The Effect of Acute Exogenous Oral Ketone Supplementation on Blood Glucose Levels in Type 2 Diabetes
Phase: NA
Conditions: Ketosis, Type 2 Diabetes
Sponsor: University of British Columbia

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
Title: The effect of acute exogenous oral ketone supplementation on blood 
glucose levels in type 2 diabetes  
Research Question: Does exogenous ketone supplementation impact 
glucose levels in people with type 2 diabetes? 
Objectives 
a) To determine whether acute ketone supplementation impacts plasma 
glucose levels compared to a placebo. 
b) To observe blood ketone levels after ingestion of an acute dose of 
exogenous ketones. 
c) To compare changes in insulin concentrations and C-peptide 
metabolism after acute ketone supplementation versus a placebo. 
d) To determine whether acute ketone supplementation alters non-
esterified fatty acids (NEFA) and inflammatory cytokines 
e) To determine influence of acute ketone supplementation in cerebral 
blood flow (CBF), brain-derived neurotrophic factor (BDNF), and 
cognitive function 
f) To evaluate influence of acute ketone supplements in histone 
acetylation and Beta-hydroxybutyrate(BHB)-ylation in peripheral blood 
mononuclear cells (PBMC) /leukocytes. 
g) To determine whether acute ketone supplementation influences appetite 
and satiety levels and causes any gastrointestinal (GI) distress 
 
Hypothesis: 
a) Exogenous ketone supplementation will lower blood glucose compared 
to a placebo 
b) When compared to placebo, exogenous ketone supplementation will 
lower NEFA concentration and suppress inflammation by decreasing 
inflammatory markers 
c) Exogenous ketone supplementation will increase neurovascular 
coupling, improve cognitive function, and increase BDNF compared to 
placebo 
d) Compared to placebo, exogenous ketone supplements will increase 
histone acetylation and in peripheral blood mononuclear cells (PBMC) 
/leukocytes 
e) Participants will report greater satiety over the observation period 
following ketone supplementation compared to placebo  
 
 
Background Information 
Approximately one in four Canadians have type 2 diabetes (T2D) or prediabetes, 
conditions which are threatening to bankrupt healthcare systems in Canada and 
globally [1]. Existing measures can work well in controlled environments, but drugs 
are costly, require prescriptions and have side-effects, while diet-induced weight 

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
loss and regular exercise require precise management and have adherence 
issues.  
Previously, increases in blood ketones have been shown to reduce blood glucose 
but therapeutic application was limited due to the need for ketone infusion or 
severe dietary restrictions. The recent discovery and commercialization of 
exogenous oral ketone supplements represents a nutritional breakthrough that 
now allows someone to raise blood ketone levels by consuming a nutritional 
supplement in liquid form. In three previous UBC CREB approved experiments 
(H16-01846), we have shown that acute ingestion of the oral ketone monoester 
((R)-3-hydroxybutyl (R)-3-hydroxybutyrate) immediately lowers glucose and 
improves glucose tolerance in healthy humans and individuals at risk for T2D [2] . 
The logical next step in this research is to examine the impact of oral β-OHB 
supplements on blood glucose levels in T2D. With CIHR Bridge Grant funding the 
overall aim of this project is to test the glucose-lowering effects of oral ketone 
monoester supplement in humans with T2D. 
 
In addition, β-hydroxybutyrate appears to protect cells from inflammation and 
oxidative stress triggers. The direct effect of β-hydroxybutyrate on inflammation 
has been tested in recent cell culture and animal-based studies. The results show 
that elevating β-OHB can not only influence innate immune cell signalling, but can 
attenuate pro-inflammatory activity, which has been shown to play a major role in 
the perpetuation of inflammation associated with various diseases, including T2D 
[3]. Whether oral ketone supplements can similarly suppress inflammation in 
humans with T2D has not been tested.  
 
Ketones also provide an alternative fuel for the brain and have been shown in 
animal studies to enhance cognitive function [4]. The mechanism(s) appear related 
to enhanced metabolism of ketones by the brain [5], increased blood flow to the 
brain [6], or elevated levels of BDNF [7]. No studies have tested whether 
exogenous ketones can improve brain blood flow, cognitive function or BDNF in 
humans.  
 
