Category Archives: Tips and Tricks

MADSheet – A Spreadsheet Tool for Modified Atkins Diet Administration

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We came into the ketogenic diet in a non-standard way for Nora.  We started with a low glycemic index diet for a few weeks in the fall of 2011, then to a modified Atkins diet for a few weeks, then to a 3:1 ratio ketogenic diet for a few months, and finally to a 3.5:1 ratio ketogenic diet from April of 2012 to April of 2014.  Each increase provided better seizure control.

Because we transitioned slowly into the ketogenic diet instead of the traditional 24 hour hospital induction, we had time to develop many of our own tools for tracking Nora’s diet and seizures.  When we went full keto, we continued to use these self-developed tools — mainly a Google Docs spreadsheet — with the approval of our neurologist and dietician team.  (Although we administered the diet differently, we greatly support the Charlie Foundation’s Keto Calculator, and recommend that tool for administering the ketogenic diet.)

Starting April 2014, after two years of seizure freedom, we slowly weaned Nora by decreasing the ketogenic diet ratio by 0.25 every 3-4 weeks.  In December of 2014 we finally weaned down to a 1:1 ratio.  We then transitioned to a modified Atkins diet in which only carbs are tracked (as opposed to the full suite of carbs, protein, fat, and fiber).  This greatly simplifies administration of the diet, but we still use a simplified version of our spreadsheet.

We get a lot of questions about our methods for administering the diet, and because the modified Atkins diet can be done with less strict medical oversight, we are now posting a version of this spreadsheet in case anyone finds it useful for administering the modified Atkins diet.  (For the ketogenic diet, we recommend using the Charlie Foundation’s Keto Calculator as that is a widely supported and vetted tool.)

We recommend using a tool like this if you aren’t sure you are estimating portions right, and want to learn the proper proportions of foods using a gram scale (a traditional kitchen gram scale will be fine, no need to measure to the tenth of a gram as in the ketogenic diet). We have also found it useful in weaning off the ketogenic diet, after you have been accustomed to weighing all food and want to learn how to think in portion sizes again and only count the carbs, not the ratio.

Note that the modified Atkins diet is still a high-protein, high-fat diet. You are still going for a 1:1 ratio. This spreadsheet only helps you count carbs and is not intended to help you plan full meals at a 1:1 ratio. Notice that cheese and meats are not listed (unless it is a product with significant carbs). Add protein and fats to every meal, and use the higher fat foods in the spreadsheet (labeled in green) to supply healthy fats.

WARNING
The modified Atkins diet is less demanding on the patient than the ketogenic diet, but it is still a restricted diet with potential side effects.  We strongly recommend you inform your medical care team if you are going to use the MAD diet for your child.  Low carb diets can interact with other medications, and some medical conditions are contraindicated with low carb diets and could be very dangerous.  Check with your medical team.  If your child is struggling, sick, or is continually not feeling well, stop the the diet and check with your medical team.

You can download the MADSheet (version 1) here: MADSheet-v1.

Instructions are given in the “INSTRUCTIONS” tab in the spreadsheet.  Foods with no (or very little) carbs (such as butter) are not listed in the spreadsheet as they don’t need to be calculated and weighed.  But they will still be part of most meals.  As an example, for a morning snack for Nora I would like 3 grams of carbs of apple and 1 gram of carb of 85% dark chocolate and 3 grams of carbs of peanut butter.  Using the MADSheet, I put 3, 1, and 3  respectively in cells J24, J27, and J29.  It is then calculated that I need 24 grams of apple, 3.6 grams of chocolate, and 24 grams of peanut butter.  If I were doing this for Nora I would then put an additional dollop of butter in with the peanut butter to push the ratio up a bit, but I don’t need to measure that as it doesn’t have any carbs.  (In the full keto version of the diet though, I do need to calculate and weigh the correct amount of butter along with everything else.)

Lastly, the MADSheet tool is not intended as an optimized, finished product in any way.  We do not guarantee the spreadsheet to be free of errors or bugs.  We are providing it as a template or starting point to be modified as necessary to fit the needs of the user.  Please delete foods, add foods, change and modify cells and calculations as you see fit.  Please take care to double check all calculations and formulas, especially after making modifications.  This is not intended as medical advice.  Please check all methods with your medical team.  Use at your own risk.

Foods by Ratio

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Continued good news: Nora is down to a 1.25:1 ratio today and still seizure free. We are in the home stretch!

