Guiding Ketogenic Diet with Breath Acetone Sensors

Update on Measuring Ketones

Ketone bodies are an energy substrate produced by the liver and used during states of low carbohydrate availability, such as fasting or prolonged exercise. High ketone concentrations can be present with insulin insufficiency and are a key finding in diabetic ketoacidosis (DKA). During states of insulin deficiency, lipolysis increases and a flood of circulating free fatty acids is converted in the liver into ketone bodies-mainly beta-hydroxybutyrate and acetoacetate. During DKA, beta-hydroxybutyrate is the predominant ketone in blood. As DKA resolves, beta-hydroxybutyrate is oxidized to acetoacetate, which is the predominant ketone in the urine. Because of this lag, a urine ketone test might be increasing even as DKA is resolving. Point-of-care tests are available for self-testing of blood ketones and urine ketones through measurement of beta-hydroxybutyrate and acetoacetate and are cleared by the US Food and Drug Administration (FDA). Acetone forms through spontaneous decarboxylation of acetoacetate and can be measured in exhaled breath, but currently no device is FDA-cleared for this purpose. Recently, technology has been announced for measuring beta-hydroxybutyrate in interstitial fluid. Measurement of ketones can be helpful to assess compliance with low carbohydrate diets; assessment of acidosis associated with alcohol use, in conjunction with SGLT2 inhibitors and immune checkpoint inhibitor therapy, both of which can increase the risk of DKA; and to identify DKA due to insulin deficiency. This article reviews the challenges and shortcomings of ketone testing in diabetes treatment and summarizes emerging trends in the measurement of ketones in the blood, urine, breath, and interstitial fluid.

Effectiveness of breath acetone monitoring in reducing body fat and improving body composition: a randomized controlled study

When attempts to lose body fat mass frequently fail, breath acetone (BA) monitoring may assist fat mass loss during a low-carbohydrate diet as it can provide real-time body fat oxidation levels. This randomized controlled study aimed to evaluate the effectiveness of monitoring BA levels and providing feedback on fat oxidation during a three-week low-carbohydrate diet intervention. Forty-seven participants (mean age = 27.8 ± 4.4 years, 53.3% females, body mass index = 24.1 ± 3.4 kg m-2) were randomly assigned to three groups (1:1:1 ratio): daily BA assessment with a low-carbohydrate diet, body weight assessment (body scale (BS)) with a low-carbohydrate diet, and low-carbohydrate diet only. Primary outcome was the change in fat mass and secondary outcomes were the changes in body weight and body composition. Forty-five participants completed the study (compliance rate: 95.7%). Fat mass was significantly reduced in all three groups (allP< 0.05); however, the greatest reduction in fat mass was observed in the BA group compared to the BS (differences in changes in fat mass, -1.1 kg; 95% confidence interval: -2.3, -0.2;P= 0.040) and control (differences in changes in fat mass, -1.3 kg; 95% confidence interval: -2.1, -0.4;P= 0.013) groups. The BA group showed significantly greater reductions in body weight and visceral fat mass than the BS and control groups (allP< 0.05). In addition, the percent body fat and skeletal muscle mass were significantly reduced in both BA and BS groups (allP< 0.05). However, no significant differences were found in changes in body fat percentage and skeletal muscle mass between the study groups. Monitoring BA levels, which could have motivated participants to adhere more closely to the low-carbohydrate diet, to assess body fat oxidation rates may be an effective intervention for reducing body fat mass (compared to body weight assessment or control conditions). This approach could be beneficial for individuals seeking to manage body fat and prevent obesity.

A Novel Acetone Sensor for Body Fluids

Ketones are well-known biomarkers of fat oxidation produced in the liver as a result of lipolysis. These biomarkers include acetoacetic acid and β-hydroxybutyric acid in the blood/urine and acetone in our breath and skin. Monitoring ketone production in the body is essential for people who use caloric intake deficit to reduce body weight or use ketogenic diets for wellness or therapeutic treatments. Current methods to monitor ketones include urine dipsticks, capillary blood monitors, and breath analyzers. However, these existing methods have certain disadvantages that preclude them from being used more widely. In this work, we introduce a novel acetone sensor device that can detect acetone levels in breath and overcome the drawbacks of existing sensing approaches. The critical element of the device is a robust sensor with the capability to measure acetone using a complementary metal oxide semiconductor (CMOS) chip and convenient data analysis from a red, green, and blue deconvolution imaging approach. The acetone sensor device demonstrated sensitivity of detection in the micromolar-concentration range, selectivity for detection of acetone in breath, and a lifetime stability of at least one month. The sensor device utility was probed with real tests on breath samples using an established blood ketone reference method.

Research progress of electronic nose technology in exhaled breath disease analysis

Exhaled breath analysis has attracted considerable attention as a noninvasive and portable health diagnosis method due to numerous advantages, such as convenience, safety, simplicity, and avoidance of discomfort. Based on many studies, exhaled breath analysis is a promising medical detection technology capable of diagnosing different diseases by analyzing the concentration, type and other characteristics of specific gases. In the existing gas analysis technology, the electronic nose (eNose) analysis method has great advantages of high sensitivity, rapid response, real-time monitoring, ease of use and portability. Herein, this review is intended to provide an overview of the application of human exhaled breath components in disease diagnosis, existing breath testing technologies and the development and research status of electronic nose technology. In the electronic nose technology section, the three aspects of sensors, algorithms and existing systems are summarized in detail. Moreover, the related challenges and limitations involved in the abovementioned technologies are also discussed. Finally, the conclusion and perspective of eNose technology are presented.

