Perhaps one of the most surprising findings of this study was the activity and total number of centers in Asia providing the diet. The Children's Medical Institute of the National University Hospital in Singapore contacted us for this survey but has not yet started offering the ketogenic diet to patients. 50 patients annually as well. The diet can be difficult to maintain in many countries in Asia owing to the cultural tendency toward carbohydrate-rich foods such as rice and noodles as the primary source of energy, especially for children. Traditional meals include fish, vegetables, and rice, which can make substitutions difficult. In the 1980s, many centers in Asia switched over from the classic ketogenic diet to the MCT oil-based diet for this reason. However, nearly all centers believed the recent trend toward a “Western style” of foods for children has made it somewhat easier to adapt the ketogenic diet over the past few years.
The St. Luke's Medical Center in Manila, the Philippines, uses many native processed foods such as longaniza (fried ground pork with spices), chicharon (pork fat), butong pakwan (watermelon seeds), beef tapas, coconut milk, and cashews. Infants and children receiving only formula have had no cultural difficulties in starting the diet. Parents of patients in Taiwan have created a cookbook of recipes with local foods, including sushi. In Hong Kong, specifically, many families with children with intractable seizures have been counseled by the neurologists to try the diet, but the families are opposed to the concept of restricting food for children with severe disabilities, as this is thought to be one of the few ways that they can provide care to these children (28). Moreover, meals are often created by grandparents or domestic helpers, which requires extra education time by physicians. Another unique problem to China is the many different provinces with different dialects, cultures, and food.
The dietitians providing the diet have had difficulties in devising recipes for each individual province. Families universally dine together and share the same foods in a communal manner, which makes providing a different meal (and calculating portions) for an individual child extremely problematic. The typical Indian diet varies from state to state, with 20-30 different culinary specialties requiring individual meal plans. A significant source of fat in the Indian diet is ghee, which the center has found increases cholesterol and triglycerides on occasion. Many patients are vegetarians or vegans and also will not eat any food that grows under the soil (e.g., onions, garlic, potatoes). Religious beliefs preclude many families from eating certain foods (e.g., beef), either universally or during certain religious periods. Many of the center's families do not read English, which is difficult for providing recipes and education. Nutritional labeling also is not mandatory in India, so that commercial products are difficult to use, similar to what was reported in Saudi Arabia.
Last, a strong cultural aversion exists to fasting children, which has led the center to eliminate this aspect of the diet in favor of a 48-h low-carbohydrate period without calorie restriction. Nathan is interested in using lower ketogenic diet ratios (e.g., 2:1 or even 1.5:1), as he has found that large ketosis can still occur, and the diet is more palatable. In Bangkok, Thailand, the diet was managed by Kankirawatana (9), who published his work in a Thai journal in 2001. However, shortly afterward, he left Thailand and is currently at the University of Alabama at Birmingham. At this time, Jirapinyo, a pediatric gastroenterologist, is still involved with the diet in Bangkok, and has created three specific diet recipes. As Thai food is apparently not rich in fats, and coconut milk is one of the few sources available, these three recipes were designed to be inexpensive, palatable, and simple enough for children to eat for several days to initiate the diet. After that point, vegetables and other foods are gradually introduced.
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