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Modern nutrition for modern lifestyles We are the forefront of modern nutrition. Shop All Products. Building towards a healthier society We start with inspired science and insights from our community. The use of the ketogenic diet, by this time, restricted to difficult cases such as Lennox—Gastaut syndrome , declined further. In the s, medium-chain triglycerides MCTs were found to 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, and sipped during the meal or incorporated into food.
He tested it on 12 children and adolescents with intractable seizures. 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 M. Freeman at Johns Hopkins Hospital , which had continued to offer the therapy. Under the diet, Charlie's epilepsy was rapidly controlled and his developmental progress resumed. 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. In , Abrahams produced a TV movie, First Do No Harm , starring Meryl Streep, in which a young boy's intractable epilepsy is successfully treated by the ketogenic diet. By , the ketogenic diet was available from around 75 centres in 45 countries, and less restrictive variants, such as the modified Atkins diet, were 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. These studies generally examined a cohort of patients recently treated by the physician a retrospective study and selected patients who had successfully maintained the dietary restrictions. However, these studies are difficult to compare to modern trials. One reason is that these older trials suffered from selection bias , as 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, 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. Concerns over child health and growth led to a relaxation of the diet's restrictions. 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 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 in , looked at 19 studies on a total of 1, patients.
A Cochrane systematic review in found and analysed eleven randomized controlled trials of ketogenic diet in people with epilepsy for whom drugs failed to control their seizures. The other trials compared types of diets or ways of introducing them to make them more tolerable. A systematic review in looked at 16 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 the diet, for various reasons, and the quality of evidence was inferior to studies on children. Health issues include high levels of low-density lipoprotein , high total cholesterol , and weight loss. The ketogenic diet is indicated as an adjunctive additional treatment in children and young people with drug-resistant epilepsy. The two less restrictive dietary variants—the low glycaemic index treatment and the modified Atkins diet—are more appropriate for adolescents and adults, mainly due to better adherence. These include Dravet syndrome , infantile spasms , myoclonic-astatic epilepsy , tuberous sclerosis complex and for children fed by gastrostomy tube.
Several possible explanations exist for this gap between evidence and clinical practice. Because the ketogenic diet alters the body's metabolism, it is a first-line therapy in children with certain congenital metabolic diseases such as pyruvate dehydrogenase E1 deficiency and glucose transporter 1 deficiency syndrome ,  which prevent the body from using carbohydrates as fuel, leading to a dependency on ketone bodies. 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 bodies would consume their own protein stores for fuel, leading to ketoacidosis , and eventually coma and death. The ketogenic diet is usually initiated in combination with the patient's existing anticonvulsant regimen, though patients may be weaned off anticonvulsants if the diet is successful.
Some evidence of synergistic benefits is seen when the diet is combined with the vagus nerve stimulator or with the drug zonisamide , and that the diet may be less successful in children receiving phenobarbital. The ketogenic diet is not considered a benign , holistic, or all-natural treatment. As with any serious medical therapy, it may result in complications, although these are generally less severe and less frequent than with anticonvulsant medication or surgery.
Long-term use of the ketogenic diet in children increases the risk of slowed or stunted growth, 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 class of anticonvulsants known as carbonic anhydrase inhibitors topiramate , zonisamide 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.
However, has not been tested in a prospective controlled trial. 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 on 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. Since any unplanned eating can potentially break the nutritional balance required, some people find the discipline needed to maintain the diet challenging and unpleasant.
Some people terminate the diet or switch to a less demanding diet, like the modified Atkins diet or the low-glycaemic index treatment diet, because they find the difficulties too great. The Johns Hopkins Hospital protocol for initiating the classic ketogenic diet has been widely adopted. At the initial consultation, patients are screened for conditions that may contraindicate the diet. A dietary history is obtained and the parameters of the diet selected: the ketogenic ratio of fat to combined protein and carbohydrate [Note 8] , the calorie requirements and the fluid intake. The day before admission to hospital, the proportion of carbohydrate in the diet may be decreased and the patient begins fasting after his or her evening meal. The following breakfast and lunch are similar, and on the second day, the "eggnog" dinner is increased to two-thirds of a typical meal's caloric content.
By the third day, dinner contains the full calorie quota and is a standard ketogenic meal not "eggnog". After a ketogenic breakfast on the fourth day, the patient is discharged. Where possible, the patient's current medicines are changed to carbohydrate-free formulations. When in the hospital, glucose levels are checked several times daily and the patient is monitored for signs of symptomatic ketosis which can be treated with a small quantity of orange juice. Lack of energy and lethargy are common, but disappear within two weeks.
Variations on the Johns Hopkins protocol are common. The initiation can be performed using outpatient clinics rather than requiring a stay in hospital. Often, no initial fast is used fasting increases the risk of acidosis , hypoglycaemia, and weight loss. Rather than increasing meal sizes over the three-day initiation, some institutions maintain meal size, but alter the ketogenic ratio from to If the diet does not begin with a fast, the time for half of the patients to achieve an improvement is longer two weeks , but the long-term seizure reduction rates are unaffected.
