Metabolic adaptations to a high-fat diet in endurance cyclists

Preexercise High-Fat Meal Following Carbohydrate Loading Attenuates Glycogen Utilization During Endurance Exercise in Male Recreational Runners

ABSTRACT

Iwayama, K, Tanabe, Y, Yajima, K, Tanji, F, Onishi, T, and Takahashi, H. Preexercise high-fat meal following carbohydrate loading attenuates glycogen utilization during endurance exercise in male recreational runners. J Strength Cond Res 37(3): 661-668, 2023-This study aimed to investigate whether one preexercise high-fat meal can increase glycogen conservation during endurance exercise, as compared with one preexercise high-carbohydrate meal. Ten young male recreational runners (22.0 ± 0.6 years; 171.3 ± 0.9 cm; 58.3 ± 1.9 kg; maximal oxygen uptake [V̇ o2 max], 62.0 ± 1.6 ml·kg -1 ·min -1 ) completed 2 exercise trials after high-carbohydrate loading: eating a high-carbohydrate (CHO; 7% protein, 13% fat, 80% carbohydrate) meal or eating a high-fat (FAT; 7% protein, 42% fat, 52% carbohydrate) meal 3.5 hours before exercise. The order of the 2 trials was randomized, and the interval between trials was at least 1 week. The experimental exercise consisted of running on a treadmill for 60 minutes at 95% of each subject's lactate threshold. Muscle and liver glycogen content were assessed using noninvasive carbon magnetic resonance spectroscopy before the experimental meal as well as before and after exercise; respiratory gases were measured continuously during exercise. The respiratory exchange ratio during exercise was statistically lower in the FAT trial than in the CHO trial ( p < 0.01). In addition, muscle ( p < 0.05) and liver ( p < 0.05) glycogen utilization during exercise was less in the FAT trial than in the CHO trial. Therefore, one high-fat meal following carbohydrate loading reduced muscle and liver glycogen use during the 60-minute exercise. These results suggest that this dietary approach may be applied as a strategy to optimize energy utilization during endurance exercise.

Effect of a low carbohydrate, high fat diet versus a high carbohydrate diet on exercise efficiency and economy in recreational male athletes

BACKGROUND

Exercise efficiency and economy are key determinants of endurance exercise performance. In this cross-over intervention trial, we investigated the effect of adherence to a low carbohydrate, high fat (LCHF) diet versus a high carbohydrate (HC) diet on gross efficiency (GE) and (OC) during exercise, both after 2 days and after 14 days of adherence.

METHODS

Fourteen recreational male athletes followed a two-week LCHF diet (<10 energy % carbohydrate) and a two-week HC diet (>50 energy % carbohydrate), in random order, with a wash-out period of three weeks in between. After 2 and 14 days on each diet, the athletes performed a 90-minutes submaximal exercise session on a bicycle ergometer. Indirect calorimetry measurements were done after 60 minutes of exercise to calculate GE and OC.

RESULTS

GE was significantly lower on the LCHF diet compared to the HC diet, after 2 days (17.6±1.9 vs. 18.8±1.2%, P=0.011, for the LCHF and HC diet respectively), not after 14 days. OC was significantly higher on the LCHF diet compared to the HC diet, after 2 days (1191±138 vs. 1087±72 mL O<inf>2</inf>/kCal, P=0.003, for the LCHF and HC diet respectively), and showed a strong tendency to remain higher after 14 days, P=0.018.

CONCLUSIONS

Although LCHF diets are popular strategies to increase fat oxidation during exercise, adherence to a LCHF diet was associated with a lower exercise efficiency and economy compared to a HC diet.

Octanoic Acid-Enrichment Diet Improves Endurance Capacity and Reprograms Mitochondrial Biogenesis in Skeletal Muscle of Mice

Background: Medium Chain Fatty Acids (MCFAs) are a dietary supplement that exhibit interesting properties, due to their smaller molecular size. The acute consumption of MCFAs is expected to enhance exercise performance. However, the short-term effects of MCFAs on endurance performance remains poorly understood. The aim of our study is to evaluate the octanoic acid (C8)-rich diet effect on endurance capacity, and to explore their molecular and cellular effects. Methods: C57BL/6J mice were fed with a chow diet (Control group) or an octanoic acid-rich diet (C8 diet) for 6 weeks. Spontaneous activity, submaximal and maximal exercise tests were carried out to characterize the exercise capacities of the mice. Beta-oxidation and mitochondrial biogenesis pathways were explored in skeletal muscle by RT-qPCR, Western Blot (Quadriceps) and histochemical staining (Gastrocnemius). Results: Mice fed with a C8-rich diet presented a higher spontaneous activity (p < 0.05) and endurance capacities (p < 0.05) than the control, but no effect on maximal effort was observed. They also presented changes in the skeletal muscle metabolic phenotype, with a higher number of the oxidative fibers, rich in mitochondria. At the molecular level, the C8-diet induced an AMPK activation (p < 0.05), associated with a significant increase in PGC1a and CS gene expression and protein levels. Conclusion: Our study provided evidence that C8-enrichment as a food supplementation improves endurance capacities and activates mitochondrial biogenesis pathways leading to higher skeletal muscle oxidative capacities.

Ketogenic diets, physical activity and body composition: a review

Obesity remains a serious relevant public health concern throughout the world despite related countermeasures being well understood (i.e. mainly physical activity and an adjusted diet). Among different nutritional approaches, there is a growing interest in ketogenic diets (KD) to manipulate body mass (BM) and to enhance fat mass loss. KD reduce the daily amount of carbohydrate intake drastically. This results in increased fatty acid utilisation, leading to an increase in blood ketone bodies (acetoacetate, 3-β-hydroxybutyrate and acetone) and therefore metabolic ketosis. For many years, nutritional intervention studies have focused on reducing dietary fat with little or conflicting positive results over the long term. Moreover, current nutritional guidelines for athletes propose carbohydrate-based diets to augment muscular adaptations. This review discusses the physiological basis of KD and their effects on BM reduction and body composition improvements in sedentary individuals combined with different types of exercise (resistance training or endurance training) in individuals with obesity and athletes. Ultimately, we discuss the strengths and the weaknesses of these nutritional interventions together with precautionary measures that should be observed in both individuals with obesity and athletic populations. A literature search from 1921 to April 2021 using Medline, Google Scholar, PubMed, Web of Science, Scopus and Sportdiscus Databases was used to identify relevant studies. In summary, based on the current evidence, KD are an efficient method to reduce BM and body fat in both individuals with obesity and athletes. However, these positive impacts are mainly because of the appetite suppressive effects of KD, which can decrease daily energy intake. Therefore, KD do not have any superior benefits to non-KD in BM and body fat loss in individuals with obesity and athletic populations in an isoenergetic situation. In sedentary individuals with obesity, it seems that fat-free mass (FFM) changes appear to be as great, if not greater, than decreases following a low-fat diet. In terms of lean mass, it seems that following a KD can cause FFM loss in resistance-trained individuals. In contrast, the FFM-preserving effects of KD are more efficient in endurance-trained compared with resistance-trained individuals.

Effect of a High Fat Diet vs. High Carbohydrate Diets With Different Glycemic Indices on Metabolic Parameters in Male Endurance Athletes: A Pilot Trial

Consuming low glycemic carbohydrates leads to an increased muscle fat utilization and preservation of intramuscular glycogen, which is associated with improved flexibility to metabolize either carbohydrates or fats during endurance exercise. The purpose of this trial was to investigate the effect of a 4-week high fat low carbohydrate (HFLC-G: ≥65% high glycemic carbohydrates per day; n = 9) vs. high carbohydrate low glycemic (LGI-G: ≥65% low glycemic carbohydrates daily; n = 10) or high glycemic (HGI-G: ≥65% fat, ≤ 50 g carbohydrates daily; n = 9) diet on fat and carbohydrate metabolism at rest and during exercise in 28 male athletes. Changes in metabolic parameters under resting conditions and during cycle ergometry (submaximal and with incremental workload) from pre- to post-intervention were determined by lactate diagnostics and measurements of the respiratory exchange ratio (RER). Additionally, body composition and perceptual responses to the diets [visual analog scale (VAS)] were measured. A significance level of α = 0.05 was considered. HFLC-G was associated with markedly decreased lactate concentrations during the submaximal (−0.553 ± 0.783 mmol/l, p = 0.067) and incremental cycle test [−5.00 ± 5.71 (mmol/l) × min; p = 0.030] and reduced RER values at rest (−0.058 ± 0.108; p = 0.146) during the submaximal (−0.078 ± 0.046; p = 0.001) and incremental cycle test (−1.64 ± 0.700 RER × minutes; p < 0.001). In the HFLC-G, fat mass (p < 0.001) decreased. In LGI-G lactate, concentrations decreased in the incremental cycle test [−6.56 ± 6.65 (mmol/l) × min; p = 0.012]. In the LGI-G, fat mass (p < 0.01) and VAS values decreased, indicating improved levels of gastrointestinal conditions and perception of effort during training. The main findings in the HGI-G were increased RER (0.047 ± 0.076; p = 0.117) and lactate concentrations (0.170 ± 0.206 mmol/l, p = 0.038) at rest. Although the impact on fat oxidation in the LGI-G was not as pronounced as following the HFLC diet, the adaptations in the LGI-G were consistent with an improved metabolic flexibility and additional benefits regarding exercise performance in male athletes.

