15 Immediate pre-exercise carbohydrate & the

boogeyman of hypoglycemia.
By Alan Aragon

16 Muscle gain in men and women: What’s the

difference?
By Alan Aragon
Copyright © June 1st, 2020 by Alan Aragon
Home: www.alanaragon.com
Correspondence: support@alanaragon.com

2 One Meal A Day (OMAD): is there merit in the

midst of madness?
By Lorenzo Pansini

7 Crisis of confidence averted: Impairment

of exercise economy and performance in
elite race walkers by ketogenic low
carbohydrate, high fat (LCHF) diet is
reproducible.
Burke LM, Sharma AP, Heikura IA, et al. PLoS One.
2020;15(6):e0234027. eCollection 2020. [PubMed]

10 The effect of 12 weeks of equicaloric high

protein diet in regulating appetite and body
composition of women with Normal Weight
Obesity: a randomized controlled trial.
Haghighat N, Ashtary-Larky D, Bagheri R, et al.
published online ahead of print, 2020 Jun 9]. Br J
Nutr. 2020;1-20. [PubMed]

13 Effects on the Body Composition Response to

High-Intensity Interval Training. The BEER-
HIIT Study.
Molina-Hidalgo C, De-la-O A, Jurado-Fasoli L,
Amaro-Gahete FJ, Castillo MJ. Beer or Ethanol
Nutrients. 2019;11(4):909. [PubMed]

