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Colin, I just came across this in a (frustrating) autism literature search: PMID  25072037 SandyGeorgia ( Talk) 16:58, 6 April 2015 (UTC)

Many of its sources are outdated. How to proceed? You want a page header template? Each outdated reference identified with an in-line template?

   Bfpage | leave a message  19:37, 5 May 2015 (UTC)

Since Colin stays pretty well on top of this article, I suggest you list sources that are not included on this talk page. Just because a source appears dated doesn't mean there is anything newer with which to replace it ... if you have instances where there are newer sources that aren't used, please list here. (Defacing an FA with tags without discussing first on talk isn't usually a good thing :) SandyGeorgia ( Talk) 19:39, 5 May 2015 (UTC)

Bfpage, I see you went ahead with tagging without responding here first. Sometimes an old source may be the best source, or the only source. Unless you have indications that these are bad sources, tagging the articles isn't the best. [1] Do you have sources indicating this information is no longer good? SandyGeorgia ( Talk) 19:50, 5 May 2015 (UTC)

Greetings! I see there is much interest in this topic. I am not familiar with Colin. My edits are really very minor, feel read to revert them and if you don't have roll-back permissions I'll do it myself. I meant no offense. I was under the impression that medical articles are supposed to be cited with references within the past five years. There even templates that automatically display an update tag after a certain period of time so that when an article is written initially, they can be edited to flag that it needs to be updated. I saw that there were no automated update tags in the article and assumed that I was doing the editors a favor by bringing these possibly outdated references to your attention. Please assume good faith on my part. I don't believe I've that ever been accused of defacing an article before, that's a new one. Let me know if you want to rollback my edits, I will not be offended. If you would like me to perform the rollback also please let me know I can do it with a click.

   Bfpage | leave a message  20:02, 5 May 2015 (UTC)

DO you have any reason to believe that information is outdated, or any indication that there are newer and better sources? If not, then you can just edit the article and remove the tags you added. I already removed them once, and you reinstated them. (I presume you saw this message in your edit screen?) SandyGeorgia ( Talk) 20:12, 5 May 2015 (UTC)

We got caught up in an edit conflict. Which means I saw your message AFTER I applied the last tag. It is gone now. My evidence for believing that the information is outdated is that the year is 2004, eleven years ago. I presume that there are better sources. ... Now that I've thought about it for a little bit, I have to quietly disagree with you when you say that an old source is better than no source. That may not necessarily be true. When we edit Wikipedia we also have to decide what to leave out and as time goes by some of those references get more and more unreliable. I would be glad to help you out except that I'm trying to get some of the missing articles created on pathogenic bacteria. I have not had any problems finding references or pathogenic bacteria that have been published in the past five years, so I'm not sure why it would be difficult to find references to support information in this article that has been published in the past five years. There is nothing wrong with another well-intentioned, experienced editor like myself applying maintenance tags to an article with the best of intentions and in good faith. I thought you could use some help and identifying some of your older sources. The Very Best of Regards,    Bfpage | leave a message  20:19, 5 May 2015 (UTC)

No problem-- I was just trying to get your attention, and you are reading intent into my message that isn't there. The idea is that, just because a source appears old, doesn't mean there is something newer or better to replace it with. SandyGeorgia ( Talk) 20:23, 5 May 2015 (UTC)

This source is over my head:

• Paoli A, Bosco G, Camporesi EM, Mangar D. Ketosis, ketogenic diet and food intake control: a complex relationship. Front Psychol. 2015 Feb 2;6:27. doi: 10.3389/fpsyg.2015.00027. PMID  25698989.

SandyGeorgia ( Talk) 20:23, 5 May 2015 (UTC)

I can understand it, do you want me to take a crack at it and see if it updates some of the older references?

   Bfpage | leave a message  00:17, 6 May 2015 (UTC)

Wow! I got about 32 returns on review articles on this topic for the past five years...hmmm, perhaps it is possible to update with more recent med journal review articles. Just saying,

   Bfpage | leave a message  00:22, 6 May 2015 (UTC)

This one looks like a good replacement for your 2004 reference but I can't pay for it:

<ref name="GlauserLoddenkemper2013">{{cite journal|last1=Glauser|first1=Tracy A.|last2=Loddenkemper|first2=Tobias|title=Management of Childhood Epilepsy|journal=CONTINUUM: Lifelong Learning in Neurology|volume=19|year=2013|pages=656–681|issn=1080-2371|doi=10.1212/01.CON.0000431381.29308.85}}</ref> The abstract mentions and confirms (generally) the diet for epilepsy.    Bfpage | leave a message  00:35, 6 May 2015 (UTC)

Hi folks. It is good to question if an FA is up-to-date, particularly one promoted Dec 2009. My, how time flies. Bfpage, there's no need to link to MEDRS since I created that guideline back in 2006 and this page is watched by a number of editors who helped shape it. I'm quite sure your edits are good-faith. The "needs update?" tag doesn't seem that intrusive or "defacing" as some tags, but an initial talk page request is probably the most polite way of making initial enquiries about sources. There will, for sure, be quite a number of featured/good articles for which the main authors have long-since departed, and perhaps a reader of the article who is qualified to help may feel inspired to improve/update the sources. I did research some new sources a few years ago but was disappointed that there wasn't really anything new to say. There seemed little point in replacing one review for another simply because the latter had a more recent date on it. I don't think the Neal randomised trial, for example, is likely to be updated with a newer RCT. It did its job wrt providing RCT evidence for insurance and government bodies who make decisions about efficacious medical treatments they wish to fund. The basic process of ketosis has been understood for nearly a century and more modern sources add nothing new. We still really don't understand why such a diet helps with epilepsy, though. I guess that's rather frustrating for Western science, but epilepsy is a problem with the brain, not individual neurons or chemical reactions, and we don't really understand the brain either. At least it has some plausible explanations and doesn't break the laws of physics like homoeopathy :-).

Looking at the areas that were tagged. I think the lead paragraph is basic stuff that hasn't changed since the 1920s. The lead sentence and sections that deal with research and possible other disease treatments is most likely to become outdated. I'm not aware of any medical uses for the KD that have reached mainstream other than for epilepsy. Just about any brain disorder from cancer to Alzheimer's to Tourette syndrome has been considered, as well as usage for dieting and diabetes control. I don't think epilepsy's rank after stroke in terms of serious neurological disorders has changed, or may ever change. The history of the diet and its conclusion with it becoming a standard (albeit not primary) therapy once again, is unchanged.

In terms of source-aging we have to consider any article is dealing with lots of different facts. If the best history of a disease/therapy was written 10 year ago, then that's still the best source even if there are some modern sources that copy/paste/tweak it. Has anyone improved on Temkin's "The Falling Sickness: A History of Epilepsy" book, for example? Some areas of our knowledge of the body are changing faster than others. Some diseases and therapies get more research than others. I dare say that cancer therapy, particularly common cancers, is a fast moving subject. This one less so. So I wouldn't hold the "five years old" guideline as anything other than a very crude measure. My point I suppose isn't really the age of the sources, but whether, when reading new sources, one realises that the facts are now considered to be wrong or are out of date. And for that, one really needs to do a literature search, rather than just look at the references list. I guess it is time I did another search .... :-) -- Colin° ^Talk 21:30, 5 May 2015 (UTC)

Thank you for such a gracious explanation. The reference I initially had problems with is 11 years old. I have found when I want to update an article, I can usually find the same information from the older article in a newer one, that is to say, the newer article becomes a possible tertiary source, confirming (updating and verifying) that the older reference is, indeed, still valid by its being quoted in a later article. The reiteration of the history of a disease/syndrome/pathology is almost always confirmed even in the abstract of a newer review article, thereby creating a source independent of Wikipedia confirming the validity of the original source. Sometimes there is a surprise waiting in a newer review article that calls into question the information in the older article. This has been my experience, and apparently I have erred thinking that this was the case for this topic.

Along the same lines, of course we have to expect that even FA articles will need to updated and being the notoriously bold editor that I am, it did not even cross my mind that there might be a problem tagging some references and just posting a passing announcement right before I began my tagging. There actually needs to be a procedure in place that delists FA articles, although it at first doesn't make sense because a featured article has the title due to the fact that it was featured. Does this happen? how does a FA go to a B or C?

   Bfpage | leave a message  00:13, 6 May 2015 (UTC)

Colin, there is something I've been wanting you to look at (above under autism), and there are three new sources I just added to the article. SandyGeorgia ( Talk) 22:05, 5 May 2015 (UTC)

I see them. Will look into those too. -- Colin° ^Talk 19:03, 6 May 2015 (UTC)

I am initiating the process of reviewing the FA status of this article by posting this message on the talk page. My main concerns are with older references which really weren't addressed adequately for me. I will take a closer look at the article to highlight more of the concerns that I see that may need improvement.

Respectfully and with appreciation toward all who have contributed to this article,

   Bfpage | leave a message  00:54, 6 May 2015 (UTC)

Bfpage, see Wikipedia:Featured article review for the process. I would appreciate that discussion be kept to the talk page and you are very patient with me wrt improvements. An article that is six years old doesn't need instant rewrite, and this article took me many many months to write. I encourage you to not be too dogmatic with reference age. For example, Wheless JW. "History and origin of the ketogenic diet" 2004 may well still be the best history of the diet. Certainly most reviews I've seen that cover the history will just cite this. Typically the introduction section of a paper is not considered first-class source material, as this may be subject to the most cursory of peer-review (it isn't really the point of the paper, after all). So even if a modern review begins with a historical overview that cites Wheless, I don't believe that makes the modern review a better source for our purpose. I get your point that second citation level adds another pair of professional eyes that confirm the validity of the material, but I also feel that generally many papers are rather poor on the history and merely plagiarise other works. For example, at least one paper has taken text from this Wikipedia article. It is obvious if you think about it, that neurologists are not actually professional historians. So they are about as competent at times as some celebrity model is competent to offer opinions on MMR :-). Another factor wrt sourcing is how contentious the fact is. Highly contentious material may demand up-to-date sources from the best journals. But material that nobody questions may be better sourced to the most comprehensive or authoritative article or book even if that's an old one.

I'd appreciate if you could point out issues where the article text is actually wrong our outdated. Having older references isn't actually an error or fault, merely a warning sign that a new review of the literature may be helpful. If you have found newer sources that might replace older ones, then that could be a big help, though I'd want to check the source was actually better and that we weren't losing something merely to gain newer date. -- Colin° ^Talk 08:40, 6 May 2015 (UTC)

Dear Colin, I can only say that the article is superb and that you deserve accolades for bringing it up to featured status. I am not on a witch hunt, or riding a very fast train. I believe at this point, improving the article can all take place right here on the talk page. I will be glad to help because at this point, I have been able to find more up-to-date sources to support statements that are sourced by older references (I believe) Since I am not an expert on the topic, I don't feel competent to 'fix it myself'. Of course, when the history of the development of the diet is sourced, we are citing history and not medical articles. The requirements for more recent med journal review articles would not apply. I will be working with you, not against you.

• first piece of good news is that there are 128 page watchers. They surely may lend a hand.

The Very Best of Regards,

   Bfpage | leave a message  12:33, 6 May 2015 (UTC)

this request seems to be based on misguided assumptions about WP:MEDDATE. Jytdog ( talk) 12:38, 6 May 2015 (UTC)

Thank you for your comment. Best Regards,    Bfpage | leave a message  15:22, 6 May 2015 (UTC)

• the second piece of good news is that by entering different terms into the search parameters, you get the results you are looking to on the topic of diet and epilepsy. I apologize if I am telling you something that you already know. I will post some examples shortly.    Bfpage | leave a message  15:09, 6 May 2015 (UTC)

• Don't worry, I often find I am explaining something that the other person knows, and you don't know me. I should be able to find my way round PubMed even if I am a bit rusty, and can get hold of most sources including subscription ones. Free ones are good to have if equivalent since that benefits our readers most. I need to spend a bit of time renewing my acquaintance with the sources I have already. And also locate some possible new ones. And also give the article an inspection to see if any changes made to it need fixing. I have limited time to spend on this on any day (sometimes none) so please be patient and avoid any significant undiscussed changes. -- Colin° ^Talk 18:43, 6 May 2015 (UTC)

I am glad to read this response of yours. I was reading concerns about possibly insulting you in some way, and I am glad to read that you and I have the same goals and ideals that we can work on maintaining FA status while at the same time seeing if anything better AND newer has been published. Again, it is not like this is an emergency and needs to be fixed tomorrow. It is good to know that you have subscriptions to possible review articles that I don't have. Take your time and I will be sure to let you know before I make any major edits such as replacing one source with another. Well, I have list to start with by reading some of those articles that I found in my searches. I will also look on google books to see if anything (better AND newer) has come out since 2009 which is the year that most of the references seem to cluster around. Best Regards,

   Bfpage | leave a message  19:09, 6 May 2015 (UTC)

Search results for free med journal review articles published in the past five years

• this page only results in displaying results with the keywords ketogenic diet.
• this page shows the results when I entered the keywords epilepsy and diet
• this page shows the results when I entered the keywords ketogenic and epilepsy.

