International Journal of

Environmental Research
and Public Health

Review
Efficacy of Nutritional Strategies on the Improvement of the
Performance and Health of the Athlete: A Systematic Review
J. Javier Perez-Montilla 1 , Maria Cuevas-Cervera 1 , Ana Gonzalez-Muñoz 2, *, Maria Carmen Garcia-Rios 3
and Santiago Navarro-Ledesma 1, *

1 Department of Physiotherapy, Faculty of Health Sciences, Campus of Melilla, University of Granada,

Querol Street, 5, 52004 Melilla, Spain; perezmontilla@correo.ugr.es (J.J.P.-M.);
maaricuevass@correo.ugr.es (M.C.-C.)
2 Clínica Ana González, Avenida Hernan Nuñez de Toledo 6, 29018 Malaga, Spain
3 Department of Physiotherapy, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain;
mcgrios@ugr.es
* Correspondence: anagonzalez.fisioterapeuta@gmail.com (A.G.-M.); snl@ugr.es (S.N.-L.)

Abstract: Evidence shows that the use of food strategies can impact health, but a clear consensus
about how the effects of different food strategies impact improvement in the athlete’s performance and
health remain unclear. This study evaluated how food strategies, specifically intermittent fasting and
a ketogenic diet affect health and performance in healthy athletes. Study selection for this review was
based on clinical trial studies analyzing changes in performance and health in athletes. The Pubmed,
Web of Science, PEDro, Dialnet, Scopus, CINAHL, ProQuest, Medline and Cochrane databases
were searched. The Physiotherapy Evidence Database (PEDro) scale, PEDro Internal Validity Scale



(IVS) and Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a


variety of fields (QUALSYT) checklists were used to evaluate the risk of bias of the included studies.
Citation: Perez-Montilla, J.J.;
Articles were selected based on criteria concerning the effectiveness of nutritional strategies on
Cuevas-Cervera, M.;
Gonzalez-Muñoz, A.; Garcia-Rios,
athletes’ performance; articles should be randomized clinical trials (RCTs) or uncontrolled clinical
M.C.; Navarro-Ledesma, S. Efficacy trials; they should be human studies and they should have been published less than 7 years ago.
of Nutritional Strategies on the A total of 15 articles were evaluated, 8 randomised clinical trials and 7 non-randomized clinical
Improvement of the Performance and studies, with 411 participants who satisfied our inclusion criteria and were included in this review.
Health of the Athlete: A Systematic The results of the study showed intermittent fasting and time-restricted feeding as strategies that
Review. Int. J. Environ. Res. Public produce health benefits. On the other hand, the ketogenic diet did not reach an appropriate consensus.
Health 2022, 19, 4240. https:// The articles presented a medium level of methodological quality in the PEDro scale, low quality in
doi.org/10.3390/ijerph19074240 IVS scale and high quality in QUALSYT scale. Despite the lack of studies analyzing changes in the
Academic Editor: Dagrun Engeset performance and health of athletes after the use of different nutritional strategies, intermittent fasting
and time-restricted feeding should be considered since they seem to be effective, and further studies
Received: 16 February 2022
are necessary.
Accepted: 31 March 2022
Published: 1 April 2022
Keywords: intermittent fasting; sport; caloric restriction; fasting; ketogenic diet; time-restricted feeding
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations. 1. Introduction
Lifestyle factors such as nutrition, poor sleep, smoking, stress, unhealthy diet, and
obesity/overweight have been shown to have an impact on health and chronic condi-
Copyright: © 2022 by the authors.
tions [1]. Among such factors, nutrition is considered to be one of the most important, with
Licensee MDPI, Basel, Switzerland. current research being steered towards the study of the effect of diet on pain and systemic
This article is an open access article inflammation biomarkers [2].
distributed under the terms and Nutrition influences health depending on the type of diet and the amount of daily
conditions of the Creative Commons intake. The quality as well as the quantity of food that is ingested has an impact on the
Attribution (CC BY) license (https:// metabolic and molecular health of the organism [3,4]. To achieve an improvement and
creativecommons.org/licenses/by/ have an influence on health, different nutritional strategies such as caloric restriction (CR),
4.0/). intermittent fasting (IF) and ketogenic diet (KD) are used. An increasing body of evidence

Int. J. Environ. Res. Public Health 2022, 19, 4240. https://doi.org/10.3390/ijerph19074240 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 4240 2 of 23

from basic research points to the existence of beneficial effects of intermittent and periodic
fasting in chronic conditions [5,6].
In the sports field, all these aforementioned nutritional strategies are an important
subject within sports and nutrition sciences, since their ability to increase performance
benefits in athletes remains controversial. It is known that nutritional requirements for
athletes are high, even in the most optimized subjects; total body glycogen stores (500 g,
yielding approximately 2000 kcal of energy if completely oxidized) would be insufficient to
supply the necessary energy for endurance events such as an Iron Man triathlon, which is
estimated to require almost 9000 kcal of energy to complete. In contrast, even very lean
athletes store massive amounts of energy (63,000 kcal or more) in adipose tissues [6]. To
achieve enough muscle and liver glycogen stores, a high CHO diet has been traditionally
promoted for athletes in order to maximize their performance, as well as their ability to
keep their efficacy [7]. However, low-carbohydrate diets offer a ‘metabolic advantage’
by increasing total energy expenditure. When comparing different methods, substantial
increases in average daily energy expenditure have been found during low-carbohydrate
diets when compared with high-carbohydrate diets, as measured by the doubly labelled
water method, although such results appear to be inconsistent [8], and are opposite to
the recommendations from international organizations such as the International Olympic
Committee, the Academy of Nutrition and Dietetics, the American College of Sports
Medicine, and Dieticians of Canada, which indicate that athletes with high training loads
should consume a high-carbohydrate diet [9].
It is also of great importance to point out differences in the effects of nutritional
strategies, such as IT, CR and KT, in aerobic or anaerobic exercises. The mild systemic
acidity caused by KD might predispose the muscle to more rapidly develop more severe
acidosis during high-intensity anaerobic exercise, thereby inhibiting muscle contractile
function and impairing performance. In this scenario, it would be expected that high-
intensity, short-duration exercise performance would be lower when athletes use KD as
compared to high-carbohydrate diets. On the other hand, KD mayincrease performance in
endurance sports [10].
In this regard, the body of research is increasing, but more studies are needed to
increase the knowledge to answer questions such as the specific nutritional requirements
for athletes when using different strategies, when it is best to use each strategy, and whether
those strategies are safe for athletes or not. In all cases, it is currently recommended that
athletes should undertake an audit of their event and their personal experiences to balance
the risk of impaired performance in their activity [10].
The caloric restriction has been shown to greatly reduce the segregation of hormonal
and metabolic factors involved in biological deterioration due to aging [11]. Another
factor reduced through caloric intake is low-grade inflammation, which is characterized
by appearing during increases in the concentration of inflammatory markers without the
need of other symptoms. This type of inflammation is associated with poor physical
activity, being overweight, tobacco use and poor eating habits. Other benefits of decreased
caloric intake have been shown, such as an increase in life expectancy, delayed onset of
aging-related diseases, avoiding or preventing age-related brain deficits, increasing visual
cortex plasticity, and improving cognitive function [12–16].One of the diets based on caloric
restriction is intermittent fasting, which is a dietary regimen consisting of periods in which
caloric intake is reduced and others in which a normal diet is followed [13]. The objective
of this regimen is to induce a reduction in net energy intake that makes it fall below energy
expenditure, thus creating a negative energy balance state that induces weight loss, among
other results [17]. This practice has emerged as an effective therapeutic strategy to improve
multiple cardiometabolic endpoints, ranging from reducing weight or body fat, improving
insulin sensitivity, reducing glucose and insulin levels, lowering blood pressure, improving
lipid profiles, and reducing biomarkers of inflammation and oxidative stress [17–19].Within
the sports field, the IF approach seems compatible with a more favorable metabolic profile,
and this likely contributes to positive variations in body composition (maintenance of fat-
Int. J. Environ. Res. Public Health 2022, 19, 4240 3 of 23

