>> Everyone and thank you for joining the American brain tumor Association's webinar

series. Thank you for participating in today's free educational webinar. I webinar today will

address ketogenic diet for brain tumor patients. Presented by Leonora Renda, RDN. Please

note that all lines during our webinar tonight are muted. If you have a question would like to

ask please type and submit it using the question box in the webinar control panel on the

right-hand side of your screen. Ms. Renda will answer as many questions as possible at the

end of the presentation. Tomorrow you will receive an invitation to complete a brief

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moment so we can begin our webinar recording here.

The American brain tumor Association is pleased to welcome you back to our webinar

series. I webinar today will discuss ketogenic diet for brain tumor patients. My name is

Jillann Demes I'm a Senior program manager at the American brain tumor Association. I'm

delighted to introduce our speaker today Leonora Renda. Leonora is an outpatient oncology

dietitian at the University of Arizona Cancer Center at St. Joseph's Hospital and medical

Center in Phoenix, Arizona. And is the lead dietitian for phase 1 and phase 2 clinical trial for

newly diagnosed GBM and the ketogenic diet. She received her Bachelor of Science

degree, concentration and dietetics from Illinois State University and completed her dietetics

internship at the Arizona Department of Health Services. She is currently working on her

Masters degree at Arizona State University. And just as a side note Leonora is today with

us joining us from London. I want to thank you so much for joining us today and joining us

from London. We appreciate it. You may now begin your presentation

>> I want to thank you for the opportunity to be a speak about this diet thank you very much

everyone for joining me I hope you'll get a lot of information out of the webinar and we can

help in any way that we can as we move forward.

>> Today will talk about the ketogenic diet for brain tumor patients. The objective for today

will be to recognize the components of a ketogenic diet we call it a KT diet described how to

achieve ketosis in each patient, and identify the challenges associated with the specialty

diet. As well as increasing knowledge of the results that have been seen thus far in our

research studies.

>> Just as a note less than 5% of the patients diagnosed with a grade for brain tumor which

is called the glioblastoma or GBM will survive for five years. Usually like expectancy is a two

months despite all of the advances in radiation, chemotherapy and surgery, the survival

rates have not changed in the last 20 years. GBM is the most commonly found brain tumor

as well as the most deadly. There is a renewed interest in cellular metabolic therapy as an

adjunct treatment for cancer. Originally -- emerging research and animal a case study

suggest that a KT diet. Or inhibit the growth of a GBM brain tumor. Remembering that life

expectancy is 18 months to get five years even if the brain tumor is a total in section of the

tumor the tumor will recur around the margins of the removal. The research is interesting to

see if we can stop that growth. The hypothesis is that a KD diet during radiation treatment

will permit the tumor growth in adult GBM patients.

>> Here are a few other statistics about the tumors. There is a grade 2, three, and four

tumor. As you can see with the five your surround the rate so we're working to try to

increase the survival rate for all of our patients. The pathways have really been studied

since the 1920s you can see in 1923 it was observed that tumors convert high levels of

glucose to lactate even with oxygen present we also found out that cancer patients have

increased levels of inflammation impaired glycogen synthesis and an increase breakdown

of both protein and stored fat in the body, as well as an increase utilization of fat in the

muscles and increase of Gluconeogenesis in the liver also increase metabolic glycolysis

the tumors reliance on glucose is elevated. You see the tumor really wants to feed on that

glucose. I see a lot of patients will be using -- losing weight during treatment you see

breakdown of lean body mass with protein as a protein is used for energy so my patients

have an increase for protein calories one third more than it normally would. My patients

used to say I'm eating the same amount of food but I'm still losing weight. That's because

you have increased need because of all these metabolic changes.

>> Also if you take a look at the cancer metabolic pathways you'll see that Gluconeogenesis

increases the patients total energy expenditure again that one third increase for their

expenditure activity level and then their entry-level to the cancer. You also see the insulin

sensitivity and glucose tolerance decreased which again increase the blood glucose

available for the cancer cells. So all of a sudden you see this huge increase of glucose in

the body because it cancer needed to grow. You also see an increase glucose uptake

which is due to an overexpression of glucose transporter hormone to gross transporter 1

and Hexokinase both -- it using that glucose. You'll see the glucose uptake of the muscle

and the glycogen synthesis leads to that extreme fat loss and muscle wasting in cancer

patients.

