12 What characterizes a healthy diet?

By Alan Aragon

16 Does cold water immersion enhance training

recovery?
By Alan Aragon

Copyright © September 1st, 2020 by Alan Aragon

Home: www.alanaragon.com
Correspondence: support@alanaragon.com

2 Fundamentals & practical points for making

weight in combat sports.
By Scott Habermehl

6 The bright and the dark sides of L-carnitine

supplementation: a systematic review.
Sawicka AK, et al. [published online ahead of print,
2020 Jul 16]. Am J Clin Nutr. 2020;nqaa167. [JISSN]

8 Acute glycemic and insulinemic effects of

low-energy sweeteners: a systematic review
and meta-analysis of randomized controlled
trials.
Greyling A, Appleton KM, Raben A, Mela DJ.
[published online ahead of print, 2020 Jul 16]. Am J
Clin Nutr. 2020;nqaa167. [PubMed]

10 The influence of cyclical ketogenic reduction

diet vs. nutritionally balanced reduction diet
on body composition, strength, and
endurance performance in healthy young
males: a randomized controlled trial.
Kysel P, Haluzíková D, Doležalová RP, Laňková I,
Lacinová Z, Kasperová BJ, Trnovská J, Hrádková V,
Mráz M, Vilikus Z, Haluzík M. Nutrients. 2020 Sep
16;12(9):E2832. [PubMed]

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


Fundamentals & practical points for making
weight in combat sports.
By Scott Habermehl
_______________________________________________
Background
Fighters are always in search of an edge over their
opponents. Acute manipulations in body weight are typical
among combat sports in the attempt to create a potential
advantage within controlled weight classes. The goal is to
drop total body mass (weight) prior to the weigh-in and
regain the same or more body mass prior to the fight. This
is known as the “weight cut.”
Olympic events like Tae Kwon Do, Judo, Free-style
Wrestling, Boxing etc. as well as professional leagues like
the UFC, King of the Cage, Bellator, etc., all incorporate
weight classes in hopes to create an equal playing field
among athletes. Official weigh-ins are held prior to a
competitive event, or on subsequent days in multi-day
competitions or tournament-style events, to ensure that
athletes have met the requirements of their intended
division. This is known as “making weight.”
Timeframe considerations
Different sports have different timelines from when an
athlete weighs in, ranging from a couple hours to more
than a day before the actual event. Timelines are based on
the rules of the specific sport and organization. The longer
the timeframe between weigh-in and competition, known
as the recovery time, the more options the athlete has to
manipulate the variables. This has allowed athletes the
opportunity to make further chronic or even acute changes
in total body mass, thus theoretically giving an advantage
in size, strength, and leverage over a smaller opponent.
Despite the original intentions of matching opponents
similar in size, fighters often attempt to qualify for a
weight class that is lighter than their day-to-day normal
body mass. It’s common for these athletes to attempt
making the lightest weight class possible, allowing the
greatest potential fluctuation in recovering body weight.
Performance and the fighter’s health have a breaking point
Alan Aragon’s Research Review – September 2020
that must still be respected. Cutting too much weight too
quickly can be dangerous and/or hinder an athlete’s
abilities. For this reason, extreme practices of weight
cutting are not advised.
There are various ways fighters can cause acute weight
loss (AWL) and manipulate their total body mass with the
most common coming from increased exercise and a
restriction of total food and fluid intake. The dietary
changes usually come from a restriction in carbohydrates
and/or fats and fiber, sometimes with an overall reduction
in total energy of over 35% in the final week and/or 100%
restriction on the day of the weigh-in, along with
manipulations of fluids and electrolytes. However, being
in a caloric deficit in the final week should not be
necessary, as the focus should be on the weight of the
food, not the caloric value of the food. All body fat should
have been lost prior to the final week.
Male fighters typically should be between 7-15% body fat,
with Female fighters being between 16-22% body fat. Of
course, this is just a range, and can be slightly different
from person to person. A leaner fighter is not necessarily a
better fighter. However, if the required body fat has not all
been lost leading into the final week, the fighter is not
going to be at their best, as the final week should be about
manipulating gut content and fluids, not body fat.
Determining the amount of total body mass loss needed
within the given timeline and considering the recovery
time between the weigh-in and the event, tells the fighter
and/or their coach which approach would be best used.
Typically, no more than 2-8%, 10% being the theoretical
maximum for males and 8% for females of bodyweight
loss in the last week(s) prior to competition, should be the
goal. If a fighter has more than this to lose at
approximately two weeks out from the event, making
weight becomes increasingly more difficult, yields greater
health risks, and will likely hinder the athlete’s
performance. In this scenario, choosing a later event or a
heavier weight class is recommended.
The common mistake being made, is a fighter being in a
caloric deficit in the days leading up to the fight in order to
make weight. Dietary restrictions are generally needed to
maximize acute weight loss, but the restrictions should
come from amounts and types of foods, not from their
[Back to Contents] Page 2
caloric value. Avoiding an energy deficit is advised in the
final week. Strategically manipulating fiber, carbo-
hydrates, electrolytes, and fluids is the most effective
strategy to achieve the desired weight drop in total body
mass, while still allowing the restoration of performance
after the weigh-in. Implementing further reductions of
body mass by means of dehydration and/or glycogen
depletion may be necessary and are effective strategies but
also start to swing the pendulum away from the ability to
recover.
The strategies in their order of application:
1) Gut content: removal of fiber and heavier foods
leading up to the weigh-in.
2) Fluid restrictions & sodium reductions: reduction
from normal intake can vary. May incorporate a
water load.
3) Active dehydration: exercise.
4) Passive dehydration: saunas, hot showers/baths
etc. (use sparingly).
5) The depletion of carbohydrates is best utilized
only if the fighter has sufficient recovery time
between the weigh-in and the fight.
Assuming the fighter has lost all the required fat mass in
the months prior to the final week, he/she should be within
the 2-8% (10% max for men, 8% for women) range of
body weight above the desired weight class. Aiming for
approximately 1.5-2% body mass loss from gut content
and 2-3% from fluid manipulations and mild dehydration
(if necessary) should be the primary staples. Glycogen
depletion to gain the last drop of body mass is ideally only
done when the recovery time from the weigh-in to the fight
is greater than 24 hours. For this reason, I like to see 10%
for males and 8% for females being the absolute max total
body mass to be lost but only if the fighter has a recovery
opportunity of 24 hours or more. This allows opportunity
for glycogen depletion in the final week, and enough time
to replete the glycogen post weigh-in. If a fighter does not
have a full day or more of recovery, attempting to fully
deplete glycogen is not advised.
Remember, the loss of calories from the removal of
carbohydrates should be allocated to Proteins and fats to
maintain energy balance. Carbs = 4kcals/g. Protein =
4kcals/g. Fats = 9kcals/g.
Alan Aragon’s Research Review – September 2020
If there is less than 24 hours recovery time, shooting for
~5% as a max drop in total body mass is recommended,
which should be accomplished by the removal of gut
content and fluid restriction/dehydration. Note: The use of
a water load has been studied and shown to help further
reduce total body mass by means of more fluid excretion,
but the positive effects were only slight. For that, it is
suggested that a water load is to be used as a last resort,
only if the above protocol(s) do not cause sufficient
results, as the inconvenience, disrupted sleep and
discomfort may outweigh the minimal positive effects.
The strategy below is a breakdown of the final week
leading up to a weigh-in for an acute weight loss (AWL)
scenario utilizing all of the most effective strategies. When
the fighter is ready on time, the final week will result in a
lower total body mass by manipulations of total body
water and gut residue only, not a loss of fat mass.
Remember, an acute weight cut is highly individualized
and should be practiced ahead of time. The steps I’ve
outlined below are general ranges and should be fine-tuned
to the specific fighter’s physiology and psychology, as
well as the rules of their given sport and organization.
Implementing the strategies
Reminder: carbohydrate and fiber restriction times will
depend, as gastric emptying as well as glycogen depletion
rate times can vary from individual to individual, so
practicing the acute weight-cut week ahead of schedule is
advised. Pay careful attention to the recovery time as
well, as this should be factored into your approach to the
weight cut.
▪ Two weeks out, have a consistent sodium and fluid
intake as well as the fighters “normal” day-to-day
walk around weight.
▪ 7 days out, Assess a hydrated fighters body weight
and body composition in a fasted, well rested state
after the use of the bathroom. The fighter should
not be dehydrated.
▪ If fighter is >10% do not compete. If between 5%-
10%, consider heavier weight class or implement a
low carbohydrate diet, eating <50g/day beginning
3-7days pre weigh-in. If <5%, carbohydrate intake
can remain the same.
[Back to Contents] Page 3
 ▪ 120 hrs or ~5 days pre weigh-in, reduce sodium to
<500mg/day.
▪ 48-96 hrs or 2-4 days pre weigh-in, reduce fibrous
foods and total daily fiber intake to <10g.
▪ 24-36 hrs or 1-1.5 days pre weigh-in, restrict total
fluid intake and utilize regularly scheduled training
to promote further water loss thru sweat. Added
clothing, increased temperature, etc. can also be
utilized here.
▪ 0-24 hrs or <1day pre weigh-in, the use of
dehydrating techniques such as hot baths/showers,
saunas etc. Ideally best to keep this limited and as
close to the weigh-in as possible.
▪ Immediately post weigh-in, begin the recovery
process.
The recovery process will vary tremendously, depending
on the methods used for the acute weight loss, so its
impossible to give it a template. The key is to rehydrate
with some fluids, electrolytes and carbs immediately post
weigh-in, followed up with strategic fuel based on the
recovery timeline. Sports drinks like Gatorade, Powerade,
etc. are great examples, or you can use water, salt and
some candy etc. The goal should be to take in 125-150% in
terms of liters (L) vs. body mass lost in kilograms (kg)
from fluids. So, for every kg lost, you want to try and
drink 1.5 L from post weigh-in to a couple hours before
the event, with an immediate 600-900 ml drink, combined
with some sodium and sugar post weigh-in. Follow this
with sipping consistent fluids at a rate of approximately 1
L every hour up until 3 hours before bed, continuing again
in the morning up until 3 hours before the event. If it’s a
same day weigh-in, same rules apply, only you stop
drinking approximately 3 hours before the fight.
Research shows that an approximate 2.8% dehydration
was recoverable within 3 hours of aggressive refueling, but
6% dehydration was still not recovered even after 15
hours, so it’s obvious now why being too dehydrated for a
weigh-in on the same day as the event would be so
problematic.
Carbs should ideally be taken in liquid form for the first
couple meals, followed by acute feedings between 0.3-1.5
g/kg. I like to use 1 g/kg with foods you are familiar with
and know will not cause any digestive issues or
discomfort. The amount of glycogen depletion accrued
Alan Aragon’s Research Review – September 2020
during the final week as well as avoiding GI discomfort
leading up to the event will help to determine the amounts
of Carbohydrates necessary. Full glycogen stores may not
be necessary.
To summarize, the final week and implementation of an
acute weight cut involves a complex interaction of many
factors and variables. The rules of the sport, organization,
recovery time between weigh-in and competition are also
all things to be considered when designing the approach
and methods used to accomplish the acute weight loss and
should be practiced ahead of time and catered the
individualization of each athlete.
Take-away points
▪ Be ~2-8% (10% max for males, 8% max for
females) above desired weight class 2 weeks out.
▪ Know your recovery timeline and implement the
appropriate AWL accordingly.
▪ Day before weigh-in = 5-10% body mass drop.
Same day weigh-in = 2-5% body mass drop.
▪ Deplete gut content first.
▪ >24 hr recovery time warrants a glycogen depletion
strategy. If not, stick with fluid and gut content
manipulations.
▪ Use active dehydration over passive dehydration if
possible and minimize passive dehydration if you
implement it.
▪ 600-900 ml immediately post weigh-in, include
sodium & carbohydrates.
▪ Sip fluids at a rate of 1L/hr. and carbs at ~0.3-1.5
g/kg/hr (if depleted) until ~3 hrs before the event.
▪ 8-12% above the desired weight class after weigh-
in, prior to the event is an indication of a successful
weight-cut.
Further reading
Matthews JJ, Stanhope EN, Godwin MS, Holmes MEJ,
Artioli GG. The magnitude of rapid weight loss and rapid
weight gain in combat sport athletes preparing for
competition: a systematic review. Int J Sport Nutr Exerc
Metab. 2019 Jul 1;29(4):441–452. [PubMed]
[Back to Contents] Page 4
Reale R, Slater G, Burke LM. Acute weight loss strategies
for combat sports and applications to Olympic success. Int
J Sports Physiol Perform. 2017 Feb;12(2):142-151.
[PubMed] [ResearchGate]

