Help, Thanks, Wow

Ann Lamott wrote a book called: “Help, Thanks, Wow: The Three Essential Prayers.” I’m sure she is not the first one to notice. Honestly, I haven’t read the book (yet). But now that I know to look, I’m seeing the pattern.

Exactly 4 years ago, the day before Thanksgiving, we entered the “help” phase when Nora had her first seizure. We saw doctors, started keppra, got lots of help from our community. Then she was seizure free for quite a long time, until they came back and the myoclonics appeared. At this time three years ago we were practically shrieking “HELP!” from the rooftop because nothing was working. Then we found the ketogenic diet, Dr. Wray joined OHSU, and we got started.

It worked. We started her on the Modified Atkins Diet (MAD) and saw improvement. Thank you. After breakthrough seizures we started increasing the ratio. Fewer seizures with each increase in ratio until we reached 3.5:1 and held steady there. Since her last seizure in April 2012 we have been counting the seizure free days. Thank you! By July of 2012 she was weaned off of all antiepileptic drugs and she was growing and developing normally. THANK YOU! In April 2014, after 2 years seizure free, we started a slow wean off the diet.

IMG_2288Now, we enter “WOW.” Almost 3 years on diet therapy, 2 years and 7 months seizure free, and Nora is weaned back to the 1:1 ratio of the Modified Atkins Diet. We have come full circle and are re-learning MAD again. When we do the ketostix urine test at home, she still has some ketones but it is very weak now.

Not that we don’t continue to say “help.” Nora’s kidneys have been acting up again. She complained that her “side hurt,” and when we asked her to show us she put her hand right over her kidney and drew a line around to her bladder. She had a urine test earlier in the week–yep, crystals were present, maybe stones. Maybe a small stone had already passed; we will never know. This isn’t a major threat, but a bummer. We are so close to the end of the diet and she is otherwise great. Skipping is her latest hobby and she is excited for swimming lessons because she likes going in the deep side of the pool now. Her ultrasound was normal, so her pediatrician wants to wait on further testing while keeping her hydrated to help stop any stones from forming.

Normally I don’t get too down about this stuff and didn’t this summer with her kidney issues, but it wears a person down over time. When you know a family with a health problem, especially a child, your heart goes out to them for the anxiety and fear for the beloved one’s health and safety. But one thing I’ve learned is that it is not just the fear of the health consequences, but also the sheer amount of time and energy that goes into coordinating doctors, tests, advocating to get something done in a reasonable time, making sure that lab work contains an order for the right information, sorting out what is meaningful and what it not, doing the research to ask the right questions and understand the answers. I’ve learned the hard way that you should double check things up-front instead of making the trip back to the clinic for another blood draw. I feel grateful that Ted and I are in this together and Nora is such a trooper about it, but at the end of the day it still leaves you exhausted and saying “help” even when there is nothing left to do.

Looking for more reasons to say “thank you” is a powerful strategy. As long as I was in contact Dr. Wray regarding her kidneys, I asked if we could do a blood test to check her blood acidity (see The Blood Acid Chronicles post for more info). She is still taking baking soda dissolved in water twice per day and would be a happy girl if weaning the diet means that she can stop taking baking soda. She was a super champ about the blood draw (despite requiring 2 pokes) and we brought flowers to Erika, our favorite phlebotomist, because she is changing jobs and we won’t get to see her anymore. Erika and I cried, but not Nora. Even after all of that, Nora lost it when I dropped her off at school because she was late. Thank goodness for teachers who say, “I’ve got this.”

The next day we got to “thank you” again: Nora’s blood acidity is back in the normal range. She can wean off of baking soda in the next 2 weeks….IF she has no kidney stones. The baking soda helps to keep stones at bay too. If Nora doesn’t complain about the side pain anymore then we will make sure she stays hydrated and start weaning the baking soda too. Wow!

I can hardly believe that Nora is a 1:1 again. We will continue to calculate and weigh food for the next 3 weeks, as scheduled, to get a feel for MAD portions. Then we will start estimating some meals without weighing if all is still going well. We still have her carbs capped at 38 g per day, which has been the limit for the last 3 weeks. At some time we will start moving up the carbs and down on the protein to try to stay around 1:1, but as we start estimating meals those numbers will be less precise.

We have to feel this out and keep watching Nora, which brings me back to HELP! all over again. Not that there is anything imminently wrong, but I’m holding my breath and hold the hope tight in my heart like a small fluttering bird. I know we have been in the hopeful watching and waiting before as we began the first count of seizure-free days. I hope that one day 3 months from now, then 6 months from now, then 1 year from now the reality of that monumental passage of time will hit me and I will live in a place of Thank You! and WOW! But right now we wait in hope for those days. Help! Thank you! and Wow! all come and go through the same revolving doors through our lives and right now they are making me a little dizzy.

 

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Foods by Ratio

Continued good news: Nora is down to a 1.25:1 ratio today and still seizure free. We are in the home stretch!

Just a word about the “ratio” for newcomers to the ketogenic diet. Remember that the ratio is the amount of fat per amount of net carbs+protein in a food (and remember to first get net carbs by subtracting fiber from total carbs; fiber is good!).

Example: In 100 g of macadamia nuts, there are approximately 80 g fat, 6 g net carb and 8 g protein. The math:

80 g fat /(6 g net carb + 8 g protein ) = 80 g/14 g = 5.7
Thus, there are about 5.7 g fat for every 1 gram of net carbs + protein in macadamia nuts. They have a ratio of about 5.7:1.

The ratio is a “magic number” in the ketogenic diet, with higher fat telling your body to use fat as an energy source by turning fat into ketone bodies for fuel. The traditional form of the diet uses a 4:1 ratio. Nora’s highest ratio was 3.5:1 for 2 years. Since April we have moved it down by 0.25 increment steps (so 3.25:1, 3:1, 2.75:1, etc.) every 3 weeks.

As we have moved down the ratio step by step, I’ve realized that I have a way of thinking about keto foods by ratio when I am building a meal. In the beginning of the diet, the big challenge is to think low-carb. Then you add in the fat needed to get the ratio. But after doing this for so long and having a broader range of known low-carb foods, I’ve started thinking about foods by their ratio instead of their carb content alone. That helps us create keto meals that use naturally high-foods, rather than taking big doses of fat on the side, and that gets much easier as we move down on the ratio.

The spreadsheet that we made to calculate meals shows us the ratio of each food that we are using, so as we changed ratios over the last 6 months I realized how much I was using that knowledge about the ratios. I hope that explaining it and giving some examples can be a guide to others.

At very high ratios, there are very few foods that are above that ratio on their own. Fat sources are critical to boost the ratio of any meal. All-fat foods that are served to achieve a high ratio are: heavy cream, butter, oil (Nora takes fish oil, others use lightly flavored oils like canola), and coconut oil for its ketone-availability.

