Transcript Nutrition and Epilepsy

Nutrition and Epilepsy
HEALTHY LIFESTYLE AND THERAPEUTIC
APPROACHES
COURTNEY SCHNABEL, MS, RD, CDN
Overview
 Healthy Lifestyle
 Nutrition Specifics for Epilepsy
 Therapeutic Approaches
Healthy Lifestyle
GENERAL TIPS FOR WELLBEING
Overview
 Nutritionally balanced diet with adequate fluid
intake
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Balancing macronutrients (fat, carbohydrate, protein)
Eating a wide variety of foods to maximize micronutrient
intake
 Maintain a healthy weight by consuming the
appropriate amount of calories, fat, protein and
carbohydrate
 Physical Activity as tolerated
Balanced Diet: My Plate
Maintaining a Healthy Diet
 Balance calorie intake with
 Make half your grains
 Cut back on portion sizes
 Drink water and avoid
energy output
 Make half your plate
vegetables
 Choose low fat dairy
 Cut back on foods with
solid fats, added sugar and
added salt
whole
sugar sweetened beverages
 Control your food: eat at
home more often
 Choose lean protein
 Try new foods
Maintaining Adequate
Nutrition
NUTRIENTS OF CONCERN IN PEOPLE WITH
EPILEPSY
Epilepsy and Diet
 Many nutrients and have been implicated in the
treatment of epilepsy, however, only the Ketogenic
and Modified Ketogenic Diets have been medically
proven to effectively treat epilepsy.
 Antiepileptic drugs may cause disturbances in the
metabolism of some nutrients, therefore, following a
balanced diet is critical.
Deficiency
 There is evidence that deficiencies in certain vitamins
and minerals can alter brain activity and cause seizures
 In developed countries, vitamin and mineral deficiencies
are rare except in extreme cases of malnutrition
 Weak or no scientific evidence to support that
supplementation of these vitamins and minerals (without
evidence of deficiency) is beneficial for seizure control.
Calcium
Functions
 One of the most essential
minerals. Found mainly in bone,
teeth and soft tissue.
 Involved in: cell signaling, bone
formation, enzyme activity,
 Adults: 1200 mg/day
 Children: 700-1300 mg/day
 Deficiency: kidney disease,
extremely high sodium intakes,
hormonal disorders,
malnutrition
Food Sources & Implications
 Dairy: milk, yogurt cheese,
Green Veggies (kale, broccoli,
spinach, bok choy), Beans,
Tofu, Fortified products (OJ,
cereal).
 AEDS : Carbamazepine,
phenobarbital, phenytoin,
primidone and valproate can
increase vitamin D
metabolism, depleting
calcium
Magnesium
Functions
 Energy production, structural
role, cell signaling
 Adults: 320-420 mg/day
 Children: 80-410 mg/day
(based on age range)
 Deficiency: prolonged
gastrointestinal problems,
alcoholism, malnutrition
Food Sources & Implications
 Grains (bran cereal,
shredded wheat, brown
rice, oat), Nuts (almonds,
hazelnuts, peanuts), Green
vegetables (spinach, lima
beans, swiss chard, okra),
Molasses, bananas, milk.
 AEDs: some reports of
phenytoin and
phenobarbital reducing
magnesium levels.
B6 (pyridoxine)
Functions
Food Sources
 Must be obtained from the diet,
 Fortified cereal.
cannot be made by the body
 Nervous system function
(synthesis of neurotransmitters),
red blood cell formation,
hormone function
 Deficiency: uncommon and rare
cause of seizures in infants.
Alcoholics are at highest risk
 Adults: 1.3 -1.5 mg/day
 Children: .5-1 mg/day
 Protein (turkey,
chicken, fish)
 Potatoes, spinach,
vegetable juice,
hazelnuts
Omega-3 Fatty Acids
Functions
Food Sources
 Essential fatty acid
 Cold water fish: salmon,
 Anti-inflammatory,
involved in brain function,
cell signaling.
mackerel, halibut, sardines, tuna,
herring
 Flax products
 Soybeans and soybean oil
 Ratio of Omega 3:Omega 6
is important for antiinflammatory benefit.
American diet contains 1425 times more Omega 6
than Omega 3.
 Canola oil
 Walnut and walnut oil
 Pumpkin seeds
Carnitine
Functions
Sources & Implications
 Non-essential (made
 Red meat, dairy, fish,
 Helps the body turn fat
 AEDs: valproate can
by the body)
into energy
 Needs to be taken
under medical
supervision
avocado, wheat, asparagus,
tempeh, peanut butter
deplete levels of carnitine.
Supplementation should be
determined by the medical
team and based on blood
levels.