A lot of that falls from cancer [ Indiscernible ] were we see all of the food is being used for

energy as well as the body breaking down. Glucose is the preferred energy for all of our

bodies, the cancer cells love it but also ketone bodies which come from fatty acids for

energy under condition so if you think about it imprint of times we now have a lot of food

around so the body have to be old utilize the [ Indiscernible ] to supply energy even on

crossing because levels decrease glycogen free fatty acid in your cheap -- chief bodies [

Indiscernible ]

>> There's a little diagram of what Gluconeogenesis looks like C can see how the body is

using the amino acids as well as the lipids for energy and glucose for the blood. It's a little

schematically you can see how it's used. The stored glycogen in the liver is used for energy

and broken down so we can use it as well as the facts for energy. What is ketosis? It is the

condition where levels of ketone bodies are high in the blood due to the breakdown of fatty

acids in the liver. Ketosis happens when there is not enough glucose in the blood stream

and then the brain and the body can then use the fats for energy. So I'll make sure the body

is able to run. It's important that the brain uses the fat also. Fatty acids are metabolized

instead of glucose and through that metabolism the excess ketones then begin to regulate

and appear in the blood. The ketones are produced in the liver from the fatty acids and are

three different kinds Jeni, Hydro butyrate, and acetone. We measure the acetates and the

hydroxide butyrate. For our patients for brain tumor patients newly diagnosed GBM patients,

this is the standard treatment. Normally he was see a craniotomy which be totally resected

and people were partially. That would be the surgery part of that the next step would be

external beam radiation therapy given concurrently with Temozolamide. That goes together

both the oral chemo as well as the radiation usually the readmission will last for six weeks

your all three weeks before you then are put back on the temozolomide. It started one

month after chemoradiation is together. So normally when a patient comes in for treatment

this the standard that will happen for this GBM patient. Throughout this 99% of the GBM

therapy includes high-dose steroids to reduce edema and swelling of the brain post-surgery

and during radiation. We want to keep these edema is down as much as possible because

that will increase all kinds of physical and mental issues so we tried to keep that down.

During the treatment we know the steroids potentially raises blood serum levels of glucose

and so they are constantly giving an abundant supply of glucose and glutamine. We know

that this elevated serum glucose level during GBM treatment predicts usually a poor box

gnosis. You can take a look at that steroid to help we may -- we may know -- shifting gears

and talk about the ketogenic diet. The ketogenic diet has been around for a long time since

1920. At that time it was used as a treatment for seizure disorders. Presently 15 -- 45% of

all cases are in operable with epilepsy or they have a medical -- medication resistant strain

of epilepsy. So we know that's a large amount of people that need to help.

The ketogenic diet is administered under the care of the neurologist and a registered

dietitian nutritionist. We also require pre-laboratory evaluation before any patient is on this.

Usually mostly in pediatrics epilepsy as were most of the patients have that patients are

actually [ Indiscernible ] so we know the patient can be on the ketogenic diet and not lose

weight but also continue to grow and develop throughout the adolescent years into

adulthood. The ketogenic diet is widely accepted in varying cultures and cuisines across the

world. At the conference I met in London we talk about how to cook with the ketogenic diet

is all different kinds of cultures and we will be able to maintain a diet and remain the

treatment for pediatric epilepsy.

>> The ketogenic diet is calculated by using a ratio of fat content to combined

carbohydrates and protein content. We have several diet there's a 4 to 1 ratio part that to

one carbohydrate and protein. There are 3 to 1, to the one, and he wants to one. We

consider the classic ketogenic diet is an individualized instruction meal plan based on the

needs of the patients. Within that meal plan there are special recipes that are provided all

the foods are weighed in grams and female must be even in its entirety to get the best

results. Diet management may also include a medical food with that 4/1 ratio of fat plus card

and protein they have 3 to 1, and the 221 also. But sometimes you can use [ Indiscernible ]

formula constructed to maintain a ratio.

>> Our medical nutritional therapy for call starts with a diet initiation. We want to be able to

burn the glucose out of the body and switch the body from using glucose as a fuel to

ketones. In order to do that we will reduce the calories to the resting energy expenditure of

the patient and that's called the REE that is the amount of energy the patient would need to

survive. The metabolized the food for their brain to function and their organs to function. If

they were laying down the rest of the day. We look at that resting energy expenditure on

this diet we limit the carbohydrates to at least 10 g per day. Again we're trying to limit

glucose and allow the body to burn off all the stored glucose that it has. Usually fry patients

it takes three or five days for that to happen and after the patient is in ketosis the diet made

as part of the diet goes to play and that is liberalized to 20 g of carbohydrates and the

proteins are raised to meet the patient needs

>> This type has some side effects of the want to go over these. This diet is low in vitamins

and minerals. In order to make a difference we add a multiple daily vitamin and mineral to

be taken. My patients usually take up to the daily diet needed we don't make it those we

keep it at the daily values that a normal person would need. A person can develop high

cholesterol on this diet. Sometimes they do sometimes they don't. The patient enters into

the diet, what we'll do is will switch the diet to resolve around healthy fats such as olive oil,

canola oil, the sunflower, safflower, it could be also [ Indiscernible ] oil but we tried to have

healthy fats. Another side effect could be constipation.

