HEALTHY LIFESTYLE AND THERAPEUTIC APPROACHES

COURTNEY SCHNABEL, MS, RD, CDN

Nutrition and Epilepsy

Overview

Healthy Lifestyle

Nutrition Specifics for Epilepsy

Therapeutic Approaches

GENERAL TIPS FOR WELLBEING

Healthy Lifestyle

Overview

Nutritionally balanced diet with adequate fluid intake Balancing macronutrients (fat, carbohydrate, protein) Eating a wide variety of foods to maximize

micronutrient intake

Maintain a healthy weight by consuming the appropriate amount of calories, fat, protein and carbohydrate

Physical Activity as tolerated

Balanced Diet: My Plate

Maintaining a Healthy Diet

Balance calorie intake with energy output

Cut back on portion sizes

Make half your plate vegetables

Choose low fat dairy

Cut back on foods with solid fats, added sugar and added salt

Make half your grains whole

Drink water and avoid sugar sweetened beverages

Control your food: eat at home more often

Choose lean protein

Try new foods

NUTRIENTS OF CONCERN IN PEOPLE WITH EPILEPSY

Maintaining Adequate Nutrition

Epilepsy and Diet

Many nutrients and have been implicated in the treatment of epilepsy, however, only the Ketogenic and Modified Ketogenic Diets have been medically proven to effectively treat epilepsy.

Antiepileptic drugs may cause disturbances in the metabolism of some nutrients, therefore, following a balanced diet is critical.

Deficiency

There is evidence that deficiencies in certain vitamins and minerals can alter brain activity and cause seizures

In developed countries, vitamin and mineral deficiencies are rare except in extreme cases of malnutrition

Weak or no scientific evidence to support that supplementation of these vitamins and minerals (without evidence of deficiency) is beneficial for seizure control.

FunctionsFunctions Food Sources & ImplicationsFood Sources & Implications

One of the most essential minerals. Found mainly in bone, teeth and soft tissue.

Involved in: cell signaling, bone formation, enzyme activity,

Adults: 1200 mg/day

Children: 700-1300 mg/day

Deficiency: kidney disease, extremely high sodium intakes, hormonal disorders, malnutrition

Dairy: milk, yogurt cheese, Green Veggies (kale, broccoli, spinach, bok choy), Beans, Tofu, Fortified products (OJ, cereal).

AEDS : Carbamazepine, phenobarbital, phenytoin, primidone and valproate can increase vitamin D metabolism, depleting calcium

Calcium

FunctionsFunctions Food Sources & ImplicationsFood Sources & Implications

Energy production, structural role, cell signaling

Adults: 320-420 mg/day

Children: 80-410 mg/day (based on age range)

Deficiency: prolonged gastrointestinal problems, alcoholism, malnutrition

Grains (bran cereal, shredded wheat, brown rice, oat), Nuts (almonds, hazelnuts, peanuts), Green vegetables (spinach, lima beans, swiss chard, okra), Molasses, bananas, milk.

AEDs: some reports of phenytoin and phenobarbital reducing magnesium levels.

Magnesium

Functions Functions Food SourcesFood Sources

Must be obtained from the diet, cannot be made by the body

Nervous system function (synthesis of neurotransmitters), red blood cell formation, hormone function

Deficiency: uncommon and rare cause of seizures in infants. Alcoholics are at highest risk

Adults: 1.3 -1.5 mg/day

Children: .5-1 mg/day

Fortified cereal.Protein (turkey,

chicken, fish)Potatoes, spinach,

vegetable juice, hazelnuts

B6 (pyridoxine)

FunctionsFunctions Food SourcesFood Sources

Essential fatty acid

Anti-inflammatory, involved in brain function, cell signaling.

Ratio of Omega 3:Omega 6 is important for anti-inflammatory benefit. American diet contains 14-25 times more Omega 6 than Omega 3.

Cold water fish: salmon, mackerel, halibut, sardines, tuna, herring

Flax products

Soybeans and soybean oil

Canola oil

Walnut and walnut oil

Pumpkin seeds

Omega-3 Fatty Acids

FunctionsFunctions Sources & ImplicationsSources & Implications

Non-essential (made by the body)

Helps the body turn fat into energy

Needs to be taken under medical supervision

Red meat, dairy, fish, avocado, wheat, asparagus, tempeh, peanut butter

AEDs: valproate can deplete levels of carnitine. Supplementation should be determined by the medical team and based on blood levels.

