I'd like to introduce you to our symposium this morning entitled Very Low Calorie Ketogenic Diets Beyond Obesity. I'm Dr. Frank Gonzalez from the University of Illinois Chicago Reproductive Endocrinology and this is Dr. Lourdes Ibanez from Barcelona, Spain. We have three presentations this morning and also some questions and answers. We'll begin with speaker number one. This is Dr. Massimiliano Caprio from the Laboratory of Cardiovascular Endocrinology, San Rafael, Pisana, Rome. He will be presenting Immunometabolic Effects of Ketogenic Diets. Dr. Caprio. Thank you, Chair. I'm very happy to be here today. I'm actually replacing Dr. Dixie who could not come to give this presentation for COVID disease, unfortunately. So I hope to do a good job. These are my disclosures. This is the outline of the talk. We will deal on the pleiotropic action of ketone bodies. In particular, we will try to explain the immunologic Warburger effect with all the novel therapeutic opportunities related to the capacity to modulate immune cells metabolism. Immunometabolic effects of nutritional ketosis with its implication in the use of ketogenic diets during COVID-19 disease. Ketogenic diets and endothelial cell metabolism, inflammation, and atherosclerosis. So this is just to introduce the wide effects, systemic effects of ketone bodies on human health that are well beyond the production of ATP and energy production. As you can see, ketone bodies have profound activity on mitochondrial biogenesis, on autophagy, and they act at the systemic level on the brain. I remember you that ketogenic diets were first developed more than 100 years ago in children with epilepsy that did not respond to treatment. The powerful effects of ketone bodies on the heart, and we know that nowadays there are protocols studying the effect of ketone bodies on inotropic fraction and in heart failure. The effects on skeletal muscle, gut, and liver, and especially the modulation of microbiota, and of course, fat metabolism. First of all, I would like to introduce this concept that ketogenic diets are extremely heterogeneous. So you can prescribe several kinds of ketogenic diet depending on the scope and on the target, on the patient that you have in front. So the common characteristic is a marked reduction of carbohydrates that should be below 30 grams per day. It is true that there are different thresholds to obtain ketosis, but usually in order to obtain a valuable nutritional ketosis, we have to stay below this threshold. And according and depending on the calories, the total calories per day, we can manage the concentration of lipids. In this session, we will particularly deal with very low-calorie ketogenic diets, and of course, these are extremely low-calorie diets, about 100 kilocalories per day, and also the lipid content is quite reasonable and reduced. So these are not hyperlipidic diets, whereas if you don't have the necessity to lose weight, you can also increase the number and the percentage of fat, then you can have low-calorie ketogenic diet, isocaloric-caloric ketogenic diet. With the Italian Society of Endocrinology, we wrote this position statement three years ago just to realize which could have been the major indication of very low-calorie ketogenic diet in the context of endocrine disease. And of course, apart from severe obesity, we identified several comorbidities of obesity that responded very well to this protocol, very low-calorie ketogenic diet. In particular, the obesity associated with sarcopenia, the obesity associated with type 2 diabetes, hypertriglyceridemia, and hypertension. We also identified some area of disease where the recommendation was still weak due to the scarcity of studies. In particular, we will deal today, Professor Gambineri will talk about the obesity associated with polycystic ovary syndrome, but there are several other conditions where this nutritional protocol has promising results, so that we will probably have to revise this consensus statement. Several mechanisms of action of ketogenic diets are strictly related to their immunometabolic effect. In particular, we know since years that there is a rapid and strong inhibition of the NLRP3 inflammasome. So there is a dampening of inflammation, especially related to the activation of this receptor that is the GPR109 that is abundantly expressed in monocyte and macrophage. There is an increase in antioxidant protein. There is a marked effect on neuroprotection and on neuroinflammation. Just to give you an example, this protocol is extremely successful in patients affected by severe migraine. We recently finished a clinical trial with really interesting results. Of course, also the atherosclerosis and endothelial inflammation is related to their anti-inflammatory effects. So, this is just to show how beta-hydroxybutyrate prevents the assemblage of the inflammasome through an inhibition of potassium efflux and ask polymerization and speck formation. But since several years ago, we knew that the Warburg effect was strictly related to cancer cells. And it was interesting to see that all immune cells from every class, both myeloid and lymphoid lineage, both innate and adaptive immunity, they have this capacity to reprogram their metabolism. And this glycolytic reprogram is well conserved among all inflammatory immune subsets. In particular, the pro-inflammatory signals are a strong message in order to enhance the glycolytic pathways, whereas when we upregulate the oxidation pathway, there is a favorable effect on Treg expression, so an anti-inflammatory effect, on macrophage M2 polarization, and also on the tolerogenic dendritic cells. So, in general, the oxytocin metabolism is anti-inflammatory, is more anti-inflammatory. This elegant study that was performed by Dr. Dixit group showed that ketogenic diets have a profound effect also in resident T cells in adipose tissue. So, of course, ketogenic diets, this was a study performed in mice, determined an improvement in glucose tolerance, as you can see here. And they selectively expanded, as you can see here, there was an increase, there was a profound effect in the immune compartment with the reduction of eosinophils and the reduction of total macrophage in adipose tissue, and there was also a complete reassessment of inflammatory metabolic gene expression in total fat, with an increased expression of CPT1-alpha, that is the enzyme that is required for the transport of long-chain fatty acids into the mitochondria, so this enzyme is critical for the phosphorylative oxidative metabolism. These odors, they used the single-cell RNA-seq that was performed only on resident cells, resident immune cells in adipose tissue that were fax-sorted, and as you can see, the ketogenic diets selectively expanded this population that was a gamma-delta T cell population, that is not abundant, this was quite difficult and methodologically tricky, and preferentially the CD44-positive, CD27-negative gamma-delta cells, that is the cells that express and produce interleukin-17 and activate Treg cells. So in particular, these cells, in these cells, the ketogenic diets determine an increase in the extragenular matrix remodeling and tissue homeostasis, so there was, as you can see here, a profound modification of gene expression. Not only there was this increase in T gamma-delta cells, but this increase was also related to an improved metabolic outcome, so the glucose tolerance in these mice was improved, as you can see here, and the loss of gamma-delta T cells, in particular with this model that was knocked out for