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Is ketosis dangerous?

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 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 24 hours.  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 a diabetic (usually a Type I diabetic, but sometimes this occurs in very late-stage, insulin-dependent, Type II diabetics) fails 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), 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.

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About the Author:

Peter Attia, M.D., is the co-founder and President of the Nutrition Science Initiative (NuSI), a non-profit based in San Diego, CA. He received his B.Sc. from Queen's University in Canada and his M.D. from Stanford Medical School in California. After his surgical residency in general surgery at Johns Hopkins he worked as a consultant at McKinsey & Company. He founded NuSI with scientific journalist Gary Taubes in 2012.

Discussion

  1. esther wieringa  January 22, 2012

    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.

    (reply)
  2. Ash Simmonds  January 23, 2012

    Thanks for taking the torch from Taubes, there’s a huge keto community on Reddit where I’ve posted a link to this site – I reckon over coming months you’ll be getting quite a few visits from curious Reddittors.

    (reply)
    • Peter Attia  January 23, 2012

      Fantastic. Thank you so much for your support.

  3. Kayla  January 23, 2012

    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)

    (reply)
    • Peter Attia  January 24, 2012

      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!

    • James  July 20, 2013

      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.

    • Maggie Love  October 3, 2013

      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

    • Laura Rockow  June 23, 2014

      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.

    • Laura Rockow  June 23, 2014

      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.

  4. Timothy Steve Wang  January 24, 2012

    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

    (reply)
    • Peter Attia  January 24, 2012

      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.

  5. Anthony  February 6, 2012

    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

    (reply)
    • Peter Attia  February 6, 2012

      Sure, definitely possible. The Inuit and Masai lived in ketosis and never checked once!

    • Nick  December 10, 2012

      The Eskimos are not ketotic on their usual diet.
      http://www.jbc.org/content/80/2/461.full.pdf

      Instead, they rely on gluconeogenesis:
      http://discovermagazine.com/2004/oct/inuit-paradox#.UMWb97avIXI

    • Peter Attia  December 12, 2012

      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.

    • Duck Dodgers  October 14, 2014

      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.

    • Peter Attia  October 16, 2014

      Thanks Richard.

    • Richard Nikoley  October 17, 2014

      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.

  6. Fritz  February 9, 2012

    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

    (reply)
    • Peter Attia  February 10, 2012

      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.

    • Fritz  February 11, 2012

      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

    • Peter Attia  February 11, 2012

      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.

  7. Alex Carvalho  February 12, 2012

    Does ketosis stress the liver? Are there any known adverse effects in the long run?

    (reply)
    • Peter Attia  February 12, 2012

      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).

    • Alex Carvalho  February 12, 2012

      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.

  8. Alex Carvalho  February 13, 2012

    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?

    (reply)
    • Peter Attia  February 13, 2012

      mmol/L and mM are the same thing. Congrats!

  9. StrongJoe  February 16, 2012

    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!

    (reply)
  10. Tom  February 23, 2012

    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?

    (reply)
    • Peter Attia  February 23, 2012

      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).

    • Michele  April 12, 2012

      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….

    • Peter Attia  April 12, 2012

      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.

    • amanda  December 19, 2013

      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?

    • Peter Attia  December 19, 2013

      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.

    • Hemming  January 31, 2014

      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.

    • Peter Attia  January 31, 2014

      Did they measure your ketone levels in the hospital?

    • Hemming  January 31, 2014

      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.

    • Hemming  February 16, 2014

      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.

    • Peter Attia  February 16, 2014

      Interesting

    • Hemming  February 19, 2014

      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.

    • Stephen  February 27, 2014

      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.

  11. Kathleen  March 3, 2012

    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!

    (reply)
  12. Sam Hight  March 6, 2012

    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.

    (reply)
    • Peter Attia  March 6, 2012

      Sam, I’m sorry I need to refrain from answering this question. Metformin is different from insulin — it works by suppressing hepatic glucose output, so it effectively reduces the need for more insulin.

    • Sam Hight  March 7, 2012

      No problem. I’m sorry to put you in an awkward position with my question – I should have been much less personal. Thank you for your response.

    • Peter Attia  March 7, 2012

      Appreciate your understanding, Sam.

  13. John Wilson  March 14, 2012

    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?

    (reply)
    • Peter Attia  March 14, 2012

      I would need to see the study to comment.

    • Robert Fransdonk  September 2, 2013

      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.

  14. Crilly Butler  March 17, 2012

    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!

    (reply)
    • Peter Attia  March 17, 2012

      As long as you’re not a type 1 diabetic, your pancreas will always make enough insulin to suppress ketones before they get dangerously high.

  15. Katy  March 19, 2012

    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?

    (reply)
    • Peter Attia  March 19, 2012

      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.

  16. Ben Gilsdorf  April 12, 2012

    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

    (reply)
    • Peter Attia  April 13, 2012

      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!

  17. Thomas Mark  April 19, 2012

    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?

    (reply)
    • Peter Attia  April 19, 2012

      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.

    • Thomas Mark  April 21, 2012

      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

    • Renée  May 29, 2013

      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

  18. Mike  April 20, 2012

    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.

    (reply)
    • Peter Attia  April 20, 2012

      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.

  19. Tina Thomas  April 22, 2012

    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

    (reply)
    • Peter Attia  April 22, 2012

      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.

  20. Tina Thomas  April 22, 2012

    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

    (reply)
  21. Gabriel Zirpolo  April 27, 2012

    Hi Peter,
    In regards to Keto-Adaption, once a person had adapted to ketones and the body knows how to use them, is it possible to go in and out of ketosis and still be keto adapted? For example over a weekend or a period of a few days you eat, lets say 100 grams of carbs two days in a row which knocks you out of ketosis. Can you body switch right back to fat burning in the absence of the carbs that took you out of ketosis or do you need to go through another period of adaptation? Also what is the effect of alcohol on ketosis? By alcohol I mean a glass or two not a binge session.

    (reply)
    • Peter Attia  April 27, 2012

      Tough to say because it’s HIGHLY dependent on what set of circumstances “kick you out” of ketosis. I’ll try to address this in my upcoming post/series on ketosis. Hopefully by July.

  22. Gabriel Zirpolo  April 28, 2012

    Thanks for the reply…A followup question when you get to that seies in July is once Keto-Adapted can you live in the “zone of misery” and switch back and forth between fat burning and sugar burning? From my understanding after reading Phinny/Volek book Getting in Ketosis is fairly easy its the process of your body adapting that takes time. If each time we get knocked out of ketosis we have to start over from square one then it becomes super important to make sure you stay in that under 50 Gram/1.5 gm/kg protein. If your body “remembers” it’s keto adapted then I guess it’s possible to stay in the “zone of misery” low carb where your body easily switches to fat burning when it’s low on glucose. I look forward to your series in July

    (reply)
  23. Sue  May 4, 2012

    I read Gary’s book about 8 weeks ago and didn’t do anything right away. But, it really appealed to the logical side of me and I’ve been very low carb for about 6 to 7 weeks – I’ve lost some weight and fit into jeans that were getting too tight. I’ve been researching and reading everything I can find though over the last 20 years or so I’ve read everything there is on the subject of weight loss. I’ve been incorporating a “free” day every now and then (no more than once a week) where I will allow myself to have pizza and / or a wine cooler, etc. I seem to have no problem going right back to the low carb the next day. Is this having a negative effect? How do I know if I’m “in Ketosis?” Thanks!

    (reply)
    • Peter Attia  May 4, 2012

      Depends how you define negative. For some people who want to stop smoking, it’s easier to stop outright, rather than smoke one day per week. Check other comments and posts for ketosis question.

  24. Art  May 5, 2012

    Peter: Thank you for your work and inspiration, which for me is reminiscent of one of my “mentors,” Jack LaLanne, who also broke from the mainstream. Question: I am an avid weightlifter, including plyometrics, and avid ultra runner, having completed the Leadville 100 and Hardrock 100 runs and placed high in a hand full of 50s. I just started experimenting with Paleo 5 months ago with much success (felt great and took 9th in a 50 mile run at age 49) and now am a week into ketosis. I have added dairy to obtain more fat and believe it is not working for me — I feel bloated at times and yucky, kind of like when I used to pound sugar. Any tips for how to obtain enough fat on a ketogenic diet while eliminating dairy? Thank you kindly and keep up the great work and heavy training! Art

    (reply)
    • Peter Attia  May 5, 2012

      Vary the type and quantity of dairy. A week into ketosis most people feel bad regardless, so it’s not clear the dairy is the problem. More oils, of course, are key if you can’t tolerate dairy.

  25. Art  May 5, 2012

    Will do. Thank you.

    (reply)
  26. Xiaolei  May 7, 2012

    Hi Peter,

    After reading through your blog and all the comments, I am tempted to start a ketogenic diet myself. However, I have two questions that I hope you could shred some light on:

    1, I was a little worried about high level of ketone could be problematic until I have read that insulin keeps ketone out of dangerous level. However, would insulin resistance develop as a result of the continued need to regulate ketone?

    2, I also want to know the difference between full ketosis and borderline ketosis. I eat around 60-80g carb, and 120-150 g protein, and rest fat for a 6’4, 240 lb body and I want to know whether the above two states are quantitatively or qualitatively different in term of fuel consumptions and body functioning (especially brain).

    I want to try and challenge myself for a full ketosis diet but I want to know all the potential benefit (from where I am right now to ketosis) and potential risk (switching between states) before making a decision. Thanks a lot for your time and have a nice day.

    (reply)
    • Peter Attia  May 7, 2012

      1. Even someone with IR has more than enough insulin to shut off ketone production before it gets too high. It’s only a problem for those with virtually no insulin.
      2. Semantics, I guess. I think of ketosis as binary. Either you have fasting levels of B-OHB greater than 0.5 mM or you don’t.

  27. bill  May 16, 2012

    In the last sentence in the second to last paragraph, the word ‘though’ might properly be ‘through’?

    (reply)
  28. MM  May 18, 2012

    I notice that someone posted a comment elsewhere asking for your thoughts on the oft-reported link between very-low-carb diets and hypothyroidism. For what it is worth, I am interested, too.

    Nearly a year of VLC has been good for me in most respects, but the catch is that thyroid function has steadily deteriorated — a very big catch!

    A lot of people in the low-carb world claim that approximately 70g per day of carbohydrate is required to prevent this. Some go so far as to argue that traditionally VLC cultures were able to thrive only because their diet included animal thyroid.

    Thank you for a great website.

    (reply)
    • Peter Attia  May 18, 2012

      Yes, I will address this at some point…hopefully before 2015… kidding. Sort of. There is SO much to write about.

  29. MM  May 20, 2012

    Thanks so much for your reply!

    For what it is worth, I am sure that I am not the only one who would love to see this topic move to the head of the queue. There are few more pressing issues in the online VLC community at present. Reports of hypothyroid symptoms are now common, as are reports of symptoms resolving with the reintroduction of carbohydrate.

    Since the amount of carbohydrate under discussion is rather small (50 to 100 grams), anyone having thyroid trouble on VLC might simply conduct a trial for a couple of months. Unfortunately, this is not an option for those whose dysglycemia is severe enough to make even that modest amount of carbohydrate intolerable. (Since poor thyroid function is often claimed to be a cause of dysglycemia, this is something of a Catch-22.)

    There has got to be a way out other than exogenous thyroid hormone.

    (reply)
    • Martin  October 11, 2013

      Interesting connection,

      I knew people with hypothyroidism are often overweight and the opposite with hyperthyroidism.

      I suspect I am the second case since I cannot gain weight no matter what and have many other symptoms as well. I’m getting my thyroid hormone test on Monday.

      I wonder if keto diet can help me. Will dig deeper.

      Thanks for everything.

  30. Annyck  May 23, 2012

    Hi Peter,
    My mom and I have recently started reducing our carb intake and my dad, who is a severe diabetic, wanted to do it as well. Recently, he has lost a ton of weight because, I would assume, of diabetic ketoacidosis, but I was wondering if he consumed a diet mainly of fat and protein, if his body could rely on this for energy since his cells cannot take up any glucose. However, would this further increase the problem since he does not have any insulin in his body? What if he took insulin at every meal like he usually does? Thank you.

    (reply)
    • Peter Attia  May 23, 2012

      Hopefully your dad is NOT in DKA. If your dad is T1D or very advanced T2D, DKA is a real possibility if his foray into NUTRITIONAL ketosis is not medically supervised. If he is a more typical T2D, this rarely poses a problem.

  31. Karen Self-Ruby  May 31, 2012

    I will understand if you dont have time to answer this question. Perhaps someone else can.
    What is a polite reply I can offer people who hear I eat very low carb or that I am in ketosis and they say “thats dangerous” or “thats not good for your liver/kidney/body”?. I found myself saying “Ive done my research and have found that there is nothing dangerous about it”. Then they said “cholesterol will give you blocked arteries” Arrggg!!!
    P.S.New defenition of wealthy: Someone who can afford to use ketone blood test strips daily.Freaking expensive.

    (reply)
    • Peter Attia  May 31, 2012

      Karen, in such situations, when the skeptics are many, loud, and (not to be insulting, but just to be accurate) largely ignorant, I usually turn the question on them…Tell ME why nutritional ketosis is so dangerous? Ultimate, however, as Frederic Bastiat said so eloquently, “We must admit that our opponents in this argument have a marked advantage over us. They need only a few words to set forth a half-truth; whereas, in order to show that it is a half-truth, we have to resort to long and arid dissertations.”

  32. Priscilla  June 1, 2012

    I had an urine sample done today with my annual physical. Ketones were high; don’t know the exact numbers. Blood was taken as well. How is the state of ketosis determined? Is it through urine or blood or both? Thank you.

    (reply)
    • Peter Attia  June 1, 2012

      Blood is more accurate than urine. Also, once your body starts really “learning” to use ketones for energy, urine and breath levels can go down.

  33. Eric  June 1, 2012

    Hi Peter, I switched today to an 85% Fat 10% Protein 5% carbs diet form a typical Paleo diet. I got the shivers and felt like I was going to faint. This does not seem to be normal (especially the shivering)and was pretty scary. Do you have any suggestions?

    (reply)
  34. Aviv  June 2, 2012

    Peter

    1. If not supplementing with enough sodium/magnesium/potassium, could that hold someone from actually being keto-adapted or suppresses ketones from fat oxidation? or is it just makes you feel bad WHILE in ketosis?

    2. Could I be in ketosis where I only burn dietary fat for the production of B-OHB and nothing from stored fat? i.e for some reason the body has no access to stored fat and it uses only dietary fat as its energy source???

    3. How long after a meal would you check your ketones? I want to check how does different food products impacting my ketones in blood, say measuring at a fasted morning state, eat few tablespoons of cream cheese and than check it again 30 minutes after. Is it a good reliable testing way??

    Thanks!

    (reply)
    • Peter Attia  June 2, 2012

      1. Performance, feel.
      2. If in ketosis, but still consuming more energy than expending, unlikely to oxidize fat.
      3. Any time. Depends what you’re looking to measure.

  35. Eugene  June 2, 2012

    Hi,

    Back in my biochemistry days, I noted that there was a pentose phosphate pathway (PPP) in the metabolism of glucose. It was essential for creating NADPH and glutathione which is particularly important as an antioxidant, and the whole pathway important for proper RNA replication.
    It needs glucose for this to occur.
    I was wonder does being in ketosis affect this much?

    (reply)
    • Peter Attia  June 2, 2012

      Two ways to think about this:

      1. A human cannot survive a few minutes, let alone a few years without the ability to carry out the reaction of NADP to NADPH. Without exaggerating, this reaction is literally one of the fundamental parts of life. Cyanide kills people in seconds by interfering with a similar process of electron transport. The fact that no one is dropping dead 3 days into a ketotic diet is a hint that that process is not being dangerously interrupted.
      2. The reaction does not require glucose, per se. It requires glucose-6-phosphate. This can be made not only from glucose, but a host of gluconeogenic precursors.

      The same reason people in ketosis still make glycogen sort of explains why people in ketosis can still make NADPH and other byproducts of the PPP.

  36. Karen Self-Ruby  June 15, 2012

    Dr. Thank you for taking the time to answer our same questions over and over again. After studying your site, I am having a GREAT time enjoying food, and drink (red wine in moderation) losing weight rather quickly, and not having to gag down fruits and veg I never really cared for. EVERYTHING you warned about, ie. too much protein=falling out of ketosis and supplementing sodium to remedy lo carb flu, is the gospel truth. It’s really working and I thank you so very much for demonstrating what amounts to loving interest in others by creating this incredible blog. Thank you a million times.

    (reply)
    • Peter Attia  June 15, 2012

      So glad this is helping you. Keep enjoying your journey and spreading the word.

  37. fiona  June 16, 2012

    Peter,
    If a person is eating < 30 gms carbs/day, moderate protein and high fat but only has a blood ketone level of 0.4, what does their brain use for fuel? Are the glucose and ketone levels high enough to fuel the brain for long periods of concentration?
    Thanks.

    (reply)
    • Peter Attia  June 17, 2012

      Totally depends on when that measurement is taken. Single time point measurements are interesting, but can be misleading. If you can afford the cost of the strips, it might be worth doing 5 or 6 throughout a “typical” day and looking at the response of glucose and B-OHB to activity and intake.

  38. Ryan Van Der Linden  June 17, 2012

    I got my Abbot Precision Xtra and ketone strips…woke up this morning …tested and was .7 soooo I’m in! Sweet, it feels really good to KNOW the truth if I’m eating right or not. My fasting blood glucose was 73, I feel great. I spent 100 bucks on the meter 10 ketone strips and 100 glucose strips. I’ve been eating this way on and off for years losing while on and gaining while off. The results above are after one month of commitment to the diet ideals. This journey is about integrity.

    Today I’m going test my ketones throughout the day, just to get some base line data so I have some understanding of how my levels fluctuate relative to lifestyle and eating.

    Its easy to look at .7 and think “hmm thats not very powerful”. Like “hmm I must barely be in ketosis and therefore it must not be working really all that good.” “It sure would be better if I woke up and was at 2.0, because that is more and therefore better.”

    Peter are the above thoughts/perspective in quotes way off/unfounded and false?

    Forever grateful.

    (reply)
    • Peter Attia  June 18, 2012

      Curious to see your results. Over one year in, and I’m still learning every day about how my body responds (production and consumption of B-OHB). It’s an amazing journey!

