Navigating Artificial Sweeteners on a Ketogenic Diet

Authors: Laura Dority, MS, RD, LD & Taylor Parrish, RDN, LD  

Editor: Amy Merwarth, RD, LD 

While a ketogenic diet can be a highly effective option for epilepsy, it also comes with challenges and nuances of adhering to this low-carbohydrate, high-fat dietary approach.  A common question that arises is the role of artificial and non-nutritive sweeteners which are often found in “keto-marketed” convenience foods.  Are sweeteners friends or foes in the realm of ketosis? 

Let's delve into the science and practical considerations.

First, what are artificial and non-nutritive sweeteners? Artificial and non-nutritive sweeteners are sugar substitutes that provide sweetness without the calories and carbohydrates of sugar. 

One advantage of artificial and non-nutritive sweeteners is their minimal impact on blood sugar and insulin levels. Since they are not metabolized in the same manner as sugar, they generally do not cause significant fluctuations in blood glucose, making them potentially suitable for those striving to maintain ketosis.

How do sweeteners work? Sweeteners bind to the receptors that register sucrose (sugar) molecules. This activates a signal to the brain that registers a sweet taste. Sweeteners are processed by the body differently than real sugar. Some are broken down into less desirable products while others aren’t broken down at all and may cause GI discomfort and impact gut health. 

It’s important to approach all sweeteners cautiously. Some individuals may experience cravings or increased appetite after consumption. Additionally, while these sweeteners are deemed safe for most people, some individuals may have sensitivities or adverse reactions to specific types.

Among the myriad of sweeteners available, some popular options include sucralose, aspartame, and saccharin. Non-nutritive sweeteners such as stevia, monk fruit extract, allulose, and erythritol are also favored choices among ketogenic enthusiasts. With any of these options, always be mindful of hidden sources of carbohydrates in products, such as fillers or bulking agents, which could potentially disrupt ketosis.

Let’s dig into each of these a little bit deeper. 

• Sucralose (Brand name: Splenda) is an artificial sweetener that is 600 times sweeter than sugar. It is not absorbed or digested but instead is excreted in the stool. It has zero calories but is often combined with filler ingredients such as dextrose or maltodextrin that can add carbohydrates and calories. 

• Aspartame is an artificial sweetener that is 200 times sweeter than sugar. You may see it used in conjunction with acesulfame potassium (Ace K). Many keto RDs advise patients to avoid aspartame. However, it can be difficult to meet hydration goals for some kids without the typical aspartame-sweetened beverages such as Crystal Light, Powerade Zero, or Propel Fitness Water. Your ketogenic team may suggest you double dilute these beverages to help cut back on intake while also achieving proper hydration. Aspartame is not heat stable so it should not be used in baking or any cooking method. 

• Saccharin (Brand name: Sweet-N-Low) is an artificial sweetener that is 300 times sweeter than sugar but has a bitter or metallic aftertaste. You may see it used in conjunction with other sweeteners- such as aspartame. The body cannot metabolize saccharin, so it is excreted in the urine.

• Stevia is a non-nutritive sweetener extracted from the leaf of the steviol glycoside plant. Depending on the form and brand, it is 150-300 times sweeter than sucrose. It generally has a slower onset of sweetness and a longer duration compared to sugar. Some forms have a bitter aftertaste so you may see stevia used in conjunction with other sweeteners- specifically erythritol. The least bitter-tasting form is stevia glycerite. 

• Allulose & Tagatose are newer sweeteners in the keto world. They have a similar look, mouthfeel, and sweetness level to sugar. Allulose is naturally found in figs, raisins, and maple syrup while tagatose is found in milk and some fruits. Neither are fully metabolized and are excreted primarily in the urine. However, they do contain a small amount of carbohydrates and calories (0.4 calories per gram) so check with your keto team before using these products to determine if you should count any carbohydrates when consuming products with large amounts. 

• Monk Fruit Sweetener (also known as Luo Han Guo) is a non-nutritive sweetener extracted from the fruit of a monk fruit tree native to Southern China. In its pure form, it is 300 times sweeter than sugar but has an unpleasant aftertaste. During processing the bad aftertaste is removed, and the final product is available in a liquid extract or powder. 

• Sugar Alcohols are a broad category of sweeteners you may find in keto products. Sugar alcohols are made through a fermentation process and contain varying amounts of calories and carbohydrates. They are NOT all created equal. Xylitol, sorbitol, mannitol, and erythritol are the most common. Even moderate amounts of sugar alcohol can lead to GI upset, specifically loose stools. 

• Erythritol is excreted in the urine, leads to less GI distress, and is considered the most keto-friendly. You will often find erythritol combined with other sweeteners such as stevia and/or monk fruit. Erythritol is not as sweet as these options, so it is added for its sugar-like crystalline appearance and texture while the stevia and monk fruit add the sweet taste. Some keto programs advise avoidance of all sugar alcohols (including erythritol) while other programs may allow a small amount of erythritol but advise you to count a small percentage in your carbohydrate limit. 

If you are looking for guidance on exact sweetener products that are keto-friendly check out this “Using Sweeteners on the Ketogenic Diet” guide from the Ketogenic Dietitians Research Network. 

How much do we absorb? Although most sweeteners are not absorbed and claim to be 0 calories, they can still cause GI side effects and harm the gut microbiome potentially triggering a glucose/insulin hormone response. This is different from the way sugar raises glucose but can still have an impact on ketosis. Your gut microbiome is as unique as your fingerprints so responses to sweeteners are individualized. 

Are sweeteners safe? There is limited long-term data (especially in children) about the use of sweeteners. Study results are inconclusive and often contradict each other. We know that excessive amounts of sugar are not good for overall health and certainly not epilepsy, but less is known about artificial and non-nutritive sweeteners. 

The U.S. Food & Drug Administration (FDA) has approved some sweeteners under the Generally Recognized as Safe (GRAS) category of food additives for use below what they call an acceptable daily intake (ADI). The FDA sets these levels based on amounts that have the potential to cause cancer or mutations.  A GRAS approval typically means that a product has not caused cancer in lab studies of animals.  Therefore, the amount needed to impact taste alterations or disrupt the gut microbiome is likely much less. 

Most of these ADIs are at a high level and likely will not be reached by children on a ketogenic diet. However, younger patients may be at risk for consuming amounts above the recommended guidelines if they rely heavily on keto-processed foods. If you want to learn more about the FDA’s stance on sweeteners, check out this resource.  

You can think of sweeteners as you would sugar, they are best consumed in moderation as excessive long-term ingestion may cause issues. Even plant-based or “natural sweeteners” which are often perceived as “healthier” may not be ideal. Many plant-based pharmaceuticals have side effects and the plants used can be toxic. 

The good news about most of these sweeteners is they are significantly sweeter than sugar so a small amount goes a long way in terms of flavor. 

How do I know how much sweetener is in a product? Unfortunately, unless it is a sugar alcohol, the manufacturer does not have to list the amount on the nutrition label. You will find the sweetener listed in the ingredient list, but the amount won’t necessarily be included.  

When should I introduce sweeteners to my ketogenic diet? When interviewing several ketogenic dietitians, it became clear that the utilization of sweeteners on a ketogenic diet is individualized. Some clinicians allow the use of sweeteners right away while others will wait a month to introduce them. Others will allow sweeteners once ketosis is achieved and then evaluate any change in ketosis with consumption. 

The consensus of the group was that it was up to families if they wanted to incorporate sweeteners into the plan. If having some sweeteners  make the ketogenic diet more feasible/attainable and seizure improvement was achieved, then the benefits likely outweigh the negatives. 

Here are some other take home tips we gleaned from our interviews with clinicians:   

• Consume products with sweeteners in moderation (or not at all if you can),  try to limit to 1 serving or less/day.  

• For beverages with sweeteners, dilute them. Beverages are the largest contributor of artificial sweeteners. 

• Reserve consumption of sweeteners for special occasions (holidays, birthdays, parties). 

• When in ketosis, the desire for sweets (aka cravings) tends to go away as glucose levels stabilize so don’t assume you will need sweet-tasting food on your keto journey. 