Alan Aragon’s Research Review – June 2020 [Back to Contents] Page 1


One Meal A Day (OMAD): is there merit in the
midst of madness?
By Lorenzo Pansini
_______________________________________________
One Meal A Day (OMAD) is a type of intermittent fasting
that has become a cult hit in recent years. OMAD is often
presented by its promoters as a superior method for
various benefits, such as weight loss, appetite control, and
a slew of health-related claims. To the surprise of many,
OMAD has been studied in the human literature for
decades. Do the sensatrionalized benefits in diet books
align with the findings in the research literature? Let’s dive
in and have a look, but first a quick primer on what
OMAD is all about.
What is OMAD?
OMAD is a dietary pattern (not really a diet) based on a
single daily meal. For this reason, OMAD is an extreme
form of time-restricted feeding (TRF),1 that is, that type of
intermittent fasting (IF) where it is expected to eat in a
restricted window of time during the day. If the regular
TRF is characterized by a feeding window between 4 and
10 hours,1,2 with OMAD the only request is to eat in the
time window needed to consume the single meal; in other
words, it is TRF with a 23/1 ratio or something similar.
The research interest in studies examining the comparative
effects of a traditional pattern versus a single meal are
scarce, but they exist.3-6 It’s notable that OMAD in
research is rarely described as a type of TRF, probably for
its more extreme characteristics keeping it far-removed
from more common patterns of 2-4 meals.
The early human OMAD research emerged in the 60s
under the name of single daily meal,5,6 and only during the
2000s, it began to be better known online under the current
acronym. The pattern has achieved a significant increase in
popularity likely starting from 2017, when several books
have been published. Thanks to the catchy acronym, it has
emerged as popular fad diet.
Precisely because of this rampant craze and the
sensationalist tones of questionable books and web
articles, in a few years, OMAD has gone from being
Alan Aragon’s Research Review – June 2020
perhaps one of the worst food patterns to the secret to
solve all health & weight problems. However, an impartial
look at the published research provides a considerably
more cautious, and less flattering picture.
Thermic effect of food and body fat
Any self-respecting fad-diet must be considered as more
effective for fat loss, giving it a sort of "magic" metabolic
advantage, in this case, compared to multiple meals.
Research shows that meal frequency does not significantly
affect the thermic effect of food (TEF), and it’s interesting
to note that some studies have found a higher TEF with
OMAD, but with differences too small to be considered
practically meaningful (<20 kcal).7
It’s much more important to look at the inherent long-term
effects of OMAD on fat changes compared to multiple
meals, i.e. under energy-matched conditions. Although
body composition was not measured, classic metabolic
ward studies of the 1960s enforced isocaloric conditions
and didn't observe any difference or advantage in weight
changes between OMAD and frequent meals.5,6 A recent
metabolic ward study confirmed similar fat changes
between a very low-calorie diet with 5 meals and
OMAD.8,9 the 5-meal condition resulted in slightly higher
fat loss, but this was likely confounded by the sequence of
consecutive stages.8,9
One of several common limitations in these metabolic
ward studies was the short duration (14-20 days), while the
longer-term free-living studies (5-6 weeks and a cross-over
design) observed similar10,11 or greater fat loss for OMAD
compared to frequent meals.3 Since the free-living setting
can't perfectly match calories between treatments when a
clear OMAD advantage was observed, this was attributed
to the lower calorie intake.3
Fat-fee mass
The early studies that compared the nitrogen balance
between OMAD and multiple meals showed no
difference.6,10,11 This lead to the conclusion that a single
meal is not less sparing/preservative of lean mass. Long-
term studies where fat-free mass (FFM) was monitored or
estimated did not observe a negative impact of OMAD
compared to multiple meals, even with calorie
restriction.3,8,10,11
[Back to Contents] Page 2
The issue has been better studied by a recent meta-analysis
(co-authored by Alan), finding that no particular meal
frequency favors FFM gain or maintenance, especially
after a sensitivity analysis removed a study with outlying
results.7 The published studies (including those on
OMAD), however, used poor FFM measurements (BIA or
simple estimates), muscle mass was not directly measured,
and involved sedentary and/or non-resistance trained
populations. Based on the limited available evidence, it’s
not possible to provide a clear answer about the effects of
OMAD on lean and muscle mass, nor on its effects in
combination with resistance training.
Some authors have suggested that very low meal
frequency would suppress anabolism when protein intake
is suboptimal and/or when calorie restriction is chronic and
marked;12,13 others suggest a minimum of 4 meals (with at
least 20 g of protein each) to maintain optimal anabolic
state.14 This is based on the notion that a more frequent
muscle protein synthesis stimulation throughout the day
positively affects the net muscle protein balance,14,15 but
strong long-term evidence is still lacking.
Health parameters
The health parameters issue is the most serious and
delicate, and upon which OMAD fad-diet books have
likely created the most dangerous misinformation. Thevery
first metabolic ward study on eucaloric OMAD found a
worsening of the lipid profile (especially plasma
cholesterol) compared to 3-10 meals,5 and other classic
later studies confirmed worsening of total and LDL
cholesterol, insulin resistance (both IGT and IFG), and
blood pressure when compared to 3 or more meals.3,4,10,11
Some of the side effects had already been mentioned in an
old 1997 review about the relationships between lipid
profile and meal frequency, which included the OMAD
studies published until that time.16 Only one of the studies
published to date has not observed worsening of lipid
profile,6 but the results were confounded by the strong
calorie restriction (~600 kcal/day), in contrast to the others
where the diets were eucaloric or moderately hypocaloric.
One might suspect that a lag time would be required to
allow for adaptation and normalization, but several of
these lasted 5-8 weeks,3,10,11 a period long enough to
Alan Aragon’s Research Review – June 2020
observe adaptations. Another limitation is the population
studied, but worsening has been seen in both
hyperlipidemic overweight/obese and normolipidemic/
normal-weight subjects.
Appetite and calorie intake
Perhaps one of the few concrete merits of OMAD is the
spontaneous reduction of caloric intake, allowing it to
establish a calorie restriction in an ad libitum context. This
advantage has been observed several times for normal TRF
(feeding window up to 8-10 hours),17,18 and a much
narrower feeding window is assumed to emphasize this
benefit. In fact, a free-living eucaloric study comparing
OMAD and multiple meals found a slight fat loss
advantage over 3 meals, despite the isocaloric targets.3
Compared to 3 meals, the study found adverse changes in
various appetite parameters (hunger and desire to eat),
which gradually increased over the 8 weeks.3 On the other
hand, the OMAD group reported excessive fullness during
and after the meal, struggling to eat it all. In addition, the
OMAD treatment resulted in fat loss (2.1 kg) which
correlated with a slightly lower calorie intake (~65 kcal).
It is assumed that if the subjects had not been forced to
consume calories at maintenance, the ad libitum intake
would have been further reduced. A previous OMAD
study reported distraction from hunger during the day for
over half of the subjects, and 40% of them reported a
preference over 6 meals.11 If a person adheres to the long-
term pattern for personal preference, OMAD is certainly
an easy way to lose weight, but probably at the expense of
a slight deterioration in health parameters compensated
only in part by calorie restriction.
Feeding window timing: early-OMAD vs late-OMAD
Currently, some research teams are strongly promoting the
TRF feeding window positioned in the early part of the
day (early-TRF). The supposed benefits include
improvements in insulin sensitivity, blood pressure,
inflammation, oxidative stress and appetite,1,19 but the
topic is still debated (see May and September 2019 issues
by AARR for Alan's comments).
Few people know the existence of many old “obscure” 80s
studies that compared e-TRF and l-TRF in an OMAD
[Back to Contents] Page 3
style. Some of these were conducted by Franz Halberg's
team (defined by some as the father of modern
chronobiology)20,21 the others by two Italian teams, Sensi
& Capani et al, and Caviezel et al.11 Halberg's studies
found that a 2000 kcal or an ad libitum OMAD at
breakfast caused weight loss, whereas this same meal
provided at dinner weight was maintained.20,21
Sensi & Capani's team observed slightly higher weight
loss with very-low-calorie late-OMAD (~700 kcal/day),
while Caviezel found that very low-calorie (~600 kcal/day)
early-OMAD produced greater weight loss than late-