High intramuscular triglyceride turnover rates and the link to insulin sensitivity: influence of obesity, type 2 diabetes and physical activity

Large intramuscular triglyceride (IMTG) stores in sedentary, obese individuals have been linked to insulin resistance, yet well-trained athletes exhibit high IMTG levels whilst maintaining insulin sensitivity. Contrary to previous assumptions, it is now known that IMTG content per se does not result in insulin resistance. Rather, insulin resistance is caused, at least in part, by the presence of high concentrations of harmful lipid metabolites, such as diacylglycerols and ceramides in muscle. Several mechanistic differences between obese sedentary individuals and their highly trained counterparts have been identified, which determine the differential capacity for IMTG synthesis and breakdown in these populations. In this review, we first describe the most up-to-date mechanisms by which a low IMTG turnover rate (both breakdown and synthesis) leads to the accumulation of lipid metabolites and results in skeletal muscle insulin resistance. We then explore current and potential exercise and nutritional strategies that target IMTG turnover in sedentary obese individuals, to improve insulin sensitivity. Overall, improving IMTG turnover should be an important component of successful interventions that aim to prevent the development of insulin resistance in the ever-expanding sedentary, overweight and obese populations. Novelty: A description of the most up-to-date mechanisms regulating turnover of the IMTG pool. An exploration of current and potential exercise/nutritional strategies to target and enhance IMTG turnover in obese individuals. Overall, highlights the importance of improving IMTG turnover to prevent the development of insulin resistance.

What Is the Evidence That Dietary Macronutrient Composition Influences Exercise Performance? A Narrative Review

The introduction of the needle muscle biopsy technique in the 1960s allowed muscle tissue to be sampled from exercising humans for the first time. The finding that muscle glycogen content reached low levels at exhaustion suggested that the metabolic cause of fatigue during prolonged exercise had been discovered. A special pre-exercise diet that maximized pre-exercise muscle glycogen storage also increased time to fatigue during prolonged exercise. The logical conclusion was that the athlete's pre-exercise muscle glycogen content is the single most important acutely modifiable determinant of endurance capacity. Muscle biochemists proposed that skeletal muscle has an obligatory dependence on high rates of muscle glycogen/carbohydrate oxidation, especially during high intensity or prolonged exercise. Without this obligatory carbohydrate oxidation from muscle glycogen, optimum muscle metabolism cannot be sustained; fatigue develops and exercise performance is impaired. As plausible as this explanation may appear, it has never been proven. Here, I propose an alternate explanation. All the original studies overlooked one crucial finding, specifically that not only were muscle glycogen concentrations low at exhaustion in all trials, but hypoglycemia was also always present. Here, I provide the historical and modern evidence showing that the blood glucose concentration-reflecting the liver glycogen rather than the muscle glycogen content-is the homeostatically-regulated (protected) variable that drives the metabolic response to prolonged exercise. If this is so, nutritional interventions that enhance exercise performance, especially during prolonged exercise, will be those that assist the body in its efforts to maintain the blood glucose concentration within the normal range.

Factors Influencing Substrate Oxidation During Submaximal Cycling: A Modelling Analysis

BACKGROUND

Multiple factors influence substrate oxidation during exercise including exercise duration and intensity, sex, and dietary intake before and during exercise. However, the relative influence and interaction between these factors is unclear.

OBJECTIVES

Our aim was to investigate factors influencing the respiratory exchange ratio (RER) during continuous exercise and formulate multivariable regression models to determine which factors best explain RER during exercise, as well as their relative influence.

METHODS

Data were extracted from 434 studies reporting RER during continuous cycling exercise. General linear mixed-effect models were used to determine relationships between RER and factors purported to influence RER (e.g., exercise duration and intensity, muscle glycogen, dietary intake, age, and sex), and to examine which factors influenced RER, with standardized coefficients used to assess their relative influence.

RESULTS

The RER decreases with exercise duration, dietary fat intake, age, VO_2max, and percentage of type I muscle fibers, and increases with dietary carbohydrate intake, exercise intensity, male sex, and carbohydrate intake before and during exercise. The modelling could explain up to 59% of the variation in RER, and a model using exclusively easily modified factors (exercise duration and intensity, and dietary intake before and during exercise) could only explain 36% of the variation in RER. Variables with the largest effect on RER were sex, dietary intake, and exercise duration. Among the diet-related factors, daily fat and carbohydrate intake have a larger influence than carbohydrate ingestion during exercise.

CONCLUSION

Variability in RER during exercise cannot be fully accounted for by models incorporating a range of participant, diet, exercise, and physiological characteristics. To better understand what influences substrate oxidation during exercise further research is required on older subjects and females, and on other factors that could explain additional variability in RER.

Comparing Acute, High Dietary Protein and Carbohydrate Intake on Transcriptional Biomarkers, Fuel Utilisation and Exercise Performance in Trained Male Runners

Manipulating dietary macronutrient intake may modulate adaptive responses to exercise, and improve endurance performance. However, there is controversy as to the impact of short-term dietary modification on athletic performance. In a parallel-groups, repeated measures study, 16 trained endurance runners (maximal oxygen uptake (V˙O_2max): 64.2 ± 5.6 mL·kg^-1·min^-1) were randomly assigned to, and provided with, either a high-protein, reduced-carbohydrate (PRO) or a high-carbohydrate (CHO) isocaloric-matched diet. Participants maintained their training load over 21-consecutive days with dietary intake consisting of 7-days habitual intake (T1), 7-days intervention diet (T2) and 7-days return to habitual intake (T3). Following each 7-day dietary period (T1-T3), a micro-muscle biopsy was taken for assessment of gene expression, before participants underwent laboratory assessment of a 10 km treadmill run at 75% V˙O_2max, followed by a 95% V˙O_2max time to exhaustion (TTE) trial. The PRO diet resulted in a modest change (1.37-fold increase, p = 0.016) in AMPK expression, coupled with a significant increase in fat oxidation (0.29 ± 0.05 to 0.59 ± 0.05 g·min^-1, p < 0.0001). However, a significant reduction of 23.3% (p = 0.0003) in TTE post intervention was observed; this reverted back to pre levels following a return to the habitual diet. In the CHO group, whilst no change in sub-maximal fuel utilisation occurred at T2, a significant 6.5% increase in TTE performance (p = 0.05), and a modest, but significant, increase in AMPK (p = 0.042) and PPAR (p = 0.029) mRNA expression compared to T1 were observed; with AMPK (p = 0.011) and PPAR (p = 0.044) remaining significantly elevated at T3. In conclusion, a 7-day isocaloric high protein diet significantly compromised high intensity exercise performance in trained runners with no real benefit on gene markers of training adaptation. A significant increase in fat oxidation during submaximal exercise was observed post PRO intervention, but this returned to pre levels once the habitual diet was re-introduced, suggesting that the response was driven via fuel availability rather than cellular adaptation. A short-term high protein, low carbohydrate diet in combination with endurance training is not preferential for endurance running performance.

Skeletal Muscle Mitochondrial Function after a 100-km Ultramarathon: A Case Study in Monozygotic Twins

PURPOSE

Very little research has investigated the effects of ultraendurance exercise on the bioenergetic status of muscle. The primary objective of this case study was to characterize the changes that occur in skeletal muscle mitochondria in response to a 100-km ultramarathon in monozygotic twins. A second objective was to determine whether mitochondrial function is altered by consuming a periodized low-carbohydrate, high-fat diet during training compared with a high-carbohydrate diet.

METHODS

One pair of male monozygotic twins ran 100 km on treadmills after 4 wk of training on either a high-carbohydrate or periodized low-carbohydrate, high-fat diet. Muscle biopsies were collected 4 wk before the run, as well as 4 and 52 h postrun. Blood draws were also performed immediately before as well as 4 and 52 h after the run.

RESULTS

Four hours postrun, respiratory capacity, citrate synthase activity, and mitochondrial complex protein content were decreased. Two days later, both twins showed signs of rapid recovery in several of these measures. Furthermore, blood levels of creatine phosphokinase, C-reactive protein, and aspartate transaminase were elevated 4 h after the run but partially recovered 2 d later.

CONCLUSION

Although there were some differences between the twins, the primary finding is that there is significant mitochondrial impairment induced by running 100 km, which rapidly recovers within 2 d. These results provide ample rationale for future investigations of the effects of ultraendurance activity on mitochondrial function.