Low-carb foods that Nora eats regularly but have very little fat: berries, red pepper, carrots, popcorn, apples, low-carb tortilla (Mission Carb Balance), sliced turkey or ham. We have to serve enough fat, either through the all-fat options or higher ratio foods in order to meet her fat needs at her current ratio.

Here is a table of regularly-used whole foods organized by their ratio, amounts given per gram of food served. Each color indicates a different ratio range:

Red = greater than 4:1
Orange = between 3:1 and 4:1
Green = between 2:1 and 3:1
Blue = between 1:1 and 2:1
Purple = Less than 1:1, but not insignificant fat content

Screen Shot 2014-11-01 at 11.55.30 AM

If you start by thinking about your child’s ratio, you can see the foods that are above and below that ratio. Higher-ratio foods can support or increase the ratio when paired with lower-ratio foods. At the traditional ketogenic diet ratio of 4:1, macadamia nuts and kalamata olives are superstars, with avocado not far behind. But even though you can’t make a 4:1 meal without fat supplementation (actually you could, but it would be a lot of macadamia nuts!), you can choose higher-ratio foods in order to put less fat on the side.

If you move down the ratio to 3:1, you get a few more of those helpful foods. We looked at all of the cream cheese options at our grocery stores and use a brand called Primrose, which has a higher fat content than some other brands.

It’s interesting that there are not many whole foods in the 2:1 to 3:1 range (green) that we use regularly. Sour cream was the only other one in my master list, but Nora doesn’t like it. Some brands of cream cheese fall into this ratio too. Many of the baked goods I make are in the 2:1 ratio because you can mix fats, nuts, eggs, etc., to end up with a 2:1 ratio item.

When we went below 2:1 on Nora’s wean schedule, I realized that there were a lot more foods on either side of her ratio and it got me thinking about foods by their ratios. Now that we are at 1.25:1, Green & Black’s 85% dark chocolate is above her ratio! We can put dark chocolate on berries, maybe with some nuts on the side, and have a perfectly delicious at-ratio snack without a side of cream.

After our next step down in 3 more weeks, Nora will be at 1:1 which is considered the Modified Atkins Diet (MAD) and we can start estimating meals. Knowing which foods are above the 1:1 line, and which are just below the 1:1 line, will help us make combinations of food that keep her meals around 1:1 without all of the calculating and weighing.

This list also shows some interesting contrasts. Just look at the nuts. Macadamia nuts are a stand out by any measure. It is amazing that they stay solid when warm! Walnuts are also excellent. But almonds are pretty far down on the list as a ketogenic diet food. They are not bad, but if I were going to give nuts to Nora I would choose a higher-fat nut that does not require fat supplementation (if possible). Peanut butter is also fairly low ratio, although we would normally think of it as a creamy high-fat food. We have always supplemented it with fat by mixing it with butter. Almond butter is actually a better keto-choice because it is lower carb and higher ratio.

Cheeses are interesting too. Cream cheese has always been the keto diet food of choice. But cheddar (and Monterey jack, which has the same ratio as cheddar), beats out whole milk mozzarella. Both beat out string cheese, which was one thing that was hard to take away from Nora at the beginning, and is not going to be a go-to food even after moving to MAD because it is well below 1:1 ratio. Nora also loves cottage cheese, but it is very low ratio. She enjoys cottage cheese swimming in cream, like cottage cheese soup! It is easier to add fat to cottage cheese than string cheese.

Proteins are the same story. Eggs, pork and beef are higher in fat than chicken and fish, as we all probably know. But even in the chicken category, chicken thigh is 0.42:1 ratio and chicken breast (not listed above), is only 0.12:1 ratio. And chicken thigh is cheaper and tastier, an all round better choice.

There are a few fun discoveries on the list. I love that edamame has both protein and fat. It’s a fun veggie that works on the keto diet or MAD with other fatty foods. Traditional full-fat Greek yogurt is at-ratio right now for Nora! She has it for breakfast every morning, topped with a few berries and some of her granola (the current recipe I made is 2:1 and balances out the berries). The Flackers that she enjoys are now above-ratio too. But even if your child is on a higher ratio, they are a cracker that fits well with the diet and can be topped with a high-ratio food like cream cheese and butter.

No matter where the ratio lands in a diet therapy, you can make meals more palatable by serving some high-ratio whole foods and not putting so much fat on the side. It gets easier at lower ratios when you have a larger selection of foods that are naturally above a 1:1 ratio. These are natural, healthy foods for any body and even better for anyone on a diet therapy for epilepsy or other medical reason.

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Lessons Learned

Lessons learned on the ketogenic diet, in no particular order:

  • Screen Shot 2014-09-20 at 10.30.30 AMCartoned cream can be clumpy.  A great deal of fat can be left behind, stuck to the sides of the paper carton.  We open the carton, scrape out the solid cream stuck to the sides, and transfer it all into a mason jar. There we mix it up gently as best we can. Then, we like these reCap lids for pouring cream out of the mason jar (get the right size for your jars). Nora had a bout of breakthrough seizures after several seizure-free months early on the diet, and I strongly suspect this was part of the problem.  Because of all the fat being left behind in the carton, her ratio would have effectively been quite a bit lower than our target of 3.5:1 at the time.
  • Keto-food superstars.  Foods that are fantastic for the ketogenic diet:
    • Base: avocados, macadamia nuts
    • Sweets: raspberries, strawberries, blueberries, dark chocolate (85%), red peppers
    • Protein: cheddar, eggs, ham, turkey, bacon
    • Flavorings: no-carb peppermint and vanilla flavorings, and cocoa powder for making cream in to “milk” or chocolate “milk”
    • Fiber: low-carb high-fiber tortillas, raspberries, avocados, Flackers, flax meal
    • Fat: butter, cream, macadamia nuts, coconut oil, kalamata olives
    • Low-carb: pickles, seaweed snacks
    • See this post, Quick Keto Meals, too.
  • Fiber.  We consider fiber to be the fourth macronutrient (along with fat, carbs, and protein).  It serves three very important functions: helping with constipation; helping to give weight and texture to a meal; effectively increasing the amount of sweet tasting foods.  This is because “net carbs” are what matter; that is, the total carbs minus the fiber.  This is one reason why raspberries are such keto superstars: they have plenty of carbs and delicious berry goodness, but they have a very high fiber content, which reduces their effective net carb count, which in turn allows Nora to have a lot of them.
  • Equipment.
    • The US Balance US-TT1000 scale is great.  It’s easy to use for home, and it has a built-in protective lid and runs on batteries for taking on travel or to a restaurant.
    • Small rubber spatulas help you scrape the full measured amount of food out of a dish and serve it to your child.
    • Screen Shot 2014-09-20 at 10.04.22 AMSmall silicone pinch bowls. We like these, made by NorPro.  They are microwave-safe, so you can melt a small amount of butter, coconut oil or dark chocolate for drizzling over other foods. You can thaw a small amount of frozen berries to mix into cream or yogurt. They are sturdy but flexible, so you can cream butter into cream cheese or nut butters for a smooth high-fat spread. You can scrape them clean with a butter knife or spreader to get all of the fat out. And they are cheap! Order them online or buy at a kitchen store. We have 8 and use ours everyday.
    • Screen Shot 2014-09-20 at 10.09.01 AMSmall spreaders (also called cheese spreaders or hors d’oeuvres knives) pair nicely with the small silicone pinch bowls. We have these cheap ones and they have worked fine. If you have a small child who can self-feed, they can use the spreaders themselves to put butter+nut butter mixture on a Flacker, for example. They work perfectly for scraping the silicone bowl clean.
    • Ice cream pop holders are wonderful. You can make very simple ice pops or add a bit of no-carb drink, one crushed raspberry, or cream to make a quick frozen treat. Any frozen keto treat will freeze solid, so you might as well make it a pop and let your child eat it slowly. For kids adjusting to the diet, this can be a real treat and make them feel like they are getting more to eat because it lasts longer. You can find more on our ice cream pop mold recommendations here, our post Cook’s Little Helpers.
    • We have also collected a lot of small dishes. We actually use one of the IKEA play sets daily. They are ceramic, food-safe, dishwasher-safe and microwave-safe. Serving sizes are smaller on the keto diet and it’s ridiculous to put Nora’s servings into regular sized bowls.  Kid-sized plates and bowls are psychologically helpful as it makes the keto meal look fuller.  They also fit nicely on the scale.
    • On the topic of dishes, we often let Nora choose a small dish if we are out shopping and need a little reward pick-me-up for good behavior. Many grocery stores carry some dishes. Maybe a little whisk, cream pourer, ramekin, or even a pretty napkin or candle that she can pick out. Several fun dishes have entered our collection, and the small meals made in the special dishes make the food feel a little more fun and special.
  • Restaurants.  You can eat out at restaurants if you are careful and have appropriate expectations.  Sushi and seafood restaurants work great as salmon sashimi, edamame and crab are all very keto friendly (be careful with fish, to be sure it is only grilled or poached).  Another good option is to order a burger at a grill with no bun for your keto-kid.  Typically we have the meal pre-calculated and pre-packed except for the protein portion, which will be supplied by the restaurant.   We’ll weigh what we need of sashimi or hamburger at the table using our portable scale.  There is of course some risk of hidden carbs, but we find it to be reasonably safe if we are at a restaurant with a menu we know well.  I think meat from the restaurant — as opposed to something carby — tends to be a safer bet overall as it is usually prepared with nothing additional other than some fat or oil for cooking. However, many restaurants with a kid menu will have carrot or celery sticks as a side option, or possibly apple slices. Salads with dressing on the side can also get you greens and cucumbers to incorporate into the meal.  You can always ask the server or cook if any additional  information is necessary. It is also courteous to inform your server that your child has dietary restrictions, so they understand why you are dissecting her meal and giving her a little extra food from home, such as cream that you have brought with.
  • Consistency.  There is no cheating on the ketogenic diet.  Early in the diet, ketosis is fragile and the metabolism is eager to switch back to glucose-mode.  Even a small amount of extra carbs can open the door for breakthrough seizures.  Consistency allows for better troubleshooting too.  Which brings us to…
  • Breakthrough seizures.  Expect breakthrough seizures and a few rough periods even after extended periods of success.  It seems that everyone we have talked with has had the experience of several weeks or months of good seizure control, followed by a period of loss of seizure control, followed by regaining seizure control.  When this happens, keep your spirits up and look for any recent changes or anomalies (such as the clumpy cream issue).  Be strict and rigorous and keep going.  Seizure control will likely come back.
  • Even daily ratio.  Consider applying the ratio evenly throughout the day.  Early on in Nora’s treatment, before we went to a full ketogenic diet, we were very lax about what the ratio was during any particular meal, so long as the ratio was met over the course of the day.  This means you could have a very carby, low-ratio morning and a very fatty, high-ratio afternoon, for example.  It seems that seizure control improved when we evened things out.  The one exception is at dinner and bedtime, where dinner is usually low on the ratio, and bedtime is higher, so that we can get a last chunk of fat into her to last all night.  We made this change after some early morning tonic-clonic seizures in the spring of 2012.
  • Routines and expectations.  Establishing routines and expectations ease the day-to-day grind.  For example, Nora has three routines around supplements: baking soda in the morning after breakfast and in the evening during teeth-brushing before bed; calcium in her bedtime cream; and a multivitamin and calcium in her morning snack B^3.  She’s not crazy about taking the baking soda and the calcium, but now that it is a well-established routine, there is no more fighting about it.
  • Keto-friendly alternative sweets.  When possible, try to have a keto-friendly alternative for your child at birthday parties and other events where ice cream, cupcakes, etc…are served.  This requires forethought and planning, but is huge for the psychological aspect for your child. If you can find out what kinds of treats will be served, you can make something similar. However, Nora now likes to just pick her favorite treat to bring along, even if it is different from the party treat. It’s still natural for her to admire the other treats, but you can help to…
  • Help your child understand the restrictions.  We are very sensitive to this and we stress frequently to Nora that although her diet imposes some limits, it is still a very healthy diet with many truly delicious meals, and many people have some sort of diet restriction.  When we first started the diet, Nora really took to a book called “The Princess and the Peanut Allergy.”  She strongly identified with the food restrictions of the main character and the struggles and efforts of her friend to accommodate her.  Try to help your child see the diet restrictions amongst your family and friends to help them understand that having some sort of restriction — whether it is a nut allergy, gluten intolerance, upset stomach after eating certain foods, low-sodium diet, etc… – is normal.
  • Solidarity!  Eat keto-friendly yourself.  Eating meals that look similar to what your child eats will help them feel better about the diet.  Skip the bread and sugar; eat nuts, protein, vegetables, and fruit.  As a happy side-effect, you may very well feel better and lose weight.  Christy and I have both dropped about 15-20 pounds when we modified our eating to be more like Nora’s.  Honestly, there have been many times after putting Nora’s dinner together (e.g., skillet-fried ham-and-cheese, avocado, red pepper, nuts), I’ve thought “I want that!” (Christy says: It takes all of my willpower to not eat Nora’s cheddar crackers!) Also, don’t eat the birthday treats at a party. It’s better for you and helps her feel like she’s not the only one.
  • Don’t expect miracles.  Be happy with improvements in quality of life.  We were one of the lucky ones that got full seizure control.  But even if Nora still had some seizures (and I must accept that she might have more seizures at some point in her life), her quality of life would be much better than it was before the diet.  If you are considering the ketogenic diet, chances are you are in the difficult group of epilepsies.  Many of these epilepsies come with other problems too.  The ketogenic diet may not be a miracle cure, but it could still be a great help.
  • It’s not “hard.”  It is different.  If you think the ketogenic diet might help your child, don’t accept any statement that the diet is “hard” as a reason for not trying it.  I wouldn’t say the diet is hard.  Epilepsy is hard.  The diet is a tool that may improve your child’s quality of life and development.  (Remember that if your child has failed two anti-epileptic drugs, the diet is statistically more likely to help than a trial on a third drug. Also, certain epilepsies respond particularly well to the diet.) However, the diet does require some changes to your thinking and expectations.  Once you get your routines down and everyone gets a few months to adjust, the diet is not significantly harder than having other diet restrictions.  Just different.

