Whole Person Care Protocol (Exercise Performance and Body Composition)

3X4 Genetics Test + Blueprint Report

The 3X4 Blueprint test analyzes 170 genes to create a personalized report, providing actionable insights into weight balance, exercise response, and recovery. It enables providers to tailor lifestyle and treatment recommendations to optimize metabolic, muscle, and overall health outcomes.

Genova Diagnostics Metabolomix+

The Metabolomix+ test analyzes key nutritional biomarkers, identifying needs for antioxidants, B vitamins, minerals, and more. It offers actionable insights for addressing fatigue, inflammation, and mitochondrial dysfunction—key factors in muscle health and recovery.

Beta-hydroxy-beta-methylbutyrate (HMB)

3 g per day for 3–12 weeks (Kerksick 2018)

• HMB supplementation increased muscle mass among untrained and elderly subjects by an additional 0.5–1 kg versus controls. (Kerksick 2018)
• Trained athletes supplementing with HMB may have reductions in fat mass, (Durkalec-Michalski 2015)(Durkalec-Michalski 2016)(Durkalec-Michalski 2017) though there are mixed results on whether trained athletes tend to gain muscle mass. (Kerksick 2018) Longer training periods (over six weeks) and periodization may increase the likelihood of lean mass gain. (Wilson 2013)
• A 2018 meta-analysis of trained athletes showed that HMB did not affect bench press strength, leg press strength, body mass, fat-free mass, or fat mass. (Sanchez-Martinez 2018) 
• A 2019 meta-analysis on untrained subjects aged 50–80 only showed a small, borderline statistically significant effect on handgrip strength (ES=0.19, p=0.06), with no effects found on leg strength, muscle mass, or fat mass. (Courel-Ibáñez 2019)
• Doses up to 6 g per day have been well tolerated with no adverse effects. (Wilson 2013)(Gallagher 2000)

Adverse effects

• Supplementation with 3 g per day is well tolerated and not associated with any adverse effects. (Rathmacher 2004)

Creatine monohydrate

Loading phase of 0.3 g/kg body weight or ~5 g four times daily for 5–7 days, followed by a maintenance phase of 3–5 g per day ongoing (Kreider 2017)

Alternatively, 3 g per day ongoing; however, ergogenic effects may not manifest until towards the end of the first 28 days (Kreider 2017)

• Generally, high-intensity and/or repetitive exercise performance is increased by 10–20%. (Kreider 2017)
• Meta-analyses on both upper (Lanhers 2017) and lower (Lanhers 2015) limb performance showed small strength benefits (ES=0.235–0.317), with the largest being on the pectoralis major and minor for the bench press (5.3%). (Lanhers 2017)
• Creatine is effective for bouts of exertion ~1–10 seconds long, with rest periods of 0.5–5 minutes. (Bemben 2005)(Butts 2018) It may also be helpful for continuous bouts of exertion between ten seconds and two minutes. (Bemben 2005)
• There are likely no differences in effect size based on age, sex, and training status. (Lanhers 2017) There’s insufficient evidence to suggest that other forms of creatine (beyond creatine monohydrate, such as creatine HCl) have superior absorption or effectiveness. (Jäger 2011)
• Robust evidence shows a small increase in body mass (~0.26 kg, possibly due to increased water retention from hyper-hydration of the muscle) (Kreider 2017) following creatine supplementation during the loading phase, which tends to disappear during the maintenance phase. (Branch 2003) Despite this mass gain, there’s no high-quality evidence to suggest ergolytic effects of creatine even in endurance athletes, which may be attributed to creatine’s other benefits (e.g., muscle hydration, heat tolerance, enhanced recovery). (Kreider 2017)
• Despite significant research on creatine, its use in women remains underexplored. A 2021 review on creatine supplementation in women’s health highlighted the following musculoskeletal benefits:
  • In adolescents and young adults, creatine supplementation may support strength, muscle development, exercise performance, and recovery (without significant weight gain) by enhancing energy availability during high-intensity activities.
  • In post-menopausal women, creatine, especially when combined with resistance training, may help support muscle and bone health, strength, functionality, and overall quality of life. It may also reduce inflammation and oxidative stress, contributing to better musculoskeletal health. (Smith-Ryan 2021)

