A Randomized, Double-blind, Placebo Controlled Trial of Testosterone Undecanoate for Optimizing Physical and Cognitive Performance During Military Operations (OPS II)
Phase: PHASE4
Conditions: Caloric Restriction, Exercise, Sleep
Sponsor: Pennington Biomedical Research Center

Page 1 of 40
V6.0
8.3.2020
Protocol Title: A randomized, double-blind, placebo controlled trial of testosterone 
undecanoate for optimizing physical and cognitive performance during military 
operations (OPS II)
Running Title: OPS II
Onsite PI Name: Jennifer C. Rood, PhD, Pennington Biomedical Research Center 
(PBRC), Baton Rouge, LA.
Offsite PI Name: Stefan M. Pasiakos, PhD, US Army Research Institute of 
Environmental Medicine (USARIEM), Natick, MA.
Medical Investigator: Frank Greenway, MD, PBRC
Sub-Investigator’s Name(s): Lee M. Margolis, PhD, USARIEM; Alyssa N. Varanoske, 
Ph.D., USARIEM; Arny A. Ferrando, PhD., University of Arkansas for Medical Sciences 
(UAMS) 
Consultant Name (s):  Harris R. Lieberman, PhD, USARIEM
Protocol Version Date: 3 August 2020
IRB Review History
Initial Approval V1.0 on May 10, 2019
Version 2.0 on August 21, 2019
Version 3.0 on August 23, 2019
Version 4.0 September 9, 2019
Version 5.0 December 23, 2019
Executive Summary
Warfighters frequently conduct training and combat operations under multi-stressor 
conditions that degrade muscle function [1]. The stressors contributing to functional 
decline during strenuous military operations include the integrated effects of high 
physical activity, sleep deprivation, and energy deficit. Energy deficits and sleep 
deprivation suppress skeletal muscle and whole-body anabolism and accelerate protein 
catabolism [2], in part by inhibiting endogenous testosterone synthesis [3, 4]. This 
results in a hypogonadal state and concomitant muscle atrophy, which contribute to 
declines in muscle function [5]. Pharmacologic restoration of eugonadal testosterone 
concentrations may be an effective strategy to attenuate functional decline by promoting 
anabolism and mitigating muscle mass losses typically observed during military 
operations. In the Optimizing Performance for Soldiers I (OPS I) study [6], healthy, non-
obese men supplemented with 200 mg of testosterone enanthate per week during 28-d 
of exercise- and diet-induced energy deficit gained lean body mass (LBM) and lost less 
total body mass than controls, who experienced a 20% reduction in total testosterone 
concentrations. The beneficial effects of testosterone were sustained into recovery and 
occurred without concomitant increases in health-related risk. While OPS I 
demonstrated an anabolic benefit, several experimental limitations preclude definitive 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020
NCT04120363

