Practical Applications of the Ketogenic Diet in Patients with Parkinson's Disease

The use of the Ketogenic Diet in the treatment of Parkinson’s Disease does appear to be very promising. Unlike that of epilepsy though, there is a lack of clinical data on the practical application of using the diet in this disease state. This predominantly is due to it being such an emerging area. That being said, there is now a lot of lab and animal work as well as case studies of people implementing the diet for themselves and seeing the effects.

What Is a Ketogenic Diet?

As highlighted in my ketogenic and epilepsy article, there are different forms of the ketogenic diet. Below is a highlight of the differing approaches that can be taken to achieve ketosis.

The Classical Ketogenic Diet

Generally classed with having a ratio of either 4:1 (4 g of fats with 1 g of carbs and protein combined) or a 3:1 ratio (3 g of fat with 1 g of carbs and protein combined). This is the hardest form of ketogenic diet to follow with the fat generally sitting at 90% of total calories for the day.

Medium Chain Triglyceride (MCT) Ketogenic Diet

The diet provides around 50% of the calories from MCT oil with a much higher carbohydrate allowance at around 19% of total calories with the remainder coming from protein and long-chain triglycerides (LCTs).

Modified Atkins Ketogenic Diet

Seen as more of an easier form of ketogenic diet to follow. It allows for a ratio of 1-2:1 (1 or 2 g of fat to 1 g of carbohydrates and proteins combined). It follows the principle of the popular Atkins diet except it states that the carb content should stay at the initiation phase of the diet without any increases being allowed.

The major aim of this type of ketogenic diet is to ensure that your carbohydrate stays around 20 g/day for adults 15 g/day for adolescents and 10 g for children. There is no set restriction on calories or protein and fat is encouraged to be consumed. The percentage of total calories with this approach is 30% protein, 65% fat and 5% carbohydrates.

Low Glycemic Index Ketogenic Diet (LGID)

This follows the principles of the glycemic index and load. Foods ranging from 0-50 are classed as having a low glycemic value and are the ones included for this dietary approach. The percentage of total calories with this approach is 30% protein, 60% fat and 10% carbohydrates.

What Type of Ketogenic Diet Should be Followed in Parkinson’s Disease?

Currently there is a lack of clinical data looking at the application of the ketogenic diet in patients with Parkinson’s Disease, this means that we do not have a lot of data to say which type of ketogenic diet will be right for this condition.

Parkinson's Disease and the Classical Ketogenic Diet

One study that has been carried out in humans analysed the effects of the classical ketogenic diet (1). This looked at individuals having a 4:1 ratio whereby for every 5 g of food, 4 g should be that of fat and 1 g is of protein and carbohydrates combined. The participants followed this dietary approach for 28 days. For the patients that were the most compliant to the diet, they reported mean ketone concentrations of 6.6 mmol/L (range between 4.8 - 8.9 mmol/L). Two of the patients did not follow the diet as closely but they still reported ketone levels ranging from 1.13 - 1.56 mmol/L.

The study demonstrated that all participants reported improvements in their Parkinson’s Disease scores independent of how high the ketones were raised. The hypothesis often is that the higher the ketone level then the greater symptomatic relief. However, from this study and the studies carried out in epilepsy, we can see that if there is a slight increase in ketone bodies, it can bring about symptomatic relief.

As will be noted in the case studies below, people who have been following a variation of the ketogenic diet also report that they still notice symptomatic relief without having to be as strict as say the classical approach.

Although this study would highlight the potential for the classical ketogenic diet approach, we know from the research in adults with epilepsy, being able to stick with this form of ketogenic diet can be challenging. For this reason, individuals looking to implement the ketogenic diet for Parkinson’s Disease may be better suited trialling the Modified Atkins Approach and/or the LGID.

Main Considerations Of Following a Ketogenic Diet in Parkinson’s Disease

Although there is only the one human clinical study that has looked at the ketogenic diet in Parkinson’s Disease, from what we know about the disorder, there are other considerations to think of.

Protein Level

The medication that people are on to help with the symptoms of Parkinson’s Disease is known as Levodopa. Studies have shown that the intake of protein can cause negative interactions with this medication making the drug less effective (2).

Given the adherence problems that have been noted with the classical ketogenic diet in adults, the majority of people opting for this dietary approach generally may follow one of the other three ketogenic approaches.

