Wikipedia:Featured article candidates/Ketogenic diet/archive1


 * The following is an archived discussion of a featured article nomination. Please do not modify it. Subsequent comments should be made on the article's talk page or in Wikipedia talk:Featured article candidates. No further edits should be made to this page.

The article was promoted by Karanacs 19:38, 16 December 2009.

Ketogenic diet

 * Nominator(s): Colin°Talk 21:46, 3 December 2009 (UTC)

This medical dietary therapy was inspired by a detox regime that involved, em, not eating, which worked... for a while. It is used to treat epilepsy when the drugs don't work. Lots of cream but no sweeties. The article has passed a Good Article review, undergone a peer review, copyediting, and received a review by a world expert, which have all been immensely helpful. I believe it is ready for FA. What do you think? Colin°Talk 21:46, 3 December 2009 (UTC)

Support— I have watched Colin develop this article for a very long time. Colin is a paradigm of patience, over the years, he has invited comments from many respected editors—the peer review was exceptionally valuable—and Colin has even managed to get a world-renowned expert to comment and provide a review. I have absolutely no doubts what so ever on the reliability of the sources and the free use of the images. To many, this might be regarded as an esoteric subject, but to parents of a child who suffers from epilepsy, this article is essential reading. It's great to know that Wikipedia has the best article on this subject on the internet; and one that will soon be one the Main Page—I am sure. In the spirit of openness, I have to say that Colin and I occasionally correspond by email and that Colin has provided very valuable criticisms of my contributions, and I was told that the expert review was forthcoming. Graham Colm Talk 22:24, 3 December 2009 (UTC)
 * Thanks Graham. The only patience required would have been with anyone watching the glacial speed of my article development. Colin°Talk 19:05, 4 December 2009 (UTC)

Support. I reviewed this article earlier, and thought it was FA quality then. It's even better now. My goodness. Thanks, Colin! Eubulides (talk) 09:12, 4 December 2009 (UTC)
 * Thanks Eubulides for your support and careful re-reading of the article today. That stray apostrophe eluded everyone else for nearly 18 months. Colin°Talk 19:05, 4 December 2009 (UTC)

Support (Note: I was a peer reviewer for this article.) This is an impeccably sourced, wonderfully comprehensive and brilliantly written article - it manages that delicate balancing act of being both scientifically precise and understandable by the lay reader. Like Graham, I should note that Colin and I occasionally correspond by email - we chat about life, the universe, and everything. Oh, and I think I sent him some sources. :) Awadewit (talk) 20:29, 4 December 2009 (UTC)
 * It is so important to me that Wikipedia's medical articles are accessible to all, so I'm very pleased to have your support on that point. Thank you. Colin°Talk 20:49, 4 December 2009 (UTC)

Strong support A fantastic piece of work. Congratulations also on obtaining an external peer review (something more medical editors should pursue). The prose is of a standard I would consider brilliant; the images are free and informative; this article has been thoroughly researched, and it shows. A few minor quibbles, as always:

That's it from me. Very impressive; I may even translate it into Portuguese if time permits and my patience with pt.wikipedia magically increases. Fvasconcellos (t·c) 21:05, 4 December 2009 (UTC)
 * Thank you very much. I too like to find out about historical medical figures, write about them, and use their full name when I mention them. I created Stanley Cobb and William Gordon Lennox, who feature in the ketogenic diet story. Yes, perhaps we should create some more biographies (hint hint). I'd like to respond to your "minor quibbles" and suggestions in detail but since many of these points don't concern WIAFA, if you don't mind, I I'd like to copy most of your comment to the article talk page and respond there. We can update this page later if necessary. Colin°Talk 21:28, 4 December 2009 (UTC)
 * Sure. These indeed do not concern WIAFA (which the article meets by far). Feel free to collapse the section here. Fvasconcellos (t·c) 21:31, 4 December 2009 (UTC)


 * I support this article's promotion to FA; having participated in the peer review, copyedited it, and generally nitpicked it to death, I can't find a thing left to improve. However, there is a lot to be said for fresh eyes, and I sincerely hope that this FAC will generate a couple of new reviews to ensure we've not overlooked anything! Maralia (talk) 23:06, 4 December 2009 (UTC)


