Examining the Effect of Exogenous Ketone Supplementation on Glucose Control in Type 2 Diabetes

Study Overview
=================
Brief Summary
-----------------
Ketone bodies are a fuel source and signaling molecule that are produced by the body during prolonged fasting or if an individuals consistently eats a low-carbohydrate keto diet. Blood ketones can be used as a source of energy by the body, but they may also act as signals that impact the functioning of different cells in the body. Recently, the availability of ketone supplements that can be taken orally allows for raising blood ketones without having to fast or eat a keto diet. The investigators' studies and those of other researchers have shown that ketone supplementation can lower blood sugar without having to make any other dietary changes. Oral ingestion of ketones may therefore be an effective strategy to improve blood sugar control and influence how cells function. The main objective of this study is to determine if consuming a ketone supplement 3 times per day (before meals) for 14 days lowers blood sugar and impacts how the body's cells function. The results of this study will be used to guide future recommendations on the utility of ketone supplements for improving health in individuals with, or at elevated risk of, type 2 diabetes.

Official Title
-----------------
Effect of 14 Days of Exogenous Ketone Supplementation on Glycemic Control in Type 2 Diabetes: a Randomized Placebo-controlled Crossover Trial

Conditions
-----------------
Diabetes Mellitus, Type 2

Intervention / Treatment
-----------------
* Dietary Supplement: Exogenous Ketone Monoester
* Dietary Supplement: Placebo


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Have a type 2 diabetes diagnosis from a physician Have stable use of glucose-lowering medications for at least 3 months Exclusion Criteria: Are a competitively trained endurance athlete Are actively attempting to gain or lose weight Have a history of mental illness or existing neurological disease(s), cardiovascular events (i.e., heart attack, stroke) in the last 2 years Have hypoglycemia, irritable bowel syndrome or inflammatory bowel disease Are currently using insulin or SGLT2 inhibitors Are using more than 2 classes of glucose-lowering medication Are currently following a ketogenic diet or taking ketone supplements Are unable to commit for a 29-day trial Are unable to follow a controlled diet

