This study compared the efficacy of the modified Atkins diet (MAD) to the classical ketogenic diet (KD) in treating intractable epilepsy in children. Researchers found that after 3 months, 52% of children on the MAD saw at least a 50% reduction in seizures, with 42% seeing over a 90% reduction. These results were comparable to the KD. While the KD showed a higher response rate, this was likely due to more KD patients being younger children. When adjusting for age differences, the efficacy of the diets was similar. The researchers concluded that the MAD is a well-tolerated alternative to the KD for older children with intractable epilepsy.

1. Article Summary - PediatricsRotation
March 15, 2015
Sara Vincenzi
Citation: Danishstudyof a ModifiedAtkinsdietformedicallyintractableepilepsyinchildren:Canwe
achieve the same resultsaswiththe classical ketogenicdiet?Miranda,MariaJ.et al. Seizure - European
Journal of Epilepsy, Volume 20, Issue 2 , 151 – 155.
For almosta decade,the ketogenicdiet (KD) hasbeenusedasa meansto nonpharmacologicallytreat
epilepticseizuresinthe pediatricpopulation. Previousresearchhasshownthatabout¼ of children
experiencingepilepticseizuresdonotrespondwell-enoughtoantiepilepticdrugs,withthese children
thenconsideredbe medicallyintractable. Researchhasalsofoundthatthe combinationof the highfat,
lowprotein,lowcarbohydrate contentof the classicketogenicdiethasbeenbeneficial tothisspecific
population,withmore than50%of childrenshowingatleasta 50% decrease inseizures. Alsotonote,
about10% of these 50% of childrenwill becomeseizure-free,withsome evenbecomingmedication-
free. More recently,the modifiedAtkinsdiet(MAD) hasbeenutilizedasa more liberal diettotreat
epilepsy. While basedonthe KD,the MAD limitscarbohydrate intaketo10g per day,withessentially
free intake of protein,calories,alongwithahighfatintake,withthe average rationof fat/protein and
carbohydrate being1:1, comparedto4:1 inthe KD. The researchersof thisstudylookedtocompare
bothdiets to determineif amore liberalizeddietisjustaseffective intreatingintractableepilepsy.
Thisstudywas performedatThe DanishEpilepsyCentre (DEC),where medicallyintractable epilepsy
patientsare offeredboththe classicKDdietaswell asthe MAD since 2007. The DEC decidedtooffer
MAD as an optiontoliberalize the KDdietforchildrenwhenitwasdeemedappropriate. A total of 38
childrenranginginage from1.1-15.6 years(meanage of 8.1) were studiedfromJune 2007 until March
2009. While these 38 childrenwere startedonthe MAD,another33 childrenwere startedonthe KD.
The parentsof the childrenwere counseledonthe benefitsanddrawbacksof bothdietsbefore deciding
to proceedwitheitherdietplan. Researchersnotedthatthe parentsof the olderchildrenchose the
MAD more oftenbecause theythoughtitwouldbetterfitthe child’slifestyle intermsof compliance
since itis more liberal. The parentsof youngerchildren,however,more oftenchose the KDbecause of
greaterevidence intermsof treatmentefficacy. Theywere alsogiventhe optiontoswitchbetween
dietsif theywanted. All childreninbothgroups hadexperienced1epilepticseizure perweekalongwith
havingtried3 antiepilepticmedicationswithnoimprovement. Afterinitial assessments,atotal of 33
children(18females&15 males) were inthe MAD group,and 33 childrenwere inthe KDgroup.
Childreninthe MADgroup startedout with10g of carbohydrate daily,alongwithliberalizedcalorie,
protein,andhighfatintake. The amountof fat wasincreasedduringthe firstfew daystoavoidany
possible sideeffects. Researchersattainedweeklymeasure of bloodketones,urine ketones,andblood
glucose. Parentswere allowedtofurtherliberalize the carbohydrateintake overthe firstthree months
dependingonintake andtolerance.
