An Inside Look at How the Keto Diet Can Treat Epilepsy | Elemental – Elemental


A physician traces one boy’s story and unpacks the research

Bo Stapler, MD

  1. Lessons from the past

  2. The modern ketogenic diet

  3. Like ships passing in the night

  4. Teamwork

  5. Show me the data

  6. How does it work?

  7. Clear successes

  8. An imperfect start

  9. Shifting gears

  10. Cruise control

  11. Looking ahead

  12. Beyond the horizon

Photo: Alexander Spatari/Getty Images

The concept of fasting to treat epilepsy is far from new. In fact, the only method of treating seizures recorded in the manuscripts of the ancient physician Hippocrates was fasting. One-hundred fifty years later, another Greek doctor, Erasistratus, followed the same protocol. Fast forward to early 20th-century Paris. It was there in 1911 that physicians Gulep and Marie documented reduced severity of seizures in 20 fasting subjects.

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Current versions of the keto diet follow the same principles established by Wilder and generally fall into one of four categories.

  1. Another version of the keto diet also recommended for children is the medium-chain triglyceride, or MCT, diet. This diet utilizes MCT oils that occur naturally in palm and coconut oil as well as human, cow, and goat milk. The MCT diet allows for a few more carbohydrates but still compares favorably to the classic keto diet in terms of efficacy. On initiation of either the MCT or the classic ketogenic diet, children and their families receiving treatment for epilepsy traditionally stay three to four days in the hospital for lab testing and dietary teaching.
  2. The modified Atkins diet is less restrictive than the classic ketogenic diet. Experts more frequently recommend it for adolescents and adults due to a greater likelihood of adherence in this demographic. However, positive results have been seen in children as well. In their most recently published recommendations, the International Ketogenic Diet Study Group addressed both the modified Atkins diet and the low glycemic index diet (below) commenting, “They tend to require less time for meal calculations and allow more parental independence.”
  3. The low glycemic index diet allows for more carbohydrates as long they have a low glycemic index, meaning they don’t raise the body’s blood sugar too quickly. Strawberries, lentils, and whole-grain breads, for example, are well-suited — as opposed to pineapple, potatoes, or white bread, which have a high glycemic index.

I first became aware of the ketogenic diet during my residency training from 2011–2015, coincidentally, also in Cincinnati, Ohio. I recall caring for children who were admitted to the hospital in order to begin the diet. At that time, the idea that the keto diet could effectively treat epilepsy was emerging from the shadows of expert opinion into the light of evidence-based medicine.

Ackerman recalls how Will’s treatment began. “Under the supervision of the hospital as an inpatient, we immediately reduced all his medications, except one, and began the process.” The team of hospital staff supervising Will included pharmacists, nurses, medical trainees, pediatricians, and neurologists — all working together to care for Will, but none of them more essential than the dietitians.

The goal of the keto diet, as it relates to treating epilepsy, is to mimic a fasting state so that the brain is fueled by ketones rather than glucose.

While success stories from experts like Finnerty are compelling, some may wonder what scientific research has to say. The answer is encouraging for keto enthusiasts who, over the past few years, have witnessed a robust advancement of scientific literature on the topic.

Despite strong evidence of its efficacy, a mechanism to clearly explain the keto diet’s benefit remains elusive. Research indicates that ketones are able to reduce the excitability of neurons and stabilize synapses in the brain, but how?

Though much is left to be uncovered about how the diet works for epilepsy in general, the picture becomes more clear by looking at specific epilepsy syndromes. For a few rare diagnoses such as glucose transporter deficiency, Dravet syndrome, and pyruvate dehydrogenase deficiency, the keto diet is becoming the treatment of choice.

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Upon initiating the keto diet, Will and his family hoped to realize a similar success story but were prepared by their dietitian and other members of their care team that the road ahead would not always be easy.

The modified Atkins diet, as well as other forms of the ketogenic diet, can often take two to three months to produce an effect, but two weeks into the new diet Will and his caretakers were already looking for something they could do to improve his chances of a favorable outcome. They opted to increase the portion of dietary fats, shifting his regimen towards the classic ketogenic diet. A day’s worth of meals looked something like this:

  • Lunch: tortilla, pepperoni, mozzarella cheese, and a side of lettuce and ranch/grape-seed oil/butter mixed together
  • Dinner: a small portion of chicken nuggets and salad topped with a mixture of ranch/oil/butter, cheese, and bacon
  • Snacks: celery with a mixture of peanut butter and butter and a side of strawberries

Maintaining dietary changes over time can be challenging with any type of diet, and keto is no exception. Finnerty teaches patients and parents that the ketogenic diet is about replacing not restricting foods. “One has to relearn how to cook, measure, and prepare foods differently,” she says. “It’s not necessarily harder to do, just different.”

In addition to becoming a proven treatment for epilepsy, evidence is building that the ketogenic diet may be helpful for a number of other medical conditions as well. The most well-developed data suggest a benefit for patients with Type 2 diabetes as well as glioblastoma multiforme, a type of aggressive brain cancer.

For Will and his family, the ketogenic diet was a breakthrough, but his story didn’t end there. There was one more perk to discover. Remarkably, the success of the ketogenic diet has been shown to extend beyond its duration. One such study demonstrated that 80% of patients who were seizure-free after two years of keto remained seizure-free even after discontinuing the diet. Would this effect pan out for Will? According to his mother, “After a little over three years, we began the slow process of stair-stepping him down on his ratio while keeping his medicine in place. Will is now completely off keto and taking two doses of his seizure medicine each day. Besides a few small hiccups, he has been seizure-free ever since.”