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CLINICAL SCIENCES

Nonalcoholic Beer Reduces Inflammation and
Incidence of Respiratory Tract Illness
JOHANNES SCHERR1, DAVID C. NIEMAN2, TIBOR SCHUSTER3, JANA HABERMANN1, MELANIE RANK1,
SIEGMUND BRAUN4, AXEL PRESSLER1, BERND WOLFARTH1, and MARTIN HALLE1
1
Department of Prevention and Sports Medicine, Klinikum rechts der Isar, Technische Universitaet Muenchen, Munich,
GERMANY; 2Human Performance Laboratory, Appalachian State University and North Carolina Research Campus,
Kannapolis, NC; 3Institute for Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universitaet
Muenchen, Munich, GERMANY; and 4Institute for Laboratory Medicine, Deutsches Herzzentrum Muenchen
der Technischen Universitaet Muenchen, Munich, GERMANY

ABSTRACT
SCHERR, J., D. C. NIEMAN, T. SCHUSTER, J. HABERMANN, M. RANK, S. BRAUN, A. PRESSLER, B. WOLFARTH, and M.
HALLE. Nonalcoholic Beer Reduces Inflammation and Incidence of Respiratory Tract Illness. Med. Sci. Sports Exerc., Vol. 44, No. 1,
pp. 18–26, 2012. Purpose: Strenuous exercise significantly increases the incidence of upper respiratory tract illness (URTI) caused by
transient immune dysfunction. Naturally occurring polyphenolic compounds present in food such as nonalcoholic beer (NAB) have
strong antioxidant, antipathogenic, and anti-inflammatory properties. The objective of this study was to determine whether ingestion of
NAB polyphenols for 3 wk before and 2 wk after a marathon would attenuate postrace inflammation and decrease URTI incidence.
Methods: Healthy male runners (N = 277, age = 42 T 9 yr) were randomly assigned to 1–1.5 LIdj1 of NAB or placebo (PL) beverage
(double-blind design) for 3 wk before and 2 wk after the Munich Marathon. Blood samples were collected 4 and 1 wk before the race
and immediately and 24 and 72 h after the race and analyzed for inflammation measures (interleukin-6 and total blood leukocyte counts).
URTI rates, assessed by the Wisconsin Upper Respiratory Symptom Survey, were compared between groups during the 2-wk period
after the race. Results: Change in interleukin-6 was significantly reduced in NAB compared with PL immediately after the race (median
(interquartile range) = 23.9 (15.9–38.7) vs 31.6 (18.5–53.3) ngILj1, P = 0.03). Total blood leukocyte counts were also reduced in
NAB versus PL by approximately 20% immediately and 24 h after the race (P = 0.02). Incidence of URTI was 3.25-fold lower (95%
confidence interval = 1.38–7.66) (P = 0.007) in NAB compared with PL during the 2-wk postmarathon period. Conclusions: Consumption of 1–1.5 LIdj1 of NAB for 3 wk before and 2 wk after marathon competition reduces postrace inflammation and URTI
incidence. Key Words: EXERCISE, INFLAMMATION, UPPER RESPIRATORY TRACT ILLNESS, FLAVONOIDS

I

Long-term consumption of vegetables and fruits has been
linked to a decreased incidence of chronic disease such as
cancer and cardiovascular disease (4,17,19,42). The diseasepreventing effects of these foods are attributed in part to the
presence of phenolic compounds, which have strong antioxidant, antiinflammatory, and antipathogenic properties
(16,29,40). Plant phenolics also modulate multiple cell signaling pathways involved in cellular proliferation, differentiation, survival, and apoptosis (40). Therefore, the use of
polyphenol-rich supplements might be a promising approach
to prevent inflammation-associated diseases such as atherosclerosis, coronary artery disease, sudden cardiac death,
cancer, and diabetes mellitus (11,12,15,35).
Alcoholic beverages contain numerous nonalcoholic compounds that have potential health value (14,34). More than
2000 organic and inorganic chemicals have been identified in beer including more than 50 polyphenolic compounds
from barley and hops. Beer is a major contributor to dietary
phenolic intake and contains 366–875 mg of polyphenols
per liter (34). Beer phenolics are rapidly absorbed and increase plasma antioxidant capacity in humans (13). We hypothesized that ingestion of nonalcoholic beer polyphenols