   Bfpage | leave a message  17:02, 6 May 2015 (UTC)

Freeman's most recent book came out in 2011 and contains the same information as the 2007 text. It is not a medical textbook, but it is more recent. Is that a helpful source? Dr. James W. Wheless's newest medical textbook on epilepsy is from 2012. Why wouldn't this be a better source than his old one?

   Bfpage | leave a message  23:46, 11 May 2015 (UTC)

"Extraordinary claims require extraordinary evidence".

The claim made in this edit that "The treatment results of the [diet] are better than most of the new antiepileptic medications." is an extremely bold claim. The source used ( PMID  25221391) does confirm this but then doesn't actually present any evidence to back it up. Firstly, one must ask "in what kind of patients" and secondly one must ask "in what trials". Today, the KD is only used after many medications have failed and mostly in children. So we don't really have any modern experience of the KD as a first-line treatment (except perhaps in some rare metabolic disorders, or for trials in infantile spasms) nor do we have good contemporary evidence of its use in adults. Secondly, to state that it is better, one really requires a trial comparing it against "new anti-epileptic medications". And this hasn't been done. The closest is a randomised trial where the control group got "continuing treatment (on their existing AEDs) for three months" versus "adding the KD (on top of any existing AEDs) for three months". Advocates of the diet reckon that after you've tried several drugs, and for children especially, the diet is probably more likely to be successful than trying yet another drug. But that's their expert opinion rather than fully evidence-based results. So the issue is complicated and is mostly covered by the existing article text.

The addition of the above source as a reference in this edit is problematic. This paragraph, and that sentence is history. There's no better source for that that the current source which is an entire chapter in a professional textbook on the history. Every single article, just about, on the KD has a short "Introduction" section that covers the history in a sentence or two. The source given here is no different and adds nothing. I could pick a hundred other sources that do the same. I've already mentioned how history does not need up-to-the-minute sources. The state of epilepsy treatment in the 1920s is well documented already. But further, the source does not actually support any of the sentence. It doesn't say it was widely used or studied and doesn't mention bromides or phenobarbital. It merely says it was "initially devised in the 1920" and puts the decline down to "phenytoin and sodium valproate" (the latter drug is from late 20th century). Even if it did support the text, the source is so shallow that any reader following the link would learn nothing new about the history.

The citations in this featured article, support all the text preceding them in the paragraph up to the previous citation. So if a paragraph has one citation at the end of it, then the whole paragraph is sourced to that source. One cannot just add further citations against random sentences and phrases within the paragraph, without ideally also having access to and reading the original citation for the paragraph as a whole. Otherwise, the link between article text and sources begins to rot and soon nobody is sure what is backed up by what.

Lastly, a featured article is not written by finding random papers on PubMed (or by just reading the free ones) and inserting random facts or adding citations here and there. That approach might work for start-class articles but not when we're trying to write at this level. It will taken some time. -- Colin° ^Talk 21:54, 11 May 2015 (UTC)

I am not very good at answering many points all at once and so will have to respond slowly and methodically to help myself remain on track. First of all, if any of the perceived problems described above can be solved by simply reverting my edits, then please feel free to do so and know that there is only good faith efforts on my part to improve the article. I will not be offended in the least.

Concerning the statement (and WP policy): "Extraordinary claims require extraordinary evidence"; the statement and reference I inserted "The treatment results of the [diet] are better than most of the new antiepileptic medications." I have to say that I don't realize or recognize the 'boldness' of the statement, but at the same time defer to your greater experience on the topic when you say that it is a bold statement. The statement, though not copied word for word, simply appears along with other statements in the journal article and didn't appear any bolder than any of the other statements. The evidence to support this statement comes later in the journal article where the author describes at least seven studies to support the statement. To ask "what kind of patients" I can answer 317 Chinese children, 972 children studied by Keene et al., 54 children another systematic review by Neal, 27 children in a Sharma study, and 289 children referred to in a 'Cochrane' study. I've read the rest of the first paragraph of the comments above and remain puzzled because I am not in a position to evaluate the quality of the studies that were conducted. Nor do I have access to the protocols. I simply found a med journal review article, assuming that it has gone through a thorough peer-review process, with well-cited sources and found the information to be applicable to the topic.

Concerning "...a featured article is not written by finding random papers on PubMed (or by just reading the free ones) and inserting random facts or adding citations here and there...It will taken some time." I would not describe the process of improving this article as "finding random papers......", or at least that is not what I am doing. As for adding citations 'here and there', when content and citations are added, it happens in a piece meal fashion unless you are suggesting that a total rewrite is performed when ALL updated content and references are added at the same instance. How does editing progress unless statement by statement and reference by reference? This is only a partial response to your concerns above, I will be able to respond to more of your concerns when I have gathered the information necessary to provide a more complete response. Best Regards,

   Bfpage | leave a message  23:22, 11 May 2015 (UTC)

To expand a little on the "The efficacy of KD is better than most of the new antiepileptic drugs" claim made in the source, I think their main problem was that they weren't precise enough about the scope of that claim. For paediatric refractory epilepsy (children who have tried several drugs and are still having lots of seizures) then it may well be better than most of the new drugs -- they have probably tried the new drugs by then. But of adults -- we really don't have sufficient data. And for people newly diagnosed with epilepsy? Very much no. Most people with epilepsy achieve control of their seizures by popping a (potentially very cheap) pill once or twice a day, with manageable side-effects, and can then get on with their life and eat anything they want. In contrast the KD has a high drop-out rate and is very very expensive in terms of the trained staff needed to supervise it. To give you an idea of how unattractive it is, if the drugs haven't worked then you will be investigated for brain surgery before attempting this. If it turns out you have a focal seizure that might be helped/cured by surgery then that may be recommended. And they don't open up your head and snip things out for the fun of it :-)! So the evidence presented is on very sick children who have tried many drugs already and have been turned down for surgery. We can't, in the second sentence in the lead, make the unqualified and bold claim this is better than most drugs.

On editing. I don't think featured articles are written the same way as most WP articles are. They can be a collaborative effort for sure. But the general WP approach of a little here and a little there will at most generate something barely readable, disjointed and only moderately well sourced. I don't think a rewrite is needed, though some sections and paragraphs might well be. The history section is unlikely to change IMO unless someone feels the actual text could be written better or there are some recent developments to add. I plan to locate some improved sources and present them on the talk page along with some words about how they may affect the text. Then do some editing at a later stage. The paper you found PMID  25221391 refers to some recent studies (the older ones are already considered in this article) and cites some other recent reviews. Let's collect that info and see what new there is to say. -- Colin° ^Talk 07:52, 12 May 2015 (UTC)

I've only read the lede, so perhaps it's explained in the body of the article, but I don't understand this addition from last July bolded below:

The original therapeutic diet for paediatric epilepsy provides just enough protein for body growth and repair, and sufficient calories to maintain the correct weight for age and height. This classic ketogenic diet contains a 4:1 ratio (although a 3:1 ratio has also been used) by weight of fat to combined protein and carbohydrate. This is achieved by excluding high-carbohydrate foods such as starchy fruits and vegetables, bread, pasta, grains and sugar, while increasing the consumption of foods high in fat such as nuts, cream and butter. Thus, an individual's diet is composed of 90% and 86% of calories coming from fat, respectively.

What does the 90% and 86% refer to? The 3:1 and 4:1 ratios? Whatever, it could be clearer. -- Anthonyhcole ( talk · contribs · email) 06:09, 13 May 2015 (UTC)

It probably does, but this is getting a bit too specific for the lead. The 4:1 ratio is the classic diet's aim, but in individual patients, this may be less or more depending on how they are responding and tolerating. The difference between 90% and 86% is small. I've reverted the change for now. The message the lead should be getting across is that nearly all the calories come from fat, so perhaps we should say that rather than giving figures. -- Colin° ^Talk 07:29, 13 May 2015 (UTC)

Yes. That would be a lot clearer. :o) -- Anthonyhcole ( talk · contribs · email) 08:00, 13 May 2015 (UTC)

Source NICE Guideline CG20:

• Stokes T, Shaw EJ, Juarez-Garcia A, Camosso-Stefinovic J, Baker R. The diagnosis and management of the epilepsies in adults and children in primary and secondary care. (PDF). London: Royal College of General Practitioners; 2004. ISBN  1-84257-808-1

has been superseded by

• The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. (PDF). January 2012. National Institute for Health and Care Excellence.

• They request research on the use of the diet in adults.
• The guideline is: "Refer children and young people with epilepsy whose seizures have not responded to appropriate AEDs to a tertiary paediatric epilepsy specialist for consideration of the use of a ketogenic diet."
• Section 11.3 discusses the diet. Some useful details could be added to the article. Consideration of cost and difficulty of adherence means they recommend reserving this for children who have failed other approaches. Similarly, the additional cost of the MCT variant means it should not be tried first.

The Evidence update notes the Modified Atkins diet may be effective for children with refractory epilepsy, but they do not regard this as a fact to update in the guidance. They cite Use of the modified Atkins diet for treatment of refractory childhood epilepsy: A randomized controlled trial as evidence. This definitely looks like a fact to include in our article. However, NICE have three problems with the trial. It is not blinded (but then that is essentially impossible for this therapy), 77% participants were male and 44% vegetarian, which may limit its applicability to the UK. These issues meant they didn't recommend it in their guidance, recommneding a European setting for future trials. -- Colin° ^Talk 15:20, 17 May 2015 (UTC)

The population of the United States is roughly 5 times that of the UK. In order to ensure that Wikipedia serves as wide an audience as possible, I propose changing the style of this article to U.S. English instead of British English. — Preceding unsigned comment added by 139.78.252.149 ( talk) 21:50, 10 June 2015 (UTC)

See MOS:ENGVAR. This is the "International English" Wikipedia, not the US Wikipedia. This is no persuasive argument that this article topic should be written in US English. -- Colin° ^Talk 07:38, 11 June 2015 (UTC)

According to http://en.wikipedia.org/wiki/Wikipedia:Manual_of_Style/Dates_and_numbers#Strong_national_ties_to_a_topic this should be in US English, as the scientific research in this field has been done overwhelmingly in the US. In addition, even the images used on the page are primarily of US origin. — Preceding unsigned comment added by 139.78.252.149 ( talk) 17:41, 11 June 2015 (UTC)

A lot of research is done by the Johns Hopkins Hospital team but by no means the majority never mind an "overwhelming" amount. There are doctors, patients and researchers all over the world. Perhaps the most significant trial of the KD (both classic and MCT oil), Neal's randomised controlled trial, was based in London. And the biggest study of the Modified Atkin's Diet was a recent randomised controlled trial in India. The four photographs were taken in the UK. The actual topic is a medical diet used all over the world, which has no regional association at all. The "strong national ties" is for topics like NASA being US or Big Ben being British. -- Colin° ^Talk 12:06, 12 June 2015 (UTC)

To those who have contributed to the improvement to this article I need to let you know that I am proceeding with the request to have this featured article reviewed. Little to no progress has been made to update references that comply with WP:MEDRS. I completely understand that older references are not necessary better references but is likely not true for the whole article. Almost every reference cited is sourced to publications that are more than five years old. I might be missing something but it doesn't appear that any references include review articles, systematic review articles, meta-analyses, reliable and official webpages by the CDC or WHO or medical textbooks.

I am not criticizing the article; It's prose is excellent, it flows naturally point by point. Obviously, a lot of hard work has gone into it, but few if any significant edits have been added that provided good sources.