Just a word about the “ratio” for newcomers to the ketogenic diet. Remember that the ratio is the amount of fat per amount of net carbs+protein in a food (and remember to first get net carbs by subtracting fiber from total carbs; fiber is good!).

Example: In 100 g of macadamia nuts, there are approximately 80 g fat, 6 g net carb and 8 g protein. The math:

80 g fat /(6 g net carb + 8 g protein ) = 80 g/14 g = 5.7
Thus, there are about 5.7 g fat for every 1 gram of net carbs + protein in macadamia nuts. They have a ratio of about 5.7:1.

The ratio is a “magic number” in the ketogenic diet, with higher fat telling your body to use fat as an energy source by turning fat into ketone bodies for fuel. The traditional form of the diet uses a 4:1 ratio. Nora’s highest ratio was 3.5:1 for 2 years. Since April we have moved it down by 0.25 increment steps (so 3.25:1, 3:1, 2.75:1, etc.) every 3 weeks.

As we have moved down the ratio step by step, I’ve realized that I have a way of thinking about keto foods by ratio when I am building a meal. In the beginning of the diet, the big challenge is to think low-carb. Then you add in the fat needed to get the ratio. But after doing this for so long and having a broader range of known low-carb foods, I’ve started thinking about foods by their ratio instead of their carb content alone. That helps us create keto meals that use naturally high-foods, rather than taking big doses of fat on the side, and that gets much easier as we move down on the ratio.

The spreadsheet that we made to calculate meals shows us the ratio of each food that we are using, so as we changed ratios over the last 6 months I realized how much I was using that knowledge about the ratios. I hope that explaining it and giving some examples can be a guide to others.

At very high ratios, there are very few foods that are above that ratio on their own. Fat sources are critical to boost the ratio of any meal. All-fat foods that are served to achieve a high ratio are: heavy cream, butter, oil (Nora takes fish oil, others use lightly flavored oils like canola), and coconut oil for its ketone-availability.

Low-carb foods that Nora eats regularly but have very little fat: berries, red pepper, carrots, popcorn, apples, low-carb tortilla (Mission Carb Balance), sliced turkey or ham. We have to serve enough fat, either through the all-fat options or higher ratio foods in order to meet her fat needs at her current ratio.

Here is a table of regularly-used whole foods organized by their ratio, amounts given per gram of food served. Each color indicates a different ratio range:

Red = greater than 4:1
Orange = between 3:1 and 4:1
Green = between 2:1 and 3:1
Blue = between 1:1 and 2:1
Purple = Less than 1:1, but not insignificant fat content

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If you start by thinking about your child’s ratio, you can see the foods that are above and below that ratio. Higher-ratio foods can support or increase the ratio when paired with lower-ratio foods. At the traditional ketogenic diet ratio of 4:1, macadamia nuts and kalamata olives are superstars, with avocado not far behind. But even though you can’t make a 4:1 meal without fat supplementation (actually you could, but it would be a lot of macadamia nuts!), you can choose higher-ratio foods in order to put less fat on the side.

If you move down the ratio to 3:1, you get a few more of those helpful foods. We looked at all of the cream cheese options at our grocery stores and use a brand called Primrose, which has a higher fat content than some other brands.

It’s interesting that there are not many whole foods in the 2:1 to 3:1 range (green) that we use regularly. Sour cream was the only other one in my master list, but Nora doesn’t like it. Some brands of cream cheese fall into this ratio too. Many of the baked goods I make are in the 2:1 ratio because you can mix fats, nuts, eggs, etc., to end up with a 2:1 ratio item.

When we went below 2:1 on Nora’s wean schedule, I realized that there were a lot more foods on either side of her ratio and it got me thinking about foods by their ratios. Now that we are at 1.25:1, Green & Black’s 85% dark chocolate is above her ratio! We can put dark chocolate on berries, maybe with some nuts on the side, and have a perfectly delicious at-ratio snack without a side of cream.

After our next step down in 3 more weeks, Nora will be at 1:1 which is considered the Modified Atkins Diet (MAD) and we can start estimating meals. Knowing which foods are above the 1:1 line, and which are just below the 1:1 line, will help us make combinations of food that keep her meals around 1:1 without all of the calculating and weighing.

This list also shows some interesting contrasts. Just look at the nuts. Macadamia nuts are a stand out by any measure. It is amazing that they stay solid when warm! Walnuts are also excellent. But almonds are pretty far down on the list as a ketogenic diet food. They are not bad, but if I were going to give nuts to Nora I would choose a higher-fat nut that does not require fat supplementation (if possible). Peanut butter is also fairly low ratio, although we would normally think of it as a creamy high-fat food. We have always supplemented it with fat by mixing it with butter. Almond butter is actually a better keto-choice because it is lower carb and higher ratio.

