Metabolic Therapies:

Implications and Practical Application Dominic P. D’Agostino, PhD

Assistant Professor

Molecular Pharmacology and Physiology

Hyperbaric Biomedical Research Lab

University of South Florida Morsani College of Medicine

Metabolic Therapy Research

CNS Oxygen Toxicity (seizures)

Neurodegenerative diseases

Metabolic diseases

Cancer

CNS Oxygen Toxicity

Seizures

• Results from breathing oxygen at >2.5 ATA O2

Diving Hyperbaric O2 Therapy

Why do these seizures occur and

how can we prevent them?

Atomic Force Microscopy (AFM)

Fluorescence Microscopy

Laser Scanning Confocal Microscopy

Electrophysiology

Radio Telemetry (EEG)

Adapted to hyperbaric chambers

Methods to Study CNS-OT

Mitochondria O2

ROS

Strategies to prevent

CNS O2 toxicity?

• Dive within Exposure Limits

• Antioxidants

• Antiepileptic Drugs (AEDs)

Starvation

Delay in Seizure

(> 250%)

Bitterman, et al. Brain Res.

761, 146-50, 1997

36 hr

24 hr

How Does Starvation

Change Brain Metabolism?

Modified Diagram from: Oliver E. Owen. “Ketone Bodies as a Fuel for the Brain during

Starvation, ”Biochemistry And Molecular Biology Education Vol. 33, No. 4, 2005:246–251

Ketone Bodies Fuel the Brain

During Starvation

Ketones

-OHB

Glucose

Diagram from: Chapter 26 - Alternative Fuel Utilization by Brain, George F. Cahill, Jr. &

Thomas T. Aoki from Cerebral Metabolism and Neural Function (1980)

20IU of Insulin was administered

Subjects survived without brain damage or

coma

All 3 were asymptomatic

Ketones preserved brain

metabolism during severe

hypoglycemia

severe hypoglycemia!! (1-2 mmol/l)

Owen OE, Morgan AP, Kemp HG, Sullivan JM, Herrera MG, Cahill

GF Jr. Brain metabolism during fasting. J. Clin.Invest., 1967.

Ketosis Provides Resilience Against Hypoglycemia

Ketone

Bodies Energy substrates from fatty acid oxidation

Ketosis Blood levels >0.5 mmol/L.

Nutritional

Ketosis Dietary strategy to elevate blood ketones

Keto-

acidosis Pathologically high ketones (>10 mmol/L)

Keto-

Adaptation

Physiological shift towards using fat and

ketones for fuel

Exogenous

Ketones

Synthetic or naturally derived substances to

artificially produce “instant ketosis”

Glucose

Insulin

Diet

Body Fat

Ketones (energy!)

Difficult to sustain…

↓ Glucose ↑ BHB

↑ Acetone

(Metron)

↑ AcAc

Rapid and Sustained Ketosis (15 minutes to >2-8 hrs)

D’Agostino, D.P., et.al . AJP Regulatory, Integrative and

Comparative Physiology, 2013 May 15;304(10):R829-36.

Kesl SL, et al. Methods of sustaining dietary

ketosis in Sprague-Dawley rats. FASEB Journal

(2014) vol. 28 no. 1 Supplement 643.5

50-100 mL dose

575 %

Seizure

Resistance

Therapeutic Ketosis (KD) Ketone

Ester

D’Agostino, D.P., et.al . AJP Regulatory, Integrative and

Comparative Physiology, 2013 May 15;304(10):R829-36.

Adapted from: Kristopher Bough and Jong Rho. Anticonvulsant

Mechanism of the Ketogenic Diet. Epilepsia, 48 (1): 43-58, 2007.

Elevated Ketones Lowered Glucose

Ketogenic Diet, Ketone Esters

βHB

AcAc

Acetone

GABA/Glutamate

Ratio

2-3x Higher

TCA Cycle

Intermediates

2-5x Higher

Adenosine

Carnosine

Anserine

Glucose

Insulin

ROS

Oxidative

Stress

Neurological Disorders are Associated with

Impaired Brain Energy Metabolism

(FDG-PET Scan)

NORMAL BRAIN ALZHEIMER’S BRAIN

GLUT-3

Healthy Cells have Metabolic Flexibility

Glucose Normal Diet

(High Carb)

Ketones Ketogenic Diet

(High Fat)

Cancer Lacks Metabolic Flexibility

Ketones (Ketogenic Diet)

Cancer Glucose Normal Diet

(High Carb)

Cancer has very high rates of glucose metabolism

Cancer Imaging

(FDG-PET Scan)

