Talk:Ketogenic diet/Archive 3

Expert review
I have been very fortunate to obtain an expert review of this article (at this version) by Eric Kossoff MD from Johns Hopkins Hospital. This pointed out some mostly minor mistakes, suggested some changes and commented on various aspects. The changes I made as a result can be seen here. Dr Kossoff suggested two pieces of additional information but I have been unable to find a published reliable source for them: Hopefully some future review or publication will contain this information and it can be incorporated.
 * "Charlie's epilepsy was rapidly controlled within one week."
 * "It is nearly impossible to provide the ketogenic diet for a vegan lifestyle, but with dairy a vegetarian ketogenic diet is feasible."

Dr Kossoff described the article as a "strong work" and that the changes I made "look good". His review has been very helpful and reassuring to me. Any remaining errors are my fault :-).

-- Colin°Talk 21:01, 3 December 2009 (UTC)
 * I have been watching the changes being made to the article in light of the expert review. It is also reassuring to see that no radical changes were suggested. "Strong work" indeed, when is this contribution going to be nominated for FA? Colin, you are a paradigm of patience. Graham. Graham Colm Talk 21:24, 3 December 2009 (UTC)


 * How encouraging! A few grammatical tweaks are forthcoming; nothing major. Congratulations on getting such a rare (and positive!) expert review of your work here; it must be very satisfying. Maralia (talk) 21:37, 3 December 2009 (UTC)


 * I'm working on the nomination right now. Maralia, I've rewritten the Modified Atkins Diet section so that will be worth a close look. Thanks! Colin°Talk 21:43, 3 December 2009 (UTC)


 * Ok. It is in. Marialia, I really like your "few grammatical tweaks". I'm not sure about "six-monthly" -> "semiannually" (though the "after" --> "thereafter" is good). Is this a word more common in America? It isn't one I'd use. Colin°Talk 21:55, 3 December 2009 (UTC)
 * I have never seen "six-monthly" used anywhere. My first thought for a replacement was 'biannual', but apparently that word has also come to have a secondary meanining of 'every two years' (biennial). (I cannot put into words how very stupid I find that usage to be.) Semiannual is very common here, but if it's that non-idiomatic to you, we could rework the sentence to do away with the adjectival form. I'll take a closer look at the MAD section. Maralia (talk) 22:49, 3 December 2009 (UTC)
 * Graham has fixed the six-month problem and improved it at the same time. I was sad when "fortnight" was removed but what can I do when so many readers are impaired by a deficient dialect. Colin°Talk 21:01, 4 December 2009 (UTC)


 * PS, Colin, please forgive my immodesty; I have peer-reviewed many papers submitted for publication in highly regarded scientific journals and in my opinion this article is of such a high academic and scientific quality that you could seriously consider submitting it to one as a review. I am not, of course, suggesting that it contains any original research, but it is a comprehensive, balanced scientific review, well-worthy of publication. Graham Colm Talk 22:02, 3 December 2009 (UTC)


 * You are too kind. This article is the product of Wikipedia and could not have been written without the help I received from my wikifriends. I'm very happy it is published here, for free and for anyone to read. Colin°Talk 19:16, 4 December 2009 (UTC)

FAC comments copied for discussion
The following comments by copied from the FAC and numbered:

1. What do you think of the following changes for the "Epilepsy" section? ":Epilepsy is one of the most common neurological disorders after stroke, and affects at least 50 million people worldwide. It is diagnosed in a person having recurrent unprovoked seizures. These occur when cortical neurons fire excessively, hypersynchronously, or both, leading to temporary disruption of normal brain function. This might affect, for example, the muscles, the senses, consciousness, or a combination. A seizure can be focal (confined to one part of the brain) or generalised (spread widely throughout the brain and leading to a loss of consciousness). Epilepsy can occur for a variety of reasons; some forms have been classified into epileptic syndromes, most of which begin in childhood. Epilepsy is considered refractory to treatment when two or three anticonvulsant drugs have failed to control it. About 60% of patients will achieve control of their epilepsy with the first drug they use, whereas about 30% do not achieve control with drugs. Some of these may be candidates for epilepsy surgery, and some, for the ketogenic diet."

2. You should also probably link or explain "hypersynchronously". (Does any article even explain hypersynchronous activity?)

