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Buchholz A, Deme P, Betz JF, Brandt J, Haughey N, Cervenka MC. A randomized feasibility trial of the modified Atkins diet in older adults with mild cognitive impairment due to Alzheimer's disease. Front Endocrinol (Lausanne) 2024; 15:1182519. [PMID: 38505743 PMCID: PMC10949529 DOI: 10.3389/fendo.2024.1182519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 02/05/2024] [Indexed: 03/21/2024] Open
Abstract
Background Alzheimer's disease (AD) is increasing in prevalence, but effective treatments for its cognitive impairment remain severely limited. This study investigates the impact of ketone body production through dietary manipulation on memory in persons with mild cognitive impairment due to early AD and explores potential mechanisms of action. Methods We conducted a 12-week, parallel-group, controlled feasibility trial of a ketogenic diet, the modified Atkins diet (MAD), compared to a control diet in patients with cognitive impairments attributed to AD. We administered neuropsychological assessments, including memory tests, and collected blood samples at baseline and after 12 weeks of intervention. We performed untargeted lipidomic and targeted metabolomic analyses on plasma samples to detect changes over time. Results A total of 839 individuals were screened to yield 38 randomized participants, with 20 assigned to receive MAD and 18 assigned to receive a control diet. Due to attrition, only 13 in the MAD arm and nine in the control arm were assessed for the primary endpoint, with two participants meeting ketosis levels used to define MAD adherence criteria. The average change from baseline in the Memory Composite Score was 1.37 (95% CI: -0.87, 4.90) points higher in the MAD group compared to the control group. The effect size of the intervention on baseline MAD change was moderate (Cohen's D = 0.57, 95% CI: -0.67, 1.33). In the 15 participants (nine MAD, six control) assessed for lipidomic and metabolomic-lipidomics and metabolomics, 13 metabolites and 10 lipids showed significant changes from baseline to 12 weeks, including triacylglycerols (TAGs, 50:5, 52:5, and 52:6), sphingomyelins (SM, 44:3, 46:0, 46:3, and 48:1), acetoacetate, fatty acylcarnitines, glycerol-3-phosphate, and hydroxy fatty acids. Conclusions Attrition was greatest between baseline and week 6. All participants retained at week 6 completed the study. Despite low rates of adherence by criteria defined a priori, lipidomic and metabolomic analyses indicate significant changes from baseline in circulating lipids and metabolites between MAD and control participants at 12-week postrandomization, and MAD participants showed greater, albeit nonsignificant, improvement in memory.
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Affiliation(s)
- Alison Buchholz
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Pragney Deme
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Joshua F. Betz
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jason Brandt
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Norman Haughey
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mackenzie C. Cervenka
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Chu DY, Ravelli MN, Faltersack KM, Woods AL, Almane D, Li Z, Sampene E, Felton EA. Hypocarnitinemia and its effect on seizure control in adult patients with intractable epilepsy on the modified Atkins diet. Front Nutr 2024; 10:1304209. [PMID: 38249600 PMCID: PMC10796679 DOI: 10.3389/fnut.2023.1304209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Previous studies have demonstrated the safety and efficacy of the modified Atkins diet (MAD) in attenuating seizures in patients with intractable epilepsy. MAD works by achieving ketosis, which is heavily dependent on the metabolic compound, carnitine, to facilitate the transport of long-chain fatty acids across the mitochondria for beta-oxidation. The effect of carnitine on ketogenic diet therapy is not well-defined in the current literature. Thus, the purpose of our study is to investigate the effects of hypocarnitinemia on the efficacy of MAD. Methods A retrospective chart review was conducted, and 58 adults with epilepsy undergoing MAD were evaluated. Generalized linear mixed effects models were used to compare the low carnitine status with normal carnitine group in patient measures of body mass index, seizure frequency and severity, number of anti-seizure medications, beta-hydroxybutyrate, triglyceride, and carnitine levels across baseline, 3-9-month follow-up (timepoint 1), 1-2-year follow-up (timepoint 2), and 2+ year follow-up (timepoint 3). Results Our study revealed that 38.3% of adult patients with epilepsy following MAD experienced low free carnitine at some point through the course of diet therapy. Patients with hypocarnitinemia at timepoint 2 showed a significant percent seizure increase while seizures continued to decrease in the normal carnitine group. Fasting triglyceride levels at timepoint 1 were significantly increased in the low carnitine group compared to normal carnitine group. Change in BHB, BMI, seizure severity, and number of ASMs showcased no significant differences between the low and normal carnitine groups. Discussion It may be important for clinicians to monitor for hypocarnitinemia in adults on MAD and provide carnitine supplementation when low. Further investigations into carnitine and MAD may inform clinical decisions on carnitine supplementation to maximize the efficacy of MAD therapy.
