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A Parents Quick Guide to the Ketogenic

Diet as an Adjunctive Cancer Treatment


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A MAXLOVE PROJECT FIERCE FOODS PUBLICATION


Text: Justin Wilford, PhD
Reviewed by Carrie Loughran, RD, LD and Miriam Kalamian, EdM, MS, CNS

A PARENTS QUICK GUIDE TO THE KETOGENIC DIET

THE RATIONALE FOR THE KETOGENIC DIET AS A


CANCER TREATMENT
Overview
The ketogenic diet (KD) is a very low-carbohydrate, adequate protein, high-fat diet. There are many different ways
to do the diet but each type of KD has the common goals of 1) lowering blood glucose (i.e., blood sugar), 2)
lowering insulin and insulin-like growth factor 1 (IGF-1) levels (the chemicals in our bodies that let our cells use
blood sugar for energy) and 3) raising ketone bodies (i.e., biochemicals our livers produce from fat that our cells
can use for energy in place of blood sugar). By altering the levels of these three substances in the blood, the KD is
has been shown to suppress growth in many types of tumors.

How it works
The tumor-suppressive effect of the KD is thought to occur through one or more of the following mechanisms:

1. Scientists have known for almost 90 years that most solid cancers use blood sugar (glucose) as their primary
source of energy (Vander Heiden 2009; Seyfried 2014). The German scientist Otto Warburg discovered that
tumor cells consume glucose at a much higher rate than normal healthy cells. This has come to be known as
the Warburg effect (Seyfried 2012). The KD decreases available glucose to tumor cells. This in itself
might have a therapeutic effect. The most extensive human study to date (Fine 2012) has shown through PET
scans that even mild ketosis (~1.5 BHB mml/dl) over the span of a month can significantly reduce glucose
uptake (20%) in tumors of advanced cancer patients. Longer and more in-depth studies need to look at
whether this decrease in glucose uptake translates into tumor regression. But smaller studies suggest that this
relationship between between glucose levels and tumor progression (McGirtt 2008; Derr 2009) is real.
2. The KD increases circulating ketone bodies. In a state of ketosis, ketone bodies are used by almost all
normal cells but cannot be used by most cancer cells. A body in ketosis is more metabolically flexible because
it is using both glucose and ketone bodies for energy production. While all normal cells can use either glucose
or ketones for energy, the Warburg effect present in most cancers shows that cancer cells invariably have
defective mitochondria that cannot make use of the alternative fuel in ketone bodies (Maurer 2011). Another
way that ketosis might help is that a body in ketosis is making higher demands of mitochondria for energy
production. This makes mitochondria work harder and so may serve to increase the effect of mitochondria's
role as the body's housekeeper as it recycles old cellular parts or kills damaged cells. Perhaps potential
cancerous cells are more likely to be disposed of in a ketotic environment (Champ and Klement 2014).
3. Because cancer cells rely on glucose to repair free radical damage, limiting glucose might also limit this
reparative ability (Spitz 2000; Seyfried 2014).
4. The KD decreases circulating insulin and IGF-1, both of which are implicated in tumor progression.
This is the hypothesis favored by Fine, et al (2012). Insulin and IGF-1 activate several metabolic pathways that
are known to promote cancer growth and survival. Lower insulin should lead to an inhibition of these
pathways.
5. The KD appears to increase the sensitivity and susceptibility of cancer cells to chemotherapy and
radiation. To quote Colin E. Champ, a radiation oncologist and KD researcher: "Activation of the insulin

