Nutritional supplements, foods, and epilepsy: Is there a relationship?

Unraveling the nutritional challenges in epilepsy: Risks, deficiencies, and management strategies: A systematic review

BACKGROUND

Malnutrition and epilepsy share a complex bidirectional relationship, with malnutrition serving as a potential risk factor for epilepsy development, while epilepsy, in turn, often exerts profound effects on nutritional status. Nutritional interventions have emerged as a critical adjunctive approach in epilepsy management.

AIM

To explore the multifaceted associations between malnutrition and epilepsy, structured into three primary sections: (1) Elucidating the impact of malnutrition as a risk factor for epilepsy onset; (2) Examining the reciprocal influence of epilepsy on nutritional status, and (3) Evaluating diverse nutritional interventions in the management of epilepsy.

METHODS

A systematic search was conducted across PubMed, Scopus, and Web of Science databases utilizing defined keywords related to malnutrition, epilepsy, and nutritional interventions. Inclusion criteria encompassed various study types, including clinical trials, animal models, cohort studies, case reports, meta-analyses, systematic reviews, guidelines, editorials, and review articles. Four hundred sixteen pertinent references were identified, with 198 review articles, 153 research studies, 21 case reports, 24 meta-analyses, 14 systematic reviews, 4 guidelines, and 2 editorials meeting the predefined criteria.

RESULTS

The review revealed the intricate interplay between malnutrition and epilepsy, highlighting malnutrition as a potential risk factor in epilepsy development and elucidating how epilepsy often leads to nutritional deficiencies. Findings underscored the importance of nutritional interventions in managing epilepsy, showing their impact on seizure frequency, neuronal function, and overall brain health.

CONCLUSION

This systematic review emphasizes the bidirectional relationship between malnutrition and epilepsy while emphasizing the critical role of nutritional management in epilepsy treatment. The multifaceted insights underscore the need for a holistic approach to addressing nutritional aspects alongside conventional epilepsy management strategies.

Interactions between antiseizure medications and foods and drinks: A systematic review

Antiseizure medications (ASMs) constitute the principal of treatment for patients with epilepsy, where long-term treatment is usually necessary. The purpose of this systematic review is to provide practical and useful information regarding various aspects of the interactions between ASMs and foods and drinks. MEDLINE and ScienceDirect, from the inception to July 15, 2023, were searched for related publications. In both electronic databases, the following search strategy was applied, and the following keywords were used (in title/abstract): "food OR drink" AND "antiepileptic OR antiseizure." The primary search yielded 738 studies. After implementing our inclusion and exclusion criteria, we could identify 19 studies on the issue of interest for our endeavor. Four studies were identified in the recheck process and not by the primary search. All studies provided low level of evidence. Interactions between foods and ASMs are a common phenomenon. Many factors may play a role for such an interaction to come to play; these include drug properties, administration route, and administration schedule, among others. Drugs-foods (-drinks) interactions may change the drug exposure or plasma levels of drugs (e.g., grapefruit juice increases carbamazepine concentrations and the bioavailability of cannabidiol is increased 4-5 folds with concomitant intake of fat-rich food); this may require dosage adjustments. Interactions between ASMs and foods and drinks may be important. This should be taken seriously into consideration when consulting patients and their caregivers about ASMs. Future well-designed investigations should explore the specific interactions between foods (and drinks) and ASMs to clarify whether they are clinically important. PLAIN LANGUAGE SUMMARY: Interactions between antiseizure medications and foods and drinks may be important. This should be taken into consideration in patients with epilepsy.

Caffeinated drinks, fruit juices, and epilepsy: A systematic review

The aim of this systematic review was to provide the required information regarding different aspects of the relationship between epilepsy/antiseizure medications and non-alcoholic drinks. The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were followed. MEDLINE and Scopus from the inception until 7 August 2021 were systematically searched. These key words were used: "epilepsy" OR "seizure" OR "antiepileptic" OR "antiseizure" OR "anticonvulsant" AND "coffee" OR "tea" OR "soda" OR "juice" OR "drink" OR "cola" OR "diet" (35 key word combinations). The primary search yielded 21 458 publications (PubMed, n = 4778; Scopus, n = 16 680). Only 50 studies met all the inclusion criteria and were included in the current systematic review. In total, 17 articles investigated various non-alcoholic drinks in human studies, 11 studies were case reports/series, and 22 articles were animal/in vitro studies. None of the studies provided a class 1 of evidence. There is limited evidence suggesting that certain drinks (eg, caffeinated energy drinks) might trigger seizures. Patients with epilepsy should avoid excessive consumption of certain fruit juices (eg, grapefruit, lime, pomegranate, kinnow, and star fruit) and caffeinated drinks. However, daily coffee and tea intake can be part of a healthy balanced diet, and their consumption does not need to be stopped in patients with epilepsy. Coffee/tea consumption is not harmful if consumed at levels of 200 mg (caffeine) in one sitting (about 2½ cups of coffee) or 400 mg daily (about five cups of coffee).

