Indications
The Ketogenic diet is highly recommended for children with
uncontrolled or drug-resistant epilepsy and other neurological conditions. More research into the diet has indicated that
it could also be used to effectively manage other conditions, as indicated in
the follow-up articles. The diet should be introduced in a controlled setting,
preferably the hospital.
The Ketogenic Diet is approved by
national clinical guidelines in Scotland,[1] England and Wales[2] and reimbursed by nearly all
US insurance companies.[3] Kenya is however
quite behind in Clinical Nutrition, more so research and Medical Nutrition
Therapy, therefore the diet is not widely used in our country.
A liquid form of the ketogenic
diet is well tolerated by, infants on formula and children who are tube-fed.[4][5]
Advocates for the diet recommend
that it be seriously considered after two medications have failed, as the
chance of other drugs succeeding is only 10%.[6][7][8] The diet can be considered earlier for some epilepsy and genetic
syndromes where it has shown particular usefulness. These include Dravet
syndrome, infantile spasms, myoclonic-astatic
epilepsy and tuberous
sclerosis complex.[6][9]
The ketogenic diet alters the
body's metabolism, therefore it is a first-line
therapy in children with
certain congenital metabolic diseases such as pyruvate dehydrogenase (E1) deficiency and glucose
transporter 1 deficiency syndrome, which prevent the body from using carbohydrates as fuel, leading to a
dependency on ketone bodies. The ketogenic diet is beneficial in treating the
seizures and some other symptoms in these diseases.[13]
Contraindications
On the other hand, it is
absolutely contraindicated in the treatment of other diseases such as pyruvate carboxylase deficiency, porphyria and other rare genetic disorders of fat metabolism.[6]A person with a disorder of fatty acid oxidation is unable to metabolize
fatty acids, which replace carbohydrates as the major energy source on the
diet. On the ketogenic diet, their body would consume its own protein stores
for fuel, leading to ketoacidosis, and eventually coma and death.
Side
Effects
As we mentioned in the introductory article, the Ketogenic
diet/Keto-diet uses fats as the main energy source. Any drastic change from
using carbohydrates for energy to fat results in various side effects as the
body moves into a state of ketosis.
The side effects however occur during the initial stages as
the body adapts to the diet. The side effects are generally less severe and less frequent than with anticonvulsant
medication or surgery.
Common side effects include;
i.
Lethargy or lack of energy in the initial stages as
the body gets into a state of Ketosis.
ii.
Increased hunger, especially when the diet is
drastically introduced. To counter this, the Nutritionist should gradually
introduce the diet.
iii.
Decreased mental function
iv.
Nausea
v.
Stomach discomfort
vi.
Keto-breath
vii.
Sleep issues
viii.
A fruity urine smell. This is usually due to excretion
byproducts of the ketosis process
ix.
Some people experience digestion issues such as
constipation or diarrhea in the first 1 or 2 weeks. However this side effect
subsides once the body adjusts to the diet. If the problems persist, the
Nutritionist may look into increasing the fibre content in the diet and
prescribe Probiotics to improve the gastrointestinal system health.
x.
Depending on the type of fats included in the diet,
the blood lipids and cholesterol levels may be elevated. This can be averted by
choosing unsaturated fats. If it persists, the Ketogenic ratio can be changed,
to decrease the fat content.
xi.
Low Micronutrient intake. This can be solved by the
Nutritionist/Dietitian prescribing a Nutritional Supplement that covers the
deficit in Micronutrients.
xii.
Long-term use
of the ketogenic diet in children increases the risk of slowed or stunted
growth, bone fractures and kidney stones.
xiii.
The ketogenic diet
reduces levels of insulin-like growth factor 1 (IGF-1), which is important for childhood growth.
xiv.
The ketogenic
diet like many anticonvulsant drugs has an adverse effect on bone health. Many
factors may be involved such as acidosis and suppressed growth hormone.
xv.
About 1 in 20
children on the ketogenic diet will develop kidney stones (compared with one in
several thousand for the general population). Kidney stones are treatable and do not justify
discontinuation of the diet. Johns Hopkins Hospital gives oral potassium citrate supplements to all ketogenic diet patients,
resulting in a sevenfold decrease in the incidence of kidney stones.[16]
In order to minimize negative effects and ease your body into
the Ketogenic diet, the Nutritionist/Dietitian can start with a low Glycemic
Index diet, or the Atkins diet, which is a high protein, moderate fat, low
carbohydrate diet. The Nutritionist will then gradually increase the fat
content and decrease carbohydrates.
All three diets; the Ketogenic, Atkins and Low Glycemic Diet
MUST be prescribed by a qualified Dietitian/Nutritionist and both the patient
and diet reviewed frequently.
