Ask the Keto Dietitian Series – the Modified Atkins® Diet (MAD)

Staey Bessone

A Q&A with Ketogenic Dietitian Stacey Bessone, RDN, LDN

Can you tell us a little about yourself and your work as a ketogenic dietitian?

I am originally from Tampa, Florida and came back after finishing my education in Miami at Florida International University. I have always worked in pediatrics for my almost 24 years as a registered dietitian.  I worked in the same children’s hospital I work in now right out of school but left and came back in 2011 when I took a position to exclusively practice with the medical ketogenic diet. We developed our clinic and see patients from all over the state. We also do clinical research so we can study different aspects of the diet. About half of my patients are on the classical medical ketogenic diet and the other half are on the modified Atkins® diet (MAD). I enjoy teaching the modified Atkins® diet as it is outpatient and usually with adolescents.  I enjoy my job immensely and would never choose to do anything other than the medical ketogenic diet.  It is so rewarding and I have the best patients and families.

How long have you been a ketogenic dietitian?

I have practiced the medical ketogenic diet exclusively for the last nine years.

How many patients do you have on the medical ketogenic diet?

We usually have between 60 and 80 patients on one of the medical ketogenic diets at a time.  Often we are teaching new patients while other patients may be weaning the diet.

What is the modified Atkins® diet (MAD) for intractable epilepsy?

The modified Atkins® diet for epilepsy is a carbohydrate-controlled diet in which a patient counts carbs (minus fiber) and is encouraged to eat more fat to promote ketosis.  It is started as an outpatient (meaning the patient doesn’t need to stay in the hospital) and is simpler to begin than the classic medical ketogenic diet.

How is the MAD different from the classical medical ketogenic diet for epilepsy?

The MAD diet is different in that food is measured in household measurements like tablespoons and cups or by servings (versus using a gram scale for the classical medical ketogenic diet). Instead of focusing on the ketogenic ratio (as with the classical medical ketogenic diet), the focus is on counting carbohydrates throughout the day. Fat is encouraged to be added at every meal and snack.  There is no restriction on protein intake or foods with no carbohydrate. Patients learn to read food labels and can eat out at restaurants. It is a great option for adolescents and families that are on-the-go.

What types of patients are good candidates for the MAD?

Your healthcare professional will work with you to select the most appropriate diet option for your needs. In general, the modified Atkins® diet can be a suitable option for older children, teens, and adults who may find a restrictive diet more challenging.  Also, MAD is a good option for patients that need diet intervention immediately and may not be able to wait for a hospital admission to do the classical medical ketogenic diet. 

While not appropriate for all situations, the MAD can have a similar effect on seizure control as the classical ketogenic diet for some individuals. Most of the research shows that nearly 50% of patients on MAD have about a 50% or more reduction in seizures.

About what percentage of your keto patients are on the MAD?

About half of my patients are on the MAD.

How did the MAD come about? When was it started? Where did the idea come from?

In 2003, Dr. Eric Kossoff, a neurologist at Johns Hopkins Medicine in Baltimore, developed the novel form of the medical ketogenic diet after a patient on a classical medical ketogenic diet came for a follow up visit and had not been weighing his food and had been following the diet “loosely”.  Surprisingly, the child was still in ketosis and doing very well.  Following that patient, there was a young girl who was started on the Atkins® diet in advance of starting the classical diet and achieved ketosis with seizures stopping after three days. These patients had good seizure control so Dr. Kossoff investigated the less strict “modified Atkins® diet” with a formal study. He found that it was a viable option to manage epilepsy with similar results to the classical medical ketogenic diet.  I am happy to be part of the research team at Johns Hopkins with Dr. Kossoff (and dietitian Zahava Turner, RD, CSP, LD) for the past several years through my hospital’s partnership with Johns Hopkins Baltimore.

What are the biggest challenges for your patients following the MAD?

The biggest challenge for patients on MAD (or any other medical ketogenic diet) is sticking to the carb count and not eating any foods that are not allowed.  It can also be challenging for some patients to get enough fat. For some patients, a slip-up can lead to breakthrough seizures since the diet is helping to manage the seizures. 

