Epilepsia, 46(2):280–289, 2005
Blackwell Publishing, Inc.


C 2005 International League Against Epilepsy
Worldwide Use of the Ketogenic Diet
Eric H. Kossoff and Jane R. McGrogan
The Pediatric Epilepsy Center, Departments of Neurology and Pediatrics, The Johns Hopkins Medical Institutions, Baltimore,
Maryland, U.S.A.
Summary: Purpose: Over the past decade, the use of the ke-
togenic diet internationally has increased dramatically. The pur-
pose of this survey was to evaluate the use of the diet worldwide.
Methods: With the use of the Internet, e-mail requests for in-
formation about international ketogenic diet centers (outside the
United States) were made over a 9-month period. Assistance
also was obtained from the Child Neurology Society and Inter-
national League Against Epilepsy. Questions included patient
enrollment (total and annually), year the diet was first offered,
unique cultural and religious issues in the country, community
opinion, and research interests.
Results: Successful communication was made with 73 aca-
demic centers in 41 countries outside the United States. Sixteen
(39%) countries provided information from multiple centers. The
median duration offering the diet was 8 years (range, 1–45 years).
Epilepsy spares no racial, cultural, or national bound-
aries, affecting 100 million people worldwide. Accord-
ing to the International League Against Epilepsy (ILAE)
and World Heath Organization (WHO), in developing
countries, often a large percentage of the population with
epilepsy are not adequately treated (1). Many patients, in-
cluding those in Europe and the United States, cannot af-
ford or do not have access to all available anticonvulsants
(AEDs). Surgery, if an option, also may require a large
personal expense or distance of travel. Other therapies are
clearly needed.
The ketogenic diet is a high-fat, low-carbohydrate and
adequate protein diet that has been in use for childhood
intractable epilepsy since 1924. Efficacy and safety have
been demonstrated in several studies over the past decade
(2,3). Although initially created in the United States, its
recent resurgence here has expanded its use to most major
academic medical centers (4). At our institution alone,
nearly 500 patients have tried the diet over the past 10-
year period.
Accepted October 23, 2004.
Address correspondence and reprint requests to Dr. E.H. Kossoff at
Jefferson 128, The Johns Hopkins Hospital, 600 North Wolfe Street,
Baltimore, MD 21287-1000, U.S.A. E-mail: ekossoff@jhmi.edu
280
The average number of patients enrolled to date was 71.6 per
country, with 5.4 new patients annually. Common difficulties in-
cluded avoiding rice intake, tolerating higher fat-to-protein and
carbohydrate ratios (e.g., 4:1), finding specific nutritional labels
on foods, and handling the growing interest from large popula-
tions with limited resources. Nevertheless, cultural and religious
issues were generally not limiting; physician and patient accep-
tance of the diet as an option is high; and most meals were similar
among countries. Centers often had great pride in their programs,
and international collaborative groups are forming rapidly. A
website is now available with updated center information at
http://www.neuro.jhmi.edu/Epilepsy/Peds/ketoworldwide.htm
Conclusions: Despite occasional difficulties, the ketogenic
diet is being used worldwide. Key Words: Ketogenic diet—
Epilepsy—International—Seizures—Children.
In parallel with its increased use in the United States,
physicians in many other countries have started to of-
fer the ketogenic diet. This diet has the potential advan-
tage of theoretically being available everywhere and at
lower costs than the newer AEDs. Unlike administering
a pill, however, often significant religious and cultural is-
sues involve food, not only in its provision, but also its
withdrawal (fasting). The primary objective of this study
was to examine some of the worldwide issues involved
in providing the ketogenic diet. The secondary objec-
tive was to gather names and phone numbers of interna-
tional academic centers for physicians and parents to ob-
tain further information, refer patients, and collaborate in
research.
METHODS
Centers around the world were contacted for their par-
ticipation in a multinational study of the use of the ke-
togenic diet over a 9-month period in 2004. An ini-
tial and then follow-up e-mail was sent to the Child
Neurology Society community by use of the electronic
mail daily newsletter managed at the University of
Wisconsin–Madison (Waisman Center) by Dr. Steven
Leber. This newsletter is open to all interested physicians
and medical students in the child neurology community

WORLDWIDE KETOGENIC DIET
FIG. 1. Countries providing the ketogenic diet, as identified in this survey (highlighted in gray).
worldwide, encompassing 59 countries at this time. The
e-mail was composed of a request for members to contact
the author with names and emails of pediatric centers using
the ketogenic diet. After their initial response confirming
they had an active ketogenic diet center, physicians were
then asked to provide details of their patient enrollment
(total and annually), years providing the diet, unique is-
sues and challenges in their country, community opinion,
research interests, and a typical ketogenic meal prepared
with foods traditional to their country. No formal, stan-
dardized survey was used; e-mail responses to the previ-
ously mentioned questions were maintained in the author’s
files.
Names of physicians and centers in Canada, Eng-
land, Germany, India, Sweden, and Uruguay were known
personally before the actual initial e-mail was sent;
the author e-mailed these centers separately. Many of
the initial physicians responding provided names of
other nearby colleagues and nations providing the diet.
In addition, the ILAE (International League Against
Epilepsy) was contacted both via e-mail and through
their website (http://www.ilae.org) as were the Interna-
tional Child Neurology Association, and International Af-
fairs Committee of the Child Neurology Society. A web-
site listing several international centers started by Stan-
ford University (http://www.stanford.edu/group/ketodiet/
ketocenters.html) was used for e-mail addresses as well,
although some were not currently operational. Several
physicians were contacted via e-mail from addresses on
publications they had written about the ketogenic diet (5–
10). The authors acknowledge that this list is by no means
complete, but it represents the best efforts to contact cen-
ters via the Internet. No centers or patients were contacted
by telephone.
15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
281
RESULTS
Full historical information on ketogenic programs
was received from 70 centers in 41 countries outside the
United States (Fig. 1). Addresses are listed in alphabe-
tical order based on geographic region in Table 1 and at
http://www.neuro.jhmi.edu/Epilepsy/Peds/
ketoworldwide.htm. Of the 41 countries, 16 (39%;
Austria, Australia, Brazil, Canada, England, France, Ger-
many, Israel, Italy, Japan, Poland, Serbia, Spain, South
Africa, South Korea, and Spain) provided information
from two or more centers. Twenty centers also provided
us with representative meals and recipes that used foods
available in and traditional to their countries, some of
which with interesting food items are listed in Table 2.
The descriptions of centers and countries as listed later
represents the efforts of the authors to provide succinct
information about experiences with the ketogenic diet in
each geographic region.
In the centers that provided specific information on their
program’s history, the median length of time that the center
offered the diet was 8 years (range, 1–45 years). Several
countries with multiple centers had wide variations in en-
rollment depending on local population size and referral
base. The average number of patients enrolled to date per
country was 71.6 (range, 5–300), with 5.4 started each
year (range, 0–40).
From communications obtained, several regions and na-
tions apparently do not provide the diet. These locations
include Mexico, most of Central America including Hon-
duras, Peru, Pakistan, and the majority of Africa. Physi-
cians in these countries did, however, express interest in
starting ketogenic programs in the future. Countries not
listed in this article may provide the diet, but at the time of
Epilepsia, Vol. 46, No. 2, 2005
 15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
282 E. H. KOSSOFF AND J. R. MCGROGAN

