A KID-FRIENDLY ANTICANCER APPROACH TO KETO by Justin and AudrA Wilford
Our suggestions below come from our own experience as parents of brain tumor survivor. After our son’s brain tumor recurred in 2013, we worked with our oncologist at Children’s Hospital of Orange County to put our 6-year-old son a ketogenic diet while also pursuing standard of care treatment. We worked with several dietitians and talked with researchers examining ketogenic diets as well. His tumor responded remarkably well to the combination of radiation and long-term nutritional ketosis. We learned a great deal from our first day on the diet through over three years of verified nutritional ketosis. What follows are a few of these lessons. They are not to be taken as medical advice, but only as a statement of what we learned from doctors, researchers, dietitians, and our own sweat and tears…
A ketogenic diet, not THE ketogenic diet
There is no single ketogenic diet. There are ways of eating that put the body into nutritional ketosis, defined as a blood measurement of ketones (beta-hydroxybutyrate or BHB) over 1 mmol/l. For the purposes of suppressing cancer growth, some say ketosis should be much higher, say over 2.5 or 3 mmol/l. Unfortunately, there’s not a lot of science to guide the way here. In any case, for us, at the beginning we wanted to be over 3.0, and we found that we could do this through a version less restrictive than the traditional epilepsy 4:1 ketogenic diet. So, the first lesson in cooking with keto is that measuring is important, but the 4:1 diet is not necessary in the cancer context.
Cancer is different than epilepsy
We were originally referred to an epilepsy dietitian to help us manage the diet and watch Max’s labs for things like metabolic acidosis. We quickly learned that a big difference is that in the context of cancer, there is no sign that you’re doing it right or wrong except through taking daily blood measures (we used a Precision Xtra glucose/ketone monitor). Parents of kids with epilepsy can see immediately if too many carbs have been added to the diet because seizure activity increases. For us cancer parents, we have to stick to the blood measures or we’re shooting in the dark.
Get into a routine
Many therapeutic KDs are based on a specific ratio of calories consumed, e.g., 80% of calories from fat, 10% from protein, 10% from carbs. There are less restrictive versions (like the “Modified Atkins Diet”) that restricts carbs but allow for liberty with protein and fat. To achieve nutritional ketosis, it’s important to keep protein moderate because protein can increase insulin and can be converted into glucose when consumed above a moderate amount. So our rule of thumb was to keep carbohydrate intake to around 20 grams per day and protein around 1.5 grams per kg of body weight. Fat could always be eaten to satiety (fullness). We know that many parents can easily adjust these ratios with their dietitian.
With these levels in mind (20 grams of carbs, 75 grams of protein (for a 50 lb boy), and fat to satiety), we were able to get into a daily routine by developing a template of what his meals should look like: a non-starchy vegetable, animal protein, and a fatty sauce. This basic template could be tinkered with if his ketones were a bit low, or he had a lot of physical activity (and therefore could have a bit more veggie and protein).
Stay as whole-foods as possible
KetoCal is a shake that most hospitals use to induce and sometimes maintain ketosis. While some kids might need to start on KetoCal, the KD can be maintained through the use of whole foods. Because fats are such an important part of the KD, it is crucial to consume high-quality fats: olive, avocado, and coconut oil, grass-fed butter and heavy cream. We also payed close attention to quality, amount, and timing of protein. We aimed for unprocessed, whole animal protein, but didn’t completely remove processed meats like deli meat and sausage; we just aimed to limit these. We also tried as much as possible to purchase grass-fed meat and pasture-raised chicken and eggs, but this proved to be very expensive. We think the science suggests that these animal proteins sources are the best but that the most important factor is aiming for whole, unprocessed animal protein.
Stock up on the staples of a healthy KD
Our refrigerator and pantry looked very different after getting into the KD routine. Our pantry emptied out and our fridge filled up. The key for us was to get into a new grocery routine: find the stores that have what we want, plan to visit them once a week, and stock up.
