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Cameron T, Allan K, Kay Cooper. The use of ketogenic diets in children living with drug-resistant epilepsy, glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency: A scoping review. J Hum Nutr Diet 2024. [PMID: 38838079 DOI: 10.1111/jhn.13324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/10/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The ketogenic diet (KD) is a high fat, moderate protein and very low carbohydrate diet. It can be used as a medical treatment for drug-resistant epilepsy (DRE), glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency. The aim of this scoping review was to map the KD literature, with a focus on epilepsy and associated metabolic conditions, to summarise the current evidence-base and identify any gaps. METHODS This review was conducted using JBI scoping review methodological guidance and the PRISMA extension for scoping reviews reporting guidance. A comprehensive literature search was conducted in September 2021 and updated in February 2024 using MEDLINE, CINAHL, AMED, EmBASE, CAB Abstracts, Scopus and Food Science Source databases. RESULTS The initial search yielded 2721 studies and ultimately, data were extracted from 320 studies that fulfilled inclusion criteria for the review. There were five qualitative studies, and the remainder were quantitative, including 23 randomised controlled trials (RCTs) and seven quasi-experimental studies. The USA published the highest number of KD studies followed by China, South Korea and the UK. Most studies focused on the classical KD and DRE. The studies key findings suggest that the KD is efficacious, safe and tolerable. CONCLUSIONS There are opportunities available to expand the scope of future KD research, particularly to conduct high-quality RCTs and further qualitative research focused on the child's needs and family support to improve the effectiveness of KDs.
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Affiliation(s)
- Tracy Cameron
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, Scotland, UK
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Karen Allan
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Kay Cooper
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
- Scottish Centre for Evidence-based, Multi-professional Practice: A JBI Centre of Excellence, Aberdeen, Scotland, UK
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Diaz-Marugan L, Rutsch A, Kaindl AM, Ronchi F. The impact of microbiota and ketogenic diet interventions in the management of drug-resistant epilepsy. Acta Physiol (Oxf) 2024; 240:e14104. [PMID: 38314929 DOI: 10.1111/apha.14104] [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: 06/02/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 02/07/2024]
Abstract
AIM Drug-resistant epilepsy (DRE) is a neurological disorder characterized by uncontrolled seizures. It affects between 10%-40% of the patients with epilepsy worldwide. Drug-resistant patients have been reported to have a different microbiota composition compared to drug-sensitive patients and healthy controls. Importantly, fecal microbiota transplantations (FMTs), probiotic and dietary interventions have been shown to be able to reduce seizure frequency and improve the quality of life in drug-resistant patients. The classic ketogenic diet (KD) and its modifications may reduce seizures in DRE in some patients, whereas in others they do not. The mechanisms mediating the dietary effects remain elusive, although it is known that gut microbes play an important role in transmitting dietary effects to the host. Indeed, specific commensal microbes differ even between responders and non-responders to KD treatment. METHODS In this narrative mini-review, we summarize what is known about the gut microbiota changes and ketogenic diets with special focus on patients with DRE. RESULTS AND CONCLUSIONS By highlighting unanswered questions and by suggesting future research directions, we map the route towards future improvement of successful DRE therapy.
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Affiliation(s)
- Laura Diaz-Marugan
- Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Andrina Rutsch
- Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Angela M Kaindl
- Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Francesca Ronchi
- Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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Li W, Gu W, Liang C, Tu F, Ding L, Lu X, Guo H, Zheng G, Wu C. Efficacy and safety of a smartphone application-based treatment of ketogenic diet in pediatric refractory epilepsy. Epilepsia Open 2024; 9:278-286. [PMID: 37969060 PMCID: PMC10839295 DOI: 10.1002/epi4.12867] [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: 05/17/2023] [Accepted: 11/13/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVE We aimed to find predictors for smartphone application-based ketogenic diet (KD) treatment effectiveness and safety. METHODS The efficacy was evaluated according to the reduction in seizure frequency after the intervention of KD; safety was evaluated based on adverse effects. The ordinal logistic regression analysis was used to explore the influencing factors of efficacy. RESULTS The study sample included 116 males and 65 females with a median age of 2.27 years. The baseline frequency of seizure was more than five times/day in 123 children, 50.83% of them received three or more antiepileptic drugs (AEDs). Seventy-two patients' KD initiation mode was outpatient, and 73 completed the 12-month follow-up. A total of 88 (48.62%) patients had reported a reduction in seizure ≥50%. Compared with 12 months, those who had received KD therapy for only 3 (P = 0.009) and 6 months (P = 0.005) were more likely to show negative outcomes. Outpatient initiation had better outcomes (P = 0.029) than inpatient initiation. For the number of AEDs applied, patients on two AEDs were more likely to achieve better outcomes (P = 0.001). Adverse events had been noted among 77 patients; BMI Z-score at KD initiation was associated with adverse effects (P = 0.003). SIGNIFICANCE Our study suggested that outpatient initiation and long-term treatment of KD should be encouraged. PLAIN LANGUAGE SUMMARY Our research shows that the KD is a helpful treatment for children with refractory epilepsy, reducing seizures by more than 50% in nearly half of the cases, with some experiencing complete seizure freedom. We used a smartphone app to improve communication between patients and their healthcare teams, resulting in a high retention, and app usage was linked to reduced adverse effects. We recommend early consideration of KD treatment for patients failing two AED, encourage outpatient initiation, and advocate for longer-term KD use.