Due to the lack [ Indiscernible ] into the diet what we used his medications to be used to

help promote regular elimination and prevent constipation. Some patients will walk in and

say I don't want to lose any more weight. We can maintain the weight of our cancer patients

on this diet. Again I will increase the diet after the patient has been [ Indiscernible ] to their

total energy expenditure we make sure that we are looking at their needs for activity as well

as their needs and that along with their energy expenditure. I monitor the weight very

closely with my patients and we notice there is a decrease in weight, we can always up the

calories. Remember this diet is used in pediatric patients we want to make sure the patient

has enough calories that so that they can continue to grow and develop. Kidney stones can

also be prevented in this diet we encourage the patient to drink adequate water. I like

cancer patients to drink at least half a gallon of water per day if not more. We live in

Phoenix as were my practices and we know it's very hot we also need to have extra water.

At least 1/2 gallon water per day to prevent kidney stones. Some patients develop an upset

stomach or more acid stomach based on the diet. We neutralize that with one fourth

tablespoon of baking soda and six or 8 ounces of water four times a day to help reduce that

upset stomach. That usually happens if they have been on the diet over the long-term

maybe five or six weeks.

>> I wanted to include a sample meal this is for 2000 cal diet you can see its eggs Benedict.

The major component of this diet is heavy cream. It's used to help a patient achieved their

fat components and you can see this type has about 65 g of cream 36% fat, 48 g of butter,

14 g of Canadian bacon we do the brand so they can make sure they have the correct

nutrient analysis in the food. 60 g of eggs that's wrong and mix well 5 g of Kraft Delhi

American cheese and 15 g of strawberries. The instructions are very simple you mix the

cream and the egg together you mix in the melted butter you pour it into a frying pan you

scramble the eggs, so the eggs on Canadian bacon, top with shredded cheese and serve

with fruit. So this would be an example of a breakfast menu. You can see how it pulls

together.

>> We're trying to meet the protein requirements with the eggs and cheese as well as the

fat requirements with the cream, butter, egg and the cheese. And there are carbs with this

meal it comes with a strawberries. Here is another sample meal a little different -- not a

whole lot of preparation with this meal. It's a beef Patty with fruit and Jell-O. It has about 90

g of cream and the screen has 50 cal of fat. 17 g of cantaloupe. 30 g of Jell-O sugar-free,

52 g of beef and notice it has to be the 70% calorie lean so we know that 70% of that will

come fat when it's cooked it's cooked with oil you'll see 15 g of canola oil and 22 g of cream

cheese from organic Valley.

So in this you can do a couple of things you can take oil and added to the cream and make

it a desert you could then also take the cream cheese and use that on top of the Berger

whatever we do we want to make sure the fact that it is cooked in is also included into the

diet. We add that fat into the diet so they have together. You can use an oil spray or grow

the ground beef Patty.

>> Some recipes will be raw and some will be cooked.

>> I want to include some of the tips to have fat into the diet. This seems to be the hardest

piece to pull through with this diet. Some of the suggestions are to use high-fat meats such

as roast beef pork chops, shellfish. We suggest using heavy cream as a part of every meal.

Again you can whip the cream with some liquid stevia or vanilla extract in it to make it more

user. Some patients like to add the cream and the fruit together to make more of a desert

you can take and add water to the cream to make it taste more like milk. You can add

cream to the diet root beer to make it more like a diet group your flow. Or you can actually

use the cream with the hot chocolate and if you use the unsweetened baking chocolate is a

good way to add that into to get a different flavor. Some of my patients actually like to do the

meal and then pour the cream over the meal. So they feel it's more like a cream sauce for

them. You can also mix butter with peanut butter or cream cheese to add that extra fat. Add

oil to the cream. Also another good way to incorporate that into your diet. Mayonnaise is a

simple easy way to increase that was not a lot of oil. You can add that in with chopped meat

to make a meat salad or an egg salad or a tuna salad. I also use condiments for my patients

makes it in with some of the lettuce is a good way to be able to incorporate carbohydrates

for the vine and Brandon some people what do a chicken salad that will put sliced chicken

on it along with the dressing their heavy dressing and mayonnaise sometimes first empty

kinds on it -- pecans. You also can reheat cooked butter in a small pan it's a good way to be

able to use it again for your cooked meat in there and repeat it with butter and that will add

more fat. And a little does an easy way is to put a pinch of her in with the butter to give it

more flavor. Lot of times when I do vegetables for my patients I suggest that butter put on

the vegetables to increase the fat content without having them use a lot of oil I did have one

patient they would drink the oil so there's lots of ways to make it incorporated into the diet I

usually does its patient driven so I work with my patients to help them make the best way to

incorporate that into their diet. Another really good way to have a simple eggnog recipe

which will enable them to add a lot of cream in fact to their diet.

>> This is one of the hardest parts of the diet is to not get tired of. A lot of patience are tired

of eating the fat and they're always looking for a new way to incorporate in so we try to offer

these options for the patient so they are able to maintain their fat intake.