Otto H. Warburg

Nobel Prize (1931) Medicine

First to describe Cancer

as a Metabolic Disease

• High glycemic diets increase risk of cancer

• Hyperglycemia = poor prognosis

• Blood glucose correlated to tumor growth

• Ketogenic diet: 4:1 fat (75-85% fat) ▫ Lowers glucose, Induces ketosis

▫ Suppresses insulin

▫ Reduces growth factors

Seyfried et al. British Journal of

Cancer (2003) 89, 1375 – 1382

High Glucose and Low Oxygen

Drive the Warburg Effect Gnagnarella, et al; 2008

Average PO2

30-60 mmHg 2-30 mmHg

**Causes chemo/radioresistance

Healthy Brain Cells Brain Cancer Cells

High Pressure Oxygen Damages Cancer Cells

Neuroscience; 31;159(3):1011-22, 2009

Effect of Ketones on Cancer Cells

Even in the presence of high glucose!

Poff et al. International Journal of Cancer: 2014 Oct. 1;135(7):1711-20.

NO Ketones Ketones (5 mM)

Ketones Increase

Cancer Cell Death

Ketones Reduce

Cancer Cell

Proliferation of

Summary (pancreatic cancer model)

1. Ketones (BHB and AcAc) inhibit cancer growth

2. Ketones increase cancer cell death (apoptosis)

3. Suppressed oncogenic growth signals (e.g. c-Myc)

4. KD reduced tumor growth and prevents cachexia

Can Nutritional Ketosis and

HBOT Prolong Survival from

Metastatic Cancer?

Metabolic Stress

Glucose

Insulin Oxygen

Ketones

Dr. Angela Poff

The VM-M3 Model of

Metastatic Cancer Developed by Dr. Thomas Seyfried, Boston College

1. Similar to human metastatic cancer

2. Tumor cells glow (firefly gene)

3. Immunocompetent

Shelton, et. Al, 2009

IJC, Volume 126

Liver Metastasis

Methods: Treatment Groups

• Standard Diet

• Ketogenic Diet (KD)

• Ketone Ester (10%, KE)

• Hyperbaric Oxygen (HBOT):

▫ 2.5 ATA, 90 min, 3/week

Ketosis and HBOT dramatically slows

metastatic cancer and extends survival

Survival Time Survival Time

21 Days Post Tumor Cell Transplant

How can we Implement

Metabolic Therapy?

Practical Guidelines

* Patients should be monitored by their own physician, while working closely with the Registered Dietitian

• http://www.charliefoundation.org/ • www.ketogenic-diet-resource.com • www.dietarytherapies.com

“Standard Diet” vs. “Ketogenic Diet”

Ketogenic Diets differ from the Standard Diet in

macronutrient distribution.

Carbohydrate intake decreases to <10% of kcals.

Ketogenic diet is NOT a HIGH PROTEIN diet

Challenges To Initiation and Compliance

Liver cancer and/or elevated liver enzymes

Kidney stones and/or renal disease

Pancreatitis

Fat malabsorption issues

Gallbladder obstruction or removal

Medications

Lack of support

High cholesterol

Food selection

Weight loss

Metabolic management of cancer following changes

in plasma glucose & ketones

Metabolic Management of Cancer

Ketones

Glucose

Seyfried et al. Carcinogenesis. 2014, Mar;35(3):515-27

Zuccoli G, at al.:Case Report. Nutrition and Metabolism (Lond). 2010 Apr 22;7:33.

CASE REPORT: UNPUBLISHED

• 10 y/o male

• 2009 – Ependymoma diagnosis

• 7 neurosurgeries

• 2X radiotherapy courses

• Resistant to treatment

02/2014 – started HBOT (100 sessions) with carbohydrate restriction

Rt Parietal Lesion 100 HBOT sessions

+ Diet Therapy

Midline Lesions

Case Report: Unpublished

(5 Months)

Clinical Trials (Pilot Studies)

“Ketogenic Diet and Cancer “

Sept 1, 2014: 13 Results

Summary: Potential Therapeutic Implications

• Nutritional ketosis mimics the metabolic state of fasting

and decreases potential for seizures

• Non-toxic, cost-effective, readily implementable

• Possibly effective against aggressive, late-stage cancers

• KD and HBOT have potential synergy with standard care

• Neuroprotective against chemotherapy and radiation

Future Directions

• Determine best method to achieve the “metabolic zone”

• Determine dose for HBOT (2.5 ATA O2; 90 min; 3x/week))

• Evaluate in other cancer models (brain, breast, ovarian)