It is important to note that the Keto diet usually causes
weight loss. For weight lifters, muscle builders and athletes, it is important
to work closely with your Nutritionist/Dietitian to monitor protein intake, in
order to prevent muscle loss.
The ketogenic diet, more so the standard Keto diet is low in
Micro-Nutrients, therefore it is necessary to supplement. Your Nutritionist
should advice on whether and how you can include vegetables low in carbohydrates/Glycemic
Load in your meal plan to increase micronutrient intake.
Please note that the Ketogenic diet requires medical
supervision, to avert and effectively manage any side effects. Therefore the
diet needs to be initiated in a hospital setting.
References
1. Scottish
Intercollegiate Guidelines Network. Guideline 81, Diagnosis and management of
epilepsies in children and young people. A national clinical guideline(PDF).
Edinburgh: Royal College of Physicians; 2005. ISBN 1-899893-24-5.
2. Stokes T, Shaw
EJ, Juarez-Garcia A, Camosso-Stefinovic J, Baker R. The diagnosis and management of the
epilepsies in adults and children in primary and secondary care.(PDF). London:
Royal College of General Practitioners; 2004. ISBN 1-84257-808-1.
3. Turner Z,
Kossoff EH. The ketogenic and Atkins diets:
recipes for seizure control (PDF). Pract Gastroenterol.
2006 Jun;29(6):53, 56, 58, 61–2, 64.
4. Zupec-Kania BA,
Spellman E. An overview of the ketogenic diet for pediatric epilepsy. Nutr Clin
Pract. 2008 Dec–2009 Jan;23(6):589–96.doi:10.1177/0884533608326138. PMID 19033218
5. Kossoff EH,
McGrogan JR, Freeman JM. Benefits of an all-liquid ketogenic diet. Epilepsia.
2004 Sep;45(9):1163. doi:10.1111/j.0013-9580.2004.18504.x. PMID 15329084.
6. Kossoff EH,
Zupec-Kania BA, Amark PE, Ballaban-Gil KR, Bergqvist AG, Blackford R, et
al. Optimal clinical management of
children receiving the ketogenic diet: recommendations of the International
Ketogenic Diet Study Group.Epilepsia. 2009
Feb;50(2):304–17. doi:10.1111/j.1528-1167.2008.01765.x. PMID 18823325
7. Kossoff EH,
Freeman JM. The ketogenic diet—the physician's perspective. In: Stafstrom CE,
Rho JM, editors. Epilepsy and the ketogenic diet. Totowa: Humana Press; 2004.
p. 53–61. ISBN 1-58829-295-9.
9. Wang S, Fallah
A. Optimal management of seizures associated
with tuberous sclerosis complex: current and emerging options. Neuropsychiatr
Dis Treat. 2014 Oct 23;10:2021-30. doi:10.2147/NDT.S51789. PMID 25364257
10. Mastriani KS,
Williams VC, Hulsey TC, Wheless JW, Maria BL. Evidence-based versus reported
epilepsy management practices. J Child Neurol. 2008 Feb 15;23(5):507–14.doi:10.1177/0883073807309785. PMID 18281618
11. Stafstrom CE,
Rho JM. The ketogenic diet as a treatment
paradigm for diverse neurological disorders. Front
Pharmacol. 2012;3:59. doi:10.3389/fphar.2012.00059.PMID 22509165.
12. Gasior M,
Rogawski MA, Hartman AL. Neuroprotective and disease-modifying
effects of the ketogenic diet. Behav Pharmacol.
2006;17(5–6):431–9. PMID 16940764
13. Huffman J,
Kossoff EH. State of the ketogenic diet(s) in epilepsy (PDF).
Curr Neurol Neurosci Rep. 2006 Jul;6(4):332–40. PMID 16822355
14. Zupec-Kania B,
Werner RR, Zupanc ML. Clinical Use of the Ketogenic Diet—The Dietitian's Role.
In: Stafstrom CE, Rho JM, editors. Epilepsy and the ketogenic diet. Totowa:
Humana Press; 2004. p. 63–81. ISBN 1-58829-295-9.
15. Kossoff EH, Zupec-Kania
BA, Rho JM. Ketogenic diets: an update for child neurologists. J Child Neurol.
2009 Aug;24(8):979–88.doi:10.1177/0883073809337162. PMID 19535814
16. McNally MA,
Pyzik PL, Rubenstein JE, Hamdy RF, Kossoff EH. Empiric use of potassium citrate
reduces kidney-stone incidence with the ketogenic diet. Pediatrics. 2009
Aug;124(2):e300–4. doi:10.1542/peds.2009-0217. PMID 19596731
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