December 2, 2011

Ketosis

Is ketosis dangerous?

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You may have heard from your doctor that ketosis is a life-threatening condition. If so, your doctor is confusing diabetic ketoacidosis (DKA) with nutritional ketosis, or keto-adaptation.

First, some semantics.  Our body can produce, from fat and some amino acids, three ketone bodies (a “ketone” refers to the chemical structure where oxygen is double-bonded to carbon sandwiched between at least 2 other carbons).  These ketone bodies we produce are: acetone, acetoacetone, and beta-hydroxybutyrate (B-OHB). [For anyone who is interested, they are the 3 most right structures on the figure, below.]

Why do we make ketones? For starters, it’s a vital evolutionary advantage.  Our brain can only function with glucose and ketones.  Since we can’t store more than about 24 hours’ worth of glucose, we would all die of hypoglycemia if ever forced to fast for more than a day.  Fortunately, our liver can take fat and select amino acids (the building blocks of proteins) and turn them into ketones, first and foremost to feed our brains.  Hence, our body’s ability to produce ketones is required for basic survival.

What is diabetic ketoacidosis? When diabetics (usually Type I diabetics, but sometimes this occurs in very late-stage, insulin-dependent, Type II diabetics) fail to receive enough insulin, they go into an effective state of starvation.  While they may have all the glucose in the world in their bloodstream, without insulin, they can’t get any into their cells.  Hence, they are effectively going into starvation.  The body does what it would do in anyone – it starts to make ketones out of fat and proteins.  Here’s the problem: the diabetic patient in this case can’t produce any insulin, so there is no feedback loop and they continue to produce more and more ketones without stopping.  By the time ketone levels (specifically, beta-hydroxybutyrate) approach 15 to 25 mM, the resulting pH imbalance leads to profound metabolic derangement and the patient is critically ill.

But this state of metabolic derangement is not actually possible in a person who can produce insulin, even in small amounts.  The reason is that a feedback loop prevents the ketone level from getting high enough to cause the change in pH that leads to the cascade of bad problems.  A person who is said to be “keto-adapted,” or in a state of nutritional ketosis, generally has beta-hydroxybutyrate levels between about 0.5 and 3.0 mM.  This is far less than the levels required to cause harm through acid-base abnormalities.

Keto-adaption is a state, achieved through significant reduction of carbohydrate intake (typically to less than 50 grams per day) and moderate protein, where the body changes from relying on glycogen as its main source of energy to relying on fat.  Specifically, the brain shifts from being primarily dependent on glucose, to being primarily dependent on beta-hydroxybutyrate.  This has nothing to do with what a diabetic patient is experiencing in DKA, but does illustrate how poorly informed and quick to react the medical community is.  DKA and nutritional ketosis (or keto-adaptation) have as much in common as a house fire and a fireplace.

Photo by Andrew Yardley on Unsplash

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643 Comments

  1. Thank you!
    I knew that ketosis and ketoacidodis were different already (I got here through Gary Taubes’ blog), but this explains very clearly how they are different, and not just quantitatively but qualitatively.

    • H Peter Attia,

      I was diagnosed w insulin resistance severe kind. Three years ago. I worked on my diet most protein good fats and vegetables . I swim 6 hours a week. Last six months I thought I felt better so I added some carbs not a lot just a wrap chicken breast . One slice a pizza , little roll w tomato soup , occasional piece of apple crumb load slice for dessert. I thought I cured this hell of disease . Well my cholesterol went almost 100 points up to 317, I nearly fell off my doctors chair. The past 20 days I have been on no carbs no sugar ketosis diet I am very sensitive to all carbs or sugar amounts so I just illuminated all sugars and carbs. It has been 20 days working out w weights and stationery bike at the health club n total strict diet lots of good fats small protein and vegetables and red leaf lettuce no dressing. I only lost 3 pounds. Why? I am on ResQ fish oil and red rice yeast and coq10. Praying in three months my numbers are better.

    • We’ve been in ketosis 3 months but both suffering from cramps, blood pressure surges, sleep disturbance. I formerly had excellent blood pressure. I also have night headaches and thirst. Drinking homemade stock 2x day seems to stop cramps. Assume blood pressure increase due to increased sodium or electrolyte imbalance. Not feeling great. Can’t figure out what to do, after sifting through much info online. Lots of varied opinions but no one has accountability. I have experienced a ketosis high for about 2 weeks. Wish I knew how to repeat it. Just wish there was a knowledgeable medical practitioner in Sydney, Australia to advise on and monitor our particular health situations, even if only to name a good multi vitamin/mineral tablet. Fear doing more harm than good. Can you offer any suggestions?

      • First off–see your doctor! I could speculate all day, but that’s not helpful. Could be magnesium (too little) or sodium (too much) or potassium (too little), etc.

