Ketone Therapy in Autism (Summary of Parts 1-6)

Open the above file via Google Drive, so it is big enough to read. Click the link below. You can also take links from it to the relevant blog post.

https://drive.google.com/file/d/1Jl_JMUrX7suXz0n_yJPCLPinrvdddBhI/view?usp=sharing

In the mini series of posts on ketones and autism we have come across a long list of effects that will benefit certain groups of people.

1.     Change in gut Bacteria

2.     Ketones as a brain fuel    

3.     Niacin Receptor HCA2/ GPR109A

4.     NAD sparing

5.     CtBP Activation by reducing NADH/NAD+ ratio

6.     NLRP3 Inflammasome inhibition

7.     Class 1 HDAC inhibition

8.     Increase BDNF

9.     Ramification of Microglia

10.PKA activation

11.PPAR gamma activation

It was interesting that the beneficial effect of the Ketogenic Diet in epilepsy is driven by changes the high fat diet makes to the bacteria in your gut and seems to have nothing really to do with ketones. Well it took a hundred years to figure that one out.

In the case of Alzheimer’s, you can see that more than one effect is potentially beneficial. People with Alzheimer’s do have low glucose uptake to the brain, but they also have elevated inflammatory cytokine IL-1B.

In Huntington’s it is the HDAC inhibition effect that seems to be what helps.  This brings us back to HDAC inhibition as a potentially transformative therapy with long lasting effects. It appears that the small number of people who achieve long lasting benefit from short term use of sulforaphane or EGCG may have experienced HDAC inhibition changing the expression of up to 200 genes.  In the case of sulforaphane from broccoli, some people have gut bacteria that produces large amounts of the enzyme myrosinase, which means they convert very much more of the glucoraphanin in broccoli to sulforaphane (an HDAC inhibitor).

It does look like a low dose of a potent HDAC inhibiting cancer drug is what is needed by certain single gene autisms and perhaps some idiopathic autism. This was covered in a dedicated post where we saw the long-lasting benefit of short-term use of Romidepsin. Vorinostat, a very similar drug, but which is taken orally, should be trialled in Shank 3, Pitt Hopkins and Kabuki, to see if the same transformative long-lasting effect can be reproduced.

In Multiple Sclerosis (MS) the effect on Niacin receptor HCA2/GPR109A should help a lot, but so should PKA activation.

In mitochondrial disease it was suggested that increased ketosis will help conserve NAD, which may be deficient. Also, using ketones as an alternative brain fuel may bypass problems that occur when glucose is supposed to be the fuel and thereby boost brain function. The most important effect is likely to be activation of PPAR gamma by C10, which increases the number of mitochondria and boosts the enzyme complex 1.

Many of the people with autism and an overactive immune system stand to benefit from activating CtBP, inhibiting the NLRP3 inflammasome, or activating HCA2/GPR109A.

I think there should be clinical trials using a potent HCA2 activator in autism comorbid with immune over-activation. 

We can see that some people who respond to BHB, experience an immune rebound on cessation, so this helps narrow down the likely beneficial mode of action.  In this immune sub-group, the idea to using other activators of HCA2/GPR109A would seem worthwhile. 

PPAR gamma activation should help those with mitochondrial dysfunction, but this effect is produced only by C10, not BHB or C8. For C10 you eat a ketogenic diet or add it as a supplement (e.g. cheaper MCT oil, or coconut oil).

As recently highlighted by our reader Agnieszka, perhaps the fever effect in autism can be explained by short-term ketosis. Fever is known to sometimes raise the level of ketones, particularly in children (it is called non-diabetic ketosis).  So if your child's autism improves during, or just after fever, test the level of ketones in their urine.


Conclusion

We may have shown the benefits of a high fat ketogenic diet, but there are very many different fats and they do not all produce the same effects.

There are many saturated fatty acids, they are numbered based on how many Carbon atoms they have.

So, C8, known as Caprylic acid has the formula  C₈H₁₆O₂

Eating C8 looks to be a great way to increase the level of ketones in your blood.

Eating C10 should be good for people with mitochondrial dysfunction and people with diabetes.

Your food contains many other saturated fatty acids and your gut bacteria produce even more.

