Content uploaded by Brad J Schoenfeld
Author content
All content in this area was uploaded by Brad J Schoenfeld on Oct 09, 2017
Content may be subject to copyright.
1
Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
ABSTRACT
Objective We performed a systematic review, meta-
analysis and meta-regression to determine if dietary
protein supplementation augments resistance exercise
training (RET)-induced gains in muscle mass and
strength.
Data sources A systematic search of Medline, Embase,
CINAHL and SportDiscus.
Eligibility criteria Only randomised controlled trials
with RET ≥6 weeks in duration and dietary protein
supplementation.
Design Random-effects meta-analyses and meta-
regressions with four a priori determined covariates. Two-
phase break point analysis was used to determine the
relationship between total protein intake and changes in
fat-free mass (FFM).
Results Data from 49 studies with 1863 participants
showed that dietary protein supplementation
significantly (all p<0.05) increased changes (means
(95% CI)) in: strength—one-repetition-maximum
(2.49 kg (0.64, 4.33)), FFM (0.30 kg (0.09, 0.52)) and
muscle size—muscle fibre cross-sectional area (CSA;
310 µm2 (51, 570)) and mid-femur CSA (7.2 mm2 (0.20,
14.30)) during periods of prolonged RET. The impact of
protein supplementation on gains in FFM was reduced
with increasing age (−0.01 kg (−0.02,–0.00), p=0.002)
and was more effective in resistance-trained individuals
(0.75 kg (0.09, 1.40), p=0.03). Protein supplementation
beyond total protein intakes of 1.62 g/kg/day resulted in
no further RET-induced gains in FFM.
Summary/conclusion Dietary protein supplementation
significantly enhanced changes in muscle strength and
size during prolonged RET in healthy adults. Increasing
age reduces and training experience increases the
efficacy of protein supplementation during RET. With
protein supplementation, protein intakes at amounts
greater than ~1.6 g/kg/day do not further contribute
RET-induced gains in FFM.
INTRODUCTION
Resistance exercise training (RET) in combination
with dietary protein supplementation is a common
practice, in athletes and recreational exercisers
alike, with the aim of enhancing RET-induced
gains in muscle mass and strength. Recognised as a
potent antisarcopenic stimulus, protein supplemen-
tation has also been advocated for ageing persons
participating in RET. Despite a large volume of
work in this area, narrative reviews1–5 and even
meta-analyses6–12 yield conflicting results as to the
actual effectiveness of protein supplementation to
enhance RET-mediated gains in muscle mass and
strength. This lack of agreement on the efficacy of
protein supplementation6–12 is likely due to the use
of divergent study inclusion criteria and inclusion
of subjects with differing: ages, training statuses,
total protein intakes, protein sources and protein
doses. Thus, an evidence-based answer to the main
question of the efficacy of protein supplementa-
tion, while previously reported,7 now appears to be
controversial.4
We conducted a meta-analysis that was more
inclusive in nature than previous meta-analyses6–12
to provide a broad, systematic and evidence-based
assessment on whether protein supplementation
can augment changes in relevant RET outcomes.
We used meta-regression to evaluate the impact
of important potentially mediating covariates that
were decided a priori to the meta-analysis. The
present meta-analysis includes more than double
the number of studies and participants than the
largest published comprehensive meta-analysis on
protein supplementation during RET to date.7ST1
We also undertook an additional rational, mech-
anism-based analysis that had the aim of answering
the following question: is there a protein intake
beyond which protein supplementation ceases to
provide a measurable benefit in increasing muscle
mass during RET? To answer this question, we
recognised that the process of muscle protein
synthesis (MPS), as the primary determinant of
muscle hypertrophy,13 shows a saturable dose-re-
sponse relationship with increasing protein intake.14
Since measures of MPS show good agreement with
hypertrophy13 we theorised that the effect of daily
protein intake on RET-induced changes in muscle
mass would show a dose-responsive relationship
but that this would ultimately plateau.
METHODS
Inclusion criteria
Any randomised controlled trials (RCTs) that
combined a RET and protein supplement interven-
tion were considered for this meta-analysis. Trials
had to be at least six weeks in duration, participants
A systematic review, meta-analysis and meta-
regression of the effect of protein supplementation
on resistance training-induced gains in muscle mass
and strength in healthyadults
Robert W Morton,1 Kevin T Murphy,1 Sean R McKellar,1 Brad J Schoenfeld,2
Menno Henselmans,3 Eric Helms,4 Alan A Aragon,5 Michaela C Devries,6
Laura Banfield,7 James W Krieger,8 Stuart M Phillips1
Review
To cite: MortonRW,
MurphyKT, McKellarSR, etal.
Br J Sports Med Published
Online First: [please include
Day Month Year]. doi:10.1136/
bjsports-2017-097608
►Additional material is
published online only. To view
please visit the journal online
(http:// dx. doi. org/ 10. 1136/
bjsports- 2017- 097608).
1Department of Kinesiology,
McMaster University, Hamilton,
Canada
2Department of Health Sciences,
Lehman College of CUNY,
Bronx, New York, USA
3Bayesian Bodybuilding,
Gorinchem, Netherlands
4Sport Performance Research
Institute New Zealand, AUT
University, Auckland, New
Zealand
5California State University,
Northridge, California, USA
6Department of Kinesiology,
University of Waterloo, Waterloo,
Canada
7Health Sciences Library,
McMaster University, Hamilton,
Canada
8Weightology, LLC, Issaquah,
Washington, USA
Correspondence to
Dr Stuart M Phillips, Department
of Kinesiology, McMaster
University, 1280 Main Street,
West Hamilton, Ontario,
Canada; phillis@ mcmaster. ca
Accepted 31 May 2017
BJSM Online First, published on July 11, 2017 as 10.1136/bjsports-2017-097608
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
2Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
had to be performing RET at least twice per week, and at least
one group had to be given a protein supplement that was not
co-ingested with other potentially hypertrophic agents (eg,
creatine, β-HMB, or testosterone-enhancing compounds). Only
trials with humans who were healthy and not energy-restricted
were accepted. Manuscripts had to be original research (not a
review or conference abstract) and be written in English.
Search strategy
A systematic search of the literature was conducted (LB) in
Medline, Embase, CINAHL and SportDiscus, current to January
2017 (see online supplementary appendix 1). As appropriate,
a combination of keywords and subject headings was used for
the following concepts: protein supplementation and resistance
training or muscle strength. The original search yielded 3056
studies. Any overlooked trials were identified by consulting
other reviews and meta-analyses on the subject and were added
in manually (17 studies). After deduplication and screening
for inclusion criteria, 155 articles were independently read/
reviewed by three authors (RWM, KTM and SRM). A total of 49
RCTs were selected for inclusion in this meta-analysis (figure 1).
Data extraction
Predetermined relevant variables from each included study
were gathered independently by three investigators (RWM,
KTM and SRM). Relevant variables included those regarding
the study design, details of the RET intervention, partici-
pant characteristics, protein supplement information, placebo/
control information, performance outcomes, body composi-
tion outcomes and any other notable information (eg, sources
of bias/conflict of interest). Where data were not presented
in table or text and authors could not be reached, data were
extracted using WebPlotDigitizer (Web Plot Digitizer, V.3.11.
Texas, USA: Ankit Rohatgi, 2017) or calculated from base-
line values and/or percentage change. Where there were any
discrepancies between the three reviewers the manuscripts were
revisited by all reviewers (RWM, KTM and SRM) and agreed
on by discussion. We also conducted a post hoc reassessment
Figure 1 PRISMA flow chart.