>> Another popular diet is called a modified Atkins diet. Sometimes you'll see this as a

modified TEE diet it is different but the calories are little -- are portioned out for that protein

and carbohydrates. We take the total energy expenditure for the patient and say 60% of

their calories should come from fats 30% of the calories should come from protein, and

about 10% of the calories should come from carbohydrates. This diet can be measured in

cups and ounces and they can use a standard meal plan as a guide. The diet limits the

amount of carbohydrates while encouraging fats and really live -- so they are able to have a

lot more protein than you can for say on a regular ketogenic diet. The carbohydrates are

consumed throughout the day but not to exceed more than 20 g. And again the protein is

not limited. This diet has been able to maintain ketosis also it is initiated the same way that

we initiate the classic ketogenic diet by restricting calories and then have cashed those

calories in ketosis. This diet is a little more user-friendly when you go out to restaurants

usually with the classic by a lot of my patients will bring food with them in order to maintain

their 4 to 1 ratio but with this diet the patient is able to be a little more liberalized diet at

restaurants and straightforward. Saying that I do have a patient on the classic for the one

diet that was going to special dinner with his wife. I was able to work with the chef to take

the existing recipes for the meals for the patient and they were able to really make them into

a 4 to 1 ratio for the patient. So the patient was able to go out at the restaurant and enjoy a

nice meal with his wife. So there's lots of things that we can do as both the classic and a

modified diet there are a couple more but we are what we are looking at cancer and brain

tumors really revolves around these two diets.

>> The hypothesis that we have been working on with cancer in the diet is that we know

that cancer is a metabolic disease that may be able to be managed through systemic

metabolic therapy using metabolic control. The brain can use both the glucose and the

ketones for energy while the tumor rely solely on glucose for energy. So the basis of our

theory is in the physiologic environment glucose restriction of the tumor cells may result in

slower growth, it may seize the growth, or cause the cell growth of the tumor. And that's

what we've been looking at over the past two years

>> We think the ketones they be toxic to the cancer cells and may restrict the ability of

glutamine to the tumor. We also think that the KDE diet induces ketosis which can cause

changes in the brains homeostatic is therefore it’s logical to look at the research for the

effects of the ketone genic diet and ketosis on GBM brain tumors. So our goal to see what

we can do to extend quality-of-life as well as slow down the progression of GBM cancer.

>> There has been studies that have gone since the 19 the 1912 the talk about what

happens within the ketogenic diet. Around glucose. One study in 1912 researchers were

feeding rats a carbohydrate free diet and pre-diet of Casein and lard to decrease the tumor

growth and help with decreased mortality rates. That's when everything was lower. In 1921

the observed that glucose secretions in the urine disappeared in the diabetic patient who

develop cancer so all of a sudden there was no glucose in the urine and at that time that's

how we monitored diabetes at that time. They also noticed there was a higher consumption

of glucose in cancer tissues compared to the muscle and liver tissue. All of a sudden we

noticed that something was going on between cancer and glucose.

>> In 1995 to pediatric patients with grade 3 astrocytomas were treated with ketogenic diet

in both responded well to that treatment in both were reported tumor management with this

diet. That was very exciting to see restricting glucose and ketones really help with the

management of that tumor.

>> In 2010, there was a field patient with a GBM followed it calorie restricted diet so they

stop they reduce the calories it was a ketogenic diet, and what happened was the diet stop

the growth of the tumor but also reported that there was a 20% loss in her body weight. The

patient was on the ketogenic diet, she was able to restrict the growth of the tumor but she

also does the tumor but she went off the diet the tumor grew in the patient [ Indiscernible ]

was great to see that that growth of the tumor will be able to be stopped. In 2009, they look

at the results of non-calories restricted ketogenic diet for GBM patients and what they found

was that it suggested that there was an increase in the antitumor activity. Which means the

activity was not causing that tumor to grow. In 2012, in an animal study, the ketogenic diet

and or calories restrictions led to increased production of the ketone bodies again that the

metabolism of the fatty acids and also showed a significantly decrease of glucose

production and the proliferation of cancer cells as well as an increase in survival rates. So

all of these studies really with animal studies and case studies, what can we look at for the

patient?

>> We know a couple of things. We sold overall change in the Gene expression of the

tumor versus non-tumor tissue. What that suggested is that ketogenic diet may be useful in

the treatment of GBM. The ketogenic diet may serve as a protector of normal brain tissue

during treatment. The study results also suggest that the ketogenic diets effect on tumor

growth was not so much due to a reduction in glucose but we see it's more likely to to a

change in the G network and the interactions that regulate the signaling and the home as

stated mechanism of the cells. So actually more of a cellular change in the genes rather

than just starting the tumor.

>> This slide is from one of the research studies you can see taking a look at the ketones

as well as looking at treatment the BCNU is standard treatment actually shows the

responses in the growth of the cells so you can see a decrease of the cell when the patient

was on chemotherapy and ketones, you also see the normal ketones [ Indiscernible ] you

also look at the growth of just the chemotherapy and you see there's a huge increase in

reducing that cell growth so this is become very exciting that we are actually looking at

standard treatment along with the ketogenic diet to make an impact on the cell growth.

