Exogenous Ketone and Carbohydrate Supplementation Impact on Cognitive Function, Physical Performance, and Molecular Biomarkers in Endurance Athletes

Design rationale Published trials of exogenous ketosis in prolonged cycling have used intermittent load, which oscillates intensity and, with it, substrate preference. That format does not favour expression of the proposed mechanism, whereby ketosis suppresses glycolysis, raises fat oxidation and spares glycogen for a decisive final block. Constant prolonged load was therefore chosen as the more adequate format to test it. Those trials also compare two arms against a carbohydrate background present in every condition, without a carbohydrate-free control, which does not separate the contribution of carbohydrate from that of added ketone. The three arms used here resolve this: the placebo-to-carbohydrate contrast measures the contribution of carbohydrate, and the carbohydrate to carbohydrate-plus-ketone contrast measures the contribution of ketone added on a matched background, added rather than substituted on an isocaloric basis. The three-hour window was chosen because it is where cortisol and the inflammatory response intensify, allowing examination of whether ketosis acts beyond energy provision, as a signalling metabolite on the kynurenine pathway. Pre-experimental visit Body composition is assessed by dual-energy X-ray absorptiometry on a Lunar GE Medical Systems Prodigy Advance scanner with Encore software version 13.6, calibrated by the same technician according to manufacturer recommendations. Lean mass, fat mass, body fat percentage and bone mineral density are recorded. This assessment is performed once and characterizes the sample rather than serving as a study outcome, since it precedes any supplementation and is not repeated within conditions. The maximal incremental test follows, on a cycle ergometer, with a three-minute warm-up at 100 W and increments of 25 W every three minutes until exhaustion. Maximal oxygen uptake is determined by indirect calorimetry on a COSMED Quark CPET analyser, maximal power output by a Saris power meter with Golden Cheetah software, and heart rate by a Polar chest strap. Perceived exertion is rated on the Borg 0 to 10 scale. At each increment, 25 microlitres of capillary blood are sampled from the earlobe for lactate determination on a Yellow Springs YSI analyser, from which the anaerobic threshold is derived. Together with maximal power output and maximal oxygen uptake, the threshold informs individual load prescription for the experimental sessions. Standardization before each experimental session Participants maintain their habitual dietary pattern and their habitual training volume, intensity and frequency throughout the experimental period. In the three days preceding each visit, caffeine, non-steroidal anti-inflammatory drugs and any medication affecting intestinal transit are suspended. In the week preceding each experimental session, intense effort and systematic training are prohibited, to avoid residual fatigue or muscle inflammation; adherence is verified by direct contact and by inspection of individual training records. Gut training is prescribed in that same week, with progressive carbohydrate volume and dose taken during the participant's own training rides, adapted from the protocol of Costa et al. (2017), to increase gastrointestinal tolerance to the carbohydrate load of the experimental session. Supplements for the following week of gut training are handed to the participant before discharge from each session. Hydration follows 5 mL/kg of cold water on arrival at the laboratory, with ad libitum replacement throughout the session. Experimental session logistics Each session runs on a fixed schedule of approximately seven and a half hours from arrival to discharge. Venous blood is drawn from the antecubital vein into serum and EDTA tubes. Peripheral blood mononuclear cells are isolated from the EDTA tubes by Ficoll-Hypaque gradient at 400 g for 40 minutes. Serum is obtained after 60 minutes at room temperature followed by centrifugation at 1300 g for 10 minutes, and stored at minus 80 degrees Celsius. Capillary blood is sampled from the earlobe at defined intervals before, during and after exercise for on-site determination of lactate, glucose and beta-hydroxybutyrate on a Freestyle Optium meter, which also serves to verify that the target ketosis was reached in the CHO-KET condition. Perceived exertion is rated on the Borg 0 to 10 scale at predefined moments. Four five-minute gas exchange windows are recorded during the fixed-intensity phase, with the mask fitted continuously during the maximal effort block. Before exercise, the cycle ergometer is adjusted to the participant's measurements and the heart rate monitor is fitted. Gas exchange is recorded across four fixed windows per session: 15 minutes covering rest, warm-up and exercise onset; 5 minutes at two points during the fixed-intensity phase; and 30 minutes from 5 minutes before the end of the fixed-intensity phase through the maximal effort block and the cool-down. After the cool-down, the participant completes the post-exercise cognitive battery, showers, and is weighed. The final venous draw follows the same protocol as baseline.