Research & InnovationPhysical Health
Written By Torie Robinson

Obesity in Epilepsy: Practical Clinical Approaches - Dr. Ching Soong Khoo, Hospital Canselor Tuanku Muhriz, Malaysia

Obesity management in epilepsy needs practical, realistic support. In part two of this conversation, Dr. Ching Soong Khoo focuses on exercise safety, diet, and multidisciplinary care, highlighting why weight and physical health are often missed in routine epilepsy practice. The discussion emphasises simple clinical steps - such as baseline BMI, clinician-led conversations, and collaborative care - that can improve quality of life and overall outcomes in people with an epilepsy.

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Episode Highlights

  • Obesity: a vicious cycle

  • Identifying & improving quality of life (QoL) through physical exercise

  • Reducing seizures through physical exercise

  • Asking dieticians and pharmacists for help

  • Calculating Body Mass Index (BMI) before and during treatment

  • Holistic approach to care

About Dr. Ching Soong Khoo

Ching Soong Khoo is a distinguished Consultant Neurologist and Internal Medicine Physician from Hospital Canselor Tuanku Muhriz UKM, also serving as an Associate Professor at Universiti Kebangsaan Malaysia. He possesses deep expertise in complex neurological conditions such as epilepsy, Alzheimer's disease, and traumatic brain injury. His specialisation allows for comprehensive patient care, integrating internal medicine insights with advanced neurological treatments.

Full profile: Ching Soong Khoo

Topics mentioned

  • Obesity

  • Diet

  • Fitness

Related papers:

  • Trailer

    00:00 Ching Soong Khoo

    “So what has gone wrong? So you have to check that again, whether it's, the physical limitation/activity limitation, or whether it's because of food or because of the treatment!”

    Introduction

    00:11 Torie Robinson

    Welcome to Epilepsy Sparks Insights! I’m your host, Torie Robinson, and here we talk with specialist clinicians and researchers to spark improved understandings of the epilepsies worldwide. If you’re new here, please subscribe so you don’t miss future conversations - and let’s get into today’s episode! This episode continues my conversation with Consultant Neurologist Dr. Ching Soong Khoo on obesity in epilepsy.

    Last week, we discussed why obesity is so common in people with an epilepsy, what the research shows about physical activity, and why physical health is often overlooked in routine care. In this episode, we focus on what can actually help - including exercise safety, diet, multidisciplinary care, and changes in everyday clinical practice.

    Obesity: a vicious cycle

    00:51 Ching Soong Khoo

    For me, have a sweet tooth, so I have to control myself. So I think sometimes, some patients with epilepsy probably do not have this mechanism to control, you know, the food-binging desire. So it can be very dangerous. So it's like a vicious cycle. You don't move, you don't exercise, and you keep eating…

    01:16 Torie Robinson

    What would you say for people who may be in this, in this circle, what could be a way to at least try and get out of it? Do you think?

    Appointments: asking how the patient is

    01:24 Ching Soong Khoo

    One of the ways to overcome this is actually coming from the treating physician/clinician class! So the way I consult my patients is very different from how I did years ago. So, years ago, probably when, before the patient sits down, I would just ask “How's the seizure control? Is it okay? Are you taking the medications?” because you're just rushing. You want to finish seeing a patient as quickly as possible because there are a lot of hearts waiting for you. But I think now, what I'm going to do is that just, you know, slow down my pace, instead of asking how your seizure control is, I would probably say “How your day is? Have you been, you know, trying to exercise?”, for example (if this is that they're sort of the main focus that you want to pay attention to, in particular for this particular clinic visit). Instead of, you know, asking whether you take your medications, you know, your seizure frequency, tell me on the average, you know, how many times you have a seizure. I think this is important, but again, to build rapport and to look into the other aspects of the management of epilepsy, we have to start off by asking that. For example, if asked “How's your day? I mean, have you been trying to exercise?” If the patient says no, then you just say “Why? Is there anything bothering you?”. Then you can start from that.

    Identifying patient’s quality of life

    02:55 Torie Robinson

    And then you can learn more about their quality of life, how they experience things day to day, their level of happiness or lack thereof. And then I think you find out more about their lives, which you can help them with - rather than, as you say, just looking at seizures. I would, I would almost say that that's malpractice, to be honest. And so many patients experience it. Like you said, you see your doctor, oh, so “How are your seizures? How many have you had?” And we're just like “I can't tell you about anything else then obviously, because all you're interested in is seizure control.”.

