Ketogenic plans AMtthews friends Nutricia booklets
What are the nutritional changes?
The KetoCal 4:1 powder recipe has been updated to include:
- Reduced levels of saturated fat and trans fat
- Added essential fatty acids
- Added soluble and insoluble fibres
- Upgraded vitamin and mineral profile including increased Calcium and Vitamin D
- Now aspartame free
Are there any changes in the appearance of the product?
The new product is darker, coarser and less uniform in appearance, which is a result of removing the trans fatty acids.
Will this affect the nutritional composition of my ketogenic recipes that use KetoCal 4:1 powder?
Yes, all recipes that use the reformulated KetoCal 4:1 will need to be recalculated using the updated macronutrient values. For EKM users this will be:
Protein per 100g = 14.4g
Carbohydrate per 100g = 2.9g
Fat per 100g = 69.2g
Please note that we have updated our range of recipe books and can send replacements upon request. Please contact the Nutricia Homeward team (0800 093 3675) to request an updated recipe book.
Have the mixing guidelines changed for reconstituting KetoCal 4:1 powder into a liquid?
Yes, we recommend that the reformulated KetoCal is made up by mixing 14.2g of powder to 86ml of water. This is a change from 20g powder to 80ml of water. Please note that your dietitian will be able provide further guidance if you are using Ketocal 4:1 powder as a tube feed.
- The ketogenic diet is a special high-fat, low-carbohydrate diet that helps to control seizures in some people with epilepsy.
- Doctors usually recommend the ketogenic diet for children whose seizures have not responded to several different seizure medicines.
- The typical ketogenic diet, called the “long-chain triglyceride diet,” provides 3 to 4 grams of fat for every 1 gram of carbohydrate and protein.
- Several studies have shown that the ketogenic diet does reduce or prevent seizures in many children whose seizures could not be controlled by medications.
What is the ketogenic diet?
The ketogenic diet is a special high-fat, low-carbohydrate diet that helps to control seizures in some people with epilepsy. It is prescribed by a physician and carefully monitored by a dietitian. It is stricter than the modified Atkins diet, requiring careful measurements of calories, fluids, and proteins.
- The name ketogenic means that it produces ketones in the body (keto = ketone, genic = producing). Ketones are formed when the body uses fat for its source of energy.
- Usually the body uses carbohydrates (such as sugar, bread, pasta) for its fuel, but because the ketogenic diet is very low in carbohydrates, fats become the primary fuel instead.
- Ketones are not dangerous. They can be detected in the urine, blood, and breath. Ketones are one of the more likely mechanisms of action of the diet; with higher ketone levels often leading to improved seizure control. However, there are many other theories for why the diet will work.
Who will it help?
- Doctors usually recommend the ketogenic diet for children whose seizures have not responded to several different seizure medicines. It is particularly recommended for children with the Lennox-Gastaut syndrome.
- The diet is usually not recommended for adults, mostly because the restricted food choices make it hard to follow. Yet, studies done on the use of the diet in adults show that it seems to work just as well.
- The ketogenic diet has been shown in small studies (case reports and case series) to be particularly helpful for some epilepsy conditions. These include infantile spasms, Rett syndrome, tuberous sclerosis complex, Dravet syndrome, Doose syndrome, and GLUT-1 deficiency. Using a formula-only ketogenic diet for infants and gastrostomy-tube fed children may lead to better compliance and possibly even improved efficacy.
- The diet works well for children with focal seizures, but may be less likely to lead to an immediate seizure-free result.
- In general, the diet can always be considered as long as there are no clear metabolic or mitochondrial reasons not to use it.
What is it like?
- The typical ketogenic diet, called the “long-chain triglyceride diet,” provides 3 to 4 grams of fat for every 1 gram of carbohydrate and protein.
- Usually when the classic ketogenic diet is prescribed, the total calories are matched to the number of calories the person needs. For example if a child is eating a 1500 calorie regular diet, it would be changed to a 1500 calorie ketogenic diet. For very young children only, the diet may be prescribed based on weight, for example 75 – 100 calories for each kilogram (2.2 pounds) of body weight. If it sounds complicated, it is! That’s why people need a dietician’s help when using this diet.
- A ketogenic diet “ratio” is the ratio of fat to carbohydrate and protein grams combined. A 4:1 ratio is more strict than a 3:1 ratio and is typically used for most children. A 3:1 ratio is typically used for infants, adolescents, and children who require higher amounts of protein or carbohydrate for some other reason.
- The kinds of foods that provide fat for the ketogenic diet are butter, heavy whipping cream, mayonnaise, and oils (e.g., canola or olive).
- Because the amount of carbohydrate and protein in the diet have to be restricted, it is very important to prepare meals carefully.
- No other sources of carbohydrates can be eaten. (Even toothpaste might have some sugar in it!)
- The ketogenic diet is supervised by a dietician who monitors the child’s nutrition and can teach parents and the child what can and cannot be eaten.
What happens first?
- Typically the diet is started in the hospital. The child usually begins by fasting (except for water) under close medical supervision for 24 hours. For instance, the child might go into the hospital on Monday, start fasting at 6 p.m. and continue to have only water until 6 a.m. on Tuesday. The diet is then started, either by slowly increasing the calories or the ratio. This is the typical Hopkins protocol.
- There is growing evidence that fasting is probably not necessary for long-term efficacy, although it does lead to a quicker onset of ketosis.
- The primary reason for admission in most centers is to monitor for any increase in seizures on the diet, ensure all medications are carbohydrate-free, and educate the families.
Does it work?
Several studies have shown that the ketogenic diet does reduce or prevent seizures in many children whose seizures could not be controlled by medications.
- Over half of children who go on the diet have at least a 50% reduction in the number of their seizures.
- Some children, usually 10-15%, even become seizure-free.
Tell me more
- Children who are on the ketogenic diet continue to take seizure medicines.
- Some are able to take smaller doses or fewer medicines than before they started the diet.
- When medications can be lowered depends on the child and the comfort level of the neurologist. Evidence suggests it can be done safely in come children – as soon as the diet is started.
- If the person goes off the diet for even one meal, it may lose its good effect. So it is very important to stick with the diet as prescribed.
- It can be hard to follow the diet 100%, especially if there are other children at home who are on a normal diet.
- Small children who have free access to the refrigerator are tempted by “forbidden” foods. Parents need to work as closely as possible with a dietician.
Are there any side effects?
- A person starting the ketogenic diet may feel sluggish for a few days after the diet is started. This can worsen if a child is sick at the same time as the diet is started.
- Make sure to encourage carbohydrate-free fluids during illnesses.
- Other side effects that might occur if the person stays on the diet for a long time are:
- Kidney stones
- High cholesterol levels in the blood
- Slowed growth or weight gain
- Bone fractures
Are any other medicine changes needed?
- Because the diet does not provide all the vitamins and minerals found in a balanced diet, the dietician will recommend vitamin and mineral supplements. The most important of these are calcium and vitamin D (to prevent thinning of the bones), iron, and folic acid.
- There are no anticonvulsants that should be stopped while on the diet. Topamax (topiramate) and Zonegran (zonisamide) do not have a higher risk of acidosis or kidney stones while on the diet. Depakote (valproic acid) does not lead to carnitine deficiency or other difficulties while on the diet either.
- Medication levels do not change while on the diet according to recent studies.
How is the patient monitored over time?
- Early on, the doctor will usually see the child every 1-3 months.
- Blood and urine tests are performed to make sure there are no medical problems.
- The height and weight are measured to see if growth has slowed down.
- As the child gains weight, the diet may need to be adjusted by the dietician.
Can the diet ever be stopped?
If seizures have been well controlled for some time, usually 2 years, the doctor might suggest going off the diet.
- Usually, the patient is gradually taken off the diet over several months or even longer. Seizures may worsen if the ketogenic diet is stopped all at once.
- Children usually continue to take seizure medicines after they go off the diet.
- In many situations, the diet has led to significant, but not total, seizure control. Families may choose to remain on the ketogenic diet for many years in these situations.
Where can I find out more information about the diet?
Other than the internet, there are several books about the ketogenic diet available.
- One is The Ketogenic Diet: A Treatment for Children and Others with Epilepsy, by Drs. Freeman and Kossoff, which discusses the Johns Hopkins approach and experience.
- The Charlie Foundationand Matthew’s Friends are parent-run organizations for support.
https://www.charliefoundation.org/ < Ketogenic site
http://astore.amazon.com/ketocook-20?_encoding=UTF8&node=13 <<Sugar free syrup
http://astore.amazon.com/ketocook-20?_encoding=UTF8&node=14 low carb noodles
http://astore.amazon.com/ketocook-20/detail/B0007Y9WHQ shredder for vegetables
http://astore.amazon.com/ketocook-20?_encoding=UTF8&node=18 almond, coconut flour
http://astore.amazon.com/ketocook-20?_encoding=UTF8&node=20 whey, organic shortening
http://astore.amazon.com/ketocook-20/detail/B000Z978SS Erythritolol natural sweetener
100% Pure All Natural Guar gum powder is a thickening agent derived from guar beans that has enjoyed much use in various baking applications. It is primarily used in hypoallergenic recipes that use different types of whole grain flours. Because the consistency of these flours allows the escape of gas released by leavening, guar gum is needed to improve the thickness of these flours, allowing them to rise as normal flour would. It is especially useful as a binder in gluten-free baking. We use this Guar Gum in all our Fresh baked bread products here at Gluten Free You and Me Guar Gum is also an excellent all-purpose thickener for salad dressings, ice creams, puddings, gravies, sauces, soups and more
Directions: Like xanthan gum, measure carefully when using guar gum in gluten-free recipes or you may end up with heavy, stringy baked goods.
Bread and pizza dough recipes: Add 2 teaspoons guar gum per cup of gluten-free flour.
Cake, muffin,quick bread,cookie, and bar recipes: Add 1 teaspoon guar gum per one cup of gluten-free flour Suggestion: Multiply the amount of xanthan gum in a recipe by 2 if you plan to use guar gum as a substitute for Xanthan Gum.
http://astore.amazon.com/ketocook-20/detail/B00C3HL6N8 < locust bean Gum
- 100% Food Grade (beware cheap industrial grade products not meant for human consumption)
- ✡ Highest Quality Assured by Strict Orthodox Union Certification Standards
- Made from plant seeds. Excellent thickener and stabilizer
- Works synergistically with other gums
- Perfect for Molecular Gastronomy and Modernist Cooking applications http://modernistcuisine.com/
http://astore.amazon.com/ketocook-20/detail/B00JPGLW66 < Kappa carrageenan
Modernist Pantry is my only trusted source for purchasing high-quality kappa carrageenan, which is used for making the soymilk-based block cheeses in The Non-Dairy Formulary. Modernist Pantry ships worldwide and is an excellent resource for obtaining high-quality agar powder, guar gum and xanthan gum too. ~ Skye Michael Conroy (The Gentle Chef), Author of The Non-Dairy Formulary
- Amazon Sales Rank: #17542 in Grocery & Gourmet Food
- Brand: Modernist Pantry
- Ingredients: 100% Food Grade Kappa Carrageenan
- Dimensions: 8.50″ h x 5.50″ w x 1.00″ l,
- 100% Food Grade (beware cheap industrial grade products not meant for human consumption)
- Made from natural seaweed. Excellent vegan gelling agent for creating brittle gels.
- ✡ Highest Quality Assured by Strict Orthodox Union Certification Standards
- Recommended by The Gentle Chef for Creating Vegan Cheeses
- Perfect for Molecular Gastronomy and Modernist Cooking applications
http://www.matthewsfriends.org/keto-kitchen/keto-cooking-channel/ Keto cooking videos
https://www.amazon.com/Natural-Coconut-Organic-Coconuts-Philippines/dp/B01L9PK0P4/ref=pd_lutyp_im_3_6?_encoding=UTF8&pd_rd_i=B01L9PK0P4&pd_rd_r=HPG27SWM2ER4KY0B2F6S&pd_rd_w=VBLoW&pd_rd_wg=qNQ1i&refRID=HPG27SWM2ER4KY0B2F6S&th=1 MCT oil
Is a ready to use medium chain triglyceride (MCT) ‘emulsion’ containing no carbohydrate or protein, therefore a convenient way to increase the MCT fat content in a ketogenic diet.
Betaquik can be simply used as an alternative to milk, flavoured with suitable ‘sugar free’ syrups, or used in cooking/baking. It has a normal boiling point and can be frozen into an ice lolly.
Once opened it should be refrigerated and used within 2 days.
Is a ready to use fat ‘emulsion’ containing no carbohydrate or protein, therefore a convenient way to increase the fat content in a ketogenic diet.
Carbzero can be simply used as an alternative to milk, flavoured with suitable ‘sugar free’ syrups, or used in cooking/baking. It has a normal boiling point and can be frozen into an ice lolly.
Once opened it should be refrigerated and used within 2 days.
A low carbohydrate, orange flavoured powdered vitamin, mineral and trace element supplement suitable for the ketogenic diet. Can be made up with permitted fluids, made into a jelly or even mixed with cream.
A great alternative to liquid MCT. MCTprocal is a neutral tasting powder that is a fabulous way to get MCT into the diet whilst adding texture to foods. MCTprocal does contain carbohydrate and protein which does need calculating for any version of the diet where it is used
It is a fat ‘emulsion’ and the plain version has no carbs or protein contained in it, so it can prove a useful way of getting the fat into the ketogenic diet. You can use it instead of double cream although you can’t whip it. It can be used in sugar free jellies or in quiche recipes.
If you want to use it as a sauce for a dinner – when you have cooked everything take it off the heat and just pour over the top. Don’t ‘fry’ it or it will separate.
Calogen flavoured with sugar free DaVinci syrups can be added to make a kind of ‘milkshake’ drink to go with a meal.
What is sugar?
Sugar is the generic name for a class of easily metabolized carbohydrates. There are different types of sugars. The most commonly known are:
- Sucrose (also called saccharose), the common household ‘sugar’, obtained from sugar cane or sugar beet.
- Lactose (milk sugar), contained in milk
- Maltose (malt sugar), contained in malted starch
- Fructose (fruit sugar), contained in fruits
- Glucose (also called dextrose), contained in grapes
Sugar cane is one of the oldest cultivated crops known to man. As far back as prehistoric times it was refined in eastern Asia.
Cane sugar was unknown in Europe until the Middle Ages and for a long time it was available only to the upper classes. Not until the much more affordable beet sugar was discovered in the 18th century was there any widespread use of sugar in Europe.