>> If you take a look at the levels of the patient you can look at this and see this is the

excess ketones that will be in the blood so you take a look at the study you can see the

blood you see that on the ketogenic site -- diet the Ketocal which is the blue line will see an

increase level in the ketones availability in the body you also see with the Ketocal diet in

radiation the total increase in the level of ketones in the body. You can see [ Indiscernible ]

post implementation -- implantation of cancer cells you see the ketones are extremely high

on that diet. That means that the body actually using the ketone transferring over from

glucose to the ketones glucose levels being high with the diet.

>> You can take a look and see the glucose part of it remember we want to manage both of

those and you can see the glucose is going to be higher in the standard diet and higher

during the radiation and again lower when you add the ketogenic diet both the radiation and

chemotherapy. So we are looking to reduce tumor as well as increase the ketones for

energy.

>> In 2010, you'll see that the findings of the research study yielded the effects of the

ketogenic diet on antitumor activity during radiation therapy we saw a decrease in that.

You'll with an increase in the antitumor activity during radiation in the mouse model. The

ketogenic diet did very little to affect the weight of the animal you see the symptoms for both

standard diet and ketogenic diet was the same with a decrease in body weight the

ketogenic diet had no difference from the standard diet around weight.

>> Because here's the weight implementation you see the standard diet, and the keto diet

pretty much the same. You'll take a look at the standard diet plus radiation as well as the

keto diet and radiation you see what's better results around the weight with the keto diet

and radiation combined versus the standard diet. And radiation.

>> Post implementation you see as far as chemotherapy you'll see the results again for the

chemotherapy both in a standard diet and the keto diet just about the same. So there's no

difference in the areas the biggest difference of the weight gain was the keto diet and

radiation

>> As far as survival, and the mouse model, this is looking at the standard diet as well as

Ketocal diet. It significant you'll see a drop off in the survival rates of the standard diet at

about 36 days after implementation and you can see a decrease the rate in the keto diet at

250. We'll take a look and see what looks like in that area so you can see the difference.

>> If you take a look at the standard diet as well as the keto diet you'll see that the survival

rate again was about 30 days on a standard diet and you see about close to 50 days for the

keto diet plus the chemotherapy combined. There was a little increase in life expectancy

with that.

>> If you take a look at this slide this is an interesting slide. This is the standard diet and

radiation plus standard diet and the Ketocal diet. So he took a look at where we are at the

standard diet the majority of [ Indiscernible ] was the first 55 days. We have one [

Indiscernible ] that want to 150 days. It's interesting to note with that outlier [ Indiscernible ]

and through that weight reduction they lost weight and able to survive longer than the rest of

the diet -- you'll see connected with the weight because the weight drops COC that's were

the differences if you look at the diet around Ketocal and radiation together you will see that

the mice did not die the actually lived to almost 300 days. Can see that life expectancy a

mouse model went from standard diet plus radiation with decrease in survival rate to my

surviving a long time both with radiation and chemotherapy. Very interesting piece to look at

to see what actually happens within a model.

>> This is the [ Indiscernible ] we actually implanted the cancer into the mouse. So when

the our eyes were done you could see there's a tumor. This takes a look at radiation using

keto diet together. You will see day three, today 12. And at a 15 you still see the tumor but

then at a 18 your hard pressed to see any of the tumor left. When you go from the 36, 48,

72, 84, 110, 122, 134, with no reoccurrence of the tumor. The diet was switched so the

patient went off of the classic what we say the classic for the one diet onto a regular diet

and lived today 300 with no tumor regrowth.

>> This picture talks about what happens with tumor size at death on a standard diet. We're

switching gears from looking at what happens with Ketocal diet and treatment we're looking

at the diet as a whole. It's interesting because we see the tumor size in a standardized diet

is small were on the Ketocal diet is larger we were able to take a look at the size of them

and so that makes what happened within a model and what was the difference? Usually

within -- at death we'll see the tumor and edema the swelling being both causes of death

the tumor that we look at. We wondered what that meant for the keto diet and the standard

diet. We took another look at what was going on with you demon in the brain so we wanted

to see the MRI measurement of edema and what we found is to look at the tumor signals

and took a look and see what the tumor looks like and know what the size was and we

wanted to take a look at the measurement of Edina.

We can see the high level of Edina in the standard diet versus the low part of edema that is

happening in the ketogenic diet we think the connection between Edina and the standard

diet and edema in the keto diet will be less of the swelling and more of the tumor growth

rather than looking at the size of the tumor being the same. We know edema play the huge

part of the standard diet were in the keto diet it was low. Always try to prevent the edema in

the brain due to the tumor.

