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Howard EE, Allen JT, McNiff JL, Small SD, O'Fallon KS, Margolis LM. Ketone monoester plus high-dose glucose supplementation before exercise does not affect immediate post-exercise erythropoietin concentrations versus glucose alone. Physiol Rep 2024; 12:e70009. [PMID: 39174870 PMCID: PMC11341272 DOI: 10.14814/phy2.70009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 08/07/2024] [Accepted: 08/07/2024] [Indexed: 08/24/2024] Open
Abstract
The objective of this study was to examine the effect of consuming ketone monoester plus a high dose of carbohydrate from glucose (KE + CHO) on the change in erythropoietin (EPO) concentrations during load carriage exercise compared with carbohydrate (CHO) alone. Using a randomized, crossover design, 12 males consumed KE + CHO (573 mg KE/kg body mass, 110 g glucose) or CHO (110 g glucose) 30 min before 4 miles of self-paced treadmill exercise (KE + CHO:51 ± 13%, CHO: 52 ± 12% V̇O2peak) wearing a weighted vest (30% body mass; 25 ± 3 kg). Blood samples for analysis were obtained under resting fasted conditions before (Baseline) consuming the KE + CHO or CHO supplement and immediately after exercise (Post). βHB increased (p < 0.05) from Baseline to Post in KE + CHO, with no change in CHO. Glucose and glycerol increased (p < 0.05) from Baseline to Post in CHO, with no effect of time in KE + CHO. Insulin and lactate increased (p < 0.05) from Baseline to Post independent of treatment. EPO increased (p < 0.05) from Baseline to Post in KE + CHO and CHO with no difference between treatments. Although KE + CHO altered βHB, glucose, and glycerol concentrations, results from this study suggest that KE + CHO supplementation before load carriage exercise does not enhance immediate post-exercise increases in EPO compared with CHO alone.
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Affiliation(s)
- Emily E. Howard
- Military Nutrition DivisionU.S. Army Research Institute of Environmental Medicine (USARIEM)NatickMassachusettsUSA
| | - Jillian T. Allen
- Military Nutrition DivisionU.S. Army Research Institute of Environmental Medicine (USARIEM)NatickMassachusettsUSA
| | - Julie L. McNiff
- Military Nutrition DivisionU.S. Army Research Institute of Environmental Medicine (USARIEM)NatickMassachusettsUSA
- Oak Ridge Institute for Science and EducationBelcampMarylandUSA
- Soldier Sustainment DirectorateU.S. Army Combat Capabilities Development Command Soldier CenterNatickMassachusettsUSA
| | - Stephanie D. Small
- Military Nutrition DivisionU.S. Army Research Institute of Environmental Medicine (USARIEM)NatickMassachusettsUSA
- Oak Ridge Institute for Science and EducationBelcampMarylandUSA
- Faculty of Kinesiology & Physical EducationUniversity of TorontoTorontoOntarioCanada
| | - Kevin S. O'Fallon
- Soldier Effectiveness DirectorateU.S. Army Combat Capabilities Development Command Soldier CenterNatickMassachusettsUSA
| | - Lee M. Margolis
- Military Nutrition DivisionU.S. Army Research Institute of Environmental Medicine (USARIEM)NatickMassachusettsUSA
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Drummer DJ, McNiff JL, Howard EE, Gwin JA, Carrigan CT, Murphy NE, Wilson MA, Michalak J, Ryan BJ, McClung JP, Pasiakos SM, Margolis LM. Exogenous erythropoietin increases hematological status, fat oxidation, and aerobic performance in males following prolonged strenuous training. Physiol Rep 2024; 12:e16038. [PMID: 38757249 PMCID: PMC11099744 DOI: 10.14814/phy2.16038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
This study investigated the effects of EPO on hemoglobin (Hgb) and hematocrit (Hct), time trial (TT) performance, substrate oxidation, and skeletal muscle phenotype throughout 28 days of strenuous exercise. Eight males completed this longitudinal controlled exercise and feeding study using EPO (50 IU/kg body mass) 3×/week for 28 days. Hgb, Hct, and TT performance were assessed PRE and on Days 7, 14, 21, and 27 of EPO. Rested/fasted muscle obtained PRE and POST EPO were analyzed for gene expression, protein signaling, fiber type, and capillarization. Substrate oxidation and glucose turnover were assessed during 90-min of treadmill load carriage (LC; 30% body mass; 55 ± 5% V̇O2peak) exercise using indirect calorimetry, and 6-6-[2H2]-glucose PRE and POST. Hgb and Hct increased, and TT performance improved on Days 21 and 27 compared to PRE (p < 0.05). Energy expenditure, fat oxidation, and metabolic clearance rate during LC increased (p < 0.05) from PRE to POST. Myofiber type, protein markers of mitochondrial biogenesis, and capillarization were unchanged PRE to POST. Transcriptional regulation of mitochondrial activity and fat metabolism increased from PRE to POST (p < 0.05). These data indicate EPO administration during 28 days of strenuous exercise can enhance aerobic performance through improved oxygen carrying capacity, whole-body and skeletal muscle fat metabolism.
