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Conflict of interest: JSV receives royalties for low-carbohydrate nutrition books. He is founder, consultant, and stockholder of Virta Health Corp.; a member of the advisory boards for Atkins Nutritionals Inc., UCAN Co., Ketone Sciences, and Axcess Global; and has received honoraria from Metagenics and Pruvit. SDP receives royalties for low-carbohydrate nutrition books. He is founder and stockholder of Virta Health Corp. and a member of the advisory board for Atkins Nutritionals Inc. RMK has had investigator-initiated research funding from the National Dairy Council and the Almond Board of California. He receives royalties from a patent for ion mobility analysis of lipoproteins and from a textbook on nutrition and cardiometabolic health. He is on the scientific advisory boards of, and has stock options from, Virta Health, and DayTwo, and is a part-time employee of JumpstartMD.

Purpose Preexercise ingestion of exogenous ketones alters the metabolic response to exercise, but effects on exercise performance have been equivocal. Methods On two occasions in a double-blind, randomized crossover design, eight endurance-trained runners performed 1 h of submaximal exercise at approximately 65% V˙O2max immediately followed by a 10-km self-paced time trial (TT) on a motorized treadmill. An 8% carbohydrate-electrolyte solution was consumed before and during exercise, either alone (CHO + PLA), or with 573 mg·kg−1 of a ketone monoester supplement (CHO + KME). Expired air, HR, and RPE were monitored during submaximal exercise. Serial venous blood samples were assayed for plasma glucose, lactate, and β-hydroxybutyrate concentrations. Results CHO + KME produced plasma β-hydroxybutyrate concentrations of approximately 1.0 to 1.3 mM during exercise (P < 0.001), but plasma glucose and lactate concentrations were similar during exercise in both trials. V˙O2, running economy, respiratory exchange ratio, HR, and RPE were also similar between trials. Performance in the 10-km TT was not different (P = 0.483) between CHO + KME (mean, 2402 s; 95% confidence interval, 2204–2600 s) and CHO + PLA (mean, 2422 s; 95% confidence interval, 2217–2628 s). Cognitive performance, measured by reaction time and a multitasking test, did not differ between trials. Conclusions Compared with carbohydrate alone, coingestion of KME by endurance-trained athletes elevated plasma β-hydroxybutyrate concentrations, but did not improve 10-km running TT or cognitive performance.

Introduction Ketogenic diets (KDs) that elevate ketones into a range referred to as nutritional ketosis represent a possible nutrition approach to address the emerging physical readiness and obesity challenge in the military. An emerging body of evidence demonstrates broad-spectrum health benefits attributed to being in nutritional ketosis, but no studies have specifically explored the use of a KD in a military population using daily ketone monitoring to personalize the diet prescription. Materials and Methods To evaluate the feasibility, metabolic, and performance responses of an extended duration KD, healthy adults (n = 29) from various military branches participated in a supervised 12-wk exercise training program. Fifteen participants self-selected to an ad libitum KD guided by daily measures of capillary blood ketones and 14 continued their normal mixed diet (MD). A battery of tests were performed before and after the intervention to assess changes in body mass, body composition, visceral fat, liver fat, insulin sensitivity, resting energy metabolism, and physical performance. Results All KD subjects were in nutritional ketosis during the intervention as assessed by daily capillary beta-hydroxybutyrate (βHB) (mean βHB 1.2 mM reported 97% of all days) and showed higher rates of fat oxidation indicative of keto-adaptation. Despite no instruction regarding caloric intake, the KD group lost 7.7 kg body mass (range −3.5 to −13.6 kg), 5.1% whole-body percent fat (range −0.5 to −9.6%), 43.7% visceral fat (range 3.0 to −66.3%) (all p &lt; 0.001), and had a 48% improvement in insulin sensitivity; there were no changes in the MD group. Adaptations in aerobic capacity, maximal strength, power, and military-specific obstacle course were similar between groups (p &gt; 0.05). Conclusions US military personnel demonstrated high adherence to a KD and showed remarkable weight loss and improvements in body composition, including loss of visceral fat, without compromising physical performance adaptations to exercise training. Implementation of a KD represents a credible strategy to enhance overall health and readiness of military service members who could benefit from weight loss and improved body composition.

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