As sugar consumption increased, so too did the number of diseases that are related to excessive sugar consumption, the most important of which include caries and obesity and diseases associeted with overweight such as diabetes and cardiovasular diseases.
What are intense sweeteners?
The following intense sweeteners currently are approved in the EU:
- Acesulfame-K (E 950)
- Aspartame (E 951)
- Cyclamate (E 952)
- Saccharin (E 954)
- Neohesperidine DC (E 959)
- Thaumatin (E 957)
Only Aspartame, Acesulfame-K, Saccharin and Cyclamate are commonly used in table-top sweeteners.
Intense sweeteners are organic compounds that are not carbohydrates. They have a much greater sweetening strength than sugar, and yet have either an extremely low energy value (calorie count) or none at all.
Saccharin, Cyclamate and Acesulfame-K are organic compounds that taste sweet but contain no calories. Saccharin is about 450 times sweeter than the comparable amount of sugar, Cyclamate roughly 35 times and Acesulfame-K around 200 times. These sweeteners are excreted from the body essentially unchanged and unused.
Aspartame consists of a combination of two amino acids, L-aspartic acid and L-phenylalanine, and is digested and broken down by the body in the same way as any protein. One gram of Aspartame contains 4 calories. However, since Aspartame is 200 times sweeter than the comparable amount of sugar, these calories are negligible. Thus Aspartame is virtually calorie free.
Which name belongs to which category?
As a consumer it is not easy to differentiate between the various types of sweetening agents on the market today. In particular, consumers often confuse sweeteners and sugar substitutes, although they are very different. But those who take a close look at the list of ingredients gradually get to know what is behind each name.
|Sugar and type of sugar||Sugar substitutes
(polyols, bulk sweeteners)
|Sucrose (from cane sugar)||Lactitol||Acesulfame-K|
|Sucrose (from beet sugar)||Maltitol||Aspartame|
|Lactose (from milk)||Mannitol||Cyclamate|
|Maltose (from malting, malted starch)||Sorbitol||Saccharin|
|Fructose (from fruit)||Xylitol||Neohesperidine|
|Glucose / dextrose (from grapes)||Isomalt||Thaumatin|
Features and differences
- Sweeteners are calorie free or low in calorie – sugar substitutes are not:
The most important difference between sugar substitutes (polyols) and sweeteners is that intense sweeteners have virtually no calories or are calorie free, whereas polyols have 2.4 kilocalorie per gram.
- Sweeteners are many times sweeter than sugar substitutes (polyols):
Most polyols are about half as sweet as ‘ordinary’ sugar. In contrast, sweeteners have a far greater sweetening strength, some up to 450 times that of sugar.
- Sweeteners and sugar substitutes – both are good for your teeth:
Neither sweeteners nor sugar substitutes attack the teeth because the acid-forming bacteria in the mouth do not ‘accept’ them as a source of nutrients. ‘Tooth-friendly’ sweetening products allow you to enjoy sweetness while looking after your teeth at the same time. In view of the laxative effect of sugar substitutes, however, they should not be consumed to excess.
The calorie-free sweetener Saccharin was discovered as long ago as 1879. Since the turn of the century, it has been used to sweeten food and drink. There was a massive increase in its use during both world wars when sugar became scarce.
Saccharin is about 300 – 500 times sweeter than sugar.
Utilisation in the body
Saccharin is not absorbed or broken down in the body and is rapidly excreted unchanged via the kidneys.
- When sugar is replaced by Saccharin, the calorie count in food and drink is reduced.
- Very stable – has a long shelf-life
- Suitable for cooking and baking
- Protects the teeth and can be used by people with diabetes
- Has a synergistic effect when combined with other sweeteners. (These sweetener combinations are sweeter than the sum of the individual sweeteners.)
Cyclamate is a calorie-free sweetener that was discovered in 1937.
Cyclamate is about 30 to 40 times sweeter than sugar.
Utilisation in the body
Cyclamate is usually excreted unchanged via the kidneys. In a few people (less than 5%) a limited amount is broken down in the gastro-intestinal tract.
- When sugar is replaced by cyclamate the calorie count in food and drink is reduced.
- Stable – has a long shelf-life
- Suitable for cooking and baking
- Protects the teeth and can be used by people with diabetes
- Has a synergistic effect when combined with other (low-calorie) sweeteners. (These sweetener combinations are sweeter than the sum of the individual sweeteners.)
Aspartame is a low-calorie sweetener that is about 200 times sweeter than sugar. Because of its intense sweetening strength, the amounts required are so small that Aspartame can be regarded as practically calorie-free.
Aspartame contains two amino acids, L-aspartic acid and L-phenylalanine, two of the building blocks of protein.
The amino acids that make up Aspartame occur naturally in most protein foodstuffs, e.g. meat, cereals, milk products and vegetables.
During digestion, Aspartame is broken down into phenylalanine, aspartic acid and traces of methanol. Phenylalanine is one of the essential building blocks of protein. Methanol occurs naturally in the human body and is contained in many foodstuffs. The amount of methanol in Aspartame is very small compared to the amounts that occur naturally in food. For instance, tomato juice contains 6 times the amount of methanol as in the same volume of a soft drink sweetened with Aspartame.
- Tastes good
- Intensifies aromas, particularly in citrus and other fruit this form.
- The calorie content of food and drink can be drastically reduced by replacing sugar with Aspartame
- A minuscule amount of Aspartame with one-tenth of a calorie has the same sweetening strength as a teaspoon of sugar, which has 16 calories
- Protects the teeth, does not encourage caries
Acesulfame-K is a calorie-free sweetener. It was discovered in 1967.
Acesulfame-K is 130 to 200 times sweeter than sugar.
Utilisation in the body
Acesulfame-K is not broken down in the body but is excreted unchanged via the kidneys.
- When sugar is replaced by Acesulfame-K, the calorie count in food and drink is reduced.
- Rapidly detectable sweet taste
- Long shelf-life, very stable during normal food preparation and processing, withstands heat and therefore suitable for cooking and baking.
- Protects the teeth and can be used by people with diabetes
- Has a synergistic effect when combined with other (low-calorie) sweeteners. (These sweetener combinations are sweeter than the sum of the individual sweeteners.)
Sucralose was discovered in 1976. From 1980 onwards joint technical development by Tate & Lyle and McNeil Speciality Products (a subsidiary of Johnson & Johnson). Sucralose is the common name for a new high-intensity sweetener derived from ordinary sugar.
Sucralose is about 600 times sweeter than sugar.
Utilisation in the body
Sucralose is not broken down in the body but is excreted unchanged via the kidneys.
- high quality of sweetness
- good water solubility
- excellent stability in a wide range of processed foods and beverages
- synergistic sweetening effect in combination with other low-calorie sweeteners
- Like sugar, sucralose will hydrolyse in solution, but only over an extended period of time under extreme conditions of acidity and temperature
- Sucralose does not promote tooth decay
Thaumatin was discovered in the middle of the nineteenth century. A low-calorie (virtually calorie-free) protein sweetener and flavour modifier. The substance is often used for its flavour modifying properties and not as a sweetener.
Thaumatin is approximately 2000-3000 times sweeter than sucrose.
Utilisation in the body
Thaumatin is metabolised by the body as any other dietary protein.
- Totally natural, intense sweetness.
- Multi-functional ingredient with benefits to flavours and sweeteners
- Stable in freeze-dried form and soluble in water and aqueous alcohol
- Effective masking properties
- Does not promote tooth decay
- Heat and pH stable
- Synergistic when combined with other low-calorie sweeteners (the combinations are sweeter than the sum of the individual sweeteners)
- Adds mouth-feel
Discovered in 1963. Neohesperidine DC is about 1500 – 1800 times, customary concentration 400 – 600 times sweeter than sugar. Neohesperidine DC is a low-calorie sweetener and flavour enhancer which may be produced by hydrogenation of neohesperidine, a flavonoid occurring naturally in bitter oranges.
Neohesperidine DC is 1500 – 1800 times sweeter than sucrose at threshold levels. At practical use levels, it is about 400-600 times as sweet as sucrose. Relative to and in mixture with aspartame and acesulfame-K, neohesperidine DC is several (7 to 20) times sweeter depending upon the food in which such mixtures are used.
Utilisation in the body
Neohesperidine DC is not absorbed to a significant extent. It is metabolized by the intestinal flora, yielding the same or similar breakdown products as its naturally occurring analogues.
- In combination with other sweeteners it shows remarkable synergistic effects.
- Enhances the quality of sweetener blends
- Even at very low concentrations it can still improve the overall flavour profile and mouthfeel of certain foods
- Acts as a flavour enhancer and modifier rather than as a sweetener
- Neohesperidine DC also has bitterness-reducing properties
- Is heat stable and can therefore be used in foods requiring pasteurization or UHT processes
- Does not promote tooth decay and may be used in products for people with diabetes
Steviol glycosides (INS 960) are natural, sweet tasting constituents of Stevia rebaudiana a plant native to South America, belonging to the Compositae family. Steviol glycoside preparations are obtained by hot-water extraction from the leaves of the plant, followed by further concentration, purification and (usually) spraydrying.
Steviol glycoside preparations (min. 95% Steviol glycosides) are approximately 200 to 300 times sweeter than sucrose.
Depending on regulations and approval status Steviol glycoside preparations may find broad applications as a sweetener as Steviol glycosides are heat stable. Water extracts of the crushed leaves of the stevia plant have been used as a sweetener for many years in some countries in South America and in Asia.
- When sugar is replaced by Steviol Glycosides the calorie count in food and drink is reduced.
- Stable – has a long shelf-life
- Suitable for cooking and baking
- Protects the teeth and can be used by people with diabetes
Regulatory statuseuropean union
In Europe, steviol glycosides are not yet approved for use as a sweetener. The European Food Safety Authority (EFSA) has conducted a general safety assessment for the approval of Steviol glycosides as a sweetener in foodstuffs and for use as a flavour enhancer. A positive scientific Opinion from EFSA, setting an ADI of 4 mg/kg body weight, was published on 14th April 2010. The European Commission are currently drafting legislation for the authorisation and placing on the market of this substance in the EU.
This is an MCT product and you can use liquigen in the same way as Calogen.
NB – Both Calogen and Liquigen need to be stored in the fridge once opened. Once opened do not keep it for longer than 14 days. Write the date you opened the bottle in black marker pen on the label – that way you won’t forget and you won’t go over the 14 days.
Ketocal Powder comes in 4:1 and 3:1 powders as well as liquids available in original and vanilla flavours. It is frequently used for those patients that are tube fed. It is also a very useful item for those that are taking a ketogenic diet orally.
These are the vitamin and mineral supplements that need to be taken when on the ketogenic diet. They come in powder form and tablets. The powder tastes foul so hiding the taste could be a problem for small children, strong flavoured juice can be used or even putting some in sugar free jelly can be done.
The tablets are huge, so again this may not be sensible to use for a small child.
Super Soluable Maxijul Powder
A glucose powder that can be used to treat hyperketosis / hypoglycaemia, as well as being used to adjust the ketogenic ratio in some tube feeds.
A protein powder that can be added to feeds / shakes as recommended.
Classical & MCT Ketogenic Diets (Traditional Diets)
A high fat, low carbohydrate diet was first described in the medical literature in 1921 as a treatment for epilepsy in children, following other reports of the beneficial effects of fasting on seizure control. The diet was designed to mimic the metabolic changes that occur in the body during starvation, i.e. adaption to spare muscle protein breakdown and draw on energy reserves of body fat. Muscles and other tissues progressively switch energy source from glucose to free fatty acids which are converted to ketone bodies (acetoacetate and b-hydroxybutyrate); these become the primary energy substrate for brain and other metabolically active tissues in the absence of adequate glucose supply. This state of ketosis is characterized by the rising levels of ketone bodies which can be measured in the blood or urine. The diet became known as the ‘ketogenic diet’ and is the basis of the classical ketogenic diet still used today.
This classical diet is based on a ratio of ketone producing foods in the diet (fat) to foods that reduce ketone production (carbohydrate and protein). A ‘ketogenic’ ratio of at least 3:1 is usually needed for maintenance of a good state of ketosis and optimal seizure control, although this varies between individuals and some will need a lower 2:1 ratio or a higher 4:1 ratio. In a 3:1 diet, 87% of the energy is provided by fat, in a 4:1 diet this increases to 90%. Fat is usually provided from food sources such as butter, mayonnaise, margarine, oil, cream, or a supplement that is available on medical prescription. Protein intake is based on minimum requirements for growth and is generally provided by a high-biological value source at each meal such as meat, fish, eggs or cheese. Carbohydrate is very restricted; starchy foods are not allowed, the main sources being a limited portion of vegetables or fruit.
The medium chain triglyceride (MCT) ketogenic diet was developed in the 1970s as an alternative to the classical diet. MCT is absorbed and transported more efficiently in the body than other types of fat and will yield more ketones per unit of dietary energy. Therefore less total fat is needed on the MCT diet allowing more protein and carbohydrate food sources to be included. The traditional MCT diet provided a higher amount of energy from MCT however led to reports of gastro-intestinal problems in some children, and a modified version with less MCT was suggested. In practice a starting MCT level is now chosen that will allow good ketosis but avoid risk of side effects; this can be increased as needed and tolerated. MCT should be included in all meals and snacks; this is provided from an oil or emulsion, both available on medical prescription. The remaining energy in the MCT diet is provided from carbohydrate, protein and fat from foods. Larger portions of carbohydrate and protein will allow increased choice. A randomized controlled trial of both classical and MCT ketogenic diets was reported in 2009 and did not find either type of diet to be significantly better in terms of efficacy or tolerability, concluding both diets have their place in the treatment of childhood epilepsy.
Both the classical and MCT ketogenic diet involve strict dietary calculation and weighing of all foods. The dietitian will calculate an individual diet prescription, based on energy and protein requirements. This is likely to be started at a lower ratio or MCT content and built up over a few days as tolerated. From this prescription, recipes can be developed; this is usually done using a computer program. Exchange lists may be used as an alternative means to implement the prescription; this method is commonly used in the MCT diet. Vitamin and mineral supplementation will be needed with classical and MCT ketogenic diets due to their restrictions; this will be prescribed by the dietitian after assessment of individual requirements and dietary provision. On-going diets will need careful fine-tuning to achieve optimal results.
