The Ketogenic Diet for

Bodybuilders and
Physique Athletes
Adam Tzur, BA1 and Brandon M. Roberts, PhD, CSCS2
1
Sci-Fit.net, Kristiansand, Norway; and 2The Strength Guys Inc., Birmingham, Alabama

ABSTRACT When preparing for competition, macronutrient needing to be manipu-

bodybuilders and physique athletes lated to achieve nutritional ketosis
In the past decades, the ketogenic diet
aim to improve body composition by (66). Hence, a KD can be high, mod-
Downloaded from http://journals.lww.com/nsca-scj by BhDMf5ePHKbH4TTImqenVNPUfnk57qBdHxCDYPyMa63vjAv5ecGdkqkNc1YvlmCx on 10/05/2020

has received scientific interest as

reducing fat mass, and maintaining or erate, or low in protein and fat as long
a diet which may be beneficial for
increasing muscle mass (36,37,70,82). as carbohydrate intake is restricted to
athletes. We summarize the ketogenic ,50 g per day (1,66,80). Some con-
To achieve this goal, competitors typ-
literature and give competitive body- cerns have emerged as to whether
ically go through various phases
builders and physique athletes advice a high-protein intake will prevent keto-
throughout the year, with the “off-sea-
on whether the diet and ketone sup- sis; however, the literature is replete
son” serving to increase muscle mass
plements are suitable for off-season with studies where participants con-
through a caloric surplus. This hyper-
and in-season use. The diet is effective sumed a high-protein diet and were
caloric phase typically leads to gains of
for fat loss and has a strong hunger- both muscle mass and fat mass (37,39). in ketosis (12,13,41,42,56,61,86,92).
reducing effect. Current evidence Subsequently, athletes must reduce fat Hence, the diet fits bodybuilders and
suggests it is suboptimal for bulking mass through a caloric deficit before physique athletes who require high
and gaining lean mass. Upon starting the physique contest. This practice is protein intakes to preserve muscle
the diet, negative side effects should mass during contest preparation (36).
known as “in-season,” “contest prepa-
be expected and prevented by ration,” or “competition preparation” As discussed in this article, the KD has
increasing intake of electrolytes, fiber, (14,36,37,39,70). several potential strengths and weak-
and water. Exogenous ketones are nesses as a tool for weight loss and
One recent method that has gained
currently not recommended. performance. For example, the diet re-
traction is the KD. It has historically
duces ad libitum food intake, which
been used to treat epilepsy, and tradi-
can be considered both a strength
tionally consists of a low-carbohydrate
and a weakness depending on the
(,50 g), high-fat, and low-protein
INTRODUCTION AND goals of the competitor. However, it
BACKGROUND intake (1,18,54,66,91). After an initial suffers from poor adherence in both
hysique competitions and body- adaptation period, the low level of die- diseased and healthy populations

P building shows are increasing in

popularity in the United States.
In these shows, athletes pose for judges
tary carbohydrate intake causes tissues
to use fat and ketones as a primary fuel
source (54,74). The diet achieves keto-
(45,54,95). Physique athletes may be
an exception to poor adherence
because they often go to more extreme
who present scores based on muscu- sis when dietary fat is oxidized in the measures to adhere to diets. Other det-
larity, level of body fat, symmetry, liver to create 3 main types of ketones: riments of the KD include reduced
beauty, posing skills, as well as other acetone, B-hydroxybutyrate (BHB) muscle glycogen content, which raises
factors (15,36,37,70). Competitors use and acetoacetate (2,66). As blood glu- the question of whether athletic perfor-
a multitude of diets to achieve their cose and insulin levels drop, blood mance, strength, and hypertrophy
goals, and in recent times, the keto- ketone levels increase, and at 0.5
genic diet (KD) has emerged as mmol/L BHB, it is said that nutritional
a potential diet for both the off- ketosis is achieved (30,33,34). KEY WORDS:
season and in-season. bodybuilding; physique competition; resis-
In terms of macronutrient composi-
tance training; nutrition; ketogenic diet; low
Address correspondence to Adam Tzur, tion, evidence from the past decades
carbohydrate
[email protected]. suggests that carbohydrate is the only

