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Medical Nutrition Therapy for the Ketogenic Diet

Medical Nutrition Therapy for the Ketogenic Diet

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Medical Nutrition Therapy for the Ketogenic Diet

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  1. Medical Nutrition Therapy for theKetogenic Diet Breanne C. Bian Concordia College – Moorhead, MN

  2. Objectives • Be able to describe the ketogenic diet • Have a clear understanding of epilepsy • Be able to understand the correlation of ketosis and the ketogenic diet • To gain an understanding of the nutrition care process for the ketogenic diet • Calculate ketogenic diet for a child • Be able to explain the ethical issues involved with the diet

  3. History • Ketosis is a modern concept, but fasting is not • Ancient civilizations associated fasting with curing seizures • First modern recording of the ketogenic diet was in 1921 by Dr. Wilder. • Introduced the high-fat, low-protein, low-carbohydrate diet ketone production • Charlie Foundation • Advocates of the ketogenic diet • Presently, the ketogenic diet is considered an important treatment option for individuals with epilepsy

  4. What is the Ketogenic Diet? • An effective method for treatment of refractory epilepsy in children • The diet mimics aspects of starvation by forcing the body to burn fat rather than carbohydrates. • Designed to induce a continuous state of ketosis • High amounts of ketones in the body successfully reduce seizures • Diet consists of: • High fat • Low Carbohydrate • Low protein

  5. Understanding Epilepsy • When seizures continually occur for unknown reasons or because of an underlying problem that cannot be corrected • neurological condition that effects electrical functions (nerves) of the brain. • May affect a person's consciousness, bodily movements or sensations • Normal brain function cannot return until the electrical bursts subside. • Conditions in the brain that produce these episodes may have been present since birth, or they may develop later in life due to injury, infections, structural abnormalities in the brain, exposure to toxic agents, or for reasons that are still not well understood. • Epilepsy affects people of all ages, all nations, and all races.

  6. Cause of Epilepsy • Seven out of ten people with epilepsy, no cause can be found. • Among the rest, the cause may be any one of a number of factors that can make a difference in the way the brain functions: • Head injuries or lack of oxygen during birth may damage the electrical system in the brain • Other causes include brain tumors, genetic conditions, lead poisoning, problems in development of the brain before birth, and infections such as, meningitis • Epilepsy is often thought of as a condition of childhood, but it can develop at any time of life. • There are 125,000 new cases every year, and 30% of them begin in childhood • Another period of relatively high incidence is in people over the age of 65.

  7. Diagnosing Epilepsy • The doctor's main tool in diagnosing epilepsy is performing a careful medical history with as much information as possible about what the seizures looked like and what happened just before they began – parents feedback. • Second major tool is an electroencephalograph (EEG). • Machine that records brain waves picked up by tiny wires taped to the head. Brain waves during or between seizures may show special patterns which help the doctor decide whether or not someone has epilepsy. • Imaging methods: • CT (computerized tomography) • MRI (magnetic resonance imaging) • Used to search for any growths, scars, or other physical conditions in the brain that may be causing the seizures. • In a few research centers, positron emission tomography (PET) imaging is used to identify areas of the brain which are producing seizures.

  8. Electroencephalograph (EEG)

  9. Seizures vs. Epilepsy • Seizures are a symptom of epilepsy. • Epilepsy is the underlying tendency of the brain to produce sudden bursts of electrical energy that disrupts brain function. • Having a single seizure does not necessarily mean a person has epilepsy. • High fever, severe head injury, lack of oxygen -- a number of factors can affect the brain enough to cause a single seizure. • Epilepsy is an underlying condition (or permanent brain injury) that affects the how electrical energy behaves in the brain, making it susceptible to recurring seizures.

  10. Understanding Ketosis • Ketosis is a state in metabolism when the liver excessively converts fat into fatty acids and ketone bodies which can be used by the body for energy. • When the body produces ketone bodies = ketosis • Ketone bodies are a by-product of the lipid metabolic pathway after the fat is converted to energy • If there is very little carbohydrate in the diet, the liver converts fat into fatty acids and ketone bodies. The ketone bodies pass into the brain and replace glucose as an energy source.