Modified Ketogenic Diets (MKD)
Modified ketogenic diets follow similar principles to the traditional classical and medium chain triglyceride (MCT) ketogenic regimes in that they are very low in carbohydrate and high in fat. Therefore, they have a similar effect in altering the balance of fuels available for energy production in the body; moving the body away from using (mainly) glucose for energy to using (mainly) fat for energy
The Modified Atkins Diet (MAD)
In 2003 the team at Johns Hopkins Hospital, Baltimore, USA, discovered that a modified version of the popular Atkins weight loss regime could produce nutritional ketosis and influence seizure symptoms. Since then, around 30 studies, following approximately 400 children and adults, have indicated that the MAD can deliver similar outcomes to the traditional regimes but tends to be easier to follow and is readily tolerated better(1,2).
Following are key aspects of the original USA MAD protocol:
- Carbohydrate intake is initially restricted to 10g per day for children and 20g per day for adults. Note this relates to available or net carbohydrate and EXCLUDES FIBRE.
- Fatty foods are encouraged and should be eaten at each meal / snack
- Protein is allowed freely
- No calorie restriction initially ( this is adjusted according to any weight changes)
- Vitamin and Mineral supplements are necessary
The Low Glycaemic Index Treatment (LGIT)
In 2002, the team at Massachusetts General Hospital, Boston USA started using a novel modified regime that shifted the emphasis towards glucose control rather than simply targeting ketosis (3). It is known that the ketogenic diet readily leads to flat and stable blood glucose levels and that a spike in the blood glucose (due to extra carbohydrate consumption) can trigger a significant increase in seizure activity. Hence the LGIT combines what is known about the varying speeds of glucose absorption from foods (the glycaemic effect of foods and the Glycaemic Index; GI) with a level of carbohydrate restriction that still requires the body to burn fat as its main energy source. Studies in children (3, 4) and young adults (4) indicate a similar level of effectiveness but improved compliance in comparison with traditional ketogenic regimes.
Following are key aspects of the LGIT protocol:
- Carbohydrate intake is restricted to 40-60g and evenly distributed throughout the day.
Note: this figure is total carbohydrate and INCLUDES FIBRE.
- Carbohydrate choices are restricted to foods with a GI Index less than 50.
Note: Most lists in books define Low GI as less than 55
- Fatty foods are encouraged and should be eaten at each meal / snack
- Normal amounts of protein can be eaten
- No calorie restriction initially ( this is adjusted according to any weight changes)
- Vitamin and Mineral supplements are necessary
Who are modified ketogenic diets suitable for?
The advantage of modified regimes is the flexibility of meal choice due to the main focus being around carbohydrate counting, alongside portion guidance to ensure adequate calories from fats. Therefore, they can be a really good option for older children, teenagers and adults who are consistent eaters and willing to count and monitor carbohydrate and fat intake through the day.
Who may require a more traditional ketogenic approach?
A more structured or ‘hybrid’ traditional /modified approach may work better in institutional or care home settings, where many staff may be involved in food choice, preparation and feeding.
Ketogenic tube feeds also tend to be based on a classical ketogenic regime so if there are any additional oral meals or snacks required alongside, these tend to be based around classical principles too.
Modified ketogenic diet prescriptions in the UK;
- Most UK ketogenic teams use modified regimes based on the USA MAD but the initial level of carbohydrate restriction may be higher and vary from one centre to another. Some teams also specify guideline amounts of fat to ensure that weight is maintained, gained or lost in accordance with the needs of the individual.
- Ketogenic diets tend to be based on low carbohydrate foods that also happen to fall into the ‘Low GI’ category (eg. non starchy vegetables, nuts, berry fruits and double cream). This is because they offer larger portions of food per gram of carbohydrate they provide; delivering much better value in meals compared to tiny portions of high carbohydrate, high GI options such as potato.
- Carbohydrate prescriptions relate to the ‘available’ or ‘net’ carbohydrate in foods and exclude fibre. (Carbohydrate data on food labels in the UK and Europe excludes fibre).
- Modified diets generally require vitamin and mineral supplementation, based on individual requirements.
- Some teams may incorporate MCT supplements (MCT oil or emulsion) as a ‘fine tuning’ aid to enhance the effectiveness of modified diets.
The MAD and LGIT regimes have much in common, but take a slightly different approach to carbohydrate choices. They are both less restrictive and therefore simpler to implement than the traditional ketogenic regimes and can make eating out much easier. However, all ketogenic therapy, whether traditional or modified in its approach requires the same level of medical screening, preparation, monitoring and individual ‘fine-tuning’ from a ketogenic team (normally a neurologist and an experienced registered dietitian).
- Sharma S, Sankhyan N, Gulati S, Agarwala A. Use of the modified Atkins diet for treatment of refractory childhood epilepsy: a randomized controlled trial. Epilepsia 2013 54(3):481-486.
- Kossoff EH, Cervenka MC, Henry BJ, Haney CA, Turner Z. A decade of the modified Atkins diet (2003–2013): Results, insights, and future directions. Epilepsy & Behavior 2013 9:437–442
- Pfeifer HH & Thiele EA. Low-glycemic index treatment: A liberalized ketogenic diet for treatment of intractable epilepsy. Neurology 2005 65:1810-1812.
- Muzykewicz DA, Lyczkowski DA, Memon N, Conant KD, Pfeifer HH, Thiele EA. Efficacy, safety and tolerability of the low glycemic index treatment in pediatric epilepsy. Epilepsia 2009 50(5):1118-1126
The Diet Prescription
Ketogenic dietary therapies are designed to cause a metabolic shift within the body, with fat becoming the primary fuel rather than carbohydrate and ketone bodies replacing glucose as an energy source for the brain. Although all diets are based around similar principles of low carbohydrate and high fat intake and will all be tailored to individual nutritional requirements, the way in which the different protocols are implemented and resulting diet prescriptions will vary as outlined below.
Traditional ketogenic diets
The classical ketogenic diet is very low in carbohydrate and high in fat with protein provided to meet necessary minimum requirements for growth. It is calculated in a ratio of grams of fat to protein plus carbohydrate. Diets are most commonly prescribed at a 3:1 ratio (3g of fat to 1g of protein plus carbohydrate combined, 87% of dietary energy as fat) or 4:1 ratio (4g of fat to 1g of protein plus carbohydrate, 90% of dietary energy as fat) or somewhere in-between; a lower 2:1 starting ratio is often used which is increased as tolerated. Fat is mainly from foods, such as cream, butter, oil and mayonnaise although products available on prescription can also be useful. Carbohydrate is usually limited to small servings of vegetables and/or fruits. A dietitian calculates an individual dietary prescription with all meals and snacks at the correct ketogenic ratio; recipes or exchange lists are provided and food must be weighed to ensure dietary accuracy.
The medium chain triglyceride (MCT) ketogenic diet allows considerably more carbohydrate and protein as the substitution of some of the fat with an MCT source will increase ketosis therefore total fat intake can be reduced. The amount of MCT will vary depending on tolerance and individual requirements but is usually between 40-60% of total energy intake. MCT is given in the diet as an oil or emulsion that are available on prescription and included in all meals and snacks. Although the dietitian calculates an individualised prescription and all food is weighed, the more generous carbohydrate and protein intake means that exchange lists are generally used to implement the prescription rather than the calculation of recipes.
Free foods are very limited on the traditional ketogenic diets and fluid is not restricted but an adequate intake encouraged to reduce risk of kidney stones. Energy intake is carefully controlled as excess will be stored as fat which can compromise ketosis and seizure control. At the outset of a diet calculation, the energy prescription will be individually calculated, taking into account current dietary intake, nutritional requirements, current weight and height, recent growth trends, activity and seizure level and any medications. Imaginative use of food combinations is important to accommodate the low carbohydrate and high fat content and computer calculation tools such as Electronic Ketogenic Manager (EKM) can help with recipe development. Full vitamin, mineral and trace element supplementation is necessary to avoid nutritional deficiencies; the dietitian will advise on this taking into account any provision from the foods allowed on the diet.
Modified ketogenic diets
More recently two types of diet protocol modified from the traditional ketogenic diets have been developed.
The modified Atkins diet restricts carbohydrates and encourages high fat foods, but does not limit or measure protein or total calories. The original protocol as developed at the Johns Hopkins Hospital USA initiates the diet with a very low 10-20g carbohydrate intake daily (depending on age); this is then increased after 1 month with the final prescribed amount dependent on seizure control. In the UK a higher starting carbohydrate is frequently used, e.g. 20-30g daily; this is then reduced if necessary within the first couple of weeks on the diet. Protein is allowed freely on the modified Atkins diet and high fat foods are encouraged and should be eaten at each meal/snack to promote ketosis. Some centres use exchange lists to ensure an adequate fat intake although the overall energy content of the diet is not usually prescribed but adjusted with on-going dietary advice as needed.
The low glycaemic index treatment is more generous in carbohydrate which at 40-60g daily (including fibre) provide approximately 10% of dietary energy, but only those with a glycaemic index of less than 50 are allowed. An even daily carbohydrate distribution is recommended and this should always be eaten alongside a protein and/or fat source to reduce the overall glycaemic index of a meal or snack. Protein, fat, and calories are monitored, but not as strictly as on a traditional ketogenic diet. Food is not weighed, but based on portion sizes.
The modified diets will usually also require nutritional supplementation as advised by the dietitian to ensure requirements of vitamins, minerals and trace elements are being met, and again adequate fluid intake is encouraged.
In practice many dietitians are adopting a more flexible, ‘patient-tailored’ approach to ketogenic therapy, especially when treating older children and adults. This may combine elements from one or more of the different types of ketogenic diet rather than sticking to a rigid diet protocol.
Dietary fine tuning
The aim of fine-tuning a diet is to establish the prescription for optimal efficacy and on-going dietary modifications are an essential component of the dietetic care. Regular home monitoring of ketone levels, weight and seizures are important. Although ketone levels can be useful as an indication of how the body has adjusted to the diet, and to ensure they are not excess, the level of ketosis associated with the best seizure control will vary between individuals. The amount of carbohydrate and fat in a prescription can influence the ketone levels; decreasing carbohydrate and increasing fat will usually act to raise levels and increasing carbohydrate and reducing fat will lower ketone levels. Replacing some of the long chain fat provided from food and supplement sources in the diet with MCT supplements will also increase ketone levels.
Energy intake and weight changes can also influence ketosis and seizure control. The energy prescription on ketogenic diets will need regular review and fine-tuning as the child grows and the diet becomes established. For example as seizure activity decreases, mobility may increase and with it energy needs. Regular weight checks will enable calorie modifications as needed.
As a child grows, the diet may need re-calculating to increase protein intake in line with increases in body weight. Meal and/or snack distribution may also need changing to fit with changes in lifestyle. Micronutrient intakes should always be checked by the dietitian if they are likely to be altered by dietary modifications, and supplementation reviewed as necessary.
The two currently most suitable and nutritionally complete are Phlexy-vits (Nutricia), available in powder sachet and tablet form and recommended for children over 11 years, and FruitiVits (Vitaflo).
1) Vitamins, minerals and trace elements
Is there a risk of deficiency on ketogenic therapy?
Historically, ketogenic diets were not always fully supplemented with micronutrients, however early reports of problems in children date back to 1979. During this year there were two published papers about nutritional deficiency while on the ketogenic diet; the first reported two patients who presented with optic neuropathy caused by thiamine deficiency (Hoyt & Billson, 1979), and the second reported reduced bone mass due to vitamin D deficiency in five patients (Hahn et al, 1979).
More recently, selenium deficiency was found in nine children on the ketogenic diet, including one who developed cardiomyopathy (Bergqvist et al, 2003). This research group have also reported poor vitamin D status in children on the diet which can compromise bone health because of the resulting loss of bone mineral content (Bergqvist et al, 2007 and 2008). One case report describes a nine year old girl on the ketogenic diet who developed scurvy due to vitamin C deficiency (Willmott & Bryan, 2008). Plasma magnesium levels can be lowered (Kang et al, 2004) which may be a particular problem in children on the classical ketogenic diet despite micronutrient supplementation (Christodoulides et al, 2011).
Risk of nutritional deficiency may be increased by a limited food intake pre-ketogenic treatment in a child with severe disability or the effects of multiple anticonvulsant drugs, and the restrictive nature of any type of ketogenic diet makes it necessary to be fully nutritionally supplemented with vitamins, minerals and trace elements. Although the medium chain triglyceride (MCT) ketogenic diet, the modified Atkins diet and the low glycaemic index treatment are less restrictive than the classical ketogenic diet, it is still essential that all children using any of these diets are fully assessed by a dietitian who can advise on their nutritional adequacy and recommend the necessary supplementation based on a child’s nutritional requirements. A diet history that accurately records food intake over a few days should ideally be done at least once a year, and the prescribed supplementation checked regularly, so that the provision of micronutrients can be assessed by the dietitian to ensure that all requirements are met, and no nutrient is being given in unnecessary excess.
What are nutritional requirements?
The UK guidelines on nutritional requirements of children aged between 0-18 years are based on the report of the COMA Panel on Dietary Reference Values (DRVs), Department of Health Report on Health and Social Subjects No 41, published in 1991. These recommendations refer to groups, and any individual is likely to have requirements which fall within a range of recommended intakes for their age group. For this reason, an upper and lower value for requirements is given for each nutrient, these are termed reference nutrient intake (RNI) and lower reference nutrient intake (LRNI) respectively. The RNI of a nutrient would be considered the amount that would meet the requirements of nearly all of the people in a group. Many nutrients also have a value given for estimated average requirement (EAR), about half a group of people would be expected to have a requirement above this level, and about half below. If there is limited information on requirements for a particular nutrient, a value for safe intake may be used. So, when assessing vitamin and mineral requirements, the dietitian would want to be sure that a prescribed diet and supplementation met the RNI for age for as many nutrients as possible. In children who are very small for their age it may be more appropriate to use the requirements for their height age, rather than actual age. This would be assessed on an individual basis by the dietitian.
What supplements do we use?
In the UK, there are limited carbohydrate-free micronutrient supplements that are available to be prescribed for children on a ketogenic diet. The two currently most suitable and nutritionally complete are Phlexy-vits (Nutricia), available in powder sachet and tablet form and recommended for children over 11 years, and FruitiVits (Vitaflo), available in powder sachet form and recommended for children aged 3-10 years. Other types of supplement can be bought over the counter and may be more palatable, however must be carbohydrate-free and discussed with the dietitian as may not provide the full range of micronutrients needed e.g. inadequate calcium and phosphate. Calcium supplements may not be necessary on an MCT diet if adequate amounts of milk are consumed as part of the prescription, but this should be individually assessed by the dietitian.
