militaryfamilieslearningnetwork.org/event/22028 The Ketogenic Diet: Is it another fad? Thanks for joining us! We will get started soon. While you’re waiting you can get handouts, etc. by following the link below. This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
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The Ketogenic Diet: Is it another fad? · The Clinical Pathway . continued. Diet Discontinuation. Ineffective: rapid after 36 - months. Effective: gradual after 18-24 months. Serious
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militaryfamilieslearningnetwork.org/event/22028
The Ketogenic Diet: Is it another fad?
Thanks for joining us! We will get started soon.While you’re waiting you can get handouts, etc. by following the link below.
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
Connecting military family service providers and Cooperative Extension professionals to research
and to each other through engaging online learning opportunities
militaryfamilieslearningnetwork.org
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
• Presented 9 abstracts and 10 presentations related to ketogenic diet therapy for epilepsy at regional, national, and international conferences
• Invited reviewer for The Academy of Nutrition and Dietetics practice paper on ketogenic diet therapy for epilepsy, published in 2017
• Research Interests:- Alternative use of the ketogenic diet,
especially pediatric traumatic brain injury- Impact of social support networks on
adherence of ketogenic diet for children and adults with epilepsy
Disclosures
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• Employer:– Department of Neurology, Keck School of Medicine of USC– Department of Pediatrics, LAC+USC Medical Center– Clinical Nutrition Services, Children’s Hospital Los Angeles
• Research Funding: Vitaflo Ltd.• Programmatic Funding:
– The Epilepsy Foundation of Greater Los Angeles– The Charlie Foundation– The Carley Eissman Foundation
Objectives
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• Define the ketogenic diet using language and protocols outlined in the standard of care for epilepsy
• Discuss the science behind the ketogenic diet’s role in the treatment of chronic disease (i.e. obesity and type II diabetes) as well as athletic performance
• Discuss strategies to streamline sessions with patients interested in ketogenic diets
Epilepsy
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Epilepsy is a neurological disorder caused by malfunctioning nerve cell activity in the brain. These
malfunctions cause episodes called seizures.
Begley, CE, et al. The cost of epilepsy in the United States: an estimate from population-based clinical and survey data. Epilepsia, 2000; 41(3): 342-351.
Epilepsy
7Brodie, MJ, et al. Evaluation and management of drug-resistant epilepsy. Neurology, 2012; 78(20): 2548.www.cdc.gov
Epilepsy: the 4th most common neurological disorder•Epidemiology
– Prevalence: 2.5-3 million – Refractory: ⅓ of those with epilepsy
•Etiology:– Age dependent:
• Neonates: metabolic disorders, brain malformations, HIE, ICH• Infants and children: fever, brain tumor, infections• Children & adults: congenital or genetic factors, head trauma• Seniors: Alzheimer’s, stroke, head trauma
– Idiopathic: ⅓ of all epilepsies
Ketogenic Diet
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The ketogenic diet is high in fat, supplies moderate protein, and is low in carbohydrate. This metabolic
shift results in the production of ketone bodies.
Fat Ketone
Presenter
Presentation Notes
Please note: Ms. Lowe made the graphics in this slide.
Ketogenic Diet: epilepsy
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How did this come about?• Hippocrates: fasting• King James version Mark 9:14-29
– “He fell on the ground and wallowed foaming…and he said unto them, this kind can come forth by nothing but prayer and fasting”.
• 1920’s– Geyelin (endocrinologist): 1st reported fasting as a
treatment for epilepsy– Wilder (Mayo Clinic): ketogenic diet
Wheless, JW. History of the ketogenic diet. Epilepsia, 2008, 49(Supp 8): 3-5.
Ketogenic Diet: epilepsy
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How did this come about? continued• 1940: development of antiepileptic drugs• 1994: The Charlie Foundation
– Dateline segment– “…First Do No Harm”– Impact: publications
• 1994: 3• 1995: 20• 2018: 420
Wheless, JW. History of the ketogenic diet. Epilepsia, 2008, 49(Supp 8): 3-5.www.webofscience.com
“The ketogenic diet should be strongly considered in a child who failed two to three anticonvulsant therapies,
regardless of age or gender, and particularly in those with symptomatic generalized epilepsies”.
Kossoff, EH, et al. Optimal clinical management of children receiving the ketogenic diet: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia, 2018; 3(2): 175-192.
