Use of a therapeutic ketogenic diet as an adjunct treatment for some mental health disorders has recently become popular but some people are under the impression a therapeutic ketogenic diet is the same as a keto diet used for weight loss, or improved blood sugar for people with type 2 diabetes. There are similarities, but a keto diet and a therapeutic ketogenic diet are very different.
Firstly as outlined below, there is no one “keto diet” but a range of keto diets. What keto diets have in common is that they restrict carbohydrate, while offering a range of protein intake. They don’t require people to weigh and measure their food, nor to track serum glucose or ketones, although some choose to.
Therapeutic ketogenic diets, on the other hand tightly regulate the amount of protein and carbohydrate relative to the amount of fat. As diet prescriptions, therapeutic ketogenic diets such as a 4:1, 3:1 or 2:1 require ingredients to be weighed, and for blood glucose and blood ketones levels to be measured and tracked.
Therapeutic Ketogenic Diets
Therapeutic ketogenic diets have been used for more than 100 years in the treatment of epilepsy and diabetes and more recently as adjunct treatment in some types of cancer and in mental health.
These are very high fat diets that range from 65-72% fat (2:1), to as high as 90% fat (4:1) [1], and since the amount of protein, fat and carbohydrate is tightly controlled, ingredients are weighed. Monitoring and tracking blood glucose and blood ketone levels is also required to ensure that the desired therapeutic level of ketones is achieved, and maintained.
Three Types of Therapeutic Ketogenic Diets
A therapeutic ketogenic diet is a “dietary prescription”. Just as medication has a “dosage”, the amount of each ingredient in a meal is specified and weighed so that the dietary prescription is achieved.
The very high fat and minimal protein content of 4 : 1 and 3 : 1 ketogenic diets makes Meal Plan design both time consuming, and challenging. It is not easy to come up with palatable food combinations with the precise amounts of protein, fat and carbohydrate required, and meals in 4:1 and 3:1 diets are really more a combination of precise amounts of specific ingredients, assembled to be as palatable as possible.
Classic Ketogenic Diet (KD) – 4 : 1
The 4:1 Classic Ketogenic diet has long-standing use in treating epilepsy and seizure disorder, and is sometimes used as adjunct treatment along with chemo and radiation in specific cancers, such as glioblastoma.
The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs. That is, for every 5 grams of food there are 4 grams of fat and 1 gram of protein and/or carbohydrate.
In the classic Ketogenic Diet, 80% (i.e. 4/·5=80%) of calories come from fat and 20% (i.e. 1í·5=20%) from a combination of protein and carbohydrate.
Depending on the application, protein may be determined as 1 g of protein per kg body weight, carbohydrate as 10-15 g per day total, and the remainder of calories provided as fat. Sometimes, protein is set at 10% or 15% of calories, and carbohydrate ranging from 5% – 10% of calories.
Modified Ketogenic Diet (MKD) – 3 : 1 ratio
The Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein and carbohydrate with 75% of calories from fat, and 25% from a combination of protein and carbohydrate. Protein may be set at 15% of calories with a maximum of 10% of calories coming from carbohydrate.
Modified Atkins Diet (MAD) – 2 : 1 ratio
The Modified Atkins Diet (MAD) has a 2 : 1 ratio, with 2 parts fat for every 1-part protein and carbohydrate. Fat is set at 60% of calories, protein at 30% of calories, and carbohydrate at 10% of calories.
A Keto Diet
There is no one “keto diet”, but rather a range of keto diets. What these diets have in common is that they limit carbohydrate intake to 10% or less of daily calories in order to promote the body’s production of ketones.
The popular high fat / moderate protein version of a keto diet with ~75% fat and 15% protein is commonly referred to as “the keto diet” but as outlined below, this is not the only keto diet, nor the first. This style of keto diet was popularized in 2016 by the publication of Dr. Jason Fung’s two books, The Obesity Code[2] and The Complete Guide to Fasting[3], as well as Dr. Andreas Eenfeldt’s book, The Low Carb, High Fat Revolution[4], and his Diet Doctor website.