  39. Amy  June 20, 2012

    Hi Peter,

    First, thank you for doing this. It is a great gift of time, knowledge, and energy. Thank your wife, too! She must be a good soul.

    If you have time (haha), just a few question about peri-menopause, hypothyroid, and ketosis. I am not looking for personal medical advice, but I am trying to figure out whether this eating plan will realistically work for someone like me with certain health “barriers” (for lack of a better word).

    I have tried, in earnest, to work on slimming down (15-20 pounds) since January. I have always led a healthy life style in terms of activity/exercise. I thought my eating habits were excellent, but have made that same transformational journey to a low carb/paleo type of eating since this winter. Unfortunately, my weight has continued its’ merry creep upwards. I tried Atkins induction, but weight kept going up, not down (I promise, I followed the plan to a T). At any rate, now I am on day three of the “fat fast” (85-90% fat, ultra low carb and protein), and can I tell you that I think I am, once again, gaining weight? So…my question is….does everybody really have the ability to convert to ketosis? My body certainly feels, for the first time, that it has the ketosis “flu” (feel very tired, kind of achy and under the weather)….does this mean I am in it and should continue, despite my weight increasing? Can thyroid issues continue to be a barrier? I have been on medication for four years…it worked really well until a year ago. My levels (I get them all checked) all look good. I have read Chris Kressers’ website and he has written a bit about thyroid and low carb, and I think he actually recommends in certain cases, to increase carbs!! Holy cow, what is a person to do?!

    One last one: my fasting blood glucose has been increasing this year, despite the low carb eating. I used to have blood tests in the 70s-80s, but for the past six months they have also been on the rise. I have not eaten sugar, gluten or grains, and extremely minimal dairy since January. I now take the FBS daily and my levels range from 95-118. Postprandial readings, 1 -2 hours later, are usually both elevated, sometimes as high as 120. Can low carb eating actually increase fasting blood glucose levels in a person who has hypothyroidism?
    Thanks in advance–I know you are busy and may not ever even answer this!
    Amy

    (reply)
    • Peter Attia  June 24, 2012

      Amy, I will eventually try to write about this issue, at least at the limits of what is known (which is not much). Hope you can hang in there until then.

    • sten bsell  November 26, 2013

      You can check your morning blood sugar. If it is over 100 your liver produces too much glycogen during the night.
      I think it is due to metabolic syndrome and a fatty pancreas that is “wrongly set” , probably due to years of high (fast) carb and fructose consumption.
      Interesting to hear what Peter thinks!

      It can be temporarily remedied by exercise the day before (the more the better). On low carb that reduces glycogen depots and and if not replenished by food, part of liver night production is used to replenish the glycogen depots. A glass of wine the night before diverts liver capacity to clear up the alcohol toxic bi-products allowing fro less blood sugar to be made. But these are not real solutions.
      We “know” the pancreas in cases like this – I have been there and I am getting slowly out of it – is churning out glucagon even when blood sugar is over normal. A set point error. It seems reducing visceral fat around pancreas in particular – has solved the problem to the extent that former diabetic-2 has regained normal blood sugar control. At same time visceral fat around pancreas reduced 25%, measured by CT scan before and after. What did they do: Near starvation diet for 4 weeks forcing an otherwise unwilling body to burn the visceral fat that had “clogged up” the function of organs ! I think there are other methods but if I was DB-2 I would have no hesitation to ask my doctor for his diligent assistance in such a program.

  40. MM  June 20, 2012

    I apologize for the somewhat off-topic nature of this question, but I could not find a more appropriate spot for it!

    Do general guidelines for blood donation differ for someone on a long-term ketogenic diet? I can’t imagine that the usual fruit juice and cookies are a good idea, but is there something that should be done post-phlebotomy (or pre-) to avoid hypoglycemic problems?

    (reply)
    • Peter Attia  June 21, 2012

      Good question. I don’t know the answer.

    • Kaylen  April 6, 2013

      Did you find an answer, or have you tried donating blood since going low carb? I was planning to bring a high-fat shake to drink after I donate blood since obviously the cookies are a no go.

  41. Martin  July 5, 2012

    Thank you for your blog. My wife and I are trying to enter ketosis but I have a doubt: When in a low carb diet is recomended that you eat 1g protein/kg of weight, is that lean body weight or total body weight? I think we are not in ketosis by eating too much protein…

    Thanks.

    PD: you may want to correct the title of the illustration…(title=”DNA vs NK”) in the html code.

    (reply)
    • Peter Attia  July 5, 2012

      If you’re trying to get into ketosis, it’s more about the absolute amount of protein being limited. A general rule of thumb is that 25% of each gram of protein over 100 gm/day is treated like carbohydrate. Hence, I target about 40 gm/day of carb and 120 gm/day of protein.

  42. Randa  July 5, 2012

    Hi Dr. Attia,

    First, I would like to thank you so much for your blog and for taking the time to respond to so many questions. I absolutely love reading your posts – not only do they provide a wealth of information in a way that is very understandable, but they are extremely motivational as well. Thank you!

    Second, I have a question about ketosis and increasing one’s fat intake. If our meals are made up of 75% or more from fat each day, won’t our body use the fat that we ingest as energy before using our stored fat? So, if we eat a lot of fat, could ketosis just mean that our body is using the fat from our recent meals and not from our body’s fat storage?

    Thank you again for the great work that you do!

    (reply)
    • Peter Attia  July 6, 2012

      Yes, exactly. But remember, they only way to to get into ketosis is to consume a high amount of fat (or to starve), because even small amounts of carbs or anything beyond modest amounts of protein shut off the process.

      The key is to still consume less fat (actually, less total energy) than your body is burning which, based on the recent JAMA study and a host of others, is probably increasing relative to what it was doing in a high-carb environment.

  43. Randa  July 9, 2012

    Dr. Attia – thank you so much for your quick response. I have another question – when you are counting your carbs, do you count the total number of carbs in each serving, or do you deduct the fiber and count only the “net” or “active” carbs? I have read several conflicting views on this, and I would appreciate some clarification. Thank you again, and I really hope you have a book on the way!

    (reply)
    • Peter Attia  July 9, 2012

      Total. It’s a higher bar and easier to keep track of (for me, at least).

  44. Tracy  July 9, 2012

    I recently spent a month in ketosis and was going really well felt great. No weight loss tho. Lots of water lost I think. Anyway I had severe pains in the stomach and went to er with suspected appendicitis. The doc noticed the ketones in urine and checked bloods. All good including lowest blood glucose level I’ve ever had (I have impaired fasting glucose, pre diabetes) but bicarbonate levels below normal. I was severely dehydrated and he gave me three litres of saline intravenously. My crp level was 45 which I think indicates inflammation or infection. They also found a fatty liver with a hemangioma. Anyway question is, is it possible I was in acidosis with normal blood glucose ? Is this anything to worry about…ie the bicarbonate level or to be expected ? How could I prevent this in future ? Is drinking more water enough or should I have upped my sodium as well ? I wasn’t taking any supplements. I think the pain was unrelated to the ketosis by the way. I was in a deep purple state according to ketostix should I up my carbs in future to stay in a lighter state ? Lastly, why no weight loss do you think ?

    (reply)
  45. Tom  July 14, 2012

    Peter, I’ve only just stumbled onto your site which I can’t believe, having been paleo/low carb for 10 months now! Decided to check out the link Mark Sisson put on his site recently and am very impressed; very comprehensive and easy to understand, thank you.

    I would love to know your thoughts on non-ketotic low carb. My wife and I generally eat low carb, but will eat some occasional bean salads, and maybe some starch after a workout – she probably eats “too much” fruit as well! Because I’m trying to – well, get ripped, frankly – I tend to try to use the carbs that I do eat strategically, i.e. bigger, carbier meals after workouts (a la leangains I suppose) and I do fast for the first half of the day, with more like VLC and calorie restriction on non-training days.

    I have heard from *somewhere* (can’t remember where) that really, upping your fat whilst eating any significant amount of carbs is worse than eating a carb-based diet, but this seems like nonsense to me. My wife and I are pretty well “fat-adapted” it seems – I suspect we dip in and out of ketosis with minimal symptoms, and can very easily skip one, two or even three meals. I don’t spend much deliberate time in ketosis because of the muscle building goals, so I keep protein pretty high most days, but for instance over a weekend I will eat minimal calories and mostly fat to try to burn a few ounces of my ass!

    I’ll get to the point… I suppose what I’m saying is, we have still vastly reduced our intake of carbs (definitely under 100g per day, probably closer to 50g) – and have upped our fat intake to compensate. Do you know of any reason why this should be harmful – I kind of feel that given how toxic sugar is, any degree of lower carb is a good thing – or do you feel it is it imperative that we aim for ketosis? And if so, any tips for muscle building whilst ketotic?

    (reply)
    • Peter Attia  July 15, 2012

      The non-ketotic LC approach is a great one for many people. It all depends on what you’re optimizing for.

  46. Dawn  July 18, 2012

    I started a keto diet 8 months ago. I lost a lot of weight, feel better, and watched my cholesterol levels and blood pressure all go down. I feel wonderful. My initial reason for doing this was because my blood sugar levels were rising. They were 120 fasting before staring. So, 8 months later, I get my blood sugar re-checked, again fasting. Still 120. My doctor then did an A1C, as we were concerned. That came back at 4.5! Is there something with being in ketosis that would cause the high blood sugar reading, yet my A1C is fantastic?

    (reply)
    • Peter Attia  July 18, 2012

      It could be a function of many things, including last meal timing, activity level. I assume your A1C was higher than 4.5 the first time?

    • Jo  July 23, 2012

      Dawn, fasting blood sugar levels can also be high due to the dawn phenomenon. And the A1c is an average, you can have highs & lows and have a good A1c.

  47. Francisca  July 25, 2012

    Dr Attia,

    I found your blog almost by accident and it got me hooked almost inmediatly, great Job!

    The concept of Ketosis is very interesting for me, and I have a couple of questions:

    I’m a 27 yo woman that “suffers” of hyperactivity, I have a huge apetite, but thankfully I don’t gain weight, more or less. Right now I’m about 70 kg (30% of fat) which everyone says is pretty good for my 1.74 mt height. I’d like to try a ketosis diet, but I’m really not sure how to do it or how to start. I’m assuming that the first days are going to be horrible, becasue one of my weak points are pasta and sushi. I don’t eat every day, more likely once a week one or another, not both, but they tend to be pretty big rations because of my apetite. Do you have any suggestions ideas to make this less traumatic? How should I start this process?

    Another question, in your glossary it appeard that ketone bodies are produced partially by the kidneys, will a ketosis regime stress them? I ask because I have multiple kidneys stones (7 and 6 on each side) and they are not tratable becasue of the place where they are. I also can’t do a special diet, becasue they are of both types (ureic acid and calcium) so that would mean that I can’t eat almot everything. I’ve been on treatmen since I was 12, but I wanted to ask if there is any connection that I should be aware of.

    Thank you!

    (reply)
    • Peter Attia  July 26, 2012

      You’ve come to right spot. Most of your questions are addressed throughout various posts and comments. I’ll also be doing a sort of “Ketosis 101″ post in the future to summarize much of this.

    • Salim Morgan  September 7, 2013

      Petro of the Hyperlipid website has the same personal experience and wrote a very interesting discussion of it. If you don’t know his website, just Google [Hyperlipid]. It’s near the top. It’s title is Hyperlipid but the URL is something else. The article is titled “Physiological insulin resistance”. I find it a must-read.

  48. Dawn  July 27, 2012

    Thank you Peter and Jo. In regards to whether my A1C was higher before, I never had it checked. I am not on any diabetic medication, and started the Keto diet to help prevent this. My carbs are extremely low, under 25/day. I always eat breakfast. I have not been exercising much, just walks with the dog.

    Was just curious if the changes caused by the diet had any effect on my morning blood sugar. I fasted 12 hours before the test. Interestingly, before I was on this diet, I also fasted 12 hours before the morning blood sugar, and still had a similar reading of 120 fasting. Figured my fasting blood sugar would be much better after being on this diet for so long. So, was upset to see it didn’t make a difference.

    (reply)
  49. Tania  July 31, 2012

    I would be interested on your thoughts about hypothyroidism and ketosis.

    (reply)
    • Peter Attia  July 31, 2012

      It’s on the list. Please check coming soon before posting questions.

  50. ralph  August 5, 2012

    Does ketosis make you acidotic (my B-OHB can run at around 6mM rather than 1-3mM on Freestyle Optium exceed blood testing) and I wondered if this higher level causes more acidosis and whether this can be a problem longer term?

    (I am one of the T1DM you mention who, when in ketosis, can get away with no basal and few bolus insulin doses (perhaps a total of 6u per day) keeping sugars at around 85 despite the low insulin due to this diet. I wonder whether this low level of insulin (often I must have none in my blood stream when in ketosis?) allows me to run higher ketones (6mM) than would occur if I had some background endogenous insulin and whether this higher level is bad from a more acidic point of view?)

    (I am not asking re ketoacidosis – with normal blood sugars I think I am less likely to slip into that (but given my normal sugars are due to the diet rather than presence of insulin, am not sure on this point so obviously anyway monitor ketone levels carefully!) but in this question I am asking more about acidoisis produced by 6mM of B-OHB which is after all acidic. I don’t seem to have any respiratory increase which I might expect if I was having to compensate for acidosis, urine is acidic on test sticks but I think that is normal…). many thanks for a great blog, very interesting

    (reply)
    • Peter Attia  August 7, 2012

      It’s important to distinguish between the acidosis I think you’re referring to (e.g., cellular acidosis in a cancer cell with defective mitochondria) vs. some change in overall body pH. Being in nutritional ketosis does not change body pH (though, as the name suggests, DKA does).

    • Heather  September 27, 2012

      Ralph (Aug. 5 comment, above): Interesting comment. I, too, have T1DM, but I’m finding it’s the basal insulin I need to keep doing, whereas my bolus doses have decreased dramatically (total daily dose, basal + bolus, is about 18 units … quite a bit higher than yours, but lower than the 25 – 30 units I used to take before going LC). How long have you had D? Any idea if you still have any beta cell function? I’ve had it 25 years, and I’m pretty sure I’m past the “honeymoon” phase.

      Dr. Peter: Terrific website. Thank you! Your site, along with Mark Sisson’s and a few others, is finally helping me to get my blood sugars off the carb/insulin-induced roller coaster. This is huge. And — “lucky” me — my diabetes allows me to get blood-monitoring keto strips covered by insurance … though I’m several weeks in (keeping close tabs on carb and protein intake) and have yet to register anything close to ketosis on the meter (urine strips, yes; blood, no). A little frustrating, but blood sugar control is my main goal for now, and that’s going very well.

      Thanks again and all the best for your NUSI projects … sounds very exciting!

      Heather
      Vancouver, BC

  51. ralph  August 5, 2012

    Why does it take time to adapt to ketosis? (Surely it is what normal human beings fall into after 4-6 hrs or so of not eating (eg at night) so it should not take 3 weeks to adapt to?

    (I can understand that due to high carb diets people may have chronically downregulated their ketone burning pathways and hence take ~3 weeks to get them back to speed when they first go low carb but, if you go back to a high carb diet after that, you upregulate glucose burning back to normal in 24hrs or so, so why in turn can’t you upregulate ketone burning in (say) 24 hrs if you go back to it relatively quickly after previous, recent ketosis?)

    In other words is flipping in and out of ketosis not such a problem as people say once you have got the ketone utilising enzyme pathways running well (and if it is a problem, does it imply ketosis is not a pathway we should be using except in emergencies or as a back up to glucose??).

    Many thanks again for a really thoughtful and informative blog.

    (reply)
    • Peter Attia  August 7, 2012

      Anyone will be in ketosis within 36-48 hours of starvation, or about 2-5 days of significant carb reduction in the presence of normal protein. The “adaptation” is more about the body “working out” the kinks — learning how to prioritize fat oxidation and using fat to make B-OHB, rather than glycogen as the primary energy source.

    • Heather  September 27, 2012

      This is a question I have, too.

      A related T1D issue … I recently had a cold, which increased my daily insulin requirements, even though my diet remained the same (ie. LCHF). I’m wondering if this brief period of higher insulin hampered my process of keto-adaptation. If so, and if indeed the re-adaptation process is lengthier than carb re-adaptation, then I think it could be difficult for those of us who are pancreatically challenged to remain in ketosis — perhaps non-diabetics as well, if things like illness, stress, hormonal variation etc. tend to cause a rise in insulin levels.

      I’m hoping that flipping in and out of ketosis — as you call it, Ralph — isn’t much of a problem, but the difficulties I’m having getting into it in the first place are making me wonder!

  52. Donna  August 5, 2012

    Can Ketosis cause tinnitus (the thumping type, not the ringing)? I read that being in ketosis can cause higher blood pressure and there is a vein behind the ear drum. Should I see my doctor?

    (reply)
    • Peter Attia  August 6, 2012

      I am not aware of this complication. Always a good idea to seek medical attention for something like this. Ketosis generally lowers blood pressure significantly, though.

  53. Jared  August 28, 2012

    Hi Peter,

    Since your level of carb intake is next to nothing, I am curious what you think of diets such as the Perfect Health Diet that recommend getting safe starches to avoid the long and short term side effects of ketosis such as being more susceptible to disease, dry eyes and mouth, and gut cancers farther down the road. Not sure which path I should take right now for best results for the short and long term.

    Thanks,
    Jared

    (reply)
    • Peter Attia  August 28, 2012

      Try it out and see if it works for you. We’re all a bit different, so there are few “absolute” rules in nutrition. Rule are “relative.”

  54. mark  August 30, 2012

    Dr. Attia,

    What would be more logical of why someone in ketosis would not loose weight, too many calories intake, too much insulin production, something else?

    Thanks,
    Mark

    (reply)
    • Peter Attia  August 30, 2012

      It would imply they are taking in more calories than their body is expending (but remember, there are many ways the body expends energy besides exercise).

