Dr. D'Agostino: The pre-clinical animal model data was so compelling that it has inspired, not from our lab, from other investigators, you know, looking at this too, a dozens of clinical trials that are ongoing right now. If you just go to clinicaltrials.gov and google and just or just type in ketone supplement, I think you get like 30 or 40 clinical trials that are looking at ketone supplements. And just a few years ago, there was none, right? So, there's a lot of other people instead of us looking at this idea of...I guess you could call it a ketogenic diet .

But I think of exogenous ketones are calorie-containing molecules that are essentially in some ways found in nature, some of them are, some of them aren't. But they do elevate a bioidentical ketone bodies in the blood and in tissues. So, in many ways, they're not so much like a drug. It's like creatine monohydrate, right? So you can take...creatine is found in meat and it's found in other things. We can take exogenous creatine, and it has not only effect on skeletal muscle but on the brain. And I think we're getting an appreciation for creatine as like a nootropic even.

I look at ketones as being kind of the next creatine, but it's going to take a while for the research. I think there's like 700 or more trials or studies on creatine, you know, showing the efficacy and the positive effect, whereas maybe there's maybe like 50 to 100 with ketones, but it's expanding very rapidly. It's very nascent literature, but the nascent literature has spawned many other labs, you know, outside of our lab and labs that were doing it well before our lab. But I became so interested in this idea that it...I just changed my whole research direction away from drugs to look at diet and supplements. Sorry, that was long-winded.

Dr. Patrick: No, it's fantastic, so much information. You mentioned that, you know, in different contexts, these different types of ketone supplements can have, you know, varying effects or be used for different things. If you're just looking at ketone...you know, beta-hydroxybutyrate levels as an endpoint, what would be the difference in taking a ketone ester versus a ketone salt? How long would you see an increase in the, you know, beta-hydroxybutyrate levels is how transient? Is it side effects-wise, you know, with these different...? And the formulations as well. Like there's all kinds of formulations that you see.

Dr. D'Agostino: So, you can get an elevation of ketones for one hour or six to eight hours depending on the formulation and depending upon if you took the ketone supplement with...on an empty stomach or taken it with food or combined, for example, a ketone ester with a ketone electrolyte salt, right? If you take ketone salts and you combine it with medium-chain triglycerides, the fat delays gastric absorption and pushes the pharmacokinetic curve, if you will, to the right. And this is important. You get a little bit slower elevation of blood ketones, and then you have a significant sustainment of hyperketonemia over time and the decrease in the spike. So a very rapid spike in ketones contributes to a release in insulin.

So, if you consume a ketone ester at a large dose on an empty stomach, you have a very large increase in beta-hydroxybutyrate and acetoacetate too depending on the formulation. And it's that rate of change, the relative rate of change of metabolites, similar to like if you have a very rapid, you know, relative spike in leucine, it's going to kick on skeletal muscle protein synthesis, but if it's a gradual spike, maybe it won't kick on the metabolic machinery associated with skeletal muscle protein synthesis. The rapid elevation of ketones can produce a counter-regulatory effect, which is a release in insulin, and then that can shut down your own natural ketone production. So, the way to go about doing it is to formulate something that causes a predictable but gradual rise in ketones and sustains that for a period of time and has a predictable decrease over time.

So the way to do that simply is to take...the way that I do it on a daily basis is beta-hydroxybutyrate that's bound to electrolyte sodium that has sodium, potassium, calcium, magnesium in that formulation, so balanced electrolytes, more or less like the electrolyte supplements that are on the market. So, LMNT is one. I think maybe Liquid IV or Gatorade or even these things. So, the higher sodium, you know, but you want to match it with some potassium, calcium, magnesium. And then the electrolytes in themselves will actually delay gastric absorption a little bit. So salt does that. And if you combine that with MCT too, that delay it. The salts can actually delay gastric absorption, so it's not so much of a rapid rise.

If you take a beta-hydroxybutyrate ester, you have 1,3-butanediol typically is bound to beta-hydroxybutyrate. When you consume that, the beta-hydroxybutyrate is quickly liberated, so it spikes your glucose or your ketones up very high. But in regards to glucose, actually, that comes down pretty low. And you had to ask me that question. Why does glucose drop, so down into hypoglycemic ranges with a single large dose like 30 to 50 milliliters of like a pure ketone ester, something like that, right?

Yeah. So, in the beginning, I thought it was insulin, and it is insulin. So the threshold for me at least...I measure insulin quite often in response to this, and what I find is that if you take a ketone supplement and it boosts you 1 to 2 millimolar like a delta, a change, an increase, then the elevation of insulin is almost imperceptible according to like the assays that we're using. But if you were to consume a ketone ester and get up into the three, four, and five range, then that produces an elevation of insulin equivalent to eating...you know, drinking like 2 to 4 ounces of OJ or like 10 grapes or like a small orange, right? So, for me, it goes from like 3 to 6 or 8 or 10, right, insulin, my blood insulin levels. And it's equivalent to maybe eating about 30 or 40 grams of protein. So you would get that amount. Whereas if you consume, you know, Ketostart or another exogenous ketone supplement, and you consume it like 10 grams of pure BHB, and you get that elevation of about 1.5 millimolar...

Dr. Patrick: Is that a full packet of Ketostart?