 * Thank you. Your peer review comments were particularly helpful for pointing out sections that didn't flow or were confusing. Colin°Talk 17:43, 5 December 2009 (UTC)


 * Image review performed at peer review and all images checked out. Awadewit (talk) 14:52, 5 December 2009 (UTC)


 * Thank you for doing this important task. Colin°Talk 17:43, 5 December 2009 (UTC)


 * Support (and recuse). Disclaimer:  my comments on and MOS-y cleanup of the article a year and a half ago cause me to be listed as the fourth editor by edit count on the article, and I consider Colin a Wikifriend and one of our finest medical editors. This article is beautiful; digestible, fully compliant with MOS and MEDMOS, well sourced, easy to read, and I've watched for almost two years as Colin patiently worked on it and waited for sources to become available and an external review.  Well done, Colin!  Sandy Georgia  (Talk) 16:55, 5 December 2009 (UTC)
 * Thank you, Sandy. Your support means a lot. Colin°Talk 17:43, 5 December 2009 (UTC)


 * Support Add me to the pile-on support. Very interesting, and easy to read. I do have a few minor suggestions. Sasata (talk) 18:10, 5 December 2009 (UTC)
 * "Although popular for a while, it was discarded by most academic centres" To me the word discarded should be used with physical objects, I would suggest "discontinued" here
 * "In the 1960s, it was discovered that medium-chain triglycerides (MCTs) are much more ketogenic than normal dietary fats (which are mostly long-chain triglycerides). This is because MCTs are absorbed rapidly and contain many calories." I think it needs to be made a bit clearer that the main difference between MCTs and LCTs is in the rate of absorption; both are high in calories.
 * "Gastrointestinal side effects were a problem" link to stomachache?
 * "the results were presented to the American Epilepsy Society in 1996 and were published in 1998." How about a citation to whatever this was published in?
 * "On the ketogenic diet, their body would consume its own protein stores for fuel, leading to acidosis," acidosis is linked several times later in the article, but not here on the first mention
 * "Supplements are necessary to counter the dietary deficiency of many micronutrients.[4]" I'd be interested to know what micronutrients are typically lacking in a carbohydrate-restricted diet.
 * "... crystals that act as a nidus for calcium stone formation" gloss or wikt link nidus?
 * "Even "sugar-free" food can contain carbohydrates such as maltodextrin, sorbitol, starch and fructose" I think these carbs are worthy of links
 * I think the "Discontinuation" section should have the acronyms EEG and MRI linked
 * In the "Seizure pathology" section, I suggest wlinking refractory; probably inhibitory postsynaptic potential and excitatory postsynaptic potential could be piped somewhere in that section as well
 * reference format needs a little tweaking: compare these page ranges: 500-6, 589-96, 113-120. Also, current ref #27 has p. when it should be pp.
 * Thank you for these comments and for your support. I'll work on them and respond later tonight. Colin°Talk 18:23, 5 December 2009 (UTC)
 * Re discarded vs discontinued. My source uses the imagery "fell by the wayside". I see your point about physical objects. The problem with "discontinued" is that it isn't a continuous thing like a car production line but a lots of individual treatments. I'm thinking about it. Anyone got any other suggestions?
 * Abandoned? Sasata (talk) 03:26, 6 December 2009 (UTC)
 * Sounds good to me. Fvasconcellos (t·c) 12:27, 6 December 2009 (UTC)
 * Done. Good. Colin°Talk 15:55, 6 December 2009 (UTC)
 * Re MCT. I've removed they "contain many calories". That gave the wrong impression and it appears they actually have a slightly lower kcal/g than LCTs (8.3 compared to 9.0). I've replaced the sentence with info from another source.
 * Re gastrointestinal side effects. The effects were vomiting, diarrhoea, abdominal cramps and nausea. Stomach-ache only really fits one of those.
 * That's all for tonight. Colin°Talk 23:11, 5 December 2009 (UTC)
 * I'd use "gastrointestinal upset" for this particular combination. Fvasconcellos (t·c) 12:27, 6 December 2009 (UTC)
 * Are you suggesting replacing "Gastrointestinal side effects were a problem" with "Gastrointestinal upsets were a problem"? Sasata was suggesting a wikilink but I'm not sure we have one that covers all the side effects. Colin°Talk 15:55, 6 December 2009 (UTC)
 * Maybe "Gastrointestinal upset was a problem"? I don't think a wikilink is feasible unless you spell out each side effect. Fvasconcellos (t·c) 17:11, 6 December 2009 (UTC)
 * Done. Colin°Talk 19:43, 6 December 2009 (UTC)
 * Re "published in 1998" I've added a footnote link after the word "published". Does that work? Colin°Talk 15:55, 6 December 2009 (UTC)
 * Re "micronutrients" I've now expanded this in the "Classic diet" section. Rather difficult to get your 5 A Day on this diet! Colin°Talk 16:41, 6 December 2009 (UTC)
 * Re "nidus". Added Wiktionary link.
 * Re "maltodextrin, sorbitol, starch and fructose". Added wikilinks.
 * Re "EEG and MRI". Added wikilinks.
 * Re "Seizure pathology". Wikilinked "refractory period". I haven't wikilinked the other two. I'm afraid reworking this section to incorporate those phrases is beyond my abilities.
 * Re "page ranges". I've fixed "113–120" to "113–20". Were there any others that were wrong? I think the single "p." for a page range is OK according to this. Fvasconcellos is the expert.
 * Thanks for those suggestions. They've been really helpful. Colin°Talk 19:43, 6 December 2009 (UTC)


