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Dietary treatments for epilepsy now safer and easier.

EXPERT ANALYSIS AT AES 2013

WASHINGTON - Advances in dietary therapy for nonlesional epilepsy have made it a more feasible approach for many patients because of options that now include a "smarter and gentler" ketogenic diet and a modified Atkins diet, Dr. Eric Kossoff said at the annual meeting of the American Epilepsy Society.

"We've come a long way in making diets easier, safer, [and] more palatable, and that's really opened up many different options for patients who didn't have diet as an option before," said Dr. Kossoff, a pediatric neurologist at Johns Hopkins Children's Center, Baltimore. For patients with nonlesional epilepsy, diets can be helpful--sometimes even resulting in seizure freedom--and should be considered earlier in the course of treatment, he added.

Most of his discussion focused on pediatric patients, but he said that some children continue the diet into adulthood, and there is increasing interest in the potential of dietary approaches, particularly a modified Atkins diet, for adults with nonle-sional epilepsy. Adult epilepsy diet centers also are starting to appear in large U.S. cities and internationally.

The currently recommended ketogenic diet (high fat, moderate protein, and low carbohydrate) is far less rigid and restrictive than the traditional ketogenic diet used for more than 80 years, which entailed starting the diet in the hospital with intensive dietician involvement, precisely weighing food with a gram scale, and following the diet for 6 months to 2 years, he pointed out. Dieticians have more leeway in making the diet more palatable, with resources like the online Keto-Calculator program that helps families plan and create meals.

There is now more information that health care practitioners can use to predict the type of patient more likely to respond to diet. Fasting and hospital admission are no longer needed, and adverse events are anticipated and prevented, not treated, said Dr. Kos-soff, medical director of the Ketogenic Diet Center at the John M. Freeman Pediatric Epilepsy Center at Johns Hopkins. In a 2007 study of diet in 45 children with lesional epilepsy, there was some response to diet, but none of the children were seizure free (Seizure 2007;16:615-9). At Johns Hopkins and other epilepsy centers in the United States and elsewhere, the ketogenic diet is mostly recommended as a treatment for nonlesional epilepsy, based on this study and anecdotal experience, with the exception of tuberous sderosis, he added.

In addition, clinical data from multiple prospective and retrospective studies have provided solid evidence that the diet can be effective, he said. These include "dramatic" results of a randomized controlled study, which found that 38% of the children on the ketogenic diet had more than a 50% reduction in baseline seizures after 3 months, compared with 6% of controls (Lancet Neurol. 2008;7:500-6). "This really did change a lot of mindsets that diet had not been proven," he said. Based on the results of the available studies combined, there is about a 50%-55% likelihood of a response with diet and about a 15% likelihood of being seizure free, he noted.

The need to fast is now being reconsidered by most centers, Dr. Kos- soff said. A 2005 randomized controlled study that compared the effects of starting the diet with fasting to gradually introducing the diet without a fasting period found that while fasting resulted in a more rapid rise in serum ketones, seizure-free and seizure-reduction rates at 3 months were similar in both groups. Fasting can be viewed as "an IV load of a ketogenic diet," he added. "It gets the seizure improvement to occur quicker, but long term, it doesn't seem to make much of a difference."

Improvements in addressing weight loss, vomiting, constipation, and other potential side effects of the ketogenic diet include the use of supplements such as multivitamins, vitamin D, and selenium, as well as laxatives. At Johns Hopkins, Dr. Kossoff and his associates have found that the use of oral citrates reduces the risk of kidney stones associated with the diet to less than 1% (from about 5%-6%).

Traditionally, the ketogenic diet has been recommended for up to 2 years, but most studies indicate that patients who will benefit will start to respond within 2-4 weeks, and it is not necessary to wait for 6 months to see if they respond. He and his asso-dates recommend waiting for at least 3 months to see if a patient responds.

Traditionally, 2 years on the diet has been recommended, but there are studies indicating a shorter period of time may be adequate. Some patients, however, have a recurrence when they stop the diet and need to continue the diet into adulthood for as long as 20-30 years, if necessary.

In addition to the classic ketogenic diet, Dr. Kossoff described several other less restrictive dietary treatment options. The modified Atkins diet falls between a regular diet and a classic ketogenic diet, with high fat (about 65% vs. about 90% with the dassic ketogenic diet) and low carbohydrates. Also with the modified Atkins diet, there is no need to fast, restrict calories or fluids, hospitalize the patient, or weigh food on a gram scale. Over a decade, 32 studies involving 400 patients treated with this approach, including 17 prospective studies, have provided evidence that the diet is effective, with almost a 50% responder rate and a 13% seizure-free rate, "remarkably similar to what we see with a classic ketogenic diet," he noted.

This is the dietary approach most likely to be used in adults, he added.

The Low Glycemic Index diet is also a high-fat, low-carbohydrate diet, but it primarily targets the type of carbohydrates in the diet, aiming for a glycemic index of less than 50. Interestingly, this diet does induce urinary ketosis but is effective, "suggesting that these diets may work by mechanisms we are not completely sure of, not necessarily ketosis," Dr. Kossoff said.

Dr. Kossoff had no disclosures. He was lead author of the International Ketogenic Diet Study Group's recommendations on the ketogenic diet in children (Epilepsia 2009;50:304-17).

emechcatie@frontlinemedcom.com

Caption: Studies show a 50%-55% likelihood of a response with diet and a 15% likelihood of being seizure free.

Caption: DR. KOSSOFF
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Title Annotation:NEUROLOGY
Author:Mechcatie, Elizabeth
Publication:Clinical Psychiatry News
Date:Feb 1, 2014
Words:1027
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