The Open Sports Sciences Journal




ISSN: 1875-399X ― Volume 14, 2021
RESEARCH ARTICLE

Impact of Ketogenic Diet on Body Composition during Resistance Training among Untrained Individuals



Maryam Hadizadeh1, *, Wee Yet Gan1, Hamidreza Mohafez2, Yasuhiro Sugajima3
1 Centre for Sport and Exercise Sciences, University of Malaya, Jalan Universiti, 50603Kuala Lumpur, Malaysia
2 Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, Jalan Universiti, 50603Kuala Lumpur, Malaysia
3 Department of Health and Sports Sciences, School of Health Sciences, Asahi University, Japan

Abstract

Background:

Resistance training (RT) has been established as the most efficient approach for lean body mass maintenance required for preserving a sufficiently high metabolism during weight loss.

Objective:

This study aimed to evaluate the impacts of the ketogenic diet (KD) and regular diet (RE) in combination with 8-week resistance exercise (RT), on body weight, body fat mass (BFM), and lean body mass (LBM) of untrained individuals.

Methods:

Twenty untrained participants were randomly assigned to the RE+RT and KD+RT as control and experimental groups, respectively. Sixty to ninety minutes of diversified resistance exercise were performed by both groups, three sessions weekly, and diet was self-administered with a recommended daily energy and protein intakes. Body composition was measured using a Bioelectrical Impedance Analyzer. One-way Analysis of Covariance (ANCOVA) was applied to analyze the data.

Results:

The results showed a greater post-intervention adjusted mean for body weight and LBM in the normal dietary group in comparison with the experimental group. After controlling for baseline measurements, there was a statistically significant difference in body weight (p < .0005) and BFM (p =.001) between groups.

Conclusion:

Resistance training along with a ketogenic diet may decrease BFM without notable changes in LBM, whilst RT on a normal diet might increase LBM without remarkably influencing BFM.

Keywords: Resistance training, Lean body mass, Ketogenic diet, Weight loss, Body fat mass, Dietary carbohydrate.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 13
First Page: 114
Last Page: 119
Publisher Id: TOSSJ-13-114
DOI: 10.2174/1875399X02013010114

Article History:

Received Date: 4/8/2020
Revision Received Date: 7/10/2020
Acceptance Date: 16/10/2020
Electronic publication date: 24/12/2020
Collection year: 2020

© 2020 Hadizadeh et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Centre for Sport and Exercise Sciences, University of Malaya, Jalan Universiti, 50603 Kuala Lumpur, Malaysia; Tel: +603-79676986; E-mail: mary@um.edu.my





1. INTRODUCTION

The global prevalence of obesity has increased at an alarming rate, signalling an urgent need for safe, effective and sustainable weight-loss strategies. In the early 1920s, the ketogenic diet (KD), which is a high-fat (70%), very-low-carbohydrate (5%), moderate-protein diet (25%) [1Wilder RM. The effects of ketonemia on the course of epilepsy. Mayo Clin Bull 1921; 2: 307-8.], was formulated as a treatment for intractable epilepsy in children. However, when antiepileptic agents became available, the diet fell out of favor. Despite this, since 2018, the KD has gained so much traction that the term “keto” is now seven to ten times more popular than the terms “Paleo” and “Atkins” [2Joshi S, Ostfeld RJ, McMacken M. The Ketogenic Diet for Obesity and Diabetes-Enthusiasm Outpaces Evidence. JAMA Intern Med 2019; 179(9): 1163-4.
[http://dx.doi.org/10.1001/jamainternmed.2019.2633] [PMID: 31305866]
, 3Keto, Paleo, Atkins. https://trends.google.com/trends/explore?date= 2015-11-20%202018-12-20&q=keto,paleo,atkins [(Accessed April 09, 2020).];]. This is perhaps due to the efficacy of the KD as a potential weight loss strategy because of the low-carb diet trend. The fundamental principle of this diet is that drastic restriction of dietary carbohydrate, with its resulting ketosis, promotes fat oxidation, increased energy expansion and satiety promotes negative calorie balance and eventual weight loss [4Paoli A, Rubini A, Volek JS, Grimaldi KA. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr 2013; 67(8): 789-96.
[http://dx.doi.org/10.1038/ejcn.2013.116] [PMID: 23801097]
].

