RESEARCH
A prospective study: Growth and nutritional status
of children treated with the ketogenic diet
YEOU-MEI CHRISTIANA LIU, MS, RD; SHELLEY WILLIAMS, RD; CARLOTA BASUALDO-HAMMOND, MSc, RD;
DEREK STEPHENS, MSc; ROSALIND CURTIS, MD, FRCP(C)
ABSTRACT
Objective To assess the nutritional status of children treated
with the classic and medium-chain triglyceride (MCT) keto-
genic diets.
Design A prospective, nonrandomized study design was used
to measure nutrient intakes, growth, and biochemical indexes
of children, age 1 to 16 years, with intractable epilepsy before
and after 4 months’ treatment with the classic and MCT keto-
genic diets. None of the children had been on earlier dietary
regimens.
Subjects Of 58 children asked to participate in the study
between September 1998 and July 2000, consent was ob-
tained for 30 children. Fourteen children on the classic diet
and 11 children on the MCT diet completed the study (83%
completed).
Statistical analysis performed Paired t tests were done on
anthropometric and biochemical indexes. Nutrient intakes
were compared with Dietary Reference Intakes (DRIs).
Results Both groups had statistically significant height in-
creases of 2 to 3 cm (P⬍.05), but did not have significant in-
creases in height/age percentiles. Weight percentiles de-
creased by approximately 10 percentiles for both diets;
P⫽.043 for classic diet and .051 for MCT diet. Nutrient in-
takes from the diet and vitamin and mineral supplements met
the DRIs except for phosphorus (both diets) and folate (clas-
sic diet). All biochemical indexes, including albumin, re-
mained within the normal range. For the MCT diet, there was
a 0.7 decrease in the ratio of total cholesterol to high-density
lipoprotein ratios (P⬍.0009) at 4 months.
Applications When treating children on a ketogenic diet,
clinicians should recommend adequate intake of energy and
protein, a higher proportion of unsaturated to saturated di-
etary fats, and consider vitamin and mineral supplements.
J Am Diet Assoc. 2003;103:707-712.
T
he ketogenic diet, introduced by Wilder in 1921 (1), con-
tinues to be one of the most effective therapies for intrac-
table seizures in the pediatric population (2-9). Approx-
imately 1 in 5 people with epilepsy have ongoing seizures
that do not respond to drug treatment (intractable seizures).
Although the anticonvulsant mechanism of the ketogenic diet
is unknown, studies show that the number and severity of sei-
zures may decrease for more than two thirds of children
treated with this diet (10,11). For some children, the ketogenic
diet can be more effective than anticonvulsant medications
(12).
The diet consists of approximately 70% to 90% of energy
from fat, with the remaining energy from protein and carbohy-
drate (13). There are two main types of ketogenic diets: the
classic ketogenic diet and the medium-chain triglyceride
(MCT) ketogenic diet. The classic ketogenic diet produces ke-
tosis by limiting intake of carbohydrate and protein to less than
10% of energy combined. The MCT diet uses medium-chain
triglyceride fat to produce ketosis. This allows for a larger in-
take of carbohydrate and protein (approximately 29% of en-
ergy from carbohydrate and protein combined).
The benefits of the ketogenic diet are well known, but less is
known about the nutritional risks of the diet and potential im-
pact on growth (14,15). A study of 21 children treated with the
Y-M C. Liu, D. Stephens, and R. Curtis are with The
Hospital for Sick Children, Toronto, Ontario, Canada.
Y-M C. Liu and R. Curtis are also with Bloorview MacMil-
lan Children’s Centre, North York, Ontario, Canada. Y-M
C. Liu is a certified health education specialist. S. Wil-
liams is with Lakeridge Health Corporation, Oshawa, On-
tario, Canada. C. Basualdo-Hammond is with Capital
Health, Edmonton, Alberta, Canada. At the time of the
study, S. Williams and C. Basualdo-Hammond were with
Bloorview MacMillian Children’s Centre, North York, On-
tario, Canada.
Address correspondence to Yeou-Mei Christiana Liu,
MS, RD, The Hospital for Sick Children, Room 6D47,
Atrium, 555 University Ave, Toronto, Ontario, Canada
M5G 1X8. E-mail: christiana.liu@sickkids.ca.
Copyright © 2003 by the American Dietetic Association.
0002-8223/03/10306-0005$35.00/0
doi: 10.1053/jada.2003.50136
Journal of THE AMERICAN DIETETIC ASSOCIATION / 707
 RESEARCH
Table 1
Macronutrient composition of the classic and medium chain triglyceride ketogenic diets, as a percent of energy
Parameter Classic dieta
Diet ratio 4.3:1 Diet ratio 4.0:1
(% of kcal) (% of kcal)
Carbohydrate 2-3 3-5
Protein 6-7 5-7
Fat 91 90
MCTb 0 0
a
Diet ratio⫽[fat (g)⫼(protein⫹carbohydrate) (g)]. When the diet ratio increases, the percent of energy from carbohydrate decreases in order to provide sufficient
protein for growth and development.
b
MCT⫽medium-chain triglyceride.
classic ketogenic diet found that nutritional status was main-
tained for 6 months of diet intervention (14). More recently, a
retrospective review of children receiving the classic ketogenic
diet found that linear growth of some children might be re-
tarded (16). The objective of this study was to use a prospec-
