This document summarizes research on metabolic therapies and their implications and applications. It discusses how starvation induces ketosis, protecting the brain during hypoglycemia. Ketone bodies can fuel the brain during fasting and may help manage neurological disorders. Cancer lacks metabolic flexibility and relies heavily on glucose, unlike healthy cells. Ketogenic diets and ketone supplements inhibit cancer growth in animal models by lowering glucose and increasing ketones. Combining a ketogenic diet with hyperbaric oxygen therapy shows promise for treating metastatic cancer and extending survival in mice. Future research aims to establish optimal methods for nutritional ketosis and test metabolic therapies in clinical trials.

1. Metabolic Therapies:
Implications and Practical Application
Dominic P. D’Agostino, PhD
Assistant Professor
Molecular Pharmacology and Physiology
Hyperbaric Biomedical Research Lab
University of South Florida Morsani College of Medicine

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

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

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

5.  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

6. 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

7. How Does Starvation
Change Brain Metabolism?

8. 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

9. 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

10. 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”

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

12. ↓ 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

13. 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.

14. 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
βHB
AcAc
Acetone
GABA/Glutamate
Ratio
2-3x Higher
TCA Cycle
Intermediates
2-5x Higher
Adenosine
Carnosine
Anserine
Glucose
Insulin
ROS
Oxidative
Stress

15. Neurological Disorders are Associated with
Impaired Brain Energy Metabolism
(FDG-PET Scan)
NORMAL BRAIN ALZHEIMER’S BRAIN
GLUT-3

16. Healthy Cells have
Metabolic Flexibility
Glucose
Normal Diet
(High Carb)
Ketones
Ketogenic Diet
(High Fat)

17. Cancer Lacks Metabolic Flexibility
Ketones
(Ketogenic Diet)
CancerGlucose
Normal Diet
(High Carb)
Cancer has very high rates of glucose metabolism

18. Cancer Imaging
(FDG-PET Scan)
Otto H. Warburg
Nobel Prize (1931) Medicine
First to describe Cancer
as a Metabolic Disease

19. • High glycemic diets increase risk of cancer
• Hyperglycemia = poor prognosis
• Blood glucose correlated to tumor growth
• Ketogenic diet: 4:1 fat (75-85% fat)
▫ Lowers glucose, Induces ketosis
▫ Suppresses insulin
▫ Reduces growth factors
Seyfried et al. British Journal of
Cancer (2003) 89, 1375 – 1382
High Glucose and Low Oxygen
Drive the Warburg Effect Gnagnarella, et al; 2008
Average PO2
30-60 mmHg 2-30 mmHg
**Causes chemo/radioresistance

20. Healthy Brain Cells Brain Cancer Cells
High Pressure Oxygen Damages Cancer Cells
Neuroscience;
31;159(3):1011-22, 2009

21. Effect of Ketones on Cancer Cells
Even in the presence of high glucose!
Poff et al. International Journal of Cancer: 2014 Oct. 1;135(7):1711-20.
NO Ketones Ketones (5 mM)
Ketones Increase
Cancer Cell Death
Ketones Reduce
Cancer Cell
Proliferation of

22. Summary (pancreatic cancer model)
1. Ketones (BHB and AcAc) inhibit cancer growth
2. Ketones increase cancer cell death (apoptosis)
3. Suppressed oncogenic growth signals (e.g. c-Myc)
4. KD reduced tumor growth and prevents cachexia

23. Can Nutritional Ketosis and
HBOT Prolong Survival from
Metastatic Cancer?
Metabolic Stress
Glucose
Insulin Oxygen
Ketones
Dr. Angela Poff

24. The VM-M3 Model of
Metastatic Cancer
Developed by Dr. Thomas Seyfried, Boston College
1. Similar to human metastatic cancer
2. Tumor cells glow (firefly gene)
3. Immunocompetent
Shelton, et. Al, 2009
IJC, Volume 126
Liver Metastasis
Methods: Treatment Groups
• Standard Diet
• Ketogenic Diet (KD)
• Ketone Ester (10%, KE)
• Hyperbaric Oxygen (HBOT):
▫ 2.5 ATA, 90 min, 3/week

25. Ketosis and HBOT dramatically slows
metastatic cancer and extends survival
Survival Time
Survival Time
21 Days Post Tumor Cell Transplant