Cheeses are interesting too. Cream cheese has always been the keto diet food of choice. But cheddar (and Monterey jack, which has the same ratio as cheddar), beats out whole milk mozzarella. Both beat out string cheese, which was one thing that was hard to take away from Nora at the beginning, and is not going to be a go-to food even after moving to MAD because it is well below 1:1 ratio. Nora also loves cottage cheese, but it is very low ratio. She enjoys cottage cheese swimming in cream, like cottage cheese soup! It is easier to add fat to cottage cheese than string cheese.

Proteins are the same story. Eggs, pork and beef are higher in fat than chicken and fish, as we all probably know. But even in the chicken category, chicken thigh is 0.42:1 ratio and chicken breast (not listed above), is only 0.12:1 ratio. And chicken thigh is cheaper and tastier, an all round better choice.

There are a few fun discoveries on the list. I love that edamame has both protein and fat. It’s a fun veggie that works on the keto diet or MAD with other fatty foods. Traditional full-fat Greek yogurt is at-ratio right now for Nora! She has it for breakfast every morning, topped with a few berries and some of her granola (the current recipe I made is 2:1 and balances out the berries). The Flackers that she enjoys are now above-ratio too. But even if your child is on a higher ratio, they are a cracker that fits well with the diet and can be topped with a high-ratio food like cream cheese and butter.

No matter where the ratio lands in a diet therapy, you can make meals more palatable by serving some high-ratio whole foods and not putting so much fat on the side. It gets easier at lower ratios when you have a larger selection of foods that are naturally above a 1:1 ratio. These are natural, healthy foods for any body and even better for anyone on a diet therapy for epilepsy or other medical reason.

Lessons Learned

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Lessons learned on the ketogenic diet, in no particular order:

  • Screen Shot 2014-09-20 at 10.30.30 AMCartoned cream can be clumpy.  A great deal of fat can be left behind, stuck to the sides of the paper carton.  We open the carton, scrape out the solid cream stuck to the sides, and transfer it all into a mason jar. There we mix it up gently as best we can. Then, we like these reCap lids for pouring cream out of the mason jar (get the right size for your jars). Nora had a bout of breakthrough seizures after several seizure-free months early on the diet, and I strongly suspect this was part of the problem.  Because of all the fat being left behind in the carton, her ratio would have effectively been quite a bit lower than our target of 3.5:1 at the time.
  • Keto-food superstars.  Foods that are fantastic for the ketogenic diet:
    • Base: avocados, macadamia nuts
    • Sweets: raspberries, strawberries, blueberries, dark chocolate (85%), red peppers
    • Protein: cheddar, eggs, ham, turkey, bacon
    • Flavorings: no-carb peppermint and vanilla flavorings, and cocoa powder for making cream in to “milk” or chocolate “milk”
    • Fiber: low-carb high-fiber tortillas, raspberries, avocados, Flackers, flax meal
    • Fat: butter, cream, macadamia nuts, coconut oil, kalamata olives
    • Low-carb: pickles, seaweed snacks
    • See this post, Quick Keto Meals, too.
  • Fiber.  We consider fiber to be the fourth macronutrient (along with fat, carbs, and protein).  It serves three very important functions: helping with constipation; helping to give weight and texture to a meal; effectively increasing the amount of sweet tasting foods.  This is because “net carbs” are what matter; that is, the total carbs minus the fiber.  This is one reason why raspberries are such keto superstars: they have plenty of carbs and delicious berry goodness, but they have a very high fiber content, which reduces their effective net carb count, which in turn allows Nora to have a lot of them.
  • Equipment.
    • The US Balance US-TT1000 scale is great.  It’s easy to use for home, and it has a built-in protective lid and runs on batteries for taking on travel or to a restaurant.
    • Small rubber spatulas help you scrape the full measured amount of food out of a dish and serve it to your child.
    • Screen Shot 2014-09-20 at 10.04.22 AMSmall silicone pinch bowls. We like these, made by NorPro.  They are microwave-safe, so you can melt a small amount of butter, coconut oil or dark chocolate for drizzling over other foods. You can thaw a small amount of frozen berries to mix into cream or yogurt. They are sturdy but flexible, so you can cream butter into cream cheese or nut butters for a smooth high-fat spread. You can scrape them clean with a butter knife or spreader to get all of the fat out. And they are cheap! Order them online or buy at a kitchen store. We have 8 and use ours everyday.
    • Screen Shot 2014-09-20 at 10.09.01 AMSmall spreaders (also called cheese spreaders or hors d’oeuvres knives) pair nicely with the small silicone pinch bowls. We have these cheap ones and they have worked fine. If you have a small child who can self-feed, they can use the spreaders themselves to put butter+nut butter mixture on a Flacker, for example. They work perfectly for scraping the silicone bowl clean.
    • Ice cream pop holders are wonderful. You can make very simple ice pops or add a bit of no-carb drink, one crushed raspberry, or cream to make a quick frozen treat. Any frozen keto treat will freeze solid, so you might as well make it a pop and let your child eat it slowly. For kids adjusting to the diet, this can be a real treat and make them feel like they are getting more to eat because it lasts longer. You can find more on our ice cream pop mold recommendations here, our post Cook’s Little Helpers.
    • We have also collected a lot of small dishes. We actually use one of the IKEA play sets daily. They are ceramic, food-safe, dishwasher-safe and microwave-safe. Serving sizes are smaller on the keto diet and it’s ridiculous to put Nora’s servings into regular sized bowls.  Kid-sized plates and bowls are psychologically helpful as it makes the keto meal look fuller.  They also fit nicely on the scale.
    • On the topic of dishes, we often let Nora choose a small dish if we are out shopping and need a little reward pick-me-up for good behavior. Many grocery stores carry some dishes. Maybe a little whisk, cream pourer, ramekin, or even a pretty napkin or candle that she can pick out. Several fun dishes have entered our collection, and the small meals made in the special dishes make the food feel a little more fun and special.
  • Restaurants.  You can eat out at restaurants if you are careful and have appropriate expectations.  Sushi and seafood restaurants work great as salmon sashimi, edamame and crab are all very keto friendly (be careful with fish, to be sure it is only grilled or poached).  Another good option is to order a burger at a grill with no bun for your keto-kid.  Typically we have the meal pre-calculated and pre-packed except for the protein portion, which will be supplied by the restaurant.   We’ll weigh what we need of sashimi or hamburger at the table using our portable scale.  There is of course some risk of hidden carbs, but we find it to be reasonably safe if we are at a restaurant with a menu we know well.  I think meat from the restaurant — as opposed to something carby — tends to be a safer bet overall as it is usually prepared with nothing additional other than some fat or oil for cooking. However, many restaurants with a kid menu will have carrot or celery sticks as a side option, or possibly apple slices. Salads with dressing on the side can also get you greens and cucumbers to incorporate into the meal.  You can always ask the server or cook if any additional  information is necessary. It is also courteous to inform your server that your child has dietary restrictions, so they understand why you are dissecting her meal and giving her a little extra food from home, such as cream that you have brought with.
  • Consistency.  There is no cheating on the ketogenic diet.  Early in the diet, ketosis is fragile and the metabolism is eager to switch back to glucose-mode.  Even a small amount of extra carbs can open the door for breakthrough seizures.  Consistency allows for better troubleshooting too.  Which brings us to…
  • Breakthrough seizures.  Expect breakthrough seizures and a few rough periods even after extended periods of success.  It seems that everyone we have talked with has had the experience of several weeks or months of good seizure control, followed by a period of loss of seizure control, followed by regaining seizure control.  When this happens, keep your spirits up and look for any recent changes or anomalies (such as the clumpy cream issue).  Be strict and rigorous and keep going.  Seizure control will likely come back.
  • Even daily ratio.  Consider applying the ratio evenly throughout the day.  Early on in Nora’s treatment, before we went to a full ketogenic diet, we were very lax about what the ratio was during any particular meal, so long as the ratio was met over the course of the day.  This means you could have a very carby, low-ratio morning and a very fatty, high-ratio afternoon, for example.  It seems that seizure control improved when we evened things out.  The one exception is at dinner and bedtime, where dinner is usually low on the ratio, and bedtime is higher, so that we can get a last chunk of fat into her to last all night.  We made this change after some early morning tonic-clonic seizures in the spring of 2012.
  • Routines and expectations.  Establishing routines and expectations ease the day-to-day grind.  For example, Nora has three routines around supplements: baking soda in the morning after breakfast and in the evening during teeth-brushing before bed; calcium in her bedtime cream; and a multivitamin and calcium in her morning snack B^3.  She’s not crazy about taking the baking soda and the calcium, but now that it is a well-established routine, there is no more fighting about it.
  • Keto-friendly alternative sweets.  When possible, try to have a keto-friendly alternative for your child at birthday parties and other events where ice cream, cupcakes, etc…are served.  This requires forethought and planning, but is huge for the psychological aspect for your child. If you can find out what kinds of treats will be served, you can make something similar. However, Nora now likes to just pick her favorite treat to bring along, even if it is different from the party treat. It’s still natural for her to admire the other treats, but you can help to…
  • Help your child understand the restrictions.  We are very sensitive to this and we stress frequently to Nora that although her diet imposes some limits, it is still a very healthy diet with many truly delicious meals, and many people have some sort of diet restriction.  When we first started the diet, Nora really took to a book called “The Princess and the Peanut Allergy.”  She strongly identified with the food restrictions of the main character and the struggles and efforts of her friend to accommodate her.  Try to help your child see the diet restrictions amongst your family and friends to help them understand that having some sort of restriction — whether it is a nut allergy, gluten intolerance, upset stomach after eating certain foods, low-sodium diet, etc… — is normal.
  • Solidarity!  Eat keto-friendly yourself.  Eating meals that look similar to what your child eats will help them feel better about the diet.  Skip the bread and sugar; eat nuts, protein, vegetables, and fruit.  As a happy side-effect, you may very well feel better and lose weight.  Christy and I have both dropped about 15-20 pounds when we modified our eating to be more like Nora’s.  Honestly, there have been many times after putting Nora’s dinner together (e.g., skillet-fried ham-and-cheese, avocado, red pepper, nuts), I’ve thought “I want that!” (Christy says: It takes all of my willpower to not eat Nora’s cheddar crackers!) Also, don’t eat the birthday treats at a party. It’s better for you and helps her feel like she’s not the only one.
  • Don’t expect miracles.  Be happy with improvements in quality of life.  We were one of the lucky ones that got full seizure control.  But even if Nora still had some seizures (and I must accept that she might have more seizures at some point in her life), her quality of life would be much better than it was before the diet.  If you are considering the ketogenic diet, chances are you are in the difficult group of epilepsies.  Many of these epilepsies come with other problems too.  The ketogenic diet may not be a miracle cure, but it could still be a great help.
  • It’s not “hard.”  It is different.  If you think the ketogenic diet might help your child, don’t accept any statement that the diet is “hard” as a reason for not trying it.  I wouldn’t say the diet is hard.  Epilepsy is hard.  The diet is a tool that may improve your child’s quality of life and development.  (Remember that if your child has failed two anti-epileptic drugs, the diet is statistically more likely to help than a trial on a third drug. Also, certain epilepsies respond particularly well to the diet.) However, the diet does require some changes to your thinking and expectations.  Once you get your routines down and everyone gets a few months to adjust, the diet is not significantly harder than having other diet restrictions.  Just different.

