International Journal of Sport Nutrition and Exercise Metabolism, 2014, 24, 694  -700

http://dx.doi.org/10.1123/ijsnem.2014-0016
© 2014 Human Kinetics, Inc
www.IJSNEM-Journal.com
CASE STUDY

Case Study: Natural Bodybuilding Contest Preparation

Brandon M. Kistler, Peter J. Fitschen, Sushant M. Ranadive,
Bo Fernhall, and Kenneth R. Wilund

The purpose of this study was to document the physiological changes that occur in a natural bodybuilder
during prolonged contest preparation for a proqualifying contest. During the 26-week preparation, the athlete
undertook a calorically restrictive diet with 2 days of elevated carbohydrate intake per week, increased car-
diovascular (CV) training, and attempted to maintain resistance-training load. The athlete was weighed twice
a week and body composition was measured monthly by DXA. At baseline and every 2 weeks following CV
structure and function was measured using a combination of ultrasound, applanation tonometry, and heart
rate variability (HRV). Cardiorespiratory performance was measured by VO2peak at baseline, 13 weeks, and
26 weeks. Body weight (88.6 to 73.3 Kg, R2 = .99) and percent body fat (17.5 to 7.4%) were reduced during
preparation. CV measurements including blood pressure (128/61 to 113/54mmHg), brachial pulse wave
velocity (7.9 to 5.8m/s), and measures of wave reflection all improved. Indexed cardiac output was reduced
(2.5 to 1.8L/m2) primarily due to a reduction in resting heart rate (71 to 44bpm), and despite an increase in
ejection faction (57.9 to 63.9%). Assessment of HRV found a shift in the ratio of low to high frequency (209.2
to 30.9%). Absolute VO2 was minimally reduced despite weight loss resulting in an increase in relative VO2
(41.9 to 47.7ml/Kg). In general, this prolonged contest preparation technique helped the athlete to improve
body composition and resulted in positive CV changes, suggesting that this method of contest preparation
appears to be effective in natural male bodybuilders.

Keywords: resistance training, cardiovascular, interval training

Bodybuilding is an aesthetic sport where competitors
are judged on muscular size and symmetry. Typically,
competitors gain an advantage by significantly reduc-
ing their fat mass to levels not normally observed in the
general public. Adequately preparing for a bodybuild-
ing competition requires years of intense preparation to
increase skeletal muscle size followed by a more acute
contest preparation in which athletes attempt to lose fat
mass while maintaining muscle mass (Maestu et al., 2010;
van der Ploeg et al., 2001). During this contest preparation
athletes generally lose weight by both reducing caloric
intake and increasing aerobic activity while trying to
maintain resistance-training volume. However, athletes
use a wide variety of preparation techniques and many
athletes fail to reach the low levels of body fat necessary
to be successful.
Despite limited evidence, there is a perception that
bodybuilding in general, and contest preparation specifi-
cally, may have negative cardiovascular consequences.
Kistler and Wilund are with the Dept. of Kinesiology and
Community Health, and Fitschen the Division of Nutritional
Sciences, University of Illinois at Urbana-Champaign, Urbana,
IL. Ranadive is with the Anesthesiology Department, Mayo
Clinic, Rochester, MN. Fernhall is with the College of Applied
Health Sciences, University of Illinois at Chicago, Chicago,
IL. Address author correspondence to Kenneth R. Wilund at
kwilund@illinois.edu.
This is based largely off of previous bodybuilding case
studies and lay publications which have mostly focused
on the negative consequences of peripheral aspects of the
sport such as anabolic steroid use and other performance
enhancing drugs. For example, impaired vasoreactivity
was observed after steroid use in bodybuilders (Lane et
al., 2006) and myocardial ischemia was reported after
clenbuterol use in two male bodybuilders (Huckins &
Lemons, 2013). Similarly, venous thrombosis (Jaillard et
al., 1994), multiorgan dysfunction (Schafer et al., 2011),
and early onset diabetes (Geraci et al., 2011) have all
been reported in bodybuilders after steroid and/or growth
hormone use.
Although there are numerous accounts of adverse
events in bodybuilders using performance-enhancing
drugs, the effects of bodybuilding contest preparation
in natural bodybuilders, not using drugs, is less studied.
A recent case study followed a professional natural
bodybuilder and provided a physiological profile during
contest preparation (Rossow et al., 2013). While this was
an excellent characterization of the changes that occur
during contest preparation and recovery, we provide a
description of this athlete’s contest preparation strategy
and different physiological measures. This additional
information may help provide a more comprehensive
assessment of the adaptations that occur during contest
preparation and help athletes in bodybuilding and similar
sports make decisions about the techniques they may use

