Advocates for the diet recommend that it be seriously considered after two medications have failed, as the chance of other drugs succeeding is only 10%.[9][31][32] The diet can be considered earlier for some epilepsy and genetic syndromes where it has shown particular usefulness. These include Dravet syndrome, infantile spasms, myoclonic-astatic epilepsy, and tuberous sclerosis complex.[9][33]
The low glycaemic index treatment (LGIT)[49] is an attempt to achieve the stable blood glucose levels seen in children on the classic ketogenic diet while using a much less restrictive regimen. The hypothesis is that stable blood glucose may be one of the mechanisms of action involved in the ketogenic diet,[9] which occurs because the absorption of the limited carbohydrates is slowed by the high fat content.[5] Although it is also a high-fat diet (with approximately 60% calories from fat),[5] the LGIT allows more carbohydrate than either the classic ketogenic diet or the modified Atkins diet, approximately 40–60 g per day.[18] However, the types of carbohydrates consumed are restricted to those that have a glycaemic index lower than 50. Like the modified Atkins diet, the LGIT is initiated and maintained at outpatient clinics and does not require precise weighing of food or intensive dietitian support. Both are offered at most centres that run ketogenic diet programmes, and in some centres they are often the primary dietary therapy for adolescents.[9]
Variations on the Johns Hopkins protocol are common. The initiation can be performed using outpatient clinics rather than requiring a stay in hospital. Often, no initial fast is used (fasting increases the risk of acidosis, hypoglycaemia, and weight loss). Rather than increasing meal sizes over the three-day initiation, some institutions maintain meal size, but alter the ketogenic ratio from 2:1 to 4:1.[9]
A Cochrane systematic review in 2018 found and analysed eleven randomized controlled trials of ketogenic diet in people with epilepsy for whom drugs failed to control their seizures.[2] Six of the trials compared a group assigned to a ketogenic diet with a group not assigned to one. The other trials compared types of diets or ways of introducing them to make them more tolerable.[2] In the largest trial of the ketogenic diet with a non-diet control[16], nearly 38% of the children and young people had half or fewer seizures with the diet compared 6% with the group not assigned to the diet. Two large trials of the Modified Atkins Diet compared to a non-diet control had similar results, with over 50% of children having half or fewer seizures with the diet compared to around 10% in the control group.[2]

There are three instances where there’s research to back up a ketogenic diet, including to help control type 2 diabetes, as part of epilepsy treatment, or for weight loss, says Mattinson. “In terms of diabetes, there is some promising research showing that the ketogenic diet may improve glycemic control. It may cause a reduction in A1C — a key test for diabetes that measures a person’s average blood sugar control over two to three months — something that may help you reduce medication use,” she says.
^ Ketogenic "eggnog" is used during induction and is a drink with the required ketogenic ratio. For example, a 4:1 ratio eggnog would contain 60 g of 36% heavy whipping cream, 25 g pasteurised raw egg, saccharin and vanilla flavour. This contains 245 kcal (1,025 kJ), 4 g protein, 2 g carbohydrate and 24 g fat (24:6 = 4:1).[17] The eggnog may also be cooked to make a custard, or frozen to make ice cream.[37]
When your body burns its stores of fat, it can be hard on your kidneys. And starting a ketogenic diet -- or going back to a normal diet afterward -- can be tricky if you’re obese because of other health issues you’re likely to have, like diabetes, a heart condition, or high blood pressure. If you have any of these conditions, make diet changes slowly and only with the guidance of your doctor.
A survey in 2005 of 88 paediatric neurologists in the US found that 36% regularly prescribed the diet after three or more drugs had failed, 24% occasionally prescribed the diet as a last resort, 24% had only prescribed the diet in a few rare cases, and 16% had never prescribed the diet. Several possible explanations exist for this gap between evidence and clinical practice.[34] One major factor may be the lack of adequately trained dietitians who are needed to administer a ketogenic diet programme.[31]
The Mayo Clinic Diet is the official diet developed by Mayo Clinic, based on research and clinical experience. It focuses on eating healthy foods that taste great and increasing physical activity. It emphasizes that the best way to keep weight off for good is to change your lifestyle and adopt new health habits. This diet can be tailored to your own individual needs and health history — it isn't a one-size-fits-all approach.
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