|Year : 2019 | Volume
| Issue : 1 | Page : 37-40
Ketogenic Diet- An Evidence Based Direction for Seizure Control
Judie Arulappan1, Suja Karkada1, Sathish Kumar Jayapal2, Vidya Seshan1
1 College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
2 Center of Studies and Research, Directorate of Planning and Studies, Ministry of Health, Sultanate of Oman
|Date of Web Publication||30-Apr-2019|
College of Nursing, Sultan Qaboos University, Muscat
Sultanate of Oman
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The ketogenic diet is a high fat, low carbohydrate and adequate protein diet. This diet is used in treating difficult to control epilepsy in children. The diet helps the body in utilizing fat than carbohydrate. The liver converts fat into fatty acids and ketone bodies. The ketone bodies replace glucose as an energy source. An elevated level of ketone bodies in the blood, a state known as ketosis reduces the frequency of seizure episodes.
|How to cite this article:|
Arulappan J, Karkada S, Jayapal SK, Seshan V. Ketogenic Diet- An Evidence Based Direction for Seizure Control. Int J Nutr Pharmacol Neurol Dis 2019;9:37-40
|How to cite this URL:|
Arulappan J, Karkada S, Jayapal SK, Seshan V. Ketogenic Diet- An Evidence Based Direction for Seizure Control. Int J Nutr Pharmacol Neurol Dis [serial online] 2019 [cited 2019 Dec 8];9:37-40. Available from: http://www.ijnpnd.com/text.asp?2019/9/1/37/257487
| Introduction on Ketogenic Diet|| |
Ketogenic diet (KD) is one of the alternative management options for patients including children and adults whose epilepsy is not controlled with antiepileptic drugs. This therapeutic diet is rich in fat, low in carbohydrate with adequate protein, and controls seizures in patients. In general clinical practice, physicians advise this diet for patients with epilepsy, which should be carefully monitored by a dietitian. Ketogenic diet was initially recommended and designed in 1924 by Dr Russell Wilder at the Mayo Clinic. This diet is also called as “long chain triglyceride diet.” Evidences suggest that ketogenic diet reduces and controls further occurrence of seizures in majority of the patients for whom the seizures are not controlled with medications. A 2015 research finding says that a chemical named “decanoic acid” that is generated as an end product of ketogenic diet helps to control seizures.
| Mechanism of Action of the Ketogenic Diet|| |
The term “ketogenic” implies to ketones. Ketogenic diet produces ketones in the body. Ketones are generated when fat is used by the body for its energy. In general, the body uses carbohydrate for its energy. However, in ketogenic diet the carbohydrates are low and fat in high quantity. Hence, the body uses fat for its energy. When fat is used by the body ketones are produced. Generally, it is believed that ketones are not too dangerous for the body. The ketones are detected in urine, blood, and breath. It is observed that the higher the ketone level, the better is seizure control in patients. A number of children who follow ketogenic diet have a minimum of 50% reduction in the number of seizure attacks. Almost 10%–15% of children or patients with epilepsy become totally seizure free with the consumption of ketogenic diet.
Generally, physicians advise children who follow ketogenic diet to continue taking medications for seizures. Recent research evidence suggests that the dose of medications can be reduced slowly as soon as the diet is started. If the patient skips ketogenic diet, the good effect of the diet may be lost. Hence, it is very essential that the diet is consumed regularly as prescribed. Sometimes, it may be too difficult to follow ketogenic diet at home if the family has other children who eat normal diet. The young children may have access to the places where food is stored, which may tempt them to eat the food that may be non-ketogenic. Therefore, it is recommended that the parents should work in collaboration with the dietitian to make a ketogenic diet plan.