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receptor and several pathways downstream within cancer cells allows them to more readily fix damage from
chemotherapy and radiation. However, keep in mind that radiation therapy works mostly by interacting with
the water molecules in and around cancer cells to create free radicals that attack the cancer cells, causing
DNA damage. Restricting glucose through a ketogenic diet may take advantage of this inability to counter
damage from free radicals, making radiation more effective. A study in mice has shown that radiation therapy
efficacy is significantly increased in the face of a ketogenic diet when treating brain tumors." I have included
this study (Abdelwahab 2012) plus another showing synergy with chemotherapy and radiation together (Allen
2013).
6. The KD appears to help the bodys immune system fight tumors. Researchers at Harvard University
have recently published a series of papers describing how cancer hides from immune cells (Husain, et al
2013). The natural byproduct of tumors consuming an extremely high amount of glucose is lactate. The high
levels of lactate in the tumor environment serve to hide the tumor from the bodys immune system. A KD
lowers glucose metabolism and thus lowers the amount of lactate being produced by the tumor. This in turn
allows for the immune cells to see the tumor better.
7. Lastly, some researchers speculate that ketones themselves might have some anti-cancer eect that is
yet unknown. This hypothesis is currently being studied. In a recent study, researchers showed that ketone
supplementation can reduce cancer growth even in the presence of high glucose (Poff et al 2014). This

suggests that the ketones have an independent anticancer effect.

HOW TO BEGIN A KETOGENIC DIET FOR THE TREATMENT


OF CANCER
Partner with a ketogenic specialist
If you havent already, sign up for our consultation program. We fully fund initial consultations with ketogenic
dietitians who work long-distance. You should also check to see if your childs hospital has a ketogenic clinic in
their neurology department. The diet is widely used to treat patients with epilepsy. While the KD doesnt have to be
a difficult diet to follow and maintain for most kids and adults once they are in ketosis, challenges can emerge. A
consultation with an experienced dietitian will help your child safely get into ketosis and maintain maximum health
while on the diet.

Tell your oncologist that you intend to put your child on a ketogenic diet
Expect your doctors to be highly skeptical of the ketogenic diet. But they also need to know that you are choosing
to use this powerful therapy. To assuage your doctors fears you can tell him/her that Childrens Hospital of Orange
County has passed a protocol to use the KD as an adjunctive cancer treatment and is presently treating several
pediatric glioma patients with the KD. You can tell them that the University of Iowa is currently conducting human
trials with the KD as a treatment for several different types of cancer. Mice studies have been and are being
conducted at Boston College, Duke University, Yale University, and Barrow Neurological Institute in Phoenix. Share
with them our review summary of the latest research on the KD and cancer. It can be found in the resource section
at www.maxloveproject.org. Finally, if they remain skeptical or even disapproving, then remember that you are in

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charge and they are only advisors. Many parents have seen their doctors follow only after they start the diet. Once
they see the child healthy and happy and in full ketosis, much of their fear subsides. And remember: the KD has
been used for 90 years with epileptic children. It has been shown to be perfectly safe.

If it seems overwhelming then start slow


Although your dietitian may want to start quickly with a fast, you may choose to start slow. Keep in mind that most
dietitians will have experience only with epilepsy. In these cases the goal is to stop seizures as quickly as possible,
and so the KD is initiated as quickly as possible. You and your child might be happier if you phase in the diet over
the course of a couple weeks by first cutting out all sugar (this means honey, syrup, cane juice and fruit juices).
After a few days of no sugar, cut out all refined carbohydrates (all pasta, white rice, chips, crackers and bread) and
high-glycemic fruit (all fruit except for berries). After a few days of no sugar, refined carbohydrates, or highglycemic fruit, cut out all grains (no rice, wheat, oats, quinoa, millet, etc.) and all dairy except for butter, heavy
cream, full fat sour cream, and a limited amount of fatty cheeses. By day 15 you are pretty much on the ketogenic
diet. You might be wondering what youre going to eat now that youve taken all this stuff out of your childs diet.
Well provide a quick list and a bunch of resources below.

Talk with your dietitian about supplementation


Important supplements on the ketogenic diet include probiotics, sodium (salt), magnesium, potassium, calcium,
and vitamin D. Potential supplements include omega-3 fatty acids (fish oil) and curcumin (turmeric).