Is there any research on using KetoCal® with the MAD?

Yes. There was a study in 2011 in children that found using KetoCal with the MAD increased both fat intake and the ketogenic ratio (1.8:1) in comparison with MAD alone (1.01:1). A follow-up study in adults in 2018 showed that starting the MAD diet using KetoCal during the first month in a randomized protocol had better long term compliance and higher fat intake compared to those who did not use the formula.

– Stacey

Thank you, Stacey, for your insights about the modified Atkins® diet for epilepsy!

Hear from patients who have tried the modified Atkins® diet:

Looking for a hospital or program that offers the medical ketogenic diet or modified Atkins® diet? Click here to find one near you.

Learn more about the medical ketogenic diet or modified Atkins® diet for epilepsy here.

Atkins® is a trademark of Atkins® Nutritionals, Inc and not affiliated or endorsed by Nutricia North America.

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

KetoCal is a medical food for the dietary management of intractable epilepsy and is intended for use under medical supervision. Talk with your healthcare provider to determine if KetoCal is right for you.

Silas & Kane’s Glut1DS & Ketogenic Diet Journey

My twin 18-month-old boys, Silas & Kane, just love music and new experiences. We just celebrated our 2nd Christmas! I love watching them light up seeing all the joy around us at this time of year. It brings us so much peace.

First Seizure Experience & a Misdiagnosis

When the boys were just 4 months old, Kane had his first seizure. I was so frightened as I was a new mom. I didn’t know what was happening. We all rushed to our local children’s hospital. While we were there, Silas started having “Aberrant Gaze Saccades”, also known as “Intermittent Involuntary Gaze (IIG)”, which looked like his eyes were crossed. He couldn’t shake out of it and would become very distressed. Lots of tests were being done on the boys and we spent days in the hospital.

One day, a few doctors came into our room and asked my husband and I, “how do you want us to tell you this information?”. My heart instantly broke and I felt a huge lump in my throat as I answered “just tell me straight up.” They told us that my twins had a rare condition called Leukodystrophy. They explained that there was no cure and that they would not live see their 5th birthday. To say I was devastated would be an understatement. I told myself that if there was any way on this earth I could get a miracle of a misdiagnosis, I would do everything in my power to make sure my boys have the best life possible.

Days later, we were so relieved to learn that the boys had in fact been misdiagnosed initially. After more agonizing days in the hospital and lots of blood tests, EEG’s, spinal taps & everything else, we got the REAL Diagnosis: Glut1 Deficiency Syndrome.

Glut1 Deficiency Syndrome & The Ketogenic Diet

Glucose Transporter Type 1 Deficiency Syndrome or Glut1 Deficiency Syndrome is a rare genetic condition that impairs the brain metabolism. Glucose cannot be properly transported into the brain, essentially starving it from the energy it needs to function and thrive. Common signs and symptoms can include seizures, movement disorders, speech and language disorders, and developmental delays. There is no cure and they will live with this condition for the rest of their lives. However, I was exploding with joy when learning that my sons had Glut1 Deficiency Syndrome! You’re all thinking I’m crazy, I know, but I could not stop crying happy tears, as in my eyes, my boys were given a second chance at life compared to the initial diagnosis we were given. I wasted no time in trying to educate myself as much as I possibly could about this condition.

My boys were put on an antiepileptic medication and we were sent home. I was noticing that my boys were not improving. They were still having multiple Aberrant Gaze Saccades a day and they were not meeting their milestones. At our next doctor’s appointment, I expressed my frustration with how the medications were not working and I mentioned that through my research, I read that the ketogenic diet was very successful in managing seizures in children with Glut1 Deficiency Syndrome. They were hesitant as a lot of parents claim that the ketogenic diet is too hard to keep up with. I told them that I need to own up to my promise that I made to myself, that I was going to do everything possible for my boys with this new chance at life. They saw how motivated I was, and they were happy to let me begin.