n contrast to moderate physical activity, the physiologic stress of prolonged and intensive exercise has been
linked in multiple animal and human studies to transient
inflammation and immune dysfunction and elevated incidence of upper respiratory tract illness (URTI) (8,10,23,
25,28,33,38). Immunonutrition support for endurance athletes, especially during periods of intensive training and race
events, is a burgeoning area of scientific endeavor.

Address for correspondence: Johannes Scherr, M.D., Department of
Prevention and Sports Medicine, Klinikum rechts der Isar, Technische
Universitaet Muenchen, Connollystr. 32, D–80809 Munich, Germany;
E-mail: scherr@sport.med.tum.de.
Submitted for publication March 2011.
Accepted for publication May 2011.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.acsm-msse.org).
0195-9131/12/4401-0018/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2012 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e3182250dda

18

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

for 3 wk before the Munich Marathon would attenuate postrace inflammation and decrease URTI incidence.

Study Design
This prospective, volunteer- and observer-blinded, placebocontrolled trial (the Be-MaGIC Study: Beer, Marathon,
Genetics, Inflammation, and the Cardiovascular system)
investigated the effects of consuming 1–1.5 LIdj1 of nonalcoholic beer on postrace inflammation and URTI incidence in healthy male runners. The study protocol was
approved by the ethics committee (approval reference
no. 2384/09, University Hospital Klinikum rechts der Isar,
Munich, Germany), and the conduct of the study was consistent with the Good Clinical Practice provisions of the
Declaration of Helsinki. All participants gave written informed consent before enrollment. Participants were randomly assigned in a 1:1 ratio—stratified by age blocking
from 20 to 40 yr and from 40 to 60 yr—either to the intervention group (nonalcoholic beer with polyphenols) or to
the control group (beverage with equal composition except
for polyphenols). The random allocation sequence was
generated by the independent staff at the local Institute
for Medical Statistics and Epidemiology.
Participants

Outcome and End Point Definitions

Participants were recruited by 1) advertisements in local
newspapers as well as national running journals in Germany,
2) announcements via the Internet, 3) from athletes who had
participated in preparticipation screening in our outpatient
clinic, and 4) from track-and-field groups near Munich.
Inclusion criteria were male, age 20–60 yr, history of at
least one successfully finished half marathon, intention to
participate in the Munich Marathon 2009 (42.195 km), and
written informed consent.
Exclusion criteria were known cardiac disease, pharmaceutical treatment for diabetes mellitus or arterial hypertension, musculoskeletal or psychiatric disease, neoplasia, acute
or chronic infection or inflammatory disease, known malabsorption, use of medications or supplements influencing
immune function, and history of alcohol and/or drug abuse
or addiction.

The primary outcome parameter was plasma interleukin-6
(IL-6). The related primary end point criterion was the group
difference in change of IL-6 (before to after the marathon).
Secondary outcomes included 1) the blood total leukocyte count and 2) incidence of URTI. A clinically relevant
URTI was defined if the global severity score of the Wisconsin Upper Respiratory Symptom Survey (WURSS-21)
was greater than 7, representing either one severe symptom
or impairment or seven mild symptoms/impairments presented simultaneously (see below) (3).
Secondary outcomes that were recorded as part of the trial
protocol not reported here include cardiovascular measurements (diastolic and systolic cardiac function, arteriovenous
ratio, and ECG).
Clinical measurements. Participants were examined
to assess inclusion and exclusion criteria 4 wk before the
race (visit V1). Preexisting but yet unknown hepatic disease
was excluded by investigating liver enzymes before inclusion in the study. Additional baseline data were collected
during the week before the race (visit V2) and included
questionnaires that assessed training history (training distance per week during the last 10 wk before the race, previous marathon races finished), history of cardiovascular
risk factors (e.g., family history of cardiovascular disease),
the WURSS-21, physical examination, anthropometry,
clinical chemistry, ECG, and echocardiography.
Collection of blood samples and assessment of blood
pressure were performed within 1 h after finishing the race

