Seizures in Children: Ketogenic Diet
Guest: Lauren McNider – Dietetic Services
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Lauren McNider who is a registered dietician here at the Medical University of South Carolina. We’re going to be talking about the ketogenic diet. Lauren, what is the ketogenic diet.
Lauren McNider: The ketogenic diet is a special high fat diet that is used to treat seizures. Whipping cream, fats and vegetable oil are used to provide the necessary fat. The diet eliminates foods such as bread, cereal, pasta, starchy vegetables, like potatoes, dried beans and peas.
Dr. Linda Austin: Anything carbohydrate, really, it sounds like?
Lauren McNider: You’re pretty much eliminating most of your carbohydrate sources of food, including milk and sweets. All foods must be carefully prepared and weighed on a gram scale and each meal must be eaten in its entirety for the diet to be most effective.
Dr. Linda Austin: Now, this is an anti-seizure diet, is that right?
Lauren McNider: That’s correct.
Dr. Linda Austin: How effective is this diet?
Lauren McNider: It has showed greater than 90 percent reduction in seizures in about 50 percent of the children on the diet. Other benefits of the diet include decreasing their seizure medications. A lot of the anti-epileptic drugs make children very sedated. So, their quality of life when they can come off these drugs is greatly increased.
Dr. Linda Austin: Interesting. Now, can this diet be used in adult epilepsy patients as well?
Lauren McNider: The classic ketogenic diet is designed for children. For adolescents, it’s a little bit harder to follow. So, for adult patients, we do a modified Atkins diet or the low glycemic index treatment. We’re looking at using the low glycemic index treatment in the future, but for now, just sticking with a modified Atkins, which is similar to Dr. Atkins’ Diet Revolution.
Dr. Linda Austin: High protein, high fat, low carb?
Lauren McNider: We are pushing more fats than protein.
Dr. Linda Austin: Interesting. How long has this diet been around?
Lauren McNider: This diet was actually discovered back in biblical times, or mentioned. There’s actually a reference in the King James Version, Mark 9:14, of Jesus curing the demonic body by telling him to pray and fast. So there’s mention of fasting and curing epilepsy then. Then, in 1921, Dr. Wilder of the Mayo Clinic introduced the modern ketogenic diet in an attempt to reproduce metabolic effects of starvation. It’s been used since then, but probably less frequently since 1950 when more AEDs (anti-epileptic drugs) became available.
Dr. Linda Austin: So, basically, was the history that it was noted that when people fasted for religious reasons, they tended to have fewer seizures? Is that how it came about?
Lauren McNider: Well, that’s when it was, kind of, first noted. Really, in the early 1920s was when it started to be used more formally as a treatment.
Dr. Linda Austin: Now, you mentioned that it helps reduce seizure in about 50 percent of children who use it, is that right?
Lauren McNider: That’s right.
Dr. Linda Austin: Is there a particular profile, like a type of seizure that it seems to be more effective with?
Lauren McNider: Well, there’s no way to predict, beforehand, whether it’s going to be successful. You just simply have to try it. Traditionally, the diet has been used in young children between ages one and six. They have myclonic, atonic and tonic-clonic seizures. Recent studies are confirming that it benefits children age one and older children, although older children, in adolescence, seem to rebel more with the diet. And every decade since 1920, studies consistently show that 50-75 percent of children will be helped considerably by the diet.
Dr. Linda Austin: And they rebel because foods like pizza and things like that are not allowed?
Lauren McNider: Right. It’s very strict. The recipes are carefully designed by a dietician and everything has to be weighed on a gram scale and they’re required to eat every bit of the meal.
Dr. Linda Austin: So, you don’t particularly recommend that moms and dads just start this on their own, but they really ought to consult with a dietician, especially when you’re talking about a child’s nutrition.
Lauren McNider: Oh, absolutely. They definitely should be seen by a neurologist and the doctor or nurse practitioner will prescribe the diet, and it’s carefully monitored and followed by a dietician.
Dr. Linda Austin: How do you initiate the diet? Do you go cold turkey onto the diet or do you gradually ease into it?
Lauren McNider: What we do here at MUSC is gradually introduce them to the diet. Now, initially, when it was first studied in the 1920s, there was a fasting period and patients would fast until they lost about 10 percent of their body weight. But now we’re eliminating the fasting as that can lead to some very adverse effects, such as dehydration any hypoglycemia. What we do now is have them eat their normal breakfast at home and then we make two ketogenic shakes. The ketogenic shake is similar to eggnog. It has heavy whipping cream, eggs, oil, and KetoCal, which is a ketogenic formula, a high fat/low carb ratio.
Dr. Linda Austin: How is it believed that this actually works? How does it help seizures?
Lauren McNider: Well, no one is certain how the diet works. One theory attributes the anti-seizure effect of the diet to the ketones that the ketogenic diet produces. Our body normally burns glucose, which is sugar, for energy, and the body can use these ketones as a source of energy, rather than glucose. Although scientists don’t know why this energy produces a reduction in seizures, the consensus from a recent conference is that there’s not just one, but several mechanisms to the diet’s efficiency.
Dr. Linda Austin: How long can a child stay on the diet?
Lauren McNider: Typically we have them on the diet two to three years. During that time, their lipids, as well as several other labs, are monitored every three months. We wean them off the diet after about three years.
Dr. Linda Austin: And then what happens?
Lauren McNider: They go back to a regular diet, eat normal food and introduce carbohydrates back into their diet. Typically, children won’t crave sweets because they’ve been on this high fat regimen for so long. It’s very interesting. They go back to eating a normal diet and do just fine.
Dr. Linda Austin: Without a recurrence of seizures?
Lauren McNider: Right. Well, not in all cases. Some children experience a significant reduction in seizures. Instead of having, maybe, over 100 seizures a day, they’re reduced to less than 10 or 20 a day. So, you might have that effect or, maybe, the effect of coming off their anti-epileptic drugs. There could be several different outcomes. But that is the ultimate goal, to have them off the diet, seizure- free, and no longer taking seizure medications.
Dr. Linda Austin: Do the doctors, though, ever recommend that they go back on it if they start to relapse?
Lauren McNider: I haven’t come across that yet. I’ve just been working with the diet for about a year, but that is a possibility.
Dr. Linda Austin: You know, one of the concerns, of course, with a high fat/high protein diet has been adverse consequences, especially the load on the kidneys, as well as long-term nutritional concerns. Is that an issue with putting children on this diet?
Lauren McNider: Absolutely. With the classic ketogenic diet as well as the modified Atkins’, the most common adverse effect of the diet is constipation. There are solutions to prevent this problem, including eating high fiber vegetables, which are allowed on the diet, and drinking plenty of water. A less common adverse effect is kidney stones. This problem can be prevented by making sure the child drinks enough water and avoids anti-seizure medications, which cause kidney stones, such as Zonegran and Topamax. Other less common adverse effects include elevated lipids, decreased growth rate. Lab studies are necessary during the course of the ketogenic diet therapy to ensure that the child is receiving proper nutrition and to minimize any adverse effects.
Dr. Linda Austin: Well, thanks so much for talking with us about this today.
Lauren McNider: Oh, absolutely.
Dr. Linda Austin: If somebody wants more information, where should they go?
Lauren McNider: Have them contact the pediatric neurology clinic here at MUSC.
If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection: (843) 792-1414.