    • Dr. Attia, I just discovered your blog and it is the most focused information about ketogenics that I’ve found yet. I have two general questions for you and figured this was the best place to post them. I am on a forced ketogenic, no-dairy, low-oxalate, low-fiber diet, likely due to gastro damage related to a severe bout of food poisoning years ago. (the food poisoning or the antibiotics, that’s the question). I figured out the diet by myself, over a 2-year period, by intuition and trial-and-error. I’ve now been on it for almost 3 years, exclusively, with one or two unsuccessful “trials” to see if anything had changed. It is only recently that I have found MDs who believe me, and support me, although they admit they have no idea what to do, other than for me to continue to stay on the diet, and have my nutritional and medical status monitored. Off the diet, I am ill with a cascade of symptoms, the worst being nausea, stomach/abdominal pain, gastroparesis, diarrhea, fatigue, brain fog, palpitations. On the diet, I’ve got more energy than I have in years, and am fully productive at work, school and home, and able to exercise. Blood pressure is very low, cholesterol (both good and bad) are both high so I’m told they cancel out. Weight is stable after an initial 20-lb loss (I’m 5-9″, 130 lbs). All other measures are in normal range. I eat mostly: fish, a little egg, a little chicken, and a few well-cooked and/or pureed low-oxalate vegetables. LOTS of olive oil in various forms. Probiotic powder once a day. Absolutely no other meds/supplements due to starchy fillers, additives, etc which I just can’t tolerate. Oolong tea, filtered water, no other beverages. (although plain water causes nausea too). Carry my own food wherever I go.

      So here are the questions: First, It looks like I’m on this for life (I’m 56). What do we know about the long-term effects of the ketogenic diet? Second, research appears to be nonexistent. Heaven forbid people should just change what they eat and not need any meds/interventions. Who’s doing research, if any? What sources can I send my doctor/dietitian to for good information?
      Thank you. I am beginning to think there is a “black market” on medical information related to diet. There seems to be a growing gap between those folks on the web who are figuring things out, anecdotally, and the medical establishment, which REALLY doesn’t know what this is all about. We’re developing a whole understanding that is completely under the radar.

    • Sorry for hijacking your comment but you are the only place there’s a post comment option on my device (??) I’m on high protein/high fat diet. It has alleviated my near nonstop ear-ringing/hissing and permanent dizziness. Every time I eat a carb (vegetables much worse than fruit! Green leaves are ok. No reaction whatsoever from watermelon Everything else I try (other veggies & fruit, even if eaten AFTER fats) sends my head spinning and tinnitus back in full force). All organic cos I have severe MCS (on top of CFIDS and a host of overlapping illnesses caused by HMT)

      Now I’m getting sharp stabbing pain (kidney level) and out of the blue, developed hives from so many oysters. (A tin a day due to pyroluria, which that helped alleviate the symptoms greatly). I did some googling and landed here & other sites talking about dangers of too much protein (I eat pork, pork and more pork; fish and more fish; shellfish is now out; eggs, chicken and NO beef, triggers violent L-T symptoms):
      So what about people like me? It now seems I can’t eat carbs or protein! What is left is pure fat. Even pork rinds have protein, thought they were just fat. So what else is there? Butter and VCO. I can’t live just on that. (I did a NO carb diet years ago, paid dearly with bloody digestive symptoms…)

      I’ve been disabled for 3 decades. Now I’m afraid of this ketosis thing (this is a new diet to me for past 2 months now) and the high protein which damages kidneys but the standard high carb diet has my brain/mind affected so badly. What am I supposed to eat? Please suggest. Thanks.

    • Just in case you suggest it: I’ve severe nut and seeds allergy (OAS), to most of them nuts, developed recently besides 1 since childhood. (Pumpkin, sunflower, almost all nuts and peanuts don’t agree with me; bad symptoms come back)

  2. Very clear explanation. I’ve been in ketosis for a couple months now and the good effect extend beyond weight loss. So much so that I have shockingly stated “even if I never lost another pound I wouldn’t go back to eating more carbs”. My brain is soooo happy on ketones, less anxious, resilient, clear-headed. My body doesn’t experience the up and downs of blood sugar instabilities, the excess weight is coming off (sometimes quick, sometimes slow – I’m just starting to become more active – I have energy now!), and the miscellaneous rashes and dry skin are resolving. I have hope now that I can actually lose weight and keep it off, not to mention improving my health and staying active.
    Fringe benefits: butter, bacon, and pork sausage (homemade, no nasty wheat crumbs)

    • You know, Kayla, I understand EXACTLY what you’re saying. My “experiment” with ketosis was only supposed to be 12 weeks. Yes, I lost a bit more weight and improved my disease risk numbers, but the part that got me addicted (and reason I, too, can’t imagine “leaving” ketosis) is the brain and energy part!

