In week 4, we provided participants with a home-based blood ketone monitoring device (Precision Xtra® System; Abbott Diabetes Care, Alameda, California) and ketone strips. Participants used these supplies to measure β-hydroxybutyrate (BOHB) [35 (link)] in their blood. We taught participants how to use the monitoring device in person and asked them to measure their blood ketones before dinner, two to three times a week, on alternating days. Participants reported ketone measurements via an online survey on a weekly basis. The ketone monitoring devices store data, which staff checked at every weekly class (starting in week 5) and every monthly class (starting at month 4) to confirm self-reported measurements. We defined our target BOHB level as between 0.3 and 3.0 mmol/L. Although the level of carbohydrate restriction needed to achieve ≥0.3 BOHB varies between individuals, most individuals need to restrict to fewer than 50 g per day of non-fiber carbohydrate to achieve this blood ketone range [36 (link)]. For the current analyses, we used ketone data from the final five weeks of the 6-month study period.
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