Talk:Ketogenic diet/Archive 2

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The pie charts

...are useful, but don't look very inviting at the start of the article. (A bit off-putting to be honest). Better to have one "showing a Ketostix being held against the scale", most readers, these, days, have experience of similar tests, and the image would add a bit of drama. I guess the test is done on urine? If so, it shouldn't be too difficult to show a positive and a negative reaction juxtaposed? Just a thought. --GrahamColm ^Talk 23:31, 26 March 2008 (UTC)

Agree, I just wanted something to fill the gap for now. Yes, the test is looking for ketones in the urine and is done at least daily. Hmm, not sure I've got that in the body text. Were you thinking of two sticks, one positive and one negative? I think that might look a bit posed (as the article isn't about urine tests) and the tub shows the colour of a negative result anyway. I thought about just showing a positive stick held next to the appropriate colour box.

Although this test for ketosis is an important part of the ketogenic diet, it seems a secondary aspect compared to the diet. The main pic should really be about the subject, which is food. I had considered taking a picture of food, though I'm not sure what. Ideas:

A full meal, prepared on a plate, such as the breakfast in the Classic diet section.
The ingredients for a meal, set in little dishes like a cookery program.
A picture of an electronic gram scale being used to weigh butter or cream. Having to weigh food to the nearest gram is an important aspect.

Any other ideas or preferences? Perhaps a combination of the latter two? For the KetoCal picture, I could show the made-up feed in a Flexitainer bottle with a tube running from it. Or show the made-up feed and the tin together in one pic? Colin°^Talk 13:57, 27 March 2008 (UTC)

Lead: efficacy

Thanks for your edits, Graham. Although I haven't kept them all, they've made me think hard about the wording so hopefully the result is an improvement.

I took the RCT trial back to singular as the plural made it sound like all RCT trials are unfeasible/unethical rather than just one on this therapy.
I replaced "support" with "recommend", which is stronger and the source allows for this.
The refractory link wasn't helpful so I've placed the word in parenthesis after "difficult-to-control" earlier in the lead.
I've replaced "control the condition" with "be effective". Depends what one considers "control" but a common interpretation would be seizure freedom. For refractory epilepsy, seizure freedom is so unusual that it isn't even a category in most AED trials (50% reduction is good enough).
I've replaced "additional" with "alternative". The doctor has the option to add or replace medications so "additional" doesn't always apply. This sentence may merit further work later.

Colin°^Talk 20:14, 27 March 2008 (UTC)

Food photos

Following an offer to take some food photos, here's some more thoughts about it, continuing the points made above.

I don't want the subject of the photos to stray too far into WP:OR. For example, ideally a ketogenic meal should be based on a published recipe. The article lists some sample meals that must be measured out on a scale accurate to the gram. I have a book chapter full of recipes (and there are more online) but these tend not to include weights as the exact amounts need to be calculated for the individual by a dietician (using a computer program, or tables). So turning those recipes into meals is possibly a step too far. I'm reluctant to use an unpublished recipe. I'll keep looking to see if I can find other exact recipes. Here's another one from a textbook:

45g of 36% heavy whipping cream
19g chicken breast (cooked, no skin)
33g butter
16g of "group B" vegetable. Examples of such vegetables (cooked weight) are beets, broccoli, brussels sprouts, carrots, cauliflower, green beans, onion, spinach, tomato.

Everyone wants the meals to be as palatable as possible, so many recipes produce a meal that looks similar to ordinary food (burger, omelette, tuna-mayo). Now that might be an important point to make in the article, but such a picture wouldn't be iconic enough for the lead photo. This may mean that a picture of a meal would be good for the Classic section, where the meal plan is detailed, but not for the lead.
The high fat nature of the diet is key, as is the very precise preparation required. This makes me think that a close up picture of an electronic scale weighing something like butter or heavy whipping cream (double cream) would be a good choice. Photos of the ingredients laid out like a cookery program might work but might also be too small to see.

Colin°^Talk 22:09, 6 April 2008 (UTC)

Lead

This part of the lead is not clear: The diet mimics aspects of starvation by forcing the body to use fat rather than carbohydrate as an energy source. The body produces excess ketone bodies, a state known as ketosis.

It needs a something like The diet mimics aspects of starvation by forcing the body to use fat rather than carbohydrate as an energy source and by-products are excess ketone bodies that produce a state known as ketosis.

Which is very clumsy I know, but at the moment it is not clear that the excess ketones are a result of the diet. GrahamColm ^Talk 12:25, 9 April 2008 (UTC)

Thanks. Yes I can see now that it isn't clear to the reader. It is this ketosis that occurs during fasting that is the "aspect" the diet is trying to copy. That isn't clear either. The "mechanism of action" is the hard stuff in this article. I'll have a think. Colin°^Talk 12:46, 9 April 2008 (UTC)

To do

Aspects that still need to be covered/explained.

