#05 - Dom D'Agostino, Ph.D.: ketosis, n=1, exogenous ketones, HBOT, seizures, and cancer

Hey everyone, welcome to the Peter Atiyah Drive. I'm your host, Peter Atiyah. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other subsessions I've gathered along the way. I've spent the last several years working with some of those successful, top-performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you with a higher quality, more fulfilling life.

If you enjoy this podcast, you can find more information on today's episode and other topics at PeterAtiyahMD.com. On this episode, I interview my good friend, Dominic D'Agostino. Dom, as he is known by, is a professor at the University of South Florida. His PhD is in neuroscience, and that's where he got his background, but Dom is probably most recognizable to people listening to this, because he is certainly one of the experts on ketosis, and that's in all variants of it, so starvation ketosis, nutritional ketosis, and in particular, the use of exogenous ketones.

Gosh, Dom and I go way back. We met probably a little over five years ago and instantly formed a friendship around our obsessive N of 1 experiments, although I will say he is closer to winning a Darwin Award on the basis of his N of 1s than I am. A couple notes about this podcast. First, this is highly technical at times, and in fact, we'll timestamp it in the show notes, but I would say roughly the first hour is even a little more technical than I had intended to go.

I think part of the issue is just once I get talking with Dom about this stuff, I couldn't stop asking him questions, and I think there were times when I guess we forgot we were recording a podcast, and it was just us getting really technical. I don't think it's too technical to follow if you had some background in understanding of biochemistry, but we'll do our best in these show notes to make sure that we're given even the recreational user the necessary tools to follow this. Now, that said, if you get 20 minutes into this thing and you're like, I don't understand what the hell these guys are talking about, do not hesitate to skip ahead. There's a lot of stuff that gets later on into the podcast, and this is a long podcast, nearly three hours.

There's a lot of stuff we get into at the end that I think will be kind of the stuff people really want to know, even if they don't want to get into gory details. So, in particular, we talk very specifically about all of the ketones, and I'm getting a lot of questions about Peter. What's the instrument of ketone ester, ketone salt? What are the monoesters?

What are the diesters? Where does MCT fit into this? What about the caprylic acid? And, you know, how many should we be using this one versus this one?

And what are the advantages of this matter? This is going to be your dissertation level course in that subject matter. The other thing that we get into at the very end, and we almost end on this, but again, look to the timestamps for exactly where it is, is we get into what I consider one of the most interesting discussions I've ever had on what I sort of loosely describe as a metabolic oncologist playbook. So, when I asked Dom about this, he had just some of the most interesting insights, and I was really impressed by the breadth and the organization of his thinking around this.

Now, I want to point out something here, and I say it in the show, but it's really important for me to caveat this here. This cannot be construed as medical advice. Dom is not a medical doctor. He doesn't pretend to be one on TV.

He is a research scientist who focuses on basic and translational research. He collaborates with lots of physicians. He is involved in a number of clinical trials, but ultimately, Dom is not offering medical advice, and frankly, nor is anybody, nor should anybody be on a podcast. So, this information I ask because I get asked this stuff a lot, and frankly, I don't know enough about this sort of outreaching and outlying metabolic therapies out there, but I hope that if people are listening to this and they're afflicted by cancer, which, statistically speaking, is obviously going to happen given that one of the six people are going to get cancer in their lifetime, I hope that if some of this stuff does scratch someone's sort of desire to understand more, that they can use some of the resources we're going to link to to potentially identify the right places where either a clinical trial will be taking place, or they could at least pursue some of these things under the appropriate medical guidance.

I could go on and on about other nits and nats in here, but honestly, I think the best thing to do right now is probably pay a little bit of attention, maybe more than usual, to the show notes. Treat this a little bit like a buffet. Go to the places you want to go to. Of course, I would recommend the entire thing if you really have an interest in this subject matter, and I hope that this podcast is going to answer many of the questions that I see people asking out there.

I actually learned quite a bit on this, and I tend to know the subject matter reasonably well, so without any further delay, welcome to the podcast with Dominic D'Agostino. Hey, Tom. Hey, Pete. How are you, man?

I'm doing well. How are you? I'm doing really well, and I'm really grateful for you making the trip all the way up here. I know that in part you're visiting family, but it's great that you've carved out time to come from New Jersey all the way up to the lovely city of Manhattan.

I appreciate the invite, and I love being here. Well, there's going to be a number of people listening to this today who are already incredibly familiar with who you are, the work you've done. And I certainly consider you probably one of the two most authoritative persons on the subject we're going to get into today. But for anybody who's listening to this who is not entirely familiar with you, I suspect by the end of today they're going to want to get a lot more familiar with you.

So I actually remember the day we met, and it's kind of funny. I was in Florida giving that talk at IHMC, and I knew of you by name, but I didn't know who you were or what you looked like, so I wouldn't have recognized you, and I gave a talk. This would have been 2011 maybe, maybe 2012. And at the end of the talk, it was like a Q&A, and it was a long Q&A, and it just went on and on and on.

And then you asked a question. I wish I could say I remember the question, but I knew from the question that that guy knows what he's talking about. Not to embarrass you, it was like a love at first sight. I was just so giddy to be able to sit there and have dinner with you.

Same, same here. Yeah, I knew who you were, and I was looking forward to that talk. I made the drive up there, and I felt like we were connected before we even connected. We're definitely on the same wavelength on this stuff.

Yeah, you've got such an interesting history that we're going to get into about how you got interested in this space. But also I think one of the things that many people might not appreciate fully that I appreciate just because of the convenience and luxury of how we met was just your interest in self-experimentation as well. And sometimes when you're studying something or interested in something that is not entirely mainstream yet, you have to bootstrap it, and you have to look at limited amounts of animal data, limited amounts of in vitro data, and then sometimes combine it with insights that you get through early experimentation on yourself. Absolutely so.

I immerse myself in what I'm doing. I think that's sort of what we can do. That's how we learn. Yeah, that's the best way to learn.

So you did your PhD in neuroscience, correct? Yeah. So what was it in physiology? In physiology.

So you're finishing your PhD, and you're planning to do a postdoc? Yeah, I did it in the neural control of autonomic regulation. So the brainstem mechanism sort of sends O2, oxygen, and CO2, and modulates respiratory rhythm generation and also a cardiovascular sympathetic tone to the heart, like those neurons, and how they sense oxygen. During my PhD, I got interested in diving physiology, and it was amazing to me that we don't really understand how our brains and our physiology functions in extreme environments as it pertains to elevated hyperbaric pressure, elevated oxygen, CO2, anesthetic gases, for example.

We know the anesthetic potency of a gas is proportional to its lipid solubility, but we don't really know what that means, like why, what's happening at the level of the membrane or the mitochondria. So my postdoctoral fellowship was actually developing technologies to study that, and that would be hyperbaric atomic force microscopy, and that was like, that's what I just delved into for three years. So how does that work? So I know what hyperbaric means, I know what microscopy means.

Tell me about the part about the force. The first term for atomic force microscopy was scanning probe microscopy. And instead of using light or electrons, it uses a very sharp kit probe that can be so sharp it's monoatomic. And it essentially raster scans across the sample and can detect very subtle changes in the topography of the sample that you're scanning, right?

So it actually spawned the whole nanotechnology world. So this particular instrument was used to characterize materials and really helped develop Silicon Valley in many ways. And it's a microscope that we took basically an off-the-shelf atomic force microscope that gives you the scanning resolution of an electron microscope but also has the capacity to image living cells and took this technology and put it inside an environmental chamber, a hyperbaric chamber. And part of my project was doing the electrical, the fluid, and the gas penetrations to make the thing functional and also doing a series of studies and calibration tests to determine that we could reliably make hyperbaric atomic force microscopy measurements inside this chamber.

And with this technology, it gives us insight at the nanoscopic level of what's happening to the mitochondria, to the cell membrane. So I got a grant through the Department of Defense, which they gave these equipment grants to develop this technology and also a grant to use it, and later another grant to put a confocal microscope. You might have heard of a laser scanning. I actually used a confocal microscope in my undergrad thesis to do optional optical sectioning of...

No, because I was an engineer. So I was interested in a question of, did the direction of extrusion that you put on a tibial plateau, so when you do joint replacements, does the direction in which you extrude what's called ultra-hynol-like polyethylene, does that predict its fracture? And it turned out it did. But the tool to help us measure that was this confocal microscope.

So that was my introduction to high-end microscopy. It's an amazing tool, yeah. So the second... Everyone's got one, right?

Yeah, they're the toys that we have in the lab. So that was the next phase of sort of my experiments was installing a laser scanning confocal so we could optically section individual cells and look at the mitochondria inside the cells under great levels of oxygen and hyperbaric pressure, essentially, pressure of an inner gas, like helium and nitrogen. So to simulate, for example, a Navy SEAL dive or a deep-sea dive. And in the context of developing this technology and imaging a wide variety of cells from primary neurons to alleoblastoma cells to human dermal fibroblasts, smooth muscle cells, I noticed that cancer cells would produce proportionally more superoxide anion, which is the precursor oxygen-free radical that comes from the mitochondrial electron transport chain as a consequence of normal metabolism.

And the cancer cells looked to have what appeared to be chock-full of mitochondria, and they were moving around very dynamic structures. And under normal levels of oxygen, they kind of produced a normal level of superoxide anion or oxygen-free radicals. But when we hit the cancer cells with hyperbaric oxygen, the superoxide production went off the charts. And it was very apparent to me that they were producing excess-free radicals, and as we made measurements over time, it was very apparent that it was accelerating membrane lipid peroxidation, which we use a variety of tests.

One is a T-MARS test where we look at malandialdehyde production. And the technology, the atomic force microscopy, allows us to look at very subtle changes of the surface of the membrane. You measure the perturbations on the surface of the membrane in nanoscopic changes, and we look at membrane roughness. And you could look at the roughness of the membrane and calculate that, and that can correlate to membrane lipid peroxidation.

And it correlates, the numbers correlate well. So what you're looking at is the physical correlate of membrane lipid peroxidation when you capture that data with atomic force microscopy. Is that clear? Yeah, let me back up and make sure I can disaggregate this into steps.

So the first thing that you notice is lots of mitochondria in cancer cells. And these are what types of cancer lines. The main one that I was working with, that I ended up publishing the paper in neuroscience with, was U87 glioblastone cells. And they were taken out of a 44-year-old patient.

So human cell line. Human cell line, yeah. A lot of people use it. And these are astrocytes, right?

These are not neurons. Yeah, of a glial. Yes, yes. So observation one, lots of mitochondria.

Okay, good to know. Because obviously there's an understanding that Warburg pointed out that says, hey, like, you know, these things largely are anaerobic, not aerobic, so they shouldn't really need much of mitochondria. And then what you're saying is you put them into a hyperbaric environment. And how hyperbaric?

How many times atmospheric pressure would you need? I saw the observation at, so normal oxygen is 0.2 ATA. We say atmospheric absolute. And I saw a big jump up in superoxide anion production at 0.95.

So that's almost five times atmospheric pressure. That's almost five times, yeah. And actually, 0.95, if you're breathing, produces a PO2 in the brain, similar to breathing 2.5 atmospheres of oxygen. And then I actually went up to the experiment with 3.25 atmospheres of oxygen.

And then that basically was cooking the cells from the inside out. The mitochondria were producing so much oxidative stress through reactive oxygen species. So superoxide anion can go to hydroxyl radical through the Fenton reaction, through hydrogen peroxide, and that can be driven in different ways. And I basically saw the mitochondria exploding under hyperbaric oxygen conditions.

And I'm sorry, but do you have a control in this of non-cancerous wheel cells that are not doing the same thing? Yeah, so most of my experiments prior to this with, like, smooth muscle cells, I was looking at primary cortical neurons, primary hippocampal neurons. At the time, I was just basically looking at, I was doing these experiments to validate the tool that we had just built. So no one actually had imaged living cells under hyperbaric conditions because no one had a hyperbaric microscope before.

So I didn't actually know what I was even looking at. I was not a cancer biologist. I knew that cancer cells were rapidly proliferating, so they probably had amped up metabolism. But it was just a very interesting observation to me.

It was very interesting that they were also dying. And I figured cancer cells should be hardy, and you should be able to throw everything but the kitchen sink at them, and they should live. And then when I saw them, basically, the mitochondria exploding and the membranes starting to become permeable and, you know, necrotic cell death, I became more and more interested in that. And we ended up publishing the observation.

But I didn't actually know what it meant. Like, I published it more like, here, I built this cool tool, and we did this experiment. And I was actually just looking at the cell line as a model system to study reactive oxygen species and oxygen toxicity seizures because part of the military was funding me to understand the cellular and molecular mechanisms of oxygen toxicity seizures. And it's thought that high levels of oxygen creates oxidative stress, and that perturbs the brain in a way that causes these grand maltonic-clonic seizures.

And we were developing tools. You can't understand it unless you know fundamentally what's happening at the level of the cell and the mitochondria. So I want to come back to that because that now makes sense for why diving could increase that risk because if you're using an oxygen rebreather, you're getting a higher concentration of oxygen, and then you're under multiple atmospheres of pressure, you now basically replicated in a person what you were seeing in a cell. But going back to the cell thing for a sec, do the free radicals that get generated destroy other cells beyond the cell that is generating the free radical?

Or is the problem largely contained to the cell? It's a dose-dependent phenomenon, right? And we were studying cells in this particular experiment in a petri dish or on a coverslip. So yeah, it's sort of like an intact neural network or cellular network.

So the cells are literally connected to one another, unlike a tissue cell where you have an intact cell architecture, which that's a little bit different. But the oxygen-free radicals and the substances that the cells produce do actually influence other cells adjacent to it or juxtaposed to it. That's obvious from some of the experiments we do in cell signaling. You know, if one cell becomes permeable and we could detect cell death with various molecules like ethneum, homo, dimer 1, when that cell dies, it can stimulate excitotoxic events in surrounding cells.

Same thing happens with cancer cells. It's obvious that cancer cells use reactive oxygen species for growth and proliferation. And I know this is something that may be contradicting to many people. We view free radicals as something that's damaging that the cell needs to get rid of.

But they're very powerful signaling molecules, especially for cancer cells and growth and proliferation and in normal tissues. Can you mean nuclear signaling? Nuclear signaling and activation of transcription factors. Basically, there are many, I study, as a neuroscientist, I study redox-sensitive ion channels.

