+Epilepsy and

the Ketogenic Diet

Coral Rudie December 14, 2012

+What is Epilepsy?

 Epilepsy: a brain disorder in which a person has repeated seizures over time.

 Seizures: episodes of disturbed brain activity that causes changes in behavior  Symptoms of seizures can range in individuals from

starring spells to violent convulsions to loss of alertness

 Types of seizures  Absence (petit mal)  Generalized tonic-clonic (grand mal)  Partial (focal)

 Seizures typically begin between ages 5 and 20, but can occur at any age

Board, A.D.A.M. Editorial. "Epilepsy." PubMed Health. U.S. National Library of Medicine, 18 Nov. 0000. Web. 02 Dec. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001714/>. Connolly-Schoonen, Josephine, PhD, RD. "Ketogenic Deit in the Treatment of Epilepsy." Dietetic Internship Seminar. Stony Brook University, Stony Brook, NY. 15 Oct. 2012. Lecture.

+Incidence & Prevalence

 200,000 new cases of epilepsy are diagnosed each year.

 Prevalence of active epilepsy is estimated as nearly 3 million in the United States.

 Incidence is highest in individuals under the age of 2 and over 65.

 326,000 children through age 15 have epilepsy.  More than 300,000 persons over the age of 65

have epilepsy.  Males are slightly more likely to develop

epilepsy than females.

"Incidence and Prevalence." Incidence and Prevalence. Epilepsy Foundation, n.d. Web. 02 Dec. 2012. <http://www.epilepsyfoundation.org/aboutepilepsy/whatisepilepsy/statistics.cfm>.

+Pathophysiology of Epilepsy

  The seizures result from excessive neuronal discharges in the brain

  Seizures may be due to medical conditions, injury to the brain, or idiopathic (unknown)

  Some common causes include:

  For most people, epilepsy is a life long condition

Board, A.D.A.M. Editorial. "Epilepsy." PubMed Health. U.S. National Library of Medicine, 18 Nov. 0000. Web. 02 Dec. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001714/>. Escott-Stump, Sylvia. "Epilepsy/ Seizure Disorders." Nutrition and Diagnosis-related Care. Philadelphia: Lippincott Williams & Wilkins, 2002. 151. Print.

• Stroke/ TIA • Dementia • Traumatic brain injury • Infections (brain abscess, meningitis, encephalitis, and AIDS) • Congenital brain defects

• Metabolism disorders present at birth (phenylketouria) • Brain tumor • Medications (antidepressants, tramadol, cocaine, amephetamines)

+Diagnostic Criteria

  Electroencephalogram (EEG)

  Patient may need to wear EEG for a long period of time to identify abnormal brain activity

  Lab Values

  Blood chemistry, blood sugar, complete blood count, kidney function tests, liver function tests, lumbar puncture (spinal tap), and test for infectious disease

  CT and MRIs are also common

  Patient Medical History

  Family history of seizures

  Associated medical conditions

  Current medications

Board, A.D.A.M. Editorial. "Epilepsy." PubMed Health. U.S. National Library of Medicine, 18 Nov. 0000. Web. 02 Dec. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001714/>. "Diagnosing Epilepsy - WebMD." WebMD. WebMD, 1 June 2012. Web. 02 Dec. 2012. <http://www.webmd.com/epilepsy/guide/diagnosing-epilepsy>. Image: http://www.downwardspiralintothevortex.com/2011/07/sexual-deviation-diagnostic-criteria-in.html

+ Recommended Treatments   Medications

  Anticonvulsants can be taken to prevent seizures   Surgery

  First line of treatment for seizures due to tumors, abnormal blood vessels, bleeding of the brain

  Often used if medications don’t work   Ketogenic diet

  This diet therapy is not a first-line treatment for epilepsy, it is primarily used for children whose seizures are not well controlled by available medications.