Handheld device quantifies breath acetone for real-life metabolic health monitoring

Non-invasive breath analysis with mobile health devices bears tremendous potential to guide therapeutic treatment and personalize lifestyle changes. Of particular interest is the breath volatile acetone, a biomarker for fat burning, that could help in understanding and treating metabolic diseases. Here, we report a hand-held (6 × 10 × 19.5 cm³), light-weight (490 g), and simple device for rapid acetone detection in breath. It comprises a tailor-made end-tidal breath sampling unit, connected to a sensor and a pump for on-demand breath sampling, all operated using a Raspberry Pi microcontroller connected with a HDMI touchscreen. Accurate acetone detection is enabled by introducing a catalytic filter and a separation column, which remove and separate undesired interferents from acetone upstream of the sensor. This way, acetone is detected selectively even in complex gas mixtures containing highly concentrated interferents. This device accurately tracks breath acetone concentrations in the exhaled breath of five volunteers during a ketogenic diet, being as high as 26.3 ppm. Most importantly, it can differentiate small acetone changes during a baseline visit as well as before and after an exercise stimulus, being as low as 0.5 ppm. It is stable for at least four months (122 days), and features excellent bias and precision of 0.03 and 0.6 ppm at concentrations below 5 ppm, as validated by proton-transfer-reaction time-of-flight mass spectrometry (PTR-ToF-MS). Hence, this detector is highly promising for simple-in-use, non-invasive, and routine monitoring of acetone to guide therapeutic treatment and track lifestyle changes.

The development of wearable technologies and their potential for measuring nutrient intake: Towards precision nutrition

Appropriate food intake and nutritional status are crucial for the maintenance of health and disease prevention. Conventional dietary assessment is mainly based on comparisons of nutrient intakes with reference intakes, failing to meet the needs of personalised nutritional guidance based on individual nutritional status. Given their capability of providing insights into health information non-invasively in real time, wearable technologies offer great opportunities for nutrition monitoring. Nutrient metabolic profiles can be monitored immediately and continuously which could potentially offer the possibility for the tracking and guiding of nutrient intake. Here, we review and highlight the recent advances in wearable sensors from the perspective of sensing technologies for nutrient detection in biofluids. The integration of biosensors with wearable devices serves as an ideal platform for the analysis of biofluids including sweat, saliva and tears. The wearable sensing systems applied to the analysis of typical nutrients and important metabolites are demonstrated in terms of carbohydrates, proteins, lipids, vitamins, minerals and others. Taking advantage of their high flexibility and lightweight, wearable sensors have been widely developed for the in situ quantitative detection of metabolic biomarkers. The technical principles, detection methods and applications are summarised. The challenges and future perspectives for wearable nutrition monitoring devices are discussed including the need to better determine relationships among nutrient metabolic profile, nutrient intake and food intake. With the development of materials, sensing techniques and manufacturing processes, wearable technologies are paving the way towards personalised precision nutrition, although there is still a long way to go before they can be utilised for practical clinical applications. Joint research efforts between nutrition scientists, doctors, engineers and sensor researchers are essential to further accelerate the realisation of reliable and practical wearable nutrition monitoring platforms.

A user preference analysis of commercial breath ketone sensors to inform the development of portable breath ketone sensors for diabetes management in young people

Background

Portable breath ketone sensors may help people with Type 1 Diabetes Mellitus (T1DM) avoid episodes of diabetic ketoacidosis; however, the design features preferred by users have not been studied. We aimed to elucidate breath sensor design preferences of young people with T1DM (age 12 to 16) and their parents to inform the development of a breath ketone sensor prototype that would best suit their diabetes management needs.

Research designs and methods

To elicit foundational experiences from which design preference ideas could be generated, two commercially available breath ketone sensors, designed for ketogenic diet monitoring, were explored over one week by ten young people with T1DM. Participants interacted with the breath ketone sensing devices, and undertook blood ketone testing, at least twice daily for five days to simulate use within a real life and ambulatory care setting. Semi-structured interviews were conducted post-testing with the ten young participants and their caregivers (n = 10) to elicit preferences related to breath sensor design and use, and to inform the co-design of a breath ketone sensor prototype for use in T1DM self-management. We triangulated our data collection with key informant interviews with two diabetes educators working in pediatric care about their perspectives related to young people using breath ketone sensors.

Results

Participants acknowledged the non-invasiveness of breath sensors as compared to blood testing. Affordability, reliability and accuracy were identified as prerequisites for breath ketone sensors used for diabetes management. Design features valued by young people included portability, ease of use, sustainability, readability and suitability for use in public. The time required to use breath sensors was similar to that for blood testing. The requirement to maintain a 10-second breath exhalation posed a challenge for users. Diabetes educators highlighted the ease of use of breath devices especially for young people who tended to under-test using blood ketone strips.

Conclusions

Breath ketone sensors for diabetes management have potential that may facilitate ketone testing in young people. Our study affirms features for young people that drive usability of breath sensors among this population, and provides a model of user preference assessment.

