Ketogenic diets for drug-resistant epilepsy.
Level 1 - systematic review of randomized trials
Systematic review and meta-analysis of randomized controlled trials
PubMed 32588435 · doi:10.1002/14651858.CD001903.pub5
What was done
This Cochrane systematic review and meta-analysis evaluated randomized and quasi-randomized controlled trials of ketogenic diets (including classic ketogenic diets, medium-chain triglyceride diets, and modified Atkins diets) versus usual care or alternative ketogenic protocols for drug-resistant epilepsy across all ages. Authors extracted data independently, assessed risk of bias, and conducted intention-to-treat meta-analyses reporting risk ratios (RRs) with 95% confidence intervals (CIs) for seizure freedom, seizure reduction (50% or greater), and adverse effects.
What was found
Thirteen studies with 932 participants (711 children, 221 adults) were included. In children compared to usual care (4 studies, n = 385), ketogenic diets increased seizure freedom (RR 3.16, 95% CI 1.20 to 8.35; P = 0.02; very low certainty) and seizure reduction of 50% or more (RR 5.80, 95% CI 3.48 to 9.65; P < 0.001; low certainty). In adults compared to usual care (2 studies, n = 141), zero participants achieved seizure freedom, and seizure reduction did not reach statistical significance (RR 5.03, 95% CI 0.26 to 97.68; P = 0.29; very low certainty). In child diet comparisons, up to 55% achieved seizure freedom on a classic 4:1 ketogenic diet and up to 25% on a modified Atkins diet. Gastrointestinal symptoms (vomiting, constipation, diarrhea) were the most common adverse events.
Why it matters
Ketogenic dietary therapies provide an effective non-pharmacological treatment option that substantially reduces seizures in children with drug-resistant epilepsy. However, evidence supporting their efficacy in adults remains inconclusive.
Limits
All 13 included trials had high risk of performance and detection bias due to lack of blinding. Studies had small sample sizes causing serious imprecision, leading to low to very low GRADE certainty across all outcomes. Adult data were limited to only 221 participants across studies.
Cited by
- supports The ketogenic diet has been utilized clinically for over a century to reduce the frequency and severity of epileptic seizures.