1 the Effect of Nutritional Ketosis on Strength and Power in Tactical

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The Effect of Nutritional Ketosis on Strength and Power in Tactical Athletes

Thesis

Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in

the Graduate School of The Ohio State University

Emily Barnhart

Graduate Program in Kinesiology

The Ohio State University

2018

Thesis Committee

Dr. William Kraemer, Advisor

Dr. Jeff Volek

Dr. Carl Maresh

Copyrighted by

Emily Barnhart

2018

Abstract

The primary purpose of this investigation was to compare performance adaptations in tactical athletes utilizing a ketogenic diet (KD) vs. control (CON) during a

12-week strength and conditioning program in conjunction with their standard military fitness training. Little research has been conducted on the effects of a ketogenic diet on strength and power outcome goals, yet a ketogenic diet has demonstrated to be physiologically beneficial in other populations. Participants self-selected to a diet intervention KD (n=15), or CON (n=14). The training intervention included 6 weeks of resistance training, emphasizing back squat and bench press, and 6 weeks of power training, emphasizing Olympic lifts and plyometric training. PRE and POST- intervention, countermovement jump (CMJ), 1 RM back squat and bench press, repeated sprint intervals, an obstacle course, VO2 Max, and body composition measures were assessed. At Week 1 (MP1) and Week 6 (MP2) an abbreviated performance battery was conducted including CMJ, 1 RMs, and the sprint intervals. For KD, BF% was significantly higher PRE (25.6 ,SE 5.0) than POST (20.26, SE 4.9) compared to CON

PRE (22.0, SD 8.6) and POST (21.3, SD 8.4). For KD, FM was significantly higher PRE

(46.5, SE 9.8) than POST (33.6, SE 7.6) compared to CON PRE (38.2, SD 17.5) and

POST (36.9 SD 16.7). For KD, LBM was significantly higher PRE (135.9, SE 13.7) than

POST (132.9, SE 14.8) compared to CON PRE (131.4, SD 9.5) and POST (133.1, SD

10.1). There were no significant effects between groups for performance measures.

Absolute back squat PRE (mean 110.33, SE 5.41) and MP1 (mean 111.72, SE 4.76) were both significantly less than MP2 (mean 122.53, SE 4.47) and POST (mean 125.90, SE

4.50). Relative back squat PRE (mean 1.34, SE .06) and at MP1 (mean 1.37, SE .06) were both significantly less than MP2 (mean 1.53, SE .06) and POST (mean 1.59, SE

.06). Relative bench press PRE (mean 1.10, SE 0.07) and at MP1 (mean 1.11, SE 0.07) were both significantly less than MP2 (mean 1.16, SE 0.07) and POST (mean 1.18, SE

0.07). There was no effects of time or training on power measures. In summary, resistance training two days per week significantly improved leg strength but had little effect on upper body strength and power. A ketogenic diet had similar strength gains and performance measures compared to CON. This indicates a ketogenic diet can be an effective weight management tool in tactical athletes without causing detriment to power and strength-related tasks.

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Acknowledgments

To Dr. William Kraemer, for believing in me enough to bring me to The Ohio

State from UConn, for creating a team environment, and continuously encouraging me to spin every plate, thank you.

To Dr. Jeff Volek, for seamlessly incorporating me into your lab group and letting me play such an integral part in the huge endeavor of TANK, thank you.

To Dr. Carl Maresh, for providing an excellent example of leadership to this

“basement” and for sparking my passion for exercise physiology from the very first class in Connecticut (with old projector slides instead of a PowerPoint), thank you.

To the entire A24 crew, thank you for pushing me, believing in me, commiserating and celebrating with me, and ultimately making those eighty-hour work weeks some of the most fun and rewarding times in my life.

And finally, to my family for creating the most supportive environment I could ask for. Thank you for being incredible role models.

Vita

2011 ...... Ellington High School

2015 ...... B.S. Exercise Science, U. of Connecticut

2015-2016 ...... Graduate Teaching Associate, Department

of Exercise Science, The Ohio State

University

2016 to present ...... Graduate Research Associate, Dr. Volek

Research Group, The Ohio State University

Publications

Caldwell, L.K., W. H. Dupont, M. K. Beeler, E. M. Post, E. C. Barnhart, V. H. Hardesty, J. P. Anders, E. C. Borden, J. S. Volek, W. J. Kraemer (2018) The Effects of a Korean Ginseng, GINST15, on Perceptual Effort, Psychomotor Performance, and Physical Performance in Men and Women

DuPont, W. H., B. J. Meuris, V. H. Hardesty, E. C. Barnhart, L. H. Tompkins, M. J. P. Golden, C. J. Usher, P. A. Spence, L. K. Caldwell, E. M. Post, M. K. Beeler & W. J. Kraemer (2017) The Effects Combining Cryocompression Therapy following an Acute Bout of Resistance Exercise on Performance and Recovery. J Sports Sci Med, 16, 333-342. v

Flanagan, S. D., W. H. DuPont, L. K. Caldwell, V. H. Hardesty, E. C. Barnhart, M. K. Beeler, E. M. Post, J. S. Volek & W. J. Kraemer (2017) The Effects of a Korean Ginseng, GINST15, on Hypo-Pituitary-Adrenal and Oxidative Activity Induced by Intense Work Stress. J Med Food.

Kraemer, W. J., Caldwell, L. K., & Barnhart, E. C. (2017). Chapter 4: Developing a resistance training program for volleyball. In Handbook of Sports Medicine and Science: Volleyball (2nd ed., pp. 38-48). International Olympic Committee.

Fields of Study

Major Field: Kinesiology

Table of Contents

Abstract ...... ii Acknowledgments ...... iv Vita ...... v List of Tables ...... ix List of Figures ...... x Chapter 1. Introduction ...... 1 Chapter 2: Literature Review ...... 7 Foundational Concepts of Strength and Conditioning for Tactical Athletes ...... 7 Choice of Exercise ...... 11 Order of Exercise ...... 12 Volume of Exercise ...... 12 Intensity of Exercise ...... 13 Rest Periods Between Sets and Exercises ...... 15 Periodization and Programming ...... 16 Exercise Testing ...... 18 Modern Military Testing and Training ...... 19 A History of the Ketogenic Diet ...... 21 Physiological Adaptations to a Ketogenic Diet ...... 26 Keto-Adaptation and Athletic Performance ...... 28 Summary ...... 32 Chapter 3: Methods ...... 33 Experimental Approach ...... 33 Participants ...... 34 Testing Preparation ...... 35 Testing Timelines and Protocols ...... 36 vii

Countermovement Vertical Jump Testing ...... 37 One Repetition (1 RM) Testing ...... 38 Interval Sprints on the Hi-Trainer ...... 39 Obstacle Course Completion ...... 39

VO2 Max Testing ...... 40 Diet Interventions ...... 40 Resistance Training Intervention...... 41 Statistical Analyses ...... 45 Chapter 4: Results ...... 46 Body Composition ...... 46 1 RM Strength ...... 48 Countermovement Vertical Jump ...... 50 Repeated Sprint Intervals ...... 51 -1 -1 VO2 Max ml ·kg · min ...... 53 Obstacle Course Time to Completion ...... 53 Chapter 5: Discussion ...... 54 Conclusion ...... 61 References ...... 62 Appendix A: Informed Consent Document ...... 73 5. Can I stop being in the study? ...... 85 9. Will my study-related information be kept confidential? ...... 89 13. What are my rights if I take part in this study? ...... 91 14. Who can answer my questions about the study? ...... 92 Signing the consent form ...... 93

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List of Tables

Table 1. Participant Characteristics ...... 34 Table 2. PRE and POST testing battery...... 37 Table 3. MP1 and MP2 abbreviated performance testing battery...... 37 Table 4. Mesocycle 1 Template ...... 43 Table 5. Mesocycle 2 Template ...... 44 Table 6. Body Composition ...... 47 Table 7. Strength Measures...... 49 Table 8. Comparison of Power Measures ...... 52 Table 9. Aerobic Capacity ...... 53

List of Figures

Figure 1. Size Principle ...... 9 Figure 2. Force Velocity Curve ...... 14 Figure 3. Experimental Research Design ...... 34 Figure 4. Obstacle Course ...... 40 Figure 5. Comparison of Body Composition Measures ...... 48 Figure 6. Comparison of Strength Measures ...... 50

Chapter 1. Introduction

There are currently 1.3 million active military personnel in The United States

(DoD 2018). These tactical athletes protect and serve by utilizing their minds and bodies.

American soldiers need to maintain readiness to face any and all threats, and any decline in physical condition limits a warfighter’s ability to protect and serve. Therefore, mental and physical readiness must be at the forefront of military training. Among many, a critical difference between a tactical athlete and a sport professional is that a sporting outcome is win or lose. A tactical situation can be life or death. Further, a tactical athlete must also maintain readiness for duty year-round versus using traditional seasonal training methods (Szivak and Kraemer 2015). The Armed Forces have unpredictable scheduling and assignments and must be prepared to succeed in any environment or climate. Tactical athletes must gain and maintain physical prowess for any situation and be ready to deploy for a mission at any time.

Strength and conditioning programs are important parts of a soldier’s year around training program (Kraemer and Szivak 2012). We hypothesized that an additional program in addition to normal military fitness training would enhance soldier’s military physical readiness preparations (Kraemer and Szivak 2012). In addition to the demands of warfare, most soldiers typically carry a load of 44 to 46 kg (Escamilla 2018, Purdam et

1 al. 2004). As a result, up to 80% of injuries in combat units are attributed to training and load carriage, and the lower back often suffers from this as the most commonly injured body part (Pagnani and Russell 1994, Purdam et al. 2004, Quigley and Richards 1996,

Rauh et al. 2006). There are data to indicate larger, more muscular individuals tend to perform better in load carriage tasks, implying improved strength training during physical readiness training (PRT) can decrease this injury risk and improve injury statistics

(Kraemer 2004, Knapik et al. 2003). Strength training can improve upper body strength, increase lean mass, and strengthen tendons, ligaments, and bones, leading to an increased ability to successfully manage load carriage (Knapik et al. 2003). Strength training can also improve upper body strength which has been shown to be an important component to high intensity load carriage in both men and women (Kraemer et al. 2001). Reducing load carriage frequency in addition to strength and power exercises can further mitigate many overuse injuries (Hooper et al. 2013, Knapik et al. 2003, Schuh-Renner et al. 2017).

A major impedance to the military’s ability to maintain soldier readiness is the state of health in our nation. Similar to civilian patterns, prevalence of obese and overweight members in the military is increasing (McCarthy et al. 2017). Current military tactics to promote health, physical readiness, and cognitive function emphasize a carbohydrate-based diet and provide sugar-based supplements for energy during tactical missions. The guidelines largely align with general Academy of Nutrition and Dietetics’ guidelines and performance fueling tactics. The Tactical Strength and Conditioning

(TSAC) nutrition guidelines, in particular, promote carbohydrates as a main source of

2 energy, high fiber and protein, and increased fat during periods of high-energy demand to help reach an optimal increase in calories. Macronutrient guidelines aim to a standard of

45-65% carbohydrate, 15-35% protein, and 20-35% fat (Barringer and Crombie 2017).

For such energetic demands this may not be the optimal nutritional approach for dietary fueling and preparation.

However, it is theorized that a drastic shift in these fueling guidelines may further benefit an athlete’s performance, cognition, and body composition. A diet fueled primarily by carbohydrate provides a short-term benefit, but may not be most effective in military personnel, particularly during sustained operations in which carrying fuel sources may be logistically challenging. Upon the exhaustion of carbohydrate stores in the body, and external sources to refuel, physical performance can deteriorate (Phinney

2004). However, if an athlete has previously undergone ‘keto-adaptation’, the soldier will ideally be able to effectively access lipid stores as a fuel source and to maintain performance throughout the mission.

Keto-adaptation often promotes more favorable changes in body composition.

Typical weight loss occurs due to energy restriction results in lean tissue mass losses (de

Souza et al. 2012). However, a ketogenic diet may maintain lean body mass while promoting fat loss over muscle loss (Cox et al. 2003, Redman et al. 2007, Benoit, Martin and Watten 1965, Wilson et al. 2017). Increasing lean mass and decreasing fat mass to a

3 healthy, athletic standard can improve endurance performance and help prevent injuries during tactical training (Knapik et al. 2003, Mujika, Ronnestad and Martin 2016).

Keto-adaptation occurs when carbohydrate intake is restricted to less than ~40 grams/day. Ketones are produced in the liver from fatty acids and serve as an alternative fuel source in the body, particularly in the brain. Adapting to a high-fat, moderate- protein, low-carbohydrate ketogenic diet takes at least several weeks of nutritional ketosis and indicates metabolic adaptations to favor fat-utilization as a fuel source. Elite endurance athletes, in particular, have become incredible fat burners with long-term adaptation to a ketogenic diet (Volek et al. 2016).

Little research has been done in the area of keto-adaptation among strength and power athletes, and even less in a ketogenic diet among a military population. Thus, there is a dramatic need to examine the effects and feasibility of a sustained 12-week ketogenic diet in military personnel compared to those following typical high carbohydrate dietary guidelines control (CON) vs. a ketogenic diet (KD) while performing standard military fitness training along with a strength and power-based program in the weight room.

Specifically, this study compared a maximal back squat, bench press, countermovement jump, power output during ten repeated ten-second sprint intervals, and a military-based abbreviated obstacle course. It was hypothesized that this shift in training methods can increase strength, power, and tactical performance in modern-day warfare. Maximal squat, bench, and countermovement jump all rely on phosphocreatine stores as an

4 immediate fuel system and are likely not affected by a decrease in glucose uptake and utilization in the muscle. Sustainable power output, such as repeated sprint intervals, in theory may be impeded due to a lack of glycogen availability in the muscle. Yet, interestingly keto-adapted athletes have similar glycogen stores and resynthesis rates post-exercise carbohydrate-adapted athletes (Volek et al. 2016).