3. In "History": Although popular for a while, it was discarded by most academic centres in the 1940s when anticonvulsant drugs became available. Effective anticonvulsant drugs? Bromides and barbs where already around, weren't they?

4. Kudos for not explicitly or unequivocally attributing authorship of On the Sacred Disease and Epidemics to Hippocrates.

5. Any more context on Rollin Woodyatt? Something such as "Chicago physician Rollin Woodyatt..." We really should have an article on him. Could be a challenge, hint hint... Same with Merritt, Putnam and Huttenlocher, but this is a personal preference of mine (providing context for researcher names) and is in no way necessary.

6. In "Discontinuation": ...it has been suggested that children with tuberous sclerosis who achieve seizure freedom could remain on the ketogenic diet indefinitely. Could or should?

7. Anything on the efficacy of LGIT?

8. Maybe you could add something on the availability of the different formulas. Can you get them in the UK, for example? I see Ketonia is from South Korea—is it commercially available elsewhere? Fvasconcellos (t·c) 21:05, 4 December 2009 (UTC)


 * Re #1. I've incorporated those changes and added the VNS to the options on drug failure, rewording the final sentence so it doesn't copy my source too closely. All three are mentioned by my source. Colin°Talk 23:15, 4 December 2009 (UTC)
 * Excellent, thanks! Fvasconcellos (t·c) 23:57, 4 December 2009 (UTC)
 * Re #2. I'm struggling to come up with a sourced definition of hypersychronous. It doesn't seem to appear in any dictionaries or medical dictionaries. My source uses as it is part of the ILAE official definition of a seizure. I guess all these technical writers assume their readers can combine "hyper" with "synchronous" and work out the intended meaning. What to do? Colin°Talk 23:28, 4 December 2009 (UTC)
 * Well, it is sort of easy to make a mental picture of, isn't it? Fvasconcellos (t·c) 23:57, 4 December 2009 (UTC)
 * Re #3. I can't really add "effective" since phenobarbital is effective even if it is somewhat sedating. Phenytoin brought not just a less sedating AED to the table, but also created a new way of discovering AEDs that encouraged the development of new drugs. Some sources regard phenytoin as a mixed blessing since scientists stopped trying to understand seizures or why the KD worked, and just did lots of experiments in the hope of randomly finding a new chemical that worked. I made this change. Colin°Talk 23:43, 4 December 2009 (UTC)
 * Excellent. You could go with something really fancy and say "when the discovery of phenytoin ushered in a new era for pharmacologic therapy of epilepsy..." etc. Hmm, I've been reading too many press releases... Fvasconcellos (t·c) 23:57, 4 December 2009 (UTC)
 * I want to keep this part brief as it is just the lead for the History section. There is more detail in the subsection "Anticonvulsants and decline". Colin°Talk 10:31, 5 December 2009 (UTC)
 * Quite right. Your edit is already enough, I was mostly joking anyway! Fvasconcellos (t·c) 12:11, 5 December 2009 (UTC)
 * Re #6. The source says "Perhaps ... should". The committee guidelines say "may require longer". I'd be reluctant to change it to "should" as the case for prolonging treatment is based on more factors than just the child's medical condition. Colin°Talk 10:31, 5 December 2009 (UTC)
 * OK. Fvasconcellos (t·c) 12:11, 5 December 2009 (UTC)
 * Re #7. I've added a short paragraph here. Colin°Talk 11:15, 5 December 2009 (UTC)
 * Excellent, that's exactly what I was looking for. Fvasconcellos (t·c) 12:11, 5 December 2009 (UTC)
 * Re #8. I'm not sure I could do this is a comprehensive way. KetoCal is made by SHS International, who are based in Liverpool UK. It is also available in the US. I guess the availability will vary according each country's healthcare infrastructure and prescribing guidelines. Colin°Talk 11:27, 5 December 2009 (UTC)
 * No problem. Best not to add anything if it will be hard to source, etc. Fvasconcellos (t·c) 12:11, 5 December 2009 (UTC)
 * Congratulations again, Colin. I am eagerly anticipating your next FA effort :) Fvasconcellos (t·c) 12:11, 5 December 2009 (UTC)

Rollin Woodyatt
Diabetes and insulin.


