Ketogenic diet - the practical details

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(By Dr Sarah Myhill and Craig Robinson)

Introduction

This webpage is designed to give the practical details of the ketogenic diet and also to provide guidance for the following of such a diet for the severely disabled. The dietary data is most usually taken from the USDA (United States Department of Agriculture) Database Entry, or otherwise, where there is a proprietary brand, then from that brand's nutritional label.

Please note that the recommendations on this page are subject to any other dietary considerations that individual patients may have, such as fermenting gut problems (see Fermentation in the gut and CFS) and any other issues such as allergies and intolerances. See also Stone Age Diet

An overall guide for a ketogenic diet is:

  • Protein content (1gm per 1lb body weight) say 150grams
  • Carbohydrates - up to 50grams
  • Calories 2000kCal per day
WORK TO THESE GUIDELINES, USING THE DATA CONTAINED IN THE TABLES BELOW. HOWEVER, ONE CANNOT RELY PURELY ON THESE
GUIDELINE AMOUNTS TO ENSURE KETOSIS - SEE NOTES ON THE USE OF MONITORING EQUIPMENT BELOW.

Essential practical details for commencing a ketogenic diet

Establish a list of very low carbohydrate foods and make sure that your pantry is well stocked with such. Always look at the labels which detail the carbohydrate content of foods - this is very helpful. These carbohydrate values given on labels are normally total carbs which include all starches, sugars and soluble fibre. Some people prefer to use net carbs (sugars and starches, with fibre excluded) on the grounds that soluble fibre is fermented into short chain fatty acids. Linseed is a good example – it is said to have virtually zero carbs because although 100grams contains 29grams of total carb, 27grams is fibre and so just 2grams is starch and sugar. I find I can eat several slices of linseed bread and stay in ketosis - some cannot!
All carb amounts on this webpage are disclosed excluding the dietary fibre content.

Table of Fats, Oils and Proteins - generalised table

By way of introduction, here is a generalised table of very low carb content fats, oils and proteins:

How much in a day? ...of which type of food? /Carb content Important Notes
Fat
ad lib
(These are all saturated fats)
Lard, dripping, leaf fat, meat fat, coconut oil, palm oil
Possibly butter (but allergy to dairy is common)
Carbs zero
Saturated fats are the only fats that should be used hot for roasting, frying and grilling.
Oils
ad lib
(these are mono or poly unsaturated)
Nut oil seed oil, vegetable oil and fish oil.
Carbs zero
Only use these oils cold (heating them flips them to trans-fats). Make sure they are cold pressed oils.
Protein
Approx 1 gram per pound of body weight
Meat (beef chicken, pork, venison, and other game)
Poultry (chicken, duck, turkey, game birds)
Fish
Carbs zero BUT see next column....
….. excess protein can be turned into carbohydrate by the liver.
A ketogenic diet is not a high protein diet
Other Protein Bacon,salami,sausage
Eggs
Coyo (coconut yoghurt) plain

Very low carbs
0.5 grams of carb in one egg
Coyo (coconut yoghurt) plain - 0.5grams of carb in 100gms! A great addition to the diet


Specific Table of other foods

Here is a table of higher content carb food types and the amounts of each that can be eaten in a day.

How much in a day? ...of which type of food? / Carb content of 100 grams is... Amount allowed in day to comply with recommended daily carb content (taken as 10gms in all cases)
Vegetables and salad
10-15grams of carb
Spiralised vegetables roasted in lard is a great dish!
See Spiralite Vegetable Spiraliser
Courgette 2.1gms
Green leafy vegetables eg spinach, watercress 1.4gms
Brassicas 2.6gms
Mushrooms 3.2gms
Green beans 3.6gms
Onions 7.3gms
Swede 6.7gms
Carrot 7.2gms
Butternut squash 10gms
Leek 12.2gms
CARE WITH ROOT VEGETABLES
Potato 14.8gms
Parsnip 13.1 gms
470gms of courgette OR
710gms of leaves OR

380gms of brassica OR
310 gms of mushroom OR
270 gms of green bean OR
140 gms of onion OR
150gms of swede OR
140gms carrot OR
100 gms of Butternut squash OR
80 gms of leek OR