In summary, a diet low in carbohydrates can increase ketone production and fat utilization and potentially provide an advantage to military personnel by aiding in the maintenance of cognitive and physical performance when operating under stresses such as sleep deprivation, heat, dehydration, and undernutrition (Kyröläinen 2010, Niro 2005).

These stressors often occur in combination with poor provision of nutrients (Niro 2005,

Askew EW 1987). Adaptation to a ketogenic diet may benefit military performance via increased endurance and fat oxidation. Adopting a periodized strength and conditioning program can further benefit tactical athletes by improving body composition, muscular strength, and power aiding in today’s military missions involving quick, explosive tasks.

This type of training may help alleviate overuse injuries associated with more traditional

PRT programs. Strength training for the tactical athlete should mimic the scientific methods used for elite athletes. A needs analysis, periodized resistance training, and individualization whenever possible are important to improve the health and performance of soldiers (Kraemer and Szivak 2012). These two tools in combination allow our military personnel to maintain the necessary year-round readiness for any assignment or environment that may come their way. Therefore, the primary purpose of this

5 investigation was to compare performance adaptations in tactical athletes utilizing a KD vs. CON during a 12-week strength and conditioning program in conjunction with their standard military fitness training.

Chapter 2: Literature Review

Foundational Concepts of Strength and Conditioning for Tactical Athletes

Many elements affect the physicality and success of the modern day tactical athlete. Overall, athletes with a high level of physical fitness, particularly via resistance training, can improve fighting capacity and performance under stressful conditions

(Alvar, Sell and Deuster 2018). Comprehensive training includes strength, plyometric training, speed, agility, flexibility, and aerobic training. Military conflicts no longer require prolonged marches carrying heavy loads from front to front. Our current tactical environment is an “anaerobic battlefield” (Kraemer and Szivak 2012). Military tasks include lifting, sprinting, casualty evacuation, et cetera, all of which require muscular strength and power. These tasks can often be repetitive, or soldiers are asked to complete multiple successive missions day after day, which also requires a strong aerobic base.

Our current military warfighter, in short, needs to have the capability to complete any type of physical task successfully (Kraemer, Feltwell and Szivak 2017).

Muscular strength can be particularly critical as a foundational base for all other activities (Suchomel and Comfort 2018). Muscular strength is defined as the ability to create force against an external resistance (Stone 1993). Increases in muscular strength are associated with greater rates of force development, leading to increases in ability to

7 create force and a higher speed, or power (Turner and Comfort 2017). Power is more technically defined as the rate of work performed per unit of time, and differs greatly between the playing level of athletes, with higher level athletes usually holding the ability to create large amounts of force in a short time-span (Fry 1991).

Physiologically, increases in muscular strength are due to increases in muscle cross- sectional area allowing a greater capacity for force production (Suchomel and Comfort

2018). Hypertrophy is the increase in the size of individual muscle sarcomeres. This creates an increase in cross-sectional area and increases the force a muscle can produce due to a greater interaction potential between actin and myosin. The gain in size also creates a greater pennation angle, or the angle in which the muscle fibers are in relation to the force-producing axis (or bone), to allow more cross-bridge interactions within an area of muscle, thus creating more force potential (Kawakami, Abe and Fukunaga 1993).

Resistance training can increase muscle cross-sectional area by adding sarcomeres in parallel, which increases overall force production because each sarcomere acts independently to produce force. Plyometric training, or high-velocity training, may add sarcomeres in series, which increase the shortening or concentric velocity of muscle, allowing for increased performance in power movements, but not necessarily total force production (Stone 2007). See Figure 1.

Figure 1. Size Principle The size principle of motor unit recruitment dictates that motor units are orderly recruited from lower threshold to higher threshold activation cut-offs as required for external force production. Red circles = size and number of Type I muscle fibers, Tan circles = size and number of Type II muscle fibers. Larger circles = more muscle fibers that are recruited in an all or none fashion when the recruitment threshold for activation is met.

Further, the magnitude and rate of force produced depends on the number and type of motor units recruited. A motor unit is an alpha motor neuron and all of the muscle fibers it innervates. Classically, Henneman theorized the Size Principle in 1965, which indicates motor units are recruited based on a sizing principle (e.g., number of fiber, size of fibers, etc.) (Duchateau and Enoka 2011). Typically, motor units are recruited smallest to largest, indicating that these larger motor units are only recruited when high levels of force production are necessary in a given muscle. Therefore, a fundamental principle was established in resistance training: “In order for a motor unit to be trained, it must be recruited.” (Suchomel and Comfort 2018). The size principle is also operational for both concentric and eccentric force-time curves.

However, this theory may be slightly oversimplified. Motor units must first synchronize to achieve greater force production, a process that greatly improves over the initial six weeks of strength training (Milner-Brown and Stein 1975). Therefore, a novice will see greater improvements in strengths over their first six weeks of training than an experienced lifter, not because of increases in muscle size, but due to increases in neural motor unit synchronization. Further, heavy strength training can down-regulate neuromuscular inhibition to allow increased force production, more so allowing greater improvements in strength during initial draining in novice lifters (Aagaard et al. 2002).

Apart from specific physiological and neurological adaptations to exercise, it is important to design a strength training program intended for optimal gains by using the variables: specificity, progressive overload, variation, volume, frequency, duration, and intensity (Ratamess 2017). It is also important to consider the acute program variables within each workout: exercise choice, exercise order, number of sets and reps (volume), training intensity (load), and rest periods (Kraemer 2007). Volume and intensity specifically have strong indications on training goals. For example, muscular strength is classically trained with 6 or fewer repetitions, 2-6 sets, and at 70-95%. Power: 1-5 repetitions, 3-5 sets, and at 30-50%. Hypertrophy typically requires larger volume: 6-12 repetitions, 3-6 sets, and at greater than 65%. Muscular endurance, or the ability of a muscle to repeatedly exert a submaximal force through a given ROM or at a single point over a given time, is trained best when 2-3 sets are performed at a submaximal percentage of 1RM that elicits more than 12 repetitions (Alvar et al. 2018, Thomas et al.

2007, Schoenfeld 2010, Laputin P 1982). Greater detail in the acute program variables is explored below.

Choice of Exercise

Variety is an important factor when designing a workout, as each type of exercise has specific pro’s and con’s. Body weight exercises, for example, can be specific to an individual, and train multiple muscle groups. They provide easy accessibility and versatility and are related to increases in strength for untrained (Kraemer et al. 2001).

However, in trained individuals, they lack the ability to provide an overloading stimulus and lead to improvements in muscular endurance, rather than strength, which in itself is important if muscular endurance is the desired outcome goal (Turner and Comfort 2017).

Free weight exercises provide similar benefits to body-weight exercises, yet allow progressive overloading, improvements in muscular strength, and may also recruit and train muscle stabilizers. In essence, it forces the lifter to control the external mass in multiple degrees of movement. Weightlifting can provide improvements in both strength and power more than jump training or kettlebell training (Suchomel and Comfort 2018).

Other exercise choices that should be considered include single-joint versus multi-joint, unilateral and bilateral movements, machines, bands, balls, sleds, and plyometric training, which should be a combination of lower and upper explosive movements (Turner and

Comfort 2017).

It is important to train power using movements that require high velocity and power output, such as plyometric training and lifting movements that are not inhibited by the joint’s deceleration for protection of the joint (Newton et al. 1997). The clean and jerk, in males, can produce a relative power output of up to 80 watts/kg. A squat only produced 11-30 watts/kg in this research observation, and the bench press as low as 0.3 watts/kg (McMahon 2018). Thus, it would be inept to use bench press to train upper body power output.

Order of Exercise

The order in which exercises are performed is important considering later exercises are affected by fatigue and typically the exercises at the end of the workout will suffer in their performance if adequate rest is not allowed (Spreuwenberg et al. 2006).

Athlete safety should be the main concern when ordering exercises. In general, a workout should be completed from complex to simple, multi-joint before single-joint,

Olympic lifts first, and heaviest weights first (Ratamess 2017). This should allow the athlete to complete difficult lifts with greater efficiency or increased loading and prevent fatigue-related injuries.

Volume of Exercise

Volume, or the product of the number of sets, repetitions, and weight, is important to fluctuate throughout training programs to avoid overtraining and allow for variance in ability, motivation, and time. However, volume does need to increase over time as lifters

12 progress, and is an important factor in hypertrophy training (Figueiredo, de Salles and

Trajano 2018). It also plays a vital role in the variation or periodization of workouts in a resistance training program.

Intensity of Exercise

With regards to intensity, or the amount of weight lifted, it is important to provide a spectrum throughout training. However, outcomes are greatly influenced along this spectrum. Increases in cross-sectional muscle area, or hypertrophy, are typically achieved when the training phase includes intensity 60-80% of the 1 rep max (1RM) (Turner and

Comfort 2017). A 1RM is the maximal amount of weight that can be lifted through a complete range of motion with the proper form. Heavier percentages of a 1RM are required for optimal recruitment of motor units as mentioned by Henneman’s Size

Principle. Thus, 80-85% of 1RM is needed to increase strength, particularly in trained individuals (Lasevicius et al. 2018).

These heavier loads also enhance the magnitude and rate of force production and can thus improve power as well. See Figure 2. However, as previously discussed, it is also important to develop power using high velocity movements at less than 60% of

1RM. Velocity is the inverse of load, slows when the weight is heavier, making high velocity training impossible at heavier intensities (Barnes and Dawes 2017). In elite

Olympic weightlifters, however, it is possible, or even ideal, to train explosive-force at

90% of said lift (clean/jerk/snatch) (Ammar et al. 2017).

Figure 2. Force Velocity Curve A continuum of optimum training percentages based on outcome goal. As load (force) decreases, velocity can increase. Optimal training intensities to elicit improvements in power output are 30-60%.

Finally, consider the training status of the athlete. Maximal strength should be the first focus before training velocity or power. However, in highly trained athletes, the degree that strength can influence performance diminishes, and the focus should adjust to more sport-specific training, i.e. speed, power, agility, etc. while maintaining strength levels (Kraemer and Newton 2000). A typical standard for this level is a barbell back squat 1RM greater than two times the athlete’s body weight (Stone 2007).

Rest Periods Between Sets and Exercises

Many factors effect which length of rest should be chosen. When the goal is to lift at a high percentage of 1RM, adequate muscle recovery is necessary to illicit repeated success with heavy loads. In muscle, it is estimated 85% of phosphorylcreatine (PCr), or the muscle’s immediate, high-intensity energy source, is resynthesized within two minutes of rest, 90% in four minutes, and 100% in eight minutes (Harris et al. 1976).

However, it is important to train the muscle’s ability to resynthesize PCr quickly, so allowing full recovery during training is not ideal.

Guidelines for tactical strength and conditioning specifically recommend a two- minute rest interval when training strength. Men with greater strength may require more.

Athletes with a greater VO2 Max can often tolerate a shorter interval, though greater strength increases occur with longer rest intervals between sets, typically two to three minutes (Alvar et al. 2018).

Further, “power is dictated by the amount and rate at which ATP is synthesized and then hydrolyzed” (Turner and Comfort 2017). Peak ATP turnover occurs at about 15 mmol·kg-1, or roughly two seconds of maximal work capacity (Gaitanos et al. 1993). A

10-second sprint depletes ATP 15-30%, and the subsequent amount of ATP resynthesis is a critical factor in the power output of the next sprint (Jones et al. 1985). PCr has an even faster turnover rate of 80 mmol·kg-1 resulting in an almost completely diminished store in muscle after a 10-second sprint. (Gaitanos et al. 1993, Glaister 2005)

Training using intervals, often called high-intensity interval training (HIIT) that accumulate an oxygen deficit will induce desired outcomes in metabolic pathways to allow for greater success in activities that require repetitive bouts of high power output, such as repeated sprints (Bishop, Girard and Mendez-Villanueva 2011, Bogdanis et al.

1996). One study showed 10 repeated 6-second sprints with a 30-second rest period increased the ratio of PCr used during metabolism as high as 80% by the last sprint.

Glycolysis rates decreased down to 16%. This change in metabolism, along with an increase in muscle lactate, resulted in a 27% decrease in power output (Gaitanos et al.

1993). Training to improve these factors, or repeated-sprint ability (RSA) overall usually involves a 1:1 work to rest ratio for at least 5 to 10 minutes (Baker, McCormick and

Robergs 2010). Aerobic capacity is important in developing RSA as well, and is often trained using little to no rest intervals with a work rate at a lesser percentage of VO2 Max.

Periodization and Programming

The concept of progressive overload must be applied within a program by manipulating one or all of the five acute program variables. Hans Selye first described this in 1956 is General Adaptation Syndrome. A stress (resistance training) must be introduced to initiate the “alarm phase” in which performance decreases. The body then adapts to the stimulus in the “resistance phase” and performance returns to baseline.

Supercompensation can then occur to improve performance and create a new, elevated baseline (Selye 1984). This process, continuously repeated over a period of time, in

16 various ways with periods for “alarm” and periods for “supercompensation” is periodization.

Over time, various methods of periodization have developed. Linear periodization gradually increases intensity over time, while reducing volume, to allow strength and power to peak at the end of a hypertrophic training phase (Siff 1999, Smith 2003). Block periodization divides training into specialized mesocycles, typically 2 to 4 weeks, sometimes 6-weeks in length, to develop a specific goal within each cycle (Ratamess

2018). Research often indicates block periodization may help achieve better outcomes compared to other models by allowing a specific characteristic, such as power, to be trained while maintaining previous development, such as strength, and is an the approach that can be used in program design (Turner and Comfort 2017). Finally, nonlinear periodization varies intensity and volume in a 7 to 10-day cycle, often allowing for athlete readiness to train, and other factors that may impact day-to-day training (Siff

1999, Smith 2003). Also, with military schedules as with long-season athletes it allows more flexibility in the scheduling. In fact, a modification of this called, “flexible nonlinear periodization” may provide the most program design freedom to respond to other schedule and activity challenges (e.g., unexpected missions, hard practices etc.).

