Peter Attia series on ketosis

Peter Attia MD has started a series of posts on ketosis.

This is important because he does a great job of producing highly informative, detailed, well-researched posts.

Part 1 is up, on The Eating Academy

Ketosis – Advantaged or misunderstood state? (Part I)

It was on Dr. Peter Attia’s blog that I first learned of the existence of a home blood ketone monitor, about last March, as I wrote about in a previous post.

This is my first attempt at re-blogging. This is an important post and worthy of more than just a comment or posting to my facebook page. Lots of other good content on this site. Re-posted from Eathropology, by Adele Hite, MPH RD


Nostalgia for a misremembered past is no basis for governing a diverse and advancing nation.

David Frum

The truth is that I get most of my political insight from Mad Magazine; they offer the most balanced commentary by far. However, I’ve been very interested in the fallout from the recent election, much more so than I was in the election itself; it’s like watching a Britney Spears meltdown, only with power ties. I kept hearing the phrase “epistemic closure” and finally had to look it up. Now, whether or not the Republican party suffers from it, I don’t care (and won’t bother arguing about), but it undeniably describes the current state of nutrition. “Epistemic closure” refers to a type of close-mindedness that precludes any questioning of the prevailing dogma to the extent that the experts, leaders, and pundits of a particular paradigm:

“become worryingly untethered from reality”

“develop a distorted…

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Ketosis in a Nutshell – Part 2, Crazy Little Things

Oh, just an alternate fuel system  – no biggie …..

Got Ketones?

When you break down fats for energy production and you do this while there is a low glucose supply, you wind up with a little bit left at the end, which is then metabolized to acetoacetate. Acetoacetate can be metabolized to acetone or beta-hydroxybutyrate. All three of these molecules then circulate in the blood stream.  They are referred to as ketones, although technically beta-hydroxybutyrate does not fit the definition for ketones. Functionally, beta-hydroxybutyrate acts like a ketone in that it can readily be metabolized back to acetoacetate, thus acting as sort of a transit or storage form of ketones.

English: Synthesis of ketone bodies from acety...

English: Synthesis of ketone bodies from acetyl-CoA Deutsch: Synthese von sog. Ketonkörpern aus Acetyl-CoA (Photo credit: Wikipedia)

In chemistry, there are many, many molecules that are of the type classed as ketones.  When we refer to “ketones” in your body, we are specifically meaning the three molecules I have named above.  The term “ketone bodies” has been used as a catch-all phrase for these specific three molecules (one of which is a ketone supplier, rather than a ketone itself).

When it comes to the ketones present in the blood stream, these have been made by the liver predominantly, although the kidneys are a minor source.  We are learning more about ketone metabolism. For example, recent research suggests that cells in the brain that metabolically support the neurons can make ketones and can scale up the production of ketones when needed.  This would be for local use – we don’t think of these as leaving the brain to supply ketones in the blood stream.

How Ketones Function in Your Body  (terminology list at bottom of Part 1)

  • They can be burned as a fuel.  There are three fuel types the body can use – glucose, fatty acids and ketones.  The neurons in the brain can only burn glucose and ketones. The brain uses a lot of energy every day. During fasting or starvation, the body would have to break down a lot of protein to supply the brain with enough glucose for all its energy needs.  In prolonged fasting or starvation, the muscles would be consumed at a quick rate.  Persistence of muscle strength and survival are much longer because ketones can replace a lot of the glucose the brain needs. Ketones can not supply all your needs for glucose. Glucose must be at least at low normal levels in the blood at all times and is produced by the liver as needed (unless metabolic or liver function is very impaired by illness, drugs or genetic metabolic illness).
  • This allows the dietary glucose supply to be low  – in fact, there is no need for glucose from the diet. (Sugars and starches are the source for glucose in the diet. Starch is pure glucose.) This has profound implications for the management of all forms of diabetes and pre-diabetes and impaired insulin function. It also has profound implications in sweet addiction and food addiction.  The body requires much less insulin than when glucose is being absorbed from food as a major part of the diet.
  • Ketones aren’t glucose – they don’t need the glucose transport system, and so are not hindered by insulin resistance. For example, this has implications in Alzheimer’s Disease as research is exploring the theory that part of what is going on in Alzheimer’s Disease is “Type 3 diabetes” – that is, insulin resistance of the brain and abnormal insulin metabolism in the brain.
  • Ketones are burned for energy differently than glucose.  Also, they produce less stress in the mitochondria and cells.  This means there is potential for ketones to be useful to cells that are damaged or stressed or with abnormal metabolism.
  • Burning ketones for energy requires less oxygen to produce a given amount of energy than when burning glucose.  This means ketones have the potential for benefit in situations of low oxygen supply – such as injured tissue or stroke.
  • Ketones are being studied for potential direct effects besides as a fuel – such as increasing adenosine production and thereby suppressing abnormal excitability in the brain.

The topic is much more involved than this list suggests. See links below to very detailed review articles.

The Whole is More Than the Sum of its Parts

In sustained dietary ketosis:

  • there are elevated levels of ketones circulating in the blood (and some research suggests extra ketones being made in the brain)
  • there are the effects noted above on fuel supply and handling
  • the ketone fuel supply is steady and ample
  • the blood glucose level is steady and normal or low normal, with low requirements for insulin

Therefore, when evaluating any apparent benefits observed with dietary ketosis, it is difficult to tease out which of the possible mechanisms (or which combinations of possible mechanisms) are at play. (Again, if you are interested, check out the links below.)

Note that if ketones are elevated because ketones are directly given (this is being developed for medical application) or because of a high intake of medium chain triglycerides, there is not necessarily a low carbohydrate intake from food, and so the effects on blood glucose levels and insulin requirements would not be the same.