Interventions
After assessing inclusion and exclusion criteria, participants were randomly allocated in a 1:1 ratio to the following interventions for 3 wk before, during, and 2 wk after the
Munich Marathon race: 1.0–1.5 L of nonalcoholic beer per
day (intervention group) or 1.0–1.5 L of a control beverage,
which contained the same ingredients like the nonalcoholic
beer except for polyphenols. In addition, taste, color, and
foaming of the control beverage were almost identical with
the nonalcoholic beer. The overall polyphenol content of the

NONALCOHOLIC BEER, MARATHON, AND INFLAMMATION

Medicine & Science in Sports & Exercised

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

19

CLINICAL SCIENCES

MATERIALS AND METHODS

placebo drink was null, whereas that of the nonalcoholic
beer, measured by the Folin–Ciocalteu test, was 32.6 T 0.1 mg
of gallic acid equivalents per 100 g (mg GAE/100 g)
and consisted predominantly of catechin (4.7 mg GAE/100 g),
epicatechin (0.8 mg GAE/100 g), procyanidin B-3 (3.3 mg
GAE/100 g), other proanthocyanidin acids (0.5 mg GAE/
100 g), vanillic acid (1.5 mg GAE/100 g), syringa acid
(4.2 mg GAE/100 g), p-cumar acid (1.5 mg GAE/100 g),
ferulic acid (5.2 mg GAE/100 g), sinapinic acid (0.4 mg
GAE/100 g), other hydroxycinnamic acids (0.9 mg GAE/
100 g), isoxanthohumol (3.9 mg GAE/100 g), and other
flavonols (5.4 mg GAE/100 g). The beverage for the intervention group (ERDINGER Alkoholfrei) was manufactured
and bottled by the brewing company Erdinger Weissbraeu,
Werner Brombach GmbH, Erding, Germany. The beverage
for the control group was composed, manufactured, and
bottled by Ha¨rtsfelder Familienbrauerei Hald, Dischingen,
Germany. Both beverages were bottled in identically shaped
bottles, differed only in the color of the bottle caps, and
were administered in true double-blind fashion.
To ensure compliance of participants, telephone interviews asking for drinking protocols and a training diary
were performed on a weekly basis. In addition, all participants kept a diary to document their exact fluid intake, including the study beverage.

