Ketogenic Diet, Epigenetics, and Chronic Conditions with Dr. Dominic D’Agostino

It’s been exactly a hundred years since the ketogenic diet was developed, and yet we are still discovering its many benefits, including its positive effects on the epigenome. How fascinating is that? In this episode of New Frontiers, I’m thrilled to have renowned nutrigenomics researcher and fellow epigenetics aficionado Dr. Lucia Aronica interview one of the world’s top experts on the ketogenic diet – Dominic D’Agostino. Dom is also a neuroscientist, accomplished researcher, and associate professor of Molecular Pharmacology and Physiology at the University of Florida. In this episode, Dr. Aronica and Dr. D’Agostino discuss the therapeutic uses of the keto diet, including emerging applications in type 2 diabetes, anxiety, and anorexia, the neuroprotective and epigenetic regulatory effects of ketones, and why more is not necessarily better. It is an episode packed with the latest research and clinical pearls from these two experts – you wouldn’t want to miss it! If you don’t mind, please consider leaving a review on iTunes, or wherever you listen to New Frontiers! Every thumbs-up helps us reach more people! ~DrKF

Ketogenic Diet, Epigenetics, and Chronic Conditions with Dr. Dominic D’Agostino

with Special Guest Host Dr. Lucia Aronica

Can a ketogenic diet positively modulate epigenetics? And can exogenous ketones produce the same benefits? In this episode of New Frontiers, we have two amazing research scientists dive into the world of ketones and the ketogenic diet. Our host, Dr. Aronica, renowned Stanford epigeneticist, talks with Dominic D’Agostino, neuroscientist and associate professor at the University of South Florida, about the ketogenic diet’s therapeutic benefits beyond epilepsy. Dr. D’Agostino has published multiple papers on the science behind the keto diet, with a special focus on nutritional therapies for neurological disorders, cancer, and metabolic optimization. Together Dr. Aronica and Dr. D’Agostino discuss established and emerging applications of the ketogenic diet and how to mitigate potential side effects, the diet’s fasting-mimicking and metabolic effects, the neuroprotective and epigenetic mechanisms of ketones, and much more.

In this episode of New Frontiers, learn about:

Dr. Lucia Aronica: Welcome to New Frontiers in Functional Medicine, where we interview the best minds in functional medicine. And today is no exception. I have been a past guest on New Frontiers and I’m thrilled to now be sitting in the host seat. Our special guest today is Professor Dominic D’Agostino, better known as Dom, one of the world’s top experts in the ketogenic diet and fasting and how to use them for optimal health and performance. Dom is a beast when it comes to performing dead-lifts, when fasting and publishing papers on the science of keto.

And Dominic is associate professor at the University of South Florida Morsani College of Medicine and research scientist at the Institute for Human and Machine Cognition. His research focuses on developing nutritional and metabolic based therapies for neurological disorders, cancer and metabolic optimization, and is supported by the Office of Naval Research, Department of Defense, private organizations and nonprofit foundations. Dom, thanks for being with us today.

Dr. Dom D’Agostino: Thank you. It’s great to be on. Thanks for having me as a guest. I appreciate it.

Dr. Lucia Aronica: I have recently had the pleasure to work with you on a review on the ketogenic diet, and I’m excited to have the opportunity today to help you share your landmark research on the ketogenic diet with the wider audience of patients and clinicians interested in using the keto diet to optimize health and performance. So I am an Italian and I grew up eating a diet based on pasta, pizza and pane, which stands for bread in English. And when I hear D’Agostino, I think of Italy and pasta. So my first question to you is, did you also grow up in an Italian pasta family? And if so, how did you become interested in the keto diet and what a keto diet looks like?

Dr. Dom D’Agostino: Yeah. So I am Italian. And so we share that heritage. And about 100 years ago, my family came to United States from Northern Italy. And I grew up eating a lot of pasta and we had some big Sunday dinner with family. And bread and pasta was an integral part of our daily dinner and routine. So it was a bit of a shock to my parents when I started studying this low carb diet and actually started following it myself. And saw a lot of improvements in my own things that I had battled throughout the years like eczema, like skin conditions and things like that, rapidly cleared up when I went to low carb and then ultimately a ketogenic diet.

The ketogenic diet is very different in that it is a diet that is defined by an objective biomarker. And that biomarker is the presence of ketones. And when you’re in a state of ketosis, we call that hyperketonemia. So hyperketonemia can be the measurement of ketones in the blood as beta-hydroxybutyrate; in the urine, typically  acetoacetate; or in the breath as a breath acetone. So a ketogenic diet is by definition only ketogenic if you have an elevation of these ketone levels. And so many ketogenic diets that you hear in pop culture are really not ketogenic, because they’re not restricted in carbohydrates enough to produce a state of ketosis. So I think that’s one important consideration.

The ketogenic diet is a medical therapy. And that’s how I got interested in it. Before there was all this buzz about the ketogenic diet, I was studying seizures, tonic-clonic seizures that occur from breathing high concentrations of oxygen under hyperbaric pressure. So breathing oxygen with an increase in barometric pressure increases the concentration of oxygen. And the applications of hyperbaric oxygen therapy are limited by something called the central nervous system oxygen toxicity, which we’ll call seizures. It’s all also a limitation for Navy SEAL divers that use a closed-circuit rebreather.

So there’s no way to predict or prevent oxygen toxicity seizures. And the drugs that I was using were not working. And I discovered that the ketogenic diet is actually used when drugs fail for epilepsy. So I started writing grants. And after many attempts, I finally got a grant funded through the Department of Defense over 10 years ago. And we studied oxygen toxicity seizures and a mitigation strategy to prevent it, which is therapeutic ketosis. And that can be delivered with a ketogenic diet or ketone supplementation. So that’s how I got on this path. I studied nutrition as an undergraduate in college, and then I majored in physiology and neuroscience for my PhD, but was able to incorporate nutrition back into my research program.