  55. Aviv  August 30, 2012

    Hi Peter
    I know you busy as hell, but just had to ask it here (since I think other people might want to know), if you ever encounter anyone like me?
    I am still “flirting” with Ketosis as you calling it, you said you struggled to “get in” for 3 months, I am getting in to my 5th now… Since AHS I am doing intermittent fasting and still not much helps…
    Which leads me to my question, did you ever encounter in your experience with nutritional Ketosis the next scenario:
    Yesterday – woke up with 1.5 on the morning (so happy), decided not to eat until after work, theoretically my Ketones should go up, or at least stay the same right?
    2 “Bulletproof coffee” w. 2 teaspoons ghee during the day and nothing else (last one was around noon).
    By 6:30PM my ketone level dropped to my usual 0.5. (always going down during the day rather than going up – no matter what I eat, or not eating at all as you can see)
    What’s the story???
    I’ll check it again today – woke up with 0.9…

    By the way, inspired by you, I finally opened my own blog in Hebrew for the folks in little Israel – http://meeverlapaleo.blogspot.com/

    Thanks for inspiring me with your material, the more people we’ll get to around the world – the better.

    Later buddy

    (reply)
    • Peter Attia  August 31, 2012

      Aviv, activity can in cases increase hepatic production of B-OHB and in other cases decrease it. I wonder if that’s what you’re experiencing? I wonder if you might be obsessing over the numbers (e.g., 0.9 vs. 1.5) too much? [talk about the pot calling the kettle black...]. If you feel well, that would matter more to me. If you don’t, then perhaps resuming your previous diet, which seemed to be doing amazing things for you, would be another idea?

    • Aviv  August 31, 2012

      As always, appreciate your respond Peter
      Trying not to be obsessed about the numbers, actually didn’t have my strips for a while now.
      I was just wondering if there’s any explanation…
      Anyway I feel great, many things are moving the right way, I’ll give it few more months and take it from there.
      Thing is I really want to give Ketosis a chance, I do believe it’s actually the most healthy natural state for us to live in, and I love the sharp mental aspect thru out the day (no crashes like I use to have)
      My theory regarding last year was that I somehow I entered Ketosis accidentally for the first time in my life (becoming very lean, more energetic than the sun itself and in generally almost euphoric) – after reading so much about it, it sure felt like it.
      Than I messed it up, trust me I know I did (a lot of Paleo “safe starches” with an increased fat intake is not a good idea), and gained almost 20lbs and now having a hard time going back (weight + Ketotic).

      If you think I remember what I ate last year… oh boy…

  56. Julia  September 3, 2012

    Hi Peter,
    I just stumbled upon you while I was listening to the Ben Greenfield podcast and was really intrigued by your journey. I have been reading a bit of the work put out by Jack Kruse and am beginning my own personal experiment. I love physiology (my favorite class in school). I don’t need to lose weight, but am very very eager to get back into long distance running after I clear up some nagging hamstring issues and muscle imbalances. Lowering inflammation is a key to this journey.

    Since I have osteoporosis I am naturally concerned with lowering blood pH and how it may effect bone remodeling. You don’t mention much about this and I get the idea that once I am keto-adapted this should not be an issue. Could you explain this?

    Also, currently I only have pH urine strips and I am definitely spilling ketone in the urine—-which I hope does not indicate a low blood pH. In the podcast you mentioned that you constantly monitor your own blood pH. Can I do this at home? I’m a nursing student so I don’t have tons of $$ but would be willing to save up some money if I can check my levels. Any other comments you may have are welcome!
    Thank you so much!!

    (reply)
  57. Caryn Lipson  September 9, 2012

    Hi, I was looking through the comments and replies on this post and am wondering – isn’t there some way of eating that you can get/remain healthy without having to constantly measure how much of specific food items you’re eating and keep on testing your blood, etc.?

    (reply)
    • Peter Attia  September 9, 2012

      Of course. The only time one measures anything is during the early stages of ketosis to figure out if you’re there. This is irrelevant for all but a select few.

  58. Kim L  September 20, 2012

    I came here looking for information about ketosis and acidosis after high anion gap (20mmol/L) and low CO2 (20.5 mmol/L) results on a metabolic panel. Blood pH was not measured. Over the past 21 months, I’ve lost 120 lbs with a moderately low carb (~100g/d) diet, so… I’ve been in a sustained state of mild ketosis for a fairly long time. Given that information, should I be concerned about these values?

    (reply)
    • Peter Attia  September 20, 2012

      Kim, I can’t provide medical advice.

  59. PK  September 21, 2012

    Peter,

    I was telling a friend of mine about the ketogenic diet you describe, (which more or less I have been following for about a year now) and he said that he tried it years ago(basically Adkins) and that he got kidney AND gallstones while on it. Is this a potential issue? He claims the ketone bodies are highly acidic, and leach magnesium, potassium and calcium from your bones/body to buffer the blood, is this true? (he owns a health food store)

    He also warns that the high protein (don’t know what he considers high) of this type of diet is bad for your brain (brain calcification & dementia were 2 of his concerns) and that while good for weight loss, it is to hard to maintain for long periods of time and requires too much supplementation to work…

    Your thoughts?

    PK

    (reply)
    • Peter Attia  September 24, 2012

      Ketosis is actually a low- to moderate protein diet. In fact, I consume about 60% of the protein I used to consume. Impossible to comment on the factors the led to your friend’s conditions, though it’s certainly possible a poorly formulated (e.g., failure to balance minerals) low-carb diet could have played a role in these.

  60. Keith  October 1, 2012

    Dr. Attia,

    I feel so fortunate to have stumbled upon your blog. I started my ketogenic lifestyle February 15, 2012. I have lost 57 pounds, 7 inches off my waist, and brought body fat down from 32% to around 17%. Of the 57 pounds I’ve lost, I estimate that 47 of those pounds was fat loss. All of this was accomplished within the first 6 months. However, in the last 6 weeks I have totally stagnated and hit the world’s worst plateau. I have been following the advice of a trainer/nutritionist that typically works with bodybuilders and physique competitors, and I have now found (due to the information on your blog), I was very likely taking in too much protein (trainer advised 1g protein per pound of “ideal” body weight target). But eating this way, I simply can’t get this last 10 pounds, or 2 inches off my waist.

    I found your blog while researching how to eat for a half-marathon that I’m training for. This will be the longest competitive race I’ve ever run (prior to this I’ve only done a few 5k’s). My trainer/nutritionist suggested switching to a Cyclical Ketogenic Diet (basically “carbing-up / carb-loading” on my long-run training days and for the 1/2 marathon on race day). I’m in week 3 of my 12-week designed training program. While I’m in really great physical shape now – and I’m getting Personal Bests in my 5k training runs and rocking 10-minute miles with ease on my longer Saturday training runs – I gain 10 pounds every time I cycle back onto carbohydrates and I get the world’s worst case of the Runner’s Trots because my system just can’t handle all those carbs/fiber. My last training run made me decide I just can’t do that any longer. I spent more time on the toilet before and after my 6-mile run, than I did actually performing the 6-mile run. I don’t want to spend every one of the 13.1 miles of my half-marathon searching for the next Port-A-Potty.

    I was so pleased to read your article “How a low carb diet affected my athletic performance (Part 4)”. I am going to have my trainer/nutritionist check it out with me at our next meeting. And I now plan on running this marathon on Ketones – not carbs!!! And I believe I’ve discovered, through your blog, the key to get these pesky last 10 pounds off (I will reduce protein intake now to 1-1.5g protein per kg instead of 1g/lb…so will now be eating only about 80-120g protein per day instead of 175-180g). The best part of that is that I will get to replace those calories with more yummy fat!!!

    For the naysayers and curious out there…when I switched to a ketogenic lifestyle I had my Primary Care Physician run exhaustive blood and vital statistics panels (every six weeks) to make sure what I was doing was safe. ALL lab values and vitals have remained in normal range throughout (and were normal to start). I have been eating this way for 7-1/2 months now. My doctor told me to stop coming in for labs so often. He actually originally advised against a ketogenic lifestyle due to “conventional wisdom” . He was afraid I would get high blood pressure, and that my cholesterol would go up. Neither has happened. I would switch doctors, but they almost all seem to think this way. This is why you must be an active participant in the doctor-patient relationship. In fact, the physician has a PA working for him that is a big proponent of ketogenic lifestyle and they proceeded to get into a little bit of a disagreement about it in front of me one day (I got a good chuckle out of that).

    I’ll report back here how I do on my “un-conventional” 1/2 marathon diet. Thanks again for the time and research you’ve put into this.

    -Keith

    (reply)
    • Peter Attia  October 1, 2012

      Amazing story, Keith. Congratulations! What does your doctor think today?

  61. Mari  October 5, 2012

    Hi ,
    I am really very upset and depressed today . I have come out of ketoises and have so have swelling in my body .please can someone answer
    Thanks

    (reply)
  62. HelenB  October 9, 2012

    Hi,
    Recently diagnosed with Type II diabetes, a weight of 103kg and a history of severe hypertension from the age of 16, I need o lower my weight and get in control of my diet to prevent furthering my diabetes. I was referred here and a few other sites. I am lucky my doctor is okay with me doing the lchf lifestyle change. However, I am struggling to find basic meal plans online to direct me which would be helpful. I have cut (for the most part) simple carbs out of what I am eating (no bread/no rice/no potatoes) except when I slip up and I’ve only been doing this a month so I’m happy that on most days I manage to stay away from anything that isn’t a complex carb. I’ve increased my fats and protein but I’m still not sure I’ve got it right. Apart from my doctor there are no known resources in my city that I can turn to.

    Can you direct me?

    (reply)
    • Peter Attia  October 10, 2012

      Helen, I hope this entire blog is a helpful resource for you, as the underlying problem in T2D is insulin resistance.

  63. Amy  October 11, 2012

    Hi Peter,

    Have you come across any research on side effects from HFLC eating and hypothyroidism? I have tried, with no success, to lose 15 pounds using HFLC. I began in January. After reading, tinkering, realizing I was making many of the same mistakes as others here (too much protein, too little fat, too many calories) I began an 80-5-15 (and 1500-1800 cals or so) eating plan a month ago. I lost three pounds initially, but it came back on as the month progressed. More concerning to me was the tight chest and chest pain I experienced. I took in the recommended amounts of sodium, magnesium, and water to counteract the side effects of ketosis. I do take medication (88/100 mcg synthroid EOD and 5 mcg Cytomel daily) for hypothyroidism. I actually stopped my small daily dosage of Cytomel as I thought my heart was “revving” a bit too much for my comfort. The chest discomfort did not stop until I took a break from the HFLC. While the palpitations have ceased since I have stopped the HFLC five days ago, my weight has popped up another five pounds. I assume it is from the increased carbs and will either settle down in a few days. Interesting side bar: though I reverted to eating low calorie and mod carbs (1300 or so calories, 75-90 gr. carbs) my weight has gone up.

    It is so frustrating to read about others’ experiences and success with this way of eating. I feel like I can make it through the difficult transition part (the nausea can be debilitating, especially in the evening) but I don’t get the weight loss that others do here, plus the strange chest side effect.

    Last side note: I am a 47 year old, healthy and active female. No health issues aside from thyroid. Perhaps peri-menopausal.

    Thanks,

    Amy

    (reply)
    • Peter Attia  October 11, 2012

      Great question, Amy. I was having lunch with Chris Kresser yesterday and we actually talked a bit about this. I do plan to summarize all of this info in the next while, but until then, I think you’ll get great value out of his work on this topic: http://chriskresser.com/thyroid

  64. Ray  October 12, 2012

    So during the normal process of a ketogenic diet, something I’m doing now going on about two weeks, what does the typical insulin activity look like throughout the day? I seem to remember reading that it was going to be naturally higher in the morning after I wake up, but can’t seem to find that definitively.

    I’ve recently dropped my protein intake a little after listening to an interview with you and saw nearly immediate results so this made more curious as to the overall pattern of insulin throughout the day assuming a genuinely ketogenic diet.

    (reply)
    • Peter Attia  October 12, 2012

      Highly depended on timing and type of meal.

  65. Dawn  October 12, 2012

    I am a believer in low carb high fat diets. I started one after reading What Makes Us Fat by Gary Taubes. However, I am breastfeeding a 1 month old son. Could ketosis be harmful to him? Your thoughts would be greatly appreciated.

    (reply)
    • Peter Attia  October 14, 2012

      Dawn, lots of data show that very low GI carb diets are entirely safe in ketosis. Furthermore, many cultures lived in ketosis and breastfed. However, I am not aware of a study that directly addresses your question. Perhaps someone else is. I can’t give you a recommendation, but I can say that eliminating sugars and simple carbs is entirely safe (and probably very beneficial).

  66. Sophie  October 14, 2012

    Hi Dr. Attia, I am just beginning to look into the idea of Ketosis. Do you have any articles/posts written about how one achieves ketosis specifically? How many grams of protein, carbs, fats, etc? How to know once ketosis has been achieved? Where can I find a good beginners guide that will give me specifics. I am hoping to lose weight and I am already eating paleo (for the past year)- so most of the “hard” work is done.
    Thanks!

    (reply)
    • Peter Attia  October 14, 2012

      I don’t have one specific post (yet…it’s on my list), but I’ve pretty much answered every question on the topic throughout the comments section of the first post on “what I eat.” The best book to read on this topic is The Art and Science of Low Carbohydrate Living by Phinney and Volek.

  67. Janine  October 30, 2012

    I started this “diet” because for the past year and a half I have lost over 54 pounds. I am now tring to lose the last 20 and for the life of me no matter how clean I was eating my weight wouldn’t budge. My dr told me to try this. He has been doing it now and recommends it to his patients. I started this past Friday and its Tuesday and I have lost SIX pounds. I can’t beleive it. I already feel less bloated all over. I have energy like crazy. I have been using coconut oil as my main source of fat. My question is. I have anxiety and panic disorder I am on meds for it for about 20 years. This forces me to research this constantly and pick out all the negative. I went and bought the ketone strips and they are the purplish they can be. Is it possible to go into ketosis so fast??? It’s been five days. I do not wants anxiety disorder to force me into eating carbs because I am scared something is going wrong and I will die of ketoacidosis or liver failure. These are the thoughts in my head. I know my dr wouldn’t have put me on this unless he thought I was ok. But this is my question. If you have time could you please write back?
    Janine

    (reply)
    • Peter Attia  October 31, 2012

      Your doctor recommended a ketogenic diet? Very cool. Please let readers know what city you’re in and who your doctor is. Yes, it’s possible to get into ketosis in a week.

  68. Anne  November 6, 2012

    I’ve been doing a nutritional ketosis diet for 3 weeks now. I have lost 10.8 lbs with hopes of another 12-15 lbs. I just got my ketone strips in the mail and tested myself this morning before eating or drinking anything. My ketone level was 5.4 (my glucose was 73). i know the ketone target is between .5-3.0. So my question is what do I adjust to lower my ketones? Do I need to? My target protein is about 66 grams and I get less than 30 grams of carbs a day. I do love this diet. I’m not hungry, I feel good, my mild depression is gone. Should I adjust?

    (reply)
    • Peter Attia  November 6, 2012

      I see no need to do so. Ketone levels in that range would only be problematic for a type I diabetic person.

  69. Micheal  November 9, 2012

    Thank you so much Dr. Attia for your time and for this blog. I really enjoy how thorough your approach is and love that you examine and pick apart all of the science and the exact biological functions which affect and determine the different conditions and bodily states that we are examining.

    I had a question regarding body-building performance in relation to a constant ketotic state. I actually first learned about ketosis by reading opinions and thoughts about body-builders who followed what are called cyclical ketogenic diets (CKDs) and targeted ketogenic diets (TKDs). Most of these people seem to suggest that, while a ketotic state is excellent for reducing the accumulation of excess fat (“cutting”), it is necessary to have a “carb-up” or a “carb-load” where you take a certain day or period of time in your training to consume carbohydrates to restore glycogen levels in the muscles.

    I was curious if it is truly necessary to consume at least some carbohydrates to maximize muscle growth or if maximum (or at least, near maximum) muscle growth can be achieved solely in a constant, uninterrupted ketotic state.

    (reply)
    • Peter Attia  November 9, 2012

      Michael, great question. I do not *know* the answer, and I’m not even sure it’s been studied as rigorously as possible. There is so much going on in bodybuilding, and I’m just not sure about the tools and techniques necessary to achieve maximum muscle mass (relative to fat mass). I’m sure there is something out there to point to this, but I’m not an expert on this.

  70. Jodi  November 21, 2012

    Peter, I am a 52 yo female, Recently just entered menopause and have been low carb for a few months now. I just started going LCHF and am measuring my blood ketones. They range from 0.9 to 1.9 so far, but after 10 days no weight loss. Will I evenly have success and its just taking longer because of age? My carb intake is between 10-20 grams per day. Thank you for any advice you can give me.

    (reply)
    • Peter Attia  November 21, 2012

      So hard to speculate without a lot of information. I’m working on a ketosis post this week, which may provide insight.

  71. Bob West  November 21, 2012

    Hi Peter,

    Just a short word of support…. I check in every day, and read whatever responses to comments you have been able to post. I’m sure that I’m not alone in appreciating the fact that, although you are insanely busy with NuSI, and even try to have a personal and family life, you still pay attention to the many people who are reaching to you for unbiased information they can use in their lives.

    I imagine that most people who frequent this blog feel the same gratitude and admiration I have for the fact that you keep contributing so much. This is not even slightly flattery; it’s actually an understatement. Please feel the respect, and, by the way, get some rest.

    The NuSI project is one of the most important things that are going on right now, as is this blog. So feel good and carry on. And get some rest.

    Thanks,
    Bob.

    (reply)
    • Peter Attia  November 21, 2012

      Bob, thank you so much your support. I really appreciate it. Some days it’s tougher than others and I question my sanity for taking on this project with the enormous toll it takes on my personal life. I wish I could say I was completely immune to negative personal attacks which, sadly, happen every week. Of course, for every nut job out there taking a personal swipe at me, there are 19 people like you with only the most encouraging things to say. I do wonder why I allow the 1 of 20 to get to me? Any way, long way of saying, your note means a lot, especially this week.

    • Donna  November 22, 2012

      It’s much easier to believe in the negative,Peter, than the positive. If you listen to all that goes on around you, you will hear that most people willingly believe in the negative and discount the positive with ‘I was lucky’ attitude. It’s something all of us struggle with to some extent. Where does it come from? Who knows and is it really that important to find out the ‘why’? For myself, I have been reading the Second Book of the Tao compiled by Stephen Mitchell. It tells me not to focus on the negative or the positive but to see all as ‘is’. It’s not personal. Odd thing is when I am able to do that (which I am imperfect at doing) the hurt melts away and I am able to move forward.

