Fasting has been used as a therapy for seizures since the earliest times and in the Bible, Mark describes how Jesus cured a boy with epilepsy (1). In 1911, 2 physicians in Paris used starvation to treat 20 children and adults for epilepsy and reported that seizures were less severe. In 1921 Dr Rawle Geylin presented a paper to the American Medical Association Convention in which he described how cognitive improvement was achieved by the use of fasting as a treatment for epilepsy. This stimulated a research study at Harvard where it was discovered that when starvation was used to treat epilepsy there was usually an improvement in seizure control within 2-3 days. It was suggested that this was due to a change in metabolism because the absence of food or just a shortage of carbohydrates forced the body to utilise fat.
In 1921, there 2 important observations were made:
- When a person starves or consumes a diet with a low proportion of carbohydrates and a high proportion of fat, acetone and beta-hydroxybutyric acid (both of these are ketones) build up in the blood
- Research at the Mayo Clinic led to the suggestion that that the benefits of fasting could be obtained if the presence of ketones could be achieved by other means.
This led to the development of the “ketogenic diet” (KD) which consisted of 1 g of protein per kg of body weight in children, 10-15 g of carbohydrates per day and all the rest of the diet was fat. When this diet was used to treat children with epilepsy there were definite improvements in behaviour and in cognitive ability. Initial reports of success were soon confirmed and the use of the KD became established practice and was widely used during the 1920s and 1930s. Most of the standard text books which appeared between 1941 and 1980 had texts with full chapters describing the diet, telling how to initiate it, and how to calculate meal plans. A text book published in 1972 (2) described results for over 1000 children who had followed the KD. Complete control was achieved in 52% while there was improved control in 27%.
In 1938, new drugs which claimed to be suitable for the treatment of epilepsy started to appear on the market and the emphasis began to shift so that use the KD went into decline. Paediatric neurologists came to regard the drugs as the way forward. So the KD was used less and less. As a consequence fewer dietitians were trained in the use of the diet, which meant that it was often implemented incorrectly. As a result it was perceived to be ineffective and therefore fell out of favour.
There was little use until the early 1990s when a television programme in the USA described the story of a young boy, named Charlie who failed conventional therapies for his infantile-onset epilepsy, including numerous anticonvulsant medications and one surgical intervention (3). However when he was introduced to the KD, he achieved seizure freedom and remarkable neurodevelopmental recovery. At an international conference in 2008, Charlie, then aged 17 years, made a huge impact when he described his experience and expressed his thanks to all the dietitians, physicians, nurse and others who looked after him while being treated with the KD. He explained how the diet had controlled his seizures to such an extent that he was able to discontinue his use of antiepileptic drugs (AEDs) and, in essence, gave him his life back
He made the critical point as follows:
“I was one of the few lucky ones. Since the diet was invented there have been millions of kids all over the world just like me, who were as sick as I was, but whose families either never heard about the diet or were talked out of it.”
What is particularly important is that the television programme generated considerable interest in the KD so that it was once again it became accepted as a recognised treatment and many research projects were initiated. In one study, at the outset there were 150 children who averaged 410 seizures per month being treated with a mean of 6.2 antiepileptic medications (4). After 3 months, 83% were still complying with the KD and 34% had >90% decrease in seizures. At 6 months, 71% still remained on the diet and 32% had a >90% decrease in seizures. At 1 year, 55% remained on the diet and 27% had a >90% decrease in seizure frequency. Most of those discontinuing the diet did so because it was either insufficiently effective or too restrictive. It was concluded that the KD was more effective than many of the new anticonvulsant medications and was well tolerated by children and families when it was effective.
A more recent study, using a questionnaire, was designed to find out if the improvement was maintained after the treatment with the KD was discontinued at least 6 months earlier (5). At the time of documented KD discontinuation, 31 (31%) were seizure free, 16 (16%) had a 90–99% seizure reduction, 12 (12%) had 50–90% seizure reduction, and 42 (42%) had <50% seizure control compared to before starting the KD. At the time of the survey the level of >50% control was higher than when the KD was stopped, 79% versus 52%. This clearly demonstrates that the effectiveness of the treatment had been maintained. There was no indication of long term serious adverse effects. There was overwhelming support for this approach to treatment with 96% of respondents willing to recommend it to other families.
There is no doubt that the KD does work for some patients. Clearly this would be unrealistic. There are many different forms of the condition and the scope for success may well depend on treating as early as possible. Certainly the success rates compare very favourably with those which have been reported for a number of drugs used to treat epilepsy. In fact most drugs which are available do not have anything like the efficacy reported for KD. Further research should provide greater understanding of how the KD works that might well enable improvements to be made in its effectiveness. Although this discussion is confined to epilepsy, there is now growing understanding and awareness that the impact of the KD is much broader. There is convincing evidence that reducing sugar and other carbohydrates coupled with an increase in certain fats is a means of overcoming diabetes, heart disease, cancer and Alzheimer’s Disease. Hence the case for adopting a KD type diet as a strategy for improving public health generally is extremely compelling.
On the other hand, there appears to be little concern about adverse side-effects with the KD and since it simply involves some alteration in the composition of the diet, these would not be expected.
It is relevant to speculate why drug therapy was allowed to replace the KD as a treatment for epilepsy. There must be a very strong suspicion that the activities of the drug companies in pushing their products were based on exaggerating the benefits and playing down any associated adverse effects. There is plenty of evidence that this is typical of how these companies operate (7,8). By contrast, resources to support the use of the KD were probably very limited and therefore no match for the deep pockets of the pharmaceutical industry. Charlie commented on the huge numbers of people who missed out on a potentially successful treatment because of the neglect of the KD and it was fortunate that his father was in a position to make the TV programme which had such an impact.
It is especially ironic that the KD would be enormously helpful to those millions who are suffering from diabetes (both Type 1 and Type 2) and other chronic diseases but are not being given the information by the main stream health professionals. Perhaps we can learn some lessons from the above which might help get the KD promoted to the general public.
This is already happening in South Africa so maybe other countries will be watching carefully. Next February there will be a major international Summit in Cape Town which could turn out to be of enormous significance. Already many of those who are actively promoting and campaigning for a re-think on nutrition policies have signified their intention to be present. It is to be hoped that there will be a critical mass which will have an enormous impact right across the globe.
The first event which will be for two days is aimed primarily at medical practitioners. The content will focus on scientific data, studies and facts relating to a lifestyle based on a KD type diet. This will be followed by a one-day event which will be geared to the needs of the general public.
Further details are available on the official website at http://www.lowcarbhighfatexperts.com/
- J W Wheless (2008) http://onlinelibrary.wiley.com/enhanced/doi/10.1111/j.1528-1167.2008.01821.x/
- Livingston S. (1972) Comprehensive management of epilepsy in infancy, childhood and adolescence. Charles C. Thomas, Springfield , IL , pp. 378–405.
- C E Stafstrom et al (2008) http://onlinelibrary.wiley.com/enhanced/doi/10.1111/j.1528-1167.2008.01820.x/
- J M Freeman et al (1998) http://pediatrics.aappublications.org/content/102/6/1358.abstract
- A Patel et al (2010) http://onlinelibrary.wiley.com/enhanced/doi/10.1111/j.1528-1167.2009.02488.x/