  11. How and Why Ketones are Tested • When dealing with epilepsy it is necessary to perform frequent blood tests for a more accurate reading. • Handheld units are making this process easier • A finger prick is needed resulting in a drop of blood for the testing strip, as opposed to waiting in the doctors office to have your blood drawn. (very similar to diabetes) • Ketones levels are tested to make sure they are present and not at an unstable level. If ketones reach a dangerous level  ketoacidosis will result

  12. Why the Ketogenic Diet? • The two main reasons for use of the Ketogenic Diet: • Unacceptable seizure frequency • Medication toxicity • No to little success with conventional treatment • Consists of anticonvulsant medications • Anticonvulsant medications often control or reduce the frequency of seizures, some patients show little to no improvement  turning to the ketogenic diet. • The diet has been successful in many treatments of epilepsy • Its use is restricted to severe cases of epilepsy. • If individual does not respond to anticonvulsant medications of other forms of treatment, Doctor’s and epilepsy specialists will then turn to the ketogenic diet

  13. Ketogenic Diet:Produces a state of ketosis, which helps control seizures • Diet is calorie restricted • High fat • Low protein and carbohydrate • Provides a ratio of fat to carbohydrate and protein • Ranging from 2:1 – 5:1 • 4:1 is the highest accepted ratio for most individuals • 82-92% of energy is converted from fat • Fluid intake is restricted to maintain urine specific gravidity at 1.020-1.025 • Fluid intake dilutes blood ketones

  14. GOAL of the Ketogenic Diet • To help control seizure activity and to promote ongoing age-appropriate growth and development.

  15. Initiation of Ketogenic Diet • Step One: Fasting • Promote ketosis  prescribe a fasting period (12-38 hours) • Patient will start fasting after dinner on the day they are admitted to the hospital • Water, sugar free beverages are allowed during fast • Step Two: Review patient’s diet history • Doctor's will make every attempt they can to incorporate food preferences  design diet for child • Step Three • Calculate energy, protein and fat levels child need to produce appropriate ketone levels • An appropriate ratio will be determined for the child • Step Four: Start ketogenic diet • Once ketones age generated, diet begins

  16. The Meal Plan • Based on calorie needs for growth and to maintain ketosis • 5 ketogenic food exchange groups: • Meat • Fruit • Vegetables • Fats • Heavy whipping cream (36%) • No “light” or “low-fat” labeled food products • Contain added carbohydrate to replace fat

  17. Meat: Poultry, fish eggs and cheese • One meet exchange: 1 oz. = 30gm weight • 7 gm protein • 5 gm fat • 73 kcal • Bacon = 30 grams and 2 fat exchanges • Chicken/turkey = 30 grams • Salmon = 30 grams • Cheese (cottage) = 50 grams

  18. Fruit • One fruit exchange: NO sugar may be added (100%) • 6 grams carbohydrates • 24 kcals • Apple • Fresh= 40 gm • Sauce= 60 gm • Juice= 60 gm • Orange • Fresh= 50gm • Juice= 60gm

  19. Vegetables • One vegetable exchange • 1 gram protein • 3 gram carbohydrate • 16 kcals • All vegetables are 100 grams • Broccoli • Spinach • Carrots • Cucumber • Peppers (red or green)

  20. Fats and Oils • One fat exchange • 4 grams fat • 36 kcals • Butter/margarine • 5 grams • Mayonnaise • 5 grams • Oils (canola, peanut, etc) • 5 grams

  21. Heavy Whipping Cream (36%) • One 36% gourmet whipping cream exchange • 1.2 gram protein • 22 gram fat • 1.8 gram carbohydrate • 187 kcals • Gourmet whipping cream • 60 grams

  22. Nutrition Care Process (NCP) • Assessment • Weight, height, BMI, nutrient intake • Diagnosis • Nutritional status • Intervention • Calculate exchanges and configure diet program • Monitoring • Regular check-ups, ketone testing

  23. NCP • Kaden, a 9YO boy, to be placed on a 4:1 ketogenic diet. According to the growth charts he is 50% for height, but 90% for his weight. Nutrition Care Process. Retrieved Sep. 30, 2008, from

  24. NCP: Assessment and Diagnosis • Assessment: • Weight: 32 kg • Ideal weight: 29 k • Height: 134 cm • BMI: 17.8 • Diagnosis: • Current nutritional status • Growth chart • Ketogenic diet ratio • 4:1

  25. NCP: Intervention • Total kcal allowance is found my multiplying his ideal body weight by 60 (the calorie per kg level recommended for a 9YO) • 29 x 60= 1,740 kals/day • Kaden’s dietary units: • 4 gram of fat (x 9 calories/gram)= 36 calories • 1 gram carbohydrate + protein (x 4 calories/day)= 4 calories • TOTAL dietary units= 40 calories • Total dietary units: 43.5 dietary units/day • Daily needed carbohydrate needs= 14.5 g. carbohydrate • Daily fat allowance= 174 g. fat • Daily protein needs= 29 g. protein