  In patients with seizures that result from metabolic disorders, such as glucose transporter type 1 (GLUT-1) deficiency or pyruvate dehydrogenase deficiency the ketogenic diet may be considered first line therapy

  The diet is not appropriate for patients that have metabolic disorders such as: organic acidurias, lipid transport, or storage disorders and pyruvate carboxulate deficiency because a low-carb, high-fat diet would be harmful

Board, A.D.A.M. Editorial. "Epilepsy." PubMed Health. U.S. National Library of Medicine, 18 Nov. 0000. Web. 02 Dec. 2012. Miranda,. "Alternative Diets to the Classical Ketogenic Diet- Can We Be More Liberal?" Epilepsy Reseach 100 (2012): 278-85. Elsevier. Web. 28 Nov. 2012. American Dietetic Association. Nutrition Care Manual®. Epilepsy: Overview/Disease Process/ Biochemical & Nutrition Issues.

+History of the Ketogenic Diet

  Hippocrates

  The Bible

  1924- diet was officially discovered by Dr. Peterman at the Mayo Clinic

  Created a diet that stimulated a fasting state

  1940- decrease in diet popularity due to increasing amount of medications available

  1994- new increase in popularity of the diet, when Jim Abrahams, a movie producer, was searching for alternative treatment for his son’s, Charlie, uncontrollable seizures.

  The family started the Charlie foundation to create awareness about the ketogenic diet

"KetoCalculator -- Ketogenic Diet." KetoCalculator -- Ketogenic Diet. N.p., 2006. Web. 02 Dec. 2012. <https://www.ketocalculator.com/ketocalc/diet.asp>. Image: http://www.charliefoundation.org/

+Rationale for the Ketogenic Diet

 Starvation has been shown to result in decreased seizure activity, however the mechanism is poor understood

 Starvation causes the body to go into acidiosis, ketosis, dehydration, and hypoclycemia

 Thus, the aim of the ketogenic diet is to induce the symptoms of starvation such as ketosis, which can done by restricting carbohydrate intake

 May be due to changes in neuronal metabolism, whereby the ketone bodies behave as inhibitory neurotransmitters, thus having an anticonvulsant effect

American Dietetic Association. Nutrition Care Manual®. Epilepsy: Overview/Disease Process/ Biochemical & Nutrition Issues. http://nutritioncaremanual.org/comtent.cfm?ncm_content_id=83554. Accessed November 20, 2012. Mahan, L. Kathleen, and Sylvia E. Stump. Krause's Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders/Elsevier, 2008. Print.

+Ketogenic Diets

“Classic” Ketogenic Diet- Long Chain Triglycerides   Provides 75% of estimated energy needs   3 to 5 times as much fat as protein and carbohydrates

combined   Ratio of Fat: Carbohydrates and Protein- 3-4:1   Protein: 1g/ kg   Carbohydrates: 5-20g/ day   Fats: 90 % of calories

  Examples: Whipping cream, butter, and other high fat foods

  Can be used for patients on tube feeds   Fluids are carefully controlled not to exceed 2 liters/ day

Miranda,. "Alternative Diets to the Classical Ketogenic Diet- Can We Be More Liberal?" Epilepsy Reseach 100 (2012): 278-85. Elsevier. Web. 28 Nov. 2012. American Dietetic Association. Nutrition Care Manual®. Epilepsy: Overview/Disease Process/ Biochemical & Nutrition Issues.. Connolly-Schoonen, Josephine, PhD, RD. "Ketogenic Deit in the Treatment of Epilepsy." Dietetic Internship Seminar. Stony Brook University, Stony Brook, NY. 15 Oct. 2012. Lecture. Mahan, L. Kathleen, and Sylvia E. Stump. Krause's Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders/Elsevier, 2008. Print.

+Ketogenic Diets

Medium Chain Triglycerides   MCT oils are more ketogenic then LCT fats

  Provides 100% of estimated nutrients needs

  30- 60% of needs come from MCT oils, allows for a more generous amount of carbohydrates and protein

  For the best ketogenic results: 40-50% MCT oils, 10% other fats, 10% protein, 15-19% carbohydrates

  Ratio of Fat: Carbohydrates and Protein- 3:1

  Can be used for patients on tube feeds

  Fluids are not limited

Miranda, Maria J., Zahaav Turner, and Gwyneth Magrath. "Alternative Diets to the Classical Ketogenic Diet- Can We Be More Liberal?" Epilepsy Reseach 100 (2012): 278-85. Elsevier. Web. 28 Nov. 2012. American Dietetic Association. Nutrition Care Manual®. Epilepsy: Overview/Disease Process/ Biochemical & Nutrition Issues. Mahan, L. Kathleen, and Sylvia E. Stump. Krause's Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders/Elsevier, 2008. Print.