 * Graham EA. A tribute to Rollin Turner Woodyatt. Q Bull Northwest Univ Med Sch. 1956;30(3):286–9..
 * Colwell AR. Rollin Turner Woodyatt, 1878–1953. Proc Inst Med Chic. 1954 Apr 15;20(4):103–6..
 * Root HF. Rollin Turner Woodyatt. Trans Am Clin Climatol Assoc. 1954;66:liv–lv..
 * Keeton RW. Rollin Turner Woodyatt, 1878–1953. Trans Assoc Am Physicians. 1954;67:36–8..
 * Eli Lilly: Insulin Discovery.

Colin°Talk 21:18, 6 December 2009 (UTC)

Diabetes and obesity
A recent edit added the following text:


 * The ketogenic diet is also shown to be successful for the treatment of obesity. Ketones are known to suppress the appetite therefore causing the person on the diet to eat less because they have a satisfied or full feeling. At first, starvation, which is also known as fasting, was the way that doctors went about helping obese patients. The patients could only consume water, minerals, and vitamins. But starvation is a difficult and rigorous type of dieting which is detrimental to the health of the patients. The ketogenic diet is now an option for helping obese patients. The low carbohydrate idea became extremely popular when Dr. Atkins came out with his limiting carbohydrate diet with unlimited protein and fat and protein intake.[1] Carbohydrates are know to raise insulin levels, so a restriction of carbohydrates from the diet would help lower insulin levels and treat diabetes II. The ketogenic diet lowers weight, treats diabetes II, increases HDL cholesterol, and improves blood glucose control.[2] People with obesity follow a low carbohydrate ketogenic diet and have better results then those following low fat diets.


 * [1]
 * [2]

The first part, concerning obesity, is sourced to Lyle McDonald's self-published book. Wikipedia does not accept self-published sources as adequate to verify our content.

The second part, concerning diabetes, is sourced to a primary research study on 84 patients with obesity and type 2 diabetes mellitus over 24 weeks. Our medical sourcing guidelines strongly discourage using primary research for medical facts or clinical guidance. For example, the above study looked at improvements in "glycemic control, measured by hemoglobin A1c" and was relatively short-term for a proposed long-term lifestyle change. We need an authoritative review and support from professional bodies (such as the ADA) before we can confidently state that the ketogenic diet "treats diabetes".

For these reasons, I've removed the text. I am endeavouring to locate more sources on these topics with a view to a small expansion in this area. However, the main topics for these aspects are the articles low-carbohydrate diet and diabetic diet. Colin°Talk 18:31, 7 December 2009 (UTC)

Diabetes
Research reviews/opinions:


 * Accurso A, Bernstein RK, Dahlqvist A, Draznin B, Feinman RD, et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutr Metab (Lond). 2008 Apr 8;5:9..
 * Wylie-Rosett J, Davis NJ. Low-carbohydrate diets: an update on current research. Curr Diab Rep. 2009 Oct;9(5):396-404. ..

The first of these defines a low-carbohydrate diet as less than 130 g/d or 26% of a nominal 2000 kcal diet (per ADA guidelines) and a very low carbohydrate ketogenic diet (VLCKD) as less than 30 g/d. It states that ketonuria generally occurs below 50 g/d (10% of the above diet). Most popular low-carb diets have an initial (induction) phase that is ketogenic but this is not continued into the maintenance phase. It is not clear whether some of the benefits concern the low-carb aspect or the ketogenic aspect.

Colin°Talk 18:53, 7 December 2009 (UTC)

Obesity
I'm working on a short paragraph on weight-loss using low-carbohydrate ketogenic diets. Here's first draft. Comments?


 * Low-carbohydrate diets such as the Atkins Diet are a popular choice for those attempting to lose weight. Unlike the ketogenic diet for epilepsy, these diets do not restrict protein or overall calories. Low-carbohydrate diets typically begin with a weight-loss phase that limits carbohydrates to less than 20 g per day, a level that is ketogenic. The amount of carbohydrates is then slowly increased for the maintenance phase (though they remain at levels below a typical American diet). Ketosis does not significantly affect the uptake of consumed calories, though it may reduce appetite. Compared with a typical low-fat diet, a low-carbohydrate diet may produce greater weight loss at six months but this difference disappears at one year. There have been no studies on low-carbohydrate diets over one year in duration or studies measuring the effect on mortality or cardiovascular events (such as heart attack or stroke). There is concern that such diets limit fruit, vegetables and legumes and are nutritionally inadequate.[1]


 * [1] Last AR, Wilson SA. Low-carbohydrate diets. Am Fam Physician. 2006 Jun 1;73(11):1942-8. . (Lay summary here).

