I did write extensively about the potential to treat some autism using the ketone BHB (beta hydroxybutyrate). This can be achieved either by following a strict ketogenic diet or just by eating medical foods that contain/produce BHB.
Some readers are now big consumers of BHB supplements and anyone taking BHB should be interested in today’s paper, that I assume was paid for by Nestlé.
Nestlé make everything from baby milk formula to George Clooney’s Nespresso. You may not be aware that they also have a business selling medical food; they have been looking at ketones to treat Alzheimer’s for some time. This is quite similar to Mars developing Cocoa flavanols to improve heart and brain health.
Most ketone supplements are sold to help you lose weight or boost athletic performance. The military also uses ketones in survival rations.
We saw that you can increase the level of ketones in your body by supplementing: -
· MCT oil (medium chain triglyceride oil, which usually contains about 60% caprylic C8 acid and 40% capric C10 acid). This is a product already sold by Nestlé
· Neat caprylic acid, C8
· BHB salts (potassium, sodium, calcium etc)
· BHB esters (also called ketone esters KE)
These products range from expensive to very expensive.
People requiring ketones as an alternative fuel to glucose, like those with Alzheimer’s need quite large amounts of the supplements. In Alzheimer’s a glucose transporter at the blood brain barrier is restricting the flow of glucose in blood and so the brain is starved of “fuel”. Mitochondria in the brain can be powered by both ketones and glucose, so if not enough glucose cannot get through, you have the option to increase the amount of ketones.
Babies fed with mother’s milk are on a high ketone diet. You can safely combine both glucose and ketones as a fuel for your body.
The news from today’s paper has already been translated to a usable therapy.
There is growing interest in the metabolism of ketones owing to their reported benefits in neurological and more recently in cardiovascular and renal diseases. As an alternative to a very high fat ketogenic diet, ketones precursors for oral intake are being developed to achieve ketosis without the need for dietary carbohydrate restriction. Here we report that an oral D-beta-hydroxybutyrate (D-BHB) supplement is rapidly absorbed and metabolized in humans and increases blood ketones to millimolar levels. At the same dose, D-BHB is significantly more ketogenic and provides fewer calories than a racemic mixture of BHB or medium chain triglyceride. In a whole body ketone positron emission tomography pilot study, we observed that after D-BHB consumption, the ketone tracer 11C-acetoacetate is rapidly metabolized, mostly by the heart and the kidneys. Beyond brain energy rescue, this opens additional opportunities for therapeutic exploration of D-BHB supplements as a “super fuel” in cardiac and chronic kidney diseases.
One of the main benefits of ketones is their ability to act as an alternative energy source to glucose or fatty acids for production of ATP by mitochondria. Caloric restriction and intermittent fasting also produce transient mild-moderate ketosis (6, 7).
While a high dose of MCT can provide a moderate increase in blood ketones (+0.5–1.0 mM), gastrointestinal intolerance and high caloric load limit their use. Second, ketone esters (KE) made of a BHB ester linked to butanediol provide one molecule of D-BHB after digestion, with the butanediol being further metabolized by the liver to D-BHB (9). KE increase blood ketones above 1 mM but are also limited at high dose by their gastric tolerability and severe bitterness (10).
Third, perhaps the most physiologic way to raise blood ketones is via the oral intake of D-BHB itself. Exogenous D-BHB is directly absorbed into the circulation, with some of it being converted to AcAc by the liver, and both ketones being distributed throughout the body. Until recently, only racemic mixtures of dextro (D) and levo (L) BHB (D+L-BHB) were available and oral human studies with them have been reported (9, 11–14). As L-BHB is not metabolized significantly into energy intermediates and is slowly excreted in the urine (9, 15), D+L-BHB would be anticipated to be less ketogenic than pure D-BHB.
Levo, Dextro and Racemic
When certain chemicals are manufactured, they usually contain an equal mixture of the left-handed and right-handed version, this is called a racemic mixture. These versions are called enantiomers.
One enantiomer is an optical stereoisomer of another enantiomer. The two molecules are mirror images of each other, which are not superimposable - much like your left and right hand.
In the case of the chemical BHB, only the right-handed version has an effect on your body. If you take the salt potassium BHB, half of the product has no effect other than raise your level of potassium.
Zyrtec is an antihistamine made of Cetirizine, but it is a racemic mixture. If you want pure L-Cetirizine, you would buy Xyzal not Zyrtec.
Arbaclofen/ R-baclofen is the right-handed version of baclofen
Rezular/R-verapamil is the right-handed version of verapamil.
Back to the study:
The study compared three therapies: -
D-BHB
14.1 g of pure salts of the D enantiomer of D-BHB were used. The D-BHB supplement tested was formulated as a mixture of three salts: sodium D-beta-hydroxybutyrate, magnesium (D-beta-hydroxybutyrate and calcium (D-beta-hydroxybutyrate). Each oral serving provided 12 g D-beta-hydroxybutyric acid, 0.78 g sodium, 0.42 g magnesium, and 0.88 g calcium, citrus flavouring and sweetener (Stevia), dissolved in 150 mL of drinking water.