| Carbohydrate, Fat, and Protein Ratio of Ketogenic Diet|| |
Ketogenic diet provides on an average three to four grams of fat for every one gram of carbohydrate and protein. It is recommended that ketogenic diet contains a minimum of 75–100 calories and 1–2 grams of protein for every kilogram of body weight. The ratio of the fat to carbohydrate and protein is known as the “ketogenic diet ratio.” A ratio of 4:1 is recommended for patients with epilepsy. A ratio of 3:1 is advisable for infants, children, and adolescents who require greater amount of protein and carbohydrate for their growth and development.
| Recommended Ketogenic Foods|| |
The most recommended ketogenic foods are butter, cream, mayonnaise, canola, and olive oil. Medium chain triglyceride (MCT) diet is also recommended. This diet reduces cholesterol and triglycerides in the body. This diet can be recommended for patients who cannot tolerate other fats. This diet provides a variety of nutrients that include fat, carbohydrate, and protein. MCT oil can be recommended with a ratio of 60% in children for seizure control. Modified Atkins diet is also recommended since it uses high proportion of fat and restricted quantities of carbohydrate. In this diet, there is no restriction of fluids and calories. Proteins are not restricted in this diet as they provide 35% of energy. Foods such as bacon, eggs, mayonnaise, butter, meat, whipping cream, avocado, nuts, olive oil, and cheese are recommended. Studies have reported that 40%–50% of patients had seizure control and 15% of patients became seizure free. Low glycemic index treatment also can be an alternative for ketogenic diet. This diet monitors the level of glucose in the blood. It reduces the level of glucose and increases the insulin resistance. Carbohydrates having low glycemic index are used in this diet. A total of 40–60 g of carbohydrates are allowed in this diet, which should have low glycemic index. Sixty percent of calories are permitted from fat in this diet. This diet is found to be beneficial in reducing generalized and partial seizures.
| Need for Medicines and Other Nutrients While Consuming Ketogenic Diet|| |
Ketogenic diet does not contain all vitamins and minerals that are available in the balanced diet. The patients should be advised to take vitamin and mineral supplements while on ketogenic diet. They should also consume more of vitamin-D, calcium, iron, and folic acid. The anti-convalescents should be continued while on ketogenic diet. The recent studies show that the medication levels in the blood does not change while the patients are on ketogenic diet.
| Beneficiaries of Ketogenic Diet|| |
The diet is best suitable for various types of seizures and epilepsy syndromes, which include myoclonic astatic epilepsy, infantile spasms, Dravet syndrome, tuberous sclerosis, intractable epilepsy, pyruvate dehydrogenase (PDH) deficiency, mutations in GLUT-1, and children with glycogenosis type V.
| Evidence-based Directions on the Benefits of Ketogenic Diet|| |
It is suggested that ketogenic diet may be beneficial for controlling seizure in few specific epilepsy syndromes.,,, It is emphasized to follow the concept of using dietary therapy for the emergency management of seizures that are resistant to pharmacotherapy.,,,,,,,,
It is well documented in many studies that pediatric and adult patients with status epilepticus had better outcomes with ketogenic diet. Research recommends ketogenic diet for patients with refractory status epilepticus, both for adults and children regardless of their etiology. Various evidences highlight the beneficial effects of ketogenic diet on status epilepticus.,,,,,,,,,,, It is reported that the patients with refractory focal status epilepticus responded well to ketogenic diet within seven days. The patients with status epilepticus were either treated with ketogenic diet, modified Atkin’s diet, or low glycemic index diet. The patients with status epilepticus were treated with ketogenic diet via nasogastric tube, and the diet was effective within 7–10 days. The patients with febrile illness-related epilepsy syndrome can also be considered for treatment with ketogenic diet. For nine patients with status epilepticus, ketogenic diet was introduced through nasogastric tube, and the seizure control was achieved in 4–6 days.
