Ketogenic diet benefits body composition and well-being but not performance in a pilot case study of New Zealand endurance athletes

This was a pilot, 10-week intervention undertaken with five case studies. A control group was not included. The study took place at AUT, Human Potential Centre; ethics was approved by the AUT Ethics Committee (application 15/415).

Prior to the start of the intervention, participants underwent a series of tests and a full consultation for dietary instruction and planning as follows:Performance test. Participants reported to the lab in the morning in a fasted state and underwent a performance test on three occasions: i. one week prior to the intervention (familiarisation), ii. immediately prior to the intervention (baseline), and iii. Immediately post the intervention (post). To determine \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm{V}}^{.}{\mathrm{O}}_{2\mathrm{peak}} $$\end{document}V.O2peak and gas exchange thresholds (GET) an incremental cycle test was performed using an electromagnetically controlled cycle ergometer (Ergoselect 100, Ergoline, Bitz, Germany) in a temperature-controlled laboratory (21 °C, 65% rH). The test commenced at 30 W and increased by 30 W every 3 min until volitional exhaustion. Participants were instructed to maintain a cadence of 80 revolutions.min⁻¹. Oxygen uptake (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm{V}}^{.}{\mathrm{O}}_2 $$\end{document}V.O2) was measured continuously using a breath-by-breath metabolic system (Metamax 3b, Cortex, Leipzig, Germany), and heart rate was continuously measured using a short-range telemetry device (Suunto M2, Suunto, Vantaa, Finland). The \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm{V}}^{.}{\mathrm{O}}_{2\mathrm{peak}} $$\end{document}V.O2peak was defined as the highest 30s \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm{V}}^{.}{\mathrm{O}}_2 $$\end{document}V.O2 value and the GET was identified independently by two experienced investigators using the V-slope method [11].Dietary instruction. An initial consultation was conducted with each participant by the primary researcher/Registered Dietitian directly after the performance test. Participants were provided with a daily macronutrient prescription of <50 g total carbohydrate, 1.5 g.kg protein and ad libitum fat. A detailed explanation of the practical application of the ketogenic dietary principles along with appropriate tracking and monitoring procedures was provided. Participants were provided with a sample diet and were advised to add variations as long as they adhered to the carbohydrate and protein macronutrient thresholds. They were instructed to track their diet using a dietary analysis programme Easy Diet Diary® (Xyris Software (Australia) Pty Ltd). Diets were monitored weekly by the primary researcher, and participants were contacted and offered additional support if they deviated. The primary researcher maintained regular contact with all participants throughout the 10-week study duration.Exercise instruction. The participants were all seasoned athletes, and participated on a regular basis in endurance events, i.e., mountain biking, road biking, running and multisport events (which included running, cycling and kayaking), both recreationally and competitively. Hence, their training protocols did not vary much from month-to-month. They were instructed to continue with their existing training volumes for the duration of the intervention.Ketone blood testing. Each participant was shown how to measure blood ketone levels via finger prick, and provided with a FreeStyle Optium ketone meter and ketone strips. They were instructed to measure their blood ketone levels daily between 2 pm and 4 pm. Nutritional ketosis was defined as a blood ketone (beta-hydroxybutyrate) level > 0.5 mmol/l.Anthropometric testing. Body weight and skinfolds were measured by an ISAK level one accredited anthropometrist, prior to and at the conclusion of the intervention, at the same time of the day. A sum of (∑) 8-site skinfold ISAK protocol was applied: triceps, biceps, subscapular, iliac crest, supraspinale, abdominal, front thigh and medial calf [12].Interviews and focus group. A 20–30 min individual interview was conducted on the phone during week 5 week and a 60-min focus group was conducted in person once the intervention had concluded. The importance of this qualitative work was to assess both the individual and the groups’ overall experiences of being on this diet for 10 weeks. The group session provided a chance for athletes to compare experiences and translate findings to future practice.