    Reducing seizures through physical exercise

    03:25 Torie Robinson

    And then that's a bit crazy anyway, because - tell me what you think about this - but I think, if you can improve a person's physical health, their physical fitness, you improve quality of sleep much of the time and mood, which can reduce seizure likelihood.

    03:41 Ching Soong Khoo

    I can’t agree more! I got a few patients who actually have frequent episodes of aura [focal full conscious seizures]. What we usually do is that we try to adjust the medications or try to add on more medications. So one fine day, one of the ladies actually with epilepsy comes in and tells me that she's getting less auras. I said “What have you done?!” - because medications are all the same. She said, she's picked up a new hobby. I said “What's that?” She said, well, she started learning the indoor rock climbing!

    04:17 Torie Robinson

    Oh, cool!

    04:18 Ching Soong Khoo

    Yes, how cool! And of course, I mean, in terms of safety, I'm not so concerned because it's done indoors, you know, with a trainer, you know, available and with all the safety measures being there. But she's been doing that for years and really she has seen a remarkable improvement. Of course, she's still taking the medications. She doesn’t skip. However, she experiences fewer and fewer aura episodes.

    04:45 Torie Robinson

    That's amazing. so, and again, so I imagine that's both, well, the exercise itself and the fewer seizures has improved her quality of life.

    04:55 Ching Soong Kho

    So, it's like a win-win situation, right?!

    04:59 Torie Robinson

    Exactly.

    Improving quality of life and confidence through through physical exercise

    05:00 Ching Soong Khoo

    All right, obviously she's happy, she has improved physical and mental health. And, I think, even emotions and cognitive health… because when you do this, when you exercise, when you learn this activity, I'm sure you'll get to some new friends, you expand your network, you talk more, you socialise. I think these are all very important aspects when it comes to the management of epilepsy, and these are all often overlooked. As I always say, because we just focus on the only parameter, which is the seizure count.

    05:49 Torie Robinson

    And then all of this combined, if a person is obese, it can often reduce their weight and bring them to a healthier weight.

    05:58 Ching Soong Khoo

    And I think one of the very important positive outcomes is that you feel more confident.

    Clinicians asking dieticians and pharmacists for help re patient obesity

    06:06 Torie Robinson

    Yes. And I would say that if people feel that - because I've certainly been there several times - if you feel that you can't exercise or you feel that you can't change your diet (because sometimes you are in that space, right, mentally); ask for help and be open with your neurologist about that.

    06:26 Ching Soong Khoo

    Absolutely. So I think one of the things is that during my day to day practice, when I see that the weight is an issue and I think that I just can't solve it. And of course I will get my pharmacists and as well as dietitians to be in, to be involved in the management of epilepsy! Why pharmacists is that we have to look into the medication list. Sometimes, again, it's often neglected because there are medications which I'm not familiar with and the interactions of which might cause a problem with the weight.

    07:09 Torie Robinson

    Mm-hmm

    07:09 Ching Soong Khoo

    Unhealthy for example, you know, you gain weight excessively, you know “I just can't wrap my head around why, why you gain weight!”, you know, for example, so it's because of the interaction of certain medications or certain medications that I'm… I do not know, that could potentially put on weight. And of course, dietitians are very important. Tthe dietitian could advise you on the right calorie intake, what what to be avoided, because I always say that I probably know “some”, but I'm not the best person to talk about the diet plan. So multidisciplinary is so much important when it comes to managing patients with epilepsy.

    Festivities - managing food intake

    07:50 Torie Robinson

    Very much so. And actually, I was just thinking this is a really interesting time for us to have this podcast. What would you say to people given this time of year and think… especially people who might be overweight or obese and have an epilepsy? What would you recommend for us right now?

    08:04 Ching Soong Khoo

    So of course, try to enjoy as much as you can. But in the meantime, I always tell myself, if I eat more today, then probably I exercise more the next day. So, everything is a balance. For example, vegetables, minerals are good, but you can't just overdo it. You can't just be eating vegetables ignoring some of the important food. Chocolate is not totally harmful, but do it in moderation.

