On the Metabolism of Exogenous Ketones in Humans

Background and aims: Currently there is considerable interest in ketone metabolism owing to recently reported benefits of ketosis for human health. Traditionally, ketosis has been achieved by following a high-fat, low-carbohydrate ketogenic diet, but adherence to such diets can be difficult. An alternative way to increase blood D-beta-hydroxybutyrate (D-beta HB) concentrations is ketone drinks, but the metabolic effects of exogenous ketones are relatively unknown. Here, healthy human volunteers took part in three randomized metabolic studies of drinks containing a ketone ester (KE); (R)-3-hydroxybutyl (R)-3-hydroxybutyrate, or ketone salts (KS); sodium plus potassium beta HB. Methods and Results: In the first study, 15 participants consumed KE or KS drinks that delivered similar to 12 or similar to 24 g of beta HB. Both drinks elevated blood D-beta HB concentrations (D-beta HB C-max: KE 2.8mM, KS 1.0mM, P < 0.001), which returned to baseline within 3-4 h. KS drinks were found to contain 50% of the L-beta HB isoform, which remained elevated in blood for over 8 h, but was not detectable after 24 h. Urinary excretion of both D-beta HB and L-beta HB was < 1.5% of the total bHB ingested and was in proportion to the blood AUC. D-beta HB, but not L-beta HB, was slowly converted to breath acetone. The KE drink decreased blood pH by 0.10 and the KS drink increased urinary pH from 5.7 to 8.5. In the second study, the effect of a meal before a KE drink on blood D-beta HB concentrations was determined in 16 participants. Food lowered blood D-beta HB C-max by 33% (Fed 2.2 mM, Fasted 3.3 mM, P < 0.001), but did not alter acetoacetate or breath acetone concentrations. All ketone drinks lowered blood glucose, free fatty acid and triglyceride concentrations, and had similar effects on blood electrolytes, which remained normal. In the final study, participants were given KE over 9 h as three drinks (n = 12) or a continuous nasogastric infusion (n = 4) to maintain blood D-beta HB concentrations greater than 1 mM. Both drinks and infusions gave identical D-beta HB AUC of 1.3-1.4 moles. min. Conclusion: We conclude that exogenous ketone drinks are a practical, efficacious way to achieve ketosis.