Ketogenic diet - the practical details
(By Dr Sarah Myhill and Craig Robinson)
Stylistic note: Use of the first person singular refers to me, Dr Sarah Myhill. One can assume that the medicine and biochemistry are mine, as edited by Craig Robinson, and that any classical and mathematical references and quotes or historical and linguistic notes are Craig’s!
Please see My book, The PK Cook book - go paleo-ketogenic and get the best of both worlds for full details.
This webpage is designed to give the practical details of the ketogenic diet and also to provide guidance for the following of such a diet for the severely disabled. The dietary data is most usually taken from the USDA (United States Department of Agriculture) Database Entry, or otherwise, where there is a proprietary brand, then from that brand's nutritional label.
Please note that the recommendations on this page are subject to any other dietary considerations that individual patients may have, such as fermenting gut problems (see Fermentation in the gut and CFS) and any other issues such as allergies and intolerances.
Guidelines for Protein, Carbohydrate and Calorie intake
These guidelines are necessarily that - guidelines! Please see the section below on 'Monitoring Equipment for ketosis' - we are all individuals and we must all find our own way, within these general principles. The key thing is to get into ketosis and to stay there!
That said, an overall guide for carbohydrates and calories is:
- Carbohydrates - up to 50grams
- Calories 2000kCal per day
Protein intake needs more thought because of the possibility that the body may convert it into sugar where it is eaten in excess.
- Protein - A rule of thumb is to allow 0.7 to 0.9 grams of protein per pound of lean body mass.
REMEMBER - The PK diet is not a high protein diet. It is a high fat and fibre diet.
So, for example I weigh 140lbs which means my lean body mass is about 100lbs. You can calculate your lean body mass at Lean body mass calculator
Proteins are found in such foods as meat, eggs, fish and shellfish. These are zero carbohydrate BUT, as mentioned, if eaten in excess the body can convert them into sugars. Here are some common protein-rich foods:
|Food||Protein content in gms per 100gms||On the plate looks like……approx|
|Beef||26||A medium beef burger|
|Pork||31||A small pork chop|
|Bacon||Up to 39 depending on how fat! One slice 8 grams|
|Lamb||26||One lamb chop|
|Chicken, Duck||20||Whole breast or whole leg|
|Fresh Fish||29||A good chunk!|
|Prawns||25||A prawn 'cocktail' starter|
As calculated above, my lean body mass is about 100lbs and so this means that I can eat about 80 grams of protein a day without having to reduce my carbohydrate ration [see below].
For me this amounts to:
- Breakfast: 2 eggs (26), 2 rashers bacon (16). My bacon is very fat.
- Supper: tinned fish starter (8) and pork chop (30)
What to do if you exceed your protein limit?
If one should exceed the protein limit, then the amount by which this limit is exceeded should be deducted from the daily carbohydrate ration on the approximate basis that one gram of protein can be converted to one gram of carbohydrate. So, if you exceed your protein limit by 5grams then you should reduce your carbohydrate limit by 5grams.
WORK TO THESE GUIDELINES, USING THE DATA CONTAINED IN THE TABLES BELOW. HOWEVER, ONE CANNOT RELY PURELY ON THESE GUIDELINE AMOUNTS TO ENSURE KETOSIS - SEE NOTES ON THE USE OF MONITORING EQUIPMENT BELOW.
Essential practical details for commencing a ketogenic diet
Establish a list of very low carbohydrate foods and make sure that your pantry is well stocked with such. Always look at the labels which detail the carbohydrate content of foods - this is very helpful. These carbohydrate values given on labels are normally total carbs which include all starches, sugars and soluble fibre. Some people prefer to use net carbs (sugars and starches, with fibre excluded) on the grounds that soluble fibre is fermented into short chain fatty acids. Linseed is a good example – it is said to have virtually zero carbs because although 100grams contains 29grams of total carb, 27grams is fibre and so just 2grams is starch and sugar. I find I can eat several slices of linseed bread and stay in ketosis - some cannot!
All carb amounts on this webpage are disclosed excluding the dietary fibre content.
