Current Nutrition Reports

https://doi.org/10.1007/s13668-019-00294-0

GASTROENTEROLOGY, CRITICAL CARE, AND LIFESTYLE MEDICINE (SA MCCLAVE, SECTION

EDITOR)

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

Matthew B. Kaspar 1 & Kerstin Austin 2 & Martin Huecker 3 & Menaka Sarav 4

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Purpose of Review To review the available literature/evidence on low carbohydrate/high fat (LCHF) and low carbohydrate
ketogenic (LCKD) diets’ effects on human athletic performance and to provide a brief review of the physiology and history of
energy systems of exercise.
Recent Findings Multiple studies have been conducted in an attempt to answer this question, many within the last 3–5 years.
Studies are heterogenous in design, intervention, and outcome measures.
Summary Current available data show that LCHF and LCKD do not significantly enhance or impair performance in endurance
or strength activities. However, there is a trend towards improved body composition (greater percent lean body mass) across
multiple studies. While this may not translate to enhanced performance in the primarily laboratory conditions in the reviewed
studies, there could be a benefit in sports in which an athlete’s strength-to-weight ratio is a significant determinant of outcome.

Keywords : Ketogenic diet . Low carbohydrate diet . Athletic performance . Endurance sports . Strength sports

Introduction utilize one substrate over another eventually became a subject

Over the last 20–30 years, low carbohydrate high fat (LCHF)
and low carbohydrate ketogenic diets (LCKD) (collectively
“ketogenic diets”) have enjoyed a resurgence in the lay and
scientific press [1, 2]. Initially seen as a method to combat the
worsening obesity epidemic, the idea that the body’s metabol-
ic and energy systems could be remodeled to preferentially
This article is part of the Topical Collection on Gastroenterology, Critical
Care, and Lifestyle Medicine
* Matthew B. Kaspar
matthew.kaspar@vcuhealth.org
1
Department of Internal Medicine, Division of Gastroenterology,
Hepatology, and Nutrition, Virginia Commonwealth University
Medical Center, 1200 East Broad Street, P.O. Box 980509,
Richmond, VA 23298, USA
2
Division of Gastroenterology and Hepatology, University of
Wisconsin School of Medicine and Public Health,
Madison, WI 53705, USA
3
Department of Emergency Medicine, University of Louisville School
of Medicine, Louisville, KY, USA
4
Division of Nephrology and Hypertension, NorthShore University
Health System, University of Chicago, Chicago, USA
of interest. Researchers discerned a potential not to simply
treat disease, but to maximize human performance in healthy
subjects. After a series of papers failed to demonstrate signif-
icant benefit, the concept of performance enhancement via
adaptation to a high-fat diet was considered unlikely to suc-
ceed [3]. The pace of research in this area slowed significantly
and focus returned to a muscle-glycogen-based model of per-
formance enhancement. However, with the popular resur-
gence of a variety of diets such as the “paleolithic” and “keto”
diets, investigator interest in LCHF and LCKD returned.
The aims of this review are to review the history of LCHF
and LCKD, provide a historical perspective on our under-
standing of energy systems in exercise, and to summarize
the available evidence regarding the utility of LCHF and
LCKD in enhancing athletic performance.
History of Ketogenic Diet
The term “ketogenic diet” first emerged in a 1922 manuscript
[4], describing the use of a diet low in carbohydrate (20 g/day)
and high in fat (90 g/day) in the successful treatment of a 28-
year-old woman who presented to the Mayo clinic in diabetic
ketoacidosis. Even in 1922, the concept of the medical utility