    • Well Kayla, I think the watchword is “everything in moderation”, and I’m more than a little concerned about your “no nasty wheatcrumbs” parting shot: Mankind and our evolutionary predecessors have included grains, roots & tubers, and starchy fruits as significant (to say the least) parts of our diet for millions of years with no apparent harm, for one thing. For another, only a tiny fraction of the billions of people in the world, can afford to consume meats, whether fatty like pork and bacon (from animals fed mainly carbohydrates), or lean and stringy desert goats, often enough to sustain themselves on such fare. This I know first-hand, from going among near-desert dwellers and interviewing them: They might kill a goat once or twice a year for special feasts, daily about all they eat is milet. And your weight-loss campaign (I have to watch my own carefully, so I know what you’re going through) will certanly go more quickly and surely if the fat is coming mainly off your own body-layers, rather than ingested pork products. ByTheWay, Durum Wheat, especially when grown in dry areas like Kazakhstan, provides substantial amounts of healthful proteins. Nor is gluten a dirty word either, though that’s another subject.

    • James,

      When using the turn of phrase ‘for one thing,’ please have your facts straight. 
      The human race hasn’t even been around ‘for millions of years,’ let alone a million, for one thing.
      For another, they haven’t been cultivating grains all over the world and I certainly don’t think apes, our ‘evolutionary predecessors’, went out and planted barley to chew on. They ate leaves (low carb) and grubs and bugs (high fat, high protein) with seasonal fruits (occasional carbs from sugars). 
      This I know first hand, from not being shortsighted, that we are more evolutionarily suited to live on a ketosis diet. The exceptions to this rule are people that are descendants of cultures that learned to cultivate grains early and those from cultures that never experienced frost. Killing frosts make it impossible to survive exclusively on cultivated foods. Look at China. People from northern China are still more likely to be pig farmers, and those from the south rice farmers. Why? Cuz pigs grow in the winter off of scraps just fine. They’re cheap, they’re easy and they’re tasty. And they grow rice in the south because it’s too damn wet and then too damn dry to grow other grains.
       Most important to this point, I think, is that cultivation of land based crops in general didn’t become an effective means of providing nutrition until after the last major Ice Age. (hint: it didn’t happen millions of years ago). To continue, many areas prior to the Iron Age couldn’t even cultivate the land much less the grains, unless they were rich. And then, controlling the weather is still impossible. Until modern shipping routes and distribution were established, there was a slim chance that any one area could produce enough grains within their means to sustain them through bad times. Grain isn’t edible if it rots away from excess moisture or never grows from being overcast. Grain that succumbs to blight and infestation isn’t useable or is already gone. From experience, (I raise goats, the most popular animal ever. No joke.), raising animals and grain can easily lead to well fed (or dead) stock and NO grain. Goats are smart, but they’re opportunists. They’ll eat a crop then die from bloat and then you WILL starve. 
      And also on goats… Goats raised on spare grass have SUPER high fats contents in their milk! Which is what Mongolians drink! Cuz there ain’t no damn water! So while they don’t eat the goats very often, they consume TONS OF PROTEIN AND FAT. They also make butter… And cultured milk products. Which have very little carbs and are high in protein and fats.
      Remember continental divides and cultural habits and that we’re essentially talking about how evolutionary traits affect the way we process nutrients. You can’t lump everyone into one category and feed them all the same. I’m violently allergic to soy and penicillin, treat me as though I’m everyone else and you could kill me. And another thing, a ketogenic diet is not for everyone and might not make sense since we’re all told that fat is bad or whatever’s got you stuck on that wheat of yours. Maybe the flaky, fluffy, cilia degrading taste?
      And before you throw out discouraging comments bout people’s diet plans and fat layers, understand that getting calories from fats is easier than getting them from carbs, but a persons conditioned aversion to the consumption of fats most often drives them to consume less calories on a ketogenic diet. Also, a ketogenic diet curbs appetites more so than a carbohydrate loaded diet. When your body is in ketosis, it burns fat and doesn’t store it, unlike when it has plenty of carbs and it stores all the fat, for another. Your carbs are making you fat, raising your cholesterol, and sapping your energy!
      By the way, Durum wheat, DESPITE being grown in dry areas like Kazakstan, has more beneficial nutrients and proteins that OTHER wheats grown in dry areas. Grown side by side in ideal conditions most wheats are pretty much nutritionally the same, Durum was just originally cultivated in Italy and has been selected since 7000BC for exceptional hardiness.
      We cultivate all our feeds for our goats, we live in the super North East of North America and have difficulties getting grains to sprout and not rot out or get froze out from a cold snap, even in modern times with a tractor. A tractor doesn’t stop it from raining for 2 months. Nor does it make sure it stays 65° for 17 days straight in May. Of course, they have stuff we can spray on our corn for that, but I don’t want to eat that crap… 
      Or we could buy it, but high prices for food, which IMH2GO should be freakin’ free, are the reason why billions of people are starving. 
      If only they had goats. 
      What a rant!

      Maggie Love

    • Kayla – how long did your rash/dry skin last and did you do anything to resolve it? I’ve been wondering if keto rash and candida die off rash are one in the same.

    • Kayla – how long did your rash/dry skin last and did you do anything to resolve it? I’ve been wondering if keto rash and candida die off rash are one in the same.