gamma-delta T cells, as you can see, the glucose tolerance definitely was much worse compared to wild-type mice. Also there was an increase in macrophage infiltration in fat, and in total Tregs were reduced. So the same outdoors, and this study was published before the COVID-19 disease, this was a few months earlier, they used a model of influenza virus in mice, and again, thanks to the activation due to the ketogenic diet of this gamma-delta T cells population, these mice were able to improve the blood oxygen saturation, so this determined a decrease in mortality in mice infected with influenza virus. In particular, there was an increase in mucus-producing cells in the lung, so these cells were present also in the epithelium in the lung, and they have been shown also in human lung, and they helped the production of mucus, and as you can see here, when mice did not follow ketogenic diet, but there was a pharmacological administration of ketones through ketone esters given to mice, this increase in mucus was not observed, so only ketogenic diet was able to improve the mucus production. As you can see here, again, the T gamma-delta cells were not activated by exogen ketone bodies. So there was this short paper that was performed on human volunteers who were taking ketone esters, so they were assuming ketone supplements, and 30 minutes after the administration of ketone supplements, they took the blood and they studied the NLRP3 activation, and it seems that there was an increase in the activation of the inflammasome with increased production in interleukin beta. So this was a negative effect of exogenous ketone supplements. So probably this is the interpretation. The ketogenic diets not only increased the liver production of ketones, but also prepared the body to oxidize ketones. So there is an upregulation of all the enzymes that are able to oxidize ketones. In particular, there is the activation of PPR-alpha that is the primary coordinating transcription factor that is required for ketolysis, and of course PPR-alpha is activated by free fatty acids, because we know that during ketogenic diet there is a massive release of free fatty acid that is not observed with the pharmacological supplementation. So probably this is an alert for the use of ketone supplements. So taking inspiration from these papers during the first terrible experience we had with COVID-19 in Italy, we wrote this paper just summarizing the potential protective effect of ketogenic diets on the inflammation and on the COVID disease outcome due to the double effect, both to the innate immunity, in particular through the effects on the inflammasome, and through the stimulatory effect on T-gamma-delta cells on adaptive immunity. In particular, there are data showing that T-gamma-delta cells are also enriched in the skin and in the mucosa of humans. So they really may represent a very important surveillance response during COVID disease. The aim of the study was especially related to the prevention of COVID disease infection. We know that during the lockdown there was a massive increase in obesity and type 2 diabetes. So a rapid nutritional protocol that determined fat mass loss and improvement in glucose metabolism and improvement of nutritional status and of blood pressure, of course, determined a much lower risk to have COVID disease with an unfavorable outcome. As you can see here, this is just a small study where an isocaloric ketogenic diet was studied in people admitted to the intensive care unit of the Hospital of Genoa. And as you can see here, there were a trend in reduction in mortality and in admission to intensive care unit in the patient. This is, of course, a retrospective analysis in patients that follow this isocaloric ketogenic diet. This other paper, very elegant, that showed this was performed in human volunteers undergoing a very low-calorie ketogenic diet, both in vivo and in vitro. The human T cells' immune capacity of this subject was markedly improved just three weeks after the beginning of this ketogenic diet, as you can see here. There was also an increase in the respiratory reserve, in total energy supply, and in reactive oxygen species signaling. So the overall T cells' function was markedly increased. This is a paper that is just published by the group of Felipe Casanova in Spain, that was probably one of the most active scientists designing clinical trials with the very low-calorie ketogenic diet. As you can see here, he compared the immunomodulatory effect of a very low-calorie ketogenic diet that was compared with bariatric surgery and with a low-calorie, not ketogenic diet. And you can see, as you can see here, there were enormous changes, and the more marked effect were observed in the group undergoing the ketogenic diet. So body weight was not the cause of this particular immunomodulation. Just to conclude my talk, I would like to show you this recent paper, who for the first time described that cardiac endothelial cells are not only able to transport ketone bodies, and to transport to all tissues that are able to oxidize ketone bodies, but they are also able to oxidize ketone bodies. And this is relevant because it's associated with the proliferative potential of cells. So in particular, this paper showed that endothelial cells, and only cardiac endothelial cells, not other endothelial cells, were able to proliferate. And this was related to the phosphox metabolism, since if you knock down the SCOT, that is the enzyme, the key enzyme in ketolysis, this effect was not observed. This is the first observation of such a proliferative effect during the phosphox metabolism, usually glycolysis is associated with a mass effect and biosynthesis. We actually are performing in vivo studies of mice, this is a model of early atherosclerosis that uses APOE knockout mice undergoing a high-fat diet in the presence of aldosterone. So these mice are able in four weeks to develop atherosclerotic plants. As you can see here, we took a group of mice and treated them with a ketogenic diet containing the exact amount of fat of the high-fat diet, but not containing or containing very low carbohydrates. As you can see here, there was a reduction in body weight and an improvement in glucose tolerance as seen here. But importantly, after four weeks, there was a marked reduction in plaque size, lipid content of the plaque in the aortic arch, and this is the first demonstration in vivo of an anti-atherosclerotic effect of ketogenic diets. This was also associated with a marked reduction in transcript level of several critical endothelial markers, in particular of endothelial activation, ICAM-1 and VUCAM-1, inflammation, MCP1, TNF-alpha, and interleukin 6, and also macrophage polarization with an increase of M2-specific markers of macrophage polarization. So, the take-home message of this presentation is that several protocols of ketogenic diet exist, and each one with very specific clinical indication. Ketogenic diet displayed profound action, both on innate and adaptive immunity, with a very powerful anti-inflammatory effect, and this is a very important point because we know that all of these people have very high levels of low-grade inflammation, but also they have severe complication related to chronic inflammation of bones and of soft tissues. So, this determines a marked improvement in the lifestyle of this patient. The immunometabolic effects of ketogenic diet also explain the favorable effect in glucose metabolism, cardiac function, and endothelial inflammation. And finally, I want to stress this concept that