Page 2 of 40
V6.0
8.3.2020
recommendations to efficaciously adopt supplemental testosterone therapy as a 
Warfighter biomedical performance enhancement (BPE) strategy. The weekly 
intramuscular injections used in that study are not practical for Warfighters operating in 
austere environments. Further, the dose of the short-acting enanthate ester used 
produced testosterone concentrations exceeding the normal physiological range within 
days after administration, followed by a precipitous decline and prolonged hypogonadal 
state in recovery, which may not be well tolerated by Warfighters during combat and 
training operations. Third, the magnitude of stress imposed by physical activity and 
decreased energy intake did not adequately mimic the multi-faceted stress experienced 
during real-world military operations [4, 7, 8]. Finally, the muscle function tests used in 
OPS I lacked military relevancy and failed to demonstrate relevant performance 
improvements in participants receiving testosterone, despite LBM gains. The 
Optimizing Performance for Soldiers II (OPS II) study will address OPS I study 
limitations and test whether a standard, low dose of long-acting testosterone 
undecanoate (TU, 750 mg administered once) safely and steadily maintains 
normal testosterone concentrations, promotes anabolism, spares LBM, and 
enhances militarily-relevant measures of muscle function and performance 
without cognitive impairment during and in recovery from a highly-controlled, 20-
d simulated, multi-stressor (i.e., high physical activity, sleep deprivation, and 
energy deficit) military operation.  
Objectives
1. Determine the effects of a single dose of TU on LBM, anabolism, muscle and 
cognitive function and performance during simulated operational stress. 
2. Determine the effects of a single dose of TU on LBM, anabolism, muscle and 
cognitive function and performance recovery from simulated operational stress. 
Hypotheses
1. TU will maintain testosterone within normal clinical range, spare LBM, stimulate 
anabolism, and sustain muscle function without cognitive impairment during 
simulated operational stress. 
2. TU administration prior to 20-d of simulated operational stress will not cause 
hypogonadism during recovery, nor negatively affect LBM, muscle and cognitive 
functional recovery.   
Background
Biomedical Performance Enhancement: Rationale & Results from OPS I
Modest energy deficits can reduce body mass and improve health of overweight and 
obese adults [9]. The composition of body mass lost during moderate energy 
deprivation (500-1000 kcal/d or 20-40% of total daily energy expenditure, TDEE) [9] is 
predominantly body fat mass (FM). However, when energy deficits are more severe 
(~1000-3500 kcal/d or ~50-100% of TDEE) than energy deficits imposed for healthy 
weight loss [10], substantial LBM loss is observed [8, 11]. Warfighters (e.g., light 
infantry, special operations forces) conducting strenuous training and combat 
operations commonly experience sustained periods of severe, unavoidable energy 
deficit, the effects of which resemble the pathophysiology of semi-starvation and lead to 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 3 of 40
V6.0
8.3.2020
significant LBM loss and degraded lower-body muscle function [8, 12, 13]. Further, 
some Warfighters experience these severe and unavoidable periods of energy deficit 
and associated loss of LBM repeatedly over their military career, raising concerns about 
the potential accumulated effects of those energy deficits on health-readiness. The US 
military has sponsored considerable research to develop nutritional countermeasures to 
mitigate LBM loss under these conditions; however, dietary interventions, including 
increased protein intake, have been, by themselves, ineffective in sparing LBM during 
severe energy deficit [14-16]. 
The extent to which LBM is lost in male Warfighters during strenuous, multi-stressor 
operations may, in part, be attributable to reductions in testosterone concentrations. 
Energy deficit inhibits endogenous testosterone synthesis by suppressing the 
hypothalamic-pituitary-gonadal (HPG) axis [3]. Reductions in testosterone are 
accompanied by muscle atrophy and decreased muscle strength [5]. The use of 
exogenous testosterone to maintain eugonadal concentrations during severe energy 
deficit may attenuate reductions in LBM and preserve muscle function. In 2015, Dr. 
Pasiakos of USARIEM and Dr. Rood of PBRC conducted the OPS I study, a 
multidisciplinary, multi-institutional collaborative project that tested the effects of 
supplementing men exposed to severe energy deficit with testosterone. OPS I was a 
three-phase, randomized, double-blind, placebo-controlled trial in 50 non-obese men 
(mean ± SD, 25 ± 5 y): 14-d run-in, free-living, eucaloric diet phase; 28-d live-in, 55% 
exercise- and diet-induced energy deficit (P2) with (200 mg testosterone enanthate per 
week, TEST) or without (placebo, PLA) exogenous testosterone phase; and 14-d 
recovery, free-living, ad libitum diet phase [6].  
The primary findings from OPS I were that participants receiving weekly intramuscular 
injections of TEST gained LBM and lost less total body mass compared to those 
receiving placebo (Figures 1A-B). The change in total testosterone concentrations 
during the energy deficit was strongly correlated with changes in LBM (r = .76, P < 
.001). TEST fully recovered their body weight and were 2.8 kg heavier at the end of the 
14-d recovery period than PLA, due entirely to LBM. TEST did not differ from PLA with 
respect to lower-body muscular strength and endurance decline, incidence of adverse 
events, or have any negative effect on cardio-metabolic health biomarkers during 
energy deficit or recovery (Pasiakos et al. unpublished).
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 4 of 40
V6.0
8.3.2020
Figure 1. Change in body weight and composition during energy deficit and recovery. 
Least squares mean ± SE change in body weight (A) and composition (B, lean body 
mass, LBM; fat mass, FM) during phase 2 (P2, 55% energy deficit) and phase 3 (P3, 
recovery/weight regain) relative to the final body weight and composition measured 
during phase 1 (eucaloric diet) for TEST (n=24) and PLA (n=26). Data not sharing the 
same letter superscript within a treatment are different; and *indicates a between group 
difference (phase-by-treatment interaction). TEST, 55% energy deficit + 200 mg 
testosterone enanthate per week during P2; PLA, 55% energy deficit + 1 mL sesame 
seed oil placebo per week during P2 (Pasiakos et al. unpublished).
OPS I Lessons Learned & Justification for OPS II
The results from OPS I suggest that testosterone supplementation may be an effective 
and safe pharmacological BPE strategy to mitigate LBM losses experienced by 
Warfighters during sustained, multi-stressor training and combat operations. However, 
certain experimental limitations in OPS I currently preclude a definitive recommendation 
to adopt supplemental testosterone therapy as a Warfighter BPE strategy. The 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 5 of 40
V6.0
8.3.2020
testosterone dose, formulation, and administration schedule employed in OPS I is 
logistically impractical, and a more militarily feasible intervention is needed. The inability 
to induce a hypogonadal state and LBM loss in the participants receiving weekly 
placebo injections suggests the magnitude of stress imposed by the exercise- and diet-
induced energy deficit in OPS I was far less than the stress Warfighters can endure 
during real-world training and combat operations, so our approach needs to be tested 
under more realistic conditions. Most importantly, the use of muscle performance 
measures that were insufficiently sensitive to demonstrate militarily relevant benefits of 
supplemental testosterone on muscle function, despite gains in LBM in OPS I, requires 
further investigation to conclusively demonstrate whether our proposed intervention can 
improve Warfighter performance. These limitations are clear gaps in knowledge that 
must be addressed before supplemental testosterone recommendations for Warfighters 
can be further considered. 
Testosterone Formulations, Pharmacokinetics & Logistical Considerations 
Testosterone is available in several 
therapeutic formulations with unique 
pharmacokinetic profiles, 
advantages, and disadvantages 
(Table 1; adapted from [17]). In OPS 
I, we administered 200 mg of 
testosterone enanthate per week by 
intramuscular (IM) injection. One 200 
mg injection of testosterone 
enanthate can elicit a 
supraphysiological increase in 
testosterone concentrations that lasts 
~7-d before declining back within the 
normal physiological range (Figure 
2; adapted from [18]). The transient 
hypertestosteronemia and rapid 
decline in testosterone necessitates 
weekly (or biweekly) intramuscular 
injections, which if an injection is 
missed, can result in hypogonadal 
state until the next dose is delivered, 
or until endogenous testosterone production is recovered [17]. In OPS I, total and free 
testosterone concentrations were approximately 4% and 7% higher, respectively, than 
the upper-end of the normal physiological range at the end of the 28-d energy deficit. In 
recovery, concentrations declined to hypogonadal levels, 21-d after receiving the last 
dose of testosterone enanthate. Recovery of endogenous testosterone production was 
variable, ranging from 28-d to 11-mo. We attributed the mild hypertestosteronemia and 
delayed recovery of endogenous testosterone production to the administration of the 
short-acting enanthate ester and administering a greater dosage of testosterone 
enanthate (200 mg/wk) than typically recommended as the initial dose for clinical 
replacement therapy (75-100 mg/wk or 150-200 mg/2-wk [17]). Although there were no 
negative effects of short-term supplemental testosterone enanthate administration at 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 6 of 40
V6.0
8.3.2020
200 mg/wk in OPS I, providing weekly intramuscular injections of a supraphysiological 
dose during real-world training and combat operations is not likely to be practical or 
even feasible.  
Table 1. Clinical pharmacology of testosterone (T) formulations approved in the United 
States and Europe (taken from [17]).  
Formulation 
Typical Starting 
Doses 
Pharmacokinetic 
Profile 
Advantages 
Disadvantages 
T enanthate 
or cypionate 
150–200 mg IM 
every 2 wk or 
75–100 mg/wk 
After a single IM injection, 
serum T concentrations 
rise into the 
supraphysiological range, 
then decline gradually 
into the hypogonadal 
range by the end of the 
dosing interval 
Relatively 
inexpensive, if 
self-administered; 
flexibility of dosing 
Requires IM injection; 
peaks and valleys in serum 
T concentrations that may 
be associated with 
fluctuations in symptoms 
50–100 mg of 
1% transdermal 
gel; 
20.25–81 mg of 
1.62% gel or 40–
70 mg of 2%; 
T transdermal 
gels: 1%, 
1.62%, or 2% 
transdermal gel 
applied to skin; 
check package 
insert for 
application site 
and instructions 
With appropriate dose, 
restores serum T and E2 
concentrations to the 
physiological male range; 
less fluctuation of T 
concentrations than T 
enanthate or cypionate 
Provides flexibility 
of dosing, ease of 
application, good 
skin tolerability; 
less erythrocytosis 
than injectable T 
Potential of transfer to a 
female partner or child by 
direct skin-to-skin contact; T 
concentrations may be 
variable from application to 
application; skin irritation in 
a small proportion of treated 
men; moderately high DHT 
concentrations (of unknown 
significance) 
T Axillary 
Solution 
60 mg of T 
solution applied 
in the axillae 
Restores serum T and E2 
concentrations to the 
physiological male range 
Provides, good 
skin tolerability 
Potential of transfer to a 
female partner or child by 
direct skin-to-skin contact; T 
concentrations may be 
variable from application to 
application; skin irritation in 
a small proportion of treated 
men; moderately high DHT 
concentrations (of unknown 
significance) 
Transdermal 
T patch 
One or two 
patches, 
designed to 
nominally deliver 
2–4 mg of T 
during 24 h 
applied every 
day on 
nonpressure 
areas 
Restores serum T, DHT, 
and E2 concentrations to 
the physiological male 
range 
Ease of 
application 
Serum T concentrations in 
some T-deficient men may 
be in the low-normal range; 
these men may need 
applications of two patches 
daily; skin irritation at the 
application site occurs 
frequently in many patients 
Buccal, 
bioadhesive T 
tablets 
30-mg controlled 
release, 
bioadhesive 
tablets twice 
daily 
Restores serum T, DHT, 
and E2 concentrations to 
the physiological male 
range; absorbed from the 
buccal mucosa 
Convenience and 
discreet 
Gum-related adverse 
events in 16% of treated 
men 
T pellets 
Pellets 
containing 600–
1200 mg T 
implanted SC; 
the number of 
pellets and the 
regimen may 
Serum T peaks at 1 
month and then is 
sustained in normal range 
for 3–6 mo, depending on 
formulation 
Requires 
infrequent 
administration 
Requires surgical incision 
for insertions; pellets may 
extrude spontaneously; 
rarely, local hematoma and 
infection may occur 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 7 of 40
V6.0
8.3.2020
vary with 
formulation 
Injectable 
long-acting T 
undecanoate 
in oil 
United States 
regimen: 750 mg 
IM, followed by 
750 mg at 4 wk, 
and 750 mg 
every 10 wk 
When administered at a 
dose of 750 mg IM, 
serum T concentrations 
are maintained in the 
normal range in most 
treated men 
Requires 
infrequent 
administration 
Requires IM injection of a 
large volume (3 or 4 mL); 
coughing episode reported 
immediately after injection 
in a small number of men 
Nasal T gel 
11 mg two or 
three times daily 
Serum T concentrations 
are maintained in the 
normal range in most 
treated men 
Rapid absorption 
and avoidance of 
first pass 
metabolism 
Multiple daily intranasal 
dosing required; local nasal 
side effects, not appropriate 
for men with nasal 
disorders 
There are several alternatives to testosterone enanthate, many of which do not require 
IM injections, including transdermal gels, patches, buccal, bio-adhesive tablets, and 
nasal gels (Table 1). However, while these formulations are non-invasive, and can be 
administered by the end-user, they require daily or multiple daily applications 
(transdermal and nasal gels), and carry added risks, including skin-to-skin transfer to 
others (transdermal gels) and gum- and nasal-related adverse events (buccal, bio-
adhesive tablets, nasal gels). More importantly, allowing Warfighters to self-medicate 
with a Schedule III controlled substance (i.e., mild to moderate potential for abuse, 
physical and psychological dependence) while operating under extreme physiological 
and psychological stress raises health and ethical concerns. Long-acting testosterone 
formulations that require infrequent administration by licensed clinicians are much more 
viable options. Subcutaneous implantable testosterone pellets are an example of a 
long-acting testosterone formulation that maintains normal physiological testosterone 
concentrations for 3 to 6-mo (2-4 doses per year). However, the implantation requires a 
minor surgical procedure, which increases the risk of adverse events (e.g., infection, 
pellets may extrude from incision), and the overall logistical burden to the patient and 
Department of Defense.
In contrast to the aforementioned approaches, intramuscular injection of testosterone 
undecanoate can maintain testosterone concentrations within the normal physiological 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 8 of 40
V6.0
8.3.2020
range for 8-10-wk (Figure 3; adapted from [19]) with considerably less clinical or 
logistical burden. The clinical testosterone undecanoate dosing regimen requires an 
initial 750 mg IM injection, followed by another 750 mg at wk 4, and 750 mg every 10-
wk thereafter [17]. This dosing regimen may be logistically feasible for Warfighter 
populations (i.e., special operations forces, etc.) who are most vulnerable to muscle loss 
and functional decline while routinely conducting strenuous operations as part of their 
annual training and deployment cycle. Further, following cessation of testosterone 
undecanoate administration, testosterone declines gradually over time, which reduces 
likelihood of becoming hypogonadal between doses, or after ceasing treatment. Based 
on these factors, OPS II will test if testosterone undecanoate (TU, 750 mg 
administered once) safely and steadily maintains normal testosterone 
concentrations, promotes anabolism, spares LBM, and enhances militarily-
relevant measures of muscle function without cognitive impairment during and in 
recovery from a 20-d simulated, multi-stressor military operation.             
Operational Stress, Testosterone Status, and Lean Mass Loss: Beyond Energy Deficit. 
In OPS I, we isolated the consequences of exercise- and diet-induced energy deficit 
from the additional stressors experienced during strenuous military operations. As a 
result, we were able to demonstrate that the overall metabolic stress and its associated 
consequences on testosterone and LBM during military operations is greater than can 
be accounted for by the energy deficit alone. More specifically, we observed a 20% 
reduction in total testosterone in OPS I study controls, which is comparable to declines 
observed in our previous controlled underfeeding study within a similar population [20], 
but much less than the decline in testosterone observed during strenuous military 
operations [4, 7, 8]. We employed an energy deficit (i.e., 55%) that was similar to 
energy deficits observed during real-world military operations, but total daily energy 
expenditure and the absolute energy deficit (~2000 kcal/d) were less than those 
observed in the field [8, 15, 16, 21], suggesting that a greater absolute energy deficit 
may have been necessary to induce the intended decline in total testosterone. In 
addition, we used discrete aerobic-type exercise bouts in OPS I to increase exercise-
induced energy expenditure during the 28-d energy deficit, followed by periods of 
adequate rest. Energy deficits during real-world military operations often result from low-
to-moderate increases in metabolic demand sustained for long periods. During real-
world military operations, recovery is also minimal and Warfighters are often sleep 
deprived. Sleep restriction (5-h per night), alone, can suppress total testosterone by as 
much as 15% [4]. In a study that involved strenuous military training and produced a 
substantial energy deficit, continuous sleep (3-h), compared to non-continuous sleep, 
attenuated reductions in testosterone [22]. We did not restrict sleep in OPS I; therefore, 
the stressors applied (i.e., increased physical activity and decreased energy intake) may 
not have mimicked the multi-faceted stressors experienced during real-world military 
operations, which generally produce marked suppression of testosterone and 
catabolism of lean mass [11, 15, 16]. 
The preservation of LBM in OPS I study controls was also unexpected. We speculated 
that the combination of higher-protein feeding and the physical training stimulus in OPS 
I accounted for this finding. More specifically, energy deficiency suppresses muscle 
anabolism [23, 24], yet consuming a higher-protein diet (1.2-2.4 g protein/kg/d) while 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 9 of 40
V6.0
8.3.2020
underfed restores muscle anabolic rates to those observed during energy balance [24, 
25]. The anabolic restorative effects of higher-protein diets during energy deficit are 
potentiated by training effects of repeated high-volume exercise [26], providing the 
conditions by which lean mass may be maintained [27].The addition of supplemental 
testosterone may have provided an anabolic stimulus that was additive to the stimulus 
provided by protein and exercise, explaining, in part, the gain in lean mass in the 
testosterone group. Studies showing that testosterone or testosterone analogue 
administration enhances protein synthetic efficiency support our speculation, meaning, 
for a given amount of intracellular essential amino acids, a greater proportion is routed 
towards protein synthesis than towards oxidative metabolism, thus conserving muscle 
protein mass [28, 29]. While plausible, Warfighters are unlikely to routinely meet 
operational dietary protein requirements (i.e., 1.5-2.0 g protein/kg/d) [30] while 
subsisting primarily on combat rations because rarely is a full daily allotment of combat 
rations provided [in the US, i.e., equal to three Meal, Ready-to-Eat (MRE), ~120 g of 
total protein (~1.5 g protein/kg/d for an average 80 kg male)] or consumed [31]. Thus, 
the synergistic effects of higher-protein feeding and high-volume exercise on lean mass 
retention likely does not occur during real-world military operations [15, 16]. 
Furthermore, whether testosterone modulates muscle and whole-body anabolic status 
during prolonged, severe energy deficit, regardless of amount of dietary protein 
consumed, has never been studied.   
OPS II will address these limitations and gaps in knowledge by limiting dietary 
protein intake [15% of total energy provided (~0.8 g protein/kg/d based on an 
average 80 kg male and provision of ~two MREs per day)] during a 20-d simulated 
military operation comprised of very high total daily energy expenditures caused 
by sustained elevations in exercise-induced energy expenditure that, when 
combined with sleep deprivation, should cause severe absolute energy deficits, 
marked reductions in testosterone, and catabolism of lean mass. Muscle and 
whole-body anabolic status will also be assessed during OPS II by using stable 
isotope tracer techniques.  
Warfighter Performance Enhancement
Lower-body muscle function declined similarly for both groups during the energy deficit 
in OPS I, despite no loss of LBM in either group. The decline in muscle function may 
have been due to neuromuscular fatigue [32] and reduced motivation over time [33, 34]. 
A similar inability to detect differences in muscle function with testosterone 
supplementation has also been demonstrated in young men receiving exogenous 
testosterone during 28-d of bed rest [35], in middle-aged, obese males receiving 
exogenous testosterone for 56-wk [36], and in older, overweight males receiving 
testosterone supplementation for 6-mo [37]. The discordance between the LBM change 
and muscle functional decline in OPS I for those receiving supplemental testosterone 
may be attributable, in large part, to the test metrics employed, as isokinetic and 
isometric dynamometry may not be sensitive to military-relevant performance 
improvement. OPS II will use a battery of muscle function and performance 
outcomes to test the possible performance enhancing effects of supplemental 
testosterone during strenuous training and combat operations. The test battery 
will include Warfighter occupational tasks commonly performed under stress, 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 10 of 40
V6.0
8.3.2020
including load carriage, as well as reproducible and validated metrics of lower-
body power, anaerobic and aerobic capacity. 
Military Relevance & Anticipated Deliverables 
OPS II supports the Military Operational Medicine Research Program’s Physiological 
Health and Performance Program Area under the BPE Work Unit. The intent of the BPE 
Work Unit is to execute basic and applied research to identify and develop biomedical 
strategies and solutions that safely and ethically enhance Warfighter physical, cognitive, 
sensory and behavioral performance in training and operational environments, enabling 
lethality and overmatch. The threat OPS II addresses is suboptimal performance and 
the capability gap we intend to close pertains to medical readiness, as Army units 
possess limited capacity to provide countermeasures to protect against health threats 
before and during deployment to sustain 90% medical fitness for duty rate for an 
operational environment. OPII will address the BPE near-term objective – to identify one 
effective androgen replacement therapy that enhances Warfighter physical and 
cognitive performance during simulated, multi-stressor military operations. Deliverables 
include evidence-based guidance for supplemental testosterone use for performance 
enhancement in Warfighters. Guidance will be transitioned to the United States Special 
Operations Command (USSOCOM), including the Army, Naval, Marine Corps Forces, 
Air Force, and Joint Special Operations Commands. 
 
Experimental Design and Overview
The study will be a double-blind, randomized, placebo controlled trial in 32 physically-
active men (18-35 y) exposed to 20 complete days (days 8-27) of simulated operational 
stress followed by 20 complete days of recovery (days 29-48, Figure 4). After 
completing baseline testing (Phase 1, P1), participants will be randomized to receive 
either a single intramuscular injection of testosterone undecanoate (TU; 750 mg, 
standard pharmaceutical dose [17]) or an iso-volumetric placebo (PLA, sesame oil 
solution) (day 8). The 20-d simulated operational stress (Phase 2, P2) will be highly 
controlled (live-in study on the inpatient unit at PBRC) and consist of 4 successive 
cycles of undulating stress, starting with 2 consecutive days of low stress followed by 3 
consecutive days of high stress. Low and high stress days will result from low and high 
militarily-relevant exercise-induced energy expenditures, adequate and restricted sleep 
(8 h/d vs. 4/d), and diet restriction to produce energy deficits that range from 
approximately 960 kcal/d to 2975 kcal/d. After completing P2, participants will be 
released from PBRC, resume their habitual physical activity routines, and will be 
provided a controlled diet to consume, to assess physiological, endocrine, and cognitive 
recovery from sustained, severe operational stress (Phase 3, P3). Measures of muscle 
function will be the primary study endpoint. Secondary endpoints include body 
composition, whole-body and skeletal muscle anabolism, endocrine-, metabolic-, and 
safety-related biomarkers, cognitive function, and mood. This study design will allow us 
to test the hypothesis that a practical, single administration of TU elicits physiological 
enhancement during severe operational stress without psychological impairment. 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 11 of 40
V6.0
8.3.2020
Note: Corresponding Train Schedule is attached as Appendix A. 
Primary Study Endpoint
Measures of muscle function will serve as the primary study endpoint. Body mass loss 
and adherence to the prescribed exercise, diet, and restricted sleep intervention will be 
used as a daily measures of compliance and conformance to the experimental design. 
Day 50 will signal the end of study (EOS) for all participants.     
The study may be terminated if a participant withdraws, is unable to comply with the 
prescribed exercise, diet, and restricted sleep intervention, has complications with study 
procedures, particularly TU administration, muscle biopsies, and exercise.  Participants 
are required to complete all study measures at the given time points.  In the event a 
procedure cannot be completed or is refused, participant continuation in the trial will be 
determined by the PI and MI. Noncompliance to the intervention will be addressed on a 
case by case basis.
Recruitment Methods
The PBRC staff has an extensive history of successfully recruiting and conducting large 
funded trials on exercise and dietary restriction interventions. Study recruitment will rely 
on previous methods, which have proven successful at enrolling volunteers who are 
consistent with the demographics of the region. OPS I recruited potential participants 
over a 2 year period to randomize and complete 50 participants. PBRC also has a 
Clinical Trials Recruitment Core with at least 2 full-time staff dedicated solely to 
recruiting for clinical trials. In addition to phone calls, participants can screen via the 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 12 of 40
V6.0
8.3.2020
PBRC website (https://www.pbrc.edu/clinical-trials/) and study-specific web pages are 
designed by the Recruiting Core. Both methods, phone and web, are funneled into a 
computerized participant-tracking system that allows for eligibility checks and real-time 
reporting. Investigators are able to track the recruitment status of their studies in real 
time using the PBRC intranet.
The metro Baton Rouge, LA, area has a population of 411,000. The Clinical Trials 
Recruitment Core completes 5000 phone screens per year from potential volunteers. 
Study recruitment will rely on the existing methods of the Clinical Trials Recruitment 
Core to advertise that were deemed successful in the recruitment of OPS I. Methods 
included but are not limited to local media (print, radio, TV), paid targeted digital 
campaigns, earned media, social media (Facebook, Twitter, etc.), community outreach 
events and presentations, and collaborative relationships with local universities, sport 
vendors, health food vendors, etc. 
Inclusion and Exclusion Criteria
Inclusion Criteria  

Men aged 18-35 years

Ability to understand verbal or written instructions/testing materials in English. 