694

during prolonged weight loss. Therefore, the purpose of
this study was to provide an assessment of the physiologi-
cal changes that occur in an amateur natural bodybuilder
when preparing for a bodybuilding contest.
Presentation of Athlete
and Athlete Assessment
An amateur natural male bodybuilder (age 26), with
10 years resistance training experience and who had
competed in seven competitions over the previous eight
years, was followed during the 26 weeks leading up to a
natural bodybuilding competition. The athlete won the
competition earning him a natural pro card and giving
him the opportunity to compete for prize money against
other professional natural bodybuilders in the future. As
a part of this contest, the athlete underwent a polygraph
and urine test to ensure that he was not using any perfor-
mance enhancing drugs. This study was approved by the
institutional review board at the University of Illinois in
accordance with the Declaration of Helsinki. The subject
was informed of all aspects of the study, provided written
Informed Consent, and gave permission to publish after
reviewing the final document.
Overview of the Intervention
The athlete undertook the following lifestyle modifica-
tions 26 weeks before a proqualifying natural bodybuild-
ing contest. The participant tracked his diet and training
in a diary, and all food was weighed to the nearest gram
throughout the duration of the study.
Diet Intervention
At the start of contest preparation, the bodybuilder con-
sumed 250 g protein, 240 g carbohydrate, and 70 g fat
per day on 5 days of the week. On 2 high-carbohydrate
days evenly spaced throughout the week, 225 g protein,
400 g carbohydrate, and 65 g fat was consumed daily.
When rate of weight loss slowed, a 5 to 10g reduction
in daily fat or carbohydrate intake was implemented to
maintain weight loss. At the end of contest preparation,
the bodybuilder was consuming 250 g protein, 140 g
carbohydrate, and 51 g fat per day on 5 days of the week
and 225 g protein, 255 g carbohydrate, and 46 g fat
per day on two days of the week. Macronutrient intake
was within 5g of target values on all days. Throughout
contest preparation 30g branched chain amino acids, 3g
beta-hydroxy-beta-methylbutyrate (HMB), 2g fish oil,
5g creatine monohydrate, 6g beta- alanine, and a multi-
vitamin, were consumed daily.
Exercise Training Protocol
Weight training was performed 5 days of the week,
approximately 1 to 1.5 hr per day, throughout contest
preparation. Each muscle group was trained twice weekly
Adaptation to Contest Prep  695
with 1 day primarily in the 3 to 8 repetition range and
the other primarily in the 8 to 15 repetition range. This
quantity of resistance training was maintained throughout
the preparation. At the start of contest preparation, two
40-min sessions of high intensity interval training (HIIT)
were performed per week. This HIIT generally consisted
of a 30-s all-out sprint, followed by 4:30 of active jog-
ging recovery. Aerobic exercise was added as needed
though out contest preparation to maintain a constant
rate of weight loss. At the end of contest preparation,
the subject performed four 60min sessions of HIIT and
two 30min sessions of low intensity steady-state aerobic
exercise per week.
Data Collection and Analysis
Bodyweight was measured twice a week immediately
upon waking and following an overnight fast. All other
measurements took place at the same time and on the
same day of the week following a 3-hr fast. Diet and
exercise were tracked daily. Body composition was mea-
sured once a month. VO2peak was measured at baseline
and on Week 13 and Week 26. All other measurements
were taken every other week throughout the study in the
order listed below.
Bodyweight
The subject tracked his weight in minimal clothing to
the nearest tenth of a pound biweekly and immediately
upon waking using a standard scale (Tanita BWB-600,
Arlington Heights, IL).
Body Composition
Whole body fat, lean, and bone mass were measured
every 4 weeks by dual emission x-ray absorptiometry
(DXA) (Hologic QDR 4500A, Bedford, MA).
Blood Pressure
Brachial systolic (SBP) and diastolic (DBP) blood pres-
sure were measured using an automated cuff (Omron
HEM-907XL, Lake Forest, IL) following 15 min of quiet
resting. Two measurements were taken and the value
reported represents the average of the two blood pressure
readings. If either the SBP or DBP differed by greater than
5 mm Hg additional measurements were taken.
Pulse Wave Analysis and Velocity
Pressure waveforms were obtained from the right radial
artery using a strain transducer. Radial waveforms were
used to generate Aortic waveforms using a validated
transfer function (Sphygmacor, ATCor Medical, Aus-
tralia). Pulse wave velocity (PWV) was obtained using
waveforms obtained from the same strain transducer
placed over the radial, carotid, and femoral arteries. Dis-
tances between points were measured using a standard
696   Kistler et al.

