Chapter 11

Carbohydrate Metabolism During

Exercise
Kelly M. Hammond, Marc J. Fell, Mark A. Hearris and James P. Morton
Research Institute for Sport and Exercise Sciences Liverpool John Moores University, Liverpool, UK

11.1 INTRODUCTION during exercise also improved exercise performance and

capacity (Coyle et al., 1986; Bosch et al., 1994; Tsintzas
The study of carbohydrate (CHO) metabolism in relation et al., 1995; Jeukendrup et al., 1997; Jeukendrup and
to sport and exercise is a field of investigation that is now Jentjens, 2000). Such studies relied on the use of
over 100 years old. Indeed, almost a century ago, Krogh stable isotope methodology (to quantify exogenous CHO
and Lindhard (1920) reported the efficiency of CHO as a oxidation) as well as magnetic resonance imaging to
fuel source during exercise and also demonstrated that quantify liver glycogen depletion during exercise (Casey
fatigue occurs earlier when subjects consume a high-fat et al., 2000). As such, it is now generally accepted that
diet (as compared with a high CHO diet) in the days pre- liver glycogen depletion is also a major contributing cause
ceding an exercise bout undertaken at a fixed workload. of fatigue during endurance exercise. It is noteworthy,
Levine et al. (1924) also observed that runners who com- however, that CHO feeding can also improve performance
pleted the 1923 Boston marathon exhibited hypoglycemia via nonmetabolic effects through modulating regions of
immediately postexercise, thus, suggesting that low CHO the brain associated with reward and motor control
availability may be linked to fatigue. These early studies (Carter et al., 2004a,b; Chambers et al., 2009).
provided the initial evidence that CHO was an important In addition to a simple “fuel store,” our understanding
fuel source for exercise performance. of CHO metabolism has advanced considerably with the
Nonetheless, much of the foundation of our understand- use of more sophisticated molecular biology techniques. In
ing of CHO metabolism was developed by Scandinavian this regard, it is now accepted that glycogen is more than
researchers in the late 1960s with the introduction of the a store (Philp et al., 2012), acting as a regulator of many
muscle biopsy technique (Bergstrom and Hultman, 1966; key cell-signaling pathways related to promoting the oxi-
Bergstrom et al., 1967; Hermansen et al., 1967). These dative phenotype, insulin sensitivity, contractile processes,
researchers provided the platform for modern day sports obesity, protein degradation, and autophagic processes
nutrition practice in a series of studies that collectively (Philp et al., 2012; Bartlett et al., 2015). When taken
demonstrated: (1) muscle glycogen is depleted during exer- together, it is remarkable that whole-body storage of only
cise in an intensity-dependent manner; (2) high CHO diets 500 g of substrate can exert such profound effects on mul-
increase muscle glycogen storage and subsequently tiple tissues, organs, and systems, the result of which has
improve exercise capacity; and (3) muscle glycogen stor- considerable effects to human health and performance.
age is enhanced following prior glycogen depletion (i.e., The aim of this chapter is to therefore present a con-
the super-compensation effect), the magnitude of which is temporary review of our understanding of CHO metabo-
dependent on high CHO availability. This body of work lism with specific reference to exercise metabolism and
remains some of the most highly cited papers in the field physiology. We begin by presenting an overview of CHO
and is referenced accordingly in contemporary sport nutri- storage followed by outlining regulatory steps in the
tion guidelines (Thomas et al., 2016). control of both muscle glycogen metabolism and muscle
The field continued to develop throughout the 1980s glucose uptake. We then proceed to discuss how manipu-
and 1990s with the consistent finding that CHO feeding lating substrate availability (i.e., CHO availability itself)

Muscle and Exercise Physiology. DOI: https://doi.org/10.1016/B978-0-12-814593-7.00011-6

© 2019 Elsevier Inc. All rights reserved. 251
252 SECTION | III Muscle Metabolism and Exercise Physiology

and alterations to specifics of the exercise protocol (e.g., branch-like structure via 1:4 and 1:6 glycosidic bonds.
intensity, duration) and training status of the athlete can Glycogen granules are formed on the protein glycogenin
all affect the magnitude of CHO utilized during exercise. and can be as large as 42 nm in diameter as well as having
The previous section, therefore, provides the platform to potentially 12 tiers. At its maximal size, the granule can
discuss the well-known effects of both endogenous (i.e., consist of as much as 55,000 glucosyl units (Graham et al.,
liver and muscle glycogen) and exogenous (i.e., CHO 2008). Nonetheless, the majority of glycogen granules in
feeding during exercise) CHO availability on exercise human skeletal muscle are reported to be 25 nm in diameter
performance. Finally, we then discuss the role of CHO with approximately 8 tiers (Marchand et al., 2002).
availability on modulating aspects of training adaptation, Although muscle glycogen has traditionally been quantified
a field of research that has grown rapidly in the last through acid hydrolysis in whole muscle homogenate, it is
decade. Due to space constraints, it is not possible to of course apparent that glycogen is expressed and utilized in
review all papers in the field, though we have chosen to fiber type-specific patterns as well as being located in spe-
highlight and integrate those seminal papers that have cific intracellular locations within muscle cells themselves.
significantly advanced our understanding of both meta- Using histochemical techniques, it has typically been
bolic regulation and practical application. reported that resting glycogen content is not apparently
different between type I and type II fibers (Essen and
Henriksson, 1974; Essen et al., 1975; Stellingwerff et al.,
11.2 OVERVIEW OF CARBOHYDRATE 2007). Nonetheless, using biochemical quantification
(a more quantitative measure) it has been reported that
STORAGE type II fibers may contain 50 100 mmol
(kg d.w.)21 more
CHO is predominantly stored as glycogen in both the liver glycogen than type I fibers (Tsintzas et al., 1995, 1996).
(approximately 100 g) and muscle (approximately 400 g) Regardless of method of quantification, glycogen depletion
with 5 g also circulating in the bloodstream as glucose. during exercise is dependent on fiber type recruitment pat-
In skeletal muscle, glycogen is typically expressed as terns depending on the specifics of the exercise protocol.
mmol
kg21 of dry muscle weight (d.w.) where concentra- For example, during prolonged steady-state type protocols,
tions in whole muscle homogenate can vary from 50 to type I fibers show a preferential depletion whereas during
800 mmol
kg21 depending on training, fatigue, and die- near maximal or supra-maximal type activity, type II fibers
tary CHO intake (see Fig. 11.1). become recruited and show considerable glycogen depletion
The glycogen granule itself is essentially a tiered struc- (Gollnick et al., 1974). In activities involving high-intensity
ture of glucose units (i.e., polymers) that is formed in a intermittent exercise (e.g., a soccer match), considerable

1000
Exhaustion
900 Train-low
Untrained rest
Trained rest
Muscle glycogen mmol ⋅ (kg d.w.)–1

800
Highly trained and CHO loaded
700

600

500

400

300

200

100

0
Population/status

FIGURE 11.1 Variations in muscle glycogen storage according to fatigue status, training status, and dietary CHO intake. Data are compiled from
studies including Bussau, V.A., et al., 2002. Eur. J. Appl. Physiol. 87, 290 295, Bartlett, J.D., et al., 2012. J. Appl. Physiol. 112, 1135 1143,
Taylor, C., et al., 2013. Eur. J. Appl. Physiol. 113, 1457 1468, Impey, S.G., et al., 2015. Physiol. Rep. 4, e12803 (taken from Fig. 11.2,
Hearris, et al., 2018. Nutrients 10, E298, under the terms of the Creative Commons Attribution 4.0 International License, https://creativecommons.
org/licenses/by/4.0/).
 Exercise and Carbohydrate Metabolism Chapter | 11 253