108 VOLUME 42 | NUMBER 5 | OCTOBER 2020 Copyright Ó National Strength and Conditioning Association

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 could be hampered in the long term. In particular, there is no clear evidence study found that gymnasts who were
However, there is very little research that carbohydrate restriction is detri- on a KD lost fat and maintained lean
on KD in populations that resemble mental (15,20). In fact, “no further ben- mass without any negative changes in
physique athletes. eficial actions of carbohydrates are strength and power performance. How-
Exogenous ketones are a novel supple- evident concerning muscle hypertro- ever, protein intake was not matched in
ment that has the potential to mimic phy when a protein supplement that the study with the KD consuming 2.43
some effects of the KD without chang- maximally stimulates muscle protein the amount of protein consumed in the
ing dietary intake. This is thought to synthesis is ingested” (20), and carbo- western diet period (200 versus 83 g,
occur through elevations in blood ke- hydrates do not seem to augment mus- respectively), which is a major limitation.
tones, also termed exogenous ketosis cle protein synthesis when dietary Similarly, a recent article investigating the
(79). There are 2 main types of ke- protein is adequate (22,43,47). Looking effects of KD on body composition and
tones—esters and salts—with ketone es- beyond the acute muscle protein syn- performance, in weightlifting athletes
ters seeming to be more beneficial, thesis response, carbohydrates may with similar protein intake, found
given the studies on performance and have beneficial effects on strength a decrease in lean body mass without
side effects. The concept behind exog- performance, depending on the dura- negative effects on performance (28).
enous ketones is that they could offer tion and intensity of exercise (15,20). Finally, a study in CrossFit athletes found
recovery benefits in combination with The degree of carbohydrate availabil- that performance improved with a con-
or independent of dietary changes (79). ity could be key, where ketogenic car- comitant decrease in body fat and main-
Some also theorize that the supple- bohydrate restriction could be more tenance of lean body mass on a 6-week
ments could ease the side effects expe- detrimental than a less drastic restric- KD (29). Taken together, these data indi-
rienced upon starting the KD (34). tion. A diet sufficient in carbohy- cate there may not be a performance dec-
drates could hypothetically allow rement directly caused by a KD, but there
The KD has been well studied in
for greater long-term gains in muscle could be changes in lean body mass.
endurance and obesity research, but
mass by allowing greater training vol-
there is currently limited research To date, 2 studies have found an
umes (15). However, low-
available in bodybuilders or physique increase in lean body mass using the
carbohydrate studies have shown
athletes. Thus, we will review the KD (87,92) with only one of those
similar training adaptations (20).
potential usage of a KD in this popu- using a resistance training intervention
lation using studies from other types of A significant portion of this discussion (92). Wilson et al. (92) found that a 10-
athletes and the general population. relates to the importance of muscle week resistance training program, in
glycogen. During the first 6+ weeks combination with KD or a western
of the KD, intramuscular glycogen diet, increased lean body mass and
HYPERTROPHY AND stores are reduced by around 40–50% decreased fat mass by 4.4 and 2.4%,
PERFORMANCE (9,32,49,64,65). Such a reduction could respectively. Strength and power
A primary goal of bodybuilders and hypothetically reduce training capacity increased to the same extent in both
physique athletes is to optimize muscle and performance, given that resistance conditions (92). However, this study
hypertrophy. A secondary goal is com- training primarily involves the has notable technical limitations
monly to maintain or increase strength phosphagen (ATP-CP) and glycolytic including a glycogen supercompensa-
performance. As such, it is of interest systems (27,46,81). In addition, the tion protocol and data-reporting issues;
whether the KD is superior, inferior, or duration, intensity, and volume of for a more thorough analysis, see (96).
comparable to other diets for increas- training are major contributors to mus- Other studies have found the preserva-
ing muscle mass and strength. Because cle glycogen utilization (46). This tion of muscle mass with no significant
there are currently no studies on body- reduction in glycogen could translate increases (29,40,44,63,84). For exam-
builders or physique athletes on a KD, to a reduced training session volume, ple, Vargas et al. (84) evaluated the effi-
we must make inferences from similar which may reduce the amount of cacy of a KD in trained men using
populations. hypertrophy accrued in the off-season a randomized, controlled, parallel
Dietary guidelines for strength and or lean mass retained during the com- study for 8 weeks among 3 groups:
power athletes emphasize a high- petition season (15). control, ketogenic, and nonketogenic.
carbohydrate intake (75). Recommen- One group of athletes that are muscular All groups consumed a high-protein
dations for physique athletes in the off- and lean are gymnasts, therefore any diet (;2/g/kg/d). The goal of the
season and competition prep are 3–8 changes in this population might reflect study was to induce an energy surplus
g/kg (39,69). However, there is cur- those we could expect in bodybuilders. A to increase lean body mass; yet, of the 3
rently a debate about optimal carbohy- study on elite gymnasts for 2 ;4-week groups, only the non-KD group gained
drate intake for hypertrophy and periods found no differences in chin-ups body weight and lean body mass,
strength development. The discussion or dips when comparing a ketogenic ver- whereas the KD group lost fat mass.
highlights that the data are conflicting. sus western diet (63). Ultimately, the A similar finding was reported by

