Not your parents’ ketogenic diet – Flexibility in 2020

Adherence to ketogenic dietary therapies in epilepsy: A systematic review of literature

Treatment adherence, defined as the degree to which the patient actively follows the plan of care, is very difficult for subjects undergoing ketogenic dietary therapies (KDTs). This is a relevant issue because adherence to dietary therapies is considered 1 of the primary determinants of the treatment's success. This paper aimed to review the literature evidence about KDT adherence according to age and diagnosis of patients. Performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method, this systematic review included clinical trials and observational studies. The risk of bias was assessed by the RoB 2.0 Cochrane tool and the quality of evidence according to the Mixed Methods Appraisal Tool system. Twenty-two articles were included, with more than half (n = 12) having average quality (2-3 stars). The studies' heterogeneity in measuring adherence and diagnosis made it difficult to compare results. Mean adherence rates were 71.5%, 66%, and 63.9% for children, adolescents, and adults, respectively. Adherence and compliance rates varied according to the follow-up period (79.7%, 66.7%, and 37.7% at 6, 24, and 36 months, respectively). The most frequent reasons for low adherence were linked to inefficacy in seizure control, adverse effects, food refusal, difficulty in preparing KDT meals or diet restrictiveness, lack of motivation, poor parental compliance, or cost of the diet. To conclude, there is a lack of standardized tools to measure adherence. Several studies highlighted the families' challenges in adhering to KDTs. These factors should be considered when creating strategies and resources on family education.

Effect of Ketogenic Diet on Obesity and Other Metabolic Disorders: Narrative Review

Obesity is defined as an abnormal or excessive accumulation of fat that increases the burden of different chronic diseases in the population. It has reached epidemic proportions and is a major risk factor for a variety of diseases, including hypertension, cardiovascular disease, type 2 diabetes, dyslipidaemia, atherosclerosis, and some malignancies. Weight gain is a result of excessive energy intake compared to energy expenditure (energy loss from metabolism and physical exercise). A ketogenic diet has a more useful effect on obesity than other diets. A ketogenic diet is a low-carbohydrate, high-fat, moderate-protein diet that induces the production of ketone bodies by mimicking the breakdown of a fasting state. The mechanism behind the ketogenic diet is still unknown, although it obviously helps people with obesity lose weight. Several pathways for the ketogenic diet effect on weight loss have been hypothesized by researchers, including reduced appetite due to effects on appetite control hormones and a possible direct appetite suppressant action of ketone bodies; reduced lipogenesis and increased lipolysis; greater metabolic efficiency; and increased metabolic costs.

A Mixed-Lipid Diet (Medium-Chain and Long-Chain Triglycerides) for Better Tolerability and Efficiency in Pediatric Epilepsy Patients

Purpose: In the past, the use of medium-chain triglycerides (MCTs) for a ketogenic diet (KD) was expected to improve both patients’ and caregivers’ adherence to treatment, but many gastrointestinal problems have been reported. Through a calculated partial administration of MCTs in a KD, we aimed to reduce these complications, while maintaining acceptable seizure reduction. Methods: At a tertiary referral center for pediatric patients with epilepsy, MCT oil was given in a 1:1 ratio with long-chain triglycerides to patients on KDs. Patients who began the diet from February 2019 to February 2020 were reviewed retrospectively, and 47 patients with at least 3 months of follow-up records were enrolled in the studyResults: Overall, 29.8% of patients on a KD with an adjusted MCT ratio experienced complications, such as gastrointestinal symptoms and behavioral food refusal, compared to 63.0% of prior KD patients. The mean seizure reduction rate was 68.45%±40.61%, which was not significantly different from the comparison group’s rate of 64.84%±34.24%. Conclusion: Adjusted MCT incorporation into a KD showed comparable seizure control results, with better tolerability of the diet.

Research Involvement in a Group of Registered Dietitian Nutritionists Specializing in Ketogenic Diet Therapies for Epilepsy

BACKGROUND

There is a growing need for studies on ketogenic diet (KD) therapies. Registered dietitian nutritionists (RDNs) should lead efforts to better understand nutritional risks and benefits of the KD to inform evidence-based practices.

OBJECTIVE

The purpose of this study was to explore participation in research amongst RDNs practicing in KD therapies for epilepsy and identify barriers to participation.

DESIGN

This cross-sectional study collected professional experience, research involvement and output, and perceived barriers to conducting research.

PARTICIPANTS/SETTING

This study surveyed 66 RDNs practicing in KD therapies for epilepsy.

MAIN OUTCOME MEASURE

Research involvement was assessed using the Dietitian Research Involvement Survey (DRIS) score. Research output was reported as type and number of publications. Barriers to research included lack of time, resources, administrative support, training, and/or skill.

