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 DOI: 10.1177/0883073813488671

2013 28: 1034 originally published online 13 May 2013J Child NeurolMackenzie C. Cervenka, Bobbie Henry, Janak Nathan, Susan Wood and Jeff S. Volek

Worldwide Dietary Therapies for Adults With Epilepsy and Other Disorders  

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Special Issue Article

Worldwide Dietary Therapies for AdultsWith Epilepsy and Other Disorders

Mackenzie C. Cervenka, MD1, Bobbie Henry, RD2, Janak Nathan, MD3,Susan Wood, RD4, and Jeff S. Volek, PhD, RD5

AbstractDuring the 3rd International Symposium on Dietary Therapies held in Chicago, Illinois, there was a first-ever, half-day sessiondevoted to the management of adults with epilepsy and other disorders with dietary treatments. Speakers from 3 different con-tinents shared their successes, challenges, and future directions in their management of these patients. Diets used to treat adultsincluded the classic ketogenic diet, the modified Atkins diet, and a low glycemic index treatment. The utility of dietary therapieswas demonstrated not only in patients with epilepsy but also patients with propriospinal myoclonus, astrocytoma, type 2 diabetes,obesity, hyperlipidemia, and metabolic disorder. The session provided evidence that dietary therapies are safe and effective inadults.

Keywordsketogenic diet, Atkins, seizure, epilepsy, adult

Received April 1, 2013. Accepted for publication April 1, 2013.

Dietary therapies have been successfully used in treating adults

with medically resistant epilepsy for nearly a century,1 but until

recently, they have been offered primarily in children. There

has been a recent explosion in the interest in managing adult-

hood epilepsy with dietary treatments worldwide, prompting

a 4-hour session at the 3rd International Symposium on Dietary

Therapies in Chicago, Illinois. Lecturers (the authors of this

article) included registered dietitians and physicians from the

United States (MCC, BH, JSV), the United Kingdom (SW),

and India (JN). Speakers presented their dietary protocols, and

while these protocols had many similarities (counting fat and

carbohydrates, measuring ketones, and tracking seizures),

important differences were also discussed. Researchers also

shared preliminary efficacy results. While prior studies have

reported that approximately 30% of adult patients have a

greater than 50% reduction in seizures with dietary therapies,

with fewer than 10% becoming seizure free,2 preliminary

results reported by these groups indicate higher rates of seizure

reduction and seizure elimination among patients treated at

these centers.

Barriers to treatment were identified, including lack of train-

ing, comfort, or familiarity with dietary treatments among prac-

titioners, dietitians, and nutritionists caring for adult patients

with epilepsy. Lack of affordable health care can also limit

access to these treatments. In addition, hesitance on the part

of the health care community can occur out of concern for pos-

sible adverse effects. An entire 60-minute session was devoted

to discussing the benefits of using low-carbohydrate diets in a

variety of conditions in addition to epilepsy (JSV), and cases in

which other neurological conditions were treated with dietary

therapies were discussed (SW).

Overall, this session illustrated the clear benefits of dietary

therapies for adults with epilepsy and other conditions and the

importance of improving education and awareness about diet-

ary treatments to continue to expand their availability to adult

patients with epilepsy worldwide.

Diet Therapies in North America

Adult patients seen at Johns Hopkins Hospital for the dietary

management of seizures are treated at the Adult Epilepsy Diet

Center under the care of an adult neurologist (MCC) and an

adult dietitian (BH) and with consultation from a pediatric

1 Department of Neurology, Johns Hopkins University School of Medicine,

Baltimore, MD, USA2 Institute for Clinical and Translational Research, Johns Hopkins University

School of Medicine, Baltimore, MD, USA3 Department of Neurology, Shushrusha Hospital, Mumbai, India4 Matthew’s Friends, Lingfield, United Kingdom5 Department of Kinesiology, University of Connecticut, Storrs-Mansfield, CT,

USA

Corresponding Author:

Mackenzie C. Cervenka, MD, Johns Hopkins University School of Medicine,

600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287.

Email: Mcerven1@jhmi.edu

Journal of Child Neurology28(8) 1034-1040ª The Author(s) 2013Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0883073813488671jcn.sagepub.com

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neurologist with expertise in dietary treatments (Eric Kossoff,

MD).

