4.3.1 Diet initiation

In younger and disabled adults, it may be more appropriate to initiate a ketogenic diet as an inpatient [48]. The advantages of an admission include the ability to observe the patient and medically intervene if needed, and provide more time to educate the caregiver on how to maintain the diet upon returning home. In general, fasting is not employed in adults, although an induction fast might be useful if a quicker response is required (for example, if the adult is having multiple daily seizures, an induction fast might lessen the interference of the epilepsy on the initiation of the diet) [48]. The same graded approach used to introduce the diet in children may also be used in adults [48].

In most cases, adults with epilepsy can initiate their ketogenic diet as an outpatient, especially if they have selected the MAD, LGIT diet, or a non-conventional ketogenic diet. In most adults, it is not necessary to employ a graded approach when initiating a ketogenic diet at home, but if required then clear instructions should be provided on how to do so.


Table 8.

Implementing a ketogenic diet in an adult with epilepsy.

### 4.3.2 Diet maintenance

ketogenic services also supplement adults with calcium, vitamin D, and magne-

Lastly, education is essential; the adult needs to understand exactly what is required of them to implement their diet. A classroom-based format, with multiple adult patients present, can be advantageous [26]. The dietitian should demonstrate how to identify sources of fat, protein, and carbohydrate, how to count net carbohydrate (total carbohydrate minus fiber) for those on a MAD or non-conventional ketogenic diet, how to identify foods with a low glycemic index for those on an LGIT diet, and how to navigate potential pitfalls [26]. Helpful additional resources

Once the adult has been prepared, their chosen diet can be implemented (Table 8) [47]. The ketogenic service should provide as much support as the adult needs, but also encourage them to develop a sense of "ownership" over their diet,

In younger and disabled adults, it may be more appropriate to initiate a ketogenic diet as an inpatient [48]. The advantages of an admission include the ability to observe the patient and medically intervene if needed, and provide more time to educate the caregiver on how to maintain the diet upon returning home. In general, fasting is not employed in adults, although an induction fast might be useful if a quicker response is required (for example, if the adult is having multiple daily seizures, an induction fast might lessen the interference of the epilepsy on the initiation of the diet) [48]. The same graded approach used to introduce the diet in

In most cases, adults with epilepsy can initiate their ketogenic diet as an outpatient, especially if they have selected the MAD, LGIT diet, or a non-conventional ketogenic diet. In most adults, it is not necessary to employ a graded approach when initiating a ketogenic diet at home, but if required then clear instructions should be

> If inpatient, decide on induction fast and diet introduction If outpatient, provide clear instructions to caregiver

If to be ceased, consider switching to another ketogenic diet

Review at 3 and 6 months, and 6-monthly after

If to be ceased, decide on rate of diet cessation If relevant, consider diet cessation and driving

Initiation Decide whether to initiate as inpatient or outpatient

Maintenance Adult self-monitors seizure control and ketone levels

Cessation Identify when diet should be ceased (if ever)

Monitor for adverse effects Document beneficial effects

should be provided [55] and any expectations addressed.

thus conferring a feeling of empowerment over their epilepsy.

4.3 Implementing a ketogenic diet in an adult

Epilepsy - Advances in Diagnosis and Therapy

children may also be used in adults [48].

Stage Steps

Implementing a ketogenic diet in an adult with epilepsy.

provided on how to do so.

Table 8.

162

sium [3, 47].

4.3.1 Diet initiation

Ketogenic diets often work rapidly, within days [43]. The adult should regularly monitor their blood BHB level daily for the first several weeks, then two or three times a week once readings indicate that constant physiological ketosis has been achieved. There are no firm recommendations regarding optimal blood BHB levels in adults [3], although aiming for at least 2 mmol/L at all times seems reasonable. If seizure control or ketone levels are not responding as expected, a 3-day food diary may be useful to discover potential oversights in diet implementation.

The neurologist or dietitian should be in regular phone or email contact during the initial weeks of the diet, with multidisciplinary follow-up visits at 3 and 6 months, and every 6 months thereafter [3]. The neurologist should document the adult's seizure response to the diet; regardless of any improvement, anti-epileptic drugs should not be altered unless necessary, as alterations may make it difficult to gauge diet efficacy on seizure control. Recommended follow-up tests include complete blood count, electrolytes, liver and kidney function tests, fasting lipid profile, calcium, and vitamin D [47]. If osteopenia is a concern, a bone density scan may be warranted every 5 years or less [47], and bone protection therapy prescribed as needed. The dietitian should monitor weight, nutritional intake, and fluid hydration at every visit, and alter each as required.

Adverse effects may occur in adults on a ketogenic diet, but are generally transient, and rarely serious enough to necessitate stopping the diet [47]. The two most common adverse effects in adults are hyperlipidemia and weight loss [48]. Raised LDL levels are seen in least one-quarter of adults with epilepsy [48]. However, triglyceride levels often decline, and HDL levels usually increase [47]. Moreover, among healthy adults following a low-carbohydrate diet, the LDL increase is due to increased LDL particle size rather than particle number, which may be associated with a lower risk of atherosclerosis [56]. Furthermore, LDL and total cholesterol levels typically normalize within a year of commencing the diet [57], and return to baseline within 3 months of stopping it [50]. Weight loss is also common on a ketogenic diet, seen in at least one-fifth of adult with epilepsy [48], but since many such adults are overweight or obese, this adverse effect is often desired and beneficial [47]. Other adverse effects, such as kidney stones and osteopenia or osteoporosis, are rare in adults [47].

Benefits other than seizure control may also occur with a ketogenic diet, including improved arousal, alertness, concentration, energy, and mood [3, 47]. Moreover, adults on a ketogenic diet often report increased quality of life scores [58]. Given that many adults with epilepsy suffer from impaired quality of life, these additional benefits may be significant and should be documented.

### 4.3.3 Diet cessation

Unlike children, the long-term benefits on seizure control in adults with epilepsy may not outlast dietary therapy [59]. Further studies are needed to determine if this is the case for all adults.

It is customary to maintain a ketogenic diet for at least 3 months before passing judgment on its efficacy in seizure control [3]. The exception to this rule is if the seizures worsen for longer than 1–2 weeks after commencing the diet, or if a serious adverse effect occurs—in either case, it may be wise to discontinue the diet sooner.

If the adult experiences a greater than 50% seizure reduction and no serious adverse effects, their ketogenic diet can be maintained indefinitely [3]. If the adult starts to perceive their diet as overly restrictive, yet it remains effective at controlling seizures, it can be switched over to another type of ketogenic diet.

Most ketogenic diets in adults are ceased slowly, over weeks or months on an individual basis [3], although many can be ceased abruptly without negative consequences. The sole exception may be the CKD, which can be ceased gradually by decreasing the ratio of fat to protein plus carbohydrate weekly or monthly, from 4:1 to 3:1 to 2:1 to 1:1, followed by the reintroduction of regular foods.

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An important consideration during diet cessation is the effect on driving restrictions. If a ketogenic diet has conferred complete seizure freedom for a long enough period of time such that the adult has returned to driving, stopping the diet applies the same driving restrictions as when anti-epileptic drugs are altered or modified [3].
