Epilepsy Case Study IAmy GoodPriority Nutrition Care Distance Dietetic Intern: Community RotationJanuary 2014

Contents• Overview of client

• Description of epilepsy– Prevalence

– Diagnosis

– Medical treatment

• Medical nutrition therapy for epilepsy

• Nutritional assessment of client– Nutrition diagnosis

– Nutrition intervention

– Monitoring and evaluation

Client Overview• Female

• 4 years and 10 months old

• Past medical history of hydrocephalous

• Current medical history of epilepsy– Being treated with Keppra

What is epilepsy?• Seizure disorder

• Seizure occurs when a rush of electrical impulses affects the brain

• Epilepsy can be categorized as:– Symptomatic – linked to a specific disease or

abnormality or

– Cryptogenic – not linked to a specific disease

Prevalence of epilepsy• <2 years old and >65 years old

• Male

• Racial minority

• 200,000 new cases of epilepsy each year

Medical diagnosis of epilepsy• History of seizures

– Frequency

– Type

• Electroencephalograph (EEG)

Two main types of seizures DescriptionTonic-clonic (grand mal) seizure Lasts 1-2 minutes, groggy/disoriented for

minutes to hours after regaining consciousness, postictal phase is characterized by sleep, headache, confusion, soreness

Absence (petit mal) seizure May appear to be daydreaming, lasts only a few seconds, no postictal fatigue/disorientation, no loss of consciousness

Medical treatment of epilepsy• Antiepileptic drugs

– Some antiepileptic medications increase vitamin D metabolism in the liver

• Inhibits the absorption of calcium in the intestines. Long term use of these medications may result in osteomalacia or rickets.

– Side effects range from anorexia to upset stomach to suicidal tendencies

• Important for doctors to be involved and have regular follow ups when clients are taking antiepileptic drugs

Medical Nutrition Therapy: Ketogenic Diet• Can be used for children with all types of seizures

• Last resort if medication is not working

• 1/3 of children following the ketogenic diet became seizure free

• The diet initiates ketosis – Ketones in the blood are elevated

– Ketones are formed when glycogen stores have run out

• Not yet understood how diet decreases seizure occurrence

Two types of ketogenic diet• “Traditional” ketogenic diet

– Introduced in the 1920’s

– Diet begins with fasting to induce ketonuria

– 4:1 ratio of fats to protein/CHO

– Fats should make up typically 75% of calories

– Fluids are restricted to no more than 2L/day

– Foods such as bread and pasta are not allowed

– Vitamin and mineral supplementation is encouraged to provide full nutrition

“Traditional” Ketogenic Diet BreakdownSample meal plan for 2,000 calorie diet

Meal Fat (g) Protein (g) Carbohydrates (g) Calories (kcal)

Breakfast 40 20 0 440

Lunch 55 35 4 651

Dinner 60 50 4 756

Snack 15 5 0 155

Total 170 110 8 2002

Two types of ketogenic diet• MCT-based approach

– Diet begins with fasting to induce ketonuria

– Replaces long-chain fats with medium-chain triglycerides (MCT)

– Ketosis can be more easily achieved with MCT so nonketogenic foods are allowed (carbohydrates)

– Fluid is not restricted

Typical Ketogenic Diet Menu Using MCT Oil

Food Item Amount (g) Carbohydrates (g) Protein (g) Fat (g) Energy (kcal)

BreakfastWhite bread 5 2.8 0.4 0.2 13Eggs, scrambled 48 6.1 5.5 74Cream, heavy whipping

10 0.3 0.3 3.8 36

Margarine or butter5 5.0 45

MCT oil 12 12.0 108Fat 11 11.0 99Drink sweetened w/ nonnutritive sweetner 240

Total 2.8 6.8 37.5 375LunchAmerican cheese 12 2.2 2.8 3.6 52Ham 23 0.7 3.7 3.9 53MCT oil mayonnaise

11 11.0 99

Fat 19 19.0 171Drink sweetened w/ nonnutritive sweetener 240

Total 2.9 6.5 37.5 375DinnerTurkey 19 6.3 0.7 32Tomato 10 0.5 0.1 0.0 3Green beans 10 0.6 0.2 0.0 3Potatoes 12 1.4 0.2 0.0 8Margarine 15 15.0 135MCT oil mayonnaise

11 11.0 99

Fat 10 10.0 90Drink sweetened w/ nonnutritive sweetener 240

Total 2.8 6.8 36.7 370Daily Total 8.5 20.1 111.7 1120MCT, Medium-Chain TriglycerideAdapted from Krause’s Food and Nutrition Therapy 12th Edition.

Ketogenic diet• Typically used for two years

• Caloric intake is the same as with any child– Calculated by RD using age, gender, weight, height, and

activity level

• Requires a lot of counseling– New foods

– Compliance with diet

• Implications– Growth problems

– Nutrient deficiencies

Client Assessment and Energy/Nutrient Requirements

• 1200 kcal/day

• 3-5 ounces of protein

• 1-1.5 cups of fruit

• 1.5-2.5 cups of vegetables

• 4-6 ounces of grains

• 2.5-3 cups of dairy

Lab Value

Age 4 years 10 months old

Height 46”

Weight 55#

BMI 18.3 (normal)

Hgb 13.5g/dl

Current Client Medication and Nutrient Analysis• Children’s

multivitamin

• Keppra (antiepileptic)– Avoid consumption of

raw ginkgo seeds as it can decrease effectiveness of drug

Meal AmountCarbohydr

ates (g)Fat (g) Protein (g)

Calories (kcal)

Breakfast

Frosted Flakes

30g 27 0 1 110

2% milk 1 cup 11.4 4.8 8.1 122

Lunch

Peanut butter and jelly sandwich on white bread

1 sandwich 47 19 12 400

2% milk 1 cup 11.4 4.8 8.1 122

Dinner

Macaroni and cheese

1 cup 48 3 1 260

2 % milk 1 cup 11.4 4.8 8.1 122

Snack

Grape juice 1 cup 38 0 1 140

Total 194.2 36.4 39.3 1,276

Percentage of daily calories

61% 26% 13%

Nutrition Diagnosis, Intervention, Monitoring and Evaluation

• Diagnosis– Food and nutrition related knowledge deficit related to

the use of a training cup as evidenced by training cup use after two years of age

• Intervention– Will offer a regular cup daily as opposed to a training cup

to decrease chance of dental carries

– Will offer 2 servings of quality protein daily, such as chicken, eggs, or beans

– Will try to replace one carbohydrate serving at dinner with a fat or protein serving, daily

• Monitoring and evaluation– Follow up appointment to re-evaluate goals

– Referral to physician if necessary