Ketogenic Diet: epilepsy
How well does medication work?•1st drug trial: 49% seizure freedom•2nd drug trial: 13% seizure freedom•3rd drug trial: 4% seizure freedomHow well does the diet work?•Seizure control:
– ≥50% reduction in frequency: 65%– ≥90% reduction in frequency: 30%– Freedom: 10-15%
•Other noted benefits:– Cognition and learning– Behavior and alertness
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Brodie, MJ, et al. Evaluation and management of drug-resistant epilepsy. Neurology, 2012; 78(20); 2548.Kossoff, EH, et al. Optimal clinical management of children receiving the ketogenic diet: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia, 2018; 3(2): 175-192.
Ketogenic Diet: epilepsy
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Ketogenic Diet
MCT OilClassic
Low GlycemicModified Atkins
Ketogenic Diet: epilepsy
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Defining the Ketogenic Ratio•Fat (g) to combined carbohydrate (g) and protein (g)•Purpose: regulate degree of ketosis•Example: 4:1
36kcals + 4 kcals = 40kcals per Dietary Unit1000kcals x Dietary Units ÷ 40kcals = 25 Dietary Units
25 Dietary Units x 4 = 100g Fat25 Dietary Units x 1 = 25g CHO + Protein
Fat Fat Fat Fat
CHO + Protein
X 9 kcals = 36 kcals
X 4 kcals = 4 kcals
Zupec-Kania, B. Diet therapy for epilepsy. The Charlie Foundation, 2012.
Ketogenic Diet: epilepsy
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Diet Therapy Ratio Fat (g) Protein (g) CHO (g)
Classic
4:13:12:11:1
100979177
171820
30-50
61426
20-40MCT Oil 1:1 78 25 50
MAD 1:1 72 52-62 10-20LGIT 1:1 70 40-60 40-80
Regular Diet 0.2:1 33 35 140
Highest
Lowest
KETONES
Defining the Ketogenic Ratio continued
Zupec-Kania, B. Diet therapy for epilepsy. The Charlie Foundation, 2012.
• Used as an energy source for:– Pancreatic insufficiency– Impaired chylomicron transportation
• Physiology:– Bypasses lymphatic system– Yields more ketones of kcal
• Side effect: GI disturbanceKossoff, EH, et a. Ketogenic and Modified Atkins Diet. Sixth Edition.
Ketogenic Diet: epilepsy
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The MCT Oil
Diet Characteristics
Calories: adequate, controlledProtein: 12% kCals or 2 x RDAFat: • Total: 70-80% kCals• MCT: 30-60% kCalsCarbohydrates: 10% kCals
Initiation Inpatient or Outpatient
EducationOptions:• RDN provides recipes from gram scale• Exchange list and household measures
Kossoff, EH, et a. Ketogenic and Modified Atkins Diet. Sixth Edition.Hottenlocher, PR, et al. Medium chain triglycerides as a therapy for intractable childhood epilepsy. Neurology, 1971; 1: 1097-1103.Schwartz, RH, et al. Metabolic effects of three ketogenic diets in the treatment of severe epilepsy. Dev Med Child Neurol, 1989; 31: 152-160.
Ketogenic Diet: epilepsy
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The Modified Atkins Diet (MAD)• Pioneer Patients
– 9yo boy on Classic since age 5• Behavioral issues• Switched to Atkins:
– Seizures remained under control– Less cheating episodes
– 7yo girl with Classic initiation admission scheduled• Seizure frequency: 70-80 daily• Provided book prior to admission: Dr. Atkins’ New Diet
Revolution• Seizure free within 3 days; admission canceled
Kossoff, EH, et a. Ketogenic and Modified Atkins Diet. Sixth Edition.
Ketogenic Diet: epilepsy
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The MAD
Diet Characteristics
Calories: adequate, but not controlledProtein: ad libFat: encouragedCarbohydrates: 10-30g daily• Any type of carbohydrate• Can be eaten all at once• Total versus net (subtract fiber)
Initiation OutpatientEducation Exchange list and household measures
Kossoff, EH, et a. Ketogenic and Modified Atkins Diet. Sixth Edition.
Ketogenic Diet: epilepsy
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The Clinical Pathway
Elective Admission (3-5 days)
Diet initiation Labs (BMP, BHB) Education
Consultations
Dietitian Social worker Pharmacist
Neurological Evaluation
Metabolic screening Referral to KD Insurance authorization
Kossoff, EH, et al. Optimal clinical management of children receiving the ketogenic diet: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia, 2018; 3(2): 175-192.
Ketogenic Diet: epilepsy
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The Clinical Pathway continued
Diet DiscontinuationIneffective: rapid after 3-6
monthsEffective: gradual after 18-
24 months Serious complications
Post-Hospitalization
Phone support F/U at 1m & q3m Monitor: labs, growth, seizures
If indicated: adjust Rx and/or diet
Kossoff, EH, et al. Optimal clinical management of children receiving the ketogenic diet: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia, 2018; 3(2): 175-192.
