Role of Intermittent Exogenous Ketosis in the Physiological and Muscular Adaptive Response to Endurance Training

Role of Intermittent Exogenous Ketosis in the Physiological and Muscular Adaptive Response to Endurance Training. A Study in Young, Male Volunteers.

In a recent study (Poffé et al., 2019), we demonstrated that increasing the concentration of ketone bodies in the blood through the ingestion of a ketone ester (KE) post-exercise and just before sleeping time during a 3-week overtraining period resulted in suppression of the physiological symptoms of overtraining. Consistent KE intake improved endurance performance, positively affected the autonomic regulation of the heart, suppressed the increase of nocturnal sympathetic activity, and increased spontaneous energy intake. In addition, KE intake had a positive effect on muscular adaptive response, as evidenced by the significantly increased muscular angiogenesis. Therefore, in this study, we aim to investigate whether the oral administration of ketones after exercise and just before bedtime also has a positive effect on the adaptive response during a well-dosed endurance training program. Since suppression of nocturnal sympathetic activity can positively influence sleep quality, we will also study the effect of KE and the training period on sleep quality.

To investigate this, we will use a randomized, placebo-controlled parallel research design. Well-trained male cyclists will participate in a fully controlled intervention period of 8 weeks. During the intervention period, participants will follow a supervised cycling training program (5-7 training sessions per week) with a gradual buildup aimed at improving endurance capacity.

Throughout the intervention period, participants will ingest 25g ketone ester or a corresponding placebo after each training session and 30 minutes before bedtime. Endurance performance will be evaluated before the start of the training period (pretest), after week 3 (midtest), after week 7 (posttest) of the training period, and at the end of the training intervention (posttest+taper). Additionally, blood samples will be taken at the pre-test and post-test to analyze markers of hormonal status and inflammation. Muscle biopsies will be taken from the vastus lateralis muscle of the right leg at pretest and posttest to analyze cross-sectional area, muscle fiber typing, angiogenesis, protein synthesis and degradation, mitochondrial function, and energy substrate concentrations. One month after the intervention period, an additional biopsy will be taken to study changes in gene expression (epigenetic modifications). Sleep will be evaluated via polysomnography (PSG) at the pretest, midtest and posttest. Finally, before and after the training period, resting and exercise echocardiography will be taken to investigate investigate structural and morphological changes of the heart.

Study Overview

• Status: Active, not recruiting
• Conditions: Exercise Adaptations
• Intervention / Treatment: Dietary supplement: Placebo; Dietary supplement: Ketone ester

• Study Type: Interventional
• Enrollment (Actual): 30
• Phase: Phase 2

Contacts and Locations

Study Locations

• Belgium
  • Vlaams-Brabant
    • Leuven, Vlaams-Brabant, Belgium, 3000
      • Exercise Physiology Research Group

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Physically fit and regularly involved in physical activity (2-5 exercise sessions of > 30min per week)
• Good health status confirmed by a medical screening
• VO2max higher than 50 ml.min-1.kg-1
• Body Mass Index (BMI) between 18 and 25
• Normal sleep pattern as assessed by the Pittsburgh Sleep Quality Index (PSQI, appendix 2)

Exclusion Criteria:

• Any kind of injury/pathology that is a contra-indication to perform high-intensity exercise
• Intake of any medication or nutritional supplement that is known to affect exercise performance or sleep
• Intake of analgesics, anti-inflammatory agents, or supplementary anti-oxidants, from 2 weeks prior to the start of the study.
• Night-shifts or travel across time zones in the month preceding the study
• Blood donation within 3 months prior to the start of the study
• Smoking
• More than 3 alcoholic beverages per day or more than one glass if wine per day
• Involvement in elite athletic training at a semi-professional or professional level
• Any other argument to believe that the subject is unlikely to successfully complete the full study protocol

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: Control group; Placebo is provided	Dietary supplement: Placebo; 16.4g pure medium triglyceride oil mixed with 1 mM of bitter sucrose octaacetate. A dose of 25g of the placebo drink is provided immediately after each training session and 30 minutes before sleeptime throughout the training period.
Experimental: Experimental groep; Ketone ester is provided	Dietary supplement: Ketone ester; A dose of 25g of ketone ester after each training session and 30 minutes before sleeptime throughout the training period.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in mean power output during a 30min cycling time trial	Change in mean power output during a self-paced 30 min cycling time trial on a cyling ergometer	Pretest (before the start of the training intervention) - Midtest (after week 3 of the training intervention) - Posttest (after week 7 of the training intervention) - Posttest+taper (after week 8 of the training intervention)
Change in capillarization of the musculus vastus lateralis	Change in capillarization (CFPE-index) of the musculus vastus lateralis	Pretest (before the start of the training intervention) - Posttest (after week 7 of the training intervention)
Change in sleep efficiency	Change in sleep efficiency measured by polysomnography	Pretest (before the start of the training intervention) - Midtest (after week 3 of the training intervention) - Posttest (after week 7 of the training intervention)
Change in REM sleep	Change in REM sleep measured by polysomnography	Pretest (before the start of the training intervention) - Midtest (after week 3 of the training intervention) - Posttest (after week 7 of the training intervention)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in the nocturnal urinary excretion of dopamine	Change in the nocturnal urinary excretion of dopamine	Pretest (before the start of the training intervention) - Midtest (after week 3 of the training intervention) - Posttest (after week 7 of the training intervention)
Change in the nocturnal urinary excretion of noradrenaline	Change in the nocturnal urinary excretion of noradrenaline	Pretest (before the start of the training intervention) - Midtest (after week 3 of the training intervention) - Posttest (after week 7 of the training intervention)
Change in the nocturnal urinary excretion of adrenaline	Change in the nocturnal urinary excretion of adrenaline	Pretest (before the start of the training intervention) - Midtest (after week 3 of the training intervention) - Posttest (after week 7 of the training intervention)
Change in maximal oxygen uptake	Change in maximal oxygen uptake measured during a maximal incremental exercise test on a cycling ergometer	Pretest (before the start of the training intervention) - Midtest (after week 3 of the training intervention) - Posttest (after week 7 of the training intervention)

Collaborators and Investigators

• Sponsor: KU Leuven

Publications and helpful links

General Publications

• Poffe C, Ramaekers M, Van Thienen R, Hespel P. Ketone ester supplementation blunts overreaching symptoms during endurance training overload. J Physiol. 2019 Jun;597(12):3009-3027. doi: 10.1113/JP277831. Epub 2019 May 22.
• Robberechts R, Albouy G, Hespel P, Poffe C. Exogenous Ketosis Improves Sleep Efficiency and Counteracts the Decline in REM Sleep Following Strenuous Exercise. Med Sci Sports Exerc. 2023 Jun 1. doi: 10.1249/MSS.0000000000003231. Online ahead of print.

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2022
• Primary Completion (Actual): May 1, 2023
• Study Completion (Estimated): December 31, 2023

Study Registration Dates

• First Submitted: June 27, 2023
• First Submitted That Met QC Criteria: June 27, 2023
• First Posted (Actual): July 6, 2023

Study Record Updates

• Last Update Posted (Actual): July 6, 2023
• Last Update Submitted That Met QC Criteria: June 27, 2023
• Last Verified: June 1, 2023

More Information

Terms related to this study

• Keywords: Sleep; ketone bodies; Exercise adaptations
• Additional Relevant MeSH Terms: Metabolic Diseases; Acid-Base Imbalance; Acidosis; Ketosis
• Other Study ID Numbers: S66150

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No