• If you are craving something sweet, try cinnamon for a more subtle, natural sweetness. 

• Keep in mind consuming sweeteners may lead to increased sweet cravings which could lead to non-compliance issues on the diet. 

In conclusion, sweeteners have a certain place and can be valuable tools for those following a ketogenic diet, offering a way to enjoy sweetness without compromising blood sugar control or ketosis. However, they are not all created equal and can impact each person differently because of the unique composition of our gut microbiome.  Sweeteners should be used mindfully and in conjunction with a balanced, whole-foods-based approach to nutrition. As always, consult with your ketogenic diet team to provide personalized guidance and support on navigating the intricacies of your ketogenic lifestyle.

References (or some light reading): 

• Moriconi E., et al. Neuroendocrine and Metabolic Effects of Low-Calorie and Non-Calorie Sweeteners. Front in Endocrinol(Lausanne). 2020;11:444. 

• Suez J., et al. Personalized microbiome-driven effects of non-nutritive sweeteners on human glucose tolerance. Cell. 2022;185(18):3307-3328. 

• Richardson I. and Frese S. Non-nutritive sweeteners and their impacts on the gut microbiome and host physiology. Front Nutr. 2022;9:988144.

The Ultimate Guide to Eating Enough Fat on a Ketogenic Diet

Author: Laura Dority, MS, RD, LD  

Edited by: Amy Merwarth, RD, LD 

Hey there, fellow keto enthusiasts! Today, let's dive deep into one of the fundamental aspects of the ketogenic lifestyle: fat consumption. We all know that fat is king when it comes to fueling bodies on this low-carb, high-fat journey. But sometimes, getting enough fat can be tricky. I'm excited to share a compilation of expert tips from ketogenic dietitians on how to ensure you're getting ample fat while enjoying a variety of delicious options.

Embrace Healthy Fats & Variety: Be sure to prioritize healthy fats like avocados, nuts, seeds, and olive oil. These fats not only provide essential nutrients but also contribute to overall heart health. It’s difficult to meet fat goals by using just one fat option, so be sure to mix and match your fats. At each meal, incorporate fats from a variety of sources.  

Start with Full-Fat Foods: Opt for full-fat versions of dairy products such as cheese, yogurt, and cream. These dairy delights are rich in fat and offer a creamy texture that can elevate any dish.

Heavy cream is often a staple in many keto plans but drinking it day after day can get boring.  Try these tips:

• Dilute with water and add liquid sugar-free sweeteners and/or vanilla extract*.  

• Whip into a fluffy cream and serve with low-carb berries, sugar-free Jell-O*, and/or low-carb yogurt.  

• Flavor with sugar-free syrups and/or flavorings (such as DaVinci)*. Then freeze to make ice cream or popsicles. 

• Combine with butter and tomato sauce or butter, garlic, and cheese to create creamy sauces. 

• Combine with a small amount of dry sugar-free pudding powder* to make mousse. 

Mayonnaise is another high-fat option that can add flavor to your keto diet.

• Mix with a pinch of herbs and salt and serve as a dip for low-carb veggies. 

• Mix liberally into chopped chicken, eggs, or tuna to make a “salad”. 

• Whip into raw scrambled eggs and then cook. 

• Mix into keto waffles or pancakes to give a light, fluffy texture. 

Cook with Coconut Oil: Coconut oil is a fantastic source of medium-chain triglycerides (MCTs), which are easily converted to ketones by the liver, providing a quick energy boost. Use it for sautéing, baking, or adding a tropical twist to your keto smoothies.

Butter Can Be Your Friend: While butter shouldn’t be the only fat in your keto plan, it can certainly make meeting fat goals easier.

• Soften and mix with a sugar-free flavoring (Walden Farms, DaVinci) or liquid stevia*. Then place into molds or ice cube trays and store in the fridge or freezer to harden.

• Blend into full-fat cream cheese for a high-fat dip. 

• Mix a pinch of herbs with 2-3 Tbsps. of melted butter for a topping with meats and vegetables. Try refrigerating this mixture for 3 days to enhance the flavor. 

• For something sweet, mix with unsweetened applesauce and/or low-carb yogurt to boost the fat content. 

Incorporate Fatty Fish: Fish such as salmon, mackerel, and sardines are loaded with omega-3 fatty acids, which support brain health and reduce inflammation. Aim to include fatty fish in your meals at least twice a week.

Snack on Nuts and Seeds: Keep a stash of nuts and seeds like macadamia, almonds, walnuts, and chia seeds on hand for convenient, high-fat snacks. Just be mindful of portion sizes as they do contain small amounts of carbohydrates which can add up.  

• Mix chia or flaxseeds with heavy cream or unsweetened almond milk and let chill to make breakfast porridge. Add sugar-free flavorings* or low-carb berries for extra sweetness. 

• Create trail mix by combining nuts, seeds, cacao nibs, and unsweetened shredded coconut flakes. 

• Make “flackers” by mixing ground flaxseeds with oil, dried herbs, and water. Spread flat on a sheet pan and bake until crispy. 

• Grind macadamia nuts or almonds into flour and use in keto waffles or pancakes.

Avocado Everything: Avocados are a keto dieter's best friend. Mash onto low-carb toast, add to eggs, use as a dip, blend into smoothies, or simply slice them up for a satisfying snack. Their creamy texture and rich flavor make them a versatile addition to any meal. For more ways to work avocados into your keto diet, check out Avocados All the Way handout. 

Dress with Olive Oil: Ditch the store-bought salad dressings and opt for homemade vinaigrettes made with extra virgin olive oil. Not only does olive oil add flavor to your salads, it's also packed with heart-healthy monounsaturated fats. You can also add olive oil to applesauce, soups, low-carb yogurt, or nut butters to boost the fat content. Use liberal amounts when cooking meats and/or vegetables and add to chicken, egg, or tuna salad in addition to mayonnaise.  

Enjoy Nut Butters: Indulge in almond butter, peanut butter, or cashew butter for a deliciously satisfying fat boost. To add even more fat, mix butter with nut butters in a 50/50 breakdown. Spread on celery sticks, drizzle over low-carb pancakes, or simply enjoy by the spoonful. Choose “natural” varieties or make your own! Always read the nutrition label on nut butter products as some do add sugar and other forms of carbohydrates. 

Experiment with Fat Bombs: Fat bombs are small, high-fat snacks perfect for keeping you fueled between meals or a way to add more fat into meals. With a short ingredient list and one-bowl prep, they are a cinch to whip up. Make a large batch at the beginning of the week and enjoy them all week long. They can be made in a variety of ketogenic ratios and calorie levels. If you are looking to boost ketones or fat content of meals, be sure to choose a fat bomb that has a high ratio. Get creative with flavors such as chocolate, coconut, or peanut butter to satisfy your sweet cravings while staying on track with your macros. They are also a great option for a bedtime snack if you need to boost ketones overnight.  Looking for fat bomb recipes,- check out The Ultimate Fat Bomb Guide. 

Remember, the key to success on a ketogenic diet is finding a balance that works for you. By incorporating a variety of healthy fats into your meals and snacks, you can ensure you're meeting your fat goals while enjoying a delicious and satisfying eating experience. So go ahead, embrace the fat, and fuel your body for success on your keto journey!

*Be sure to check with your ketogenic diet medical team about the appropriateness of sugar-free products and artificial/non-nutritive sweeteners and your unique nutritional needs. 

References: 

• Charlie Foundation Parent’s Guide Booklet 

• Carb Manager. “How to Get Enough of the Right Fats on Keto (and Avoid the Bad Ones).” Accessed February 22, 2024. 

• UVA Health: UVA Ketogenic Diet Clinic Tips by Ingredient to Increase Fat Intake 

Unraveling the Mysteries of Fats: A Comprehensive Guide to Keto-Friendly Fats

By: Laura Dority, MS, RD, LD

Fats, often misunderstood and unfairly vilified, play a crucial role in our diet, especially for those embracing the ketogenic lifestyle. It's time to demystify the different types of fats, understand their sources, and appreciate the health benefits each type brings to the table.

