclists dif- 74. Bescós R, Rodríguez FA, Iglesias X, Benítez A, Marina M, Padullés JM, et al.
fer? South African Journal for Research in Sport. Phys Educ Recreation. High energy deficit in an ultraendurance athlete in a 24-hour ultracycling
2014;36:137–52. race. Proc (Bayl Univ Med Cent). 2012;25(2):124–8. PubMed PMID: 22481841;
56. Kupchak BR, Kazman JB, Vingren JL, Levitt DE, Lee EC, Williamson KH, et al. PubMed Central PMCID: PMCPMC3310508.
Blood hemostatic changes during an Ultraendurance Road Cycling Event in 75. Bescós R, Rodríguez FA, Iglesias X, Knechtle B, Benítez A, Marina M, et
a hot environment. Wilderness Environ Med. 2017;28(3):197–206. https://doi. al. Nutritional behavior of cyclists during a 24-hour team relay race:
org/10.1016/j.wem.2017.05.002. Epub 2017/07/26. a field study report. J Int Soc Sports Nutr. 2012;9(1):3. https://doi.
57. Knechtle B, Forte P, Weiss K, Cuk I, Nikolaidis PT, Sousa CV, et al. Biophysical org/10.1186/1550-2783-9-3.
characterization of the first ultra-cyclist in the world to break the 1,000 km 76. Borgenvik M, Nordin M, Mikael Mattsson C, Enqvist JK, Blomstrand E, Ekblom
barrier in 24-h non-stop road cycling: a case report. Front Cardiovasc Med. B. Alterations in amino acid concentrations in the plasma and muscle in
2022;9:990382. https://doi.org/10.3389/fcvm.2022.990382. Epub 2022/10/29. human subjects during 24 h of simulated adventure racing. Eur J Appl
58. Allen SV, Hopkins WG. Age of peak competitive performance of Elite Physiol. 2012;112(10):3679–88. https://doi.org/10.1007/s00421-012-2350-8.
athletes: a systematic review. Sports Med. 2015;45(10):1431–41. https://doi. Epub 2012/02/22.
org/10.1007/s40279-015-0354-3. 77. Chlíbková D, Knechtle B, Rosemann T, Tomášková I, Chadim V, Shortall M.
59. Knechtle B, Käch I, Rosemann T, Nikolaidis PT. The effect of sex, age and Nutrition habits in 24-hour mountain bike racers. Springerplus. 2014;3:715.
performance level on pacing of Ironman triathletes. Res Sports Med. https://doi.org/10.1186/2193-1801-3-715. Epub 2015/02/13.
2019;27(1):99–111. PubMed PMID: 30418036. 78. Enqvist JK, Mattsson CM, Johansson PH, Brink-Elfegoun T, Bakkman L, Ekblom
60. Lepers R, Rüst C, Stapley P, Knechtle B. Relative improvements in endur- B. Energy turnover during 24 hours and 6 days of adventure racing. J Sports
ance performance with age: evidence from 25 years of Hawaii Ironman Sci. 2010;28:947–55.
racing. Age (Dordrecht Netherlands). 2012;35. https://doi.org/10.1007/ 79. Francescato MP, di Prampero PE. Energy expenditure during an ultra-endur-
s11357-012-9392-z. ance cycling race. J Sports Med Phys Fit. 2002;42 1:1–7.
61. Nikolaidis P, Villiger E, Ardigò L, Waśkiewicz Z, Rosemann T, Knechtle B. The 80. Goedecke JH, Clark VR, Noakes TD, Lambert EV. The effects of medium-chain
age of peak performance in women and men duathletes - the paradigm of triacylglycerol and carbohydrate ingestion on ultra-endurance exercise
short and long versions in ‘Powerman Zofingen’. Open Access J Sports Med. performance. Int J Sport Nutr Exerc Metab. 2005;15(1):15–27. https://doi.
2018;9. https://doi.org/10.2147/OAJSM.S167735. org/10.1123/ijsnem.15.1.15. PubMed PMID: 15902986.
