Ketogenic Diet for Epilepsy

Description of the Diet and Sample Menu

Testing for Seizures. Photo: Getty Images/Keith Brofsky

The ketogenic diet for epilepsy is a special diet which has helped many children and some adults achieve better (or even full) control of their seizures. It is a first-line treatment for a few specific epilepsy syndromes, such as epilepsy due to mutations in GLUT-1 or pyruvate dehydrogenase deficiency.

History of the Ketogenic Diet for Epilepsy

The ketogenic diet for epilepsy (KDE) was developed in the 1920s by Dr. Hugh Conklin in Michigan.

But once effective medications were developed, the diet was used less frequently. It has regained recognition and study and is now a standard backup plan for children whose epilepsy is difficult to control with medication. With over 300,000 children in the U.S. with seizure disorders, this has become an important addition to the arsenal of treatments for epilepsy. Researchers are beginning to see how it might help adults and people with a variety of neurologic disorders.

It is vital that anyone using this diet for a seizure disorder do it under the supervision of an experienced physician and dietitian. There are many nuances and individual variations that will influence the exact diet for each person, and coordinating this with medications can be tricky. This is not something that should ever be attempted on your own.

Basics of the Ketogenic Diet for Epilepsy

The ketogenic diet for epilepsy is a very high-fat diet, with just enough protein for body maintenance and growth, and very low amounts of carbohydrate.

In the ketogenic state, the body generates molecules called ketones (also called ketone bodies) when fats are metabolized. The goal of the KDE is for the brain to use ketones for energy rather than glucose as much as possible. Ketones are (largely) water-soluble, so they are easily transported to the brain.

The brain cannot use fatty acids for energy, but it can use ketones for a large portion of its energy requirements. 

The KDE is usually begun in a hospital setting, and often begins with a one- to two-day fasting period (though there may be a trend away from both of these requirements). After determining the proper amount of protein (depending on age, etc.), the diet is structured as a ratio of fat grams to protein grams plus carb grams. It usually begins with a 4 to 1 ratio, and then can be fine-tuned from there. The diet is often calorie-limited and fluid-limited as well. Additionally, no packaged "low-carb foods" (shakes, bars, etc.) are allowed for at least the first month.

Because a gram of fat has more than twice the calories of a gram of protein or carbohydrate, this equation means that at least 90 percent of the calories in the diet come from fat. This is a very strict diet, and it takes time to learn how to put together meals that fit the formula. All food must be weighed and recorded.

Weaning off the diet is attempted after two years, though some children are kept on the diet for longer.

A Typical Day's Menu

Below is a shortened description of a menu appearing in the paper, "The Ketogenic and Atkins Diets: Recipes for Seizure Control," Practical Gastroenterology, June 2006.

 It's meant to give the idea of what children eat on the diet, not an exact prescription. Remember, all of these foods are carefully weighed and measured.

  • Breakfast: Eggs made with heavy cream and butter, bacon, small piece of fruit
  • Lunch: Tuna salad (made with mayo and heavy cream) on lettuce
  • Dinner: Cheeseburger made with extra fat, small salad, green beans
  • Snacks: "Keto custard" made from egg and heavy cream. "Keto yogurt" made by mixing sour cream, heavy cream, and a small amount of fruit. "Peanut butter balls"  a mixture of peanut butter and butter

Variations of this plan substitute coconut oil or MCT oil for some of the heavy cream and butter.

Another sample menu appears in "The Ketogenic Diet: A Practical Guide for Pediatricians," Pediatric Annals, December 2016.

How Effective is the Ketogenic Diet for Epilepsy?

Studies generally show that about a third of patients will have at least a 90 percent reduction in seizures, and another third will experience a 50 percent to 90 percent reduction. This is remarkable, considering that these patients are generally those whose seizures are not well-controlled with medications. Note that the term "epilepsy" encompasses a group of disorders with different causes that are not all fully understood, which is part of the reason different people respond to different treatments.

Why Does the Diet Work?

There are a few theories about how and why the diet works, but no one knows for sure. Changes in neurotransmitters, gene expression, and influences on neuron receptors are some of the possibilities.

Alternatives to the Super-Strict Ketogenic Diet

A popular alternative that helps many is called the Modified Atkins Diet. This diet is far less restrictive, as calories, fluids, and protein are not measured. The diet begins with 10 grams of carbohydrate per day for the first month, and then slowly moving to 15 or 20 grams. It is similar to a very strict ​induction phase of Atkins. There has been at least one study, though, where some achieved better seizure control when they switched from the Atkins diet to the KDE.

Can Adults With Seizures Benefit From the Ketogenic Diet?

There have been a few studies of the modified Atkins Diet in adults with seizure disorders, and the results are similar to studies with children. Interestingly, it was remarked in one of the reports that it was more difficult to keep adults on the diet since they obviously have more control over what they eat. Research is still limited in this area and more trials are needed.

Sources:

Kossoff, et al. Will seizure control improve by switching from the modified Atkins diet to the traditional ketogenic diet? Epilepsia 51:12 (2010) 2496-2400.

Luat AF, Coyle L, Kamat D. The Ketogenic Diet: A Practical Guide for Pediatricians. Pediatric Annals. 2016;45(12). doi:10.3928/19382359-20161109-01.

Lutas A, Yellen G The ketogenic diet: metabolic influences on brain excitability and epilepsy. Trends in Neurosciences. 36:1 (2013) 32-40

Martin K, Jackson CF, Levy RG, Cooper PN. Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database of Systematic Reviews. September 2016. doi:10.1002/14651858.cd001903.pub3. 

Weber S, et al. Modified Atkins diet for children and adolescents with medial intractable epilepsy. Seizure. 18:4 (2009) 237-240

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