A variety of studies have deduced that a lower carbohydrate diet with no energy limitation seems to be as efficient as low-fat energy straitened diets in triggering weight reduction to a certain extent during a time of up to 1 year [5Brinkworth GD, Noakes M, Buckley JD, Keogh JB, Clifton PM. Long-term effects of a very-low-carbohydrate weight loss diet compared with an isocaloric low-fat diet after 12 mo. Am J Clin Nutr 2009; 90(1): 23-32.
[http://dx.doi.org/10.3945/ajcn.2008.27326] [PMID: 19439458]
-7Gardner CD, Trepanowski JF, Del Gobbo LC, et al. Effect of low-fat vs low-carbohydrate diet on 12-month weight loss in overweight adults and the association with genotype pattern or insulin secretion: The DIETFITS randomized clinical trial. JAMA 2018; 319(7): 667-79.
[http://dx.doi.org/10.1001/jama.2018.0245] [PMID: 29466592]
]. A systematic review concluded that high-protein or low-carb diets are more efficient within a period of six months and as efficient as low-fat diets in reducing the possibility of cardiovascular disease and losing weight till one year [6Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr 2013; 110(7): 1178-87.
[http://dx.doi.org/10.1017/S0007114513000548] [PMID: 23651522]
, 8Hession M, Rolland C, Kulkarni U, Wise A, Broom J. Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities. Obes Rev 2009; 10(1): 36-50.
[http://dx.doi.org/10.1111/j.1467-789X.2008.00518.x] [PMID: 18700873]
].

A major concern connected with the efficiency of any regime for losing weight is its effect on body composition, hence making it difficult to compare the effectiveness of various diets based on the reduction of body weight alone. Numerous slimming diets that reduce body fat occurs with an implicit lean body mass (LBM) reduction, which in many instances, it has been suggested as a justification for the long run fail of several weight-loss programs [9Stiegler P, Cunliffe A. The role of diet and exercise for the maintenance of fat-free mass and resting metabolic rate during weight loss. Sports Med 2006; 36(3): 239-62.
[http://dx.doi.org/10.2165/00007256-200636030-00005] [PMID: 16526835]
]. This is because maintaining or increasing LBM is important for preserving a sufficiently high metabolism to minimize the tendency of weight return, which is the main problem regarding the so-called “yo-yo” effect [10Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2009; 41(2): 459-71.
[http://dx.doi.org/10.1249/MSS.0b013e3181949333] [PMID: 19127177]
] apart from keeping adequate body function with aging [11Koopman R, van Loon LJ. Aging, exercise, and muscle protein metabolism. J Appl Physiol (1985) 2009; 106(6): 2040-8.
[http://dx.doi.org/10.1152/japplphysiol.91551.2008] [PMID: 19131471]
].