free mass and reductions in fat mass) and exercise performance. Furthermore, IF seems to
improve insulin resistance, which is a key factor in using an appropriate metabolic energy
distribution. However, there is a lack of studies analyzing the effects of different IF protocols
on specific parameters of physical performance [20]. Although fasting is tolerable and
safe, it is possible that adverse effects may appear, such as headache, feelings of dizziness
and moments of hunger, but maintaining good hydration helps to reduce these effects.
Furthermore, extendingfasting for too long, beyond 48 h, leads to numerous harmful side
effects on health, such as excessive weight loss, anemia, diarrhea, malnutrition, eating
disorders, organic damage and impoverishment of the effect of the immune system [21].
The ketogenic diet is characterized by maintaining a carbohydrate intake below
50grams a day or by being no more than 10% of total energy ingested. Previously, this diet
was related to the treatment of epilepsy and as a method of losing weight, and is still used,
presenting good results [22,23]. Now it has reappeared with a role closer to the sport field
due to the interest generated by aerobic athletes in obtaining a vast energy source. Carbo-
hydrates are mainly stored as glycogen in an organism, which make up about 1680kcal. On
the other hand, the energy stored as fat is considered almost unlimited because a pound of
fat can contain up to 3500kcal, which extends the endurance of the athletes. However, the
beneficial effects of the ketogenic diet on athletic performance remain inconclusive [24–26].
Furthermore, although the time course for all changes in body function with KD requires
systematic research, maximal changes to muscle fat metabolism occur within 3–4 weeks,
and probably 5–10 days of adaptation [10].
The current literature is limited when showing the use of nutritional strategies in the
improvement of athletes’ performance, which is usually focused on isolated nutritional
strategies. The different and current strategies that are used as key factors in improving the
quality of life and performance of athletes, as well as the point up to which the improve-
ments occur and the specific exercise is used, remain unclear. Thus, these gaps need to be
addressed as this information is of great importance. This systematic review serves as the
basis for future research on the effects of using these dietary strategies in the sports field, in
both health and performance optimization, as well as in the prevention of potential injuries.
The main objective of this study is to analyze the scientific evidence on the effectiveness
of different nutritional strategies in improving the performance of athletes and their health,
and additionally to assess the methodological quality of the selected clinical trials.

2. Materials and Methods

2.1. Study Design
The present study is a systematic review of the literature of both randomized and non-
randomized clinical trials, and was conducted in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [27].

2.2. Search Strategy

A search for randomized clinical trials according to PRISMA’s methodological criteria
for systematic reviews and meta-analyses was carried out [28]. Uncontrolled trials were
also added to the search.
Our research question was based on the following elements, following the description of
the components of the PECO strategy. (Participants: healthy adult athletes aged between 18
and 65 years; exposure: improvement in the quality of life and optimization of sports perfor-
mance after application of resistance and strength training; comparator: application or not of
alternative nutritional strategies; outcome: effectiveness of nutritional strategies in the health
of the athlete and, therefore, in their sports performance; study design: systematic review.)
Two independent investigators (JJPM and MCC) searched the following electronic
databases from inception to September 2021 using optimized search strategies: Pubmed,
Web of Science, PEDro, Dialnet, Scopus, CINAHL, ProQuest, Medline and Cochrane.
A sensitive search strategy using relevant search terms that were developed from Med-
ical Subject Headings (MeSH) and Descriptors in Health Sciences dictionaries (DeCS) was
Int. J. Environ. Res. Public Health 2022, 19, 4240 4 of 23

used. These terms MeSH and DeCS were: “Caloric Restriction” [Mesh], “Sport”, “Fasting”
[Mesh], “Strength Training”, “Physical Activity”, “High Intensity Training”, “Resistance
Training” [Mesh], “Resistance Exercise”, “Aerobic Exercise”, “Dietary Intervention”, “Di-
etary Intake” and “Healthy”.
The Boolean operators used were: AND/OR.
The search strategy used in ProQuest and CINAHL was: (“strength training” OR
“resistance training” OR “resistance exercise” OR “aerobic exercise” OR “physical activity”
OR “sport”) AND (“fasting” OR “caloric restriction”) AND (“healthy”).
Limits and filters applied in ProQuest were: articles, published in the last 5 years,
human subjects, age of participants between 19 and 64 years old and language in English
or Spanish.
Limits and filters applied in CINAHL were: published in the last 5 years, human sub-
jects, age of participants between 19 and 64 years old and language in English or Spanish.
The search strategy used in Scopus, Medline and Cochrane was: ((“strength training”)
OR (“resistance training”) OR (“resistance exercise”) OR (“aerobic exercise”) OR (“physical
activity”) OR (sport)) AND ((fasting) OR (“caloric restriction”) OR (“ketogenic diet”))
AND (healthy).
Limits and filters applied in Scopus were: articles, published in the last 5 years and
language in English or Spanish.
Limits and filters applied in Medline were: published in the last 5 years, age of
participants between 19 and 64 years old and language in English or Spanish.
Limits and filters applied in Cochrane were: clinical trials, published in the last 5 years
and language in English or Spanish.
The search strategies used in Pubmed, Web of Science, PEDro and Dialnet were:
Pubmed: “caloric restriction” [Mesh] AND “sports” [Mesh], “fasting” [Mesh] AND
“sport” [Mesh], “fasting” [Mesh] OR “caloric restriction” [Mesh] AND sport” [Mesh].
Web of Science: (“fasting” AND sport), (“intermittent fasting” AND sport), (“caloric
restriction” AND sport), ((“fasting” OR “caloric restriction”) AND sport).
PEDro: “fasting” AND “sport”.
Dialnet: “intermittent fasting” AND “sport”, “caloric restriction” AND “sport”, “fast-
ing AND sport”.
Limits and filters applied in PubMed were: clinical trial, published in the last 7 years,
human subjects, age of participants between 19 and 64 years old and language in English
or Spanish.
Limits and filters applied in Web of Science were: clinical trials, published in the last
7 years, human subjects and language in English or Spanish.
Limits and filters applied in PEDro were: clinical trials and published in the last
7 years.
Limits and filters applied in Dialnet were: articles, published in the last 7 years and
language in English or Spanish.

2.3. Elegibility Criteria

The PECOS framework, as aforementioned, was followed to determine which studies
were included in the present systematic review. Each study had to meet the following inclu-
sion criteria: (i) studies that test the effectiveness of fasting on athletes’ performance; (ii) ar-
ticles should be randomized clinical trials (RCTs) or uncontrolled clinical trials; (iii) human
studies published fewer than 7years ago. The exclusion criteria were as follows: (i) stud-
ies with subjects with pathologies and (ii) the language of the articles was not English
or Spanish.

2.4. Study Selection

All studies identified by the search strategy were screened using the eligibility criteria
that were specified previously. The first stage of assessment involved the screening of titles
and abstracts by two reviewers (JJPM and MCV). The same reviewers undertook the second
Int. J. Environ. Res. Public Health 2022, 19, 4240 5 of 23

stage, screening the full text. In cases of disagreement, a decision was made by consensus
or, when necessary, a third reviewer (SNL) was consulted.

2.5. Data Extraction

Two independent reviewers (JJPM and MCC) who were blinded to each other extracted
the following relevant data from each study: study details (first author, year of publication),
characteristics of participants, setting, pain condition, SE measuring instrument, outcome
measures, duration of follow-up, and study design. If there was any discrepancy between
reviewers, a third reviewer was consulted (SNL).

2.6. Assessment of Methodological Quality

The evaluation of the methodological quality of the chosen studies was carried out by
means of the PEDro scale translated into Spanish [29]. The scale scores 11 items: specified
eligibility criteria, random allocation, concealed allocation, similarity at baseline, subject
blinding, therapist blinding, assessor blinding, >85% follow up for at least one key outcome,
intention-to-treat analysis, between-group statistical comparison for at least one key out-
come, and point and variability measures for at least one key outcome. The methodological
criteria were classified as follows: if the criterion is met, it obtains 1 point, and if not,
0 points. The first item of the PEDro scale does not count in the score of methodological
quality; hence, it was eliminated from the tables to avoid confusion. The PEDro Scale is
recognized as a valid measure of the methodological quality of clinical trials due to the
findings supporting its use in this category of trials [30]. The “Standard Quality Assess-
ment Criteria for Evaluating Primary Research Papers from a Variety of Fields”(QUALSYT)
checklist was used for the quality assessment of non-randomized trials. The scale is made
up of 14 criteria that can be answered by four options: Yes, No, Partial and N/A. These
items assess whether: the question or objective is sufficiently described, the design is
evident and appropriate to answer the study question, the method of subject selection is
described and appropriate, the subjects are sufficiently described, if random allocation to
treatment group was possible, it is described, if interventional and blinding of investigators
to intervention was possible, it is reported, if interventional and blinding of subjects to in-
tervention were possible, it is reported, the outcome and means of assessment are reported,
the sample size is appropriate, the analysis is described and appropriate, some estimate of
variance is reported, it is controlled for confounding variables, the results are reported in
sufficient detail and the results support the conclusions. The maximum obtainable score is
1. The final score is calculated as follows: Total sum = (number of “Yes” × 2) + (number of
“Partial” × 1); Possible sum = 28 − (number of “N/A × 2); Final score: total sum/possible
sum = ≤1.
To increase the methodological quality of the systematic review, the internal validity
of each study was measured by the PEDro Internal Validity Scale(IVS) [29]. Seven internal
validity criteria were collected from the PEDro scale. Criteria 2, 3, 5, 6, 7, 8 and 9 were
selected to form the IVS and must be classified as follows: Articles with an IVS between 6
and 7 are considered to have a high methodological quality; articles with an IVS between
4 and 5 are considered to have an average methodological quality; articles with an IVS
between 0 and 3 are considered to have a low methodological quality.

