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In this study we evaluated the therapeutic efficacy of KetoCalВ®, a new nutritionally balanced soybean oil ketogenic diet that was formulated specifically for managing refractory epilepsy in children [34].
The objective of this study was to determine if the KetoCalВ® ketogenic diet could be therapeutic against experimental mouse and human brain tumors when administered in restricted amounts according to recommendations for treatment of children with refractory epilepsy. We found that KetoCalВ®, a nutritionally balanced and commercially available ketogenic diet for children with epilepsy, significantly reduced the orthotopic growth and the vascularity of the mouse astrocytoma (CT-2A) and the human glioma (U87). Although we previously showed that CR of a high carbohydrate standard diet or of a rodent ketogenic diet similarly reduce blood glucose levels, which tumor cells depend upon for survival [10,11], our findings in this study showed that administration of KetoCalВ® under restricted conditions was more effective in elevating circulating ketone bodies than was administration under unrestricted conditions.
Although Nebeling and co-workers were successful in managing childhood astrocytoma with a medium-chain triglyceride ketogenic diet [29,73], this KD formulation can be difficult to implement, is not standardized, and can produce some adverse effects as previously observed in children taking the diet for epilepsy management [32-34].
The effects KetoCalВ® on tumor growth, vascularity, and mouse survival were compared with that of an unrestricted high carbohydrate standard diet.
The restricted KetoCalВ® diet reduced plasma glucose levels while elevating plasma ketone body (ОІ-hydroxybutyrate) levels. The findings in human pediatric astrocytoma were confirmed in the experimental mouse CT-2A astrocytoma using a lard-based rodent ketogenic diet [8,9].
Influence of diet on body weight in B6 mice bearing the mouse CT-2A astrocytoma (A), and in SCID mice bearing the human U87 glioma (B).
In contrast to other ketogenic diet formulations (lard-based or medium chain triglyceride diets), which are not standardized or commercially available, KetoCalВ® is a nutritionally complete medical food for children that would be widely available for alternative indications such as malignant brain cancer.
Influence of diet on the intracerebral growth of the CT-2A (A) and the U87 (B) brain tumors.
Influence of diet on plasma glucose and ОІ-OHB levels in B6 mice bearing the CT-2A astrocytoma (A and C), or in SCID mice bearing the human U87 glioma (B and D). Influence of diet on vascularity in the CT-2A (A and B) and the U87 (C) brain tumors grown orthotopically in B6 or SCID mice, respectively.
KetoCalВ® could be administered to patients with brain tumors at medical centers or clinics currently using the ketogenic diet for managing epilepsy.
Furthermore, genes for ketone body metabolism will be useful for screening brain tumors that could be targeted with KetoCalВ® or other calorically restricted high fat low carbohydrate diets. A dependency on glucose for energy together with defects in ketone body metabolism largely account for why the brain tumors grow minimally on either a ketogenic-restricted diet or on a standard-restricted diet.
CR and some KDs, however, are not standardized diets and may be difficult to implement in the clinic due to issues of compliance.

