First Eat Right - Dietitian Nutritionist Dr. Nafeesa's Diet & Nutrition Clinic

Pls take this seriously. We Gain Nothing But Brain Drain By Taking Up the Junk Food Lane.

​Ref;  All video credits to DW Documentary https://www.youtube.com/watch?v=TLpbfOJ4bJU

Junk is thrown into the dustbin and cleared out of our homes every single day to keep our heavenly abodes neat and clean. Humanity lives by these principles taking extensive care to keep their homes (even if we don’t care much about our surroundings) clean but fails to keep their own body clean and healthy-our love for junk food shows a steady graphical increase with every passing day! Junk literally means garbage or trash but we shell out money or don’t mind putting on excess weight to indulge in junk foods. Eating yummy pizzas, burgers, crispy French fries, sweetened muffins or spicy hot dogs gratify our taste buds and invoke pleasure. Most humans feel content with such short-term happiness overlooking the long-term painful effects that could be caused due to our ignorance. Yes! High-calorie foods stacked with fats and sugars not only affect our physical health making us fat and prone to diseases but ruin our mental health too-they are hazardous enough to shrink our brain!
 
Shame on Us for Neglecting Our Brains
 
The human brain is an exciting organ that’s been an all-time favorite among researchers. It is full of surprises and information that help understand ourselves better. Even while sleeping our brain never relaxes but functions 24*7 to stay alive-not just to breathe but to lead a meaningful life! Humans need energy and fuel to function which is obtained from none other than the food that we eat. Anything that goes into the mouth does impact the brain in one way or the other-some foods in one way (promoting health)and some other foods in many ways (for instance, the junk or processed foods that ruin cognition, add body weight, etc.). While earlier research showed that certain foods have the ability to improve happiness also termed as mood-enhancing foods, we now have a greater number of research probing into the side effects of consuming junk food as individuals now are more inclined towards eating them.
 
Obesity is ruling the world due to which there are several health issues cropping up but we constantly keep forgetting the fact that health is a combination of both mental and physical health. While we were busy scrutinizing the impact of energy-dense foods on calorie gain the consequences of junk food on mental health remains unpopular among individuals though researchers have done their jobs well. Research and studies are shedding more and more light on this-increased violence, depression, anger, aggression, irritation, dissatisfaction among citizens could be due to increased intake of high-fat/high-sugar foods. Also, these foods act like slow poison subtly affecting our neurons, neurotransmitters, parts of the brain such as the hippocampus, memory capabilities and emotions. Are we inviting self-destruction here? How did it all begin?
 
Well-being & Health Starts from the Fetus
 
A mother is a child’s first relationship in this world through which the baby gets to know others. The relationship between a mom and a child starts right from fetal stage going strong until death. Women enjoy the best phase of life during pregnancy eating to their heart’s content and being pampered. Many go on an indefinite eating spree laying their hands on everything they could get. This puts the pregnant mother at risk for inappropriate weight gain which could lead to delivery-related problems. Besides, the developing fetus is at a very high risk of obesity and this is evidently clear with research results. But what we don’t know is that the nourishment of the expectant mothers affects the mental health of kids too. It’s only since the last decade that significant research and developments have been done in this field (maternal nutrition affects risk of mental illnesses, depression and anxiety in kids).
 
Food Intake of Expectant Mothers Affects Mental Health of Newborns
There are evidences showing that diet affects the development of neurotransmitter systems in the offspring and immune development too which in turn affects risk of mental health problems later in life. Rodent studies show that a diet rich in fats and sugars increases sympathetic nervous system activity and the creatures become hyperactive. We also know that lack of omega 3 fatty acids during fetal development reduces brain plasticity leading to anxiety-driven behavior in adult mice. A group of researchers studied the relationship between the mom’s nutritional intake during pregnancy and the child’s nutritional intake during the first five years of life and its effect on the child’s emotional health.
 
The study consisting of 23,020 children and women sent across self-reported questionnaires to pregnant women (17 weeks) and later after childbirth at regular intervals. The pregnant women were given a food frequency questionnaire (FFQ) which probed into their intake of more than 200 foods and beverages. The items were divided into two dietary patterns-health and unhealthy. The child’s diet was also analyzed from the baby’s 18th month using a 36 item FFQ which included foods such as cereal porridge, dairy-based products and fruit juices. The food range varied as the child grew old and during every stage the foods included were categorized as healthy (veggies, fruits, milk, etc.) or unhealthy (sweets, soda, chips, cookies, ice creams, etc.).
 
