Breanne C. Bian

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Medical Nutrition Therapy for theKetogenic Diet

• Breanne C. Bian
• Concordia College Moorhead, MN

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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

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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

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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

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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.

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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.

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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.

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Electroencephalograph (EEG)
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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.

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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.

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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

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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, Doctors
  and epilepsy specialists will then turn to the
  ketogenic diet

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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 21 51
• 41 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

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GOAL of the Ketogenic Diet

• To help control seizure activity and to promote
  ongoing age-appropriate growth and development.

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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 patients 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

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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

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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

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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

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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)

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Fats and Oils

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

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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

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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

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NCP

• Kaden, a 9YO boy, to be placed on a 41
  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 www.adaevidencelibrary.com/file
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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
• 41

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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
• Kadens 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

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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)
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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

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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

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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

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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.

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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

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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.

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Questions
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References

• Dorman, J. (2003). Pediatric Ketogenic Diet for
  Intractable Seizures. Todays 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.

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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.