Hi everyone,
It was a hectic day. After standing for almost 15 hours in the operating room, now I have like a 3-hour recess (to break my fast and maybe sleep) before I need to go in again for an appendicectomy (simple procedure to remove appendix). I hope it will be over soon, working in the fasting month is quite challenging. At one point I can smell my own ketogenic breath (I wear a face mask), it wasn't a pleasant smell, but I'm happy to know that I'm burning my own fat to provide my body and brain with the necessary fuel. Now, in this article, we're going to look into ketogenic diet and how it can be a beneficial way of preventing seizure.
The ketogenic diet has been a popular type of diet for the past couple of decades if you're struggling to lose some of your fats which make your abdomen seems flabby. Even though this type of diet was purely medical in the past (it has been prescribed to treat epilepsy and diabetes mellitus type II), the benefits of losing weight and better concentration which have been reported in a few studies were quickly noted by the public making it one of the most popular diet aside from the Atkin's diet and the Paleo diet.
There are a lot of other types of diet, nowadays, and the majority of them were actually derived from the same few concepts of losing weight. They were either utilizing the calorie deficit technique, achieving ketogenic state for maximizing fat burning or eating a lot of fibre-rich foods to slow down glucose absorption into the circulation (that's why most of the vegan and vegetarian population look lean and healthy). However, I think we all can agree that people starting to realise that the culprit behind the increasing trend of obesity all this while was non-other than the deadly, white and sweet substance called the sugar.
In the 1920s, before the introduction of the food pyramid, there are a lot of physicians which have been using fat and protein diet to treat people who were diagnosed with diabetes mellitus type II and epilepsy. In a book entitled "The Physiology Of Taste" by Bill Bufford, he wrote some of the complaints made by his patients throughout the treatment of Diabetes Mellitus type II. They felt miserable as they have to avoid sugary foods in order to lose weight. We can assume that in the past, people knew that the potential culprit behind the obesity and diabetes mellitus type II were sugar and it is okay to eat foods which are high in fat and protein but in the 1970s, the food pyramid was introduced which encourage people to eat more of carbohydrates like rice, bread and pasta. Since then, the obesity trend has been shooting upwards.
Even though we knew that eating fat doesn't necessarily equate to bad health, but we are still quite uncomfortable with the idea of eating fat to get healthy. After all, numerous studies in the past have shown that an increased consumption of fat can lead to cardiovascular problems. A study conducted in 2017 by Cristopher Kosinki and Francois R. Jornayvaz which was published in the PubMed Central (PMC) has found that people who practised Ketogenic diet are associated with improvements in the cardiovascular risk factor. The risk factors include:
- Obesity
- Diabetes Mellitus Type II
- HDL cholesterol level
If you've ever heard about a friend of yours were eating a low carb, high fat and moderate protein foods, then he/she were practising Ketogenic diet. The standard proportion of macros are 75% fats, 20% proteins and less than 5% carbohydrates. The idea is to keep the amount of glucose in the body as low as possible but within a normal range which will trigger the body to mobilise body fat content in the form of ketone bodies to be used as an energy fuel. As long as the glucose level were low (within normal range), insulin will not be secreted and as a result, the level of ghrelin (hormones related to hunger) will be kept at a lower level.
Prescribing The Ketogenic Diet To A Patient With Seizure
In clinical settings, patients (especially children) will be prescribed with a ketogenic diet if anti-seizure medications were no longer effective in preventing the disease. It's not well known how a high-fat low carb diet meal plan could protect patients from developing seizures but prescribing this diet to patients were proven difficult as the diet was quite strict compared to the other kind of diets. There are a few kinds of theories which have been proposed in the past to explain how the diet protects people from seizures which include:
- Restrict the production of reactive oxygen species in the brain
- Increase the production of a neurotransmitter (γ-aminobutyric acid) by affecting the tricarboxylic acid cycle
- Provide a high energy level to the brain tissues
All of them will eventually lead to hyperpolarization of neurons which will cause stabilisation of the synaptic functions hence prevent seizures (Rogovik A.L. and Goldman R.D., 2010). The ketogenic diet can be classified into a few types and some are designed to improve palatability among people who were practising it. However, it is worth noting that, some variant of ketogenic diets in the clinical setting were unbalanced as they were designed for achieving a maximum amount of benefits in the shortest amount of times. Patients were often asked to fast for 24 to 48 hours prior to the diet plan (they can drink plain water during that period) in order to deplete blood glucose to the lowest level possible (within a normal range), forcing the body to use fat cells instead. This would mean, patients will be in ketosis even before the ketogenic diet is started.