OMAD only in severely obese, but not in moderately
obese.22 It’s notewirthy that all Italian studies were
conducted in metabolic ward, but were still of very poor
quality, lacking important pieces of information, and
harboring a high risk of bias.22 The duration of all these
studies was always rather short (1-3 weeks), health
parameters and body composition were not monitored, and
many are brief reports or symposium presentations that
cannot be retrieved, and many data are not reported,20-22
Likely the most reliable comparative early- vs late-OMAD
study to date, conducted in metabolic ward, showed
similar, albeit slightly higher fat loss for the very low-
calorie (1000 kcal/day) early-OMAD over 18 days.8 But
these differences may have been influenced by the various
treatments in consecutive order in the same subjects, and
in any case, were not considered significant.
Since energy balance predominantly dictates changes in fat
mass2 it's likely that there is no inherent effect of the
feeding window timing or placement, as suggested by the
authors of the most reliable study in this regard.8
Differences in health parameters attributed to TRF cannot
be ruled out, but the issue requires further study to move
toward definitive conclusions.
Alternate-day OMAD
The term Intermittent Energy Restriction (IER) identifies
those intermittent fasting patterns super-family consisting
of 1-4 so-called fast days in the week, alternated with the
remaining weekly days around maintenance or ad libitum
(feed days). Fast days usually consist of a semi-fast, with a
high calorie restriction of up to 75% of the energy needs.
Perhaps the most famous type of IER-style IF is the
alternate-day fasting (ADF), which alternates feed days
Alan Aragon’s Research Review – June 2020
and semi-fast days every other day over the week.
Since it goes from days of energy abundance to semi-
fasting, ADF research is essentially a very-low-calorie
OMAD followed every other day (therefore 3-4 days a
week).23 ADF research generally shows an improvement in
health parameters similar to chronic calorie restriction, and
other IER models, such as the classic 5:2, also show
similar results.23-25 This would mean that when the OMAD
is expected only for 2-4 days of the week in a very-low-
calorie mode, the impact on the health parameters can be
very different from the eucaloric or slightly low-calorie
OMAD followed chronically. Moreover, even one of the
early 60s studies on chronic very-low-calorie OMAD
(~600 kcal/day) showed a similar lipid profile
improvement compared to multiple meals.6
Some IER-ADF promoters have argued that this pattern
can spare lean mass compared to chronic energy restriction
(ideally matching weekly energy balance).26 However, this
idea has been questioned, since in most cases similar
effects have been observed.24 In addition, doubts have
been raised regarding the reliability of the fat mass
measurement measurements.27
Conclusions
One Meal A Day (OMAD) is likely the most extreme and
controversial intermittent fasting pattern/TRF variant. On
the one hand, it can be an interesting strategy to reduce ad
libitum calorie intake. It might surprise some that it doesn't
have a clear negative impact on lean mass compared to
multiple meals, even if from a theoretical and mechanistic
standpoint it's not considered optimal for muscle growth.
On the other hand, the alleged metabolic benefit of OMAD
for fat loss described by some fad-diet books is very
implausible. What deserves greater consideration is the
worsening of health parameters such as the lipid profile
(TC and LDL-C) and insulin resistance (IGT and IFG),
even with moderate calorie restriction, and also in
metabolically healthy subjects. These sid-effects do not
seem to exist if the calorie restriction is substantial (≤1000
kcal/day). Unfortunately, this aggressive deficit can further
challenge the sustainability of OMAD.
Before choosing this pattern, you should stop and ask
yourself the real reason behind this choice: have you been
[Back to Contents] Page 4
smitten by the catchy acronym? Are you prone to jumping
on the latest trends? Or, is it an informed choice after an
honest, objective examination of the data? In most cases,
the answer is the former.
Nevertheless, OMAD is not a pattern deserving of
universal dismissal. When inserted in a very-low-calorie
mode on some days of the week (i.e., in an IER-ADF-style
intermittent fasting), its potentially deleterious impact can
be avoided. If applied in this way, OMAD fits well with
flexible calorie cycling modalities. It can be incorporated
with a variable cadence through the week according to the
need to control or lose weight. Using OMAD as a tactical
tool would minimize its potential for negative impacts on
health parameters.
References:
1. Kessler K, Pivovarova-Ramich O. Meal timing, aging,
and metabolic health. Int J Mol Sci. 2019 Apr
18;20(8). pii: E1911. [PubMed]
2. Aragon AA et al. International Society of Sports
Nutrition position stand: diets and body composition. J
Int Soc Sports Nutr. 2017 Jun 14;14:16. [PubMed]
3. Stote KS et al. A controlled trial of reduced meal
frequency without caloric restriction in healthy,
normal-weight, middle-aged adults. Am J Clin Nutr.
2007 Apr;85(4):981-8. [PubMed]
4. Carlson O et al. Impact of reduced meal frequency
without caloric restriction on glucose regulation in
healthy, normal-weight middle-aged men and women.
Metabolism. 2007 Dec;56(12):1729-34. [PubMed]
5. Gwinup G et al. Effect of nibbling versus gorging on
serum lipids in man. Am J Clin Nutr. 1963
Oct;13:209-13. [PubMed]
6. Bortz WM et al. Weight loss and frequency of feeding.
N Engl J Med. 1966 Feb 17;274(7):376-9. [PubMed]
7. Schoenfeld BJ, Aragon AA, Krieger JW. Effects of
meal frequency on weight loss and body composition:
a meta-analysis. Nutr Rev. 2015 Feb;73(2):69-82.
[PubMed]
8. Nonino-Borges CB et al. Influence of meal time on
salivary circadian cortisol rhythms and weight loss in
obese women. Nutrition. 2007 May;23(5):385-91.
[PubMed]
9. The meals number in the TRF 22/2 stages was not
declared, but the main author Carla Barbosa Nonino
confirms it through personal communication: "The
Alan Aragon’s Research Review – June 2020
subjects ate a single meal."
10. Young CM et al. Frequency of feeding, weight
reduction, and body composition. J Am Diet Assoc.
1971 Nov;59(5):466-72. [PubMed]
11. Young CM et al. Metabolic effects of meal frequency
on normal young men. J Am Diet Assoc. 1972
Oct;61(4):391-8. [PubMed]
12. McDonald L. The Protein Book: A Complete Guide
for the Athlete and Coach. Lyle McDonald, 2007.
13. McDonald L. Women's Book: A Guide to Nutrition,
Fat Loss, and Muscle Gain. Lyle McDonald, 2018. pp.
249-250.
14. Schoenfeld BJ, Aragon AA. How much protein can
the body use in a single meal for muscle-building?
Implications for daily protein distribution. J Int Soc
Sports Nutr. 2018 Feb;27;15:10. [PubMed]
15. Trommelen J et al. The muscle protein synthetic
response to meal ingestion following resistance-type
exercise. Sports Med. 2019 Feb;49(2):185-197.
[PubMed]
16. Mann J. Meal frequency and plasma lipids and
lipoproteins. Br J Nutr. 1997 Apr;77 Suppl 1:S83-90.
[PubMed]
17. Gabel K et al. Effects of 8-hour time restricted feeding
on body weight and metabolic disease risk factors in
obese adults: A pilot study. Nutr Healthy Aging . 2018
Jun 15;4(4):345-353. [PubMed]
18. Chow LS et al. Time‐restricted eating effects on body
composition and metabolic measures in humans who
are overweight: A feasibility study. Obesity (Silver
Spring). 2020 May;28(5):860-869. [PubMed]
19. Hutchison AT et al. Time-restricted feeding improves
glucose tolerance in men at risk for type 2 diabetes: a
randomized crossover trial. Obesity (Silver Spring).
2019 May;27(5):724-732. [PubMed]
20. Cornelissen G. When you eat matters: 60 years of
Franz Halberg's nutrition chronomics. Open Nutr J.
2012;4:16–44. [ResearchGate]
21. Halberg F, Haus E, Cornélissen G. From biologic
rhythms to chronomes relevant for nutrition. In:
Marriott BM. Not Eating Enough: Overcoming
Underconsumption of Military Operational Rations.
Washington DC: National Academy Press; 1995.
[NCBI Bookshelf]
22. Fong M, Caterson ID, Madigan CD. Are large dinners
associated with excess weight, and does eating a
smaller dinner achieve greater weight loss? A
[Back to Contents] Page 5
 systematic review and meta-analysis. Br J Nutr. 2017
Oct;118(8):616-628. [PubMed]
23. Tinsley GM, La Bounty PM. Effects of intermittent
fasting on body composition and clinical health
markers in humans. Nutr Rev. 2015 Oct;73(10):661-
74. [PubMed]
24. Seimon RV et al. Do intermittent diets provide
physiological benefits over continuous diets for weight
loss? A systematic review of clinical trials. Mol Cell
Endocrinol. 2015 Dec 15;418 Pt 2:153-72. [PubMed]
25. Cioffi I et al. Intermittent versus continuous energy
restriction on weight loss and cardiometabolic
outcomes: A systematic review and meta-analysis of
randomized controlled trials. J Transl Med. 2018; 16:
371. [PubMed]
26. Varady KA. Intermittent versus daily calorie
restriction: which diet regimen is more effective for
weight loss? Obes Rev. 2011 Jul;12(7):e593-601.
[PubMed]
27. Tinsley GM et al. Intermittent fasting programs and
their effects on body composition: Implications for
weight-restricted sports. Strength Cond J. 2015
Aug;37 (5), 60-71. [SCJ]