So the redox state of an ion channel can dictate the permeability and the gating functions of that ion channel, which is intimately linked to cellular excitability by influencing the resting membrane potential. So as a neuroscientist, you know, you can study a very particular, and cells have hundreds of thousands of ion channels, specific ion channels that are redox-regulated. But what was obvious is that cancer cells have elevated rates of reactive oxygen species that they use for growth and proliferation and also fuels metastasis and invasiveness of cancer cells. And because they overproduce oxygen-free radicals in the context of high oxygen, you can push the cells above their antioxidant potential and then trigger apoptosis.

So it's like a double-edged sword. It's basically a U-shaped curve or inverted, depending on how you want to think about it, where a cancer cell is not only optimized to survive, it's optimized to thrive at a certain level of elevated reaction. Yeah, an elevated level, but if you go too far, it becomes counter. Yeah, so they have elevated endogenous antioxidant capacity, right?

But because their mitochondria are defective in many ways, and that term is kind of controversial, some people think the Warburg effect definitely endows the cells many benefits, but the aberrant activity of the mitochondria is creating this excess-free radicals. And hyperbaric oxygen... oxygen and chemotherapeutic drugs that augment oxidative stress are therapeutic modalities that can be used. It was very apparent to me seeing that in a hyperbaric chamber looking at a microscope looking at these cells and no one had seen it before because no one had hyperbaric.

Yeah and that kind of at the same time I was growing these cells under different conditions. I was very interested in lactate and I became interested in ketones too just not for this reason. I was not interested in the ketogenic diet. I was looking at it for a different reason actually but I noticed that the cancer cells were not growing as rapidly as they should in the context of 1, 2, and 5 millimolar of beta-hydroxybutyrate which I was growing them in and I thought the lab tech may have been doing something that was influencing but she sure wasn't so we would pull the media off and put regular media on without the ketones and the cancer cells would start growing rapid.

Why were you using ketones in the media? Well I was looking at a variety of different substrates back in 2008 and 9. I see so you were just lactate, glucose, BHB. Yeah 2-deoxyglucose, yeah lactate.

I was using a variety of ketones and ketones were like well let's just see what ketones do. You know the ketones were something that the body would produce in fasting but I didn't I didn't even know the anti-seizure properties of the ketogenic diet. I just thought of it as like what do brains and a couple odd papers that came out like ketones could be used as fuel. I was very interested in alpha-L polylactate, various forms of lactate that could be used to preserve brain energy metabolism in the face of oxidative stress and the ketones just they sort of shined so basically what they were able to do was allow the neurons to preserve their membrane potential and normal cellular function even in the context of extreme oxidative stress and it made sense right because the ketogenic diet you know I started looking more into this and discovered that the ketogenic diet was a very effective anti-seizure strategy even when drugs fail.

About two-thirds of patients respond favorably you get you know 10 or 15 percent of super responders and never have seizures again you can get them off your meds and it was probably working through a mechanism independent of any anti-seizure compound because the ketogenic diet worked when drugs failed you know suggesting it was working through a different mechanism or many mechanisms kind of in synchrony. So the tools that we developed really sort of started to allow us to understand from a cellular and molecular mechanism how ketones are working and I was looking at other compounds at the time but it's just as I kept studying I was looking at sigma receptor agonists I was looking at other antioxidants many different antioxidants and combinations of antioxidants that were catalase mimetics superoxide dismutase mimetics you know all these things that were in theory they should work really well but nothing was really working as well as ketones and it also motivated me because when I discovered the ketogenic diet was a grossly underutilized anti-seizure strategy I was like wow I could go back to my nutrition roots because when I was undergrad I majored in nutrition science but I didn't pursue a PhD in nutrition because nutrition was not like a real science like there was no jobs in nutrition and in the 90s was a decade of the brain so it was like let me try to get into a cellular neuroscience program so I kind of just left nutrition and this was my opportunity to bring nutrition back into my research projects into the lab. Going back to that BHB in the media did you have the same amount of glucose in as you had in the BHB free media? Yeah so we did everything in the context of the same amount of glucose.

In other words the benefit was from the addition of BHB not the reduction of glucose. Absolutely yep and as I started to get into the literature and read into this a little bit more we started doing glucose subtraction and adding ketones and saw that normal healthy neurons functioned and thrived in a low glucose environment if the ketones were present but the cancer cells would die and this was also replicated and published in various neuroblastoma cell lines and I think Skinner was one a person that published I found that he was at University of Florida but he was a fellow and just had left the school at the time and then I went up there and gave a talk I think in 2010 and that further that got me more and more interested in studying cancer even though it was not funded to do so it was like this pet project that was completely very intellectually stimulating to me and something that I could not just shelf and come back to at a later time. I had to I felt like the environment was kind of hot for this so I just kept reaching out to different scientists and showing them my data and asking them to explain it like top level cancer biologists and then I stumbled across Tom Seiford actually. Why do you think Tom was one of the few people that lashed on this was it simply because he'd already been thinking the same things or because it's really it is interesting when you think about how many really interesting and impressive people in cancer and not sort of come around to thinking about this stuff.

Now in 2009 I think it was 2009 and I'm sure you know I've read this paper a thousand times it sort of I think was the first obvious mainstream view of this was the Matt Vanderheiden, Luke Cantlie, Craig Thompson science paper. Is that 2009? Does that sound right? Yeah which reminded me they had a couple papers around that time.

Which one was it? Well this is the one that offered an explanation for the Warburg effect. Yeah yeah yeah. It was just like energy.

That's right. It was. Expanding biomass. Right.

Directing metabolites do that. Yeah and that was interesting because that's a different explanation than presumably Tom would offer right? It's accepting the Warburg effect is very powerful but the question that Tom has really set out to address no one is arguing the Warburg effect is present but the initiation of the Warburg effect and that damaged mitochondrial respiration causes an energetic crisis that kicks on the oncogenes that basically turn on the genes that are the essence of the Warburg effect. Let's describe it.

I should only take for granted that everyone listening knows what the Warburg effect is. So for someone who doesn't know how would you explain the Warburg effect? The Warburg effect simply stated is insufficient mitochondrial oxidative phosphorylation or what we call respiration with compensatory fermentation in the form of establishing the cell establishes its energy its production of ATP our energy currency through glycolysis and substrate level phosphorylation and it's well recognized that cancer cells 90% of them I would say had a Warburg phenotype meaning that they have highly accelerated glycolysis and substrate level phosphorylation. So let me simplify that a little bit more.

Our cells can turn glucose into something called pyruvate and that occurs outside of mitochondria and that's not a highly energy efficient process. It doesn't generate much ATP. You then have a decision to make as a cell which is basically how quickly does the body want ATP and as a general rule when it wants it quickly it's an anaerobic environment. You think about things that drive quick ATP requirement and so then it will just turn this pyruvate into lactate.

That's the glycolytic pathway which is not particularly efficient either. It doesn't generate that much more ATP but it has the luxury of saying I can guarantee to do this quickly and I don't need to be limited by cellular oxygen. Under ideal circumstances you want to generate the most ATP you would shuttle that pyruvate into the mitochondria as acetyl-CoA and you have this other process. So what you're saying is the Warburg effect is hey even under conditions at rest a cancer cell seems to disproportionately do this glycolytic thing and it generates its ATP that way as opposed to going into the mitochondria.

Exactly even in the presence of normal oxygen it utilizes glycolysis and pumps out lactate. So under no other conditions do normal cells ferment and pump out lactate. Now Warburg did he win a Nobel Prize for this observation? He won a Nobel Prize yeah for his work in metabolism cancer cells yeah and it was is more kind of appreciated a little bit later what the implications of this was but it was part of his Nobel Prize.

You know I remember reading an article about this one that has since escaped me but maybe I'm wrong so correct me but one of the reasons that the hypothesis was because this was the 1920s if I recall. Yeah. So one of the reasons that this sort of got discarded for lack of a better word or at least ignored was people tend to focus on the exceptions and there were exceptions right certain lung cancers certainly seem to pose an exception to the Warburg effect and so the idea was well look if you have an exception then the rule is not so much a rule anymore and is there another reason why the Warburg effect was largely ignored for you know a generation and a half to two generations? Travis Christopherson wrote a book about You can understand the gene etiology of cancers and different types of cancers then that would explain cancer in a much more fundamental level and that is the case there is a dynamic interplay between metabolism and genetics so now we have an appreciation that metabolites you could call them oncometabolites are epigenetic drivers and metabolism is just not something it's just not producing ATP there are so many different intermediates and reox signaling and so many different signaling molecules from metabolism that have epigenetic regulation and I think that has become when I got into this there was no cancer metabolism conferences you know and now there's a dozen or more where Lou Cantlie is a keynote speaker and Craig Thompson is and this has all sort of exploded shortly after some of the observations that I made and it's just you know it's I don't think it's coincidence Do you remember that night?

Yeah yeah I remember when we had that dinner in DC at that conference Yeah Georgetown conference I still look back at that as one of those remarkable rooms to be sitting in as a fly on the wall because there was only about 12 people there Yeah And you know you had Lou Cantlie, you had Michael Bishop, Steve Rosenberg, David Sabatini David Sabatini Who else was there? Michael Pollock Evander Heiden Yeah Matthew Evander Heiden I mean you basically had some of the most thoughtful cancer scientists in the world certainly in the United States in one room And that was an amazing conversation Yeah that was If I go back in time We should take that We should report that That was golden We'll talk those guys into getting in a room again I mean I think what you're basically saying is look part of its reason for being discarded or at least forgotten about was a new sexier idea emerged which is hey we started to understand the role of the genome and there's this weird sort of debate you hear And the observation of things like viruses you know which could you know encode and change our DNA Yes But the viruses that cause cancer are the very same viruses that damage the mitochondria that damage the DNA of mitochondria and causing respiratory insufficiency which triggers an energetic crisis which can trigger the activation of oncogene through retrograde response So that needs to be appreciated too but there was this explosion of technologies that allowed us to understand genetics and that was sort of being leveraged to really delve into the cancer I think there was some politics influencing that So was the first thing you did from that point because there's really two separate problems that you're talking about The first is why are these seizures occurring and I'm referring very specifically to your DARPA funded work which was why is it that when these special forces guys are doing their ultra secret dives which require rebreathers why are a subset of them having these fatal seizures? Well it's at the Office of Navy Research Oh it was at the Office of Navy Research They were doing warfighter performance actually with ketone esters which is prior to you know what I was saying So that's one problem and the other problem that you've also articulated is hey what's going on with cancer Yes So oxygen toxicity seizures are a limitation for Navy SEAL divers and we don't know how to predict them or prevent them It's also a limitation of hyperbaric oxygen therapy So if you have carbon monoxide poisoning and you need to live so you need to get that carbon monoxide off your hemoglobin you need to basically increase the PO2 in your tissues Carbon monoxide has a much higher affinity than oxygen for hemoglobin so you have to basically outcompete it Yes So if you were to take a ketone ester which we know now increase your resistance to oxygen toxicity by like 600% and take a ketone ester and then get inside a hyperbaric chamber you have a much greater chance of living If you have wounds there's 14 different applications for hyperbaric oxygen therapy we think that therapeutic ketosis strategy would make it much safer and more efficacious So in the context of an oxygen rebreather the advantage is that there's a stealth component because you don't produce bubbles you can dive in a quiet lake and go all the way across and surprise your enemy but at just 50 feet of seawater within 10 minutes at 50 feet of seawater you run the risk of getting oxygen toxicity seizures That's pretty shallow Wait, wait, say that again At 50 feet of seawater in 10 minutes you're on a drag or rebreather according to the oxygen dive tables that has been enough to trigger seizure in many guys so that produces a PO2 in your brain of about roughly 2,000 times higher than what your oxygen level in your brain would be right now 2,000% higher So that needs to be sort of appreciated and of course this could all be averted if you just stick to the dive tables but if you have enemy fire with 50 calorie machine guns coming down on you and you want to stay down if the water's clear you've got to go down deeper if you have a plan of mine and get to the bottom of a ship or a bridge you might be underwater for three or four hours and the enemy's still up there and you've got to get down there and do your job and dive deep and avoid that and after a time you have pulmonary option toxicity too if you're down there long enough but generally speaking these rebreaters are for shallow diving but situations where they need to go down deeper Do you have an estimate of how many Navy divers just in the United States both in training or combat would die in a given year from this or be injured? It's pretty rare and if they do get hit with oxygen our friend Kurt Parsley will tell you that Navy SEALs are notorious about not telling what their issues are with their health so if they do have a seizure they would be kicked out a lot of these guys because that may make them a weak link that they're vulnerable so we know recreational divers have pushed a limit who have been hit a couple times with this and we're doing some studies right now recreational divers so it's very underreported but studies have shown I always show a video in one of my talks of a guy in a chamber where he has a mask on and the mask is breathing 100% oxygen and the guy inside the chamber is breathing hyperbaric air and within 2.7 atmospheres of oxygen he gets hit with a seizure and has a really violent tonic-clonic seizure and it stops as soon as you remove the oxygen mask and start breathing air even if it's at the same barometric pressure the seizures stop so one of the beneficial things of these seizures if there's a beneficial component to it is that they quickly stop as soon as you remove the hyperbaric oxygen source or you go from breathing 100% oxygen to hyperbaric air so what's happening is that the high levels of oxygen are creating oxidative stress and actually impeding various metabolic processes in the brain and the brain is becoming hyperexcitable and the neurons are firing so many action potentials that the cells essentially can't maintain their membrane potential and you get excitotoxicity that causes mass firing in the neurons and a seizure and this is obviously under a very supra-physiologic super-physiologic it only happens in these extreme environments of pressures and the reason for it now is you have S-nitrosylation of glutamic acid decarboxylase there's two different isozymes and then what we think now is that you have more glutamate to GABA ratio so the enzyme that converts our gamma-immunopatric acid is actually created from glutamate so you have much more excitatory than inhibitory neurotransmitter so that ratio changes and it's a redox-dependent reaction actually you have S-nitrosylation of this enzyme that converts more glutamate to GABA so you have increased neuronal firing increased release of glutamate and also less conversion of glutamate to GABA which has a brain-stabilizing effect so this is going off topic for just a second but we know that as people age we see greater and greater oxidative damage so we see the susceptibility to ROS going up does any of what you learned in this super-physiologic environment where in a very short period of time you're going to generate a ton of ROS by exposing someone to high pressure and high O2 does anything you learned in that environment offer an insight into non-super-physiologic or normal aging and disease progression yeah I think in many different ways so it's almost like exercise right if you exercise intensely your reactive oxygen species are going to go up inflammation all these things kick on so high pressure oxygen increases oxidative stress and that kicks on many different processes that can endow the cell with greater cellular protection so it can for example cause an increase in superoxide dismutase it can enhance our antioxidant defenses so the oxidative stimulus is a trigger for adaptive processes that can allow our systems to be more resilient against the same level of oxidative stress this happens very robustly in a young animal and is significantly attenuated in an older animal and I think that needs to be appreciated so the adaptive response to the stimulus it varies genetically probably between the individual there's a lot of individual variability you between people and even if you take the same person under different conditions, whether it be if they're sleep deprived, what they ate that day, maybe if they're dealing with a little viral illness or something, their susceptibility to oxygen toxicity seizures can be greatly affected by a lot of different variables.