glycogen depletion is observed in both muscle fiber types definitive need to further quantify intracellular glycogen
thus reflecting recruitment patterns to support both moderate utilization in a variety of exercise settings, according to
and high-intensity running speeds (Krustrup et al., 2006). training status, age, and gender.
The use of transmission electron microscopy (TEM)
has also revealed that glycogen is stored in three distinct 11.3 REGULATION OF CARBOHYDRATE
subcellular pools contained in the myofibrils (intramyofi- METABOLISM
brillar glycogen, 5% 15% of total glycogen pool),
between myofibrils (intermyofibrillar glycogen, 75% of An overview of key steps in the regulation of CHO
total glycogen pool) and also beneath the sarcolemmal metabolism is provided in Fig. 11.2. There are a number
region (sub-sarcolemmal glycogen, 5% 15% of total gly- of potential sites of control that can regulate the interac-
cogen pool). In endurance-trained athletes, it appears that tion of CHO and lipid metabolism during endurance exer-
both intramyofibrillar and sub-sarcolemmal glycogen cise. These include availability of intramuscular and
stores are greater in type I fibers compared with type II extra-muscular substrate (controlled by diet and the action
fibers whereas inter-myofibrillar glycogen storage is of key hormones such as the catecholamines and insulin),
greater in type II fibers (Nielsen et al., 2011). In relation the abundance of transport proteins involved in transport-
to acute exercise itself, it is also apparent that intramyofi- ing substrates across both the plasma and mitochondrial
brillar glycogen stores show a preferential depletion membranes and, of course, the activity of the key regula-
(Marchand et al., 2007) and that failure to restore this spe- tory enzymes involved in the metabolic pathways. The
cific pool in the immediate hours after exercise is associ- activity of regulatory enzymes can be modified acutely
ated with impaired Ca21 release from the sarcoplasmic through covalent modification (i.e., phosphorylation and
reticulum (SR) (Nielsen et al., 2011; Ortenblad et al., dephosphorylation largely under hormonal control) and/or
2011). Clearly, our understanding of muscle glycogen allosteric regulation via important signaling molecules
storage has advanced considerably and there remains a that are produced in the muscle as a result of contraction,

FIGURE 11.2 Overview of CHO metabolism and main control points. Key regulatory enzymes are well recognized as PHOS, HK, PFK, LDH, and PDH.
Additionally, the rate of muscle glucose uptake can also determine the flux through glycolysis. Taken from Fig. 11.2, Hearris, M.A., et al., 2018. Nutrients
10, E298, under the terms of the Creative Commons Attribution 4.0 International License, https://creativecommons.org/licenses/by/4.0/.
254 SECTION | III Muscle Metabolism and Exercise Physiology

for example, ADP, AMP, IMP, Pi, Ca21, and H1. synthase; ETC, electron transport chain; G-1-P, glucose-1-
Enzyme activity can also be modified through substrate phosphate; G-6-P, glucose-6-phosphate; Glu, glucose;
activation or product inhibition such that increasing the GLUT4, glucose transporter 4; H1, hydrogen ion; H2O,
substrate concentration increases catalysis whereas water; IRS-1, insulin receptor substrate 1; HK, hexokinase;
increased product concentration may inhibit the reaction. LDH, lactate dehydrogenase; O2, oxygen; NAD, nicotin-
Finally, enzyme activity can be regulated long term amide adenine dinucleotide; TCA cycle, tricarboxylic acid
through increasing the muscle cell’s content of the actual cycle; Pi, inorganic phosphate; PCr, phosphocreatine; PFK,
enzyme protein (i.e., more of the enzyme is actually pres- phosphofructokinase; PhK, phosphorylase kinase; Phos,
ent) as would occur with endurance training. Clearly, glycogen phosphorylase; PI3-K, phosphoinositide 3-kinase.
muscle cells possess a highly coordinated and regulatory
network of signaling and feedback pathways which func-
11.3.1 Effects of Exercise Intensity
tion to ensure ATP demand is matched by ATP synthesis.
From a physiological perspective, key factors such as and Duration
exercise intensity, duration, nutritional status, training sta- As exercise intensity progress from moderate (i.e., 65%
tus, etc. can all regulate substrate utilization during exer- _ 2max ) to high-intensity (85% VO
VO _ 2max ), muscle glycogen-
cise, largely through influencing the potential regulatory olysis and glucose uptake increases such that CHO metab-
control points discussed earlier. This section will outline olism predominates. In contrast, there appears to be
the regulation of CHO utilization during endurance exer- reduction in whole-body lipid oxidation due to a reduction
cise where we pay particular attention to what is currently in both plasma FFA and intramuscular triglyceride oxida-
considered the predominant sites of regulation that is rele- tion. Maximal rates of lipid oxidation are considered to
vant to the specific situation. As a prelude to the text to occur around 65% VO _ 2max though this is dependent on a
follow, it is pertinent to highlight that major metabolic number of other factors such as training status, gender,
control points include glycogen phosphorylase (see and diet (Achten and Jeukendrup, 2004).
Fig. 11.3), muscle glucose uptake (see Fig. 11.4) and The breakdown of muscle glycogen to glucose-1-
pyruvate dehydrogenase (PDH) (see Fig. 11.5). phosphate is under the control of glycogen phosphorylase
ADP, adenosine diphosphate; AK, adenylate kinase; and this reaction requires both glycogen and Pi as sub-
Akt, protein kinase B; AMP, adenosine monophosphate; strates. Phosphorylase, in turn, exists as a more active a
ATP, adenosine triphosphate; Ca21, calcium; CHO, carbo- form (which is under the control of phosphorylation by
hydrate; CK, creatine kinase; Cr, creatine; CS, citrate phosphorylase kinase) and also as a more inactive b form

FIGURE 11.3 Regulation of glycogen

phosphorylase activity. Positive allosteric
effectors are shown in green.
ADP, adenosine diphosphate; AMP, adeno-
sine monophosphate; ATP, adenosine tri-
phosphate; Ca21, calcium; cAMP, cyclic
adenosine monophosphate; GS, G protein;
GDP, guanosine diphosphate; GTP, guano-
sine triphosphate; PKA, protein kinase A; Pi,
inorganic phosphate.
 Exercise and Carbohydrate Metabolism Chapter | 11 255

FIGURE 11.4 Regulation of muscle glucose

uptake.
AMP, adenosine monophosphate; AMPK, 5ʹ aden-
osine monophosphate-activated protein kinase;
Akt, protein kinase B Ca21, calcium; CaMK,
calmodulin-dependent protein kinase; G-6-P, glu-
cose-6-phosphate; GS, glycogen synthase; HK,
hexokinase; IRS-1, insulin receptor substrate 1; PI
3-K, phosphatidylinositol 3-kinase.

FIGURE 11.5 Regulation of PDH activity.

ADP, adenosine diphosphate; ATP, adenosine triphos-
phate; Ca21, calcium; Pi, inorganic phosphate; PDH,
pyruvate dehydrogenase.

(which exists in a dephosphorylated form due to the the onset of contraction (Parolin et al., 1999), it appears
action of protein phosphatase 1). Given that phosphory- that post transformational mechanisms are in operation
lase can be transformed via covalent modification (i.e., during more prolonged periods of high-intensity exercise
phosphorylation by phosphorylase kinase) mediated given that glycogenolysis still occurs despite reduced
through adrenaline, it would be reasonable to expect that transformation. In this regard, vital signals related to the
greater phosphorylase transformation from b to a may be energy status of the cell play a more prominent role.
one mechanism to explain increased glycogenolysis evi- Indeed, as exercise intensity progresses from moderate to
dent with increasing exercise intensity. This would also high-intensity exercise, the rate of ATP hydrolysis
be logical given that sarcoplasmic Ca21 levels would be increases so much so that there is a greater accumulation
increased with high-intensity exercise (given the need for of ADP, AMP, and Pi. In this way, the increased accumu-
more rapid cross-bridge cycling) and that Ca21 is a potent lation of Pi as a result of increased ATP hydrolysis can
positive allosteric regulator of phosphorylase kinase increase glycogenolysis as it provides increased substrate
through binding to the calmodulin subunit. However, the required for the reaction. Furthermore, greater accumula-
percentage of phosphorylase in the more active a form tions of free ADP and AMP can also subsequently fine
does not appear to be increased with exercise intensity tune the activity of phosphorylase a through allosteric
and, in fact, is decreased after only 10 min of high- regulation (Howlett et al., 1998). Finally, although it is
intensity exercise, which may be related to the reduced well documented that phosphorylase is under the
pH associated with intense exercise (Howlett et al., 1998). hormonal control of adrenaline, infusion of adrenaline to
Whereas this mechanism of transformation (mediated by levels beyond that of endogenous production during high-
Ca21 signaling) may be in operation within seconds of intensity exercise (85% VO _ 2max ) does not augment
256 SECTION | III Muscle Metabolism and Exercise Physiology