Further concepts of stress adaptation have developed. Verkhoshansky suggested the concept of stimulus-fatigue-recovery-adaptation, proposing detraining occurs in the absence of additional stimuli. Zatsiorsky and Kraemer in 2006 added the principle of

17 diminishing returns. Monotonous training volume, intensity, and method can lead to stagnation and a decreased rate of adaptation. However, too much variability can decrease adaptation and development of specific skills. Matveyev in 1997 also introduced the concept of a loading paradigm, in which training gradually increases, and is subsequently followed by a period of active recovery. This typically follows a 3:1 paradigm, though can vary depending on intensity of training and fitness level of the athlete. While there are many approaches, the basic essence of periodization is to progress through a foundation of strength and endurance to more specific skill work, like power. There is typically an inverse relationship between volume and intensity and a need for continuous, diverse stimuli with appropriate recovery.

Exercise Testing

It is important to include exercise testing to assess the value of the program created and the fitness level of the athlete compared to a standard, which may be a population, but is often themselves. The timing, selection, and order of fitness testing is essential to understand in order to ensure the assessment is testing the appropriate variable. For example, as we know, muscular strength is the maximum amount of force a muscle can produce. Therefore, a one rep maximum test is most appropriate to accurately determine muscular strength. Muscular power, however, requires rate of work to be assessed per unit of time. Tests for power include explosiveness, such as a vertical jump.

Testing should occur at the beginning and end of the specific training cycle that focuses on improving the test component. The environment of testing should remain as controlled

18 as possible throughout different sessions. Finally, according to the NSCA (National

Strength and Conditioning Association) tests should be completed in the following order:

• non-fatiguing (i.e. vertical jump)

• agility

• maximum strength (i.e. 1RM)

• Sprint testing

• Muscular endurance

• Fatiguing anaerobic capacity

• Aerobic Capacity

Testing should involve a warm up and cool down and standardized instructions and demonstrations. Any criteria to maximize safety should be considered in all testing sessions.

Modern Military Testing and Training

The Army initially implemented mandatory fitness testing after WWI, and included a 100-yd dash, broad jump, fence climb, hand grenade throw, and an obstacle course (Alvar et al. 2018). Physical testing in the military provides unique challenges in that testing must be easy to complete with little equipment, training, and budget. As testing batteries in the armed forces over the years have evolved, efforts have been made to improve relevancy of both military testing and training as the landscape of the battlefield has transformed.

In a series of studies assessing Basic Training, observations of excess endurance training were noted, without enough stimulus to increase maximal strength (in leg extensors) over the eight-week period (Santtila et al. 2008). However, the team later noted that the demands of Basic Training may compromise the potential adaptation to strength training, though this does not make it any less vital for military tasks (Santtila et al. 2010). Again, the challenge the military faces is creating a training program with little budget and equipment and with the same mental readiness training that has been tried and tested through the decades. Current standards of training, which often includes a highly endurance-based program, provides an environment to train mental toughness, but may interfere with strength and power development, particularly in lower extremities (Santtila,

Kyrolainen and Hakkinen 2009). In a similar study involving Army Basic Training,

Harman et al. note improvements in physical performance, but questions if the

Standardized Physical Training program can sustain long-term gains using solely body weight-based training methods (Harman et al. 2008). Again, however, weight-based training methods are low-budget and easy to implement.

These traditional army-style calisthenics will improve performance during the initial two-to-three months of training. Long term, a more traditional resistance program is necessary. Substantial improvements have been noted in military personnel that include resistance training with weights (Alvar et al. 2018). Per Kraemer et al. in 2004, APFT scores responded positively to all types of resistance training, indicating that any form of periodized strength and conditioning program is likely to produce greater results than the

20 current standard military training. However, only the group with resistance training, specifically, improved 2-mile load carriage times, even though all other groups improved unloaded 2-mile times (Kraemer 2004). In 2002, Williams et. al. (Williams, Rayson and

Jones 2002) made a similar statement imploring the British Army to include a carefully designed resistance training program within their 8-week basic training, specifying that many military tasks require handling materials, which, in the task’s nature, requires muscular strength. Finally, it is important to note that although women begin with a lesser baseline strength ability, gender differences can be reduced with resistance training

(Kraemer et al. 2001).

It is important to consider both the feasibility of the training, testing, and programming while also providing resources to give optimal performance outcomes to our soldiers. This is true in all aspects of military training, including diet and lifestyle modifications. Next, the history and effectiveness of a ketogenic diet is explored as an avenue for improved military outcomes.

A History of the Ketogenic Diet

Recently, the concept of a high-fat, very low-carbohydrate lifestyle, or a ketogenic diet, has been highly debated throughout the scientific, nutrition, and athletic communities. While a ketogenic diet may seem to be a new topic in both the health and performance worlds, its history dates back as far as 1872 with William Harvey’s notes

“On Corpulence in Relation to Disease” (W 1872).

Then, in an expedition from 1878-1880, known as the Schwatka Expedition, records exist of incredible athletic feats on an extremely high-fat, Inuit diet (consisting mostly of whale blubber). It is reported Schwatka walked 65 miles in less than 48 hours to reach safety and journey home. Similarly, Vilhjalmur Stefansson explored the

Canadian Arctic Coast, again, with a local Inuit tribe and local diet. Stefansson was so impressed with the performance benefits of the local cuisine, he recreated the diet in a lab setting for 12-months to continue to study the outcomes. Unfortunately, it was

Stefansson’s advocacy of a high-fat diet to WWII troops that inadvertently led to the dismissal of high-fat, low-carbohydrate for performance in the research world, which will be further discussed later. Stefansson was certainly a dividing force in the field of nutrition for performance, and it is not until many decades later that research in high-fat diets for performance began to surface again (Phinney 2004).

In the early 1920’s two men, Wilder and Winter of the Rochester Mayo Clinic, began clinical research in ketogenic diets. Though formulated slightly different in those days, the concept remains similar. A diet composed of mostly fat, moderate protein (1 g/kg or less), and very small amounts of carbohydrate induces a state of ketosis, where the body adapts to utilize fat and ketone bodies for energy. These researchers at the

Rochester Mayo Clinic formulated the diet with a ketogenic to glucogenic food ratio, usually 2:1. In the 1920’s these researchers expressed interest in this diet for the

22 treatment of diabetic patients (Wilder and Winter 1922). However, research utilizing a ketogenic diet with diabetic patients didn’t occur until quite a few decades later.

Most of the early research was in epileptic children (WS and EF 1930, Ellis 1931,

Cooder 1933). Researchers also used a ketogenic diet to treat urinary tract infections.

Adaptation to the diet lowers pH below 5.0, due to acetone and diacetic acid in the urine, and kills the bacteria causing the infection (Wilson 1933, Robb and MD 1933,

Summerfeldt, Johnston and Kaake 1935).

In the 1960’s, research teams observed the effect of this diet intervention on body weight and body composition. Benoit et. al., in 1965 examined 7 active Navy personnel; all overweight with an average body fat percentage of 44%. In a controlled cross-over study, these men fasted for 10 days, ate a normal high-carbohydrate diet composition at

1,000 calories for 4 days, then completed 10 days of a ketogenic diet at 1,000 calories per day. Of course, these men lost a significant amount of weight during both interventions

(9.6 kg and 6.6 kg respectively), but the type of weight loss that occurred raised eyebrows. 62% of weight lost in the fasting intervention was lean body mass. During the ketogenic intervention, almost all of weight lost was from fat mass. In fact, less than 1% of weight loss came from lean body mass in the ketogenic intervention (Benoit et al.

1965).

These figures certainly piqued interest. That paper supported “the contention

[that] high fat diets are most effective in treating obesity” (Benoit et al. 1965). However, the research continued to focus on epilepsy, and even schizophrenia, though with very little luck due to psychiatric patients sneaking carbohydrates to those in the study

(Pacheco, Easterling and Pryer 1965).

Then, in 1972, The Atkins Diet Revolution was published. It was not the first of its kind, starting as the “banting” diet, then the Air Force Diet (1961), “Calories Don’t

Count” (1964), and The Drinking Man’s Diet (1972). However, The Atkins Diet was, and remains today, one of the most popular weight loss books on the shelves.

In 1972, JAMA published a skeptical review. However, much of this reviews statements are correct, and the Atkins book, while not a true ketogenic formula, did not do itself justice in the claims Dr. Atkins made. A person following this diet could eat as much as they wanted, yet it still produced weight loss. JAMA correctly denies this by stating no diet can produce weight loss without a reduction in calories, regardless of macronutrient breakdown. However, fat is very satiating, and most on an Atkins diet do reduce calories, albeit inadvertently. The review accredits the initial greater rate of weight loss to sodium and water loss, which is true when sodium intake is not increased during adaptation. Atkins also claims weight loss is due to a “fat mobilizing hormone”. It is unclear if such a phenomenon exists. The authors rightly express serious concern about the nutrition information Atkins provided to the public when no mechanism was known

24 at the time. The authors also expressed concern of hyperlipidemia, hypercholesterolemia, increased risk of coronary heart disease, artherosclerosis, hyperuricemia, and increased fatigue after 2 days on the diet (1973).

Atkins is an important milestone in the history of a high-fat, low-carbohydrate lifestyle for two reasons. It produced a huge amount of public interest and attention. Yet, it made unscientific claims and “selling points”, causing researchers and dietitians at the time to brush it aside, with little interest in discovering the true mechanisms. A ketogenic diet completely strays from typical dietary guidelines, so it is somewhat understandable why researchers were hesitant to study it. Atkins only further turned that hesitancy into utter dismissal.

Research in the latter part of the 1970’s remained slow. However, in the 1980’s, the first study examining exercise and a ketogenic diet is published by Phinney et. al. out of The University of Vermont. 6 obese subjects consumed a ketogenic diet (less than 10 g/day CHO) and exercised for 4 weeks. VO2 Max decreased at week 1, then increased

155% from baseline during post testing. Similarly, muscle glycogen significantly decreased at week 1, but normalized to starting levels by post testing (Phinney et al.

1980). This first week drop in performance levels becomes an immensely important, and unfortunately neglected, divide in low-carbohydrate performance research.

Phinney et. al. repeated this study in 1983 with a healthy population and eucaloric diet. Again, performance was not compromised after adaptation. Metabolically, Phinney emphasizes an important finding here: Fat becomes the predominant muscle source during exercise. While research previously noted RQ levels below .70 at rest, Phinney here notes an RQ during exercise dropping from .83 to .72 from pre- to post-intervention.

An RQ (respiratory quotient) closer to .70 denotes fat as a primary fuel source.

Furthermore, there was a 3-fold decrease in glucose oxidation and 4-fold decrease in muscle glycogen use during exercise (Phinney et al. 1983). It is here, we start to consider these implications on endurance athletics. Fat as a fuel source, as opposed to glycogen or glucose metabolism, provides an exponential increase in stored potential energy. Even in thin athletes, stored fat holds greater than 20,000 kcal compared to glycogen stores around 2,000 kcal (Hyde, Miller and Volek 2017).

Both in exercise, and other populations, research in this area began to gain speed throughout the 1990’s, bringing searchable articles from scholarly sources up to 154. This number then explodes in the early 2000’s up to 732 articles by 2010, and continues to grow today.

Physiological Adaptations to a Ketogenic Diet

Much of the divide in the research community revolves around long-term health outcomes. Specifically, debate often includes concern over the impact of cholesterol and lipid outcomes from a high-fat diet. It is typically accepted that a standard American diet

26 high in fat, specifically saturated and trans fats, leads to a greater risk of cardiovascular disease. However, it is important to consider diet and lifestyle factors as a whole (Ruiz-

Nunez, Dijck-Brouwer and Muskiet 2016). A well-controlled ketogenic diet, in spite elevated saturated fat intake, has been shown to decrease cholesterol in obese individuals, both with initially high levels and normal ranges of cholesterol (Phinney et al. 1980,

Jabekk et al. 2010, Dashti et al. 2006). Specifically, an increase in HDL cholesterol and decrease in LDL cholesterol is typically observed (Westman et al. 2007, Dashti et al.

2006). In studies where little change in LDL cholesterol occurs, the size of the lipid particle still improves from small to large particles (Westman et al. 2007). A decrease in fasting triglycerides is characteristic as well (Jabekk et al. 2010, Westman et al. 2007).

Metabolically, the body shifts from glucose metabolism to fatty acid and ketone metabolism. Glucose-dependent cells and tissues, such as red blood cells and the renal medulla, receive glucose through gluconeogenesis and glycogenolysis (Westman et al.

2007). Gluconeogenesis is the metabolic generation of glucose for energy from non- carbohydrate sources. Glycogenolysis is the metabolic breakdown of glycogen to free glucose for energy. After 11 days of intervention, recorded rates of gluconeogenesis increased up to 15% (Bisschop et al. 2003). An increase in lipoprotein lipase activity is also observed after 4 weeks of adaptation, indicating a greater capacity for triglyceride uptake and storage in muscle (Kiens et al. 1987).

Hormonally, a decrease in serum insulin is observed along with an increase in total T4. No changes in glucagon, testosterone, IGF-1, cortisol, or T3 are noted (Volek et al. 2002). Little side effects and risk factors have been observed. Some experience constipation, headache, weakness and skin rash (Westman et al. 2007). One case does report hypertriglyceridemia-related pancreatitis due to the patient’s increase in triglyceride levels (Buse et al. 2004).

Keto-Adaptation and Athletic Performance

Research indicates metabolic adaptations to a ketogenic diet occur over 2 to 4 weeks (Westman et al. 2007). Research that does not allow at least a 14-day adaptation period often demonstrates declines in performance, and studies that failed to meet this adaptation period have been disregarded in this review.

There is still adequate literature that follows an appropriate study design and utilizes a well-formulated ketogenic diet. This research often observes positive changes to various aspects of performance. However, most research has been conducted with endurance-based athletes and testing, or with body composition as the main outcome goal. Little is known on the effects of a ketogenic diet and strength and power outcomes.