Physically active (as determined by accelerometry and review of a physical 
activity log)

Not taking any prescription medications and/or willing to refrain from all 
medication use prior to and throughout the entire study period, unless 
provided/approved by the study physician 

Willing to refrain from alcohol, smoking, e-cigarettes or use of any nicotine 
product, caffeine, and dietary supplement use throughout the entire study period.

At the discretion of the study physician, wash-out period for medications, 
supplements, and over the counter medications (OTCs) is ≥ 1-4 weeks

Wash-out period for caffeine and alcohol is ≥ 7 days

Willing to live on the PBRC inpatient unit for 20 consecutive days

Meets age-specific US Army body composition standards according to Army 
Regulation 600-9, which includes estimates of percent body fat based on height, 
weight, and circumference measures (neck and waist)  

Total testosterone concentration is within the normal physiological range (300-
1,000 ng/dL).
Exclusion Criteria 

Musculoskeletal injuries that compromise exercise capability

Diagnosed cardiometabolic disorders (i.e., hypertension, hyperlipidemia, kidney 
disease, diabetes, etc.)

Allergies or intolerance to foods, vegetarian practices, or history of complications 
with lidocaine 

Anabolic steroid, human growth hormone, or nutritional testosterone precursor-
like supplement use within the past 6 months 

Will not refrain from smoking (any nicotine product), alcohol, caffeine, or any 
other dietary supplement during the study 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 13 of 40
V6.0
8.3.2020

Adults unable to consent

Women

Prisoners 

Sedentary or engages in insufficient quantities of physical activity per week 
(aerobic and/or resistance training as determined by accelerometry and review of 
a physical activity log)

Exceeds age-specific US Army body composition standards according to Army 
Regulation 600-9

Previous history of kidney stones unless otherwise approved by the medical 
investigator

Systolic blood pressure > 150 or diastolic blood pressure > 95 mmHg

Previous history of breast or prostate cancer

Previous history of Chronic Obstructive Pulmonary Disease or Obstructive Sleep 
Apnea

Prostate-Specific Antigen (PSA) > 3ng/ml, Hematocrit > 50%, or positive urine 
drug screening

Based on the investigative team’s clinical judgment, a subject may not be 
appropriate for participation in the study.
Enrolling individuals based on US Army body composition standards (Appendix B) will 
ensure a population representative of the US military is studied.
Number of Subjects
Muscle function (lower-body muscular strength and power) is the primary study 
endpoint. The intended total energy deficit during the 20-d period of simulated 
operational stress [high total daily energy expenditures caused by low-to-moderate 
intensity physical work for extended periods of time (~≥10 h/d), restricted food intake 
and sleep] in the present study will be ~43,380 kcal (~2,169 kcal/d) which, based on our 
meta-regression of data generated from military field studies, should cause a ~9% 
reduction in total body mass and ~7% decline in lower-body muscle function (Murphy 
Sport Med). The magnitude of energy deficit and anticipated body mass loss exceeds 
the energy deficit and ~7% reduction in body mass that occurred during the first four 
weeks of US Army Ranger training that concomitantly lowered total testosterone 
concentrations by ~50% (pre-Ranger training, ~433 ng/mL; week four of Ranger 
training, ~202 ng/dL). We anticipate a similar decline in total testosterone and, based on 
the results from OPS I (Pasiakos et al. unpublished), expect body mass loss in TU to be 
~50% less than PLA, such that lower-body muscular strength and power declines from 
baseline are attenuated by 50% in TU relative to PLA. The sample size necessary to 
determine the estimated differences between treatments is 15 per group (Table 2). To 
account for possible attrition (5% attrition in OPS I prior to randomization), 16 
participants will be assigned to each group (32 total participants). To successfully enroll 
and complete testing on 32 participants, we request the ability to enroll up to 38 to 
randomize and complete 32. Enrollment will stop once 32 participants have completed 
the study.  
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 14 of 40
V6.0
8.3.2020
Table 2. Power Analysis and Sample Size Justification
Hypothesized Effect  (mean ± SD)
Percent Δ lower-body strength and power following the 20-d intervention, %
PLA
9.0 ± 6.75
TEST
4.5 ± 3.38
Effect Size
1.25
Alpha
0.05
Power
0.90
Sample Size
15 per group
5% study attrition
32 participants total
Study Timeline
Individuals who respond to recruitment materials and indicate interest in study 
participation will be provided with study-specific information. If still interested, potential 
participants will be asked a series of demographic and health-related questions to 
assess eligibility via phone/web-based methods (approximately 15 min). Individuals who 
meet the initial inclusion/exclusion criteria via self-reported responses will be invited to 
attend the first of two screening visits at PBRC.  Details of each study visit are 
described below.  See Train Schedule in Appendix A. 
Screening Visit 1. SV1

The study consent form will be reviewed with the participant to ensure all questions 
and concerns are clarified before the participant signs the consent form and before 
any procedures are conducted. Those who are still interested in participating will 
be asked to sign the consent form.  

Height, weight, blood pressure, and pulse will be measured. Participants who do 
not meet the height/weight criteria will have eligibility assessed by neck and waist 
circumference measurements to estimate percent body fat according to Army 
Regulation 600-9 (Appendix B). 

A medical history, Physical Activity Readiness Questionnaire (PAR-Q) will be 
administered and CVD risk stratification assessed.

Information regarding the participant’s current medications will be recorded.

A study dietitian will meet with the participant to discuss current eating habits and 
dietary requirements for each phase of the study.

Eligibility criteria will be reviewed. All participants who maintain eligibility criteria will 
be provided an accelerometer to wear. The accelerometer will be worn daily and 
only removed during water-required activities. Additionally, a physical activity log 
will be completed.  An appointment will be scheduled approximately 1 week later 
for Screening Visit 2.
Screening Visit 2. SV2

The participant’s accelerometer & physical activity log will be reviewed for 
completeness and to determine activity levels.  

The participant will have an EKG and a complete physical exam where medical 
history will be reviewed by physician, NP, or PA.

Weight, blood pressure, and pulse will be measured.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 15 of 40
V6.0
8.3.2020

Fasting blood will be drawn for CBC, Chem 26, PSA, testosterone, and study 
archives.

Urine will be collected for a urinalysis and urine drug screening.

A barriers interview will be conducted (Appendix C).

A Three Factor Eating Questionnaire (TFEQ), or equivalent measure, will be 
administered to exclude restrained eaters.

Information regarding any changes in medications or any adverse events will be 
recorded.

Resting metabolic rate will be measured. 

The participant will be asked to wear the weighted pack and go on a practice ruck 
march.

Eligibility criteria will be reviewed. All participants who maintain eligibility criteria will 
continue to wear an accelerometer, record their physical activity, and will complete 
a 3-day food record (2 weekdays, 1 weekend day) one week prior to the start of 
phase 1.  An appointment will be scheduled for Day 1 within 45 days of SV2.    

If more than 45 days lapse between screening measures and D1 scheduled date, 
participants may be asked to repeat measures to re-assess eligibility.
Phase 1: Out-Patient Baseline Testing. Days 1–7

During the P1, participants will return to PBRC once a day to eat and receive 
additional meals for the day. Participants will be weighed daily and energy 
adjustments made if needed. Participants will be asked to record their food and 
activity daily throughout P1. Additionally, participants will wear a wrist and waist-
worn accelerometer throughout P1. Time commitment for P1 is ~1-5-h per day.   

Blood sample by venipuncture will occur on day 1.

Practice on the cognitive tests will be performed on days 2, 4, and 6 for 
approximately 1.5-2-h. The timing (day of testing or time of day) of training 
sessions is not critical.

Sleep will be monitored daily using a wrist-worn monitor and by completion of the 
Modified Pittsburg Sleep Quality Index (PSQI) each day. 

Body composition (dual energy X-ray absorptiometry, DXA; bioelectrical 
impedance, BIA; circumference measurements) will be measured on day 7.

To measure total body water, a urine sample will be collected prior to having the 
consuming deuterium water on day 7. A 4 hour post urine sample will be collected 
after dosing. 

Skeletal muscle protein balance will be measured on day 7 (PRE on Figure 4), 
including 2, bolus intravenous injections of stable isotopes (2H5-phenylalanine, 1-
13C-phenylalanine), 2 percutaneous muscle biopsies of the vastus lateralis, and 10 
intravenous blood draws.

Whole-body protein balance will be measured on day 7 (PRE) using an oral dose 
of 15N-alanine and 24-h urine sample. Participants will have a blood draw to 
measure BUN and to complete the 24 hour urine sample on day 8.

Muscle function and performance will be assessed on day 4 and 5, including the 
vertical jump test, deadlift, Wingate, treadmill VO2peak, and time trial. 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 16 of 40
V6.0
8.3.2020
Familiarization will occur on day 1. *May be administered on alternative visit days 
(+/- 2 days) as scheduling and availability permits.
Randomization
Immediately following P1 testing on day 7, participants will be randomized to receive 
either a single IM injection of testosterone undecanoate (TU; 750 mg, standard 
pharmaceutical dose [17]) or an iso-volumetric placebo (PLA, sesame oil solution) on 
the morning of day 8 after checking into the in-patient unit at PBRC and before initiating 
the 20-d of simulated operational stress. A randomization scheme will be determined 
using a block design (n=32) and age stratification (< 29 years or ≥ 29 years). 
Randomization will be done by a biostatistician with no direct study affiliation. Prior to 
the start of the study, the randomization schedule will be given to the pharmacist. The 
PBRC clinical research pharmacist will have no direct contact with participants. 
Treatment administration will be performed by a physician assistant, nurse practitioner, 
or nurse who will not be aware of treatment assignments. Participants and all study 
personnel will be blinded to treatment group. The code will be kept as a locked 
electronic file on a secure server by the pharmacist until study completion or there is a 
need to break the code for safety of the participant.    
Phase 2: Simulated Operational Stress. Days 8-28

During the simulated operational stress phase, participants will live on the in-
patient unit at PRBC in a 24-h per day controlled setting. Once a day, participants 
will have their vitals (BP, pulse) measured. All meals (~2 rations per day) will be 
eaten on the unit and monitored. Participants will be weighed daily and wear a 
wrist-worn accelerometer throughout P2. Since participants will reside on the in-
patient unit during P2, the time commitment for this phase is 24-h per day.  

An IM injection (placebo or testosterone) will be administered on day 8, after a 
blood sample is collected. 

Throughout phase 2, participants will be highly physically active, completing 
supervised exercise sessions to elicit low (days 8, 9, 13, 14, 18, 19, 23, and 24) 
and high stress (days 10, 11, 12, 15, 16, 17, 20, 21, 22, 25, 26, and 27) energy 
expenditure and deficit prescriptions. 

Participants will be allowed 8-h of sleep on low (approx. 2200-0600-h; days 8, 9, 
13, 14, 18, 19, 23, and 24) and 4-h of sleep on high stress (approx. 0100-0500-h; 
days 10, 11, 12, 15, 16, 17, 20, 21, 22, 25, 26, and 27) days. Sleep outside these 
defined periods will not be allowed. Sleep will be monitored daily using wrist-worn 
monitors.  

Blood sample by venipuncture will occur on days 8, 9, 10, 12, 14, 16, 18, 20, 22, 
24, and 26.

Cognitive testing will be performed on days 12, 14, 17, 22, and 27 over a 1.5-2-h 
period each day.

Sleep will be monitored daily using a wrist-worn monitor and by completion of the 
Modified Pittsburg Sleep Quality Index (PSQI) each day. 