Researchers studying the benefits of ketogenic diet affirm its use for the treatment of status epilepticus. However, to implement the diet in the treatment of such patients requires a ketogenic diet team which includes a trained neurologist and a dietitian. This specialized team will provide the possibility to continue the diet and implement long-term treatment when it is successful.,
| Possible Side Effects of Ketogenic Diet|| |
The patient usually feels tired and dull with a feeling of sluggishness for few days after the diet is started. The symptoms may worsen if the child is sick while starting the ketogenic diet. The healthcare workers should encourage the child and educate the parents to take carbohydrate-free fluids during illness. Kidney stones, hyperlipidemia, dehydration, constipation, slow growth or weight gain, and bone fractures are the common long-term side effects of consuming ketogenic diet. Hunger, lack of energy, and vomiting are also common.,
| Monitoring Patients on Ketogenic Diet|| |
Although the child is on ketogenic diet, the child should be monitored closely every 1–3 months. Blood and urine test should be performed to make sure that the child doesn’t have any other medical problems. The growth should be monitored by measuring the height and weight. As the child gains weight, the diet should be adjusted by the dietitian. The ketone levels should be checked in the blood and urine.
| Time to Stop Ketogenic Diet|| |
The ketogenic diet can be stopped, if the seizures are controlled at least for two years. The diet should be slowly tapered from more to less quantity. Seizures will worsen if the diet is stopped at once. The children should be advised to continue the medicines after they stop consuming the diet. In many situations, ketogenic diet has led to significant seizure control, but not in total. The family members should be advised to follow the ketogenic diet for their children for many years.
| Before, During, and After Treatment with Ketogenic Diet|| |
The patient should be asked to fast on the day and night before starting the diet. The diet will be gradually introduced over several days, so that the body will get used to the change. The children are usually admitted in the epilepsy unit when the ketogenic diet is started. The patient may feel tired and may feel lack of energy during the first few days. The care givers will be trained to prepare the ketogenic diet at home. However, it is highly recommended that ketogenic diet is given to children in a hospital under the supervision of a physician and dietitian.
| Existing Practice on Use of Ketogenic Diet across the World|| |
Though ketogenic diet is found to be beneficial in controlling and preventing seizures, few physicians and dietitians recommend the diet as its cost is high, need close monitoring, besides fear of potential complications.
| Use of Ketogenic Diet in Gulf Cooperation Council (GCC) Countries for Treating Epilepsy|| |
The Arab Gulf countries, namely, Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates have experienced a rapid change in their socio-economic situation, food consumption patterns, and lifestyle and health status during the past four decades. This was mainly caused by the sharp increase in income due to accumulated oil revenues. Communicable diseases have almost diminished and diet-related chronic diseases have become the main health problems. However, under nutrition and micronutrient deficiencies still exist, especially among vulnerable groups. The action needed to promote healthy nutrition and a healthy lifestyle has been emphasized at several meetings in Arab Gulf counties. In 1997, the first workshop on diet, nutrition and a healthy lifestyle in the Arab Gulf countries was held in Manama, Bahrain. Two main recommendations were proposed: establishing food-based dietary guidelines (FBDG) for the Arab Gulf countries, and promoting a healthy lifestyle in these countries.,,
The division of Pediatric Neurology at King Faisal Specialist Hospital & Research Center in Jeddah was one of the few centers that provided ketogenic diet treatment option in the Middle East. Over the last two years, eight children with intractable epilepsy were placed on the ketogenic diet at the center. Overall, 38% (3/8) reached accepted efficacy (>50% seizure reduction), which is lower than the 50% efficacy in published literature. This data is due to poor compliance and follow up.
| Use of Ketogenic Diet in Sultanate of Oman for Treating Epilepsy|| |
In Oman, an attempt was made to establish guidelines on healthy eating. However, these guidelines lacked in some aspects related to the prevention and control of diet-related chronic disease such as reduced intake of salt and added sugar in foods, weight maintenance, and avoiding alcoholic drinks and smoking. Encouraging drinking of water and other liquids were given very little attention. In general, these guidelines were prepared for the people who are responsible to educate the public, but not directed to the public. However, no specific guidelines were developed for treating epilepsy patients with ketogenic diet.