But that adaptive response, so we know hyperbaric oxygen stimulates the production of stem cells as much as something like GM-CSF, like Neupogen or Leucine. It's that powerful. It causes the production and the release of stem cells, which hone in on sites of injury and aid in repair. So that's why its most utilized application is actually for enhancing wound production or wound healing effects.

I see. You mentioned that there were 14 approved applications. I wasn't aware that there were that many. I think it's 15 now.

So what are some of the others? Not to put you on the spot to rattle off all 15, but we can look it up. But just off the top of your head, what other ones do you know? Yeah, radiation necrosis.

So for cancer, if you are getting radiation therapy for cancer, it is FDA approved for that. So if you have patients who have radiation therapy, of course there's decompression sickness. So recreational diving, if you get bent, another term for bent is decompression. It's the same deal.

It's basically getting nitrogen out by basically beating it out with oxygen. Yep, carbon dioxide poisoning, obviously. Diabetic wounds. All the hyperbaric, the UHMS, so Hyperbaric Medicine Society approves the facilities, and I would say 90 plus percent of their revenue generated from that is diabetic wounds, which is a huge problem.

Like you probably in your practice you probably see people with wounds that just don't heal. Well, I don't see my practice, but I certainly cut my teeth on it during residency, no pun intended. Significant problem. Yep, so that's, I mean, that's a few different applications.

And there's a lot of sort of rare things. There's noise-induced hearing loss. If you use, that's one of the newer applications. That could be some things that are kind of counterintuitive.

So when we think of high-pressure oxygen, a lot of times you think of retinopathy of prematurity, right? If you put a newborn and give them high levels of oxygen, you could cause them to go blind. Right? A newborn.

So that's an interesting... Meaning a newborn is more susceptible? More susceptible to oxygen. It was very common, I guess you could say, to put newborns on high levels of oxygen if they're born premature.

And what is it about the newborn that makes more susceptible? It's a development of their lungs. Is it the angiogenic component of this? Yes, yes, that could be a component, too.

And maybe they just don't have the robust endogenous antioxidant, you know, capacity. It probably might be the angiogenic component, too. Do you know off the top of your head if elevated mercury or mercury toxicity is an indication for hyperbaric? Because I've heard of a lot of people doing this, but it strikes me as a little off-label.

Probably not. There's so much off-label stuff being done. So one of the things that I'm really interested in testing is for traumatic brain injury. And I do think that low levels of hyperbaric oxygen therapy, if used shortly after a traumatic brain injury, I think the faster you restore oxygenation, increase oxygenation to hypoxic pockets.

And I think from my perspective, giving something like a ketone ester with lower levels of hyperbaric oxygen therapy would probably work. That's probably by far the most controversial application because there are some remarkable responses from people who have even a regeneration of brain cells after the hypoxic injury, for example, in kids who are very resilient anyway. I know after Paul Harch has been on pretty much all the major news networks with a girl that sustained an incredibly severe hypoxic injury and brain death and regenerated some of her brain function and brain tissue. How old was the girl?

She was pretty young, I think, five or six, I believe. And I met her, actually, at one of the conferences. And it's very clear that nothing was working for her until she did hyperbaric oxygen therapy. But kids are completely it could be another story.

You know, we don't know if we could replicate that. But there are a lot of stories out there, anecdotal reports, but it just has not been studied appropriately. And those studies need to be done. What do you see as the resistance?

I mean, when you look at what's happened in the last five years in the NFL, that has brought, along with, I think, just the returning vets, TBI is, I mean, I don't think you could walk down Madison Avenue and hit someone with a rock who hadn't at least heard the term TBI. So everybody knows what it is. We've got, you know, these two completely different demographics who are highly affected by it, athletes and soldiers. What's the hang-up?

I mean, you and I have spent a lot of time behind the scenes trying to get organizations like the NC2A interested in studying this. I'm struggling to understand what the hang-up is. You know, they're looking for devices to, you know, quantify TBI's and concussions. So that's a lot of funding is going into that area, at least when we talk about the NFL hit challenge and something that, you know, we submitted to.

You know, I don't really know. I don't really know. I think the scientific rationale for a metabolic-based therapy for the brain makes a lot of sense in restoring oxygenation. I think the waters are very muddy, though, when it comes to hyperbaric oxygen with TBI.

I mean, we even did some rat studies where repeated doses of hyperbaric oxygen in a concussion or a brain injury model of a rat caused more injury, can exacerbate the effects, whereas a single dose of hyperbaric oxygen right after, at least in our rat model, decrease the infarct size by maybe 30%, something like that. So this is dangerous. I mean, we don't want someone listening to this who's suffered a TBI thinking, I'm going to go to some off-label clinic and just, you know, repeatedly expose myself to hyperbaric. The point here is, this has to be studied.

It has to be studied rigorously. It has to be studied empirically. And I haven't even gotten to something we will get into later, which is the potential augmentation of the exogenous ketone. Yeah, yeah.

I would not do hyperbaric oxygen therapy if people are going to do it with and without, you know, what I say. I would definitely do hyperbaric oxygen therapy if you're going to do it in strong nutritional ketosis, because a consequence of hyperbaric oxygen therapy could be CNS oxygen toxicity. So you do not, the last thing you want if you have a brain injury is to have a seizure. And we know 85% of all penetrating traumatic brain injuries lead to seizures in people who have had penetrating.

What about blunt? I mean, it's less than that, but how much less? Yeah, so I don't know. I guess you'd have to quantify the blunt.

The severity. Yeah, but when it comes to penetrating, but it's upwards of about 85% of penetrating traumatic brain injuries have seizures. And that's because you have excess glutamate, you know, and that's the very thing that's actually contributing to oxygen toxicity seizures, right? So I think the biggest thing to do is to augment your brain energy metabolism to burn energy more efficiently.

The ketones do that and lower neuroinflammation. And I think there's a variety of ways to do that, but you don't want to throw more fuel on the fire. And I think high levels of hyperbaric oxygen therapy could be doing that. I think maybe these soft chambers that go to like 1.4, 1.5 maybe a better means to implement that.

Let's get into ketosis a little bit. I want to come back and talk about cancer. I want to come back and talk about the exogenous ketones, both the salts, the esters and even different molecules. But one of the most interesting experiments we've seen in the physiology of ketones, like, you know, as far as old school experiments was the George Cahill starvation experiments, right?

I was highly motivated by that study. We're going to link to it here, but why don't you give people the Reader's Digest version of what George Cahill did? It could probably never be done again. Yeah, yeah.

And I was very lucky to connect with him. Before he died. He passed away in 2012. I connected with him a few years before that.

And just to figure out, you know, did he really do these studies? And there was a lot of studies that also didn't get published that were pretty remarkable too, that somehow they got past ethics review at Harvard Medical School. But essentially what he did, a very elegant study to look at brain energy metabolism, the 80 difference in blood and metabolites in subjects that fasted for 40 days. And most of the subjects were divinity students, I believe, or maybe conscientious subductors to the war or something like that.

But each person had a different story behind it. And he fasted these subjects for 40 days. And just to be clear, there's water and mineral only. Water, no calories.

Yeah, they took a mineral supplement. And they also were, they weren't lean subjects, so they were subjects who, from their perspective, were overweight, if not obese subjects. So they had some weight to lose. And it was a very well-documented and well-controlled study where they monitored free fatty acids, insulin, glucose, beta-hydroxybutyrate, acetoacetate, and acetone.

And let me pause you there for a moment for the listener. We'll come back to this because I want you to explain the difference between beta-hydroxybutyrate or BHB, acetoacetate or ACAC, and acetone. How they're produced, which ones are metabolite active, which ones aren't. But hopefully by me just saying this, pitching the two of us, we'll remember to come back to that.

Yeah, so essentially three ketone bodies, beta-hydroxybutyrate being the primary ketone that's elevated and more stable in the blood and probably more likely to be a brain fuel. So, and if we just focus on that ketone body, after seven days, it reached a level to where it was at or above the level of glucose in the subject. So glucose came down from five to six millimolar down to three and stayed at three millimolar throughout the duration of the experiment, throughout the duration of the fast from day seven, essentially to the remainder of the 40 days. So for the Yankees listening to this who aren't familiar with the metric system, three millimolar is about 55 milligrams per deciliter.

Yeah. So that's pretty darn low. Yeah. But what's interesting is it gets down there, I think it was between day seven and day 10, it hit three millimolar, and then it just never went down again.

Yeah, yeah. What the heck is going on? These people don't eat any glucose. How do they sell?

And what that tells you by definition is their liver still had glycogen because you have to be putting that glucose out from the liver. Yep. So the maintenance of glucose is under very powerful homeostatic mechanisms. So we're hardwired from an evolutionary perspective to maintain glucose.

And the glucose can be coming from gluconeogenic amino acids, so we are breaking down some muscle. And then the glycerol backbone of triglycerides, too, also contributes to the production of... So triglycerides being the storage form of fatty acids. You have a three-carbon backbone that's called a glycerol backbone.

It has three of these free fatty acids that become free once they're cleaved. They become the substrate that you're going to explain to us in a few minutes is how you make BHB or beta-hydroxybutyrate. But you don't just throw that glycerol out. You connect the liver and turn that back into glycogen within itself to then slowly trickle out into the bloodstream.

Exactly, yeah. So when Cahill did this, if I recall, insulin levels also got very low. By day seven, the insulin levels were at rock bottom and sort of stayed there. Yeah, yeah, they were really low.

One of the interesting things about the experiment, in addition to the stuff I want to hear about, which is the brain metabolism, and how did the brain partition those fuels, is was it this experiment or a different one where he was able to give insulin lower glucose levels but not generate CNS trauma through that? Yeah, so the subjects were asymptomatic for hypoglycemia, and they felt really fine. Down to what level, like one millimolar? Yeah, so they infused, IV infusion of 20 IUs of insulin and pushed glucose from three millimolar, or thereabouts, down to roughly one millimolar, which is like 18 milligrams per deciliter.

Which would be fatal. That would be a fatal level of glucose. Even two becomes like coma and essentially fatal if it's maintained. I hit two very briefly during an insulin suppression test I had at Stanford, and I was no longer in ketosis because I was doing a insulin suppression test.

So I started at about two and a half or three millimolar, but 90 minutes later, my ketones had withered down to like 0.3, 0.4, and then my glucose hit about 38 milligrams per deciliter, and that was the day I thought I was gone. That's a dangerous area. I have a little self-experiment I can mention after this, but essentially what they did, which was a very bold and gutsy demonstration, they injected insulin, which facilitated glucose disposal in the patients, essentially, and brought blood glucose down to roughly one millimolar, which is universally fatal, and the subjects were relatively asymptomatic for hypoglycemia, which was remarkable. Their ketones were maintained at about above five to six millimolar.

That is out-freaking-rageous. When you just have to think about how you could take a normal, healthy volunteer and do something, I mean, we're all in the spirit of learning, but when you just think about that from an ethical standpoint, I can't do that in mice. I'm not allowed to do that in mice. The IACUC, the Institute for Rental Care and Use Committee, would not approve fasting for more than 20.

I think it's for 24 at our institution. Yeah, so that's for mice. Maybe rats might be 48. But yeah, and the use of insulin to further that.

I might serve on the IACUC. I mean, these things would be quickly rejected. I mean, this was a wild, wild west. Yeah, yeah.

And then just the last thing on this topic that I remember, which I'd love to expand on, is what did we learn about how the brain partitioned fuel? How much of the brain's energy, once you were in that steady state after about 10 days, came from glucose, beta-hydroxybutyrate, and acetoacetate? Yeah, so beta-hydroxybutyrate accounted for approximately 60% of the energy and probably 10% acetoacetate. And roughly at that point, after about 10 days, only about a third of the energy was coming from glucose, right?

And basically what's in your blood, as far as ketones and glucose, is what your brain is utilizing. You know, your brain's in a hungry state and it's effectively utilizing it and clearing those metabolites. You can do that. It was a very elegant demonstration and it kind of changed our understanding of brain energy metabolism as glucose being exclusive predominant fuel.

So in a fed state, they were consuming 100% of their brain energy metabolism was from glucose. But only after being fasted did that change. And he went on to read a number of reviews and went on with Dr. Veach, who actually created and developed some that they published together.

Veach was a postdoc with Cale, wasn't he? A postdoc, yeah. He was a student of Pons Krebs, actually. And then, yeah, he was one of his best students from my understanding, yeah, from word of mouth.

Yeah, they went and they worked together in different capacities. Yeah, I think he might have been a fellow with him. I think most people listening to this, if they can dig back to high school biology, that name Krebs will sort of ring a bell, right? Yeah, it should, yeah, yeah.

So you mentioned that Cahill shared with you stuff that wasn't even published. Do you remember anything that struck you as super interesting that was unpublished? Yeah, you know, some things maybe... Not worth talking about?

Well, yeah, I don't know if he... There was some stories and then I heard some stories through other people too. Well, I don't want to make you say anything that you're not comfortable saying publicly. But I would say that some of the work that was done in animals definitely suggested that glucose could go lower, even lower, and that you could really transition your metabolic physiology to be fueled off fats and ketones and that that was against what we knew.

These were remarkable observations that changed the whole context of what we knew about metabolic physiology and brain energy metabolism. Do we know today if the brain can use lactate directly as a fuel without it having to go through the Corey cycle? Yeah, it most certainly can. I think lactate's actually a great fuel.

And that's one of the first fuels I got interested in when I was studying hypoxia and then later even hyperoxia I was thinking about using lactate, different forms of orally available lactate like poly-L lactate. I think it's in the product Cytomax if you remember for cycling. I used to use Cytomax, yeah. So I was actually interested in that and that actually led me to ketones.