I’d like to make this  a “living” list.  To all of our keto comrades, I invite you to email us or comment on your particular lessons learned.  I’ll add them to the list above.

Throw Back Thursday, 2.5:1

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Tonight I was emailing a parent who had contacted us for help with getting started with the Modified Atkins Diet (MAD). I shared the links to the information that Doernbecher gave us when we started (http://www.atkinsforseizures.com/). They basically told us to go to it, and away we went. MAD is a very DIY diet treatment, at least when we started.

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The parent’s specific question was how we documented Nora’s diet when we got started, so I took a picture of one day from the first food log that we kept, dated 12/15/11.

Excuse the handwriting and the food stains. We stood at the kitchen counter and wrote down everything Nora ate, along with the grams of carbs, protein and fat (each column of numbers). Then added up down the column to see total carbs, protein and fat and to calculate the ratio (fat/(carbs+protein)).

We got those numbers from a nutrition database and nutrition fact panels, and had a little “cheat sheet” for commonly used foods that we kept on the fridge. After a few weeks, I knew a lot of them off the top of my head.

In those days of MAD we were estimating and using common measurements, like 1/2 T of cream or 1/4 avocado, rather than weighing everything in grams. Everything was much less precise. Although we could see a difference in her seizures at the time, we didn’t yet have complete control.

Little notes found their way onto the page too: three small myoclonics and one medium myoclonic in the morning, along with feeling tired and hungry. Ketone readings at different points during the day.

On the back side of this page, I noticed that the final ratio for the day was 2.5:1. Just where we are now. And ready to step down to 2.25:1 tomorrow, still seizure free. What a difference 2.5 years made.

