Keto Diet in Epilepsy

 

What is Ketogenic Diet?

The ketogenic diet is a high-fat, moderate protein, low carbohydrate diet.

When to add the keto diet to epilepsy?  

Diet Therapy is to be started when the subject is having a refractory seizure and no control in seizures observed on the usage of  Anti-epileptic Drugs.

Ketogenic Diet Therapy is effective in-

l Epilepsy: Myoclonic Atonic Seizure (Down Syndrome), Infantile Spasms ( West Syndrome)

l Genetic/IEM: Glut 1 deficiency syndrome, PDHD (The first line of Treatment in these diseases is a ketogenic diet)

l Structural: Tuberous Sclerosis Complex 

l Dravet Syndrome

l Febrile Infection-related epilepsy syndrome (FIRES)

KDT is contradictory for use in -

l Disorders in fatty acid metabolism (Fatty acid transport and oxidation)

l Propofol concurrent use.

l Children with mitochondrial disease.

l Inability to maintain adequate nutrition.

l Patients or caregiver Noncompliance.

So what should be done before it

Criteria For patient Selection for Ketogenic Diet Therapy-

l Type of Epilepsy  

l Age of the Patient.

l Motivation and Compliance

l Failure of anti-epileptic drugs

l Literacy and socioeconomic Factors

l Other Medical Condition  ( Infantile Spasm, Mentally Retarded Children diagnosed  with  Epilepsy )

What is to be done before the Initiation of the Ketogenic Diet?

l Predict Counseling

l Personal History

l Anthropometry

l Medical History

l Diet History

l Investigation -CBC, Serum bicarbonate, Total Protein, Calcium, Liver and Kidney profile, Vitamin D levels, Fasting Lipid Profile, Free and Total Carnitine, Selenium Levels, Anticonvulsant drug levels, EEG, Serum beta-hydroxybutyrate levels (BOH), Urin calcium and creatinine, Zinc Levels, Copper Levels, Renal Ultrasound, Bone mineral density (DEXA scan) after 2 years on the KD.

Carbohydrate washout or Pre Keto Diet-

This diet's main constituents are protein and fats and negligible carbohydrates.

The main target of using this diet is to achieve a ketosis stage of 4+.

 Key Considerations while the subject is on Pre Keto Diet-

l Offering small frequent meals

l Checking of urine ketones

l Diet needed to be followed for 2-3 days to achieve the targeted stage of ketosis

Considerations While planning a Keto Diet-

l Ideal Body Weight

l Calories approx. 80-90% of RDA is given to the child as per his age group

l keto Ratio ( 4:1, 3:1,2:1)

Specification  For Special Categories Patients on Keto Diet -

l Weight of Children ( Either underweight/Overweight)

l For Underweight- 75% of RDA + 100 Kcal

l For Overweight- 75% of RDA -100 Kcal

l Fluid allowance - No restriction on fluid intake as per present research

Steps to be followed to enhance the effectiveness of the Ketogenic Diet

l Make only one change at a time.

l It might Take 15 -30 days to assess the efficacy of the diet.

l Testing of urine should be done for ketosis regularly ( 3-4/ day) around the same time.

   l Ensuring charting is done immediately.

l Warning signs of excess Ketosis to be explained.

 Side effects of Keto Diet-

 

Short Term Effects	Long Term Effects
Hyotension	Growth Retardation
Drowsiness	Nutrient Deficiency ( Anemia, Hypo magnesia, Selenium Deficiency, Zinc Deficiency, Osteopenia
Dehydration	Hyperlipidemia
Nausea
Vomiting
Constipation
Hyperuricemia

 

Factors to be Considered while on Keto Diet

l Offer small frequent meals.

l Use liberal oil ( Prefer a combination of Oils).

l Supplementation of Vitamins and Minerals in Diet.

l In case of Vomiting / decreased appetite seek medical aid.

Follow-Up Considerations For Children for Those KD is initiated

l Anthropometry

l Follow should be done every 3 Months for an individual on KDT (3,6, 9,12) for the first year of KDT after that every six months till the Individual is on Ketogenic Diet Therapy.

l Checking of ketone charts which are maintained by patients.

l Recheck of ketone testing should be done at every visit.

l Variations in recipes served to the patient.

l Evaluations of weighing scales for accuracy.

l Problem of Diarrhea, Constipation, or urine frequency to be addressed at every follow-up.

Laboratory Investigation such as CBC, Serum bicarbonate, Total Protein, Calcium, Liver and Kidney profile, Vitamin D levels, Fasting Lipid Profile, Free and Total Carnitine, Selenium Levels, Anticonvulsant drug levels, EEG, Serum beta-hydroxybutyrate levels (BOH), Urine calcium and creatinine, Zinc Levels, Copper Levels, Renal Ultrasound, Bone mineral density

 Nutrition Recommendations in different   Keto diet

MCT Keto Diet

l In the MCT keto diet 30% of energy is provided by Long Chain triglyceride (LCT ) fat, 30% of energy from MCT, and 40% of Energy from combined carbohydrate( 19%), Protein (10%), and fat( 11%).

l When To initiate MCT Keto Diet?

l Patient is not on Valproate

l Are not on gastric Tube Feeding

l Are Picky Eaters

l Having Large Appetite

l Are older than 1 year of age especially adolescent

Low Glycemic Index Treatment

l In this type of diet 40 - 60 grams of carbohydrates are provided per day.

l Source of carbohydrate is low glycemic  Index food. With a Glycemic index of Up to 50 or Less.

Modified Atkins Diet

l It is a high fat low carbohydrate diet.

l It is used when KD and MCT diets are too restrictive to follow.

Advantages -

l No fasting and hospitalization are required.

l No limit to the time and amount of eating.

l Wider Variety, No constant supervision is needed.

l No calculation and weighing are required.

Disadvantage- 

A consistent level of Ketosis is not achieved in the case of subjects on a modified Atkins diet.