Ketogenic Diet

Written By Brittyn Coleman, MS, RDN/LD

What is the Ketogenic Diet?

  • The Ketogenic Diet is a high fat, moderate protein, low carbohydrate diet that was developed for the treatment of pediatric epilepsy in 1920. It has recently emerged as a potential treatment for autism and may offer improvements to cognition, social skills and some behaviors. [1]

  • Calories in a ketogenic diet come from 65-75% of fat, 15-25% protein, and 5-10% carbohydrates. 

  • Typically it is recommended that carbohydrates are limited to 20-50 grams per day. 

  • Although the ketogenic diet has gained popularity in recent years, it was originally introduced by modern physicians as a treatment for childhood epilepsy in the 1920s. [10]

  • There are five variations of the Ketogenic diet all varying slightly in protocols [2]: 

    • Classic Ketogenic Diet

    • Modified Ketogenic Diet

    • MCT Ketogenic Diet

    • Modified Atkins Ketogenic Diet

    • Low Glycemic Index Ketogenic Diet

    • Intermittent Fasting

What are Ketones?

  • Ketones are an alternate energy source the body can use to supply energy to the heart, brain, and muscles. [2]

  • Ketones are produced when there is not enough glucose available for energy. 

What is Ketosis?

  • Ketosis or ‘nutritional ketosis’ occurs when the body is depleted of carbohydrates for an extended period of time resulting in the production of ketones. 

  • This large increase in ketones produces a state known as ketosis. 

  • As long as the body is not getting enough carbohydrates, it will remain in this state of ketosis.

  • Ketosis actually evolved as a survival mechanism in humans to avoid death when food was scarce.

Potential Benefits of a Ketogenic Diet:

  • Improved cognition and memory [7]

  • Improved concentration [7]

  • Decreased yeast and urinary tract infections 

  • Blood sugar balance and improved insulin sensitivity

  • Migraine support [4]

  • Weight management

    • Weight management on a ketogenic diet is only possible through following strict macronutrient requirements.

    • Despite the reputation of a ketogenic diet for weight management, overconsumption of calories will still result in weight gain 

 
 

Who Might Benefit From a Ketogenic Diet?

  • Children with autism

  • Individuals with epilepsy or who experience drug-resistant seizures [8]

  • Those with Parkinson’s disease

  • Those with Type 1 or 2 Diabetes

  • Those with gut dysbiosis and SIBO


Who Is the Ketogenic Diet Not Appropriate For?

  • Children and teenagers, unless for specific therapeutic conditions such as epilepsy and autism and under the guidance of a trained professional [3,4]

  • Those with impaired fat digestion or liver disease 

  • Those with adrenal fatigue

  • Those with thyroid concerns

  • People trying to gain weight or who have a hard time keeping weight on

  • People with eating disorders 

  • People with Type 1 Diabetes and uncontrolled blood sugar 

  • Those with Type 2 Diabetes who are on insulin 

  • Anyone taking prescription medications should work closely with their doctor as the ketogenic diet can alter metabolism significantly enough that medications may need to be adjusted.

 
 

Recommended Foods

  • Lower Carbohydrate, Non-Starchy Vegetables [9]:

    • Mushrooms, broccoli, zucchini, green leafy vegetables (arugula, kale, spinach), tomatoes, celery, cauliflower, onions, leeks, eggplant, green beans, cabbage, brussels sprouts, bok choy, asparagus, artichoke, cucumber, jicama, radishes, olives, celery root, fennel, peppers, spaghetti squash 

  • Proteins 

    • Beef, bison, eggs, lamb. pork, poultry (chicken, duck, turkey), fish (salmon, mackerel, sardines, tuna), shellfish, wild game (venison, elk, boar), soy protein (tofu / tempeh) 

  • Dairy & Substitutes

    • Heavy cream, butter, sour cream, cottage cheese, high-fat, plain Greek yogurt, cheeses (swiss, brie, goat, blue, feta, mascarpone, ricotta), almond, coconut, flax, hemp milk, plain coconut/almond yogurt 

      • *Since many children with autism have food sensitivities to dairy, should they follow a ketogenic diet, it is recommended that they work with a dietitian to implement a dairy-free modified ketogenic diet. 

  • Seeds 

    • Chia, flax, hemp, pumpkin, sesame, sunflower butters, sunflower, tahini

  • Fats & Oils

    • Avocado oil, butter or ghee, coconut oil, extra virgin olive oil, macadamia nut oil, lard & tallow.