Adverse effects

• One of the longest studies of high-dose creatine supplementation (up to 30 g per day for five years) has shown no detrimental effects in healthy individuals. (Bender 2016) Additionally, there’s no compelling evidence that creatine supplementation negatively affects kidney function in healthy or clinical populations. (Kreider 2017)

Omega-3 fatty acids (EPA/DHA)

3 g of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in 2:1 ratio for eight weeks (Ochi 2018)

• EPA and DHA may improve nitric oxide (NO) production. They have been found to reduce vascular resistance, increase cardiac stroke volume, and increase cardiac output, which may result in increased oxygen delivery during exercise and increased VO2 max. (Walser 2008)(Zebrowska 2015)
• Various RCTs have shown that EPA and DHA are associated with increased lipid peroxidation both post exercise and at rest (e.g., malonaldehyde), in addition to increased antioxidant enzyme activities (e.g., superoxide dismutase, glutathione peroxidase). (Lewis 2020)
• Improved reaction time and mood were seen across all sports (professional rugby, soccer, athletics, and karate) examined in RCTs in this 2020 SR of sport supplementation of EPA and DHA. (Lewis 2020)
• 13 cyclists were given 660 mg EPA and 440 mg DHA twice daily for three weeks, and versus placebo, their NO production and VO2 max were significantly higher with omega-3 supplementation. (Zebrowska 2015)
• EPA and DHA might decrease post-exercise muscle soreness and improve range of motion. A SR noted a reduction of delayed-onset muscle soreness (DOMS) in six of 12 trials and a lessened range of motion deficit after exercise in three of five trials. They also found interesting findings worthy of further exploration: lessened muscle strength deficit after exercise in two of six trials and a reduction of swelling in the muscle in one of five trials. Results were mixed but generally found no effect on muscle protein synthesis (MPS). (Ochi 2018)

Adverse effects

• Supplementary omega-3 fatty acids appear to have a low risk of adverse effects, as only one of five RCTs in an SR (Lewis 2020) reported adverse effects, noting poor palatability, gastrointestinal distress, and nausea in 10% of participants. (Oliver 2016)
• High omega-3 consumption may prolong bleeding time; (Meydani 1991) however, the FDA has recognized that intakes of up to 3 g per day of omega-3 fatty acids are generally recognized as safe in humans, even with regards to claims on bleeding tendencies. (US FDA 2004)

PeptiStrong™ (NPN_1)

2.4 g once per day to 10 g twice per day for a minimum of two weeks

• A randomized double-blind placebo-controlled trial conducted on 30 healthy males found that 14 days of PeptiStrong™ supplementation improved strength recovery, reduced fatigue, and suppressed myostatin levels following exercise-induced muscle soreness. It also enhanced muscle protein synthesis and regeneration biomarkers, supporting faster recovery and improved performance compared to a placebo over 72 hours. (Kerr 2023)
• A randomized controlled trial studied the effects of NPN_1 versus milk protein (MPC) on muscle loss and recovery in 30 healthy young men. After seven days of leg immobilization followed by 14 days of recovery, both supplements similarly prevented muscle size loss. However, NPN_1 led to higher MPS rates during recovery, suggesting it may better support muscle rebuilding after inactivity. (Weijzen 2023)

Adverse effects

• In a randomized, double-blind, placebo-controlled trial involving 30 healthy males, no serious adverse events were observed. Non-serious adverse events included two reports of muscle tightness during isokinetic dynamometry, one instance of elevated blood pressure that resolved after testing without complications, and one case of total body DOMS, which temporarily prevented participation in day 16 testing. The affected individual fully recovered and reported no pain 48 hours after day 17. (Kerr 2023)

Whey protein

20–75 g per day for two weeks to 15 months (Wirunsawanya 2018)

• Whey protein is generally an easy-to-mix, digest, and absorb milk-derived protein supported by a large body of evidence for improving cardiovascular factors and body composition. (Morifuji 2010)(Sousa 2012)
• A 2018 SR and MA found whey protein supplementation in individuals who are overweight and/or obese to be associated with significant reductions in body weight and fat mass and increases in lean mass. With the resultant weight loss, the authors noted significant improvements in systolic and diastolic blood pressure, glucose, high-density lipoprotein, and total cholesterol and fat mass. (Wirunsawanya 2018)
• Optimal daily protein intake likely reduces the effect of whey protein supplementation. (Huang 2021) For active individuals aiming to improve body composition, this intake is likely 1.6–2.4 g of protein per kilogram of body weight. (Burke 2019) Whey protein may be a tool consumers can use to hit this protein target.
• A 2018 SR and MA found that whey protein may be a useful tool to lose weight and preserve muscle mass for those following a hypocaloric diet. (Bergia 2018)

