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The Chemistry of the Ketogenic Diet: Updates and Opportunities in Organic Synthesis International Journal of Molecular Sciences Review The Chemistry of the Ketogenic Diet: Updates and Opportunities in Organic Synthesis Michael Scott Williams * and Edward Turos * Department of Chemistry, University of South Florida, Tampa, FL 33620, USA * Correspondence: [email protected] (M.S.W.); [email protected] (E.T.) Abstract: The high-fat, low-carbohydrate (ketogenic) diet has grown in popularity in the last decade as a weight loss tool. Research into the diet’s effects on the body have revealed a variety of other health benefits. The use of exogenous ketone supplements to confer the benefits of the diet without strict adherence to it represents an exciting new area of focus. Synthetic ketogenic compounds are of particular interest that has received very little emphasis and is an untapped area of focus for chemical synthesis. In this review, we summarize the chemical basis for ketogenicity and opportunities for further advancement of the field. Keywords: ketogenic diet; ketosis; keto; epilepsy; exogenous ketone supplements; acetoacetate; β-hydroxybutyrate 1. Introduction The ketogenic diet, a high-fat, low-carbohydrate diet, has a long history of use begin- ning primarily as a treatment option for epilepsy [1,2]. However, it is only in the last few Citation: Williams, M.S.; Turos, E. decades that the diet has been popularized among the general public. Renewed clinical The Chemistry of the Ketogenic Diet: interest in the diet and its emerging popularity as a weight-loss tool have led to a larger Updates and Opportunities in scope of research into the diet’s effects on the body and the discovery of a broad range of Organic Synthesis. Int. J. Mol. Sci. physical, biochemical, and cosmetic benefits. 2021, 22, 5230. https://doi.org/ Even with expanding research interest in the ketogenic diet, most prior reported 10.3390/ijms22105230 studies have been done in clinical settings or in biology labs [3,4]. Emerging research shows that certain ketogenic supplements can confer some of the benefits of the ketogenic Academic Editor: Roberto Bei diet while following a normal diet [5,6]. Difficulty in adherence to the ketogenic diet is often cited as a reason why it is abandoned due to limited food options. If these obstacles Received: 29 April 2021 can be overcome, a wide array of possibilities may open up. Yet, very little work has Accepted: 12 May 2021 Published: 15 May 2021 been done so far in expanding the options to do this, particularly from the chemistry side. This review will cover the history and health-related aspects of the ketogenic diet and its biochemical basis as well as highlight some exciting opportunities in organic synthesis to Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in devise routes to potential new ketogenic compounds as components or supplements of the published maps and institutional affil- ketogenic diet. iations. 2. History of the Ketogenic Diet Dietary fasting has been a common societal practice in various religions for thousands of years, and as a treatment for epilepsy for over a century. Much of the early reported information is based on the personal experience of cultists and physicians instead of Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. scientifically motivated clinical trials. In 1911, two French physicians Guelpa and Marie This article is an open access article published a report detailing their use of fasting to treat epileptic seizures, in which six of distributed under the terms and their 26 patients showed a reduction in the severity of their seizures or the rate of seizure conditions of the Creative Commons occurrence [7]. No further details were provided. At the American Medical Association Attribution (CC BY) license (https:// convention in 1921, Geyelin presented a report of a controlled study involving 36 epileptic creativecommons.org/licenses/by/ patients who used fasting as a treatment plan [8]. The results showed that 80% of these 4.0/). patients experienced a decrease in the number of seizures. Despite this promising outcome, Int. J. Mol. Sci. 2021, 22, 5230. https://doi.org/10.3390/ijms22105230 https://www.mdpi.com/journal/ijms Int. J. Mol. Sci. 2021, 22, x FOR PEER REVIEW 2 of 18 patients who used fasting as a treatment plan [8]. The results showed that 80% of these patients experienced a decrease in the number of seizures. Despite this promising out- come, fasting saw sporadic use among physicians to try to control epileptic seizures, but Int. J. Mol. Sci. 2021, 22, 5230 no formal clinical trials were done and its use as a long-term trea2tment of 18 method was obvi- ously not viable. Around the same time, research into the use of diet modification to control diabetes fasting saw sporadic use among physicians to try to control epileptic seizures, but no formalmellitus clinical was trials developing. were done and The its use difference as a long-term between treatment