In the MAD group, 52% (17/33) of childrenwere considered“responders”afterthree monthsof
treatmentwiththe diet,meaningtheyhadseenatleasta 50% reductioninseizure occurrence. Of the
17 responders,14 (42%) showedgreaterthan90% decrease inseizure occurrence. Itwasnotedthat
some of the children initiallythoughttobe responderslostthe effectof the dietandthenreturnedto
theirpre-MADstate. A total of 17 childrenstuckwiththe MAD forat leastone year withgreaterthan
50% decrease inseizures,with4showingmore thana 90% reduction. Nosignificantchange inamount

2. of antiepilepticmedicationsinthese childrenwasseenoverthe course of treatment. Throughanalysis
of the bloodwork,all childrenwere inaketoticstate one weekafterinitiatingthe MAD.
Whencomparingthe KD and MAD group,there was nosignificantdifference relatedtonumberof
respondersinthe groups,butchildreninthe KADshowedahigher incidence of beingresponders(MAD
= 39%, KD = 60%, p = 0.06). The researchersalsonote thatthe age of childreninthe MAD group was
much higherthanthe childreninthe KDgroup; to eliminatebiasbasedonage,a sub-groupanalysiswas
performed,whicheliminatedpatientsgreaterthan10 yearsoldin the MAD group. Afterdoingthis,
there wasno significance atall inresultsbetweengroups.
Aftercompletionof the studyandanalysisof resultsandtolerance,the researchersconcludedthatthe
MAD dietisin fact well tolerated,withmore thanhalf seeingatleasta50% reductioninseizure activity,
with¼ of childrenshowingmore thana90% reductioninactivityafter3monthson the diet. These
valuesare comparable tothe KD diet. Asa whole,resultsof the MADgroupwere similarand
comparable tothe KD group, aside fromthe KD childrenshowinghigherincidence of beingresponders.
The researchersnotedthistrendwaslikelydue tothe KDbeingusedmore ofteninyoungerchildren.
Whenthisage difference wasadjustedfor,thistrendvirtuallydisappeared. Ultimately,they
determinedthateitherMADor KD isan appropriate optionforolderchildrensince bothshowedsimilar
results.
I decidedtolookmore intothe researchinvolvingaketogenicdietinpediatricpatientsafterspending
one of mydays at DuPontChildren’sHospital with the PICURD,whohad a lot of patientsshe saw for
epilepsy. Ihadheardof the dietthroughoutundergrad,butIwas reallyinterestedinhavingherexplain
it andenjoyedlearningaboutthe complexitiesof the diet,includingthe differentsupplementsneeded,
howto determine aKDdietfor an enteral dietorder,andwhatcan happenif the dietisnotordered
correctly. I was alsoshockedhowveryexactthe diethadto be ordered;andhow childrenona po
ketogenicdietandtheirparentshave tomeasure foodouttothe exact gram, and how any slight
variationcanleadto seriouseffects. Afterdoingsome of myownfurtherresearchIsaw the modified
Atkinsdiet,andcontinuedtolookfora recentstudycomparingthe two. I thinkthe authorsmake a
great pointthatsomethinglike anMADmightbe more appropriate foranolderchildwhocan make
theirownchoicesandis lesslikelytobe as consistentwiththe dietthanayoungerchildorinfantwhois
essentiallypassive in the matter. Itwill definitely be interestingtosee where furtherresearchtakesthis
topic.
- A dietitiancoulddiscusswiththe parentsof childrenwithintractableseizureswhatresearchhas
shownintermsof high-fatdiets,andexplainwhattheirpossible optionsare intermsof dietand
nutritionsupportif necessary.
- The dietitiancouldalsospecificallypresentboththe standardketogenicdietaswell asthe
modifiedAtkin’sdiettothe parentsand/orchildif able,againpresentingcurrentresearch
findingsonbothandallowthe parent’sand/orchildtodecide whattheywouldthinkisbest.
Ultimatelyitistheirchoice.