Adverse effects

• A 2019 SR and MA of whey protein concentrates, isolates, and hydrolysates noted no adverse effects in any of the trials examined. (Castro 2019)

Lifestyle recommendations

Lifestyle strategies are foundational to achieving sustainable, long-term health outcomes. Balanced nutrition, structured exercise, restorative sleep, and stress management are vital components of whole person care. The lifestyle recommendations in this protocol offer a range of tools for providers to customize plans that empower patients to achieve their unique performance and wellness goals.

Nutrition

Carbohydrates requirements 

• <one hour of exercise per day: 3–5 g/kg of body weight per day
• One hour of exercise per day: 5–7 g/kg of body weight per day
• 1–3 hours of exercise per day: 6–10 g/kg of body weight per day
• >three hours of exercise per day: 8–12 g/kg of body weight per day (Burke 2011)

Evidence:

• The Institute of Medicine has set the recommended dietary intake of carbohydrates at 130 g per day for a sedentary individual. (Trumbo 2002) However, carbohydrate intake should be adjusted to an athlete’s activity level, with common targets for daily consumption summarized above.

Protein requirements

• Average individual: 0.8 g/kg of body weight per day 
• Most athletes: 1.4 to 2 g/kg of body weight per day
• Athletes trying to keep a fat-free mass: Up to 2.4 g/kg of body weight per day 

Evidence:

• Athletes require more protein than the general population, with a recommended daily intake of 1.4–2 g/kg of body weight to support their training needs and prevent protein malnutrition. (Jäger 2017)(Kerksick 2018)
• For those aiming to maintain fat-free mass while restricting energy intake, daily protein intake may need to be as high as 2.4 g/kg of body weight. (Burke 2019)
• Distributing protein intake around training sessions can help reduce muscle protein breakdown during exercise and enhance recovery post-exercise by leveraging the anabolic window. (Jäger 2017)(Kerksick 2018) To maximize MPS, athletes should consume 20–40 g of protein approximately every three hours, depending on their body weight. (Kersick 2017) For example, a 90 kg athlete with a daily target of 180 g of protein could achieve this by consuming five meals or snacks containing 36 g of protein each.

Fat requirements

• 30% of calories (20–35%) from fat is recommended for most athletes, which should consist of less than 10% saturated fat and contain higher amounts of polyunsaturated fats and essential fatty acids. (Bytomski 2018)(Jenner 2019)(Thomas 2016)

Evidence:

• Athletes are generally advised to maintain 20–35% of their daily caloric intake from fat, with less than 10% from saturated fat and higher amounts from polyunsaturated fats and essential fatty acids to support overall health and performance. (Bytomski 2018)(Jenner 2019)(Thomas 2016) 
• Consuming more than 35% of calories from fat may compromise carbohydrate and protein intake, negatively affecting recovery and performance, or lead to weight gain if caloric excess occurs. 
• Insufficient fat intake (below 10–20% of calories) may lower testosterone levels, which can impair MPS and performance, particularly during periods of overtraining. (Kerksick 2018)(Whittaker 2021)(Fry 1998)(Pasiakos 2019)
• Chronic low-fat diets may also deplete fat-soluble vitamins and omega-3 fatty acids, which are essential for reducing inflammation and supporting recovery. (Thomas 2016)(Lewis 2020)

Caloric requirements 

Resting metabolic rate (RMR) (Frankenfield 2005)

• Males: RMR = 9.99 x weight (kg) + 6.25 x height (cm) – 4.92 x age + 5
• Females: RMR = 9.99 x weight (kg) + 6.25 x height (cm) – 4.92 x age – 161

Total daily energy expenditure (TDEE) (Bytomski 2018)

• RMR is multiplied by an activity factor: 
  • 1.4–1.69 for sedentary or lightly active individuals 
  • 1.7–1.99 for moderately active individuals
  • 2–2.4 for elite or endurance athletes

