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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
Dr Attia, I’ve been eating under 40g of carbs a day for about 3 weeks and I find that I’m super tired and have minor headaches? Is this normal and/or when will it subside? Is there anything I can eat or do that will help? Thank you!
Yes it’s normal if you’re not making the necessary adjustments — water, sodium, magnesium — addressed extensively in the blog and elsewhere.
Hi, been in ketosis since April, to manage my fibromyalgia and chronic migraines. Never have I felt better!
About a week ago, I started to have sensitive spots, felt like trigger points that are common with fibro, except this time there was a lump.. Felt like a fatty tumor.
Over the next few days I developed more. Mostly in the rib area where there is more fat. They are just under the skin, very tender to the touch.
I’m not over weight. Didn’t start this to loose weight, but I have lost over 10 lbs since I started and lots of inches here and there.
Is there any info on ketosis causing tumors of this kind to increase?
I have an appointment with my doctor which I know he will not like my choice of diet.
Thanks Peter,
Susan
Do you have any info that might enlighten me?
Hard to say without being your doctor.
Is it OK to do the Ketogenic diet if you have Hep C ? I have heard that coconut oil can actually be good for the liver.
I don’t know enough about this to comment.
Hello Mr.Peter
My wife (aged about 31years) is a patient of diabetic & hypertension from 04 years (when she was carry my baby) & as she do not want to take Insulin, my doctor gave her diabetic medicine, for this she is taking 1.5gms of metformin per day & also medicine for hypertension, her body weight is 62kgs & on Yesterday when she having a acute stomach pain & vomiting, I take her to another doctor & after taking her blood & urine & also USG, we came to know that KETON BODY is present in her body & she is carrying 06-07 gallbladder stone (total measuring of 112mm), her current blood sugar is 240, the doctor immediately advised me to admit her to hospital, now she is in hospital .
So, plz advice me what steps should I take now??
Rajat, I can’t give medical advice through my blog.
Hello. I am 30 years old and I have a type 1 diabetes. My diabetes was diagnosed less than 4 months ago. I used the insuline (4 injections per day) for 3 months and about 3 weeks ago I switched to low-carb diet and I am completely off the insuline. Before turning to low-carb diet, my results were quite bad. I had a lot of hypos and hypers. Since I’ve switched to low-carb diet, my blood sugar levels have been perfect (about 1 gramme/l). However, when I measured ketones yesterday, the result was 0,4 grammes/l (Keto-Diastix by Bayer). When I first discovered I had diabètes, they warned me that I should check for ketons only if my blood sugar level is over 2,5 grammes/l. Do you find it dangerous if I have high ketones but perfect blood sugar levels? Should I go back to injecting some insuline? Thank you so much in advance.
You definitely want to keep your doctor involved. Typically, it’s almost impossible to have BHB higher than 6-7 mM, even in complete starvation. DKA typically occurs in the setting of BHB > 15 mM. In the case of DKA, it’s really a profound manifestation of starvation, which you’re unlikely to be in with the right nutrition is present.
I am currently stuck in ketosis ans can’t seem to get out I’m eating vegetables and meat and fruit but nothing seems to throw me out , I’m losing weight but don’t need to, any advice ?
Starch.
Awesome post!
I am a type 1 diabetic, very well controlled. Blood sugars are kept extremely solid on a daily basis…
Few questions I have for you.
Q. Is it possible to achieve nutritional ketosis (fat adaption) in a perfectly controlled diabetic? I find I function so much better on fat and protein in terms of mental clarity and performance, never mind body composition benefits…
Q I do inject insulin for some prot/fat meals (as would be the case in a non diabetic via natural slin release), what would be the cause for this, gluconeogenisis?
Q. When blood sugar levels are high (for a short period of time) is this highly catabolic to muscle tissue even when in a full fed state (i.e full glycogen stores)
1. Yes, but requires great care and a knowledgeable doctor. See book by Richard Bernstein, who is himself T1D
2. Yes, GNG from the protein
3. Not sure, probably depends equally on AA availability.
Dear Dr. Attia,
Having been on a very successful low-carb diet, I have a good understanding of being in and out of ketosis. When I had mentioned this to my biochemistry professor, he warned me of the punishment my kidneys may endure if I fail to drink plenty of water to keep them flushed.
Do you have any recommendations or thoughts on this?
Sincerely,
Bob
It’s never a bad idea to drink “plenty” of water, so I’m not sure this insight is particularly helpful, though he may be assuming (erroneously) that you’re talking about a high-protein diet. Still erroneous, but…
I would like to know if a Type 2 Diabetic that did not eat properly for days, ie, ice cream, whole milk, lasagna, fried chicken, potatoes (fried and hash browns), cheddar cheese, pizza, white bread, white rice, can test positive for alcohol with NO alcohol consumption?