Common Name	Systematic Name	Structural Formula	Lipid Numbers
Propionic acid	Propanoic acid	CH3CH2COOH	C3:0
Butyric acid	Butanoic acid	CH3(CH2)2COOH	C4:0
Valeric acid	Pentanoic acid	CH3(CH2)3COOH	C5:0
Caproic acid	Hexanoic acid	CH3(CH2)4COOH	C6:0
Enanthic acid	Heptanoic acid	CH3(CH2)5COOH	C7:0
Caprylic acid	Octanoic acid	CH3(CH2)6COOH	C8:0
Pelargonic acid	Nonanoic acid	CH3(CH2)7COOH	C9:0
Capric acid	Decanoic acid	CH3(CH2)8COOH	C10:0
Undecylic acid	Undecanoic acid	CH3(CH2)9COOH	C11:0
Lauric acid	Dodecanoic acid	CH3(CH2)10COOH	C12:0
Tridecylic acid	Tridecanoic acid	CH3(CH2)11COOH	C13:0
Myristic acid	Tetradecanoic acid	CH3(CH2)12COOH	C14:0
Pentadecylic acid	Pentadecanoic acid	CH3(CH2)13COOH	C15:0
Palmitic acid	Hexadecanoic acid	CH3(CH2)14COOH	C16:0
Margaric acid	Heptadecanoic acid	CH3(CH2)15COOH	C17:0
Stearic acid	Octadecanoic acid	CH3(CH2)16COOH	C18:0
Nonadecylic acid	Nonadecanoic acid	CH3(CH2)17COOH	C19:0
Arachidic acid	Eicosanoic acid	CH3(CH2)18COOH	C20:0

C4, familiar as Butyric acid, helps maintain the integrity of the intestinal barrier and the blood brain barrier.  Butyric acid, or butyrate, is also an HDAC inhibitor and it seems that in animal models, and some humans, a small amount can be beneficial but large amounts can have a negative effect. A small amount in humans seems to be about 500 mg a day.  There are earlier posts is this blog on butyrate.

C3, familiar as Propionic acid, is bad for you and too much propionic acid will by itself cause autistic behaviours. NAC counters the effect of propionic acid in mouse models.

All those people eating coconut oil are consuming a 99% mixture of fatty acids with 1% phytosterols.

Phytosterols like β-Sitosterol, Stigmasterol, Avenasterol and Campesterol likely explain why coconut oil actually reduces "bad" cholesterol, rather than increasing it, as predicted by the American Heart Association and others. This counters the negative effect of the Palmitic acid (C16).

Lauric acid (C12) is thought to increase HDL ("good") cholesterol and may have a beneficial effect on acne.

Myristic acid (C14) is also thought to increase HDL ("good") cholesterol.

Palmitic acid (C16) raises LDL ("bad") cholesterol and large amounts have other negative effects.

Oleic acid is also found in olive oil and is seen as a fat with beneficial effects.

Fatty acid content of coconut oil
Type of fatty acid			pct
Caprylic saturated C8			7%
Decanoic saturated C10			8%
Lauric saturated C12			48%
Myristic saturated C14			16%
Palmitic saturated C16			9.5%
Oleic monounsaturated C18:1			6.5%
Other			5%
black: Saturated; grey: Monounsaturated; blue: Polyunsaturated

So the only "bad" part of coconut oil is the Palmitic acid (C16).

As for MCT oil, what is in that?

In pharmaceutical MCT oil, like the one sold by Nestle, the contents are:-

Shorter than C8      1%

C8 (Octanoic)      54%

C10 (Decanoic)   41%

Longer than C10    4%

What is the effect of those fatty acids with more than 10 carbon atoms?  Nobody likely knows.

Cooking with MCT Oil? 

This is what Nestle has in mind for dinner.


Mct Spaghetti With Meat Sauce

4 Tbsp. MCT Oil® (Medium Chain Triglycerides)
1 lb. very lean ground veal or beef
1 tsp. salt
1/2 tsp. pepper
1/4 cup chopped onion
3 Tbsp. chopped green pepper
1 cup MCT Tomato Sauce (see recipe on site)
2 cups cooked spaghetti

Heat MCT Oil; add veal, salt and pepper.
Cook until meat is brown.
Add onion, green pepper, and tomato sauce. Cook for 30 minutes over low heat.
Add cooked spaghetti, stir and serve.

