Sugar Alcohols: Are They Compatible with the Ketogenic Diet?

If you are following or considering a ketogenic diet or modified Atkins diet (MAD) for the management of intractable epilepsy, you may have heard talk about sugar alcohols and whether they are compatible with the diet. In today’s blog post, ketogenic dietitian Stacey Bessone will tell us more about sugar alcohols and what role they play with the ketogenic diets.


Sugar alcohols are a specific type of carbohydrate called “polyols”. Sugar alcohols are naturally occurring in fruits and vegetables and often added to foods as a reduced-calorie alternative to sugar. Some common sugar alcohols you may see in food ingredient lists include:

  • Malitol
  • Sorbitol
  • Isomalt
  • Xylitol
  • Erythritol

It’s important to be aware that some sugar alcohols may cause some people to experience bloating, gas and diarrhea, even when consumed in small amounts.

Sugar Alcohols & Glycemic Index

Interestingly, most sugar alcohols are incompletely absorbed in the small intestine, so they do not raise blood sugar the same way as sucrose (table sugar). However, since they are partially absorbed, they may affect blood glucose levels to some degree.   This can be observed by looking at the glycemic indexes of sugar alcohols compared to sugar. Glycemic index is a measure of the increase in blood glucose when a food is digested and absorbed. It is based on a numeric scale from zero to 100, where the glycemic index of glucose (a type of sugar you get from foods and the form that your body uses for energy) is 100. The glycemic index of sucrose (table sugar) is around 65, whereas the glycemic indexes of the main sugar alcohols are between 0 and 45. Therefore, sugar alcohols may raise your blood glucose, although not as much as sugars like sucrose and glucose.

[i],[ii]

 

One specific type of sugar alcohol, Erythritol, is metabolized differently than other sugar alcohols. Erythritol is fully absorbed in the small intestine and excreted in the urine unchanged, so it does not affect blood glucose levels like other sugar alcohols. As you can see in the chart above, the glycemic index of erythritol is zero.

Calories in Sugar Alcohols

Sugar alcohols provide fewer calories per gram compared to regular carbohydrates. Sugar alcohols are therefore often used as a reduced-calorie alternative to sugar.

Sugar Alcohols, Erythritol, and the Ketogenic Diet

So, are sugar alcohols allowed on the ketogenic diet and modified Atkins diet (MAD)?  Technically, most sugar alcohols should be counted as regular carbohydrates and kept to a minimum on the ketogenic and modified Atkins diets (MAD). Although they may affect blood glucose differently in different people, most sugar alcohols have the potential of raising blood sugar. The exception to this rule is erythritol, since it is metabolized differently and does not affect blood glucose.  I generally tell my ketogenic diet and modified Atkins diet (MAD) patients that when reading a food label for carbohydrate content, erythritol is the only sugar alcohol that can be deducted from total carbohydrate content. I also tell my patients that sugar alcohol can only be deducted from the total carbohydrate amount if erythritol is the only sugar alcohol used in a product. When other sugar alcohols are used in addition to erythritol, the sugar alcohol content cannot be deducted, so I tell my patients to read the food label’s ingredient list carefully.

Speak to Your Healthcare Provider

Each dietitian has his/her own protocols, so while I allow my keto patients to deduct erythritol but no other sugar alcohols from total carbohydrate content, your provider may have different recommendations. As always, it’s important to speak to your dietitian about which foods and ingredients are allowed for your unique diet.

– Stacey

 

I was paid by Nutricia for my time to write this blog post, however, my opinions are my own.

The ketogenic diet for epilepsy should be used under medical supervision.

[i] Regnat K, Mach RL, and Mach-Aigner AR. Erythritol as sweetener—where from and where to? Appl Microbiol Biotechnol. 2018; 102(2): 587–595.

[ii] Livesey G. Nutr Res Rev. Health potential of polyols as sugar replacers, with emphasis on low glycaemic properties.2003 Dec;16(2):163-91.

 

 

KetoCal® Air Travel Tips

Traveling for the holidays? We want to make sure you have no trouble taking your KetoCal with you. Here are some tips for air travel with KetoCal:

Ship it ahead of time:

When possible, many families prefer to ship KetoCal to their destination ahead of time. When you purchase KetoCal from Nutricia, shipping is free for orders over $25. You can order by calling 1-800-365-7354. We recommend that you order a week or so in advance so that you don’t have to worry about whether or not your formula will get there in time for your arrival. Be sure to ask your family/friends/hotel staff to store the KetoCal indoors at room temperature (it should not be stored outdoors in cold weather).

Flying with KetoCal:

Medical Necessity Letter: When flying with KetoCal, we recommend that you get a letter from your doctor or dietitian explaining that KetoCal is a medically necessary formula used with the ketogenic diet for the management of epilepsy/Glut1DS/PDHD. You may not need it, but it never hurts to have it in case you have any trouble getting your KetoCal through security.