a personalized nutritional approach is particularly important for ketogenic diets, and this depends really on the characteristic of the patient. So, we have also to use specific supplements. We know how much supplements are necessary because this is not well-balanced nutritional protocol, so the use of vitamins, salts, and cofactors is really important to obtain better results. See, this just shows how the nutritional ketosis can be used in inflammatory disease, in cardiac disease, and also in cancer. I don't have the time, unfortunately, to deal with this aspect, but also the immunomodulation of several transcript factors are really relevant in the co-adjuvation of chemotherapy. And so, ketogenic diets can also be considered a very important co-adjuvant therapy for the cancer therapy. So, I want to thank my group in Rome that helped me in all these activities, and also thank you for the kind attention. Thanks a lot. We can entertain any questions from the audience, either by coming up to the podium, and also you can scan it. It's not up there right now. Anybody have any questions? Hi, I'm Nick Webster, San Diego. Thanks for a great overview. That was a really nice talk. So, I just wanted to ask you, what do you think about chronic elevation of ketone bodies versus transient elevation that you can achieve using a time-restricted eating approach? So this is a good point. In the position statement, we do not recommend the chronic elevation of ketones. So the ketogenic diet have to be shorter protocols. And of course you cannot leave during, I mean, this is too unbalanced. So it depends on what is your objective. I make you an example, a patient with a persistent and not-respondent migraine, unfortunately, needs to spend a lot of time in ketogenesis. Since as soon as you reintroduce carbohydrates, there is an increase in migraine attacks. Children with mutation of glucose transported, they need to live on ketogenic diets. So this is really important. But when we talk about very low ketogenic diets in the context of metabolic disease, we usually recommend not to overpass three months of treatment and then to gradually reintroduce carbohydrates. And this can be repeated, of course. Moreg Young from Melbourne, Australia. Very nice talk, Marci. My question is about the period of time of fasting. How important for the success of the ketogenic diet is it to have a, to maintain the period of fasting over night? This is also a very good point. So fasting is really important because the highest production of ketones occurs during the night. So of course, we always give advice not to keep a quite wide ketogenic window during the night. This is also used during chronic intermittent fasting protocol, for example. And in my experience, my opinion, there are no published data about it, but I recommend not to eat too late. And also, I encourage people, if they don't want to have breakfast early in the morning, they can also wait. So the ketogenic window, the fasting window, the higher the fasting window, the higher the production of ketones. And the study from Casanova showed that during the active ketogenic period phase of the nutritional protocol, there is a higher modulation of immunity and also a higher effect in terms of body weight loss. Thank you. So you don't give them an exact time, but you figure while they sleep, they can eat early and eat late the next day. Yeah, but this also is good to reset the bad habits. For example, it has been observed by another study from the group of Casanova. He measured the quality of life. There are several questionnaires and he also studied the sleep quality. And the sleep quality really improved. Several patients noticed this aspect. So in order to sleep well, you cannot eat too late. Some of us are guilty of that. Do we have any other questions? Well, thank you very much. Thank you. It is my pleasure to present our second speaker, Professor Alessandra Gambineri from the Division of Endocrinology and Diabetes Prevention and Care of the University of Bologna. She will speak about ketogenic diets and PCOS. So good morning. Thank you. Thank you for this invitation. And this is an opportunity for me to present you the first data on a randomized controlled diet trial in very low-calorie ketogenic diet and obese PCOS that we recently concluded and is still unpublished. We are preparing the paper. So I want to dedicate the first few slides to introduce PCOS and to give you some key points to understand why we should use a very low-calorie ketogenic diet in a subgroup of PCOS, in particular, in obese PCOS women. We know that PCOS is a very, very frequent endocrine and metabolic disease that affect approximately 20% of women in the reproductive age. And we know that the diagnostic criteria is based in the presence of hyperandrogenism that can be clinical and or biochemical in association with ovarian dysfunctions. We know today that PCOS identifies with in hyperandrogenic disorders that is the always present and main pathogenic factors that can be present with different degree. But we know also that the hyperandrogenism interact usually with other pathogenic factors and these create a very heterogeneity CT in the phenotype of this population that produce an heterogeneity in the clinical and treatment in the clinical expression and in management of this disease. And we can consider a unifying hypothesis in the pathogenesis of these disorders that start from the hyperandrogenism. So all patients affected by PCOS have a primary abnormality in androgen secretion. However, there are usually some other pathogenic mechanism. The main recognized are insulin resistance and adipose tissue dysfunction and visceral adiposity. But we have a huge spectrum of this disease. In one side, usually in the lean phenotype, the main pathogenic factor is the primary abnormality in androgen secretion. And usually insulin resistance and adipose tissue dysfunction as well as visceral adiposity can be present that are not so important in the pathophysiology of this sub-phenotype. In the other part of the spectrum, we have the obese PCOS phenotype where the main pathogenetic factors are insulin resistance and adipose tissue dysfunction and visceral adiposity that usually trigger androgen excess. So in this kind of phenotype, our main target of treatment should be insulin resistance and adipose tissue dysfunction as well as visceral adiposity. And we know that in obesity, a part of insulin resistance in PCOS is sustained by the adipose tissue. There are some studies, one of these is shown here where insulin resistance measured by the hyperinsulinemic clamp that is the gold standard to measure in vivo insulin resistance. Insulin resistance is present in approximately 49% of obese PCOS against the 78% in overweight and 59% of lean PCOS. That's supporting that obese has an important role in determining insulin resistance in PCOS. And we know also that at parity of body mass index, PCOS women have more important insulin resistance with respect to non-PCOS women, thus suggesting that probably this is due to the presence of dysfunctional adipocytes and to a preferential visceral fat distribution that we observed in PCOS women. In fact, there are many studies that demonstrate an intrinsic dysfunction of adipose tissue in PCOS with a consequent production of many drivers of developing or aggravating insulin resistance. There are some studies that compare PCOS with non-PCOS women and demonstrate that at parity of BMI, PCOS women have produced from the adipose tissue more free fatty acids, more androgens, more