Muscle soreness will be measured each day using a Visual Analog Scale (VAS).

Body composition (DXA, BIA, and circumferences) will be measured on day 28.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 17 of 40
V6.0
8.3.2020

To measure total body water, a urine sample will be collected prior to having the 
consuming deuterium water on day 28. A 4 hour post urine sample will be collected 
after dosing. 

Skeletal muscle protein balance will be measured on day 28 (POST on Figure 4), 
including 2, bolus intravenous injections of stable isotopes (2H5-phenylalanine, 1-
13C-phenylalanine), 2 percutaneous muscle biopsies of the vastus lateralis, and 10 
intravenous blood draws. 

Whole-body protein balance will be measured on day 28 (POST) using an oral 
dose of 15N-alanine and 24-h urine sample. Participants will have a blood draw to 
measure BUN and to complete the 24 hour urine sample on day 29.

Muscle function and performance will be assessed on day 25 and 26, including the 
vertical jump test, deadlift, Wingate, treadmill VO2peak, and time trial. 
Familiarization will occur on day 23. *May be administered on alternative visit days 
(+/- 2 days) as scheduling and availability permits 
Phase 3: Recovery. Days 29-50

For days 29-50 (i.e., day 50 constitutes the EOS; participants will be released from 
the in-patient unit after completing all tests on day 28, POST) participants will 
return to PBRC once a day to eat and receive additional meals for the day. 
Participants will be weighed daily and wear a wrist and waist-worn accelerometer 
throughout P3. The energy provided will be the same as that provided during P1. 
Participants will be asked to record their food and activity daily throughout P3. 
Time commitment during P3 is about 1-5-h per day.  

Blood sample by venipuncture will occur on days 29, 32, 38, 44, and 50. 

Cognitive testing will be performed on days 32 and 38 over a 1.5-2-h period each 
day.

Sleep will be monitored daily using a wrist-worn monitor and by completion of the 
Modified Pittsburg Sleep Quality Index (PSQI) each day. 

Body composition (DXA, BIA, and circumferences) will be measured on day 49.

To measure total body water, a urine sample will be collected prior to having the 
consuming deuterium water on day 49. A 4 hour post urine sample will be collected 
after dosing. 

Skeletal muscle protein balance will be measured on day 49 (recovery, REC on 
Figure 4), including 2, bolus intravenous injections of stable isotopes (2H5-
phenylalanine, 1-13C-phenylalanine), 2 percutaneous muscle biopsies of the vastus 
lateralis, and 10 intravenous blood draws. Participants will undergo 6 total muscle 
biopsy procedures during the entire study period (4 on one leg and 2 on the 
opposite leg, 3 total incisions).

Whole-body protein balance will be measured on day 49 (POST) using an oral 
dose of 15N-alanine and 24-h urine sample. 

Muscle function and performance will be assessed on day 46 and 47, including the 
vertical jump test, deadlift, Wingate, treadmill VO2peak, and time trial. 
Familiarization will occur on day 44.  *May be administered on alternative visit days 
(+/- 2 days) as scheduling and availability permits

Participants will return on day 50 to have a blood draw to measure BUN and to 
return the 24 hour urine sample.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 18 of 40
V6.0
8.3.2020
PRN: As Needed Follow-up Visit