I’d like to make this  a “living” list.  To all of our keto comrades, I invite you to email us or comment on your particular lessons learned.  I’ll add them to the list above.

Posted in Tips and Tricks | 10 Comments

Fall Keto Clinic Visit

We traveled to Portland yesterday, fighting the morning traffic for Nora’s keto clinic appointment. Nora continues to thrive and we delight in Dr. Wray’s obvious delight in her continued good health and seizure freedom. He ran her through the clinical neurological tests and we talked about lab numbers and other questions. Audrey, her dietician, said that Nora has one of the most beautiful growth charts of all of her keto kids. Knuckles all around! By the way, knuckles are the new handshake if you want to avoid illness this winter. Now you are in the know–pass it on.

It’s been a little while since we have given an update here, so I will catch you up. We continue to wean Nora from the keto diet a bit at a time. Better yet, she is still seizure free, 29 months running. Since the previous post, we brought her down to 2.25:1 for 3 weeks, then 2:1 for another 3 weeks. That was the last step in her wean plan before this keto clinic appointment. Yesterday we got the next steps in the plan, which I have scheduled at 3 to 4 week intervals:

9/17-10/11: 1.75:1 ratio, 120 g fat, 33 g protein, 35 g carbs
10/12-11/1: 1.5:1 ratio, 116 g fat, 42 g protein, 35 g carbs
11/2-11/22: 1.25:1 ratio, 111 g fat, 50 g protein, 38 g carbs
11/23-12/13: 1:1 ratio, 104 g fat, 65 g protein, 38 g carbs OR 104 g fat, 50 g protein, 54 g carbs OR somewhere in between (explanation below)

After 12/14: 1:1 ratio via Modified Atkins Diet (MAD); unlimited protein, approximating meals instead of weighing to the gram.

The plan was always to move to MAD, but seeing what that means for Nora became more interesting based on our current wean trajectory. The first weaning steps had her protein increasing to get her up to the recommended daily intake of protein for a child her size, which is around 26 g of protein per day. After she hit that target, each wean step increased her carbs and decreased her fat, keeping total calories the same. At 2:1, she was getting 35 g of carbs each day. As we continue the wean, you will see above that the protein is coming up again, while the carbs stay the same for awhile. Then when we hit the target of 1:1 we have some options for the mix of carbs and protein.

The interesting part: if a kid is on the Modified Atkins Diet as a stand-alone therapy, they cap carbs at 10 g to 20 g per day, which is less than Nora is getting right now. Because we are coming off of the diet they took the route toward a more normal diet first and favored increasing carbs, but that isn’t exactly the route to ending with the MAD therapy. Thus, as she continues to wean off the keto diet, we will now do a little course correction and increase her protein again, but there is no reason to take away her extra carbs if she is tolerating them well. And she is not only tolerating them well, but genuinely enjoying them! It has been wonderful to have a higher carb allotment during our summer fresh fruit season. Nora has enjoyed peaches, plums, pears and melons this summer, and just added back some bananas because she really wanted to try them again. We’ve even added a gram or two of honey to her steamed cream and toasting bread with butter. She gets enough carbs to enjoy that little bit of sweetness.

Following the schedule, her carbs will inch up a bit again by Christmas break, then we can slowly make adjustments between the carbs and protein if we want to go higher on her carb allotment. That will be our decision to make when we get there. We will also be able to start experimenting with approximating meals instead of weighing, which we will probably do gradually as well. We will be able to give Nora an idea of the foods that she can freely eat on MAD, given that her protein will be unlimited. But even now we increase her protein and match the fat needs if she is hungry. She has never been on a calorie restricted form of the keto diet.

Nora visits Ramona Quimby (from Ramona the Pest, by Beverly Cleary) at Grant Park in Portland.

Nora visits Ramona Quimby (from Ramona the Pest, by Beverly Cleary) at Grant Park in Portland.

In a funny twist of freedom, Nora ended up with an approximated lunch yesterday because we forgot to bring the scale to Portland with us! We planned for lunch at the McMenamin’s Kennedy School, where the Ted and the kids watched “How to Train Your Dragon 2″ in the theater-pub. Nora had the hamburger kid’s meal, which comes with a side of carrot sticks and apples if you ask for them (normally it will come with celery as an option, but Nora doesn’t like celery even though she can eat it freely!) We had the meal all calculated, and brought cream to drink on the side, but no scale. Ted did a great job of estimating the hamburger and veggies and Nora was just fine.

Now that I am writing about this end-stage to the wean, I wish I had more time and quiet to talk with Dr. Wray about it. He took the kids into the hallway to do the walking/running parts of the neurological test and we got a chance to talk to Audrey about the wean, but I have more questions. I want to talk about the difference between the typical MAD breakdowns with so little carbs, and Nora being on higher carbs. I’m not sure if we are still shooting for mild ketosis or if we should expect her to come out of ketosis if we push her carbs up to 54 g in the final 1:1 option. In the end, the real answer is: “We don’t know. Nora will show us what works for her.” That’s the right answer because everyone is different. But it still helps a parent to talk it out in a little more detail for your own kid. That’s always a take-away from these appointments for me: to be extra prepared in thinking through the questions and taking extra time to develop questions in the moment.

And it sure would help if the kids were not in the room making a racket. We cram the 4 of us and 3 of her keto team into a small exam room, and my brain stops functioning efficiently. But that’s my problem, and it’s not treatable by modern medicine. Just a little more mindfulness.

We will have another appointment in March and are free to ask questions along the way. In one more bit of good news, Nora might be free of blood draws for some time and can start scaling back on the baking soda when she gets to 1:1.