Therefore, nutritional ketosis induced by supplementing with exogenous oral 
ketones is an intriguing therapeutic strategy, particularly for individuals with T2D 
who have elevated glucose, increased inflammation, and altered brain function. 
Further investigation is necessary to explore the potential metabolic effects of 
ketone supplementation in people with T2D. Given our past findings and expertise 
in this area, we are poised to conduct this urgently needed research now. 
 
 
 
 
 
 
 

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
Research Method 
 
Experimental design 
A randomized placebo-controlled, cross-over pilot study in which 20 adults with 
type 2 diabetes will participate in two experimental trials. All participants will 
provide written informed consent during an initial familiarization visit.  
Following screening, eligible participants (N=20) will participate in two 
experimental trials of β-OHB supplementation versus placebo with order of 
treatment balanced, separated by ~7 days. Pre-menopausal women will be tested 
in the follicular phase (days 3-9) to minimize any potential changes in insulin 
sensitivity across the menstrual cycle [8]. Participants will be asked to refrain from 
structured exercise and alcohol, and limit physical activity to their activities of daily 
living on the day before each trial. A standardized diet with ~50% energy from 
carbohydrate, ~30% fat, ~20% protein (energy based on Harris-Benedict equation 
with an activity factor of 1.4) will be oriented on the day before each trial. 
Participants will then fast overnight (8-10h) and refrain from taking any medications 
24 hours before the morning of the trial. Upon arrival, an indwelling intravenous 
catheter will be inserted and a baseline fasting blood sample will be obtained. The 
oral β-OHB supplement or placebo will be consumed in liquid form (~20-25 mL). 
Both drinks are masked with a proprietary calorie-free strawberry flavour 
developed by H.V.M.N®, USA, which results in the same taste profile for each. 
The β-OHB supplement will provide 0.3 g/kg β-OHB in the form of the ketone 
monoester (R)-3-hydroxybutyl (R)-3-hydroxybutyrate (ΔG®, TDeltaS, Oxford, UK). 
We used this dose in our supporting pilot study and published work shows it can 
consistently raise blood β-OHB levels to ~2-3 mmol/L within 15-30 minute[9] [2] 
[10]. Post consumption of the β-OHB or placebo blood samples will be obtained at 
30, 60, 90,120, 150 and 180 minutes. 
The primary outcomes will be total plasma glucose as represented by the 3-hour 
area under the curve. Secondary outcomes include plasma insulin and C-peptide 
levels, plasma free fatty acids (FFA), inflammatory cytokines, cerebral blood flow 
(CBF), cognitive function, BDNF, signalling molecules, self reported hunger and 
fullness by a Visual Analog Scale (VAS) and GI symptom questionnaire scores – 
all measured across 180 minutes post-supplementation. 
 
Metabolite and hormone analyses 
Blood samples will be collected into EDTA tubes and processed using established 
procedures in our lab [11] [12] [13] [14]. Blood β-OHB levels will be measured using 
the Abbot Freestyle Precision Neo® ketone meter. Plasma will be collected by 
centrifugation and will be stored at -80°C for batch analyses of glucose, insulin, 
FFA and cytokines as we have described [11] [12]. C-peptide will be measured by 
ELISA (Millipore #EZHCP-20K) in order to further characterize the impact of oral 
β-OHB on insulin secretion. Peripheral blood mononuclear cells will be isolated to 
measure histone acetylation and inflammatory signalling. Histones acetylation will 
be quantified with flow cytometry using the Histone H3 Acetylation Assay Kit 

 
 
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Faculty of Health and Social Development 
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3333 University Way 
Kelowna, BC  V1V 1W5 
(Millipore/Sigma Aldrich, CA ). Inflammatory pathways and signalling will be 
assessed by standard western blotting techniques. 
 
The study will involve 2 visits to the laboratory:  
Visit 1: Eligibility and Testing 1 
Visit 2: Testing 2 
 
 
VISITS SUMMARY 
 
Visit 1: Baseline screening (duration 60 minutes) 
Individuals with T2D will be recruited by poster and online advertisement. We will 
also invite past study participants who have consented to be contacted for future 
research.  
Individuals must be able to read and understand English in order to complete the 
study diet and activity logs. On the initial visit potential participants will read through 
the information and consent form, ask any questions, and provide written informed 
consent. They will received a signed copy of the document. The postdoctoral fellow 
research lead (Dr. B. Oliveira) will ensure that the subjects understand the details 
of the study and consent form. Following informed consent, eligibility criteria will 
be confirmed by detailed medical history questionnaire and baseline 
measurements.  
Inclusion criteria will be: i) physician-diagnosed T2D of ≥1 year; ii) current HbA1c 
of 6.5-8.0%; iii) treatment with lifestyle or stable (≥3 months) oral glucose-lowering 
medications; iv) blood pressure of <160/99 mm Hg assessed according to 
guidelines; v) non-smoking; vi) no prior history of CVD or stroke; vii) not on 
hormone replacement therapy, corticosteroids, or anti-inflammatory medications; 
viii) 20–75 years old and iv) if vaccinated for COVID-19, have been vaccinated at 
least four weeks prior to participation in the study 
Exclusion criteria will include: i) being a competitive endurance athlete; ii) taking 
exogenous insulin or SGLT2 inhibitors; iii) following a ketogenic diet, low-calorie 
diet, periodic fasting regimen, or consume ketogenic supplements; iv) being unable 
to travel to and from the university; v) being unable to follow the controlled diet 
instructions; vi) being pregnant or planning to become pregnant during the study 
(if female); vii) disorders of fat metabolism, chronic pancreatitis, had gastric bypass 
surgery and/or gallbladder disease; vii) being unable to read or communicate in 
English.  
Based on our previous studies ~55% of males and ~70% of females with T2D who 
volunteer will meet these eligibility criteria so we anticipate no recruitment issues. 
We will allow statins and anti-hypertensive medications if on a stable dose for 3 
months because the majority of T2D patients are on at least one of these 
medications; excluding them would leave a small pool for recruitment and limit the 
generalizability of our findings. Excluding exogenous insulin will avoid potential 
interactions and risk of hypoglycemia. SGLT-2 inhibitors (which are rarely used in 
BC because they are not covered by the provincial drug plan) will also be excluded 

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
because of reports of euglycemic ketoacidosis with this drug [15]. Potential risks 
of hypoglycaemia with the most common diabetes medications (i.e., metformin, 
DPP-IV inhibitors, and GLP-1 agonists) are very low so we will be recruiting from 
a large pool that is representative of the T2D population. 
Females will complete the menstrual cycle questionnaire in order to determine 
when the follicular phase is for testing purposes. Anthropometric and physiologic 
measurements will be collected (height, body weight, waist circumferences, blood 
pressure) for baseline participant characterization. The Montreal Cognitive 
Assessment (MoCA) will be used as a screening tool to ensure cognition levels 
meet the studies’ requirements. Participants will be instructed about the 
standardized diet ~50% energy from carbohydrate, ~30% fat, ~20% protein 
(energy based on Harris-Benedict equation with an activity factor of 1.4) that will 
be oriented on the day before each trial. They will be asked to refrain from 
structured exercise and alcohol, and limit physical activity to daily living tasks as 
well as. Participants will then fast overnight (8-10 h) and refrain from taking any 
medications 24 hours before trial visits. 
 
Experimental Trial A (duration 210 minutes) 
Females will complete experimental trials in the follicular phase. Participants 
will report to the laboratory after an overnight fast (8-10 hours). Adherence to 
the 24 hour diet will be confirmed upon arrival in the laboratory, as well as 
information about physical activity and sleep. An indwelling intravenous 
catheter will be inserted into the antecubital vein for repeated blood sampling 
by a trained phlebotomist (Dr Jonathan Little and Dr. Barbara Oliveira). Blood 
(5 ml) will be drawn into EDTA tubes for measurement of plasma samples 
before being frozen in a -80 degree Celsius research refrigerator. There will be 
7 intravenous blood draws in total for a total of ~35 ml of blood collected in each 
trial. The first collection will occur prior (0) to consumption of ketone or placebo 
drink. Another 6 blood draws will occur at 30 minute intervals (30, 60, 90, 120, 
150, 180) after ingestion of the ketone or placebo drink. Thirty minutes after 
ingestion, participants will be instructed to complete the gastrointestinal 
distress questionnaire. Brain blood flow and blood pressure will be measured 
non-invasively and a cognitive test battery will be performed in separate 
intervals throughout the study. During the visit participants will answer a brief 
questionnaire regarding satiety and hunger. Subjects will be reminded to not 
perform exercise or to consume alcohol or medications 24 hours prior to the 
next visit. 
 