Body composition outcomes often indicate favorable changes in overall weight, fat mass and lean body mass. Weight loss can be expected following a ketogenic diet and energy restriction over time (Cox et al. 2003, Redman et al. 2007). At this point, it

28 should be assumed that weight loss occurs due to calorie restriction, and not necessarily the macronutrient composition. However, changes in lean body mass (LBM) and fat-free mass (FFM) have been observed to be notably different between various weight-loss approaches. As previously mentioned, in 1965, 7 active Navy personnel, averaging 44% body fat, underwent 10 days of fasting, a 4-day 1000-calorie diet, and then 10 days of a ketogenic diet. Understandably, more weight loss occurred in the fasting period compared to the 1000-kcal ketogenic period (9.6 kg vs. 6.6 kg), but it should be noted that 62% of weight loss was from LBM in the fasting period and less than 1% from LBM in the ketogenic intervention (Benoit et al. 1965).

Further, in a 10-week diet and exercise training study, the ketogenic group experienced significant increases in LBM and muscle thickness while the control group did not. At the same time, both groups experienced significant differences in fat loss

(Wilson et al. 2017). After a different 10-week trial in women, no significant differences in LBM occurred, though significant fat mass was lost in the ketogenic + exercise group.

The normal diet + exercise group experienced the opposite phenomenon, with gains in

LBM, but no losses in FFM (Jabekk et al. 2010). In a 6-week non-energy restricted trial

(with no control group), healthy males lost about 2 kg equally from LBM and FFM

(Urbain et al. 2017).

Strength and power outcomes in power athletes are limited in research to date. In theory, anaerobic performance is likely to be effected when following a ketogenic diet

29 due to reduced muscle glycogen concentrations (Westman et al. 2007). However, in endurance athletes, muscle glycogen repletion and utilization rates are similar in both keto-adapted and control elite ultra-endurance runners. These runners showed no significant difference in resting muscle glycogen after a 180-minute run and after 120- minutes of recovery (Volek et al. 2016). In a 100 km time trial in cyclists, followed by a critical power test, power significantly increased by 1.4 w/kg in the keto-group compared to .7 w/kg in the control (McSwiney et al. 2017). However, it is unclear if this is related to changes in weight in the keto-group throughout the intervention. One study indicated a decrease in peak power (10%) and mean power (20%) during the initial Wingate sprint after 6-weeks of a ketogenic diet and training (Fleming et al. 2003). Others have noted a lack of improved Wingate power (W) after 10-weeks diet and training in the ketogenic group versus improvements in a high-carbohydrate control group. However, improvements in power were observed after the reintroduction of carbohydrate for one week (Wilson et al. 2017). It is important to continue to explore further questions regarding a ketogenic diet and power output.

Strength outcomes are similarly, if not more, limited. Two human studies observed strength, via 1RM. Wilson et al. noted an improved squat and bench 1RM in both a ketogenic group and Western diet group after 10-weeks of hypertrophy training

(Wilson et al. 2017). Jabekk et al., 2010 noted no difference in ability to perform during strength training sessions while on a ketogenic diet, but did not note specific gains or losses (Jabekk et al. 2010).

Paoli et al. completed a study of 9 elite male gymnasts on 30 days of a ketogenic diet. However, the diet composition included 40.7% protein and 54.8% fat, and a control with 46.8% carbohydrate and only 14.7% protein (Paoli et al. 2012). A well-formulated ketogenic diet is high in fat (70-75% intake), moderate in protein (15-20%), and low in carbohydrate (5-15%). It is ideal for a control group to follow standard nutrition guidelines of 45-65% carbohydrate intake. Therefore, the results of Paoli’s study cannot be indicative of a ketogenic diet.

Rats following a ketogenic diet gained 17% greater gastrocnemius muscle mass compared to a control chow. However, it is important to note that the ketogenic chow contained 20.2% protein and the control chow only 15.2%. Certain amino acids were consumed in greater quantities in the control group, but it is important to control for protein in similar studies in the future (Roberts MD 2016).

Protein intake is a common debate for two reasons. One, a poorly formulated ketogenic diet with too much protein can metabolically divert the subject away from ketogenic pathways. Essentially, an excess of protein will metabolically decrease rates of ketosis. Two, because of the nature of performance research, strength and power in particular, protein intake is important to control when changes in muscle mass are observed. Protein is necessary to induce muscular hypertrophy, so it is debated whether hypertrophy occurs due to higher protein content within the diet or due to ketosis (Aragon

31 et al. 2017). Very few studies match protein intake between the ketogenic and control groups, so it is difficult to eliminate this research from examination. However, protein should be considered when examining body composition data and needs to be further researched in the future.

It is important to clarify expectations of a well-formulated ketogenic diet and consider protein intake in research moving forward. Studies are also needed in elite-level power and strength athletes to clarify both maximal and relative strength and power outcomes. The TANK study hopes to fill some of these gaps in the research.

Summary

In summary, program design for a modern-day warfighter should focus on strength and power training as a foundation for military tasks. Program variables should be focused to elicit maximal improvements in these two outcome goals. Little research has been conducted on the effects of a ketogenic diet on these outcome goals, yet a ketogenic diet has demonstrated to be physiologically beneficial in other populations.

Chapter 3: Methods

Experimental Approach

This study used an experimental research design comparing KD versus CON.

This study was part of a larger study examining molecular and cardiovascular aspects of the KD. Participants completed a battery of physical, cognitive, and metabolic tests before and after a 12-week intervention. Participants were given an overview of each diet and self-selected into the KD or CON group. Groups were matched based on age, sex, and body composition. Participants in both groups completed 12-weeks of a strength and conditioning intervention based on the length of subject’s time in the diet component of the study. Participants were recreationally trained based on ACSM standards and instructed to maintain, not increase, their training volume during the study. The full research design is depicted in Figure 3.

Figure 3. Experimental Research Design

Participants

Each participant was briefed on the risks and benefits of the study before signing an institutionally approved informed consent document (Appendix A). The study was approved by the Ohio State University’s Institutional Review Board for use of human subjects in research. The characteristics of the experimental participants can be seen in

Table 3.

CON KD Sex F=2, M=12 F=2, M=13 Age (yrs) 24.6 (9.0) 27.4 (6.8) Height (cm) 179.4 (5.2) 175.5 (5.7) Weight (kg) 79.8 (5.5) 85.7 (7.8) BMI 24.9 (2.4) 27.9 (2.9) BF (%) 22.0 (8.6) 25.6 (5.0) Participant characteristics presented as Means (SE).

Table 1. Participant Characteristics

A total of 29 participants completed this study, (KD n=14, CON n=15). There were no significant differences between groups at baseline. All participants were involved in the United States military as active duty, veterans, or enrolled in the ROTC program at The Ohio State University. Sex was distributed as 86.2% male (n=25) and

13.8% female (n=4). Female participants were equally distributed between groups (KD n=2, CON n=2). Race was equally distributed between groups as 72.4% Caucasian

(n=21), 13.8% Asian (n=4), 10.3% Hispanic (n=3), and 6.9% Black (n=2). There were no significant differences between groups for age (KD 27.4 yrs ± 6.8, CON 24.6 yrs ± 6.8), height (KD 175.5 cm ± 5.7, CON 179.4 ± 5.2), BMI (KD 27.9 ± 2.9, CON 24.9 ± 2.4), or body fat percentage (KD 25.6 ± 5.0, CON 22.0 ± 8.6). There were 22 training sessions over the 12-week training period and 2 midpoint abbreviated test sessions. There was no significant difference between groups for program completion rates (KD mean 78.9%, SE

.03, CON mean 77.4%, SE .03).

Testing Preparation

Participants were asked to refrain from physical exercise, drugs, and alcohol 24- hours prior to their performance testing dates and follow a typical sleeping pattern. CON participants were asked to consume a typical diet prior to testing. The KD consumed their typical pre-intervention, high-carbohydrate diet prior to testing, and then a standardized ketogenic diet prior to midpoint and post-intervention test dates. Participants were asked to consume adequate water intake prior to testing and encouraged to drink an 8-ounce glass of water prior to bed and upon waking. Participants otherwise arrived at least 8-

35 hours fasted to complete the testing battery. All performance testing was completed in the participant’s same pair of athletic sneakers.

Testing Timelines and Protocols

PRE, MP1, MP2, and POST testing consisted of the identical procedures and testing protocols. PRE and POST testing batteries were extensive and included biological, neural, and cardiac assessments not evaluated in this paper. A full depiction of

PRE and POST testing batteries is included in Table 2. MP1 was precisely completed between day 4 and 7 of the nutritional intervention in place of the second training session.

MP2 was completed at week 6 of the intervention in place of the 12th training session.

The midpoint performance tests included a hydration test via urine specific gravity using a High Precision TS400 Clinical Refractometer (Reichert Inc., Buffalo, NY) to make sure all participants were considered hydrated (USG ≤ 1.025) for all testing protocols, a dynamic warm up protocol (e.g., body weight squats, lunges, etc.), maximal strength determined by a 1RM test using a barbell, countermovement vertical jump (CMJ) test on the force plate, and a repetitive interval sprint test on a Hi-Trainer in laboratory testing device. A full depiction of the MP1 and MP2 testing battery is included in Table 3.

Test Session 1: Test Session 2: Test Session 3: RMR Rest CMR Hydration

DEXA Bruce Protocol (VO2) Blood Sample ANAM Stress MRI CMJ Muscle Biopsy Squat 1RM Bench 1RM Sprint Intervals Obstacle Course A minimum 48 hr. recovery period was required between test sessions.

Table 2. PRE and POST testing battery.

Midpoint Session: Hydration CMJ Squat 1RM Bench 1RM Sprint Intervals

Table 3. MP1 and MP2 abbreviated performance testing battery.

Countermovement Vertical Jump Testing

A countermovement vertical jump was used to determine whole body muscular performance capabilities (DuPont et al. 2017). Participants performed a practice jump, followed by 3 maximal effort countermovement vertical jumps with 30 seconds between each jump. The CMJ started in the upright position with the participants hands on their hips and was initiated with a downward movement by flexing at the knees and hips

(eccentric phase) until their knee angle was approximately 90°. They immediately extended their knees and hips to jump up in the air with maximal effort. Jump power (W) data was collected using an Advanced Mechanical Technology Inc. (AMTI) force plate 37

(Watertown, MA) with a sample rate of 200 Hz. The best of three attempts was used for analysis. Jump power was analyzed using Accupower 2.0 software (AMTI, Watertown,

MA, USA).

One Repetition (1 RM) Testing

Maximal strength 1 RM strength was determined for the squat and bench press using a free weight barbell (EliteFTS, London, OH). For the squat, each participant descended to the parallel position by flexing the knees and hips until the greater trochanter of the femur reached the same horizontal plane as the superior border of the patella and then completed the movement by ascending to the upright and standing position. Proper form throughout the lift was evaluated to verify a proper lift. For the bench press, each participant eccentrically lowered the bar until it contacted the chest and then upon touching (no bouncing) the chest the bar was then returned to the starting position with fully extended elbows. Any trials failing to meet standardized technique criteria were not counted as a good lift. The procedure for the 1 RM testing consisted of a warm up of of 5–10 repetitions with approximately 40–60% of perceived maximum, a second set consisting of three to five repetitions with approximately 60–80% of perceived maximum followed by one repetition attempts with progressively heavier weight until the

1 RM was achieved. This was determined within 3-5 maximal attempts and 3-5 minutes of rest was allowed between efforts and is previously described in greater detail (Kraemer et al. 2006).

Interval Sprints on the Hi-Trainer

Ten, ten-second sprint intervals were completed on a self-propelled, resistance treadmill (Hi-Trainer, Bromont, Canada). Participants completed the ten intervals in two sets of five. Both sets consisted of 5, 10-second sprint intervals with a 10-second walking rest period. Participants were given a 2-minute rest period between the 1st and

2nd set. To propel the treadmill, participants angled their chest against the force pads close to a 30-45º angle. This is designed to mimic the body position of an acceleration phase of a sprint. Participants were familiarized with the machine and allowed to adjust the height and angle of the force pads. These preferences were recorded in the PRE- session and repeated for all subsequent test batteries. Participants were encouraged to exert maximal effort for each sprint and discouraged from pacing.

Obstacle Course Completion

Participants completed a short obstacle course that included a 30m sprint, zig zag run, and 70 kg casualty drag. Participants started in the prone position, sprinted 30m to a cone, then zig-zagged through 9 cones, and were instructed to drag the dummy completely beyond the final completion line. A diagram of the obstacle course is depicted in Figure 4. Completion time was recorded by two researchers using two stop watches. The average of the two times was calculated for data analysis.

Figure 4. Obstacle Course

VO2 Max Testing

VO2 Max testing was completed in conjunction with MRI data collection at The

Ohio State University Wexner Hospital. Participants were instructed to complete a brief warm up before completing a Bruce Protocol to exhaustion. A Bruce protocol starts at a treadmill speed of 2.7 km·h-1, a 10% incline, and increases in speed and gradient every 3 minutes until the subject reaches exhaustion (Bruce 1971). Oxygen consumption (RQ) was measured via indirect calorimetry (ParvoMedics TrueOne 2400).

Diet Interventions

Participants that self-selected into the KD diet intervention group were provided nutritional education on the types of foods, risks, and expected outcomes prior to the nutrition intervention. Participants received weekly groceries and pre-made meals. All meals were prepared in the Research Kitchen on The Ohio State University campus. KD performed a daily fasted, morning finger-prick to observe blood ketone and glucose levels. The level of carbohydrate, protein, and fat were adjusted to maintain blood ketone levels at an appropriate range. The main goal of the ketogenic diet was to enter a state of

40 nutritional ketosis (blood ketones >.05). Body composition was not a primary concern, and participants were encouraged to eat to satiety.

