New study teams researchers from College of Arts and Sciences, USF Health

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Jan. 9, 2019 — The ketogenic diet has proven successful in helping people lose weight and improve their overall health, including those with epilepsy. The low-carb diet transitions the body from burning sugar to burning fat and ketones for energy. New research suggests that increasing blood ketones by using ketogenic supplementation can reduce seizures without dietary restriction.

A study published this month in Physiological Reports finds supplementing a normal, carbohydrate-rich diet with specific ketogenic agents may significantly delay tonic-clonic seizures caused by exposure to high levels of oxygen.

Oxygen toxicity is a complication that can arise following hyperbaric oxygen therapy, an FDA approved treatment used to manage various medical conditions, such as carbon monoxide poisoning, air/gas embolism and diabetic wounds. It involves inhaling pure oxygen in a pressurized or hyperbaric chamber.

“Exposure to high-pressure oxygen is also a danger to recreational, technical and military scuba divers, including Navy SEAL divers, as a seizure manifesting underwater can be lethal,” said lead author Csilla Ari D’Agostino, PhD, research assistant professor in the Department of Psychology at the University of South Florida College of Arts and Sciences. “As a scuba diver, I am very excited about the implications of these findings, since during 20 years of diving I have heard many stories about the dangers of being exposed to high partial pressure of oxygen and it is something that always has to be considered when planning a dive.”

An experienced scuba diver, Csilla Ari D’Agostino, PhD (pictured here), says the ketogenic supplement findings also have implications for recreational, technical and military scuba divers, who are at risk for lethal seizures induced by exposure to high-pressure oxygen.

Dr. Ari D’Agostino and her team, including collaborators from the USF Health Morsani College of Medicine’s Department of Molecular Pharmacology and Physiology and the USF College of Pharmacy, used a small hyperbaric environmental chamber to test the effects of ketogenic agents on rats. The animals were freely fed standard rodent chow, consisting of 70% carbohydrates. They also received different ketogenic supplements one hour before being exposed to pure oxygen in the chamber, which was pressurized to simulate technical and military dive operations. These conditions were maintained until physical symptoms of a seizure were observed.

The team found that the most effective supplement was a combination of ketone ester and medium-chain triglyceride oil in delaying the onset of hyperbaric oxygen-induced seizures. The latency to seizures was delayed by 219 percent in that group and the seizure severity was significantly reduced as well with ketone supplementation. The neuroprotective effects of ketone supplements were associated with an elevation of blood ketone levels.

The study was conducted using the Hyperbaric Biomedical Research Laboratory at the USF Health Morsani College of Medicine.

The findings show that boosting the level of blood ketones by specific ketone supplements produce therapeutic ketosis, which, in turn, may provide increased resistance to seizures induced by extreme levels of hyperbaric oxygen. Importantly, the findings support that this neuroprotective effect may not require strict adherence to dietary restrictions and can be achieved through supplementation alone.

The study was supported in part by grants from the federal Office of Naval Research.

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At the University of South Florida’s Hyperbaric Biomedical Research Laboratory, ongoing work to combat oxygen toxicity seizures in Navy divers has expanded to include research that may lead to non-toxic cancer therapies combining dietary supplements and hyperbaric oxygen.

Jay Dean, PhD, professor in the Department of Molecular Pharmacology and Physiology, USF Health Morsani College of Medicine, created and has directed the collaborative research facility since it opened in 2006.  The laboratory houses chambers that can mimic the adverse environments of high atmospheric pressure (hyperbaric) experienced by deep-sea divers. With instrumentation specially designed to operate under extreme pressures, Dr. Dean and his colleagues can analyze the molecular responses of cells as well as the physiological changes in animal models exposed to changing concentrations of oxygen, nitrogen and other gases.

Jay Dean, PhD, professor of molecular pharmacology and physiology, established and directs the USF Hyperbaric Biomedical Research Laboratory.

To date, Dr. Dean and his USF colleague, Dominic D’Agostino, PhD, have adapted electrophysiology, radio-telemetry and various types of microscopy techniques for use under hyperbaric pressures, including fluorescence, confocal and atomic force microscopy.

“Atomic force microscopes are common, but not atomic force microscopes placed under hyperbaric pressure,” said Dr. Dean, one of the world’s leading experts in hyperbaric neurophysiology. “We’ve been able to successfully apply very powerful research tools to these unique conditions.” 

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Probing oxygen toxicity’s role in seizures

In the last decade Dr. Dean’s laboratory, sponsored by the Office of Naval Research Undersea Medicine Program, has helped shed light on the role of hyperbaric oxygen toxicity in triggering seizures. The condition can be a life-threatening by-product of breathing too much oxygen at high ambient pressures that impacts deep-sea divers as they swim deeper and longer.

