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Submitted
October 1, 2020
Accepted
October 9, 2021
Published
December 11, 2021
Main Article Content
Abstract
The Ketogenic Diet (KD) is a high fat, low carbohydrate and restricted protein diet which has been used for the treatment of drug resistant epilepsy in children. It is considered the treatment of choice for refractory nonsurgical epilepsy in children. However, despite this being a very useful and relatively simple treatment, children from developing countries have not been able to benefit as much as their counterparts in more privileged settings. In this article, the challenges faced by pediatric neurologists and parents who wish to use the diet in children with refractory epilepsy are discussed, and also the simple low cost innovations which can be used to overcome these challenges are suggested. The evolution from the use of the classic ketogenic diet to the flexible use of the modified Atkins diet in low resource settings will be discussed.
Keywords
Ketogenic diet; Modified Atkins diet; Low glycemic index treatment; refractory epilepsy
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Copyright (c) 2021 Suvasini Sharma
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How to Cite
Sharma, S. (2021). Dietary therapies for epilepsy in low resource settings: challenges and successes. Journal of the International Child Neurology Association, 1(1). https://doi.org/10.17724/jicna.2021.212
References
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1. Kossoff E, and Cervenka M. Ketogenic Dietary Therapy Controversies for Its Second Century. Epilepsy Curr. 2020;20(3):125-9.
2. Goswami JN, and Sharma S. Current Perspectives On The Role Of The Ketogenic Diet In Epilepsy Management. Neuropsychiatric disease and treatment. 2019;15(3273-85.
3. Sondhi V, Agarwala A, Pandey RM, Chakrabarty B, Jauhari P, Lodha R, Toteja GS, Sharma S, Paul VK, Kossoff E, et al. Efficacy of Ketogenic Diet, Modified Atkins Diet, and Low Glycemic Index Therapy Diet Among Children With Drug-Resistant Epilepsy: A Randomized Clinical Trial. JAMA pediatrics. 2020.
4. Newton CR, and Garcia HH. Epilepsy in poor regions of the world. Lancet (London, England). 2012;380(9848):1193-201.
5. Singhi P. Infectious causes of seizures and epilepsy in the developing world. Dev Med Child Neurol. 2011;53(7):600-9.
6. Chawla S, Aneja S, Kashyap R, and Mallika V. Etiology and clinical predictors of intractable epilepsy. Pediatr Neurol. 2002;27(3):186-91.
7. Kaushik JS, Patra B, Sharma S, Yadav D, and Aneja S. Clinical spectrum and treatment outcome of West Syndrome in children from Northern India. Seizure. 2013;22(8):617-21.
8. Kapoor D, Sidharth, Sharma S, Patra B, Mukherjee SB, and Pemde HK. Electroclinical spectrum of childhood epilepsy secondary to neonatal hypoglycemic brain injury in a low resource setting: A 10-year experience. Seizure. 2020;79(90-4.
9. Meyer AC, Dua T, Boscardin WJ, Escarce JJ, Saxena S, and Birbeck GL. Critical determinants of the epilepsy treatment gap: a cross-national analysis in resource-limited settings. Epilepsia. 2012;53(12):2178-85.
10. Cameron A, Bansal A, Dua T, Hill SR, Moshe SL, Mantel-Teeuwisse AK, and Saxena S. Mapping the availability, price, and affordability of antiepileptic drugs in 46 countries. Epilepsia. 2012;53(6):962-9.
11. Watila MM, Xiao F, Keezer MR, Miserocchi A, Winkler AS, McEvoy AW, and Sander JW. Epilepsy surgery in low- and middle-income countries: A scoping review. Epilepsy & behavior : E&B. 2019;92(311-26.
12. Sharma S, Gulati S, Kalra V, Agarwala A, and Kabra M. Seizure control and biochemical profile on the ketogenic diet in young children with refractory epilepsy--Indian experience. Seizure. 2009;18(6):446-9.
13. Bergqvist AG, Schall JI, Gallagher PR, Cnaan A, and Stallings VA. Fasting versus gradual initiation of the ketogenic diet: a prospective, randomized clinical trial of efficacy. Epilepsia. 2005;46(11):1810-9.
14. Seo JH, Lee YM, Lee JS, Kang HC, and Kim HD. Efficacy and tolerability of the ketogenic diet according to lipid:nonlipid ratios--comparison of 3:1 with 4:1 diet. Epilepsia. 2007;48(4):801-5.
15. Nathan JK, Purandare AS, Parekh ZB, and Manohar HV. Ketogenic diet in Indian children with uncontrolled epilepsy. Indian Pediatr. 2009;46(8):669-73.
16. Raju KN, Gulati S, Kabra M, Agarwala A, Sharma S, Pandey RM, and Kalra V. Efficacy of 4:1 (classic) versus 2.5:1 ketogenic ratio diets in refractory epilepsy in young children: a randomized open labeled study. Epilepsy Res. 2011;96(1-2):96-100.