Reale R, Slater G, Burke LM. Individualised dietary

strategies for Olympic combat sports: Acute weight loss,
recovery and competition nutrition. Eur J Sport Sci. 2017
Jul;17(6):727-740. [PubMed]

Reale R, Slater G, Cox GR, Dunican IC, Burke LM. The

effect of water loading on acute weight loss following
fluid restriction in combat sports athletes. Int J Sport Nutr
Exerc Metab. 2018 Nov 1;28(6):565-573. doi:
10.1123/ijsnem.2017-0183. [PubMed]

_______________________________________________
Scott Habermehl
Owner & Head Coach at Hollywood Built

▪ McGill Method Certified plus 2x’s

Master’s Assessment Certification
▪ Bio-Force Certified Conditioning Coach
▪ 3x’s Bayesian Bodybuilding (4, 5, & 8)
▪ PN1 Nutrition Certification
▪ Strength/Performance/Conditioning/
Prep Coach for over a Decade

I’ve spent over a decade coaching 100’s of individuals from general

weight loss, body re-composition and low back pain to sport specific
training for amateurs and pros alike.

Website: https://hollywoodbuilt.com/
FB: https://www.facebook.com/HollywoodBuilt/
IG: https://www.instagram.com/hollywoodbuilt/
Email: hollywoodbuilt@gmail.com

