The Modified Atkins Diet:
A Valuable Treatment for Epilepsy in China
Dr. Kossoff lecturing in Hong Kong
How did the modified Atkins diet become used?
The modified Atkins diet was first created at Johns Hopkins Hospital in 2002 by Dr. Eric Kossoff 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?
The modified Atkins diet allows for considerably more protein and a bit more carbohydrate than the ketogenic diet, yet remains high in fat (Figure). It is also unlimited in regards to fluid and calorie intake, so if a child is hungry or thirsty, they can just eat or drink more (just not carbohydrates!).
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). Also, the goal is not weight loss (as it is with the traditional Atkins diet).
For adults, we recommend 20 grams per day at diet onset. In addition, the modified Atkins diet is started as an outpatient (with approximately 30-45 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 neurologist to help coordinate care, but the modified Atkins diet needs less time and can be done with limited dietitian support. Also, the entire family can eat “low carb” on the Modified Atkins diet, including in restaurants outside the home, which is not as easy with the ketogenic diet.
Differences between the ketogenic and the modified Atkins diet:
Ketogenic Diet Modified Atkins Diet
Calories (% recommended Measured carefully Unrestricted
Fluids (“) Measured, but often ad lib Unrestricted
Fat 80% 60%
Protein 15% 30%
Carbohydrates 5% 10%
Fasting period Occasionally done No
Admission to hospital Usually No
Meal plans computer-created Yes No
Foods weighed and measured Yes No
Sharing of foods at family meals No Yes
Ability to eat foods made in No Yes
“Low carbohydrate” store-bought Not used Allowed sparingly
Intensive education provided Yes No
Multiple studies over many Yes Yes, recently
years proving benefits
What does the research tell us in children?
Our early findings led to a formal 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. It seemed that those children with more stable blood ketones did best.
In 2007, another 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.
Just in 2010, even more studies have shown benefit in Denmark with 33 children and results similar to the ketogenic diet. We published results in 2010 in Journal of Child Neurology, that using the modified Atkins diet along with a ketogenic high-fat shake called “KetoCal” (www.myketocal.com) improved results compared to the modified Atkins diet alone. After 2 months, 70% of children had at least a 50% reduction in seizures. This improvement seemed to be due to the higher fat intake rather than increased ketones. Interestingly, the KetoCal supplement only seemed to be necessary during the first month – which hints that the modified Atkins diet (and maybe all dietary treatments) have their maximal effect during the first month, and a “stricter” and higher fat first month is ideal. After that, the modified Atkins diet can be significantly loosened in restrictiveness.
Recently as well, we looked at children who started on the modified Atkins diet and then switched to the traditional ketogenic diet. About a third of these children had improvement, especially those with a type of epilepsy called “Doose syndrome”. No child without improvement on the modified Atkins diet improved on the ketogenic diet. These results tell us that both diets are very alike – the ketogenic diet likely is just a “high dose” of dietary treatment and the modified Atkins diet a “low dose”. It is fine to switch between diets if the neurologist and dietitian agree.
Now today in 2011, there have been 213 children in the published literature who have been put on the modified Atkins diet. 99 (46%) have had >50% seizure reduction and 59 (28%) have had >90% seizure reduction. These results are similar to the ketogenic diet. At Johns Hopkins Hospital, we offer both diets to the families that see us and let them choose. We tend to recommend it for teenagers (and adults). We tend to discourage it for babies and those children with gastrostomy tubes. Otherwise, it’s up to the parents to decide.
What about 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 completed and published our results in Epilepsia in 2008 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.
In 2011, there have been 59 adults published in the literature who have been treated with the modified Atkins diet. Of these 59, 16 (27%) had >50% seizure reduction. Only one adult has become seizure-free. This suggests that adults may have a harder time with the modified Atkins diet and MAY be less likely to respond. As more adults are put on this diet, we’ll know more if this is true or not. At Johns Hopkins Hospital, we have just started a clinic for adults using this diet in August 2010, and it is very popular.
The modified Atkins diet for China?
Could the modified Atkins diet be a valuable treatment for children and adults in China. We think so. We have studied this diet for countries with large populations that have limited dietitian support and think it will be very helpful. Children in Honduras are currently using this diet with the guidance of a neurologist but without a dietitian. It is also being widely used in India for this reason as well. Countries such as Korea and Japan have found the modified Atkins diet very attractive as it allows for more rice, increased sharing of foods at meal times, and less time in preparing foods. Stay tuned for more information as it becomes widely used in China!
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.
Kang HC, Lee HS, You SJ, Kang du C, Ko TS, Kim HD. Use of a modified Atkins diet in intractable childhood epilepsy. Epilepsia. 2007 Jan;48(1):182-6.
Kossoff EH, Turner Z, Bluml RM, Pyzik PL, Vining EP. A randomized, crossover comparison of daily carbohydrate limits using the modified Atkins diet. Epilepsy Behav. 2007 May;10(3):432-6.
Carrette E, Vonck K, de Herdt V, Dewaele I, Raedt R, Goossens L, Van Zandijcke M, Wadman W, Thadani V, Boon P. A pilot trial with modified Atkins’ diet in adult patients with refractory epilepsy. Clin Neurol Neurosurg. 2008 Sep;110(8):797-803.
Kossoff EH, Rowley H, Sinha SR, Vining EPG. A prospective study of the modified Atkins diet for intractable epilepsy in adults. Epilepsia, 2008;49:316-9.
Kossoff EH, Dorward JL, Molinero MR, Holden KR. The modified Atkins diet: a potential treatment for developing countries. Epilepsia. 2008 Sep;49(9):1646-7.
Kossoff EH, Bosarge JL, Miranda MJ, Wiemer-Kruel A, Kang HC, Kim HD. Will seizure control improve by switching from the modified Atkins diet to the traditional ketogenic diet? Epilepsia 2010;51: 2496-2499.
Tonekaboni SH, Mostaghimi P, Mirmiran P, Abbaskhanian A, Abdollah Gorji F, Ghofrani M, Azizi F. Efficacy of the Atkins diet as therapy for intractable epilepsy in children. Arch Iran Med. 2010 Nov;13(6):492-7.
Kossoff EH, Dorward JL, Turner Z, Pyzik PL. Prospective study of the modified Atkins diet in combination with a ketogenic liquid supplement during the initial month. J Child Neurol 2011; 26: 147-151.
Kumada T, Miyajima T, Oda N, Shimomura H, Saito K, Fujii T. Efficacy and tolerability of modified Atkins diet in Japanese children with medication-resistant epilepsy. Brain Dev. 2011 Jan 14. [Epub ahead of print]
Miranda MJ, Mortensen M, Povlsen JH, Nielsen H, Beniczky S. Danish study of a Modified Atkins diet for medically intractable epilepsy in children: Can we achieve the same results as with the classical ketogenic diet? Seizure. 2011 Mar;20(2):151-5.