TABLE 1. Physicians providing the ketogenic diet who participated in this survey, listed alphabetically by
country within regional areas
NORTH AMERICA
Drs. Peter and Carol Camfield, Dalhousie University and the IWK Health Centre, PO Box 9700 Halifax, Nova Scotia Canada, B3K 6R8; Phone:
902-470-8479; Fax: 902-470-8486
Dr. Rosalind Curtis, Hospital for Sick Children Dept. of Neurology, 555 University Ave Toronto, ON M5G 1X8 Canada; Phone: (416) 753-6057;
Fax: (416) 753-6046; E-mail: roscurtis@rogers.com
Dr. Kevin Farrell British, Columbia Children’s Hospital, 4480 Oak Street Room A303, Neurology, Vancouver, BC V6H 3V4 Canada; Phone: (604)
875-2121; Fax: (604) 875-2285; E-mail: kevin farrell@telus.net
Drs. Daniel Keene and Sharon Whiting, Children’s Hospital of Eastern Ontario, 401 Smyth Rd Ottawa, ON K1H 5L7 Canada; Phone: (613)
523-5140; Fax: (613) 523-2256; E-mail: dkeene@exchange.cheo.on.ca
Dr. Jeff Kobayashi, The Bloorview Macmillan Children’s Centre, 25 Buchan Court, Toronto ON M2J 4S9 Canada; Phone: (416) 425-6220 ext 6276;
Fax: (416) 753-6046; E-mail: jkobayashi@bloorviewmacmillan.on.ca
Dr. Anne Lortie, Hospital St. Justine, 3175 Cote-Ste-Catherine, Montreal, PQ H3T 1C5 Canada; Phone: (514) 345-4931; Fax: (514) 345-4787;
E-mail: lortie.a@sympatico.ca
Dr. Elaine Wirrell, Alberta Children’s Hospital, Division of Neurology, 1820 Richmond Rd SW, Calgary, AB T2T 5C7 Canada; Phone: (403)
943-7306; Fax: (403) 943-7609; E-mail: elaine.wirrell@calgaryhealthregion.ca
SOUTH AMERICA
Dr. Luis R. Panico Mendoza, 3373 (3000), Santa Fe, Argentina; Phone/fax: +54 342 4558768; E-mail: dietasur@hotmail.com http://usuarios.arnet.
com.ar/mdemartini/index.htm
Dr. Maria Joaquina Marques-Dias, Professor of Neurology, University of São Paulo, Av Dr Eneas C Aguiar 647, 05403-900 São Paulo, SP Brazil;
Phone: (11) 3069 8673; Fax:(11) 3069 8503; E-mail: majomadi@usp.br
Dr. Marcio M Vasconcelos, Av. das Americas, 700 sl 229 bl 6, 22640-100 Rio de Janeiro - RJ Brazil; Phone: (21) 2132-8080; E-mail: mmvascon@
centroin.com.br
Dr. Andrea Avellanal, Hospital Británico Benito Nardone 2217 11.300 Montevideo Uruguay; Phone: 5982-711 91 86 E-mail: cinacina@adinet.com.uy
Dr. Luis Carlos Núñez, López, Pediatric Neurologist Carrera 29 # 47-108 Edificio Somes. Consultorio 20, Bucaramanga, Colombia; Phone: 577
6475723; Fax: 577 6436124 extension 136; E-mail: lcnl007@intercable.net.co
EUROPE
Dr. Martha Feucht, Universitatsklinik fur Neuropsychiatrie des Kindes- und Jugendalters, Wahringer Gurtel 18-20, 1090 Vienna, Austria; Phone:
+43-40400-3012; Fax: +43-40400-2793; E-mail: martha.feucht@univie.ac.at
Dr. Barbara Plecko, University Klinik für Kinder-und Jugendheilkunde Graz Auenbruggerplatz 30, A-8036 Graz, Austria; Phone: +43 316 385
82813; Fax: +43 316 385 2657; E-mail: barbara.plecko@meduni-graz.at
Dr. Lieven Lagae, Kinderneurologie - Epilepsie Klinische Neurofysiologie University Hospitals of Gasthuisberg Herestraat, 49 B-3000 Leuven
Belgium; Phone: +32 16 34 38 45; Fax: +32 16 34 38 42; E-mail: Lieven.Lagae@uz.kuleuven.ac.be
Dr. Elina Liukkonen, Helsinki and Vusimaa Hospital Hospital for Children and Adolescents, PO Box 280, Finland; Phone: 011-358-9-4711-4711;
Fax: 011-358-9-471-80-413; E-mail: elina.liukkone@hus.fi
Dr. Anne de Saint-Martin, Neuropédiatre Service de Pédiatrie, 1 CHU de Hautepierre, 67098 Strasbourg, Cedex, France; Phone: 33(0)388127734;
Fax: 33(0)388128156; E-mail: anne.desaintmartin@chru-strasbourg.fr
Dr. Olivier Dulac, Hopital Saint Vincent de Paul 149 Rue di Sevres Paris, 75743 France; Phone: 33 140 488111; E-mail: o.dulac@nck.ap-hop-paris.fr
Dr. Laurence Lion Francois, Centre Hospitalier Lyon Sud Département de Neurologie pédiatrique, 165 chemin du grand Revoyet, 69 495 Pierre Bénite
Cédex, France; Phone: 04 78 86 14 95; Fax: 04 78 86 57 16; E-mail: laurence.lion@chu-lyon.fr
Dr. F.A.M. Baumeister, Child Neurology Kinderklinik und Poliklinik der Technischen Universität München, Kinderklinik Schwabing, Kölner Platz 1,
80804 München Germany; Phone: 089-3068-3352; Fax: 089-3068-3887; E-mail: FAM.Baumeister@lrz.uni-muenchen.de
Dr. Joerg Klepper, Dept. of Pediatric Neurology University of Essen, Hufelandstr. 55, D-45122 Essen, Germany; Phone: +49 201 723 2356 or 2333;
Fax: +49 201 723 2333; E-mail: joerg.klepper@uni-essen.de
Dr. Dietz Rating, Dept. of Pediatric Neurology Children’s Hospital University of Heidelberg, Im Neuenheimer Feld 153, 69120 Heidelberg,
Germany; Phone: 49.6221.56-2334, -2311; Fax: 49.6221.56 5744; E-mail: Dietz.Rating@med.uni-heidelberg.de
Dr. A. Covanis, Neurology Department The Children’s Hospital “Agia Sophia”, Thivon and Levadis 11527, Athens, Greece; Phone: +302107751637;
E-mail: graaepil@otenet.gr
Dr. Yr Sigurdardottir, Icelandic diagnostic Center, Digranesvegi 5, 200 Kopavogur, Iceland; Phone: (354) 510-8400; Fax: (354) 510-8401; E-mail:
yr@greining.is
Drs. Bryan Lynch and Aisling Myers, The Children’s University Hospital, Temple Street Dublin, 1 Ireland; Phone: 00-353-86-8197831; E-mail:
aislingmyers@hotmail.com
Dr. Giangennaro Coppola, Clinic of Child Neuropsychiatry, Second University of Naples, Italy; Phone: 0039-81-5666695; Fax: 0039-81-5666694;
E-mail: giangennaro.coppola@unina2.it
Dr. Federico Vigevano, Department of Neurology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy; Phone: 0039-06-68592262; Fax:
0039-06-68592463; E-mail: vigevano@opbg.net
Dr. Paul Augustijn, Observatie Kliniek voor Kinderen “Primula” S.E.I.N., Postbus 540, 2130 AM Heemstede, The Netherlands; Phone:
31(0)23-558800; Fax: 31(0) 23-558229; E-mail: paugustijn@sein.nl
Dr. Maria Zubiel, Dept. of Child Neurology, Institute of Polish Mother Memory Hospital, 93-338 Lodz, Rzgowska 281/289 Poland; Phone: 004842
2712080; Fax: 004842 2711412; E-mail: mzubiel@op.pl
Dr. Sergiusz Jozwiak, Professor and Head, Pediatric Neurology, The Children’s Memorial Health Institute, Al.DZieci Polskich 20, 04-736 Warszawa,
Poland; Fax: 4822- 8157402; E-mail: jozwiak@czd.waw.pl
Dr. Sergey Aivazyan, Head of Child Neurology, The Child Moscow Research Hospital Aviatorov Street, 38 SoIntsevo Moscow, Russia; Phone: (095)
4521022, +79166204051; E-mail: abc1231961@mail.ru
Dr. Lesley Nairn, Consultant Paediatrician, Royal Alexandra Hospital, Paisley Scotland; Phone: 0141 580 4460; E-mail:
Lesley.Nairn@rah.scot.nhs.uk
Dr. Nebojsa J. Jovic, Clinic of Neurology and Psychiatry for Children and Youth Dr. Subotica 6a Street 11, 000 Belgrade, Serbia and Montenegro;
Phone: +381 11 2658 355; Fax: +381 11 64 50 64; E-mail: njjovic@eunet.yu
Dr. J. Campistol, Cap Servei de Neurologia, Hospital Sant Joan de Déu Passeig, Sant Joan de Déu, 2 08950-Esplugues, (Barcelona). Spain; Phone: 93
2532153; Fax: 93 2033959; E-mail: campistol@hsjdbcn.org
Dr. Antonio Gil-Nagel, Servicio de Neurologı́a Programa de Epilepsia Hospital Ruber Internacional, La Masó 38, Mirasierra 28034 Madrid Spain;
Phone: 0034-913875250; Fax: 0034-913875333; E-mail: agnagel@ya.com

