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Research · Supplements

Ketone esters and ketone salts

A meta-analysis of 13 trials found no change in exercise performance with ketone esters or salts. Recovery measures also did not change. Blood glucose fell by about 0.5 mmol/L after ingestion. Pooled trials report modest cognitive gains and higher ejection fraction in heart failure. Gut discomfort accompanied a slower time trial in elite cyclists.

Add to Bio HackChecked 2026-11-09
Status
Sold as foods and dietary supplements in the US.
Also called
exogenous ketones, ketone monoester, (R)-3-hydroxybutyl (R)-3-hydroxybutyrate, ketone diester, 1,3-butanediol acetoacetate diester, ketone salts, beta-hydroxybutyrate, BHB, β-hydroxybutyrate, D-BHB
Taken for
endurance, exercise performance, recovery, focus, cognition, blood sugar, appetite, heart health, ketosis without dieting

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help3

Reported risks2

What people take it for, and what was found

Shown to help3

Moderate

Blood glucose

Shown to lower blood glucose about 0.47 mM after single doses, more with monoesters than salts.

The numbers and sources
Effect
Compared with placebo, exogenous ketones raised blood BHB by 1.98 mM (95% CI 1.52 to 2.45) and lowered blood glucose by 0.47 mM (95% CI -0.57 to -0.36). Monoesters had larger effects than salts [4].
Population
43 trials with 586 participants [4].
Sources
[4]
Caveats
Almost all trials were single doses. Evidence on longer use was limited [4].
Moderate

Cognition

Shown to improve cognitive performance modestly over placebo in healthy adults and people with conditions such as Alzheimer's disease, more at higher doses.

The numbers and sources
Effect
Across 29 trial arms (1,117 participants), exogenous ketones improved cognitive performance over placebo (SMD 0.29, 95% CI 0.16 to 0.41). Higher daily doses were associated with larger effects [5].
Population
Healthy adults and people with neuropsychiatric conditions including Alzheimer's disease [5].
Sources
[5]
Caveats
One meta-analysis pooling varied tests, populations and formulations.
Moderate

Heart function in heart failure

Shown to raise ejection fraction about 3% in patients with heart failure, and about 4% with reduced ejection fraction. Hospitalization and death were not pooled.

The numbers and sources
Effect
Across 6 RCTs, ketone supplementation raised left ventricular ejection fraction by 3.12% (95% CI 0.95 to 5.30) and by 4.25% in heart failure with reduced ejection fraction. Cardiac output rose by 1.24 L/min in that group [6].
Population
Patients with heart failure [6].
Sources
[6]
Caveats
Small cohorts with varied treatment durations. Hospitalization and death were not pooled.

Not shown to help3

Strong

Exercise performance

Not shown to change exercise performance in sprints to events of about 50 minutes, with either ketone esters or salts.

The numbers and sources
Effect
Across 13 RCTs, acute ketone supplementation did not change overall performance (Hedges' g -0.05, 95% CI -0.30 to 0.20), endurance time trials (g -0.04), ketone esters (g -0.07) or ketone salts (g -0.02) [1]. A separate review of 10 RCTs found 3 positive, 10 null and 3 negative outcomes among 16, with high heterogeneity [2].
Population
Sprints to events of about 50 minutes [1]; 112 participants, 109 of them men [2].
Sources
[1], [2]
Caveats
Ultra-endurance events were not covered [1]. Nearly all participants were men [2]. The second review was funded by the US Army [2].
Moderate

Recovery after exercise

Not shown to change muscle soreness, glycogen refilling or creatine kinase after exercise in active adults.

The numbers and sources
Effect
Across 7 pooled studies, muscle soreness (SMD 0.39, 95% CI -0.29 to 1.07) and glycogen resynthesis did not differ from control. Post-exercise lactate was slightly higher with ketones (MD 0.34 mmol/L, 95% CI 0.02 to 0.66). Creatine kinase did not change [3].
Population
16 studies reviewed, mostly physically active men [3].
Sources
[3]
Caveats
Exploratory meta-analysis of few studies.
Moderate

Blood pressure

Not shown to change systolic or diastolic blood pressure, with single doses or longer use.

The numbers and sources
Effect
Across 10 studies, systolic (SMD -0.14, 95% CI -0.40 to 0.11) and diastolic pressure did not change, acutely or with longer use [7].
Population
187 participants [7].
Sources
[7]
Caveats
Randomized and non-randomized studies were pooled.

Doses studied

A kinetics study gave the monoester at 140, 357 or 714 mg per kg as single doses and three times a day for 5 days, up to 2.14 g per kg per day [8]. Metabolic studies gave drinks delivering about 12 or 24 g of BHB [9]. A cycling trial gave a ketone diester at 2 × 250 mg per kg before a time trial [10].

Risks

Reported risks2

Limited

Gut discomfort and slower performance

One small trial found a ketone diester slowed a cycling time trial by 2% in elite cyclists, with gut discomfort.

