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THE IMPLEMENTATION OF a ketogenic diet (KD) to treat intractable childhood epilepsy has ancient origins. As elements of the treatment have advanced over the centuries, clinicians are hopeful the diet's uses can be expanded to address other neurological disorders. The CDC estimates 1 percent of children ages 0–17 (approximately 750,000) are a–ected by epilepsy or seizure disorders. The majority of these children receive first line pharmacologic treatment, which e–ectively treats their epilepsy. However, 20–30 percent of patients do not respond to medications, and one of the most e˜ca- cious alternative therapies is the KD. THE HISTORY OF KETOGENIC DIETS Use of the diet dates back to 500 B.C., when instances of fasting and diet modi- fications were reported as a treatment for epilepsy. In modern times, the use of starvation to treat epilepsy was noted by two Parisian physicians, Gulep and Marie, in 1911. Physicians and others within the healthcare community began experimenting with fasting to manage epilepsy in the United States during the early 20th century. A diet-ba sed approach to epilepsy management continued to gain popu- larity, especially after Drs. Wilder and Peterman of the Mayo Clinic developed a specific formula in 1924. However, as researchers developed better antiepileptic pharmacologic treatments, use of the ketogenic diet declined. More recent ly, obser vationa l a nd clinical studies have begun to reassert its importance for treating intractable epilepsy in children as well as adults. The KD and its variations (modified Atkin's diet, low glycemic diet, medium-chain triglyceride diet) are now used in over 45 countries worldwide. KD BASICS In clinical practice, patient families more frequently drive the conversation back to this nonpharmacological treatment. Parents of children who have epilepsy of ten come across t he K D in on line research and bring it up to a child's physi- cian. Instead of being a fallback measure, the KD is becoming a first line of defense. The preva i ling t heor y behind t he mechanism of the KD is that the high- fat, low-carbohydrate, adequate-protein approach encourages the production of ketones within the body which, in turn, act in the brain to reduce seizures. The exact mechanisms behind ketones' ability to counteract seizures are not yet fully understood, but there are at least four working theories under ongoing research. Developing the correct ratio of fat to carbohydrate and protein consumption is a delicate process requiring strict compliance and monitoring. A multi- disciplinary approach, with dietitians, nursing, clinicians, pharmacists, social workers as well as parents, teachers and other care providers is critical. Usually, children are only kept on the ketogenic diet for two years. Besides e–ects on sei- zure frequency, patients report increased alertness, improved concentration and developmenta l ga ins. Diet therapy is overall tolerated in well-chosen patients, but some side e–ects can be seen. Growing number of publications sum- marizing one centur y of data confirm its reliable e˜cacy, with over ha lf of ch i ld ren on t he d iet ex per ienci n g a 50 percent reduction in the number of seizures and 10–15 percent, even becom- ing seizure-free. W it h t he r e s u r genc e of i nt er e s t i n t he K D, cli n icia ns a re beg i n n i ng to consider its potentia l for treating other neurologic disorders including, but not limited to, autism, Parkinson's disease, Alzheimer's disease, malignant brain tumors, migraine, neuromuscular disorders and multiple sclerosis. There is a lso growing experience in use of KD for patients with medica lly refractor y status epilepticus. Dr. Lucyna Zawadzki is board-certified in Neurology with s pecial qualifica- tions in Child Neurology, Epilepsy and Ne uro phys iology. S h e i s D irecto r of Pediatric Epilepsy and Neurophysiology at Akron Children's NeuroDevelopmental Science Center in Akron, Ohio. ■ of the Ketogenic Diet in Treating Intractable Childhood Epilepsy and Beyond BY LUCYNA ZAWADZKI, MD EVOLVING ROLE 1 8C L I N I C A L S E C T I O N : E P I L E P S Y