What is the best way to then achieve higher ketosis levels initially? One option is to fast children before starting the MAD. However, this approach raises concerns regarding hypoglycemia and acidosis, especially in the setting of an outpatient approach, as is typically used for starting the MAD. Some families specifically ask for the MAD to avoid an admission or fasting period. Another option would be to give the KD first, then switch to the MAD after one month. However, the significant time and financial burden involved in a KD admission and training would decrease interest in the MAD approach by families contacting our center, and not truly test the MAD effectiveness as a primary therapy. Other potential ways to increase ketosis include carnitine supplementation, MCT oil inclusion, and calorie restriction. All of these options, however, have their own financial and safety implications.