Epilepsy is one of the world’s oldest non-communicable conditions. Epilepsy is a chronic disorder of the brain characterized by recurrent seizures, which are brief episodes of involuntary movement that may involve a part of the body or the entire body. It may be accompanied by loss of consciousness and control of bowel or bladder function. The seizures are a result of excessive electrical discharges in the brain cells. Seizures can vary from the briefest lapses of attention or muscle jerks to severe and prolonged convulsions. Seizures can be infrequent as 1 per year to several per day. Epilepsy is defined as having 2 or more unprovoked seizures, thus, a once in a life time seizure will not be classified as epilepsy. Epilepsy is more common in children and in adults older than 65 but may occur at any age. In many parts of the world stigma surrounds the condition making it difficult for sufferers to seek medical help.
Causes of epilepsy is classified into three:
- Genetic defect.
- Structural/metabolic changes in the brain caused by head trauma, stroke, brain tumours, and infection due to meningitis, AIDS or viral encephalitis.
- Unknown – the cause of epilepsy is not yet known.
Epilepsy can be managed but not cured and can be controlled with medication, or surgery. Some epileptic syndromes resolve in childhood. About 25% of people with epilepsy do not have seizure control even with the best available medications.
Managing Seizures with Diet
For centuries, we have known that fasting can help get seizures under control. Unfortunately, this was not very useful, as people could not starve for life. Now we know that a high fat, low carbohydrate diet can trick the body into thinking it is starving. When the diet is calculated just right, we could cause the body to think it is fasting, and indeed, seizures would stop. The ketogenic diet is the most medically researched diet in the world, and one of the most common therapies for epilepsy worldwide. The ketogenic diet has been shown to stop seizures in about 50%-90% of cases where even the best medications could not stop seizures (medically refractory seizures). However not all individuals with medical refractory epilepsy can be considered for the Ketogenic Diet. These are patients who have metabolic/genetic diseases and are not able to utilize fat in the body system.
How Does the Ketogenic Diet Work?
With the absence of enough carbohydrate (the preferred energy source for the body), ketosis is stimulated by supplying fat as the major source of calories, while restricting carbohydrate and moderating protein consumption. Ketosis is the mitochondrial ß-oxidation of fatty acids in the liver that generates large quantities of ketone bodies; acetone, acetoacetate and ß-hydroxybutryate (BHB). In simple words, the fat is broken down in the liver to produce these three main ketones bodies when carbohydrate intake is restricted. The brain readily uses these ketone bodies for energy, and excess production of ketone bodies results in a state of ketosis. Several mechanisms of action have been proposed on how these ketones stop seizures. For our discussion the most important point to note is that somehow when these ketones get to the brain, the seizures stop, or frequency reduce.
Types of Ketogenic Diet
There are four main types of ketogenic diet and the differences are mainly due to the percentage of fat, carbohydrate and protein in the diet. These are:
The classic: This has up to 90% or more of daily energy intake as fat. Typically, a ratio of 4 (fat):1(carbohydrates and protein), 3 (fat):1(carbohydrates and protein). It is the most restrictive and is suitable for children on tube feeding and formula fed infant.
Medium-chain triglyceride (MCT) ketogenic diets: The MCT diet contains a lot of MCT – medium chain triglycerides. Medium Chain Fats (MCT) are more effectively absorbed than long chain fats and does not require carnitine to transport it into the cells. This increases the ketogenic potential of the MCT’s. This means less overall total fat is needed when we add MCT’s. This is suitable for children or teenagers who are oral eaters, who do not have chronic diarrheal/vomiting issues. The MCT Keto diet is contraindicated with some medications. Children who are picky eaters or who have large appetites can benefit from this and those whose families have the finances to afford the cost of MCT oil.
Low glycaemic index treatment (LGIT): Children or patients are encouraged to eat foods that are of low Glycaemic index (<50) and do not spike the blood with glucose. About 40g-60g of carbohydrates per day is allowed. This is suitable for oral eaters whose families may not too able to afford the very structured nature of the other keto diets. It can be followed without weighing of the foods.
Modified Atkins diet (MAD): The modified Atkins diet is not as strict as the classical and MCT diets. Patients must eat lots of protein and fat, and just count their carbohydrate. This maybe preferred for older children/teenagers and families who are unable to weigh foods. It is suitable for teenagers and children who are oral eaters that like large amounts of protein and fatty foods. There is a restriction of 10-15 gm of carbohydrate per day with no limits on protein, fat and calories.
The management of retractable epilepsies should take a multidisciplinary approach involving dietitians, neurologists, nurses, pharmacists and social workers. It is advisable to consult with a registered dietitian. The diet must be planned with specific diet calculations to ensure adequate nutrition and energy is provided to patients. It is not a life time diet. It must be calculated, initiated by a registered dietitian, maintained and wean off by the dietitian. The diet must be modified the diet to ensure maximum seizure control while ensure nutritional needs of the child is met. It should be done under the appropriate medical supervision. A ketogenic diet for seizure control may be useful to your child. Ask your doctor about it.