This means that the protein level may be slightly higher and should be considered if you are on medication. Try having your medication 30-60 minutes before a meal. Otherwise you may benefit from a protein redistribution diet whereby you consume most of your daily allowance for protein in the evenings (Please note that if you are going to proceed with that option that you should receive help from a trained health professional).

It is still important to make sure you are getting enough protein to maintain optimal muscle, bone health etc. The intake for the day should be around 1g/kg of body weight (½ g/lb of body weight).

Food Aversions to Some Protein Sources

Some individuals with Parkinson’s Disease have also reported that they have developed specific food aversions to proteins such as meats, dairy and eggs. This could make the selection of foods a little trickier. Sometimes a change in the way that the protein is cooked i.e. scrambled vs boiled eggs has been shown to help with this.

Impaired Gastrointestinal Tract

One of the areas that Parkinson’s Disease can affect is that of the GI tract. This can lead to problems including constipation, inability to chew and/or swallow foods. All of this means that the selection of foods needs to be careful and based on what can be tolerated by the body.

If you have specific problems with chewing or swallowing then selecting foods and snacks such as ketogenic based smoothies, soups or drinks may be of more benefit.

Unplanned Weight Loss or Weight Gain

The medications that people are placed on with Parkinson’s disease can cause the side effects of either loss of appetite or an increase in hunger (especially cravings for sweet foods). This can then lead to people either unintentionally losing or gaining weight, both of which can cause issues to health.

As well as looking at the specific macronutrient distribution (fats, carbs and proteins) of the ketogenic diet, the calorie content must also be looked at.

Further to this, ketone bodies themselves can cause a natural appetite suppressing effect so further care must be taken to ensure adequate calories are consumed. If you are also using external aids such as MCT oil etc., again this will provide additional calories and so the weight of an individual may need to be monitored.

Case Studies

As mentioned above there still lacks a lot of significant clinical data on the use of the ketogenic diet for Parkinson’s Disease. However, there are now several individuals who have taken to trialling the diet for themselves resulting in a few n=1 form of data.

Please note than n=1 does not mean that a ketogenic diet for Parkinson’s will be right for everyone nor is it conclusive clinical data. What works for one person may not necessarily work for another.

The major theme that actually came out of my research and interviewing people for this article is that you must work with the ketogenic diet but find what fits for you, especially when it comes to the individual foods. Some people I spoke with found they tolerated certain dairy such as cheese and cream but not other forms like milk or yoghurt.

Case Study 1

One case study is a man who has had Parkinson’s Disease for the past 15 years. One of the management tools that he utilises to control his disease is that of a Low Glycemic Index Ketogenic Diet.

His diet is based upon eating carbohydrates that has ≤ 50 on the glycemic index with a fat percentage at around 60% of his total calories. He also has introduced the use of a “fat” based coffee in the morning which contains butter, heavy cream and coconut (more details about external aids below). He has found significant improvements in his symptoms of Parkinson’s disease since following the diet and using the “fat” drink.

Case Study 2

Another male who has had Parkinson’s Disease for around 8 years, had severe symptoms of the disease. Before changing his diet, he was almost wheelchair bound, on 8 tablets of painkillers every day and attending a palliative care physician.

After changing his diet to that of a ketogenic diet mixed with MCT oil, coconut oil and DHA supplements, he has managed to reverse many of his symptoms. Again, he has found that he does not need to be so strict in the way of being fully ketogenic (more follows the Modified Atkins Approach). What he finds to be important is the addition of the added fats and keeping the overall carbohydrate count low (which helps over all with the calorie count).

Case Study Overview

Talking with other individuals who have been following the ketogenic diet for Parkinson’s Disease there is a consensus that most find the Modified Atkins or Low Glycemic Index Diet easier to adhere to, whilst still seeing improvements in their symptoms.

It should be noted that they also do point out that the ketogenic diet for them, has just been one cornerstone in their treatment. The diet should not be perceived as a cure but another therapeutic tool to help with alleviating the symptoms of the disease. A major point which was repeated was that one ketogenic dietary approach may work for one person but might not work for the next.

External Ketone Aids - Is There a Role for Them in Parkinson’s Disease?

As discussed in the previous article, whilst the exact cause of Parkinson’s remains unclear, it is established that people with the disease have an impaired mitochondrial function. Due to the proposed impact that ketone bodies can have on mitochondria function, it is hypothesised that they may be warranted as a treatment within Parkinson’s Disease.