>> Another study that started talking about the keto diet was done in 2013. This diet was in

human studies in the findings of this study yielded low serum glucose levels during GBM

treatment and at those levels may improve the clinical outcomes for the patient. From

August from August 2010 until April 2013, six patients with grade 3 and great for gliomas

followed the ketogenic diet. The patient study underwent tumor resection and debunking

they want to follow the standard treatment with no signs of progression. So whatever we

talked about the surgery tumors the six weeks of radiation, and chemotherapy concurrently,

followed a brief break and then chemotherapy. The study shows no signs of progression

that tumor

>> The patients received education on the diet they received books they could use as well

as direct education they also managed the diet keep their hard carbohydrates to 50 g per

day a little different when you look at the classic ketogenic diet. In those patients who do not

achieve ketosis on this diet, the Dan restricted the carbohydrates to 30 g per day and a

limited the protein as needed. So in other words they dropped the requirements a little to

see if they could get the patient into ketosis. We were able to get the patients ketosis they

monitored that and look at the urine ketones during using a ketones strip for two weeks and

then they switched to the serum glucose and ketones using a glucose keto monitor and

finger sticks and they also collected all of the diet information around the diet. There are

nonfasting glucose levels they were between 76 and 93 mg and 93 mg/dL. Results show

that the ketogenic diet was safe and well tolerated during standard treatment with high-dose

steroids. That's important those high-dose steroids that we talked about earlier, they

confuse those infuse the body with glucose. Even with glucose we were able to keep their

glucose levels lower and we were able to achieve ketosis.

>> This retrospective data shows or suggest that the dietary restrictions of carbohydrates

through the ketogenic diet reduces serum glucose levels significantly even in conjunction

with the high-dose steroid which may affect these response to standard treatment and

prognosis. So very interesting study of the patient. It's interesting to see we were able to

achieve ketosis during standard treatment.

>> The Institute that I work at is in Phoenix and also [ Indiscernible ] center as well as has a

clinical trial is only going on. People that are involved in the study are listed here.

>> The candidate Judy -- the ketogenic diet as adjuvment therapy. We're looking at overall

and progression free survival is the goal of our study. We also looking at the quality of life of

our patient three treatment as well as the neurocognitive quality-of-life we're doing

neurocognitive testing before treatment and then after treatment we look at quality and the

neurocognitive effects. We look at changes in seizure activity steroids used and/or edema

to see if we can decrease steroid use and decrease edema .

>> Our patients monitor their blood glucose and ketone levels daily and keep track of that.

The diet effectiveness and we look at those levels to see if I need to reject the dive for the

patient either decreasing calories or increasing calories ways to increase carbohydrates, or

decrease as needed. That's how we are monitoring how the patient is doing.

>> Were able to get some RSG 1 foundation a Ketokit and that includes a scale meters,

strips as well as urine strips for our patients to use. Our goal is to have our ketone levels

above three preferably around for and to keep our glucose levels around 70. Patients are

monitored for uric acid cholesterol triglycerides, LDH acidosis, and we also look at free

carnitine. Carnitine may be decreased does we will do less test to see where a patient is [

Indiscernible ] we also look at health related quality of life testing. To see where they fall

within that area. That is extremely important we want good quality of life on the diet three

treatment.

>> We also look at changes in seizure activity changes in anti-seizure medications,

changes in steroids, and we look at neurocognitive assessments and wheels look at

molecular tests will look at methylation to see what is happening as far as that area in the

brain tumor.

>> Pre-radiation guidelines -- we want to make sure that were able to give them the scale to

use to measure the food, the precision Xtra glucose keto monitor with strips, they will

receive the urine strips as well as instructions on how to use the keto meter and the urine

strips. We also have the monitor those levels so they receive a chart to keep track of them. I

also work with that patient to develop a meal pattern that meets their needs some patients

want to be in that some people would prefer less tax or more stacks I also worked to make -

- they changes for the palatability of the diet to make sure the meal patterns are cater to

their needs. I have some patients that want to eat fish more than redmeat so we have to

work with them in that diet pattern so they can actually use that pattern.

I work with a program called Ketocalculator in order to work with this program the patient

has to work with a registered dietitian we work together as partners in the diet the dietitian

will set up the calorie requirements specific ratio of ketones the fact to glucose and proteins

together as far as the palatability of the diet. I will put that together for my patients my

patients than can create standard meals for example the eggs Benedict and the dates and

fruits and Jell-O are standard meal patterns that they could have or I work with them to

create a meal pattern that they like a recipe that they like the Ketocalculator has the ability

to the dietitian to enter different products that what the patient would like to have. Have my

patients take a picture of something in the store of the nutritional analysis of food and send

it to me and then I can Gmail or by text I'm able to enter that into the Ketocalculator to the

patient and then use that product as part of their diet. I very good patients that are looking

something new all the time. We work very closely together. They have to have access to a

computer and again, working with myself. The patient also have to agree with the following

life scale changes on them to take a multivitamin daily drink at least 1/2 gallon of water

daily, focus on non-starchy vegetables such as cauliflower, broccoli, lettuce. Stay with

potatoes and corn and green peas which are starchier. They have to be able to eat foods

high in fat such as heavy cream, avocado, butter/margarine, Manes and olive oil. We need

them to eat three meals a day and then with or without snacks. It's better for the diet if they

are able to meet the stacks with the meal to continually have the patient with the fact and

the ratio of fat carbohydrates and protein together in order to supply energy for the patient. I

patient has to be able to make those changes as well as being comfortable to test their

blood and their ketone levels daily.