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Affiliation(s)
- Devin J. Drummer
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
- Oak Ridge Institute for Science and EducationBelcampMarylandUSA
| | - Julie L. McNiff
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
- Combat Feeding DivisionU.S. Army Combat Capabilities Development Command (DEVCOM)NatickMassachusettsUSA
| | - Emily E. Howard
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Jess A. Gwin
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Christopher T. Carrigan
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Nancy E. Murphy
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Marques A. Wilson
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Julia Michalak
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
- Oak Ridge Institute for Science and EducationBelcampMarylandUSA
| | - Benjamin J. Ryan
- Thermal and Mountain Medicine DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - James P. McClung
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Stefan M. Pasiakos
- Office of Dietary Supplements, National Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMarylandUSA
| | - Lee M. Margolis
- Military Nutrition DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
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Soni S, Tabatabaei Dakhili SA, Ussher JR, Dyck JRB. The therapeutic potential of ketones in cardiometabolic disease: impact on heart and skeletal muscle. Am J Physiol Cell Physiol 2024; 326:C551-C566. [PMID: 38193855 PMCID: PMC11192481 DOI: 10.1152/ajpcell.00501.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 01/10/2024]
Abstract
β-Hydroxybutyrate (βOHB) is the major ketone in the body, and it is recognized as a metabolic energy source and an important signaling molecule. While ketone oxidation is essential in the brain during prolonged fasting/starvation, other organs such as skeletal muscle and the heart also use ketones as metabolic substrates. Additionally, βOHB-mediated molecular signaling events occur in heart and skeletal muscle cells, and via metabolism and/or signaling, ketones may contribute to optimal skeletal muscle health and cardiac function. Of importance, when the use of ketones for ATP production and/or as signaling molecules becomes disturbed in the presence of underlying obesity, type 2 diabetes, and/or cardiovascular diseases, these changes may contribute to cardiometabolic disease. As a result of these disturbances in cardiometabolic disease, multiple approaches have been used to elevate circulating ketones with the goal of optimizing either ketone metabolism or ketone-mediated signaling. These approaches have produced significant improvements in heart and skeletal muscle during cardiometabolic disease with a wide range of benefits that include improved metabolism, weight loss, better glycemic control, improved cardiac and vascular function, as well as reduced inflammation and oxidative stress. Herein, we present the evidence that indicates that ketone therapy could be used as an approach to help treat cardiometabolic diseases by targeting cardiac and skeletal muscles.
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Affiliation(s)
- Shubham Soni
- Cardiovascular Research Centre, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Seyed Amirhossein Tabatabaei Dakhili
- Cardiovascular Research Centre, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - John R Ussher
- Cardiovascular Research Centre, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Robberechts R, Poffé C. Defining ketone supplementation: the evolving evidence for postexercise ketone supplementation to improve recovery and adaptation to exercise. Am J Physiol Cell Physiol 2024; 326:C143-C160. [PMID: 37982172 DOI: 10.1152/ajpcell.00485.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
Over the last decade, there has been a growing interest in the use of ketone supplements to improve athletic performance. These ketone supplements transiently elevate the concentrations of the ketone bodies acetoacetate (AcAc) and d-β-hydroxybutyrate (βHB) in the circulation. Early studies showed that ketone bodies can improve energetic efficiency in striated muscle compared with glucose oxidation and induce a glycogen-sparing effect during exercise. As such, most research has focused on the potential of ketone supplementation to improve athletic performance via ingestion of ketones immediately before or during exercise. However, subsequent studies generally observed no performance improvement, and particularly not under conditions that are relevant for most athletes. However, more and more studies are reporting beneficial effects when ketones are ingested after exercise. As such, the real potential of ketone supplementation may rather be in their ability to enhance postexercise recovery and training adaptations. For instance, recent studies observed that postexercise ketone supplementation (PEKS) blunts the development of overtraining symptoms, and improves sleep, muscle anabolic signaling, circulating erythropoietin levels, and skeletal muscle angiogenesis. In this review, we provide an overview of the current state-of-the-art about the impact of PEKS on aspects of exercise recovery and training adaptation, which is not only relevant for athletes but also in multiple clinical conditions. In addition, we highlight the underlying mechanisms by which PEKS may improve exercise recovery and training adaptation. This includes epigenetic effects, signaling via receptors, modulation of neurotransmitters, energy metabolism, and oxidative and anti-inflammatory pathways.