This is a standard high carbohydrate mouse chow diet (SD) and contains a balance of mouse nutritional ingredients. Because we previously showed that CR of the high carbohydrate standard diet has anti-tumor and anti-angiogenic effects against the CT-2A and U87 experimental brain tumors [10,11], we did not include a hypocaloric group for the high carbohydrate diet in this study. It is important to mention that the anti-angiogenic and growth inhibitory effects of KetoCalВ® were observed only when the diet was administered in restricted amounts but were not seen when the diet was administered ad libitum, or in unrestricted amounts. This preclinical study in mice indicates that the restricted KetoCalВ® diet should be an effective alternative therapeutic option for managing malignant brain cancer in humans.
For example, CR in mice mimics therapeutic fasting in humans, involving water-only dieting, whereas medium chain triglyceride or lard-based ketogenic diets can cause gastrointestinal and kidney problems in both children and adults [30-33]. Moreover, the restricted KetoCalВ® diet reduced brain tumor growth and microvessel density, while extending mouse survival. For the survival analysis, the dietary treatment was initiated 7 days after subcutaneous implantation and continued until the tumors reached 2.5 cm3. The SD-UR, KC-UR, and KC-R represent the standard high carbohydrate diet fed unrestricted, the KetoCalВ® diet fed unrestricted, and the KetoCalВ® diet fed in restricted amounts, respectively. Consequently, the restricted KetoCalВ® mouse groups were compared to mouse groups receiving either the standard chow diet or the KetoCalВ® diet in unrestricted amounts.
This degree of dietary restriction gradually produced an approximate 20 - 23% body weight reduction by 11 days post i.c.
These findings support previous observations that restriction of dietary calories has powerful anti-angiogenic and anti-inflammatory effects against cancer, including brain cancer [9-11,51,57,58]. In contrast to most conventional brain tumor therapies, which indiscriminately target both normal cells and tumor cells, CR and particularly restricted ketogenic diets such as KetoCalВ® are the only known therapies that can target brain tumor cells while enhancing the health and vitality of normal brain cells [5,29]. This preclinical study indicates that restricted KetoCalВ® is a safe and effective diet therapy and should be considered as an alternative therapeutic option for malignant brain cancer.
Our goal was to develop a more effective alternative diet therapy for brain cancer that could extend survival without compromising the health and vitality of normal cells. The KetoCalВ® ketogenic diet was obtained as a gift from Nutricia North America (Rockville, MD, formally SHS International, Inc.). In this regard, the calorically restricted ketogenic diet for brain cancer management stands apart from all conventional therapeutic approaches. Adjuvant steroidal medications, which are often prescribed to brain tumor patients and which can produce severe adverse effects, might also be reduced under the restricted KetoCalВ® diet since glucocorticoid levels increase naturally under calorically restricted conditions [74-76].

This preclinical study indicates that KetoCalВ® is a safe and effective diet therapy for malignant brain cancer and can be considered as an alternative or adjuvant therapeutic option. Ketogenic diets and calorically restricted diets can also antagonize cancer cachexia [9,11,77].
This could also involve the use of low glycemic diets, which are effective in maintaining low circulating glucose levels and are easier to implement than some ketogenic diets [79,80]. These findings are also consistent with our previous studies in mice showing that circulating ОІ-OHB levels are greater under restricted than unrestricted dietary conditions [8,18,55,56]. The reduction in glucose levels following restriction of dietary calories largely accounts for why tumors grow minimally on either restricted ketogenic diets or on restricted high carbohydrate standard diets. We suggest that the genes for these enzymes could be useful markers for screening brain tumors and other tumor types that may be responsive to therapy using restricted KetoCalВ® or other restricted ketogenic diets. These observations, considered together with the anti-angiogenic effects of the diet, suggest that the restricted KetoCalВ® diet can manage brain tumors through multiple integrated systems. Additionally, the diets could be combined with specific drugs to further enhance therapeutic efficacy. Compliance may be better with KetoCalВ® as this diet was designed for managing refractory human epilepsy under calorically restricted conditions. Our results in mouse and human brain tumor models suggest that the restricted KetoCalВ® diet will be an effective alternative therapy for managing malignant brain cancer in humans and should be considered as either a first line or adjuvant therapeutic option.
A comparison of the nutritional composition of the SD and the KetoCalВ® diet is presented in Table 1. For example, a 40% CR diet in mice is comparable to therapeutic fasting in humans, which can be difficult for many people [30].
In addition to reducing circulating glucose levels, a restriction of total calories also reduces potential adverse effects of the high fat content of the diet since energy homeostasis is maximized under CR regardless of caloric origin [8,30]. The restricted KetoCalВ® diet should therefore be easier to implement than therapeutic fasting for brain cancer patients.

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