The dose of any chosen supplement will be calculated by the dietitian to avoid risk of either under- or over supplementation of any nutrient. Whereas vitamins, minerals and trace elements do have a vital role in the body, and we must ensure children on the diet are not deficient, it must be noted that adding in further supplements additional to those recommended by the dietitian could in fact prove harmful. Any other supplements should therefore always be discussed with the dietitian/medical team. Children on a ketogenic diet will have regular blood monitoring to check nutritional status. This should include fat-soluble vitamins due to the risk of high levels of vitamins A and E (Christodoulides et al, 2011). Children who show deficiencies of particular nutrients on blood monitoring may need additional supplementation of that nutrient, a common example is vitamin D (although requirements of this vitamin will vary with the seasons, as it is synthesised in the body when exposed to sunlight).
What is carnitine?
Carnitine is a small water soluble compound. It is absorbed well from food, with the main dietary sources from protein such as milk, meat and eggs. It can also be synthesised in the body, formed from two amino acids, lysine and methionine. Over 90% of body stores are in muscle. L-carnitine is the biologically active form of carnitine. Carnitine has an essential role in fat metabolism; it combines with long chain fatty acids to form acylcarnitines (esters) to enable their transport into the cell mitochondria for oxidation. This process by which carnitine facilitates the transfer of long chain fat into the mitochondria is often referred to as the carnitine shuttle, as once carnitine has transported the fatty acid esters across the inner mitochondrial membrane, it is shuttled back across this membrane for the process to be repeated. Once inside the mitochondria, oxidation of fatty acids occurs in stages, with two carbons removed at each stage to form acetyl coA; this either enters the Krebs cycle, or is used to synthesise ketone bodies. The intermediates of this oxidation process can combine with carnitine in the mitochondria, forming acylcarnitines. Acetyl CoA also combines with carnitine within the mitochondria to form acetyl carnitine; this then leaves the mitochondria with ketone bodies.
Medium chain fatty acids have a direct passage into the cell mitochondria for oxidation, and so have no need for the carnitine shuttle.
Carnitine and the ketogenic diet
Carnitine is thought to be important on the ketogenic diet because the high fat intake means more fatty acids need to be transported into the mitochondria for oxidation, requiring more carnitine and therefore increasing risk of depletion of body carnitine stores. This risk may be magnified as food restrictions could reduce dietary carnitine intake and is of particular importance in diets with high long chain fat intake rather than MCT. An additional risk in some individuals is that long term use of the medication sodium valproate also can lead to carnitine deficiency. If carnitine is deficient, it will be difficult to achieve adequate ketosis on the ketogenic diet, due to impaired ketone body synthesis; energy levels may also be impaired.
There have been limited studies examining whether carnitine deficiency does occur on the ketogenic diet. Berry Kravis et al, in 2001, reported a study which looked at plasma total carnitine levels in 46 patients (age range 1-24 years) who were on the classical ketogenic diet; this included 38 who were followed from diet initiation, and an additional eight already on the diet at the time of the study. Of the 38 patients monitored from diet initiation, three were started on carnitine supplementation at baseline due to low levels, and five others needed supplementation later in diet treatment (3 after 1 month, 2 after 6 months). One of the additional eight patients already on the diet needed carnitine supplementation due to low levels after 1 year. So, out of all the ketogenic diet patients who were not started on carnitine when starting the diet, 6 (18%) went on to have low total carnitine levels and need supplementation later. None of them showed any clinical signs of carnitine deficiency, and did not show any worsening of seizure control with low carnitine levels. The average total carnitine in patients who were never carnitine supplemented was lower after one and six months on the diet than at baseline, but this then increased again by 12 and 24 months. The conclusions from this study were that although total carnitine does decrease over the first few months of ketogenic diet treatment, and in some patients, dip into the deficiency range, it then normalises after the first months, with no evidence of a continued decline in levels.
One other study, reported in 2005 by Coppola et al, measured plasma free carnitine levels in 164 epilepsy patients (age 1mo-26 years). None of the 11 patients who were on the classical ketogenic diet developed abnormal levels of free carnitine.
Assessing carnitine status and supplementation
The two studies discussed above used total and free carnitine. Total carnitine includes free carnitine and all the acylcarnitines, i.e, all carnitine-fatty acid esters including the intermediates of the fat oxidation process that have combined with carnitine. In a state of ketosis, even β-hydroxybutyrate will combine with carnitine to form β-hydroxybutryl carnitine – these will all be included in the acylcarnitine fraction. Another suggested measure of carnitine status is the ratio of plasma acylcarnitine to free carnitine. A consensus paper on carnitine supplementation in childhood epilepsy suggested a free carnitine level of less than 20µmol/litre or an acyl:free carnitine ratio greater than 0.4 (after 1 week post term) indicated a deficiency (DeVivo et al, 1998). These were arbitrary values, and different centres may use other age-dependent ranges, frequently a lower free carnitine cut-off for deficiency. We do not know what measures accurately determine status as plasma levels are not a true reflection of total body stores which are mostly in muscle. Although free carnitine does give some useful indication of status in patients on the ketogenic diet, the acyl:free ratio does not. Because of the increase in fat metabolism and ketosis that occur while on the diet, as discussed above, levels of acylcarnitines including acetyl carnitine will be greatly increased and this will result in an elevated ratio. This is a normal consequence of being on the ketogenic diet and is likely to reflect the level of ketosis, rather than an indication of carnitine status. Further supplementation with carnitine will have no effect on reducing the ratio and may even cause an increase due to formation of acetyl carnitine. It has been suggested that the ratio may normalise slightly with time on the ketogenic diet with adaptation to the ketotic state (Berry-Kravis et al, 2001).
Despite current consensus that children on the ketogenic diet should not be routinely supplemented with carnitine unless showing biochemical or symptomatic deficiency (Kossoff et al, 2009), a number of families of children using the diet do choose to use either medically prescribed or bought over-the-counter carnitine supplements, regardless of biochemical status, with reports of improved well-being, energy levels and seizure control. As true carnitine deficiency will impair oxidation of fatty acids in the mitochondria and ketone production, a drop in ketone levels would be expected. Anecdotal reports do suggest ketone levels may improve with additional carnitine supplementation especially if previously showing an unexplained drop, even if plasma carnitine levels are normal, indicating it may be a useful additional tool for dietary fine-tuning. Any supplements used should be of the L-carnitine form, be commenced at a low dose and increased gradually. DeVivo et al (1998) recommended supplementing patients with biochemical deficiency at 100mg per kg body weight per day, in three or four divided doses, up to maximum of 2g/day. There may be poor absorption, diarrhoea or an increase in seizures if high doses are started without gradual build-up. A starting dose of 10mg/kg is frequently used for patients on the ketogenic diet, which is increased as needed; many children do not require above 50mg/kg per day.
3) Essential fatty acids (‘healthy oils’)
What are essential fatty acids?
Essential fatty acids (EFA) are fatty acids that we need for our health but cannot be synthesised in the human body from any other fatty acids provided in our diet. They belong to the class of fatty acids called polyunsaturated fatty acids (PUFAs). There are two types of EFA, omega-3 and omega-6. These names refer to the chemical structure of the fatty acid; both types are unsaturated, that is, they contain carbon-carbon double bonds, the type is determined by the final double bond being either at the n-3 or n-6 position. The main essential omega-3 fatty acid is alpha-linolenic acid (ALA), and the main essential omega-6 fatty acid is linoleic acid. Although the human body cannot synthesise either of these fatty acids from scratch, it can use them to synthesise other essential fatty acids. ALA is a precursor of the longer chain omega-3 fatty acids eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA), and linoleic acid is a precursor of the longer chain omega-6 fatty acids gamma-linolenic acid (GLA), dihomogamma-linolenic acid (DGLA) and arachadonic acid (AA). These longer chain fatty acids can also be provided directly from dietary sources.
Biological roles of EFA
Both omega-3 and omega-6 EFA have a role in maintaining normal growth and development including that of the brain, and are important components of all cell membranes in the body. However the two classes of EFA are metabolically and functionally separate, and often have important opposing physiological functions. AA (omega-6), DGLA (omega-6), and EPA (omega-3) are used to synthesise eicosanoids in the body, these are signalling molecules that exert complex control over many bodily systems, mainly in inflammation or immunity. There are four families of eicosanoids—the prostaglandins, prostacyclins, the thromboxanes and the leukotrienes. The eicosanoids derived from AA tend to increase inflammation (an important component of the immune response), blood clotting, and cell proliferation, while those derived from EPA and DGLA decrease those functions. The amounts and balance of omega-3 and omega-6 fats in a diet will affect the body’s eicosanoid-controlled functions and are therefore important in maintaining optimum health. It is widely believed that Western diets tend to have too much omega-6, particularly in relation to omega-3 fatty acids, and that this imbalance can increase risk of cardiovascular disease, cancer, osteoporosis and other inflammatory disorders.
Food sources of EFA
The main food sources of the different EFA are shown in the table below:
|Omega-3ALA||Dark, green leafy vegetables, certain nuts and seeds and their oils (flaxseed/linseed oil, hempseed oil, walnut oil)|
|EPA||Oily fish, fish oil supplements|
|DHA||Oily fish, fish oil supplements|
|Omega-6Linoleic acid||Commonly used polyunsaturated vegetable cooking oils, including sunflower, safflower, corn, cottonseed, and soybean. Processed foods containing these oils. Nuts, sesame and sunflower seeds|
|GLA||Plant based oils including evening primrose oil, borage seed oil and blackcurrant seed oil. Some hempseed oils.|
|AA||Egg yolk, meats|
The oil highest in omega-3 fats is flaxseed (linseed), with over 50% of fatty acids as omega-3, and a ratio of 0.3:1 omega-6: omega-3. Hempseed oil also has a good balance, with about 20% omega-3, and a ratio of approximately 3:1 omega-6: omega-3. Walnut oil is often recommended as a good source of EFA: this is lower in omega-3, about 3-11% of fatty acids, with a ratio of approximately 5:1 omega-6: omega-3.
Eye Q liquid is widely used as a dietary supplement in children. This contains fish oil (EPA and DHA, omega-3), and evening primrose oil (GLA, omega-6), and also vitamin E. Some children on the ketogenic diet may also use the nutritional products Calogen and/or Ketocal (Nutricia). These are both supplemented with omega-3 and omega-6 EFA, the amount provided will depend on the amount of the product used.
Recommended intakes of EFA
It is recommended that a healthy diet should consist of approximately 2 – 4 times more omega-6 than omega-3 fatty acids however a typical Western diet tends to contain 15 – 20 times more omega-6 than omega-3 fatty acids due to the amount of vegetable oils and processed foods eaten. Healthy eating guidelines recommend lowering omega-6 intake and increasing omega-3 by reducing processed foods, including oily fish, and replacing some of the commonly used vegetable oils with oils higher in omega-3 fats or olive oil (monounsaturated oil, so contains relatively low amounts of both omega-3 and omega-6 fatty acids, but known to be very beneficial for cardiovascular health) (Simopoulos et al, 2000; Hibbeln et al, 2006). Although there are no recommendations for exact amounts of EFA in the diet of children, current UK department of Health dietary reference values suggest that ALA (omega-3) should provide approximately 0.2% of total dietary energy, and linoleic acid (omega-6) approximately 1% of total dietary energy. Although in most cases, the longer chain omega-6 fatty acids GLA and DGLA and omega-3 fatty acids EPA and DHA can be formed in the body from linoleic acid and ALA, there is increasing evidence that there may also be additional requirement for these longer chain fatty acids to be provided directly from the diet in some cases.
Is it safe to use evening primrose oil supplements in epilepsy?
There was concern for a number of years that evening primrose oil might cause seizures and advice was given not to use this in epilepsy. Evidence was based on two studies published in the early 1980s on use of evening primrose oil in schizophrenia treatment. A re-examination of this data (Puri, 2007) found the original reports to be spurious and concluded the oil might actually have benefits in epilepsy, suggesting that any contra-indications for use of evening primrose oil in epilepsy be removed from all medical formularies.
Recommendations for use of EFA supplements while on the ketogenic diet
To ensure a good balance between omega-3 and-6 fatty acids, the oil source should be varied wherever possible, and if using large amounts of a polyunsaturated vegetable cooking oil such as those listed in the above table (omega-6 sources), a small amount of an omega-3 source added to the diet as well, such as flaxseed/linseed oil, hempseed oil or walnut oil. The amounts of these omega-3 oils used can be very small, e.g. 2-3ml a day, but this should ensure a child is receiving the correct balance of EFA. This is also important for children following the MCT diet, especially if receiving a large percentage of their energy from the MCT source, to ensure that adequate EFA are provided. General healthy eating recommendations should also be included wherever possible on any type of ketogenic diet within the constraints of the prescription, and these include regular oily fish and dark green vegetables, both good omega-3 sources. Olive oil, although not containing any EFA, can also be included, as has known benefits on cardiovascular health.
There have been questions about whether any one particular type of EFA rich oil is better to use as a supplement on the ketogenic diet. Although flaxseed oil contains the highest proportion of omega-3 fatty acids, adequate supply can easily be provided from small amounts of walnut oil which is more widely available. There is no evidence of advantages of any one oil type. A study examining the effects of hempseed and flaxseed oil on healthy adult volunteers found no differences in fasting serum total or lipoprotein lipids, plasma glucose or insulin level or haemostatic factors between the two oils (Schwab et al, 2006).
Supplemental oils may need to be accounted for in the energy prescription, and should not be used in quantities greater than the small amounts already mentioned as they provide additional fat-soluble vitamins, notably A and E. There have also been concerns about the risk of increased bleeding time with long-term use of excessive amounts of a high omega-3 oil source in the diet. As with any type of dietary supplement, use should always be discussed with a dietitian and medical team before commencing.
Bergquist AGC, Chee CM, Lutcha L, Rychik J, Stallings VA (2003). Selenium deficiency associated with cardiomyopathy: a complication of the ketogenic diet. Epilepsia 44 (4):618-620.
Bergqvist AG, Schall JI, Stallings VA (2007). Vitamin D status in children with intractable epilepsy, and impact of the ketogenic diet. Epilepsia 48 (1):66-71
Bergqvist AG, Schall JI, Stallings VA, Zemel BS (2008). Progressive bone mineral content loss in children with intractable epilepsy treated with the ketogenic diet. Am J Clin Nutr. 88 (6):1678-1684
Berry-Kravis et al (2001). Carnitine levels and the ketogenic diet. Epilepsia 42 (11), 1445-1451.