Dr. D'Agostino: It's kind of like double...almost it's like double dosed in a way. So I usually do half a packet and then...

Dr. Patrick: Which is I'm drinking right now, right?

Dr. D'Agostino: Yep. So, consuming a full packet typically I get about 1.5 millimolar, so I feel the effect. But I've actually consumed two packets, and I start to get a bump in insulin, but one packet, no. And the bump in insulin is relatively small probably because the mineral load is delaying, you know, the absorption into the system a little bit. So I think that that's really important because we know like insulin suppression is also important for the anti-seizure effects. So we think that a reduction in glycolysis is therapeutically part of the scenario of the anti-seizure effect of the ketogenic diet because 2-deoxy glucose has a pretty strong anti-seizure effect. And that is being advocated and used clinically in some studies as the ketogenic diet in a drug, so a glycolytic inhibitor, 2-deoxy glucose. So, you consume this drug and it's like 25 milligrams per kilogram, and if you go higher than that, then it becomes cardiotoxic. So it's not an ideal approach, but it inhibits the glycolytic pathway in a way that sort of mimics effects of the ketogenic diet.

So when we increase insulin, insulin stimulates glycolysis, and I think that that could be a negative thing in the context of maybe cancer or seizures or other things that we're interested in therapeutically managing. There's the ketogenic diet and exogenous ketones, and they're not mutually exclusive. But I actually think they're synergistically, you know, when they're combined together. So, if you follow a more liberal version of the ketogenic diet like a modified Atkins diet or modified ketogenic diet or low glycemic index therapy, which is like a one-to-one ketogenic diet, and then supplement ketones on top of that, then I think what you have in my opinion is an optimized ketogenic diet for a lifestyle. This needs to be studied and validated in clinical trials. But I think it would also be optimal for epilepsy, for cancer, for managing type 2 diabetes, and also for weight loss. So the ketones have a satiating effect on the brain.

So the ketones are alternative energy substrate, and when your brain is metabolizing ketones, and it actually experiences low glucose, it doesn't go into an energetic crisis. So it's not signaling that you need to eat. And I think that's really interesting. There have been cases where you could produce a hypoglycemic shock that would be fatal...otherwise fatal. But if your ketones are elevated, you're asymptomatic for hypoglycemia. So that's a remarkable example of the effects of ketones on preserving, maintaining brain energy metabolism, and that has real-world effects in the context of everyday living.

And if you go on a diet, you inadvertently need to go into a calorie deficit. So calories do matter for one thing, and you have to achieve and maintain a protracted calorie deficit to lose weight and to some extent, sustain that weight for a period of time. Then you can go back to a more eucaloric ketogenic diet or eucaloric diet. It will necessitate like low glucose, low insulin, and you're going to get hungry, but if your ketones are elevated, that's where ketones shine. They really shine in the context of calorie restriction or an energy deficit because you have a better fuel flow to the brain in that context, right? So if you're on a low-calorie diet that's producing a state of hypoglycemia, but your ketones are not elevated, that's going to be a painful diet to adhere to and sustain.

Dr. Patrick: Right.

Dr. D'Agostino: Not fun.

Dr. Patrick: No. And it's funny. Like, I absolutely noticed that when I was doing my ketogenic diet. Like I said, I was doing a lot more intermittent fasting, and it was a lot easier to do. I mean, you do feel...I felt satiated. And this kind of gets into another topic, and I did want to kind of ask you about the difference between...you mentioned the diester for ketone esters, but there's also monoester, right? Is there a difference in terms of efficacy, I mean, if you're just kind of wanting to elevate your ketone levels? And again, it seems as though I prefer... I've tried all these different types of ketone supplements, and I personally am not a huge fan of the really quick spike and then like...like to me, it's kind of crashing because my glucose levels get so low, and then when the ketones wear off, it's like, "Where's my energy?"

Dr. D'Agostino: So you have, yeah, hypoglycemia and hypoketonemia, and you might also be kicking yourself out of ketosis. So it could be a dose thing. The 1,3-butanediol beta-hydroxybutyrate monoester, that was developed by...in part by Dr. Richard Veach. That was one of the first ketone esters that we actually...you know, I became interested in, and it did not have anti-seizure effects. I didn't lose enthusiasm because I knew there was so many other molecules that could be developed.

We worked on a couple different molecules. And the next one was the diester. Actually, first, we had the monoester. 1,3-butanediol-acetoacetate monoester had very strong anti-seizure effects. And then we could do more of a transesterification reaction, it's just more or less a stoichiometric reaction where you just add more ketones, in this case, acetoacetate 2-1-3-butanediol. So it's 1,3-butanediol, which gets metabolized in the liver completely pretty much to beta-hydroxybutyrate. That molecule with a reaction, we can add to acetoacetate molecules.

And, you know, both of these things, the monoester and the diester, they taste nasty, they taste like gas. But they have very distinctly different effects at least in the context of the anti-seizure effects. So when we developed the ketone diester, and we used that in our animal model of tonic-clonic seizures, which was, in this case, high-pressure oxygen, but we then tested it in various other seizure models too, it had a very strong anti-seizure neuroprotective effect. And then if we use 1,3-butanediol or any other ketone, it didn't really have that profound anti-seizure effect.