KD is only recommended under supervision of specialists (paediatric neurologist, dietician) experienced in its use.
Lay explanation: insufficient carbohydrate to "burn" the fat results in ketone bodies as by product. Body first uses stores of glucose and glycogen. If fasting, it then burns body fat.
Extract what is common between the variants ("The ketogenic diet is calculated by a dietician for each child; age, weight, activity levels, culture and food preferences all affect the meal plan. A computer program may be used to help generate meals.", etc.)
Expand how the classic diet is calculated. Note approx 1g of protein per kg body weight.
Explain calorie restriction (they diet doesn't work if weight is being gained beyond that expected for age, also less calories are needed to digest such a high fat diet). Aim is for child to be normal weight for age/height.
Explain fluid restriction (used by some centres). Currently only noted under side effects.
Diet inadequate in vitamins and calcium -- requires supplements.
Classic 4:1 diet provides 90% of calories as fat. (Shown in pie chart but not text.)
MCT diet provides 60% of calories as MCT oil. (Shown in pie chart but not text.)
Can only eat permitted and carefully calculated meals and snacks. Portions are small but ketosis reduces appetite and thirst.
Note that the JH 150 trial involved children who had an average of 400 seizures a month and had tried more than six anticonvulsants, on average.
Ideal goal is seizure and medication freedom, but this only a minority result. Many achieve a reduction in both.
Even small amounts of carbohydrates can upset the diet and lead to seizures: medicines must be examined and sugar-free versions preferably used. Even suntan lotion can contain enough sorbitol to be absorbed.
Desired Ketostik levels: ≥ 4 mmol/L.
The diet is complex and can be difficult to follow.

Colin°^Talk 16:44, 9 April 2008 (UTC)

Image tweaking

Colin, do you think your images would benefit from a bit of tinkering?

Original

tinkered with

Graham GrahamColm ^Talk 17:32, 9 April 2008 (UTC)

Yes. That's a better overall colour and brightness though perhaps a little too much contrast. That picture was taken indoors and the camera didn't get the white balance right, plus I've been told it was confused by the white background into underexposing. Since you can't restore what has been lost due to underexposure, there are limits to how much it can be improved. One thing we do want to be reasonably accurate is the colour swatches. I've exchanged it as it is better but next week I'll try to take a more dynamic shot with a test stick.

Cheers, Colin°^Talk 18:11, 9 April 2008 (UTC)

A quick review

I think the Lead can be simplified a little given that all the detail follows in the body.

This is just a suggestion, something to discuss/think about:

The Ketogenic diet is a high fat, minimum protein, low carbohydrate diet primarily used in the treatment of refractory, (difficult to control) epilepsy in children. A ketogenic diet causes the body to break down fat and to produce excess waste products called ketones; a state known as ketosis. The diet contains four times more fat than carbohydrate and protein combined and, by forcing the body to burn more fat than carbohydrate for energy, the diet produces some of the symptoms of starvation. To produce ketosis, food containing sugar and starch, such as pasta, potatoes, is not eaten.

The diet was developed in the 1920s, but it’s use declined following the introduction of effective drugs to control epilepsy. In the 1990s the Hollywood film producer Jim Abrahams, whose son’s severe epilepsy was controlled by ketosis created the Charlie Foundation to promote the diet. The foundation sponsored a multicentre research programme and the results, which were published in 1996, marked the beginning of a renewed scientific interest in the diet.

Most dietary fat is made form molecules called long chain triglycerides and a variant of the diet, known as the MCT diet is based on a form of coconut oil that is rich in rarer fats called medium chain triglycerides, (MCT). The oil is very ketogenic and it use allows for a more varied regime.

The efficacy of the diet has not been tested in a large, double-blind, randomised controlled trial. Such a trial is regarded as unfeasible and possibly unethical, but meta-analysis of the many published uncontrolled prospective and retrospective studies of the diet provides sufficient evidence to support it’s clinical use.

In children with refractory epilepsy, a ketogenic diet is more likely to be effective than alternative anticonvulsant drugs. There is some evidence that adults with epilepsy might benefit from the diet and that a less strict regime, such as a modified Atkin’s could be effective.

In the History section the expression in a world with -is a bit too informal. How about, Once discarded in favour of modern ....

