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Ketogenic Diet

Ketogenic Diet

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Published by Ranjith Kumar
ketogenic diet is now recommended by PDA for resistant seizures this is an article prepared by me, may be more useful for ur routein intiation and maintanance of ketogenic diet in childrens
ketogenic diet is now recommended by PDA for resistant seizures this is an article prepared by me, may be more useful for ur routein intiation and maintanance of ketogenic diet in childrens

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Categories:Types, Reviews, Book
Published by: Ranjith Kumar on Aug 26, 2011
Copyright:Attribution Non-commercial

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08/06/2013

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Dr Ranjith Kumar C.S
 Page 1
Ketogenic diet
 
Intractable epilepsy means at least one seizure every 2 months and have tried atleast 3 AEDs
 
Non-pharmacological treatment options :epilepsy surgery, vagus nerve timulation,and the ketogenic diet
.
 
The ketogenic diet is a high-fat, adequate-protein, and low carbohydrate diet,designed to mimic many of the biochemical changes associated with prolongedstarvation
 
The antiepileptic effect of starvation resulted from ketosis.
 
Mechanism of action:
 
On the ketogenic diet, the brain utilizes fat rather than glucose as the primarycerebral energy source. Administration of the ketogenic diet leads to major changes in the basicbiochemistry and physiology of the central nervous system.
 
ACIDOSIS:
 
Acidosis
 
decreases neuronal excitability
and seizuresusceptibility by
decreasing sensitivity of specific subtypes of glutamate
 receptors
 
and decreasing gap junction coupling.
 
 
KETONE BODIES METABOLISM AND KETOSIS:
reduction of aspartate and transamination of glutamate in the brain on theketogenic diet.
 
During ketosis, the acetate level increases in the braincausing increased production of glutamine.
 
CHANGES IN ENERGY STATE OF THE NEURON:
 
Ketosis leads to an increased ratio of ATP to ADP in the brain, whichincreases the activity of the ATPdependent sodium pumps found inneuronal and glial membranes,
 
This will result in hyperpolarization(DECREASED NEURONAL EXCITABILITY) and increased glutamateuptake.
 
CALORIE RESTRICTION:
 
Calorie restriction will decrease blood glucose, which will reduce theglycolytic energy available for seizures.
 
INCREASED PLASMA LIPIDS:
 
Children on the ketogenic diet have
elevated serum polyunsaturated fatty
 acids levels.These free lipids have been shown to have antiepilepticproperties.
 
NEUROPROTECTIVE EFFECTS:
 
 
 
Dr Ranjith Kumar C.S
 Page 2
Types of ketogenic diet:
CLASSICAL KETOGENIC DIET:
 
The classical diet contains a ratio of 4 grams of fat to each gram of protein andcarbohydrate combined.
 
A ratio of 3:1 is preferred In children under 18 months of age
 
The desired energy intake is 75% of recommendation for age, and the proteincontent is 1g/kg/day.
 
Children on this diet may have slowed height or weight velocity, if caloricrequirements are underestimated
MCT OIL DIET:
 
The MCT diet is calculated using 100% of the recommended daily energy intakefor the child’s age and size (as compared to 75% for the classical diet).
 
Sixty percent of the total energy is derived from MCT.
 
The remainder is distributed among saturated fat, carbohydrate, and protein
 
the diet is not very palatable, tasteless, and difficult to swallow
 
S/E: Gastrointestinal distress, in the form of abdominal pain and diarrhea
MODIFIED MCT VERSION DIETS:
 
This regimen was developed to overcome the practical difficulties of the MCTdietary calculations.
 
Only 30% of the daily energy intake is provided from MCT
 
It is often incorporated in the classical ketogenic diet for a variety of reasons,including increasing the protein and carbohydrate allowances while maintainingadequate ketosis, countering constipation, and improving dyslipidemiaINDICATIONS:
 
For the management of recalcitrant seizures
 
 
Complex myoclonic epilepsy with associated tonic-clonic convulsions
 
 
For infants with pyruvate dehydrogenase deficiency and glucosetransporter protein deficiency
 
ABSOLUTE CONTRAINDICATIONS:
 
pyruvate carboxylase deficiency,
 
organic aciduria,
 
mitochondrial disorders
 
fatty acid oxidation problems
 
carnitine deficiency.
 
 
Dr Ranjith Kumar C.S
 Page 3
NOTE:
 
appears safe and effective for infants with epilepsy who are younger than 2 yr of age.
INITIATION:
 
The ketogenic diet should be initiated gradually during a 3-5 day hospitalizationfollowing a 24-48 hour fast and fluid restriction (caffeine and sugar free)
 
Initial hospitalization is advisable to observe potential side effects of fasting, suchas hypoglycemia, vomiting, and dehydration
 
Fasting is continued with 20% fluid restriction.
 
Urine ketones should be checked by dipstick with every void. Once urinaryketones reach 3+ to 4+ (80-160 mg/dl), the diet can be started.
 
Some authors suggested that seizure control correlates better with serum ß-hydroxybutyrate than with urinary ketones
 
The diet is started at a ratio of 4:1 of fat to protein and carbohydrate.
 
The exact dietary components are calculated according to age, weight, height,and activity level
 
The protein component is based on the protein requirements for age and size.
 
Carbohydrate intake is typically 5-10 g/day.
 
The targeted total caloric intake is typically 75% of that recommended for age.
 
One third of the calculated total calories is given on day one, followed by 2/3 onday 2 and full-calories afterward
MAINTENANCE.:
 
Patients are discharged home on the full diet in addition to multivitamins andcalcium supplements
 
Urine ketones should be checked several times per week, and the diet slowlyadjusted to maximize seizure control
 
Follow-up should be monthly to monitor body weight, height, and compliance
 
Laboratory studies are performed at base line and then every 3-6 months,including blood count, lipid profile, electrolytes, renal, liver function tests, andbeta hydroxybutyrate
 
Once the seizures are controlled, AEDs can be tapered slowly
 
If the seizures continue, one must be sure that there are no additionalcarbohydrates taken from unknown sources.
 
The diet should be maintained for at least 3 months to assess the seizure outcome

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