 
 

Foods to Avoid

  • Most Fruits [9]: 

    • Dried fruits, fruit juices, fruit jams & jellies, freeze dried fruits

  • Grains

    • Amaranth, barley, bread, rice, buckwheat, bulgur, cereal, corn meal, tortillas, couscous, crackers, flour, grits, noodles/pasta, millet, oatmeal/rolled oats, rye, quinoa, sorghum, wheat flakes

  • Starchy Vegetables:

    • Carrots, pumpkin, beets, peas, winter squashes (butternut, acorn, delicata), potatoes (white, red, purple, sweet), parsnips, burdock root, rutabaga, corn

  • Beans & Legumes:

    • Black beans, Navy beans, Kidney beans, Garbanzo beans, Lentils, Lima beans, Fava beans, Pinto beans, Split peas, 

  • Others:

    • Candy, sodas, sugar-sweetened beverages, powdered drink mixes, diet sodas, fast foods, fried foods, and processed oils (soybean, peanut, safflower, corn, canola, cottonseed).

Lifestyle Considerations for A Ketogenic Diet

Nutritional supplements, sleep, electrolytes, hydration, exercise, and activity levels all play a role in the proper implementation of a ketogenic diet. 

Individuals with underlying digestive concerns, which is common among children with autism, may need additional support. Therefore, it is very important that you are working under the supervision of a practitioner or dietitian to make individualized recommendations. 

Supplement Recommendations:

  • MCT Oil - Medium Chain Triglyceride is a high-fat supplement that is easily converted into ketones. Ketones are an alternate fuel source that can be readily used as fuel by the brain and have been shown to be beneficial in patients with epilepsy. Particularly when used as part of the MCT Ketogenic diet. [1]

  • Electrolytes - When following a Ketogenic diet, it is important to stay hydrated and replenish electrolytes, such as sodium, magnesium, & potassium. The hormonal changes related to the metabolic state of ketosis causes the kidneys to excrete more of these minerals.

Helpful Resources:

Websites:

Cookbooks:

DISCLAIMER: Before starting any supplement or medication, always consult with your healthcare provider to ensure it is a good fit for your child. Dosage can vary based on age, weight, gender, and current diet.

Ketogenic Diet & Autism in the Research

Ketogenic Diet and Behavior

  • One study found that when a modified ketogenic gluten-free diet with supplemental MCT was administered for 3 months, there was an improvement in core features of autism (ADOS-2) [1]

    • There was a direct relationship between core feature scores and HDL levels. [1]

    • ADOS-2 is a standardized assessment tool for communication, social interaction, imaginative use of materials, and repetitive behaviors. [1]

Ketogenic Diet and the Gut Microbiota

  • The Ketogenic diet was shown to decrease the total number of gut bacteria and create a more balanced gut microbiota. [5]

  • When studying the microbiota of epileptic children, one study found that their microbiome differed greatly from non-epileptic children. [6]

    • A ketogenic diet was shown to increase friendly bacteria and decrease harmful bacteria in children with epilepsy which suggests that the diet could quickly reduce the frequency of seizures in children with drug resistance epilepsy. [6]

  • The positive impact of the Ketogenic diet on gut microbiota could explain why the diet may be beneficial for the treatment of autism symptoms, particularly abdominal pain, constipation and diarrhea. 

  • More research needs to be done to confirm this relationship. 

Ketogenic Diet versus Gluten-Free, Casein-Free 

  • One study compared the impacts of a modified Ketogenic Atkins diet and a gluten free casein free (GFCF) diet on 45 children with autism aged 3-8. [7]

  • The study found that both diets showed significant improvements in measures of Childhood Autism Rating Scale (CARS) and Autism Treatment Evaluation Test (ATEC) scales. [7]

  • The modified Ketogenic Atkins diet scored better in improvements of cognition and sociability as compared to the GFCF diet. 

  • In conclusion, both the Ketogenic Atkins diet and the GFCF diet could be recommended to safely improve some autistic symptoms. 

Modified Ketogenic Diet With MCT Oil

  • A modified gluten-free ketogenic diet with supplemental MCT is a potentially beneficial treatment option to improve the core features of autism spectrum disorder [1]. 

Ketogenic Diet and Epilepsy

  • The ketogenic diet has been shown to be effective as a diet treatment therapy for drug-resistance epilepsy [8].

  • One review concluded that children that effectively followed the ketogenic diet saw a 50% or greater reduction in the number of occurrences of seizures as compared to children that did not follow the diet.

  • There was a 3x greater probability that children following the diet would gain freedom from seizures.

  • It is important to note that many of the study participants dropped out due to how difficult it was to follow the diet.