glycogenolysis (Chesley et al., 1995), likely due to regulators of fuel utilization patterns during exercise and
already sufficient activation of phosphorylase through the this concept is discussed in the next section.
local mechanisms discussed earlier.
In addition to muscle glycogen, the contribution of
plasma glucose to ATP production also increases with
11.3.2 Effects of Substrate Availability
exercise intensity. The most likely explanation for this is Modifying substrate availability through dietary manipu-
due to increased muscle blood flow (and hence substrate lation (such as loading regimens, preexercise meals or
delivery) in addition to increased muscle fiber recruitment providing enhanced substrate availability during exercise)
(Rose and Richter, 2005). Although glucose uptake is also has been consistently shown to alter metabolic regulation
regulated by GLUT4 content, GLUT4 is unlikely to play a during endurance exercise through various control points.
role in this situation given that GLUT4 translocation to the Increasing muscle glycogen concentration enhances gly-
plasma membrane is not increased with exercise intensity cogenolysis during exercise (Hargreaves et al., 1995) by
(Kraniou et al., 2006). Once glucose is transported into the enhancing phosphorylase activity given that glycogen is a
cytosol, it is phosphorylated to glucose-6-phosphate under substrate for phosphorylase. The enhanced glycogenolysis
the control of hexokinase. Evidence suggested that hexoki- with elevated glycogen stores does not appear to
nase activity is also not limiting given that patients with affect muscle glucose uptake (Hargreaves et al., 1995;
type 2 diabetes (who have reduced maximal hexokinase Arkinstall et al., 2004). In addition to glycogenolysis,
activity) display normal patterns of exercise-induced glu- muscle glycogen also appears to be a potent regulator of
cose uptake likely due to normal perfusion and GLUT4 PDH activity (and thus CHO oxidation) during exercise.
translocation (Martin et al., 1995). In contrast, during Indeed, commencing exercise with reduced muscle glyco-
intense exercise at near maximal or supra-maximal inten- gen attenuates the exercise-induced increase in PDH
sity, glucose phosphorylation may be rate limiting to glu- activity and vice versa (Kiilerich et al., 2010), likely due
cose utilization given that high rates of glucose-6- to reduced glycolytic flux as well as increased resting
phosphate secondary to muscle glycogen breakdown can content of PDK4 (the kinase responsible for deactivating
directly inhibit hexokinase activity (Katz et al., 1986). PDH) when glycogen concentration is low. PDH regula-
Once glucose enters the glycolytic pathway, the rate- tion appears particularly sensitive to nutritional status
limiting enzyme to glycolysis is considered as phospho- even at rest. In fact, just three days of a low CHO (but
fructokinase (PFK). PFK is allosterically activated by increased fat diet) up-regulates PDH kinase activity and
ADP, AMP, and Pi and this mechanism is likely to explain down-regulates PDH activity (Peters et al., 1998).
high rates of glycolysis during intense exercise even in the Although the effects of exercise intensity on substrate
face of metabolic acidosis when PFK could be inhibited. utilization were discussed previously, it appears that mus-
In contrast to exercise intensity, prolonged steady-state cle glycogen availability can influence fuel metabolism
exercise lasting several hours is characterized by a shift over and above that of exercise intensity. Indeed,
toward increased lipid oxidation and reduced CHO oxida- Arkinstall et al. (2004) observed that glycogen utilization
tion rates. This shift in oxidation rates is accompanied by was enhanced during exercise at 45% VO _ 2max that was
an increased contribution of plasma FFA toward energy commenced with high glycogen (591 mmol
(kg d.w.)21)
expenditure and a decreased reliance on both muscle glyco- as opposed to exercise at 70% VO _ 2max commenced with
gen and IMTGs. Studies examining the regulatory mechan- low glycogen concentration (223 mmol
(kg d.w.)21)
isms underpinning this shift in substrate utilization have despite the higher intensity. In contrast to glycogen utili-
suggested that a reduction in muscle glycogen availability zation and CHO oxidation rates, lipid oxidation was high-
(due to progressive glycogen depletion) and hence a est when exercise was commenced with reduced glycogen
reduced glycolytic flux down-regulate PDH activity stores. The shift towards fat oxidation when preexercise
thereby leading to reduced CHO oxidation. In addition, muscle glycogen is low is likely mediated by a number of
progressive increases in plasma FFA availability (due to contributing factors. Firstly, reduced glycogen availability
continual lipolysis in adipose tissue) stimulate lipid oxida- is associated with increased plasma FFA availability as
tion. The down-regulation of PDH activity as exercise well as adrenaline concentrations thus favoring conditions
duration progresses may be due to reduced pyruvate flux for augmented lipid oxidation and lipolysis, respectively,
therefore reducing substrate production required for the compared with conditions of high glycogen concentration
PDH reaction (Watt et al., 2002). In addition, more recent (Arkinstall et al., 2004). However, when a preexercise
data demonstrate an up-regulation of PDH kinase activity meal is ingested and glucose infused during glycogen-
during exercise which would therefore directly inhibit PDH depleted exercise such that minimal differences exist
activity (Watt et al., 2004). Taken together, these data are between plasma FFA and adrenaline, lipid oxidation is
consistent with the many observations that increasing or still augmented (Roepstorff et al., 2005). In such circum-
decreasing substrate availability is one of the most potent stances, available evidence points to regulation within the
 Exercise and Carbohydrate Metabolism Chapter | 11 257

muscle cell itself and more specifically, a carnitine medi- levels occurring during fasted exercise
ated increase in lipid oxidation. Indeed, these researchers (6.1 μmol
kg21
min21). Taken together, while these
observed lower PDH activity, acetyl-CoA, and acetyl car- data suggest that only small elevations in insulin can
nitine content and increased free carnitine concentrations attenuate lipolysis (i.e., 10 30 μU/mL), they also demon-
during exercise when glycogen depleted compared with strate a limitation within the muscle cell itself during
glycogen loaded conditions. Interestingly, ACC phosphor- CHO fed conditions. In accordance with reduced lipid
ylation increased and malonyl CoA decreased similarly in oxidation following CHO feeding, CHO oxidation was
both conditions despite higher AMPK activity when gly- increased due to increased glucose uptake (and oxidation)
cogen was reduced. Such data provide further evidence as well as muscle glycogenolysis. The enhanced rates of
that malonyl CoA is not involved in regulating lipid glycogenolysis was suggested to be due to increased allo-
metabolism during exercise but provide further support steric activation of phosphorylase given that AMP and Pi
for a critical role of carnitine in regulating the interaction production is greater during conditions of reduced plasma
between CHO and lipid utilization (Wall et al., 2011). FFA availability, as is the case with CHO feeding.
When compared with exercise after overnight fasting, In an effort to ascertain the source of limitation to
ingestion of CHO-rich meals within the hours before lipid oxidation within the muscle following CHO feeding,
exercise (as well as CHO ingestion during exercise) has Coyle et al. (1997) infused octanoate (an MCFA) or pal-
been shown to enhance endurance performance (Wright mitate (an LCFA) during 40 min of exercise at 50%
et al., 1991). Consequently, it is common practice for ath- _ 2max after an overnight fast or 60 min after ingesting
VO
letes to adopt such dietary approaches to competition. 1.4 g
kg21 of glucose. As expected (based on the previ-
However, it is now well documented that pre- and during ously discussed study), plasma FFA and lipid oxidation
exercise CHO ingestion is one of the most potent ways to was higher in the fasted trials while CHO oxidation was
alter the pattern of CHO utilization during exercise lower in this condition compared with the glucose trials.
through a number of control points. One of the main However, the major finding of this study was that the per-
responses to CHO feeding is to attenuate plasma FFA centage of palmitate oxidized during the glucose trial was
availability and lipid oxidation while simultaneously reduced compared with fasting (70% vs 86%, respec-
increasing CHO oxidation rates. The reduced plasma FFA tively) whereas octanoate was unaffected (99% vs 98%,
availability is due to an attenuation of lipolysis that is reg- respectively). These data therefore suggest that LCFA
ulated by increased circulating insulin concentrations uptake into the mitochondria is reduced with CHO feed-
caused by CHO feeding. The antilipolytic effect of insulin ing and when taken in the context of previous sections in
is mediated through its ability to activate the enzyme this chapter, it becomes increasingly apparent that any
phosphodiesterase which degrades cAMP and thereby condition which accelerates glycolytic flux (e.g.,
attenuates activation of protein kinase A and eventually increased intensity, muscle glycogen, glucose feeding)
hormone sensitive lipase (HSL). can regulate intramuscular lipid metabolism, which again
Convincing data confirming that lipolysis limits fat points to a carnitine mediated limitation. Furthermore,
oxidation following CHO feeding is provided by more recent data has demonstrated that the increased insu-
Horowitz et al. (1997). In this study, male subjects com- lin and decreased adrenaline levels which accompany glu-
pleted 60 min of exercise at 45% VO _ 2max in fasted condi- cose ingestion during exercise appears to result in an
tions or 1 h after consuming 0.8 g
kg21 of glucose (to attenuation of intramuscular HSL activity (Watt et al.,
induce a high insulin response), 0.8 g
kg21 fructose (to 2004), thus highlighting an additional point of control.
induce a low insulin response) or an additional glucose
trial during which intralipid and heparin were infused so
as to maintain plasma FFA availability in the face of high
11.3.3 Effects of Training Status
insulin. In accordance with the insulin response, lipolysis Endurance training results in a number of profound physi-
(as indicated by rate of appearance of glycerol) was ological and metabolic adaptations which function to
reduced with CHO feeding and plasma FFA availability reduce the degree of perturbations to homeostasis for a
was reduced in these conditions. In addition, rates of given exercise intensity and ultimately, delay the onset of
lipolysis exceeded lipid oxidation rates during fasted exer- fatigue. Adaptations to endurance training are most recog-
cise, whereas in the CHO conditions, rates of lipolysis nized functionally by an increase in maximal oxygen
appeared to equal lipid oxidation rates thus implying that uptake as well as a rightward shift in the lactate threshold.
lipolysis limits fat oxidation. However, when intralipid From a metabolic perspective, the most prominent adapta-
and heparin was infused during an additional glucose tion is an increase in the size and number of mitochondria
trial, lipid oxidation rates were enhanced by 30% (i.e., mitochondrial biogenesis) which essentially permits
(4.0 μmol
kg21
min21) compared with the glucose only a closer matching between ATP requirements and produc-
trial (3.1 μmol
kg21
min21) but were still not restored to tion via oxidative metabolism. The adaptive response of
258 SECTION | III Muscle Metabolism and Exercise Physiology