Ketogenic Diet: epilepsy
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• Drug-nutrient interactions• Laboratory monitoring• Side effects
Kossoff, EH, et al. Optimal clinical management of children receiving the ketogenic diet: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia, 2018; 3(2): 175-192.
Ketogenic Diet: epilepsy
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Side
Effe
cts
Reflux
Constipation
Acidosis
Carnitine Deficiency
Hypoglycemia
Hyperlipidemia
Kossoff, EH, et al. Optimal clinical management of children receiving the ketogenic diet: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia, 2018; 3(2): 175-192.
Ketogenic Diet: epilepsy
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It’s Not Easy• Cervenka, et al (2016)
Cervenka, MC, et al. Establishing an adult epilepsy diet center: experience, efficacy and challenges. Epilepsy & Behavior, 2016; 58: 61-68.Brown, J, et al. Feasibility of a ketogenic diet in low income communities in Los Angeles. Epilepsy Summit, Scottsdale, AZ, 2017.
Lack of support 16.3% (n=7/43)Meal preparation 23.3% (n=10/43)
Ketogenic Diet: epilepsy
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Nutritionally Incomplete• Zupec-Kania, et al (2008)
Zupec-Kania, B, et al. Long-term management of the ketogenic diet: seizure monitoring, nutrition, and supplementation. Epilepsia, 2008; 49(Supp 8): 23-26.
Presenter
Presentation Notes
his evaluation was based on an average of 3 days, from a se- lection of nutrient dense foods. Overall, the more liberal the ratio, the higher the nutrient density of the diet. The 4:1 KD met only 3 of the 28 DRIs evaluated, while the 1:1 KD met 12 of 28 DRIs. It is evident from this preliminary study that the KD is deficient in many known micronutrients
Questions
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Ketogenic Diet: obesity
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Does it work? The Short Term• Moreno, et al (2014)
Moreno, B, et a. Comparison of a very low-calorie-ketogenic diet with a standard low-calorie diet in the treatment of obesity. Endocrine, 2014; 47: 793-805.
Ketogenic Diet: obesity
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Does it work? The Long Term• Moreno, et al (2016)
Moreno, B, et al. Obesity by very low-calorie-ketogenic diet at two years: reduction in visceral fat and on the burden of disease. Endocrine, 2016; 54: 681.
Ketogenic Diet: obesity
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How might it work? Satiety• Johnstone, et al (2008)
Johnstone, AM, et al. Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad llibitum. Am J Clin Nutri, 2008; 87: 44-55.
Ketogenic Diet: diabetes
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Does it work? Type 2• Saslow, et al (2017)
Saslow, LR, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutrition and Diabetes, 2017; 7: 304.
Ketogenic Diet: diabetes
37
Does it work? Type 1• Lennerz, et al (2018)
Lennerz, B, et al. Management of type 1 diabetes with a very low-carbohydrate diet. Pediatrics, 2018; 141(6): 1-10.
↑ Increase↓ Decrease+ Positive- Negative No Change
Laffel, L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metabolism Research and Review, 1999; 15(6): 412-425.
Ketogenic Diet: athletics
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Keto-Adaption
The human body can adapt to use fat as its primary fuel during submaximal exercise, while at the same time
freeing itself from obligate high rate of live and muscle glycogen.
McSwiney, FT, et al. Keto-adaption enhances exercise performance and body composition responses to training in endurance athletes. Metabolism, 2018; 81: 25-34.
Ketogenic Diet: athletics
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Does it work?• McSwiney, et al (2018)
– Self-selected:• Group 1: high carbohydrate (n=10)• Group 2: low carbohydrate (n=10)
– Findings:• Group 2 had a greater reduction in BMI (-5.9 v -0.8, p=0.006)• Low carbohydrate group had a greater reduction in body fat % (-
4.6% v 0.7%, p=0.008)• Group 2 had a significant increase in the six second sprint peak
power test (+0.8 v -0.01, p=0.025)• Group 2 had a significant increase in peak power for the critical
power test (+1.4 v -0.7, p=0.047)
McSwiney, FT, et al. Keto-adaption enhances exercise performance and body composition responses to training in endurance athletes. Metabolism, 2018; 81: 25-34.
