The Ketogenic Diet
Modern variants of the ketogenic diet
Fatty acids, lipids and oils
There are three modern variants of the Ketogenic diet.
classical Ketogenic diet is the “original” version diet, but recently two other forms have come to the fore. These alternate Ketogenic diets are termed the Modified Ketogenic Diet (MKD) (also known as the Modified Atkins Diet or MAD) and the Medium Chain Triglyceride oil diet. Both these diets rely less on caloric restriction and have lower macronutrient ratios than the classic Ketogenic diet. The MCT oil diet is supplemented with medium chain triglycerides (MCT) which are highly ketogenic and have been shown to display anti-convulsant properties.
Up until recently, the most well-studied and widely-used variant is the classical Ketogenic diet, which is characterized by its 4:1 ratio. This ratio refers to the amount of fats (primarily long chain fatty acids) and the sum of the carbohydrates (sugars) and proteins. So for every 4g of fat there is 1g of protein and carbohydrates. This form of the diet is very stringent and its use is marred by poor compliance. The reasons for failure to comply range from diet fatigue (kids getting bored with the food) to poor discipline (not saying “no”) and taste intolerance. As a result, the classical Ketogenic diet is often used in patients who are fed via a gastrostomy, where discipline, diet fatigue and taste intolerance become negligible. Despite very obvious benefits in seizure management, the classical Ketogenic diet was not the subject of a randomised clinical trial until 2008.
In the randomised controlled ketogenic trial published in 2008 (Elizabeth G Neal, 2008) 145 children (aged 2-16 years), with a history including 2 failed AEDs, were placed on the Ketogenic diet. Overall, the Ketogenic patients had a reduction of baseline seizures of 62% as opposed to the control group (Not Ketogenic Diet) which had a baseline of 136.9% after 3 months. Going into greater detail, the results showed that 7% of the candidates had a greater than 90% reduction in seizures. None of the control group experienced this kind of improvement. In fact, the baseline seizure level in the control group
increased. In this trial, the most common side effects were
constipation, vomiting, lethargy and hunger.
A milder variation of the classical Ketogenic diet is the modified Ketogenic diet (aka modified Atkins diet) which was the result of accidental discovery. It was first informally observed in families using the classical diet who had eventually stopped using scales and portion control. The families observed that the diet - although non-compliant to the stringent guidelines and rules of the classical diet - still resulted in elevated ketones and seizure control. It was first used formally in 2002 at Johns Hopkins Hospital, and differs from the classical diet in that there are no restrictions on calories, fluids or proteins. Carbohydrates are counted and monitored and fat intake is strongly encouraged.
The modified Ketogenic diet has been extensively researched and shows similar efficacy to that of the classical Ketogenic diet. Its milder less stringent nature makes compliance easier. This makes it more acceptable to patients. However the classical ketogenic diet is often initiated should the modified diet not provide the desired results.
The MCT oil diet is widely used in Canada and UK. The most important component of the diet is, as the name suggests, MCT oil. MCT oils are more “Ketogenic” than Long chain triglycerides. The rationale behind the diet is that using a more Ketogenic oil allows for greater flexibility in foods in which the MCT oil compensates for the more relaxed regimen. There has been significant interest in MCT oils as anticonvulsants of late.
In summary, the Ketogenic diet - in all its forms - restricts the intake of carbohydrates and boosts the fat intake. This mimics the metabolism of starvation, which from a practical perspective, is the time when optimal neurological and physical function is essential for survival. All three versions of the diet are effective in the management of epilepsy.
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