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Affiliation(s)
- Daniel Y. Chu
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Michele N. Ravelli
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Kelly M. Faltersack
- Department of Clinical Nutrition, University of Wisconsin Hospitals and Clinics, Madison, WI, United States
| | - Arron L. Woods
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Dace Almane
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Emmanuel Sampene
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Elizabeth A. Felton
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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Paibool W, Schimpf S, Nordli DR, Phitsanuwong C. Modified Atkins diet in children with epilepsy with eyelid myoclonia (Jeavons syndrome). Epilepsy Behav 2023; 145:109347. [PMID: 37459720 DOI: 10.1016/j.yebeh.2023.109347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Epilepsy with eyelid myoclonia(EEM) or Jeavons syndrome is considered a genetic generalized epilepsy with a typical age of onset in childhood. Many types of seizures can be observed, including eyelid myoclonia, absence, generalized tonic-clonic, and myoclonic seizures. Seizures tend to be difficult to control requiring polypharmacy treatment or become drug-resistant. Dietary therapy, particularly with Modified Atkins Diet (MAD), as a treatment of seizures in this syndrome has rarely been studied. We report efficacy and tolerability of MAD in children with epilepsy with eyelid myoclonia. METHODS We reviewed medical records of children with EEM treated at the University of Chicago Ketogenic Diet program from 2017 to 2022. Patient's demography, seizure characteristics, EEG findings, response to treatment, and adverse effects were reviewed. RESULT Six patients with EEM were identified. Average age of seizure onset was 6 (2-11) years and an average age when the MAD started was 10.7 (6-15) years. All patients were started on MAD and completed at least 6 months on the diet at the time of report. An average of 4 (0-9) anti-seizure medications (ASM) had been tried prior to the MAD. All patients achieved ketosis with an average level of serum beta-hydroxybutyrate of 1.9 (1.03-3.61) mmol/L. At the 6-month follow-up visit, all patients (100%) experienced a greater than 50% seizure reduction, 3/6 patients (50%) had more than 90% seizure reduction, 1/6 patients (17%) became seizure-free. All seizure types demonstrated a greater than 80% reduction in frequency.Absence and myoclonic seizures showed the greatest reduction with 100% seizure reduction. Eyelid myoclonia and generalized tonic-clonic seizures showed more than 80% seizure reduction.Moreover, all patients reported improvement in alertness, mood, and concentration. Initial weight loss and mild gastrointestinal disturbances were reported in 2/6 patients (33%) and corrected with dietary adjustment. CONCLUSION The Modified Atkins Diet has shown to be effective and welltolerated for children with EEM in our study. Cognitive improvement has also been subjectively reported in all patients. Adverse effects are tolerable and correctable. The MAD, therefore, may be considered as a treatment option for patients with epilepsy with eyelid myoclonia.
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Affiliation(s)
- Watuhatai Paibool
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA; Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kean, Thailand.
| | - Stephanie Schimpf
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA
| | - Douglas R Nordli
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA
| | - Chalongchai Phitsanuwong
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA
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Gundogdu BS, Gaitanis J, Adams JB, Rossignol DA, Frye RE. Age-Related Changes in Epilepsy Characteristics and Response to Antiepileptic Treatment in Autism Spectrum Disorders. J Pers Med 2023; 13:1167. [PMID: 37511780 PMCID: PMC10381477 DOI: 10.3390/jpm13071167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Despite the high prevalence of epilepsy in individuals with autism spectrum disorder (ASD), there is little information regarding whether seizure characteristics and treatment effectiveness change across age. Using an online survey, seizure characteristics, effectiveness of antiepileptic treatments, comorbidities, potential etiologies, and ASD diagnosis were collected from individuals with ASD and seizures. We previously reported overall general patterns of treatment effectiveness but did not examine the effect of seizure characteristics or age on antiepileptic treatment effectiveness. Such information would improve the personalized medicine approach to the treatment of seizures in ASD. Survey data from 570 individuals with ASD and clinical seizures were analyzed. Seizure severity (seizure/week) decreased with age of onset of seizures, plateauing in adolescence, with a greater reduction in generalized tonic-clonic (GTC) seizures with age. Seizure severity was worse in those with genetic disorders, neurodevelopmental regression (NDR) and poor sleep maintenance. Carbamazepine and oxcarbazepine were reported to be more effective when seizures started in later childhood, while surgery and the Atkins/modified Atkins Diet (A/MAD) were reported to be more effective when seizures started early in life. A/MAD and the ketogenic diet were reported to be more effective in those with NDR. Interestingly, atypical Landau-Kleffner syndrome was associated with mitochondrial dysfunction and NDR, suggesting a novel syndrome. These interesting findings need to be verified in independent, prospectively collected cohorts, but nonetheless, these data provide insights into novel relationships that may assist in a better understanding of epilepsy in ASD and provide insight into personalizing epilepsy care in ASD.
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Affiliation(s)
| | - John Gaitanis
- Department of Neurology and Pediatrics, Hasbro Children's Hospital, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - James B Adams
- School for Engineering of Matter, Transport and Energy, Arizona State University, Tempe, AZ 85281, USA
| | - Daniel A Rossignol
- Rossignol Medical Center, Aliso Viejo, CA 92656, USA
- Autism Discovery and Treatment Foundation, Phoenix, AZ 85050, USA
| | - Richard E Frye
- Autism Discovery and Treatment Foundation, Phoenix, AZ 85050, USA
- Rossignol Medical Center, Phoenix, AZ 85050, USA
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Sharma S, Whitney R, Kossoff EH, RamachandranNair R. Does the ketogenic ratio matter when using ketogenic diet therapy in pediatric epilepsy? Epilepsia 2023; 64:284-291. [PMID: 36471628 DOI: 10.1111/epi.17476] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/26/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
The ketogenic diet (KD) is a widely used therapeutic option for individuals with medically refractory epilepsy. As the diet's name implies, ketosis is a historically important component of the diet, but it is not well understood how important ketosis is for seizure control. The ketogenic ratio is defined as the ratio of fat to carbohydrate plus protein by weight in the diet (grams). Traditionally, the classic KD contains a 4:1 ratio, and a very high proportion of fat in the diet. The classic KD, with its high proportion of fat and limited carbohydrate intake can be restrictive for patients with epilepsy. Recently, there is experience with use of lower ketogenic ratios and less-restrictive diets such as the modified Atkins diet and the low glycemic index treatment. In this narrative review, we examine the role of ketosis and ketogenic ratios in determining the efficacy of the KD in children with epilepsy.