Table of Fats, Oils and Proteins - generalised table
By way of introduction, here is a generalised table of very low carb content fats, oils and proteins:
|How much in a day?||...of which type of food? /Carb content||Important Notes|
(These are all saturated fats)
| Lard, dripping, leaf fat [leaf fat - the dense fat occurring in layers around the kidneys of some animals, especially pigs], meat fat, coconut oil, palm oil
Possibly butter (but allergy to dairy is common)
|Saturated fats are the only fats that should be used hot for roasting, frying and grilling.|
(these are mono or poly unsaturated)
| Nut oil seed oil, vegetable oil and fish oil.
|Only use these oils cold (heating them flips them to trans-fats). Make sure they are cold pressed oils.|
Approx 0.7 to 0.9 grams of protein per pound of lean body mass.
| Meat (beef chicken, pork, venison, and other game)
Poultry (chicken, duck, turkey, game birds)
Carbs zero BUT see next column....
| ….. excess protein can be turned into sugar.|
A ketogenic diet is not a high protein diet
|Other Protein|| Bacon,salami,sausage
Coyo (coconut yoghurt) plain
Very low carbs
0.5 grams of carb in one egg
Coyo (coconut yoghurt) plain - 0.5grams of carb in 100gms! A great addition to the diet
Specific Table of other foods
Here is a table of higher content carb food types and the amounts of each that can be eaten in a day.
|How much in a day?||...of which type of food? / Carb content of 100 grams is...||Amount allowed in day to comply with recommended daily carb content (taken as 10gms in all cases)|
| Vegetables and salad
10-15grams of carb
Spiralised vegetables roasted in lard is a great dish!
See Spiralite Vegetable Spiraliser
| Courgette 2.1gms
Green leafy vegetables eg spinach, watercress 1.4gms
Green beans 3.6gms
Butternut squash 10gms
CARE WITH ROOT VEGETABLES
Parsnip 13.1 gms
| 470gms of courgette OR|
710gms of leaves OR
380gms of brassica OR
310 gms of mushroom OR
270 gms of green bean OR
140 gms of onion OR
150gms of swede OR
140gms carrot OR
100 gms of Butternut squash OR
80 gms of leek OR
67gms of potato OR
76gms of parsnip
|Vegetables and salad continued
10-15grams of carb
| Lettuce, rocket 1.7gms
spring onion 4.4gms
| 588gms of lettuce OR|
555gms of radish OR
320gms of cucumber OR
370gms of tomato OR
710gms of sauerkraut OR
340gms of peppers OR
230gms of spring onions
|Nuts and seeds
5-10 grams of carb
| Brazils 4 gms
| 250 gms of brazils OR|
140gms of walnuts OR
140grams of peanuts OR
100 gms of almonds OR
500gms of linseed OR
37gms of cashews
|Fruits and berries
5-10 grams of carb
Raspberry 5 gms
350gms of olives OR
167gms of strawberry
500gms of avocado
175gms of gooseberry
200gms of raspberry
86gms of blueberry
Table of snacks and "taste enhancers"
Here is a table of snacks and "taste enhancers".
|General Food Type||Specific examples||Important Notes|
zero or very low carb
| Lemon juice
Mayonnaise and French dressing
| Stevia is safe and effective
The sugar alcohol xylitol has a glycaemic index of 13 and so use sparingly.
Both are antimicrobial.
| Artificial sweeteners such as aspartame and saccharine are toxic.|
Other sugar alcohols (eg sorbitol, mannitol) increase glucose in the blood and are fermented in the gut
|Pork scratchings||Once fully keto-adapted one should not need to snack - but eating crunchy food is satisfying!|
|Alcohol|| Must be zero carb eg brandy, gin, whisky, vodka.
The body “burns” alcohol before fat - this may stall weight loss
| Care – alcohol tolerance is reduced on a ketogenic diet – you get drunk quicker!|
Will power is reduced with alcohol! Don’t fall off the wagon.
Alcohol is toxic.
| Water or fizzy water
Herbal tea (including Green Tea)
|Always quench your thirst with water before drinking tea and coffee.|
Gets its own section!
| 90% dark chocolate
(say 14gms carbs per 100gms)
| 70 gms daily equates to 10gms of carbs BUT beware as too much may disturb sleep.