cytokines, more oxidative stress, more cortisol through the expression of this enzyme that is the 11-beta-hydroxysteroid of the heterogeneous type one that convert cortisone into active cortisol into the adipose tissue and produce more pro-inflammatory and pro-insulin resistance adipokines and less adiponectin. In addition, we know that PCOS women when compared with non-PCOS women have more expression of visceral adiposity and we know how visceral adiposity can impact insulin resistance more than subcutaneous adipose tissue for many reasons that I have summarized in this slide. For example, visceral adipose tissue drains directly to the liver through the portal circulation, is more vascular and innervated. The adipocytes are more sensitive to lipolysis, contains more inflammatory immune cells, have higher expression of 11-beta-HD1 and the higher density of glucocorticoid as well as androgen receptors. So, we can say again that in obese PCOS phenotype the main treatment targets are obesity and insulin resistance. Conditions that maintain each other and that also aggravates hyperandrogenes but also inflammatory and oxidative stress. And insulin resistance and obesity should be treated together to obtain the best outcome. Accordingly, in obese PCOS weight loss results in a significant attenuation of clinical and metabolic manifestations for most patients. And in some cases it produce a complete remission of the syndrome. There are some data that demonstrated that a weight loss in obese PCOS is able to produce a recovery from the syndrome in approximately 37% of patients. However, we know also that correct guidelines recommend not a lot of weight loss, five to 10% of weight loss to obtain beneficial effects on hormones, metabolism and clinical outcomes in particular ovulatory dysfunction and infertility. However, we know also that approximately 25% of obese PCOS fail to respond to standard lifestyle intervention programs. Probably for many factor that are insulin resistance, hyperandrogenes, visceral adiposity but also there are some studies that demonstrate a low basal metabolic rate, a low postprandial thermogenesis, frequently a low physical activity but also psychological distress that determines a non-compliance to the diet. So the background to try to understand if specific diets like very low calorie ketogenic diet could be an effect in PCOS, in obese PCOS. And we start from many trials in obesity, in the general obesity that demonstrate that well-sick APDs is able to produce a rapid but also long lasting weight loss. We have now data that demonstrate a maintenance of body weight loss for 24 months, preferential loss of fat, body mass and visceral fat and maintenance of lean body mass. A marked improvement of insulin resistance and hyperinsulinemia and also decrease of low grade inflammation and oxidative stress. Other than a reduction in perceived stress and improvement of general well-being that could be the basis for increasing the compliance of our patients to the diet. There are now so many studies published until now in ketogenic diet in PCOS and only one that use very low calorie ketogenic diet in obese PCOS for 45 days. All these studies, however, demonstrated an improvement of anthropometric, metabolic and hormonal variables. And in the two studies where a gynecological clinical outcome was measured, it was demonstrated an improvement of also of this outcome in particular an improvement of menses and fertility rate. This is the study published, the only study available in publication on very low calorie ketogenic diet in obese PCOS. They use a mixed ketogenic diet. In the right side you can see the composition of the diet. And as you can see here, they obtained an improvement of most all the data that they analyzed. So these patients decreased BMI waste, that is the surrogate, clinical surrogate for measuring visceral adipocyte. Fatty mass, more than free fatty mass. Fasting and fasting glucose and insulin and OMA ER, that is the surrogate for measuring insulin resistance. But also they obtained a decrease of LH to FSH ratio of total testosterone. And an increase in sex hormone binding globulin, that is the protein that is produced by the liver bind testosterone. And in female it binds approximately 70% of testosterone in the blood. And the testosterone that is bind to sex hormone binding globulin is not able to bind to the androgen receptor. So higher is the circulating level of sex hormone binding globulin, lower is the level of free testosterone. So the testosterone be available for androgen receptors. And in this study, they also demonstrated that all patients that had some problems in the menses or in pregnancy, they have an improvement. So all improved menses. And we also add 42% of pregnancy rate within the patients that had a regularization of cycle. However, this is the only study and is a no randomized study. So we decide to perform these randomized controlled trials that we have completed very, very few weeks ago. And this is an open label monocentric randomized controlled trials that included 30 PCOS patients with a diagnosis of PCOS by NIH criteria. So all patients said clinical and or biochemical hyperandrogenous plus ovulatory dysfunctions or polycystic ovarian morphology ultrasound. They had age range between 18 and 45 years and a BMI between 28 and 40 kilogram four square meters. The primary outcomes of the study were changing body weight and changing body composition measured by bioimpedance geometry. And the secondary outcomes were changing body fat measured by waist circumference, changing metabolic parameters, also insulin and insulin resistance, changing hyperandrogenemia. And we use a liquid chromatography standard spectrometry for the measurements of steroids. But also we measure ear sooties by using a vedodermoscopy, but also, sorry, the score of RMR-Galwe but also vedodermoscopy that is a more objective method of measurements of insulins, of ear sooties. We also measure change in ovulation by performing the measuring the blood of progesterone and estradiol and ovarian ultrasonography, ovarian morphology. And we also measure some changes in psychological well-being and distress by using specific questionnaires. This is the study protocol. We have a screening period measurement at baseline. A first part of treatment of eight weeks where we treated 15 patients in the experimental group by very low-calorie ketogenic diet and 50 patients by LCD, that is a standard low-calorie diet. And the second part of the study of other eight weeks where we treated the experimental group with low-calorie diet and the control group continued into the LCD. This is the scan of the phase of the two phases in the experimental group. And we used for this study the PRONOCAL approach. Okay, this is the study protocol at T0, baseline T1 and T2. We did all the measurements. Ovulation monitoring was performed at baseline and at the end of the study. We had two dropouts in the experimental group during the first period of treatment. So during the very low-calorie ketogenic diet treatment, one for renal disease and the second one because she was not tolerated the products of the diet. And another dropout in the control group for not compliance. So at the end of the study, we had 13 patients treated in the experimental group and 14 patients treated in the control group. And briefly, these are the main important results of our study. So by the red lines, there is the modification of the parameter within the experimental diet, the experimental group. And with the black