Results showed that kids whose moms ate a greater proportion of junk foods showed increased levels of externalizing behavior (antisocial behavior, hostility and aggression). It was also observed that kids who ate junk during the first five years of their development showed evident traits of aggression, anger and irritation. A study in Germany showed that increased intake of confectionery but not sugar-sweetened drinks/snacks led to increased risk of emotional problems and higher intake of healthy foods led to decreased risk of such problems. Human genome is extremely vulnerable to environmental factors during early developmental years of life and any disturbance to normal development affects the mental health of the developing offspring.
 
Processed Foods Silently Increase Violence Levels in Individuals
 
The more we stuff our brain with junk food the less space it has for chemicals needed for its proper functioning. Most are aware of the popular phrase ‘You are what you eat’-foods intake and dietary patterns shape our behavior and characteristics by affecting structural development of the brain, neurotransmitters and brain functioning. It is already well-established that malnourished kids show high risks of aggression, violence, antisocial behavior, declined cognition and externalizing problems. It is around 7, 12 and 15 years that a child’s brain functional development reaches its peak. Insufficient nutrition (especially proteins and energy insufficiency) affects the development of the brain’s grey matter in the prefrontal cortex that’s involved in judgement, attention, planning and self-control.
 
Omega 3 fatty acids leads to structural changes in the brain. This nutrient is vital for optimal grey matter volume in the brain in areas that are associated with mood and behaviors. The brain’s grey matter consists of 90% fats and sadly, our human body cannot produce it. The only means of obtaining this fat (omega 3’s) is via the diet that we eat. Dietary intake of polyunsaturated fatty acids has varied greatly over the years thereby reducing omega 3 intakes as well. That’s due to the over consumption of processed foods that lack any of the good fats or nutrients. Rather, one is expected to increase the intake of fatty fish such as salmon, tuna and sardines, nuts, flax seed and leafy vegetables.
 
A research study on juvenile jail inmates showed that most boys lacked all important nutrients needed for a healthy life. Once they were given nutrient-rich diets the percentage of violent incidents caused decreased by more than 50%. Though it’s only a hypothesis that nutritional food can decrease aggression and violence rates it is clearly evident from researches that violent prisoners (lacking in essential nutrients) who were supplemented with nutrient-enriched foods full of vitamins, minerals, proteins and fatty acids exhibited reduced levels of disciplinary offences and violence rates drops significantly.
 
Sugar: Most Potent Drug Used Universally
Increased sugar intake is a sure devil and a study shows that kids aged below 10 who ate sugar-rich foods such as cakes and chocolates regularly are at an increased risk of committing crime during their early adult years.  Food could be a medium for improving well-being and optimizing mental state of individuals.
 
The bite of a chocolate, just a drop of honey on the tongue or some sugar particles makes even babies experience ultimate pleasure and they long for more. Kids become used to regular intakes of sugar-laden foods such as cupcakes, caramel popcorn, cakes and sweets right from their younger age-in the form of reward foods that are regularly given by parents for completing homework, refraining from violent activities and so on. Eating such foods makes kids happy, at least for some time. They are full of joy and excitement until they eat it and even until the taste lingers in their tongue. But after a while, the same tantrums begin and surprisingly, the satisfaction comes only when the quantity given too increases. This is even proved by a research study.
 
Researchers at the University of Oregon probed into the influence of sweet foods on brain. They gave ice creams/milkshakes to two groups of people and recorded their brain activity using MRI. One group was given a daily supply of ice creams while the other group was given the same food only once a week. Results showed that the group that regularly consumed ice creams experienced reduced pleasure and increased dissatisfaction in comparison to the other group. The reward response of the brain decreases and the brain becomes hypersensitive to food images. For instance, the picture of an ice cream or juice activates brain regions and the individual immediately wishes to eat them for satisfying their taste buds and pleasure centers. By treating ourselves or feeding our kids with more and more junk foods that are sugar-dense we are inviting trouble to our lives.
 
Sugar could be considered a potent drug in the same lines of morphine, cocaine and alcohol. The more we consume, the greater we yearn for again and again. It could be called as an intoxicant too! Once we enjoy the taste of it our minds never stop craving for more. Research shows that increased glucose intake has the potential to alter areas of the brain that control emotions. Our satiety levels keep decreasing, pleasure-seeking traits keep increasing and our brain stoops to any low level to gratify our pleasure needs-in terms of any junk food that we could lay our hands on.
 