After day 50, if the participant’s testosterone concentrations are not within normal 
reference range (300-1000 ng/dL), a blood sample by venipuncture will occur 
every 90 days until levels have returned to within normal reference range.
Note: If timeline deviations are unavoidable (e.g. equipment issues, participant 
illness, unforeseen delays, etc.) schedule alterations, that will not affect study 
outcomes, may be necessary and are at the discretion of study staff. 
Study Parameters & Procedure Descriptions
Total daily energy requirements and P1 and P3 dietary intake
During the screening visits, participants will meet with registered dietitians and complete 
a 3-day food and activity records to determine habitual dietary intake, physical activity 
patterns, and exercise-induced energy expenditure. Pre-study activity levels and 
exercise-induced energy expenditures will be maintained during P1 and P3. Activity will 
be verified during P1 and P3 using accelerometry and activity records. Physical activity 
will be highly controlled and monitored during P2. 
The 3-d records will also be used by registered dietitians to calculate daily energy needs 
for P1 and P3. Resting metabolic rate will be measured by indirect calorimetry using a 
Deltatrac II Metabolic Cart (Sensormedics, Yorba Linda, CA) with a ventilated hood prior 
to the start of P1. During P1 (baseline, pre-operational stress), participants will be 
provided a controlled, weight-maintaining diet designed to match the macronutrient 
distribution of the diet during P2 (15%, 55%, and 30% total energy from protein, 
carbohydrate, and fat, respectively). During P3 (recovery, post-operational stress), 
participants will be provided the same controlled diet provided in P1 to assess weight 
regain and physiological recovery. The macronutrient distribution of these diets is based 
on a combination of observations made during field operations [15, 16, 38, 39], the 
composition of Meal, Ready-to-Eat (MREs, primary food source for P2), and the current 
Military Dietary Reference Intakes (as stated in Army Regulation 40-25). Registered 
dietitians will develop individualized menus consisting of breakfast, lunch, dinner, 
snacks, and energy-containing beverages for P1 and P3. Breakfast meals will be 
consumed at PBRC under supervision and all other meals and energy-containing 
beverages will be provided for consumption offsite. P1 and P3 diet compliance will be 
verified by research staff. 
Note: The micronutrient content of the P1 and P3 will be consistent with current 
recommendations. Micronutrient intake during P2 may be lower than P1 and P3. 
To maintain operational relevance and to explore the impact of sustained, severe 
energy deficit on micronutrient-related markers of nutritional status, intake will 
not be augmented with supplementation. 
20-d Simulated Operational Stress
The 20-d simulated operational stress will be highly controlled (live-in study on the 
inpatient unit at PBRC) and consist of 4 successive cycles of undulating stress, starting 
with 2 consecutive days of low stress followed by 3 consecutive days of high stress 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 19 of 40
V6.0
8.3.2020
(refer to Figure 4). Low and high stress days will result from low and high militarily-
relevant exercise-induced energy expenditures, adequate and restricted sleep (8 h/d vs. 
4/d), and diet restriction (~2 combat rations per day throughout the 20-d intervention) to 
produce energy deficits that range from approximately 960 kcal/d to 2975 kcal/d. This 
level of deficit was selected based on a recent meta-analysis of field studies conducted 
in military environments that identified this level as the upper end of mean energy 
deficits observed during various military training exercises, and will produce a total 
energy deficit over 20-d (~43,380 kcal) that is expected to induce decrements in body 
mass, LBM, testosterone concentrations, and muscle function [13]. 
For physical activity, varied low-, moderate-, and intermittent high-intensity endurance 
and muscle loading-type exercise will be performed to reproduce conditions normally 
observed during strenuous, sustained military operations [1], and increase participants’ 
exercise-induced energy expenditure to approximately 960 kcal/d to 2975 kcal/d above 
their P1 total daily energy expenditure, and to generate an energy expenditure of 
approximately 3600 kcal/d to 5625 kcal/d (based on an estimated mean P1 total daily 
energy expenditure of 2650 kcal/d; exact values will differ based on actual P1 energy 
expenditures). The increase in total daily energy expenditures from physical activity will 
be achieved by performing multiple exercise sessions daily lasting 2-3-h per session, 
using a variety of endurance and muscle loading modalities that mimic movements and 
activities common during field training and combat operations. Steady-state load 
carriage endurance-type exercise will be the primary exercise modality (~30-40% of 
total body mass carried). However, activities will also include walking and hiking without 
a loaded pack, jogging and field-based military activities. These activities will be 
completed both in the laboratory using exercise equipment and in a modified military 
training grounds on the PBRC campus. The military activities will include Army Physical 
Readiness-type training, simulated body evacuations, an obstacle course and others. 
The exercise intensity and exercise modalities will be programmed to limit the risk of 
developing an overuse or acute injury by alternating exercise sessions between low-
intensity weight-bearing modes and moderate- to high-intensity non-weight-bearing 
exercise while still maintaining the prescribed low and high stress-induced deficits. 
The same total energy provided during P1 (and P3) will also be provided during P2. 
However, the primary food source during P2 will be US combat rations, specifically the 
Meal, Ready-to-Eat (MRE, on average participants will receive the equivalent of ~2 
MREs, ~2600 kcal/d). Registered dietitians will develop individualized MRE-based 
menus. The macronutrient distribution of the P2 diets will be consistent with P1 and P3 
(15%, 55%, and 30% total energy from protein, carbohydrate, and fat, respectively).  
Anthropometrics and body composition
Height will be measured using a stadiometer. Semi-nude body weight will be measured 
after an overnight fast and morning void using a calibrated digital scale (GSE Inc. Model 
450, GSE Scale Systems, Novi, MI) during each screening visit and daily throughout 
P1, P2, and P3. Body composition (bone, fat, lean, and body water) and circumferences 
will be measured after an overnight fast and morning void on days 7 (PRE), 28 (POST), 
and 49 (REC) using a 4-compartment model derived from DXA (Hologic DXA, 
Discovery A, Hologic, Marlborough, MA) and BIA (3D Fit3D system, 3D Size Stream 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 20 of 40
V6.0
8.3.2020
system, Impedimed SFB7, InBody S10, Jawon Cozy 930; or similar) [40].  Multi-
compartment methods (2, 3, and 4-compartment) will be used to calculate total body fat, 
FFM, protein and hydration (TBW/FFM, ECW/ICW).
Total body water (TBW) will also be measured by deuterium dilution on days 7 (PRE), 
28 (POST), and 49 (REC). Participants will provide a pre-dose urine sample and will 
then be orally dosed with deuterium water (99.9% D2O) at 0.15 g/kg body weight. The 
water will be given orally and then the dose cup rinsed with 50 mL of unlabeled (tap) 
water. A second urine sample will be collected 4 hours post dose. The enrichment of 
deuterium in the urine at 4 hours will be used to determine TBW.
Muscle Function and Performance
A battery of muscle function and performance tests will be conducted on days 4, 5, 25, 
26, 46, and 47 to assess lower-body strength, power, anaerobic and aerobic capacity 
during P1, P2, and P3 (Table 3). Participants will be familiarized to the test battery on 
days 1, 23, and 44. The order and timing of tests will be standardized (i.e., 
strength/power  anaerobic capacity  aerobic capacity, as listed in Table 3). Ratings 
of perceived exertion (RPE) will be recorded during each battery. The RPE scale will be 
presented on a video monitor and participants will be asked to give a verbal response 
that will be recorded by a research team member (< 30 sec to complete).
Table 3. Muscle Function and Performance Test Battery
Test
Purpose
Vertical Jump Test [41]
Measure lower-body peak power
Deadlift (component of the Army Combat Fitness 
Test)1
Operational test used in the Army to assess upper- 
and lower-body muscular strength, anaerobic and 
cardiorespiratory endurance, and lower-body and 
upper-body explosive power
Wingate Test
Measures anaerobic capacity
Treadmill VO2peak
Measures peak aerobic capacity. Will be used as 
an outcome and as a reference point to determine 
the appropriate exercise workloads for the exercise 
bouts before starting P2
Time Trial2
Militarily-relevant aerobic performance outcome
1OPS II will employ a modified execution of the deadlift from the Army Combat Fitness 
Test. 2Load carriage is an essential aerobic-based Warfighter task and according to 
Army Techniques Publication (ATP) 3-21.18, Soldiers are expected to carry a standard 
fighting load of 68.9 lbs. and move at a rate of 4 km per hour in an ideal situation. As 
such, OPS II will test time to complete a 4 km (2.5 miles) ruck march (i.e., load carriage) 
with participants wearing a 31.3 kg (68.9 lbs.) pack. 
Cognitive Function, Personality, Mood, and Sleep
A battery of cognitive performance tests and questionnaires will be administered to 
assess cognition, personality, and mood during P1, P2, and P3 (Table 4). Sleep will be 
monitored throughout the study. During P2, participants will be allowed 8-h of sleep 
between 2200-0600-h for low stress days, whereas, participants will be allowed only 4-h 
of sleep between 0100-0500-h on high stress days. Sleep outside these defined periods 
will not be permitted during P2.   
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 21 of 40
V6.0
8.3.2020
Table 4. Cognitive Function, Personality, Mood, and Sleep Test Battery
Test
Description
Cognitive tests
Balloon Analogue Risk Task (BART) [43]
Measure of willingness to take risks versus “play it safe” 
using a simulated balloon task. The more expanded the 
balloon gets, the more points are earned.  All points are 
lost if the balloon is over-inflated and pops. There is 
also a risk-learning component to this task.
Scanning Visual Vigilance Task [44]
This test of vigilance is sensitive to a wide variety of 
environmental conditions, nutritional factors, sleep loss, 
and very low doses of hypnotic drugs and stimulants. It 
was designed to simulate various critical military 
activities that require maintenance of vigilance such as 
sentry duty and sonar watch.
Psychomotor Vigilance [45]
Measure of simple visual reaction time which is 
particularly sensitive to the vigilance decrements 
associated with sleep restriction or disruption
Match to Sample [46]
Assesses short-term spatial memory (working memory) 
and pattern recognition skills
N-back Task [47]
Measures working memory and requires on-line 
monitoring, updating, and manipulation of remembered 
information and allows for the parametric assessment of 
different working memory loads.
Provoked Aggression [48]
This task is referred to as the Electrical Stimulation Task 
in the informed consent form.  This task assesses 
participant’s propensity toward retaliatory increases in 
applied pain level.  Two electrodes will be attached to 
the skin and to an electrical stimulator (STMISO, Biopac 
Systems, Inc.). The stimulator applies a brief pulse of 
electrical current to provide an uncomfortable stimulus 
to the participant. The electrodes are placed at two 
standard locations on any limb, following a 
manufacturer protocol, to prevent electrical current from 
traveling to the rest of the body beyond the limb. A gel is 
rubbed onto the skin at the electrode site to enhance 
conductance. In addition, the device conforms to the 
IEC 601-2-10 international regulatory standard that 
prescribes limits on the voltage, pulse energy, and pulse 
width that can safely be applied by the device to human 
subjects.  The levels of stimulation applied to the 
participant are tested by study staff before they are 
applied to any research participant.  During the task, the 
participant engages in a simple game with a digital 
opponent; after each round, the winner is allowed to 
apply a stimulus to the opponent, and is instructed to 
set the intensity of the applied pain to a value of their 
choosing.  The participant is not told that there is no real 
human opponent, and both the outcomes of the trials 
and the intensities of the applied electrical stimulus are 
actually preordained.  The task assesses the degree to 
which a study intervention heightens the propensity 
toward retaliatory aggression against a provoking 
adversary, across varying levels of provocation.
The provoked aggression task involves partial 
participant deception, and the procedure requires 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 22 of 40
V6.0
8.3.2020
incomplete disclosure on the informed consent form.  
The reason to incorporate deception is that the outcome 
of primary interest is the participant’s intent to engage in 
aggressive acts toward a human being that is provoking 
him.  Proxy measures, including self-reported feelings of 
aggression and biomarkers of arousal, are not 
informative enough to accurately depict this intent.  
Because the participant must be given the opportunity 
to engage in actions that appear to be aggressive, we 
have no realistic option besides creating the illusion that 
the participant is engaging in a retaliatory act, when in 
fact no actual discomfort is inflicted on any other human 
being.  Thus, deception is unavoidable to collect the 
required data.
At the end of their involvement in the study, participants 
will not be debriefed about the partial deception present 
in the provoked aggression task.  The key reason for 
non-disclosure is that completing participants who learn 
about the deception will be able to alert new study 
recruits about the deception, thus invalidating any future 
data collected from them.  Because Baton Rouge is not 
a large city, we expect that there will be many 
opportunities for study participants to have social 
interactions outside of PBRC, and therefore there will be 
many opportunities for completing participants to alert 
new recruits to the deception.
*Will only be administered on D6, D27, D32, and D38 of 
cognitive battery (+/- 2 days)
Psychology/Personality
Buss-Perry Aggression Questionnaire [49, 
50] 
29-item questionnaire measuring levels of Physical 
Aggression, Verbal Aggression, Anger, and Hostility and 
has shown utility for examining the impact of 
testosterone on aggressive impulses.
Profile of Mood States [46, 51-54]
65-item inventory of self-reported mood states that is 
sensitive to a wide variety of stressors including 
undernutrition and sleep loss
Evaluation of Risks Scale [55]
Assesses willingness to take risks through participant 
responses to 24 items on a visual analog scale
Modified Pittsburgh Sleep Quality Index 
(PSQI) [56]
Self-rated questionnaire which assesses sleep quality 
and disturbances on a nightly basis for each night of the 
protocol. Generates scores on subjective sleep quality, 
sleep latency, sleep duration, habitual sleep efficiency, 
and sleep disturbances.
Sleep Monitoring/Actigraphy
Assesses spontaneous motor activity, circadian 
rest/activity cycles, and sleep using a watch-sized, 
wrist-worn device
PRE, POST, and REC Muscle and Whole-Body Anabolism
Skeletal muscle and whole-body anabolic status (protein synthesis, protein breakdown, 
and net protein balance) will be measured on days 7 (PRE), 28 (POST), and 49 (REC) 
by using the minimally invasive pulse bolus tracer injection technique [57] and the end-
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 23 of 40
V6.0
8.3.2020
product method [58]. Following an overnight fast (no less than 8-h), intravenous 
catheters will be placed into a forearm vein on each arm, one for blood sampling and 
one for bolus stable isotope administration. A blood sample will be drawn to establish 
background amino acid enrichment before the tracer injections. Immediately thereafter, 
participants will provide a urine sample to establish background isotopic enrichments for 
whole-body measures. At the start of the 60-min tracer study (0 min; Figure 4), a bolus 
injection of 2H5 phenylalanine (35 µmol/kg) will be administered [59]. At the same time, 
participants will consume a single oral dose of 15N alanine (333 µmol/kg) and begin 
collecting their urine for the next 24-h. A bolus injection of 13C6 phenylalanine (35 
µmol/kg) will be administered 30-min after the first bolus was administered.
Venous blood samples will be obtained in 5-min intervals for the first 30-min of the 
tracer study and at 10-min intervals for the remaining 10-min (10 total blood samples 
over 60-min). Muscle biopsies of the vastus lateralis will be obtained at the 10-min and 
60-min point of the tracer study. Muscle biopsies will be snap frozen in liquid nitrogen 
and stored at -80ºC. Blood samples will be centrifuged and serum will be stored at -
80ºC. Muscle, blood, and urine samples will be analyzed for isotope enrichments using 
gas and liquid chromatography mass spectrometry [57]. 
Mixed-muscle fractional synthesis rate (FSR) will be calculated using the formula:
where EB(t) is the enrichment of bound phenylalanine enrichment at time t and EM(t) is 
the enrichment of free phenylalanine at time t [57]. 
Mixed-muscle fractional breakdown rate (FBR) will be calculated using the formula:
where EA(t) and EM(t) are the arterialized and muscle free phenylalanine enrichments at 
time t and QM/TM is the ratio of free to bound phenylalanine in muscle [57].   
Net muscle protein balance (M-NET) will be calculated as the difference between FSR 
and FBR.  
Whole-body nitrogen flux (Q, g N/24 h) will be determined using urinary urea enrichment 
according to Fern et al. [60]. Whole-body protein synthesis (PS) and breakdown (PB) 
will be calculated according to Stein et al. [61]. 
Q = PS + NEX and Q = PB + NIN
PB = Q – NIN and PS = Q - NEX
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 24 of 40
V6.0
8.3.2020
where NEX is urinary urea nitrogen excretion and NIN represents nitrogen intake during 
the 24-h urine collection period. 
Net whole-body protein balance (WB-NET) will be calculated as the difference between 
whole-body PS and PB. 
Note: Muscle biopsies will be collected while the participants are under local 
anesthesia (1% lidocaine) using a 5-mm Bergstrom needle with manual suction 
[62]. Two specimens will be taken on each tracer study day (PRE, POST, and 
REC) from the same incision (3 total incision and 6 total biopsies if all tracer 
studies are completed). Up to 250 mg of muscle tissue (multiple passes may be 
required to obtain adequate sample) will be collected during each biopsy 
procedure.  
A segment of muscle collected at each time point will used to explore the potential 
mechanisms by which testosterone regulates muscle anabolism and the metabolic 
response to the simulated operational stress. In brief, testosterone targets several 
molecular pathways regulating muscle mass [63]. Rodent models providing exogenous 
testosterone or using castration models to diminish endogenous testosterone have 
identified alterations in androgen receptor activation of the Akt-mTORC1 signaling 
pathway [64-66], satellite cell proliferation and differentiation [67-69], SMAD/FOXO 
activation of proteolytic atrogene expression [70], and autophagy [70]. Additionally, 
exogenous testosterone may increase mitochondrial biogenesis and quality by 
upregulating PGC-1α [71], which may indirectly support muscle mass by facilitating 
greater utilization of fatty acids as an energy substrate. OPS II will provide a unique 
opportunity to explore these pathways in healthy individuals exposed to severe 
metabolic stress.  
To assess these pathways we will employ global gene array analysis using Illumina 
next-generation sequencing (Illumina Inc., San Diego, CA, USA). Total RNA will be 
isolated from muscle using the Trizol/ethonal precipitation. Quantity and quality of RNA 
will be assessed using a Nanodrop ND-1000spectrophotometer (Nanodrop, Wilmington, 
DE, USA). 500 ng total RNA will be used to construct sequencing libraries. Samples will 
be amplified using index-tagged primers to facilitate multiplexing. Image analysis and 
base calling will be performed using the Illumina pipeline. Genes will be defined as 
differentially expressed when >±1.5-fold compared with baseline values and a value of 
P < 0.05.
Following RNA-Seq, identified target pathways will be further assessed using Western 
blot. Briefly, muscle will be homogenized in ice-cold buffer (1:10 wt/vol) and centrifuged 
for 15 min at 10,000 × g at 4°C.  Protein concentration of supernatant (lysate) will be 
determined. Muscle lysates will be solubilized in Laemmli buffer, with equal amounts of 
total protein (15 μg) separated by SDS-PAGE using precast Tris·HCl gels (Bio-Rad). 
Proteins will be transferred to polyvinylidene fluoride (PVDF) membranes and exposed 
to commercially available primary antibodies at 4°C overnight. Labeling will be 
performed using secondary antibody (anti-rabbit IgG conjugate with horseradish 
peroxidase; Cell Signaling Technology), and chemiluminescent reagent will be applied 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 25 of 40
V6.0
8.3.2020
(Super Signal, West Pico Kit; Pierce Biotechnology, Rockford, IL, USA). Blots will be 
quantified using a phosphoimager (ChemiDoc XRS; Bio-Rad) and Image Lab software 
(Bio-Rad). To confirm equal protein loading per well a normalizing protein will be 
assessed.
Finally, microRNA regulating identified pathways by RNA-Seq will also be assessed as 
a potential mechanism contributing to testosterone and energy deficit induced 
alterations in muscle mass. Equal amounts of total RNA will be synthesized into cDNA 
for analysis using a TaqMan® microRNA RT kit (Applied Biosystems). Individual probes 
or microarrays will be used to assess changes in microRNA expression. 
Statistics
All analyses will be considered 2-tailed, with α = 0.05 considered statistically significant. 
All primary analyses will be based on the intention-to-treat principle using SAS (SAS 
Institute version 9.4, Cary, NC, USA), unless otherwise noted. Between group 
comparisons for all baseline, pre-study variables and P1, P2, and P3 dietary intake, 
total daily energy expenditure, exercise-induced energy expenditure, total sleep, % and 
absolute energy deficit will be assessed using two sample Student’s t-tests. Primary 
analysis of muscle function and performance, body composition, muscle and whole-
body anabolism, endocrine, metabolic, and safety biomarkers will be performed using a 
mixed effect linear model. Treatment (TU and PLA), phase (P1, P2, and P3), phase-by-
treatment interaction, age, and pre-study values (only for body composition and clinical 
parameters) will be considered fixed effects covariates in the model. The random effect 
will include an unstructured covariance matrix to account for the correlation within-
participants over time. Least squares means from the model will be used to estimate 
interaction effects. Familywise error rate will be adjusted using the Bonferroni correction 
when appropriate.   
Data and Specimen Banking
Study participants will be assigned unique subject identification (ID) numbers. Study 
subject ID numbers will be used on all data collection instruments, to include 
questionnaires, data collection forms, biological specimen tubes, and computer records.  
A master list linking the participants’ names and ID numbers will be kept in a password-
protected computer file with access restricted to the onsite PI (Dr. Rood of PBRC) and 
study navigator (Ms. Harris). Biological samples that are moved off-site (including to 
USARIEM) for analysis will not contain any personally identifiable information and will 
be labeled with only the unique subject ID numbers. Staff at these sites, including the 
USARIEM PI (Dr. Pasiakos) will not have access to the master list at any time.
Data collection forms will be kept under lock and key, or password-protected if 
computerized, and under the control of the onsite PI (Dr. Rood of PBRC) and study 
navigator (Ms. Harris). Only personnel assigned to the research study by Dr. Rood will 
have access to the data.  Hard-copy data records will be stored for a minimum of 5 
years and a maximum of 10 years from the time the study is completed and then 
destroyed.  
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 26 of 40
V6.0
8.3.2020
The PBRC has a fully integrated, campus-wide, automated data management system. 
All data are entered into a Central Database using existing methodology that has been 
fully validated and undergoes continuous quality assurance by the PBRC Research 
Computing Core and NORC. Most data are automatically uploaded from the 
instruments that measure the endpoint. All self-report inventories and questionnaires 
will be completed in REDCap via surveys. Participants will be asked to complete the 
survey via laptop, computer, or tablet. Data will be exported from REDCap for analysis.  
Exercise testing data will be downloaded from the Parvo Medics’ TrueOne® 2400 cart 
directly following each test and reviewed for integrity. All data are backed up daily, and 
the Research Computing Core at the PBRC oversees all data management.
 
