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Sauls RM, Buro AW, Kirby RS. Lifestyle Behavioral Interventions and Health-Related Outcomes Among People with Epilepsy: A Review of Randomized Controlled Trials. Am J Health Promot 2024; 38:720-730. [PMID: 38414186 DOI: 10.1177/08901171241235731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
OBJECTIVE To gather and assess current literature on the prevalence and efficacy of lifestyle behavioral interventions (sleep, nutrition, physical activity) for health outcomes, including QOL, psychological well-being, behavioral changes, and seizure frequency, among PWE. DATA SOURCE A review was conducted of English-language articles identified from PubMed, Scopus, and Embase between January 2013 to January 2023. STUDY INCLUSION AND EXCLUSION CRITERIA Inclusion criteria were randomized controlled trials (RCT) with human subjects diagnosed with epilepsy who participated in a lifestyle behavioral intervention. DATA EXTRACTION Two researchers independently completed the title, abstract, and full-text reviews. Information extracted includes study population, duration, type of intervention, findings, and outcomes. DATA SYNTHESIS Data was narratively synthesized to show level of evidence and degree of consistency in findings. Results: 4001 studies identified, 66 full texts reviewed, and 24 included. A majority (n = 16) of studies utilized diet specific RCTs, and some focused on physical activity (n = 7) and sleep (n = 1). Diet-specific RCTs (eg, ketogenic, Modified Atkins) reported reduced seizure frequency with adverse effects, such as gastrointestinal complications. Physical activity-based interventions found that maintained levels of exercise improved QOL and psychological well-being. However, physical activity and diet-based interventions did not have lasting effects after study conclusion. Only the behavioral sleep intervention reported that sleep quality improved significantly and was maintained post-intervention. CONCLUSION Future research is needed to establish the relationship between lifestyle behavioral interventions on QOL and other health outcomes (eg, seizure frequency).
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Affiliation(s)
- Rachel M Sauls
- Department of Non-Therapeutic Research Operations, H. Lee Moffitt Cancer Center, Tampa, FL, USA
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Acadia W Buro
- College of Population Health, University of New Mexico, Albuquerque, NM, USA
| | - Russell S Kirby
- College of Public Health, University of South Florida, Tampa, FL, USA
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2
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Mustafa MS, Shafique MA, Aheed B, Ashraf F, Ali SMS, Iqbal MF, Haseeb A. The impact of ketogenic diet on drug-resistant epilepsy in children: A comprehensive review and meta-analysis. Ir J Med Sci 2024; 193:1495-1503. [PMID: 38315271 DOI: 10.1007/s11845-024-03622-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024]
Abstract
The ketogenic diet (KD), characterized by high-fat and low-carbohydrate intake, is currently gaining widespread popularity as a treatment for drug-resistant epilepsy (DRE). In addition to the traditional ketogenic diet, several variants have been introduced to enhance compliance and flexibility, such as the modified Atkins diet (MAD) and the low glycemic index diet (LGID). These adaptations aim to provide patients with more manageable and sustainable options while harnessing the potential therapeutic benefits of DRE. The objective of this study is to evaluate the efficacy and safety of the KD in pediatric patients who exhibit DRE. In this study, we conducted a thorough review of existing literature by searching Cochrane, Embase, Medline, and PubMed. Our approach involved predefined criteria for data extraction and the assessment of study quality. Eleven RCTs with 788 participants were included in this study. The pooled effect estimates revealed a significant association between dietary interventions and seizure frequency reduction of > 50% (OR 6.68, 96% CI 3.52, 12.67) and > 90% (OR 4.37, 95% CI 2.04, 9.37). Dietary interventions also increased the odds of achieving seizure freedom (OR 4.13, 95% CI 1.61, 10.60). The common adverse effects included constipation (39.07%) and vomiting (10%). In conclusion, dietary interventions, notably the KD, hold promise for pediatric DRE, reducing seizures and achieving freedom. These non-pharmacological options improve the quality of life of non-responsive and non-surgical patients. The KD has emerged as a potential therapeutic approach. Further research is needed to address the limitations and investigate their long-term effects.
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Affiliation(s)
- Muhammad Saqlain Mustafa
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Muhammad Ashir Shafique
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan.
| | - Bilal Aheed
- Department of Biochemistry, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Farheen Ashraf
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Syed Muhammad Sinaan Ali
- Department of Medicine, Liaquat National Hospital and Medical College, National Stadium Rd, Karachi, Karachi City, Sindh, 74800, Pakistan
| | - Muhammad Faheem Iqbal
- Department of Medicine, Dow University of Health Sciences, V246+X8C, Mission Rd, Nanak Wara Nanakwara, Karachi, Karachi City, Sindh, Pakistan
| | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
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3
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Faheem Y, Jaiswal A, Shergill K, Boppana K, Almansouri NE, Bakkannavar S, Yu AK. Keto Clarity: A Comprehensive Systematic Review Exploring the Efficacy, Safety, and Mechanisms of Ketogenic Diet in Pediatric Epilepsy. Cureus 2024; 16:e54863. [PMID: 38533170 PMCID: PMC10964213 DOI: 10.7759/cureus.54863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/23/2024] [Indexed: 03/28/2024] Open
Abstract
Epilepsy, a widespread neurological disorder characterized by recurrent seizures, affects millions globally, with a significant impact on the pediatric population. Antiepileptic drugs (AEDs) constitute the primary treatment; however, drug-resistant epilepsy (DRE), especially in children, poses a therapeutic challenge. Alternative interventions, such as surgery, vagus nerve stimulation, and the ketogenic diet (KD), have been explored. This systematic review aims to investigate various types of KDs, their distinctions, their effectiveness, and their safety concerning the reduction of seizure frequency, achieving seizure freedom, and the occurrence of adverse events. The study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A comprehensive search was conducted using databases such as PubMed Central (PMC), MedLine, and Science Direct to identify relevant articles. Eligibility criteria and quality assessment tools were applied to evaluate the potential risk of bias and select 11 articles for inclusion in this review. The selected articles encompassed four randomized controlled trials (RCTs), two systematic reviews, and five narrative reviews. The data collected for this review was completed on October 2, 2023. Challenges, such as palatability, cultural factors, and adherence difficulties, were identified. Family or caregiver involvement plays a pivotal role in treatment success. Despite numerous RCTs and reviews, information gaps persist, hindering conclusive outcomes. Evaluating the risk-benefit ratio is crucial, considering potential side effects. The highly individualized nature of KD therapy, influenced by diverse seizure types and syndromes, necessitates a trial-and-error approach monitored by a multidisciplinary team. Long-term safety and efficacy demand continuous real-life patient data review. In summary, while KD presents a promising alternative for DRE, its success relies on meticulous planning, individualized implementation, and ongoing research to address existing challenges and information gaps.
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Affiliation(s)
- Youmna Faheem
- Pediatrics, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Amisha Jaiswal
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kainaat Shergill
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kusalik Boppana
- Internal Medicine and Gastroenterology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Naiela E Almansouri
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, University of Tripoli, Tripoli, LBY
| | - Saloni Bakkannavar
- Pediatrics, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ann Kashmer Yu
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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4
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Falsaperla R, Sortino V, Striano P, Kluger G, Ramantani G, Ruggieri M. Is ketogenic diet a 'precision medicine'? Recent developments and future challenges. Eur J Paediatr Neurol 2024; 48:13-16. [PMID: 37984007 DOI: 10.1016/j.ejpn.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/26/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023]
Abstract
Recently, precision medicine has attracted much attention in the management of epilepsies, but it remains unclear if the increasingly utilized ketogenic diet approaches can truly be considered precision medicine in all epilepsy treatment. Currently, it is the standard treatment for patients with GLUT1 deficiency and the latest NICE guidelines highlight ketogenic diet as a therapeutic option for multi-drug resistant epilepsy patients. Ketogenic diet is presumed to be a precision medicine tool when applied to the treatment of seizures secondary to GLUT1 transporter deficiency. In contrast, the genetic and epigenetic mechanisms modulated by ketogenic diet and underlying its efficacy in other epilepsy types can only be hypothesized to relate to mechanisms of neuroprotection, neuromodulation, and reduction of neuroinflammation. Early ketogenic diet initiation in well-selected patients, would allow immediate action in the direction of neuroprotection and modulation of neuroinflammation, ensuring higher success rates and lower "cost" to the patient in terms of quality of life and comorbidities. These considerations have fueled an increasing interest in investigating the efficacy, side effects, and adherence to long-term use of the ketogenic diet in epilepsy treatment in large contemporary cohorts, available within the scope of multicentric collaborations, such as the European Network for Therapy in Rare Epilepsies (NETRE). Future directions should involve the use of precision medicine, applied to each patient with the help of "omics", whose use should be expanded and inclusive.