The classic ketogenic diet is used for adults receiving the

majority of their nutrition through enteral feedings. Liquid or

powdered ketogenic formulas can meet an adult’s nutrition

requirements, although they can require additional supple-

ments depending on their medical needs (eg, vitamin D

deficiency, osteopenia, or osteoporosis). Patients seen at the

Adult Epilepsy Diet Center who are transitioning from the

pediatric ketogenic diet clinic are continued on the ketogenic

diet with adjustments made as needed to improve seizure

control or address long-term side effects.

For adults considering initiating dietary therapy de novo,

who are independent, employed, and care for dependent chil-

dren or other family members, the modified Atkins diet can

provide a less restrictive and less time-consuming alternative

to the classic ketogenic diet. When starting the ketogenic diet

at Johns Hopkins Hospital, children are admitted for a con-

trolled fast, and they and their families receive several days

of instruction on how to administer the diet. The infrastructure

is not yet in place to offer this for adult patients. Initiation of the

modified Atkins diet does not require hospital admission or

fasting and allows for more flexibility and variety in food and

beverages than the ketogenic diet.

The standard modified Atkins diet protocol used at Johns

Hopkins Hospital includes a diet prescription of a limit of 20

g of net carbohydrates per day with ‘‘high’’ fat and fluid intake.

Depending on the body mass index of the adult, seizure

frequency and severity, serum lipid levels, and side effects, the

carbohydrate limit or total caloric intake can be increased or

decreased, the types and amount of fat can be specified, and

fluid or fiber intake can be increased.

Patients on all dietary therapies monitor their weights

weekly, urine ketones twice a week, and seizure frequency

daily using a seizure calendar, computer spreadsheet, or mobile

application, whichever they find most convenient. Clinicians

review calendars monthly to monitor progress and provide

feedback. The dietitian monitors diet compliance and caloric

intake using food records as needed.

The Adult Epilepsy Diet Center opened in August 2010 and

was established after a need was identified for providing diet-

ary treatment to 3 specific patient populations: children who

have ‘‘graduated’’ from a pediatric ketogenic diet center, adults

already on diet therapies requesting a consultation or continued

follow-up, and adults interested in starting diet therapies.

Clinicians at the center see adults with all seizure types, with

pharmacoresistant epilepsy, and less commonly, patients with

new-onset seizures desiring dietary treatment as monotherapy.

At the time of the Chicago meeting in September 2012, over

70 patients had been seen at the authors’ clinic. The majority of

patients were not on diet therapies at the time of the first visit.

Several had started the ketogenic or modified Atkins diet

before their first visit. Of those on dietary therapies prior to

being seen, the longest diet duration was 36 years. Seizure

diagnoses included localization-related, idiopathic generalized,

and symptomatic epilepsies.

All patients on the ketogenic diet seen at the clinic were

originally started on the diet at an outside hospital or at the

Johns Hopkins Pediatric Ketogenic Diet Center. Their keto-

genic ratios have been maintained, decreased, or tapered com-

pletely to a regular diet, but none have transitioned to other

dietary therapies. Adult patients who came to the center for a

second opinion regarding their current seizure management

with diet therapy—whether the modified Atkins diet, ketogenic

diet, or low glycemic index treatment—were evaluated to

determine whether their diet regimen was optimized and to

screen and manage any side effects.

Of the adults who were naı̈ve to diet therapy, the majority

started the modified Atkins diet, and less than a quarter elected

not to begin the diet because they were in the process of adjust-

ing their anticonvulsant medications or because they felt that it

would be too difficult to follow. Close to 70% of patients who

tried the diet had a greater than 50% reduction in seizures, and

nearly a quarter became seizure free. Most patients saw

improvement within the first week and all but 1 within the first

month. Diagnoses of patients who became seizure free included

localization-related epilepsy, juvenile myoclonic epilepsy,3

Lennox-Gastaut syndrome, tuberous sclerosis, and idiopathic

generalized epilepsy. Over 40% of patients elected to stop the

diet within 3 days to 17 months after starting, and reasons

reported have included side effects, restrictiveness, and inade-

quate seizure control. Side effects encountered included mild

constipation, abdominal pain, weight loss, inadequate micronu-

trients, transient hyperlipidemia, and nephrolithiasis.