Follow your child and get on a low-carbohydrate, high-fat diet with them.
Many of the most popular diets today (Paleo, South Beach, Wheat Belly, Atkins) are low-carb, high-fat. Why?
Because it is a very healthy diet and a very delicious one as well. It has been shown to be an effective treatment for
obesity, metabolic syndrome, and diabetes. Emerging research is showing that it might also be effective for brain
health, mood and anxiety regulation, and building physical endurance. It will make it much easier on your child if
he/she sees you eating exactly as he/she does.

Dont be discouraged by the KDs dietary limitations


It can be a wonderful and delicious way to eat! Its not a joke: you can really eat eggs, bacon, butter, and heavy
cream while on the diet and be extremely healthy! Saturated fat is not a killer, it is your friend.

MAINTAINING THE KETOGENIC DIET


Start testing glucose and ketone bodies (beta-hydroxybutyrate)
The most accurate way to test both is with the Precision Xtra Blood Glucose and Ketone Monitoring System by
Abbott Diabetes Care. You will need to use their small lancet to get a quick poke of blood, squeeze the blood into
a small disposable strip that you insert into the monitor, and then wait a couple seconds for a reading to appear.
The small poke is not fun for kids at first but it really is small and usually disappears within a minute or. Many

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parents offer a treat like a sugar-free candy after every poke. Some children start to ask for a poke in order to get
the candy!

Become a keto-expert!
The most important factor in maintaining the KD for you and your child is the level of your own knowledge of how
the diet works and what sort of foods will deliver maximum benefit. Here are several resources that explain in lucid
detail how a low-carbohydrate, high-fat diet works and how you can maintain it.
BOOKS
Phinney, Stephen and Jeff Volek. 2012. The Art And Science Of Low Carbohydrate
Performance. Lexington, KY: Beyond Obesity.
Phinney, Stephen and Jeff Volek. 2011. The Art And Science Of Low Carbohydrate Living: An
Expert Guide To Making The Life-Saving Benefits Of Carbohydrate Restriction Sustainable
And Enjoyable. Lexington, KY: Beyond Obesity.
Seyfried, Thomas. 2012. Cancer As a Metabolic Disease: On the Origin, Management, and
Prevention of Cancer. New York: Wiley.
Wahls, Terry. 2014. The Wahls Protocol. New York: Avery.
Kalamian, Miriam. 2013. Get Started With The Ketogenic Diet For Cancer. Self-published
eBook.
Perlmutter, David. 2013. Grain Brain. The Surprising Truth About Wheat, Carbs, and Sugar.
Hachette Book Group.
KEY SCIENTIFIC JOURNAL ARTICLES, IN CHRONOLOGICAL ORDER (a summary of these
articles is available in the resources section at www.maxloveproject.org)
Nebeling, Linda C. and Edith Lerner. 1995. Implementing A ketogenic diet based on mediumchain triglyceride oil in pediatric patients with cancer. Journal of the American Dietetic
Association 95 (6): 693 - 697.
Kossoff, Eric H, et al. 2009. Optimal clinical management of children receiving the ketogenic
diet: Recommendations of the international ketogenic diet study group. Epilepsia 50 (2):
304-317.
Vander Heiden, M. G., Cantley, L. C., & Thompson, C. B. (2009). Understanding the warburg
effect: The metabolic requirements of cell proliferation. Science, 324(5930), 1029-33.
Skinner, Robert, Angelica Trujillo, Xiaojie Ma, and Elizabeth A Beierle. 2009. Ketone bodies
inhibit the viability of human neuroblastoma cells. Journal of Pediatric Surgery 44 (1):
212-216.
Stafford, Phillip, et al 2010. The ketogenic diet reverses gene expression patterns and
reduces reactive oxygen species levels when used as an adjuvant therapy for glioma.
Nutrition & Metabolism 7 (1): 74.
Klement, Rainer J. and Ulrike Kmmerer. 2011. Is there a role for carbohydrate restriction in
the treatment and prevention of cancer? Nutrition and Metabolism 8 (1):75.
Scheck, Adrienne C, Mohammed G. Abdelwahab, Kathryn E. Fenton, and Phillip Stafford.
2012. The ketogenic diet for the treatment of glioma: Insights from genetic profiling. Epilepsy
Research 100 (3): 327-37.
Fine, Eugene J., et al. 2012. Targeting insulin inhibition as a metabolic therapy in advanced
cancer: A pilot safety and feasibility dietary trial in 10 patients. Nutrition 28 (10): 1028-35.
Fath, Melissa A., Andrean L Simons, and Jeffrey Erickson. 2012. Enhancement of cancer
therapy using ketogenic diet. In Oxidative Stress in Cancer Biology and Therapy. Ed. Douglas
R Spitz. Humana Press.
Abdelwahab, Mohammed G., et al. 2012. The ketogenic diet is an effective adjuvant to
radiation therapy for the treatment of malignant glioma. PLoS One 7 (5): e36197.

