A study with an intent-to-treat prospective design was published in 1998 by a team from the Johns Hopkins Hospital[20] and followed-up by a report published in 2001.[21] As with most studies of the ketogenic diet, no control group (patients who did not receive the treatment) was used. The study enrolled 150 children. After three months, 83% of them were still on the diet, 26% had experienced a good reduction in seizures, 31% had had an excellent reduction, and 3% were seizure-free.[Note 7] At 12 months, 55% were still on the diet, 23% had a good response, 20% had an excellent response, and 7% were seizure-free. Those who had discontinued the diet by this stage did so because it was ineffective, too restrictive, or due to illness, and most of those who remained were benefiting from it. The percentage of those still on the diet at two, three, and four years was 39%, 20%, and 12%, respectively. During this period, the most common reason for discontinuing the diet was because the children had become seizure-free or significantly better. At four years, 16% of the original 150 children had a good reduction in seizure frequency, 14% had an excellent reduction, and 13% were seizure-free, though these figures include many who were no longer on the diet. Those remaining on the diet after this duration were typically not seizure-free, but had had an excellent response.[21][22]

A Cochrane systematic review in 2018 found and analysed eleven randomized controlled trials of ketogenic diet in people with epilepsy for whom drugs failed to control their seizures.[2] Six of the trials compared a group assigned to a ketogenic diet with a group not assigned to one. The other trials compared types of diets or ways of introducing them to make them more tolerable.[2] In the largest trial of the ketogenic diet with a non-diet control[16], nearly 38% of the children and young people had half or fewer seizures with the diet compared 6% with the group not assigned to the diet. Two large trials of the Modified Atkins Diet compared to a non-diet control had similar results, with over 50% of children having half or fewer seizures with the diet compared to around 10% in the control group.[2]

These chewy cookies take the same amount of prep and ingredients compared to dirty keto cookies — and the results are packed with nutrients and rich flavor. With a dough made out of almond meal, gut-loving collagen protein, cocoa powder, and melty chunks of dark chocolate, this recipe bakes up into a sinful-tasting dessert with benefits. Just 2.5 net carbs per cookie.
Wow Gloria, you really do love this – way to to go! We just need to work on portion control now 😉 The recipe states serves 6. All that info is right at the top of each recipe. Don’t worry, many scroll past it eagerly wanting to get to the recipe itself. It is the beginning of summer there, but I will continue to make this throughout summer as my youngest absolutely loves it.

Thanks for this article. I just started a Keto diet so found it appropriate to my current lifestyle. Though I don’t believe your bottom line is strong enough since you simply stating that the diet is “hard to follow” and food is “notoriously unhealthy” without evidence going deeper into why those “notoriously unhealthy” foods are worse than keeping carbohydrate-heavy food that are addictive and give the body a quick sugar high for energy. I believe “hard to follow” is your opinion only, since acceptable Keto foods are found at all restaurants easily and also all grocery stores. All the foods you mention: “rich in very colorful fruits and vegetables, lean meats, fish, whole grains, nuts, seeds, olive oil, and lots of water” are all Keto-friendly. Many people have been on a Keto-diet for years. A healthy lifestyle is a healthy mindset change and making right choices – it’s not going to be easy.


The low glycaemic index treatment (LGIT)[49] is an attempt to achieve the stable blood glucose levels seen in children on the classic ketogenic diet while using a much less restrictive regimen. The hypothesis is that stable blood glucose may be one of the mechanisms of action involved in the ketogenic diet,[9] which occurs because the absorption of the limited carbohydrates is slowed by the high fat content.[5] Although it is also a high-fat diet (with approximately 60% calories from fat),[5] the LGIT allows more carbohydrate than either the classic ketogenic diet or the modified Atkins diet, approximately 40–60 g per day.[18] However, the types of carbohydrates consumed are restricted to those that have a glycaemic index lower than 50. Like the modified Atkins diet, the LGIT is initiated and maintained at outpatient clinics and does not require precise weighing of food or intensive dietitian support. Both are offered at most centres that run ketogenic diet programmes, and in some centres they are often the primary dietary therapy for adolescents.[9]

Before starting, ask yourself what is really realistic for you, Mattinson suggests. Then get your doctor’s okay. You may also work with a local registered dietitian nutritionist to limit potential nutrient deficiencies and talk about vitamin supplementation, as you won’t be eating whole grains, dairy, or fruit, and will eliminate many veggies. “A diet that eliminates entire food groups is a red flag to me. This isn’t something to take lightly or dive into headfirst with no medical supervision,” she says.