109
Strength and Conditioning Journal | www.nsca-scj.com

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 The Ketogenic Diet

McSwiney where endurance athletes used in athletic populations for weight athletes to consume a caloric surplus.
reported increased caloric intake, yet loss. In this article, we decided to focus To the best of our knowledge, 2 studies
lost ;6 kg body weight (56). These on fat loss rather than weight loss as have prescribed a hypercaloric KD
findings could be due to the increased the outcome of interest. Using body (56,84). Participants lost weight in both
satiety and the reduced appetite effect weight as a metric should be done studies, indicating that they did not
of a KD. Thus, the KD may not be with care because weight consists of adhere to the hypercaloric assignment.
a good strategy for physique athletes both fat mass and fat-free mass. Body- This is likely attributable to the hunger-
in the off-season who are attempting builders and physique athletes are pri- reducing effects and spontaneous caloric
to gain muscle mass (15). It should marily focused on reducing fat mass, reduction in free-living, ad libitum
be noted that lean body mass is a poor not fat-free mass. Furthermore, the conditions.
proxy for muscle mass and is con- KD initially leads to a rapid reduction In summary, the KD leads to compa-
founded by shifts in total body water. in glycogen and water weight due to rable fat losses when both groups in
Hence, the evidence around hypertro- the diet’s dehydrating effects a study eat the same number of calo-
phy in the context of ketogenic dieting (19,26,62). If body weight is equated ries. People on the KD typically lose
is limited. with fat mass, athletes may inaccu- body weight quicker, but this is due
Another concern for physique athletes rately perceive rapid weight loss to to glycogen reduction and water loss.
is the “flat” appearance resulting from be fat loss. With that in mind, we The diet has hunger-reducing effects,
low glycogen levels. The flat appear- restrict our discussion to fat mass. which lead participants to eat fewer
ance is due to low muscle glycogen A large body of literature suggests the calories. Thus, the diet is not suitable
levels, which could cause muscles to diet effectively induces fat loss in both for athletes aiming for a caloric surplus
appear smaller than if one were not untrained (10–12,40,41,42,57,61,71,76,85) during off-season bulking.
on a KD. Because physique athletes and trained populations (29,63,68,
have high incidences of body dysmor- 87,92,93). The studies reveal that the
phia this could lead to negative psy- KETO FLU AND SUBJECTIVE SIDE
KD promotes equal or superior fat EFFECTS
chological effects (37). One way to mass loss compared to control diets.
offset ketogenic glycogen losses is to During the first weeks and months of
However, most of the studies are con- the KD, a myriad of physiological and
use carbohydrate refeeds, yet that founded by unmatched protein and
comes at a risk because athletes will metabolic effects take place. Some of
caloric intakes between groups. The these include a decrease in liver glyco-
no longer be in ketosis and may need KD groups typically consume fewer
to readapt. Some observational evi- gen stores to maintain physiological
calories and more protein. These limi- blood glucose levels (8). Reduced insu-
dence suggests that long-term adapted tations prevent any certain conclusions
ketogenic athletes have normal glyco- lin levels lead to increased natriuresis,
on whether the diet has superior fat kaliuresis, and diuresis (33). Combined,
gen stores and utilization (86). This in- loss properties. Yet, some unique ad-
dicates that glycogen compensation these effects lead to a loss of total body
vantages do present themselves for water and electrolytes (19,26,62). Elec-
occurs given a sufficiently long period
the diet. trolyte imbalance may follow. Further-
of adaptation.
In particular, the diet leads to spontane- more, ketogenic participants have been
In summary, the KD has never been shown to consume less dietary fiber
ous hunger reduction. Most studies pre-
rigorously studied in a group of phy- compared to baseline in several studies
scribe no caloric limit to ketogenic
sique athletes for long periods to deter- (4–6,58).
participants, and so they are only asked
mine whether there would be any
to restrict carbohydrates. Even if no calo- As a consequence, numerous negative
differences in strength or hypertrophy
ric limit is set, participants reduce caloric subjective side effects occur. The most
outcomes. Given the results in similar
intake on their own initiative (3,25). Fur- commonly reported side effects that
athletes and resistance-trained partici-
thermore, participants report that their are relevant for physique athletes
pants, the diet seems suitable for main-
hunger is reduced in multiple ketogenic include: headaches, constipation, diar-
taining muscle mass and strength. Yet,
studies (24,25,41,42,48,51,53,55,60,72,76). rhea, nausea, pain, and fatigue
given the issues for athletes to increase
The combination of lowered hunger (6,48,58,59,73,89,90,94). A less com-
caloric intake and body weight, the
and spontaneous caloric restriction may monly reported effect is feeling weak
KD seems unsuitable for off-season
be a useful tool for competitors who are (asthenia) (59).
bulking.
aiming at reducing their caloric intake. These side effects are collectively and
FAT LOSS AND HUNGER Although hunger reduction is considered colloquially referred to as “keto flu”
The KD has been used as a therapeutic a benefit in most situations, there are sce- (31,34,54). Keto flu is a normal part
tool in obesity and diabetes research narios where it is counterproductive. In of ketogenic adaptation, yet the dura-
for decades. More recently, it has been particular, off-season bulking requires tion of this adaptation is unclear. Some

