Introduction
Dr. Eric Westman: It’s my pleasure to talk to Dominic D’Agostino.
You’ll love this video because Dominic is in a position of seeing an emerging science, and then being part of meeting planning and going to meetings that puts him in a unique position to know the future, almost like a crystal ball.
Dominic D’Agostino: Thank you for having me, and thank you for everything that you’ve contributed to the field. Maybe your listeners know, but I’m sure there are other listeners that don’t. You were like an icon in the field. I started in 2008, and Dr. Atkins, of course, but Steve Phinney and Jeff Volek, I lump you in with these people who were doing it way before I stepped in. I didn’t formally do funded research on ketones until maybe 2009 or 2010, but you were at this for a long time before I ever came into this field. I didn’t even know what ketones were!
Dr. Eric Westman: I’m passing the baton along. If you step back, the clinical doctors had a method that they never published papers on. I was able to formalize some of the research and actually use a method at a university that is persistent, simple, and corrects a lot of the internet stuff. I want to ask you about something. Should people be measuring ketones? It gets a lot of people off track, in my view. Before we get to that, if someone didn’t know who you were, who are you? Where were you trained? What are you doing these days, and how did you get into the keto world?
Training and getting into the keto world
Dominic D’Agostino: I have always been interested in nutrition, going back to 1990, and 1991. I think I was keeping nutrition journals as a high school student, mostly to gain weight for football. I also started lifting weights. I was a skinny kid and needed to gain a little bit of weight for football. I broke my leg playing football, so during that time off, I invested a lot of time and effort in learning about nutrition and weightlifting. Then I decided in my senior year of high school that I was going to major in nutrition at Rutgers University in New Jersey.
I majored in nutrition science for the first year, and then about a year into nutrition, I realized, where is nutrition going to take me? What can I do with nutrition? I didn’t see many paths, so I figured it would probably be good to double major in biology, too, because I wanted to be a doctor at the time, either a physician’s assistant or a medical doctor. So, I double-majored in nutrition. I didn’t know anything about ketones or ketogenic diets. All I knew was that ketosis was a dangerous state to avoid.
Dr.. Eric Westman: Are we in the mid-90s?
Dominic D’Agostino: Yes, mid-90s. So, 1994 -1995. It was interesting because during that time I was majoring in nutrition and Dateline NBC came on, and Jim Abrahams was on Dateline NBC talking about the ketogenic diet. The only thing I knew about the ketogenic diet was that it was a radical diet for bodybuilders to lose fat. Also, my cousins, two of them, claimed that the Atkins diet was the only thing that worked for them, but they were our weird cousins who adopted this strange diet. I remember seeing the Dateline NBC with Jim Abrahams, and that got me interested, but not that interested. I thought it was very curious.
Dr. Eric Westman: It was fringe.
Dominic D’Agostino: Yes, fringe. I wasn’t so much into neuroscience at the time, so it didn’t spark enough curiosity for me to seek to understand how a ketogenic diet could change brain energy metabolism or the neuropharmacology of the brain. I was into other things. I was into nutrition for fitness mostly. That’s probably why I majored in it. During my junior year in college, I was mentored by the dean of research at Rutgers University, Robert Wood Johnson Medical School. She had a pretty big influence on mentoring me to go the basic science route. So, my undergraduate work then became my PhD dissertation, which was on the neural control of autonomic regulation, specifically, the brainstem mechanisms that control respiration and understanding the oxygen-sensing mechanisms in that.
PhD and post-doctoral fellowship opportunities
Dominic D’Agostino: That then became my PhD dissertation, and after my PhD, I was in a post-doctoral fellowship program funded by the Office of Naval Research to look at oxygen toxicity seizures. So, I was double majoring in nutrition and biology and started working in a lab my junior year under the dean of research at Rutgers University, specifically studying oxygen chemosensitivity in the brainstem and how our brain controls our physiology, specifically cardiorespiratory physiology. I majored in physiology and neuroscience for my PhD. During that process, while looking at different post-doctoral fellowship opportunities, I had one lined up at Dartmouth College, which was very enticing. Then I got recruited to Wright State University near Ohio State University. I think it may have started as a satellite campus of Ohio State, on a military-related project because I was also very much into scuba diving. That was to understand fundamentally what caused central nervous system oxygen toxicity. These are seizures that limit Navy SEAL divers using closed-circuit rebreathers. Oxygen toxicity also limits the application of hyperbaric oxygen therapy, which has 14 different FDA-approved applications. Carbon monoxide poisoning, decompression sickness, and wound healing are big ones.