Highly Selective and Sensitive Detection of Breath Isoprene by Tailored Gas Reforming: A Synergistic Combination of Macroporous WO3 Spheres and Au Catalysts

Precise detection of breath isoprene can provide valuable information for monitoring the physical and physiological status of human beings or for the early diagnosis of cardiovascular diseases. However, the extremely low concentration and low chemical reactivity of breath isoprene hamper the selective and sensitive detection of isoprene using oxide semiconductor chemiresistors. Herein, we report that macroporous WO₃ microspheres whose inner macropores are surrounded by Au nanoparticles exhibit a high response (resistance ratio = 11.3) to 0.1 ppm isoprene under highly humid conditions at 275 °C and an extremely low detection limit (0.2 ppb). Furthermore, the sensor showed excellent selectivity to isoprene over five interferants that could be exhaled by humans. Notably, the selectivity to isoprene is critically dependent on the location of Au nanocatalysts and macroporosity. The mechanism underlying the selective isoprene detection is investigated in relation to the reforming of less reactive isoprene into more reactive intermediate species promoted by macroporous catalytic reactors, which is confirmed by the analysis using a proton transfer reaction quadrupole mass spectrometer. The sensor for breath analysis has high potential for simple physical and physiological monitoring as well as disease diagnosis.

Detection of transdermal biomarkers using gradient-based colorimetric array sensor

Accurate assessment of dietary macronutrients intake is critical for the effective management of multiple diseases, such as obesity, diabetes, cardiovascular disease, metabolic disease, and cancer. Conventional self-reporting method is burdensome, inaccurate, and often biased. Though blood analysis and breath analysis can provide evidence-based information, they are either invasive or subject to human errors. Here we reported a wearable transdermal volatile biomarkers detection system based on novel colorimetric sensing technology for dietary macronutrients intake assessment. This technique quantifies the emission rates of transdermal volatile biomarkers via a gradient-based colorimetric array sensor (GCAS). The optical system of the GCAS device tracks the localized color development associated with the chemical reaction between the volatile biomarkers and the porous sensing probes, and determines the biomarkers emission rates through image processing algorithms. The localized chemical reaction and the image-based signal processing also make the GCAS capable for multiplexed detection of multiple analytes simultaneously. The GCAS sensor has been applied for transdermal acetone detection on 5 subjects in a keto diet intervention. The study indicates that the transdermal acetone increases after the subjects consuming keto diets and it decreases to basal level after intaking carb-rich diets. The transdermal acetone response from the GCAS sensor correlates well with breath acetone concentration in the range between 0 and 40 ppm and the correlation factor (R²) is as high as 0.8877. This method provides a noninvasive, low-cost, and wearable tool for assessing dietary macronutrients intake outside of lab or hospital settings. It could be widely applied in disease management, weight control, and nutrition management.

Adherence to Low-Carbohydrate Diets in Patients with Diabetes: A Narrative Review

Evidence suggests that low carbohydrate (<130 g/day of carbohydrate) (LCD) and very low carbohydrate, ketogenic diets (typically <50 g/day of carbohydrate) (VLCKD) can be effective tools for managing diabetes given their beneficial effects on weight loss and glycemic control. VLCKD also result in favorable lipid profile changes. However, these beneficial effects can be limited by poor dietary adherence. Cultural, religious, and economic barriers pose unique challenges to achieving nutritional compliance with LCD and VLCKD. We review the various methods for assessing adherence in clinical studies and obstacles posed, as well as potential solutions to these challenges.

Accuracy of a breath ketone analyzer to detect ketosis in adults and children with type 1 diabetes

OBJECTIVE

To assess the accuracy of a breath ketone analyzer to detect ketosis in adults and children with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This is a proof-of-concept, prospective study comparing breath ketone analyzer and blood ketone meter to detect ketosis.

RESULTS

A total of 500 measurements from 19 adults and children with type 1 diabetes were analyzed. There was a significant association between the breath ketone analyzer and blood ketone meter results in non-fasting adults (p = 0.0066), but not in children (p = 0.4579). In adults, a cut-off of 3.9 PPM on the breath ketone analyzer maximized the Youden Index with an AUC of 0.73. This cut-off for the breath ketone analyzer had 94.7% sensitivity and 54.2% specificity to detect ketosis (≥0.6 mmol/L in blood ketone meter).

CONCLUSIONS

The breath ketone analyzer may be considered as a non-invasive screening tool to rule out ketosis in adults with type 1 diabetes.

Acetone Sensing and Catalytic Conversion by Pd-Loaded SnO2

Noble metal additives are widely used to improve the performance of metal oxide gas sensors, most prominently with palladium on tin oxide. Here, we photodeposit different quantities of Pd (0–3 mol%) onto nanostructured SnO₂ and determine their effect on sensing acetone, a critical tracer of lipolysis by breath analysis. We focus on understanding the effect of operating temperature on acetone sensing performance (sensitivity and response/recovery times) and its relationship to catalytic oxidation of acetone through a packed bed of such Pd-loaded SnO₂. The addition of Pd can either boost or deteriorate the sensing performance, depending on its loading and operating temperature. The sensor performance is optimal at Pd loadings of less than 0.2 mol% and operating temperatures of 200–262.5 °C, where acetone conversion is around 50%.

Measuring ketone bodies for the monitoring of pathologic and therapeutic ketosis

BACKGROUND

The ketone bodies β-hydroxybutyrate (BOHB) and acetone are generated as a byproduct of the fat metabolism process. In healthy individuals, ketone body levels are ∼0.1 mM for BOHB and ∼1 part per million for breath acetone (BrAce). These levels can increase dramatically as a consequence of a disease process or when used therapeutically for disease treatment. For example, increased ketone body concentration during weight loss is an indication of elevated fat metabolism. Ketone body measurement is relatively inexpensive and can provide metabolic insights to help guide disease management and optimize weight loss.