Dr. Lucia Aronica: Thank you. And I love the way you framed the keto diet as a metabolic state, because I think this helps bring everyone into the conversation and explain that the keto diet is not yet another nutritional tribe; it is a unique metabolic state that is achieved in an environment of low insulin, where you produce ketone bodies as an alternative fuel and as unique energy metabolism, gene expression and epigenetics properties that really change our physiology. And this transformation is at the base of also the clinical application of a ketogenic diet.

And this is a concept that I also teach at Stanford. I have a certificate course on the keto diet. And I think I start there. And I start with also the common feature between a ketogenic diet and fasting. And I think as a matter of fact, a ketogenic diet was initially used as a fast-mimicking diet, probably was the first popular fast mimicking diet used for epilepsy. So without the proven clinical applications of a ketogenic diet and the more new emerging ones.

Dr. Dom D’Agostino: Yeah. I usually preface the ketogenic diet a description by talking about fasting, because in 1921, the ketogenic diet was more or less developed and tested at the Mayo Clinic. So we’re going back 100 years ago. The idea was to, do the very thing, to mimic the anti-seizure effect of fasting. And it was observed that if you feed very high fat, adequate protein enough to prevent protein malnutrition and essentially zero carbohydrates, the metabolic physiology mimics in many ways the physiology of fasting. That’s the suppression of the hormone insulin and the transition of the metabolism to burning primarily fat as an energy source. And when it comes to the applications of the ketogenic diet, being in that physiological state, changing your metabolism changes the neuropharmacology of your brain in ways that we’re just learning to understand it now. There’s a lot of research.

We’re doing a lot of research in this area as our many others to understand the anticonvulsant and neuroprotective effects of the ketogenic diet and the anti-cancer effects and the glucose lowering effects. So there’s many interesting effects. The ketogenic diet is the standard of care, we could say, for epilepsy in the context of drug refractory epilepsy or drug-resistant. I would like to see the ketogenic diet as more of a first line therapy for epilepsy in those that are willing to follow it, but most neurologists do not have a nutritionist that they can work with to implement it in the patient.

So usually when a patient fails one or more anti-epileptic drugs, they have the option of surgery and different medical devices, like a vagal nerve stimulator and things like that. But the ketogenic diet has the lowest potential for risk and also the highest efficacy of the last-ditch approach. And actually, when drugs fail, the ketogenic diet works. And we understand that it’s working through a mechanism that is probably independent of any anti-seizure drug, because it works when the drugs fail.

The general consensus is that the ketogenic diet works through many mechanisms in synergy. So that’s why it works for epilepsy, it works for neuro-metabolic diseases like glucose transporter type 1 deficiency syndrome, where there’s a deficiency in the GLUT1 transporter at the blood brain barrier. So the brain is starved of glucose. And when we elevate ketone levels, the ketones can then restore and preserve brain energy metabolism. And then that is a therapeutic modality that actually can keep children alive that have GLUT1 deficiency.

So we study, we have a GLUT1 syndrome mice that we study. Also, another application would be pyruvate dehydrogenase deficiency complex. So ketones can be metabolized independent of glucose or independent of insulin, and they don’t require pyruvate dehydrogenase. So it can basically bypass that rate limiting step for glucose oxidation, and then cross the cell membrane in the mitochondrial membrane to preserve and maintain a cellular metabolism. So it’s used for glucose pyruvate dehydrogenase deficiency syndrome and GLUT1 deficiency to restore energy metabolism.

And there are many other expanding applications. So Angelman syndrome, we published on this. It seems to be very therapeutic for that. We published a mouse model. And now we have a clinical trial that’s ongoing. We study Kabuki syndrome. So in the context of Kabuki syndrome, the ketones are having epigenetic effects that were first observed by Dr. Bjornsson at Johns Hopkins. We reached out to him and got his mouse model of Kabuki syndrome and we bred the mice up. And now my PhD student is looking at the ketone induced epigenetic regulation in this mouse model. And we’re looking at the various epigenetic signatures. And we’re looking at things like beta-hydroxybutyleration, which the beta hydroxybutyrate can directly interact with the histone. And we’re just starting out various assays to look at that.

But other things, including neurodegenerative diseases like Parkinson’s and Alzheimer’s and ALS. So we’ve studied these in the past and cancer too. So cancer is another. That’s a whole different topic. But there are probably more than 40 clinical trials right now looking at the ketogenic diet for cancer. 10 years ago, there were none. So now there’s 40. The ketogenic diet seems to further augment the therapeutic efficiency of drugs like pyruvate or the PI3 kinase inhibitors. So there’s a whole class of drugs called PI3 kinase inhibitors. They work remarkably well, but they tend to increase insulin. So in the context of insulin suppression with a ketogenic diet, then the drugs become efficacious, but only in the context of a ketogenic diet. So the data is indicating that they have good utility, but only when paired with the ketogenic diet.

And a new study came out on checkpoint inhibitors, including the PD-1. And the ketogenic diet seems to enhance these checkpoint inhibitors, which is very interesting. And we’re working with the Moffitt Cancer Center, and we’re doing preclinical animal model work at Moffitt, and we’re hoping to set up a clinical trial. So there are many different emerging applications of the ketogenic diet. And maybe a big one I didn’t even mention was Type II Diabetes and weight loss. So this is a whole other topic that we can discuss. The ketogenic diet works remarkably well for weight loss. And we’re just understanding the reasons why for that, and part of that is through calorie restriction, but there’s also probably some other mechanisms coming into play there.

