Back in the dark ages of the ketogenic diet during the 1980s, the response to a diet that was 90% fat was, “Yuck!” Everyone—physicians, the public, and parents—all knew that such a high fat diet was unpalatable, unhealthy, and couldn’t possibly be a treatment for anything. Fat was thought to be bad, and the ingestion of such a diet would inevitably lead to heart disease, strokes, and death. “A diet for treating epilepsy? Crazy, we’re still trying to find the proper medication(s). We’re not looking for unsubstantiated alternative therapy.” “All that’s true is rarely new, and all that’s new is rarely true.”
Over the ensuing decade, the high fat, ketogenic diet has been shown to be palatable, not unhealthy, and highly effective in treating many forms of epilepsy, and perhaps other diseases as well. Indeed, it is more effective and less toxic than any of the current anticonvulsant medications.
The concept of a mere diet being able to control otherwise uncontrollable seizures seemed far-fetched to many back in 1994, when we reintroduced the ketogenic diet with the initial publication of The Epilepsy Diet Treatment: An Introduction to the Ketogenic Diet. Seventeen years later, with the help of the first four editions, the ketogenic diet has become a widely accepted therapy for children with difficult-to-control seizures. It has won over skeptics and gained acceptance among both physicians and the public. Medical centers around the world are developing the expertise needed to administer the treatment successfully. The limiting factor in its use seems to be the lack of adequately trained dietitians who are the prime ingredient in the diet’s implementation and success.
There are few new therapies in modern medicine that have come to the fore in so short a time. Modern medicine still treats most epilepsy in children and adults with anticonvulsant medications. Because it is based on food, the ketogenic diet is considered by many to be an alternative therapy. However, it is one of the few alternative therapies that has, through careful controlled studies, shown demonstrated success and become a part of mainstream medical treatment. We, therefore, no longer consider it alternative.
Since the first edition of this book was published, and even since the most recent fourth edition, a huge amount of new information has been generated on the ketogenic diet. This is the reason we felt a new edition was needed. Two landmark randomized, controlled trials have shown the world that the diet works. Recent and ongoing studies suggest that the former rigidity of the standard ketogenic diet may not always be needed, and we believe this new edition reflects the relaxing of the rules a bit. This is especially true in the last 10 years, during which the alternative ketogenic diets have been actively used—the modified Atkins diet and low-glycemic index treatment (LGIT); an entire section devoted to these treatments is now included in this edition. The title of this book is no longer THE Ketogenic Diet, but Ketogenic Diets! The diet is being used more and more for adults and even for conditions other than epilepsy.
More countries than ever are using the diet in sometimes innovative ways. The ketogenic diet is not just the “Hopkins diet.” This edition, unlike any other before, has contributions from dietitians at several other centers who will share their keys to success.
Although once thought to be the treatment of last resort, used only when all medications have failed and when surgery for the epilepsy was not an option, the diet is now considered when a child has failed only one or two medications and may be a treatment of initial choice for infantile spasms. This idea, hopefully a sign of things to come, is the subject of an entirely new chapter in this edition.
The diet has come a very long way, and this fifth edition book marks another milestone along its path. But even today, with all the new anticonvulsant medications that come on the market, there are still many children and adults with difficult-to-control seizures. The ketogenic diet, if properly done, remains more effective than any of these new anticonvulsant medications. It seems clear that if the diet were a drug, companies would be heavily promoting it as the treatment of choice for difficult-to-control epilepsy. We have been fortunate to have the support of several companies that make ketogenic formulas and supplements, but even that support is limited.
CAUTION: The ketogenic diet should ONLY be used under close medical supervision. The decision to use the diet should be the result of a dialogue between physicians and parents. It is rarely successful without the continuing support of an experienced physician and a knowledgeable dietitian.
The ketogenic diet is NOT the answer for everyone’s seizures. But even so, it may be worth trying. The diet is more effective than any of the anticonvulsants on the market after medications have failed and with fewer side effects. More than one-half of the children with difficult-to-control epilepsy who attempt the diet achieve more than a 50% control of their seizures, which is nearly twice the average (about 30% who respond to a new drug). Dr. Helen Cross showed that nicely in her study from 2008. They are usually able to reduce or eliminate their anti-epileptic medications and may remain seizure-free even when the diet is discontinued. For many, it may result in a better quality of life with fewer side effects than any other current therapy.
There still remain many, many questions about the ketogenic diet. We do not yet understand fully how it works, but that it works is clearly established. This new edition of Ketogenic Diets reflects the many advances in understanding that have taken place since interest in the diet was resurrected and the first edition of this book published 17 years ago.
Eric H. Kossoff, MD
John M. Freeman, MD
Zahava Turner, RD, CSP, LDN
James E. Rubenstein, MD