METHODS

This review of the literature provides metabolic mechanisms and typical concentration ranges of ketone bodies, which can give new insights into these conditions and rationale for measuring ketone bodies.

RESULTS

Diseases such as heart failure and ketoacidosis can affect caloric intake and macronutrient management, which can elevate BOHB 30-fold and BrAce 1000-fold. Other diseases associated with obesity, such as brain dysfunction, cancer, and diabetes, may cause dysfunction because of an inability to use glucose, excessive reliance on glucose, or poor insulin signaling. Elevating ketone body concentrations (e.g., nutritional ketosis) may improve these conditions by forcing utilization of ketone bodies, in place of glucose, for fuel. During weight loss, monitoring ketone body concentration can demonstrate program compliance and can be used to optimize the weight-loss plan.

CONCLUSIONS

The role of ketone bodies in states of pathologic and therapeutic ketosis indicates that accurate measurement and monitoring of BOHB or BrAce will likely improve disease management. Bariatric surgery is examined as a case study for monitoring both types of ketosis.

A Study on Seizure Detection of EEG Signals Represented in 2D

A seizure is a neurological disorder caused by abnormal neuronal discharges in the brain, which severely reduces the quality of life of patients and often endangers their lives. Automatic seizure detection is an important research area in the treatment of seizure and is a prerequisite for seizure intervention. Deep learning has been widely used for automatic detection of seizures, and many related research works decomposed the electroencephalogram (EEG) raw signal with a time window to obtain EEG signal slices, then performed feature extraction on the slices, and represented the obtained features as input data for neural networks. There are various methods for EEG signal decomposition, feature extraction, and representation, and most of the studies have been based on fixed hardware resources for the design of the scheme, which reduces the adaptability of the scheme in different application scenarios and makes it difficult to optimize the algorithms in the scheme. To address the above issues, this paper proposes a deep learning-based model for seizure detection, mainly characterized by the two-dimensional representation of EEG features and the scalability of neural networks. The model modularizes the main steps of seizure detection and improves the adaptability of the model to different hardware resource constraints, in order to increase the convenience of the algorithm optimization or the replacement of each module. The proposed model consists of five parts, and the model was tested using two epilepsy datasets separately. The experimental results showed that the proposed model has strong generality and good classification accuracy for seizure detection.

Room-Temperature Catalyst Enables Selective Acetone Sensing

Catalytic packed bed filters ahead of gas sensors can drastically improve their selectivity, a key challenge in medical, food and environmental applications. Yet, such filters require high operation temperatures (usually some hundreds °C) impeding their integration into low-power (e.g., battery-driven) devices. Here, we reveal room-temperature catalytic filters that facilitate highly selective acetone sensing, a breath marker for body fat burn monitoring. Varying the Pt content between 0-10 mol% during flame spray pyrolysis resulted in Al2O3 nanoparticles decorated with Pt/PtOx clusters with predominantly 5-6 nm size, as revealed by X-ray diffraction and electron microscopy. Most importantly, Pt contents above 3 mol% removed up to 100 ppm methanol, isoprene and ethanol completely already at 40 °C and high relative humidity, while acetone was mostly preserved, as confirmed by mass spectrometry. When combined with an inexpensive, chemo-resistive sensor of flame-made Si/WO3, acetone was detected with high selectivity (≥225) over these interferants next to H2, CO, form-/acetaldehyde and 2-propanol. Such catalytic filters do not require additional heating anymore, and thus are attractive for integration into mobile health care devices to monitor, for instance, lifestyle changes in gyms, hospitals or at home.

Breath Acetone Sensing Based on Single-Walled Carbon Nanotube-Titanium Dioxide Hybrids Enabled by a Custom-Built Dehumidifier

Acetone is a metabolic byproduct found in the exhaled breath and can be measured to monitor the metabolic degree of ketosis. In this state, the body uses free fatty acids as its main source of fuel because there is limited access to glucose. Monitoring ketosis is important for type I diabetes patients to prevent ketoacidosis, a potentially fatal condition, and individuals adjusting to a low-carbohydrate diet. Here, we demonstrate that a chemiresistor fabricated from oxidized single-walled carbon nanotubes functionalized with titanium dioxide (SWCNT@TiO₂) can be used to detect acetone in dried breath samples. Initially, due to the high cross sensitivity of the acetone sensor to water vapor, the acetone sensor was unable to detect acetone in humid gas samples. To resolve this cross-sensitivity issue, a dehumidifier was designed and fabricated to dehydrate the breath samples. Sensor response to the acetone in dried breath samples from three volunteers was shown to be linearly correlated with the two other ketone bodies, acetoacetic acid in urine and β-hydroxybutyric acid in the blood. The breath sampling and analysis methodology had a calculated acetone detection limit of 1.6 ppm and capable of detecting up to at least 100 ppm of acetone, which is the dynamic range of breath acetone for someone with ketosis. Finally, the application of the sensor as a breath acetone detector was studied by incorporating the sensor into a handheld prototype breathalyzer.

Effect of short-term ketogenic diet on end-tidal carbon dioxide

BACKGROUND & AIMS

Previous studies have shown that end-tidal carbon dioxide (EtCO₂) is lower with the presence of supraphysiological ketones as in the case of chronic ketogenic diet (KD) and diabetic ketoacidosis (DKA). This study aimed to determine changes in EtCO₂ upon short term KD.