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Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico "Rodolico-San Marco", San Marco Hospital, University of Catania, Catania, Italy; Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco", San Marco Hospital, Catania, Italy.
| | - Vincenzo Sortino
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco", San Marco Hospital, Catania, Italy; Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pasquale Striano
- IRCCS 'G. Gaslini Institute', Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.
| | - Gerhard Kluger
- Research Institute for Rehabilitation, Transition, and Palliation, PMU Salzburg, Salzburg, Austria; Epilepsy Center for Children and Adolescents, Schön Clinic Vogtareuth, Vogtareuth, Germany
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, and University of Zurich, Zurich, Switzerland.
| | - Martino Ruggieri
- Unit of Clinical Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, AOU "Policlinico", PO "G. Rodolico", via S. Sofia, 78, 95124, Catania, Italy
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5
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Chan HY, Janssen LMM, Wijnen BFM, Hiligsmann M, Majoie MHJM, Evers SMAA. Economic evaluations of nonpharmacological treatments for drug-resistant epilepsy: A systematic review. Epilepsia 2023; 64:2861-2877. [PMID: 37545415 DOI: 10.1111/epi.17742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/08/2023]
Abstract
This study was undertaken to systematically identify and critically appraise all published full economic evaluations assessing the cost-effectiveness of nonpharmacological interventions for patients with drug-resistant epilepsy. The Population, Intervention, Comparison, Outcome, Study criteria was used to design search strategies for the identification and selection of relevant studies. Literature search was performed using the MEDLINE (via PubMed), Embase, International Health Technology Assessment, National Institute for Health Research Economic Evaluation Database, and Cost-Effectiveness Analysis Registry databases to identify articles published between January 2000 and May 2023. Web of Science was additionally used to perform forward and backward referencing. Title, abstract, and full-text screening was performed by two independent researchers. The Consensus Health Economic Criteria (CHEC) checklist and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 were applied for quality assessment. A total of 4470 studies were identified, of which 18 met our inclusion criteria. Twelve of the studies conducted model-based economic evaluation, and others were trial-based. Three studies showed that epilepsy surgery was cost-effective in adults, whereas this remained inconclusive for children (two positive, three negative). Three studies showed negative economic outcome for ketogenic diet in children. One of four studies showed positive results for self-management. For vagus nerve stimulation, one study showed positive results in adults and another one negative results in children. One recent study showed cost-effectiveness of responsive neurostimulation (RNS) in adults. Finally, one study showed promising but inconclusive results for deep brain stimulation (DBS). The mean scores for risk of bias assessment (based on CHEC) and for reporting quality (CHEERS 2022) were 95.8% and 80.5%, respectively. This review identified studies that assessed the cost-effectiveness of nonpharmacological treatments in both adults and children with drug-resistant epilepsy, suggesting that in adults, epilepsy surgery, vagus nerve stimulation, and RNS are cost-effective, and that DBS and self-management appear to be promising. In children, the cost-effectiveness of epilepsy surgery remains inconclusive. Finally, the use of ketogenic diet was shown not to be cost-effective. However, limited long-term data were available for newer interventions (i.e., ketogenic diet, DBS, and RNS).
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Affiliation(s)
- Hoi Yau Chan
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Luca M M Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Ben F M Wijnen
- Center of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Marian H J M Majoie
- Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, the Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
- School of Health Professions Education, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Kempenhaeghe and Maastricht, the Netherlands
| | - Silvia M A A Evers
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
- Center of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
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6
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Rohwer N, El Hage R, Smyl C, Ocvirk S, Goris T, Grune T, Swidsinski A, Weylandt KH. Ketogenic Diet Has Moderate Effects on the Fecal Microbiota of Wild-Type Mice. Nutrients 2023; 15:4629. [PMID: 37960282 PMCID: PMC10648986 DOI: 10.3390/nu15214629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/17/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
The ketogenic diet (KD) is a high-fat, low-carbohydrate diet that has been reported to have neuroprotective effects. The health effects of KD might be linked to an altered gut microbiome, which plays a major role in host health, leading to neuroprotective effects via the gut-brain axis. However, results from different studies, most often based on the 16S rRNA gene and metagenome sequencing, have been inconsistent. In this study, we assessed the effect of a 4-week KD compared to a western diet (WD) on the colonic microbiome of female C57Bl/6J mice by analyzing fecal samples using fluorescence in situ hybridization. Our results showed distinct changes in the total number of gut bacteria following the 4-week KD, in addition to changes in the composition of the microbiome. KD-fed mice showed higher absolute numbers of Actinobacteria (especially Bifidobacteria spp.) and lower absolute levels of Proteobacteria, often linked to gut inflammation, in comparison with WD-fed mice. Furthermore, an increased abundance of the typically rare genus Atopobium was observed. These changes may indicate the possible anti-inflammatory effects of the KD. However, since the overall changes in the microbiota seem low, the KD effects might be linked to the differential abundance of only a few key genera in mice.
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Affiliation(s)
- Nadine Rohwer
- Medical Department B, Division of Hepatology, Gastroenterology, Oncology, Hematology, Endocrinology and Diabetes, Brandenburg Medical School, University Hospital Ruppin-Brandenburg, 16816 Neuruppin, Germany;
- Faculty of Health Sciences, Joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, Brandenburg Medical School and University of Potsdam, 14476 Potsdam, Germany
- Department of Molecular Toxicology, German Institute of Human Nutrition Potsdam-Rehbruecke, 14558 Nuthetal, Germany
| | - Racha El Hage
- Department of Vascular Surgery, University Hospital Ruppin-Brandenburg, Brandenburg Medical School, 16816 Neuruppin, Germany;
| | - Christopher Smyl
- Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Soeren Ocvirk
- Intestinal Microbiology Research Group, German Institute of Human Nutrition Potsdam-Rehbruecke, 14558 Nuthetal, Germany
- ZIEL—Institute for Food and Health, Technical University of Munich, 85354 Freising-Weihenstephan, Germany
| | - Tobias Goris
- Intestinal Microbiology Research Group, German Institute of Human Nutrition Potsdam-Rehbruecke, 14558 Nuthetal, Germany
| | - Tilman Grune
- Department of Molecular Toxicology, German Institute of Human Nutrition Potsdam-Rehbruecke, 14558 Nuthetal, Germany
| | - Alexander Swidsinski
- Medical Department, Division of Hepatology and Gastroenterology, Campus Mitte, Charité Universitätsmedizin, 10117 Berlin, Germany
- Department of General Hygiene, Institute of Public Health, M Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
| | - Karsten-H. Weylandt
- Medical Department B, Division of Hepatology, Gastroenterology, Oncology, Hematology, Endocrinology and Diabetes, Brandenburg Medical School, University Hospital Ruppin-Brandenburg, 16816 Neuruppin, Germany;
- Faculty of Health Sciences, Joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, Brandenburg Medical School and University of Potsdam, 14476 Potsdam, Germany
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Hone-Blanchet A, Antal B, McMahon L, Lithen A, Smith NA, Stufflebeam S, Yen YF, Lin A, Jenkins BG, Mujica-Parodi LR, Ratai EM. Acute administration of ketone beta-hydroxybutyrate downregulates 7T proton magnetic resonance spectroscopy-derived levels of anterior and posterior cingulate GABA and glutamate in healthy adults. Neuropsychopharmacology 2023; 48:797-805. [PMID: 35995971 PMCID: PMC10066400 DOI: 10.1038/s41386-022-01364-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/08/2022]
Abstract
Glucose metabolism is impaired in brain aging and several neurological conditions. Beneficial effects of ketones have been reported in the context of protecting the aging brain, however, their neurophysiological effect is still largely uncharacterized, hurdling their development as a valid therapeutic option. In this report, we investigate the neurochemical effect of the acute administration of a ketone d-beta-hydroxybutyrate (D-βHB) monoester in fasting healthy participants with ultrahigh-field proton magnetic resonance spectroscopy (MRS). In two within-subject metabolic intervention experiments, 7 T MRS data were obtained in fasting healthy participants (1) in the anterior cingulate cortex pre- and post-administration of D-βHB (N = 16), and (2) in the posterior cingulate cortex pre- and post-administration of D-βHB compared to active control glucose (N = 26). Effect of age and blood levels of D-βHB and glucose were used to further explore the effect of D-βHB and glucose on MRS metabolites. Results show that levels of GABA and Glu were significantly reduced in the anterior and posterior cortices after administration of D-βHB. Importantly, the effect was specific to D-βHB and not observed after administration of glucose. The magnitude of the effect on GABA and Glu was significantly predicted by older age and by elevation of blood levels of D-βHB. Together, our results show that administration of ketones acutely impacts main inhibitory and excitatory transmitters in the whole fasting cortex, compared to normal energy substrate glucose. Critically, such effects have an increased magnitude in older age, suggesting an increased sensitivity to ketones with brain aging.
