Diet Therapy For Epilepsy ANGELA SAMUELS RD CNSC

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? – 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: 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

Initiation of the Diet Outpatient family meeting with dietitian and epileptologist to discuss diet Inpatient admission coordinated with RD and Epilepsy team Patient admitted on Sunday/Monday evening to EMU Plan for a minimum 3 -5 day admission All meds converted to sugar free prior to admission All formulas obtained prior to admission

Nutritional Assessment/Diet Calculation Height, weight and BMI/weight-for-height plotted on 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)

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 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 My. Ketocal. 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 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 • • Carbohydrates – 10% daily calories Protein – 20 -30% daily calories Fat – 60 -70% calories Choose foods with glycemic index <55

Resources Angela Samuels - dietitian acsamuels 23@gmail. com