muscle mitochondria is also accompanied by increases in training-induced changes in hormone concentrations such
capillary density, substrate transport proteins and as adrenaline, insulin, and glucagon are unable to explain
increased activity of the enzymes involved in the main all of the effects (Phillips et al., 1996). Rather, it is possi-
metabolic pathways. In addition, endurance training ble that the actual rate of muscle glucose uptake acts as a
increases the capacity for skeletal muscle to store glyco- feedback signal to regulate glucose output from the liver
gen and triglycerides thereby increasing substrate avail- (Phillips et al., 1996).
ability. In relation to substrate utilization during exercise
following endurance training, the most notable response
is a reduction in CHO utilization with a concomitant 11.4 CARBOHYDRATE AND EXERCISE
increase in lipid oxidation (Henriksson, 1977). PERFORMANCE
For a given exercise intensity, glycogen utilization is
Given the effects of exercise intensity, duration and train-
reduced with exercise training (Karlsson and Saltin,
ing status on muscle glycogen utilization, it follows that
1971), an effect that is confined locally to the actual mus-
glycogen depletion (in both muscle and liver) is a major
cles that were trained (Saltin et al., 1976). The reduced
cause of fatigue in both endurance and high-intensity
glycogenolysis observed after training was not due to any
(intermittent) type activities. As such, traditional nutri-
change in phosphorylation transformation, but rather allo-
tional advice for these types of activities (whether it is
steric mechanisms (Chesley et al., 1996; Le Blanc et al.,
competitive situations or training sessions) is to ensure
2004). Indeed, exercise in the trained state is associated
high daily CHO intake before, during and after the activ-
with reduced content of ADP, AMP, and Pi thereby pro-
ity so as to promote both performance and recovery.
viding a mechanism leading to reduced phosphorylase
activity. Le Blanc et al. (2004) also observed reduced
pyruvate and lactate production during exercise under- 11.4.1 Muscle Glycogen and Carbohydrate
taken in the trained state as well as reduced PDH activity.
As a result of the reduced CHO flux, it is therefore likely
Loading
that the attenuated pyruvate production (in addition to The basic principles of CHO loading were developed in
reduced ADP accumulation) may have attenuated PDH the late 1960s where it was identified that a period of
activity. exhaustive exercise followed by several days of high die-
In addition to training-induced reductions in muscle tary CHO intake induces a super-compensation effect so
glycogenolysis, several investigators have observed that that glycogen storage is augmented (Bergstrom and
training reduces exercise-induced liver glycogenolysis, as Hultman, 1966; Bergtrom et al., 1967). A less extreme
demonstrated by the rate of appearance of glucose in the form of CHO loading was developed in the 1980s where
circulation. There is some evidence (although this is not Sherman et al. (1981) observed that a simple exercise
consistent within the literature) that endurance training taper in conjunction with several days of increased dietary
also increases skeletal muscle gluconeogenesis following CHO intake was also sufficient to increase glycogen stor-
training (Bergman et al., 2000). In accordance with age. It is now generally accepted that trained athletes can
reduced rates of glucose production, muscle glucose increase glycogen storage in both type I and II fibers
uptake is reduced when exercise is undertaken at the within 24 48 h of increased CHO intake (Bussau et al.,
same absolute workload following a period of endurance 2002). In relation to practical application, it is also
training (Bergman et al., 1999). accepted that high glycemic foods are superior to low gly-
Despite the fact that training increases total muscle cemic foods (Burke et al., 1993) in augmenting glycogen
GLUT4, the reduction in exercise-induced muscle glucose storage and that dietary intakes of 8 12 g
kg21 per day
uptake is most likely caused by a reduced translocation are required (Thomas et al., 2016). The general consensus
of GLUT4 to the sarcolemma following training thereby from the wealth of studies undertaken in the past 40 years
reducing the capacity to transport glucose (Richter et al., is that CHO loading can improve performance and capac-
1998). This particular study utilized a knee extensor train- ity especially when the exercise is greater than 90 min in
ing and exercise model where only one limb was trained duration (Hawley et al., 1997). The enhanced perfor-
but yet both limbs performed the exercise protocol before mance effect is likely initially mediated by a delay in the
and after training. In this way, training-induced alterations time-point at which energy availability becomes limiting
in hormonal and cardiovascular status were minimized to the maintenance of the desired workload, which in the
and the reduced glucose uptake and GLUT4 translocation case of race pace is dependent on sustained and high rates
was likely mediated by local contractile factors. In sum- of CHO oxidation (O’Brien et al., 1993; Leckey et al.,
marizing the link between liver glucose production and 2016). Indeed, in reviewing the literature Hawley et al.
muscle glucose uptake, it is generally accepted that (1997) cited that CHO loading can improve exercise
 Exercise and Carbohydrate Metabolism Chapter | 11 259

