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.

Vanilla Cake with Vanilla Buttercream Frosting Recipe

Chef Rachel Finn

She’s done it! – Chef Rachel, the amazing medical ketogenic diet chef, has come up with the perfect 4:1 cake recipe with the most delicious buttercream frosting! We recently debuted this cake recipe at the Glut1 Deficiency Foundation family meeting and it was a hit – lots of smiles, thumbs-ups, “yummy”s and requests for seconds from the kids (and some of the parents!). We hope you love it just as much!  

Note – You can also use this same recipe to make cake pops. This recipe is also available in a 3:1 ratio.

Makes approximately 6 servings (approximately 250 calories each). You can adjust serving size to yield desired calorie requirement. Ask your dietitian for help.

4:1 Vanilla Cake with Buttercream Frosting Recipe:

Ingredients:

  • 44 g KetoCal® 4:1 Powder
  • 42 g Almond flour (whole ground blanched almonds)
  • 46 g Egg (raw, mixed well)
  • 2 g Vanilla extract – pure
  • 2 g Baking powder – Calumet®* (Kraft®*)
  • 50 g Mayonnaise, Hellmann’s®*/Best Foods®*    
  • 40 g Butter
  • 60 g Cream, 36%
  • 7 g Pudding powder Kraft®* FatFr/SugarFr, Inst.Vanilla   

Directions:

  • Preheat oven to 325 F.
  • Weigh KetoCal® powder, almond flour, egg, mayonnaise, baking powder, and vanilla extract. Save cream, butter, and pudding powder for later.
  • Mix KetoCal powder, almond flour, egg, mayonnaise, baking powder, and vanilla extract in a large mixing bowl. Mix with a spatula until well blended.
  • Pour batter into a greased very small baking dish – we used a 7.5 x 5.5 x 1.8 (3 cup) glass baking dish.
  • Spread batter evenly in baking dish.
  • Place baking dish into the oven.
  • Bake for approximately 15-20 minutes, or until edges start to brown and a toothpick comes out clean. Keep a close eye on it as it bakes as oven baking times may vary.
  • While baking, prepare your frosting recipe.
  • Weigh heavy cream, butter, and sugar-free pudding powder.
  • Add heavy cream to a large bowl. Using a hand blender, whip cream until it starts to stiffen to whipped cream consistency.
  • Add pudding powder and butter to the same bowl with the cream, then blend until mixture is blended. Do not over blend or frosting will become too stiff. If this happens, add a small amount of water to thin out frosting.
frosting
  • Remove cake from oven and allow to cool.
cake
Cake without frosting
  • Once cake is completely cool, spread frosting as evenly as possible over the top.
cake with frosting
Cake with frosting
  • Serve immediately or store in the refrigerator. Note – frosting will melt if exposed to heat or direct sunlight.

*Optional, add “keto sprinkles” (granulated stevia leaf extract sweetener mixed with a dash of food coloring) on top of the frosting. If you do this, be sure to add the stevia leaf extract sweetener as an ingredient to the recipe and account for any extra carbs – you may need to add a bit of extra butter to the frosting recipe to even out the ratio.

Cake decorated with “keto sprinkles”

Makes approximately 6 servings of cake (about 250 calories per serving). Can adjust serving size to reach needed calorie amount.

One serving of cake
One serving of cake (shown with “keto sprinkles”)

Nutritional Information:

For total recipe:

  • Calories: 1515

Per serving (6 servings per recipe):

  • Calories: 252

For full nutritional information for this 4:1 recipe – visit https://myketoplanner.com/4299-chef-rachel-s-4-1-vanilla-cake-buttercream-frosting-recipe-from-glut1-conference.aspx.

To view 3:1 recipe, visit https://myketoplanner.com/4301-chef-rachel-s-3-1-vanilla-cake-frosting-recipe-from-glut1-conference.aspx.

KetoCal® is medical food for the dietary management of intractable epilepsy and is intended for use under medical supervision. Talk to your healthcare provider about whether KetoCal is right for you.