In Fasting could you use used - rather than employed?
He had similar results - would got or saw be better?
In diet, there lurks a nasty meanwhile.
In Efficacy Although urinary ketone levels are checked daily, the levels do not correlate with seizure effect. It's the seizure effect that's vague.
I have to read the paragraph beginning Electoencephalogram (EEG).... several times before I understand it. Could this be written more clearly? (It's OK after they will stick with it.)
Under Indications, is drug-resistant epilepsy an accepted term. I know about drug-resistant bacteria and viruses but ..?
The pyruvate dehydrogenase... bit will stop some readers dead in their tracks. Does it need simplfying or more explanation? Will the reader know that these are enzymes used to metabolise glucose?

Colin, this is all for now, more to come, but not much because I don't have any major problems of comprehension and the article is well written and interesting. I will be more than happy to keep on commenting. Graham GrahamColm ^Talk 18:56, 11 April 2008 (UTC)

More comments and suggestions

General

I think it would help the reader if the Variants section is moved up the article to follow History. In the Variants section terms are defined that at the moment are used higher up and thus require inverted commas such as “classic” and “eggnog”.

I wasn't totally happy with a top-level section called Variants. Perhaps the classic version should be promoted to main discussion and the MCT/Atkins/Formula variants left here?

Colin°^Talk 20:15, 13 April 2008 (UTC)

Yes, that would do the trick. GrahamColm ^Talk 20:24, 13 April 2008 (UTC)

The article seems to over ice the cake a little in stressing that KD is mainstream. It says so straight away under History, please check that the three or four other occurrences are helpful.

History

I would delete the phrase the non-mainstream use of and write. The ketogenic diet is a mainstream therapy that was scientifically developed to improve on the success and limitations of fasting to treat epilepsy.
..treatment of refractory epilepsy. I would just continue the sentence thus: …treatment of refractory epilepsy that cannot be controlled by different drugs.

I stuck a short lead paragraph in this section as I didn't want two headings in a row. I'm not sure the summary works or is necessary so soon after the lead. Any ideas? Colin°^Talk 20:15, 13 April 2008 (UTC)

Fasting

A couple of problematic sentences here:

Later analysis of Conklin's records show 20% achieved seizure freedom and 50% had improvement. Needs to say % of children.

I'll check this. It might not be clear what population group he refers to. Colin°^Talk 20:15, 13 April 2008 (UTC)

Conklin's ideas were adopted by neurologists in mainstream practice. – Is the mainstream bit needed here?
.. with a fast and then a starch- and sugar-free diet. – Followed by a starch free diet?

Are you suggesting I drop "sugar-"? I thought starch and sugars were different but both carbohydrates. The wording here comes from my source. I'll check. Colin°^Talk 20:15, 13 April 2008 (UTC)

Sorry, it was the "then" I took objection to. Leave the sugar in. GrahamColm ^Talk 20:30, 13 April 2008 (UTC)

He had similar results, but there was no long-term follow-up. His study gave similar results but he did not follow up the subjects in the long term?

Anticonvulsants

We have mainstream here once more.
Neurologists had drugs.. drugs were available to neurologists that were effective…?
The use of the ketogenic diet, by this time, restricted to difficult cases such as Lennox-Gastaut syndrome, declined further.

Revival

A multicentre prospective study began in 1994 and was presented. – Presumably the results were presented.
The form of classic or MCT ketogenic diet offered varies with the hospital and also culturally. - ?culturally why?

I'd like to expand this with some sources I have (though perhaps not in this section). Asia has a real problem with rice or noodles being so integral to their diet. Apart from areas where a Western diet is encroaching, MCT oil may be required to achieve ketosis and/or the ketogenic ratio may be much lower. Another example is India, where there is religious reluctance to fast children -- so they don't use an initial fast. Colin°^Talk 20:15, 13 April 2008 (UTC)

Colin, this would be a very interesting addition. GrahamColm ^Talk 20:26, 13 April 2008 (UTC)

have emerged as alternatives – come into use?

Efficacy

General comments. Expressions such as “stuck with”, “drop out”, “dropped out” and “give up on” don’t sound encyclopedic. Does Modern mean recent. (This might just be me but the opposite of modern is old-fashioned). We have halves and thirds mixed-up with %. Should we be consistent?

The patient group in older studies is also different. ..was different?
See my comments above about the EEG section.
The initial fast has been likened to an intravenous loading dose of anticonvulsant, and may be particularly beneficial where there is some medical urgency that outweighs the increased risk of acidosis - the meaning is not quite clear to me.

This sentence is too compressed. And the reader will not be familiar with the concept of a loading does. My source is drawing a parallel to e.g., start the patient on phenytoin but give a loading dose IV so that it starts immediately and brings the drug levels up. Then continue a maintenance dose (orally). This is in contrast to some anticonvulsants that must be started slowly to avoid side effects but clearly won't be effective for a while. If a patient is having very frequent seizures then using a fast to kick-start the diet may be helpful even if that hospital's protocol doesn't typically fast. Colin°^Talk 20:15, 13 April 2008 (UTC)

by spoiling the ketogenic diet – is spoiling the best word here?
Other study options being trialled include a controlled parallel-group where patients are randomised to receive the diet after a short interval (4 weeks) or a long interval (16 weeks). I don’t understand this.