      You could refocus the attacks back on the person who directs it toward you and wonder what in their life makes them take not an approach of respect and helpfulness but one of harm and hurt. I admire what you have done in sharing your struggles and your learning. I admit to a certain amount of difficulty in dealing with some of the things said by you and others. That is my problem, not yours or anyone elses. I’ve refrained brom positing because I’ve noticed a certain caustic tone creeping out in my replies and I needed to step back and reevaluate where I want to come from.

      On the other hand, I did read Mistakers Were Made but not by me. I found the discussion intriguing. I kind of got bogged down in the end and really couldn’t understand how a person could recognize cognitive dissonance happening at the time it is happening. It seems to me that only upon reflection can it be discovered. I did wish that the author covered more of the idea of ‘saving face’ I think that happens most of the time. When faced with information that does not match, it isn’t that the information isn’t accepted privately, it means that outwardly it has to be discarded because one ‘must save face’ especially if it is in the area of a person’s speciality. You cannot go against the norm unless you are willing to gamble your job, your professionalism and something else which I am now blanking out on. Oh well…. I guess I’ve gone on long enough.

      As the saying goes, Peter, Keep on trucking. You are doing ‘good’

    • Peter Attia  November 23, 2012

      Thanks for your thoughts and reflections, Donna. I speak with Carol Tarvis (author of Mistake Were Made) quite frequently to better understand your exact question.

    • Michele  November 22, 2012

      I can only second Bob’s very well put opinion. On this Thanksgiving there are a lot of people out there who are better off because of the sacrifice you put into this blog, NuSI and the subject in general. And, as one person tells another and the information spreads and starts changing minds, the multiplicative effect of the good done is beyond measurement. From the little insight you have given us as to the wonderful and supportive family you have, they realize this.

      You’ve given us a lot to be thankful for Peter. Happy Thanksgiving.

    • Peter Attia  November 22, 2012

      Michele, thanks so much for such kind words.

  72. T.Low  November 21, 2012

    Peter,

    After losing 55 pounds last spring through Ketosis, my wife and I enjoyed our best summer in the last 10 years. I could not believe the spring in my step, the endless endurance I enjoyed on the mountain bike, and feeling like I’d found the fountain of youth. I was reading EatingAcademy 2hours a night, most nights, for most of the summer. Great stuff.

    Then, 2 weeks ago, as my 1 month old slept in my arms and my 2 yr old played at my feet, my doctor called and told me I have Lou Gehrig’s Disease (ALS).

    The symptoms began last winter with some hand issues, but I thought it was an old riding injury getting arthritic.

    Since then, I’ve read about possible effects of the Ketogenic diet delaying the progression of ALS and there is actually a clinical trial on it finishing up this December. When I asked my (highly reccomended) neurologist about any possible interplay between ketosis and ALS progression, she replied “Ketogenic diet causes loss of lean muscle mass which would lead to a quicker loss of breathing capabilites”.

    I raised a finger to help emphasis the point I was about to make to her, but when I openned my mouth to speak, all that came out was big fat heavy sigh.

    Is this up your alley at all? Do you know anything about theoretical interplay between motor neurons and ketones? I need to do my homework before I go to my first appointment at the ALS clinic.

    Since we had the newborn, I’ve been slacking quite a bit on my diet. I think I want to maximize my ketone production to aid against the ALS.

    Thanks,
    T.Low Tom

    (reply)
    • Peter Attia  November 21, 2012

      Tom, first off I can’t even begin to express my empathy for you and your family. I do not know what you are going through and won’t try to pretend I do. Your question is a very reasonable one and, believe it or not, one I started addressing on the plane yesterday as I work on a post for this week about the real ins and outs of ketosis. Because I can imagine you don’t want to wait a few more days for this post to come out, let me know point you (and your neurologist) immediately in the direction Richard Veech (NIH) and Kieren Clarke (Oxford) who are the leading authorities on ketone esters and neurologic diseases. Not to dump too much on you, but here is a list of their work that I’ve read:

      “Ketoacids? Good Medicine?” George F. Cahill, Jr., Richard L. Veech, Transactions of the American Clinical and Climatological Association, Vol. 114, 2003.

      “The therapeutic implications of ketone bodies: the effects of ketone bodies in pathological conditions: ketosis, ketogenic diet, redox states, insulin resistance, and mitochondrial metabolism,” Richard L. Veech, Prostaglandins, Leukotrienes and Essential Fatty Acids, 70 (2004) 309-319.

      “Ketones: Metabolism’s Ugly Duckling,” TB VanItallie, TH Nufert, Nutrition Reviews, Oct 2003, Vol. 61, No 10, 327-341.

      “Brain Metabolism during Starvation,” OE Owen, AP Morgan, HG Kemp, JM Sullivan, MG Herrera, GF Cahill, Jr., J Clin Invest, 1967, Vol. 46, p. 1589-1595

      “Ketone Bodies as a Fuel for the Brain during Starvation,” OE Owen, Biochemistry And Molecular Biology Education, 2005, Vol. 33 No. 4, p. 246–251

      “Insulin, ketone bodies, and mitochondrial energy transduction,” K Sato, Y Kashiwaya, et. al., including Dr. Richard Veech, Research Communications, The FASEB Journal, Vol. 9, May 1995, p. 651-658

      “Brain metabolism during fasting,” OE Owen, AP Morgan, HG Kemp, JM Sullivan, MG Herrera, GF Cahill Jr., J Clin Invest, 1967, Vol. 46, p. 1589-95

      “Cerebral metabolic adaptation and ketone metabolism after brain injury,” ML Prins, 2008, Journal of Cerebral Blood Flow and Metabolism, Vol. 28, p. 1-16

      “Treatment of Parkinson disease with diet-induced hyperketonemia: A feasibility study,” T. VanItallie, C. Nonas, A Di Rocco, K Boyar, K Hyams and SB Heymsfield, Neurology, 2005, Vol. 64, p. 728-730

      “Brain Fuel Metabolism, Aging, and Alzheimer’s Disease,” S. Cunnane, S Nugent, M Roy, et. al, Nutrition, Jan. 2011

  73. Jodi  November 21, 2012

    Thank you any info would be appreciated!!

    (reply)
  74. T.Low  November 22, 2012

    Peter,

    I cannot thank you enough for the prompt and very helpful reply. (I read it first thing this morning). And thank you very much for the kind words. The household is asleep, I’ll check out those leads..

    Here is one of the clinical trials I mentioned. You may or may not find it informative (if you haven’t already seen it). Is it really that big of a question as to weather it’s tolerable or not?

    “Safety and Tolerability of the Ketogenic Diet in Amyotrophic Lateral Sclerosis (ALS)

    Condition(s): Amyotrophic Lateral Sclerosis

    NCTId: NCT01035710

    Official Title

    Phase I/II Study of Safety and Tolerability of the Ketogenic Diet in ALS

    Clinical Trial Summary

    Can what you eat alter the progression of amyotrophic lateral sclerosis (ALS)? We propose that the answer may be yes. Mitochondrial dysfunction may play a pivotal role in the death of motor neurons in ALS. Ketones, generated from ketogenic diets, can overcome certain types of mitochondrial dysfunction and in doing so, help restore the motor neuron to better health and thereby slow or stop the disease progression. The primary aim of our study is to prove that ketogenic diets are safe and tolerable in patients with ALS so that larger studies to test this hypothesis can be safely performed.”

    Thanks again, Peter.

    (reply)
  75. T.Low  November 23, 2012

    Wow. Dr Wahls is now Bookmarked to the top of my list. Once again, thank you so much and have great holiday weekend.

    It’s amazing how much brighter a day can be when one gets even a small glimpse of hope.

    Cheers,

    Tom

    (reply)
  76. Ru El  November 28, 2012

    “Keto-adaption is a state, achieved through significant reduction of carbohydrate intake (typically to less than 50 grams per day)”

    Hi Dr Attia,
    Is 50 grams total carbs or net carbs (total carbs – fiber carbs)?
    Thanks,
    Ru El

    (reply)
    • Peter Attia  November 29, 2012

      Depends on too many factors. I’ve always gone by 50 total. The subtracted fiber is a bonus.

  77. Kevin  November 29, 2012

    Dr. Attia,

    I am a rather large individual at 6’7″ tall and currently about 375 pounds. I am about to turn 40 years old and my weight has made a pretty constant incline since my skinny days of high school. I am in the first few days of a Nutritional Ketosis diet with my family. We are structuring it off the “Two Week Test” where at the end of two weeks of nearly no carbs, each of us can analyze how we feel and whether or not to continue with very restricted carbohydrates or start reintroducing natural, unrefined carbs.

    I am very excited about the prospect that I’ve been doing it all wrong all these years and my poor eating habits and lethargy may be more of a “marker” for an underlying problem of insulin resistance than the problem itself. My primary concern at this point is the effects on Kidney function. Due to complications for cancer surgery in the mid 1990’s, I only have one kidney. I have had no complications resulting from the single kidney since the surgery. I have read very contradictory information on whether or not a Ketosis based diet can be downright dangerous in regards to kidney function, particularly for someone like me who has to live the rest of his days without a backup.

    I understand I should get medical advice from my doctor, but I would love to hear your opinion on the matter.

    Thank you in advance.

    Kevin

    (reply)
    • Peter Attia  November 30, 2012

      Consider delaying your 2 week experiment until you’ve had a chance to really understand the nuances of this diet. I would hate to see you get turned off because you made some of the common mistakes. In the next few weeks I’ll be addressing these. Also, do read The Art and Science of Low Carbohydrate Living by Volek and Phinney.

  78. Michelle  December 31, 2012

    Hi,

    I have been on very low carb diets and have not been able to get into ketosis or lose weight past the first week or two. Would this have to do with insulin issues? I also retain a ton of water.

    (reply)
  79. Cheryl  January 6, 2013

    Dr Attia, I have started on NK a few months ago after a huge stall on LC. I am 51 yo, post-meno recently, within 10lbs of goal weight of 120, I am 5’4″. I do not seem to be able to lose weight on NK. I have tweaked it up and down on protein/fat, average 20g carbs most days. I have friend, little older, early 60s, and she is having the same issue, not losing at all. She is quite religious about logging food, and consumes CO as well. The commonality we both have is a previous eating disorder, anorexia many years back. We both survived; gained weight, gained too much weight, lost weight on LC, stalled. We are wondering if you would opinion that some permanent damage was done in our youth, and now our metabolism is protecting us from what it may perceive as returning to the past? Thank you for any information you may have or resources to read.

    (reply)
  80. Maria  January 9, 2013

    I was wondering if you had written about ketosis and people who seem to get hypothyroid symptoms. I understand ketosis naturally lowers thyroid function and that this is a good thing, and that this is without problems for many. In fact it is healthier. It is however a problem for others as they simply do not feel well. I am wondering what could be the underlying ‘malfunction’ for such a reaction, why those people feel better adding carbs and staying out of ketosis, and what one could do to prevent this from happening. Thanks fr any insight you can give.

    (reply)
    • Peter Attia  January 9, 2013

      Tough to say without knowing more. Could be a number of issues, including what you describe.

  81. George  January 9, 2013

    Hi, I was wondering how ketosis fits in with bodybuilding. I recently started bodybuilding and have been taking a lot of protein. Does ketosis correlate with catabolism? I need lots of protein. I am 254lbs 17 yrs old and have 34% body fat. What should my protein be like if o want to build muscle?

    (reply)
    • Peter Attia  January 9, 2013

      Not sure what you mean. Do you mean can you lose bodyfat and gain muscle in ketosis? If so, data from Jeff Volek says you can.

  82. Maria  January 9, 2013

    Could you name just a few so I can look further? :) Thanks.

    (reply)
    • Peter Attia  January 9, 2013

      A few what (I don’t see previous comment in my dashboard)?

    • Maria  January 9, 2013

      A few issues that could be involved in hypothyroid issues with symptoms making it hard for someone to keep going keto. They feel better when adding carbs.

    • Peter Attia  January 9, 2013

      Ahhh…check out Chris Kresser on this, along with Ron Rosedale.

  83. Ken  January 18, 2013

    Hi Dr. Attia! Love your site and what your are doing to get the word out there! Just two questions…I’ve been in ketosis for about a month and a half and have been noticing my short term memory is starting to become a little spotty at times…have you experienced this and do you think its transient? The second question is a fun one, i’ve been having a hard time trying to find the right ratio of fat and fiber to have consistent solid bowel movements…do you have an idea of how to help with this and what you do for yourself? Thanks so much, if you have any insights it would be greatly appreciated!

    (reply)
    • Peter Attia  January 18, 2013

      I have not heard this complaint. I wonder what is going on? As for regularity, it varies a lot by person. MCT oil, other fats, bouillon, and fiber in leafy veggies can all help.

  84. Ken  January 18, 2013

    I’m sure it has something to do with my brain adapting, not to mention that my mind races a little more now…constructively which i’m happy about so that might have something to do with it. I feel that a lot more of my little actions are going on autopilot to make room with the improved cognition.
    Thanks for the advice, i take MCT oil everyday and i’ve got to just up my intake of fiber and fat. It’s so amazing to get rid of the insulin/glucose ball and chain that was connected to my leg that these little complications are worthwhile to work out. Keep up the good work!

    (reply)
  85. Venkat  January 31, 2013

    Hi Pete,
    Thanks for the post. I have a question for you.

    I am a Type II diabetic, on a low carb (<40 grams a day) for the last 5 years and everytime the Dr peforms the urine test, he comes back saying it had ketones.
    Most of the afternoons I do not eat anything after lunch until dinner and hence just before dinner, my blood sugar level will be ~75. Is presence of ketones in my blood stream not letting me pass out? else I hear that low blood sugar will trigger the brain to shut down (symptom: pass out).

    Thanks in advance for your reply.

    Thanks

    Venkat

    (reply)
    • Peter Attia  February 1, 2013

      Would need to know more to provide insight, but if you’re eating <40 gm/day, I would expect ketones in your blood and possibly urine. The ketones in your blood are offsetting the low glucose in your blood. Are you still diabetic? Or did you mean a former type II?

    • Venkat  February 1, 2013

      Hi Peter,

      Not sure how to respond to your response to my question since I did not see a reply right below your response.

      To the question if I am a former type II or a current type II, I am a former type II if I stay low carb, current type II if I eat carbs.

      I started low carbing after reading Dr Bernstein’s book, Dr. Michael R Eades, David Mendosa posts during May 2008.I do minimal to no exercises… have reserved that if the insulin resistance shows its ugly head, I would leverage exercise as a tool to handle insulin resistance at that stage.

      I think you answered my question by stating that “The ketones in your blood are offsetting the low glucose in your blood”. I had a doubt if thats the case, I want to run it by a qualified person and hence I checked with you.

      Thanks a lot for your quick reply. Please let me know if I need to provide information. And Thanks a lot for all the posts on ketosis. It is very very informative.

      Thanks

      Venkat

  86. Ryan L  February 5, 2013

    Great Read.I am back on ketosis The first time I was on this diet I got down to 7% bf ,Now Im aiming for 3% I Train for 2 hours a day weights and an hour cardio .I found today. My 1 to 4 rep range was fine and strong but then I just fail immediately not the slow decline in strength like normal.I’m hoping this muscle endurance issue is temporary but even if not I’m prepared to do this for the 12 week duration.Last time I was having a high carb meal once a week hut found it took to long to get back into ketosis.So this time I am not.I will keep you posted regularly.I am currently 12% bf at 92 kg I know they call me obese in the BMI scale sucks that bmi

    (reply)
  87. Stuart  February 11, 2013

    Hey Doctor Pete

    I’m looking to go Keto adaptive but I don’t eat any meats, only fish. Is it possible for me to go into ketosis?

    Many thanks for your advice!

    Kindest regards
    Stuart

    (reply)
    • Peter Attia  February 11, 2013

      Possible, but pretty tough, especially if you eat dairy or eggs. If you are ok with dairy and eggs, but not meat, it’s pretty easy, as long as you don’t require 4,000 kcal/day like I do.

  88. Stuart  February 11, 2013

    Yeah, I eat eggs and dairy!

    Only just started eating full fat products as I used to do a lot of weight lifting and tended to keep my body fat around 7%! I’ve just got back into mountain biking and road riding after a few years off! I’ve always consumed considerable amounts of carbs, but since reading volek and Phinney’s book, low carb performance, it has completely made me re evaluate my diet?

    Not sure I could go sub 50gms of carbs a day, but I’ll give it a go! Only so much cheese and full fat Greek yogurt a man can eat! I’ve cut out all foods containing added sugar, that’s made a big difference!

    I have a feeling this could prove a difficult transition for me!

    Thanks again Pete!

    Stuart

    (reply)
    • Peter Attia  February 12, 2013

      No need to, Stuart. Just make a a few small changes at a time.

  89. Mark  February 12, 2013

    Question has some forethought to it but here goes: Lets say I have a weight loss goal and I hit it while on a ketogenic diet… How would I go about safely re-introducing carbs without gaining rebound weight? Would I just simply eat carbs in moderation like I should have done in the first place or does it require extreme limitations?

    (reply)
  90. noel-holly  February 18, 2013

    Dr. Attia I just found your site from MDA. I’ve been eating a low Carb high fat diet for a few months to lose weight. I occasionally find I want to add a bit of sweet potato or white potato. Are there any potential negative consequences from going in and out of ketosis? Thanks

    (reply)
    • Peter Attia  February 18, 2013

      Not sure, other than the possible need to re-adapt.

    • mark  February 22, 2013

      You may want to check out retrograding the starches in potatoes, not sure about sweet potato. I’m T2 diabetic and know for sure I can eat Anasazi beans and new potatoes if prepared properly, boil and let cool to room temperature then refrigerate at least 24 hours – cooling to room temp before refrigerating is key. Potatoes can be cut up and made into a low carb potato salad or can do like I do beans, I warm on lower power in microwave to just above room temp with butter. Have had my BG drop 1 hour PP compared to pre meal on a couple of occasions with the beans and have heard others mention same thing with the potatoes.

  91. mark  February 22, 2013

    Dr. Attia,

    You stated that being in dietary ketosis does not affect body pH. Does that mean that body pH “could” be low by the ketogenic diet and production of ketones doesn’t lower it more? I’ve read that meats, eggs, cheeses, saturated fats, lower alkalinity and I eat plenty of those.