Thank you for your immediate response.
Tamara Canovas
Hmmm, I’ll need to reflect on this. But funny enough, my brother (a prosecutor) was once involved in case like this (DUI). Don’t recall outcome.
Please, any information especially available in print as there was absolutely NO way possible my husband consumed alcohol. I was with him and we were never apart at any time during those days and had absolutely no access to any outside locations! This is becoming a legal issue and I am in need of documentation to support this. If he threw Ketones in his urine or if the sugar levels were high (due to a severally bad diet) along with yeast in his urine, would this not also produce a false positive on a Type 2 diabetic?
One more thing. One month prior the doctor lowered his Glucophage from 1000mg BID to 500mg BID
Glad I found this site!
I’ve done this diet many times in my past, starting the first time when I was a teenager. Somewhere around 46,I found it the best, or only way to keep the few pounds off that wanted to accumulate. I found when I did it in the winter for a few months, I could go back to fruits etc. for Spring/Summer/Fall without a problem. However, now I’m battling about 10 extra pounds for the past few years, that won’t come off, and then realized I haven’t done the diet in a couple of years. I work out like crazy, do plyometrics, run, lift weights. So rather than wait for winter, I started the diet about 2 months ago. The weight is just not easily coming off, but I suspect I should have waited for winter (I don’t know what that is, it just works best then).
Now the biggest complaint I have about this diet: LOSS of energy. There was an immediate change in my endurance. I was surprised to find that I needed to take breaks doing Insanity, take breaks in my weight-lifting/cardio workout and even with regard to weight-lifting, seems as if I have lost muscle, as my muscle don’t have the endurance they did before. I can still pick up the same weight, but I can’t lift it as many times without rest as before. I’ve started the MCT oil, which I think is a help, but no where near what I was doing before. With that said, I was vegetarian, which I think promotes endurance anyway. I can’t compare this diet to a ‘normal’ meat-eaters diet, as it was pretty optimal and maybe my endurance/strength was unusual anyway.
But, I’d appreciate any feedback, as I think this is the biggest drawback for me on the diet. Oh, except … yeah. Don’t really like eating animals, and it’s pretty much unavoidable on the diet!
The title says diabetes, but really it’s diabetes and obesity.
Dr. Jason Fung also has a 6-part series on his channel about obesity per se.
I believe Canadian Dr. Fung has put his finger on the holy grail that T. Colin Campbell, Gary Taubes, Peter Attia, and others have been trying to find. They each have a point, and I think Fung has put it together beautifully.
I reached these same conclusions, incidentally, before finding his work – and was really gratified and impressed when I saw he’d reached the same essential conclusions.
I would add that you should follow the main recommendation he’ll make in this video, which is entirely worth your time, and for best results in terms of energy and mood add in carb cycling – with at least (but not necessarily more than) one high-carb day a week, and possibly a couple moderate carb days as well.
Oh, by the way, I am in ketosis. I am still measuring it daily, as I am trying to introduce some foods in such as nuts etc. I range from moderate to heavy ketones daily.
Peter,
I would like to know if going on this diet would cause me to get high cholesterol?
It sometimes raises cholesterol levels slightly; more often it has no effect on total cholesterol; sometimes it lowers it. However, the vast majority of the time it raises your HDL cholesterol, also known as the “good cholesterol”, and this betters your “risk ratio” and lowers your chance of hear attack. Usually LDL cholesterol stays the same or falls somewhat.
The only way to know for sure is to try it and get your doctor to monitor your progress with lab results.
Note: I’m not a doctor. This is my layperson’s interpretation of the literature, but I think you’ll find it’s correct.
First things first, if one is a vegan-paleo ( veggies, fruit/ seafood/poultry) are they getting enough carbs without eating wheat products? And sorry to mention this, but would a lack of carbs totally, cause a late period? Another thing is. if one has no known heart conditions, but has started to have odd palpitations in the past two weeks of being carb free, is this to do with the lack of actual carbs? I drink a lot of tea and coffee ( between 2-3 cups a day), but not a lot of actual water, should I increase my water intake if I want to remain on a ketotonic diet? Could a ketotonic diet resemble hyperthyroid symptoms? Could hyperthyroidism become masked if on a ketotonic diet? What would you suggest eating if I want to eat actual wheat carbs? I eat no-sugar oatmeal, whole wheat crackers, etc.