And then once I got more into studying ketones and discovered somehow it slipped past me all the years I thought I knew what a ketogenic diet was but then I read about the history of the ketogenic diet been used for almost a century and I realized that it was like the standard of care for seizures and then understanding that these ketones can largely replace glucose as the energy source and then they have these signaling properties that are even independent of metabolism that are remarkable. Over the last five years a lot of these big labs are looking at the epigenetic effects of ketones functioning as class 1, class 2 functioning as a suppressor of the NLRP3 inflammasome producing less inflammation in a metabolic independent way. So you obviously pretty quickly come to this idea that these ketones are interesting molecules and they're interesting for a couple of reasons at the very least what you just said which is they have signaling properties that make them kind of unique. Outside of the exogenous ketones though you have to also undergo a pretty extreme physiologic change at least in a western culture to make enough of these to matter and you have to restrict carbohydrates and protein to get there.

So did you first personally get interested in this from a nutritional standpoint and then eventually through this exogenous pathway or vice versa? Yeah, so ketone esters to my knowledge in 2008 didn't exist. They actually did but I didn't know of them. I discovered them on a DARPA website as some work that was being funded in developing the ketone esters for warfighter performance.

But at the time when I decided to go down the route of the ketogenic diet I reached out to the ketogenic diet out the johns hopkins and the crew which is where the anti-seizure therapy was pioneered yeah mayo clinic first and then they worked together with hopkins i would say the bulk of the the work that was done to develop the protocols for the ketogenic diet which are in use today was developed at johns hopkins and i got eric kossoff books his book with uh published with john freeman which was i just went out and did the classical ketogenic diet the four to one ratio so four parts fat and one part being protein and carbohydrates it equates out to 87 to upwards of 90 fat maybe 10 protein and like one or two percent carbohydrate so i mean it's like basically eating super low carb and then adding mountains of fat on top of that plate making like a super low carb meal with protein restrict and then add some butter and a couple cups of heavy cream with that and that's i started weighing everything out and when did you start that 2008 i think in nine i think it was 2008 or nine that eric kossoff uh published the modified ketogenic diet which was more liberal in protein and increasing protein from 10 to 25 and 30 or 25 is a huge difference like you can that's actually a diet that i mostly adhere to now and i followed the ketogenic diet and i bought the strips were very expensive at the time there was a couple different kits that i got to measure my own ketones and you know i immersed myself in it i got obsessed with it and i wanted to know what it felt like to have a brain that ran on ketones and how high did your levels get measured in the blood i kind of struggled to get up there even with the classical ketogenic diets two and 2.5 i would typically with the classical ketogenic this is before mcts so i wasn't quite using mcts yet in 2009 i started incorporate the same time i discovered the modified ketogenic diet was the same time i started using mcts and a modified ketogenic diet with mcts got my ketone levels up probably higher than the classical ketogenic diet which was just mostly you know a dairy-based long-chain fat sort of derived diet so let's tell everybody how we make ketones and then we'll tell them what mct is yeah so let's talk about starvation ketosis and then if there's differences between that that are worth highlighting with nutritional that would be great but evolutionarily i'm gonna deprive you from eating for a few days how do you survive well you start burning up your liver glycogen okay so 24 hours later you've got that down to about half of its half to a quarter of its supply through the suppression of the hormone insulin we start mobilizing fat from adipose tissue which are cells pretty much all cells in the body especially muscles and heart cells burned fat like a superior energy source long-chain fatty acids don't effectively cross the blood brain barrier so through accelerated fat oxidation beta oxidation fats in the liver that stimulates the accumulation of acetyl-CoA which forms acetyl-CoA and ultimately beta-hydroxybutyrate so you start spilling these ketone bodies through accelerated fat oxidation in the liver the liver lacks sexenyl-CoA transferase so it does not actually use the ketone bodies for fuel and they become available for your brain central nervous system and peripheral issues so the liver is one and some people five to one generally speaking about four to one so acetyl acetate is unstable in that it can spontaneously decarboxylate to acetone which is volatile and we blow it off in our breath does it have metabolic activity can we it was thought that it didn't but more recent work is suggesting that the carbons of acetone do find their way into sort of lipid biosynthesis and some other things but it's kind of rare for that it's not a great ATP source not no not not really it has some effect on neurons so it has an anti-convulsant effect through i believe opening a potassium channel which could hyperpolarize membrane potential and actually help attenuate some hyper excitability in the brain so there are people that study you know the effects of acetone as a sub-narcotic levels of acetone right acetone can be pretty narcotic and be problematic but acetone levels that are 0.5 millimolar and even upwards of one millimolar can have a neuroprotective effect once you get above one millimolar you start to dissolve some of the membranes and you can have sort of uh yeah you have problematic you know acetone as a pretty powerful solvent right it's a nail polish remover but small levels of acetone and neuroprotective and that's actually something that we study so how do co-acetate and beta-hydroxybutyrate enter the Krebs cycle in other words where do we get ATP from them it depends on the cells so different cells have different we're looking at this now different ketolytic enzymes right so they can feed in through a number of different pathways like i said the liver is the production site of beta-hydroxybutyrate and when it comes to skeletal muscle they have a range of ketolytic enzymes that can allow them to enter the Krebs cycle at different different areas so succinate for example so you can replenish tca cycle intermediates with succinate you can acetyl acetate can break down and provide acetyl coa for the Krebs so what we're finding is that the Krebs cycle is not the simple cycle that we thought it was especially as it relates to cancer cells so it's almost like we can't even look at the biochemistry book and kind of pinpoint different pathways with substrate level phosphorylation there are a number of different pathways like the malate aspartate shuttle that are associated with cancer cells if we go back to those pathways did you see that paper that came out in nature two days ago about aspartate being a rate limiting step in cancer metabolism in the mitochondria i didn't see that i haven't bob and i were talking about it today it's interesting because the paper was part of it was written through a lens of hey this might be how metformin can exert some of its anti-cancer benefits by interfering with aspartate i think it was interfering with degradation of aspartate but again i haven't read the paper yet just sort of the abstract but there was yet another like i didn't know that wow every day i feel like i feel like i'm getting dumber because the rate at which i'm being exposed to information is exceeding the rate at which i'm assimilating it so it just feels like i'm on a downward spiral through stupidity there are textbook pathways that i used to just rattle off and it all seems so simple and then you know i read three or four papers and i realized that i probably shouldn't talk about it in simplistic terms like that and we're kind of going down the rabbit hole of glutamine lysis right so glutamine is the fermentable fuel so ketones are a non-fermentable fuel whereas cancer cells will use glucose and glutamine as the two primary fermentable fuels that's funny i mean i know that biochemically i never thought of it in those terms though yeah yeah it's not fermentable that's interesting so that's kind of what i'm thinking about you know in terms of ketone metabolism with glutamate so or glutamine glutamine can make glutamate right and alanine and aspartate and lactate and glutamine lysis is kind of driven by the malate aspartate shuttle and that has become a major focus now of many cancer researchers are looking to target glutamine it's not it's not easy i mean because if you have a glutaminase inhibitor that has tremendous side effects right yeah so we need to approach this in a very nuanced sort of way when it comes to targeting glutamine yeah so let's go back to the mct so you talked about how you started out on the four to one ratio which is interesting i started out four to one i spent three years on just four to one i never deviated from four to one but then you mentioned you went to two to one which is obviously much easier to do but you augmented with mct so mct of course stands for medium chain glyceride they're a type of saturated fat and they're of a certain length and i don't even remember anymore is it eight to fourteen carbons is what we define as mct yeah eight to ten i think eight to fourteen from in that but when we talk about the ketogenic ones the uh they're more closer to the yeah so why does why does taking those make this process easier when you consume them orally they are transported to the liver via hepatic portal circulation and they're not packaged into chylomicrons and you know long chain fatty acids when we eat them they're packaged into chylomicrons and they go through essentially enter the lymphatic system and have a different route of entry they're metabolized really differently whereas medium chain fats go directly to the liver through hepatic circulation it's like a bolus of fat going to the liver and it's a type of fat that's rapidly oxidized right the liver is chock full of mitochondria so if i want to study mitochondria i'll take out a chunk of the liver and isolate it from that because that's the easiest thing to do so the mitochondria really burn up medium chain triglycerides very quickly and uh there's very high rates of fat oxidation in the liver from an oral bolus of medium chain triglycerides so they're much less likely to be stored as fat they're a source of calories and they can be incorporated into meals and into foods to further enhance and boost the ketone levels of the ketogenic diet or even if you're not on a ketogenic diet they can be consumed with a high carbohydrate diet and actually elevate ketones in the blood yeah i mean i've heard that but i've never actually measured it probably because i've only done this with liquid mct which you end up getting to sort of gi tolerance becomes an issue probably before you get a high enough level but if you're on a high carb diet and you consume i don't know two to three tablespoons of mct how high could you reasonably expect your vhb to get depending on your absorption anywhere between 0.5 to 1 millimolar that's high yeah even on a high yeah if it's pure c8 maybe uh so with c8 you get about 20 maybe 30 percent elevation above like a mix of the c10 c8 which is generic there's some work being done that c10 may actually have some beneficial effects i mean that's kind of the idea behind the product exona that was on the market you know a while back i don't know if it's on the market i don't know what it is yeah it's basically c8 it's powdered c8 oh i used to just order pure c8 yeah you can order it like from sigma or something like that yeah well dave ask for his brain octane is caprylic triglyceride and perillo nutrition makes caftree which is a c8 oil so if you buy pure c8 not in triglyceride form caprylic if you just uh just straight like acid yes that'll kill you i mean you consume that i bought i made a mistake early on and bought from sigma caprylic acid but not yet you need to buy how did you catch that mistake before investing it i bought it from sigma and i think i was going to use it in experiments and we're going to mix it you know with a ratchet i wanted to go through a legitimate source and i put a little bit on my finger and it kind of burnt my tongue off and i realized wait a second i think i need the triglyceride form of caprylic acid i need a caprylic triglyceride yeah i almost killed myself you almost won a darwin award yeah yeah you know i never listen to someone probably did that before accidentally uh kills himself yeah have you had any experience with powdered mcts yeah yeah so powdered mcts allow me to increase my ketone levels higher than uh and i use the quest powdered mct formula there's a couple on the market now maybe yeah i have vats of this stuff at home because i feel like anyone who's ever made a ketone product just somehow figures out my address and sends them to me so i have a pantry full of every type of ketone you can imagine i do too but i haven't got you probably get more than me i just haven't got around to trying any of the mct powder but i'm getting ready to do a long fast in a couple of weeks and i was thinking i really ought to get make sure i'm back in ketosis the week before i deprive myself of food for a week yeah so i was actually just thinking about this last week because i gotta fire up those powdered mct and kickstart this thing because i don't have like a couple months to get fully adapted yeah they are great i mean mcts are kind of like the poor man's ketone ester right so they are they're found in nature they're versatile you can call them the middle classes man yeah given how expensive ketone esters are now that's right that's right yeah so i tinkered a lot with mcts early on and increased my tolerability from maybe 30 milliliters a day to 150 milliliters a day really easy hang on a second that's ridiculous yeah anytime i went to 30 in one sitting 10 tablespoons yeah that's that's hard to fathom you need to incorporate it with food so i was spreading it what i found i needed to do was instead of doing intermittent fasting now which i pretty much do now i spread it out over like four meals and maybe would have a little bit of mct in the coffee too and not including that in a meal so i was eating a modified ketogenic diet but spreading that mct out with salad dressings putting it on vegetables and things like that and i was able to because if anybody's listening to this and they're just sitting there thinking what can i do to have a bowel prep like the answer is just drink mct it's better than fleets phosphorus soda you will you'll spend a day in the bathroom and you'll have a great but you can work your way up to it so there's a number of transporters obviously that are upregulated and you are enhancing the breakdown and transport of these and mcts actually do cross the blood ring barrier so we did studies in rats where we they're getting absorbed portally how do we know oh okay some of them i forget the percentage but i think and some people say it's like 50 percent of mcts converted to ketones but i think it's something like about 20 percent of mcts and it depends on the energetic state of the liver you know which is a master regulator and your your physiology in general but you have a fairly significant portion of the mcts being converted to ketones but the mcts do enter the blood and they can cross the brain barrier unlike the long chain fats and they for example if you take out the hippocampi of rats that are eating an mct-based ketogenic diet you'll find mct levels are significantly elevated so they're crossing they're getting into the brain and the brain is utilizing mcts as fuel and do we know if that has any anti-seizure effect independent of the ketone that might be produced alongside it that's a big area of research right now that mcts is functional fats so and i've never heard that term before functional fats yeah like well fats with drug-like properties so i think there's a number of patents around c10 actually that i know they have in the uk i think it might be a pharmaceutical now so c10 actually has anti-seizure properties so there's some people argue that the effects of the ketogenic diet at least mcts is not due to ketones but actually due to the mcts and not the ketones so there's a little bit there's a couple groups out there that are sort of arguing that and i think they have a case but i think it's it's probably a comment definitely a combination of the ketones and and the mcts so mcts do have interesting properties do you know elizabeth thiel at boston children's so i remember having breakfast with her about six years ago and asking her a question at the time i don't think she knew the answer to and she was gracious enough to explain that and she was there with someone else in her lab so it was a very spirited awesome discussion but i wonder if the answer is known today the question was basically do you believe that the anti-seizure properties of a ketogenic diet are more the result of the brain having another fuel to displace glucose or due to the reduction in glucose that invariably accompanies ketogenesis and at the time she shared with me very compelling data that would could argue either of those points potentially suggesting it was the combination of them do you have a point of view on this or is there more information today that sears you one way or the other well i know she's done some work with a low glycemic index diet and so carbohydrate reduction but without the production of ketones yeah so a reduction it's carbohydrate restriction but only to the effect of maybe 20 or 25 you know and then carbohydrates that are low glycemic index and what are the results of that intervention for different types of seizures it can have a positive effect and for certain certain types of seizures that's not the first line of therapy for you know very powerful tonic-clonic seizures in you want to go right to the classical ketogenic diet but it does have a number of applications for different types of seizure disorders and what about if you take someone on a fully carbed diet who's having recalcitrant seizures and you give them ketone exogenous ketone does that have anti-seizure benefit yeah so those studies have not been done yet and there's a study being recruiting right now for something called angelman syndrome which is a rare genetic disorder that has seizures where the exogenous ketones are the therapy independent of the diet so they're just being added on top of the diet there are people out there because exogenous ketones are commercially available that are using this in place of the ketogenic diet because the families are either unwilling or for various reasons unable to use the ketogenic diet and they you know use are using exogenous ketones and the feedback that i'm getting could be biased but it does seem to have an effect it obviously has an effect in animal models the animal models that we work with we give