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
3
Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
of 10 randomly selected studies and compared the extracted
results.15 Coder drift was <10% in all cases for each investigator
and inter-rater (RWM, KTM and SRM) reliability was excellent
(>95%).
A total of 58 different body composition and 66 perfor-
mance outcomes were extracted from the final 49 studies.16–64
Primary outcomes were limited and amalgamated to include two
different performance outcomes and four different body compo-
sition outcomes based on those most commonly reported in the
49 RCTs. Performance outcomes were: one-repetition-max-
imum strength (1RM; measured by any 1RM strength test) and
maximum voluntary contraction (MVC; measured by both isoki-
netic and/or isometric contractions using a dynamometer with
any muscle group/action). Body anthropometric and composi-
tion outcomes included: total body mass (TBM; measured by
any scale); fat-free mass (FFM) and bone-free mass (or lean mass
if FFM was not available; FFM; measured by dual-energy X-ray
absorptiometry (DXA), hydrodensitometry, or whole-body air
plethysmography (BodPod) ); fat mass (FM; measured by DXA,
hydrodensitometry and/or BodPod); muscle fibre cross-sec-
tional area (CSA;measured in any fibre subtype (I, IIa, and/or
IIx) obtained from either vastus lateralis and/or latissimus dorsi
biopsies using microscopy); and mid-femur whole muscle CSA
(mid-femur CSA, measured by MRI and/or CT).
Data syntheses
When data were reported in different units (eg, pounds vs kilo-
grams) the data were converted to metric units. In all analyses
the comparator group received an identical RET intervention
but was non-supplemented or placebo-supplemented. If a study
included a protein-supplemented group, a non-supplemented
control group and a placebo-supplemented control group that
were all part of the RET intervention, the protein-supplemented
and placebo-supplemented groups were retrieved. If a study had
multiple time points, only the preintervention and postinterven-
tion outcomes were retrieved. Where the change in SD (ΔSD)
was available it was collected alongside the preintervention and
postintervention SD. Where ΔSD was not reported, the correla-
tion coefficient (corr) for each primary outcome was calculated
according to the Cochrane Handbook for Systematic Reviews
of Interventions:65 corr = (SDpre
2 + ΔSDpost
2 − SDchange
2) / (2 ×
SDpre× SDpost) and the ΔSD was then calculated as:
ΔSD = (SDpre
2
+ ΔSDpost
2 – 2 × corr × SDpre× SDpost).
The change in mean (ΔMean) and ΔSD were calculated for
each condition and uploaded to RevMan (Review Manager
(RevMan), V.5.3. Copenhagen: The Nordic Cochrane Centre,
The Cochrane Collaboration, 2014). Where studies had more
than one protein-supplemented group (eg, soy and whey),
measure of MVC (eg, isokinetic and isometric) or measure of
1RM (eg, bench press and leg press) the ΔMean and ΔSD were
independently calculated and later combined, unless other-
wise stated, using the RevMan calculator (Review Manager
(RevMan), V.5.3. Copenhagen: The Nordic Cochrane Centre,
The Cochrane Collaboration, 2014).
Meta-analyses
Random-effects meta-analyses were performed in RevMan
(Review Manager (RevMan), V.5.3. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2014) on the
change in each outcome. Effect sizes are presented as mean
difference (MD) with means±SD and 95% CIs for 1RM, TBM,
FFM, FM, fibre CSA and mid-femur CSA and as standardised
mean difference (SMD) and 95% CIs for MVC because it had
multiple outcomes presented on non-comparable scales (eg, N
and Nm).
Heterogeneity and risk of bias
Heterogeneity was assessed by χ2 and I2 and significance was set
at p<0.05. The internal validity of each study was determined
by domain-based evaluation to quantify risk of bias for each
study65 and was independently performed by three investigators
(RWM, KTM and SRM). The data included in the meta-analyses
were restricted to studies with less than three reported high or
unclear risk domains (predominately due to reported conflicts
of interest and lack of blinding investigators and/or participants;
(see online supplementary appendix 2)). Funnel plots were visu-
ally inspected to determine publication bias. Multiple sensitivity
analyses were performed to determine if any of the results were
influenced by the studies that were removed.
Meta-regression
In an effort to understand the sources of heterogeneity meta-re-
gressions were performed on 1RM, FFM and fibre CSA because
they were statistically significant, had considerable unexplained
heterogeneity (I2) and had a sufficient number of studies (≥10).
Meta-regression was used instead of subgroup analyses to allow
for the use of continuous covariates and to allow for the inclu-
sion of more than one covariate at a time. Four covariates were
chosen a priori to be included in our meta-regression: baseline
protein intake (g/kg/day), postexercise protein dose (g), chrono-
logical age and training status because there is evidence that
baseline protein intake,66 protein dose,14 age67 and training
status68 could influence the efficacy of protein supplementa-
tion; summarised here.4 5 These covariates were meta-regressed
individually and together in a random-effects meta-regression
model using Stata (StataCorp. 2011. Stata Statistical Software:
Release 12. College Station, Texas, USA). The random-effects
meta-regression used residual restricted maximum likelihood
to measure between-study variance (τ2) with a Knapp-Hartung
modification as recommended.69 When all four covariates were
analysed together permutation tests were performed (n=1000)
to address the issue of multiple testing by calculating adjusted
p values.70 Additional covariates were identified and individually
analysed post hoc to further explore the unexplained variance of
the effect of protein supplementation during RET on changes in
1RM and FFM. Continuous covariates were: MD in the change
in protein intake (g/day), MD in the total relative protein intake
(g/kg/day), number of repetitions/set, number of sets/exercise,
number of exercises/session, number of sessions/week, number
of weeks and total RET volume in kg: repetitions/set × sets/exer-
cise × exercises/session × sessions/week × intervention duration
in weeks. Categorical variables were: protein supplement source
(whey vs soy), sex (male vs female), type (dietary-supplement
vs RET-supplement), whole-body RET (whole-body RET vs
not whole-body RET) and RET supervision (supervised vs not
supervised). Protein supplement source was limited to soy and
whey because there were few study groups that were provided
either a casein (n=321 59 60;) or pea (n=122;) protein supplement
exclusively.
Subgroup analyses
Subgroup analyses were performed in RevMan (Review Manager
(RevMan), V.5.3. Copenhagen: The Nordic Cochrane Centre,
The Cochrane Collaboration, 2014). Subgroup analyses were
performed on changes in FFM and 1RM with training status
(untrained vs trained) as the subgroup to generate forest plots
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
4Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
and neatly present training status as a categorical variable.
Subgroup analyses were also performed on changes in FFM with
age categorised into subgroups (old (>45 years) and young (<45
years)) to be presented below for the interested reader.
Breakpoint analysis
To investigate the influence of protein intake as a continuous vari-
able on individual study arms (as opposed being limited to MDs
between groups in a meta-regression) linear and segmental regres-
sions on the change in FFM (measured by DXA) were plotted
against daily and baseline protein intake. Linear and segmental
regressions were performed using GraphPad Prism (V.6, GraphPad
Software, La Jolla, California, USA) to determine models of best fit
as has been previously done in acute tracer trials measuring MPS.14
Where segmental regression was the preferred model the slope
of the second line was set to zero to determine the break point
(biphasic regression). Each group from each study that presented
daily or baseline protein intake with changes in FFM from DXA
was included. Significance was set at p<0.05 and data for the
break point is presented as mean (95% CI).
