 Variations on the Johns Hopkins protocol are common . The initiation can be performed using outpatient clinics rather than requiring a stay in hospital . Often there is no initial fast ( fasting increases the risk of acidosis and hypoglycaemia and weight loss ) . Rather than increasing meal sizes over the three @-@ day initiation , some institutions maintain meal size but alter the ketogenic ratio from 2 : 1 to 4 : 1 . 