I developed various technologies like hyperbaric microscopes, patch clamp electrophysiology, and radio telemetry. All these things are capable of being done inside a hyperbaric chamber, allowing us to look at the mitochondria under graded levels of oxygen and pressure. This simulates extreme environments, everything from the undersea environment to the space environment. I was in a pharmacology program and physiology, and I was mostly interested in anti-epileptic drugs. They had a limited effect, but the thing that worked better than anything else, fast-forwarding now about four years of research, was putting in ketones. Sodium beta-hydroxybutyrate and acetoacetate in my experimental preparation blocked the free radicals and seizure activity.
When we moved it to animal models, we developed a ketone ester. Taking a little bit of a step back, the military did not like the ketogenic diet at the time because it was high fat. You’re familiar with the reasons why, but they actually asked me to come up with a ketogenic diet in a drug. We tested a number of molecules that didn’t work, and then we found one, a ketone ester, that worked remarkably well. We kept studying that and developed different formulations.
Introduction to ketosis
Dominic D’Agostino: My introduction to the world of ketosis was mostly from the seizure community. Dr. Jong Rho pushed me into this field more or less and said it would be a fruitful direction. Eric Kossoff, the late John Freeman, Dr. McKenzie Cervenka and the Hopkins team, including Adam Hartman, were instrumental. I ended up going to the American Epilepsy Society, where they had a special interest group in ketogenic therapies. That was my introduction to ketogenic diets, from their accepted clinical application in drug-resistant epilepsy. I viewed the ketogenic diet as a prescription diet. There’s low carb, and then there’s prescription-strength low carb, which would be a very calculated, measured, and quantified ketogenic diet.
Then we asked the question and connected with Dr. Richard Veech at the NIH and Dr. Mary Newport, who was giving her husband coconut oil, which converts to ketones. I was interested in the diet, and people were put into my sphere, like the late Dr. George Cahill, Sami Hashim, and Theodore VanItallie. These icons in the field pushed me in this direction.
The fundamental question I had was, could you induce therapeutic ketosis by elevating the ketones? Would those ketones have anti-seizure effects? Would it preserve brain energy metabolism in the face of excitotoxic insult, and could it be used to metabolically manage seizure disorders or neurometabolic disorders? I was interested in glucose transporter deficiency syndrome and a range of different disorders we could talk about. That launched my career, developing a ketone ester, testing it, and discovering it worked better than anything we had seen before. In 2010, I stumbled upon Dr.Thomas Seyfried’s work in cancer. Then I had some people come into my sphere who implemented this, and it worked for them. That really got me motivated.
I had a PhD student, Dr. Angela Poff (not a doctor at that time), whose father had a brain tumor. She was highly motivated to study cancer, but I told her I was not a cancer biologist and was just learning. She was motivated enough to spearhead a number of projects in my lab. This resulted in about a half-dozen publications showing that therapeutic ketosis, combined with hyperbaric oxygen or even by itself, and other metabolic drugs like DCA and metformin, could target energy metabolism.
Another project we studied was Alzheimer’s disease, initiated by Dr. Mary Newport at the Byrd Alzheimer’s Center. I had a PhD student working with Alzheimer’s mouse models. They’re not the best, but we saw some interesting results. Within one year, we had very encouraging data on seizures, cancer, and Alzheimer’s disease. I remember that year being very exciting for me, I couldn’t sleep. I was so excited, and it’s been a fun ride ever since.
Thoughts on administering ketones, get some benefit without changing the whole diet
Dr. Eric Westman: One of the questions I’m sure my listeners are thinking is, “Does this apply to me?” With your understanding now of giving people ketones and administering that while they’re eating carbs. Apparently, these are people eating an American diet, not doing a keto diet. What is the difference between the metabolic state of someone drinking ketones while eating carbs and someone generating their own fat-burning nutritional ketosis and having a ketone level while not eating carbs? It was shocking to me that Dr. Mary Newport could put coconut oil on her husband’s cornflakes, and because she didn’t really know anything about the keto diet, I had eyes wide open about whether you could administer ketones and get some benefit without changing the whole diet. What’s your take on that now, through the years?
