Dominic D'agostino - Mastering Ketosis

1. Mastering Ketosis
(Metabolic Biohacking with Exogenous Ketones)
Dominic P. D’Agostino, PhD
Assistant Professor
Molecular Pharmacology and Physiology
University of South Florida Morsani College of Medicine

2. Metabolic Therapy
Research
CNS Oxygen Toxicity (seizures)
Neurodegenerative diseases
Metabolic diseases
Cancer
Performance and Resilience

4. Oxygen Rebreather
100% O2
No Bubbles = Quiet

5. CNS Oxygen Toxicity
Seizures
• Results from breathing oxygen at >2.5 ATA O2
DivingHyperbaric O2 Therapy

6. Why do these seizures occur and
how can we prevent them?

7.  Atomic Force Microscopy (AFM)
 Fluorescence Microscopy
 Laser Scanning Confocal Microscopy
 Electrophysiology
 Radio Telemetry (EEG)
 Adapted to hyperbaric chambers
Methods to Study CNS-OT
MitochondriaO2
ROS

8. Strategies to prevent
CNS O2 toxicity?
• Dive within Exposure Limits
• Antioxidants
• Antiepileptic Drugs (AEDs)
 Starvation
Delay in Seizure
(> 250%)
Bitterman, et al. Brain Res.
761, 146-50, 1997
36 hr
24 hr

9. How Does Starvation
Change Brain Metabolism?

10. Modified Diagram from: Oliver E. Owen. “Ketone Bodies as a Fuel for the Brain during
Starvation, ”Biochemistry And Molecular Biology Education Vol. 33, No. 4, 2005:246–251
Ketone Bodies Fuel the Brain
During Starvation
Ketones
-OHB
Glucose

11. Diagram from: Chapter 26 - Alternative Fuel Utilization by Brain, George F. Cahill, Jr. &
Thomas T. Aoki from Cerebral Metabolism and Neural Function (1980)
20IU of Insulin was administered
Subjects survived without brain damage or
coma
All 3 were asymptomatic
Ketones preserved brain
metabolism during severe
hypoglycemia
severe hypoglycemia!! (1-2 mmol/l)
Owen OE, Morgan AP, Kemp HG, Sullivan JM, Herrera MG, Cahill
GF Jr. Brain metabolism during fasting. J. Clin.Invest., 1967.
Ketosis Provides Resilience Against Hypoglycemia

12. Ketone
Bodies
Energy substrates from fatty acid oxidation
Ketosis Blood levels >0.5 mmol/L.
Nutritional
Ketosis
Dietary strategy to elevate blood ketones
Keto-
acidosis
Pathologically high ketones (>10 mmol/L)
Keto-
Adaptation
Physiological shift towards using fat and
ketones for fuel
Exogenous
Ketones
Synthetic or naturally derived substances to
artificially produce “instant ketosis”

13. Glucose
Insulin
Diet
Body Fat
Ketones
(energy!)
Difficult to sustain…

14. ↓ Glucose ↑ BHB
↑ Acetone
(Metron)
↑ AcAc
Rapid and Sustained Ketosis (15 minutes to >2-8 hrs)
D’Agostino, D.P., et.al . AJP Regulatory, Integrative and
Comparative Physiology, 2013 May 15;304(10):R829-36.
Kesl SL, et al. Methods of sustaining dietary
ketosis in Sprague-Dawley rats. FASEB Journal
(2014) vol. 28 no. 1 Supplement 643.5
50-100 mL dose

15. 575 %
Seizure
Resistance
Therapeutic Ketosis (KD)
Ketone
Ester
D’Agostino, D.P., et.al . AJP Regulatory, Integrative and
Comparative Physiology, 2013 May 15;304(10):R829-36.

16. Adapted from: Kristopher Bough and Jong Rho. Anticonvulsant
Mechanism of the Ketogenic Diet. Epilepsia, 48 (1): 43-58, 2007.
Elevated Ketones Lowered Glucose
Ketogenic Diet, Ketone Esters, MCT Oil
βHB
AcAc
Acetone
GABA/Glutamate
Ratio
2-3x Higher
TCA Cycle
Intermediates
2-5x Higher
Adenosine
Carnosine
Anserine
Glucose
Insulin
ROS
Oxidative
Stress

17. Does feeding ketones or ketone
precursors enhance performance?

18. 225
230
235
240
245
250
255
260
265
0-5min 5-10min 10-15min 15-20min 20-25min 25-30min
Ketones Placebo
Power(watts)
* *
**
*
* P < 0.02
* * P < 0.002
Ketone Esters Improve
Muscle Power Output
(Oxford University and NIH)
Power output in rowers

19. Do plasma ketones increase metabolic efficiency under aerobic
conditions?
Asked another way:
At a given rate of mechanical work (180 watts), would the
addition of exogenous ketones reduce oxygen
consumption?
Mini-experiment
• Keto-adapted subject completed two 20-minunte test
rides at ~60% of VO2 max (5 L/min) on a load
generator
• This amounted to 180 watts and approximately
3 L/min of VO2 (power at ~60% of FTP)
• Test set #1: mild nutritional ketosis
• Test set #2: Artificial Ketosis: 60 minutes following
ingestion of 15.6 gm BHB ketone salt,
• Measurements included plasma glucose and BHB
(every 5 minutes); VO2 and VCO2 (every 15 seconds);
HR (continuous)
Peter Attia, MD