    • I, too, got here by way of Taubes’s work, but this site takes it farther. Taubes for me is off the mark when he says that exercise is no route to weight loss. Nonsense, say I. I honestly have eaten no carbs for some time, but for what is in a sugar and fruit free bowl of oatmeal, and skim milk. And I find that I can moderately stationary bike, say at 110 heart rate, for hours without problem, as long as five, as well as weight train moderately, while eating a lot of protein. It clearly burns up all the glycogen, then fat, then burns fat overnight to replenish glycogen. No bonking, no fatigue, no brain fog. I have to pee like a race horse in the wee hours, but that’s a small price. When I get back to a thirty inch waist, I’ll return to some fresh fruit and beans for maintenance, and move to short, high intensity workouts and weight work. But this flat out works, no question. Ans the standard daily recommendations for carbs are negligent nonsense. Insulin is the enemy, period

    • hello kayla,
      i hope you still feel great as you described so clearly above.

      i went gluten free on november, i felt great almost immediately; then i started as a new year resolution sugar free and the result added to gluten free is even better; but now that i went to try ketosis i have been feeling the nutricional ketosis in the very low levels, always around 0.5, 0.6; i guess the protein intake is still to high, the carbs i take from my veggies are to much because i am getting above the 50 gr./day of carbs; and the fat percentage not high enough; since i try to put more fat on that to much protein i guess i will be more effective than the current result i am getting; still, i lost around 3kg. in one month; but the problem is that i don’t need to lose weight because i am now 65kg. to 184cm. tall; all my blood tests are ok and for the cholesterol part of it i now have total cholesterol of 240 when one year ago it was 170; the increase came from hdl going from 59 to 84 and ldl going from 101 to 150; the triglycerides are on 47 mg; so all looks good for me but not for my doctor who went suspicious of this high cholesterol level of 240! i feel happy about it! it seems the losing weight is no more and i hope to achieve gaining weight. is that possible? like peter atria said i got a better brain and lot more energy and i feel good about it so i hope i can keep dieting low carb high fat and on ketosis for very long time

  3. Hi Dr. Attia,

    Love reading your posts and have been on Keto for a few months now. I was wondering if you could help me see why the beta-hydroxybutyrate is considered a ketone body.

    Thanks,

    Steve

    • Steve, you’re “technically” right, beta-hydroxybutyrate is probably better classified as a carboxylic acid, however, functionally it still behaves (and gets produced under the same circumstances) as the other 2 endogenous ketone bodies (acetone and acetoacetone). The difference, as you probably know, is that beta-hydroxybutyrate has an extra carbon (over acetoacetone) and lacks the second double bond between the #4 carbon and oxygen. The important point is that it’s produced endogenously by the liver, from fat, and the brain consumes it.

  4. Dr Peter. Is it possible you could be in a Keto state and not know it? Curious, as I have dropped all grains from the diet and don’t intentionally take on carbs. I am only an occassional salad and veg eater, so the only carbs I would be getting most of the time would be incidental through other foods. My previous supply of carbs virtually ALL came from grain based food, pasta, bread, rice, cereals etc.
    I’m still alive so if I am in a Keto state, its not killing me.
    Regards, Anthony – Brisbane, Australia

      • Nick, I have this a read and immediately suspected, as you point out, that this population was not in ketosis. I suspect this was due to their over-consumption of protein.
        However, it’s worth nothing that their ‘research subjects’ came from the west coast of Greenland and the Baffin Straights.
        The Inuit in this region had been interacting with Europeans (starting with Eric The Red and the Norse) starting in about 800 ad. The Europeans, who were essentially protein-starved since their adoption of agriculture, very likely transmitted their cultural value of lean over fat. Thus these ‘Inuit’ were already far from their aboriginal cultural roots long before Heinbecker and friends arrived.

        Stefansson published many papers and books long before this paper was published. Note however that this is not mentioned or referenced in Heinbecker’s paper. Perhaps is was because Stefansson loudly proclaimed that truly aboriginal Inuit treasured fat over lean. And concurrent with this paper’s publication, he demonstrated that 15% protein and >80% fat intake could maintain health, well-being, and nutritional ketosis.

        If you need another reason to question this paper, note that Heinbecker claims that 280 grams of protein from animal flesh contains 54 grams of glycogen. Phinney’s analysis of ‘market meats’ in Cambridge MA in 1979 indicated that 125 g/d of protein was associated with <10 grams of glycogen (and thus less than half as much glycogen per gram of protein). Assuming that killing a 'market meat' animal did not involve shooting it after a long chase, these market meat animals' meat should contain more glycogen than hunt meat. Thus his 54 g/d estimate of glycogen intake among aboriginal Inuit is seriously suspect.

        But in the end, let the data speak for itself. We reproduced Stefansson's 1928 Bellevue diet at MIT in 1979, feeding my subjects about 125 g/d of market meat protein, and they maintained serum BOHB levels of 1.5 - 2.5 mM.

        I guess it comes down to using wisdom to choose which dots to connect. My choice is that Stefansson was a better channel to the aboriginal Inuit culture, and eating the diet he chose in Bellevue resulted in better health, better function, and nutritional ketosis.

