Epilepsy arises from an untethered electrical activity in parts of the brain that often manifests as seizures. Around 70 million people worldwide experience epilepsy, of which one-third (around 23 million people) are resistant to anti-seizure medications. In this kind called drug-resistant epilepsy, the affected have multiple uncontrolled seizures.
Read more: Understanding epilepsy
“A 12-year-old girl came to us on 25 November 2021. She had achieved all the developmental milestones but started getting seizures when she was nine. She had drug-resistant epilepsy and used to have around 6-7 seizures a day,” says Dr Mala Manral, a dietitian from the neurology department of the All India Institute of Medical Sciences (AIIMS), Delhi.
Surgery is often the only resort to control drug-resistant epileptic seizures. However, for those not eligible for surgery, experts recommend specific high-fat diets, commonly known as the keto diet, along with medications.
This cure-on-a-plate is an age-old tale from the 1920s, where they found that a ‘fat-heavy’ diet reduced the epileptic symptoms and kicked the epileptic seizures out of the park.
The veto on keto
But a diet high in fats comes with a hefty price for people from different regions. Studies have found that the keto diet does not sit well with people with guts attuned to carbohydrates-based diets and causes digestive disturbances. Indian community, for example, consumes a high amount of carbohydrates compared to other societies. The keto diet is highly stringent regarding fat percentage in meals, so it does not allow variations.
Read more: The good, bad and ugly of ketogenic diets
To find a palatable and flexible alternative to the keto diet, scientists at AIIMS looked at another high-fat diet – the Atkins diet. It could be adjusted to suit the Indian palate by allowing carbohydrate consumption, and it came to be named the modified Atkins diet or MAD.
The researchers combined the diet with the standard anti-epileptic treatment and observed the effect on seizure occurrence. The experiment results were published in Neurology, the medical journal of the American Academy of Neurology.
The 12-year-old girl who consulted Dr Manral was one of the 160 participants of the study as she was ineligible for surgery. After conducting all the necessary preliminary tests and investigations, Dr Manral, the first author of the study, started the girl on a customised MAD strategy along with the standard anti-epileptic medication.
MAD is good
Manjari Tripathi, a professor of neurology at AIIMS and the corresponding author of the study, explains that the modified Atkins diet consists of 60 per cent fats, 30 per cent protein and 10 per cent carbohydrates. “The carbohydrate intake is limited to 20 grams a day, which allows for more flexibility and variation than the keto diet,” she says.
For their experiment, they enrolled 160 people with epilepsy between the ages of 10-55 and divided them into two groups. The researchers gave one group the modified Atkins diet with the standard anti-seizure medicines, while the other received only the conventional drug treatment.
The researchers noticed that a quarter of the diet-plus-medicines group had 50 per cent fewer seizure occurrences. These people also had better cognition, increased alertness and an improved quality of life. Whereas in the medicine-only group, seizure occurrence reduced in only 2.5 per cent of the people.
When fats are not the villain
How do fats reduce seizures? The high-fat diet has fewer carbohydrates, so the body uses fats instead of glucose as the primary source of energy. The fat breaks down to form molecules called ketones.
Studies have found that ketones reduce the hyperexcitation of neurons, which is the underlying cause of seizures. Prof Tripathi says, “Ketones reduce the number of excitatory neurochemicals like glutamate, and increase the inhibitory neurotransmitter, such as GABA, in the brain.” Thus, ketones help in stabilising neuron function, she adds.
Read more: A holistic way of managing epilepsy
“Ketones also work by altering the gut microbiome to produce certain microorganisms which are anti-seizure, and they reduce the number of inflammatory substances in the brain,” says Prof Tripathi.
The super responder
Recalling the 12-year-old girl’s condition, Dr Manral says they educated the parents to keep a food log to ensure that the child followed the diet with specific daily intake of calories and protein as recommended.
Dr Manral is ecstatic as she narrates the 12-year-old girl’s response to their modified treatment. “Within four days of giving the diet, by 29 November 2021, the child had only two seizures per day, and by 5 December 2021, she did not have any seizures and has remained seizure-free since then,” she says.
She also adds that the diet is customised as the results vary from person to person.
While the study emphasises the important role diet plays in managing epilepsy, Dr Manral plans to further study how MAD alters the gut microbiome in people with epilepsy. She also expects to find some genetic biomarkers that predispose them to the condition.
“We are so happy the study has shown that the diet is effective. We make sure that the caregivers feel a little more involved in the care, which would even support people with epilepsy in their recovery,” says Prof Tripathi.
Editor’s Note: Second Monday of February is observed as International Epilepsy Day which falls today, 13 February 2023.