17. Kossoff EH, Rowley H, Sinha SR, and Vining EP. A prospective study of the modified Atkins diet for intractable epilepsy in adults. Epilepsia. 2008;49(2):316-9.
18. Kossoff EH, McGrogan JR, Bluml RM, Pillas DJ, Rubenstein JE, and Vining EP. A modified Atkins diet is effective for the treatment of intractable pediatric epilepsy. Epilepsia. 2006;47(2):421-4.
19. Sharma S, Sankhyan N, Gulati S, and Agarwala A. Use of the modified Atkins diet for treatment of refractory childhood epilepsy: a randomized controlled trial. Epilepsia. 2013;54(3):481-6.
20. Sharma S, Jain P, Gulati S, Sankhyan N, and Agarwala A. Use of the Modified Atkins Diet in Lennox Gastaut Syndrome. Journal of Child Neurology. 2015;30(5):576-9.
21. Mehta R, Goel S, Sharma S, Jain P, Mukherjee SB, and Aneja S. Efficacy and tolerability of the modified Atkins diet in young children with refractory epilepsy: Indian experience. Annals of Indian Academy of Neurology. 2016;19(4):523-U131.
22. Sharma S, Sankhyan N, Gulati S, and Agarwala A. Use of the modified Atkins diet in infantile spasms refractory to first-line treatment. Seizure. 2012;21(1):45-8.
23. Sharma S, Goel S, Jain P, Agarwala A, and Aneja S. Evaluation of a simplified modified Atkins diet for use by parents with low levels of literacy in children with refractory epilepsy: A randomized controlled trial. Epilepsy Research. 2016;127(152-9.
24. Baby N, Vinayan KP, Pavithran N, and Grace Roy A. A pragmatic study on efficacy, tolerability and long term acceptance of ketogenic diet therapy in 74 South Indian children with pharmacoresistant epilepsy. Seizure. 2018;58(41-6.
25. Kossoff EH, Al-Macki N, Cervenka MC, Kim HD, Liao J, Megaw K, Nathan JK, Raimann X, Rivera R, Wiemer-Kruel A, et al. What are the minimum requirements for ketogenic diet services in resource-limited regions? Recommendations from the International League Against Epilepsy Task Force for Dietary Therapy. Epilepsia. 2015;56(9):1337-42.
References
1. Kossoff E, and Cervenka M. Ketogenic Dietary Therapy Controversies for Its Second Century. Epilepsy Curr. 2020;20(3):125-9.
2. Goswami JN, and Sharma S. Current Perspectives On The Role Of The Ketogenic Diet In Epilepsy Management. Neuropsychiatric disease and treatment. 2019;15(3273-85.
3. Sondhi V, Agarwala A, Pandey RM, Chakrabarty B, Jauhari P, Lodha R, Toteja GS, Sharma S, Paul VK, Kossoff E, et al. Efficacy of Ketogenic Diet, Modified Atkins Diet, and Low Glycemic Index Therapy Diet Among Children With Drug-Resistant Epilepsy: A Randomized Clinical Trial. JAMA pediatrics. 2020.
4. Newton CR, and Garcia HH. Epilepsy in poor regions of the world. Lancet (London, England). 2012;380(9848):1193-201.
5. Singhi P. Infectious causes of seizures and epilepsy in the developing world. Dev Med Child Neurol. 2011;53(7):600-9.
6. Chawla S, Aneja S, Kashyap R, and Mallika V. Etiology and clinical predictors of intractable epilepsy. Pediatr Neurol. 2002;27(3):186-91.
7. Kaushik JS, Patra B, Sharma S, Yadav D, and Aneja S. Clinical spectrum and treatment outcome of West Syndrome in children from Northern India. Seizure. 2013;22(8):617-21.
8. Kapoor D, Sidharth, Sharma S, Patra B, Mukherjee SB, and Pemde HK. Electroclinical spectrum of childhood epilepsy secondary to neonatal hypoglycemic brain injury in a low resource setting: A 10-year experience. Seizure. 2020;79(90-4.
9. Meyer AC, Dua T, Boscardin WJ, Escarce JJ, Saxena S, and Birbeck GL. Critical determinants of the epilepsy treatment gap: a cross-national analysis in resource-limited settings. Epilepsia. 2012;53(12):2178-85.
10. Cameron A, Bansal A, Dua T, Hill SR, Moshe SL, Mantel-Teeuwisse AK, and Saxena S. Mapping the availability, price, and affordability of antiepileptic drugs in 46 countries. Epilepsia. 2012;53(6):962-9.
