Dr. Eric Kossoff – Ketogenic Diets and Seizure Management

Dr. Eric Kossoff – Ketogenic Diets and Seizure Management

July 27, 2019 3 By William Morgan


– Thank you Ken, and thanks
to Jeff and the organizers.
I’m really thrilled and honored
to be invited here today.
It was probably about a year ago,
maybe year and a half ago,
that I was speaking with Jeff,
and Jeff said, “I have this idea.
“I’m thinking about having
a conference at Ohio State.
“Would you come?”
I said, “Absolutely.”
He also told me it was
gonna be small meeting.
(laughing) I swear.
To me, I think a little
think tank small meeting.
Hmm, interesting.
So, again, really thrilled to be here.
I’m going to give you, in 30 minutes,
actually 29 and half minutes,
a sort of brief overview
of a very exciting aspect
of what we do for ketogenic diets,
which is treating epilepsy.
It’s got a long history, a
very interesting history.
And that’s what I’m gonna try to give you,
sort of an overview, and
touch base very briefly
on a few hot topics,
and then we’ll have time
for questions and then
during the lunch break,
I’m glad to chat with anyone else
who wants to talk about it.
Wait a sec, we’re all
having trouble with this.
How hard do you hold, there we go, okay.
Those are my disclosures.
These are some of the groups that I help
with the advisory boards for,
and some royalties that I’m
also involved with as well.
One of my absolute
favorite advisory boards
that I have been part of
now for about 10 years,
is actually Atkins Nutritionals.
Many of the experts here
today, Jeff and others,
are on this medical advisory
board with me as well.
There are some times I wonder why
I’m still part of the board.
As a neurologist, I think I
bring a different perspective
to sort of the use of ketogenic diets
for all kinds of conditions.
But I think maybe one of the major reasons
that I’m part of the board still today,
is I have somewhat of a
larger historical view.
And I think we heard from Jay yesterday,
he mentioned the idea of a tipping point
that maybe here today,
this is prime example
of how we’re at the tipping point
of using ketogenic diets.
In the epilepsy world, we’re past that.
We’re actually beyond the tipping point.
And so I’m gonna give you
a little bit of a tidbit
maybe of where things
could go in the future.
It’s exciting and kinda cool.
Where you know the diet
for epilepsy is mainstream.
It is everywhere.
And so what happens when that happens
maybe for your world?
I would like to think that
this is exciting and–
(person speaking lightly in background)
Ah, thank you; that explains it.
Okay, you heard from Collin.
He showed you a nice image
from 1919, I think it was;
1930; I’ll go a little
further back to zero.
So, we go really far back
in the use of the concept
of fasting and dietary
manipulation for epilepsy,
even before they knew what epilepsy was.
This is a reference in
the Bible of what appears
to have been an adult patient
who had childhood-onset epilepsy,
continued to have seizures.
They brought him to Jesus,
and what Jesus recommended
was prayer and fasting.
They knew it worked, for a
long time they knew it worked.
And, actually they didn’t know why.
And so in 1921, some really
smart researcher said,
“Hey, maybe we can come up with
“something that’s sustainable.
“We can do fasting for
long periods of time,
“we know that’s possible,
but is there something
“we could do for months
to perhaps even years
“as a treatment for
patients with epilepsy.”
And so we’re approaching now
the 100 year anniversary,
about three years away.
July 1921 was the first article published
on the ketogenic diet for epilepsy,
back from the Mayo Clinic,
where they decided to try a
high-fat, low-carbohydrate diet
and see if this would
at least, at the time,
mimic the effects of
starvation, mimic fasting.
Actually, even still today, you
see in chapters and reviews,
they’ll say things like
the diet was created
to mimic starvation; true, but we actually
know now on a scientific level,
they’re probably two
completely separate therapies.
We know the diet works.
Interestingly, in some animal data,
and a little bit of human data,
that fasting works by a
completely separate mechanism
to help suppress seizures.
But, again, this was back in 1921.
That’s why it was created.
Still, generally, in very wide-spread use
today for epilepsy.
Things have changed though.
For a while, it was extremely popular.