Navy SEALs are especially at risk because they wear a closed circuit rebreather, to mitigate the narcotic and other debilitating effects of nitrogen and carbon dioxide breathed under increasing ocean pressure. The special device filters out these gases in such a way that bubbles do not appear on the water’s surface – useful in helping avoid enemy detection. However, the additional stealth comes at a cost. The ratio of oxygen the divers breathe greatly increases the deeper they plunge (essentially becoming pure oxygen) and, when combined with physical exertion and mission stress, can lead to nausea, dizziness, seizures, and even coma or death – all symptoms of oxygen toxicity.

Deep-sea divers can be at risk for oxygen toxicity seizures, a life-threatening condition caused by breathing too much oxygen at high ambient pressures. – U.S. Department of Defense photo

A possible countermeasure, anti-seizure sedatives, requires high doses that could impair warfighters’ mental and physical performance.

Without a reliable way to treat oxygen toxicity or predict which divers are more prone to seizures than others, the Navy takes rigorous precautions to restrict all divers to no more than 10 minutes in 50 feet of seawater.

“This risk of central nervous system oxygen toxicity limits oxygen’s use — not only in diving operations, but also its clinical applications in hyperbaric oxygen therapy,” Dr. Dean said.

Hyperbaric oxygen therapy, which increases blood oxygen to temporarily restore blood gases and tissue function, can help treat unhealed wounds, burns, crushing injuries, decompression sickness, carbon monoxide poisoning, and other medical conditions. The therapeutic benefit might be maximized if the doses of hyperbaric oxygen administered could be boosted without the risk of central nervous system oxygen toxicity.

In their search to find solutions, Dr. Dean and colleagues analyze the response of individual brain cells to the powerful effects of oxygen and other gases under altered pressure. In the laboratory’s hyperbaric chambers, they measure changes in brain cell membranes and electrical activity, and the damage of oxygen-induced free radicals.

An intracellular recording of the electrical signaling by a brain cell (middle trace) in a rodent brain slice that is stimulated by hyperbaric oxygen (top trace).

The researchers also monitor physiological changes in the breathing and heart rate of normal rats moving about in a chamber mimicking the environment of an increasingly deep dive. An electroencephalogram (EEG) shows electrical signals in the brain in real time, indicating the hyperexcitability that precedes and peaks with oxygen toxicity seizures.

Promising discoveries to predict, delay seizures

The USF group has made what could be a key discovery – the breathing rate of the rats exposed to pure oxygen increases several minutes before a seizure starts. “This may be a biomarker – a physiological signal that predicts the impending seizure,” Dr. Dean said.

If this early-predictor hypothesis bears out in larger animal models, Dr. Dean said, the next step would be to work with the Navy to devise and test a mask-fitted with a device designed to monitor divers’ breathing underwater. The ultimate aim: preventing oxygen-induced seizures to safely allow Navy SEALs to dive deeper and longer.

Another of the laboratory’s major findings evolved from an idea by Dr. Dean’s former postdoctoral fellow, Dominic D’Agostino, PhD, to harness the power of ketones, natural compounds produced by the body when it burns fat during periods of fasting or calorie restriction.

Dominic D’Agostino, PhD, associate professor of molecular pharmacology and physiology who collaborates with Dr. Dean, has expanded the laboratory’s research to include metabolic therapeutics. His group is investigating the combination of the ketogenic diet and/or ketone supplements with hyperbaric oxygen as a potential non-toxic cancer therapy.

Now an associate professor of molecular pharmacology and physiology, Dr. D’Agostino has focused on better understanding how the ketogenic diet — a special low-carbohydrate, high-fat diet that elevates blood ketones — produces anticonvulsive and neuroprotective effects. And, more recently he has worked with collaborators in academia and industry to develop and test naturally derived and synthetic supplements to boost blood ketones to mimic the ketogenic diet’s therapeutic effects.

Successfully used by physicians to treat drug-resistant epilepsy or other seizure disorders, the ketogenic diet shifts the brain’s energy source from glucose toward using ketones as a super fuel. However, it takes several days, or event weeks, for the body to adapt to this change in brain energy metabolism. That limitation and other problems associated with adhering to such a strict low-carbohydrate diet make nutritional ketosis less than ideal for Navy SEALs on a mission.

“The big advantage of putting the diet in a pill or liquid form is that you can achieve therapeutic ketosis in 30 minutes, instead of a week,” Dr. D’Agostino said.

A microscopic image of neurons hyper-excited by exposure to pure oxygen under high pressure in the hyperbaric chamber.