The ketogenic diet consisted of ~40g or less of carbohydrate per day and an estimated macronutrient breakdown of roughly 70% fat, 20% protein, and 10% carbohydrate. Protein intake was estimated at a moderate 0.6-1.0 gram per pound of lean body mass. Intake of carbohydrate was instructed to come from non-starchy vegetables, nuts, seeds, fruits, and other protein-based food sources. Intake of non-starchy vegetables, berries, lean protein, and moderation of alcohol was encouraged. Participants in the CON group were asked to track their food consumption by recurring 3-day food records and maintained carbohydrate intake above 45%. Both interventions had the ability to meet with a Registered Dietitian whenever they felt necessary.

Resistance Training Intervention

Participants in both the KD and CON groups were instructed to complete a resistance and power training program at The Ohio State University’s Exercise Science

Lab. Training was completed in groups or in individual sessions under the supervision of a Certified Strength and Conditioning Specialist (CSCS) to ensure participant safety and precision in complex movements. Participants completed two days per week of exercise training at the OSU lab, and one day per week of OSU Army ROTC PT. Participants not involved in the OSU Army ROTC program were instructed to complete a third day of physical training involving endurance or body-weight circuit training. Participants were

41 further encouraged to continue their level of training volume prior to beginning the exercise intervention by also incorporating these training protocols. Thus, a participant that exercised four days per week prior to the study was instructed to complete two days of supervised strength training, one day of bodyweight endurance-based training, and one day of their regular training while completing the study.

The training program was divided into two mesocycles: strength, then power. The first day of training involved technique and form corrections, and low volume, to allow an easy transition into the workouts. MP1 then counted as the second training day during that week. The following 4 weeks included 2 sessions per week that included barbell back squat, bench press, a variety of other strength-based and injury preventative exercises and concluded with ~15 minutes of circuit-style metabolic training. Squat and bench progressed in a linear fashion in the following pattern:

3x12 @ 60% 1RM

3x8 @ 70% 1RM

3x6 @ 80% 1RM

4x4 @ 90% 1RM

3x12 @ 65% 1RM

3x6 @ 85% 1RM

4x4 @ 95% 1RM

For the first session of week 6, the participant completed a training session instructing proper Olympic lift technique in the Olympic clean and jerk. MP2 occurred as the second training day for week 6. The following 3 to 6 weeks of training included a rotation of strength, power training, and metabolic conditioning, with a large emphasis on power training through the Clean and Jerk and plyometric exercises. A sample training program for both mesocycles is provided in Tables 4 and 5.

Mesocycle 1 Training Program Template

Section: Exercise Sets Reps Weight Rest Time WARM UP

STRENGTH SQUAT 2-3 minutes LOWER BODY STRENGTH EXERCISE

BENCH 2-3 minutes UPPER BODY STRENGTH EXERCISE

STRENGTH EXERCISE 2-3 minutes STRENGTH EXERCISE

CONDITIONING PLYOMETRIC EXERCISE <1 minute PLYOMETRIC EXERCISE PLYOMETRIC EXERCISE

COOL DOWN

Table 4. Mesocycle 1 Template

Mesocycle 2 Training Program Template 43

Rest Section: Exercise Sets Reps Weight Time WARM UP

POWER OLYMPIC 1-3 min. OLYMPIC

PLYOMETRIC <1 min. PLYOMETRIC PLYOMETRIC PLYOMETRIC

STRENGTH STRENGTH 1-2 min. STRENGTH STRENGTH STRENGTH COOL DOWN

Table 5. Mesocycle 2 Template

In addition to these two training sessions per week, participants also completed a third unsupervised session. Those enrolled in The Ohio State University’s ROTC program completed PRT one day per week and replaced PRT with this training program two days per week. Those not enrolled in ROTC were instructed to complete an aerobic- based or body-weight circuit-style training day in addition to the training intervention.

Statistical Analyses

Data were analyzed using SPSS version 25.0(IBM, Inc., Armonk, NY, USA).

Means and standard deviations (SD) were calculated for each variable. Missing data points were interpolated using an average percent change. An independent t-test was used to confirm matched groups at baseline. When a significant difference between baseline groups occurred, a 2(Diet) x 3(Time) ANOVA was used with percent change between time points as a variable and baseline as a covariate. A mixed-method ANOVA

(Diet x Time) was used to determine significant differences amongst means. A 2(Diet) x

4(Time) ANOVA was used to assess strength, countermovement jump, body weight, and

Hi-Trainer sprint assessments. A 2(Diet) x 2(Time) ANOVA was used to assess VO2

Max and time to-completion for the obstacle course. When necessary, a Greenhouse-

Geisser correction was used to correct for violations of sphericity. Significant F tests were further investigated using pairwise post-hoc comparisons with a Bonferroni adjustment for multiple comparisons (p ≤ .05). Significance in this investigation was defined as P ≤ 0.05.

Chapter 4: Results

The primary findings in this study were that the KD had a significant effect of body composition without affecting performance measures. There was a significant improvement in back squat and VO2 Max for both groups and no effect of time or diet on bench, CMJ, sprint intervals, or obstacle course time to completion. There was a significant effect of diet on body weight, BF%, FM, and FFM.

Body Composition

There was a significant difference between groups at PRE body weight, p < .05.

Using PRE body weight as a covariate, and percent change between time points, there was a significant effect of time and diet, p < .01. Weight loss from PRE to midpoint 1

(MP1) was significantly greater in KD (-2.21%, SE 2.0) compared to CON (.16%, SE

1.6). Weight loss from PRE to midpoint 2 (MP2) was significantly greater in KD (-

5.55%, SE 3.32) than CON (-.01%, SE 1.9). Weight loss from PRE to POST was significantly greater in KD (-7.17%, SE 3.9) than CON (.26%, SE 2.5). There was a significant effect of time and diet on BF%, p < .01. For KD, BF% was significantly higher PRE (25.6 ,SE 5.0) than POST (20.26, SE 4.9) compared to CON PRE (22.0, SD

8.6) and POST (21.3, SD 8.4). There was a significant effect of time and diet on FM, p <

.01. For KD, FM was significantly higher PRE (46.5, SE 9.8) than POST (33.6, SE 7.6)

46 compared to CON PRE (38.2, SD 17.5) and POST (36.9 SD 16.7). There was a significant effect of time and diet on LBM, p <.01. For KD, LBM was significantly higher PRE (135.9, SE 13.7) than POST (132.9, SE 14.8) compared to CON PRE (131.4,

SD 9.5) and POST (133.1, SD 10.1). See Table 6.

CON KD PRE POST PRE POST Body Mass (kg) 79.85 (1.92) 80 (1.53) 85.47 (1.854) 79.147 (1.48) Percent Fat 22.036 (1.86) 21.321 (1.82) 25.613 (1.80) 20.26 (1.75) Fat Mass (kg) 17.35 (3.76) 16.78 (3.42) 21.14 (3.634) 15.26 (3.30) Lean BM (kg) 59.72 (3.17) 60.50 (3.42) 61.79 (3.06) 60.41 (3.30)

Table 6. Body Composition Comparison of body composition between groups. Results presented as Means (SE).

Figure 5. Comparison of Body Composition Measures * significantly different from PRE and CON, p < .05.

1 RM Strength

There was a significant time effect for absolute max barbell back squat, p<.01.

Absolute back squat PRE (mean 110.33, SE 5.41) and at MP1 (mean 111.72, SE 4.76) were both significantly less than midpoint 2 (mean 122.53, SE 4.47) and POST (mean

125.90, SE 4.50). There was also a significant effect of time for relative barbell back squat, p <.01. Relative back squat PRE (mean 1.34, SE .06) and at MP1 (mean 1.37, SE

.06) were both significantly less than MP2 (mean 1.53, SE .06) and POST (mean 1.59, 48

SE .06). There were no significant differences between groups at any time point for either absolute or relative back squat. See Table 7.

One participant had a pre-existing shoulder injury and did not complete a max bench press for MP1, MP2, or POST. The participant’s data was excluded from analysis

(KD: n = 14; CON: n = 14). Analysis of means revealed no significant differences between groups or over time for absolute max bench press. There was a significant time effect for relative bench press, p<.01. Relative bench press PRE (mean 1.10, SE 0.07) and at MP1 (mean 1.11, SE 0.07) were both significantly less than MP2 (mean 1.16, SE

0.07) and POST (mean 1.18, SE 0.07). There were no significant differences between groups for relative bench press. See Table 7.

CON PRE MP1 MP2 POST Squat 1RM (kg) 103.1 (24.9) 106.4 (23.1) 119.2 (21.7) 122.4 (24.1) Rel. Squat 1.31 (.35) 1.34 (.34) 1.51 (.32) 1.54 (.35) Bench 1RM (kg) 84.6 (29.4) 85.2 (29.2) 89.5 (28.7) 90.9 (29.1) Rel. Bench 1.07 (.39) 1.08 (.39) 1.14 (.39) 1.15 (.39) KD PRE MP1 MP2 POST Squat 1RM (kg) 117.6 (32.5) 117.05 (27.8) 125.9 (26.0) 129.4 (24.3) Rel. Squat 1.37 (.34) 1.40 (.29) 1.56 (.30) 1.63 (.26) Bench 1RM (kg) 95.9 (33.1) 95.6 (31.2) 95.1 (28.2) 95.9 (29.0) Rel. Bench 1.12 (.35) 1.14 (.33) 1.18 (.33) 1.21 (.32)

Table 7. Strength Measures Comparison of strength measures between groups. Results presented as Means (SE).

Figure 6. Comparison of Strength Measures * indicates significance from PRE and MP1 p <.05.

Countermovement Vertical Jump

There were no observed significant effects of time or diet on rate of power development or CMJ. See Table 8.

Repeated Sprint Intervals

One participant repeatedly became sick during the sprint intervals and failed to complete all ten sprint intervals at any time point. The participant’s data was excluded from analysis (KD: n = 14; CON: n = 14). There was a significant difference at baseline for average power output between groups p < .01. Average power for KD (mean 580.14,

SD 99.5) was significantly greater than CON (mean 465.82, SD 100.6). There was a significant difference at baseline for maximum power output between groups, p < .01.

Maximum power for KD (mean 1046.34, SD 228.2) was significantly greater than CON

(822.54, 180.2). There were no significant effects of time or diet in average power or maximum when PRE was used as a covariate for observed percent changes between time points. There were no significant differences between groups at baseline for any other variables. There were no significant effects of time or diet for relative average power, relative maximum power, average speed in sprint set 2 vs. sprint set 1, average power in sprint set 2 vs. sprint set 1, speed and power of sprint 1 vs. sprint 5, or speed and power of sprint 6 vs. sprint 10. See Table 8.

CON PRE MP1 MP2 POST CMJ (cm) 34.3 (9.7) 32.3 (8.3) 33.5 (8.0) 35.6 (11.0) Avg. Power (W) 465.8 (26.9) 507.4 (24.3) 540.7 (32.0) 507.9 (32.3) Max Power (W) 822.5 (48.2) 935.7 (60.4) 897.1 (44.6) 933.0 (73.5) Avg Power 2v.1 -73.9 (21.8) -56.0 (16.7) -43.7 (12.3) -4.1 (36.3) P Decline 1 -221.6 (36.7) -250.2 (32.9) -209.7 (22.5) -216.5 (20.9) P Decline 2 -128.6 (28.0) -169.4 (22.7) -142.1 (23.6) -190.8 (24.5) Avg. Speed (m/s) 3.14 (.19) 3.35 (.16) 3.46 (.14) 3.33 (.14) Max Speed (m/s) 4.79 (.29) 4.92 (.21) 4.96 (.18) 4.98 (.20) Avg. Speed 2v.1 -.43 (.12) -.37 (.08) -.33 (.06) -.32 (.09) S Decline 1 -1.09 (.22) -1.13 (.17) -1.08 (.15) -1.29 (.15) S Decline 2 -.42 (.13) -.55 (.14) -.69 (.11) -.79 (.16) Relative Avg. P 5.89 (.37) 6.40 (.35) 6.80 (.39) 6.37 (.41) Relative Max P 10.38 (.65) 11.77 (.76) 11.26 (.54) 11.72 (.97) Rel. P 2v.1 -.94 (.28) -.72 (.21) -.55 (.16) -.06 (.46) Rel. P Decline 1 -2.75 (.56) -3.15 (.40) -2.64 (.30) -2.71 (.27) Rel. P Decline 2 -1.61 (.34) -2.11 (.27) -1.76 (.29) -2.38 (.31) KD PRE MP1 MP2 POST CMJ (cm) 34.0 (8.3) 33.4 (8.3) 33.6 (6.8) 34.7 (7.1) Avg. Power (W) 580.1 (26.6) 583.3 (34.1) 574.3 (35.9) 549.5 (27.9) Max Power (W) 1046.3 (61.0) 1029.5 (67.2) 1032.4 (73.2) 1031.0 (97.0) Avg Power 2v.1 -82.6 (22.7) -79.0 (16.8) -103.0 (34.5) -72.7 (15.2) P Decline 1 -269.7 (48.8) -287.0 (35.8) -271.9 (38.9) -241.3 (29.9) P Decline 2 -161.5 (24.0) -228.3 (32.5) -187.9 (28.3) -169.8 (35.9) Avg. Speed (m/s) 3.27 (.13) 3.40 (.11) 2.81 (.34) 3.38 (.13) Max Speed (m/s) 5.08 (.23) 5.11 (.18) 4.26 (.51) 5.13 (.23) Avg. Speed 2v.1 -.41 (.11) -.42 (.08) -.34 (.09) -.39 (.08) S Decline 1 -1.20 (.24) -1.13 (.17) -1.06 (.21) -1.12 (.13) S Decline 2 -.51 (.14) -.59 (.19) -.41 (.15) -.41 (.18) Relative Avg. P 6.82 (.25) 6.97 (.32) 7.10 (.39) 6.93 (.29) Relative Max P 12.29 (.64) 12.27 (.66) 12.76 (.82) 13.00 (1.18) Rel. P 2v.1 -.95 (.27) -.93 (.20) -1.25 (.43) -.92 (.19) Rel. P Decline 1 -3.07 (.56) -3.39 (.40) -3.34 (.45) -3.03 (.35) Rel. P Decline 2 -1.87 (.26) -2.68 (.36) -2.32 (.33) -2.12 (.43) Table 8. Comparison of Power Measures

Table 8 Cont. Results presented as Means (SE). 2v.1 indicates the Average of the second set of 5 intervals vs. the 1st set of 5. Decline 1 indicates the peak S or P in the 5th sprint minus the 1st sprint. Decline 2 indicates the peak in the 10th sprint minus the 6th sprint.