METHODS

Healthy subjects were screened not to have conditions that exerts abnormal EtCO₂ nor contraindicated for KD. Subjects underwent seven days of KD while the EtCO2 and blood ketone (beta-hydroxybutyrate; β-OHB) parameters were sampled at day zero (t0) and seven (t7) of ketosis respectively. Statistically, the t-test and Pearson's coefficient were conducted to determine the changes and correlation of both parameters.

RESULTS

12 subjects completed the study. The mean score ± standard deviation (SD) for EtCO₂ were 35.08 ± 3.53 and 35.67 ± 3.31 mm Hg for t0 and t7 respectively. The mean score ±SD for β-OHB were 0.07 ± 0.08 and 0.87 ± 0.84 mmol/L for t0 and t7 respectively. There was no significant difference of EtCO₂ between the period of study (p > 0.05) but the β-OHB increased during t7 (p < 0.05). There was also no correlation between the parameters.

CONCLUSIONS

These findings suggest that EtCO₂ may not be utilized to determine short term nutritional ketosis.

Highly selective gas sensing enabled by filters

Portable and inexpensive gas sensors are essential for the next generation of non-invasive medical diagnostics, smart air quality monitoring & control, human search & rescue and food quality assessment to name a few of their immediate applications. Therein, analyte selectivity in complex gas mixtures like breath or indoor air remains the major challenge. Filters are an effective and versatile, though often unrecognized, route to overcome selectivity issues by exploiting additional properties of target analytes (e.g., molecular size and surface affinity) besides reactivity with the sensing material. This review provides a tutorial for the material engineering of sorption, size-selective and catalytic filters. Of specific interest are high surface area sorbents (e.g., activated carbon, silica gels and porous polymers) with tunable properties, microporous materials (e.g., zeolites and metal-organic frameworks) and heterogeneous catalysts, respectively. Emphasis is placed on material design for targeted gas separation, portable device integration and performance. Finally, research frontiers and opportunities for low-cost gas sensing systems in emerging applications are highlighted.

The Ketogenic Diet: Breath Acetone Sensing Technology

The ketogenic diet, while originally thought to treat epilepsy in children, is now used for weight loss due to increasing evidence indicating that fat is burned more rapidly when there is a low carbohydrate intake. This low carbohydrate intake can lead to elevated ketone levels in the blood and breath. Breath and blood ketones can be measured to gauge the level of ketosis and allow for adjustment of the diet to meet the user’s needs. Blood ketone levels have been historically used, but now breath acetone sensors are becoming more common due to less invasiveness and convenience. New technologies are being researched in the area of acetone sensors to capitalize on the rising popularity of the diet. Current breath acetone sensors come in the form of handheld breathalyzer devices. Technologies in development mostly consist of semiconductor metal oxides in different physio-chemical formations. These current devices and future technologies are investigated here with regard to utility and efficacy. Technologies currently in development do not have extensive testing of the selectivity of the sensors including the many compounds present in human breath. While some sensors have undergone human testing, the sample sizes are very small, and the testing was not extensive. Data regarding current devices is lacking and more research needs to be done to effectively evaluate current devices if they are to have a place as medical devices. Future technologies are very promising but are still in early development stages.

Effects of Reduced Carbohydrate Intake after Sprint Exercise on Breath Acetone Level

Assessment of breath acetone level may be an alternative procedure to evaluate change in fat metabolism. The purpose of the present study was to investigate the effect of insufficient carbohydrate (CHO) intake after sprint exercise on breath acetone level during post-exercise. Nine subjects conducted two trials, consisting of either reduced CHO trial (LOW trial) or normal CHO trial (NOR trial). In each trial, subjects visited to laboratory at 7:30 following an overnight fast to assess baseline breath acetone level. They commenced repeated sprint exercise from 17:00. After exercise, isoenergetic meals with different doses of CHO (LOW trial; 18% for CHO, 27% for protein, 55% for fat, NOR trial; 58% for CHO, 14% for protein, 28% for fat) were served. Breath acetone level was also monitored immediately before and after exercise, 1 h, 3 h, 4 h, and 15 h (on the following morning) after completing exercise. A significant higher breath acetone level was observed in LOW trial than in NOR trial 4 h after completion of exercise (NOR trial; 0.66 ppm, LOW trial; 0.9 ppm). However, breath acetone level did not differ on the following morning between two trials. Therefore, CHO intake following an exhaustive exercise affects breath acetone level during early phase of post-exercise.

Breath Acetone Measurement-Based Prediction of Exercise-Induced Energy and Substrate Expenditure

The purpose of our study was to validate a newly developed breath acetone (BrAce) analyzer, and to explore if BrAce could predict aerobic exercise-related substrate use. Six healthy men ran on a treadmill at 70% of maximal oxygen consumption (VO_2max) for 1 h after two days of a low-carbohydrate diet. BrAce and blood ketone (acetoacetate (ACAC), beta-hydroxybutyrate (BOHB)) levels were measured at baseline and at different time points of post-exercise. BrAce values were validated against blood ketones and respiratory exchange ratio (RER). Our results showed that BrAce was moderately correlated with BOHB (r = 0.68, p < 0.01), ACAC (r = 0.37, p < 0.01) and blood ketone (r = 0.60, p < 0.01), suggesting that BrAce reflect blood ketone levels, which increase when fat is oxidized. Furthermore, BrAce also negatively correlated with RER (r = 0.67, p < 0.01). In our multiple regression analyses, we found that when BMI and VO_2max were added to the prediction model in addition to BrAce, R² values increased up to 0.972 at rest and 0.917 at 1 h after exercise. In conclusion, BrAce level measurements of our BrAce analyzer reflect blood ketone levels and the device could potentially predict fat oxidation.