Dominic D’Agostino: I was firmly of the opinion that your body needed to physiologically change its metabolism from a glucose-based metabolism, not to completely fat and ketone metabolism, but that there was a transitional period. Then that led me to look into it, as the military was pushing me into coming up with a ketogenic diet in a drug, I was able to get into databases, a DARPA database and I found out that research was being done by the late Dr. Richard Veech, who I admire. He was a bit of a mentor to me, and also Dr. Kieran Clarke from Oxford. Later that year, I went to Oxford and gave a talk to her lab, and that stimulated more discussions there.
This idea that you could acutely drink ketones and have some kind of therapeutic effect was only compelling to me because of where it was coming from. It was coming from Dr. Richard Veech, who was mentored by Hans Krebs, who was mentored by Otto Warburg. There was a long line of genius-level knowledge, wisdom, and expertise on metabolism. I read his review articles dating back to 2001, with Dr. George Cahill and Britton Chance. These physiologists were icons to me, so I got very curious and thought, “I need to test this.”
The first thing we tested was fasting animals, a rat, for 24 to 36 hours, and we knew that it had a remarkable anti-seizure effect, better than any anti-seizure drug. Fasting and certain diets had shown anti-seizure effects. The idea was to acutely induce ketosis in 15 to 30 minutes and subject animals to five atmospheres of oxygen, which reliably produces a tonic-clonic seizure. When we did that with a beta-hydroxybutyrate monor-ester, it didn’t work. When we tested another molecule that elevated acetoacetate and beta-hydroxybutyrate in a sort of redox ratio and balanced the two ketones, then it worked.
It worked so well that I remember an hour passing. The rats usually seized within about five minutes, and we were all standing around the chamber. There’s a little window, and we were watching the rat after an hour and it’s grooming itself like it’s nothing. We had never seen anything like that before.
Dr. Eric Westman: You did it again to make sure it wasn’t just a mistake?
Dominic D’Agostino: I’ve heard about “super rats,” like the military created a special rat. I thought, “Maybe this is a super rat.” The next one, and the next one, five in a row, showed the same results, and we thought, “This is really interesting.”
Dr. Eric Westman: From what I’m hearing, at least for brain protection and seizure response, the type of ketone you administer matters. Not all ketones you drink, eat, or administer would have the same effect. I’ve been calling for research on the administration of ketones. I don’t even know what the latest is with the company that sells the product, but I just want some research.
Dominic D’Agostino: I try to stay away from companies as much as possible, even though some have our patents and things like that. I don’t even return emails or talk to them. I’ll vaguely reference things based on ketones we tested in the lab.
Does the administration of ketones provide a signal that it helps clinically?
Dr. Eric Westman: By now, there might be recurring signals or cases of people drinking those products and fixing problems. Do you have any signal for that? Often, these come up in the comments section after a YouTube video. If there are enough of them, I can’t ignore those kinds of things, although I need to formalize all that.
Does the administration of ketones seem to provide a signal that it helps clinically?
Dominic D’Agostino: Yes, I get dozens of emails every day. I also think I’m a bit biased. People tell me what they think I want to hear, and they ask for advice. Typically, most people are doing a low-carb or a ketogenic diet, and then they add ketones, for example. There’s no replacement for a good diet. That’s the most important thing, a well-formulated low-carb or ketogenic diet, or a well-formulated Mediterranean diet, or any kind of diet.
Dr. Eric Westman: We have a wide range of humans. I remember in the smoking cessation world, which I was in for a decade as the inventor of the nicotine patch, there were studies that showed you could administer vitamin C to protect a smoker from lung cancer. That kind of grated on me. Why don’t you just get them to quit? There may be a role for someone who can’t get off sugar, someone who is totally addicted. Of course, you want to get them off the crappy diet, as you say, but if there’s an addiction, and you can add something to prevent or help, I’m not sure, that in the clinical world, this is what happens, while it might not be ideal.
Dominic D’Agostino: Yes, you don’t go to an alcoholic and say, “You can have alcohol but just one or two drinks, and then just try to stay sober.” I consider myself a super-disciplined person, but there were points in my life where I felt food was controlling me. It was usually when I was in a caloric deficit, and your brain just kind of goes – especially if you’re eating carbohydrates – you become fixated on food.