Alan Aragon’s Research Review – June 2020 [Back to Contents] Page 6


Crisis of confidence averted: Impairment of
exercise economy and performance in elite
race walkers by ketogenic low carbohydrate,
high fat (LCHF) diet is reproducible.
Burke LM, Sharma AP, Heikura IA, et al. PLoS One.
2020;15(6):e0234027. eCollection 2020. [PubMed]
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
Alan Aragon’s Research Review – June 2020
Registry: ACTRN12619000794101. FUNDING
SOURCE: This study was funded by a Program Grant
from the Australian Catholic University Research Funds to
Professor Louise Burke (ACURF, 2017000034).
Strengths
While innovation can be considered a conceptual strength
of a study, a strength of this one is replication of previous
results.1 As a general principle, arriving at similar results
when testing a previous protocol strengthens our
confidence in the results. In other words, replication
increases the probability that the results were not
accidental or due to confounding variables or a lack of
methodological integrity. An added design strength of the
present study was its inclusion of a periodized condition
with a nonlinear carbohydrate intake aimed toward
enhancing metabolic adaptations to training. The previous
study which was (in part) replicated, consisted of 2
separate training camps, whereas the present one was
conducted over a single training camp with greater control
& cohesion. All foods and beverages were provided to the
subjects by the research team. Protein and total energy
intake was similar among the 3 conditions, with
carbohydrate being the only manipulated variable.
Above is the layout of the study (larger image here).
Protein was abundant in the high-carbohydrate (HCHO)
and periodized carbohydrate (PCHO) conditions, at 2.0 &
2.2 g/kg during the initial 25-day adaptation phase, and the
10-day de-adaptation phase. In the low-carbohydrate
(LCHF) condition, protein intake was 2.2 & 2.3 g/kg in the
respective phases. Carbohydrate in LCHF was 35 g/day in
the adaptation phase, and 552 g/day in the de-adapt phase.
Carbohydrate in the other groups were similar, collectively
ranging 490-534 g/day.
[Back to Contents] Page 7
Limitations
The authors acknowledged that there might be criticism
leveled at the relatively short duration of the study (25-day
adaptation period). However, the authors also note that this
time period exceeds the duration required to maximize
changes in substrate utilization (in this case increased fat
oxidation), which is within approximately 1-2 weeks.2-5
Another acknowledged limitation was the suppression of
significant changes in body composition often seen in
studies of self-administered or ad libitum ketogenic diets –
which in several studies have resulted in greater reduction
in body fat due to a spontaneous reduction in energy
intake.4 The authors also conceded that the study’s short
duration leaves open questions about the ability of long-
term carbohydrate restriction to impair bone remodeling,
immune response, and iron metabolism, or training quality
(particularly higher-intensity output). Although it can be
considered a strength that the subjects were elite
competitive endurance athletes, it’s also possible that the
results might not be generalizable to unathletic
populations.
Comment/application
Shown above are the baseline race time (white bar) and
post-adaptation race time (gray bar) for completing the 10
km race. Credit to the authors for showing individual data.
A clear hierarchy of effectiveness with HCHO being the
superior protocol (4.8% improvement), PCHO was the
middle performer with a lesser reduction in race
completion time (2.2% improvement). LCHF was the only
group that showed decreased performance (2.3% slower).
The latter finding was the replication that the authors of
the present study are so excited about. This performance
decrease was also seen in the ketogenic condition in a
previous study also involving elite race walkers (I
Alan Aragon’s Research Review – June 2020
reviewed this study in the December 2016 issue of
AARR).1 The increased rates of fat oxidation seen in the
LCHF group were accompanied by in reduced economy
(in other words, increased oxygen demand for a given
speed).
After Race 2, a subset of the subjects underwent a 20 km
race after 2.5 weeks of HCHO protocol. HCHO & PCHO
(designated as CHO/HCHO in the above graph) improved
from Race 1 to Race 2 with no further improvement to the
20 km race, whereas the LCHF group (designated as
CHO/HCHO in the above graph) had significantly slower
performance in Race 2, and their 20 km performance was
slower than what could be predicted from Race 1.
These results cast further doubt not on ketoadaptation as
an endurance performance-enhancing strategy. The
findings also do not shed a particularly positive light on
the hope for periodized/non-linear carbohydrate intake.
The latter is an emerging strategy that has a mix of
positive6,7 and null results8 compared to conventional,
linear high-carbohydrate intake. Although there is still
plenty of uncharted ground in the investigation of
carbohydrate manipulation for optimizing performance,
prolonged ketogenic dieting might carry greater potential
for risk than benefit. Burke issues the following cautionary
note in a recent review:9
“The available literature suggests that keto-adaptation
may impair muscle glycogen utilisation handicapping
the ideal model of enhanced availability and capacity
for both fat and CHO utilisation.”
References
1. Burke LM, Ross ML, Garvican-Lewis LA, et al. Low
carbohydrate, high fat diet impairs exercise economy
and negates the performance benefit from intensified
[Back to Contents] Page 8
 training in elite race walkers. J Physiol.
2017;595(9):2785-2807. [PubMed]
2. Goedecke JH, Christie C, Wilson G, et al. Metabolic
adaptations to a high-fat diet in endurance cyclists.
Metabolism. 1999;48(12):1509-1517. [PubMed]
3. Burke LM, Angus DJ, Cox GR, et al. Effect of fat
adaptation and carbohydrate restoration on metabolism
and performance during prolonged cycling. J Appl
Physiol (1985). 2000;89(6):2413-2421. [PubMed]
4. Burke LM, Hawley JA, Angus DJ, et al. Adaptations
to short-term high-fat diet persist during exercise
despite high carbohydrate availability. Med Sci Sports
Exerc. 2002;34(1):83-91. [PubMed]
5. Aragon AA, Schoenfeld BJ, Wildman R, et al.
International society of sports nutrition position stand:
diets and body composition. J Int Soc Sports Nutr.
2017;14:16. [PubMed]
6. Marquet LA, Brisswalter J, Louis J, et al. Enhanced
Endurance Performance by Periodization of
Carbohydrate Intake: "Sleep Low" Strategy. Med Sci
Sports Exerc. 2016;48(4):663‐672. [PubMed]
7. Impey SG, Hearris MA, Hammond KM, et al. Fuel for
the Work Required: A Theoretical Framework for
Carbohydrate Periodization and the Glycogen
Threshold Hypothesis. Sports Med.
2018;48(5):1031‐1048. [PubMed]
8. Gejl KD, Thams LB, Hansen M, et al. No Superior
Adaptations to Carbohydrate Periodization in Elite
Endurance Athletes. Med Sci Sports Exerc.
2017;49(12):2486‐2497. [PubMed]
9. Burke LM. Ketogenic low-CHO, high-fat diet: the
future of elite endurance sport? [published online
ahead of print, 2020 May 2]. J Physiol.
2020;10.1113/JP278928. [PubMed]