 
 
 
 

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
Protocol timeline 
 
 
 
 
 
            
 
 
 
 
 
 
 
- Follow and 
record diet.  
- Come to lab 
fasted.  
(8-10hrs) 
 
 
24 Hours 
before 
0 min 
30min 
60min 
90min 
120min 
150min 
180min 
Up to  
210 min 
ketone
or
placebo
drink

Bloodsamples
Gastrointestinal 
disturbance 
questionnaire 
Brain blood 
flow test 
+ 
Cognition 
test 
Brain blood 
flow test 
+ 
Cognition 
test 
Brain blood 
flow test 
+ 
Cognition 
test 
Satiety/ 
Hunger 
questionnaire 
Satiety/ 
Hunger 
questionnaire 
Satiety/ 
Hunger 
questionnaire 
Satiety/ 
Hunger 
questionnaire 
 
Visit 2: Experimental Trial B 
Subjects will return fasted to the laboratory at least 2 days after the fisrt visit. 
Adherence to the 24 hour diet will be confirmed upon arrival in the laboratory. 
Participants will be instructed to identify any deviations in diet before beginning the 
second trial. Protocol for the second visit will be the same as visit 1, although 
participants will receive the remaining condition (ketone supplementation or 
placebo).  
Statistical Analyses 
 
Descriptive statistics (means, SD, and frequencies) will be calculated and Q-Q 
plots of residuals used to test for normality and skewness. Significance will be set 
at P<0.05. Data with a time component will be analyzed using a linear mixed 
effects model with subjects as a random factor and condition and time as fixed 
factors using SAS. Main effects of condition and condition X time interactions will 
be probed with planned comparisons to examine differences between β-OHB and 
placebo at each time point. Data with skewed distributions will be log-transformed 
or non-linear mixed effects models will be used. All participants will be included in 
the intention-to-treat (ITT) analyses and missing data will not be imputed, per 
contemporary guidelines with use of linear mixed models [16].  
 
Sample Size 
Twenty participants will be included in this cross-over study. In our pilot study on 
healthy volunteers we saw a ~15% reduction in glucose area under the curve after 

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
ketone supplementation versus placebo. Using means and standard deviations 
from our previously published study in people with T2D (N=51) [17] for fasting 
glucose (8.6 +/- 2.3) a 15% reduction in blood glucose corresponds to an effect 
size d = 0.73. Assuming 80% power with an alpha level of 0.05 and a moderate 
correlation between repeated measures of r=0.7 (calculated using G*Power v3.1) 
a total sample size of n=14 is needed to detect differences between ketone and 
placebo conditions. To preserve power and account for any dropouts or missing 
blood samples we will recruit 20 participants, aiming for equal males and 
females.[2] [17] 
 
Significance 
The results of this study will help determine whether supplementation with 
exogenous ketones can alter metabolism and subsequently improve blood glucose 
levels. This is a pilot study and it will provide useful data to better answer future 
research questions and aid in the design of longer term studies.  
 
 
 
 
OUTCOMES MEASUREMENTS AND METHODS 
 
The primary outcome measure is the plasma glucose concentrations over the 3-
hour period following the ingestion of the beverages. Secondary measures will 
include plasma insulin and C-peptide, free fatty acids, inflammatory cytokines, 
CBF, cognitive function and neurovascular coupling, inflammation signalling 
molecules, appetite/satiety levels and gastrointestinal distress questionnaire.  
 