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Affiliation(s)
- Ruben Robberechts
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Chiel Poffé
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
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Nelson AB, Queathem ED, Puchalska P, Crawford PA. Metabolic Messengers: ketone bodies. Nat Metab 2023; 5:2062-2074. [PMID: 38092961 DOI: 10.1038/s42255-023-00935-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/20/2023] [Indexed: 12/21/2023]
Abstract
Prospective molecular targets and therapeutic applications for ketone body metabolism have increased exponentially in the past decade. Initially considered to be restricted in scope as liver-derived alternative fuel sources during periods of carbohydrate restriction or as toxic mediators during diabetic ketotic states, ketogenesis and ketone bodies modulate cellular homeostasis in multiple physiological states through a diversity of mechanisms. Selective signalling functions also complement the metabolic fates of the ketone bodies acetoacetate and D-β-hydroxybutyrate. Here we discuss recent discoveries revealing the pleiotropic roles of ketone bodies, their endogenous sourcing, signalling mechanisms and impact on target organs, and considerations for when they are either stimulated for endogenous production by diets or pharmacological agents or administered as exogenous wellness-promoting agents.
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Affiliation(s)
- Alisa B Nelson
- Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Eric D Queathem
- Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Biochemistry, Molecular Biology and Biophysics, University of Minnesota, Minneapolis, MN, USA
| | - Patrycja Puchalska
- Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Peter A Crawford
- Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
- Department of Biochemistry, Molecular Biology and Biophysics, University of Minnesota, Minneapolis, MN, USA.
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ROBBERECHTS RUBEN, ALBOUY GENEVIÈVE, HESPEL PETER, POFFÉ CHIEL. Exogenous Ketosis Improves Sleep Efficiency and Counteracts the Decline in REM Sleep after Strenuous Exercise. Med Sci Sports Exerc 2023; 55:2064-2074. [PMID: 37259248 PMCID: PMC10581428 DOI: 10.1249/mss.0000000000003231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Available evidence indicates that ketone bodies may improve sleep quality. Therefore, we determined whether ketone ester (KE) intake could counteract sleep disruptions induced by strenuous exercise. METHODS Ten well-trained cyclists with good sleep quality participated in a randomized crossover design consisting of two experimental sessions each involving a morning endurance training and an evening high-intensity interval training ending 1 h before sleep, after which polysomnography was performed overnight. Postexercise and 30 min before sleeping time, subjects received either 25 g of KE (EX KE ) or a placebo drink (EX CON ). A third session without exercise but with placebo supplements (R CON ) was added to evaluate the effect of exercise per se on sleep. RESULTS Blood d -β-hydroxybutyrate concentrations transiently increased to ~3 mM postexercise and during the first part of the night in EX KE but not in EX CON or R CON . Exercise significantly reduced rapid eye movement sleep by 26% ( P = 0.001 vs R CON ) and increased wakefulness after sleep onset by 95% ( P = 0.004 vs R CON ). Interestingly, KE improved sleep efficiency by 3% ( P = 0.040 vs EX CON ) and counteracted the exercise-induced decrease in rapid eye movement sleep ( P = 0.011 vs EX CON ) and the increase in wakefulness after sleep onset ( P = 0.009 vs EX CON ). This was accompanied by a KE-induced increase in dopamine excretion ( P = 0.033 vs EX CON ), which plays a pivotal role in sleep regulation. In addition, exercise increased sleep spindle density by 36% ( P = 0.005 vs R CON ), suggesting an effect on neural plasticity processes during sleep. CONCLUSIONS These data indicate that KE ingestion improves sleep efficiency and quality after high-intensity exercise. We provide preliminary evidence that this might result from KE-induced increases in dopamine signaling.