26. How can we Implement
Metabolic Therapy?
Practical Guidelines
* Patients should be monitored by their own physician,
while working closely with the Registered Dietitian
• http://www.charliefoundation.org/
• www.ketogenic-diet-resource.com
• www.dietarytherapies.com

27. “Standard Diet” vs. “Ketogenic Diet”
 Ketogenic Diets differ from the Standard Diet in
macronutrient distribution.
 Carbohydrate intake decreases to <10% of kcals.
 Ketogenic diet is NOT a HIGH PROTEIN diet

28. Challenges To Initiation and Compliance
 Liver cancer and/or elevated liver enzymes
 Kidney stones and/or renal disease
 Pancreatitis
 Fat malabsorption issues
 Gallbladder obstruction or removal
 Medications
 Lack of support
 High cholesterol
 Food selection
 Weight loss

29. Metabolic management of cancer following changes
in plasma glucose & ketonesMetabolic Management of
Cancer
Ketones
Glucose
Seyfried et al. Carcinogenesis. 2014, Mar;35(3):515-27
Zuccoli G, at al.:Case Report. Nutrition and Metabolism (Lond). 2010 Apr 22;7:33.

30. CASE REPORT: UNPUBLISHED
• 10 y/o male
• 2009 – Ependymoma diagnosis
• 7 neurosurgeries
• 2X radiotherapy courses
• Resistant to treatment
02/2014 – started HBOT (100 sessions) with
carbohydrate restriction

31. Rt Parietal Lesion
100 HBOT sessions
+ Diet Therapy
Midline Lesions
Case Report: Unpublished
(5 Months)

32. Clinical Trials (Pilot Studies)

33. “Ketogenic Diet and Cancer “
Sept 1, 2014: 13 Results

34. Summary: Potential Therapeutic Implications
• Nutritional ketosis mimics the metabolic state of fasting
and decreases potential for seizures
• Non-toxic, cost-effective, readily implementable
• Possibly effective against aggressive, late-stage cancers
• KD and HBOT have potential synergy with standard care
• Neuroprotective against chemotherapy and radiation

35. Future Directions
• Determine best method to achieve the “metabolic zone”
• Determine dose for HBOT (2.5 ATA O2; 90 min; 3x/week))
• Evaluate in other cancer models (brain, breast, ovarian)
• Explore nontoxic metabolic drugs (e.g. Metformin)
• Test a phytonutrient cocktail (e.g. green tea, turmeric, etc)
• Clinical Trails
Questions?

36. 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

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

38. 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

39. Elevated rates of glycolysis and fermentation, excessive lactate production
– up to 200 X rate of normal cells
• Drives anabolic processes
• Acidifies microenvironment
• Most consistent cancer phenotype,
present in most, if not all, cancers
Anaerobic
Fermentation
~2 ATP
per glucose
Aerobic
Respiration
~38 ATP
per glucoseMitochondrion
+O2 +O2
Cancer Metabolism & The Warburg Effect
Healthy
Cell
Cancer
Cell

40. Tumor hypoxia promotes cancer
progression and the Warburg Effect
Regulation of cancer cell metabolism by hypoxia-inducible factor 1; Semenza, G.
HIF-1 implicated in every aspect of
cancer progression

41. Reported Positive Effects of
Nutritional Ketosis
• Weight loss (Atkins diet)
• Alzheimer’s disease Nutr Metabolism 2009 Aug 10;6:31
• Parkinson’s disease Curr Treat Options Neurol. 2008 Nov;10(6):410-9.
• Lou Gehrig’s disease (ALS) BMC Neurosci. 2006 Apr 3;7:29
• Traumatic brain injury J Neurotrauma. 2011 Sep;28(9):1813-25
• Cancer Nutr Metabolism . 2007 Feb 21;4:5.
• Seizures J Child Neurol. 2009 Aug;24(8):979–88
How can we exploit the neuroprotective
and metabolic effect of ketones?

42. Case Report (published)
Stage IV Glioblastoma
The Metabolic Zone
Zuccoli G, at al.: Case Report. Nutrition and
Metabolism (Lond). 2010 Apr 22;7:33.
Human Studies?

43. • The Warburg Effect is a
universal feature of
cancers and serves as
the basis for one of the
most important
diagnostic tools in
cancer treatment
• Radioactively-labeled
glucose quickly taken up
by cancer cells
Metastatic Melanoma
FDG-Glucose PET Scan

45. Oxygen Rebreather
100% O2
No Bubbles = Quiet