3. Results
3.1. Characteristics of the Selected Studies
3.1.1. Study Characteristics
A total of 32,232 citations were identified through electronic databases. The number
of studies retrieved from each database and the number of studies excluded in each
screening phase are shown in Figure 1. A final number of 21 studies satisfied our inclusion
criteria and were included in this review. Of these 21 studies,14 are randomized controlled
trials [25,31–43] and 7 are non-randomized trials [24,44–49], with a total of 407 participants
who satisfied our inclusion criteria and were included in this review. There are 24 race
Int. J. Environ. Res. Public Health 2022, 19, 4240 6 of 23

walkers, 76 cyclist, 21 sprinters, 143 performed resistance training, 12 overload training,

8 runners and 127 participants who did not specify their physical activity.

Figure 1. PRISMA screening process for selection of articles for review.

3.1.2. Methodological Quality

The degree to which studies met the quality criteria varied considerably. The method-
ological quality assessment of all included studies is presented in Tables 1–5. Characteristics
of the selected studies are shown in Table 6.
Int. J. Environ. Res. Public Health 2022, 19, 4240 7 of 23

Table 1. Methodological assessment with PEDro scale. Articles 1 to 10.

BinNaharudin Carr, Cheriff Chowdhury Dethlefsen Edinburgh Gasmi Grant Grant Gueldich
Item et al. et al. et al. et al. et al. et al. et al. et al. et al. et al.
(2018) (2018) (2016) (2018) (2018) (2019) (2017) (2017) (2019) (2019)
2 X X X X X X
3 X
4 X X X X X X
5
6 X
7 X
8 X X X X X X
9 X X X X X
10 X X X X X X X X X
11 X X X X X X X X X X
TotalPEDro 5/10 4/10 4/10 5/10 2/10 6/10 6/10 4/10 7/10 3/10
1. The selection criteria were specified. 2. Subjects were randomly assigned to groups. 3. The assignment was
hidden. 4. The groups were similar at baseline in relation to the most important prognostic indicators. 5. All
subjects were blinded. 6. All therapists who administered the therapy were blinded. 7. All assessors who
measured at least one key outcome were blinded. 8. Measures of at least one of the key outcomes were obtained
from more than 85% of the subjects initially assigned to the groups. 9. Results were presented for all subjects who
received treatment or were assigned to the control group, or where this could not be the case, the data for at least
one key outcome were analyzed by ‘intention to treat’. 10. Results of statistical comparisons between groups were
reported for at least one key outcome. 11. The study provides point and variability measures for at least one key
outcome. Different colors represent the methodological quality of studies with a high (red), or unclear (yellow) or
low (green) risk of bias and applicability concerns.

Table 2. Methodological assessment with PEDro scale. Articles 11 to 21.

Kysel McAllister Moro Moro Shaw Sjödin Terada Vargas Vidic’ Zajac Zinn
Item et al. et al. et al. et al. et al. et al. et al. et al. et al. et al. et al.
(2020) (2019) (2016) (2020) (2020) (2020) (2019) (2018) (2021) (2014) (2017)
2 X X X X X X X X X X
3
4 X X X X X X X X X
5
6 X
7 X X X X
8 X X X X X X X X
9 X X X X X X X
10 X X X X X X X X X
11 X X X X X X X X X X X
TotalPEDro 7/10 6/10 7/10 7/10 3/10 4/10 7/10 6/10 5/10 6/10 1/10
1. The selection criteria were specified. 2. Subjects were randomly assigned to groups. 3. The assignment was
hidden. 4. The groups were similar at baseline in relation to the most important prognostic indicators. 5. All
subjects were blinded. 6. All therapists who administered the therapy were blinded. 7. All assessors who
measured at least one key outcome were blinded. 8. Measures of at least one of the key outcomes were obtained
from more than 85% of the subjects initially assigned to the groups. 9. Results were presented for all subjects who
received treatment or were assigned to the control group, or where this could not be the case, the data for at least
one key outcome were analyzed by ‘intention to treat’. 10. Results of statistical comparisons between groups were
reported for at least one key outcome. 11. The study provides point and variability measures for at least one key
outcome. Different colors represent the methodological quality of studies with a high (red), or unclear (yellow) or
low (green) risk of bias and applicability concerns.
Int. J. Environ. Res. Public Health 2022, 19, 4240 8 of 23

Table 3. Assessment of internal quality using IVS scale. Articles 1 to 10.

BinNaharudin, Cheriff Chowdhury Dethlefsen Edinburgh Gasmi Grant Grant Gueldich

Carr et al.
Item et al. et al. et al. et al. et al. et al. et al. et al. et al.
(2018)
(2018) (2016) (2018) (2018) (2019) (2017) (2017) (2019) (2019)
2 X X X X X X
3 X
5
6 X
7
8 X X X X X X X
9 X X X X X
IVS 3/7 1/7 2/7 2/7 0/7 3/7 2/7 1/7 4/7 2/7
Quality Low Low Low Low Low Low Low Low Medium Low
Different colors represent the methodological quality of studies with a high (red), or unclear (yellow) or low
(green) risk of bias and applicability concerns.

Table 4. Assessment of internal quality using IVS scale. Articles 11 to 21.

Kysel McAllister Moro Moro Shaw Sjödin Terada Vargas Vidic´ Zajac Zinn
Item et al. et al. et al. et al. et al. et al. et al. et al. et al. et al. et al.
(2020) (2019) (2016) (2020) (2020) (2020) (2019) (2018) (2021) (2014) (2017)
2 X X X X X X X X X X
3
5
6 X
7 X X X X
8 X X X X X X X X
9 X X X X X X X
IVS 4/7 3/7 4/7 4/7 1/7 2/7 4/7 3/7 2/7 3/7 0/7
Quality Medium Low Medium Medium Low Low Medium Low Low Low Low
Different colors represent the methodological quality of studies with a high (red), or unclear (yellow) or low
(green) risk of bias and applicability concerns.

Table 5. Methodological assessment using the QUALSYT.

Carr et al. Cheriff et al. Dethlefsen Gueldich et al. Shaw et al. Zajac et al. Zinn et al.
ITEM
(2018) (2016) et al. (2018) (2019) (2020) (2014) (2017)
1 Yes Yes Partial Partial Yes Yes Parcial
2 Yes Yes Yes Yes Yes Yes Partial
3 Partial Yes Yes Partial Yes Partial Partial
4 Yes Partial No Yes No Yes Yes
5 No N/A N/A N/A N/A N/A N/A
6 No N/A N/A N/A N/A N/A N/A
7 No N/A N/A N/A N/A N/A N/A
8 Yes Yes Yes Yes Yes Yes Yes
9 Yes Yes Yes Yes Yes Yes Partial
10 Yes Yes Yes Yes Yes Yes Yes
11 Yes Yes Yes Yes Yes Yes Partial
12 Yes Partial Partial Yes Yes Yes N/A
13 Yes Yes Yes Yes Yes Yes Yes
14 Yes Yes Yes Yes Yes Yes Yes
Total 0.75 0.90 0.81 0.90 0.90 0.95 0.75
1. The purpose is specifically explained. 2 The population studied was clearly explained. 3. The participation
rate for eligible individuals was at least 50%. 4. All subjects were recruited from the same or similar population.
5. The sample size, a description or estimate of the variance and effect were justified. 6. Exposures of interest were
measured before the results were performed. 7. The time period was long enough to reasonably expect to see an
association between the exposure and the outcome. 8. The study was examined at different exposure levels with
respect to the outcome. 9. Exposure measures were clearly defined, valid, reliable, and consistently implemented
in the participants. 10. Exposures were evaluated more than once over time. 11. Outcome measures were clearly
defined, valid, reliable, and consistently implemented in the participants. 12. Outcome assessors were blinded to
the exposure status of the participants. 13. Loss to follow-up after the start of the study was less than 20%. 14. Key
confounders were measured and statistically adjusted for their impact on the exposure–outcome relationship.
Different colors represent the methodological quality of studies with a high (red), or unclear (yellow) or low
(green) risk of bias and applicability concerns.
Int. J. Environ. Res. Public Health 2022, 19, 4240 9 of 23

Table 6. Characteristics of the selected studies.