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Affiliation(s)
- Antoine Hone-Blanchet
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA
| | - Botond Antal
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794, USA
| | - Liam McMahon
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794, USA
| | - Andrew Lithen
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794, USA
| | - Nathan A Smith
- Center for Neuroscience Research, Children's National Research Institute, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, 20012, USA
- Del Monte Institute for Neuroscience, Department of Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - Steven Stufflebeam
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA
| | - Yi-Fen Yen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA
| | - Alexander Lin
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA
| | - Bruce G Jenkins
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA
| | - Lilianne R Mujica-Parodi
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794, USA
- Laufer Center for Physical and Quantitative Biology, Stony Brook University, Stony Brook, NY, 11794, USA
- Department of Physics and Astronomy, Stony Brook University, Stony Brook, NY, 11794, USA
| | - Eva-Maria Ratai
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02129, USA.
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8
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He F, Qiu J, Li H, Guo H, Wang S, Ding Y, Xu S, Wang Z, Feng J, Zhang P, Ding M, Wang S. Efficacy of the ketogenic diet in Chinese adults versus children with drug-resistant epilepsy: A pilot study. Epilepsy Behav 2022; 134:108820. [PMID: 35839644 DOI: 10.1016/j.yebeh.2022.108820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We compared the efficacy and safety of ketogenic diet (KD) therapy as a treatment for Chinese adults versus children with drug-resistant epilepsy. METHODS The classic KD was initiated in 19 adults and 29 children with drug-resistant epilepsy. The KD ratio and the dosage of antiseizure medication (ASM) were delicately modulated by the ketogenic team. RESULTS At 12 months after diet initiation, 11 adults (8 on a KD ratio of 3:1 and 3 on a ratio of 2:1) and 20 children (9 on a ketogenic diet ratio of 3:1 and 11 on a ratio of 2:1) remained on the diet. The retention rate for adult KD therapy recipients was 79.0% at 6 months and 57.9% at 12 months after diet initiation, which was not significantly different from the retention rate for children (82.8% at 6 months and 68.9% at 12 months; P > 0.05). The efficacy rate of KD therapy (seizure freedom or ≥50% reduction in seizure frequency) did not significantly differ between adults (63.2%) and children (75.8%, P = 0.517). Alleviation of seizure severity was observed in 68.4% of adults and 63.6% of children who were not seizure free on KD therapy. Antiseizure medication was reduced in 34 out of all 48 individuals at the final follow-up. CONCLUSION Our study demonstrated that KD therapy is a safe and effective treatment for Chinese adults as well as children with drug-resistant epilepsy.
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Affiliation(s)
- Fang He
- Department of Nutrition, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingjing Qiu
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hong Li
- Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huilan Guo
- Department of Nutrition, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shan Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yao Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Sha Xu
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhongjin Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianhua Feng
- Department of Pediatrics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Pianhong Zhang
- Department of Nutrition, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Meiping Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuang Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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9
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Carroll JH, Martin-McGill KJ, Cross JH, Hickson M, Williams E, Aldridge V, Collinson A. Core outcome set development for childhood epilepsy treated with ketogenic diet therapy: Results of a scoping review and parent interviews. Seizure 2022; 99:54-67. [PMID: 35598573 DOI: 10.1016/j.seizure.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/23/2022] [Accepted: 05/10/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Clinical trials on childhood epilepsy treated with ketogenic diet (KD) use a wide range of outcomes, however, patients and decision-makers often do not perceive the outcomes used as the most important. We sought parental opinion on outcomes of importance and compared these to outcomes reported in published research. METHODS Ethical approval (London-Surrey-REC19/LO/1680). A scoping review identified outcomes reported in previous studies of childhood epilepsy and KD. Parents were recruited from nine KD centres (UK), charities and social media (international), then interviewed (Jan-April 2020) to explore priority outcomes. Content analysis identified all outcomes in transcripts. Parent identified outcomes were compared with those in the scoping review. Outcomes were collated and grouped into domains according to the COMET Taxonomy. RESULTS Of 2663 articles;147 met inclusion criteria. 921 verbatim outcomes were sorted into 90 discrete outcomes, reduced to 70 in consultation with the study advisory group, then classified into 21 domains. Parents (n = 21) identified 39 outcomes as important from the scoping review and seven new outcomes. They prioritised both physiological and functional outcomes in contrast to past studies, which prioritised physiological outcomes. CONCLUSION Little consistency exists in the outcomes used in childhood epilepsy and KD research. Those traditionally used do not adequately reflect parents' important outcomes for their child. Clinical trials should consider the broader priorities of parents when choosing outcomes, in particular, functional outcomes. Identified outcomes will inform an international two-round Delphi-study with parent, professional and researcher participants to develop a core outcome set for this clinical area (COMET registration #1116).
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Affiliation(s)
| | | | - J Helen Cross
- Developmental Neurosciences, UCL, NIHR BRC Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mary Hickson
- Faculty of Health, University of Plymouth, Devon, United Kingdom
| | - Emma Williams
- Matthew's Friends, Lingfield, Surrey, United Kingdom
| | - Val Aldridge
- Matthew's Friends, Lingfield, Surrey, United Kingdom
| | - Avril Collinson
- Faculty of Health, University of Plymouth, Devon, United Kingdom
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Desli E, Spilioti M, Evangeliou A, Styllas F, Magkos F, Dalamaga M. The Efficacy and Safety of Ketogenic Diets in Drug-Resistant Epilepsy in Children and Adolescents: a Systematic Review of Randomized Controlled Trials. Curr Nutr Rep 2022; 11:102-116. [PMID: 35303283 DOI: 10.1007/s13668-022-00405-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Drug-resistant epilepsy represents around one-quarter of epilepsies worldwide. Although ketogenic diets (KD) have been used for refractory epilepsy since 1921, the past 15 years have witnessed an explosion of KD use in the management of epilepsy. We aimed to review evidence from randomized controlled trials (RCTs) regarding the efficacy and safety of KD in drug-resistant epilepsy in children and adolescents. RECENT FINDINGS A literature search was performed in the Pubmed, Cohrane, Scopus, ClinicalTrials.gov, and Google Scholar databases. Predefined criteria were implemented regarding data extraction and study quality. Data were extracted from 14 RCTs in 1114 children and adolescents aged from 6 months to 18 years. Primary outcome was seizure reduction after the intervention. In 6 out of the 14 studies, there was a statistical significant seizure reduction by > 50% in the KD-treated group compared with the control group over a follow-up of 3-4 months. Secondary outcomes were adverse events, seizure severity, quality of life, and behavior. Gastrointestinal symptoms were the most frequent adverse events. Serious adverse events were rare. We conclude that the KD is an effective treatment for drug-resistant epilepsy in children and adolescents. Accordingly, RCTs investigating long-term impact, cognitive and behavioral effects, and cost-effectiveness are much anticipated.
