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Ketogenic Diet

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1. The Ketogenic Diet 2. introduction <ul><li>high-fat, </li></ul><ul><li>adequate protein,…
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  • 1. The Ketogenic Diet
  • 2. introduction <ul><li>high-fat, </li></ul><ul><li>adequate protein, </li></ul><ul><li>lowcarbohydrate diet </li></ul><ul><li>used for the treatment of intractable childhood epilepsy since the 1920s. </li></ul>
  • 3. history <ul><li>Jesus </li></ul><ul><li>Huge conklin -1921, water diet </li></ul><ul><li>Geyelin -1921,AMA convention </li></ul><ul><li>Phenytoin-1938 </li></ul><ul><li>Charlie foundation-1992 </li></ul>
  • 4. Conklin paper
  • 5. Mechanisms of action
  • 6. Mechanisms of action <ul><li>Ketone bodies- GABA </li></ul><ul><li>Increased expression ofGlial fibrillary acidic protein( GFAP ) in dentate gyrus of hippocampus </li></ul><ul><li>Depressive effect on synoptic reorganisation </li></ul>
  • 7. Mechanisms of action <ul><li>Calorie restriction alone has been demonstrated in mice to impair seizure susceptibility. this may activate ATP sensitive potassium channels that may critically be involved in the regulation of seizure activity. </li></ul>
  • 8. Indications <ul><li>several epilepsy syndromes, </li></ul><ul><li>particularly in myoclonic astatic epilepsy, Dravets syndrome, and tuberous sclerosis </li></ul><ul><li>focal and generalised epilepsy </li></ul>
  • 9. s
  • 10. Calculation of the ketogenic diet <ul><li>The ratio of fats to carbohydrates and protein is based on the age, size, weight and activity level of the patient. </li></ul><ul><li>A young child or infant often receives a 3 :1 diet to provide additional protein. </li></ul><ul><li>Older children will receive a 4:1 diet with the exception of obese children (3:1 ). </li></ul><ul><li>Adolescents will often be started on a 3 :1 diet </li></ul>
  • 11. Calculation of the ketogenic diet <ul><li>Calories targeted at 75% of the recommended daily intake for age </li></ul><ul><li>overweight children may be given only 25-30% of the recommended calories until they approach their ideal body weight. </li></ul><ul><li>Fluids are targeted at 80% of daily needs </li></ul>
  • 12. Initiation of the ketogenic diet
  • 13. Maintaining ketosis
  • 14. Types of KD <ul><li>Classic ,FAT:CHO+PRO-4:1 </li></ul><ul><li>MCT oil ,3:1 </li></ul><ul><li>Modified Atkins , 60% fat, 30% protein and 10% carbohydrate </li></ul>
  • 15. Ketogenic meals
  • 16. KD classic diet,1500 kcal <ul><li>Breakfast : egg with bacon </li></ul><ul><li>28 g egg, 11 g bacon, 37 g of 36% heavy whipping cream, 23 g butter, 9 g apple. </li></ul><ul><li>Snack : peanut butter ball </li></ul><ul><li>,6 g peanut butter, 9 g butter. </li></ul><ul><li>Lunch : tuna salad , </li></ul><ul><li>28 g tuna fish, 30 g mayonnaise, 10 g celery, 36 g of 36% heavy whipping cream and 15 g lettuce. </li></ul><ul><li>Snack : keto yogurt </li></ul><ul><li>18 g of 36% heavy whipping cream, 17 g sour cream, 4 g strawberries and artificial sweetener . </li></ul><ul><li>Dinner : cheeseburger </li></ul><ul><li>22 g minced (ground) beef, 10 g American cheese , 26 g butter, 38 g cream, 10 g lettuce and 11 g green beans. </li></ul><ul><li>Snack : keto custard </li></ul><ul><li>25 g of 36% heavy whipping cream, 9 g egg and pure vanilla flavouring </li></ul>
  • 17. KD LIQUID
  • 18. KD POWDER
  • 20. Efficacy of the ketogenic diet at 3, 6 and 12 months, showing the percentage of children in each outcome category. From a prospective study of 150 children treated at Johns Hopkins Hospital
  • 21.   Seizure control at 6 months at 12 months Number initiating the diet: 150 over 90% 48 (31%) 41 (27%) 50-90% 29 (19%) 30 (20%) under 50% 29 (19%) 8 (5%) Number continuing the diet   106   (71%) 83 (55%)