Christodoulides SS, Neal EG, Fitzsimmons G, Chaffe HM, Jeanes YM, Aitkenhead H, Cross JH. The effect of the classical and medium chain triglyceride ketogenic diet on vitamin and mineral levels. J Hum Nutr Diet. 2012; 25(1):16-26.
Coppola et al (2006). Plasma free carnitine in epilepsy children, adolescents and young adults treated with old and new antiepileptic drugs with or without ketogenic diet. Brain Dev 28 (6), 358-365.
DeVivio et al (1998). L-carnitine supplementation in childhood epilepsy: current perspectives. Epilepsia 39, 1216-1225.
Hahn T, Halstead L, DeVivo D. (1979), Disordered mineral metabolism produced by ketogenic diet therapy, Calcified Tissue Int 28, 17-22.
Hibbeln JR, Nieminen LR, Blasbalg TL, Riggs JA, Lands WE (2006). Healthy intakes of n−3 and n−6 fatty acids: estimations considering worldwide diversity. Am J Clin Nutr 83(6):1483S–1493S.
Hoyt CS, Billson FA (1979). Optic neuropathy in ketogenic diet. British J Opthalmol 63 (3), 191-194.
Kang HC, Chung DE, Kim DW, Kim HD. Early- and late-onset complications of the ketogenic diet for intractable epilepsy. Epilepsia 2004; 45:1116-1123.
Kossoff et al (2009). Optimal clinical management of children receiving the ketogenic diet: Recommendations of the International Ketogenic Diet Study Group. Epilepsia 2009; 50(2):304-317.
Puri BK (2007). The safety of evening primrose oil in epilepsy. Prostaglandins Leukot Essent Fatty Acids 77(2):101-103.
Schwab U, Callaway J, Erkkilä A, Gynther J, Uusitupa M, Järvinen T (2006). Effects of hempseed and flaxseed oils on the profile of serum lipids, serum total and lipoprotein lipid concentrations and haemostatic. Eur J Nutr 45 (8):470-477.
Simopoulos AP, Leaf A, Salem Jr N (2000). Statement on the essentiality of and recommended dietary intakes for n−6 and n−3 fatty acids. Prostaglandins, Leukot Essent Fatty Acids 63:119–121
Willmott NS, Bryan RA (2008). Case report: scurvy in an epileptic child on a ketogenic diet with oral complications. Eur Arch Paediatr Dent 9 (3):148-52.
Products from Nutricia are intended for diagnosed patients for the nutritional management of diseases and medical conditions and therefore should be used under the direction of Healthcare Professionals.
The Anamix Range
The Anamix range offers a specific nutrient profile of energy-containing protein substitutes based on amino acids to aid growth and development in children with inborn errors of metabolism. The Anamix range are foods for Special Medical Purposes or Medical Food and are intended for patients who are medically diagnosed for use under medical supervision.
Infant: from birth to 1 year of age and as a supplementary feed up to 3 years of age.
Junior and Junior LQ: suitable for children 1-10 years of age.
First Spoon: from the age of 6 months to 5 years of age.
For more detailed product information please visit nutricia.co.uk/products.
A high energy, nutritionally incomplete and long chain triglyceride fat emulsion consisting of approximately 50% LCT fat and 50% water. Calogen is a medical nutrition product for patients who are unable to meet their energy requirements from normal food and drink. Calogen is suitable for patients requiring electrolyte restrictions, can be used to replace milk in protein restricted diets, and can be used as an energy enhancer in tube and sip feeds and as a part of the management of the LCT ketogenic diet.
High energy, high protein oral nutritional supplement enriched with arginine, zinc and antioxidants. Available in three flavours: Vanilla, strawberry and chocolate.
A food for special medical purposes for the dietary management of pressure ulcers, and must be used under medical supervision.
Flocare® Infinity™ pump
A small, lightweight, portable enteral feeding pump to suit any situation.
The Flocare Infinity pump safely and accurately delivers a nutritional regimen without compromising quality of life. It is built to simplify the enteral feeding experience. It is washable under running water and can be used in any orientation.
Nutricia’s Flocare range of innovative medical devices, accessories and supporting tools have been developed to simplify enteral feeding.
For more detailed product information, please visit nutriciaflocare.com.
FortiCare is a nutritionally complete, high energy (1.6kcal/ml), high protein, ready to drink, milkshake-style medical nutrition product. It is enriched with n-3 fatty acids, antioxidants and fibre. FortiCare can be used to supplement the diet of patients unable to meet their nutritional requirements from other foods, or used as a sole source of nutrition.
A high protein medical nutrition food containing whey protein, leucine and vitamin D. FortiFit Pro is for the dietary management disease related malnutrition and must be used under medical supervision. A 40g serving provides 21g protein and 150kcal.
Fortimel Compact Energy
An energy dense 1.5 kcal/ml), moderate protein oral nutritional supplement, enriched with all essential minerals, vitamins and trace elements. Provides a similar nutritional value to that of standard 200ml supplement but in a smaller (125ml) volume to aid compliance. Gluten and lactose free. Fortimel Compact Energy is a food for special medical purposes for the dietary management of disease related malnutrition and must be used under medical supervision.
Fortimel Compact Protein
A high protein, energy dense medical nutrition supplement for the dietary management of disease related malnutrition. It contains all essential minerals, vitamins and trace elements, providing 18 g of protein and 300 kcal in 125 ml. Available in the following flavours: Banana, Berries, Mocha, Peach, Mango, Strawberry and Vanilla. Fortimel Compact Protein must be used under medical supervision.
A high protein, energy dense medical nutrition supplement for the dietary management of disease related malnutrition. It contains all essential minerals, vitamins and trace elements and is available in 200ml bottles, with one serving providing 18g protein and 300kcal. Fortimel Extra must be used under medical supervision.
The Infatrini range
Infatrini is a nutritionally complete, energy and protein-dense, ready-to-use feed. It is for use from birth to 9kg in body weight (or 18 months of age) Infatrini is suitable for use as a sole source of nutrition.
Infatrini is a food for special medical purposes (FSMP) for the dietary management of infants with faltering growth or who have increased nutritional requirements and/or require fluid restriction. To be used under medical supervision.
The KetoCal range
The KetoCal range provides a convenient way of administering the ketogenic diet for children with diagnosed intractable epilepsy requiring a nutritionally complete or supplementary ketogenic feed that can be efficacious and is well tolerated.
KetoCal 3:1: A nutritionally complete infant powder formulated to provide the 3:1 ketogenic ratio from birth.
KetoCal 4:1: A nutritionally complete powder formulated to provide the 4:1 ketogenic ratio from the age of 1.
KetoCal 4:1 LQ: a liquid dietary supplement formulated to a 4:1 ratio to be used in conjunction with the ketogenic diet from the age of 1.
Liquigen is an unflavoured, nutritionally incomplete emulsion consisting of approximately 50% oil and 50% water. It can be used as a part of the management of the MCT ketogenic diet for intractable epilepsy. Suitable for infants, children and adults.
The Lophlex range
The Lophlex range offers convenient amino acid supplements in on-the-go formats, small in volume and easy to take anytime, anywhere to fit in with busy lifestyles. For children (>4) and adults with inborn errors of metabolism. The Lophlex range are Foods for Special Medical Purposes or Medical Food and are intended for patients who are medically diagnosed for use under medical supervision.
Lophlex LQ Juicy and Lophlex Sensation: children from 4 years of age and adults, including pregnant women (in conjunction with standard folic acid supplementation).
Lophlex (powder): suitable for children 8 years and adults.
For more detailed product information please visit nutricia.co.uk/products.
The Loprofin range
A range of low-protein foods for use in the dietary management of patients with inherited metabolic disorders, renal of liver failure, who require a low protein diet.
The Loprofin range are Foods for Special Medical Purposes or Medical Food and are intended for patients who are medically diagnosed for use under medical supervision.
For more detailed product information please visit nutricia.co.uk/products.
MCT oil is a unflavoured, nutritionally incomplete emulsion containing MCT fats, which can be used as a part of the management of the MCT ketogenic diet for intractable epilepsy. Suitable for infants, children and adults.
The Milupa range
Products in the Milupa range contain no artificial colours or sweeteners to aid taste. With over 40 years of experience in the dietary management of inborn errors of metabolism, the recently updated Milupa range provides comprehensive nutritional options from birth to adulthood. The Milupa range are Foods for Special Medical Purposes or Medical Food and are intended for patients who are medically diagnosed for use under medical supervision.
Milupa 1 and 1-Mix: from birth to 1 year of age.
Milupa 2 and 2-Mix: Toddlers and children >1 year of age.
Milupa 2 Secundaand 2-Shake: children and adolescents +8 years of age.
Milupa 3 Advanta and 3-Shake: adolescents over 15 years of age.
For more detailed product information please visit milupa-metabolics.com.
The Neocate range
All products in the Neocate range are intended for the dietary management of cow’s milk allergy, multiple food protein allergies and other indications where an amino acid diet is recommended. All products in the Neocate range must be used under medical supervision after full consideration of all feeding options, including breastfeeding.
For more detailed product information please visit global.neocate.com.
The Nutilis range
The Nutilis range offers patients with swallowing difficulties an effective way to take in adequate nutrition and hydration. The range includes easy-to-use pre-thickening powders, pre-thickened oral nutritional supplements and pre-thickened hydration drinks.
For more detailed product information please visit Nutilis.com.
The Nutri range
The Nutri range offers a complete range of high quality nutrition across all age groups – from infancy to adulthood for people with inborn errors of metabolism. The Nutri range are Food for Special Medical Purposes or Medical Food and are intended for patients who are medically diagnosed for use under medical supervision.
PKU Nutri 1 Concentrated: For dietary management of PKU from birth to 12 months.
PKU Nutri 1 Energy: For dietary management of PKU from birth to 12 months and as a supplement up to 3 years.
PKU Nutri 2 Concentrated: For dietary management of PKU in children over 1 year.
PKU Nutri 2 Energy: For dietary management of PKU in children over 1 year.
PKU Nutri 3 Concentrated: For dietary management of PKU in children over 9 years and adults.
PKU NUtri 3 Energy: For dietary management of PKU in children over 9 years and adults.
The Nutrini range
Nutrini is a food for special medical purposes for the dietary management of disease related malnutrition in both younger (9-20kg body weight, ~1-6 years) and older children (NutriniMax: 21-45kg body weight, ~7-12 years). It is a nutritionally complete, ready-to-use tube feed range, and is suitable as a sole source of nutrition. To be used under medical supervision.
The NutriniDrink range
NutriniDrink (also known as Fortini) is a food for special medical purposes for the dietary management of disease related malnutrition in children. It is a nutritionally complete, high energy, ready-to-use range of drinks and foods and is suitable as a sole source of nutrition. To be used under medical supervision.
The Nutrison range
Nutrison offers a comprehensive and innovative tube feed range intended for enteral nutritional support for those patients with functional or partially functional gastrointestinal tract who are unable or unwilling to eat sufficient quantities of foods to meet their nutritional requirements.
The Nutrison range are foods for special medical purposes or medical foods and are intended for patients who are medically diagnosed for use under medical supervision.
Nutrison Advanced Cubison
Cubison is a 1kcal/ml tube feed for the dietary management of disease related malnutrition in patients with impaired wound healing, including pressure and leg ulcers. Cubison is a fibre rich feed, high in protein and enriched with arginine, vitamins, trace elements and antioxidants. Cubison is nutritionally complete and suitable as a sole source of nutrition for adults and children over 6 years of age.
Souvenaid® is a new approach in medical nutrition for people with early Alzheimer’s disease. It provides a unique combination of nutrients designed to support brain connections. Souvenaid is a convenient once-daily drink, available in three flavours: vanilla, strawberry, cappuccino.
- Omega 3 DHA and EPA
- Uridine monophosphate
- B‐vitamins and other co‐factors
Souvenaid is a food for special medical purposes for the dietary management of early Alzheimer’s and must be used under medical supervision.
For more detailed product information, please visit souvenaid.nutricia.com.
http://primalendurance.libsyn.com/ ketogenic podcast
Few things have been debated as much as “carbohydrates vs fat.”
Some believe that increased fat in the diet is a leading cause of all kinds of health problems, especially heart disease.
This is the position maintained by most mainstream health organizations.
These organizations generally recommend that people restrict dietary fat to less than 30% of total calories (a low-fat diet).
However… in the past 11 years, an increasing number of studies have been challenging the low-fat dietary approach.
Many health professionals now believe that a low-carb diet (higher in fat and protein) is a much better option to treat obesity and other chronic, Western diseases.
In this article, I have analyzed the data from 23 of these studies comparing low-carb and low-fat diets.
All of the studies are randomized controlled trials, the gold standard of science. All are published in respected, peer-reviewed journals.
Most of the studies are being conducted on people with health problems, including overweight/obesity, type II diabetes and metabolic syndrome.
Keep in mind that these are the biggest health problems in the world.
The main outcomes measured are usually weight loss, as well as common risk factors like Total Cholesterol, LDL Cholesterol, HDL Cholesterol, Triglycerides and Blood Sugar levels.
1.Foster GD, et al. A randomized trial of a low-carbohydrate diet for obesity. New England Journal of Medicine, 2003.
Details: 63 individuals were randomized to either a low-fat diet group, or a low-carb diet group. The low-fat group was calorie restricted. This study went on for 12 months.
Weight Loss: The low-carb group lost more weight, 7.3% of total body weight, compared to the low-fat group, which lost 4.5%. The difference was statistically significant at 3 and 6 months, but not 12 months.
Conclusion: There was more weight loss in the low-carb group, significant at 3 and 6 months, but not 12. The low-carb group had greater improvements in blood triglycerides and HDL, but other biomarkers were similar between groups.
- Samaha FF, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity.New England Journal of Medicine, 2003.
Details: 132 individuals with severe obesity (mean BMI of 43) were randomized to either a low-fat or a low-carb diet. Many of the subjects had metabolic syndrome or type II diabetes. The low-fat dieters were calorie restricted. Study duration was 6 months.
Weight Loss: The low-carb group lost an average of 5.8 kg (12.8 lbs) while the low-fat group lost only 1.9 kg (4.2 lbs). The difference was statistically significant.