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Affiliation(s)
- Suvasini Sharma
- Neurology Division, Department of Pediatrics, Lady Harding Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rajesh RamachandranNair
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
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Yıldırım GK, Yağcı M, Uygur AÇ, Özen H, Yarar C, Çarman KB. Evaluation of ketogenic diet therapy in children diagnosed with drug-resistant epilepsy: a single-center experience. Turk J Pediatr 2022; 64:435-445. [PMID: 35899556 DOI: 10.24953/turkjped.2020.3091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND We evaluate here the effect of the ketogenic diet (KD) on children with drug-resistant epilepsy (DRE) in terms of clinical effectiveness, anthropometric measurements, and some electroencephalogram (EEG) and biochemical findings. METHODS Included in the study were 18 children (median age 70 months, 61.1% female) who received the classical KD and modified Atkins diet (MAD) for at least one year due to DRE. The patients` demographic and laboratory data; weight, height and body mass index values; EEG and electrocardiographic findings; abdominal ultrasonography findings; and biochemical parameters were recorded at baseline and at 12 months after the initiation of the diet. A reduction of ≥50% in the number of seizures was accepted as a response to KD. RESULTS Classic KD was chosen for 14 patients (77.8%), and MAD for four patients (22.2%). The response to KD therapy (≥50% reduction) was 55.5% (n = 10) (p = 0.008), and one patient even became seizure-free. By the 12th month of treatment, 10 patients had experienced a reduction of more than 50% in epileptiform discharges, as indicated by EEG findings. There was no difference in seizure reduction between the patients who received classical KD and MAD. A total of 11.1% of the children lost weight during KD treatment. The most common side effect was constipation (n = 10, 55.6%). At the end of one year of treatment, total cholesterol and low density lipoprotein cholesterol (LDL-C) LDL-C levels had increased dramatically, while fasting blood glucose levels had decreased significantly. CONCLUSIONS Our study suggests that KD treatment provides good clinical efficacy in the treatment of pediatric DRE, and can significantly reduce the frequency of epileptic discharges. Also, total cholesterol and LDL-C levels increased significantly, and fasting blood glucose levels decreased significantly compared to the baseline levels.
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Affiliation(s)
- Gonca Kılıç Yıldırım
- Divisions of Child Nutrition and Metabolism, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Murat Yağcı
- Department of Pediatrics Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Anıl Çiğdem Uygur
- Departments of Nutrition and Dietetics, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Hülya Özen
- Departments of Statistics, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Coşkun Yarar
- Divisions of Pediatric Neurology, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Kürşat Bora Çarman
- Divisions of Pediatric Neurology, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
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Husari KS, Cervenka MC. Ketogenic Diet Therapy for the Treatment of Post-encephalitic and Autoimmune-Associated Epilepsies. Front Neurol 2021; 12:624202. [PMID: 34220664 PMCID: PMC8242936 DOI: 10.3389/fneur.2021.624202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/19/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction: Acute Encephalitis is associated with a high risk of acute symptomatic seizures, status epilepticus, and remote symptomatic epilepsy. Ketogenic diet therapies (KDT) have been established as a feasible and safe adjunctive management of refractory- and super-refractory status epilepticus. However, the role of KDT in the chronic management of Post-encephalitic epilepsy (PE) and autoimmune-associated epilepsy (AE) is unknown. This study aims to investigate the use of KDT in patients with PE and AE. Methods: A retrospective single-center case series examining adult patients with PE and AE treated with the modified Atkins diet (MAD), a KDT commonly used by adults with drug-resistant epilepsy. Results: Ten patients with PE and AE who were treated with adjunctive MAD were included. Four patients had either confirmed or presumed viral encephalitis, five patients had seronegative AE, and one patient had GAD65 AE. The median latency between starting MAD and onset of encephalitis was 6 years (IQR: 1–10). The median duration of MAD was 10 months (IQR: 3.75–36). Three patients (30%) became seizure-free, one patient (10%) achieved 90% seizure freedom, and three patients (30%) achieved a 50–75% reduction in their baseline seizure frequency, while three patients (30%) had no significant benefit. Overall, seven patients (70%) achieved ≥50% seizure reduction. Conclusion: In addition to its established role in the treatment of RSE, KDT may be a safe and feasible option for the treatment of chronic PE and AE, particularly in those with prior history of SE. Prospective studies are warranted to explore the efficacy of KDT in management of patients with PE and AE.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology, Johns Hopkins Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, United States
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, United States
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McDonald TJW, Diaz-Arias L, Vizthum D, Henry-Barron BJ, Schlechter H, Kossoff EH, Cervenka MC. Six-month effects of modified Atkins diet implementation on indices of cardiovascular disease risk in adults with epilepsy. Nutr Neurosci 2021; 25:1548-1557. [PMID: 33487129 DOI: 10.1080/1028415x.2021.1875301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND/AIMS Ketogenic diet therapies (KDTs) offer a needed therapeutic option for patients with drug-resistant epilepsy. The current study investigated biochemical and anthropometric indices of cardiovascular disease (CVD) risk in adults with epilepsy treated with KDT over 6 months. METHOD 65 adults with epilepsy naïve to diet therapy were enrolled in a prospective longitudinal study and instructed on modified Atkins diet (MAD) use. Seizure frequency, anthropometric measures, blood levels of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, apolipoproteins A1 and B, and lipoprotein sub-fractions were assessed at baseline, 3 months, and 6 months. RESULTS Subsequent to study enrollment, 34 participants were lost to follow-up, elected not to start, or stopped MAD prior to study completion, leaving a total of 31 participants in the study at 6 months. Compared to baseline, participants on MAD showed significant reductions in median seizure frequency/week, weight, body mass index, waist and hip circumference, and percent body fat at 3 and 6 months. Compared to baseline, participants on MAD for 3 months showed significantly increased levels of total, small and medium LDL particles, ApoB and ApoB/A1 ratio. At 6 months, only small LDL particles and ApoB levels remained elevated and levels of ApoA1 had risen, suggesting possible compensatory adaptation over time. CONCLUSIONS This study provides evidence demonstrating the efficacy and cardiovascular safety of 6 months of MAD use by adults with epilepsy. It also highlights an index of CVD risk - small LDL particles - that should be closely monitored..Trial registration: ClinicalTrials.gov identifier: NCT02694094..