The most efficient approach for retaining or increasing LBM is through resistance exercises [12Miller T, Mull S, Aragon AA, Krieger J, Schoenfeld BJ. Resistance training combined with diet decreases body fat while preserving lean mass independent of resting metabolic rate: A randomized trial. Int J Sport Nutr Exerc Metab 2018; 28(1): 46-54.
[http://dx.doi.org/10.1123/ijsnem.2017-0221] [PMID: 28871849]
]. Resistance training has been established to restrict the LBM loss during weight reduction [13Longland TM, Oikawa SY, Mitchell CJ, Devries MC, Phillips SM. Higher compared with lower dietary protein during an energy deficit combined with intense exercise promotes greater lean mass gain and fat mass loss: a randomized trial. Am J Clin Nutr 2016; 103(3): 738-46.
[http://dx.doi.org/10.3945/ajcn.115.119339] [PMID: 26817506]
, 14Peterson MD, Sen A, Gordon PM. Influence of resistance exercise on lean body mass in aging adults: a meta-analysis. Med Sci Sports Exerc 2011; 43(2): 249-58.
[http://dx.doi.org/10.1249/MSS.0b013e3181eb6265] [PMID: 20543750]
]. Moreover, resistance exercise is capable of ameliorating metabolic disorders that come along with poor glycemic control and overweight, to cut down both the requirement and diabetes medication, systolic blood pressure and abdominal adiposity [15Peterson MD, Rhea MR, Sen A, Gordon PM. Resistance exercise for muscular strength in older adults: a meta-analysis. Ageing Res Rev 2010; 9(3): 226-37.
[http://dx.doi.org/10.1016/j.arr.2010.03.004] [PMID: 20385254]
].

Nutritional interventions that could result in exceptional LBM retention during weight loss would be beneficial to athletes in the weight-class restricted sports or those looking to improve body composition by preserving LBM while reducing fat mass for competitions. However, it has been reported that very-low-carbohydrate diets bring about substantial losses of LBM [16Greene DA, Varley BJ, Hartwig TB, Chapman P, Rigney M. A low-carbohydrate ketogenic diet reduces body mass without compromising performance in powerlifting and olympic weightlifting athletes. J Strength Cond Res 2018; 32(12): 3373-82.
[http://dx.doi.org/10.1519/JSC.0000000000002904] [PMID: 30335720]
], but other authors disagree [17Jabekk PT, Moe IA, Meen HD, Tomten SE, Høstmark AT. Resistance training in overweight women on a ketogenic diet conserved lean body mass while reducing body fat. Nutr Metab (Lond) 2010; 7(1): 17.
[http://dx.doi.org/10.1186/1743-7075-7-17] [PMID: 20196854]
-19Merra G, Miranda R, Barrucco S, et al. Very-low-calorie ketogenic diet with aminoacid supplement versus very low restricted-calorie diet for preserving muscle mass during weight loss: a pilot double-blind study. Eur Rev Med Pharmacol Sci 2016; 20(12): 2613-21.
[PMID: 27383313]
].

To date, the efficacy of KD in athletes seeking to improve body composition as well as those looking to improve strength and power performance, has gained minimal attention. The majority of exercise studies that have examined high-fat diets thus far and have also contained a number of carbohydrates sufficient to limit or prevent ketosis, have been underpowered, and/or were too short to allow for adaptation to the diet [20Noakes T, Volek JS, Phinney SD. Low-carbohydrate diets for athletes: what evidence? Br J Sports Med 2014; 48(14): 1077-8.
[http://dx.doi.org/10.1136/bjsports-2014-093824] [PMID: 24861453]
]. The results also revealed that an experimental diet was unable to achieve the full spectrum of benefits expected from a sustained ketogenic diet [20Noakes T, Volek JS, Phinney SD. Low-carbohydrate diets for athletes: what evidence? Br J Sports Med 2014; 48(14): 1077-8.
[http://dx.doi.org/10.1136/bjsports-2014-093824] [PMID: 24861453]
].

As the fat loss may seem to be lesser on fat-limited diet compared to carbohydrate-limited one, and since resistance training (RT) looks to be the most successful approach for muscle mass increment, an amalgamation of both strategies may increase the chance of weight loss with a favorable change in body composition. As such, the aim of the current study is to evaluate the impacts of ketogenic and normal diets, in combination with resistance exercises on body composition, in particular body weight, lean body mass and body fat mass (BFM). We hypothesized that there would be a significant difference in selected variables from pre to post-intervention and between two groups.

