Elimination of Gradual Calorie Advancement in Initiation of the Ketogenic Diet (P03.008)

OBJECTIVE: To determine whether initiation of the ketogenic diet at full calories reduces hypoglycemia. BACKGROUND: Inpatient initiation of the ketogenic diet has historically involved gradual advancement of calories and/or diet ratio. Hypoglycemia during this initiation period is common. We sought to determine if initiation of the diet at goal calories would reduce the incidence of hypoglycemia when compared to gradual advancement of calories. DESIGN/METHODS: Fifty four patients were admitted to a tertiary care hospital for elective initiation of the ketogenic diet between 7/7/08 and 9/17/12. All patients were placed on a ketogenic diet initiation pathway. In September 2010, the pathway was modified from a gradual caloric advancement to initiation at goal calories. We selected 27 consecutive patients before and after the change for comparison. Each case was reviewed for incidence of hypoglycemia, number of days to reach full ketosis (defined as 4+ urine ketones), acidosis requiring commencement of sodium citrate, and length of admission. Hypoglycemia was defined as blood glucose (BG) RESULTS: In the group with gradual advancement of calories (n=27), there were seven instances of hypoglycemia in five patients. Eight patients were started on sodium citrate. Length of admission averaged 4.5 days, and 23 patients reached full ketosis, in an average of 2.3 days, by discharge. In the group started at full caloric ratio (n=27), there were six instances of hypoglycemia in four patients. Nineteen patients were started on sodium citrate. Length of admission averaged 4.8 days, and 22 patients reached full ketosis, in an average of 2.9 days, by discharge. CONCLUSIONS: The elimination of gradual advancement of calories does not significantly impact length of admission and/or days to reach ketosis. It may decrease the incidence of hypoglycemia, but likely increases acidosis. Disclosure: Dr. Bansal has nothing to disclose. Dr. Cramp has nothing to disclose. Dr. Kao has received personal compensation in an editorial capacity for serving as chief editor, child neurology articles at Medscape/emedicine. Dr. Carpenter has nothing to disclose.