Barriers to treatment include lack of familiarity or comfort

with the diet by the patient’s local neurologist, primary care

physician, or other members of the medical community. Few

centers in the United States offer dietary therapy as a treatment

option for adult patients with medically resistant epilepsy and

are not equipped or financed to provide necessary dietitian

support. Future goals in the administration of dietary therapies

to adults in the United States to overcome these barriers are to

increase awareness in the health care community regarding the

safety and efficacy of these therapies and to expand their use

through telemedicine to provide care and guidance to adult

patients without the means to attend outpatient diet clinics.4

Patients have presented with unique circumstances that require

further investigation including dietary therapy during preg-

nancy and as monotherapy and in athletes, adults with status

epilepticus,5-7 and patients with medically resistant idiopathic

generalized epilepsy.3

Diet Therapies in India

At Shushrusha Hospital in Mumbai, India, Dr Janak Nathan

cares for adolescents and adults with medically resistant epi-

lepsy and has used the classic ketogenic diet and studied the

efficacy, compliance, tolerability, and side effects in these

patients since 1996. He works with Dhanashri Khedekar, Sonal

Bailur, and Nida Khan, who have all received their master’s

degrees in clinical nutrition.

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‘‘Indianization’’ of the classic ketogenic diet has been

implemented according to the cultural differences of various

regions in India and also according to the likes and dislikes

of patients. The use of ready-to-eat or ready-to-make foods is

restricted in this diet. A combination of dietary oils has been

recommended to maintain the blood lipid levels within an

acceptable range for all patients.

Dr Nathan’s team prospectively followed 27 adults (mean

age, 26.7 years; age range, 18-57 years) and 17 adolescents

(mean age, 13.75 years; age range, 12-18 years) with uncon-

trolled epilepsy treated with the classic ketogenic diet. Seizure

charts, height and weight measurements, biochemical para-

meters, and electroencephalography recordings were maintained

throughout the treatment period. Tolerability, compliance, and

side effects were noted at every follow-up. Compliance was

graded as good, fair, average, and poor depending on the urine

ketone levels checked 3 to 4 times daily.

In adults, the diet duration was between 2 to 118 months.

Twenty had localization-related epilepsy without an identified

lesion and 7 with an identified lesion. In adolescents, the diet

duration was between 6 to 92 months. Four had localization-

related epilepsy without a lesion and 7 with a lesion, 4 had idio-

pathic generalized epilepsy, and 2 had Lennox-Gastaut

syndrome.

The efficacy rate (90%-99% seizure reduction) was 52% for

adults and 65% for adolescents, while the responder rate (>50%seizure reduction) was 70% for adults and 76% for adolescents.

The time taken to achieve a 90% to 99% reduction in seizures

was 6 to 118 months in adults and 6 to 92 months in adoles-

cents. No correlation was observed between outcome and sei-

zure type, seizure syndrome, compliance, or the ketogenic

ratio.

No major side effects were reported. A mild, reversible side

effect consisted of steatorrhea, which required a short course of

treatment with pancreatic enzymes. Occasional temporary

nausea was reported. A high triglyceride level was observed

in 1 patient, which was corrected with the use of a combination

of dietary oils.

As shown in Table 1, 12 adults elected to stop the ketogenic

diet because they found it too restrictive and 6 due to inade-

quate efficacy. One patient remains on diet therapy. Eighty-

nine percent of patients followed the diet for a year or more.

Ten adolescents stopped the diet because they felt that it was

too restrictive. Seventy-one percent of adolescent patients

followed the diet for a minimum of 1 year.

Diet Therapies in the United Kingdom

Susan Wood is a registered dietitian who works at Matthew’s

Friends in Lingfield, United Kingdom. She has identified a

great need for the provision of adult dietary therapy in the

United Kingdom, with approximately 20 adults on dietetically

supported, medically monitored therapy and 13 adults being

cared for in 12 pediatric ketogenic centers in the United King-

dom due to the lack of adult services (Susan Wood, personal

communication, August 2012). A revision of the United

Kingdom’s National Institute for Clinical Health and Excel-

lence guidance on epilepsy in January 20128 made no mention

of ketogenic diet therapies for adults but did recommend

research into its potential applications. This is an improvement

on the previous National Institute for Clinical Health and

Excellence guidance in 2004 in which it stated that ‘‘the keto-

genic diet should not be recommended for adults with epi-

lepsy.’’ However, it is unlikely that there will be an increase

in the access and funding of ketogenic therapy for adults until

there is publication of randomized controlled trial evidence

indicating that it can deliver improved seizure control and qual-

ity of life in a cost-effective manner. Such a trial is underway in

Norway (ClinicalTrials.gov: NCT01311440) and under discus-

sion in the United Kingdom.