Ketogenic Diet: athletics
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How does it work?• Volek, et al (2016)
– Elite, ultra-marathoners & iron man triathletes (n=20)– Matched groups:
• Group 1: high carbohydrate• Group 2: low carbohydrate
– Findings:• Group 2 had a two-fold higher rates of peak fat oxidation during
graded exercise (p<0.0001) AND sustained submaximal running (p<0.0001)
• Group 2 had a greater capacity to oxidize fat at higher exercise intensities (p<0.0001)
• No difference in rate of glycogenolysis pre- and during exercise, and rate of glycogen synthesis during recovery
Volek, JS, et al. Metabolic characteristics of keto-adapted endurance runners. Metabolism, 2016; 65: 100-110.
Questions
42
Ketogenic Diet: so what now?
43
Message 1: “Nothing about me without me” –Valerie Billingham
• Individualized care– Psychosocial experience– Tailoring treatment– Communication– Patient as priority– Accessible care
Robinson, JH, et al. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract, 2008; 20: 600-607.Barry, MJ, et al. Shared decision making – the pinnacle of patient-centered care. NEJM, 2013; 366(9): 780-781.
Ketogenic Diet: so what now?
44
Message 2: communicate with their primary provider• Collaboration enhances care coordination and
continuity of care• The ketogenic diet results in a physiologic and
metabolic shift• The ketogenic diet is nutritional incomplete• Unknown long-effects of the ketogenic diet
Ketogenic Diet: so what now?
45
Message 3: The Ketogenic Diet has a reputation• Bacon and butter• Trendiest diet in 2018
• The Ketogenic Diet is an efficacious treatment option for refractory epilepsy for both adults and pediatric patients
• While the evidence for the use of the Ketogenic Diet in disease states other than epilepsy are limited, we are starting to understand how it may play a role in chronic disease management and athletics
• As practitioners, we should support the decisions our clients/patients make and assist them in making healthful
52This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
• Begley, CE, et al. The cost of epilepsy in the United States: an estimate from population-based clinical and survey data. Epilepsia, 2000; 41(3): 342-351.
• Brodie, MJ, et al. Evaluation and management of drug-resistant epilepsy. Neurology, 2012; 78(20): 2548.• www.cdc.gov• Wheless, JW. History of the ketogenic diet. Epilepsia, 2008, 49(Supp 8): 3-5.• www.webofscience.com• Kossoff, EH, et al. Optimal clinical management of children receiving the ketogenic diet: updated recommendations of the
International Ketogenic Diet Study Group. Epilepsia, 2018; 3(2): 175-192.• Zupec-Kania, B. Diet therapy for epilepsy. The Charlie Foundation, 2012.• Kossoff, EH, et a. Ketogenic and Modified Atkins Diet. Sixth Edition.• Hottenlocher, PR, et al. Medium chain triglycerides as a therapy for intractable childhood epilepsy. Neurology, 1971; 1: 1097-
1103.• Schwartz, RH, et al. Metabolic effects of three ketogenic diets in the treatment of severe epilepsy. Dev Med Child Neurol, 1989;
31: 152-160.• Brown, J. NPO & TPN Guidelines. Epilepsy Summit, Manhattan Beach, CA, 2015. Cervenka, MC, et al. Establishing an adult
epilepsy diet center: experience, efficacy and challenges. Epilepsy & Behavior, 2016; 58: 61-68.• Brown, J, et al. Feasibility of a ketogenic diet in low income communities in Los Angeles. Epilepsy Summit, Scottsdale, AZ,
• Zupec-Kania, B, et al. Long-term management of the ketogenic diet: seizure monitoring, nutrition, and supplementation. Epilepsia, 2008; 49(Supp 8): 23-26.
• Moreno, B, et a. Comparison of a very low-calorie-ketogenic diet with a standard low-calorie diet in the treatment of obesity. Endocrine, 2014; 47: 793-805.
• Moreno, B, et al. Obesity by very low-calorie-ketogenic diet at two years: reduction in visceral fat and on the burden of disease. Endocrine, 2016; 54: 681.
• Johnstone, AM, et al. Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad llibitum. Am J Clin Nutri, 2008; 87: 44-55.
• Saslow, LR, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutrition and Diabetes, 2017; 7: 304.
• Lennerz, B, et al. Management of type 1 diabetes with a very low-carbohydrate diet. Pediatrics, 2018; 141(6): 1-10.• Laffel, L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metabolism
Research and Review, 1999; 15(6): 412-425.• McSwiney, FT, et al. Keto-adaption enhances exercise performance and body composition responses to training in endurance
athletes. Metabolism, 2018; 81: 25-34.• Volek, JS, et al. Metabolic characteristics of keto-adapted endurance runners. Metabolism, 2016; 65: 100-110.• Robinson, JH, et al. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse
Pract, 2008; 20: 600-607.• Barry, MJ, et al. Shared decision making – the pinnacle of patient-centered care. NEJM, 2013; 366(9): 780-781.