Checked Luggage: If you are packing KetoCal in your checked luggage, it might be useful to include the medical necessity letter in your bag in case it gets searched by the Transportation Security Administration (TSA).

Carry-On Bags: If you are bringing KetoCal in your carry-on bag, be prepared for some additional screening and give yourself extra time so that you aren’t stressed about missing your flight. Be sure to pack a little extra formula in case of flight delays, which are fairly common during peak travel days around the holidays.

As you likely know, there are limits to the quantity of liquids you can carry on when flying (3.4 fluid ounces or 100 milliliters). Luckily, formulas and medically necessary liquids are exempt from this quantity limit, although they require extra screening. As soon as you arrive at security, notify the TSA agent that you are traveling with medically necessary liquid formula. Have the medical necessity letter from your healthcare provider handy in case you need it. If you do not want the formula to go through an X-ray or to be opened, notify the TSA officer. You will have to go through additional screening in this case, so be sure to give yourself extra time.

Powders may also require additional screening at TSA checkpoints. When you arrive at security, notify the TSA officer that you are traveling with medically necessary powdered formula. Have the medical necessity letter from your healthcare provider handy in case you need it.

  • Ice packs: Ice packs, freezer packs, gel packs, and other accessories used to keep your formula cool are allowed through security as long as they are frozen or partially frozen. Like formula, they may require additional screening.

For more information, check out the TSA guidelines for travel with medications, including liquids, and for travel with children, including formula.

Happy Holidays and Safe Travels!

Mallory

 

KetoCal is a medical food and is intended for use under medical supervision.

The ketogenic diet for epilepsy should be used under medical supervision.

Back to School Tips for Families on the Ketogenic Diet

As your children head back to school, we hope you can use these tips by ketogenic dietitian Lindsey Thompson, MS, RD, CSP, LD. Thanks, Lindsey!

Starting the new school year can be a mix of emotions from both excitement to apprehension, especially for families with a child on the ketogenic diet. Here are some tips to help get you through these upcoming weeks as school approaches.

Meet with the teacher and staff at the school

It is important, particularly if your child will be at a new school this year, to make sure all of the staff members who are in contact with your child are aware of his or her special diet and restrictions. If your child has an Individualized Education Program (IEP), you likely already have a meeting scheduled. Be sure to discuss:

  • Dietary restrictions- Many parents I have worked with find it helpful to compare the ketogenic diet to a food allergy (“my son has an allergy to carbohydrates or sugar”). Although this is an oversimplification of the diet, sometimes using the comparison helps staff understand the scope of the ketogenic diet when applied to epilepsy management.
  • Classroom items to avoid – In addition to the dietary restrictions, make sure staff are aware that classroom items containing carbohydrates could be harmful for a child on the ketogenic diet to use (for example, modeling clay/play dough, which contains flour). I tell classroom staff that when in doubt, have the child wear gloves when using a product in question.
  • Parties & Special Events – It is also important to review with the teacher the schedule of class parties or events that may contain food. Have the teacher let you know in advance when there will be a party or food so that you can send an appropriate ketogenic alternative for your child.

Ease into the school routine

Switching from the summer schedule to school schedule can be stressful. Kids with epilepsy may especially need additional time to adjust their sleep schedules in preparation for school. Practice your family’s school routine a few weeks in advance, perhaps in preparation for a day at the zoo or another activity. Set the alarms, have your children get up and ready, and pack that keto lunch for your child. You may even practice getting to the bus stop or driving to school to estimate the correct time needed. Practicing beforehand will make the first day of school go more smoothly.

Meal prep

As any keto parent knows, meal prepping for the ketogenic diet is very time consuming. Schedule a day or time to prepare ketogenic meals and snacks for school ahead of time. Many parents like to choose a day when a spouse or other caregiver is available to help keep the kids occupied, like a weekend day.

Try to keep school lunches simple. If your child likes to drink KetoCal®, your school can provide a serving of KetoCal for the same cost as a school lunch, which may save you time in having to meal prep. See this link for more information about the KetoCal and National School Lunch Program: https://www.myketocal.com/schoollunch/.

Helpful supplies for school lunches

Supplies that are helpful on the ketogenic diet lunches include:

  • An insulated lunch bag with an ice pack (to keep cream and other fats cold)
  • Small containers for holding the smaller portions of food required on the ketogenic diet
  • Some families like a bento-style lunch box and kids find that can be fun as well

Having a child on the ketogenic diet is a lot of work and preparation, but it is worth the effort. All of you keto parents and caregivers are doing great! I hope these tips will help ease you and your child on the ketogenic diet into a safe and happy school year!

-Lindsey

I was paid by Nutricia for my time to write this post, however, my opinions are my own.

KetoCal is a trademark of SHS International LTD.

KetoCal is a medical food for use under medical supervision.