Name Type of Study Sample Intervention Measurements Results

From day 4 the intervention
decreased their body mass
(p < 0.001).
Both groups had a trial
period to get used to the Decrease in the performance of the
program for 7 days. Every Wingate Test in the intervention
2 days, they performed the during the first days (p < 0.05).
Wingate Test and in the next However, it recovered after the
session, a prolonged fourth day (p < 0.05).
N = 20 men high-intensity cycling test,
Control: 10 both in a period of 10 days. VO2 peak. Decrease in the performance of the
Age: 20 ± 1 This period was repeated cycling test in the intervention
BinNaharudin et al. twice interspersing a Blood and during the sessions, but there was a
RCT
(2018) Intervention: 10 4-week break. urine samples. tendency to recover performance in
Age: 21 ± 1 the later phases. Compared to Day
The control 5 times a day Body mass. 0, the cycling test performance in
Losses: 0 consumed a total of the intervention group reduced on
2492 ± 20 kcal. Day 2 (p < 0.0001), Day 4 (p < 0.001),
Day 6 (p < 0.001), Day 8 (p < 0.05)
The intervention 4 times a and Day 10 (p < 0.05).
day consumed a total of
1500 ± 55 kcal by After the exercises, the intervention
skipping lunch. had higher blood glucose levels
(p < 0.05) and lower blood levels of
triglycerides in the last sessions
(p < 0.01).
Within each of the three groups,
there was a significant increase in
VO2max compared with baseline
(p < 0.05).

Blood pH: At 4 min and 6 min

post-exercise there were no
significant difference between pH of
All groups followed an HCHO and LCHF (95% CI = (−0.10;
N = 28 (17 men and intensive supervised 0.02) and (−0.08; 0.04), respectively.
Walking economy.
7 women) training session every day
for 3 weeks. Bicarbonate: there were no
VO2 peak tested
Control: 8 significant differences in
Non-randomized on treadmill.
Control had a high-carb diet. post-training intervention blood
Carr et al. (2018) parallel
Intervention A: 9 [HCO3-] between groups
group study Net endogenous acid
Intervention A had a (F(1,161.15) = 0.14; p = 0.71).
production (NEAP).
Intervention B: 7 low-carb and high-fat diet.
Lactate: Post-intervention, there
Blood samples.
Losses: 4 Intervention B had a diet of were no significant differences
periodic carbohydrates. between groups (F(14,311.07) = 1.28;
p = 0.22).
Post-intervention, NEAP was
significantly higher in LCHF
compared with HCHO control
(95% CI = (10.44; 36.04)) but there
was no difference for PCHO
compared with HCHO
(95% CI = (−19.06; 7.23)).
Speed sprint and vertical stiffness
declined in the fasting session
compared to the control session
(p = 0.030). During the two first
sprints of the second repeated
In both sessions, endurance
sprints set, sprint speed
tests were carried out based
significantly decreased in the
Counterbalanced on sprint repetitions.
fasting session (p = 0.003) compared
test
N = 21 men to the control session
Control session: they Biomechanical and
Age: 29.8 ± 5.9 (p = 0.048), while horizontal power
Quasi- followed a normal diet. biochemical markers
declined in the fasting session
Cherif et al. (2016) experimental measured by blood
Intervention: 21 compared to the control session
study Intervention session: fasted samples and body
only in sixth sprint (p = 0.017).
14 h for 3 days in a row. mass index.
Losses: 0
Uncontrolled
Triglyceride levels improved during
trial After 7 days of intervention,
fasting (p = 0.037). Total cholesterol
the diets are exchanged
(p = 0.581) and LDL-c (p = 0.835)
between groups.
levels did not vary in this session.

HDL-C was higher in fasting

session compared to control session
at post-exercise (p = 0.039).
Int. J. Environ. Res. Public Health 2022, 19, 4240 10 of 23

Table 6. Cont.

Name Type of Study Sample Intervention Measurements Results

N = 31 (12 men and For 6 weeks:
19 women)
Control group followed a
There were no differences between
Control: 15 (6 men diet which consisted of
Body mass the levels of energy regulation,
and 9 women) ingesting ≥ 700 kcal, during
glycerin, peptides and appetite.
Age: 36 ± 12 the first 2 h after waking up,
Chowdhury, Resting
RCT of the 1100 kcal
et al. (2018) metabolic rate Glucagon concentrations were
Intervention: 16 daily maximum
lower in the intervention group
(6 men and
Appetite Score compared to control group, where it
10 women) Intervention group remained
went up (p = 0.06).
Age: 35 ± 10 in fasted state until midday.
Their total daily intake was
Losses: 0 1200 kcal.
Phosphorylation and protein levels
of several proteins related to
autophagy were higher in the
trained group
(p < 0.05).
Amino acid
Skeletal muscle LC3I protein
Both groups fasted for 36 h quantification.
content was ~30% lower
and samples were taken 2,
N = 17 men (p < 0.05) at 12, 24, and 36 h than at
12, 24 and 36 h after the Lysing of
2 h after the meal in
Quasi- last meal. muscle tissue.
Trained: 6 untrained subjects.
experimental
Age: 27 ± 4
Dethlefsen et al. study The trained group had a Polyacrylamide gel
The LC3II protein content in
(2018) VO2max above on electrophoresis
Untrained: 7 skeletal muscle was ~20% lower (p
Uncontrolled 55 mL·min−1 ·kg−1 . with sodium
Age: 28 ± 3 < 0.05) at 12 and 24 h and tended to
trial dodecylsulfate
be lower (p = 0.059) at 36 h than at
The untrained group had a followed by
Losses: 4 2 h after the meal in
VO2max below Western blotting.
untrained subjects.
45 mL·min−1 ·kg−1 .
Blood samples.
The p62 protein content in skeletal
muscle was ~60% lower (p < 0.05) at
24 h than 2 h after the meal in
untrained subjects, whereas fasting
had no effect on p62 protein content
in trained subjects.
Subjects followed 3 different
programs for a 24 h period
with 1 week of washout
between them:
Participants who fasted before
Breakfast followed by rest: exercise strategy consumed less
breakfast was eaten and no calories compared to the other
N = 12 men type of exercise Blood samples strategies (p < 0.01).
Age: 23 ± 3 was performed.
Expired gas samples Energy expenditure was only
Edinburgh et al.
RCT Intervention: 12 Breakfast before exercise: significatively lower when
(2019)
breakfast was eaten and Energy expenditure breakfast was followed by rest
Losses: 0 60 min of cycling at 50% (p < 0.01).
1.1.1 peak power output Energy intake
was performed. There was a significant usage of
plasmatic glucose with the fasting
Fasting before exercise: before exercise strategy (p = 0.03).
breakfast was skipped and
60 min of cycling at 50% of
peak power output
was performed.
N = 40 men
Energy (kcal/day)
Control: 20 During the months February, There was no significant difference
Young men: 10 March and April: Fat in muscular strength in any group.
Age: 24.90 ± 1.10
Aged men: 53.90 ± 4.09 Intervention group followed Wmax Concentration levels of hemoglobin,
12 h of fasting 2 days a week red cells and white cells were
Gasmi et al. (2017) RCT
Intervention: 20 with a rest stage of 48 h Red cells significantly higher in young
Young men: 10 (Monday and Thursday) participants (p > 0.05).
Age: 26.90 ± 1.97 Hemoglobin
Aged men: 10 Control group kept their There was no improvement in levels
Age: 51.60 ± 5.87 usual diet. Running-based of CD3, CD4+, and CD8+ (p > 0.05).
anaerobic sprint test
Losses: 0
Int. J. Environ. Res. Public Health 2022, 19, 4240 11 of 23

Table 6. Cont.

