Dementia can be caused by many different conditions (such as severe head trauma, strokes, and degenerative diseases) and can occur at any age. However, it is most common in the elderly, and Alzheimer’s disease (AD) is the most frequent cause. Physicians and scientists have studied whether diet plays a role in determining who gets AD and whether changes in diet may be useful in treating some of the symptoms. The research done so far has been focused on four major areas: individual nutrients, specific foods, dietary supplements, and special diets. The most common dietary recommendation for the prevention of AD is to eat a “heart-healthy” diet. Several “medical foods” for AD have been developed and are being marketed. These include ketogenic agents, such as Axona and combinations of cell membrane-supporting nutrients, such as Souvenaid.

This chapter presents the core principles underpinning the modified ketogenic diet (MKD)-UK approach, but diet centers in different parts of the United Kingdom, and indeed across the world, may navigate the initiation, prescription, and fine-tuning of their hybrid keto journeys slightly differently. The MKD-UK prescription process starts out with an estimation of individual energy requirements, just like the classic KD. This is then translated into an approximate distribution of 5% energy coming from carbohydrates, 75% from fat, and 20% from protein. The guidance for protein is simply to include a good quality source at each meal, choosing moderate-sized portions with no weighing. Therefore, the MKD-UK delivers an element of the classic KD control over the most antiketogenic (carbohydrate) and proketogenic (fat) components of the diet, while maintaining the more liberal modified Atkins diet approach to protein (although adjustment to protein portions may come along during the fine-tuning phase, if required).

For children who are seizure free, there is anxiety and fear about seizures coming back. In prior editions of this book, this chapter was brief and there was little real research to guide the recommendations. Plan ahead—in most situations, weaning the diet is not an emergency. The long-term consequences of remaining on the ketogenic diet for many years have been studied recently, and although most children do very well, there can be problems. Previous editions of this book and even the 2009 consensus statement suggested that weaning the diet over “several” months was “traditional”, but there has never been proof that a slow wean is best. It is natural for a parent to feel anxious when a child is going off the diet. The ketogenic diet therapy’s goal is to treat a problem—seizures. Once the problem is gone, the therapy should also end.

Perhaps the most common question asked of us by parents and patients is whether or not we believe the ketogenic diet is likely to be helpful versus trying another medication (or surgery or vagus nerve stimulation [VNS]). Quoting the odds is helpful, but because everyone with epilepsy is different, is there a way to know who will respond to the diet and who will not? This chapter provides a brief description on: when in the course of epilepsy?; and who is likely to be a super responder to the diet? Close communication with the physician and dietitian is not only a good idea; it’s mandatory to make the diet work. The hospital team also must spend considerable time and energy to make the diet program effective with email and phone contact with families, handling illnesses and providing support, and watching and monitoring for both expected and unexpected problems.

Fasting’s healing properties have been noted since the beginning of recorded history in both Eastern and Western traditions. Fasting was specifically recognized as a treatment for epilepsy in the 1920s, and there are anecdotal reports of seizure reduction during illnesses with limited food intake, that is, unintentional fasting. This chapter briefly discusses the types of fasting. A potential benefit of adding intermittent fasting to a ketogenic diet therapies (KDT) is a simplification to the diet, which could lead to longer duration of KDT. Fasting is not a replacement for KDT, but it can provide additional benefits. In general, fasting is not recommended for people who are underweight, pregnant, breastfeeding, become overketotic easily, or in those with an eating disorder. Talk with your KDT team if you are interested in fasting. Some medications may need adjustments, especially if you take medicine for diabetes.

Fasting and prayer have been mentioned as treatments for seizures and epilepsy since biblical times. Hippocrates in 400 BCE described a man with seizures due to a burn injury who was successfully treated with “complete abstinence from food and water”. The ketogenic diet was widely used throughout the 1930s. In fact, the diet was widely used for conditions such as absence (petit mal) epilepsy, which has recently been rediscovered as a type of seizure that responds well to the diet. This chapter briefs on: the discovery of the ketogenic diet; and the start of the modern era and renewed interest in the diet. The 27 years since the founding of The Charlie Foundation has seen a rebirth in interest in the ketogenic diet. Five clinical diets are available today and there are many different ways to start the diet with countless ways to combine and adapt these diets.

This chapter briefs on motivations for creating a diet center for adults. In addition to controlling seizures, motivations for adults to start a ketogenic diet may include avoiding the side effects of additional antiseizure drugs, reducing antiseizure drugs, weight loss, reducing headaches, treating other neurologic conditions, and improving cognition. Some patients are eligible for epilepsy surgery but are not yet prepared to move forward with the procedure or are in the process of being evaluated for surgery when they decide to try the diet. Adults started on a ketogenic diet at another ketogenic diet center who are tolerating it well with good seizure control are most often kept on the same diet when transitioning to the AEDC with modifications as needed. A typical clinic day in the AEDC is structured with 1-hour new-patient visits in the morning with the epileptologist and with the registered dietitian.

Despite its proven efficacy in the treatment of intractable epilepsy (seizure disorders that have failed to respond to the proper use of two or more antiseizure medications), the ketogenic diet is still regarded sometimes as a “treatment of last resort” by neurologists and other physicians who manage patients with seizures. The ketogenic diet can be used as “first-line” therapy in certain situations, and actually there is general agreement that it is the “treatment of choice” in two conditions. These two prominent examples of first-line treatment are glucose transporter-1 deficiency and pyruvate dehydrogenase complex deficiency syndromes. There are some barriers in the medical system to using the ketogenic diet before trying medication. First, dietitians and neurologists have to change their mind-set about the diet and consider it an appropriate “emergency” treatment option. Second, families would have to be patient (sometimes for months) and give the diet a chance to work.

What value does the ketogenic diet have in improvement of some of the more troubling behaviors seen in children with autism? Although this is a relatively new idea, the history of the diet and autism goes back several decades. Even in the earliest papers written on the diet in the 1920s and 1930s, patients with intellectual disability were described as “brighter” and “more alert” with the use of the ketogenic diet. If we as parents are thinking about classic ketogenic diet for our child with autism but not epilepsy, it would probably have to be the modified Atkins diet or low glycemic index treatment, and with the help of a dietitian familiar with these treatments. Any supplements, probiotics, oils, or other foods would have to be changed to low carb. The authors also strongly advise making sure our child’s autism specialist is involved and set goals determined beforehand.

If one learns one thing from this chapter, make it this: The modified Atkins diet (MAD) is not a high-protein diet. Don’t make the mistake of replacing carbohydrates with protein. Instead, replace the carbohydrates with fat! Never underestimate the value of comparison shopping. This chapter provides a brief description on: grocery shopping tips; eating out; tracking your diet and meal planning; breakfast tips; lunch tips; dinner tips; and snack and dessert tips. Tracking your diet with a food diary, an online program, or phone app will make the diet very manageable and will help to ensure that you are following the guidelines that your clinical team has recommended for you. When one is on MAD, some special things to pay attention to are: fluid; fiber; salt; eat vegetables; and vitamin and mineral supplementation.