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KETOGENIC DIET
Description
The ketogenic diet is designed to establish and maintain ketosis. The diet is very high in fat and severely restricted in carbohydrates. This is done by calculating the diet to provide 3 to 4 grams of fat for each 1 gram of protein and carbohydrate combined, thus converting the fuel burned by the body from carbohydrate to fat. A physician prescribes the ratio of 3:1 or 4:1 as appropriate for each individual patient. The diet is calculated to meet the specific needs of each individual for calories and protein, and provides little to no carbohydrate depending on protein requirements. Even with the high fat content of the diet, weight is usually maintained with very little gain. This is possible because calories are calculated to meet only 75% of the individual’s Dietary Reference Intake (DRI) for energy. The foundation of the diet is either heavy whipping cream or MCT oil. The diet using whipping cream is described below.
Indications
The diet serves as an adjunct to anti-convulsant medications in controlling intractable seizures. It is used in cases of resistance to medications or drug toxicity (1,2). Sustained ketosis appears to be important in modifying the convulsive threshold (1,3). The diet seems to be most effective in children 18 months to 10 years of age (4), although it can be used with older children and adults with varying degrees of success. The diet is administered to those who have myoclonic absence (drop) and atonic seizures, which are difficult to control with medications. It may also benefit children with generalized tonic-clonic (grand mal) seizures and seizures of the Lennox-Gestault Syndrome. The ketogenic diet can be used for all types of seizures, especially if medication therapy is not effective (5).
The diet requires a trial period of 2 to 3 months during which effectiveness is assessed and the diet is adjusted to maintain strong ketosis. Once it is determined that the diet is effective on controlling seizure activity, a commitment of 1 to 2 years is required after which weaning is done gradually. Because of the extreme dietary regimens involved in this diet, the Johns Hopkins Pediatric Epilepsy Center recommends use of the ketogenic diet for those individuals who have more than 2 seizures a week despite treatment with at least 2 different anticonvulsant medications (6).
Nutritional Adequacy
The ketogenic diet is inadequate in vitamin B-complex vitamins, folate, iron, calcium, and zinc. The diet must be supplemented with vitamins, iron and calcium in forms that are sugar-free.
How to Order the Diet
Order as “Ketogenic Diet.” A nutrition consult by a registered dietitian must accompany the diet order, as the diet has to be precisely calculated. All medications must be carbohydrate free, as well as toothpaste. The diet must be initiated in a hospitalized setting under close supervision.
Planning the Diet
A gram scale and a copy of the Epilepsy Diet Treatment book (6) are paramount in administering this diet effectively.
Calculation (5)
1.Sample patient: age and weight
Age 5
Height 43 inches
Weight in kilograms 18.46 (40.6 lb)
Ideal weight 18.46 (50th percentile)
Ketogenic Ratio (fat calories:nonfat calories ratio)
Up to 2 years 3:1
2 years to 12 years 4:1
Over 12 years 3:1
A 4:1 Ketogenic diet is prescribed for the patient, which at 50th percentile matches the ideal weight for his age and size.
2.Calories per kilogram: Calculate the ideal body weight for the child’s height using the NCHS growth charts. Determine the number of calories per kilogram based on the child’s age and ideal weight from the following chart (7). Additional adjustments for caloric needs will need to be individualized based on patient’s activity level.
Up to 1 year 80 kcal/kg
12 - 18 months 75 kcal/kg
18 months - 3 years 70 kcal/kg
4 - 6 years 65 kcal/kg
7 - 8 years 60 kcal/kg
9 - 10 years 55 kcal/kg
11 - 14 years 40 kcal/kg or less
3. Total calories: Determine the total number of kcal in the diet by multiplying the child’s ideal weight by the number of calories required per kilogram.
The patient, age 5 and weighing 18.46 kg, needs a total of 65 x 18.46 or 1,200 kcal per day.
