1. Dietary Treatments of Epilepsy
Antoaneta Balabanov, MD
Epileptologist
Kelly Roehl, MD, RDN
Registered Dietitian Nutritionist
Dietary Treatments of Epilepsy Clinic
Rush Epilepsy Center
Rush University Medical Center
Chicago, IL

2. No Disclosures

3. Rush Epilepsy Center Established in 1970’s by Dr. Frank Morell
patients
Comprehensive Team
7 Epilepsy Attending Physicians
4 Neurophysiology Fellows Annually
1 Epilepsy Fellow
3 Nurse Practitioners
3 Registered Nurses
Social Worker
Registered Dietitian

4. Rush Dietary Treatments of Epilepsy Clinic
Initiated: December 2012
Team:
Attending Epileptologist (Antoaneta Balabanov)
Registered Dietitian (Kelly Roehl)
Patient Assessment & Follow Up:
>200 patients assessed

5. Why dietary treatments of epilepsy?
30% of all patients with epilepsy are medically intractable
AEDs and side effects
Surgical treatments are not always an good option for the medically intractable patients
Brain stimulation – efficacy varies and takes time

6. What are the dietary treatments of epilepsy?
Ketogenic Diet (KD) Medium Chain Triglycerides Diet (MCT) Modified Atkins Diet (MAD) Low Glycemic Index Diet (LGID)

7. History

8. 2003 Modified Atkins (Hopkins)
Historical Timeline
Biblical references
Hippocrates
1921 Mayo Clinic
1970s MCT diets
1994 Charlie Foundation
2003 Modified Atkins (Hopkins)
2008 Low GI (Hopkins)
Present Day
Mayo Clin Bulletin :
JAMA (10):
J Child Neurol. 2009; 24(8): .

9. Low Carbohydrate Diets
Restrict: processed foods, grains, desserts, sugar-sweetened beverages, starchy vegetables
Moderation: fruit, dairy, carrots & sweet potatoes, legumes, dark chocolate, red wine
Focus: Vegetables (all non-starchy), avocado, nuts, fats & oils, leafy greens, eggs, fish, meat, poultry

10. Ketogenic Diets Restrict: carbohydrate (<60 g/day)
Moderation: protein ( g/kg)
Liberal: fats (60-90% of total calories)

11. Classic Ketogenic Diet (4:1, 3:1)
Mimics the metabolism of starvation, which create ketones (ketosis)
High fat, adequate protein, low carbohydrates
Starting diet requires hospitalization
Traditionally used in children <2 years

12. What does a ketogenic diet look like?
Fat
Protein
Carbohydrate

13. Classic Ketogenic Diet – Why Not?
Too restrictive, not palatable
Constraining of daily life-requires weighting food to the gram
Requires a dietitian with special training
Inpatient stay to start the diet
Socially “unacceptable”

14. Modified Ketogenic Diets

15. Modified Atkins Diet (MAD)
Not intended for weight loss, but can occur
Does not restrict calories
Does not restrict protein intake
Restricts carbohydrates to 10-20mg a day
High fat is encouraged
Ratio 2:1 to 1:1
No weighting and measuring of food is needed
Outpatient initiation
No fasting needed

16. What does MAD look like?
Fat
Protein
Carbohydrate

17. Low Glycemic Index Diet/Treatment
Not intended for weight loss, but can occur
Does not restrict calories
Does not restrict protein intake
Restricts carbohydrates to mg a day
Fat intake not necessarily encouraged
Ratio 0.7-1:1
No weighting and measuring of food is needed
Outpatient initiation
No fasting needed

18. What does LGID/T look like?
Essentially same as MAD
Fat
Protein
Carbohydrate

19. MAD vs LGID/T MAD LGID/T Low carb, adequate protein, high fat
Carbs: g/day
All carbs allowed
Moderate to high ketosis
Stable blood sugar
Low carb, adequate protein, high fat
Carbs: g/day
Only low GI carbs (GI <50)
Low ketosis
Stable blood sugar