Invade Your Fading Memory Before You Lose It Altogether
 
Hippocampus, the brain’s CPU or memory center is frightfully affected by the junk that we eat. It is a part of the limbic system that helps in converting essential information from short-term memory to long-term memory and is also integral for spatial memory (help humans find directions or help rats find foods using particular routes). Our brain stores memories which are formed through connections that happen between neurons-this is called as neuroplasticity and it happens throughout our lives. Research shows that an individual whose diet comprises of junk foods mostly reduces the neuroplasticity capabilities of the brain-the process through which we cherish our happy memories forever in our life or learn new things. Its this ability that helps people excel in studies, remember multiple things or possess cognitive abilities.
 
A research team led by Prof. Margaret Morris at the University of Sydney showed how spatial memory damages are extensively observed in rats which were fed with junk foods such as pastries and doughnuts. Rats fed such foods doubled their food intake ratio and were never satisfied with the quantity of food fed to them. These creatures were also put to a test using two tea cups that were placed in two positions between which the rodents kept moving around. After sometime, one of the tea cups was removed but the rats, which are generally highly skilled in spatial memory skills (the ability with which they locate foods in a maze), failed to recognize the moved object. This shows the effect of junk food consumption on poor spatial memory skills in rodents. In humans too we have various studies reporting the effects of energy-dense food consumption on decreased hippocampus performance.
 
The same foods also prevent the formation of new neurons (neurogenesis) that are essential for forming new memories. They even lead to inflammation in the brain that damage these neurons in the process. Researchers in Australia have showed that a diet consisting of cakes, cookies or sugary drinks for 5 continuous days can increase inflammation levels in the hippocampus. Such people also  always feel hungry because its the hippocampus that receives fullness signs from the gut. And, when the hippocampus is damaged this cycle is broken causing people to desire for more and more food as they don’t receive satiety signs anymore.
 
Gut Microbiota & Food Choices
 
The human gut is indispensable for digesting food and expelling the unwanted ones. But recent research shows that the gut by itself could be a micro brain that rules our appetite and moods. Research even shows that our gut could be the culprit behind cravings for junk foods too. There is a two-way communication between the brain and the gut that happens via the brain-gut axis which is responsible for supervising our eating habits. This is evident from different research results-for instance, those who crave for more sweets have a different microbial breakdown composition in their urine that’s different from those who don’t crave.
 
The food we eat affects the bacterial composition of our gut. Its a conventional concept that our body desires for the nutrients it generally lacks. A study on flies that lacked proteins showed that surprisingly these specimens did not reach out for protein-rich foods placed in front of them even though they lacked this nutrient. The results showed that two specific microbes were responsible for suppressing the appetite for these proteins which made the researchers wonder whether the gut microbiota could affect food choices!
 
If that is true, then its better that we hold control over our gut composition before it starts affecting our food choices. This is possible by consuming enriching meals laden with ample nutrients. For instance, the best choice could be a Mediterranean diet that includes fruits, vegetables, nuts, seeds, legumes, olive oil, fish and whole grain, foods that are rich in all the essential nutrients needed for the healthy functioning of our body. Researches show that the degree of change in diet has a direct impact on the degree of change in emotions. In a study, a group of individuals who were habituated to regular consumption of junk foods switched over to a better diet-the healthy Mediterranean diet. Results showed that after a period of time, the degree of change in the diet had a direct impact on the degree of change in depression. As a welcome relief, the Mediterranean diet led to a decrease in depression levels proving that nutritious food choices go a long way towards better mental and physical health.
 
We have studies that have compared traditional diets such as the Mediterranean diets or the traditional Japanese diet to the Western diets whose results show that the risk of depression is 25-35% lower in those who eat these traditional diets. Such enormous difference is due to the nutritional composition of these diets which include fruits, vegetables, unprocessed grains and fish with optimal quantities of dairy and meat. Above all, these diets contain negligible amounts of sugar and refined foods that are the staple ingredients in junk foods and the Western diets. Unprocessed foods present in traditional diets are fermented and act as natural probiotics improving gut health.
 