tape measure. PWV was calculated using time delay
between proximal and distal waveforms (Chiu et al.,
1991) between the carotid artery and femoral artery
(aortic PWV; aPWV) and from the carotid artery and
radial artery (brachial PWV; bPWV).
Arterial and Cardiac Ultrasound
Arterial and cardiac images were collected with the
subject in the supine position using ultrasound (Hitachi
Aloka Medical, Tokyo, Japan). Carotid IMT was deter-
mined from a 10mm segment proximal to the carotid
bifurcation (Fahs et al., 2011). A combination of B and
M-mode ultrasound images were used to measure arterial
stiffness using the β-stiffness index (Fahs et al., 2011).
To determine End Diastolic Volume (EDV), End Sys-
tolic Volume (ESV), Stroke Volume (SV), Cardiac Output
(CO), and Ejection Fraction (EF), a 2-D M-Mode image
was obtained in the parasternal long-axis view using a
3.5MHz transducer. The image was analyzed in duplicate
using the Teichholz equation (Helak & Reichek, 1981). Car-
diac data were indexed using the Dubois formula for body
surface area (Rowland et al., 2002; Rowland et al., 1998).
Heart Rate and Blood Pressure Variability
Beat-to-beat heart rate intervals were recorded using an
electrocardiogram at 1000Hz (Biopac Systems, Califor-
nia, USA). During heart rate variability measurements the
participant maintained a breathing rate of 12 breaths per
minute with the aid of a metronome. Data were visually
inspected for any artifacts and analyzed for total power,
high frequency (0.15 to 0.4 Hz) and low frequency
(0.04 to 0.15Hz) using commercially available software
(WinCPRS, Absolute Aliens, Finland).
Beat-to-beat blood pressure variability was collected
using finger plethysmography (Finometer Pro, Finapres,
The Netherlands). Breathing was controlled at 12 breaths
per minute via metronome. Data were visually inspected
for any artifacts and analyzed using commercially avail-
able software (WinCPRS, Absolute Aliens, Finland).
Runs of three or more consecutive beats that increased
(Up-Up) or decreased (Down-Down) SBP by at least
1mmHg and also had a coinciding change in the R-R
interval were identified. The slope of the line defined by
the R-R intervals and SBP was used as an estimate of the
sensitivity of the baroreceptor (BRS).
Biochemical Assays
Fasted blood samples were collected monthly, aliquoted,
and stored at –80°C until analysis. Oxidized Low-Density
Lipoprotein (ox-LDL) and high sensitivity C-reactive
protein (CRP) were measured in triplicate using commer-
cially available ELISA kits (ox-LDL: Mercodia, Uppsala,
Sweden; CRP: Alpco, Salem, NH). Total cholesterol was
measured in triplicate by the cholesterol oxidase method
using a commercially available kit (Thermo Scientific,
Waltham, MA).
Peak Oxygen Consumption
VO2peak was tested on the treadmill using a Bruce
protocol. Gasses were measured and averaged every
30 seconds using a COSMED Quark B2 metabolic cart
(Rome, Italy). The VO2peak was recorded as the highest
value obtained over a 30-second period.
Statistics
For weight loss, a coefficient of determination (R2) was
determined for the linear fit.
Results of the Nutrition Plan
Anthropometrics and Body Composition
The participant lost 15.3 kg over the course of the contest
preparation in a highly linear manner (~.58kg/week, R2
for the linear fit of the data= 0.9932). Additional measures
of body composition are presented in Table 1.
Arterial Function
The carotid Intima-Media thickness was 0.50 mm and did
not change throughout the preparation period. Measures
of arterial structure and function are presented in Table
2. In addition to brachial BP, aortic blood pressure from
the transformed radial pressure waveform demonstrated
a decrease in aortic SBP and aortic DBP.