CLINICAL SCIENCES

(visit V3). Follow-up examinations 24 (visit V4) and 72 h
(visit V5) after the marathon race (ECG, echocardiography,
blood samples, and blood pressure) were performed in identical settings.
The WURSS-21 is a responsive, reliable, and valid tool
for assessing symptoms, functional impairments, and global
severity and global change of common cold (1–3). Participants were asked to complete a WURSS-21 questionnaire
every evening 1 wk before the race (to get familiar with
the questionnaire) and 2 wk after the race. Only complete
questionnaires were used for analyses. In case of incomplete questionnaires, participants were contacted up to five
times via phone, mail, or face to face.
Participants were requested not to use medications influencing inflammation such as nonsteroidal anti-inflammatory
drugs (NSAIDs). Furthermore, subjects were asked to refrain
from all polyphenol-containing foods, especially beverages
such as wine, beer, and fruit juice, as well as fresh and dried
fruits or vegetables. In addition, they were asked to minimize
intake of fatty foods and large doses of vitamins (e.g., vitamin C 9 500 mgIdj1 or vitamin E 9 800 IUIdj1) and to
refrain completely from mineral supplementation (e.g., selenium) and probiotic yogurt during the entire study period.
Subjects were instructed in multiple workshops by a nutrition scientist on how to record food intakes using standard
nutrition diaries. These workshops took place once a week
in the 4 wk before the race, and all participants were asked to
take part at least once. In addition, supervised running sessions were offered once per week to ensure compliance and
to provide an opportunity to ask questions concerning the
trial. Nutritional intake was recorded with a 3-d nutritional
record before visit V2 and before the marathon. All participants were asked not to change their dietary habits during
the study period.
During the marathon, all participants were asked to use
an HR monitor to calculate exercise intensity. %HRmax
was calculated as a ratio of mean HR during marathon
and HRmax. HRmax was calculated by the following formula:
HRmax = 208 j 0.7 age (yr) (41).
Body mass index was calculated as the ratio of weight
and the square of height in meters (kgImj2). Total body fat
was assessed by the skinfold caliper technique (6). Hypertension was defined as previously reported (7). An elevated
cholesterol level was defined as more than 240 mgIdLj1.
Smoking was defined as current smoking or having smoked
within the previous year.
Laboratory Measurements
Blood samples. Fasting blood samples were drawn
from an antecubital vein with subjects in supine position at
visits V1, V2, V4, and V5. Fasting was defined as abstinence from all food for at least 8 h. Only blood collection
directly after the race (V3) was not in a fasted state. Routine
complete blood counts were performed by a clinical hematology laboratory to provide hemoglobin and hematocrit for

20

Official Journal of the American College of Sports Medicine

determination of plasma volume change using the method of
Dill and Costill (9). IL-6 and all other dehydration-dependent concentrations were corrected for changes in plasma
volume in accordance to the method of Dill and Costill.
Other blood samples were centrifuged in sodium heparin
or EDTA tubes, and plasma was aliquoted and stored within
1 h at j80-C for further analyses. None of the specimens
showed signs of hemolysis.
IL-6. IL-6 was measured using a solid-phase two-site
chemiluminescent immunometric assay on the IMMULITEÒ
system (Siemens Healthcare, Eschborn, Germany). Expected
values in healthy individuals range from nondetectable to
5.9 ngILj1. The analytical sensitivity is 2 ngILj1. The measuring range is up to 1000 ngILj1.
Leukocytes and differential hemogram. Complete
blood counts and the differential hemogram were performed
using a Sysmex SF-3000 Automated Hematology Analyzer
(Sysmex Deutschland GmbH, Norderstedt, Germany). Expected values in healthy individuals range from 4 to 9
109 Lj1. The intermeasure coefficient of variation (CV)
under actual routine conditions is 1.5% at a leukocyte count
of 6.6 109 Lj1.
High-sensitivity C-reactive protein (hs-CRP). HsCRP was measured quantitatively with an immune turbidimetric method on an AU2700 analyzer (Olympus Germany,
Beckman Coulter, Krefeld, Germany). The measuring range
of this assay was 0.7–800 mgILj1. The interassay CV under actual routine conditions was 1.5% at a concentration of
13 mgILj1. The intra-assay CV was 0.76% at a concentration of 5.7 mgILj1. The upper reference limit in healthy
volunteers was G5.0 mgILj1.
Sample Size Calculation
Sample size calculation was based on the primary end
point criterion, the difference in marathon-induced change
of IL-6 between the study groups. Because of the expected
right-skewed distribution of IL-6, differences in changes of
logarithmized IL-6 levels (relative group differences) were
considered as the base for inferential statistics. From previous publications, a coefficient of variation of 0.60 for IL-6
changes was expected for the proposed study population
(37). With respect to this condition and by assuming a
clinically relevant difference of at least 20% for change of
IL-6 between the study groups during the marathon race, a
sample size of 100 individuals per group had been calculated
to be required to achieve an 80% power in the statistical
analysis of the primary end point at a two-sided 0.05 level of
significance. According to a possible dropout rate of up to
20%, a total of at least 250 individuals had to be included in
the study to warrant the specified power requirements.
Statistical Methods
Statistical analyses were conducted using the PASW
Statistics software (version 18.0.2 for Windows; SPSS, Inc.;
Chicago, IL) and R software version 2.11.1 (R Foundation

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Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

CLINICAL SCIENCES

FIGURE 1—Study flow diagram. NSAID, nonsteroidal anti-inflammatory drug.