of a low-carbohydrate diet was not a novel one, having been
described as an effective treatment for epilepsy at least 10
years prior [5]. However, with the introduction of phenobar-
bital as an antiepileptic and insulin in the early 1920s as more
mainstream alternative treatments to the primary therapeutic
indications of the ketogenic diet, it fell into relative obscurity.
In the 1970s, largely in response to the erupting obesity epi-
demic, interest in ketogenic diets resurged, with publications
in the scientific [1] and lay press [2].
History of Energy Systems in Exercise
Our modern understanding of human metabolism and energy
production is the result of almost a century of research.
Starting in the early 1920s, investigators focused primarily
on carbohydrate and glucose, observing that periods of carbo-
hydrate fasting led to premature fatigue [6] and that marathon
runners had significantly decreased blood glucose levels post-
race [7]. While carbohydrate deprivation and blood glucose
were known to correlate with energy production and perfor-
mance, it was not until the complete characterization of the
oxidative pathway of energy utilization (Krebs/TCA/citric ac-
id cycle) in 1937 [8] and the discovery that adenosine triphos-
phate (ATP) functioned as a primary/immediate source of en-
ergy to the majority of biochemical functions [9] that a mod-
ern and mechanistic understanding of human metabolism was
fully described.
In terms of athletic performance, glucose remained a pri-
mary focus until the 1960s, when the advent of new muscle
biopsy techniques and electron microscopy shifted focus to
intramuscular glycogen. In 1967, primarily as a result of
new needle muscle biopsy techniques, investigators demon-
strated the depletion of muscle glycogen after exercise via
biopsy of paired quadriceps muscles which had been
exercised asymmetrically on a cycling ergometer [10]. This
seminal work in muscle physiology and energy utilization
strengthened the idea that intramuscular glycogen served as
a primary source of energy during exercise. As a result, re-
search seeking to optimize human performance focused pri-
marily on devising strategies to maximize intramuscular gly-
cogen stores [10–12].
As understanding of energy utilization progressed, re-
searchers began to believe that energy requirements of exer-
cise, particularly long-duration exercise, were limited by the
body’s ability to store glycogen. In even the most optimized
subjects, total body glycogen stores (500 g, yielding approx-
imately 2000 kcal of energy if completely oxidized) would be
insufficient to supply the necessary energy for endurance
events such as an Iron Man triathlon which is estimated to
require almost 9000 kcal of energy to complete [13]. In con-
trast, even very lean athletes store massive amounts of energy
(63,000 kcal or more) in adipose tissues [13].
Curr Nutr Rep
The concept that “muscular work” shifted the body’s pat-
tern of energy utilization from oxidation of fatty acids at rest to
glycolysis as intensity of work increased was not new. Since
1920 [6], an emerging body of work hinted at the possibility
that training could “shift” the intensity at which this transition
might occur [14, 15].
The concept that an athlete could adapt to a LCKD without
detriment to performance was first described by Phinney et al.
in 1983 [16•]. In this study, five well-trained cyclists
underwent testing of VO2max and endurance cycling capacity
(measured as time to exhaustion cycling at 62–64% of
VO2Max) after 4 weeks of adaptation to a diet consisting of
1.75 g/kg/day protein and 20 g carbohydrate/day, with the
remainder of the daily required calories provided as fat. At
the end of the trial, the cyclists demonstrated a shift in fuel
utilization towards fat (RQ 0.83 to 0.72) during the endurance
exercise trial and maintained performance on the endurance
cycling test. Subsequent studies [17, 18] demonstrating that
depleting intramuscular glycogen had no negative impact on
muscle force and endurance reinforced enthusiasm for the idea
that optimizing the body’s ability to oxidize fatty acids during
exercise might offer an avenue to maximally utilize stored
energy during exercise. In particular, there was interest in
“shifting” the VO2Max at which the body transitions from
using fat to carbohydrate as a primary source of fuel [19].
For the two decades following Phinney’s 1983 study, a ma-
jority of research on the role of LCHF and LCKD in athletic
performance focused on various strategies of carbohydrate
deprivation and reloading and yielded overall negative results
[20•]. A summary of this body of research is beyond the scope
of this article but many comprehensive reviews of the subject
are available elsewhere [20•].
LCKD and LCHF Diets in Athletic Performance
The concept of “athletic performance” is broad and heteroge-
neous. At the simplest, athleticism could be categorized in
terms of intensity, duration, and frequency of activity. At one
end of this spectrum are events requiring a very high intensity
of effort over a short amount of time such as Olympic
weightlifting. Endurance events such as marathons (26.2
miles), ultramarathons (50+ miles), and multistage events
such as the Tour de France take place over the course of days
to weeks. Most real-world instances of any particular sport
involve a variety of intensities and durations of action. For
example, even within “simple” racing events, an athlete’s
power output is unlikely to be static as conditions of the event
(whether environmental or from other competitors) require
varying levels of intensity in order to complete a sprint, chase