    • Peter, An article by Per Wikholm was published in this month’s LCHF Magasinet, where Per demonstrates that the Inuit could not have been in ketosis given that the scientific literature is abundantly clear, over and over again, that the Inuit consumed too much protein, and more importantly, Per debunks Stefansson’s claims for high fat with writing from his own books—Stef admitted in the pemmican recipes that Arctic caribou was too lean to make pemmican that supported ketosis.

      The most popular LCHF bloggers in Sweden, Andreas Eenfeldt/Diet Doctor and Annika Dahlquist have reluctantly agreed with Per’s findings—admitting that the Inuit were likely not ketogenic from their diet.

      I’ve put together a comprehensive review of the scientific literature regarding the Inuit, encompassing over two dozen studies, spanning 150 years, with references from explorers, including Stefansson.

      http://freetheanimal.com/2014/10/damned-inuit-diet.html

      In the comments section of that post, Per gives a brief overview of how he was able to prove Stefansson’s observations on high fat intake were flawed.

      The post is a review of all the available literature that I could find (over two dozen studies). But, the literature certainly does not in any way support ketosis from the Inuit diet due to such high protein consumption.

      As Per (and Stefansson) points out, the caribou is too lean and as the many quotes show, the Inuit were saving their blubber and fat for the long dark Winter to power their oil lamps and heat their igloos. Again and again, we see that in the literature, as even Stefansson admits this.

      As far as glycogen is concerned, their glycogen intake is probably not worth scrutinizing given the well-documented high protein consumption in every published study. It really is besides the point. But, interestingly, we did find evidence that diving marine mammals have much more glycogen than land mammals do—to assist them in their extended dives. And it seems that in combination with the cold temperatures, the glycogen in marine fish and mammals take longer to degrade than land mammals do. References for this are shown in the comments of that link.

      Heinbecker’s figures actually came from Krogh & Krogh’s 1908 observations, which we found and quoted in the article—though Heinbecker does say that it matches up with his own observations. Rabinowitch confirmed Krogh & Krogh’s observations as well on his own Canadian expedition. The Kroghs clarified in their 1914 paper that glycogen accounted for a little more than half of the 54g/d of carbs in the diet (the rest was from bread and sugar, which had been available since at least 1855). Even Draper (1977) also concurred with their high protein consumption in his paper, “The Aboriginal Eskimo Diet in Modern Perspective”.

      In fact, I could not find any reliable evidence that the Inuit consumed a high fat and restricted protein diet. Even McClellan and DuBois admitted in the published literature for the Bellevue Experiment that their Western ketogenic diet did not replicate the Eskimo diet.

      Cheers.

      PS — The Masai are almost certainly not an example of a ketogenic culture. They consumed large quantities of honey and milk, and were observed trading their meats for carbohydrates weekly with neighboring tribes. See Chris Masterjohn’s, “A Glimpse of the Masai Diet at the Turn of the 20th Century — A Land of Milk and Honey, Bananas From Afar” post for details.

    • You’re welcome, Peter.

      Except, I only learned of this when Duck emailed me about it. I don’t work that way, as a sock puppet. Don’t need to. Duck is truly a different person and, even I don’t know his true Identity.

      I don’t ask, he doesn’t offer.

  5. Dr. Attia,

    Thank you for getting right to the nut on so many issues!

    My question is whether I’m reading the implication of your dieting progress report correctly: Have you found that, if one gets too much protein while lowering carbs below 30mg, weight loss will be less likely?

    My reason for the question: I have maintained for a couple of years on lo-carb after reading Gary Taubes’ “Good Calories, Bad Calories,” but I can’t seem to keep losing down to the <25 BMI my doctor recommends. I am otherwise very healthy (with controlled high blood pressure) and fit, a moderate regular exerciser, age 63, male. I have never tried testing for nutritional ketosis; perhaps I should?

    Thank you for your work!
    Fritz

    • Fritz, the protein issue is really most important if trying to be in a state of nutritional ketosis (rather than non-ketotic low-carb). Even with sufficiently low carb intake, too much protein will stimulate enough insulin to prevent ketone formation. Before jumping to ketosis, you may want to experiment with the elimination of other foods, such as dairy and non-sugar sweeteners which, for some, inhibit fat mobilization.

      • Dr. Attia,

        Thank you! I’ll try it.

        I like your clean writing style: clear, straight talk without being personally abusive toward those who disagree–i.e., compassionate. Although I do agree with everything you and Mr. Taubes have said. So I’m looking forward to your book. You are working on one, aren’t you?

        Fritz

        • Fritz, thank you so much for your support and very kind praise. I’m not currently working on a book, due to time constraints, but ultimately I would like to assemble one.

    • Alex, there are no known long-term (deleterious) side-effects of being in nutritional ketosis. Keep in mind how many civilizations lived in this state for their entire lives (e.g., Inuit, Massai).