>> This would be the protocol that we would follow nutritionally. One week prior to RTI me

with my patients and their family members or caregivers to talk about the diet it's that time I

give them samples one week menu to make out as well as the recipes that accompany that

menu. So they have a clear understanding of what the diet looks like and how they can

prepare the diet, I tried to do a variety of different meals simple meals, complex meals,

depending on what the patient would like to do. Some people like to cook, some people like

to look make as simple as possible. Some people use the Ketocalculator as part of their

meal. We look at that menu and discuss about how to get on the Ketocalculator and how to

select meals. They pick the meals that they would like to use I going then and look at the

recipes make sure it is the proper ratio of fat to carbohydrates plus protein. I calculated and

I verify it. The patient will begin the ketogenic diet one week prior to radiation therapy the

fact calorie initiation requirement is reduced to the energy expenditure that is based on the

weight and the height and the age of the patient. I will take a look at all of those factors to

come up with their best plan.

The patient must monitor daily there glucose and ketones using the meter and they report

that to me within the first week. We want to make sure that they are in ketosis. Like I said

three -- five days after the initiation of the diet ketosis is usually achieved and then I will

liberalize the diet to meet the patients total energy expenditure. There are times that I've

had patients [ Indiscernible ] after one day at patients that took seven days for them to go

into ketosis. We really monitor that it's very individual. Look closely at it and do everything

we can to get them into ketosis once they are there, we liberalize everything. If unable to

achieve ketosis in five days, the cooking procedures will be reviewed and lab and modify

the calorie intake or meal plan as needed. During radiation therapy the calorie requirement

is increased to the total energy rigged expenditure would base that on the weight stability. I

look at the calories that they eat, how stably are in their way. Sometimes will add an

additional snack if I notice the way is dropping. We try to maintain that weight. The meal

plans are directed by me and they consist of the three meals a day and stacks as needed. A

typical diet is a small amount of fruit and/or vegetables, protein rich fruit and the majority of

that calories are consistent by a source of fat such as butter heavy cream or mayonnaise.

All of those things would work into the diet. They monitor the levels again throughout all of

radiation and also we use the Medication for constipation

>> During radiation things does several things happen within the patient I will see the

patient is a little more fatigue during radiation treatment. I also see that sometimes the

patient has a lot of -- loss of appetite with cancer and also during radiation. Those are all

normal side effects. Within this population for our study we try to monitor those and help the

patient to be able to achieve the diet and then manage any side effects.

>> Post treatment -- outpatients will continue on the classic 4/1 ketogenic diet for two -- four

weeks after the completion radiation we do that because we know the effects of radiation

lapse after completion we want them to get every benefit they can. I usually recommend the

patient waits for the first 10 after radiation treatment and then onto the chemotherapy

section the next part of treatment the patient can transition to a modified Atkins diet if they

choose. I have some patients that want to stay on the classic for the one diet and some

choose to move on to modified Atkins diet.

>> I want to show you a case study that we have with one of our patients. To show you how

there are plans work together. We have a 37-year-old woman that has a large anaplastic

astrocytoma. The treatment insisted a subtotal section of the Lords we were unable to get

all of the tumor out was followed by the ketogenic diet with radiotherapy and the current

temozolomide. Those chemotherapy followed by the Temozolamide.

Over one year after surgery there has been no additional tumor growth in the patient and

she is clinically improved. Health and therapy related quality of life measurements are also

shown she's been doing extremely well within that area. This is some of the scores that we

have for the functional assessment. As far as what's happening within the brain tumor.

>> This is Jillian. Were about six minutes over and we have a lot of questions. Do you mind

skipping to the conclusions and then we tried to ask a few questions because it's about six

minutes over the top of the hour.

>> Okay.

>> I will go through these quickly so you can see the patient was able to maintain ketosis

you can also see this is a post scan for the tumor was one month after. This was well

tolerated in all patients the results are culinary to maybe in improving the quality of life in

addition to the time of progression. Functional status is generally well preserved throughout

the treatment. In individual cases the diet is tolerated long term. Weight stability was

achieved again this is the study we like to other studies also.

>> References are here.

>> Thank you. On of the major questions about eight or 10 of them work for individuals who

wondering if this is for only GBM there wondering if it's for their tumors we had questions

about all of those as well as [ Indiscernible ]

>> I've been working it is only for GBM. Could be -- our research is focused on TPM. We do

know it can be open to other tumors as well. It doesn't have to be just brain tumors. It could

be your looking breast, and other ones as well.

>> Thank you. The common as question is how do someone find a dietitian who is familiar

with this type of diet?

