## Sample Diet Calculation Traditional Cream Based Diet

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April is a 6-year-old girl. She weighs 21 kg (SO to 75 percentile weight for age) and is 1 10 em tall (10 to 25 percentile height for age). Her weight for height is 90 to 95 percentile. She is on the following medications: Tegretol 700 mg/day and Celontin 600 mg/day.

1. Energy needs. Caloric needs for patients on the ketogenic diet are lower than the Recommended Daily Allowance (RDA). (Table 30-4). If the child is overweight, energy needs are based on ideal weight for height. For example:

April is overweight. Her ideal weight would be 18.25 kg. Calorie amount = 18.25 kg x 65 kcal/kg = 1186 kcal/day.

2. Ketogenic ratio. Most children are started on a 4:1 ketogenic ratio. Very young (< IS months) or overweight children may be started on a 3:1 or 3.5:1 ratio of fat to protein and carbohydrates. Use a 3:1 ratio for children > 12 years old. (eg. April is overweight; therefore, she will start with a 3:1 ratio.)

3. Dietary Units. Dietary units are the building blocks of the ketogenic diet. One dietary unit reflects the amount of calories in one block of the ratio, as follows:

Ratio Fat

CHO+PRO kcal/Dietary Unit

1 g x 4 kcal/g = 1 g x 4 kcal/g = 1 g < 4 kcal/g = 1 g x 4 kcal/g =

Table 30-3. Possible Complications of the Ketogenic Diet

Complication Therapy

Short-term Dehydration

Hypoglycemia

Vomiting

Diarrhea

Food refusal

Long-term

Kidney stones Metabolic acidosis Hyperuricemia Lethargy Refusal to eat

Malnutrition

### Carnitine deficiency

Increase fluid. If already at maximum fluid allotment, increase by 5-10% Assure that meals are fully completed. May need to decrease the ratio (eg. change from a 4:1 ratio to a 3:1 ratio) Maintain the ketogenic diet as tolerated. Monitor fluid to prevent dehydration. May require dextrose-free IV fluid Monitor fluid intake to prevent dehydration. Increase fiber intake (either by increasing use of vegetables or with calculated amounts of bran fiber)

Adjust meals to decrease portion size. May use a lower ketogenic ratio temporarily to help make meals more appealing (a lowered ratio will increase the portion size of solids and decrease the amount of added fat)

Increase fluid intake

Increase fluid intake. May need to decrease the ketogenic ratio Increase fluid intake

Assure that kcal level and ratio are appropriate (See food refusal, above). May need to discontinue diet if prolonged Monitor weight weekly during the first month on the diet. Weight loss should not exceed 1 lb per week, and is not encouraged for patients younger than 2 years. Monitor serum albumin every 3-4 months; may need to increase the protein allotment or calories Monitor blood carnitine profiles; may need supplementation

For example. April will have a 3:1 ratio, so each dietary unit will he made up of 31 keal.

4 Dietary unit quantity per day. Divide the total daily calories by the number of calories per dietary unit. For example:

= dietary units/da\

31 kcal/dietary unit

5 Fat allowance. Multiply the number of dietary units by the units of fat in the prescribed ketogenic ratio to determine the grams of fat permitted daily. For example:

6. Protein-carbohydrate allowance. Multiply the number of dietary units by the number of units of protein plus carbohydrate, in the prescribed ketogenic ratio. For example:

38 units x 1 £ CHO+PR()/ilietar> unit = 38 g C'HO + PRO I »here C'HO = carbohydrate: PRO = protein I

7. Protein Allowance. Determine the protein allowance, using Table 30- 5. Base the calculation on ideal weight

Table 30-4. Energy Intake Goals for the Ketogenic Diet kcal Age (years) Ketogenic kcal

Table 30-4. Energy Intake Goals for the Ketogenic Diet kcal Age (years) Ketogenic kcal

 < 1 80 kcal/kg 1 — 1 75 kcal/kg