Name Type of Study Sample Intervention Measurements Results

The values of body composition
were lean soft tissue (p = 0.30), fat
mass (p = 0.14) and body fat
(p = 0.37).

Muscular performance increased in

Both groups performed a both groups, but the intervention
N = 28 men resistance training program group showed greater
3 days/week for 8 weeks. improvements in lower body
Control: 8 strength and upper and lower body
Age: 22.0 ± 2.4 Control continued with his Body composition. endurance. The exercises that
Grant et al. (2017) RCT usual diet. evaluated the muscular
Intervention: 10 Muscle performance. performance were bench press
Age: 22.9 ± 4.1 Intervention could only eat 1-RM (p = 0.35), bench press
in a period of 4 h a day endurance
Losses: 10 4 times a week without (p = 0.17), hip sled 1-RM (p = 0.07)
limitation of quantity. and hip sled endurance (p = 0.97).

There was greater increase in lean

soft tissue in the control group of
2.3 Kg on average, as opposed to
−0.2 Kg in intervention group, but
it is not a significative difference.
Fat rate: statistically significant
changes in favor of intervention
(p = 0.12).

Muscular performance increased in

all groups with no significant
All groups completed an
Lean mass and fat differences between them. The
endurance training program
rates. analyzed values were resistance
for 8 weeks.
N = 40 women training volume (p > 0.05),
Body composition. muscular performance
Control followed a
Control: 14 (p > 0.05), rate of force development
normal diet.
Age: 22.0 ± 2.4 Muscle performance. (p > 0.05) vertical jump performance
(p > 0.05), physical activity energy
Intervention A: could
Intervention A: 13 Resting metabolic expenditure (p = 0.034), sedentary
Grant et al. (2019) RCT consume calories between
Age: 22.1 ± 2.1 rate and use time (p = 0.048), moderate- or
12 am and 8 pm hours.
of substrates. vigorous-intensity physical activity
Intervention B:13 (p > 0.05), steps per day (p > 0.05).
Intervention B: could
Age:22.3 ± 3.4 Brachial
consume calories between
blood pressure. There are no significant differences
12 am and 8 pm in addition
Losses: 16 in metabolic and physiological
to consuming β-hydroxy
Blood and characteristics. The analyzed values
β-methyl
saliva samples. were Urinary HMB concentrations
butyrate supplements.
(p < 0.01), body composition
(p > 0.05), resting metabolism
(p > 0.05), blood variables (p > 0.05),
vascular assessments (p > 0.05) and
cortisol awakening response
(p > 0.05).
Voluntary activation
level (VAL).
VAL (p < 0.05) and MVIC (p < 0.001)
The intervention fasted for a
Electromyographic values decreased during the first
month following the
signals. week of Ramadan.
tradition of Ramadan.
Contraction potential Neuromuscular efficiency (p = 0.15)
The group performed
Quasi- N = 10 men at rest. and the potential of contraction at
3 repetitions of a maximum
experimental Age: 22.06 ± 1.98 rest (p = 0.07) remained stable
voluntary isometric
Gueldich et al. study Depression, anxiety throughout the month.
contraction of knee
(2019) Intervention: 10 and fatigue: Profile of
extension with
Uncontrolled Mood States The values of the POMS-f were
electrostimulation during
trial Losses: 0 questionnaire in higher during the first week.
4 phases: one week before
French version Significant difference in comparison
Ramadan, at the end of the
(POMS-f). with before Ramadan and the other
first week, during the fourth
measured days. p < 0.005 in week 1,
week and two weeks after
Maximum voluntary p < 0.01 in week 4 and p < 0.001
its completion
isometric contraction after Ramadan.
(MVIC) values.
1.1.2
Int. J. Environ. Res. Public Health 2022, 19, 4240 12 of 23

Table 6. Cont.

Name Type of Study Sample Intervention Measurements Results

During an 8-weekperiod,
both groups followed a
programmed diet with
strength and resistance
training. Muscles from chest,
Both groups decreased body weight,
back and legs were trained
body fat mass and body mass index.
in 3 sessions on 3 different
Lean body mass and body water
days. Resistance training
content were significantly reduced
consisted of a 30 min run at
by the intervention, while they
constant heart rate at 70% of
Body composition were not influenced in control
N = 25 men maximal heart rate. In
group (p < 0.05).
addition, the total energy
Muscle strength
Control: 12 intake of each participant
Intervention did not produce a
Age: 24 ± 4 was calculated and reduced
Endurance significant improvement in muscle
Kysel et al. (2020) RCT by 500kcal per day.
performance strength, while control group was
Intervention: 13
able to improve it (p < 0.05).
Age: 23 ± 5 Cyclical ketogenic reduction
Peak workload
diet: first 5 days of the week
Respiratory exchange ratio
Losses: 0 the carbohydrate
Peak oxygen uptake decreased in subjects
consumption was reduced to
on intervention while it did not
30 g per day and on the last
vary in control group (p < 0.05).
2 days it was increased to
8–10 g per kg of
Spiroergometric results were higher
non-fat tissue.
in control group (p < 0.05).
Nutritionally balanced
reduction diet: only the 500
kcal per day restriction
was included.
Both groups could only eat
Blood pressure.
in a period of 8 h a day for
N = 26 men 28 days.
Body composition.
Age: 22 ± 2.5 In both groups, body fat and blood
Pilot study The control (ab libitum) pressure decreased (p < 0.05).
Blood samples.
McAllister et al. Control: 12 could consume as much as
(2019) Randomized and they wanted in the set In both groups there were increases
Hunger, satiety,
controlled Intervention: 10 time interval. in HDL-c and adiponectin
concentration, mood,
(p < 0.05).
energy, alertness and
Losses: 4 The intervention (isocaloric)
focus: visual
should be kept 300 kcal/day
analogue scale.
below a normal daily intake.
Greater decrease in fat (p = 0.0448)
and maintenance of lean mass in
favor of intervention group.
Height and weight.
Increased strength in both groups
without a significant difference
Fat and lean
between them ( p > 0.05).
Both trained for 8 weeks mass rates.
N = 34 men
(3 sessions per week) in a
Age: 29.21 ± 3.8 Insulin growth factor levels type 1
resistance training program. Muscle areas
(p = 0.0397) and testosterone
Control: 17 (p = 0.0476) decreased in
Moro et al. (2016) RCT Control: ate at 8 am, 1 pm Aspirated oxygen
intervention group.
and 8 pm. and expelled
Intervention: 17
carbon dioxide.
Decreased respiratory rate in
Intervention: ate at 1 pm,
Losses: 0 intervention group (p = 0.0421).
4 pm and 8 pm. Blood samples.
Decreased glucose (p = 0.0011) and
Upper and lower
insulin levels (0.0303) in
limb strength.
intervention group. Due to that,
there were an improvement in the
homeostatic model assessment in
intervention group.
Int. J. Environ. Res. Public Health 2022, 19, 4240 13 of 23

Table 6. Cont.