Anthropometric Measures 
 
Waist circumference, height (cm) and weight (kg) will be measured using 
standard procedures. Body mass index (BMI) will be calculated as kg/m2.  
Physiological Measures 
 
Resting blood pressure and heart rate will be collected for descriptive purpose. 
Before both measures, participants will be instructed to sit quietly and rest for 5 
minutes. A finger tip heart rate monitor will track heart rate. Blood pressure will be 
collected using a cuff around the upper arm, a stethoscope will be placed in the 
cubital fossa for systolic and diastolic blood pressure.   
Blood Sampling 
 
Venous blood samples for plasma glucose, insulin, free fatty acids, C-peptide and 
cytokines will be obtained by a researcher trained in phlebotomy (Dr. Little and Dr. 

 
 
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Faculty of Health and Social Development 
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3333 University Way 
Kelowna, BC  V1V 1W5 
Oliveira). Repeated blood samples will be obtained by intravenous catheter in an 
antecubital vein kept patent with sterile saline. The procedure will follow sterile 
conditions within our laboratory (Arts Building Rm 115B) with biosafety and blood 
collection accreditation as approved previously (e.g., H14-01636; H15-00205; 
H12-02268). Approximately 5 mL of blood will be collected into vacutainer tubes 
and processed at 7 timepoints for a total of 35 mL per test day. Plasma insulin will 
be measured on a 96-well plate using a commercially available high-sensitivity 
human insulin ELISA (Mercodia, Upsulla, Sweden). Plasma glucose will be 
measured using a hexokinase method and free fatty acids by colorimetric assay. 
Glucose, insulin, free fatty acids and cytokines will all be analyzed on a Chemwell 
2910 clinical chemistry analyzer (Awarness Technologies, Connecticut, United 
States of America). C-peptide will be measured by ELISA (Millipore #EZHCP-20K). 
Plasma will also be analyzed through metabolomics technology by UVic-Genome 
BC Proteomics Centre. De-identified samples containing frozen plasma in 
microtubes (samples identified by an ID code only with no personal identifiers)  will 
be sent on dry ice to UVic following UBC Biosafety guidance for transmission of 
biological materials. Results containing the analyte concentration are sent by 
secure email back to UBC PI.  
Histones acetylation will be quantified with flow cytometry using the Histone H3 
Acetylation Assay Kit (Millipore/Sigma Aldrich, CA). PBMCs will be isolated and 
inflammatory pathways and signalling assessed by standard western blotting 
techniques. They will also Blood β-OHB levels will be measured using the Abbot 
Freestyle Precision Neo® ketone meter, Abbott, England after ketone or placebo.  
 
Cognitive Function 
 
The Montreal Cognitive Assessment (MoCA) will be used as a screening tool 
ensure that all participants are ‘cognitively normal’. The tests will be administered 
and interpreted by a trained researcher (Dr. Oliveira). In the unlikely event that a 
participant’s performance on the MoCA is below the cognitively normal range, Dr. 
Walsh will encourage participants to contact their family physician to discuss their 
performance. 
Cognitive function will be assessed using an iPad-based app (BrainBaseline, 
Digital Artefacts). A battery of 3 tests that collectively assess executive functions 
and processing speed will be used. Each test will take less than 3 minutes to 
complete. There is no prognostic validity to these tests (i.e., assessing cognitive 
impairment), rather they are intended to demonstrate within- and between-subject 
changes for research purposes. There are no risks associated with this measure.  
CBF Measurement 
Intracranial blood flow velocity will be measured non-invasively with transcranial 
Doppler ultrasound (TCD) in the middle and posterior cerebral arteries 
simultaneously. Our group within the Centre for Heart Lung and Vascular Health 
(CHLVH) has conducted both validation and reproducibility studies involving TCD.  
The day-to-day reproducibility of middle cerebral artery velocity in adults has a 

 
 