That’s coming from someone who had no problems with carbohydrates growing up, eating pasta from an Italian family and all that. I realized that as soon as I cut that out, it wasn’t a weight problem for me. My eczema went away, my thought processes were clearer, and I entered keto nutrition. When I entered a tenure-track position at the university, which required very long hours, teaching full-time, reading grants full-time, and doing research, I had boundless energy once my body entered ketosis. It was like this smooth energy.
Dr. Eric Westman: We’ve shared dinner a few times. At what point was that?
Dominic D’Agostino: Intermittent fasting, too. Maybe I took that a little bit too far because, over the course of ten years of doing it, I ended up losing quite a bit of muscle. Luckily, I had some weight to lose, including muscle. Now I maintain a healthy weight and I maintain the physical parameters I want to prioritize.
MCT
What’s remarkable for me, and what people know me for, is ketogenic diet research, but also the development and application of exogenous ketone supplementation, including MCT. I do think that the foundation of any health optimization would involve diet. Of course, there are situations where people are unable or unwilling to follow it.
For example, I just got off a call with Mount Sinai. They’re managing multiple acyl-CoA dehydrogenase deficiency (MADD), which is a fatty acid oxidation disorder. The beta-hydroxybutyrate is incredibly therapeutic and can reverse cardiomyopathy. Just giving ketones can do that, but they can’t even tolerate MCT or any kind of fat. So, they’re on relatively moderate-protein, very high-carb, and then they use ketone supplementation, four times per day, with really high doses of a ketone salt, a sodium ketone salt.
We tend to work with disorders that we know are highly responsive to ketogenic therapies, and out of that came cancer research. We’re studying things like Angelman syndrome, Kabuki syndrome, PP syndrome, all these things I never thought I would go into. I was steered into different research paths because the parents of kids with these disorders would reach out to me. I’d think, “Okay, that makes sense.”
For the general population, I get lots of parents who have kids with ADHD. Once they improve their kids’ nutrition and get sugar out of the mix, they’re getting them off medication. They’re sending me pictures of their report cards going from C/D students to A/B students. Many of them are also giving exogenous ketones, and I think that’s helping. Especially if it’s a drink that tastes good. As you know with addiction, maybe complete restriction doesn’t always work, but if you can replace instead of restrict, that’s something.
We do research on allulose in cancer research because it can block or occupy the GLUT5 transporter. If you formulate a diet that’s high in protein, moderate-to-high fat, and has fiber and allulose, then you also use MCT. So, protein, fiber, MCT, and allulose, these things can comprise a diet, and none of those things will turn into fat. Excess protein, fiber, and allulose won’t turn into fat. I’m not too particular about the fiber, but I think it can be beneficial. Allulose tastes sweet like sugar, but it won’t convert to fat, and MCT oil is quickly oxidized and essentially does not get turned into fat.
Explaining what MCT is, what it stands for and what it does.
Dr. Eric Westman: Please explain MCT, what it stands for, and what it does.
Dominic D’Agostino: MCT, I think of medium-chain triglyceride, also sold as MCT, like a poor man’s ketone ester. You can buy MCT oil from CVS, Walgreens, or Amazon for about 15-20 bucks for a whole liter of it. And that’s a lot of calories. MCT oil is derived from coconut oil or palm kernel oil. I try to choose ones that come from coconut oil, just from a sustainability point of view. It doesn’t have any taste at all. It’s comprised of triglycerides that are 8 to 10 carbons, so that would be caprylic triglyceride, capric, also known as octanoic acid (8 carbons) or decanoic acid (10 carbons).
These medium-chain triglyceride oils, when you consume them, go very quickly to the liver via what’s called the hepatic portal circulation. The liver then dramatically increases the oxidation of these fats, which stimulates ketogenesis. A relatively large portion of MCT, depending on the physiological state, if you take it with a stimulant like caffeine, or if you’re fasted, converts more MCT to ketones. You can also put it into your oatmeal and have MCT, which contributes to small amounts of ketones and also reduces the glycemic response too. This is a type of fat that is not packaged into chylomicrons like long-chain fatty acids, which enter the lymphatic system. Instead, it goes directly to the liver, gets burned, and enters circulation. Some of it converts to ketones.