At the start of the trial, all the children maintain their current treatment programme for 4 weeks, and their carers start a seizure diary. This establishes a baseline. Then half the children start the diet but the other half have to wait another 12 weeks. They act as a control, which is necessary since epilepsy is so variable and often childhood epilepsy will see some improvements over time. Neither group is denied the therapy and the group randomised to wait probably wouldn't have been taken any earlier anyway (since there's a waiting list mainly due to lack of trained dieticians). Does that make sense? How to explain that briefly? Colin°^Talk 15:35, 12 April 2008 (UTC)

More later. GrahamColm ^Talk 15:00, 12 April 2008 (UTC)

Thanks a lot, Graham. This is all really useful stuff and you have offered some good suggestions. I won't get a chance to spend time on the article till tomorrow afternoon. Colin°^Talk 15:35, 12 April 2008 (UTC)

No hurry. BTW have sent you an e-mail. GrahamColm ^Talk 16:04, 12 April 2008 (UTC)

Some more sugestions

Indications and contra-indications

The folk with pyruvate dehydrogenase and glucose transporter deficiencies are presumably put on the diet primarily to control lactic acidosis, so in their case the mode of action is understood? (I am assuming here that they do not have “classical” epilepsy and that the seizures are caused by deficiencies in glucose metabolism).

I'll read again why these conditions lead to epilepsy, but believe the KD provides an alternative energy source as the normal glucose one is no good. Yes, there is a difference with these symptomatic epilepsies in that we aren't relying on an anticonvulsant effect but are actually fixing (or working around) a metabolic problem. I'm not sure how much to expand on these as I think they are pretty rare and usually don't get much coverage in medical reviews (though I do recall some papers spending a paragraph or so on this). Colin°^Talk 20:29, 13 April 2008 (UTC)

Other conditions that generally contraindicate are defects in fatty acid oxidation. - These are metabolic defects? Are they hereditary?

I'll check. I think so. Colin°^Talk 20:29, 13 April 2008 (UTC)

Interactions

the opposite sequence..- is confusing.

Adverse effects

Oral potassium citrate is preventative and had no clear…. - has no clear?
..bone phosphate acts as an acid buffer. – bone phosphates neutralise the acid?

Initiation

.. the ketogenic ratio. - This is the first time this expression is used so it needs explaining or rewording.
A dietary history…
..they are allowed to drink, but not before dinner,
..restricted to one-third of the usual calories for a meal. Does a meal have usual calories?
Medicines are exchanged for carbohydrate-free formulations. Medicines are used instead of?

I'll reword this. Don't see how "instead of" works. Any medications the child is on has to have its carbohydrate measured and added to the allowance. If a sugar/sorbitol-free version can be used instead, then that helps with the meal plan. Colin°^Talk 20:29, 13 April 2008 (UTC)

Deviations - is not best word here. Variations is better.
(but is still achieved)
The initiation can be performed.- Is there a better word than initiation?

Maintenance

..with fine tuning. - minor adjustments to the regimen?

Discontinuation

..to reduce or discontinue anticonvulsant drugs. - drug intake?
..two or three month period. - over two or three months.

Variants

..leave or vomit the fat. Deliberately?

I'll check. The source might not say. I don't think it would be deliberate as we aren't talking about people with an eating disorder. Colin°^Talk 20:29, 13 April 2008 (UTC)

Mechanism of action

As it stands this section will be a problem for some readers. I will comment later on this. But for now I see that only one source is used. Are there others? GrahamColm ^Talk 16:48, 12 April 2008 (UTC)

Dietry or dietary?

I think it's the latter but I'm not sure. GrahamColm ^Talk 19:27, 13 April 2008 (UTC)

You are too kind. Fixed. Colin°^Talk 20:29, 13 April 2008 (UTC)

Comments

British english?

~~Not sure if these are typos or just english variants:~~

The ketogenic diet results in adaptive changes to brain energy metabolism that increases the energy reserves; ketone bodies are a more efficient fuel than glucose, and the number of mitrochondria is increased. (Isn't it "mitochondria" without the "r"?)

The developement of epilepsy (epileptogenesis) is a process that is poorly understood. (I've never seen it spelled like that before.)

A number of rare metabolic disease may benefit directly from the ketogenic diet. (Should disease take an "s" since it's plural?)

--Phenylalanine (talk) 22:34, 26 April 2008 (UTC)

Grammatical and other issues

These were retrospective studies, that only report on patients who stuck with the diet. (Consider rewording as follows: "These were retrospective studies, which only reported on patients who stuck with the diet.")

