The ketogenic diet (KD) is one of the most effective therapies for drug-resistant epilepsy. The efficacy of the medium-chain triglyceride KD (MCTKD) is as excellent as the classic KD (CKD), which has been documented in several subsequent retrospective, prospective, and randomized studies. MCT oil is more ketogenic than long-chain triglycerides. Therefore, the MCTKD allows more carbohydrate and protein food, which makes the diet more palatable than the CKD. The MCTKD is not based on diet ratios as is the CKD, but uses a percentage of calories from MCT oil to create ketones. There has also been literature which documents the associated gastrointestinal side effects from the MCTKD, such as diarrhea, vomiting, bloating, and cramps. Therefore, the MCTKD has been an underutilized diet therapy for intractable epilepsy among children.The author has used up to >70% MCTKD diet to maximize seizure control with gastrointestinal side effects optimally controlled. As long as health care professionals carefully manage MCTKD, many more patients with epilepsy who are not appropriate for CKD or modified Atkins diet or low glycemic index treatment will benefit from this treatment. A comparison between the MCTKD and other KDs is also discussed. (Biomed J 2013;36:9-15)

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SUMMARYThe medium-chain triglyceride diet (MCTD) is a variant of the classic 4:1 ketogenic diet (KD) introduced in 1971 by Huttenlocher as an attempt to improve the palatability of the KD by allowing more carbohydrates yet preserving ketosis. Although initially found to be equally effective as the classic KD, use of the MCTD declined because of frequent gastrointestinal side effects such as cramps, diarrhea, and vomiting. EFFICACY OF MCT KETOGENIC THERAPYBecause medium-chain triglycerides (MCT, C6-C12) are more ketogenic than long chain triglycerides (LCT) (Schön et al., 1959), Huttenlocher introduced a variant of the classic ketogenic diet (KD) to allow more carbohydrate (Huttenlocher et al., 1971). This medium-chain triglyceride diet (MCTD), with a ketogenic ratio of approximately 1.2:1, was thus more palatable than the classic 4:1 KD. Efficacy was excellent, with 58% of patients achieving >90% seizure reduction, a similar success rate to that achieved on the classic KD. One study that directly compared MCTD with a classic KD showed no difference in seizure control (Schwartz et al., 1989). The MCTD successfully suppressed a similar spectrum of seizures as the classic KD (e.g., minor motor, akinetic and myoclonic seizures). This excellent efficacy was verified in several subsequent studies (Table 1). However, the MCTD was frequently associated with gastrointestinal (GI) side effects including diarrhea, vomiting, bloating, and cramps (Table 1) (Sell et al., 2005). We are now in the process of studying 43 children with a mean age of 7.3 years (range: 2-16 years), on a MCTD consisting of 71% total fat, 19% carbohydrate, and 10% protein, a ratio of approximately 1.2:1. The children are divided into three groups: one group is receiving 40-55% MCT, another group is getting 60% MCT, and the third group is receiving a >60% MCT diet. At present, 21% of children are seizure free, 19% has a >90% seizure reduction, and another 42% has a 50-90% seizure reduction. In the past 3 years, with careful monitoring and management, we estimate 100% compliance; prior to 2005, about 7% of the cohort experienced gastrointestinal problems and discontinued the diet. Therefore, in our hands, the MCTD is providing superb efficacy and minimal side effects. The MCTD has been used with a variety of seizure types and underlying etiologies.

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