Transcript Novel Screening Tool, FORMS - Epilepsy Foundation of Greater

Dietary Treatments
of Epilepsy
Antoaneta Balabanov, MD
Epileptologist
Kelly Roehl, MD, RDN
Registered Dietitian Nutritionist
Dietary Treatments of Epilepsy Clinic
Rush Epilepsy Center
Rush University Medical Center
Chicago, IL
NO DISCLOSURES
Rush Epilepsy Center
• Established in 1970’s by Dr. Frank Morell
• 5000-6000 patients
• Comprehensive Team
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7 Epilepsy Attending Physicians
4 Neurophysiology Fellows Annually
1 Epilepsy Fellow
3 Nurse Practitioners
3 Registered Nurses
Social Worker
Registered Dietitian
Rush Dietary Treatments of Epilepsy Clinic
• Initiated: December 2012
• Team:
- Attending Epileptologist (Antoaneta Balabanov)
- Registered Dietitian (Kelly Roehl)
• Patient Assessment & Follow Up:
>200 patients assessed
Why dietary treatments of epilepsy?
• 30% of all patients with epilepsy are
medically intractable
• AEDs and side effects
• Surgical treatments are not always an
good option for the medically intractable
patients
• Brain stimulation – efficacy varies and
takes time
What are the dietary treatments of epilepsy?
Ketogenic Diet (KD)
Medium Chain Triglycerides Diet (MCT)
Modified Atkins Diet (MAD)
Low Glycemic Index Diet (LGID)
History
Historical Timeline
Biblical
references
Hippocrates
1921
Mayo
Clinic
1994
Charlie
Foundation
1970s
MCT diets
2008
Low GI
(Hopkins)
2003
Modified Atkins
(Hopkins)
Present Day
Mayo Clin Bulletin. 1921. 2:307-308.
JAMA. 1938. 95(10): 707-709
J Child Neurol. 2009; 24(8):979-988.
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Low Carbohydrate Diets
Restrict: processed foods, grains,
desserts, sugar-sweetened
beverages, starchy vegetables
Moderation: fruit, dairy, carrots &
sweet potatoes, legumes, dark
chocolate, red wine
Focus: Vegetables (all non-starchy),
avocado, nuts, fats & oils, leafy
greens, eggs, fish, meat, poultry
Ketogenic Diets
Restrict: carbohydrate (<60 g/day)
Moderation: protein (0.8-1.2 g/kg)
Liberal: fats (60-90% of total calories)
Classic Ketogenic Diet (4:1, 3:1)
• Mimics the metabolism of starvation, which
create ketones (ketosis)
• High fat, adequate protein, low carbohydrates
• Starting diet requires hospitalization
• Traditionally used in children <2 years
What does a ketogenic diet look like?
Classic Ketogenic Diet
“American” Diet
2%
8%
35%
49%
90%
Fat
16%
Protein
Carbohydrate
Classic Ketogenic Diet – Why Not?
• Too restrictive, not palatable
• Constraining of daily life-requires
weighting food to the gram
• Requires a dietitian with special training
• Inpatient stay to start the diet
• Socially “unacceptable”
MODIFIED KETOGENIC DIETS
Modified Atkins Diet (MAD)
• Not intended for weight loss, but can occur
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Does not restrict calories
Does not restrict protein intake
Restricts carbohydrates to 10-20mg a day
High fat is encouraged
Ratio 2:1 to 1:1
• No weighting and measuring of food is needed
• Outpatient initiation
• No fasting needed
What does MAD look like?
Modified Atkins Diet
“American” Diet
6%
35%
30%
49%
64%
16%
Fat
Protein
Carbohydrate
Low Glycemic Index Diet/Treatment
• Not intended for weight loss, but can occur
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Does not restrict calories
Does not restrict protein intake
Restricts carbohydrates to 40-60 mg a day
Fat intake not necessarily encouraged
Ratio 0.7-1:1
• No weighting and measuring of food is needed
• Outpatient initiation
• No fasting needed
What does LGID/T look like?
Low Glycemic Index
Diet/Treatment
Essentially
same as MAD
“American” Diet
6%
35%
49%
30%
64%
16%
Fat
Protein
Carbohydrate
MAD vs LGID/T
MAD
• Low carb, adequate protein,
high fat
• Carbs: 10-20 g/day
• All carbs allowed
• Moderate to high ketosis
• Stable blood sugar
LGID/T
• Low carb, adequate protein,
high fat
• Carbs: 40-60 g/day
• Only low GI carbs (GI <50)
• Low ketosis
• Stable blood sugar
What is Glycemic Index?