Dr. Lucia Aronica: Thank you very much, Dominic. I will try to recap a little bit what you just said to summarize it for clinicians and patients. So basically, the ketogenic diet works through several different mechanisms. It’s not only about lowering insulin, so a metabolic mechanism, but ketones also act as a signaling molecule and have several physiological effects in our body. And that’s why they are such a versatile tool for different conditions that seem to have in common, either a defect in glucose utilization in the body or perhaps were where it’s beneficial to lower insulin or stabilize glucose in the blood. And this applies to so many genetic conditions, chronic conditions.

Of course, probably the more established application of the keto diet pertains those diseases that don’t have an alternative established therapy. So, for example, you mentioned that the keto diet is the first line therapy for some rare genetic conditions. But now there is more and mounting research on the effectiveness of a keto diet for common diseases. One of them Type II Diabetes and many, many other diseases. So that’s very interesting.

And so you also mentioned a couple of mechanisms with epigenetics. I just would like to say that it will be lovely to collaborate one day. We do have extensive epigenetic data, Whole Genome Bisulfite Sequencing on the DIETFITS Study that was not keto diet. But we do see was a low carb versus low fat. But there are striking differences in DNA methylation, which is a type of epigenetic modification between the low fat and the low carb arm. And we see, for example, up-regulations of fat metabolism genes in the low carb diet. And if you identify interesting targets in your Kabuki study, then we could see whether there is an overlap with our dataset. So-

Dr. Dom D’Agostino: That would be great. Yeah, I would love that. Yeah. My student is working on the assays now. And epigenetics, we do think there’s a big role. When you shift metabolism, a lot of epigenetic changes happen and it may not be due to the ketones, but things like different metabolites are probably epigenetic regulators, things like lactate and other metabolites. But ketones are very interesting for two reasons as epigenetic regulators, because when we go into a state of ketosis, there’s a proportionally high concentration. We’re talking about not nano molars, not micro molars, but we have millimolar concentrations of ketones in the blood, the beta hydroxybutyrate. And it’s a small molecule that permeates tissues into the mitochondria. So by virtue of just it being at such a high concentration, it can have pretty significant epigenetic regulation. And now we think it can directly interact with the histone, which we are delving into that.

I want to take just a quick step back on the mechanisms. And brain mechanisms, we know that it elevates GABA and decreases glutamate. So this is something that we saw on an Angelman syndrome model. And it does it through GAD65 and 67. So glutamic acid decarboxylase is an enzyme that we make GABA, gamma aminobutyric acid. We make that from glutamate. So what is happening in humans and in animals is that we are converting more of an excitatory amino acid transmitter into a brain stabilizing inhibitory amino acid transporter. So GABA through chloride mediated postsynaptic inhibition opens up a channel that hyper-polarizes the membrane potential of the neurons. And that prevents hyper-excitability. And you can control seizures by virtue of that.

But we also published a series of paper. And one just came out on adenosine. So we did metabolomics a long time ago, and we never published it. We still haven’t published that data, but there was so much data, we’re still looking at it. But the one thing that jumped out was adenosine was very, very high with exogenous ketones and ketogenic diet. And the adenosine is acting on the adenosine A1 receptor, which impacts membrane potential through a potassium channel. So these are mechanisms that we definitely know are working to be neuroprotective and brain stabilizing.

So GABA is up. And that’s why we think being in a state of ketosis has an antianxiety effect and can also impact behavior and also sleep in a positive way through adenosine and also through GABA. And we haven’t looked at dopamine and serotonin yet, but we do know that these two mechanisms, adenosine and GABA, we’ve reproduced it in different model systems. And they’re very important mechanisms linked to the anti-seizure effect, and probably the antianxiety and positive behavioral effects we’re seeing with the ketogenic diet too.

Dr. Lucia Aronica: That’s fascinating, how it is possible to use nutrition to bring our own body mechanisms of bringing homeostasis back in place, just manipulating this mechanism with nutrition. And so a question I have is about potential side effects of the keto diet and people who may be at risk when trying a ketogenic diet.

Dr. Dom D’Agostino: Yeah. So the ketogenic diet is not a therapy without risk. So there is a risk to doing the ketogenic diet. And that’s an important message to convey and it’s very important message to families that are using the ketogenic diet for their kids, for epilepsy and things like that. So some of the things that come up in the literature, if you do it, is it decreases the growth in children. So this was primarily due to the protein restriction. The American Epilepsy Society has a special interest group called SIG with dietary therapies, and I’ve chaired that in the past for several years. And this topic comes up. And there’s much discussion about it. But we know that we can be actually more liberal with protein. Instead of 8% protein, we can increase that to 10, 12 and even 15%, and in some cases use a modified Atkins diet with upwards of 20 to even 30% protein, and still maintain a state of ketosis.

There’s a science and an art to doing this. But a classical ketogenic diet will lower insulin so much, it lowers IGF-1, and this has resulted we think in some cases in children not achieving their terminal height. Although, I would like to add, that we work very close with the Charlie Foundation. So Jim Abrahams is a Hollywood producer and his son, Charlie, had drug-resistant epilepsy and he responded very well to the ketogenic diet. And a movie was made to highlight his therapy with Meryl Streep. So Meryl Streep did a movie about the ketogenic diet called First Do No Harm. And it was to highlight the story of Charlie.

So Charlie towers over me. He’s like 6’3” or 6’4”. He followed a low protein ketogenic diet and grew taller than both of his parents. So there are exceptions to the rule. So they make a big deal about how it’s going to stunt the growth of kids. But I’ve never seen really conclusive evidence of that. There is evidence of kidney stones. So in early versions of the ketogenic diet, when you put someone on the ketogenic diet, you restrict their fluids to about 80% of water restriction. I don’t know why they did this, but they saw that, the idea was that you would get higher ketones if you restrict fluids. And this was a common practice for many years in the 60s, 70s and 80s and 90s to restrict water. And then there was about a five times increase in kidney stones.