Antibiotic Time

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Quick update and tip for childhood illness!

Nora is still doing fine on 3:1. We will step down to 2.75:1 next weekend, right after the last day of school and kindergarten graduation.

Last week Anders came down with strep throat, which was diagnosed very quickly. He got the pink liquid antibiotic of amoxicillin and was feeling better 24 hours later. We were on the look-out for another family member to fall ill, especially Nora.

I started feeling cruddy on Saturday, so I went to urgent care and took Nora with me even though she said she felt fine. They did throat swabs on both of us. The rapid tests came back negative, but Nora’s 24 hour culture came back positive (but not mine! I’m was feeling better the next day.)

Nora has not needed an antibiotic in over 2 years! We referred back to our illness preparedness plan post and found little guidance on how to deal with antibiotics. Ted went to the pharmacy to explain the situation, and thankfully the pharmacist was happy to work with us.

He explained that they mix powdered amoxicillin with the “pink stuff” right at the pharmacy but he did not have any information about the ingredients in the pink stuff. Instead of mixing, we took home plain capsules of amoxicillin. Dosage is 1 capsule in the morning, one at night. Nora doesn’t swallow large pills, so we open the capsule and mix the powder with a bit of yogurt. Nora doesn’t mind the taste, and this is a girl who has taken a lot of medicine mixed in stuff. She knows when it tastes bad and is not afraid to say so. Now we have 9 more days of morning and night doses and we are in the clear. Glad we caught this now so that she is healthy for kindergarten graduation!

Keto Valentine’s Day Love

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Nora woke up yelling “Valentine’s Day!” She loves love. She made her own Valentines for all of her classmates after being inspired by the card she received from Grandma Sheryl. She started with making a heart, and wrote “Happy Heart Day” and just kept rolling until she made one for each member of her class! I only helped with the heart shape, otherwise it was all-Nora.

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For a little extra special keto treat to bring to school, I melted her daily B^3 and poured it into a heart-shaped silicone cup to re-harden with the apples on top. I also made a “cookie” of ground macadamia-coconut oil-blueberry to solidify in another heart mold. Easy!

Her teacher sent home a note asking the kids to bring cards to exchange, but she didn’t really specify that candy was not welcome. I’m sure Nora will see some candy today, and we’ve had a talk about it. As an alternative, I made some Lego-guy chocolates from the Charlie Foundation’s Chocolate Candy recipe (with video!). I added a drop of peppermint extract to one batch for a twist. Unfortunately the heads fall off when they pop out of the mold. Good thing they are not long for this world anyway.

Happy Valentine’s Day! Spread the keto-love!

Popcorn!

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Nora gets popcorn! What a revelation! I read on another keto-mom blog that popcorn was her son’s favorite snack, and I was kinda like “shyeah, right. Not gonna work for Nora. Too many carbs.” Sorry I doubted you Sara. Now I’m with it.

I did look up the nutrition facts on popcorn after I saw that blog post and still thought that it wouldn’t work easily. It didn’t have as much fiber as I expected, and Nora could probably only have a few grams. I thought that her few grams would just look pathetic next to a serving that the rest of us would get. And I didn’t have any popcorn in the house, so that was also a big barrier to trying it.

I was motivated to try it again because her class is having a popcorn party tomorrow for their accumulated good behavior. I bought some popcorn to test it out. Super easy way to make plain popcorn for everyone: put some plain kernels in a small paper bag and microwave it for a few minutes, take it out when the popping slows down, or it will burn. That’s it! You will never eat that chemical-laden microwave popcorn again!

For tomorrow’s popcorn snack, Nora will get:
4.5 g popcorn
5.5 g butter (melted on and drizzled on popcorn)
5 g melted coconut oil mixed with 8 g ground macadamia nuts and a drop of banana flavoring, chilled to make a “cookie”

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162 calories
3.3 g carb
1.2 g protein
16 g fat
1.3 fiber
3.5:1 ratio

And look at all that popcorn! A near proper bowl! It is super carby per gram, but it’s so light that you get a lot of popcorn per gram. That’s the key to success.

This will be her morning snack at school when everyone has popcorn, so we will load her breakfast with protein and very little carbs so that she is evened out by lunch. She is excited! And it sure helps that she is up to 14 g carbs per day, on her way to 16-17 g. We can easily squeeze in a few extra carbs with snack.

I am sure that popcorn will also become a favorite snack for Nora too.

The simplest keto meals

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Ted here. This post is about the very simplest keto meals. Especially from the perspective of the secondary cook.