    I’m highly suspect of anything negatively said about saturated fats, especially when lumped in with other things said to cause certain conditions. I am in ketosis and have become interested in pH since trying to figure out if I am deficient in magnesium or potassium and read about sodium and/or potassium bicarbonate usage.

    Assuming my pH is low, would you be able to recommend a way to determine the best means of raising alkalinity based on blood test results i.e. I’m going to the doctor to get blood work ordered next week and wonder if any specific test should be requested. In 10 years of lab work I see no blood pH in any results and was going to ask for that. Sodium and potassium numbers have always been in the normal ranges, sodium lower, potassium mid.

    Slowly converting my GP to thinking that LCHF may not be so bad, but I think he is still stuck on the ADA and AHA recommendations since he referred to my way of eating as “Crisco diet” due to the use of coconut oil.

    Thanks,
    Mark

    (reply)
    • mark  February 22, 2013

      Addendum to prior post: I say low pH and raising alkalinity. Could be misnomer, because I know that there can be varying levels of alkalinity at a specific pH. You may want to set me straight on what I asked.

      Thanks again,
      Mark

    • Peter Attia  February 22, 2013

      The question is what does one mean by “body pH?” Arterial blood pH? Venous blood pH? cellular pH? There is so much misinformation around this…the body is shockingly good at keeping pH at 7.4 in the plasma. For the sake of space and time, I can’t even begin to get into acid-base balance, but it’s very well understood. Not sure why this issue is concern for so many folks, though. I guess it speaks to bad information? Ketosis = DKA?

  92. Paula  March 3, 2013

    Hi
    I am a recently diagnosed type Two and am on 1500 mg of metformin per day. Taking metformin has had little effect on my blood glucose levels.
    I happened to stumble across ketogenic diet information. The whole process of ketosis ( while still new and a little confusing) is making more sense to me than any other eating plan I have seen. I am hopeful that starting this eating regime will have the desired effect.
    This forum has been very informative. Thank you for giving me some sensible arguments to consider.
    Great site. I’m sure I will be visiting it regularly.

    (reply)
  93. Philip  March 3, 2013

    Hi Peter

    Great blog… this has been an invaluable source that has allowed me to quickly experience the benefits of a ketoadaptive diet that you you have described. Couple questions below. If you know any good references off top of your head, those would be appreciated as well.

    First question: Can you comment on any longitudinal or prospective data that is either currently available or anticipated on pediatric epileptic or other patient cohorts who have been in long term nutritional ketosis? I suspect there isn’t much currently (from browsing pubmed quickly). Perhaps this is a NUSI objective?

    Second question: I’m not particularly concerned about this, but just wondering if you have had similar comments come up about acetone: a friend (a chemist of course) was concerned about the long term risks of “chronic” endogenous acetone exposure produced in nutritional ketosis. He cited the adverse effects of long term environmental acetone exposure. When I looked this up, I havent seen anything that convincingly suggests that even long term environmental exposures to acetone have any significant adverse health effects. “Haters” will be haters I suppose :-)! Their loss.

    Thank you for your efforts and keep up the great work. I ‘ve learned a lot from you

    (reply)
    • Peter Attia  March 4, 2013

      1. I’m not very close to this literature, but I’m also not how sure how applicable it would be. Some of those diets are really different from most us in NK. VERY heavy n-6 PUFA oil dependent.
      2. There is almost no production of acetone in NK. All the ketones are essential an equilibrium of B-OHB and acetoacetate.

    • Philip  March 6, 2013

      Thanks Peter. What are your thoughts on the value of generating longitudinal data on individuals on NK by choice (those who have experienced the benefits of NK and have adapted the diet by choice)? The only reason I ask is that it seems this is an easy fall-back position of detractors: they can point out all the hypothetical risks involved of NK which might be observed over time which haven’t been evaluated, despite any immediate benefits that might be documented by individuals in NK, such as improvement in serum surrogate markers, subject report outcomes, etc.

      Without such data, do you think it is difficult to defend the position that NK has benefits that extend beyond the surrogate markers? That being said I understand that designing such a long term outcome study could be daunting (ie sample size).

      Normally I would think that science would speak for itself. but in this situation, overcoming the inertia of the nutritional industry is a daunting task. I’m looking forward to hearing more about the NUSI sponsored studies that I’m certain are going to challenge this conventional wisdom.

    • Peter Attia  March 7, 2013

      The problem with such data is that if they are not controlled, for example, if they rely on volunteers, they are subject to too many biases.

  94. Paula  March 5, 2013

    Hi Peter
    I have been reading that one of the symptoms of ketosis is a dry mouth. What is the cause of this, and does it have any bearing on your level of hydration.

    (reply)
  95. Paula  March 5, 2013

    Hi Peter

    I am curious to know if the dry mouth symptom related to ketosis has any bearing on hydration levels?

    (reply)
    • Noella  March 6, 2013

      Hello I am new here and have tried to catch up on all the posts. Not there yet. I have been toying with Paleo for over 4 years. I have learned a great deal in the past few years but have managed only to decrease my consumption of grains and sugar but have never made a true commitment. Although I am not over weight, I am “skinny fat”-little belly and more recently back fat. I have never enjoyed exercising but understand that it is beneficial I just don’t -yet. I can be very restrictive with my carbs and probably have gone into ketosis -most recently this past week. I felt fine and saw a decrease in appetite and tummy issues resolved. However my mood plummeted and I still feel very tired both upon awakening and throughout the day. My age is 43 and I had premature menopause at 38. I take BHRT prescribed by an MD (only progesterone and testosterone no estrogens). Should a person prone to depression and moodiness ingest a minimum amount of carbs or do I need to make a clean commitment for several months? Could inadvertently cycling in and out of ketosis be causing my low mood? Should I carb count to ensure steady intake and should I be taking supplements in addition to Vit D and omega 3? I have Raynaud’s syndrome and today my joints were aching. My primary goal is to increase my energy and feel rested, especially when I wake up in the morning. I should mention that my family has suffered great distress due the illness of our child. I want to model some good behavior especially as our eldest child is gaining weight. I welcome input from readers and Dr Attia…

    • Noella  March 6, 2013

      Paula, yesterday I was reading an old post of Dr Eades’ and he states that low carb diet requires more sodium and water than you are probably used to ingesting. Check out his blog. He wrote a series of books including Protein Power with his wife.

  96. Yusra  March 19, 2013

    Hi Dr. Attia
    Thank you for sharing your information . I need to know more about MCT and Ketosis .
    How much ketone bodies can be produced in their process of energy production .
    As I am reading about the use of MCT in the treatment of Alzheimer’s in their ketogenic diet .
    I know the difference between LCFA and MCFA in their metabolism . Would you please tell me the difference in their ketone body production . in other words is it right to say , to reach ketosis level we can depend on MCT better ?THANK YOU

    (reply)
    • Peter Attia  March 19, 2013

      You certainly do not need MCT to be in ketosis, and MCT alone, does not ensure ketosis.

  97. Kevin  April 1, 2013

    Hello Dr. Attia,

    I read that urine test strips have little to no value in determining whether I am in ketosis or not. Therefore, I was planning on buying a product to test my blood instead. The only one I can easily find is the Precision Xtra device which measures both glucose and ketone bodies. Do you think this is a good investment? I really want to make sure I can trust the test results. Which product do you use for your own tests?

    Thank you,

    Kevin

    (reply)
    • Peter Attia  April 1, 2013

      I use that brand.

    • Kevin  April 2, 2013

      Thanks for the reply, and thanks for the website in general. The information listed here was invaluable for setting up my keto diet. In fact, just a week ago I didn’t even know what ketosis was and now I already feel like a pro! Also, the fact that you are a physically active person reassured me that it is possible to cut carbs and still be involved in sports. I am pretty active myself and I must admit that such a huge reduction in carbs scared me a bit at first.

      In any case, I hope I’ll be able to raise awareness about low-carb goodness here in Montreal. People seem to find the concept so unnatural and wrong.

      Cheers!

  98. tj  May 10, 2013

    Hi Dr Peter….

    Im a couple weeks into Ketogenic diet….and I generally work out 2 times per day….can I still consume the customary 1 gram protein/ 1 lb of body weight and still be in Ketosis….

    My main source of fat is coconut oil and eat I one solid meal of meat and veges at night. I consume about 10 tablespoons a day of coco oil in my protein shakes…..evenly spaced throughout the day…

    ultimate goal is to maintain and build muscle but to get less than 50 g of carbs per day…

    no one speaks about these issues….I need your guidance…

    tj

    (reply)
  99. Ceren Gultekin  May 17, 2013

    Hi,
    Recently, I’ve been diagnosed with hypoglycemia and using diaformin for a week now. My doctor also put me in a diet that’s high on protein, no carbs (except brown bread) and lots of healty snacks. My blood sugar levels never been better.

    My question is, my fingers started to taste sweet. No sweetness on arms though.. I can feel it on my lips too. I asked my doctor, he had no clue. Than with some research online, I came across people who also have sweet fingers according to ‘ketons.’

    I’m still searching for a solution, wondering if this is an adapdation process or a dangerous symptom of something else.

    Thank you!
    Ceren

    (reply)
    • Peter Attia  May 17, 2013

      You could ask your doctor to check your ketone levels, I guess?

  100. Kate  May 18, 2013

    Hi there,

    First thank you for providing such thorough and detailed info on your site. I am furious that conventional diet/medical advice is so wrong. I have been working towards keto adapting since april and have finally sorted out the amount of protein i can eat to stay in optimal (past 2 weeks).

    Early weight loss, then a lb every other week, now two lb last week. I like the slow loss as i am also doing some resistance training 2-3 times a week now to tone up as i lose.

    1. My question is what should fasting glucose be? I have been 4.2 at the lowest (with ketones at 3.1 – the highest fasting that same day).

    2. i would also like to know when i should go in for blood tests and what i tell my doctor if my cholesterol is higher than he would like to see. I remember you saying that there is a different analysis of the numbers he could do.

    Thank you for your great work!

    Aside from the gradual weight loss, i can finally breathe out of both of my nostrils ( i thought i had a blockage or something for the past 15 years), i avoided two flu/colds that came through our household since april (unheard of for me) , i have the mental clarity that i only get while taking bifentin ( for adhd), but WITHOUT THE HYPERNESS; and my chronic tendonitis in both my elbows and knee have virtually disappeared and has enabled me to successufully do my weight training. I have to say that i have accomplished more in the past 6 weeks than i have in over 4 years: focused, no automatic multi-tasking (i can remain focused and prioritize easily), and my creativity has returned; AND NO MORE DEPRESSION, i have suffered from depression my whole life. (I still have the same stress, now i can handle it much better).
    I have managed to stave off carb cravings easily by thinking about how horrible and depressed i felt all my life while on carbs and sugar addiction (with blood ketone testîng i have figured i cannot eat many at all, must be my polish genes!)

    This diet has saved me from a life of stress and misery, literally!

    Thanks,
    Kate, a fellow canadian

    (reply)
    • Peter Attia  May 19, 2013

      Kate, a normal fasting glucose is probably below 5.2 mM, but it’s dependent on many things. The series on cholesterol will help with your second question, including the yet-to-be-written part X.

  101. Renée  May 29, 2013

    Question:
    47yo female, on ketogenic diet since 12/1/2012 with no problems, carb levels 20-40 daily, restricted dairy, cautionary protein levels. When with friends I may occasional have 2-4 drinks totaling no more than 5 carbs cumulatively over a 4 hour period. I am comfortable driving if need be. Recently, though, I read that this diet causes the ketones to change to isopropyl alcohol that is not separated out in a breathalyzer machine from ethanol (drinking alcohol) and the diet combined with low carb alcohol can cause you to continue to burn ketones thus elevating the result of a BAC taken with a breathalyzer. I have been advised if ever in that situation to request poste haste a blood alcohol test by needle, which will segregate the ethanol from the converted ketones. Have you had experience with this phenomenon? 2011 State of Georgia v. Redstrom covers this specifically – it seems pertinent information for those choosing ketogenic lifestyles to be aware of if there is merit?

    (reply)
    • Peter Attia  May 29, 2013

      I am not aware of this. Interesting, if true. One more reason not to drink and drive.

  102. Matz Haugen  May 29, 2013

    Hey,
    I was wondering if there is any link between a ketogenic diet and high alkaline Phosphotase (ALP) values. From my limited wikipedia knowledge this enzyme seems to be involved in the digestion of fat in the liver.
    Thanks,
    Matz

    (reply)
    • Peter Attia  May 29, 2013

      I guess anything is possible in some % of the population, but this is not a common pattern seen (I assume you’re asking about high serum alk phos).

  103. George Atkinson  June 2, 2013

    Question:
    What might be the dangers of a very strick raw vegan diet for someone who actually desires to enter ketosis while fasting and engaging in that kind of diet? Our son has just done a very strict 3-day liquid fast and now has very little appetite and is only eating small quantities of organic raw fruits and vegetables. He believes that ketosis under these conditions is beneficial and he says that he has been eliminating parasites and toxins. He has been following a Youtube raw vegan guru who touts the healing powers of this sort of diet to cure seemingly everything. How dangerous is this?

    (reply)
  104. EnglishRose  June 16, 2013

    Very interesting reading. Thank you.
    I have been sugar free before and it was wonderful for years. This year I got it back on track. First I moved to 3 regular meals a day, no snacks, only good whole foods but keeping in the chocolate/dried fruit/fruit after meals. That gave me structure.

    Then I took out the chocolate AND the fruit. That cut the addiction which is wonderful,. No more cravings, sugar addiction symptoms, driving out to buy the chocolate etc etc. However as I’d never gone as far before (fruit had to go too as I over eat it massively) I had appalling “candida die off” (I fit every symptom of that) and the worst day was about day 21 (!!!) of coming off fruit/sugar. Then suddenly I woke up not feeling dreadful and exhausted any more. I lost virtually no weight – may be one pound over 2 weeks despite giving up all the fruit and chocolate and not eating more of anything else (I never have milk or cheese or wheat products and hate alcohol and caffeine). I only drink water.

    Only then did I give up my brown rice and baked potato/sweet potato. So I have done 3 days low carb so far. I seem to be able to continue with it because I healed the sugar/fruit addiction first before I took out the brown/good carbs. That is why it seems to be working as I don’t have sugar withdrawal as it was already taken out.

    Also the good bit for me with 30 pounds to lose (which makes me feel so bad it even puts me off going on dates at the moment) I have actually lose some weight immediately in the last 3 days eating like this. I have lots of veg at lunch and dinner, swede, peppers, aubergine, (and spinach with butter every day – my only dairy). I was surprised yesterday’s calories were 1000 when normally with the potato etc they are nearer 2000 and I did not feel hungry either. (I am the person who ate just as extras 1000 calories of nut and raisins at a time or had the daily 500 calorie trip to the coffee shop to buy hot chocolate and chocolates. So for once in about 3 years it feels possible to lose the weight.
    I tried a ketosis strip yesterday but it just looked normal colour and yet the Spakrpeople food analysis of yesterday’s food had hardly any carb in the veg.
    Anyway thanks for the great thread.

    (reply)
  105. Victor  June 18, 2013

    Hello Dr. Attia,

    Amazing thread. I am addicted. I used to eat what is considered a low fat, well balanced diet and eventually cut down to an extremely low caloric daily intake. I’ve eaten like this for years and all that has happened is that over time I have become at least 45 lbs overweight. I would consider myself fit but overweight. Two weeks ago after stumbling upon your eating academy website and this thread, I began a high fat low carb diet and have lost 9 lbs with relatively no negative symptoms. I want to continue this way of eating, but still worry about the long term impact of a high fat diet. Is there something I am missing? While most skeptics seem to focus on sustainability of such a diet, my concern is the negative health effects of too much fat intake. What does the body do with excess fat that we ingest?

    Hopefully low carb – high fat for life. Thank you so much for this thread.

    (reply)
    • Peter Attia  June 18, 2013

      Victor, you might find the post (with talk) “how did we come to believe saturated fat is bad for us” interesting and helpful.

  106. Jordan  June 21, 2013

    Hi Peter,

    First off, thanks for this blog. It’s extremely informative.

    I’m on day 12 of ketoadaptation, eating less than 20g net carbs per day, mostly in the form of carrots, broccoli, and cauliflower. For the last day or so, I’ve been experiencing some mild but recurring chest pain – a dull throb in the sternum that lasts for a few seconds and then disappears. I’m a 27 y/o male, generally fit with no serious medical conditions – so this is a bit worrisome. I realize its difficult to assess a symptom of this nature without knowing more about my medical history and status – just wondering if you’ve experienced or have heard of anything of this nature with regards to the first few weeks of ketoadaptation.

    Thanks for any feedback you can provide.

    (reply)
    • Peter Attia  June 21, 2013

      Jordan, probably worth sharing with your doctor. Not something I have seen in ketosis.

  107. Christina Ovenden  June 21, 2013

    Hi there, I’m looking for advise. I have been sugar free for a good 6 months and feeling better, losing weight etc etc and recently diagnosed (1 week ago) with Type 1 diabetes (I’m also 37yr old, work as a physiotherapist and exercise daily). My hospital based dietitian completed a food diary with me and advised me that I need more carb’s especially with now having injections of insulin, so have gone back to cereals in the morning, eating some bread. My stomach is now bloated and sore, blood sugars still all over the place. What’s your opinion/advise about diet for type 1’s? any carb’s better?

    (reply)
    • Bob West  June 24, 2013

      Hi Christina, I’m not Peter and I’m certainly no expert, but if you would like some more info, you might try Richard Bernstein’s book on diabetes and diet:

      http://www.amazon.com/Dr-Bernsteins-Diabetes-Solution-Achieving/dp/0316182699/ref=sr_1_1?s=books&ie=UTF8&qid=1372080802&sr=1-1&keywords=richard+bernstein

      He’s a Type 1 diabetic and an MD specializing in diabetes. Peter has occasionally mentioned his work. (His recommendation is low carb, by the way.)

      Again, I’m not a doctor, not Peter, not any kind of expert, and cannot give advice. But you may find his perspective useful. I hope it helps you.

    • Mandy  July 4, 2013

      Ahhh…yes. The same thing happened to me! They had me eating more food than I could possibly eat. Looking back I still find it hard to believe they wanted me to eat so much! Like the guy above me said, I’m no doctor, but I have been through that and have found the advice to be the worst advice I have ever received.