There were very few
drugs out on the market.
And in the 1940s, and
1950s, we reached our,
what we call, our second generation
of anti-epileptic drugs.
We are now in the third generation.
And you can see sort of an
escalating number of drugs
coming out on the market.
I don’t think this necessarily
caused a decline of the diet,
but it certainly gave
patients other options.
And so they started using
some of these other options.
And for many of them,
these are very successful.
Most patients, about 75%
of patients worldwide
with epilepsy, are easily controlled
with very low side-effects on medications.
They can keep things private,
they can do whatever they
want with their diet,
and go about their business.
But, again, lots of
different drugs out there.
So lots of other options for our families.
And as drugs came on the market,
we certainly, around that time,
saw the decline of the diet,
in terms of common use around the world.
We’re still seeing that somewhat today.
And I’ll show you kinda
where we are in 2018.
We certainly do have our challenges.
Families see all these
medications out there,
researchers are trying them.
The biggest challenge
today, any of you familiar
with epilepsy world, medical marijuana.
So we actually just had
the first medical marijuana
pharmaceutical agent approved
by the FDA a few weeks ago.
Probably gonna come out in a few months;
called Cannabidiol, or Epidiolex
is the trade name for it.
Probably the biggest obstacle,
at least to me in my
ketogenic diet practice,
patients want to try Cannabidiol instead.
I say, “You can try it
“and then come back to
me when it doesn’t work.”
In the early 1990s, we
were not in a good place.
As these drugs were
coming out on the market,
and you really had to struggle
to find ketogenic diet centers.
There were a few of them in the US,
scattering around the world, but not many.
And it was generally used only after
multiple medications had failed.
If you went to the American
Epilepsy Society meeting,
good luck trying to find
anything on the ketogenic diet.
The first poster was actually in 1995;
the first poster on the ketogenic
diet at the AES meeting.
And it was really kinda
perceived and written about
in chapters and reviews
as an alternative therapy.
And so we’ve really come a
long way in telling patients
this is a non-pharmacologic therapy,
not an alternative therapy per se.
The Charley Foundation is really
one of the biggest factors
in sorta of changing the mindset.
And maybe will be true today in sort of
metabolic disease, diabetes, and cancer
is what apparent support
group really can do
for changing public
mindset; pretty amazing.
The Charley Foundation
in 1993 was sort of born
from the experiences of a father
of a child with epilepsy
and who really wanted
to get the word out, and
really get research out,
that this was again an
established therapy at the time,
and had been an established
therapy for 75 years;
yet really wasn’t being widely used.
And so the Charley Foundation in 1993
really changed the whole
landscape of my world
of ketogenic diets for epilepsy.
There are lots of books out there.
I know there’s some out in the hallways.
These are just devoted specifically,
for the most part, to neurology epilepsy
using recipe books for specifically
patients with epilepsy.
As you can see in many
different languages,
and we’ll come back to some of the
international use a little bit later.
There’s been an explosion of research,
true for your field, true for mine.
We’ve gone from now a paper every month
to now about a paper a day.
I just checked this morning.
There were two more papers,
including one was actually
an RCT for Parkinson’s,
that I have to read on the plane.
Incredible, hard to keep
up with all of the field.
For a long time, one of the big arguments
that would come up usually at the
American Epilepsy Society meeting
was they’d say, “Yeah, that’s great Eric.
“These are single center,
often retrospective,
“case series of ketogenic
diets for epilepsy.
“We need randomized controlled
trials;” they’re done.
And so we actually now have
seven randomized control trials,
both pediatrics and adults,
all different variants of the diet.
All showing good benefit.
The argument that
existed for a long while.
They would say, “Well, you know,
do these really work” is over.
Okay, you really don’t
even hear that anymore
at any of Epilepsy Society meetings.
There’s no discussion that maybe diet
should be studied more in
randomized control trials.
Again, the tipping point has passed.
We’re now doing more
interesting sorta studies.
This is from the Cochrane Review.
This is one of these
reviews where they look
at all the literature to date.
Back in 2012, they came
out with a statement
in one of their reviews,
looking specifically
at ketogenic diets for epilepsy.