I am no way suggesting that this article is less than a good article and I know it was created and edited in good faith (except by vandals). Best Regards,

   Bfpage | leave a message  10:33, 23 July 2015 (UTC)

@ Bfpage: this is the job of Wikipedia:Featured article review, which would be the logical next step. Cas Liber ( talk · contribs) 15:11, 23 July 2015 (UTC)

MEDRS says "five years or so", not "five years", and also says "These instructions are appropriate for actively researched areas with many primary sources and several reviews and may need to be relaxed in areas where little progress is being made or few reviews are being published." We normally use ten years as the approximate rule of thumb for rare diseases, and it seems likely to me that this rare treatment should be handled in the same manner. By that standard, about a quarter of sources are "outdated", but that includes items that are one of multiple citations and/or in the ==History== section or otherwise not covered by MEDDATE anyway. Also, quite a lot of those "outdated" sources are exactly one year "too old", which does not worry me very much.

Also, the actual point of MEDDATE is to present accurate, current information. Is there anything in there that you think is sourced to something "outdated" and the actual content of the sentence or paragraph needs to change? WhatamIdoing ( talk) 16:46, 23 July 2015 (UTC)

Whenever I have written content that contained a reference that was before 2008, my edit has been reverted. Therefore I assumed that this was the standard for every editor. Wrong assumption on my part. I am pleased to read that it doesn't worry you too much. I also am not worried too much. As I said before, my intent was to suggest that outdated references be updated. Apparently, no one wants to update the references. As for being rare disease, the information on the diet has expanded to include other disorders other than epilepsy. In that way the article isn't as comprehensive as it could be. I intend to walk away from this. It really isn't worth the contentiousness. In the spirit of civility and assuming good faith on the part of other editors I will withdraw my request and stay away from featured articles. It just isn't worth it. There is no cabal but I have never gotten any support from other medical editors. I was enlisted to help you out in reviving the haitian wikipedia, but that wasn't an encouraging action for me, even though you and Doc James seemed pretty enthusiastic. I feel that my participation was something you could 'check off' on a to-do list and fulfill the goals of reviving the haitian wikipedia. This is how I feel, it is not an accusation. I felt the same way about Doc James enthusiasm about my translating medical articles. I am very discouraged regarding my participation in Project Medicine. If you care to see how discussions have typically been regarding topics with which I am involved, you will notice a pattern of opposition on the talk page. I feel that I am not helping the Project at this time. This is not an accusation, it is an expression of my discouragement in editing. Best Regards,

   Bfpage | leave a message  13:18, 24 July 2015 (UTC)

Bfpage, I don't mind you querying the quality of articles, particularly FAs. And I did forget all about this page again. When you say that you've had work reverted because the sources were old, then I wonder... Was the edit you added contentious at all and the other user was using the age of the source as a proxy rather than directly raise issues with the text? Or was the text fine and uncontentious, and the editor was being rather picky? For new work, I'd prefer to use a recent source unless one couldn't be found. But if your edit genuinely improved WP with new information that isn't out-of-date, and all you add access to was an old source, then perhaps the revert was unfair and uncollaborative. But it doesn't follow that we need to go around deleting or demoting existing text just when the sources get old. I think your focus should instead be on the article text and comparing that to what you think recent sources say. I'm sorry I don't have time to investigate your contributions/opposition any further -- these sort of interpersonal problems are part of the reason I don't edit much here -- it's such a timesink. All I can suggest is that WP is a big place and I'm sure there must be a part of that you can usefully contribute to without making you depressed. Regards, Colin° ^Talk 14:21, 24 July 2015 (UTC)

Colin, I did not have any edits reverted in your article. I removed the tags myself. I was making a comment about my edits in general. You are courteous and considerate. I am not depressed-only discouraged. I'll get over it. It is a timesink, one good reason to end the discussion, friend. Best Regards,

   Bfpage | leave a message  15:08, 24 July 2015 (UTC)

Sorry. In May I promised I'd look at researching new sources for this article but I have not got round to doing that. I don't really understand the comment made elsewhere that the article lacks sources that are "academic journal review articles, systematic review articles, governmental websites and policies and medical textbooks". It includes each of these. I discussed the issue of ageing sources earlier on this talk page, so won't repeat. Ok, I will make a renewed effort this weekend to do some research and post my findings here as a step towards updating the article. My main concern isn't really about updating sources for the sake of it. Are there facts that are now considered incorrect or otherwise superseded? Is there information missing from the article? Is the weight given to aspects of the subject appropriate when reviewing the current literature? I firmly believe in applying WP:WEIGHT and building an article from the body of literature, rather than accumulating random factoids. -- Colin° ^Talk 10:21, 24 July 2015 (UTC)

My impression that the sources didn't meet MEDRS was was based on the titles of the journal articles that were cited. When challenged, I began to read the references (if I had access) and saw that just because the work 'review' isn't in the reference title, doesn't mean it isn't a review article. There is more research indicating that the diet helps in the treatment of brain cancer, reverses the expression of some alleles and a few other new things I referenced above. I am sorry if you think I am collecting random factoids-that is not my intent. I found the new research intriguing and thought it would be a good addition to the article. Best Regards,

   Bfpage | leave a message  15:08, 24 July 2015 (UTC)

( edit conflict)@ Bfpage: questioning and reviewing articles is important and valid. I am not familiar with the article, but if you find review articles that are more recent or cover broader aspects then they most certainly should be included. However, querying content here solely because your edits were reverted elsewhere is not the right way to go. Furthermore, medical articles do get eroded steadily on wikipedia and are important to keep an eye upon. Please discuss specific issues as you find them. Cas Liber ( talk · contribs) 14:15, 24 July 2015 (UTC)

Thank you for your response. I gave links to recent developments in the discussion above. Of course I'm not querying content solely because my edits were reverted elsewhere, I'm not sure what that even means. Actually the reversion of my edits in Project Medicine is something I have come to expect and in good faith the editors that revert my edits are doing their very best to improve the encyclopedia. There are some high numbers in my editor interaction with an editor and I need a break from that. It doesn't look good and I have had trouble with administrators before over my interactions. There really isn't a need to discuss the eroding references, I typically just update content with more recent references. Editors in Project Medicine work hard to replace outdated references. I will certainly take your advice to discuss specific issues as I find them...that is what I thought I was doing on this talk page. Best Regards and thank you for your interest,

   Bfpage | leave a message  14:49, 24 July 2015 (UTC)

Dear ketogenic diet editors. I've just come across:

• Cyclic ketogenic diet (  | talk | history | protect | delete | links | watch | logs | views)

- a rather poor article. Is this a viable distinct topic? And if so does it merit its own article, or at most a mention here? Alexbrn ( talk) 05:30, 23 July 2015 (UTC)

• • Various low-carbohydrate diets are used for slimming or body-building or as a lifestyle choice. Some are ketogenic and some are only ketogenic for a phase of the diet. Most are also high protein. Most are followed by adults rather than sick children. Etc, etc. There's an adjective in common with the medical therapy discussed here, but that's about all. -- Colin° ^Talk 15:54, 24 July 2015 (UTC)

This text (copyedited a bit) was added by an IP:

Because many anti-epileptic treatments are also effective for bipolar disorder, the ketogenic diet has been suggested as a potential treatment; ^[1] two case studies were reported in which patients with bipolar II disorder achieved remission on the diet and discontinued medication. ^[2] As of yet, no clinical trials have been conducted to assess its potential effectiveness.

1. Please note that this Featured article uses list-defined references; per WP:CITEVAR, please attempt to respect the citation style.
2. See the prominent edit notice that pops up whenever editing this article.
3. This text discusses two case studies and uses a citation from 2001 for which no article title or PMID is given.

Including this text is likely WP:UNDUE, but a correct citation would be helpful. SandyGeorgia ( Talk) 18:58, 30 April 2015 (UTC)

The ketogenic diet is not the same as chemical anticonvulsants. Two cases doesn't prove anything. Until more research on manic-depressives is done, it is best to leave that out. Andrea Carter ( at your service | my good deeds) 07:47, 21 August 2015 (UTC)

In the Other Applications section, the third paragraph cites a 2013 review and says "the only evidence of benefit is anecdotal". This article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215472/ has a slightly stronger conclusion and cites clinical studies that I think can be described as preliminary rather than anecdotal. Since I've never edited a featured article, I'll leave that observation here for consideration. JonSidener ( talk) 17:30, 15 May 2016 (UTC)

Thanks JonSidener. The article cites some preclinical studies (i.e. non-human) and some pilot and phase 1 trials, which are not designed to provide "evidence of benefit". See Phases of clinical research. And those phase 1 trials were cited via ClinicalTrials.gov -- i.e. they hadn't actually published. So I don't think we've even got preliminary evidence of benefit for humans, published in a form we can cite per WP:MEDRS. Perhaps there is a newer review? -- Colin° ^Talk 07:26, 16 May 2016 (UTC)

doi:10.1136/practneurol-2015-001288 JFW |  T@lk 11:40, 17 May 2016 (UTC)

This is essentially an article about the ketogenic diet as a treatment for epilepsy. If it were titled as such, it might merit the star. As a general treatment of the subject, it is too specific. It doesn't have much to say about the widespread use of the diet for weight-loss and treatment of diabetes. It doesn't say anything about how the diet actually works - the chemistry. — Preceding unsigned comment added by 80.174.78.122 ( talk) 09:33, 20 July 2016 (UTC)

As it says at the top of the article; "This article is about a dietary therapy for epilepsy. For information on ketogenic diets as a lifestyle choice or for weight loss, see Low-carbohydrate diet and No-carbohydrate diet." In serious literature, the discussion of this topic is predominantly as an epilepsy treatment. Alexbrn ( talk) 09:39, 20 July 2016 (UTC)

Plus, as indicated in the "Seizure Control" section, we don't actually know all that much about how the ketogenic diet works as a treatment for epilepsy. An article can be well written and well sourced (and therefore deserving of FA status) even if its subject is not well understood. Kajabla ( talk) 15:55, 22 July 2016 (UTC)

If this article is only about Ketogenic diet and epilepsy then why is it not in the heading?

quote: "This article is about a dietary therapy for epilepsy. For information on ketogenic diets as a lifestyle choice or for weight loss, see Low-carbohydrate diet and No-carbohydrate diet." Alexbrn ( talk) 15:09, 13 September 2017 (UTC)

Aging

Where do I put this in the article? https://www.sciencedaily.com/releases/2017/09/170905145551.htm BernardZ ( talk)

Nowhere, it has no encyclopedic value. Alexbrn ( talk) 15:09, 13 September 2017 (UTC)

Why do you think so? BernardZ ( talk) 16:41, 18 September 2017 (UTC)

It's a piece of churnalism based on some primary research - which we avoid. Alexbrn ( talk) 16:45, 18 September 2017 (UTC)

The article is very good but ran into a problem when it described propagation of a nerve impulses. It stated that the charge propagated from one neuron's synapse to another. Actually the synapse is the shared gap between two (or usually many) neurons. I also thought the contrast with "electrical pathways" was not particularly useful. In general the concept of a physical electrical connection, like with electric circuits, is misleading. There are ion channels which speed up charge-potential propagation. It is unlike the conductance of electrons through a copper wire. But since the article is portraying the seizures as a chemical imbalance, the mention of the other method of charge propagation in the brain is a distraction. The age of fable ( talk) 05:23, 16 September 2017 (UTC)

I re-edited the page, and provided information on the talk page of the person who rolled back my previous correction. Please review the Wikipedia page on "Synapse." The diagram clearly shows that the synapse is the space between two neurons. So it is not correct to state that a charge is propagated from "one neuron's synapse to another." The age of fable ( talk) 07:41, 26 September 2017 (UTC)

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The Epilepsy section seems out of place here. At best, a single sentence from this section could be incorporated elsewhere in the article, but its placement (as the first section) and content (which is mostly about Eplipesy as a disease and other treatments of it) seems very out of place. The ketogenic diet's role in the treatment of epilepsy is only mentioned in passing, and with almost no usable detail. This needs to be worked on by someone with some knowledge of how to incorporate it better into the narrative flow of the article. For an FA level article, it's quite substandard! -- Jayron 32 15:36, 27 March 2018 (UTC)

@ Jayron32: the point of it is to offer a brief summary of epilepsy, because this diet is used to treat it. SarahSV ^(talk) 15:41, 27 March 2018 (UTC)