Alan Aragon’s Research Review – September 2020 [Back to Contents] Page 5


The bright and the dark sides of L-carnitine
supplementation: a systematic review.
Sawicka AK, et al. . [published online ahead of print, 2020
Jul 16]. Am J Clin Nutr. 2020;nqaa167. [JISSN]
BACKGROUND: L-carnitine (LC) is used as a
supplement by recreationally-active, competitive and
highly trained athletes. This systematic review aims to
evaluate the effect of prolonged LC supplementation on
metabolism and metabolic modifications. METHODS: A
literature search was conducted in the MEDLINE (via
PubMed) and Web of Science databases from the inception
up February 2020. Eligibility criteria included studies on
healthy human subjects, treated for at least 12 weeks with
LC administered orally, with no drugs or any other multi-
ingredient supplements co-ingestion. RESULTS: The
initial search retrieved 1024 articles, and a total of 11
studies were finally included after applying inclusion and
exclusion criteria. All the selected studies were conducted
with healthy human subjects, with supplemented dose
ranging from 1 g to 4 g per day for either 12 or 24 weeks.
LC supplementation, in combination with carbohydrates
(CHO) effectively elevated total carnitine content in
skeletal muscle. Twenty-four-weeks of LC
supplementation did not affect muscle strength in healthy
aged women, but significantly increased muscle mass,
improved physical effort tolerance and cognitive function
in centenarians. LC supplementation was also noted to
induce an increase of fasting plasma trimethylamine-N-
oxide (TMAO) levels, which was not associated with
modification of determined inflammatory nor oxidative
stress markers. CONCLUSION Prolonged LC
supplementation in specific conditions may affect physical
performance. On the other hand, LC supplementation
elevates fasting plasma TMAO, compound supposed to be
pro-atherogenic. Therefore, additional studies focusing on
long-term supplementation and its longitudinal effect on
the cardiovascular system are needed. FUNDING
SOURCE: This work was supported by National Science
Centre in Poland, grant number 2014/15/B/NZ7/00893.
Strengths
Eligibility criteria was pragmatically based on the PICOS
strategy, which was applied in this case as follows:
Alan Aragon’s Research Review – September 2020
(P)articipants: human subjects
(I)nterventions: oral L-carnitine (LC) supplementation
(C)omparisons: supplementation versus placebo,
supplementation versus control, or pre- and post-
supplementation conditions in a single group
(O)utcomes: muscle protein regulation, body composition,
strength, and various clinical parameters
(S)tudy design: randomized controlled trials, non-
randomized controlled trials, non-randomized non-
controlled trials.
Another strength of the review was its inclusion of studies
lasting a minimum of 12 weeks. Exclusion of multi-
ingredient supplements containing LC lowered the
confounding potential of other active compounds.
Limitations
The authors acknowledged that the 12-week minimum trial
length could have also served as a limitation since
elevations in muscle carnitine would require at least ~100
days of supplementation.1-3 Additional limitations they
mentioned were varied study designs involving different
supplementation protocols, different outcome measures,
and a high degree of heterogeneity of the subject
characteristics across the studies. I would add that the
authors did not implement an established quality control
system such as the PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) guidelines,4
or the systematic review protocol set forth by the Cochrane
Collaboration.5 An extra step toward ensuring
methodological transparency could also have been taken
by registering the systematic review in the PROSPERO
database.6
Comment/application
The main findings of the systematic review can be
summed up as follows:
▪ The collective evidence of LC’s effectiveness in body
fat reduction is best described as modest & mixed.
LC supplementation failed to increase fat oxidation
and improve exercise performance by in trials lasting
up to 4 weeks. However, it’s possible that these trials
were simply not long enough to allow sufficient
[Back to Contents] Page 6
 accumulation of muscle carnitine levels. In
Askarpour et al’s recent large meta-analysis of 43
RCTs,7 it was found that LC supplementation
modestly decreased bodyweight by an average of -
1.13 kg, and fat mass by an average of 1.16 kg.
However, LC supplementation did not significantly
change body fat percentage or waist circumference.
In another recent meta-analysis of RCTs, Talenezhad
reported similar findings.8 LC decreased body weight
by an average of 1.21 kg, and fat mass by 2.08 kg.
However, there was no significant reduction of body
fat percent or waist circumference.
▪ LC supplementation has shown beneficial effects on
muscle protein balance (synthesis versus breakdown)
and anabolic signaling molecules in animal studies.
However, the evidence for muscle anabolism in
humans is lacking.1,2
▪ LC supplementation has shown benefits for
increasing lifting performance study,9 and
disappointing endurance training effects.10,11
▪ Protein retention via LC supplementation in male but
not female sarcopenic patients was seen.
▪ LC supplementation may impart antioxidant effects
as well as reductions in muscle soreness.
▪ TMAO elevations have been seen as a result of LC
supplementation, but the clinical significance of this
is questionable.
Despite glimmers of usefulness, LC supplementation has a
scarce evidence basis for enhancing resistance training
adaptations, and a weak basis for enhancing endurance
performance and body composition. I’d personally save
my money for groceries.
References
1. Shannon CE, Ghasemi R, Greenhaff PL, Stephens FB.
Increasing skeletal muscle carnitine availability does not
alter the adaptations to high-intensity interval training.
Scand J Med Sci Sports. 2018 Jan;28(1):107-115.
[PubMed]
2. Stephens FB, Wall BT, Marimuthu K, Shannon CE,
Constantin-Teodosiu D, Macdonald IA, Greenhaff PL.
Skeletal muscle carnitine loading increases energy
expenditure, modulates fuel metabolism gene networks
and prevents body fat accumulation in humans. J Physiol.
2013 Sep 15;591(18):4655-66. [PubMed]
Alan Aragon’s Research Review – September 2020
3. Wall BT, Stephens FB, Constantin-Teodosiu D,
Marimuthu K, Macdonald IA, Greenhaff PL. Chronic
oral ingestion of L-carnitine and carbohydrate increases
muscle carnitine content and alters muscle fuel
metabolism during exercise in humans. J Physiol. 2011
Feb 15;589(Pt 4):963-73. [PubMed]
4. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche
PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J,
Moher D. The PRISMA statement for reporting
systematic reviews and meta-analyses of studies that
evaluate health care interventions: Explanation and
elaboration. PLoS Med. 2009;6:e1000100. [PubMed]
5. Henderson LK, Craig JC, Willis NS, Tovey D, Webster
AC. How to write a Cochrane systematic review.
Nephrology (Carlton). 2010 Sep;15(6):617-24. [PubMed]
6. Schiavo JH. PROSPERO: An International Register of
Systematic Review Protocols. Med Ref Serv Q. 2019
Apr-Jun;38(2):171-180. [PubMed]
7. Askarpour M, Hadi A, Miraghajani M, Symonds ME,
Sheikhi A, Ghaedi E. Beneficial effects of l-carnitine
supplementation for weight management in overweight
and obese adults: An updated systematic review and
dose-response meta-analysis of randomized controlled
trials. Pharmacol Res. 2020 Jan;151:104554. [PubMed]
8. Talenezhad N, Mohammadi M, Ramezani-Jolfaie N,
Mozaffari-Khosravi H, Salehi-Abargouei A. Effects of l-
carnitine supplementation on weight loss and body
composition: A systematic review and meta-analysis of
37 randomized controlled clinical trials with dose-
response analysis. Clin Nutr ESPEN. 2020 Jun;37:9-23.
[PubMed]
9. Koozehchian MS, Daneshfar A, Fallah E, Agha-Alinejad
H, Samadi M, Kaviani M, Kaveh B M, Jung YP,
Sablouei MH, Moradi N, Earnest CP, Chandler TJ,
Kreider RB. Effects of nine weeks L-Carnitine
supplementation on exercise performance, anaerobic
power, and exercise-induced oxidative stress in
resistance-trained males. J Exerc Nutrition Biochem.
2018 Dec 31;22(4):7-19. [PubMed]
10. Lee JK, Lee JS, Park H, Cha YS, Yoon CS, Kim CK.
Effect of L-carnitine supplementation and aerobic
training on FABPc content and beta-HAD activity in
human skeletal muscle. Eur J Appl Physiol. 2007
Jan;99(2):193-9. [PubMed]
11. Rafraf M, Karimi M, Jafari A. Effect of L-carnitine
supplementation in comparison with moderate aerobic
training on serum inflammatory parameters in healthy
obese women. J Sports Med Phys Fitness. 2015
Nov;55(11):1363-70. [PubMed]
[Back to Contents] Page 7