+Alternative/ Liberal Ketogenic Diets Modified Atkins Diet

  High fat, low carbohydrates

  Carbohydrate- 10g/ day for children, 20g/day for adults

  Protein is allowed freely and fat is encouraged

  Ratio of Fat: Carbohydrates and Protein- 1:1

  Induces moderate to high ketosis

  Can be initiated on an outpatient basis

  Can be used for patients on tube feeds

Miranda, Maria J., Zahaav Turner, and Gwyneth Magrath. "Alternative Diets to the Classical Ketogenic Diet- Can We Be More Liberal?" Epilepsy Reseach 100 (2012): 278-85. Elsevier. Web. 28 Nov. 2012. "Modified Atkins Diet." Modified Atkins Diet. Charlie Foundation, n.d. Web. 03 Dec. 2012 Image: http://www.bestslimmingpills.org/atkins-diet/

+Alternative/ Liberal Ketogenic Diets Low Glycemic Index Treatment

  CHO: 40-60g of low GI carbohydrates ( GI < 50)

  Ratio of Fat: Carbohydrates and Protein- 0.7:1

  It doesn’t limit protein, fats, fluid, or total calories:

  Protein: 20%

  Fat: 50-60%

  Ketosis is lower than in classic KD

  Not appropriate for children who receive

100% of their nutrition from feeding tubes

  Can be initiated on an outpatient basis

Miranda,. "Alternative Diets to the Classical Ketogenic Diet- Can We Be More Liberal?" Epilepsy Reseach 100 (2012): 278-85. Elsevier. Web. 28 Nov. 2012. "Low Glycemic Index Treatment." Low Glycemic Index Treatment. Charlie Foundation, n.d. Web. 03 Dec. 2012 Image ://ginews.blogspot.com/

+Comparison of Diets

Diet Type Ratio Fat, g Pro, g Carb, g

Ketogenic 4:1 100 (90%) 17 8

3:1 97 18 14

2:1 91 20 26

1:1 77 38-58 20-40

Mod Atkins 1:1 72 (~65%) 52-62 10-15 1st mo, 5 g up to 30

MCT 3:1 97 18 14

Low GI Tx 0.7:1 70 40-60 40-60

Regular 0.2:1 33 (~35%) 35 140

This is based on a 1000 calorie diet

Connolly-Schoonen, Josephine, PhD, RD. "Ketogenic Deit in the Treatment of Epilepsy." Dietetic Internship Seminar. Stony Brook University, Stony Brook, NY. 15 Oct. 2012. Lecture.

+Micronutrient Issues

 Diet is inadequate in many micronutrients  Individuals on the diet will need to take vitamin

and mineral supplements that have carbohydrate free fillers  Nutrients that need to be supplemented:

  Iron  Calcium  Vitamin C  Vitamin D  Vitamin B Complex  Selenium

American Dietetic Association. Nutrition Care Manual®. Epilepsy: Overview/Disease Process/ Biochemical & Nutrition Issues. http://nutritioncaremanual.org/comtent.cfm?ncm_content_id=83554. Accessed November 20, 2012.

+Side Effects of Ketogenic Diet

 Constipation  Kidney stones  Hyperlipidemia/

Dyslipidemia  Hypoglycemia  Hyperuricemia  Gastroesophageal

reflex

 Pancreatitis  Cardiomyopathy  Excessive Ketosis  Dehydration  Unstable medication

levels  Emesis

American Dietetic Association. Nutrition Care Manual®. Epilepsy: Overview/Disease Process/ Biochemical & Nutrition Issues. http://nutritioncaremanual.org/comtent.cfm?ncm_content_id=83554. Accessed November 20, 2012. Connolly-Schoonen, Josephine, PhD, RD. "Ketogenic Deit in the Treatment of Epilepsy." Dietetic Internship Seminar. Stony Brook University, Stony Brook, NY. 15 Oct. 2012. Lecture.