2. METHODOLOGY

2.1. Participants

This study was carried out with 20 participants who were randomly assigned to the intervention group (n = 10) with the mean age 35.2 ± 10.1 years, height 1.66 ± 0.1 m, bodyweight 64.9 ± 16.1 kg, and BMI 23.59 ± 4.56; and control group (n = 10) with the mean age 33.2 ± 10.5 years, height 1.69 ± 0.1 m, bodyweight 68.8 ± 12.5 kg, and Body Mass Index (BMI) 24.12 ± 3.6. Control group received a regular diet and resistance exercise (RE+RT), and the intervention group was imposed on the keto diet and resistance exercise (KD+RT). They had not previously been taking low carbohydrate diets and had not attended resistance training for the past six months. Participants were omitted if they had been on androgenic-anabolic steroids within the last two years, had any physical disabilities or recent medical conditions that would interfere with resistance exercises. All participants were asked for a written informed consent after an explanation of the procedure and possible risk of the experiment prior to the start of the study. The research was reviewed and approved by the University Malaya advisory panel for research involving human participants on 05/09/2019.

2.2. Training Protocol

Following a two-week diet adaptation period for the KD+RT group, both groups participated in an 8-week resistance training. All exercises were performed at FitClub, a 24-hour Gym and all sessions supervised by at least one qualified instructor. The eight-week personal training program consists of three hypertrophy sessions per week, organized into a two-day upper limb and one-day lower limb, along with at least 24-hour rest between each session to encourage recovery [21Chen JL, Yeh DP, Lee JP, et al. Parasympathetic nervous activity mirrors recovery status in weightlifting performance after training. J Strength Cond Res 2011; 25(6): 1546-52.
[http://dx.doi.org/10.1519/JSC.0b013e3181da7858] [PMID: 21273908]
].

Prior to data collection, a familiarization phase was expected to take place in order to accustom all participants to the exercises in the personal training program. Within this session, the 8-repetition maximum (8-RM) test for all exercises was assessed for all individuals. All sessions were conducted after a 10-min warmup with low intensity on a cardio machine. Stimulation of mechanical strain was done by utilizing the medium to high loads [22Schoenfeld BJ. The mechanisms of muscle hypertrophy and their application to resistance training. J Strength Cond Res 2010; 24(10): 2857-72.
[http://dx.doi.org/10.1519/JSC.0b013e3181e840f3] [PMID: 20847704]
]. The volume did not decline as the rest between sets remained for three minutes [23Grgic J, Lazinica B, Mikulic P, Krieger JW, Schoenfeld BJ. The effects of short versus long inter-set rest intervals in resistance training on measures of muscle hypertrophy: A systematic review. Eur J Sport Sci 2017; 17(8): 983-93.
[http://dx.doi.org/10.1080/17461391.2017.1340524] [PMID: 28641044]
]. To obtain better recovery, push and pull exercises were intermixed [24Fleck SJ, Kraemer W. Designing resistance training programs 2014.]. Groups were requested to enhance loads as long as they exceeded rates of repetition without having an error in technique. In the meantime, participants were requested to retain their level of physical activity and avoid participation in any other resistance exercises during the time of this study. Participants of both groups had consistent attendance in the exercise sessions.

2.3. Diet Intervention

Daily multivitamin and mineral supplements, LifePak (Nuskin, USA), were given to the participants of both groups. Individuals in each group were counseled during a single group session by a registered dietitian. Participants in the KD+RT group were informed about the principles and usage of dietary intervention and were given an available eBook on the ketogenic diet (“The complete ketogenic diet for beginners”) [25Kimmich M. The complete ketogenic diet for beginners 2018.] in addition to handouts. An average energy surfeit was set up for participants of both groups upon determination of their weekly training load and energy expenditure.

The preparation of food was self-administered, while a daily caloric consumption of 39 kcal/kg/day was recommended for all participants to encourage a hyper-energetic condition. A protein consumption of 2 gr/kg/day was advised for both groups to ensure maximal anabolic response [26Aragon AA, Schoenfeld BJ, Wildman R, et al. International society of sports nutrition position stand: diets and body composition. J Int Soc Sports Nutr 2017; 14: 16.
[http://dx.doi.org/10.1186/s12970-017-0174-y] [PMID: 28630601]
]. Macronutrient Distribution of macronutrient for regular diet participants was about 20% fat, 35% carbohydrate and 45% protein, while for the keto diet group, macronutrient distribution of macronutrient was about 70% fat, 5% carbohydrate and 25% protein. They were allowed Ad libitum meal timing and frequency during the day.

