Ketogenic diet - modified Atkins

Aim

To provide a carbohydrate (CHO) controlled diet to assist in the management of seizures.

Characteristics

CHO is controlled using exchanges, which are weighed in grams or portion controlled. High fat, high protein foods are encouraged. Ketogenic nutritional supplement may be given as a milk substitute or meal replacement. CHO free fluids and low joule drinks are permitted. Each diet must be individualised for each patient. Compared with other ketogenic diets, menu items that do not contain significant amounts of CHO are likely to be expressed in serves rather than grams. Other items may be expressed in grams or partial serves (e.g. ½ fresh apple, 70g mashed potato). This diet is far less restrictive than the ketogenic – classic/MCT diet. The diet may be commenced with 10g per day of carbohydrate, increased to 15g per day at one month and then to 20-30g per day thereafter as tolerated or as determined by the clinical dietitian.

Diet type	% energy from fat	% energy from protein	% energy from CHO
Modified Atkins diet	Approx. 60%	Approx. 30%	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 under the supervision of a neurologist and experienced clinical dietitian. Must be planned individually and managed by an on-site clinical dietitian on a meal-by-meal basis. Any change to nutrient composition/food 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 dietitians’ instruction.

Assessment and frequent review by a dietitian is essential for all patients on this diet. Ongoing follow-up and comprehensive education of the patient and their family onto the Ketogenic Modified Atkins diet is important for its success. Menu serve sizes of CHO must be determined by the dietitian.

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. 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. 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" vegetable per meal	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, all others. CHO content must be counted 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	Reduced fat milk
Beverages	<0.3g CHO/100g Low joule caffeine-free soft drinks and cordials, water, bonox Ketogenic nutrition supplement	Fruit juice, soft drinks and cordials containing sugar, flavoured milks
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 Fat supplements (MCT, 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. Kossof, EH & Dorward JL The Modified Atkins Diet Epilepsia, 49 (suppl. 8): 37-41 2008.
8. Shaw V and Lawson M. 2007. Clinical Paediatric Dietetics. 3rd Edition. Blackwell Publishing.