      • Thanks, Dr. Attia. I look forward to reading your coming post on the “Misery Zone” and how to deal with it. I’ve been in ketosis for about 10 days now, and I have been feeling great. I’ve already shed 5 pounds and trimmed my waist by one inch. Today, however, I woke up with migraines, which I usually have when my liver is overloaded, feeling weak and irritable. Two bowls of lettuce with lots of Helmann’s Mayonnaise made me feel better. Maybe I was just running too low on fat.

  6. I just got my ketone test strips and got a reading of 0.9 mmol/L. Is this the same unit of measurement you used in this article (mM)? If not, how do I convert one into the other?

  7. Peter Attia, forgive me if this is a bit off topic, but… This makes any

    person upset: Diets ultimately lead you to put on weight in the long run which has become more and more evident in the excess weight epidemic that\\\’s

    hurting this junk food, little exercise generation. Are you concerned that stadium seats have

    to be increased in order to support the increase in peoples increasing, ahem…girth? This means that we are transforming into a much larger place (and by

    no means in an exceedingly great way) of

    people than all of us have ever have previously which happens to be previously two decades alone. Our young ones are afflicted by being overweight associated

    problems for instance having diabetes as well as heart

    problems.

    I read that in a research project seventy heavy American children inside the age ranges of 6 to 19 have been subjected to many battery of medical tests to observe the actual result that the eating habits rich in fat had on their youthful

    figures. The final results have been eye opening. All was cursed with

    high cholesterol levels and were included in the high-risk group of acquiring heart disease and heart failure that a number of subjects were already exhibiting warning signs of.

    Could there be any sort of a cure for all of us? I feel the answer is certainly. Apparently

    just about all we need is definitely a little bit of diet and exercise. We almost all will need to embark on performing

    it Today!

  8. I’m a little confused. You said that non-diabetics have a feedback loop to prevent ketones from rising too much and that diabetics don’t because they can’t produce insulin. I thought a non-diabietic in ketosis would not be generating any insulin (and if they did, they would no longer be in ketosis). Can you clarify on how this feedback loop works?

    • If ketones ever get too high in a non-diabetic, they will ultimately cause some release of insulin, which suppresses ketones, keeping the person from generating too many (i.e., dangerous levels).

    • I’ve been thinking and assume that in non-diabetics the release of insulin in response to too high ketone levels would rarely happen because the body is more efficient at using ketones for fuel as opposed to glucose. Right?

      Hence the benefits for which you prefer being in ketosis plus its safety due to the feedback loop in non-diabetics….

      • If B-OHB levels get high enough, typically in the range of about 5 mM, they do result in insulin secretion as a feedback loop. T1D or T2D with pancreatic burnout can’t do this, which is why they can end up in DKA.

    • I’m really curious about this too! I am not diabetic and I after two weeks of low carb, I ended up in the hospital with ketoacidocis. I’m trying to figure out what happened to me and the ER Dr is saying it was due to my low carb diet, but i feel like that doesn’t make sense! I’d really appreciate some insight or if you could point me in a direction to find out more. I know I am producing insulin, so is there another way that feedback loop can fail?

      • Correct, that does not make sense. I have read of one case study in the medical literature of someone without type 1 diabetes having ketoacidosis, which did not result from a low carb diet. So I’d question that diagnosis.

    • Hi Peter,

      Last week I had a seizure where I went into cramps, lost consciousness and felt like I couldn’t breathe. The interesting things is that I had a lot of the symptoms of ketoacidosis and that I had been measuring my breath acetone during the day and it was consistently >930nmol/l (what this equates to of BHB I can’t say but at least deep ketosis). My blood sugar was measured at 115mg/dl around 2-2.5h after finishing dinner, all my blood markers were normal while my blood pressure got low during the night and I was given fluid at the hospital.
      I know this is close to impossible for anyone to explain why it happened but I can’t help thinking if there is some level of ketones where you do experience some of the symptoms of ketoacidosis without actually having ketoacidosis in a pathological way. My blood sugar was higher than I would have thought at that time of day and maybe that could be due to a low insulin level.
      Anyway, this wasn’t as much to get a medical response from you but more to share the story as it sounds similar to Amanda’s.

    • I would be very surprised if they did and now it annoys the hell out of me that I didn’t at least ask for it – even though they would have looked at me like I was an alien and most likely turned it down. I will get access to all of the results within a short period.
      I’ve only seen one study and one n=1 comparing breath acetone to BHB http://i.imgur.com/HcBrJSs.jpg . I’ve been testing with the Ketonix for a couple of weeks now and I’m almost always yellow or red even after meals (suggesting that I’m at least >0.5mmol/l).

      I was thinking of getting a blood glucose monitor to see if this is a consistent pattern. A new version with a more granular scale of the Ketonix will also soon be released so that I can better quantify my ketones and compare them to how I feel.

    • Hi Peter,

      FYI, I got all of the results from my blood sample. While a handful of numbers came out too low I really noticed that my potassium was 3.3mmol/l which I’m suspecting could have been a contributing factor to my seizure.