Also, what’s interesting about medium-chain triglycerides is that, unlike long-chain fats, they cross the blood-brain barrier, so they can get into the brain and into the mitochondria, where they’re used as an energy source. I didn’t even know that until we were feeding MCTs. We were mixing the ketone ester with MCT, and we were mixing ketone salts with MCT because it always made the exogenous ketones work much better.
When you deliver it that way, it stimulates your own endogenous ketone production while you’re also delivering exogenous ones. So, in our case, that always worked better. It was actually more than additive, it was synergistic. That’s one of the patents we have because I didn’t expect it. We looked at the data and did a human pilot trial, and we were, “Okay, we see why.” The ketones stayed elevated above and beyond, kind of shifting the pharmacokinetic curve to the right, if you will. When you give exogenous ketones and mix them with the oil, it sustains ketosis for six to eight hours instead of two or four hours. That was one of the observations. MCTs are great. You can make salad dressing out of MCT, incorporate it into your meals, put it on your vegetables, or make coffee with it.
Some people don’t tolerate MCT. What I would say to that is, start with a teaspoon and work up. I was similar, at least on an empty stomach, but if I combined MCT with long-chain fats or protein, I could tolerate quite a bit. At one point, I was experimenting with MCTs and got up to 60 to 100 milliliters per day. That was enough to basically elevate my ketones a good one to two millimolars throughout the day. That represents a significant amount of energy in the blood, that level of ketones can be used by the brain as a source of energy. We’ve also seen that this level of ketones has anti-inflammatory effects. It reduces reactive oxygen species in every model system we looked at. My student is studying the metabolic control of epigenetic regulation, where the ketone body, beta-hydroxybutyrate, and maybe acetoacetate too, alter gene expression in ways that are beneficial, like upregulating antioxidant genes and improving genes associated with neuroprotection and resilience. Never thought I would go down that path, but we are.
Dr. Eric Westman: That’s independent of the diet, is that correct?
Dominic D’Agostino: Yep, that is independent of the diet.
Should testing and advocating be done?
Dr. Eric Westman: Could you do better? The people I’ve been teaching, in Keto Made Simple, I say, “Don’t measure, don’t check your ketones, don’t drink ketones. Just change the food. You’ll be great; you’ll be fine.”
Is there, in your experience, a role for adding ketones, MCT, coconut oil, or anything that might enhance the ketone level beyond the diet itself? I mean, not just theoretical. I think theoretically, you could add something to a nutritional ketosis kind of diet and get added benefits. That’s what we’re trying to look for, but I don’t see anyone really testing that yet.
What’s your opinion? Should we be testing or advocating all of these things?
Dominic D’Agostinio: Yes, all great questions. The preclinical work would suggest that exogenous ketones are highly efficacious. The human randomized control trials, everybody’s interested in athletic performance. That’s the one thing I don’t study much, but we look at performance in the context of extreme environments, like hypothetically, on top of Mount Everest or underneath the water, in those cases, brain energy, performance, reaction time, decision-making, all those things improve. Your general mental state improves in ketosis.
There is absolutely no replacement for a good diet. I don’t think you can undo a bad diet. A lot of people have their diets on point, and a lot of people don’t. For example, my wife does not want to follow a low-carb ketogenic diet. That said, we went to a meeting in Switzerland, and she met Anthony Chaffee. After I’ve been talking about low-carb and keto for such a long time, she decides to do a carnivore diet. She has vitiligo, a skin autoimmune disorder, and Joe Rogan had mentioned that it cured his vitiligo. She wanted to try, so she did the carnivore diet. This is someone who did not want to do a ketogenic or low-carb diet, and it worked. This is something that may not happen with ketone supplementation. She was already using ketone supplementation, but that didn’t do it.
Dr. Eric Westman: Is she doing supplementation? Is she in ketosis? Does she measure?
Dominic D’Agostino: Yes, she measures. She usually stays about 0.6 to 0.8 (mmol/L), then she’ll boost it with ketones.
Dr. Eric Westman: Carnivore is a subset of a low-carb keto diet. The irony is, I should just reiterate: she said, “No, I won’t do this keto thing, but I’ll do carnivore,” which is a keto thing, right?
Dominic D’Agostino: That’s right.
Dr. Eric Westman: Is her vitiligo better? I’ve met her. I don’t know how private she is about that.