Sustained Ketosis Brings A Reduction in Appetite

Something about being in sustained dietary ketosis results in a reduction in appetite, which develops over the first days or, in some cases, weeks. This is not an abolition of appetite (although this can uncommonly occur at the beginning – thought possibly due to a too rapid shift into the starvation/ketosis adaptation). The appetite is not killed, just lessened.

This is a general human reaction to sustained dietary ketosis.  You don’t have to have any trouble handling carbohydrates to have this response.  It doesn’t matter whether you are slim, overweight or obese.  It happens in the young and the old.  It doesn’t matter if you have insulin resistance or not.  Of course, there is variability between people in this, as in all things.  Keep in mind – some people do not seem to be metabolically suited to do well with ketosis and some people should avoid ketosis for various medical reasons.  There are people with rare genetic metabolic problems who should definitely avoid being in ketosis (and this condition may not be obvious, even into young adulthood).

We have little insight into this phenomenon, but it has long been noted. We don’t know what it is about dietary ketosis that causes this. It is likely a combination of more than one of the mechanisms above.  I am not aware of any research attempt to really study this phenomenon.  This seems a little surprising to me given the massive research effort to find usable medications that will lessen appetite.  Of course, such a medication would be a financial block-buster, so there is money available for that research.  Does the degree of appetite reduction relate only to the blood ketone level?  Does it relate more to the degree of stability of the blood sugar?  Do variations in liver glucose output matter – for example, liver insulin resistance or glucose output precipitated by a stress hormone spike?  Can we learn to manage this phenomenon to best take advantage of it?  It would be nice if we had the knowledge to be able to enter this state of reduced appetite with the least costs in terms of effort, dietary limitations, risks, etc.

The reduction in appetite does bring its own risks:

  • it is easy to mistake feeling adequately fed with being adequately nourished
  • it is easy to become lazy about food and meal preparation – eating from a narrow range of foods and not taking the time to prepare vegetables, salads, etc.
  • relying on ketosis for appetite control and using this as a way to avoid learning about and dealing with other factors affecting your appetite/satiety balance, such as stress and sleep.  Good health is always best served by a broad approach to wellness – over-relying on any one health strategy can lead to neglect of other aspects of your health.
  • acting as a source of confusion when people slip in and out of a ketotic state

A Tipping Point in The Balance of Actual and Potential Benefits Versus Actual and Perceived Practical Usability?

The implications of an alternate fuel system are enormous. The major block hindering progress towards more people deriving more benefit from this potential is the actual and perceived difficulties in people learning and following the diet and finding the ketogenic diet worthwhile over time.

The benefits side of the balance going up …

The very successful use of ketogenic diets in epilepsy, as well as the insistence of  patients and patient’s parents that they value this option despite the difficulties involved, has helped spur a growing amount of research into the therapeutic use of ketones and ketosis.  Findings from other fields, such as the theories of so-called “Type 3 diabetes” as a possible factor in Alzheimer’s disease, have also increased the realization of the actual and potential benefits of ketogenic diets.

There is an increased drive to re-consider the benefits of nutritional ketosis given:

  • the now very large numbers of people
  • who have medical problems for which there are presently limited or poor treatment options ( e.g. obesity, blood sugar control, Alzheimer’s, etc.)
  • who might find benefit from nutritional ketosis
  • or who at least might benefit in the near future from further research into the subject area.

How about the practical usability side of the balance?

To be continued ….. Part 3

*** Also, please see addendum published today at the bottom of Part 1

Ketosis in a Nutshell – Part 1, What’s Up? (

Related articles

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –

Some recent publications:  (links fixed)

(1) very interesting recent paper, full text available, plus active links to almost all of the 192 papers in the list of references (“KD” = ketogenic diet):

“Rekindled interest in metabolic and dietary therapies for brain disorders complements new insight into their mechanisms and broader implications. Here we describe the emerging relationship between a KD and adenosine as a way to reset brain metabolism and neuronal activity and disrupt a cycle of dysfunction. We also provide an overview of the effects of a KD on cognition and recent data on the effects of a KD on pain, and explore the relative time course quantified among hallmark metabolic changes, altered neuron function and altered animal behavior assessed after diet administration. We predict continued applications of metabolic therapies in treating dysfunction including and beyond the nervous system.”

The nervous system and metabolic dysregulation: emerging evidence converges on ketogenic diet therapy.

Ruskin DN, Masino SA.  Front Neurosci. 2012;6:33. Epub 2012 Mar 26.

PMID: 22470316  Free PMC Article

(2) extensive review article, full text available, extremely detailed on scientific investigation of metabolic effects of ketones and ketosis

The neuroprotective properties of calorie restriction, the ketogenic diet, and ketone bodies.

Maalouf M, Rho JM, Mattson MP.  Brain Res Rev. 2009 Mar;59(2):293-315.  Review.

PMID: 18845187   Free PMC Article

(3) review article, this links to abstract, but full text does not seem to be open access

“The large categories of disease for which ketones may have therapeutic effects are:(1)diseases of substrate insufficiency or insulin resistance,(2)diseases resulting from free radical damage,(3)disease resulting from hypoxia.”

The therapeutic implications of ketone bodies: the effects of ketone bodies in pathological conditions: ketosis, ketogenic diet, redox states, insulin resistance, and mitochondrial metabolism.

Veech RL.

Prostaglandins Leukot Essent Fatty Acids. 2004 Mar;70(3):309-19. Review.

PMID: 14769489

(4) interesting discussion, which challenges some current widely-held concepts in biochemistry.  It would be interesting to see a rebuttal by a biochem prof. Full text available.

Metabolic effects of the very-low-carbohydrate diets: misunderstood “villains” of human metabolism.

Manninen AH.   J Int Soc Sports Nutr. 2004 Dec 31;1(2):7-11.