11. Watila MM, Xiao F, Keezer MR, Miserocchi A, Winkler AS, McEvoy AW, and Sander JW. Epilepsy surgery in low- and middle-income countries: A scoping review. Epilepsy & behavior : E&B. 2019;92(311-26.
12. Sharma S, Gulati S, Kalra V, Agarwala A, and Kabra M. Seizure control and biochemical profile on the ketogenic diet in young children with refractory epilepsy--Indian experience. Seizure. 2009;18(6):446-9.
13. Bergqvist AG, Schall JI, Gallagher PR, Cnaan A, and Stallings VA. Fasting versus gradual initiation of the ketogenic diet: a prospective, randomized clinical trial of efficacy. Epilepsia. 2005;46(11):1810-9.
14. Seo JH, Lee YM, Lee JS, Kang HC, and Kim HD. Efficacy and tolerability of the ketogenic diet according to lipid:nonlipid ratios--comparison of 3:1 with 4:1 diet. Epilepsia. 2007;48(4):801-5.
15. Nathan JK, Purandare AS, Parekh ZB, and Manohar HV. Ketogenic diet in Indian children with uncontrolled epilepsy. Indian Pediatr. 2009;46(8):669-73.
16. Raju KN, Gulati S, Kabra M, Agarwala A, Sharma S, Pandey RM, and Kalra V. Efficacy of 4:1 (classic) versus 2.5:1 ketogenic ratio diets in refractory epilepsy in young children: a randomized open labeled study. Epilepsy Res. 2011;96(1-2):96-100.
17. Kossoff EH, Rowley H, Sinha SR, and Vining EP. A prospective study of the modified Atkins diet for intractable epilepsy in adults. Epilepsia. 2008;49(2):316-9.
18. Kossoff EH, McGrogan JR, Bluml RM, Pillas DJ, Rubenstein JE, and Vining EP. A modified Atkins diet is effective for the treatment of intractable pediatric epilepsy. Epilepsia. 2006;47(2):421-4.
19. Sharma S, Sankhyan N, Gulati S, and Agarwala A. Use of the modified Atkins diet for treatment of refractory childhood epilepsy: a randomized controlled trial. Epilepsia. 2013;54(3):481-6.
20. Sharma S, Jain P, Gulati S, Sankhyan N, and Agarwala A. Use of the Modified Atkins Diet in Lennox Gastaut Syndrome. Journal of Child Neurology. 2015;30(5):576-9.
21. Mehta R, Goel S, Sharma S, Jain P, Mukherjee SB, and Aneja S. Efficacy and tolerability of the modified Atkins diet in young children with refractory epilepsy: Indian experience. Annals of Indian Academy of Neurology. 2016;19(4):523-U131.
22. Sharma S, Sankhyan N, Gulati S, and Agarwala A. Use of the modified Atkins diet in infantile spasms refractory to first-line treatment. Seizure. 2012;21(1):45-8.
23. Sharma S, Goel S, Jain P, Agarwala A, and Aneja S. Evaluation of a simplified modified Atkins diet for use by parents with low levels of literacy in children with refractory epilepsy: A randomized controlled trial. Epilepsy Research. 2016;127(152-9.
24. Baby N, Vinayan KP, Pavithran N, and Grace Roy A. A pragmatic study on efficacy, tolerability and long term acceptance of ketogenic diet therapy in 74 South Indian children with pharmacoresistant epilepsy. Seizure. 2018;58(41-6.
25. Kossoff EH, Al-Macki N, Cervenka MC, Kim HD, Liao J, Megaw K, Nathan JK, Raimann X, Rivera R, Wiemer-Kruel A, et al. What are the minimum requirements for ketogenic diet services in resource-limited regions? Recommendations from the International League Against Epilepsy Task Force for Dietary Therapy. Epilepsia. 2015;56(9):1337-42.
2. Goswami JN, and Sharma S. Current Perspectives On The Role Of The Ketogenic Diet In Epilepsy Management. Neuropsychiatric disease and treatment. 2019;15(3273-85.
3. Sondhi V, Agarwala A, Pandey RM, Chakrabarty B, Jauhari P, Lodha R, Toteja GS, Sharma S, Paul VK, Kossoff E, et al. Efficacy of Ketogenic Diet, Modified Atkins Diet, and Low Glycemic Index Therapy Diet Among Children With Drug-Resistant Epilepsy: A Randomized Clinical Trial. JAMA pediatrics. 2020.
4. Newton CR, and Garcia HH. Epilepsy in poor regions of the world. Lancet (London, England). 2012;380(9848):1193-201.
5. Singhi P. Infectious causes of seizures and epilepsy in the developing world. Dev Med Child Neurol. 2011;53(7):600-9.
6. Chawla S, Aneja S, Kashyap R, and Mallika V. Etiology and clinical predictors of intractable epilepsy. Pediatr Neurol. 2002;27(3):186-91.
