The ketogenic diet is a high- fatadequate- proteinlow-carbohydrate diet that in medicine is used primarily to treat seizure plan for adults refractory epilepsy in children. The diet forces the body to burn fats rather than carbohydrates. Normally, the carbohydrates contained in food are converted into glucosewhich is then transported around the body and is particularly important in fueling seizure plan for adults. However, if there is little carbohydrate in the diet, the liver converts fat into fatty acids and ketone bodies.
The ketone bodies pass into the brain and replace glucose as an energy source. An elevated level of ketone bodies in the blood, a state known as ketosisseizure plan for adults, leads to a reduction in the frequency of epileptic seizures. The original therapeutic diet for paediatric epilepsy provides just enough protein for body growth and repair, and sufficient calories [Note 1] to maintain the seizure plan for adults weight for age and height.
The classic therapeutic ketogenic diet was developed for treatment of paediatric epilepsy in the s and was widely used into the next decade, but its popularity waned with the introduction of effective anticonvulsant medications. This classic ketogenic diet contains a 4: This is achieved by excluding high-carbohydrate foods such as starchy fruits seizure plan for adults vegetables, bread, seizure plan for adults, pasta, grains and sugar, while increasing the consumption of foods high in fat such as nuts, seizure plan for adults, cream, and butter.
However, medium-chain triglycerides MCTs —made from fatty acids with shorter carbon chains than LCTs—are more ketogenic. A variant of the classic diet known as the MCT ketogenic diet uses a form of coconut oilwhich is rich in MCTs, to provide around half the calories. As less overall fat is needed in this variant of the diet, a greater proportion of carbohydrate and protein can be consumed, allowing a greater variety of food choices.
The foundation sponsored a multicentre research study, the results of which—announced in —marked the beginning of renewed scientific interest in the diet. Possible therapeutic uses for the ketogenic diet have been studied for various neurological disorders in addition to epilepsy: These occur when cortical neurons fire excessively, hypersynchronouslyor both, leading to temporary disruption of normal brain function.
This might affect, for example, the muscles, the senses, consciousness, or a combination. A seizure can be focal confined to one part of the brain or generalised spread widely throughout the brain and leading to a loss of consciousness.
Epilepsy may occur for a variety of reasons; some forms have been classified into epileptic syndromesmost of which begin in childhood.
Epilepsy is considered refractory not yielding to treatment when two or three anticonvulsant drugs have failed to control it. When drugs fail, other options include epilepsy surgeryvagus nerve stimulation and the ketogenic diet. The ketogenic diet is a mainstream dietary therapy that was developed to reproduce the success and remove the limitations of the non-mainstream use of fasting to treat epilepsy. An early treatise in the Hippocratic CorpusOn seizure plan for adults Sacred Diseasecovers the disease; it dates from c.
Its author argued against the prevailing view that epilepsy was supernatural in origin and cure, and proposed that dietary therapy had a rational and physical basis. The first modern study of fasting as a treatment for epilepsy was in France in Two benefited enormously, but most failed to maintain compliance with the imposed restrictions.
Around this time, Bernarr Macfaddenan American exponent of physical culturepopularised the use of fasting to restore health. His disciple, the osteopathic physician Hugh Conklin, of Battle Creek, Michiganbegan to treat his epilepsy patients by recommending fasting.
Ina Dr McMurray wrote to the New York Medical Journal claiming to have seizure plan for adults treated epilepsy patients with a fast, seizure plan for adults, followed by a starch- and sugar-free diet, since Inseizure plan for adults, prominent endocrinologist H.
Rawle Geyelin reported his experiences to the American Medical Association convention. He achieved similar results despite only having studied the patients for a short time.
Further studies in the s indicated that seizures generally returned after the fast. As professor of paediatrics at Johns Hopkins HospitalJohn Howland used the money to fund research undertaken by neurologist Stanley Cobb and his assistant William G.
InRollin Woodyatt reviewed the research on diet and diabetes. Russell Wilder, at the Mayo Clinicbuilt on this research and coined the term ketogenic diet to describe a diet that produced a high level of ketone bodies in the blood ketonemia through an excess of fat and lack of carbohydrate, seizure plan for adults.
Wilder hoped to obtain the benefits of fasting in seizure plan for adults dietary therapy that could be maintained indefinitely. His trial on a few epilepsy patients in was the first use of the ketogenic diet as a treatment for epilepsy. Peterman documented positive effects improved alertness, behaviour and sleep and adverse effects nausea and vomiting due to excess ketosis, seizure plan for adults. The diet proved to be very successful in children: Bythe diet had also been studied in teenagers and adults.
Although the adult results are similar to modern studies of children, they did not compare as well to seizure plan for adults studies. Barborka concluded that adults were least likely to benefit from the diet, seizure plan for adults, and the use of the ketogenic diet in adults was not studied again until During the s and s, when the only anticonvulsant drugs were the sedative bromides discovered and phenobarbitalthe ketogenic diet was widely used and studied.
This changed in when H. Houston Merritt and Tracy Putnam discovered phenytoin Dilantinand the focus of research shifted to discovering new drugs. With the introduction of sodium valproate in the s, drugs were available to neurologists that were effective across a broad range of epileptic syndromes and seizure types. The use of the ketogenic diet, by this time restricted to difficult cases such as Lennox—Gastaut syndromedeclined further.
In the s, it was discovered that medium-chain triglycerides MCTs produce more ketone bodies per unit of energy than normal dietary fats which are mostly long-chain triglycerides. The oil was mixed with at least twice its volume of skimmed milk, chilled, seizure plan for adults, and sipped during the meal or incorporated into food.