>> A lot of the dietitians that work with this diet do with pediatric apoplexy that would be a

good place to start. The conference I not there a lot of dietitians that are looking to start

expanding the practice to look -- work with cancer patients. I would say that they can

contact me and I can help find someone or to take a look within their other areas to see if

there's someone that they can really work with. That was my suggested looking at pediatric

[ Indiscernible ] and see what is out there.

>> Questions about the diet people are wondering about what if I am a vegetarian? What if I

don't drink [ Indiscernible ]? What about food allergies? How easy it that to make

substitutions to the diet plan?

>> It can be very easy. I'm working with a patient who is [ Indiscernible ] was not drink any

of the cream. So if we take a look at that were using olive oil and the cans and Allah Cotto's

we're not using the cream so you can make adoptions. Budgetary you can take a look at

other options we have to be cautious because make sure the carbohydrates are still low but

we have to really also take a look at what we can do to maintain that protein requirement for

the patient and not just the carbohydrate. So yes, as far as food allergies, I make each of

my diet plans for the patient. So I have patients that will not eat fish for patients don't eat red

meat or patients that can be having problems with allergies. We work through this one on

one. We can tailor it to the patient.

>> If this for people who are in treatment or is this for people for survivors or maybe trying to

maintain the survivorship?

>> I can't speak to the survivorship piece but I do think if for me the survivorship diet that I

was looking at if I wanted one in this Avenue would be the Atkins? I think the one that you

can do a little more easily without so much assessment diet of a dietitian. It's easier to do

than really scenario. You can do the classic for the one but I think have to work really

closely with the dietitian so that they are monitoring all of the side effects that can come up

because of the diet. I would think in treatment, anytime you can limit or lowered the glucose

in your diet is a good idea. We don't have clinical research again that shows that but

anecdotally following the promise of this diet I think it might be beneficial we don't know yet.

Again what's great about this therapy it does no harm. It doesn't hurt you in any way. There

are no potentially harmful side effects that come from it. You can deal with the constipation

you can deal with high cholesterol lots of things to do to make those changes.

>> Do you recommend anyone doing this without your clinical support? What's the age

range we've had people ask questions about their 83-year-old mother and their three-year-

old child.

>> We actually -- that's an interesting question. When you look at what happens epilepsy

pediatric epilepsy. Children do this. You are able to do is very young three-year-olds of

course. 83, if they can manage it in the quality of life is there, if they are able to make those

yes. I have one patient the daughter says, she eats anything I get her in the mother says

you whatever she gives me I eat. It depends on the patient. Yes, across the board. A lot of

patients are in their 60s or 80s. I have some patients in the 30s and 40s. It's a broad

spectrum I think it really depends on the patient. And their willingness to make this change

and to follow it. I do think if you are going to be on any kind of ketogenic diet you must meet

with the dietitian to at least get on the plan and to understand the diet because it's not the

acting dynes -- diet the Atkins diet on steroids Atkins diet and the for the one is really

medical nutritional therapy. So why encourage a dietitian.

There are two sources of dietitian boxes out there that might be helpful unites states there

foundation called Charlie's foundation that deals with epilepsy and are starting to look at

cancer may have resources dietitians. And then [ Indiscernible ] in Europe is the one that's

pulling forward with research and trying to bring people together and I would go to their

website and take a look at that and that these friends. They have information about all of the

diets it's great resource for everybody.

>> You did mention people could contact you do they do that through the University? We

can put my email address up somewhere and if we could do that he could contact me

through my email.

>> We can put that at our website later on when we post the webinar. We are on the time. I

thank you for extending your time with us. I really appreciate it. I appreciate everyone for

hanging on with us. I am going to run for everyone back to our website where will have this

posted in just a few days. It will be posted to our anytime learning section. I'm going to

pause and stop our recording and I will tell you about some future webinars that we have

coming in the next few months. One moment --

>> We might you to continue to check back at our website, www.ABTA.org for other brain

tumor related information. Our next to webinars are Tuesday, November 4 from 1:00 to 2:00

the latest innovations of surgically treating brain tumors. With Julian Bales the surgical

director of North Shore urological Institute and chairman, of the Department of

neurosurgery. Will discuss how technology is revolutionizing the way there are surgeons

treat brain tumors. He was your case studies and provide insight into the technology and

other minimally invasive procedures including NICO brain, and offers promising outcomes

for patients with otherwise inoperable brain tumors. Then Thursday, Then Thursday,

December 11, from 1:00 to 2:00, we will have attrition will supplements for brain tumor

patients. Join Rekha Chaudhary assistant professor of medicine at the University of

Cincinnati neuroscience Institute. She will present supplements for brain tumors. She will

present the research behind nutritional supplements which ones to avoid which ones will

help with various side effects and if there's any new studies on the horizon involving brain

tumors and supplements. This concludes our webinar. Thank you for joining us and please

be sure to complete its are those the feedback survey you will receive shortly following the

session. You may now I'll disconnect.

>> [Event concluded]