On the ketogenic diet at a 3:1 ratio, Nora ate about 1200 calories per day. Broken down into grams, that is 10 grams of net carbohydrates, 28 grams of protein, and 115 grams of fat. Quick note on net carbs: you can take total carbs (starch and sugar) in a food and subtract the fiber because it moves right through the body without raising blood sugar. Fiber is awesome! Net carbs are strictly limited to 10 grams, so any wiggle room in the target amounts comes from varying protein and fat.
A 3:1 ratio means that Nora ate 3 grams of fat for every gram of carb + protein, so if she eats just 1 more gram of protein, I need to provide 3 more grams of fat. But that adds up to extra calories very fast. One gram of protein has 4 calories (carbs also have 4 calories per gram), while 1 gram of fat has 9 calories. So if she gets an extra gram of protein plus 3 grams of fat, that adds 31 calories (4 calories from protein + 27 calories from fat) to her diet. Considering that the keto diet is also calorie restricted—too many calories can interfere with ketosis and seizure control—we have to stick to these numbers fairly closely.
The traditional ketogenic diet sets a strict limit on carbs, protein and fat for each meal and snack, but our delivery of the diet is modified to allow some flexibility in each meal. We just try to keep it fairly even through the day until reaching the correct breakdowns by the end of the day. It requires some planning ahead and having targets, but allows flexibility. Each family should decide what works best for them and work with their dietician. To get started, it is probably best to stick to simple meal plans, especially meals that your child likes. As you get comfortable you could add new foods and flexibility to the diet when you need it.
One modification we made was to give Nora a higher ratio at bedtime. Her last breakthrough seizures were in the middle of the night so we adjusted by allowing a lower ratio at dinnertime then giving her an extra boost of fat at bedtime to keep her in ketosis until morning.
Below is an example of Nora’s meals for one day at 1200 calories, 3:1 ratio (she was 4; if you follow the blog, notice that later we increased her ratio to 3.5:1). She tends to eat the same breakfast and snacks every day—she goes through phases, eating the same things until she complains, then we switch it up and she sticks with the new plan for awhile, and so on. We build the lunch and dinners throughout the day depending on what the rest of us are eating or what we have in the house. We kept track of each meal as we built and served them, writing it all down and calculating a running total in the spreadsheet. Most families will use the KetoCalculator to achieve the same results.
Example day, 3:1 ratio, 1200 calories:
Breakfast: 1.7 g carbs, 3.65 g protein, 16.1 g fat, 2.5 g fiber (166 calories)
- 30 g of Chocolate Hazelnut Cereal (Chocolate Hazelnut Cookies, broken up)
- 6 g Organic Valley Heavy Cream, thinned with water to make “milk”
Snack: 1.8 g carb, 1.3 g protein, 9.3 g fat, 1.2 g fiber (96 calories)
- 1 Peanut butter-butter mix (with crushed vitamins, calcium)
- 12 g apple slices
Lunch: 1.45 g carb, 10.1 g protein, 34.3 g fat, 1.5 g fiber (354 g calories)
- 30 g Avocado
- Tuna salad: 20 g Full-fat Traditional Greek Gods Yogurt, 30 g tuna, 8 g shredded parmesan (of course, you could use mayo, but Nora doesn’t like it)
- 45 g cream plus 5 g coconut oil (steamed with cocoa powder, or add a bit of the cream to the tuna salad if you want to smooth the consistency)
Afternoon Snack: 2.7 g carb, 2.4 g protein, 15.6 g fat, 1 g fiber (160 calories)
- Berry Frozen Yogurt Pop (revised from lined recipe at 3:1 ratio, includes whey protein powder)
Dinner: 1.1 g carb, 10.5 g protein, 22.5 g fat, 2.25 g fiber (250 calories)
- 12 g baby carrots
- 40 g egg + 15 g cream, scrambled
- 14 g shredded cheddar
- 7 g Flackers + 4 g butter (can mix butter with a sprinkle of cinnamon)
Bedtime Snack: 1.25 g carb, 0.2 g protein, 17.2 g fat, 1.4 g fiber (160 calories)
- 22 g raspberries
- 30 g cream + 5 g coconut oil (steamed with a drop of vanilla or pinch of cocoa powder and crushed calcium tablet)
Totals for the day: 10 g carb, 28.1 g protein, 115 g fat, 9.9 g fiber (1200 calories)
We also have to be sure that Nora is drinking enough fluids. We use a supplement called CALM, which is a powder to mix into water to make her “lemonade.” It has a magnesium supplement, which is a gentle laxative, and a calcium supplement which most keto kids need (notice we also mix 500 mg calcium into one serving of her hot cocoa, above). This version is lemonade flavored and slightly sweetened with stevia. That is the only no-carb sweetener she has been getting. She doesn’t mind drinking her hot cocoa without sweetener (although she spits out any “cocoa pits” that don’t get completely dissolved).
For more ideas and lists of foods that work on a ketogenic diet, see these posts: