Why consider the
Modified Atkins Diet
for the treatment of
refractory epilepsy
Yvette McMurtrie
Client Services Coordinator
Epilepsy Queensland, Brisbane, Australia
he majority of people with
epilepsy become seizure free
with antiepileptic medications, but
approximately 20-30% will have
refractory epilepsy, for which seizures
persist despite accurate diagnosis and
carefully monitored treatment (Berg et
al., 2001). The Ketogenic Diet (KD) was
originally developed in the USA in the
early 1920s and has recently become
increasingly accepted internationally. It
is considered an important alternative to
drug therapy for children with medically
intractable seizures (Freeman et al.,
2007). The KD, however, remains
restrictive and prescriptive, requiring
careful monitoring by a dietician. Use
in adults has been attempted but in view
of its restrictions has been extremely
difficult and has been noted that even
when a benefit is seen, adults are not
able to continue with the KD in the
immediate term (Cross, 2010).
The Modified Atkins Diet (MAD)
has been used to treat intractable
or refractory epilepsy since 2003
(Kossoff et al., 2008) and the results
are promising. An average of 56% of
patients experienced greater than 50%
seizure reduction and an average of 16%
of patients experienced greater than 90%
seizure reduction. This demonstrates
that the MAD is remarkably similar to
the KD in effectiveness. The MAD is
also generally thought to be easier to
stick to and have fewer side effects than
the KD (Cervenka et al., 2012).
The MAD was created at the John
Hopkins hospital in an attempt to create
a more palatable and less restrictive
dietary treatment. The MAD induces
ketosis without fluid, energy or protein
restriction (Kossoff et al., 2010). The
MAD can be initiated in an out-patient
setting and is possibly suitable for both
children and adults.
So how do the diets differ? Essentially
both the KD and MAD are high fat
diets with very little energy coming
from carbohydrate. On the MAD,
daily carbohydrates are limited initially
to 10g/ day in children with planned
increase after one month to 15g, then
20-30 g as tolerated based on seizure
control. Adults are started on 15 g/day
and can be increased to 20-30g/day
after one month. A high fat intake is
encouraged. Unlike the KD, however,
fasting or food weighing is not required.
Calories and fluids are also not restricted
on MAD the way they are on KD. The
ratios of energy coming from different
nutrients in the Ketogenic and Modified
Atkins Diets are outlined in figure 1.
Research does indicate that the diet
is most effective in Doose, Dravet
and West syndrome (Oguni et al.,
2002; Caraballo et al.,2005; Kossoff
et al., 2008). In these syndromes diet
therapy could possibly be considered
earlier in the management rather than
later. Kossoff et al., (2010) found that
children with Doose (Myoclonic Astatic
Epilepsy) had an almost 100% responder
rate with more that 90% reduction in
seizures. There have not, however,
been many studies in adults with other
syndromes and thus the diet may be just
as effective in these.
Patients on the MAD experience fewer
serious side effects than on the KD.
Most of the side effects were manageable
and patients were more likely to be
able to tolerate being on the diet for a
longer period. The MAD is generally
considered less restrictive on lifestyle
(Kossoff et al, 2010). There are no
studies to date, however, that examine
the long term side effects of the MAD.
Similar to the KD, families and adults
alike on MAD report not only seizure
reduction as a beneficial side effect of
the diet but also improved concentration,
Figure 1. Diet compositions: ratio, grams of fat, protein and carbohydrate. (Epilepsia © ILAE)
Typical Western
Ketogenic Diet
Modified Atkins
alertness and behaviour (Weber et al.,
2009) and this is before medications
were reduced. Weber also found that
children were more awake during the
day and slept better at night.
Independent from its effect on seizure
frequency and severity, MAD may also
be beneficial in patients with clinical
obesity or those desiring weight loss
(Smith et al.,2011). Some adult patients
on MAD experienced adverse side
effects of elevated LDL cholesterol
levels. However, Cervenka et al.(2012)
found that on carnitine supplements,
combined with dietary counselling
to avoid saturated fat and increase
consumption of unsaturated fat, the
levels of LDL and total cholesterol
returned to normal.
It is essential to note though that
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neither the MAD nor KD can be
considered a ‘natural treatment’. They
have side effects like any medication.
Further, the KD requires a high level of
dietary supervision, commitment and
resources, the MAD less so, but still a
challenge. Although a varied diet can be
provided within the requirements, both
are still very limiting on lifestyle. For
this reason dietary therapy should only
be considered for drug resistant epilepsy,
that is, after two appropriate medications
have failed and only undertaken with
strict medical supervision (Cross, 2010).
Response (or seizure reduction)
to the diet at three months predicted
the response to the diet at 12 months
for most patients (Smith et al.,2011).
Therefore a three month trial of MAD
may be sufficient to determine whether
or not it is an efficacious and sustainable
Even though results for MAD and
the KD are good, very few patients
achieve complete long term seizure
freedom. Treatment is also ongoing and
requires a sustained commitment. An
additional drawback of dietary therapy
in both adults and children is the lack
of dietician expertise and perceived
complicated nature of using the diet by
the average neurologist without KD and
MAD experience (Kossoff & Doward,
2008). Despite increasing evidence of
efficacy and an increasing awareness
amongst families, there is still a lack of
choice for either the family or the health
professional owing to a lack of resources
required. Waiting lists for MAD or KD
services are long.
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