2.1.1. MKNA Arm
ketosis
KETOSIS
The MKNA program involves seven 1 h virtual group meetings via a HIPAA-compliant Zoom meeting across six weeks. Each meeting was led by a clinical psychologist and nurse practitioner with expertise in functional medicine and involved nutritional education and psychoeducation. Each session dedicated approximately half of the time toward diet and nutrition content and the second half of the session toward MI-BCT components. All sessions were led based on a structured PowerPoint presentation to increase fidelity. In regard to the nutrition components, the first two sessions introduced MKN, how to track macronutrients, and how to use the program resources (e.g., recipes, informational handouts, and individualized calculators). In weeks two through six, participants were asked to attend weekly sessions to learn about topics related to MKN, eating healthy on a budget, and trouble-shooting questions about the diet. Participants were provided weekly with individualized gram recommendations for fats, proteins, and carbohydrates based on their age, sex, BMI, and activity level. Each week, these individualized recommendations titrated toward a ketogenic ratio: all participants began at a 50% fat, 25% protein, and 25% net carbohydrate recommendation and titrated up to a 70% fat, 25% protein, and 5% carbohydrate ratio. Once in a state of ketosis, however, participants were recommended to stay at the least restrictive ratio possible. Given this titration, participants were not expected to evidence urine ketones until weeks 3 or 4 of the program. Participants were provided with guidance for completing their own meal planning and preparation, allowing substantial individual differences; however, emphasis was placed on consuming the types of foods consistent with a Mediterranean diet (e.g., fish, olive oil, and unprocessed foods), while applying a ketogenic macronutrient ratio. Participants were provided with over 130 optional breakfast, lunch, dinner, and snack recipes to assist with meal planning, in addition to informational handouts, phone application recommendations, and tools for tracking macronutrients.The second half of each session for the MKNA arm was dedicated to motivational discussions (e.g., goal setting and values) and teaching MI-BCT skills (e.g., overcoming obstacles, managing slips, and positive reappraisal). Early sessions placed greater emphasis on building motivation and then shifted toward learning basic cognitive restructuring and behavioral skills, and final sessions focused on overcoming future obstacles and maintaining motivation. Participants received a workbook with worksheets focused on learning MI-BCT strategies (e.g., problem solving and cognitive restructuring) and informational handouts. In session, examples of each skill were reviewed, and participant discussion and feedback was encouraged. Participants were asked to complete worksheets between sessions and bring these the following week to share with the group, although sharing was optional.