Nutritional intake and its impact on patients with epilepsy: an analytical cross-sectional study

BACKGROUND

Anecdotal reports have proposed that diet might influence the occurrence of seizures.

OBJECTIVES

Our objectives were to assess nutritional status in a sample of patients with epilepsy and to investigate the impact of nutrition on epilepsy control.

PATIENTS AND METHODS

One hundred and fifty patients with epilepsy participated in the study. To assess nutritional status, sociodemographic characteristics, anthropometric measurements, dietary food intake, and 24-hour food intake were evaluated. Patients answered questions using a food frequency questionnaire.

RESULTS

In patients with epilepsy, there was insufficient intake of water, fiber, potassium, magnesium and some vitamins (C, E, B12, folate and niacin); suboptimal intake of calories, zinc, calcium, and some vitamins (A, B1 and B6); optimal intake of total fats; and over-intake of proteins, carbohydrates, phosphorus, iron, sodium, and vitamins D and B2. Moreover, there was a statistically significant difference between patients with controlled versus uncontrolled seizures regarding frequency of vegetable intake and percentage of caloric intake from the recommended dietary allowance. Stepwise logistic regression indicated that those with low intake of vegetables had a 2.3 times higher likelihood of uncontrolled seizure occurrence compared to those with a high intake of vegetables per week. Also, those with optimal caloric intake were 80% less likely to have uncontrolled seizures than those with too much caloric intake.

CONCLUSION

Macro- and micronutrient intake were unbalanced in patients with epilepsy. Patients who consumed too many calories and too few vegetables were more likely to have improper seizure control.

Clinical trials of vitamin-mineral supplementations in people with epilepsy: A systematic review

OBJECTIVE

The purpose of the current study was to systematically review the literature on the clinical trials of vitamin-mineral supplementations in people with epilepsy (PWE) to treat their seizures.

METHODS

MEDLINE and Scopus from inception to August 25, 2020 were searched for related published manuscripts. The search keywords included "vitamin or folate or folic acid or biotin or thiamine or carnitine or zinc or manganese or selenium or omega-3 fatty acid or linoleic acid or micronutrient or trace element or supplementation" AND "epilepsy or seizure".

RESULTS

We could identify 26 related articles. Seventeen studies provided class 2 of evidence and the rest provided class 3 of evidence. Eight studies investigated polyunsaturated fats, seven groups studied folic acid, four studies explored the effects of vitamin D, two investigated vitamin E, and three others studied multivitamin cocktails. There was one study on zinc and one on selenium. There is some evidence on the efficacy of polyunsaturated fats in treating seizures in PWE. The evidence on the efficacy of multivitamin cocktails in adults is promising.

CONCLUSION

High quality data on the efficacy of nutritional (vitamins-minerals) supplementations in treating seizures in PWE is scarce; however, designing future clinical trials of polyunsaturated fatty acid supplementation for drug-resistant seizures in adults with focal epilepsy and in children, and also multivitamin supplementations in adults with focal epilepsy seems reasonable and promising. Such clinical trials should be well-designed, randomized, and placebo controlled, with enough sample size and adequate follow-up of 12 months or more.

Hypoallergenic diet may control refractory epilepsy in allergic children: A quasi experimental study

Recent data has suggested a definitive role for inflammatory processes in the pathophysiology of epilepsy. In this study we hypothesized that food allergies, as chronic inflammatory processes, underlie the pathophysiology of refractory idiopathic epilepsy and investigated whether food elimination diets may assist in managing refractory epilepsy. The study was conducted on 34 patients up to 16 years of age with refractory convulsions who attended the Allergy Outpatient Clinic, Mofid Children Hospital between 2015 and 2016 with youngest and oldest participants at ages of 3 months and 16 years old, respectively. The participants were categorized into three groups according to the results of skin prick test and serum specific IgE measurements. Elimination diets were instituted for the patients with non IgE-mediated and mixed food allergies. The study was conducted for a period of 12 weeks. The participants were assessed for at least 50% reduction in number of seizures following the intervention. There was a significant reduction in number of seizures (p < 0.001) following the intervention. Seventeen patients (50%) did not experience any seizures after 8 weeks of treatment and 12 patients (35%) had a significant (51-99%) decrease in the number of their seizures. Five patients did not show any changes in their daily seizure frequency. The obtained data suggest that food allergy may play a role in triggering refractory epilepsies and their adequate response to treatment. A trial of elimination diet showed more than 50% seizure reduction in more than 85% of the children studied. However, we believe these results are preliminary and they motivate a fully controlled study in the future.

Folate homeostasis in epileptic rats

Folate is involved in metabolic processes and it has been implicated in both aggravation and amelioration of seizures. The aim of the current work was to study the effect of chronic temporal lobe epilepsy (TLE) on the plasma and brain concentrations of folate and on its uptake carriers in the brain - the reduced folate carrier (RFC), folate receptor α (FRα) and proton coupled folate transporter (PCFT). We utilized the rat lithium pilocarpine model for TLE. Approximately two months following status epilepticus, rats with spontaneous recurrent seizures (SRS) were sacrificed for brain and plasma folate concentration analyses and folate uptake carrier expression studies. RT-PCR and western blot analyses were utilized for quantification of folate carriers' mRNAs and proteins, respectively. The distribution of folate carriers in the brain was studied using immunohistochemistry. In the SRS rats we found lower plasma concentrations (10 ± 0.9 in control vs. 6.6 ± 1.6 ng/ml in SRS, P < 0.05), but preserved cortical and increased hippocampal levels of folate (0.5 ± 0.1 in control vs. 0.9 ± 0.2 ng/mg in SRS, P = 0.055). Hippocampus - to - plasma ratio of folate concentration was 3-fold higher in the SRS group, compared with the controls (0.13 ± 0.03 vs. 0.04 ± 0.02, respectively; P < 0.01). mRNA and protein levels of the folate uptake carriers did not differ between SRS rats and controls. However, immunofluorescent staining quantification revealed that the emission intensity of both RFC and FRα was elevated 8-fold and 4-fold, respectively, in hippocampal CA1 neurons of SRS rats, compared to controls (P < 0.01). PCFT was unquantifiable. If corroborated by complementary research in humans, the findings of this study may be utilized clinically for supplemental therapy planning, in imaging the epileptic focus, and for drug delivery into the epileptic brain. Further studies are required for better elucidating the clinical and mechanistic significance of altered folate balances in the epileptic brain.

Milk from different species: Relationship between protein fractions and inflammatory response in infants affected by generalized epilepsy

The present study was undertaken to evaluate the effect of protein fractions from bovine, caprine, and ovine milk on production of cytokines and reactive oxygen species (ROS) and reactive nitrogen species (RNS) by cultured peripheral blood mononuclear cells (PMBC) from infants with generalized epilepsy. Bovine, caprine, and ovine bulk milks were pasteurized and analyzed for chemical composition. Then, PBMC were isolated from 10 patients with generalized epilepsy (5 males; mean age 33.6±5.4mo). Production of tumor necrosis factor-α (TNF-α), IL-10, IL-6, and IL-1β was studied in cultured PBMC (from infants with epilepsy and controls) stimulated by bovine, caprine, and ovine milk and casein and whey protein fractions, and levels of ROS and RNS were measured in the culture supernatant. The ability of PBMC to secrete cytokines in response to milk and protein fraction stimulation may predict the secretion of soluble factor TNF-α in the bloodstream of challenged patients. Bovine, caprine, and ovine bulk milks induced low-level production of IL-10 by cultured PBMC in at least 50% of cases; the same behavior was observed in both casein and whey protein fractions for all species studied. Bovine and ovine milk and their casein fractions induced production of lower levels of IL-1β in 80% of patients, whereas caprine milk and its casein fraction induced the highest levels in 80% of patients. The amount of IL-6 detected after stimulation of PBMC by milk and its fractions for all species was lower than that of other proinflammatory cytokines. In the bovine, total free radicals were higher in bulk milk and lower in the casein fraction, whereas the whey protein fraction showed an intermediate level; in caprine, ROS/RNS levels were not different among milk fractions, whereas ovine had higher levels for bulk milk and casein than the whey protein fraction. Lower levels of ROS/RNS detected in PBMC cultured with caprine milk fraction could be responsible for the lower levels of TNF-α cytokine in the corresponding fraction. Cytokines might be useful biomarkers to discriminate the effects of foods on the inflammatory response; dietary strategies could help in alleviating the negative effects of epilepsy in infants.

Methylxanthines, seizures, and excitotoxicity

Clinical evidence, in particular the wide use of theophylline as a bronchodilator, suggests that methylxanthines can cause seizures in patients without known underlying epilepsy. Theophylline is also known to be an added risk factor for seizure exacerbation in patients with epilepsy. The proconvulsant activity of methylxanthines can best be explained by their antagonizing the brain's own anticonvulsant adenosine. Recent evidence suggests that adenosine dysfunction is a pathological hallmark of epilepsy contributing to seizure generation and seizure spread. Conversely, adenosine augmentation therapies are effective in seizure suppression and prevention, whereas adenosine receptor antagonists such as methylxanthines generally exacerbate seizures. The impact of the methylxanthines caffeine and theophylline on seizures and excitotoxicity depends on timing, dose, and acute versus chronic use. New findings suggest a role of free radicals in theophylline-induced seizures, and adenosine-independent mechanisms for seizure generation have been proposed.