    08:38 Torie Robinson

    Yeah.

    Stress and desserts!

    08:39 Ching Soong Khoo

    That's a key thing. Eat in moderation. If you think that you, like me, I do it all the time; sometimes I feel stressed, you know, fo you know “stressed”, if spelt backwards, it's “desserts”! So yeah, yeah. So interesting it is. So you try to, you know, take something that will make you feel better, then you know, the next day probably you should not do that anymore. Or  you should exercise more.

    09:07 Torie Robinson 

    Let's not become reliant upon it because sugar is addictive, right, and it's… we just have to sometimes, I think, try and keep track of it. But again, if it's difficult for people, speak to your neurologist about it because it is part of your overall health. And I love your modesty with what you were saying before, that you can't know everything as a clinician. You can't. So as again, you said there's a multidisciplinary team that's required such as with the dietician, sometimes even like a cardiologist, sometimes you've got to get your bloods taken, all this different stuff. It's so important rather than just to look at “Let's control the seizures”, because that's wrong.

    09:45 Ching Soong Khoo

    That's right.

    Calculating Body Mass Index (BMI) before and during treatment 

    09:46 Torie Robinson

    If you could change one aspect of epilepsy care related to physical health, whether it be the obesity pandemic or something else, what would you do?

    09:55 Ching Soong Khoo

    I would say, calculate the BMI [(Body Mass Index)]! It's so simple and quantitative. Because one of the challenges that we face is that we do not usually measure the patient's weight before initiating the treatment. So therefore…

    10:10 Torie Robinson

    True!

    10:12 Ching Soong Khoo

    Yeah, we are unable to determine the patient gains weight because of the treatment rendered by you. And it's also a very important marker for you to know if you should start intervening. For example, if the patient’s BMI is such, and months later after follow-up, it has drastically gone up, so what has gone wrong? So you have to check that again, you know, whether it's the physical limitation/activity limitation, or whether it's because of food or because of the treatment! Always have a baseline. It's just like your EEG and MRI, you know, you have a baseline so that you know, 10 years ago it was normal. Now 10 years down the line it’s, you know, become something different.

    11:01 Torie Robinson

    I know some people say “Oh, I hate BMI because we're all different”, but it's I think at the moment sort of the best overall measurement of whether a person's weight is healthy or not healthy.

    Holistic approach to epilepsy care

    11:13 Ching Soong Khoo

    That's right. So, I think it is important, again, to understand the importance of a holistic approach in the management of epilepsy. Again, seizure count and seizure frequency are just one of the very near parameters that we are looking at. There’s are more to it. It's just a tip of the iceberg that we're looking at. We should expand our horizon. have to view in patients with epilepsy like the other patients. There are many things that we have to look into. The blood sugar, the blood pressure, you know, you can't just be sitting down with a blood pressure of 200 over 100 and you keep talking about how many seizures do you have in the last one month, haha, or three months, right? When the blood pressure is so high, you should do something about that!

    12:07 Torie Robinson

    Exactly, and then if you don't know what to do, refer them to a colleague or seek a colleague.

    Journey of a thousand miles begins with a single step

    12:11 Ching Soong Khoo

    A lot of times I do not know what I should do! So talk to your friendly colleagues, you know. Like [with] psychiatric illnesses; If you think that something is not right with these patients mentally, you know, [if] I think that the patient is under a great deal of stress, reach out to your friendly, psychiatric colleague and seek help. As the old saying goes, a journey of a thousand miles begins with a single step! So encouragement from us, the clinicians, is important. We can definitely make a difference by addressing their concerns about exercise through just our day-to-day conversations at the clinic. So we as clinicians, we should do more. We have to understand more and we have to treat the patient always as a whole. So, do not limit our assessment only to the things they are associated with, for example seizures. We have to think beyond it.

    Final thoughts

    13:26 Torie Robinson

    Thank you again to Ching Soong for such a thoughtful and practical discussion. I hope that this and the last episode help you feel more supported and confident when thinking about physical health in epilepsy. If you found our chat helpful, please give it a like and subscribe, and hit the bell so you are notified when new episodes drop. I’d love to hear your thoughts or experiences in the comments below. If you’d like to support Epilepsy Sparks, channel membership is one option - members get early access to new episodes. See you next time.

Torie Robinson
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