Done -- Colin°^Talk 21:56, 27 April 2008 (UTC)

The patient group in older studies is also different; modern patient groups tend to study children with refractory epilepsy. (Patient groups don't study; they are studied.)

Changed to most modern studies include only children... -- Colin°^Talk 21:56, 27 April 2008 (UTC)

Children with refractory epilepsy are more likely to find the ketogenic diet to be effective than trying an alternative anticonvulsant drug. (Consider revising as follows: "Children with refractory epilepsy are more likely to find the ketogenic diet to be effective and to stay on such a diet than to try an anticonvulsant drug.")

Not sure what your change is trying to say. I accept it is a complex sentence that might benefit from simplifying. However, the suggested alternative says ...are more likely to XXX than to try an anticonvulsant drug. It isn't the trying of drugs we are comparing but it is the effectiveness of trying A rather than B. Thoughts? -- Colin°^Talk 21:56, 27 April 2008 (UTC)

How about: Children with refractory epilepsy are more likely to find the consumption of the ketogenic diet to be effective than the intake of alternative anticonvulsant drug. Also, have you considered this (which slightly changes the meaning of the sentence): Children with refractory epilepsy are likely to find the consumption of the ketogenic diet to be more effective than the intake of alternative anticonvulsant drug. --Phenylalanine (talk) 08:41, 1 May 2008 (UTC)

In the UK, the National Institute for Health and Clinical Excellence state that the diet should not be recommended for adults with epilepsy due to insufficient evidence of efficacy. (the NIHCE "states"...)

Done -- Colin°^Talk 21:56, 27 April 2008 (UTC)

The lack of randomised controlled trials meant that a Cochrane review in 2003 concluded that the diet was merely "a possible option" in the treatment of intractable epilepsy. (I would reword the sentence as follows "Based on the lack of randomised controlled trials, a Cochrane review in 2003 concluded that the diet was merely "a possible option" in the treatment of intractable epilepsy.")

Done, but said "Due to the lack..." -- Colin°^Talk 21:56, 27 April 2008 (UTC)

Oral potassium citrate is preventative and had no clear disadvantages; its routine use is under investigation. (Consider changing "and had no clear" to the present tense - the rest of the paragraph uses the present tense.)

Done -- Colin°^Talk 21:56, 27 April 2008 (UTC)

During their stay in hospital, the patient has their glucose levels checked and is monitored for signs of symptomatic ketosis (which can be treated with a small quantity of orange juice). ("Patient" is singular, "their" is plural.)

Hmm. Tried to reword this. Ended up with a rather passive sentence. I'm thinking that to make it active, I need to bring in the folk doing the monitoring. But are they doctors, physicians, nurses, or some other general healthcare-staff term. -- Colin°^Talk 21:56, 27 April 2008 (UTC)

Lack of energy and lethargy are common but disappear by two weeks. (I prefer "disappear after two weeks".)

Source says lack of energy "regained over the ensuing two weeks" rather than "after two weeks". Have changed to within two weeks". -- Colin°^Talk 21:56, 27 April 2008 (UTC)

Deviations from the Johns Hopkins protocol are common. If there is no initial fast, the time to reach ketosis is longer (but still achieved within five days), and there were fewer initial complications. (It should read "and there are fewer...")

Done -- Colin°^Talk 21:56, 27 April 2008 (UTC)

Their use allows the fat content to be lowered and consequently greater protein and carbohydrate intake. (I would say "and consequently enables greater protein and carbohydrate intake")

Done -- Colin°^Talk 21:56, 27 April 2008 (UTC)

On the ketogenic diet, carbohydrates are severely restricted so cannot provide for all the metabolic needs of the body. (I would say "and so cannot provide...")

Done -- Colin°^Talk 21:56, 27 April 2008 (UTC)

Most energy is instead produced by a high rate of fatty-acid oxidation in the cell mitochondria. (I would say "Most of the energy it requires is...")

Yes, this probably isn't the clearest explanation. But I can't say "it" as it isn't clear what "it" is (the cell, the body?). -- Colin°^Talk 21:56, 27 April 2008 (UTC)

It is protective in many of these models and has a different protection profile to any known anticonvulsant. (What logical connection is established by the preposition "to"?)

I've replaced "to" with "than". Is that better? -- Colin°^Talk 21:56, 27 April 2008 (UTC)

Case reports on indicate a possible use in treating brain tumours (astrocytomas). (Case reports on what?)