Due to the explorative nature of this study, and our small sample size, quantitative data is presented as individual responses. Data was analysed using mean change scores, with Cohen’s effect sizes and associated confidence limits applied to quantify magnitude of change. We also elected to apply a probability statistic using a student’s t-test to determine the statistical meaning of the change. All statistics were generated and applied using Microsoft Excel 2016. We acknowledge that applying statistical models hold limited meaning in this context and it is not our intention to make any inferences about these outcomes to athlete populations. As such, outcomes with a significance level of p < 0.05 should be considered a trend only; and p < 0.01 significant only in the sense that further work is required to substantiate these findings. Interviews and the focus group were recorded and transcribed, after which data was analysed using thematic analysis. The data for the interviews and focus groups were combined and is presented as key themes with supporting transcripts.

Each curve displays the cross-over point i.e., the point at which peak fat oxidation is reached, and the point at which carbohydrate takes over as the predominant fuel source. Mean peak absolute fat oxidation and standard deviation (SD) increased by 41.3% (0.6 ± 0.1 to 0.8 ± 0.1 g.min⁻¹, p = 0.001). All of the athletes increased their peak fat oxidation. The exercise intensity relative to \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm{V}}^{.}{\mathrm{O}}_{2 \max } $$\end{document}V.O2max at which peak absolute fat oxidation occurred (Fat_max) increased by 31.2% from pre- to post-intervention (48.2 ± 8.7 to 63.2 ± 5.7%\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm{V}}^{.}{\mathrm{O}}_{2 \max } $$\end{document}V.O2max_,p = 0.06). Similarly, Fat_max relative to WR_max increased by 21.5% from pre- to post-intervention (39.5 ± 11.9 to 48.0 ± 8.9%WR_max, p = 0.18). Two out of the five athletes showed an increase in Fat_max relative to WR _max, and the remaining three showed no change.

All participants showed a decrease in time to exhaustion (TTE), the mean time and SD reduction was 2 ± 0.7 min (p = 0.004). More varied responses were noted in the change in VO2 Max (mean change −1.69 ± 3.4 ml.kg.min (p = 0.63)), peak power (mean change −18 ± 16.4 W (p = 0.07)) and ventilatory threshold, VT2 (mean change −6 ± 44.5 W (p = 0.77)), with some athletes improving (VT2 and VO2 max) or staying the same (VT2 and peak power).

The reduced body fat can likely be explained by a resultant calorie deficit created by the diet, as participants reported enhanced feelings of satiety and a reduction in overall food intake. This outcome was unsurprising and comparable to findings in previous research on both strength and endurance athletes [13–15]. Initial weight reduction can be associated with a loss in body water through glycogen depletion, [16, 17], and this was also likely the case in this study; however fat loss was evident as per skinfold changes. A further theory relating to weight loss, which is as yet, rigorously tested, is an increased drive for fat breakdown rather than storage as circulating levels of insulin remain low during ketogenic diets [18]. Perhaps a combination of all three mechanisms can explain the weight loss. A limitation of the study was a lack of energy comparison prior to, and during the study, which would have provided some clarity about these mechanisms.

All participants had a greater fatty acid oxidation at a higher given intensity at the end of the trial compared to baseline. This finding of enhanced fat utilisation aligns with those of several other groups that have incorporated ketogenic and non-ketogenic dietary protocols [5, 19, 20]. Furthermore, this substrate utilisation alteration can be attributed to the change in diet as training was kept relatively consistent throughout the intervention. Our participants also had a higher oxygen cost at sub-maximal workloads due to the higher use of fat as an energy substrate. However, this did not benefit exercise capacity.

