The Ketogenic Diet: A Practical Guide for Pediatricians

Effect of the ketogenic diet as a treatment for refractory epilepsy in children and adolescents: a systematic review of reviews

CONTEXT

Epilepsy is one of the most prevalent neurological disorders in childhood. Antiepileptic drugs are the preferred treatment. However, 30% of children continue suffering seizures. A ketogenic diet (KD) is one of the emerging alternative treatments.

OBJECTIVE

This review aims to analyze the current evidence regarding the use of a KD for the treatment of refractory epilepsy (RE) in childhood.

DATA SOURCES

A systematic review of reviews was performed, based on MEDLINE (PubMed) as at January 2021.

DATA EXTRACTION

The data extracted included the first author's last name; the year of publication; the country; the study design; the population; the diagnosis, concept, and description of KD types; and major outcome.

RESULTS

Twenty-one reviews were included, 8 with systematic methodology (2 of them included a meta-analysis) and 13 with unsystematic methodology. The main difference between the 2 types of reviews is the reproducibility of their methodology. Therefore, the results of each type of review were analyzed separately. Each type of review described 4 categories of KD: classic KD, modified Atkins diet (MAD), use of medium-chain triglycerides (MCTs), and low glycemic index treatment (LGIT). In terms of effectiveness, the considered systematic reviews reported reductions in the frequency of seizures greater than 50% in about half of the patients. Reviews without systematic methodology reported that 30%-60% of the children showed a 50% or greater reduction in seizures. The most frequently described adverse effects in the 8 systematic reviews were: vomiting (6/8), constipation (6/8), and diarrhea (6/8); and in the unsystematic reviews: vomiting and nausea (10/13), constipation (10/13), and acidosis (9/13).

CONCLUSION

KD can be an effective treatment for RE, with a more than 50% reduction in the frequency of seizures and cognitive improvement being achieved in half of the pediatric patients. The effectiveness of the various types of KD is comparable, and the KD can be adapted to the needs of the patient.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021244142.

Factors Associated with Neuroimaging Abnormalities in Children with Afebrile Seizure: A Retrospective Multicenter Study

Introduction: Neuroimaging is recommended for patients with seizures to identify intracranial pathology. However, emergency physicians should consider the risks and benefits of neuroimaging in pediatric patients because of their need for sedation and greater sensitivity to radiation than adults. The purpose of this study was to identify associated factors of neuroimaging abnormalities in pediatric patients experiencing their first afebrile seizure. Methods: This was a retrospective, multicenter study that included children who presented to the emergency departments (ED) of three hospitals due to afebrile seizures between January 2018– December 2020. We excluded children with a history of seizure or acute trauma and those with incomplete medical records. A single protocol was followed in the three EDs for all pediatric patients experiencing their first afebrile seizure. We performed multivariable logistic regression analysis to identify factors associated with neuroimaging abnormalities. Results: In total, 323 pediatric patients fulfilled the study criteria, and neuroimaging abnormalities were observed in 95 patients (29.4%). Multivariable logistic regression analysis showed that Todd’s paralysis (odds ratio [OR] 3.72, 95% confidence interval [CI] 1.03-13.36; P=0.04), absence of poor oral intake (POI) (OR 0.21, 95% CI 0.05-0.98; P=0.05), lactic acidosis (OR 1.16, 95% CI 1.04- 1.30; P=0.01), and higher level of bilirubin (OR 3.33, 95% CI 1.11-9.95; P=0.03) were significantly associated with neuroimaging abnormalities. Based on these results, we constructed a nomogram to predict the probability of brain imaging abnormalities. Conclusion: Todd’s paralysis, absence of POI, and higher levels of lactic acid and bilirubin were associated factors of neuroimaging abnormalities in pediatric patients with afebrile seizure.