Acute glycemic and insulinemic effects of low-
energy sweeteners: a systematic review and
meta-analysis of randomized controlled trials.
Greyling A, Appleton KM, Raben A, Mela DJ. [published
online ahead of print, 2020 Jul 16]. Am J Clin Nutr.
2020;nqaa167. [PubMed]
BACKGROUND: It has been suggested that low-energy
sweeteners (LES) may be associated with an increased risk
of metabolic diseases, possibly due to stimulation of
glucose-responsive mechanisms. Objective: We conducted
a systematic review and meta-analysis of human
intervention studies examining the acute effect of LES
intake on postprandial glucose (PPG) and postprandial
insulin (PPI) responses, in order to comprehensively and
objectively quantify these relations. METHODS: We
systematically searched the Medline, OVID FSTA, and
SCOPUS databases until January 2020. Randomized
controlled trials comparing acute postprandial effects on
PPG and/or PPI after exposure to LES, either alone, with a
meal, or with other nutrient-containing preloads to the
same intervention without LES were eligible for inclusion.
PPG and PPI responses were calculated as mean
incremental area under the curve divided by time. Meta-
analyses were performed using random effects models
with inverse variance weighing. RESULTS: Twenty-six
papers (34 PPG trials and 29 PPI trials) were included.
There were no reports of statistically significant
differences in the effects of LES on PPG and PPI
responses compared with control interventions. Pooled
effects of LES intake on the mean change difference in
PPG and PPI were -0.02 mmol/L (95% CI: -0.09, 0.05)
and -2.39 pmol/L (95% CI: -11.83, 7.05), respectively. The
results did not appreciably differ by the type or dose of
LES consumed, cointervention type, or fasting glucose and
insulin levels. Among patients with type 2 diabetes, the
mean change difference indicated a smaller PPG response
after exposure to LES compared with the control (-0.3
mmol/L; 95% CI: -0.53, -0.07). CONCLUSIONS:
Ingestion of LES, administered alone or in combination
with a nutrient-containing preload, has no acute effects on
the mean change in postprandial glycemic or insulinemic
responses compared with a control intervention. Apart
from a small beneficial effect on PPG (-0.3 mmol/L) in
Alan Aragon’s Research Review – September 2020
studies enrolling patients with type 2 diabetes, the effects
did not differ by type or dose of LES, or fasting glucose or
insulin levels. This review and meta-analysis was
registered at PROSPERO as CRD42018099608.
FUNDING SOURCE: Unilever, a commercial food and
beverage manufacturer.
Strengths
This paper is conceptually strong, since there has been a
lot of confusion and controversy about the adverse
potential of artificial sweeteners on the proposed basis that
they elicit similar acute responses to sugar. The PRISMA
(Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) guidelines were employed in order to
establish quality control of the literature included in the
systematic review/meta-analysis.1 Transparency of the
review methods was bolstered by registering the paper in
the PROSPERO database.2 A relatively large number of
studies qualified for the analysis (34 trials examining
postprandial glucose, and 29 examining postprandial
insulin.
Limitations
The authors diligently acknowledged the following
limitations:
▪ The authors did not have an a priori hypothesis that
the individual sweeteners would differ in the
physiological responses they elicited. Thus, the
authors chose to pool the effects of the sweeteners
together. However, a post hoc network meta-analysis
was done to determine whether there was any
meaningful heterogeneity, and this was not the case.
▪ Most of the studies had relatively small sample
sizes, which inherently compromises statistical
power.
▪ Due to the sweet-tasting nature of the experimental
treatments, only a small number of the studies were
double-blinded. This opens the possibility for bias
on the part of the subjects as well as the authors.
However, a post hoc analysis of only the double-
blind studies in the analysis had similar results to the
main analysis.
[Back to Contents] Page 8
 ▪ Most of the studies examined the effects of a single
low-energy sweetener (LES) administered alone. In
the commercial/real-world, most food and beverage
contain a combination of 2 or more LESs.
Nevertheless, the authors remain skeptical of a
combination of LESs having different effects on
glucose homeostasis compared to a single LES.
Comment/application
The main finding of this systematic review & meta-
analysis was an overall lack of effect on acute postprandial
glycemic and insulinemic responses. Importantly, this lack
of effect occurred whether ingested alone or in
combination with other nutrients. Compared to control
conditions, LESs do not independently change
postprandial (post-meal) blood glucose or insulin
responses. This finding was observed on a standard 120-
minute postprandial period of analysis for glucose and
insulin. This was also observed in studies with test periods
shorter than 120 minutes. A valid concern is the effect of
LES on glycemic control in diabetics. This question has
been addressed by Behnen et al,3 who examined 9 clinical
trials totaling 490 subjects. They concluded that LESs
imparted no significant effects on glycemic control and
insulin response (regardless of type 1 or 2 diabetes). The
practical/clinical implications of the present meta-analysis’
findings align with a recent consensus paper by Ashwell et
al,4 which concluded the following:
“Based on reviews of clinical evidence to date, the panel
concluded that LCS can be beneficial for weight
management when they are used to replace sugar in
products consumed in the diet (without energy
substitution). The available evidence suggests no
grounds for concerns about adverse effects of LCS on
sweet preference, appetite or glucose control; indeed,
LCS may improve diabetic control and dietary
compliance. Regarding effects on the human gut
microbiota, data are limited and do not provide
adequate evidence that LCS affect gut health at doses
relevant to human use.”
A final wrinkle I would throw into this discussion is that
while meta-analyses are important for gaining a big-
picture view of the evidence, individual study findings
Alan Aragon’s Research Review – September 2020
should not be ignored. It’s inevitable that different LESs
have different physiological effects.5 A recent example is a
12-week trial by Higgins et al,6 comparing the effects of
sucrose (table sugar), aspartame, stevia (rebA), saccharin,
and sucralose. Sucralose was the only sweetener that led to
a significant decrease in energy intake compared to
baseline. Saccharin led to an increase in bodyweight, and
hunger ratings in the saccharin group were significantly
greater than all other groups. Fortunately, saccharin is
nearly commercially extinct with the exception of the pink
packets of Sweet N’Low at your local greasy spoon diner.
References
1. Liberati A, Altman DG, Tetzlaff J, Mulrow C,
Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ,
Kleijnen J, Moher D. The PRISMA statement for
reporting systematic reviews and meta-analyses of
studies that evaluate health care interventions:
Explanation and elaboration. PLoS Med.
2009;6:e1000100. [PubMed]
2. Schiavo JH. PROSPERO: An International Register of
Systematic Review Protocols. Med Ref Serv Q. 2019
Apr-Jun;38(2):171-180. [PubMed]
3. Behnen EMT, Ferguson MC, Carlson A. Do Sugar
Substitutes Have Any Impact on Glycemic Control in
Patients with Diabetes? Journal of Pharmacy
Technology. 2013;29(2):61-65. [JPT]
4. Ashwell M, Gibson S, Bellisle F, Buttriss J,
Drewnowski A, Fantino M, Gallagher AM, de Graaf
K, Goscinny S, Hardman CA, Laviada-Molina H,
López-García R, Magnuson B, Mellor D, Rogers PJ,
Rowland I, Russell W, Sievenpiper JL, la Vecchia C.
Expert consensus on low-calorie sweeteners: facts,
research gaps and suggested actions. Nutr Res Rev.
2020 Jan 13;33(1):1-10. [PubMed]
5. Hunter SR, Reister EJ, Cheon E, Mattes RD. Low
Calorie Sweeteners Differ in Their Physiological
Effects in Humans. Nutrients. 2019 Nov
9;11(11):2717. [PubMed]
6. Higgins KA, Mattes RD. A randomized controlled trial
contrasting the effects of 4 low-calorie sweeteners and
sucrose on body weight in adults with overweight or
obesity. Am J Clin Nutr. 2019 May 1;109(5):1288-
1301. [PubMed]
[Back to Contents] Page 9