Christy is a food wizard. She gets food. She can create new things from basic components. She can produce batches of treats for Nora that we can use over the week. That is not an area of significant competence for me, but I can certainly make simple keto meals for Nora. So what do we do when energy and time are low, more complex treats are not available, and Nora needs to eat? Here is our most basic template for an easy lunch (or dinner).

Base:
Start with a base of avocado. Avocados are stellar. They are at about a 3.5:1 ratio on their own, plus they are fibrous. They can be simply diced, or spread as butter. We’ll generally start with 20 to 30 grams of avocado for a meal. Macadamia nuts (see more on them below) can also serve the role of a meal base. Both avocados and macadamia nuts work well to start the meal calculation because they are both high ratio, and give you a solid start on all four of the major constraints: carbs, protein, fat, and fiber.

Carbs:
The major sweet parts of the lunch come from apple, red pepper, carrots or berries (e.g., blueberries, strawberries, and raspberries). Peppers and raspberries get priority because of their high fiber and low carb content (relatively). Apples, blueberries, strawberries, and carrots pack much more of a carb punch, so those are added if the other major constraints are met and there is still a bit of carb to give. Generally there will be 5 to 30 grams of total fruit, depending on the mix.

Protein:
Cheddar cheese is the primary protein base. Nora likes it, it is easy to cut and weigh, and it has a good amount of fat too.  It is versatile too in that it can be served sliced, cubed, shredded, melted, or melted and reformed.  Something like 10 grams to 20 grams is typical. Sliced turkey and ham are also popular. Ham is nice because it has some fat. Sometimes we’ll put cream cheese and butter on the sliced meat and roll it up to get more fat in there.

Fat:
Cream is our primary fat, either mixed with water and a few drops of vanilla flavoring to make “milk,” or steamed in our espresso machine with a pinch of cocoa powder. The amount of cream will be between 10 and 40 grams, depending on what else is in the meal. We’ll might also look for opportunities to put butter on or in things. The other two big fat delivery mechanisms are macadamia nuts and kalamata olives. Those are especially nice if I want to avoid liquids (i.e., cream) in the meal, for example, with a packed lunch. Macadamia nuts do have some carbs, so it will use up some of that allotment, but their high fat and high fiber content provide a significant tradeoff for that. Kalamata olives are one of very few foods that have both fat and carbs, but no protein, so they make a natural keto complement to meat and cheddar. However, they have no fiber.

Fiber:
The fourth constraint. Generally I check for fiber when I am satisfied with the amount of carbs and the ratio of the meal. If the fiber content is too low — we shoot for about 11 grams of fiber for Nora over the day — then I’ll circle back and see if I can trade something out for more raspberries, macadamia nuts, or Flackers. Flaxmeal is another option, and can be mixed in with any butter in the meal.

Variety:
Lastly, we’ll check to see if there is a reasonable variety of textures and tastes. Meaning, is there something creamy and something crunchy? Is there something sweet and something salty?

A typical, very simple lunch:
8 g apple
15 g avocado
15 g cheddar cheese
8 g Flacker with 8 g butter
15 g macadamia nuts
13 g cream with water and vanilla flavoring to make “milk”
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3.52:1 ratio
2.5 g carbs
6.9 g protein
33.1 g fat
4.4 g fiber
336 calories

At the bare minimum, if I have avocado, cheddar cheese, raspberries, and cream, I can cobble together the most basic tasty meal that satisfies all the constraints. Add some sliced meat, other berries, apples, peppers, carrots, cream cheese, macadamia nuts, kalamata olives, and Flackers, and we can switch things up enough to keep the simple meals interesting from day to day.

Keto clinic checkup and diet changes

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On Monday we made our way to Portland for another keto clinic check up with Dr. Wray. Nora continues to thrive. She is in her 20th month of seizure freedom! Her growth rate is right on track even after 2 years of diet therapy, 60th percentile for height and 75th for weight (I think she’s ready for a growth spurt). Dr. Wray reviewed her history and genetic testing and feels that there is no reason to keep her on a carb-restricted diet in the long term. Very good news.

Her labs were all fine. For those of you keeping score at home, her cholesterol panel was good at 188, triglycerides at 54, LDL (bad) minimally elevated at 135 and HDL (good) normal to good at 42. Her blood bicarb level was at 21, which is normally low but not too low.