Ages Eligible for Study
-----------------
Minimum Age: 30 Years
Maximum Age: 69 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Experimental<br>Participants will consume 15 g of an active oral exogenous ketone monoester supplement 15 minutes prior to each meal of the day for a 14-day period. Pre-intervention (baseline) and post-intervention measurements will be obtained before and immediately after the 14-day period. All meals will be provided throughout the supplementation period Participants will wear a continuous glucose monitor for the first 10 consecutive days during the supplementation period. | Dietary Supplement: Exogenous Ketone Monoester<br>* Participants will consume 15g of the oral ketone monoester supplement 15 minutes prior to each meal of the day for 14 days. All meals will be provided throughout the 14-day supplementation period.<br>* Other names: KetoneAid KE4 Ketone Ester, D-β-hydroxybutyrate-R 1,3-Butanediol;|
| Placebo Comparator: Placebo<br>Participants will consume a flavor-matched placebo drink and undergo the same procedures described in the Experimental Arm | Dietary Supplement: Placebo<br>* Participants will consume an equivalent volume (30ml) of the active intervention supplement 15 minutes prior to each meal for 14 days. All meals will be provided throughout the 14-day placebo supplementation period.<br>* Other names: Flavor- and volume-matched placebo supplement;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Glucose Control: Change in Fructosamine | Change in glucose control (from pre-intervention Day 0) will be quantified by serum fructosamine obtained by fasting blood sample in both conditions. | Day 14 (post-intervention) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Vascular function | Vascular function will be assessed by flow mediated dilation of the brachial artery using vascular ultrasound. A cuff will affixed on the forearm, distal to the brachial artery and will be inflated for 5 minutes. Flow mediation dilation will be measured over a 3-minute period following cuff release. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Cognition: N-back test | Cognition will be assessed using a customized battery of psychometrically validated tests within the domain of executive functions using the computer-based app Inqisit6 Lab (Millisecond). The test will be the n-back test. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Cognition: Digit-symbol substitution test | Cognition will be assessed using a customized battery of psychometrically validated tests within the domain of executive functions using the computer-based app Inquisit6 Lab (Millisecond). The test will be the digit-symbol substitution test. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Change from baseline plasma insulin at 14 days | Plasma insulin from venous blood samples will be measured using a high-sensitivity human insulin enzyme-like immunosorbent assay (ELISA) run in duplicate. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Change from baseline plasma free fatty acids at 14 days | Free fatty acids from venous blood samples will be measured by colorimetric assay run in duplicate. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Change from baseline circulating inflammatory cytokines at 14 days | Key inflammatory cytokines including CRP will be quantified by Mesoscale Discovery U-PLEX run in duplicate. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Phagocytosis | Phagocytosis of fluorescent-labelled E. coli by immune cells from whole blood will be quantified by flow cytometry | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Oxidative Burst | LPS-stimulated oxidative burst by immune cells from whole blood will be quantified by flow cytometry | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Degranulation | Immune cell degranulation will be quantified by enzyme-linked immunosorbent assay run in duplicate (quantifying myeloperoxidase and elastase in whole blood cell culture supernatants). | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Immune Cell Phenotyping | Phenotyping of macrophages and T cells will be quantified by surface and intracellular staining by flow cytometry. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Complete blood count | A 5-part white blood cell differential and complete blood count will be quantified by hematology analyzer. | Day 0 (Pre-intervention) and Day 14 (post-intervention) | 
| Glycemic Control: 2hr postprandial hyperglycemia | Glycemic control will be measured by continuous glucose monitoring using the G6 CGM (Dexcom) in both the active and placebo supplement conditions. Glycemic control will be quantified by assessing 2hr postprandial hyperglycemia. | Day 1 through to Day 10 | 
| Glycemic Control: 24hr average glucose area under the curve (AUC) | Glycemic control will be measured by continuous glucose monitoring using the G6 CGM (Dexcom) in both the active and placebo supplement conditions. Glycemic control will be quantified by assessing 24hr average glucose AUC. | Day 1 through to Day 10 | 
| Glycemic Control: Fasting glucose | Glycemic control will be measured by continuous glucose monitoring using the G6 CGM (Dexcom) in both the active and placebo supplement conditions. Glycemic control will be quantified by assessing fasting plasma glucose. | Day 1 through to Day 10 | 
| Glycemic Control: Change in Fasting Plasma glucose | Change in fasting plasma glucose (from pre-intervention Day 0) will be measured by fasting blood sample in both the active and placebo supplement conditions. | Day 14 | 
| Glycemic Control: Glycemic variability | Glycemic control will be measured by continuous glucose monitoring using the G6 CGM (Dexcom) in both the active and placebo supplement conditions. Glycemic control will be quantified by assessing glycemic variability. | Day 1 through to Day 10 | 
| Glycemic Control: Time in Target Range | Glycemic control will be measured by continuous glucose monitoring using the G6 CGM (Dexcom) in both the active and placebo supplement conditions. Glycemic control will be quantified by assessing time in target range. | Day 1 through to Day 10 | 
| Glycemic Control: HbA1c | Glycemic control will be measured by assessing HbA1c using a point-of-care analyzer. | Day 0 (pre-intervention) and Day 14 (post-intervention) | 
| Lipid Panel | Lipid panel (total cholesterol, high-density cholesterol, low-density cholesterol, triglycerides, non-HDL cholesterol, cholesterol/HDL ratio) will be measured using a point-of-care analyzer. | Day 0 (pre-intervention) and Day 14 (post-intervention) | 
| Body weight | Change in body weight will be measured using a body weight scale. | Day 0 (pre-intervention) and Day 14 (post-intervention) | 
| Blood pressure | Change in blood pressure will be measured using an automated blood pressure device. Both systolic and diastolic blood pressure will be measured. | Day 0 (pre-intervention) and Day 14 (post-intervention) | 
| Blood beta-hydroxybutyrate | Change in fasting blood beta-hydroxybutyrate will be measured using a standard assay. | Day 0 (pre-intervention) and Day 14 (post-intervention) | 
| Physical activity | Physical activity will be assessed using an accelerometer (activePal) worn throughout the entire intervention period. | Day 0 (pre-intervention) to Day 14 (post-intervention) | 
| Sedentary time | Sedentary time will be assessed using an accelerometer (activePal) worn throughout the entire intervention period. | Day 0 (pre-intervention) to Day 14 (post-intervention) | 
| Sleeping time | Sleeping time will be assessed using an accelerometer (activePal) worn throughout the entire intervention period. | Day 0 (pre-intervention) to Day 14 (post-intervention) | 
| Resting heart rate | Change resting heart rate will be measured using an automated heart rate monitor device. | Day 0 (pre-intervention) and Day 14 (post-intervention) | 
| Waist circumference | Change in waist circumference will be measures using a measurement tape. | Day 0 (pre-intervention) and Day 14 (post-intervention) | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
3-Hydroxybutyric Acid, Glycemic Control, Hyperglycemia, Ketones, Glucose Control, Inflammation, Immune cell function, Cognition