RESULTS
Participant characteristics
Participant details and outcomes are presented elsewhere
(see online supplementary table 1. A total of 49 studies from
17 countries met the inclusion criteria (figure 1). There were 10
studies in resistance-trained participants and 14 study groups in
exclusively female participants. Publications ranged from 1962
to 2016. There was a total of 1863 participants (mean±SD;
35±20 years).
RETcharacteristics
The RET characteristics are also presented elsewhere
(see online supplementary table 1). The RET interventions
lasted from 6 weeks to 52 weeks (13±8 weeks) performing
RET between 2 days and 5 days per week (3±1 days/week) with
between 1 to 14 exercises per session (7±3 exercises/session),
1 to 12 sets per exercise (4±2 sets/exercise) and anywhere
between 3 to 25 repetitions per set (9±4 repetitions/set). Four
studies used just lower-body RET, two studies used just knee
extensor RET, one study used elbow flexor RET only, and two
studies used one lower-body and one upper-body exercise only.
Protein supplementation
Details regarding the experimental (protein supplementation)
and control (placebo- or no-supplement) groups are presented
elsewhere (see online supplementary table 2). A range of 4 g to
106 g of protein was supplemented per day to the protein
group (36±30 g/day; young: 42±32 g/day; old: 20±18 g/day)
with a range of 5 g to 44 g of protein supplemented postexer-
cise on training days (24±11 g; young: 24±12 g; old: 23±10
g). Twenty-three conditions supplemented with whey protein,
3 with casein protein, 6 with soy protein, 1 with pea protein, 10
with milk or milk protein, 7 with whole food (eg, beef, yogurt,
between-meal snack) and 13 with non-specific protein blends or
blends containing multiple protein sources (eg, whey, casein, soy
and egg). In 40 studies the participants consumed part or all
of their daily protein supplement after their RET sessions. In
36 studies with 48 different conditions authors reported either
total (g/day) or relative (g/kg/day or %kcal/day) daily protein
intake preintervention and/or postintervention. There was an
increase in daily protein intake in the protein group (mean±SD;
range: 23±41 g/day; −25 g/day to 158 g/day; p=0.004) and no
change in the control group (1±14 g/day; −17 g/day to 40 g/
day; p=0.83) such that the change in daily protein intake was
significantly greater in the protein group (p=0.01). Relative
daily protein intake (g/kg/day) increased in the protein group
(pre: 1.4±0.4, post: 1.8±0.7, Δ: 0.3±0.5 g/kg/day, p=0.002)
and did not change in the control group (pre: 1.4±0.3, post:
1.3±0.3, Δ: −0.02±0.1 g/kg/day, p=0.48) such that there was
a greater change in the protein group (p<0.001). Daily energy
intake (kcal/day) was gathered from 23 studies with 29 condi-
tions and did not change with the prolonged RET and protein
supplementation nor was it significantly different between the
protein or control groups (Δ protein group: 50±293 kcal/day, Δ
control group: 70±231 kcal/day, p=0.71).
Heterogeneity and risk of bias
Significant heterogeneity was found for changes in 1RM
(χ2=53.49, I2=33%, p=0.003) and fibre CSA (χ2=30.97,
I2=68%, p=0.0006). Nine studies were removed based on risk of
bias17 18 25 26 50 63 (see online supplementary appendix 2) or publi-
cation bias assessment24 32 64 (see online supplementary figure 1).
In particular, four studies were removed from 1RM,17 26 32 50 four
from TBM,17 18 63 64 three from FM,17 18 63 five from FFM,17 18 24 63
64 three from MVC25 26 50 and one from fibre CSA.50
Sensitivity analyses
Sensitivity analysis was performed with the nine high-risk studies
mentioned above included in the outcomes they were removed
from to determine if their removal changed any of the results. The
inclusion of those studies did not influence the difference in means
or significance in 1RM, TBM, FFM or mid-femur CSA; however,
when Mitchell et al50 was included in the fibre CSA assessment
the effect of protein supplementation (310 µm2 (51, 570), p=0.02)
was eliminated (153 µm2 (−137, 443), p=0.30). This is likely
due to the small number of studies that included muscle biopsies
but may warrant caution when interpreting the effect of protein
supplementation on changes fibre CSA during RET. In no instance
did fixed-effect meta-analysis deliver a different magnitude of
effect or significance compared with random-effect meta-analysis.
Meta-analyses
Protein supplementation during prolonged RET significantly
improved gains in 1RM strength (MD: 2.49 kg (0.64, 4.33),
p=0.01; figure 2) but had no effect on MVC (SMD: 0.04
(-0.09, 0.16), p=0.54). Protein supplementation did not have
a significant effect on changes in TBM (MD: 0.11 kg (−0.23,
0.46), p=0.52) but improved changes in FFM (MD: 0.30 kg
(0.09, 0.52), p=0.007; figure 3), FM (MD: −0.41 kg (−0.70,–
0.13), p=0.005), fibre CSA (MD: 310 µm2 (51, 570), p=0.02;
see online supplementary figure 2: panel A) and mid-femur CSA
(MD: 7.2 mm2 (0.20, 14.30), p=0.04; see online supplementary
figure 2: panel B) during prolonged RET.
Meta-regression.
The results from the full model meta-regressions are presented in
table 1. When combined, baseline protein intake, protein dose,
age and training status did not explain any of the variance in the
changes in 1RM (15 studies, 1216 subjects, p=0.77) or FFM (15
studies, 642 participants, p=0.12). There were insufficient obser-
vations (<10) when all covariates were compared with the changes
in fibre CSA.
Univariate meta-regressions on changes in 1RM and FFM
following prolonged RET are also presented in table 1. None
of our covariates explained any of the heterogeneity of protein
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
5
Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
supplementation’s effect on changes in 1RM: baseline protein
intake (21 studies, 814 participants, p=0.59), age (27 studies,
802 participants, p=0.78), training status (28 studies, 858 partic-
ipants, p=0.40) and post-exercise protein dose (23 studies, 589
participants, p=0.13). In contrast, when the ability of protein
supplementation to affect changes in FFM was evaluated with
univariate meta-regressions, the postexercise protein dose was
the only covariate that did not influence the efficacy of protein
supplementation on changes in FFM (20 studies, 793 participants,
p=0.25) whereas baseline protein intake (22 studies, 988 partic-
ipants, p=0.045; see online supplementary figure 3: panel A),
age (25 studies, 1033 participants, p=0.02; figure 4) and training
status (26 studies, 1089 participants, p=0.03) all influenced the
effect of protein supplementation. When the effect of protein
supplementation on changes in FFM was evaluated with age strat-
ified into two subgroups the difference between old (>45; 67±7
years; MD: 0.06 (-0.14, 0.26)) and young (<45; 24±4 years; MD:
0.55 (0.30, 0.81)) participants remained significant (χ2=8.71,
I2=89%, p=0.003). There were no covariates that explained any
of the variance in the change in fibre CSA following RET: age
(10 studies, 474 participants, I2=65%, Adj. R2=-3%, p=0.50),
baseline protein intake (8studies, 384 participants, I2=43%, Adj.
R2=-44%, p=0.84), postexercise protein dose (10 studies, 270
participants, I2=77%, Adj. R2=-38%, p=0.92) and training status
(11 studies, 586 participants, I2=71%, Adj. R2=-24%, p=0.94).
