When we began diet therapy for Nora, we started out easier with the Modified Atkins Diet (MAD). We could see that it helped, but didn’t completely control her seizures at the time, so we kept stepping up the ratio over several months until she was on a 3.5:1 ratio ketogenic diet. Now we are through the wean and back to Modified Atkins again. We just keep taking steps and all is well. Still seizure-free, growing and full of energy!

In early December her ratio was lowered down to 1:1, which is Modified Atkins Diet, but we were still calculating and weighing all of her food. When the kids got out of school for winter break we took another step: we are only calculating and weighing the carbs that Nora eats, but giving her any protein and fat that she wants. Although we are still using the gram scale, we spend a lot less time working out each of Nora’s meals and she is happy to eat cheese or nuts when she wants to.

We also moved her up to 40 grams of carbs, just another baby step up, but it has allowed her to have yet more fruits and vegetables.

Eventually we will be estimating all of her foods, even the carbs. But after calculating and weighing to the gram for so long, we realized that we really don’t know portion sizes! We weigh things without really looking at how much is there. We are using this time as a chance to re-learn portion sizes so that we can eyeball meals that will be a good balance for Nora.

Ted reconfigured the spreadsheet that we use to calculate meals for our latest step. Now we enter the number of carbs we want to give her from various available foods, and the spreadsheet tells us how many grams of each food to serve. It’s pretty sweet. He color coded it so that we learn which foods are “danger zone,” “caution,” and “almost-free.” The coding is based on the number of carbs per calories in the food. For example, if she were to eat her whole 40 g of carbs from raisins in a day, she would only get 13% of her day’s calories and would need a lot of other foods. If she got her hands on the raisin box and went to town, she would stuff way too many carbs into herself before she was full. But if she ate her whole 40 g allotment of carbs by eating macadamia nuts, she would get 379% of her calorie needs in the day! In other words, she would naturally stop eating macadamia nuts before she could get close to 40 g of carbs because she might explode. Ted is so clever.

There are several foods that fall into the “almost free” category, which we may just remove from the spreadsheet altogether soon and make them free. Macadamia nuts, walnuts, cream cheese, string cheese, avocado, flacker. Of course, any carb-free food is free too. As long as we get some of these “almost free” and carb-free foods with fat into her every day, we have no problem keeping her at a 1:1 ratio. During the first several days of estimating we double-tracked it using both of our spreadsheets. We calculated her carbs and estimated her meat, cheese and fat portions, then weighed them and put the amounts served into our old spreadsheet to find the ratio over the day. We were easily at or above a 1:1 ratio as long as we were mindful about the basic ratio of each food.

Our Foods by Ratio post has helped us to keep her ratio on track. The big danger-food in that list, in my experience, is cottage cheese. Even full-fat cottage cheese has a very low ratio. During one of our MAD transition days, I gave her a meal of cottage cheese, turkey, and applesauce. I knew immediately that it would be very low fat, so supplemented with some tea and cream and added cream to her cottage cheese too. She actually prefers her “soupy” cottage cheese anyway!

Transitioning her to a more normal diet has been interesting. She loves having more banana and a bit of honey with her peanut butter. Now she eats her MAD About Granola every morning with whole milk! The granola is over 1:1 ratio, so adding whole milk at a 0.4:1 ratio can balance it out to 1:1. Whole milk is still pretty carby; it is in the “danger zone” category of foods but she loves it.

Other new foods get surprising results. I offered her a bit of rice, maybe a tablespoon, equal to around 5 grams of carbs. She wouldn’t eat it! She had a big bowl of edamame instead, and some sweet potato. Another night I offered her a fried Korean dumpling, 6.6 g carbs per dumpling and most of her dinner allotment for carbs. She took one bite and didn’t want any more. It is interesting how her tastes have changed, or maybe she is just nervous about trying too many new things, which is expressed in disliking the food. I’m not in any hurry as long as she is happy.

Although it is supposed to be easier than the ketogenic diet, I remember feeling like MAD was harder because Nora couldn’t eat all of the protein. It is 2-3 times the daily protein requirements for a child her age. Now that she is free to eat or not eat the protein that we serve, she seems happier. Although I still don’t understand how a child can refuse her whole serving of our Christmas ham (honestly, “do I have to eat the ham?” what the heck?). She does not refuse bacon, however.

For Christmas brunch I made the basic waffle recipe from The Joy of Gluten Free, Sugar Free Baking with minor modifications. I was able to use whole milk and the whole family ate it. No more 2-recipe mornings for pancakes or waffles for us!