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Faculty of Health and Social Development 
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3333 University Way 
Kelowna, BC  V1V 1W5 
coefficient of variation of <4.5%. The TCD probe that will be placed lightly against 
the skin between the temple and ear (temporal window) and will be held in place 
by a specialized headband that will worn by participants for the entirety of the 
experiment. Blood pressure will be measured non-invasively using a finger cuff 
affixed to the middle finger of the participant’s non-dominant hand. The 
combination of intracranial blood flow velocity and blood pressure will be used to 
calculate an index of vascular conductance (i.e., vasodilation) during the 
neurovascular coupling (NVC) protocols.   
Assessment of Neurovascular Coupling (NVC) 
Using neuronal activation (via a visual stimulus) we evoke localized changes in 
blood flow in the brain. We will activate the occipital lobe (while measuring velocity 
in the posterior and middle cerebral arteries) using checkerboard displayed on a 
tablet. Eight cycles will be completed, each consisting of 20 s eyes-closed followed 
by 40 s of activation (eyes open). An auditory prompt will provide notification of 
“eyes-open” and “eyes-closed” periods. The cerebral blood velocity response will 
be averaged across the 8 trials for each participant.  
 
Questionnaires: 
Medical History Questionnaire: 
A customized Medical and Health Status Questionnaire will be used to assess 
inclusion/exclusion criteria and prior history of medical conditions.  
Female menstrual cycle questionnaire 
Female participants will be asked about the timing of their menstrual cycle in 
order so that all participants can be tested in the follicular phase.  
Gastrointestinal Distress Questionnaire 
Gastrointestinal (GI) disturbances will be measured using a 10 cm visual 
analogue scale (7). The questionnaire will report subjective GI symptoms after 
ingestion of either the ketone supplement or placebo. 
Self reported hunger/fullness Visual Analog Scales (VAS) 
Participants will rate each of the following 4 questions by marking vertically on a 
horizontal line with descriptive anchors on either side (“not all” to “extremely”): 1) 
How hungry do you feel; 2) How satisfied do you feel; 3) How full do you feel; 4) 
How much do you think you can eat. The VAS scores will be converted to a 0–
100 scale, as previously described (Flint et al, 2000).  
All questionnaires are included as attachments.  
Protection of Human Subjects: 
All participants will be given a unique study code, with all data and information 
gathered connected with this code. Only the PI will have access to the master list 
linking the codes with participant names. Participant information and data will be 

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
either stored in a locked filing cabinet, or on an internal UBC network drive 
accessed only through a dedicated LAN internet connection on a password 
protected computer in the PIs laboratory with Salto passcard access only to the 
members of the research lab.    
 
 
POTENTIAL PROBLEMS AND ALTERNATIVE STRATEGIES 
Diet compliance: We will encourage accurate recording of diet by providing clear 
instructions and training participants on the necessary detail required. Together 
with the assessment of dislikes and allergies we will personalize each intervention 
diet and provide all food in order to enhance compliance, as the foods provided 
will be based on preference, except altering the macronutrient composition of 
meals. Participants will complete a food log to record consumption of the study 
diets (and any additions/subtractions) and be asked to return any food not 
consumed.  
Blood sampling: The insertion of a needle for blood sampling (intravenous and 
finger pricks) is a common medical practice and involves minimal risk provided 
proper 
precautions 
are 
taken. 
There 
may 
be 
some 
discomfort, 
discoloration/bruising with the cannula/venipuncture needle insertion. But the risk 
of pain and infection will be minimized by using an experienced trained 
phlebotomist, and of course by ensuring the needle is inserted and removed under 
completely sterile conditions.  
Protection of personal data: All participants will be given a unique study code, with 
all data and information gathered connected with this code. Only the PI will have 
access to the master list linking the codes with participant names. Participant 
information and data will be either stored in a locked filing cabernet, or on an 
internal UBC network drive accessed only through a dedicated LAN internet 
connection on a password protected computer in the PIs laboratory with Salto 
passcard access only to the members of the research lab.    
Informed consent and ethics: Prior to beginning the study Informed consent will be 
obtained from participants and they will be informed they can withdraw at any time. 
Ketone supplements: Ketone supplements are indicated to be safe for 
consumption and have GRAS (generally recognized as safe) status by the FDA 
[9]. The protocol for this study was reviewed by the CIHR Nutrition and Health 
Panel and received Bridge Grant Funding (reviews and our responses attached). 
We have conducted two previous (H16-01260, H16-01846) and have one ongoing 
trial (H18-02930) using this supplement in similarly-designed studies. We have not 

 
 
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Faculty of Health and Social Development 
School of Health and Exercise Sciences 
3333 University Way 
Kelowna, BC  V1V 1W5 
seen any GI distress or adverse effects of the supplement in any of these 
experimental trials (>200 individual consumption events with both the supplement 
and placebo). Participants will be under close supervision after ingestion of ketone 
supplements, and the researchers will confirm that the participant is not 
experiencing any  adverse effects prior to leaving the laboratory. 
 