Additional univariate meta-regressions are presented in else-
where (see online supplementary table 3). Only whether the RET
was whole-body (27 studies, including only 4 studies that were not
whole-body RET, I2=2%, Adj. R2=76%, p=0.01) or supervised
(28 studies, I2=5%, Adj. R2=58%, p=0.047) explained part of
the variance in the effectiveness of protein supplementation on
changes in 1RM. No other covariates explained any of the variance
associated with the efficacy of protein supplementation on changes
in 1RM or FFM.
Breakpoint analysis
Biphasic regression (42 study arms, 723 participants) explained
more variation than a linear regression between the change in
Figure 2 Forest plot of the results from a random-effects meta-analysis shown as mean difference with 95% CIs on one-repetition-maximum (1RM;
kg) in untrained and trained participants. For each study, the circle represents the mean difference of the intervention effect with the horizontal line
intersecting it as the lower and upper limits of the 95% CI. The size of each circle is indicative of the relative weight that study carried in the meta-
analysis. The rhombi represent the weighted untrained, trained and total group’s mean difference. Total: 2.49 kg (0.64, 4.33), p=0.01, untrained:
0.99 kg (−0.27, 2.25), p=0.12 and trained: 4.27 kg (0.61, 7.94), p=0.02.
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
6Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
Figure 3 Forest plot of the results from a random-effects meta-analysis shown as mean difference with 95% CIs on lean or fat-free mass (FFM;
kg) in untrained and trained participants. For each study, the circle represents the mean difference of the intervention effect with the horizontal
line intersecting it as the lower and upper limits of the 95% CI. The size of each circle represents the relative weight that study carried in the meta-
analysis. The rhombi represent the weighted untrained, trained and total group’s mean difference. Total: 0.30 kg (0.09, 0.52) p=0.007, untrained:
0.15 kg (−0.02, 0.31), p=0.08 and trained: 1.05 kg (0.61, 1.50), p<0.0001.
Table 1 Meta-regression output.
Model N
1RM (kg) Fat-free mass(kg)
Coeff. (95% CI) τ2Adj. R2I2pValue N Coeff. (95% CI) τ2Adj. R2I2pValue
No covariates 28 2.49 (0.64 to 4.33) 6.05 33% 0.01 27 0.30 (0.09 to 0.52) 0.05 7% <0.01
Univariate
Baseline protein intake 21 2.85 (-8.15to 13.84) 7.82 1% 37% 0.59 22 0.64 (0.02 to 1.27) 0 100% 0% 0.045
Protein dose 23 0.13 (-0.04to 0.31) 3.16 40% 0% 0.13 20 0.02 (-0.01to 0.04) 0.09 0% 0% 0.25
Age 27 0.01 (-0.09to 0.11) 6.51 −9% 34% 0.78 25 −0.01 (-0.02 to 0.00) 0 100% 0% 0.02
Training status 28 5.77 (-2.96to 7.13) 5.77 5% 31% 0.40 26 0.75 (0.09 to 1.40) 0.03 49% 0% 0.03
All covariates 15 5.36 10% 0% 0.77 15 0 100% 0% 0.12
Baseline protein intake 15 6.40 (-11.62to 24.42) 0.43 15 −0.57 (-2.50to 1.37) 0.95
Protein dose 15 0.05 (-0.78to 0.88) 0.70 15 −0.01 (-0.07to 0.06) 0.99
Age 15 0.07 (-0.18to 0.33) 0.23 15 −0.01 (-0.02to 0.00) 0.19
Training status 15 −2.81 (-20.80to 15.17) 0.63 15 1.19 (-1.34to 2.19) 0.48
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
7
Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
FFM and daily protein intake (break point=1.62 (1.03, 2.20)
g/kg/day, slope=1.75, R2=0.19, df=36) and is presented as
a segmental regression despite not being statistically signifi-
cant (p=0.079;figure 5) When plotting the change in FFM
against baseline protein intake, linear regressions explained
significantly more variance than biphasic regressions in both
young (slope=−1.54 g/kg/day, R2=0.17, df=34) and old
(slope=0.16 g/kg/day, R2=0.04, df=14) participants with a
statistically significant difference between age groups (p=0.042;
see online supplementary figure 3: panel D).
DISCUSSION
This is the largest meta-analysis on interventions including
dietary protein supplementation with muscle and strength-re-
lated outcomes during prolonged RET to date. Our main
finding was that dietary protein supplementation augmented
RET-induced increases in 1RM strength (figure 2) and FFM
(figure 3). For changes in FFM, dietary protein supplementation
was more effective in resistance-trained individuals (table 1 and
figure 3), less effective with increasing chronological age (table 1
and figure 4) and did not increase beyond total protein intakes
of ~1.6 g/kg/day (figure 5). Our data show dietary protein
supplementation is both sufficient and necessary to optimise
RET adaptations in muscle mass and strength.
Previous meta-analyses6–12 have reached varying conclusions
when examining the impact of protein supplementation on
changes in lean mass or FFM and 1RM strength during RET. The
discrepancies are likely a consequence of differing study inclusion
criteria. For example, previous meta-analyses have included only
trained participants,8 only older adults,9 11 supplements containing
more than just protein,8 10 only one source of protein,8 12 shorter
RET interventions,10 12 frail/sarcopenic participants7 9 11 and/or
participants who were energy-restricted.6 7 12 Previously, the largest
comprehensive meta-analysis to date on protein supplementation
during RET included 22 studies and 680 participants7 and did
show a significant effect of protein supplementation on RET-stim-
ulated gains in strength and FFM. In agreement with this previous
report,7 and strengthening the conclusion of that same report by
including 49 studies and 1863 participants, we show that protein
supplementation augmented gains in FFM and strength with RET.
Strength
The average RET-induced increase, with all measures of 1RM
included, was 27 kg (mean±SD ; 27±22 kg22 32). Notably,
dietary protein supplementation augmented the increase in 1RM
strength by 2.49 kg (9%; figure 2;Figure 2 see online supple-
mentary figure 4), which strongly suggests that the practice of
RET is a far more potent stimulus for increasing muscle strength
than the addition of dietary protein supplementation. None of
our covariates (age, training status, postexercise protein dose or
baseline protein intake) influenced the efficacy of protein supple-
mentation on changes in 1RM strength. Improving performance
of a specific task (eg, the 1RM of an exercise) is predominately
determined by the practice of that task.71 Though protein supple-
mentation may slightly augment changes in 1RM (~9%), which
may be important for those competing in powerlifting or weight-
lifting, it is pragmatic to advocate that if an increase in 1RM is
the objective of an RET programme, a sufficient amount of work
and practice at or around the 1RM is far more influential than
protein supplementation.
Muscle mass
In addition to increasing changes in muscle strength, RET alone
(≥6; 13±8 weeks) resulted in an increase in FFM (1.1±1.2 kg ),
an increase in fibre CSA (808±) and an increase in mid-femur
CSA (52±30 mm239 65). Dietary protein supplementation
augmented the increase in FFM by 0.30 kg (27%; Figure 3;
see online supplementary figure 4), fibre CSA by 310 µm2 (38%;
see online supplementary figure 1: Panel A) and mid-femur CSA
by 7.2 mm2 (14%; see online supplementary figure 1: panel
B). The postexercise protein dose did not affect the efficacy
of protein supplementation on RET-induced changes in FFM
whereas training status (positive), age (negative) and baseline
protein intake (positive) did. Relative to untrained participants,
resistance-trained participants have a smaller potential for
muscle growth72 and an attenuated postexercise muscle protein
turnover.73 As a result, we speculate that trained persons may
have less ‘degrees of freedom’ to change with RET and therefore
have a greater need for protein supplementation to see increases
in muscle mass. Our thesis is supported by the observation of
a more consistent impact of protein supplementation on gains
Figure 4 Random-effects univariate meta-regression between age
and the mean difference in fat-free mass (FFM) between groups.