 * Support meets FA criteria, well done. Dincher (talk) 21:13, 5 December 2009 (UTC)
 * Thank you for reviewing the article, Dincher, and for your support. Colin°Talk 23:48, 5 December 2009 (UTC)


 * Note An IP has added some material about using the ketogenic diet for weight loss and for diabetes. The text isn't bad and is mostly cited so I can't just chuck it out. But it needs some work. The weight loss material probably belongs in the low-carbohydrate diet article with some mention here. The diabetes researchers have agreed to call their proposed diet therapy the Very low-carbohydrate ketogenic diet (LCKD) to avoid confusion with the well-established diet for epilepsy controll. Perhaps it is time for that article to be created. Neither "indications" have achieved clinical acceptance AFAIK although the diabetes one looks promising. It is interesting that most of the early researchers who invented the ketogenic diet for epilepsy were also researching diabetes. Colin°Talk 10:37, 7 December 2009 (UTC)
 * It appears to be a primary study; unless mentioned in reviews, why not delete it per WP:MEDRS, WP:UNDUE and WP:RECENTISM? Sandy Georgia  (Talk) 13:42, 7 December 2009 (UTC)
 * may review this. I'll need to get hold of it. I see diabetic diet covers this topic too. Colin°Talk 14:43, 7 December 2009 (UTC) BTW there's a discussion of this aspect with Eubulides at the peer review. Perhaps Eubulides can help me out here (hint hint) Colin°Talk 14:48, 7 December 2009 (UTC)
 * I'm afraid I lack easy access to Wylie-Rossett & Davis 2009, though it appears quite relevant. I'm no expert in this area, but my impression also is that the KD doesn't have at all the same clinical acceptance in other areas. I'm not sure it's wise at this stage to hive off Low-carbohydrate ketogenic diet into a separate article for diabetes, as the phrase "low-carbohydrate ketogenic diet", often with a comma before (or parentheses around) "ketogenic", is used in obesity and other areas besides diabetes. See, for example, (neurological disorders),  (prostate cancer),  (diet in general),  and  (obesity); these are all reviews. More than one source makes a point that the same or similar effect seen in epilepsy might also explain the (very preliminary) results in other neurological disorders. For example the following review, which now that I've seen the abstract may need to be cited in Ketogenic diet regardless of what's decided about subarticles.
 * Google Scholar says Maalouf et al. is cited by Kossoff et al. 2009 and by Kossoff & Rho 2009, which are already listed as sources, and maybe these more-recent sources are good enough. Eubulides (talk) 17:15, 7 December 2009 (UTC)
 * Google Scholar says Maalouf et al. is cited by Kossoff et al. 2009 and by Kossoff & Rho 2009, which are already listed as sources, and maybe these more-recent sources are good enough. Eubulides (talk) 17:15, 7 December 2009 (UTC)