Although, now we know that you should be hydrating as much as possible, you should supplement with electrolytes, you tend to decrease a lot of potassium, sodium and calcium, the calcium from bones, you have a mild metabolic acidosis. And the pH of your urine becomes a little bit more acidic. And then that prevents solubilization of uric acid. And that creates something that the calcium can bind to, to creates stones. But if you supplement with potassium citrate, that neutralizes the urine in a way that can prevent the kidney stones. So electrolytes are really important and actually sodium. So we demonize sodium, but actually you need to get a lot of extra sodium when you initiate a ketogenic diet. And that will help alkalinize your body, offset the acidosis and actually prevent many of the keto flu symptoms.

So when we go on a ketogenic diet, you suppress the hormone insulin, and that has a diuretic effect, but it also has a natriuretic effect. A natriuretic effect means that your body dumps a lot of sodium. And with sodium, your fluid levels will drop and you’ll become hypovolemic. So there’ll be contraction of the plasma volume, and that will decrease brain blood flow. It can, and you can get a headache and then circulation, you get orthostatic hypotension and things like that. So it’s really important to increase your sodium, to increase your electrolytes and increase your fluid when you initiate a ketogenic diet. And that can mitigate many of the side effects. So there’s fat intolerance. There’s, the clinicians say vomiting, nausea, diarrhea, fat intolerance, constipation, but all these things are typically the first week or two during the initiation of the ketogenic diet. And then people adapt to the high fat intake over time.

But the long-term ones that come up are the kidney stones, the growth in kids, stunted growth, but we think with higher protein, that’s a non-issue. And the biggest issue that comes up is changes in lipid profile. So the LDL cholesterol, and triglycerides, usually in kids, sometimes they increase or decrease depending on the type of ketogenic diet. But the biggest discussion right now with ketogenic diets is an elevation in LDL cholesterol. And we do not know what this means in the context of a ketogenic diet, but it’s being studied and it’s being investigated. And you need an NMR lipid profile to understand the different lipid sub-fractions to understand if it’s atherogenic or benign. So that’s a quick overview of some of the potential side effects and concerns that some doctors may have with the ketogenic diet.

Dr. Lucia Aronica: Thank you for providing this wonderful summary, Dom. I think the key concept here is that the ketogenic diet is a different metabolic state. And in this context, traditional risk factors such as LDL might have a different effect on our physiology and might be not so concerning. And that’s why we need more in-depth testing in these cases. We also see in our studies. We’re now running a small pilot with a traditional well-formulated ketogenic diet versus a more Mediterranean low carb diet.

And we see the same mild elevation in LDL, but we didn’t perform in-depth LDL testing. But at the same time, we see a beneficial, greater decrease of triglycerides on the keto diet, which triglycerides are also very important, actually, in affecting how bad or good an LDL particle is. And so when we see that triglycerides go down, this is a good indication that the LDL might be of a better kind. But anyway, context is key.

Dr. Dom D’Agostino: Very important. Yeah. So LDL particle size, particle number, Lp(a), your insulin level is very important, your glycemic control, the hs-C-reactive protein, your inflammation markers. You have to look at it in the context of other biomarkers, which is very… You cannot. Even the statin, even the literature on the drugs to lower LDL, basically say not to prescribe this drug in the context of it as a single biomarker. You have to view it in the context of other biomarkers.

Dr. Lucia Aronica: Yes. And you mentioned the need of perhaps supplementing with electrolytes in the early phase of a keto diet. Do you think there is need for other supplement nutrients that may be lacking on a keto diet?

Dr. Dom D’Agostino: Yeah, I do. After looking at a lot of blood work, especially in kids that are drinking ketogenic shakes like KetoCal, these medical shakes are mostly like dairy fats, and I’m a big advocate of formulating a ketogenic diet from real food, from whole food, I think has many advantages. One is that it can prevent nutrient deficiencies. So the things that in the literature are selenium, there’s a couple cases. There’s some literature to suggest that the ketogenic diet can deplete selenium, but if you’re eating things like fish and animal products and eggs and things like that, I do not think selenium’s… I’ve never seen my selenium level low. And I haven’t seen it; only in people that use these medical ketogenic diets that are drinking these shakes and other, just a high dairy fat. I think dairy can be okay, but it has to be a bit more of a balanced approach.

Carnitine. So carnitine pretty much always shows up low in kids. So that is an indication that your body is burning so much fat. You are transporting so much fat into the mitochondria and your body is a fat burning machine. And one of the carriers for fat is carnitine. And it tends to be pretty low in kids. And now they’ll have fatigue and brain fog and things like that. And we supplement carnitine tartrate, I think. And there’s a couple different forms of carnitine. There’s acetyl-L-carnitine, and that can cross the blood brain barrier. I supplement with that. But carnitine and selenium. And then I’m a big believer in electrolytes, like magnesium, potassium, sodium and calcium too. Calcium’s a pretty strong buffer and that can help offset the mild metabolic acidosis that does occur with a ketogenic diet.

So you can take a ketone supplement and beta hydroxybutyrate can be ionically bound to an electrolyte, like sodium beta-hydroxybutyrate, sodium or potassium beta-hydroxybutyrate. So the ketone salts can elevate ketones and also give electrolytes. There’s an electrolyte product called LMNT that Robb Wolf makes. It’s L-M-N-T. I like that. I use that. Or you can just put a lot of salt on your salad and take a magnesium supplement, which I do before bed. It has a relaxing effect. So the three things that I see on blood work is low magnesium, sometimes low sodium, low carnitine and low selenium. So these are things I tend to tell people to supplement.