There are a few more summer highlights to catch up on, things I could have blogged about but didn’t have much to report in terms of lessons-learned. We traveled to North Dakota to visit family for the first time since starting the diet. We got a cat and named her Gracie. We went camping, visited friends in La Pine and spent a week at the Oregon coast. We ate our rooster, Freddie, and enjoy eating the eggs from our hens, Sparklebeak, Starfall and Solveig. Nora is in first grade and started taking piano lessons. We hope she learns some Spanish this year to put her nice accent to use. Nora still loves to sing and dance. She is a happy kid, and that’s what really matters every minute of every day.

Posted in Nora's History | 3 Comments

Throw Back Thursday, 2.5:1

Tonight I was emailing a parent who had contacted us for help with getting started with the Modified Atkins Diet (MAD). I shared the links to the information that Doernbecher gave us when we started (http://www.atkinsforseizures.com/). They basically told us to go to it, and away we went. MAD is a very DIY diet treatment, at least when we started.

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The parent’s specific question was how we documented Nora’s diet when we got started, so I took a picture of one day from the first food log that we kept, dated 12/15/11.

Excuse the handwriting and the food stains. We stood at the kitchen counter and wrote down everything Nora ate, along with the grams of carbs, protein and fat (each column of numbers). Then added up down the column to see total carbs, protein and fat and to calculate the ratio (fat/(carbs+protein)).

We got those numbers from a nutrition database and nutrition fact panels, and had a little “cheat sheet” for commonly used foods that we kept on the fridge. After a few weeks, I knew a lot of them off the top of my head.

In those days of MAD we were estimating and using common measurements, like 1/2 T of cream or 1/4 avocado, rather than weighing everything in grams. Everything was much less precise. Although we could see a difference in her seizures at the time, we didn’t yet have complete control.

Little notes found their way onto the page too: three small myoclonics and one medium myoclonic in the morning, along with feeling tired and hungry. Ketone readings at different points during the day.

On the back side of this page, I noticed that the final ratio for the day was 2.5:1. Just where we are now. And ready to step down to 2.25:1 tomorrow, still seizure free. What a difference 2.5 years made.

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Nora’s MAD About Granola!

Last week we took Nora’s ratio down to 2.5:1 and she is still doing great! We are getting ready to go back to North Dakota and Minnesota to visit friends and family for the first time since starting the diet, so we stepped her down a little earlier than scheduled so that we could get a good 10 days of 2.5:1 under our belt before traveling.

Traveling, especially air travel, feels like a big hurdle. We’ve been analyzing our list of regular foods to figure out what we need to pack, what we can shop for on arrival, and how to keep it simple yet appealing for Nora. Interestingly, we have noticed that bringing up her carbs has made us rely on heavy cream even more even though she is getting slightly less total fat. There are very few whole foods that have both carbs and significant fat (pretty much just kalamata olives). So for every extra serving of carbs, she still needs 2.5 g of fat on the side. We didn’t realize it at the time, but changing the ratio was easier when we were adding protein because protein foods (think cheese) usually have fat in them. Even small adjustments have changed the meal planning landscape.

Now, on to granola:

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In these years of keto cooking I’ve come across a few paleo-granola recipes and always thought I should make some for Nora. However, I always hesitated because I couldn’t imagine putting in any honey or dried fruits when she was more carb-restricted, so any recipe that worked for her would have amounted to a pile of crunchy nuts. Maybe not worth the effort when she eats plenty of raw nuts already.

IMG_4894Now that she gets 25 grams of carbs per day (remember when it was 10 g of carbs per day…for almost 2 years?), I threw one of the paleo-granola recipes into my recipe analyzer website and saw my opportunity. Nora is now eating dried currants and honey! It’s just a bit, but they are in there. And this granola is so very delicious, with just a hint of sweetness, that it is much more than a pile of crunchy nuts. It is at 2.1:1 ratio, so just a bit of extra fat brings her to 2.5:1. It will be highly packable and a very “normal” breakfast on our trip. Nora also loves it! She asked for granola instead of popcorn when she watched a movie with friends recently and keeps suggesting it as a snack option. As she says, it’s like cereal, only better!

I would recommend this recipe for anyone doing MAD, low-carb, gluten-free, paleo (is this recipe paleo? I can’t keep track, decide or modify for yourself). I’ve been eating it for breakfast with my kefir too. I went back to the commercial granola this morning for comparison and preferred the homemade granola because it was more flavorful and crunchy, and not as sweet. Nora has had it for breakfast daily with full-fat plain Greek yogurt, heavy cream, and a few fresh blueberries, formulated for a 2.5:1 ratio.

If you or your child are on a high-ratio strict ketogenic diet, this batch-process might not be appropriate for you. You may still be able to make granola, but you will want to divide the ingredients down into individual servings so that you know exactly how much carb, protein and fat is served at one time. When I take 20 g of granola out of the batch, I don’t know if Nora is getting 3 or 7 currants in her breakfast. I only eyeball it to make sure I’m getting a spoonful of granola with a reasonable mix of nuts and currants. At this point I’m confident that the difference won’t matter for her, but back when we were striving for seizure control and counting the days and months of seizure-freedom I would not have taken chances with it. Alternatively, I think you could leave out the currants and be more confident that any serving taken from the batch is approximately equivalent in carbs because the honey is equally distributed.

Actually, you can completely revamp this recipe any way you like, as long as you keep the general proportions the same. This is my 2nd version of granola. The first time I used dried cranberries instead of currants and slivered almonds instead of pecans. I also included sunflower seeds in that batch, and less coconut. The first time, I basically pulled all of the nuts and dried fruits out of my cupboard and used what I had on hand. In this version, I bought the ingredients that I needed to make it lower carb and higher fat.

I know that most people won’t have brown rice protein powder in the cupboard, and it is not essential to the recipe. It’s been hanging out in our cupboard since Nora’s MAD days, when I was trying to cram more protein into everything I made for her. Now I want to use it up! Go ahead and experiment with what you like, but remember that if you are keeping close track of nutritional information you will have to analyze your recipe accordingly. The nutritional facts given here are specific to these ingredients and to be used as a reference only. Nutritional facts for the whole batch are given, and please see the note on nutritional information at the end of the post for more details.

