# Ketogenic Diet Plus Resistance Training Applied to Physio-Pathological Conditions: A Brief Review
## 5 Ketogenic Diet Plus Resistance Training  
It is well established that increasing dietary protein intake alongside an exercise intervention, especially resistance training, attenuates the body mass loss-induced reduction in muscle mass. Participants adhering to a KD consumed significantly higher amounts of dietary protein than those adhering to a non-KD. Nevertheless, the KD produces an unpleasant impact on muscle mass, which is lost in resistance-trained individuals, as is evidenced in a recent meta-analysis [81]. It also evidenced significant fluctuations of thyroid-stimulating hormone (TSH) reported during the VLCKD, as we demonstrated with our research group after only three days of it [82]. On the other hand, recently, [PERSON] et al. (28) conducted a study on altitude performance, showing that despite the absence of carbohydrates, the ICKD led to an improvement in cardiorespiratory fitness (VO2 max). Carbohydrate restriction leads to decreases in blood glucose, and it is possible that increased gluconeogenic activity could promote muscle mass loss to provide an amino acidic substrate to replenish the glucose and dietary protein intake's small contribution to gluconeogenesis [83]. It is worth mentioning that a given resistance training workload (stimulus) requires special nutritional needs (e.g., energy, protein, creatine monohydrate) and recovery time (e.g., sleep quality, rest days, tapering). Following the 4 Rs framework proposed by [PERSON] et al., nutritional strategies to optimize post-exercise recovery encompass rehydration, refueling, repairing, and rest--pre-sleep nutrition [84]. If these are fulfilled by means of nutritional adherence and compliance, exercise-targeted adaptations might be achieved. Although it is suggested that the KD could lead to a more efficient utilization of energy substrates during exercise (enhancing oxidative metabolism), the impact of cardiac or muscle status for health and disease is not well understood [85]. Currently, the scientific community of exercise and sports agrees that carbohydrates (5-8 g/kg/day) are crucial for achieving improvements in muscle strength and hypertrophy [86]. Indeed, recent studies by several authors have demonstrated that the net effect of the KD on strength and/or hypertrophy is likely to be diminished in most cases [87, 88, 89, 81]. For most individuals engaged in moderate-to-high volume resistance training, emphasizing moderate-to-high intensity exercise performance, or primarily aiming to increase lean mass, KDs may not be the most optimal choice [90]. A recent systematic review with a Bayesian meta-analysis by [PERSON] et al. concluded that while the KD can be a useful strategy for total and body fat losses, a small negative effect on fat-free mass has been observed among the analyzed clinical trials; thus, the KD might not be suitable for enhancing 1-RM strength or high-intensity cyclic performances in trained individuals [91]. This suggests that those persons looking to maximize resistance training adaptations should consider a more balanced or traditional macronutrient distribution that allows for adequate carbohydrate intake, especially if they are unfamiliar with, do not enjoy, or do not adhere to the KD. In this regard, our research group recently demonstrated that resistance-trained individuals following a KD may experience performance declines and higher perceived effort in the early weeks as they adapt to reduced carbohydrate consumption. However, the KD did not influence resistance exercise performance in terms of the volume load, number of repetitions, or velocity loss at the end of the intervention [92]. Similarly, [PERSON] et al. (2019) reported improvements in body composition with no significant changes in strength performance after high adherence to the KD in US military personnel [93]. Some studies have also shown that the KD might not impair body composition or performance in CrossTrainers who meet the energy requirements, protein intake, and adhere to the KD [94, 95].