Epilepsia, Vol. 46, No. 2, 2005

 15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WORLDWIDE KETOGENIC DIET 283

TABLE 1. Contd.
Dr. Per Amark Astrid Lindgrens, Childrens Hospital, Karolinska Hospital S-171 76, Stockholm, Sweden; Phone: +46 8 5177 7026; Fax: +46 8 5177
7608; E-mail: per.amark@ks.se
Dr. Gabriela Wohlrab, University Children’s Hospital, Neurophysiological Department, Steinwiesstrasse 24, CH-8032 Zürich Switzerland; Phone:
0041 1 266 77 01; E-mail: Gabriele.Wohlrab@kispi.unizh
Dr. Meral Topcu, Prof. of Pediatrics and Pediatric Neurologist, Hacettepe Children’s, Hospital, Dept. of Child Neurology, 06100 Ankara Turkey;
Phone: 90-312-3051165; Fax: 90-312-4266764; E-mail: mtopcu@hacettepe.edu.tr
Dr. Helen Cross, Reader and Honorary Consultant in Paediatric Neurology, Institute of Child Health and Great Ormond Street Hospital for Children,
NHS Trust The Wolfson Centre, Mecklenburgh Square, London WC1N 2AP UK; Phone: 44-207-813-8488; Fax: 44-207-829-8627; E-mail:
h.cross@ich.ucl.ac.uk
Dr. Colin Ferric, Department of Paediatric Neurology, Clavendon Wing, Leeds General Infirmary, Leeds L52 9NS, UK; Phone: 0113 392 2188; Fax:
0113 392 5731; E-mail: Collin.Ferric@leedsth.nhs.uk
Dr. Frances Gibbon, Department of Child Health, University Hospital of Wales, Cardiff, UK; Phone: 44 29 2074 3542; E-mail:
Frances.Gibbon@cardiffandvale.wales.nhs.uk
Dr. Jayaprakash A Gosalakkal, Consultant Paediatric Neurologist, University Hospitals of Leicester, CDC/Windsor, LRI Leicester LE1 5WW UK;
Phone: 011441162585564; Fax: 011442587637; E-mail: Jay2world@aol.com
Dr. Sunny George Philip, Consultant Paediatric Neurologist, Birmingham Children’s Hospital, Birmingham UK B4 6NH; Phone: 011441213338149;
Fax: 011441213338151; E-mail: SUNNY.PHILIP@bch.nhs.uk
Dr. Timothy Martland, Consultant Paediatric Neurologist, The David Lewis Centre Mill House, Warford Near Alderley Edge Cheshire SK9 7UD UK;
Phone: +44 161 727 2346; E-mail: Timothy.Martland@CMMC.nhs.uk
Dr. Ruby Schwartz, Central Middlesex Hospital Acton Lane, London NW10 7NS UK; Phone: 020 8453 2121; Fax: 020 8453 2096; E-mail:
Ruby.Schwartz@nwlh.nhs.uk
Dr. Neil H. Thomas, Consultant Paediatric Neurologist, Southampton University Hospitals NHS Trust Southampton General Hospital, Mailpoint 021,
Tremona Road, Southampton SO16 6YD, UK; Phone: +44 23 8079 4457; Fax: +44 23 8079 4962; E-mail: neil.thomas@suht.swest.nhs.uk
MIDDLE EAST
Dr. Mohammad Ghofrani, Professor of Paediatric Neurology, Shaheed Beheshti University of Medical Sciences and Health Services: Mofid Hospital,
Shariati St., Tehran, Iran; Phone: 98 21 22200041
Dr. Bruria Ben’Zeev Safra, Children’s Hospital Sheba Medical Center, Ramat Gan Israel, 52621; Phone: 97235302577; E-mail:
benzeev4@netvision.net.il
Dr. Tally Lerman-Sagie, Director of Pediatric Neurology Unit, Wolfson Medical Center, Holon Israel; Phone: 97235028458; Fax: 97235028141;
E-mail: asagie@post.tau.ac.il
Dr. Generoso G. Gascon, Dept. of Neuroscience, MBC J-76 King Faisal Specialist Hospital & Research Center, PO Box 40047, Jeddah 21499 Saudi
Arabia; Phone: +(966-2) 667-7777, Ext. 5813; Fax: +(966-2) 667-7777, Ext. 5819; E-mail: generoso gascon@hotmail.com
AFRICA
Dr. Simon Strachan, Bedford Gardens Hospital Paediatric Centre, Bradford Road, Bedford Gardens, Gauteng South Africa; Phone: (011) 493
2613/(011) 622 2771; E-mail: sstracha@mweb.co.za; E-mail: megawlk@absamail.co.za
Dr. Jo M. Wilmshurst, Head of Paediatric Neurology 5th Floor ICH Department of Paediatrics, Red Cross Children’s Hospital, Rondebosch, Cape Town
7700 South Africa; Fax: 027 21 689 2187; E-mail: wilmshur@ich.uct.ac.za
ASIA
