Dr. Patrick: What's the best way to measure your actual ketones? Is it blood, breath?

Dr. D'Agostino: Good question. Yeah.

Dr. Patrick: Best versus also most like easy for people as well. I mean, they're both kind of important.

Dr. D'Agostino: Again, like people don't like this, but it depends. So that's my answer to a lot of things. So it's context-dependent. The clinicians that are managing epilepsy patients say that urine is great, and they're not going to change from urine, and they're doing...because they don't want to prick the kid's finger too, right? So I did blood. I like using the glucose ketone index.

Dr. Patrick: What is that?

Dr. D'Agostino: It's your glucose over ketones in millimolar concentration. So, if you're fasting, it takes me about 72 days...72 hours to get...although the guy fasted for 360 or 80 days. Fasting for 72 hours gets my glucose ketone index to one where my glucose comes down to about 3 millimolar and my ketones come up to 3 millimolar. So that would be a glucose ketone index of one. Although I haven't measured LC3 and other components of the autophagosome, it's my belief that achieving and sustaining a glucose ketone index of one for 24 hours will induce and perhaps maximize autophagy. No doubt that you can get more benefits five, seven days, but then at five days and seven days, I see a suppression in testosterone and other things I don't like. So, for me, three days is like the sweet spot. I can achieve a glucose ketone index of one. And then my breath acetone is off the charts. And I think breath acetone is probably your best ketone to measure if you want to lose fat. So, all the carbons of the acetone you're blowing off essentially are from fat. So, when you look at the device and it's reading like 40, it's like you're just like basically exhaling fat carbons from that.

Breath acetone is great because with beta-hydroxybutyrate I could be at 2 or 3 millimolar and just walk around the house or do some activity, and then I'm back down to like below one. That's because your body is using the beta-hydroxybutyrate as fuel. And if you have a calorie deficit, you have high tissue uptake of beta-hydroxybutyrate, right? Whereas my breath acetone seems to be more stable and a better correlate of fat oxidation. And it's also easier. So if you're blowing into a breath acetone meter five times a day, that's a lot of money in strips and a lot of poking your finger. So I use the Readout Health Biosense device. And I don't know. I've blown into mine like 1000 times, and that would be cost-prohibitive from a ketone monitoring perspective and a lot of finger pricks associated with that. And it has a pretty cool app and also a fasting sort of meter in with it. I think they collaborate with Zero Fasting. So I think there's some collaboration there, but it can show you if you're doing a fasting and using that. Although it's more of a clinical device, but now it's broken into more mainstream. So it's an FDA-approved class 1 or whatever, physical device...medical device for measuring ketones.

And I became interested in acetone because it correlates with seizure control. So, acetone does. So, I recommend it to parents who have kids that are managing and they don't want their fingers pricked and the urine ketone strips are not very accurate. So, to answer your question, I think both blood ketone measurements. If you're just starting the ketogenic diet, it may be good to just use urine to say yes you're in ketosis, you're not. It's like semi-quantitative. And then spend the money to get a ketone meter. Like the Keto-Mojo device is probably one of the best, and then a breath acetone meter is good for people who are doing fasting and for people that are really interested in like weight loss.

Dr. Patrick: What about using blood glucose levels as a proxy? Like is there...?

Dr. D'Agostino: That's like super interesting. Yeah. We had an NIH workshop sort of on this, and I brought this up as a continuous ketone monitoring or continuous glucose monitoring system. And now you have the ketone monitoring system with app. It has Lingo device now, which does like glucose, ketones, lactate, and also alcohol. But a CGM device is like the ultimate device to look at dietary adherence to a ketogenic diet because it should be...the trace should be completely flat, and if there's big excursions, then that person is not on a ketogenic diet. I guess if they're under stress or they're exercising really hard, you might get a blip, but generally speaking like a CGM trace is a very, very good way to tell if someone is adhering to a ketogenic diet. So these things should be used I think, and generally speaking, the community also feels that this needs to be used. But it's an off-label use at this time.

Dr. Patrick: Is there like a level that's like a range or does it vary? Like would you...if you were to give an estimate guesstimate.

Dr. D'Agostino: Of what?

Dr. Patrick: Of blood glucose level to like...

Dr. D'Agostino: For a ketogenic diet?

Dr. Patrick: Yeah. To say, like, "I'm probably in ketosis because my blood glucose levels are X."

Dr. D'Agostino: Yeah. Well, I could show you on my... So, what was very interesting when I woke up this morning, I spiked 40 milligrams per deciliter. I've never seen that before like ever. So my CGM trace typically looks like...oh, probably now it's going to be...maybe I'm excited and maybe it's all over the place, but it's going to look like... I added, like, an extra 30 so it wouldn't go off negative during everything. But right now if you subtract 30 from that number, that's what your CGM trace should look like on a ketogenic diet. You've worn a CGM before.