62. Pozzi L, Knechtle B, Knechtle P, Rosemann T, Lepers R, Rüst CA. Sex and 81. Konopka AR, Castor WM, Wolff CA, Musci RV, Reid JJ, Laurin JL, et al. Skeletal
age-related differences in performance in a 24-hour ultra-cycling draft-legal muscle mitochondrial protein synthesis and respiration in response to
event– a cross-sectional data analysis. BMC Sports Sci Med Rehabilitation. the energetic stress of an ultra-endurance race. J Appl Physiol. 2017;123
2014;6(1):19. https://doi.org/10.1186/2052-1847-6-19. 6:1516–24.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 16 of 18

82. Koopman R, Pannemans D, Jeukendrup AE, Gijsen AP, Senden JM, Halliday D, 102. Bischof M, Knechtle B, A.Rüst C, Knechtle P, Rosemann TJ. Changes in Skinfold
et al. Combined ingestion of protein and carbohydrate improves protein bal- thicknesses and Body Fat in Ultra-endurance cyclists. Asian J Sports Med.
ance during ultra-endurance exercise. Am J Physiol Endocrinol Metabolism. 2013;4:15–22.
2004;287(4):E712–20. 103. Knechtle B, Andonie JL, Salas OF, Knechtle P, Kohler G. [The effect of a multi-
83. Maunder E, Kilding AE, Plews DJ. Substrate metabolism during Ironman Tri- stage ultra-endurance triathlon over ten times an iron-man-triathlon on fat
athlon: different horses on the same courses. Sports Med. 2018;48(10):2219– mass and skeletal muscle mass–the world challenge deca iron 2006]. Praxis.
26. https://doi.org/10.1007/s40279-018-0938-9. Epub 2018/05/20. 2008;97:16885–92.
84. Nikolaidis PT, Veniamakis E, Rosemann T, Knechtle B. Nutrition in Ultra-endur- 104. Knechtle B, Knechtle P, Schück R, Andonie JL, Kohler G. Effects of a Deca
ance: state of the art. Nutrients. 2018;10(12):1995. https://doi.org/10.3390/ Iron Triathlon on body composition: a case study. Int J Sports Med.
nu10121995. PubMed PMID:. 2008;29(4):343–51. https://doi.org/10.1055/s-2007-965354. Epub 2007/09/21.
85. Rowlands DS, Hopkins WG. Effects of high-fat and high-carbohydrate diets 105. Knechtle B, Schwanke M, Knechtle P, Kohler G. Decrease in body fat during
on metabolism and performance in cycling. Metabolism. 2002;51(6):678–90. an ultra-endurance triathlon is associated with race intensity. Br J Sports
https://doi.org/10.1053/meta.2002.32723. Epub 2002/05/31. Med. 2008;42(7):609–13. https://doi.org/10.1136/bjsm.2007.040956. Epub
86. Wilson PB, Rhodes GS, Ingraham SJ. Saccharide Composition of Carbo- 2007/12/01.
hydrates Consumed during an Ultra-endurance Triathlon. J Am Coll Nutr. 106. Hue O, Voltaire B, Hertogh C, Blonc S. Heart rate, thermoregulatory and
2015;34:497–506. humoral responses during a 9-day cycle race in a hot and humid climate. Int
87. Knechtle B, Pitre J, Chandler C. Food habits and use of supplements in J Sports Med. 2006;27(9):690–6. https://doi.org/10.1055/s-2005-872919. Epub
ultraendurance cyclists - the race across AMerica (RAAM) 2006. Sportmed 2006/04/06.
Sporttraumatologie. 2007;55. 107. White JA, Ward C, Nelson H. Ergogenic demands of a 24 hour cycling event.
88. Armstrong LE, Casa DJ, Emmanuel H, Ganio MS, Klau JF, Lee EC, et al. Nutri- Br J Sports Med. 1984;18(3):165–71. https://doi.org/10.1136/bjsm.18.3.165.
tional, physiological, and perceptual responses during a summer ultraendur- Epub 1984/09/01.
ance cycling event. J Strength Cond Res. 2012;26(2):307–18. https://doi. 108. Barrero A, Chaverri D, Erola P, Iglesias X, Rodríguez FA. Intensity profile during
org/10.1519/JSC.0b013e318240f677. Epub 2011/11/23. an ultra-endurance triathlon in relation to testing and performance. Int J
89. Black KE, Skidmore PM, Brown RC. Energy intakes of ultraendurance cyclists Sports Med. 2014;35(14):1170–8. https://doi.org/10.1055/s-0034-1374601.
during competition, an observational study. Int J Sport Nutr Exerc Metab. Epub 2014/09/12.