Monounsaturated Fats

Sources: Olive oil, avocados, nuts (especially almonds), seeds (pumpkin, sesame)

Health Benefits: Monounsaturated fats are associated with heart health, as they can help lower bad LDL cholesterol levels while maintaining or increasing good HDL cholesterol. They are also rich in antioxidants, supporting overall well-being.

Smoke Point: Moderate (suitable for light sautéing and low to medium heat cooking)

Omega-9 Fatty Acids 

Sources: Olive oil, avocados, almonds.

Benefits: Omega-9s are monounsaturated fats associated with heart health. While they are not classified as essential (meaning the body can produce them), incorporating omega-9-rich foods into your diet can still have positive effects on cardiovascular health.

Saturated Fats

Sources: Butter, coconut oil, animal fats (beef, pork, lamb), cheese

Health Benefits: Contrary to popular belief, saturated fats are not the villains they were once considered to be. They provide a stable source of energy, aid in hormone production, and contribute to the structure of cell membranes. Additionally, they can increase levels of beneficial HDL cholesterol.

Smoke Point: High (good for cooking at higher temperatures)

Medium Chain Triglycerides (MCTs)

Sources: Coconut oil, palm kernel oil, MCT oil.

Health Benefits: MCTs are a unique type of fat that is rapidly absorbed and metabolized by the body, providing a quick source of energy. They are popular in the ketogenic community for their potential to enhance ketone production, aiding those following a low-carb diet.

Smoke Point: Varies (coconut oil has a higher smoke point than MCT oil).

Polyunsaturated Fats

Sources: Fatty fish (salmon, mackerel), flaxseeds, chia seeds, walnuts, sunflower seeds

Health Benefits: Rich in essential fatty acids, particularly omega-3 and omega-6, polyunsaturated fats are vital for brain function, cardiovascular health, and reducing inflammation. They are considered heart-healthy when consumed in balance with other fats.

Smoke Point: Varies, generally moderate (be cautious with high-temperature cooking)

Omega-3 Fatty Acids

Sources: Fatty fish (salmon, mackerel, sardines), flaxseeds, chia seeds, walnuts

Benefits: Omega-3s are renowned for their anti-inflammatory properties, supporting heart health, brain function, and joint health. They play a crucial role in reducing the risk of chronic diseases.

Omega-6 Fatty Acids

Sources: Sunflower seeds, safflower oil, corn oil, soybean oil

Balance is Key: While omega-6s are essential, the Western diet often contains an imbalance of omega-3 to omega-6 ratios, contributing to inflammation. Aim for a balanced intake of both for optimal health.

Tips for Adding Healthy Fats to Your Ketogenic Diet: 

1. Cooking with Healthy Oils

• Use olive oil for salad dressings or light sauteing.

• Cook with coconut oil for its high smoke point and unique flavor. 

• Incorporate MCT oil into smoothies and other beverages for a quick energy boost. 

2. Include Fatty Fish in Your Diet

• Enjoy salmon, mackerel, or sardines a few times a week for a rich source of omega-3s. 

3. Snack on Nuts and Seeds

• Almonds, walnuts, and chia seeds make for convenient and nutritious snacks. 

4. Avocado Love

• Add slices of avocado to salads, omelets, or enjoy it on its own as a satisfying snack. 

• Please be sure to check out our recently released clinician handout, Great Ways to Eat Avocados, for more ideas on incorporating avocados into your ketogenic diet. 

5. Cheese, Please

• Include moderate amounts of cheese for both flavor and fat content but be aware of serving sizes as cheese is also high in protein. Exceeding protein on your ketogenic diet may lead to poor ketosis and negatively impact outcomes. 

Understanding the nuances of fats is a fundamental aspect of a successful ketogenic journey. By embracing a variety of healthy fats in your diet, you not only support your nutritional needs and ketogenic ratio but also unlock a world of culinary possibilities. Remember, diversity and balance are key as you navigate the diverse landscape of fats on your ketogenic journey.  Be sure to check out our free Fat Bomb handout that includes some great and tasty fat bomb recipes and ideas.

Avocados, Avocados, Avocados: The Perfect Keto Food

By: Laura Dority, MS, RD, LD

Are avocados the perfect food for the ketogenic diet? The answer may very well be yes…or at least close to the perfect food and here is why: 

• Rich in healthy monounsaturated fat

• Contain omega-3 fatty acids 

• High in fiber and low in net carbohydrates

• Fun Fact: They have the highest fiber content of any fruit. 

• Loaded with vitamins including C, E, K, B6, riboflavin, niacin, folate, pantothenic, magnesium, and potassium.

• Fun fact: Avocados have 60% more potassium than bananas. 

The nutrition stats for ½ an avocado (approximately 100 grams) is 160 calories, 15 grams of fat, 2 grams of protein, 8.5 grams of carbohydrate, 6.5 grams of fiber, and less than 1 gram of sugar (net carbs 2 grams) which is a ~ 3.75:1 ketogenic diet ratio of fat grams to protein and net carb grams combined. 

Overall avocados contain a wide range of nutrients and may have various health benefits. These include improving digestion (poop, poop, poop) and supporting optimal cholesterol patterns for heart health.  There’s evidence to show that including avocados daily in a (regular) diet lowers cholesterol and triglycerides.

Different Kinds of Avocados

The Hass avocado is the most common variety available in the US and is higher in fat as well as fuller in flavor compared to Florida avocados.

Hass avocados generally come from California and Mexico and have dark green or black skin that is bumpy.

Florida avocados are grown in Florida (as the name implies) but also in the Caribbean islands. The Florida avocado is generally larger than the Hass avocado and has bright green skin that is relatively smooth. 

The main difference between these 2 types of avocados is that the Hass avocado has a higher fat content; therefore, a higher calorie content and in most cases has a softer/creamier texture.  

General Buying & Storing Tips 

• Color alone is not the best way to determine ripeness. While a Hass avocado will turn dark green or black as it ripens, Florida avocados generally retain their light-green skin even when ripe. 

• The best way to tell if an avocado is ripe is to gently squeeze the fruit. Ripe, ready-to-eat avocados will be firm but give way to gentle pressure. 

• Firm avocados will ripen faster when stored next to other fruit (within 2-3 days) – especially an apple or kiwi fruit due to the ethylene these fruits give off that naturally promotes ripening.  

• You can also speed up ripening by placing the avocado in a paper bag and storing it at room temperature (2-5 days). 

• Only refrigerate ripe or soft avocados. These can be refrigerated until it is eaten and should last for at least 2 more days. 

• After cutting open the avocado, leave the pit inside and the skin on to help keep the remainder fresh. 

• You may freeze cut-up avocado by wrapping it with plastic wrap to avoid air contact. Exposure to air will cause the avocado to brown due to oxidation. While the brown color may visually not be as appealing as green, there is no harm in eating a browning avocado.  

• You can also squeeze a few drops of lemon juice on the exposed surface of the avocado. The citric acid from the lemon juice can help prevent browning.

Check out the California Avocado Commission website for more great tips on buying, storing, & freezing avocados. 

Eating Avocados 

And now onto the fun part…. eating the avocado! However, we know it might be hard to get your kiddos to even try an avocado let alone eat them consistently as part of their daily (sometimes multiple times a day) ketogenic meals. 

The key is to be creative and not give up. Keep in mind sometimes it takes up to 20+ offerings for a kiddo to try new food! Don’t forget to get the kiddo involved in the prepping and cooking process to facilitate independence and excitement when trying new foods and eating their keto meals (if age and developmentally appropriate of course). 

Avocados can be worked into meals: 

• As part of a: 

• Salad

• Soup: 

• You can make a soup focusing on avocados as the main ingredient or just add chunks of avocados to other soups. 

• Scrambled Eggs: 

• When scrambled eggs are about halfway done, add diced avocado. You can also add them after the eggs are cooked and cool. Top with cheese and herbs. 

• Pancakes: 

• Add avocado to your low-carb pancake mix to provide extra fiber and fat. 

• Smoothies: 

• Combine avocado with green, leafy vegetables, berries, low-carb yogurt, and/or nut-based milk. 

