Fact sheetDiet specifications

Published on 1 Nov 2012


Ketogenic diet - classic and modified MCT

This document is part of the ACI Diet Specifications for Paediatric Inpatients. It is not to be used for patient education.

Aim

To provide a very high fat, very low carbohydrate (CHO) diet that is adequate in protein to assist in the management of seizures.

Characteristics

Very high fat, very low CHO diet that drives the body to produce ketones. CHO free fluids and low joule drinks are permitted. Protein is controlled at a level that is sufficient for growth, as determined by dietetic review. Ketogenic nutritional supplement may be given as a milk substitute or meal replacement. Each diet must be calculated and individualised for each patient. The diet may be started at 50% calories and increased gradually or may be introduced by a gradual increase in the percentage of energy provided by fat with a corresponding decrease in energy provided by CHO and protein. MCT oil fat supplement is given with every meal on the MCT ketogenic diet according to dietitian prescription.

Diet type % energy from fat % energy from protein % energy from CHO
Classic 90% 5-7% 3-5%
Modified MCT 40% MCT
40% LCT
As requirements Approx 10%

Indications

Used to help control refractory epilepsy.

Nutritional adequacy

Can be nutritionally adequate with the inclusion of a ketogenic nutrition supplement.

Precautions

Must only be initiated by a Neurologist and an experienced clinical dietitian. Must be planned individually with regards to protein, carbohydrate and fat requirements in accordance with medical therapy. It must be managed by an on-site clinical dietitian on a meal by meal basis. Any change to nutrient composition or menu substitutions may directly affect seizure control and medication requirements. Facility must be provided for meals to be prepared and plated in an on‑site kitchen according to the clinical dietitian’s instruction.

Important aspects to preparing the ketogenic diet:

  1. Prepare only the ingredients/foods that are specified in each menu.
  2. All ingredients/foods must be supplied and no substitutions are allowed.
  3. Weigh & check all foods precisely.
  4. Use a spatula to clean all fat ingredients from the cooking dish onto the plate.

Assessment and frequent review by a clinical dietitian is essential for all patients on this diet. Ongoing follow-up and comprehensive education of the patient and their family onto the ketogenic diet is vital and must be ensured before starting the diet. Serve sizes of fat, CHO and protein must be determined by the clinical dietitian. All items on meal tray must be individually weighed prior to plating and double checked by a dietary assistant or equivalent trained personnel. All items served must be eaten by patient and any wastage monitored and reported to dietitian and medical team.

Ongoing medical and clinical dietetic review and support is essential for patient safety.

Specific menu planning guidelines

(The clinical dietitian may override these guidelines at their discretion)

Allowed Not allowed
Hot main dishes

All. High fat preferable, such as fried and roast meats; creamy sauces. Protein and CHO content must be controlled, defined by individual requirements

None
Sauces, gravies

All. Extra serves available. CHO content must be counted

None
Starchy vegetables/pasta/rice

All. CHO content must be counted

None
Vegetables

Maximum ¾ cup per meal total of “free” vegetables: alfalfa, asparagus, beans, bok choy, broccoli, brussels sprouts, cabbage, capsicum, carrot, cauliflower, celery, cucumber, eggplant, leek, lettuce, mushrooms, onion, silverbeet, spinach, sprouts, squash, snow peas, tomato, zucchini, avocado (fat content must be counted)

All other veg allowed, but CHO must be counted

Serve with butter/margarine/cream/oil preferably

None
SoupsAll. Serve with cream/sour cream preferably
CHO content must be counted
None
Sandwiches

May request partial serves (e.g. ¼)

All. High fat spreads and fillings preferable

CHO content must be counted

None

Salads, dressings

Vinegar, oils, mayonnaise

All full fat salad dressings

Maximum ¾ cup of "free" vegetables

Low fat salad dressing (containing sugar)
Breads, cereals

All. CHO controlled

-
Spreads

Butter, margarine, Vegemite™, peanut butter

Extra serves butter/margarine available

Jam, honey
Hot breakfast choices

All. CHO content must be counted

None
Fruit

Fresh fruit, canned fruit drained, or in water
CHO content must be counted

Canned fruit in syrup, dried fruit

Yoghurt

Full fat yoghurt

Reduced fat yoghurt

Desserts

Diet jelly, full fat ice-cream, custard, all others

CHO content must be counted

Preferably serve with whipped/thin/double cream

Sugared jellies, ice blocks, sweetened toppings

Milk and cheese

Preferred milk option is milk substitute of
cream diluted to taste or ketogenic nutrition supplement

Full fat cheese

CHO content must be counted

Milk

Beverages

<0.3g CHO/100g for undiluted beverages

Low joule caffeine-free soft drinks and
cordials, water, bonox

Fruit juice, soft drinks and cordials containing
sugar, flavoured milks, drinks containing
caffeine
Biscuits

All, preferably high fat, or with high fat spread

CHO content must be counted

Restrict high sugar biscuits

Miscellaneous

Soy sauce

Tomato sauce/BBQ sauce (count CHO)

Salt, pepper, herbs, garlic, ginger

Whipped/thin cream/sour cream/double
heavy cream – extra serves available

Full fat mayonnaise. CHO content must be counted

Fat supplements (e.g. MCT or LCT)

Sugar-free lollies

Sugar, lollies, chocolate, glucose polymer

Standard nutritional supplement drinks

References

  1. Agency for Clinical Innovation. Nutrition standards for paediatric inpatients in NSW hospitals. Sydney 2011.
  2. Agency for Clinical Innovation. Nutrition standards for adult inpatients in NSW hospitals. Sydney 2011.
  3. Dietitians Association of Australia. 2009. Nutrition Manual 8th ed. Canberra: DAA.
  4. American Dietetic Association. Paediatric Nutrition Care Manual. Chicago: ADA.
  5. Freeman JM, Kossoff EH, Freeman JB, Kelly MT. (2006) The ketogenic diet: a treatment for epilepsy in children and others 4th ed. Demos, New York.
  6. Kossoff EH, Zupec-Kania BA, Amark PE, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R, Buchhalter JR, Caraballo RH, Helan Cross J, Dahlin MG, Donner EJ, Klepper J, Jehle RS, Kim HD, Christiana Liu YM, Nation J, Nordli DR Jr, Pfeifer HH, Rho JM, Stafstrom CE, Thiele EA, Turner Z, Wirrell EC, Wheless JW, Veggiotti P, Vining EP, Charlie Foundation, Practice Committee of the Child Neurology Society; International Ketogenic Diet Study Group. 2009. Optimal clinical management of children receiving the ketogenic diet: Recommendations of the International Ketogenic Diet Study Group. Epilepsia, 50 (2): 304-317.
  7. Shaw V and Lawson M. 2007. Clinical Paediatric Dietetics. 3rd Edition. Blackwell Publishing.
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