Yes, that's fine, but we can a) incorporate such information into another section instead of giving it the prominence of the first such section and b) phrase it better to indicate why the diet is used and how it is kept to treat it. Your explanation is fine, the actual placement and specific text used in this article does not adequately convey that. Someone needs to fix that. -- Jayron 32 15:45, 27 March 2018 (UTC)

It's a background section, leading into the article, which is about how the diet is used as a treatment. It's a standard way of handling something like this. SarahSV ^(talk) 15:54, 27 March 2018 (UTC)

@ Jayron32: I'm not sure what solution you're looking for. This article is about a treatment for epilepsy, so it is natural to begin with a background section briefly describing the salient points about epilepsy. It covers very concisely: epidemiology, diagnosis, etiology, symptoms, classification and treatment – which is where the ketogenic diet is mentioned, of course. Which of those background points do you wish to see removed? Personally, I can clearly see the relevance of that chain of information to this article, and I'm surprised that you can't. -- RexxS ( talk) 16:18, 27 March 2018 (UTC)

You're quite right. I apologize for being confused myself. Re-reading it all, it seems to be fine. That's what happens when I find myself outside of my area of expertise. Mea culpa, you're all correct, and I'll go back in my corner and stop trying to be useful (and failing miserably). -- Jayron 32 16:28, 27 March 2018 (UTC)

A "background" section is not a standard section in MEDMOS which is designed not to be medical marketing. (A background section is extremely common in medical marketing material.) This whole page ignores MEDMOS as well as MEDRS in several places. Very surprising to see it is an FA. Jytdog ( talk) 21:13, 27 March 2018 (UTC)

Water fluoridation is a health article, that starts with a "Goal" section. It is not possible for a MEDMOS guideline to envision every possible type of article. If you can find a better structure in a dietary article, please suggest it, but MEDMOS doesn't seem to have a Dietary organization structure, and there is no other dietary FA I can find. I also wanted to mention that, on the image you object to, it is easy to replace. That's the advantage of images :) Also, speaking in capacity as former FAC delegate, objections (re WP:WIAFA) must be "actionable". SandyGeorgia ( Talk) 21:25, 27 March 2018 (UTC)

Actually MEDMOS sections are very much suggestions only and writers are encouraged to diverge should an alternative be more appropriate. I should know, Jytdog, because I wrote it. And MEDRS. When I wrote the suggested sections in MEDMOS, it was based on a handful of FACs and I found absolutely no consistently whatsoever. Nor is there consistency today. It was purely a "you might want to start with this" idea. Unfortunately, Doc James took this as literal gospel truth and went around modifying articles "per MEDMOS" and thus totally destroying the flow the writer had created. Ironically, "Changing an established article simply to fit these guidelines" is explicitly discouraged by MEDMOS. Nothing less than vandalism, and very very sad. -- Colin° ^Talk 21:29, 27 March 2018 (UTC)

Painful reminder that what User:Tony1 created, one crusade destroyed! I had forgotten ... darn you for the reminder. SandyGeorgia ( Talk) 21:40, 27 March 2018 (UTC)

POV pushers tend to treat policies and guidelines as "suggestions". We obviously have a walled garden fanpage here. I will leave you all to play in it. Jytdog ( talk) 22:09, 27 March 2018 (UTC)

I see that Iztwoz added the text "Medium-chain fatty acids octonoic and heptanoic acids can cross the barrier and be used by the brain." with a few sources. They don't appear to meet WP:MEDRS as they seem to be studies on mice and rats, rather than humans. We need secondary sources that directly discuss these acids wrt the ketogenic diet's mechanism in humans. If we can't find suitable sources for this, it should be removed. -- Colin° ^Talk 14:06, 31 March 2018 (UTC)

Yes I added that taking it from Brain metabolism section - was unaware at the time of need for MEDRS (and also of need to make clear ref to mouse and rat models)....The material has been there for almost three years so am pleased that you have now removed it. There are some good recent reviews PMID 21855298 on Triheptanoin and PMID 27868154 that might be of help. Best -- Iztwoz ( talk) 17:08, 31 March 2018 (UTC)

Hi Colin have just seen same info added on Human brain page which passed GA and has refs:PMID 22403540; PMID 23072752; and PMID 15717057 -- Iztwoz ( talk) 17:18, 31 March 2018 (UTC)

Iztwoz, thanks for this. I'll certainly consider this role in possible mechanism as I read more. To avoid WP:OR I really need a review on the KD in humans that links this research. Like PMC  3534786 but perhaps newer still. -- Colin° ^Talk 17:26, 31 March 2018 (UTC)

I am rather puzzled by this revert by User:Zefr with summary "Preliminary research; speculative" The edit removed several updates I made to the article today:

• this: I added another, new, source for the treatment of glucose transporter 1 deficiency syndrome. This is very much the established treatment for the disease and has been for many years.
• this: I liked to " Warburg effect" which is the name being given to the reason why cancer cells are particularly susceptible to changes in glucose metabolism
• this: I replaced the existing text on cancer research with a newer review. The text makes it very clear that this is at the trial stage and is very much appropriate WP:WEIGHT for the topic (other professional resources on the KD give a similar, if not more, amount of room to potential new treatment uses of the KD, particularly cancer).
• this: I removed text based on an old review. The research has moved on from "anecdotal".
• this: I add the results of a 2018 systematic review on the KD for epilepsy in adults. This is neither "research" nor "speculative". The KD is offered to adults at many highly respected epilepsy specialist centres. Again, this is something noted in all reviews and texts on the KD. The lack of a paragraph on this topic meant the article was under-WP:WEIGHT.

I ask Zefr to restore my edits and to take more care in future. I'm not some random newbie here. -- Colin° ^Talk 15:59, 2 April 2018 (UTC)

The edits and sources used confirm the KD is a speculative format that does not yet meet encyclopedic information, as revealed in this edit and source. None of this is proven conclusively, so fails WP:MEDASSESS. For treating epilepsy, the most recent Cochrane review, PMID 26859528 as shown in the conclusions, describes this area as preliminary, inconclusive, and to date, poorly studied, i.e., unencyclopedic because it fails WP:V. -- Zefr ( talk) 16:19, 2 April 2018 (UTC)

(ec) Zefr I'm quite familiar with the literature on this topic, as I wrote the article, and have spent the weekend refreshing my appreciation of the topic. I know about the Cochrane review because I added it to the article yesterday. The world does not revolve round Cochrane, which is merely one form of systematic review with limitations to their approach. The text I added was based on a systematic review, and was one of two systematic reviews I looked at, but decided to only cite one. WP:MEDASSESS has systematic reviews at the top, which this is. Btw, "None of this is proven conclusively" is perhaps a suitable game for hard sciences like physics but never true for medicine, and the KD has never been suggested as a first line treatment, except for some rare conditions. Have a look at this recent review from Norway. Search for the word "adult". You will find this article gives similar weight to that. There are plenty other examples. It most certainly does not fail WP:V as the statements added can be sourced to multiple first-class reviews. It also does not fail WP:WEIGHT as the topic is entirely appropriate to cover based on the literature. It is also not speculative, as the KD is indeed offered to adults in epilepsy centres across the world, and not just as part of some trial. That last point is a basic fact that should make you pause and think.

Additionally you removed other edits unrelated to the complaint you made above. That was simply disruptive. -- Colin° ^Talk 16:38, 2 April 2018 (UTC)

this article notes there are three centres in the UK offering the KD to adults. In addition, Johns Hopkins have a Adult Epilepsy Diet Center which has treated over several hundred patients. There's also a large RCT underway in Norway. There was an RCT in Iran. And so on. Plenty evidence that this diet is used in adults, is covered in the literature, and we need to somehow describe the degree of efficacy/tolerance and evidence rather than just suppressing this with reverts. -- Colin° ^Talk 17:16, 2 April 2018 (UTC)

Another revert

There's quite a bit in this article that doesn't meet the standards of WP:MEDRES. Consider this material: "The ketogenic diet may be a successful treatment for several rare metabolic diseases. Case reports of two children indicate that it may be a possible treatment for astrocytomas, a type of brain tumour. Autism, depression, migraine headaches, polycystic ovary syndrome and diabetes mellitus type 2 have also been shown to improve in small case studies. There is evidence from uncontrolled clinical trials and studies in animal models that the ketogenic diet can provide symptomatic and disease-modifying activity in a broad range of neurodegenerative disorders including amyotrophic lateral sclerosis, Alzheimer's disease and Parkinson's disease, and may be protective in traumatic brain injury and stroke." Case reports on two children, small case studies, uncontrolled clinical trials, and studies in animal models are not appropriate grounds for claims of efficacy. Peter coxhead ( talk) 16:32, 2 April 2018 (UTC)

Wrt, this revert with comment "the fact that randomized trials were recommended shows that the evidence does not meet WP:MEDRS". Peter, I trust you also are unfamiliar with the topic, nor have carefully read the article. The text you removed is not in the "efficacy" section nor is in the "indications" section. If I was claiming the KD was indicated as a treatment for cancer, then you'd be quite right to demand better quality evidence. But this is a section on possible future uses of the KD and quite clearly so. I am planning to update some of the text here as I find newer sources. The KD is actively being studied clinically for certain cancers, which, as I note, appear "promising", and no more. Some of those cancers, particularly brain cancers, have no effective treatment at all. Please can you restore your text and can you guys try to edit more constructively and collaboratively. Particularly as neither of you are familiar with the topic, your first step should be to ask question. If either of you were actually familiar with the literature, you wouldn't be making these reverts, because this article says no more than any of countless literature reviews, and professional-level medical textbooks on the topic have done for many years now. If you can't edit constructively, take this off your watchlist and find something else to do. -- Colin° ^Talk 16:46, 2 April 2018 (UTC)

And Peter, you've even broken the references on the page. Wikipedia does not need careless uncollaborative editors. -- Colin° ^Talk 16:53, 2 April 2018 (UTC)

@ Colin: I suggest you review your comments above which are inappropriately aggressive and certainly not collaborative.

I agree, of course, that I should have removed the now unused list defined reference; it was a mistake. I do not agree that it was wrong to remove the material I removed. A 2018 review suggested the evidence from rigorous preclinical and clinical studies of ketogenic diets in cancer therapy was promising, and recommended randomised clinical trials to establish which specific cancers benefit – if you write "to establish which specific cancers benefit" the clear implication is that we know that some cancers do, but just need to find out which specific ones. It makes a claim of efficacy in respect of some cancers, regardless of what section it is in. It's not acceptable unless supported by appropriate MEDRS-compliant sources showing the benefit in the case of some cancers. It could be re-written to be more tentative, but then why include it? We don't routinely include reports on treatments undergoing trials, because can be dangerously misleading to non-scientific readers.

I haven't yet removed the material I've highlighted at the start of this section; perhaps you'd like to comment first. Peter coxhead ( talk) 17:20, 2 April 2018 (UTC)

Peter, I'm annoyed about the reverts, which have removed hours of article research. Sorry about the tone. I hope you understand that reverts are by definition an unconstructive editing approach. Did you conduct hours of research before removing the text?

I can't access this paper but it is cited in this one. "10 of the 24 (42%) clinical studies included in a recent review [1] provide evidence for the anti-tumor effect of KDs, whereas seven (29%) showed no effect and only one study reported a pro-tumor effect of the KD.". The text I added was specifically related to "Based on the results of rigorous preclinical and clinical studies performed thus far, the KD would appear to be a promising and powerful option for adjuvant therapy for a range of cancers. Cancer-specific recommendations await the findings of randomized controlled clinical trials." I'm open to suggestions for alternative wording.

Wrt "why include it". Well because of WP:WEIGHT. In the reliable literature on the KD, what weight do our sources place on these potential new uses of the KD. The answer is very similar to what we have here. We have a very short section that lists a number of research areas. Take this 10 year old review who's scope is very similar to the "other uses" section scope. This is a valid area of coverage on WP. And this source which extensively covers the topic on cancer. I do appreciate the care needed wrt speculative research on Cancer, and I'm not editing the cancer articles to suggest readers should go out and try the KD. Also Wikipedia is not Censored, so we don't remove stuff just because we think non-scientific readers might misunderstand it.

