Ketogenic Diet

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As most people who work in the field of epilepsy treatment are aware, there has been a great deal of interest recently in the use of the ketogenic diet to reduce the severity of seizures in patients with epilepsy, particularly younger patients with very severe disease. The controversy surrounds the reported efficacy of the diet, its unknown mechanism of action, and the difficulty of maintaining it in the context that its value has not been proven in largescale controlled clinical trials. Also, although administration of the diet requires the full participation of a dietitian or nutritionist, many dietitians are not trained to provide this highfat and verylow carbohydrate diet.
with severe epilepsy on the ketogenic diet who experience improvements in mood, behavior, and cognition. Unfortunately, this improvement carries with it an increase in activity, possibly hyperactivity, in terms of awareness and exploration of the surroundings; this may correlate with observations of increased irritability in some children on the diet.
A Practical Approach
In his presentation titled “The Ketogenic Diet Is It Worth The Trouble?” James Wheless, M.D., associate professor at the Texas Comprehensive Epilepsy Program, the University of Texas Medical School in Houston, described the complex approach he uses at this medical center to implement the ketogenic diet. He emphasized that two factors are extremely important: the integration of a team approach and education of the parents and the child. The team should include the epileptologist’s nursing staff and other office personnel (for training and to answer questions) and a dietitian trained in the implementation of this diet. The Table shows the John Hopkins Hospital multicenter protocol used by Dr. Wheless and his group for administration of the ketogenic diet.
Dr. Wheless commented on several of the practical issues involved in implementing the ketogenic diet. “Nutritional labeling of food has made all of this much easier”, was one of his points. Parents undergo an extensive training procedure with a specially trained dietitian on how to prepare ketogenic diet meals and how to shop in supermarkets. The team approach is very important, with the dietitian perhaps being the most important member. One problem is that most dietitians have not been trained to handle this sort of highfat, lowcarbohydrate diet. In terms of education of the parents, Dr. Wheless said he has found it helpful to refer to this whole process as “Ketosis therapy” because if it’s thought of as a medical therapy people have appropriate expectations about its outcome, whereas if it’s thought of as a diet people expect it to be foolproof and without adverse effects. “This is a medical therapy, and like any medical therapy, it can have adverse effects, but we try to balance them against the potential benefit,” said Dr. Wheless.
TABLE
A protocol for administration of the ketogenic diet. Developed as a multicentered research protocol at the Johns Hopkins Hospital, Dr. James Wheless and his group at the University of Texas Medical School in Houston participated in the development of this protocol
Hospitalization for 3 to 5 days
Initial fast
Fluids 67% 75% maintenance
Check urine ketones
Check blood glucose every 6 hours
Initial EEG
Education
Simplify AED regimen
Days 2 3 (urine ketones 160 mg/dL)
Start ketogenic diet 4:1 ratio (onethird total calories using eggnog for 2 3 meals)
Stop Dextrostix
Then twothirds total calories using eggnog per meal for 2 3 meals
Days 3 5
First regular meal on 4:1 ratio diet
Discharge with vitamin B and calcium supplementation
AED regimen
At 1 month
Neurologist, nurse, dietitian
Adjust diet if needed
SMA20, CBC, platelets
Lipoprotein electrophoresis
AED level(s) if needed
3, 6, 12 months
Neurologist, nurse, dietitian
SMA20, CBC, platelets
Lipoprotein electrophoresis
AED level(s) if needed
Maintain for 2 years
Wean over 1 year

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