2012;22(1):19–23. https://doi.org/10.1123/ijsnem.22.1.19. Epub 2012/01/18. 109. Berglund B, Berglund L. [»Shermer’s neck« is a rare injury in long-distance
90. Hulton AT, Lahart I, Williams KL, Godfrey R, Charlesworth S, Wilson M, et al. cycle races. Association with diplopia described for the first time]. Lakar-
Energy expenditure in the Race across America (RAAM). Int J Sports Med. tidningen [Internet]. 2015 2015/12//; 112:[DR7I p.]. http://europepmc.org/
2010;31(7):463–7. https://doi.org/10.1055/s-0030-1251992. Epub 2010/05/11. abstract/MED/26671432.
91. Armstrong LE, Johnson EC, Ganio MS, Judelson DA, Vingren JL, Kupchak BR, 110. Brayson D, Frigiola A, Clark JE. Dynamic heart rate response to multi-day
et al. Effective body water and body mass changes during summer ultra- unsupported ultra‐endurance cycle racing: a case report. Exp Physiol.
endurance road cycling. J Sports Sci. 2015;33:125–35. 2019;104:174–9.
92. Gauckler P, Kesenheimer JS, Kronbichler A, Kolbinger FR. Edema-like symp- 111. Chlíbková D, Ronzhina M, Nikolaidis PT, Rosemann T, Knechtle B. Non-
toms are common in ultra-distance cyclists and driven by overdrinking, steroidal anti-inflammatory drug consumption in a Multi-stage and a 24-h
use of analgesics and female sex - a study of 919 athletes. J Int Soc Sports Mountain Bike Competition. Front Physiol. 2018. https://doi.org/10.3389/
Nutr. 2021;18(1):73. https://doi.org/10.1186/s12970-021-00470-0. Epub fphys.2018.01272. 9:1272. Epub 2018/09/25.
2021/12/06. 112. Devrim-Lanpir A, Bilgic P, Kocahan T, Deliceoğlu G, Rosemann T, Knechtle B.
93. Goulet EDB, Hoffman MD. Impact of Ad Libitum Versus Programmed Drinking Total dietary antioxidant intake including Polyphenol Content: is it capable to
on Endurance Performance: A Systematic Review with Meta-Analysis. Sports fight against increased oxidants within the body of Ultra-endurance athletes?
Med. 2019;49(2):221– 32. Epub 2019/01/20. https://doi.org/10.1007/s40279- Nutrients [Internet]. 2020 2020/06//; 12(6):[E1877 p.].
018-01051-z. PubMed PMID: 30659500. 113. Gamage PJ, Fortington LV, Finch C. Epidemiology of exertional heat illnesses
94. Knechtle B, Chlíbková D, Nikolaidis PT. [Exercise-Associated hyponatre- in organised sports: a systematic review. J Sci Med Sport. 2019.
mia in endurance performance]. Praxis. 2019;108(9):615–32. https://doi. 114. Knechtle B, Kohler G. Running performance, not anthropometric fac-
org/10.1024/1661-8157/a003261. PubMed PMID: 31288661. tors, is associated with race success in a Triple Iron Triathlon. Br J Sports
95. Knechtle B, Chlíbková D, Papadopoulou S, Mantzorou M, Rosemann T, Niko- Med. 2009;43(6):437–41. https://doi.org/10.1136/bjsm.2007.039602. Epub
laidis PT. Exercise-Associated Hyponatremia in endurance and Ultra-endur- 2007/12/01.
ance performance-aspects of sex, race location, ambient temperature, sports 115. Knechtle B, Zingg MA, Rosemann TJ, Stiefel M, Rüst CA. What predicts per-
Discipline, and length of performance: a narrative review. Medicina (Kaunas) formance in ultra-triathlon races?– a comparison between Ironman distance
[Internet]. 2019 2019/08//; 55(9):[E537 p.]. triathlon and ultra-triathlon. Open Access J Sports Med. 2015;6:149–59.