Because the ketogenic diet alters the body's metabolism, it is a first-line therapy in children with certain congenital metabolic diseases such as pyruvate dehydrogenase (E1) deficiency and glucose transporter 1 deficiency syndrome,[35] which prevent the body from using carbohydrates as fuel, leading to a dependency on ketone bodies. The ketogenic diet is beneficial in treating the seizures and some other symptoms in these diseases and is an absolute indication.[36] However, it is absolutely contraindicated in the treatment of other diseases such as pyruvate carboxylase deficiency, porphyria, and other rare genetic disorders of fat metabolism.[9] Persons with a disorder of fatty acid oxidation are unable to metabolise fatty acids, which replace carbohydrates as the major energy source on the diet. On the ketogenic diet, their bodies would consume their own protein stores for fuel, leading to ketoacidosis, and eventually coma and death.[37]
Early studies reported high success rates; in one study in 1925, 60% of patients became seizure-free, and another 35% of patients had a 50% reduction in seizure frequency. These studies generally examined a cohort of patients recently treated by the physician (a retrospective study) and selected patients who had successfully maintained the dietary restrictions. However, these studies are difficult to compare to modern trials. One reason is that these older trials suffered from selection bias, as they excluded patients who were unable to start or maintain the diet and thereby selected from patients who would generate better results. In an attempt to control for this bias, modern study design prefers a prospective cohort (the patients in the study are chosen before therapy begins) in which the results are presented for all patients regardless of whether they started or completed the treatment (known as intent-to-treat analysis).[19]

Wondering what fits into a keto diet — and what doesn’t? “It’s so important to know what foods you’ll be eating before you start, and how to incorporate more fats into your diet,” says Kristen Mancinelli, RD, author of The Ketogenic Diet: A Scientifically Proven Approach to Fast, Healthy Weight Loss, who is based in New York City. We asked her for some guidelines.

Another difference between older and newer studies is that the type of patients treated with the ketogenic diet has changed over time. When first developed and used, the ketogenic diet was not a treatment of last resort; in contrast, the children in modern studies have already tried and failed a number of anticonvulsant drugs, so may be assumed to have more difficult-to-treat epilepsy. Early and modern studies also differ because the treatment protocol has changed. In older protocols, the diet was initiated with a prolonged fast, designed to lose 5–10% body weight, and heavily restricted the calorie intake. Concerns over child health and growth led to a relaxation of the diet's restrictions.[19] Fluid restriction was once a feature of the diet, but this led to increased risk of constipation and kidney stones, and is no longer considered beneficial.[18]


Potatoes and gravy are total comfort food — and luckily, there’s a keto version. These are made with cauliflower, which is quite low-carb, particularly when compared to potatoes. Made with cream, butter, rosemary and parmesan, this mash is creamy, full of flavor and smooth. You’ll finish it all off with a stock-based gravy, that would be perfect on a roast, too.
About 20% of children on the ketogenic diet achieve freedom from seizures, and many are able to reduce the use of anticonvulsant drugs or eliminate them altogether.[18] Commonly, at around two years on the diet, or after six months of being seizure-free, the diet may be gradually discontinued over two or three months. This is done by lowering the ketogenic ratio until urinary ketosis is no longer detected, and then lifting all calorie restrictions.[46] This timing and method of discontinuation mimics that of anticonvulsant drug therapy in children, where the child has become seizure-free. When the diet is required to treat certain metabolic diseases, the duration will be longer. The total diet duration is up to the treating ketogenic diet team and parents; durations up to 12 years have been studied and found beneficial.[9]

