Getting ready to start ketogenic dietary therapy (KDT) - For children and their carers

This leaflet is designed for families with children who have been diagnosed with drug-resistant epilepsy, have attended a ketogenic assessment clinic and are considering ketogenic dietary therapy.

What is KDT?

KDT is used to help manage drug-resistant epilepsy. It is a medically supervised high fat diet, which is low in carbohydrate and contains enough protein for normal growth. It is an unnatural diet and every meal will need to be made following a detailed food prescription. These prescriptions have been carefully calculated for each child dependent on their age, eating preferences and activity levels.

Getting ready to start

This booklet suggests changes to make in the weeks leading up to starting KDT. This should make transitioning to the diet easier and therefore the therapy more likely to succeed:

• Establishing regular meal and snack times.
• Reducing sugar intake and cutting out sweets and chocolates as snacks.
• Increasing fat intake.
• Reducing portion sizes of carbohydrate-rich foods.
• Try some lower carbohydrate alternatives to high carbohydrate foods.
• Trying some ketogenic recipes.

It is important to introduce changes gradually.

Week 1

Establishing regular meal and snack times

The Ketogenic Diet should be treated like a medication that needs to be taken at regular times throughout the day. For the diet to be most effective, meals should not be missed and snacks should be taken throughout the day. It may take longer than a week to establish a regular meal pattern. Please give yourself enough time to do so as regular meals and snacks are very important.

Best to avoid

• Getting up late (which can make the morning routine hurried)
• Relying on foods bought away from home (as suitable options may not always be available)
• Leaving foods available to see on counter tops and easily accessed cupboards
• Giving foods as rewards or treats.

Good to consider

• Establish a good morning routine that allows enough time for breakfast
• Bring foods from home to eat when out
• Set aside a cupboard or shelf in a fridge that your child can be encouraged to seek foods from if they are hungry. Place locks on cupboards (if needed)
• Find other activities that your child would enjoy as rewards or treats, e.g. story time, colouring books or stickers, additional play time.

Week 2

Reducing sugar and very high carbohydrate foods

Sugars are found in sweets, chocolate, cakes and biscuits. Sugar is not an essential part of the diet and eating less may benefit the whole family.

Best to avoid

• All sweets and chocolates
• Jam, honey
• Regular fizzy drinks, fruit juice
• Sweetened milkshakes and yoghurt
• Cakes and puddings
• Biscuits
• Sweetened breakfast cereals.

Good to consider

• Nuts or berries as snacks
• Marmite, cream cheese, unsweetened peanut butter (for example Meridian or Whole Earth) as savoury spreads
• Water, sugar-free squash, or sugar-free / diet drinks
• Full fat milk or low carbohydrate milk alternatives e.g. Alpro soya light (fresh) or unsweetened almond milk
• Berries, melon or sugar free jelly with cream
• Crackers or rice cakes with butter and cream cheese. Consider making low-carb biscuits
• Cooked breakfasts (such as eggs with bacon, ham and mushrooms). Add additional cream / butter to omelettes or scrambled eggs.

Week three

Increasing fat intake

A high fat intake is an essential part of all Ketogenic Diets. Fat needs to be increased gradually.

Start by first adding extra fat to one meal of the day and then look to increase the fat in every meal over the next two to three weeks.

• Ensure all dairy choices are full fat varieties and not low fat, reduced fat or fat free (for example choose whole milk)
• Fry foods in oil or butter as an alternative to grilling, poaching or steaming foods
• Add butter to vegetables, spread thickly onto bread, toast or crackers
• Add mayonnaise or oil to salads
• Add double cream to soup, use with berries and sugar free jellies, add to milky drinks
• Use mayonnaise as a dip (can flavour with tomato paste)
• Consider making some ‘fat bombs’ as snacks (see recipe on page 8).

Week 4

Reducing portions of starchy carbohydrates

All ketogenic diets reduce the portion size of carbohydrate-based foods. Try to reduce current portion sizes by a quarter. Choose wholemeal or wholegrain varieties where possible. Continue to add fat to all portions of carbohydrate-based foods.

Good to consider

Rice:

• Fry or toss in butter
• Consider trying ‘cauliflower rice’ or ‘celeriac rice’ as alternatives (blend / grate them until they resemble rice and fry in oil).

Pasta:

• Toss in butter, oil, pesto or cream cheese
• Consider trying spiralised courgette as an alternative to spaghetti.

Potatoes or chips:

• Mash potatoes with butter and cream, fry or roast potatoes in oil
• Consider replacing potatoes with celeriac.

Bread:

• Try some lower carb bread products, such as Hovis Lower Carb, Hi-Lo, Livlife and seriously lower carb loaf (see below for details).