    • Not to drag this out but just as another FYI. The other results which were off were
      Thrombocytes 136 10E9/l
      Hemoglobin 7.5 mmol/l
      Bilirubin 4 µmol/l
      Albumin 36 g/l
      Potassium 3.3 mmol/l
      Zinc 10 µmol/l
      Blood glucose 129.6 mg/dl
      I don’t have a background in medicine so I’m not sure what to make of it. I don’t think the numbers are going to kill me but I don’t like them given my recent history of anorexia. Next up is an EEG to rule out epilepsy.

    • Hi Hemming, low electrolyte levels (sodium, potassium, magnesium) are common in keto diets. While I am not a medical professional either, your symptoms sound similar to what happens to endurance athletes (e.g. long distance bike riders) who over-hydrate without replacing the electrolytes lost from sweating. This can cause headaches, heart palpitations, muscle cramps, seizures, fainting, etc.

      When on a keto diet you need to make a daily effort to replenish your electrolytes. Sodium is easy; just salt your meals. However, many keto dieters will buy a salt substitute such as Morton’s Lite Salt which is basically half sodium and half potassium. You can take supplements for magnesium.

      However, there are keto friendly natural sources of potassium and magnesium. Spinach and almonds are your friends! They both contain high amounts of both electrolytes. I eat one or both every single day.

    • I find this really interesting. I also had an experience similar to amanda. After two weeks of Keto, my resting heart rate went up to 120-130. I went to the ER and the ER doctor concluded I had keto acidosis. My ketone levels were tested at the hospital and were 6.4mM. Haven’t been able to find any more information on this anywhere.

  9. Hi Peter,

    Per the information above, am I correct in understanding that it is the feedback loop that causes a person who is living in full nutritional ketosis to gain weight if too much fat is consumed? You “fat-feed” yourself to the point where insulin is produced, thereby moving yourself out of ketosis and sending the fat to storage?

    You mentioned in a different post that there are four ways that energy/calories can be used in our systems. Can I find more information about how that works on this site. (I am visiting China and do not have access to books at the moment)

    This is far and away the best nutritional website I have ever encountered. You do very fine work. THANK YOU!

  10. Hi Peter,

    I have a question about gestational diabetes. My pregnant wife was recently diagnosed and is starting (temporary) insulin shots today. The concern is that her body is keeping too high a blood sugar level but if she does not eat enough carbs there is the danger of keto-acidosis from excess ketone production. I’m wondering if you can offer anything about this aspect of ketone production and diabetes, specifically whether gestational diabetes is due to lowered insulin production instead of insulin resistance. From that, I’m interested to know whether insulin injections are the right treatment option or a nutritionally focused treatment plan.

    With gestational diabetes being a shorter term issue (weeks for us rather than months) I suspect insulin is the best option since diet may take more time than we have to produce the required results. But I have heard that those women who are prone to insulin resistance are also more likely to become gestational diabetics which sounds more like diet as a long term solution (for any future children that we have).

    If I can monopolise your comments with one further question, I’m curious how drugs such as Metformin work (as compared to insulin). Metformin seems to work on the cells to allow the already present insulin to do its work. Does Metformin treat insulin resistance rather than a lack of insulin? And, if Metformin works for a patient, does that mean your principles on this site will work to overcome their form of developed diabetes?

    Thank you in advance for your input, and for your great website. I will continue to share with my networks.

    Sam

    PS. I won’t consider your response as medical advice. I am just curious about these things as our info seems conflicting a lot of the time.

  11. Hi Peter:
    I have been on a ketogenic (or near ketogenic) diet for three months now and I really like it for many reasons. I was discussing this with a friend this week who participated in a study at the University of Vermont nutritional/metabolic group some years ago where she was put on a protein sparing modified fast (12 oz of low fat protein food/day, potassium supplement, water, and a couple cups of black coffee) to determine the level of glycogen reduction in muscle tissue due to this kind of diet. She said virtually all participants had what they called “Ketone brain”, which was characterized by short term memory loss (e.g. you walk into a room and forget why)and the doctors involved said symptoms were similar to what alcoholics experience. Even limited amount of carbohydrate consumption would make the symptoms disappear. What do you think was happening in this case? Would this suggest that although the brain can thrive on (mostly) ketones there is a minimal carbohydrate intake requirement for optimal brain function?

    • Hi John, you state that your friend is on a ‘low fat protein food / day’ diet. If this diet is based around ‘low fat’, then it’s not a Ketogenic diet and the symptoms (short term memory loss) may be a result of taking in too few calories. I myself find that with a true Ketogenic diet, my short term memory has improved. Hope this helps.

  12. Believe me, I do understand the difference between ketosis and keto-acidosis. So here’s my question: Given that someone’s high level of ketosis is due to a very-low-carb diet, is there any possibility that this high level of ketones in the body can have an adverse effect? My urine ketone level has been between 40 and 80 for a couple of months, and my weight loss has been excellent (24 lbs so far). But could this ketone level possibly be dangerous? Thanks!