Conclusion: The low-carb group lost significantly more weight (about 3 times as much). There was also a statistically significant difference in several biomarkers:
- Triglycerideswent down by 38 mg/dL in the LC group, compared to 7 mg/dL in the LF group.
- Insulin sensitivityimproved on LC, got slightly worse on LF.
- Fasting blood glucoselevels went down by 26 mg/dL in the LC group, only 5 mg/dL in the LF group.
- Insulinlevels went down by 27% in the LC group, but increased slightly in the LF group.
Overall, the low-carb diet had significantly more beneficial effects on weight and key biomarkers in this group of severely obese individuals.
- Sondike SB, et al. Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents.The Journal of Pediatrics, 2003.
Details: 30 overweight adolescents were randomized to two groups, a low-carb diet group and a low-fat diet group. This study went on for 12 weeks. Neither group was instructed to restrict calories.
Weight Loss: The low-carb group lost 9.9 kg (21.8 lbs), while the low-fat group lost 4.1 kg (9 lbs). The difference was statistically significant.
Conclusion: The low-carb group lost significantly more (2.3 times as much) weight and had significant decreases in Triglycerides and Non-HDL cholesterol. Total and LDL cholesterol decreased in the low-fat group only.
- Brehm BJ, et al. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women.The Journal of Clinical Endocrinology & Metabolism, 2003.
Details: 53 healthy but obese females were randomized to either a low-fat diet, or a low-carb diet. Low-fat group was calorie restricted. The study went on for 6 months.
Weight Loss: The women in the low-carb group lost an average og 8.5 kg (18.7 lbs), while the low-fat group lost an average of 3.9 kg (8.6 lbs). The difference was statistically significant at 6 months.
Conclusion: The low-carb group lost more weight (2.2 times as much) and had significant reductions in blood triglycerides. HDL improved slightly in both groups.
- Aude YW, et al. The national cholesterol education program diet vs a diet lower in carbohydrates and higher in protein and monounsaturated fat.Archives of Internal Medicine, 2004.
Details: 60 overweight individuals were randomized to a low-carb diet high in monounsaturated fat, or a low-fat diet based on the National Cholesterol Education Program (NCEP).
Both groups were calorie restricted and the study went on for 12 weeks.
Weight Loss: The low-carb group lost an average of 6.2 kg (13.6 lbs), while the low-fat group lost 3.4 kg (7.5 lbs). The difference was statistically significant.
Conclusion: The low-carb group lost 1.8 times as much weight. There were also several changes in biomarkers that are worth noting:
- Waist-to-hip ratiois a marker for abdominal fat. This marker improved slightly in the LC group, not in the LF group.
- Total cholesterolimproved in both groups.
- Triglycerideswent down by 42 mg/dL in the LC group, compared to 15.3 mg/dL in the LF group.
- LDL particle sizeincreased by 4.8 nm and percentage of small, dense LDL decreased by 6.1% in the LC group, while there was no significant difference in the LF group.
Overall, the low-carb group lost more weight and had much greater improvements in several important risk factors for cardiovascular disease.
- Yancy WS Jr, et al. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia.Annals of Internal Medicine, 2004.
Details: 120 overweight individuals with elevated blood lipids were randomized to a low-carb or a low-fat diet. The low-fat group was calorie restricted. Study went on for 24 weeks.
Weight Loss: The low-carb group lost 9.4 kg (20.7 lbs) of their total body weight, compared to 4.8 kg (10.6 lbs) in the low-fat group.
Conclusion: The low-carb group lost significantly more weight and had greater improvements in blood triglycerides and HDL cholesterol.
- JS Volek, et al. Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women.Nutrition & Metabolism (London), 2004.
Details: A randomized, crossover trial with 28 overweight/obese individuals. Study went on for 30 days (for women) and 50 days (for men) on each diet, that is a very low-carb diet and a low-fat diet. Both diets were calorie restricted.
Weight Loss: The low-carb group lost significantly more weight, especially the men. This was despite the fact that they ended up eating more calories than the low-fat group.
Conclusion: The low-carb group lost more weight. The men on the low-carb diet lost three times as much abdominal fat as the men on the low-fat diet.
- Meckling KA, et al. Comparison of a low-fat diet to a low-carbohydrate diet on weight loss, body composition, and risk factors for diabetes and cardiovascular disease in free-living, overweight men and women.The Journal of Clinical Endocrinology & Metabolism, 2004.
Details: 40 overweight individuals were randomized to a low-carb and a low-fat diet for 10 weeks. The calories were matched between groups.
Weight Loss: The low-carb group lost 7.0 kg (15.4 lbs) and the low-fat group lost 6.8 kg (14.9 lbs). The difference was not statistically significant.
Conclusion: Both groups lost a similar amount of weight.
A few other notable differences in biomarkers:
- Blood pressuredecreased in both groups, both systolic and diastolic.
- Total and LDL cholesteroldecreased in the LF group only.
- Triglyceridesdecreased in both groups.
- HDL cholesterolwent up in the LC group, but decreased in the LF group.
- Blood sugarwent down in both groups, but only the LC group had decreases in insulin levels, indicating improved insulin sensitivity.
- Nickols-Richardson SM, et al. Perceived hunger is lower and weight loss is greater in overweight premenopausal women consuming a low-carbohydrate/high-protein vs high-carbohydrate/low-fat diet.Journal of the American Dietetic Association, 2005.
Details: 28 overweight premenopausal women consumed either a low-carb or a low-fat diet for 6 weeks. The low-fat group was calorie restricted.
Weight Loss: The women in the low-carb group lost 6.4 kg (14.1 lbs) compared to the low-fat group, which lost 4.2 kg (9.3 lbs). The results were statistically significant.
Conclusion: The low-carb diet caused significantly more weight loss and reduced hunger compared to the low-fat diet.
- Daly ME, et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes.Diabetic Medicine, 2006.
Details: 102 patients with Type 2 diabetes were randomized to a low-carb or a low-fat diet for 3 months. The low-fat group was instructed to reduce portion sizes.
Weight Loss: The low-carb group lost 3.55 kg (7.8 lbs), while the low-fat group lost only 0.92 kg (2 lbs). The difference was statistically significant.
Conclusion: The low-carb group lost more weight and had greater improvements in the Total cholesterol/HDL ratio. There was no difference in triglycerides, blood pressure or HbA1c (a marker for blood sugar levels) between groups.
- McClernon FJ, et al. The effects of a low-carbohydrate ketogenic diet and a low-fat diet on mood, hunger, and other self-reported symptoms.Obesity (Silver Spring), 2007.
Details: 119 overweight individuals were randomized to a low-carb, ketogenic diet or a calorie restricted low-fat diet for 6 months.
Weight Loss: The low-carb group lost 12.9 kg (28.4 lbs), while the low-fat group lost only 6.7 kg (14.7 lbs).
Conclusion: The low-carb group lost almost twice the weight and experienced less hunger.
- Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study.The Journal of The American Medical Association, 2007.
Details: 311 overweight/obese premenopausal women were randomized to 4 diets: A low-carb Atkins diet, a low-fat vegetarian Ornish diet, the Zone diet and the LEARN diet. Zone and LEARN were calorie restricted.
Weight Loss: The Atkins group lost the most weight at 12 months (4.7 kg – 10.3 lbs) compared to Ornish (2.2 kg – 4.9 lbs), Zone (1.6 kg – 3.5 lbs) and LEARN (2.6 kg – 5.7 lbs). However, the difference was not statistically significant at 12 months.
Conclusion: The Atkins group lost the most weight, although the difference was not statistically significant. The Atkins group had the greatest improvements in blood pressure, triglycerides and HDL. LEARN and Ornish (low-fat) had decreases in LDL at 2 months, but then the effects diminished.
This study was covered in detail here.
- Halyburton AK, et al. Low- and high-carbohydrate weight-loss diets have similar effects on mood but not cognitive performance.American Journal of Clinical Nutrition, 2007.
Details: 93 overweight/obese individuals were randomized to either a low-carb, high-fat diet or a low-fat, high-carb diet for 8 weeks. Both groups were calorie restricted.
Weight Loss: The low-carb group lost 7.8 kg (17.2 lbs), while the low-fat group lost 6.4 kg (14.1 lbs). The difference was statistically significant.
Conclusion: The low-carb group lost more weight. Both groups had similar improvements in mood, but speed of processing (a measure of cognitive performance) improved further on the low-fat diet.
- Dyson PA, et al. A low-carbohydrate diet is more effective in reducing body weight than healthy eating in both diabetic and non-diabetic subjects.Diabetic Medicine, 2007.
Details: 13 diabetic and 13 non-diabetic individuals were randomized to a low-carb diet or a “healthy eating” diet that followed the Diabetes UK recommendations (a calorie restricted, low-fat diet). Study went on for 3 months.
Weight Loss: The low-carb group lost 6.9 kg (15.2 lbs), compared to 2.1 kg (4.6 lbs) in the low-fat group.
Conclusion: The low-carb group lost more weight (about 3 times as much). There was no difference in any other marker between groups.
- Westman EC, et al. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus.Nutrion & Metabolism (London), 2008.
Details: 84 individuals with obesity and type 2 diabetes were randomized to a low-carb, ketogenic diet or a calorie restricted low-glycemic diet. The study went on for 24 weeks.
Weight Loss: The low-carb group lost more weight (11.1 kg – 24.4 lbs) compared to the low-glycemic group (6.9 kg – 15.2 lbs).
Conclusion: The low-carb group lost significantly more weight than the low-glycemic group. There were several other important differences:
- Hemoglobin A1cwent down by 1.5% in the LC group, compared to 0.5% in the low-glycemic group.
- HDL cholesterolincreased in the LC group only, by 5.6 mg/dL.
- Diabetes medicationswere either reduced or eliminated in 95.2% of the LC group, compared to 62% in the low-glycemic group.
- Many other health markers like blood pressure and triglycerides improved in both groups, but the difference between groups was not statistically significant.
- Shai I, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet.New England Journal of Medicine, 2008.
Details: 322 obese individuals were randomized to three diets: a low-carb diet, a calorie restricted low-fat diet and a calorie restricted Mediterranean diet. Study went on for 2 years.
Weight Loss: The low-carb group lost 4.7 kg (10.4 lbs), the low-fat group lost 2.9 kg (6.4 lbs) and the Mediterranean diet group lost 4.4 kg (9.7 lbs).
Conclusion: The low-carb group lost more weight than the low-fat group and had greater improvements in HDL cholesterol and triglycerides.
- Keogh JB, et al. Effects of weight loss from a very-low-carbohydrate diet on endothelial function and markers of cardiovascular disease risk in subjects with abdominal obesity.American Journal of Clinical Nutrition, 2008.
Details: 107 individuals with abdominal obesity were randomized to a low-carb or a low-fat diet. Both groups were calorie restricted and the study went on for 8 weeks.
Weight Loss: The low-carb group lost 7.9% of body weight, compared to the low-fat group which lost 6.5% of body weight.
Conclusion: The low-carb group lost more weight and there was no difference between groups on Flow Mediated Dilation or any other markers of the function of the endothelium (the lining of blood vessels). There was also no difference in common risk factors between groups.
- Tay J, et al. Metabolic effects of weight loss on a very-low-carbohydrate diet compared with an isocaloric high-carbohydrate diet in abdominally obese subjects.Journal of The American College of Cardiology, 2008.
Details: 88 individuals with abdominal obesity were randomized to a very low-carb or a low-fat diet for 24 weeks. Both diets were calorie restricted.
Weight Loss: The low-carb group lost an average of 11.9 kg (26.2 lbs), while the low-fat group lost 10.1 kg (22.3 lbs). However, the difference was not statistically significant.
Conclusion: The low-carb group lost more weight. Triglycerides, HDL, C-Reactive Protein, Insulin, Insulin Sensitivity and Blood Pressure improved in both groups. Total and LDL cholesterol improved in the low-fat group only.
- Volek JS, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet.Lipids, 2009.
Details: 40 subjects with elevated risk factors for cardiovascular disease were randomized to a low-carb or a low-fat diet for 12 weeks. Both groups were calorie restricted.
Weight Loss: The low-carb group lost 10.1 kg (22.3), while the low-fat group lost 5.2 kg (11.5 lbs).
Conclusion: The low-carb group lost almost twice the amount of weight as the low-fat group, despite eating the same amount of calories.
This study is particularly interesting because it matched calories between groups and measured so-called “advanced” lipid markers. Several things are worth noting:
- Triglycerideswent down by 107 mg/dL on LC, but 36 mg/dL on the LF diet.
- HDL cholesterolincreased by 4 mg/dL on LC, but went down by 1 mg/dL on LF.
- Apolipoprotein Bwent down by 11 points on LC, but only 2 points on LF.
- LDL sizeincreased on LC, but stayed the same on LF.
- On the LC diet, the LDL particles partly shifted from small to large (good), while they partly shifted from large to small on LF (bad).
- Brinkworth GD, et al. Long-term effects of a very-low-carbohydrate weight loss diet compared with an isocaloric low-fat diet after 12 months.American Journal of Clinical Nutrition, 2009.
Details: 118 individuals with abdominal obesity were randomized to a low-carb or a low-fat diet for 1 year. Both diets were calorie restricted.
Weight Loss: The low-carb group lost 14.5 kg (32 lbs), while the low-fat group lost 11.5 kg (25.3 lbs) but the difference was not statistically significant.
Conclusion: The low-carb group had greater decreases in triglycerides and greater increases in both HDL and LDL cholesterol, compared to the low-fat group.
- Hernandez, et al. Lack of suppression of circulating free fatty acids and hypercholesterolemia during weight loss on a high-fat, low-carbohydrate diet.American Journal of Clinical Nutrition, 2010.
Details: 32 obese adults were randomized to a low-carb or a calorie restricted, low-fat diet for 6 weeks.
Weight Loss: The low-carb group lost 6.2 kg (13.7 lbs) while the low-fat group lost 6.0 kg (13.2 lbs). The difference was not statistically significant.
Conclusion: The low-carb group had greater decreases in triglycerides (43.6 mg/dL) than the low-fat group (26.9 mg/dL). Both LDL and HDL decreased in the low-fat group only.
- Krebs NF, et al. Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents.Journal of Pediatrics, 2010.
Details: 46 individuals were randomized to a low-carb or a low-fat diet for 36 weeks. Low-fat group was calorie restricted.
Weight Loss: The low-carb group lost more weight and had greater decreases in BMI than the low-fat group.
Conclusion: The low-carb group had greater reductions in BMI. Various biomarkers improved in both groups, but there was no significant difference between groups.
