Effects of Ashwagandha ( Withania somnifera) on Physical Performance: Systematic Review and Bayesian Meta-Analysis

Diego A Bonilla, Yurany Moreno, Camila Gho, Jorge L Petro, Adrián Odriozola-Martínez, Richard B Kreider, Diego A Bonilla, Yurany Moreno, Camila Gho, Jorge L Petro, Adrián Odriozola-Martínez, Richard B Kreider

Abstract

Ashwagandha (Withania somnifera) is considered a potent adaptogen and anti-stress agent that could have some potential to improve physical performance. This preferred reporting items for systematic reviews and meta-analyses (PRISMA)-based comprehensive systematic review and Bayesian meta-analysis aimed to evaluate clinical trials up to 2020 from PubMed, ScienceDirect, and Google Scholar databases regarding the effect of Ashwagandha supplementation on physical performance in healthy individuals. Besides implementing estimation statistics analysis, we developed Bayesian hierarchical models for a pre-specified subgroup meta-analysis on strength/power, cardiorespiratory fitness and fatigue/recovery variables. A total of 13 studies met the requirements of this systematic review, although only 12 were included in the quantitative analysis. A low-to-moderate overall risk of bias of the trials included in this study was detected. All Bayesian hierarchical models converged to a target distribution (Ȓ = 1) for both meta-analytic effect size (μ) and between-study standard deviation (τ). The meta-analytic approaches of the included studies revealed that Ashwagandha supplementation was more efficacious than placebo for improving variables related to physical performance in healthy men and female. In fact, the Bayesian models showed that future interventions might be at least in some way beneficial on the analyzed outcomes considering the 95% credible intervals for the meta-analytic effect size. Several practical applications and future directions are discussed, although more comparable studies are needed in exercise training, and athletic populations are needed to derive a more stable estimate of the true underlying effect.

Keywords: cardiorespiratory fitness; exercise tolerance; herbal supplements; muscle strength; quality of life; sleep latency.

Conflict of interest statement

D.A.B. serves as Science Product Manager for MTX Corporation® in Europe, a company that sells a dietary product with Ashwagandha, has acted as a scientific consultant for MET-Rx in Colombia and is a current scientific affiliate to the “Creatine in Health” scientific advisory board for AlzChem (Tostberg, GmbH). R.B.K. has conducted a number of industry-sponsored studies on sport nutrition-related nutrients that include Ashwagandha, has served as a paid consultant and received honorariums to speak at conferences by industry, and currently serves as chair of the “Creatine in Health” scientific advisory board for AlzChem. The other authors declare no conflicts of interest.