      The only thing that is true is that once you are on insulin, you tend to need some complex carbs because they tend to make you less likely to go into shock. Your situation is difficult because your insulin dosage is prescribed by your physician for this particular diet. I can’t tell you what to do, but I can tell you what I did.

      I stopped taking insulin completely and changed to an all vegetable and low meat diet plus plenty of supplements to lower blood sugar. I drink cinnamon tea instead of water; nopal leaf; gymnema leaf; bitter melon; neem tea; vandyl sulfate; chromium piccolinate; magnesium; and gentle yoga. Most of the time it keeps me under the 200’s. If it doesn’t, then I take small amounts of insulin. I use humilin because it has the least amount of additives and its over the counter. In case I reach low numbers I eat an apple since it is both sweet and starchy. It is more likely to bring your numbers up without sending you [way the hell] over the top. Its all risky business because as opposed to taking the processed god-knows-what glucose tablets your blood sugar may not rise fast enough to keep you from having a medical emergency. In my experience, the trick to not have numbers all over the place is to take the least amount of insulin needed to stay inside your acceptable range.

  108. Deborah  June 23, 2013

    Hi Peter,

    Just found this site. What a brilliant job you’re doing, helping so many people. Wonder if you could give me a bit of advice please? I have bladder cancer (CIS – clear at the mo through BCG installations every 3 months). I have asked about an optimum diet to help, but am just told to eat healthily, which I have always done anyway (more or less!). I have read about a ketogenic diet and various others and I get very confused, as they seem to contradict each other. Is it true that if you are in ketosis cancer cells cant reproduce, as they cant use ketones for reproduction, only sugar? I have altered my diet to cut out as much carb as poss, living primarily on protein (chicken & fish in the main), vegetables and fruit. I havent tested myself though, so have no idea of levels. I was told good carbs were fine, so Im very confused right now! My bladder is very inflamed through constant interference, so I want to adapt my diet for that also. Any advice you can give me would be much appreciated.
    Regards,
    Deborah

    (reply)
    • Peter Attia  June 24, 2013

      Deborah, I do plan to do a post on cancer. Short answer is we don’t have enough insight to say definitively. I do have a hard time imagining any scenario where cancer outcomes would be better on a diet full of sugar and simple carbs, though.

  109. reginald  June 28, 2013

    Hi,
    Wondering if ketogenic diet (the high fat part) might be contra-indicated in someone with a tendency to develop high triglycerides (eg 8-10mmol/L)? Not necessarily have them that high all the time but can get that high if diet is off. And not talking about an obese person or alcohol drinker, just a poor fat clearer eg Apo E2/E4. Or would the body increase clearance if low carbs?

    Thanks

    (reply)
    • Peter Attia  June 28, 2013

      Reginald, I do there are folks in whom KD is not a good idea, though I don’t know what the trait or traits is/are in them making this so. It might be apoCII polymorphisms?

  110. Mandy  July 4, 2013

    Having type 1 diabetes I have reached some very high levels of ketones and found it interesting that it never lead to acidosis. I have read that people with diabetes tend to have acidic bodies and I took on measuring my pH regularly for some time. Never once did I see a low reading, if anything it tends to be seemingly high. The only explanation I can find is that my diet is very rich in vegetables. In a way it was sort of a disappointment. I have been in search for solutions to my increasing web of health problems and was hoping it would be something as simple as pH.

    On a side note, I saw your discussion on TED (as probably many other people did). I am surprised you never mentioned anything about the effects of additives like MSG (injected into lab rats to cause type two diabetes) or aspartame in the effects of obesity and diabetes. Or the obvious effects of pesticides and arsenic (regularly fed to chickens to plump them up) in causing type two diabetes and obesity. There are published experiments that show that once a blood pesticide concentration is controlled for there is no relationship between obesity and type two diabetes. I really thought that this was what your TED talk was going to be about. I really hope you are looking into this in your research.

    (reply)
  111. Bryant Hardwick  July 6, 2013

    Hey there Peter, I know someone asked the bowel movement question but my wife generally suffers from this. I was hoping to see an improvement as we are both finishing our first week working towards ketosis. She usually tries to keep the salads a regular meal additional but was wondering if you or anyone have any recommendations on how to remediate this? Thanks for your time.

    (reply)
    • Bryant Hardwick  July 7, 2013

      For the time being we’ll keep leafy greens coming, lots of water and turns out fat intake was a bit lower than what it should be so will adjust those accordingly.

    • Peter Attia  July 7, 2013

      And salt, ideally delivered in bouillon helps, too. MCT is very powerful, also, but in small doses.

  112. Filip Zawadiak  July 10, 2013

    Hello Peter, I’m on low carb diet over a year now. Inspired by your blog I spend few days doing intense measurements of B-OHB and glucose levels, adding MCT/Coconut oil at the same time. What I observed is that when B-OHB level went up from 0.8 to 3+ my glucose levels dropped to values I never saw before. I used to be extremely hungry with 4.6 and strong headache, now few days later I’m not in hurry to eat with glucose 3.4 and ketones in 4-5 range, and no headache. My morning glucose levels also did fall from 5.6-6.1 (usually the highest in a day) to 4.6.

    I suspect it’s the effect of inhibiting glucagon from high ketone levels. And I read that glucagon actually might cause headache and increased glucose level from gluconeogenesis. Possiby it’s also quick method to avoid “ketosis flu”?

    Could it be that metabolism can run in number of stable operating points and with MCT you can actually quickly and easily switch from one to the other? Did you found any research papers about it?

    (reply)
  113. Mel  July 16, 2013

    Hi Peter,
    Thanks for this interesting article. I recently had a blood test for beta-hydroxybutyrate and it is 1.07 mM or mmol/L. My doctor thinks this could be sign of an inborn error of metabolism and wants to do additional testing. The standard laboratory range is .02-.27 mmol/L or mM. I eat a diet high in good fats with relatively low carbs. I eat ample amounts of coconut oil, coconut butter, and coconut meat and I have heard that coconut oil produces even more ketones than other fats. Point being that I doubt that this level of beta-hydroxybutyrate is concerning. Would you agree? Also, I wanted to make sure that levels you are discussing in your article are blood levels, right?

    (reply)
    • Peter Attia  July 16, 2013

      Correct, I always refer to blood levels of B-OHB in mM. A level of 1 mM is completely “normal” for someone eating fewer than about 50 gm/day of CHO.

  114. Dana Jo Parker  July 18, 2013

    Hi Dr. Attia, I wonder if you could help me understand an question about ketosis that a friend has suggested. She cited studies where epileptic children on ketogenic diets developed kidney stones at a fairly high rate: 6% in the first year and 25% after 5 years. She warned that staying in ketosis for long periods of time could cause kidney stones, yet I have been in ketosis for almost 15 years! I am a voracious reader and happen to know that kidney stones are not typical in those who are on low carb diets.

    Can you think of an explanation of why epileptic children on these diets would have such a high rate of kidney stones? One notable fact from these studies was that they reduced water intake in the epileptic subject to 80% of normal intake. Is that the answer?

    (reply)
    • Peter Attia  July 18, 2013

      Very likely. It could also represented an easy-to-correct failure to appropriately supplement something like calcium citrate, if appropriate.

  115. cajunu  July 18, 2013

    Hello Dr

    I believe I have been keto-adaptive for about three months (through measuring urine). I recently purchased a ketone blood test unit and my morning ketones for past five days have been between 3.7 – 4.3. I eat about 60g protein and about 30g carbs. Fat is via normal fats in meats, heavy cream, home made mayonnaise, avocados and coconut oil throughout the day. I haven’t lost weight in about 21 days (want to lose about 6kg). My questions – is it possible that the coconut oil is generating a ‘false’ reading of ketones? If coconut oil creates more ketones, is taking 3 tablespoons of c/nut oil the same as lowering carbs/proteins (which leads to the high reading on the ketone meter). Does high coconut oil which leads to higher ketones mean a higher fat burning? (I’m a 56 yo woman.)

    (reply)
    • Peter Attia  July 18, 2013

      Read the post I just wrote today. Perfect timing of your question.

  116. Melina  July 18, 2013

    Hi Peter,
    Thanks for addressing my question. It is appreciated! I had one further question. When you mention that ketosis happens when you eat less than 50 grams carbs a day, are you referring to net carbs (minus the fiber grams I mean)? Thanks in advance for the clarification.

    (reply)
    • Peter Attia  July 19, 2013

      Probably total for most people, but it is what is. In other words, it’s some amount — varying dramatically by person and activity level — and 50 gm total is good place to start.

  117. HSHOBX  July 20, 2013

    Dr. Attia,

    I was diagnosed with Type 2 diabetes in November. I freaked, starting research online how to control it, and started eliminating almost all carbs from my diet. As of today I have lost 34 pounds, and lowered my A1C from 7.9 to 5.6 (that last is based on the Bayer Self-Check, it might not be totally accurate.) My fasting glucose in now ranging from 85-95 from a high of 197!

    I stopped taking a few weeks ago Metformin. Okay all good.

    Now the bad. The other day I was feeling shaky and weak, feeling as if I couldn’t breath kind of. I thought I was having a panic attack even though I don’t suffer from them. My glucose was 109, so nothing alarming. I checked my urine though and it was off the chart high. I was very scared, thought it was maybe Ketoacidosis, and headed to the hospital. They hooked me to IV and pumped almost 2 liters into me – said I was dehydrated based on the urine tests. But that my other blood numbers were fine.

    Now I wonder: was it just that I am so low-carb? And that the staff doesn’t deal with that often? They wanted me to drink juice even though my blood wasn’t too low! I took a sip and of course my blood spiked to 200 so I threw it away when they left the room…

    I have read that ERs sometimes err by pumping too much fluid at a diabetic.

    Your thoughts or opinions?

    (reply)
    • HSHOBX  July 20, 2013

      Re-reading that, the grammar is all off ! I sound as if English is my second language. Sheesh.

  118. mason fisher  July 21, 2013

    My room mate told me about this diet. I just wanted some tips on what to eat. I have been eating half a pound to a pound of beef jerky through out the day along with chicken for lunch and dinner with spinach and broccoli. Is there any thing I should try different. Just starting up.

    (reply)
  119. Bryant Hardwick  July 22, 2013

    Hey Peter, I have looked through a few posts and cannot find anything related to my question but can you tell me if there is a distinguishable correlation between the production of all ketones? For instance, for every B-OHB “unit” is a unit of acetoacetic acid created? I ask because, I as well, tested with a Ketostix and I’ve seen the numerical range of B-OHB in the blood you’ve spoken about but wasn’t sure if what this product measures should be viewed in the same light.

    Basically looking to find out how to interpret the results from this measurement stick. And sorry if this had been covered, a link to a page if I missed it would suffice. Thank you for your time.

    (reply)
    • Peter Attia  July 22, 2013

      Bryant, excellent question. I do address this is part I of the ketosis posts, but briefly, BHB and AcAc exist in an equilibrium, and the ratio depends on production of BHB vs. consumption of AcAc in the Krebs cycle. A ration of anywhere from 0.5:1 to 1:0.5 is common. Acetone is much less common, and is a “terminal” pathway — once it’s made, there is no going back.

  120. Andrea Smith  July 25, 2013

    My husband and I decided to embark on a journey toward ketosis about a week ago. I have a friend who has tried it himself with much success and has been sort of a “coach” through our process of transitioning. We have been on a high fat low carb diet for about a year (but we were eating too much protein at that time) so I figured the transition may not be as big of a deal for us as opposed to someone on a standard american diet. As it turns out it’s been much more of a challenge than I expected. A range of symptoms including very low blood pressure, nausea, loss of appetite, intense/vivid dreams, hot flashes, bouts of anxiety, loopiness, lethargy, extreme muscle soreness, muscle cramps and I don’t need to go on (though mind you I’m still able to go to work). I knew all of these side effects I could experience through transitioning and even more fortunate I knew how to mitigate these issues by educating myself first and consulting my experienced friend.
    But the point I am getting at is I read up a good bit on high fat diets this past year, anything from recipe ideas to the biochemistry behind ketosis (for example Phinney and Volek’s works), but I have to admit I wasn’t very prepared for the transition period. And I think this is what many people would struggle with the most (and perhaps leave a bad taste in their mouth, no pun intended) if they didn’t understand the potential range of side effects while transitioning. I’ve found it interesting to monitor my husband and I, who have virtually identical active and dietary lifestyles, yet have some significant differences in our transition experiences.
    Do you think some day there could be a Blog about the Adaptation phase and people’s experiences with transitioning? I see it similar to any other support group such as Alcoholics anonymous, etc trying to adapt to a lifestyle change. I believe the journey to ketosis could often be more difficult than staying there.

    (reply)
  121. Jaime  July 26, 2013

    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!

    (reply)
    • Peter Attia  July 26, 2013

      Yes it’s normal if you’re not making the necessary adjustments — water, sodium, magnesium — addressed extensively in the blog and elsewhere.

  122. Susan Gabriel  August 5, 2013

    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?

    (reply)
    • Peter Attia  August 6, 2013

      Hard to say without being your doctor.

  123. Josie  August 6, 2013

    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.

    (reply)
    • Peter Attia  August 6, 2013

      I don’t know enough about this to comment.

  124. RAJAT SINHA  August 10, 2013

    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??

    (reply)
    • Peter Attia  August 10, 2013

      Rajat, I can’t give medical advice through my blog.

  125. Adrian  August 10, 2013

    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.

    (reply)
    • Peter Attia  August 12, 2013

      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.

  126. Annika Hackler  August 26, 2013

    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 ?

    (reply)
    • Christoph Dollis  September 21, 2013

      Starch.

  127. Paul Green  August 27, 2013

    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)

    (reply)
    • Peter Attia  August 27, 2013

      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.

  128. Bob Davis  September 3, 2013

    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

    (reply)
    • Peter Attia  September 3, 2013

      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…

  129. Tamara Canovas  September 7, 2013

    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

    (reply)
    • Peter Attia  September 7, 2013

      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.

    • Tamara Canovas  September 7, 2013

      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?

    • Tamara Canovas  September 7, 2013

      One more thing. One month prior the doctor lowered his Glucophage from 1000mg BID to 500mg BID

  130. Sylvia  September 8, 2013

    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!

    (reply)
  131. Sylvia  September 8, 2013

    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.

    (reply)
  132. Asa  September 9, 2013

    Peter,

    I would like to know if going on this diet would cause me to get high cholesterol?

    (reply)
    • Christoph Dollis  September 21, 2013

      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.

  133. Amy#2  September 13, 2013

    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…

    (reply)
    • Pam  September 14, 2013

      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.

  134. Justa  September 15, 2013

    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.

    (reply)
  135. Kyle  September 16, 2013

    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”.

    (reply)
    • Peter Attia  September 17, 2013

      You should check with your doctor. I can’t safely (or legally) play one on line.

    • Christoph Dollis  September 21, 2013

      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.

  136. Elna Caravias  September 17, 2013

    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.

    (reply)
    • Peter Attia  September 18, 2013

      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.

  137. Christoph Dollis  September 21, 2013

    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?

    (reply)
    • Christoph Dollis  September 21, 2013

      Also, note that while we notate it differently here, 1mmol/L = 1 mM.

  138. Lorna  September 24, 2013

    My husband was just diagnosed with stage 4 pancreatic cancer. My research keeps leading me to a ketogenic diet any thoughts?

    (reply)
  139. Gina Todd  September 24, 2013

    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

    (reply)
  140. Nayef  October 5, 2013

    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

    (reply)
  141. Adam Hudson  October 8, 2013

    While glycogen stores can be depleted within 24 hours as you say, the brain still needs glucose and we make it from smaller molecules through gluconeogenesis.

    (reply)
  142. Lynda Kamrath  October 8, 2013

    I am SOOO glad to have found you. I am a type 2 diabetic (67 years old) and have been trying to get in charge of my health for years. I follow a basically vegetarian diet, get plenty of exercise (swimming, weight room, walking my dogs, and occasionally biking), and work with a diabetic dietitian, acupuncturist, therapist, as well as an MD (OD). I have problems with balance and intestinal problems that I have been trying to get in control for years. I am now looking at a possibility of “Normal Balance Hydrocephalus” and considering treatment for that. It just seems to go on and on. I usually get up early in the morning and start researching medical information on the computer. Loved that video you did about the fat diabetic who had an amputation. BTW, I lost 35 pounds at the beginning of 2012 (without trying) and have been trying to gain weight since then. I am not at all fat, but can identify with that woman and with you having to do an amputation. Life just isn’t fair, is it?

    (reply)
  143. Peter Aston  October 10, 2013

    HI Peter,

    Thank you so much for all your hard work and dedication.

    I started the Ketogenic diet 10 days ago and I feel fantastic – for the most part very joyous, clear headed, and even-kiel. The only negative thing troublesome is that I am having these bouts of intense anxiety, and my face and hands start to get really tingly, almost as if they are going numb.

    Is this a normal part of keto-adaptation? It may be occurring around 3-4 hours after exercise, if I am in a stressful situation. Do you think it’s just my blood sugar dropping too low? Will this stop happening when I am fully adapted.

    Thank you so much for your time and energy. You are a hero of mine!

    Peter

    (reply)
    • Peter Attia  October 10, 2013

      Hard to say, other than perhaps hypokalemia and/or hypoMg. Supplementing sodium and Mg may address.

  144. Peter Aston  October 10, 2013

    Hey Peter,

    This is Peter again.

    I’m guessing that the symptoms of tingling face and hands as well as anxiety are to do with hypoglycemia?
    Or could it be too many ketones (maybe the exercise makes my ketones soar 4-5 hours later?)

    Does stress cause a hypoglycemic response?
    Or maybe I just have TOO much energy, and it leads to anxiety?

    It’s just strange because I am otherwise very healthy – normal body weight, athletic

    I love everything about the diet, except for these bouts of anxiety. I’m hoping this is just part of the keto-adaption process!!!

    If so, how long does it take to fully adjust?
    Thank you so much for your time brother!

    (reply)
  145. Kerrie Moor  October 11, 2013

    hi,i wonder can anyone give me information on whether its safe to go into ketosis with no gallbladder ?

    (reply)
  146. Adam  October 25, 2013

    Hi Dr. Attia, I have a friend who is overweight and I put her on a HF/LC diet with 30 minute walking everyday. She has lost about 4 kgs into week 4. However, she recently broke out with a bad rash. It is even painful. I have read that this can happen when a person who is overweight begins to burn fat for energy. I have never had this happen to me, maybe because I was never overweight. I have been on a ketogenic diet for over 2 years. Have you heard of the keto/rash? Anything she can do to relieve the rash but remain in ketosis?