Breakfast cereal:

• Choose low sugar varieties and serve with full fat milk.

Vegetables:

• Add butter or margarine.

Salad:

• Serve with oil or mayonnaise.

Lower carbohydrate products to try

Some lower carbohydrate bread options:

• Livlife – available from Waitrose, Ocado, Coop and online
• The Seriously Low Carb Loaf – lowest in carbohydrate compared to all the other low-carb breads. Available online
• Hovis Lower Carb – available from Asda, Sainsbury's, Ocado, Amazon
• Hovis Lower Carb – available from Asda, Sainsburys, Ocado, Amazon
• Lo Dough – versatile low carbohydrate bread that can be used as a pizza base or to make wraps, toasties, quiche and breadcrumbs. Available online
• The Heart of Nature Grain Bread – available from Waitrose and online

Some lower carbohydrate pasta and rice options:

• Explore Cuisine Organic Edamame Spaghetti – available from Asda
• Black soya bean spaghetti – available from Ocado
• Swoodles – available from Tesco
• Soya bean / black bean spaghetti – available from Aldi
• Boodles – lower carbohydrate, butternut squash noodles available from Sainsbury's
• Cauliflower rice – a lower carbohydrate alternative to classic rice. Available from most large supermarkets.

Some sugar-free syrup options:

• Da Vinci sugar-free – Available on Amazon
• Skinny syrup – Available in Morrisons and on their website
• Walden Farm – Available via their website and on Amazon.

Low carbohydrate cookery

The following recipes are free from flour and sugar. They are useful to use when on a ketogenic diet to replace biscuits, cakes and chocolate. You may find it useful to try some keto cooking before actually starting a ketogenic diet.

Keto Chocolate Truffles (makes 6)

Each truffle has 1g carbohydrate.

Ingredients

• 25g Extra thick double cream
• 5g Cocoa powder
• 8g Grated plain chocolate (with at least 70% cocoa solids)
• 7g Butter
• A few drops of vanilla extract

Method

1. Place the cream, butter and 4g of the cocoa powder in a saucepan and bring to a simmer
2. Remove from the heat and beat in the grated chocolate and vanilla extract.
3. Pour into a dish and leave to firm up in the fridge overnight.
4. Remove and form into six small balls.
5. Roll in the remaining cocoa powder.

Keep in fridge before serving.

Keto Cookies (makes 3 cookies)

Ingredients

• 13g Pecan nuts – grind to a fine paste
• 6g Butter
• 3g Dark chocolate (with at least 70% cocoa solids)
• 5g Coconut flour (with at least 60% fat content)
• A few drops liquid sweetener 2 drops vanilla essence

Method

1. Melt the chocolate and butter together.
2. Add the remaining ingredients and stir well.
3. Divide into three and place in silicone baking moulds.
4. Bake at 190^oC (170^oC fan oven) for approximately 10 minutes.
5. Leave to cool in the moulds.

Ketogenic Pizza

Ingredients

Crust:

• 1½ cups (6 oz.) mozzarella cheese, shredded
• 2 tbsp cream cheese
• ¾ cup (3 oz.) almond flour
• 1 tsp white wine vinegar
• 1 egg
• ½ tsp salt

Topping:

• ½ cup unsweetened tomato sauce
• ½ tsp dried oregano
• 1½ cups (6 oz.) mozzarella cheese, shredded
• Optional - meat of your choice

Method

1. Preheat the oven to 400°F (200°C).
2. Heat mozzarella and cream cheese in a non-stick pan over medium heat or in a bowl in the microwave oven. Stir until they melt together. Add the other ingredients and mix well. Tip: use a hand mixer with dough hooks.
3. Flatten the dough on parchment paper, making a circle about 8 inches (20 cm) in diameter.
4. Prick the crust with a fork (all over) and bake in the oven for 10 – 15 minutes until golden brown. Remove from the oven.
5. Spread a thin layer of tomato sauce on the crust. Top the pizza with meat and plenty of cheese. Bake for 10 – 15 minutes or until the cheese has melted.
6. Sprinkle with oregano and enjoy!

Additional things to consider

Medicines may need to change to preparations which give the lowest amount of carbohydrate. Your doctor or dietitian will advise on this.

Consider supervision at snack times and school meals - who will help keep your child safe at school?

Consider who provides meals and snacks for your child - what help will they need to understand KDT?

Where can I get more information?

We recommend the following websites, which provide a wide range of reliable information on the ketogenic diet:

• Matthew’s Friends (opens in a new tab)
• Charlie Foundation (opens in a new tab)
• Epilepsy action (opens in a new tab)
• Daisy Garland (opens in a new tab)