PMID: 18500949   Free PMC Article

(5) A recent line of research suggests a cautionary attitude towards ketosis as evidence suggests some (or many, or most ??) tumors can be fueled by ketones produced by fibroblasts closely associated to the tumor cells. This is just the most recent of a number of papers regarding this line of research.  Of note, they are not researching the effect of ketones in the blood stream – this research is specifically and only about ketones produced in fibroblasts right by the malignant cells (part of the tumor mass itself).  Also, this work does not negate the line of research suggesting some cancers may be unable to metabolize ketones and may show reduced growth when ketones are high and glucose is low normal (especially malignant gliomas) – see below.

Ketone body utilization drives tumor growth and metastasis.

Martinez-Outschoorn UE, Lin Z, Whitaker-Menezes D, Howell A, Sotgia F, Lisanti MP.

Cell Cycle. 2012 Sep 19;11(21). [Epub ahead of print]  PMID: 22992619

(6) ketogenic diet being investigated for potential benefit in brain cancer (Note: there must always be glucose in the blood.  No glucose in the blood equals rapid death.  It is not possible to starve tumors by cutting off the glucose supply in the blood. The blood glucose can be brought down to low-normal, minimally fluctuating levels.)

Is the restricted ketogenic diet a viable alternative to the standard of care for managing malignant brain cancer?

Seyfried TN, Marsh J, Shelton LM, Huysentruyt LC, Mukherjee P.

Epilepsy Res. 2012 Jul;100(3):310-26.  PMID: 21885251

Ketosis in a Nutshell – Part 1, What’s Up?

Macadamia integrifolia (Macadamia Nut) - culti...

– – an inside joke – macadamia nuts are popular among those seeking ketosis.

We Newly Have Practical Access to a Potentially Major Health Intervention

CLUNK  – – Click, click … whirrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr …….

The recent adoption of home testing of blood ketones as a tool in the use of nutritional ketosis is like a missing gear being dropped into place. Many streams of knowledge and progress are brought together in a new and newly workable way.

Ketosis and Nutritional Ketosis – What is this?

You can learn to eat in a way that causes you to burn a lot of fat while burning low amounts of glucose. In the process, your liver will produce ketones, these will travel in your blood stream (ketosis) and be burned for energy. You have altered your “nutrition” to be in a state of “ketosis” – thus the term “nutritional ketosis”. This is also referred to as eating a “ketogenic diet”. When you do this over time, you gradually become more adapted to functioning in this state. This is called being “keto-adapted”.

This is all entirely different from diabetic ketoacidosis, which is a very serious medical emergency that can develop very rapidly and is potentially fatal. Ketoacidosis is precipitated by dehydration in the context of insulin deficiency. A person who is not deficient in insulin function will not develop ketoacidosis.

It seems to be talked about a lot recently. Why the buzz?

This is an eating strategy that can act as powerfully as a medication.

This eating strategy may improve your sense of well-being and physical performance.

It may be useful in many more situations, involving many more people, than we thought.

It has now become much more practical to use as a long-term choice than we thought.

Known and Potential Uses:

(1) Medical

When considering what we know of nutritional ketosis, plus what new insights and research suggest, nutritional ketosis has or may have a substantial role to play in:

  • blood sugar control
  • management of metabolic syndrome
  • visceral fat control
  • obesity
  • appetite control
  • epilepsy, in both children and adults
  • Alzheimer’s Disease and some other neurological conditions
  • and what others unknown?

(2) General Well-Being

Besides the above, many people who have become keto-adapted report that they just feel a lot better over-all. Many report improved energy levels, mood or mental clarity.

(3) High Performance

Beyond that, being in nutritional ketosis can mean improved physical performance, particularly in endurance activities. Competitive athletes are making use of this.

Great – But is it Usable? Is it Practical Long Term?

The key to unlocking the great potential for benefit is that nutritional ketosis must be a realistic, practical option for long-term use. This has been the major block. Why consider it as an option for people to use if it just seems to be much more of a burden that a help?  Why do a lot of research about something that won’t be used?  It must be worthwhile – the benefits must be worth the “costs” in effort, limitations, risks, etc.

The key criticism of ketogenic diets and thus of the use of nutritional ketosis as a health tool or medical treatment has been that they are “too difficult” and not worthwhile over time.

(1) Poor testing options mean we have not been able to accurately assess either long term benefits or long term practicality.

A “ketone” is a type of molecule, not just one molecule. However, the tests measure just one of the types of ketone molecules that the body produces when in ketosis.

Until recently, the only test for ketosis that could be used day-to-day at home was urine test strips. Blood ketone testing could be done at a medical lab, but this was too expensive and awkward for routine use. The trouble is, urine test strips are not very useful for monitoring the level of ketosis once a person has become adapted over weeks to being in ketosis.

The reason ketone test strips were developed and marketed is so people with diabetes can test themselves for ketones and so have early warning if they are headed for ketoacidosis and need to seek urgent medical attention. The urine strips test for a molecule called acetoacetate, which shows up in the urine right away when someone is just going into ketosis or has been in ketosis a short time. For diabetics, this works very well and is a cheap, convenient test (at least, for those people with diabetes who are not chronically in low-level ketosis from choosing to eat in a way to be in nutritional ketosis).

When people eat in a way to develop ketosis, the body adapts to this. Part of this adaptation is that the metabolism of the various ketone molecules changes. The level of acetoacetate molecules go down, so that, for example, the person can be in a low level of ketosis and yet this might not show on a urine test strip.  In this situation, use of blood ketone testing provides much better information.  Blood ketone home monitors test for a different ketone molecule called beta-hydroxybutyrate.

Blood ketone home monitors have been available for a while, but have been little known outside of the field of diabetes and even then, not widely used. Their potential role as a tool in the use of nutritional ketosis has only recently arisen as a topic.

The particular trigger for this was the publication in April 2012 of the influential book The Art and Science of Low Carbohydrate Performance by Jeff S. Volek, PhD, RD and Stephen D. Phinney, MD, PhD. Subsequently, awareness and interest in the topic has surged in the wake of the reports by Jimmy Moore of the very widely followed blog Livin” La Vida Low Carb, detailing of his personal experiences with using blood ketone testing. Jimmy Moore’s n=1 Experiments: Nutritional Ketosis Day 91-120

(To be fair, I should acknowledge that the first mention I saw of blood ketone testing meters was on Dr. Peter Attia’s site in March 2012.)