Drs. Ada Yung and Virginia Wong, Department of Paediatrics and Adolescent Medicine, University of Hong Kong Queen Mary Hospital, Hong Kong
SAR; Phone: (852)-2855-4485; Fax: (852)-2855-1523; E-mail: vcnwong@hkucc.hku.hk; E-mail: ayung@hkucc.hku.hk
Dr. Janak Nathan, Shushrusha Hospital, Ranade Road, Dadar W Mumbai 400028 India; Phone: 091-22-24446615; E-mail: jsvpnat@hotmail.com
http://www.ketodietindia.org
Dr. Yukio Fukuyama, Child Neurology Institute, 6-12-17-201 Minami-Shinagawa, Shinagawa-ku Tokyo 140-0004 Japan; Phone: 81-3-5781-7680; Fax:
81-3-3740-0874; E-mail: yfukuyam@sc4.so-net.ne.jp
Dr. Hirokazu Oguni, Dept. of Pediatrics, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku Tokyo 162-8666 Japan; Phone: +81 3
3353 8111; Fax: +81 3 5269 7338; E-mail: hoguni@ped.twmu.ac.jp
Dr. Benilda Sanchez, Head of the Epilepsy Monitoring Program of St. Luke’s, Manila, Philippines; Phone: (632)723-0301 ext.5452; Fax:
(632)727-5452; E-mail: beni779@hotmail.com
Dr. Hian-Tat Ong, Consultant, Paediatric Neurology and Developmental Paediatrics, Children’s Medical Institute, National University Hospital,
Singapore; Phone: 065-67724391; Fax: 065-67797486; E-mail: OngHT@nuh.com.sg
Dr. Yong Seung Hwang, Professor, Pediatrics, Pediatric Neurology Seoul National University Children’s Hospital, 28 Yon Gun Dong, Jong Ro Gu
Seoul, 110-744 South Korea; Phone: 82-2-760-3629; Fax: 82-2-743-3455; E-mail: childnr@plaza.snu.ac.kr
Dr. Heung Dong Kim, Associate Professor, Dept. of Pediatrics, Director in Child Neurology, Yonsei University College of Medicine, Severance
Hospital 134, Shinchondong, Seodaemun-gu, Seoul, 120-752 South Korea; Phone: 82-2-361-5511; Fax: 82-2-393-9118; E-mail:
hdkimmd@yumc.yonsei.ac.kr
Dr. Huei-Shyong Wang, Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University Taiwan; Phone: 886 (0)968
110264; Fax: 886 3 3277295; E-mail: wanghs444@cgmh.org.tw
Dr. Pipop Jirapinyo, Professor of Pediatrics, Pediatric Nutritionist Nutrition Unit Department of Pediatrics, Faculty of Medicine Siriraj Hospital,
Mahidol University, 2 Prannok Road Bangkoknoi, Bangkok 10700 Thailand; Phone: (662) 411-2535; E-mail: sipjr@mahidol.ac.th
Dr. Pongkiat Kankirawatana, Director, Clinical Neurophysiology Lab Pediatric Neurology, CHB-314 The Children’s Hospital of Alabama, 1600 7th
Ave S., Birmingham, AL 35233-1711, (information regarding Thailand experience); Phone: 205-996-7850; Fax: 205-996-7867; E-mail:
PKankirawatana@peds.uab.edu
AUSTRALIA/NEW ZEALAND
Dr. Deepak Gill, Paediatric Neurologist, Children’s Hospital at Westmead, Cnr Hawkesbury Rd & Hainsworth St., Westmead Sydney NSW 2145
Australia; Phone: 02 9845 2694; Fax: 02 9845 3905; E-mail: DeepakG@chw.edu.au
Dr. John Lawson, Child Neurologist, Sydney Children’s Hospital, Sydney Australia; Phone: 61 2 93821658; Fax: 61 2 93821580; E-mail:
Lawson@sesahs.nsw.gov.au
Dr. Mark T. Mackay, Consultant Neurologist, Department of Neurology, Royal Children’s Hospital, Flemington Road, Parkville Victoria 3052
Australia; Phone: +613-9345-5641; Fax: +613-9345-5977; E-mail: mark.mackay@rch.org.au
Dr. Lakshmi Nagarajan, Princess Margaret Hospital for Childern, GPO Box D184, Perth WA 6840, Australia; Phone: (08) 9340 8364; E-mail:
Lakshmi.Nagarajan@health.wa.gov.au
Dr. Thorsten Stanley, Senior Lecturer in Paediatrics Wellington School of Medicine and Health Sciences, University of Otago, PO Box 7343 Wellington
South Wellington, New Zealand; Phone: +64 4 3855 999; Fax: +64 4 3855 898; E-mail: paedtvs@wnmeds.ac.nz

Epilepsia, Vol. 46, No. 2, 2005

 15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
284 E. H. KOSSOFF AND J. R. MCGROGAN