I've removed "on". -- Colin°^Talk 21:56, 27 April 2008 (UTC)

--Phenylalanine (talk) 01:23, 27 April 2008 (UTC)

Thanks for that. Phenylalanine has gone on wikibreak, so if anyone else can help me with the above queries, I'd appreciate it. Colin°^Talk 21:56, 27 April 2008 (UTC)

I'm back from my break. Cheers! (P.S. You might want to take a look at this.) --Phenylalanine (talk) 08:41, 1 May 2008 (UTC)

GA Review

This review is transcluded from Talk:Ketogenic diet/GA1. The edit link for this section can be used to add comments to the review.

Good article nomination on hold

This article's Good Article promotion has been put on hold. During review, some issues were discovered that can be resolved without a major re-write. This is how the article, as of July 6, 2008, compares against the six good article criteria:

1. Well written?:

Generally too complex and often in passive voice. Try simplifying sentences and switching to active voice. For example, just from the lead:

"primarily used in the treatment of difficult-to-control (refractory) epilepsy in children." - "primarily used to treat difficult-to-control (refractory) epilepsy in children."

Think you fixed that one. Colin°^Talk 22:43, 7 July 2008 (UTC)

"The diet is calculated to have just enough protein..." - "The diet has just enough protein..."

Changed. Colin°^Talk 22:43, 7 July 2008 (UTC)

"To achieve this, a number of foods are effectively eliminated (for example, starchy fruits and vegetables, bread, pasta, grains and sugar)." - "This is achieved by eliminating foods containing large amounts of starch and sugar, such as starchy fruits and vegetables, bread, pasta, grains and sugar."

I've rephrased this with a sentence that discusses reducing carbs and increasing fat. Colin°^Talk 22:43, 7 July 2008 (UTC)

"which allows for some relaxation of the carbohydrate and protein restriction." - "allowing less restrictive carbohydrate and protein intakes.

I've rephrased this and added the consequential benefit. Colin°^Talk 22:43, 7 July 2008 (UTC)

Unclear what the "normal metabolic process" is, Would be simpler to just say "Normally glucose is used as fuel for the body and the brain. However, if carbohydrate..."

If the primary author of metabolism is unclear then I must be doing something wrong :-). Can you elaborate? The problem I see with the suggestion, particularly as the third sentence of the article, is that it says nothing about how glucose is acquired (might someone even think we consume sufficient quantities of glucose?). Is the transformation of carbs (and protein) into glucose not a "metabolic process"? I need a bit of help here. Colin°^Talk 22:43, 7 July 2008 (UTC)

I think we can ignore gluconeogenesis in the lead, just for simplicity's sake. What do you think of the new version?

Much better. However, we've got two "body"s in the sentence. Can the first one be replaced by an organ (is it the liver)? Colin°^Talk 10:23, 9 July 2008 (UTC)

I've always disliked the use of science as an adjective eg "scientifically developed" or "scientifically study", you could either say "study" or "developed" or "developed by nutritionists"

I've dropped it. But you've just offended a bunch of (medically and scientifically trained) dietitians by confusing them with nutritionists (Gillian McKeith, need I say more?) That's the distinction I was trying to emphasise by the use of "scientifically". Colin°^Talk 22:43, 7 July 2008 (UTC)

Oh dear. Me too. Colin°^Talk 16:15, 8 July 2008 (UTC)

Describing somebody as a "disciple" is a bit overblown.

The word appears in most of my sources and originally comes from the great Lennox's contemporary account. Reading about the two characters, I think it is appropriate and I can't think of a good alternative. Colin°^Talk 22:43, 7 July 2008 (UTC)

Unclear what the idea is in "The idea was to maintain the benefits of fasting over a much longer period."

I've rephrased this, does that help? Colin°^Talk 22:43, 7 July 2008 (UTC)

This sentence is hanging "and first used urine testing to monitor the level of ketosis." - do you mean was the first to use urine testing?

Changed. Colin°^Talk 22:43, 7 July 2008 (UTC)

"difficult to produce palatable meals, which led to problems with compliance." - recast this in terms of the patient's view. eg "which meant that people found it difficult to follow the diet for long periods."

I've rephrased this, closer to the source too. The suggested alternative would produce two "difficult"s. Colin°^Talk 22:43, 7 July 2008 (UTC)

Unclear what culture has to do with this dies, in the sentence "The form of classic or MCT ketogenic diet offered varies with the hospital and also culturally."

I'll come back to this and expand. Colin°^Talk 22:43, 7 July 2008 (UTC)

for a period of time this is always a phrase to avoid. It is vague and adds nothing to the sentence. Either say abut how long "about 2-3 months" or give a range "ranging from 2 months, up to five years" (numbers invented, don't quote me!)