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Affiliation(s)
- Evangelia Desli
- 4th Department of Pediatrics, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece.
| | - Martha Spilioti
- 1st Department of Neurology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Athanasios Evangeliou
- 4th Department of Pediatrics, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Foteinos Styllas
- 1st Department of Ophthalmology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Faidon Magkos
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian, University of Athens, Athens, Greece
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11
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Pizzo F, Collotta AD, Di Nora A, Costanza G, Ruggieri M, Falsaperla R. Ketogenic diet in pediatric seizures: a randomized controlled trial review and Meta-Analysis. Expert Rev Neurother 2022; 22:169-177. [PMID: 35144527 DOI: 10.1080/14737175.2022.2030220] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The ketogenic diet is a non-pharmacologic treatment option for children with drug-resistant epilepsy. This systematic review and meta-analysis aimed to assess the efficacy of the ketogenic diet on seizures frequency in children. METHODS We reviewed the literature using Cochrane, EMBASE, MEDLINE, and highly qualified journals. Randomized controlled trials were chosen to investigate the seizures-free regime or at least 50% seizures reduction after three months from the starting of the ketogenic diet or earlier. We have selected articles from January 2011 to January 2020. RESULTS Eight articles were eligible. The data show a significant reduction in seizure frequency in the dietary treatment pediatric population. The rate of a seizures-free regime or at least 50% seizures reduction was 48.31% of patients in the intervention group. Our overall meta-analysis underlined the significant efficacy. The KD group is 5.6 times more likely than the control group to have a 50% reduction of seizures after three months of the diet or earlier. QUADAS and AMSTAR assessments showed a low risk of bias and adequate accuracy. CONCLUSION The results show that the KD reduces seizure frequency in children with drug-refractory epilepsy. KD is an effective treatment option for children and adolescents with refractory epilepsy.
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Affiliation(s)
- Francesco Pizzo
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ausilia Desiree Collotta
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessandra Di Nora
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giuseppe Costanza
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, AOU "Policlinico", PO "G. Rodolico", Via S. Sofia, 87, 95128, Catania, Italy
| | - Raffaele Falsaperla
- General Pediatrics and Pediatric Acute and Emergency Unit,Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico-San Marco, San Marco Hospital, University of Catania, Catania, Italy
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Analysis of Factors That May Affect the Effectiveness of Ketogenic Diet Treatment in Pediatric and Adolescent Patients. J Clin Med 2022; 11:jcm11030606. [PMID: 35160058 PMCID: PMC8836595 DOI: 10.3390/jcm11030606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/16/2022] [Accepted: 01/23/2022] [Indexed: 02/06/2023] Open
Abstract
Purpose. The aim was to find predictors for ketogenic diet (KD) treatment effectiveness. In addition, recognized factors influencing the efficacy of KD were analyzed based on the ILAE (International League Against Epilepsy) proposed Classification and Definition of the Epilepsy Syndromes. Methods. A sample of 42 patients treated with KD were analyzed. The effectiveness of KD was assessed according to the type of diet, the type of seizures, and the known (KE) or undetermined genetic etiology (UNKE). The group of KE consisted of patients with CACNA1S, CHD2, DEPDC5, KIF1A, PIGN, SCN1A, SCN8A, SLC2A1, SYNGAP1 pathogenic variants. The usefulness of the new Classification and Definition of Epilepsy Syndromes proposed by the ILAE was evaluated. Results. KD therapy was effective in 69.05% of cases. No significant correlation was observed with the type of diet used. KE was related to greater effectiveness after KD treatment. KD treatment was most effective in the reduction of non-focal seizures. Considering the ILAE proposed classification, it was found that KD efficacy was higher in patients with simultaneous focal and tonic-clonic seizures compared to patients with only tonic-clonic or focal seizures. Conclusion. The occurrence of focal seizures does not determine the potential ineffectiveness of treatment with a ketogenic diet. A significant efficacy of ketogenic diet treatment was observed in the group of patients with focal and generalized seizures, as well as epileptic and developmental encephalopathies. The etiology of epileptic seizures plays a more significant role. The new classification will make it easier to select patients who can benefit from this form of treatment.
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Ketogenic diet for epilepsy: an overview of systematic review and meta-analysis. Eur J Clin Nutr 2022; 76:1234-1244. [PMID: 35027683 DOI: 10.1038/s41430-021-01060-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 11/24/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023]
Abstract
Ketogenic diet therapy (KDT) is an established nonpharmacologic treatment in various types of epilepsy. We aim to evaluate the quality of the systematic reviews and meta-analyses (SRMAs) of KDT for epilepsy and summarize the evidence on their effects. We conducted an overview on MEDLINE, EMBASE, Cochrane Database of Systematic Review, and Web of Science from database inception to 3 September 2020. Two investigators independently performed study selection to include SRMAs, extracted data and assessed the quality of SRMAs with the AMSTAR-2 and PRISMA statement. Twenty-four SRMAs were selected which encompassed a total of 255 original studies. Four reviews assessed the effects of KDT on infant patients; thirteen reviews reported on children and adolescent patients; eight reviews focused on adults or all patients; four assessed cognitive and behavior outcomes; three assessed quality of life; two assessed growth and development outcomes; seventeen reported on adverse effects; seven reported on retention; ten reported on attrition and reasons; and four reported on death outcomes. Overall, positive effects of KDT for epilepsy on seizure frequency reduction, as well as cognition and behavior were observed. In contrast, the effects of KDT on quality of life, growth and development were more controversial. The present overview indicates that KDT is safe. The most prevalent adverse events were GI, weight loss, and metabolic disorders, while the most common reasons for discontinuance were the lack of observed efficacy and dietary intolerance.
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15
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Ünalp A, Baysal BT, Sarıtaş S, Güzin Y, Edizer S, Akışın Z, Yılmaz Ü. Evaluation of the effects of ketogenic diet therapy on sleep quality in children with drug-resistant epilepsy and their mothers. Epilepsy Behav 2021; 124:108327. [PMID: 34627070 DOI: 10.1016/j.yebeh.2021.108327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Sleep disorders are common in drug-resistant children with epilepsy and their mothers. Ketogenic diet therapy (KDT) may have positive effects on sleep quality. The aim of this study was to evaluate the sleep quality of children with epilepsy and their mothers after starting KDT. METHODS Using a prospective cross-sectional model, pre- and post-KDT questionnaires were given to the study subjects. A children's sleep habits questionnaire was administered to children with epilepsy, and the Pittsburgh sleep questionnaire was administered to their mothers. Sociodemographic and some clinical categorical variables of the patient group were evaluated using descriptive statistics. Evaluation of the data was conducted using the Wilcoxon and paired t-tests as parametric and non-parametric tests. RESULTS Of 24 patients scheduled to begin KDT between January 2019 and January 2020, 14 were included in the study. Regarding sleep quality, improvement was reported in 7 (50%) of 14 patients, deterioration in 5 (35.7%) patients, and no change was seen in 2 (14.3%) patients. Sleep quality was reported to improve in all working mothers. Seven (50%) patients reported no seizures and 6 (42.9%) patients reported more than 50% seizure reduction. Although there were improvements in sleep scores in both groups, these improvements were not statistically significant. A significant decrease in sleep anxiety was reported in children after the third month of the KDT (p = 0.09). CONCLUSIONS The results of this study determined that three months of KDT offered significant improvement on the sleep anxiety of children with epilepsy. It was thought that paying attention to patient selection may lead to better sleep quality by increasing compliance to KDT. However, a larger scale study and longer term follow-up should be done.