Dominic D’Agostino: I don’t think she’d mind mentioning it. She was trying some creams, but they’re steroids, and they do work a little, but they get into circulation, so she didn’t want to use them. Then the vitiligo came back, I think, even more. She’s convinced that following the carnivore diet now is helping.
A side-effect that she didn’t expect is that she lost weight. She didn’t need to lose weight, but she went down 10 to 12 lbs. She’s literally full all the time, and she’s told me, “This is unbelievable. I have so much energy.”
Dr. Eric Westman: Like taking a shot or a pill, right?
Dominic D’Agostino: Yes, it’s amazing. I was telling her this for years, but only after talking to Anthony Chaffee, who is very articulate, she decided to try it.
Would one get added benefits from taking exogenous ketones?
Dr. Eric Westman: There’s a saying, “The cobbler’s children wear no shoes,” so of course, the person who said, “Keto!” has a family that eats carbs. My kids eat carbs too.
Back to the question of ketones. When you’re saying ketosis helps on Everest or in extreme environments, is that someone who’s in nutritional ketosis and then adds ketones to it? That’s what I’m trying to get at. If I’m watching this and I’m in ketosis and I’m not measuring it, would I get added benefits from taking exogenous ketones?
Dominic D’Agostino: You get benefits above and beyond a well-formulated low-carb or non-ketogenic diet with exogenous ketones. Exogenous ketones tend to have little or no effect in a healthy person in regards to exercise unless that person is in an extreme environment or there is some type of pathology that impairs insulin sensitivity or glucose metabolism. That could be an insulin-resistant person, so sometimes they respond really well to that.
I think it’s important to mention that studies looking at ketones often give an acute dose, then make the participants exercise to exhaustion, expecting it to work like an immediate energy boost. It’s like giving someone a steroid injection and expecting their bench press to go up. I don’t think of exogenous ketones as something like caffeine or amphetamines that acutely increase performance. I think of it more like a steroid, which would be a training aid. It enhances your adaptation to, for example, resistance training over time. It creates an environment where you get a favorable adaptation to a training stimulus, like recovery.
There are over 100 clinical trials on clinicaltrials.gov just on ketone supplementation. This is being studied, and I think publications will start coming out in two or three years. We have a couple of studies in the pipeline.
Metabolic Health Summit and how it came about
Dr. Eric Westman: Switching gears to the meetings, this is where you get to see the public data. These days, sometimes the paper comes out before the meeting presentation, but in the old days, you would get a preview of what’s happening at meetings.
How did the Metabolic Health Summit come about, and how did you become the driving force behind this amazing event?
Dominic D’Agostino: Thanks for asking about that. The Metabolic Health Summit started as the Metabolic Therapeutics Conference, and I think in 2010, I believe, I got a little internal grant from the University of South Florida to hold a small neuroscience meeting as part of this Neuroscience Collaborative. I think that was in 2009 or 2010. We had Eric Kossoff come, and I think we had some of the leaders in the epilepsy world. It was like, “Wow, that was fun. Why don’t we do this again?” But there was no money available.
The people I choose to work in the lab have to be personally motivated. They have to have a limbic level of motivation, something that drives them beyond just intellectual curiosity. I happened to have a group of very eager students who were able to do a lot of the logistics, putting together the event and communicating with leaders in the field, like Jeff Volek. You’ve been at many meetings too.
I think the first real conference didn’t happen until 2015. We took a couple of gap years. I was attending the American Epilepsy Society meetings then and made some contacts there. Eventually, it was funded by the Epigenix Foundation, which was a spin-off foundation from Quest Nutrition. The guys at Quest Nutrition were very generous, providing us with a donation that helped secure the venue and modest honorariums for the speakers. I remember the first room we had, I think the capacity was 200, but midway through, somehow the word got out. All the seats were filled, there were people standing at the back, and more people trying to get in the door. We were like, “Whoa, okay!” The next year, in 2016, we opened up the whole ballroom. It went from 200 to 600 attendees without any advertising at all, no social media or anything.
Then it jumped from that, and we had to move it to California. I think we did two or three years in Long Beach, then more recently in Santa Barbara, and in Clearwater. It was really driven by pure interest and curiosity from the low-carb community. The Metabolic Health Summit is a combination of basic science research because that’s what I focus on, clinical research, and patient experiences. We also have people like you and others with clinical experience, but also the motto is “Science to Application.” The most important thing is to have practitioners there who can speak to how to implement this because that has been a gap, a bottleneck if you will.