Nutrition facts for 1 mini-waffle, 29 g of batter. Nutritional analysis by www.caloriecounts.com

Hazelnut Waffles or Pancakes
110 g (1 cup) Bob’s Red Mill Hazelnut Flour
110 g (1 cup) Bob’s Red Mill Almond Flour
2 tsp baking powder
100 g (2 large) eggs
110 g (1/2 cup) Organic Valley Whole Milk

Mix the dry ingredients in a medium bowl and the wet ingredients in a small bowl. Combine and mix very well until the batter has a uniform consistency. Alternatively, you can put all ingredients in an electric mixer and mix on medium for about 3 minutes, stopping to scrape down the bowl. If you are making large waffles, whip the batter well until it is foamy and aerated.

Cook as pancakes or in a waffle iron as usual.

If you like, you can add a no-carb sweetener, cinnamon or nutmeg for flavor. After weighing and cooking some for Nora, I added maple syrup to the batter to make pancakes for the rest of the family.

We made mini-pancakes and waffles, 29 g of batter each, as shown in the nutrition facts. Then each pancake has 2 grams of net carbs and a 1.5:1 ratio. We paired it with ham, a dollop of cream cheese, and blueberries with a touch of maple syrup (wow!). Nora is all about Celestial Seasonings Country Peach tea with cream these days, a nice way to add a little decadent fat as a treat.

Last week we took Nora’s ratio down to 2.5:1 and she is still doing great! We are getting ready to go back to North Dakota and Minnesota to visit friends and family for the first time since starting the diet, so we stepped her down a little earlier than scheduled so that we could get a good 10 days of 2.5:1 under our belt before traveling.

Traveling, especially air travel, feels like a big hurdle. We’ve been analyzing our list of regular foods to figure out what we need to pack, what we can shop for on arrival, and how to keep it simple yet appealing for Nora. Interestingly, we have noticed that bringing up her carbs has made us rely on heavy cream even more even though she is getting slightly less total fat. There are very few whole foods that have both carbs and significant fat (pretty much just kalamata olives). So for every extra serving of carbs, she still needs 2.5 g of fat on the side. We didn’t realize it at the time, but changing the ratio was easier when we were adding protein because protein foods (think cheese) usually have fat in them. Even small adjustments have changed the meal planning landscape.

Now, on to granola:

In these years of keto cooking I’ve come across a few paleo-granola recipes and always thought I should make some for Nora. However, I always hesitated because I couldn’t imagine putting in any honey or dried fruits when she was more carb-restricted, so any recipe that worked for her would have amounted to a pile of crunchy nuts. Maybe not worth the effort when she eats plenty of raw nuts already.

Now that she gets 25 grams of carbs per day (remember when it was 10 g of carbs per day…for almost 2 years?), I threw one of the paleo-granola recipes into my recipe analyzer website and saw my opportunity. Nora is now eating dried currants and honey! It’s just a bit, but they are in there. And this granola is so very delicious, with just a hint of sweetness, that it is much more than a pile of crunchy nuts. It is at 2.1:1 ratio, so just a bit of extra fat brings her to 2.5:1. It will be highly packable and a very “normal” breakfast on our trip. Nora also loves it! She asked for granola instead of popcorn when she watched a movie with friends recently and keeps suggesting it as a snack option. As she says, it’s like cereal, only better!

I would recommend this recipe for anyone doing MAD, low-carb, gluten-free, paleo (is this recipe paleo? I can’t keep track, decide or modify for yourself). I’ve been eating it for breakfast with my kefir too. I went back to the commercial granola this morning for comparison and preferred the homemade granola because it was more flavorful and crunchy, and not as sweet. Nora has had it for breakfast daily with full-fat plain Greek yogurt, heavy cream, and a few fresh blueberries, formulated for a 2.5:1 ratio.

If you or your child are on a high-ratio strict ketogenic diet, this batch-process might not be appropriate for you. You may still be able to make granola, but you will want to divide the ingredients down into individual servings so that you know exactly how much carb, protein and fat is served at one time. When I take 20 g of granola out of the batch, I don’t know if Nora is getting 3 or 7 currants in her breakfast. I only eyeball it to make sure I’m getting a spoonful of granola with a reasonable mix of nuts and currants. At this point I’m confident that the difference won’t matter for her, but back when we were striving for seizure control and counting the days and months of seizure-freedom I would not have taken chances with it. Alternatively, I think you could leave out the currants and be more confident that any serving taken from the batch is approximately equivalent in carbs because the honey is equally distributed.

Actually, you can completely revamp this recipe any way you like, as long as you keep the general proportions the same. This is my 2nd version of granola. The first time I used dried cranberries instead of currants and slivered almonds instead of pecans. I also included sunflower seeds in that batch, and less coconut. The first time, I basically pulled all of the nuts and dried fruits out of my cupboard and used what I had on hand. In this version, I bought the ingredients that I needed to make it lower carb and higher fat.

