Over the past 5 years since its introduction, our center and others have researched methods to make the MAD both more tolerable and efficacious. Important clues came in 2007, in which an initial carbohydrate limit of 10 grams per day was compared to 20 grams per day in a randomized , prospective, crossover design. Although the hypothesis was that these two carbohydrate limits were equivalent, this was only true after the 3-month crossover period. At diet onset, there was a significantly higher likelihood of a >50% seizure reduction when a stricter, 10 grams/day MAD was used (60% vs. 10%, p=0.03). Ketosis was higher in that group at 1 month as well, similar to previous findings that the 1-month ketosis levels correlated with efficacy. These results suggested that a stricter, higher ketotic, start to the MAD was important - although loosening restrictions after 1-3 months was also reasonable and did not adversely affect seizure control.