NONALCOHOLIC BEER, MARATHON, AND INFLAMMATION

Medicine & Science in Sports & Exercised

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

21

CLINICAL SCIENCES

for Statistical Computing, Vienna, Austria). The mean value
and SD for normally distributed data or the median and
interquartile range (IQR) for nonnormally distributed data
were reported for descriptive purposes. Assumption of normal distribution of data was verified by using descriptive
methods (skewness, outliers, and distribution plots) and inferential statistics (Shapiro–Wilk test).
The primary end point criterion was statistically evaluated
by the use of a Student’s t-test on means of changes in
logarithmized IL-6 values (corresponding to a test of group
differences in median changes of IL-6). Furthermore,
ANCOVA models were used for the analysis of secondary
end point criteria. To evaluate differences in the time course
of measured parameters (e.g., URTI levels or total blood
leukocyte counts), generalized estimation equation models
(GEE) were used. The GEE approach adequately reflects the
structure of repeated data and allows for simultaneous consideration of within- (time) and between-subject (group)
effects. Within the GEE analysis, adjustment of different
baseline levels was considered, and smoothing spline functions were applied to approximate functional shape of measurement level course by time. Odds ratios were provided
with 95% confidence interval (CI).
All statistical tests were conducted with two sides at a
0.05 level of significance. For the purpose of sensitivity
analysis, statistical evaluations of the primary and secondary
end points were performed on the full analysis set (FAS) and
per-protocol (PP) populations. For the primary end point, the
FAS included data of all participants who had IL-6 measurements before and after the marathon. For the secondary
end points, the FAS included all individuals who had a
complete URTI questionnaire from race day up to day 13
after the race. PP population was defined by all patients who
did not take any nonsteroidal anti-inflammatory drug medication during the study period and who ingested an average

of at least 1 L of the study beverage per day (Fig. 1). PP
data are presented in this article, with FAS data provided
in the online supplemental material (see Supplemental Digital Content (SDC) 1–5; SDC 1 (http://links.lww.com/MSS/
A99) is a table that shows the baseline characteristics of all
randomized study participants. SDC 2 (http://links.lww.com/
MSS/A100) is a table that illustrates the incidence of
URTI for all groups in the 13 d after the race. SDC 3 (http://
links.lww.com/MSS/A101) is a figure that illustrates the IL-6
values for the intervention and control groups at all visits for
the FAS. SDC 4 (http://links.lww.com/MSS/A102) is a figure
that shows the incidence of clinically relevant URTI after a
marathon race in the FAS group. SDC 5 (http://links.lww.com/
MSS/A103) is a figure that illustrates the leukocyte counts
for the intervention and control groups at all visits for the
FAS and PP groups.).

RESULTS
Participants’ Characteristics
We assessed 374 participants for eligibility, 277 of whom
were randomly assigned to either the intervention group
(nonalcoholic beer beverage) or the control group (Fig. 1).
During the recruitment phase of the trial from June 1,
2009, through September 1, 2009, 277 participants were enrolled in the trial and were followed up to October 25, 2009.
Baseline characteristics for subjects adhering to study
requirements are given in Table 1 (see Table, SDC 1, http://
links.lww.com/MSS/A99, for baseline characteristics of all
subjects).
A poststudy survey was performed and ensured that the
participants did not know whether they were consuming nonalcoholic beer with or without polyphenols (data not shown).

