We came into the ketogenic diet in a non-standard way for Nora. We started with a low glycemic index diet for a few weeks in the fall of 2011, then to a modified Atkins diet for a few weeks, then to a 3:1 ratio ketogenic diet for a few months, and finally to a 3.5:1 ratio ketogenic diet from April of 2012 to April of 2014. Each increase provided better seizure control.
Because we transitioned slowly into the ketogenic diet instead of the traditional 24 hour hospital induction, we had time to develop many of our own tools for tracking Nora’s diet and seizures. When we went full keto, we continued to use these self-developed tools — mainly a Google Docs spreadsheet — with the approval of our neurologist and dietician team. (Although we administered the diet differently, we greatly support the Charlie Foundation’s Keto Calculator, and recommend that tool for administering the ketogenic diet.)
Starting April 2014, after two years of seizure freedom, we slowly weaned Nora by decreasing the ketogenic diet ratio by 0.25 every 3-4 weeks. In December of 2014 we finally weaned down to a 1:1 ratio. We then transitioned to a modified Atkins diet in which only carbs are tracked (as opposed to the full suite of carbs, protein, fat, and fiber). This greatly simplifies administration of the diet, but we still use a simplified version of our spreadsheet.
We get a lot of questions about our methods for administering the diet, and because the modified Atkins diet can be done with less strict medical oversight, we are now posting a version of this spreadsheet in case anyone finds it useful for administering the modified Atkins diet. (For the ketogenic diet, we recommend using the Charlie Foundation’s Keto Calculator as that is a widely supported and vetted tool.)
We recommend using a tool like this if you aren’t sure you are estimating portions right, and want to learn the proper proportions of foods using a gram scale (a traditional kitchen gram scale will be fine, no need to measure to the tenth of a gram as in the ketogenic diet). We have also found it useful in weaning off the ketogenic diet, after you have been accustomed to weighing all food and want to learn how to think in portion sizes again and only count the carbs, not the ratio.
Note that the modified Atkins diet is still a high-protein, high-fat diet. You are still going for a 1:1 ratio. This spreadsheet only helps you count carbs and is not intended to help you plan full meals at a 1:1 ratio. Notice that cheese and meats are not listed (unless it is a product with significant carbs). Add protein and fats to every meal, and use the higher fat foods in the spreadsheet (labeled in green) to supply healthy fats.
The modified Atkins diet is less demanding on the patient than the ketogenic diet, but it is still a restricted diet with potential side effects. We strongly recommend you inform your medical care team if you are going to use the MAD diet for your child. Low carb diets can interact with other medications, and some medical conditions are contraindicated with low carb diets and could be very dangerous. Check with your medical team. If your child is struggling, sick, or is continually not feeling well, stop the the diet and check with your medical team.
You can download the MADSheet (version 1) here: MADSheet-v1.
Instructions are given in the “INSTRUCTIONS” tab in the spreadsheet. Foods with no (or very little) carbs (such as butter) are not listed in the spreadsheet as they don’t need to be calculated and weighed. But they will still be part of most meals. As an example, for a morning snack for Nora I would like 3 grams of carbs of apple and 1 gram of carb of 85% dark chocolate and 3 grams of carbs of peanut butter. Using the MADSheet, I put 3, 1, and 3 respectively in cells J24, J27, and J29. It is then calculated that I need 24 grams of apple, 3.6 grams of chocolate, and 24 grams of peanut butter. If I were doing this for Nora I would then put an additional dollop of butter in with the peanut butter to push the ratio up a bit, but I don’t need to measure that as it doesn’t have any carbs. (In the full keto version of the diet though, I do need to calculate and weigh the correct amount of butter along with everything else.)
Lastly, the MADSheet tool is not intended as an optimized, finished product in any way. We do not guarantee the spreadsheet to be free of errors or bugs. We are providing it as a template or starting point to be modified as necessary to fit the needs of the user. Please delete foods, add foods, change and modify cells and calculations as you see fit. Please take care to double check all calculations and formulas, especially after making modifications. This is not intended as medical advice. Please check all methods with your medical team. Use at your own risk.
Oh my goodness…just spent four hours today attempting to create my own spreadsheet. You posting this is a godsend! Thank you thank you!
Great, you also get to be a beta tester! Let us know how it goes and if the layout makes sense. Feel free to make changes.
This spreadsheet is really helpful for the MAD diet where you only count carbs and then estimate protein and fat. I guess starting out with this I’m struggling to figure out definitely what we want our goals to be…MAD, or a strict 1:1… For our daughter we have her on a low glycemic diet with added in fat… this has done a lot for her… so, now we’re looking to see if we can tighten it up a bit, but aren’t sure whether to do MAD or 1:1 (simply so I can see that she is getting the right ratio in all areas of fat / protein / carbs). Being veterans at this by now, you guys probably just have a really good idea overall of what Nora is getting. My question is… do you still have a specific goal each day for Protein and Fat servings for Nora? Or (I remember your wife mentioned you’re now just letting her eat what protein she feels comfortable with as that was working).. so, does that mean, besides counting carbs are you just aiming at only getting a certain amount of fat servings in?
