__% of epilepsy uncontrolled w/ meds
30
surgical candidates are those with ___ that can be removed
lesions
high fat diet designed to mimic metabolic effects of starvation, used to treat epilepsy
keto diet
ketone bodies produced by ____
liver mitochondria
short and medium chain f.a. are oxidized only in ____, long and very long chain oxidized in ___ as well
mitochondria; peroxisomes
how are ketone bodies made?
shunt excess acetyl coA to ketogenesis
why infant brain more efficient extract/utilize ketone bodies from blood?
higher lvls ketone metabolizing enzymes and monocarboxylic acid transporters
___ can produce ketone bodies under conditions of glucose utilization
astrocytes
brain ^ lvls of monocarboxylic acid transporters and ketone metabolizing enzymes rapidly during periods of _____
stress (trauma, ischemia, low glucose)
direct mechanism of ketogenic diet fxn:
alternative fuel provision
indirect mech of keto diet fxn:
mito biogenesis, neurotransmitter metabolism, antioxidant status, epigenetic mechanism
free fatty acids metabolize into ___ and ___
acetoacetate; betahydroxybutyrate
GABA is an _____ neurotransmitter and is synth by ____ cycle intermediate alpha ketoglutarate via glutamate and glutamate decarboxylase
inhibitory; Kreb’s
___ is a known inhibitor of glutamate decarboxylase
aspartate
possible mechanisms of keto diet on GABA?
affect GABA lvls, shunt flow, or responsiveness within brain
K ATP channels activated when cell ATP levels are ____, they have a _____ effect
low; hyperpolarization
Keto increases ____ levels, stabilizing membrane potential
ATP
how does keto diet work directly?
alternative fuel provision
how does keto diet work indirectly?
mitochondrial biogenesis, neurotransmitter metabolism, antioxidant status, epigenetic mechanism
common adverse events:
renal stones/haematuria, hypoglycemia
keto bloodwork is performed pre-keto and every ___ months
6
pre-keto screen for ____
f.a. oxidation defects
ab ultrasound used to check for ____
non alcoholic fatty liver
all ingredients in meal must be ___
weighed or measured
variables to consider when initiating keto?
family, community resources, keto diet team, hospital resources, keto diet candidate
variables pt keto diet candidate?
time away from work, selective food preferences, time away from family in hospital, coping skills to change, med acuity
family considerations?
equipment and food affordability, family dynamics to cope with change, cost of admission
community resources to consider?
keto diet family support groups, outpatient lab access, internet access, cooking demos, education of local community/work place/school
keto diet team considerations:
availability of RD, inpatient/outpatient services, professionals available
hospital resources to consider:
training of staff, cost of admission, availability of team members, outpatient/inpatient
recommendations for pre-keto diet evaluation:
teaching/counselling, nutr evaluation of current diet, eating pattern, anthro, labs
methods of initiation?
outpatient/inpatient, slow/fast titration, how to titrate, hydration restriction/no restriction, fasting/non fasting
inpatient initation uses ___ titration, appropriate for med unstable pt
rapid
rapid titration is over ____ and slow is over ___
days; weeks
advantage of slow titration?
less side effects, no hospital admission needed, adjustment to lifestyle gradual, longer window monitor efficacy, RD time not as concentrated (more balance), ease of new lifestyle transition
advantages rapid titration?
achieve ketosis sooner, seizure control sooner, pt/family very motivated and capable for rapid change
disadvantage of gradual?
take longer see seizure control
disadvantage of rapid?
KD prescription more restrictive than necessary, acute side effects, fast adjustment
side effects common to fasting:
hypoglycemia, acidosis, IVF, wt loss
ketogenic ratio is grams of ___ to sum of grams of ______
fat; pro and CHO
what are typical keto ratios?
3:1 and 4:1
challenge of keto ratios?
difficult compare KD prescription when describing in ratios, since don’t adequately describe g of pro and CHO
method 2 of titration?
titrate via % calories of macros or grams
% calories is more ____ than keto ratios
precise
what is method 3 of titration?
set initial goal of g of CHO/day
modified atkins diet has ____ g CHO / day
10-20
low glycemic index diet has _____ g CHO/day
40-60
examples of menus/exchange lists?
fruit and veg exchange, food exchange, custom menus, glycemic index lists, fat/pro/CHO exchange list
inpatient rapid titration uses ____ keto diet, outpatient slow titration uses ______ ratio, ___ initiation
classical; low; slow
outpatient rapid titration uses ___ diet and ___ diet
modified atkins; low glycemic
after first month of modified atkins may ^ net CHO by _____ g/day
5-10
diff between keto and mod atkins?
restricted vs unrestricted cals, sometimes fasting vs. no fasting, measure food vs no measuring food
home monitoring for low ratio slow initation:
daily cap blood sugars, daily urine ketones, weekly blood ketones
how to rehydrate in inpatient?
non-dextrose IV solutions, 0.5 strength pedialyte (oral or tube feeding)
reasons for hypoglycemia?
losses from vomiting/diarrhea, inadequate/poor intake
measure cap blood sugars q ___ hours until resolved then can reduce to q ____ hours
3-4; 4-6
goal for hypoglycemia is ___mmol/L or greater
3.0
reasons for acidosis:
prolonged fasting, poorly hydrated, carbonic anhydrase inhibitor meds, keto ratio is too high, keto ratio is acceptable but pt refuses to take in CHO component of meal
normal pH bicarb is ___ mmol/L or greater
18
goal when have ketosis is ___ mmol/L
8-16
if hyperketosis, consider giving ____% more non carb fluid
10-25
if < 8 mmol/L in urine may be false low, make sure urine sample was ___
fresh
__ scores to determine trend of growth
z
reasons for constipation:
very low fibre intake in keto diet, inadequate fluid intake, gut motility is compromised