Ketogenic Diets: You Want Me to Eat What?

Written by Laura Dority MS, RD, LD

As a ketogenic dietitian I often get the “You want me to eat what?” question or at a minimum the “Are you serious?” look.  A ketogenic diet is certainly a different way of eating, especially for those that grew up in the non-fat and fat-free health era of the 80’s and 90’s where Fig Newton’s and SnackWell’s Fat Free cookies were all the rage.  However, a ketogenic diet has been shown in multiple research studies to be beneficial for seizure control.  In fact, across all epilepsy types more than 50% of patients (both adults and pediatrics) have a positive response to ketogenic diet therapies.  

So first and foremost, what exactly is a ketogenic diet? 

A ketogenic diet is an umbrella term for four different low carbohydrate diet options to treat epilepsy and potentially other neurological conditions.  The four diet variations include the “classic” ketogenic diet, the modified Atkins diet, the low glycemic index treatment (LGIT), and the medium chain triglyceride (MCT) diet.  Keep in mind any combination of these diets may be used.  All of these variations are high fat and low carbohydrate with the goal of transitioning the human body from burning carbohydrates (glucose/sugar) as a fuel source to burning fat (ketones) instead which reduces the occurrence of seizures.   Each variation of the diet is slightly different and no one variation is ideal for every patient.  If you want to learn more about the differences between the ketogenic diet variations, I would highly recommend checking out this great chart

Next, does it really work?

Absolutely!  Research has been collected on the diet since the 1920’s and multiple studies from across the globe have documented that 1 out of every 2 patients who attempt the diet get at least a 50% improvement in their seizure control.   Ten to 15% even become seizure-free.   Depending on the patient, medications may still be necessary while other patients can reduce their medication amounts or discontinue medication entirely.  Ketogenic diet therapies can be beneficial for all age groups from infants to adults.  Unfortunately there is no way to predict ahead of time who will respond favorably. 

So what does a day on the ketogenic diet look like?

Butter!  Cream!  Bacon!  While those ingredients can certainly be a part of a ketogenic diet, I definitely do not give people an all you can eat buffet of them.  In fact, I have a lot of patients that do not eat any butter or cream and prefer an oil only approach to their fat intake.   Healthy fat options on a ketogenic diet are olive oil, canola oil, coconut oil, avocados and olives.  The diet plan also encourages leafy greens and other low-carbohydrate vegetables along with a variety of meats, cheeses and nut-based products.  In recent years, lots of great and tasty ketogenic recipes have become available.  Almond cookies, cupcakes, and candy are all options when made with the right ingredients.  Charleston is even home to the Keto Hope Foundation Bakery which produces a delicious cheddar cracker and almond bread product.  Honestly with a little effort you can make just about anything ketogenic. 

If I wanted to try a ketogenic diet, how do I decide which variation is best?

Ketogenic diet therapies are not a one-size fits all.  Every single patient/family I have worked with over the past ten years has a unique meal plan tailored to their seizures, lifestyle and social support.  Typically when I meet with families I discuss all the different options, and then together we can make an informed decision of which variation would work best.  In general, I find that the modified Atkins diet and/or low glycemic index treatment work best for adults and adolescents who may be more successful with a less restrictive approach compared to the infants and young children who typically do great on a “classic” approach.

How is a ketogenic diet started? 

Depending on the type of diet variation some patients are started in the hospital (classic, MCT) over 3 to 4 days while other variations (modified, LGIT) are started outpatient after an initial consultation.  Some patients will get into ketosis quickly while other patients may have a slower transition that requires some initial tweaking.   At times we aggressively put patients into ketosis while other patients I may reduce carbohydrates and increase fats over several weeks so their body (and mind) can transition slowly to the different eating habits. 

What are some of the side effects of a ketogenic diet?

The most frequent side effect is constipation.  Typically this can be resolved with increased hydration, high fiber vegetables and avocados and/or incorporating coconut oil and probiotics into the daily plan.   Other side effects may include weight loss or weight gain and rarely kidney stones and abnormal cholesterol levels.  In general most side effects can be prevented or treated with appropriate follow-up (clinic visits, e-mail/phone communication, regular lab work) with the ketogenic team.

How can I learn more about ketogenic diets?

Start by checking out the The Charlie Foundation for Ketogenic Therapies which provides great information on all the different variations of ketogenic therapy.   If you choose to google information, please be cautious as many resources on the internet are not accurate or may not be tailored specifically to epilepsy and thus can be very misleading.  You can also talk to your neurologist about a referral to a ketogenic dietitian who can discuss how this therapy can be tailored to your specific needs.  To locate a ketogenic diet program in your area check out this map or reach out to a private ketogenic consultant here.  It is important to note that a ketogenic diet should never be attempted without the assistance of a dietitian well-versed in this therapy.

Are there other nutrition changes that can help my epilepsy that are not as restrictive as a ketogenic diet?  

Yes! Start by gradually lowering your refined sugar and processed food intake such as juice, candy, cookies, sweet tea, and soda.   Focus on adding healthy fats to your daily regimen (olive oil, coconut oil, avocados).   Incorporate more fiber and fish into your diet which can reduce inflammation.   Maintaining a healthy BMI and staying active is crucial for overall well-being and health.  Here is a great handout to help you get started.  In addition, certain vitamins and supplements may also be beneficial depending on the type of epilepsy but please discuss these options with your neurologist or dietitian prior to purchasing.  


Epilepsy Foundation

Keto Hope Foundation

Charlie Foundation

Academy of Nutrition and Dietetics