Dr. Lucia Aronica: Great. Thank you. And you mentioned just now exogenous ketone supplements. So while on nutritional ketosis, we produce endogenously ketones just in this metabolic state. With exogenous ketones, we can also take them as a supplement perhaps to boost ketosis. For which therapeutic applications do you see that exogenous ketones might be useful?

Dr. Dom D’Agostino: Yeah. A lot of the research that I do, the original research that got funded by the Department of Defense, they did not like the idea of a ketogenic diet, because it was high in fat, and it was going to be difficult to implement. If you consume an exogenous ketone, you can get into fasting levels of ketosis within 30 minutes, whereas a diet typically takes about 48 to 72 hours to get your ketones high. So the idea then that we experimentally tested and then we’ve published on this is using ketone esters, and then later we formulated a balanced electrolyte preparation of ketones combined with a ketogenic fat called medium chain triglycerides or MCT oil.

And the ketone esters continue to taste horrible, but we’re using them for different clinical applications. And they have their place. I consume them occasionally when I’m testing things, but I don’t like to consume them. Even though the majority of my work has been done on ketone esters, I actually prefer ketone salts because they taste good, they give electrolytes. And if you combine a ketones salt with MCT, you are delivering exogenous ketones and then stimulating your own ketone production by delivering fat. MCT goes to the liver by hepatic portal circulation and not through chylomicrons, like long-chain fats. So you get a bolus of fat to the liver, and then it delays gastric absorption, but also extends the pharmacokinetic profile of the ketones over time.

So in the past, I was thinking that the higher the ketones the better, and I could achieve that with the ketones esters that we’re using in the lab. But now I have a concern actually, that if your ketones levels get too high, we’ve seen animals actually die from ketosis with ketone esters. So I don’t talk about that much, because we want to put keto esters in a good light. But we have seen that if you administer ketones with a gavage or IV high enough, you can produce ketoacidosis and that could be toxic.

So the potential for getting into keto acidosis with a ketone salt or MCT is not going to happen because it’s self-limiting. You’ll have GI distress before you get into high levels of ketosis. So just getting ketones elevated an extra one to two millimolar can provide a level of 10 to 20% available energy to the brain. So we know this, that if you elevate one millimolar would be equivalent to a boost in available brain energy of 10%. And then you don’t really see physiological changes in blood pH. So we measure things like blood pH and liver function, things like that overtime.

Whenever we get ketones into that one to two millimolar range with exogenous ketones, we never see anything negative happen. But if we give a very powerful ketone ester, that may be important for things like glucose transporter or status epilepticus or cancer or other things. But I personally experimented with high levels and felt sick. So when I get my levels to like three, four, five, but if I keep my levels at one to two, I can feel an energy boost and I don’t have any negative effects.

So for the average person listening to this, I think ketone esters, a low dose could be okay, but they taste horrible and they’re expensive. So the ketone salts are probably a better option for daily use. And also you can get ketones high enough to get signaling effects. So some of the signaling effects we’re looking at are suppression of the NLRP3 inflammasome, which we’ve published on. We formulated a diet, our colleagues at Yale implemented it and saw that the NLRP3 inflammasome could be suppressed by the two different enantiomers of beta-hydroxybutyrate. It comes as is a mirror image of the two. So you have D-beta-hydroxybutyrate and L. And both of them are metabolized in the body, and they both have epigenetic effects. The D-beta-hydroxybutyrate may have a more favorable energetic profile, whereas the L beta hydroxybutyrate gets metabolized slower, the concentration gets higher in tissues, and it may have a more stronger signaling effect.

So from an epigenetic perspective, but also from suppression of the NLRP3 inflammasome, just by virtue as it gets metabolized much slower than the D enantiomer. So now we’re looking at the two different enantiomers of beta-hydroxybutyrate, and seeing if there’s a functional difference, and if there’s a difference in signaling and things like that. So you can elevate ketones with MCT oil. I’m a big fan of MCT oil if you can tolerate it, ketone electrolyte salts or the different ketone esters that are on the market.

Dr. Lucia Aronica: Great, thank you for providing such a detailed explanation. And so basically the applications for these exogenous ketone supplements could be enhancement of energy and epigenetic and physiological effects of ketones for those who are already following the keto diet or even reaching higher state of ketosis in the therapeutic range for some therapeutic applications such as, for example, cancer, right?

Dr. Dom D’Agostino: Or without any. So this was a little bit hard for me to accept, but when we studied it, we proved it to be the case. So the animals that we studied were on a high carbohydrate diet. And we administered an exogenous ketone supplement. That put them into a state of ketosis higher than we could ever achieve with a ketogenic diet. And then that had very profound anti-seizure effects if it was administered 30 minutes prior to putting the animal in five atmospheres of oxygen, which causes seizure within five minutes.

So this idea is that you can give the brain a ketone supplement like a drug and it completely changes your metabolism within the 30 minutes, and its elevates its ketones, and the ketone itself has anti-seizure effects and changes metabolism, which surprised me, because I really thought that your system would have to adapt over time. But I talked to different investigators, the late, Dr. Richard Veatch, he was a student of Hans Krebs of the Krebs cycle. So he actually developed ketone esters back in the 90s. And he had projects funded by DARPA for war fighter performance and things like that.

