NUTRITION MANAGEMENT
KETOGENIC DIETS FOR EPILEPSY: PAST, PRESENT AND FUTURE
This article provides us with a timeline of the ketogenic diet, how it originated and how it has developed over the years, highlighting a 2017 survey that assessed the impact of NICE guidance. A STEP BACK IN TIME
Reports of starvation associated with a reduction or cessation of seizures in people with epilepsy, date as far back as the Hippocrates era. Centuries later, in the Gospels, Mark (9.29, King James Version) described a boy with seizures, which only ‘prayer and fasting’ could cure. In the early 1920s, Dr Wilder, from the Mayo Clinic, proposed to mimic the state of starvation and produce ketosis with a high-fat, low-carbohydrate diet.1 This led to the introduction of the socalled ‘classical ketogenic diet (KD)’, typically with a 4:1 ratio of grams of fat to grams of protein and carbohydrate, as a treatment for people with epilepsy. The initial enthusiasm for the KD was ousted by the discovery of diphenylhydantoin in 1938 and the advent of new easy-to-administer anti-epileptic drugs (AEDs). Although widely used, concerns were quickly raised regarding adverse side effects of these drugs. In the 1970s, in an attempt to make dietary treatment more palatable, Huttenlocher introduced the MediumChain Triglyceride (MCT) KD.2 Based on the premise that MCTs are more ketogenic per calorie, the MCT KD, which originally derived 60% of its calories from MCT oil, allowed a greater bulk of protein and carbohydrate compared with the predominantly long-chain classical KD. A modified MCT KD was later developed, designed to minimise gastrointestinal side effects, which derived 30% of its calories from MCT oil and 41% from long-chain fats.3
KDs experienced a new lease of life in 1994 following NBC-TV’s Dateline report on Charlie Abrahams, who became seizure-free with KD treatment started at Johns Hopkins Hospital, Baltimore. The Charlie Foundation was then formed by Charlie’s father, the film director Jim Abrahams, helping to further publicise dietary treatment in the public and academic domains with the film First Do No Harm in 1997, and supporting the first multicentre prospective study of the classical KD.4 To this day, the foundation continues to provide information for professionals and families regarding KDs.
Dr Natasha Schoeler, UCL Great Ormond Street Institute of Child Health
Kirsty Martin-McGill, University of Liverpool and University of Chester
THE NOUGHTIES
In the early 2000s, Dr Eric Kossoff from Johns Hopkins Hospital, published on the use of the Atkin’s diet as a treatment for epilepsy5 and, later, on the development of the KD variant, the Modified Atkin’s Diet (MAD).6 The MAD was intended as a more liberal alternative to the classical KD, with fats ‘encouraged’ rather than specifically measured and protein ‘unlimited’. In 2005, colleagues from Massachusetts General Hospital published on a further ‘liberalised’ dietary regimen, the Low Glycaemic Index Treatment (LGIT), which aimed to minimise the increase of blood glucose following food consumption rather than producing ketones per se.7 The LGIT allowed a greater intake of carbohydrate (around 60% of total energy) compared with other KD types, with only low-glycaemic index foods allowed.
Victoria Whiteley, Royal Manchester Children’s Hospital
REFERENCES Please visit the Subscriber zone at NHDmag.com
www.NHDmag.com May 2019 - Issue 144
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