Thanks very much for this Eubulides. After considering the subject, the added material, and the sources used by the added text (self-published book and primary research paper), I am confident enough to just revert the addition. I'll work on a small addition using better sources. I also need to read Maalouf et al., though I think my head is going to hurt with the effort. Colin°Talk 18:38, 7 December 2009 (UTC)


 * Comments -
 * What makes http://www.epilepsy.com/ a reliable source?
 * Likewise http://www.centerwatch.com/?
 * Likewise http://www.drugs.com/?
 * Otherwise, sources look okay, links checked out with the link checker tool. Ealdgyth - Talk 20:47, 7 December 2009 (UTC)


 * Thank-you for checking out the sources, Ealdgyth. Here's my response:


 * While these web-resources might not be a first choice per WP:MEDRS, I believe they are more than sufficiently reliable for the facts being drawn from them. I have deliberately chosen not to use these lesser sources to make claims about clinical matters such as efficacy, side effects, indications, etc.


 * Epilepsy.com's 2008 Annual Report says it is a "leading online resource for trusted information on epilepsy". It contains over 3,700 pages written by epilepsy professionals. The editorial board is impressive. The two articles used form part of a series called "Keto News", written by Eric Kossoff who is also the author of many papers cited by this Wikipedia article. The series has a topic editor.


 * Do ketogenic diets work for adults with epilepsy? Yes! is used to support the statement "Although the adult results are similar to modern studies of children, they did not compare as well to contemporary studies. Barborka concluded that adults were least likely to benefit from the diet". The rest of the paragraph is sourced to a scholarly book. I've read Barborka's paper.
 * The Ketogenic Diet…in a bottle? is used to support the fact that Ketonia is another formula product and "Alternatively, a liquid ketogenic diet may be produced by combining Ross Carbohydrate Free soy formula with Microlipid and Polycose." This latter fact could be sourced to an academic journal article if required.


 * According to their website, CenterWatch is "a Boston-based publishing and information services company focusing on the clinical research industry, is a business of Jobson Medical Information, LLC." It's writers and editors look professional to me. Their article on Axona is used for FDA approval information.


 * Drugs.com aims to be "the Internet’s most trusted resource for drug and related health information". They have an editorial staff of pharmacists and their content is drawn (licenced) from reputable drug information supplies. I have used this source for the proposed mechanism of action of Axona and the ingredients.


 * Colin°Talk 22:12, 7 December 2009 (UTC)


 * I'd be happier with information from third-party sources that showed their reliability, not information for the sites themselves. You can also approach it differently, if the various articles are attributed to specific authors, by showing (with third-party sources again) that the authors of the pages are noted in their field. I'm not going to say "utterly unreliable" here, but they are a drag on the otherwise fine sourcing of this article as it stands. (I do so enjoy all those PMIDs, they make my life SOOO easy...) Ealdgyth - Talk 22:33, 7 December 2009 (UTC)


 * I don't know how to go about finding a third-party to show their reliability without then querying that third-party's reliability/independence. I suspect lots of folk just repeat the press-release "About Us" paragraph. I've dropped the CenterWatch and Drugs.com sources and am now using the manufacturer's Prescribing Information leaflet. I'd prefer to get this direct from the FDA, and the FDA website does have a good database to search for such things. Unfortunately, it isn't in the database. Perhaps it is too new. If the manufacturer 's PI leaflet isn't considered reliable enough then I'm quite happy to drop caprylidene from the article until better sources can be found at a future date. Wrt the two epilepsy.com articles, here's the detail on the author and topic editors:


 * Both Epilepsy.com articles are written by Eric Kossoff MD.
 * His profile at Johns Hopkins Hospital says he is Assistant Professor of Neurology and Pediatrics, though that profile looks a little out of date. He's written 77 papers indexed by MedLine (can't get the hyperlink for PubMed to work cause it has [] in it), many on the ketogenic diet.


