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Nutrition & Epilepsy

Jenny Schoenfeld, ARNP Pediatric Epilepsy

Swedish Neuroscience Institute

Outline

•  Diet Therapies for Epilepsy: – Ketogenic Diet & Modified Atkins Diet

•  Vitamins & Nutritional Deficiencies:

– Bone Health: Calcium & Vitamin D – Carnitine

– Folic acid

– Cholesterol – Supplements, vitamins & herbs

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Diet Therapies for Epilepsy

Ketogenic Diet (KD) Modified Atkins Diet (MAD)

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What is the Ketogenic Diet?

•  High fat, low carbohydrate, and adequate protein diet •  Ketones become the primary fuel for the brain •  Started in the hospital

•  All foods must be carefully prepared and weighed on a gram scale.

•  Count the carb content in meds, vitamins, toothpaste, lip balm, sunscreen…everything!

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How Effective is the Ketogenic Diet? •  1/3 of patients will discontinue the KD due to ineffectiveness or

difficulty with adherence or tolerability •  1/3 of patients will have a 50-90% reduction in seizures •  1/3 of patients will have > 90% seizure reduction

–  Half of these individuals will become seizure free (15-17%)

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Who is a Candidate for the KD? •  Continue to have seizures despite medications •  Medications cause side effects •  Not a candidate for epilepsy surgery •  Family is willing to commit the time and effort •  Patients with certain rare metabolic disorders should not start

on the KD

•  Effective regardless of seizure type or seizure syndrome

•  The KD is NOT a healthy, all-natural treatment for epilepsy.

–  Break down fats into ketones in the absence of glucose –  Brain uses ketones, not glucose, for energy

•  Regular diet: Carbohydrates Glucose •  Protein Amino Acids

•  Fat: Triglycerides Fatty acids Ketones

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Mechanism of Action Energy Metabolism: Fuel Sources

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The Ketogenic Diet How does it work? $ $ $ $$

Liver produces ketones from fatty acids $

When there is no glucose available, the brain uses ketones for fuel

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Eat high fat

Supplying the body with fuel in the form of fat with no carbohydrates

Fatty acids

How does the KD actually improve seizure control?

Well, we don’t exactly know… But animal studies have shown: •  The KD increases fatty acid oxidation, altering

metabolism to a state of ketosis ! this results in decreased neuronal hyperexcitability

•  Ketone bodies decrease neuronal excitation

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When Do Seizures Improve?

•  Variable

•  Minimum 3-4 months trial period

•  Diet may require initial “fine-tuning” of calories and meal plans before beneficial results are seen.

Duration on the Ketogenic Diet

•  Typical duration is ~ 2-3 years (or longer) •  Balance the risks and benefits with long-term therapy

•  Risk factors for seizure recurrence after weaning off KD: –  Presence of recent EEG epileptiform activity – Abnormal MRI –  Seizure frequency

Martinez, et al., Epilepsia 2007, 48(1):187–190.

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Starting the Ketogenic Diet $$

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Urine ketones are checked regularly at home

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http://www.myketocal.com/index.html

Powder Formula 3:1 and 4:1 ratio Liquid KetoCal 4:1 ratio

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KetoCal: more palatable options!

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Ketogenic Diet Sample Meals

Breakfast: 40g 36% Heavy cream 32g Sausage links 24g Avocado 5g Canola oil

Lunch: 40g 36% Heavy cream 18g Sliced turkey breast 22g Raw cucumber slices

and celery sticks 22g Mayonnaise

Dinner: 40g 36% Heavy cream 20g Baked cod 43g Roasted cauliflower 23g Butter

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Ketogenic Diet Labs Initial Labs & F/u Monitoring

•  Acylcarnitine profile, Urine organic acids, Serum amino acids •  Lactate; pyruvic acid •  CBC/diff; CMP (sodium, potassium, AST, ALT, alk phos, albumin, total

protein, calcium, glucose, CO2, chloride, BUN, creatinine)

•  Vitamin D, selenium, phosphorus, zinc, magnesium, uric acid, ferritin, carnitine, free and total

•  Fasting lipid panel •  Beta-Hydroxybutyrate •  Urinalysis (urine ketones, urine specific gravity, blood)

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Vitamins & Supplements Low-Carb

Side Effects on the Ketogenic Diet

•  Constipation # 1 out-pt

•  Vomiting # 1 in-pt

•  Nausea •  Reflux •  Diarrhea •  Kidney stones (2-5%)

•  High cholesterol •  Osteopenia

•  Delayed growth •  Dehydration

•  Hypoglycemia

•  Metabolic acidosis

•  Platelet dysfunction •  Vitamin & nutritional

deficiencies (carnitine, vitamin D, selenium)

Epilepsia. 2004;45(9):1116-23. Am J Clin Nutr. 2008;88(6):1678-84. J Child Neuro. 2008;23(7):758-61

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What about teens & adults with epilepsy?