Ketones and Autism Part 6 - Capric Acid (C10) for Mitochondrial Disease, in Particular Complex 1, plus more on Metformin

Capric Acid (C10) is so named because it smells like a goat (Goat in Latin = Caper)

Photographer: Armin Kübelbeck, CC-BY-SA, Wikimedia Commons

Rather than Goaty acid, C10 is called Capric acid, or indeed Decanoic acid (after its 10 carbon atoms). Today’s post is indirectly again about ketones, because if you eat a Ketogenic Diet (KD) you are likely to consume a fair amount of Capric acid (C10).

I have written a lot in this blog about mitochondria, even though I do not think my son has mitochondrial dysfunction. Clearly many people with autism do have a lack of one or more of the critical mitochondrial enzyme complexes that allow glucose to be converted to ATP (usable energy), by the clever process OXPHOS (Oxidative phosphorylation).

The “rate limiting” enzyme is usually Complex 1, meaning that is the one it is most important not to be short of.

Another favourite, but obscure, subject of this blog is PPAR gamma.

Peroxisome proliferator-activated receptors (PPARs) are a group of proteins that function as transcription factors regulating the expression of certain genes. Transcription factors are particularly important because they trigger numerous effects.

PPAR gamma plays a key role in fat storage and glucose metabolism, but has other functions. 

Activation of PPAR-gamma by Capric acid (C10) has been shown to increase the number of mitochondria, increase the mitochondrial enzyme citrate synthase, increase complex I activity in mitochondria, and increase activity of the antioxidant enzyme catalase. 

So, if you have autism and impaired mitochondrial function, C10 may well give a benefit because it can increase the peak power available to your brain.

The ketogenic diet component decanoic acid increases mitochondrial citrate synthase and complex I activity in neuronal cells

The Ketogenic diet (KD) is an effective treatment with regards to treating pharmaco-resistant epilepsy. However, there are difficulties around compliance and tolerability. Consequently, there is a need for refined/simpler formulations that could replicate the efficacy of the KD. One of the proposed hypotheses is that the KD increases cellular mitochondrial content which results in elevation of the seizure threshold. Here, we have focussed on the medium-chain triglyceride form of the diet and the observation that plasma octanoic acid (C8) and decanoic acid (C10) levels are elevated in patients on the medium-chain triglyceride KD. Using a neuronal cell line (SH-SY5Y), we demonstrated that 250-μM C10, but not C8, caused, over a 6-day period, a marked increase in the mitochondrial enzyme, citrate synthase along with complex I activity and catalase activity. Increased mitochondrial number was also indicated by electron microscopy. C10 is a reported peroxisome proliferator activator receptor γ agonist, and the use of a peroxisome proliferator activator receptor γ antagonist was shown to prevent the C10-mediated increase in mitochondrial content and catalase. C10 may mimic the mitochondrial proliferation associated with the KD and raises the possibility that formulations based on this fatty acid could replace a more complex diet. We propose that decanoic acid (C10) results in increased mitochondrial number. Our data suggest that this may occur via the activation of the PPARγ receptor and its target genes involved in mitochondrial biogenesis. This finding could be of significant benefit to epilepsy patients who are currently on a strict ketogenic diet. Evidence that C10 on its own can modulate mitochondrial number raises the possibility that a simplified and less stringent C10-based diet could be developed.

Capric Acid (C10) as a PPARγ agonist

As shown in the above study the mechanism by which C10 benefits the mitochondria is via PPARγ agonism.

Here is another study confirming that C10 is indeed a PPARγ agonist.

Identification and Mechanism of 10-Carbon Fatty Acid as Modulating Ligand of Peroxisome Proliferator-activated Receptors

Background: Mechanism of action of medium chain fatty acid remains unknown.

Results: Our results show that decanoic acid (C10) binds and activates PPARγ.

Conclusion: Decanoic acid acts as a modulator of PPARγ and reduces blood glucose levels with no weight gain.

Significance: This study could lead to design of better type 2 diabetes drugs.

Other PPARγ agonists

PPARγ agonists have been covered previously in this blog and we know that glitazones, a class of drugs for diabetes, do improve some types of autism. Glitazones are PPARγ agonists.

Metformin, a very widely used drug for type 2 diabetes, works differently to Glitazones, but I did suggest a while back it should help some types of autism. Last year it was indeed found to be beneficial in Fragile X.

