The nutritional adequacy of the ketogenic diet in paediatric epilepsy: Detailed nutrient analysis and dietary recommendations

Affiliations

¹ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Nutrition and Dietetics Department, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, NSW, Australia. Electronic address: erica.tsang@health.nsw.gov.au.
² TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia.
³ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia.
⁴ TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.
⁵ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.
⁶ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; The Brain and Mind Centre, The University of Sydney, NSW, Australia.
⁷ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; The Brain and Mind Centre, The University of Sydney, NSW, Australia.

PMID: 40669820
DOI: 10.1016/j.clnesp.2025.07.023

Free article

Comparative Study

The nutritional adequacy of the ketogenic diet in paediatric epilepsy: Detailed nutrient analysis and dietary recommendations

Erica Tsang et al. Clin Nutr ESPEN. 2025 Oct.

Free article

. 2025 Oct:69:274-285.

doi: 10.1016/j.clnesp.2025.07.023. Epub 2025 Jul 14.

Authors

Affiliations

¹ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Nutrition and Dietetics Department, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, NSW, Australia. Electronic address: erica.tsang@health.nsw.gov.au.
² TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia.
³ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia.
⁴ TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.
⁵ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.
⁶ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; The Brain and Mind Centre, The University of Sydney, NSW, Australia.
⁷ Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, NSW Australia; The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; The Brain and Mind Centre, The University of Sydney, NSW, Australia.

PMID: 40669820
DOI: 10.1016/j.clnesp.2025.07.023

Abstract

Background and aims: Much of the focus of ketogenic diet (KD) literature has been on the macronutrient profile, as the appropriate distribution of carbohydrate, fat and protein is essential to inducing ketosis. Few studies have evaluated the micronutrient adequacy of the KD in paediatric epilepsy, despite the importance of adequate vitamin and mineral intake in growth and development. Our study evaluated the nutritional adequacy of the Modified Atkins Diet (MAD) and Classical Ketogenic Diet (CKD) in children with epilepsy, relative to baseline diets and Nutrient Reference Values (NRVs).

Methods: Twenty children with epilepsy on the MAD and CKD underwent dietary analysis of 28 key nutrients at baseline and 3 months on diet ( ± multivitamin). Nutrient intake was expressed as % relative to recommended daily intake (RDI), adequate intake (AI), and upper limit as per the Australian NRVs. Nonparametric statistical comparisons were performed with a significance of p < 0.05.

Results: Sixty percent of children were KD 'responders,' exhibiting >50 % seizure reduction with median beta-hydroxybutyrate (blood ketone) level of 2.75 mmol/L on MAD and 4.25 mmol/L on CKD. Despite restriction of fruits, vegetables, dairy and wholegrains, children on MAD (without multivitamin) met 100 % of RDI for all nutrients except potassium. Intake of fibre and polyunsaturated fat increased significantly on the MAD compared to baseline. With multivitamin supplementation, some children on MAD were close to meeting upper limits for vitamin A, zinc, and selenium. Dietary recommendations to optimise nutritional adequacy using a 'food-first' ketogenic approach are provided.

Conclusions: Although it is commonly reported that the restrictive nature of the KD induces nutritional deficiencies, our findings indicate that a well-designed MAD can induce positive dietary changes including increased fibre intake, increased mono- and polyunsaturated fat intake, and increased omega-3 essential fatty acid intake in children with epilepsy, whilst producing adequate ketosis.

Keywords: Micronutrient; Neurology; Nutrient reference value.

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Conflict of interest statement

Declaration of competing interest The authors report no competing interests.

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The nutritional adequacy of the ketogenic diet in paediatric epilepsy: Detailed nutrient analysis and dietary recommendations

Affiliations

The nutritional adequacy of the ketogenic diet in paediatric epilepsy: Detailed nutrient analysis and dietary recommendations

Authors

Affiliations

Abstract

Conflict of interest statement

Publication types

MeSH terms

Substances

LinkOut - more resources

Full Text Sources

Miscellaneous