Rephrased but there are no number to give. Colin°^Talk 22:43, 7 July 2008 (UTC)

"spotting issues with compliance" - "checking if the patient is following the diet"

Rephrased, but can't say "check" twice so I've gone with "confirm". Colin°^Talk 22:43, 7 July 2008 (UTC)

"The initial fast has been likened to an intravenous loading dose of medication, used with certain anticonvulsants, where treatment begins with a large dose of the drug and maintained on a lower dose." - you could probably cut this, it is a bit of a digression

Dropped. Colin°^Talk 22:43, 7 July 2008 (UTC)

The sentence "Children with refractory epilepsy are more likely to find the ketogenic diet to be effective than trying an alternative anticonvulsant drug" needs to be merged with the rest of the text, rather than being a paragraph on its own.

Moved to end of earlier paragraph. Colin°^Talk 22:43, 7 July 2008 (UTC)

The section on MCT oil repeats some of the material from earlier.

I'll come back to this. Colin°^Talk 22:43, 7 July 2008 (UTC)

"liquid feed that has none of the palatability issues" - what palatability issues? Unclear what this is referring to, is it comparing the liquid feed to the classic ketogenic diet?

I've rephrased and expanded this a little. Perhaps I need to make it clear that the MCT diet also has palatability issues (consuming that much oil-emulsion isn't fun). Colin°^Talk 22:43, 7 July 2008 (UTC)

2. Factually accurate?:

"There are no harmful or beneficial interactions between anticonvulsant drugs and the ketogenic diet." - this needs a citation, it is also unlikely to be true, since RCTs are lacking and all we can probably say is that no interactions are known at present.
"These are generally less severe and less frequent than with anticonvulsant medication or surgery." - needs a citation, perhaps the Paediatrics review?
"the combination of these anticonvulsants and the ketogenic diet does not appear to elevate that risk." - needs a citation
"Oral potassium citrate is preventative and has no clear disadvantages; its routine use is under investigation." - needs a citation

3. Broad in coverage?: Pass

4. Neutral point of view?: Pass

5. Article stability? Pass

6. Images?:

The caption "Urinary ketones are tested daily." doesn't tell you what the image actually is.

Please address these matters soon and then leave a note here showing how they have been resolved. After 48 hours the article should be reviewed again. If these issues are not addressed within 7 days, the article may be failed without further notice. Thank you for your work so far. Tim Vickers (talk) 17:49, 6 July 2008 (UTC)

I believe I've fixed the issues in section 2. I'll try and address the specific issues from section 1 tomorrow (but will let you know if I can't manage that in time). Then I'll work on the more general complex/passive issues. Wrt "cultural" issues, Graham had the same query in his review above. I will try to add something here, I've got a source that covers it. Colin°^Talk 22:59, 6 July 2008 (UTC)

You've made more than enough progress for this to be a GA. To be honest it didn't need much! Tim Vickers (talk) 03:05, 9 July 2008 (UTC)

Potential as treatment for cancer

I've added a new paragraph under 'Other Applications' mentioning recent studies looking at the use of ketogenic diets in the treatment of cancer, although it would be preferable to find the original studies instead of using a secondary source, as well as desirable for someone to expand upon the theories behind this treatment. Andybellenie (talk) 21:39, 11 August 2008 (UTC)

Andybellenie, thanks for trying to improve this article. However, I've decided to revert those changes for several reasons:

The mouse study text cites Medical News Today. It would be better to cite a paper in a peer reviewed journal than an online medical newspaper. However, mouse studies on cancer are ten-a-penny and there's no indication this has any clinical relevance. To get that perspective, one needs to find a high-quality secondary source such as a review in a medical journal.
The study described by the TIME article "is still in its early, difficult stages". Let's wait till it is published in a peer-reviewed journal. We generally avoid newspapers and magazines as sources for medical information, see WP:MEDRS, as they tend to hype and over-simplify the issues.
The journal article cited (Nebeling 1995) is a primary source. WP:MEDRS prefers high quality secondary sources such as the review (Hartman 2007) already used. That review cites Nebeling's work as well as one other article. I thought the existing sentence covered the material satisfactorily: that the published research in humans amounts to case studies on two children. Since so little has been published or researched in this area, I don't feel it warrants a paragraph yet (WP:WEIGHT) but once more research is published, I hope we can say something more positive.

