SUMMARYIn 2003, a case series was published describing the benefits of a less restrictive ketogenic diet (KD) started as an outpatient without a fast and without any restrictions on calories, fluids, or protein. This "Modified Atkins Diet" (MAD) restricts carbohydrates to 10 g/day (15 g/day in adults) while encouraging high fat foods. Now 5 years later, there have been eight prospective and retrospective studies published on this alternative dietary therapy, both in children as well as adults. In these reports, 45 (45%) have had 50-90% seizure reduction, and 28 (28%) >90% seizure reduction, which is remarkably similar to the traditional KD. This review will discuss basics and tips to best provide the MAD, evidence for its efficacy, suggestions about the role of ketosis in dietary treatment efficacy, and its side effect profile. Lastly, the possible future benefits of this treatment for new-onset seizures, adults, neurologic conditions other than epilepsy, and developing countries of the world will be discussed. KEY WORDS: Modified Atkins diet, Ketosis, Children, Epilepsy, Ketogenic. The modified Atkins diet (MAD) was created at JohnsHopkins Hospital as an attempt to create a more palatable and less restrictive dietary treatment primarily for children with behavioral difficulties and adolescents that parents and neurologists were reluctant to start on the traditional ketogenic diet (KD). Recognizing that there is only limited evidence that high ratios, calorie and fluid restriction, fasting, and an inpatient diet initiation are necessary (Vaisleib et al., 2004;Bergqvist et al., 2005), the MAD was designed to mimic ketosis while providing similar but unlimited quantities of high fat (and protein) foods. As is commonly the case, parents and patients were the ones to first realize a stricter version of the Atkins diet controlled seizures either de novo or after loosening the restrictions of the KD and we first reported a case series of six children and adults in 2003(Kossoff et al., 2003. Half of these patients had at least a 50% reduction in seizures.Today it is no longer considered a new treatment; the MAD has been reported as efficacious in eight publications to date by centers in four countries (Kossoff et al.,

The modified Atkins diet is a high-fat, low-carbohydrate treatment for intractable childhood epilepsy. As data suggest that a stricter diet onset can be more effective, we added a ketogenic supplement to the modified Atkins diet during its initial month. Thirty children with intractable epilepsy were prospectively started on the modified Atkins diet in combination with a daily 400-calorie KetoCal shake. At 1 month, 24 (80%) children had >50% seizure reduction, of which 11 (37%) had >90% seizure reduction. There was no significant loss of efficacy during the second month after KetoCal was discontinued. The use of this ketogenic supplement increased daily fat intake and thus the ketogenic ratio (1.8:1 versus 1.0:1 in the modified Atkins diet alone, P = .0002), but did not change urinary or serum ketosis. The addition of a ketogenic supplement to the modified Atkins diet during its initial month appears to be beneficial.

Dietary therapies are established as beneficial for symptomatic generalized epilepsies such as Lennox-Gastaut syndrome; however, the outcome for idiopathic generalized epilepsy has never been specifically reported. The efficacy of the ketogenic and modified Atkins diet for childhood and juvenile absence epilepsy was evaluated from both historical literature review and patients treated at Johns Hopkins Hospital. Upon review of 17 published studies in which absence epilepsy was included as a patient subpopulation, approximately 69% of 133 with clear outcomes patients who received the ketogenic diet had a >50% seizure reduction, and 34% of these patients became seizure free. At Johns Hopkins Hospital, the ketogenic diet (n = 8) and modified Atkins diet (n = 13) led to similar outcomes, with 18 (82%) having a >50% seizure reduction, of which 10 (48%) had a >90% seizure reduction and 4 (19%) were seizure free. Neither age at diet onset, number of anticonvulsants used previously, particular diet used, nor gender correlated with success.

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