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Affiliation(s)
- Aycan Ünalp
- Health Sciences University, İzmir Faculty of Medicine, Department of Pediatrics-İzmir, Turkey.
| | - Bahar Toklu Baysal
- Health Sciences University, Dr. Behçet Uz Childrens Education and Research Hospital, Department of Pediatric Neurology-İzmir, Turkey
| | - Serdar Sarıtaş
- Health Sciences University, Dr. Behçet Uz Childrens Education and Research Hospital, Department of Pediatric Neurology-İzmir, Turkey
| | - Yiğithan Güzin
- Health Sciences University, Dr. Behçet Uz Childrens Education and Research Hospital, Department of Pediatric Neurology-İzmir, Turkey
| | - Selvinaz Edizer
- Health Sciences University, İzmir Faculty of Medicine, Department of Pediatrics-İzmir, Turkey
| | - Zeynep Akışın
- Health Sciences University Dr. Behçet Uz Childrens Education and Research Hospital, Department of Nutrition and Dietitian, İzmir, Turkey
| | - Ünsal Yılmaz
- Health Sciences University, İzmir Faculty of Medicine, Department of Pediatrics-İzmir, Turkey
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Takahara S, Soni S, Maayah ZH, Ferdaoussi M, Dyck JRB. Ketone Therapy for Heart Failure: Current Evidence for Clinical Use. Cardiovasc Res 2021; 118:977-987. [PMID: 33705533 DOI: 10.1093/cvr/cvab068] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/09/2021] [Accepted: 03/09/2021] [Indexed: 02/07/2023] Open
Abstract
During conditions that result in depleted circulating glucose levels, ketone bodies synthesized in the liver are necessary fuel substrates for the brain. In other organs such as the heart, the reliance on ketones for generating energy is less life threatening as the heart can utilize alternative fuel sources such as fatty acids. However, during pathophysiological conditions such as heart failure, cardiac defects in metabolic processes that normally allow for sufficient energy production from fatty acids and carbohydrates contribute to a decline in contractile function. As such, it has been proposed that the failing heart relies more on ketone bodies as an energy source than previously appreciated. Furthermore, it has been suggested that ketone bodies may function as signaling molecules that can suppress systemic and cardiac inflammation. Thus, it is possible that intentionally elevating circulating ketones may be beneficial as an adjunct treatment for heart failure. Although many approaches can be used for 'ketone therapy', each of these has their own advantages and disadvantages in the treatment of heart failure. Thus, we summarize current preclinical and clinical studies involving various types of ketone therapy in cardiac disease and discuss the advantages and disadvantages of each modality as possible treatments for heart failure.
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Affiliation(s)
- Shingo Takahara
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Shubham Soni
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Zaid H Maayah
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mourad Ferdaoussi
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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17
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A Concise Review of Ketogenic Dietary Interventions in the Management of Rare Diseases. J Nutr Metab 2021; 2021:6685581. [PMID: 33628494 PMCID: PMC7899763 DOI: 10.1155/2021/6685581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/29/2021] [Indexed: 11/20/2022] Open
Abstract
Dietary interventions are now being used as an adjunct therapy in the treatment of rare diseases. One such method is the high-fat, moderate-protein, and very low-carbohydrate diet which produces ketosis and therefore called the ketogenic diet. Some of the more common conditions that are treated with this method are pharmacoresistant epilepsy, infantile spasms, glycogen storage diseases, and other forms of rare metabolic disturbances. With this review, we look at different uses of the ketogenic diet in treating rare diseases and the recommendations based on current evidence.
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Christensen MG, Damsgaard J, Fink-Jensen A. Use of ketogenic diets in the treatment of central nervous system diseases: a systematic review. Nord J Psychiatry 2021; 75:1-8. [PMID: 32757903 DOI: 10.1080/08039488.2020.1795924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Studies have consistently shown that patients with epilepsy could benefit from ketogenic diets (KDs). Recent evidence suggests that KD could be used in the treatment of central nervous system (CNS) diseases. The aim of this systematic review was to investigate the use and efficacy of KD, modified Atkins diet (MAD) and medium-chain triglyceride (MCT) diet in infants, children, adolescents, and adults with CNS diseases. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Main databases, i.e. EMBASE, PubMed and PsycINFO, were searched on 4 December 2019. Only randomized clinical trials (RCTs) were included and only if they reported KD, MCT or MAD interventions on patients with CNS diseases. RESULTS Twenty-four publications were eligible for inclusion (n = 1221). Twenty-one publications concerned epilepsy, two concerned Alzheimer's disease (AD), and one concerned Parkinson's disease (PD). All studies regarding epilepsy reported of seizure reduction compared to baseline. MCT did not significantly change regional cerebral blood flow (rCBF) in patients with AD, but MAD significantly improved memory at 6 weeks (p = .03). KD significantly improved motor and nonmotor functions in patients with PD at 8 weeks (p < .001). There was a trend towards fewer adverse effects in MAD compared to KD. CONCLUSION In conclusion, various forms of KDs seem tolerable and effective as part of the treatment for epilepsy, AD and PD, although more investigation concerning the mechanism, efficacy and adverse events is necessary.
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Affiliation(s)
| | - Jakob Damsgaard
- Psychiatric Centre Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Anders Fink-Jensen
- Psychiatric Centre Copenhagen, University of Copenhagen, Copenhagen, Denmark
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Diet in the Treatment of Epilepsy: What We Know So Far. Nutrients 2020; 12:nu12092645. [PMID: 32872661 PMCID: PMC7551815 DOI: 10.3390/nu12092645] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023] Open
Abstract
Epilepsy is a chronic and debilitating neurological disorder, with a worldwide prevalence of 0.5–1% and a lifetime incidence of 1–3%. An estimated 30% of epileptic patients continue to experience seizures throughout life, despite adequate drug therapy or surgery, with a major impact on society and global health. In recent decades, dietary regimens have been used effectively in the treatment of drug-resistant epilepsy, following the path of a non-pharmacological approach. The ketogenic diet and its variants (e.g., the modified Atkins diet) have an established role in contrasting epileptogenesis through the production of a series of cascading events induced by physiological ketosis. Other dietary regimens, such as caloric restriction and a gluten free diet, can also exert beneficial effects on neuroprotection and, therefore, on refractory epilepsy. The purpose of this review was to analyze the evidence from the literature about the possible efficacy of different dietary regimens on epilepsy, focusing on the underlying pathophysiological mechanisms, safety, and tolerability both in pediatric and adult population. We believe that a better knowledge of the cellular and molecular biochemical processes behind the anticonvulsant effects of alimentary therapies may lead to the development of personalized dietary intervention protocols.