As the method is quite aggressive, patients should be monitored frequently. They were often hospitalised for a minimum of 3 days before being discharged with a few notes and parental counselling to ensure adherence to the meal plan for the treatment of seizures, especially in children. While being hospitalised, the usual amount of calories being given to the patient during his/her first meal is 1/3 out of the normal calories intake. The second meal will be 2/3 out of the normal calories intake and eventually, the third meal will be the normal calories intake. The introduction of the diet in a patient should be done gradually to minimise adverse events while giving the full benefits of the diet (Bergqvist et al, 2005).
Recently (April 2018), a group of scientists have discovered a potential mechanism which could explain how ketogenic diet treats seizures. They conclude that the effect which prohibits seizure from taking place in people who were eating a high-fat diet might be caused by the alteration of the gut microbiome. In the experiment, they divided mice into a few groups according to what they have been fed with. Among all of them, they noticed that a group of mice with has been fed with a high-fat, low-carb diet for a period of 4 days had a significant alteration to their gut microbiome which led to fewer seizure episodes than the other group of mice.
There are two bacterial populations that were increased as a consequence of the ketogenic diet in mice:
- Akkermansia muciniphila
- Parabacteroides
To investigate the efficacy of these bacteria for the treatment of seizures, they treated mice which have never been fed with the ketogenic diet with both of these bacteria. The result? Well, the mice which have been treated with both of the gut bacteria experienced less seizure even without giving them a high-fat, low-carb diet. However, the treatment would only work if a mouse is being treated with both of these bacteria. This could mean there is some form of synergistic effect brought by both of these bacteria when they were together. Both of these bacteria were said to have some kind of effect to the neurotransmitter which would further cause a properly functioning synapse.
So how do we know if the bacteria, not the ketogenic diet are the reasons why the seizures have been treated? Well, after getting those result, they tried to replicate it by feeding mice which don't have any gut bacteria in them. These mice (called the sterile mice) were produced either by treating them with a cocktail of antibiotics or raising them in a sterile environment. They found that the event of seizures was not reduced even with a properly planned ketogenic diet which strengthens the point of these bacteria being the most probable reasons, why seizures are treated with ketogenic diet; both of these bacteria might have just replicated when they were exposed to the environment created by the consumption of foods related to the ketogenic diet.
If this is, in fact, true, it will solve the 100 years (probably more) curiosity related to how seizure can be prevented with a ketogenic diet. Medical doctors in 1920s might have just prescribed this diet to treat seizures just because they were effective but now, we might have just understood why is it so. There are a lot of studies or clinical trials that should be conducted to investigate this hypothesis further. I just want to say, as a medical doctor, I'm quite excited by this kind of discovery. This is a truly promising field with a bright future and someday we might be able to explain to our patients why we are prescribing certain treatments to our patients.
Sources
- How the Keto Diet Helps Prevent Seizures: Gut Bacteria May Be Key
- The Gut Microbiota Mediates the Anti-Seizure Effects of the Ketogenic Diet
- Ketogenic diet for treatment of epilepsy
- Fasting versus gradual initiation of the ketogenic diet: a prospective, randomized clinical trial of efficacy.
- Effects of Ketogenic Diets on Cardiovascular Risk Factors: Evidence from Animal and Human Studies
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