The presence and subsequent compliance with ketosis state for the KD+RT group were controlled through evaluating urinary ketones, concentration of acetoacetic acid and acetone, using reagent strips (Ketone Reagent Strips for Urinalysis, DIRUI Industrial Co., Ltd., Jilin, China) twice weekly, starting from the second week until the completion of the study. Keto diet group was asked to start up the dietary intervention with a maximum 20 gr/day of carbohydrate and to steadily enhance carbohydrate consumption, but not exceeding 5% of their caloric consumption, at their choice, until they retained a change in color on the urine test strips.

2.4. Body Composition

Measurements of body composition were conducted at baseline (week 2) and following the resistance training intervention (week 10), using an InBody 570 Multi-frequency Bioelectrical Impedance Analyzer (Biospace Co., Ltd, CA, USA). The InBody 570 body composition analyzer splits body mass into three components: fat, muscle, and bone mineral [27Miller RM, Chambers TL, Burns SP. Validating inbody 570 multi-frequency bioelectrical impedance analyzer versus DXA for body fat percentage analysis. J Exerc Physiol Online 2016; 19(5): 71-8.
[http://dx.doi.org/10.1249/01.mss.0000487979.68551.d7]
]. A wall-mounted stadiometer was used to measure participant's height without shoes.

2.5. Statistical Analyses

One-way Analysis of Covariance (ANCOVA) was applied to examine the impact of a “regular diet and resistance exercise” and “keto diet and resistance exercise” on post-intervention Body Fat Mass, Body Weight, and Lean Body Mass after controlling for pre-intervention Body Fat Mass, Body Weight, and Lean Body Mass, respectively. Moreover, a paired-sample t-test was applied to evaluate the changes from pre-intervention for each individual group. Statistical analyses were done using SPSS for Windows, version 24. p ≤ 0.05 was considered statistically significant in the interpretation of the results. Moreover, the preliminary assumptions were checked without any serious violations.

3. RESULTS

Adjusted means and standard errors (SE) for post-intervention of measured variables along with their unadjusted means and standard deviation (SD) for pre and post-intervention, are presented in Table 1. Changes from baseline and their corresponding p-value are also reported for each individual group. The KD+RT group showed a statistically significant decrease of 2.90 kg in Body Weight, t (9) =-5.75, p < .0005, while the RE+RT group significantly gained weight by 1.29 kg, t (9) = 2.88, p =.018. Bodyweight was greater in the RE+RT group (M = 68.21, SE = 0.48 kg) compared to the KD+RT group (M = 63.93, SE = 0.48 kg) post-intervention after controlling for baseline body weight. There was also a significant difference in post-intervention body weight among the groups, F (1, 17) = 39.19, p < .0005, partial η2 = .697.

Table 1
Unadjusted means and standard deviations (SD) for pre- and post-intervention body composition components, adjusted means and standard errors (SE) for post-intervention body composition components after controlling for their pre-intervention, and changes from baseline measurements.



Body fat mass elicited statistically significant mean decrease of 1.51 kg, t (9) =-6.05, p < .0005, and 4.38 kg, t (9) =-5.96, p < .0005 for group on regular diet and group on keto diet, individually. After adjustment for pre-intervention body fat mass, RE+RT group demonstrated higher mean (M = 19.39, SE = 0.42 kg) compared to the KD+RT group (M = 16.91, SE = 0.42 kg). Furthermore, there was a significant difference in post-intervention body fat mass among the groups, F (1, 17) = 17.087, p =.001, partial η2 = .501.