Alan Aragon’s Research Review – June 2020 [Back to Contents] Page 9


The effect of 12 weeks of equicaloric high protein
diet in regulating appetite and body composition
of women with Normal Weight Obesity: a
randomized controlled trial.
Haghighat N, Ashtary-Larky D, Bagheri R, et al. published
online ahead of print, 2020 Jun 9]. Br J Nutr. 2020;1-20.
[PubMed]
BACKGROUND: Normal weight obesity (NWO)
syndrome is associated with metabolic diseases.
PURPOSE: The present study aimed to investigate the
effects of 12 weeks of a high-protein (HP) versus a
standard protein (SP) diet on appetite, anthropometry, and
body composition in NWO women. DESIGN: In this
clinical trial, 50 NWO women were randomly allocated to
an HP (n=25) or an SP (n=25) diet groups. Women in the
HP and SP groups consumed 25% and 15% of their total
energy intake from protein for 12 weeks. Weight, fat mass
(FM), lean body mass (LBM), waist circumference (WC),
and appetite were evaluated at baseline and following their
three-month intervention. RESULTS: After 12 weeks, the
LBM was higher in HP compared to no significant
changes in the SP group [mean between-group difference=
1.5 kg (95% confidence interval {CI}, 3.1 to 0.01, effect
size {d}= 0.4)]. Furthermore, the HP group had lower FM
[mean between-group difference, -1.1 kg (95% CI, 1 to -
3.3; d= -0.2)], body fat percentage (BFP) [mean between-
group difference, -2 % (95% CI, 0.7 to -5.2; d= -0.3)] and
WC [mean between-group difference, -1.4 cm (95% CI,
0.6 to -3.6; d= -0.2)] at the end of the study in comparison
to the SP group. In both groups, weight and appetite were
unchanged over time without significant differences
between groups. CONCLUSIONS: 12 weeks of eucaloric
diets with different dietary protein content resulted in no
significant weight loss in women with NWO. However, an
HP diet significantly improved body composition (LBM,
FM, BFP, and WC) in this population. FUNDING
SOURCE: The study supported by Ahvaz Jundishapur
University of Medical Sciences, Ahvaz, Iran (grant No.:
94S87).
Strengths
This study broached the important but scarcely addressed
topic of normal-weight obesity (NWO), defined as a
normal BMI (18.5–24.9 kg/m2) and an excess in body fat
percent, defined by the highest tertiles in NHANES III
Alan Aragon’s Research Review – June 2020
(>23.1% in men and >33.3% in women).1 While BMI can
be a useful screening tool at the general population level, it
still is a proxy for body composition, and thus is an
inferior tool at the individual level. Furthermore, the
greater level of lean mass in athletic populations degrades
the validity of BMI for approximating adiposity.2-4
Limitations
The authors diligently acknowledged several limitations
▪ Appetite analysis was based on a visual analogue scale
(VAS) whose nature is inevitably subjective, despite
having been validated in the literature.5
▪ There was a lack of objective (blood or urine-
mediated) measures of compliance and analysis.
▪ The trial only involved women with NWO, so the
generalize the results to other populations is open to
question.
▪ Subjects in both groups lost a nonsignificant amount
of weight despite the aim to administer weight-
maintenance programs. (1.0 & 1.2 kg in SP and HP,
respectively).
▪ The use of bioelectrical impedance (BIA) to assess
body composition is not the gold standard for body
composition measurement.
▪ A “per protocol” analysis was done, which excludes
the data from drop-outs in the analysis, which has the
potential to miss data that could have differently
influenced the results.6
I would add that the trial did not involve any exercise. One
subject in the HP group was actually kicked out for
starting an exercise program. I’d speculate that a structured
resistance training program would have uncovered even
greater effects in favor of the HP group, due to the
synergistic relationship between protein feeding and
progressive overload.7
Comment/application
[Back to Contents] Page 10
As shown above, the high-protein (HP; ) group gained
lean mass (1.3 kg) and lost fat mass (0.9 kg), while the
standard protein (SP) group lost lean mass (0.3 kg) and
gained fat mass (0.2 kg). So, HP led to favorable
recomposition, while SP resulted in recomp in the wrong
direction. Keep in mind that single-frequency BIA was
used in this study to assess body composition, and multi-
frequency BIA would have been a more valid & reliable
method.8,9
Also shown in the previous table, there was a lack of
difference in appetite ratings between the groups.
Interestingly, this occurred despite the marked differences
in protein intake. Through the length of the intervention,
daily protein intake in HP ranged 115-118 g (~1.8 g/kg),
while SP ranged 69-70 g (~1.1 g/kg). This finding was
somewhat unexpected. It’s easy to jump to the conclusion
that higher protein equals greater satiety, given the sound
basis for this presumption in the literature.10-16 Protein is
consistently more satiating than other macronutrients in
single-meal designs. These findings have been explored
mechanistically, and it appears that protein’s satiating
effects are mediated by glucagon-like peptide-1 (GLP-1),
peptide YY (PYY), and glucagon.17
The findings of the present study do not indicate a greater
satiating effect of the higher-protein condition. This
finding is not completely anomalous. A recent example of
a lack of advantage to the higher-protein condition was
Hall et al (reviewed in the May 2020 issue of AARR),18
who compared a plant-based, low-fat diet with an animal-
based ketogenic diet. The lower-protein plant-based diet
outperformed the latter for fat loss and lean mass retention.
However, the treatment period was a paltry two weeks,
and the plant-based diet had substantially more fiber than
the ketogenic diet (whose fiber content was very low).
Another recent example was Roberts et al19 who found that
higher protein intake (2.9 g/kg) was not more satiating
than lower protein intake (1.8 g/kg).
Nevertheless, these findings don’t warrant the conclusion
that higher protein is not an important satiating factor in
dietary programming for weight/fat loss. The totality of
evidence must be taken into consideration; not just a
handful of studies that happen to raise eyebrows. An 24-
study meta-analysis by Wycherly et al20 found that,
compared to an energy-restricted SP diet, an isocaloric
prescribed HP diet was superior for reductions in total
Alan Aragon’s Research Review – June 2020
mass, fat mass, and was also better for preserving
reductions in in fat-free mass and resting energy
expenditure.
In free-living, very-high-protein conditions, protein’s
satiating effect is downright impressive. Antonio et al have
conducted several trials22-24 showing a lack of significant
change in body composition despite substantial increases
in calories from protein, ranging ~400-800 kcal above
baseline intakes. High-protein conditions in these trials
ranged from 3.3-4.4 g/kg, and their lower-protein
comparators ranged 1.8-2.6 g/kg. Trial lengths ranged 2-6
months, providing ample opportunity for different effects
on body composition to materialize, but instead, the extra
protein seemingly disappeared. A likely explanation is that
the amplified satiating effect of the extra protein drove
down the intake of the rest of the macronutrients.
Additional speculations involve increased energy
expenditure via exercise-mediated and non-exercise-
mediated processes, as well as good, old-fashioned
misreporting. The take-home point is that protein’s
satiating impact can be a potent satiating factor on both
sides of the energy balance equation.
References
1. Romero-Corral A, Somers VK, Sierra-Johnson J, et al.
Normal weight obesity: a risk factor for
cardiometabolic dysregulation and cardiovascular
mortality. Eur Heart J. 2010;31(6):737-746. [PubMed]
2. Etchison WC, Bloodgood EA, Minton CP, et al. Body
mass index and percentage of body fat as indicators for
obesity in an adolescent athletic population. Sports
Health. 2011;3(3):249-252. [PubMed]
3. Kruschitz R, Wallner-Liebmann SJ, Hamlin MJ, et al.
Detecting body fat-A weighty problem BMI versus
subcutaneous fat patterns in athletes and non-athletes.
PLoS One. 2013;8(8):e72002. Published 2013 Aug 26.
[PubMed]
4. Ode JJ, Pivarnik JM, Reeves MJ, Knous JL. Body
mass index as a predictor of percent fat in college
athletes and nonathletes. Med Sci Sports Exerc.
2007;39(3):403-409. [PubMed]
5. Flint A, Raben A, Blundell JE, Astrup A.
Reproducibility, power and validity of visual analogue
scales in assessment of appetite sensations in single
test meal studies. Int J Obes Relat Metab Disord.
2000;24(1):38-48. [PubMed]
[Back to Contents] Page 11
6. Ranganathan P, Pramesh CS, Aggarwal R. Common
pitfalls in statistical analysis: Intention-to-treat versus
per-protocol analysis. Perspect Clin Res.
2016;7(3):144-146. [PubMed]
7. Guimarães-Ferreira L, Cholewa JM, Naimo MA, et al.
Synergistic effects of resistance training and protein
intake: practical aspects. Nutrition. 2014;30(10):1097-
1103. [PubMed]
8. Yamada Y, Watanabe Y, Ikenaga M, et al.
Comparison of single- or multifrequency bioelectrical
impedance analysis and spectroscopy for assessment
of appendicular skeletal muscle in the elderly. J Appl
Physiol (1985). 2013;115(6):812-818. [PubMed]
9. Gába A, Kapuš O, Cuberek R, Botek M. Comparison
of multi- and single-frequency bioelectrical impedance
analysis with dual-energy X-ray absorptiometry for
assessment of body composition in post-menopausal
women: effects of body mass index and accelerometer-
determined physical activity. J Hum Nutr Diet.
2015;28(4):390-400. [PubMed]
10. Paddon-Jones D, Westman E, Mattes RD, Wolfe RR,
Astrup A, Westerterp-Plantenga M. Protein, weight
management, and satiety. Am J Clin Nutr.
2008;87(5):1558S-1561S. [PubMed]
11. Leidy HJ. Increased dietary protein as a dietary
strategy to prevent and/or treat obesity. Mo Med.
2014;111(1):54-58. [PubMed]
12. Astrup A, Raben A, Geiker N. The role of higher
protein diets in weight control and obesity-related
comorbidities. Int J Obes (Lond). 2015;39(5):721-726.
[PubMed]
13. Kim JE, O'Connor LE, Sands LP, Slebodnik MB,
Campbell WW. Effects of dietary protein intake on
body composition changes after weight loss in older
adults: a systematic review and meta-analysis. Nutr
Rev. 2016;74(3):210-224. [PubMed]
14. Campos-Nonato I, Hernandez L, Barquera S. Effect of
a High-Protein Diet versus Standard-Protein Diet on
Weight Loss and Biomarkers of Metabolic Syndrome:
A Randomized Clinical Trial. Obes Facts.
2017;10(3):238-251. [PubMed]
15. Galbreath M, Campbell B, LaBounty P, et al. Effects
of Adherence to a Higher Protein Diet on Weight
Loss, Markers of Health, and Functional Capacity in
Older Women Participating in a Resistance-Based
Exercise Program. Nutrients. 2018;10(8):1070.
[PubMed]
Alan Aragon’s Research Review – June 2020
16. Santesso N, Akl EA, Bianchi M, et al. Effects of
higher- versus lower-protein diets on health outcomes:
a systematic review and meta-analysis. Eur J Clin
Nutr. 2012;66(7):780-788. [PubMed]
17. Belza A, Ritz C, Sørensen MQ, Holst JJ, Rehfeld JF,
Astrup A. Contribution of gastroenteropancreatic
appetite hormones to protein-induced satiety. Am J
Clin Nutr. 2013;97(5):980-989. [PubMed]
18. Hall KD, Guo J, Courville AB, Boring J, Brychta R,
Chen KY, et al. A plant-based, low-fat diet decreases
ad libitum energy intake compared to an animal-based,
ketogenic diet: An inpatient randomized controlled
trial [Internet].[NutriXiv]; 2020.
19. Roberts J, Zinchenko A, Mahbubani K, et al. Satiating
Effect of High Protein Diets on Resistance-Trained
Subjects in Energy Deficit [published correction
appears in Nutrients. 2019 Jul 08;11(7):]. Nutrients.
2018;11(1):56. [PubMed]
20. Wycherley TP, Moran LJ, Clifton PM, Noakes M,
Brinkworth GD. Effects of energy-restricted high-
protein, low-fat compared with standard-protein, low-
fat diets: a meta-analysis of randomized controlled
trials. Am J Clin Nutr. 2012;96(6):1281-1298.
[PubMed]
21. Antonio J, Peacock CA, Ellerbroek A, Fromhoff B,
Silver T. The effects of consuming a high protein diet
(4.4 g/kg/d) on body composition in resistance-trained
individuals. J Int Soc Sports Nutr. 2014;11:19.
Published 2014 May 12. [PubMed]
22. Antonio J, Ellerbroek A, Silver T, et al. A high protein
diet (3.4 g/kg/d) combined with a heavy resistance
training program improves body composition in
healthy trained men and women--a follow-up
investigation. J Int Soc Sports Nutr. 2015;12:39.
[PubMed]
23. Antonio J, Ellerbroek A, Silver T, Vargas L, Peacock
C. The effects of a high protein diet on indices of
health and body composition--a crossover trial in
resistance-trained men. J Int Soc Sports Nutr.
2016;13:3. [PubMed]
24. Antonio J, Ellerbroek A, Silver T, et al. A High
Protein Diet Has No Harmful Effects: A One-Year
Crossover Study in Resistance-Trained Males. J Nutr
Metab. 2016;2016:9104792. [PubMed]
[Back to Contents] Page 12