exogenous ketones on top of a standard rat chow which is high carbohydrate chow and it uh it works very well for uh cns option toxicity but also for things like phenyl and tetrazole seizures pct seizures even for absence seizures we use a particular animal model with absence seizures or absence seizures it works for that so it works for a variety of different seizure models independent we are circumventing sort of the dietary restriction that's typically associated with getting into therapeutic ketosis and just simply giving exogenous ketones and elevating you you exogenous ketones but a consideration is that exogenous ketones lower blood glucose so you have and in some cases it lowers it really low like the high dose ketone esters that we do in our models it pushes and rats typically maintain a glucose around 140 to 150 and it'll push it down to 40 so milligrams per deciliter yeah and that's approaching the maximum tolerable dose of the ketone ester and it's interesting when we go above the maximum tolerable dose we actually see glucose spike up and this is a phenomenon that we see it's almost like stressing out the liver just regulating the liver in some way it's the data we're trying to figure out but if you titrate in ketone salts or ketone salt mct combination or various ketone esters it's inversely proportional to as you elevate ketones you have a very predictable reliable decrease in blood glucose that's above and beyond the decrease in blood glucose that you'd observe with something like metformin and we use metformin for many many studies in a lab and we have a lot of experience so what do we think you know it's funny i was up in san francisco like a month ago and i was talking with steve finney who you know the outside i said you're one of the people who i would say knows more about ketosis than anyone alive and certainly steve would have to be in that category so i would if i were going to just guess i would say between you and steve finney if the answer isn't really known on ketosis the answer might not be known yeah yeah so but and steve and i were having this really fun discussion with a few other folks about why is it that the ketones are driving down the glucose levels and conversely and maybe this is a different question of course but why is it that when we do these experiments of you take somebody in nutritional ketosis and you make them do really really aggressive exercise you know do a two-minute all-out effort on the rowing machine that the ketones go way down and the glucose goes way up is it solely a consumption and a glucose output issue is there something else going on you know and i was like well i kind of always assumed that we knew the answer that it was the explanation i had but you know wasn't at the end of the discussion i was like actually i pretty much now i don't think i know the answer to the question i don't think we do i have three potential explanations one could be an exogenous ketone induced release in insulin that facilitates glucose disposal so where that happens you do get i mean it's not like consuming a protein bolus or a carbohydrate bolus but you do get an elevation of ketones that's how we moderate our ketone levels right so as our ketone levels if we're on a ketogenic diet and our ketones become elevated there's ketone urea we pee out some ketones and there's a number but one is a ketone induced release of insulin which then feeds back on the liver to like a rheostat really and lowering beta oxidation which totally makes sense because that's the reason that type 1 diabetes can get ketoacidosis they lose the checkpoint yep yep and other researchers like if you ask richard beach he'll tell you that insulin sensitivity is increased so the insulin that you have available and associated signaling is being enhanced in the presence of ketones so is that an immediate change or is that a change that takes place over a long period of time that sounds like a long-standing issue i think there's a number of regulatory things that happen i know in his study where rats were fed standard rodent chow but 30 to 20 ketone ester i think within that chow their baseline insulin levels went down like 50 percent so that's just simply by you know just the addition of the ketone just the addition of the ketone over time over i think it was like maybe three weeks i gotta look to see the study but it was it was consuming ketone ester that was integrated into the rat chow over a number of weeks decreased baseline levels of insulin significantly i mean it was like a huge effect and the implications of that you know it was a rat study you know you can argue but i can tell you experimentally that or just you know testing on myself that the same observation happens i can actually if i get a significant amount of my calories from exogenous ketones and i do that over several weeks and i measure my insulin it gets below the reference range whereas if i get back to a regular ketogenic diet i'm always on the low end of the reference range but i did find if i consume the maximum tolerable dose of the ketone ester or ketone salt and then i measure insulin you know an hour or two after that i do get a little bump up in insulin but it's nowhere near the bump i would get up if i ate an equivalent amount of calories from protein or carbohydrates which would shoot me up to like you know eight or ten or something like that you know with a big dose but it's just somewhere around i bump it up from like 1.5 to like 2.5 or three or something like that that's super yeah and that's my baseline it's usually between one and two so how has your igf level changed in the years that you've been on ketosis have you tracked that much i have not i've gotten it measured a few times but not not reliably like i do insulin quite often like every every two months or so like i'm doing that if i'm doing an experiment i may do multiple measurements of insulin like throughout the week but i haven't measured igf1 recently i did a while back and i was just in the normal range but i wasn't fasting i didn't that's the one variable i wish i would have tried insulin was i can assume my gf1 might have been a little bit low yeah so just for listeners and stuff how do we measure ketones i mean people talk about urine strips versus blood what are you measuring in each and breath for that matter you have three ways to measure these things which one do we prefer and why for a newbie getting into this i think the urine ketone strips will at least tell you if you're in ketosis or non-ketosis what is it measuring it's measuring what does it tell you urine acetoacetate is measured and now there's a urine beta-hydroxybutyrate kits that are available so you could do that so the abbot labs precision extra and the keto mojo are two devices that will measure basically an assay a home assay kit for beta-hydroxybutyrate and we have used both of those things and kind of measured it against various assays in the lab and blood that we send out for analysis and it's pretty close pretty close plus or minus maybe 10 or 15 percent what does the urinary level even though it's a qualitative assay but you know everybody says hey my urinary ketone thing lit up right purple can we infer anything from that about the blood level of bhv or acetoacetate usually you know unless you're running kind of dehydrated you know if you have a normal hydration state and your urine acetoacetate is 40 milligrams per deciliter above you are probably hitting one millimolar or above if you're anywhere between 40 and 80 to i think 160 milligrams per deciliter so you're in a state of ketosis if you're at 15 that's like light pink or something you're usually probably not in a state what i would say you know that might be a normal state if you wake up in the morning and sort of acid state you might be hitting that but generally speaking you need to be about 80 milligrams per deciliter on a urine ketone strip and the one thing i didn't do rather when i was doing my sort of long four aims of ketosis is i didn't use the urine meters at all i was just you know i was i was keeping abit in business basically with how many of those precision extra strips i was going through so i don't know if my urinary excretion actually declined over time when my body became better and better at retaining this potentially preferred fuel have you done anything on that either personally or in the lab so what we use in the lab is the clinitex status device and that device takes the semen's 10sg kit so the multi-stick so you can buy for a similar cost as the keto stick you could buy the semen's 10sg multi-stick and that measures 10 things including urine acetyl acetate and you could take that urine strip and stick that in a device that will give you more of a quantified number i see so that's how you were giving me quantitative information on the urine because i've only seen the qualitative stuff well it's a color change on the strip that's measured in the device yeah so over the years i rejected urine ketone strips as something that just wasn't very accurate and the more i use them making hundreds if not thousands of measurements the more i gain an appreciation that it can be a pretty useful device but i think it's it's kind of useful for the individual your hydration status definitely changes it i mean i've been in situations where i'm dehydrated where i've come out of the water after like a six hour dive and i peed on those things and it's like it's like screaming and i knew i mean i did some dives where i purposely wasn't in ketosis for some of the research that we do and i was deep into ketosis because i was you know very very dehydrated i didn't know someone to dive for six hours i was on the nasa nemo extreme environment mission operations trip so i was a crew member on that where i maintained i was in saturation for 10 days in a hyperbaric environment and uh that involves like an 18 19 hour decompression to come out so it's a nasa sort of mars analog mission where you work with astronauts underneath the sea and i maintained the state of ketosis throughout that whole mission and uh and did lots of lots of measurements on myself down there and i saw really when i one time i got out after maybe it was a six hour eva so essentially you're in a hyperbaric habitat on the bottom of the ocean and then you go out into the water and then you come back inside the hyperbaric habitat but when you're out in the water even though you're down in the keys the water water pools heat from you like 200 times faster than air so even though it's like you know upper 80s i come out of that hypothermic and dehydrated my blood glucose always was in like the 30s sometimes in the 40s when i was on akita i was testing some of the ketone supplements wow what were the other people experiencing under those circumstances well we'll find out with uh this my wife actually was selected as a crew member for nasa nemo 23 i was on 22 and i did not get the irv protocol approved to do all the metabolic studies that i wanted to do but i became an end of one on that and i collect a lot of data on myself so with this new mission we have the nemo nasa nemo 23 we'll be able to make some pretty comprehensive metabolic measurements including things like hemoglobin h1c we're going to measure inflammation hscrp glucose ketones all these things on all the crew members interestingly this year it's a it's an all-female crew so you have like samantha christopher reddy the famous european tracy caldwell dyson who i've known at nasa and my wife and it's all female so we'll have some female data to go along with this what surprised you the most in your end of one what did you see that you least expected i saw i predicted that the habitat would really trigger inflammation that was probably from the elevated co2 levels and the elevated oxidative stress i chose to stay in a state of ketosis with the idea that that was my baseline state we're doing studies on sleep we're using the or ring probably familiar with that on sleep and also the polar v800 to collect heart rate variability data gut microbiome we're doing body composition measurements we're doing uh stress so we use the nih toolbox and joggle to look at cognitive psych parameters so that data has not been shared to me so i don't know my wife collected some of that data and that's being analyzed you know later on for publication but from a metabolic perspective from a hormone perspective some of the things living in that environment for 10 days decreased my testosterone almost at a 25 decrease in testosterone from uh the time and so we're fairly maybe fairly sleep deprived i average about six hours of sleep per night but i was getting like two and a half hours of deep sleep which is more deep sleep than typically yeah i was like i don't know if it's a it might be an artifact of how the sleep is being estimated in other words you know if you're assuming you're giving out the aura ring right yeah so the aura ring is measuring but i usually get about 90 minutes sometimes like last year last night i got one hour and 53 minutes of deep sleep but i usually get about one hour one and a half hours of deep sleep but i got over two hours every night and instead of seven hours of sleep a night i was getting consistently just you know five to six hours of sleep a night so where are you getting mostly short change on rem yeah on rem but my rem was even not that bad usually i was getting about an hour you know an hour round which is not as much as i like yeah that's too low usually two is optimal for me i think so yeah we measured sleep the things that really stood out were being in the water really pushes my body into and being hypothermic really turns me into a fat burning machine my ketones go off the chart and my glucose goes way down it almost looks like a six-hour eva when i came back into the habitat look like i fasted for a week so i have all that data for that too that i need to compile now should we be looking at that we meaning people as a potential way to replicate fast under a more stressful state looking at what just underwater yeah do you think it was a combination of temperature and pressure primarily that was driving that effect so over the holidays we went to thailand and we did i did a lot of nitrox dyes something like 30 nitrox dyes and i made these measurements too and i did see trends for decreased glucose and nitrox dyes were doing like an hour maybe hour and a half dyes at the most and i saw trends but nothing like the trends i saw in the saturation environment when we did these long evas so do you think that the temperature i think the temperature the temperature really has to have a difference because you come out and you're kind of shaky you know even though you feel very comfy when you're down there the first two or three hours and then by the end the last you know four five six hours for a longer eva you start like shaking a little bit uncontrollably you know but it's kind of subtle even though the water is kind of warm like it feels warm but it's just your body temperature is going down and they were on the days maybe i wasn't getting as much calories as i as i needed i came out of that mission lighter than i've ever been before i came out when we got back to mainland and i stepped on the scale i was 207 which is super low for me i ended up losing about maybe i went in kind of late because i was training for it i'm not a very good swimmer like you i had to really train to meet like you it would be like a total day in the park for you to meet all the criteria for that but i had to train really hard to meet the swim requirements so i ended up losing a little bit of weight but when i came out i would definitely did the whole mission i lost nine pounds and i came out so i went in 216 so i went in pretty late i'm like 221 now so last year i entered the mission at 216 and i came out like 207 which was like i thought the scale was wrong so even though i ate a lot of calories during that mission my metabolic rate was really high you know and that was a consequence of that is so interesting because those are two completely contradictory concepts to me on the one hand you're saying hey my glucose levels went down my ketone levels went up it looked like i had fasted for a week but of course if you fasted for a week your metabolic rate would be going down and not up in fact you would expect to see autophagy skyrocket whereas i'm sitting here as i'm listening to you thinking would autophagy have increased during that period of time or decreased i think anything that pushes glucose that low and ketones that high and i think not really without knowing it we're pretty task loaded so you don't have all the time you know that much time to eat i mean part of the mission is that they're training this is part of it's the only nasa analog where astronauts are actually part of the crew members like other things like high seas mission or nasa hero mission actually uses everyday folks and they push them to the limits to see how they can break them but the nasa nemo mission is actually training sort of astronauts so they task load you to see what you're doing and you don't have a whole lot of time to eat but i was i was consuming what my normal calories would be but i was under i underestimated my calories for this and i think it put me in a calorie deficit would probably decrease my testosterone may have i think my cortisol level increased but it was still within the normal range and you're away from the light so your circadian is probably a bit screwed up too being in the episode you're only at like 60 feet so you do see some of the light come down and but uh but it's probably a little bit different than i'm a very light sort of sun worshiper like i always try to get some light in the middle you know in the beginning of the day and that's part of something i always do so it was a bit disruptive in that sense so let's talk about ketone esters et cetera so to your knowledge what's the first exogenous ketone that was ever manufactured is that vitale one or exogenous ketone manufactured so 1-3-butane diol has been around a long time since the 1950s actually mit did some research as a space fuel so that was a publication in 1975 where they were trying to identify an alternative energy fuel for long duration space flight and best candidate was 1-3-butane diol which is sort of a synthetic compound that breaks down completely to beta-hydroxybutyrate meaning the liver is not required to transform it into bhg the liver is required yeah through a couple simple steps so sodium beta-hydroxybutyrate would be the first sort of ketone exogenous ketone that was used clinically and that there's a number of papers that utilize that for rare metabolic disorders actually so that would be the first one and a lot of ip and you know sort of the patents that came out were sodium beta-hydroxybutyrate and then maybe explain for people what the differences between a salt and an ester so we'll leave the coacetate out of that for a moment yeah but if you talk about beta-hydroxybutyrate but you can have a coacetate salt too so i can mention that so i didn't know that i thought it was only a diester so that's what i want to hear about that so on the bhb front people are sort of inundated with ketone salts ketone esters and a whole bunch of like weird stuff like raspberry ketones and stuff but let's just leave the nonsense off the table yeah but if you just talk about comparing a ketone a bhps or to a bhp salt what's the