Dr. Patrick: Yeah. I need to get a new one.

Dr. D'Agostino: So I'm 74. Yeah. But when I woke up this morning, I had a big...I only had maybe like four and a half hours of sleep or something. So it could be that, it could be the different time zone or something like that.

Dr. Patrick: Oh, yeah, totally. That was the first thing I learned from my CGM was...because I started wearing it when my son was like four or five months old. I was waking up multiple times to breastfeed. I mean, so my sleep was insanely disrupted and fragmented, and my blood glucose was just...it was just going out of control. And it was always on the nights when I was like waking up multiple times and not getting enough sleep. And that was, like, one of the biggest things I learned from my CGM that was surprising to me.

Dr. D'Agostino: Where were your highs? Like how high were your highs? So mine spiked to almost like 130 or 140, and that's unheard of. Like I've never seen that. But that just could be due to the time change and getting about half of the normal sleep that I get. I mean, I feel fine now. Okay. Yeah. But it was just highly variable. Yeah.

Dr. Patrick: I can't recall. It's been too many years, but they were...yeah. It was something like that. It was above 120, you know, like where it was like, this is postprandial level, you know, like this is pretty, you know, intense, you know, like a robust effect. High-intensity training. I was doing a lot of spin class and stuff like hour-long like pretty intense spin. That would help. So if I do the spin and then have the disruption that night after the spin, it was way better. Like my glucose was way better. So like the exercise totally helped negate some of the glucose dysregulation that I was having. I don't know what exactly was happening about my glucose spiking so high. So that was also a learning. I learned so much from the CG, and I haven't worn it for a couple of months because I have to...I think I'm going to do Levels because my prescriptions like expired.

Dr. D'Agostino: Levels is great.

Dr. Patrick: Now I'm like, "Okay, I think I'm going to move to Levels."

Dr. D'Agostino: I'm not going to mention the other, but I did a couple different companies and I just wore it. Well, they're in beta now. The difference about Levels is that it's kind of coaching you, and you also have the option to...I mean, you could just push and get to a nutritionist. So I guess that's good for people. Maybe not like us but for the average. But it has so many features built in. Where I exercise, it'll say, you know, "What did you do here? We saw that you exercised." It learns my body. Even if I have a cup of coffee in the morning, it learns my sort of dawn effect. And I just take a picture of my food. It marks it and then it sends me an email the next day of the picture of my food, my average glucose effect, my metabolic score, and things like that. So it's so easy. Otherwise, I mean, you could just buy a CGM I guess if you had someone prescribe it to you and just look at the CGM trace and then make your own inference. As long as I engage with the app and I take a picture of my food and everything, I get the email the next day, and that tells me what happened to my glycemic response the whole day. And it also gives me a weekly thing. So all I have to do is just engage with the app once a day, and it sends me like a daily report and also a weekly report where I could see like every day.

And there's so many features. I don't even use like 90% of the features but I use like 10% of the features and it's very useful to me.So we're doing a clinical trial right now with CGM. And people have app fatigue. Not everybody wants to be on an app all day. But you can engage with it as much as you want or just, you know, engage with it two or three minutes per day is enough to really be getting a lot of insight into your own metabolism.

Dr. Patrick: Just wearing the CGM without even having to do all the app stuff really helped me figure out what foods that I should be eating and portion sizes and all that stuff because it was like...

Dr. D'Agostino: What were your biggest surprises?

Dr. Patrick: The cooked spinach was the one because I was like, "Oh, the sugar and it has a low glycemic." But what you said makes a lot of sense. That was a big surprise. And then another really big surprise was like a lot of these like cauliflower rice, you know, like I was traveling on part of this, you know, where I was on a ketogenic diet, and so I would like order food that was like this is keto and you get something that says keto. And I'm like, "This is not keto at all." I'm like, "It's like spiking me so high." And then you like track down the ingredients, and it's like sugar. And I'm like, "Really? You're calling this keto but you actually have added sugar in it." Other surprises where I was taking some like collagen gummy chewables that didn't have any sugar allegedly. And my blood glucose just went through the roof, and I'm like, "What's in this? This is something..."

Dr. D'Agostino: Same thing. I tried some kind of sugar-free gummy, it shot me off the chart. And all the bars that I get sent. So, 90% of the...

Dr. Patrick: Anything that's keto.

Dr. D'Agostino: Yeah. The only bar that has completely ketogenic is a Keto Brick. So it's like the brick is 90 grams of fat and I think like maybe 30 grams of protein and like hardly any carbohydrates and it's 1000 calorie brick. And that's like truly the only ketogenic, you know, bar. There's a bunch of bars out there, Keto Brick. Yeah. Check them out.