There are five versions of the ketogenic diet used to treat epilepsy. The original, now known as the Classic Ketogenic Diet, was created in 1923, followed by more recent types known as the Modified Ketogenic Diet, the Medium Chain Triglyceride (MCT) Diet, the Modified Atkins Diet, and the Low-Glycemic Index Treatment (LGIT). The various types of ketogenic diets have been used for years and have been studied in people with epilepsy who have failed to achieve seizure control with anti-seizure medications.The “classic” ketogenic diet (KD) is the most restrictive of the five versions. It follows the “ketogenic ratio” of 4:1 or 4 grams of fat for every 1 gram of protein and carbohydrate.3 People with epilepsy who follow this diet can expect to consume about 80-90% of their calories from fat, 6-8% from protein, and 2-4% from carbohydrates.
The traditional KD is prescribed by a doctor and begins with a 24-hour fast followed by an inpatient hospital stay for two to three days while the patient is monitored for ketosis. In some cases, however, the patient may be able to start the KD at home over four weeks by slowly increasing the ketogenic ratio each week from 1:1 to 4:1.
Food and drink should be weighed and measured on a scale due to the strictness of this diet. During the inpatient visit, a dietitian will 1) calculate the patient’s meal ratio; and 2) educate the patient or caregivers to help maintain the diet after leaving the hospital. People following the classic KD must also take vitamin and mineral supplements to make up for the nutrients this diet lacks.
Modified Ketogenic Diet
The Modified Ketogenic Diet is slightly less restrictive than the classic KD and follows a ratio range of 3:1 (3 grams of fat for every 1 gram of protein and carbohydrate) down to a 1:1 ratio.4 Although this diet was not officially recognized in the 2018 update to the recommendations by the International Ketogenic Diet Study Group, it may be a more comfortable way to start or taper off the classic KD.
This version reduces the body’s reliance on fat as the primary source of calories and allows for more protein and carbohydrates. Still, people following the modified KD may need to take vitamin and mineral supplements to make up for the nutrients this version lacks.
Medium Chain Triglyceride (MCT) Diet
The Medium-Chain Triglyceride (MCT) diet follows a ketogenic ratio of 1.9:1 or 1.9 grams of fat for every gram of protein and carbohydrate. Medium-chain triglycerides (MCT) are a type of fat that is generally made by processing coconut and palm oils – they are not found in traditional foods.4 Not only does the body digest MCTs more efficiently than the fat typically found in food (long-chain triglycerides (LCT)), but it also produces more ketones. Because of this, people following the MCT diet can incorporate more protein and carbohydrates into their diet compared to the classic KD.
People who follow this diet can expect to consume about 60% of their calories from MCT in addition to traditional fats, protein, and carbohydrates. This version of the KD is traditionally started in the hospital under the supervision of a neurologist and dietician and MCT is given as an oil or nutritional supplement with each meal and/or snack. This level of MCT, however, may cause stomach issues or discomfort and the dietician may recommend starting with a lower MCT percentage (40-50%) before adjusting up or down. People following this diet must also take vitamin and mineral supplements to make up for the nutrients this version lacks.
Modified Atkins Diet (MAD)
The Modified Atkins Diet (MAD) is a mix between the classic KD and the Atkins Diet.3, 5 It is less restrictive than the classic KD and generally follows a ratio of 1:1 (or one gram of fat for every gram of protein and carbohydrate). People on this diet may consume 65% of their calories from fat, 25% from protein, and 10% from carbohydrates. Unlike the classic KD, there are no restrictions on the amount of liquids, calories, or protein consumed, but there is still a limit for carbohydrates. This diet may be a good option for children, those that find it difficult sticking to the classic KD, or those with behavioral problems.
Low Glycemic Index Treatment
The Low Glycemic Index Treatment (LGIT) is a diet that emphasizes eating complex carbohydrates instead of simple sugars to consume foods with a low glycemic index (GI).3 The glycemic index is a number that ranges from 0-100 and describes how much a particular food increases the level of sugar in your blood after you eat it. Foods that have a high GI include most carbohydrates, which produce large increases in blood sugar and insulin levels. Foods with a low GI (e.g., unprocessed whole grains, meats, dairy, some fruits, and vegetables) produce smaller increases in blood sugar and insulin levels. High GI foods are those higher than 50; therefore, low-glycemic index foods are those less than 50.
Patients may consume a diet with 60% fat, 20-30% protein, and a 10% carbohydrate content. There are no restrictions on fat and protein intake, and LGIT allows for a larger carbohydrate intake; however, these carbohydrates must have a GI of less than 50. Young people may prefer LGIT because it is more tolerable compared to other versions of the KD, though it does produce a lower level of ketosis.