- Guldbrand, et al. In type 2 diabetes, randomization to advice to follow a low-carbohydrate diet transiently improves glycaemic control compared with advice to follow a low-fat diet producing a similar weight loss.Diabetologia, 2012.
Details: 61 individuals with type 2 diabetes were randomized to a low-carb or a low-fat diet for 2 years. Both diets were calorie restricted.
Weight Loss: The low-carb group lost 3.1 kg (6.8 lbs), while the low-fat group lost 3.6 kg (7.9 lbs). The difference was not statistically significant.
Conclusion: There was no difference in weight loss or common risk factors between groups. There was significant improvement in glycemic control at 6 months for the low-carb group, but compliance was poor and the effects diminished at 24 months as individuals had increased their carb intake.
Here is a graph that shows the difference in weight loss between studies. 21 of 23 studies reported weight loss numbers:
The majority of studies achieved statistically significant differences in weight loss (always in favor of low-carb). There are several other factors that are worth noting:
- The low-carb groups often lost 2-3 times as much weight as the low-fat groups. In a few instances there was no significant difference.
- In most cases, calories were restricted in the low-fat groups, while the low-carb groups could eat as much as they wanted.
- When both groups restricted calories, the low-carb dieters still lost more weight (7, 13, 19), although it was not always significant (8, 18, 20).
- There was only one study where the low-fat group lost more weight (23) although the difference was small (0.5 kg – 1.1 lb) and not statistically significant.
- In several of the studies, weight loss was greatest in the beginning. Then people start regaining the weight over time as they abandon the diet.
- When the researchers looked at abdominal fat (the unhealthy visceral fat) directly, low-carb diets had a clear advantage (5, 7, 19).
Two of the main reasons why low-carb diets are so effective for weight loss are the high protein content, as well as the appetite-suppressing effects of the diet. This leads to an automatic reduction in calorie intake.
You can read more about why this diet works here: Why do Low Carb Diets Work? The Mechanism Explained
Despite the concerns expressed by many people, low-carb diets generally do not raise Total and LDL cholesterol levels on average.
Low-fat diets do lower Total and LDL cholesterol, but it is usually only temporary. After 6 to 12 months, the difference is not statistically significant.
There have been some anecdotal reports by doctors who treat patients with low-carb diets, that they can lead to increases in LDL cholesterol and some advanced lipid markers for a small percentage of individuals.
One of the best ways to raise HDL cholesterol levels is to eat more fat. For this reason, it is not surprising to see that low-carb diets (higher in fat) raise HDL significantly more than low-fat diets.
Having higher HDL levels is correlated with improved metabolic health and a lower risk of cardiovascular disease. Having low HDL levels is one of the key symptoms of the metabolic syndrome.
18 of the 23 studies reported changes in HDL cholesterol levels:
You can see that low-carb diets generally raise HDL levels, while they don’t change as much on low-fat diets and in some cases go down.
Triglycerides are an important cardiovascular risk factor and another key symptom of the metabolic syndrome.
The best way to reduce triglycerides is to eat less carbohydrates, especially sugar.
19 of 23 studies reported changes in blood triglyceride levels:
It is clear that both low-carb and low-fat diets lead to reductions in triglycerides, but the effect is much stronger in the low-carb groups.
Blood Sugar, Insulin Levels and Type II Diabetes
In non-diabetics, blood sugar and insulin levels improved on both low-carb and low-fat diets and the difference between groups was usually small.
3 studies compared low-carb and low-fat diets in Type 2 diabetic patients.
Only one of those studies had good compliance and managed to reduce carbohydrates sufficiently. This lead various improvements and a drastic reduction in HbA1c, a marker for blood sugar levels (15).
In this study, over 90% of the individuals in the low-carb group managed to reduce or eliminate their diabetes medications.
When measured, blood pressure tended to decrease on both low-carb and low-fat diets.
How Many People Made it to The End?
A common problem in weight loss studies is that many people abandon the diet and drop out of the studies before they are completed.
I did an analysis of the percentage of people who made it to the end of the study in each group. 19 of the 23 studies reported this number:
The average percentage of people who made it to the end of the studies were:
Average for the low-carb groups: 79,51%
Average for the low-fat groups: 77,72%
Not a major difference, but it seems clear from these studies that low-carb diets are at the very least NOT harder to stick to than other diets.
This is an important point, because low-fat diets are usually calorie restricted and require people to weigh their food and count calories.
Individuals also lose more weight, faster, on low-carb. This may improve motivation to continue on the diet.
Despite the concerns expressed by many health experts in the past, there were zero reports of serious adverse effects that were attributable to either diet.
Overall, the low-carb diet was well tolerated and had an outstanding safety profile.
It is Time to Retire The Fad
Keep in mind that all of these studies are randomized controlled trials, the gold standard of science. All are published in respected, peer-reviewed medical journals.
These studies are scientific evidence, as good as it gets, that low-carb is much more effective than the low-fat diet that is still being recommended all over the world.
It is time to retire the low-fat fad!
The ketogenic diet is a low-carb, high-fat diet that offers many health benefits.
This article is a detailed beginner’s guide to the ketogenic diet.
It contains everything you need to know.
What is a Ketogenic Diet?
Bottom Line: The ketogenic diet (keto) is a low-carb, high-fat diet. It lowers blood sugar and insulin levels, and shifts the body’s metabolism away from carbs and towards fat and ketones.
Different Types of Ketogenic Diets
There are several versions of the ketogenic diet, including:
- Standard ketogenic diet (SKD):This is a very low-carb, moderate-protein and high-fat diet. It typically contains 75% fat, 20% protein and only 5% carbs (1).
- Cyclical ketogenic diet (CKD):This diet involves periods of higher-carb refeeds, such as 5 ketogenic days followed by 2 high-carb days.
- Targeted ketogenic diet (TKD):This diet allows you to add carbs around workouts.
- High-protein ketogenic diet:This is similar to a standard ketogenic diet, but includes more protein. The ratio is often 60% fat, 35% protein and 5% carbs.
However, only the standard and high-protein ketogenic diets have been studied extensively. Cyclical or targeted ketogenic diets are more advanced methods, and primarily used by bodybuilders or athletes.
The information in this article mostly applies to the standard ketogenic diet (SKD), although many of the same principles also apply to the other versions.
Bottom Line: There are several versions of the ketogenic diet. The standard ketogenic diet (SKD) is the most researched and most recommended.
Ketogenic Diets Can Help You Lose Weight
One study found that people on a ketogenic diet lost 2.2 times more weight than those on a calorie-restricted low-fat diet. Triglyceride and HDL cholesterol levels also improved (17).
Another study found that participants on the ketogenic diet lost 3 times more weight than those on the Diabetes UK’s recommended diet (18).
For more details on the weight loss effects of a ketogenic diet, read this article: A Ketogenic Diet to Lose Weight and Fight Disease.
Bottom Line: A ketogenic diet can help you lose much more weight than a low-fat diet. This often happens without hunger.
Ketogenic Diets for Diabetes and Prediabetes
Diabetes is characterized by changes in metabolism, high blood sugar and impaired insulin function (27).
One study found that the ketogenic diet improved insulin sensitivity by a whopping 75% (29).
Another study in patients with type 2 diabetes found that 7 of the 21 participants were able to stop all diabetes medications (28).
In yet another study, the ketogenic group lost 24.4 lbs (11.1 kg), compared to 15.2 lbs (6.9 kg) in the higher-carb group. This is an important benefit when considering the link between weight and type 2 diabetes (2, 31).
Additionally, 95.2% of the ketogenic group was also able to stop or reduce diabetes medication, compared to 62% in the higher-carb group (2).
This article has more details about low-carb diets and diabetes.
Bottom Line: The ketogenic diet can boost insulin sensitivity and cause fat loss, leading to drastic improvement for type 2 diabetes and prediabetes.
Other Health Benefits of the Ketogenic Diet
The ketogenic diet actually originated as a tool for treating neurological diseases, such as epilepsy.
Studies have now shown that the diet can have benefits for a wide variety of different health conditions:
- Heart disease:The ketogenic diet can improve risk factors like body fat, HDL levels, blood pressure and blood sugar (32, 33).
- Cancer:The diet is currently being used to treat several types of cancer and slow tumor growth (4, 34, 35, 36).
- Alzheimer’s disease:The diet may reduce symptoms of Alzheimer’s and slow down the disease’s progression (5, 37, 38).
- Epilepsy:Research has shown that the ketogenic diet can cause massive reductions in seizures in epileptic children (3).
- Parkinson’s disease:One study found that the diet helped improve symptoms of Parkinson’s disease (39).
- Polycystic ovary syndrome:The ketogenic diet can help reduce insulin levels, which may play a key role in polycystic ovary syndrome (40).
- Brain injuries:One animal study found that the diet can reduce concussions and aid recovery after brain injury (41).
- Acne:Lower insulin levels and eating less sugar or processed foods may help improve acne (42).
However, keep in mind that research into many of these areas is far from conclusive.
Bottom Line: A ketogenic diet may provide many health benefits, especially with metabolic, neurological or insulin-related diseases.
Foods to Avoid
In short, any food that is high in carbs should be limited.
Here is a list of foods that need to be reduced or eliminated on a ketogenic diet:
- Sugary foods:Soda, fruit juice, smoothies, cake, ice cream, candy, etc.
- Grains or starches:Wheat-based products, rice, pasta, cereal, etc.
- Fruit:All fruit, except small portions of berries like strawberries.
- Beans or legumes:Peas, kidney beans, lentils, chickpeas, etc.
- Root vegetables and tubers:Potatoes, sweet potatoes, carrots, parsnips, etc.
- Low-fat or diet products:These are highly processed and often high in carbs.
- Some condiments or sauces:These often contain sugar and unhealthy fat.
- Unhealthy fat:Limit your intake of processed vegetable oils, mayonnaise, etc.
- Alcohol:Due to its carb content, many alcoholic beverages can throw you out of ketosis.
- Sugar-free diet foods:These are often high in sugar alcohols, which can affect ketone levels in some cases. These foods also tend to be highly processed.
Bottom Line: Avoid carb-based foods like grains, sugars, legumes, rice, potatoes, candy, juice and even most fruits.
Foods to Eat
You should base the majority of your meals around these foods:
- Meat:Red meat, steak, ham, sausage, bacon, chicken and turkey.
- Fatty fish:Such as salmon, trout, tuna and mackerel.
- Eggs:Look for pastured or omega-3 whole eggs.
- Butter and cream:Look for grass-fed when possible.
- Cheese:Unprocessed cheese (cheddar, goat, cream, blue or mozzarella).
- Nuts and seeds:Almonds, walnuts, flaxseeds, pumpkin seeds, chia seeds, etc.
- Healthy oils:Primarily extra virgin olive oil, coconut oil and avocado oil.
- Avocados:Whole avocados or freshly made guacamole.
- Low-carb veggies:Most green veggies, tomatoes, onions, peppers, etc.
- Condiments:You can use salt, pepper and various healthy herbs and spices.
It is best to base your diet mostly on whole, single ingredient foods. Here is a list of 44 healthy low-carb foods.
Bottom Line: Base the majority of your diet on foods such as meat, fish, eggs, butter, nuts, healthy oils, avocados and plenty of low-carb veggies.
A Sample Ketogenic Meal Plan For 1 Week
To help get you started, here is a sample ketogenic diet meal plan for one week:
- Breakfast:Bacon, eggs and tomatoes.
- Lunch:Chicken salad with olive oil and feta cheese.
- Dinner:Salmon with asparagus cooked in butter.
- Breakfast:Egg, tomato, basil and goat cheese omelet.
- Lunch:Almond milk, peanut butter, cocoa powder and stevia
- Dinner:Meatballs, cheddar cheese and vegetables.
- Breakfast:A ketogenic milkshake (try this or this).
- Lunch:Shrimp salad with olive oil and avocado.
- Dinner:Pork chops with Parmesan cheese, broccoli and salad.
- Breakfast:Omelet with avocado, salsa, peppers, onion and spices.
- Lunch:A handful of nuts and celery sticks with guacamole and salsa.
- Dinner:Chicken stuffed with pesto and cream cheese, along with vegetables.
- Breakfast:Sugar-free yogurt with peanut butter, cocoa powder and stevia.
- Lunch:Beef stir-fry cooked in coconut oil with vegetables.
- Dinner:Bun-less burger with bacon, egg and cheese.
- Breakfast:Ham and cheese omelet with vegetables.
- Lunch:Ham and cheese slices with nuts.
- Dinner:White fish, egg and spinach cooked in coconut oil.
- Breakfast:Fried eggs with bacon and mushrooms.
- Lunch:Burger with salsa, cheese and guacamole.
- Dinner:Steak and eggs with a side salad.
Always try to rotate the vegetables and meat over the long term, as each type provides different nutrients and health benefits.
For tons of recipes, check out this link: 101 Healthy Low-Carb Recipes.
Bottom Line: You can eat a wide variety of tasty and nutritious meals on a ketogenic diet.
Healthy Ketogenic Snacks
In case you get hungry between meals, here are some healthy, keto-approved snacks:
- Fatty meat or fish.
- A handful of nuts or seeds.
- Cheese witholives.
- 1–2 hard-boiled eggs.
- 90%dark chocolate.
- A low-carb milk shake with almond milk, cocoa powder and nut butter.
- Full-fat yogurt mixed with nut butter and cocoa powder.
- Strawberries and cream.
- Celery with salsa and guacamole.
- Smaller portions of leftover meals.
Bottom Line: Great snacks for a keto diet include pieces of meat, cheese, olives, boiled eggs, nuts and dark chocolate.
Tips for Eating Out on a Ketogenic Diet
It is not very hard to make most restaurant meals keto-friendly when eating out.
Most restaurants offer some kind of meat or fish-based dish. Order this, and replace any high-carb food with extra vegetables.
Egg-based meals are also a great option, such as an omelet or eggs and bacon.
Another favorite is bun-less burgers. You could also leave the bun and swap the fries for vegetables instead. Add extra avocado, cheese, bacon or eggs.
At Mexican restaurants, you can enjoy any type of meat with extra cheese, guacamole, salsa and sour cream.
For dessert, ask for a mixed cheese board or double cream with berries.
Bottom Line: When eating out, select a meat, fish or egg-based dish. Order extra veggies instead of carbs or starches, and have cheese for dessert.
