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.

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.