Regular diet and keto diet groups indicated significant mean increase of 2.8 kg, t (9) =7.21, p < .0005 and 1.48 kg, t (9) =2.52, p =.033 in lean body mass, respectively. Although mean of lean body mass was greater in the RE+RT group (M = 48.416, SE = 0.511 kg) compared to the KD+RT group (M = 47.414, SE = 0.511 kg) after controlling for pre-intervention scores, there was not a significant difference in post-intervention lean body mass among two groups, F (1, 17) = 1.788, p =.199, partial η2 = .095.

4. DISCUSSION

Combination of carbohydrate-restricted diet with resistance exercise led to a greater reduction of body fat mass and body weight compared to the regular diet with similar resistance exercise. The findings are aligned with other studies reporting a considerable decrement of body fat mass and body weight when carbohydrate consumption is sustained at a low level, reduced or restricted altogether [18Kephart WC, Pledge CD, Roberson PA, et al. The three-month effects of a ketogenic diet on body composition, blood parameters, and performance metrics in crossFit trainees: A pilot study. Sports (Basel) 2018; 6(1): 1.
[http://dx.doi.org/10.3390/sports6010001] [PMID: 29910305]
, 28Volek JS, Phinney SD, Forsythe CE, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids 2009; 44(4): 297-309.
[http://dx.doi.org/10.1007/s11745-008-3274-2] [PMID: 19082851]
].

Although our findings are backed by some sources of information from previous researches, there exist some inconsistent conclusions due to the shortage of studies separating the effect of keto diet with and without resistance exercise on muscle hypertrophy and body fat mass. These studies concluded that the decrement in body fat mass during and after KD is accompanied by an incidental reduction in lean body mass [29Perissiou M, Borkoles E, Kobayashi K, Polman R. The effect of an 8 week prescribed exercise and low-carbohydrate diet on cardiorespiratory fitness, body composition and cardiometabolic risk factors in obese individuals: A randomised controlled trial. Nutrients 2020; 12(2): 482.
[http://dx.doi.org/10.3390/nu12020482] [PMID: 32075010]
, 30Rauch JT, Silva JE, Lowery RP, et al. The effects of ketogenic dieting on skeletal muscle and fat mass. J Int Soc Sports Nutr 2014; 11: 40.
[http://dx.doi.org/10.1186/1550-2783-11-S1-P40]
]. Despite the contrary, it should be highlighted that no physical exercise intervention, in particular resistance training, was applied to the participants in the aforementioned studies.

In the present study, it has been found that participants in the KD+RT group decreased body fat mass, whereas preserving LBM, comparable findings have additionally been reported when an ordinary energy-restricted diet had been combined with resistance exercise [13Longland TM, Oikawa SY, Mitchell CJ, Devries MC, Phillips SM. Higher compared with lower dietary protein during an energy deficit combined with intense exercise promotes greater lean mass gain and fat mass loss: a randomized trial. Am J Clin Nutr 2016; 103(3): 738-46.
[http://dx.doi.org/10.3945/ajcn.115.119339] [PMID: 26817506]
]. Nonetheless, the hunger curb associated with the increased levels of ketone bodies in a carbohydrate-restricted diet [31Gibson AA, Seimon RV, Lee CM, et al. Do ketogenic diets really suppress appetite? A systematic review and meta-analysis. Obes Rev 2015; 16(1): 64-76.
[http://dx.doi.org/10.1111/obr.12230] [PMID: 25402637]
] is an edge to the other low-fat or regular diets. Carbohydrate restriction lowers levels of insulin due to the reduction of glucose availability; this, in turn, increases the concentration of counter-regulatory hormones like catecholamines and glucagon, encouraging the lipolysis of adipose tissues [32Westman EC, Feinman RD, Mavropoulos JC, et al. Low-carbohydrate nutrition and metabolism. Am J Clin Nutr 2007; 86(2): 276-84.
[http://dx.doi.org/10.1093/ajcn/86.2.276] [PMID: 17684196]
]. According to reports, the loss of body fat is inversely related to serum insulin levels in a 6-week carbohydrate-restricted diet [33Volek JS, Sharman MJ, Love DM, et al. Body composition and hormonal responses to a carbohydrate-restricted diet. Metabolism 2002; 51(7): 864-70.
[http://dx.doi.org/10.1053/meta.2002.32037] [PMID: 12077732]
]. Majority of the variability in fat loss (circa 70%) in the study was explained by lower serum insulin levels due to the change in metabolism from fat storage to oxidation and fatty acid release.