• Explore nontoxic metabolic drugs (e.g. Metformin)

• Test a phytonutrient cocktail (e.g. green tea, turmeric, etc)

• Clinical Trails

Questions?

the USF TAMPA TEAM

Al Bino

Dr. Raffaele Pilla

(alumnus)

Carol Landon

Shannon Kesl

Jacob

Sherwood

Dr. Chris Rogers

Dr. Rami Grossman

(alumnus)

Dr. Angela Poff Nate Ward Geoff

Ciarlone Dr. Heather Held

Teryn

Gerhed

(fall 2014)

Dr. Csilla Ari

Dr. Dominic

D’Agostino

Dr. J.B. Dean

Dr. Helen McNally

Purdue University

Resources

www.ketogenic-diet-resource.com

www.dietarytherapies.com

http://www.charliefoundation.org/

http://www.rsg1foundation.com/

http://www.nutritionchoices.ie/

www.ketonutrition.org

Questions?

References Poff A, Ari C, Seyfried TN, D’Agostino, DP. The Ketogenic Diet and Hyperbaric Oxygen Therapy

act Synergistically to Prolong Survival in Mice with Systemic Metastatic Cancer. PLoS ONE,

2013; 8 (6): e65522 DOI: 10.1371/journal.pone.0065522

Seyfried TN, Poff A, D’Agostino, DP. Cancer as a Metabolic Disease: Implications for Novel

Therapeutics. Carcinogenesis. 2014, Mar;35(3):515-27. doi: a10.1093/carcin/bgt480..

Poff A, Ari C, Seyfried TN, D’Agostino, DP. Ketone Supplementation Decreases Tumor Cell

Viability and Prolongs Survival of Mice with Metastatic Cancer. International Journal of Cancer:

IJC-13-2481, 2013.

Seyfried TN, Marsh J, Mukherjee P, Zuccoli G, D’Agostino DP. Metabolic Therapy: A New

Paradigm for Managing Malignant Brain Cancer. Cancer Letters, 2014 Jul 25. pii: S0304-

3835(14)00352-8. doi: 10.1016/j.canlet.2014.07.015.

D'Agostino DP, Olson JE, Dean JB. Acute hyperoxia increases lipid peroxidation and induces

plasma membrane blebbing in human U87 glioblastoma cells. Neuroscience; Mar

31;159(3):1011-22, 2009.

Seyfried TN, Marsh J, Mukherjee P, Zuccoli G, D’Agostino DP. Could Metabolic Therapy Become

a Viable Alternative to the Standard of Care for Managing Glioblastoma? Oncology &

Hematology Review, 2014;10(1):13–20

Elevated rates of glycolysis and fermentation, excessive lactate production

– up to 200 X rate of normal cells

• Drives anabolic processes

• Acidifies microenvironment

• Most consistent cancer phenotype,

present in most, if not all, cancers

Anaerobic

Fermentation

~2 ATP

per glucose

Aerobic

Respiration

~38 ATP

per glucose Mitochondrion

+O2 +O2

Cancer Metabolism & The Warburg Effect

Healthy

Cell

Cancer

Cell

Tumor hypoxia promotes cancer

progression and the Warburg Effect

Regulation of cancer cell metabolism by hypoxia-inducible factor 1; Semenza, G.

HIF-1 implicated in every aspect of

cancer progression

Reported Positive Effects of

Nutritional Ketosis • Weight loss (Atkins diet)

• Alzheimer’s disease Nutr Metabolism 2009 Aug 10;6:31

• Parkinson’s disease Curr Treat Options Neurol. 2008 Nov;10(6):410-9.

• Lou Gehrig’s disease (ALS) BMC Neurosci. 2006 Apr 3;7:29

• Traumatic brain injury J Neurotrauma. 2011 Sep;28(9):1813-25

• Cancer Nutr Metabolism . 2007 Feb 21;4:5.

• Seizures J Child Neurol. 2009 Aug;24(8):979–88

How can we exploit the neuroprotective

and metabolic effect of ketones?

Case Report (published) Stage IV Glioblastoma

The Metabolic Zone

Zuccoli G, at al.: Case Report. Nutrition and Metabolism (Lond). 2010 Apr 22;7:33.

Human Studies?

• The Warburg Effect is a

universal feature of

cancers and serves as

the basis for one of the

most important

diagnostic tools in

cancer treatment

• Radioactively-labeled

glucose quickly taken up

by cancer cells

Metastatic Melanoma

FDG-Glucose PET Scan

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Oxygen Rebreather

100% O2 No Bubbles = Quiet