67gms of potato OR
76gms of parsnip
Vegetables and salad continued
10-15grams of carb
Lettuce, rocket 1.7gms
radish 1.8gms
cucumber 3.1gms
tomato 2.7gms
sauerkraut 1.4gms
peppers 2.9gms
spring onion 4.4gms
588gms of lettuce OR
555gms of radish OR
320gms of cucumber OR
370gms of tomato OR
710gms of sauerkraut OR
340gms of peppers OR
230gms of spring onions
Nuts and seeds
5-10 grams of carb
Brazils 4 gms
Walnuts 7gms
Peanuts 7gms
Almonds 10gms
Linseed 2gms
Cashews 26.7gms
250 gms of brazils OR
140gms of walnuts OR
140grams of peanuts OR
100 gms of almonds OR
500gms of linseed OR
37gms of cashews
Fruits and berries
5-10 grams of carb
Olives 2.8gms
Strawberry 6gms
Avocado 2gms
Gooseberry 5.7gms
Raspberry 5 gms
Blueberry 11.6gms
Blackcurrant 11gms

350gms of olives OR
167gms of strawberry
500gms of avocado
175gms of gooseberry
200gms of raspberry
86gms of blueberry
90gms blackcurrant


Table of snacks and "taste enhancers"

Here is a table of snacks and "taste enhancers".

General Food Type Specific examples Important Notes
Savouries
zero or very low carb
Lemon juice
vinegar
garlic
mustard
salt
pepper
spices
Mayonnaise and French dressing
None
Sweetener
zero carb
Stevia is safe and effective
The sugar alcohol xylitol has a glycaemic index of 13 and so use sparingly.
Both are antimicrobial.
Artificial sweeteners such as aspartame and saccharine are toxic.
Other sugar alcohols (eg sorbitol, mannitol) increase glucose in the blood and are fermented in the gut
Nibbles
zero carb
Pork scratchings Once fully keto-adapted one should not need to snack - but eating crunchy food is satisfying!
Alcohol Must be zero carb eg brandy, gin, whisky, vodka.
The body “burns” alcohol before fat - this may stall weight loss
Care – alcohol tolerance is reduced on a ketogenic diet – you get drunk quicker!
Will power is reduced with alcohol! Don’t fall off the wagon.
Alcohol is toxic.
Drinks
zero carb
Water or fizzy water
Real coffee
Tea
Herbal tea (including Green Tea)
Always quench your thirst with water before drinking tea and coffee.
Chocolate
Gets its own section!
90% dark chocolate
(say 14gms carbs per 100gms)
70 gms daily equates to 10gms of carbs BUT beware as too much may disturb sleep.


Dairy Products

Most of the diets I advocate are dairy free for reasons given previously (See Stone Age Diet) . The "safest" dairy product is butter – it is the milk protein and milk sugar that are such a problem. Ghee is ideal since it is free of milk protein.

Sample recipes

Have a go at some new recipes as detailed below. My life as a ketogenic was transformed by linseed bread, coconut cream, salad dressing, coconut chocolate, crumble topping and a spiraliser!

If in doubt eat more fat and less carbs.

a- Coconut cream: This is my favourite recipe – the resulting cream has the taste and texture of double cream. Ingredients: one 450ml tin of coconut milk, dollop of melted coconut oil (more for thick cream, less for thin cream), ½ teaspoon sunflower lecithin. Sweeten to taste with stevia. Whizz up in food processor. Put in fridge. Use as you would use cream – delicious in black coffee.

b- Coconut Yoghurt: same as above but use fermented coconut milk.

c- Chocolate cream: – as above but stir in 60grams (½ pot) Green and Black’s cocoa powder.

d- Coconut chocolate: – mix one 450gram pot of coconut oil with a whole 125gram pot of Green and Black’s cocoa powder. Pour into ice cube containers and put in deep freeze. Eat direct from deep freeze.

e- Linseed Bread: 100grams linseed ground up into a flour, 20grams ground almonds, ½ tspn bicarb soda, ½ tspn salt. Stir in 2 eggs, 1/3 cup water, 1/3 cup olive oil. Mix well .Stick it in the oven 150 degrees C for 60mins. Slice thinly.

f- Crumble topping for berry pies: 100grams linseed ground up into a flour, 100grams desiccated coconut, teaspoon cinnamon, sweeten with stevia, dollop of coconut oil to stick it together.

g- French Dressing: – crushed clove garlic, dollop olive oil, juice whole lemon, 1 teaspoon mustard, generous pinch sea salt, pepper, ½ tspn treacle (sorry about that - not essential - but it does blend all to make a gorgeous texture!). Mix.