Name Type of Study Sample Intervention Measurements Results

Reduction inbody fat in favor of the
intervention group (p = 0.01).
Both groups cycled
The resting metabolic rate has no
500 ± 50 km a week divided
significant interaction between
into 6 weekly cycling
N = 16 men Body composition. groups (p > 0.05).
sessions for 4 weeks.
Control: 8 Resting There is no significant difference
Controls (ND) consumed a
Age: 19.38 ± 1.60 metabolic rate. between groups in sports
complete diet divided into
Moro et al. (2020) RCT performance (p > 0.05).
3 meals between 7 am
Intervention: 8 Peak power
and 9 pm.
Age: 19.38 ± 2.39 output (PPO). The intervention shows a decrease
in inflammatory markers (p < 0.005).
Intervention (ERT)
Losses: 0 Blood samples.
consumed a complete diet at
Leucocytes decreased in both
an interval of 8 h (10 am
groups (p = 0.001), but the
to 6 pm).
difference between baseline and
final values was only significant for
the control group.
For 31 days, participants
were on a certain diet with a
week of interspersed rest.
Diets had no significant effects on
Blood and saliva
VO2 peak or exercise tests until
N = 10 men The intervention with samples.
exhaustion (p > 0.05).
Cross design ketogenic diet consumed
Intervention: 8 <50 g/day of carbohydrates. Incremental exercise
Shaw et al. (2020) The ketogenic diet can alter the pro-
Uncontrolled Age: 29.6 ± 5.1 Diet was composed of test to exhaustion:
and anti-inflammatory immune
trial 15–20% proteins and days 1 and 31 ran to
response of cytokines (p < 0.05) and
Losses: 2 80–85% fats. exhaustion at 70% of
the segregation of immunoglobulin
their VO2 peak.
A (p < 0.001).
The intervention with his
usual diet did not vary their
consumption.
The first results did not show a
During a 4-week period,
significant change in strength and
each group followed their
time to fatigue in the
programmed diet. After the
intervention group.
first intervention was VO2 max
N = 24 women complete, a washout period
Time to fatigue in cycling test was
Age:18–30 of 15 weeks took place. The Lactate
reduced by 2 min in intervention
groups then interchanged
group (p < 0.001).
Control: 8 their diets for another Handgrip time to
Sjödin et al. (2020) RCT
4 weeks. fatigue and strength
Participants experienced an
Intervention: 9
improvement in muscular fatigue
Control group followed a Graded Incremental
during the exercise days.
Losses: 7 program diet from the Ergometer
National Food Agency. Cycling Test
Ketogenic diet had an unfavorable
effect on muscle fatigue and might
Intervention group followed
affect perceived exertion during
a ketogenic diet.
daily life activities.
Mean of T85% was longer in the
intervention (p = 0.038).
High intensity
aerobic Aerobic capacity did not vary
N = 25 men Both groups trained 4 weeks
endurance: T85%. between groups (p > 0.05).
(3 sessions/week). Aerobic
Control: 9 cycling of
Aerobic capacity: Mechanical work (p = 0.010) and
Age: 34.0 ± 8.2 maximum intensity.
(VO2 peak). Peak Power Output (p = 0.021) were
Terada et al. (2019) RCT
lower in the intervention group, but
Intervention: 11 Control: they consumed
Mechanical still can have a greater impact on
Age: 33.3 ± 7.2 exogenous carbohydrates.
work.Peak power the ability to sustain high-intensity
output (PPO). aerobic endurance exercise
Losses: 5 Intervention: night fasting.
compared to control group.
Fatigue rate.
Fatigue rate did not vary between
groups (p > 0.05).
Int. J. Environ. Res. Public Health 2022, 19, 4240 14 of 23

Table 6. Cont.

Name Type of Study Sample Intervention Measurements Results

Participants were organized
into 3 groups to participate
in the 8-week-long study:

Control group: they did not

follow any programmed diet
N = 26 men
or training during the study. There was significant reduction in
Age: 30 ± 4.5
fat mass and visceral adipose tissue
Intervention A: followed a in the ketogenic diet (p < 0.05).
Control: 5
ketogenic diet
Vargas et al. (2018) RCT Body composition Total body weight and muscle mass
Intervention A: 9
Intervention B: followed a were significantly higher in the
non-ketogenic diet non-ketogenic group compared to
Intervention B: 10
the ketogenic group, which stayed
The exercise training neutral (p < 0.05).
Losses: 2
consisted of 4 sessions per
week (1 session/day) and 3
days of rest. Upper and
lower limbs were trained
separately in 2 sessions for
each one.
Subjects participated for 4
weeks in a familiarization
program before starting the
intervention. Participants
were organized into Both groups lost a similar amount
2 groups: of lean body mass and fat mass
N = 20 men (p = 0.001) but preserved their
Age: 42.7 ± 1.5 Control group: a maximal upper and lower limbs
Bloodsamples
non-ketogenic diet was strength (p > 0.05).
Control: 9 followed.
Vidic et al. (2021) RCT Body composition
Basal and free testosterone
Intervention: 9 Intervention group: a increased in both groups (p < 0.01).
Maximal strength
ketogenic diet
Losses: 2 was followed. Insulin levels decreased
significantly in both groups
Both groups carried out (p < 0.01).
4 strength training sessions
per week for8 weeks. Upper
and lower limbs strength
were trained every week.
High volume training in a ketogenic
Both groups performed
diet increases fat metabolism
moderate and intense
during exercise, observable by low
cycling exercises for 3 days
triglyceride levels during max effort
preceded by 4 weeks of
training and resting (p = 0.001).
carrying out the
N = 8 men
assigned diet.
Age: 28.3 ± 3.9 The ketogenic diet reduces body
Biochemical analysis.
Cross design mass (p = 0.011), fat content
Intervention A had a
Intervention A: 4 (p = 0.001) and post-exercise muscle
Zajac et al. (2014) mixed diet. VO2 peak.
Uncontrolled damage, which was observed by
study Intervention B: 4 lower rest and exercise plasma
Intervention B had a Body composition.
creatine kinase and
low-carb ketogenic diet.
Losses: 0 lactate dehydrogenase.
After a month with the
The ketogenic diet reduces physical
assigned diet and a week of
performance at high intensities
rest, the groups interchange
evidenced by a lower lactate
their diets.
concentration (p = 0.001).
The group continued with Decreased sports performance,
their usual training and also visible by a decrease in time to
N = 5 (4 women
performed endurance events Sports exhaustion (p = 0.004).
and 1 man)
Pilot study for 10 weeks. performance test.
Reduction in body fat, measured by
Zinn et al. (2017) Intervention: 5
Uncontrolled or The intervention consumed Body composition. skin folds (p = 0.001).
Age: 49 to 55
randomized study <50 g of carbohydrates per
day, 1.5 g of protein per kilo Improvements in the well-being of
Losses: 0
and freedom to consume the the subjects (any p-value
desired amount of fat. was calculated).

Seven studies, in addition to being evaluated on the PEDro scale, were also measured
on the QUALSYT since they were non-randomized controlled clinical studies.
The characteristics of the intervention and the results of the studies chosen for the
review are shown as follows.
Int. J. Environ. Res. Public Health 2022, 19, 4240 15 of 23

3.2. Intermittent Fasting

The main differences found between fasting and non-fasting groups were related
to physical performance, concentration of glucagon-like-peptide-1, phosphorylation and
levels of some proteins related to autophagy (presented LC3I, LC3II and p62 proteins),
plasmatic glucose and consumed calories. No differences were found between groups
when comparing the systemic concentration levels of the energy-regulating hormones [32].
It is of great importance to specify the results obtained in each kind of exercise given the
differences found between them when they are being performed, such as energy production
methods and energy distribution, when focusing on aerobic or anaerobic predominance.
In this regard, sprinters decreased speed when they fasted for 14 h per day over a
period of 3 days. However, their glucose levels remained stable after training and were
higher than those of HDLc and free fatty acids [44]. The concentration of glucagon-like-
peptide-1 in the non-fasting group was higher than the fasting group [32].
In endurance sports, the phosphorylation and levels of some proteins related to
autophagy have been seen to be higher when fasting for 36 h when compared to untrained
subjects [45].
Specific isometric contraction has been measured in sport populations after practicing
Ramadan. The levels of voluntary activation and voluntary maximum isometric contraction
showed a decrease during the first week of Ramadan, measured by the neuromuscular
efficiency and the potential for contraction at rest [46].
Anaerobic and high-intensity performance has been shown to be decreased by assess-
ment with the Wingate and cycling tests after fasting [31].
Finally, fasting before exercise could regulate blood glucose levels, leading to a
metabolic shift, which increases fat metabolism and decreases fat storage after a reduction
in the total caloric intake [33,50].

3.3. Time Restricted Feeding

The mean differences between the TRF groups and the non TRF groups were re-
lated to strength, resistance, healthy cardiometabolic markers, decreased body fat, de-
creased levels of testosterone and insulin growth factor type 1 (IGF-1), increased levels
of adiponectin, weight loss, improvements in body composition and an increase in peak
power output/bodyweight, and a reduction in white blood cells that usually appear after
intense sports. There were no differences in muscle mass loss, hypertrophy, lean mass,
muscle measurement in centimeters nor total cholesterol or triglycerides.
Cyclists have been shown to improve body composition and an increase in peak
power output/bodyweight (PPO/Body weight) when compared to controls after using
TRF intervention [39]. Furthermore, cyclists have shown to improve high intensity aerobic
endurance using this nutritional strategy [41].
Strength has been shown to increase after TRF intervention, measured by bench press
1-RM and hip sled 1-RM [35].
Resistance has been shown to increase after TRF intervention, measured by bench
press endurance and hip sled endurance [35].
Anaerobic capacity in sprint runners increased in healthy runners when compared to
adult runners after a TRF intervention [34].
Health status has been shown to be improved after a TRF intervention, specifically in
biomarkers such as blood pressure and increased adiponectin and HDLc, as well as body
fat and cardiometabolic markers [37].