We still can’t get Cytra-K in crystal form as before, so we will continue with baking soda (6 g dissolved in water given over the course of the day). She has avoided stomach upset after we learned to give small amounts of baking soda solution between meals. It seems to be a problem on an empty or full stomach. We have the option of using Cytra K oral solution (great cherry flavor!), but the stats I got from the dietician suggest that it has 3 g of carbs in her daily dose. We don’t think that’s a good trade off, when she could be getting 3 g of carbs through fruits and veggies. We will stick to the baking soda for as long as Nora tolerates it.

The biggest news is that we are going to adjust her diet to prepare for weaning her in April after her 2 years seizure-free. For the last 6 months she has been getting about 11 g carbs, 25-26 g protein and about 130 g of fat per day, which is 1300-1350 calories at a 3.5:1 ratio (fat to carb+protein).

That’s a small amount of carbs even by keto diet standards for this number of calories. When we increased her calories last time, the dietician suggested going up to about 16-17 g carbs, which felt like a big jump from 10 g of carbs, so we only increased it to 11 g at that time. Now we are going to keep the calories and ratio the same, but bring her carbs up to 16-17 g per day. That gives us a new daily target of 16-17 g carb, 20-21g protein, 128-133 g fat.

We will increase it by a gram every few days, so that she is up to 16 or 17 by the holiday break. Today she is up to 13 and is fine so far! When we told her that we were going to let her have more fruits and veggies she was so excited! It’s tiny baby steps to coming off the diet, but slow changes give us peace of mind. Slow but significant for Nora. Although she won’t do it all at once, going from 11 g to 16 g of carbs will feel pretty good!

I often get the question about “what does 1 g of carbs look like?” Of course, it depends on the food. It’s hard for me to answer on the fly because now I think in grams, not number of blueberries or baby carrots. Today I calculated one gram of carb for several of Nora’s regular foods. Some of them have significant fat and protein as well (so they are bigger servings), for those I listed their ratio too:

IMG_43031 g of carbs in:
8 g blueberry
17 g macadamia nuts (5.43:1 ratio)
8 g apple
14 g carrot
11 g almonds (1.63:1 ratio)
46 g avocado (3.62:1 ratio)
15 g kalamata olives (4.5:1 ratio)
16 g strawberry (not pictured)
18 g raspberry (not pictured)

With 5 extra grams of carbs per day, Nora can have about 6 more baby carrots per day, or 40-50 small blueberries! That’s a lot!

Dr. Wray continues to be delighted by Nora, and to delight us. Anders joined us for the appointment because of a no-school snow day. Dr. Wray made a note of Anders presence in his follow-up report we received in the mail, and that is name is “pronounced with a soft A, which is the Norwegian articulation of his name.” See doc, we read these things with care. Anders thanks you.

Bringing Keto to Kindergarten, Part 3

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It’s almost half way through the school year!

When things are going along fine but you know there are potential problems lurking, it’s hard to feel really at ease. You can’t really know that things will be fine until something goes wrong and you see how everyone handles it. We had our first real keto-problem at school yesterday. It was handled perfectly. We have a new kind of peace of mind about Nora at school.

We have been sending her “milk” in a small mason jar with a drink/pour lid. I’ve always been afraid that it will pop open and spill all over the lunch box, losing all of that necessary fat to make up her ratio. It didn’t spill yesterday–the jar broke! Nora opened her lunch box to cream and broken glass. Yikes.

The school called me, but I was teaching and my phone was off. They called Ted next, who was much more clever than I would have been. When I heard their message I was ready to jump on my bike and get new cream over there. Luckily I called the school back first and found out that it was taken care of.

When Ted got the call, he asked if they had any butter at the school. They did not (really? not part of a healthy school lunch, I guess). The secretary suggested that they have olive oil in the teacher’s break room, so Ted calculated that 2 teaspoons of olive oil would do the trick. Nora wasn’t happy about it, but she took it and no one had to leave work.

On a related note, we still have not made a formal 504 plan with the school. The nurse has not contacted me about it again, and in the rush of daily life I have not pushed it. It is comforting to know that her teacher (who was part of the chain of command) and the school staff were aware of her needs and worked with us to find a solution.

Nora also had her routine blood draw yesterday for Monday’s keto clinic appointment with Dr. Wray. Ted took her in when the lab opened at 7:30, so she was a little late to school. When she came into her classroom some of her friends came over to give her hugs and brought her to the rug where they were singing and dancing their morning songs. Ted left with a warm and happy feeling about Nora’s school. That’s another wonderful kind of peace of mind.

Many thanks and muchas gracias to the wonderful people of Garfield school who take care of Nora every day!