I think this aspect could be written to use the words "anti-tumour effect" which of course is only one aspect of a cancer therapy (the others being is the effect enough to modify in a clinically meaningful way, and do patients tolerate the treatment, does it have side effects, does it make some cancers worse, can we identify the patients who would benefit and those that don't, etc). Do you agree? I really don't mind discussing this to improve the article, I'm just not keen to play at reverts with anyone. That's a very tiresome way to work. -- Colin° ^Talk 17:52, 2 April 2018 (UTC)

Peter, would this be acceptable:

A 2018 review looked at the evidence from preclinical and clinical studies of ketogenic diets in cancer therapy. The clinical studies in humans are typically very small, with some providing weak evidence for anti-tumour effect, particularly for glioblastoma, but in other cancers and studies, no anti-tumour effect was seen. Better, larger trials, which focus on specific cancers, are needed before any clinical recommendations can be made.

That seems entirely supported by the source, and one short paragraph on cancer is imo valid per WP:WEIGHT in the literature as a whole. -- Colin° ^Talk 18:11, 2 April 2018 (UTC)

@ Colin: this is much better; I might well not bother to include it, but I don't object if you want to. Peter coxhead ( talk) 18:23, 2 April 2018 (UTC)

Thanks. See also PMID 28325264 ( full text) which particularly covers malignant glioma. This search shows 12 ongoing clinical trials on glioblastoma alone. This is far from a small obscure area of research. -- Colin° ^Talk 18:45, 2 April 2018 (UTC)

@ Colin: can you comment please on the material I highlighted at the start of this section? I think it should be removed. Peter coxhead ( talk) 18:31, 2 April 2018 (UTC)

That text is (I hope, unless someone has squeezed an extra few diseases in there) sourced to this paper "Clinical Aspects of the Ketogenic Diet". As such it is a good source for assessing WP:WEIGHT. It has a "OTHER APPLICATIONS OF THE KETOGENIC DIET" section where I original drew the material from. There's also this review and others. I think therefore the only argument for removal is age (10 years old source) or perhaps the wording could be improved. What I'd like to find now is a similar review on the non-epilepsy therapeutic directions. Just because the source is old, doesn't necessarily mean is is wrong. If we can find sources that reject what it claimed (e.g. better newer sources find no benefit whatsoever of alzheimers), that would be best. I'd rather not just delete the whole paragraph because one source is old, without a good search to show modern literature contradicts it or no longer gives it any weight. There's no rush (the text has been in the article for years) so perhaps we could work on improvement rather than deletion. -- Colin° ^Talk 18:45, 2 April 2018 (UTC)

@ Colin: the problem is that this material claims efficacy for a wide range of diseases, but doesn't remotely meet the standards of WP:MEDRS, in particular WP:MEDASSESS – the studies are all at the bottom two levels of the diagram (and even then beneficial effects were only shown in a relatively small proportion of them). The sources used contain many statements like this one: "Finally, even though there are no direct or strong evidence of the usefulness of KD in humans, this nutritional approach appears promising and so deserves further clinical extensive trials." On the basis of the sources I've seen that are used in the article, a very brief mention outside epilepsy can be justified, along the lines of "There is no strong evidence for the usefulness of the ketogenic diet in humans, although animal studies, case studies and small cohort studies suggest further research should be undertaken." I don't accept the argument that because the material has been there for years there should be a bias towards keeping it; errors and deviations from consensus guidelines should be corrected however long they have been present. If there are more up to date sources at the higher levels of WP:MEDASSESS, then the material can be restored. Peter coxhead ( talk) 07:29, 3 April 2018 (UTC)

Peter let's look at the whole of WP:MEDASSESS. While there is certainly scope to tweak the wording wrt "claims of efficacy" this is an important area of research in the KD. We are absolutely not getting into the business of citing case studies, small cohorts, etc, and that is exactly what MEDASSESS says writers should not do, and MEDRS is a source-citation guideline, not an article content guideline. MEDASSESS says:

For example, results of an early-stage clinical trial would not be appropriate in the Treatment section on a disease because future treatments have little bearing on current practice. The results might – in some cases – be appropriate for inclusion in an article specifically dedicated to the treatment in question or to the researchers or businesses involved in it. Such information, particularly when citing secondary sources, may be appropriate in research sections of disease articles.

So how do we determine if these small studies are appropriate for inclusion. The core policy (which trumps WP:MEDRS) is WP:OR and specifically WP:WEIGHT:

Neutrality requires that each article or other page in the mainspace fairly represent all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint in the published, reliable sources...

Keep in mind that, in determining proper weight, we consider a viewpoint's prevalence in reliable sources, not its prevalence among Wikipedia editors or the general public...

articles ... should strive to treat each aspect with a weight proportional to its treatment in the body of reliable, published material on the subject

How do we do that? By becoming familiar with the body of reliable, published material on the subject. In this case, reviews that specifically discuss research directions for the KD and articles that provide an overview of the KD. Professional textbooks is another possibility, though they may be lacking for the KD. Wrt overall weight, I have determined that a small set of paragraphs at the end of the article is appropriate weight for the topic. For the weight of each research direction, we have sources like Hartman, and others that look at the huge topic of cancers, say. We cover the research based on the weight given to that research in secondary sources. If, for example, there is now nobody researching the KD and Alzheimers ( this suggests there is, but of course we need a published review paper, not database search results) then mentioning that would be undue weight. However, if researching the KD and Alzheimers is actually an active area of research for this diet, and mentioned by the literature on the diet, then we cannot, cannot, choose to not mention it just because Wikipedians think the research is at too early a stage. These are not things for us to judge, and that's absolute policy, not just some guideline about sources.

The current text was appropriate weight when written. I think the "Case reports of two children indicate that it may be a possible treatment for astrocytomas, a type of brain tumour." sentence can go, because cancer is covered more fully later anyway. What we need to do now is redetermine the weight in reliable published sources, and then find the best way to appropriately mention the research and its tentative results. We can't just go "chop chop" based on our own personal judgement of the research, even if MEDRS gives advice about judging research [MEDRS is specifically concerned with the sources cited], because policy forbids that as much as it forbids "add add". The two aspects are balanced, which is what WP:WEIGHT is all about.

Can we agree that the approach to this is not for two editors to judge if one trial or report meets MEDASSESS or not. That's exactly original research and we are forbidden. At the top of MEDRS it says "Cite reviews, don't write them". Let's do a (secondary-source) literature search and discuss the findings of that per WP:WEIGHT. -- Colin° ^Talk 08:04, 3 April 2018 (UTC)

I'm afraid we cannot agree on your first sentence. We're not talking about writing our own reviews, but about choosing which sources to include. We do that all the time – as an extreme example, we include pseudoscience sources only in a very limited way, and never as if they were equivalent to scientific sources. The best way forward, I think, is to ask some experienced MEDRS regulars to give their views. Peter coxhead ( talk) 11:07, 3 April 2018 (UTC)

I've invited Jtdog to comment since he seems to be a regular 'expert' in MEDRS discussions. See User talk:Jytdog#Issues at Ketonic diet. Peter coxhead ( talk) 11:13, 3 April 2018 (UTC)

Peter I am indeed talking about sources. And I don't wish to debate studies, for that is OR. I'm keen that we write this section in a careful way, but it is simply a notable fact that the KD is being researched as a possible treatment for a number of neurological conditions, and this research is at various stages, including clinical trials in humans. It really isn't up to you to decide, for example, "that's too small a cohort" to be worth mentioning. Although one can view MEDASSESS as a guide to quality of research (and is very handy to show to a newbie for one reason why their primary source is not acceptable) it specifically says "This guideline is not general in nature, but specifically concerns quality when used as a source for encyclopedic articles on Wikipedia". It specifically says "Editors should not perform detailed academic peer review" MEDASSESS is also only concerned with quality of evidence. But evidence (of efficacy, safety, tolerability, cost-benefit, etc) is only one aspect. It influences how we write about this research: what claims we can make. It does not, absolutely not, influence whether we write about this research. That job goes to WP:WEIGHT. And to assess that, you need to do a literature search.

Pinging User:Graham Beards and User:SandyGeorgia who are "experienced MEDRS regulars" and have taken medical articles to FA.-- -- Colin° ^Talk 11:31, 3 April 2018 (UTC)

G'morning. All of Wikipedia's {{ Guideline}}s say:

This page documents an English Wikipedia guideline. It is a generally accepted standard that editors should follow, though it is best treated with common sense, and occasional exceptions may apply.

Wikipedia's reliable sources (RS) guideline clarifies that the policy pages at V and NPOV take priority, and that the guideline is to help identify sources subject to common sense and standard practice. MEDRS similarly is intended to provide guidance on how to meet WP:V in medical content. WP:WEIGHT is part of a policy page, NPOV, not a guideline; both WP:V and WP:NPOV take priority over a guideline, and our objective in writing content should be to attain neutrality and verifiability.

In my time as WP:FAC delegate, and before that as a reviewer, I read at least 4,000 discussions of articles at FAC. One thing that is quickly observed is the number of reasons and examples of why a guideline is a guideline, as opposed to policy, and why guidelines are signposts to good practice of how to apply policy, rather than absolutes. There is often misunderstanding about how to apply each (guideline or policy), but when these discussions occurred among Wikipedia's top content editors, common sense and logic yielded the better result over black-and-white thinking, and policy reigned over guideline.

In the case of medical content, things have become a bit complicated because WP:MEDRS is no longer in line with WP:V or synced with WP:RS, and would probably not be accepted as a guideline in its current state, making it hard to know what do to about its interpretation in today's articles. Sorry to leave you with that bad news :( But in the general, yes, WP:V and WP:NPOV reign, and WP:WEIGHT is part of NPOV. SandyGeorgia ( Talk) 12:28, 3 April 2018 (UTC)

I agree that common sense should take precedence here, and lengthy discussions about how to interpret guidelines are not helpful. Written mainly by Colin, this article has undergone an external expert review. At the time of the review the section in question concluded with: "As of 2008, there is insufficient evidence to support the use of the ketogenic diet as a treatment for these conditions." And this is probably still the case. Since 2008, there has been steady flow of research publications on the use of the diet for conditions other than epilepsy, and it would be failing our readers, to not mention this at the end of the article with appropriate caveats. As an FA writer, former FAC Delegate, and reviewer, I do not have any problem with this paragraph or the with the sources used, as no major claims for efficacy are made. Colin, (who by the way wrote WP:MEDRS), is dutifully maintaining a Featured Article, and, to be blunt, I see much of this as tantamount to disruption. We proudly have one of the best extant articles on KD and the inclusion of a short paragraph at the end of the article on other uses does not detract from this. Graham Beards ( talk) 15:05, 3 April 2018 (UTC)

Other Conditions

Will list papers here as I find them.

• Alzeimers. PMID 19664276 "Study of the ketogenic agent AC-1202 in mild to moderate Alzheimer's disease: a randomized, double-blind, placebo-controlled, multicenter trial". As a primary source, this must be discussed via secondary sources on the KD, of which there are several. -- Colin° ^Talk 11:43, 3 April 2018 (UTC)
• PMID 21872441 "Neuroprotection in metabolism-based therapy" Alzheimer disease and Parkinson disease in human trials. ALS, aging, ischemia, trauma and mitochondrial cytopathies in pre-clinical research.
• PMID 22322415 "Ketogenic diets: new advances for metabolism-based therapies". Autism, Alzheimer's disease, migraine, hypoxic-ischemic encephalopathy, Parkinson disease, amyotrophic lateral sclerosis, and traumatic brain injury -- "in either animal studies or limited human trials as having potential benefit" "Brain tumors have now been investigated in humans" -- Colin° ^Talk 11:49, 3 April 2018 (UTC)
• PMID 28701250 "the ketogenic diet also seems to have some utility in Alzheimer's disease, Parkinson's disease, and glaucoma..." If this can make the Abstract of a general article on the KD (equivalent to our lead section) then WP:WEIGHT demands we include it in some form here.
• PMID 25101284. "emerging data suggests that ketogenic diet could be also useful in amyotrophic lateral sclerosis, Alzheimer, Parkinson's disease, and some mitochondriopathies" This is exactly the kind of review we need for this section. Covers several "other applications" of KD (excluding cancer).
• PMID 22509165 (already cited) Aging, Alzheimer Disease, Parkinson Disease, Amyotrophic Lateral Sclerosis, Cancer, Stroke, Mitochondrial Disorders, Brain Trauma, Psychiatric Disorders (Depression), Autism, Migraine.
• PMID 29263011. Lancet Neurology. "The mechanisms underlying the ketogenic diet might also have roles in other disorders, such as preventing neurodegeneration in Alzheimer's disease, the proliferation and spread of cancer, and insulin resistance in type 2 diabetes."
• PMID 22101998. "Future non-epilepsy indications such as Alzheimer disease, amyotrophic lateral sclerosis, autism, and brain tumors are under active investigation" Another general article on the KD in epilepsy, that notes these other applications in the abstract.
• PMID 27868154. "Alternative Fuels in Epilepsy and Amyotrophic Lateral Sclerosis".
• PMID 29434537. "A phase III clinical trial evaluating the safety and the tolerance of KD in ALS patients fed through a gastrostomy tube has been conducted in the United States (clinicaltrials.gov NCT01016522), but results have not yet been published", "Both the KD and the low glycemic index diets have been administered to patients and have illustrated promising results in seizures of Angelman Syndrome", "A recent study suggested that the use of KD in mitochondrial myopathy enhanced muscle strength and delayed the progression of the disease but might induce muscle damage in a subpopulation". Also notes Parkinson’s, Rett syndrome, Alzheimer’s disease.
• PMID 25671178. Stroke (theory).
• PMID 19049605. Brain trauma (theory).
• PMID 28527061. Migraine. "Clinical data on KD in migraine-obtained from 150 patients investigated in case reports and prospective studies-suggest that KD may be a rapid onset effective prophylaxis for episodic and chronic migraine"
• PMID 27841033. "Ketogenic diet and childhood neurological disorders other than epilepsy: an overview". Looks useful but I can't access the full text. "various childhood neurologic disorders such as mitochondriopathies, alternating hemiplegia of childhood (AHC), brain tumors, migraine, and autism spectrum disorder (ASD).
• PMID 23049588. Metabolic disorders (GLUT1 deficiency syndrome, PDHC deficiency, Mitochondrial disorders, etc), Specific epilepsy disorders (Dravet syndrome, MAE, Super-refractory status epilepticus). Other neurologic disorders (Alzheimer's disease, Parkinson's disease)
• PMID 24847102. "KD is increasingly being studied for therapeutic efficacy in a number of neurological disorders, including epilepsy, headache, neurotrauma, Alzheimer’s disease (AD), Parkinson’s disease (PD), sleep disorders, brain cancer, autism, pain, and amyotrophic lateral sclerosis (ALS)" discusses each with proposed mechanisms.
• PMID 18990309. Metabolic defects, Malignancy, Trauma and ischemia, Neurodegenerative disorders, Parkinson’s disease, Alzheimer disease, Amyotrophic lateral sclerosis, Autism, Depression

That's probably enough for now. There are enough reliable sources that one could, if inclined, write an article on the research underway wrt the ketogenic diet (and related diets and meal-formulae) for diseases other than epilepsy. NPOV means we should look at this diet (and its related and sub-types) not from the POV of a clinician saying "NICE haven't approved it for brain tumours yet" but from a NPOV that says we cover exactly what the professional reliable literature covers, and in the weight they cover it. -- Colin° ^Talk 12:43, 3 April 2018 (UTC)

The potential adverse effects of a ketogenic diet are not thoroughly explained, or even touched upon in some cases. An addition of a short sub-paragraph on metabolic acidosis in this section would be useful to better explain the ketogenic diet and the possible risks associated with self-implementing such eating behaviors. -- Willgriffen2 ( talk) 18:53, 12 May 2018 (UTC)

Hi Willgriffen2. This article is about the use of a ketogenic diet for medical purposes and it is only undertaken with close medical supervision. Acidosis is mentioned but serious acidosis should not occur when supervised. The Low-carbohydrate diet article is the place to discuss lifestyle diets, some of which are ketogenic, and the risks of following an extreme diet oneself. -- Colin° ^Talk 20:51, 15 May 2018 (UTC)

The "Other applications" section claims the product Axona was granted status as a "medical food" by the FDA in 2009. The citation does not support this claim. It also runs counter to the Axona page itself, which states that Axona was declared MISBRANDED as a medical food by the FDA in 2013, which has a very good citation, specifically the warning letter from them. Due to this, I'm removing the whole chunk, also someone else more knowledgeable is welcome to add back in (correct and cited) information about the product. — Preceding unsigned comment added by LordQwert ( talk • contribs) 19:44, 21 July 2017 (UTC)

@ Kelly222:: The cited source says:

There are several uncontrolled trials and animal studies describing the potential benefits of the KD for neurologic conditions other than epilepsy and the metabolic conditions described previously. These include amyotrophic lateral sclerosis (ALS), Parkinson's disease, Alzheimer's disease, migraine, autism, narcolepsy, brain tumors, and traumatic brain injury (Freeman et al., 2007). At this time, there is insufficient evidence to recommend the use of the KD for these conditions other than on an investigational basis.

Although most of the paper is about epilepsy, it does specifically address these "other applications". It's fairly early in the longest section of the paper, and pretty easy to overlook. I probably would have missed it, except that I searched for the word Alzheimer rather than trying to read the whole thing. WhatamIdoing ( talk) 06:17, 20 October 2018 (UTC)

I think this article needs a revamp. Its like looking up a article about mathematics and getting one about algebra, with the a hint to look under sciences for a general description of mathematics. While its true that keto fits under the general category of a low carb diet, by no means its a synonym Pfote ( talk) 07:39, 21 December 2018 (UTC)

This issue has been discussed already (see talk page archives). The ketogenic diet for epilepsy is a distinct subject and deserves its own article. It has almost no relation to the various lifestyle diets people use for weight loss or other aspirations. The use of a medically supervised fully ketogenic diet for some other neurological diseases still remains in the research phase, whereas this is an established (nearly 100 years) therapy for childhood epilepsy.

Most very low carb lifestyle diets are not specifically ketogenic or are only ketogenic for a short period. A fully ketogenic diet is very difficult to maintain without strong motivation, very difficult to remain healthy without dietitian input and requires supplements, and has long-term serious side effects like reduced growth (in children) and bone loss/weakening. The aims and issues of a VLCD in overweight adults are quite distinct from the aims and issues of a diet used to treat seriously ill children, who have proven resistant to drug treatments, and who aren't suitable for surgery. None of the professional literature on these topics discuss those diets together except in passing. Therefore neither should Wikipedia. There is certainly room to improve Low-carbohydrate diet. Should the very-low carb variants of that class of diets warrant their own article then the issue is finding a name for it on Wikipedia and also finding quality literature that specifically discusses it alone. Most weight-loss literature happily conflates ketogenic with very low carb, and there appears little agreement on the terminology. Some professionals use the term "Very low carbohydrate ketogenic diet" (VLCKD) when discussing it for e.g. possible diabetes treatment (again, while there is research here, none of the major diabetes guidelines specifically recommends a VLCKD). They do so because they appreciate the need to discuss quite different therapies with different names. A VLCKD is a possible weight-loss / diabetes therapy, but again, there's only so much one can write using reliable professional sources. The current literature/guidelines suggest that no one diet is superior to any other, over the long term, though some diets may suit some individuals better than others, and that (nearly) eliminating food groups is unlikely to produce a healthy eating pattern in individuals or long term health benefits. -- Colin° ^Talk 09:31, 21 December 2018 (UTC)

I read this article for the first time just now.. I was somewhat alerted when the "team of practicing professionals" was introduced, with no alternatives to the formula, and likely US AMA-centric. Then when I got to the "diet description" it said, without equivocation, that breakfast includes bacon ?!? Seriously, this is just obnoxious.. vast portions of the world's population do not eat this food. The overall tone reminds me of 1950s Americana where medical advice is just handed down without question. It is culturally-inappropriate or worse. Definitely re-think the prescriptive parts of this.. I am offended, actually, and I am an US citizen. — Preceding unsigned comment added by 75.101.48.113 ( talk) 02:37, 24 December 2018 (UTC)

This is just an example meal plan. Yes it comes from an American source, but most of the professional sources on the KD for epilepsy are American, which is where the diet was invented and remained popular. There is a section elsewhere in the article that discusses the issues with implementing this diet in other cultures or with religious restrictions on eating. I don't know why you should find it surprising that a team of professionals supervise a strict diet in children who have severe epilepsy. Perhaps you are confusing this article with a low carb diet for tubby adults. -- Colin° ^Talk 08:16, 24 December 2018 (UTC)

This edit below in italics is a summary of primary research on use of the ketogenic diet for obese or diabetic people. The first two sources are literature reviews of preliminary research, and the third is an opinion article acknowledging the absence of clinical research on these conditions. For encyclopedic content (as opposed to writing for a journal or media article), WP:MEDRS emphasizes use of a systematic review or meta-analysis of completed, high-quality Phase III clinical trials, which have not been done. Until there is a more complete research picture and publication of a premium review, the information remains too preliminary to use for the article. -- Zefr ( talk) 01:22, 5 February 2019 (UTC)

The ketogenic diet is being studied in the treatment of obesity and type 2 diabetes, with promising results. ^{[1] [2] [3]}

Not only is the edit problematic, but the IPs need to know that WP:EDITWAR and WP:3RR apply to all of them-- they are both from Los Angeles, and one is UC Irvine. (The first source is a review, but Colin may need to have a look at it.) SandyGeorgia ( Talk) 01:34, 5 February 2019 (UTC)

PMID 30289048 may be a review, but it seems rather gushing and it appears the journal has no impact factor so I'm sensing a WP:REDFLAG fluttering. The conclusion has:

Compelling evidence exists for the use of nutritional ketosis for the management of weight and the components of metabolic syndrome. Through the utilization of alternative fuel sources, namely ketones, we can capitalize on the antagonistic relationship of high glucagon and low insulin levels that promote breakdown of fat for fuel, sparing of glycogen in muscles, and de novo gluconeogenesis as needed. Further research is needed into long-term adherence and practicality of VLCKD, but the current results are promising for weight management, lipid profiles, and insulin sensitivity.

Alexbrn ( talk) 12:44, 5 February 2019 (UTC)

Yes, but I am waiting for Colin, who knows the material best, to weigh in. There is some evidence, and the source claims to be a review, so ... SandyGeorgia ( Talk) 15:58, 5 February 2019 (UTC)

There's quite bit of secondary material in this area. Of the recent stuff PMID 29541907 is free-to-read, and the journal is reputable. Alexbrn ( talk) 17:14, 5 February 2019 (UTC)

Thanks, Alex ... Colin, who knows the sources well, can probably craft some MEDRS-compliant text. SandyGeorgia ( Talk) 17:16, 5 February 2019 (UTC)

Thanks Alex. I've got some other demands IRL at the moment that are keeping me from editing so much. I think there is WP:WEIGHT for briefly mentioning this research here (but less so at the disease articles, which have plenty other treatment options with more advanced evidence base). But we also want to keep the focus on this neurological diet therapy rather than just being some extreme low-carb weight loss variant. I think we should say something, in the research section, and point readers at the low carb diet article. Btw, there's that VLCKD (very low carb ketogenic diet) term in use by the diabetes/weight-loss researchers.