*Hellmann’s® and Best Foods® are registered trademarks of the Unilever Group of Companies. Calumet® and Kraft® are registered trademarks of Kraft Foods Group Brands LLC. Unilever and Kraft Foods Brands LLC are not affiliated with Nutricia North America and have not endorsed the proposed use of their products in this recipe. Specific brand names are referenced to ensure consistent nutritional composition necessary to maintain the medical ketogenic diet.

For more information on the medical ketogenic diet for the management of intractable epilepsy, visit www.ketogenicdietforepilepsy.com.


New KetoCal 2.5:1 Liquid – Questions & Answers

We are pleased to introduce the first and only nutritionally complete ketogenic formula in a 2.5:1 ratio with MCT, specifically developed for adults and children 8 years of age and older. Below is a collection of common questions and answers about KetoCal 2.5:1 Liquid.

1. What is KetoCal 2.5:1 Liquid?

KetoCal 2.5:1 Liquid is a convenient, ready-to-feed ketogenic formula with a 2.5:1 ratio, with added medium-chain triglyceride (MCT) oil, fiber, and DHA. It is available in great-tasting vanilla.

2. Who is KetoCal 2.5:1 for?

KetoCal 2.5:1 was specifically designed for adults and children age 8 and over who are following the ketogenic diet for the management of intractable epilepsy. KetoCal 2.5:1 is a medical food and is intended for use under medical supervision.

3. How do I know if KetoCal 2.5:1 is right for me or my loved one?

Check with your healthcare provider to determine if KetoCal 2.5:1 is appropriate for you or your loved one.

4. How does KetoCal 2.5:1 better meet the nutritional needs of adults, adolescents and older children?

KetoCal 2.5:1 was specially designed to meet the nutritional needs of adults and children over the age of 8. Specifically, KetoCal 2.5:1 provides:

  • Higher protein compared to 4:1 ketogenic formulas, to meet the higher protein needs of adults, adolescents and older children
  • Age-specific content of vitamins and minerals
  • 25% of the fat from MCT oil
  • Multi-fiber blend

By providing a convenient, ready-to-feed ketogenic formula, KetoCal 2.5:1 can help to simplify the ketogenic diet.

5. Why is this formula in a 2.5:1 ratio?

Adults and adolescents have higher protein needs compared to younger children. A modified ketogenic diet or MAD provides more protein than a 4:1 ketogenic diet and may help meet protein needs. For patients who use ketogenic formula, it may be necessary to add protein to 4:1 formulas to meet their higher protein needs*. KetoCal 2.5:1 provides a solution for these patients by providing higher protein compared to a 4:1 ketogenic formula.

6. How can KetoCal 2.5:1 be used?

KetoCal 2.5:1 can be used as a:

  • Sole source of nutrition**
  • Tube feeding
  • As a snack or at meal times
  • To create delicious ketogenic recipes

7. How does KetoCal 2.5:1 taste?

KetoCal 2.5:1 comes in great-tasting vanilla flavor. See for yourself! Ask your healthcare provider for a sample today or request one here.

8. How do you prepare KetoCal 2.5:1?

KetoCal 2.5:1 is a convenient, ready-to-feed product. Simply shake for 5 seconds and drink or pour into the feeding bag. There is no measuring or mixing required!

9. Are there coverage and cost assistance options for KetoCal 2.5:1?

Yes, KetoCal 2.5:1 may be covered by your insurance or Medicaid. It may also be covered by the National School Lunch Program or by the KetoCal Assistance Program. For more information, visit https://myketocal.com/reimbursement.aspx or www.nutricia-na.com/NutriciaNavigator.

10. How can I try a sample of KetoCal 2.5:1?

Ask your healthcare provider for a sample of great-tasting vanilla KetoCal 2.5:1 or request a sample here.

11. Where can I learn more about KetoCal 2.5:1?

You can learn more about KetoCal 2.5:1 at https://myketocal.com/ketocal2_5-1.aspx.

*Older children, adolescents and adults have higher protein needs compared to younger children.
**May be used as a sole source or supplemental nutrition depending on the age and energy (caloric) needs of the individual.