And they said, “These studies suggest
“that in children, the ketogenic diet
“results in short-to-medium term benefits
“in seizure control.”
And there’s still some work
to be done in long-term benefits,
but granted that’s an excellent comment.
The efforts of which are comparable
to modern epileptic drugs,
we actually didn’t think
they were going to say
that in their review.
So we have this out there
when insurance companies,
or certainly certain governing bodies say,
“Well, you know, is there
evidence the diet works?”
We give them this Cochrane Review,
the discussion, the
argument, ends very quickly.
August, where are we today?
It is actually now just
certainly widespread
beyond the United States borders.
Multiple countries doing ketogenic diets.
Some are actually involved in multi-center
national guidelines that are out there.
As you can, and I’ll come back to it,
there are certainly areas,
more the lightly-shaded gray,
that we have some work to do.
And I’ll wrap up at the
end with what we’re doing
to try to help some parts of the world
that don’t have ketogenic
therapies for epilepsy.
And now, today, again,
it’s a very different world
than when I started my fellowship.
We still typically use the ketogenic diet
after two drugs have failed,
because, for the most part, drugs do work
with relatively low side effects.
Most pediatric epilepsy centers
have a ketogenic diet center.
I have competition.
It’s the reality of what things are,
and it’s good for patients,
but it is tough sometimes
for recruiting for trials.
Nationwide Children’s, only
a couple of miles away,
has actually a very good
ketogenic diet center.
They’re everywhere.
It’s actually for pediatrics,
and that’s why I underlined it.
For adults, not so much
yet, but it’s changing.
It is one of the four major
therapies we use for epilepsy.
So we use medications, we
use electrical stimulation,
or vagus nerve stimulation.
We do epilepsy surgery,
and we do dietary therapy.
And most chapters reviews
articles will list
those as the key four therapies
out there for epilepsy.
Very very cool.
And it is actually getting
easier and easier nowadays
for families to be convinced.
I think a lot of that has to
do with all of you in the room.
And sorta of the low-carb
ketogenic movement
has really changed the landscape
of what parents are perceiving.
And more and more now,
I have families come in
where the child has epilepsy.
They are thinking about dietary therapy.
And the mom and the dad say,
“Oh, we’re on it ourselves.”
I say, “Great, it’ll actually make things
“easier around the house.”
And it’s not as much of a
difficult discussion to have
about starting the ketogenic diet.
We are in an exciting year.
It’s actually the 25th anniversary
of the Charley Foundation.
And it’s really gonna change
the landscaping of what we do.
We are about to have our sixth biannual
ketogenic diet conference
again focused on neurology.
It’s gonna be held on the
island of Jeju, off South Korea.
A little bit harder to get
to, maybe, then Columbus.
It’s coming up in a couple of months.
We’re actually really excited about that.
There have been ketogenic trainings
with very creative names,
specifically focused on epilepsy,
to train ketogenic
dietitians; London, Baltimore,
and there’s one coming up
in Buenos Aires in October.
The ketogenic diet, as a
session at a national meeting,
is really starting to take off.
At the European at
Congress on Epileptology,
the very first time ever, they
had a ketogenic diet session.
That was just held a few weeks ago.
And then at the American
Epilepsy Society in November,
I’m chairing a session.
And that’s, again, really historic,
and the first time ever that’s happened.
And, as well, we put together a guideline
for families, for
patients, for researchers
about the clinical management
of the ketogenic diet.
We published this in 2008.
We just recently did a revision of this,
sort of updating the data,
updating over the last 10 years,
what has changed in the field.
And that was just published
online about two weeks ago.
So this is available; it’s actually free.
The open access fee was paid
by the Charley Foundation.
Sorry, the Carson Harris
Foundation paid for that.
So if you’re interested,
you can go look this up
online and download it.
So, kind of what’s exciting
and where are we today?
I think where the field is going,
and again to summarize
in the time I have left.
Number one has been what can we do
to make the diet safer,
easier, more accessible
to children out there who wish to try it.
It still can be difficult,
and still can have some side effects.