The influence of cyclical ketogenic reduction diet
vs. nutritionally balanced reduction diet on body
composition, strength, and endurance
performance in healthy young males: a
randomized controlled trial.
Kysel P, Haluzíková D, Doležalová RP, Laňková I,
Lacinová Z, Kasperová BJ, Trnovská J, Hrádková V, Mráz
M, Vilikus Z, Haluzík M. Nutrients. 2020 Sep
16;12(9):E2832. [PubMed]
BACKGROUND: The influence of ketogenic diet on
physical fitness remains controversial. We performed a
randomized controlled trial to compare the effect of
cyclical ketogenic reduction diet (CKD) vs. nutritionally
balanced reduction diet (RD) on body composition, muscle
strength, and endurance performance. METHODS: 25
healthy young males undergoing regular resistance training
combined with aerobic training were randomized to CKD
(n = 13) or RD (n = 12). Body composition, muscle
strength and spiroergometric parameters were measured at
baseline and after eight weeks of intervention. RESULTS:
Both CKD and RD decreased body weight, body fat, and
BMI. Lean body mass and body water decreased in CKD
and did not significantly change in RD group. Muscle
strength parameters were not affected in CKD while in RD
group lat pull-down and leg press values increased.
Similarly, endurance performance was not changed in
CKD group while in RD group peak workload and peak
oxygen uptake increased. CONCLUSIONS: Our data
show that in healthy young males undergoing resistance
and aerobic training comparable weight reduction were
achieved by CKD and RD. In RD group; improved muscle
strength and endurance performance was noted relative to
neutral effect of CKD that also slightly reduced lean body
mass. FUNDING SOURCE: This research was funded by
Funded by CZ-RO (“Institute for Clinical and
Experimental Medicine—IKEM, IN 00023001”) and RVO
VFN 64165 to M.H.
Strengths
Cyclical ketogenic dieting (CKD) has been discussed
within the bodybuilding and fitness community and in the
lay literature since the 1990’s with Dan Duchaine’s
Bodyopus and Mauro DiPasquale’s Anabolic Diet, and in
the early 2000’s with Lyle McDonald’s Ultimate Diet 2.0.
Despite roughly 30 decades of existence in physique
Alan Aragon’s Research Review – September 2020
culture, CKD plus resistance training has never landed in
the peer reviewed literature, until now. To my knowledge,
the present study is the first of this kind to make it into the
ivory tower. Subjects had a minimum of one year of
resistance & aerobic training experience. The CKD
assigned to the subjects was reflective of CKDs typically
engaged in the real world: 5 days keto (carbohydrate
maximum of 30 g/day), 2 days high-carb (8-10 g/kg
LBM). Protein was set at 1.6 g/kg, which is sufficient in
most cases for facilitating muscle gain or retention.
Ketosis was objectively assessed via urinary & blood
ketone levels.
Limitations
The authors acknowledged that the trial duration (8 weeks)
was short, and sample was small (25 subjects). Only men
were included – leaving the response of other populations
to this intervention open to speculation. Although the
assigned intakes were specified, the actual intakes were
not reported in the manuscript (despite the mentioning that
subjects kept food records, with weekly compliance checks
done by a nutritionist). Big questions remain in the
absence of this information. As it stands, we don’t know
how close or far the accrual intakes were form the targets
assigned. The results might also be limited to the training
protocol used. Strangely, although the training split was
specified (3 days per week, each day focused on a different
muscle group – chest, legs, back), sets, reps, and load were
not specified. The training session was reported to last 60
minutes, including a 30 minute run at 70% TFmax (130-
140 beats per minute), but this still leaves missing details
about the resistance training protocol, since a wide
variation of loading permutations can occur within a 30-
minute timeframe.
Comment/application
[Back to Contents] Page 10
As shown above, both groups significantly reduced body
fat, which is expected. However, reductions in lean mass
and body water were not significant in the control diet
(RD), but were significant in the CKD.
As shown above, the CKD failed to cause significant
increases in lifting strength with any of the 3 exercises,
while the RD caused significant gains in lat pull-down and
leg press strength (both diets failed to increase bench press
strength).
As shown above, RD improved several measures of
aerobic performance (peak workload, peak oxygen uptake,
peak workload per kg, and work capacity at a heart rate of
170 beats per minute) while the CKD failed to
significantly increase any of these measures. Overall, the
control diet, targeted to contain 55% carbs, 15% protein,
and 30% fat, was the superior performer, for both body
composition outcomes (lean mass retention, specifically),
and measures of aerobic fitness.
At the outset of the trial, the authors hypothesized that the
CKD would be more effective more efficacious in
improving endurance measures, as seen in McSwiney et
al’s trial, where the ketogenic diet group lost body fat and
(erroneously) reported that endurance performance was
improved (those interested in an in-depth discussion of the
crucial flaws in the methodology and reporting of
McSwiney’s study can go here).2 Ultimately, the authors
Alan Aragon’s Research Review – September 2020
conceded that their results are consistent with recent well-
controlled trials showing that ketogenic diets impair
endurance performance.3,4 I would also add the greater loss
of lean mass in the ketogenic diet group is consistent with
several recent studies reporting similar inferiority in lean
mass retention or gain.5-8 In the case of the present study, it
appears that the 2-day carb-ups (8-10 g/kg LBM) were
insufficient to compensate for the ergolytic effect of the 5-
day ketogenic periods. More research investigating this
model or similar would provide more definitive
conclusions.
References
1. McSwiney FT, Wardrop B, Hyde PN, Lafountain RA,
Volek JS, Doyle L. Keto-adaptation enhances exercise
performance and body composition responses to training in
endurance athletes. Metabolism. 2018 Apr;81:25-34.
[PubMed]
2. Tzur A, Roberts A. Critical analysis of mcswiney et al’s
2017 keto study. Updated June 2017. [Sci-Fit]
3. Burke LM, Ross ML, Garvican-Lewis LA, Welvaert M,
Heikura IA, Forbes SG, Mirtschin JG, Cato LE, Strobel N,
Sharma AP, Hawley JA. Low carbohydrate, high fat diet
impairs exercise economy and negates the performance
benefit from intensified training in elite race walkers. J
Physiol. 2017 May 1;595(9):2785-2807. [PubMed]
4. Burke LM, Sharma AP, Heikura IA, Forbes SF, Holloway
M, McKay AKA, Bone JL, Leckey JJ, Welvaert M, Ross
ML. Crisis of confidence averted: Impairment of exercise
economy and performance in elite race walkers by
ketogenic low carbohydrate, high fat (LCHF) diet is
reproducible. PLoS One. 2020 Jun 4;15(6):e0234027.
[PubMed]
5. Vargas S, Romance R, Petro JL, Bonilla DA, Galancho I,
Espinar S, Kreider RB, Benítez-Porres J. Efficacy of
ketogenic diet on body composition during resistance
training in trained men: a randomized controlled trial. J Int
Soc Sports Nutr. 2018 Jul 9;15(1):31. [PubMed]
6. Greene 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
Dec;32(12):3373-3382. [PubMed]
7. Kephart WC, Pledge CD, Roberson PA, Mumford PW,
Romero MA6, Mobley CB, 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 Jan 9;6(1). pii: E1. [PubMed]
8. Vargas-Molina S, Petro JL, Romance R, Kreider RB,
Schoenfeld BJ, Bonilla DA, Benítez-Porres J. Effects of a
ketogenic diet on body composition and strength in trained
women. J Int Soc Sports Nutr. 2020 Apr 10;17(1):19.
[PubMed]
[Back to Contents] Page 11