down a breakaway, or defend against an attack. Furthermore,
field sports such as soccer or rugby are not only characterized
by alternating periods of low-to-moderate-to-high intensity
Curr Nutr Rep
activity, but rely on an athlete’s ability to maintain mental
acuity, rapidly synthesizing a broad range on inputs in order
to make correct tactical or play decisions. Finally, complexi-
ties related to an athlete’s decision making, strategy, coaching
input, etc. must be considered. As such, caution must be taken
when generalizing any conclusion made from studying exer-
cise performed in laboratory conditions to real-world athletic
competition.
Summary of Evidence
For the purpose of this review, only studies evaluating adap-
tations and effect of LCHF or LCKD were included. Studies
were included if total calories from fat were > 60% and car-
bohydrate < 25% or < 50 g/day, with the remainder from
protein in accordance with previously suggested macronutri-
ent compositions of LCHF and LCKD diets. Adaptation peri-
od was not used as a criterion for inclusion. In an effort to
provide as broadly informative a summary as possible, all
sports/events/intensities of exercise were included.
A total of 16 studies were included for review and are
summarized in Table 1. Studies represented a broad range of
activities but all focused primarily on activities with objective
measurements of performance: race times, times to exhaus-
tion, maximum weight lifted, or number of repetitions. No
studies evaluated head-to-head competition or attempted to
quantify performance in field sports. Subjects from diverse
populations (elite/Olympic-level athletes to amateurs across
both sexes) were represented.
Endurance Exercise Performance
Eleven of the studies included in this review focused on en-
durance exercise. Many investigators studied performance in
medium to long duration, steady-state endurance activity, like-
ly based on expectations that fat-adapted athletes would be
more likely to realize performance benefit in these types of
activities. Studies were heterogenous in design, athlete char-
acteristics, diet protocols, and testing protocols. Sample sizes
were generally low (n = 5–11), and time given for adaptation
to the dietary intervention ranged from 7 days [35] to 12
weeks [23]. Details of dietary intervention were heterogenous,
with total daily carbohydrate ranging from 50 g or 10% of
total calories per day to not more than 25% of daily calories
from carbohydrate per day. Not all studies performed a labo-
ratory assessment of ketosis.
Prior knowledge regarding metabolic adaptations to LCHF
and LCKD was expanded, and no studies appeared to show
detriment to subjects. The majority of these studies failed to
demonstrate obvious benefit of LCHF or LCKD in athletic
performance, with a few exceptions:
-In 1989, O’Keeffe et al. tested seven highly trained female
cyclists’ time to exhaustion (TTE) while cycling at 80% of
VO2max after 7 days of adaptation to low/moderate/high-
CHO (13%, 54%, and 72% of daily calories form CHO).
Results were significant for TTE correlating positively and
with percent of carbohydrate in the diet.
-In 2002, Rowlands et al. tested seven trained male cyclists
in a 100-km time trial, with evaluation of maximum power
output over the final 5 km after 14 days of adaptation to high-
CHO (70% total energy from carbohydrate, 14% from fat) or
high-fat (15% of total energy from carbohydrate, 66% from
fat). They found a small but significant improvement in last-
5k power output in the high-fat group (1.3 times greater, p =
.04), but failed to show a significant difference in overall
times. No significant difference in body mass or lean body
mass was found.
-In 2014, Zajac et al. performed VO2Max testing in eight
amateur off-road cyclists after 28 days of a LCHF diet (15%
CHO, 70% fat), finding a small but significant decrease in
maximum workload in the LCHF group. This reduction in
maximum workload echoed Phinney’s 1983 result and rein-
forced the theory that fat adaptation may not benefit athletes
desiring to function at very high intensities for prolonged pe-
riods of time.
Of note, multiple studies demonstrated favorable changes
in body composition [23, 24, 28, 29], suggesting a possible
benefit of ketoadaptation for athletes in whom weight and
body composition (ratio of lean to adipose body mass) might
play a significant role.
Various explanations have been posited for these largely
negative results. While studies have suggested that muscle
adaptation can begin as early as 5 days into a LCHF of
LCKD [33], it is possible that many of these studies did not
allow sufficient adaptation time for full benefit. Additionally,
the activities studied may not have provided a truly optimal
setting to demonstrate benefit of LCKD and LCHF diets, as
few evaluated events of sufficient duration (whether by single
or repeated efforts). Proponents argue that muscle glycogen
must be depleted completely to allow the keto-adapted ath-
lete’s benefit to manifest. Additionally, none of the studies
reviewed measured recovery time, an area wherein a keto-
adapted athlete might garner advantage due to relatively low
reliance on the time-consuming process of replacing muscle
glycogen.
Strength Performance
Only five studies evaluating LCKD and LCHF diets’ effects
on power/strength performance were identified as being suit-
able for inclusion in this review. This represents an emerging
area of scientific interest, as early studies demonstrated favor-
able changes in body composition in athletes on LCKD or
Table 1 Summary of recent studies of LCHF and LCKD in athletes

Study Athletes tested Study design Diet intervention(s) Ketosis Performance metric Result Notes/comments
author/year and adaptation period confirmed
(and method)

Greene 14 male and Randomized LCKD: < 50 g or < 10% TDI Yes Athlete-selected lift Decrease in body mass and improvement in
2018 [21] female crossover CHO/day Snatch, clean and jerk, bench press, LBM in LCKD power-to-weight
weightlifters UD: > 250 g CHO/day squat, deadlift No significant change to ratio in LCKD group
12 weeks adaptation in each diet w 1RM in any tested event
14-day washout between
Waldman Trained men Within-subject LCHF: Fat > 50%, < 25% CHO No Time to exhaustion on graduated No difference in TTE increase in fat oxidation
2018 [22] N = 11 repeated 15 days intensity run protocol, tested after 5 days in LCHF diet
measures days 0, 5, 10, 15
McSwiney Endurance Non-randomized HC vs LCKD Yes Body composition by DEXA LCKD body mass significantly Mean TT performance
2018 [23] cyclists N = 20 controlled trial HC 65% CHO 20% fat 14% protein Cycling performance decreased. Lean body mass change in LCKD group
LCKD > 75% fat, 10.15% protein, Six-second sprint, 100-km time trial preserved in both groups from large effect in 3/9
< 50 g/day CHO at 0 and 12 weeks TT: No significant difference athletes
12 weeks SS: peak power higher in Peak power improvement
LCKD group due to decrease in body
mass
Heatherly Male endurance Within-subject LCHF: Yes Running No significant difference in • Improved body composition
2018 [24] runners, N = 8 repeated 70% fat 5-km time trial, graduated 5-km TT performance and higher rates of fat
measures < 50 g/day CHO intensity/pace oxidation in LCHF group
21 days
Kephart Crossfit athletes Nonrandomized KD vs control Yes • 1RM back squat and power clean No significant difference KD group with significant
2018 [25] N = 12 controlled trial 70% fat, < 50 g CHO/day • Push-ups to volitional fatigue between KD and CTL change in DEXA-estimated
12 weeks • 400-m run fat mass, no significant
change in lean body mass
Burke 2017 Elite male race Nonrandomized • High-CHO: 60–65 CHO/15–20% Yes • 10-km race walk 10-km walk: significant • No significant changes in
[26•] walkers N = 21 controlled trial protein 20% fat improvements in HCHO body composition between
• Periodized CHO-high CHO and PCHO groups. two groups.
around training No significant change in LCHF
• LCHF < 50 g/day CHO, 75–80%
fat, 15–20% protein
21 days
Wilson 25 • WD 55% CHO, 20% protein, Yes • 1RM bench press No difference in performance LBM increased similarly in
2017 [27] resistance-- 25% fat • 1RM back squat between groups both groups during
trained • KD 5% CHO, 20% protein, • Wingate peak power × 10 s training period but only
males age 75% fat in KD group during
18–30 • Reintroduction of carbohydrate carbohydrate reintroduction
N = 25 in week 11 to prevent DEXA phase in week 11
confounding
10 weeks
Zinn 2017 5 endurance Case series • LCKD < 50 g CHO, Yes • Graded intensity cycling trial, No significant difference Significant loss in body
[28] athletes 1.5 g/kg protein time to exhaustion after LCKD weight and fat mass
10 weeks (measured as
sum of 8 skinfolds)
Crossover • LCHF: Yes • VO2Max test
Curr Nutr Rep
Table 1 (continued)