At first, I was very overwhelmed as I had 2 babies who required this diet. I thought “Can I ACTUALLY do this?”  I was worried that maybe I was a little in over my head. We started the diet at home with the help of a dietitian who helped start the boys out on a ketogenic formula recipe. We slowly worked our way up to the 4:1 ketogenic ratio. Within the first few days, I instantly saw an increase in energy. They were starting to smile, laugh, and hold their head up on their own! I was so overjoyed with how well the diet was working! We weaned off the antiepileptic medication with success! The hard work was totally paying off.

We recently passed our 1-year milestone since they started the diet on December 21st, 2017. The boys have not had a seizure since the day they started the ketogenic diet! I know that there will be challenges as they get older and we may have hiccups along the way, but I am hopeful that the ketogenic diet will keep the seizures suppressed for the most part.

Now that the boys are toddlers exploring new foods, KetoCal® formula makes it SO easy to make really yummy recipes. My boys love cream cheese pancakes that I make with the Ketocal 4:1 LQ Vanilla (recipe below). We have a very busy lifestyle with lots of child therapy & hospital appointments. I just make a big batch of pancakes and bring them on the go! I remember a time when I felt so overwhelmed and I couldn’t think of any ideas of easy meals to make for the boys, so I sent Nutricia a message on Facebook and they sent me TONS of super easy, awesome recipes! I felt like I won the lottery! The boys also love when I use the formula to make smoothies.

The Boys’ Life Today

The boys were off to a rough start the first few months of their lives, which has caused some delays for them. At 18 months old, they still struggle with their balance. They cannot stand on their own or walk. They say “mamma” and “dada”, and they will point to things that they want. The boys are extremely motivated to start walking and they use big boxes to push around the house to help them walk. They attend water therapy, music therapy & physical therapy.

My husband and I made the decision to start a low carbohydrate lifestyle ourselves as we wanted our home to be a place where they don’t feel different or left out. We know that this is something that will be life long, so we want to make this as easy as possible for them. We want them to grow up seeing mom and dad eating the same food as them and to see that eating healthy is a good thing! As they get older, I want them to be able to open the refrigerator or cupboards without having to see food they “can’t have”. It has made me so much more passionate about the ketogenic lifestyle & I could not be more grateful for how it has impacted all of our lives!

Advice for Other Parents

My advice to any parent seeking out the ketogenic diet for their child: If medications are not working and your child is still suffering from seizures, then what do you have to lose with trying the ketogenic diet?  Ask your child’s neurologist about whether the ketogenic diet might be helpful. If you do end up starting the ketogenic diet, be patient and don’t give up! It can be difficult with all the fine-tuning, but I can assure you that it’s absolutely worth it!

– Francine

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

KetoCal is a medical food intended for individuals age 1 year and up. It is intended for use under medical supervision.

 

 

ketogenic diet pancake recipe

Silas & Kane’s Cream Cheese Pancake Recipe (4:1 ketogenic ratio):

  • 19 g Egg (raw, mixed well)
  • 15 g Cream cheese
  • 15 mL Formula: KetoCal® 4:1 LQ (measure in mL) Nutricia
  • 1 g Butter
  • Berries (optional; needs to be calculated into recipe)

Directions:

  1. Mix eggs, cream cheese, KetoCal® 4:1 LQ and half of the butter into a batter.
  2. Pour into a greased pan on medium heat and cook until brown; flip and repeat.
  3. Use remaining butter as topping.
  4. Optional – Top with berries (be sure to calculate this into the recipe)

You can also view this recipe on MyKetoPlanner here.

Please note, this recipe is for a 4:1 ketogenic ratio. As always, please check with your healthcare provider to ensure that this recipe is appropriate for you or your child. The recipe may need to be adjusted to meet your ketogenic ratio and calorie requirements.

 

KetoCal® Air Travel Tips

Traveling-with-KetoCalTraveling 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 medical 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 for the dietary management of intractable epilepsy and is intended for use under medical supervision. Talk with your healthcare provider about whether KetoCal is right for you.

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