Blood, muscle, and urine samples will be stored frozen at PBRC until analysis can be 
completed. Specific muscle, blood, and urine samples will be shipped to the University 
of Arkansas for Medical Sciences (Dr. Ferrando) for isotopic analyses of muscle and 
whole-body anabolism. Specific muscle samples will also be shipped to USARIEM (Dr. 
Pasiakos) for molecular analyses of endocrine-medicated anabolic signaling. Packaging 
and shipping of biological samples will be overseen by the onsite PI (Dr. Rood) or study 
navigator (Ms. Harris), and will be completed in accordance with International Air 
Transport Association regulations to ensure that viable biological samples reach their 
intended destination.  
Any blood, muscle, or urine samples remaining after analysis will be stored indefinitely 
to assess biomarkers associated with the study outcomes, which includes any 
biomarkers of endocrine, metabolic, or safety not currently identified in the protocol.  
Any use of the samples outside of this defined protocol will be submitted as a protocol 
amendment or a new protocol.
Standardization of Procedures and Quality Control
The research team has extensive experience using the procedures and methods 
required to conduct this study. Standard operating procedures in place throughout the 
units at Pennington Biomedical will be utilized for repeatable, valid data collection and 
quality.  
Data Analyses
See detailed Statistics section described above.
Power analysis.
See in Number of Subjects section listed under inclusion and exclusion section for 
detailed statistical power analyses.
Data and Safety Monitoring Board
This study will use a data and safety monitoring board (DSMB) and Safety Officer. The 
DSMB will receive quarterly reports via email. One or more meetings each year may be 
conducted in person or via conference call if deemed appropriate by the DSMB chair. 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 27 of 40
V6.0
8.3.2020
Prior to the start of recruitment, the DSMB will give formal approval of the study protocol 
and informed consent. Detailed descriptions of the DSMB and Safety Officer are 
provided below:  

Size and Composition of DSMB: The DSMB will consist of 4 members both 
internal and external to PBRC.  The planned composition is as follows: 
Biostatistician (1), Exercise Physiologist (1), Clinician (1), and Layperson (1).

Major Responsibilities of DSMB Members:

Sign and abide by a statement of confidentiality 

Disclose any actual or potential conflicts of interest

Oversee safety of participants to include review of adverse events

Review reports of related studies as appropriate

Review major proposed modifications

Monitor recruitment and adherence

Reports:  Following each meeting, the DSMB will provide written documentation 
regarding findings for the study as a whole and any relevant recommendations 
related to continuing, changing, or terminating the study. All DSMB 
recommendations will be submitted to the onsite PI (Dr. Rood), with a copy 
provided to the PBRC Institutional Review Board (IRB). Annually, the DMSB chair 
will provide a written summary report approving that the study can continue. 

Qualifications and Responsibilities of the Safety Officer:  The Safety Officer for this 
trial will be familiar with the adverse event definitions and reporting requirements 
for the study. The Safety Officer will review reports sent by the study navigator as 
they occur and will determine whether there is any corrective action or stopping 
rule violation. The Safety Officer will send written documentation of the decision to 
the onsite PI (Dr. Rood).
Adverse Events
Serious adverse events (SAE) include: 

Death.

A life-threatening event.

Severe illness including worsening of a pre-existing condition, injury or accidents.

An inpatient hospitalization, surgical procedure, or a treatment to prevent a SAE.

A permanent disability or incapacity.

A clinically significant abnormal laboratory or diagnostic test result.

Any other event that, in opinion of the principal investigator or study physician, 
might have resulted in a serious adverse event if medical intervention had not been 
initiated. 
For OPS II purposes, an adverse event or experience is defined as any health-related 
unfavorable or unintended medical occurrence that happens after randomization. 
Examples of Adverse Events include but are not limited to the following:

A clinically significant laboratory or clinical test result at follow up assessments.

An event that results in 3 consecutive missed exercise sessions.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 28 of 40
V6.0
8.3.2020

An event that requires a visit to a physician because it alters participant’s ability to 
exercise.

An event that occurs as a result of a study procedure which is not listed in the 
Risks section of the informed consent.
Adverse events will be reported to the onsite PI (Dr. Rood), project manager (Ms. 
Harris), Chair of the PBRC IRB, Chair of the study DSMB, and Safety Officer throughout 
the trial as necessary. Adverse event data will be collected from Baseline (day 1) until 
the final closeout visit. Adverse Events classified as serious will be reported from the 
date of consent through the final closeout visit. Adverse Event data will be analyzed 
quarterly, but serious or life-threatening adverse events require immediate reporting and 
follow-up. We anticipate most adverse events will be mild and the participant will be 
able to resume intervention activities within a day or two of reporting the event.  
In the event an adverse event that occurs on campus results in a serious or life 
threatening situation, the investigator or other project staff present will begin emergency 
measures, as appropriate, and call 911. 

For minor physical injury, the individual will be encouraged to see a health care 
practitioner of his or her choice.

If the study participant experiences psychological or emotional distress, the project 
staff will cease research activities and attempt to calm and reassure the 
participant.  The participant will be directed to an appropriate health care 
practitioner for further assessment and treatment as needed.

The investigator and/or project staff will record detailed narrative notes describing 
the adverse event they witnessed or that was reported by participant. The Safety 
Officer will complete the form Notification of an Adverse Event. 
Adverse Event reporting will follow the requirements of the PBRC IRB. Serious adverse 
events that are unexpected and related to the study will be reported within 48-h. Other 
adverse events that are not serious but are unexpected and are associated with the 
study procedures will be reported within 10-d.
Safety Measures during Physical Activity
Exercise interventions are conducted on-site and all sessions are conducted and 
supervised by trained PBRC exercise interventionists, who monitor potential adverse 
experiences and symptoms. During the physical activity sessions a defibrillator and on-
site trained staff are available to deal with medical emergencies. Also, institutional and 
community EMS services are activated if needed. Participants will be taught the 
importance and proper method of warming-up prior to and cooling-down following 
structured activity sessions. Heart rate will be monitored throughout the intervention 
sessions. If at any point during a physical activity session, participants develop chest 
pain, shortness of breath, or dizziness, they are instructed to rest and to contact their 
physicians if these symptoms persist or recur with further physical activity.  
Procedures to minimize discomfort include warm-up and cool-down activities that 
include stretching, light walking or cycling. Participants are also supervised and 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 29 of 40
V6.0
8.3.2020
instructed on correct physical activity techniques. 
If for any reason the participant reports an injury, chest pain, shortness of breath, or 
dizziness, they are referred to their doctor, or the study clinician calls the doctor or other 
health care provider. In addition, specific criteria for suspending or stopping physical 
activity are developed to adjust the program for intercurrent illness.
Stopping Rules
There is more than minimal risk for participating in this trial. Nevertheless, in addition to 
monitoring recruitment and compliance to the intervention, we also will monitor the rates 
of injury in our participants. The Safety Officer, in conjunction with the study 
investigators, will alert the IRB and DSMB if a larger than reasonably expected injury 
rate occurs in either of the treatment groups. Other issues that are related to the 
stopping rules include:

New information – It is unlikely that new information will become available during 
this study that would result in discontinuing the trial.

Limits of assumption – It is possible that the value of data analysis will be limited 
by differences between the intervention groups at baseline or because of study 
dropouts or missing data. Baseline differences will be analyzed annually and 
effects on the power to detect differences in the outcome measures will be 
evaluated and discussed with the PIs (Drs. Rood and Pasiakos), Safety Officer, 
and the USARIEM Project Officer. Although an excessive number of dropouts 
could occur, this has not been our past experience, particularly with OPS I. In OPS 
I, only 3 participants withdrew and did so prior to randomization. There were no 
dropouts once the study began – i.e., retention was 100%. However, this study will 
expose participants to greater overall stress and we expect that dropout rates 
could reach 20%. If that occurs, the Safety Officer will initiate a meeting with the 
PIs (Drs. Rood and Pasiakos) to discuss strategies to increase retention. If the 
dropout rate exceeds 50%, the safety officer will meet with the PIs to determine 
whether or not the study should continue.

Limit of rules – We acknowledge that circumstances, other than what are listed, 
may justify stopping the study.
Withdrawal of Subjects
We will attempt to retain program participants once randomized at a retention rate of 
≥80% for study completion through day 50 (REC). It is our desire to analyze results on 
all participants who were included into the program (e.g. completed SV1 visit). In 
accordance with the declaration of Helsinki/Tokyo/Venice/Hong Kong, participants have 
the right to withdraw from the program at any time for any reason. The investigator also 
has the right to withdraw participants from the program treatments in the event of 
intercurrent illness, adverse experience, treatment failure, protocol violation, or other 
reasons. Should a participant decide to withdraw, all efforts will be made to complete 
and report follow-up observations as thoroughly as possible. 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 30 of 40
V6.0
8.3.2020
Risks to Subjects
This study does not involve major risk to screeners and trial participants. Efforts to 
minimize the potential risks of the assessment methods and outcome variables include 
frequent monitoring by the investigators to assure that no participant suffers any 
adverse effects from participating in the study. The study procedures include:

Body weight.  There is no risk to participants who record their body weight. 

Blood Pressure Testing.  Participants may experience temporary discomfort during 
blood pressure recordings due to the pressure of the cuff on their arm.

Venipuncture (blood draw).  There is the possibility of pain and bruising at the vein 
on the participant’s arm where the needle is inserted.  Aseptic (sterile) technique 
and trained personnel minimize these risks.  

Venous catheterization. There is a possibility of pain, bruising, or infection at the 
site of the needle insertion for the IV line. Trained personnel minimize this risk.  

Dual Energy X-ray Absorptiometry (DXA) and Bio-electrical Impedance (BIA).  The 
amount of radiation used for DXA is very small. The radiation dose for this scan is 
equivalent to the radiation an individual is naturally exposed to in the environment 
in less than one day. The completion of 3 scans over the course of OPS II is 500 
times below the limit for radiation exposure per year. The OPS II protocol will follow 
Pennington SOP 1121 related to radiation dose limits. There are no risks 
associated with BIA. 

Archive of Biological (Blood, Muscle, and Urine) Samples. The primary risk to 
participants regarding archiving biological samples for future research is the risk of 
loss of confidentiality and/or privacy. Most banks need to maintain a link between 
the identities of donors and coded specimens to be able to collect valuable clinical 
follow-up information about the donor. To insure participants’ privacy and 
confidentiality, their samples will be labeled with a unique subject ID.  PBRC, 
USARIEM, UAMS, and other study collaborators will store participant samples with 
unique IDs and a minimum number of personal identifiers to meet laboratory 
standards. Storage and disposal of samples will be conducted in a manner 
conforming to the appropriate care and handling of biological specimens as 
outlined through the Institutional Biohazard Committee Guidelines.

Muscle Biopsy. Mild to severe pain, soreness, bruising, and a small scar are 
common risks. A hematoma (collection of blood in the tissue) may occur. There is 
a slight risk that a superficial nerve may be cut; the nerve may heal, or it may result 
in a permanent loss of sensation in the skin at the biopsy site.

24-h Urine Collection. There are no known risks of collecting urine into a container.

Testosterone. Potential side effects of testosterone treatment include acne, 
oiliness of skin, increased growth of body hair, breast tenderness, a reversible 
increase in hemoglobin, sleep apnea, pain at the injection site, leg edema, weight 
gain, aggressiveness, oil embolism, and emotional lability. Emotional lability is 
when an individual experiences rapid or exaggerated changes in mood.  

EKG. There are minimal risks associated with this test. There is a small possibility 
there may be some redness or irritation while cleaning the skin prior to applying the 
electrodes or if a participant happens to be allergic to the adhesive.   

Exercise testing. There is minimal risk of injury or a cardiovascular event during 
exercise testing. We believe the risk of an event during exercise testing is 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 31 of 40
V6.0
8.3.2020
minimized with a pretest review of the medical history, physical examination by a 
physician, use of a highly trained staff, and well-defined emergency 
procedures. Participants may experience temporary discomfort during blood 
pressure recordings due to the pressure of the blood pressure cuff on the arm.  All 
tests are conducted in the presence of an exercise physiologist with extensive 
experience in conducting maximal exercise tests as well as a Research Associate 
specializing in cardiology.  All laboratory staff are trained in basic CPR and/or 
ACLS (advanced cardiac life support). In the event of a life threatening emergency, 
the subject would be treated with ACLS by a staff M.D. and research nurses and 
subsequently be transported to the nearest acute care medical-surgical facility via 
Emergency Medical Services which is a parish wide paramedic response unit. The 
closest facility is approximately 0.25 miles away. 

Exercise interventions. The proposed exercise interventions are unlikely to cause 
major problems. We have conducted numerous exercise training studies and have 
never had a serious adverse event. There is the possibility of adverse events 
ranging from minor musculoskeletal problems to, in very rare cases, cardiovascular 
events. Exercise bouts will include a variety of modes (walking, cycling, elliptical, 
running, and pack walking) and intensities (low to high) at the discretion of the 
trainer to ensure compliance to the intervention as well as minimizing injury.  
Occasionally study participants experience minor orthopedic problems, but most 
are self-correcting with rest and standard first aid. Exercise supervisors are trained 
in first aid and basic CPR. Each staff member is trained in either advanced or basic 
life support, and an automated external defibrillator and fully-stocked crash cart are 
kept on site. Although some study participants will be at moderately elevated risk 
for CVD, they will receive a thorough health screen including a physical 
examination by a study physician and a maximal exercise test. According to the 
available data on adverse events resulting from the types of exercise proposed 
here, risk should be low in this study. Fatal events during exercise are extremely 
rare. 