If you’re wondering about the difference between ketosis and diabetic ketoacidosis, you’re not alone. “The word ketone is scary for most people with type 1 diabetes because they relate ketones to diabetic ketoacidosis,” says Patti Urbanski, MEd, RD, CDE, a certified diabetes educator with St. Luke’s Hospital in Duluth, Minnesota. “But with the ketogenic diet, we’re talking about a much lower level of ketones.”
The brain is composed of a network of neurons that transmit signals by propagating nerve impulses. The propagation of this impulse from one neuron to another is typically controlled by neurotransmitters, though there are also electrical pathways between some neurons. Neurotransmitters can inhibit impulse firing (primarily done by γ-aminobutyric acid, or GABA) or they can excite the neuron into firing (primarily done by glutamate). A neuron that releases inhibitory neurotransmitters from its terminals is called an inhibitory neuron, while one that releases excitatory neurotransmitters is an excitatory neuron. When the normal balance between inhibition and excitation is significantly disrupted in all or part of the brain, a seizure can occur. The GABA system is an important target for anticonvulsant drugs, since seizures may be discouraged by increasing GABA synthesis, decreasing its breakdown, or enhancing its effect on neurons.[7]

No human population has ever lived in a permanent state of ketosis. Ketogenic diets are dangerous for pregnant women and developing fetuses, and the only human population that has ever subsisted on this dietary pattern advocated by keto diet proponents could only do so because of a genetic mutation that prevents them from going into ketosis. Unfortunately, it has the unintended but unavoidable consequence of reducing the survival prospects of their infants.
Hi, I'm Amanda. I’ve been cooking primal keto and lactopaleo recipes for over a decade, and have developed recipes for top nutrition coaches and ketogenic meal subscription boxes. I'm the author of Keto Life (a guide) and the best-selling Wicked Good Ketogenic Diet Cookbook (a cookbook). Ever heard the phrase,"never trust a skinny chef"? Well, consider me super trustworthy. I will probably never be "skinny," and that’s OK because I’m not here to teach you how to lose weight, my goal is to provide you with awesome recipes. I absolutely adore the ketogenic lifestyle, and it has helped me overcome a number of health issues. I hope my recipes help you do the same, while eatin’ good!

Advocates for the diet recommend that it be seriously considered after two medications have failed, as the chance of other drugs succeeding is only 10%.[9][31][32] The diet can be considered earlier for some epilepsy and genetic syndromes where it has shown particular usefulness. These include Dravet syndrome, infantile spasms, myoclonic-astatic epilepsy, and tuberous sclerosis complex.[9][33]
The past 4 years I was suffering from mild to severe pain all over my body and unrelenting fatigue, sleep disturbances, brain fog, etc. Diagnosed with Sjogren’s Syndrome and Fibromyalgia. Medication included Vicodin, Morphine and a muscle relaxer. I would not take Plaquenall (spelling?), Lyrica or other “biologics”. I was taking a bunch of supplements but nothing was improving.  

There are many ways in which epilepsy occurs. Examples of pathological physiology include: unusual excitatory connections within the neuronal network of the brain; abnormal neuron structure leading to altered current flow; decreased inhibitory neurotransmitter synthesis; ineffective receptors for inhibitory neurotransmitters; insufficient breakdown of excitatory neurotransmitters leading to excess; immature synapse development; and impaired function of ionic channels.[7]


Conklin's fasting therapy was adopted by neurologists in mainstream practice. In 1916, a Dr McMurray wrote to the New York Medical Journal claiming to have successfully treated epilepsy patients with a fast, followed by a starch- and sugar-free diet, since 1912. In 1921, prominent endocrinologist Henry Rawle Geyelin reported his experiences to the American Medical Association convention. He had seen Conklin's success first-hand and had attempted to reproduce the results in 36 of his own patients. He achieved similar results despite only having studied the patients for a short time. Further studies in the 1920s indicated that seizures generally returned after the fast. Charles P. Howland, the parent of one of Conklin's successful patients and a wealthy New York corporate lawyer, gave his brother John Elias Howland a gift of $5,000 to study "the ketosis of starvation". As professor of paediatrics at Johns Hopkins Hospital, John E. Howland used the money to fund research undertaken by neurologist Stanley Cobb and his assistant William G. Lennox.[10]
Even in endurance sports that don’t require sprinting, ketogenic-style diets are disadvantageous according to a ketogenic diet and exercise article published in Sports Medicine[5]: “a high-fat, low-carbohydrate ketogenic diet may impair exercise performance via reducing the capacity to utilize carbohydrates, which forms a key fuel source for skeletal muscle during intense endurance-type exercise.” The article concluded, “At present there are no data available to suggest that ingestion of ketone bodies during exercise improves athletes’ performance under conditions where evidence-based nutritional strategies are applied appropriately.”

