Transcript Diet treatments for epilepsy 2014

Diet Therapy For Epilepsy
ANGELA SAMUELS, RD CNSC
NORTHEAST REGIONAL EPILEPSY GROUP
What is the goal for diet therapies in epilepsy?
 Diet therapies mimic starvation which has
been found to be effective for seizure
control.
 Goal: change body’s metabolism from
utilizing glucose for energy to using fat.
 Types of diets: ketogenic diet, modified
Atkins diet, and low glycemic index
treatment diet.
What is the diet?
 Individually prescribed high fat, very
low carbohydrate, and adequate protein
diet.
 Ratio of grams of fat : combined grams
of carbohydrate and protein determines
degree of ketosis (typically for
ketogenic diet 3:1- 4:1)
How does it work?
 How does it work? – likely multiple
mechanisms including changing the
efficiency of nerve cell mitochondria,
alters utilization of GABA and glutamic
acid, modulation of neuronal
hyperexcitability.
Does it work?
 Half of patients have at least 50% or better decrease
in seizure frequency.
 30% will have greater than 90% improvement, 1015% will be seizure free.
 Compared to patients who fail 2 AEDS – 30% chance
of controlling seizures with further medications.
 45% of patients discontinue the diet within 12
months of initiation.
-Kossoff Et Al., Ketogenic Diets: treatment for epilepsy
and other disorders.
Myths about diet therapy
 This is a “natural” or “holistic” therapy
 The diet will completely control
seizures
 Taking the diet will allow patients to
discontinue all medications
 Only need a short period of time to see
if the diet is effective
Who should use the diet?
 Medication failure / Unacceptable seizure frequency
 Excessive medication side effects
 Glucose Transporter Deficiency (GLUT-1)
 Pyruvate Dehydrogenase Deficiency
Who should not go on the diet?
 Relative:
 Initiation during stress/sepsis/infection
 Family/caregiver noncompliance
 Hyperlipidemia ?
 Absolute:
 Inborn errors of metabolism such as pyruvate carboxylase
deficiency, organic acidurias
 Disorders which involve defects in fatty acid transport or Boxidation
 Medications interfering with carbohydrate metabolism
(corticosteroids)
What are short term side effects of ketogenic
diet
During diet initiation
 Dehydration: ketosis inhibits thirst
 Hypoglycemia:
 Asymptomatic common
Symptomatic rare
 Vomiting
 Acidosis
What are the long term side effects of
ketogenic diet?
 Constipation. Very common
 Poor Growth. Should be uncommon
 Vitamin, Mineral deficiencies.
 Hyperlipidemia. 30-60%? Risk of
pancreatitis with hypertriglyceridemia?
 Kidney stones (rare)
Who is the team?
 Dietary team: dietician, physician, social worker,
nurse.
 Dietician role:
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Address nutritional content and supplementation of food
Help make adjustments to type of foods to optimize seizure
control or alleviate side effects
Help design meal plans that work with the child’s tastes
Help family check the carbohydrate content of foods and
medicines (ketocalculator)
Who is the team?
 Physician role:
 Identify appropriate patients for this therapy
 Make sure that the patient does not have a medical condition
that could worsen in the setting of diet
 Monitor cholesterol, bone density, electrolyte abnormalities.
 Social worker role:
 Identify family needs during the diet
 Identify concerns regarding compliance
 Provide support to families
 Nursing role:
 Point person for the patient
 Helps direct patient to appropriate party
Classic Ketogenic Diet
 Hospital initiation
 Calorie controlled
 All meals and snacks must be precisely weighed and measured
 Computer program/recipe books
Ex. Ketocalculator, Keto Cookbook
 Equipment: digital scale that measures in grams, small spatulas,
mixing bowls, measuring cup and spoons
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Initiation of the Diet
Outpatient family meeting with dietitian and
epileptologist to discuss diet
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 Inpatient admission coordinated with RD and
Epilepsy team
 Patient admitted on Sunday/Monday evening to
EMU
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Plan for a minimum 3-5 day admission
All meds converted to sugar free prior to
admission
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All formulas obtained prior to admission
Nutritional Assessment/Diet Calculation
 Height, weight and BMI/weight-for-height plotted on
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growth chart
Diet and weight history
Food allergies/preferences/intolerances
Calories - 75-90% of the DRI for age
Meet the DRI protein requirements
Divide calories into meals/snacks or formula schedule
 variety
 food preferences
 protein adequacy
Formula/Tube Feeding Diet
 RCF (Ross Carbohydrate
Free)
 Microlipid (safflower oil
emulsion)
 Polycose (glucose polymers)
Ketocal (Nutricia
North America)
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Vitamin and Mineral Supplementation
 Sugar free Flintsones vitamin
 Centrum Advanced Formula
 Nano VM (1-3) (4-8) (Solace Nutrition)
 Phlexy-vits (Nutricia)
 Polyvisol
 Calcium Carbonate (with meals)
 Calcium Citrate (between meals)
Sick Days
 Vomiting and /or diarrhea - sugar free fluids, water,Crystal light,
broth, diet caffeine free soda, Powerade Zero
 Offer fluids every 1-2 hour while awake
 Monitor for signs of dehydration, hypoglycemia, lethargy and rapid
breathing
 IV hydration may be indicated to break the cycle
 Once eating and drinking again start light, small frequent meals or
½ strength formula if used
Modified Atkins Diet
Modified Atkins Diet
 Outpatient initiation
 Not calorie controlled
 Lower in fat and higher in protein and
carbohydrates
Getting Started
Diet starts with 10 grams carbs per day for children and 10-15 grams of
carbs per day for adults
 What foods contain carbohydrates
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Starches
Bread, rice,
pasta, cereal,
crackers, bagels,
pretzels, chips,
pancakes, etc.