h- Mayonnaise: - all the above – but add in 2 egg yolks, ½ tspn lecithin, whizz up in food processor

Monitoring Equipment for ketosis

You cannot rely simply on what you eat and how much you eat to know that you have done enough to get into ketosis. Some people can eat 100 grams of carb per day and get into ketosis. Some have to reduce to below 30 grams (includes me – dammit!). Monitor your blood sugar and ketones using a Freestyle Optimum meter. (Amazon.co.uk link for FREESTYLE OPTIUM NEO GLUCOSE AND KETONE METER) It takes about 2 weeks to become keto-adapted so do not be disheartened in the early stages. Women find it harder to get into ketosis than men, and we are all different! Measuring ketones in urine is not reliable BUT it may work for you. Ketostix for urine testing are less expensive than blood ketone measuring sticks. See My online shop link for multistix and also Urine MULTISTIX analysis interpretation Breath testing is reliable but the meters are expensive - see Ketonix website.

The Biochemistry of ketosis

As you keto-adapt, blood sugars will come down and then they will become remarkably stable, fluctuating only by a few tenths of a millimol per litre. Ketones should appear and levels should be 0.5 to 3.0 millimols. Levels tend to be lower in the morning and higher as the day goes on. After exercise ketones may rise to 4 millimols. Please note in diabetic keto-acidosis levels are above 10 millimols.

There is the world of difference between the ketosis of low carb and the ketosis of uncontrolled diabetes. To compare the two is like comparing the thirst quenching properties of water with water as a killer by drowning! Low level ketosis is highly desirable metabolically speaking, but some doctors use diabetic ketosis to create false alarm against the ketogenic diet.

Constipation may be a problem - in which case use linseed – this can be incorporated into the diet as linseed bread or as a crumble topping. Although linseed has a total carb load of 29gms per 100gms, 90% of this is fibre and only 10% as starch. This means that some people can eat large amounts of linseed and remain in ketosis.

A ketogenic diet is demanding of minerals – you will need extra salt (5 grams per day added to food) and a good multi-mineral daily with 300mgs of magnesium.

Finally remember that there are three major hormonal considerations in order to get into ketosis:

  • An insulin spike (from a moment of indiscretion such as snaffling a bar of cheap chocolate or bag of crisps or a biscuit) will spike insulin and switch off fat burning for many hours. This means you will have a window of time of some hours when you cannot access fuel either from carbs (because the sugar spike has been pushed into fat by insulin) or from fat (because insulin blocks this). This may mean you feel awful for those hours. Knowing this is good incentive to say on the wagon!
  • Female sex hormones induce a metabolic syndrome. This is why women must eat fewer carbs than men to get into ketosis. I suspect the Pill and HRT will have a similar effect.

Generalised Ketogenic Shopping List (no food preparation or cooking) for the severely disabled

Initially do not worry too much about the protein content – some people can get into ketosis with a high protein diet. If you can’t then you may need to think about that!