So he convinced me that you don’t need to follow a ketogenic diet that you can do a ketone ester. But then again, he had patents on it and he had a vested interest in it. So I was a little bit skeptical. So I was focused on the diet. And then I tested different ketone esters and they didn’t work. The ketone ester that prevented seizures was a particular ketone ester that elevated beta-hydroxybutyrate and acetyl acetate in a one-to-one ratio. So there’s a redox effect in the liver and also in the blood. And it appears that for reasons that we’re still trying to understand that you need to keep the ratio beta-hydroxybutyrate to acetyl acetate to get anti-seizure effects. So we’ve seen this in many model systems, and we’re looking at that now.

But this idea is that there are people that are unwilling or unable to follow a ketogenic diet, because of, you have situations like autism or Angelman syndrome where the kids are very picky about their food, some people have an intolerance to fat and they can’t follow the macro-nutrient profile to produce and sustain ketosis. So we see this. And also with cancer patients, just getting enough calories in them is difficult to do. So you want them to eat whatever they can eat, although you want to restrict sugar and carbohydrates, because you want to improve different metabolic markers. But a ketone supplement can help to reduce glucose. So it has a very powerful glucose lowering effect. And I can go into discussing why that happens.

But raising ketones has anti-cancer effects, it has anti-inflammatory effects, has neuroprotective effects. So my strategy would be to do a ketogenic diet and then use an exogenous ketone as an adjuvant to further enhance the therapeutic efficacy of the ketogenic diet. But in the context of people who will not follow the ketogenic diet, a ketone supplement seems to be efficacious under some conditions. And there’s at least 40 clinical trials right now on clinicaltrials.gov not looking at ketogenic diets, looking at ketone supplements, which five years ago, there was none. So now there’s a lot of human clinical trials being done right now.

Dr. Lucia Aronica: Wow, that’s fascinating. I was concerned that perhaps ketones and glucose are conflicting fuels, and so having both in the system would confuse the body potentially. But it seems that clinically, it’s fascinating. Biology is so complex and never ends surprising me really.

Dr. Dom D’Agostino: Yeah. It is interesting that you bring that up. It’s like eating fat and carbs together, you have fat and glucose elevated and your body knows what to do with it. So it’s just another fuel for the body. And there are counterregulatory mechanisms when you consume exogenous ketones that happen. And one is that if you consume exogenous ketones and you get your levels above two millimolar, you can measure an increase in insulin. So that’s actually how we regulate physiologically our state of ketosis. We go on a ketogenic diet, we burn a high level of fat in the liver, and then we produce ketones. The ketones get into the blood and they will… Through ketone urea, you eliminate some ketones, but you get ketone-induced increase in insulin. And an elevation of insulin will then feed back to the liver and reduce fatty acid oxidation in the liver. It’s the Acetyl-CoA coming from beta-oxidation of fatty acids in the liver that produced the ketones.

So a little bit of increase in insulin will turn it down. So if you consume a lot of exogenous ketones, that will shut down your own ketone production, but you have to consume enough that gets your level, at least from the biological assay we use, that gets your level above a delta of two millimolar, which is easy to achieve with a ketone ester. But with a ketone salt, that’s the limits about how you can go. So ketone salts generally don’t increase insulin, which is probably good if you’re trying to burn fat. So you have that scenario.

But if you consume ketones, it lowers your blood glucose for a number of reasons. I think I thought it was doing it because it was just releasing insulin. You consume ketones, you measure your glucose or you wear… I wear a continuous glucose monitor on the back of my arm here. So if I consume ketones, the glucose goes down, I was just figuring the ketones were causing a release of insulin, and then you have glucose disposal with the insulin. But what’s happening is there’s probably a decrease in things like glucagon, maybe a small increase in insulin, but there’s a decrease in gluconeogenesis. And there was a paper just published last week that the availability of alanine goes down. So gluconeogenic amino acids go down.

So ketones have an anti-catabolic effect. So their biological function from an evolutionary perspective, when we get into a state of ketosis after not eating for a couple days is that they provide energy to the heart and the brain to prevent the catabolism of gluconeogenic amino acids in the skeletal muscle. So ketones protect your skeletal muscle from being degraded so you don’t have to break down your skeletal muscle to get glucose. So, right. So ketones will largely replace glucose as a primary fuel. And then in that way, they are protein sparing, and we say, they’re anti-catabolic.

So there’s good data to show that there’s a very large reduction in alanine. So alanine goes down, lactate goes down suggesting that glycolysis goes down. So it’s interesting. The glucose lowering effect of ketones may be the most important function that they have. And it was something that I was a little bit hesitant to report, because I was thinking that hypoglycemia is bad, but if you elevate ketones, while glucose goes down, you’re asymptomatic for hypoglycemia, because the ketones are basically providing and giving your brain enough energy.

And there was a study that was done by Oliver Owen and George Cahill at Harvard Medical School back in 1967, where they fasted subjects for 60 days and they injected, or for 40 days rather, they injected insulin into subjects that were fasted and lowered their blood glucose down to 20 milligrams per deciliter. And they were asymptomatic for hypoglycemia, because their ketones were so high. So if they were on a standard American diet and you inject someone with insulin that’s normal and healthy and put them into hypoglycemia, you would put them into a coma and they would die. But because they were fasting and their ketones were five to seven millimolar, they were completely asymptomatic for hypoglycemia.

So that’s actually a really important observation is that we could give ketones therapeutically for things like hypoglycemic shock, for insulin shock, and if you give them to type II diabetics, you could reverse insulin resistance, I think, and lower insulin and increase or reduce your glucose levels too over time. So that’s a potential application that they’re studying now. We’re doing it in animals, but there’s human clinical trials now.

Dr. Lucia Aronica: Yeah. That’s great that you brought that study by Cahill and others up, because that’s one, I think, of the foundational studies to really understand the physiology of fasting and ketosis and why ketones can really bypass our brain’s need for glucose. And also thanks for helping me also better contextualize the use of exogenous ketones. I was aware of these feedback mechanisms that endogenous ketones can trigger in our body so that they lower our own endogenous production, but it seems as you described, that basically there is a built-in feedback already in our body because ketosis is such a fundamental mechanism of biology.