• Check out this Avocado & Hazelnut Smoothie from Matthews Friends and this Shamrock Smoothie from the Charlie Foundation. 

• Sauces: 

• Avocados make for a very creamy sauce. They pair well with tomato sauces as well as an easy addition to cauliflower mac and cheese. 

• Dips 

• Hummus: Add avocado to your hummus mixture to increase the creaminess, fat, and fiber content. 

• Try this Avocado Dip from Matthews Friends 

• Simply seasoned with salt and pepper

• Cut the avocado into chunks and drizzle with olive oil, balsamic vinegar, pepper, and/or salt. You can also try adding paprika, cayenne pepper, or lemon juice. 

• Stuffed

• Fill an avocado with an egg and bake for 15-20 minutes at 425° F. Add crumbled bacon and season with fresh herbs. 

• Here is another stuffed avocado recipe: Avocado Boats from Matthews Friends 

• Note: This recipe calls for double cream which is ~48% fat content compared to ~36% in heavy cream. Double cream can be difficult to find in the US. You may need to use more heavy cream in this recipe to make up for the difference in fat content. 

• As toppings

• Use for toppings of keto sandwiches, tacos, or pizza. 

• Try this Avocado Toast from Ketolicious Kid 

• Grilled 

• Cut the avocado in half and remove the seed. Drizzle with lemon juice and olive oil. Place cut side down on grill and cook for 2-3 minutes. Season. 

• Pickled 

• Place 1 cup of white vinegar, 1 cup of water, and 1 tablespoon of salt in a saucepan and bring the mixture to a boil. Pour the mix into a jar and add three diced, unripe avocados. Seal them with a lid and let them marinate for a few days before eating. 

Here are some great dessert-like avocado recipes: 

Charlie Foundation 

• Avocado Ice Cream 

• Chocolate Avocado Truffles

Matthews Friends 

• Avocado Brownie

• Avocado Pudding

• Chocolate Avocado Pudding 

• Avocado Ice Lollies 

In addition, check out our old blog post, Beat The Heat with Keto Popsicle Treats, where we list several popsicle recipes that incorporate avocado with formula but honestly, you can switch the formulas out for heavy cream and/or nut-based milk. 

Are you still struggling to get your little one excited about avocados?  Try rewarding him/her with these non-food-related items to get your kids on Team Avocado!  

• Avocado Plush

• Avocado Pop-It 

• Avocado Squishy Stress Ball 

• Avocado Bricks  

• Avocado Smash Game 

This is only the tip of the iceberg for all the great ways you can incorporate avocados into your ketogenic diet journey. Leave us a comment with your favorite idea or avocado recipe!

Quality Nutrition Sources - Why Quality Matters?

By: Kayla Hansmann, MS, RD, LD, CLC

When thinking about diet quality – across the spectrum of all diets, you’d be hard-pressed to find someone who would argue that the quality of what we’re eating isn’t important. While that might not be one of the first steps in implementing a medically prescribed ketogenic diet, it can certainly take precedence down the road once some of the other critical boxes are checked and everyone is feeling comfortable with how to navigate this new way of eating.

Dietary choices and lifestyle habits can be daunting to implement all at once so most dietitians will recommend some initial tweaks and changes to get you on your way to the desired diet endpoint. When doing so, most individuals and practitioners note that even these simple (yet consistent!) nutrition changes up front result in better control of seizures as well as improved behavior overall. The underlying theme in these changes includes reduced amounts of processed and packaged foods, no added sugar, and less concentrated sources of carbohydrates overall. 

Let’s dig into this a little further. Stripping away processed foods leaves us with whole, natural foods that provide higher satisfaction for both our palate and our body’s systems. Processed foods are more likely to include ingredients that are: 

• harder for our bodies to digest

• more likely to lead to abdominal distress (constipation or diarrhea)

• prone to causing glucose spikes that lead to energy rollercoasters (often exhausting our body’s insulin)

• more likely to lead to bloating and/or increased gas

• providing an excess of calories and/or unhealthy fats without a ‘place to go’

…in other words: likely to increase inflammation which can increase our prevalence of acute or chronic illness and undesirable weight trends.

One easy way we can look at creating a plate or a day’s worth of meals that prioritize whole, natural foods is by following the “one ingredient rule”. Even if a food isn’t fresh or raw, you can flip over to the ingredient list to ensure each of the ingredients listed is just ONE ingredient, or itself, in whole-unadulterated form. Cut out the ingredients, cut out the processing! 

Once you’ve successfully gotten the majority of your meals and snack to encompass the one ingredient rule, you will notice your body starting to crave these foods more and a reduced desire to grab or reach for its other processed counterparts. Our bodies are smart and adapt—once you get to a certain point, your body CRAVES what it is actually eating!

Let’s recap, ways to add quality to our diet and why it matters, with an emphasis on keto-friendly sources:

Proteins

• Aim for minimally processed proteins (i.e. whole chicken, eggs, ground turkey, various cuts of steak) – these foods are satiating and can keep us feeling full longer while also contributing important and highly available amino acids, B vitamins, iron, zinc, and choline. When possible, choose pasture-raised poultry for the higher amounts of omega 3’s found in the eggs and meat. 

• Choose high-fat dairy which is also helpful in terms of satiety but also a good source of calcium, phosphorus, and vitamin D for strong bones, growth, and development.

• Try and work in fresh fish a few times a week – omega 3 city! The EPA and DHA (omega-3 fatty acids) provide tremendous benefits for your heart, brain, lungs, and circulation.

Carbohydrates: 

• Fruits & veggies – think: The higher the fiber, the lower the net carbohydrates. Fiber is not only FILLING but feeds the healthy bacteria in our gut (a happy gut = better absorption of important nutrients and increased bowel motility).

Fats: 

• Nuts & seeds – great ways to add crunch with a fantastic mix of healthy fats, fiber, and often a better source of sodium to naturally “salt” our diet. A favorite keto staple is flaxseed and chia seeds which are loaded with alpha-linolenic (ALA) fatty acids – a commonly forgotten omega-3!

• MOST IMPORTANTLY FATS – think half solid, half liquid. If we can make at least 50% of our fats unsaturated (usually liquid) and the other 50% or less saturated (usually solids: butter, coconut oil, fats from animals), we are on our way to improved fasting blood levels of triglycerides and cholesterol. Butter/ghee is a great way to pack a punch, but we want to ensure that we’re incorporating mono- and omega-3 poly-unsaturated fats to boost our HDL cholesterol and provide protection against heart disease as well as packing a dose of potent antioxidants. Amazing monounsaturated fat sources are extra virgin olive oil and avocados. 

The final trick to adding quality? Self-love and self-regulation! Without these two essential ingredients, we’ll be cycling through the roundabout of shame and guilt that will make it very difficult to lead to healthy habits long-term. A calm and stress-free environment helps us digest food better, enjoy food more, and be more likely to grab the more nutritious choice time after time.

Supplements, Supplements, Supplements: What Are They for and Why Are They Important?

By: Laura Dority MS RD LD

As a ketogenic dietitian, I get a lot of comments and questions about the vitamin/mineral supplements recommended on a keto diet. “I wanted to do this diet to get off some medications and now I have to take a handful of vitamins every day” is a complaint I’ve heard a time or two. And I totally get it – it’s a valid complaint! On the other hand, as the RD, I am concerned when patients do not grasp that vitamins and minerals are JUST AS IMPORTANT as some medications.  

So let’s talk some details about why your ketogenic dietitian is recommending certain vitamin/minerals and why it’s important not to be wishy-washy about consistently taking them. 

Let’s start with a simple definition – vitamins and minerals are nutrients needed in small quantities in order for the human body to develop and function properly. In most cases, our bodies cannot make vitamins and minerals; therefore, we have to get them from outside sources such as food and sunlight. 13 vitamins and more than 20 minerals have been identified and are primarily present in carbohydrates (fruits, vegetables, enriched grains) and in proteins (nuts, meats, dairy). Fats, such as oil and butter, contain few vitamins/minerals yet contribute to the majority of the calories consumed on a keto diet. 

