Carbohydrate ingestion eliminates hypoglycemia and improves endurance exercise performance in triathletes adapted to very low- and high-carbohydrate isocaloric diets

Very-low-carbohydrate diets (LCHF; <50 g/day) have been debated for their potential to lower pre-exercise muscle and liver glycogen stores and metabolic efficiency, risking premature fatigue. It is also hypothesized that carbohydrate ingestion during prolonged exercise delays fatigue by increasing carbohydrate oxidation, thereby sparing muscle glycogen. Leveraging a randomized crossover design, we evaluated performance during strenuous time-to-exhaustion (70% V̇o_2max) tests in trained triathletes following 6-wk high-carbohydrate (HCLF, 380 g/day) or very-low-carbohydrate (LCHF, 40 g/day) diets to determine <i>1</i>) if adoption of the LCHF diet impairs time-to-exhaustion performance, <i>2</i>) whether carbohydrate ingestion (10 g/h) 6-12× lower than current CHO fueling recommendations during low glycogen availability (>15-h pre-exercise overnight fast and/or LCHF diet) improves time to exhaustion by preventing exercise-induced hypoglycemia (EIH; <3.9 mmol/L; <70 mg/dL), and <i>3</i>) the "keto-adaptation" time course through continuous substrate monitoring while caloric intake, physical activity, and fat-free mass are maintained. Time-to-exhaustion performance was similar across both dietary interventions. Minimal carbohydrate supplementation prevented EIH and significantly increased time to exhaustion equivalently in LCHF and HCLF interventions (22%). The LCHF diet significantly lowered 24-h glucose concentrations, which normalized after 4 wk, at the same timepoint peak blood ketone (<i>R</i>-β-hydroxybutyrate) concentrations normalized. These findings <i>1</i>) demonstrate that an LCHF diet sustains strenuous endurance performance, <i>2</i>) establish that minimal carbohydrate supplementation was sufficient to enhance exercise performance on LCHF and HCLF diets by mitigating EIH, and <i>3</i>) indicate that a minimum 4-wk adaptation period to an LCHF diet is required to ensure normalization of metabolic homeostasis, glycemic control, and exercise performance.<b>NEW & NOTEWORTHY</b> This study examines the belief that very-low-carbohydrate diets (LCHF) impair prolonged exercise performance during strenuous exercise by comparing it with high-carbohydrate diets in competitive triathletes. After 6-wk diet adaptation, time-to-exhaustion (TTE) performance was similar across both diets. Minimal carbohydrate supplementation (10 g/h) during exercise eliminated exercise-induced hypoglycemia and improved TTE by 22% on both diets. These findings suggest that LCHF diets do not impair exercise performance and require a 4-wk adaptation period for metabolic homeostasis.