References 
1. 
Canadian Diabetes Association, A.C., An economic tsunami: th cost of diabetes in 
Canada. I2009: http://www.diabetes.ca/documents/get-
involved/FINAL_Economic_Report.pdf. 
2. 
Myette‐Côté, É., et al., Prior ingestion of exogenous ketone monoester attenuates the 
glycaemic response to an oral glucose tolerance test in healthy young individuals. The 
Journal of physiology, 2018. 596(8): p. 1385-1395. 
3. 
Neudorf, H., et al., Oral Ketone Supplementation Acutely Increases Markers of NLRP3 
Inflammasome Activation in Human Monocytes. Molecular nutrition & food research, 
2019: p. 1801171. 
4. 
Kashiwaya, Y., et al., A ketone ester diet exhibits anxiolytic and cognition-sparing 
properties, and lessens amyloid and tau pathologies in a mouse model of Alzheimer's 
disease. Neurobiology of aging, 2013. 34(6): p. 1530-1539. 
5. 
Krikorian, R., et al., Dietary ketosis enhances memory in mild cognitive impairment. 
Neurobiology of aging, 2012. 33(2): p. 425. e19-425. e27. 
6. 
Puchowicz, M.A., et al., Diet-induced ketosis increases capillary density without altered 
blood flow in rat brain. American Journal of Physiology-Endocrinology and Metabolism, 
2007. 292(6): p. E1607-E1615. 
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Park, C.H. and Y.-S. Kwak, Analysis of energy restriction and physical activity on brain 
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Diamond, M.P., D.C. Simonson, and R.A. DeFronzo, Menstrual cyclicity has a profound 
effect on glucose homeostasis. Fertility and sterility, 1989. 52(2): p. 204-208. 
9. 
Clarke, K., et al., Kinetics, safety and tolerability of (R)-3-hydroxybutyl (R)-3-
hydroxybutyrate in healthy adult subjects. Regulatory Toxicology and Pharmacology, 
2012. 63(3): p. 401-408. 
10. 
Cox, P.J., et al., Nutritional ketosis alters fuel preference and thereby endurance 
performance in athletes. Cell metabolism, 2016. 24(2): p. 256-268. 
11. 
Barry, J.C., et al., Hyporesponsiveness to the anti-inflammatory action of interleukin-10 in 
type 2 diabetes. Scientific reports, 2016. 6: p. 21244. 
12. 
Robinson, E., et al., Short-term high-intensity interval and moderate-intensity continuous 
training reduce leukocyte TLR4 in inactive adults at elevated risk of type 2 diabetes. 
Journal of applied physiology, 2015. 119(5): p. 508-516. 
13. 
Wan, Z., et al., One-week high-fat diet leads to reduced toll-like receptor 2 expression 
and function in young healthy men. Nutrition research, 2014. 34(12): p. 1045-1051. 
14. 
Wan, Z., et al., Reduction of AMPK activity and altered MAPKs signalling in peripheral 
blood mononuclear cells in response to acute glucose ingestion following a short-term 
high fat diet in young healthy men. Metabolism, 2014. 63(9): p. 1209-1216. 
15. 
Fralick, M., S. Schneeweiss, and E. Patorno, Risk of diabetic ketoacidosis after initiation 
of an SGLT2 inhibitor. New England Journal of Medicine, 2017. 376(23): p. 2300-2302. 
16. 
Chakraborty, H. and H. Gu, A mixed model approach for intent-to-treat analysis in 
longitudinal clinical trials with missing values. 2009. 
17. 
Francois, M.E., et al., Combined interval training and post-exercise nutrition in type 2 
diabetes: a randomized control trial. Frontiers in physiology, 2017. 8: p. 528. 

 
 
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Faculty of Health and Social Development 
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3333 University Way 
Kelowna, BC  V1V 1W5