tive study design to assess growth velocity and potential nutri-
tional risks for children on both types of ketogenic diets.
METHODS
A prospective, nonrandomized design was used. The study par-
ticipants were children from the neurology clinic at The Hospi-
tal for Sick Children and the complex epilepsy clinic at Bloor-
view MacMillan Children’s Centre in Toronto, Ontario, Canada,
between September 1998 and July 2000 who met inclusion and
exclusion criteria (N⫽58). Research ethics board approval was
obtained from each center. A consent form was signed by all
parents/caregivers before their children were enrolled. To be
eligible for the study, children were required to meet admission
criteria for the ketogenic diet program as per site-specific pro-
tocols. Admission criteria included age between 1 and 16 years
and at minimum two unsuccessful trials with different anticon-
vulsant medications. Children were assigned to one of the two
diets based on their individual and family preferences, the fam-
ily’s financial situation (because some families could not afford
the oil needed for the MCT diet), and the medical team’s as-
sessment of which diet would likely achieve greater compliance
and tolerance.
Sixteen subjects were recruited for the classic ketogenic diet
and 14 for the MCT ketogenic diet. Before starting the either
diet, the children fasted until their urine became strongly pos-
itive for urine ketones (8-16 mmol/L),* which took, on average,
24 to 48 hours. Children were generally started on the classic
ketogenic diet with a ratio of fat to protein and carbohydrates
by weight of 4:1, which was increased (eg to 4.3:1) or de-
creased (eg 3.5:1) depending on the child’s urine ketones and
seizure control (17) (Table 1). Children treated with the MCT
ketogenic diet received 40% to 60% energy from MCT oil, and
diets were adjusted according to the child’s urinary ketones
and seizure control (17). Urine ketone concentrations were
measured by dipstick (acetoactate). Maintenance fluid was
used to meet fluid recommendation (18). The children’s diets
were supplemented with sugar-free multivitamin and mineral
*To convert mmol/L urine ketone to mg/dL, multiply mmol/L by 10. To
convert mg/dL urine ketone to mmol/L, multiply mg/dL by 0.1. Urine
ketone of 8-16 mmol/L⫽80-160 mg/dL.
708 / June 2003 Volume 103 Number 6
Medium-chain triglyceride diet
Diet ratio 3.5:1 60% (% 50% (% 40% (%
(% of kcal) of kcal) of kcal) of kcal)
3-8 19 19 19
4-9 10 10 10
88 11 21 31
0 60 50 40
tablets, calcium tablets with magnesium and zinc, and iron tab-
lets or liquid iron. The individual nutrient dosages were pre-
scribed according to each child’s Dietary Reference Intakes
(DRIs) (19-21) to help each child achieve at least 100% of the
Recommended Dietary Allowance (RDA) or Adequate Intake
(AI), as applicable. Protein requirements were approximately 1
gram/kg body weight per day (17). The initial energy prescrip-
tion was estimated to be 75% of estimated total energy expen-
diture from basal energy expenditure calculation plus an activ-
ity factor (17,18). Individualized menus, meal patterns, and
food scales were used to ensure that children received the
prescribed amount of macronutrients.
The parents completed 7-day food records before the chil-
dren enrolled in the study and after the children had been on
the ketogenic diet for 4 months. Before the diet was started,
parents were provided with written and oral instructions for
recording intake. Common household measuring cups, spoons,
and ounce scales were used to estimate portion size. Decimal
gram scales were used for measuring portion sizes for all foods
while children were treated with the ketogenic diet to ensure
accurate portion sizes and maintenance of ketosis. Therefore,
food records for children treated with the ketogenic diet were
based on precise weight measurements.
The ESHA Food Processor Nutrient Analysis and Fitness
software (ESHA 1999, Esha Research Professional Nutrition
Analysis Software and Database, Version 6.4, Salem, OR) used
the Canadian Nutrient File database (Canadian Nutrient File
Database, 2000 edition) to analyze the nutrient composition
and to compare intakes of energy, protein, vitamins, and min-
erals. When starting dietary intervention, nutrient intakes were
adjusted for patients who had nutritional deficiencies based on
initial biochemical assessment. Prestudy and poststudy in-
takes, including reported vitamin and mineral intake, were
compared with DRIs, RDAs, or AIs, as applicable, to obtain the
percent DRI.
The following growth measures were taken at the beginning
of the study and at 4 months: height, weight, mid-arm circum-
ference, and triceps skinfold. Standardized methods were used
for all measurements (22). Height was measured with a stadi-
ometer (Genetech Inc, San Francisco, CA), a nonflexible mea-
suring tape, or a standard length board, depending on whether
children were ambulatory. The heights and weights were com-
pared with the standards for linear growth derived from the
Tanner-Whitehouse growth charts (Castlemead Publications,
Hertford, Herfordshire, United Kingdom; revised September
1997). Ideal body weight was the appropriate weight for height
 RESEARCH