110 VOLUME 42 | NUMBER 5 | OCTOBER 2020

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 side effects resolve in mere days or of (R)-3-hydroxybutyl (R)-3- glucose ingestion, which could be
weeks, whereas others are reported to hydroxybutyrate, and a ketone diester, due to changes in ghrelin (78). How-
last for months or even years. consisting of R,S-1,3-butanediol ace- ever, in healthy males completing
It behooves physique athletes to con- toacetate diester. Both types of ketones a training program with overreaching
sider the physical and psychological are capable of producing increases in symptoms, a KME supplement did not
impact the KD may have on them circulating BHB (16,17,52). The
change hunger or ghrelin, although
and their training during the contest increase generally occurs within 30–
there was an increase in food intake
preparation period. Feeling fatigued 60 minutes of consuming the ketone
supplement and can stay elevated for (67). These 2 studies provide some
and weak may limit training volume insight, but it is currently unclear as
and intensity. Constipation, diarrhea, 2–3 hours (16). Some studies give
exogenous ketones multiple times, to whether ketones can help physique
and nausea may limit diet adherence.
which can increase the amount of time athletes.
Headache and pain may be an addi-
tional obstacle to overcome during ketones are elevated (50,79). Taken Exercise recovery is another area where
mentally strenuous competition together, it is clear that exogenous ketones have been studied. If they could
phases. However, it is not given that ketones increase the concentration of improve recovery between bouts of
individuals will experience all reported ketones in the blood (16).
training, then physique athletes could
side effects. Between-study and indi- The majority of the literature on perform better, either through an
vidual variance in side effects is ketone supplements has studied their increase in training frequency or inten-
substantial. interaction with endurance-type train- sity. Three studies have investigated
The literature reports several ways to ing, which is not very applicable to
this area, although none of them used
prevent keto flu during the induction physique athletes (17,38,67,83). Fur-
resistance training (17,38,83). Ulti-
phase of the diet, which includes elec- thermore, evidence is mixed with the
majority of studies showing no in- mately, the evidence is mixed with the
trolyte supplementation to counteract ability to help glycogen synthesis with
electrolyte imbalance (7,23,58,88,94), creases in performance (52). One study
found that a ketone ester intake could ketone consumption (with carbohy-
adequate fluid intake to prevent the drates). Physique athletes are unlikely
effects of the diet-induced diuresis prevent the development of overreach-
ing during endurance exercise (67). to train twice a day or at such a high
(23,88,94), and fiber supplements to volume (like cyclists) that glycogen re-
help with constipation (58,77). However, the two groups were not
matched for energy intake, which is synthesis is a major limiting factor given
In summary, physique athletes should a major confounder. proper nutrition.
be aware of the consequences of keto A major concern with any supplement
induction. Steps should be taken to Because the KD can decrease appetite
and hunger, potentially driven through is side effects. Ketone supplements are
prevent these side effects, and athletes no exception in this case. They have
should be cautious of initiating the diet increased circulating ketones, it is pos-
sible that exogenous ketones could act been reported as tasting pungent and
during late stages of contest prep. bitter (21,38,50,79). This can be a poten-
in the same manner. Although there
have been no studies in physique ath- tial deterrent from consumption, but
EXOGENOUS KETONES letes taking these supplements, there taste has the potential to change in
Exogenous ketones are a novel supple- are data suggesting it could help with the future.
ment that can be used by the body. hunger, which would be of benefit dur- The evidence for physique athletes to
There are a number of different types ing competition preparation or for ath- include ketone supplementation for in-
of ketone supplements in the literature letes trying to lose weight. Indeed, creases in performance, recovery, or to
including ketone esters and ketone consumption of a ketone ester can reduce appetite is very weak. Until fur-
salts (35). Ketone esters are further reduce appetite for 4 hours (78). Stubbs ther research is completed, it is
divided with two different types. A et al. found that acute KME ingestion unlikely they would benefit a physique
ketone monoester (KME), consisting suppressed appetite compared to athlete.

Table 1
Effects upon initiation of the ketogenic diet
Period Intramuscular glycogen stores Total body water Body weight Side effects Hunger

When Decreased by 20–54% Decreased by ;1–5 kg Decreased, Increased, Decreased,

starting after 1–6 weeks after 1–8 weeks highly variable highly variable highly variable
the diet
Changes are dependent on level of calorie and carbohydrate restriction.

111
Strength and Conditioning Journal | www.nsca-scj.com

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 The Ketogenic Diet

PRACTICAL APPLICATIONS risk of dehydration and decreasing adhesion markers in individuals taking
The most relevant effects for body- muscle size. statins. Nutr Res 33: 905–912, 2013.
builders and physique athletes are  Exogenous ketones because they 5. Baron JA, Schori A, Crow B, Carter R,
summarized in Table 1. provide no clear advantage for Mann JI. A randomized controlled trial of
bodybuilders or physique athletes. low carbohydrate and low fat/high fiber
The KD is an effective fat loss tool, on diets for weight loss. Am J Public Health
Albeit, this recommendation may
par with other calorie-restricted diets. 76: 1293–1296, 1986.
change in the future as ketone for-
Participants frequently report large re- 6. Bazzano LA, Hu T, Reynolds K, et al. Effects
mulations improve.
ductions in hunger, and caloric intake of low-carbohydrate and low-fat diets: A
Coaches are advised to inform their randomized trial. Ann Intern Med 161: 309,
tends to decrease spontaneously. athletes on the potential upsides and 2014.
These benefits may aid athletes who downsides of the diet.
are struggling with hunger and adher- 7. Bhanpuri NH, Hallberg SJ, Williams PT,
A. Tzur owns and operates Sci-Fit.net. B. et al. Cardiovascular disease risk factor
ence issues. Resistance training perfor-
M. Roberts receives funding from various responses to a type 2 diabetes care model
mance does not seem to be hampered including nutritional ketosis induced by
companies for education or coaching
by KD in trained populations. sustained carbohydrate restriction at 1
services and also has an ownership stake
year: An open label, non-randomized,
Downsides of the KD include reduced in LogSmarter LLC. controlled study. Cardiovasc Diabetol 17:
intramuscular glycogen stores and intra- 56, 2018.
muscular water, which alter muscle size.
8. Bilsborough SA, Crowe TC. Low-
For bodybuilders, this perceived Adam Tzur is the
carbohydrate diets: What are the potential
decrease in muscle mass may be detri- owner of Sci- short- and long-term health implications?
mental. Furthermore, multiple negative Fit.net. Asia Pac J Clin Nutr 12: 396–404, 2003.
side effects are experienced during initi- 9. Bogardus C, LaGrange BM, Horton ES,
ation of the diet and to a greater extent Sims EA. Comparison of carbohydrate-
than other calorie-restricted diets. The containing and carbohydrate-restricted
hypocaloric diets in the treatment of
effects include headache, constipation, obesity. Endurance and metabolic fuel
and fatigue. Physique athletes should homeostasis during strenuous exercise.
take care to preemptively counteract J Clin Invest 68: 399–404, 1981.
them using electrolyte and fiber supple- 10. Brehm BJ, Seeley RJ, Daniels SR,
mentation while increasing fluid intake. Brandon M. D’Alessio DA. A randomized trial
comparing a very low carbohydrate diet
There are several circumstances where Roberts is the
and a calorie-restricted low fat diet on body
the KD is appropriate for bodybuilders Director of weight and cardiovascular risk factors in
and physique athletes: Research and healthy women. J Clin Endocrinol Metab
 During early stages of contest prep- Education for 88: 1617–1623, 2003.
aration, when the competitor has The 11. Brehm BJ, Spang SE, Lattin BL, et al. The
time to adjust and adapt to the diet. Strength Guys. role of energy expenditure in the differential
 For competitors who struggle with weight loss in obese women on low-fat and
adherence due to hunger issues. low-carbohydrate diets. J Clin Endocrinol
 If athletes experience few side effects Metab 90: 1475–1482, 2005.

