Practice Paper of the Academy of Nutrition and Dietetics: Classic and Modified Ketogenic Diets for Treatment of Epilepsy.

Registered dietitian nutritionists are often the first line and the most influential team members when it comes to treating those on KD therapy. This paper offers registered dietitian nutritionists insight into the history of KD therapy, an overview of the various diets, and a brief review of the literature with regard to efficacy; provides basic guidelines for practical implementation and coordination of care across multiple health care and community settings; and describes the role of registered dietitian nutritionists in achieving successful KD therapy.

The low-carbohydrate diet and cardiovascular risk factors: Evidence from epidemiologic studies

Recent randomized controlled trials document that low-carbohydrate diets not only decrease body weight but also improve cardiovascular risk factors. In light of this evidence from randomized controlled trials, dietary guidelines should be re-visited advocating a healthy low carbohydrate dietary pattern as an alternative dietary strategy for the prevention of obesity and cardiovascular disease risk factors.

How to Reintroduce New Foods in Phase 2

In Phase 2, Ongoing Weight Loss (OWL), some of “new” carbohydrate foods are reintroduced, typically in the following order:

  • Nuts and seeds, nut and seed butters and nut and seed flours
  • Berries, cherries and melon (but not watermelon)
  • Plain, unsweetened whole-milk yogurt, cottage cheese and ricotta 
  • Legumes such as chickpeas, lentils, etc.
  • Tomato and vegetable juice “cocktail”

Not everyone can add back all these foods; others may be able to add only small portions or have them only occasionally. There are five important points to understand when reintroducing carbohydrate foods:

1.  Count carbs. If an individual has been strictly following a meal plan or estimating grams of Net Carbs in Phase 1, Induction, now is the time to start counting them.

2.  One at a time. Only one new food within a rung on the Carb Ladder should be reintroduced each day or several days. That way, if a food reawakens cravings or uncontrollable hunger, causes gastric distress or stalls or reverses weight loss, the patient can easily identify it—and back off for the time being. So, for example, at rung 4 he or she might start with a small portion of blueberries. Assuming no problems, it would be fine to move on to strawberries a couple of days later. In OWL, most people can also consume additional low-carb specialty foods beyond those suitable for Induction. Again, they should be introduced one at a time to assess any reactions.

3.  More variety, not more food. The range of foods is increasing, but the amount of food being consumed each day is not, or at least not very much. As an individual continues to add small amounts of carbohydrate foods, he or she doesn’t have to do anything other than make sure he or she is not overdoing protein intake (typically 4–6 ounces at each meal). Patients should be guided by their appetite and distinguish it from habit. The moment they feel they’ve had enough, they should stop eating. Staying well hydrated also helps moderate appetite.

4.  Stay with foundation vegetables. As your patients add new foods, they’ll substitute some of them for other carb foods they’re already eating, but not the 12–15 grams of Net Carbs from foundation vegetables. For example, a person can now have cottage cheese in lieu of some of the hard cheese she’s been eating in Induction. Instead of an afternoon snack of green olives, another person might switch off with macadamias. They both will still be eating those Induction-friendly foods, but they can branch out a bit. As long as individuals track their carb intake, eat the recommended amount of vegetables and feel pleasantly full but not stuffed, they should do fine.

5.  Write it down. The process of adding back foods doesn’t always happen smoothly. It’s essential to understand which food is causing a negative response, such as the return of cravings or uncontrollable hunger. That tells a person to back off it. Counsel your patients to continue to note what they’re adding, how much and their reactions, if any, in their diet journal.

Objectives and Guidelines for Phase 2

In Phase 2, Ongoing Weight Loss (OWL), patients learn how to gradually increase their Net Carb intake and add variety to their diet—while continuing to stay in control of their appetite, lose weight and feel energized. We recommend individuals remain in OWL until they’re within 10 pounds of their goal weight before moving to Phase 3, Pre-Maintenance. 

What’s Similar to Induction?

Initially, the differences between Phase 1, Induction, and OWL are relatively minor, but the gradual additions to the diet mark the beginning of the return to a permanent way of eating. Everything else remains the same as in Induction. Patients continue to:

1.    Count their daily intake of grams of Net Carbs.

2.    Eat 4–6 grams of protein at each meal, including breakfast, depending upon height and gender. Tall men can eat up to 8 ounces. 

3.    Eat sufficient natural fats, meaning enough to feel pleasantly full, which varies by individual. It’s not necessary to skimp on fat but don’t overdo it either. 

4.    Drink about eight glasses of water and other acceptable fluids, which can include a couple of cups of caffeinated coffee, tea or colas with acceptable sweeteners.

5.    Make sure that salt intake is sufficient (unless on a therapeutic low- sodium).

6.    Take both multivitamin/multimineral and omega-3 supplements.

What Is Different from Induction?

There are two key distinctions between the first and second phases of Atkins: 

1.    The slightly broader array of healthful acceptable foods in OWL includes nuts and seeds (which individuals who have spent more than two weeks in Induction may already be eating), berries and a few other relatively low-carb fruits, a wider array of dairy products, a few vegetable juices and legumes such as lentils and kidney beans. 

2.    The gradual increase in overall carb intake.  Despite eating more carbs and gradually introducing a greater variety of them, however, it’s important to understand that this transition from one phase to the next is gradual and incremental. 

Finding One’s Personal Tolerance for Carbs 

A key objective of OWL is to determine one’s carbohydrate threshold without interfering with weight loss and other factors. If health issues, such as high blood sugar levels, are of concern, their ongoing improvement is also critical. Phase 2 is a period in which each dieter explores which foods he or she can and cannot handle. All this is part of the process of finding one’s personal Carbohydrate Level for Losing (CLL): the number of grams of Net Carbs that can be consumed in one day without interfering with weight loss or prompting hunger, cravings, fatigue or reversal of health indicators. 