 * The "Do ketogenic diets work for adults..." article had topic editor Steven C. Schachter MD
 * His profile at Harvard's Beth Israel Deaconess Medical Center says he's Professor of Neurology and has written eight books on epilepsy and is founding editor and editor-in-chief of the journal Epilepsy & Behaviour. He's also president of the American Epilepsy Society.


 * The "The Ketogenic Diet…in a bottle?" article had topic editor Robert S. Fisher MD.
 * His profile at Stanford's Comprehensive Epilepsy Center (dated 2006) says he is Professor of Neurology, former president of the American Epilepsy society, the board of the International League Against Epilepsy and Editor-in-Chief of the journal Epilepsia.


 * Are these guy's employers (Johns Hopkins, Harvard and Stanford) trusted enough or do I need something more third party. If so, it is going to be really hard to tell if the third party hasn't just ripped off these official bios. I don't think those two articles "drag" the sources down as they are written and edited by the same folk who would write and edit an equivalent journal article. The information drawn from them is at the less-important end of the spectrum. Colin°Talk 00:06, 8 December 2009 (UTC)
 * Nah, all that looks good. University sites won't utterly make things up, if they look like they know what they are doing to you folks in the med project, I think we can consider this dealt with. The leaflet's fine. Ealdgyth - Talk 00:40, 8 December 2009 (UTC)
 * Comment You'll never find the caprylidene PI in Drugs@FDA, Colin, as it is a medical food (an entirely different beast for regulatory purposes). Fvasconcellos (t·c) 00:49, 8 December 2009 (UTC)
 * Just to clarify, still waiting on centerwatch. Ealdgyth - Talk 22:12, 8 December 2009 (UTC)
 * I've dropped the CenterWatch and Drugs.com sources. I think they are both reliable sources but don't know how to prove it. Is my alternative (the manufacturer's Prescribing Information leaflet) acceptable? Colin°Talk 22:28, 8 December 2009 (UTC)
 * Yeah, it was, I'd already stuck the drugs.com one, and the other is now struck so you're good! Ealdgyth - Talk 22:48, 8 December 2009 (UTC)

Comment: The ordering of this article does not seem to be the best. Epilepsy should be discussed under things the diet is used to treat rather than starting off as the first section as it is also used to treat obesity. History is also not of primary importance and should be near the end rather than right at the start. Doc James (talk · contribs · email) 00:53, 8 December 2009 (UTC)


 * Thanks for reviewing the article and your comments. As far as I know, a deliberately ketogenic diet is not used as a long-term treatment for any medical condition other than epilepsy (and the rare metabolic conditions mentioned). Low-carbohydrate diets have been studied for several (including the study you mention) but I'm not aware that any professional body or health authority recommends long-term use of a low-carbohydrate ketogenic diet for obesity or diabetes, for example. The key aspect of these diets tends to be the very low carbs (and relatively high protein) rather than deliberately being ketogenic. Since their ketogenic nature is typically a secondary characteristic, one that is perhaps only true for an initial phase of the diet, and of unproven significance, I think that low-carbohydrate diet is a more appropriate article to discuss these in any detail.


 * Wrt history being first: this is the order suggested by WP:MEDMOS (though I'm all for not sticking with MEDMOS suggestions if there's a good reason). All my comprehensive review papers and both my books begin with sections and chapters on the history. It is a gentle introduction to the topic and unlike modern drugs developed by faceless corporations, the 100 year history of dietary treatment for epilepsy is, IMO, interesting. Is there any consensus to move sections? What do others think? Colin°Talk 20:19, 8 December 2009 (UTC)


 * I like the History section where it is. For me, this is sort of part of the the introduction to the article. It gives a good background and, as Colin has said, many review articles in the medical literature are structured like this. I don't like to see history sections "relegated" and I hate to see them tagged on at the end. A good history section early on makes for an engaging read IMHO, and this is one of the FA criteria. Graham Colm Talk 21:23, 8 December 2009 (UTC)