and enjoy the diet. 12. Brinkworth GD, Noakes M, Clifton PM,
Buckley JD. Effects of a low carbohydrate
Circumstances where no recommen- REFERENCES weight loss diet on exercise capacity and
dation can be given due to the current 1. Adam-Perrot A, Clifton P, Brouns F. Low-
tolerance in obese subjects. Obesity 17:
state of the literature: carbohydrate diets: Nutritional and physiological
1916–1923, 2009.
aspects. Obes Rev 7: 49–58, 2006.
 During off-season bulking. The 13. Burke LM, Ross ML, Garvican-Lewis LA,
hunger-reducing effects of the diet 2. Anderson JC. Measuring breath acetone et al. Low carbohydrate, high fat diet
and the inability to increase lean for monitoring fat loss: Review. Obesity impairs exercise economy and negates the
(Silver Spring) 23: 2327–2334, 2015. performance benefit from intensified
mass are potential negatives. Yet, in-
dividuals vary, and some may not 3. Aragon AA, Schoenfeld BJ, Wildman R, training in elite race walkers. J Physiol 595:
et al. International society of sports nutrition 2785–2807, 2017.
experience these effects. Personal
position stand: Diets and body 14. Chappell AJ, Simper T, Barker ME.
experimentation is warranted.
composition. J Int Soc Sports Nutr 14: 16, Nutritional strategies of high level natural
We do not recommend: 2017. bodybuilders during competition
 Initiating the KD during late stages of 4. Ballard KD, Quann EE, Kupchak BR, et al. preparation. J Int Soc Sports Nutr 15: 4,
contest prep. This is due to the side Dietary carbohydrate restriction improves 2018.
effects as well as losses of intramus- insulin sensitivity, blood pressure, 15. Cholewa JM, Newmire DE, Zanchi NE.
cular glycogen and water increasing microvascular function, and cellular Carbohydrate restriction: Friend or foe of