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Affiliation(s)
- Wei Li
- Department of Clinical Research CenterChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Wei Gu
- Department of Clinical Research CenterChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Chao Liang
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Fulai Tu
- Key Laboratory of Environmental Medicine Engineering, Department of Epidemiology and Health Statistics, School of Public HealthSoutheast UniversityNanjingChina
| | - Le Ding
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Xiaopeng Lu
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Hu Guo
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Guo Zheng
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Chunfeng Wu
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
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Chen S, Su X, Feng Y, Li R, Liao M, Fan L, Liu J, Chen S, Zhang S, Cai J, Zhu S, Niu J, Ye Y, Lo K, Zeng F. Ketogenic Diet and Multiple Health Outcomes: An Umbrella Review of Meta-Analysis. Nutrients 2023; 15:4161. [PMID: 37836444 PMCID: PMC10574428 DOI: 10.3390/nu15194161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Numerous studies have examined the effects of ketogenic diets (KD) on health-related outcomes through meta-analyses. However, the presence of biases may compromise the reliability of conclusions. Therefore, we conducted an umbrella review to collate and appraise the strength of evidence on the efficacy of KD interventions. We conducted a comprehensive search on PubMed, EMBASE, and the Cochrane Database until April 2023 to identify meta-analyses that investigated the treatment effects of KD for multiple health conditions, which yielded 23 meta-analyses for quantitative analyses. The evidence suggests that KD could increase the levels of low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C), the respiratory exchange rate (RER), and could decrease total testosterone and testosterone levels (all p-random effects: <0.05). The combination of KD and physical activity can significantly reduce body weight and increase the levels of LDL-C and cortisol. In addition, KD was associated with seizure reduction in children, which can be explained by the ketosis state as induced by the diet. Furthermore, KD demonstrated a better alleviation effect in refractory childhood epilepsy, in terms of median effective rates for seizure reduction of ≥50%, ≥90%, and seizure freedom. However, the strength of evidence supporting the aforementioned associations was generally weak, thereby challenging their credibility. Consequently, future studies should prioritize stringent research protocols to ascertain whether KD interventions with longer intervention periods hold promise as a viable treatment option for various diseases.
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Affiliation(s)
- Shiyun Chen
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Xin Su
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Yonghui Feng
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Ruojie Li
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Minqi Liao
- Institute of Epidemiology, Helmholtz Zentrum Munich-German Research Center for Environmental Health, Ingolstadt Landstr. 1, 85764 Neuherberg, Germany;
| | - Laina Fan
- Department of Clinical Medicine, International School, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China;
| | - Jiazi Liu
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Shasha Chen
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Shiwen Zhang
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Jun Cai
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Sui Zhu
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
| | - Jianxiang Niu
- General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, No. 1 Tongdao North Road, Hohhot 010000, China;
| | - Yanbin Ye
- Department of Clinical Nutrition, The First Affiliated Hospital, Jinan University, Guangzhou 510630, China;
| | - Kenneth Lo
- Department of Food Science and Nutrition, The Hong Kong Polytechnic University, Kowloon, Hong Kong 100872, China
- Research Institute for Future Food, The Hong Kong Polytechnic University, Kowloon, Hong Kong 100872, China
| | - Fangfang Zeng
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No. 601 Huangpu Road West, Guangzhou 510632, China; (S.C.); (X.S.); (Y.F.); (R.L.); (J.L.); (S.C.); (S.Z.); (J.C.); (S.Z.)