Each circle represents a study and the size of the circle reflects the
influence of that study on the model (inversely proportionate to the SE
of that study). The regression prediction is represented by the solid line
(−0.01 kg (−0.02,–0.00), p=0.02).
Figure 5 Segmental linear regression between relative total protein
intake (g/kg body mass/day) and the change in fat-free mass (ΔFFM)
measured by dual energy X-ray absorptiometry. Each circle represents a
single group from a study. Dashed arrow indicates the breakpoint=1.62
g protein/kg/day, p=0.079. Solid arrow indicates 95% CI, (1.03to 2.20).
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
8Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
in FFM in resistance-trained individuals than in novice trainees
(figure 3).
Older individuals are anabolically resistant74 and require
higher per-meal protein doses to achieve similar rates of MPS,
the primary variable regulating changes in skeletal muscle
mass,75 compared with younger participants.14 The average
supplemental daily protein dose given to older participants was
surprisingly low (20±18 g/day); thus, it is perhaps not surprising
that we did not find that older individuals were responsive to
protein supplementation (Figure 4). Though age did not affect
the RET-induced change in fibre CSA, the negative effect age
had on changes in FFM leads us to speculate that even though
exercise sensitises muscle to the effect of protein ingestion,3
older persons have an increased need for higher protein intakes
to optimally respond to this effect and see gains in FFM.76
It has been theorised that the increased deviation from normal
protein intake (g/kg/day) will positively affect the RET-induced
gains in FFM.77 Contrary to this thesis, we found that a higher
prestudy protein intake actually resulted in a greater effect of
protein supplementation on changes in FFM (table 1); however,
this was likely driven by the lower mean baseline protein intake
(old: 1.2±0.2 g/kg/day, young: 1.5±0.4 g/kg/day) and daily
protein dose (old: 20±18 g/day, young: 42±32 g/day) in the
studies that included older participants (see online supplemen-
tary figure 3: panel B and D). Indeed, a sensitivity analysis that
did not include older (>45; 65±14 years) versus younger (<45;
24±4 years) individuals found that baseline protein intake had
no effect on the efficacy of protein supplementation in young
individuals (see online supplementary figure 3, panel C). In an
unadjusted meta-regression analysis, a higher baseline protein
intake in young individuals actually attenuated the change in
FFM (see online supplementary figure 3, panel D).
A goal of this meta-analysis was to deliver evidence-based recom-
mendations that could be readily translated. A crucial point is that
even though the mean baseline protein intake for the 1863 partic-
ipants was ~1.4 g protein/kg/day, which is 75% greater than the
current US/Canadian recommended dietary allowance (RDA),78
an average supplementation of ~35 g protein/day still augmented
RET-stimulated gain in FFM (figure 3) and 1RM strength
(figure 2). Thus, consuming protein at the RDA of 0.8 g protein/
kg/day appears insufficient for those who have the goal of gaining
greater strength and FFM with RET. This conclusion is emphasised
for older men79 and women80 81 wishing to obtain strength and
gain lean mass with RET and protein supplementation.
A recent retrospective analysis showed a ‘breakpoint’ for the
stimulation of MPS when ingesting an isolated protein source at
0.24 g protein/kg and 0.40 g protein/kg in younger and older
participants, respectively.14 Given the observation of a dose-re-
sponsive relationship between protein intake and MPS82–85 and
the fact that MPS is aligned with muscle hypertrophy,13 we
elected to use an identical two-segment regression approach
between total daily protein intake and changes in FFM (figure 5)
as has been done for changes in protein dose and MPS.14 Here
we provide significant insight (using 42 study arms including 723
young and old participants with protein intakes ranging from 0.9
g protein/kg/day to 2.4 g protein/kg/day) by reporting an unad-
justed plateau in RET-induced gains in FFM at 1.62 g protein/kg/
day (95% CI: 1.03 to 2.20). These results are largely in congru-
ence with previous narrative reviews that comment on the
optimal nutritional strategies to augment skeletal muscle adapta-
tion during RET.3 86 Given that the CI of this estimate spanned
from 1.03 to 2.20, it may be prudent to recommend ~2.2 g
protein/kg/d for those seeking to maximise resistance train-
ing-induced gains in FFM. Though we acknowledge that there
are limitations to this approach, we propose that these findings
are based on reasonable evidence and theory and provide a prag-
matic estimate with an incumbent error that the reader could
take into consideration.
Although the present analysis provides important and novel
data, there are limitations that we acknowledge. First, the lack of
RET research in older individuals has led to inconclusive recom-
mendations from previous meta-analyses specifically focusing on
older individuals.9 11 Indeed, in this manuscript there were only
13 studies that met our inclusion criteria in older (>45 years)
individuals and only six of those studies reported baseline protein
intakes with changes in FFM. In addition, only four studies27 29
33 45 in older individuals had participants that consumed what
we consider to be close to optimal total protein intake (~1.2 g/
kg/day to 1.6 g/kg/day) in non-exercising adults5 during or postin-
tervention provided. Furthermore, only two studies23 30 in older
individuals provided a postexercise supplemental protein dose that
we consider to be close to optimal (~35–40 g) to stimulate FFM
accretion in elderly individuals.76 Given that older adults require
more protein per day,79–81 consume less protein per day87 and that
dietary protein ingestion and RET are effective strategies to main-
tain muscle mass and function with age,67 future RET research
should focus on using higher protein doses (or potentially higher
leucine), larger sample sizes and longer interventions in ageing
populations. Second, we included a variety of additional covari-
ates into univariate meta-regressions to elucidate the variables that
may modify whether protein supplementation affects RET-induced
changes in muscle mass and strength. Such an approach is gener-
ally considered to be hypothesis generating. The only significant
findings we found were that if the RET sessions were whole-body
(adjusted R2=76%, p=0.01) or supervised (adjusted R2=58%,
p=0.047), protein supplementation was more effective at
augmenting changes in 1RM. No variable affected changes in FFM
(see online supplementary table 3). Given the relatively small effect
that protein supplementation has on changes in FFM and 1RM,
clearly other variables as a component of RET programmes are of
much greater importance. Our meta-analyses also only included
studies with participants that were at or above their energy require-
ments, which may have omitted the significant impact protein has
during periods of weight loss with RET.88 Lastly, we found that
the postexercise protein dose did not affect the efficacy of protein
supplementation on RET-induced changes in FFM. Our analysis,
and those from others,6 leads us to conclude that the specifics of
protein supplementation (eg, timing, postexercise protein dose or
protein source) play a minor, if any, role in determining RET-in-
duced gains in FFM and strength over a period of weeks. Instead,
our results indicate that a daily protein intake of ~1.6 g/kg/day,
separated into ~0.25 g/kg doses,14 is more influential on adaptive
changes with RET, at least for younger individuals.