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Allen, Bryan G, et al. 2013. Ketogenic diets enhance oxidative stress and radio-chemotherapy responses in lung cancer xenografts. Clinical Cancer Research. Author manuscript,
online only.
Poff, Angela M., Csilla Ari, Thomas N. Seyfried, and Dominic P. DAgostino. 2013. The
ketogenic diet and hyperbaric oxygen therapy prolong survival in mice with systemic
metastatic cancer. PLoS One 8 (6): e65522.
Husain, Zaheed, Yannu Huang, Pankaj Seth, and Vikas P. Sukhatme. 2013. Tumor-Derived
lactate modifies antitumor immune response: Effect on myeloid-derived suppressor cells and
NK cells. The Journal of Immunology 191 (3): 1486-1495.
Klement, Rainer J. and Colin E. Champ. 2014. Calories, carbohydrates, and cancer therapy
with radiation: Exploiting the five R's through dietary manipulation. Cancer Metastasis Rev 33
(1): 217-229.
Seyfried, Thomas N., Roberto Flores, Angela M. Poff, and Dominic P. DAgostino. 2014.
Cancer as a metabolic disease: Implications for novel therapeutics. Carcinogenesis 35 (3):
515-527.
Poff, AM, C. Ari, P. Arnold, T.N. Seyfried, and D.P. D'Agostino. 2014. Ketone supplementation
decreases tumor cell viability and prolongs survival of mice with metastatic cancer.
International Journal of Cancer. In press.
Champ, Colin E., Joshua D. Palmer, Jeff S. Volek, Maria Werner-Wasik, David W. Andrews,
James J. Evans, Jon Glass, Lyndon Kim, and Wenyin Shi. 2014. Targeting metabolism with a
ketogenic diet during the treatment of glioblastoma multiforme. Journal of Neuroncology. In
press.
Mathews, Edward H., B. Andr Stander, Annie M. Joubert, and Leon Liebenberg. 2014.
Tumor cell culture survival following glucose and glutamine deprivation at typical physiological
concentrations. Nutrition 30 (2): 218-227.
KEY BLOGS ON THE SCIENCE OF LOW-CARB, HIGH-FAT (KETOGENIC) DIETS
Peter Attia, MD: www.eatingacademy.com
Colin E. Champ, MD: http://www.cavemandoctor.com/category/cancer/
Richard David Feinman, PhD: http://rdfeinman.wordpress.com
Dominic DAgostino, PhD: http://ketonutrition.blogspot.com
Peter Hyperlipid: http://high-fat-nutrition.blogspot.com
Bill Lagakos, PhD: http://caloriesproper.com
Robb Wolf: http://robbwolf.com/blog/
Andreas Eenfeldt, MD: http://www.dietdoctor.com/about
Jimmy Moore: http://livinlavidalowcarb.com/blog/
KEY BLOGS FOR KETOGENIC RECIPES
http://mariamindbodyhealth.com (she also has several keto-friendly books. Check her out on
Amazon: Maria Emmerich)
http://www.charliefoundation.org/recipes/ (a U.S.-based ketogenic diet advocacy group for
epilepsy treatment)
http://www.thepaleomom.com/recipes (she uses maple syrup and honey in some recipes so
watch out)
http://www.ketogenic-diet-resource.com/low-carb-recipes.html
KEY WEBSITES FOR MORE INFORMATION
The Charlie Foundation http://www.charliefoundation.org
Miriam Kalamian, M.S., EdM., C.N.S.. (ketogenic diet health coach) http://
dietarytherapies.com
Carrie Loughran, R.D. (ketogenic diet dietician) http://www.ketocare.com
http://site.matthewsfriends.org (a UK-based ketogenic diet advocacy group for epilepsy
treatment)
Ellen Davis (ketogenic diet advocate) http://www.ketogenic-diet-resource.com

