In support of this, Yudkoff and colleagues have published widely on the impact of ketone bodies on brain glutamate and GABA metabolism (Yudkoff et al., 2007). In one study, the addition of either acetoacetate or β-hydroxybutyrate was associated with diminished consumption of glutamate via transamination to aspartate and increased formation of labeled GABA (Daikhin et al., 1998). Ketone bodies had earlier been shown by the same group to enhance synthesis of GABA in synaptosomes prepared from rodent forebrain (Erecinska et al, 1996).

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Over the past decade, much progress has been made in dissecting apart the mechanisms underlying the anticonvulsant (and potentially, neuroprotective) effects of the KD (Gasior et al., 2006; Bough & Rho, 2007). The complex systemic and metabolic changes induced by a high-fat, low-carbohydrate diet – not surprisingly – provide fertile ground for very innovative and speculative hypotheses linking certain adaptations to a net anticonvulsant effect, ones that by necessity take researchers back to the earlier days of introductory biochemistry and human physiology. While many intriguing concepts and research data have been reviewed systematically in the context of the international symposium from which this supplement stems, the fundamental question of how the KD works remains as tantalizing as ever.

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Thus, if fatty acids (and perhaps more specifically, polyunsaturated fatty acids or PUFAs), enhance mitochondrial uncoupling, and if this basic downstream mechanism is responsible for both anticonvulsant and neuroprotective effects (which has yet to be demonstrated), then could taking a chemical uncoupler such as 2,4-dinitrophenol (DNP) render the same effects? Of course, it is well known that DNP, a potent mitochondrial uncoupler that greatly increases the basal metabolic rate, and once used to treat obesity in the 1930’s, has a major untoward side-effect profile – namely, high fever and the risk of death. Clearly, if mitochondrial uncoupling were to represent the essential target, then less potent (and less toxic) compounds are required, and novel delivery systems need to be developed.

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Given these findings, it is not surprising that investigators have studied the effects of dietary supplementation with PUFAs alone, to determine whether these substrates can render an anticonvulsant effect. Early case reports suggested that seizures might be better controlled with this approach (Schlanger et al., 2002). However, a recent randomized trial in adult patients with epilepsy failed to demonstrate superiority of a PUFA supplement (EPA) plus DHA, 2.2 mg/day in a 3:2 ratio) over placebo (Bromfield et al., 2008). Thus, the jury is still out as to whether PUFAs alone can mirror the clinical effects of the KD.

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