Excess energy is stored as triacylglycerol (TAG) in the liver and other tissues with lack of exercise and over-nutrition. In theory, carbohydrate-restriction should result in a diminished hepatic formation of TAG and very-low-density lipoproteins [34Schwarz JM, Linfoot P, Dare D, Aghajanian K. Hepatic de novo lipogenesis in normoinsulinemic and hyperinsulinemic subjects consuming high-fat, low-carbohydrate and low-fat, high-carbohydrate isoenergetic diets. Am J Clin Nutr 2003; 77(1): 43-50.
[http://dx.doi.org/10.1093/ajcn/77.1.43] [PMID: 12499321]
]. This is consistent with our findings wherein a substantial loss of body fat mass was observed in participants on the very-low-carbohydrate diet.

Even though there was no considerable increase in mean lean body mass in the KD+RT group, notwithstanding the incorporation of 8-week resistance exercise, there was no reduction in LBM in contrary to the findings of other weight loss studies [35Wycherley TP, Moran LJ, Clifton PM, Noakes M, Brinkworth GD. Effects of energy-restricted high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2012; 96(6): 1281-98.
[http://dx.doi.org/10.3945/ajcn.112.044321] [PMID: 23097268]
]. Some reduction of LBM is more or less expected with a low carbohydrate diet [18Kephart WC, Pledge CD, Roberson PA, et al. The three-month effects of a ketogenic diet on body composition, blood parameters, and performance metrics in crossFit trainees: A pilot study. Sports (Basel) 2018; 6(1): 1.
[http://dx.doi.org/10.3390/sports6010001] [PMID: 29910305]
], and as Merra et al. [19Merra G, Miranda R, Barrucco S, et al. Very-low-calorie ketogenic diet with aminoacid supplement versus very low restricted-calorie diet for preserving muscle mass during weight loss: a pilot double-blind study. Eur Rev Med Pharmacol Sci 2016; 20(12): 2613-21.
[PMID: 27383313]
], has concluded that very-low-carbohydrate diets do not promote catabolism of LBM provided a sufficient amount of protein is consumed.

The increase in or maintenance of lean body mass attributed to resistance workout has also -already been expressed in calorie- limited diets in females [17Jabekk PT, Moe IA, Meen HD, Tomten SE, Høstmark AT. Resistance training in overweight women on a ketogenic diet conserved lean body mass while reducing body fat. Nutr Metab (Lond) 2010; 7(1): 17.
[http://dx.doi.org/10.1186/1743-7075-7-17] [PMID: 20196854]
]. It is then possible to associate the incorporation of resistance exercise with the maintenance of LBM in the KD+RT group.

The lower insulin levels and lower energy intake may in part be the reason behind a lower increase in lean body mass in the KD+RT group. Theoretically, the formation of TAG, glycogen and proteins in anabolic processes are stimulated by the higher insulin levels induced by higher carbohydrate consumption [36Tipton KD, Wolfe RR. Exercise, protein metabolism, and muscle growth. Int J Sport Nutr Exerc Metab 2001; 11(1): 109-32.
[http://dx.doi.org/10.1123/ijsnem.11.1.109] [PMID: 11255140]
]. Another possible explanation for the non-significant increase in LBM within the KD+RT group might be the use of skeletal muscle protein as fuel. Amino acids may become a part of glucose production via gluconeogenesis in dietary-induced ketosis when excessive amounts of protein (above the recommended 25% to 30% of an approximately 2,000 kcal diet) are consumed [37Browning JD, Weis B, Davis J, et al. Alterations in hepatic glucose and energy metabolism as a result of calorie and carbohydrate restriction. Hepatology 2008; 48(5): 1487-96.
[http://dx.doi.org/10.1002/hep.22504] [PMID: 18925642]
]. The association between the reduction of LBM and low protein consumption has been found in low-calorie diets [38Loenneke JP, Loprinzi PD, Murphy CH, Phillips SM. Per meal dose and frequency of protein consumption is associated with lean mass and muscle performance. Clin Nutr 2016; 35(6): 1506-11.
[http://dx.doi.org/10.1016/j.clnu.2016.04.002] [PMID: 27086196]
].