Energy Deficit. There is a small risk of hypoglycemia when starting a diet lower in 
energy than participants are accustomed to and increasing energy expenditure via 
exercise. Regular blood work and monitoring (including vitals) will be completed 
throughout the phases for safety checks. Prior to inclusion in the trial, all 
participants are screened to exclude those with medical or mental disorders that 
are unsuitable for the trial.  Additionally, a barriers interview will be completed 
during screening to further explain study demands, assess barriers to participation, 
and screen for psychological and behavioral contraindications to the trial. The 
clinical site physician will review the medical procedures and psychological health 
of each participant and attest to suitability for inclusion to into the trial. Once 
enrolled in the trial, study staff with psychological and behavioral expertise will 
make daily rounds on the unit to assess mental stability and health of the 
participants. Any participant displaying undue distress or other negative 
psychological symptoms as a result of the trial procedures, the onsite PI (Dr. Rood) 
and MI (Dr. Greenway) will assess if continuation in the trial is warranted. An on-
call physician is also available after hours and on weekends.  
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 32 of 40
V6.0
8.3.2020

Stable isotope tracer studies. The amino acid isotope administered intravenously 
and orally are stable, and thus are not radioactive. The isotopes used in this study 
are considered safe. 

Accelerometry. There are no risks associated with measuring activity and sleep 
with accelerometers. Accelerometers fit comfortably on the participant’s arm and at 
the waist and can be easily removed should they become unconformable. 

Sleep deprivation. The possible risks of sleep deprivation include fatigue, irritability, 
bad mood, and slowing of mental performance. 

Electrical Stimulation. The purpose of the electrical stimulator is to provide an 
aversive stimulus to the participant. The experience of pain caused by the 
stimulation could be mentally distressing. We will minimize this risk by carefully 
explaining the electrical stimulus to the participant. To insure that the level of 
discomfort experienced during the test is not excessive, we will expose the 
participant to incrementally increasing levels of electrical stimulation to identify the 
level of stimulation required to induce moderate but not extreme discomfort. Similar 
electrical stimulation procedures are commonly used in the human research 
literature with no reports of injury. [72-75] Some subjects may experience irritation 
of the skin from the conductance gel used in the sensors. This clears up quickly 
once the sensors and the gel are removed.

Muscle function and performance testing. The possible risks of the muscle function 
and performance testing include soreness, joint injuries, muscle strains, blisters, 
lower-back and shoulder pain. Risks will be mitigated by allowing familiarization 
and ensuring proper technique with constant verbal feedback by trained exercise 
physiologists. 