Effects on the Body Composition Response to
High-Intensity Interval Training. The BEER-HIIT
Study.
Molina-Hidalgo C, De-la-O A, Jurado-Fasoli L, Amaro-
Gahete FJ, Castillo MJ. Beer or Ethanol Nutrients.
2019;11(4):909. [PubMed]
BACKGROUND: High-intensity interval training (HIIT)
is promoted as a time-efficient strategy to improve body
composition but concomitant beer intake, which is
common among physically active individuals, may
interfere with these effects. PURPOSE: The primary aim
of this study is to determine the effects of a 10-week (2
days/week) HIIT program on anthropometric and body
composition measurements, and to assess whether those
effects are influenced by the moderate consumption of
beer (at least 5 days/week), or its alcohol equivalent.
DESIGN: Young (24 ± 6 years old) healthy adults (n = 72,
35 females) volunteered for a non-training group (Non-
Training group) or for HIIT training. Those going for
training choose whether they preferred to receive alcohol
or not. Those choosing alcohol were randomly allocated
for receiving beer (5.4%; T-Beer group) or the equivalent
amount of alcohol (vodka; T-Ethanol group) in sparkling
water. Those choosing no-alcohol were randomly allocated
for receiving alcohol-free beer (0.0%; T-0.0Beer group) or
sparkling water (T-Water group). From Monday through
Friday, men ingested 330 mL of the beverage with lunch
and 330 mL with dinner; women ingested 330 mL with
dinner. Before and after the intervention, anthropometry
and body composition, through dual-emission X-ray
absorptiometry, were measured. RESULTS: No changes
in body mass, waist circumference, waist/hip ratio, visceral
adipose tissue or bone mineral density occurred in any of
the groups. By contrast, in all the training groups,
significant decreases in fat mass together with increases in
lean mass (all p < 0.05) occurred. These positive effects
were not influenced by the regular intake of beer or
alcohol. CONCLUSIONS: In conclusion, a moderate beer
intake does not blunt the positive effect of 10-week HIIT
on body composition in young healthy adults. FUNDING
SOURCE: This research was partially funded by an
unrestricted grant of the Centro de Información Cerveza y
Salud (CICS), Madrid, Spain.
Strengths
Let’s call the title what it is: hilarious. Comedy within a
study title can be considered a strength, in my opinion.
Alan Aragon’s Research Review – June 2020
Beverage assignments were coded and blinded to the
knowledge of the research staff. This is the first study to
examine moderate beer & other alcoholic beverage
consumption’s effect on body composition when under-
going physical training designed to induce changes in body
composition, in real-life conditions. The training program
was low-frequency (2 days per week), which can be
considered a strength given that the subjects represented
the general population undergoing a realistic/sustainable,
periodized program. Dual X-ray absorptiometry (DXA)
was used to assess body composition. This allowed for the
assessment of visceral adiposity as well.
Limitations
The authors acknowledged the following limitations:
▪ Sample size was relatively small (72 subjects
allocated to 5 groups), therefore the study could be
underpowered to detect meaningful differences in
body composition between groups.
▪ Although 10 weeks is likely sufficient to detect
significant changes, long-term effects are still open to
question.
▪ Physical activity level was not objectively monitored,
and variation in this regard has the potential to
confound results.
▪ No specific dietary protocol or guidelines were
assigned, and no dietary records were taken/assessed.
▪ Subjects were not randomly allocated to the groups.
This design choice was driven primarily by ethical
limitations.
I would also add that the results of this study could be
limited to the level of alcohol consumption (24-36 g of
ethanol/day for men, 12-24 g of ethanol/day for women).
This is the equivalent of approximately 1-2 drinks/day for
women and 2-3 drinks/day for men. The effects of
amounts consumed beyond this moderate intake (in the
same context of this study) remain open to question.
Comment/application
The main findings of this study were as follows: 1) The
non-training group showed no changes in any of the
parameters tested. 2) All 4 of the training groups (beer,
alcohol-free beer, water, non-beer alcoholic beverages)
showed significant increases in lean mass and significant
[Back to Contents] Page 13
decreases in fat mass, with no significant between-group general obesity? A systematic review and meta-
differences. Among the training groups, significantly analysis. Nutr Rev. 2013;71(2):67-87. [PubMed]
reduced visceral fat compared baseline was only seen in 3. Traversy G, Chaput JP. Alcohol Consumption and
the alcohol-free beer, and the water condition. Between- Obesity: An Update. Curr Obes Rep. 2015;4(1):122-
group differences in visceral fat were not significant. In a 130. doi:10.1007/s13679-014-0129-4. [PubMed]
nutshell, moderate alcohol consumption did not appear to 4. SAMHSA. 2018 National Survey on Drug Use and
put a dent on progress in this untrained, general Health (NSDUH). Table 5.4B—Alcohol Use Disorder
population. in Past Year among Persons Aged 12 or Older, by Age
Group and Demographic Characteristics: Percentages,
The findings of the present study align with previous 2017 and 2018. Available here.
research. A systematic review by Sayon-Orea et al1
included 31 studies in total, consisting of 14 cross-
sectional studies, 13 prospective cohorts, and 4
intervention trials. Overall, alcohol consumption was not
linked to weight gain unless heavy drinking was engaged
(4 or more drinks per day). Light-to-moderate alcohol
intake (1-2 drinks per day), showed the potential to protect
against weight gain, particularly in the case of wine.
Bendsen et al2 conducted a meta-analysis of intervention
studies and found that beer intakes exceeding 500 ml
(approximately 16 oz) resulted general and abdominal
obesity, whereas insufficient data were available to draw
any firm conclusions about the association between
obesity and intakes below 500 ml.

