Acute Ingestion of Ketone Monoesters and Precursors Do Not Enhance Endurance Exercise Performance: A Systematic Review and Meta-Analysis

There has been much consideration over whether exogenous ketone bodies have the capacity to enhance exercise performance through mechanisms such as altered substrate metabolism, accelerated recovery, or neurocognitive improvements. This systematic review aimed to determine the effects of both ketone precursors and monoesters on endurance exercise performance. A systematic search was conducted in PubMed, SPORTDiscus, and CINIAHL for randomized controlled trials investigating endurance performance outcomes in response to ingestion of a ketone supplement compared to a nutritive or nonnutritive control in humans. A meta-analysis was performed to determine the standardized mean difference between interventions using a random-effects model. Hedge's g and 95% confidence intervals (CI) were reported. The search yielded 569 articles, of which eight were included in this review (80 participants; 77 men and three women). When comparing endurance performance among all studies, no significant differences were found between ketone and control trials (Hedges g = 0.136; 95% CI [-0.195, 0.467]; p = .419). Subanalyses based on type of endurance tests showed no significant differences in time to exhaustion (Hedge's g = -0.002; 95% CI [-0.312, 0.308]; p = .989) or time trial (Hedge's g= 0.057; 95% CI [-0.282, 0.395]; p = .744) values. Based on these findings, exogenous ketone precursors and monoesters do not exert significant improvements on endurance exercise performance. While all studies reported an increase in blood ketone concentrations after ingestion. ketone monoesters appear to be more effective at raising concentrations than precursors.