Most of the diets I advocate are dairy free. The "safest" dairy product is butter – it is the milk protein and milk sugar that are such a problem. Ghee is ideal since it is free of milk protein.
Have a go at some new recipes as detailed below. My life as a ketogenic was transformed by linseed bread, coconut cream, salad dressing, coconut chocolate, crumble topping and a spiraliser!
If in doubt eat more fat and less carbs.
a- Coconut cream: This is my favourite recipe – the resulting cream has the taste and texture of double cream. Ingredients: one 450ml tin of coconut milk, dollop of melted coconut oil (more for thick cream, less for thin cream), ½ teaspoon sunflower lecithin. Sweeten to taste with stevia. Whizz up in food processor. Put in fridge. Use as you would use cream – delicious in black coffee.
b- Coconut Yoghurt: same as above but use fermented coconut milk.
c- Chocolate cream: – as above but stir in 60grams (½ pot) Green and Black’s cocoa powder.
d- Coconut chocolate: – mix one 450gram pot of coconut oil with a whole 125gram pot of Green and Black’s cocoa powder. Pour into ice cube containers and put in deep freeze. Eat direct from deep freeze.
e- Linseed Bread:
OLD RECIPE - 100grams linseed ground up into a flour, 20grams ground almonds, ½ tspn bicarb soda, ½ tspn salt. Stir in 2 eggs, 1/3 cup water, 1/3 cup olive oil. Mix well .Stick it in the oven 150 degrees C for 60mins. Slice thinly.
NEW IMPROVED RECIPE - You can access this improved recipe using only linseed, salt and water here -
And here is my YouTube video, demonstrating how to make this NEW IMPROVED RECIPE - YouTube Link - A Quick Method For Making Delicious Paleo-ketogenic Bread - NEW RECIPE
f- Crumble topping for berry pies: 100grams linseed ground up into a flour, 100grams desiccated coconut, teaspoon cinnamon, sweeten with stevia, dollop of coconut oil to stick it together.
g- French Dressing: – crushed clove garlic, dollop olive oil, juice whole lemon, 1 teaspoon mustard, generous pinch sea salt, pepper, ½ tspn treacle (sorry about that - not essential - but it does blend all to make a gorgeous texture!). Mix.
h- Mayonnaise: - all the above – but add in 2 egg yolks, ½ tspn lecithin, whizz up in food processor
Monitoring Equipment for ketosis
You cannot rely simply on what you eat and how much you eat to know that you have done enough to get into ketosis. Some people can eat 100 grams of carb per day and get into ketosis. Some have to reduce to below 30 grams (includes me – dammit!). Monitor your blood sugar and ketones using a Freestyle Optimum meter. (Amazon.co.uk link for FREESTYLE OPTIUM NEO GLUCOSE AND KETONE METER) It takes about 2 weeks to become keto-adapted so do not be disheartened in the early stages. Women find it harder to get into ketosis than men, and we are all different! Measuring ketones in urine is not reliable BUT it may work for you. Ketostix for urine testing are less expensive than blood ketone measuring sticks. See My online shop link for multistix and also Urine MULTISTIX analysis interpretation Breath testing is reliable but the meters are expensive - see Ketonix website.
The Biochemistry of ketosis
As you keto-adapt, blood sugars will come down and then they will become remarkably stable, fluctuating only by a few tenths of a millimol per litre. Ketones should appear and levels should be 0.5 to 3.0 millimols. Levels tend to be lower in the morning and higher as the day goes on. After exercise ketones may rise to 4 millimols. Please note in diabetic keto-acidosis levels are above 10 millimols.
There is the world of difference between the ketosis of low carb and the ketosis of uncontrolled diabetes. To compare the two is like comparing the thirst quenching properties of water with water as a killer by drowning! Low level ketosis is highly desirable metabolically speaking, but some doctors use diabetic ketosis to create false alarm against the ketogenic diet.