The average increase in LBM is established to be 0.06 kg of LBM for each session of exercise (derived from 2 kg gain in 14 weeks) from the outcomes of 29 researches evaluating changes in LBM following resistance training in untrained individuals as outlined by Fleck & Kraemer [24Fleck SJ, Kraemer W. Designing resistance training programs 2014.]. The KD+RT group in our study experienced an increase of 1.48 kg in mean LBM within 8 weeks of three sessions per week (0.06 kg increase in each exercise session), which is consistent as discussed in previous studies.

Exercise, in particular resistance exercise, is an effective standalone intervention in a weight loss strategy as it is able to increase one’s metabolic rate. As such, resistance exercise is a beneficial addition to weight loss diets due to their synergistic effects. Meckling & Sherfey [39Meckling KA, Sherfey R. A randomized trial of a hypocaloric high-protein diet, with and without exercise, on weight loss, fitness, and markers of the Metabolic Syndrome in overweight and obese women. Appl Physiol Nutr Metab 2007; 32(4): 743-52.
[http://dx.doi.org/10.1139/H07-059] [PMID: 17622289]
] reported that the best weight loss results were achieved through a combination of exercise and low-carbohydrate high-protein diet. The aforementioned findings were also in line with those of Krebs et al. [40Krebs NF, Gao D, Gralla J, Collins JS, Johnson SL. Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents. J Pediatr 2010; 157(2): 252-8.
[http://dx.doi.org/10.1016/j.jpeds.2010.02.010] [PMID: 20304413]
], who also demonstrated improved body composition with a similar strategy. It is therefore probable to conclude from these studies that the combination of carbohydrate-limitation and resistance training trumps both low-fat diets with exercise and low-carbohydrate diets without exercise in improving body composition.

A handful of participants in this present study experienced substantial alterations in body composition for a short time period. If more information about the individual differences in response to resistance training combined with carbohydrate-limitation diet could be further examined, this approach may confirm to be important over the overweight and obesity management.

There are several limitations to this study that should be considered. First, limited variables were determined and measured with a minimal intervention time of eight weeks. Second, only body composition measurements were investigated without any record of blood measures. Finally, Habitual dietary intake was also not assessed; therefore, there is a possibility of some disparities in energy consumption, although participants were asked to pursue particular dietary guidelines.

CONCLUSION

According to the study findings, we can conclude that resistance training performed three times per week in untrained participants on a ketogenic diet might decrease body fat mass without notable changes in LBM, whilst resistance training combined with a normal diet may increase LBM without meaningful altering body fat mass.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The research was reviewed and approved by University Malaya advisory panel for research involving human participants on 05/09/2019 Malaysia.

HUMAN AND ANIMAL RIGHTS

No animals were used for this study. All humans research procedures performed in the current study were followed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later mendments or comparable ethical standards.

CONSENT FOR PUBLICATION

All participants were informed about the protocol and gave their written informed consent before participating in the study.

AVAILABILITY OF DATA AND MATERIALS

The data that support the findings of this study are available from the corresponding author, [HM], upon reasonable request.

FUNDING

The authors received no financial support for the research, authorship, or publication of this article.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We would like to thank all the participants that volunteered in this study.

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