I know that most people won’t have brown rice protein powder in the cupboard, and it is not essential to the recipe. It’s been hanging out in our cupboard since Nora’s MAD days, when I was trying to cram more protein into everything I made for her. Now I want to use it up! Go ahead and experiment with what you like, but remember that if you are keeping close track of nutritional information you will have to analyze your recipe accordingly. The nutritional facts given here are specific to these ingredients and to be used as a reference only. Nutritional facts for the whole batch are given, and please see the note on nutritional information at the end of the post for more details.

Nutritional information in one whole batch of MAD About Granola. See below for individual serving nutritional information. Analysis by http://caloriecount.about.com

MAD About Granola
200 g (1-2/3 cup) walnuts
200 g (1-2/3 cup) pecans
100 g (3/4 cup) macadamia nuts
50 g (2/3 cup) zante currants
50 g (1/2 cup) Bob’s Red Mill golden flaxseed
30 g (1/3 cup) unsweetened shredded coconut
10 g (1 Tbsp) brown rice protein powder
30 g (1 large) egg white, lightly beaten
30 g (2 Tbsp) water
40 g (3 Tbsp) coconut oil
40 g (2 Tbsp) honey
5 g (1 tsp) vanilla extract
1 g (1/2 tsp) ground cinnamon
1 g (1/4 tsp) salt

Preheat the oven to 200 degrees F and line a baking sheet or roasting pan with parchment paper or a silicone baking mat.

Measure the whole nuts and currants and pulse in a blender or food processor to chop the nuts, but don’t grind them into a fine meal. Pour into a large mixing bowl. You will get some nut dust, which is ok. If there are any nuts that are nearly whole, pull them out and chop down to smaller pieces. Everything should be coarsely chopped. Next, measure the flaxseed, coconut and protein powder (if using) and add to the chopped nuts. Combine well.

In another mixing bowl, whisk together the egg white with the water until bubbly and slightly foamy.

In a microwave-safe bowl, melt the coconut oil. Measure and whisk in the honey, vanilla extract, cinnamon and salt. The cinnamon makes it look dark, as in the photo. Add this to the egg/water mixture and whisk well. Use a rubber spatula to be scrape all of the mixture out of the bowl.

Combine the wet and dry ingredients, stirring everything well to make sure it is all coated. The mixture should be evenly moist but not pooling liquid on the bottom of the bowl. The liquid will pick up all of the small loose bits and bind them together, which is just what we are looking for.

Spread the granola mixture evenly on the parchment or silicone mat-lined baking sheet or roasting pan and bake for at least 60 minutes, stirring after 20 minutes, and again after 40 minutes. After the last stir I pressed the mixture firmly into the pan so that chunks could bake together. Turn off the heat and let the granola sit inside the oven until cool. I waited several hours. I made it in the morning and did the hour of low baking, then took it out of the oven in the evening after dinner. The granola will continue to dry and form clusters in that time.

Use a spatula to gently break the granola into clusters. Some loose bits will also break off. It’s all good. Transfer everything to a 2-quart sealable glass jar, or any airtight container to keep it fresh.

Nutritional information note: Notice from the nutritional information that the raw measured ingredients add up to 787 grams before cooking. After cooking, the whole batch weighed 710 grams. Typically baked goods lose about 10% of their weight by volume when the moisture cooks out of the food, which is true here as well. That means that you get more carbs, protein and fat per gram of cooked food because only the water weight disappears. When you calculate the nutrition per cooked serving in a batch like this, you have to divide by the cooked weight to get accurate nutritional data.

For every 1 g of cooked granola in this recipe, there are:
Carbs: 0.13 g
Protein: 0.15 g
Fat: 0.58 g
Fiber: 0.09 g

Add that up, and you get 0.97 g of macronutrients in 1 g of granola. We can infer that there is 0.03 g of water left too. Math and science at work!

In a 20 g serving typical for Nora, a scant 1/4 cup, this recipe has:
Carbs: 2.64 g
Protein: 2.91 g
Fat: 11.66 g
Fiber: 1.86 g
127 calories
2.1:1 ratio

Enjoy! Inspiration for this recipe from: http://www.theroastedroot.net/paleo-granola/ and http://againstallgrain.com/2012/01/29/grain-free-scd-paleo-vanilla-granola/. But just google paleo granola and you will find many more! Try it and you will never go back to commercial granola or cereal!

Nora’s birthday pool party, with keto cheesecake and strawberries, post-sunscreen and goggles!