So what can we do to help that,
knowing it works, and, again,
neurologists know it works.
What can we do to make
it easier and safer?
The second is what are
the mechanisms of action?
You’ve heard about that
a lot this conference.
It may be very different for
epilepsy; it probably is.
And so there’s some interesting
work going on there.
Third, are who should go on the
ketogenic diet for epilepsy?
Epilepsy is a very complicated disease.
Multiple syndromes, genetics, structural,
inflammation that can cause it.
Are there conditions that children
should be put on the diet
first rather than later on.
And then lastly, I’ll wrap up
with some of the international work
to bring it to developing countries.
So this is the traditional
initiation, what I was taught,
as a resident back several years ago,
in terms of how to start
the ketogenic diet.
It is traditionally
started in the hospital
after two to four days
of teaching the family
and initiating the foods in the hospital.
Traditionally started with
a 24-hour fasting period,
where overnight the child is fasted.
They’re on clear fluids,
and then the ketogenic diet
is gradually started over a few days.
My dietitians are very
busy creating the meals,
usually at a set ratio,
typically a four to one ratio.
A fat to carbohydrate
and protein combined.
Though it’s an example
from the Hopkins Kitchen
of a typical ketogenic breakfast
brought to one of our families;
very high fat, again, about 90-92%
calories made up of fat.
What you had out the in break rooms
would not be acceptable
for some of our ketogenic diet patients.
The families are educated daily,
and the foods are weighed
and measured very carefully.
We see these children back very frequently
with emails in between
every three to six months.
That’s a photograph of our keto clinic,
as we call it, which we have every month,
where we bring the children back,
neurologists, dietitians, researchers,
just sort of putting everything together,
trying to help these children.
Most of them do stay on their medications,
about four out of five
stay on their medications,
although we try to reduce the doses,
sometimes get them off them.
And then generally, at least
in the pediatric world,
after about two years, we
try to get them off the diet,
back to what they were eating before.
In most pediatric
epilepsies, things do change.
Some children do outgrow their seizures.
And so after two years, we’ll
try to wean them off the diet
and see if their seizures
remain controlled.
If it doesn’t work after
about three months,
we move on and try other things.
And so the children come off the diet
typically at two years.
I tell them send me a Christmas card.
Sometimes they send a picture.
And there’s actually one of my children
proving that she is no
longer on the ketogenic diet.
(audience laughing)
And so it’s great, and it’s nice.
It’s one of the nice things
about pediatric epilepsy,
is that we can actually cure
their underlying epilepsy.
Maybe on their on their own, but maybe
we can move things along
quicker with dietary therapy.
And so one of the questions
that often comes up.
This child is relatively happy.
She probably doesn’t want
to be in the hospital.
She’d rather be home, but, you know,
she has her food in front of her.
And she’s asking us, you know,
“Why do I need to be here?
“Why does this need to be so strict?”
And so sorta of one big thing in the field
has been moving, how
can we make it easier?
Do we need to be so strict?
Does it have to be the “Hopkins Protocol?”
And actually the good data
that it’s out there would say,
“You know, you can do
things very differently
“and still have the same
benefits for seizure control.”
You do not have to fast.
You do not have to necessarily
even admit children.
You can do it as an outpatient.
Some other researchers have
had some very creative ideas
of bringing the diet ratio up every month
to gradually get the child used to it.
So creative ideas.
Often a lot of these studies
are started by dietitians,
which is really great.
They come up with these
ideas, and then we study them.
We also have multiple
different diets available.
The classic ketogenic
diet, as you can see there,
second from the left, after
the standard “normal diet,”
which nobody should eat anyway.
You can see there’s the
classic ketogenic diet.
But there’s some variance of it.
There’s the medium-chain triglyceride diet
started in the 1970s out of Chicago.
The modified Atkins Diet,
which we created at
Hopkins in around 2001.
And then the low-glycemic index treatment
in about 2005 was created at Mass General.
And they’re all generally the same.
As I tell most families, these are all,
for the most part, high-fat,
low-carbohydrate diets.
Maybe the protein is a
little bit different.
Slight variance on how we start
and how we manage these children.