Table 1  Changes in Body Composition During Contest Preparation in an Amateur Natural Male
Bodybuilder
Week
Measure 0 4 8 12 16 20 24 28
Whole body lean mass (Kg) 75.2 73.8 74.0 72.4 72.0 70.5 70.6 68.6
Whole body fat mass (Kg) 15.9 13.2 11.4 10.6 9.5 7.3 6.1 5.5
Body fat (%) 17.5 15.2 13.3 12.8 11.6 9.4 7.9 7.4
Bone mineral content (Kg) 3.17 3.17 3.22 3.20 3.18 3.30 3.28 3.31
Bone mineral density (g/cm3) 1.35 1.36 1.38 1.37 1.38 1.40 1.39 1.42
 Adaptation to Contest Prep  697

Cardiac Function Biochemical Analysis

The indexed left ventricular mass was 107.2 g/m2 at base- C-Reactive Protein was 0.15 mg/L, total cholesterol was
line and did not change appreciably throughout the study. 121.55 mg/dL, and oxidized LDL cholesterol was 30.8
Additional measures of cardiac function are reported in Units/L at baseline with minimal changes over the course
Table 3. of the training.

Autonomic Function Peak Oxygen Consumption

Changes in autonomic function are summarized in Table
4. Despite minimal changes in the overall variability, we
observed a shift in variability toward the high frequency
domain (LF/HF, Figure 1) and an increase in baroreceptor
sensitivity (up-up/down-down).
Absolute VO2peak was 3.751, 3.579, and 3.434 L at base-
line, 13 and 26 weeks respectively. When normalized for
current body weight relative VO2peak was 41.91, 44.19,
and 47.69 ml/Kg respectively.

Table 2  Measures of Arterial Structure and Function

Week
Measure 0 2 4 6 8 10 12 14 16 18 20 22 24 26
Brachial SBP 128 125 121 119 120 120 122 116 116 110 109 115 115 113
Brachial DBP 61 62 52 54 52 54 53 53 53 47 51 50 54 54
Aortic PWV (m/s) 6.7 5.1 5.7 5.7 5.4 6.9 5.7 6.1 5.4 5.6 5.6 5.2 5.6 6.1
Brachial PWV (m/s) 7.9 7.7 8.2 7.4 8.8 7.1 8.6 8.1 7.5 6.4 6.7 7.1 7.1 5.8
B-Stiffness 8.4 6.3 10.2 6.8 8.7 10.3 6.7 7.2 6.6 10.2 8.5 7.1 7.9 8.9
Augmentation –1 1 0 1 –2 0 1 0 –3 –2 –1 –1 –3 –5
pressure (mm Hg)
AIx at 75 (%) –3 –6 –9 –7 –15 –8 0 –5 –15 –17 –15 –17 –19 –28
SEVR (%) 115 162 159 155 171 150 125 143 135 180 195 189 236 208
Heart rate (bpm) 71 56 57 57 54 56 69 62 61 50 50 46 50 44
Note. PWV = pulse wave velocity, AIx = augmentation index, SEVR = sub-endocardium viability ratio

Figure 1 — Changes in the ratio of low and high frequency domains of heart rate variability during prolonged contest preparation
in a natural male bodybuilder.
698   Kistler et al.