The numbers and sources
Effect
In 10 elite cyclists, a ketone diester taken before a 31 km time trial slowed performance by 2% (±1%), with gut discomfort and higher perceived effort [10]. At the highest monoester dose, some gastrointestinal effects were reported when large volumes of milk-based drink were consumed [8].
Population
Professional male cyclists [10]; healthy adults [8].
Sources
[8], [10]
Caveats
Different ketone compounds. The kinetics study did not report symptom rates in its abstract.
Limited

Blood and urine pH, and the L-isomer in salts

Small studies found the monoester lowered blood pH slightly and ketone salts raised urine pH, with blood electrolytes staying normal.

The numbers and sources
Effect
The monoester lowered blood pH by 0.10. Ketone salts raised urinary pH from 5.7 to 8.5. Ketone salt drinks contained 50% L-BHB, which stayed elevated in blood for over 8 hours. Blood electrolytes stayed normal [9].
Population
Healthy volunteers in three metabolic studies [9].
Sources
[9]
Caveats
Short studies. Effects of repeated use were not measured.

Checked, no increase found1

Limited

Higher resting heart rate

Small trials found resting heart rate did not rise significantly overall, though one found lower heart rate variability after a monoester dose.

The numbers and sources
Effect
Resting heart rate tended to rise (SMD 0.17, 95% CI -0.14 to 0.47), and higher supplement doses were associated with larger increases [7]. In 18 healthy adults, 0.3 or 0.6 g/kg of a ketone monoester lowered two heart rate variability measures of vagal activity (pRR50 and RMSSD) at 45 and 120 minutes against placebo [11]. In 19 healthy adults, 0.4 g/kg did not change resting heart rate, blood pressure or muscle sympathetic nerve activity, at rest or under stress [12].
Population
187 participants in 10 studies [7]. Healthy adults aged about 23 in two crossover trials [11][12].
Sources
[7], [11], [12]
Caveats
The overall change was not significant. The dose relationship came from meta-regression [7]. The crossover trials gave single doses [11][12].

Claims tested and not found

  1. That ketone supplements improve exercise performance. Pooled trials found no change for esters or salts [1].
  2. That ketone supplements speed recovery. Soreness, glycogen resynthesis and creatine kinase did not differ from control [3].
  3. That ketone supplements lower blood pressure. Systolic and diastolic pressure did not change [7].

Sources

  1. Valenzuela PL, Morales JS, Castillo-García A, et al. Acute Ketone Supplementation and Exercise Performance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. International Journal of Sports Physiology and Performance. 2020. https://doi.org/10.1123/ijspp.2019-0918
  2. Margolis LM, O'Fallon KS. Utility of Ketone Supplementation to Enhance Physical Performance: A Systematic Review. Advances in Nutrition. 2020. https://doi.org/10.1093/advances/nmz104
  3. Bomans S, Jimenez Garcia B, Leemans L, et al. Effects of exogenous ketones on post-exercise recovery: A systematic review and meta-analysis. Journal of Sports Sciences. 2026. https://doi.org/10.1080/02640414.2026.2750608
  4. Falkenhain K, Daraei A, Forbes SC, et al. Effects of Exogenous Ketone Supplementation on Blood Glucose: A Systematic Review and Meta-analysis. Advances in Nutrition. 2022. https://doi.org/10.1093/advances/nmac036
  5. Bonnechère B, Stephens EB, Boileau AC, et al. The effect of exogenous ketone bodies on cognition across health and disease: a systematic review and meta-analysis. Frontiers in Nutrition. 2026. https://doi.org/10.3389/fnut.2026.1802531
  6. Liao LP, Church LA, Melville H, et al. Effect of ketone supplementation, a low-carbohydrate diet and a ketogenic diet on heart failure measures and outcomes: a systematic review and meta-analysis. Heart. 2025. https://doi.org/10.1136/heartjnl-2025-326082
  7. Marcotte-Chénard A, Tremblay R, Falkenhain K, et al. Effect of Acute and Chronic Ingestion of Exogenous Ketone Supplements on Blood Pressure: A Systematic Review and Meta-Analysis. Journal of Dietary Supplements. 2023. https://doi.org/10.1080/19390211.2023.2289961
  8. Clarke K, Tchabanenko K, Pawlosky R, et al. Kinetics, safety and tolerability of (R)-3-hydroxybutyl (R)-3-hydroxybutyrate in healthy adult subjects. Regulatory Toxicology and Pharmacology. 2012. https://doi.org/10.1016/j.yrtph.2012.04.008
  9. Stubbs BJ, Cox PJ, Evans RD, et al. On the Metabolism of Exogenous Ketones in Humans. Frontiers in Physiology. 2017. https://doi.org/10.3389/fphys.2017.00848
  10. Leckey JJ, Ross ML, Quod M, et al. Ketone Diester Ingestion Impairs Time-Trial Performance in Professional Cyclists. Frontiers in Physiology. 2017. https://doi.org/10.3389/fphys.2017.00806
  11. Thiessen J, Rourke A, Pocchi G, et al. Acute exogenous ketone monoester supplementation decreases indices of cardiac vagal modulation in a dose-dependent manner in healthy adults. Applied Physiology, Nutrition, and Metabolism. 2026. https://doi.org/10.1139/apnm-2025-0394
  12. Seto E, Nardone M, Thiessen JS, et al. Effects of acute ketone monoester ingestion on heart rate, blood pressure and muscle sympathetic nerve activity at rest and stress in healthy adults. Physiological Reports. 2025. https://doi.org/10.14814/phy2.70584

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