•  Ketogenic diet is effective for teens and adults •  Biggest barrier: COMPLIANCE! $

Epilepsia, 44(6):847–851, 2003

Modified Atkins Diet (MAD) •  MAD is more liberal. No gram scale. No calorie

restriction.

•  Count daily NET CARBS

•  Net Carbs = Total Carbohydrate (g) – Dietary Fiber (g)

•  Max of 10 – 20 grams of net carbs per day

•  Increase fat intake!

•  Very very low carb! Very high in fat.

•  Less dietitian involvement in meal planning

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Modified Atkins Diet Start with 10 – 15 grams of net carbs/day

How many grams of carbohydrate are in a small apple?

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Can an apple be included on the MAD?

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One small apple with skin •  Total Carbohydrate 20 g •  Dietary Fiber 3 g

Total Net Carbs in 1 small apple = 17 g (20 – 3 = 17)

Can an apple be included on the MAD?

Modified Atkins Diet: High Fat$

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How Effective is the MAD?

•  Approximately ! of all patients have a reduction in seizures by 50-90%.

•  Recommend 3-4 month minimum trial period •  Potentially less likely to have an immediate

reduction in seizures, compared to KD $

Diet Comparison

Classic Ketogenic Diet 4:1

Modified Atkins Diet Standard “Regular” Diet

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Additional Resources CharlieFoundation.org MatthewsFriends.org

Epilepsy.com/KetoNews $

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Epilepsy: Vitamins & Nutrients

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Bone Health: Calcium & Vitamin D

•  Long term seizure medications can weaken bones •  Seizures increase the risk of broken bones/injury •  Calcium and vitamin D can all help strength bones •  Supplements vs. Dietary intake?

– Depends on age, intake, nutritional needs, risk factors, and vitamin deficiencies

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Bone Density

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Infants: 200 - 260 mg; Children: 700 - 1000 mg; Adults: 1000 - 1300 mg Food and Nutrition Board National Academics (of North America) 2001 Dietary Reference Intakes

Calcium Intake

Vitamin D •  Recommended dose 400 IU to 800 IU daily •  But, dose depends on vitamin D level: 400 to 50,000 IU

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Carnitine •  Important for energy production in the body •  Helps the body utilize fat for energy Reasons for carnitine supplements? •  Genetic reasons: inborn errors of metabolism •  Medications and dietary reasons:

– Certain seizure medications (valproic acid) – Taking multiple seizure medications – Ketogenic Diet (high fat diet)

Epilepsia, 39(11): I216- 1225, 1998

Dietary Sources of Carnitine

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Folate (Folic Acid)

•  Folate: water-soluble, B vitamin •  Helps produce and maintain new cells •  Produce normal red blood cells to prevent anemia •  Needed to make DNA and RNA •  Especially important during periods of rapid cell

division and growth, such as infancy and pregnancy.

Some seizure medications can interfere with folic acid absorption and metabolism.

Folate Deficiency & Supplements

•  In infants and children: can slow overall growth rate •  In adults, a particular type of anemia can result from long

term deficiency; associated with depression •  During Pregnancy: increased risk of neural tube defects,

congenital malformations, and low birth weight, premature infants.

ALL young women with epilepsy should take daily folic acid supplements before and during pregnancy. Recommended dose: 400 to 2000 mcg daily

Neurol Neurosurg Psychiatry 2009; 80:506. $

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Dietary Sources of Folic Acid

Cholesterol •  Some seizure medications can increase cholesterol

levels •  Ketogenic diet can increase cholesterol •  Ways to Decrease Cholesterol:

–  exercise, healthy diet, omega oils, cholesterol lowering medications, change seizure medications, or change KD if needed

•  Unhealthy fats (butter) increase LDL “bad cholesterol”

•  Healthy fats (olive oil) increase HDL “good cholesterol,” and decrease LDL

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•  The more the better…right? •  “It’s all natural!”

Federal law does not require dietary supplements to be proven safe to FDA’s satisfaction before they are marketed.

Herbal therapies and certain vitamins can interact with medications, potentially causing harm and/or accumulate toxic levels

Too much of a good thing? Excessively high doses of vitamins can cause toxicity.

Vitamins, Supplements, Herbs

www.fda.gov/ForConsumers/default.htm