Breath acetone change during aerobic exercise is moderated by cardiorespiratory fitness

Exhaled breath acetone (BrAce) was investigated during and after submaximal aerobic exercise as a volatile biomarker for metabolic responsiveness in high and lower-fit individuals in a prospective cohort pilot-study. Twenty healthy adults (19-39 years) with different levels of cardiorespiratory fitness (VO_2peak), determined by spiroergometry, were recruited. BrAce was repeatedly measured by proton-transfer-reaction time-of-flight mass spectrometry (PTR-TOF-MS) during 40-55 min submaximal cycling exercise and a post-exercise period of 180 min. Activity of ketone and fat metabolism during and after exercise were assessed by indirect calorimetric calculation of fat oxidation rate and by measurement of venous β-hydroxybutyrate (βHB). Maximum BrAce ratios were significantly higher during exercise in the high-fit individuals compared to the lower-fit group (t-test; p= 0.03). Multivariate regression showed 0.4% (95%-CI = -0.2%-0.9%, p= 0.155) higher BrAce change during exercise for every ml kg^-1 min^-1 higher VO_2peak. Differences of BrAce ratios during exercise were similar to fat oxidation rate changes, but without association to respiratory minute volume. Furthermore, the high-fit group showed higher maximum BrAce increase rates (46% h^-1) in the late post-exercise phase compared to the lower-fit group (29% h^-1). As a result, high-fit young, healthy individuals have a higher increase in BrAce concentrations related to submaximal exercise than lower-fit subjects, indicating a stronger exercise-related activation of fat metabolism.

Characterization of a high-resolution breath acetone meter for ketosis monitoring

Background

The ketone bodies beta-hydroxybutyrate (BHB) and acetone are endogenous products of fatty acid metabolism. Although ketone levels can be monitored by measuring either blood BHB or breath acetone, determining the precise correlation between these two measurement methods has been challenging. The purpose of this study is to characterize the performance of a novel portable breath acetone meter (PBAM) developed by Readout, Inc., to compare single versus multiple daily ketone measurements, and to compare breath acetone (BrAce) and blood BHB measurements.

Methods

We conducted a 14-day prospective observational cohort study of 21 subjects attempting to follow either a low-carbohydrate/ketogenic or a standard diet. Subjects were asked to concurrently measure both blood BHB and BrAce five times per day and report the results using an online data entry system. We evaluated the utility of multiple daily measurements by calculating the coefficient of variation (CV) for each daily group of measurements. We calculated the correlation between coincident BrAce and blood BHB measurements using linear ordinary least squares regression analysis. We assessed the ability of the BrAce measurement to accurately predict blood BHB states using receiver operating characteristic (ROC) analysis. Finally, we calculated a daily ketone exposure (DKE) using the area under the curve (AUC) of a ketone concentration versus time graph and compared the DKE of BrAce and blood BHB using linear ordinary least squares regression.

Results

BrAce and blood BHB varied throughout the day by an average of 44% and 46%, respectively. The BrAce measurement accurately predicted whether blood BHB was greater than or less than the following thresholds: 0.3 mM (AUC = 0.898), 0.5 mM (AUC = 0.854), 1.0 mM (AUC = 0.887), and 1.5 mM (AUC = 0.935). Coincident BrAce and blood BHB measurements were moderately correlated with R² = 0.57 (P < 0.0001), similar to literature reported values. However, daily ketone exposures, or areas under the curve, for BrAce and blood BHB were highly correlated with R² = 0.80 (P < 0.0001).

Conclusions

The results validated the performance of the PBAM. The BrAce/BHB correlation was similar to literature values where BrAce was measured using highly accurate lab instruments. Additionally, BrAce measurements using the PBAM can be used to predict blood BHB states. The relatively high daily variability of ketone levels indicate that single blood or breath ketone measurements are often not sufficient to assess daily ketone exposure for most users. Finally, although single coincident blood and breath ketone measurements show only a moderate correlation, possibly due to the temporal lag between BrAce and blood BHB, daily ketone exposures for blood and breath are highly correlated.

Superior Acetone Selectivity in Gas Mixtures by Catalyst-Filtered Chemoresistive Sensors

Acetone is a toxic air pollutant and a key breath marker for non-invasively monitoring fat metabolism. Its routine detection in realistic gas mixtures (i.e., human breath and indoor air), however, is challenging, as low-cost acetone sensors suffer from insufficient selectivity. Here, a compact detector for acetone sensing is introduced, having unprecedented selectivity (>250) over the most challenging interferants (e.g., alcohols, aldehydes, aromatics, isoprene, ammonia, H2, and CO). That way, acetone is quantified with fast response (<1 min) down to, at least, 50 parts per billion (ppb) in gas mixtures with such interferants having up to two orders of magnitude higher concentration than acetone at realistic relative humidities (RH = 30-90%). The detector consists of a catalytic packed bed (30 mg) of flame-made Al2O3 nanoparticles (120 m2 g-1) decorated with Pt nanoclusters (average size 9 nm) and a highly sensitive chemo-resistive sensor made by flame aerosol deposition and in situ annealing of nanostructured Si-doped ε-WO3 (Si/WO3). Most importantly, the catalytic packed bed converts interferants continuously enabling highly selective acetone sensing even in the exhaled breath of a volunteer. The detector exhibits stable performance over, at least, 145 days at 90% RH, as validated by mass spectrometry.