In a first of its kind study, Dr. D’Agostino tested whether feeding laboratory rats ketone esters and placing them in the hyperbaric chamber simulating underwater conditions could delay oxygen toxicity seizures. It worked.

More research is needed, but the experiments pave the way for a ketone supplement that would allow Navy SEALS to dive longer while protecting them against seizures, Dr. Dean said. “If what we’ve observed in rat model experiments holds true in humans, the Navy diver should be able to increase the amount of time spent at a depth of 50 feet of seawater (10 minutes) by 600 percent… which means that the divers could get more work done with fewer dives.”

“When the brain is running off ketones, it becomes much more resilient in terms of preserving brain energy and preventing a seizure,” Dr. D’Agostino said.

Based on research led by Dr. D’Agostino, USF has several patents pending for producing brain metabolism-enhancing ketone supplements, which may have a broad range of applications for neurodegenerative diseases like Alzheimer’s and ALS, diabetes and certain cancers as well as seizure disorders – all associated with impairments in metabolic regulation.

Earlier this year USF hosted the first international conference drawing doctors and researchers to discuss the effects of nutritional ketosis and metabolic therapeutics on the treatment of various diseases.

Stephanie Ciarlone, MS, a doctoral student in the USF Health Byrd Alzheimer’s Institute Laboratory of Edwin Weeber, PhD, (seated) professor of molecular pharmacology and physiology. Ciarlone’s preclinical studies of ketone esters in an Angelman syndrome mouse model are helping lay the foundation for what may be the first clinical trial of a USF-developed ketone ester in children with the rare neurogenetic disorder. — Photo by Sandra C. Roa, USF Health Communications

Among the presenters was Stephanie Ciarlone, MS, a doctoral student in the USF Health Byrd Alzheimer’s Institute laboratory of Edwin Weeber, PhD, where her research focuses on treatment options for Angelman syndrome, including ketone esters. This rare neuro-genetic disorder affects young children who commonly suffer debilitating drug-resistant seizures as the condition worsens.

With Dr. D’Agostino as a collaborator, a recent study by Ciarlone found that ketone supplements, without dietary restriction, delayed the onset of seizures and reduced the their number by 50 percent in a mouse model of Angelman syndrome. The ketone esters also improved learning and memory and motor coordination in the mice.

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Dr. Weeber, professor of molecular pharmacology and physiology, is working with Dr. D’Agostino to move their preclinical studies to the first clinical trial of a USF-developed ketone ester in children with Angelman syndrome. The study is expected to begin within a year.

From neuroprotection to exploring non-toxic cancer therapy

A serendipitous thing happened while Dr. D’Agostino and Angela Poff, PhD, research associate, were studying the neuroprotective effects of ketone supplements in different cell models. While examining cancer cells under a microsope specially designed to withstand the barometric pressure in the hyperbaric chamber, they observed that these cells were selectively vulnerable to high pressure oxygen at levels not harmful to healthy cells. They also noticed that the cancer cells did not proliferate when put in a petri dish with ketone supplements as a fuel source.

Cancer cells exhibit altered metabolic processes that could potentially be exploited to shut down their proliferation and survival. Solid tumors have areas of low oxygen, or hypoxia, that actually help promote a cancer’s aggressive growth. “So, the idea was that if we put more oxygen into the blood, which is what the hyperbaric oxygen chamber does, it will diffuse further into the tissue and help shut down areas promoting the tumor growth,” Dr. Poff said.

Angela Poff, PhD, research associate, led a study targeting cancer metabolism with hyperbaric oxygen and ketosis.

In addition, cancer cells use carbohydrate-derived glucose to generate most of their energy, so some research suggests a ketogenic diet that rigorously limits carbohydrates may help slow cancer’s growth, Dr. Poff said.

Armed with this two-pronged approach, the researchers embarked on their first cancer experiments in the Hyperbaric Lab. They discovered that combining hyperbaric oxygen and ketosis reduced the proliferation of metastatic cancer cells. Then, moving their research to a mouse model for aggressive metastatic cancer, they showed that combining a ketogenic diet and ketone supplements with hyperbaric oxygen therapy slowed tumor growth and doubled the survival time of the rodents. Their study was published online last year in PLOS ONE and the theory behind this approach was highlighted in an article in Carcinogenesis.

Hyperbaric oxygen by itself only slightly inhibited the spread of cancer in the mice. “But when we combined hyperbaric oxygen with ketosis induced by the ketogenic diet and our ketone ester, the potent synergistic effect was greater than the individual therapies alone,” Dr. Poff said. In particular, adding the ketone ester to the mix of the ketogenic diet and hyperbaric oxygen boosted the anti-cancer effects.