capacity by approximately 20% and time-trial perfor- glucose transporters, it is now known that exogenous
mance can increase by 2% 3%. In addition to providing CHO oxidation rates can increase to 1.8 g
min21 with
substrate availability for ATP production, it is now recog- the addition of sucrose or fructose to the CHO blend
nized that glycogen availability (especially the intramyo- (Jeukendrup, 2014). When taken together, it is thought
fibrillar storage pool) can directly modulate contractile that CHO feeding during exercise may therefore augment
function. Indeed, a series of studies from Ørtenblad et al. exercise performance via multiple mechanisms consisting
(Ørtenblad et al., 2011, 2013; Geji et al., 2014) have col- of muscle glycogen sparing (Stellingwerff et al., 2007),
lectively shown a preferential utilization of this storage liver glycogen sparing (Gonzalez et al., 2015) and mainte-
pool during exercise in a manner that also correlates with nance of plasma glucose and CHO oxidation rates (Coyle
impaired Ca21 release from the SR. Such impaired et al., 1986). However, despite the proposed mechanisms
excitation-contraction (EC) coupling is likely to be of par- it is important to acknowledge that exercise duration,
ticular importance during those situations where higher intensity, nutritional status prior to exercise, CHO intake
power outputs and sprint finishes are required in the very rate and the CHO type/blend consumed during exercise
late and finishing stages of races. will all have an impact upon the efficacy of these
mechanisms, fuel metabolism and performance.
It is noteworthy that exogenous CHO feeding during
11.4.2 Preexercise Carbohydrate Availability
exercise also improves performance (Jeukendrup et al.,
Whereas the 1960s and 1970s focused on CHO loading 1997) when exercise duration is ,60 min (i.e., glycogen
studies, research in the next two decades examined the availability is not limiting), an effect that is not apparent
effects of preexercise feeding as well as consuming addi- when glucose is directly infused to the bloodstream dur-
tional CHO during exercise. Preexercise feeding (i.e., ing exercise (Carter et al., 2004a). Such data suggest that
3 4 h before competition) is not only advantageous as it CHO feeding may also improve exercise performance via
can lead to further elevations in muscle glycogen content nonmetabolic effects but through direct effects on the cen-
(Wee et al., 2005) but can also restore liver glycogen con- tral nervous system (Carter et al., 2004b). To this end, the
tent which is usually depleted after an overnight fast. The last decade of research has resulted in a growing body of
latter is particularly important given that liver glycogen literature demonstrating that simply “rinsing” CHO in the
content is related to exercise capacity (Casey et al., oral cavity (for 10-s periods every 5 10 min during exer-
2000). Sherman et al. (1991) observed that time-trial per- cise) is also ergogenic to performance (Burke and
formance after 90 min of steady-state exercise at 70% Maughan, 2015), an effect that is independent of sweet-
_ 2max was greater when 150 g of CHO was consumed
VO ness (Chambers et al., 2009) and that is especially appar-
before exercise compared with 75 g of CHO, both of ent in the absence of a preexercise CHO meal (Lane
which were greater than no meal. The enhanced perfor- et al., 2013) and low preexercise muscle glycogen
mance effect was associated with maintenance of blood (Kasper et al., 2015).
glucose concentration late during exercise which is impor- The conventional approach to CHO fueling during
tant because liver glucose production and muscle glucose exercise is to consume 6% 8% CHO beverages, although
uptake and oxidation become more important when mus- relying solely on this approach does not allow for flexibil-
cle glycogen concentrations begin to decline. In a further ity in terms of individual variations in body mass or
study, the same authors also observed that performance actual fluid requirements given variations in ambient con-
can be further increased when CHO is ingested during ditions (Lee et al., 2014). As such, many athletes rely on
exercise in addition to a preexercise meal (Wright et al., a CHO fueling approach that is based on a combination
1991). As such, current CHO guidelines for preexercise of solids (e.g., bars), semi-solids (e.g., gels) and fluids
feeding advise an intake of 1 4 g
kg21 body mass (e.g., sports drinks) so as to collectively meet their per-
3 4 h prior to exercise (Thomas et al., 2016). sonalized exogenous CHO targets, typically in the region
of 30 90 g
h21 depending on exercise duration.
11.4.3 Carbohydrate Feeding During Nevertheless, although there is little difference in exoge-
nous CHO oxidation rates (albeit in fluid matched condi-
exercise tions) between the aforementioned sources (Pfeiffer et al.,
In addition to high endogenous preexercise muscle glyco- 2010a,b), it is noteworthy that many athletes experience
gen stores, it is widely accepted that exogenous CHO gastrointestinal discomfort when attempting to hit these
feeding during exercise also improves physical, cognitive targets, possibly related to extreme differences in osmo-
and technical elements of performance (Stellingwerff and lality between commercially available CHO gels (Zhang
Cox, 2014). Whereas it was generally accepted that exog- et al., 2015) as well as the presence of fiber, fat, and pro-
enous CHO oxidation rates were thought to be limited at tein in energy bars (Pfeiffer et al., 2012). As such, it is
approximately 1 g
min21 due to saturation of intestinal now advised that athletes should clearly practice their
260 SECTION | III Muscle Metabolism and Exercise Physiology

approach to in-competition fueling during those training II (CaMKII). These kinases subsequently phosphorylate
sessions of similar intensity and duration as competition. downstream targets such as transcription factors and tran-
As a general rule of thumb, it is suggested that scriptional coactivators to induce the up-regulation of
30 60 g
h21 of CHO (glucose polymers) is consumed gene expression (Jager et al., 2007). The most well-
during events lasting ,60 90 min whereas in events studied regulator of mitochondrial biogenesis is the tran-
.2 3 h, 60 90 g
h21 (glucose/fructose blends) is the scriptional coactivator peroxisome proliferator-activated
recommended rate (Thomas et al., 2016) receptor-γ coactivator-1α (PGC-1α). The importance of
PGC-1α as a mediator of mitochondrial biogenesis is evi-
dent from rodent studies demonstrating that overexpres-
11.5 CARBOHYDRATE AND TRAINING sion increases oxidative enzyme activity (Lin et al., 2002)
ADAPTATION and improves exercise capacity (Calvo et al., 2008). In
11.5.1 Overview of Molecular Regulation of humans, elevated PGC-1α mRNA levels are observed fol-
lowing endurance exercise with the highest abundance
Training Adaptations typically present in the first 2 4 h of recovery (Gibala
Being a highly malleable tissue, skeletal muscle has the et al., 2009; Bartlett et al., 2012).
ability to undergo major adaptations and alter its pheno- Both AMPK and p38MAPK can directly phosphory-
type in response to exercise stimuli. Upon the onset of late PGC-1α during acute exercise resulting in its translo-
muscle contraction, multiple molecular signaling path- cation to both the nucleus and the mitochondria. In
ways are activated which subsequently contribute to the the nucleus, it interacts with transcription factors such
adaptive responses within skeletal muscle. In the past as NRF-1, NRF-2, estrogen-related receptor (ERRα), per-
decade of research, accumulating data suggest that these oxisome proliferator-activated receptor (PPARδ), and
signaling pathways are also sensitive to nutrients as well myocyte enhancer factor 2 (MEF2), to induce the up-
as exercise, and that this cross-talk between exercise and regulation of proteins involved in glucose and fatty acid
nutrition stimuli can be manipulated to up-regulate the transport and oxidation. Upon localization to the mito-
adaptive responses to training. Endurance athletes typi- chondria, PGC-1α forms a complex with mitochondrial
cally focus their training to enhance those adaptations transcription factor A (Tfam) at the D-loop region to
within the muscle which will subsequently increase exer- coordinate up-regulation of muscle mitochondrial content
cise capacity and fatigue resistance. Such adaptations and the capacity for substrate metabolism and oxidative
include enhanced cardiac output, increased mitochondrial phosphorylation (Safdar et al., 2011). In addition to PGC-
content, lipid oxidation and angiogenesis, all of which are 1α, the tumor suppressor protein p53 has now emerged as
recognized functionally by increased whole-body oxygen a potential regulator of mitochondrial biogenesis. Indeed,
uptake (VO_ 2max ) and rightward shift of the lactate thresh- acute exercise induces the posttranslational modification
old curve. From an endurance perspective, perhaps the of p53 (Bartlett et al., 2012), and similarly to PGC-1α,
most important of these adaptive responses is the increase this protein also translocates to the nucleus (Philip et al.,
in mitochondrial content, termed mitochondrial biogene- 2011) and the mitochondria (Saleem and Hood 2013) to
sis. This increase in mitochondrial mass ultimately allows interact with Tfam.
endurance athletes to exercise at higher intensities for lon- The principle of promoting high CHO availability
ger periods. A schematic overview of the proposed before, during, and after exercise is the foundation on
mechanisms underpinning skeletal muscle adaptive which traditional sports nutrition guidelines are based.
responses to training is displayed in Fig. 11.6. Although this is essential for promoting maximal compe-
In response to each individual exercise bout, acute tition performance and ensuring adequate recovery, accu-
transcriptional changes take place within the muscle in mulating data now suggest that restricting CHO before,
the hours during recovery, and it is the accumulation of during, and in recovery from endurance-based exercise
these acute responses over time that subsequently alters augments the cell signaling and gene expression responses
the muscle to a more oxidative phenotype through the associated with oxidative adaptations in human skeletal
expression of new proteins (Perry et al., 2010). When muscle. Indeed, both acute and training-based studies
muscle contraction begins, a number of metabolic pertur- have collectively observed that the reduction of both
bations within muscle cells (i.e., increased AMP/ATP endogenous and/or exogenous CHO promotes mitochon-
ratio, Ca21 flux, lactate, hypoxia, and energy availability) drial enzyme activity and protein content, increases both
occur which collectively trigger the activation of key reg- whole body (Yeo et al., 2008b) and intramuscular Hulston
ulatory protein kinases. The most extensively studied of et al. (2010) lipid metabolism and can improve both exer-
these kinases are p38 mitogen-activated protein kinase cise capacity (Hansen et al., 2005) and performance
(p38MAPK), AMP-activated protein kinase (AMPK), sir- (Marquet et al., 2016). This approach to CHO periodiza-
tuin 1 (SIRT1), and calmodulin-dependent protein kinase tion has been termed train-low, compete-high, a model
 Exercise and Carbohydrate Metabolism Chapter | 11 261