There is already a built-in system that when we elevate ketones to a certain level, that automatically this stimulates a little insulin and reduces gluconeogenesis. And so glucose in this way, also inhibits the accumulation of ketones to a pathologic level. And basically by using exogenous ketones, even when there is some insulin, we are playing safe, because we already have this built-in feedback mechanism in place. And so once we understand physiology, this makes us feel more safe and empowered also to trick the system therapeutically with new approaches. So you mentioned that there are several clinical trials now using exogenous ketones. And so what are the other human clinical trials being done now?

Dr. Dom D’Agostino: Yeah, there are many. Actually I gave a talk at a NIH workshop on this. Type II diabetes, there’s one on type 1 diabetes, believe it or not, there are many with exercise. So there’s the Institute for Human & Machine Cognition, which I’m an affiliate of. They’re doing some things with exercise. Alzheimer’s disease, Parkinson’s disease, a number of neurodegenerative diseases. Some of the more interesting ones are for behavioral effects too. So there’s a couple with behavioral disorders. There’s one, I think for anorexia. And there’s one for alcohol withdrawal syndrome. So using exogenous ketones. So the ketones can help to stabilize the homeostasis in the brain, we could say metabolic homeostasis in the brain.

And there were a number of people emailing me that they were able to get off of alcohol, because they’re using exogenous ketones. And so I see people are… There’s two clinical trials on alcohol withdrawal syndrome. So using ketones for that. And one of our ketone esters is actually 1,3-butanediol acetoacetate diester. 1,3-butanediol is a di-alcohol or glycol, and it’s actually metabolized through the alcohol dehydrogenase pathway in the liver. And when you drink a lot of it, you feel buzzed like you’re drunk more or less.

So I think if you were to consume a ketone ester while you’re getting off of alcohol, it would give you the buzz, but you’re not getting a lot of the negative toxic consequences of alcohol. So I’m okay, being from an Italian family, even as a kid, I would have wine. I think alcohol is okay. Alcoholism is a big problem in the US, but it’s so interesting to see all these emerging applications for weight loss, for quite a few with type II diabetes and many different brain disorders. And what I’m describing to you is not the ketogenic diet, these are actually ketones supplement studies.

So I had went a couple years without looking at clinicaltrials.gov. So it was a very interesting to see all these clinical trials popping up. It’ll be very interesting to see what kind of positive, neutral or negative effects. So that’s not to say that it’s going to be effective, but at least people are studying that. And with the ketogenic diet, we’re doing a study right now in partnership with Levels Health, which makes the continuous glucose monitor. The name of that study is “Using Continuous Glucose Monitor for Metabolic Optimization”.

So basically we have subjects that are part of a 12-week wellness program. And with my colleague, Dr. Allison Hull, who would be great on your show. She’s a medical doctor. She graduated from university of South Florida and has a medical clinic at the Florida Medical Institute. And we have a study where subjects wear a continuous glucose monitor, we do blood work, we are looking at anxiety, we’re looking at depression, we’re looking at sleep, we’re using Cronometer to measure all the macronutrients. And I have medical students helping with it. Some of my undergrads and PhD students are helping with it. We did 30 subjects, but these are nondiabetic subjects. So they’re non-diabetic subjects wearing a continuous glucose monitor as a behavioral tool to modify behavior, to enhance compliance and adherence to a low carbohydrate diet, a ketogenic diet.

And the results are very impressive, but they so far with 30 subjects, but we’re underpowered. So we need actually to increase our sample size, another 50 subjects. So we are pausing, analyzing the data for the first cohort. And then we’re starting to recruit another 30 to 50 subjects so we can get statistical power, but we’re seeing some of the most robust data is actually on reduction in anxiety, a decrease in depression and an improvement in sleep and a decrease in fatty liver. So all these things, even with a relatively small cohort, we’re seeing some interesting effects.

Some of the metabolic markers, they’re not changing that much, because the subjects are already fairly metabolically healthy. They don’t have Type II Diabetes. You have to do blood work to show you don’t have any underlying conditions or Type II Diabetes before even entering into this clinical trial, but that’s ongoing right now. And I’ll be excited to present some of the data at the Metabolic Health Summit, which is a conference that we host. And you are speaking at that. We are very excited to have you there.

Dr. Lucia Aronica: Thanks for invitation. I’m excited to be with you and mingle with the other scientists in the field.

Dr. Dom D’Agostino: Yeah. We are super excited to have you speaking on expanding the idea that metabolism can impact epigenetics, is near and dear to our hearts, because it’s a PhD project of my students. So I’ve encouraged my student to… She’s a little bit shy, but to come up to you and talk to you about that.

Dr. Lucia Aronica: Great. That would be a great start of hopefully long collaboration.

Dr. Dom D’Agostino: Yeah, for sure.

Dr. Lucia Aronica: Yeah. And if you need another subject for your study, count me in. Although, I assume that, if somebody’s already know knowledgeable about the keto diet and already compliant, because he or she has already embraced the keto diet as a lifestyle, then you wouldn’t see a lot of behavior differences when using a CGM, which by the way, I think is a powerful tool that can teach people a lot about their physiology and response to food. And I think this can potentially revolutionize healthcare by putting really health in the hands of people.

And so it’s a great study. I have some of my students that are clinicians using CGM also in Italy. And I’m sure if you need collaboration with them. I actually are looking for collaborators who wants to analyze their data. They have clinics. And so yeah, lots of potential future collaborations.