In the meantime, medical and dietetic support are provided

on a case-by-case basis and are variable due to the following:

(1) a lack of clinical ketogenic experience among adult neurol-

ogists and little funded dietetic time, (2) a perception that keto-

genic therapy is ineffective in adults and too difficult to sustain,

and (3) concerns about the wider health implications of high-fat

diets in adults.

Although the majority of adult cases treated in the United

Kingdom have epilepsy alone, 2 cases are described in Table 2

as demonstrating further potential uses of dietary therapies

in adults. Both individuals presented have been on ketogenic

therapy for approximately 16 months and are educated, articu-

late, and tenacious. Considering the barriers to treatment, it is

unlikely that they would have found their way to supported

ketogenic therapy without such self-determination. Dietetic

support was provided charitably by Matthew’s Friends or was

funded by the National Health Services.

Low-Carbohydrate, High-Fat Diets in Adults

Major barriers to the delivery of dietary therapies to adults stem

from the negative perception in the health care community that

Table 1. Patient Retention Rates Among Adolescents and Adults onthe Classic Ketogenic Diet in India.

Retentionrate, mo

Adults (n ¼ 27) Adolescents (n ¼ 17)

Toorestrictive

Inadequateresponse

Toorestrictive

Inadequateresponse

0-6 16-12 2 312-18 4 2 118-24 3 3 (1 died)24-36 1 136-48 1 248-60 160-72 172-7878-8484-90 190-96 1118

1036 Journal of Child Neurology 28(8)

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dietary therapies are unhealthy or dangerous, with concerns

especially about the potential risk of hyperlipidemia in adults

on high-fat diets. The final session at the International Sympo-

sium focused on the administration of low-carbohydrate, high-

fat diets to adults and the evidence supporting their positive

impact on medical conditions such as hyperlipidemia, type 2

diabetes, obesity, metabolic syndrome, and cardiovascular dis-

ease, presented by Dr Jeff S. Volek. He also provided strategies

for avoiding potential side effects of ketogenic diets.

A primary application of very low-carbohydrate ketogenic

diets in adults is in the management of insulin-resistant condi-

tions. Insulin resistance is the hallmark of type 2 diabetes and

is also the primary defect underlying metabolic syndrome.

Metabolic syndrome often presents as dyslipidemia (high

serum triglycerides, low serum high-density lipoprotein, and

a predominance of small low-density lipoprotein particles),

hyperglycemia, hyperinsulinemia, hypertension, vascular dys-

function, and increased inflammation and adiposity. With

respect to carbohydrate metabolism, insulin resistance is asso-

ciated with impairments in hepatic glucose output and skeletal

muscle glucose uptake as well as a greater propensity to convert

glucose to fat (de novo lipogenesis). Thus, insulin resistance is

characterized by the impaired metabolism of carbohydrates, or

in other words, it is a ‘‘carbohydrate-intolerant’’ state that is most

effectively managed by restricting dietary carbohydrates to a

level that can be tolerated.

Several studies have evaluated the efficacy of low-

carbohydrate diets in individuals with insulin resistance. The

results have been overwhelmingly positive, especially when

compliance is high in patients with type 2 diabetes. For exam-

ple, Bistrian et al9 reported the withdrawal of insulin and major

weight loss in a matter of weeks in patients with type 2 diabetes

who were fed a very low-calorie and -carbohydrate diet. Gum-

biner et al10 showed that obese patients with type 2 diabetes fed

a low-calorie diet restricted in carbohydrates led to signifi-

cantly greater improvements in glycemic control and hepatic

Table 2. Two Cases of Adults Treated With Dietary Therapies in the United Kingdom.