which promotes CHO restricted training for augmenting increases in those genes involved in metabolic regulation
adaptation, but ensures high CHO availability during when commencing exercise following an overnight fast
competition to promote maximal performance. rather than the ingestion of a CHO-rich breakfast. Data
from the latter study also suggest that the expression of
genes involved in the regulation of lipid metabolism was
11.5.2 Fasted Training suppressed when CHO was fed before, during, and after
The idea that CHO restriction augments markers of train- 2-h cycling as opposed to the same exercise undertaken in
ing adaptation first emerged when data demonstrated the fasted state. In a subsequent 6-week training study
enhanced expression of genes involved in mitochondrial design, Van Proeyen et al. (2011) attempted to elucidate
biogenesis and substrate oxidation following exercise whether these responses to a single bout of fasted exercise
undertaken with reduced muscle glycogen availability. could be sustained over a longer period. The authors
For example, Pilegaard et al. (2002) demonstrated that the observed augmented citrate synthase (CS) and β-HAD
acute exercise induced increases in PDK4, UCP3, and activity when regular 2-h steady-state cycling was per-
CPT1 mRNA expression were all augmented to a greater formed in the fasted state compared to following the con-
extent when preexercise muscle glycogen levels were low sumption of a breakfast. Nonetheless, the augmented
compared to normal levels. Similarly, both Cluberton biochemical adaptations did not translate to improved
et al. (2005) and Civitarese et al. (2005) observed exercise performance.

FIGURE 11.6 Overview of key molecular signaling pathways regulating endurance training adaptations.
4EBP1, eukaryotic translation initiation factor 4E-binding protein 1; AMPK, 5ʹ adenosine monophosphate-activated protein kinase; COX, cytochrome
c oxidase; CPT-1, carnitine palmitoyltransferase 1; FA, fatty acid; FABP, fatty acid binding protein; HSL, hormone sensitive lipase; IMTGs, intramus-
cular triglycerides; mTORC1, mammalian target of rapamycin complex 1; p38MAPK, p38 mitogen-activated protein kinase; p70S6K, ribosomal pro-
tein S6 kinase beta-1; PDK4, pyruvate dehydrogenase lipoamide kinase 4; PPAR, peroxisome proliferator-activated receptor; PGC-1α, peroxisome
proliferator-activated receptor gamma coactivator 1-alpha; Tfam, transcription factor A.
262 SECTION | III Muscle Metabolism and Exercise Physiology

11.5.3 Postexercise Carbohydrate Restriction steady state and HIT exercise each day, whereas in the
“low” group, steady-state exercise was performed in the
In addition to restricting CHO prior to endurance exercise morning and HIT exercise performed after a 1 2-h recov-
training, data also demonstrate beneficial adaptive ery period during which time CHO was restricted. Before
responses when restricting CHO during the postexercise and after this training block, muscle biopsies were obtained
recovery period. Indeed, Pilegaard et al. (2005) explored to assess markers of adaptation, and a time-trial was com-
this idea with participants completing 75-min of cycling pleted to examine performance improvements in each
at 75% VO _ 2max followed by the consumption of a diet
group. Despite significant increases in CS and, β-HAD
either high or low in CHO for the next 24-h. These activity, COXIV protein content, and rates of fat oxidation
authors observed that although the mRNA expression of in the “low” group following training, time-trial perfor-
PDK4, LPL, UCP3, and CPT1 increased in response to mance was still similar in both groups. Interestingly, the
exercise, activation was only sustained in the low CHO enhanced adaptive responses still occurred in the “low”
group following the 24-h. In a twice-per-day, 6-week group despite cyclists having to reduce exercise intensity
training study it has also been observed that when glucose during HIT training session. These findings suggest that
is consumed during recovery from the first session, the even when overall training intensity is reduced, reduced
enhanced oxidative adaptations are blunted compared to CHO availability is associated with an adaptive response.
when CHO is restricted, despite reduced levels of muscle In a similar study design, Hulston et al. (2011) also
glycogen (Morton et al., 2009). When taken together, reported greater increases in intramuscular lipid oxidation
responses from these studies suggest that reducing CHO and the expression of CD36 and β-HAD following training
availability in the recovery period also modulates the low compared with training high.
muscle adaptive process.

11.5.5 Sleep-Low/Train-Low Models

11.5.4 Twice-per-day Training Models
Subsequent train-low investigations have adopted a
On the basis of the molecular evidence derived from acute “sleep-low/train-low” approach, whereby participants per-
studies, Hansen et al. (2005) were the first to investigate form an evening training session and then restrict CHO
the idea that repeated exercise (i.e., exercise training) during the recovery period so they go to sleep with low
with reduced CHO availability augments oxidative adap- levels of muscle glycogen. A morning training session is
tations and subsequent endurance performance. In a 10- then subsequently performed the following day under
week long training study using single leg knee extensor levels of low muscle glycogen availability. This method
exercise and training 5 days per week, participants either was first examined using whole-body exercise by Bartlett
trained one limb every day with normal levels of muscle et al. (2013), whereby participants were required to per-
glycogen, or the contralateral limb twice every second form an acute bout of HIT running under conditions of
day whereby the second session was undertaken with either high or low CHO availability. In the low condition,
reduced muscle glycogen availability. Exercise during the participants had performed glycogen-depleting exercise
twice-per-day sessions was interspersed with 2-h of recov- the evening prior to the trial, and CHO was restricted dur-
ery, during which time no CHO was consumed. In this ing and in recovery from exercise. The phosphorylation
way, both limbs performed identical work, but one limb of p53 was significantly higher immediately post and 3-h
performed 50% of these sessions with low muscle glyco- postexercise in the low compared to the high trial.
gen availability. The authors observed greater increases in Additionally, the mRNA expression of PDK4, Tfam,
CS activity in the limb which had undertaken training COXIV, and PGC-1α were all significantly greater in the
with lower levels of muscle glycogen compared to nor- low trial at 3-h postexercise compared to when CHO was
mal. Additionally, greater improvements in exercise consumed before, during, and after exercise. In a subse-
capacity were observed in the “low” limb compared to quent study (Lane et al., 2015), a sleep-low strategy was
normal, suggesting that repeatedly training in this way employed whereby participants ingested isoenergetic diets
may lead to performance gains in the long term. containing 8 g
kg21 CHO, but timing of ingestion was
Yeo et al. (2008b) subsequently explored this concept altered to elicit sleeping low. They consumed either
using a “real-world” design more applicable to elite ath- 8 g
kg21 CHO prior to evening HIT then slept low, or
letes. Using well trained male cyclists in a 3-week training consumed 4 g
kg21 CHO prior to the evening HIT then
block, cyclists trained 6 times per week, either once every 4 g
kg21 CHO before bed. The following morning they
day with high muscle glycogen availability in one group, then completed a 2-h steady-state cycling protocol. While
or twice every other day so the second session was under- fat oxidation and PDK4 mRNA expression were signifi-
taken with reduced levels of muscle glycogen in the other cantly greater following fasted morning exercise, those
group. In the “high” group cyclists alternated between genes involved in the regulation of mitochondrial
 Exercise and Carbohydrate Metabolism Chapter | 11 263