The Role of Ketogenic Diet in the Treatment of Neuroblastoma

The ketogenic diet (KD) was initially used in 1920 for drug-resistant epileptic patients. From this point onward, ketogenic diets became a pivotal part of nutritional therapy research. To date, KD has shown therapeutic potential in many pathologies such as Alzheimer's disease, Parkinson's disease, autism, brain cancers, and multiple sclerosis. Although KD is now an adjuvant therapy for certain diseases, its effectiveness as an antitumor nutritional therapy is still an ongoing debate, especially in Neuroblastoma. Neuroblastoma is the most common extra-cranial solid tumor in children and is metastatic at initial presentation in more than half of the cases. Although Neuroblastoma can be managed by surgery, chemotherapy, immunotherapy, and radiotherapy, its 5-year survival rate in children remains below 40%. Earlier studies have proposed the ketogenic diet as a possible adjuvant therapy for patients undergoing treatment for Neuroblastoma. In this study, we seek to review the possible roles of KD in the treatment of Neuroblastoma.

Clinical and genetic analysis of nonketotic hyperglycinemia: A case report

BACKGROUND

Nonketotic hyperglycinemia (NKH) is a rare autosomal recessive genetic disorder of abnormal glycine metabolism caused by insufficient activity of the glycine cleavage enzyme system. Glycine is believed to function mainly as an inhibitory neurotransmitter, but it can also act as a co-agonist of the N-methyl-D-aspartate (NMDA) receptor. The accumulation of a large amount of glycine in the brain leads to neuronal and axonal injury via overactivation of NMDA receptors located in the hippocampus, cerebral cortex, olfactory bulb, and cerebellum and to stimulation of the inhibitory function of glycine receptors located in the spinal cord and brain stem, resulting in central apnea, hiccups, and hypotonia in the early stage of the disease.

CASE SUMMARY

The child described in this report had typical clinical manifestations of NKH, such as hiccups, disturbance of consciousness, hypotonia, and convulsions, within the first week after birth. Whole-exome genetic testing revealed that the child had a compound heterozygous mutation, namely, c.395C>A (p.S132X) and c.2182G>A (p.G728R), in the GLDC gene, and he was diagnosed with NKH. For treatment, we administered an oral levetiracetam solution and added topiramate and prednisone for epilepsy control, but the epilepsy remained uncontrollable. Ketogenic diet therapy was started at 6 mo of age, his seizures were significantly reduced, and there were no obvious adverse reactions during ketogenic treatment. Furthermore, we found that with the development of the disease, high levels of serum glycine decreased or even disappeared without intervention, and as the disease progressed, the corpus callosum became dysplastic.

CONCLUSION

This case shows that plasma glycine levels cannot be used to evaluate the prognosis of NKH, that the development of the corpus callosum can be affected by NKH, and that a ketogenic diet may be effective for seizure control in NKH patients.

The efficacy of non-fasting ketogenic diet protocol in the management of intractable epilepsy in pediatric patients: a single center study from Saudi Arabia

Objective

To review the characteristics and outcomes of pediatric patients on a ketogenic diet (KD), an established treatment option for individuals with intractable epilepsy, in a tertiary epilepsy center.

Methods

This retrospective study included pediatric patients diagnosed with intractable epilepsy who had experienced no benefits from at least two appropriately chosen antiseizure medications. All patients were hospitalized, started a KD without fasting, and were observed for complications and tolerance. The etiology of epilepsy, side effects, and KD efficacy on seizure outcomes were also examined.

Results

Of 16 children included in the study, nine (56%) experienced significant seizure improvement, with three becoming seizure-free during the KD. Ten patients were fed orally, and six were fed through gastrostomy feeding tubes. Most were on a 3:1 ratio, and nine reached ketosis within the first three days of KD initiation. Initial recurrent hypoglycemia was documented in four patients, and four experienced vomiting and acidosis. Most families complied with the diet, and all of the children gained weight during the study period.

Conclusion

Ketogenic diets are an established and effective treatment for childhood epilepsy, with reversible mild adverse effects. A non-fasting KD protocol is a safe and effective option for children with intractable epilepsy.