TABLE 1. Baseline characteristics of the study participants completing the study.

Fluid intake
Study beverage (LIdj1)
Other beverage (LIdj1)
Anthropometry
Age (yr) (median (IQR))
Body mass index (kgImj2)
Total body fat (%)
Mean blood pressure, systolic/diastolic (mm Hg)
Marathon run
Marathon time (h:min)
Minimum/maximum race time (h:min:s)
Mean HR during race (bpm)
HRM/calculated HRmax (%)
Training history
Training distance per week during the last 10 wk before race (km)
Previous marathon races finished (median (IQR))
Cardiovascular risk factors (%)
Diabetes mellitus (type 1 or 2)
Family history of cardiovascular disease
Hypercholesterolemia (total cholesterol Q 240 mgIdLj1)
Hypertension (RRsys 9 140 mm Hg or RRdia 9 90 mm Hg)
Smoker/ex-smoker

Intervention Group (n = 58)

Control Group (n = 63)

P

1.22 T 0.16
1.49 T 0.83

1.28 T 0.26
1.72 T 0.93

0.18
0.20

44 (36–51)
23.4 T 2.1
15.5 T 4.0
126 T 11/82 T 7

42 (35–49)
23.8 T 2.1
14.6 T 4.5
127 T 12/83 T 7

0.37
0.24
0.22
0.91

3:43:19 T 0:24:20
2:53:50/4:42:34
156 T 11
89.1 T 4.5

3:49:18 T 0:32:24
2:51:01/5:25:40
156 T 11
89.6 T 4.7

0.41

0.97
0.41

49.7 T 18.2
4 (1–7)

53.6 T 22.4
3 (1–7)

0.43
0.69

0%
57%
12%
9%
4%/0%

0%
46%
14%
16%
4%/2%

1.00
0.22
0.72
0.21
1.00

Data are presented as mean T SD or median (IQR).
HRM, mean HR during marathon race; RRdia, diastolic blood pressure; RRsys, systolic blood pressure.

22

Official Journal of the American College of Sports Medicine

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Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

CLINICAL SCIENCES

FIGURE 2—IL-6 values for the intervention and control groups at all
visits. *P = 0.03.

Primary Outcome
Immediately after the race, the increase in IL-6 was
significantly lower in the intervention compared with the
control group (median (IQR) = 23.9 (15.9–38.7) vs 31.6
(18.5–53.3) ngILj1, P = 0.03). Groups did not differ in
plasma IL-6 levels at all other laboratory visits (Fig. 2).
Secondary Outcome
URTI. The response rate for complete recording of the
WURSS-21 questionnaire during the 2-wk period after
the Munich Marathon race event was 61% (168 of 277
participants).

FIGURE 4—Leukocyte counts for the intervention and control groups
at all visits. GEE analysis: difference in leukocyte levels at V3 (immediately after the race) and V4 (24 h after the race), overall comparison:
mean difference T SE = 1.2 109 T 0.65 109 Lj1, P = 0.02.

Postrace URTI incidence was significantly higher in the
control group compared with the intervention group (odds
ratio = 3.25 (95% CI = 1.38–7.66), P = 0.007, Fig. 3). On
the basis of these data, the number needed to treat was estimated to be 8.
As shown in Figure 3, percentage of participants with
clinically relevant URTI increased in the days after the race,
with two peaks especially apparent 1 and 5 d after the race.
Data for the URTI incidence between the groups for each
day are given in the table of SDC 2 (http://links.lww.com/
MSS/A100).
Blood count and hs-CRP. With measurements at V1
and V2 as adjustment covariates, a significant group difference in total blood leukocyte counts was measured immediately and 24 h after the race (overall comparison: mean
difference T SE = 1.2 109 T 0.65 109 Lj1, P = 0.02)
(Fig. 4).
Consistent results were observed for hs-CRP with a lower
clinically relevant increase in hs-CRP 24 h after the race in
the intervention group compared with the control group
(j6.8%, 95% CI = j16.2% to +3.6%, P = 0.169).
Adverse Events
Gastrointestinal problems due to the study beverage were
only seen in the control group (n = 3, 2%). In the intervention group, no dropouts caused by adverse effects were
observed.