Research has shown time and time again that all forms of keto diet therapy (“classic”, modified, MADE, LGIT) are lacking multiple vitamins and minerals including the following: 

• Vitamins: B’s (thiamin, folate, riboflavin, niacin, B12), C, D 

• Minerals: Calcium, magnesium, phosphorus, selenium, zinc, iron

Studies show growth problems may be related to calcium and vitamin D levels.  A systematic review in 2011 showed drops in selenium and magnesium levels at 12 months for children on the “classic” keto diet and multiple case studies have been reported for low selenium as well.  

Supplementation, or in some cases carefully chosen foods in specific quantities, is 100% necessary to prevent vitamin and mineral deficiencies. Keep in mind that the more restrictive the approach of keto diet therapy, the higher the risk of nutrient deficiencies. Why? The higher the fat intake the lower the carb and protein intake; therefore, lower amounts of vitamins and minerals naturally found in the foods being consumed. 

How does your ketogenic dietitian determine what supplements are needed?  

Vitamins and mineral needs are based on the Dietary Reference Intake (DRI) which are developed and published by the Institute of Medicine.  The DRI represents the most current scientific knowledge on nutrient needs of healthy populations. While these guidelines vary by age and sex, they are not necessarily a reflection of exactly how much an individual will need. An individual’s needs may be higher or lower due to a variety of factors such as medications, metabolism, lean body mass, and mobility (to name a few). Unfortunately, there are not specific standards for the epilepsy population. Despite the fact that individual needs may vary slightly, using the DRI guidelines is the best way to assure the majority of nutrient needs are met. 

Ketogenic Formula Options: 

• KetoVie® products manufactured by Cambrooke™ Therapeutics and KetoCal® products manufactured by Nutricia contain large amounts of vitamins and minerals. In order to avoid over supplementing, the amounts of vitamins and minerals provided by these products should be considered. On the other hand, just because you are on one of these products doesn’t mean additional supplementation is not needed – it all depends on the volume, labs and the individual. 

• Keto Peptide manufactured by Functional Formularies does not contain large amounts of vitamins and minerals so additional supplementation will be necessary. 

Standard of Care Guidelines for Ketogenic Diet Therapy: 

• Classic & Modified Ketogenic Diet/Orally Fed: All vitamins and minerals should be met with supplementation.  The small amount naturally found in foods being consumed are a bonus.  Patients will need a multivitamin, calcium and vitamin D at a minimum. Additional phosphorus and salts are also commonly needed. 

• Modified Atkins Diet/LGIT: All patients should take a multivitamin as well as a calcium and vitamin D supplement. 

• Classic Ketogenic Diet/G-tube or J-tube Fed: For patients that receive a consistent amount of ketogenic formula, the amount of vitamins and minerals provided by these products is calculated and then any remaining “gaps” are filled with supplementation.  

  • For example, a patient taking 720 mL (24 ounces) of KetoCal 4:1 Liquid meets all the DRIs for a 7 year old female EXCEPT calcium – which only meets 64%, so additional calcium would be recommended to achieve 100% of the DRI goal. 

Your ketogenic dietitian will also look at lab values and overall health goals to determine need for additional supplementation.  

When choosing supplements look for tablets and powders since they are usually the lowest in carbs/sugar. Most liquid and gummy forms will contain too many carbs and should be avoided. Chewables and oral disintegrating tablets can also contain carbs so should be used only under the recommendation of your ketogenic dietitian. Sometimes a chewable vitamin may be recommended if that is the easiest option for the patient and the benefits of the supplement outweigh the risk of the carbs provided. Your ketogenic RD may calculate the carb amount into your individual plan if needed.  

Multivitamins: 

A multivitamin is going to fill in the most nutrient gaps. Your standard multivitamin (Centrum®/One-A-Day®) are going to contain around 15 to 20 nutrients. When evaluating multivitamins be sure to choose one that includes iron and selenium, but they generally do not contain a significant amount of calcium. Keep in mind that even for pediatric patients an adult formulation may be ideal. 

Some of my favorite multivitamins that are keto-friendly are Nano VM® and Phlexy-vits.  Both are powders, contain 27 vitamins and minerals (versus ~15 found in your standard multivitamin) -- and they contain large amounts of calcium. Due to their completeness, using one of these specialty vitamins may allow you to reduce the number of supplements needed on a daily basis – think of it as an all-in-one approach. 

Calcium and Vitamin D:  

Evidence strongly indicates that patients with epilepsy have a higher risk of fractures – 2-6X the risk compared to the general population.  Assuring adequate calcium and vitamin D can dramatically reduce this risk. 

Numerous low carbohydrate formulations are widely available. Getting a product with both calcium and vitamin D (and sometime even magnesium) can cut back on the number of supplemented needed. 

Calcium is best absorbed in divided doses of 500-600 mg each. Calcium carbonate should be consumed with food versus calcium citrate which can be taken with or without food. Some patients tolerate the citrate form better. Keto friendly food sources of calcium include cheese, fortified unsweetened nut-based milks (almond/coconut/etc) and leafy greens such as kale and broccoli. 

Vitamin D has many functions in the human body – far outside just bone health – including an active role in immunity, blood pressure, cardiac health, cancer prevention and cognition.  When choosing a supplement, cholecalciferol (D3) may be better absorbed than ergocalciferol (D2). Doses are commonly prescribed based off of blood levels but 1000 IU is a good maintenance starting point for most patients. Do not fall into the mind set of more is better though because vitamin D supplements in large amounts can be toxic.  Generally exceeding more than 4000 IU/day is not recommended.  

Frustrating Fact: Heavy cream – a huge component of many keto diets- does not contain significant amounts of vitamin D or calcium.  I know, I know….it’s a dairy product so one would think it would be a good source but unfortunately that is not the case. 

Other vitamin/mineral supplements: 

Phosphorus: The more restrictive forms of keto diet therapy may need additional phosphorus supplementation. Good keto friendly food sources of phosphorus include dairy, meat, poultry, nuts, eggs, pumpkin seeds and peanut butter. 

Zinc: In most cases the amount in a multivitamin will be adequate.  Your keto team will likely check your blood level periodically and if low an additional supplement may be needed.  Zinc deficiency can impair growth and wound healing as well as alter taste and lead to hair loss. Keto friendly food sources include meat, seafood, and nuts/seeds.  

Selenium: As long as your multivitamin includes selenium the risk of deficiency is very low. Your keto team will check your level yearly.  Good keto friendly food sources include meat, seafood and Brazil nuts. 

Fish Oils (Omega-3’s): Often supplemented for overall health for those that do not eat a consistent amount of fatty fish or to help lower elevated triglyceride levels. When choosing a supplement be sure to choose a marine source and one that provides about a 50/50 mix of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). 

Carnitine: Carnitine is important for the conversion of fat into useable energy. Due to the high fat content of the keto diet and higher demand for carnitine, levels may decrease (especially for those on valproate/valproic acid). Generally, supplementation is recommended when free carnitine levels are low. Deficiency presents as muscle weakness, poor weight gain, hypoglycemia and fatigue. The best source of dietary carnitine are meat products. 

Salts: Your keto team may recommend a variety of salt products such as potassium-based salt substitutes, lite salt, or table salt. These are generally prescribed in small quantities to meet your potassium, salt and chloride needs and to keep your electrolytes in balance.  If your team has included these on your keto regimen, it is important to consistently take these products every single day. 

This list of supplements could go on and on…your keto team may recommend pancreatic enzymes to aid in digestion, sunflower lecithin (choline) for elevated cholesterol, potassium citrate for kidney stone prevention and/or sodium bicarbonate for acidosis. You as a caregiver or patient may be interested in taking other supplements such as herbs, probiotics, exogenous ketones, and/or essential oils.

My best recommendation, regardless of which role you play - the caregiver/patient or the healthcare professional -- is…LISTEN TO EACH OTHER. If your healthcare team is recommending a supplement, it’s for a reason –take it as prescribed as it may make the keto diet more effective and prevent side effects.  If your patient is inquiring about a supplement that is not well studied – keep an open mind. After first evaluating if the supplement is safe, allow the patient to use it. Maybe it will help – as we know many supplements are not well studied but that doesn’t necessarily mean they aren’t effective. Remember, it’s a team approach that includes both the healthcare providers but also the patient and caregivers! 