STATISTICAL ANALYSES

Data were summarized using descriptive statistics such as means and standard deviations, medians and interquartile ranges, counts and percentages, as appropriate.

RESULTS

The median DRIS score was 31 out of 60 (range: 16-60). Thirty-two participants (48.5%) reported publishing or presenting data, and only 13.6% published a manuscript on ketogenic diet therapies as a leading author. The main barriers to participating in research were insufficient time (83.3%), insufficient funding (81.8%), and priority of work (70.8%). Research involvement scores were not affected by lack of time and resources, however scores were lower in RDNs reporting lack of interest, training, and skill in research.

CONCLUSIONS

While ketogenic RDNs participated in research, most were not leading projects or publications. To increase research involvement amongst RDNs, focus should include overcoming structural barriers while facilitating knowledge acquisition for those lower on the research continuum.

Ketogenic diet for human diseases: the underlying mechanisms and potential for clinical implementations

The ketogenic diet (KD) is a high-fat, adequate-protein, and very-low-carbohydrate diet regimen that mimics the metabolism of the fasting state to induce the production of ketone bodies. The KD has long been established as a remarkably successful dietary approach for the treatment of intractable epilepsy and has increasingly garnered research attention rapidly in the past decade, subject to emerging evidence of the promising therapeutic potential of the KD for various diseases, besides epilepsy, from obesity to malignancies. In this review, we summarize the experimental and/or clinical evidence of the efficacy and safety of the KD in different diseases, and discuss the possible mechanisms of action based on recent advances in understanding the influence of the KD at the cellular and molecular levels. We emphasize that the KD may function through multiple mechanisms, which remain to be further elucidated. The challenges and future directions for the clinical implementation of the KD in the treatment of a spectrum of diseases have been discussed. We suggest that, with encouraging evidence of therapeutic effects and increasing insights into the mechanisms of action, randomized controlled trials should be conducted to elucidate a foundation for the clinical use of the KD.

Caloric Restriction and Ketogenic Diet Therapy for Epilepsy: A Molecular Approach Involving Wnt Pathway and KATP Channels

Epilepsy is a neurological disorder in which, in many cases, there is poor pharmacological control of seizures. Nevertheless, it may respond beneficially to alternative treatments such as dietary therapy, like the ketogenic diet or caloric restriction. One of the mechanisms of these diets is to produce a hyperpolarization mediated by the adenosine triphosphate (ATP)-sensitive potassium (KATP) channels (KATP channels). An extracellular increase of K+ prevents the release of Ca2+ by inhibiting the signaling of the Wnt pathway and the translocation of β-catenin to the cell nucleus. Wnt ligands hyperpolarize the cells by activating K+ current by Ca2+. Each of the diets described in this paper has in common a lower use of carbohydrates, which leads to biochemical, genetic processes presumed to be involved in the reduction of epileptic seizures. Currently, there is not much information about the genetic processes implicated as well as the possible beneficial effects of diet therapy on epilepsy. In this review, we aim to describe some of the possible genes involved in Wnt pathways, their regulation through the KATP channels which are implicated in each one of the diets, and how they can reduce epileptic seizures at the molecular level.

Telemedicine, drug-resistant epilepsy, and ketogenic dietary therapies: A patient survey of a pediatric remote-care program during the COVID-19 pandemic

OBJECTIVE

The purpose of this study was to assess parent satisfaction with the management of ketogenic diet therapies (KDTs) through telemedicine using WhatsApp as the main tool.

METHODS

Parent satisfaction was longitudinally evaluated through questionnaires. The survey was developed with Google Questionnaire forms and sent via WhatsApp. The questionnaire consisted of 13 items concerning the management of KDTs using telemedicine in the context of the coronavirus disease 2019 (COVID-19) pandemic. Our population of patients has limited financial resources and low levels of education. Given that many families did not have either computers or WIFI, or any other access to information or communication technology, WhatsApp was chosen as a tool as it was available on the cell phones of all families and the professionals.

RESULTS

Our survey showed that 96.3% of the parents were satisfied with the management of KDTs through telemedicine. The main benefits observed were the possibility of continuing treatment during the COVID-19 pandemic and the ease of accessing the professional team from the comfort of their home. Overall, 72.2% of the families would recommend using telemedicine for KDTs in any situation regardless of the pandemic. None of the families reported that they would recommend against treatment by telemedicine. The availability of a social support network (parents WhatsApp group) coordinated by professionals from the KDT team was considered to be useful by most respondents (90%).

CONCLUSIONS

Our study suggests that management of children with DRE on KDTs through telemedicine is feasible, well accepted by the families, and probably as safe as conventional medicine. WhatsApp may be an interesting telemedicine tool to start and maintain KDTs.