Table 3  Ultrasound Measures of Cardiovascular Structure and Function

Week
Measure 0 4 8 12 14 18 22 26
EDVi (ml/m2) 66.7 65.1 68.0 57.6 65.6 59.2 57.5 64.0
ESVi (ml/m2) 28.3 26.4 29.9 22.4 27.0 23.7 20.9 22.9
SVi (ml/m2) 38.6 38.7 38.1 34.9 38.3 35.5 36.4 40.8
COi (L/m2) 2.5 2.2 2.0 2.5 2.4 1.9 1.9 1.8
Ejection Faction (%) 57.9 59.4 56.1 60.7 58.7 59.9 63.5 63.9
Note. EDVi = end diastolic volume indexed, ESVi = end systolic volume indexed, SVi = stroke volume indexed, COi = cardiac output indexed.

Table 4  Measures of Autonomic Function

Measure Week
0 2 4 6 8 10 12 14 16 18 20 22 24 26
RMSSD (ms) 35 31 31 37 56 55 17 25 39 26 61 66 34 65
pNN50 (%) 14.1 9.4 9.5 15.4 39.4 37.5 0.5 3.6 19.5 5.5 46.3 51 12.6 56.2
Total Power(ms2) 3279 1961 1206 1501 3520 4477 870 2147 2494 3694 2732 2136 5482 3606
High Frequency (ms2) 662 339 456 437 979 1171 221 377 663 430 1018 1147 520 1548
Low Frequency (ms2) 1384 397 438 585 486 1315 204 270 816 178 857 565 237 478
LF/HF (%) 209.2 117.1 95.9 133.9 49.7 112.3 92.4 71.7 123 41.5 84.2 49.2 45.5 30.9
Up-Up (ms/mmHg) 11.7 12.6 11.4 16 13.4 14.7 9.8 8.7 13.1 8.9 14.7 18.6 13 25.7
Down-Down (ms/mmHg) 11.7 11.3 8.3 15.8 10 26.9 7.3 8.7 14 14.7 21.5 25.5 17.2 24.8
Note. RMSSD = root mean square of the successive difference, pNN50 = proportion of beats that differ by greater than 50 ms

Discussion previous case study we did not observe an increase in

The contest preparation strategy used by this athlete
led to highly linear weight loss (R2 = .9932). While this
high amount of weight loss did lead to a reduction in
lean mass (–8.8%), the athlete was successfully able to
lose enough fat mass to reduce body fat percentage and
get lean enough to win his natural pro card. A surprising
finding from our study was the increase in both bone
mineral content (BMC) and bone mineral density (BMD).
This is contrary to what is typically observed following
caloric restriction (Villareal et al., 2006), and possibly
due to the repeated impacts associated with the added
HIIT and aerobic exercise (Villareal et al., 2006). Another
possible explanation is that the high level of protein intake
may have helped maintain bone by stimulating IGF-1
(Sukumar et al., 2011); however this is contrary to the
popular belief that high protein diets are detrimental to
bone health (Barzel & Massey, 1998).
Similarly to a previous case study (Rossow et al.,
2013), we found many positive cardiovascular adapta-
tions during contest preparation including reduced blood
pressure, reduced arterial stiffness, and increased relative
VO2peak. In addition, both case studies also observed a
reduction in cardiac output, increase in ejection fraction,
and reduction in resting heart rate. The reduction in car-
diac output and improvement in systolic function mimic
the changes that are generally seen with high amounts
of weight loss (Poirier et al., 2011). However, unlike the
stroke volume or end diastolic volume. These ambigu-
ous findings are likely due to the extremely low resting
heart rate (27bpm) observed in the previous case study.
We also undertook a number of novel cardiovascular
measurements. We found significant changes in wave
reflection, including reduced augmented pressure, aug-
mentation index, and an increase in the subendocardial
viability ratio (an estimation of coronary perfusion). The
improvement in coronary perfusion that we observed
during contest preparation is the opposite of what has
been observed in bodybuilders using steroids (Huckins
& Lemons, 2013). These positive improvements in wave
reflection are likely the result of a combination of both a
slowing of the return wave due to the reduction in central
arterial stiffness and a reduction in the size of the returned
wave as a result of reduced impedance mismatch between
the central and peripheral arteries (Mitchell et al., 2004).
In addition, we found that biochemical markers of cardio-
vascular health were relatively unchanged, possibly due to
the low levels of inflammation and cholesterol at the start.
Bodybuilding contest preparation also resulted in
significant changes in autonomic function. While the
overall heart rate variability fluctuated throughout train-
ing, we found a shift in the ratio of variability in the low
and high frequency domains, suggesting a shift toward
parasympathetic nervous system dominance. Having
greater vagal influence of the heart over time is associ-
ated with increased electrical stability and a reduction