(2) Any medical treatment that cannot be well monitored or adapted to the individual over time will always appear less effective and more burdensome than it truly need be.

It may be that the benefits of nutritional ketosis have been masked by lack of ability to monitor or target the degree of ketosis properly for individual tolerance and benefit. That is, perhaps the lack of good testing options has meant that the way ketosis has been used has made that it appear less effective than it really can be and, at the same time, more difficult or burdensome to live with than need be.

Deliberately eating in a way to cause ketosis has basically been used in two ways:

  • as a medical treatment for epilepsy, in which extremely strict diets were used
  • as part of a low carbohydrate weight control plan (Atkins Diet), of which ketosis is a major tenant. The lack of ability to accurately test to see if a person stays in ketosis over time, and the degree of ketosis, has likely been a source of confusion and inconsistency – likely major factors in the degree of variability in people’s responses and how people do over time.

(3) Blood ketone testing brings individuals a better chance of finding lasting benefit.

Consider a person who has benefits from being in sustained ketosis (being keto-adapted). If that person is going in and out of ketosis or having wide fluctuations in their degree of ketosis, those benefits will come and go in confusing, unpredictable ways.  In this case they may well find that the efforts and costs (things they give up, changes in their life, any side-effects and risks, etc.) are not worthwhile over time. If they choose to abandon their efforts to be in ketosis, they then get zero benefits.

If they can use home testing of whether they are in ketosis and the degree of ketosis, they can use this to more accurately perceive any benefits. With more effort and time they can get a reasonable idea of what level of ketosis is associated with what degree of benefit. In terms of the costs, they will have realized what eating patterns or other factors are required for them to be able to be in ketosis or at certain levels of ketosis. From experience, that person can begin to form a judgement of what the balance of benefit versus cost is for them. There is a better chance that they may find at least some level of benefit that they are able to enjoy long term because they are able to choose a level of costs that they personally find worthwhile.

The benefits a person can notice for themselves will often be only part of the story.  Assessment by their physician, possibly including lab tests and other investigations, is a necessary part of considering what the benefits have been.  Even then, some of the benefits may be difficult to evaluate and some may be slow to develop and only evident over years.

Similarly, it is dangerous and unwise to assume that the harms and burdens a person notices themselves are the whole picture. Again, assessment by a physician, possibly including lab tests and other investigations, is a necessary part of considering what harms there have been and what the ongoing risks are. Even then, there may be unrecognized or hidden harms that do not become evident until some years later

(4) Blood ketone testing will open up progress in understanding and research.

People can communicate with each other and with their health providers much more effectively about their experiences with nutritional ketosis.  Researchers can target new questions and new areas of potential benefit.

For example, many research studies have been done to evaluate the benefits of low carbohydrate diets. Yet, none of them have used monitoring of blood ketone levels as a tool to evaluate the presence or depth or variability of nutritional ketosis despite the fact that it is one of the key proposed beneficial mechanisms of low carbohydrate programs. (** see addendum below for correction)  Again, consider the fact that if a person is unknowingly moving in and out of ketosis they are likely to find this very disruptive and un-satisfactory, which could well lead to abandonment of the intended eating plan and a perception that it is not worthwhile.

So, There is Promise  – What are the Risks or Concerns?

We are in the early stages of understanding about nutritional ketosis and how this might be useful for general well-being or medical purposes. The potential for benefit seems to be large.

What we already know for sure is that some people’s bodies seem to adapt well to ketosis and some people’s do not. There are some people for whom nutritional ketosis is not suitable.

We need to learn much more about possible side-effects and potential for harm, especially long-term. We do already know about some side-effects and harms that can develop that we need to be cautious about – for example dehydration, exaggerated  medication effects and serious problems with sodium and potassium. There is considerable potential for harm from un-recognized long-term deficiencies of essential nutrients, as feeling “full” does not in any way mean that one is well “filled” with the essential vitamins and minerals.

As with everything else in health and medicine, there is wide variation between people in the benefits and the harms that any individual may personally experience.

The trade-offs and cautions and risks (an incomplete list):

  • this requires following a very specific eating pattern, and this needs to be learned
  • that eating pattern needs to be consistent over time, with little use of “breaks” or “holidays” from the eating pattern
  • it takes a while for your body to adapt to using ketones for fuel and, until then, you may have side-effects and feel tired or unwell
  • you will be more susceptible to dehydration, to low blood sugar, and to potentially serious problems with the “electrolytes” sodium, potassium, calcium and magnesium. If you don’t take the time and effort to learn about these things,and are not prepared to be disciplined about them, do not consider proceeding.  Beyond that, there are medical conditions and medications and herbal (and other) therapies that can mean you are even more susceptible to these problems, and these must be considered. Nutritional ketosis is not appropriate in all situations.
  • there are certain situations or medical conditions that would mean that you should not use nutritional ketosis (or should do so only with knowledgable professional help). One particularly critical consideration is that there are certain medications that may need to be changed or doses adjusted before starting and possibly at frequent intervals in the first days, weeks and months.
  • you will need to put some time and effort into learning how to not harm yourself with poor nutrition while eating this way. Feeling full does not in any way mean that your full nutrient requirements are being met. Poor nutrition can be hidden and not produce warning signals that are obvious or easily understood. Our ability to monitor with lab tests how well you are stocked with the many essential vitamins and minerals is remarkably poor.
  • children and pregnant women require special consideration beyond the scope of this article.

This is an incomplete list. Even 5 years from now, it will not be possible for anyone to produce a complete list. The full risks of harm from nutritional ketosis, especially over a prolonged time, are not known. Have caution.