+Treatment Initiation

 The diet is usually initiated gradually in a hospital setting over a 3-4 day period  During the initiation phase blood sugar and ketone

levels are monitored.  Recent studies suggest that it is not necessary to have

a fasting period prior to diet initiation  The modified Atkins diet and the low glycemic index

diet can be initiated from home  Over the next to 3 years patients will need growth

check ups, lab test, nutritional and neurological evaluations and fine tuning of the diet to maximize effectiveness

"KetoCalculator -- Ketogenic Diet." KetoCalculator -- Ketogenic Diet. N.p., 2006. Web. 02 Dec. 2012. <https://www.ketocalculator.com/ketocalc/diet.asp>. "Ketogenic Diet." Ketogenic Diet. Charlie Foundation, n.d. Web. 03 Dec. 2012. <http://www.charliefoundation.org/faq/ketogenic-diet.html>. Mahan, L. Kathleen, and Sylvia E. Stump. Krause's Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders/Elsevier, 2008. Print.

+Sample Meals

Breakfast Lunch Dinner

• 2 eggs, fried in butter • 1 ounce of chopped onion, or other low carb vegetable • 1 oz of full fat cheese • 4 slices bacon • Coffee with 1 oz heavy cream

• 3 cups of salad greens • 6 oz chicken breast strips, cooked in butter or olive oil • 4 T high fat, low carb salad dressing • 1 ounce of full fat cheese • 1 celery stalk with 1 oz cream cheese • water or unsweetened flavored sparkling

• 6 oz grilled or pan fried steak • Mushrooms sauteed in butter • Broccoli or other low carb vegetable • Water beverage • Coffee with heavy cream

"Ketogenic Diet Menu." Ketogenic Diet Resouce. N.p., 2011. Web. 02 Dec. 2012. <http://www.ketogenic-diet-resource.com/ketogenic-diet-menu.html>.

+Cost & Length of Treatment

 Cost of treatment   The diet requires a lot of time, to measure and prepare the

special meals   Financially beneficial, in comparison to total costs of care

and medications   Will need to work with an RD for at least 35 hours

 Length of treatment  The diet tends to show seizure control improvement

after 10 weeks  Patient need to follow the diet for 2-3 years  Tapper diet gradually 2nd and 3rd year

Connolly-Schoonen, Josephine, PhD, RD. "Ketogenic Deit in the Treatment of Epilepsy." Dietetic Internship Seminar. Stony Brook University, Stony Brook, NY. 15 Oct. 2012. Lecture. "KetoCalculator -- Ketogenic Diet." KetoCalculator -- Ketogenic Diet. N.p., 2006. Web. 02 Dec. 2012. <https://www.ketocalculator.com/ketocalc/diet.asp>. ” Ketogenic Diet." Ketogenic Diet. Charlie Foundation, n.d. Web. 03 Dec. 2012. <http://www.charliefoundation.org/faq/ketogenic-diet.html>.

+Efficacy of Treatment

  Compliance to the diet is easiest for pre-school aged children and becomes more difficult as children get older

  Children also have a greater capacity to extract and oxidize ketones

  Many studies have been done on the efficacy of the classic Ketogenic diet, which suggest:

  50% of children will experience at least 50% reduction in seizures on the KD

  one third may achieve a 90% seizure reduction

  10% will eventually become seizure-free and even medication free

"KetoCalculator -- Ketogenic Diet." KetoCalculator -- Ketogenic Diet. N.p., 2006. Web. 02 Dec. 2012. <https://www.ketocalculator.com/ketocalc/diet.asp>. Miranda, Maria J., Zahaav Turner, and Gwyneth Magrath. "Alternative Diets to the Classical Ketogenic Diet- Can We Be More Liberal?" Epilepsy Reseach 100 (2012): 278-85. Elsevier. Web. 28 Nov. 2012. "Ketogenic Diet." Ketogenic Diet. Charlie Foundation, n.d. Web. 03 Dec. 2012. <http://www.charliefoundation.org/faq/ketogenic-diet.html>.