Support. A few comments on an otherwise stellar article. Most are simply intended to clarify the information based on my own questions. Particular kudos on the "mechanism of action" which I found very informative and yet very readable.
 * I am inclined to agree with Doc James' suggestion that the history section should be moved down a bit. In addition to his reasoning, I felt I was able to better understand the history section after reading the rest of the article.
 * In the Fasting section were the "Twenty patients, of all ages..." all epileptic? I assume so but this should be clearly stated.
 * In the Outcomes section "The children who received delayed treatment acted as a control, which is particularly important for medical conditions where patients may get better or worse regardless of treatment." Is epilepsy this type of medical condition?
 * In Maintenance there was a bit of a disconnect. Are the "Urinary ketone levels are checked daily" using the ketone test strips mentioned int the next sentence?
 * Also in Maintenance, this sentence confused me a bit: "A short-lived increase in seizure frequency may occur during illness or if ketone levels fluctuate." Is the seizure increase during illness also related to fluctuation of ketone levels? Or more simply do ketone levels fluctuate during illness? If not then why else might seizures increase during illness?
 * Finally in Worldwide the sentence reading "In Israel, religious rules prevent mixing meat and milk in one dish". The assertion here that kosher = Israel is too narrow and might lead to the interpretation that there are civil "kosher laws" in Israel that everyone must follow. A better way to say this might be along the lines of: "For example, Jewish dietary laws prevent mixing meat and milk in one dish".--DO11.10 (talk) 20:48, 8 December 2009 (UTC)
 * Thank you on the compliment, DO11.10. I'm out of time tonight but will look through your comments tomorrow. Cheers, Colin°Talk 22:36, 8 December 2009 (UTC)


 * I've clarified text wrt the fasting patients comment, the medical conditions comment, the keto test strips comment, and the Israel/Jewish comment. Thanks for those.


 * An illness or fever is one of several factors that can increase seizure frequency in epilepsy (others include stress, sleep deprivation, menstruation and fatigue). I'm not sure of the reason why. The reason for the fluctuation in ketone levels more usually a compliance one: the child has consumed some sweets. I can see the two could be linked if for example the child was off their food then the wouldn't be consuming enough to produce strong levels of ketones. But essentially the two reasons aren't linked. Do you think the text needs to be changed?


 * I think the problem is the "if" here, which, in my mind at least, suggested that there might be link. Maybe "A short-lived increase in seizure frequency may occur during illness or when ketone levels fluctuate" more explicitly separates the two?  --DO11.10 (talk) 22:02, 9 December 2009 (UTC)


 * I haven't yet moved this history section. At the moment there seems to be a mix of views and I'm sure there isn't just one correct way to order an article. However, assuming it stays at the front, were there any specific things in the history that you didn't understand until after you had read the rest of the article. Or was it just a vague fitting-together feeling? Colin°Talk 17:55, 9 December 2009 (UTC)


 * Yes, my comment was based a vague fitting-together feeling. On my first read through I was probably more interested in finding out with the diet was rather than its history. Having reread the article again today I guess the order doesn't really matter... --DO11.10 (talk) 22:02, 9 December 2009 (UTC)


 * Thanks for the support. Yes the "when" separates them but I'm now worrying if perhaps "fluctuate" is a poor choice. I also don't want to make the association between those things and increased seizures sound inevitable. I'll review my sources wrt reasons for temporary loss of seizure control to see if I can phrase this better. Cheers, Colin°Talk 22:59, 9 December 2009 (UTC)


 * Support. An excellent example of the high-quality content that Wikipedia can produce when an experienced and knowledgeable editor like Colin gets to work. Excellent use of MEDRS (almost exclusively high-quality reviews) and very good porting of a highly technical scientific subject to lay terminology. Marvellous! JFW | T@lk  13:55, 13 December 2009 (UTC)
 * Thank you for your support JFW. Colin°Talk 18:38, 13 December 2009 (UTC)


 * Closing note: This candidate has been promoted, but there may be a delay in bot processing of the close.  Please see WP:FAC/ar, and leave the  template in place on the talk page until the bot goes through. Karanacs (talk) 19:53, 16 December 2009 (UTC)
 * The above discussion is preserved as an archive. Please do not modify it. No further edits should be made to this page.