112 VOLUME 42 | NUMBER 5 | OCTOBER 2020

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 resistance-based exercise performance? 28. Greene DA, Varley BJ, Hartwig TB, muscle glycogen synthesis in humans. Med
Nutrition 60: 136–146, 2019. Chapman P, Rigney M. A low-carbohydrate Sci Sports Exerc 49: 1789–1795, 2017.
16. Clarke K, Tchabanenko K, Pawlosky R, ketogenic diet reduces body mass without 39. Iraki J, Fitschen P, Espinar S, Helms E.
et al. Kinetics, safety and tolerability of (R)- compromising performance in powerlifting Nutrition recommendations for
3-hydroxybutyl (R)-3-hydroxybutyrate in and olympic weightlifting athletes. bodybuilders in the off-season: A narrative
healthy adult subjects. Regul Toxicol J Strength Cond Res 32: 3373–3382, review. Sports (Basel) 7: E154, 2019.
Pharmacol 63: 401–408, 2012. 2018.
40. Jabekk PT, Moe IA, Meen HD, Tomten SE,
17. Cox PJ, Kirk T, Ashmore T, et al. Nutritional 29. Gregory RM. A low-carbohydrate Høstmark AT. Resistance training in
ketogenic diet combined with 6-weeks of overweight women on a ketogenic diet
ketosis alters fuel preference and thereby
crossfit training improves body conserved lean body mass while reducing
endurance performance in athletes. Cell
composition and performance. Available at: body fat. Nutr Metab (Lond) 7: 17, 2010.
Metab 24: 256–268, 2016.
https://clinmedjournals.org/articles/ijsem/
18. D’Andrea Meira I, Romão TT, Pires do 41. Johnston CS, Tjonn SL, Swan PD, et al.
international-journal-of-sports-and-
Prado HJ, et al. Ketogenic diet and Ketogenic low-carbohydrate diets have no
exercise-medicine-ijsem-3-054.php?
epilepsy: What we know so far. Front metabolic advantage over nonketogenic
jid5ijsem. Accessed February 10, 2020.
Neurosci 13: 5, 2019. low-carbohydrate diets. Am J Clin Nutr 83:
30. Guerci B, Benichou M, Floriot M, et al. 1055–1061, 2006.
19. Denke MA. Metabolic effects of high- Accuracy of an electrochemical sensor for
protein, low-carbohydrate diets. Am J 42. Johnstone AM, Horgan GW, Murison SD,
measuring capillary blood ketones by Bremner DM, Lobley GE. Effects of a high-
Cardiol 88: 59–61, 2001. fingerstick samples during metabolic protein ketogenic diet on hunger, appetite,
20. Escobar KA, VanDusseldorp TA, Kerksick deterioration after continuous and weight loss in obese men feeding ad
CM. Carbohydrate intake and resistance- subcutaneous insulin infusion interruption libitum. Am J Clin Nutr 87: 44–55, 2008.
based exercise: Are current in type 1 diabetic patients. Diabetes Care
43. Kato H, Suzuki H, Inoue Y, et al. Co-
recommendations reflective of actual 26: 1137–1141, 2003.
ingestion of carbohydrate with leucine-
need? Br J Nutr 116: 2053–2065, 2016. 31. Hamdy O, Tasabehji MW, Elseaidy T, et al. enriched essential amino acids does not
21. Evans M, Patchett E, Nally R, et al. Effect of Fat versus carbohydrate-based energy- augment acute postexercise muscle
acute ingestion of b-hydroxybutyrate salts restricted diets for weight loss in patients protein synthesis in a strenuous exercise-
on the response to graded exercise in with type 2 diabetes. Curr Diab Rep 18: induced hypoinsulinemic state.
trained cyclists. Eur J Sport Sci 18: 376– 128, 2018. Springerplus 5: 1299, 2016.
386, 2018. 32. Harber MP, Schenk S, Barkan AL, 44. Kephart WC, Pledge CD, Roberson PA,
22. Figueiredo VC, Cameron-Smith D. Is Horowitz JF. Alterations in carbohydrate et al. The three-month effects of
carbohydrate needed to further stimulate metabolism in response to short-term a ketogenic diet on body composition,
muscle protein synthesis/hypertrophy dietary carbohydrate restriction. Am J blood parameters, and performance
following resistance exercise? J Int Soc Physiol Endocrinol Metab 289: E306– metrics in CrossFit trainees: A pilot study.
Sports Nutr 10: 42, 2013. E312, 2005. Sports (Basel) 6: E1, 2018.
23. Forouhi NG, Misra A, Mohan V, Taylor R, 33. Harvey CJdC, Schofield GM, Zinn C, 45. Kirkpatrick CF, Bolick JP, Kris-Etherton PM,
Yancy W. Dietary and nutritional et al. Low-carbohydrate diets differing et al. Review of current evidence and
approaches for prevention and in carbohydrate restriction improve clinical recommendations on the effects of
management of type 2 diabetes. BMJ 361: cardiometabolic and anthropometric low-carbohydrate and very-low-
k2234, 2018. markers in healthy adults: A randomised carbohydrate (including ketogenic) diets
clinical trial. PeerJ 7: e6273, 2019. for the management of body weight and
24. Foster GD, Wadden TA, Peterson FJ, et al.
other cardiometabolic risk factors: A
A controlled comparison of three very-low- 34. Harvey CJDC, Schofield GM, Williden M.
scientific statement from the national lipid
calorie diets: Effects on weight, body The use of nutritional supplements to
association nutrition and lifestyle task
composition, and symptoms. Am J Clin induce ketosis and reduce symptoms
force. J Clin Lipidol 13: 689–711.e1,
Nutr 55: 811–817, 1992. associated with keto-induction: A narrative
2019.
review. PeerJ 6: e4488, 2018.
25. Gibson AA, Seimon RV, Lee CMY, et al. Do 46. Knuiman P, Hopman MTE, Mensink M.
ketogenic diets really suppress appetite? A 35. Harvey KL, Holcomb LE, Kolwicz SC.
Glycogen availability and skeletal muscle
systematic review and meta-analysis. Obes Ketogenic diets and exercise performance.
adaptations with endurance and resistance
Rev 16: 64–76, 2015. Nutrients 11: 2296, 2019.
exercise. Nutr Metab 12: 59, 2015.
26. Gomez-Arbelaez D, Bellido D, Castro AI, 36. Helms ER, Aragon AA, Fitschen PJ.
47. Koopman R, Beelen M, Stellingwerff T,
et al. Body composition changes after very- Evidence-based recommendations for
et al. Coingestion of carbohydrate with
low-calorie ketogenic diet in obesity natural bodybuilding contest preparation:
protein does not further augment
evaluated by 3 standardized methods. Nutrition and supplementation. J Int Soc
postexercise muscle protein synthesis. Am
J Clin Endocrinol Metab 102: 488–498, Sports Nutr 11: 20, 2014.
J Physiol Endocrinol Metab 293: E833–
2017. 37. Helms ER, Prnjak K, Linardon J. Towards E842, 2007.
27. Gorostiaga EM, Navarro-Amézqueta I, a sustainable nutrition paradigm in
48. Krebs NF, Gao D, Gralla J, Collins JS,
Cusso R, et al. Anaerobic energy physique sport: A narrative review. Sports
Johnson SL. Efficacy and safety of a high
expenditure and mechanical efficiency 7: 172, 2019. protein, low carbohydrate diet for weight
during exhaustive leg press exercise. PLoS 38. Holdsworth DA, Cox PJ, Kirk T, et al. A loss in severely obese adolescents.
One 5: e13486, 2010. ketone ester drink increases postexercise J Pediatr 157: 252–258, 2010.