Diabetes drug may help symptoms of autism-associated condition

 "Basically, it's something like a wonder drug," Sonenberg said.

The study suggests that metformin might also be used to treat other autism spectrum disorders, said Ilse Gantois, a research associate in Sonenberg's lab at McGill.

"We mostly looked at the autistic form of behaviour in the Fragile X mouse model," explained Gantois, who is co-lead author with McGill researchers Arkady Khoutorsky and Jelena Popic. "We want to start testing other mouse models to see if the drug could also have benefits for other types of autism."

Metformin is very cheap and has been used in humans for 60 years. It is another example of re-purposing a drug from Grandpa’s medicine cabinet to treat Grandson’s autism. 

Metformin has been trialled to combat obesity in idiopathic autism caused by antipsychotics. It did help with weight gain, but no comments were made about behavioural improvements, but then those studied were on antipsychotic drugs, which might mask such effects. 

Glitazone-type drugs appear more problematic than Metformin.

There are natural PPAR gamma agonists and they are often used to lower cholesterol, lower blood sugar and improve insulin sensitivity.

Sytrinol, a product containing flavanols tangeretin and nobiletin does indeed have a positive effect on some people’s autism, but for most people (but not all) the effect is lost after a few days.

Our doctor reader Maja, did suggest combining it with a PPARα agonist to see if the effect might be maintained.

This combination has indeed been researched for type 2 diabetes.               

The effect of dual PPAR alpha/gamma stimulation with combination of rosiglitazone and fenofibrate on metabolic parameters in type 2 diabetic patients.

There actually is another natural substance that is an agonist of both PPARγ and PPARα, Berberine, the alkaloid long used in Chinese medicine.

In the research it is suggested that “BRB localizes in mitochondria, inhibits respiratory electron chain and activates AMPK”, which is not what you would want. But this may not be correct.

People who like supplements might want to follow up on Berberine.

Berberine is used by many people with diabetes and a few with autism, for all kinds of reasons, from mercury to GI problems.

Berberine is a potent agonist of peroxisome proliferator activated receptor alpha.

Although berberine has hypolipidemic effects with a high affinity to nuclear proteins, the underlying molecular mechanism for this effect remains unclear. Here, we determine whether berberine is an agonist of peroxisome proliferator-activated receptor alpha (PPARalpha), with a lipid-lowering effect. The cell-based reporter gene analysis showed that berberine selectively activates PPARalpha (EC50 =0.58 mM, Emax =102.4). The radioligand binding assay shows that berberine binds directly to the ligand-binding domain of PPARalpha (Ki=0.73 mM) with similar affinity to fenofibrate. The mRNA and protein levels of CPT-Ialpha gene from HepG2 cells and hyperlipidemic rat liver are remarkably up-regulated by berberine, and this effect can be blocked by MK886, a non-competitive antagonist of PPARalpha. A comparison assay in which berberine and fenofibrate were used to treat hyperlipidaemic rats for three months shows that these drugs produce similar lipid-lowering effects, except that berberine increases high-density lipoprotein cholesterol more effectively than fenofibrate. These findings provide the first evidence that berberine is a potent agonist of PPARalpha and seems to be superior to fenofibrate for treating hyperlipidemia.

Berberine activates peroxisome proliferator-activated receptor gamma to increase atherosclerotic plaque stability in Apoe^-/- mice with hyperhomocysteinemia.

                                                                                                                                     

Sources of Capric Acid (C10)

Goat milk is a good source of capric acid.

Capric acid is 8-10% of coconut oil and 4% of palm kernel oil

Capric acid is a large component (about 40%) of the less expensive MCT oil supplements.

http://cdn.intechopen.com/pdfs/39464/InTech-The_effect_of_fatty_acids_in_goat_milk_on_health.pdf

1.2. Fatty acid composition in goat milk fat Average goat milk fat differs in contents of its fatty acids significantly from average cow milk fat, being much higher in butyric (C4:0), caproic (C6:0), caprylic (C8:0), capric (C10:0), lauric (C12:0), myristic (C14:0), palmitic (C16:0), linoleic (C18:2), but lower in stearic (C18:0), and oleic acid (C18:1) (Table 1). Three of the medium chain fatty acids (caproic, caprylic, and capric) have actually been named after goats, due to their predominance in goat milk. They contribute to 15% of the total fatty acid content in goat milk in comparison to 5% in cow milk (Haenlein, 1993). The presence of relatively high levels of medium chain fatty acids (C6:0 to C10:0) in goat milk fat could be responsible for its inferior flavour (Skjevdal, 1979). 