CONCLUSION
Dietary protein supplementation augments changes in muscle
mass and strength during prolonged RET. Protein supple-
mentation is more effective at improving FFM in young or
resistance-trained individuals than in older or untrained individ-
uals. Protein supplementation is sufficient at ~1.6 g/kg/day in
healthy adults during RET. Based on limited data we observed no
overtly apparent sex-based differences but acknowledge that far
less work has been done in women than men. This analysis shows
that dietary protein supplementation can be, if protein intake
is less than 1.6 g protein/kg/day, both sufficient and necessary
to optimise RET-induced changes in FFM and 1RM strength.
However, performance of RET alone is the much more potent
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
9
Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
stimulus, accounting, at least according to this meta-analysis, for
a substantially greater portion of the variance in RET-induced
gains in muscle mass and strength.
Summarybox
Background
►There is no consensus on the efficacy of protein
supplementation during prolonged resistance exercise
training(RET).
Novel findings
►Dietary protein supplementation augments changes in
fat-free mass (FFM, (0.30 kg (0.09, 0.52), p=0.007) and
one-repetition-maximum strength (2.49 kg (0.64, 4.33),
p=0.01) during prolonged RET.
►Dietary protein supplementation during RET is more
effective at increasing changes in FFM in resistance-trained
individuals (0.75 kg (0.09, 1.40), p=0.03) and less effective
in older individuals (−0.01 kg (−0.02,–0.00), p=0.02).
►Protein supplementation beyond a total daily protein intake
of~1.6 g/kg/day during RET provided no further benefit on
gains in muscle mass or strength.
Acknowledgements SMP thanksthe Canada Research Chairs, Canadian Institutes
for Health Research, and the Natural Science and Engineering Research Council of
Canada for their support during the completion of this work.
Contributors RWM, BJS, MH, EH, AAA, MCD, JWK and SMP contributed to the
conception and design of the study. RWM, BJS, MH, EH, AAA, MCD, LB, JWK and
SMP contributed to the development of the search strategy. LB conducted the
systematic search. RWM, KTM and SRM completed the acquisition of data. RWM
and SMP performed the data analysis. All authors assisted with the interpretation.
RWM and SMP were the principal writers of the manuscript. All authors contributed
to the drafting and revision of the final article. All authors approved the final
submitted version of the manuscript.
Competing interests SMP has received grant support, travel expenses, and
honoraria for presentations from the US National Dairy Council. This agency has
supported trials reviewed in this analysis.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data are available in the submitted manuscript or as
supplementary files.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
RefeRences
1 Dideriksen K, Reitelseder S, Holm L. Influence of amino acids, dietary protein, and
physical activity on muscle mass development in humans. Nutrients 2013;5:852–76.
2 Hulmi JJ, Lockwood CM, Stout JR. Effect of protein/essential amino acids and
resistance training on skeletal muscle hypertrophy: a case for whey protein. Nutr
Metab 2010;7:51.
3 Morton RW, McGlory C, Phillips SM. Nutritional interventions to augment resistance
training-induced skeletal muscle hypertrophy. Front Physiol 2015;6:245.
4 Reidy PT, Rasmussen BB. Role of Ingested amino acids and protein in the
Promotion of Resistance Exercise-Induced Muscle protein anabolism. J Nutr
2016;146:155–83.
5 Phillips SM, Chevalier S, Leidy HJ. Protein "requirements" beyond the RDA:
implications for optimizing health. Appl Physiol Nutr Metab 2016;41:565–72.
6 Schoenfeld BJ, Aragon AA, Krieger JW. The effect of protein timing on muscle strength
and hypertrophy: a meta-analysis. J Int Soc Sports Nutr 2013;10:53.
7 Cermak NM, Res PT, de Groot LC, et al. Protein supplementation augments the
adaptive response of skeletal muscle to resistance-type exercise training: a meta-
analysis. Am J Clin Nutr 2012;96:1454–64.
8 Naclerio F, Larumbe-Zabala E. Effects of Whey protein alone or as part of a Multi-
ingredient Formulation on strength, Fat-Free Mass, or lean Body Mass in Resistance-
Trained individuals: a Meta-analysis. Sports Med 2016;46:125–37.
9 Finger D, Goltz FR, Umpierre D, et al. Effects of protein supplementation in older
adults undergoing resistance training: a systematic review and meta-analysis. Sports
Med 2015;45:245–55.
10 Nissen SL, Sharp RL. Effect of dietary supplements on lean mass and strength gains
with resistance exercise: a meta-analysis. J Appl Physiol 2003;94:651–9.
11 Thomas DK, Quinn MA, Saunders DH, et al. Protein supplementation does not
significantly augment the effects of resistance exercise training in older adults: a
systematic review. J Am Med Dir Assoc 2016;17:959.e1–959.e9.
12 Miller PE, Alexander DD, Perez V. Effects of whey protein and resistance exercise on
body composition: a meta-analysis of randomized controlled trials. J Am Coll Nutr
2014;33:163–75.
13 Damas F, Phillips SM, Libardi CA, et al. Resistance training-induced changes in
integrated myofibrillar protein synthesis are related to hypertrophy only after
attenuation of muscle damage. J Physiol 2016;594:5209–22.
14 Moore DR, Churchward-Venne TA, Witard O, et al. Protein ingestion to stimulate
myofibrillar protein synthesis requires greater relative protein intakes in healthy older
versus younger men. J Gerontol A Biol Sci Med Sci 2015;70:57–62.
15 Cooper H, Hedges L, Valentine J. The handbook of research synthesis and meta-
analysis. New York: Russell Sage Foundation, 2009.
16 Andersen LL, Tufekovic G, Zebis MK, et al. The effect of resistance training combined
with timed ingestion of protein on muscle fiber size and muscle strength. Metabolism
2005;54:151–6.
17 Antonio J, Ellerbroek A, Silver T, et al. A high protein diet (3.4 g/kg/d) combined
with a heavy resistance training program improves body composition in healthy
trained men and women--a follow-up investigation. J Int Soc Sports Nutr
2015;12:39.
18 Antonio J, Peacock CA, Ellerbroek A, et al. The effects of consuming a high protein
diet (4.4 g/kg/d) on body composition in resistance-trained individuals. J Int Soc
Sports Nutr 2014;11:19.
19 Arazi H, Hakimi M, Hoseini K. The effects of Whey protein supplementation on
Performance and hormonal adaptations following resistance training in Novice Men.
Baltic Journal of Health and Physical Activity 2011;3.
20 Arnarson A, Gudny Geirsdottir O, Ramel A, et al. Effects of whey proteins and
carbohydrates on the efficacy of resistance training in elderly people: double blind,
randomised controlled trial. Eur J Clin Nutr 2013;67:821–6.
21 Babault N, Deley G, Le Ruyet P, et al. Effects of soluble milk protein or casein
supplementation on muscle fatigue following resistance training program: a
randomized, double-blind, and placebo-controlled study. J Int Soc Sports Nutr
2014;11:36.
22 Babault N, Païzis C, Deley G, et al. Pea proteins oral supplementation promotes
muscle thickness gains during resistance training: a double-blind, randomized,
Placebo-controlled clinical trial vs. whey protein. J Int Soc Sports Nutr 2015;12:3.
23 Bemben MG, Witten MS, Carter JM, et al. The effects of supplementing with creatine
and protein on muscle strength following a traditional resistance training program in
middle-aged and older men. The Journal of Nutrition 2010;14:155–9.