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Nutritional information in one whole batch of MAD About Granola. See below for individual serving nutritional information. Analysis by http://caloriecount.about.com

MAD About Granola
200 g (1-2/3 cup) walnuts
200 g (1-2/3 cup) pecans
100 g (3/4 cup) macadamia nuts
50 g (2/3 cup) zante currants
50 g (1/2 cup) Bob’s Red Mill golden flaxseed
30 g (1/3 cup) unsweetened shredded coconut
10 g (1 Tbsp) brown rice protein powder
30 g (1 large) egg white, lightly beaten
30 g (2 Tbsp) water
40 g (3 Tbsp) coconut oil
40 g (2 Tbsp) honey
5 g (1 tsp) vanilla extract
1 g (1/2 tsp) ground cinnamon
1 g (1/4 tsp) salt

Preheat the oven to 200 degrees F and line a baking sheet or roasting pan with parchment paper or a silicone baking mat.

f1829440Measure the whole nuts and currants and pulse in a blender or food processor to chop the nuts, but don’t grind them into a fine meal. Pour into a large mixing bowl. You will get some nut dust, which is ok. If there are any nuts that are nearly whole, pull them out and chop down to smaller pieces. Everything should be coarsely chopped. Next, measure the flaxseed, coconut and protein powder (if using) and add to the chopped nuts. Combine well.

In another mixing bowl, whisk together the egg white with the water until bubbly and slightly foamy.

In a microwave-safe bowl, melt the coconut oil. Measure and whisk in the honey, vanilla extract, cinnamon and salt. The cinnamon makes it look dark, as in the photo. Add this to the egg/water mixture and whisk well. Use a rubber spatula to be scrape all of the mixture out of the bowl.

Combine the wet and dry ingredients, stirring everything well to make sure it is all coated. The mixture should be evenly moist but not pooling liquid on the bottom of the bowl. The liquid will pick up all of the small loose bits and bind them together, which is just what we are looking for.

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Spread the granola mixture evenly on the parchment or silicone mat-lined baking sheet or roasting pan and bake for at least 60 minutes, stirring after 20 minutes, and again after 40 minutes. After the last stir I pressed the mixture firmly into the pan so that chunks could bake together. Turn off the heat and let the granola sit inside the oven until cool. I waited several hours. I made it in the morning and did the hour of low baking, then took it out of the oven in the evening after dinner. The granola will continue to dry and form clusters in that time.

Use a spatula to gently break the granola into clusters. Some loose bits will also break off. It’s all good. Transfer everything to a 2-quart sealable glass jar, or any airtight container to keep it fresh.

Nutritional information note: Notice from the nutritional information that the raw measured ingredients add up to 787 grams before cooking. After cooking, the whole batch weighed 710 grams. Typically baked goods lose about 10% of their weight by volume when the moisture cooks out of the food, which is true here as well. That means that you get more carbs, protein and fat per gram of cooked food because only the water weight disappears. When you calculate the nutrition per cooked serving in a batch like this, you have to divide by the cooked weight to get accurate nutritional data.

For every 1 g of cooked granola in this recipe, there are:
Carbs: 0.13 g
Protein: 0.15 g
Fat: 0.58 g
Fiber: 0.09 g

Add that up, and you get 0.97 g of macronutrients in 1 g of granola. We can infer that there is 0.03 g of water left too. Math and science at work!

In a 20 g serving typical for Nora, a scant 1/4 cup, this recipe has:
Carbs: 2.64 g
Protein: 2.91 g
Fat: 11.66 g
Fiber: 1.86 g
127 calories
2.1:1 ratio

Enjoy! Inspiration for this recipe from: http://www.theroastedroot.net/paleo-granola/ and http://againstallgrain.com/2012/01/29/grain-free-scd-paleo-vanilla-granola/. But just google paleo granola and you will find many more! Try it and you will never go back to commercial granola or cereal!

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Meet the cows who make the cream: Organic Valley farm visit

IMG_4848Nora and I took the perfect keto kid field trip! We visited an Organic Valley dairy farm just 30 minutes from our house, makers of Nora’s brain-healing heavy cream. We are very good Organic Valley customers and Nora was happy to meet the cows that make “her” cream. She keeps asking to have her own dairy so that she can sell milk door-to-door. I keep telling her that the city will not allow us to have a cow in the backyard. She should focus her attention to her chickens. Visiting cows is the best that I can do.

Double J Jersey dairy farm is run by the Bansen family, Jon and Juli and their four children. Their oldest, Ross, is now a part-owner of the farm after getting a business degree in Iowa and traveling the world for a year visiting dairy farms. Their other children have their own responsibilities on the farm, the youngest is a senior in high school. They moved to the farm with a 2 year old and a newborn, then in 2000 they converted to organic pastured production and joined Organic Valley, a cooperative of 1,800 dairy farmers across the US committed to the economic success of mid-sized family-owned dairy farms along with the environmental benefits of organic production.

Keto families also love Organic Valley because our dietitians tell us that it is the only cream that is reliably free of carbs. The whole milk comes from the cow, and the cream is then separated at the creamery but some of the lactose in the milk could remain with the cream. Many other brands of cream report 0.5 g of carb per serving, some report zero, but in reality might be up to 0.5 g to 1 g of carb after processing. Keto dietitians recommend Organic Valley because in their experience it is all fat, just the good stuff. When we calculate Organic Valley cream for Nora’s meals, we count it as 40% fat, 60% water. Nothing else.

Nora displays her butter. Photo courtesy of Ann Shriver.

Nora displays her butter. Photo courtesy of Ann Shriver.

Our first farm activity was taking those familiar cartons of heavy cream and making our own butter! We poured some cream into a glass jar and shook for about 10 minutes. It got thicker and thicker until it didn’t even seem like anything was sloshing around in there, then all of a sudden it was a clunking chunk of yellow butter! The buttermilk that had separated was thin and I let Nora drink it right from the jar, along with tasting that yellow buttery deliciousness. It was the softest, most buttery butter I had ever tasted. Where else can you take a tour and get perfect high-quality fat for samples? Try it yourself. It’s like magic!

All of the Bansens who gave us the tour were wearing Organic Valley t-shirts that said “who is your farmer?” In this world of industrial food from nowhere, we are privileged to see the origins of our food, and the cows are fortunate to live such a comfortable life. The milk truck comes to their farm every other day and takes it to creameries in Portland, where Organic Valley rents processing facilities from other creameries (Darigold and Alpenrose, in Portland) to process and package the raw milk into the dairy products that we buy at the store. The organic milk is run first thing in the morning when the machines are clean. If you look at the printed code on your milk or cream carton you can see where your milk was processed before being delivered to the grocery store. Nora’s Organic Valley cream has the code 41-33. Put that code into this website: Where is my milk from? It was processed at Alpenrose Dairy creamery in Portland, OR, but it came from an Organic Valley dairy. There is a good chance it came from Jon Bansen’s Jersey cows, but alternatively his cousin Dan and niece Jamie also have their own Organic Valley dairy in Oregon;  brother, Bob, runs the dairy the boys grew up on in Yamhill County, Oregon; and Jon’s older brother, Pete, operates the original family dairy back in Ferndale, California. It is highly likely that Nora’s Portland-processed cream came from a Bansen cow!

Happy cow, waiting to be milked in a few short hours.

Happy cow, waiting to be milked in a few short hours.

