Ketogenic Diets for Epilepsy

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The use of the Ketogenic Diet to treat epilepsy is well established, and continues to evolve. This page is intended to be an introduction that will provide sufficient background for those that are interested to help them pursue the diet further through deeper reading and conversations with their epilepsy healthcare professionals.

1 History

The use of fasting and the Ketogenic diet has a long history[1]. From early times the use of fasting to treat epilepsy was well known, but it was only in the 1920s that the use of a Ketogenic diet emerged to achieve the benefits in a sustainable manner.

1.1 Pre-modern Fasting

It has long been known that fasting is a treatment for epilepsy. As long ago as 500 BC the Hippocratic collection noted fasting as the therapeutic treatment for epilepsy. In the Gospel of Mark, Jesus says that a boy with the symptoms of epilepsy can only be cured with fasting.

1.2 The Emergence of the Ketogenic Diet in the 1920s

The first modern use of fasting to treat epilepsy was 1911, but fasting has the obvious limitation that it cannot be maintained indefinitely without starvation. It was in 1921 that it was first observed that either fasting or a low carbohydrate/high fat diet caused a rise in ketone levels. It was proposed that a low carbohydrate/high fat diet might mimic the benefits of fasting, and by 1925 the first Ketogenic Diet had been formulated. This early diet used 1 gram of protein per Kg of body weight, 10-15g of carbohydrate and the remainder of calories from fat.

1.3 The Rise and Fall of the Ketogenic Diet

The use of the Ketogenic Diet was recorded in almost all text books between 1940 and 1980, and the diet was used extensively in the 1920s and 1930s. When the first anti-epileptic drug was discovered in 1938, the focus of research moved from diet to pharmacology. The rise of the new anti-epilepsy drugs caused the dietary modification approach to fall from favor. As less children were placed on the diet, there was less demand for trained dietitians, which in turn reduced the availability of the diet, creating a positive feedback cycle.

1.4 Charlie, and the Modern Reemergence of the Ketogenic Diet

The Ketogenic Diet came to prominence again with Charlie, a 2 year old boy with intractable epilepsy. Charlie was taken to John Hopkins and put on the Ketogenic Diet out of desperation and he quickly became seizure free. This use of the Ketogenic Diet gained a lot of media attention and Charlie's father started The Charlie Foundation to help support and publicize the use of the Ketogenic Diet. As a result, the Ketogenic Diet is now available for Epilepsy treatment in over 45 countries. However, it still remains a treatment of last resort, even though the results compare favorably with drug treatments.

2 Outline of the Ketogenic Diet

The Ketogenic Diet is normally started during a hospital inpatient stay. This is for monitoring during the initial stages, and to provide suitable education on the diet. The diet typically starts with a short fast, which both helps jump start the production of Ketones and produces sufficient appetite to make it easier for the patient to consume the new foods. After the fasting period, the calorie intake is typically increased in a stepwise fashion; 1/3rd the first day, 2/3rd the second day, then the full allotment from then on[2].

3 Evolution of the Ketogenic Diet for Epilepsy

There have been a number of evolutions to the Ketogenic Diet.

  • Calorie restriction is no longer used. It was believed that having less calories than required for maintenance or growth would improve the success rates on the Ketogenic Diet, but this is no longer believed to be true.
  • Fluid intake is no long restricted. This restriction may have been used as higher urine ketone levels would be seen when dehydrated, but this is an artifact of measuring ketones in the urine rather than a true elevation of ketone levels.
  • New diets have emerged (see below) that are easier to comply with and do not require hospitalization for induction.

4 Success rate for Epilepsy

So far the ketogenic diet has only been widely used on children who have not responded to multiple medications, so the success rate could be quite different if it were applied sooner. Also 'success' can be subjective; for some only a total prevention of all seizures would constitute success, whereas others might consider a reduction in the seizure frequency successful. Generally with the ketogenic diet, around of 50% of patients have a 50% reduction in seizures, 25% have 90% reduction in seizures, and around 10% become seizure free. The success rate also varies with the type of epilepsy – please read chapter 5 ("Is my child a good candidate for the Ketogenic Diet") of Ketogenic Diets: Treatments for Epilepsy and Other Disorders, by Eric H. Kossoff for more details. In adults, weight loss is correlated with better response, though this could be due to the weight loss indicating better compliance with the diet[3]. The experts suggest that if the Ketogenic Diet is going to help with childhood seizures, it will do so within 3 months.

5 Types of Ketogenic Diets for Epilepsy

There are several types of Ketogenic Diet used for epilepsy treatment:

  • Ketogenic Ratio Diet. This diet has strict controls over calorie intake, carbohydrate intake, protein intake and the Ketogenic Ratio, which is typically between 3:1 and 4:1. The diet is normally started with a hospital stay and includes a short fast.
  • MCT Diet. This is a variant of the traditional diet that uses MCT oil that produces more ketones than other oils. This variant allows for a greater carbohydrate intake, and thus freedom of food choices, but MCT tends to cause digestive problems.
  • Modified Atkins Diet (MAD). The MAD started by accident, when a child was put onto the Atkins diet prior to starting the traditional Ketogenic Diet and their seizures stopped. The MAD is stricter than the usual Atkins Diet.
  • Low Glycemic Index Treatment (LGIT). The LGIT restricts the carbohydrate intake to only those foods with a Glycemic Index of less than 50. However, the LGIT is more than just restricting the glycemic index, and requires a fat intake of 60% with a ketogenic ratio of 1:1. The LGIT is similar to the MAD and restricts carbohydrates to 40-60 grams/day.

Here's part of a comparison table available from[4]:

Question Ketogenic Ratio Diet MCT Diet Low Glycemic Index Treatment Modified Atkins Diet
Medical Supervision Yes Yes Yes Yes
High in fat? Yes Yes Yes Yes
Low in Carbs? Yes Yes Yes Yes
Ketogenic Ratio? 4:1 to 1:1 Not ratio based ~1:1 ~1:1
Carbs allowed on 2000 Cal diet? 7g (4:1) to 110g (1:1) 95g 40-60g 20-30g
How is foot measured? Weighed Weighed Weighed or estimated Estimated
Initiation Hospital Hospital Home Home
Calorie controlled? Yes Yes Yes No
Health Checks for the Ketogenic Diet Yes Yes Yes Yes
Side Effects? Yes Yes Yes Yes

6 Notes

  • The Ketogenic Diet has traditionally been fine tuned to maintain urine ketone levels to 3-4+ (80-160 mmol).
  • Studies have shown a correlation between >90% seizure control and lower blood glucose levels.
  • The availability of blood testing for Measuring Ketones is likely to improve our knowledge, as urine testing has rather limited accuracy.
  • It is unclear if the Ketogenic Diet is safe for pregnancy in the general population, but it is probably much safer than anticonvulsant drugs that have known birth defect risks
  • Taking a large drink can cause some (but not all) children to experience 'breakthrough seizures'[5].

7 See Also

8 References

  1. James W. Wheless, History of the ketogenic diet, Epilepsia, volume 49, 2008, pages 3–5, ISSN 00139580, doi 10.1111/j.1528-1167.2008.01821.x
  2. Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2469
  3. Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 4020
  4. YM. Liu, HS. Wang, Medium-chain triglyceride ketogenic diet, an effective treatment for drug-resistant epilepsy and a comparison with other ketogenic diets., Biomed J, volume 36, issue 1, pages 9-15, doi 10.4103/2319-4170.107154, PMID 23515148
  5. Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2220