line, there is the modification in the control group. So this first significance is the reference to the modification during the first part of the study and that is during the second part. This is the statistical analysis within the single treatment group during all the study and this is the statistical analysis comparing the modifications between the two study groups. So relative to BMI and waste, we can see here that BMI decreased in both groups, but significantly more in the experimental than in the control group. The experimental group, but not the control group had significantly reduced waist circumference, but mainly during the first eight weeks of the study. So during the very low calorie ketogenic diet treatment. As expected from the studies in obese population on PCOS, we observed also in this study that experimental group, but not the control group had significantly reduced in pedentiometry measure of fat mass and fat-free mass. However, only changes in fat mass were significantly higher in the experimental compared to the control group. Insulin, fasting insulin or MER significantly increased in the experimental group only mainly during the first eight weeks of the study, so during the very low calorie ketogenic diet treatment. However, when comparing changes in these parameters between the two groups, no significant differences were found. Testosterone was slightly higher at baseline in the experimental group with respect to control group, but we did not observe significant changes in both groups during the study. However, we have an amazing increase of sex hormone binding globulin and therefore a decrease in free testosterone that was calculated by Vermeulen method during the first part of the study only in the experimental group but no modification we observed in the control group. What about ovulation? Ovulation occurrence at baseline was similar in the two groups but it differs significant by the end of the study. At the end of the study, that was only 16 weeks, we observed an occurrence of ovulation in 46, in an improvement of ovulation of 46% in the experimental group that was significant against 21.4% in the control group. So a very important improvement of ovulation considering the very short time of treatment of this population. So what we can conclude from this study, this randomized controlled studies, the very low calorie ketogenic diet is a valid method for reducing total and visceral fat, rapidly ameliorating hyperandrogenes. We observed a very important increase of sex hormone binding globulin and a decrease of free testosterone through and an improvement of ovulatory dysfunction in obese PCOS women. It's ameliorating insulin resistance and hyperinsulinemia too but probably this is not the main effect of this drug. Also in the amelioration of ovulation, we should consider the possibility that very low calorie ketogenic diet could have a direct effect at the ovary, reducing lipotoxicity as well as inflammation and oxidative stress and use this mechanism to improve ovulation in PCOS women. So I would like to thank all people that collaborate with me in this important study and the protocol group, protocol group that supported us for this study. Thank you to all of you for the attention. Thank you. presentation. Consider the comment of the previous speaker not to continue ketogenic diet more than three months. What's the long-term follow-up that you're planning to do with your patient? Yes, thank you for this question. We are continuing to follow up these patients and at the moment we had two pregnancies so this is a very important point for us and that arrived approximately three months after the stop of very low-calorie ketogenic diet so and most of them they are maintaining or still reducing body weight during, they are continuing normal low-calorie diet and they maintain the body weight and some of them are still losing weight. So I guess you don't agree with the previous speaker on how long you can continue with the ketogenic diet? I think from the data that we have in literature we should treat for a brief time and so to correct rapidly the mechanism that in some way creates alterations in the ovulation or also in inflammation and so they lose weight and then they can maintain the effect by using a normal low-calorie diet. Hi, thank you for the nice talk. Liz Cunruther from Chicago. Do we have any information in women with PCOS who are on just a ketogenic diet, not necessarily very low-calorie? That's a very good point. I'd like to, there are no, there are some data that use ketogenic diet but they use all in overweight on obese patients and they obtain a good data too. They are uncontrolled at the trials but they improved. In this study there was an improvement of almost all parameters. I think that a good point could be to treat lean PCOS women with a normal caloric ketogenic diet and see what happened. For example in ILH that is a problem for these patients. It could be the possibility to obtain a reduction because we can treat hyperandrogenes because they increase very importantly sex hormone binding globally but at the moment there are no data on this. It could be of interest to start to treat normal weight patients with a ketogenic diet. So, ciao insegnante italiani, ma chiamo Luiz Bianchi ma non parla italiano. So my name is Luiz Bianchi, I'm from Brazil. I'd like to thank the brilliant presentation. So we have shown some unquestionable data about the ketogenic diet in this setting but I noticed that was a remarkable difference between the total calorie intake between those groups. I would like to comment some of this. Yes, we decided to use this protocol that is different also in the phase of recovery so of the introduction of low calorie diets but this was the protocol was designed as this. So we probably this is the reason why in our experimental group they continue to lose weight or also during the LCD phase. However after that time we could we pass it to all patients in LCD and they continue to lose weight or maintain weight. So but this is the protocol that we decide to use to compare a normal standard low calorie diet with this kind of protocol of diet. Thank you for that lovely presentation. It was wonderful to see more data on reproductive health outcomes which has been a challenge in terms of trying to synthesize data on what are the actual benefits of some of these various types of dietary interventions. And so I you alluded a little bit to pregnancy when I saw the data I was really curious about the quality of the ovulations and so I was wondering if you had any reproductive hormone data and and what are your thoughts on on ovulatory cyclicity versus sporadic ovulations which are as you can appreciate things that were most easy to capture in these longitudinal studies. Thank you, thank you. I absolutely agree with you because we need more data on the quality of ovulation and to see whether these patients that ovulate can also have a pregnancy. So there are no data actually in the literature that demonstrate an increase of pregnancy and increase of rate of pregnancy in this population but maybe we need some more data on this. I have a question. I really enjoyed your presentation of the study you're doing as something seminal. Plan on checking any inflammatory parameters besides metabolic parameters because they're going to be there. Thank you. At the moment no but we stored some samples to do some analysis and I think the inflammation is important but probably also the AMH yes it could be a possibility to see what happened in these patients and so we will do in the next time. I have at the moment enough data on this. Thank you. I have a question too. Would you recommend a ketogenic diet for overweight and obese patients independently of the endocrine metabolic profile or should they be directed towards a particular profile of patients? This is a very important question. I don't know because there are no data at the moment that demonstrate whether for example more insulin resistant patients have a higher response to a very low calorie ketogenic diet that others. At the moment what I could recommend is to use this diet when we want to obtain a very rapid improvement of these conditions. For example obese women that want to have pregnancy or even if they want to start a fertilization program it could be the possibility I think in this moment to to use this kind of diet in all patients that want this and that the failure from normal low calorie diet that we know that they have a lot of these patients have a failure from this from the normal low calorie diet. Okay thank you very much. Thank you very much Dr. Professor Gambineri. So we have to switch to the next. So our last presentation is from Alfredo Genco. He's from Sapienza University of Rome and he will be speaking on the role of ketogenic diets in pre and post bariatric patients. First of all thank you for the kind invitation. A role of a ketogenic diet in pre and post bariatric surgery and bariatric patients. I have another disclosure. Here you can see a summary of all the option treatment in morbid obese patients. Start taking from the left side of the picture. Less invasive option to the right side of the picture. The more invasive treatment like bariatric surgery. In the middle there is the new field that is born over this last five years. The bariatric endoscopy. We know that the surgery, bariatric surgery represented the only effective option therapeutic option for morbid obesity. Many many papers up to now have been demonstrated on this reality. That is why as we very well know the results of the diet program alone or long-term treatment of morbid obesity is a disaster. Long-term diet alone, long-term morbid obese patients. Because of the 95% of the patients return at the starting point. This is the cause of this bariatric explosion of bariatric surgical treatment of obesity and but we have to do first of all is an easy consideration. Only 1.5% or 2% of the morbid obese patients eligible for bariatric surgery arrived in the operating room. Because most obese patients, the majority of these patients refuse bariatric surgical treatment. So we have the problem to have to give an answer to 95, 99% of morbid obese patients. This is a big problem. Just two words regarding the classification of surgical treatment of obesity. As we know we have the field of restrictive procedure against the malabsorptive procedure. In the middle there are the metabolic bariatric surgical procedure. Here just for historic consideration the gastric bending almost no longer performed due to the 40% of the patients that need after five years of treatment with the gastric bending needing to go to in the operating room for the failure. The gastric bypass and above all the liver gastrectomy are the gold standards. They represent now the gold standard of the surgical treatment of morbid obesity. A few data regarding both of these surgical procedures. Excessive weight loss after five years was 60%. Diabetes control or improving in 91% of the patients. Hypertension 85% of the patients and the reduced surgery only in 2.8%. Here you can see, sorry there is something in Italian language, the effect of this important weight reduction in all comorbidities and the effect on the mortality. Compare the mortality of bariatric patients 0.68 compared with the morbid obese patients not submitted to bariatric procedure. An important problem of bariatric surgery is the complication that we have. We have important complication for example in anastomic leak in above all in patients submitted to gastrectomy with a leak gastrectomy that arrives even till 7% or in the ruin why gastric bypass arrived to 6%. Gastric intestine bleeding in more or less 2% of the patients. And the post-operative mortality there is a mortality of 0.1 to 1.1%. The majority of this complication is related to the weight, is related to the weight. Here you can see the situation and the clinical situation of our patient when they arrive to the surgeon asking for surgical treatment. We have patients like this for example, patients that have this apnea index patient with 34 episodes of apnea per hour. 34 per hour. This means 100 episodes of apnea every night. This means this patients sleep less in the night and sleep more during the day. Another problem, the disaster in terms of oxygen saturation and respiratory function. Here you can see the orthostatic position, the clinostatic position, the saturation is a disaster. And you can see the problematic, the problem that our anesthesiologists have to resolve in the time of intubation because when the patient has a 40 centimeters of neck, the probability of problematic intubation is only 5%. But if it is a neck circumference around to 60%, the problematic intubation become arrives to 35%. One patient of three. And another important problem, above all, when we perform laparoscopic, and now it's all performed laparoscopically, here you can see the problem that we have in terms of visceral fat, abdominal fat, and in terms of hepatic volume. We have no space to work inside the abdomen. Now we know very very well that the preoperative weight loss of modest proportion, 10 to 20%, reduces the complication of a surgery in extreme obese patients. So this is a reality, it's very very important. And this means that if we go to treat the patients like this, with 34 episodes of apnea per agua, with the nitrogastric balloon, here you can see how it's important, how their respiratory function can improve. And the same, how can improve in terms of oxygen saturation. And this means that the proof that we treat the patients before bariatric surgical procedure, we can improve all the control, all the comorbidities, and can prevent complication. Nitrogastric balloon is an important tool that help surgeons before the treatment, but nitrogastric balloon is invasive, even if less invasive than surgery, it's expensive, and needs six months of treatment at least in order to achieve good results. In comparison with the very low-calorie ketogenic diet, this is not invasive. It is cheaper, and the treatment duration is only six or eight weeks, and no more. There are many, as someone before the night has told you, there are many many different ketogenic diet. This is the diet that very often our nutritionists use. And this is a paper we have done, a study we have published a few years ago, where we put together three different temporary treatments, like a nitrogastric balloon, and we had the very low-calorie ketogenic diet. This is an example of pre-treatment. In these patients we had patients treated with a very low ketogenic diet, sorry, no sorry, this is the very low ketogenic diet in patients before surgery. This is Dr. Folletto's study. We have two groups of patients, submitted to a very low ketogenic diet, compared with the low-calorie diet, with a body mass index of 46. And here you can see the very low ketogenic diet is 1.4 grams of protein, with less than 30 grams of carbohydrate, a 700 kilocalorie diet, compared with the low-calorie diet, with over 800 kilocalories of calories of the diet, with 0.8 to 1.5 grams of