24 Brown EC, DiSilvestro RA, Babaknia A, et al. Soy versus whey protein bars: effects on
exercise training impact on lean body mass and antioxidant status. Nutr J 2004;3:22.
25 Bunout B, Barrera G, de la Maza P, et al. Effects of nutritional supplementation and
resistance training on muscle strength in free living elders. results of one year follow. J
Nutr Health Aging 2004;8:68–75.
26 Burke DG, Chilibeck PD, Davidson KS, et al. The effect of whey protein
supplementation with and without creatine monohydrate combined with resistance
training on lean tissue mass and muscle strength. Int J Sport Nutr Exerc Metab
2001;11:349–64.
27 Campbell WW, Crim MC, Young VR, et al. Effects of resistance training and dietary
protein intake on protein metabolism in older adults. Am J Physiol 1995;268(6 Pt
1):E1143–E53.
28 Candow DG, Burke NC, Smith-Palmer T, et al. Effect of whey and soy protein
supplementation combined with resistance training in young adults. Int J Sport Nutr
Exerc Metab 2006;16:233–44.
29 Candow DG, Chilibeck PD, Facci M, et al. Protein supplementation before and after
resistance training in older men. Eur J Appl Physiol 2006;97:548–56.
30 Carter JM, Bemben DA, Knehans AW, et al. Does nutritional supplementation
influence adaptability of muscle to resistance training in men aged 48 to 72 years. J
Geriatr Phys Ther 2005;28:40–7.
31 Coburn JW, Housh DJ, Housh TJ, et al. Effects of leucine and whey protein
supplementation during eight weeks of unilateral resistance training. J Strength Cond
Res 2006;20:284–91.
32 Cribb PJ, Williams AD, Stathis CG, et al. Effects of whey isolate, creatine, and
resistance training on muscle hypertrophy. Med Sci Sports Exerc 2007;39:298–307.
33 Daly RM, O'Connell SL, Mundell NL, et al. Protein-enriched diet, with the use of lean
red meat, combined with progressive resistance training enhances lean tissue mass
and muscle strength and reduces circulating IL-6 concentrations in elderly women: a
cluster randomized controlled trial. Am J Clin Nutr 2014;99:899–910.
34 Deibert P, Solleder F, König D, et al. Soy protein based supplementation supports
metabolic effects of resistance training in previously untrained middle aged males.
Aging Male 2011;14:273–9.
35 Eliot KA, Knehans AW, Bemben DA, et al. The effects of creatine and whey protein
supplementation on body composition in men aged 48 to 72 years during resistance
training. J Nutr Health Aging 2008;12:208–12.
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
10 Morton RW, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097608
Review
36 Erskine RM, Fletcher G, Hanson B, et al. Whey protein does not enhance
the adaptations to elbow flexor resistance training. Med Sci Sports Exerc
2012;44:1791–800.
37 Farup J, Rahbek SK, Vendelbo MH, et al. Whey protein hydrolysate augments tendon
and muscle hypertrophy independent of resistance exercise contraction mode. Scand J
Med Sci Sports 2014;24:788–98.
38 Hartman JW, Tang JE, Wilkinson SB, et al. Consumption of fat-free fluid milk after
resistance exercise promotes greater lean mass accretion than does consumption
of soy or carbohydrate in young, novice, male weightlifters. Am J Clin Nutr
2007;86:373–81.
39 Herda AA, Herda TJ, Costa PB, et al. Muscle performance, size, and safety responses
after eight weeks of resistance training and protein supplementation: a randomized,
double-blinded, placebo-controlled clinical trial. J Strength Cond Res 2013;27:3091-
100.
40 Hoffman JR, Ratamess NA, Kang J, et al. Effects of protein supplementation on
muscular performance and resting hormonal changes in college football players. J
Sports Sci Med 2007;6:85–92.
41 Hoffman JR, Ratamess NA, Tranchina CP, et al. Effect of protein-supplement timing on
strength, power, and body-composition changes in resistance-trained men. Int J Sport
Nutr Exerc Metab 2009;19:172–85.
42 Hulmi JJ, Kovanen V, Selänne H, et al. Acute and long-term effects of resistance
exercise with or without protein ingestion on muscle hypertrophy and gene
expression. Amino Acids 2009;37:297–308.
43 Hulmi JJ, Laakso M, Mero AA, et al. The effects of whey protein with or without
carbohydrates on resistance training adaptations. J Int Soc Sports Nutr 2015;12:48.
44 Hulmi JJ, Tannerstedt J, Selänne H, et al. Resistance exercise with whey protein
ingestion affects mTOR signaling pathway and myostatin in men. J Appl Physiol
2009;106:1720–9.
45 Iglay HB, Apolzan JW, Gerrard DE, et al. Moderately increased protein intake
predominately from egg sources does not influence whole body, regional, or muscle
composition responses to resistance training in older people. J Nutr Health Aging
2009;13:108–14.
46 Josse AR, Tang JE, Tarnopolsky MA, et al. Body composition and strength changes in
women with milk and resistance exercise. Med Sci Sports Exerc 2010;42:1122–30.
47 Kerksick CM, Rasmussen CJ, Lancaster SL, et al. The effects of protein and amino
acid supplementation on performance and training adaptations during ten weeks of
resistance training. J Strength Cond Res 2006;20:643–53.
48 Leenders M, Verdijk LB, Van der Hoeven L, et al. Protein supplementation during
resistance-type exercise training in the elderly. Med Sci Sports Exerc 2013;45:542–52.
49 Mielke M, Housh TJ, Malek MH, et al. The effects of whey protein and leucine
supplementation on strength, muscular endurance, and body composition during
resistance training. Journal of Exercise Physiology Online 2009;12:39–50.
50 Mitchell CJ, Oikawa SY, Ogborn DI, et al. Daily chocolate milk consumption does
not enhance the effect of resistance training in young and old men: a randomized
controlled trial. Appl Physiol Nutr Metab 2015;40:199–202.
51 Negro M, Vandoni M, Ottobrini S, et al. Protein supplementation with low fat
meat after resistance training: effects on body composition and strength. Nutrients
2014;6:3040–9.
52 Oesen S, Halper B, Hofmann M, et al. Effects of elastic band resistance training and
nutritional supplementation on physical performance of institutionalised elderly--A
randomized controlled trial. Exp Gerontol 2015;72:99–108.
53 Olsen S, Aagaard P, Kadi F, et al. Creatine supplementation augments the increase
in satellite cell and myonuclei number in human skeletal muscle induced by strength
training. J Physiol 2006;573(Pt 2):525–34.
54 Paoli A, Pacelli Q, Cancellara P, et al. Protein supplementation does not further
increase latissimus dorsi muscle fiber hypertrophy after eight weeks of resistance
training in novice subjects, but partially counteracts the fast-to-slow muscle fiber
transition. Nutrients 2016;8:331.
55 Paoli A, Pacelli QF, Neri M, et al. Protein supplementation increases postexercise
plasma myostatin concentration after 8 weeks of resistance training in young
physically active subjects. J Med Food 2015;18:137–43.
56 Rankin JW, Goldman LP, Puglisi MJ, et al. Effect of post-exercise supplement
consumption on adaptations to resistance training. Journal Am American Nutr
2004;23:322–30.
57 Reidy PT, Borack MS, Markofski MM, et al. Protein supplementation has minimal
effects on muscle adaptations during resistance exercise training in Young Men: a
Double-Blind Randomized clinical trial. J Nutr 2016;146:1660–9.