** Addendum Sep 29/12  – Touched by an Angel – Thank-you to Jenny Ruhl for gently pointing out my carelessness in this paragraph.  What I wrote was not correct as stated and what I wrote did not match very closely what I was trying to express.  I’ll take another stab at it.  – Many studies have been done to investigate the usefulness of the “low carb diet” approach to weight loss. These fall into two types. One type of study is basic research – “what can we demonstrate happens when we carefully do “x””.  “How does the body respond under these circumstances?” They are done on relatively small numbers of people and under close supervision.

The other type of study is designed to see how useful the intervention “x” proves to be in larger numbers of people in something closer to a real-world situation  – this intervention “x” may have certain effects on the body, but is it useful under practical circumstances?  When you offer this to people, do the benefits play out as expected?  As part of this – do people continue with the intervention or do they abandon it for one reason or another?  As it turns out, generally in these larger studies there are many people who do not follow the low carb eating plan as instructed for very long into the study period.

These results form a major justification for the continued claim and perception that “low carb diets” may be theoretically useful but fail in the long run, and they fail specifically because people find they are not able to stay with the diet plan.

“Low carbohydrate diets” are not necessarily ketogenic diets, although they may be, and this causes confusion and error.  From what I recall, the emphasis in these larger studies is on the “low carb intake” rather than on the “dietary ketosis” itself.  If you go back to Dr. Atkins’ 1972 book, he strongly emphasized the critical role of ketosis, with low carb being the means to that end. Then you have to ask yourself, what is being tested?  I think the question has been muddied, which, if so, would certainly compromise the usefulness of the research results.  In research, it is all about the question.  If people aren’t taught that ketosis is the central target, how to be in ketosis and then adequately supported in understanding, trouble-shooting and individualizing their lifestyle/health/diet program to optimize their ability to attain and maintain ketosis, then what is being tested may be any manner of other useful questions about various degrees of limitation of carbs in the diet, but the results of the study will have no meaning towards questions about dietary ketosis.  Having people do urine ketone testing may or may not represent this level of focus and support.

For example, the description of the low carb diet used in the 2008 study published in the New England Journal of Medicine, in which they did use urine ketone testing:

“This low-carb, non-calorie restricted diet aimed to provide 20g/day of carbohydrates during the induction phase (first 2 months), and returned to this level of severe carb restriction after each religious holiday. At other times participants were instructed to increase carbs gradually up to maximum of 120g/day to maintain the weight loss. Total calories, protein and fat intake from any source (except industrial –trans fats) were not limited.”

This is a brief summary of the “low carb diet” used in this study:

Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet.

Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz Z, Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Blüher M, Stumvoll M, Stampfer MJ; Dietary Intervention Randomized Controlled Trial (DIRECT) Group.

N Engl J Med. 2008 Jul 17;359(3):229-41. Erratum in: N Engl J Med. 2009 Dec 31;361(27):2681.

PMID: 18635428  Free Article

They were testing a more liberal version of the “Atkins diet”, which is a perfectly valid thing to do.  There are many aspects of the whole ball of wax referred to loosely as “low carb” that are in need of study.  They were not trying to study ketosis and they did not claim to have learned anything about the value or effects of sustained ketosis.  In the full text, they only report the urine ketone level at baseline (pre-diet) and at 24 months.  I don’t see any mention of urine ketone testing at any other time or of the participants using at-home urine ketone testing as a way to monitor whether they are in ketosis or as a way to prompt any changes in what they are doing.  Of course, a part of the reason for this may be the awareness of the imprecision of urine ketone testing in milder states of ketosis once a period of adaptation to ketosis has passed.

Given that they are reporting on their results with a “low carbohydrate diet”, even though they did not study ketosis, the results may be mis-interpreted as applying to sustained ketosis.

If people are unknowingly and inconsistently moving in and out of ketosis, it would be expected that they would experience the appearance and disappearance of both welcome effects and unwelcome side-effects.  It would be expected, in that circumstance, for weight and appetite and energy levels to fluctuate widely.  This could be expected to be very discouraging and result in many people abandoning the diet.  The sudden jump in hunger when moving out of ketosis would often lead to even greater food intake, putting the person firmly out of ketosis.  Carbohydrate craving in this circumstance can simply be a sign of moving out of ketosis, but, without proper education and awareness about ketosis, is likely to always be interpreted as an emotional desire for carbs or as “missing them” too much (which can also happen).

I hope that the increase generally in research and interest related to ketosis, along with the availability of home blood ketone meters, will lead to :

  • a clearer framing of the question and study design, taking the above into consideration – are they studying ketosis or not
  • if they are NOT studying ketosis, a recognition of the importance of a study design that does not ignore the possible confounding factor of ketosis
  • if they are proposing to be studying ketosis, or Dr. Atkins’ original claims, a recognition that teaching the study participants a “low carb diet” or “very low carb diet” and having it “sort of” followed is not any longer an acceptable proxy for studying a “ketogenic diet”


To be continued …. Part 2

Important Note: This article is written to promote discussion. It is not intended to be medical advice. It is not intended to promote the use of a ketogenic diet or nutritional ketosis by any specific individual. Any person who would like to consider the use of a ketogenic diet or nutritional ketosis should first seek the advice of their personal physician. This article is an overview and does not provide enough information for anyone to use for clinical decision-making.

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The Terms

“Ketosis”  means there are “ketones” in your blood. People have at least a very small amount of ketones in their blood all the time. Generally, the word “ketosis” is only used when the ketones are more than just the usual very low day-to-day background level.

“Ketones”  are a type of molecule you produce in your metabolism. They are produced in the liver during the breakdown of fat molecules. These ketones do not show up in the blood at more than trace levels unless there is a lot of fat being broken down in the presence of low supplies of glucose. Insulin stops the production of more than trace amounts of ketones, and insulin levels are higher with increasing amounts of glucose.  Ketones are a valuable fuel molecule and an essential part of our metabolism. They are not directly harmful in any way except if they reach extremely high levels, which can only happen in diabetes (see “ketoacidosis”).

