Epilepsy and the Ketogenic Diet

Abstract

Epilepsy and the Ketogenic Diet. C. Stafstrom and J. Rho, eds. Totowa, NJ: Humana Press, 2004, 375pp. Although initially used as a treatment for epilepsy >80 years ago, the ketogenic diet has experienced a resurgence of interest since the early 1990s. This diet is offered as a therapeutic option by most pediatric epilepsy centers, and much work is under way to determine its mechanisms of action. This book is the first to review thoroughly both clinical and basic science advances in knowledge on this topic and is extremely timely, if not overdue! Epilepsy and the Ketogenic Diet is an excellent resource for physicians, dietitians, and other health care professionals who care for patients on the ketogenic diet as well as for scientists interested in this topic. It strikes an excellent balance between clinical and basic science aspects, succinctly summarizing the current state of knowledge and directing future areas of research. In his provocative introduction, Dr. Schwartzkroin does an excellent job of setting the stage by identifying integral clinical and research questions. This book is divided into three sections: “Background,”“Clinical Aspects,” and “Basic Science Perspectives.” The first chapter begins with an overview of epilepsy, which, although quite basic at the start, provides a clear overview of normal and abnormal neuronal function, summarizing the cellular mechanisms leading to epilepsy and the consequences of seizures in the developing brain. This chapter is followed by an entertaining historical review of the ketogenic diet. The second section, “Clinical Aspects,” begins with overviews from a physician’s, dietitian’s, and nurse's perspective. The “Physician's Perspective” chapter is extremely practical and very appropriately written by Drs. Kossoff and Freeman of Johns Hopkins, the group with the longest and most extensive experience with the ketogenic diet. Some discrepancies on how to screen candidates and what to do with concurrent antiepileptic drugs exist among these three chapters, reflecting differences in protocol among centers, but these are minor. The concept of the “ketogenic ratio” and basics of diet calculation are clearly explained, and potential problems, such as dealing with intercurrent illness and surgery, constipation and hunger, are addressed. In a chapter that will be of interest to adult epileptologists, 26 adults treated at a single center are reviewed, showing that the ketogenic diet also is a promising therapy at this age. The last few chapters in the “Clinical Aspects” section address innovative clinical issues, including the use of magnetic resonance spectroscopy in determining the mechanism of action and fate of ketones, and other dietary therapies for epilepsy, including choline and polyunsaturated fatty acid enrichment. The last section, “Basic Science Perspectives,” addresses both traditional and more recently proposed mechanisms of action, including calorie restriction, ketosis, alterations in brain amino acids and energy metabolism, and effects of norepinephrine, galanin, and neuropeptide Y. Each chapter is written by a scientist whose research interest is in that key area and is extensively referenced. Potential antiepileptogenic and neuroprotective effects of the diet also are reviewed. This section is very readable, even for clinicians less familiar with experimental animal work, as experimental protocols are clearly explained. For example, in the chapter, “Effects of the Ketogenic Diet on Acute Seizure Models,” the authors begin by reviewing limitations and benefits of acute seizure models and cellular mechanisms underlying each model, rather than just describing the effect of the diet on each model. In addition to summarizing the key knowledge to date in each area, future research directions are proposed. Although several very promising leads have been identified, exactly how the ketogenic diet works remains a mystery. Two valuable appendices to the clinician appear at the end of the book, the first of which lists caloric content (by carbohydrate and total) for most medications, and the second of which identifies valuable ketogenic diet resources, including books, organizations, and web-based services. In conclusion, this book clearly fills a much-needed void, as it is the first to address clinical and basic science aspects in an up-to-date manner. Both editors, Drs. Stafstrom and Rho, are well recognized for their substantial contributions to pediatric epilepsy. Epilepsy and the Ketogenic Diet will be a valuable resource for clinicians, dietitians, and nurses who prescribe the ketogenic diet and for scientists who continue to search for answers as to how this diet works.