Carnitine

Other Vitamins/Minerals

Vitamin B1 (Thiamine) deficiency can cause seizures (rare and found mostly in alcoholism) Many foods are fortified with Thiamine and there are

many good sources in the diet (Grains, Bread, Nuts) AED: long term phenytoin use can deplete thiamine

Anecdotal reports of Vitamin E supplementation reducing seizures, but these were not reproducible in clinical studies unless deficiency was present.

Conclusions

Eat a balanced diet and get tested if you believe you are deficient in a specific nutrient

Do not start vitamin and mineral supplements unless you speak with your physician

A regular multivitamin is usually sufficient as a “back up” if you believe your diet is lacking in nutrients

THE KETOGENIC AND MODIFIED KETOGENIC DIETS

Therapeutic Approaches

The Ketogenic Diet

Developed in the 1920s, but fell out of use after the introduction of AEDs. Popularity has been increasing in the past 10 years.

Needs to be monitored closely by the medical team (RNs, NPs, MDs, RD)

Calorie controlled, high fat, low carbohydrate, moderate protein diet consumed in exact portion sizes

Stats

Stats: 50% of the children who begin the diet will have a 50% improvement in their seizures. About 30% of those children will have a >90%

improvement About 10-15% of those children will become seizure

free.

Candidates

Greatest success has been in children under the age of 18, but more recently research documented the benefits of a modified ketogenic diet in adults.

All patients are candidates for the ketogenic diet unless they have a pre-existing metabolic condition that prevents them from participating in this therapy.

Individuals with Doose Syndrome, Tuberous Sclerosis, Lenox-Gastaut and GLUT-1 transporter deficiency respond particularly well to the diet. Being used in Infantile Spasms as well.

How it works

Body switches from burning glucose (carbohydrates) to burning fat for energy

By-product of fat breakdown is ketone bodies (acetone, beta-hydroxybutyrate and acetoacetate) Ketones can be measured in the urine and blood to tell us “how well” our bodies are using fat as energy

Many proposed mechanisms to how the diet works – most common is the suppression of neurotransmitter activity from the presence of ketone bodies and the absence of glucose (sugar) breakdown.

How It Works

Carbohydrates and protein are restricted to encourage the breakdown of fat as a primary fuel source

Fat in the diet is increased to provide an energy substrate so that the body does not breakdown too many of its own fat stores (unless weight loss is indicated)

Calories are controlled to encourage weight maintenance and avoid “fat storing” and encourage “fat burning”

Diet Specifics

Diet Specifics

All meals are weighed on a gram scale and are carefully calculated by the dietitian.

No unscheduled or uncalculated meals

All meals are consumed in a ratio (4:1, 3:1, 2:1 etc.).

Not nutritionally balanced – requires vitamin and mineral supplements

Ratio??

The ratio is: (The amount of fat) : (the amount of protein +

carbohydrate) in the meal. In a 4:1 meal there are 4 grams of fat for every .5

grams of protein and .5 grams of carbohydrate For example: If a meal has 64 grams of fat, 12

grams of protein and 4 grams of carbohydrate 64 grams fat : 16 grams of protein and carbohydrate (12

g protein + 4g carbohydrate) This is a 4:1 ratio

Sample Meal: Spinach Quiche with Swiss Cheese

Ingredients:

50 grams of heavy cream 8 grams raw onion34 grams of raw spinach10 grams of egg, mixed well15 grams of swiss cheese24 grams of butter

Recipe provides: 400 calories in a 4:1 ratio (40 grams of fat, 7 grams of protein and 3 grams of carbohydrate)

Directions

1. Cut raw onion/scallion into fine pieces, then sauté in butter.2. Cut spinach into small pieces then add to the above mixture.3. Add egg and cream together and blend well.4. Mix spinach mixture into egg/cream mixture.5. Add in shredded Swiss Cheese.6. Pour mixture into a custard dish that has been sprayed with oil spray.7. Sprinkle with a pinch of Nutmeg. Bake at 300° for 25 minutes or until golden brown.

Side Effects

Elevated lipids and cholesterolKidney stonesConstipation AcidosisSlowed growthFood Aversions

**Side effects on the diet can usually be managed by your dietitian without having to come off the diet

Modified Ketogenic Diets: Modified Atkins

Developed as a less restrictive version of the ketogenic diet.

Still high fat, low carbohydrate, but high-moderate protein and not calorie restricted.