in cardiovascular mortality, although most of this work
comes from clinical populations (Heart Rate Variability,
1996). In addition, we saw an increase in BRS as mea-
sured by both upward and downward blood pressure
runs. BRS is an important regulator of blood pressure,
and impaired BRS is associated with numerous clinical
outcomes (La Rovere, Pinna, & Raczak, 2008). We have
previously found that these improvements in autonomic
function occur in response to aerobic training, but not
resistance training (Collier et al., 2009). However, it is
unknown if the adaptations we observed in this contest
preparation resulted from changes in diet, activity, or
some combination.
In summary, contest preparation in an amateur natu-
ral male bodybuilder resulted in highly linear weight loss
and a number of other positive physiological changes.
These physiological changes included reductions in body
fat, blood pressure, resting heart rate, wave reflection,
and arterial stiffness. We also observed shifts in heart
rate and blood pressure variability and improved BRS.
In total, these data indicate that this prolonged contest
preparation technique appears to be effective in a natural
male bodybuilder.
References
Barzel, U.S., & Massey, L.K. (1998). Excess dietary protein can
adversely affect bone. The Journal of Nutrition, 128(6),
1051–1053. PubMed
Chiu, Y.C., Arand, P.W., Shroff, S.G., Feldman, T., & Carroll,
J.D. (1991). Determination of pulse wave velocities with
computerized algorithms. American Heart Journal, 121(5),
1460–1470. PubMed doi:10.1016/0002-8703(91)90153-9
Collier, S.R., Kanaley, J.A., Carhart, R., Jr., Frechette, V.,
Tobin, M.M., Bennett, N., . . . Fernhall, B. (2009). Cardiac
autonomic function and baroreflex changes following 4
weeks of resistance versus aerobic training in individu-
als with pre-hypertension. Acta Physiologica (Oxford,
England), 195(3), 339–348. PubMed doi:10.1111/j.1748-
1716.2008.01897.x
Fahs, C.A., Yan, H., Ranadive, S., Rossow, L.M., Agiov-
lasitis, S., Echols, G., . . . Fernhall, B. (2011). Acute
effects of firefighting on arterial stiffness and blood
flow. Vascular Medicine, 16(2), 113–118. PubMed
doi:10.1177/1358863X11404940
Geraci, M.J., Cole, M., & Davis, P. (2011). New onset
diabetes associated with bovine growth hormone and
testosterone abuse in a young body builder. Human and
Experimental Toxicology, 30(12), 2007–2012. PubMed
doi:10.1177/0960327111408152
Heart rate variability: Standards of measurement, physiological
interpretation, and clinical use. Task Force of the European
Society of Cardiology and the North American Society of
Pacing and Electrophysiology. (1996). Circulation, 93(5),
1043–1065.
Helak, J.W., & Reichek, N. (1981). Quantitation of human left
ventricular mass and volume by two-dimensional echocar-
diography: in vitro anatomic validation. Circulation, 63(6),
1398–1407. PubMed doi:10.1161/01.CIR.63.6.1398
Adaptation to Contest Prep  699
Huckins, D.S., & Lemons, M.F. (2013). Myocardial ischemia
associated with clenbuterol abuse: report of two cases. The
Journal of Emergency Medicine, 44(2), 444–449. PubMed
doi:10.1016/j.jemermed.2012.02.057
Jaillard, A.S., Hommel, M., & Mallaret, M. (1994). Venous sinus
thrombosis associated with androgens in a healthy young
man. Stroke, 25(1), 212–213. PubMed doi:10.1161/01.
STR.25.1.212
La Rovere, M.T., Pinna, G.D., & Raczak, G. (2008). Barore-
flex sensitivity: measurement and clinical implications.