TABLE 2. Representative ketogenic diet meals from this publication had not contacted the authors. We did not
participating countries (ratios and calories calculated based receive any information from a center that had abandoned
on best estimates when not specifically provided)
the use of the ketogenic diet.
Argentina
56 g 36% fat heavy whipping cream
28 g sirloin beef North and Central America
8g carrots At this time, nearly 80 centers in the United States be-
10 g celery sides ours provide the ketogenic diet, according to the
9g mayonnaise
9g canola oil Charlie Foundation (personal communication). The diet
(400 kcal, 3:1) has been in use since 1924, with relatively little modifica-
Belgium tion (4). Although it is thought by the medical community
50 g iceberg lettuce
15 g avocado currently to be a proven, useful therapy for intractable
25 g pecans childhood epilepsy, the availability of the diet is still lim-
20 g pineapple ited in certain regions, mostly because of lack of trained
12 g olive oil
(312 kcal, 4:1) dietitians (11). Many ongoing studies exist of the basic
France science and clinical aspects of the ketogenic diet, and a
50 g foie gras recently published scientific textbook was contributed to
100 g mushrooms or broccoli
70 g fromage; triple crème cheese by many national centers (12). For information about cen-
47 g butter ters in the United States, please contact the authors or the
50 g apricot Charlie Foundation (http://www.charliefoundation.org).
(882 kcal, 2.7:1)
Germany We received information from seven centers in Canada
90 g bratwurst grob/Schweinsbratwurst grob including two in Toronto, one each in Calgary, Montreal,
(sausage) Nova Scotia, Ottawa, and Vancouver. Most of the centers
80 g sauerkraut (sauerkraut)
50 g cooked potatoes had been started in or before 1995. Both centers in Toronto
30 g whipping cream (30% fat) and Alberta Children’s Hospital in Calgary initially pro-
73 g grapeseed-oil vided only the MCT (medium chain triglycerides) oil diet
(1109 kcal, 3.6:1 ratio)
India before more recently offering a classic 4:1 diet as well.
34 g chicken The group at the Hospital for Sick Children in Toronto has
40 g onion perhaps the largest enrollment in Canada, with 25 patients
93 g tomato
1g ginger started per year and 200 children aged 1–16 years enrolled
1g garlic to date. Enrollment in 2003 declined somewhat because
34 g ghee (fat) of the SARS (severe acute respiratory syndrome) outbreak
(394 kcal, 1.8:1 ratio) clove, bay leaf, green chili, red chili
powder there. Community opinion about the ketogenic diet is fa-
Israel vorable throughout Canada’s centers, with many outside
35 g tahina sauce (sesame seed, lemon juice, referrals and many families requesting its use. Most diets
salt, yogurt)
2g olive oil are not unusual; however, Dr. Farrell in Vancouver de-
50 g cucumber scribed a First Nations child who ate mainly wild game
26 g heavy cream such as fish and deer, and store-bought products were not
(224 kcal, 3:1 ratio)
Singapore used. Physicians from several other international centers
8g Beehoon (rice noodle) have been trained in Canada, including physicians from
17 g pork, lean, boiled Australia, Saudi Arabia, and Costa Rica.
20 g cabbage, green, boiled
33 g sesame oil Considerable research interests exist in Canada, includ-
(364 kcal, 2.5:1 ratio) ing the evaluation of acetone as a major anticonvulsant
South Africa component of the ketogenic diet, and the ability to monitor
160 g cooked gemsquash
8g fish biltong (dried) breath acetone by using a portable device is currently be-
2g butter ing investigated (13,14). In addition, the group in Toronto
160 g Orley whipTM is interested in cognitive changes (15). Farrell (personal
(442 kcal, 4:1 ratio)
Sweden
communication) in Vancouver has completed a project
29 g octopus evaluating intermediary metabolism both before and dur-
9g canola oil ing the diet as compared with clinical response. Wirrell (5)
11 g creme fraiche 34%
3g tomato sauce
has published information on the outcome of starting the
3g leek diet without a fast. The group in Ottawa published their
34 g calogen (emulsion based on peanut oil) experience with the diet in 1999 (16).
1g omega-3
14 g squash (zucchini)
Elsewhere, in Mexico and Central America, the diet is
10 g tomato generally not being used. Currently no ketogenic diet pro-
(460 kcal, 3.7:1 ratio) gram exists in Costa Rica; however, Erick Sell, a pediatric

Epilepsia, Vol. 46, No. 2, 2005


WORLDWIDE KETOGENIC DIET
neurology fellow at the Hospital for Sick Children in
Toronto, is being trained in the use of the diet for his return
to Costa Rica in late 2005. He plans to start a ketogenic
diet clinic at the National Children’s Hospital in San Jose,
which will be the first center in Costa Rica. A program also
is being planned by the Food and Pharmaceutical College
of Havana University in Cuba, but is not yet available.
Dr. Chais Calana Gonzalez (paulozao@ifal2.uh.cu) is the
contact for this potential center.
South America
We received information from centers in Argentina
(Santa Fe), Brazil (Sao Paolo and Rio de Janeiro), Colom-
bia, and Uruguay. All centers began their programs ∼5–
6 years ago. The center in Santa Fe, Argentina, is very ac-
tive and reports occasionally helping patients in Colombia,
Chile, and Spain.
In Argentina, the predominant religion is Catholicism,
and the historical references to fasting in the Bible have
helped convince parents of its value. Many physicians
are less convinced and, according to the Argentinian cen-
ter, research and abstracts were not initially accepted at
local medical conferences and patients were rarely re-
ferred. The group at Santa Fe is interested in electroen-
cephalographic changes that occur with the diet (6). A
website for information about this site is available at
http://usuarios.arnet.com.ar/mdemartini/index.htm
Despite the large population of Brazil (170 million peo-
ple), the diet has also been avoided in both the medical
community and the general population. According to the
physician who contacted us, no articles in Portuguese have
been written about the diet. Parents have a difficult time
finding an electronic scale to weigh foods and specific in-
gredients. MCT oils reportedly are too expensive for most
families. Meal plans are generally calculated for a tradi-
tional four meals per day rather than three. Because of the
hot weather, the group in Sao Paolo does not restrict water
intake (and has not seen difficulties). In Uruguay, the diet
is meeting with some success and national acceptance, al-
though medical insurance does not always cover families’
diet admission costs.
The ketogenic diet is currently being promoted in
Colombia, with approximately four patients started to date
by two physicians, Luis Lopez and Estela Novoa. Novoa
(caes 950@hotmail.com) reports a large need for the diet,
and a foundation has been applied to for assistance.
Europe
Europe is a well-established site for providing the diet,
and many countries responded to our Internet survey, in-
cluding Austria, Belgium, England, Finland, France, Ger-
many, Greece, Iceland, Ireland, Italy, The Netherlands,
Poland, Portugal, Russia, Scotland, Serbia, Spain, Swe-
den, Switzerland, and Turkey. Centers in Europe have been
enrolling patients for as long as 30 years (England and
Serbia), although some started as recently as 2–4 years
15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
285
ago (Poland, Russia, and Switzerland). Enrollment also is
variable, but typically all centers were starting five to six
patients annually. Other than the United States, Canada,
and Australia, the countries of Europe were unique in the
large number of centers within each nation. We received
information from eight centers in England (22 centers in
total according to a study from 2000), and three in Ger-
many (with reports of 11 in total), three in France and
Serbia, and two each in Italy, Poland, and Spain (17). The
Netherlands center that contacted us reported at least four
other centers also providing the diet in that country. Many
of these centers are working in networks clinically and in
research trials. However, some countries have large refer-
ral bases with limited centers, such as the single group in
Moscow, Russia.
The perception of physicians in Europe is that general
community opinion regarding the diet is favorable, with
numbers of these centers seeing an increase in referrals.
Many newspapers (including tabloids) and the Internet
extol the virtues of the diet but seem also to provide mis-
information about its being easy to provide. A major dif-
ficulty expressed by nearly all centers is a lack of dietitian
time and resources, even though many neurologists are
interested in providing the diet. In England specifically,
financial resources with the current health care system
also place a strain on a ketogenic diet program that typi-
cally does not earn money. The group in Poland attributes
much of its success to a strong collaboration with the gas-
troenterologists, similar to what is described by Thailand.
Avoidance of foods did not appear to be a problem, and
families in Italy were willing to give up pasta and breads,
and those in France were able to avoid pastries with ap-
propriate guidance. However, several of the investigators
had some initial difficulty adapting the “Mediterranean
diet” to the ketogenic diet. In Turkey, the only restric-
tion is a religious aversion to eating pork. Many countries
have unique recipes of traditional foods; Belgium has even
created a full-color brochure with recipes for family use.
This brochure is available electronically. The majority of
the centers use a standard ketogenic diet; MCT oil and
SHS KetoCal (http://www.shsweb.co.uk) are commonly
used as well. In most centers, children are fasted during a
hospital admission; two exceptions are Sweden, where the
diet is provided with an initial 24-h fast (rather than 48 h),
followed by discharge to home for diet initiation, and The
Netherlands, in which children are not fasted at all. These
physicians have found a shortened (or absent) fast can still
lead to ketosis, as described in previous studies (5).
Publications on the ketogenic diet by European nations
have been plentiful (7,17,18–22). Nearly all centers re-
ported research interests; one of the most notable is a
randomized, controlled, multicenter trial of 120 children
nearing completion in England, headed by Helen Cross
at Great Ormond Street Hospital. This trial compares the
MCT and classic ketogenic diets, with a control period
Epilepsia, Vol. 46, No. 2, 2005