In a well done narrative review by Traversy and Chaput,3

the important point is made that intervention studies
examining the effects of drinking typically last 4-10
weeks. Therefore, a small gain of 1 kg over a 10 week
period, while insignificant within the context of the
timeframe, would amount to 26 kg in 5 years if no
energetic compensation occurs. I would add the reminder
that in addition to the potential for “sneaky” caloric
accumulation, there’s also the potential for addiction and
dependency. According to the 2018 National Survey on
Drug use and Health, 5.8% of US adults are reported to
have alcohol use disorder.4

References

1. Sayon-Orea C, Martinez-Gonzalez MA, Bes-Rastrollo

M. Alcohol consumption and body weight: a
systematic review. Nutr Rev. 2011;69(8):419-431.
[PubMed]
2. Bendsen NT, Christensen R, Bartels EM, et al. Is beer
consumption related to measures of abdominal and

Alan Aragon’s Research Review – June 2020 [Back to Contents] Page 14


Immediate pre-exercise carbohydrate & the
boogeyman of hypoglycemia.
By Alan Aragon
The above graphic is by Henning Langer (@wod_science
on Instagram), which was accompanied by a
recommendation to “Always consume your carbs well
before (2h) before the workout to avoid this ‘rebound
hypoglycemia.” Being familiar with the body of literature
in this area, I took issue with this claim. So, I dove into the
fray and had a nice little exchange with Langer, who
conceded that his cautionary position about the danger/risk
of hypoglycemia was overstated. However, he stuck to his
guns with the claim that the risk of hypoglycemia is not
worth the low probability of performance enhancement of
carbohydrate consumed closer to the exercise bout than 1-
4 hours. The latter was where he left off in our comment
exchange, but his original claim specified a 2-hour
minimum.
To Langer’s credit, he was able to cite the joint position
stand of the AND/DC/ACSM on nutrition and athletic
performance.1 In the manuscript, pre-event fueling
guidelines are listed as 1-4 g/kg consumed 1-4 hours
before exercise lasting longer than 60 minutes. The
position stand omits any fueling recommendation within
the 60-minute period before the bout, so this can be
interpreted as a recommendation to not consume anything
at all. However, there is a rather substantial body of
literature to consider in light of the idea that we should
avoid carbohydrate ingestion immediately pre-exercise to
avoid hypoglycemia negatively impacting performance.
A thoroughly done review by Ormsbee et al2 tabulated 15
studies where carbohydrate was administered within 60
Alan Aragon’s Research Review – June 2020
minutes of endurance exercise (timing ranged 15-60
minutes pre-exercise, with 60, 45, and 30 minutes being
the most common lead times). The 15 studies contained 27
groups of subjects (various types of carbohydrate were
compared, most commonly high-GI such as glucose vs
lower-GI such as sucrose or fructose). The most common
carbohydrate dose was 1 g/kg. Out of these 27 groups, 16
showed no effect, 10 groups showed a performance
increase, and only 1 study showed a performance decrease.
Although the majority of studies examining this timeframe
(≤60 minutes pre-exercise) show no effect, 37% of the
treatments showed performance enhancement from
carbohydrate ingestion compared to placebo. This is no
small minority, and it is therefore worth investigating on
an individual basis to determine whether an immediate
pre-exercise carbohydrate (within 60 minutes out) benefits
performance. Given that only a single group within one of
the studies showed a performance decrement, the threat of
hypoglycemia hindering performance is very low, and is
outweighed tenfold by the potential for increased
performance despite fluctuations in glycemia. Ormsbee et
al’s findings reflect the conclusions of a review by
Jeukendrup and Killer,3 which are worth quoting:
“…it is clear that the risk of reduced performance is
minimal as almost all studies point towards unaltered
or even improved performance.”
Perhaps unsurprisingly, the glycemic index (GI) of the pre-
exercise carbohydrate is unlikely to have meaningful
impact on performance. In the largest meta-analysis on
this topic to date, Burdon et al4 found that there was no
clear advantage of consuming a low-GI pre-exercise meal
for endurance performance regardless of carbohydrate
ingestion during exercise.
References
1. Thomas DT, Erdman KA, Burke LM. Position of the
Academy of Nutrition and Dietetics, Dietitians of Canada,
and the American College of Sports Medicine: Nutrition and
Athletic Performance [published correction appears in J
Acad Nutr Diet. 2017 Jan;117(1):146]. J Acad Nutr Diet.
2016;116(3):501-528. [PubMed]
2. Ormsbee MJ, Bach CW, Baur DA. Pre-exercise nutrition:
the role of macronutrients, modified starches and
supplements on metabolism and endurance performance.
Nutrients. 2014;6(5):1782-1808. [PubMed]
3. Jeukendrup AE, Killer SC. The myths surrounding pre-
exercise carbohydrate feeding. Ann Nutr Metab
2010;57(suppl 2):18–25. [ANM]
4. Burdon CA, Spronk I, Cheng HL, O'Connor HT. Effect of
Glycemic Index of a Pre-exercise Meal on Endurance
Exercise Performance: A Systematic Review and Meta-
analysis. Sports Med. 2017;47(6):1087-1101. [PubMed]
[Back to Contents] Page 15