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Luisa Diaz-Arias
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diane Vizthum
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, USA
| | - Bobbie J Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, USA
| | - Haley Schlechter
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, USA
| | - Eric H Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
BACKGROUND Studies have consistently shown that patients with epilepsy could benefit from ketogenic diets (KDs). Recent evidence suggests that KD could be used in the treatment of central nervous system (CNS) diseases. The aim of this systematic review was to investigate the use and efficacy of KD, modified Atkins diet (MAD) and medium-chain triglyceride (MCT) diet in infants, children, adolescents, and adults with CNS diseases. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Main databases, i.e. EMBASE, PubMed and PsycINFO, were searched on 4 December 2019. Only randomized clinical trials (RCTs) were included and only if they reported KD, MCT or MAD interventions on patients with CNS diseases. RESULTS Twenty-four publications were eligible for inclusion (n = 1221). Twenty-one publications concerned epilepsy, two concerned Alzheimer's disease (AD), and one concerned Parkinson's disease (PD). All studies regarding epilepsy reported of seizure reduction compared to baseline. MCT did not significantly change regional cerebral blood flow (rCBF) in patients with AD, but MAD significantly improved memory at 6 weeks (p = .03). KD significantly improved motor and nonmotor functions in patients with PD at 8 weeks (p < .001). There was a trend towards fewer adverse effects in MAD compared to KD. CONCLUSION In conclusion, various forms of KDs seem tolerable and effective as part of the treatment for epilepsy, AD and PD, although more investigation concerning the mechanism, efficacy and adverse events is necessary.
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Affiliation(s)
| | - Jakob Damsgaard
- Psychiatric Centre Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Anders Fink-Jensen
- Psychiatric Centre Copenhagen, University of Copenhagen, Copenhagen, Denmark
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Na JH, Kim HD, Lee YM. Effective and safe diet therapies for Lennox-Gastaut syndrome with mitochondrial dysfunction. Ther Adv Neurol Disord 2020; 13:1756286419897813. [PMID: 32082420 PMCID: PMC7005978 DOI: 10.1177/1756286419897813] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Lennox-Gastaut syndrome (LGS) is a typical intractable form of epilepsy that most often occurs between the second and sixth year of life. This study aimed to evaluate the clinical efficacy and safety of ketogenic diet therapies (DTs) for LGS with mitochondrial dysfunction. Methods: This was a retrospective study involving 20 LGS patients with mitochondrial dysfunction who received several DTs from 2004 to 2014 at a single tertiary care center. Seizure reduction rate, cognitive function, retention rate, electroencephalography (EEG) changes, and adverse effects were examined before and after DTs. Results: The retention rates at 1 and 2 years after initiation of DTs were 45% and 40%, respectively. After 1-year follow up, we observed seizure freedom in two patients, 75% seizure reduction in two patients, 50% reduction in three patients, and 25% reduction in one patient. After 2-year follow up, the outcomes were seizure freedom in two patients, 90% seizure reduction in one patient, 75% reduction in two patients, and 50% reduction in two patients. EEG findings improved in nine patients. Nine patients were treated with DTs for 1 year; all patients demonstrated improved cognitive status. Eight patients were treated with DTs for 2 years, of whom seven had improved cognitive status. Poor tolerability of DTs was due to poor oral intake and gastrointestinal problems. Conclusions: We demonstrate that, in LGS with mitochondrial dysfunction, improvement of seizures and cognitive function are not inferior to those in other patients treated with DTs. This study showed that DTs are efficacious and feasible for LGS patients with mitochondrial dysfunction and can significantly improve their prognosis.
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Affiliation(s)
- Ji-Hoon Na
- Departments of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Heung-Dong Kim
- Departments of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Mock Lee
- Department of Pediatrics, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Korea
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Sadeghifar F, Penry VB. Mechanisms and Uses of Dietary Therapy as a Treatment for Epilepsy: A Review. Glob Adv Health Med 2019; 8:2164956119874784. [PMID: 31548917 PMCID: PMC6743206 DOI: 10.1177/2164956119874784] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/26/2019] [Accepted: 07/18/2019] [Indexed: 11/20/2022] Open
Abstract
One-third of patients with epilepsy do not respond to antiepileptic drugs and may
seek complementary and alternative treatment modalities. Dietary therapies such
as the ketogenic diet (KD), the modified Atkins, the medium-chain triglyceride,
and the low glycemic index diet have been successfully implemented in some forms
of epilepsy and are growing in utilization. The KD is a high-fat, low-protein,
low-carbohydrate diet that has been used for various conditions for over a
century. Insights into the mechanism of action of these diets may provide more
targeted interventions for patients with epilepsy. Knowledge of these mechanisms
is growing and includes neuroprotective effects on oxidative stress,
neuroinflammation, potassium channels in the brain, and mitochondrial
function.
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Affiliation(s)
| | - Vanessa Baute Penry
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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12
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Abstract
The ketogenic diet (KD) has been used for a long time as a therapeutic approach for drug-resistant epilepsy. It is a high-fat, low-carbohydrate, and adequate protein diet. There are various types of KD with some differences in their compositions that mainly include classic KD, medium-chain triglyceride diet, modified Atkins diet, and low glycemic index treatment. The anti-seizure mechanisms of KDs have not yet completely understood but, some possible mechanisms can be theorized. The aim of the present study was to review the various types of KD and explain the probable biochemical mechanisms involved in its anti-seizure property.
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Affiliation(s)
- Mohammad Barzegar
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammadreza Afghan
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahid Tarmahi
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Meysam Behtari
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Sina Raeisi
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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13
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D'Andrea Meira I, Romão TT, Pires do Prado HJ, Krüger LT, Pires MEP, da Conceição PO. Ketogenic Diet and Epilepsy: What We Know So Far. Front Neurosci 2019; 13:5. [PMID: 30760973 PMCID: PMC6361831 DOI: 10.3389/fnins.2019.00005] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
Abstract
The Ketogenic Diet (KD) is a modality of treatment used since the 1920s as a treatment for intractable epilepsy. It has been proposed as a dietary treatment that would produce similar benefits to fasting, which is already recorded in the Hippocratic collection. The KD has a high fat content (90%) and low protein and carbohydrate. Evidence shows that KD and its variants are a good alternative for non-surgical pharmacoresistant patients with epilepsy of any age, taking into account that the type of diet should be designed individually and that less-restrictive and more-palatable diets are usually better options for adults and adolescents. This review discusses the KD, including the possible mechanisms of action, applicability, side effects, and evidence for its efficacy, and for the more-palatable diets such as the Modified Atkins Diet (MAD) and the Low Glycemic Index Diet (LGID) in children and adults.