3.4. Ketogenic Diet

The mean differences between the KD groups and the non-KD groups were related
to salivary immunoglobulin A, decreased strength and endurance, decreased stamina,
reduction in fat mass and visceral adipose tissue, increased insulin level, an increase
in fat metabolism after intense exercise, reduction in body weight by decreasing the fat
content and a decrease in muscle damage after exercise. There were no differences between
Int. J. Environ. Res. Public Health 2022, 19, 4240 16 of 23

groups when comparing blood pH, concentrations of lactate in the blood and the levels of
bicarbonate, VO2max, grip strength and testosterone level.
Resistance trainers have been shown not to improve strength after using a KD inter-
vention when compared to controls [25]. Furthermore, resistance trainers have been shown
not to improve endurance after using a KD intervention when compared to controls [25,47].
On the other hand, endurance athletes have reported an improvement in their well-being,
easier recovery and benefits in the health of their skin and a reduction in inflammation
after using a KD intervention [49].
With regard to muscle strength and hormone profile in male resistance trainers, no
significant differences have been found when compared to controls [43].
Cyclists have presented a decrease in the performance of high-intensity exercises,
evidenced by a low concentration of lactate after using a KD strategy [48].

4. Discussion
The objective of this study is to evaluate the existing evidence on different nutritional
strategies in the improvement of the quality of life and performance of the athlete. This
review shows that IF and TRF improve the health of the athletes. In terms of performance,
there is still controversy in the current research. Aerobic performance, such as resistance
or endurance training, seems to be decreased by IF, TRF and KD in the short term, but
benefits from nutritional strategies in the long term. Moreover, athletes performing aerobic
exercises described an increased well-being, easier recovery, benefits in the health of their
skin and a reduction in inflammation after using the KD strategy. Anaerobic exercise, such
as strength training, measured by bench press, leg press, lat pull downs and sprints, seem
to be increased when using a TRF strategy and decreased when using a KD in the short
term. Nevertheless, both strategies may be useful in the long term.

4.1. Intermittent Fasting

Physical performance was observed to deteriorate during the first days of the transi-
tion period from a usual diet to intermittent fasting in four studies [31,41,44,46]. However,
a recovery of performance in the last days of intervention was recognized in two stud-
ies [31,41]. In addition, one study [46] explained that intermittent fasting increased the
levels of depression, anxiety and fatigue during the first week; hence, the negative effects
of IF, which occur at the beginning of this diet, are due to the change in diet. Therefore, a
study with longer intervention time may clarify the lack of understanding of intermittent
fasting´s effects in the long term.
In the research by Cheriff A et al. [44] and Bin Naharudin MN et al. [31], blood glucose
levels were found to remain stable after exercise in fasting subjects. Cheriff A et al. [44]
indicate an increase in free fatty acids in blood, while Bin Naharudin MN et al. [31] confirm
a decrease in blood triglycerides levels. Thus, a decomposition of triglycerides is observed
to create free fatty acids as a source of energy, which causes a decrease in body mass, as
explained by Dethlefsen MM et al. [45], without the need to break down muscle tissue.
Dethlefsen MM et al. [45] verified the effects of 36 h of fasting and stated that the levels
of phosphorylation and LC3I, LC3II and p62 proteins, related to autophagy, were lower in
the non-sports group. In the trained group, autophagy was expected to start between 12
and 24 h after fasting. However, beclin1 was required to start the process, indicating that
there were autophagy markers in the blood but not enough to initiate the process in the
sports group, which suggests that a 36 h fast may serve to regulate skeletal musculature
autophagy in subjects who perform sports. Furthermore, Edinburgh et al. [33] showed
that exercise during fasting decreased plasmatic glucose levels by modulating them when
compared to controls that carried out exercise after having breakfast.
Three main theories have been suggested to explain the benefits of IF on improving
metabolic effects, such as better insulin sensitivity, and on metabolic markers, such as
systolic blood pressure, HbA1c, fat mass and triglycerides, even in eucaloric conditions:
(i) the Ketosis theory, (ii) oxidative stress hypothesis and (iii) the circadian rhythm hy-
Int. J. Environ. Res. Public Health 2022, 19, 4240 17 of 23

pothesis [19]. The first is widely known for its postulated mechanism of metabolic shift,
which increases fat metabolism and decreases fat storage after a reduction in total calorie
intake. The second focuses on mitochondrial metabolism, which decreases the cellular
inflammatory process. The third is thought to affect our internal 24 h circadian rhythm at
both a central and peripheral cellular level when altering the timing of food intake. These
theories open new possibilities to plan the specific moment to use a nutritional strategy
based on a specific goal. In the performance of athletes, this may be to increase insulin
sensitivity or to improve energy metabolism based on the moment of the match or training.
However, there is little evidence in this regard and more studies are needed to propose
optimal IF protocols for athletes [50].

4.2. Time-Restricted Feeding

The TRF has managed to equal [36,38] and even surpass [35,39] the improvements
in strength and endurance of the control group by carrying out different diets, but with
similar caloric content. This shows that that TRF does not decrease sports performance and
can be practiced by athletes without fear of losing performance. Gasmin et al. [34] showed
that the use of two days per week of TRF for 3 months increased the level of red and white
blood cells, hemoglobin, hematocrit and neutrophiles in young athletes when compared
to old athletes, which suggests that the efficacy of this nutritional strategy may be related
to age.
With regard to the development of muscle mass, Grant M et al. explains that although
there was no decrease in it, the control group achieved a significant increase compared
to the intervened group [35]. On the other hand, Grant M et al. and Moro T et al. stated
that there was no significant difference in the improvements of the groups [36,38]. The
differences between the studies most likely lie in the intervention times, the exercises
performed during the intervention and the range of hours in which the subjects were fed.
Therefore, it can be concluded that there is no decrease in muscle mass when practicing
such a diet.
There was a significant reduction in terms of body fat in the intervened group in three
studies [37–39]. Hence, the maintenance of lean body mass and decreasing fat could be
considered a good method to control body weight.
As regards endocrine effects, it should be noted that in the three aforementioned
studies adiponectin was observed, which accompanies an improvement in insulin affin-
ity [37–39]. Both Moro T et al. and Moro T et al. reflected a decrease in testosterone
and IGF-1 levels after exercising in the intervened group [38,39]. However, Moro T et al.
indicated that white blood cell levels decreased significantly less in the TRF group than in
the control group after intense exercise [39].
McAllister MJ et al. indicates a reduction in blood pressure and increased HDLc
in the intervened group [37]. On the other hand, Moro T et al. states that there was no
significant variation in cholesterol levels in any group. The difference in outcomes in both
articles probably comes from the different exercises and intervention times applied in
each study [38].
In the study by Grant M et al., the effects of TRF were verified along with HMB
supplementation, but did not show significantly different results compared to the group
that only practiced TRF [36].