Thickness Optimization of Highly Porous Flame-Aerosol Deposited WO3 Films for NO2 Sensing at ppb

Nitrogen dioxide (NO2) is a major air pollutant resulting in respiratory problems, from wheezing, coughing, to even asthma. Low-cost sensors based on WO3 nanoparticles are promising due to their distinct selectivity to detect NO2 at the ppb level. Here, we revealed that controlling the thickness of highly porous (97%) WO3 films between 0.5 and 12.3 μm altered the NO2 sensitivity by more than an order of magnitude. Therefore, films of WO3 nanoparticles (20 nm in diameter by N2 adsorption) with mixed γ- and ε-phase were deposited by single-step flame spray pyrolysis without affecting crystal size, phase composition, and film porosity. That way, sensitivity and selectivity effects were associated unambiguously to thickness, which was not possible yet with other sensor fabrication methods. At the optimum thickness (3.1 μm) and 125 °C, NO2 concentrations were detected down to 3 ppb at 50% relative humidity (RH), and outstanding NO2 selectivity to CO, methanol, ethanol, NH3 (all > 105), H2, CH4, acetone (all > 104), formaldehyde (>103), and H2S (835) was achieved. Such thickness-optimized and porous WO3 films have strong potential for integration into low-power devices for distributed NO2 air quality monitoring.

Advances in Mid-Infrared Spectroscopy-Based Sensing Techniques for Exhaled Breath Diagnostics

Human exhaled breath consists of more than 3000 volatile organic compounds, many of which are relevant biomarkers for various diseases. Although gas chromatography has been the gold standard for volatile organic compound (VOC) detection in exhaled breath, recent developments in mid-infrared (MIR) laser spectroscopy have led to the promise of compact point-of-care (POC) optical instruments enabling even single breath diagnostics. In this review, we discuss the evolution of MIR sensing technologies with a special focus on photoacoustic spectroscopy, and its application in exhaled breath biomarker detection. While mid-infrared point-of-care instrumentation promises high sensitivity and inherent molecular selectivity, the lack of standardization of the various techniques has to be overcome for translating these techniques into more widespread real-time clinical use.

Catalytic Filter for Continuous and Selective Ethanol Removal Prior to Gas Sensing

Ethanol is a major confounder in gas sensing because of its omnipresence in indoor air and breath from disinfectants or alcoholic beverages. In fact, most modern gas sensors (e.g., graphene, carbon nanotubes, or metal oxides) are sensitive to ethanol. This is challenging because ethanol is often present at higher concentrations than target analytes. Here, a simple and modular packed bed filter is presented that selectively and continuously removes ethanol (and other alcohols like 1-butanol, isopropanol, and methanol) over critical acetone, CH₄, H₂, toluene, and benzene at 30-90% relative humidity. This filter consists of catalytically active ZnO nanoparticles (d_BET = 55 nm) made by flame aerosol technology and annealing. Continuous oxidation of ethanol to CO₂ and H₂ was observed at filter temperatures above 260 °C while below that, unwanted acetaldehyde was formed. Most remarkably, ethanol concentrations up to 185 ppm were removed from exhaled breath in preliminary tests with an alcohol intoxicated volunteer, as confirmed by mass spectrometry. At the same time, almost 4 orders of magnitude lower (e.g., 0.025 ppm) acetone concentrations were preserved. This was superior to previous catalyst filters (e.g., CuO, SnO₂, and Fe₂O₃) with overlapping ethanol and acetone conversions and related to ZnO's surface basicity. The ZnO filter performance was stable (±2.5% conversion variability) for, at least, 21 days. Finally, when combined with a Si-doped WO₃ sensor, the filter effectively mitigated ethanol interference when sensing acetone without compromising the sensor's fast response and recovery times. Such catalytic filters can be combined readily with all gas sensors.

Rapid and Selective NH3 Sensing by Porous CuBr

Fast and selective detection of NH3 at parts-per-billion (ppb) concentrations with inexpensive and low-power sensors represents a long-standing challenge. Here, a room temperature, solid-state sensor is presented consisting of nanostructured porous (78%) CuBr films. These are prepared by flame-aerosol deposition of CuO onto sensor substrates followed by dry reduction and bromination. Each step is monitored in situ through the film resistance affording excellent process control. Such porous CuBr films feature an order of magnitude higher NH3 sensitivity and five times faster response times than conventional denser CuBr films. That way, rapid (within 2.2 min) sensing of even the lowest (e.g., 5 ppb) NH3 concentrations at 90% relative humidity is attained with outstanding selectivity (30-260) over typical confounders including ethanol, acetone, H2, CH4, isoprene, acetic acid, formaldehyde, methanol, and CO, superior to state-of-the-art sensors. This sensor is ideal for hand-held and battery-driven devices or integration into wearable electronics as it does not require heating. From a broader perspective, the process opens exciting new avenues to also explore other bromides and classes of semiconductors (e.g., sulfides, nitrides, carbides) currently not accessible by flame-aerosol technology.