    (reply)
    • Peter Attia  October 25, 2013

      I think I’ve heard one other person mention this. Was transient, if I recall.

    • billings  October 25, 2013

      I get a rash when I over do protein. A result of excessive nitrogen release I believe. Up the fat intake and it goes away.

  147. Brian Fogle  October 26, 2013

    My observation is that when I was under 30 or so years of age, I could eat virtually anything and everything and not gain an ounce. Once I reached 30-35 years of age, I started to become aware that overindulgence would lead to weight gain, though still not being too difficult to control by portion management. Around 40, it didn’t matter what portions I ate. If I ate the RDA style diet and didn’t exercise feverishly, I gained weight. I then began to experiment with the Atkins diet and within 6 weeks lost 35 lbs. I am now 53 years old and immediately start to gain weight if a stray fro more than a week or so from the low carb diet. Despite the diet, and probably because I have orthopedic issues (right total hip, left total knee, and c4-5 cervical fusion – generally rampant osteoarthritis) my activity level is diminished and I continue to be unable to lose all the abdominal fat. Any suggestions?

    (reply)
    • Peter Attia  October 26, 2013

      Really hard to know Brian, without some detective work. Consistency of dietary intervention is probably most critical, once you identify which eating strategy works best, which it sounds like you’ve got a handle on.

  148. Brian Fogle  October 26, 2013

    PS:
    One of my best friends is an anesthesiologist who continues to hold contempt for the ASA3’s of the world, especially if they are obese smokers. I wish he could come to realize, as you did, that the problem is far more complex and that most people wish they didn’t have the problems they do.

    (reply)
  149. Yoga  October 30, 2013

    Hi Dr. Attia,

    First, I would like to thank you so much for your blog and for taking the time to respond to so many questions. I like reading your posts .
    I weight train 6 days a week and 1 or 2 days of cardio ( 10K run ) . Just started changing my diet currently i eat 50 to 100 grams of carb 100 to 150 grams of protein and 100 to 150 grams of fat and once a week carb up ( height 5ft10in. weight 73kg ) . i started improving my cardio from this diet and did not loose any strength and also gained some muscle while loosing fat , this diet works great but i wanted to ask you is there any changes i can do. Also i wanted to ask how long will it take to become a fat burning machine . And what will happen if i consume too much fat with very less protein and carb like more than 5000 calorie will i gain weight .

    (reply)
    • Peter Attia  October 30, 2013

      I’m not sure what a ‘fat burning machine’ is, but within a few weeks to months of dietary change, RQ will fall, which implies greater access to FFA. It can take longer, for reasons I alluded to in another post, to fully adapt at the mitochondrial level, though. Your other question is addressed in the post on fat flux.

  150. Mihail  November 1, 2013

    Hello Peter,
    I am trying this diet lately, I am in my forth week now. I am not in ketosis yet, I still need to find my way, I am working on it.
    I am diabetic type 1 and I need to know if there is any way to get high ketosis whilst have normal blood sugar levels (70-115). It would be enough for me just to check my BG and inject insulin when necessary, or do I still need to check ketones as well?
    I know what ketosis acidosis means I have been through one when I was diagnosed but still a bit confused how this works. I have read a lot on your blog which is awesome!!

    (reply)
    • Peter Attia  November 1, 2013

      Mihail, as a T1D you really need to be consulting with a physician in person (not over the internet) who can help you. You may also want to start by reading Richard Bernstein’s book. Dr. Bernstein is himself a T1D.

  151. Mihail  November 1, 2013

    Hi Peter,
    I’ve read the book already as you adviced me few weeks ago.But in the boook there isn’t any word about ketosis. He keeps talking about low carb, recepies examples and what a marvel this diet is. Your blog says away more interesting and detailed stuff.
    About the doctors they don t have a clue what I am talking about. They say ketosis is dangerous. And when I ask them why, they cannot explain. Until I ll find a good doctor I was hoping you can help me with regards thia ketons and normal blood sugar. I really wnt to try this diet.
    Thank you for what are yoy doing with your blog and NuSi. On this planet we need people like you.

    (reply)
  152. Rick  November 4, 2013

    Dr. Attia,

    Thank you so much for defining scientifically what this diet does for your body. I am 34 yrs( Former High School Science teacher) old and just realized a few months ago that I have been “sick” my entire life. Ever since I was a little boy I was always in the doctors office for terrible stomach cramps, anxiety, ADD, chronic heart burn, body aches and pains, constant headaches, not to mention I was 50 lbs overweight and all the highs and lows that come from eating carbohydrates.

    I have been L C HF for two months with one slip up( not my fault…I was served a non diet drink and was I shaky and sick twenty minutes after and for two days felt poorly).

    ALL THE ABOVE AILMENTS ARE GONE!! No medicine has been able to do what this way of eating has. I want to stand on a mountain top and shout to the world how bad carbs are( for me). I have never felt better in my entire life. Really. So much so that if I didn’t lose another pound, heck even if I gained weight, I still would never eat another chocolate chip cookie again because of all the other benefits.

    I thoroughly enjoy cooking and preparing my own food ( as well as my son’s) he’s not keto adapted. My diet consists of 70-80% fat, 15-20% protein and the rest carb in the form of leafy veggies.

    .My “control” if you will, was feeling terrible all the time. I thought that’s just how people felt. Man I was wrong.

    Total convert Here!! 238 lbs sept 1st to 209 lbs (and losing) November 1st.

    Rick

    (reply)
    • Peter Attia  November 5, 2013

      Congratulations, Rick, and thank you for sharing the transformation.

  153. Edd  November 10, 2013

    Hi there.
    Would appreciate a little advice, I am on a water fast (drinking two black coffees and peppermint teas as well predate) and on the third day I woke up really lightheaded, fatigued and quite drained. I felt so bad I had to eat a little bread and some eggs. Can this be the keytones making me feel so wretched? And if yes, is there anything I can do to lessen this?

    Thank you!

    (reply)
    • marly harris  November 11, 2013

      What you attempted is not a fast. Water only is a proper fast. Doing it that way, the hunger ceases after several days. I’ve fasted regularly all of my life (I’m 80) and the long-lasting results have been miraculous. My longest fast was 30 days (I took a leave from my job) and I walked several miles daily.

      It has its humorous side. When I was modeling, the photographer asked me whether I have a moveable tumor because I was always a different size for the shoot. During that era, I was fasting two days a week, losing 2 pounds every fasting day. Four pounds wasn’t that much to lose but it does alter dress size.

      I now eat one meal daily after a 19-hour fast; I am able to do an intense weight-resistance workout daily (well, six days a week). Having been born with genetic heart disease, being highly functioning and not too bad looking at this age makes me feel like Wonder Woman.

    • Peter Attia  November 12, 2013

      Now THAT is fasting!

    • Yossi Mandel  November 13, 2013

      From writing that you ate bread I assume that you weren’t eating low carb before the water fast. A water fast for someone not in ketosis starts with a minimum of 3 days of increasing pain, sometimes more. It is also difficult for some people to water fast without a lot of sodium, magnesium and potassium supplements – you’ll feel weak and vague aches much later on as well. If you want to go into a water fast cold, maybe try taking MCT oil the first few days and supplement with electrolytes every day.

      You’ll feel better if you switch to ketosis first and then water fast. After the weeks of adaptation, say the average of 6 weeks, you may be able to switch in and out of water fasting while remaining in ketosis and not having the withdrawal from glucose symptoms. But Dr. Attia writes here that the big nightly meal on intermittent fasting would knock him out of ketosis and made him feel uncomfortable, so it varies by person – you may still feel uncomfortable.

  154. Julie Mauldon  November 14, 2013

    Hello my daughter has just been diagnosed with a Glioma brain tumour, her partner has her on the Ketogenic diet, is ketosis a bad thing and is she liable to get ketosis if so is that good or bad plz help me understand

    (reply)
    • Peter Attia  November 15, 2013

      Julie, I’m sorry to hear about your daughter. Ketosis is not a bad thing, but the question you’re obviously asking I don’t know the answer to (will it help your daughter?). I will be writing about this in the coming month or so, though.

    • BobM  November 18, 2013

      Julie,

      I have an interest in this topic too. I’m sure Dr. Attia’s upcoming article will be help answer your questions. In the mean time, I found this article to be helpful for me in understanding the interplay between cancer and ketosis. I hope it can be useful to you too.

      http://www.cavemandoctor.com/2013/01/01/an-introduction-a-ketogenic-diet-for-cancer/

      Bob

  155. Mohit  November 15, 2013

    Hi Peter,

    I’m sure you’ve addressed this question somewhere, but what is the impact of a ketogenic diet on bone health? Does it create an acid environment that leeches calcium and other minerals from the bones ?

    Thanks

    (reply)
    • Peter Attia  November 15, 2013

      I have not seen this studies, but I recommend people do a 24 hour urine collection to look for calcium oxalate and such to determine if they need supplementation. NK does not create an acid environment like DKA.

  156. Daniel  November 15, 2013

    So, something I’ve been wondering that I can’t seem to find on the internet anywhere is what is the normal range of ketones for someone on a ketogenic diet, meaning they go from no carbs to a few carbs. I asking because I might intake something with like 19 grams of carbs one day, and have nothing with carbs the next. And preferably in mg/dl. rather than mmol/L.

    I look at my ketone urine strips. They are ReliOn ketone strips that I bought from the Wal-mart diabetes section, and my ketones increase rather rapidly when I cut my carbs out. Within three to four days of having next to no carbs or maybe a few, I was already between “small” and “moderate”, which is given the numbers 15mg/dl for small and 40 mg/dl for moderate.

    Then next day, I ate half a dozen donuts in one setting from Dunkin Donuts because I just had that sweet tooth you get when you’re still working yourself into that ketogenic diet. Anyhow, several hours later, I tested my urine again, and it was between 5 and 15 trace and small. Since the donuts, I kept up with the ketogenic diet. and the next morning I was in between 15 and 40, small and moderate again. Then, later that day, I was around 40, moderate. Then the next morning, today, I’m between 40 and 80 Moderate and Large. So, I’m trying to figure out what the maximum safe levels of ketones are for me. I’m about 250lbs, but I can rapidly lose weight on this diet. I’ve struggled to do this diet for about 3 or 4 months now, and I’m finally at a point where I actually feel more energetic. It used to be I was feeling semi-run-down and somber, but now all of a sudden yesterday, I didn’t have any carbs at all, but for some reason, I was feeling rather energetic, more than I had in a long time. It reminisced of the days of when I was a kid. It made me wonder if my body was finally adapting to a low-carb diet. As it is now, I don’t crave sugar this morning. I don’t really crave anything. I ate a few pork rinds, and I seem to be mostly satisfied for now. Before, don’t usually crave anything in the mornings either, but I guess I’ll see how the day progresses. Anyhow, I’m re-hydrating to see how that affects my keytone levels.

    (reply)
  157. Miriam Sanchez  November 19, 2013

    I have been trying to follow a low carb (ketogenic diet) for approximately 5 weeks now. I am still very
    addicted to carbs and I believe that I am in and out of ketosis, but I am not sure. When I check my
    ketones with urine strips, I am at lower end of ketone production. Sometimes they show no ketone
    production at all. I understand that checking the blood would be more accurate. I go to the gym almost
    every day believing that if I exercise I can burn off some of the extra carbs that may have been stored
    as glycogen as a result of my eating too many carbs. I try to stay as low as 20 carbs per day, but some days
    I can go as high as 50 carbs. I have lost approximately 17 pounds in 5 weeks. I am a type 2 diabetic. Some days I don’t feel too well, but I can’t tell if it is the diabetes, the high blood pressure or the diet. My triglycerides are normal. Am I doing the right thing?

    (reply)
  158. John  November 22, 2013

    I have PD and have been eating 12 TBS CO daily. I seem to get swings in ketone levels. I start my day with a brisk walk which gives me a good level of ketones (PD symptoms fade) but when I start snacking my ketones drop. I think I need to consume low glycemic carbs, to sustain ketone levels. Can you suggest some foods that would help ?

    (reply)
  159. Roy  November 23, 2013

    I AM NOT ASKING NOR EXPECTING MEDICAL ADVICE __ You are released from that expectation and totally indemnified — Just would like more info on when ketosis will kick in and begin work on scar and tumor and other foreign tissue.

    Please please help me — or forward to another doctor that might be able to answer my questions? A dr Lupo? I can’t find him — anyone else? all of your i indemnified by me — just looking for info on when ketosis begins — must I get rid of all adipose tissue first? Please help.

    Please help — I’m in day 35 of a 40-60 day water only fast — purpose to use ketosis to burn out a kidney tumor – already been thru the warnings from Veterans doctors who freely say they have only had a single course in nutrition (some time ago) and have been warned by them that electrolytes can affect my heart — avoiding all glycerine, glucose, glycerol and anything but water — still have adipose tissue and am simply wondering when in the process, ketosis will begin to digest kidney tumor? Doctors want to cut and rip and take out kidney because “After all you have 2 and only need 1″ mentality. Ketosis strips show high ketones between 80 and 160 — but as I say adipose tissue still present. Have cat scans will be happy to send you if yu want them — doctor will do another cat scan when i finish fast — attempting a complete fast till hunger returns — but I am hopeful that body will have digested tumor long before that tie. Can you advise as the when that work may start?

    I survived a subdural hematoma this time last year and amazed my doctor (apparently only 22 out of a 100 do so) and when burr hole was opened fluid squirted two feet across operating room (doctor said in 2000 operations he’d never seen that) and then my brain which was supposed to take up to a week or so to expand reexpanded in less than 30 minutes — so I have a remarkable gift of the Lord Jesus in my particular immune system. I am counting on the complete fast to consume scar tissue left over and perhaps even help heal my vision– VA doctor has me down for more blood tests next week to make sure of electrolytes — but has grudgingly accepted that I’m doing this no matter what. Tumor was somewhere around 2.2cm in middle of right kidney — applying my faith and fasting to consume it — have already surprised oncologist with fact that it had not shown signs of growth – (one doctor said of the other ‘He was amazed you had not yet had to pick out a coffin’) . I really want to finish this ast and believe ketosis will help cure. Still on water only — hunger is gone (I coo almost daily for my wife and do not cheat ) but I can find nothing on web about when ketosis may begin work on scar tissue and tumors. Must all adipose tissue be gone first? Can you help? Again will send catscans if you wish — but haven’t had one since I began fast over 30 days ago — prepared to go to sixty days if necessary or until hunger returns. I AM NOT ASKING NOR EXPECTING MEDICAL ADVICE __ You are released from that expectation and totally indemnified — Just would like more info on when ketosis will kick in and begin work on scar and tumor and other foreign tissue. Current weight at 180 down from 260 but much of that is water weight — have fasted before but this is longest so far — have been advised that quitting and starting again could allow tumor to rebound and metastasize.. Believe God will help me make sure that doesn’t happen – so just looking for your opinion or info on the matre — not your medical advice that could freak out other doctors.

    Sincerely — Roy Pearcey

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    • sten bsell  November 29, 2013

      If it was me I would add charcoal to absorb some toxins possibly released during this extraordinary fast. Instead of just breaking the fast when you do later, I would switch to a high fat moderate protein green vegetables and zero bread strong starches – diet after, to keep blood sugar and IGF-1 low hereby giving slim chances for tumor to rebound. I would also take some sea salt with the water but your doctor is apparently checking electrolytes and making additions as required.
      The follow on high fat diet ( start slowly ! build up over maybe 2 weeks ! ) could help clearing toxins from the liver, again with charcoal support to avoid recirculation. Add magnesium then to avoid hard slow moving stools.
      I am no doctor. It’s just my 5 cents.
      It’s all yours and the best of luck!

  160. sara  November 24, 2013

    Hi, I am a mother of 2 boys one of them is diabetic type 1 ,, today i checked BG and Ketone of my second child who is not diabetic and his BG= 4.7 and his Ketone=0.4 …do I have to be worried for my son or no ,,,, Thanks so much

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    • Peter Attia  November 24, 2013

      DKA does not occur until BHB levels get in the range of 15 to 20 mM. This only occurs in people with T1D or very late stage T2D.

  161. sara  November 24, 2013

    thanks so much for your reply

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  162. T. Lewis  December 2, 2013

    I’m wondering if you could comment on this study suggesting that being in ketosis could eventually lead to a fatty liver?

    http://ajpendo.physiology.org/content/299/5/E808

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    • Peter Attia  December 2, 2013

      This is an interesting study, and the senior author, Schulman, is a good scientist. There are 2 issues, I guess, with this paper:
      1. I’m not sure if testing a “KD” is mice — a natural herbivore — offers any insight into omnivores — humans. I’m skeptical of animal research in general, but nothing is worse than mice. Even rats offer a better model.
      2. The “KD” is pretty odd, in that it was protein deficient, less than 5%. Notwithstanding the first issue, this issue also poses a significant methodological flaw that should not be over looked.

    • T. Lewis  December 3, 2013

      Thank you so much for replying! I agree with your concerns about the study but I wish there was more data on the subject to put it to rest in my head. I stay in ketosis most of the time and plan to be that way for the rest of my life and I definitely don’t want to be doing anything to harm my liver. My liver panels are fine but as I understand it you can have a fatty liver with ok liver panels.

    • Peter Attia  December 4, 2013

      Yup, nobody should aspire to have fatty liver…

    • Vicente  February 25, 2014

      What is the point of testing effects on animals that have already been tested on humans? you have this study from 2007: “The effect of a low-carbohydrate, ketogenic diet on nonalcoholic fatty liver disease: a pilot study”, and this one from 2011: “Short-term weight loss and hepatic triglyceride reduction: evidence of a metabolic advantage with dietary carbohydrate restriction”. As far as I know serious studies IN HUMANS show an improvement in NAFLD when low-carb diets are followed. May be there are also studies showing the opposite effect IN HUMANS.

      So, ok: “A high-fat, ketogenic diet causes hepatic insulin resistance IN MICE”. Who cares if mice should follow or avoid ketogenic diets? I don’t care because I am not a mouse.