A Broad Range of CLLs

Carbohydrate tolerance can range from 25 grams of Net Carbs to 60–80 grams or even more. If a patient is losing less than a pound a week on average, he or she is probably close to his or her carbohydrate tolerance and shouldn’t increase carbohydrate intake. An individual’s CLL is influenced by age, gender, level of physical activity, hormonal issues, medications and other factors such as cyclical weight loss and regain. Younger people and men tend to have an advantage. Increasing activity may or may not raise a person’s CLL. 

Big Benefits 

The goal for each patient is to enjoy as broad a range of whole foods as possible—but without losing the benefits of controlling carbohydrates: continued weight loss, appetite control, the absence of obsessive thoughts about food, high energy and a general sense of well-being. It’s always better to stay slightly below one’s carb tolerance than to overshoot it and then have to back up. The delicate balancing act is crucial to understanding one’s own metabolism, which will ultimately enable healthy weight maintenance. That said, some “backing and forthing” is often needed to identify one’s CLL. Once he or she finds it, the patient should remain there until 10 pounds from goal weight.

What to Expect

After a month or two in OWL, most people have a pretty good idea of where their CLL will land. If it’s easy to add back a variety of carbohydrate-containing foods, a CLL of 50 or more grams of Net Carbs a day is likely. However, difficulty introducing carbohydrate foods higher on the carb ladder may mean having a CLL somewhere between 25 and 50. 

10 Ways to Ease the Transition to Pre-Maintenance

As your patients leave Phase 2, Ongoing Weight Loss (OWL), and move on to Phase 3, Pre-Maintenance, it’s natural for them to feel conflicted. They’re impatient to reach their goal, but it’s important for them to understand that slow and steady weight loss is the correct path to permanent weight control. If they follow these 10 guidelines their transition to Pre-Maintenance should be smooth sailing.

1.    Continue to count. Your patients may feel like old Atkins hands after several months on the program, but as they home in on their goal weight, it’s all the more important that they continue to track their Net Carb intake. Only that way can they understand their specific tolerance for carbs as they gradually increase the amount and variety of carbohydrate foods they’re eating. 

2.    Eat those veggies. They should continue to include at least 12–15 grams of foundation vegetables in their daily carb count. Although they may be able to add starchy vegetables in this phase, they should regard them as incremental, not as a substitute for the salad greens and other low-carb, high-fiber veggies they’ve been eating all along.

3.    Climb the carb ladder carefully. Following the Carb Ladder gradually increases the range of foods, but should not change the amount of food consumed.

4.     Introduce one new food at a time. As they return to the world of apples, acorn squash and brown rice, caution your patients to gauge the impact of each food before moving on to the next.

5.    Stick to two portions of fruit a day. The sugar in fruit is natural, but that doesn’t mean it should be overdone. If they have half an apple, for example, they should eat only one serving of berries that day.

6.    Don’t overdo protein. As more carbohydrate foods are added, it may be necessary to reduce protein intake slightly if your patient was at the top of the intake range for his or her gender and height.

7.    Drink up. For both general hydration and to help keep hunger at bay, it’s important to continue to drink eight glasses of water and other acceptable liquids each day.

8.    Watch for fat hunger. As a person approaches his goal weight, the body burns less of its own fat and relies more on dietary fat. That may necessitate adding some slices of avocado to a salad, more olive oil to vegetables or another dollop of whipped cream to berries. 

9.    Eat regularly. Advise your patients once more not to go for more than four to six hours between meals or a meal and a snack; and stop eating the moment they feel they’ve had enough.

10.    Advance cautiously. Now that they’re increasing their daily carb intake in 10-gram increments every week or several weeks, your patients should be on the alert for weight regain or the return of symptoms such as excessive hunger or carb cravings.

Finding One’s Ace in Phase 3

Once your patients have achieved their goal weight in Pre-Maintenance, but before they move to Phase 4, Lifetime Maintenance, they’ll need to find their Atkins Carbohydrate Equilibrium (ACE). In contrast to the Carbohydrate Level for Losing (CLL), which relates to weight loss, the ACE is the number of grams of Net Carbs an individual can consume each day, while neither losing nor gaining weight. Many people wind up with an ACE of 65 to 100 grams of Net Carbs, but others have a considerably lower ACE and a very few people an even higher one.

It’s Not Just About Weight

Merely looking at weight loss can oversimplify the issue of carb tolerance. Even if one is maintaining his weight with an ACE of say, 65 grams of Net Carbs, he might still be reawakening food cravings or blood sugar swings or experiencing lack of energy, which could make it difficult to maintain that level of carb intake long term. The ability to concentrate and any tendency to retain fluid must also be considered. The objective is not to push carb intake to the absolute limit but to advance to a point that is comfortable to maintain and doesn’t stimulate the return of any of the old symptoms of extreme hunger, carb cravings, afternoon energy crashes and the like. Impress upon your patients that finding their ACE is not just a matter of staying at the right weight; it’s also about being able to do so comfortably. 

Keep the Atkins Edge

What’s unique about the low-carb way of eating compared to other diets is that adhering to first one’s CLL and later one’s ACE results in profound metabolic changes, enabling better control of calorie intake. Conversely, if a person exceeds his ACE, he is forcing his body to burn more glucose while blocking fat burning. This makes it harder to control appetite and feel satiated, with the result that lost pounds are almost certainly regained. As long as one stays at or just below his ACE he’ll be able to stay in control of his appetite—and therefore his weight.