D-β-hydroxybutyrate (D-3HB), a monomer of microbial polyhydroxybutyrate (PHB), is also a natural ketone body produced during carbohydrate deprivation to provide energy to the body cells, heart, and brain. In recent years, increasing evidence demonstrates that D-3HB can induce pleiotropic effects on the human body which are highly beneficial for improving physical and metabolic health. Conventional ketogenic diet (KD) or exogenous ketone salts (KS) and esters (KE) have been used to increase serum D-3HB level. However, strict adaptation to the KD was often associated with poor patient compliance, while the ingestion of KS caused gastrointestinal distresses due to excessive consumption of minerals. As for ingestion of KE, subsequent degradation is required before releasing D-3HB for absorption, making these methods somewhat inferior. This review provides novel insights into a biologically synthesized D-3HB (D-3-hydroxybutyric acid) which can induce a faster increase in plasma D-3HB compared to the use of KD, KS, or KE. It also emphasizes on the most recent applications of D-3HB in different fields, including its use in improving exercise performance and in treating metabolic or age-related diseases. Ketones may become a fourth micro-nutrient that is necessary to the human body along with carbohydrates, proteins, and fats. Indeed, D-3HB being a small molecule with multiple signaling pathways within the body exhibits paramount importance in mitigating metabolic and age-related diseases. Nevertheless, specific dose-response relationships and safety margins of using D-3HB remain to be elucidated with more research. KEY POINTS: • D-3HB induces pleiotropic effects on physical and metabolic health. • Exogenous ketone supplements are more effective than ketogenic diet. • d-3HB as a ketone supplement has long-term healthy impact.© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.