Effects of a Low-Carbohydrate High-Fat Diet Combined with High-Intensity Interval Training on Body Composition and Maximal Oxygen Uptake: A Systematic Review and Meta-Analysis

The low-carbohydrate high-fat (LCHF) diet has recently been subject to attention on account of its reported influences on body composition and physical performance. However, the combined effect of LCHF with high-intensity interval training (HIIT) is unclear. A systematic review and meta-analysis were conducted to explore the effect of the LCHF diet combined with HIIT on human body composition (i.e., body weight (BM), body mass index (BMI), fat mass (FM), body fat percentage (BFP), fat-free mass (FFM)) and maximal oxygen uptake (VO_2max). Online libraries (PubMed, Web of Science, EMBASE, Cochrane Library, EBSCO, CNKI, Wan Fang) were used to search initial studies until July 2021, from which 10 out of 2440 studies were included. WMD served as the effect size with a confidence interval value of 95%. The results of meta-analysis showed a significant reduction in BM (WMD = −5.299; 95% CI: −7.223, −3.376, p = 0.000), BMI (WMD = −1.150; 95% CI: −2.225, −0.075, p = 0.036), BFP (WMD = −2.787; 95% CI: −4.738, −0.835, p = 0.005) and a significant increase in VO_2max (WMD = 3.311; 95% CI: 1.705, 4.918, p = 0.000), while FM (WMD = −2.221; 95% CI: −4.582, 0.139, p = 0.065) and FFM (WMD = 0.487; 95% CI: −3.512, 4.469, p = 0.814) remained unchanged. In conclusion, the LCHF diet combined with HIIT can reduce weight and fat effectively. This combination is sufficient to prevent muscle mass loss during LCHF, and further enhance VO_2max. Further research might be required to clarify the effect of other types of exercise on body composition and physical performance during LCHF.

Performance effects of periodized carbohydrate restriction in endurance trained athletes - a systematic review and meta-analysis

Endurance athletes typically consume carbohydrate-rich diets to allow for optimal performance during competitions and intense training. However, acute exercise studies have revealed that training or recovery with low muscle glycogen stimulates factors of importance for mitochondrial biogenesis in addition to favourable metabolic adaptations in trained athletes. Compromised training quality and particularly lower intensities in peak intervals seem to be a major drawback from dietary interventions with chronic carbohydrate (CHO) restriction. Therefore, the concept of undertaking only selected training sessions with restricted CHO availability (periodized CHO restriction) has been proposed for endurance athletes. However, the overall performance effect of this concept has not been systematically reviewed in highly adapted endurance-trained athletes. We therefore conducted a meta-analysis of training studies that fulfilled the following criteria: a) inclusion of females and males demonstrating a VO₂max ≥ 55 and 60 ml · kg^− 1 · min^− 1, respectively; b) total intervention and training periods ≥ 1 week, c) use of interventions including training and/or recovery with periodized carbohydrate restriction at least three times per week, and d) measurements of endurance performance before and after the training period. The literature search resulted in 407 papers of which nine studies fulfilled the inclusion criteria. The subsequent meta-analysis demonstrated no overall effect of CHO periodization on endurance performance compared to control endurance training with normal (high) CHO availability (standardized mean difference = 0.17 [− 0.15, 0.49]; P = 0.29). Based on the available literature, we therefore conclude that periodized CHO restriction does not per se enhance performance in endurance-trained athletes. The review discusses different approaches to CHO periodization across studies with a focus on identifying potential physiological benefits.

Efficacy of Popular Diets Applied by Endurance Athletes on Sports Performance: Beneficial or Detrimental? A Narrative Review

Endurance athletes need a regular and well-detailed nutrition program in order to fill their energy stores before training/racing, to provide nutritional support that will allow them to endure the harsh conditions during training/race, and to provide effective recovery after training/racing. Since exercise-related gastrointestinal symptoms can significantly affect performance, they also need to develop strategies to address these issues. All these factors force endurance athletes to constantly seek a better nutritional strategy. Therefore, several new dietary approaches have gained interest among endurance athletes in recent decades. This review provides a current perspective to five popular diet approaches: (a) vegetarian diets, (b) high-fat diets, (c) intermittent fasting diets, (d) gluten-free diet, and (e) low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diets. We reviewed scientific studies published from 1983 to January 2021 investigating the impact of these popular diets on the endurance performance and health aspects of endurance athletes. We also discuss all the beneficial and harmful aspects of these diets, and offer key suggestions for endurance athletes to consider when following these diets.

A 2 Week Cross-over Intervention with a Low Carbohydrate, High Fat Diet Compared to a High Carbohydrate Diet Attenuates Exercise-Induced Cortisol Response, but Not the Reduction of Exercise Capacity, in Recreational Athletes

Low carbohydrate, high fat (LCHF) diets are followed by athletes, but questions remain regarding effects of LCHF on metabolic adaptation, exercise-induced stress, immune function and their time-course. In this cross-over study, 14 recreational male athletes (32.9 ± 8.2 years, VO2max 57.3 ± 5.8 mL/kg/min) followed a two week LCHF diet (<10 En% carbohydrates (CHO), ~75En% Fat) and a two week HC diet (>50 En% CHO), in random order, with a wash-out period of >2 weeks in between. After 2 days and 2 weeks on either diet, participants performed cycle ergometry for 90 min at 60%W_max. Blood samples for analysis of cortisol, free fatty acids (FFA), glucose and ketones, and saliva samples for immunoglobin A (s-IgA) were collected at different time points before and after exercise. The LCHF diet resulted in higher FFA, higher ketones and lower glucose levels compared to the HC diet (p < 0.05). Exercise-induced cortisol response was higher after 2 days on the LCHF diet (822 ± 215 nmol/L) compared to 2 weeks on the LCHF diet (669 ± 243 nmol/L, p = 0.004) and compared to both test days following the HC diet (609 ± 208 and 555 ± 173 nmol/L, both p < 0.001). Workload was lower, and perceived exertion higher, on the LCHF diet compared to the HC diet on both occasions. A drop in s-IgA following exercise was not seen after 2 days on the LCHF diet, in contrast to the HC diet. In conclusion, the LCHF diet resulted in reduced workload with metabolic effects and a pronounced exercise-induced cortisol response after 2 days. Although indications of adaptation were seen after 2 weeks on the LCHF diet, work output was still lower.

Tuning fatty acid oxidation in skeletal muscle with dietary fat and exercise

Both the consumption of a diet rich in fatty acids and exercise training result in similar adaptations in several skeletal muscle proteins. These adaptations are involved in fatty acid uptake and activation within the myocyte, the mitochondrial import of fatty acids and further metabolism of fatty acids by β-oxidation. Fatty acid availability is repeatedly increased postprandially during the day, particularly during high dietary fat intake and also increases during, and after, aerobic exercise. As such, fatty acids are possible signalling candidates that regulate transcription of target genes encoding proteins involved in muscle lipid metabolism. The mechanism of signalling might be direct or indirect targeting of peroxisome proliferator-activated receptors by fatty acid ligands, by fatty acid-induced NAD⁺-stimulated activation of sirtuin 1 and/or fatty acid-mediated activation of AMP-activated protein kinase. Lactate might also have a role in lipid metabolic adaptations. Obesity is characterized by impairments in fatty acid oxidation capacity, and individuals with obesity show some rigidity in increasing fatty acid oxidation in response to high fat intake. However, individuals with obesity retain improvements in fatty acid oxidation capacity in response to exercise training, thereby highlighting exercise training as a potential method to improve lipid metabolic flexibility in obesity.

A ketogenic diet combined with exercise alters mitochondrial function in human skeletal muscle while improving metabolic health

Animal data indicate that ketogenic diets are associated with improved mitochondrial function, but human data are lacking. We aimed to characterize skeletal muscle mitochondrial changes in response to a ketogenic diet combined with exercise training in healthy individuals. Twenty-nine physically active adults completed a 12-wk supervised exercise program after self-selection into a ketogenic diet (KD, n = 15) group or maintenance of their habitual mixed diet (MD, n = 14). Measures of metabolic health and muscle biopsies (vastus lateralis) were obtained before and after the intervention. Mitochondria were isolated from muscle and studied after exposure to carbohydrate (pyruvate), fat (palmitoyl-l-carnitine), and ketone (β-hydroxybutyrate+acetoacetate) substrates. Compared with MD, the KD resulted in increased whole body resting fat oxidation (P < 0.001) and decreased fasting insulin (P = 0.019), insulin resistance [homeostatic model assessment of insulin resistance (HOMA-IR), P = 0.022], and visceral fat (P < 0.001). The KD altered mitochondrial function as evidenced by increases in mitochondrial respiratory control ratio (19%, P = 0.009), ATP production (36%, P = 0.028), and ATP/H₂O₂ (36%, P = 0.033) with the fat-based substrate. ATP production with the ketone-based substrate was four to eight times lower than with other substrates, indicating minimal oxidation. The KD resulted in a small decrease in muscle glycogen (14%, P = 0.035) and an increase in muscle triglyceride (81%, P = 0.006). These results expand our understanding of human adaptation to a ketogenic diet combined with exercise. In conjunction with weight loss, we observed altered skeletal muscle mitochondrial function and efficiency, an effect that may contribute to the therapeutic use of ketogenic diets in various clinical conditions, especially those associated with insulin resistance.

Low-carbohydrate diets: Effects on metabolism and exercise - A comprehensive literature review

BACKGROUND & AIMS

Low-carbohydrate diets (LCD) have gained substantial attention in recent years for their potential in health promotion and treatment of diseases, but they remain controversial in nutrition guidelines and exercise performance. Herein, through a literature review, we discuss the current evidence base by considering management of LCD and potential coupling of these dietary regiments with physical exercise.

METHODS

We performed a comprehensive literature review with no date limits as a means of including seminal to current studies.