Fruits
All fruits have
carbohydrate
however they vary
in the amount. An
average size piece
of fruit has
approximately 30
grams of
carbohydrate
Vegetables
Dairy
Sweets
Other
All vegetables have
carbohydrate, but
some have much more
than others. Peas,
corn, potatoes, and
lima beans are
considered “starchy”
vegetables and have
over twice the amount
of carbohydrate in
them than other
vegetables.
All dairy
products will
have
carbohydrate.
This includes
milk, yogurt,
ice cream, and
cheese. Most
cheeses are
minimal and
can be used
often on this
diet.
Cookies, candy,
chocolate, gum,
etc. Note that
sugar free DOES
NOT MEAN
carbohydrate free!
Gum, salad
dressings, sauces,
condiments
(ketchup,
barbeque sauce)
have
carbohydrate.
Make sure to read
all food labels!
Step One: Eliminate All High Calorie Beverages
High calorie beverages include juice, soda, and flavored
milks. Each of these items have well over 10 grams of
carbohydrate in just one serving. Acceptable substitutions
for these items include water, unsweetened iced tea, diet
soda, many diet Snapple and Crystal Light products, and
seltzer water.
Step Two: Eliminate Sweets and High
Carbohydrate Condiments
Sweet and sugary foods are very high in carbohydrate. It may be
difficult to eliminate these from your diet. Try and substitute some of
these sweets.
Example: Instead of chocolate milk, try one tablespoon of
unsweetened cocoa powder (~3 grams carbohydrate) and mix with
heavy cream. This can also be heated to make hot chocolate. You can
sweeten it with a drop or two of liquid Stevia
Example: Make a popsicle with diet soda (diet root beer or orange
soda) and heavy cream. Use an ice cube tray (or small cups) to make
these treats. Fill up half with diet soda and half heavy cream. Place in
freezer and let sit for a frozen treat.
Example: Experiment with Ketocal of Ketobake These products can be
used as a baking agent. Popular items include cakes, muffins, and
cookies.
Check out MyKetocal.com and Ketobake.com for recipes
Step Three: Eliminate Fruits
The average medium size fruit has ~30 grams of
carbohydrate. It will be an option to use all 10 grams
towards a small portion of fruit. Start by decreasing your
current portions by half. In addition, try to get the most
out of what you are eating. You can eat almost ½ cup of
blueberries for 10 grams or 1/3 of a banana. Eating several
blueberries will help make the portion seem bigger.
Step Four: Increase Protein Sources
It is essential to increase protein and fat intake in order to
take in adequate calories as well as promote ketosis. High
protein foods should be the staple of this diet as they are
considered “free foods.” High protein foods include all
meats, poultry, seafood, and eggs. One of these items should
be included in every meal.
Step Five: Decrease Starchy Food
Intake
This can often be the most difficult step in starting the diet
as starchy foods make up a large percentage of a regular
diet. Try to decrease portion sizes of these items at each
meal.
For example: Instead of making a sandwich with two
slices of bread, only use one but double up on the protein
source. Once portion sizes have decreased, eliminate all
starchy foods from one meal per day.
Step Six: Adding Fat Into Your Diet
This step is essential for success. As a refresher, pure fat sources are oil, butter,
margarine, heavy cream (double check food labels as some have a small amount
of carbohydrate), and mayonnaise.
Fat can be added to meals in the following way:
● Using dilute heavy cream as a beverage/milk substitute.
● Adding heavy cream when making scramble eggs.
● Always frying meat products in oil.
● Melt butter and pour over meat or poultry as a sauce.
● Use mayonnaise as a dip for turkey, bacon, or chicken.
● Make cream sauces with heavy cream and cheese to pour on top of meat or
small portions of vegetables.
MCT
• Short for Medium Chain Triglycerides
• Derived from coconut and palm oil
• Incorporate slowly into diet because it may cause a
laxative effect
• Coconut oil is liquid at room temperature and solid
when refrigerated
• Use similar to butter – mix into vegetables or spread
on low carb bread/crackers
Putting it all together
 Contact your dietitian regularly to monitor
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progress with the above steps
Once you have reached your goal for
carbohydrates you should check urine ketones at
home
Follow up labs?
Sugar free meds
Vitamin/Mineral Supplements
Can we increase carbs?
Low Glycemic Index Treatment
• Goal of diet is the same as Ketogenic and Modified
Atkins – reduce seizures
• More liberal: 40-60 grams carbohydrates/day
• Carbs should be evenly distributed
• Carbs should be eaten with protein and fat
• Designed to prevent fluctuations in blood sugar
Diet Distribution
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Carbohydrates – 10% daily calories
Protein – 20-30% daily calories
Fat – 60-70% calories
Choose foods with glycemic index <55
Resources
Angela Samuels - dietitian
[email protected]