Monitoring Glucose Concentrations in Children with Epilepsy on a Ketogenic Diet

Ketogenic diet (KD) and pulsatile dexamethasone therapy (PDT) are commonly used in the treatment of children with drug resistant epilepsy. Potential side effects of the KD are hypoglycemia, whereas PDT might lead to hyperglycemia. One practical option to measure glucose concentrations regularly is the flash glucose monitoring system (FGM). In this single-center study in Germany, two pediatric patients with epilepsy (age: 6.0 and 6.8 years) received FGM from the beginning of the KD over six months, in the year 2020, and one patient (9.8 years) was observed for one month on PDT and switched to the KD thereafter. Glucose concentrations were measured by using an FGM system and capillary blood measurement. Seizure frequency, changes in cognition, motor performance, social behavior, and sleep quality were evaluated. The mean hypoglycemia rate per day (65 mg/dL and lower) declined significantly in patient 1 and 2 after three months. Patient 3 showed in total seven hyperglycemic events during PDT. Patient 1 became seizure free. Improvement of attention and memory performance were reported. FGM during the KD as a treatment for drug resistant epilepsies in childhood is a practical option to explore and to avoid hypoglycemia during the KD and hyperglycemia during PDT.

VLCKD: a real time safety study in obesity

Background

Very Low-Calorie Ketogenic Diet (VLCKD) is currently a promising approach for the treatment of obesity. However, little is known about the side effects since most of the studies reporting them were carried out in normal weight subjects following Ketogenic Diet for other purposes than obesity. Thus, the aims of the study were: (1) to investigate the safety of VLCKD in subjects with obesity; (2) if VLCKD-related side effects could have an impact on its efficacy.

Methods

In this prospective study we consecutively enrolled 106 subjects with obesity (12 males and 94 females, BMI 34.98 ± 5.43 kg/m²) that underwent to VLCKD. In all subjects we recorded side effects at the end of ketogenic phase and assessed anthropometric parameters at the baseline and at the end of ketogenic phase. In a subgroup of 25 subjects, we also assessed biochemical parameters.

Results

No serious side effects occurred in our population and those that did occur were clinically mild and did not lead to discontinuation of the dietary protocol as they could be easily managed by healthcare professionals or often resolved spontaneously. Nine (8.5%) subjects stopped VLCKD before the end of the protocol for the following reasons: 2 (1.9%) due to palatability and 7 (6.1%) due to excessive costs. Finally, there were no differences in terms of weight loss percentage (13.5 ± 10.9% vs 18.2 ± 8.9%; p = 0.318) in subjects that developed side effects and subjects that did not developed side effects.

Conclusion

Our study demonstrated that VLCKD is a promising, safe and effective therapeutic tool for people with obesity. Despite common misgivings, side effects are mild, transient and can be prevented and managed by adhering to the appropriate indications and contraindications for VLCKD, following well-organized and standardized protocols and performing adequate clinical and laboratory monitoring.

Can the Ketogenic diet lead to Wernicke's encephalopathy?

BACKGROUND

Wernicke's encephalopathy (WE), a neurological disorder due to the deficiency of thiamine, is often underdiagnosed in the pediatric population. The classic triad of mental status changes, oculomotor abnormality, and ataxia is observed in only 16-21% of all pediatric presentations. Wernicke's is most often associated with alcohol dependence, but also malignancy, parenteral nutrition, and gastrointestinal (GI) malformations. The correlation between following a Ketogenic diet and acquiring Wernicke's, however, has not previously been reported.

CASE REPORT

A 16-year-old previously healthy male presented with an eleven-day history of neurological deficits and GI upset. The patient had recently lost one hundred pounds while following a "ketogenic" diet. He was subsequently diagnosed with Wernicke's, received intravenous thiamine, and was transferred to the inpatient rehabilitation, where he received extensive diet education. After making significant functional improvement, he was discharged home.