113
Strength and Conditioning Journal | www.nsca-scj.com

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 The Ketogenic Diet

49. Krotkiewski M, Landin K, Mellström D, Tölli consuming a low-carbohydrate/high- reactive protein, and raises serum
J. Loss of total body potassium during rapid protein vs high-carbohydrate/low-fat diet. adiponectin and high density lipoprotein-
weight loss does not depend on the J Am Diet Assoc 105: 1433–1437, 2005. cholesterol in obese subjects. Metabolism
decrease of potassium concentration in 62: 1779–89, 2013.
61. Noakes M, Foster PR, Keogh JB, et al.
muscles. Different methods to evaluate Comparison of isocaloric very low 72. Saslow LR, Kim S, Daubenmier JJ, et al. A
body composition during a low energy diet. carbohydrate/high saturated fat and high randomized pilot trial of a moderate
Int J Obes 24: 101–107, 2000. carbohydrate/low saturated fat diets on carbohydrate diet compared to a very low
50. Leckey JJ, Ross ML, Quod M, Hawley JA, body composition and cardiovascular risk. carbohydrate diet in overweight or obese
Burke LM. Ketone diester ingestion impairs Nutr Metab 3: 7, 2006. individuals with type 2 diabetes mellitus or
time-trial performance in professional prediabetes. PLoS One 9: e91027, 2014.
62. Nymo S, Coutinho SR, Torgersen LCH,
cyclists. Front Physiol 8: 806, 2017. et al. Timeline of changes in adaptive 73. Schiavo L, Pilone V, Rossetti G, et al. A 4-
51. Lobley GE, Johnstone AM, Fyfe C, et al. physiological responses, at the level of week preoperative ketogenic
Glucose uptake by the brain on chronic energy expenditure, with progressive micronutrient-enriched diet is effective in
high-protein weight-loss diets with either weight loss. Br J Nutr 120: 141–149, reducing body weight, left hepatic lobe
moderate or low amounts of carbohydrate. 2018. volume, and micronutrient deficiencies in
Br J Nutr 111: 586–597, 2014. patients undergoing bariatric surgery: A
63. Paoli A, Grimaldi K, D’Agostino D, et al.
prospective pilot study. Obes Surg 28:
52. Margolis LM, O’Fallon KS. Utility of ketone Ketogenic diet does not affect strength
2215–2224, 2018.
supplementation to enhance physical performance in elite artistic gymnasts. J Int
performance: A systematic review. Adv Soc Sports Nutr 9: 34, 2012. 74. Scott JM, Deuster PA. Ketones and human
Nutr 11: 412–419, 2020. performance. J Spec Oper Med 17: 112–
64. Phinney SD, Bistrian BR, Evans WJ,
116, 2017.
53. Martin CK, Rosenbaum D, Han H, et al. Gervino E, Blackburn GL. The human
Change in food cravings, food preferences, metabolic response to chronic ketosis 75. Slater G, Phillips SM. Nutrition guidelines
and appetite during a low-carbohydrate without caloric restriction: Preservation of for strength sports: Sprinting, weightlifting,
and low-fat diet. Obesity (Silver Spring) submaximal exercise capability with throwing events, and bodybuilding.
19: 1963–1970, 2011. reduced carbohydrate oxidation. J Sports Sci 29(Suppl 1): S67–S77,
Metabolism 32: 769–776, 1983. 2011.
54. Masood W, Uppaluri KR. Ketogenic diet.
In: StatPearls. Treasure Island, FL: 65. Phinney SD, Horton ES, Sims EAH, et al. 76. Soenen S, Bonomi AG, Lemmens SGT,
StatPearls Publishing, 2020. Available at: Capacity for moderate exercise in obese et al. Relatively high-protein or “low-carb”
http://www.ncbi.nlm.nih.gov/books/ subjects after adaptation to a hypocaloric, energy-restricted diets for body weight loss
NBK499830/. Accessed March 17, 2020. ketogenic diet. J Clin Invest 66: 1152– and body weight maintenance? Physiol
1161, 1980. Behav 107: 374–380, 2012.
55. McClernon FJ, Yancy WS, Eberstein JA,
Atkins RC, Westman EC. The effects of 66. Pinckaers PJM, Churchward-Venne TA, 77. Sondike SB, Copperman N, Jacobson MS.
a low-carbohydrate ketogenic diet and Bailey D, van Loon. LJC. Ketone bodies Effects of a low-carbohydrate diet on
a low-fat diet on mood, hunger, and other and exercise performance: The next magic weight loss and cardiovascular risk factor
self-reported symptoms. Obesity 15: 182, bullet or merely hype? Sports Med 47: in overweight adolescents. J Pediatr 142:
2007. 383–391, 2017. 253–258, 2003.