Constipation may be a problem - in which case use linseed – this can be incorporated into the diet as linseed bread or as a crumble topping. Although linseed has a total carb load of 29gms per 100gms, 90% of this is fibre and only 10% as starch. This means that some people can eat large amounts of linseed and remain in ketosis.
A ketogenic diet is demanding of minerals – you will need extra salt (5 grams per day added to food) and a good multi-mineral daily with 300mgs of magnesium.
Finally remember that there are three major hormonal considerations in order to get into ketosis:
- An insulin spike (from a moment of indiscretion such as snaffling a bar of cheap chocolate or bag of crisps or a biscuit) will spike insulin and switch off fat burning for many hours. This means you will have a window of time of some hours when you cannot access fuel either from carbs (because the sugar spike has been pushed into fat by insulin) or from fat (because insulin blocks this). This may mean you feel awful for those hours. Knowing this is good incentive to say on the wagon!
- To be able to fat burn you need thyroid hormones – get your thyroid checked! See Thyroid - the correct prescribing of thyroid hormones
- Female sex hormones induce a metabolic syndrome. This is why women must eat fewer carbs than men to get into ketosis. I suspect the Pill and HRT will have a similar effect.
Generalised Ketogenic Shopping List (no food preparation or cooking) for the severely disabled
Initially do not worry too much about the protein content – some people can get into ketosis with a high protein diet. If you can’t then you may need to think about that!
|FOOD||kCal per 100grams||Carbohydrates (gms) per 100grams (NB - excludes Fibre)||Fat (gms) per 100grams||Fibre (gms) per 100grams||Protein (gms) per 100grams|
|Tinned sardines in Olive Oil –boneless||225||0.0||15.4||0.1||21.7|
|Tinned sardines in Tomato Juice||142||1.5||7.5||Trace||17.0|
|Grilled sardines in a tin||198||0.0||11.9||Trace||22.8|
|Tinned Tuna chunks in spring water||113||0.0||0.5||Trace||27.0|
|Tinned Tuna chunks in brine||113||0.0||0.5||Trace||27.0|
|Tinned Tuna chunks in Olive Oil||209||0.0||9.2||0.0||18.4|
|Tinned Yellow-fin Tuna in Olive Oil||180||Trace||8.0||Trace||27.0|
|Tinned Mackerel in Tomato and Basil sauce||132||5.7||6.3||Trace||12.8|
|Tinned Steam cooked Mackerel in Olive Oil||260||0.0||20.0||Trace||20.0|
|Tinned Grilled mackerel fillet||245||0.0||17.0||Trace||23.0|
|Tinned Pink Salmon in water||131||Trace||5.4||Trace||20.4|
|Tinned Red Salmon in water||151||Trace||7.8||Trace||20.4|
|Tinned pilchards in tomato sauce||159||2.4||10.1||Trace||14.5|
|Cornish Pilchard fillets in Olive Oil||205||0.5||13.0||Trace||22.0|
|Cornish Pilchard fillets in tomato sauce||161||1.8||9.1||Trace||18.0|
|German Pepper salami||319||0.7||25.3||1.1||21.5|
|Serious Pig snacking salami||422||0.0||32.7||0.0||32.0|
|Coyo Natural coconut yoghurt||182||0.5||19.0||Trace||3.0|
|Coyo Vanilla coconut yoghurt||182||0.5||19.0||Trace||3.0|
|Coyo Chocolate coconut yoghurt||196||3.9||19.0||Trace||2.3|
|Coyo Cherry coconut yoghurt||177||5.9||16.0||Trace||2.6|
|Coyo Mango coconut yoghurt||177||5.7||16.0||Trace||2.6|
|Biona organic creamed coconut||664||24.0||68.0||14.0||6.0|
|Alpro soya yoghurt - plain||50||2.1||2.3||1.0||4.0|
|Alpro pineapple peach and passionfruit soya yoghurt||78||10.3||1.9||0.8||3.6|
|Alpro strawberry and rhubarb soya yoghurt||74||9.4||1.9||1.0||3.6|
|Alpro Vanilla yoghurt||75||9.5||2.2||1.0||3.7|
|Pistachios – roasted and salted||562||18.0||45.0||10.0||20.0|
|Roasted salted peanuts||567||7.0||49.0||9.0||26.0|
|Organic hemp seeds||455||2.8||31.8||30.6||24.0|
|Organic Flax seed||534||2.0||42.0||27.0||18.0|
|Macadamia Nut Butter||711||13.7||65.0||9.0||7.8|
|90% Lindt dark chocolate||594||16.5||52.8||13.2||10.0|
|99% Lindt dark chocolate||540||8.0||50.0||6.0||14.0|
|Green and Black’s 85% dark chocolate||630||22.5||53.5||11.5||9.4|
|Pralus - Le 100% dark chocolate||610||18.0||56.0||13.0||9.0|
Meals suggestions for the severely disabled (no food preparation or cooking) using the above table
Linked below you will find 7 days' worth of meal suggestions for those following the ketogenic diet who are severely disabled. These are included by way of example as to how one can construct meals using the information on this page. In the short term these may be somewhat repetitive, but as energy levels improve you can start cooking, maybe one meal a day.