Exploring the Flavors of Indian Spices
 
India is a country that’s proud of its cultural heritage, vibrant colors and above all, our healthy food habits and ingredients that promote good health, the most important of which are spices. Spices were an integral part of Indian medicines but now are being studied worldwide for their benefits in improving mental health. We love masala and spicy food. Spices such as turmeric, pepper, ginger and cumin seeds are a regular part of our daily cooking which shows that Indians have always been well-equipped for safeguarding their mental health. Spices have been shown to promote brain health, increase memory and cognition, enhance our focus and concentration and above all, protect brain cells health. Studies show that turmeric helps in repairing brain cells, cinnamon shows promising signs of improved cognition, the flavourful saffron is quoted to decrease depression and black pepper helps in increasing brain function and decreasing depression risks. But recent decades show a greater decline in the usage of such ingredients as many people have adopted the Western dietary routines and are fans of junk foods too. When our motherland is laden with all the wonderful spices and ingredients that promise wellness, health and fitness why are we craving for junk foods that take this all away and ruin our life? Include spices such as nutmeg, cloves, cinnamon, pepper, cumin, ginger and garlic in your daily cooking to reap potential health benefits.
 
It’s never feasible to make a radical change and stick to it. Try to cut down a couple of junk items from your food list every week. Experience the changes in physical and mental health that happen for the better as a result of this. Then, reintroduce the cut down foods once again and see how bad you feel in terms of overall health. First hand experience of both would definitely encourage every one of you to eradicate the presence of junk foods from your life forever. Once you feel the joy of better mental stability, happiness, better mood levels, decreased aggression and irritability why would you feel like going back to your unhealthy junk food life? Eat a variety of food with well-balanced nutrients, relish on your sweets or cookies rarely and exercise regularly for a healthy life. 

Ref :  https://www.dw.com/en/coronavirus-uk-human-vaccine-trials-to-begin/a-53206212

https://www.who.int/blueprint/priority-diseases/key-action/Novel_Coronavirus_Landscape_nCoV_11April2020.PDF?ua=1
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A potential coronavirus vaccine being developed at the UK's University of Oxford is due to begin testing on human volunteers on Thursday.
Health Secretary Matt Hancock said the UK was at the "forefront of the global effort" to produce a vaccine, and was investing in manufacturing capacity to ensure any successful candidate could be made available to the public as soon as possible.
"Vaccine development is a process of trial and error, and trial again," he said, adding that the government was "throwing everything" at vaccine projects.
Read more: Coronavirus vaccine: 'Clinical tests' in Germany soon
The University of Oxford will receive 20 million pounds ($24.5 million; €22.5 million) from the government, Hancock said. Another project at the Imperial College London will receive 22.5 million pounds.
The World Health Organization has said developing a safe vaccine will take at least 12 to 18 months, but scientists at Oxford say they expect to produce a million doses of an experimental vaccine as early as September.

C-section delivery, a rarity in older days has become very common now. Call it a delivery of convenience to overpower nature by bringing in the newborn into this world at an auspicious time fixed by us or as a result of lifestyle changes that hamper the natural delivery mode that leads to failure in labour pain, correct positioning/fixation of the baby’s head and so on. Whatever it is, caesarean rates have spiked up from 6.7% in 1990 to 19.1% in 2014. Various reasons quoted for such increase in rates include advanced maternal age at childbirth, physician fear of litigation, decrease in vaginal births after C-section and access to private health insurance.
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Gut microbiota shapes an individual’s health and babies born through C-section delivery are not exposed to the mom’s vagina as compared to babies born through natural delivery-initial microbiota of the fetus depends on the bacteria composition transferred from the mom to the child via her birth canal. Gut microbiome of c-section babies is not diverse and we have studies showing that their gut microbiome might harvest more dietary nutrients predisposing them to be obese/overweight. There have been numerous theories suggesting that kids born through C-section deliveries face higher risk of being obese/overweight compared to kids born through natural birth. Lets look at various studies that tried to find out the real link between mode of delivery and risk of overweight/obesity.

Evidence from Cohort Study
Detailed here is the growing up in Ireland (GUI) study that recruited 11,134 infants born in Ireland born between Dec 2007 and June 2008. When the infants were 9-months old all the families participated in a face-to-face questionnaire session conducted by trained interviewers. When the child was 3- and 5-years old all the mother-infant pairs followed up with home-based interview sessions. But after imposing various exclusion criteria the research team was left with 11,049 infant-mother pairs at baseline. Even those infants born through vaginal breech delivery were excluded from the study.