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Abstract
BACKGROUND Ketogenic diets (KDs) are high in fat and low in carbohydrates and have been suggested to reduce seizure frequency in people with epilepsy. Such diets may be beneficial for children with drug-resistant epilepsy. This is an update of a review first published in 2003, and last updated in 2018. OBJECTIVES To assess the effects of ketogenic diets for people with drug-resistant epilepsy. SEARCH METHODS For this update, we searched the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 26 April 2019) on 29 April 2019. The Cochrane Register of Studies includes the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), and randomised controlled trials (RCTs) from Embase, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We imposed no language restrictions. We checked the reference lists of retrieved studies for additional relevant studies. SELECTION CRITERIA RCTs or quasi-RCTs of KDs for people of any age with drug-resistant epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently applied predefined criteria to extract data and evaluated study quality. We assessed the outcomes: seizure freedom, seizure reduction (50% or greater reduction in seizure frequency), adverse effects, cognition and behaviour, quality of life, and attrition rate. We incorporated a meta-analysis. We utilised an intention-to-treat (ITT) population for all primary analyses. We presented the results as risk ratios (RRs) with 95% confidence intervals (CIs). MAIN RESULTS We identified 13 studies with 932 participants; 711 children (4 months to 18 years) and 221 adults (16 years and over). We assessed all 13 studies to be at high risk of performance and detection bias, due to lack of blinding. Assessments varied from low to high risk of bias for all other domains. We rated the evidence for all outcomes as low to very low certainty. Ketogenic diets versus usual care for children Seizure freedom (RR 3.16, 95% CI 1.20 to 8.35; P = 0.02; 4 studies, 385 participants; very low-certainty evidence) and seizure reduction (RR 5.80, 95% CI 3.48 to 9.65; P < 0.001; 4 studies, 385 participants; low-certainty evidence) favoured KDs (including: classic KD, medium-chain triglyceride (MCT) KD combined, MCT KD only, simplified modified Atkins diet (MAD) compared to usual care for children. We are not confident that these estimated effects are accurate. The most commonly reported adverse effects were vomiting, constipation and diarrhoea for both the intervention and usual care group, but the true effect could be substantially different (low-certainty evidence). Ketogenic diet versus usual care for adults In adults, no participants experienced seizure freedom. Seizure reduction favoured KDs (MAD only) over usual care but, again, we are not confident that the effect estimated is accurate (RR 5.03, 95% CI 0.26 to 97.68; P = 0.29; 2 studies, 141 participants; very low-certainty evidence). Adults receiving MAD most commonly reported vomiting, constipation and diarrhoea (very low-certainty evidence). One study reported a reduction in body mass index (BMI) plus increased cholesterol in the MAD group. The other reported weight loss. The true effect could be substantially different to that reported. Ketogenic diet versus ketogenic diet for children Up to 55% of children achieved seizure freedom with a classical 4:1 KD after three months whilst up to 85% of children achieved seizure reduction (very low-certainty evidence). One trial reported a greater incidence of seizure reduction with gradual-onset KD, as opposed to fasting-onset KD. Up to 25% of children were seizure free with MAD and up to 60% achieved seizure reduction. Up to 25% of children became seizure free with MAD and up to 60% experienced seizure reduction. One study used a simplified MAD (sMAD) and reported that 15% of children gained seizure freedom rates and 56% achieved seizure reduction. We judged all the evidence described as very low certainty, thus we are very unsure whether the results are accurate. The most commonly reported adverse effects were vomiting, constipation and diarrhoea (5 studies, very low-certainty evidence). Two studies reported weight loss. One stated that weight loss and gastrointestinal disturbances were more frequent, with 4:1 versus 3:1 KD, whilst one reported no difference in weight loss with 20 mg/d versus 10 mg/d carbohydrates. In one study, there was a higher incidence of hypercalcuria amongst children receiving classic KD compared to MAD. All effects described are unlikely to be accurate. Ketogenic diet versus ketogenic diet for adults One study randomised 80 adults (aged 18 years and over) to either MAD plus KetoCal during the first month with MAD alone for the second month, or MAD alone for the first month followed by MAD plus KetoCal for the second month. No adults achieved seizure freedom. More adults achieved seizure reduction at one month with MAD alone (42.5%) compared to MAD plus KetoCal (32.5%), however, by three months only 10% of adults in both groups maintained seizure reduction. The evidence for both outcomes was of very low certainty; we are very uncertain whether the effects are accurate. Constipation was more frequently reported in the MAD plus KetoCal group (17.5%) compared to the MAD only group (5%) (1 study, very low-certainty evidence). Diarrhoea and increase/change in seizure pattern/semiology were also commonly reported (17.5% to 20% of participants). The true effects of the diets could be substantially different to that reported. AUTHORS' CONCLUSIONS The evidence suggests that KDs could demonstrate effectiveness in children with drug-resistant epilepsy, however, the evidence for the use of KDs in adults remains uncertain. We identified a limited number of studies which all had small sample sizes. Due to the associated risk of bias and imprecision caused by small study populations, the evidence for the use of KDs was of low to very low certainty. More palatable but related diets, such as the MAD, may have a similar effect on seizure control as the classical KD, but could be associated with fewer adverse effects. This assumption requires more investigation. For people who have drug-resistant epilepsy or who are unsuitable for surgical intervention, KDs remain a valid option. Further research is required, particularly for adults with drug-resistant epilepsy.
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Affiliation(s)
- Kirsty J Martin-McGill
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Clinical Sciences and Nutrition, University of Chester, Chester, UK
| | - Rebecca Bresnahan
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Paul N Cooper
- Centre for Clinical Neurosciences, Salford Royal Hospitals NHS Trust, Salford, UK
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Wells J, Swaminathan A, Paseka J, Hanson C. Efficacy and Safety of a Ketogenic Diet in Children and Adolescents with Refractory Epilepsy-A Review. Nutrients 2020; 12:nu12061809. [PMID: 32560503 PMCID: PMC7353240 DOI: 10.3390/nu12061809] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023] Open
Abstract
Epilepsy in the pediatric and adolescent populations is a devastating condition where individuals are prone to recurrent epileptic seizures or changes in behavior or movement that is the direct result of a primary change in the electrical activity in the brain. Although many children with epilepsy will have seizures controlled with antiseizure medications (ASMs), a large percentage of patients are refractory to drug therapy and may consider initiating a ketogenic diet. The term Ketogenic Diet or Ketogenic Diet Therapy (KDT) refers to any diet therapy in which dietary composition results in a ketogenic state of human metabolism. Currently, there are 4 major Ketogenic diet therapies—the classic ketogenic diet (cKD), the modified Atkins diet (MAD), the medium chain triglyceride ketogenic diet (MCTKD) and the low glycemic index treatment (LGIT). The compositions of the 4 main KDTs differ and limited evidence to distinguish the efficacy among different diets currently exists. Although it is apparent that more randomized controlled trials (RCTs) and long-term studies are needed to evaluate efficacy, side effects and individual response to the diet, it is imperative to study and understand the metabolic profiles of patients with epilepsy in order to isolate which dietary restrictions are necessary to maximize clinical benefit.
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Affiliation(s)
- Jana Wells
- College of Allied Health Professions, University of Nebraska Medical Center, 984045 Nebraska Medical Center, Omaha, NE 68198-4045, USA;
- Correspondence:
| | - Arun Swaminathan
- Department of Neurological Sciences, University of Nebraska Medical Center, 988440 Nebraska Medical Center, Omaha, NE 68198-8440, USA;
| | - Jenna Paseka
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine 4350 Dewey Ave, Omaha, NE 68105, USA;
| | - Corrine Hanson
- College of Allied Health Professions, University of Nebraska Medical Center, 984045 Nebraska Medical Center, Omaha, NE 68198-4045, USA;
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Ketogenic diet for the treatment of pediatric epilepsy: review and meta-analysis. Childs Nerv Syst 2020; 36:1099-1109. [PMID: 32173786 DOI: 10.1007/s00381-020-04578-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
UNLABELLED The ketogenic diet (KD), containing high levels of fat and low levels of carbohydrates, has been used to treat refractory epilepsy since the 1920s. In the past few decades, there has been more interest in less restrictive KDs such as the modified Atkins diet (MAD). PURPOSE Our aim was to review all evidence regarding the efficacy and tolerability of the KD and MAD from randomized controlled trials (RCTs) in children and adolescents with refractory epilepsy. METHODS We reviewed the current literature using Cochrane, EMBASE, and MEDLINE (using PubMed). We implemented predefined criteria regarding dataextraction and study quality. RESULTS We identified five RCTs that generated seven publications and recruited 472 children and adolescents with refractory epilepsy (≤ 18 years). The primary outcome (seizure frequency reduction (SFR) ≥ 50%) was attained in 35-56.1% of the participants in the intervention group, compared with 6-18.2% in the control group. Our meta-analysis underlined the significant efficacy of the KD compared with the control group: RR = 5.1 (95% CI 3.18-8.21, p < 0.001). Additionally, only two studies mentioned possible biomarkers to objectively evaluate the efficacy. Secondary outcomes, such as seizure severity and quality of life, were studied in three trials, leading to indecisive generalization of these findings. Gastro-intestinal adverse effects were the most prevalent, and no severe adverse effects were reported. CONCLUSION Despite the heterogeneity between all studies, the beneficial results underline that dietary interventions should be considered for children and adolescents with refractory epilepsy who are not eligible for epilepsy surgery. Future studies should be multi-center and long-term, and evaluate potential biomarkers and adverse effects.