DISCUSSION
FIGURE 3—Incidence of clinically relevant URTI after the marathon
race in the intervention group (black striped) and control group (gray).

NONALCOHOLIC BEER, MARATHON, AND INFLAMMATION

This study is the first to show that consuming 1–1.5 LIdj1
of nonalcoholic beer with polyphenols for 3 wk before a

Medicine & Science in Sports & Exercised

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

23

CLINICAL SCIENCES

marathon race reduces postrace inflammation and URTI
incidence. Subjects in the intervention group ingested about
400 mg of gallic acid equivalents per day of a complex
mixture of polyphenols from the nonalcoholic beer beverage.
Numerous food products and supplements have been
tested in athletes as countermeasures to exercise-induced
inflammation, oxidative stress, immune dysfunction, and
URTI, and most have not emerged as efficacious (26).
Results from randomized double-blind studies in human
athletes with large doses of purified flavonoids such as
quercetin have been disappointing, but when mixed with
other flavonoids and food components, impressive antiinflammatory and antioxidative effects have been reported
after exercise (29,30).
Polyphenol-rich plant extracts are being tested by an increasing number of investigative teams as performance aids
and have surfaced as effective countermeasures to exerciseinduced oxidative stress and inflammation (24). Polyphenols
and flavonoids vary widely in bioavailability, and most are
poorly absorbed, undergo active efflux, and are extensively
conjugated and metabolically transformed, all of which can
affect their bioactive capacities (22). There is a growing realization that bioactive influences of individual polyphenols
are potentiated when included in a cocktail or an extract of
other polyphenols and nutrients (21). Two or more polyphenols ingested together may increase bioavailability and
decrease elimination via competitive inhibition of glucuronide and sulfate conjugation in both the intestine and the
liver and by inhibiting efflux transporters. Thus, the antiinflammatory and antioxidative effects of plant foods are not
produced by a single component but rather by complex
mixtures of interacting molecules. Our data indicating antiinflammatory effects in athletes after a marathon race from
ingesting a cocktail of polyphenols from beer are consistent
with this viewpoint.
Many polyphenols suppress viral replication under in
vitro conditions, an effect due in part to modulation of the
cellular redox milieu (5,16). Quercetin supplementation
during a 5-wk period reduced URTI incidence in exercisestressed cyclists without altering immune function (29). The
beneficial influence of quercetin on URTI incidence in endurance athletes, however, has not been a consistent finding
(27,39). The reduction in URTI incidence reported in this
study from beer polyphenols is a novel finding and suggests
that a complex mixture of plant phenolics exerts antiviral
effects during the 2-wk period after marathon competition.
Polyphenol-rich beverages and supplements that exert
anti-inflammatory and antipathogenic influences within the
context of athletic endeavor may also prove to be efficacious
in chronically inflamed groups such as the obese. Inflammation is a key mechanism in the pathogenesis of certain
disease states, supporting the proposed strategy of increased
polyphenol intake for prevention of cancer, diabetes mellitus, and cardiovascular disease (4,17,19,40,42). Therefore,
polyphenol-rich beverages and supplements might be a
promising approach to prevent and positively modulate