  • 22. Cochrane review <ul><li>In 2003, a Cochrane review of the published literature found there were no randomised controlled trials on the ketogenic diet. </li></ul><ul><li>The review concluded that there was &quot;no reliable evidence from randomised controlled trials to support the use of ketogenic diets for people with epilepsy&quot; and stated that the diet was merely &quot; a possible option&quot; in the treatment of intractable epilepsy </li></ul>
  • 23. Neurologists survey <ul><li>A survey in 2005 of 88 paediatric neurologists in the US found that </li></ul><ul><li>36% regularly prescribed the diet after three or more drugs had failed; </li></ul><ul><li>24% occasionally prescribed the diet as a last resort ; </li></ul><ul><li>24% had only prescribed the diet in a few rare cases ; </li></ul><ul><li>16% had never prescribed the diet. </li></ul><ul><li>There are several possible explanations for this gap between the evidence and clinical practice </li></ul>
  • 24. efficacy <ul><li>The first randomised controlled trial was published in 2008 , which had an intent-to-treat prospective design, but no blinding. </li></ul><ul><li>It studied 145 children , half of whom started the ketogenic diet immediately, and half after a three-month delay. </li></ul><ul><li>Of the children in the diet group , 38% had at least a 50% reduction in seizure frequency, </li></ul><ul><li>7% had at least a 90% reduction ; </li></ul><ul><li>one child became seizure-free . </li></ul><ul><li>Only 6% of the control group saw a greater than 50% reduction in seizure frequency and no children had a 90% reduction . </li></ul><ul><li>The mean seizure frequency of the diet group fell by a third; </li></ul><ul><li>the control group's mean seizure frequency actually got worse </li></ul><ul><li>Neal EG, Chaffe HM, Schwartz RH et al. The ketogenic diet for the treatment of childhood epilepsy: a randomised controlled trial. Lancet Neurol 2008; </li></ul>
  • 25. RCT contd <ul><li>the ketogenic diet group were further randomised to receive either the MCT diet or the classical diet ; results showed there was no significant difference in the responder rates or mean reduction in seizure frequency between the two groups. </li></ul><ul><li>Neal EG, Chaffe HM, Schwartz RH et al. A randomised controlled trial of classical and medium chain triglyceride ketogenic diets in the treatment of childhood epilepsy. Epilepsia 2008; </li></ul>
  • 26. Side-effects
  • 27. nephrolithiasis <ul><li>hypercalciuria occurs due to increased bone demineralisation with acidosis (bone phosphate acts as an acid buffer) </li></ul><ul><li>hypocitraturia, which normally helps to dissolve free calcium. </li></ul><ul><li>The urine has a low pH, which stops uric acid from dissolving, leading to crystals that act as a nidus for calcium stone formation. </li></ul><ul><li>Many institutions restrict fluids on the diet to 80% of normal daily needs </li></ul>
  • 28. Growth <ul><li>growth velocity deviates more from the expected trajectory the longer an individual is on the diet, particularly in the young </li></ul><ul><li>Neal EG, Chaffe HM, Edwards N, Lawson M, Schwartz R, Cross JH. Growth of children on classical and medium chain triglyceride ketogenic diets. Pediatrics 2008 ; </li></ul>
  • 29. NON EPILEPTIC INDICATIONS <ul><li>Case reports on two children indicate a possible use in treating astrocytomas , </li></ul><ul><li>Autism, depression, migraine headaches, polycystic ovary syndrome , and type 2 diabetes mellitus have been shown to benefit in small case studies. </li></ul><ul><li>uncontrolled clinical trials and studies in animal models has shown that the ketogenic diet can provide symptomatic and disease-modifying activity in a broad range of neurodegenerative disorders including amyotrophic lateral sclerosis , Alzheimer’s disease and Parkinson’s disease , and may be protective in traumatic brain injury and stroke </li></ul><ul><li>As of 2008 [update] , there is not sufficient evidence to support the use of the ketogenic diet as a treatment for these conditions </li></ul>
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