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In the pasture where the cows would be grazing later in the day.

We walked out to the pasture with Jon, where he told us about his rotational grazing method and his real job: to take care of the bacteria that make a healthy soil to grow nutritional pasture, which in turn takes care of the bacteria in the cow’s gut to break it down and turn it into nutritional milk. He moves the herd through paddocks with movable fencing every day when the plants are just the right height for grazing: healthy long green tender plants up to our shins that let the cows eat their 300 pounds of grass per day (really?!?), but have not become so tall and fibrous that they are hard to digest. He could count 15 different species in the pasture, some of which are “weeds” that the cows eat and many of which he planted with a no-till process that keeps the soil intact and healthy. The cows munch down the pasture so that the plants can spring up again, while working their “nutrients” into the soil to fertilize (I stepped in some of those “nutrients” in the barn!). Cows have 4 stomaches and are “fermentation vats on legs,” as Jon told us. The plants turn sunlight into food to grow, the cows turn those plants that we can’t digest into milk (sugars, protein and fat), and if we take care of the pasture and cows we get the nutritious milk and cream. It’s a pretty sweet deal and we should thank our farmers.

Kids take a walk through the fly vacuum!

Kids take a walk through the fly vacuum!

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Ross demonstrates the automatic cow brush.

These cows live a comfortable life. They are out on pasture from the first spring day when the Oregon winter rains break, usually in March. Jon says that the first day out to pasture is the best day of the year, even better than Christmas. When they have to be inside, during the winter or very bad weather, they are sheltered in open air barns with bedding. During the winter they eat silage that was cut from their own fields and stored on the farm. The farm has bird houses everywhere, especially up in the rafters of the barns. They are home to swallows and swifts that feast on the flies and keep the cows comfortable. There is also a fly vacuum that the cows walk through when the go to the milking parlor twice a day. It is a low, gentle suction that takes the flies off of their bellies.

The barn also has a full-body cow brush, which turns on when a cow rubs against it. They can use it whenever they want it. The ladies can come over for a full-body brush/massage when they are in the barn. Ross said that in the winter they even butt heads about getting a turn, so they put in 2 of them. In the spring when they are shedding there is a lot of hair left on the floor.

When the cows are in the barn for the winter, their waste moves into a concrete lagoon beside the barns. There was no mistaking that this was a dairy farm by the smell, but it was a clean rich odor, not a sickening manure smell. The lagoon is managed properly and the waste is spread over the fields in a thin layer 3 times per year to keep the nutrients in the cycle, worked back into the earth where the plants can take up the nitrogen and use it again in the growing cycle.

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The milking parlor.

We also visited the milking parlor, a small clean room where they go twice per day. There is a heater on the ceiling for cold winter days, and large fans in the walls used in the warm summer. The cows get about 2 pounds of organic grain when they come in for milking, a mix of barley, oats, and corn. It’s a little “incentive” to come off the pasture. They don’t need the grain but it’s a treat, like “junk food” for cows. Ross told us that they like it and it gives them a little extra quick energy for making all of that milk. Nora really wanted to see how the milk and cream is put into the containers, but we will have to go to the creamery in Portland for that tour.

Nora and a 2 day old calf.

Nora and a 2-day old calf.

We can’t forget that cows have calves, which is the start of the whole milk-making process. There was a group of cows that were waiting to calve, the “dry cows” because they will not make milk until after they give birth and are not given hormones to increase or prolong milk production. When the calves are born, Juli Bansen becomes their caretaker. She sees that they get enough milk and food to grow. The males are sold to a nearby farm who raises them for beef, sold specially as Jersey beef to Portland restaurants. Jerseys are good at making milk, but their small frames are not the breed of choice for large cattle feeding operations. The Bansen’s special breed and organic production make them perfect for specialty beef. The females may be added to the herd or sold to other dairy farms.

Because they are an organic dairy, they may not use any antibiotics or hormones. If a cow gets sick and needs medicine they have to take her out of the herd and sell her to a conventional dairy. The Bansens said that after they switched to organic and gained experience, they almost never have a sick cow. All of the time spent on pasture and nearly 100% pasture fed means that the cows’ bodies are allowed to do what they are meant to do: ferment and break down green plants. They are out in the open and not exposed to excess waste or stress that will tax their immune systems. A happy cow is a healthy cow.

It was a pleasure to see the Bansen farm at work and listen to their experiences. It was clear that they take great pride in their dairy and the health of their animals. Their house was right next to the barns, surrounded by lush gardens lined with bird houses and a chicken run. A blue heron soared across the fields into a stand of trees while we were walking to the pasture. The calves were kept just steps from the front yard. They clearly enjoy their lifestyle and it makes a good living, so much that their oldest son is in the process of taking over the dairy so that his parents can retire. It is a special thing to see people love what they do, surrounded by healthy land and animals, both domestic and wild. It feels good to know that we are supporting their work by buying their milk and cream, which is in turn keeping Nora’s brain healthy and growing. We were there celebrating their success and we thank the Bansens and other Organic Valley farmers for giving us a healthy option for Nora that we can feel good about in every way.

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Continuing to wean and a berry tart for spring

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Nora’s birthday pool party, with keto cheesecake and strawberries, post-sunscreen and goggles!

We moved Nora’s ratio down to 2.75:1 about 10 days ago and she continues to thrive. So much has been going on that we have not had time to write a thing–dance recital, kindergarten graduation, Father’s Day, summer vacation, and Nora’s birthday! She turned 6 last Sunday and enjoyed a pool party with her friends. She requested Keto-Perfect Cheesecake as her birthday treat, with lots of strawberries on top! Half of the cake was lunch, the other half was afternoon snack and part of dinner. What a great day!

This feels like a significant step down in ratio because Nora’s myoclonic seizures didn’t stop until we were using a 3:1 ratio in a consistent way throughout her day. We are now below what felt like our “safe” point. Ted has checked ketone levels with the urine dip sticks and found that she isn’t in the highest ketosis level all of the time anymore, although still quite strong. From here on out we increase her carbs and decrease her fat because she is now getting the daily protein requirements for a kid her age. When we stepped it down to 2.75:1, she went from 17 g of carbs per day to 21 g of carbs per day. That’s a pretty big jump, 4 extra grams of carbs is a treat (see 1 gram of carb of various foods here). Hooray for fresh berry season! We are getting at least 1/2 pint of raspberries from our own bushes every day and getting to the farmers’ market weekly to make the most of her new carb allotment. I’m starting to think about trying the higher-carb fruits and veggies that have been off-limits.

Look at all of those berries!

Look at all of those berries!

