Evaluation of a ketogenic diet for improvement of neurological recovery in individuals with acute spinal cord injury: study protocol for a randomized controlled trial

Aynur Demirel, Jia Li, Casey Morrow, Stephen Barnes, Jan Jansen, Barbara Gower, Keneshia Kirksey, David Redden, Ceren Yarar-Fisher, Aynur Demirel, Jia Li, Casey Morrow, Stephen Barnes, Jan Jansen, Barbara Gower, Keneshia Kirksey, David Redden, Ceren Yarar-Fisher

Abstract

Background: Therapies that significantly improve the neurological and functional recovery of individuals with spinal cord injury (SCI) are still urgently needed. The ketogenic diet (KD) has been shown to improve forelimb motor function in an SCI rat model, likely by reducing inflammation and cell death in the spinal cord. Furthermore, our recent pilot study in patients with SCI showed that, compared with a standard hospital diet (SD), 5 weeks of KD started during acute care improved upper extremity motor function and reduced serum levels of a neuroinflammatory blood protein. The primary goals of the current study are to: 1) show the safety and feasibility of administering a KD during acute care for SCI; 2) determine if consuming 5 weeks of a KD significantly improves motor and sensory functions, functional independence and glycemic control; and 3) quantify serum biomarkers that are linked to improvements in neurological recovery and functional independence via targeted proteomics.

Methods/design: In a single-masked, longitudinal, randomized, parallel-controlled study, a total of 60 eligible, acutely traumatic spinal cord injured (cervical 5 to thoracic 12) participants ranging in age from 18 to 60 years with American Spinal Injury Association impairment scale (AIS) grades A-C (AIS-A, sensorimotor complete; AIS-B, sensory incomplete/motor complete; and AIS-C, nonfunctional motor incomplete) are being enrolled. Neurological and functional examinations, resting energy expenditure, blood, urine, and stool collections, and protein analyses related to neurological recovery will be performed within 72 h of injury (baseline measure) and repeated after 5 weeks of KD or SD (discharge measure). We anticipate a completion rate of 80% with a total of 48 participants.

Discussion: Intervention with a more neuroprotective diet during acute care of SCI can be implemented anywhere in the world at low cost and without major regulatory hurdles. Better functional recovery will lead to a better quality of life and long-term health outcomes in individuals with SCI. While this study targets SCI, if successful it has the potential to improve neurological outcomes for individuals with various traumatic injuries.

Trial registration: NCT03509571 Registered on April 28, 2018.

Keywords: Diet; High-protein diet; Ketogenic; Low-carbohydrate diet; Nutrition therapy; Proteomics; Spinal cord injury.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Effects of the ketogenic diet (KETO) versus standard diet (SD) on motor and sensory scores in patients with spinal cord injury. (a) American Spinal Injury Association Impairment Scale (AIS) upper extremity motor scores (UEMS) and lower extremity motor scores (LEMS). (b) AIS light touch (LT) and pin-prick (PP) sensory scores
Fig. 2
Fig. 2
Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) schedule. *Allocation and baseline testing occur within 72 h of injury; postintervention assessments are performed prior to each patient’s discharge. ¥Including cholesterol, triglycerides, high-density lipoprotein cholesterol and calculated low-density lipoprotein cholesterol. &As reflected by liver enzymes, alanine aminotransferase, aspartate transaminase, alkaline phosphatase, albumin, bilirubin and total protein. $Serum fibrinogen, extracellular signal-regulated kinase 1/2, CD11b/CD18 integrin receptor, epidermal growth factor and receptor levels. AIS American Spinal Injury Association Impairment Scale, Wk week
Fig. 3
Fig. 3
Flow diagram for the overall study design. KD ketogenic diet, SCI spinal cord injury, SCIM Spinal Cord Independence Measure, SD standard hospital diet, UAB University of Alabama at Birmingham

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