Closer to a 1:1 or 2:1 ketogenic diet

No head to head comparisons of keto vs. modified atkins, but promising results (~50% success rate)

More manageable for adults and older children

Modified Atkins

Diet Specifics

Participants are encouraged to eat in a 1:1 or 2:1 ratio and are required to “count carbohydrates”

First Month: Induction (most important). 10 grams of carbohydrate per day for children and 20 grams per day for adults

Encourage high fat, adequate fluid intake

Counting Carbohydrates

To count carbohydrates, a carbohydrate counting book or a reputable web application is used.

To get more “bang for your buck” we encourage low glycemic foods, high fiber foods

Using high fiber foods such as vegetables and nuts allows for larger portion sizes. This method is called counting “net carbohydrates” and

is done by subtracting the dietary fiber content from the total carbohydrates.

Food Label

Cooked Cauliflower

(1 cup portion)

Sample Meal: Eggplant “Parmesan”

INGREDIENTS:

½ raw eggplant (1/2 pound)2 tablespoons olive oil1 teaspoon almond flour (Bob’s Red Mill©)¼ cup shredded whole milk mozzarella 4 ounces Walden Farms Tomato Basil Sauce©

 

Recipe provides: (520 calories, 37g fat, 7g carbohydrate , 9g protein) in a 2:1 ratio

DIRECTIONS:

Cut eggplant into circles

Dip egg plant in olive oil and thenin almond flour to coat. Place onbaking sheet with non-stick cookingspray.

Bake in the oven at 350 degreesuntil crisp.

Remove from oven. Mix remainingoil into tomato sauce and topeggplant circles with tomato sauceand then mozzarella cheese.

Return to the oven and bake untilcheese is melted (about 10minutes).

Additional Modified Diets

Low Glycemic Index Treatment 60% fat, higher carbohydrate (40-60 grams per day). Ratio of

1:1. Only carbohydrates with a glycemic index of <50 are allowed

(glycemic index refers to a food’s effect on blood sugar) Preliminary studies have shown that more than half of patients

who begin LGIT have a >50% reduction in seizures, however some parents report difficulty following/calculating the GI of foods.

The MCT Ketogenic Diet 70-75% fat (mostly in the form of MCT and LCT), more protein

and carbohydrate then classic ketogenic diet Similar results to classical ketogenic diet, but some studies

reported it was less tolerable than classic KD due to the large amount of MCT oil

Conclusion: Therapeutic Approaches

The Ketogenic and Modified Ketogenic diets are proven medical therapies

They do not work for everyone, but the results are promising

These diets should NEVER be attempted without the supervision of your Neurologist/Treatment Team and a Registered Dietitian familiar with Ketogenic Diets.

Learn More About the Diet

Helpful websites: The Charlie Foundation(www.charliefoundation.org) The Carson Harris Foundation: Parent support group

(www.carsonharrisfoundation.org) Epilepsy Cure Initiative: Canada based support group

(www.epilepsycureinitiative.ca) Epilepsy Foundation (www.epilepsyfoundation.org) www.atkinsforseizures.com: recipes, general information http://www.epilepsy.com/epilepsy/treatment_atkins_diet information Matthew’s Friends: Ketogenic and MAD support group for the UK

(www.matthewsfriends.org) Epilepsy Foundation (www.epilepsyfoundation.org) – Go to “FORUM” for

parent comments/support

Books/Resources Keto Kid: Helping Your Child Succeed on the Ketogenic Diet: B. Synder,

DemosHealth (parent friendly) Epilepsy: Patient and Family Guide: 3rd Edition. Devinsky. Demos Health Ketogenic Diets 5th Edition. Kossoff, Freeman, Turner, Rubenstein. Demos

Health.

Conclusions

Adequate and balanced nutrition is important for well-being.

Following a balanced diet and maximizing nutrient intake may have its benefits for epilepsy

There are PROVEN dietary approaches to help treat seizures

Speak with your physician and dietitian before starting any of the diet therapies

References

Linus Pauling Institute. Micronutrient Information Center. Accessed 4/19/12 at:http://lpi.oregonstate.edu/infocenter/

Kossof f E, Freeman J, Turner Z, Rubenstein J (2011) Ketogenic Diets: Treatments for Epilepsy and Other Disorders (5th ed). New York, NY: Demos Health

Devinsky O (2007). Epilepsy Patient and Family Guide (3rd ed). New York, NY: Demos Health.