Fasting A Precursor To The Ketogenic Diet

It was not until the early twentieth century that medical use of the ketogenic diet emerged as a strategy to mimic the biochemical effects of fasting (or starvation) (Fig. 2). Guelpa and Marie, both French physicians, authored the first scientific report on the value of fasting in epilepsy (6). They reported that seizures were less severe during treatment, but no details were given. In the United States, contemporary accounts of fasting were also recorded early in the twentieth century (Table 1); the first was a report on a patient of an osteopathic physician, Dr. Hugh W. Conklin, of Battle Creek, Michigan, and the second concerned Bernarr Macfadden (7,8). Macfadden was a physical fitness guru/cultist and publishing genius of the early part of the 20th century (9). He called the medical profession an organized fraud and said that people who followed his rules could live to age 120. At age 31 (in 1899), he established his first magazine, Phys-

From: Epilepsy and the Ketogenic Diet Edited by: C. E. Stafstrom and J. M. Rho © Humana Press Inc., Totowa, NJ

Hugh Conklin
Fig. 1. Raphael's Transfiguration of Christ. (Reproduced with permission from ref. 5.)

ical Culture. He advised readers how to develop themselves physically, how to maintain their health, and how to cope with illness. He illustrated it with photographs of himself lightly clad, with muscles bulging (Fig. 3A). Each issue carried articles about sickly men and women who became healthy, strong, and beautiful through proper diet and exercise. The magazine's circulation had reached 500,000 by the end of World War I. Macfadden was widely recognized, and one of his followers, Angelo Siciliano, won Macfadden's "America's Most Perfectly Developed Man" contest twice. Using the winnings, Siciliano went on to establish his own muscle-building business under the name of Charles Atlas.

Macfadden offered advice on a subject he knew very little about—coping with illness. He maintained that any disease could be cured by exercise and diet. He also emphasized fasting. His rationale was that because much of the body's energy goes into digesting food, if there is no food to digest, more energy could be applied to recovering health. Macfadden claimed that fasting for 3 d to 3 wk could alleviate and cure about any disease, including asthma, bladder disease, diabetes, prostate disease, epilepsy, impotence, paralysis, liver and kidney disease, and eye troubles. He had become nationally recognized, and his ideas were well known (Fig. 3B). Dr. Conklin began as an

Hours of starvation

Fig. 2. Biochemical changes that occur with fasting (Reprinted with permission from ref. 94.)

Hours of starvation

Fig. 2. Biochemical changes that occur with fasting (Reprinted with permission from ref. 94.)

assistant to Macfadden and adopted his method of fasting to treat various ailments (4). It was his practice of fasting to treat epilepsy and the results, which drew the attention of another pioneer in epilepsy studies, H. Rawle Geyelin, an endocrinologist at the New York Presbyterian Hospital.

Dr. Geyelin, a prominent physician from New York, first reported at the American Medical Association (AMA) convention in 1921 his exposure to fasting as a treatment of epilepsy (10). In 1919 he had the opportunity to observe a young cousin who had epilepsy for 4 yr (11). The patient's seizures were not controlled by numerous treatments that had been recommended by several neurologists. The patient also failed to respond to the conventional treatments of the day, bromides and phenobarbital. Then Dr. Conklin had the child fast four times over several months: the seizures stopped after the second day of fasting, and the boy had none in over 2 yr of follow-up. After observing two other patients who apparently had been cured of epilepsy by Dr. Conklin, Dr. Geyelin began using the same fasting treatment to see if he could confirm the results in a larger group of patients. Not knowing what the effects of the fast would be, Dr. Geyelin initially used variable periods of fasting. He finally adopted a 20-d period for the fast, although he admitted this was entirely arbitrary. Geyelin was the first to document that "when one wanted to turn a clouded mentality to a clear one it could almost always be done with fasting." This observation languished until recent times, when behavioral and developmental improvements attributed to the ketogenic diet were reported (12). Dr. Geyelin documented the efficacy of fasting in 36 patients (see Table 1) and closed his presentation by remarking that this was a preliminary report, and further study was needed.

Table 1

Efficacy of Fasting, 1921-1928

Table 1

Efficacy of Fasting, 1921-1928

No. of

Age (yr)

Success

First author

patients

of Patients

Seizure typea

Diet

rate (%)

Comments

Geyelin R,

30

3.5-35

PM, GM

Fasting

87% Seizure free

Results based on 20-d fast; no long-term follow-up

1921 (10)

Weeks DF,

64

7-61

PM, GM

Fasting

47% Seizure free during fast

Patients fasted for 3 wk; all had seizures after

1923(86)

return to regular diet

Talbot FB,

23

Children

UN

Fasting

Seizure free during fast

Seizures returned in all after fast

1926 (37)

Lennox WG,

27

13-42

UN

Fasting

50% had marked reduction in

Phenobarbital stopped on admittance; fast lasted

1928 (4)

seizures during the fast

4-21 d

Fig. 3. Bernarr Macfadden. (A) As he appeared in a photograph in his magazine Physical Culture, illustrating his bulging muscles. (Reproduced with permission from the Qu'igley Photographic Archives, Georgetown University Library.) (B) With presidential candidate Franklin D. Roosevelt (in car) in 1931. Macfadden tried to ingratiate himself with Roosevelt as a part of a strategy to be appointed as the first Secretary of Health.

