A New Choice on the Menu: Five Years of the Modified Atkins Diet for Epilepsy

Science Editorials and Reviews - Edited by Sheryl R. Haut, MD

December 3, 2007

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This editorial was developed for AAN.com, which is publishing expert opinions on a variety of hot topics in neurology.

Eric H. Kossoff, MD
Assistant Professor, Pediatrics and Neurology
Medical Director, Ketogenic Diet Program
The John M. Freeman Pediatric Epilepsy Center
The Johns Hopkins Hospital
Baltimore, MD
Author Disclosure Statement

Summary

The modified Atkins diet is a less restrictive, higher protein and carbohydrate, outpatient-initiated dietary therapy for epilepsy in both children and adults who would otherwise use the ketogenic diet. It has been used and researched for the past five years with outcomes similar to the ketogenic diet thus far. Recent data has also suggested this is a valuable new therapy for adults with intractable epilepsy, and although difficult to maintain, leads to a rapid seizure improvement when effective.


How did the modified Atkins diet become used?

The modified Atkins diet was first created at Johns Hopkins Hospital in 2002 as a result of two observations.

  • First, the family of a 7-year-old girl with daily partial seizures was counseled to start the ketogenic diet, but the admission date was scheduled for one month in the future. The center suggested that her mother begin reducing her daughter's carbohydrates and increasing high fat foods to "get her ready" for the lifestyle change that the ketogenic diet would entail; Dr. Atkins' New Diet Revolution was suggested as a resource. Three days later the child's seizures stopped, and her urine ketones were 80 mg/dL. Her ketogenic diet admission was cancelled and she remained on the Atkins diet with 10 grams per day of carbohydrates for the next three years.
  • A second child, a 10-year-old boy with refractory absence epilepsy, had discontinued the ketogenic diet one year earlier due to restrictiveness. When seizures recurred, the family independently began providing high fat and low carbohydrate foods without measuring and weighing, and he immediately became ketotic with improved seizures. Our dietitian calculated he was eating approximately 10-20 grams per day of carbohydrates. These two children in combination with four additional patients (including three adults) started de novo on the Atkins diet were reported in Neurology in 2003, sparking substantial interest in this diet.

What benefits does the modified Atkins diet have over the traditional ketogenic diet?


Figure 1

The modified Atkins diet allows for considerably more protein and carbohydrate than the ketogenic diet, yet remains high in fat (Figure 1). It is also unlimited in regards to fluid and calorie intake. The diet is considered "modified" from the traditional Atkins diet due both to its increased fat (patients are educated to eat foods such as butter, oils, mayonnaise and heavy whipping cream in large proportions), and reduced carbohydrates (10 grams per day versus the 20 grams per day Atkins diet "initiation period," with planned weekly increases based on weight loss results). For adults, we recommend 15 grams per day at diet onset. In addition, the modified Atkins diet is started as an outpatient (with approximately 30 minutes of counseling time required) without a fasting period. Vitamin supplementation, routine serum and urine laboratory monitoring, and home urine ketone checks are similar to the traditional ketogenic diet. Both require a dietitian and neurologist to help coordinate care, but the modified Atkins diet needs less time.

What are the results from formal, prospective studies in children?

These early findings led to a prospective study of this diet for children with intractable epilepsy that was supported by the Dr. Robert C. Atkins Foundation and published in Epilepsia in 2006.

  • Twenty children were started on 10 grams/day and then followed for six months. Sixteen (80%) completed the study and majority remained on the diet afterwards. After six months, 65% had >50% improvement, of whom seven (35%) had >90% improvement (four were seizure free).
  • A prospective study from South Korea one year later in Epilepsia described similar, although slightly less efficacy. In our study, total cholesterol increased from 192 to 221 mg/dl, but triglycerides, HDL, and LDL were constant over the six-month period. Most children did not lose weight.
  • The most recent pediatric study from our group involved a randomized, crossover design and determined that children receiving 10 grams of carbohydrates per day had better seizure reduction at three months, and that switching to 20 grams of carbohydrates per day at three months led to better tolerability without loss of efficacy. As a result, we recommend starting the diet strictly, using a limit of 10 grams per day of carbohydrates, but increasing to 20 grams per day after one month.

Could the modified Atkins diet be used for adults?

The future of the modified Atkins diet may, however, rest in treating adults rather than children. Since the traditional ketogenic diet is rarely offered to adults with refractory seizures who are not surgical candidates, there is a need for nonpharmacologic therapies such as diets. We have recently completed and published our results in Epilepsia using a nearly identical prospective protocol to the pediatric study, with adults aged 18-53 years. Results were similar to children, with 47% having a seizure reduction at three months and 33% at six months. Improvement occurred rapidly when present, within a median of two weeks. Many patients lost weight purposefully, with a mean of 6.8 kg weight loss over the study period, which correlated with seizure control at three months. However, the modified Atkins diet did increase total cholesterol (mean 187 to 201 mg/dL) and the discontinuation rate was higher than in children. Even adults with dramatic seizure improvement still found this diet restrictive and chose to discontinue it during the study period. We are currently conducting a follow-up study of the modified Atkins diet for adults that involves Internet administration and guidance.

The present and future of the modified Atkins diet

The modified Atkins diet has been in use now for five years and there have been six publications describing its use in children and adults. In total, 90 patients have been reported, with 42 (47%) having a >50% seizure reduction, of which 25 (28%) had >90% seizure reduction. This is remarkably similar to results reported in meta-analyses of the ketogenic diet.

Assuming then that both diets are similar, where should the modified Atkins diet fall in the treatment algorithm of neurologists? In general, we recommend the modified Atkins diet for:

  • adolescents, adults, and younger children with difficulty staying on or starting the ketogenic diet due to behavioral problems.
  • families with limited time, or those lacking financial resources to cover the costs involved with the ketogenic diet (including the admission)
  • patients at centers with limited dietitian support.
Contrarily, we suggest the standard ketogenic diet for children under two years of age (in order to better monitor growth and nutritional issues), formula-fed patients (infants and gastrostomy-tube fed) in which there is an easy ketogenic diet formula available, children who responded to the modified Atkins diet slightly but had difficulty maintaining ketosis, and families who require the detailed support and instruction given by dietitians providing the ketogenic diet.

More studies are in process in order to better provide the modified Atkins diet, but also to use as a first-line therapy for new-onset seizures. In addition, a true comparison study of the modified Atkins to ketogenic diet has been discussed. One thing is clear: more dietary choices means more options for our toughest patients.

Acknowledgment

The author thanks Sheryl R. Haut, MD, for her review of the manuscript.

Citations

Kossoff EH, Krauss GL, McGrogan JR, Freeman JM. Efficacy of the Atkins diet as therapy for intractable epilepsy. Neurology 2003;61:1789-91.

Kossoff EH, McGrogan JR, Bluml RM, Pillas DJ, Rubenstein JE, Vining EP. A modified Atkins diet is effective for the treatment of intractable pediatric epilepsy. Epilepsia 2006;47:421-4.

Kossoff EH, Rowley H, Sinha SR, Vining EPG. A prospective study of the modified Atkins diet for intractable epilepsy in adults. Epilepsia, in press.

Author Disclosure

Dr. Kossoff has received personal compensation from UCB Pharma, Inc., for serving on a speakers’ bureau. He has received research support from Cyberonics, UCB Pharma, Inc., and the Dr. Robert C. Atkins Foundation, which is not affiliated with Atkins Nutritionals, Inc.