7. Kaushik JS, Patra B, Sharma S, Yadav D, and Aneja S. Clinical spectrum and treatment outcome of West Syndrome in children from Northern India. Seizure. 2013;22(8):617-21.
8. Kapoor D, Sidharth, Sharma S, Patra B, Mukherjee SB, and Pemde HK. Electroclinical spectrum of childhood epilepsy secondary to neonatal hypoglycemic brain injury in a low resource setting: A 10-year experience. Seizure. 2020;79(90-4.
9. Meyer AC, Dua T, Boscardin WJ, Escarce JJ, Saxena S, and Birbeck GL. Critical determinants of the epilepsy treatment gap: a cross-national analysis in resource-limited settings. Epilepsia. 2012;53(12):2178-85.
10. Cameron A, Bansal A, Dua T, Hill SR, Moshe SL, Mantel-Teeuwisse AK, and Saxena S. Mapping the availability, price, and affordability of antiepileptic drugs in 46 countries. Epilepsia. 2012;53(6):962-9.
11. Watila MM, Xiao F, Keezer MR, Miserocchi A, Winkler AS, McEvoy AW, and Sander JW. Epilepsy surgery in low- and middle-income countries: A scoping review. Epilepsy & behavior : E&B. 2019;92(311-26.
12. Sharma S, Gulati S, Kalra V, Agarwala A, and Kabra M. Seizure control and biochemical profile on the ketogenic diet in young children with refractory epilepsy--Indian experience. Seizure. 2009;18(6):446-9.
13. Bergqvist AG, Schall JI, Gallagher PR, Cnaan A, and Stallings VA. Fasting versus gradual initiation of the ketogenic diet: a prospective, randomized clinical trial of efficacy. Epilepsia. 2005;46(11):1810-9.
14. Seo JH, Lee YM, Lee JS, Kang HC, and Kim HD. Efficacy and tolerability of the ketogenic diet according to lipid:nonlipid ratios--comparison of 3:1 with 4:1 diet. Epilepsia. 2007;48(4):801-5.
15. Nathan JK, Purandare AS, Parekh ZB, and Manohar HV. Ketogenic diet in Indian children with uncontrolled epilepsy. Indian Pediatr. 2009;46(8):669-73.
16. Raju KN, Gulati S, Kabra M, Agarwala A, Sharma S, Pandey RM, and Kalra V. Efficacy of 4:1 (classic) versus 2.5:1 ketogenic ratio diets in refractory epilepsy in young children: a randomized open labeled study. Epilepsy Res. 2011;96(1-2):96-100.
17. Kossoff EH, Rowley H, Sinha SR, and Vining EP. A prospective study of the modified Atkins diet for intractable epilepsy in adults. Epilepsia. 2008;49(2):316-9.
18. Kossoff EH, McGrogan JR, Bluml RM, Pillas DJ, Rubenstein JE, and Vining EP. A modified Atkins diet is effective for the treatment of intractable pediatric epilepsy. Epilepsia. 2006;47(2):421-4.
19. Sharma S, Sankhyan N, Gulati S, and Agarwala A. Use of the modified Atkins diet for treatment of refractory childhood epilepsy: a randomized controlled trial. Epilepsia. 2013;54(3):481-6.
20. Sharma S, Jain P, Gulati S, Sankhyan N, and Agarwala A. Use of the Modified Atkins Diet in Lennox Gastaut Syndrome. Journal of Child Neurology. 2015;30(5):576-9.
21. Mehta R, Goel S, Sharma S, Jain P, Mukherjee SB, and Aneja S. Efficacy and tolerability of the modified Atkins diet in young children with refractory epilepsy: Indian experience. Annals of Indian Academy of Neurology. 2016;19(4):523-U131.
22. Sharma S, Sankhyan N, Gulati S, and Agarwala A. Use of the modified Atkins diet in infantile spasms refractory to first-line treatment. Seizure. 2012;21(1):45-8.
23. Sharma S, Goel S, Jain P, Agarwala A, and Aneja S. Evaluation of a simplified modified Atkins diet for use by parents with low levels of literacy in children with refractory epilepsy: A randomized controlled trial. Epilepsy Research. 2016;127(152-9.
24. Baby N, Vinayan KP, Pavithran N, and Grace Roy A. A pragmatic study on efficacy, tolerability and long term acceptance of ketogenic diet therapy in 74 South Indian children with pharmacoresistant epilepsy. Seizure. 2018;58(41-6.
25. Kossoff EH, Al-Macki N, Cervenka MC, Kim HD, Liao J, Megaw K, Nathan JK, Raimann X, Rivera R, Wiemer-Kruel A, et al. What are the minimum requirements for ketogenic diet services in resource-limited regions? Recommendations from the International League Against Epilepsy Task Force for Dietary Therapy. Epilepsia. 2015;56(9):1337-42.