20. Results – Test set #1 (mild nutritional ketosis alone)
Time Glucose
(mM)
BHB
(mM)
HR (avg per
segment)
VO2 (avg and total per
segment)
VCO2 (avg and total per
segment)
RQ
(avg)
0 5.7 0.7 -- -- -- 0.87
5 5.5 0.7 126 2,624 mL/min; 13.1 L 1,990 mL/min; 10.0 L 0.77
10 5.3 0.6 137 3,121 mL/min; 15.6 L 2,422 mL/min; 12.1 L 0.78
15 5.2 0.6 143 3,212 mL/min; 16.1 L 2,438 mL/min; 12.2 L 0.76
20 5.1 0.6 146 3,297 mL/min; 16.5 L 2,624 mL/min; 12.1 L 0.74
Total -- -- 138 3,066 mL/min; 61.3 L 2,321 mL/min; 46.4 L 0.76
Total O2 requirement: 61.3 L in 20 min; 48.0 L in last 15 min; 32.5 L in last 10 min
2,000
3,000
4,000
VO2
VCO2
0.70
0.85
0.80
0.75
RQ

21. Results – Test set #2 (mild nutritional ketosis + 100 ml BHB salt solution)
Time Glucose
(mM)
BHB
(mM)
HR (avg per
segment)
VO2 (avg and total per
segment)
VCO2 (avg and total per
segment)
RQ
(avg)
0 5.3 2.6 -- -- -- 0.91
5 4.6 2.2 127 2,521 mL/min; 12.6 L 1,977 mL/min; 9.9 L 0.80
10 5.2 1.9 140 2,992 mL/min; 15.0 L 2,401 mL/min; 12.0 L 0.80
15 4.7 1.7 143 3,014 mL/min; 15.1 L 2,400 mL/min; 12.0 L 0.80
20 4.3 1.7 145 3,038 mL/min; 15.2 L 2,390 mL/min; 12.0 L 0.79
Total -- -- 138 2,888 mL/min; 57.8 L 2,290 mL/min; 45.8 L 0.80
2,000
4,000
3,000
VCO2
VO2
0.85
0.90
0.80
0.75
RQ
Total O2 requirement: 57.8 L in 20 min; 45.2 L in last 15 min; 30.1 L in last 10 min

22. 2,800
2,900
3,000
3,100
3,200
3,300
3,400
3,500
VO2
VO2 (BHB)
Effect of Acute Ketosis on Oxygen Consumption at Fixed Power Output (180 Watts)
Segment Test 1 Test 2 (BHB) Difference
Last 5 min 3,298 mL/min 3,032 mL/min -8.8%
Last 10 min 3,255 mL/min 3,023 mL/min -7.7%
Last 15 min 3,210 mL/min 3,012 mL/min -6.6%
Full 20 min 3,065 mL/min 2,890 mL/min -6.0%

23. • Ketosis provides metabolic resilience
• Ketone supplementation circumvents need for
carb restriction to sustain ketosis
 Would performance effect be greater at higher
levels of ATP demand (e.g., 90% of VO2 max?)
 What are the long term side effects?
 What is the optimal dose and ketone formula?
 Do exogenous ketones produce better response
keto-adapted individuals?
Potential Insights and Questions
Questions?

24. the USF TAMPA TEAM
Al Bino
Dr. Raffaele Pilla
(alumnus)
Carol Landon
Shannon Kesl
Jacob
Sherwood
Dr. Chris Rogers
Dr. Rami Grossman
(alumnus)
Dr. Angela Poff Nate Ward
Geoff
Ciarlone Dr. Heather Held
Teryn
Gerhed
(fall 2014)
Dr. Csilla Ari
Dr. Dominic
D’Agostino
Dr. J.B. Dean
Dr. Helen McNally
Purdue University

25. Resources
 www.ketogenic-diet-resource.com
 www.dietarytherapies.com
 http://www.charliefoundation.org/
 http://www.rsg1foundation.com/
 http://www.nutritionchoices.ie/
 www.ketonutrition.org

26. References
 Poff A, Ari C, Seyfried TN, D’Agostino, DP. The Ketogenic Diet and Hyperbaric Oxygen Therapy
act Synergistically to Prolong Survival in Mice with Systemic Metastatic Cancer. PLoS ONE,
2013; 8 (6): e65522 DOI: 10.1371/journal.pone.0065522
 Seyfried TN, Poff A, D’Agostino, DP. Cancer as a Metabolic Disease: Implications for Novel
Therapeutics. Carcinogenesis. 2014, Mar;35(3):515-27. doi: a10.1093/carcin/bgt480..
 Poff A, Ari C, Seyfried TN, D’Agostino, DP. Ketone Supplementation Decreases Tumor Cell
Viability and Prolongs Survival of Mice with Metastatic Cancer. International Journal of Cancer:
IJC-13-2481, 2013.
 Seyfried TN, Marsh J, Mukherjee P, Zuccoli G, D’Agostino DP. Metabolic Therapy: A New
Paradigm for Managing Malignant Brain Cancer. Cancer Letters, 2014 Jul 25. pii: S0304-
3835(14)00352-8. doi: 10.1016/j.canlet.2014.07.015.
 D'Agostino DP, Olson JE, Dean JB. Acute hyperoxia increases lipid peroxidation and induces
plasma membrane blebbing in human U87 glioblastoma cells. Neuroscience; Mar
31;159(3):1011-22, 2009.
 Seyfried TN, Marsh J, Mukherjee P, Zuccoli G, D’Agostino DP. Could Metabolic Therapy Become
a Viable Alternative to the Standard of Care for Managing Glioblastoma? Oncology &
Hematology Review, 2014;10(1):13–20