58 Rozenek R, Ward P, Long S, et al. Effects of high-calorie supplements on body
composition and muscular strength following resistance training. J Sports Med Phys
Fitness 2002;42:340–7.
59 Snijders T, Res PT, Smeets JS, et al. Protein ingestion before Sleep increases Muscle
Mass and strength gains during prolonged Resistance-Type exercise training in
healthy young men. J Nutr 2015;145:1178–84.
60 Verdijk LB, Jonkers RA, Gleeson BG, et al. Protein supplementation before and after
exercise does not further augment skeletal muscle hypertrophy after resistance
training in elderly men. Am J Clin Nutr 2009;89:608–16.
61 Volek JS, Volk BM, Gómez AL, et al. Whey protein supplementation during resistance
training augments lean body mass. Journal of American College of Nutrition
2013;32:122–35.
62 Weisgarber KD, Candow DG, Vogt ES. Whey protein before and during resistance
exercise has no effect on muscle mass and strength in untrained young adults.
International Journal of Sport Nutrition Exerc Exercise Metabolism 2012;22:463–9.
63 White KM, Bauer SJ, Hartz KK, et al. Changes in body composition with yogurt
consumption during resistance training in women. International Journal of Sport
Nutrition and Exercise Metabolism 2009;19:18–33.
64 Willoughby DS, Stout JR, Wilborn CD. Effects of resistance training and protein plus
amino acid supplementation on muscle anabolism, mass, and strength. Amino Acids
2007;32:467–77.
65 Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of InterventionsThe
Cochrane Collaboration2011 http://www. handbook. cochrane. org/.
66 Gorissen SH, Horstman AM, Franssen R, et al. Habituation to low or high protein
intake does not modulate basal or postprandial muscle protein synthesis rates: a
randomized trial. Am J Clin Nutr 2017;105.
67 Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal
dietary protein intake in older people: a position paper from the PROT-AGE Study
Group. J am med Dir Assoc 2013. ;14:542–59.
68 Pasiakos SM, McLellan TM, Lieberman HR. The effects of protein supplements
on muscle mass, strength, and aerobic and anaerobic power in healthy adults: a
systematic review. Sports Med 2015;45:111–31.
69 Higgins JP, Thompson SG. Controlling the risk of spurious findings from meta-
regression. Stat Med 2004;23:1663–82.
70 Harbord RM, Higgins JP, Stata M-regressioninThe Stata Journal 2008;8:493–519.
71 Buckner SL, Jessee MB, Mattocks KT, et al. Determining strength: a case for multiple
methods of measurement. Sports Med 2016.
72 Brook MS, Wilkinson DJ, Mitchell WK, et al. Skeletal muscle hypertrophy adaptations
predominate in the early stages of resistance exercise training, matching deuterium
oxide-derived measures of muscle protein synthesis and mechanistic target of
rapamycin complex 1 signaling. Faseb J 2015;29:4485–96.
73 Kim PL, Staron RS, Phillips SM. Fasted-state skeletal muscle protein synthesis after
resistance exercise is altered with training. J Physiol 2005;568(Pt 1):283–90.
74 Wall BT, Gorissen SH, Pennings B, et al. Aging is accompanied by a blunted muscle
protein synthetic response to protein ingestion. PLoS One 2015;10:e0140903.
75 Rennie MJ, Wackerhage H, Spangenburg EE, et al. Control of the size of the human
muscle mass. Annu Rev Physiol 2004;66:799–828.
76 Churchward-Venne TA, Holwerda AM, Phillips SM, et al. What is the optimal amount
of protein to support Post-Exercise skeletal muscle reconditioning in the older adult?
Sports Med 2016;46:1205–12.
77 Bosse JD, Dixon BM. Dietary protein to maximize resistance training: a review and
examination of protein spread and change theories. J Int Soc Sports Nutr 2012;9:42.
78 Trumbo P, Schlicker S, Yates AA, et al. Dietary reference intakes for energy,
carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. Journal of the
American Dietetic Association 2002;102:1621–30.
79 Rafii M, Chapman K, Elango R, et al. Dietary protein requirement of men >65 years
old determined by the indicator amino acid oxidation technique is higher than the
current estimated average requirement. J Nutr 2016;146:681–7.
80 Tang M, McCabe GP, Elango R, et al. Assessment of protein requirement in
octogenarian women with use of the indicator amino acid oxidation technique. Am J
Clin Nutr 2014;99:891–8.
81 Rafii M, Chapman K, Owens J, et al. Dietary protein requirement of female adults
>65 years determined by the indicator amino acid oxidation technique is higher than
current recommendations. J Nutr 2015;145:18–24.
82 Moore DR, Robinson MJ, Fry JL, et al. Ingested protein dose response of muscle and
albumin protein synthesis after resistance exercise in young men. Am J Clin Nutr
2009;89:161–8.
83 Yang Y, Breen L, Burd NA, et al. Resistance exercise enhances myofibrillar
protein synthesis with graded intakes of whey protein in older men. Br J Nutr
2012;108:1780–8.
84 Pennings B, Groen B, de Lange A, et al. Amino acid absorption and subsequent muscle
protein accretion following graded intakes of whey protein in elderly men. Am J
Physiol Endocrinol Metab 2012;302:E992–E999.
85 Robinson MJ, Burd NA, Breen L, et al. Dose-dependent responses of myofibrillar
protein synthesis with beef ingestion are enhanced with resistance exercise in middle-
aged men. Appl Physiol Nutr Metab 2013;38:120–5.
86 Phillips SM, Van Loon LJ. Dietary protein for athletes: from requirements to optimum
adaptation. J Sports Sci 2011;29 Suppl 1(Suppl 1):S29–S38.
87 U.S.. Department of Agriculture ARS. Nutrient intakes from food and beverages: mean
amounts consumed per individual, by gender and age. What We Eat In America:
NHANES, 20142011:12:12.
88 Longland TM, Oikawa SY, Mitchell CJ, et al. Higher compared with lower dietary
protein during an energy deficit combined with intense exercise promotes
greater lean mass gain and fat mass loss: a randomized trial. Am J Clin Nutr
2016;103:738–46.
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
strength in healthy adults
training-induced gains in muscle mass and
supplementation on resistance
meta-regression of the effect of protein
A systematic review, meta-analysis and
Laura Banfield, James W Krieger and Stuart M Phillips
Menno Henselmans, Eric Helms, Alan A Aragon, Michaela C Devries,
Robert W Morton, Kevin T Murphy, Sean R McKellar, Brad J Schoenfeld,
published online July 11, 2017Br J Sports Med
http://bjsm.bmj.com/content/early/2017/07/11/bjsports-2017-097608
Updated information and services can be found at:
These include:
References
#BIBL
http://bjsm.bmj.com/content/early/2017/07/11/bjsports-2017-097608
This article cites 81 articles, 17 of which you can access for free at:
service
Email alerting box at the top right corner of the online article.
Receive free email alerts when new articles cite this article. Sign up in the
Notes
http://group.bmj.com/group/rights-licensing/permissions
To request permissions go to:
http://journals.bmj.com/cgi/reprintform
To order reprints go to:
http://group.bmj.com/subscribe/
To subscribe to BMJ go to:
group.bmj.com on July 17, 2017 - Published by http://bjsm.bmj.com/Downloaded from