Other Vitamins/Minerals
 Vitamin B1 (Thiamine) deficiency can cause seizures
(rare and found mostly in alcoholism)
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Many foods are fortified with Thiamine and there are many
good sources in the diet (Grains, Bread, Nuts)
AED: long term phenytoin use can deplete thiamine
 Anecdotal reports of Vitamin E supplementation
reducing seizures, but these were not reproducible in
clinical studies unless deficiency was present.
Conclusions
 Eat a balanced diet and get tested if you believe you
are deficient in a specific nutrient
 Do not start vitamin and mineral supplements unless
you speak with your physician
 A regular multivitamin is usually sufficient as a “back
up” if you believe your diet is lacking in nutrients
Therapeutic Approaches
THE KETOGENIC AND MODIFIED KETOGENIC
DIETS
The Ketogenic Diet
 Developed in the 1920s, but fell out of use after the
introduction of AEDs. Popularity has been
increasing in the past 10 years.
 Needs to be monitored closely by the medical team
(RNs, NPs, MDs, RD)
 Calorie controlled, high fat, low carbohydrate,
moderate protein diet consumed in exact portion
sizes
Stats
 Stats: 50% of the children who begin the diet will
have a 50% improvement in their seizures.
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About 30% of those children will have a >90% improvement
About 10-15% of those children will become seizure free.
Candidates
 Greatest success has been in children under the age of 18,
but more recently research documented the benefits of a
modified ketogenic diet in adults.
 All patients are candidates for the ketogenic diet unless
they have a pre-existing metabolic condition that
prevents them from participating in this therapy.
 Individuals with Doose Syndrome, Tuberous Sclerosis,
Lenox-Gastaut and GLUT-1 transporter deficiency
respond particularly well to the diet. Being used in
Infantile Spasms as well.
How it works
 Body switches from burning glucose (carbohydrates) to
burning fat for energy
 By-product of fat breakdown is ketone bodies (acetone,
beta-hydroxybutyrate and acetoacetate) Ketones can be
measured in the urine and blood to tell us “how well” our
bodies are using fat as energy
 Many proposed mechanisms to how the diet works –
most common is the suppression of neurotransmitter
activity from the presence of ketone bodies and the
absence of glucose (sugar) breakdown.
How It Works
 Carbohydrates and protein are restricted to encourage
the breakdown of fat as a primary fuel source
 Fat in the diet is increased to provide an energy substrate
so that the body does not breakdown too many of its own
fat stores (unless weight loss is indicated)
 Calories are controlled to encourage weight maintenance
and avoid “fat storing” and encourage “fat burning”
Diet Specifics
Diet Specifics
 All meals are weighed on a gram scale and are
carefully calculated by the dietitian.
 No unscheduled or uncalculated meals
 All meals are consumed in a ratio (4:1, 3:1, 2:1 etc.).
 Not nutritionally balanced – requires vitamin and
mineral supplements
Ratio??
 The ratio is:
 (The amount of fat) : (the amount of protein + carbohydrate)
in the meal.
 In a 4:1 meal there are 4 grams of fat for every .5 grams of
protein and .5 grams of carbohydrate
 For example: If a meal has 64 grams of fat, 12 grams of
protein and 4 grams of carbohydrate
64 grams fat : 16 grams of protein and carbohydrate (12 g protein
+ 4g carbohydrate)
 This is a 4:1 ratio
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Sample Meal: Spinach Quiche with Swiss Cheese
Ingredients:
Directions
50 grams of heavy cream
8 grams raw onion
34 grams of raw spinach
10 grams of egg, mixed well
15 grams of swiss cheese
24 grams of butter
1. Cut raw onion/scallion into fine
pieces, then sauté in butter.
2. Cut spinach into small pieces
then add to the above mixture.
3. Add egg and cream together and
blend well.
4. Mix spinach mixture into
egg/cream mixture.
5. Add in shredded Swiss Cheese.
6. Pour mixture into a custard dish
that has been sprayed with oil
spray.
7. Sprinkle with a pinch of Nutmeg.
Bake at 300° for 25 minutes or
until golden brown.
Recipe provides: 400 calories in a
4:1 ratio (40 grams of fat, 7 grams
of protein and 3 grams of
carbohydrate)
Side Effects
 Elevated lipids and cholesterol
 Kidney stones
 Constipation
 Acidosis
 Slowed growth
 Food Aversions
**Side effects on the diet can usually be managed by
your dietitian without having to come off the diet
Modified Ketogenic Diets: Modified Atkins
 Developed as a less restrictive version of the ketogenic
diet.
 Still high fat, low carbohydrate, but high-moderate
protein and not calorie restricted.