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Affiliation(s)
- Isabella D'Andrea Meira
- Epilepsy Department, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil.,Neurology Department, Federal Fluminense University, Rio de Janeiro, Brazil
| | - Tayla Taynan Romão
- Neurology Department, Federal Fluminense University, Rio de Janeiro, Brazil
| | - Henrique Jannuzzelli Pires do Prado
- Epilepsy Department, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil.,Neurology Department, Federal Fluminense University, Rio de Janeiro, Brazil
| | - Lia Theophilo Krüger
- Epilepsy Department, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
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14
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Fasulo L, Semprino M, Caraballo R. [Multidisciplinary teamwork in the clinical application of the ketogenic diet]. Medicina (B Aires) 2019; 79:225-231. [PMID: 31284260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
The ketogenic diet is an established, effective and well-tolerated treatment in refractory epilepsy. This paper provides practical information on the administration of ketogenic diet. It goes over the standardized protocols and the new ones that allow to broaden the scope regarding the clinical management of the ketogenic diet. It addresses issues such as the implementation, counseling and follow-up as well as the application and how to proceed in special situations such as anesthesia or acute illness. Finally, the aim of this paper is to highlight the relevance of the multidisciplinary teamwork and the family support throughout this laborious but interesting treatment.
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Affiliation(s)
| | | | - Roberto Caraballo
- Hospital de Pediatría SAMIC Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
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15
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McDonald TJW, Cervenka MC. The Expanding Role of Ketogenic Diets in Adult Neurological Disorders. Brain Sci 2018; 8:E148. [PMID: 30096755 PMCID: PMC6119973 DOI: 10.3390/brainsci8080148] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022] Open
Abstract
The current review highlights the evidence supporting the use of ketogenic diet therapies in the management of adult epilepsy, adult malignant glioma and Alzheimer's disease. An overview of the scientific literature, both preclinical and clinical, in each area is presented and management strategies for addressing adverse effects and compliance are discussed.
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA.
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA.
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16
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Kverneland M, Molteberg E, Iversen PO, Veierød MB, Taubøll E, Selmer KK, Nakken KO. Effect of modified Atkins diet in adults with drug-resistant focal epilepsy: A randomized clinical trial. Epilepsia 2018; 59:1567-1576. [PMID: 29901816 DOI: 10.1111/epi.14457] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Ketogenic diets reduce seizures in children with drug-resistant epilepsy. Whether adults benefit from similar treatment has not been clarified. We therefore examined the efficacy of the modified Atkins diet in adults with drug-resistant focal epilepsy. METHODS We performed a randomized clinical trial (RCT) with patients >16 years who had at least 3 seizures per month despite having tried at least 3 antiepileptic drugs. They were randomized to either 12 weeks on the modified Atkins diet (diet group) or habitual diet (control group). Primary endpoint was a change in seizure frequency from baseline to the intervention period, comparing those on diet with controls. RESULTS We assigned 37 patients to the diet group and 38 to the control group. Nine of the patients in the diet group and 4 controls were excluded. Of those who completed the dietary intervention (n = 24), median seizure change was -1.0 (interquartile range [IQR] -13.7-8.8), while in the control group (n = 32) the median change was 4.5 (IQR -4.8-33.5). The median difference between the groups was -7.0 (95% confidence interval [CI] -37.0-3.0; P = .21). In the intention-to-treat analysis, the relative risk (RR) for achieving >50% seizure reduction was 1.8 (95% CI 0.3-10.2; P = .65), while for achieving >25% seizure reduction RR was 2.43 (95% CI 0.94-6.28; P = .06). We observed no serious adverse events. SIGNIFICANCE In this RCT investigating the effect of an adjunctive modified Atkins diet on seizure frequency in adults with difficult-to-treat focal epilepsy, we found a significant reduction in seizure frequency in the diet group compared to the controls, but only for moderate benefit (>25% seizure reduction) among those who completed the intervention. However, seizure response varied considerably between individuals, perhaps negatively influenced by a drop in serum concentrations of antiepileptic drugs.
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Affiliation(s)
- Magnhild Kverneland
- National Center for Epilepsy, Oslo University Hospital, Sandvika, Norway.,Department of Nutrition, University of Oslo, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ellen Molteberg
- National Center for Epilepsy, Oslo University Hospital, Sandvika, Norway
| | - Per O Iversen
- Department of Nutrition, University of Oslo, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Marit B Veierød
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Oslo Center of Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Erik Taubøll
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Kaja K Selmer
- National Center for Epilepsy, Oslo University Hospital, Sandvika, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Medical Genetics, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Karl O Nakken
- National Center for Epilepsy, Oslo University Hospital, Sandvika, Norway
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17
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Di Lorenzo C, Coppola G, Di Lenola D, Evangelista M, Sirianni G, Rossi P, Di Lorenzo G, Serrao M, Pierelli F. Efficacy of Modified Atkins Ketogenic Diet in Chronic Cluster Headache: An Open-Label, Single-Arm, Clinical Trial. Front Neurol 2018; 9:64. [PMID: 29483892 PMCID: PMC5816269 DOI: 10.3389/fneur.2018.00064] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/24/2018] [Indexed: 01/03/2023] Open
Abstract
Introduction Drug-resistant cluster headache (CH) is still an open clinical challenge. Recently, our group observed the clinical efficacy of a ketogenic diet (KD), usually adopted to treat drug-resistant epilepsies, on migraine. Aim Here, we aim to detect the effect of KD in a group of drug-resistant chronic CH (CCH) patients. Materials and methods Eighteen drug-resistant CCH patients underwent a 12-week KD (Modified Atkins Diet, MAD), and the clinical response was evaluated in terms of response (≥50% attack reduction). Results Of the 18 CCH patients, 15 were considered responders to the diet (11 experienced a full resolution of headache, and 4 had a headache reduction of at least 50% in terms of mean monthly number of attacks during the diet). The mean monthly number of attacks for each patient at the baseline was 108.71 (SD = 81.71); at the end of the third month of diet, it was reduced to 31.44 (SD = 84.61). Conclusion We observed for the first time that a 3-month ketogenesis ameliorates clinical features of CCH. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT03244735.