protein, and with carbohydrates less than 80 grams. The methods of the study is a study of 33 days of the treatment. After 10 days of treatment with the ketogenic diet, the patients were submitted to a low-calorie ketogenic diet. These are the characteristics of the patients. And here you can see the important results in terms of weight reduction, in terms of weight reduction, statistically significant in terms of kilograms. And here you can see important results in terms of hospital stay. This means that the ketogenic diet helps us to reduce the cost of the treatment, because in the group submitted to a low-calorie diet, we have 10% of the patients with more than three days of hospital stay. In patients treated with the calorie ketogenic diet, we had only 2.8% of the patients that stay in the hospital more than three days. And the same in the group, no ketogenic group, the incidence rate of bleeding is statistically significant greater than the group of ketogenic diet. This is another important study of Dr. Piloni, metabolic effect safety acceptability of a very low-calorie ketogenic diet scheme on candidates for bariatric surgery. This is more or less the same scheme, the starting point, 10 days of very low, very low catagenic diet and 20 days of low calorie non-catagenic diet. Here you can see the scam. And here you can see the results in terms of waist circumference, where you can see that 50% of the waist circumference reduction is achieved during the first 10 days of treatment with catagenic diets. If we were to see what happened in terms of BMI reduction, we can achieve seven points of BMI reduction. But what is important for surgeons who have to perform a laparoscopic bariatric procedure, the right liver lobe diameter is reduced to 5 centimetres and the left lobe diameter is reduced to 1 centimetre. This means that after one month of treatment, the liver volume is reduced to about 7 centimetres. This is very important in order to perform the operation laparoscopically. And more, you can see the total cholesterol, important results and important results in terms of triglycerides and ketonemia that demonstrate the time T1, the 10 days during which the patients were subjected to ketogenic diets. This is the same picture as before. You can see what changed in the pre-treatment in terms of abdominal fat and after one month. And what changed in terms of hepatic volume at T0 and at T3. One month later, an important reduction of hepatic volume. In terms of fat mass, here you can see the important reduction of the fat mass from 44% to 36%. And in terms of glucose control, 118 to 90.9 milligrams. In terms of HbA1c, visceral fat. Another paper, interesting, performed by Dr. Leonetti from Rome, where compared the OBD diet, OBD means pre-operative diet regimen, compared with another group of low-calorie diet, they treat the group of study patients with a calorie diet, 10 days of a very low-calorie diet, ketogenic diet, of only about 500 kilocalories, with carbohydrates 15 grams, 80 grams of protein and lipids 23-24. The second time, from 11 to 20 days, they increased the amount of carbohydrates, 55 grams, 80 grams of protein, 30 grams of lipids. And then at the last period, 10 days, low-calorie diet increasing the carbohydrates and arriving at 145 grams of carbohydrates. The control group, submitted to only low-calorie diet, received the carbohydrates, 150 grams of carbohydrates, and the protein, 90 grams, 42 of lipids. And see what happened in the group submitted to ketogenic diet. This patient lost about 14 kilos, 4.9 points of BMI reduction, and 20 centimeters of waist circumference. And the neck circumference is reduced by 3 points, 3.0 centimeters of neck circumference, and ketoneuria that you can see in the first 10 days of the treatment. And the hunger. The patients, this is the most important patient, and explain to us why the group of patients submitted to ketogenic diet lose weight, and the group of patients submitted to low-calorie non-ketogenic diet doesn't lose weight. Because this patient, this last group, the patient feels hunger. And this doesn't occur in the patient treated with the ketogenic diet, because ketogenic diet induces satiety, and imports satiety. In terms, in this diabetic patient, in terms of glycemic control, 197 at the starting point, 147 milligrams one month later. Group of comparison, low-calorie diets, you can see weight reduction only 6-7 kilos against 14 kilos. A BMI reduction, only 2.0 BMI reduction against 4.7 BMI reduction. And the neck circumference actually doesn't change. Well, I told you something about intragastric balloon. Intragastric balloon is an important treatment, endoscopic procedure. Here you can see, now we have many of intragastric balloons. Here there is a first classification of intragastric balloon on the left side. Intragastric balloon that need the endoscopic for the treatment. On the right side, the so-called swallowable balloon that doesn't need the endoscopic for the treatment. And this is the balloon, an American balloon, made here in the United States, but you can't use it up to now because it didn't receive the everyday approval. We can use it in Europe and the Middle East. I show you what happened to this patient. Can you help me, please? This is a movie. It's a movie. No. Now. I go back. Now. Now. Okay. It's a movie. We wanted to play a movie. It's a video. You have time. No problem. Take your time. Yes. Okay, good. This is the ellipse balloon, swallowable balloon. The balloon is in that capsule that the patient swallowed. Here, we are no longer in the endoscopic unit. We are in the radiologic unit. This is a balloon that is not so easy, but it's possible. She looks a little stressed. And with just seven minutes... This woman is our colleague. Not bad. Look, finish. Now we fill the balloon with 550 milliliters of solution. This balloon has a diameter of 12 centimeters. And 600 grams of weight. It stays in the stomach for four months. After four months, it destroys the valve. And it empties and goes away. This is an example. This is a patient. You want to try here? This is the same procedure. Different patient, same procedure. The first patient with lower BMI. This patient with a higher BMI. Okay? Good. The treatment with intragastric balloon is only one part of the complex treatment that the patient needs to receive. And for this reason, the intragastric balloon has to be performed by the team. Why has it to be performed by the team? Because in a patient like this, we have to explain to a patient like this that placing an intragastric balloon is not enough in order to become a woman like this. So we have to explain very well what we are going to do. Indication for intragastric balloon is a prior surgery or in the case of the patient's refused surgery. Or in order to control all comorbidities in patients with lower BMI. In this study with a big number of patients, we achieved an important weight reduction with more or less 7.0 BMI in 3200 more than patients. We have an important problem when treating the patient with intragastric balloon. The problem is what you can see now. That 70% of the overall weight reduction we are able to achieve in the first 3-4 months. After this period, the cold or wet reduction arrived to the plateau. And if we change the diet, even if we give a low-calorie diet, the patient is not able to lose weight. For this reason, we think to treat this patient with two temporary treatments. One temporary treatment option. The first option is an intragastric balloon. The second option is a very low-calorie