After initiation, the child regularly visits the hospital outpatient clinic where they are seen by the dietitian and neurologist, and various tests and examinations are performed. These are held every three months for the first year and then every six months thereafter. Infants under one year old are seen more frequently, with the initial visit held after just two to four weeks. This fine-tuning is typically done over the telephone with the hospital dietitian  and includes changing the number of calories, altering the ketogenic ratio, or adding some MCT or coconut oils to a classic diet.
A short-lived increase in seizure frequency may occur during illness or if ketone levels fluctuate. The diet may be modified if seizure frequency remains high, or the child is losing weight. Even "sugar-free" food can contain carbohydrates such as maltodextrin , sorbitol , starch , and fructose. The sorbitol content of suntan lotion and other skincare products may be high enough for some to be absorbed through the skin and thus negate ketosis.
This is done by lowering the ketogenic ratio until urinary ketosis is no longer detected, and then lifting all calorie restrictions. When the diet is required to treat certain metabolic diseases, the duration will be longer. The total diet duration is up to the treating ketogenic diet team and parents; durations up to 12 years have been studied and found beneficial. The length of time until recurrence is highly variable, but averages two years. Of those who have a recurrence, just over half can regain freedom from seizures either with anticonvulsants or by returning to the ketogenic diet. Recurrence is more likely if, despite seizure freedom, an electroencephalogram shows epileptiform spikes, which indicate epileptic activity in the brain but are below the level that will cause a seizure.
Recurrence is also likely if an MRI scan shows focal abnormalities for example, as in children with tuberous sclerosis. Such children may remain on the diet longer than average, and children with tuberous sclerosis who achieve seizure freedom could remain on the ketogenic diet indefinitely. The ketogenic diet is calculated by a dietitian for each child. Age, weight, activity levels, culture, and food preferences all affect the meal plan. Highly active children or those with muscle spasticity require more food energy than this; immobile children require less.
The ketogenic ratio of the diet compares the weight of fat to the combined weight of carbohydrate and protein. This is typically , but children who are younger than 18 months, older than 12 years, or who are obese may be started on a ratio. The quantity of fat in the diet can be calculated from the overall energy requirements and the chosen ketogenic ratio. Next, the protein levels are set to allow for growth and body maintenance, and are around 1 g protein for each kg of body weight. Lastly, the amount of carbohydrate is set according to what allowance is left while maintaining the chosen ratio. Any carbohydrate in medications or supplements must be subtracted from this allowance. The total daily amount of fat, protein, and carbohydrate is then evenly divided across the meals.
A computer program such as KetoCalculator may be used to help generate recipes. Only low-carbohydrate fruits and vegetables are allowed, which excludes bananas, potatoes, peas, and corn. Suitable fruits are divided into two groups based on the amount of carbohydrate they contain, and vegetables are similarly divided into two groups. Foods within each of these four groups may be freely substituted to allow for variation without needing to recalculate portion sizes. For example, cooked broccoli, Brussels sprouts, cauliflower, and green beans are all equivalent. Fresh, canned, or frozen foods are equivalent, but raw and cooked vegetables differ, and processed foods are an additional complication. Parents are required to be precise when measuring food quantities on an electronic scale accurate to 1 g.
The child must eat the whole meal and cannot have extra portions; any snacks must be incorporated into the meal plan. A small amount of MCT oil may be used to help with constipation or to increase ketosis. The classic ketogenic diet is not a balanced diet and only contains tiny portions of fresh fruit and vegetables, fortified cereals, and calcium-rich foods. In particular, the B vitamins , calcium , and vitamin D must be artificially supplemented. This is achieved by taking two sugar-free supplements designed for the patient's age: a multivitamin with minerals and calcium with vitamin D.
Normal dietary fat contains mostly long-chain triglycerides LCTs. Medium-chain triglycerides MCTs are more ketogenic than LCTs because they generate more ketones per unit of energy when metabolised. Their use allows for a diet with a lower proportion of fat and a greater proportion of protein and carbohydrate,  leading to more food choices and larger portion sizes. The classical and modified MCT ketogenic diets are equally effective and differences in tolerability are not statistically significant.
First reported in , the idea of using a form of the Atkins diet to treat epilepsy came about after parents and patients discovered that the induction phase of the Atkins diet controlled seizures. The ketogenic diet team at Johns Hopkins Hospital modified the Atkins diet by removing the aim of achieving weight loss, extending the induction phase indefinitely, and specifically encouraging fat consumption.
Compared with the ketogenic diet, the modified Atkins diet MAD places no limit on calories or protein, and the lower overall ketogenic ratio about does not need to be consistently maintained by all meals of the day. The MAD does not begin with a fast or with a stay in hospital and requires less dietitian support than the ketogenic diet. Carbohydrates are initially limited to 10 g per day in children or 20 g per day in adults, and are increased to 20—30 g per day after a month or so, depending on the effect on seizure control or tolerance of the restrictions. Easy-to-Rank Keywords. Easy-to-Rank Keywords This site does not rank for these popular keywords, but they could if they wanted to.
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