Delivery mode was split into four categories namely vaginal delivery (VD), assisted VD, elective/planned caesarean section (CS) and emergency/unplanned CS. Moms who opted for the last two options were either in pre-labour or in labour respectively. The time of labour contractions is important as the offspring’s microbial colonisation begins later. For instance, children born by pre-labour CS have no exposure to vaginal microflora whereas kids born through CS in labour comparatively have an advantageous edge as they are likelier to be exposed to the mom’s microbiome. Each of the child’s height, weight and BMI measurements were taken and they were all classified as thin, normal & overweight/obese depending on the values procured. Breastfeeding practice was also considered as mothers who opted for elective CS were unlikelier to breastfeed and its known that babies who don’t breastfeed are at a higher risk of obesity.

Results
8,175 of the 11,049 infants were delivered vaginally-almost 60% was by normal VD and the rest was by assisted VD. 26% of the deliveries were by CS-12.7% by elective CS and 13.3% by emergency CS. 51.1% of the participants were boys and almost 55% of deliveries were by assisted VD and emergency CS. Among women who opted for elective CS almost 50.4% of them 35 years and above. After birth it was observed that 13.9% kids were macrosomic (more than 4 kilograms), 10.9% were large for gestational age; at the age of 3, 1,767 (18.7%) of them were overweight and 506 (5.3%) were obese and at the age of five, 1389 (15.8%) of them were overweight and 437 (5%) were obese. While 5030 (57%) children were within normal BMI ranges between 3 and 5 years of age 175 (2%) were obese. Almost 3% kids who were obese at age 3 became non-obese at age five while 3% who were not obese at age 3 became obese at age 5. 13.2% mothers who delivered vaginally and 21.5% who delivered by CS were obese.

At 3 years: Results showed that a clear link between elective CS and obesity risk could be found at age 3 compared to those kids delivered vaginally (normal).  Overweight risk was linked to emergency CS and not elective CS. Elective CS was not linked to obesity risk at age 3 among appropriate for gestational age (AGA) infants. Small for gestational age (SGA) infants had a median birth weight of 3 kilogram and there was a link between emergency CS and obesity in AGA non-macrosomic kids.

At 5 years: There was a slight link between elective CS and obesity risk when the children were five years old and a similar link was seen between emergency CS and obesity risk as well.

Between age 3 and 5: Here, no association was found between elective CS and any BMI category transition. Kids born through emergency CS were at an increased risk of remaining obese between 3 and 5 years of age while those born through emergency CS were at an increased risk of making any other BMI transition.
This study doesn’t clearly prove that there is a causal relationship between elective CS and childhood obesity. An increased risk of obesity in kids born through emergency CS and not elective suggests that there is no causal effect due to vaginal microflora.

Obesity Risk in Preschool Kids in China
C-section delivery in some Chinese cities exceed 50% and generally too, rates of birth by CS has increased from 18% in 1992 to 40% in 2000. At the same time, overweight/obesity rates of kids also have increased from 12.6% in 1997 to 22.1% in 2009. A group of researchers set forth to analyse the effect of CS delivery and risk of childhood obesity in a large sample of preschool kids. 9103 kids aged 3-6 years from 35 different playschools in 5 different kids were included whose parents were given a questionnaire. It was observed that 8900 of 9103 were valid and hence, weight and height information of all these children were collected. WHO guidelines were taken for branding a kid to be overweight (BMI between 85th and 95th percentile) or obese (BMI ≥95th percentile). Delivery mode was also noted down classifying the child into one of the following categories-vaginal delivery and CS (elective/non-elective).

Information on the mother’s age, education, smoking and drinking status, pre-pregnancy weight, maternal weight, breastfeeding status and the child’s birthweight and sex were noted. Maternal pre-pregnancy BMI was calculated based on maternal height and pre-pregnancy weight and paternal BMI was also calculated based on weight and height values.

Results
67.3% kids were born via C-section delivery. It was moms who delivered after the age of 36, who were obese/overweight before pregnancy and with a higher education level (who gained more weight during pregnancy) who were at a higher risk of CS delivery. Of the total kids, 939 kids who were delivered through CS were obese and around 25% kids were not breastfed. Of the 5992 CS deliveries, 4016 (67%) were bon-elective and 1977 (33%) were elective. Of notable interest is the fact that paternal age, BMI and smoking status affected the delivery mode. CS delivery increased the risk of overweight/obesity in kids, both elective and non-elective types.

Longitudinal Cohort Study: Ireland
A longitudinal birth cohort with phenotyping of mom and infant was used to probe into the exact association between CS delivery, prelabour CS and childhood body composition and growth. Data for the study was fetched from the Screening for Pregnancy Endpoints (SCOPE) study and its follow-up prospective Irish birth cohort, the babies after SCOPE (BASELINE) study.