4.3. Ketogenic Diet

This diet focused on fat metabolism as a source of energy and is supported by two
studies. Two studies agree that there was an increase in fat metabolism significantly in the
subjects who followed this diet [48,49]; however, other studies [24,25,47] did not show a
significant difference between the control and the intervened group. The differences in
outcomes may be due to the distinct characteristics of the individual subjects recruited.
Carr AJ et al. indicated that among the three groups that participated in the study, there
Int. J. Environ. Res. Public Health 2022, 19, 4240 18 of 23

were no significant differences between groups, arguing that this could be caused by the
high performance capacity of the subjects, who were elite athletes [24].
Research in three studies showed that body mass was reduced in the intervened
group [25,48,49]. However, Kysel C et al. and Gasmin et al. indicate that in addition to
reducing fat content, lean body mass was also metabolized [25,34].
The studies of Kysel P et al. [25], Zajac A et al. [48] and Zinn C et al. [49] stated that
the participants felt that their athletic performance was significantly reduced compared
to the controls and therefore they did not consider it a good diet to improve physical
performance. Specifically, Sjodin et al. [40] concluded that a ketogenic diet decreased
endurance in physically active women while they were using said nutritional strategy.
On the other hand, the participants of Zinn C et al. [49] indicated an improvement
in their well-being, greater speed of recovery, benefits in the health of their skin and a
reduction in inflammation.
Our results are in line with current research on the effects of KD in the athletic popula-
tion. It affects physical health and has positive effects on fat oxidation but shows conflicting
results regarding the effects of a KD on performance, which are mostly shown in the long
term. Thus, there are both beneficial and detrimental effects after using a KD strategy in
athletic populations [10,51–53]. Further research is required to establish recommended
protocols regarding a KD for athletes. Furthermore, deleterious effects on stool microbiota
and iron metabolism have been shown [51].
Further research exploration is still needed using different intervention times and
variation in the individual characteristics of subjects, with different types of exercise and
sports levels.
Finally, current research shows limited evidence when sub-grouping findings to spe-
cific athletic populations when using nutritional strategies to improve performance. In this
regard, in order to compound the findings, the effects of specific nutritional interventions to
improve performance has only been possible to be shown in relation to resistance athletes,
sprinters and cyclists.
Resistance athletes have been shown to increase performance when using IF and TRF
interventions, but not when using KD. However, long-term benefits have been shown after
using a KD intervention.
Professional sprinters have been shown to increase performance when using TRF but
decrease it after using an IF intervention.
Professional cyclists have shown to increase performance when a TRF intervention
has been followed.

4.4. Strengths and Limitations of the Study

First, the methodological quality of the literature was reviewed with the PEDro, IVS
and QUALSYT scales, which increases the quality of the present study and consequently
the quality of the results obtained. Second, the review of the literature deals with an
innovative topic in which eating habits in the field of sports and the aim of improving the
health and performance of the athlete are combined. Third, the conclusions of the review
serve as a proposal for future studies in which variations in the health and performance of
athletes are analyzed after the proposed interventions.
However, some limitations have to be recognized. Some variables in the results may be
produced by the individual characteristics of the subjects, for example the different sports
performed which included race walkers, cyclists, sprinters, runners, resistance training and
overload training, and, furthermore, there were 127 participants who did not specify their
preferred physical activity. In addition, because of heterogeneity and risk of bias between
studies, we could not reach a clear consensus about specific effects of IF, TRF and KD on
specific aerobic or anaerobic sports or sub-grouping. Interventions were based on changing
the eating habits of sports subjects; hence, participation was limited. Additionally, the
length of the intervention studies was also limited. Finally, this review concluded that the
analyzed articles presented a medium level, a low level and a high level of methodological
Int. J. Environ. Res. Public Health 2022, 19, 4240 19 of 23

quality in the PEDro scale, the IVS scale and the QUALSYT scale, respectively. Thus, the
results from the present review should be interpreted with caution. Apart from PEDro,
IVS and QUASYLT used in this study, grey literature databases such as NHS Evidence,
New York Academy of Medicine Grey Literature Report, Explore the British Library, TRIP
database, National Guideline Clearinghouse, Grey Source, and Open Grey may be explored
to detect any relevant unpublished work. However, due to the huge number of references
obtained in the main search we considered it unnecessary to increase the search with
unpublished work.

4.5. Clinical Application of the Results

Intermittent fasting and time-restricted feeding allow athletes to maintain their phys-
ical performance in the same way as with their usual diets, but with the presence of
numerous positive effects, such as body weight control by metabolizing fat as an energy
source without breaking down muscle tissue, increasing adiponectin levels and conse-
quently improving insulin sensitivity, maintaining white blood cell levels after intense
exercise, reducing systemic inflammation caused by low levels of glucose and omega 6
and finally improving personal well-being. However, these nutritional strategies are not
in line with recommendations from international organizations such as the International
Olympic Committee, the Academy of Nutrition and Dietetics, the American College of
Sports Medicine, and Dieticians of Canada, which indicate that athletes with high training
loads should consume a high-carbohydrate diet [9].
These effects can be effective in preventing injuries and optimizing healing processes
under clinical conditions. By reducing systemic inflammation, controlling body weight,
improving insulin sensitivity, and strengthening the immune system, health and quality
of life greatly improve. Furthermore, these health benefits will prevent injuries, such as
muscle inflammation caused by the accumulation of lactic and pyruvic acid, joint wear or
muscle tear, as well as the acceleration of the healing process resulting in optimal recovery.
In this regard, IF before exercise may be used as an injury prevention strategy. A recent
study by Navarro et al. showed significant differences in load tendon thicknesses (patellar
tendon and Achilles tendon) between runners with different number of meals per day,
as well as a negative association between tendon thicknesses and meals per day. The
hypothesis behind this is based on the likely insulin resistance and hyper-insulinemia state
in the athlete, which induces the overexpression of undercarboxylated osteocalcin and
loss of bone density and collagen tissue damage by activation of RANKL in bones and
increased uptake of glucose in collagen tissue, respectively. The increase in intracellular
glucose activates the polyol pathway that induces the production of sorbitol and fructose
under severe oxidative stress, which could be responsible for mitochondrial damage and
tissue breakdown [54].
On the other hand, although it is out with the focus of the study, it is important to
highlight that current research shows nutritional interventions as strategies that benefit
the nervous system. In this context, IF produces effects through metabolic, cellular, and
circadian mechanisms, leading to anatomical and functional changes in the brain, which
might be protective in the development of neurological disorders. Theoretically IF may also
be beneficial for neurodevelopmental and mood disorders, but hardly any experimental
data exists on this topic [55,56]. Nutritional strategies in order to improve both central and
peripheral nervous system may be of great interest to increase health and performance in
athletes and future studies are needed [57].

4.6. Future Studies

Studies analyzing the effects of different nutritional strategies, not only IF, TRF or
KD but others such as the Mediterranean and vegan diets, on performance, quality of life,
nervous system and brain improvement, prevalence of injuries and injury recovery times
in athletes, not only in the short but also in the long term, are necessary, as well as specific
data on both aerobic and anaerobic sports.
Int. J. Environ. Res. Public Health 2022, 19, 4240 20 of 23

IF before exercise may be used as an injury prevention strategy, but more studies in
this line are needed.
Furthermore, studies taking the circadian rhythm into account when planning the
timing of food intake based on the time of a match or training in order to increase the
athlete’s performance would be of great interest.

5. Conclusions
The methodological quality of the studies assessed with the PEDro scale is consid-
ered medium, the internal validity of them is considered low and those valued with the
QUALSYT scale had a high quality.
TRF may improve athletic performance in both professional sprinters and resistance
athletes through increasing adiponectin levels and insulin sensitivity and decreasing both
testosterone and IGF-1 levels after intense physical activity.
An athlete undertaking 5–6 h of exercise after intermittent fasting will improve their
performance, specifically resistance athletes, although inconclusive results exist for anaero-
bic exercise where it may be impaired within the first week.
Both IF and TRF decrease body mass without significantly affecting lean mass.
The ketogenic diet reduces body mass by consuming fat, but with the risk of ca-
tabolizing lean mass. In relation to performance, controversy still exists in the current
research, since there are both beneficial and detrimental effects after using a KD strategy in
athletic populations.
The use of different dietary strategies may improve the health and performance
of athletes, mainly in the long term after using a KD, while IF and TRF may improve
performance in professional sprinters and resistance athletes in the short term.

Author Contributions: Conceptualization, S.N.-L. and A.G.-M.; methodology, J.J.P.-M. and M.C.-C.;
software, M.C.G.-R.; validation, S.N.-L., A.G.-M. and M.C.G.-R.; formal analysis, J.J.P.-M., M.C.-C.
and S.N.-L.; investigation, J.J.P.-M. and S.N.-L.; resources, J.J.P.-M., M.C.-C. and A.G.-M.; data
curation, J.J.P.-M., M.C.-C. and S.N.-L., writing—original draft preparation, J.J.P.-M., and S.N.-L.;
writing—review and editing, S.N.-L., A.G.-M.; visualization, M.C.G.-R.; supervision, S.N.-L. and
M.C.G.-R.; project administration, S.N.-L. All authors have read and agreed to the published version
of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data availability can be asked for the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations

TRF Time-restricted feeding

QUALSYT Standard Quality Assessment Criteria for Evaluating Primary Research Papers
from a Varietyof fields
IVS PEDro Validity Internal Scale
PEDro Physiotherapy Evidence Database

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