With all of the milestones, particularly moving down the ratio and her birthday, both Ted and I have been feeling more anxious. We don’t take for granted that Nora is so big, healthy and smart today, which sometimes makes the wean seem all the more perilous. The better things are with Nora, the more we have to lose if epilepsy lashes out at her again. Of course, we still have every reason to believe that she will wean off the diet and do fine, but some of these moments have us holding our breath, hoping that it is all behind us. We went camping last weekend. Nora could not remember going camping before, it has been so long since we went as a whole family. She loved every minute of it and we had watermelon with our dinner, including some for Nora. We are going back to visit family and friends in the Midwest this summer, which we have not done since starting the diet. We hope that this is the new normal.

I’ve done some extra baking to let her enjoy the new ratio, mostly using almond meal more than I have before. I tried this berry tart crust recipe, slightly modified from the Almond-Pecan Piecrust recipe in The Joy of Gluten Free, Sugar Free Baking and it turned out great. Sturdy enough to remove the tart mold and look like something from the French bakery while being simple and delicious. It’s a keeper.

Nutritional information for one Tart/Pie Crust, with berries. Nutritional analysis by http://caloriecount.about.com/

Nutritional information for one Tart/Pie Crust, with berries. Nutritional analysis by http://caloriecount.about.com/

Tart or Pie Crust
(1 serving, 2.5:1 ratio)
13 g almond meal/flour
3 g ground pecans, or hazelnut meal/flour
3 g coconut flour, Bob’s Red Mill
6 g butter, melted
0.3 g baking powder
1 g vanilla extract
dash of salt
4 to 5 g water as needed (see below)

Preheat oven to 325°F. Weigh and mix together nut flours, baking powder and salt. You can use a sprinkle of no-carb sweetener such as stevia if desired.

Melt butter and mix in vanilla extract. Stir into dry ingredients and add water just until the mixture is stiff, like the consistency of playdough.

Put the dough into a single-serving tart or pie pan, spread it with your fingertips until it is evenly distributed. You could also shape it into a flat circle on parchment paper or a silicone baking sheet. Prick the bottom and sides a few times with a fork to prevent air pockets. Cover the edges with aluminum foil (or not) and bake for 10 minutes if using a cream-like or custard filling. I haven’t tried it, but I bet the blueberry panna cotta recipe would be wonderful if added to a baked tart crust. I’ve got a mind to try the vanilla cream pie filling recipe from the cookbook as well, with appropriate modifications.

IMG_4779To make it a berry tart, calculate the amount of berries and coconut oil or butter you want to use as a topping. For example, for a 3:1 ratio, you could add 10 g blueberries, 20 g raspberries, and dot with 5 g coconut oil (pictured). Bake for about 20 minutes or until berries are bubbly and crust is browned. Then serve 14 g cream on the side, as whipped cream, with tea, or as “keto milk” thinned with water and with a drop of vanilla flavoring.

I’ve used this basic recipe for berry tart and cheesecake for family and friends after trying it for Nora. Using a full-sized recipe and pie pan, I made the chocolate crust version adding cocoa powder and sugar (of course, for Nora I would use stevia instead of sugar–the chocolate requires some sweetener or it would be too bitter). The crust got rave reviews from a group of grad students! I personally like the flavor better if I skip the coconut flour, but it holds together better if it is included. This recipe is versatile enough to be modified for your needs. If you want to make a firm-sided tart, make sure to use the coconut flour version and a little more water. If you don’t mind it a little more crumbly, use all pecan or hazelnut and slightly less water. It’s all good.

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Antibiotic Time

Quick update and tip for childhood illness!

Nora is still doing fine on 3:1. We will step down to 2.75:1 next weekend, right after the last day of school and kindergarten graduation.

Last week Anders came down with strep throat, which was diagnosed very quickly. He got the pink liquid antibiotic of amoxicillin and was feeling better 24 hours later. We were on the look-out for another family member to fall ill, especially Nora.

I started feeling cruddy on Saturday, so I went to urgent care and took Nora with me even though she said she felt fine. They did throat swabs on both of us. The rapid tests came back negative, but Nora’s 24 hour culture came back positive (but not mine! I’m was feeling better the next day.)

Nora has not needed an antibiotic in over 2 years! We referred back to our illness preparedness plan post and found little guidance on how to deal with antibiotics. Ted went to the pharmacy to explain the situation, and thankfully the pharmacist was happy to work with us.

He explained that they mix powdered amoxicillin with the “pink stuff” right at the pharmacy but he did not have any information about the ingredients in the pink stuff. Instead of mixing, we took home plain capsules of amoxicillin. Dosage is 1 capsule in the morning, one at night. Nora doesn’t swallow large pills, so we open the capsule and mix the powder with a bit of yogurt. Nora doesn’t mind the taste, and this is a girl who has taken a lot of medicine mixed in stuff. She knows when it tastes bad and is not afraid to say so. Now we have 9 more days of morning and night doses and we are in the clear. Glad we caught this now so that she is healthy for kindergarten graduation!

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Stepping down to 3:1

Nora has been cruising along as 3.25:1 for the last 3.5 weeks. Her wean schedule calls for going 3 to 4 weeks at each step down. Originally we thought that we would keep 3.25:1 for 4.5 weeks, because we started mid-week and will make changes on the weekends. She is doing so well that we decided to go for the next step down last Saturday. All is well!

We’ve been looking forward to 3:1 from the meal planning angle because many of the whole foods that make up the backbone of Nora’s diet are well above 3:1, like avocados, cream cheese and macadamia nuts. There are a few others that are at or near 3:1 that now will support the ratio instead of dragging it down, like walnuts. I suppose “so much easier” is really a matter of perspective. After doing it for a few days we can see the difference between 3.5:1 and 3:1.

This month’s ratio change brings her up to 26 g of protein, her full requirement for a kid of her age and size. Her carbs will only come up 0.5 g. That means that this month we adjust to getting more cheese and meat in her diet, and the step downs after this will be marching up the carbs while decreasing the fat.

I like to have at-ratio popsicles made for easy afternoon snacks. I didn’t re-do any recipes for first step down, but I redid them last weekend to get to 3:1. It made me realize that we don’t have a lot of at-ratio recipes for her. Instead we build meals around various foods that she requests, adding the necessary fat to the meal in other ways. I recalculated her berry frozen yogurt pops and chocolate chip frozen yogurt pops and made a batch of each at 3:1 this weekend (note that the linked recipes are at 3.5:1, but decreasing the cream or increasing the berries, yogurt or protein powder appropriate changes the ratio). Very little has changed in those popsicles, Nora won’t even notice the difference, but now we have a stash of snacks to get us through a few weeks.

This is a short and sweet update, so here’s a fast keto-fact observation: Nora very rarely ever passes gas. If she does toot or burp, it’s a huge hilarious surprise! Maybe other keto-families have noticed this phenomenon too?

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