Some slight variations on
sorta of maybe the mechanism.
Some people think the
low-glycemic index treatment,
which does not usually create
ketosis, interestingly,
may work again by a different mechanism
than the ketogenic diet.
In our consensus paper, we actually looked
at all of the data, all the different ways
to start and maintain the diet.
And really tried to
express to the researchers
and the neurologists and dietitians
that flexibility is the key.
We actually were very clear
that fluid and calorie restriction,
there’s no evidence that that
makes much of a difference.
All of these diets seem to work.
We generally encourage the
ketogenic diet for under age two,
just so the dietitian can be more careful
with the management,
the fluid, the calories,
and exactly knowing what
the child is getting.
And we kind of lean more towards
the modified Atkins diet
for teenagers and adults.
Most centers still do bring
children into the diet,
80% including our center at Hopkins,
we still do admit for three
days to start the diet.
But the vast majority
of our consensus panel
said you can do it as an outpatient
if that’s more appropriate
for your center.
And very few nowadays are fasting,
but you can do it as an
optional if you wish to,
although not in infants.
We’re also a little more
clear about supplements.
Many of our children
come in on medications
for their seizures.
They leave on those medications,
but also many different supplements;
multivitamin, calcium, vitamin D.
A lot of centers are
giving extra selenium now.
Some good conversations I had
with Steve Phinney over the years.
We actually use a lot of salts now,
which has been very
helpful for our families
and our patients for getting rid
of some of the side effects.
Most of the supplements,
though, are optional.
Center by centers can
make these decisions.
This was table five in
our consensus paper.
So the second topic that
I’ll talk about briefly,
is can you replace the
ketogenic diet in a pill?
Of course, that would be wonderful.
No dietary management necessary.
Stay on what you’re eating;
don’t change your lifestyle.
But switch it to a pill.
And it comes out often,
these are some images
captured from the press.
When the press catches wind
of a basic science study,
usually my patients email me first,
and then the press emails me second.
And they say, “Why can’t we just do this?
“This works in mice. Of course, let’s
“stop the ketogenic diet and switch.”
It is complicated; I won’t go
through all the basic science.
I am not a basic scientist.
If questions, ask Stephen
maybe during the break.
But, of course, we know
the diet is complicated
and changes your metabolism to burn fat
instead of glucose when
that’s what’s provided.
But we also know there
are multiple mechanisms
at work, not just ketosis, but perhaps
polyunsaturated fatty acid levels.
Maybe adenosine you’ve heard
about during this meeting.
All very interesting, all potentially
seem to link to mitochondria.
Your mitochondria seems to
work better in your neurons
when you’re on a ketogenic diet.
And maybe, as we think
that’s why it helps epilepsy.
And you can look at this,
a lot of my colleagues
who are clinical neurologists,
will look at this and go, “Oh my gosh.”
You know, it’s so complicated,
we really don’t know why it works.
Or you can look at it the way
a lot of pharmaceutical companies
are starting to look at it, and say,
“That’s very interesting.”
Because we have sodium-channel drugs.
We have calcium-channel drugs.
We have potassium-channels.
Most of these are channel drugs.
And we kinda have a lot of them.
But this may be a target of mechanism
of the action that’s completely unique;
almost a metabolic class of medications.
And so they often hang out at
the back of our conferences.
And we’re like that’s a
pharmaceutical company.
And they ask great questions
often during the break.
And the idea being that
maybe we can’t completely
recapitulate the diet in one pill.
But if we can take one aspect
of the mechanism of action,
could it be helpful for
some patients with epilepsy,
maybe useful for patients who
failed multiple medications
but couldn’t go on a dietary therapy.
Some of these are in clinical trials.
Some of these still
have numbers and letters
and no names yet.
And so you can look at it two ways.
You can say is it a substitute?
Okay, these are some of the therapies
that are currently in clinical trials.
Some are pretty far along, again,
based on some information
for the ketogenic diet,
or is it a supplement?
Maybe someone is on the ketogenic diet,
they’ve had a 90% reduction
in their seizures,
they’re not completely seizure free,
could you then add one
of these supplements?