| Challenges in Adhering to Ketogenic Diet|| |
There are no restrictions when the ketogenic diet is given to the children. The cost is less than modern anti-convalescents. The benefits are high in controlling the seizures. However, the fasting and dietary changes are affected by religious and cultural practices. When the food is prepared by a family member other than the parents, they must be well educated about the preparation of the diet. When the family members eat together, it may be too difficult to isolate the child’s meal. In many countries, the food labelling is not mandatory. Hence, the calculation of fat, protein and carbohydrate is very difficult. In some countries, it is hard to find medicines which are sugar free. In many developing countries, the ketogenic diet is expensive, because the diary fats and meat are expensive than grain, fruits and vegetables. However, if these challenges are managed, the ketogenic diet can be highly recommended in people living with epilepsy.
| Future Directions—Ketogenic Diet Caregiver Support Network|| |
The authors recommend starting ketogenic diet counseling sessions for caregivers of children with epilepsy with the joint effort of neuro physician, nurses and dietitian. As a future direction, ketogenic diet caregivers support network may be started to help families of children with epilepsy.
| Conclusion|| |
The ketogenic diet may be successful in the treatment of epilepsy and several rare metabolic diseases. There is evidence from clinical trials that ketogenic diet is more suitable in managing seizure episodes. Hence, the authors recommend the use of ketogenic diet in children with epilepsy. Ketogenic diet has numerous benefits.
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Conflict of interest
The authors declare that there is no conflict of interest regarding the publication of this paper.
| References|| |
Kossoff EH, Zupec-Kania BA, Amark PE, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R et al.
Optimal clinical management of children receiving the ketogenic diet: Recommendations of the International Ketogenic Diet Study Group. Epilepsia 2009;50:304-17.
Wheless JW. History of the ketogenic diet. Epilepsia 2008;49:3-5.
Payne NE, Cross JH, Sander JW, Sisodiya SM. The ketogenic and related diets in adolescents and adults—A review. Epilepsia 2011;52:1941-8.
Bach AC, Babayan VK. Medium-chain triglycerides: An update. Am J Clin Nutr 1982;36:950-62.
Sirven JI, Ozuna J, Schachter SC, Sierzant T, Sherman FT. Diagnosing epilepsy in older adults. Geriatrics 2005;60:30-5.
Neal E, editor. Dietary treatment of epilepsy: Practical implementation of ketogenic therapy. John Wiley & Sons; 2012.
Kossoff EH, Zupec-Kania BA, Rho JM. Ketogenic diets: An update for child neurologists. J Child Neurol 2008;24:979-88.
Caraballo RH, Cersósimo RO, Sakr D, Cresta A, Escobal N, Fejerman N. Ketogenic diet in patients with myoclonic-astatic epilepsy. Epileptic Disord 2013;8:151-5.
Vining EP. Long-term health consequences of epilepsy diet treatments. Epilepsia 2008;49:27-9.
Nangia S, Caraballo RH, Kang H, Nordli DR, Scheffer IE. Is the ketogenic diet effective in specific epilepsy syndromes? Epilepsy Res 2012;100:252-7.
Bodenant M, Moreau C, Sejourne C, Auvin S, Delval A, Cuisset JM et al.
Interest of the ketogenic diet in a refractory status epilepticus in adults. Rev Neurol 2008;164:194-9.
Wusthoff CJ, Kranick SM, Morley JF, Christina Bergqvist AG. The ketogenic diet in treatment of two adults with prolonged non convulsive status epilepticus. Epilepsia 2010;51:1083-5.
Nabbout R, Copioli C, Chipaux M, Chemaly N, Desguerre I, Dulac O et al.
Ketogenic diet also benefits Dravet syndrome patients receiving stiripentol: A prospective pilot study. Epilepsia 2011;52:e54-e7.