4. Dietary unit composition: Dietary units are the building blocks of the ketogenic diet. A 4:1 diet has dietary units made up of 4 gm of fat to each 1 gm of protein plus carbohydrates. Because fat has 9 calories/g (9 x 4 = 36), and protein and carbohydrates each have 4 kcal/g (4 x 1 = 4), a dietary unit at a 4:1 diet ratio has 36 + 4 = 40 kcal. The caloric value and breakdown of dietary units vary with the ketogenic ratio.
Ratio Fat Calories Carbohydrates plus Protein Calories Calories per Dietary Unit
2:1 2 g x 9 kcal/g = 18 1 g x 4 kcal/g = 4 18 + 4 = 22
3:1 3 g x 9 kcal/g = 27 1 g x 4 kcal/g = 4 27 + 4 = 31
4:1 4 g x 9 kcal/g = 36 1 g x 4 kcal/g = 4 36 + 4 = 40
5:1 5 g x 9 kcal/g = 45 1 g x 4 kcal/g = 4 45 + 4 = 49
The patient’s dietary units will be made up of 40 calories each because he is on a 4:1 ratio.
5. Dietary unit quantity: Divide the total calories allotted by the number of calories in each dietary unit to determine the number of dietary units to be allowed daily.
Each of the patient’s dietary units on a 4:1 ratio contains 40 calories, is allowed a total of 1200 kcal/day, so he receives 1200/40 = 30 dietary units per day.
6. Fat allowance: Multiply the number of dietary units’ times the units of fat in the prescribed ketogenic ratio to determine the number of fat grams permitted daily.
On his 4:1 diet, with 30 dietary units per day, the patient will have 30 x 4 or 120 g of fat per day.
7. Protein and carbohydrate allowance: Multiply the number of dietary units times the number of protein plus carbohydrate in the prescribed ketogenic ratio, usually one, to determine the combined daily protein plus carbohydrate allotment.
On his 4:1 diet, the patient will have 30 x 1 or 30 g of protein and carbohydrate per diet.
8. Protein allowance: To maintain health, a 5-year-old child should eat a minimum of 1 g of protein for every kilogram of weight and/or meet the DRI for protein for age.
At 18.56 kg, the patient should eat 18.5 g of protein per day out of his total protein and carbohydrate allotment of 30 g.
9. Carbohydrate allowance: Determine the grams of carbohydrate allotted by subtracting the protein allotment from the total protein plus carbohydrate allotment. Carbohydrates are the diet’s filler and are always determined last.
The patient’s carbohydrate allotment is 30 - 18.5 = 11.5 gm carbohydrate daily.
10. Meal Order: Divide the daily fat, protein and carbohydrate allotments into 3 equal meals. It is essential that the proper ratio of fat to protein plus carbohydrate be maintained at each meal.
The patient’s diet order reads:
Daily Per Meal
Protein |
18.5 g |
6.2 g |
Fat |
120 g |
40 g |
Carbohydrate |
11.5 g |
3.8 g |
Kcal |
1,200 |
400 |
11. Liquids: Multiply the child’s ideal weight by 65 to determine the daily cubic centimeter allotment of liquid. As few as 60cc/kg but as many as 70cc may be adequate, depending on the child’s activity level and the climate in which they live. Liquid intake should be spaced throughout the day with no more than 120 - 150 cc being given at any one time. Liquids should be non-caloric such as water, herbal or decaffeinated tea or decaffeinated sugar-free diet soda. Sugar free soda should be limited to no more than 1 calorie per day. In hot climates, the cream may be excluded from the fluid allotment. The liquid allotment may also be set equal to the number of calories in the diet.
The patient, who lives in New York and gets 1200 kcal per day on the diet, is allowed 1200 cc of fluid per day, including his allotted cream.
