The principles of Roberta's diet
Welcome to the enigmas of lipids, embedded in the paradoxes of the ketogenic diet, in turn embedded within the Zen of Epilepsy. No one ever said this was a primrose path (pun intended)!
Balance of fats
While there are no established guide-lines for proportions of different fats to be used in the diet, I have developed my own principles based on nearly 30 years of reading, observation of various food cultures, and personal experimentation with diet:
In arriving at this position, the following considerations are relevant:
There are some fats I have isolated to be a problem in children with seizure disorders- most specifically fats in canola oil, olive, peanut, safflower and mustard oil should be avoided, which translates to avoidance of mustard, spinach, peanuts and peanut butter and foods containing canola, peanut, olive and safflower oil. In addition, the use of hydrogenated vegetable oil and margarine should be avoided completely as the trans fats in hydrogenated fats profoundly shut down endocrine, immune and brain metabolism.
Dr Kane's work has evolved from her own experience, at age 22, of rejecting medical advice to institutionalise her infant son whose neurological prognosis after an accident was hopeless. I cannot recommend Dr Kane's work to anyone, but I do know that she's coming from "the right place": a parent's faith that there is an answer.
Biochemistry is complicated in its own right, but fatty acid chemistry is complex in the extreme. Personally, I am waiting to have my daughter's chemistries redone according to Dr Kane's methodology. In the meantime, I am following Dr Kane's recommendation to avoid the above foods and oils. Also, my own inclination at this point is to avoid oils - they are all highly processed, after all - and to supply a variety of wholesome ketogenic foods containing excellent sources of essential fatty acids I'm using a wide variety of fresh, organic seeds and nuts: especially macadamia (of course!); sesame; almond; pecan (nb: small children can choke easily on nuts. Fresh nut butters can be easily made in a food processor or purchased at a health food store or by healthful mail order services). I believe that the ketogenic diet can be a nutritious diet if a wide variety of pure, whole foods are incorporated into the daily menus. The bulk of the fat is simply burned for energy, so "all that fat" really doesn't matter at all. It's the "icing on the cake" that needs to be carefully chosen for maximum metabolic efficiency.
I started Roberta on the diet with misgivings about using saturated fat. The first menus I received, which were hand calculated by Millie Kelly, called for 100g of 36% cream with each meal. I've experimented a good deal with different kinds of oils since then - but I feel strongly now that heavy cream is the most powerful component in Roberta's diet.
What I've observed in Roberta is that the bulk of the fat should be saturated with small amounts of unsaturates.
I believe that saturated fats probably produce ketones more efficiently than unsaturated fats. I've spoken to a couple of chemists about this and they agree intuitively. I think cholesterol is not high on our collective list of worries! But it is true that the body must ingest essential fatty acids from unsaturated sources . There are no RDA's for essential fatty acids to date. Pure extra virgin olive oil is a healthy mono unsaturate that has stood the test of millennia. Very small quantities are required.
Just because there's abundant fat in the diet plus a transport mechanism for getting it across the walls of the mitochondria (which carnitine does) , it doesn't follow that fat is being burned efficiently. It seems to me I read somewhere that water is necessary for the burning of fats.
We tried adding MCT oil. We used menus drawn up again by Millie Kelly, who included 5 g MCT oil per 500 calorie meal. We didn't see any difference. When I experimented using MCT as the sole fat, Roberta would seize. I've experimented a good deal with different oils, and I've come to the conclusion that I don't like them! What I do now is avoid them altogether! To ensure a good essential fatty acid profile, we use fresh, whole foods: as wide a variety as possible of raw, unprocessed nuts, seeds (nb: you have to be careful feeding nuts to small children - making nut butters is probably best) and marine oils from tuna or salmon a couple of times a week. Roberta eats a very healthy diet! "All that fat" is simply burned up for energy!
Essential fatty acids
Essential fatty acids are called essential for good reason. Since the body cannot make them, they must be supplied by food. Anyone of any age can become depleted as an aftermath of illness and/or chronic stress. But babies and small children are especially at risk for essential fatty acid deficiencies because they need them for brain and CNS development and, unlike adults, they have no accumulated stores to draw on.
Most children on the ketogenic diet are getting some unsaturated fats from vegetable oils. But are some children getting no unsaturates? What constitutes a well balanced essential fatty acid spectrum? What would be a sensible ratio of saturates to unsaturates?
Dieticians will say "But we have no RDA's for essential fatty acids." Not good enough for us parents! Back to the drawing-boards!
I have been leery of proportions of essential fatty acids in the ketogenic diet because the diet has always been done with a preponderance of saturated fats. I was wondering if some children weren't getting too large a quantity of essential fatty acids. But it certainly makes sense that the gut has to be in shape in order that absorption take place. I give Roberta acidophilus and digestive enzymes also. Is caprylic acid a digestive aid? I have always suspected that Roberta's very first deficiency problem after weaning from the breast was GLA. I do give her select essential fatty acids but with great caution because I really don't have a sense of their working with the ketogenic diet.
I would speculate that the ketogenic diet lays the groundwork and specific essential fatty acids provides the finishing touches. The following is a quotation from the dietician's bible -Human Nutrition, Burton and Foster, McGraw Hill, 1988, p.84:
Since the chances of ingesting essential unsaturated fatty acids are inversely related to the proportion of ordinary saturated fats in the diet, it would probably be wise to add to the existing concept of a balanced diet (i.e. protein, fat, carbohydrate, minerals and vitamins) a new proviso concerning a (yet unspecified ) balance between the intake of saturated and unsaturated fats, and between omega-3 and omega-6 fatty acids.