type method 1 and was obviouslytype 2 diabetes was not un- notderstood viable. at that time and so there was no distinction made. Newburgh and Marsh re- portedAround the the use same of time,a high-fat, research low-carbohydrate into the use of diet modification diet to tomanage control diabetes diabetics in 1920 [9–11]. In mellitus was developing. The difference between type 1 and type 2 diabetes was not understood1921, Woodyatt at that time published and so there a review was no distinctionarticle on made. the modification Newburgh and Marshof diet to control diabetes reportedmellitus the based use of a on high-fat, his own low-carbohydrate research dietand to that manage of diabeticsPhilip inShaffer, 1920 [9– 11who]. In sought to study the 1921,relationship Woodyatt publishedbetween a acetoacetic review article onacid the and modification glucos ofe in diet vitro to control [12,13]. diabetes It had long been known mellitus based on his own research and that of Philip Shaffer, who sought to study the β relationshipthat diabetic between patients acetoacetic often acid had and glucosean increain vitrosed[12 concentration,13]. It had long been of knownacetoacetic acid, (R)- -hy- thatdroxybutyric diabetic patients acid, often and had acetone an increased in their concentration blood (ketonemia) of acetoacetic and acid, urine (R)-β- (ketourea) based on hydroxybutyricresearch done acid, by and Gerhardt acetone in in their 1865 blood [14]. (ketonemia) These andthree urine compounds (ketourea) based are on collectively known as research done by Gerhardt in 1865 [14]. These three compounds are collectively known as thethe ketone ketone bodies bodies (Figure (Figure1). 1). FigureFigure 1. The1. The Ketone Ketone Bodies. Bodies. This increase in blood concentrations of the ketone bodies had been shown by Geel- mudyenThis in 1897 increase to be caused in blood by an increase concentrations in the metabolism of the of fattyketone acids, bodies due to diabetic had been shown by Geel- patients’mudyen inability in 1897 to metabolize to be caused glucose by at an a rate increase fast enough in the to meet metabolism caloric needs of [15 fatty]. acids, due to dia- This can be dangerous for those with diabetes because unchecked ketonemia can lead tobetic a state patients’ we now know inability as diabetic to metabolize ketoacidosis, whereglucose excess at ketonea rate bodies fast enough acidify the to meet caloric needs blood,[15]. This leading can to be nausea, dangerous weakness, for and those even death.with di Woodyattabetes suggestedbecause aunchecked diet based ketonemia can lead onto Newburgha state we and now Marsh’s know research as diabetic where the ketoacid amount ofosis, carbohydrates where excess consumed ketone did bodies acidify the not exceed the quantity the body could metabolize, and to supplement the diet with fats. Thisblood, prevented leading the to buildup nausea, of sugar weakness, in the blood and (hyperglycemia), even death. oneWoodyatt of the causes suggested of a diet based on ketonemia.Newburgh Woodyatt and Marsh’s believed thatresearch over time, where resting the the am pancreasount of would carbohydrates increase the consumed did not body’sexceed capability the quantity to metabolize the body carbohydrates could metabolize, and a normal diet and could to supplement be resumed. The the diet with fats. This discovery of insulin in 1921 and its use to treat diabetes mellitus starting in 1922 decreased theprevented need for other the treatmentbuildup options, of sugar but in the the interest blood in high-fat, (hyperglycemia), low-carbohydrate one diets of the causes of ketone- continuedmia. Woodyatt to grow [16 believed]. that over time, resting the pancreas would increase the body’s capabilityLater that to same metabolize year, Wilder carbohydrates published a report and based a on normal Geyelin’s diet use ofcould fasting be as aresumed. The discov- treatment for epilepsy and suggested that it may be due to the patients’ ketonemia [17]. Referencingery of insulin Shaffer’s in work,1921 Wilder and its suggested use to inducing treat diabetes ketonemia notmellitus through starting fasting, but in 1922 decreased the throughneed for a high-fat, other low-carbohydratetreatment options, diet he but referred the to inte as therest “ketogenic in high-fat, diet”. Peterman,low-carbohydrate diets con- onetinued of his to colleagues, grow [16]. formulated the optimized amounts of macronutrients for the diet, as being no more than 15 g of carbohydrates a day, 1 g of protein per kilogram of body weight,Later and the that remaining same caloricyear, Wilder deficit made published up of fats. a This report is nearly based identical on Geyelin’s to the use of fasting as moderna treatment ketogenic for diet, epilepsy a 4:1 ratio and of fatssuggested to carbohydrates that it and may protein be due with to amaximum the patients’ ketonemia [17]. allowanceReferencing of 50 gShaffer’s of carbohydrates work, per Wilder day.
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