96. Meyer M, Knechtle B, Bürge J, Knechtle P, Mrazek C, Wirth A, et al. Ad 116. Knechtle B, Bragazzi NL, Rosemann T, Rüst CA. Pacing in a self-paced world
libitum fluid intake leads to no leg swelling in male Ironman triathletes - an record attempt in 24-h road cycling. Springerplus [Internet]. 2015 2015;
observational field study. J Int Soc Sports Nutr. 2012;9(1):40. https://doi. 4:[650 p.].
org/10.1186/1550-2783-9-40. Epub 2012/09/04. 117. Knechtle B, Wirth A, Knechtle P, Rüst CA, Rosemann T, Lepers R. No improve-
97. Moyen NE, Ganio MS, Wiersma LD, Kavouras SA, Gray M, McDermott BP, et al. ment in race performance by naps in male ultra-endurance cyclists in a
Hydration status affects mood state and pain sensation during ultra-endur- 600-km ultra-cycling race. Chin J Physiol. 2012;55(2):125–33. https://doi.
ance cycling. J Sports Sci. 2015;33:1962–9. org/10.4077/cjp.2012.Baa022. Epub 2012/05/09. PubMed PMID: 22559737.
98. Rüst CA, Knechtle B, Knechtle P, Rosemann TJ. Higher prevalence of exercise- 118. Lucas SJ, Anglem N, Roberts WS, Anson JG, Palmer CD, Walker RJ, et
associated hyponatremia in triple iron ultra-triathletes than reported for al. Intensity and physiological strain of competitive ultra-endurance
ironman triathletes. Chin J Physiol. 2012;55(3):147–55. exercise in humans. J Sports Sci. 2008;26(5):477–89. Epub 2008/02/16. doi:
99. Knechtle B, Gnädinger M, Knechtle P, Imoberdorf R, Kohler G, Ballmer P, et 10.1080/02640410701552872. PubMed PMID: 18274945.
al. Prevalence of exercise-associated hyponatremia in male ultraendur- 119. Luk H-Y, Levitt DE, Lee EC-H, Ganio MS, McDermott BP, Kupchak BR, et al. Pro-
ance athletes. Clin J Sport Med. 2011;21(3):226–32. https://doi.org/10.1097/ and anti-inflammatory cytokine responses to a 164-km road cycle ride in a
JSM.0b013e31820cb021. Epub 2011/03/24. hot environment. Eur J Appl Physiol. 2016;116:2007–15.
100. Pollastri L, Lanfranconi F, Tredici G, Burtscher M, Gatterer H. Body Water Status 120. Vingren JL, Budnar RG, McKenzie AL, Duplanty AA, Luk H-Y, Levitt DE, et al.
and short-term maximal power output during a Multistage Road Bicycle The acute testosterone, growth hormone, cortisol and interleukin-6 response
race (Giro d’Italia 2014). Int J Sports Med. 2016;37(4):329–33. https://doi. to 164-km road cycling in a hot environment. J Sports Sci. 2016;34:694–9.
org/10.1055/s-0035-1565105. Epub 2015/12/25. 121. Mattsson CM, Enqvist JK, Brink-Elfegoun T, Johansson PH, Bakkman L,
101. Black KE, Skidmore P, Brown RC. Fluid balance of cyclists during a 387-km Ekblom B. Reversed drift in heart rate but increased oxygen uptake at fixed
race. Eur J Sport Sci. 2014;14(Suppl 1):S421–8. PubMed PMID: 24444237. Epub work rate during 24 h ultra-endurance exercise. Scand J Med Sci Sports.