Evidence:

• Caloric requirements vary based on individual factors such as body weight, height, age, and activity level. The Mifflin-St Jeor equation is a reliable method for estimating RMR, which serves as the foundation for determining daily energy needs. (Frankenfield 2005)
• To estimate TDEE, RMR is multiplied by an activity factor: 1.4–1.69 for sedentary or lightly active individuals, 1.7–1.99 for moderately active individuals, and 2–2.4 for elite or endurance athletes. (Bytomski 2018)
• While advanced methods like the doubly labeled water (DLW) technique provide precise caloric measurements, practical alternatives such as heart rate monitors and accelerometers can closely estimate caloric expenditure. (Johansson 2007) 

Patient resources

• Plant-based protein
• Omega-3 fatty acids
• Healthy diet grocery guide
• Eating healthy on a budget
• Pre- and post-exercise nutrition

Hydration

Requirement:

• 6–12 ounces (177–355 mL) of water every 15–30 minutes during exercise (Bytomski 2018) 

Evidence:

• Fluid and electrolyte intake are important considerations during exercise as the body can lose 10–81 oz (0.3–2.4 L) of water per hour. This varies based on environment, sex, body size, and length of activity. (Thomas 2016) 
• As 51 oz (1.5 L) of fluid may be lost before thirst is perceived, (NA 2013) thirst may not act as a good initial gauge to signal the need for fluid intake. Instead, athletes should generally proactively consume 6–12 ounces (177–355 mL) of water every 15–30 minutes during exercise. (Bytomski 2018)

Practitioner resource

• A practitioner’s guide to sports supplements

Patient resource

• Weekly hydration tracker

Sleep

Recommendation: 

• Athletes should aim for 9–10 hours of sleep nightly to support recovery, compared to the 7–9 hours recommended for the general population. (Fullagar 2015)

Description:

• Endurance and performance: Sleep deprivation and restriction reduce endurance and anaerobic performance, with impacts like shorter time to exhaustion and lower muscle glycogen levels, limiting prolonged activity.
• Cognition: 
  • Sleep deprivation and sleep restriction impact cognitive-dependent activities (e.g., tennis serving) more than gross motor tasks (e.g., swimming).
  • Cognitive effects include slower reaction times, poor decision-making, and reduced alertness, affecting sports requiring quick thinking.
• Perceived exertion: Sleep loss raises perceived exertion during exercise, further reducing performance.
• Hormones:
  • Growth hormone (GH) is released during non-rapid eye movement (REM) sleep sleep, particularly in the deeper stages. Sleep restriction can reduce GH secretion, which is critical for tissue repair, growth, and overall recovery.
  • Cortisol is highly influenced by circadian rhythms and stress levels. The impact of sleep restriction on cortisol is inconsistent in studies. Some report no significant change, while others suggest that cortisol levels may decrease or fluctuate due to altered circadian timing during sleep restriction. Reduced cortisol could theoretically impair energy regulation and response to physical stress.

• Inflammation: sleep restriction can significantly elevate pro-inflammatory cytokines like interleukin 6 (IL-6) and tumor necrosis factor-alpha (TNF- α). For instance, IL-6 has been shown to increase threefold the day after sleep restriction. TNF-alpha levels also rise, doubling in some cases. These increases in pro-inflammatory markers are associated with heightened inflammation, reduced recovery potential, and an increased risk of chronic diseases.
• Mood: Sleep loss also worsens mood, increasing fatigue, confusion, and lowering motivation, indirectly impacting performance. (Fullagar 2015)

Patient resource

• Lifestyle tips for better sleep

Mindfulness-based interventions 

• Mindfulness-based interventions (MBIs) improve athletic performance by reducing anxiety, enhancing focus, and managing competition pressure.
• They promote emotional regulation, reduce performance-related worries, and increase self-compassion.
• Techniques like mindfulness-acceptance-commitment (MAC) training enhance mental resilience and regulate emotions.
• Mindfulness helps reduce pre-competition stress and general anxiety, positively impacting performance.
• Athletes practicing mindfulness experience lower cortisol levels and improved recovery times. (Wang 2023)(Si 2024)

Patient resource

• Mindfulness