Table 2
Comparison of height, weight, triceps skinfold, mid-arm circumference, and mid-arm muscle before and after 4 months treated with the
ketogenic diet

Parameter Classic diet (nⴝ14) Medium-chain triglyceride diet (nⴝ11)

Prediet 4 mo P value Prestudy 4 mo P value
MeanⴞSDa MeanⴞSD MeanⴞSD MeanⴞSD

Weight (kg) 21.3⫾8.8 20.8⫾8.2 .367 31.8⫾18.6 31.6⫾18.5 .779

Weight (percentile) 48.6⫾42.1 39.1⫾39.7 .043* 54.0⫾42.3 44.5⫾40.0 .051
% IBWb 103.4⫾12.9 98.6⫾15.1 .154 106.1⫾18.1 95.2⫾30.6 .127
Height (cm) 110.3⫾20.4 113.2⫾18.5 .040* 127.1⫾27.5 129.0⫾26.9 .001*
Height/age (percentile) 42.8⫾37.7 42.0⫾34.7 .861 53.0⫾30.3 52.1⫾32.6 .832
TSFc (mm) 9.1⫾5.2 8.5⫾5.0 .276 8.8⫾3.8 8.91⫾3.8 .690
MACd (mm) 177.1⫾39.0 170.3⫾33.1 .132 211.4⫾45.1 209.6⫾44.7 .154
MAMCe (mm) 147.5⫾29.5 143.4⫾22.2 .385 182.1⫾42.0 181.4⫾40.5 .612
a
SD⫽standard deviation.
b
IBW⫽ideal body weight.
c
Triceps skinfold.
d
Mid-arm circumference.
e
Mid-arm muscle circumference.
*Statistically significant difference, P⬍.05.