Images of rat brain slices used to study how hyperbaric oxygen disrupts brain cell function to cause seizures.

Next, the USF researchers say they will work on fine-tuning the combination therapy – finding what doses of ketone supplementation and levels of oxygen work to optimize the anti-cancer effects.

While more research is needed, Dr. D’Agostino said, “this combination therapy could represent a non-toxic strategy to help metabolically manage cancer and enhance the effectiveness of standard cancer treatment with chemotherapy and radiation.”

Dr. D’Agostino and Dr. Poff

The USF Hyperbaric Biomedical Research Laboratory houses various pressure chambers, including a 3.2-ton one specially designed for use with an atomic force microscope, which mimic the extreme environmental conditions challenging deep-sea divers.

The USF Hyperbaric Laboratory, including an interview with Dr. Dean, will be included in an upcoming independent documentary on nitrogen narcosis, a major limiting factor in the performance of deep-sea divers. The video will feature Sherri Ferguson of Simon Fraser University in British Columbia, who studies the health effects of narcosis in divers.

Video and photos by Katy Hennig, USF Health Office of Communications 

The mouse model study combined a ketogenic diet and supplements with hyperbaric oxygen therapy 

Tampa, FL (June 10, 2015) — A team of researchers from the Hyperbaric Biomedical Research Laboratory at the University of South Florida (USF) has doubled survival time in an aggressive metastatic cancer model using a novel combination of non-toxic dietary and hyperbaric oxygen therapies.

The study, “Non-toxic metabolic management of metastatic cancer in VM mice: Novel combination of ketogenic diet, ketone supplementation, and hyperbaric oxygen therapy,” was published online today in PLOS ONE.

Led by principal investigator Dominic D’Agostino, PhD, assistant professor in the Department of Molecular Pharmacology and Physiology at the USF Health Morsani College of Medicine, the recently published research shows the beneficial effects of using ketone supplements in conjunction with a non-toxic therapeutic regimen developed previously by the team.  Ketones are produced when the body begins burning fat instead of carbohydrates for energy.

Principal investigator Dominic D’Agostino, PhD, and research associate Angela Poff, PhD, measure tumor growth in the mice receiving the investigational treatment in USF’s Hyperbaric Biomedical Research Laboratory

The research group previously published a study in PLOS ONE demonstrating the anti-cancer effects of therapeutic ketosis induced by the high-fat, low-carbohydrate ketogenic diet (KD) combined with hyperbaric oxygen therapy (HBOT), which involves breathing high-pressure oxygen.  Inducing therapeutic ketosis solely with the ketogenic diet can be difficult, however, so the USF researchers created novel metabolic agents that induce ketosis without dietary restriction.  These ketone supplements slowed cancer growth on their own, and further enhanced the combined therapeutic effects of KD and HBOT.

In the recent USF study, mice with advanced metastatic cancer were fed either a standard high-carbohydrate diet or a carbohydrate-restricted ketogenic diet with ketone supplements and HBOT.  Therapeutic ketosis causes the body to shift from using glucose to fatty acids and ketones bodies for energy.

Normal healthy cells readily adapt to using ketone bodies for fuel, but most cancer cells lack this metabolic flexibility. Solid tumors also have areas of low oxygen, which promote tumor growth and metastatic spread.  HBOT involves breathing 100 percent oxygen at elevated barometric pressure, saturating the tumors with oxygen.  When administered properly, both ketosis and HBOT are non-toxic and may even protect healthy tissues while simultaneously damaging cancer cells.

Animals receiving the combination of KD, ketone supplements, and HBOT lived 103 percent longer than mice fed a standard high-carbohydrate diet. The researchers believe their study demonstrates the potential of these non-toxic therapies to contribute to current cancer treatment regimens and significantly improve the outcome of patients with advanced metastatic cancer.

Researchers at USF and elsewhere are investigating the potential benefits of the physiological state of therapeutic ketosis for several major diseases. The USF team believes these novel ketone supplements may be effective in other disorders besides cancer and have ongoing studies to test their potential use in wound healing, epilepsy, amyotrophic lateral sclerosis (ALS), Alzheimer’s disease, glucose transporter type 1 (GLUT1) deficiency syndrome, and exercise performance.

The cancer study, funded by a charitable donation from Scivation Inc., was inspired by the research of Professor Thomas Seyfried of Boston College.  Dr. Seyfried has advanced the theory that cancer is a metabolic disease, leading to the development of new strategies to treat and prevent cancer.  The USF researchers are currently collaborating with other scientists to explore options for establishing human clinical trials.

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