We moved Nora’s ratio down to 2.75:1 about 10 days ago and she continues to thrive. So much has been going on that we have not had time to write a thing–dance recital, kindergarten graduation, Father’s Day, summer vacation, and Nora’s birthday! She turned 6 last Sunday and enjoyed a pool party with her friends. She requested Keto-Perfect Cheesecake as her birthday treat, with lots of strawberries on top! Half of the cake was lunch, the other half was afternoon snack and part of dinner. What a great day!

This feels like a significant step down in ratio because Nora’s myoclonic seizures didn’t stop until we were using a 3:1 ratio in a consistent way throughout her day. We are now below what felt like our “safe” point. Ted has checked ketone levels with the urine dip sticks and found that she isn’t in the highest ketosis level all of the time anymore, although still quite strong. From here on out we increase her carbs and decrease her fat because she is now getting the daily protein requirements for a kid her age. When we stepped it down to 2.75:1, she went from 17 g of carbs per day to 21 g of carbs per day. That’s a pretty big jump, 4 extra grams of carbs is a treat (see 1 gram of carb of various foods here). Hooray for fresh berry season! We are getting at least 1/2 pint of raspberries from our own bushes every day and getting to the farmers’ market weekly to make the most of her new carb allotment. I’m starting to think about trying the higher-carb fruits and veggies that have been off-limits.

Look at all of those berries!

With all of the milestones, particularly moving down the ratio and her birthday, both Ted and I have been feeling more anxious. We don’t take for granted that Nora is so big, healthy and smart today, which sometimes makes the wean seem all the more perilous. The better things are with Nora, the more we have to lose if epilepsy lashes out at her again. Of course, we still have every reason to believe that she will wean off the diet and do fine, but some of these moments have us holding our breath, hoping that it is all behind us. We went camping last weekend. Nora could not remember going camping before, it has been so long since we went as a whole family. She loved every minute of it and we had watermelon with our dinner, including some for Nora. We are going back to visit family and friends in the Midwest this summer, which we have not done since starting the diet. We hope that this is the new normal.

I’ve done some extra baking to let her enjoy the new ratio, mostly using almond meal more than I have before. I tried this berry tart crust recipe, slightly modified from the Almond-Pecan Piecrust recipe in The Joy of Gluten Free, Sugar Free Baking and it turned out great. Sturdy enough to remove the tart mold and look like something from the French bakery while being simple and delicious. It’s a keeper.

Nutritional information for one Tart/Pie Crust, with berries. Nutritional analysis by http://caloriecount.about.com/

Tart or Pie Crust
(1 serving, 2.5:1 ratio)
13 g almond meal/flour
3 g ground pecans, or hazelnut meal/flour
3 g coconut flour, Bob’s Red Mill
6 g butter, melted
0.3 g baking powder
1 g vanilla extract
dash of salt
4 to 5 g water as needed (see below)

Preheat oven to 325°F. Weigh and mix together nut flours, baking powder and salt. You can use a sprinkle of no-carb sweetener such as stevia if desired.

Melt butter and mix in vanilla extract. Stir into dry ingredients and add water just until the mixture is stiff, like the consistency of playdough.

Put the dough into a single-serving tart or pie pan, spread it with your fingertips until it is evenly distributed. You could also shape it into a flat circle on parchment paper or a silicone baking sheet. Prick the bottom and sides a few times with a fork to prevent air pockets. Cover the edges with aluminum foil (or not) and bake for 10 minutes if using a cream-like or custard filling. I haven’t tried it, but I bet the blueberry panna cotta recipe would be wonderful if added to a baked tart crust. I’ve got a mind to try the vanilla cream pie filling recipe from the cookbook as well, with appropriate modifications.

To make it a berry tart, calculate the amount of berries and coconut oil or butter you want to use as a topping. For example, for a 3:1 ratio, you could add 10 g blueberries, 20 g raspberries, and dot with 5 g coconut oil (pictured). Bake for about 20 minutes or until berries are bubbly and crust is browned. Then serve 14 g cream on the side, as whipped cream, with tea, or as “keto milk” thinned with water and with a drop of vanilla flavoring.

I’ve used this basic recipe for berry tart and cheesecake for family and friends after trying it for Nora. Using a full-sized recipe and pie pan, I made the chocolate crust version adding cocoa powder and sugar (of course, for Nora I would use stevia instead of sugar–the chocolate requires some sweetener or it would be too bitter). The crust got rave reviews from a group of grad students! I personally like the flavor better if I skip the coconut flour, but it holds together better if it is included. This recipe is versatile enough to be modified for your needs. If you want to make a firm-sided tart, make sure to use the coconut flour version and a little more water. If you don’t mind it a little more crumbly, use all pecan or hazelnut and slightly less water. It’s all good.