286 E. H. KOSSOFF AND J. R. MCGROGAN
for 50% of patients, in terms of seizure frequency, behav-
ior, laboratory studies, and growth in a similar manner
to a previous study from the England (7). Jörg Klepper’s
group in Germany is interested in young infants and the
diet for GLUT-1 (glucose transporter 1) deficiency; Plecko
(21) is evaluating the diet for inborn errors of metabolism;
and Amark (22) in Sweden is investigating the pharma-
cokinetics of concomitant anticonvulsants, influence of
fatty acids on neurotransmission, and effects of the diet
on CSF amino acids. Several countries have held interna-
tional conferences, including two in 2004 in Rimini, Italy,
and Fulda, Germany.
Middle East
Centers in Iran, Israel, and Saudi Arabia are providing
the ketogenic diet in the Middle East. A center in Iran ex-
ists, with an abstract presented in 2002 describing >200
patients (8). We were unable to contact the physician per-
sonally, but several other physicians in Tehran confirm
that the center is active.
In Israel, the centers in Sheba and Holon have enrolled
∼50 patients since 1998, and start five patients annually.
The community opinion appears to be quite positive, with
many patients self-referred, but support groups and child
and adult neurologists recommend the diet to their pa-
tients. Many families, especially those that are Orthodox
Jewish, have a strong aversion to medications and are will-
ing to try an alternative. The group from Holon recently
had an article published in the Israeli Medical Associa-
tion journal (23). Research interests include an evaluation
of the social aspects of the diet in children with normal
intelligence.
Some unique issues are found in Israel, most commonly
because of the inability to mix meat and milk for reli-
gious/kosher purposes. Dishes made with fish (tuna) and
eggs can include heavy whipping cream, but those with
beef are given alone. Bread used for religious purposes
(e.g., matzoh and challah) are discouraged for a 4:1 ratio
diet. Fruits, vegetables, and olive oil, popular in Israel,
however, are encouraged. In some families, the father is
a Cohen (priest class) and is not allowed into a hospital
with dead bodies, requiring the diet to be started as an
outpatient without a fast.
The ketogenic diet program at King Faisal Specialist
Hospital & Research Center in Jeddah, Saudi Arabia, is
in its early stages, with five patients enrolled so far in its
first year. Many issues unique to Saudi Arabia make the
diet somewhat difficult to administer. Most of the country
has never heard of the diet, and many children are referred
from a long distance, which makes compliance after dis-
charge difficult. Foods are rarely quantified in terms of fat,
protein, and carbohydrate components, and AEDs and vi-
tamins are almost never carbohydrate free. Only a single
nurse in the hospital is apparently familiar with the keto-
genic diet (having originally trained in Toronto, Canada),
Epilepsia, Vol. 46, No. 2, 2005
15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
and he frequently has to educate other nurses. Last, parents
are not typically the daily caregivers of children, as maids
provide daily care and thus must be educated separately.
Africa
Only South Africa, with centers in Pretoria and Cape
Town, appears to provide the diet in Africa. Several coun-
tries in Northern Africa and Kenya replied that the keto-
genic diet is not being provided in their regions. Both
centers in South Africa have been providing the diet
for the past several years, with ∼10–15 patients each
(one to three annually). The center in Cape Town admits
children in small groups for the extra benefit of family
support (similar to what is done in the United States).
Despite many families from vastly different socioeco-
nomic classes, they have seen friendships, and gather-
ings occur outside the admission period. Costs for pre-
made ketogenic foods in South Africa can be high, and the
Red Cross Children’s Hospital charity group, as well as
Orley Foods, which provides a heavy cream product called
“Orley whip” (http://www.orley.co.za/html/CSI.htm), has
covered some of the financial costs. Because of the large
referral base and size of the country, the centers have at-
tempted to establish a support network for interested neu-
rologists and dietitians with the help of the Epilepsy South
Africa organization. Patients have not been referred from
other countries in Africa, even though no other nations
provide the diet. Many unique foods are used including
pumpkin porridge, brinjal pizza (vegetable), biltong (dried
meat), boerewors (beef sausage), naartjie (fruit), and kiri
cheese.
Asia
Perhaps one of the most surprising findings of this study
was the activity and total number of centers in Asia pro-
viding the diet. The Children’s Medical Institute of the
National University Hospital in Singapore contacted us
for this survey but has not yet started offering the keto-
genic diet to patients. Nearly all centers in Asia began
offering the diet during the period from 1995 to 1998,
with Japan the sole exception (1959). Programs have en-
rolled from 11 (Hong Kong) to as many as 93 (India)
and >100 (Japan), with centers in the Philippines, Tai-
wan, and Thailand, each with >50 patients annually as
well. A textbook has been written in Japanese (24). The
two groups in South Korea have one of the largest patient
enrollments in the world combined despite only 9 years;
with 400 patients (40–60 annually) and several research
projects under way, including a recent publication regard-
ing diet complications (25–27).
The diet can be difficult to maintain in many countries in
Asia owing to the cultural tendency toward carbohydrate-
rich foods such as rice and noodles as the primary source of
energy, especially for children. Traditional meals include
fish, vegetables, and rice, which can make substitutions
difficult. In the 1980s, many centers in Asia switched over