Btw, if "a systematic review or meta-analysis of completed, high-quality Phase III clinical trials" were required for every condition-treatment option before doctors prescribed or performed any therapy, there would never be a queue at the chemists, and the surgeons would have lots more time for golf. -- Colin° ^Talk 21:36, 5 February 2019 (UTC)

With the understanding that this article's primary subject is "a diet-based medical treatment for refractory pediatric epilepsy", rather than "a diet that produces certain effects on fat metabolism", then all of the other applications are irrelevant. That said, I think it is appropriate to have the ==Other applications== section, and I think that it might be appropriate to mention diabetes and obesity, citing, e.g., this StatPearls. It'd be convenient to have an article on the Very low-carbodydrate ketogenic diet (summarized here; usually, ≤50 g carbs plus achieving measurable ketosis), so that we could link to it in that description. WhatamIdoing ( talk) 18:23, 7 February 2019 (UTC)

I think having a Very low-carbodydrate ketogenic diet article would present us with a tricky fork problem, because of the difficulty of classification mentioned above. Alexbrn ( talk) 19:17, 7 February 2019 (UTC)

The difficulty of setting a dividing line between "low-carb" and "very low-carb ketogenic" diets? (It should be easy to set a dividing line between "dietary treatments for refractory pediatric epilepsy" and, well, diets for anything else.) WhatamIdoing ( talk) 20:56, 14 February 2019 (UTC)

Yes, precisely that difficulty. Alexbrn ( talk) 21:06, 14 February 2019 (UTC)

I have had type 2 diabetes since the last decade. Havnen't been able to keep it in remission. Recently got YouTube recommended videos to watch. Two people: Dr. Berry and ? (Beat Diabes) say that a Ketogenic Diet can have massive positive effects on Type 2 Diabetes. This article doesn't really mention that. It focuses instead on the application for healing/reversing Epilepsy. Dr. Berry's YouTube channel: https://www.youtube.com/channel/UCIma2WOQs1Mz2AuOt6wRSUw

Beat Diabetes https://www.youtube.com/channel/UCmKsQWqGmDPIWgrVqGYbc3w

So a section on the application of a Ketogenic Diet on Diabetics is in store. Jimj wpg ( talk) 07:00, 18 November 2019 (UTC)

Jimj wpg, various low-carb diets have been trialled for diabetes. Some of these low-carb diets are ketogenic (or are ketogenic in their initial phase) but they differ quite a lot from the diet this article discusses, which has been around for 100 years to treat epilepsy. The article you want is Low-carbohydrate diet, which has some mention of KD. -- Colin° ^Talk 10:30, 21 November 2019 (UTC)

• Ketogenic diet activates protective γδ T cell responses against influenza virus infection Science Immunology 15 Nov 2019: Vol. 4, Issue 41, doi: 10.1126/sciimmunol.aav2026 Sciencemag.org

X1\ ( talk) 23:05, 20 November 2019 (UTC)

X1\ we don't normally mention rat or mice experiments on Wikipedia or directly cite research papers. See WP:MEDRS. If something comes of this research that has meaning for humans, then there will be papers and other articles for us to cite in whichever article is appropriate. -- Colin° ^Talk 10:34, 21 November 2019 (UTC)

I think there should be first at the very top a very short definition of the diet itself all alone, without connecting it to one specific use.

This should be followed by the general discussions of the chemical reactions in the body, then should come its variants described in laymans terms, and the different reasons ketogenic diet is actualised, such as its applications against things we face today. The ketogenic diets use as a cure for childhood epilepsy must be there for sure, but one should recognize that there are many other reasons ketogenic diet is being discussed, argued for-and-against, practiced, found useful, found it should be avoided in certain situations, etc.. These should be listed early and given their own chapters on equal footing. The list is long: weight control, diabetes, sport, evolutionary advantage, its disappearance from common practice in recent history, degrees/phases of ketogenesis, relationship to other bodily functions, methods-, techniques- and tools for its practice.

I am tending to believe that we need several supporting pages; May be we need a new page with this name for the LCAPHF diet, and the present page sould be renamed "Ketogenic Diet Therapy". Cobanyastigi ( talk) 20:05, 5 June 2019 (UTC)

The reason why this article is about epilepsy treatment aspects of the ketogenic diet is because that reflects the balance of reliable sources in the real world. There is also an article on ketosis. The discussion of the "keto" diet as a weight-loss fad/lifestyle choice is at Low-carbohydrate diet. Alexbrn ( talk) 01:29, 6 June 2019 (UTC)

This is the only use of a ketogenic diet with convincing evidence of efficacy and safety, though it requires considerable medical supervision from a neurologist and dietitian. It has been used for nearly 100 years for epilepsy and might well be used for another 100 since we are no closer to understanding its mechanism or finding a way of achieving this effect in a pill. Whereas extreme low-carb high-protein diets, which achieve a degree of ketosis but not under medical supervision, became fashionable in 2018 and it is too soon to know if they are anything more than a fad. Certainly there is increasing evidence of the importance of fibre in one's diet, which is sorely lacking in a ketogenic diet. Please read the various talk archives about this. None of our reliable sources take the approach you suggest. -- Colin° ^Talk 21:18, 6 June 2019 (UTC)

This diet is also recommended for people with certain Glycogen storage diseases, it's not just for treating epilepsy. The page takes the title of 'Ketogenic diets' and dedicates the topic to 'Ketogenic diets for the treatment of epilepsy'. Would it be cool to add a section talking broadly about the effect of ketogenic diets in GSDs? Ramiel~enwiki ( talk) 06:25, 7 January 2020 (UTC)

• Kossoff, EH; Zupec-Kania, BA; Auvin, S; Ballaban-Gil, KR; Christina Bergqvist, AG; Blackford, R; Buchhalter, JR; Caraballo, RH; Cross, JH; Dahlin, MG; Donner, EJ; Guzel, O; Jehle, RS; Klepper, J; Kang, HC; Lambrechts, DA; Liu, YMC; Nathan, JK; Nordli DR, Jr; Pfeifer, HH; Rho, JM; Scheffer, IE; Sharma, S; Stafstrom, CE; Thiele, EA; Turner, Z; Vaccarezza, MM; van der Louw, EJTM; Veggiotti, P; Wheless, JW; Wirrell, EC; Charlie, Foundation.; Matthew's, Friends.; Practice Committee of the Child Neurology, Society. (June 2018). "Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group". Epilepsia open. 3 (2): 175–192. doi: 10.1002/epi4.12225. PMID  29881797.

An update to the existing ref #9. Hopefully most citations can be moved over to this new guideline, though some may need modifying, and some additional recommendations may be warranted. This is the most important source: consensus recommendations by world experts reviewing the research and clinical experience.

• Husari, Khalil S.; Cervenka, Mackenzie C. (May 2020). "The ketogenic diet all grown up—Ketogenic diet therapies for adults". Epilepsy Research. 162: 106319. doi: 10.1016/j.eplepsyres.2020.106319.

Adult epilepsy.

• van der Louw, Elles; van den Hurk, Dorine; Neal, Elizabeth; Leiendecker, Bärbel; Fitzsimmon, Georgiana; Dority, Laura; Thompson, Lindsey; Marchió, Maddelena; Dudzińska, Magdalena; Dressler, Anastasia; Klepper, Joerg; Auvin, Stéphane; Cross, J. Helen (November 2016). "Ketogenic diet guidelines for infants with refractory epilepsy". European Journal of Paediatric Neurology. 20 (6): 798–809. doi: 10.1016/j.ejpn.2016.07.009. PMID  27470655.
• Infants. European guidelines.
• Blackford, R (May 2020). "Not your parents' ketogenic diet - Flexibility in 2020". Epilepsy research. 162: 106307. doi: 10.1016/j.eplepsyres.2020.106307. PMID  32163829.

Commentary on changes over last decade or so.

• Höhn, S; Dozières-Puyravel, B; Auvin, S (December 2019). "History of dietary treatment from Wilder's hypothesis to the first open studies in the 1920s". Epilepsy & behavior : E&B. 101 (Pt A): 106588. doi: 10.1016/j.yebeh.2019.106588. PMID  31677579.

Early history

• Cai, QY; Zhou, ZJ; Luo, R; Gan, J; Li, SP; Mu, DZ; Wan, CM (December 2017). "Safety and tolerability of the ketogenic diet used for the treatment of refractory childhood epilepsy: a systematic review of published prospective studies". World journal of pediatrics : WJP. 13 (6): 528–536. doi: 10.1007/s12519-017-0053-2. PMID  28702868.

Review

• van der Louw, E; Aldaz, V; Harvey, J; Roan, M; van den Hurk, D; Cross, JH; Auvin, S; Review, Group. (January 2020). "Optimal clinical management of children receiving ketogenic parenteral nutrition: a clinical practice guide". Developmental medicine and child neurology. 62 (1): 48–56. doi: 10.1111/dmcn.14306. PMID  31313290.

Ketogenic parenteral nutrition

-- Colin° ^Talk 20:06, 15 May 2020 (UTC)

While historically (since 1921), ketogenic diets have been used to treat epilepsy, contemporary usage to treat obesity and type 2 diabetes mellitus is far more common. Research and clinical experience indicate that a ketogenic diet is more effective at controlling the high blood sugars of diabetes than are current diabetes medicines (more on this below).

I have Type 2 diabetes mellitus, and have found like other patients that a ketogenic diet (a diet that induces ketosis, a form of metabolism that obtains energy from oil and fat in the diet instead of sugar and starch) will control diabetes effectively without the need for increasing use of diabetic medicines over time (details and research results are discussed toward the end of this comment).

I believe that a major contribution to public health would result from educating everyone concerning the use of a ketogenic diet as an alternative to an ever-increasing need for diabetic medicines in patients who are in glycolysis (normal carbohydrate-burning metabolism). Diabetic medicines are typically increased over time as the disease progresses (and the body's insulin resistance increases and pancreatic function decreases).

Details and Research

Ketosis is a unique form of metabolism, which can be induced by diet. This has been known since 1921 when the ketogenic diet was first standardized at Mayo Clinic to treat certain forms of epilepsy.

The contemporary use of a ketogenic diet to treat obesity, diabetes, and certain other diseases is medically controversial due to the following factors:

1. A similarly-named but different condition, ketoacidosis, is life-threatening; it is common to blame ketosis (which is simply a form of metabolism and is medically benign) for generating ketoacidosis, which it does not do, or for itself having the effects of ketoacidosis, which it does not have.

2. The definition of a ketogenic diet has been misunderstood in various ways (such as a diet containing less than 5% carbohydrates, which may or may not generate ketosis, depending on the individual).

3. There has been an enthusiastic rush to publish research which has resulted in several negative poor-quality studies being published (in some of these studies, the subjects were not measured for being in ketosis).

4. It is relatively difficult to obtain funding, since ketosis results in less drug usage rather than the need for a specific pharmaceutical.

While patient response to being in ketosis is seen to be dramatically positive in a number of studies (in terms of the reversal of obesity and/or the elimination of the need for medications to obtain diabetic control), and while measuring ketosis is not difficult since it is produces dramatically different physiological markers from the usual glycolysis, ketogenic diets are not yet recommended by doctors, dietitians, and nutritionists as standard practice due to the many common misunderstandings and the poor meta studies reflecting the many poor studies that have been published to date.

Here are some studies and meta studies of true ketogenic diets and their results in diabetes:

• A low-carbohydrate, ketogenic diet to treat type 2 diabetes ( https://link.springer.com/article/10.1186/1743-7075-2-34):

"[A ketogenic diet] had positive effects on body weight, waist measurement, serum triglycerides, and glycemic control in a cohort of 21 participants with type 2 diabetes. Most impressive is that improvement in hemoglobin A1c was observed despite a small sample size and short duration of follow-up, and this improvement in glycemic control occurred while diabetes medications were reduced substantially in many participants."

• Benefits of Ketogenic Diet for Management of Type Two Diabetes: A Review ( https://obesity.imedpub.com/benefits-of-ketogenic-diet-for-management-of-type-two-diabetes-a-review.php?aid=14629):

"The prevalence of type two diabetes (T2D) has been increasing sharply worldwide. Many recent studies have been done to determine the effective strategies for better management of type two diabetes. One of these strategies was the Ketogenic Diet, which when performed on rats and human showed very impressive results. The benefits of having some ketone bodies circulating in the body have numerous benefits such as weight loss, improvement of HbA1c levels, reversal of nephropathy, cardiac benefits and treatment for dyslipidemia."

• Implementing a low-carbohydrate, ketogenic diet to manage type 2 diabetes mellitus ( https://www.ncbi.nlm.nih.gov/pubmed/30289048):

"Reducing carbohydrate intake to a certain level, typically below 50 g per day, leads to increased ketogenesis in order to provide fuel for the body. Such low-carbohydrate, ketogenic diets were employed to treat obesity and diabetes in the 19th and early 20th centuries. Recent clinical research has reinvigorated the use of the ketogenic diet for individuals with obesity and diabetes. Although characterized by chronic hyperglycemia, the underlying cause of T2DM is hyperinsulinemia and insulin resistance, typically as a result of increased energy intake leading to obesity. The ketogenic diet substantially reduces the glycemic response that results from dietary carbohydrate as well as improves the underlying insulin resistance. This review combines a literature search of the published science and practical guidance based on clinical experience."