2014/01/22. 2010;20(2):298–304. Epub 2009/06/03. https://doi.org/10.1111/j.1600-
0838.2009.00878.x. PubMed PMID: 19486489.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 17 of 18

122. Millet GY, Martin V, Temesi J. The role of the nervous system in neuromuscu- 140. Kraemer WJ, Fragala MS, Watson G, Volek JS, Rubin MR, French DN, et al.
lar fatigue induced by ultra-endurance exercise. Appl Physiol Nutr Metab. Hormonal responses to a 160-km race across frozen Alaska. Br J Sports Med.
2018;43(11):1151–7. https://doi.org/10.1139/apnm-2018-0161. PubMed 2008;42(2):116–20. https://doi.org/10.1136/bjsm.2007.035535. discussion 20.
PMID: 29726694. Epub 2007/07/20.
123. Rogers IR, Speedy D, Hillman D, Noffsinger B, Ing- 141. Geesmann B, Gibbs JC, Mester J, Koehler K. Association between Energy Bal-
lis S, Wilderness. Environ Med. 2002;13(2):135–9. https://doi. ance and metabolic hormone suppression during Ultraendurance Exercise.
org/10.1580/1080-6032(2002)013[0135:RFCIAW]2.0.CO;2. Int J Sports Physiol Perform. 2017;12(7):984–9. https://doi.org/10.1123/
124. Smith KA, Kisiolek JN, Willingham BD, Morrissey MC, Leyh SM, Saracino PG, et ijspp.2016-0061. Epub 2016/12/15.
al. Ultra-endurance triathlon performance and markers of whole-body and 142. El Helou N, Berthelot G, Thibault V, Tafflet M, Nassif H, Campion F, et al. Tour
gut-specific inflammation. Eur J Appl Physiol. 2019;120:349–57. De France, Giro, Vuelta, and classic European races show a unique progres-
125. Sousa CV, Pereira RW, Rosemann T, Nikolaidis PT, Knechtle B. Self-selected sion of road cycling speed in the last 20 years. J Sports Sci. 2010;28:789–96.
pacing during a World Record Attempt in 40 Ironman-Distance triath- https://doi.org/10.1080/02640411003739654.
lons in 40 days. Int J Environ Res Public Health [Internet]. 2020 2020/04//; 143. Knechtle B, Rosemann T, Nikolaidis PT. Self-Selected Pacing during a 24 h
17(7):E2390 p.]. Track Cycling World Record. Int J Environ Res Public Health. 2019;16(16).
126. Knechtle B, Knechtle P, Rosemann T. No Association between Skinfold thick- Epub 2019/08/21. https://doi.org/10.3390/ijerph16162943. PubMed PMID:
nesses and Race Performance in Male Ultra-endurance cyclists in a 600 km 31426293; PubMed Central PMCID: PMCPMC6720958.
Ultra-cycling Marathon. Hum Mov. 2009;10(2):91–5. https://doi.org/10.2478/ 144. Garvican-Lewis LA, Clark B, Martin DT, Schumacher YO, McDonald W,
v10038-009-0018-y. Stephens B, et al. Impact of Altitude on Power output during Cycling Stage
127. Knechtle B, Knechtle P, Rüst CA, Rosemann T, Lepers R. Finishers and Racing. PLoS ONE. 2015;10(12):e0143028. https://doi.org/10.1371/journal.
nonfinishers in the ‘Swiss Cycling Marathon' to qualify for the ‘Race across pone.0143028. Epub 2015/12/03.
America ‘. J Strength Cond Res. 2011;25(12):3257–63. https://doi.org/10.1519/ 145. Fernández-García B, Pérez-Landaluce J, Rodríguez-Alonso M, Terrados
JSC.0b013e31821606b3. Epub 2011/11/15. N. Intensity of exercise during road race pro-cycling competition. Med
128. Bell PG, Furber MJ, Antón-Solanas KAVANS, Swart A. The physiological Sci Sports Exerc. 2000;32(5):1002–6. https://doi.org/10.1097/00005768-
Profile of a multiple Tour De France winning cyclist. Med Sci Sports Exerc. 200005000-00019. Epub 2000/05/05.