Demographicsand diagnosis 22-year-old female with propriospinal myoclonus

47-year-old male with astrocytoma (WorldHealth Organization grade II) and partial seizures

Past medicalhistory

10-year history of propriospinal myoclonus presenting assevere abdominal muscle spasms; medications not effec-tive in managing the frequency or intensity of daily attacks;required 5 to 6 emergency hospital admissions per monthfor intravenous diazepam via a portal catheter; significantimpairment in quality of life and entirely dependent onfamily for support and requiring medical treatment fordepression

3-year history of worsening partial seizures, with an averageof 10 per day; poor level of concentration, inability to keeptrack of conversations, and a general lack of energy andenthusiasm for life

Medications sodium valproate: 400 mg twice a day; levetiracetam:2000 mg twice a day; lacosamide: 400 mg twice a day

Levetiracetam: 1500 mg twice a day; lamotrigine: 200 mgtwice a day; clobazam: 10 mg (AM) and 20 mg (PM)

How they learnedabout ketogenictherapy

Explored the Internet for help Wife heard of it through a work contact

Justification fordiet therapy

All drug options had been tried Could not face any further drug trials

Support offered Treatment was supported by her adult neurologist, and theNational Health Service funded her therapy throughMatthew’s Friends

Neurologist and oncologist would not provide support fordietary therapy; general practitioner provided basicbiochemical monitoring; dietetic support was providedcharitably by Matthew’s Friends

Diet prescribed Modified Atkins diet: 15 g of carbohydrate Modified Atkins diet: 20 g of carbohydrateOutcome During the first year of diet therapy, attacks became less

frequent (with approximately 17-18 spasm-free days permonth), the intensity decreased, and the sodium valproatedose was slowly tapered off; she no longer requiresemergency department visits, and the portal vein catheteris likely to be removed within a few months; she now livesin her own flat with a personal assistant in the daytime onlyand is studying at college and carrying out associatedworkplace training; she is living a life that neither she norher family could have envisioned prior to her treatmentwith ketogenic therapy

Within a few weeks, he reported that the intensity andfrequency of the seizures had decreased; the new-foundstability enabled his neurologist to recommend taperingclobazam, and this was finally withdrawn 8 months aftercommencing ketogenic therapy; this has resulted in a sig-nificant improvement in his concentration and overallenergy levels with no worsening of seizures; he reportsthat ketogenic therapy has given him a huge chunk of hislife back

Side effects Weight loss initially (intentional); elevated total cholesterolinitially but declined throughout the course of treatmentwith an increase in the fraction of high-density lipoproteincholesterol and a decrease in the fraction of low-densitylipoprotein cholesterol

Mild constipation; high total cholesterol initially butsignificantly improved throughout the course of treatmentwith an increase in the fraction of high-density lipoproteincholesterol and a decrease in the fraction of low-densitylipoprotein cholesterol

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glucose output compared to a nonketogenic diet, and the mag-

nitude of improvements was directly related to circulating

ketone levels. Boden et al11 fed obese patients with type 2

diabetes a low-carbohydrate (<20 g/d) diet for 2 weeks and

showed remarkable improvements in plasma glucose, hemo-

globin A1C, and a 75% increase in insulin sensitivity as

determined by the euglycemic hyperinsulinemic clamp. In a

year-long study in patients with type 2 diabetes, Dashti

et al12 showed that a ketogenic diet led to significant weight

loss and improvements in fasting circulating levels of glucose

(–51%), total cholesterol (–29%), high-density lipoprotein cho-

lesterol (63%), low-density lipoprotein cholesterol (–33%), and

triglycerides (–41%). Other studies also support the long-term

efficacy of ketogenic diets in managing the complications

of type 2 diabetes.13,14 Dramatically better results with low-

carbohydrate diets have also been reported in individuals with

metabolic syndrome.15

Despite the positive studies supporting low-carbohydrate

diets for managing insulin resistance, many health care profes-

sionals remain concerned about the higher intake of fat,

especially saturated fat. Of note, 3 recent meta-analyses all

reported no association between saturated fat intake and the

incidence of cardiovascular disease.16,17 Although these find-

ings imply that saturated fat is not a culprit in promoting heart

disease, it is important to distinguish between dietary and cir-

culating levels of saturated fat. Individuals with higher levels

of serum saturated fat have an increased risk of developing

metabolic syndrome,18 diabetes,19 heart attacks,20 and heart

failure.21 Dr Volek’s research group has discovered that dietary

carbohydrate is a primary determinant of serum fatty acid lev-

els. Compared to control patients on a low-fat diet, individuals

consuming a ketogenic diet that had 3 times the quantity of

saturated fat showed less saturated fat in their blood.22 Thus,

dietary saturated fat has little to do with blood saturated fat, but

exceeding one’s carbohydrate tolerance has the likely outcome

of increasing blood levels of saturated fat and the risk for heart

disease.