Such external aids that have been used to try and elicit a rise in ketone bodies are coconut oil, MCT oil, ketone salts and ketone esters. Again, it must be highlighted that in terms of scientific studies, there still remains a lack of solid clinical data on their application, particularly in humans.

Exogenous Ketones in Parkinson’s Disease

A study in mice administered exogenous ketones in the way of beta-hydroxybutyrate (BHB) for 7 days (3). They showed that administration of the BHB offered protection against the structural and functional effects that occur in Parkinson’s Disease. What is also interesting to note is that the animals presented with improvements of the disease even with ketone levels of 0.9 mmol/L.

Similar lab based studies also demonstrate that BHB administration protects neurones and helps to correct the defects seen in the mitochondria (4), (5).

Case Study 1

A recent case study report has looked at the use of ketone salts being given to one participant carried out at the ASPI facility in Tampa, Florida. An individual who has had Parkinson’s Disease for the past 20 years was given a dose of 10 g of beta hydroxybutyrate salts.

The participant was measured using an eye tracking device that measures abnormal eye movement, a characteristic in Parkinson’s Disease. The average score for individuals his age is 17, before supplementation he scored 6 on the scale. After supplementation with the exogenous ketone salts, he scored an average of 18 and reported shaking in his hands had stopped.

Case Study 2

Another similar case study was seen in a gentleman who was classed as disabled in 2014. After 6 weeks of taking exogenous ketone salts, coupled with intermittent fasting and a more paleo based form of ketogenic diet, he noticed marked improvements in his Parkinson’s Disease.

Before using the exogenous ketones his rating on the Unified Parkinson’s Disease Rating was that of ¾. Now with the ketone salts it sits at ½. What is important to note from this case study though is that he still continued with his standard medication. He did report that anytime he missed medication, he would find the symptoms returning. The exogenous ketones are not “curing” the disease, but in adjunct with standard care it appears to be improving them.

Again, when interviewing the case study individuals, there was a clear consensus that for many, using an external aid such as coconut oil or MCT did appear to offer greater symptom relief.

Whilst the animal data and now emerging case studies of the use of ketone salts and esters is promising, it is still very early data.

Ketone Salts or Ketone Esters?

It needs to be noted that there is a clear difference between both esters and salts. It is thought that the ketone salts are not as potent as the esters and as they are packaged with electrolytes such as sodium, chloride or magnesium, they can cause dehydration. Another point is that only the ketone salts are predominantly commercially available at the minute.

Example Meals and Day of Modified Atkins Ketogenic Diet

Below is an example day based on the Modified Atkins Ketogenic approach (the ratio is calculated at 1.2:1). It needs to be emphasised that this is an example day and it may not be suitable for everyone.

Many people with Parkinson’s Disease find that they have certain food intolerances specific to them. Using the ketogenic diet as a template and then building from there may be better suited to certain individuals.

• Breakfast: Creamy Keto Cinnamon Smoothie
• Lunch: Low-Carb Tex Mex Soup
• Dinner: Paleo Greek Meatballs aka Soutzoukakia OR Mediterranean Cauli-Rice with Fried Halloumi
• Snack: Avocado & Egg Fat Bombs OR Cheesy Pesto Fat Bombs

Take-Home Message

Promising Results but More Research is Needed

Whilst the ketogenic diet is proving to look very promising for the use within Parkinson’s Disease, there is much more research needing to be done before specific conclusions can be made.

The specific ketogenic diet that will work for one person will not appear to work for another. Likewise, if we look at the data in adults with epilepsy following a ketogenic diet, we see that around 30% report improvements in their seizures. This indicates that even for some adults following the ketogenic diet, it may still not offer symptomatic benefits.

The same may then also be hypothesised for adults with Parkinson’s Disease. Some people may find that they try this dietary approach and discover no improvements in their symptoms.

External Ketone Aids May Help Amplify the Benefits

Many of the case study’s reported that the use of the external aids of coconut oil and MCT oil appeared to help amplify the benefits seen with the ketogenic diet alone. Again this may be very individual based and advice should be sought from a trained professional if you are unsure.

Likewise, the use of ketone esters and salts, could appear promising to help those that may struggle with the practical applications of the diet. Much more scientific data is needed for both the short and long term on their application. Experiments with regards to the salts can be done but please do seek medical advice before trialling with these.

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