Fig. 3. Bernarr Macfadden. (A) As he appeared in a photograph in his magazine Physical Culture, illustrating his bulging muscles. (Reproduced with permission from the Qu'igley Photographic Archives, Georgetown University Library.) (B) With presidential candidate Franklin D. Roosevelt (in car) in 1931. Macfadden tried to ingratiate himself with Roosevelt as a part of a strategy to be appointed as the first Secretary of Health.

Dr. Stanley Cobb of Harvard was in the audience that day and commented that he had experimentally used starvation to prevent convulsions in an animal model. At that time, Cobb did not know that the father of the first child Geyelin had discussed would come to him in 1922 and ask him to explain the mechanism of action of starvation in treating epilepsy; we pick up this thread of the story again later in this section.

At this time, Dr. Conklin believed that epilepsy, which he labeled "intestinal epilepsy," had its origin in the intestines and was curable (13). He thought that a toxin secreted from the Peyer's glands was taken up in the lymphatics, stored in the lymph glands and other tissues, and from time to time discharged into the bloodstream, causing epileptic convulsions. He reasoned (based on influence from Macfadden) that dur-

ing a fast, the tissues freely pour their poison content into the bloodstream, through which means the toxins are eliminated. In his manuscript, he outlines his treatment for epilepsy and technique for initiating and breaking the fast. Typically, he deprived the patient of all food for 18-25 d, or as long as the person was physically able to stand it. Conklin reported that his cures of epilepsy were 90% in children younger than 10 yr, 80% in adolescents 10-15 yr old, 65% in patients 15-25 yr old, and 50% between 25 and 40 yr, above age 40, the percentage was very low.

However, even before Conklin published his results with fasting, word of his successful treatment had spread to others in more conventional neurology practices (4,14). Hig-gins, while addressing the Pennsylvania State Medical Society in 1928, commented, "About 1917 the attention of the medical world was drawn to the finding that the attacks in many cases of epilepsy were stopped, or lessened in severity and frequency, by starvation" (14). Dr. Penfield, of the Montreal Neurological Institute, and his colleague Dr. Erickson, also recognized Conklin's fasting therapy in their 1941 textbook on epilepsy (15). Lennox acknowledged that Conklin, by 1928, had the most experience in treating patients with epilepsy by fasting (probably hundreds of patients over approx 20 yr [4]).

Conklin and Macfadden's views on the origins and treatment of epilepsy were adopted by others (4). This is reflected in Dr. McMurray's letter to the New York Medical Journal describing digestive disturbances as an impressive finding in his patients with epilepsy and the use of fasting followed by a starch- and sugar-free diet as a treatment beginning in 1912 (16). Dr. A. Goldbloom, a physician at the Children's Memorial Hospital in Montreal, was more skeptical. He wrote, "A year or two ago we allowed ourselves to be startled by the news of an asserted real cure for epilepsy. A drugless healer in the middle west [Conklin] had been curing epileptics, it was said, by subjecting them to long periods of starvation" (17). He then related the story of a 10-yr-old girl who had failed therapy with bromide and Luminal® (phenobarbital), was having 60-100 petit mal seizures a day, and became seizure free on the fifth day of her fast. However, after the fast was broken, the seizures gradually returned.

Goldbloom stated, "It would seem from this case that the starvation treatment is effective only while it is continued and while the patient remains in bed, but that it has no enduring qualities. The explanation of the improvement is first that the patient is kept in bed, and secondly that the fermentative and putrefactive intestinal processes, so often the exciting causes of convulsions, even in a non-epileptic child, are reduced for the time being to a minimum. So far as children are concerned, one often sees children who have been considered epileptics in whom the epilepsy is found to be purely of intestinal origin, and who are therefore permanently cured by the application of strict dietetic measures" (17).

Lennox would later relate the relationship of Conklin's practice to the origin of the ketogenic diet (4,18). In an interesting anecdote, he relates the story of HTH, the boy initially presented by Dr. Geyelin to the AMA convention.