On the whole, maximal aerobic performance was reduced, another comparable outcome to similar research [21–23], the exception being one athlete in Phinney et al.’s 4-week cycling study [5], and Zajac et al.’s eight off-road cyclists [6], who all showed performance increases. The performance decrement in our study, and others, is likely due to changes in metabolic pathways that impair glycogen metabolism at higher exercise intensities [24–26]. Specifically, a down-regulation of the carbohydrate oxidative enzyme, pyruvate dehydrogenase (PDH), which via conversion of pyruvate to acetyl-coenzyme A, links the glycolytic pathway with the Krebs cycle [27]. PDH is said to be reduced rapidly through a reduction in circulating insulin and an increase in circulating levels of free fatty acids [28]. Evidence suggests that PDH is upregulated upon carbohydrate reintroduction [25]; however, there is little insight into its fate along with other mitochondrial enzymes in the context of low carbohydrate availability. Despite similarities in findings with other studies, some of these studies are limited by short-duration low carbohydrate diets [28–30]. Future research with chronically fat-adapted athletes is needed to investigate these micro-level mechanisms alongside performance outcomes. Recently, Volek et al.’s work [19] with chronically fat-adapted ultra-endurance athletes (>6 months) not only demonstrated a 2.3 times greater fat oxidation rate in the LCHF group compared with the mainstream dietary group, but also demonstrated no difference in resting and replete muscle glycogen stores between groups. Authors suggest a homeostatic muscle glycogen repletion mechanism arising from hepatic gluconeogenesis, which might serve to provide clues into why many athletes report optimal performance, anecdotally, when having eaten in an LCHF manner for extended periods of time. While this is a plausible speculation, a similar study by Webster et al., [20] showed no difference in gluconeogenic rates during exercise in fasting LCHF and mixed-diet athletes. In fact, glucose was produced endogenously to a greater extent in the mixed diet group, and was attributed to greater rates of hepatic glycogenolysis. Researchers concluded that gluconeogenesis during exercise may remain stable across a range of dietary regimes after an overnight fast, but that hepatic glycogenolysis is influenced by dietary carbohydrate. Further exploration of fuel contributions to gluconeogenesis and the effect of different feeding protocols on endogenous glucose producing mechanisms is warranted. It is important to note that both of these studies did not incorporate a performance measure, leaving the questions to this key issue unanswered [19, 20].

This is one of the few studies to report specifically on endurance athletes’ experiences of undertaking a ketogenic diet. Athletes reported similar negative physiological experiences to those reported by athletes in comparable ketogenic diet studies [13, 14, 31]. However, they also reported experiencing benefits throughout the trial. One of these benefits was enhanced recovery; possibly, the rise in blood ketones had some influence, as beta-hydroxybutyrate has been associated with upregulating antioxidant gene expression and decreasing reactive oxygen species [32]. However, further research is required to substantiate this within athletic populations.

From a physical well-being perspective, the cases of improved skin, and the resolution of an ongoing prostate issue, were major points of discussion of benefits experienced. We speculate that it is the reduction of systemic inflammation as a result of a lower total sugar [33] and Omega 6 fatty acid intake, thereby rebalancing the Omega 6:3 fatty acid ratio in an anti-inflammatory direction [34] that gave rise to these outcomes. All participants were consuming high-Omega 6 industrial seed oils prior to the study (used as cooking fat and derived from processed foods). During the study these fats were replaced with coconut oil, butter and olive oil; i.e., fats containing minimal Omega 6 fatty acid content.

Being a translational study, we followed up participants informally 12 months after the study concluded. They were all still competing in endurance events, and while not eating a ketogenic diet, none of them had returned to their previous high carbohydrate, low fat style of eating. Collectively, they reported that once the study concluded they gradually increased their carbohydrate intake until the point at which they felt their performance at high intensities return. They were still restricting carbohydrate and eating more fat than mainstream guidelines recommend, and reported having discovered the optimal macronutrient ratio that satisfied a performance, body composition and a health goal.

This study had several limitations: Its design as a pilot case study, with no standardisation of training prevents any inference from being made to athletic populations. However, it is still relevant to both the researcher and the practitioner as it provides insights into what is considered important for athletes, particularly those in the 40+ age range. i.e., alongside improving performance, they are also more cognisant of their overall health and well-being. A lesson learned from undertaking this research, and a key consideration for researchers and practitioners, is to encourage a reduction in athlete training intensity and volume in the early weeks of embarking on a ketogenic diet. This will likely induce less early fatigue and other negative symptoms related to training, and allow for metabolic adaptations to occur in a lower stress milieu.