Participants from the BASELINE study were recruited around their 15th week of pregnancy in which 1774 gave their written informed consent and 1537 of them had infants recruited into the BASELINE study. The researchers segregated mode of delivery into four different categories namely unassisted vaginal delivery (VD), operative VD, prelabour lowest segment (LS) CS and LSCS in labour. Operative VD included the use of either forceps or vacuum for delivery. Whole body density, height and weight measurements for each infant were calculated and the kid was classified as either thin, normal, overweight or obese depending on BMI values.

Result
Of the 1305 infants 943 of them were delivered vaginally while the rest were delivered by CS: prelabour LSCS (12%) and LSCS in labour (15.8%). 13% of infants were macrosomic at birth and 11% were large for gestational age. At 2 years of age, 116 (10.9%) kids were overweight/obese and at the age of 5, the number increased to 118. Around 6 months the mean BMI of infants delivered vaginally and by CS was 17.3 and 17.6.
When infants were 2 months old there was no link between prelabour CS and body fat percentage (BF%) and LSCS in labour when compared to kids delivered through unassisted VD. Infants delivered through CS had higher BMI at six months of age compared to those born vaginally. But there was no link between prelabour CS or LSCS in labour and risk of being overweight/obese at age 2. When the kid was 5 years old, there was a nonsignificant link between prelabour CS and the risk of being overweight/obese. There is no clear evidence to support the link between prelabour CS and offspring being overweight/obese in early childhood.

No Link between Mode of Delivery & Overweight Risk
A research team was interested in the long-term effect of CS delivery on offspring health as CS delivery rates are presently higher than ever. They compared the BMI of almost 1,00,000 male individuals who were 18 years and divided them into three categories based on their mode of delivery-vaginally, elective C-section or non-elective C-section. Results showed that 5.5% and 5.6% of participants delivered through elective and non-elective C-section were obese compared to 4.9% of men delivered vaginally. The researchers commented that the mom’s weight before pregnancy had a greater impact on inheriting obesity or affecting foetal health in comparison to which mode of delivery played a negligible role in determining obesity/overweight risk. Researchers could observe that mode of delivery did not play a strong role in impacting obesity risk of offspring even after accounting for various factors such as BMI, maternal age, gestational age and presence of diabetes, BP and smoking in the mothers.
Mothers should be more concerned about their pre-pregnancy weight and health, take good care of themselves during the pregnancy tenure and focus on delivering a healthy baby rather than worrying about the mode of delivery.

References
The Impact of Caesarean Section on the Risk of Childhood Overweight & Obesity: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181954/pdf/41598_2018_Article_33482.pdf

Caesarean Section May Increase the Risk of Both Overweight & Obesity in Preschool Children: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-1131-5

Association between Caeserean Section Delivery and Obesity in Childhood: https://bmjopen.bmj.com/content/9/3/e025051

Study Debunks Notion that C-section Would Increase Risk of Obesity in the Child: https://www.sciencedaily.com/releases/2019/12/191206152948.htm

Different diets have been implemented for the purpose of weight loss and most of them pass the test of time only as fad diets that don’t last long. But there are some others which have been strongly suggested even by physicians and health experts to resolve various health issues in individuals-such as the DASH or Ketogenic diet. The DASH diet has been approved for lowering hypertension and the Ketogenic diet exists as an effective treatment against epilepsy. Almost 70% of people with epilepsy could have their seizures controlled with anti-epileptic drugs (AEDs) and for those whose seizures are not arrested with AEDs, the Ketogenic diet proves to be an effective treatment plan. Following the diet helps in reducing the number of seizures, severity of each and also evoke other benefits.
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The Ketogenic diet (KD) is a high fat, low carbohydrate, controlled protein diet used since the 1920s as an effective treatment for intractable epilepsy. Though its only a modified nutrient intake plan, physicians suggest taking up KD only after two suitable medications have been tried and have not provided any fruitful results. KD might be used for adults and children with maximum monitoring done on infants who have been suggested for the diet. It works on the principle that our body uses glucose from carbs as a source of energy. Chemicals called ketones are formed when our body uses fat as an energy source and a fatty acid called decanoic acid might be involved in the way the diet works. The KD mimics the body’s response to starvation by using fat as the primary energy source in the absence of sufficient carbohydrate source. Though the exact process by which ketosis control seizures is unknown researchers hypothesize that ketones have an anticonvulsant effect when crossing the blood brain barrier. It’s a known fact that the various options available for treating kids with pharmacoresistant epilepsy is limited and even surgery is not a viable option for most of them. Almost 30% kids with seizures remain unresponsive to pharmacologic treatment or suffer from extreme side effects of AEDs. It was then that the International Ketogenic Diet Study Group consisting of 26 paediatric epilepsy specialists and dietitians came to a conclusion that KD should be the suggested mode of treatment for those children who failed 2 or 3 anticonvulsant therapies, especially in those with symptomatic generalized epilepsies.