 Closer to a 1:1 or 2:1 ketogenic diet
 No head to head comparisons of keto vs. modified atkins,
but promising results (~50% success rate)
 More manageable for adults and older children
Modified Atkins
Diet Specifics
 Participants are encouraged to eat in a 1:1 or 2:1 ratio
and are required to “count carbohydrates”
 First Month: Induction (most important). 10 grams
of carbohydrate per day for children and 20 grams
per day for adults
 Encourage high fat, adequate fluid intake
Counting Carbohydrates
 To count carbohydrates, a carbohydrate counting
book or a reputable web application is used.
 To get more “bang for your buck” we encourage low
glycemic foods, high fiber foods
 Using high fiber foods such as vegetables and nuts
allows for larger portion sizes.
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This method is called counting “net carbohydrates” and is done
by subtracting the dietary fiber content from the total
carbohydrates.
Food Label
Cooked Cauliflower
(1 cup portion)
Sample Meal: Eggplant “Parmesan”
INGREDIENTS:
DIRECTIONS:
½ raw eggplant (1/2 pound)
2 tablespoons olive oil
1 teaspoon almond flour (Bob’s Red
Mill©)
¼ cup shredded whole milk mozzarella
4 ounces Walden Farms Tomato Basil
Sauce©
Cut eggplant into circles
Recipe provides: (520 calories, 37g fat,
7g carbohydrate , 9g protein) in a 2:1
ratio
Dip egg plant in olive oil and then
in almond flour to coat. Place on
baking sheet with non-stick cooking
spray.
Bake in the oven at 350 degrees
until crisp.
Remove from oven. Mix remaining
oil into tomato sauce and top
eggplant circles with tomato sauce
and then mozzarella cheese.
Return to the oven and bake until
cheese is melted (about 10
minutes).
Additional Modified Diets
 Low Glycemic Index Treatment
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60% fat, higher carbohydrate (40-60 grams per day). Ratio of 1:1.
Only carbohydrates with a glycemic index of <50 are allowed
(glycemic index refers to a food’s effect on blood sugar)
Preliminary studies have shown that more than half of patients who
begin LGIT have a >50% reduction in seizures, however some
parents report difficulty following/calculating the GI of foods.
 The MCT Ketogenic Diet
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70-75% fat (mostly in the form of MCT and LCT), more protein and
carbohydrate then classic ketogenic diet
Similar results to classical ketogenic diet, but some studies reported
it was less tolerable than classic KD due to the large amount of MCT
oil
Conclusion: Therapeutic Approaches
 The Ketogenic and Modified Ketogenic diets are
proven medical therapies
 They do not work for everyone, but the results are
promising
 These diets should NEVER be attempted without the
supervision of your Neurologist/Treatment Team
and a Registered Dietitian familiar with Ketogenic
Diets.
Learn More About the Diet
 Helpful websites:
 The Charlie Foundation(www.charliefoundation.org)
 The Carson Harris Foundation: Parent support group
(www.carsonharrisfoundation.org)
 Epilepsy Cure Initiative: Canada based support group (www.epilepsycureinitiative.ca)
 Epilepsy Foundation (www.epilepsyfoundation.org)
 www.atkinsforseizures.com: recipes, general information
 http://www.epilepsy.com/epilepsy/treatment_atkins_diet information
 Matthew’s Friends: Ketogenic and MAD support group for the UK
(www.matthewsfriends.org)
 Epilepsy Foundation (www.epilepsyfoundation.org) – Go to “FORUM” for parent
comments/support
 Books/Resources
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Keto Kid: Helping Your Child Succeed on the Ketogenic Diet: B. Synder, DemosHealth
(parent friendly)
Epilepsy: Patient and Family Guide: 3rd Edition. Devinsky. Demos Health
Ketogenic Diets 5th Edition. Kossoff, Freeman, Turner, Rubenstein. Demos Health.
Conclusions
 Adequate and balanced nutrition is important for well-
being.
 Following a balanced diet and maximizing nutrient
intake may have its benefits for epilepsy
 There are PROVEN dietary approaches to help treat
seizures
 Speak with your physician and dietitian before starting
any of the diet therapies
References
 Linus Pauling Institute. Micronutrient Information
Center. Accessed 4/19/12 at:
http://lpi.oregonstate.edu/infocenter/
 Kossof f E, Freeman J, Turner Z, Rubenstein J (2011)
Ketogenic Diets: Treatments for Epilepsy and Other
Disorders (5th ed). New York, NY: Demos Health
 Devinsky O (2007). Epilepsy Patient and Family
Guide (3rd ed). New York, NY: Demos Health.