By Eric Kossoff MD
Editor, Keto News
Most parents and neurologists consider the ketogenic diet as only including heavy whipping cream, mayonnaise, butter, and oils. For most children receiving this therapy, they are correct. In order to create a solid food diet in which 90% of the calories are fat, these foods make up a large portion of the child’s usual intake. However, the ketogenic diet can alternatively be easily provided as a liquid-only formulation to both infants as well as children with gastrostomy tubes. To some parents this is a surprise, but many ketogenic diet experts have been utilizing these formulas for years with good results.
What are these formulas?
There are several ways to provide the ketogenic diet as a formula. Perhaps the most simple is to use Nutricia KetoCal™, which is available in a powdered mix and either a 3:1 or 4:1 ratio. Water is added and calories are calculated by a dietitian. The 4:1 KetoCal has a slight vanilla flavor; the 3:1 KetoCal is unflavored. These formulas are milk-based, include corn syrup solids, and are nutritionally complete.
For children in whom separate components (e.g. fat, carbohydrate, and protein) are desired, or who have a lactose intolerance, “modular” ketogenic diets can be created using Ross Carbohydrate Free™ (Abbott Nutrition), Microlipid™ (Nestle Nutrition), and Polycose™ (Abbott Nutrition). A product in South Korea is also in clinical use called Ketonia™ has also been studied and is in active use, specifically for infantile spasms. A revised formulation called Ketonia II™ is now available without MCT (medium chain triglyceride) oil included. Lastly, Accera Pharmaceuticals, Inc. has developed a powdered MCT (medium chain triglyceride) oil-based powder (40 grams) that is designed to provide oral ketones to adults with Alzheimer’s disease. It is clinically available, includes both milk and soy protein, and is called Axona™ (http://www.about-axona.com).
How well do they work?
Interestingly, not only do the ketogenic diet formulas help in children with epilepsy on the ketogenic diet, but two limited studies suggest they work better than a solid food ketogenic diet. The first study, by our team at Johns Hopkins, was published in Epilepsia in 2004 and described 61 children who were on all-liquid ketogenic diets (27% of all children started on the ketogenic diet at Johns Hopkins over a 6-year period). Surprisingly, 59% of these children had a >90% reduction in seizures, which is nearly twice the average response for children receiving the ketogenic diet overall. One year later, Dr. Hosain and his colleagues at Cornell University Medical Center in New York published similar results in Pediatric Neurology. Six (50%) of 12 children had >90% reduction in seizures after 12 months of receiving a formula-only ketogenic diet.
Why do children receiving an all-liquid ketogenic diet do so well? The answer is not clear. Part of the success may be due to the perfect compliance, with ketosis assured and cheating nearly impossible. However, the reason for the doubling of seizure control is likely clearly more complicated than that, and may have to do with fatty acid composition of these formulas or other factors.
Are there other advantages?
Other than benefits for seizure control and compliance, there are some other potential advantages to liquid ketogenic diets. KetoCal™ is nutritionally complete, so there is no need for additional multivitamin and calcium supplementation. It also includes selenium, carnitine, and zinc, often supplemented additionally on solid food ketogenic diets. We have also heard anecdotally of less constipation with the liquid formulas. Lastly, children receiving all-liquid ketogenic diets appear to be significantly less likely to have elevated total cholesterol. In one study, there was one-third the risk of total cholesterol above 200 mg/dL if the child was receiving only ketogenic diet formula. Only 17% of children taking only ketogenic formulas had elevated total cholesterol during their time on the ketogenic diet. Why would this be the case? When you compare the cholesterol values of formula and a typical solid-food ketogenic diet, it becomes very clear:
Average cholesterol and fat content in one day using three different ketogenic diets (4:1 ratio and 1000 calories). Reproduced from Nizamuddin, et al. 2008.
|Solid food diet*||Modular formula**||Nutricia KetoCal™|
|Total Fat (grams)||104||100||100|
|Saturated Fat (grams)||63||20||23|
|Saturated Fat as Percent of Total Daily fat||60%||20%||23%|
*This represents using three distinct meals to create a 1000 calorie diet, including chicken, salmon, eggs, oil, heavy whipping cream, and vegetables.
** Microlipid™(Nestle Nutrition), Ross Carbohydrate Free™ (Abbott Nutrition), and Polycose™ (Abbott Nutrition) in combination to create a 4:1 ratio.
***0.01 mg of cholesterol for both products.
The future of ketogenic formulas
Although predominantly used in 2009 for infants and children with gastrostomy tubes with intractable epilepsy receiving the ketogenic diet, these formulas may have other uses in the future. There is an ongoing study at our institution to see if the modified Atkins diet with supplemental KetoCal™ shakes (10 ounces daily) for the first month is more likely to result in seizure control than the modified Atkins diet alone. In this study, the ketogenic formula is used in addition to solid foods, rather than as the entire diet. Ketogenic shakes (e.g. Axona™ and KetoCal™) are being used clinically and in research for non-epilepsy indications such as Alzheimer’s disease and ALS (Lou Gehrig’s Disease) respectively. Information about non-epilepsy indications for the ketogenic diet was discussed in the August 2008 edition of KetoNews.