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Affiliation(s)
| | - Gianluca Coppola
- G. B. Bietti Foundation-IRCCS, Research Unit of Neurophysiology of Vision and Neurophthalmology, Rome, Italy
| | - Davide Di Lenola
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome Polo Pontino, Latina, Italy
| | - Maurizio Evangelista
- Istituto di Anestesiologia, Rianimazione e Terapia del Dolore, Università Cattolica del Sacro Cuore/CIC, Rome, Italy
| | - Giulio Sirianni
- Delle Medical Center, Wellness and Dietary Medicine, Rome, Italy
| | - Paolo Rossi
- INI, Headache Clinic, Grottaferrata, Rome, Italy
| | - Giorgio Di Lorenzo
- Laboratory of Psychophysiology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Mariano Serrao
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome Polo Pontino, Latina, Italy
| | - Francesco Pierelli
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome Polo Pontino, Latina, Italy.,INM Neuromed IRCCS, Isernia, Italy
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18
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El Rashidy OF, Nassar MF, El Gendy YG, Deifalla SM, Gaballa S. Experience with MAD on children with epilepsy in Egypt after classic KD failure. Acta Neurol Scand 2018; 137:195-198. [PMID: 29034969 DOI: 10.1111/ane.12856] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Modified Atkins diet (MAD) is a less restrictive type of ketogenic diet (KD) as compared to the classic one. The aim of this study was to evaluate the impact of 9 months MAD treatment on the growth and seizure control in patients with intractable epilepsy as well as the quality of life (QoL) of their mothers. SUBJECTS AND METHODS The study included 15 patients with intractable epilepsy who could not tolerate their classic KD management plan. From the 15 recruited cases, only seven patients completed this nine months prospective study. After neurological reassessment, the patients were prescribed MAD tailored from the local Egyptian ingredients. Arabic translation of the WHO Quality of life Instruments (WHOQOL-BREF) scale was calculated for the mothers initially and 9 months later. Daily seizure frequency with severity assessment by Chalfont scale was recorded as well as monthly weight and length throughout the study period. RESULTS Mothers 'QoL in all WHOQOL-BREF domains significantly improved (P < .001) after nine months follow-up coupled by significant decrease in Chalfont scores from 51.00 ± 15.45 to 20.57 ± 21.45 and daily seizure frequency from 13.29 ± 6.99 to 2.71 ± 3.68. Regarding anthropometric data, there was significant increase in patients' weight and length as well as in the z-score for weight and length. CONCLUSION After nine months of MAD, growth and seizure parameters significantly improved in the intractable epilepsy patients as well as their mothers& QoL. We thus recommend MAD as a more flexible alternative in intractable epilepsy patients who can not tolerate classic KD.
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Affiliation(s)
- O. F. El Rashidy
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - M. F. Nassar
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - Y. G. El Gendy
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - S. M. Deifalla
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - S. Gaballa
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
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19
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Ahola S, Auranen M, Isohanni P, Niemisalo S, Urho N, Buzkova J, Velagapudi V, Lundbom N, Hakkarainen A, Muurinen T, Piirilä P, Pietiläinen KH, Suomalainen A. Modified Atkins diet induces subacute selective ragged-red-fiber lysis in mitochondrial myopathy patients. EMBO Mol Med 2016; 8:1234-1247. [PMID: 27647878 PMCID: PMC5090657 DOI: 10.15252/emmm.201606592] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Mitochondrial myopathy (MM) with progressive external ophthalmoplegia (PEO) is a common manifestation of mitochondrial disease in adulthood, for which there is no curative therapy. In mice with MM, ketogenic diet significantly delayed progression of the disease. We asked in this pilot study what effects high-fat, low-carbohydrate "modified Atkins" diet (mAD) had for PEO/MM patients and control subjects and followed up the effects by clinical, morphological, transcriptomic, and metabolomic analyses. All of our five patients, irrespective of genotype, showed a subacute response after 1.5-2 weeks of diet, with progressive muscle pain and leakage of muscle enzymes, leading to premature discontinuation of the diet. Analysis of muscle ultrastructure revealed selective fiber damage, especially in the ragged-red-fibers (RRFs), a MM hallmark. Two years of follow-up showed improvement of muscle strength, suggesting activation of muscle regeneration. Our results indicate that (i) nutrition can modify mitochondrial disease progression, (ii) dietary counseling should be part of MM care, (iii) short mAD is a tool to induce targeted RRF lysis, and (iv) mAD, a common weight-loss method, may induce muscle damage in a population subgroup.