Study Athletes tested Study design Diet intervention(s) Ketosis Performance metric Result Notes/comments
author/year and adaptation period confirmed
Curr Nutr Rep

(and method)

Zajac 2014 8 amateur off-road • CHO 15%, fat 70% No significant performance Significant decrease in
[29] cyclists • 28 days advantage with LCHF diet body mass and % body
fat in LCKD group
Paoli 2012 8 elite artistic RCT with • LCHF: CHO < 25 g/day, No • Squat jump, countermovement No significant change in • Significant decrease in
[30] gymnasts crossover 55% fat jump, chin-ups, parallel bar strength measurements body weight without
• 30 days dips (repetitions to exhaustion) significant change in
muscle mass
(skinfold measurements)
Vogt 2003 11 trained male Randomized • LCHF: CHO 3.6 g/kg No • Running: 21 km TT No significant benefit No significant change in
[31] duathletes crossover • Fat 53% total energy • Cycling: 40-min protocol of LCHF diet body mass or composition
• HC CHO 6.9 g/kg w progressive exertion No significant difference
• 5 weeks in VO2 max or power
output for running
or cycling
Rowlands 7 trained male Randomized • HCHO: 70 ± 9% TE CHO, No • 15-min time trial No difference between groups No significant difference in
2002 [32] cyclists crossover 14 ± 2+ fat • Incremental testing body mass or lean body
• HF: 15 ± 4% CHO, • 100-km trial, time trial + max mass
66 ± 10% fat power over final 5 km
• 11 days HF followed by
2.5 days CHO loading
• 14 days
Goedecke 16 Parallel group • LCHF: fat 70% TE No • Cycling No significant difference • MCT intake prior to and
1999 [33] endurance-- • Control: fat 30 ± 10% • 2.5-h ride at 63% in 40-km TT performance during performance testing
trained • 15 days VO2Max + 40-km time trial between groups. • Demonstrated metabolic
cyclists • Tested days 0, 5, 10, 15 adaptations after 5 days
Lambert Trained male Randomized • HF: Fat 67% TE, CHO Yes. • Cycling No effect on Wingate
1994 [34] cyclists N = 5 crossover 7% TE • 30 s Wingate + TTE at 90% or TTE
• HC: CHO 73.6% TE, VO2max + TTE at 60%
fat 12% TE VO2max
• 14 days
O’Keeffe 7 highly trained Randomized • Low CHO (13% TE) No • Cycling: TTE at 80% VO2Max Exercise time on LCHO
1989 [35] female cyclists crossover • Moderate CHO (54% TE) diet significantly shorter
• High CHO (72%) than MCHO and HCHO
• 7 days diets
Phinney 5 trained male Crossover • LCHF: fat 85% total Yes, serum • Cycling: No change in TTE • Significant decrease in
1983 [36] cyclists energy, CHO < 20 g/day ketones • TTE at 62–64% VO2max muscle glycogen utilization
• 28 days • Significant change in RQ

