Ketogenic diet - classic and modified MCT

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
Soups	All. 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.