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Affiliation(s)
- Sofia Ahola
- Research Program of Molecular Neurology, Biomedicum Helsinki University of Helsinki, Helsinki, Finland
| | - Mari Auranen
- Research Program of Molecular Neurology, Biomedicum Helsinki University of Helsinki, Helsinki, Finland.,Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirjo Isohanni
- Research Program of Molecular Neurology, Biomedicum Helsinki University of Helsinki, Helsinki, Finland
| | - Satu Niemisalo
- Obesity Research Unit, Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Niina Urho
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jana Buzkova
- Research Program of Molecular Neurology, Biomedicum Helsinki University of Helsinki, Helsinki, Finland
| | - Vidya Velagapudi
- Metabolomics Unit, Institute for Molecular Medicine Finland FIMM University of Helsinki, Helsinki, Finland
| | - Nina Lundbom
- Department of Radiology, University of Helsinki and HUS Radiology Helsinki Medical Imaging Center, Helsinki, Finland
| | - Antti Hakkarainen
- Department of Radiology, University of Helsinki and HUS Radiology Helsinki Medical Imaging Center, Helsinki, Finland
| | - Tiina Muurinen
- Department of Clinical Physiology and Nuclear Medicine, Laboratory of Clinical Physiology, Helsinki University Hospitals, Helsinki, Finland
| | - Päivi Piirilä
- Department of Clinical Physiology and Nuclear Medicine, Laboratory of Clinical Physiology, Helsinki University Hospitals, Helsinki, Finland
| | - Kirsi H Pietiläinen
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Medicine, Division of Endocrinology, Helsinki University Central Hospital, Helsinki, Finland
| | - Anu Suomalainen
- Research Program of Molecular Neurology, Biomedicum Helsinki University of Helsinki, Helsinki, Finland .,Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Neuroscience Center, University of Helsinki, Helsinki, Finland
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20
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Strowd RE, Cervenka MC, Henry BJ, Kossoff EH, Hartman AL, Blakeley JO. Glycemic modulation in neuro-oncology: experience and future directions using a modified Atkins diet for high-grade brain tumors. Neurooncol Pract 2015; 2:127-136. [PMID: 26649186 DOI: 10.1093/nop/npv010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Indexed: 02/05/2023] Open
Abstract
Dietary glycemic modulation through high-fat, low-carbohydrate diets, which induce a state of systemic ketosis and alter systemic metabolic signaling, have been incorporated into the clinical management of patients with neurological disease for more than a century. Mounting preclinical evidence supports the antitumor, proapoptotic, and antiangiogenic effects of disrupting glycolytic metabolism through dietary intervention. In recent years, interest in incorporating such novel therapeutic strategies in neuro-oncology has increased. To date, 3 published studies incorporating novel dietary therapies in oncology have been reported, including one phase I study in neuro-oncology, and have set the stage for further study in this field. In this article, we review the biochemical pathways, preclinical data, and early clinical translation of dietary interventions that modulate systemic glycolytic metabolism in the management of primary malignant brain tumors. We introduce the modified Atkins diet (MAD), a novel dietary alternative to the classic ketogenic diet, and discuss the critical issues facing future study.
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Affiliation(s)
- Roy E Strowd
- Department of Neurology , Johns Hopkins School of Medicine , Baltimore, Maryland (R.E.S., M.C.C., E.H.K., A.L.H., J.O.B.); Department of Pediatrics , Johns Hopkins School of Medicine , Baltimore, Maryland (E.H.K., A.L.H.); Department of Oncology , Johns Hopkins School of Medcine , Baltimore, Maryland (J.O.B.); Institute for Clinical and Translational Research , Johns Hopkins School of Medicine , Baltimore, Maryland (B.J.H.)
| | - Mackenzie C Cervenka
- Department of Neurology , Johns Hopkins School of Medicine , Baltimore, Maryland (R.E.S., M.C.C., E.H.K., A.L.H., J.O.B.); Department of Pediatrics , Johns Hopkins School of Medicine , Baltimore, Maryland (E.H.K., A.L.H.); Department of Oncology , Johns Hopkins School of Medcine , Baltimore, Maryland (J.O.B.); Institute for Clinical and Translational Research , Johns Hopkins School of Medicine , Baltimore, Maryland (B.J.H.)
| | - Bobbie J Henry
- Department of Neurology , Johns Hopkins School of Medicine , Baltimore, Maryland (R.E.S., M.C.C., E.H.K., A.L.H., J.O.B.); Department of Pediatrics , Johns Hopkins School of Medicine , Baltimore, Maryland (E.H.K., A.L.H.); Department of Oncology , Johns Hopkins School of Medcine , Baltimore, Maryland (J.O.B.); Institute for Clinical and Translational Research , Johns Hopkins School of Medicine , Baltimore, Maryland (B.J.H.)
| | - Eric H Kossoff
- Department of Neurology , Johns Hopkins School of Medicine , Baltimore, Maryland (R.E.S., M.C.C., E.H.K., A.L.H., J.O.B.); Department of Pediatrics , Johns Hopkins School of Medicine , Baltimore, Maryland (E.H.K., A.L.H.); Department of Oncology , Johns Hopkins School of Medcine , Baltimore, Maryland (J.O.B.); Institute for Clinical and Translational Research , Johns Hopkins School of Medicine , Baltimore, Maryland (B.J.H.)
| | - Adam L Hartman
- Department of Neurology , Johns Hopkins School of Medicine , Baltimore, Maryland (R.E.S., M.C.C., E.H.K., A.L.H., J.O.B.); Department of Pediatrics , Johns Hopkins School of Medicine , Baltimore, Maryland (E.H.K., A.L.H.); Department of Oncology , Johns Hopkins School of Medcine , Baltimore, Maryland (J.O.B.); Institute for Clinical and Translational Research , Johns Hopkins School of Medicine , Baltimore, Maryland (B.J.H.)
| | - Jaishri O Blakeley
- Department of Neurology , Johns Hopkins School of Medicine , Baltimore, Maryland (R.E.S., M.C.C., E.H.K., A.L.H., J.O.B.); Department of Pediatrics , Johns Hopkins School of Medicine , Baltimore, Maryland (E.H.K., A.L.H.); Department of Oncology , Johns Hopkins School of Medcine , Baltimore, Maryland (J.O.B.); Institute for Clinical and Translational Research , Johns Hopkins School of Medicine , Baltimore, Maryland (B.J.H.)
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21
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Abstract
There is scanty data regarding the efficacy and tolerability of the modified Atkins diet in children with Lennox-Gastaut syndrome. This study was a retrospective review of children with Lennox-Gastaut syndrome treated with the modified Atkins diet from May 2009 and March 2011. The diet was initiated in those children who persisted to have daily seizures despite the use of at least 3 appropriate antiepileptic drugs. Twenty-five children were started on a modified Atkins diet, restricting carbohydrate intake to 10 g/d. After 3 months, 2 patients were seizure-free, and 10/25 children had >50% reduction in seizure frequency. At 6 months, of 11 patients on the diet, 3 were seizure free and 8 had >50% reduction in seizure frequency. At 1 year, all 9 children on diet had >50% reduction in seizure frequency. The side effects of the diet were mild. The modified Atkins diet was found to be effective and well tolerated in children with Lennox-Gastaut syndrome.