-1 -1 VO2 Max ml ·kg · min

-1 -1 There was a significant effect of time on VO2 Max ml ·kg · min , p<.05. VO2

POST (mean 47.56, SE 1.21) was significantly higher than VO2 PRE (mean 45.39, SE

1.30). See Table 9. There were no differences between groups at either time point.

Obstacle Course Time to Completion

There were no observed significant effects of time or diet on time to completion for the Obstacle Course (OC). See Table 9.

CON KD PRE POST PRE POST

VO2 (ml/min/kg) 45.9 (8.2) 46.6 (6.9) 44.9 (5.9) 48.5 (6.2) OC (sec) 39.0 (4.7) 39.0 (7.9) 39.0 (6.7) 36.7 (5.7)

Table 9. Aerobic Capacity Comparison of aerobic capacity between groups. Results presented as Means (SE).

Chapter 5: Discussion

Strict adherence to a ketogenic diet did not cause any detrimental effects on training adaptations following a 12-week resistance training program even while simultaneous improvements in body composition occurred. This is truly a novel finding, highlighting the potential for ketogenic diets in high performance populations.

For both the KD and CON, the training program elicited a significant increase in lower body strength via absolute and relative back squat. There was a significant increase in relative bench press and a significant improvement in VO2 Max. Simultaneously, there was a significant effect of the diet on measures of body composition. There were significant decreases in BF%, FM, and FFM in KD, while no significant changes were noted in CON.

Prior to training, both groups’ combined relative barbell back squat of 1.3 is similar to those of untrained freshmen ROTC recruits (Thomas et al. 2004). This indicates that traditional military training strategies do not emphasize lower body strength. The baseline training status of the study participants helps to explain the greater improvements in strength observed over the first six weeks of the program. These increases are likely associated with neuronal adaptations (Latella, Kidgell and Pearce

2012). Strength training two days per week improved relative back squat to 1.6. 54

However, the ability to squat 2 times body weight (or relative 2.0) is a common athletic standard (Oliver et al. 2017). The group likely could not achieve this standard only strength training twice per week. Wilson et. al. (2017) observed significant strength improvements in resistance trained males with an average baseline relative back squat of

1.56 on a ketogenic diet. Wilson’s study followed a 7-week, 3-day per week split training program with a 2-week taper (Wilson et al. 2017). Still, this comparison may indicate that three or more strength sessions per week would improve strength results.

The volume of this intervention was chosen based on ROTC PRT time expectations, so perhaps ROTC should consider increasing frequency of PRT days.

Similarly, relative bench press failed to meet athletic standards. Relative bench press of about 1.1 prior to the intervention falls into an acceptable standard of 1.0 for women but below the male standard of 1.5 (Medicine 2014). The lack of significant strength improvements in bench press suggests neuronal adaptations to upper body strength training may have already occurred, indicating participants were better trained in upper body than lower body strength prior to study enrollment. Prior to the intervention

(PRE), some relative bench presses were as high as 1.9x body weight and these individuals likely needed greater than two training sessions per week to attain significant improvements. However, other individuals had relatives as low as 0.38 and did see improvements in bench press over time. The diversity of these group led to a large SE value, and likely why significant improvements were not observed with the training program. However, this wide variation in individual strength is a good representation of

55 a diverse military and confirms the notion that military training programs should be individualized as much as possible to maximize individual training outcomes.

The training program did not significantly improve CMJ. However, again, there was a wide range of performance abilities at baseline, with less trained individuals showing greater improvements after training. Both plyometric training and Olympic weightlifting can improve vertical jump, and even a small improvement of 10% is associated with better practical performance of jumping and sprinting (Hackett et al.

2016, Kons et al. 2018). Improvements in performance reached 15% in some individuals in both KD and CON. Further, few participants had a program completion rate >90%

(n=5), and thus most likely did not train power long enough to elicit significant improvements. The majority of missed training sessions occurred during the Power

Mesocycle which included 11 training sessions. Research implies 12-60 plyometric training sessions are necessary to improve CMJ and power (Kons et al. 2018).

Compliance likely played a role in these results.

Diet and training also had no effect on sustainable power as measured via repeated sprint intervals on a self-propelled resistance treadmill. Finding similar results in power performance between CON and the ketogenic group is encouraging as other studies have reported mixed results. Fleming et al. (2003) found an increase in peak power and mean power after six weeks of a ketogenic diet. Conversely, McSwiney et al.

(2017) observed a significant increase in critical power as measured by a Wingate test in

56 trained cyclists on a ketogenic diet following a 10-week diet and training intervention compared to control (McSwiney et al. 2017). These discrepancies reveal the need for future research utilizing a well-controlled ketogenic diet without weight loss in elite strength and power athletes, rather than endurance athletes.

The training program focused on aerobic conditioning on a third, unsupervised training day. ROTC participants completed this day with OSU ROTC leaders. There was a significant improvement in VO2 Max but not obstacle course time to completion.

The group met the Fair to Good categories for VO2 Max both PRE and POST intervention which indicates military training can train cadets to average performance levels of aerobic conditioning (Medicine 2014). However, there is also evidence that new ROTC recruits experience significant decreases in VO2 performance after the introduction of PRT (Thomas et al. 2004). Long ruck marches are also a common practice in PRT to train aerobic performance. However, as high as 80% of injuries in combat units are attributed to training and load carriage (Rauh et al. 2006). There are other ways the military can focus on improving VO2 Max, and the improvements in VO2

Max in this study may have well been a result of high intensity interval training (HIIT) and repeated sprint intervals during strength sessions (Batacan et al. 2017). Further, this concurrent, simultaneous training of aerobic and anaerobic performance measures may have attenuated strength and power performance adaptations.

The only measures that significantly differed between groups were related to body composition. Implementation of a ketogenic diet and caloric restriction has consistently been associated with improvements in body composition (Cox et al. 2003, Redman et al.

2007). There was a significant difference of body weight at baseline, but BF%, FM, and

FFM were statistically similar between groups prior to the intervention. Participants could self-select into either diet intervention. Both groups were encouraged to meet with a Registered Dietitian, not to restrict calories and to eat to satiety. Therefore, the weight loss that occurred in the KD group, an impressive 6.32 kg group average in 12-weeks, happened due to a natural, unintentional restriction of calories. Weight loss was as high as 15 kg in 12 weeks for some individuals. Nutritional ketosis has been observed to preserve FFM compared to fasting with a 1% weight loss from LBM in a ketogenic intervention and 62% weight loss from FFM with 10 days of fasting in overweight Navy personnel (Benoit et al. 1965). In a different 10-week diet and exercise training study, the ketogenic group experienced significant increases in LBM and muscle thickness while the control group did not. At the same time, both groups experienced significant differences in fat loss (Wilson et al. 2017). In a 10-week trial in women, no significant differences in LBM occurred, though significant fat mass was lost in the ketogenic + exercise group. The normal diet + exercise group experienced the opposite phenomenon, with gains in LBM, but no losses in FFM (Jabekk et al. 2010). Similar to this, KD lost significant FFM compared to CON which showed gains in FFM, but it is difficult to truly compare the two when KD lost body weight and CON did not.

Finally, based on MP1 assessments, the KD did not experience an initial decline in performance. A ketogenic diet is often associated with a decrease in performance during the first week of adaptation (Burke et al. 2000, Starling et al. 1997, Havemann et al. 2006). This could be due to the participants’ training status or, more likely, from the provision of a well-formulated ketogenic diet. Sodium loss, in particular, was controlled which may have alleviated symptoms to keto-adaptation, but further research is necessary.

In summary, the primary findings demonstrate that military training should be refocused to ensure optimal adaptations. Two days of strength training per week is likely not enough to create the well-rounded tactical athletes the military desires. With the average-to-poor level of baseline fitness within this group, it should be emphasized again that a needs analysis, periodized strength training program, and individualization when possible should be implemented within PRT (Kraemer and Szivak 2012). It is challenging to create programs with little budget, little equipment, and for large groups that can maintain tradition, improve mental resilience, and train cadets to an elite standard of such a wide variety of tasks. However, a focus on strength and power training needs to be prioritized. Typical PRT does not improve strength or power, yet strength is critical for performance and injury prevention in soldiers (Oliver et al. 2017,

Knapik et al. 2003). ROTC in particular, which feeds a substantial group into active duty and often has access to fitness centers in a collegiate setting, should aim to implement resistance and power training in small groups. ROTC programs in a university setting

59 should aim to educate cadets on strength and power training and incorporate periodized resistance training more than two times per week. Due to the diverse fitness levels observed, these groups could ideally be stratified based on training status to help individualize military training.

Further, a ketogenic diet led to significant improvements in body composition without affecting strength, power, or aerobic performance compared to CON. Thus, a

KD can be used as an important weight control tool in the military. Weight is a growing concern within this population. Prevalence of obesity in the military is increasing

(McCarthy et al. 2017). More concerning, 71% of Americans age 17-24 are ineligible to serve based on health and fitness (Feeney 2014). It is difficult in many ways to recruit volunteers, and it is estimated only 1% of Americans are “eligible and inclined”, so it is critical to focus on maintaining health and fitness in all military personnel (Feeney 2014).

In future research, it is important to explore the effect of sodium intake during adaptation. It is also important to study these variables in other groups, such as a more homogenous, elite-level group with improved training volume. It may be important to determine strength changes while controlling for protein intake between groups. Finally, while female soldiers can meet physical military standards and gender differences can be reduced with resistance training, it is important to examine differences between sexes

(Kraemer et al. 2001).

It is also important to consider the effect of a ketogenic diet in a controlled laboratory setting versus a prolonged military mission with soldiers in a highly fatigued and depleted state. By preparing soldiers for lipid-utilization during extended missions, soldiers may be able to sustain optimal levels of performance and mental capacity in suboptimal conditions. It is important to further research these conditions in which a ketogenic diet may have a clear benefit.

Conclusion

In summary, those following a ketogenic diet and resistance training two days per week significantly improved leg strength and body composition without affecting upper body strength and power. There were no significant differences in any performance measures between KD and CON, yet KD showed significant improvements in body composition. This indicates a ketogenic diet can be an effective weight management tool in tactical athletes without affecting performance.

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Appendix A: Informed Consent Document

The Ohio State University Consent to Participate in Research

Study Title: Tactical Athletes in Nutritional Ketosis (TANK)

Principal Investigator: Jeff Volek, Ph.D., R.D.

Sponsor:

● This is a consent form for research participation. It contains important information about this study and what to expect if you decide to participate. Please consider the information carefully. Feel free to discuss the study with your friends and family and to ask questions before making your decision whether or not to participate. ● Your participation is voluntary. You may refuse to participate in this study. If you decide to take part in the study, you may leave the study at any time. No matter what decision you make, there will be no penalty to you and you will not lose any of your usual benefits. Your decision will not affect your future relationship with The Ohio State University. If you are a student or employee at Ohio State, your decision will not affect your grades or employment status. ● You may or may not benefit as a result of participating in this study. Also, as explained below, your participation may result in unintended or harmful effects for you that may be minor or may be serious depending on the nature of the research. ● You will be provided with any new information that develops during the study that may affect your decision whether or not to continue to participate. If you decide to participate, you will be asked to sign this form and will receive a copy of the form. You are being asked to consider participating in this study for the reasons explained below. 1. Why is this study being done?

The availability of glycogen (stored carbohydrate) and the ability to utilize body fat as an energy source are limiting factors for mental and physical performance, each of

which are important for military-specific performance. When dietary carbohydrate is limited to ~40 grams/day, the body becomes more efficient at utilizing body fat as an energy source and also produces ketone bodies as an alternative source of energy. The main purpose of this study is to determine the effect of a low-carbohydrate, ketogenic diet on metabolic function and mental and physical performance, including military-specific assessments. A secondary purpose of this study is to determine if different blood levels of ketones lead to a difference in benefits.

2. How many people will take part in this study?

We are planning to enroll a total of 45-60 people in this study.

3. What will happen if I take part in this study?

Overview

Eligibility for participation in this study is dependent on the results of the tests conducted during the screening visit. Participants who qualify will participate in either a control group or one of two dietary intervention groups. If you are in the control group, you will be asked to continue to follow your typical diet for a period of 12 weeks. If you are in one of the intervention groups, you will be asked to follow a low-carbohydrate, ketogenic diet for 12 weeks. All food will be made and provided to you. Depending on the intervention group you are assigned to, you may also be asked to take a daily ketone supplement. Regardless of group assignment, you will undergo a comprehensive series of tests at the beginning and end of the 12 week study period. Abbreviated cognitive and physical performance monitoring will be completed at set intervals following weeks 1, 4, and 8 in order to evaluate adaptations and intervention effects on specific performance measures. Throughout this duration, you may also be asked to maintain dietary records or perform finger-stick blood testing with a meter that will be provided to you.

Screening

The purpose of the screening meeting is to determine if you meet our qualifying criteria, inform you of your rights as a participant, and to confirm your willingness to participate. We will provide you with a few questionnaires including medical history, physical activity history, dietary history, and an MRI screening form. You cannot participate in this study unless you are deemed safe to do so based upon the full screening process and you read, fully understand, and sign this informed consent document providing us with written consent.