I’m a twenty three year old female who is moderately active each day, and generally healthy. I was a compulsive exerciser for the last few years, but since about four or six months ago I’ve tried to lower the amount. Could this change be factored into symptoms. I’m sorry if this is too personal, but maybe you could answer atleast some of these questions. Maybe others are experiencing the same as I…
Amy–lots of questions in your post. Your heart palpitations may be as simple as too much caffeine. Cut that down, increase your water, see what happens. You can’t change everything at once and know what is effective. This is one of the concepts Peter is always showing us.
Hi Dr. I’m on this ketosis only diet since 2 weeks now and have started developing slight to a bit unbearable pain in my waist sides. Can you please advice what this could possibly be? Kindest regards.
Hi Peter,
My girlfriend and I have been in ketosis for a while now and feel this is the correct way to eat. We both experience a thumping heart when we are sub 20g of carbs or sugar. Is this normal? I’ve checked my BP and i’m fine. I cant really ask a docotor, as you know they will say, “why would you eat like that”.
You should check with your doctor. I can’t safely (or legally) play one on line.
I am totally not a doctor, so take this with a huge grain of salt.
One thing that occurs to me is that on very low-carb, your body has to produce more glucose, and this means adrenal hormone secretions. Plausibly you are both unusually sensitive to its effects (which isn’t necessarily bad – it could be that you’re particularly in tune with your body).
Anyway, throw that in the list of possibilities when you talk about it with your doctor.
Hi Peter
Firstly, thanks for bringing Nutritional Ketosis into homes across the world! Including Souh Africa!
I really, really hope that you could assist me with a (hopefully simple) question in Ketogenics.
I see that you are an expert in the field so I am pretty sure this is easy for you to answer.
Here is the BIG question: Is it safe for me to go up to 3.0 mmol/dl and on the odd day even 4.0?
I am currently on a Ketogenics diet for weight loss. I am consistently between mmol/dl 0.2 and 3.0 Some days maximum 4. (I have a little blood meter at home ?)
I have been between these readings for about 3 months now. I feel healthy and great. And my weight loss is coming on nicely .
When I exercise I eat an additional 30grams Nett Carbs prior to exercise.
Before I started on this I got my levels checked and they were all normal. Uric acid, glucose, blood pressure and cholesterol. (That’s what I gathered from the internet can be affected from Ketosis).
Thank you so SO much in advance! There are so few experts in this field that I really value your opinion.
So long as one has a working pancreas (i.e., all but someone with T1D or the most advanced stage of T2D), there is no physiologic reason to be worried about BHB levels being “too high.” In starvation, BHB levels tend to plateau at about 7 mM, which is still below the levels that cause DKA. Why? Because at that level, BHB stimulates insulin which creates negative feedback, most likely.
OK, but what if my ketones come in at neither range and are in between them: 8 mmol/L? For example, after 40 hours of water fasting, followed by a day of very-low carb eating.
What then?
Also, note that while we notate it differently here, 1mmol/L = 1 mM.
My husband was just diagnosed with stage 4 pancreatic cancer. My research keeps leading me to a ketogenic diet any thoughts?
Lorna, I’m very sorry to hear this. I will be writing a post about this in the coming month or so, but in the mean time you may want to look at the work of Dr. Seyfried. Here is a clip: https://articles.mercola.com/sites/articles/archive/2013/06/16/ketogenic-diet-benefits.aspx
I just watched your 25 June 2013 TED talk- What great insight! i am not a doctor, but researching and reading about nutrition is a hobby of mine. Has your team considered the role that good bacteria (probiotics etc) play in the metabolism and digestion of food, and how it affects insulin resistance? In the book The Art of Firmentation, Sandor Katz discusses a new theory that humans and bacteria co-evolved and therefore we don’t just benefit from good bacteria, we need them. Modern diets tend to sabotage the balance of good bacteria in the digestive system, and sugar laden yogurts snd processsed foods “with probiotics” are not the answer. I am convinced that the role of good bacteria is critical to metabolic balance in the human body. When an insulin resistant person eliminates sugar and carbohydrates from their diet, they are allowing the good bacteria in their digestive tract to regain a foothold and function properly as metabolic assistants. While this may not be the total picture, it must surely play a role. Anyway, that’s my theory. Thanks for all you do!
respectfully,
Gina
Thank you, Gina.
Hi,
I got to know a lot about ketosis through your article and your replies to the comments above. I would like to know 2 things
1.The role of protein in a ketogenic diet.
2.In a reply to one of the comment, you have mentioned that around above 100g of protein intake this begins to change to carbohydrate as well. What is the maximum grams of carbohydrates we can take to remain in ketosis. Thank you