             

Conclusion

If someone responds well to coconut oil or cheaper MCT oil the reason may have more to do with PPAR gamma and improved mitochondrial function than anything to do with ketones and what they do.

Cheaper MCT oils are mainly a mixture of C8 and C10. To maximize the production of the ketone BHB you really want just C8, but if what you really need is a PPAR gamma agonist, to perk up your mitochondria, it is the C10 you need.

You may indeed benefit from both ketones and agonizing PPAR gamma, in which case you either follow the Ketogenic Diet, or supplement BHB, C8 and C10.

I think this explains why some people with autism reportedly respond well to teaspoon-sized doses of cheaper MCT oil or small amounts of coconut oil.

If you have Complex 1 mitochondrial dysfunction then a dose of Capric acid (C10) is likely to help.

Berberine may, or may not be, as effective as C10. I doubt we will ever know. I think C10 is the better option. 

I wonder when the Canadian researchers will publish their results showing whether Metformin is beneficial beyond Fragile X syndrome. They do not really know why it helps, but that is a repeating theme in medicine.  It is a cheap safe drug, so it would be a pity to waste time finding out if it could be repurposed for some autism.

Back to School and Try to be Cool

The Milaneses and their shops

                                             
Another school year has begun, which is always a good time for Monty, with ASD now aged 15. He loves his small international school; he has been there since was 3 years old. School is fun because he gets lots of attention and stimulation. Other children are surprisingly nice to him and the teachers get to meet someone with autism.

In kindergarten and the early years of primary/junior school boys with autism often get taken care of by some of the nicer girls. It is like having a live human doll to mother. It is amazing how this pattern repeats among different children with autism. This gradually seems to fade away as girls discover that they need to be cool and kids with special needs tend not to be cool.

We had a visit over the summer from a Dutch girl who was one of these nice little girls when she was younger. Now she is also 15 and has not seen Monty for a few years. The difference between them now is much starker than 10 years ago, but there still is a bond.

Last year at school for friendship development day they had to climb a small mountain, this year they went bowling. The girls in the year above wanted to teach Monty how to bowl and they did. The year above is unusual in being mainly girls.

I know that most children with autism/Asperger's cope with junior school but many, particularly Aspies, really hate high school, because they do not fit in and so they get bullied. Monty has never experienced any such problems, but he is not an Aspie, so he is not a target.  People who are a tiny bit different get bullied, people who are more different tend not to get picked on.

Big brother has graduated from high school and gone to University in Milan, Italy, far away. In his time at school the class were not so nice to the Aspie boy they had in their group and he was not nice to them. I think it was a lost opportunity; ultimately it is up to parents to make things happen.  Parents often blame schools, but most schools have no expert knowledge and have many other issues to deal with. Much more could be done to integrate those who are just a tiny bit different.

I think that to fit in, the special needs pupil needs to be “cool” and have an assistant who is seen by the class as “cool”. What counts as cool? How you dress, sport you do, musical skills etc. For the assistant it includes how old you behave; having an Assistant who behaves like a 50-year-old, is not going to help integrate a teenager.

Most kids figure out what is cool, but if you have any degree of autism you may not. I think some people would indeed benefit from “cool lessons”, you could call it “how to be a teenager”. There are workshops for Aspie teenagers, a little bit like this. 

In our household this new school year is much more about big brother. We have lots of video calls about Italian bureaucracy, how to cook, how expensive going out is, but how cheap Italian coffee is (no Starbucks).  Overall Milan is beautiful city, full of very fashion-conscious people who do seem to enjoy life.  The Italian students in class can be identified by their expensive sunglasses and their going for “aperitivo”.  The foreign boys are going for birra, bier, pivo, bira or cerveza, which is cheap in a supermarket but very expensive elsewhere. 

Bocconi is Italy’s top University for economics; it seems pretty well organized and is very inclusive. They have many students from poorer countries, who get substantial financial support from the University, which is the opposite of what happens in England (where foreign students face paying up to 3 times more for tuition). Germany is also good in this regard, where even Medical School is free to all, but you do need to learn German. Big brother is getting to practise his foreign languages, but tuition is in English.