Maybe ketone esters, maybe triheptanoin?
Add one of these therapies,
see if that would help
the diet more than before.
We really don’t know yet.
We don’t know what interaction
necessarily for a family
for a child on a ketogenic diet,
with some of these therapies could be.
It could be good, but
it could maybe be bad.
We just don’t know yet.
One of the hot topics, I know
it’s come up several times,
just even today, is the microbiome.
This just came out very recently,
that maybe this maybe
another mechanism of action.
Some very interesting
research has come out,
out of the UCLA group,
suggesting that this
maybe at least partially responsible
by changing your gut microbiome,
in terms of GABA being accentuated,
glutamate being dropped,
maybe that’s why it helps seizures.
So stay tuned on this.
We also know who it works well for.
This is table one of our consensus paper,
which are conditions,
specific epilepsy conditions,
that we know the diet seems to have
a preferential benefit for.
Some of these conditions, I know have been
talked about yesterday and
a little bit this morning;
GLUT1 deficiency, infantile
spasms, tubular sclerosis;
where the diet seems
particularly beneficial,
such that maybe we
should be using the diet
sooner rather than later.
Most neurologists know
this table; it’s great.
They refer sooner rather than later;
we get these children on
the diet more rapidly.
Two hot topics here, infants.
We heard from Dr. Noakes
about this earlier;
is infants sort of a population that could
go on dietary therapy?
If you went back into the 1960s,
the answer was absolutely not.
This was from Sam Livingston’s book on
treating infants with ketogenic diets,
and he said not to do it.
He said that they won’t make ketones
and really was not an appropriate therapy
for children under one year of age.
Fast forward 2002, Doug
Nordli from Chicago,
said, “You know, when you
look at our population,
“infants did fine; they did make ketones;
“their seizures were improved.
“You shouldn’t necessarily be discouraged
“from starting an infant with epilepsy
“on the ketogenic diet.”
And now just three years
ago, out of Vienna,
they actually looked at
children under age two
versus children over age two,
and those under age two did better.
So we’ve come like 180 degrees,
and probably one of the most
rapid growing populations in my group,
are actually now infants being put on
ketogenic diets for their epilepsies.
And they do extremely well.
Just two years ago, the Europeans
put out their own particular guidelines,
focusing on ketogenic
diet therapy for children
below the age of two with epilepsy.
Really interesting work.
On the opposite extreme,
we talked about infants,
adults are probably equally fast growing.
I do pediatric epilepsy.
My age population stops around 18;
20 if they’re really cool,
and they’re in college,
and we talk about college stuff.
But 18 is usually my
cutoff; and I had a problem.
So my patients would grow up.
Some of them needed to
stay on dietary therapy.
They turn 18, and I had
nowhere to send them.
In addition, we’d get
contacts from 30-40 years old
with epilepsy who’d say, “Where can I go?”
And we, again, had nowhere
really to send them.
That’s really changing very quickly.
Our adult epilepsy diet center started
about eight year ago; it’s very busy.
For every child I put on the diet,
they probably put two adults on the diet.
Initially we thought it would be a lot of
transition patients who came
from my pediatric clinic;
about 20% of them are like that.
But about 80% are adults
who just had never
tried ketogenic diets before.
And they have very severe epilepsy,
failed multiple medications.
Some of them had epilepsies
that, by their nature,
certainly could have been on
it when they were children,
but just no one had ever
talked to them about it.
The outcomes look good.
This is actually very similar results
to what we see in the pediatric world;
that about a 50% response rate,
seizure free in about 15 to
20% of that response rate.
The dark, the black is
the problematic area.
What do we do to keep patients compliant?
In the pediatric world, it’s
not as much of an issue for me.
Parents usually can keep their child
on the ketogenic diet.
Adults are more willful.
Adults will do what they want to do.
Adults, for the most part, want to drive.
And if you are 99% better,
but still having a
seizure, you cannot drive.
And so a lot of adults,
that’s not good enough,
and they will sometimes stop the diet.
Different goals and objectives.
There’s a lot of issues where
thinking about for adults,
some very interesting
research questions out there
that hopefully will be answered
over the next few years.
How do we improve compliance?
What are the ramifications
if their lipid profiles are elevated?
A lot of the adults with epilepsy,
going on modified Atkins
or ketogenic diets,
are normal weight.
They don’t have metabolic
syndrome or any problems,
and so sometimes they do
have some side effects
by being on this diet.
What can we do to help that?
One of the big questions
that I think would be wonderful
if we can answer soon,
and the idea of maybe a
registry has been thrown around,
is pregnancy.
A lot of women come to us.
They don’t want to be on
the anti-epileptic drugs
because of the absolute
known effects on pregnancy.
And they say, “We wanna
go on the ketogenic diet
“cause that’s safer.”
And we say we really don’t know that yet.
We think that’s probably true,
but we don’t know that 100%.
This is just one example
of a success story.
The woman here closest to me in the black
actually has GLUT1 deficiency,
became pregnant, on a ketogenic diet,
delivered the baby that you see there
with the beautiful red hair.
Also, turned out had GLUT1 deficiency.
She has been on a ketogenic diet
since before she was born, theoretically.
(audience laughing)
And the natural history
of GLUT1 deficiency
would be to expect deficits.
And you can see, she’s
doing really really well.
A sort of proof of
principle that you can be
really aggressive before
even the epilepsy starts,
and these children can do well.
But this is just one patient.
There are a few out there, but we need
more information about pregnancy for sure.
And then lastly, I’ll
wrap up with sort of the
developing world; what can we do here?
It’s easier said than done.
I get a lot of contacts
from people in Africa,
Caribbean, Southeast Asia.
They are interested, they know what we do.
They say, “Can we start a
ketogenic diet center here?”
It can be very difficult.
Through the International
League Against Epilepsy,
we’ve started some early
work in terms of making
the diet more accessible to
these parts of the world.
The first step was to create a website.
So if you Google ILAE and ketogenic,
this comes up right away.
The ILAE is the International
League Against Epilepsy,
probably the preeminent ketogenic,
I’m sorry, preeminent epilepsy, excuse me,
international group.
And they helped us fund this website,
which has information,
recipes, free articles.
Because we know a lot
of developing countries
don’t have subscriptions to
some of the medical journals,
so they can download
the articles for free.
We created a guideline,
where we sort of took our
classic ketogenic diet
for epilepsy guideline down a little bit
and said what’s the absolute
minimum that you need
if perhaps you’re in rural
parts of Southeast Asia,
in terms of labs, followup,
do you need a dietitian.
That was a sorta interesting discussion.
And things are starting to move.
These are just a few screen
shots of some of the headlines
from some of the articles
that have been published
really just in the last three years;
Africa, Ghana, Morocco, South India;
some really interesting studies.
And different ideas and
ways to make the diet
more accessible to those areas by, again,
bringing things down a little bit.
So, to wrap up; again, thank
you for your attention.
Flexibility in the diet
and supplements, I think,
have made it more accessible and easy
for many of our patients, not all,
but certainly have helped.
Metabolic-based treatments,
as we’re often calling them,
not just necessarily all ketogenic,
are now potentially a
new anti-convulsant class
that the pharmaceutical
industry is interested in.
We are certainly extending
the age boundaries
down to infancy and even into adulthood,
and trying to bring the
diet around the world
as much as we can over the next few years.
If you want to hear more,
come to Jeju Island.
(audience laughing)
It should be really cool,
supposedly an old volcano.
It’s a resort off the coast of Korea,
where the next keto meeting is gonna be,
October 5th through 9th.
And, again, just like all the speakers,
I would like to thank Jeff.
Jeff and I have interacted over the years.
This was actually Jeff speaking
at our ketogenic conference
that we had in Chicago,
hosted by the Charley
Foundation many years ago.
He is certainly much more of a
celebrity and rockstar than I am.
And they were all lining
up to ask him questions
at the break; it was really cool to see.
And so we’ve learned a lot
from each other the years.
And this is our ketogenic diet team.
It really is a team
approach to make it work
for these children with epilepsy.
Thank you.
(applause)