RELEVANCE

This case illustrates the importance of including Wernicke's in the differential diagnosis when a pediatric patient presents with neurological deficits after rapid weight loss. Wernicke's encephalopathy may be fatal in the pediatric population, therefore, it must be treated immediately if clinically suspected. Children presenting with Wernicke's would benefit from early intervention, intensive inpatient rehabilitation, and comprehensive education regarding the role of food and exercise on weight loss and health.

Medical management of children with type 1 diabetes on low-carbohydrate or ketogenic diets

OBJECTIVES

Low-carbohydrate and ketogenic diets are becoming increasingly popular choices for people with type 1 diabetes (T1D) aiming to achieve optimal glycemic control. A carbohydrate-restricted diet in children has been associated with negative health effects including poor linear growth and inadequate bone mineralization. Guidelines for monitoring children and adolescents choosing to follow a carbohydrate-restricted diet do not exist. We aimed to create a clinical protocol outlining how to clinically and biochemically follow patients choosing a carbohydrate-restricted diet with the goal of medical safety.

METHODS

An interdisciplinary committee was formed and reviewed current consensus guidelines for pediatric patients on carbohydrate-restricted diets for epilepsy and metabolic disorders. A literature search was done to determine management strategies for children with T1D on a low-carbohydrate or ketogenic diet. Key health parameters that require monitoring were identified: growth, glycemic control, bone health, cardiometabolic health, and nutritional status. These health outcomes were used to develop a protocol for monitoring children on carbohydrate-restricted diets.

RESULTS

A one-page protocol for medical providers and educational materials for families interested in following a low-carbohydrate or ketogenic diet were developed and successfully implemented into clinical care.

CONCLUSION

Implementing a protocol for children on carbohydrate-restricted diets in clinic allows medical providers to ensure medical safety while being open to discussing a family's dietary preferences. Following children in the protocol over time will lead to informed clinical guidelines for patients with T1D who choose to follow a carbohydrate-restricted diet.

Validity and efficacy of diets used for preoperative weight reduction among patients qualified for bariatric surgery

INTRODUCTION

Bariatric surgery is the most effective method of weight reduction among patients suffering from morbid obesity. Reduction of body weight before surgery is an important element. The aim of the study was to present the current knowledge on preoperative weight reduction and diet for this purpose.

MATERIAL AND METHODS

To achieve the aims of the paper, articles available in the PubMed / MEDLINE database published in 2005-2020 were used, as well as the guidelines of societies such as Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons, American Association of Clinical Endocrinologists, The Obesity Society and American Society for Metabolic & Bariatric Surgery, International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter and European Association for the Study of Obesity.

RESULTS

Studies show that even a modest reduction in weight in the early preoperative period facilitates surgery and reduces the number of complications. The available data do not support the effect of preoperative weight loss on increased postoperative weight loss. The use of balanced, energy-restricted diet in the preoperative period prepares the patient for changes in the way of nutrition, which improves the nutritional status of patient. Low calorie (LCD) or very low calorie (VLCD) diet can be an effective method of weight loss before surgery, however, this approach does not allow to modify eating habits. The use of a very low calorie ketogenic diet (VLCKD) remains under discussion.

CONCLUSIONS

There is a need for large randomized trials to assess short and long term benefits of preoperative weight loss and methods of weight loss among patients qualified for bariatric surgery, also the standardization of nutritional management in the preoperative period.

Hypercalcemia in Children Using the Ketogenic Diet: A Multicenter Study

CONTEXT

The ketogenic diet is associated with progressive skeletal demineralization, hypercalciuria, and nephrolithiasis. Acute hypercalcemia has been described as a newly recognized complication of this treatment.

OBJECTIVE

To describe the clinical characteristics of acute hypercalcemia in children on the ketogenic diet through analysis of the presentation, response to treatment, and natural history in a large cohort of patients.