Lennox stated, "a New York corporation lawyer and his wife were troubled because of the daily seizures of their son. The boy's uncle (Dr. John Howland) was a professor of pediatrics, but the best medical advice and treatment of the day failed to help. In despair, the parents turned to Dr. Hugh Conklin, a disciple of Bernarr Macfadden, a physical cultist. The treatment was called, euphemistically, a water diet. This meant starvation for three or four weeks. Dramatically, the boy's seizures left him."

Around 1919, Charles Howland, the boy's father and a wealthy New York corporate lawyer, gave his brother $5000 to determine whether there was a scientific basis for the success of the starvation treatment of his son (19,20). Dr. John Howland, professor of pediatrics at Johns Hopkins and director of the newly opened Harriet Lane Home for Invalid Children was H.T.M.'s uncle. The gift from Charles Howland was used to create the first laboratory at the Harriet Lane Home. By 1937, the John Howland Memorial Fund was established at Johns Hopkins and used to support research on the ketogenic diet (21). Lennox reports that initially two physicians sought confirmation and explanation for the surprisingly favorable results of fasting. One was Dr. James Gamble. In 1915 Dr. Howland recruited Gamble, who had recently developed an interest in clinical chemistry, to the Harriett Lane staff.

By 1919, Harvey reports, "Dr. Howland had developed a deep interest in the treatment of epilepsy by the ketosis of starvation. Gamble went to work on this problem..." (22). These children were ideal subjects for the metabolic balance studies of the 1920s because their intake was limited to water, and fecal material was greatly reduced. Gamble and his colleagues initially reported the study of the acid-base balance of two fasting children (23). This report produced little information regarding the mechanism of action of fasting on epilepsy, but it was the beginning of a 30-yr study by Gamble of factors affecting the water balance in children. His report formed a pattern for clinical research and created the basis for the fields of pediatric electrolyte physiology and nephrology. He also was the first to note increased calcium excretion on the ketogenic diet, with a resulting need for calcium supplementation (24).

The other doctor recruited by Howland was H. Rawle Geyelin, who had reported his results at the 1921 AMA convention in Boston. Urinary acid excretion had been highest in patients whose seizures were best controlled. At that time, W. G. Lennox was studying cardiology under Dr. Francis Peabody at Boston's Peter Bent Brigham Hospital. Lennox reported that he was "Thrilled by Geyelin's demonstration and having a compelling interest in epilepsy and its treatment, my missionary zeal was abruptly transferred from Chinese to the epileptic" (18). Geyelin's extensive clinical and laboratory data were never published, but he later told Lennox that long-term freedom from seizures occurred in 15 of 79 children treated (19%), but in only 1 of 200 adults (0.5%) (4,11). Lennox's personal review of Conklin's short case records of 127 patients with epilepsy indicated that 20% achieved seizure freedom, and some improvement occurred in 50% (4).

In 1922 the parents of H.T.H. asked Dr. Stanley Cobb, associate professor of neuropathology at Harvard Medical School, to explain why starvation worked as a treatment for epilepsy (18). Cobb enlisted the assistance of a young colleague, W. G. Lennox. Lennox and Cobb reported on a selected group of five patients during a 2-wk period of fasting (24). Lennox himself served as a control during one fast period of 14 d and several shorter ones. Chemical assays of the blood and urine were performed in the subjects and controls. All showed an increase in serum uric acid and acidosis, which was excreted in the urine if the fast was broken with carbohydrate or by a purine-free protein diet, but not if broken by the intake of 40% cream. Also, they noted the increase in serum uric acid and acidosis typically developed after 2 or 3 d and was accompanied by a decrease in seizures.

Lennox stated, "Initiation of the use of bromides in 1857 and of phenobarbital in 1912 had demonstrated that the chemical action of these sedative drugs could lessen seizures. The third decade of the twentieth century witnessed a measure of control through a change of body metabolism. Simple absence of food or dearth of carbohydrate in the body forced the body to burn acid-forming fat" (18). The efficacy of fasting led to a flurry of clinical and research activity. Theories arose to explain the success of starvation. Dehydration (23,26), ketosis (24,27-29), and acidosis (25,30,31) were all advanced as mechanisms to explain the efficacy of fasting. Metabolic balance studies had been used by many investigators of this era to understand the interrelationships of fat, protein, and carbohydrate metabolism to the ketoacidosis and disturbed glucose utilization that occurs in diabetes.

Good Carb Diet

Good Carb Diet

WHAT IT IS A three-phase plan that has been likened to the low-carbohydrate Atkins program because during the first two weeks, South Beach eliminates most carbs, including bread, pasta, potatoes, fruit and most dairy products. In PHASE 2, healthy carbs, including most fruits, whole grains and dairy products are gradually reintroduced, but processed carbs such as bagels, cookies, cornflakes, regular pasta and rice cakes remain on the list of foods to avoid or eat rarely.

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