12. Every child on the ketogenic diet should take a daily dose of a sugar-free vitamin/mineral supplement. For infants or children who have difficulty chewing, 600 to 650 mg of oral calcium, in a sugar-free form, such as calcium gluconate or calcium carbonate or calcium magnesium liquid and a sugarless multi-vitamin with iron, such as Poly-Vi-Solâ liquid or drops can be used. A sugar free multivitamin mineral Chew Tab is a better choice for children over 1 year of age that can chew.
Introducing The Ketogenic Diet
The diet must be introduced in the hospitalized care setting. Initially “ketogenic eggnog” is given after the initial two-day fast or when the ketones have reached the 160 level (4+).
To introduce to children, a ketogenic eggnog is provided a sample full meal recipe follows. The child should receive 1/3 of the child’s full meal recipe first meal, 2/3’s of the full meal recipe the second meal, and progress to the full recipe by the third meal.
Calculating The Ketogenic Eggnog
Step 1: Calculate the recipe based on 1/3 of the child’s total allotted calories. Select an amount of cream that contains close but not equal to the amount of total allotted fat.
Weight Protein Fat Carbohydrate
Cream 97 g 1.9 g 34.9 g 2.9 g
Egg
________________________________________________________________________________________
Should be 6.2 g 40.0 g 3.8 g
Step 2: Subtract the carbohydrate in the cream used from the total allotted carbohydrate: 3.8 g - 2.9 g = 0.9 g.
Step 3: Add the remaining amount of carbohydrate to the total allotted protein: 6.2 g + 0.9 g = 7.1 g.
Step 4: Subtract the protein used in the cream from the sum in Step 3.7.1 g - 1.9 g = 5.2 g.
Step 5: Using the food values chart (8), give the amount of egg that contains 5.2 g of protein.
Recipe for 1 Full Meal
Weight Protein Fat Carbohydrate
_______________________________________________________________________________
Cream 97 g 1.9 g 34.9 g 2.9 g
Egg 43 g 5.2 g 5.2 g -----
_______________________________________________________________________________________
Actual total 7.1 g 40.1 g 2.9 g
Should be 6.2 g 40.0 g 3.8 g
In the ketogenic eggnog, the carbohydrate will be lower than the allotment and the protein will be higher than the allotment. The amount of fat should always be within a close proximity to the allotment. On occasion, depending on different ketogenic ratios used, small amounts of oil may be needed.
The 4:1 ketogenic ratio may be double-checked by adding the grams of protein and carbohydrate in the meal and multiplying by four (4). The sum should be the amount of fat in the meal, in this case, 40.0 g. Since (7.1 g + 2.9 g) x 4 = 40.0 g, the ratio is correct.
When the full quantity is reached, real food may be served or the child may be given eggnog again.
The Ketogenic Eggnog Recipe
Ketogenic eggnog is the only meal that does not need to be eaten all at once. This way the child sipping eggnog will not be under as much pressure as when he/she is faced with a plate of unfamiliar food. At home, the parents can prepare more appetizing, familiar meals. However, it is important that parents be given enough training in preparing solid food meals so they will be able to do it comfortably at home. Ingredients required for the ketogenic eggnog are:
Heavy Cream
Egg
Vanilla Extract
Saccharin (optional)
The patient’s first meal of eggnog will be 1/3 of the full meal recipe:
32 g Heavy Cream
14 g Egg
up to 5 drops Vanilla
up to ¼ grain Saccharin
46 cc Total
The patient’s second meal of eggnog will be 2/3 of the full meal recipe:
64 g Heavy Cream
28 g Egg
up to 5 drops Vanilla
up to ¼ grain Saccharin
92 cc Total
The patient’s third meal of eggnog will be the full meal recipe.
92 g Heavy Cream
14 g Egg
up to 5 drops Vanilla
up to ¼ grain Saccharin
140 cc Total
Regular meals are provided to the patient usually by the third meal and/or prior to discharge.