Butter, from grass-fed, pasture-raised animals (Organic Valley brand is the best, followed by Kerrygold)
Heavy Cream (if possible from grass-fed, pasture-raised animals)
Coconut Oil (virgin, cold-pressed)
MCT (Medium-Chain Triglyceride Oil, derived from coconut and palm oil)
Avoid all seed oils (corn oil, sunflower oil, canola oil, etc.) if possible. They are pro-inflammatory.
Eggs (organic, omega-3)
Meat from organic, grass-fed, pasture-raised animals (don’t trim the fat)
Hot dogs from grass-fed, pasture-raised animals (Applegate brand)
Cheese from grass-fed, pasture-raised animals (look for highest fat-to-protein ratio)
Fatty fresh fish like Wild Salmon
Organic bacon (Applegate Brand)
Organic chicken (always served with fat-based sauce like hollandaise, bearnaise, cream
Veggies. We’ve only listed ones that most kids will eat. They should all be served in fat, either olive oil dressing, melted butter, or a cheese sauce (mixed with coconut oil or MCT oil). Be sure to include salt to taste:
Any type of leafy green (a whole head of green leaf lettuce only has 10 g of carbs)
Broccoli (1/2 cup cooked = 6 g of carbs/3g of fiber)
Cauliflower (1/2 cup cooked = 6 g of carbs/3g of fiber)
Asparagus (1/2 cup cooked = 4 g of carbs/2g of fiber)
Green beans (1 cup cooked = 10 g of carbs/4g of fiber)
Cucumber (1 whole = 4 g of carbs/1 g of fiber)
Carrots (8 baby carrots = 7 g of carbs/2 g of fiber)
Fruit. Most fruit and ALL juices are off the list. It is best to space out fruit consumption as well so that all 20 grams of allowed carbs don’t come at one sitting. Below are some good low-glycemic choices.
Berries (1 cup of halved strawberries = 12g of carbs/3 g of fiber)
Cherries (4 cherries = 4g of carbs/1g of fiber)
Apple slices (1 cup = 15g of carbs/3g of fiber)
It’s not just about the diet
We found that Max’s ketone and glucose numbers would vary depending on several other factors beside diet. If his sleep was majorly disrupted, his numbers would be off. If he had a huge day of physical activity, his numbers would be great. If he was stressed out (because he didn’t want his finger poked or was fighting with his sister), his numbers would be off. This led us to think about all the ways we can work on optimal health. It’s not just diet! Luckily we had begun work with our medical advisory board on the BE SUPER Action Plan and so had some ideas of where to start.
It’s all in the numbers
The great thing about the KD is that at the end of the day what matters is your child’s glucose and ketone numbers. This takes a lot of the guesswork out of the diet. Some kids (and adults) will be able to consume a little more carbs and protein and produce good numbers, while others will have to work a bit harder. Find the balance that’s right for you and your child. Don’t be afraid to experiment. We advise that you work with your keto coach on developing your targets and monitoring your glucose and ketone numbers.
Our Favorite Cooking Keto Resources
For all things evidence-based keto, Dr. Dominic D’Agostino’s website KetoNutrition.org also includes a food list.
For fantastic articles, how-to guides, getting started support, keto food lists and meal plans: DietDoctor.com
Maria Emmerich’s fabulous blog, filled with great kid-friendly recipes and tips: Keto Adapted by Maria Emmerich
One of our favorite recipe resources: All Day I Dream About Food
Need an app? This is it! Keto Diet App
The Charlie Foundation’s recipe resource
Keto Comfort Foods by Maria Emmerich
Quick & Easy Ketogenic Cooking by Maria Emmerich
Keto Instant Pot by Maria Emmerich
Easy Dairy-Free Ketogenic Recipes by Maria Emmerich
The Keto Reset Diet Cookbook by Mark Sisson
The Beginner’s KetoDiet Cookbook by Martina Slajerova