Rationale:
The Modified Atkins Diet (MAD) is a well-established and effective treatment for epilepsy in children.1 Outcomes of MAD in adults with drug resistant epilepsy is less established. Focal epilepsy constitutes 75-80% of epilepsies in adults,2 with approximately one-third having “drug resistant” epilepsy (DRE) which is defined as a failure of two appropriately chosen and tolerated anti-seizure medications (ASM) to control seizures. Patients with DRE often consider epilepsy surgery or neuromodulation as next options. We evaluated adherence to MAD and its efficacy to determine its viability for adults with focal DRE.
Methods:
We performed a retrospective chart review of adult patients seen in the Epilepsy Diet Clinic at the University of Colorado between 2021-2025 with a drug resistant focal epilepsy.
Results:
A total of 71 charts were reviewed including 48 with focal epilepsy and 13 with combined focal and generalized epilepsy. The median age of patients was 37 with the median onset of epilepsy at age 16. There were 19 patients who had surgical devices, and 11 with a history of status epilepticus. The most common etiology of focal epilepsy was structural (67%), followed by idiopathic (23%), genetic (6%), and autoimmune (4%). Most patients (80%) had more than one type of focal seizure based on the International League Against Epilepsy (ILAE) classification.
Of the 48 patients with focal epilepsy, 29 were started on MAD or maintained on a previously established ketogenic diet during the review period. Ultimately, 12 discontinued the diet (41%). In the 17 patients who continued the MAD, 16 had elevated serum beta hydroxybutyrate (BHB; average 1.14mmol/L), and the diet was effective in 13 (76.5%). Effectiveness was determined by a ≥ 50% reduction in the frequency of seizures. Overall, we found an average reduction in seizure frequency of 62.5% (95% CI, 46.8-78.2%) in those who continued the MAD. The degree of BHB elevation was not strongly associated with better seizure control (p-values: 0.89, 0.72).
The side effect profile was similar to what has been seen in prior studies3 with hyperlipidemia, GI symptoms, weight loss, mood, and osteopenia/porosis being the most common. No patients had an increase in seizure frequency.
Conclusions:
In our review, MAD was an effective treatment for adults with focal DRE with > 60% reduction in seizure frequency in those who were able to adhere to the diet. All patients with dietary effectiveness had elevated BHB, although the degree of BHB elevation was not associated with better seizure control. Adherence remains a challenge for all patients who attempt the MAD.
References:
1: Martin-McGill KJ, Bresnahan R, Levy RG, Cooper PN. Ketogenic diets for drug-resistant epilepsy. Cochrane Database Syst Rev. 2020 Jun 24;6(6):CD001903. PMID: 32588435.
2: Kverneland M, Molteberg E, Iversen PO, Veierød MB, Taubøll E, Selmer KK, Nakken KO. Effect of modified Atkins diet in adults with drug-resistant focal epilepsy: A randomized clinical trial. Epilepsia. 2018 Aug;59(8):1567-1576. PMID: 29901816.
3: Klein P, Tyrlikova I, Mathews GC. Dietary treatment in adults with refractory epilepsy: a review. Neurology. 2014 Nov 18;83(21):1978-85. PMID: 25355830.
Funding: None