according to the Tanner-Whitehouse growth chart. Children
with complex epilepsy have been reported to have growth
curves similar to Tanner standard growth charts (23). An as-
sumption was made that children in the study would continue
to grow along their prediet height percentile. The child’s ideal
height percentile (percentile for height at admission) was com-
pared with the child’s actual height percentile at each visit.
Triceps skinfold, mid-arm circumference, and mid-arm muscle
circumference are indicators of protein and fat stores. Lange
skinfold calipers (Beta Technology Inc, Santa Cruz, CA) were
used to measure triceps skinfolds.
Biochemical indexes included serum levels of magnesium,
calcium, phosphorus, zinc, folate, vitamin E, ferritin, sodium,
potassium, chloride, total protein, albumin, total cholesterol,
triglyceride, high-density lipoprotein (HDL), low-density li-
poprotein (LDL), hemoglobin, red blood cells (RBC), hemato-
crit, mean corpuscular volume, mean corpuscular hemoglobin,
mean corpuscular hemoglobin concentration, aspartate amino-
transferase, urea, urate, pH, and RBC folate. Blood samples
were taken after the children had fasted a minimum of 14
hours. The laboratory at The Hospital for Sick Children ana-
lyzed all blood samples using standard methods.
SAS statistical software (SAS Institute Inc, Cary, NC) and
MINITAB statistical software (Minitab Inc, State College, PA)
programs were used to perform paired t tests for comparison of
baseline and 4-month values for all biochemical levels and
growth measures. For the primary hypothesis, the differences
of height and weight, P values did not need to be adjusted. All
other measures were part of the secondary hypothesis and P
values were adjusted according to number of tests done. To
correct for the problem of greatly increasing the chance of
declaring false significance in the context of multiple testing,
the Bonferroni correction was used. This test is more conser-
vative than other tests because it reduces the likelihood that
the difference was due to chance. A greater difference between
tests is required to achieve significance than without correc-
tion. Also, because the number of t tests was considerable, a
conservative approach was considered least risky in declaring
false significance. There were 56 tests conducted, so the signif-
icance level was set at 0.05/56 ⫽ 0.0009. Hence, for 2-tailed
tests the null was rejected if the absolute t statistic with df ⫽ 12
was more than 4.32.
RESULTS
Subjects
Thirty patients (19 boys and 11 girls) were enrolled in the
study. Four months after the start of the study, 25 (83%) of 30
were still receiving the ketogenic diet. Fourteen children (9
boys and 5 girls), mean age 6.0 years (range⫽2.8 to 14.1 years),
were treated with the classic diet, and 11 children (6 boys and
5 girls), mean age 8.1 years (range⫽3.0 to 14.0 years), were
treated with the MCT diet. The 5 children who did not continue
the diet were able to tolerate the diet, but their caregivers had
difficulty with other challenges of the diet (such as lifestyle
changes and time constraints for food preparation).
Growth
The weight percentiles decreased for children on both diets at
4 months compared to prediet, but the difference between the
children’s baseline weight percentile scores and their scores at
4 months was statistically significant only for those treated with
the classic diet (P⫽.043) (Table 2). There were no statistically
significant differences in the percentage of ideal body weight
between prestudy and poststudy tests (Table 2). There were
statistically significant increases (P⬍.05) in the height of the
children in both the classic diet and the MCT diet groups.
Therefore, the majority of children seemed to be growing along
the same height percentile curve from prestudy to 4 months on
the diet.
Triceps skinfold, mid-arm circumference, and mid-arm mus-
cle circumference measurements were not significantly differ-
ent prestudy and poststudy; however, there was a trend toward
lower measurements in the classic diet group (Table 2).
Nutrient Intakes
Energy intake was similar before and at 4 months on both types
of ketogenic diet. Compared with prestudy dietary intake, pro-
tein intake was lower for the classic and MCT ketogenic diets
but met recommended nutrient intakes. Nutrient intakes for

Journal of THE AMERICAN DIETETIC ASSOCIATION / 709

 RESEARCH

Table 3
Comparison of macronutrient and micronutrient intakes before and after 4 months treated with the ketogenic diet

Parameter Classic diet (nⴝ14) Medium-chain triglyceride diet (nⴝ11)