20. What is Glycemic Index? High GI Foods
sugar, white flour, white grains, lower fiber fruits
Low GI Foods
vegetables, nuts, seeds, legumes, berries

21. Who Benefits from Ketogenic Diets?
Patients with medically intractable epilepsy that:
Are not surgical candidates
Failed surgical treatment
Patients with well controlled epilepsy that:
Experience side effects from AEDs
Would like to reduce AEDs
All patients with epilepsy that are interested!
(As long as there are not contraindications)

22. Which Diet is Best for You?
Classic Ketogenic Diet:
Pediatric patients, G-tube feedings
Modified Atkins Diet:
Medically intractable
Low Glycemic Index Diet:
Medically non-intractable
Limited cognitive abilities and/or those without family support
Modified Ketogenic Diets

23. Which Diet is Best for You?
Neurologic Considerations
Seizure type, severity & frequency
Baseline cognitive abilities
Nutrition Considerations
Baseline food knowledge, preferences
Ability to prepare meals, follow directions/recipes
Support & Investment
Family and emotional support
Patient investment (self-interest versus referral)
Willingness & readiness to make diet change

25. 25 kcal/kg
1.2 g protein/kg
35 ml/kg
~1.2:1 ratio

26. Sample Breakfast – MAD

27. Sample Lunch – MAD

28. Sample Dinner – MAD

29. Sample Snacks & Daily Totals - MAD

30. Side Effects Side Effect Treatment Weight loss Weight gain
Increase protein, carbohydrates
Weight gain
Reduce calories, ensure compliance
Constipation
Increase fiber & fluid consumption, pharmacologic
Acid reflux
Increase carbs, eliminate problematic foods, change eating patterns, pharmacologic
Hyperlipidemia
Ensure compliance, start carnitine, adjust types of fats consumed

31. Seizure improvement at 3 months1
Rush Experience
Table 1. Outcomes among adult patients with medically intractable epilepsy after 3 months following a Modified Atkins Diet (MAD) or Low Glycemic Index Diet (LGID)
n (%)
Total
n=34
Seizure improvement at 3 months1
<50% n=19 (56%)
>50% n=15 (44%)
Improvement in QOL1
27 (79%)
13 (68%)
14 (93%)
Side Effects1
5% weight loss
Constipation
Total cholesterol >200 mg/dL (n=20)
19 (56%)
6 (18%)
7 (35%)2
10 (53%)
3 (16%) --
9 (60%)
3 (20%)
1 Self-reported at 3 month follow up
2 Only 2 patients (10%) with baseline normal TC (<200 mg/dL) had TC >200 mg/dL at 3 months
Balabanov A, Roehl K. Abstract AES 2014

32. Seizure improvement at 3 months1
Rush Experience
Table 1. Outcomes among adult patients with medically intractable epilepsy after 3 months following a Modified Atkins Diet (MAD) or Low Glycemic Index Diet (LGID)
n (%)
Total
n=34
Seizure improvement at 3 months1
<50% n=19 (56%)
>50% n=15 (44%)
Improvement in QOL1
27 (79%)
13 (68%)
14 (93%)
Side Effects1
5% weight loss
Constipation
Total cholesterol >200 mg/dL (n=20)
19 (56%)
6 (18%)
7 (35%)2
10 (53%)
3 (16%) --
9 (60%)
3 (20%)
1 Self-reported at 3 month follow up
2 Only 2 patients (10%) with baseline normal TC (<200 mg/dL) had TC >200 mg/dL at 3 months
Balabanov A, Roehl K. Abstract AES 2014

33. Other Benefits of Ketogenic Diets
Improvements in patient care outcomes
Seizure frequency
Seizure severity
Quality of life
Mood
Sleep
Energy
Mental clarity
Minimal negative side effects
Regardless of improvements in seizure control!

34. Conclusions
Dietary treatment clinics are feasible option that may improve not seizures, but also quality of life.
All patients with epilepsy should be education on diet therapy for the treatment of epilepsy.
Diet clinic should be part of any comprehensive epilepsy center.

35. Questions