Side Effects and How to Minimize Them
Although the ketogenic diet is safe for healthy people, there may be some initial side effects while your body adapts.
This is often referred to as “keto flu” – and is usually over within a few days.
Keto flu includes poor energy and mental function, increased hunger, sleep issues, nausea, digestive discomfort and decreased exercise performance.
In order to minimize this, you can try a regular low-carb diet for the first few weeks. This may teach your body to burn more fat before you completely eliminate carbs.
At least in the beginning, it is important to eat until fullness and to avoid restricting calories too much. Usually a ketogenic diet causes weight loss without intentional calorie restriction.
Bottom Line: Many of the side effects of starting a ketogenic diet can be limited. Easing into the diet and taking mineral supplements can help.
Supplements For a Ketogenic Diet
Although no supplement is necessary, some can be useful.
- MCT oil:Added to drinks or yogurt, MCT oil provides energy and helps increase ketone levels.
- Minerals:Added salt and other minerals can be important when starting out, due to shifts in water and mineral balance.
- Caffeine:Caffeine can have benefits for energy, fat loss and performance.
- Exogenous ketones:This supplement can help raise the body’s ketone levels.
- Creatine:Creatine provides numerous benefits for health and performance. This can help if you are combining a ketogenic diet with exercise.
- Whey:Use half a scoop of whey protein in shakes or yogurt to increase your daily protein intake.
Bottom Line: Certain supplements can be beneficial on a ketogenic diet. These include exogenous ketones, MCT oil and minerals.
Frequently Asked Questions
Here are answers to some of the most common questions about the ketogenic diet.
- Can I ever eat carbs again?
Yes. However, it is important to eliminate them initially. After the first 2–3 months, you can eat carbs on special occasions — just return to the diet immediately after.
- Will I lose muscle?
There is a risk of losing some muscle on any diet. However, the high protein intake and high ketone levels may help minimize muscle loss, especially if you lift weights.
- Can you build muscle on a ketogenic diet?
Yes, but it may not work as well as on a moderate-carb diet. More details: Low-Carb/Ketogenic Diets and Exercise Performance.
- Do I need to refeed or carb load?
No. However, a few higher-calorie days may be beneficial every now and then.
- How much protein can I eat?
Protein should be moderate, as a very high intake can spike insulin levels and lower ketones. Around 35% of total calorie intake is probably the upper limit.
- What if I am constantly tired, weak or fatigued?
You may not be in full ketosis or be utilizing fats and ketones efficiently. To counter this, lower your carb intake and re-visit the points above. A supplement like MCT oil or ketones may also help.
- My urine smells fruity? Why is this?
Don’t be alarmed. This is simply due to the excretion of byproducts created during ketosis.
- My breath smells. What can I do?
This is a common side effect. Try drinking naturally flavored water or chewing sugar-free gum.
- I heard ketosis was extremely dangerous. Is this true?
People often confuse ketosis with ketoacidosis. The former is natural, while the latter only occurs in uncontrolled diabetes.
Ketoacidosis is dangerous, but the ketosis on a ketogenic diet is perfectly normal and healthy.
- I have digestion issues and diarrhea. What can I do?
This common side effect usually passes after 3–4 weeks. If it persists, try eating more high-fiber veggies. Magnesium supplements can also help with constipation.
A Ketogenic Diet is Great, But Not For Everyone
A ketogenic diet can be great for people who are overweight, diabetic or looking to improve their metabolic health.
It may be less suitable for elite athletes or those wishing to add large amounts of muscle or weight.
And, as with any diet, it will only work if you are consistent and stick with it in the long-term.
That being said, few things are as well proven in nutrition as the powerful health and weight loss benefits of a ketogenic diet.
More about the ketogenic diet:
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16 Foods to Eat on a Ketogenic Diet
January 23, 2017
The ketogenic diet has become quite popular recently.
There’s also early evidence to show that it may be beneficial for certain cancers, Alzheimer’s disease and other diseases, too.
A ketogenic diet typically limits carbs to 20–50 grams per day. While this may seem challenging, many nutritious foods can easily fit into this way of eating.
Here are 16 healthy foods to eat on a ketogenic diet.
However, the carbs in different types of shellfish vary. For instance, while shrimp and most crabs contain no carbs, other types of shellfish do (5).
While these shellfish can still be included on a ketogenic diet, it’s important to account for these carbs when you’re trying to stay within a narrow range.
- Clams:5 grams
- Mussels:7 grams
- Octopus:4 grams
- Oysters:4 grams
- Squid:3 grams
Aim to consume at least two servings of seafood weekly.
Summary: Many types of seafood are carb-free or very low in carbs. Fish and shellfish are also good sources of vitamins, minerals and omega-3s.
2. Low-Carb Vegetables
Non-starchy vegetables are low in calories and carbs, but high in many nutrients, including vitamin C and several minerals.
Vegetables and other plants contain fiber, which your body doesn’t digest and absorb like other carbs.
Therefore, look at their digestible (or net) carb count, which is total carbs minus fiber.
Most vegetables contain very few net carbs. However, consuming one serving of “starchy” vegetables like potatoes, yams or beets could put you over your entire carb limit for the day.
Low-carb veggies make great substitutes for higher-carb foods. For instance, cauliflower can be used to mimic rice or mashed potatoes, “zoodles” can be created from zucchini and spaghetti squash is a natural substitute for spaghetti.
Summary: The net carbs in non-starchy vegetables range from 1–8 grams per cup. Vegetables are nutritious, versatile and may help reduce the risk of disease.
Cheese is both nutritious and delicious.
There are hundreds of types of cheese. Fortunately, all of them are very low in carbs and high in fat, which makes them a great fit for a ketogenic diet.
One ounce (28 grams) of cheddar cheese provides 1 gram of carbs, 7 grams of protein and 20% of the RDI for calcium (20).
In addition, eating cheese regularly may help reduce the loss of muscle mass and strength that occurs with aging.
A 12-week study in older adults found that those who consumed 7 ounces (210 grams) of ricotta cheese per day experienced increases in muscle mass and muscle strength over the course of the study (24).
Summary: Cheese is rich in protein, calcium and beneficial fatty acids, yet contains a minimal amount of carbs.
Avocados are incredibly healthy.
3.5 ounces (100 grams), or about one-half of a medium avocado, contain 9 grams of carbs.
However, 7 of these are fiber, so its net carb count is only 2 grams (25).
Avocados are high in several vitamins and minerals, including potassium, an important mineral many people may not get enough of. What’s more, a higher potassium intake may help make the transition to a ketogenic diet easier (26, 27).
In addition, avocados may help improve cholesterol and triglyceride levels.
In one study, when people consumed a diet high in avocados, they experienced a 22% decrease in “bad” LDL cholesterol and triglycerides and an 11% increase in “good” HDL cholesterol (28).
Summary: Avocados contain 2 grams of net carbs per serving and are high in fiber and several nutrients, including potassium. In addition, they may improve heart health markers.
5. Meat and Poultry
Meat and poultry are considered staple foods on a ketogenic diet.
Fresh meat and poultry contain no carbs and are rich in B vitamins and several minerals, including potassium, selenium and zinc (29).
One study in older women found that consuming a diet high in fatty meat led to HDL cholesterol levels that were 8% higher than on a low-fat, high-carb diet (21).
It’s best to choose grass-fed meat, if possible. That’s because animals that eat grass produce meat with higher amounts of omega-3 fats, conjugated linoleic acid and antioxidants than meat from grain-fed animals (32).
Summary: Meat and poultry do not contain carbs and are rich in high-quality protein and several nutrients. Grass-fed meat is the healthiest choice.
Eggs are one of the healthiest and most versatile foods on the planet.
One large egg contains less than 1 gram of carbs and fewer than 6 grams of protein, making eggs an ideal food for a ketogenic lifestyle (33).
Although egg yolks are high in cholesterol, consuming them doesn’t raise blood cholesterol levels in most people. In fact, eggs appear to modify the shape of LDL in a way that reduces the risk of heart disease (37).
Summary: Eggs contain less than 1 gram of carbs each and can help keep you full for hours. They’re also high in several nutrients and may help protect eye and heart health.
7. Coconut Oil
Coconut oil has unique properties that make it well suited for a ketogenic diet.
To begin with, it contains medium-chain triglycerides (MCTs). Unlike long-chain fats, MCTs are taken up directly by the liver and converted into ketones or used as a rapid source of energy.
In fact, coconut oil has been used to increase ketone levels in people with Alzheimer’s disease and other disorders of the brain and nervous system (38).
What’s more, coconut oil may help obese adults lose weight and belly fat. In one study, men who ate 2 tablespoons (30 ml) of coconut oil per day lost 1 inch (2.5 cm), on average, from their waistlines without making any other dietary changes (41, 42).
For more information about how to add coconut oil to your diet, read this article.
Summary: Coconut oil is rich in MCTs, which can increase ketone production. In addition, it may increase metabolic rate and promote the loss of weight and belly fat.
8. Plain Greek Yogurt and Cottage Cheese
Plain Greek yogurt and cottage cheese are healthy, high-protein foods.
While they contain some carbs, they can still be included in a ketogenic lifestyle.
Either one makes a tasty snack on its own.
However, both can also be combined with chopped nuts, cinnamon and optional sugar-free sweetener for a quick and easy keto treat.
Summary: Both plain Greek yogurt and cottage cheese contain 5 grams of carbs per serving. Studies have shown that they help reduce appetite and promote fullness.
9. Olive Oil
Olive oil provides impressive benefits for your heart.
As a pure fat source, olive oil contains no carbs. It’s an ideal base for salad dressings and healthy mayonnaise.
Because it isn’t as stable as saturated fats at high temperatures, it’s best to use olive oil for low-heat cooking or add it to foods after they have been cooked.
Summary: Extra-virgin olive oil is high in heart-healthy monounsaturated fats and antioxidants. It’s ideal for salad dressings, mayonnaise and adding to cooked foods.
10. Nuts and Seeds
Nuts and seeds are healthy, high-fat and low-carb foods.
Although all nuts and seeds are low in net carbs, the amount varies quite a bit among the different types.
- Almonds:3 grams net carbs (6 grams total carbs)
- Brazil nuts:1 gram net carbs (3 grams total carbs)
- Cashews:8 grams net carbs (9 grams total carbs)
- Macadamia nuts:2 grams net carbs (4 grams total carbs)
- Pecans:1 gram net carbs (4 grams total carbs)
- Pistachios:5 grams net carbs (8 grams total carbs)
- Walnuts:2 grams net carbs (4 grams total carbs)
- Chia seeds:1 gram net carbs (12 grams total carbs)
- Flaxseeds: 0 grams net carbs (8 grams total carbs)
- Pumpkin seeds:4 grams net carbs (5 grams total carbs)
- Sesame seeds:3 grams net carbs (7 grams total carbs)
Summary: Nuts and seeds are heart-healthy, high in fiber and may lead to healthier aging. They provide 0–8 grams of net carbs per ounce.
Berries are low in carbs and high in fiber.
In fact, raspberries and blackberries contain as much fiber as digestible carbs.
- Blackberries:5 grams net carbs (10 grams total carbs)
- Blueberries:12 grams net carbs (14 grams total carbs)
- Raspberries:6 grams net carbs (12 grams total carbs)
- Strawberries:6 grams net carbs (8 grams total carbs)
Summary: Berries are rich in nutrients that may reduce the risk of disease. They provide 5–12 grams of net carbs per 3.5-ounce serving.
12. Butter and Cream
Butter and cream are good fats to include on a ketogenic diet. Each contains only trace amounts of carbs per serving.
For many years, butter and cream were believed to cause or contribute to heart disease due to their high saturated fat contents. However, several large studies have shown that, for most people, saturated fat isn’t linked to heart disease.
Like other fatty dairy products, butter and cream are rich in conjugated linoleic acid, the fatty acid that may promote fat loss (23).
Summary: Butter and cream are nearly carb-free and appear to have neutral or beneficial effects on heart health, when consumed in moderation.
13. Shirataki Noodles
Shirataki noodles are a fantastic addition to a ketogenic diet.
They contain less than 1 gram of carbs and 5 calories per serving because they are mainly water.
Viscous fiber forms a gel that slows down food’s movement through your digestive tract. This can help decrease hunger and blood sugar spikes, making it beneficial for weight loss and diabetes management (76, 77, 78).
Shirataki noodles come in a variety of shapes, including rice, fettuccine and linguine. They can be substituted for regular noodles in all types of recipes.
Summary: Shirataki noodles contain less than 1 gram of carbs per serving. Their viscous fiber helps slow down the movement of food through your digestive tract, which promotes fullness and stable blood sugar levels.
Olives provide the same health benefits as olive oil, only in solid form.
Olives vary in carb content due to their size. However, half of their carbs come from fiber, so their digestible carb content is very low.
A one-ounce (28-gram) serving of olives contains 2 grams of total carbs and 1 gram of fiber. This works out to a net carb count of 1 gram for 7–10 olives, depending on their size (82).
Summary: Olives are rich in antioxidants that may help protect heart and bone health. They contain 1 gram of net carbs per ounce.
15. Unsweetened Coffee and Tea
Coffee and tea are incredibly healthy, carb-free drinks.
What’s more, coffee and tea drinkers have been shown to have a significantly reduced risk of diabetes. In fact, those with the highest coffee and tea intakes have the lowest risk of developing diabetes (86, 87).
Adding heavy cream to coffee or tea is fine, but stay away from “light” coffee and tea lattes. These are typically made with non-fat milk and contain high-carb flavorings.
Summary: Unsweetened coffee and tea contain no carbs and can help boost your metabolic rate, as well as physical and mental performance. They can also reduce your risk of diabetes.
16. Dark Chocolate and Cocoa Powder
Dark chocolate and cocoa are delicious sources of antioxidants.
In fact, cocoa has been called a “super fruit,” because it provides at least as much antioxidant activity as any other fruit, including blueberries and acai berries (88).
Somewhat surprisingly, chocolate can be part of a ketogenic diet. However, it’s important to choose dark chocolate that contains a minimum of 70% cocoa solids, preferably more.
Summary: Dark chocolate contains 3–10 grams of net carbs per ounce, is high in antioxidants and may help reduce the risk of heart disease.
The Bottom Line
A ketogenic diet can be used to achieve weight loss, blood sugar control and other health-related goals.
Fortunately, it can include a wide variety of nutritious, tasty and versatile foods that allow you to remain within your daily carb range.
To reap all the health benefits of a ketogenic diet, consume these 16 foods on a regular basis.
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