In summary, individuals with metabolic syndrome, insulin

resistance, and type 2 diabetes (all diseases of carbohydrate

intolerance) are likely to see symptomatic as well as objective

improvements in the biomarkers of disease risk with a well-

formulated very low-carbohydrate diet. A more comprehensive

discussion of what constitutes a well-formulated low-

carbohydrate diet is presented elsewhere,23 but here are a few

key elements.

The magnitude of carbohydrate intolerance varies consider-

ably among people, and therefore, the level of restriction

required to optimize fat loss and achieve metabolic control

varies from person to person. Consumption of less than 50 g

of carbohydrates per day is necessary in most people to elevate

ketones above 0.5 mmol/L, which is the threshold for nutri-

tional ketosis. Ketones serve as a vital fuel source for the brain

and muscles, and recent evidence indicates that there are

modulators of gene expression up-regulating key pathways

involved in the protection from excessive oxidative stress.24

When carbohydrates are restricted to less than 50 g/d, over a

period of approximately 2 to 3 weeks, a process called keto-

adaption occurs in which the body becomes efficient at break-

ing down and burning prodigious amounts of fat. If calories are

restricted, much of that fuel comes from stored body fat.

Protein is important, but it should be consumed in modera-

tion (no more than 2 g per kilogram of body mass). Consuming

excessive amounts of protein can interfere with keto-adaptation,

and it poses an unnecessary stress on nitrogen removal from the

body. Fat calories should be emphasized to provide fuel, flavor,

and satiety. The types of fat to emphasize are the ones that the

body prefers to oxidize, which are saturated and monounsatu-

rated fatty acids.

Salt is a critically important micronutrient, especially in a

low-carbohydrate diet. When carbohydrates are restricted, the

body starts to discard water and salt. It is not uncommon for

people to lose 4 to 5 lb of water weight during the first week

of a low-carbohydrate diet. If that salt is not replaced, the body

responds by trying to retain more salt. This primarily happens

in the kidneys. As a result, the kidneys start to waste potassium,

leading to a negative potassium balance. What does all of this

mean? The loss of water and salt can reduce plasma volume,

resulting in many of the common side effects often attributed

to ketogenic diets (eg, fatigue, fainting, headache, inability to

exercise). Consuming an extra 1 to 2 g of sodium per day

alleviates these effects in most cases.

Other micronutrients and vitamins should also be supple-

mented when low-carbohydrate diets are prescribed. Recom-

mended supplements include a daily multivitamin that

contains zinc, selenium, magnesium, and iron as well as cal-

cium and vitamin D supplements.

Discussion

During the session on treating adults with epilepsy using diet-

ary therapies in the United States, the United Kingdom, and

India, over 100 adult patients were described who either began

the classic ketogenic diet or the modified Atkins diet de novo as

adults or who became adults while being treated with dietary

therapies. In addition, Dr Nathan reported his experience in

treating 17 adolescents with the classic ketogenic diet. Com-

bined, these are the largest number of adult and adolescent

patients reported using dietary therapies in recent years and for

the longest duration (up to 36 years). The largest series previ-

ously reported using the classic ketogenic diet in adults was

of 100 patients described by Barboka1 in 1930. In that series,

an average of 43% of adolescents and adults achieved a greater

than 50% reduction in seizures; of these, 12% became seizure

free. Much more recently, in 2008, Kossoff et al25 reported the

largest number of adults (n ¼ 30) treated with the modified

Atkins diet and found that 47% had a greater than 50% reduc-

tion in seizures after 3 months and that 3% (1 patient) became

seizure free. By comparison, both in adult patients at the Adult

Epilepsy Diet Center using the modified Atkins diet and at

Shushrusha Hospital in Mumbai using the classic ketogenic

diet, over a 50% reduction in seizure frequency was seen in

nearly 70% of adults and in 76% of adolescents. A reduction

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of 90% to 100% was seen in 52% of adults and 65% of adoles-

cents in the population in India on the ketogenic diet, and

seizure elimination was achieved in nearly a quarter of adults

on the modified Atkins diet at the Adult Epilepsy Diet Center.