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Affiliation(s)
- RUBEN ROBBERECHTS
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, BELGIUM
| | - GENEVIÈVE ALBOUY
- Movement Control and Neuroplasticity Research Group, Department of Movement Sciences, KU Leuven, Leuven, BELGIUM
- Leuven Brain Institute (LBI), KU Leuven, Leuven, BELGIUM
- Department of Health and Kinesiology, College of Health, University of Utah, Salt Lake City, UT
| | - PETER HESPEL
- Department of Movement Sciences, KU Leuven, Leuven, BELGIUM
| | - CHIEL POFFÉ
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, BELGIUM
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7
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Margolis LM, Pasiakos SM, Howard EE. High-fat ketogenic diets and ketone monoester supplements differentially affect substrate metabolism during aerobic exercise. Am J Physiol Cell Physiol 2023; 325:C1144-C1153. [PMID: 37721006 PMCID: PMC10635661 DOI: 10.1152/ajpcell.00359.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
Chronically adhering to high-fat ketogenic diets or consuming ketone monoester supplements elicits ketosis. Resulting changes in substrate metabolism appear to be drastically different between ketogenic diets and ketone supplements. Consuming a ketogenic diet increases fatty acid oxidation with concomitant decreases in endogenous carbohydrate oxidation. Increased fat oxidation eventually results in an accumulation of circulating ketone bodies, which are metabolites of fatty acids that serve as an alternative source of fuel. Conversely, consuming ketone monoester supplements rapidly increases circulating ketone body concentrations that typically exceed those achieved by adhering to ketogenic diets. Rapid increases in ketone body concentrations with ketone monoester supplementation elicit a negative feedback inhibition that reduces fatty acid mobilization during aerobic exercise. Supplement-derived ketosis appears to have minimal impact on sparing of muscle glycogen or minimizing of carbohydrate oxidation during aerobic exercise. This review will discuss the substrate metabolic and associated aerobic performance responses to ketogenic diets and ketone supplements.
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Affiliation(s)
- Lee M Margolis
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, United States
| | - Stefan M Pasiakos
- Office of Dietary Supplements, U.S. Department of Health and Human Services, National Institutes of Health, Bethesda, Maryland, United States
| | - Emily E Howard
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, United States
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Khouri H, Ussher JR, Aguer C. Exogenous Ketone Supplementation and Ketogenic Diets for Exercise: Considering the Effect on Skeletal Muscle Metabolism. Nutrients 2023; 15:4228. [PMID: 37836512 PMCID: PMC10574738 DOI: 10.3390/nu15194228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
In recent years, ketogenic diets and ketone supplements have increased in popularity, particularly as a mechanism to improve exercise performance by modifying energetics. Since the skeletal muscle is a major metabolic and locomotory organ, it is important to take it into consideration when considering the effect of a dietary intervention, and the impact of physical activity on the body. The goal of this review is to summarize what is currently known and what still needs to be investigated concerning the relationship between ketone body metabolism and exercise, specifically in the skeletal muscle. Overall, it is clear that increased exposure to ketone bodies in combination with exercise can modify skeletal muscle metabolism, but whether this effect is beneficial or detrimental remains unclear and needs to be further interrogated before ketogenic diets or exogenous ketone supplementation can be recommended.
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Affiliation(s)
- Hannah Khouri
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Institut du Savoir Montfort, Hôpital Montfort, Ottawa, ON K1K 0T2, Canada
| | - John R Ussher
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 2H5, Canada
| | - Céline Aguer
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Institut du Savoir Montfort, Hôpital Montfort, Ottawa, ON K1K 0T2, Canada
- Department of Physiology, Faculty of Medicine and Health Sciences, McGill University-Campus Outaouais, Gatineau, QC J8V 3T4, Canada
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9
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Robertson AA, Lynagh BM, Thompson KMA, McCarthy DG. EPOtential target for endurance performance: the effect of exogenous ketone supplementation on circulating erythropoietin levels. J Physiol 2023; 601:3991-3992. [PMID: 37566813 DOI: 10.1113/jp285257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Affiliation(s)
- Alexa A Robertson
- Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Bridget M Lynagh
- Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Kyle M A Thompson
- Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Devin G McCarthy
- Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
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Zabbal A, Alhamwi A, Sauvageau BM, Hannaian SJ. Intermittent exogenous ketosis: permissive or stimulatory for skeletal muscle angiogenesis in response to endurance training overload? J Physiol 2023; 601:2765-2767. [PMID: 37190939 DOI: 10.1113/jp284917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
- Arianne Zabbal
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Alyasamin Alhamwi
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Benjamin M Sauvageau
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Sarkis J Hannaian
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Glen Site, Montreal, Quebec, Canada
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