Ketones can be used for fuel by almost all the organs and cells of the body. One of the especially important things about them is that they are the only fuel besides glucose that the brain can use. The brain uses ketones for a fuel very readily, but ketones can not be used in all the ways that the brain uses glucose, so there is always a need for an adequate, normal level of blood glucose (some other cells also need glucose, such as the retina and the red blood cells).

“Ketone bodies”  – In chemistry, there are many, many molecules that are of the type classed as ketones.  When we refer to “ketones” in your body, by common usage we are specifically meaning three molecules named acetoacetate, acetone and beta-hydroxybutyrate.  Technically beta-hydroxybutyrate does not fit the definition for ketones. Functionally, beta-hydroxybutyrate acts like a ketone in that it can readily be metabolized back to acetoacetate, thus acting as sort of a transit or storage form of ketones. The term “ketone bodies” is useful in that it has been used as a catch-all phrase to refer to these specific three molecules (one of which is a ketone supplier, rather than a ketone itself). (Note: this description amended Sep 29/12)

“Ketoacidosis”  is a very serious, potentially fatal condition that can occur in people with diabetes. Having insulin in the blood to stops ketones from going very high, so people who produce enough of their own insulin will not develop very high ketone levels no matter how they change their food intake. Even people in starvation do not get ketoacidosis (unless they are diabetic).

“Nutritional ketosis” or “dietary ketosis” means that, because of what you have or haven’t eaten, your body is making more of the type of molecule called “ketones”. This distinguishes ketosis caused by reasons outside the body from ketosis produced by abnormal function of the body (deficiency of insulin).

“Depth of ketosis”  or “degree of ketosis” refers to how much the level of ketones in the blood rises.  You are “deeper in ketosis” as your blood level rises higher.

“Keto-adaptation”  is a term coined by researcher Dr. Stephen Phinney M.D. to refer to the fact that it takes some weeks and up to 2-3 months for a person’s body to fully adapt to functioning in a state of nutritional ketosis. That is, to become adapted to using fats and ketones as the predominant fuel, instead of the usual situation, where glucose is used as the predominant fuel. Part of keto-adaptation is that there is a normal, steady  blood level of glucose, with the glucose coming mostly from sources within the body, rather than coming mostly from the digestion and absorption of glucose from food.

Canada Day Stories

Happy Canada Day!

Having just been away and back to Toronto, I enjoyed my wonderful, near cloudless view of the country from my window seat going and coming.

I was in Toronto for the Obesity and Mental Health Conference, which was very worthwhile.  The lecture slides are on-line.  LINK

Going completely off-topic today, I have two stories for your consideration.

The first is a story of my family, written by my Grandfather about his father’s very long and adventure-filled life all over the emerging west – in the US and in Canada.  The latter decades he spent with his three sons as one of the pioneering families in the Caribou region of BC.

A brief article relating to the book and the lake where they settled – LINK.

The Rainbow Chasers, by Ervin Austin MacDonald, is available in paperback, Kindle and Nook. (Note: there is an apparent listing for a hardcover version, but this is incorrect, there has not been a hardcover edition.)

Yes, for once I have a commercial interest to disclose.  My mother and my Aunt do get royalties for this book.  Poor wages for the many hours that went into putting together the second paperback edition. 🙂

On (includes Kindle option)  LINK

On (does not offer Kindle option) LINK

On Barnes and Noble (includes Nook option) LINK

One summer when I was about 14, we went up to the region, with my mother’s sister’s family and my Grandparents.  We picked up my Grandfather’s brother and his wife in a nearby small town and stayed for a week or so in a cabin on nearby Bridge Lake.  The two brothers had not seen a lot of each other since leaving the ranch and settling in different areas of BC.  My Grandfather had not been back to the ranch in all the intervening decades.  When the brothers got together, the stories just poured out of them.  My cousin and I would come in from the lake for lunch and just stay sitting there, in our wet bathing suits, transfixed.  Only a small selection of those stories made it into the book. (Bridge Lake was named that because of the bridge that my Grandpa, his brothers and father helped build there.)

The second is the story of Sir John A. MacDonald, Canada’s first Prime Minister.  In this interview on CBC, you’ll hear of the history of Canada as you have likely never heard it before!  This link includes a first and a second interview.  It is the first interview that is particularly enlightening and entertaining. No boring history here!  LINK

This week’s audio is also on the Canada Day theme and is comedy this week, rather than the usual music selection.

The comedy show The Debaters features two comedians who “debate” (sort-of) each other on assigned topics.  This week’s show featured a debate on the “merits” of picnics versus barbeques and another debate about the Canadian flag.  LINK

Now for some sunshine.

Testing Blood Ketones Update

At the bottom is an addendum to this article (originally published May 28th).

Also, Jimmy Moore, of Livin’ La Vida Low Carb, has posted his very interesting report of the first 30 days of his trial of using blood ketone testing and I’m sure interest is going to rise quickly.

Testing Blood Ketones to Monitor Nutritional Ketosis

A number of people who follow a low-carb lifestyle have become interested in testing blood ketone levels.  The reason for this is that the amount of ketones that show up on urine testing tends to drop over time as your body adapts to burning ketones for fuel.  This makes following your urine ketone level (urine dip sticks for ketones) of limited value.

If you are eating low carb, you may be surprised to find that your level of blood ketones is much less that you expect.  The old “people are so different” game.  This matters if being in ketosis would be helpful to you personally for your fat burning and your appetite/satiety balance.  If your health is fine without dropping your carbs (actually total carbs plus some limit on protein) down far enough for ketosis, then going this extra mile isn’t something that you necessarily need to do to thrive.

It also matters if you are wanting to be in ketosis for some of its other known or proposed medical benefits (such as seizure control) or its benefits in athletic performance.

