Modified Atkins: The Ketogenic Diet for Adults with Epilepsy

What is the modified Atkins diet?

The modified Atkins diet (often abbreviated in the literature as “MAD”) is a change to the traditional “classic” ketogenic diet to make it less restrictive. Along with the MCT (medium chain triglyceride) diet and LGIT (low glycemic index treatment), it is one of three “alternative diets” used to treat patients with epilepsy.

Its history goes back to the early 2000s.  Some families who had used the ketogenic diet for many years eventually stopped weighing and measuring foods. They had noticed that ketones still remained high and seizures stayed under control. It was first formally studied in children and adults who had never tried the ketogenic diet at Johns Hopkins Hospital in 2002. This diet is now over 14 years old with greater than 500 patients published to date.  Studies show it is very similar to the classic ketogenic diet in efficacy.


The modified Atkins diet allows for the unlimited intake of fats and proteins. Allowed breakfast foods include high-fat meats such as bacon, sausage, and ham, along with eggs and cheese. You can add small amounts of low-carb vegetables to eggs for omelets. Low-carb breads may be allowed in small amounts, keeping total carbohydrate intake within prescribed levels. You can use butter liberally. Pancakes can be made from soy or almond flour, which are not made from grains. But stay away from fruit juice as it has large amounts of carbohydrates.

Lunch and Dinner

Eat as much as you’d like of meats, regardless of fat, for lunch and dinner. Mix tuna or chicken salad with mayonnaise, a high-fat, low-carb food. Add low-carb vegetables such as broccoli, cauliflower, onions, spinach, cabbage, string beans, spaghetti squash, and Brussels sprouts. Limit fruits to the allowed carbohydrate count, meaning very little fruit. An average apple, for example, contains 21 g of carbohydrate.

Snack Foods and Desserts

Snack foods often contain a lot of carbohydrates, making this a challenge. An option is low-carb flavored gelatin,  real whipped cream made with artificial sugar, or a handful of nuts. It is key to stay within the carb limits. You can also make muffins and other snacks by using almond flour, made from ground almonds and artificial sweeteners. An interesting change includes pork rinds also supply fat without carbs and make a crunchy substitute for chips.

How is it different from the Ketogenic Diet?

Although the foods are very similar, there are key differences between the modified Atkins diet and the ketogenic diet.

  • There is no fluid or calorie restriction or limitation.
  • Fats are strongly encouraged, though not weighed and measured. Most patients will consume plenty of dairy and oils.
  • One of the biggest differences is that there are no restrictions on proteins. Typically 35% of calories on this diet come from protein.
  • Foods are not weighed and measured, but carbohydrate counts are monitored.
  • It is started outside of the hospital without a fast before starting the diet.
  • Lastly, foods can be eaten more freely in restaurants and outside the home, and families (and neurologists!) can do it as well.

Who will it help?

It seems to help similar numbers of patients as the ketogenic diet. It works for men and women equally and is being used actively in adolescents and adults. Like the ketogenic diet, it is mostly used for patients with daily seizures who have not fully responded to medications.

What Does it Include?

  • Lots of high-fat foods such as bacon, eggs, mayonnaise, butter, meats, heavy whipping cream, and oils.
  • Certain fruits, vegetables, nuts, avocados, olives, and cheeses.
  • Fluids help avoid side effects, such as Fruit2O, diet soda, and other flavored waters are favorites of many patients.
  • Carbohydrates are limited and directly controlled but the patient (or parents).
  • Compared to a patient on the classic ketogenic diet, the biggest differences include more food and more proteins.
  • The diet can be supplemented with ketogenic products (e.g. formulas, shakes, baking mixes, and pre-made breads).

Where to Start

  • Talk first with your neurologist and dietitian about the benefits of this decision.
  • Once you decide, lab work is usually obtained, and ketone strips are prescribed.
  • Carbohydrates are limited (15-20 grams per day) and the foods change overnight (making it hard to transition).
  • Medications are usually left unchanged (and most patients on the modified Atkins diet are also on some medications). If medications are in liquid forms, they are usually changed to tablets to decrease carbohydrates.

Does It Work?

In studies so far, yes. About half had a 50% reduction in seizures after 6 months. Many were able to reduce medications. About a third of the patients halved the frequency of seizures by three months. Side effects linked with the diet, such as a rise in cholesterol or triglycerides, were mild. A third of the patients dropped out by the third month, unable to comply with the restrictions.

Can Adults Do It?

  • Absolutely, adults with epilepsy are one of the fastest growing groups of patients starting diets today.  Ask your neurologist to help (or refer you to an adult epilepsy diet center).
  • Outcomes are largely similar to children, with similar side effects.
  • Most adults remain on medications, probably a higher percentage than children on dietary therapy.
  • Speak to your neurologist first if you have high cholesterol, high blood pressure, heart disease, liver or kidney disease, a history of kidney stones, nutritional deficiencies, or are considering getting pregnant.

Are There Any Side Effects?

  • Potential weight loss.
  • Increased cholesterol levels are possible.
  • There is a possible feeling of nausea or illness at the start.
  • For all these reasons, the modified Atkins diet should only be done with physician supervision because of all potential issues.

How Is The Patient Monitored Over Time?

  • A dietitian should track weight and height periodically, as well as calorie intake. Dietitian involvement seems to help keep the patient on it.
  • Blood and urine monitoring every 3 months is also recommended, and checking urine ketones once or twice a week while on the diet.

Can the diet ever be stopped?

The diet can be stopped if a patient is seizure-free for a long period of time, and with the approval of a doctor. However, with adults, there are issues like driving and other dangers that make it best to keep the possibility of seizures controlled.


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