One of our modified Atkins diet study patients and her daily KetoCal™ shakes.
Nutricia is also investigating new ways in which to make KetoCal™ more accessible for children receiving it. One option may be ready-made liquids that children can bring to school such as in cardboard juice-pack styles. These will be available for sale in November 2009 according to the company. Another method to provide the benefits of KetoCal™ might be to use the powder as a flour substitute in recipes. Some of these already exist and are in clinical use, such as at www.myketocal.com.
Topic Editor: Robert S. Fisher, M.D., Ph.D.
Last reviewed 6/28/09
|Has anyone else had a feeling of complete overstimulation?||Dec 19, 2013|
|Hi, I'm Caeti! New to having seizures...I think...?||Dec 19, 2013|
|Reaching the break-up point with epileptic girlfriend. Thoughts? Advice?||Dec 19, 2013|
|TLE - PCS... Can one be awake during a grand mal ?||Dec 19, 2013|
|CA social security disability||Dec 19, 2013|
|Need some insight regarding symptoms I feel are possibly seizure related||Dec 19, 2013|
|Friend having delusions||Dec 19, 2013|
|I need some advice can I get some answers please?||Dec 18, 2013|
|Lyrica: does it really work?||Dec 18, 2013|
|Is keppra that bad?||Dec 18, 2013|
|View all Forums|
|topamax and weight loss||19,411|
|Possible cure for absence seizures||16,695|
|How exactly do aura's feel||14,770|
|Sexual Side Effects||13,634|
|MEDICAL ALERT I.D.'s||12,607|
|Over 40 Different Types Of Seizures - Revised||10,552|
|electrical shock in head?||10,131|
|Weight Gain and Depakote||9,035|
|View all Forums|
|Hyperventilation & epilepsy, a way to help yourself.||Dec 17, 2013|
|Falling Down Funny - It's Harder On Us Than It Is On You||Dec 17, 2013|
|Brain Zaps, tics & twitches||Dec 15, 2013|
|Why?!||Dec 15, 2013|
|halfway there!||Dec 13, 2013|
|withdrawal symptoms||Dec 13, 2013|
|women classic snow boots all can get 60% off||Dec 12, 2013|
|update seizure first aid||Dec 12, 2013|
|My epilepsy recovery||Dec 12, 2013|
|Feeling Sick||Dec 10, 2013|
|View all Blogs|
|my partial complex seizures||4,606|
|Topomax... The Dreaded.........||3,805|
|How can you tell if a sleep seizure happens?||3,602|
|Brain Zaps, tics & twitches||3,600|
|side effects of phenobarb.||3,226|
|Tegretol XR and ANXIETY meds||2,907|
|TYLENOL, AEDs & SEIZURES||2,844|
|Nonepileptic "Events" vs. "Seizures"||2,721|
|View all Blogs|
|Cheap Canada Goose Jackets Outlet on sale 60% off online||Dec 12, 2013|
|epilepsy only||Dec 11, 2013|
|Hawaiian and have epilepsy||Nov 28, 2013|
|Epileptics over 50 with poorly controlled seizures||Oct 28, 2013|
|The "CHillin Out" Chat group||Oct 14, 2013|
|Epilepsy Marathon||Oct 13, 2013|
|Epilepsy and Hormones||Oct 5, 2013|
|Epileptics Working from Home for Websites||Sep 18, 2013|
|new worried Mum||Jul 24, 2013|
|Types of Epilepsy||Jul 23, 2013|
|View all Groups|
|Parents Of Children With Epilepsy||269|
|Temporal Lobe Epilepsy||171|
|Women and epilepsy||170|
|Living a life with Epilepsy||133|
|Anyone with Simple Partial Seizures||109|
|Dating and Epilepsy||94|
|Epilepsy and Memory Loss??||88|
|Epilepsy Surgery Group||74|
|Absence Seizures in Kids||73|
|View all Groups|
|Newly diagnosed at age 56||Dec 19, 2013|
|My son`s future||Dec 19, 2013|
|AN Amazing Testimony On A Spell Caster Who help me to get pregnant||Dec 18, 2013|
|Suddenly I'm having seizures after many years with no problem||Dec 17, 2013|
|seizure free for 2 months||Dec 16, 2013|
|My story||Dec 16, 2013|
|my story||Dec 15, 2013|
|epilepsy||Dec 14, 2013|
|My Story||Dec 12, 2013|
|From Human Friends to Computer Games||Dec 11, 2013|
|View all Stories|
|Temporal Lobe Epilepsy||657|
|Always Have On Clean Underwear||533|
|my brain has died a thousand deaths...........||532|
|Kelly's Life With Epilepsy||496|
|What My Seizures Are Like......||434|
|Nocturnal grand mal seizures (primary generalized epilepsy)||431|
|My Daily Philosophy.....||386|
|View all Stories|