WORLDWIDE KETOGENIC DIET
from the classic ketogenic diet to the MCT oil–based diet
for this reason. However, nearly all centers believed the
recent trend toward a “Western style” of foods for chil-
dren has made it somewhat easier to adapt the ketogenic
diet over the past few years. The St. Luke’s Medical Cen-
ter in Manila, the Philippines, uses many native processed
foods such as longaniza (fried ground pork with spices),
chicharon (pork fat), butong pakwan (watermelon seeds),
beef tapas, coconut milk, and cashews. Infants and chil-
dren receiving only formula have had no cultural difficul-
ties in starting the diet. Parents of patients in Taiwan have
created a cookbook of recipes with local foods, including
sushi.
In Hong Kong, specifically, many families with chil-
dren with intractable seizures have been counseled by the
neurologists to try the diet, but the families are opposed
to the concept of restricting food for children with se-
vere disabilities, as this is thought to be one of the few
ways that they can provide care to these children (28).
Moreover, meals are often created by grandparents or do-
mestic helpers, which requires extra education time by
physicians. Another unique problem to China is the many
different provinces with different dialects, cultures, and
food. The dietitians providing the diet have had difficul-
ties in devising recipes for each individual province. Fam-
ilies universally dine together and share the same foods
in a communal manner, which makes providing a differ-
ent meal (and calculating portions) for an individual child
extremely problematic.
The Shushrusha Hospital in Mumbai (Bombay), In-
dia has created a website that has increased awareness
(http://www.ketodietindia.org). The typical Indian diet
varies from state to state, with 20–30 different culinary
specialties requiring individual meal plans. A significant
source of fat in the Indian diet is ghee, which the center has
found increases cholesterol and triglycerides on occasion.
Many patients are vegetarians or vegans and also will not
eat any food that grows under the soil (e.g., onions, gar-
lic, potatoes). Religious beliefs preclude many families
from eating certain foods (e.g., beef), either universally
or during certain religious periods. Many of the center’s
families do not read English, which is difficult for provid-
ing recipes and education. Nutritional labeling also is not
mandatory in India, so that commercial products are diffi-
cult to use, similar to what was reported in Saudi Arabia.
Last, a strong cultural aversion exists to fasting children,
which has led the center to eliminate this aspect of the diet
in favor of a 48-h low-carbohydrate period without calorie
restriction. Nathan is interested in using lower ketogenic
diet ratios (e.g., 2:1 or even 1.5:1), as he has found that
large ketosis can still occur, and the diet is more palatable.
In Bangkok, Thailand, the diet was managed by Kanki-
rawatana (9), who published his work in a Thai journal in
2001. However, shortly afterward, he left Thailand and is
currently at the University of Alabama at Birmingham. At
15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
287
this time, Jirapinyo, a pediatric gastroenterologist, is still
involved with the diet in Bangkok, and has created three
specific diet recipes. As Thai food is apparently not rich
in fats, and coconut milk is one of the few sources avail-
able, these three recipes were designed to be inexpensive,
palatable, and simple enough for children to eat for sev-
eral days to initiate the diet. After that point, vegetables
and other foods are gradually introduced. The center’s re-
search interest is in the evaluation of the ratio of serum
branched-chain to aromatic amino acids (elevated on the
diet) and its implication for seizure control (10).
Australia and New Zealand
Four centers in Australia (Perth, Sydney, Victoria, and
Westmead) and one in New Zealand (Wellington) replied
to the original e-mail. In Australia, the diet has been pro-
vided since the mid 1970s, with a total of ∼80 children
enrolled to date. The ketogenic diet has been provided
at Wellington Hospital in New Zealand since the 1980s,
although with relatively small numbers (one to two pa-
tients annually). An increasing awareness of the ketogenic
diet in the community has led to increased referrals, al-
though nutritionist support is limited. The use of serum β-
hydroxybutyrate levels has been investigated, with only
limited correlation found. No unique issues specific to
Australia or New Zealand were mentioned by any center,
and a typical meal was similar to those provided in the
United States, Canada, and England. No research projects
are ongoing, although periodic interest in using the diet
for adults has occurred.
DISCUSSION
Internationally, the ketogenic diet appears to be gaining
momentum both academically and with the general public.
With the exception of Africa and Central America, centers
providing the ketogenic diet can be found everywhere, of-
ten with several in each nation. The majority of responding
centers began to enroll children in the mid 1990s, shortly
after the time that the ketogenic diet became more widely
used in the United States. The generally few annual admis-
sions, typically five to 10 for each center, likely reflect the
difficulty in maintaining a ketogenic diet program with
limited physician reimbursement and dietitian availabil-
ity for meal calculations, education, and follow-up patient
contact. Nearly all centers, however, expressed their desire
to increase their patient numbers both locally and through
multicenter support networks. In a manner similar to that
before the mid 1990s in the United States, the diet has not
become as widely accepted in the medical community,
which has limited its use.
Several unique issues were described that were not sur-
prising to us. In many parts of Asia, rice is the main sta-
ple food, and its discontinuation is quite difficult. Several
recipes even included rice or rice noodles despite the high
carbohydrate content. When rice is used, it is difficult to
Epilepsia, Vol. 46, No. 2, 2005

