Origins in Fasting and the Discovery of Ketones
Before the term “ketogenic diet” was coined, the practice of fasting was recognized for its ability to reduce epileptic seizures. This observation dates back to ancient times, but in the early 20th century, modern medicine began to seriously investigate this phenomenon. Clinicians in the 1910s noted that epileptic patients who fasted would often experience a reduction or cessation of seizures, though the seizures would return once normal feeding resumed. Meanwhile, endocrinologist Rollin Woodyatt observed in 1921 that a state of ketosis (elevated ketone bodies in the blood) could be achieved through both starvation and a diet that was very high in fat and low in carbohydrates. This discovery provided the critical link needed to move from temporary fasting to a sustainable dietary therapy.
Dr. Russell Wilder and the Birth of “Keto”
Building on Woodyatt's work, Dr. Russell Morse Wilder at the Mayo Clinic proposed and coined the term “ketogenic diet” in 1921. Wilder's goal was to recreate the beneficial, seizure-controlling effects of fasting in a dietary form that patients could maintain long-term. The diet was developed specifically for treating intractable epilepsy, especially in children, for whom few effective medications existed at the time. Colleagues at the Mayo Clinic, including Mynie Peterman, further refined and standardized the classic protocol throughout the 1920s.
The Strict Protocol of the 1920s
The classic 1920s ketogenic diet was a rigorously calculated and controlled regimen, a stark contrast to the often flexible approaches of today. It was administered under close medical supervision, typically starting with a brief fasting period to accelerate ketosis.
- Macronutrient Ratio: The “gold standard” was a 4:1 ratio of fat to combined protein and carbohydrates by weight. This meant that approximately 90% of a patient's calories came from fat, with a very small allowance for protein (about 6%) and an even smaller amount for carbohydrates (around 4%).
- Precision Measurement: The diet required a gram scale for weighing every single ingredient. Meal plans were painstakingly calculated and tailored to ensure nutritional adequacy while maintaining the correct fat-to-carb-and-protein ratio.
- Caloric and Fluid Restriction: Unlike many modern versions, the classic 1920s diet often involved calorie and fluid restrictions. These measures were intended to maximize the ketogenic effect but raised concerns about healthy growth and led to potential side effects like kidney stones and dehydration.
Comparison: 1920s Classic Keto vs. Modern Keto
| Feature | 1920s Classic Ketogenic Diet | Modern Ketogenic Diet (for weight loss) |
|---|---|---|
| Primary Purpose | Strict medical treatment for intractable epilepsy. | Weight management, wellness, or sports performance. |
| Macronutrient Ratio | Rigidly calculated 4:1 ratio (fat:protein+carbs) by weight, around 90% fat. | Often a general high-fat, moderate-protein, very-low-carb guideline. |
| Carbohydrate Limit | Extremely low (e.g., 10-15 grams per day for children). | Typically restricted to under 50 grams per day for ketosis. |
| Medical Supervision | Required, with hospitalization often needed for initiation and monitoring. | Optional, though recommended for long-term health concerns. |
| Protocol | Precision weighing, calorie/fluid restriction, and often initiated by fasting. | More flexible, with food journaling or carb counting. |
| Patient Population | Primarily children with difficult-to-control epilepsy. | Primarily adults seeking weight loss or health benefits. |
Decline and Revival of the Diet
The ketogenic diet's use as a primary treatment for epilepsy declined dramatically after the discovery of the first effective anticonvulsant drugs, such as phenytoin, in the late 1930s. These medications offered a far less restrictive and more palatable alternative for patients. However, the diet was not completely forgotten. For the 25–30% of patients whose seizures did not respond to medication, it remained a viable treatment option. The diet experienced a significant revival in the 1990s, thanks in part to a high-profile media case and the work of Johns Hopkins Hospital. This resurgence led to further research and the development of less restrictive variants, such as the Modified Atkins Diet.
What a 1920s Keto Menu Looked Like
Given the strict ratios and caloric restrictions, a patient's meal plan in the 1920s was highly specific and medically prescribed. Recipes were designed to maximize fat intake while minimizing all other macronutrients. For a child on the diet, a daily meal might consist of:
- Breakfast: Heavy cream, butter, and a small portion of egg.
- Lunch: A carefully weighed portion of meat, a minimal amount of low-carb vegetables like lettuce, and a generous topping of oil or mayonnaise.
- Dinner: Similar to lunch, with a fatty meat or fish, and low-carb vegetables coated in oil.
- Snacks: Small amounts of unsweetened cream or butter to maintain the ketogenic ratio throughout the day.
The reliance on such a high proportion of fat meant the diet was monotonous and difficult to maintain, which is another reason it fell out of favor once pharmaceutical alternatives became available.
Conclusion: The Enduring Legacy of the First Ketogenic Diet
While a vastly different experience from the modern keto craze, the ketogenic diet in the 1920s was a groundbreaking medical treatment that provided a lifeline for those with drug-resistant epilepsy. Pioneered by dedicated researchers like Dr. Russell Wilder at the Mayo Clinic, it established the foundation for nutritional therapy in neurology. The diet’s demanding protocol highlights the desperation for effective treatments at the time and its long-standing efficacy is a testament to the power of metabolic therapy. Its history reminds us that today's popular wellness trends often have deep, serious medical roots.
For more on the diet's history, explore the timeline documented by Johns Hopkins Medicine.