He tested it on twelve children and adolescents with intractable seizures, seizure plan for adults. Most children improved in both seizure control and alertness, results that were similar to the classic ketogenic diet. Gastrointestinal upset was a problem, which led one patient to abandon the diet, but meals were easier to prepare and better accepted by the children.
The two-year-old suffered from epilepsy that had remained uncontrolled by mainstream and alternative therapies. Abrahams discovered a reference to the ketogenic diet in an epilepsy guide for parents and brought Charlie to John Freeman at Johns Hopkins Hospitalwhich had continued to offer the therapy.
This inspired Abrahams to create the Charlie Foundation to promote the diet and fund research. There followed an explosion of scientific interest in the diet. InAbrahams produced a TV movie, Bythe ketogenic diet was available from around 75 centres in 45 countries, and less restrictive variants, seizure plan for adults, such as the modified Atkins dietwere in use, particularly among older children and adults.
The ketogenic diet was also under investigation for the treatment of a wide variety of disorders other than epilepsy. Early studies reported high success rates: These studies generally examined a cohort of patients recently treated by the physician what is known as a retrospective study and selected patients who had successfully maintained the dietary restrictions.
However, seizure plan for adults, these studies are difficult to compare to modern trials. One reason is that these older trials suffered from selection biasas they excluded patients who were unable to start or maintain the diet and thereby selected from patients who would generate better results. In an attempt to control for this bias, seizure plan for adults, modern study design prefers a prospective cohort the patients in the study are chosen before therapy begins in which the results are presented for all patients regardless of whether they started or completed the treatment known as intent-to-treat analysis.
Another difference between older and newer studies is that the type of patients treated with the ketogenic diet has changed over time. When first developed and used, the ketogenic diet was not a treatment of last resort; in contrast, the children in modern studies have already tried and failed a number of anticonvulsant drugs, so may be assumed to have more difficult-to-treat epilepsy. Early and modern studies also differ because the treatment protocol has changed.
A study with an intent-to-treat prospective design was published in by a team from the Johns Hopkins Hospital  and followed-up by a report published in airport pandemic preparedness plan The study enrolled children. Those who had discontinued the diet by this stage did so because it was ineffective, too restrictive or due to illness, and most of those who remained were benefiting from it.
During this period the most common reason for discontinuing the diet was because the children had become seizure-free or significantly better. Those remaining on the diet after this duration were typically not seizure-free but had had an excellent response. It is possible to combine the results of several small studies to produce evidence that is stronger than that available from each study alone—a statistical method known as meta-analysis.
One of four such analyses, conducted inlooked at 19 studies on a seizure plan for adults of 1, seizure plan for adults, patients. A systematic review in found and analysed seven randomized controlled trials of ketogenic diet in children and young people with epilepsy.
A systematic review in looked at sixteen studies on the ketogenic diet in adults. It concluded that the treatment was becoming more popular for that group of patients, that the efficacy in adults was similar to children, the side effects relatively mild. However, many patients gave up with the diet, for various reasons, and the quality of evidence inferior to studies on seizure plan for adults. Health issues include high levels of low-density lipoprotein LDLhigh total cholesteroland weight loss.
The ketogenic diet is indicated as an adjunctive additional treatment in children and young people with drug-resistant epilepsy. Some clinicians consider the two less restrictive dietary variants—the low glycaemic index treatment and the modified Atkins diet—to be more appropriate for adolescents and adults. These include Dravet syndromeinfantile spasmsmyoclonic-astatic epilepsy and tuberous sclerosis complex. There are several possible explanations for this gap between evidence and clinical practice.
The ketogenic diet is beneficial in treating the seizures and some other symptoms in these diseases and is an absolute indication.
On the ketogenic diet, their body would consume its own protein stores for fuel, leading to ketoacidosisand eventually coma and death.
There is some evidence of synergistic benefits when the diet is combined with the vagus nerve stimulator or with the drug zonisamideand that the diet may be less successful in children receiving phenobarbital. As with any serious medical therapy, the ketogenic diet may have complications. Long-term use of the ketogenic diet in children increases the risk of slowed or stunted growth, seizure plan for adults, bone fractures and kidney stones. Like many anticonvulsant drugs, the ketogenic diet has an adverse effect on bone health.
Many factors may be involved such as acidosis and suppressed growth hormone. A seizure plan for adults of anticonvulsants known as carbonic anhydrase inhibitors topiramatezonisamide are known to increase the risk of kidney stones, but the combination of these anticonvulsants and the ketogenic diet does not appear to elevate the risk above that of the diet alone.
In adolescent and adults, common side effects reported include weight loss, constipation, dyslipidemia and, in women, dysmenorrhea. The ketogenic diet is a medical nutrition therapy that involves participants from various disciplines. Team members include a registered paediatric dietitian who coordinates the diet programme; a paediatric neurologist who is experienced in offering the ketogenic diet; and a registered nurse who is familiar with childhood epilepsy.
Additional help may come from a medical social worker who works with the family and a pharmacist who can advise seizure plan for adults the carbohydrate content of medicines. Lastly, the parents and other caregivers must be educated in many aspects of the diet for it to be safely implemented.
Implementing the diet can present difficulties for caregivers and the patient due to the time commitment involved in measuring and planning meals, seizure plan for adults. Since any unplanned eating can potentially break the nutritional balance required, some people find the discipline needed to maintain the diet challenging and unpleasant.