2017;49(1):115–23. https://doi.org/10.1249/mss.0000000000001068. Epub 146. Luciá A, Hoyos J, Carvajal A, Chicharro JL. Heart rate response to professional
2016/08/11. road cycling: the Tour De France. Int J Sports Med. 1999;20(3):167–72. https://
129. Almar M, Villa JG, Cuevas MJ, Rodríguez-Marroyo JA, Avila C, Gonzalez-Gal- doi.org/10.1055/s-1999-970284. Epub 1999/05/20.
lego J. Urinary levels of 8-hydroxydeoxyguanosine as a marker of oxidative 147. Lucía A, Hoyos J, Pérez M, Santalla A, Chicharro JL. Inverse relationship
damage in road cycling. Free Radic Res. 2002;36(3):247–53. Epub 2002/06/20. between VO2max and economy/efficiency in world-class cyclists. Med Sci
doi: 10.1080/10715760290019255. PubMed PMID: 12071342. Sports Exerc. 2002;34(12):2079–84..Df. PubMed PMID: 12471319.
130. Kupchak BR, McKenzie AL, Luk HY, Saenz C, Kunces LJ, Ellis LA et al. Effect of 148. Lucía A, Rabadán M, Hoyos J, Hernández-Capilla M, Pérez M, San Juan AF, et
cycling in the heat for 164 km on procoagulant and fibrinolytic parameters. al. Frequency of the VO2max plateau phenomenon in world-class cyclists. Int
Eur J Appl Physiol. 2015;115(6):1295– 303. Epub 2015/01/22. https://doi. J Sports Med. 2006;27(12):984–92. https://doi.org/10.1055/s-2006-923833.
org/10.1007/s00421-015-3107-y. PubMed PMID: 25603777. Epub 2006/06/02.
131. Colombini A, Corsetti R, Machado M, Graziani R, Lombardi G, Lanteri P et 149. Rüst CA, Knechtle B, Rosemann TJ, Lepers R. Men cross America faster than
al. Serum creatine kinase activity and its relationship with renal function women–the Race across America from 1982 to 2012. Int J Sports Physiol
indices in professional cyclists during the Giro d’Italia 3-week stage race. Clin Perform. 2013;8 6:611–7.
J Sport Med. 2012;22(5):408– 13. Epub 2012/06/30. https://doi.org/10.1097/ 150. Kholkine L, Servotte T, de Leeuw AW, De Schepper T, Hellinckx P, Ver-
JSM.0b013e31825e66cc. PubMed PMID: 22744001. donck T, et al. A learn-to-Rank Approach for Predicting Road Cycling race
132. Lombardi G, Lanteri P, Fiorella PL, Simonetto L, Impellizzeri FM, Bonifazi M, outcomes. Front Sports Act Living. 2021;3:714107. https://doi.org/10.3389/
et al. Comparison of the hematological profile of elite road cyclists during fspor.2021.714107. Epub 2021/10/26.
the 2010 and 2012 GiroBio ten-day stage races and relationships with 151. RCS_Mediagroup M-S. 2023 2024 [10.02.2024]. https://www.milanosanremo.
final ranking. PLoS ONE. 2013;8(4):e63092. https://doi.org/10.1371/journal. it/en/live-archive/tappa/2023/1/.
pone.0063092. Epub 2013/05/07. 152. Peloton. Ronde van Flaanderen Cyclo 2024 [10.02.2024]. https://www.
133. Menaspà P, Abbiss CR, Martin DT. Performance analysis of a world- rondevanvlaanderen.be/en.
class sprinter during cycling grand tours. Int J Sports Physiol Perform. 153. Amstel. Amstel Gold Race 2024 [10.02.2024]. https://www.amstel.nl/
2013;8(3):336–40. https://doi.org/10.1123/ijspp.8.3.336. Epub 2012/10/06. amstelgoldrace.
134. Neumayr G, Pfister R, Hoertnagl H, Mitterbauer G, Prokop W, Joannidis M. 154. Shoak MA, Knechtle B, Knechtle P, Rüst CA, Rosemann T, Lepers R. Participa-
Renal function and plasma volume following ultramarathon cycling. Int J tion and performance trends in ultracycling. Open Access J Sports Med.