Predieta 4 monthsa Predieta 4 monthsa
MeanⴞSDb %c MeanⴞSD % MeanⴞSD % MeanⴞSD %

Energy (kcal) 1,345⫾420 1,226⫾389 1,475⫾374 1,366⫾504

Proteind (g) 47.2⫾16.7 200 23.2⫾7.8 109 62.9⫾11.6 225 37.5⫾14.6 134
Total fat (g) 57⫾22 122⫾35 61⫾26 113⫾43
Carbohydrate (g) 175⫾67 9⫾3 172⫾53 68⫾23
Vitamin A (␮g) 1,326⫾1,210 300 1,734⫾333 392 1,035⫾290 223 1,717⫾88 370
Vitamin B-1 (mg) 1.5⫾1.2 251 1.2⫾0.7 206 1.4⫾0.4 170 2.2⫾0.3 273
Vitamin B-2 (mg) 1.7⫾1.1 289 1.6⫾0.8 274 1.9⫾0.7 243 2.6⫾0.4 331
Vitamin B-3 (␮g) 15.4⫾13.3 183 17.2⫾2.7 204 14.3⫾5.9 146 22.2⫾2.3 226
Vitamin B-6 (␮g) 1.7⫾1.5 287 0.7⫾0.5 122 1.5⫾0.4 186 1.6⫾0.5 201
Vitamin B-12 (␮g) 3.6⫾3.1 276 4.6⫾2.9 351 3.9⫾1.8 261 5.7⫾0.6 383
Vitamin C (mg) 98⫾59 382 61⫾33 241 76⫾49 236 122⫾87 378
Vitamin D (␮g) 5.5⫾2.9 109 4.5⫾4.3 90 5.7⫾2.9 114 12.6⫾1.7 250
Vitamin E (mg) 9.3⫾9.6 123 13.3⫾15.0 174 6.3⫾5.5 74 8.2⫾6.3 95
Folate (␮g) 278⫾305 132 124⫾59 59 215⫾58 86 248⫾73 99
Ca (mg) 856⫾384 106 786⫾403 97 907⫾376 89 1,048⫾483 103
Fe (mg) 13.2⫾14.1 142 9.9⫾8.2 107 10.6⫾3.3 123 17.6⫾6.4 204
Mg (mg) 169⫾73 115 197⫾195 134 191⫾38 99 282⫾141 147
PO4 (mg) 828⫾333 138 407⫾173 68 1,023⫾234 113 686⫾215 76
Zn (mg) 8.5⫾7.1 152 17.4⫾16.5 310 7.2⫾1.3 120 17.1⫾13.9 286
a
Intake includes foods, beverages, and vitamin and mineral supplements.
b
SD⫽standard deviation.
c
Percentage is a comparison of the population mean Dietary Reference Intake (Recommended Dietary Allowance or Adequate Intake as applicable) with actual
intake (Ref. 19-21).
d
Percentage is a comparison of the population mean protein recommendation (1 gram/kg BW) with actual intake (Ref. 17).

children on the classic and MCT ketogenic diets, including daily
multivitamin and mineral supplements, met or exceeded the
DRI for all nutrients except for phosphorus (both diets) and
folate (classic diet only) (Table 3). Both diets would have been
inadequate in most micronutrients without the addition of vi-
tamin and mineral supplements.
Biochemical Nutritional Status
For both diet groups, all poststudy biochemical values were
within the normal range, and had no statistically significant
differences between prestudy and poststudy blood work val-
ues. For children in both diet groups, the mean prestudy labo-
ratory values were all within the normal range, except the fer-
ritin value was lower than the normal range, but was corrected
after 4 months of receiving supplements along with the keto-
genic diet (Table 4).
The classic ketogenic diet had no statistically significant ef-
fect on the subjects’ lipid profiles. However, these subjects had
an increase of 0.8 mmol/L in LDL (P⫽.003), an increase of 1.0
mmol/L in total cholesterol (P⫽.003), and an increase of 1.0 for
the total serum cholesterol to HDL ratio (P⫽.201) compared
with prestudy measurements (Table 5).
The MCT ketogenic diet had a positive effect on subjects’
lipid profiles. Ten out of 11 patients had significantly lower total
cholesterol to HDL ratios (P⬍.0009) after 4 months on the
MCT ketogenic diet. Although there were no statistically sig-
nificant differences in the mean LDL level, patients reduced
their mean LDL level by 0.4 mmol/L and increased their HDL
level by 0.3 mmol/L after 4 months on the diet (Table 5).
DISCUSSION
The results of this study indicate that linear growth was main-
tained in patients from baseline to 4 months on both the classic
and MCT ketogenic diet therapies. However, body weight de-
creased for children on both types of ketogenic diets, which
may be a result of inadequate energy intake. Protein intake met
recommended intakes for both diets. Provision of appropriate
vitamin and mineral supplements resulted in micronutrient in-
takes meeting recommended nutrient requirements for most
nutrients. The MCT diet was more adequate in B vitamins as a
result of grain products being permitted on the diet.
The large standard deviation for most nutrients is partly re-
flective of the lower nutrient intakes for children who were less
compliant with the vitamin and mineral supplements.
All biochemical indexes remained within the normal range.
Because this is a short-term study, it is recognized that blood
levels may decrease in the future if subjects continue the keto-
genic diet. Monitoring nutrient intakes and biochemical in-
dexes is essential to prevent deficiencies in the long term.
Couch et al (14) found from a 6-month study of children
treated with the classic ketogenic diet that there was a signifi-
cant increase in both height and weight and no significant
changes in the biochemical indexes of their subjects. Nordli et
al (24) indicated in their study, for at least 3 months’ follow-up,
that 96.4% of infants maintained appropriate growth. This
study (24) suggested that the ketogenic diet should be consid-
ered a safe and effective treatment for infants who have intrac-
table seizures. Recently, a retrospective chart review found
that children’s growth may be suboptimal after an average 1.2
years of the classic ketogenic diet (16), highlighting the impor-
tance of close monitoring of children on a ketogenic diet.
In both diet groups, blood albumin levels did not change
during the 4-month diet intervention. The Canadian ketogenic
database for the classic ketogenic diet shows a trend of lower
albumin levels at 6 months and 12 months of diet treatment
(unpublished data, manuscript submitted). Compared with the
classic diet, the MCT diet provides more protein per kilogram of