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Haridas B. Dietary carbohydrates in the management of epilepsy. Curr Opin Clin Nutr Metab Care 2023; 26:377-381. [PMID: 37057659 DOI: 10.1097/mco.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
PURPOSE OF REVIEW The role of dietary carbohydrates in the management of epilepsy is intrinsically linked to the ketogenic diet. The ketogenic diet has been in use for well over a century now. There have been numerous adaptations to the diet. It is crucial to understand the indications and role of the ketogenic diet in the management of epilepsy. RECENT FINDINGS There have been new studies that have looked at the role of ketogenic ratios in seizure control. In addition, there has been new evidence in the role of using the ketogenic diet therapy instead of antiseizure medications. These data highlight that the ketogenic diet should be tailored for patients and caregivers. When used appropriately, it can result in a significant improvement in seizure control as well as cognitive and developmental gains. SUMMARY The ketogenic diet therapy has undergone numerous revisions and reiterations from its initial reported use in patients a century ago. This has enabled us to tailor the diet specific to each patient's underlying diagnosis.
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Affiliation(s)
- Babitha Haridas
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
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Ferraris C, Guglielmetti M, Neri LDCL, Allehdan S, Mohsin Albasara JM, Fareed Alawadhi HH, Trentani C, Perna S, Tagliabue A. A Review of Ketogenic Dietary Therapies for Epilepsy and Neurological Diseases: A Proposal to Implement an Adapted Model to Include Healthy Mediterranean Products. Foods 2023; 12:foods12091743. [PMID: 37174282 PMCID: PMC10178865 DOI: 10.3390/foods12091743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Based on the growing evidence of the therapeutic role of high-fat ketogenic dietary therapies (KDTs) for neurological diseases and on the protective effect of the Mediterranean diet (MD), it could be important to delineate a Mediterranean version of KDTs in order to maintain a high ketogenic ratio, and thus avoid side effects, especially in patients requiring long-term treatment. This narrative review aims to explore the existing literature on this topic and to elaborate recommendations for a Mediterranean version of the KDTs. It presents practical suggestions based on MD principles, which consist of key elements for the selection of foods (both from quantitative and qualitative prospective), and indications of the relative proportions and consumption frequency of the main food groups that constitute the Mediterranean version of the KDTs. We suggest the adoption of a Mediterranean version of ketogenic diets in order to benefit from the multiple protective effects of the MD. This translates to: (i) a preferential use of olive oil and vegetable fat sources in general; (ii) the limitation of foods rich in saturated fatty acids; (iii) the encouragement of high biological value protein sources; (iv) inserting fruit and vegetables at every meal possible, varying their choices according to seasonality.
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Affiliation(s)
- Cinzia Ferraris
- Ketogenic Metabolic Therapy Laboratory, Department of Public Health, Experimental and Forensics Medicine, University of Pavia, 27100 Pavia, Italy
- Laboratory of Food Education and Sport Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Monica Guglielmetti
- Ketogenic Metabolic Therapy Laboratory, Department of Public Health, Experimental and Forensics Medicine, University of Pavia, 27100 Pavia, Italy
- Laboratory of Food Education and Sport Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Lenycia de Cassya Lopes Neri
- Ketogenic Metabolic Therapy Laboratory, Department of Public Health, Experimental and Forensics Medicine, University of Pavia, 27100 Pavia, Italy
| | - Sabika Allehdan
- Department of Biology, College of Science, University of Bahrain, Sakhir P.O. Box 32038, Bahrain
| | | | | | - Claudia Trentani
- Ketogenic Metabolic Therapy Laboratory, Department of Public Health, Experimental and Forensics Medicine, University of Pavia, 27100 Pavia, Italy
| | - Simone Perna
- Division of Human Nutrition, Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, 20122 Milano, Italy
| | - Anna Tagliabue
- Ketogenic Metabolic Therapy Laboratory, Department of Public Health, Experimental and Forensics Medicine, University of Pavia, 27100 Pavia, Italy
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Pirola L, Ciesielski O, Balcerczyk A. Fat not so bad? The role of ketone bodies and ketogenic diet in the treatment of endothelial dysfunction and hypertension. Biochem Pharmacol 2022; 206:115346. [DOI: 10.1016/j.bcp.2022.115346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/20/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
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