ketogenic diet. This patient is not able to lose weight with a low-calorie diet, a Mediterranean diet. What happens when we arrive after 4 months and we change the diet in one group of this patient and give a ketogenic calorie diet? It happens what you can see here. It happens that the patients treated with only 2 months of a ketogenic diet are able to lose about 2 points of BMI reduction than the other patients treated with a low-calorie diet alone. This is an example of a patient treated with these two temporary treatments. This is a patient one year later. Now we are going to see another example. Another example of ketogenic use. This is an example, a clinical experience that we have performed just over these last months. I told you that bariatric surgery is the gold standard of treatment of mobile obese patients. This now is the truth. But bariatric surgery is achieved after 5 years in which 20-25% of the patients regain important weight. This is an important problem because when a patient regains 20-25 kg after a bypass, after a cerebral gastrectomy, after 5 years since the first bariatric procedure, if we tell the patient to come with me in the operating room, we go to see to change the operation and we do another second operation. You are crazy. You are able now to put in the operating room just 1.5% of obese patients and you want me to turn in the operating room the second time. For this reason we invented this treatment. This is a patient with sub-permitted to cerebral gastrectomy. As you all know, the cerebral gastrectomy is the most important, the most performed bariatric procedure because it is performed in 52% of all patients. It is effective, it is safe. The weight loss arrives until 50% of excess weight loss. But in 20% of these patients, the patients go against the regain. Regain means achieving a regain of 10 kg from weight loss. And we treat these patients, after 29 patients, 5 years after the cerebral gastrectomy. In 5 years they are able to lose about 16 points of BMI. And over the last year they regained 12 kg. And regaining 12 kg they regained 5 points of BMI. From 27 to 32. We treat this patient with the Mediterranean diet, low calorie Mediterranean diet. No success. A disaster. When we change the diet and add the ketogenic diet, this is the ketogenic diet that you can see now. Here you can see the treatment option we have done. In this patient in 2 months, only 2 months, we were able to reduce the weight of 10 kg. 9 kg during the first phase of 1 month. And 1.5 kg during the second month of the second phase of the treatment. But now we are doing more. And I'm going to finish. We are doing more. We are trying to maintain these patients under ketogenic diet. But we don't know until we treat these patients under ketogenic diet. There are up to now non-important studies comparing ketogenic diet long term. And long term in surgery is 5 years. Compared with the low calorie diet. We are doing on-off. 2 months of very low ketogenic diet and 4 months of Mediterranean diet. Work is in progress. Probably next year, if you invite me, I will bring here the results. On-off treatment. Conclusion, we can use very low calorie ketogenic diet. In bariatric endoscopy, this new field of treatment, we can create bariatric endoscopy therapies to improve the results. Or in bariatric surgery, as a bridge to bariatric operation, in order to control comorbidities and reduce surgical and anesthesiological complications. As weight regain is possible following bariatric surgery, very low calorie ketogenic diet cycles therapy plus lifestyle modification may represent an alternative to re-operation. However, clinic studies involving a huge number of patients are needed. Thank you. The floor is open to any questions. So interesting. Thank you so much. Why do you explain the reduction of liver size? Is fat content that goes away? We explain the reduction of the liver because these are patients with non-alcoholic fatty liver disease. And when we use ketogenic diet, the fat of the liver is reduced. For this reason, we achieve 7 centimeters of volume reduction of the liver. And this is very important because if we have the volume reduction of 7 centimeters, the weight reduction in terms of visceral fat, we can achieve a good volume available for us in order to improve performing the surgical procedure and reduce the possibility of a complication, intraoperative complication. In the same way, the reduction in the length of stay in the hospital, that is significant, that was due to reduction in complications? Or what explains the shorter length of stay? Sorry, can you repeat? I don't hear very well. What explains the reduction in the length of stay in the hospital? So, the shorter hospitalization was due to a reduction in complications? We can explain the reduction in terms of hospital stay because the patient treated with the ketogenic diet has less intraoperative complication. It doesn't go to intensive care unit. Because the first thing that happens immediately when we treat the patient with the ketogenic diet is improving of respiratory function, of all respiratory function. A patient with 50 of BMI submits to gastric bypass probably at the end of operation to go to intensive care unit. The ketogenic diet patient treated goes back immediately to his bed. Very nice talk. Thank you for giving us these novel aspects and opportunities to use very low-calorie ketogenic diets. I have a question for post-bariatric patients. How is the adherence to the very low-calorie ketogenic diets in post-bariatric patients compared to normal patients who did not perform the surgery? Do they accept well? Do they follow easily? The adherence is good or it's worse? They accept very, very well. As accept very, very well all the patients on ketogenic diet. Because when you explain, when you start the ketogenic diet for the first two days you have to be watching my eyes. Okay? Two days, just two days you are going to suffer. But then you will touch with your hands that you will no longer feel hunger. And this is easy for us. This is easy for you. Thank you. Hi, I'm a fellow from Rochester. Very interesting talk. I actually had a question about the complication of hypoglycemia that we usually see after the bariatric procedure. How different it is in those patients who are treated with the low-calorie ketogenic diet in terms of hypoglycemia after the bariatric procedures? Do we have any data? No, up to now there is no study comparing these two things. The hypoglycemia of a bariatric patient is completely different. Because there are hormonal causes that we don't have treating a patient with the ketogenic diet. In this patient we don't arrive to hypoglycemia because if you have seen the glycemia goes from 197 in diabetic patients to 140 or 135. And this is not hypoglycemia. The hypoglycemia of a post-bariatric patient is completely different. Well, there's 30 seconds left. And I just wanted to thank you for bringing it up twice in your talk. That wonderful clinical pearl of satiety. And it has something to do with alterations in ghrelin or normalisation of the regular ghrelin secretion. And those of us who use ketogenic diets, I use isocalorics, three weeks worth of an isocaloric diet and they're not hungry, which is really the clinical pearl that you brought up. I appreciate that. Thank you. Thank you so much.

symposium

keto diets

obesity

immunometabolic effects

ketone bodies

brain function

immune cell metabolism

PCOS

insulin resistance

bariatric surgery

weight loss

metabolic parameters

clinical settings