Please feel free to add 'taste enhancers' from the above table so as to add variety.
These meal suggestions require one loaf of Linseed Bread (as described above) to be cooked once a week. It is hoped that this task can be done by a carer.
Obviously, one can mix up a breakfast from one day with a lunch from another and so on, as long as one sticks to the overall guidelines.
In these meals, the 50gms carbs and 2000kCal calories limits have been adhered to. The protein levels have been kept to around 100gms. This is less than noted above and so you could divert some of your dietary intake into more protein rich foods. Protein can convert into carbs and so having low normal amounts of protein is protective against this.
A small afternoon snack has been included on each day. This has been included because it is recognised that initially it will be difficult to avoid such snacking "habits"! This is not ideal, and so, as time goes by, try to drop the snack and add equivalent amounts of protein,carbs and calories to the main meals.
Please Note that for breakfasts, where there is the advice to mix seeds with coyo or alpro yoghurt, different patients will have different tastes as to how "thick" they would like this to be. Please adjust the amount of seeds you mix in to your own taste, but do make sure that you eat all the seeds!
- Day 1 - Ketogenic Meal Suggestions
- Day 2 - Ketogenic Meal Suggestions
- Day 3 - Ketogenic Meal Suggestions
- Day 4 - Ketogenic Meal Suggestions
- Day 5 - Ketogenic Meal Suggestions
- Day 6 - Ketogenic Meal Suggestions
- Day 7 - Ketogenic Meal Suggestions
If one were to follow the 7 day meal plan as above then the weekly shopping list is:
WEEKLY SHOPPING LIST FOR THE 7 DAYS MEAL SUGGESTIONS AS ABOVE:
(as a file to be downloaded and used for the weekly shop by carer - WEEKLY SHOPPING LIST FOR THE 7 DAYS MEAL SUGGESTIONS AS ABOVE)
One loaf of Linseed Bread as above – use 250gms Linseed and scale the other ingredients up
Coyo Natural Yoghurt [125gms]
Coyo Chocolate coconut Yoghurt [125gms]
Coyo, pineapple, peach and passionfruit yoghurt [125gms pot]
Alpro Vanilla Yoghurt [200gms] and Alpro Vanilla yoghurt [150gms]
2xAlpro soya yoghurt plain [150gms]
Alpro Strawberry and rhubarb yoghurt [150gms]
Tinned Mackerel in Basil and Tomato sauce [120gms]
Tinned Tuna in spring water [120gms]
Grilled sardines in a tin [120gms]
Tinned Tuna in spring water [120 gms]
Tinned red salmon [150gms]
Cornish Pilchards in tomato sauce [120 gms]
Tinned sardines in tomato juice [125gms tin]
2xChopped Pork [200gms tin]
Tinned Gammon [200gms]
2xCorned Beef [125gms tin]
Tinned Ham [125gms tin]
Salami serious pig snacking [100gms]
Milano salami [75gms]
400gms each of tomato, cucumber, lettuce
100grams flax seed
100gms sesame seeds
150gms sunflower seeds
100gms of hemp seeds
100gms of chia seeds
50gms of pumpkin seeds
60gms of Pine nuts
30gms of Almonds
50gms of Pecans
40gms Brazil Nuts
50gms of blueberries
50gms of strawberries
50gms of raspberries
50gms of gooseberries
1 bar Green and Black’s 85% chocolate – will last 2 weeks
1 bar 90% Lindt dark chocolate – will last 2 weeks
Pot mayonnaise – will last more than one week
Pot salad cream – will last more than one week
Pot macadamia nut butter – will last more than for one week
Pot hazelnut nut butter – will last more than for one week
Pot peanut nut butter spread – will last more than for one week
Pot cashew butter spread – will last more than for one week
Pot coconut butter – will last more than for one week
- As things move forward, one could add in boiled eggs for some of the tinned fish.