One thing that we’ve done, which I think is helpful, is monetizing the event. There are companies developing food products, apps, and wearable technologies, like Abbott Nutrition. Abbott Nutrition was going to be a big sponsor with their continuous ketone monitor for our last meeting, but they had to pull out because it wasn’t yet FDA-approved. Although last week, I saw it got approved. We like to reach out to innovative companies and bring them in to showcase what they have, and their sponsorship helps support the venue and speaker fees. I don’t take any salary from it, though.
In the last meeting, we hit a bit of a rut, so we’re trying to pay off the debt from that. These meetings don’t make any money, but they’re great for networking.
Costs to put on a Metabolic Health Summit
Dr. Eric Westman: For people watching who don’t know the level of work involved in science and meetings like this, how much does it cost to put on?
Dominic D’Agostino: Luckily for me, I’m part of the promotion. The business end is run by Dr. Angela Poff and Victoria Field, and they’ve got a great team. Victoria was a TV news reporter, so she was skilled at negotiating with the hotels. They write up a budget to figure out how much we can pay for the speakers, venue costs, etc. In California, we were able to have 80 sponsors, but in Florida, we were capped at 40 due to room size. So we ended up owing money. I’d say the meetings cost around $500,000 – half a million dollars.
Dr. Eric Westman: The idea that you can do this on your own with a GoFundMe or something like that isn’t feasible. As a past president of the Obesity Medicine Association, I sat in meetings where we discussed these venues, and they are not cheap. That’s why we charge a fee to attend, although there’s also an option to watch online, which is fantastic too.
I just have to give a shout-out again, the Metabolic Health Summit brings together scientists working on epilepsy treatment, the clinical world, diabetes reversal, and innovative technologies like Virta Health, which is difficult to do. Apps and other tools are showcased too, and it’s been great to see the progress. Thanks for that, I also know it’s a lot of work to pull off these meetings and make them happen. That is so important. I’m glad you have that.
Dominic D’Agostino: I’d like to mention quickly though, that getting staff is a big part, but I integrate this into my teaching. I teach undergrad, Masters, PhD, and medical students, so I get my medical students to become volunteers for the Metabolic Health Summit. This gives them exposure because they can walk in, see the talks, and they’re completely blown away since they’ve never heard anything like it.
We do have a mandatory nutrition course at the university, but my role, as I see it, is increasingly needed to indoctrinate, if you want to use that word, first and second-year medical students. This way, they can go on and incorporate this into their practice. The Metabolic Health Summit becomes this entity where I bring in medical students as volunteers, and then they can put that on their CVs. It gives them exposure, and it completely blows their minds. That’s probably one of the most fun things about the Metabolic Health Summit.
Taking on more trainees
Dr. Eric Westman: Do you have bandwidth to take on more trainees? If someone is interested in research on ketones and all that, should I send them your way?
Dominic D’Agostino: I think so. Right now, I have my hands full with first, second, third, and fourth-year medical students, and some who have gone into residency. We’re still writing papers, but I do my best. My bandwidth is limited, but if I can’t directly mentor them, there are groups of people who work under me who can mentor them on different projects, depending on their interests.
Dr. Eric Westman: Fantastic. One of my dreams, if I had all the time and money in the world, would be to put on a conference at Duke. We’re known for nutrition and weight loss programs going back a hundred years. The Rice Diet started here. It would be only for doctors, CME-level, very practical but a deep-dive into the science. It would be a smaller meeting, and maybe a little pricey. I know the Metabolic Health Summit is more inclusive, wanting basic science and trainees and all that, but would you come to speak at a conference at Duke if I could swing that?
Dominic D’Agostino: Absolutely. We have two clinical trials at Duke with oxygen toxicity, Dr. Richard Moon, Claude Piantadosi, and Bruce Derrick. I don’t know if you know that group, but we’re doing ketogenic diet research there. I would love to come. I love Duke. It’s an amazing university, probably one of my favorites. Just walking around campus is beautiful.
Should one measure their ketone levels?
Dr. Eric Westman: A very data-driven place, too. I think the only way I could have maintained an academic home is in a data-driven place. Duke is very much that. The history of weight loss programs also started my transition into this field.
For those watching, should they be measuring their ketone levels, breath, blood, or urine? How could it help their life if they’re already in this world?