If you ketones are not in the range that you’d like, the first things to think of are (1) are you having more carbs than you thought and (2) should you cut back a bit on protein, though keeping in mind that adequate protein is essential?

If that’s not the answer, perhaps your liver is just pumping out too much glucose.  This happens when the liver becomes “insulin resistant”.  Yes, your liver can become insulin resistant just like your muscles can.  This effect is noticed most in the mornings. If you are not yet diabetic or heading into pre-diabetes, this may be happening without necessarily showing up as a notable rise in blood sugar (glucose) level if you still have enough insulin effect to clear the glucose from the blood.

If you are eating low carb, you also will have more ketones with greater activity or exercise levels.  There are also medications and medical conditions that could be a factor.  This area of science has not received enough research attention to say that we understand it very well, yet.

If you consume a significant amount of medium chain triglycerides (MCT), such as tablespoon amounts of coconut oil, you will have some ketones in your blood that are produced directly from those medium chain triglycerides that you have just eaten, whether you are truly “in a ketogenic state” or not. This is too much to explain properly in this post, so I’ll write on this topic another day.

If you are at all interested in doing this yourself, you will need to put some time and effort into learning about this topic.  You would need to thoroughly understand the safe and effective use of low carb dieting and the ins and outs of nutritional ketosis.

If you are considering low-carb eating for yourself, especially at the level of going into ketosis, you must discuss this first with your doctor as (1) there may be reasons for you that this might be a bad idea or a bad idea at this particular time, (2) you may need some testing before and during and (3) you may be on medications that could have very dangerous and potentially lethal effects if the medications are not or cannot be adjusted or changed before and during the transition.  You may need frequent medical follow-up in the first days and weeks for adjustment of medications and medication dosages.  This is an interesting problem, when you think about it.  Your health may improve so quickly that you could actually be killed by the medications you take because those medications are to help you with problems you no longer have.

The book to read that is most informative about nutritional ketosis is The Art and Science of Low Carbohydrate Performance by Jeff S. Volek, PhD, RD and Stephen D. Phinney, MD, PhD.  The price is more than reasonable ($8.95 on amazon and no I have absolutely no commercial ties or links). (Update: now available in Kindle format for $5.99)

One of the speakers at the Nutrition and Metabolism Society meeting in 2011 was Dr. Adam Hartman, who is an expert in the use of ketogenic for the control of epilepsy in children.  He made an interesting comment on the timing of testing for ketones.  When eating the typical mixture of foods that people normally consume in our society (a mix of proteins, carbohydrates and fats), ketones are highest in the morning.  This makes sense because the least flow of carbohydrates in from the digestive tract is overnight, so the body burns some fat in the night.  When eating a ketogenic diet, on the other hand, the most exposure to carbohydrates is overnight especially towards morning as the liver produces glucose to keep your brain fueled and to prepare you for getting up.  Therefore, if you are eating a very ketogenic diet, the blood ketones go up during the day as you burn more fat for fuel.

Regarding testing blood ketones, the following refers to the blood ketone test strips for the Abbott Precision Xtra (Medisense).  These come in a box of 10 strips.

Please note that the shelf life of these strips is not long (I don’t know the details) so please be aware of this before ordering a large number of testing strips or before buying from a source you don’t have confidence in.  An expiry date will be on each box and a lot number.

For people in Canada, the first place to turn to is your local pharmacy.  I bought mine at London Drugs (a major chain) over the counter for $20.00 per box of 10 strips.  I checked their on-line ordering site, and they do not offer these strips for on-line sale.  I didn’t shop around to compare price, so I am not advocating London Drugs over any other store.

People in the US face prices for these testing strips that can be quite high and also people in smaller towns may have difficulty getting testing strips locally.  I did some looking around on-line.

Also, of course I can’t vouch for any company on-line or not.  You have to look into any company or on-line seller and make a decision for yourself.

I am just reporting what I have found on-line. I have no idea whether these are good companies (or even real companies) or not.  Exercise caution.

A significant factor in cost could be the shipping fees, so you might want to take that into consideration, not just the price per box. offers at this link a box for $24.29 USD ($2.43 per test strip) lists, at this link

  • $32.42 USD (May 28/12) for box of 10 ($3.24 per test strip)
  • for 3 boxes or more (30 test strips or more) this drops to $2.49 per test strip

Universal Drug Store offers at this link a box of 10 for $19.99 USD ($2.00 per test strip)

There may be other sites that are as good or better, this is just what I found with about 20 minutes of checking.

I am not advocating that you purchase from any of these sites or that these sites will link you to a reputable business.  Buyer beware.

If you come up with something better, please let me know.

UPDATE June 14, 2012

My Abbott Precision Xtra (Medisense) is my new BFF.  Turns out I really do need the ketosis (at least for now) to have a reasonable time with appetite and I was not reliably achieving that with my low carb eating.  Despite carbs total about 15 g most days (1-2 times a week up to perhaps 25 g) and protein most days about 90 g (some days about 100 g), I was not getting a good level of blood ketones.  My fasting ketones were 0.4 mmol/L to 0.6 mmol/L and late afternoon ketones 0.9 mmol/L to 1.1 mmol/L. I have cut back a bit on protein and added some MCT oil.  It will be a while to find my best balance, but I feel an effect on appetite with my ketones in the range from about 1.5 mmol/L to 3.2 mmol/L.  Above that I feel a bit tired and out of focus.

It will take some time before there is much collective understanding about the hows and the whys of using blood ketone testing for insight into low carb eating and its benefits.  People will have to put their heads and their experiences together.  Also, we have to avoid jumping to conclusions too soon, based on only a few people’s experiences.

Addendum July 18, 2012

When I originally wrote this post on May 28th and when I composed the update on June 14th, the book “The Art and Science of Low Carbohydrate Performance” was not available in Kindle format. It was released in Kindle format on June 15th.  The price is a paltry $5.99 for this excellent book packed with useful insights into low carbohydrate nutrition.