Resources: 

Arslan N, Kose E, Guzel O. The effect of ketogenic diet on serum selenium levels in patients with intractable epilepsy. Biol Trace Elem Res 2017;178:1–6. 

Bergqvist AG, Schall JI, Stallings VA. Vitamin D status in children with intractable epilepsy, and impact of the ketogenic diet. Epilepsia 2007;48:66–71. 

Berry-Kravis E, Booth G, Sanchez AC, et al. Carnitine levels and the ketogenic diet. Epilepsia 2001;42:1445–1451. 

Christodoulides SS, Neal EG, Fitzsimmons G, et al. The effect of the classical and medium chain triglyceride ketogenic diet on vitamin and mineral levels. J Hum Nutr Diet 2012;25:16–26. 

Kossoff EH, Zupec-Kania BA, Auvin S, et al. Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open 2018;3(2):175-192.

Breastfeeding Options and Ketogenic Diet Therapy

Author: Laura Dority MS RD LD

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For decades infants with epilepsy were not considered good candidates for ketogenic diet therapy (KGD).  It was thought that infants were at a higher risk of side effects (specifically low blood sugar) and were unable to produce adequate ketones for effectiveness – in other words the risks outweighed the benefits. 

But the reality is – infants ARE GREAT patients! In 2016 the consensus statement, “Ketogenic Diet Guidelines for Infants with Refractory Epilepsy”, was published in the European Journal of Pediatric Neurology.  This was a collaboration of 15 experts (doctors, dietitians and researchers) in the field of ketogenic diet therapy.  Since these guidelines were released, more ketogenic diet programs have started implementing the diet in the infant population.  Data has grown and outcomes continue to support that infants are ideal patients.  

What about Human Milk? 

Isn’t human milk the best choice for infants? Does this still hold true for infants with epilepsy? Don’t get me wrong – breastfeeding is great and likely the best choice for most infants. Unfortunately, human milk is not naturally ketogenic when comparing it to what we need for a medical ketogenic diet.  Yes, it is high in fat but it’s not low enough in carbs to induce ketosis. 

What about changing mom’s diet? Can we put mom on a ketogenic diet and change the composition of her milk to be higher in fat and more ketogenic? I have tried this several times and unfortunately have not been successful. When we have attempted this option – we placed the mom on a modified Atkins diet (20 grams of net carbs or less) and achieved positive ketosis but the human milk composition did not change. 

However, just because we haven’t been successful yet – doesn’t mean it’s not possible. I think this option warrants more research. What if the mom went on a more restrictive diet such as “classic” or net carbs 10 grams or less? If mom is in ketosis, would the infant receive benefit from drinking human milk with ketones in it regardless if the fat/carb composition didn’t change? It’s hard to say and these are great questions we need to study as a KGD medical community.   

What are the Options for Incorporating Human Milk into a Ketogenic Diet? 

While you can’t exclusively breastfeed on a KGD, there are a few ways that you can be successful in incorporating human milk into the plan.  

Option 1: Expressed Human Milk

Likely the “easiest” and most accurate method is for mom to pump and then to utilize the expressed human milk as part of the KGD formula mixture. Depending on the infant’s age, weight, keto ratio, you can likely use anywhere from 3 to 6 ounces of human milk a day. While this is not a large volume, I always emphasize that any amount of human milk is beneficial. 

Here is an example of a 24-hour batch of keto formula with expressed human milk that is a 2.75:1 ratio and 27 calories per ounce.   

• 120 mL (4 ounces) expressed human milk

• 420 mL KetoCal or KetoVie 4:1 Formula 

• 240 mL water (to create a total volume of 780 mL)

Keep in mind that human milk is a combination of foremilk and hindmilk.  The foremilk is the first milk that is released and contains more water and less fat. The hindmilk is the milk at the end of the feed and is higher in fat. One way to try and get a higher fat human milk is to have mom pump for 3 to 5 minutes to release the foremilk. Some moms can also tell when the milk changes by noticing the thickness and color change to a creamier white.  Then you can use the hindmilk only into the keto recipe. This is usually only an option for a mom that has a good milk supply. 

Option 2: Nursing 

Another option that is not as accurate as using expressed human milk is to have the infant nurse at the breast for a set amount of time. The amount of time is going to vary drastically between infants based on efficiency of eating, age, and weight. You can start by weighing the infant before and after a feeding and document the amount of time the feeding lasted. This will give you a general idea of how much volume is consumed in a set time. Then you start to reduce the amount of nursing time and follow with a ketogenic formula.  

Let’s look at an example – If an infant takes 4 ounces in a 15 minute nursing session, stat by allowing him to nurse for 5 minutes and then follow with a 3 ounce 4:1 ketogenic ratio bottle. Then adjust based on weights and ketone levels.  Here are some adjustments you may want to consider: 

• Reduce the nursing time

• Increase the ketogenic ratio of the formula – consider 4.5:1 or 5:1

• Utilize medium chain triglycerides (MCT) into the formula 

• Allow nursing at every other feeding only. You would still follow with a keto formula bottle but at the non-nursing feedings, the infant would just get the formula in the bottle. 

• Consider pumping the foremilk so that when the infant nurses they get more hindmilk

Overall, you will need to adjust, adjust, adjust and with some patience and vigilance you can be successful. At the end of the day though the goal is seizure control so if that cannot be achieved with nursing your next step would be to switch to pumping and using expressed human milk as part of the ketogenic formula.  

Option3: Use a Supplemental Nursing System (SNS)

A supplemental nursing system (SNS) can be used so that you can give ketogenic formula at the same time the infant is nursing.  With a SNS a small tube runs next to the mom’s nipple.  As the infant sucks, they will get human milk from the nipple and the ketogenic formula through the tube at the same time.  

Similar to nursing, this is not an exact method because you won’t know the exact volume consumed from the breast but you will know how much they get from the SNS. 

Like other options, you could have the mom pump for a few minutes to get the foremilk discarded and then utilize nursing with the SNS system. Another option would be to run MCT instead of keto formula through the SNS system – starting with a very small amount to assure tolerance. 

Keep in mind that one way is not the only way and likely what is successful with one infant will not be successful for the next! Incorporating human milk into a ketogenic diet takes practice, patience and a little finesse but is worth it. You have to start with a plan and tweak it daily until ketosis is achieved.  Then ongoing adjustments will be needed on a weekly/monthly basis to keep up with growth and development.  

Even with the best of intentions and multiple tweaks and adjustments, you may not be able to get the infant into adequate ketosis or obtaining seizure benefit.  At that point, it’s time to discontinue the human milk component and switch to all ketogenic formula which is more controllable. 

Maintaining the mother’s milk supply is important throughout the KGD journey.  Regardless of the keto plan, mom should keep pumping and storing her milk. Human milk can be stored in your freezer for up to 6 months. Then if the KGD is discontinued, she can feed her infant the stored milk and resume nursing. 

Are you a mom that used human milk as part of your ketogenic diet journey?  If so, leave us a comment and let us know how you were successful.  

If you are a parent reading this article and looking to use human milk in your infants plan, talk to your ketogenic diet team.  

If you are a ketogenic dietitian and are hesitant to incorporate human milk– reach out to other ketogenic dietitians and ask for help.  

References: 

Cole N. et al. Initiating and Maintaining the Ketogenic Diet in Breastfed Infants. Childhood Obesity and Nutrition. 2010 May; 2(3):177-80.

Le Pichon JB. Et al. Initiating the ketogenic diet in infants with treatment refractory epilepsy while maintaining a breast milk diet. Seizure. 2019 July; 69:41-43.  

Van der Louw E. et al. Ketogenic diet guidelines for infants with refractory epilepsy. Eur J Paediatr Neurol. 2016 July; 20(6):798-809. 