Sports Med. 2005;26(1):2–8. https://doi.org/10.1055/s-2004-815717. Epub 2013;4:41–51. https://doi.org/10.2147/oajsm.S40142. Epub 2014/01/01.
2005/01/12. 155. Käch IW, Rüst CA, Nikolaidis PT, Rosemann T, Knechtle B. The age-related
135. Chlíbková D, Knechtle B, Rosemann T, Tomášková I, Novotný J, Žákovská A, et performance decline in Ironman Triathlon starts earlier in Swimming Than
al. Rhabdomyolysis and exercise-associated hyponatremia in ultra-bikers and in Cycling and running. J Strength Cond Res. 2018;32(2):379–95. https://doi.
ultra-runners. J Int Soc Sports Nutr. 2015. https://doi.org/10.1186/s12970- org/10.1519/jsc.0000000000001796. Epub 2017/02/23.
015-0091-x. 12:29. Epub 2015/06/27. 156. Pozzi L, Knechtle B, Knechtle P, Rosemann T, Lepers R, Rüst CA. Sex and
136. Nédélec M, Chauvineau M, Guilhem G. On the Road to Camarón: The Sleep age-related differences in performance in a 24-hour ultra-cycling draft-legal
of an Ultra-Endurance Athlete Cycling 10,000 km in 24 Days. Int J Environ event - a cross-sectional data analysis. BMC Sports Sci Med Rehabil. 2014;6:19.
Res Public Health. 2022;19(8). Epub 2022/04/24. https://doi.org/10.3390/ https://doi.org/10.1186/2052-1847-6-19. Epub 2014/06/03.
ijerph19084543. PubMed PMID: 35457410; PubMed Central PMCID: 157. Carpenter J, Weinstein S, Myseros J, Vezina G, Bell MJ. Inadvertent hypona-
PMCPMC9025025. tremia leading to acute cerebral edema and early evidence of herniation.
137. Irvine D, Jobson SA, Wilson JP. Evaluating Changes in Mental Workload Neurocrit Care. 2007;6(3):195-9. Epub 2007/06/19. https://doi.org/10.1007/
in Indoor and Outdoor Ultra-Distance Cycling. Sports (Basel). 2022;10(5). s12028-007-0032-x. PubMed PMID: 17572863.
Epub 2022/05/28. https://doi.org/10.3390/sports10050067. PubMed PMID: 158. Verbrugge F, Steels P, Grieten L, Nijst P, Tang W, Mullens W. Hyponatremia
35622476; PubMed Central PMCID: PMCPMC9146483. in Acute Decompensated Heart failure depletion Versus Dilution. J Am Coll
138. Manunzio C, Mester J, Kaiser W, Wahl P. Training intensity distribution and Cardiol. 2015;65:480–92. https://doi.org/10.1016/j.jacc.2014.12.010.
changes in performance and physiology of a 2nd place Finisher Team of 159. Kheetan M, Ogu I, Shapiro JI, Khitan ZJ. Acute and Chronic Hyponatremia.
the race across America over a 6 Month Preparation Period. Front Physiol. Front Med. 2021;8. https://doi.org/10.3389/fmed.2021.693738.
2016;7:642. https://doi.org/10.3389/fphys.2016.00642. Epub 2017/01/14. 160. Rosner MH. Exercise-associated hyponatremia. Trans Am Clin Climatol Assoc.
139. Rothschild JA, Delcourt M, Maunder E, Plews DJ. Racing and training 2019;130:76–87. PubMed PMID: 31516170.
physiology of an Elite Ultra-endurance Cyclist: Case Study of 2 record-setting 161. Chorley J, Cianca J, Divine J. Risk factors for exercise-associated hyponatremia
performances. Int J Sports Physiol Perform. 2021;16(5):739–43. https://doi. in non-elite marathon runners. Clin J Sport Med. 2007;17(6):471–7. https://
org/10.1123/ijspp.2020-0515. Epub 2021/02/07. doi.org/10.1097/JSM.0b013e3181588790. Epub 2007/11/13.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tiemeier et al. Sports Medicine - Open (2024) 10:48 Page 18 of 18

162. Noakes TD. Is drinking to thirst optimum? Ann Nutr Metab. 2010;57(Suppl Schweiz Z Sportmed. 1992;40(1):13–25. Epub 1992/03/01. PubMed PMID:
2):9–17. Epub 2010/01/01. doi: 10.1159/000322697. PubMed PMID: 21346332. 1561538.