RESULTS

Reduction of CHO intake decreases muscle glycogen, yielding greater fat oxidation and associated metabolic benefits. LCD may promote fat mass loss and regulation of biochemical parameters, such as lipid and glycemic biomarkers. The therapeutic potential of LCD towards noncommunicable diseases, particularly obesity and its comorbidities, is therefore reasonable as a dietary candidate in this context. Potential benefits to this approach are linked to enhancement of mitochondrial gene expression and mitochondrial biogenesis. As such, LCD may be a feasible tool in a 'periodized nutrition' for athletes and within clinical scenarios. Long-term observational follow-up studies have demonstrated increased mortality and cardiovascular implications of LCD. However, harmful associations may depend on the food source (e.g., animal-based vs. plant-based foods).

CONCLUSION

LCD may decrease body mass, waist circumference, and improve fat and carbohydrate metabolism. When combined with exercise, LCD seems to be an effective strategy in regulating metabolic factors of cardiovascular diseases. Conversely, LCD may be associated with higher mortality and metabolic dysregulations if it contains large amounts of animal-based foods, particularly saturated fat.

Dietary Intakes Differ by Body Composition Goals: An Observational Study of Professional Rugby Union Players in New Zealand

Preseason in rugby union is a period of intensive training where players undergo conditioning to prepare for the competitive season. In some cases, this includes modifying body composition through weight gain or fat loss. This study aimed to describe the macronutrient intakes of professional rugby union players during pre-season training. It was hypothesized that players required to gain weight would have a higher energy, carbohydrate and protein intake compared to those needing to lose weight. Twenty-three professional rugby players completed 3 days of dietary assessment and their sum of eight skinfolds were assessed. Players were divided into three groups by the team coaches and medical staff: weight gain, weight maintain and weight loss. Mean energy intakes were 3,875 ± 907 kcal·d⁻¹ (15,965 ± 3,737 kJ·d⁻¹) (weight gain 4,532 ± 804 kcal·d⁻¹; weight maintain 3,825 ± 803 kcal·d⁻¹; weight loss 3,066 ± 407 kcal·d⁻¹) and carbohydrate intakes were 3.7 ± 1.2 g·kg⁻¹·d⁻¹ (weight gain 4.8 ± 0.9 g.kg⁻¹·d⁻¹; weight maintain 2.8 ± 0.7 g·kg⁻¹·d⁻¹; weight loss 2. 6 ± 0.7 g·kg⁻¹·d⁻¹). The energy and carbohydrate intakes are similar to published intakes among rugby union players. There were significant differences in energy intake and the percent of energy from protein between the weight gain and the weight loss group.

COVID-19: Proposing a Ketone-Based Metabolic Therapy as a Treatment to Blunt the Cytokine Storm

Human SARS-CoV-2 infection is characterized by a high mortality rate due to some patients developing a large innate immune response associated with a cytokine storm and acute respiratory distress syndrome (ARDS). This is characterized at the molecular level by decreased energy metabolism, altered redox state, oxidative damage, and cell death. Therapies that increase levels of (R)-beta-hydroxybutyrate (R-BHB), such as the ketogenic diet or consuming exogenous ketones, should restore altered energy metabolism and redox state. R-BHB activates anti-inflammatory GPR109A signaling and inhibits the NLRP3 inflammasome and histone deacetylases, while a ketogenic diet has been shown to protect mice from influenza virus infection through a protective γδ T cell response and by increasing electron transport chain gene expression to restore energy metabolism. During a virus-induced cytokine storm, metabolic flexibility is compromised due to increased levels of reactive oxygen species (ROS) and reactive nitrogen species (RNS) that damage, downregulate, or inactivate many enzymes of central metabolism including the pyruvate dehydrogenase complex (PDC). This leads to an energy and redox crisis that decreases B and T cell proliferation and results in increased cytokine production and cell death. It is hypothesized that a moderately high-fat diet together with exogenous ketone supplementation at the first signs of respiratory distress will increase mitochondrial metabolism by bypassing the block at PDC. R-BHB-mediated restoration of nucleotide coenzyme ratios and redox state should decrease ROS and RNS to blunt the innate immune response and the associated cytokine storm, allowing the proliferation of cells responsible for adaptive immunity. Limitations of the proposed therapy include the following: it is unknown if human immune and lung cell functions are enhanced by ketosis, the risk of ketoacidosis must be assessed prior to initiating treatment, and permissive dietary fat and carbohydrate levels for exogenous ketones to boost immune function are not yet established. The third limitation could be addressed by studies with influenza-infected mice. A clinical study is warranted where COVID-19 patients consume a permissive diet combined with ketone ester to raise blood ketone levels to 1 to 2 mM with measured outcomes of symptom severity, length of infection, and case fatality rate.

Changes in body composition and substrate utilization after a short-term ketogenic diet in endurance-trained males

Few studies have investigated the short-term effects of a very low carbohydrate ketogenic diet (KD) on body composition and substrate utilization in trained individuals. This study investigated effects on substrate utilization during incremental exercise, and changes in body composition, in response to seven days ad libitum consumption of a KD by athletes from endurance sports. Nine young trained males (age, 21.8 ± 1.9 y; height, 1.83 ± 0.11 m; body mass, 78.4 ± 13.8 kg; body fat, 14.9 ± 3.9%; VO2peak, 54.3 ± 5.9 mL kg^-1 min^-1) were assessed before (day 0; PRE) and after (day 7; POST) seven days of consuming an ad libitum KD. Following an overnight fast, body composition was measured by dual x-ray absorptiometry, and substrate utilization was measured during an incremental (3 min stages, 35 W increments) exercise test on a cycle ergometer. After KD, W_max (PRE, 295 ± 30 W; POST, 292 ± 38 W) and VO2peak (PRE, 4.18 ± 0.33 L min^-1; POST, 4.10 ± 0.43 L min^-1) were unchanged, whereas body mass [-2.4 (-3.2, -1.6) kg; P < 0.001, d = 0.21], fat mass [-0.78 (-1.10, -0.46) kg; P < 0.001, d = 0.22] and fat-free mass (FFM) [-1.82 (-3.12, -0.51) kg; P = 0.013, d = 0.22] all decreased. The respiratory exchange ratio was lower, and rates of fat oxidation were higher, at POST across a range of exercise intensities. Maximal fat oxidation rate was ~1.8-fold higher after KD (PRE, 0.54 ± 0.13 g min^-1; POST, 0.95 ± 0.24 g min^-1; P < 0.001, d = 2.2). Short-term KD results in loss of both fat mass and FFM, increased rates of fat oxidation and a concomitant reduction in CHO utilization even at moderate-to-high intensities of exercise.

Adaptation to a low carbohydrate high fat diet is rapid but impairs endurance exercise metabolism and performance despite enhanced glycogen availability

KEY POINTS

Brief (5-6 days) adaptation to a low carbohydrate high fat diet in elite athletes increased exercise fat oxidation to rates previously observed with medium (3-4 weeks) or chronic (>12 months) adherence to this diet, with metabolic changes being washed out in a similar time frame. Increased fat utilisation during exercise was associated with a 5-8% increase in oxygen cost at speeds related to Olympic Programme races. Acute restoration of endogenous carbohydrate (CHO) availability (24 h high CHO diet, pre-race CHO) only partially restored substrate utilisation during a race warm-up. Fat oxidation continued to be elevated above baseline values although it was lower than achieved by 5-6 days' keto adaptation; CHO oxidation only reached 61% and 78% of values previously seen at exercise intensities related to race events. Acute restoration of CHO availability failed to overturn the impairment of high-intensity endurance performance previously associated with low carbohydrate high fat adaptation, potentially due to the blunted capacity for CHO oxidation.

ABSTRACT

We investigated substrate utilisation during exercise after brief (5-6 days) adaptation to a ketogenic low-carbohydrate (CHO), high-fat (LCHF) diet and similar washout period. Thirteen world-class male race walkers completed economy testing, 25 km training and a 10,000 m race (Baseline), with high CHO availability (HCHO), repeating this (Adaptation) after 5-6 days' LCHF (n = 7; CHO: <50 g day^-1 , protein: 2.2 g kg^-1 day^-1 ; 80% fat) or HCHO (n = 6; CHO: 9.7 g kg^-1 day^-1 ; protein: 2.2 g kg^-1 day^-1 ) diet. An Adaptation race was undertaken after 24 h HCHO and pre-race CHO (2 g kg^-1 ) diet, identical to the Baseline race. Substantial (>200%) increases in exercise fat oxidation occurred in the LCHF Adaptation economy and 25 km tests, reaching mean rates of ∼1.43 g min^-1 . However, relative V ̇ O 2 (ml min^-1  kg^-1 ) was higher (P < 0.0001), by ∼8% and 5% at speeds related to 50 km and 20 km events. During Adaptation race warm-up in the LCHF group, rates of fat and CHO oxidation at these speeds were decreased and increased, respectively (P < 0.001), compared with the previous day, but were not restored to Baseline values. Performance changes differed between groups (P = 0.009), with all HCHO athletes improving in the Adaptation race (5.7 (5.6)%), while 6/7 LCHF athletes were slower (2.2 (3.4)%). Substrate utilisation returned to Baseline values after 5-6 days of HCHO diet. In summary, robust changes in exercise substrate use occurred in 5-6 days of extreme changes in CHO intake. However, adaptation to a LCHF diet plus acute restoration of endogenous CHO availability failed to restore high-intensity endurance performance, with CHO oxidation rates remaining blunted.