chemical difference yeah so a salt is just an ionic bond right between the ketone molecule beta-hydroxybutyrate a monovalent or a divalent cation or an alkaline amino acid like arginine citrulline histidine lysine so you can literally ionically bond beta hydroxybutyrate to a number of different things the easiest thing to do is to bond it with sodium potassium calcium and magnesium calcium magnesium have two positive charges you can put two bhbs on them that's the advantage sort of an advantage a disadvantage i guess with magnesium bhb which is actually is very bioavailable magnesium i measured my magnesium after taking it it went quite quite high disadvantage is that your gi tolerability to something like magnesium beta hydroxybutyrate may be only somewhere between one two three grams you know three grams max per dose wow so not that much one gram three times a day at least for me had no issues i could probably tolerate two or three grams per day so it's nice i mean it's something that's contributing but ideally what you want to do with a ketone salt is because salt has a stigma called in ketone electrolyte formulations is to spread the beta hydroxybutyrate out across monovalent and divalent compounds and they're the four that have the most utility and then an ester of course is a covalent bond not an ionic bond right yeah so you can take one three butane diol and you could create a mono ester with a hydroxybutyrate right and just add it to a trans esterification reaction and combine that beta hydroxybutyrate to one three butane diol or acetoacetate you can combine with one three butane or you can take glycerol so with glycerol you can come up with a triester of glycerol which we have basically you're creating a triglyceride that instead of three fatty acids you have three bhbs it's pretty cool molecule yeah so we have some experience using anything that so yeah i told a story like many many years ago before five years ago on tim ferris's podcast about how i drank this jet fuel and almost thought i was going to go blind of course what i may or may not have omitted from that story was that you gave it to me and so the ketones today tastes a heck of a lot better than that earlier gen stuff and even when i told you that i just took a 50 ml vial you sent and chugged it in one sitting even you were sort of horrified like wait wait you didn't read the note i wrote you explaining how to dilute it and mix it i talked about it we had assuredly talked about it you're very enthusiastic about getting started yeah yeah i couldn't resist i was too so that stuff's unbearably bad yeah so what i mean where the ketones actually don't taste bad they're strong but they're awesome yeah so why does the ester is there an obvious reason from an olfactory slash taste perspective why they are so staggeringly horrible yeah or at least they were i mean i'm told they're better today yeah i would say the ketogenic potency is inversely proportional to taste so it just seems like you know the more the more potent these compounds get even the triester beta-hydroxybutyrate you know it's pretty nasty stuff meaning that glycerol triglyceride that yeah it's a great molecule i mean it has like lots of you know tremendous utility well making a ketone ester with 1,3-butane diol is really cool because the 1,3-butane diol itself is broken down yeah so that goes into another question the whole anantumor so if you use the r-hydroxybutyrate with the r-1,3-butane diol then you can really get ketone levels up pretty high and that would be sort of the delta g or the human you know ketone ester that's out there it's the r anantumor uh that would be the r yeah the r it's r what so you have you can get racemic 1,3-butane diol but that's the r anantumor of 1,3-butane diol with the r-hydroxybutyrate can we explain to everybody what the r versus l means in the anantumor world so beta-hydroxybutyrate not a seboacetate but beta-hydroxybutyrate has a stereoisomer so if you put your hands together the r beta-hydroxybutyrate or let's do d and l let's do that so the d would be equivalent to the r beta-hydroxybutyrate would be the mirror image of the l beta-hydroxybutyrate and the predominant form of beta-hydroxybutyrate in the body is d beta-hydroxybutyrate we do have a racemase enzyme that in various tissues that can convert the d to the l so but when you're in nutritional ketosis reservation ketosis you're making d anantumor of the bhv predominantly yeah so we do have the capacity to make the l but it's pretty pretty minimal so that brings up the question i think 99 of all the ketone salts being sold right now are racemic so they are the d and l when you get equal yeah yeah they're equal amount and there may be a concern there but we don't know so most of my research has actually been with the racemic compounds and they work great therapeutically in pharmacology there's a sort of history of getting the anantumor wrong i mean one of the famous stories i know of is philomide yeah philomide as well yeah so that's right philomide and phenphen were both examples of using the wrong anantumor many pharmaceuticals like i think ibuprofen i know like ephedrine you know is racemic and many of the drugs out there so and things like ringer's lactate i think you know lactate is is it d now it used to be racemic oh really i think yeah i think you can get both okay so you're saying look physiologically exists at 90 10 d to l and then you're buying something racemic you at least have to entertain the question hey am i ingesting something that might have a negative side effect yeah and so the ketone esters they're mirroring the physiology they're just going mostly d presumably well the human ketone ester from my understanding is completely d so it's produced a d beta hydroxybutyrate interestingly elevating just beta hydroxybutyrate in our seizure models even with the d does not have an anti-seizure effect so that's actually why we went to the 1,3 butane diol sorry say that again did you say that if you use a pure d salt a d salt or d ester pure d salt or pure d ester no anti-seizure no anti-seizure effect with beta hydroxybutyrate we needed and the animal models even suggest this if you just look even studies beyond our study is that you need to elevate acetyl acetate has the anti-seizure effect and we don't know exactly why that happens the ketone ester that we work with which is 1,3 butane diol acetoacetate diester elevates beta hydroxybutyrate and acetoacetate in approximately one to one ratio is that what you used to give me or was i just i gave you a bunch of things what was the one in the capsule that tasted even worse than the bhb ester actually that yeah that was the diester of acetoacetate yeah and that's really potent it was bound to what it was 1,3 butane diol that shit was from another planet of that i still have some because i've been shots of that i like to just get many gallons of that through me and done quite a bit of blood work and know pretty reliably at least in my body that it's not toxic and pretty much all the biomarkers go in a remarkably positive direction but even though i know that it's not enough for me to you know even though it has that and that's no matter how great a substance can be if it doesn't taste good you know even me i'm not going to take it you know even in a capsule exactly well i also remember you telling me because you sent them and i was like oh sweet it'll be capsules because i had seen your animal data and i was like i want that and then you said okay well i'll send you in capsules because you can't drink it it's too bad and i was like perfect situation resolved and you said not entirely you'll still taste it through the capsule yeah and i actually find it to be a great dinner party trick like like who's the biggest you know tough guy here that just wants to show me how much of this stuff they can ingest yeah yeah i mean we've done a lot work with an ester and it has remarkable effects but we think it's probably more suited for like a medical food and something that could be sort of a parental you know ivy therapy so who first synthesized that so i reached out to honoree bruning grabber at case western who was the director of the metabolomics nih funded i think metabolomics core at case western and i reached out to everybody but who had any experience you know either researching with ketone esters or synthesizing them and he kindly gave me the recipe on how to synthesize it that was above and beyond the patent it was actually a detailed recipe on how to use a kugel road distillation apparatus where to get the vacuum you didn't already know how to do that i knew it well actually so patrick arnold as you know kind of helped me with the art so in organic chemistry really is an art you know to be able to do this patrick is an artist patrick is an artist and he was he thought this was like shady stuff in the beginning and i kept sending him papers and and then he realized that this could be something big you know uh he realized that the science was there and there was a lot of big players in this field who had done remarkable research but just didn't really have what it took to like actually make it a product like synthesize it and stuff that you actually consume i became obsessed with patrick after all this stuff happened and um i actually introduced him to tim and in the show notes of this i'll make sure that we link to tim's podcast with patrick which i'd love to have patrick on the show at some point to talk about this should this show end up persisting but that episode with tim and patrick is so interesting it's like if you have any interest in endocrinology in sort of like how the hormones work how steroids work it's yeah just what a character i owe a lot to patrick i don't think i probably wouldn't have gotten tenure without i owe so much to him so i need to acknowledge him for that that there were academic icons out there who could not do what patrick did for me and he was pretty persistent in doing it too so he synthesized first the monoester and then it was a mix of monoester and diester but he nailed it down to you know ultimately getting the art of organic chemistry to where it's pretty much pure diester he's such a wonderful human being anytime i email patrick a question which invariably i do have like clinically i'll have a question about a hormoner they'll be like there's no textbook that knows the answer there's no paper that knows the answer i'm like patrick i got a crazy question for you and it's like even if he doesn't know the answer and he'll have a more thoughtful insight than you can get anywhere and it speaks to his capability so first of all you shared me something i didn't actually know today that's really interesting which is this notion that if you are purely using the d and antimer you do not get any anti-seizure benefits whereas if you're at 90 10 presumably you're getting so you don't need a lot of l but you need some of l yeah i don't think there's any studies that show using an exogenous ketone in the form of pure beta-hydroxybutyrate is beneficial so what we do know is that when you deliver exogenous ketones in a beta-hydroxybutyrate to acetoacetate ratio of one to one that that has pretty remarkable anti-seizure effects and there was some studies that were done with acetoacetate and also some studies that were done with acetone showing anti-seizure effects so i do think it's acetoacetate is necessary so what we don't know i don't think that racemic salts or racemic esters or esters that produce both d and l beta-hydroxybutyrate are a concern i have not seen data to suggest that these would be a health concern there are companies out there that are selling eight million sort of doses per month of salts that are racemic in nature and there have been sort of no consequences from that that have been reported so how are so many companies able to do this is there no ip in the salt world anymore i don't think there is ip for i think some of the early patents may expire so i don't think there's actually there's there's some intellectual property with formulations of a ketone salt and a ketogenic fat and mct and that's some of the stuff that my university has and there's some composition matter patents and maybe some use patents around the d salts i think and maybe the d ketone esters so at this point in time do you think that the ketone salts have more physiologic benefit than the ketone esters just as a function of having a higher amount of the l and antimer so i think when it comes to purely a metabolic fuel i think the d beta-hydroxybutyrate has some advantages right so we also know that in regards to some of the signaling effects especially the inflammation the nlrp3 inflammasome is suppressed by beta-hydroxybutyrate both the d and l form and we know that when we consume racemic ketone salts in the d and l form the l form tends to stick around longer and gets metabolized slower so conceivably that could be having a stronger anti-inflammatory effect because you have a ketone body and endogenous metabolite that's functioning as a very powerful signaling molecule that's suppressing an inflammatory pathway so the concentration just tends to get higher you know that's my view of it so we haven't really studied that in detail but the lab that did some of the work on showing the nature medicine paper that showed the nlrp3 inflammasome was suppressed by beta-hydroxybutyrate it occurred both in the d and l form we do know that the l form gets metabolized slower so the concentrations in the tissue may actually reach higher levels so what we have observed is that the racemic beta-hydroxybutyrate has a glucose lowering effect so we're trying to figure out but we also see that we also see that in the pure d and antimer i've seen that with the human product which is obviously a pure d phb i think they're seeing about 20 to 30 percent reduction in glucose do you see more than the racemic it tends to be the case yeah it tends to be the case especially with one three butane diol you see it and maybe it's a read-off shift in the liver that's what honore green grabber thought but it's pretty remarkable and when we compare so i have some products in my back i'll give you i have i've been doing a lot of work with d salts so i've been consuming d salts in pretty high levels that bring my ketone levels up pretty close to an ester so you can formulate sort of if the elevation of my ketones gets more than three millimolar i just start feeling a little bit weird occurring ketones at much higher than that level yeah but i don't actually i'm a pretty good ketone burner so you could do a glucose tolerance test i do a ketone tolerance test a ketone tolerance test is consuming a known amount of ketones and looking at that pharmacokinetic curve so you measure so you'll do fasting level of bd glucose insulin fatty acid ingest your ketone and then measure 30 60 90 120 minutes and athletes have challenged them with a ketone tolerance test i'm creating like a new test here they actually dispose of ketones and utilize it remarkably when you take a couch potato and it's the same as a couch potato rats you could push a couch potato rat into ketoacidosis if they're older their tissues are not effectively utilizing the ketones for fuel and i've seen that in some individuals and some people i get hundreds of emails and people show me their data and one packet of even a commercial ketone product on the market can shoot some people up to like five or six which is like just to be clear in that ketone tolerance test which by the way i freaking love this idea how have you not told me that until today holding out on your best stuff just materialized in my brain what am i going to call it you know next time you get what it is just pick up the phone you know my number you call me you tell me this stuff this is your it's like you're holding out i just want to make sure something is this independent of whether or not that athlete was in ketosis before or after in other words how much of that utilization is a function of the metabolic machinery in the muscle to utilize ketone versus hey athletes are just better at oxidation to begin with fat adapted athletes are very good ketone utilizers and have a hard time elevating their ketone levels with ketogenic diets if you take a high carb athlete who's still physical and you do this test yep how do they behave not as well and i do think that high performing athletes probably are bouncing in and out of ketosis right you have post-exercise ketosis just from the energy depletion that you get during exercise so their bodies are probably used to seeing ketones using them as fuel but if you take someone who's a real keto adapted fat burning like ketone machine and you hit them with high doses of ketones they tend to dispose of them very quickly so they've upregulated ketone transport across membranes across the blood brain barrier through the mct transporters which are upregulated and this of course is not the same mct that we talked about earlier no these are monocarboxyl acid transporters it also transport things like lactate and pyruvate and because the mct transporters are much higher and more dense in the membrane you probably clear lactate faster so i think that may contribute in part to why keto adapted athletes produce less laughing it's funny you say that i hadn't thought of that actually i didn't realize that in ketosis you upregulate mct i've always suspected that that might play a role in the genetic differences between athletes why do some athletes seem virtually unparalyzed by anaerobic activity and it's like look if you can shut a lactate out of the cell quick enough you can recycle it and reuse it we actually tried to get an irb of an n of one again ryan flary who i don't know if you know ryan you'll know of him yeah so ryan and i and a couple of other guys tried to get an n of one irb at ucst to do muscle biopsies on ourselves pre and post a certain type of nutrition exercise routine we wanted to implement that ryan has sort of pioneered with a number of endurance athletes and that was our that was one of our endpoints was could we see an upregulation of mct because the hypothesis was a certain type of training stress was going to lead to that which would obviously increase our performance at a certain level of output but super interesting to think about that to the level of the ketone potentially enhancing that signaling yeah it is a lot of things to think about there so let me caveat my next question with a really serious caveat but it's also a very serious question i was sort of on the fence about whether nationally foreign a ask you this or not, but I'm going to say, screw it, I'm going to ask you anyway. I'm going to caveat this by giving the disclaimer, which is, you're a PhD scientist, you do basic research, you are not an MD, you are not an oncologist, and nothing you say is going to be construed as medical advice. So with that said, I still have to ask you a question, which is, if tomorrow you, your wife, someone you cared about deeply, was diagnosed with cancer, and it was a cancer for which all standard therapies had been exhausted, and you are now left to the best insights you have with respect to your knowledge of cancer metabolism, tell me what pulling out all the stops looks like. And again, this is in the context of, you've taken and you are complying with all chemotherapeutic radiation therapy, hormonal therapy, surgical therapy, etc., but you're losing, right?