Note: I am an independent researcher in an unrelated field, and my interest in ketosis is as a patient and successful user of a ketogenic diet, not as a researcher.

Note: The usage of so-called keto dieting in musclebuilding and sports is a separate social phenomenon and is irrelevant to the main importance to society of true ketogenic diets in the management of obesity and type 2 diabetes.

David Spector ( talk) 13:29, 5 May 2020 (UTC)

You write "contemporary usage to treat obesity and type 2 diabetes mellitus is far more common". Citation required! This seems an extraordinary claim, since from the literature it seems the ketogenic diet for weight-loss is regarded as almost a domain of crankery/pseudoscience. The use of all sort of LC diet for weight loss is discussed at Low-carbohydrate diet where the modern science is quite thoroughly cited. Alexbrn ( talk) 13:36, 5 May 2020 (UTC)

Headbomb's script for flagging non-reliable sources is producing a big fat red no-no for https://obesity.imedpub.com/benefits-of-ketogenic-diet-for-management-of-type-two-diabetes-a-review.php?aid=14629 SandyGeorgia ( Talk) 13:38, 5 May 2020 (UTC)

Yes indeed, the Journal of Obesity & Eating Disorders is a predatory journal. Alexbrn ( talk) 13:39, 5 May 2020 (UTC)

Well, I suppose it's a good thing that Headbomb made it so glaring when the source is so bad, but it sure makes for obnoxious reading on this talk page! SandyGeorgia ( Talk) 13:42, 5 May 2020 (UTC)

I think it is a bit unfair to claim that ketogenic diet for weight-loss or diabetes is all crankery, though its lay popularity is out of proportion to the evidence. There are proper scientists who have conducted research into very low carbohydrate diets for either weight loss or diabetes control. A problem, as has been discussed on these pages before, is that such diets do tend to be quite different to the KD for epilepsy, often with high protein, and are generally aimed at a middle-aged population rather than children. There is also the sport usages, and the ongoing research into its use for treating other neurological conditions (which remains at the research stage but may well bear fruit). So I think that wrt weight lost / adult health / sport that Low-carbohydrate diet remains the best place to document those.

While the "Classic" ketogenic diet has split into four commonly-used variants, some of which are less ketogenic in their primary aim, those studying and providing such therapies continue to use the term "Ketogenic dietary therapies", rather than just "dietary therapy for epilepsy".

I think this topic is quite distinct from other diets that may or may not be ketogenic to some degree, are different in their proportion of food elements, and are aimed at a different population and purpose. That suggests the article should not become a mix of all such "keto diets" but that Wikipedia deals with them separately. Those studying sport fitness or diabetes control make no more than passing mention of the diet variants for epilepsy control: the literature does not combine them. There is often on Wikipedia a situation where different subjects may be naturally given the same article title, and we can only have one. At the present time, the ketogenic diet for epilepsy is the only therapy with strong evidence and clinical-guideline recommendations and 100 years of medical use. So its case for remaining the default topic for this article title remains solid IMO. -- Colin° ^Talk 19:59, 15 May 2020 (UTC)

I think that David Spector is correct that low-carb diets are much more popular now for diabetes than they used to be, and some recommend restricting carb intake until ketone production can be easily measured at home. However, that doesn't mean that they're on the same diet as the kids with epilepsy. I'd be willing to bet fairly large sums of money that David's healthcare providers would not recommend that any diabetic limit their fruit and vegetable intake to no more than two ounces total per day, and yet that's what the sample diet in the article does: just half an ounce of fruit, and 1.5 ounces of low-carb vegetables for the whole day. WhatamIdoing ( talk) 18:57, 21 May 2020 (UTC)

Healthcare providers generally know "ketosis" only as a specialized and medically accepted metabolic state for treating epilepsy, or else have patients who report its value in controlling type 2 diabetes or in normalizing body weight.

I doubt that many healthcare providers would venture any opinion as to how much vegetable matter should be in a patient's diet. Neither would experts in ketogenic diet, since what matters for achieving ketosis is carbohydrate and fat levels, not specific kinds of foods such as vegetables. Vegetables, in particular, range from high in carbohydrates (potatoes) to low in carbohydrates (lettuce).

A ketogenic diet suitable for the control of diabetes generally does not focus on specific foods or amounts of foods as good, bad, or recommended. The state of ketosis generally results from very low carbohydrate intake in combination with normal or elevated amounts of fats and oils, since these are metabolized for energy in ketosis. Protein levels are not of primary significance in achieving ketosis, and slightly higher protein levels are encouraged, as are high levels of non-nutritive fiber, both soluble and insoluble.

The whole field of ketogenic diet for treating diabetes and circulatory problems is still quite new, and misunderstandings outside of its clinical and research community are common (usually starting with the common confusion with ketoacidosis). Many doctors doing current research in ketosis post videos at YouTube in an attempt to alert the public to an alternative for ever-increasing medication to counter the phenomenon of ever-increasing insulin resistance, which frequently happens in type 2 diabetes, and as an intervention for the current epidemic in obesity.

So the best way to locate good studies of patient populations having success with ketogenic diets is to start at YouTube to find out which clinics are doing these studies, then looking up reports and publications. While I've seen some of these videos, and they are certainly medically impressive, I don't have the time to create a research bibliography; but one is urgently needed.

I actually started my own diet on the advice of a cardiologist whom I saw briefly, who was impressed with the research results on ketosis in his own field, on heart and circulatory health, and had educated himself about the rich information published on ketosis and diet in the treatment of obesity, type 2 diabetes, and cardiac health.

I have discussed the value of a ketogenic diet with my family doctor, my oncologist, my surgeons, several dieticians, my nephrologist, and other specialists. Not one of these medical people knew anything about ketosis or ketogenic diet other than rumors from patients. I would say that medicine has not yet discovered the immense value of ketogenic diets for conditions outside of epilepsy.

And yes, the ketogenic diet used for the treatment of epilepsy is quite different from the ketogenic diet that controls type 2 diabetes and certain other conditions. The kind of diet I maintain is actually pretty easy to do.

It was up to me to experiment on my own and discover that when I was in ketosis (as measured by Ketostix or by examining the urine--I haven't purchased a ketone breath or blood meter) my blood glucose is under good control, and when my intake of carbohydrates is just high enough to take me out of ketosis my blood glucose goes way too high and stays there all day, even at happening at a time when I was taking 2000 mg of metformin a day.

These experiences of mine match those reported by several clinicians who run ketogenic diet trials to reverse escalation in insulin dosages for dozens or hundreds of patients with advanced type 2 diabetes. Their reported success rates are high.

Wikipedia is for reporting accepted and notable knowledge and human experience, not novel medical treatments. Ketosis and ketogenic diets as used in the treatments for the conditions listed above are just now beginning to cross over the threshold for being relevant subjects for inclusion here. This is why this section is titled A Minority Opinion. Someday, much of what I've written here may become a majority opinion. David Spector ( talk) 20:02, 21 May 2020 (UTC)

I believe you will find that healthcare providers and medical organizations have been recommending that everyone eat at least 400 grams of fruits and vegetables (not counting potatoes and similar foods) for quite a number of years, and that people with diabetes are routinely encouraged to eat more than that. WhatamIdoing ( talk) 22:19, 21 May 2020 (UTC)

WhatamIdoing: What are you doing? I have not disagreed with your statement. However, it has nothing to do with this topic. Eating a certain amount of a particular food will most definitely not induce ketosis. David Spector ( talk) 11:55, 22 May 2020 (UTC)

David Spector, I encourage you to read through the archives of this article talk page. I would love someone to improve our content about very low carb diets for weight loss / diabetes control. Some researchers have used the term "very low carbohydrate ketogenic diet" which may catch on, but at the moment this research is complicated by having no one definition of a diet. Even the epilepsy KD is complicated with now four or five variants, each taking a different approach to measuring or counting foodstuffs and quantities. The main research has been on the Classic KD, and I'm not aware the others have been studied nearly as well, other than to demonstrate they can be equivalent in some patient populations. I think the main problem with all diets is sticking with it: most children on the KD do not tolerate it for long and that's even more of a problem for adolescents and adults. Some of the more recent variants are designed to be more tolerable but are still pretty restrictive. (People who are fed by tube don't have this issue, once any gastro issues are resolved). My understanding of adult diets for weight loss is that it is important to find one you can stick with, and that doesn't remove important nutrients from your diet, but that otherwise the evidence that one is superior to another is weak. But this topic I feel really belongs in another page on Wikipedia. -- Colin° ^Talk 07:49, 22 May 2020 (UTC)

Colin, as I indicated above, I have little time to work on this. Not even enough time to read the archives and comment on them intelligently. Besides, I'm actually not an expert, just someone who uses this diet successfully and has heard of several small and medium-scale studies showing that type 2 diabetes patients on high-dosage insulin can successfully titrate down and eliminate all diabetes drugs. Such patient experience and (tiny amount) of research deserves some mention, hence my "minority opinion". But extending this article for the new applications calls for contributions by an expert.

As to the confusions here and elsewhere about what constitutes a "ketogenic diet", I fully agree: we need better terminology, because these diets aren't going away.

Concerning the difficulty of staying on this or any other diet, I agree that it is a very important issue. I actually started my diet twice: the first version was too difficult for me to maintain for longer than a few months. But my second version has served me well and is not so difficult to maintain, as I mentioned above.

The kind of diet required to reverse insulin resistance or obesity does not require weighing and measuring food, or ingesting large amounts of fat. All that is necessary for successful results is staying in ketosis, as evidenced by some sort of measurement. It seems evident that epilepsy is much more difficult to treat than these other disorders through a ketogenic diet, so the diet must be more severe for epilepsy.

Also, I hope everyone remembers that even though this use of ketogenic diets is perhaps only about 15 years old, it has had a very slow start among medical specialists, with almost no external publicity other than for the faddish "muscle-building" usage, which appears medically unresearched. David Spector ( talk) 11:55, 22 May 2020 (UTC)

Could someone with sufficient permissions please edit Template:Editnotices/Page/Ketogenic diet and change «described in the articles low-carbohydrate diet and no-carbohydrate diet» to «described in the article low-carbohydrate diet»? They both link/redirect to the top of the same article. Thanks. -- Dan Harkless ( talk) 20:06, 14 September 2020 (UTC)

I set up the editnotices, and can look at this when I am on real computer, rather than iPad, SandyGeorgia ( Talk) 22:32, 14 September 2020 (UTC)

Done, turns out I could handle it with hunt-and-peck iPad typing, SandyGeorgia ( Talk) 22:35, 14 September 2020 (UTC)

Whaat? Touchscreen keyboards aren't as good as real hardware keyboards? You'll have Steve Jobs rolling in his grave. 😉 Thanks for your quick response. -- Dan Harkless ( talk) 17:46, 17 September 2020 (UTC)

The Adverse Effects section states that "excess calcium in the urine is caused by bone demineralisation".

Whilst most studies would support elevated rates of calcium in the urine, there is little evidence of a causal link to bone dimeneralisation. In fact, the citation provided is a secondary source. It does not investigate this relationship. If you examine the original paper which it cites as evidence, Furth et al. (2000), you will find that it makes no mention of bone dimeneralisation causing excess calcium - they report it as a correlation.

In a review Cao & Nielsen (2010) state... "Recent findings do not support the assumption that bone is lost to provide the extra calcium found in urine." The paper is dedicated to examining bone health in acidic diets so feel free to examine for further evidence ^[1]. — Preceding unsigned comment added by 2.99.240.221 ( talk)

The secondary source says "Hypercalciuria occurs with the ketogenic diet due to increased bone demineralization with acidosis (bone phosphate acts as an acid buffer) as well as increased calcium excretion by the kidney." The source they cite says "Acidosis could explain the hypercalciuria we observed on the diet, as acidosis decreases renal tubular calcium reabsorption, and therefore increases urinary calcium excretion. The increased urine calcium excretion in acidosis is not associated with an increase in intestinal calcium absorption, but rather results from bone mineral resorption to buffer the acid load." I don't think we or our source are misinterpreting the literature, but perhaps I'm not seeing the error. I will see if there is any newer secondary source we can use that specifically mentions this ketogenic diet therapy. The review you link is concerned with high-meat protein diets, which is not the ketogenic diet discussed in this article. -- Colin° ^Talk 09:41, 5 October 2020 (UTC)