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Get into a routine


Many KDs are based on a specific ratio of calories consumed, e.g., 80% of calories from fat, 10% from
protein, 10% from carbs. An easier way to do this is called the Modified Atkins Diet which restricts carbs
but allows for liberty with protein and fat. For an anticancer ketogenic diet, it is important to keep protein
restricted because protein can increase insulin and can be converted into glucose when consumed above
a moderate amount. So a good rule of thumb is to keep carbohydrate intake to around 20 grams
per day and protein around 1 gram per kg of body weight. Fat can always be eaten to satiety
(fullness). This, of course, can be adjusted with your dietitian.

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 and should be maintained through whole foods. Because fats
are such an important part of the KD, it is crucial to consume the highest quality fats. This means that all
meat and dairy should be organic and grass-fed or pasture-raised if possible. Grass-fed, organic meat will
ensure two things: a great reduction in harmful chemicals and hormones in the protein and fat, and a
significant increase in good fats like omega-3 fatty acids. These products can be found in most health
food grocery stores. But farmers markets are also a great option.

Stock up on the staples of a healthy KD


A.

Fats
(1) Butter, from grass-fed, pasture-raised animals (Organic Valley brand is the best, followed by
Kerrygold)
(2) Heavy Cream (if possible from grass-fed, pasture-raised animals)
(3) Coconut Oil (virgin, cold-pressed)
(4) MCT (Medium-Chain Triglyceride Oil, derived from coconut and palm oil)
(5) Olive Oil
(6) Macadamia Nuts
(7) Avocados
(8) Olives
(9) Avoid all seed oils (corn oil, sunflower oil, canola oil, etc.) if possible. They are proinflammatory.
B. Protein
(1) Eggs (organic, omega-3)
(2) Meat from organic, grass-fed, pasture-raised animals (dont trim the fat)
(3) Hot dogs from grass-fed, pasture-raised animals (Applegate brand)
(4) Cheese from grass-fed, pasture-raised animals (look for highest fat-to-protein ratio)
(5) Fatty fresh fish like Wild Salmon
(6) Organic bacon (Applegate Brand)
(7) Organic chicken (always served with fat-based sauce like hollandaise, bearnaise, )
C. Carbs
(1) Veggies. Weve 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)

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Carrots (8 baby carrots = 7 g of carbs/2 g of fiber)


(2) 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 dont come at one sitting. Below are some good lowglycemic choices.
1. Berries (1 cup of halved strawberries = 12g of carbs/3 g of fiber)
2. Cherries (4 cherries = 4g of carbs/1g of fiber)
3. Apple slices (1 cup = 15g of carbs/3g of fiber)

Its all in the numbers


The great thing about the KD is that at the end of the day what matters is your childs 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 thats right for you and your child. Dont be afraid to experiment.

www.maxloveproject.org

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