So something else needs to be done. What does that combination of that something look like? So I guess, I mean, when we think about the worst cancer, worst case scenario, we'd have pancreatics pretty bad, but probably glioblastoma would top the list of things, right? And would your answer be different if I was asking you about pancreatic adenocarcinoma versus GBM?

I think, you know, it would be, there's things like with pancreatic cancer can make it hard for someone to follow the ketogenic diet, right, and liver cancer and things like that, so they need to approach it a little bit different, and you can have a lot of unexpected consequences, metabolic consequences by someone with liver cancer if they have heavy liver mets. So let's make it simpler. Let's talk about GBM and metastatic breast cancer. Okay.

Okay, so start with GBM. Your loved one or you have GBM. Yeah, I would say it would be useful, not necessarily, you know, absolutely necessary, to ask for an FDG PET scan, do a PET CT, and especially, I mean, with GBM, it's going to light up later tomorrow. Right, so just for the listener, so FDG PET means you take glucose, you label glucose with a molecule, yeah, and then when you do the PET scan, shows by lighting up anything that absorbs that, and the most rapidly metabolizing tissues of glucose light that up, which is almost always any cancer, and then a brain normally lights up, so a brain with cancer takes that to another level.

Yeah. So you're doing that to document that this is a high glycolytic tumor. Yeah. Okay.

So even now, there's a lot of experimental things going on for GBM, but pretty much the standard of care is not offering any survival advantage when it comes to this, so we did. GBM is uniformly fatal. I believe the five-year survival is almost zero. Yeah, yeah, and the mutation rate in GBM is, they're very, very heterogeneous in regards to the number of mutations, so many of the standard of care therapies that target specific pathways just are not efficacious because you have grossly mutated cells throughout the tumor.

So I'd probably, my answer would default back to this press pulse idea that we published in Nutrition Metabolism. Is that the one in 2017? No, actually, so the 2017 paper was in Seminars in Cancer, and that was with oncologists at the Moffitt Cancer Center, where we discuss how the ketogenic diet essentially targets the Warburg effect, and in doing so, really targets all the hallmarks of cancer. So any cancer biologist, you know, is writing a review on paper, like, you know, you talk about the hallmarks of cancer.

There's enhanced proliferation, evasion of immune system, angiogenesis, all these different things, evasion of apoptosis. The ketogenic diet, nutritional ketosis, actually targets all those things, and even the aberrant metabolism and the increase in inflammation that, you know, is now a hallmark of cancer. So from the press pulse, the simplest way to describe it, at least its implementation, which I think is probably most important for the listeners, is to achieve a glucose ketone index. So press essentially means you're providing metabolic stress to the cancer cells that can stop their rapid growth and proliferation.

It's like taking your foot off the gas pedal of cancer cell growth. And there's a number of things that we could do to slow down cancer growth and proliferation and metabolically stress those cancer cells. And that can be done continuously. And pulse protocols, you have a wide expanding toolbox of modalities that can be used in an intermittent fashion that can be sort of tactically used at different time points to kill off the cancer cells that you have applied the press stress to.

So press protocols, which are done continuously, would be something like a calorie-restricted ketogenic diet, perhaps with intermittent fasting, perhaps a low-dose metformin. And what was the ketone to glucose ratio you want to see? I would want to see anywhere between a maintenance of one to two. Meaning that's the glucose to ketone ratio.

At daily maintenance of one to two, yeah. So glucose should never be more than twice the ketone level when both are measured in millimolar. Yeah. Ideally, in a perfect scenario, three millimolar ketones, three millimolar glucose.

So that's kind of hard to achieve, but not with a number of tools. So there's a number of tools that you can use to achieve that. And there are things that we could talk about, too. So the fastest way to get to a glucose ketone index and maintain that of one to two would be what I would call supplemented ketogenic intermittent fasting, right?

So when you eat within a restricted time window, say, of like six hours a day, you start eating at 2 p.m. and finish at 8 p.m. Seems relatively easy to do. And within that fasting window, if needed, you could consume calories in the form of perhaps exhaustive ketones.

And that would further lower glucose and elevate ketone levels, like within a range. And they are commercially available ketone products on the market. Millions are being consumed. And there's no adverse effects, you know, when you compare it to something like a Red Bull, which you'll find lots of adverse effects.

So there's fairly good safety data, but this needs to be safe. The difference is Red Bull sponsors a Formula One team. So it's got to be good. Yeah.

So these things are relatively safe. And their utility are that, you know, they can help you achieve a glucose ketone index. And when you do have a glucose ketone index of one to two, you are limiting fermentable fuels to the cancer cells and also most likely suppressing the hormone insulin tremendously to get there. And because I'm sure you'll be asked or I'll be asked, is the reason you are applying an intermittent or time-restricted feeding algorithm to this because during the fasted time you increase ketogenesis or because there's something specific about having complete liver and gut rest?

In other words, is there a reason that an individual shoulder should not consume exogenous ketones and or MCT during the fasting window? Yeah. I think if it's difficult for them to achieve a glucose ketone index of one to two, one of the tools in the toolbox could be to consume exogenous ketones during that fasting period. I think it can be helpful.

And you can also consume them during the feeding period too. And they provide an extra source of calories that's a non-fermentable fuel and I think have a benefit in and of itself. You could just talk about the anti-inflammatory benefits. You know, I think there's a number of different benefits.

So that press protocol is pretty aggressive. Yeah. And it can also do things like meditation and yoga, I mean, and exercise, of course, low intensity exercise, I think. But the most important thing from my perspective of the press, so we're just talking about the press, is to get that glucose ketone index to one to two.

Yeah, one to two or better. And then once that is achieved or concurrently, so you could think about different modalities for the pulse protocol. So changing your metabolic physiology with what we just described will have a huge effect on targeting the Warburg effect and also will be already targeting all the hallmarks of cancer. So you have a different person.

You have just changed that person's metabolism. You know, I mean, the glucose ketone index of the average Joe out on the street is probably something like 25 or 50. It's like nowhere near that. Right, right.

So you are literally changing the metabolic physiology of that person. So modalities that they may be resistant to or completely failed may have an effect now. So chemo, radiation, maybe immune-based therapies may be working now. That's an important point, right?

We view this as an adjuvant. So you could do a neoadjuvant, concurrent, or adjuvant approach. And I think that what I just described can be used as a neoadjuvant, concurrent, and an adjuvant approach. Yeah, so people talk about cancer approaches as, look, you want to think about the legs of a stool.

So you take a chemotherapeutic approach, you take a radiation approach, you take an immune-based approach, and you take a surgical approach. Those are really the four pillars of cancer treatment today. You're basically saying, look, there needs to be a new type of oncologist, which is a metabolic oncologist. So you have a surgical oncologist, you have a radiation oncologist, you have a medical oncologist, you have an immuno-oncologist, why don't we have a metabolic oncologist?

Yeah, things will lead that way just by the research that's being done now, the huge amount of research being done, even on oncometabolites. And all the genetics people are now focusing on how metabolism is influencing genetics. Metabolism is a driver for our biology and influencing epigenetic expression. So, you know, the work, I'd like to also point to the work of a friend of mine and colleague, Adrian Sheck, who did her work at the Baroneurological Institute, which demonstrated in a mouse model, GL261, I think, model of glioblastoma, that using temozolamide and also radiation with really focusing on radiation, that being in a state of nutritional ketosis made radiation therapy many, many times more efficacious.

And that mouse model, which is kind of a gold standard model for GBM, it actually cured the GBM in that mouse model using the ketogenic diet combined with whole brain radiation. So that was a pretty significant finding that actually spearheaded some of the ketogenic diet clinical research. And her research was done with dietary or nutritional ketosis, not exogenous supplementation? Not.

She went on to do some work with exogenous ketones and looking at how ketones can reprogram the metabolism and ketones can actually have, they are like COX-2 inhibitors, they inhibit reactive oxygen species, which is driving growth and proliferation. So that work spawned research just on ketones by themselves in her animal model. So what is in your pulse protocol then? Pulse protocol can be varied.

So hyperbaric oxygen therapy. At what frequency? Three, generally speaking. So with GBM, you have to, so a consequence of a GBM could be seizures, right?

So getting hyperbaric oxygen therapy with a GBM is really tricky. So yes, you have to start very low, probably like somewhere around 1.5 ATA, and then work up gradually from there based on the individual person. But generally speaking, the research that we did showed that not five days a week, which is typically used for wound healing, but I do think there needs to be a day off for adaptive effects to happen. So three days a week, 2.5 atmospheres for 60 minutes, three times a week.

And that produces, well, reverse tumor hypoxia, for one thing. So hyperbaric oxygen increases tissue oxygenation, not by hyperoxygenating hemoglobin, but it actually gets oxygen into the plasma. And that's a very important thing because... Meaning you solubilize oxygen within the plasma.

Yes. Because you can't really supersaturate the hemoglobin. No, no. You're at the top of the curve.

Yeah, you and I are sitting here, I don't know this area, but your hemoglobin is essentially saturated, probably 96, 98%. But the hyperoxygenation that occurs with hyperbaric oxygen therapy, and this is why oxygen therapy does not work independent of an increase in pressure, right? So the increase in pressure is needed to drive the oxygen into the plasma. And once it's in the plasma, tumors have erratic vasculature, right?

And then the red blood cells get caught inside the capillaries, and the oxygen doesn't get into the tissue inside the tumor. But if the oxygen is in the plasma, it can get past and all into the nooks and crannies of the tumor, and then reverse tumor hypoxia, which is tumor hypoxia is driving HIF-1-alpha and VEGF and causing... Oh, that's so good. So ironically, you're taking something that is initially a deficit of cancer, which is its hypoxia, but then it utilizes it as its advantage by saying, hey, I'm going to work around this.

It's going to make me more resilient. It's going to allow me to increase my vasculature. But when you're saying, hey, buddy, that little advantage you had that was a disadvantage, we're going to reverse it. We're going to hyperoxygenate you now.

We're going to take away your hypoxia. And it also makes these free radicals? Yes. So you have a dual effect, right?

So you are silencing the oncogenes, you're turning off some of the oncogenes, and also by hyperoxygenating a tumor, which its baseline is to be in a state of hypoxia, by supersaturating the tumor with oxygen, and that tumor tissue has damaged mitochondria, because hypoxia damages mitochondria. So basically, you're hyperoxygenating a whole bunch of damaged mitochondria, and essentially what that does is it skyrockets superoxide anion, which then through fenton chemistry, so when you have a lot of free iron, and you've got a whole bunch of heme and stuff that's being broken down the tumor, so you have a lot of free iron driving the fenton reaction, which is producing hydroxyl radicals, and that causes a massive oxidative stress specifically to the tumor, and you're delivering a massive oxidative stress to the tumor while it's relatively non-toxic to healthy cells that have normal metabolism, right? Because the tumor is thriving in a low-oxygen environment, and you're reversing tumor hypoxia and hyperoxygenating it, and you have this environment which is just fueling redox stress, you can then trigger apoptosis and necrosis, really driving necrosis in these tumor cells. So hyperbaric oxygen delivered at the maximum tolerable dose, three times per week, and you could further enhance the oxidative stress of the tumor by something that a lot of people haven't heard of this, but IV vitamin C.

So vitamin C, if given intravenously, you could get up to about 100 grams. You could, yeah, 25 to 100 grams is kind of pushing it, but vitamin C, ascorbic acid, also functions as a glucose antagonist. You've got to make sure you have dextrose on hand. Yeah, but not if you're in a state of ketosis, right?

So if you're in a state of ketosis, so I did a pretty high dose of vitamin C, but being in a state of ketosis, you can tolerate higher amounts, right? Do you know what's your glucose drop to? So when you measure your glucose when you're getting vitamin C, you get a false positive on the meter. Falsely high?

Yeah, you get falsely high. Well, at least the Abbott Precision Extra. Yeah, it's just, you know, when you measure that meter, that assay on the meter is also sensitive to the pH of your blood, too, and there's a redox shift, and ascorbic acid is a powerful reducing agent, and that might be altering the assay, so it's not able to get my glucose. I know I went into a hypoglycemic, but my ketones were elevated, and I took a pretty big hit, you know, of vitamin C.

And I was just doing it just for the, you know, self-experimentation. Right, so what's the thought here? So lots of people talk about... Oxidative stress.

So vitamin C driving the fentanyl reaction to produce more oxidative stress. So vitamin C is a pro-oxidant. When you get blood levels of vitamin C in the millimolar concentration, then it becomes a pro-oxidant. It's not an antioxidant.

So we're not using antioxidants, or definitely don't want to use antioxidants. Yeah, I was going to come back to that. But the next thing is, I'm sure somebody listening to this is going to say, well, I don't have access to IV vitamin C if I want to do that. You can't do it only.

You can't do it only because of what? You can't get it out of the gut enough. Yeah, you can't. You can only get, like, a very small amount.

And then, you know, your gut auto-regulates it, too. So you just look at the next thing you said, which is, again, highly counterintuitive to most people. We're hardwired to think that there's nothing better for you than antioxidants. Yeah.

But paradoxically, once you have cancer, that might not be the case. Yeah, so I think antioxidants may be blocking some of the efficacy of some of the therapies, too, right? Because many chemotherapeutic drugs, their function works through enhancing oxidative stress. Radiation sure does.

So radiation, maybe 20% of the cancer-killing effects of radiation are due to damaging the DNA with double-strain mix. But 80% of the tumor-killing effect of radiation is by the generation of reactive oxygen species. Now, does that mean you can't have blueberries and things that have low levels of antioxidants? I would say no, but you don't want to kind of saturate your body with a cocktail of antioxidants.

Like, you don't want to do a glutathione push, right, after you do... Same with NAC, so you wouldn't have NAC. I personally would not. I don't think...

None of the cancer studies and animal models or humans are supportive of the use of antioxidants, and that was a big focus of me. I mean, during my PhD, I wanted to do a post-doc research in antioxidant cocktails that were going to save the world, and none of the research on antioxidants really panned out in my mind. There's a couple things, you know, maybe for mitochondrial antioxidants for, like, free-trick's ataxia and maybe ALS and some research there, but there's pretty subtle benefits. But in the context of cancer, no, I don't think antioxidants should be avoided.

Anything else in your pulse protocol? Yeah, I mean, there's a lot of things that you could add. So with the PRESS protocol, I think a low dose of metformin could be helpful, too. So that will activate AMP kinase, maybe decrease insulin a little bit, maybe increase ketones a little bit, too.