biogenesis showed similar exercise induced increases in remains little evidence that this has any actual beneficial
both groups (Lane et al., 2015). Since the participants in effect on performance (Burke, 2015). It is possible that
this study were highly trained, they still maintained high acute elevations in circulating FFA availability during
levels of muscle glycogen despite “sleeping low,” thus exercise may regulate key cell-signaling kinases and tran-
further highlighting that the absolute muscle glycogen scription factors as well as modulating the expression of
concentration may be an important regulatory factor in genes regulating both CHO and lipid metabolism. Indeed,
modulating adaptations, especially in well trained popula- Zbinden-Foneca et al. (2013) observed suppressions in
tions. More recent work from Marquet et al. (2016) p38MAPK during exercise following the pharmacological
focused on incorporating the sleep-low strategy as part of ablation of FFA availability when compared with control
a 3-week training block with elite triathletes. Using a sim- conditions. Additionally, the enhanced p38MAPK phos-
ilar CHO feeding approach to Lane and colleagues, these phorylation observed by Cochran et al. (2010) using a
authors observed that when the sleep-low training strategy twice-per-day exercise model was associated with
was employed, 10km time-trial performance was enhanced circulating FFA availability during the after-
improved significantly compared to when normal levels noon exercise. When taken together these data suggest
of CHO were consumed across the training block. When that FFAs may act as signaling intermediates for
taken together, these findings collectively suggest that the p38MAPK when CHO is low. Further studies have also
sleep-low/train-low strategy is effective for not only fur- observed increases in resting intramuscular triglyceride
ther up-regulating the muscle adaptive responses to train- stores, HSL, AMPK-α2 activity (Yeo et al., 2008a), and
ing, but also improving endurance performance. increases in the protein content of CD36 (Cameron-Smith
While the mechanisms underpinning the aforemen- et al., 2003) in response to 5 days of high-fat feeding.
tioned adaptive responses to both acute and chronic exer- Such adaptations undoubtedly contribute to the enhanced
cise are still not fully understood, they are likely rates of lipid oxidation observed during exercise follow-
mediated by upstream signaling from AMPK and ing “fat adaptation” protocols and would appear beneficial
p38MAPK. Indeed, AMPK has the capacity to be modu- for endurance athletes.
lated by the glycogen status of the muscle through a Nonetheless, it is noteworthy that high-fat feeding
glycogen-binding domain on the β-subunit (McBride may actually impair glycogen utilization during exercise.
et al., 2009), with data suggesting that AMPK is more Indeed, Stellingwerff et al. (2006) observed a significant
active when glycogen is depleted. Findings from reduction in PDH activity following 5 days of high-fat
Wojtaszewski et al. (2003) indeed demonstrated that feeding, likely inhibiting the entry of CHO in to the
when preexercise muscle glycogen levels are reduced, Krebs cycle. More recently, data also demonstrates that
AMPKα2 activity and ACCSer221 phosphorylation are sig- acute high-fat feeding significantly increases the mRNA
nificantly elevated following steady-state cycling com- expression of PDK4 for up to 15-h postexercise, indica-
pared to when muscle glycogen is high. In a subsequent tive of suppressive effects on CHO metabolism through
study, Chan et al. (2004) also observed a significantly the PDH complex (Hammond et al., 2016). When taken
greater nuclear abundance of p38MAPK both pre- and together, these findings suggest that rather than preparing
postexercise when muscle glycogen levels were low com- elite athletes for competition, high-fat feeding may actu-
pared to high. In another twice-per-day train-low study, ally negate the capacity to utilize CHO during high-
Cochran et al. (2010) also reported significantly greater intensity exercise thus impairing performance. Indeed, in
elevations in p38MAPK phosphorylation following the a study examining the effects of a ketogenic diet during
second exercise session when participants consumed no three weeks of intense training in elite race walkers,
CHO during recovery. These data are highly suggestive Burke et al. (2017) observed that despite improvements in
of both AMPK and p38MAPK being nutrient sensitive, whole-body oxidation rates, economy, and overall perfor-
and thus likely regulating the downstream events leading mance were negatively impacted by this type of feeding
to increases in mitochondrial biogenesis including p53 when compared with periodized high CHO availability.
and PGC-1α activation. Moreover, although many endurance training-induced
skeletal muscle adaptations are regulated at a transcrip-
tional level, the turnover of myofibrillar (i.e., contractile)
11.5.6 High-Fat Feeding proteins are largely regulated through the translational
In addition to the manipulation of CHO availability to machinery and the mechanistic target of rapamycin com-
promote training adaptations, data also suggest a potential plex (mTOR) and ribosomal protein S6 kinase 1
modulatory role of high-fat availability in augmenting the (p70S6K) signaling axis (outlined in Fig. 11.6) (Moore
training response. Indeed, many studies have demon- et al., 2014). In this regard, data collected from lipid and
strated shifts in substrate utilization during exercise fol- heparin infusion suggests that high circulating FFA avail-
lowing “fat adaptation” protocols, however, there still ability actually impairs muscle protein synthesis
264 SECTION | III Muscle Metabolism and Exercise Physiology

(Stephens et al., 2015). Hammond et al. (2016) investi- effects, whereby commencing exercise with low glycogen
gated this concept using a twice-per-day, whole-body induces “work-efficient” cell signaling related to mitochon-
exercise model whereby participants completed morning drial biogenesis. For instance, the aforementioned work
HIT running and afternoon steady-state running (3.5-h demonstrates that training with low preexercise
recovery between sessions) under conditions of either (B300 mmol
(kg d.w.)21) glycogen induces a significant
high CHO, or low CHO but high-fat availability. Indeed, activation of AMPK in significantly less time (B60 min)
authors observed suppression in the activity of p70S6K at than when training is commenced with high glycogen.
3-h postexercise in the high-fat feeding trial, suggesting ACC, acetyl-CoA carboxylase; AMPK, 5ʹ adenosine
that postexercise high-fat feeding may actually impair monophosphate-activated protein kinase; Ca21, calcium;
skeletal muscle remodeling process. Additionally, it was COX, cytochrome c oxidase; p38, p38 mitogen-activated
also observed that the exercise induced increases in PGC- protein kinase; p70S6K, ribosomal protein S6 kinase
1α, p53, Tfam, CS, and ERRα were not different between beta-1; PDK4, pyruvate dehydrogenase lipoamide kinase
trials, suggesting no additional benefit high-fat feeding 4; PGC-1α, peroxisome proliferator-activated receptor
during periods of train-low. gamma coactivator 1-alpha; Tfam, transcription factor A.
Further support for the notion of a glycogen threshold
is also provided from studies that have fed CHO during
11.5.7 Muscle Glycogen Threshold exercise. Indeed, when glycogen utilization during exercise
Although it is now accepted that muscle glycogen availabil- is attenuated through exogenous CHO supplementation
ity is a potent regulator of the adaptive responses of skeletal (i.e., glycogen sparing) and hence does not surpass a “criti-
muscle to exercise training, the level of absolute glycogen cal limit,” AMPK activity is reduced (Akerstrom et al.,
required to augment the pathways regulating mitochondrial 2006). Interestingly, CHO supplementation prevented muscle
biogenesis is currently unknown. However, it appears that a glycogen concentrations surpassing 300 mmol
(kg d.w.)21
“glycogen threshold” may exist, whereby a critical absolute (similar to that of the proposed “critical threshold”), whereas
level of glycogen must be exceeded in order for significant when glycogen was reduced to 200 mmol
(kg d.w.)21 in
activation of specific cell-signaling pathways to occur. The the placebo trial, a significant activation of AMPK
majority of studies that adopt a low glycogen model com- occurred (Akerstrom et al., 2006). In contrast, when exog-
mence exercise with glycogen concentrations between enous CHO supplementation does not spare muscle glyco-
100 300 mmol
(kg d.w.)21, where the activity of key gen (and therefore allows depletion below a “critical
cell-signaling kinases, transcription factors, and transcrip- limit”) (, 200 mmol
(kg d.w.)21) AMPK activity is not
tional coactivators and expression of various metabolic suppressed (Lee-Young et al., 2006). While training with
genes are augmented when compared with exercise com- glycogen concentrations below a critical limit appears
menced with high (350 900 mmol
(kg d.w.)21) glycogen beneficial for the activation of cell-signaling cascades
(see Fig. 11.7). As such, it would appear important that exer- regulating mitochondrial biogenesis, it appears that keep-
cise is commenced with muscle glycogen concentrations ing glycogen at these levels may impair the regulation of
below 350 mmol
(kg d.w.)21 when undertaking a train-low postexercise muscle protein synthesis. Indeed, subsequent
exercise session. Nonetheless, it also appears that significant work from Impey et al. (2016) demonstrates that p70S6K
activation of cell-signaling pathways controlling mitochon- activity is suppressed when glycogen concentrations reach
drial biogenesis can still be achieved with high preexercise very low levels (B100 mmol
(kg d.w.)21) despite feed-
glycogen concentrations as long as a critical absolute ing leucine enriched whey protein. However, repletion of
amount of glycogen is exceeded during exercise (and some muscle glycogen to B250 mmol
(kg d.w.)21, via suffi-
exercise is therefore performed under conditions of low gly- cient postexercise CHO provision, appears to re-activate
cogen). For instance, Impey et al. (2015) demonstrated that p70S6K activity.
exhaustive exercise induces significant activation of AMPK In addition to regulating cell-signaling pathways con-
and expression of transcription factors (p53, Tfam) and trolling mitochondrial biogenesis and muscle protein syn-
coactivators (PGC-1α), even when commenced with high thesis, muscle glycogen also appears to regulate SR
glycogen levels (600 mmol
(kg d.w.)21). This is likely due calcium handling and thus skeletal muscle function,
to the fact that subjects surpassed a critical level of glycogen whereby contractile properties are impaired when glyco-
(B350 mmol
(kg d.w.)21) during exercise and reached gen concentrations fall below a critical limit. Chin and
exhaustion at very low levels (B100 mmol
(kg d.w.)21), Allen (1997) elegantly demonstrated that when recovery
therefore performing a significant proportion of exercise from glycogen reducing contractions occurs in the
with low muscle glycogen. Although significant activation absence of glucose and thus glycogen remains low, fiber
of cell-signaling cascades appears possible with high preex- bundles fatigue at a faster rate and show reduced tetanic
ercise glycogen levels, what is clear is that significantly Ca21 transients in a subsequent fatigue test. These find-
more “work” is required to achieve the same signaling ings have been subsequently confirmed in human skeletal
 Exercise and Carbohydrate Metabolism Chapter | 11 265

