Understanding the core principles of a ‘modified ketogenic diet’: aUKand Ireland perspective

Abstract

Background Many centres across the UK and Ireland anecdotally report using a ‘modified ketogenic diet’ (MKD) as a treatment for refractory epilepsy. Although a MKD is within the spectrum of ketogenic diets (KDs), there is little literature reporting upon its definition, use or clinical effectiveness. We aimed to understand the core principles of MKD practice and to assess whether and how the MKD differs from other KD protocols. Methods An online survey, designed by a consensus group of ketogenic dietitians, was circulated to 39 KD centres across the UK and Ireland. It consisted of 35 questions regarding dietetic practice when providing MKD. Results Eighteen centres completed the questionnaire: 13 paediatric, three adult and two combined centres. All dietitians based MKD ‘prescriptions’ on estimated total energy requirements. The average macronutrient profile was 75% fat and 5% carbohydrate, with protein ad libitum. Carbohydrate and fat targets were implemented via weighed portions (carbohydrate lists n = 18; fat lists n = 13) and ‘household measures’ (carbohydrate lists n = 2; fat lists n = 3). Of the centres, 94% (n = 17) adjusted macronutrients over time; these decisions were based on ketone levels and seizures in most cases (83%; n = 14). Ketogenic nutritional products available on prescription were used by 10 centres (56%) when initiating and by all centres when ‘fine‐tuning’ the MKD. Conclusions A modified ketogenic diet in the UK and Ireland is a hybrid KD, adopting principles from other established KD protocols and defining new elements unique to the MKD. Further research into the clinical and cost‐effectiveness of MKD would be of benefit.

Metabolism‐based therapies for epilepsy: new directions for future cures

“… 27 It should be emphasized, however, that not all clinically effective dietary treatments for epilepsy produce significant ketosis and whether the degree of ketosis correlates with seizure reduction remains under investigation. 28 Studies involving diet manipulation are challenging because they may be complicated by low participant recruitment, varying definitions for and implementation of ketogenic diet therapies utilized (despite attempts to standardize protocols), 29 and lack of adherence to study diets. Innovative, information‐maximizing study designs may help address these challenges.…”

Keto-on-the-Clock: A Survey of Dietetic Care Contact Time Taken to Provide Ketogenic Diets for Drug-Resistant Epilepsy in the UK

“…MCT KD (medium chain triglyceride ketogenic diet): 30–60% of dietary energy provided from MCT. MKD (modified ketogenic diet): as defined by Martin-McGill et al, 2019 [ 5 ]. ** KEF type: Proprietary: liquid or reconstituted powdered formulae based on the classical KD and used as is, i.e., no extra ingredients added.…”

“…Medical ketogenic diets (KDs) are a group of high fat, adequate protein, and very low carbohydrate regimens comprising five variants designed to induce ketosis: the classical KD [ 1 ], medium chain triglyceride KD (MCT KD) [ 2 ], modified Atkins diet (MAD) [ 3 ], low glycaemic index treatment (LGIT) [ 4 ], and the modified ketogenic diet (MKD) [ 5 ]. KDs are the treatment of choice for certain neurometabolic disorders, such as glucose transporter type 1 deficiency syndrome and pyruvate dehydrogenase complex deficiency, and are an effective treatment option for drug-resistant epilepsy (DRE) [ 6 , 7 ].…”

Therapeutic Use of the Ketogenic Diet in Refractory Epilepsy: What We Know and What Still Needs to Be Learned

“…Modifying the restrictiveness of CKD can be helpful when starting the diet or when tapering down to a more sustainable long-term diet. Macronutrients are adjusted over time from 3:1 to 1:1, decisions are based on ketone levels and seizure reduction rate in most cases [64]. MKD can be effective in adults, although, even with regular nutritional support, retention rates remain low [65].…”