Eligibility Criteria

You will not be eligible to participate in this study if you: 74

● Are not between the ages of 18-44 years old ● Do not have a body mass index (BMI) between 18.5-34.9 kg/m2 ● Exceed moderate risk according to the American College of Sports Medicine’s (ACSM) risk criteria ● Suffer from food allergies or gastrointestinal disorders ● Regularly use tobacco products ● Drink alcohol in excess of 3 drinks/day or 18 drinks/week ● Have used cholesterol, diabetic, or blood pressure medications in the past 3 months ● Currently use medications containing benzodiazepines or related substances (sedatives and other medications that alter sleep/consciousness) ● Use of anti-inflammatory medications (aspirin, non-steroidal anti-inflammatory drugs) on a regular basis ● Have indications of endocrine dysfunction, hormonal imbalance, or cardiovascular disease ● Have musculoskeletal injuries or physical limitations affecting ability to exercise, or increasing risk of injury or discomfort during exercise ● Have any conditions or contraindications to magnetic resonance imaging ● Are pregnant or plan to become pregnant during participation in study

Taking certain dietary supplements or training outside of ROTC physical training sessions may interfere with any of the testing that will be conducted in this study, you will be asked to discontinue any additional training or usage of these supplement(s) for the full duration of the study.

Testing Sessions

The following three test sesssions will be completed at the beginning of the study and will be repeated at the end of the study. Each test session will be separated by a minimum of 48 hours. The first and third sessions will occur in the PAES building on The Ohio State University campus. The address for this building is:

305 West 17th Ave Columbus, OH 43210

The second sesssion will occur at the Ross Heart Hospital and/or the Martha Morehouse Medical Plaza. Prior to your session, you will be informed of which location to report to. The addresses for these buildings are:

Martha Morehouse Medical Plaza 2050 Kenny Rd Columbus, OH 43221

Ross Heart Hospital 452 West 10th Ave Columbus, OH 43210

Test Session 1

Prior to this test session, you will be given a sleep monitor to assess one or more typical nights of sleep. You will also need to be fasted for this session, which means you cannot consume any food or drink other than water for 10-12 hours prior to the session. To ensure proper hydration, please consume 2 cups of water the night before the sessionand another 2 cups the morning of the session. The following will occur during this session:

1. Your height and body mass will be measured.

2. You will provide a urine sample, which we will use to ensure that you are adequately hydrated.

3. Your resting energy metabolism will be measured. This test requires that you first lie still and relax for 30 minutes. The room will be dark, quiet and at a comfortable temperature to allow you to rest. After the 30-minute rest period you will be instructed to remain awake but still. A plastic see-through hood will be placed over your head. This hood will allow you to breathe normally while we collect samples of the air you are breathing in and out. A measuring device, known as a metabolic cart, is attached to this hood via a plastic hose and measures the gases in the air collected by the hood to determine your resting energy expenditure. This test will last about 45 minutes.

4. Your body composition, which is the distribution of fat, bone, and other lean tissue, will be determined using dual-energy X-ray absorptiometry (DEXA). This involves a scanner that exposes you to a small amount of X-ray radiation. You will lie quietly on the DEXA bed while a scanning arm passes over your body from head to toe. You must remain still for about 7 minutes during this test. A certified technician will perform the scan. In addition to the DEXA scan for body composition, the circumference of your waist will be measured using a standard tape measurer.

5. You will collect a sample of cheek cells with two small bristle brushes that you will rub on the inside of your cheeks.

6. Blood will be drawn after you have sat quietly for 15 minutes. The blood will be taken via venipucture from a vein in your arm using a small needle. A total of up to 50 mL (~ 3 tablespoons) will be drawn.

7. You will perform a mental test battery including the the Paced Auditory Serial Addition Test (PASAT), the Cambridge Neurological Test Automated Battery (CANTAB) cognitive test battery, and the Virtra Firearms Training Simulator.

During the PASAT, you will listen to an audio recording of a sequence of single- digit numbers every 2-3 seconds and add each number heard to the previous from the audio recording. This process is repeated 50-60 times. Correct responses will be tracked throughout the PASAT testing process.

Virtra Firearms Training Simulator (Virtra, Tempe, AZ) will be utilized to assess cognitive function in a simulated combat-like scenario with interactive laser weapons. Virtra is designed to test reaction time, and higher level brain function capacity in a military relevant scenario that is depicted on a projector screen.

For the CANTAB battery, you will sit in a chair in front of a large touch screen computer and perform a series of tests as instructed. These tests are designed to tests your attention, concentration, mental reaction time, memory, mental processing speed, and decision-making.

The following explains each test individually:

Reaction Time Test (RTI) The task is divided into five stages, which require increasingly complex chains of responses. In each case, you must react as soon as a yellow dot appears. In some stages the dot may appear in one of five locations, and you must sometimes respond by using the press-pad, sometimes by touching the screen, and sometimes both.

Stockings of Cambridge (SOC) You will be shown two displays containing three colored balls. The displays are presented in such a way that they can easily be perceived as stacks of colored balls held in stockings or socks suspended from a beam. This arrangement makes the 3-D concepts involved apparent to you, and fits with the verbal instructions. You must use the balls in the lower display to copy the pattern shown in the upper display. The balls may be moved one at a time by touching the required ball, then touching the position to which it should be moved. The time taken to complete the pattern and the number of moves required are taken as measures of your planning ability.

Spatial Working Memory (SWM) The test begins with a number of colored squares (boxes) being shown on the screen. The aim of this test is that, by touching the boxes and using a process of elimination, you should find one blue ‘token’ in each of a number of boxes and use them to fill up an empty column on the right hand side of the screen. The 77 number of boxes is gradually increased, until it is necessary to search a total of eight boxes. The color and position of the boxes used are changed from trial to trial to discourage the use of stereotyped search strategies.

Pattern Recognition Memory Test (PRM) You will be presented with a series of visual patterns, one at a time, in the center of the screen. These patterns are designed so that they cannot easily be given verbal labels. In the recognition phase, you will be required to choose between a pattern you have already seen and a novel pattern. In this phase, the test patterns are presented in the reverse order to the original order of presentation. This is then repeated, with new patterns. The second recognition phase can be given either immediately or after a delay.

Spatial Recognition Memory Test (SRM) You will be presented with a white square, which appears in sequence at five different locations on the screen. In the recognition phase, you will see a series of five pairs of squares, one of which is in a place previously seen in the presentation phase. The other square is in a location not seen in the presentation phase. As with the PRM test, locations are tested in the reverse of the presentation order. This sub-test is repeated three more times, each time with five new locations.

Intra-Extra Dimensional Set Shift Test (IED) Two artificial dimensions are used in the test: • color-filled shapes • white lines

Simple stimuli are made up of just one of these dimensions, whereas compound stimuli are made up of both, namely white lines overlying color-filled shapes. You start by seeing two simple color-filled shapes, and must learn which one is correct by touching it.

Feedback teaches you which stimulus is correct, and after six correct responses, the stimuli and/or rules are changed. These shifts are initially intra-dimensional (e.g. color filled shapes remain the only relevant dimension), then later extra- dimensional (white lines become the only relevant dimension).

You progress through the test by satisfying a set criterion of learning at each stage (six consecutive correct responses). If at any stage you fail to reach this criterion after 50 trials, the test terminates.

Rapid Visual Information Processing Test (RVP) A white box appears in the center of the computer screen, inside which digits, from 2 to 9, appear in a pseudo-random order, at the rate of 100 digits per minute. You will need to detect target sequences of digits (for example, 2-4-6, 3-5-7, 4-6- 8) and to register responses using the press pad. 78

8. A sample of your muscle tissue will be collected. For this procedure you will lie down on a comfortable surface. We will use a local anesthetic to numb an area of your skin and thigh muscle before obtaining a very small amount of muscle (about the size of an unpopped popcorn kernel) via a muscle needle biopsy. The muscle biopsy involves taking a small piece of muscle tissue from a single incision site in your thigh muscle. Prior to the incision, the skin is cleaned and made sterile. Then the skin and tissue below are injected with local anesthetic to eliminate most of the associated pain. A small incision about the size of this dash "_____" will be made through which a needle about the size of this letter "O" is advanced into the muscle. A piece of the thigh muscle is then removed with the needle. The incision site will be closed with a suture and a light dressing will be applied.

We will provide you with an informational take-home sheet that addresses care of the biopsy incision sites and will provide you with extra band-aids and topical antibiotic.

The total anticipated duration of this testing session is approximately 3-4 hours.

Test Session 2

You will meet the research team at the Ross Heart Hospital or Martha Morehouse Medical Plaza for resting MRI and a maximum effort treadmill stress test followed by subsequent MRI to evaluate cardiac function. Prior to MRI the MRI screening form will be reviewed and you will be required to give consent for MRI. You will then be prepped and electrocardiogram patches will be applied to your torso to enable accurate HR measurement and MRI scan timing. Resting MRI imaging will involve laying on the MRI exam table while being scanned to evaluate visceral body fat, liver fat, and resting heart function. During scanning breath hold commands may be given to you. Total breath hold duration will not exceed 30 seconds.

After rest imaging your blood pressure will be measured. You will be asked to stand and safely transition yourself from the MRI table to the treadmill. The exercise stress test will involve graded increases in workload. Electrocardiogram, blood pressure, and exercise performance will be monitored by a certified exercise physiologist and or physician. The treadmill exercise will be discontinued according to the American College of Sports Medicine guidelines, volitional fatigue, or desire to end exercise testing. During testing oxygen and carbon dioxide gas exchange will be monitored with a metabolic cart. Just after exercise you will be instructed to move back to the MRI exam table immediately for post exercise imaging.

The total anticipated duration of this testing session is1.5 hours. 79

Test Session 3

You will be given a sleep monitor to use the night prior to this session. In addition, you will be asked to limit your sleep duration to 4 hours or less depending on previous testing. You will be informed in advance of this duration. You will also need to be fasted for this session, which means you cannot consume any food or drink other than water for 10-12 hours prior to the session. To ensure proper hydration, please consume 2 cups of water the night before the session and another 2 cups the morning of the session. The following will occur during this session:

1. You will provide a urine sample, which we will use to ensure that you are adequately hydrated.

2. A catheter will be inserted into a vein in your arm to allow for repeated blood draws throughout the session. Up to 50 ml (~3 teaspoons) of blood will be drawn prior to any exercise testing.

3. You will be asked to step onto a force plate. Your center of mass will be measured via force plate. perform a series of jumps on a force plate.

* Max Vertical Squat jumps Starting from a squat position on the force plate, you will jump in the air as high as you can and land on the force plate.

* Countermovement jumps Starting from an upright position on the force plate, you will squat down and then jump in the air as high as you can and land on the force plate

4. You will complete a minimum of 2 guided warm-up sets of the back squat exercise and then perform a 1 repetition maximum test sequence to determine your maximal lower body strength. You will do the same for the bench press exercise. If necessary, instruction for proper completion of these exercises will be provided.

5. You will perform a cognitive test battery performed during the test session 1.

6. You will perform a series of maximal sprints on the HiTrainer self-propelled treadmill. To make this assessment military specific, you will wear military- issued combat boots and a military-style pack containing 42 kg of load. Blood will be drawn from the catheter following each sprint.

7. You will repeat the cognitive test battery performed prior to the repeated sprint assessment. 80

8. Following a brief rest, you will complete a military-specific obstacle course. The course will consist of a 30 m sprint, followed by a 27 m zig-zag run, and then a 10 m casualty drag with 79.5 kg of load. Similar to the repeated sprint test, the obstacle course will be completed in combat boots and a pack containing 42 kg of load. Each segment of the course will be timed to assess performance.

9. Up to 50 ml of blood will be drawn from the catheter immediately after completion of the obstacle course and again at 30, 60, and 120 minutes after completion. All blood draws during this session will total to no more than 1 pint of blood (approximately 470ml).

The total anticipated duration of this testing session is about 4 hours.

Abbreviated Cognitive and Physical Performance Monitoring Session:

You will complete an abbreviated testing session to evaluate cognitive and physical performance at specified intervals during the intervention. This abbreviated test session will be completed at weeks 1, 4, and 8. The abbreviated is described below.

You will arrive at the PAES building (lower level) euhydrated and at least 24hrs post exercise. You will be asked to complete a urine specific gravity test prior to being asked to complete a warm up and subsequent anaerobic strength and power measurements.

Warm Up: The warm up will require that you walk for 5 minutes on a treadmill prior to performing both static and dynamic stretches for the hip, knee, and ankle joints guided by the research personnel.

Counter Movement Squat Jump: The purpose of this test is to measure absolute and relative power output. Starting from an upright standing position on the force place, You will squat down and then jump in the air as high as possible and land on the force plate.

Isometric Squat Force The purpose of this assessment is to measure absolute and relative lower body force production (strength). Standing on a force place and starting in a 90 degree squat position under a static barbell, You will push upward against the barbell with as much force as possible for thirty seconds.

After you complete the physical performance measures cognitive assessment in the form of the Paced Auditory Serial Addition Test (PASAT) and Virtra firearms/combat simulator will be administered as described previously. 81

Controlled Feeding

If you are in one of the dietary intervention groups, we will prepare all your meals for you in the Instructional Kitchen in the Ohio Union. Daily macronutrient intake for the low-carbohydrate, ketogenic diet will consist of < 50 g carbohydrate, ~15-20% protein, and ~70-75% fat. A wide range of whole foods will be incorporated into your meals, including non-starchy vegetables, fruits, meats, nuts and seeds, oils, cheese, butter, cream, and eggs. If there is a specific food or ingredient you would prefer to avoid, we can work with you to exclude it from your meals. You will be asked to pick-up your food at the kitchen up to 3 times per week. All your food will be prepared and packaged in reusable and microwaveable containers labeled by meal (breakfast, lunch, dinner, morning or afternoon snack). A study team member will meet with you to ask and record if the amount of food was too little, too much or adequate. Finally, when you pick-up your food you will also return the plastic containers from the previous food pick-up. Please return these containers empty and rinsed, but not washed. We will wash and sanitize all the containers after you return them.

Throughout the duration of the dietary intervention, you will be asked to finger-stick testing for glucose and ketones each day. This will provide us with the information we need to adjust your diet so that you maintain a specific level of nutritional ketosis. You will be provided with the meter and we will teach you how to use it.