  13. What if one is a type 1 diabetic under great blood sugar control using an insulin pump or injections? Will the insulin being administered always prevent ketones from becoming dangerously high? Or is there a different way to monitor ketones to make sure that they do not become dangerous?

    • Yes, insulin will lower B-OHB. So for a T1D, ketosis can be dangerous if the person is not monitoring levels and administering insulin at some point. That said, I know many T1D who are very low carb without any difficulty. No basal does and only the smallest bolus from time to time.

  14. Peter
    I have low carb for a several years. Your blog has inspired me to go Ketogenic. After about a month of struggling on the threshold of ketosis, I am now there. I feel really good, not sure if it is just in comparison to the way I felt on the threshold or not. I just realized that I am going on a trip in about 2 weeks and I don’t think I will be able to stay in ketosis. My concern is how long does the transition back to a “normal” functioning state. I take my blood pressure everyday and take sodium via bullion to keep it in range 70/110. If it falls too much I feel like crap and my performance collapses. The trip will involve high altitude (13000 ft hiking hence my concern about performance.) Based on prior experience if I were to continue to take this level of sodium on a higher carb diet my bp will go high. Any suggestions.
    Ben

    • Transition out of ketosis can be very quick (i.e., one meal). Given that you’ve only been in ketosis briefly, I think your decision to revert for this demanding trip is a good one. It really took me a couple of months to be fully adapted to ketosis to do the most rigorous stuff. Different for everyone, but reverting to “normal” for a few weeks is probably safer. Next year, you can do it ketotic, though!

  15. I have been in ketosis for six weeks or a little more (as measured with urine test strips). My problem is this: last night my partner (after some hesitation) raised a “delicate” issue: he claims my breath is bad, which was not true previously, and he suspects my new low-carb diet. I looked around a bit online and found that it is not unusual to develop bad breath when in ketosis. One site I looked at said that the bad breath is likely to be temporary and would likely disappear after a few weeks with no modification of my diet. On another site someone (purportedly an MD) said the only way to get rid of the bad breath was to introduce carbs–i.e. to come out of ketosis, which I don’t want to do. Who is right? Is there any way to treat–or to minimize–any tendency to bad breath when in ketosis?

    • Thomas, I do hear this complaint on occasion. It does appear to be transient and also somewhat responsive to “extra” rigorous oral hygiene, but I don’t have a definitive answer. I’d suggest staying with it for a while longer and trying to ramp up the teeth-brushing and mouthwash.

    • Thanks for your response. I don’t plan to reintroduce carbs to my diet any time soon, so it’s nice to have your confirmation that bad breath in ketosis may be transitory. I’ll continue brushing, rinsing, chewing parsley, and such things. (Fortunately, I like parsley)

      Tom

    • Part of the breath issue is dry mouth, which causes tartar and plaque build-up if not aggressively kept after with frequent brushing, flossing, and use of a water pic type device. Combined it all helps, but I have also found http://www.biotene.com – Biotene products for dry mouth to be very useful in restoring the natural flora to the oral cavity. Good luck!

      Renée

    • Another product that can help with dry mouth and the bad breath it can produce is Oracoat (www.oracoat.com). The tabs dissolve over time, so they last for a while and are good for overnight.

    • The bad breath could be coming from acetone you are producing whilst in a ketosis state. I personally find changing eating habits late in the evening resolves it. Do not have increased amounts of protein and fat late in the evening, it elevates your ketones and this seems to contribute to the increase in “acetone breath”.

  16. I have had hypertension since I was 17 (now I’m 20) and super high cholesterol (LDL and triglycerides are amazingly high), also my current weight is around 300 pounds. I blame my sweet tooth and my genes. Anyway, you have introduced ketosis to me and for a person aspiring to be a physician, I was convinced by the logic in the biochemistry of ketosis.
    I started around 3 days ago and my stomach hasn’t seen carbs since. Weird thing is, now I make the slightest move and my heart rate shoots up, is this normal as a start ? I do take my bisoprolol and lisinopril, but yet my heart rate jumps I can feel my heart pounding my chest.

    • Your rising HR may indicate hypovolemia (i.e., dehydration). Make sure you’re getting enough sodium and water to compensate for the water loss you’re undergoing.

  17. Hi Peter,
    My urine test strips are reading mild to moderate ketones but the Precision Xtra is saying “0.1” I wonder how that can be. I have been having a positive urine strip for 2 months and over the last week I increased my Fat intake to between 65 – 75% and Protein around to 10-15%. Any thoughts on this?
    Tina

    • The blood test is the only one that matters in this case, which is why I don’t find urine strips handy. If you’re below 0.5, you’re not “in” ketosis. I would guess too much protein and/or too much carbohydrate. Check a few days in a row in the morning before breakfast.

  18. Peter,
    Don’t even bother addressing my last comment. My urine ketostick was tan minutes ago but I have been impeccable in my protein to fat intake; so out of frustration and curiosity I did another blood test and it was 0.4. Okay, so I am convinced, blood is the way to go. Too bad it’s $5 a pop!
    Tina

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