+Efficacy of Treatment

 Modified Atkins Diet   Preliminary evidence from prospective studies showed that

the diet is effective in improving seizure control in 45% of the patients who have trialed it.

  Further pediatric and adult studies are underway.

 Low Glycemic Index Diet (after 6 months of diet)   34% had a >90% reduction

  20% had 50-90% reduction

  20% had <50 % reduction

  26% had no change or increase in seizures.

"Low Glycemic Index Treatment." Low Glycemic Index Treatment. Charlie Foundation, n.d. Web. 03 Dec. 2012. "Modified Atkins Diet." Modified Atkins Diet. Charlie Foundation, n.d. Web. 03 Dec. 2012.

+Summary

 Epilepsy is a brain disorder in which a person has repeated seizures over time.

 A Ketogenic diet can be used to controlled seizures in children who’s seizures are not well controlled by available medications.

 The ketogenic diet is a high fat, very low carbohydrate diet that puts the body into ketosis, which has been shown to reduce the incidence of seizures

 The diet is not without risk and is primarily used as a last resort, since it is difficult to follow and has many adverse side effects

+References   Board, A.D.A.M. Editorial. "Epilepsy." PubMed Health. U.S. National Library of Medicine,

18 Nov. 0000. Web. 02 Dec. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001714/>.

  "Incidence and Prevalence." Incidence and Prevalence. Epilepsy Foundation, n.d. Web. 02 Dec. 2012. <http://www.epilepsyfoundation.org/aboutepilepsy/whatisepilepsy/statistics.cfm>.

  Escott-Stump, Sylvia. "Epilepsy/ Seizure Disorders." Nutrition and Diagnosis-related Care. Philadelphia: Lippincott Williams & Wilkins, 2002. 151. Print.

  "Diagnosing Epilepsy - WebMD." WebMD. WebMD, 1 June 2012. Web. 02 Dec. 2012. <http://www.webmd.com/epilepsy/guide/diagnosing-epilepsy>.

  Miranda, Maria J., Zahaav Turner, and Gwyneth Magrath. "Alternative Diets to the Classical Ketogenic Diet- Can We Be More Liberal?" Epilepsy Reseach 100 (2012): 278-85. Elsevier. Web. 28 Nov. 2012.

  American Dietetic Association. Nutrition Care Manual®. Epilepsy: Overview/Disease Process/ Biochemical & Nutrition Issues. http://nutritioncaremanual.org/comtent.cfm?ncm_content_id=83554. Accessed November 20, 2012.

  "KetoCalculator -- Ketogenic Diet." KetoCalculator -- Ketogenic Diet. N.p., 2006. Web. 02 Dec. 2012. <https://www.ketocalculator.com/ketocalc/diet.asp>.

  "Ketogenic Diet Menu." Ketogenic Diet Resouce. N.p., 2011. Web. 02 Dec. 2012. <http://www.ketogenic-diet-resource.com/ketogenic-diet-menu.html>.

+References (Continued)

  Connolly-Schoonen, Josephine, PhD, RD. "Ketogenic Deit in the Treatment of Epilepsy." Dietetic Internship Seminar. Stony Brook University, Stony Brook, NY. 15 Oct. 2012. Lecture.

  "Ketogenic Diet." Ketogenic Diet. Charlie Foundation, n.d. Web. 03 Dec. 2012. <http://www.charliefoundation.org/faq/ketogenic-diet.html>.

  "Low Glycemic Index Treatment." Low Glycemic Index Treatment. Charlie Foundation, n.d. Web. 03 Dec. 2012. <http://www.charliefoundation.org/faq/low-glycemic-index-treatment.html>.

  "Modified Atkins Diet." Modified Atkins Diet. Charlie Foundation, n.d. Web. 03 Dec. 2012. <http://www.charliefoundation.org/faq/modified-atkins-diet.html>.

  Mahan, L. Kathleen, and Sylvia E. Stump. Krause's Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders/Elsevier, 2008. Print.