56. McSwiney FT, Wardrop B, Hyde PN, et al. 67. Poffé C, Ramaekers M, Thienen RV, 78. Stubbs BJ, Cox PJ, Evans RD, et al. A
Keto-adaptation enhances exercise Hespel P. Ketone ester supplementation ketone ester drink lowers human ghrelin
performance and body composition blunts overreaching symptoms during and appetite. Obesity (Silver Spring) 26:
responses to training in endurance endurance training overload. J Physiol 269–273, 2018.
athletes. Metabolism 81: 25–34, 2018. 597: 3009–3027, 2019. 79. Stubbs BJ, Cox PJ, Evans RD, et al. On the
57. Meckling KA, O’Sullivan C, Saari D. 68. Rhyu H, Cho S-Y. The effect of weight loss metabolism of exogenous ketones in
Comparison of a low-fat diet to a low- by ketogenic diet on the body composition, humans. Front Physiol 8: 848, 2017.
carbohydrate diet on weight loss, body performance-related physical fitness 80. Sumithran P, Proietto J. Ketogenic diets for
composition, and risk factors for diabetes factors and cytokines of Taekwondo weight loss: A review of their principles,
and cardiovascular disease in free-living, athletes. J Exerc Rehabil 10: 326–331, safety and efficacy. Obes Res Clin Pract 2:
overweight men and women. J Clin 2014. I–II, 2008.
Endocrinol Metab 89: 2717–2723, 2004. 69. Roberts BM, Helms ER, Trexler ET, 81. Tesch PA, Colliander EB, Kaiser P. Muscle
58. Miller BV, Bertino JS, Reed RG, et al. An Fitschen PJ. Nutritional recommendations metabolism during intense, heavy-
evaluation of the atkins’ diet. Metab Syndr for physique athletes. J Hum Kinet 71: 79– resistance exercise. Europ J Appl Physiol
Relat Disord 1: 299–309, 2003. 108, 2020. 55: 362–366, 1986.
59. Moreno B, Bellido D, Sajoux I, et al. 70. Robinson SL, Lambeth-Mansell A, 82. Trexler ET, Hirsch KR, Campbell BI, Smith-
Comparison of a very low-calorie-ketogenic Gillibrand G, Smith-Ryan A, Bannock L. A Ryan AE. Physiological changes following
diet with a standard low-calorie diet in the nutrition and conditioning intervention for competition in male and female physique
treatment of obesity. Endocrine 47: 793– natural bodybuilding contest preparation: athletes: A pilot study. Int J Sport Nutr
805, 2014. Case study. J Int Soc Sports Nutr 12: 20, Exerc Metab 27: 458–466, 2017.
60. Nickols-Richardson SM, Coleman MD, 2015. 83. Vandoorne T, De Smet S, Ramaekers M,
Volpe JJ, Hosig KW. Perceived hunger is 71. Ruth MR, Port AM, Shah M, et al. et al. Intake of a ketone ester drink during
lower and weight loss is greater in Consuming a hypocaloric high fat low recovery from exercise promotes
overweight premenopausal women carbohydrate diet for 12 weeks lowers C- mTORC1 signaling but not glycogen

114 VOLUME 42 | NUMBER 5 | OCTOBER 2020

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 resynthesis in human muscle. Front 88. Westman EC, Tondt J, Maguire E, Yancy males. J Strength Cond Res, 2020. [Epub
Physiol 8: 310, 2017. WS Jr. Implementing a low-carbohydrate, ahead of print.]
84. Vargas S, Romance R, Petro JL, et al. ketogenic diet to manage type 2 diabetes 93. Wood RJ, Gregory SM, Sawyer J, et al.
Efficacy of ketogenic diet on body mellitus. Expert Rev Endocrinol Metab 13: Preservation of fat-free mass after two
composition during resistance training in 263–272, 2018. distinct weight loss diets with and without
trained men: A randomized controlled trial. 89. Westman EC, Yancy WS, Edman JS, progressive resistance exercise. Metab
J Int Soc Sports Nutr 15, 2018. Tomlin KF, Perkins CE. Effect of 6-month Syndr Relat Disord 10: 167–174, 2012.
85. Volek J, Sharman M, Gómez A, et al. adherence to a very low carbohydrate diet 94. Yancy WS, Olsen MK, Guyton JR, Bakst RP,
Comparison of energy-restricted very low- program. Am J Med 113: 30–36, 2002. Westman EC. A low-carbohydrate, ketogenic
carbohydrate and low-fat diets on weight 90. Westman EC, Yancy WS, Mavropoulos JC, diet versus a low-fat diet to treat obesity and
loss and body composition in overweight Marquart M, McDuffie JR. The effect of hyperlipidemia: A randomized, controlled trial.
men and women. Nutr Metab (Lond) 1: 13, a low-carbohydrate, ketogenic diet versus Ann Intern Med 140: 769, 2004.
2004. a low-glycemic index diet on glycemic 95. Ye F, Li X-J, Jiang W-L, Sun H-B, Liu J.
86. Volek JS, Freidenreich DJ, Saenz C, et al. control in type 2 diabetes mellitus. Nutr Efficacy of and patient compliance with
Metabolic characteristics of keto-adapted Metab 5: 36, 2008. a ketogenic diet in adults with intractable
ultra-endurance runners. Metab Clin Exp 91. Wheless JW. History of the ketogenic diet. epilepsy: A meta-analysis. J Clin Neurol
65: 100–110, 2016. Epilepsia 49: 3–5, 2008. 11: 26–31, 2015.
87. Volek JS, Sharman MJ, Love DM, et al. 92. Wilson JM, Lowery RP, Roberts MD, et al. 96. Critical Analysis of Wilson et al’s. 2017
Body composition and hormonal The effects of ketogenic dieting on body Keto Study. Sci-Fit, 2017. Available at:
responses to a carbohydrate-restricted composition, strength, power, and https://sci-fit.net/wilson-keto-analysis/.
diet. Metab Clin Exp 51: 864–870, 2002. hormonal profiles in resistance training Accessed February 10, 2020.

115
Strength and Conditioning Journal | www.nsca-scj.com

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.