(A) ‘Glycogen threshold’

Wojtasewski et al.
AMPK

Steinberg et al.
ACC

Bartlett et al.
p53, ACC

Chan et al.
p38

Yeo et al.
AMPK
0 100 200 300 400 500 600 700 800+

(B)

Pilegaard et al.
PDK4

Psillander et al.
PGC-1a, PDK4, COXI

Bartlett et al.
PGC-1a, COXIV

Chan et al.
GLUT4

Impey et al.
PGC-1a, p53, Tfam
0 100 200 300 400 500 600 700 800+

(C)

Ortenblad et al.
Ca2+ release

Gejl et al.
Ca2+ release

Duhamel et al.
Ca2+ release

Impey et al.
P70S6K

0 100 200 300 400 500 600 700 800+

Muscle glycogen concentration mmol . (kg d.w.)–1

FIGURE 11.7 Summary of studies demonstrating differential metabolic responses of skeletal muscle in response to exercise commenced in condi-
tions of high or low muscle glycogen availability. Studies are categorized into those examining a) cell signalling, b) gene expression and c) muscle
contractile capacity and post-exercise signalling Shaded area represents proposed muscle glycogen threshold. Red bars represent low CHO trials and
green bars represent high CHO trials. The width of the bar represents starting and end point of muscle glycogen during the relevant exercise trials.
Taken from Fig. 11.2, Impey, S.G., et al., 2018. Sports. Med, under the terms of the Creative Commons Attribution 4.0 International License, https://
creativecommons.org/licenses/by/4.0/.
266 SECTION | III Muscle Metabolism and Exercise Physiology

muscle, where an impairment in SR Ca21 release rate and paradigms and is perhaps best communicated by the princi-
subsequent power output are apparent under conditions of ple of “fuel for the work required”. Indeed, athletes could
low muscle glycogen (Duhamel, Perco and Green, 2006; strategically reduce CHO availability prior to completing
Ortenblad et al., 2011; Gejl et al., 2014). Intriguingly, this predetermined training workloads that can be readily per-
impairment appears to occur at muscle glycogen concen- formed with reduced CHO availability, thereby inducing a
trations below 300 mmol
(kg d.w.)21, similar to the pro- “work-efficient” approach to training. Alternatively, when
posed critical threshold required to significantly activate the goals of the training session are to complete the highest
cell-signaling pathways regulating mitochondrial biogene- workload possible over more prolonged durations, then
sis. Given the importance of Ca21 for EC coupling and adequate CHO should be provided in the 24 h period prior
subsequent muscle contraction, it appears that low glyco- to and during the specific training session. Careful day-to-
gen concentrations may inhibit the ability of skeletal mus- day periodization in a meal-by-meal manner (as opposed to
cle to contract and muscle fibers may fatigue more chronic periods of CHO restriction) is likely to maintain
rapidly. When taken together, these data further allude to metabolic flexibility and still allow for the completion of
a potential muscle glycogen threshold, surmising that low high-intensity and prolonged duration workloads on heavy
muscle glycogen may not only enhance the activation of training days e.g., interval type workouts undertaken above
pathways regulating mitochondrial biogenesis, but also lactate threshold. Intuitively, train-low sessions may be best
regulate skeletal muscle contractile properties and postex- left to those training sessions that are not CHO dependent
ercise muscle protein synthesis if kept at critically low and in which the intensity and duration of the session is not
levels. likely to be compromised by reduced CHO availability
e.g., steady-state type training sessions performed at inten-
sities below the lactate threshold. Clearly, more studies are
11.5.8 Practical Applications required to investigate the optimal practical approach for
Despite the clear rationale of the train-low paradigm, there which to integrate periods of train-low in an elite athlete’s
are a number of potential limitations to this type of training training program.
that can make it difficult for exercise physiologists and
nutritionists to best periodize this type of training in to an
elite athlete’s training schedule. Indeed, reduced CHO 11.6 CONCLUSIONS
availability impairs acute training intensity (Yeo et al.,
2008b; Hulston et al., 2011) and hence if performed long Despite over 100 years of research, CHO metabolism con-
term, may actually lead to a de-training effect. tinues to intrigue muscle biologists and exercise scientists.
Additionally, given the role of CHO in preventing immu- From early recognition as a simple fuel store, it is now
nosuppression, it is possible that repeated high-intensity apparent that the glycogen granule regulates many cell-
training under conditions of low CHO increases suscepti- signaling processes related to both health and human
bility to illness and infection (Gleeson et al., 2004). performance. Nonetheless, it is clear that many of the
Restriction of CHO availability has also been shown to original questions posed in our field are still relevant
increase muscle protein breakdown (Howarth et al., 2010), today though the array of biochemical tools now at our
an effect that if performed chronically may lead to muscle disposal ensure we are better equipped to answer those
mass loss especially in conditions both calorie and CHO questions with greater precision. For example, the storage
restriction. Finally, data also demonstrate a reduced ability of the glycogen granule in specific intracellular pools
to oxidize exogenous CHO following regular training with remains a highly active research area. As a related point,
low CHO, which could lead to a negative effect on compe- the magnitude of exercise-induced utilization of specific
tition performance (Cox et al., 2010). Taking the above storage pools remains to be documented using “real-
limitations into account, it is important to recognize that world” exercise protocols that are relevant to both training
training with low CHO availability should be carefully and competition scenarios. While the specific regulatory
periodized in an athlete’s training program. control points of CHO metabolism are now well docu-
In summary, this body of literature alludes to a potential mented, the precise molecular mechanisms underpinning
muscle glycogen threshold (e.g., ,350 but .150 mmol
the regulation of CHO transport, storage, and utilization
(kg d.w.)21) surmising that reduced preexercise muscle are not yet fully known. Finally, the identification of a
glycogen may enhance the activation of those pathways potential muscle glycogen threshold has opened a new
regulating mitochondrial biogenesis but also suggest that field of study that is likely to dominate the applied nature
keeping glycogen (and energy intake) at critically low of sport nutrition research in the coming decade. From the
levels (i.e., ,100 mmol
(kg d.w.)21) may impair the regu- early studies from the pioneers in the field (e.g., Krogh,
lation of postexercise remodeling processes. In practice, Lindhard, Bergstrom, Saltin), it is clear that our field
this approach could represent an amalgamation of train-low remains as exciting as ever.
 Exercise and Carbohydrate Metabolism Chapter | 11 267

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