163. Noakes TD, Adams BA, Myburgh KH, Greeff C, Lotz T, Nathan M. The danger 170. Zehnder M, Ith M, Kreis R, Saris W, Boutellier U, Boesch C. Gender-specific
of an inadequate water intake during prolonged exercise. A novel concept usage of intramyocellular lipids and glycogen during exercise. Med Sci Sports
re-visited. Eur J Appl Physiol Occup Physiol. 1988;57(2):210–9. https://doi. Exerc. 2005;37(9):1517-24. Epub 2005/09/24. https://doi.org/10.1249/01.
org/10.1007/bf00640665. Epub 1988/01/01. mss.0000177478.14500.7c. PubMed PMID: 16177603.
164. Königstein K, Niess AM, Carlsohn A, Treff G. Hydration Management in sports. 171. Khodaee M, Luyten D, Hew-Butler T. Exercise-Associated Hyponatremia in an
Dtsch Z für Sportmedizin. 2022;73(4):137–41. Ultra-endurance Mountain Biker A Case Report. Sports Health: Multidisci-
165. Dugas JP, Oosthuizen U, Tucker R, Noakes TD. Rates of fluid ingestion alter plinary Approach. 2013;5:334–6. https://doi.org/10.1177/1941738113480928.
pacing but not thermoregulatory responses during prolonged exercise in 172. Del Campo A, Contreras-Hernández I, Castro-Sepúlveda M, Campos CA,
hot and humid conditions with appropriate convective cooling. Eur J Appl Figueroa R, Tevy MF, et al. Muscle function decline and mitochondria changes
Physiol. 2009;105(1):69–80. https://doi.org/10.1007/s00421-008-0876-6. Epub in middle age precede Sarcopenia in mice. Aging. 2018;10(1):34–55. https://
2008/10/15. doi.org/10.18632/aging.101358. Epub 2018/01/06.
166. Backx K, van Someren KA, Palmer GS. One hour cycling performance 173. Seo DY, Lee SR, Kim N, Ko KS, Rhee BD, Han J. Age-related changes in skeletal
is not affected by ingested fluid volume. Int J Sport Nutr Exerc Metab. muscle mitochondria: the role of exercise. Integr Med Res. 2016;5(3):182–6.
2003;13(3):333–42. https://doi.org/10.1123/ijsnem.13.3.333. Epub https://doi.org/10.1016/j.imr.2016.07.003.
2003/12/13. 174. Noakes TD, Gibson ASC, Lambert EV. From catastrophe to complexity: a
167. Bardis CN, Kavouras SA, Adams JD, Geladas ND, Panagiotakos DB, Sidossis novel model of integrative central neural regulation of effort and fatigue
LS. Prescribed drinking leads to Better Cycling Performance than Ad Libitum during exercise in humans: summary and conclusions. Br J Sports Med.
Drinking. Med Sci Sports Exerc. 2017;49(6):1244–51. https://doi.org/10.1249/ 2005;39(2):120–4. https://doi.org/10.1136/bjsm.2003.010330.
mss.0000000000001202. Epub 2017/01/13.
168. Knechtle B, Enggist A, Jehle T. Energy turnover at the Race across AMerica
(RAAM) - a case report. Int J Sports Med. 2005;26(6):499–503. https://doi. Publisher’s Note
org/10.1055/s-2004-821136. Epub 2005/07/23. Springer Nature remains neutral with regard to jurisdictional claims in
169. Raschka C, Plath M. [Body fat compartment and its relationship to food intake published maps and institutional affiliations.
and clinical chemical parameters during extreme endurance performance].

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:

1. use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
2. use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
3. falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
4. use bots or other automated methods to access the content or redirect messages
5. override any security feature or exclusionary protocol; or
6. share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at

[email protected]