What characterizes a healthy diet?
By Alan Aragon
_______________________________________________
What is health? According to the World Health
Organization, health can be defined as having complete
physical, mental, and social well-being; not merely the
absence of disease or infirmity.1 There are tons of fad
diets, and most of them are not just ridiculous, but
unhealthy—for not just the body, but the mind as well.
Yup, fad diets create unhealthy and sometimes dangerous
relationships with food, in addition to having poor long-
term effectiveness. The purpose of the following
discussion is to clarify the universal qualities that define a
healthy diet. Note that these are not in any particular order
of importance.
A healthy diet respects personal preference.
Consider for a moment the absurdity of the following
statement: “A diet consisting mostly of foods you hate is
ideal for long-term adherence.” Now switch the word
“hate” with “love” and it just makes so much sense—
almost a “well-duh” level of sense. What’s amazing to me
is that the principle of honoring personal preference is
probably the most over-looked and under-utilized weapon
in the dieter’s arsenal. This isn’t just a pet intuition of
mine, there’s science to support it. Quoting a recent review
by Koliaki et al:2 “…the most effective strategy to achieve
long-term weight loss and good cardiometabolic health is
shifting to a healthy dietary pattern, compatible with
individual food preferences and lifestyle habits.”
A healthy diet provides enough total energy to support
physical & mental performance goals, as well as healthy
body composition.
A diet shouldn’t just suit your personal taste preferences, it
should also provide adequate energy to optimize the
performance of every move you make. The heart of this
involves eating enough calories (and nutrients). There’s a
very broad range of physical activity demands across
Alan Aragon’s Research Review – September 2020
individuals. Competitive athletes at the elite level can have
2-4 times (or more) the total daily calorie requirements of
deskbound weekend warriors. While obesity from chronic
overeating is a major public health problem, the other side
of the coin is that chronic over-dieting is common among
athletes of all levels.
The female athlete triad is a pathological progression that
begins with disordered eating and/or under-eating, which
leads to the disruption & cessation of the menstrual cycle,
and finally a decrease in bone mineral density that can
ultimately manifest as osteopenia or osteoporosis.3 One of
the cornerstones of preventing the triad’s progression is
simply eating enough to maintain a healthy weight and
body composition. Relative energy deficiency syndrome
(REDS) also involves inadequate energy intake, but
encompasses a larger range of dysfunction, including
impaired metabolic rate, menstrual function, bone health,
immunity, protein synthesis, cardiovascular health, and
psychological health.4 The threshold of energy availability
below which the Triad and REDS can manifest is reported
to be 30 kcal/kg of lean body mass.
According to perhaps the most diligent research in this
area, normal/healthy ranges for body fat percent among the
general public were 13.4-21.7% for men and 24.6-33.2%
for women.5 These ranges reflect earlier research by
Abernathy and Black,6 who reported that the best health is
seen fat percentages averaging between 12-20% for men
and 20-30% for women. Some may look at those ranges
and immediately think of elite athletes who are far leaner.
Newsflash: elite athletic performance and optimal health
do not always run parallel. In fact, the nature of sport is
often to challenge the limits of human survival under the
most stressful conditions. For those interested, I covered
the body fat ranges of athlete populations in this graphic.
A healthy diet covers macro- and micronutrient needs.
This seems rather obvious, right? Too bad people routinely
mess up both aspects. Macronutrition—protein, carbs, and
fat—is an area that’s ripe for creating boundless fallacies
and quacky lore. As for micronutrition, it’s not easy to
meet the recommended amounts of all the essential
[Back to Contents] Page 12
vitamins and minerals. Calton et al7 assessed the
micronutrient sufficiency of four popular diets and found
them to be, on average, 56.48% deficient in meeting the
recommended amounts, lacking in 15 out of the 27
essential micronutrients analyzed. These findings
underscore the importance of predominating the diet with a
variety of whole and minimally refined foods. The
findings also build a strong case for taking a
multivitamin/mineral if you’re dieting and/or consuming a
narrow range of foods (refer to the December 2013 issue
of AARR for more commentary on multivitamin-mineral
supplements). It also illustrates the importance of being
cautious about eliminating foods or food groups, which
carries an inherent risk for incurring nutrient deficiencies.
A healthy diet has no unnecessary/unfounded food
restrictions.
A great example of unfounded elimination is the Paleo
diet, which bans nutritious foods like grains, legumes, and
dairy. The rationale for eliminating these foods is that
they’re harmful to health. This is a bold claim that lacks
scientific evidence.8 In the case of grains, the focus is on
either celiac disease or non-celiac gluten intolerance.
Conservatively speaking, over 90% of the world does not
have either condition,9,10 and therefore can safely consume
gluten-containing foods. Furthermore, the types of
commercially available gluten-free grains outnumber
gluten-containing grains by more than double. What’s
ironic is that the Paleo diet aims to ban problematic foods,
yet allows 4 of the 8 major allergens identified by the by
the Food Allergen Labeling and Consumer Protection
Act.11 It doesn’t make sense to issue a universal ban on
foods that cannot be tolerated by a small minority of the
population.
Legume banning per the Paleo doctrine is silly. They are a
staple food of some of the healthiest populations on
Earth.12 There is an abundance of their health benefits in
and a scarcity of evidence of harm.13,14 As for dairy, the
current weight of the evidence supports the net health
benefit of dairy consumption.15 Here’s a memorable
excerpt from Rafferty and Heaney’s research on the
nutritional contributions of milk:16 “NHANES 1999–2000
and CSFII 1994–1996 analyses of food sources of calcium,
Alan Aragon’s Research Review – September 2020
vitamin D, protein, phosphorus, and potassium reveal milk
to be the number 1 single food contributor of each of these
bone-related nutrients with the exception of protein in all
age groups of both sexes…”
A healthy diet respects food intolerances & allergies.
At the same time that certain food restrictions are based on
pseudoscience, imagination, and gimmickry, there are
individuals with various food intolerances, allergies, or
drug-related contraindications that require the strict
avoidance of certain foods. However, it’s worth noting that
sometimes there can be flexibility in these matters. For
example, Wilt and colleagues17 reported that the majority
of individuals diagnosed with lactose intolerance can have
up to 12 grams (equivalent to 1 cup of milk) in a sitting
with minimal to no symptoms, particularly if consumed
with other foods.
A healthy diet is convenient.
In other words, a healthy diet shouldn’t be a needless time
& effort-depleting burden. Tupperware and coolers can be
useful, but not when they become an obligation every time
you have to leave the house for more than two hours. The
idea that everyone must eat multiple, tiny meals
throughout the day in order to “stoke the metabolism” is so
mythical and incorrect. Multiple controlled studies
comparing low and high meal frequencies have failed to
detect differences in thermogenesis in the short term, and
the influence of meal frequency on body composition in
the long-term has yielded equivocal results.18 The
pendulum swings the other way, where folks think special
clinical adaptations result from lengthy stretches of fasting,
but that’s equally wishful and lacking scientific
support.19,20 Meal frequency should therefore be based on
the individual goal, personal preference, and individual
tolerance. There’s no magic with extreme lows or extreme
highs in meal frequency.
A healthy diet is affordable.
One way to over-pay for food is by subscribing to the
organic label, which often doubles the price. But is it
worth it? Thus far, a substantial body of research evidence