Dominic D’Agostino: Generally speaking, ketone levels are inversely proportional to glucose and insulin. As you reduce carbohydrates, total calories, and protein, and really follow a restrictive ketogenic diet for weight loss or type 2 diabetes, you’ll see insulin go down, and in many cases, ketones will go up. Not always, but they generally tend to go up.
If someone is embarking on this journey to lose weight and reverse type 2 diabetes, measuring ketones is a really important biomarker. Another important biomarker is glucose over ketones in millimolar concentration, called the Glucose Ketone Index (GKI). The Keto-Mojo device does that. We use it for the metabolic management of cancer and seizures, but I also think that this single biomarker, in type 2 diabetes and obesity, if they get a GKI below five, or even between four and five, it will have a profound effect on their metabolic physiology. Appetite regulation will improve, insulin sensitivity will improve, and they’re just going to lose weight. It would be almost impossible for them not to lose weight if they go from a standard diet to achieving that GKI and maintaining it, which is totally doable with just a low-carb diet.
Monitoring or no monitoring
Dr. Eric Westman: Have you seen a study published or presented at a meeting where they randomized people into no monitoring and monitoring? If both groups were strict with the diet, was there any benefit beyond just the diet change?
Dominic D’Agostino: That’s a really good question. I haven’t seen that study yet, but from the data trickling in from current clinical trials, such as ketogenic diet trials, even for metabolic psychiatry, it seems that patients who are really invested in monitoring their levels tend to have better outcomes.
Biomarkers and their glucose, their metabolic awareness, for example, if they’re wearing a continuous glucose monitor, give them biofeedback, behavioral feedback that allows them to alter their next meal. They’re going to eat less of, or avoid, the food that spiked their glucose if they’re wearing a continuous glucose monitor. This applies to people eating a standard diet or a ketogenic diet. The mere act of monitoring amplifies the person’s ownership of their own health and gives them a sense of independence.
As a doctor, you can’t be up on their labs all the time, asking them to send you their glucose and ketones. If you put a CGM on them, tell them to go home and look at it once or twice a day, and they’ll be able to see, “I ate this at 2 PM and my glucose spiked. I won’t do that again.”
Monitoring devices
Dr Eric Westman: Mark Cucuzzella has published a few clinical papers doing that. I didn’t know the status of the continuous ketone monitor. Can someone order it now?
Dominic D’Agostino: I’m in that program, technically. I have an Android, but the software for the Lingo device doesn’t work with the Android yet, so they’re rewriting the software. I think it’s still in testing.
Dr. Eric Westman: I just sent away for the Lingo with glucose, but what about the ketone one?
Dominic D’Agostino: Yes, that’s still under development. Jeff Volek showed me his data. He was wearing one at the time, and I’ve had about half a dozen people show me their data. I’m of the opinion that it’s accurate enough for the everyday person. There’s also the SiBio device out of China, and I’ve been in contact with numerous people who compared it to the Keto Mojo.
These technologies have been up-and-coming for the last five years, and I truly think that in the next five years, they’ll be available and inexpensive enough for general use.
Where to find Dominic D’Agostino
Dr. Eric Westman: For people doing the diet themselves, in orphan diseases like all of those metabolic diseases you were talking about, the mainstream paradigm was that you had to give these people carbs, and it turned off fatty acid metabolism. The medical influence you’re having is that the body runs well on fat. Ketones substitute where glucose isn’t. Even now, heart failure studies are finally being done, but the mainstream learned about it through a drug that caused ketosis.
Your view of where things are going is one of a kind. Any last comment? How do people find you, or what would your final word be?
Dominic D’Agostino: Thank you for that. I’m excited to be in this field, and I give a lot of thanks to you and many of the pioneers who spearheaded this field. If people want to find me, go to KetoNutrition.org or Metabolic Health Summit, and you’ll find past speakers and their talks. There’s also a Metabolic Health Summit YouTube page with many of the talks. There’s also the Metabolic Health Initiative, which is an ACCME-accredited medical education platform where you can get CMEs. We have additional content, like Dr. Kyle Gillett did a “Hormone 101” on GLP drugs and things like that. So there’s additional content if you’re a practitioner wanting CME credits that are deep dives into specific topics.
Dr. Eric Westman: Fantastic! I look forward to seeing you again.
You can view the full video here.