Figures

Figure A1
Figure A1
Forest plot depicting the standardized mean differences from a meta-analysis of all studies (including outliers) comparing groups with Ashwagandha or placebo on cardiorespiratory fitness. Colored squares represent the dunb for individual trials, while colored and green polygons depict the meta-analytic dunb for the indicated subgroups and for the overall (total) results, respectively. Horizontal lines represent the 95% confidence intervals for the data. Hb: blood hemoglobin concentration; VO2max: maximum oxygen uptake; WS330: Withania somnifera 330 mg; WS500: Withania somnifera 500 mg.
Figure A2
Figure A2
Forest plot depicting the standardized mean differences from a meta-analysis of all studies (including outliers) comparing groups with Ashwagandha or placebo on fatigue/recovery. Colored squares represent the dunb for individual trials, while colored and green polygons depict the meta-analytic dunb for the indicated subgroups and for the overall (total) results, respectively. Horizontal lines represent the 95% confidence intervals for the data. SRT: simple reaction time; PH-QoL: physical health component of the quality of life test; TTE: time to exhaustion; PRS: perceived recovery scale; CK: creatine kinase; SOD: superoxide dismutase; SE: sleep efficiency; QoS: quality of sleep; WS250: Withania somnifera 250 mg; WS600: Withania somnifera 600 mg.
Figure 1
Figure 1
Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram.
Figure 2
Figure 2
Network graph of the studies related to Ashwagandha supplementation. Node size is proportional to the number of citations, and the color is the publishing year. This graph was developed within www.connectedpapers.com accessed on 23 June 2020.
Figure 3
Figure 3
Risk of bias summary for included studies. Weighted bar-chart of the distribution of risk-of-bias judgments. These graphics were obtained using the robvis package within the R statistical computing environment.
Figure 4
Figure 4
Forest plot depicting the standardized mean differences from the meta-analysis of studies comparing groups with Ashwagandha or placebo on strength/power. Colored squares represent the dunb for individual trials, while colored and green polygons depict the meta-analytic dunb for the indicated subgroups and for the overall (total) results, respectively. Horizontal lines represent the 95% confidence intervals for the data. LL: lower limbs; RM: one-repetition maximum (kg); UL: upper limbs; Vmax: maximum velocity (m·s−1); Wrelative: relative power (W·kg−1); WS330: Withania somnifera 330 mg; WS500: Withania somnifera 500 mg.
Figure 5
Figure 5
Forest plot of a random effect meta-analysis on strength/power variables after Ashwagandha supplementation. (A) The plot shows the names of the studies with their respective variable or multiple comparison/multiple outcomes on the left. On the right are the θk and 95% credible interval (CrI). The value of the overall weighted mean of effect sizes is drawn as a vertical line in the middle of the plot, which represents the reference line to test the null hypothesis in each study. The posterior distributions of the estimated effect sizes for each study are shown as cyan densities. The black circle represents the posterior mean, and the horizontal line extending from the point is the 95% CrI. The bottom row is the meta-analytic effect size (µ). (B) Multivariate kernel density estimation plot of the posterior distribution of μ (x-axis) and τ (y-axis) with the darker zone indicating increased plausibility of values.
Figure 6
Figure 6
Forest plot depicting the standardized mean differences from the meta-analysis of studies comparing groups with Ashwagandha or placebo on cardiorespiratory fitness. Colored squares represent the dunb for individual trials, while colored and green polygons depict the meta-analytic dunb for the indicated subgroups and for the overall (total) results, respectively. Horizontal lines represent the 95% confidence intervals for the data. Hb: blood hemoglobin concentration; VO2max: maximum oxygen uptake; WS330: Withania somnifera 330 mg; WS500: Withania somnifera 500 mg.
Figure 7
Figure 7
Forest plot of a random effect meta-analysis on cardiorespiratory fitness variables after Ashwagandha supplementation. (A) The plot shows the names of the studies with their respective variable or multiple comparison/multiple outcomes on the left. On the right are the θk and 95% CrI. The value of the overall weighted mean of effect sizes is drawn as a vertical line in the middle of the plot, which represents the reference line to test the null hypothesis in each study. The posterior distributions of the estimated effect sizes for each study are shown as cyan densities. The black circle represents the posterior mean, and the horizontal line extending from the point is the 95% CrI. The bottom row is the meta-analytic effect size (µ). (B) multivariate kernel density estimation plot of the posterior distribution of μ (x-axis) and τ (y-axis) with the darker zone indicating increased plausibility of values.
Figure 8
Figure 8
Forest plot depicting the standardized mean differences from the meta-analysis of studies comparing groups with Ashwagandha or placebo on fatigue/recovery. Colored squares represent the dunb for individual trials, while colored and green polygons depict the meta-analytic dunb for the indicated subgroups and for the overall (total) results, respectively. Horizontal lines represent the 95% confidence intervals for the data. SRT: simple reaction time; PH-QoL: physical health component of the quality of life test; TTE: time to exhaustion; PRS: perceived recovery scale; CK: creatine kinase; SOD: superoxide dismutase; SE: sleep efficiency; QoS: quality of sleep; WS250: Withania somnifera 250 mg; WS600: Withania somnifera 600 mg.
Figure 9
Figure 9
Forest plot of a random effect meta-analysis on fatigue/recovery variables after Ashwagandha supplementation. (A) The plot shows the names of the studies with their respective variable or multiple comparison/multiple outcomes on the left. On the right are the θk and 95% CrI. The value of the overall weighted mean of effect sizes is drawn as a vertical line in the middle of the plot, which represents the reference line to test the null hypothesis in each study. The posterior distributions of the estimated effect sizes for each study are shown as cyan densities. The black circle represents the posterior mean, and the horizontal line extending from the point is the 95% CrI. The bottom row is the meta-analytic effect size (µ). (B) Multivariate kernel density estimation plot of the posterior distribution of μ (x-axis) and τ (y-axis) with the darker zone indicating increased plausibility of values.
Figure 10
Figure 10
Potential mechanisms of action with feedback control of the Ashwagandha effects on physical performance variables. 3β-HSD: 3β-hydroxysteroid dehydrogenase; 17β-HSD: 17β-hydroxysteroid dehydrogenase; DHEA: dehydroepiandrosterone; SNP: single nucleotide polymorphism.

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Source: PubMed

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