Here’s the real kicker: the reason why the Inuit don’t go into ketosis as readily as other ethnic groups is the high prevalence of a deleterious mutation in the CPT1A gene.[14] This mutation permitted adaptation to a high fat, low carbohydrate diet in the sense that those carrying the gene could survive to reproductive age while eating a diet entirely at odds with our evolutionary history. However this gene is associated with high infant mortality rates due to hypoketotic hypoglycemia: when Inuit babies’ blood glucose levels drop, they are unable to utilize ketone bodies to sustain their brains. The very mutation that permits adult survival in extreme circumstances compromises infant health – a powerful example of the trade-offs inherent to evolution. Humans can indeed adapt to an extreme environment and an extreme diet, but that adaptation comes at a high cost.

For many people, one of the more surprising side effects of starting a ketogenic diet is a bout with the “keto flu.” How so? “When you go on this diet, your kidneys don’t retain as much salt or water, which can lead to flu-like symptoms, such as fatigue and headache, or constipation,” says Laura Saslow, PhD, an assistant professor at the University of Michigan School of Nursing. “But these are typically short-lived symptoms that can be prevented or treated by increasing your salt and water intake.” However, if you have high blood pressure, speak with your doctor before adding more sodium to your diet. And know that the keto flu only lasts a week or two; symptoms typically subside once the body adjusts to the diet.
The ketogenic diet is a high-fat, adequate-protein, low-carbohydrate diet that in medicine is used primarily to treat difficult-to-control (refractory) epilepsy in children. The diet forces the body to burn fats rather than carbohydrates. Normally, the carbohydrates contained in food are converted into glucose, which is then transported around the body and is particularly important in fueling brain function. However, if little carbohydrate remains in the diet, the liver converts fat into fatty acids and ketone bodies. The ketone bodies pass into the brain and replace glucose as an energy source. An elevated level of ketone bodies in the blood, a state known as ketosis, leads to a reduction in the frequency of epileptic seizures.[1] Around half of children and young people with epilepsy who have tried some form of this diet saw the number of seizures drop by at least half, and the effect persists even after discontinuing the diet.[2] Some evidence indicates that adults with epilepsy may benefit from the diet, and that a less strict regimen, such as a modified Atkins diet, is similarly effective.[1] Potential side effects may include constipation, high cholesterol, growth slowing, acidosis, and kidney stones.[3]
Difficulty. Many experts question how long a person can realistically give up carbs. “This is a very restrictive diet that requires a drastic change in eating behaviors and even taste,” says Sandra Arevalo, MPH, RDN, CDE, a certified diabetes educator and spokesperson for the Academy of Nutrition and Dietetics. “It isn’t very practical or easy to maintain, for people both with and without diabetes.” That’s not saying you can’t stick with it, but before you commit, make a plan and set measurable goals to help you stay on track. Being prepared with the right foods can also help. Urbanski recommends making a shopping list that focuses on a few basic keto-friendly meals and snacks, so you’ll always have the right foods on hand to ensure success.
Even low carb chips can contain inflammatory yeast or protein powders from grain-fed cows. This keto recipe gives you the same crunch and zesty flavor of cheesy store-bought chips without the harmful ingredients. Simply fry thin slices of zucchini then toss with spices for the perfect crunchy snack. Fry in heat-safe grass-fed ghee or beef tallow to make this recipe more Bulletproof.
The final one is the area that I and many others who have pursued a state of ketosis fall into. At this point in my life, I have no chronic diseases, I feel great 99% of the time, but I am always looking to improve my productivity and performance. I have found being in mild-ketosis to be one of the best ways to improve my energy, mental acuity, creativity, physical strength and overall life performance.
This was a great read. I aim to restrict carbs always because I believe most are why the American population is obese. I would very much like to hear more about carb restriction excluding the discussion on processed meats and processed high salt content foods because I consume neither. I also don’t consume dairy or eggs. So can you provide some substance.