Calculating Meal Plans
When calculating the meal plan, divide the total protein, fat and carbohydrate allotted for the day by three and provide 1/3 of the allotment per meal. For example:
Weight Protein Fat Carbohydrate
Cream 65 g 1.3 g 23.4 g 1.9 g
Fruit 19 g 0.2g -- 1.9 g
Meat 20 g 4.7 g 3.3 g --
Fat 18 g -- 13.3 g --
_____________________________________________________________________
Actual Total 6.2 g 40.0 g 3.8 g
Should be 6.2 g 40.0 g 3.8 g
Calculate the whipping cream first. Heavy whipping cream (36%) should take up no more than half of the carbohydrate allotment in the meal.
The patient is allowed a total of 3.8 g carbohydrates per meal. Referring to the food value charts (9), to use half of this allotment of cream, he should eat 65 g of 36% cream, which contains 1.9 g carbohydrates.
Calculate the rest of the carbohydrate (fruits or vegetables) by subtracting the carbohydrate contained in the cream from the total carbohydrate allotment.
Referring to the food value charts, the patient can eat the remaining 1.9 g carbohydrates as 19 g of 10% fruits. The percent equals the percent of carbohydrate in the fruit (7).
10% Carbohydrate Fruits |
15% Carbohydrate Fruits |
Applesauce |
Apple |
Cantaloupe |
Apricot |
Grapefruit |
Blackberries |
Tangerine |
Blueberries |
Honeydew |
Figs |
Orange |
Nectarine |
Papaya |
Pear |
Peach |
Pineapple |
Strawberries |
Plums (Damson) |
Watermelon |
Raspberries (black) |
|
Raspberries (red) |
|
Grapes |
|
Mango |
Calculate the remaining protein (meat/fish/poultry, cheese or egg) by subtracting the protein in the cream and vegetable from the total protein allotment. The 65 g of 36% cream and the 19 g of 10% fruits contain a total of 1.5 g of protein.
The patient is allowed 6.2 gm of protein per meal, so he can eat 4.7 g of protein from meat, fish or poultry. Referring to the food value charts (9), this calculates to be 20 g of meat, fish or poultry.
Calculate the amount of fat to be allowed in the meal by subtracting the fat in the cream and protein from the total fat allotment.
The patient has to eat 40 g of fat with each meal. The cream and meat contain 26.7 g of fat, leaving 13.3 g of fat to be mixed with his meal.
Butter, margarine or mayonnaise are more frequently used because of their palatability. However, they contain only 74% fat. Therefore, the remaining grams of fat are divided by 0.74. 13.3/.74 = 17.9 or 18 g of butter, margarine or mayonnaise
Oil is not included but can be used. Oil would raise the average up higher but is not used as often as butter, margarine or mayonnaise.
Other Considerations
Because the diet may induce hypoglycemia, blood glucose levels need to be monitored during the fasting period (3). All IV’s must be glucose free. If the blood sugar drops at or below 25-mg % with symptoms of hypoglycemia, administer 15 to 30 cc (1.8 to 3.75 g carbohydrate) of orange juice. Monitor closely and administer more juice if necessary, but be aware that too much carbohydrate will delay ketosis. (See reference 5 for complete hypoglycemia plan.) Another alternative is to administer 1 oz. Pulmocareâ plus 5-cc corn/safflower oil. This provides a 4.3:1 ratio and 1.25 g carbohydrate in 30 cc, therefore, treating the hypoglycemia but not interrupting ketosis (7).
Food Guide
All foods must be weighed precisely on a gram scale. Bowes & Church’s Food Values of Portions Commonly Used (9) is a useful reference for meal planning.
The following foods and products are eliminated from the diet because they contain an appreciable amount of carbohydrates.
Foods to Avoid
| Bread Cake Candy Carbonated beverages, Cereals, sugar coated Chewing gum Cookies Cough drops or cough syrups that contain sugar Crackers Honey Ice cream, commercial |
Jam |
Potatoes |
References
Manual of Clinical Nutrition Management
Copyright © 2008 Morrison Management Specialists, Inc.
All rights reserved.