In contrast to a therapeutic ketogenic diet, the amount of protein in these keto diets is not tightly regulated, and there is no need to weigh and measure food, or track ketones. While these diets are often used for their therapeutic benefits including weight loss and improved blood sugar control, they are not therapeutic diets.
There were other types of keto diets long before popularized keto diet, above. One was the high protein / moderate fat keto diet based on the 1997 book Protein Power, written by Dr. Michael Eades and his wife Dr. Mary Dan Eades [5]. Another was the book, the New Atkins For a New You[6] which was a 2010 redesign of the original “Atkins Diet” from the 1970s, and was re-written by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD. Unlike the high fat / moderate protein popularized keto diet of today, the New Atkins For a New You was only very high fat and very low carbohydrate (20-50 g carbs per day) during “phase one” which lasts only the first two weeks.
A Well-Formulated Ketogenic Diet
Shortly after completing the 2010 book, New Atkins for a New You with Dr. Eric Westman, Dr. Stephen Phinney and Dr. Jeff Volek wrote their own book, The Art and Science of Low Carbohydrate Living [7]. Drs. Phinney and Volek outline that since ketosis can occur within a fat intake range between 65-85% of calories [pg. 77], protein intake can range from 21-30% and still result in a “well-formulated ketogenic diet”.
While Phinney and Volek’s well-formulated ketogenic diet is not a therapeutic diet per se, it does specify the amount of protein, fat and carbohydrate for weight loss and weight maintenance differently. During weight loss, the Art and Science of Low Carbohydrate Living sets carbohydrate intake for men at 7.5-10% of calories and for women at 2.5-6.5% of calories, and protein intake as high as 30% of calories and during weight maintenance, protein intake is lowered to 21%. During weight loss, fat intake is set at 60% of calories and increased to between 65-72% during weight maintenance.
A “well-formulated ketogenic diet” can range from 65% fat, 30% protein and 5% carbs to 72% fat, 21% protein and 7% fat.
Note: From a clinical perspective, I believe that the protein range of 21%-30% of calories of a well-designed ketogenic diet is more suitable for older adults to enable them to preserve muscle mass and avoid sarcopenia than the 15% protein intake of the popularized keto diet.
Final Thoughts…
While both therapeutic ketogenic diets and keto diets restrict carbohydrates, a therapeutic ketogenic diet also tightly controls the amount of protein, which makes them very different from “keto diets”.
The copious amounts of bacon and eggs and meat of popularized “keto diets” is absent in therapeutic ketogenic diets. To achieve the precise protein plus carbohydrate to fat ratio of a therapeutic ketogenic diet, individuals following one are required to weigh and measure all the ingredients to the gram. They are also required to track serum glucose and serum ketones to ensure that the a specific glucose to ketone ratio is achieved, and maintained. A therapeutic ketogenic diet is designed to a dietary prescription, where as a keto diet may result in therapeutic benefits such as weight loss and improved blood sugar, but keto diets are not therapeutic diets.
There is no one-sized-fits-all therapeutic ketogenic diet or keto diet. There are different types therapeutic ketogenic diets and a range of keto diets that can be utilized, depending on an individual’s needs, and goals.
It is important to know that there are reports of individuals starting on a 3:1 therapeutic ketogenic diet for improved mental health and transitioning to a 2:1 and doing very well. Likewise, there are anecdotal reports of people beginning with a 2:1 therapeutic ketogenic diet and once stable and feeling well, transitioning to a more liberalized keto diet with similar fat ratios that are similar. Each person’s needs are different.
I design both therapeutic ketogenic diets and different types of keto diets and support people in implementing and transitioning to other types of ketogenic diets.
References
- Kossoff, Eric & Turner, Zahava & Cervenka, Mackenzie & Barron, Bobbie. (2020). Ketogenic Diet Therapies For Epilepsy and Other Conditions. 10.1891/9780826149596.
- Fung J (2016) Obesity Code, Greystone Books, Vancouver
- Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
- Eenfeldt A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
- Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health—in Just Weeks! Bantam; New edition edition (1 December 1997)
- Westman E, Phinney SD, Volek J, (2010) The New Atkins for a New You — the Ultimate Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
- Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
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