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Affiliation(s)
- Suvasini Sharma
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Division of Pediatric Neurology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Puneet Jain
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Division of Pediatric Neurology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Sheffali Gulati
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Naveen Sankhyan
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuja Agarwala
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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22
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Kverneland M, Taubøll E, Selmer KK, Iversen PO, Nakken KO. Modified Atkins diet may reduce serum concentrations of antiepileptic drugs. Acta Neurol Scand 2015; 131:187-90. [PMID: 25312999 DOI: 10.1111/ane.12330] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Modified Atkins diet is a treatment option for patients with pharmacoresistant epilepsy that is not suitable for surgery. In the last few years, we have tried dietary treatment added to antiepileptic drugs (AEDs) in adult patients with severe epilepsy. AIM OF THE STUDY To examine a possible pharmacokinetic interaction between the modified Atkins diet and AEDs. METHODS In four patients, AED serum concentrations were measured before onset and after 4 and 12 weeks on the diet. The patients used combinations of two or three AEDs, including carbamazepine, clobazam, lamotrigine, nitrazepam, oxcarbazepine, valproate, zonisamide, and topiramate. The patients did not change the type or dose of their AEDs during the diet period. RESULTS After 12 weeks on the diet, the average serum concentrations of the respective AEDs were reduced by 35% (range 6-46%) compared to prediet values. CONCLUSIONS Modified Atkins diet used as add-on therapy to AEDs in four patients with drug resistant seizures caused a considerable decrease in AED serum concentrations. In individual patients, this could be of clinical relevance, and we recommend that AED serum concentrations should be closely monitored when offering this diet to adults with epilepsy.
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Affiliation(s)
- M. Kverneland
- Department of Refractory Epilepsy-SSE; Oslo University Hospital; Sandvika Norway
| | - E. Taubøll
- Department of Neurology; Oslo University Hospital and University of Oslo; Oslo Norway
| | - K. K. Selmer
- Department of Medical Genetics; Oslo University Hospital and University of Oslo; Oslo Norway
| | - P. O. Iversen
- Department of Nutrition; University of Oslo; Oslo Norway
- Haematology; Oslo University Hospital; Oslo Norway
| | - K. O. Nakken
- Department of Refractory Epilepsy-SSE; Oslo University Hospital; Sandvika Norway
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23
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El-Rashidy OF, Nassar MF, Abdel-Hamid IA, Shatla RH, Abdel-Hamid MH, Gabr SS, Mohamed SG, El-Sayed WS, Shaaban SY. Modified Atkins diet vs classic ketogenic formula in intractable epilepsy. Acta Neurol Scand 2013; 128:402-8. [PMID: 23679058 DOI: 10.1111/ane.12137] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The study was designed to evaluate the efficacy, safety, and tolerability of the ketogenic diet (KD) whether classic 4:1 formula or the modified Atkins diet (MAD) in intractable childhood epilepsy. PATIENTS AND METHODS Anthropometric measurements and serum lipid profile were measured upon enrollment and after 3 and 6 months in 40 patients with symptomatic intractable epilepsy. Fifteen were given MAD diet, ten were kept on classic 4:1 ketogenic liquid formula, and the rest were allowed to eat as desired. RESULTS The liquid ketogenic formula group showed significantly higher body mass index compared with those who did not receive KD after 6 months. The lipid profile of KD patients was within normal limits for age and sex during the study period. The rate of change of frequency and severity of seizures showed best improvement in ketogenic liquid formula patients followed by the MAD group than the patients on anti-epileptic medications alone. CONCLUSION The KD whether classic 4:1 or MAD is a tolerable, safe, and effective adjuvant therapy for intractable symptomatic childhood epilepsy with limited adverse effects on the growth parameters and accepted changes in the lipid profile. The liquid ketogenic formula patients showed better growth pattern and significantly more seizure control.
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Affiliation(s)
- O F El-Rashidy
- Pediatric Neurology Department, Children's Hospital, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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24
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Abstract
The classical ketogenic diet has been used for refractory childhood epilepsy for decades. It is also the treatment of choice for disorders of brain energy metabolism, such as Glut1 deficiency syndrome. Novel ketogenic diets such as the modified Atkins diet and the low glycemic index treatment have significantly improved the therapeutic options for dietary treatment. Benefits of these novel diets are increased palatability, practicability, and thus compliance-at the expense of lower ketosis. As high ketones appear essential to meet the brain energy deficit caused by Glut1 deficiency syndrome, the use of novel ketogenic diets in this entity may be limited. This article discusses the current data on novel ketogenic diets and the implications on the use of these diets in regard to Glut1 deficiency syndrome.
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Affiliation(s)
- Joerg Klepper
- Children's Hospital Aschaffenburg, Am Hasenkopf, Aschaffenburg, Germany.
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Leen WG, Mewasingh L, Verbeek MM, Kamsteeg EJ, van de Warrenburg BP, Willemsen MA. Movement disorders in GLUT1 deficiency syndrome respond to the modified Atkins diet. Mov Disord 2013; 28:1439-42. [PMID: 23801573 DOI: 10.1002/mds.25515] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/15/2013] [Accepted: 04/17/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Movement disorders are a prominent feature of glucose transporter-1 (GLUT1) deficiency syndrome (GLUT1DS). First-choice treatment is a ketogenic diet, but compliance is poor. We have investigated the effect of the modified Atkins diet as an alternative treatment for movement disorders in GLUT1DS. METHODS Four patients with GLUT1DS ages 15 to 30 years who had movement disorders as the most prominent feature were prospectively evaluated after initiation of the modified Atkins diet. Movement disorders included dystonia, ataxia, myoclonus, and spasticity, either continuous or paroxysmal, triggered by action or exercise. Duration of treatment ranged from 3 months to 16 months. RESULTS All patients reached mild to moderate ketosis and experienced remarkable improvement in the frequency and severity of paroxysmal movement disorders. Cognitive function also improved subjectively. CONCLUSIONS The modified Atkins diet is an effective and feasible alternative to the ketogenic diet for the treatment of GLUT1DS-related paroxysmal movement disorders in adolescence and adulthood.
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Affiliation(s)
- Wilhelmina G Leen
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, the Netherlands
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