A meta-analysis of 19 observational studies in 2006 showed that six months after starting a ketogenic diet almost 60% kids were relieved from seizures by more than 50% and 30% kids had almost 90% reduction in seizures. It was kids aged 1-10 with generalized seizures who were maximum benefitted by the diet. Another study conducted sometime later on 145 kids aged 2-16 years suffering from daily seizures randomly divided into the diet or control group showed that seizure percentage was lower in the diet group compared to the control group; 28 kids in the diet group experienced 50% decrease in seizures compared to only 4 in the control group who benefited and 5 kids in diet group had 90% reduction in seizures while none in the control group benefited in such ways.

Single-Centre Retrospective Analysis
KD is a valuable option for those with drug-resistant epilepsy (DRE) which can be given for a minimum period of 3 months and continued for several years if it proves to be beneficial. But, constant monitoring of the child is required to keep it effective and prevent the onset of any adverse short-term or long-term effects which might include any effect on the child’s growth. There isn’t much data regarding the effects of KD on the affected kid’s growth-A study by Peterson et al. showed that participants with marked ketosis were characterized by decrease in height for age z-scores which was not evident in those with low or moderate ketosis. The same was also shown by Spulber et al. in a study of 22 kids showing negative link between child growth rate and blood beta-hydroxybutyrate (β-OHB) concentration. A retrospective study by Nation et al. showed that a caloric and protein intake <80% of the recommended values and protein/energy ratio ≤1.4g protein/100 kcal was linked to decreased growth percentile.

The study here probed into growth changes in 34 kids suffering from DRE (n=14) or glucose transporter type 1 deficiency syndrome (GLUT1-DS, n=20) all of whom were treated with KD for 12 months. Inclusion criteria was that kids should be 2-17 years of age, there should be a diagnosis for DRE or GLUT1-DS and treatment with KD done for at least 12 months. Kids with severe organ failure, thyroid disorders or needing enteral or parenteral nutrition were excluded from the study. Growth, clinical and body composition of the participants were calculated at baseline and 12 months after follow-up. Weekly food diaries were assessed to understand the weekly food caloric intake, food preferences and intolerances and total energy intake was formulated based on every patient’s need. Kids aged 3 months-10 years were assessed of their energy needs every quarter while adolescents were analysed every 6 months. The research group ensured that every participant was provided 0.8-1.0 gram of protein per kilogram of body weight from animal sources such as meat, fish, poultry, eggs and milk. All participants took multivitamin and mineral supplements as per their age and sex.

What started as a 1:1 ketogenic diet went to 2:1, 3:1 or 4:1 ratios and participants were assessed for fasting blood ketones, supplements use and for presence of any adverse effects. Each of the participant’s height, weight, BMI and other measurements were taken.

Results
Median age of study participants was 7.5 years, kids with GLUT1-DS were diagnosed at an older age than those with DRE and hence, started with dietary treatment immediately after diagnosis. All participants with GLUT1-DS were on ambulation and did not take AEDs and 10 patients with DRE were on multiple anti-epileptic drugs of which 5 were not able to ambulate. At baseline, there was no difference in height or other parameters between both set of patients. Even after 12 months of study the median height scores did not change significantly from baseline. The kids were put into three growth pattern groups after 12 months of KD-increased (Group-I), tracking (Group-T) and decreased (Group-D) linear growth. There were 6 kids in Group-I of whom 3 had GLUT1-DS; Group-T had 21 patients of whom 13 had GLUT1-DS and Group-D had 7 kids of whom 4 had GLUT1-DS. The three groups did not differ in characteristics at baseline. There was different in energy intake in Group-T compared to Group-I. 11 of 34 kids refused food intake or incomplete meal consumption at intervals. Not much difference in fasting β-OHB levels after 12 months were observed between the three groups. There was an inverse association between fasting β-OHB blood levels at 12 months and height.