On the same page there is elucidation of the link between essential fatty acid deficiency and insulin secretion. This paragraph may well explain a key mechanism, if not the key mechanism, of the ketogenic diet:
...insulin secretion... decreases hormone-sensitive lipase activity in adipose tissue, which in turn prevents fat mobilisation and favours fat deposition. This means that access to essential fatty acids from both exogenous and endogenous sources is cut off, and deficiency states can occur in the absence of corrective measures.
Thus, the modern Western diet, rife with hyperinsulinemia (high sugar driving high insulin secretion), leads to essential fatty acid deficiency, which, in turn, can cause brain and CNS mal-function in growing children, particularly at times when nutritional reserves may be depleted by stresses such as illness, vaccination etc. I believe that, while epileptic children constitute a minority of adversely affected individuals, essential fatty acid imbalance may well be at the root of our current plague of "soft" neurological deficits.
Caution about essential fatty acids
In Dr Werbach: In "Healing With Food", Harper Collins, p. 135, there is a caveat re supplementation with omega-6 fatty acids in cases of temporal-lobe epilepsy. This caution is based upon a single study (Vaddadi, K.S. : "The use of gamma-linolenic acid and linoleic acid to differentiate between temporal lobe epilepsy and schizophrenia" in Prostaglandins Med 6:375-79, 1981). I think it is very important to explore the issue of optimal essential fatty acid. supplementation. I have been striving to turn our implementation of the ketogenic diet guidelines into a nutritious diet, a "healing" diet per se. I've used essential fatty acids up to a point, but always with caution because the ketogenic diet has traditionally been implemented with saturated fat. I've come to the conclusion that essential fatty acids should be used as essential nutrients, but sparingly as befits micro-nutrient supplementation.
Fatty acid chemistry is incredibly complicated. One of the few fatty acid experts I know of in the nutritional therapeutic field - Dr Patricia Kane - does not recommend canola oil in the dietary treatment of the epilepsy patients on whose behalf she consults.
I'm not an advocate of Udo Erasmus' book "Fats that kill, fats that heal". I haven't read it, although I believe he condemns margarine (as do all informed nutritionists), condemns butter and cream (bad for heart patients; essential for growing children; probably indispensable for myelin repair, hence those on the ketogenic diet). Fatty acid chemistry is complex and imperfectly understood to begin with, and "good" and "bad" depend on overall diet composition. Udo's oil contains both omega-3s and omega-6s. The popular trend of thought is that omega-3s (occurring most plentifully in fish) have become deficient in most diets. Flax seed oil is the vegetable-source with omega-3s that many prefer because fish have become contaminated (what isn't?) Roberta really likes Udo's 'Missing Link' digestive and essential fatty acid granules, but I've used it very sparingly because it has carbohydrates. I've consulted with Udo on the phone. He does not have the clinical experience of Dr Patricia Kane.
Flax seed oil
Flaxseed oil is very hot in health food circles because it is such a rich source of omega-3 fats. Barry Sears, however - he's the biochemist author of the two books about "The Zone" (a state of metabolic well-being achieved through dietary manipulation to keep glucagon and insulin in balance, and to produce "good" eicosanoids), has many reservations about flaxseed oil because too many omega-3 fats can create imbalances in the overall fat profile. A common sense approach might be to use a variety of oils - just as one does well to eat a variety of foods because of the subtle properties inherent in their unique composition - and bearing in mind that MCT oil might be useful in conjunction with the traditional ketogenic diet heavy cream.
Evening primrose oil (GLA)
I believe that my daughter Robert has benefited from supplementation with evening primrose oil. I started giving her conservative amounts after the airing of the Abrahams' Dateline program a couple of years ago. Since I couldn't find a keto program for her, I decided to let her eat all the fats she wanted, which amounted to a good deal of heavy cream and butter added to a nutritious diet of vegetables, fruits, whole grains, meats and fish. However, concerned with overall nutrition, I made sure she had a wide variety of high fat vegetable foods as well as saturated dairy fats - nuts, including macadamia nuts, avocado, and coconut. I also included fatty fish like salmon, and supplemented with cod liver oil as well as evening primrose oil. Roberta improved on the high fat diet.
GLA is, by functional biochemical definition, excitatory. Any excitatory chemical must be approached by epileptics with caution - even herbs like sage; rosemary is another. Evening primrose oil, which contains a highly concentrated amount of GLA, - like all manufactured food supplements - must be considered as a drug. But, whereas drugs are not nutritionally required by the human body, GLA is a required nutrient, an essential fatty acid: the body cannot make its own supply by combining other nutrients, as it does in the case of carnitine, for example. GLA is abundant in plants in very small quantities. What if an individual on the ketogenic diet is not eating much plant food? Vegetarians who eat a wide variety of plant foods are less likely candidates for fatty acid deficiencies than meat eaters because, in the balance of things, high consumption of saturated fats calls for increased demands for essential fatty acids. It is therefore reasonable to assume that some individuals on the ketogenic diet will, especially after many months on the diet, develop specific essential fatty acid deficiencies. The supplementation recommended for children on ketogenic diet therapy has been assembled in a slip-shod fashion. There has never been any input from paediatric nutritionists, nutritional biochemists and other experts. For some children this makes little difference. For others it could sabotage the treatment.
GLA is an omega-6 essential fatty acid that has an important role in prostaglandin regulation. Omega-6s have to be in balance with omega-3s (eg: fish oils and flaxseed oil). If you're supplementing with essential fatty acids, you might want to try experimenting with both - always using conservative amounts. Remember, also, that they are acids. My own experience is to beware of too many acid elements in a diet that is already skewed in that direction.
continue to The acid
return to Roberta's diet
(update 1.3: 18 July 2002)
(issue : 26 March 1998)