710 / June 2003 Volume 103 Number 6

 RESEARCH

Table 4
Comparison of biochemical data before and after 4 months treated with the ketogenic diets

Parameter Normal values Classic diet (nⴝ14) Medium-chain triglyceride diet (nⴝ11)
Prediet 4 months P value Prediet 4 months P value
MeanⴞSDa MeanⴞSD MeanⴞSD MeanⴞSD

Albumin (g/L) 33-58 38⫾3.34 38.4⫾3.6 .868 42.4⫾3.1 42.6⫾1.9 .819

Calcium (mmol/L)b 2.25-2.62 2.4⫾0.1 2.40⫾0.2 .957 2.46⫾0.1 2.46⫾0.1 .785
Zinc (␮mol/L)c 10.7-20.0 15.4⫾4.4 17.7⫾5.0 .222 18.2⫾7.8 13.8⫾3.5 .087
Vitamin E (␮mol/L)d 12.0-46.0 16.4⫾7.0 27.0⫾9.7 .003 18.8⫾9.0 20.4⫾7.5 .374
PO4 (mmol/L)e 1.16-2.10 1.5⫾0.2 1.45⫾0.1 .569 1.48⫾0.2 1.33⫾0.1 .122
Mg (mmol/L)f 0.70-0.95 0.84⫾0.1 0.77⫾0.1 .081 0.85⫾0.1 0.86⫾0.1 .795
RBC folate (mmol/L)g 421-1462 966⫾347 904⫾320 .256 694⫾192 854⫾440 .142
Ferritin (␮g/L)h 22-400 19.8⫾14.7 42.0⫾28.3 .013 21.8⫾12.1 25.5⫾12.2 .096
a
SD⫽standard deviation.
b
To convert mmol/L calcium to mg/dL multiply mmol/L by 4.01. To convert mg/dL calcium to mmol/L, multiply mg/dL by 0.25. Calcium of 2.50 mmol/L⫽10.0
mg/dL.
c
To convert ␮mol/L zinc to ␮g/dL multiply ␮mol/L by 6.54. To convert ␮g/dL zinc to ␮mol/L, multiply ␮g/dL by 0.15. Zinc of 15 ␮mol/L⫽98 ␮g/dL.
d
To convert ␮mol/L vitamin E to mg/dL multiply ␮mol/L by 0.04307. To convert mg/dL vitamin E to ␮mol/L, multiply mg/dL by 23.2. Vitamin E of 30 ␮mol/L⫽1.3
mg/dL.
e
To convert mmol/L PO4 to mg/dL multiply mmol/L by 3.1. To convert mg/dL PO4 to mmol/L, multiply mg/dL by 0.330. PO4 of 1.2 mmol/L⫽3.72 mg/dL.
f
To convert mmol/L magnesium to mg/dL multiply mmol/L by 2.43. To convert mg/dL magnesium to mmol/L, multiply mg/dL by 0.4114. Magnesium of 1.00
mmol/L⫽2.43 mg/dL.
g
To convert mmol/L RBC folate to ng/mL multiply mmol/L by 0.441. To convert ng/mL folate to mmol/L, multiply ng/mL by 2.27. RBC folate of 500
mmol/L⫽220.5 ng/mL.
h
To convert ␮g/L ferritin to ng/mL multiply ␮g/L by 1.
*Statistically significant difference P⬍.0009. (P values are adjusted according to number of tests to be done.)