And it's just a readily available, cheap drug that has a very good safety profile. 500 milligrams to 2,000 milligrams a day are usually well-tolerated, probably starting with 500 milligrams and working up. But when it comes to the pulse protocol, hyperbaric oxygen, IV vitamin C, and there are a number of drugs that we're working with now. One would be 2D oxyglucose.

which in of itself from a seizure world and I've been a reviewer for the government for different grants and stuff and this is in the context of epilepsy 2DG is sort of like the ketogenic guide in a drug so by inhibiting glycolysis it has this gets back to the question you have no ketones but you inhibit glycolic pathways perhaps even reduce sort of mTOR signaling or some glycolic and that may have anti-seizure effects so 2DG is something that we're working with now what was 2DG originally developed for pharmacologically? it's been around for a long time I think maybe it was just in the realm of experimental compound but I know there's phase 2 trials in cancer the problem is it becomes cardiotoxic above say 50 mg per kg I know there's some evidence that it's cardiotoxicity but at 25 mg per kg at least on some of the grants that I reviewed that had a pretty good safety profile for epilepsy so you know not making any recommendations out there but I think 25 mg per kg seems to be within the realm of therapeutic efficacy and safety and this is being studied in humans and they're out of phase 1 so you have phase 1 in the epilepsy world yeah and I think there's some cancer trials going on too and I do think that synergizes really well once you create the environment where you put the press protocol into action then the cancer cells become even very selectively vulnerable to other things like the 2DG will inhibit a glycolytic pathway that drives the pentothosphate pathway and that pentothosphate pathway is responsible for enhancing the endogenous antioxidant capacity of cells so it makes the cancer cells even more vulnerable to oxidative stress the more you can inhibit the glycolytic pathways so 2DG 2-dichloroacetate is something that we've worked with too inhibits PDH complex and that can also Is DCA a drug that's been on the market for a long time? It's a small molecule yeah it's been on the market for a very long time And what's its normal use? Its normal use is lactic acidosis actually so one of the side effects of metformin right is once you start increasing the dose of metformin and escalating the dose the problem that you run into it's still it's a very powerful activator of AMP kinase its effects are primarily through the liver you know inhibiting gluconeogenesis and it's a mitochondrial toxin we published a paper that it increases ROS production from the complex 1 of mitochondria so it's inhibiting complex 1 it's inhibiting yeah mildly inhibiting complex 1 and it's triggering what the cell experiences as an energetic crisis and that you know it has an activation of AMP kinase too so you are creating a scenario where that's putting a lot of persistent metabolic stress on the tumor cells and then you come in here with different modalities that have overlapping but independent mechanisms at producing oxidative stress so hyperbric oxygen IV vitamin C and then cancer specific glycolytic inhibitors 2-deoxyglucose 3-bromopyruvate and lonitamine lonitamine is also hexokinase 2 inhibitor and those three drugs that I mentioned right there they are very powerful and they need to probably be used in two weeks on two weeks off and if somebody's listening and they're thinking well how the heck could I ever do this are there physicians out there who are obviously doing this under the full and legal umbrella of ethical medical practice is everything you're talking about purely theoretical or are there ways to actually have these things implemented I think there are some physicians out there that are probably not making it public but I think they are getting success with doing 25% of what I just talked about you know most of the compounds in IV vitamin C hyperbaric oxygen therapy can be costly if you don't have a heart shell chamber but I like that with radiation if you're giving radiation to your body it's like going in there with a flamethrower and you have a lot of collateral damage whereas hyperbaric oxygen naturally elevates the precursor for oxygen free radicals and the cancer cells selectively produce more oxygen free radicals so it's a very gentle approach and instead of thinking that we should just go in there and eradicate the tumor I think it's more appropriate to give sort of a gentle stress to the tumor so the therapy that I'm describing if the patient goes into it they're going to come out of it stronger than they were going into it when you fat adapt you're a big inflammatory mess I mean you're metabolically deranged you're insulin resistant you are pushing things and you have chemo brain on top of that that may not be reversible the suppression of your immune system with chemo is setting you up for more cancers potentially other cancers so the scenario that we envision is a comprehensive metabolic based therapy where you go into it and it's a more gradual approach and you start adding these modalities sort of as you go you know get the patient acclimated you know with that glucose ketone index of one to two and then start utilizing some of these other therapies you could potentially put someone on an IV right and pulse a low dose of insulin to make them hypoglycemic even one or two millimolar and then deliver some of these agents where you've really restricted the fermentable fuels so I was you know I'm a reviewer on different manuscripts that are coming in and some of these academic and clinical oncologists are actually suggesting this in the medical hypothesis papers now and that's kind of counterintuitive because you think well we don't want the last thing we're going to do for a tumor is give insulin because it's a pulsatile and the amount of insulin it's not like 20 IUs it's something like one or two IUs so the patient comes in fasted and you give them just a little bit and that's facilitating mostly facilitating glucose uptake in the skeletal muscle so making it less available for the tumor right and that creates a scenario where you produce severe what would typically be fatal hypoglycemia and you could deliver ketones you know as an insurance and also deliver some of these agents that would you'd probably dramatically sensitize that tumor tissue to the other modalities and I know so I mean what I didn't talk about when I did the seven day fast like years ago I brought my glucose levels down really low and I got to a glucose ketone index of one or maybe even a little bit lower than one so you were about what three to four on each of them yeah well my ketones were about four or five and my glucose got down to three so that was the lowest I ever like captured and that was just a seven day fast yeah after seven day fast you know after a brisk walk at the end so I never got like ketone seven or eight like I got it like four you know after like a long fast but then I did inspired by the Cahill study I used various strategies to bring my glucose level down you know pharmacological strategies and I did it slowly and just do me a favor Dom I really would be kind of pissed off if you like offed yourself doing dumb shit because I think the world kind of needs you to stick around so see if you can just maybe get an IRB to do this in the mice or something there's nothing that would break my heart more than getting a call from your wife saying yeah Dom died of some freak hypoglycemic crazy accident what's the longest fast you've ever done well that was it and I was pretty adapted and the point I was kind of getting to that I brought my glucose down to where it was not even measurable but with exogenous ketones I was the meter didn't even read it so that to me and I did that years ago that motivated me more to basically focus on this area of research as sort of like my life research because it validated to me that this should not be happening and ketones are an alternative energy source that can be utilized in these metabolic based therapies that can be game changers for it and we also study glucose transporter type 1 deficiency syndrome right which is an inability and people who have let 1d don't get cancer to my knowledge I've talked to the doctors and they've never came across anyone with glucose transporter so that's kind of motivating too so that you can create a therapy for that that could sort of be a magic bullet well what's interesting is this is sort of in many ways old school science right where scientists would begin by sort of experimenting on themselves identifying unnatural or extreme physiologic conditions that are not predicted by the current understanding and then that sort of provokes further investigation remind me again at the end of that 7 day fast how much did you deadlift?

yeah I did 500 pounds for 10 and then I did sort of a one rep at the end with 6 plates or 585 but that's below my normal but it was amazing to me that I didn't want to push my body too hard but it was amazing that that amount of fasting does not really impact your how much of it so what was your max at that time? at that time well I was tinkering around with like Q-Jank diet fasting a lot but within a year of that time I forget if it was before or after I did 675 for 5 and maybe 5 I did 555 for an 8 to 10 so I did you know an extra plate for 8 to 10 but I went into this basically I felt like I did more I could have done more but I just wanted to stop I didn't want to hurt myself because I knew I was pushing the limits at that point and I didn't get sore at all so I did that and it wasn't like my body was broken down and sort of in a depleted state where I was wasted the next day I felt I didn't even have to recover from that like I had no lower back soreness the next day after that so I probably was like I probably feel heavier but it was a validation to me that if you're in a keto adapted state your body is very resilient and from a military standpoint too which we work pretty closely with the military I'm trying to sort of get them to understand this idea that if you are fat and keto adapted and you're faced in all severe conditions with limited food availability you could maintain your physical and cognitive resilience in those conditions which is pretty clear to me I was pretty much obsessed with eating like 6 meals a day for many years and it was very liberating not to have to do that now and I'm amazed at how little I can eat once you're keto adapted and maintain your size and your strength I'm not trying to be big anymore or try to do any records in the gym but it's amazing how easy it is to maintain once your body is adapted You've been so generous with your time I want to sort of let you get on your way I know you've got a long drive potentially tonight but I want to ask you a question or a couple maybe what do you believe today to be true that five years ago you did not believe to be true let's keep it within the purview of your ketogenic life what today do you think I think that really I would say when I got into this field I was really fascinated and immersed in this idea as ketones as an alternative energy source so it's even like space food you know and we're still working on that front but then over the last five years the observation that beta-hydroxybutyrate is a powerful endogenous metabolite that's also a signaling molecule through its HDAC activity more recently we've been working with an organization that the name of the organization is called All Things Kabuki so there's a rare genetic disease called Kabuki syndrome which is a gene defect in the KMT2D which is essentially an acetylase enzyme and a defect in that gene or that protein creates an imbalance between gene expression and gene repression and in the mouse model of Kabuki syndrome two things have worked in this mouse model one is a histone deacetylase inhibitor H-DAC inhibitor called AR42 which restores neurons in the dentate gyrus and kind of silences the pathological features in this mouse model and another thing is nutritional ketosis so nutritional ketosis functioning as a histone deacetylase inhibitor basically salvages or rescues the phenotype of this and circumvents this gene mutation the KMT2D mutation the animals have a normal neuronal density in the dentate gyrus and even from a behavioral characteristic it enhances sort of learning and memory so this idea that an endogenous metabolite can epigenetically sort of control gene transcription so I believe it's probably not unique to beta-hydroxybutyrate I think metabolites we know that's true for acetyl-CoA and other things are epigenetic drivers and I think they are really they call the shots so you can even take a step back and say the mitochondria kind of call the shots too because I think mitochondrial health and mitochondrial vitality would be the ultimate tumor suppressor so if the bioenergetic capacity of a cell in tissues are maintained to a high degree that bioenergetic efficiency is going to preserve genome stability and be far less likely to trigger oncogenes at the level of the DNA so when it comes to something like Kabuki syndrome you have a persistent molecular genetic pathology that's silenced by the elevation of beta-hydroxybutyrate functioning in a metabolic impendent way yeah through their it's HDAC activity so that to me is like mind-blowing and I think that's the direction kind of our lab is going into now I'm always fascinated with developing alternative energy substrates and alternative fuels as a form of nutrition for tactical applications space applications maybe but this idea that you could develop and even engineer nutrition to have powerful effects on gene transcription and epigenetic regulation is something I would have never predicted that's an amazing answer actually because I know that was probably a little hard for some people to follow so what you're basically saying is look five years ago you were completely intrigued and blown away by the metabolic properties of these ketones primarily as an alternative energy source and with that comes a lot of interesting stuff we talked about but at this HDAC pathway this inhibition of something that can result in epigenetic change or activation in this case you can basically take a germline acquired mutation and silence it with an epigenetic overlay that seems to be signaled by something as simple as ketones and Dr. Verden at the Buck Institute has spoken quite a bit about this as well I mean this really is one of those moments where you think holy cow we are really at the just at the cusp of learning about this stuff and if there's one reason to make sure we don't off ourselves with self-experiments it's to make sure we can stick around long enough to do this John, where can people follow you socially and then maybe more importantly see what you're doing from a research perspective Sure So the site I maintain for informational purposes would be ketonutrition.org It's .org, not .com and on that website I have a list of podcasts there's nutrition consultants resources like the Charlie Foundation which is an incredible resource that I've helped them do some educational work and Jim Abrams of the Charlie Foundation has really created an amazing resource there I have a blog and we test various ketone supplements ketogenic foods I'm self-experimenting and I've collected a lot of data and we'll be putting some of that data in the blog so I think that would be sort of like the one-stop shop website for anyone interested in hearing more about what I talked about I'd also like to mention that our lab in collaboration with Epigenics Foundation is sponsoring the Metabolic Health Summit that's occurring in January 30th to February 3rd in Long Beach, California and it's going to have an amazing array of basic scientists for example like Luke Cantley will be there be a keynote speaker Thomas Seyfried there's going to be clinicians there influencers there very interested in technologies and foods and supplements that can make nutritional ketosis accessible for people that want to use it not only therapeutically for metabolic management of a disorder but maybe also for prevention or longevity or just as a lifestyle so you're going to find there's something for everybody at the Metabolic Health Summit from basic science will be sort of what our lab is focused on but from clinical application to moving the science into human application is really the theme of that and can people register for that already? Yes, I think you can go to the website and register if you want to be a sponsor I think you can sort of download the sponsorship package there's going to be a lot of high profile representation there that would bring sort of more awareness and more reach to your product if you have a product there so we're looking for sponsors and I think we've nailed down most of our speakers but if you're interested in speaking too it might be good to contact us through the website Got it and on Twitter you're pretty active what's your handle?

Yeah, before I realize how important it is to have a handle you can remember it's Dominic Dagosti 2 We'll link to it Yeah, we'll link to it It's not that you just remember and also Facebook I'm fairly active Dominic Dagosti 1 I think that's my handle on Facebook too so I kind of cross post on each and try to use Instagram a little bit more because they tell me I've got to use it more but I'm not too happy on that Alright, we'll make sure we link to all those things I want to thank you again I owe a lot of what I know in this space to you. I can say the same. Thank you. Yeah, incredible blogs.

It's been a great resource for many. You were arguably one of the most generous people I've ever met when it comes to his insights. I don't know that you get enough credit for not only the work you've done, but for how much work you do behind the scenes as far as sharing your knowledge with people. I'll just share one very quick anecdote.

Personally, one of my best friends from medical school, his wife has breast cancer. And, you know, without any hesitation, you were more than happy to speak with them about some of these things that they could do above and beyond what she was already doing, which was participating in a clinical trial, where, by the way, she's the only woman to still be alive in this clinical trial. So the trial was closed. That agent will likely not be approved, though she will have a compassionate exemption.

But, you know, she is someone who has been on a ketogenic diet now for six years and remains incredibly indebted to the work that you've done. And her oncologist in Boston are sort of amazed that she's alive. Interestingly, next year, Lou Cantley will be explaining a very plausible mechanism for why she's still alive. That's a paper that I'm sure you're aware of.

It was just approved and will be out in nature very soon. So anyway, I can sit here and spend another hour thanking you for everything, but I know nobody really wants to hear that. So I'll be quick about it and just tell you again, Dom, you're an amazing guy. You really are one of those people that I think fits in the category of just being kind of a treasure.

And so on behalf of many people, I want to thank you. And thank you. Thank you for giving me this platform. I know your podcast will be an amazing resource for so many people.

Always great to catch up with you. Always very stimulating in so many ways. Thank you for having me. Appreciate it.

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