Intramuscular Mechanisms Mediating Adaptation to Low-Carbohydrate, High-Fat Diets during Exercise Training

Interest in low-carbohydrate, high-fat (LCHF) diets has increased over recent decades given the theorized benefit of associated intramuscular adaptations and shifts in fuel utilization on endurance exercise performance. Consuming a LCHF diet during exercise training increases the availability of fat (i.e., intramuscular triglyceride stores; plasma free fatty acids) and decreases muscle glycogen stores. These changes in substrate availability increase reliance on fat oxidation for energy production while simultaneously decreasing reliance on carbohydrate oxidation for fuel during submaximal exercise. LCHF diet-mediated changes in substrate oxidation remain even after endogenous or exogenous carbohydrate availability is increased, suggesting that the adaptive response driving changes in fat and carbohydrate oxidation lies within the muscle and persists even when the macronutrient content of the diet is altered. This narrative review explores the intramuscular adaptations underlying increases in fat oxidation and decreases in carbohydrate oxidation with LCHF feeding. The possible effects of LCHF diets on protein metabolism and post-exercise muscle remodeling are also considered.

Ketogenic Diet: from the Historical Records to Use in Elite Athletes

PURPOSE OF REVIEW

To review the available literature/evidence on low carbohydrate/high fat (LCHF) and low carbohydrate ketogenic (LCKD) diets' effects on human athletic performance and to provide a brief review of the physiology and history of energy systems of exercise.

RECENT FINDINGS

Multiple studies have been conducted in an attempt to answer this question, many within the last 3-5 years. Studies are heterogenous in design, intervention, and outcome measures. Current available data show that LCHF and LCKD do not significantly enhance or impair performance in endurance or strength activities. However, there is a trend towards improved body composition (greater percent lean body mass) across multiple studies. While this may not translate to enhanced performance in the primarily laboratory conditions in the reviewed studies, there could be a benefit in sports in which an athlete's strength-to-weight ratio is a significant determinant of outcome.

Ketogenic Diet: an Endocrinologist Perspective

PURPOSE OF REVIEW

Obesity and its related comorbidities make up a large part of healthcare expenditures. Despite a wide array of options for treatment of obesity, rates of sustained weight loss continue to be low, leading patients to seek alternative treatment options. Although the first medically utilized ketogenic diet was described nearly 100 years ago, it has made a resurgence as a treatment option for obesity. Despite increased popularity in the lay public and increased use of ketogenic dietary strategies for metabolic therapy, we are still beginning to unravel the metabolic impact of long-term dietary ketosis.

RECENT FINDINGS

There are a number of recent trials that have highlighted the short- and long-term benefits of ketogenic diet on weight, glycemic control, and other endocrine functions including reproductive hormones. This review is a summary of available data on the effectiveness and durability of the ketogenic diet when compared to conventional interventions. Ketogenic dietary strategies may play a role in short-term improvement of important metabolic parameters with potential for long-term benefit. However, response may vary due to inter-individual ability to maintain long-term carbohydrate restriction.

Ketogenic low-CHO, high-fat diet: the future of elite endurance sport?

The ability of ketogenic low‐carbohydrate (CHO) high‐fat (K‐LCHF) diets to enhance muscle fat oxidation has led to claims that it is the ‘future of elite endurance sport’. There is robust evidence that substantial increases in fat oxidation occur, even in elite athletes, within 3–4 weeks and possibly 5–10 days of adherence to a K‐LCHF diet. Retooling of the muscle can double exercise fat use to ∼1.5 g min⁻¹, with the intensity of maximal rates of oxidation shifting from ∼45% to ∼70% of maximal aerobic capacity. Reciprocal reductions in CHO oxidation during exercise are clear, but current evidence to support the hypothesis of the normalization of muscle glycogen content with longer‐term adaptation is weak. Importantly, keto‐adaptation may impair the muscle's ability to use glycogen for oxidative fates, compromising the use of a more economical energy source when the oxygen supply becomes limiting and, thus, the performance of higher‐intensity exercise (>80% maximal aerobic capacity). Even with moderate intensity exercise, individual responsiveness to K‐LCHF is varied, with extremes at both ends of the performance spectrum. Periodisation of K‐LCHF with high CHO availability might offer opportunities to restore capacity for higher‐intensity exercise, but investigations of various models have failed to find a benefit over dietary approaches based on current sports nutrition guidelines. Endurance athletes who are contemplating the use of K‐LCHF should undertake an audit of event characteristics and personal experiences to balance the risk of impaired performance of higher‐intensity exercise with the likelihood of an unavoidable depletion of carbohydrate stores.

Crisis of confidence averted: Impairment of exercise economy and performance in elite race walkers by ketogenic low carbohydrate, high fat (LCHF) diet is reproducible

INTRODUCTION

We repeated our study of intensified training on a ketogenic low-carbohydrate (CHO), high-fat diet (LCHF) in world-class endurance athletes, with further investigation of a "carryover" effect on performance after restoring CHO availability in comparison to high or periodised CHO diets.

METHODS

After Baseline testing (10,000 m IAAF-sanctioned race, aerobic capacity and submaximal walking economy) elite male and female race walkers undertook 25 d supervised training and repeat testing (Adapt) on energy-matched diets: High CHO availability (8.6 g∙kg-1∙d-1 CHO, 2.1 g∙kg-1∙d-1 protein; 1.2 g∙kg-1∙d-1 fat) including CHO before/during/after workouts (HCHO, n = 8): similar macronutrient intake periodised within/between days to manipulate low and high CHO availability at various workouts (PCHO, n = 8); and LCHF (<50 g∙d-1 CHO; 78% energy as fat; 2.1 g∙kg-1∙d-1 protein; n = 10). After Adapt, all athletes resumed HCHO for 2.5 wk before a cohort (n = 19) completed a 20 km race.

RESULTS

All groups increased VO2peak (ml∙kg-1∙min-1) at Adapt (p = 0.02, 95%CI: [0.35-2.74]). LCHF markedly increased whole-body fat oxidation (from 0.6 g∙min-1 to 1.3 g∙min-1), but also the oxygen cost of walking at race-relevant velocities. Differences in 10,000 m performance were clear and meaningful: HCHO improved by 4.8% or 134 s (95% CI: [207 to 62 s]; p < 0.001), with a trend for a faster time (2.2%, 61 s [-18 to +144 s]; p = 0.09) in PCHO. LCHF were slower by 2.3%, -86 s ([-18 to -144 s]; p < 0.001), with no evidence of superior "rebound" performance over 20 km after 2.5 wk of HCHO restoration and taper.

CONCLUSION

Our previous findings of impaired exercise economy and performance of sustained high-intensity race walking following keto-adaptation in elite competitors were repeated. Furthermore, there was no detectable benefit from undertaking an LCHF intervention as a periodised strategy before a 2.5-wk race preparation/taper with high CHO availability.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry: ACTRN12619000794101.

Effects of a Ketogenic Diet Containing Medium-Chain Triglycerides and Endurance Training on Metabolic Enzyme Adaptations in Rat Skeletal Muscle

Long-term intake of a ketogenic diet enhances utilization of ketone bodies, a particularly energy-efficient substrate, during exercise. However, physiological adaptation to an extremely low-carbohydrate diet has been shown to upregulate pyruvate dehydrogenase kinase 4 (PDK4, a negative regulator of glycolytic flux) content in skeletal muscle, resulting in impaired high-intensity exercise capacity. This study aimed to examine the effects of a long-term ketogenic diet containing medium-chain triglycerides (MCTs) on endurance training-induced adaptations in ketolytic and glycolytic enzymes of rat skeletal muscle. Male Sprague-Dawley rats were placed on either a standard diet (CON), a long-chain triglyceride-containing ketogenic diet (LKD), or an MCT-containing ketogenic diet (MKD). Half the rats in each group performed a 2-h swimming exercise, 5 days a week, for 8 weeks. Endurance training significantly increased 3-oxoacid CoA transferase (OXCT, a ketolytic enzyme) protein content in epitrochlearis muscle tissue, and MKD intake additively enhanced endurance training–induced increases in OXCT protein content. LKD consumption substantially increased muscle PDK4 protein level. However, such PDK4 increases were not observed in the MKD-fed rats. In conclusion, long-term intake of ketogenic diets containing MCTs may additively enhance endurance training–induced increases in ketolytic capacity in skeletal muscle without exerting inhibitory effects on carbohydrate metabolism.

Modulation of Cellular Biochemistry, Epigenetics and Metabolomics by Ketone Bodies. Implications of the Ketogenic Diet in the Physiology of the Organism and Pathological States

Ketone bodies (KBs), comprising β-hydroxybutyrate, acetoacetate and acetone, are a set of fuel molecules serving as an alternative energy source to glucose. KBs are mainly produced by the liver from fatty acids during periods of fasting, and prolonged or intense physical activity. In diabetes, mainly type-1, ketoacidosis is the pathological response to glucose malabsorption. Endogenous production of ketone bodies is promoted by consumption of a ketogenic diet (KD), a diet virtually devoid of carbohydrates. Despite its recently widespread use, the systemic impact of KD is only partially understood, and ranges from physiologically beneficial outcomes in particular circumstances to potentially harmful effects. Here, we firstly review ketone body metabolism and molecular signaling, to then link the understanding of ketone bodies’ biochemistry to controversies regarding their putative or proven medical benefits. We overview the physiological consequences of ketone bodies’ consumption, focusing on (i) KB-induced histone post-translational modifications, particularly β-hydroxybutyrylation and acetylation, which appears to be the core epigenetic mechanisms of activity of β-hydroxybutyrate to modulate inflammation; (ii) inflammatory responses to a KD; (iii) proven benefits of the KD in the context of neuronal disease and cancer; and (iv) consequences of the KD’s application on cardiovascular health and on physical performance.

