MAD about Atkins for Epilepsy!

Hello all!  A short detour in the sporadic blogging as I came across this 2013 paper yesterday:  A decade of the modified Atkins diet (2003–2013): Results, insights, and future directions   Eric H. Kossoff, Mackenzie C. Cervenka, Bobbie J. Henry, Courtney A. Haney, Zahava Turner

The acronym in my title has been used to denote the Modified Atkins Diet, and as the title of the paper implies, it has been utilized clinically in the treatment of epilepsy for over a decade now.  The lead author of the paper is Eric Kossoff, and here are some relevant bio points for him:
  • Associate Professor of Neurology and Pediatrics at Johns Hopkins Children's Center, Director of the Pediatric Neurology Residency Program. 
  • Coauthor of Treatment of Pediatric Neurologic Disorders and the 5th edition of The Ketogenic Diet (Amazon affiliate link).
  • Wrote the foreward to The New Atkins for a New You (2010) written by Eric Westman, Stephen Phinney and Jeff Volek.
  • Member Science Advisory Board for Atkins Nutritionals
  • Has received funding from The Dr. Robert C. Atkins Foundation (see paper) which was funded by proceeds from Atkins Nutritionals products.
  • Has received funding from Nutricia, makers of KetoCal supplement/foods used with both KD and the MAD.

I have three reasons today for this post.  

1.  Conflicts of Interest: 

Were this any other food, any other diet, etc., Kossoff would risk being called a shill, "in the pocket of ...", or otherwise be a walking billboard for COI that could potentially influence his scientific objectivity.  If you read Ketogenic Diets, as I have, you would probably agree with me that in Kossoff's case, COI are likely not an issue with this man.  In terms of advocacy, writing the foreward for TNA is probably as bad as it gets.   Still, just imagine if this were someone researching starch diets for glycogen storage diseases and being funded by Argo.  

I don't know what to think about COIs anymore except that they should be divulged completely and let the chips fall where they may.  There can be no "pristine" funding source, and there can be no truly objective governing body due to the century-plus-old practice of government and industry involvement in nutrition research.  I believe Kossoff is a shining example of doing it right.  (Please let me know if I've missed something here!).

2.  Application of Treatment:

Another thing I think Kossoff does right is keeping the message tight.  Even though the KD book mentions other neurological disorders in the subtitle, the book and this article don't stray into extrapolating results to other applications.  This is not the case for others who are essentially advocating ketogenic diets for hangnails these days!  

Kossoff also seems to maintain focus on the role of ketosis in the therapeutic efficacy of the diets he employs in treatment.  Even though MAD is shown effective, he's still looked at particular types of epilepsy or case profiles that may respond better if transitioned to the more restrictive KD.   

3.  Direction of #LCHF "Paradigm"

I saved the proverbial best for last here, as this is what really prompted my post.  

I discovered the low carb websphere on the cusp of popularity of the general low carb blog - 2009.  Already by the time I began blogging in 2010, your run-of-the-mill Atkins approach was waning, and The New Atkins and Gary Taubes' Why We Get Fat both fell short of expectations and advance hype.    Already in 2009, I encountered the "up the fat" message directed at anyone struggling with garden variety Atkins-based low carb.  Even though many low carbers have embraced or just hitched a ride on the paleo wave (seemingly crested now as well), by far the higher fat message has been the shift.  When 60% fat is not "really that high", you know the message has shifted further still.

Low carbers went keto and embraced the low carb HIGH FAT mantra.  Protein restriction became the new gimmick -- remember the steak might as well be chocolate cake quip of 2012?   Well, while everyone in LLVLClue land was upping the fat, resisting the laws of the universe, striving for fat burning beast status, and pricking fingers for ketones, apparently the original ketogenic folks were looking for ways to make the known therapeutic effects of ketosis for epilepsy accessible/doable for a wider range of patients.   

Enter the Modified Atkins Diet.  

Still high fat, but also high protein and not quite as low in carb as the uber strict therapeutic KDs in use.  

If some degree of therapeutic success achieved by traditional ketogenic diets can be achieved using a less restrictive diet, this is a good thing.  After all, if you look at the study flow charts, there are always those who drop out of the study for the "simple" reason of not being able to tolerate/maintain the diet for whatever reason.  Kossoff and colleagues have demonstrated that for some populations -- particularly teens and adults -- there may be an easier way!

There's a lesson or few here perhaps?  

If therapeutic effects can be realized (in some, perhaps in many) with a less restrictive diet, what does this say for going more restrictive trying to find some magical therapeutic low carb diet for weight loss (or diabetes)?  In my opinion, if low carbohydrate approaches are ever going to reach widespread acceptance at least for therapeutic interventions, it's going to be with a more Kossoff/KD-for-epilepsy type approach:
  • Well defined dietary parameters (e.g. what do the LC and HF really mean?)
  • Concrete clinical evidence matching to the well defined diet
  • Attention to sustainability in the real world including acknowledging the negatives about the diet and trying to accommodate those as best as possible.
  • Maintain focus all around.  Don't exaggerate outcomes for a somewhat similar diet for a possibly unrelated purpose to make claims about your dietary prescription for weight (metabolic) management.
Instead, now that the keto kraze has krested, many in the #LCHF movement are embracing ... get this ... not eating at all!   Combine this with MLM exogenous ketones that have absolutely no known utility for weight loss or metabolic issues and the path is narrowing and headed towards a cliff ...