CHO carbohydrate, HCHO high carbohydrate, HF high fat, LCHO low carbohydrate, MCHO medium carbohydrate, MCT medium chain triglycerides, RQ respiratory quotient, TE total energy, TT time
trial, TTE time to exertion, 1RM one rep maximum, B-HB beta-hydroxybutyrate, CHO carbohydrate, HC high carbohydrate, MCT medium chain triglycerides, TT time trial, TTE time to exhaustion, UD
usual diet, WD Western diet

LCHF diets without detriment to performance. Investigators
hypothesize a role for the diets’ ability to enhance the power-
to-weight ratio of an athlete, thus providing a performance
advantage. Examples of such activities include those in which
weight classes are employed to denote levels of competition,
and those in which an athlete performs activity against body
weight resistance.
In 2012, Paoli et al. published the first evaluation of LCHF
and LCKD’s role in explosive/strength athletes, testing perfor-
mance in elite artistic gymnasts [37]. In this study, eight gym-
nasts underwent a 30-day adaptation period to a very low (<
25 g/day) carbohydrate diet prior to a variety of activities
testing strength against body weight resistance. Notably, there
was no significant change in any of these metrics, despite a
mild (but significant) improvement in body composition, spe-
cifically improvement in percent body fat as estimated by a
variety of methods.
Similar results were demonstrated in resistance trained
males [27], Crossfit athletes [25], and elite Olympic and pow-
er weightlifters [21]. Kephart and Greene found favorable
changes in body composition using a more rigorous method
(DEXA) as compared to the skin fold thickness measurements
employed by Paoli. Finally, Wilson et al. demonstrated that
only the LCKD group improved lean body mass during a 1-
week reintroduction of carbohydrate at the end of their trial.
This reinforced a previously suggested concept that at least a
portion of decrease in weight and lean body mass seen with
initiation of LCKD is the result of lower concentrations of
muscle glycogen (and intramuscular water) than true loss of
adipose tissue.
Overall, from the available data, it is reasonable to con-
clude that low carbohydrate and ketogenic diets may lead to
favorable changes in body composition without significant
detriment in power or strength in single or short (< 1–2 min)
exertions performed at near-maximum capacity.
Conclusions
Despite compelling biochemical and physiologic mecha-
nisms, LCHF and LCKD have overall shown minimal signif-
icant benefit to athletes’ performance in a variety of endurance
and strength-based events. Most studies provided appropriate
time for adaptation to the dietary intervention, a potential lim-
itation in all LCHF trials. The majority of studies demonstrat-
ed significant differences in changes to body composition in
athletes on a LCHF of LCKD, with significant increases in
percent lean body mass. The few studies that failed to show
this difference either did not report body composition or stud-
ied exceptionally lean athletes. Most studies evaluated ath-
letes’ objective performance in tightly controlled laboratory
settings which may not be applicable to the dynamic and com-
plex setting of competitive sports. Acknowledging the
Curr Nutr Rep
importance of statistically significant differences in perfor-
mance, one should consider that elite athletes may win or lose
on minute differences in performance that may not be cap-
tured by a 95% confidence interval.
Based on available data, there is no data to support LCHF
or LCKD for athletic performance. Further studies evaluating
the potential benefits of LCHF diets on longer-duration events
such as ultramarathons or multistage races or to carefully
study athletes’ performance in events where athlete’s percent
lean body mass significantly affect performance are
warranted.
Compliance with Ethical Standards
Conflict of Interest Matthew B. Kaspar, Kerstin Austin, Martin
Huecker, and Menaka Sarav declare they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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