Depending on which group you are in, you may be asked to consume a dietary ketone supplement each day, the dosage for which will be dictated by your daily ketone measurements.

Training

You are expected to train on your normal schedule as regulated by Ohio State University ROTC. Research key personnel will assist in developing, supervising, and monitoring training. You will be asked to share detailed training logs with the research team that allow for assessment of training progress and completion. Training modifications will be submitted for approval by ROTC leadership prior to enactment.

Participant Completion

After you complete the study, an exit meeting will be scheduled with a member of the study team. You will receive your payment for participating in the study and any personal data that has been analyzed. This information will include body composition 82

and resting energy expenditure, and any other blood analysis that is complete at this time. Analysis of most of your data will be completed after you have finished the study, and we will make that available to you as well. This will include personal data from the blood, cheek cells, and muscle tissue we collected during the study as well as the MRI. You will only receive your own data.

Analysis

All the blood, urine, cheek cells, and muscle tissue we collect from you (we refer to them as biological specimens) will be kept in cold storage at -80oC in our biochemistry lab. Your biological specimens will be labeled with your subject identifier and not your name to maintain confidentiality. During sample analysis some of your biological specimens will be sent to collaborators who will perform some of the analysis, but your name will not be shared with them. Only your subject identifier will be provided to our collaborators. We will be measuring several markers in your biological specimens related to cardiovascular health, inflammation, and antioxidant status. However, since we will be storing your samples for up to five years, we may think of other markers to measure that we did not think of prior to the start of this study. You have the right to decline the use of your samples for any potential future analysis. Below are two check boxes indicating that you either will allow us or will not allow us to use your biological specimens to measure future markers. If you select not to allow us to use your biological specimens for future analysis, then any left over biological specimens will be destroyed. Please select an option below and sign your name with today’s date. The extra signature indicates that you have thought about, read and understand this option. Please keep in mind that the selection of either option will have no impact or penalty during your participation in the study, and you will not lose any benefits to which you are otherwise entitled.

Yes, I give permission to use my biological specimens for any future analysis. ▖

No, I do not give permission to use my biological specimens for any future analysis. ▖

Participant Signature: ______

Date: ______

4. How long will I be in the study?

The duration of this study is expected to be 14 weeks, which includes a week for baseline testing, the 12 week dietary intervention period, and another week for final 83 testing. We cannot perform testing when people become ill. Therefore if you become sick during the study, the feeding phase may be extended. The feeding phase could also be extended if we cannot find a good time for you to come in for testing due to scheduling issues. Based on these factors, the total duration of the study may exceed 14 weeks.

5. Can I stop being in the study?

You may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. Your decision will not affect your future relationship with The Ohio State University.

6. What risks, side effects or discomforts can I expect from being in the study?

Finger-stick Testing The finger stick may cause a slight immediate discomfort at the specific stick site. Under normal conditions, there are minimal risks to you when performing finger- sticks that include: bruising; light-headedness or dizziness due to fear of needles; and infection.

Blood Draws Blood draws may cause discomfort at the skin puncture site and a small bruise may develop that may persist for several weeks. There is also a small possibility of an infection. Every precaution to avoid infection will be taken including the use of sterile disposable needles and gauze and the practice of aseptic (sterile) techniques during the blood draw.

Muscle Biopsy The area of your leg in which the muscle biopsy will be performed contains no major neural or vascular structures. However, you need to understand that muscle biopsies are painful. While the pain is typically quite tolerable, it is impossible to make the biopsy a completely pain-free procedure. We will make every reasonable attempt to make you as comfortable as possible.

All biopsies will be performed by a licensed physician, who has been trained in the performance of superficial minor surgical procedures and instructed in the specifics of the muslce biopsy procedure. The muscle biopsy technique has been employed thousands of times with human volunteers. When the biopsy is performed you will be lying on your back. First, a small portion of your leg will be cleaned with alcohol and the skin and muscle will be numbed with Lidocaine. To do this, the Lidocaine will be injected using a thin needle. You will feel the poke of the needle as well as a burning sensation when the Lidocaine is injected. When the needle is placed into the muscle to numb it, the muscle will frequently respond with a rapid contraction that will feel like a brief cramp. This is normal and expected.

After the skin and muscle are numbed, your skin will be sterilized with an iodine solution called Betadine. This is done to diminish the possibility of an infection being caused by the biopsy. We will then cover the skin around this area with a sterile drape. Once you are numb, an incision will be made in your skin. Through this incision, a deeper incision will be made in the fascia around the muscle. These incisions are made so that the biopsy needle can be gently introduced into the muscle, and making the incisions will be completely painless because of the Lidocaine.

While Lidocaine does a good job of eliminating the sharp pain of an incision, it cannot fully eliminate the dull pain associated with doing the biopsy. The biopsy needle is about the same diameter as a Bic pen. After the incisions in the skin and fascia are made, the needle will be inserted through them into the muscle. Similar to when the numbing needle entered the muscle, the biopsy needle will also likely cause the muscle to cramp for a second. Once in place, the needle will be used to make three or four “snips” in the muscle, which will be removed from you. The total amount of muscle removed will be between 50 and 200 mg, or a total amount about the size of an unpopped popcorn kernel. After this, the needle will be withdrawn, some pressure will be put on the site to control bleeding, and the incision will be closed with one suture. You will not notice this muscle missing, either cosmetically or functionally. There are studies where more than 400 mg have been removed without problems.

After the procedure, you will have a pressure dressing applied to the site and your thigh will be wrapped with a compressive wrap. It will be tight, but should not be painful. The night of the procedure, you will be instructed to keep your knee bent as much as possible, apply ice to your thigh, avoid heat or massage, and avoid anti- inflammatory medication.

It is vital that you understand that your thigh will hurt after a muscle biopsy. The pain you will feel will be like a deep “Charley Horse” and will typically improve over 48-72 hours. It is impossible to quantify the pain for you. Everyone’s experience with pain is unique, and one’s sensation of pain is influenced by multiple other factors than just the procedure itself. The exact same procedure, done the exact same way, will be felt differently by different people. It will even vary in the same person if they have multiple biopsies over time. There have been situations where people have hurt for more than a week. The more accurate expectation is 48-72 hours of tolerable aching in your thigh. After the first night, you will be allowed to exercise in any way you tolerate.

Other risks include infection, which is very rare, less than 1 in 1000 biopsies. Sterile technique is used to limit this risk, and our laboratory has never had a wound infection from a muscle biopsy. If one were to occur, it is typically easily treated with oral antibiotics. There is also a risk of nerve injury associated with incisions and the biopsy, and even the use of the numbing medication has been associated with 86 prolonged numbness. While large incisions almost always generate permanent numbness around the incisions, because it is impossible to make an incision in the skin without severing small skin nerves, the incisions in this procedure are small enough, though, that this rarely happens with a muscle biopsy. Another nerve injury that can occur with a procedure in the lateral aspect of the thigh is an injury to the lateral femoral cutaneous nerve, which lies between the skin and the muscle. This nerve provides sensation to the lower, outer part of the thigh, and if it is injured there is resultant numbness of decreased sensation in this injury. Permanent injury to this nerve has never been reported in association with a muscle biopsy, but the nerve can be temporarily injured, causing a decreased sensation in this area. There is rarely any pain associated with this injury and the nerve does not go to any muscles, so there is no effect on strength or function. Most people do not find it troublesome. The duration of the temporary injuries to nerves is difficult to predict. They can last from a few days to several months and there is no predictable way to determine the duration of the injury at the onset.

Strenuous Exercise The involvement of strenuous exercise in this study means that there is risk for adverse effects. However, based on eligibility criteria for this study, which is based on ACSM guidelines, your potential for risk is minimal. The risk associated with these eligibility criteria includes a 1 in 1,666 chance of abnormal heartbeats or heart attack as well as a 1 in 18,000 chance of sudden cardiac death

Body Composition You will be exposed to a very small amount of radiation by the scanner used to measure your body composition. Exposure to any amount of X-ray radiation, no matter how low, may cause abnormal changes in cells. However, the body continuously repairs these changes and the amount of radiation is very low in this study. The total exposure for the whole body scan is approximately 125 times less than the average radiation from a standard chest X-ray.

Metabolic Rate During this test you will be asked to breathe into a ventilated hood. There is a possibility for you to feel claustrophobic, but the hood provides enough space for your head, neck and shoulders. Also, the ventilated hood is clear, so it allows normal visibility and the ability to rotate the neck, which should minimize the chances of feeling claustrophobic.

Cheek Cell Collection There are no risks associated with using a swab inside of your cheek to collect cheek cell samples.

Feeding Period

Since this is a controlled feeding study, it is important that you only eat the food we provide to you. This may be inconvenient. However, we will work with you to make sure that it is not too burdensome on your normal life and activities. Since we will be providing all your food during the feeding phase, your ability to travel during this time will be limited, but we can work with you to accommodate your travels. The diets are formulated with normal foods and thus we do not expect any significant side effects or discomforts. However, if you experience discomfort, we will work to adjust the diets to minimize symptoms.

7. What benefits can I expect from being in the study?

You may gain insights into appropriate meal portion sizing and foods that can be made from the diets you will be exposed to during the study. This experience may help inform you about ways you could modify your own diet. Our staff and registered dietitians will also be available to answer questions you may have about the diets you will be eating to aid in your nutrition education. At the end of the study and after we have completed the blood analysis, you will also receive your own results back and you will be able to see if the diet led to any improvements in your health or performance.

Indirect benefits that will be gained from participation in this study include a better understanding of how carbohydrates and fats in the American diet interact to impact health and performance. These findings may help to someday change dietary and sports nutrition guidelines.

8. What other choices do I have if I do not take part in the study?

You may choose not to participate without penalty or loss of benefits to which you are otherwise entitled.

9. Will my study-related information be kept confidential?

For all the data collected over the course of the study (i.e. records, biological samples and questionnaires) a unique subject identifier (i.e. a code) will be assigned and used instead of your name. This identifier, which links your name to your data, will only be available to research personnel. Any records that contain your name and identifier together will either be stored in the Kinesiology file storage room in a locked file cabinet or protected on a computer via password protection on the individual digital file and password protection on the computer the file(s) are stored on. All other records that only contain the subject identifier will be kept in either a file cabinet in our locked file storage room or on a password protected computer. Your name will never be used in any presentation or publication resulting from this study. The records will be maintained until the data are published and up to a maximum of five years after the completion of the study.

There may be circumstances where your information must be released. For example, personal information regarding your participation in this study may be disclosed if required by state law.

Also, your records may be reviewed by the following groups (as applicable to the research): ● Office for Human Research Protections or other federal, state, or international regulatory agencies; ● U.S. Food and Drug Administration; ● The Ohio State University Institutional Review Board or Office of Responsible Research Practices; ● The sponsor supporting the study, their agents or study monitors; and ● Your insurance company (if charges are billed to insurance).

If this study is related to your medical care, your study-related information may be placed in your permanent hospital, clinic, or physician’s office records. Authorized Ohio State University staff not involved in the study may be aware that you are participating in a research study and have access to your information.

A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by U.S. law. This website will not include information that can identify you. At most, the website will include a summary of the results. You can search the website at any time.

You may also be asked to sign a separate Health Insurance Portability and Accountability Act (HIPAA) research authorization form if the study involves the use of your protected health information. 89

10. What are the costs of taking part in this study?

Other than your time, there are no costs to participate in the study. You may need to pay for parking if you do not have an Ohio State University parking pass, but we have temporary passes that we can provide you with.

11. Will I be paid for taking part in this study?

Yes, if you complete the study you will receive a total of $200. No compensation will be provided for completing the screening visit or the baseline testing alone.

By law, payments to subjects are considered taxable income.

12. What happens if I am injured because I took part in this study?

If you suffer an injury from participating in this study, you should notify the researcher or study doctor immediately, who will determine if you should obtain medical treatment at The Ohio State University Wexner Medical Center.

The cost for this treatment will be billed to you or your medical or hospital insurance. The Ohio State University has no funds set aside for the payment of health care expenses for this study.

13. What are my rights if I take part in this study?

If you choose to participate in the study, you may discontinue participation at any time without penalty or loss of benefits. By signing this form, you do not give up any personal legal rights you may have as a participant in this study.

You will be provided with any new information that develops during the course of the research that may affect your decision whether or not to continue participation in the study.

You may refuse to participate in this study without penalty or loss of benefits to which you are otherwise entitled.

An Institutional Review Board responsible for human subjects research at The Ohio State University reviewed this research project and found it to be acceptable, according to applicable state and federal regulations and University policies designed to protect the rights and welfare of participants in research.

14. Who can answer my questions about the study?

For questions, concerns, or complaints about the study you may contact Dr. Jeff Volek. His office number is 614-688-1701 and his email address is [email protected].

For questions about your rights as a participant in this study or to discuss other study- related concerns or complaints with someone who is not part of the research team, you may contact Ms. Sandra Meadows in the Office of Responsible Research Practices at 1-800-678-6251.

If you are injured as a result of participating in this study or for questions about a study-related injury, you may contact Dr. Jeff Volek. His office number is 614-688- 1701 and his email address is [email protected].

Signing the consent form

I have read (or someone has read to me) this form and I am aware that I am being asked to participate in a research study. I have had the opportunity to ask questions and have had them answered to my satisfaction. I voluntarily agree to participate in this study.

I am not giving up any legal rights by signing this form. I will be given a copy of this form.

Printed name of subject Signature of subject

AM/PM Date and time

Printed name of person authorized to consent for subject Signature of person authorized to consent for subject (when applicable) (when applicable)

AM/PM Relationship to the subject Date and time

Investigator/Research Staff

I have explained the research to the participant or his/her representative before requesting the signature(s) above. There are no blanks in this document. A copy of this form has been given to the participant or his/her representative.

Printed name of person obtaining consent Signature of person obtaining consent

AM/PM Date and time

Witness(es) - May be left blank if not required by the IRB

Printed name of witness Signature of witness

AM/PM Date and time

Printed name of witness Signature of witness

AM/PM Date and time