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Eating in Ratio (or not)

When it comes to proper ketogenic diet application for medical necessity, most families go one of two routes:




The Classic Ketogenic Diet (CKD) ratio is a 4:1, which means 4 parts fat to every 1 part carbohydrate/protein combination. When a child is first starting the diet, often he/she will start at 4:1 but then adjust as the weeks and months go on, depending on the proficiency of ketone production, acidity levels, etc.


The every day application of the diet is definitely made easier by a lower ratio. Children's Hospital Colorado ketogenic nutritionist, Stephanie Criteser, RD, CSP, CNSC, explains, "The lower the ratio, the more grams of carbohydrates from fruits, vegetables, and dairy are allowed, making it more palatable (or tastier). Side effects such as constipation, reflux, kidney stones, and decreased bone density can occur no matter what ratio the child is on. However, the side effect risk is decreased on lower ratios. Seizures can occur if the prescribed ratio is not followed. Therefore, it is important that the child eat all of the foods incorporated into each meal."


Every calorie and gram is measured and served in the prescribed ratio in order to maintain and maximize ketone (i.e. fuel) production. This means that the child must eat the entire serving altogether (hence the important need for a good spatula that will fit in their mouth). Sometimes it is a major challenge to get a child to eat every crumb--especially if he/she is transitioning to CKD from a normal diet. A "one-bite ratio" meal can be really helpful in this situation, as it aims for each bite to have the proper ratio (making it less important for the child to eat the entire portion). Find a few examples HERE.

The "every last drop" reality and specificity are the most important and most challenging aspects of successfully administering this diet. For example, fried shrimp from a restaurant might seem okay because it's high fat, right? Wrong. Because we don't know the amount of fat clinging to each morsel or how much breading is involved, we can't know the true ratio. That is why for most recipes, we start with "plain Jane" cooked food and add in the fat, seasoning, etc. at the end (on the scale).

It is important for care-givers to keep in mind, also, that the ratio is affected by not just ingested food, but also by what is absorbed into the skin (such as lotions, soaps, etc.).

Do not lose heart, though, dear caregiver. I assure you this can be done!


Here are some helpful tips:





The scale is not a necessity here. Not every bite has to be according to a ratio. Instead, carbs are limited to a certain number per day. For example, 10 year old Mark might only be able to eat 15 grams of carbs each day, but calories in general are not restricted. The diet is severely carb restricted with unlimited fat and unlimited protein. This follows a Modified Atkins Diet (MAD) approach and could possibly accommodate more everyday "Keto" products on shelves.

However, "it is important to note that "fad keto" products cannot and should not be trusted for their advertised Net Carbs, and the patient/family should always review and re-calculate the carb content based on the serving size described.  Based on my own random checking, many products are closer to a 1:1 (or less ratio)," explains Jennifer Oliver, MSN, CPNP, Ketogenic Diet APP at Children's Hospital in Colorado.

Criteser adds, "A net carbohydrate equals grams of total carbohydrate minus grams of dietary fiber. We do not subtract most sugar alcohols from the total carbohydrate. A lot of "fad keto" products do subtract sugar alcohols, which is why they can claim to have lower net carbs than the way we want our families on MAD to count net carbs."


Obviously, it is critical to consult your nearest specialized medical provider to learn which diet is best for you. Consider, also, that different programs can function in different ways. "For example," Criteser explains, "Some programs only initiate the ketogenic diet inpatient, while others only do outpatient initiations. Some are really strict on the personal care products list, vs our program that allows lotions, hair care, soaps, wipes to just be "fragrance-free". Some programs start/stay at a 4:1 ratio no matter what. Some programs (like ours) use seizure control/ketones, side effects, tolerance to help guide our ratio decision (if the child is receiving benefit on a lower ratio, this reduces the risk of side effects). These are just examples."

Which route your family chooses depends a lot on your child's medical condition and needs, which can even change over time.

Keto vs MAD Table image_edited.jpg
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