D+L-BHB
14.5 g of an equimolar mixture of commercial D and L beta-hydroxybutyrate salt was used (KetoCaNa, KetoSports, USA). Each serving provided a mixture of 12 g D+L-Beta-hydroxybutyric acid, 1.3 g sodium, 1.2 g calcium, orange flavoring and stevia, dissolved in 150 mL of drinking water.
MCT oil
Fifteen grams of medium chain triglyceride (MCT) (60% caprylic C8 acid and 40% capric C10 acid) emulsified in 70 mL of a 5% aqueous milk protein solution.
This chart shows the concentration of ketones in your blood plasma after taking either of the three therapies.
This chart shows the concentration of just the ketone D-BHB in your blood plasma after taking either of the three therapies.
This chart shows where the ketones are going; the chart shows the distribution of the ketone “tracer” acetoacetate (AcAc) by organ after D-BHB oral intake. The effect is greatest on the heart and kidney, but some does reach the brain.
From the dynamic brain scan, CMRAcAc and KAcAc could be determined for all main regions of the brain and compared to baseline values previously determined in healthy young adults. Overall and compared to baseline, each region demonstrated an increase in CMRAcAc and KAcAc of ~4.7 and 2.3-fold, respectively, about 1 h after taking D-BHB. This indicated that AcAc is effectively taken by the brain and by other organs particularly the heart and the kidney.
Ketone production from an exogenous dietary source has been traditionally achieved by MCT. This requires a bolus intake to saturate the liver with MCFA, producing excess acetyl-CoA which is then transformed to AcAc and BHB, which are released into systemic circulation. The Cmax achieved with MCT is usually between 300 and 600 μM, with higher values being difficult to reach due to GI side effects and liver saturation. Here we show that D-BHB, a natural and biologically active ketone isomer, raises blood ketone Cmax above 1 mM without noticeable side effects. In comparison, an equivalent dose of D+L-BHB or MCT only achieved half this ketone level, with similar Tmax at 1 h. Thus, compared to D+L-BHB, D-BHB significantly reduces the salt intake needed to achieve the same plasma ketone response.
Results from a previous study (9) comparing KE to D+L-BHB showed that at the same dose of D-BHB equivalent, the increase blood ketone iAUC had the same magnitude, suggesting that exogenous D-BHB and KE produce similar ketosis.
Note that KE means Ketone Ester and the study (9) is this one: -
On the Metabolism of Exogenous Ketones in Humans
Ketone esters are available, but horribly expensive and taste really bad.
Conclusion
In previous posts the numerous possible beneficial modes of action of BHB were outlined. The summary post is here: -
Ketone Therapy in Autism (Summary of Parts 1-6)
In practise some people with autism seem to benefit a lot, some moderately and some not at all.
Monty, aged 16 with ASD, fits in the “moderately benefits” category. The combination of about 20ml of caprylic acid (C8) plus a scoop of Potassium BHB powder does produce more speech.
It is not a cheap or very convenient therapy, compared the others I use.
I would agree with Nestlé that the limiting factor with BHB salts is the “salt”. As they comment in their paper
“compared to D+L-BHB, D-BHB significantly reduces the salt intake needed to achieve the same plasma ketone response”
Giving someone with heart disease "sodium anything" is not a good idea. A potassium salt would be safer, but even then, your heart is the limiting factor on potassium use. Calcium salts are unwise in people with autism, because it appears to be able to upset calcium ion signalling, which would also be a potential risk in heart disease.
As I mentioned to one parent who is a big time user of BHB salts, if you switch to D-BHB you can either produce twice the ketones of regular potassium BHB, with the existing potassium load, or reduce your dosage by half and keep the same effect and save some money.
I think potassium D-BHB is good choice. If you are taking bumetanide you may no longer need a potassium supplement (K-BHB becomes your potassium supplement).
I think people with autism and genuine mitochondrial disease are highly likely to benefit from D-BHB. These are people who show symptoms in their entire body, i.e. lack of exercise endurance. For these people, eating (or producing via diet) large amounts of ketones will increase the production of ATP in their brains and so improve cognitive function. D-BHB undergoes a different process to glucose, as it “converted” to ATP by the process called OXPHOS
(Oxidative phosphorylation). Some people with autism lack the enzyme complexes needed to complete OXPHOS, these people who should try D-BHB.
(Oxidative phosphorylation). Some people with autism lack the enzyme complexes needed to complete OXPHOS, these people who should try D-BHB.
BHB has other beneficial effects, some relating to inflammation that seem to explain its benefit in other types of autism. The effects were investigated here.
In the brains of people with Alzheimer’s there is decreased expression of glucose transporter 1 (GLUT 1) at the blood brain barrier. This starves the brain of glucose, which is fuel for the brain. D-BHB is an alternative fuel for mitochondria that is not dependent on GLUT 1. People with early onset Alzheimer's would seem the best ones for this therapy, that would include many people with Down Syndrome.