Total Body Water: The extra neutron in the water is not radioactive and has no 
risk. 
Potential Benefits to Subjects
No direct benefits to the participants are expected. 
Vulnerable Populations
This research does not include vulnerable populations. 
Sharing of Results with Participants
Participants will be provided a summary results sheet at the completion of their 
participation in the study. The summary results will include body composition and 
muscle function/performance tests, and available lab work results. 
Resource Availability and Setting
Clinical Facility, Equipment and Personnel
A detailed description of the clinical research facilities at PBRC can be found in the 
PBRC Clinical Resources Facility description that is maintained by the clinic 
administrator of the CTU. This document is updated and approved annually. 
Exercise Facility & Campus
Pennington Biomedical is a 234 acre campus that is dedicated to research and 
education in nutrition and preventive medicine. The PBRC site has a 2,300 square foot 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 33 of 40
V6.0
8.3.2020
Exercise Training Facility, which is under the management of the Interventional 
Resources Department. Melissa Harris is the Director of this core. The exercise facility 
includes a pool, tennis court, and lighted jogging path around a 17 acre lake.  
Additionally, the campus has a 5 acre plot on the south side where a modified military 
training grounds will be established. The exercise facility offers state-of the-art 
equipment, professional intervention technicians, and optional training data capturing 
capabilities. The aerobic training room contains treadmills, stationary bikes, and 
elliptical machines. The resistance training room contains free weights and 15 different 
resistance-training machines to work a variety of muscle groups and movements.  
Multiple televisions hang from the ceilings in each room and a variety of magazines are 
available for use by the participants. Locker rooms are equipped with lockers, showers, 
and towels. Calibrated scales are available to measure body weight and work stations 
with computers are available that provide a private area to meet with participants. A 
dedicated parking lot with handicap parking is located immediately outside of the facility. 
The exercise facility is supported by a trained staff composed of full-time technicians, 
exercise interventionists, post-doctoral researchers and internship students working on 
exercise-related degrees. Each is trained in exercise interventions, basic life support 
and an automated external defibrillator and may have ACSM or ACE personal trainer 
certifications. Exercise related supplies and equipment will be provided by the study. 
These include but are not limited to: water bottles, towels, first aid and injury prevention 
supplies, musculoskeletal support supplies, rain gear, tennis shoes, and other exercise 
supplies and equipment to implement the military activities of the intervention protocol.
Prior Approvals
Before initiation of the study protocol, radiation safety will be assessed. The research 
proposed herein is funded by the US Army Medical Research and Materiel Command 
and, therefore, will require approval from the US Army Human Protections research 
Office (HRPO) subsequent to the PBRC IRB approval. However, the study will not 
require a full IRB review by the US Army (see the signed Institutional Agreement for 
Intuitional Review Board Review (IAIR)). 
Compensation
We will provide $7,500 per individual as an incentive for participation in the study. We 
think this amount is appropriate given the amount of time and procedure burden that the 
participants will spend both during the free living phase and live-in study phases. 
Participants will receive $500 after the completion of screening and P1. They will also 
receive $5000 for completion of P2. If the participant does not complete the entire P2 
live-in phase, the compensation will be prorated based on the number of days 
completed. Lastly, participants will receive remaining $2000 for completion of P3. Total 
compensation will be up to $7500. 
Provisions to Protect the Privacy Interests of Subjects
All participants are assured of their confidentiality both verbally and in the informed 
consent form. The clinical facilities are strictly limited to the staff of the research 
institution and to research participants. This is accomplished by a variety of stringent 
security measures. All medical records are stored in locked areas. Access to these 
areas is limited to the clinical support staff, director of the clinical facilities, and the 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 34 of 40
V6.0
8.3.2020
onsite PI (Dr. Rood). Participants’ medical records are filed according to ID numbers.  
All forms on the chart display the ID number. Electronic data storage is similarly 
restricted with only the onsite PI (Dr. Rood) and authorized persons having access to 
databases containing confidential clinical records, i.e. those containing name or other 
identifying information. 
Data, including body weight, body composition, exercise testing, etc. will be collected 
from participants. Data are confidentially collected from study participants and are only 
used for research purposes. All records are kept in locked file cabinets, and participant 
data can be identified only by number. Data are used only in aggregate, and no 
identifying characteristics of individuals are published or presented.
Volunteer Registry Database
It is the policy of the US Army Medical Research and Development Command that data 
sheets (60-R forms) are to be completed on all enrolled volunteers participating in 
research for entry into this Command’s Volunteer Registry Database. The information 
entered into this confidential database includes your name, address, Social Security 
Number, study name, and dates. The intent of the database is two-fold: first, to readily 
answer questions concerning an individual’s participation on research sponsored or 
funded by the USAMRDC; and secondly, to ensure that the USAMRDC can exercise its 
obligation to ensure research volunteers are adequately warned (duty to warn) of risks 
and to provide new information as it becomes available. The information with the stored 
at the USAMRCC for a minimum of 75 years. 
60-R Form Completion: Enrolled participants will complete Part A and Part B during 
Phase 1 of participation. Part C will be completed at the end of study participation. 
Completed forms will be submitted to USAMRDC by study staff.
Compensation for Research-Related Injury
In the unlikely event a participant becomes injured as a result of participation in this 
study, medical care is available. It is the policy of this institution to provide neither 
financial compensation nor free medical treatment for research-related injury. By 
participating in this study, participants are not waiving any rights they have against 
PBRC/USARIEM for injury resulting from negligence of PBRC/USARIEM or its 
investigators.
Economic Burden to Participants
Participants in this study will not incur any personal costs. 
Consent Process
Refer to Study Timeline for description of the informed consent process. 
Drugs or Devices
Study drug will be stored, dispensed and handled through the clinical trials unit 
pharmacy and pharmacist according to all pharmacy SOPs and the study protocol. 
Compliance and dispensing records will be kept in the pharmacy and individual charts. 
Nursing staff on the inpatient unit will administer the study drug per protocol. 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 35 of 40
V6.0
8.3.2020
Roles and Responsibilities
Onsite Principal Investigator (PBRC)
The PBRC, onsite Principal Investigator (PI) will assist in all aspects of the study 
including scheduling, briefing potential volunteers, being responsible for record keeping, 
quality assurance issues, maintenance of confidentiality, and notification to the DSMB in 
the event of an adverse event. Procedures will be performed only by privileged 
personnel or by personnel who are under direct supervision of the privileged personnel.   
Jennifer C. Rood, Ph.D.:  Dr. Rood will be the PBRC onsite PI of record and assume 
responsibility for the safe and scientifically sound conduct of the study. She will oversee 
all aspects of the study, assist with data collection, ensure safety and ethical treatment 
of participants, maintain required documentation for the study, obtain required 
approvals, and share (with Dr. Pasiakos) primary responsibility for data analysis and 
assist with data interpretation and publication. Dr. Rood will maintain institutional 
coordination between USARIEM, PBRC, and UAMS investigators and the PBRC IRB 
and US Army Medical Research and Materiel Command HRPO.  
Offsite Principal Investigator (USARIEM)
Stefan M. Pasiakos, Ph.D.:  Dr. Pasiakos will be the USARIEM offsite PI of record and 
share responsibility for the safe and scientifically sound conduct of the study. He will 
oversee all aspects of the study, assist with data collection, ensure safety and ethical 
treatment of participants, maintain required documentation for the study, obtain required 
approvals, and share (with Dr. Rood) primary responsibility for data analysis and assist 
with data interpretation and publication. Dr. Pasiakos will maintain institutional 
coordination between USARIEM, PBRC, and UAMS investigators and the PBRC IRB 
and US Army Medical Research and Materiel Command HRPO.  
Sub-Investigators
Drs. Varanoske and Margolis (USARIEM), and Dr. Ferrando (UAMS) will be engaged in 
this research trial. They will assist Drs. Rood and Pasiakos with protocol concept 
development, execution, data collection (i.e., Varanoske, Margolis, and Ferrando: tracer 
studies, muscle function and performance assessments, operational stress 
intervention), analysis, interpretation, and publication.  
Consultant
Dr. Lieberman (USARIEM) will consult on the cognitive testing concept development, 
execution, and data collection.
Appendices
A. Train schedule
B. AR 600-9 (Army Body Composition Program)
C. Semi-structured Barriers interview
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 36 of 40
V6.0
8.3.2020
References
1.
Henning, P.C., B.S. Park, and J.S. Kim, Physiological decrements during sustained 
military operational stress. Mil Med, 2011. 176(9): p. 991-7.
2.
Carbone, J.W., J.P. McClung, and S.M. Pasiakos, Recent Advances in the 
Characterization of Skeletal Muscle and Whole-Body Protein Responses to Dietary 
Protein and Exercise during Negative Energy Balance. Adv Nutr, 2018.
3.
Trumble, B.C., et al., Responsiveness of the reproductive axis to a single missed evening 
meal in young adult males. Am J Hum Biol, 2010. 22(6): p. 775-81.
4.
Leproult, R. and E. Van Cauter, Effect of 1 week of sleep restriction on testosterone levels 
in young healthy men. JAMA, 2011. 305(21): p. 2173-4.
5.
Finkelstein, J.S., E.W. Yu, and S.A. Burnett-Bowie, Gonadal steroids and body 
composition, strength, and sexual function in men. N Engl J Med, 2013. 369(25): p. 2457.
6.
Pasiakos, S.M., et al., Physiological and psychological effects of testosterone during 
severe energy deficit and recovery: A study protocol for a randomized, placebo-
controlled trial for Optimizing Performance for Soldiers (OPS). Contemp Clin Trials, 
2017. 58: p. 47-57.
7.
Gomez-Merino, D., et al., Effects of combined stress during intense training on cellular 
immunity, hormones and respiratory infections. Neuroimmunomodulation, 2005. 12(3): 
p. 164-72.
8.
Friedl, K.E., et al., Endocrine markers of semistarvation in healthy lean men in a 
multistressor environment. J Appl Physiol (1985), 2000. 88(5): p. 1820-30.
9.
Raynor, H.A. and C.M. Champagne, Position of the Academy of Nutrition and Dietetics: 
Interventions for the Treatment of Overweight and Obesity in Adults. J Acad Nutr Diet, 
2016. 116(1): p. 129-47.
10.
Tassone, E.C. and B.A. Baker, Body weight and body composition changes during 
military training and deployment involving the use of combat rations: a systematic 
literature review. Br J Nutr, 2017. 117(6): p. 897-910.
11.
Nindl, B.C., et al., Physiological consequences of U.S. Army Ranger training. Med Sci 
Sports Exerc, 2007. 39(8): p. 1380-7.
12.
Nindl, B.C., et al., Physical performance and metabolic recovery among lean, healthy 
men following a prolonged energy deficit. Int J Sports Med, 1997. 18(5): p. 317-24.
13.
Murphy, N.E., et al., Threshold of energy deficit and lower-body performance declines in 
military personnel: a meta-regression. Sports Med, 2018.
14.
Berryman, C.E., et al., Severe negative energy balance during 21 d at high altitude 
decreases fat-free mass regardless of dietary protein intake: a randomized controlled 
trial. FASEB J, 2018. 32(2): p. 894-905.
15.
Margolis, L.M., et al., Effects of Supplemental Energy on Protein Balance during 4-d 
Arctic Military Training. Med Sci Sports Exerc, 2016. 48(8): p. 1604-12.
16.
Margolis, L.M., et al., Effects of winter military training on energy balance, whole-body 
protein balance, muscle damage, soreness, and physical performance. Appl Physiol Nutr 
Metab, 2014. 39(12): p. 1395-401.
17.
Bhasin, S., et al., Testosterone Therapy in Men With Hypogonadism: An Endocrine 
Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2018.
18.
Schurmeyer, T. and E. Nieschlag, Comparative pharmacokinetics of testosterone 
enanthate and testosterone cyclohexanecarboxylate as assessed by serum and salivary 
testosterone levels in normal men. Int J Androl, 1984. 7(3): p. 181-7.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 37 of 40
V6.0
8.3.2020
19.
Zhang, G.Y., et al., A pharmacokinetic study of injectable testosterone undecanoate in 
hypogonadal men. J Androl, 1998. 19(6): p. 761-8.
20.
Henning, P.C., et al., High protein diets do not attenuate decrements in testosterone and 
IGF-I during energy deficit. Metabolism, 2014. 63(5): p. 628-32.
21.
Henning, P.C., et al., Recovery of endocrine and inflammatory mediators following an 
extended energy deficit. J Clin Endocrinol Metab, 2014. 99(3): p. 956-64.
22.
Opstad, P.K. and A. Aakvaag, The effect of sleep deprivation on the plasma levels of 
hormones during prolonged physical strain and calorie deficiency. Eur J Appl Physiol 
Occup Physiol, 1983. 51(1): p. 97-107.
23.
Pasiakos, S.M., et al., Acute energy deprivation affects skeletal muscle protein synthesis 
and associated intracellular signaling proteins in physically active adults. J Nutr, 2010. 
140(4): p. 745-51.
24.
Areta, J.L., et al., Reduced resting skeletal muscle protein synthesis is rescued by 
resistance exercise and protein ingestion following short-term energy deficit. Am J 
Physiol Endocrinol Metab, 2014. 306(8): p. E989-97.
25.
Pasiakos, S.M., et al., Effects of high-protein diets on fat-free mass and muscle protein 
synthesis following weight loss: a randomized controlled trial. FASEB J, 2013. 27(9): p. 
3837-47.
26.
Hector, A.J., et al., Pronounced energy restriction with elevated protein intake results in 
no change in proteolysis and reductions in skeletal muscle protein synthesis that are 
mitigated by resistance exercise. FASEB J, 2018. 32(1): p. 265-275.
27.
Longland, T.M., et al., Higher compared with lower dietary protein during an energy 
deficit combined with intense exercise promotes greater lean mass gain and fat mass 
loss: a randomized trial. Am J Clin Nutr, 2016. 103(3): p. 738-46.
28.
Ferrando, A.A., et al., Testosterone injection stimulates net protein synthesis but not 
tissue amino acid transport. Am J Physiol, 1998. 275(5 Pt 1): p. E864-71.
29.
Sheffield-Moore, M., et al., Short-term oxandrolone administration stimulates net muscle 
protein synthesis in young men. J Clin Endocrinol Metab, 1999. 84(8): p. 2705-11.
30.
Pasiakos, S.M., et al., Efficacy and safety of protein supplements for U.S. Armed Forces 
personnel: consensus statement. J Nutr, 2013. 143(11): p. 1811S-1814S.
31.
Pasiakos, S.M. and L.M. Margolis, Negative energy balance and loss of body mass and 
fat-free mass in military personnel subsisting on combat rations during training and 
combat operations: a comment on Tassone and Baker. Br J Nutr, 2017. 117(6): p. 894-
896.
32.
Millet, G.Y. and R. Lepers, Alterations of neuromuscular function after prolonged 
running, cycling and skiing exercises. Sports Med, 2004. 34(2): p. 105-16.
33.
Irwin, B.C., et al., Aerobic exercise is promoted when individual performance affects the 
group: a test of the Kohler motivation gain effect. Ann Behav Med, 2012. 44(2): p. 151-9.
34.
Carter, J.M., A.E. Jeukendrup, and D.A. Jones, The effect of carbohydrate mouth rinse on 
1-h cycle time trial performance. Med Sci Sports Exerc, 2004. 36(12): p. 2107-11.
35.
Zachwieja, J.J., et al., Testosterone administration preserves protein balance but not 
muscle strength during 28 days of bed rest. J Clin Endocrinol Metab, 1999. 84(1): p. 207-
12.
36.
Ng Tang Fui, M., et al., Effects of testosterone treatment on body fat and lean mass in 
obese men on a hypocaloric diet: a randomised controlled trial. BMC Med, 2016. 14(1): 
p. 153.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 38 of 40
V6.0
8.3.2020
37.
Emmelot-Vonk, M.H., et al., Effect of testosterone supplementation on functional 
mobility, cognition, and other parameters in older men: a randomized controlled trial. 
JAMA, 2008. 299(1): p. 39-52.
38.
Sepowitz, J.J., N.J. Armstrong, and S.M. Pasiakos, Energy Balance and Diet Quality 
During the US Marine Corps Forces Special Operations Command Individual Training 
Course. J Spec Oper Med, 2017. 17(4): p. 109-113.
39.
Margolis, L.M., et al., Energy requirements of US Army Special Operation Forces during 
military training. Nutrients, 2014. 6(5): p. 1945-55.
40.
Ng, B.K., et al., Validation of rapid 4-component body composition assessment with the 
use of dual-energy X-ray absorptiometry and bioelectrical impedance analysis. Am J 
Clin Nutr, 2018. 108(4): p. 708-715.
41.
Leard, J.S., et al., Validity of two alternative systems for measuring vertical jump height. 
J Strength Cond Res, 2007. 21(4): p. 1296-9.
42.
Zagatto, A.M., W.R. Beck, and C.A. Gobatto, Validity of the running anaerobic sprint 
test for assessing anaerobic power and predicting short-distance performances. J 
Strength Cond Res, 2009. 23(6): p. 1820-7.
43.
Lejuez, C.W., et al., Evaluation of a behavioral measure of risk taking: the Balloon 
Analogue Risk Task (BART). J Exp Psychol Appl, 2002. 8(2): p. 75-84.
44.
Fine, B.J., et al., Effects of caffeine or diphenhydramine on visual vigilance. 
Psychopharmacology (Berl), 1994. 114(2): p. 233-8.
45.
Dinges, D.P., J., Microcomputer analyses of performance on a portable, simple visual RT 
task during sustained operations. Behavior Research Methods, Instruments, & 
Computers, 1985. 17(6): p. 652-655.
46.
Lieberman, H.R., et al., Effects of caffeine, sleep loss, and stress on cognitive 
performance and mood during U.S. Navy SEAL training. Sea-Air-Land. 
Psychopharmacology (Berl), 2002. 164(3): p. 250-61.
47.
Kirchner, W.K., Age differences in short-term retention of rapidly changing information. 
J Exp Psychol, 1958. 55(4): p. 352-8.
48.
Lotze, M., et al., Evidence for a different role of the ventral and dorsal medial prefrontal 
cortex for social reactive aggression: An interactive fMRI study. Neuroimage, 2007. 
34(1): p. 470-8.
49.
Buss, A.H. and M. Perry, The aggression questionnaire. J Pers Soc Psychol, 1992. 63(3): 
p. 452-9.
50.
O'Connor, D.B., J. Archer, and F.C. Wu, Effects of testosterone on mood, aggression, 
and sexual behavior in young men: a double-blind, placebo-controlled, cross-over study. 
J Clin Endocrinol Metab, 2004. 89(6): p. 2837-45.
51.
McNair, D.M.L., M.; D.L.F, Profile of Mood States Manual. San Diego, CA: Educational 
and Industrial Testing Service., 1971.
52.
Lieberman, H.R., et al., Severe decrements in cognition function and mood induced by 
sleep loss, heat, dehydration, and undernutrition during simulated combat. Biol 
Psychiatry, 2005. 57(4): p. 422-9.
53.
Banderet, L.E. and H.R. Lieberman, Treatment with tyrosine, a neurotransmitter 
precursor, reduces environmental stress in humans. Brain Res Bull, 1989. 22(4): p. 759-
62.
54.
Shukitt-Hale, B., E.W. Askew, and H.R. Lieberman, Effects of 30 days of undernutrition 
on reaction time, moods, and symptoms. Physiol Behav, 1997. 62(4): p. 783-9.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 39 of 40
V6.0
8.3.2020
55.
Killgore, W.D., et al., Assessing risk propensity in American soldiers: preliminary 
reliability and validity of the Evaluation of Risks (EVAR) scale--English version. Mil 
Med, 2006. 171(3): p. 233-9.
56.
Buysse, D.J., et al., The Pittsburgh Sleep Quality Index: a new instrument for psychiatric 
practice and research. Psychiatry Res, 1989. 28(2): p. 193-213.
57.
Zhang, X.J., D.L. Chinkes, and R.R. Wolfe, Measurement of muscle protein fractional 
synthesis and breakdown rates from a pulse tracer injection. Am J Physiol Endocrinol 
Metab, 2002. 283(4): p. E753-64.
58.
Waterlow, J.C., M.H. Golden, and P.J. Garlick, Protein turnover in man measured with 
15N: comparison of end products and dose regimes. Am J Physiol, 1978. 235(2): p. 
E165-74.
59.
Symons, T.B., et al., Artificial gravity maintains skeletal muscle protein synthesis during 
21 days of simulated microgravity. J Appl Physiol (1985), 2009. 107(1): p. 34-8.
60.
Fern, E.B., P.J. Garlick, and J.C. Waterlow, Apparent compartmentation of body nitrogen 
in one human subject: its consequences in measuring the rate of whole-body protein 
synthesis with 15N. Clin Sci (Lond), 1985. 68(3): p. 271-82.
61.
Stein, T.P., et al., Effect of reduced dietary intake on energy expenditure, protein 
turnover, and glucose cycling in man. Metabolism, 1991. 40(5): p. 478-83.
62.
Evans, W.J., S.D. Phinney, and V.R. Young, Suction applied to a muscle biopsy 
maximizes sample size. Med Sci Sports Exerc, 1982. 14(1): p. 101-2.
63.
Rossetti, M.L., J.L. Steiner, and B.S. Gordon, Androgen-mediated regulation of skeletal 
muscle protein balance. Mol Cell Endocrinol, 2017. 447: p. 35-44.
64.
White, J.P., et al., Testosterone regulation of Akt/mTORC1/FoxO3a signaling in skeletal 
muscle. Mol Cell Endocrinol, 2013. 365(2): p. 174-86.
65.
Basualto-Alarcon, C., et al., Testosterone signals through mTOR and androgen receptor 
to induce muscle hypertrophy. Med Sci Sports Exerc, 2013. 45(9): p. 1712-20.
66.
Zeng, F., H. Zhao, and J. Liao, Androgen interacts with exercise through the mTOR 
pathway to induce skeletal muscle hypertrophy. Biol Sport, 2017. 34(4): p. 313-321.
67.
Kovacheva, E.L., et al., Testosterone supplementation reverses sarcopenia in aging 
through regulation of myostatin, c-Jun NH2-terminal kinase, Notch, and Akt signaling 
pathways. Endocrinology, 2010. 151(2): p. 628-38.
68.
White, J.P., et al., Effect of nandrolone decanoate administration on recovery from 
bupivacaine-induced muscle injury. J Appl Physiol (1985), 2009. 107(5): p. 1420-30.
69.
Serra, C., et al., Testosterone improves the regeneration of old and young mouse skeletal 
muscle. J Gerontol A Biol Sci Med Sci, 2013. 68(1): p. 17-26.
70.
Serra, C., et al., The effects of testosterone deprivation and supplementation on 
proteasomal and autophagy activity in the skeletal muscle of the male mouse: differential 
effects on high-androgen responder and low-androgen responder muscle groups. 
Endocrinology, 2013. 154(12): p. 4594-606.
71.
Guo, W., et al., Testosterone plus low-intensity physical training in late life improves 
functional performance, skeletal muscle mitochondrial biogenesis, and mitochondrial 
quality control in male mice. PLoS One, 2012. 7(12): p. e51180.
72. 
Ji-Eun Kim, Tae-Ho Lee, June-Seek Choi, Chai-Youn Kim (2010), Changes in bistable 
perception induced by fear conditioning. Journal of Vision, 10(7): 337
73. 
Tae-Ho Lee, Seung-Lark Lim, Kanghee Lee, Hyun-Taek Kim & June-Seek Choi (2009), 
Conditioning-induced attentional bias for face stimuli measured with the emotional 
Stroop task. Emotion, 9(1), 134-139. 
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020

Page 40 of 40
V6.0
8.3.2020
74. 
Tae-Ho Lee, Seung-Lark Lim, Kyu-Yong Lee & June-Seek Choi (2009), Facilitation of 
visual processing by masked presentation of a conditioned facial stimulus. Neuroreport, 
20(8), 750-754
75. 
Tae-Ho Lee & Kyungyong Yang (2008), Modulation of visual sensitivity to detect 
emotional face by fear conditioning procedure, Journal of Korea Military Academy, 1(1), 
234-244.
Pennington Biomedical IRB FWA 00006218
Approved August 24, 2020