These efficacy rates are comparable with those in an earlier

study published by Dr Nathan on children with uncontrolled

epilepsy on the ketogenic diet, which reported 59% of children

having a 90% to 100% reduction in seizures.26

In the group from India, better seizure control was observed

with a longer duration of treatment. Syndrome or seizure type

appears not to influence treatment outcome, although others

have reported that individuals with symptomatic generalized

epilepsy27 or multiple seizure types28 can respond better to the

classic ketogenic diet and that patients with juvenile myoclonic

epilepsy can respond well to the modified Atkins diet.3

Patients who stopped the ketogenic diet chose to do so due

to the restrictiveness of the diet. A tendency for poor compli-

ance in individuals older than 12 years29-31 has been reported

compared to younger individuals. Variation has also been

reported in discontinuation rates due to the restrictiveness of

the diet, from 0%32 to 22%.28 Although there were dropouts

during the course of the treatment, 89% of adults and 71% of

adolescents followed the ketogenic diet for a minimum of

1 year. By comparison, over 40% of patients elected to stop the

modified Atkins diet due to restrictiveness, side effects, or

inadequate seizure control.

Side effects were minimal in the group treated with the keto-

genic diet in India. Only 1 patient had elevated serum triglycer-

ide levels, which were then reversed with the use of mixed oils.

Other side effects were mild and reversible and consisted of

steatorrhea, nausea, and constipation. In the United States, the

most common side effects were weight loss (at times, inten-

tional) and transient hyperlipidemia.

The use of dietary therapies for adults with conditions other

than epilepsy or comorbid conditions was also discussed. Susan

Wood presented an adult with propriospinal myoclonus and

another patient with grade II astrocytoma and resultant

seizures, who were successfully treated with the modified

Atkins diet. Both patients had significant symptomatic relief,

improved energy, reduction in medications, and improved

quality of life following treatment with ketogenic therapies.

As with the patients in the United States and India, side effects

reported included weight loss, constipation, and transient

hyperlipidemia that reversed with continued dietary treatment.

Dr Volek described the benefits of low-carbohydrate and

ketogenic diets in adults with type 2 diabetes, hyperlipidemia,

and obesity, which are often comorbid diagnoses experienced

by adults with epilepsy. He provided evidence that serum satu-

rated fat was a greater determinant of the risk for developing

these conditions than saturated fat consumed and that the

increased consumption of carbohydrates had the greatest impact

on increasing serum saturated fat levels. He cautioned against

the use of high-protein diets and recommended increased sodium

consumption in patients on low-carbohydrate diets.

In conclusion, this session provided evidence that dietary

therapies are safe and effective for adults and adolescents with

epilepsy as well as other conditions. Barriers to treatment exist

worldwide, many of which can be overcome with additional

prospective controlled studies showing the efficacy of these

treatments in adults and improved education regarding the ben-

efits and side effects of these therapies in comparison to other

treatment options.

Acknowledgments

Dr Janak Nathan acknowledges Shushrusha Hospital in Mumbai,

India, as well as Dhanashri Khedekar, Sonal Bailur, and Nida Khan,

who all treat patients in Dr Nathan’s Sanjeev clinic. Dr Mackenzie

C. Cervenka and Bobbie Henry acknowledge Dr Eric Kossoff, Joanne

Barnett, Rebecca Fisher, and The Carson Harris Foundation for spon-

soring the center. Susan Wood acknowledges Emma Williams, Eliza-

beth Neal, Val Aldridge, Julie Edwards, Teresa Stein, Professor Helen

Cross, and Dr Archana Desurkar. The authors thank the inspirational

adult patients who, against the odds, find their way to ketogenic

therapy.

Author Contributions

All authors contributed equally to the preparation of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the

research, authorship, and/or publication of this article: Mackenzie C.

Cervenka receive research funding through the Johns Hopkins

School of Medicine Clinician Scientist Career Development Award.

The Adult Epilepsy Diet Center receives financial support from The

Carson Harris Foundation.

Ethical Approval

Informed consent was obtained from all patients or medical decision

makers for inclusion in this publication by the Shushrusha Hospital

Institutional Review Board, the Johns Hopkins School of Medicine

Institutional Review Board, and/or direct patient consent.

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