Dr. Dom D’Agostino: Yeah. CGM is super insightful and we’re seeing that it’s an important behavioral tool. We have subjects that don’t wear the CGM that are following low carb diet and all the different parameters associated with a wellness program. There’s a lot of education and training that Dr. Allison Hull does at her clinic. And then a group of people who do the same exact thing, but they wear a CGM. And the difference between the CGM, there’s no difference in a lot of different things. And there’s just positive effects following low carb in both groups. But with the CGM, we’re actually seeing some benefits in regards to compliance, glycemic variability, I think depression and sleep and anxiety. So these things tend to improve, not so much sure why those things are improving, but that’s some of the data that’s jumping out now. I can’t talk too much about it, because we’re just halfway through the clinical trial.

But I really do think that if you can see your glycemic response to a meal, you know not to eat that particular food if it spikes your glucose or eat less of that food. And it trains you to understand your metabolism and physiology in a way that gives you an advantage. And I think people like to improve upon it every day. We’re using the Levels app and it gives you a score. So the people following it are trying to improve their score every day. And I think that becomes a powerful behavioral tool. You’re basically gamifying the nutrition and you’re learning. And I think that’s an important component.

Dr. Lucia Aronica: Yeah, no, that’s wonderful. And thank you very much, Dominic. I would just like to end with one last question about what is your typical diet and your top three lifestyle hacks?

Dr. Dom D’Agostino: Yeah, my diet. Today, I had six eggs and three yolks. And I gave the other three yolks to my dogs. But then I had just six eggs with three yolks and some cheese for breakfast. And I use a bar called the Keto Brick. And basically, it’s the only ketogenic bar that I know of that actually has the macro-nutrient profile. So it’s Keto Brick. And it’s 1,000 calories per bar. So I had that and I had one can of mackerel today. And in an hour or two, I’ll go home and I’ll eat dinner. And it’ll be usually a salad, chicken, fish or beef and a salad and a lot of olive oil. And that’s a typical day for me.

And then three lifestyle hacks, I think you had mentioned. I would say the best hack you could do is having… Well, the first thing I do is I wake up and I go out into the sun. So I let my dogs out and I run to our cow gate, our pasture, and I’m running east right into the sun. And so that sun just wakes me up. It’s like my coffee, even before I have my coffee. So early sun, getting sun early in the morning helps to synchronize our circadian biology. I think that it resets, gets our neurotransmitters, our dopamine, our serotonin and everything going. And that exercise too could be important. Although if I exercise very intensely in the beginning, in the early day, I’m tired later on. So I just do some light walking or something in the morning.

Having a dog is another, the second one. It puts me into a routine. We walk the dog twice a day. So it gets me to do some low level physical activity. And then people who have dogs I think have better immune systems. So they’re always licking my face and just hanging all over me. Their microbiome is probably changing me and actually enhancing my immune system. So I’ve never got a cold or a flu in 10 years, probably because of dogs.

And lately, we purchased a house a few years ago. And after three years, I finally fixed the spa, the hot tub. And it’s an old concrete structure in our house. And I finally got a heater on it so I can heat it up to like 105, and then I go in that and I jump into the cold pool. And I’ll do that two or three times each night. And I think that has really helped me. So yeah, sunlight. I think the dog is like your ultimate hack, having a pet. And then I’ve been doing some cold exposure and heat exposure and experimenting with that.

Dr. Lucia Aronica: Thank you. Thank you very much. That’s wonderful, Dominic. You are truly not only a scientist, but also a wonderful human being with lots of personal scheme in the game of health optimization. So thank you very much for being with us.

Dr. Dom D’Agostino: Thank you for having me. I appreciate being on and all the educational content you put out there. Educational outreach is so important. And we’re super excited to have you part of the Metabolic Health Summit too. So I think you’re going to bring a lot more people just because of the topic and enthusiasm that you bring to this field. So we thank you .

Dr. Lucia Aronica: Thank you. Thank you very much, Dom.

Dr. Kara Fitzgerald:  As always, thank you for listening to New Frontiers in Functional Medicine, where our sponsors help bring the very best minds in functional medicine, and today is no exception. Not everyone can be a sponsor on my platform, and I so appreciate the good work, relentless research, and generous support from my friends at Biotics, TA Sciences, and Integrative Therapeutics. These are brands I know and trust in my own clinic and can confidently recommend to you. Visit them at BioticsResearch.com, TASciences.com, and IntregrativePro.com, and please, tell them you learned about them on New Frontiers.

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Dr. Dominic D’Agostino is an Associate Professor in the Department of Molecular Pharmacology and Physiology at the University of South Florida Morsani College of Medicine. He is also a Research Scientist at the Institute for Human and Machine Cognition (IHMC). In addition to his teaching responsibilities, his laboratory develops and tests nutritional strategies and metabolic-based therapies for neurological disorders, cancer and metabolic optimization. He is conducting basic science research and human clinical trials. He has a personal interest in environmental medicine and methods to enhance safety and physiological resilience of military personnel in extreme environments. His research is supported by the Office of Naval Research (ONR), Department of Defense (DoD), private organizations and nonprofit foundations.

Dr. Lucia Aronica, Ph.D., is Lecturer at the Stanford Prevention and Research Center, and R&D Lead, Genomics, at Metagenics Inc. Her research and teaching focus on how lifestyle can change gene expression thorough a process called epigenetics, and how we can use this information to design personalized lifestyle interventions for optimal health and longevity. Some topics of her courses include nutrigenomics and nutrigenetics, intermittent fasting and ketogenic diets, and the role of these interventions in personalized lifestyle medicine and longevity medicine. She has published research papers in top-ranked peer-reviewed journals such as JAMA, Cell, and Genes and Development.

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