strongly suggests that it’s a gamble at best.21 Several
systematic reviews have concluded that there’s no
[Back to Contents] Page 13
meaningful difference in nutrient quality or nutrition-
related health advantages between organically and
conventionally produced foodstuffs.22-24 Another way to
over-pay is through supplements. While there are cases
where supplementation is useful for either exercise
performance25 or preventing nutrient deficiency,7 the
majority of products range from an inert waste of money to
a dangerous waste of money.
A healthy diet is socially acceptable (and not hazardous
to the public).
I realize that people have all kinds of bizarre eating rituals
and proclivities. However, when it lowers the comfort
level, raises the anxiety level, or worse yet—endangers
those around them, that’s when it goes too far. One
obvious example (aside from non-consensual cannibalism)
is the dichotomous nature alcohol consumption. While a
moderate intake (i.e., 1-3 glasses of wine per day) has been
associated with health benefits,26,27 abusing alcohol can
affect nearly every bodily system.28 Another thing that can
cause social disharmony is the judgment of others based
on their diets, which brings us to the next point.
A healthy diet is compatible with personal ideologies.
Personal ideology refers to someone’s personal or
subjective beliefs that frame their food choices. For
example, vegetarianism is an ideological choice that many
people decide to make. A healthy diet for vegetarians
would be one that follows the rules that the individual
decides to impose within the chosen variant. There is a
multitude of ways to compose nutritionally complete diets
that happen to have philosophical, cultural, or religion-
based restrictions. It’s not healthy for people to feel
pressured to force foods that don’t fit with their ideologies.
Now, here comes the disclaimer. If you have truly wacky
ideologies and think that going on a 40-day water fast is a
good idea, you might need to re-examine your personal
ideology in the interest of your own survival.
A healthy diet is sustainable in the long-term.
Any diet you cannot permanently adhere to is simply not a
healthy diet. Fad diets fall into this category, although
some folks are tenacious enough to drag them out for a
good, long time before realizing how pointless it is. Pre-
Alan Aragon’s Research Review – September 2020
contest diets also fall into this category, no matter how
“healthy” someone thinks their semi-starvation diet is. It
bears emphasis that physique competition is not a
physically nor mentally healthy endeavor. Do many people
compete in physique sports and come out of the process
unscathed? Yes, but does it make it healthy or without
serious, potentially long-lasting risks (particularly for
varying degrees of disordered or dysfunctional eating)?
No, and this reality should be acknowledged at the outset
of the endeavor. The good news is that people can achieve
long-term adherence by individualizing their diets to suit
their personal preferences, tolerances, goals, and
ideologies.
References
1. Grad FP. [Commentary on the] preamble of the
constitution of the world health organization. Bulletin
of the World Health Organization. 2002, 80 (12).
[WHO]
2. Koliaki C, Spinos T, Spinou Μ, Brinia ΜE,
Mitsopoulou D, Katsilambros N. Defining the Optimal
Dietary Approach for Safe, Effective and Sustainable
Weight Loss in Overweight and Obese Adults.
Healthcare (Basel). 2018 Jun 28;6(3):73. [PubMed]
3. Female Athlete Triad Coalition. What is the triad?
[femaleathletetriad.org]
4. Robertson S, Mountjoy M. A Review of Prevention,
Diagnosis, and Treatment of Relative Energy
Deficiency in Sport in Artistic (Synchronized)
Swimming. Int J Sport Nutr Exerc Metab. 2018 Jul
1;28(4):375-384. [PubMed]
5. Kyle UG, Schutz Y, Dupertuis YM, Pichard C. Body
composition interpretation. Contributions of the fat-
free mass index and the body fat mass index.
Nutrition. 2003;19:597–604. [PubMed]
6. Abernathy RP, Black DR. Healthy body weights: an
alternative perspective. Am J Clin Nutr. 1996
Mar;63(3 Suppl):448S-451S. [PubMed]
7. Calton JB. Prevalence of micronutrient deficiency in
popular diet plans. J Int Soc Sports Nutr. 2010 Jun
10;7:24. [PubMed]
8. Aragon AA. The Paleo diet: claims versus evidence.
NSCA Personal Trainers Conference, 2013.
9. Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray
JA, Everhart JE. The prevalence of celiac disease in
[Back to Contents] Page 14
 the United States. Am J Gastroenterol. 2012
Oct;107(10):1538-44. [PubMed]
10. DiGiacomo DV, Tennyson CA, Green PH, Demmer
RT. Prevalence of gluten-free diet adherence among
individuals without celiac disease in the USA: results
from the Continuous National Health and Nutrition
Examination Survey 2009-2010. Scand J Leifert C. A Systematic Review of Organic Versus
Gastroenterol. 2013 Aug;48(8):921-5. [PubMed]
11. US Food and Drug Administration. Food Allergen
Labeling And Consumer Protection Act of 2004:
Questions and Answers. [FDA]
12. Buettner D, Skemp S. Blue Zones: Lessons From the
World's Longest Lived. Am J Lifestyle Med. 2016 Jul
7;10(5):318-321. [PubMed]
13. Bouchenak M, Lamri-Senhadji M. Nutritional quality
of legumes, and their role in cardiometabolic risk
prevention: a review. J Med Food. 2013
Mar;16(3):185-98. [PubMed]
14. Becerra-Tomás N, Papandreou C, Salas-Salvadó J.
Legume Consumption and Cardiometabolic Health.
Adv Nutr. 2019 Nov 1;10(Suppl_4):S437-S450.
[PubMed]
15. Thorning TK, Raben A, Tholstrup T, Soedamah-
Muthu SS, Givens I, Astrup A. Milk and dairy
products: good or bad for human health? An
assessment of the totality of scientific evidence. Food
Nutr Res. 2016 Nov 22;60:32527. [PubMed]
16. Rafferty K, Heaney RP. Nutrient effects on the
calcium economy: emphasizing the potassium
controversy. J Nutr. 2008 Jan;138(1):166S-171S.
[PubMed]
17. Wilt TJ, Shaukat A, Shamliyan T, et al. Lactose
Intolerance and Health. Evidence Reports/Technology
Assessments, No. 192. Rockville (MD): Agency for
Healthcare Research and Quality (US); 2010 Feb.
[PubMed]
18. Schoenfeld BJ, Aragon AA, Krieger JW. Effects of
meal frequency on weight loss and body composition:
a meta-analysis. Nutr Rev. 2015 Feb;73(2):69-82.
[PubMed]
19. Haiyan M, et al. Effects of intermittent fasting and
energy-restricted diets on lipid profile: A systematic
review and meta-analysis. Nutrition. Volume 77,
September 2020, 110801. [ScienceDirect]
20. Cioffi I, Evangelista A, Ponzo V, Ciccone G, Soldati
L, Santarpia L, Contaldo F, Pasanisi F, Ghigo E, Bo S.
Alan Aragon’s Research Review – September 2020
Intermittent versus continuous energy restriction on
weight loss and cardiometabolic outcomes: a
systematic review and meta-analysis of randomized
controlled trials. J Transl Med. 2018 Dec
24;16(1):371. [PubMed]
21. Vigar V, Myers S, Oliver C, Arellano J, Robinson S,
Conventional Food Consumption: Is There a
Measurable Benefit on Human Health? Nutrients.
2019 Dec 18;12(1):7. [PubMed]
22. Dangour AD, Dodhia SK, Hayter A, Allen E, Lock K,
Uauy R. Nutritional quality of organic foods: a
systematic review. Am J Clin Nutr. 2009
Sep;90(3):680-5. [PubMed]
23. Dangour AD, Lock K, Hayter A, Aikenhead A, Allen
E, Uauy R. Nutrition-related health effects of organic
foods: a systematic review. Am J Clin Nutr. 2010
Jul;92(1):203-10. [PubMed]
24. Smith-Spangler C, Brandeau ML, Hunter GE,
Bavinger JC, Pearson M, Eschbach PJ, Sundaram V,
Liu H, Schirmer P, Stave C, Olkin I, Bravata DM. Are
organic foods safer or healthier than conventional
alternatives?: a systematic review. Ann Intern Med.
2012 Sep 4;157(5):348-66. [PubMed]
25. Kerksick CM, Wilborn CD, Roberts MD, Smith-Ryan
A, Kleiner SM, Jäger R, Collins R, Cooke M, Davis
JN, Galvan E, Greenwood M, Lowery LM, Wildman
R, Antonio J, Kreider RB. ISSN exercise & sports
nutrition review update: research & recommendations.
J Int Soc Sports Nutr. 2018 Aug 1;15(1):38. doi:
10.1186/s12970-018-0242-y. [PubMed]
26. Arranz S, Chiva-Blanch G, Valderas-Martínez P,
Medina-Remón A, Lamuela-Raventós RM, Estruch R.
Wine, beer, alcohol and polyphenols on cardiovascular
disease and cancer. Nutrients. 2012 Jul;4(7):759-81.
[PubMed]
27. Snopek L, Mlcek J, Sochorova L, Baron M, Hlavacova
I, Jurikova T, Kizek R, Sedlackova E, Sochor J.
Contribution of Red Wine Consumption to Human
Health Protection. Molecules. 2018 Jul 11;23(7):1684.
[PubMed]
28. National Institute on Alcohol Abuse and Alcoholism.
Beyond hangovers: understanding alcohol’s impact on
your health. 2010 [NIAAA]
[Back to Contents] Page 15