FOOD kCal per 100grams Carbohydrates (gms) per 100grams (NB - excludes Fibre) Fat (gms) per 100grams Fibre (gms) per 100grams Protein (gms) per 100grams
Tinned Ham 112 1.1 7.1 0.1 11.0
Tinned Gammon 100 1.3 2.5 Trace 18.0
Corned Beef 225 1.1 13.5 0.1 24.8
Chopped Pork 207 0.6 15.5 0.1 16.9
Tinned sardines in Olive Oil –boneless 225 0.0 15.4 0.1 21.7
Tinned sardines in Tomato Juice 142 1.5 7.5 Trace 17.0
Grilled sardines in a tin 198 0.0 11.9 Trace 22.8
Tinned Tuna chunks in spring water 113 0.0 0.5 Trace 27.0
Tinned Tuna chunks in brine 113 0.0 0.5 Trace 27.0
Tinned Tuna chunks in Olive Oil 209 0.0 9.2 0.0 18.4
Tinned Yellow-fin Tuna in Olive Oil 180 Trace 8.0 Trace 27.0
Tinned Mackerel in Tomato and Basil sauce 132 5.7 6.3 Trace 12.8
Tinned Steam cooked Mackerel in Olive Oil 260 0.0 20.0 Trace 20.0
Tinned Grilled mackerel fillet 245 0.0 17.0 Trace 23.0
Tinned Pink Salmon in water 131 Trace 5.4 Trace 20.4
Tinned Red Salmon in water 151 Trace 7.8 Trace 20.4
Tinned pilchards in tomato sauce 159 2.4 10.1 Trace 14.5
Cornish Pilchard fillets in Olive Oil 205 0.5 13.0 Trace 22.0
Cornish Pilchard fillets in tomato sauce 161 1.8 9.1 Trace 18.0
Milano Salami 347 0.5 27.3 0.0 24.8
German Pepper salami 319 0.7 25.3 1.1 21.5
Serious Pig snacking salami 422 0.0 32.7 0.0 32.0
Coyo Natural coconut yoghurt 182 0.5 19.0 Trace 3.0
Coyo Vanilla coconut yoghurt 182 0.5 19.0 Trace 3.0
Coyo Chocolate coconut yoghurt 196 3.9 19.0 Trace 2.3
Coyo Cherry coconut yoghurt 177 5.9 16.0 Trace 2.6
Coyo Mango coconut yoghurt 177 5.7 16.0 Trace 2.6
Biona organic creamed coconut 664 24.0 68.0 14.0 6.0
Alpro soya yoghurt - plain 50 2.1 2.3 1.0 4.0
Alpro pineapple peach and passionfruit soya yoghurt 78 10.3 1.9 0.8 3.6
Alpro strawberry and rhubarb soya yoghurt 74 9.4 1.9 1.0 3.6
Alpro Vanilla yoghurt 75 9.5 2.2 1.0 3.7
Pistachios – roasted and salted 562 18.0 45.0 10.0 20.0
Almonds 576 10.0 49.0 12.0 21.0
Roasted salted peanuts 567 7.0 49.0 9.0 26.0
Salted cashews 553 26.7 44.0 3.3 18.0
Brazil nuts 656 4.0 66.0 8.0 14.0
Hazelnut kernels 628 7.0 61.0 10.0 15.0
Pecans 690 4.0 72.0 10.0 9.0
Pine Nuts 673 9.3 68.0 3.7 14.0
Walnuts 654 7.0 65.0 7.0 15.0
Chia seeds 486 8.0 31.0 34.0 17.0
Organic hemp seeds 455 2.8 31.8 30.6 24.0
Pomegranate seeds 100 18.7 1.2 4.0 1.7
Organic Flax seed 534 2.0 42.0 27.0 18.0
Pumpkin seeds 446 36.0 19.0 18.0 19.0
Sunflower seeds 584 11.0 51.0 9.0 21.0
Sesame seeds 573 11.0 50.0 12.0 18.0
Macadamia Nut Butter 711 13.7 65.0 9.0 7.8
Almond Butter 640 19.8 50.2 10.1 18.0
Hazelnut Butter 693 16.2 60.1 9.1 13.0
Cashew Butter 628 18.9 51.3 4.3 20.6
Peanut Butter 599 16.8 46.2 6.7 25.6
Coconut butter 670 7.3 64.5 16.3 6.9
90% Lindt dark chocolate 594 16.5 52.8 13.2 10.0
99% Lindt dark chocolate 540 8.0 50.0 6.0 14.0
Green and Black’s 85% dark chocolate 630 22.5 53.5 11.5 9.4
Pralus - Le 100% dark chocolate 610 18.0 56.0 13.0 9.0
Avocado 160 2.0 15.0 7.0 2.0
Mayonnaise 680 0.6 75.0 0.0 1.0
Salad Cream 336 24.0 27.0 0.3 1.6
Sauerkraut 19 1.4 0.0 2.8 0.7
Tomatoes 18 2.7 0.2 1.2 0.9
Lettuce 15 1.6 0.2 1.3 1.4
Cucumber 16 3.1 0.1 0.3 0.7

Meals suggestions for the severely disabled (no food preparation or cooking) using the above table

Linked below you will find 7 days' worth of meal suggestions for those following the ketogenic diet who are severely disabled. These are included by way of example as to how one can construct meals using the information on this page. In the short term these may be somewhat repetitive, but as energy levels improve you can start cooking, maybe one meal a day.

Please feel free to add 'taste enhancers' from the above table so as to add variety.

These meal suggestions require one loaf of Linseed Bread (as described above) to be cooked once a week. It is hoped that this task can be done by a carer.

Obviously, one can mix up a breakfast from one day with a lunch from another and so on, as long as one sticks to the overall guidelines.