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Na JH, Kim HD, Lee YM. Effective and safe diet therapies for Lennox-Gastaut syndrome with mitochondrial dysfunction. Ther Adv Neurol Disord 2020; 13:1756286419897813. [PMID: 32082420 PMCID: PMC7005978 DOI: 10.1177/1756286419897813] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Lennox-Gastaut syndrome (LGS) is a typical intractable form of epilepsy that most often occurs between the second and sixth year of life. This study aimed to evaluate the clinical efficacy and safety of ketogenic diet therapies (DTs) for LGS with mitochondrial dysfunction. Methods: This was a retrospective study involving 20 LGS patients with mitochondrial dysfunction who received several DTs from 2004 to 2014 at a single tertiary care center. Seizure reduction rate, cognitive function, retention rate, electroencephalography (EEG) changes, and adverse effects were examined before and after DTs. Results: The retention rates at 1 and 2 years after initiation of DTs were 45% and 40%, respectively. After 1-year follow up, we observed seizure freedom in two patients, 75% seizure reduction in two patients, 50% reduction in three patients, and 25% reduction in one patient. After 2-year follow up, the outcomes were seizure freedom in two patients, 90% seizure reduction in one patient, 75% reduction in two patients, and 50% reduction in two patients. EEG findings improved in nine patients. Nine patients were treated with DTs for 1 year; all patients demonstrated improved cognitive status. Eight patients were treated with DTs for 2 years, of whom seven had improved cognitive status. Poor tolerability of DTs was due to poor oral intake and gastrointestinal problems. Conclusions: We demonstrate that, in LGS with mitochondrial dysfunction, improvement of seizures and cognitive function are not inferior to those in other patients treated with DTs. This study showed that DTs are efficacious and feasible for LGS patients with mitochondrial dysfunction and can significantly improve their prognosis.
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Affiliation(s)
- Ji-Hoon Na
- Departments of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Heung-Dong Kim
- Departments of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Mock Lee
- Department of Pediatrics, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Korea
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Grimble G, Ryall J. Editorial: Ketogenic diets and tumour hypoxia - kulturkampf and 'the insurgency'. Curr Opin Clin Nutr Metab Care 2019; 22:243-249. [PMID: 31162326 DOI: 10.1097/mco.0000000000000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- George Grimble
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, United Kingdom
| | - James Ryall
- Centre for Muscle Research, Department of Physiology, School of Biomedical Sciences, The University of Melbourne, Victoria, Australia
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A double-blinded randomised dietary supplement crossover trial design to investigate the short-term influence of medium chain fatty acid (MCT) supplement on canine idiopathic epilepsy: study protocol. BMC Vet Res 2019; 15:181. [PMID: 31146740 PMCID: PMC6543566 DOI: 10.1186/s12917-019-1915-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/14/2019] [Indexed: 01/23/2023] Open
Abstract
Background Epilepsy is the most common brain disease in dogs. Recently, diets have been reported to have a positive impact on seizure activity and behaviour in various species including dogs with idiopathic epilepsy (IE). Historically, classic high fat ketogenic diets (KD) and medium chain triglycerides (MCT) KD have been successfully used to manage drug-resistant epilepsy. Similarly, an MCT enriched diet has been shown to improve seizure control and behavioural comorbidities in some dogs with IE. However, it is unknown whether an MCT dietary supplement (DS) may provide similar positive effects. Methods A 6-month prospective, randomised, double-blinded, placebo-controlled, crossover, multicentre dietary trial is designed comparing a 9% metabolic energy based calculated medium-chain triglyceride (MCT) oil supplement to a conventional ‘control’ DS. Only dogs which will have an International Veterinary Epilepsy Task Force Tier II level like diagnosis of IE which satisfied the following inclusion criteria are included: age between 6 months and ≤ 12 years; weighing between 4 and ≤ 65 kg; unremarkable interictal neurological examinations; no clinically significant findings on routine laboratory diagnostics; unremarkable brain MRI scan; have had at least 3 seizures in the previous 3 months prior to enrolment; treated with at least one ASD and being classified as resistant. All dogs are fed initially for 90 ± 2 days with either the control oil or the MCT oil alongside their normal diet, followed by 97 ± 2 days with the other supplement including a 7-day washout period. Overall, the aim is to recruit thirty-six patients at five different centres and to investigate the effect of MCTs as DS on seizure activity, tolerability, behavioural comorbidities and quality of life (QoL). Discussion Dietary interventions are rarely studied in a standardised form in veterinary medicine. The background diet, the cohort of animals and ASD received is standardised in this prospective diet trial to ensure representative data about the potential effect of MCT DS. If the study data confirms former findings, this would provide further evidence for the efficacy of MCTs as a management option for canine epilepsy. This publication should offer a repository of trial conditions and variable description with forecasted statistical analysis. Electronic supplementary material The online version of this article (10.1186/s12917-019-1915-8) contains supplementary material, which is available to authorized users.
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Goswami JN, Sharma S. Current Perspectives On The Role Of The Ketogenic Diet In Epilepsy Management. Neuropsychiatr Dis Treat 2019; 15:3273-3285. [PMID: 31819454 PMCID: PMC6883945 DOI: 10.2147/ndt.s201862] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/18/2019] [Indexed: 12/31/2022] Open
Abstract
Drug-refractory epilepsy is a commonly prevalent pediatric neurological illness of global significance. Ketogenic diet (KD) is a time-tested therapeutic modality for refractory epilepsy, which has reemerged as a robust alternative to anti-epileptic pharmacotherapy. There is a growing body of evidence which supports the anti-seizure efficacy, safety profile and feasibility of KD use in childhood epilepsy. In addition, this modality has been recognized to reduce anti-epileptic exposure, improve cognition and behavioral profile of patients as well as improve the quality-of-life of care-givers. Current indications of KD include refractory epilepsy syndromes, selected metabolic disorders (such as pyruvate dehydrogenase deficiency) and a host of varied neurological entities. KD research has broadened the knowledge-base about its mechanisms of action. Four types of KD are in vogue currently with varying nutritional constitution, palatability, administration protocols and comparable efficacy. KD initiation and maintenance are the result of concerted effort of a team of pediatric neurologist/epileptologist, nutritionist and patient's primary care-giver. Consensus is being formulated about various practical aspects of KD such as patient-selection, parental counseling, baseline work-up, dietary prescription, nutritional supplementation, concurrent anti-epileptic drug administration, follow-up and treatment-duration. Novel applications of KD include its use in neonatal epilepsy and super-refractory status epilepticus and tailor-made formulations such as cooking oil-based KD in predominantly rice-fed populations. Increasing body of clinical experience, improved nutritional designs and translational research are promoting KD as a major therapeutic modality. Currently, KD forms a core essence in the armamentarium against refractory epilepsy. In this review, we summarize the recent advances and current perspectives in the use of KD in refractory epilepsy.