  26. Intervention Cont… • Sample Diet: • Breakfast: Egg with bacon • 28g. Egg, 11g. Bacon, 37g. Of 36% heavy whipping cream, 23g. Butter, 9g. Apple • Snack: Peanut butter ball • 6g. Peanut butter, 9g. Butter • Lunch: Tuna salad • 28g. Tuna fish, 30g, mayonnaise, 10g. Celery, 36g. Of 36% heavy whipping cream, 15g. Lettuce • Snack: Keto yogurt • 18g. Of 36% heavy whipping cream, 17g. Sour cream, 4g. Strawberries • Dinner: Cheeseburger Patty • 22g. Ground beef, 10g American cheese, 26g. Butter, 10g. Lettuce, 11g. Green beans (MeritCare , 1994)

  27. NCP: Monitoring • Monitoring: • Blood sugar tests are preformed regularly to monitor the degree of hypoglycemia • Intake of the ketogenic diet should be started slowly • ½ meal for the first two meals • If tolerating, full meal should be offered for third meal • Monitor the overall growth of the child

  28. Complications and Risks • Most complications occur when the diet is initiated • Tolerance • Nausea, diarrhea, vomiting (due to high fat levels) • Hypoglycemia • Needs to be treated immediately  child can seizure due to low blood glucose • treated with giving child 1-2 tablespoons of orange juice • Long-term complications • Hyperlipidemia • Kidney stones • Vitamin and mineral deficiencies • Growth and nutritional status

  29. Growth and Nutritional Status • Ketogenic diet is not considered the most nutritional and healthful diet • Lacks: fiber, vitamins, minerals • Supplements are recommended • Multivitamin • Additional calcium and phosphorous may be recommended to promote bone mineralization and development • Growth • Linear growth in some children might be stunted • Growth needs to be monitored closely and adjustments in the diet might need to be made periodically to assist growth

  30. Ethics • Is it ethical to put a child on a diet that we know puts them at a high risk of growth abnormalities? When in the long run the diet will save them from hurting themselves during a seizure.

  31. Summary • Currently, in the United States 2.5 million children are suffering from epilepsy. • The ketogeinc diet is a way of treating epilepsy through diet restriction. The diet produces a state of ketosis, which ultimately helps control seizures. • High fat • Low carbohydrate and protein • Vitamin and mineral deficiencies can occur when on the ketogenic diet • Growth of the child needs to be monitored closely, especially the height of the child

  32. Summary Cont… • The NCP is a vital tool for registered dietitians and medical staff. It enables you to work as a team through treatment and accurately develop a sufficient diet plan for the child.

  33. Questions

  34. References • Dorman, J. (2003). Pediatric Ketogenic Diet for Intractable Seizures. Today’s Dietitian, 11, 16-20. • Carroll, J., & Koenigesberger, D. (1998). The Ketogenic Diet: A Practical Guide For Caregivers. Journal of the American Dietetic Association, 98(3), 316-321. • Christiana, Y., Stephens, D., Williams, S,. (2003). A Prospective Study: Growth and Nutritional Status of Children Treated with the Ketogenic Diet. Journal of the American Dietetic Association, 103, 707-712. • Couch, S., Deckelbaum, R., DeFelice, A., Schwarzman, R., (1999). Growth and Nutritional Outcomes of Children Treated with the Ketogenic Diet. Journal of the American Dietetic Association, 99(12), 1573-1575. • Gaby, A. (2007). Natural Approaches to Epilepsy. Alternative Medicine Review, 12(1), 9-24.

  35. References • Huffman, J., Kossoff, E., (2006). State of the Ketogenic Diet in Epilepsy. Journal of the American Dietetic Association, 6. 332-340. • MacCracken, K., Scalisi, J., (1999). Development and Evaluation of a Ketogenic Diet Program. Journal of the American Dietetic Association, 99(12), 1554-1558. • McNamara, D. (2008). Children with Absence Seizures Require Close Monitoring. Clinical Neurology News, 5, 14-15. • Nelms, M. Sucher, K. and Long, S. (2007) Ketogenic Diet. In P. Marshall (Ed.), Nutrition Therapy and Pathophysiology (pp. 368). Belmont: Thomson. • Santoro, K. (2005). Children and the Ketogenic Diet. Journal of the American Dietetic Association, 105(5), 725-726.