Reduced Glucose Tolerance and Skeletal Muscle GLUT4 and IRS1 Content in Cyclists Habituated to a Long-Term Low-Carbohydrate, High-Fat Diet

Very little is known about how long-term (>6 months) adaptation to a low-carbohydrate, high-fat (LCHF) diet affects insulin signaling in healthy, well-trained individuals. This study compared glucose tolerance; skeletal muscle glucose transporter 4 (GLUT4) and insulin receptor substrate 1 (IRS1) content; and muscle enzyme activities representative of the main energy pathways (3-hydroxyacetyl-CoA dehydrogenase, creatine kinase, citrate synthase, lactate dehydrogenase, phosphofructokinase, phosphorylase) in trained cyclists who followed either a long-term LCHF or a mixed-macronutrient (Mixed) diet. On separate days, a 2-hr oral glucose tolerance test was conducted, and muscle samples were obtained from the vastus lateralis of fasted participants. The LCHF group had reduced glucose tolerance compared with the Mixed group, as plasma glucose concentrations were significantly higher throughout the oral glucose tolerance test and serum insulin concentrations peaked later (LCHF, 60 min; Mixed, 30 min). Whole-body insulin sensitivity was not statistically significantly different between groups (Matsuda index: LCHF, 8.7 ± 3.4 vs. Mixed, 12.9 ± 4.6; p = .08). GLUT4 (LCHF: 1.13 ± 0.24; Mixed: 1.44 ± 0.16; p = .026) and IRS1 (LCHF: 0.25 ± 0.13; Mixed: 0.46 ± 0.09; p = .016) protein content was lower in LCHF muscle, but enzyme activities were not different. We conclude that well-trained cyclists habituated to an LCHF diet had reduced glucose tolerance compared with matched controls on a mixed diet. Lower skeletal muscle GLUT4 and IRS1 contents may partially explain this finding. This could possibly reflect an adaptation to reduced habitual glucose availability rather than the development of a pathological insulin resistance.

Enhancement of Fat Oxidation during Submaximal Exercise in Sedentary Persons: Variations by Medium-Chain Fatty Acid Composition and Age Group

Previous studies in recreational and trained athletes aged mostly in their 20s have reported that short-term ingestion of medium-chain triacylglycerols (MCT) enhances fat oxidation (FAO) during submaximal exercise. However, whether the FAO-enhancing effect of MCT with a different composition of medium-chain fatty acids (MCFA) occurs in older sedentary persons is unclear. The present study investigated the effect of MCT ingestion with different proportions of MCFA in sedentary participants in their 40's and 50's. Participants ingested 0 g of MCT (control), 6 g of octanoic acid-rich MCT (OAR), or 6 g of decanoic acid-rich MCT (DAR) for 14 days separated by a 14-day washout period in random order. Cumulative FAO (F_cv ) during submaximal, fixed, and incremental exercise was evaluated at workload from 20 W to the appearance of a ventilation threshold (VT). During the 20 W fixed-load exercise, F_cv was significantly (p < 0.05) higher in the OAR than in the control. At appearance of VT, intervention effect of power output was significantly higher in the OAR and DAR than in the control. In a subgroup analysis by age, intervention effects of maximal FAO rate and oxygen uptake in the upper age subgroup were higher in the OAR and DAR than in the control. In a pooled analysis with age subgroup and diet, the integrated pooled estimate of F_cv during submaximal exercise was significantly higher in 6 g of MCT ingestion than 0 g ingestion. Our data show that the effect of MCT might differ depending on the age group and the proportion of MCFA, while MCT could enhance FAO during submaximal exercise.

Carbohydrate intake and ketosis in self-sufficient multi-stage ultramarathon runners

Ultra-endurance athletes accumulate an energy deficit throughout their events and those competing in self-sufficient multi-stage races are particularly vulnerable due to load carriage considerations. Whilst urinary ketones have previously been noted in ultra-endurance exercise and attributed to insufficient carbohydrate (CHO) availability, not all studies have reported concomitant CHO intake. Our aim was to determine changes in blood glucose and β-hydroxybutyrate concentrations over five days (240 km) of a self-sufficient multi-stage ultramarathon in combination with quantification of energy and macronutrient intakes, estimated energy expenditure and evaluation of energy balance. Thirteen runners (8 male, 5 female, mean age 40 ± 8 years) participated in the study. Glucose and β-hydroxybutyrate were measured every day immediately post-running, and food diaries completed daily. CHO intakes of 301 ± 106 g·day^-1 (4.3 ± 1.8 g·kg^-1·day^-1) were not sufficient to avoid ketosis (5-day mean β-hydroxybutyrate: 1.1 ± 0.6 mmol.L^-1). Furthermore, ketosis was not attenuated even when CHO intake was high (9 g·kg^-1·day^-1). This suggests that competing in a state of ketosis may be inevitable during multi-stage events where load reduction is prioritised over energy provisions. Attenuating negative impacts associated with such a metabolic shift in athletes unaccustomed to CHO and energy restriction requires further exploration.

The impact of keto-adaptation on exercise performance and the role of metabolic-regulating cytokines

The ketogenic diet (KD) is a normocaloric diet composed of high-fat, low-carbohydrate, and adequate protein that induces fasting-like effects and results in the production of ketone bodies. Initially used widely for children with refractory epilepsy, the KD gained popularity due to its beneficial effects on weight loss, diabetes, and cancer. In recent years, there has been a resurgence in interest surrounding the KD and exercise performance. This review provides new insights into the adaptation period necessary for enhancement in skeletal muscle fat and ketone oxidation after sustained nutritional ketosis. In addition, this review highlights metabolically active growth factors and cytokines, which may function as important regulators of keto-adaptation in the setting of exercise and the KD.

Dietary Fuels in Athletic Performance

Focusing on daily nutrition is important for athletes to perform and adapt optimally to exercise training. The major roles of an athlete's daily diet are to supply the substrates needed to cover the energy demands for exercise, to ensure quick recovery between exercise bouts, to optimize adaptations to exercise training, and to stay healthy. The major energy substrates for exercising skeletal muscles are carbohydrate and fat stores. Optimizing the timing and type of energy intake and the amount of dietary macronutrients is essential to ensure peak training and competition performance, and these strategies play important roles in modulating skeletal muscle adaptations to endurance and resistance training. In this review, recent advances in nutritional strategies designed to optimize exercise-induced adaptations in skeletal muscle are discussed, with an emphasis on mechanistic approaches, by describing the physiological mechanisms that provide the basis for different nutrition regimens.

Effects of a 15-Day Low Carbohydrate, High-Fat Diet in Resistance-Trained Men

Waldman, HS, Krings, BM, Basham, SA, Smith, JW, Fountain, BJ, and McAllister, MJ. Effects of a 15-day low carbohydrate, high-fat diet in resistance-trained men. J Strength Cond Res 32(11): 3103-3111, 2018-This study examined the effects of a 15-day isocaloric low carbohydrate (<25% E), high-fat (>50% E) (LCHF) diet on physiological and metabolic alterations in resistance-trained (RT) men. College-aged RT men (n = 11) completed 4 V[Combining Dot Above]O2max tests using treadmill every 5 days during the 15-day trial. Blood was drawn intravenously pre-exercise across each experimental trial for insulin, cortisol, and glucose. Pulmonary data were collected and substrate oxidation (OXI) was calculated during exercise. Body mass decreased (p < 0.04) with no further changes in anthropometric measures. Time to exhaustion was not affected across each day. Insulin dropped below baseline values (p < 0.0005). Cortisol increased from baseline to day 5 (p < 0.004) but returned back to near baseline at day 10, whereas glucose remained within normal range throughout the duration of the study. Carbohydrate (CHO) OXI dropped (p < 0.001) from baseline to day 5, and fat OXI increased from baseline to day 5 (p < 0.0001). Heart rate decreased from baseline to day 5 (p < 0.001) and again from day 10 to 15 (p < 0.02). Oxygen uptake (V[Combining Dot Above]O2) decreased from day 5 to 10 (p < 0.0001). A nonketo LCHF diet appears to favor RT men by altering metabolic markers without decrements in aerobic performance and be a potential diet intervention used by coaches. However, the reported cardiorespiratory responses should be interpreted reasonably because of the possibility the subjects running economy improved over experimental trials.

Effects of Ad libitum Low-Carbohydrate High-Fat Dieting in Middle-Age Male Runners

PURPOSE

This study examined the effects of a 3-wk ad libitum, low-carbohydrate (<50 g·d) high-fat (~70% of calories) (LCHF) diet on markers of endurance performance in middle-age, recreationally competitive male runners.

METHODS

All subjects (n = 8) after their normal high-carbohydrate (HC) diet had anthropometric measures assessed and completed five 10-min running bouts at multiple individual race paces in the heat while physiological variables, metabolic variables, and perceptual responses were recorded. After 20 min of rest, participants completed a 5-km time trial on a road course. Subjects then consumed an LCHF diet for 3 wk and returned for repeat testing.