Colin°^Talk 08:23, 12 August 2008 (UTC)

Brief critique/movie stars

Colin, I reviewed this article on the ketogenic diet and it is thorough, well-referenced, and although a bit long, reads simply. I have two critiques. First, although well-researched and not overtly biased, it has a breathless or enthusiastic tone that makes me wonder if the person writing it has an intimate and successful first-hand experience of the diet. Second, the 'revival' of the diet was not celebrity driven, although lay awareness of it certainly may have been. The growth of publications in the ketogenic diet coincide with a period of long inactivity in the release of new anticonvulsants in the US, ending in 1995 with the introduction (and subsequent crash) of felbamate. Except for the growth in use of benzodiazepines, there were no new anticonvulsants available for a twenty year period, and that was a powerful driving force in evaluating the efficacy of the ketogenic diet. The growing number of publications in the ketogenic diet currently reside mainly in the mechanistic realm in hope that whatever makes the diet work can be tapped pharmaceutically. The problem is that my opinion is a product of personal observations; I couldn't steer you to references to support it. Suffice to say, Meryl Streep had little to do with research interest in the diet; An analogy; Bob Dole was good for advertising of Viagra, but Bob Dole didn't drive research to investigate it. Maybe relegating the popular interest in it can be gathered into a 'popular culture' or similar catagory. It merits mentioning; no anticonvulsant has inspired a movie. I guess the only equivalent is 'Awakenings' for l-dopa in Parkinsons. Karmattol (talk) 22:37, 25 September 2008 (UTC)

Firstly, thank you very much for reviewing this. If there are aspects you think could be trimmed, let me know.

Two historical reviews (Wheless 2004; Freeman et al 2007) and the interview external link all focus on the Jim Abrahams story as the turning point for the diet. Perhaps that's because it is a good story. According to these sources, the multi-centre trial was funded by the Charlie Foundation and set up to benefit from the publicity (Dateline) which resulted in a "deluge" (5,000 phone calls) of interest. The Meryl Streep movie only came out a year after the research publications "exploded" (they jumped from virtually nothing, overnight) and I agree that movie is definitely lay propaganda rather than anything that might influence research. Freemam has claimed the film "fueled a grass-roots effort for more research on the diet"[1] The Charlie story is repeated in many other reviews of the diet, so I feel it is a key part of the history section. "In popular culture" sections are discouraged as trivia, and I can't honestly think of anything else that would go there. Your analysis of the state of anticonvulsant availability in the US rings bells and I'm sure I can find sources that confirm that. You may well be right about the reasons for KD research growth. Perhaps Abrahams provided the spark and some kindling and was fortunate that there were folk around gathering firewood at the same time. BTW: Lorenzo's Oil (film) is another example.

The tone I hope is no more enthusiastic and positive than the sources. If you can give me some examples of where it should be neutral, negative or less "breathless", I would be grateful. I will bear this in mind when I run through the text again. Journal papers on the KD do tend to be rather evangelical. I suppose the authors are still fighting for funding (for dietitians, for example) and to be taken seriously.

Publications on the KD seem split in two IMO. There's basic research on the mechanism and there's clinical research into efficacy, variants, side effects, etc. There's enough of the latter to make me think plenty people are interested in using the diet rather than just finding a pill alternative. My personal uneducated opinion is that a pill replacement is unlikely, though the research should aid our understanding of epilepsy and we may discover novel mechanisms that can be attacked by anticonvulsant medication. An analogy would be the failure to capture the health benefits of a diet rich in fruit and vegetables in one simple pill. Colin°^Talk 20:44, 27 September 2008 (UTC)

Agree with your points. Karmattol (talk) 22:39, 5 October 2008 (UTC)

On the Essentiality of Dietary Carbohydrate

Plaskett, L. G. (2003). "On the Essentiality of Dietary Carbohydrate". Journal of Nutritional & Environmental Medicine. 13 (3): 161–168. doi:10.1080/13590840310001619405. {{cite journal}}: Unknown parameter |month= ignored (help)

Thermoproteus (talk) 14:50, 25 December 2008 (UTC)

New review by Kossoff et al.

There's a new review by Kossoff et al. that looks like it'd be a good source for recent developments:

Kossoff EH, Zupec-Kania BA, Rho JM (2009). "Ketogenic diets: an update for child neurologists". J Child Neurol. doi:10.1177/0883073809337162. PMID 19535814.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Eubulides (talk) 17:47, 19 June 2009 (UTC)

This is a really good review. I've got hold of it now and will be incorporating it. Colin°^Talk 22:09, 15 September 2009 (UTC)

Done. Colin°^Talk 16:48, 12 October 2009 (UTC)

Recent edits

Recent edits to the article, which in some case are welcome improvements, have introduced some problems. Some of these go against the Manual of Style. I am also concerned that all the "&nbsp" (non-breaking spaces) have been deleted, which will cause the text to be broken on many screens, (including mine). I think it should also be noted that the article is written in UK English and that it is policy that consistency of usage is conserved. (Note, "caretakers" means something completely different to "carers" in the UK—perhaps we should find a more international word). In short, I think many of today's edits need close examination to check that the meaning has been preserved and the Mos breaches have not been inadvertently introduced. Graham Colm ^Talk 22:44, 3 November 2009 (UTC)