Nam SH, Lee BL, Lee CG, Yu HJ, Joo EY, Lee J et al.
The role of ketogenic diet in the treatment of refractory status epilepticus. Epilepsia 2011;52:e181-e4.
Cervenka MC, Terao NN, Bosarge JL, Henry BJ, Klees AA, Morrison PF et al.
E-mail management of the modified Atkins diet for adults with epilepsy is feasible and effective. Epilepsia 2012;53:728-32.
Vaccarezza M, Silva W, Maxit C, Agosta G. Super-re fractory status epilepticus: Treatment with ketogenic diet in pediatrics. Rev Neurol 2012;1:20-5.
Strzelczyk A, Stafstrom CE, Rho JM, editors. Epilepsy and the ketogenic diet. Totowa, NJ: Humana Press 2004.
Strzelczyk A, Reif PS, Bauer S, Belke M, Oertel WH, Knake S et al.
Intravenous initiation and maintenance of ketogenic diet: Proof of concept in super-refractory status epilepticus. Seizure 2013;22:581-3.
Sort R, Born AP, Pedersen KN, Fonsmark L, Uldall P. Ketogenic diet in 3 cases of childhood refractory status epilepticus. Eur J Paediatr Neurol 2013;17:531-6.
Thakur KT, Probasco JC, Hocker SE, Roehl K, Henry B, Kossoff EH et al.
Ketogenic diet for adults in super-refractory status epilepticus. Neurology 2014;25:665-70.
O’Connor SE, Richardson C, Trescher WH, Byler DL, Sather JD, Michael EH et al.
The ketogenic diet for the treatment of pediatric status epilepticus. Pediatr Neurol 2014;50:101-3.
Kumada T, Miyajima T, Kimura N, Saito K, Shimomura H, Oda N et al.
Modified Atkins diet for the treatment of nonconvulsive status epilepticus in children. J Child Neurol 2010;25:485-9.
Kossoff EH, Rowley H, Sinha SR, Vining EPG. A prospective study of the modified Atkins diet for intractable epilepsy in adults. Epilepsia 2013;49:316-9.
Barañano KW, Hartman AL. The ketogenic diet: Uses in epilepsy and other neurologic illnesses. Curr Treat Options Neurol 2008;10:410.
Caraballo RH, Flesler S, Armeno M, Fortini S, Agustinho A, Mestre G et al.
Ketogenic diet in pediatric patients with refractory focal status epilepticus. Epilepsy Res 2014;108:1912-6.
Cross JH, McLellan A, Neal EG, Philip S, Williams E, Williams RE. The ketogenic diet in childhood epilepsy: Where are we now? Arch Dis Child 2010;95:550-3.
MacCracken KA, Scalisi JC. Development and evaluation of a ketogenic diet program. J Am Diet Assoc 1999;99:1554-8.
Hartman AL, Vining EP. Clinical aspects of the ketogenic diet. Epilepsia 2007; 48: 31-42.
van der Louw E, van den Hurk D, Neal E, Leiendecker B, Fitzsimmon G, Dority L et al.
Ketogenic diet guidelines for infants with refractory epilepsy. Eur J Paediatr Neurol 2016;20:798-809.
Kossoff EH, Zupec-Kania BA, Auvin S, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R et al.
Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open 2018;3:175-92.
Bahassan NA, Jan MM. Ketogenic diet. Neurosciences 2006;11:235-40.
Arab Center for Nutrition. Nutritional and health status in the Arab Gulf Countries, Bahrain; 2009. Available from: http://www.acnut.com/
FAO/WHO. Technical consultation on national food-based dietary guidelines. Cairo, Egypt: FAO/Cairo, WHO/EMRO; 2006.
Musiager AO, Miladi S, editors. Proceedings of the workshop on diet nutrition and healthy lifestyle in Arab Gulf countries, Bahrain Medical Bulletin 1998.