In these meals, the 50gms carbs and 2000kCal calories limits have been adhered to. The protein levels have been kept to around 100gms. This is less than noted above and so you could divert some of your dietary intake into more protein rich foods. Protein can convert into carbs and so having low normal amounts of protein is protective against this.

A small afternoon snack has been included on each day. This has been included because it is recognised that initially it will be difficult to avoid such snacking "habits"! This is not ideal, and so, as time goes by, try to drop the snack and add equivalent amounts of protein,carbs and calories to the main meals.

Please Note that for breakfasts, where there is the advice to mix seeds with coyo or alpro yoghurt, different patients will have different tastes as to how "thick" they would like this to be. Please adjust the amount of seeds you mix in to your own taste, but do make sure that you eat all the seeds!

If one were to follow the 7 day meal plan as above then the weekly shopping list is:

WEEKLY SHOPPING LIST FOR THE 7 DAYS MEAL SUGGESTIONS AS ABOVE:

(as a file to be downloaded and used for the weekly shop by carer - WEEKLY SHOPPING LIST FOR THE 7 DAYS MEAL SUGGESTIONS AS ABOVE)

One loaf of Linseed Bread as above – use 250gms Linseed and scale the other ingredients up

Coyo Natural Yoghurt [125gms]
Coyo Chocolate coconut Yoghurt [125gms]
Coyo, pineapple, peach and passionfruit yoghurt [125gms pot]
Alpro Vanilla Yoghurt [200gms] and Alpro Vanilla yoghurt [150gms]
2xAlpro soya yoghurt plain [150gms]
Alpro Strawberry and rhubarb yoghurt [150gms]

Tinned Mackerel in Basil and Tomato sauce [120gms]
Tinned Tuna in spring water [120gms]
Grilled sardines in a tin [120gms]
Tinned Tuna in spring water [120 gms]
Tinned red salmon [150gms]
Cornish Pilchards in tomato sauce [120 gms]
Tinned sardines in tomato juice [125gms tin]
2xChopped Pork [200gms tin]
Tinned Gammon [200gms]
2xCorned Beef [125gms tin]
Tinned Ham [125gms tin]
Salami serious pig snacking [100gms]
Milano salami [75gms]

6 avocados
400gms each of tomato, cucumber, lettuce
Sauerkraut [700gms]

100grams flax seed
100gms sesame seeds
150gms sunflower seeds
100gms of hemp seeds
100gms of chia seeds
50gms of pumpkin seeds
60gms of Pine nuts
30gms of Almonds
50gms of Pecans
10gms hazelnuts
40gms Brazil Nuts
50gms Walnuts

50gms of blueberries
50gms of strawberries
50gms of raspberries
50gms of gooseberries

1 bar Green and Black’s 85% chocolate – will last 2 weeks
1 bar 90% Lindt dark chocolate – will last 2 weeks

Pot mayonnaise – will last more than one week
Pot salad cream – will last more than one week
Pot macadamia nut butter – will last more than for one week
Pot hazelnut nut butter – will last more than for one week
Pot peanut nut butter spread – will last more than for one week
Pot cashew butter spread – will last more than for one week
Pot coconut butter – will last more than for one week

NOTES

  • As things move forward, one could add in boiled eggs for some of the tinned fish.
  • Those who are concerned about soy products should stick to the coyo option for the time being until they are able to move forward with cooking.
  • There is an alternative to the Alpro yoghurt, Provamel, which is sugar free and so some patients may prefer this in their individual circumstances.
  • If you feel that 2000kCal is too high for your personal level of activity then cutting out the snacks each day will help to reduce the calorific intake.
  • In essence it is hoped that this will be a temporary measure until the sufferer can cook more on their own and so don't think that this will be your diet forever!
  • This is far from perfect, of course, but it does fulfill a need that many of my patients have been asking for - namely how to be ketogenic if severely disabled.
  • I am currently searching for a shop bought Linseed Bread Loaf, or equivalent, to replace the home cooked version. If anyone beats me to it, please do let me know! Any other ideas are of course, as always, welcome!

Further Ideas

For further ideas have a look at the following websites:

Related Articles

External Links

Paper on CFS/ME and Diets

This paper - MITOPROTECTIVE DIETARY APPROACHES FOR CFS/ME - CALORIC RESTRICTION, FASTING AND KETOGENIC DIETS - by Courtney Craig is a useful addition to the evidence base:


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