Protocol for the Use of the Ketogenic Diet in Preclinical and Clinical Practice

Many age-related diseases are associated with metabolic abnormalities, and dietary interventions may have some benefit in alleviating symptoms or in delaying disease onset. Here, we review the commonly used best practices involved in applications of the ketogenic diet to facilitate its translation into clinical use. The findings reveal that better education of physicians is essential for applying the optimum diet and monitoring its effects in clinical practice. In addition, investigators should carefully consider potential confounding factors prior to commencing studies involving a ketogenic diet. Most importantly, current studies should improve their reporting on ketone levels as well as on the intake of both macro- and micronutrients. Finally, more detailed studies on the mechanism of action are necessary to help identify potential biomarkers for response prediction and monitoring, and to uncover new drug targets to aid the development of novel treatments.

Nanomaterial-based gas sensors used for breath diagnosis

Gas-sensing applications commonly use nanomaterials (NMs) because of their unique physicochemical properties, including a high surface-to-volume ratio, enormous number of active sites, controllable morphology, and potential for miniaturisation.

Highly selective detection of methanol over ethanol by a handheld gas sensor

Methanol poisoning causes blindness, organ failure or even death when recognized too late. Currently, there is no methanol detector for quick diagnosis by breath analysis or for screening of laced beverages. Typically, chemical sensors cannot distinguish methanol from the much higher ethanol background. Here, we present an inexpensive and handheld sensor for highly selective methanol detection. It consists of a separation column (Tenax) separating methanol from interferants like ethanol, acetone or hydrogen, as in gas chromatography, and a chemoresistive gas sensor (Pd-doped SnO2 nanoparticles) to quantify the methanol concentration. This way, methanol is measured within 2 min from 1 to 1000 ppm without interference of much higher ethanol levels (up to 62,000 ppm). As a proof-of-concept, we reliably measure methanol concentrations in spiked breath samples and liquor. This could enable the realization of highly selective sensors in emerging applications such as breath analysis or air quality monitoring.

Gas sensors using ordered macroporous oxide nanostructures

Detection and monitoring of harmful and toxic gases have gained increased interest in relation to worldwide environmental issues. Semiconducting metal oxide gas sensors have been considered promising for the facile remote detection of gases and vapors over the past decades. However, their sensing performance is still a challenge to meet the demands for practical applications where excellent sensitivity, selectivity, stability, and response/recovery rate are imperative. Therefore, sensing materials with novel architectures and fabrication processes have been pursued with a flurry of research activity. In particular, the preparation of ordered macroporous metal oxide nanostructures is regarded as an intriguing candidate wherein ordered aperture sizes in the range from 50 nm to 1.5 μm can increase the chemical diffusion rate and considerably strengthen the performance stability and repeatability. This review highlights the recent advances in the fabrication of ordered macroporous nanostructures with different dimensions and compositions, discusses the sensing behavior evolution governed by structural layouts, hierarchy, doping, and heterojunctions, as well as considering their general principles and future prospects. This would provide a clear scale for others to tune the sensing performance of porous materials in terms of specific components and structural designs.

Low-Carb and Ketogenic Diets in Type 1 and Type 2 Diabetes

Low-carb and ketogenic diets are popular among clinicians and patients, but the appropriateness of reducing carbohydrates intake in obese patients and in patients with diabetes is still debated. Studies in the literature are indeed controversial, possibly because these diets are generally poorly defined; this, together with the intrinsic complexity of dietary interventions, makes it difficult to compare results from different studies. Despite the evidence that reducing carbohydrates intake lowers body weight and, in patients with type 2 diabetes, improves glucose control, few data are available about sustainability, safety and efficacy in the long-term. In this review we explored the possible role of low-carb and ketogenic diets in the pathogenesis and management of type 2 diabetes and obesity. Furthermore, we also reviewed evidence of carbohydrates restriction in both pathogenesis of type 1 diabetes, through gut microbiota modification, and treatment of type 1 diabetes, addressing the legitimate concerns about the use of such diets in patients who are ketosis-prone and often have not completed their growth.

Breath Sensors for Health Monitoring

Breath sensors can revolutionize medical diagnostics by on-demand detection and monitoring of health parameters in a noninvasive and personalized fashion. Despite extensive research for more than two decades, however, only a few breath sensors have been translated into clinical practice. Actually, most never even left the scientific laboratories. Here, we describe key challenges that currently impede realization of breath sensors and highlight strategies to overcome them. Specifically, we start with breath marker selection (with emphasis on metabolic and inflammatory markers) and breath sampling. Next, the sensitivity, stability, and selectivity requirements for breath sensors are described. Concepts are elaborated to systematically address these requirements by material design (focusing on chemoresistive metal oxides), orthogonal arrays, and filters. Finally, aspects of portable device integration, user communication, and clinical applicability are discussed.

The Therapeutic Potential of Ketogenic Diet Throughout Life: Focus on Metabolic, Neurodevelopmental and Neurodegenerative Disorders

This chapter reviews the efficacy of the ketogenic diet in a variety of neurodegenerative, neurodevelopmental and metabolic conditions throughout different stages of life. It describes conditions affecting children, metabolic disorders in adults and disorderrs affecting the elderly. We have focused on application of the ketogenic diet in clinical studies and in preclinical models and discuss the benefits and negative aspects of the diet. Finally, we highlight the need for further research in this area with a view of discovering novel mechanistic targets of the ketogenic diet, as a means of maximising the potential benefits/risks ratio.