Short link for this post

Where will you be at 94?


Ok, bringing up Dal Richards feels a bit like cheating.  Here is Vancouver’s own Big Band Leader extraordinaire, in this video just 2 months short of his 94th birthday, proving that, at least for some people of his generation, it has been possible to maintain high health while not following a low carb diet!

If I tried to eat a typical “general mixed diet”, my health would be down the tubes in no time.

If you want to know a bit more, see the TV segment on his 94th birthday YouTube Link

Where will you be at age 94?  This summer, you can join Dal Richards as he performs on a cruise ship going up the BC coast.


A gluten-free low-carb bar in a pinch


On my recent trip to Denver for the obesity conference, I was so very glad to have found a gluten-free low-carb snack bar that I can use in a pinch.

I keep pretty much to real foods and eat quite simply.  Personally, I don’t fill my life with low-carb baking or with a lot of artificial sweeteners or sugar alcohols as sweeteners.  (For some people, though, this can be an important part of their long-term strategy that works for them.)

When travelling while eating gluten-free and low-carb, things can get difficult even when all goes according to plan.  I was glad that I planned ahead for this and had ordered from the US a box of snack bars and packed some for the trip.

I have absolutely no ties to any companies, so I’ll go ahead and mention the name Quest Bars, which I learned of through listening to Jimmy Moore’s LLVLC podcasts.  Having some of these with me really came in handy and saved me from having to go hungry on more than one occasion.

These bars are not sold in Canada.  You can, however, order them from the US for personal use (not to bring them in and sell them) as long as you stick to an amount that a Custom’s Agent would consider reasonable for personal use for a couple of months.  I ordered them from a major on-line supplement retailer that I have ordered from many times in the past 5 years or more.

To me, this is something I would only turn to for uncommon situations, such as a long flight.  If I started to think that I “needed” to have one every week or every few days, I would start to wonder about myself and to understand that I was just making up excuses.  Having the option of a gluten-free low-carb snack bar is great to know about, but if they start to call your name from the cupboard, perhaps they aren’t for you.

Gluten awareness even for low-carbers

There has been a fair amount of interest in my article on the need for gluten awareness even in the world of low-carb nutrition or grain-free eating, such as a Paleo lifestyle.

The topic is much larger than can be contained in any one blog post.  I tried to explain my thoughts a bit more in the comments section under the article, including:

With the immune system, the dose causing impact is orders of magnitude less than for the blood-sugar control system.

With the immune-system, the price to pay for small intakes is out of all proportion.

The Canadian Celiac Association is one place to look for info, such as this article on the new food labelling laws coming into effect in Canada in August.

Canada is in a transition period between the old labelling regulations and new regulations that take effect on August 4, 2012. By that date, labels for all food products sold in Canada will have to carry clear identification of the priority allergens, gluten, and added sulphites at a level greater than 10 ppm.

In Canada, gluten means “any gluten protein or modified protein, including any protein fraction derived from the grains of the following cereals: barley, oats, rye, triticale, wheat, kamut or spelt”. The definition also applies to the grains of hybridized strains of the cereals listed above.

And this article on cross-contamination:

People who need to eat gluten free need to check both the ingredients in food and any cross-contamination with gluten-containing ingredients that might happen when the food is manufactured, packaged and prepared for eating.

When you think about avoiding cross-contamination, you need to realize that crumbs matter. Look around your kitchen to see where there are crumbs – on the counter top, in the microwave, on the cutting board or in the corners of your metal baking dishes? Anywhere you see crumbs is a potential place for cross-contamination.

The Celiac Disease Foundation at has an article on gluten in medications, along with extensive other info. offers a mind-boggling list to keep in mind when reading food labels Unsafe Gluten-Free Food List (Unsafe Ingredients), along with extensive other info.

You might enjoy a “Wheat is Murder, Go Paleo” t-shirt from Tom Naughton’s site Fat Head.

I know, I know. Just eat non-processed real foods and you don’t have to worry about labels.  Yeah, that’s what I do.  But life ain’t perfect and neither are people and the penalty for small “sins” should not be so large.

When the 8 percent of us who need to avoid even tiny intakes of gluten (this is a rough estimate, true incidence not known and likely rising) are aware, knowledgable and active, life will get easier as the world adapts to our presence.

Review: Diet 101 by Jenny Ruhl

Diet 101: The Truth About Low Carb Diets (Kindle Edition)
This book is a natural continuation on from the author’s on-line interactions and blogging that led to her remarkable contribution Blood Sugar 101. There has been a perception that the main value of choosing to change the amount or type of carbohydrates (sugars and starches) in your diet is as a weight loss diet. Also, there has been a perception that this strategy is only valuable if applied very strictly – and this strict application then means that many people find it too difficult to keep up over time.

In Diet 101, Jenny Ruhl emphasises the fact that the greatest value from controlling carbs is in keeping blood sugars within the normal, non-damaging range. What if you’re not diabetic? Many people who do not meet the cut-off blood sugar test levels to be diagnosed with diabetes have blood sugar levels, at least for parts of the day, that are associated with slowly-accumulating harm to health. This problem is very widespread in our society.

What to do? This damage can be avoided, or at least lessened, by changing your intake of carbohydrate foods – by just as much as you need to and/or are able to. Even changes less than targeting perfection can bring benefits you might really value.

Jenny Ruhl explains all this in her new book in a clear, easy to understand manner, with all the back-up science also available for those who are interested. Also, she ties the excess swings in blood sugar to excess hunger drive and the tendency to gain weight. To be useful, this needs to be practical day-to-day, which is an important goal and strength of the book.

My review on Amazon of Jenny Ruhl’s new book.

Update: Please see my blog “Carpe Your Blood Sugar” inspired by the work of Jenny Ruhl and Dr. Richard K. Bernstein.  Links on the Resources page there to 3 interviews with Jenny.

(This post short link