Muscle gain in men and women: What’s the
difference?
By Alan Aragon
_______________________________________________
Observations in the field
I regularly get asked the question in this article’s title by
women with the goal of muscle gain. In my field
observations, men gain muscle faster (and seemingly with
greater ease) than women. However, the problem with this
observation is that the majority of the female population
was not aiming at hypertrophy as a primary goal. So, it’s
possible that my lens is skewed by working with a larger
proportion of men aiming for muscle gain. A wrinkle I’d
like to add is that women in general seem to have an easier
time making lower-body gains (glutes, quads, hams) than
men. Men generally seem to experience just the opposite,
where upper-body gains are more easily attained. This is
just a personal observation. It’s doesn’t happen with
ironclad consistency, but it does appear to be the tendency.
On this note, Kadi et al1 reported that in competitive
powerlifters, the upper body musculature has more
androgen receptors than the lower body. However, sex
differences in this regard are unclear. Although field
observations and personal experience can be useful, they
need to be weighed against the more rigorous and
objective findings in the scientific literature. Let’s have a
look at the research directly comparing the hypertrophic
effects of resistance training in men and women.
Resesarch comparing sex differences in muscle gain
Men have 15-20 times greater circulating testosterone than
women,2 fueling the presumption that men an inherent
anabolic advantage. With this in mind, there is surprisingly
little research directly comparing the sex-specific
hypertrophic response to training. Earlier comparisons of
the effects of resistance training on men and women have
shown a mix of results, tending toward greater absolute
gains in men, but also tending toward similar (to greater)
relative gains in women. According to Cureton et al,2 these
studies are limited by cruder measures such as fat-free
mass (FFM), total bodyweight, and circumference
measurements. So, they ran a 16-week trial involving
hydrodensitometry to assess body composition and
Alan Aragon’s Research Review – June 2020
computed tomography to measure cross-sectional area
(CSA) in untrained subjects. Men showed greater absolute
increases in muscle mass, but proportional changes were
similar between the sexes. In a 26-week trial by Bamman
et al3 on older subjects (mean age 69 y), the myofiber
hypertrophic response to progressive resistance training
was markedly greater in older men than in older women,
with a myofiber size increase of 40% and 7%,
respectively. In another study on older subjects (>65 y), 18
weeks of resistance training resulted in a modest increase
in muscle CSA, with no significant difference between the
sexes. However, the increase in muscle quality (force
generated be knee extensor isometric strength, per unit of
cross-sectional area) was substantially greater in men
compared to women.
Size & strength differences
There are obvious anatomical/morphological differences
between men and women. Miller et al6 reported that
women had 45, 41, 30, and 25% smaller muscle CSAs for
the biceps brachii, total elbow flexors, vastus lateralis, and
total knee extensors, respectively. The men had nearly
double the type I and mean fiber areas in the biceps brachii
compared to women. Men also had significantly larger
type II fiber areas in vastus lateralis. However, no sex-
specific difference was seen in the strength to CSA ratio
for elbow flexion or knee extension. It was concluded that
the greater strength in men was mainly due to larger
muscle fibers.
More recently, a 10-week trial Gentil et al7 did not find a
significant sex-based difference in upper-body strength
increases after 10 weeks of progressive resistance training
in college-aged, untrained subjects. Hannah et al8 in found
that the greater absolute strength in men could be due to
greater muscle mass, since the strength to muscle mass
ratio was similar between untrained men and women.
There is a clear lack of sex-specific comparisons in trained
subjects, so absolute or proportional differences in strength
gain are open to speculation.
Concluding ruminations
As the evidence stands, there are clear differences in
muscle size (and strength) between men and women.
What’s less definitive is whether or not women can put on
muscle at the same rate as men. The limited evidence to
[Back to Contents] Page 16
date suggests that men have the advantage in absolute
increases, but in a proportional sense, men and women’s
rates of muscle growth from resistance training are similar.
On a related note, Dreyer et al9 found a lack of sex-specific
difference in muscle protein synthesis (MPS) and anabolic
signaling in response to a bout of high-intensity resistance
exercise. Phillips10 reported that younger men and women
have similar MPS responses to feeding, whereas MPS
response is diminished in older men and women, and this
decreased MPS response is more pronounced in older
women. This is grounds for vigilance against the older
population (particularly women) not neglecting protein
intake. A systematic review & meta-analysis by Coelho-
Júnior et al11 found that higher protein intakes are
inversely associated with frailty in older adults. Baum et
al12 reported that authoritative recommendations in the
field of protein and aging range 1.2-2.0 g/kg. For
individuals of any adult age bracket seeking to maximize
muscle growth, 1.6-2.2 g/kg is appropriate for the majority
of populations.13
An interesting question is whether there are sex-specific
differences in muscle mass preservation in the face of
detraining or disuse. Ivey et al14 found greater absolute &
proportional losses of muscle volume after 31 weeks of
detraining (after 9 weeks of training) in men than in
women. A review by Rosa-Caldwell and Greene15 reported
that that men and women have different muscle atrophic
responses depending on the stimulus or pathology. Women
show greater age-related muscle atrophy, while men show
greater atrophy in response to disease states such cancer
cachexia.
1. Kadi F, Bonnerud P, Eriksson A, Thornell LE. The
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Alan Aragon’s Research Review – June 2020
5. Bamman MM, Hill VJ, Adams GR, et al. Gender
differences in resistance-training-induced myofiber
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Explosive neuromuscular performance of males versus
females. Exp Physiol. 2012;97(5):618-629. [PubMed]
9. Dreyer HC, Fujita S, Glynn EL, Drummond MJ, Volpi
E, Rasmussen BB. Resistance exercise increases leg
muscle protein synthesis and mTOR signalling
independent of sex. Acta Physiol (Oxf).
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10. Phillips SM. Sex-based differences in muscle protein
turnover and metabolism in aging: feeding and
exercise responses. Sports Science Exchange (2014)
Vol. 27, No. 121, 1-5. [PubMed]
11. Coelho-Júnior HJ, Rodrigues B, Uchida M, Marzetti
E. Low Protein Intake Is Associated with Frailty in
Older Adults: A Systematic Review and Meta-
Analysis of Observational Studies. Nutrients.
2018;10(9):1334. [PubMed]
12. Baum JI, Kim IY, Wolfe RR. Protein Consumption
and the Elderly: What Is the Optimal Level of Intake?.
Nutrients. 2016;8(6):359. [PubMed]
13. Morton RW, Murphy KT, McKellar SR, et al. A
systematic review, meta-analysis and meta-regression
of the effect of protein supplementation on resistance
training-induced gains in muscle mass and strength in
healthy adults. Br J Sports Med. 2018;52(6):376-384.
[PubMed]
14. Ivey FM, Roth SM, Ferrell RE, et al. Effects of age,
gender, and myostatin genotype on the hypertrophic
response to heavy resistance strength training. J
Gerontol A Biol Sci Med Sci. 2000;55(11):M641-
M648. [PubMed]
15. Rosa-Caldwell ME, Greene NP. Muscle metabolism
and atrophy: let's talk about sex. Biol Sex Differ.
2019;10(1):43. [PubMed]
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