High GI Foods
sugar, white flour,
white grains, lower
fiber fruits
Low GI Foods
vegetables, nuts, seeds,
legumes, berries
Who Benefits from Ketogenic Diets?
1. Patients with medically intractable epilepsy that:
• Are not surgical candidates
• Failed surgical treatment
2. Patients with well controlled epilepsy that:
• Experience side effects from AEDs
• Would like to reduce AEDs
3. All patients with epilepsy that are interested!
– (As long as there are not contraindications)
Which Diet is Best for You?
• Classic Ketogenic Diet:
• Pediatric patients, G-tube feedings
• Modified Atkins Diet:
• Medically intractable
• Low Glycemic Index Diet:
Modified
Ketogenic
Diets
• Medically intractable
• Medically non-intractable
• Limited cognitive abilities and/or those without family support
Which Diet is Best for You?
• Neurologic Considerations
• Seizure type, severity & frequency
• Baseline cognitive abilities
• Nutrition Considerations
• Baseline food knowledge, preferences
• Ability to prepare meals, follow directions/recipes
• Support & Investment
• Family and emotional support
• Patient investment (self-interest versus referral)
- Willingness & readiness to make diet change
25 kcal/kg
1.2 g protein/kg
35 ml/kg
~1.2:1 ratio
Sample Breakfast – MAD
Sample Lunch – MAD
Sample Dinner – MAD
Sample Snacks & Daily Totals - MAD
Side Effects
Side Effect
Weight loss
Treatment
Weight gain
Reduce calories, ensure compliance
Constipation
Increase fiber & fluid consumption,
pharmacologic
Acid reflux
Increase carbs, eliminate problematic foods,
change eating patterns, pharmacologic
Hyperlipidemia
Ensure compliance, start carnitine, adjust types of
fats consumed
Increase protein, carbohydrates
Rush Experience
Table 1. Outcomes among adult patients with medically intractable epilepsy after 3 months
following a Modified Atkins Diet (MAD) or Low Glycemic Index Diet (LGID)
Seizure improvement at 3 months1
Total
n=34
<50%
n=19 (56%)
>50%
n=15 (44%)
Improvement in QOL1
27 (79%)
13 (68%)
14 (93%)
5% weight loss
Constipation
Total cholesterol >200 mg/dL (n=20)
19 (56%)
6 (18%)
7 (35%)2
10 (53%)
3 (16%)
--
9 (60%)
3 (20%)
--
n (%)
Side Effects1
1
2
Self-reported at 3 month follow up
Only 2 patients (10%) with baseline normal TC (<200 mg/dL) had TC >200 mg/dL at 3 months
Balabanov A, Roehl K. Abstract 2.205. AES 2014
Rush Experience
Table 1. Outcomes among adult patients with medically intractable epilepsy after 3 months
following a Modified Atkins Diet (MAD) or Low Glycemic Index Diet (LGID)
Seizure improvement at 3 months1
Total
n=34
<50%
n=19 (56%)
>50%
n=15 (44%)
Improvement in QOL1
27 (79%)
13 (68%)
14 (93%)
5% weight loss
Constipation
Total cholesterol >200 mg/dL (n=20)
19 (56%)
6 (18%)
7 (35%)2
10 (53%)
3 (16%)
--
9 (60%)
3 (20%)
--
n (%)
Side Effects1
1
2
Self-reported at 3 month follow up
Only 2 patients (10%) with baseline normal TC (<200 mg/dL) had TC >200 mg/dL at 3 months
Balabanov A, Roehl K. Abstract 2.205. AES 2014
Other Benefits of Ketogenic Diets
• Improvements in patient care outcomes
• Seizure frequency
• Seizure severity
• Quality of life
• Mood
• Sleep
• Energy
• Mental clarity
• Minimal negative side effects
Regardless of
improvements in
seizure control!
Conclusions
• Dietary treatment clinics are feasible option
that may improve not seizures, but also
quality of life.
• All patients with epilepsy should be education
on diet therapy for the treatment of epilepsy.
• Diet clinic should be part of any
comprehensive epilepsy center.
QUESTIONS