To learn more about a SNS: https://www.medela.com/breastfeeding-professionals/products/feeding/supplemental-nursing-system

Troubleshooting Your Keto Diet: Common Mistakes and Solutions

By: Laura Dority MS RD LD

Are you having difficulty achieving adequate ketone levels?  Do you feel like you have put all your blood, sweat and tears into a keto diet but are just still stuck at negative or trace ketone levels? Let’s see if I can help by diving into some of the most common mistakes and mishaps for those on a keto diet.

Roadblock #1: Not Eating Enough Fat

In order for the keto diet to be successful you must eat a high fat – not just low carb diet.  Most experts agree that at least 70% of your calories should come from fat. Fat is an important nutrient in getting your body to produce ketones. So pile on the avocados and olive oil – don’t be afraid.  Fat is key to success! 

Roadblock #2: Eating the Wrong Types of Fat

Avoid processed fats such as vegetable oil blends.  Instead focus on a variety of natural fats including eggs, avocados, raw nuts, seeds, oils and butters.  Don’t forget about ghee, heavy cream, coconut oil and coconut cream as well.  Aim for 4-5 different fat sources throughout the day.

Roadblock #3: Eating the Wrong Amount of Calories

Both eating too many or too few calories can derail your keto diet. Signs of eating too many calories including unintended weight gain, poor ketosis and feeling sluggish. On the other hand if you are losing excessive weight or have poor energy, try increasing your calories slightly.

Roadblock #4: Not Drinking Enough Water

Adults maintaining a keto diet should drink at least 64 ounces of water daily. If you are starting the keto diet, you need even more water because as soon as you start cutting out carbs your body will start to lose water naturally.  Water is crucial to keep your body functioning at its best by circulating nutrients, flushing out toxins and burning fats. Hydration for children is weight dependent so check with your healthcare team about water goals. 

Roadblock #5: Eating Too Much Protein

The keto diet is a high fat, low carb diet – not a high protein diet. Eating too much protein will lead to protein conversion into glucose (sugar) in the body. So if you eat too much protein, your body may not use fat as an energy source. To prevent getting too much protein, focus on fat sources that do not include protein such as butter or oils over just eggs and meat. 

Roadblock #6: Eating Too Many Keto Sweets

Many keto sweets contain large amounts of sugar alcohols and sugar substitutes. These sweets have a lot of calories which may cause you to eat too many calories. In addition, they may increase your cravings for sweet foods. Keep in mind that not all sugar alcohols are created equal. Some sugar alcohols and sugar substitutes are processed like sugar in the body and may need to be counted as carbs.

Roadblock #7: Excessive Snacking

Be sure you are only snacking when you are truly hungry and not due to other factors such as emotions or boredom. If you are hungry and need a snack, nuts seeds, avocados, or cheese are great options. Focus on small portions of these foods and giving yourself enough time after eating to feel satisfied before going back for seconds.

Roadblock #8: Hidden Carbohydrates

There is no official definition for a food to be labeled “low carb.” Many foods carry this claim but are not keto friendly. Common hidden sources of carbs can be found in condiments, sauces and salad dressings. Keep in mind that foods labeled “low sugar “or “sugar free” does not necessarily mean low carb and may not be acceptable on a keto diet. Read labels carefully!

Overall the biggest mistake people make is not drinking enough water and not following the right amount of carbs, proteins and fats.  Remember at least 70% of your total calories should come from fat (often more if you are on a “classic” form of ketogenic diet therapy) 5-10% from carbs and 15-20 % from protein on most keto plans. Reach out for help from a professional before abandoning your keto journey. The best source of nutrition information is a dietitian or doctor that is familiar with keto diets.

Disclosure: Before you make any changes to your ketogenic diet always discuss with your medical team. 

Dairy Free Keto...Is that even a thing?

3/1/20

By Daisy Argudin

My keto kid is allergic to dairy and eggs so we have had to learn to make adjustments to his diet since he was small. It has made keto a bit more challenging for us but also something that made me want to try keto for his epilepsy over 2 years ago. I was used to reading every label and checking ingredients. We rarely ate out as I don’t think a chief in a restaurant can be trusted with so many restrictions. Unlike most keto families we can't pack some cheese for a snack. We can't use cream as our fat with meals. We can't add butter to everything to meet macros. Try and go through your daily food list and see how much of it is dairy. Thankfully in the last 3 years we have begun to see more and more dairy alternatives but often they are high in carbs or taste awful. The last year has brought more keto dairy free options as keto has become a popular way of life.

So how do we do it? Often I'll look for vegan keto recipes and get ideas that I can add protein into and stay within our macros. If I find something I'd like to try that has dairy then we have to find alternatives. I search many sites for new products and I'll ask my local grocery store to carry them or order some for us to try.

So what has worked for us? Dairy free cheese that is keto friendly and good is unfortunately a dream. A cheese stick of a popular brand is 4 net carbs while the shreds are 6 net carbs per ¼ cup, not worth it for us.

Butter seems to be an easy find that tastes great and we like the brands Smart Balance or Earth Balance. The macros are slightly different from dairy based butter. Dairy free butter has 9g of fat while butter has 11g. If you can find Earth Grown Coconut Spread, we find it at Aldi's, it has no carbs and 11g of fat. The flavor has a hint of coconut and is less salty than butter but very good.

Yogurt? We like Kite Hill and Silk. Both are almond based. Silk is very similar to yogurt in texture and taste. Kite Hill is slightly less thick than the silk and a bit more tart, we also use it in place of sour cream. I can add avocado or mct oil to either and it mixes in well without changing the texture or flavor.

Coconut cream, not canned coconut milk, is close to heavy cream consistency but will add a coconut flavor to whatever you are making. Silk makes a heavy whipping cream that is very close in macros and taste to heavy whipping cream. If you want to make your own, you can blend 1 part vegetable oil with 2 parts milk alternative in a blender and it will work for most recipes.

Dairy free milks. We use different ones for different meals. If I want higher protein for say a shake, I like the unsweetened Bolthouse pea protein milk with 1 net carb and 10g protein. For less protein the Ripple unsweetened pea milk with 0.5 net carbs and 8g protein. Silk almond milk has 0.5 net carbs and 1g protein so it fits as a drink with meals. All of these work well to blend in fats as needed to meet macros.

Some families are choosing to reduce their dairy intake over concerns that it is inflammatory to the body and specifically concerns that inflammatory changes in the brain can lower seizure thresholds. Some just want new meal options or are obligated to go dairy free, like us, because of allergies. Whatever your reason for trying dairy free, talk with your team and see if some of these options work for your family.

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All the brands discussed in this article are ones we personally use, my opinions are my own and I am not compensated for using or endorsing them.

The Adventures of MCT Oil

Updated: 2/1/22

By Laura Dority MS RD LD

What is all this fuss about MCT oil? What is it?  When should it be used?  Can it be harmful?  You may have heard a lot about MCT oil and its role in ketogenic diet therapy but you may also have a lot of questions about this product.  As a ketogenic dietitian I use MCT oil all the time.  In fact, I would estimate that at least 50% of my patients consume MCT oil on a daily basis - it is definitely one of my favorite hacks I recommend to patients. So let’s dig in and I’ll give you my opinion on when I use it, what the side effects are, how to identify a quality brand and more.

MCT stands for medium chain triglycerides. Triglycerides are just a fancy word for fat. Fats are made up of chains of carbon atoms and are divided into 3 categories: 

Short chain fatty acids: Fewer than 6 carbon atoms. This type of fat does not occur naturally.

Medium chain fatty acids: Contain 6-12 carbon atoms. Occurs naturally in coconut oil, palm kernel oil and in a small amount butter. 

Long chain fatty acids: More than 12 carbon atoms.

Why is this important? Long chain fatty acids are more complex for our bodies to breakdown due to the longer chain of carbons and therefore more bonds to break. MCTs are easily absorbed and bypass much of the digestion process. Because of this easier digestion, MCTs provide a quick energy source for ketone body production.  There is even some evidence to suggest there is an additional anti-epileptic effect (outside of ketone enhancement), particularly with caprylic acid (C8). For the rest of this article we are going to be primarily discussing the following MCT’s: caprylic acid (C8), capric acid (C10) and lauric acid (C12). 