- Those who are concerned about soy products should stick to the coyo option for the time being until they are able to move forward with cooking.
- There is an alternative to the Alpro yoghurt, Provamel, which is sugar free and so some patients may prefer this in their individual circumstances.
- If you feel that 2000kCal is too high for your personal level of activity then cutting out the snacks each day will help to reduce the calorific intake.
- In essence it is hoped that this will be a temporary measure until the sufferer can cook more on their own and so don't think that this will be your diet forever!
- This is far from perfect, of course, but it does fulfill a need that many of my patients have been asking for - namely how to be ketogenic if severely disabled.
- I am currently searching for a shop bought Linseed Bread Loaf, or equivalent, to replace the home cooked version. If anyone beats me to it, please do let me know! Any other ideas are of course, as always, welcome!
For further ideas have a look at the following websites:
Papers on CFS/ME, other health conditions and Ketogenic Diets
- This paper - MITOPROTECTIVE DIETARY APPROACHES FOR CFS/ME - CALORIC RESTRICTION, FASTING AND KETOGENIC DIETS - by Courtney Craig is a useful addition to the evidence base.
- In addition this case study "Crohn's disease successfully treated with the paleolithic ketogenic diet" adds to the weight of evidence.
- Many more studies supporting the beneficial health effects of a ketogenic diet can be found in My Book - "Prevent and Cure Diabetes - delicious diets not dangerous drugs" In this book, there are studies showing benefits of a ketogenic diet for diseases such as diabetes, heart disease, cancer, dementia, Parkinson's disease, generalised inflammation and infection, and epilepsy.
- In addition, Dr Dale E. Bredesen recently (September 2014) published a paper, "Reversal of Cognitive decline : A novel therapeutic program". 10 patients, including patients with memory loss associated with Alzheimer’s disease, amnestic mild cognitive impairment, or subjective cognitive impairment were treated with a ketogenic diet, supplements and hormones, etc. Nine of the 10 displayed subjective or objective improvement in cognition beginning within 3‐6 months, with the one failure being a patient with very late stage AD. The same interventions and principles apply to my ME patients who essentially have an early "dementia" due to poor energy delivery mechanisms. However since the brain is plastic in the early stages this is all reversible- as my patients demonstrate! The full paper can be viewed here - Reversal of Cognitive decline - Dr Bredesen
- My book, The PK Cook book - go paleo-ketogenic and get the best of both worlds
- My Book - "Prevent and Cure Diabetes - delicious diets not dangerous drugs"
- Fermentation in the gut and CFS
- Ketogenic diet - a connection between mitochondria and diet
- Urine MULTISTIX analysis interpretation
- Thyroid - the correct prescribing of thyroid hormones
- Lean body mass calculator
- PK Cookbook PK Bread Recipe - NEW IMPROVED!
- YouTube Link - A Quick Method For Making Delicious Paleo-ketogenic Bread - NEW RECIPE
- Amazon.co.uk link for FREESTYLE OPTIUM NEO GLUCOSE AND KETONE METER
- My online shop link for multistix
- Ketonix website
- Charlie Foundation
- Matthew's Friends
- Ketogenic Diet Resource Online version - short
- Spiralite Vegetable Spiraliser
- A patient of mine has found these 60 Amazing Fat Bomb Recipes very useful.
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