DESIGN

A multicenter case series was performed including children who developed acute hypercalcemia while treated with the ketogenic diet. Information on clinical presentation, treatment, and course of this complication was collated centrally.

RESULTS

There were 14 patients (median (range) age 6.3 (0.9 to 18) years) who developed hypercalcemia 2.1 (range, 0.2-12) years after starting the ketogenic diet. All had low levels of parathyroid hormone and levels of 1,25-dihydroxyvitamin D were low in all except one. Seven (50%) had impaired renal function at presentation. All except the 2 oldest had low alkaline phosphatase levels for age. Once normocalcemia was achieved, hypercalcemia recurred in only 2 of these patients over observation of up to 9.8 years. One patient discontinued the ketogenic diet prior to achieving normocalcemia while 4 more stopped the diet during follow-up after resolution of hypercalcemia.

CONCLUSIONS

Ketotic hypercalcemia can occur years after starting the ketogenic diet, especially in the setting of renal impairment. The mechanism is unknown but appears to be due to reduced osteoblast activity and impaired bone formation. We recommend close attention to optimizing bone health in these children, and screening for the development of ketotic hypercalcemia.

Ketogenic Diet for the Treatment and Prevention of Dementia: A Review

Dementia (major neurocognitive disorder) is an increasingly common syndrome with a significant burden on patients, caregivers, the health-care system, and the society. The prevalence of dementia will certainly continue to grow as the US population ages. Current treatments for dementia, though, are limited. One proposed nonpharmacologic approach for the delay or prevention of dementia is the use of a ketogenic diet. The ketogenic diet was originally employed to treat refractory epilepsy and has shown promise in many neurologic diseases. It has also gained recent popularity for its weight loss effects. Several preclinical studies have confirmed a benefit of ketosis on cognition and systemic inflammation. Given the renewed emphasis on neuroinflammation as a pathogenic contributor to cognitive decline, and the decreased systemic inflammation observed with the ketogenic diet, it is plausible that this diet may delay, ameliorate, or prevent progression of cognitive decline. Several small human studies have shown benefit on cognition in dementia with a ketogenic diet intervention. Future, large controlled studies are needed to confirm this benefit; however, the ketogenic diet has shown promise in regard to delay or mitigation of symptoms of cognitive decline.

Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective

Diabetes and obesity are both increasing at a fast pace and giving rise to a new epidemic called diabesity. Lifestyle interventions including diet play a major role in the treatment of diabetes, obesity and diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no global or South Asian guidelines on the non-pharmacological management of diabesity. South Asia differs from the rest of the world as South Asians have different phenotype, cooking practices, food resources and exposure, medical nutrition therapy (MNT) practices, and availability of trained specialists. Therefore, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in the South-Asians with diabesity.

Non-pharmacological Interventions for Intractable Epilepsy

In 30% of epileptic individuals, intractable epilepsy represents a problem for the management of seizures and severely affects the patient's quality of life due to pharmacoresistance with commonly used antiseizure drugs (ASDs). Surgery is not the best option for all resistant patients due to its post-surgical consequences. Therefore, several alternative or complementary therapies have scientifically proven significant therapeutic potential for the management of seizures in intractable epilepsy patients with seizure-free occurrences. Various non-pharmacological interventions include metabolic therapy, brain stimulation therapy, and complementary therapy. Metabolic therapy works out by altering the energy metabolites and include the ketogenic diets (KD) (that is restricted in carbohydrates and mimics the metabolic state of the body as produced during fasting and exerts its antiepileptic effect) and anaplerotic diet (which revives the level of TCA cycle intermediates and this is responsible for its effect). Neuromodulation therapy includes vagus nerve stimulation (VNS), responsive neurostimulation therapy (RNS) and transcranial magnetic stimulation therapy (TMS). Complementary therapies such as biofeedback and music therapy have demonstrated promising results in pharmacoresistant epilepsies. The current emphasis of the review article is to explore the different integrated mechanisms of various treatments for adequate seizure control, and their limitations, and supportive pieces of evidence that show the efficacy and tolerability of these non-pharmacological options.

Dietary Management of the Glycogen Storage Diseases: Evolution of Treatment and Ongoing Controversies

The hepatic glycogen storage diseases (GSDs) are a group of disorders where abnormal storage or release of glycogen leads to potentially life-threatening hypoglycemia and metabolic disturbances. Dietary interventions have markedly improved the outcome for these disorders, from a previously fatal condition to one where people can do well with proper care. This article chronicles the evolution of dietary management and treatment of the hepatic GSDs (types 0, I, III, VI, IX, and XI). We examine historic and current approaches for preventing hypoglycemia associated with GSDs. There is a lack of consensus on the optimal dietary management of GSDs despite decades of research, and the ongoing controversies are discussed.

The management of very low-calorie ketogenic diet in obesity outpatient clinic: a practical guide

The epidemic of obesity is growing steadily across the whole world. Obesity is not only a merely aesthetic disease but is the “mother” of most chronic diseases such as associated with a range of type 2 diabetes, cardiovascular disease, obstructive sleep apnea, and cancer. However, although there is a need to find a strategy to stop this epidemic disease, most of the times the current nutritional strategies are not effective in weight loss and in long term weight maintenance. Very low-calorie ketogenic diets (VLCKD) is increasingly establishing as a successful nutritional pattern to manage obesity; this is due to rapid weight loss that gives rise to a positive psychological cycle which in turn increases the compliance to diet. Another important key point of VLCKD is the ability to preserve fatty free mass which is known to play a role of paramount importance in glucose metabolism. Despite the clinical evidence of VLCKD there are paucity of data regarding to its management. Therefore, we will provide a useful guide to be used by nutrition experts taking care of subjects with obesity. In particular, we will report recommendations on the correct use of this therapeutic approach for weight loss and management of side effects.

[Effects of ketogenic diet on lipid metabolism in children with intractable epilepsy]

OBJECTIVE

To study the effects of ketogenic diet (KD) on lipid metabolism in children with intractable epilepsy and the risk of atherosclerosis in children treated with KD assessed by changes in lipid profile.

METHODS

The clinical data of 47 children with intractable epilepsy from 2013 to 2017 were collected. Blood lipid levels including triglycerides (TG), total cholesterol (TC), high-density lipoprotein (HDL) and low-density lipoprotein (LDL), were detected before and 3 months after KD treatment. LDL/HDL ratio, arterial stiffness index (AI), atherogenic index of plasma (AIP) and lipid comprehensive index (LCI) were calculated to assess the risk of atherosclerosis.

RESULTS

After 3 months of KD treatment, the TG and TC levels were slightly higher than those before treatment, and the HDL levels were slightly lower than those before treatment, but the differences were not statistically significant (P>0.05). The LDL levels of the children after 3 months of KD treatment were significantly higher than those before treatment (P<0.05). After 3 months of KD treatment, the LDL/HDL ratio and AI, AIP and LCI levels of the children were increased compared with those before treatment, but only the increase of the LDL/HDL ratio was statistically significant (P<0.05).

CONCLUSIONS

KD treatment may lead to increase in LDL level and LDL/HDL ratio, suggesting that KD treatment may increase the risk of atherosclerosis.

Ketone Bodies Inhibit the Opening of Acid-Sensing Ion Channels (ASICs) in Rat Hippocampal Excitatory Neurons in vitro

Objectives: Despite the long-term efficacy of antiepileptic drug treatments, frequent attacks of drug-resistant epilepsy necessitate the development of new antiepileptic drug therapy targets. The ketogenic diet is a high-fat, low-carbohydrate diet that has been shown to be effective in treating drug-resistant epilepsy, although the mechanism is yet unclear. In the ketogenic diet, excess fat is metabolized into ketone bodies (including acetoacetic acid, β-hydroxybutyric acid, and acetone). The present study explored the effect of ketone bodies on acid-sensing ion channels and provided a theoretical basis for the study of new targets of antiepileptic drugs based on “ketone body-acid sensing ion channels.”