Coconut Oil vs MCT Oil Supplement

Often times coconut oil and MCT oil are promoted as the same which is not technically true. MCT oils generally contain either 100% caprylic acid (C8), 100% capric acid (C10) or a combination of the two. Lauric acid (C12) on the other hand is the main component in coconut oil. MCT oil supplements rarely contain any of the lauric acid. Why does this matter? That question is actually a widely debated and controversial topic.  I treat MCT oil supplements and coconut oil differently. Coconut oil can be a great way to get some MCT into your keto diet but I won’t say it’s fully comparable to an actual MCT supplement. It certainly is possible that the different MCTs work differently in our bodies. A great thing about coconut oil is it’s very stable at high cooking temperatures. This is NOT the case with MCT oil supplements. 

So to pull this complex topic together- use both! Use coconut oil to cook and bake and use MCT oil has an added supplement to your daily plan to get a variety of MCTs.

When to Use:

Keep in mind that MCT oil is rather versatile and there are many reasons and ways to use this product. Often it helps with diet palatability, decreasing the amount of fat needed from other foods. Likely the most common reason to use MCT oil is for constipation management. Since it’s easily digestible it generally empties through our digestive system quicker than other oils which can combat the constipation side effect we commonly see on a keto diet.

Another reason to use MCT oil is to provide a more energy-efficient ketone producing fuel source. A tablespoon of MCT oil compared to a tablespoon of olive oil (long chain fatty acid) would produce deeper ketosis.

Patients with carnitine deficiency may also benefit from MCT oil supplementation. MCTs do not require carnitine for digestion. Over the past few years I have had a lot of patients that do not tolerate carnitine supplements. By adding a little lamb to naturally boost carnitine levels and using more MCT oil instead of long chain fats you can increase the supply of carnitine and decrease the demand at the same time.

There is also some evidence to support anti-inflammatory, anti-microbial and anti-viral properties of MCT oil but those are hard to measure in a clinic setting so I really focus on constipation, ketone production and carnitine deficiency.

How Do I Incorporate?

First and foremost, reach out to your ketogenic diet team to determine a starting dose and schedule. It may need to be incorporated into your mealtime ratio. 

• Add to beverages 

• Add to food such as low carb yogurt or a smoothie 

• Drizzle over salads 

• Incorporate into fat bombs 

• Take it like a shot

• Mix into a mayo sauce (tuna salad, dip)

Just remember, MCT oil should not be heated. It’s okay to add to hot beverages but you should not cook with it. Also, for best results, spread the MCT oil throughout the day. 

Side Effects: 

The number one side effect with MCT oil is GI discomfort and/or diarrhea. If you do experience some GI discomfort or loose stools, it does not mean you cannot tolerate ANY amount of MCT oil. It probably means you took too much-try a smaller amount and spread throughout the day. I would also advise to start small and increase slowly so your body can adjust to the digestion. This can help minimize side effects. 

Quality Brands:

It’s important to make sure you are purchasing a MCT oil supplement from a reputable company. No one wants to pay top dollar for MCT oil that ends up being a glorified vegetable oil. Remember that supplements are not regulated so you have to buy from a trusted source such as a medical food company or a company that voluntarily has their product tested by a third party. One easy way to find a reputable source is to look for the USP Verified Mark. Seeing the USP Verified Mark on a dietary supplement label indicates the product contains the ingredients listed on the label and the amount stated.

After finding the USP Verified Mark on a product, you also want to make sure the product contains both a combination of caprylic acid (C8) and capric acid (C10). It is not necessarily a requirement that the company tell you if they use both C8 and C10 so you may have to do a little digging. Here is an example label of a good product that has both the USP Verified Mark and provides a nice breakdown of both C8 and C10. Some good OTC brands often used are Now, Nutiva and Nature’s Way Organic.

Another option would be to purchase a MCT oil manufactured by a medical food company such as Liquigen® (manufactured by Nutricia) or BetaQuik® (manufactured by Vitaflo). Not only are these products manufactured by trusted companies, but the products are also emulsified. Emulsified products stay in solution – so you can avoid that separation you commonly see if you mix oil into other foods. 

Insurance Coverage: 

Most insurance companies consider MCT oil a supplement and since it’s readily available over the counter, it’s rare you can get insurance coverage. Clearly this varies widely from state-to-state but I personally have gotten coverage for kids who are fed via g-tube. I also generally have better success getting the emulsified products (Liquigen® and BetaQuik®) covered. Nutricia and Vitaflo who make these products have letters of medical necessity and patient assistance programs on their website that can be very helpful. Some Medicaid plans have oral supplement coverage that would be worth a try. Bottom line –call your insurance company - it never hurts to ask! 

As a recap – MCT oil can be a great addition to keto plans but should be individualized for the patient depending on what the goals are and how much of the product can be tolerated. Remember these are strictly just my opinions and experience with using MCT oil in my own clinical practice. Different ketogenic diet programs may use MCT oil with a different approach. 

Updates:

Recent animal studies suggest that MCT oil as 9% of total caloric intake improved spatial working memory and problem solving skills. (Epilepsy & behavior, 2021-01, Vol 114 (Pt.A) p107608)

A pilot study in healthy older adults showed improvements in working memory, inhibitory processing, problem solving and motor control that approached significance. (Alzheimer’s & dementia, 2021-12, Vol.17 (S6)

A systematic review revealed that MCT does not increase cholesterol, LDL or HDL, but does cause a small increase TG.  (The Journal of nutrition, 2021-10-01, Vol 151 (10), p.2949-2956.)

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Disclaimer: The advice mentioned in this article is my opinion only. You should always check with your medical providers if consuming MCT oil as a part of your ketogenic diet is appropriate for you. In addition to the brands mentioned in this article are strictly my opinion only and I have NOT received any funding to promote these brands.

Carnitine, Carnitine, Carnitine: Can you get enough from food sources?

9/15/19

by Daisy Argudin (loving mother of an amazing keto kid)

I'd never heard of carnitine till we began the ketogenic diet. Carnitine is an amino acid that is made in the body. L-carnitine helps the body turn fat into energy. The problem is when you are on the keto diet you eat a lot more fat and less protein than the average person. This can create a carnitine deficit as your body cannot make enough to keep up with the supply and demand. Carnitine is something your body needs because if you do not consume enough it can affect your muscles including your heart. 

We were told that Carnitor (a pharmaceutical grade supplement) was the best way to treat my son's carnitine deficiency. Although I had my doubts we followed the recommendation with my son's best interest in mind. A few days after starting the supplement he began having seizures again although we had been seizure-free for months. While trying to figure out what was going on I found several sources that said that seizures were a common side effect of Carnitor. There were other factors around the same time so I can never say that the Carnitor was in fact what brought back his seizures but I have serious mom guilt over it.

More info available at www.americanlamb.com

When the seizures returned I began to seek out alternatives to the Carnitor but was told that there were no food alternatives. While researching I found that lamb has the highest level of naturally occurring carnitine at 45 mg of carnitine per ounce of meat. The carnitine you get from food is much easier for the body to absorb and utilize versus that in the supplement. 

In my own son we were able to raise his carnitine levels to within normal range in 2 months by just adding lamb into his diet.  His free carnitine level was at 16 umol/L. A free carnitine level below 24 is generally considered deficient.  His level improved to 48 umol/L after 2 months of focusing on lamb intake at least 4 times week (each serving being 1.5 oz).  Once I saw this I began to share with other epilepsy parents and many of them have had similar results. One parent reported the free carnitine level going from 14 umol/L to 27 umol/L in less than 2 months. Another parent reported going from 6 umol/L to 30.5 umol/L in 3 months. 

YUM!!!

How much each child will need depends on their own body and the amount of fat they consume compared to how much protein they consume. Lamb can be intimidating to make but we buy it ground at our local grocery store and use it just like hamburger meat. The taste is stronger so some children prefer it mixed with ground beef but it is quite palatable.

Many healthcare providers say that the only way to get the carnitine levels within range is to take the supplement but I myself have seen that food can be a viable option. Try for yourself, consult with your dietitian and make the best choice for your child. But know that there are choices!