At this point, we are just counting carbs. Protein and fat are not recorded or calculated. We depend on Nora’s hunger level and the availability of carb-free foods like cheese and meat to allow her to self-regulate her calorie, fat, and protein needs. The first few days Nora went to carb-counting-only MAD, I still recorded everything she ate to see what ratio effectively was being achieved, and found it to be very close to 1:1.
My advice would be that it probably doesn’t make sense to do a strict 1:1. I think you will get the same benefit from MAD (carb counting only) with lower administrative overhead. Stronger ketosis starts kicking in at 3:1 and higher (for Nora, anyway), so that requires more care and precision.
WOW! Thank you for sharing this. We have had our daughter on 2:1 for a couple of months now…sort of a combo MAD/keto. Have improvement but no complete control. I had been wanting to start tracking everything so that I could see trends/what was working etc…..but I am a bit of a dinosaur with spreadsheets! Just figuring out the KetoCalculator, now trying to incorporate your spreadsheet will be super helpful. When you were on more strict ratio’s with Nora, did you use the same spreadsheet style and just add in fats/proteins? So happy for your girl that you have seizure control, and thank you for all your sharing!
Yes, we used the same spreadsheet approach, but a different spreadsheet that incorporates protein, fat, and fiber as well. As we’ve stated before, we got the OK from our medical team to do it that way after we demonstrated it to them, to assure them we were administering the diet correctly. Certainly we encourage you use a spreadsheet or log with your daughter’s diet to help see what works and what doesn’t, but in general we recommend you use the Keto Calculator as your main tool. We’ve provided this spreadsheet as a tool for MAD administration, which is not as strict, with a ratio around 1:1.
I hope your daughter continues to improve. Hang in there. She is going to be OK.
Hi Christy and Ted!
I have followed your blog for years and have found such informative information in it- thank you so much for all that you both do.
I replied to one of your post and we have come so far from back then. We were on classic keto and now after 2 1/2 years of seizure freedom for my son, Charlie, we have been given the okay to wean to MAD.
I need help, please.
I am so dependent on our spreadsheet and scale- I am having such difficulty giving him food freely, without weighing it!
So, this past week I made a decision to make him 2 meals and try my hardest to be more lenient- so, I added extra cheese and pepperoni on his pizza and gave him a squirt of whipped cream in his mouth 🙂
Would you share with me how you both weaned Nora from keto to MAD?
Any tips would be a tremendous help- I am so scared of messing something up after we have come SO FAR!!!
Thank you again for all that you have done and continue to do,
Big love from Atlanta GA
E’dy Burel Choate, RN @ Emory University Hospital
It is a pleasure to hear from you and we are so happy your son is doing so well! Undoubtedly weaning is an uncertain process and it’s normal to be anxious!
I like to think of three versions of the diet:
– Keto: carbs, fat, and protein (and fiber) are calculated and weighed for a certain ratio of carbs and protein to fat, and also a carb limit, and also a minimum amount of fiber
– MAD: only carbs are limited, calculated, and weighed
– LGI: avoiding sugars and meals which would cause blood sugar spikes; no calculation or weighing
During the wean we stayed keto but decreased the ratio down from 3.5:1 (our baseline) to about 1:1 by steps of about 0.25 every month or so. Once we got down to 1:1 (if I remember correctly we started taking steps larger than 0.25 toward the end) or so, we switched to just limiting to 10 grams of carbs, not tracking fat or protein. MAD, in other words. So we still weighed and calculated, but only with regard to carbs. This also allowed Nora to be able to choose cheese, meat, or other carb-free snacks on her own; she had freedom to go to the fridge and get cheese for herself. (I recall reading somewhere that a carb-limit combined with pushing fat will get you close to 1:1. Just for peace of mind I calculated her ratio a few days after we switched to a 10 carb limit and indeed found the ratio close to 1:1.)
Finally, we transitioned to a LGI style diet where we keep processed sugars and carbs (e.g., bread) out, but Nora can self-regulate fruit so long as she couples it with a roughly equal (by volume) amount of cheese or nuts. I haven’t tracked a day for her in a long time, but I would guess most days for her now are somewhere between 0.5:1 and 1:1.
Sooooo, to answer your question, I would say keto down to 1:1, then go MAD with a 10 g carb limit. Gradually increase that to a MAD 20 g carb limit. Then switch to LGI and stay there as long as you like. Nora is there now and I don’t see a reason we would change that until she is old enough to decide what she wants to do.
It certainly is both scary and exciting to wean. You don’t have to rush. Make controlled steps and let things get comfortable before making another step.
Does that process make sense? Let us know how we can continue to help!
Hi Christy and Ted!
you are amazing, helping others a lot. Really tremendous source of information and help to desperate people.
Our son, 11y, had a first bigger seizure. Otherwise only small, in the sleep seizures, about 10 seconds duration. Few per month only.
But, the doctors, were straight forward to insist on medication, Levetiracetam. I feel, we should try understand first the triggers, manage triggers, try other solutions. Improve sleep, avoid games/tv, try diet…
I see you were successful and we will try your approach too.
thanks a lot
Our hearts go out to your family as you deal with epilepsy. But you are being proactive and engaged, and you know your son best! You can provide the best care for him and are doing your research. Our doctors were always very impressed that we kept good records so that we could see when something was working, and when it was not. It is hard work, but it is worth it to give your son the best life possible. That’s all we want to do for our children!
Our best to you and your family,