Can a ketogenic diet treat epilepsy?

Epilepsy is a common neurological disease. During an attack, patients often experience loss of consciousness, convulsions, clenched jaws, etc. The disease course is long and recurrent, which seriously endangers the physical and mental health of patients.

In addition to anti-epileptic drugs, neuromodulation and surgical treatment, the ketogenic diet has been used to treat refractory epilepsy in children for decades.

Although its anti-epileptic mechanism is still unclear, its effectiveness and safety have been recognized.

Ketogenic Diet and Epilepsy

Our normal diet is mainly composed of carbohydrates, such as rice and noodles, which account for 45% to 60% of the total energy for the day, and fat accounts for about 20%. The ketogenic diet uses fat and protein (such as cooking oil, meat, dairy products, etc.) as the main food sources, and carbohydrates are reduced to 5% to 10%, and are mainly coarse grains and other carbohydrates with a low glycemic index (GI).

Epilepsy is a process in which neurons discharge abnormally and rapidly, leading to the depletion of brain energy, which is usually provided by glucose. The ketogenic diet converts the body's main energy source into fatty acid metabolism that produces ketone bodies, which slowly and persistently provides energy to the body, thereby inhibiting epileptic seizures.

The ketogenic diet mainly includes four options

Classic ketogenic diet: a high fat and low percentage protein + carbohydrate diet, with a common ratio of 4:1 or 3:1.

Medium-chain triglyceride diet (MCT): Allows for more carbohydrates and protein in the diet.

Modified Atkins diet (MAD): The proportions are not strictly required, and carbohydrate intake is limited to 10-15 grams per day, thus providing a more palatable and less restrictive diet.

Low glycemic index therapy (LGIT): The total daily intake of low glycemic index carbohydrates (GI value <50) can reach 40 to 60 grams.

Which patients with epilepsy are suitable for the ketogenic diet?

The main indication for the ketogenic diet is refractory epilepsy in children.

Although anti-epileptic drugs are widely used, there are still about 30% of patients with drug-resistant epilepsy, that is, after using two or more well-tolerated anti-epileptic drugs in a standardized manner, seizures are still poorly controlled. Clinical trials have shown that the ketogenic diet can reduce the frequency of seizures by more than 50% in 50% to 80% of children with refractory epilepsy, and 10% to 20% of children can achieve complete seizure freedom, and can improve their quality of life by improving their cognition, behavior, and sleep quality.

Infants and young children are ideal for starting a ketogenic diet, given their strong ability to utilize and store fat. Other conditions that should be considered for early treatment with a ketogenic diet include epileptic encephalopathy, epilepsy syndromes such as infantile spasms, and severe myoclonic epilepsy in infants (Dravet syndrome). Since the ketogenic diet uses fat as an energy source, diseases with fatty acid transport and oxidation disorders should be absolute contraindications, such as primary carnitine deficiency, β-oxidation defects, and key enzyme system defects.

At present, the main beneficiaries of the ketogenic diet for epilepsy treatment are children, but this does not mean that the ketogenic diet is ineffective for adult epilepsy; on the contrary, the ketogenic diet has good efficacy and tolerance for controlling persistent epileptic seizures in adults, and has higher safety and fewer adverse reactions than traditional drugs and anesthesia and sedation treatments. However, more and more comprehensive studies are needed to verify the effectiveness of the ketogenic diet in the treatment of adult epilepsy.

Ketogenic diet should pay attention to

It is currently believed that the classic ketogenic diet is more effective than the modified Atkins diet in reducing epileptic seizures, and the start-up period (the first 5 days of starting the ketogenic diet) is the critical period of dietary treatment. Therefore, you can start with the classic ketogenic diet and then transition to a more flexible diet plan according to your condition. The start-up phase of the ketogenic diet requires multidisciplinary evaluation and regular follow-up, and parents should be guided and urged to test their children's blood ketones and blood sugar in a timely manner. Adverse reactions require symptomatic treatment. Other serious adverse reactions such as cardiomyopathy and pancreatitis require the ketogenic diet to be stopped immediately once they occur.

It is recommended that you keep taking anti-epileptic drugs as much as possible during the first three months of the ketogenic diet; after three months, you can adjust appropriately according to the seizure situation. If you achieve complete seizure-free status after one month of medication combined with the ketogenic diet, or if the treatment effect is obvious, you can try to reduce the medication slowly. The ketogenic diet should be continued for at least three months. If the child has serious adverse reactions or the treatment is ineffective, it can be terminated; if it is effective, it should be continued for at least two years, and gradually transitioned to a normal diet according to the condition.

During the ketogenic diet, you should try to avoid eating foods with a high glycemic index, such as cakes and biscuits. In special circumstances, you can replace ketogenic ingredients and use special preparation methods to relieve the child's discomfort and maintain the ketogenic diet.

Expert introduction

Zhu Guoxing

Professor, Doctor of Medicine, Master Supervisor, Department of Neurology, Huashan Hospital Affiliated to Fudan University. Deputy Director of Epilepsy Diagnosis and Treatment Center, Fudan University. Member of the EEG and Epilepsy Group of the Neurology Branch of the Chinese Medical Association, Vice Chairman of the Drug Therapy Committee of the Chinese Anti-Epilepsy Association, Director of the Chinese Anti-Epilepsy Association, Vice Chairman of the EEG and Neurophysiology Branch of the Chinese Anti-Epilepsy Association, and Member of the Stereotactic EEG and Brain Localization Professional Committee.

Diagnostic expertise

Diagnosis and treatment of neurological diseases such as epilepsy, headache, sleep disorder, neuralgia and cerebrovascular disease, and interpretation and analysis of EEG.

Ding Ding

Researcher at the Institute of Neurology, Huashan Hospital, Fudan University. He is currently the executive director and deputy secretary-general of the Chinese Association Against Epilepsy (CAAE), a member of the CAAE Precision Medicine and Adverse Drug Reaction Monitoring Committee, vice president of the Shanghai Anti-Epilepsy Association, a member of the SUDEP Committee of the International League Against Epilepsy (ILAE), vice chairman of the International Board of Epilepsy (IBE), a member of the ILAE-IBE Executive Committee, and a member of the American Epilepsy Society (AES).