Annals of Noninvasive Electrocardiology, 13(2), 191–207.
PubMed doi:10.1111/j.1542-474X.2008.00219.x
Lane, H.A., Grace, F., Smith, J.C., Morris, K., Cockcroft, J.,
Scanlon, M.F., & Davies, J.S. (2006). Impaired vasore-
activity in bodybuilders using androgenic anabolic ste-
roids. European Journal of Clinical Investigation, 36(7),
483–488. PubMed doi:10.1111/j.1365-2362.2006.01667.x
Maestu, J., Eliakim, A., Jurimae, J., Valter, I., & Jurimae, T.
(2010). Anabolic and catabolic hormones and energy
balance of the male bodybuilders during the preparation
for the competition. Journal of Strength and Condition-
ing Research, 24(4), 1074–1081. PubMed doi:10.1519/
JSC.0b013e3181cb6fd3
Mitchell, G.F., Parise, H., Benjamin, E.J., Larson, M.G., Keyes,
M.J., Vita, J.A., . . . Levy, D. (2004). Changes in arte-
rial stiffness and wave reflection with advancing age in
healthy men and women: the Framingham Heart Study.
Hypertension, 43(6), 1239–1245. PubMed doi:10.1161/01.
HYP.0000128420.01881.aa
Poirier, P., Cornier, M. A., Mazzone, T., Stiles, S., Cummings,
S., Klein, S., . . . American Heart Association Obesity
Committee of the Council on Nutrition, Physical Activity,
and Metabolism. (2011). Bariatric surgery and cardiovas-
cular risk factors: a scientific statement from the American
Heart Association. Circulation, 123(15), 1683–1701.
PubMed doi:10.1161/CIR.0b013e3182149099
Rossow, L. M., Fukuda, D. H., Fahs, C. A., Loenneke, J. P.,
& Stout, J. R. (2013). Natural Bodybuilding Competition
Preparation and Recovery: A 12-Month Case Study. Int J
Sports Physiol Perform.
Rowland, T., Unnithan, V., Fernhall, B., Baynard, T., &
Lange, C. (2002). Left ventricular response to dynamic
exercise in young cyclists. Medicine and Science
in Sports and Exercise, 34(4), 637–642. PubMed
doi:10.1097/00005768-200204000-00012
Rowland, T.W., Melanson, E.L., Popowski, B.E., & Ferrone,
L.C. (1998). Test-retest reproducibility of maximum
cardiac output by Doppler echocardiography. The Ameri-
can Journal of Cardiology, 81(10), 1228–1230. PubMed
doi:10.1016/S0002-9149(98)00099-X
Schafer, C.N., Guldager, H., & Jorgensen, H.L. (2011). Multi-
organ dysfunction in bodybuilding possibly caused
by prolonged hypercalcemia due to multi-substance
abuse: case report and review of literature. International
Journal of Sports Medicine, 32(1), 60–65. PubMed
doi:10.1055/s-0030-1267200
Sukumar, D., Ambia-Sobhan, H., Zurfluh, R., Schlussel, Y.,
Stahl, T.J., Gordon, C.L., & Shapses, S.A. (2011). Areal
and volumetric bone mineral density and geometry at
700   Kistler et al.
two levels of protein intake during caloric restriction: a
randomized, controlled trial. Journal of Bone and Min-
eral Research, 26(6), 1339–1348. PubMed doi:10.1002/
jbmr.318
van der Ploeg, G.E., Brooks, A.G., Withers, R.T., Dollman, J.,
Leaney, F., & Chatterton, B.E. (2001). Body composition
changes in female bodybuilders during preparation for
competition. European Journal of Clinical Nutrition,
55(4), 268–277. PubMed doi:10.1038/sj.ejcn.1601154
Villareal, D.T., Fontana, L., Weiss, E.P., Racette, S.B., Steger-
May, K., Schechtman, K.B., . . . Holloszy, J.O. (2006).
Bone mineral density response to caloric restriction-
induced weight loss or exercise-induced weight loss:
a randomized controlled trial. Archives of Internal
Medicine, 166(22), 2502–2510. PubMed doi:10.1001/
archinte.166.22.2502
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