24

Official Journal of the American College of Sports Medicine

these pathologies associated with increased inflammation
(12,15,35).
Besides its origin in immune–active cells, IL-6 is also
produced in exercising skeletal muscle during strenuous
exercise (32). Therefore, the cause of the lower increase in
IL-6 in the intervention group in our study might also be in
exercising musculature. Qin et al. (36) were able to show
that polyphenols are able to decrease inflammatory markers
also at the mRNA level in myocytes.
The current trial has certain limitations. First, although
everything possible was done to obtain the completed
WURSS-21 questionnaires, 39% of subjects failed to comply. Nevertheless, the response rate was comparable to
other studies using paper-and-pencil version questionnaires
(18). In addition, we did not measure the amounts of
polyphenols absorbed from the intestinal tract and plasma
concentrations of the primary beer phenolics including
ferulic acid and catechins. Nonetheless, our results are very
clear, and the possible mechanisms of interference (e.g.,
anti-inflammatory medication, food) were minimized so
that other possible explanations for the results of our study
are unlikely.
Furthermore, we did not measure objective correlates
of upper respiratory tract infections like quantitative viral
titer or mucus weight. Therefore, we could not determine
whether the symptoms reported in the WURSS-21 questionnaire had been caused by local inflammation or infections. Therefore, we used the term ‘‘respiratory illness’’ to
cover both inflammatory and infectious entities.
Despite these limitations, the randomized design and the
large number of individuals participating in the study ensure
reliable conclusions to be drawn from the data.
An aspect that also has to be mentioned is the administration of polyphenols. In our trial, participants were asked
to drink 1–1.5 L of study beverage per day. This could be
challenging. Therefore, other forms of administration (e.g.,
tablets) should be used in future studies to simplify the
transfer to everyday use regarding period and frequency as
well as route of administration. Whether these alternative
forms of administration have similar effects as those observed in our study has yet to be determined.
Ingestion of nonalcoholic beer with polyphenols decreased both inflammation and URTI rates in athletes after
the race. The linkage between decreased inflammation and
URTI is difficult to ascertain within the multiple factors involved in URTI episodes. Heavy exertion impairs expression of Toll-like receptors (TLR), whereas flavonoids may
improve toll-interleukin 1 receptor (TIR)-domain-containing
adapter-inducing interferon-A (TRIF)-dependent signaling
TLR pathways (20,31). Thus, a focus on TLR in future studies may be one of several areas to investigate when evaluating the influence of polyphenols on inflammation and URTI
in athletes.
In conclusion, consumption of nonalcoholic beer with
polyphenols for 3 wk before the Munich Marathon reduced postrace inflammation. Continued ingestion of the

http://www.acsm-msse.org

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

Funding for the study was received from Erdinger Weissbraeu,
Werner Brombach GmbH. The funders had no direct role in the study’s
design, conduct, analysis, interpretation of data, and reporting beyond
approval of the scientific protocol in peer review for funding. No other
grants were received.
The authors thank the staff and especially the doctoral students
of the Department of Prevention and Sports Medicine, Technische
Universitaet Muenchen, for their assistance with this project. Furthermore, the authors would like to thank Jeff Christle for careful
proofreading of the article and Erich Elstner for supplying information
concerning polyphenols in beer.
The study’s ClinicalTrials.gov ID is NCT00933218. The study followed the guidelines on Good Publication Practice.

The study was primarily designed by J.S. and M.H.; J.S., M.H.,
and T.S. represent the steering committee of the Be-MaGIC study.
All other authors contributed to the design of the study and supervised the trial and statistical analysis plan in collaboration with the
staff of the Institute for Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universitaet Muenchen. The first
author (J.S.) wrote the first draft of the article, which was next revised
in detail by D.C.N. Subsequent drafts were prepared by all authors.
Besides things mentioned above, J.S., T.S., and J.H. principally did
the statistical analysis of the data. J.H., M.R., and A.P. were responsible for the administrative and technical support. Furthermore,
S.B. was responsible for the material support. B.W. additionally contributed preciously to the analysis and interpretation of the data. J.S.
has the primary responsibility for the final content of the article. All
authors read and approved the final article.
None of the authors had any personal or financial conflicts of
interest.
The results of the present study do not constitute endorsement
by the American College of Sports Medicine.

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25

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