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Affiliation(s)
| | - Suvasini Sharma
- Neurology Division, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi 110001, India
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Martin‐McGill KJ, Jackson CF, Bresnahan R, Levy RG, Cooper PN. Ketogenic diets for drug-resistant epilepsy. Cochrane Database Syst Rev 2018; 11:CD001903. [PMID: 30403286 PMCID: PMC6517043 DOI: 10.1002/14651858.cd001903.pub4] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ketogenic diets (KDs), being high in fat and low in carbohydrates, have been suggested to reduce seizure frequency in people with epilepsy. At present, such diets are mainly recommended for children who continue to have seizures despite treatment with antiepileptic drugs (AEDs) (drug-resistant epilepsy). Recently, there has been interest in less restrictive KDs, including the modified Atkins diet (MAD), and the use of these diets has extended into adult practice. This is an update of a review first published in 2003 and last updated in 2016. OBJECTIVES To assess the effects of KDs for drug-resistant epilepsy by reviewing the evidence from randomised controlled trials. SEARCH METHODS For the latest update we searched the Cochrane Epilepsy Group's Specialized Register (11 April 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 11 April 2017), MEDLINE (Ovid, 11 April 2017), ClinicalTrials.gov (11 April 2017) and the WHO International Clinical Trials Registry Platform (ICTRP, 11 April 2017). We imposed no language restrictions. We checked the reference lists of retrieved studies for additional reports of relevant studies. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials of ketogenic diets for people with drug-resistant epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently applied predefined criteria to extract data and assessed study quality. MAIN RESULTS We identified 11 randomised controlled trials (RCTs) that generated 15 publications.All trials applied an intention-to-treat analysis with varied randomisation methods. The 11 studies recruited 778 patients; 712 children and adolescents and 66 adults. We assessed all 11 studies to be at low to unclear risk of bias for the following domains: random sequence generation, allocation concealment and selective reporting. For the other domains (blinding, incomplete outcome data, other bias) assessments were varied (low, unclear and high risk of bias). We could not conduct a meta-analysis due to the heterogeneity of the studies and the quality of the evidence was low to very low (GRADE ratings).Reported rates of seizure freedom reached as high as 55% in a classical 4:1 KD group after three months and reported rates of seizure reduction reached as high as 85% in a classical 4:1 KD group after three months (GRADE rating low).One trial found no significant difference between the fasting-onset and gradual-onset KD for rates of seizure freedom, and reported a greater rate of seizure reduction in the gradual-onset KD group.Studies assessing the efficacy of the MAD reported seizure freedom rates of up to 25% and seizure reduction rates of up to 60% in children. One study used a simplified MAD (sMAD) and reported seizure freedom rates of 15% and seizure reduction rates of 56% in children. One study utilised a MAD in adults and reported seizure reduction rates of 35%, but no patients became seizure free (GRADE rating low).Adverse effects of the dietary interventions were experienced in all studies. The most commonly reported adverse effects were gastrointestinal syndromes. It was common that adverse effects were the reason for participants dropping out of trials (GRADE rating low). Other reasons for dropout included lack of efficacy and non-acceptance of the diet (GRADE rating low).Although there was some evidence for greater antiepileptic efficacy for a classical 4:1 KD over lower ratios, the classical 4:1 KD was consistently associated with more adverse effects.One study assessed the effect of dietary interventions on quality of life, cognition and behavioural functioning, reporting participants in the KD group to be more active, more productive and less anxious after four months, compared to the control group. However, no significant difference was found in quality-adjusted life years (QALYs) between the KD group and control group at four or 16 months (GRADE rating very low). AUTHORS' CONCLUSIONS The RCTs discussed in this review show promising results for the use of KDs in epilepsy. However, the limited number of studies, small sample sizes and the limited studies in adults, resulted in a low to very low overall quality of evidence.There were adverse effects within all of the studies and for all KD variations, such as short-term gastrointestinal-related disturbances and increased cholesterol. However, study periods were short, therefore the long-term risks associated with these adverse effects is unknown. Attrition rates remained a problem with all KDs and across all studies; reasons for this being lack of observed efficacy and dietary tolerance.Only one study reported the use of KDs in adults with epilepsy; therefore further research would be of benefit.Other more palatable but related diets, such as the MAD, may have a similar effect on seizure control as the classical KD, but this assumption requires more investigation. For people who have medically intractable epilepsy or people who are not suitable for surgical intervention, KDs remain a valid option; however, further research is required.
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Affiliation(s)
- Kirsty J Martin‐McGill
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
- The Walton Centre NHS Foundation TrustDietetics OfficeLower LaneLiverpoolUKL9 7LJ
| | - Cerian F Jackson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
| | - Rebecca Bresnahan
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
| | - Robert G Levy
- The Croft Shifta Health CentreBelfield RoadRochdaleUKOL16 2UP
| | - Paul N Cooper
- Salford Royal Hospitals NHS TrustCentre for Clinical NeurosciencesHope HospitalStott LaneSalfordGreater ManchesterUKM6 8HD
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Investigating owner use of dietary supplements in dogs with idiopathic epilepsy. Res Vet Sci 2018; 119:276-284. [PMID: 30064067 DOI: 10.1016/j.rvsc.2018.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/01/2018] [Accepted: 07/21/2018] [Indexed: 12/29/2022]
Abstract
Epilepsy is the most common chronic neurological disorder in dogs. Some diets have been shown to have a positive impact upon the seizure activity in dogs with idiopathic epilepsy (IE), while other diets and dietary supplements (DS), although marketed as providing health benefits, lack conclusive scientific evidence on their actual beneficial effects. A web-based owner questionnaire was designed to assess how and why owners of dogs with IE use different dietary regimes and DS. The study cohort, with 297 valid responses, consisted mainly of pure-breed (82.5%) male neutered (52.9%) dogs. Over two-thirds of owners (67.7%) changed their dog's diet after their dog received a diagnosis of IE. Nearly half of the owners (45.8%) reported giving DS, the most common being coconut oil or derived medium-chain triglyceride oil (71.3%). Some owner justifications of DS use included improvement of seizure frequency (88.2%), seizure severity (61.8%) and protection from potential drug side effects (62.5%). Many owners give DS to their dog with IE. The pharmacokinetic properties of anti-epileptic drugs, such as efficacy, absorption and clearance can be influenced by other medications, diets and possibly by DS. We propose that use of DS should be considered and monitored by veterinary surgeons in epilepsy management.
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Suraev A, Lintzeris N, Stuart J, Kevin RC, Blackburn R, Richards E, Arnold JC, Ireland C, Todd L, Allsop DJ, McGregor IS. Composition and Use of Cannabis Extracts for Childhood Epilepsy in the Australian Community. Sci Rep 2018; 8:10154. [PMID: 29977078 PMCID: PMC6033872 DOI: 10.1038/s41598-018-28127-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 06/04/2018] [Indexed: 12/20/2022] Open
Abstract
Recent surveys suggest that many parents are using illicit cannabis extracts in the hope of managing seizures in their children with epilepsy. In the current Australian study we conducted semi-structured interviews with families of children with diverse forms of epilepsy to explore their attitudes towards and experiences with using cannabis extracts. This included current or previous users of cannabis extracts to treat their child's seizures (n = 41 families), and families who had never used (n = 24 families). For those using cannabis, extracts were analysed for cannabinoid content, with specific comparison of samples rated by families as "effective" versus those rated "ineffective". Results showed that children given cannabis extracts tended to have more severe epilepsy historically and had trialled more anticonvulsants than those who had never received cannabis extracts. There was high variability in the cannabinoid content and profile of cannabis extracts rated as "effective", with no clear differences between extracts perceived as "effective" and "ineffective". Contrary to family's expectations, most samples contained low concentrations of cannabidiol, while Δ9-tetrahydrocannabinol was present in nearly every sample. These findings highlight profound variation in the illicit cannabis extracts being currently used in Australia and warrant further investigations into the therapeutic value of cannabinoids in epilepsy.
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Affiliation(s)
- A Suraev
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - N Lintzeris
- Addiction Medicine, Central Clinical School, Faculty of Medicine, The University of Sydney, Sydney, 2006, Australia
- The Langton Centre, Drug and Alcohol Services, South East Sydney Local Health District, NSW Health, Surry Hills, 2010, Australia
| | - J Stuart
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R C Kevin
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R Blackburn
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - E Richards
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - J C Arnold
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
- Department of Pharmacology, Faculty of Medicine, University of Sydney, Sydney, NSW, 2006, Australia
| | - C Ireland
- Epilepsy Action Australia, Sydney, Australia
| | - L Todd
- Epilepsy Action Australia, Sydney, Australia
| | - D J Allsop
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - I S McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia.
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