While there was no significant difference in height, weight or BMI scores between the three groups at baseline after 12 months it was observed that height and growth velocity scores were lower in Group-D than in Group-I, weight scores were impaired in Group-D and T than in Group-I. There was no difference seen in fat mass percentage between the groups at baseline nor after 12 months.

A 10-Year, Single-Centre Study on Ketogenic Diet
The KD has been used at the Children’s Memorial Hospital, Chicago since the year 1963 and researchers focused on the effect of the diet in patients under the age of 3 in a span of ten year (April 2004 to June 2014). All the patients were grouped into two-early withdrawal or adherent group. The reason behind early withdrawal was questioned and this involved three clinical features-very short-term efficiency of KD, adverse events and implementation and practise of KD. Those kids who underwent 3 months of KD treatment were further classified into 4 groups based on percentage of seizure reduction 3 months-complete seizure control, >90% improvement, 50-90% improvement and <50% improvement. Anyone who experienced >50% seizure control was categorized as responders and others as non-responders. Patients were also classified based on their age into three groups-<1-year-old, 1-2-year olds and >2 years old. Each of the participants’ calorie and protein needs were calculated and vitamin and mineral supplementation was provided based on food intake and nutrient requirements.

Results
109 patients aged below 3 were given the Ketogenic diet and included in the analysis. The median age at which seizures started in them was around 4 months of age and each of them had used medications at least 4 times before starting the diet. More than 50% of them had West syndrome and all of the 109 participants’ EEG was abnormal at the start of the diet. The youngest patient was 3 weeks old. KD was initiated at a 1:1 ratio (fat grams: carbs + protein grams) increasing up to 3:1 on day 3. 20 patients were on a 3:1 ratio, 13 were on a 3.5:1 ratio and 59 were on 4:1 ration. 4.75:1 was the maximum observed ratio and every child reached a fat: no fat ratio of 3:1 or higher except one kid (2.75:1). Solids (33%), liquids (32%) and a combination of both (33%) were given to the kids. 8 of the kids fed on expressed breast milk, median duration of the diet was 1.1 years and one patient suffered from positive urine ketosis at some point of the diet. There was no response in seizures for 3 months of KD administration.
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But after 3 months, 39% patients (n=42) experienced more than 50% reduction in seizures. Of the 42, 20 (18%) of them accomplished complete seizure control and another 3(3%) experienced >90% seizure reduction. Age was not a matter in enabling seizure reduction in kids following KD. But what surprised the researchers was the fact that a genetic mutation or a chromosomal abnormality in patients improved their response to seizures after starting on the KD diet. Though no adverse effects were seen but constipation was commonly reported in the adherent group who were on the diet for a longer period of time.

This shows that the KD is an effective and safe intervention for kids suffering from epilepsy. But given the advantages, the KD is not suitable for all kids and neither can be called ‘user friendly’ given the time and energy needed to maintain ketosis. Some kids refuse to follow the diet and even parents are stressed when diet-induced social modifications become essential. While many studies report the benefits of the diet the medical consequences of KD are not well documented. For instance, a study by Balaban-Gil et al. showed a 10% rate of serious complications in 52 kids with refractory epilepsy and we even have anecdotal reports of coma and death often blamed on metabolic diseases. Another study by Kang et al. showed that while kids following the diet reaped benefits in seizure control they also started experiencing dehydration and gastrointestinal complications within 4 weeks of diet onset. There were also cases of hypoglycaemia, aspiration pneumonia, serum lipid abnormalities, infectious diseases, electrolyte imbalance and acidosis, hepatitis and acute pancreatitis. Three patients died within 60 days of starting to follow the diet-all of them due to brain damage. But it was also observed that the dropout rate of study participants in the research conducted by Kang et al. was more than the dropout rate observed at other centres. But researchers feel that most complications of KD are temporary and could be managed with effective treatment. Ketogenic diet is complicated maybe even life threatening but with high levels of expertise, experience and monitoring it is possible to make the best of it as much as possible. The diet should be administered only by an expert dietitian who has potential knowledge and expertise in KD.

References
Impact of the Ketogenic Diet on Linear Growth in Children: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683244/pdf/nutrients-11-01442.pdf

The Ketogenic Diet in Children 3 Years of Age or Younger: https://www.nature.com/articles/s41598-019-45147-6

The Use of Ketogenic Diet in Paediatric Patients with Epilepsy : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3434405/pdf/ISRN.PEDIATRICS2012-263139.pdf
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Food for Thought: The Ketogenic Diet & Adverse Effects in Children: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1198735/pdf/epc_00044.pdf