  • More research is needed to establish a particular introduction protocol to reach ketosis. 

The Bottom Line

Overall, there is extensive evidence to suggest that a Ketogenic Diet is beneficial as a treatment for seizures in children with epilepsy. However, the relationship between the Ketogenic Diet and autism is limited and the most notable studies are unreliable due to their small sample size and short duration. The most interesting research points to the ketogenic diet being favorable for improvement of autistic behaviors such as: communication, social interaction, imaginative use of materials, and repetitive behaviors. Additionally, the ketogenic diet may play a role in the gut microbiota which is a huge player in the development and treatment of autism. Adhering to the diet requires an individualized approach and may require a modified non-dairy route. Strict macronutrient guidelines are required to be successful. Diet restrictions in conjunction with limited child preference in some children with autism add a level of complexity. Therefore, when children follow this diet long-term it is important you are working with a trained professional to ensure adequate nutrient intake for growth and development and prevent nutrient deficiencies. There is a wealth of information and recipes for the diet with clear cut guidelines to ensure success. 

Scale: 1 - 5 Stars ★

We rate the quality and quantity of the Research supporting the efficacy of the diet in improving symptoms as well as the Ease of Adherence, taking into account the cost, resources available, time required, social acclimation to the diet including options available in restaurants and grocery stores which assist in convenience and adherence

Ease of Adherence ★★★

The diet is somewhat restrictive and requires a strict adherence to macronutrient guidelines to reach ketosis but there is a wealth of guidance available. Due to a narrow range of preferences in children with autism, the diet must be modified to allow for preferences but still maintain ketosis. 


Research ★★★★

Much research has been done to support the use of diet and supplements for pediatric seizures and epilepsy. Studies between the diet and autism are limited, have a small sample size and duration. More research needs to be done in treatment of autism. 

Grade: B

  • [1] Lee RWY, Corley MJ, Pang A, et al. A modified ketogenic gluten-free diet with MCT improves behavior in children with autism spectrum disorder. Physiol Behav. 2018;188:205-211. dpi: 10.1016/j.physbeh.2018.02.006

    [2] What is a Ketogenic Diet? Keto Diet Facts, Research, and Variations. (2020, November 23). Charlie Foundation. https://charliefoundation.org/diet-plans/

    [3] Verrotti A, Iapadre G, Pisano S, Coppola G. Ketogenic diet and childhood neurological disorders other than epilepsy: an overview. Expert Rev Neurother. 2017 May;17(5):461-473. doi: 10.1080/14737175.2017.1260004. Epub 2016 Nov 21. PMID: 27841033.

    [4] Ketogenic Diet . Accessed March 16, 2021. https://www.naturalgrocers.com/article/ketogenic-diet

    [5] Newell C, Bomhof MR, Reimer RA, Hittel DS, Rho JM, Shearer J. Ketogenic diet modifies the gut microbiota in a murine model of autism spectrum disorder. Mol Autism. 2016;7(1):37. Published 2016 Sep 1. doi:10.1186/s13229-016-0099-3

    [6] Fan Y, Wang H, Liu X, Zhang J, Liu G. Crosstalk between the Ketogenic Diet and Epilepsy: From the Perspective of Gut Microbiota. Mediators Inflamm. 2019;2019:8373060. Published 2019 Jun 3. doi:10.1155/2019/8373060

    [7] El-Rashidy O, El-Baz F, El-Gendy Y, Khalaf R, Reda D, Saad K. Ketogenic diet versus gluten free casein free diet in autistic children: a case-control study. Metab Brain Dis. 2017;32(6):1935-1941. doi:10.1007/s11011-017-0088-z

    [8] D'Andrea Meira I, Romão TT, Pires do Prado HJ, Krüger LT, Pires MEP, da Conceição PO. Ketogenic Diet and Epilepsy: What We Know So Far. Front Neurosci. 2019;13:5. Published 2019 Jan 29. doi:10.3389/fnins.2019.00005

    [9] Sisson M, Kearns B. The Keto Reset Diet: Reboot Your Metabolism in 21 Days and Burn Fat Forever. First edition. Harmony Books; 2017.

    [10] Wheless JW. History of the ketogenic diet. Epilepsia. 2008 Nov;49 Suppl 8:3-5. doi: 10.1111/j.1528-1167.2008.01821.x. PMID: 19049574.

Authors

Brittyn Coleman, MS, RDN/LD, CLT

Sinead Adedipe, MS

Brittyn Coleman, MS, RDN/LD https://www.autismdietitian.com
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