RESULTS

Body mass and seven-site skinfold thickness sum decreased by approximately 2.5 kg (P < 0.01) and 13 mm (P < 0.05) after LCHF diet. Rectal temperature was higher after the first 10 min of exercise (37.7°C ± 0.3°C vs 37.3°C ± 0.2°C) in the HC diet but did not differ at any other time with LCHF diet. Heart rate and perceptual measures did not display any consistent differences between treatments excluding thirst sensation for LCHF diet. RER and carbohydrate oxidation declined significantly, whereas fat oxidation increased after LCHF diet for every pace (P < 0.01). There was no significant difference (P = 0.25) in a 5-km time trial performance, but LCHF diet (23.45 ± 2.25 min) displayed a trend of improved performance versus HC (23.92 ± 2.57 min).

CONCLUSION

Improved body composition and fat oxidation from LCHF diet potentially negate expected performance decrement from reduced carbohydrate use late in exercise for nonelite runners. An acute decrease in training capacity is expected; however, if performance improvement is not exhibited after 3 wk, diet cessation is suggested for negative responders.

Metabolic adaptations to endurance training and nutrition strategies influencing performance

Endurance performance is the result of optimal training targeting cardiovascular, metabolic, and peripheral muscular adaptations and is coupled to effective nutrition strategies via the use of macronutrient manipulations surrounding training and potential supplementation with ergogenic aids. It is important to note that training and nutrition may differ according to the individual needs of the athlete and can markedly impact the physiological response to training. Herein, we discuss various aspects of endurance training adaptations, nutritional strategies and their contributions to towards performance.

Macronutrient Intakes of Male Rugby Union Players: A Review

Rugby is a worldwide intermittent team sport. Players tend to be heavier than the majority of similar team sport athletes on whom the dietary guidelines have been developed. Therefore, the aim of the current review was to describe the intakes of rugby union players. Article databases were searched up to February 2017 and were included if they were published in English and reported dietary intakes of male rugby union players. Of the research articles identified, energy intakes were lower than two of three studies that reported intakes and expenditure, which would suggest the players were losing weight that is somewhat supported by the decreases in skinfolds seen during preseason. However, it should also be noted that there are errors in both the measurement of energy intakes and expenditure. Carbohydrate intakes ranged from 2.6 to 6.5 g·kg^-1·day^-1, which is lower than the current relative to body mass recommendations; however, this would not be classed as a low-carbohydrate diet. The consistently low intakes of carbohydrate suggest that these intake levels maybe sufficient for performance, given the players greater body mass or there are errors in the measurements. However, there is currently no evidence for the carbohydrate needs of rugby union players in terms of performance. The lower intakes than expenditure would suggest the players were losing weight. Previous research shows that rugby union players lose body fat during preseason training.

Dietary Manipulations Concurrent to Endurance Training

The role of an athlete's dietary intake (both timing and food type) goes beyond simply providing fuel to support the body's vital processes. Nutritional choices also have an impact on the metabolic adaptations to training. Over the past 20 years, research has suggested that strategically reducing carbohydrate (CHO) availability during an athlete's training can modify the metabolic responses in lieu of simply maintaining a high CHO diet. Several methods have been explored to manipulate CHO availability and include: Low-carb, high-fat (LCHF) diets, performing two-a-day training without glycogen restoration between sessions, and a "sleep-low" approach entailing a glycogen-depleting session in the evening without consuming CHO until after a morning training session performed in an overnight fasted state. Each of these methods can confer beneficial metabolic adaptations for the endurance athlete including increases in mitochondrial enzyme activity, mitochondrial content, and rates of fat oxidation, yet data showing a direct performance benefit is still unclear.

Ketone Bodies and Exercise Performance: The Next Magic Bullet or Merely Hype?

Elite athletes and coaches are in a constant search for training methods and nutritional strategies to support training and recovery efforts that may ultimately maximize athletes’ performance. Recently, there has been a re-emerging interest in the role of ketone bodies in exercise metabolism, with considerable media speculation about ketone body supplements being routinely used by professional cyclists. Ketone bodies can serve as an important energy substrate under certain conditions, such as starvation, and can modulate carbohydrate and lipid metabolism. Dietary strategies to increase endogenous ketone body availability (i.e., a ketogenic diet) require a diet high in lipids and low in carbohydrates for ~4 days to induce nutritional ketosis. However, a high fat, low carbohydrate ketogenic diet may impair exercise performance via reducing the capacity to utilize carbohydrate, which forms a key fuel source for skeletal muscle during intense endurance-type exercise. Recently, ketone body supplements (ketone salts and esters) have emerged and may be used to rapidly increase ketone body availability, without the need to first adapt to a ketogenic diet. However, the extent to which ketone bodies regulate skeletal muscle bioenergetics and substrate metabolism during prolonged endurance-type exercise of varying intensity and duration remains unknown. Therefore, at present there are no data available to suggest that ingestion of ketone bodies during exercise improves athletes’ performance under conditions where evidence-based nutritional strategies are applied appropriately.

An 8-Week Ketogenic Low Carbohydrate, High Fat Diet Enhanced Exhaustive Exercise Capacity in Mice

Current fueling tactics for endurance exercise encourage athletes to ingest a high carbohydrate diet. However, athletes are not generally encouraged to use fat, the largest energy reserve in the human body. A low carbohydrate, high fat ketogenic diet (KD) is a nutritional approach ensuring that the body utilizes lipids. Although KD has been associated with weight-loss, enhanced fat utilization in muscle and other beneficial effects, there is currently no clear proof whether it could lead to performance advantage. To evaluate the effects of KD on endurance exercise capacity, we studied the performance of mice subjected to a running model after consuming KD for eight weeks. Weight dropped dramatically in KD-feeding mice, even though they ate more calories. KD-feeding mice showed enhanced running time without aggravated muscle injury. Blood biochemistry and correlation analysis indicated the potential mechanism is likely to be a keto-adaptation enhanced capacity to transport and metabolize fat. KD also showed a potential preventive effect on organ injury caused by acute exercise, although KD failed to exert protection from muscle injury. Ultimately, KD may contribute to prolonged exercise capacity.

Keto-adaptation enhances exercise performance and body composition responses to training in endurance athletes

BACKGROUND

Low-carbohydrate diets have recently grown in popularity among endurance athletes, yet little is known about the long-term (>4wk) performance implications of consuming a low-carbohydrate high fat ketogenic diet (LCKD) in well-trained athletes.

METHODS

Twenty male endurance-trained athletes (age 33±11y, body mass 80±11kg; BMI 24.7±3.1kg/m²) who habitually consumed a carbohydrate-based diet, self-selected into a high-carbohydrate (HC) group (n=11, %carbohydrate:protein:fat=65:14:20), or a LCKD group (n=9, 6:17:77). Both groups performed the same training intervention (endurance, strength and high intensity interval training (HIIT)). Prior to and following successful completion of 12-weeks of diet and training, participants had their body composition assessed, and completed a 100km time trial (TT), six second (SS) sprint, and a critical power test (CPT). During post-intervention testing the HC group consumed 30-60g/h carbohydrate, whereas the LCKD group consumed water, and electrolytes.

RESULTS

The LCKD group experienced a significantly greater decrease in body mass (HC -0.8kg, LCKD -5.9kg; P=0.006, effect size (ES): 0.338) and percentage body fat percentage (HC -0.7%, LCKD -5.2%; P=0.008, ES: 0.346). Fasting serum beta-hydroxybutyrate (βHB) significantly increased from 0.1 at baseline to 0.5mmol/L in the LCKD group (P=0.011, ES: 0.403) in week 12. There was no significant change in performance of the 100km TT between groups (HC -1.13min·s, LCKD -4.07min·s, P=0.057, ES: 0.196). SS sprint peak power increased by 0.8 watts per kilogram bodyweight (w/kg) in the LCKD group, versus a -0.1w/kg reduction in the HC group (P=0.025, ES: 0.263). CPT peak power decreased by -0.7w/kg in the HC group, and increased by 1.4w/kg in the LCKD group (P=0.047, ES: 0.212). Fat oxidation in the LCKD group was significantly greater throughout the 100km TT.

CONCLUSIONS

Compared to a HC comparison group, a 12-week period of keto-adaptation and exercise training, enhanced body composition, fat oxidation during exercise, and specific measures of performance relevant to competitive endurance athletes.

Nutritional Ketosis and Mitohormesis: Potential Implications for Mitochondrial Function and Human Health

Impaired mitochondrial function often results in excessive production of reactive oxygen species (ROS) and is involved in the etiology of many chronic diseases, including cardiovascular disease, diabetes, neurodegenerative disorders, and cancer. Moderate levels of mitochondrial ROS, however, can protect against chronic disease by inducing upregulation of mitochondrial capacity and endogenous antioxidant defense. This phenomenon, referred to as mitohormesis, is induced through increased reliance on mitochondrial respiration, which can occur through diet or exercise. Nutritional ketosis is a safe and physiological metabolic state induced through a ketogenic diet low in carbohydrate and moderate in protein. Such a diet increases reliance on mitochondrial respiration and may, therefore, induce mitohormesis. Furthermore, the ketone β-hydroxybutyrate (BHB), which is elevated during nutritional ketosis to levels no greater than those resulting from fasting, acts as a signaling molecule in addition to its traditionally known role as an energy substrate. BHB signaling induces adaptations similar to mitohormesis, thereby expanding the potential benefit of nutritional ketosis beyond carbohydrate restriction. This review describes the evidence supporting enhancement of mitochondrial function and endogenous antioxidant defense in response to nutritional ketosis, as well as the potential mechanisms leading to these adaptations.

A shift toward a high-fat diet in the current metabolic paradigm: A new perspective

OBJECTIVE

Investigations into the relationship between dietary carbohydrate restriction and health are mixed. Current guidelines for nutrition promote low-fat foods and higher carbohydrate consumption for optimal health and weight loss. However, high-fat, low-carbohydrate diets are revealing both intra- and extracellular adaptations that have been shown to elicit favorable cardiometabolic changes associated with obesity. Moreover, dietary fat is associated with higher satiety levels from the hormones adiponectin, leptin, and cholecystokinin. Additionally, insulin responses from high-glycemic carbohydrates are known to alter these pathways, potentially leading to an increase in energy consumption and a possible mechanism for obesity.

CONCLUSION

There is convincing evidence of beneficial effects of controlled trials implementing high-fat, low-carbohydrate diets in both sedentary and obese individuals, but longer duration clinical trials are required to confirm this hypothesis.

Dietary intake is independently associated with the maximal capacity for fat oxidation during exercise

Background: Substantial interindividual variability exists in the maximal rate of fat oxidation (MFO) during exercise with potential implications for metabolic health. Although the diet can affect the metabolic response to exercise, the contribution of a self-selected diet to the interindividual variability in the MFO requires further clarification.Objective: We sought to identify whether recent, self-selected dietary intake independently predicts the MFO in healthy men and women.Design: The MFO and maximal oxygen uptake ([Formula: see text]O₂ max) were determined with the use of indirect calorimetry in 305 healthy volunteers [150 men and 155 women; mean ± SD age: 25 ± 6 y; body mass index (BMI; in kg/m²): 23 ± 2]. Dual-energy X-ray absorptiometry was used to assess body composition with the self-reported physical activity level (SRPAL) and dietary intake determined in the 4 d before exercise testing. To minimize potential confounding with typically observed sex-related differences (e.g., body composition), predictor variables were mean-centered by sex. In the analyses, hierarchical multiple linear regressions were used to quantify each variable's influence on the MFO.Results: The mean absolute MFO was 0.55 ± 0.19 g/min (range: 0.19-1.13 g/min). A total of 44.4% of the interindividual variability in the MFO was explained by the [Formula: see text]O₂ max, sex, and SRPAL with dietary carbohydrate (carbohydrate; negative association with the MFO) and fat intake (positive association) associated with an additional 3.2% of the variance. When expressed relative to fat-free mass (FFM), the MFO was 10.8 ± 3.2 mg · kg FFM^-1 · min^-1 (range: 3.5-20.7 mg · kg FFM^-1 · min^-1) with 16.6% of the variability explained by the [Formula: see text]O₂ max, sex, and SRPAL; dietary carbohydrate and fat intakes together explained an additional 2.6% of the variability. Biological sex was an independent determinant of the MFO with women showing a higher MFO [men: 10.3 ± 3.1 mg · kg FFM^-1 · min^-1 (3.5-19.9 mg · kg FFM^-1 · min^-1); women: 11.2 ± 3.3 mg · kg FFM^-1 · min^-1 (4.6-20.7 mg · kg FFM^-1 · min^-1); P < 0.05].Conclusion: Considered alongside other robust determinants, dietary carbohydrate and fat intake make modest but independent contributions to the interindividual variability in the capacity to oxidize fat during exercise. This trial was registered at clinicaltrials.gov as NCT02070055.

Low-Carbohydrate-High-Fat Diet: Can it Help Exercise Performance?

Low-carbohydrate-high-fat (LCHF) diets have been used as a means of weight loss and control of symptoms in several clinical conditions. There is emerging evidence that the metabolic changes induced by LCHF diets enhance endurance performance. The aims of this review are to examine the evidence of LCHF diets in improving various aspects of athletic performance. Long-term LCHF dietary intake may help control body weight and fat mass while maintaining lean body mass in athletes in weight-sensitive sports. LCHF-adapted endurance athletes can reach the maximal fat oxidation rate of approximately 1.5 g/min, with a lower carbohydrate oxidation rate and similar muscle glycogen content and a resynthesis rate compared to their counterparts consuming high-carbohydrate-low-fat (HCLF) diets. The elevated fat oxidation rate and glycogen sparing effect may improve performance in ultra-endurance events. These metabolic changes may also prevent the decline in performance in later stages of repeated high-intensity movements, in which the aerobic metabolism becomes more important. However, elevated blood concentrations of non-esterified fatty acids and ammonia during exercise after LCHF diets may lead to early development of central fatigue. It appears that at least several months of adaptation to a LCHF diet are required for the metabolic changes and restoration of muscle glycogen to occur. Further investigations on LCHF diets are needed regarding (1) performance after weight loss in weight-categorized sports; (2) repeated high-intensity exercise performance; (3) development of central fatigue during endurance events; (4) perceptual-motor performance during prolonged intermittent sports; and (5) ideal dietary fatty acid compositions.

Low carbohydrate, high fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers

KEY POINTS

Three weeks of intensified training and mild energy deficit in elite race walkers increases peak aerobic capacity independent of dietary support. Adaptation to a ketogenic low carbohydrate, high fat (LCHF) diet markedly increases rates of whole-body fat oxidation during exercise in race walkers over a range of exercise intensities. The increased rates of fat oxidation result in reduced economy (increased oxygen demand for a given speed) at velocities that translate to real-life race performance in elite race walkers. In contrast to training with diets providing chronic or periodised high carbohydrate availability, adaptation to an LCHF diet impairs performance in elite endurance athletes despite a significant improvement in peak aerobic capacity.

ABSTRACT

We investigated the effects of adaptation to a ketogenic low carbohydrate (CHO), high fat diet (LCHF) during 3 weeks of intensified training on metabolism and performance of world-class endurance athletes. We controlled three isoenergetic diets in elite race walkers: high CHO availability (g kg^-1  day^-1 : 8.6 CHO, 2.1 protein, 1.2 fat) consumed before, during and after training (HCHO, n = 9); identical macronutrient intake, periodised within or between days to alternate between low and high CHO availability (PCHO, n = 10); LCHF (< 50 g day^-1 CHO; 78% energy as fat; 2.1 g kg^-1  day^-1 protein; LCHF, n = 10). Post-intervention, V̇O2 peak during race walking increased in all groups (P < 0.001, 90% CI: 2.55, 5.20%). LCHF was associated with markedly increased rates of whole-body fat oxidation, attaining peak rates of 1.57 ± 0.32 g min^-1 during 2 h of walking at ∼80% V̇O2 peak . However, LCHF also increased the oxygen (O₂ ) cost of race walking at velocities relevant to real-life race performance: O₂ uptake (expressed as a percentage of new V̇O2 peak ) at a speed approximating 20 km race pace was reduced in HCHO and PCHO (90% CI: -7.047, -2.55 and -5.18, -0.86, respectively), but was maintained at pre-intervention levels in LCHF. HCHO and PCHO groups improved times for 10 km race walk: 6.6% (90% CI: 4.1, 9.1%) and 5.3% (3.4, 7.2%), with no improvement (-1.6% (-8.5, 5.3%)) for the LCHF group. In contrast to training with diets providing chronic or periodised high-CHO availability, and despite a significant improvement in V̇O2 peak , adaptation to the topical LCHF diet negated performance benefits in elite endurance athletes, in part due to reduced exercise economy.

Carbohydrate intake and resistance-based exercise: are current recommendations reflective of actual need?

Substantial research has been completed examining the impact of carbohydrate (CHO) intake on endurance exercise, whereas its role in resistance-based exercise performance, adaptation and cell signalling has yet to be fully characterised. This empirical shortcoming has precluded the ability to establish specific CHO recommendations for resistance exercise. This results in recommendations largely stemming from findings based on endurance exercise and/or anecdotal evidence despite the distinct energetic demands and molecular responses mediating adaptation from endurance- and resistance-based exercise. Moreover, the topic of CHO and exercise has become one of polarising nature with divergent views - some substantiated, others lacking evidence. Current literature suggests a moderately high daily CHO intake (3-7 g/kg per d) for resistance training, which is thought to prevent glycogen depletion and facilitate performance and adaptation. However, contemporary investigation, along with an emerging understanding of the molecular underpinnings of resistance exercise adaptation, may suggest that such an intake may not be necessary. In addition to the low likelihood of true glycogen depletion occurring in response to resistance exercise, a diet restrictive in CHO may not be detrimental to acute resistance exercise performance or the cellular signalling activity responsible for adaptation, even when muscle glycogen stores are reduced. Current evidence suggests that signalling of the mammalian target of rapamycin complex 1, the key regulatory kinase for gene translation (protein synthesis), is unaffected by CHO restriction or low muscular glycogen concentrations. Such findings may call into question the current view and subsequent recommendations of CHO intake with regard to resistance-based exercise.