288 E. H. KOSSOFF AND J. R. MCGROGAN
maintain a 4:1 ratio ketogenic diet without providing MCT
oil. The use of lower ratios (e.g., 2:1) may be necessary in
these countries. Western foods appear to be gaining popu-
larity in many countries, especially in Asia, which allows
foods such as hamburgers, cream, and mayonnaise to be
locally available for use in meals. Using the Atkins Diet
for epilepsy, with its lower ratios, has become an interest
of several Asian centers (29). Second, it is not surpris-
ing that running a center in countries with large referral
populations (e.g., Brazil, India, Russia, Saudi Arabia, and
South Africa) can be somewhat overwhelming for a sin-
gle neurologist and dietitian; resources clearly must be
allocated. In addition, many countries reported difficul-
ties attempting to quantify foods when store-bought food
labels lacked nutritional information. Although the keto-
genic diet is less expensive than newer AEDs, in devel-
oped countries, the cost of preprepared foods is not incon-
sequential and must be considered. Last, several nations
with socialized medicine, including England and much of
South America, not unexpectedly report occasional finan-
cial difficulties with the diet.
In contrast, some of the information gained during this
study was somewhat surprising. First, despite different
cultures and religions, much similarity was found among
diets worldwide, with frequent use of MCT oil, cream,
butter, and small amounts of meat, fish, and vegetables.
A universal, international ketogenic diet recipe “cook-
book” might be attainable. Second, although the fasting
period was shortened or eliminated in Canada, England,
India, Sweden, and the Netherlands, we were surprised
at how infrequently this occurred elsewhere, and most
countries continue to include fasting for children during
diet-initiation periods. Third, a strong sense of pride was
noted among centers in the rates of seizure reduction they
have seen. Although no e-mail questions addressed center-
specific efficacy (which would be impossible to validate),
physicians often provided percentages of seizure reduc-
tion and described successful patients. Few major diffi-
culties were mentioned in the centers providing the diet.
Last, an international ketogenic diet community seems to
be in the early stages of development. Many of the centers
were familiar not only with other nearby ketogenic diet
clinics, but also with their research. Several multicenter
projects and support networks are either ongoing or in de-
velopment, most notably in Canada, England, Germany,
and South Africa.
A secondary objective of this study was to create a
list of names and phone numbers of academic centers
(see Table 1). This was perhaps the most surprising re-
sult, as all this information was gathered without using
a telephone or mailing a letter. Knowing that not only
physicians, but also parents and patients, have access to
the World Wide Web, it may be advisable for ketogenic
diet centers to begin to create websites to disseminate
information and advertise their programs. Several cen-
Epilepsia, Vol. 46, No. 2, 2005
15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ters have already begun to do this. To continue to main-
tain up-to-date information for patients and physicians,
a website with multinational center information will be
maintained at http://www.neuro.jhmi.edu/Epilepsy/Peds/
ketoworldwide.htm. We acknowledge that this list is likely
not complete and encourage centers currently listed or not
mentioned at the time of this publication to contact the
author at ekossoff@jhmi.edu and be included.
REFERENCES
1. Reynolds EH. The ILAE/IBE/WHO Global Campaign against
Epilepsy: bringing epilepsy “out of the shadows.” Epilepsy Behav
2000;1:S3–8.
2. Vining EPG, Freeman JM, Ballaban-Gil K, et al. A multi-
center study of the efficacy of the ketogenic diet. Arch Neurol
1998;55:1433–7.
3. Freeman JM, Vining EPG, Pillas DJ, et al. The efficacy of the ke-
togenic diet–1998: a prospective evaluation of intervention in 150
children. Pediatrics 1998;102:1358–63.
4. Swink TD, Vining EPG, Freeman JM. The ketogenic diet 1997: Ad-
vances in Pediatrics. St. Louis, Mo: Mosby-Year Book, 1997:297–
329.
5. Wirrell EC, Darwish HZ, Williams-Dyjur C, et al. Is a fast necessary
when initiating the ketogenic diet? J Child Neurol 2002;17:179–82.
6. Panico LR, Rios VG, Demartini MG, et al. The electroencephalo-
graphic evolution of a group of patients on a ketogenic diet. Rev
Neurol 2000;30:8–15.
7. Schwartz RM, Boyes S, Aynsley-Green A. Metabolic effects of three
ketogenic diets in the treatment of severe epilepsy. Dev Med Child
Neurol 1989;31:152–60.
8. Ghofrani M. Efficacy of ketogenic diet on intractable epilepsy in
children: a report of 215 cases [Abstract]. Brain Dev 2002;24:394.
9. Kankirawatana P, Jirapinyo P, Kankirawatana S, et al. Ketogenic
diet: an alternative treatment for refractory epilepsy in children. J
Med Assoc Thai 2001;84:1027–32.
10. Jirapinyo P, Kankirawatana P, Densupsoontorn N, et al. High plasma
branched-chain amino acids: aromatic amino acids ratio in children
on the ketogenic diet: a mechanism in controlling epilepsy. J Med
Assoc Thai 2004;87:432–7.
11. Hemingway C, Pyzik PL, Freeman JM. Changing physician at-
titudes toward the ketogenic diet: a parent-centered approach to
physician education about a medication alternative. Epilepsy Behav
2001;2:574–8.
12. Stafstrom CE, Rho JM, eds. Epilepsy and the ketogenic diet. Totawa,
New Jersey: Humana Press, 2004.
13. Musa-Veloso K, Rarama E, Comeau F, et al. Epilepsy and the keto-
genic diet: assessment of ketosis in children using breath acetone.
Pediatr Res 2002;52:443–8.
14. Likhodii SS, Serbanescu I, Cortez MA, et al. Anticonvulsant prop-
erties of acetone: a brain ketone elevated by the ketogenic diet. Ann
Neurol 2003;54:219–26.
15. Noldy-MacLean NE, Hansen J, Curtis R. Neurodevelopmental ad-
vances in children on the ketogenic diet: a pilot study [Abstract].
Epilepsia 2001;42(suppl 7):161.
16. Hassan AM, Keene DL, Whiting SE, et al. Ketogenic diet in
the treatment of refractory epilepsy in childhood. Pediatr Neurol
1999;21:548–52.
17. Magrath G, MacDonald A, Whitehouse W. Dietary practices and
use of the ketogenic diet in the UK. Seizure 2000;9:128–30.
18. Coppola G, Veggiotti P, Cusmai R, et al. The ketogenic diet in
children, adolescents and young adults with refractory epilepsy:
an Italian multicentric experience. Epilepsy Res 2002;48:221–
7.
19. Galvan Manso M, Arellano M, Sans A, et al. A ketogenic diet: is this
a valid alternative in refractory epilepsy. Rev Neurol 2001;33:1010–
4.
20. Francois LL, Manel V, Rousselle C, et al. Ketogenic regimen as
anti-epileptic treatment: its use in 29 epileptic children. Arch Pediatr
2003;10:300–6.

WORLDWIDE KETOGENIC DIET
21. Klepper J, Diefenbach S, Kohlschutter A, et al. Effects of the
ketogenic diet in the glucose transporter 1 deficiency syndrome.
Prostaglandins Leukot Essent Fatty Acids 2004;70:321–7.
22. Klepper J, Leiendecker B, Bredahl R, et al. Introduction of a ke-
togenic diet in young infants. J Inherit Metab Dis 2002;25: 449–
60.
23. Ginzberg M, Watemberg N, Levi A, et al. Ketogenic diet as
antiepileptic therapy: a description of the clinical experience
and the multidisciplinary approach at the metabolic-neurogenetic
clinic at the Wolfson Medical Center. Harefuah 2004;143: 177–
81.
24. Maruyama H. Guidebook of ketogenic diet therapy for childhood
epilepsies. Tokyo: Daiichi Shuppan, 1973.
15281167, 2005, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.0013-9580.2005.42704.x by Mozambique Hinari NPL, Wiley Online Library on [04/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
289
25. Koh KN, Park SY, Lim BC, et al. Ketogenic diet in childhood in-
tractable epilepsy. J Korean CNS 2004;12:12–20.
26. Kim HD, Park JC. Benefits of nonfasting ketogenic diet in intractable
childhood epilepsy as compared with initial fasting ketogenic diet
[Abstract]. Epilepsia 2001;42(suppl 7):265.
27. Kang HC, Chung DE, Kim DW, et al. Early- and late-onset com-
plications of the ketogenic diet for intractable epilepsy. Epilepsia
2004;45:1116–23.
28. Wong V. Ketogenic diet in children with intractable epilepsy [Ab-
stract]. Brain Dev 1998;20:492.
29. Kossoff EH, Krauss GL, McGrogan JR, et al. Efficacy of the Atkins
Diet as therapy for intractable epilepsy. Neurology 2003;61:1789–
91.
Epilepsia, Vol. 46, No. 2, 2005