Methods: In this study, rat primary cultured hippocampal neurons were used. The effects of acetoacetic acid, β-hydroxybutyric acid, and acetone on the open state of acid-sensing ion channels of hippocampal neurons were investigated by the patch-clamp technique.

Results: At pH 6.0, the addition of acetoacetic acid, β-hydroxybutyric acid, and acetone in the extracellular solution markedly weakened the currents of acid-sensing ion channels. The three ketone bodies significantly inhibited the opening of the acid-sensing ion channels on the surface of the hippocampal neurons, and 92, 47, and 77%, respectively.

Conclusions: Ketone bodies significantly inhibit the opening of acid-sensing ion channels. However, a new target for antiepileptic drugs on acid-sensing ion channels is yet to be investigated.

Effect of a Sodium and Calcium DL-β-Hydroxybutyrate Salt in Healthy Adults

Background

Ketone body therapy and supplementation are of high interest for several medical and nutritional fields. The intake of ketone bodies is often discussed in relation to rare metabolic diseases, such as multiple acyl-CoA dehydrogenase deficiency (MADD), that have no alternatives for treatment. Case reports showed positive results of therapy using ketone bodies. The number of ketone body salts offered on the wellness market is increasing steadily. More information on the kinetics of intake, safety, and tolerance of these products is needed.

Methods

In a one-dose kinetic study, six healthy subjects received an intervention (0.5 g/kg bw) using a commercially available ketone body supplement. The supplement contained a mixture of sodium and calcium D-/L-β-hydroxybutyrate (βHB) as well as food additives. The blood samples drawn in the study were tested for concentrations of D-βHB, glucose, and electrolytes, and blood gas analyses were done. Data on sensory evaluation and observed side effects of the supplement were collected. The product also went through chemical food analysis.

Results

The supplement led to a significant increase of D-βHB concentration in blood 2.5 and 3 h after oral intake (p=0.033; p=0.043). The first significant effect was measured after 2 h with a mean value of 0.598 ± 0.300 mmol/L at the peak, which was recorded at 2.5 h. Changes in serum electrolytes and BGA were largely unremarkable. Taking the supplement was not without side effects. One subject dropped out due to gastrointestinal symptoms and two others reported similar but milder problems.

Conclusions

Intake of a combination of calcium and sodium D-/L-βHB salt shows a slow resorption with a moderate increase of D-βHB in serum levels. An influence of βHB salts on acid-base balance could not be excluded by this one-dose study. Excessive regular consumption without medical observation is not free of adverse effects. The tested product can therefore not be recommended unconditionally.

Conflicting Effects of Methylglyoxal and Potential Significance of miRNAs for Seizure Treatment

According to an update from the World Health Organization, approximately 50 million people worldwide suffer from epilepsy, and nearly one-third of these individuals are resistant to the currently available antiepileptic drugs, which has resulted in an insistent pursuit of novel strategies for seizure treatment. Recently, methylglyoxal (MG) was demonstrated to serve as a partial agonist of the gamma-aminobutyric acid type A (GABA_A) receptor and to play an inhibitory role in epileptic activities. However, MG is also a substrate in the generation of advanced glycation end products (AGEs) that function by activating the receptor of AGEs (RAGE). The AGE/RAGE axis is responsible for the transduction of inflammatory cascades and appears to be an adverse pathway in epilepsy. This study systematically reviewed the significance of GABAergic MG, glyoxalase I (GLO1; responsible for enzymatic catalysis of MG cleavage) and downstream RAGE signaling in epilepsy. This work also discussed the potential of miRNAs that target multiple mRNAs and introduced a preliminary scheme for screening and validating miRNA candidates with the goal of reconciling the conflicting effects of MG for the future development of seizure treatments.