For both keto and Bulletproof diets, opt for full-fat, grass-fed, raw, and organic dairy to reap the anti-inflammatory benefits of omega-3s and CLA. Dairy is a great source of fat on a ketogenic diet, but be mindful not over-do the protein. Although milk (yep, even raw, full-fat, or goat milk) is too high in lactose sugars, you can stay in ketosis with foods like butter, ghee, and colostrum. Avoid sweetened or low-fat dairy, evaporated or condensed milk, and buttermilk to keep your fat intake high.
Even after irradiation (the industry standard sterilization process that also destroys any antioxidants and health benefits), spices and herbs can spoil in your home, and often harbor aggressive mold toxins. To spice up your dishes the Bulletproof way, use high-quality, fresh or recently opened herbs and spices. Spices with especially high mold toxin risk include black pepper, powdered garlic, nutmeg, and paprika. Apple cider vinegar is the only vinegar permitted in the Bulletproof diet, as other vinegars and yeasts introduce toxins, and promote yeast growth in your gut.
Like weeknight dinners. It goes without saying that weeknight dinners should be the easiest of them all because you have neither the time nor the inclination to spend a bunch of time in the kitchen. But you still need to eat! That’s why I’ve done the work for you. These are the best and easiest low carb dinner recipes you could hope for. You’re welcome!
Our bodies are incredibly adaptive to what you put into it – when you overload it with fats and take away carbohydrates, it will begin to burn ketones as the primary energy source. Optimal ketone levels offer many health, weight loss, physical and mental performance benefits.1There are scientifically-backed studies that show the advantage of a low-carb, ketogenic diet over a low-fat diet. One meta-analysis of low-carbohydrate diets showed a large advantage in weight loss. The New England Journal of Medicine study resulted in almost double the weight loss in a long-term study on ketone inducing diets.
Fuels and feeds your brain: Ketones provide an immediate hit of energy for your brain, and up to 70% of your brain’s energy needs when you limit carbs.[6] Fat also feeds your brain and keeps it strong. Your brain is at least 60% fat, so it needs loads of good fats to keep it running.[7] Essential fatty acids such as omega-3s help grow and develop the brain, while saturated fat keeps myelin — the layer of insulation around the brain — strong so your neurons can communicate with each other.
^ Jump up to: a b c d e f g h i j k l m n o p q r s Kossoff EH, Zupec-Kania BA, Amark PE, Ballaban-Gil KR, Bergqvist AG, Blackford R, et al. Optimal clinical management of children receiving the ketogenic diet: recommendations of the International Ketogenic Diet Study Group. Epilepsia. 2009 Feb;50(2):304–17. doi:10.1111/j.1528-1167.2008.01765.x. PMID 18823325
The keto diet changes the way your body converts food into energy. Eating a lot of fat and very few carbs puts you in ketosis, a metabolic state where your body burns fat instead of carbs for fuel. When your body is unable to get glucose from carbs, your liver converts fatty acids from your diet into ketones, an alternative source of energy. Burning ketones in place of glucose reduces inflammation and spurs weight loss.[1]
Ketoacidosis, on the other hand, is dangerous. But it’s usually limited to people with type 1 diabetes, striking when their glucose levels rise due to illness or a missed insulin dose. Without insulin, cells can’t take in glucose, so they burn fat for fuel instead, producing exceptionally high ketone levels—much higher than the amount generated by the keto diet. That, in combination with high blood glucose levels, essentially poisons the blood. “It’s very easy to tell the difference between nutritional ketosis, which has no negative symptoms [aside from ‘keto breath,’ which can smell like nail polish remover], and dietary ketoacidosis, which is an illness that requires hospitalization and causes lethargy, abdominal pain, nausea, vomiting, rapid breathing, and lack of appetite,” says William Yancy, MD, program director at the Duke Diet and Fitness Center in Durham, North Carolina.

One downside to a ketogenic diet for weight loss is the difficulty maintaining it. “Studies show that weight loss results from being on a low-carb diet for more than 12 months tend to be the same as being on a normal, healthy diet,” says Mattinson. While you may be eating more satiating fats (like peanut butter, regular butter, or avocado), you’re also way more limited in what’s allowed on the diet, which can make everyday situations, like eating dinner with family or going out with friends, far more difficult. Because people often find it tough to sustain, it’s easy to rely on it as a short-term diet rather than a long-term lifestyle.
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