Does cold water immersion enhance training
recovery?
By Alan Aragon
_______________________________________________
Background
A common practice among athletes at the elite level is
post-exercise immersion into an ice-water bath at
approximately 10-15°C for 5-10 minutes, sometimes
longer. The intention of this practice is to reduce soreness
and/or swelling, and expedite recovery. The traditionally
proposed (and somewhat far-fetched) mechanisms include
the constriction of blood vessels as a means to “flush”
waste products and slow down or inhibit physiological
processes involved with tissue breakdown.1 Back in 2010,
a review by Lateef described the state of the evidence for
cold water immersion (CWI) as follows:1
“Despite this being a practice among some athletes,
especially elite ones, it is not an evidence-based
recommendation and studies performed thus far have
been small or inconclusive. Some have argued against
this practice as it offers no benefits for pain, swelling
or isometric strength and function. In fact, some
observations have been made to show that this
practice may cause muscle soreness the day after.
Perhaps it is the placebo effect that is being utilized.”
Well, ten years have elapsed since this publication
claiming that CWI is not an evidence-based practice. The
question is, how far have we come in terms of evidence for
or against it? Fortunately, there has been a substantive
amount of research since 2010 examining this question.
Let’s have a look and then draw some conclusions.
The march of the data
In 2012, a meta-analysis by Leeder et al2 found that CWI was
effective in alleviating DOMS after high-intensity exercise at
24 and 48 hours. It was concluded that CWI may reduce
muscle soreness in the first 96 hours post-exercise, especially
Alan Aragon’s Research Review – September 2020
after high-intensity exercise. CWI improved recovery of
explosive muscle power but not strength.
In 2014, Broatch et al’s findings presented a stiff challenge
to the validity of CWI.3 For the first time in CWI research,
a placebo condition was included. The placebo condition
was the same thermoneutral water immersion (34.7°C),
except the subjects were (deceptively) told that it was as
effective was CWI (10.3°C). Thirty males performed four
30-second sprints, followed by one of three 15-minute
recovery conditions: CWI, thermoneutral water immersion
placebo, or thermoneutral water immersion control. Leg
strength after maximal voluntary isometric contraction of
the quadriceps and ratings of readiness for exercise, pain,
and vigor were significantly impaired in the control
compared with those in CWI and the placebo condition,
which were similar to each other. The authors concluded
that A CWI placebo is as effective as CWI itself in muscle
strength recovery over a 48-hour period.
A similar phenomenon has been seen recently by in a
study by Wilson et al4 involving resistance trainees led to
believe that their placebo (a cornstarch pill) was BCAA.
CWI was no more effective than the placebo at affecting
markers of recovery.
In 2015, Peake et al5 presented another blow to the validity
of CWI, this time investigating potential mechanisms in
the context of resistance training. A direct comparison was
made between the post-exercise effects of CWI versus
active recovery on inflammatory cellular markers and heat
shock proteins (HSPs) in skeletal muscle. There was no
advantage of CWI compared to active recovery (10
minutes of a self‐selected low intensity on a stationary
cycle ergometer) for reducing inflammation or cellular
stress after intense resistance exercise.
In 2016, a meta-analysis by Machado et al,6 it was reported
that “CWI can be slightly better than passive recovery in
the management of muscle soreness,” and a dose-response
relationship was observed. CWI with a water temperature
of 11-15°C and an immersion time of 11-15 min were the
most effective. The impact of soreness reduction on
recovery may or may not have meaningful functional
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consequence for all goals. The goal of muscle hypertrophy
comes immediately to mind – more on this in a bit.
In 2017, a meta-analysis by Higgins et al7 found that CWI
was beneficial for recovery at 24 hours (countermovement
jump, all-out sprint, and neuromuscular function)
following team sport. CWI was also beneficial for
lowering fatigue at 48 and 72 hours However, CWI was
not effective for accumulated sprinting following team
sports. Regarding subjective measures of recovery, CWI
lowered perceptions of fatigue at 72 hours following team
sport, but did not reduce perceptions of muscle soreness.
Nevertheless, since there indeed appeared to be recovery
benefits, Higgins et al’s practical recommendations for
CWI were as follows: 2 to 5-minute immersions of 10°C
with 2-minute seated rest in ambient temperature between
immersions, with total immersion time being at least 10
minutes.
It bears repeating that the studies in this area lack a
placebo (sham) condition. As Peake et al4 demonstrated
previously, it’s possible that the placebo effect can play a
significant role in CWI’s effects. Speaking of Peake et al,
in 2017, they compared the effects of CWI with active
recovery on inflammatory & cellular stress markers
following resistance exercise in a well-controlled
crossover trial.8 Anticlimactically, CWI was found to be
no more effective than active recovery (10 minutes of a
self-selected low intensity on a cycle ergometer).
Hope for endurance-oriented, quick turn-around sports,
bummer for hypertrophy
In light of the previous findings, a 2017 review by Allan
and Mawhinney9 offered the following perspective, worth
quoting directly:
“Meta‐analyses and performance studies conducted in
the area show us that CWI may be useful within
competition settings, particularly those requiring a
short turn‐around (such as tournament situations,
athletic meets and cycling tours), of a particularly
damaging nature, or in high environmental
temperatures. However, there remains a lack of
justification for using CWI regularly during a
Alan Aragon’s Research Review – September 2020
‘pre‐season’ or preparation phase, particularly where
the goal includes a hypertrophic response, due to the
potential of dampening the adaptive response to
training.”
Toward the points made in the quote above, a 2017 study
by Lindsay et al10 showed the positive effects of CWI for
reducing soreness and biomarkers of inflammation and
physiological stress following mixed martial arts training,
which involves impact stress. A 2018 study by De Paula et
al11 reported that CWI improved subsequent 5 km running
time trial performance, when implemented after unilateral
eccentric knee flexion exercise and 90 min of treadmill
running at 70% of peak oxygen consumption.
Also in line with the points made in the quote by Allan and
Mawhinney,8 concerning effects on pathways toward
muscle hypertrophy have been observed repeatedly. A 12-
week trial by Roberts et al12 reported significant increase
in satellite cells, number of myonuclei, anabolic signaling,
and muscle strength & mass in the active recovery group,
while no significant increases in these parameters occurred
in the CWI group. They concluded that, CWI inhibits
surrogate and concrete endpoints of hypertrophy, which
may result in lesser gains in muscle size & strength in the
long-term. Congruent with these findings are subsequent
resistance training studies spanning to the present year,
showing anti-hypertrophic effect of CWI through the
inhibition of molecular factors involved in muscle
growth,13 impairment of muscle protein synthesis,14 and
blunting of muscle fiber hypertrophy.15
Concluding perspectives
Going back to the question in the title, you can see that the
answer is not simple. CWI might be useful for enhancing
training recovery, but this might not apply to the specific
pursuit of muscle hypertrophy. Interestingly, this anti-
hypertrophic effect was not accompanied by compromised
strength gain in a 7-week trial,15 but it’s not implausible to
speculate that inhibited muscle growth would impact
muscular strength potential beyond the initial stage of
strength gains in untrained subjects. A final thing to consider
is that the benefits of CWI could be largely due to the placebo
effect. So, the degree to which it works for recovery might
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depend on the degree to which you believe it does. I
personally would steer clear if the goal primary goal is
muscle gain (and by extension, muscle strength as well). For
other goals, it might be worth a try – emphasis on might.
References
1. Lateef F. Post exercise ice water immersion: Is it a
form of active recovery? J Emerg Trauma Shock. 2010
Jul;3(3):302. [PubMed]
2. Leeder J, Gissane C, van Someren K, Gregson W,
Howatson G. Cold water immersion and recovery
from strenuous exercise: a meta-analysis. Br J Sports
Med. 2012 Mar;46(4):233-40. [PubMed]
3. Broatch JR, Petersen A, Bishop DJ. Postexercise cold
water immersion benefits are not greater than the
placebo effect. Med Sci Sports Exerc. 2014
Nov;46(11):2139-47. [PubMed]
4. Wilson LJ, Dimitriou L, Hills FA, Gondek MB,
Cockburn E. Whole body cryotherapy, cold water
immersion, or a placebo following resistance exercise:
a case of mind over matter? Eur J Appl Physiol. 2019
Jan;119(1):135-147. [PubMed]
5. Peake JM, Roberts LA, Figueiredo VC, Egner I, Krog
S, Aas SN, Suzuki K, Markworth JF, Coombes JS,
Cameron-Smith D, Raastad T. The effects of cold
water immersion and active recovery on inflammation
and cell stress responses in human skeletal muscle
after resistance exercise. J Physiol. 2017 Feb
1;595(3):695-711. [PubMed]
6. Machado AF, Ferreira PH, Micheletti JK, de Almeida
AC, Lemes ÍR, Vanderlei FM, Netto Junior J, Pastre
CM. Can Water Temperature and Immersion Time
Influence the Effect of Cold Water Immersion on
Muscle Soreness? A Systematic Review and Meta-
Analysis. Sports Med. 2016 Apr;46(4):503-14.
[PubMed]
7. Higgins TR, Greene DA, Baker MK. Effects of Cold
Water Immersion and Contrast Water Therapy for
Recovery From Team Sport: A Systematic Review and
Meta-analysis. J Strength Cond Res. 2017
May;31(5):1443-1460. [PubMed]
8. Peake JM, Roberts LA, Figueiredo VC, Egner I, Krog
S, Aas SN, Suzuki K, Markworth JF, Coombes JS,
Cameron-Smith D, Raastad T. The effects of cold
water immersion and active recovery on inflammation
Alan Aragon’s Research Review – September 2020
and cell stress responses in human skeletal muscle
after resistance exercise. J Physiol. 2017 Feb
1;595(3):695-711. [PubMed]
9. Allan R, Mawhinney C. Is the ice bath finally melting?
Cold water immersion is no greater than active
recovery upon local and systemic inflammatory
cellular stress in humans. J Physiol. 2017 Mar
15;595(6):1857-1858. [PubMed]
10. Lindsay A, Carr S, Cross S, Petersen C, Lewis JG,
Gieseg SP. The physiological response to cold-water
immersion following a mixed martial arts training
session. Appl Physiol Nutr Metab. 2017
May;42(5):529-536. doi: 10.1139/apnm-2016-0582.
[PubMed]
11. De Paula F, Escobar K, Ottone V, Aguiar P, Aguiar de
Matos M, Duarte T, Araújo T, Costa K, Magalhães F,
Rocha-Vieira E, Amorim F. Post-exercise cold-water
immersion improves the performance in a subsequent
5-km running trial. Temperature (Austin). 2018 Sep
12;5(4):359-370. [PubMed]
12. Roberts LA, Raastad T, Markworth JF, Figueiredo
VC, Egner IM, Shield A, Cameron-Smith D, Coombes
JS, Peake JM. Post-exercise cold water immersion
attenuates acute anabolic signalling and long-term
adaptations in muscle to strength training. J Physiol.
2015 Sep 15;593(18):4285-301. [PubMed]
13. Peake JM, Markworth JF, Cumming KT, Aas SN,
Roberts LA, Raastad T, Cameron-Smith D, Figueiredo
VC. The Effects of Cold Water Immersion and Active
Recovery on Molecular Factors That Regulate Growth
and Remodeling of Skeletal Muscle After Resistance
Exercise. Front Physiol. 2020 Jun 30;11:737.
[PubMed]
14. Fuchs CJ, Kouw IWK, Churchward-Venne TA,
Smeets JSJ, Senden JM, Lichtenbelt WDVM, Verdijk
LB, van Loon LJC. Postexercise cooling impairs
muscle protein synthesis rates in recreational athletes.
J Physiol. 2020 Feb;598(4):755-772. [PubMed]
15. Fyfe JJ, Broatch JR, Trewin AJ, Hanson ED, Argus
CK, Garnham AP, Halson SL, Polman RC, Bishop DJ,
Petersen AC. Cold water immersion attenuates
anabolic signaling and skeletal muscle fiber
hypertrophy, but not strength gain, following whole-
body resistance training. J Appl Physiol (1985). 2019
Nov 1;127(5):1403-1418. [PubMed]
[Back to Contents] Page 18
“Until you change your thinking, you will always recycle
your experiences.”
– Biggs Burke

If you have any questions, comments, suggestions, bones

of contention, cheers, jeers, guest articles you’d like to
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Alan Aragon’s Research Review – September 2020 [Back to Contents] Page 19