Table 5
Lipid parameters and dietary fat intakes on ketogenic diets

Parameter Normal Classic diet (nⴝ14) Medium-chain triglyceride diet (nⴝ11)

values Prediet 4 months P value Prediet 4 months P value
MeanⴞSDa MeanⴞSD MeanⴞSD MeanⴞSD

Total cholesterol (mmol/L)b 3.0-5.3 4.1⫾0.8 5.1⫾1.6 .003 4.6⫾1.1 4.7⫾0.9 .665
HDL (mmol/L)c 0.31-1.66 1.30⫾0.4 1.2⫾0.4 .095 1.3⫾0.2 1.6⫾0.4 .015
LDL (mmol/L)d 0.98-3.62 2.3⫾0.8 3.1⫾1.2 .003 3.1⫾0.9 2.7⫾0.7 .04
Triglyceride (mmol/L)e 0.34-1.13 0.89⫾0.24 1.64⫾1.31 .066 0.86⫾0.32 1.08⫾0.46 .045
Total serum cholesterol/HDL ratio ⬍3.5 3.2⫾1.0 4.2⫾3.2 .201 3.9⫾1.6 3.2⫾1.4 ⬍.0009*
(PUFA⫹MUFA)/SFA intake 1.4⫾1.2 1.5⫾1.1 .755 1.1⫾0.5 0.4⫾0.7 ⬍.0009*
Total cholesterol intake (mg) 174.0⫾117.0 356.0⫾233.0 .004 303.0⫾204.0 187.0⫾111.0 .061
a
SD⫽standard deviation.
b
To convert mmol/L total cholesterol to mg/dL multiply mmol/L by 38.7.
c
To convert mmol/L HDL to mg/dL multiply mmol/L by 38.7.
d
To convert mmol/L LDL to mg/dL multiply mmol/L by 38.7.
e
To convert mmol/L triglycerides to mg/dL multiply mmol/L by 88.6.
*Statistically significant difference (lower), P⬍.0009 (P values are adjusted according to number of tests.)

body weight and has been found to be associated with higher
serum albumin levels (4).
Previous studies (10,25,26) indicated that the classic diet
has a tendency to increase patients’ total cholesterol levels.
LDL and the total cholesterol to HDL ratio are more accurate
indicators of cardiac risk than total cholesterol. Our poststudy
results showed no statistically significant increase of total cho-
lesterol, LDL, HDL, triglyceride, or the total cholesterol to HDL
ratio among those on the classic diet. There was, however, a
nonsignificant increase of LDL levels and total cholesterol to
HDL ratio, indicating a possible higher cardiac risk for classic
diet patients. The MCT diet showed the opposite effect.
In conclusion, the MCT diet seems to be a more nutritionally
adequate alternative to the classic diet to treat seizure disor-
ders and to reduce cardiac risk. However, nutritional status can
be maintained on both types of ketogenic diets. It is recognized
that the duration of the study is a limiting factor, and further
research with a larger sample size is needed to determine
whether children’s linear growth and good nutritional status
can be maintained over a longer period. Additional research to
investigate changes in nutritional status and growth following
ketogenic diet therapy would also be beneficial.
APPLICATIONS
■ In treating children on a ketogenic diet, recommending ade-
quate energy and protein to assist growth and serum protein
status is crucial. Clinicians should encourage intake of mono-
unsaturated and polyunsaturated fats to help prevent the risk
of elevated serum lipids. Supplementation of phosphorous and
folate may also be needed.

Journal of THE AMERICAN DIETETIC ASSOCIATION / 711

 RESEARCH
■ Growth and biochemical indexes of all children on a keto-
genic diet should be monitored closely, and adjustments in the
diet should be made periodically to assist growth and nutri-
tional status while maintaining seizure control.
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This study was supported by a grant from The Canadian
Foundation For Dietetic Research.