The Ketogenic Diet

introduction
• high-fat,
• adequate protein,
• lowcarbohydrate diet

• used for the treatment of intractable

childhood epilepsy since the 1920s.
 history
• Jesus
• Huge conklin-1921,water diet
• Geyelin-1921,AMA convention
• Phenytoin-1938
• Charlie foundation-1992
Conklin paper
Mechanisms of action
 Mechanisms of action
• Ketone bodies-GABA
• Increased expression ofGlial fibrillary acidic
protein(GFAP) in dentate gyrus of
hippocampus
• Depressive effect on synoptic reorganisation
 Mechanisms of action
• Calorie restriction alone has been
demonstrated in mice to impair seizure
susceptibility. this may activate ATP sensitive
potassium channels that may critically be
involved in the regulation of seizure activity.
 Indications

• several epilepsy syndromes,

• particularly in myoclonic astatic epilepsy,
Dravets syndrome, and tuberous sclerosis
• focal and generalised epilepsy
s
 Calculation of the ketogenic diet
• The ratio of fats to carbohydrates and protein
is based on the age, size, weight and activity
level of the patient.
• A young child or infant often receives a 3 :1
diet to provide additional protein.
• Older children will receive a 4:1 diet with the
exception of obese children(3:1).
• Adolescents will often be started on a 3 :1 diet
 Calculation of the ketogenic diet
• Calories targeted at 75% of the recommended
daily intake for age
• overweight children may be given only
25-30% of the recommended calories until
they approach their ideal body weight.
• Fluids are targeted at 80% of daily needs
Initiation of the ketogenic diet
Maintaining ketosis
 Types of KD
• Classic,FAT:CHO+PRO-4:1
• MCT oil,3:1
• Modified Atkins, 60% fat, 30% protein and
10% carbohydrate
Ketogenic meals
 KD classic diet,1500 kcal
• Breakfast: egg with bacon
28 g egg, 11 g bacon, 37 g of 36% heavy whipping cream, 23 g butter, 9 g apple.

• Snack: peanut butter ball

,6 g peanut butter, 9 g butter.

• Lunch: tuna salad ,

28 g tuna fish, 30 g mayonnaise, 10 g celery, 36 g of 36% heavy whipping cream and 15 g lettuce.

• Snack: keto yogurt

18 g of 36% heavy whipping cream, 17 g sour cream, 4 g strawberries and artificial sweetener.
• Dinner: cheeseburger
22 g minced (ground) beef, 10 g American cheese, 26 g butter, 38 g cream, 10 g lettuce and 11 g green
beans.
• Snack: keto custard
25 g of 36% heavy whipping cream, 9 g egg and pure vanilla flavouring
KD LIQUID
KD POWDER
Efficacy of the ketogenic diet at 3, 6 and 12 months, showing the percentage
of children in each outcome category. From a prospective study of 150

children treated at Johns Hopkins Hospital

 Seizure control at 6 months at 12 months
over 90% 48 (31%) 41 (27%)
Number initiating the diet:
50-90% 29 (19%) 30 (20%)
150
under 50% 29 (19%) 8 (5%)
Number continuing the diet 106 (71%) 83 (55%)
 Cochrane review

• In 2003, a Cochrane review of the published literature found there were

no randomised controlled trials on the ketogenic diet.

• The review concluded that there was "no reliable evidence from
randomised controlled trials to support the use of ketogenic diets for
people with epilepsy" and stated that the diet was merely "a possible
option" in the treatment of intractable epilepsy
 Neurologists survey
• A survey in 2005 of 88 paediatric neurologists in the
US found that
• 36% regularly prescribed the diet after three or
more drugs had failed;
• 24% occasionally prescribed the diet as a last resort;
• 24% had only prescribed the diet in a few rare cases;
• 16% had never prescribed the diet.
• There are several possible explanations for this gap
between the evidence and clinical practice
 efficacy
• The first randomised controlled trial was published in 2008, which had an
intent-to-treat prospective design, but no blinding.
• It studied 145 children, half of whom started the ketogenic diet
immediately, and half after a three-month delay.
• Of the children in the diet group, 38% had at least a 50% reduction
in seizure frequency,
• 7% had at least a 90% reduction;
• one child became seizure-free.
• Only 6% of the control group saw a greater than 50% reduction in
seizure frequency and no children had a 90% reduction.
• The mean seizure frequency of the diet group fell by a third;
• the control group's mean seizure frequency actually got worse
Neal EG, Chaffe HM, Schwartz RH et al. The ketogenic diet for the treatment
of childhood epilepsy: a randomised controlled trial. Lancet Neurol 2008;
 RCT contd
• the ketogenic diet group were further
randomised to receive either the MCT diet or
the classical diet; results showed there was no
significant difference in the responder rates or
mean reduction in seizure frequency between
the two groups.
• Neal EG, Chaffe HM, Schwartz RH et al. A randomised controlled trial of
classical and medium chain triglyceride ketogenic diets in the treatment of
childhood epilepsy. Epilepsia 2008;
Side-effects
 nephrolithiasis
• hypercalciuria occurs due to increased bone
demineralisation with acidosis (bone
phosphate acts as an acid buffer)
• hypocitraturia, which normally helps to
dissolve free calcium.
• The urine has a low pH, which stops uric acid
from dissolving, leading to crystals that act as
a nidus for calcium stone formation.
• Many institutions restrict fluids on the diet to
80% of normal daily needs
 Growth
• growth velocity deviates more from the
expected trajectory the longer an individual is
on the diet, particularly in the young

Neal EG, Chaffe HM, Edwards N, Lawson M, Schwartz R, Cross

JH. Growth of children on classical and medium chain
triglyceride ketogenic diets. Pediatrics 2008;
 NON EPILEPTIC INDICATIONS
• Case reports on two children indicate a possible use in
treating astrocytomas,
• Autism, depression, migraine headaches,
polycystic ovary syndrome, and type 2 diabetes mellitus have
been shown to benefit in small case studies.
• uncontrolled clinical trials and studies in animal models has
shown that the ketogenic diet can provide symptomatic and
disease-modifying activity in a broad range of
neurodegenerative disorders including
amyotrophic lateral sclerosis, Alzheimer’s disease and
Parkinson’s disease, and may be protective in
traumatic brain injury and stroke
• As of 2008[update], there is not sufficient evidence to support
the use of the ketogenic diet as a treatment for these
conditions