Another source, which is more recent but doesn't have different conclusions is:


 * [2]Clifton PM. Dietary treatment for obesity. Nat Clin Pract Gastroenterol Hepatol. 2008 Dec;5(12):672-81. ..

Colin°Talk 21:21, 7 December 2009 (UTC)


 * A 2009 study that ran for two years 19246357 and this page discusses the safety Low-carbohydrate_diet Doc James  (talk · contribs · email) 00:51, 8 December 2009 (UTC)
 * That study didn't contain a low-carbohydrate option. The lowest-carb of the four was classified as the "high-fat high-protein" option and had 35% of calories from carbs. You need to go below 20% of calories from carbs to count as a low-carbohydrate diet and to below 10% of calories from carbs to count as a very low-carbohydrate (ketogenic) diet. The authors' reply to a letter here indicates they didn't study very low-carbohydrate diets because "we had a concern — based on previous studies — that participants would not be able to sustain such a low intake beyond the initial 2 to 4 months, even with continual instruction and assistance from the research staff of dietitians and behavioral psychologists." In addition, they claim (which I've seen elsewhere) that the standard Atkins diet is not ketogenic beyond the induction phase (i.e., maintained weight loss cannot be accounted for by ketosis, and the carb levels on the maintenance phase are too high to generally be considered ketogenic). Colin°Talk 10:03, 8 December 2009 (UTC)
 * This study included a diet similar to the Atkin's diet in a 2-year study. It followed the plan of a 20g carb induction phase for two months and then rising to 120g carb maintenance phase. This "Atkins diet" is only "very low-carbohydrate" for two months and later it is "moderate carbohydrate" (another source gives a limit of 95g carbs (19% of calories) for the maintenance phase of the Atkins diet). Any fad diet can help people lose weight if you chop out major macronutrients. The trick is weight loss maintenance. The Atkins diet achieves this at carb levels that aren't ketogenic. This study confirms this: only 1 in 12 low-carb dieters had "detectable urinary ketones" (vs 1 in 20 on the low-fat diet).
 * Still, I think we should drop the "There have been no studies on low-carbohydrate diets over one year in duration" claim even though I'm not yet seeing evidence of long-term studies on diets that are fully low-carbohydrate for the duration of the study. Colin°Talk 10:36, 8 December 2009 (UTC)

Neuroprotective source
At FAC, Eubulides suggested this source might be useful to expand on the neuroprotective aspects. Todo... Colin°Talk 12:33, 11 December 2009 (UTC)

Wikiproject Food
I had included the WikiProject Food and drink banner because the article is concerned mainly with food. It was removed with the statement "I don't think so". I readded the Wikiproject because the article is in the project scope. If there is still a disagreement I'd appreciate a discussion instead of quick removal. Thank you. Hekerui (talk) 17:43, 19 December 2009 (UTC)
 * Could you explain what benefit the inclusion in WP Food and drink would bring? How would they be more able and willing to help than an average Wikipedian? The article is concerned with a medical therapy, which involve serious dietary changes that must only be attempted under medical supervision. The sources are nearly all academic medical journals. The closest you'd get to a knowledgeable food-related editor on this article would be a hospital dietitian. The Low-carbohydrate diet is an example of an article that more equally straddles the two wiki projects. I'm not totally opposed to the banner/inclusion but I don't see that it buys much. Colin°Talk 19:46, 19 December 2009 (UTC)
 * (Edit conflict) I removed the banner because I do not think this article is concerned "mainly with food" at all. Quite the opposite; it is a proven way of controlling refractory epilepsy. Please explain how this "is in the project scope"? Graham Colm Talk 19:51, 19 December 2009 (UTC)
 * It's a diet, which is about food, and when the first two sentences have diet, fat, protein, carbohydrate, and starvation in them then the it's clearly about food. Wikiprojects are not only about rounding up help directly, they are about finding stuff and also organizing so people can find things and maybe get involved. I very much believe this should stay, especially since it's not taking away anything from the article, or from any of the contributors. Hekerui (talk) 21:18, 19 December 2009 (UTC)