      In my opinion using mice as subjects and suggesting that “obese patients on such diets could lose weight but develop NAFLD and hepatic insulin resistance” is a waste of time that comes close to irresponsability. I have been dealing with NAFLD (GPT sistematically above 70) for the last 3 years. My clinical tests after 3-months of low-carb diet showed a GPT of 26 (this was 5 months ago). Of course this is just my case: just one person whose NAFLD improved with a low-carb diet.

      May be scientific journals should stop this nonsense of publishing animal experiment results when experimenting with humans is viable.

    • Peter Attia  February 25, 2014

      Very nicely put, Vicente. To your last point, unfortunately, the funding, publishing, and promoting “industries” will all be harmed by your (entirely logical) suggestion.

  163. Tomas  December 3, 2013

    Thanks for explaining the difference between DKA and keto-adaption!

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  164. Tonya  December 13, 2013

    Since started ketogenic diet I’m constipated and elevated blood pressure any suggestion Dr.Attia?

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  165. Bryan Evans  January 9, 2014

    Hello Dr Attia,

    I love you work on this site. I lost 70 lbs 2 years ago and have transformed from sedentary to very active, I rode my bike 3,700 miles last year including some road racing (I didn’t do that well, but I completed the races) I am very intrigued by the concept of keto adaptation for endurance sports. It would so much less of a hassle to not deal with all the gels/sports drinks, fueling strategies ect. So 2 weeks ago I committed to try ketosis for 90 days. I am on day 14 and have averaged 40 grams of carbs per day. I feel good, I have had a few “carb flu” days, but today I felt great while training at the end of a 15 hour fast ( I am also doing 8/16 IF most days). I ordered a precision blood meter to monitor ketones and it arrived today. About 1 1/2 hrs after my dinner this evening I took my first tests my blood glucose was 72 and my ketone level was 7.1 yes 7.1. I was a bit surprised almost alarmed. I made myself a green smoothy, spinach, coconut milk, protein powder, heavy crème, walnuts and tested again after about 40 min. Glucose was 60 and ketones 5.3. I am assuming that the smoothy elicited an insulin response which dropped both glucose and ketones does that make sense? Should I be concerned about a ketone level of 7.1 ?

    thanks for all insights you may have

    Bryan

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  166. O. Zohar  January 22, 2014

    Hi Peter, I was Paleo, veggie, fruit, not high fat not low fat for a couple of years, perfect blood tests, 25 TRI , 80 HDL 85 LDL ; I then tried to move to 100% Keto , after 60 days my cholesterol thru the roof, 163 LDL, HDL up too and TRI up to 37, but suddenly my liver work is off the mark with Bilirubin, AST and ALT slightly elevated, all slightly outside the range…

    I know by definition Keto is not for everyone, is this one of these cases, or maybe from your experience there is something wrong in the transition ? I just wondered how you would look at it, I must say in terms of feeling, i feel super strong in the gym, super good energy level, I feel very even mental energy throughout the day, I do feel better than I was on paleo, but not sure what risk i am taking

    Any input will be highly appreciated,

    Thanks

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  167. John  January 30, 2014

    hi Peter

    Thanks for all the great info you are sharing with us. I am trying out this and definitely see changes in my mood and energy levels already. I have 3 questions…
    1. Is it ok for people already diagnosed with type2 diabetes to try this out. Will it reverse their insulin resistance and make them insulin sensitive. Should one stop taking medication such as glyciphage if trying a low carb diet ? This is for my mother (70yrs old) and I was wondering if older folks can benefit from this diet.
    2. Once the chronic inflammation is reduced with reduced insulin levels is it possible to declog the arteries of patients who have build up significant plaque / artery blocks ?
    3. Since the ketone pathway is an alternative that the body uses during starvation or illness — how does reduced body fat % (below 10%) affect the ability to handle serious illness and recover. During such illness there is aversion to food intake (nausea).

    thanks
    John

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  168. Monica  February 9, 2014

    I would that I had your mental capacity. :)

    I’m a 51 yo female. and find that entering ketosis induces bfs with cramping. That and heart palpitations seem to become my companions when I am in ‘deep ketosis.’ I found electrolyte capsules to negate this effect to some degree. I assume it is the sodium after listening to Jeff Volek. Still, it is unnerving. Esp when my doctor advises me to stop the ketogenic diet as my ‘muscle is being cannibalized.’ Appreciate your consideration.

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  169. Austin Littke  February 11, 2014

    I’m more of a proponent of a diet high in fruit, vegetables, and fish as primary meat source, so I am indifferent to the health benefits of a ketogenic diet. I don’t believe it is the most optimal diet, but if you take vitamins to supplement it it’s close enough to it. Anyways, i briefly read some of the comments, and there’s a lot of people lacking knowledge. Everyone who is ketarded over ketosis always states “our ancestors this” “our ancestors that” It’s been proven (although more and more it is being discovered recently) going as far back as you can that our ancestors ate plenty of grains, and plants, and fruits. “Hunter gatherer” societies didn’t have strict meat diets, nor did they need to be in a constant state of ketosis. If you look at the longest lived societies the overwhelming majority of them are not on ketogenic diets whatsoever, although let’s be clear I’m not insisting the ketosis could yeild a similarly long lifespan. The reason these societies live long is overwhelmingly the amount of physical exercise they get each day and their feelings of contribution to society even in old age. It’s more mental/spiritual and physical than diet. To qualify that statement, by that I mean as long as you aren’t eating processed foods, it doesn’t matter if you are eating a ketogenic diet, a diet of little to no fat and many vegetables, whatever, as long as you aren’t eating processed junk and are eating as close to nature as possible. Ketosis is completely unnecessary and offers no distinct advantage over high fruit/vegetable low meat diet. The advantage of ketosis i would say is it’s much easier to maintain for long periods of time. My brother has been on a ketogenic diet for over a year and i entertained a ketogenic diet for a couple of months. It had it’s moments. What I can tell you from my experience is coconut oil was the ‘catalyst’ in the diet that I think made me feel mentally clearer at times and gave me higher energy.
    Bottom line— Empower yourself with knowledge and stop getting defensive about ketosis, the hunter-gatherer argument and such is just pathetic and unsupported beyond theory as well as most the other arguments trying to make it out to be the holy grail of diets. As far as evidence available today, it’s definitely not the MOST optimal if you are nitpicking. Anyways, as I said, BOTTOM LINE— Exercise and be spiritually and mentally sound. It’s hard to escape western ideology but try. And as long as you “shop the outsides of the aisles” and try to eat as close to nature as possible, it doesn’t matter what your diet is. Exercise and psychology are the X-factors.

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  170. christobel  February 11, 2014

    I am really glad to find your site. It is very informative. I have been on paleo for about 2 years. But I do Paleo for Athlete which means I still take some carbs usually sweetpotato. I tried to go into the keto diet unsuccessfully many times because I get heart palpitation everytime I drop my carbs. I do not understand why. Perhaps you can shed some light here. I am recently diagnose with adrenal gland fatigue and I believe that Keto diet will further stabilize my sugar level. ( I was very sick 2 years ago and switching to Paleo is probably the best thing I ever done to myself)

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  171. Norm  February 12, 2014

    Heart palpitations while going low carb are usually due to lack of sodium or in some people going low carb makes them a bit extra sensitive to caffeine/nicotine that could also contribute to heart palpitations, in some people going extremely low like under 20 grams can trigger heart palpitations. It is really a matter of working out what works or what doesn’t for you by, as we have learned from Peter, changing one variable at a time.

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    • christobel  February 13, 2014

      Thanks ! I will need to try figure this out… its driving me crazy :)

  172. Yael  February 17, 2014

    Hi Peter
    I’ve been on a Keto diet for 6 months and love it! In the first few weeks I lost 5kgs before I was in ketosis. Once my blood ketone levels went up my weight went up slightly and 6 months later I’m back where I started. Is it possible that my body doesn’t metabolize fat properly…or I’m just eating to much fat?!
    If I eat between 80-110g fat a day my ketone levels don’t go to high..if I have 200g fat ..ketones go up. How do I get my ketones up without consuming so much fat?? (Using body fat as instead of ingested fat)..Only having about 40g protein a day, any higher and sugar goes up….carbs under 15g…
    Any advise welcome !!
    Yael

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  173. Heidi  February 21, 2014

    Hi Dr. Attia,

    Thank you for your blog and all the great information you share so freely.

    Could you write something here on how a ketogenic affects someone with hypothyroid?

    There is so much controversy out there stating that someone with low thyroid should not embark on the keto nutrition protocol.
    Thank you!

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    • Peter Attia  February 22, 2014

      I don’t think anyone knows. Of the major endocrine systems, thyroid is unquestionably the hardest to diagnose because lab values mean very little. The diagnosis is clinical. So when studies talk about T3, T4, fT3, fT4, rT3, and TSH without addressing the clinical picture, there is no way to know what they are talking about. Anyone who loses weight — especially if they have been overweight for a period of time — is going to see a reduction in thyroid function. This is true of carb-restriction or “plain” calorie restriction.

  174. Chloe  February 21, 2014

    Hi Peter,

    I have learned so much from your blog. Reading your articles has given me the information I need to answer peoples comments when questioning my diet choices. I was wondering if there are any resources you can recommend as a dietary guide line/meal plan to get me started. I am new to the Keto diet and am finding it difficult to ensure I am eating enough fats while not over doing the proteins. I would appreciate any help and direction!

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    • Peter Attia  February 21, 2014

      For NK, Volek and Phinney’s “Art & Science of LC Living” is a good place to start.

  175. Rosie  February 24, 2014

    Dr A,
    Thank you – this is a fabulous site!! I’m a bit of a geek with a biochemistry degree. Currently I’m a pharma rep (don’t hold that against me) helping patients with epilepsy and have always been an advocate of a ketogenic diet in this population. After reading your articles I learned that babies are in a ketogenic state. So here’s my question: is there any danger to a low carb lifestyle when you are a breastfeeding momma? Low carb living has helped me through the years. I had a baby 4 months ago and I haven’t lost anything yet (I have PCOS and the only way of eating that helps my cravings is low carb). I cleaned out the carbs 3 days ago and dropped 5 pounds (mostly water at this point, I know), but several people scared me into thinking I could be hurting my baby. I can’t find conclusive evidence to support this, but figured I’d ask since your site is backed by the most science I have seen.
    Thanks so much,
    Rosie

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    • Peter Attia  February 25, 2014

      I was not aware that babies are in ketosis. That would surprise me. Has it been demonstrated? I’m not aware of data to support or refute the use of ketosis in breastfeeding.

  176. bill  February 25, 2014

    It started great: Within two days of embarking on Drs. Phinney/Volek’s protocol I was in ketosis, felt good and stayed there for two weeks, measuring at .7 on average, occasionally a little higher. At about the two and half week point, I started feeling lousy for the first time: measurements were only occasionally above .5. And in this past week I’ve averaged .3. Checking the records, I’m up to about 30 total carbs, which is higher than when I began, but following Phinney, I thought that 20 net carbs would be OK. Am I mistaken? The other suspects are stevia and a couple cups of coffee a day. Could that be it? I need to either get back into ketosis or stop. The brain has gone woozy. Also I’m sleeping two hours a night less despite wanting to get my prior 8 hours. Any thoughts from your experience would be very much appreciated.

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    • bill  February 25, 2014

      And I keep protein at about 100 grams or less. For the life of me, I seem to be doing this according to the prescription.

    • Peter Attia  February 25, 2014

      Hard to say. Try selective elimination for 3 day periods of time.

    • Dave  February 25, 2014

      Bill, I went through about the same thing. I think it was a slightly delayed case of fat adaptation, often called the Keto flu. I struggled through it and within about a week of it starting it was gone. I’ve been in and out of ketosis many times since and never had a problem. If you can struggle on a few more days it might resolve.

  177. bill  February 26, 2014

    Peter, thanks for the 3-day time frame, and Dave, I appreciate the encouragement. Good to get heard.

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  178. TC  February 26, 2014

    Hi Peter,
    I have been on a ketosis diet several times (LighterLife and Orsmond Clinic). I felt great, had lots of steady energy through the day and the weight came off quickly. This would be great except around week 3 I start to feel breathless. It gets worse by the day. The only way to stop the breathlessness is to eat more carbs than what I’m supposed to have. Normally this fixes it within a couple hours. But the last time the breathlessness came on faster and was much worse. It took nearly a week to feel normal again.

    The diet company says there is no way ketosis can cause this symptom. My GP said that I should not do a ketosis diet again.

    Have you heard of this happening? Do you have any ideas why this might be happening?

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    • Peter Attia  February 26, 2014

      Not sure what you’re eating and can’t speculate on medical problems.

    • christobel  March 4, 2014

      TC.. I have the same issue too which is why I faiedl in all my attempts to get into Ketosis. The heart palpitation ( esp at night) drives me crazy. I just need to up my carbs and I’ll be ok. I guess everyone is different and not every diet works for everyone.. you just need to experiment as what Peter always say. I am okie with not going into Keto as I do not have heart palpitation. I can usually tell when my body is heading towards Keto because the heart palpitation will start. I was awake last night because of heart palpitation. I am going to eat some carbs today to stop it. I wasn’t intend to go into keto ..I was just not eating much carbs last few days

  179. Rico  February 28, 2014

    Hello Dr. Attia,

    My wife and I went on the ketogenic diet since Monday (02-24-14). Using a urinalysis strip I tested around 40 mg/dL but my wife is at 160 mg/dL already… Is that unusual? If so, what changes should she make in her diet? Right now we are adding fat in when ever possible. Does this mean she can afford more carbs?

    Thanks in advance,

    Rico

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  180. Steve Baze  March 1, 2014

    Excellent information I have come to the same conclusions for many years now and live everyday exactly what you are explaining to people. Please got to my website and go to fitness page and you will see a 65 year old that is much more fit and healthy than most 25 year olds and enjoying every second of the day, everyday. Thanks for this article . It points out some very key information regarding glucose and Ketosis as a useful tool and not just a negative. What most do not realize is that there are many pieces to the puzzle of fitness/health and a lot of what we have been spoon fed is utter nonsense. Basically illusions to sell the public certain products like lots of wheat based whatever? The realization that ones metabolism is a key in the burning and conversation of fuels is paramount information and understanding. I will be adding this article to my site. Excellent , and Good on Ya !
    http://www.downtoearthprepper.com

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  181. Richard  March 2, 2014

    What would you say to the idea that the body does not have 1 unified energy economy and that certain systems prefer to use fat for fuel (skeletal muscles) and others prefer glucose (the brain) and that ketosis causes a negative hormonal reactions inside the body and that a diet that provides adequate carbohydrate supports the thyroid? Additionally I’ve read that glucose provides cleaner fuel for the body – and that a diet balanced in carbohydrate protein and fat that provides adequate metabolic cofactors is a better choice than entering a protein and fat staggered diet that forces one into a ketogenic state? I believe the real problem is PUFA and not carbohydrate .

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    • Peter Attia  March 3, 2014

      I agree there are likely different “ideal” fuels for different organs. The brain, for example, even in complete starvation when serum ketones exceed serum glucose will derive 1/3 to 1/2 of its energy from glucose and the remaining 2/3 to 1/2 from ketones. Heart and skeletal muscles, under aerobic conditions seem to prefer BHB, then FFA, then glucose. Of course, under aerobic conditions glucose is necessary.
      I am not aware of data supporting the glucose-burns-cleaner argument. If anything, more glucose means more AGE, which is far from clean.

    • Yossi Mandel  March 3, 2014

      You were very kind in your response to this. Based on everything you’ve explained until now, this hypothesis about glucose has nothing to do with carbohydrate intake, as the liver will make glucose from protein as needed. So protein and fat is needed to manufacture both ketones and glucose for the appropriate organs, but carbohydrate is not needed even in this hypothesis.

  182. Caitlin  March 3, 2014

    Peter,
    Any sources you might recommend for reading about AGE and fat? There are some materials out there that say fatty animal products are high in AGE when cooked. (for example: http://www.ncbi.nlm.nih.gov/pubmed/20497781).
    Caitlin

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    • Peter Attia  March 4, 2014

      This may be true for oils, especially PUFA when cooked at high temp. This is why many recommend coconut or palm oil for cooking (SFA –> less chance to violate a carbon-carbon bond).

  183. Steve Baze  March 6, 2014

    I would be interested in your take on the Paleo thing of current almost mania crescendo. I think it offers some good points and benefit but see a lot of hype and what seems misinformation from various outlets and sources. Many ascertions that simply eating meat and cutting out white carbs will instantly transform one to a state of health/fitness. Would like your take on the current phenom. I practice some of the concept but am not a full bore Paleo geek ? I have discussed this with others as well like Gary Collins and coming to my own conclusions. Your input would be appreciated.

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  184. Erik  March 6, 2014

    Simple question, why does it take such a low (50g) amount of carbs to stay in NK ? I would think that once you deplete your carb stores and are cruising at .5 or greater ketones, that you could eat maybe 50g of carbs per meal (x 3 per day) and if you are reasonably active, wipe that out and stay where you are ketosis-wise?

    I like to think in terms of calories, so say for lunch you have the sandwich with two 100 Cal slices of bread, and the rest protein/fat (and that’s your typical macro/nutrient ratio x 3). At rest, just sitting around figure about 100 Cals/hour (about 50% fat/50% carbs burned). So, in a typical day (just counting waking hours), your gonna wipe out that 600 cals from carbs (16 hours x 100 cals /2 = 800). And if you have much activity at all, (i.e. – A few hours of walking around, housework, etc – I’d consider that you HAVE to have destroyed that carb intake…)

    So once you are already carb depleted and in ketosis, why wouldn’t you stay there on moderate carbs, say 150g/day or so (and not have to go as low as 50g carbs a day to maintain the > .5 nutritional ketosis) ?

    I’m just wondering what the mechanism is…

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    • Peter Attia  March 7, 2014

      See post on carbs and ketones co-existing.

  185. Gin Kuzma  March 9, 2014

    Dr. Attia,

    Could you please respond to this article reporting on a non-diabetic woman who entered ketoacidosis that the doctors attributed to ketogenic diet?

    http://www.nejm.org/doi/full/10.1056/NEJMc052709#article

    I am on a forum for a medical condition that I have, and another member has posted this along with the assertion that people run the risk of death from ketogenic diet. The poster also says that there are studies showing ketogenic elevates inflammation, and the study she sites says it elevates all cholesterol and heart disease! I am not familiar with any of that. I would like to know how to respond to these assertions.

    Thank you very much for your site – I have learned a tremendous amount.

    (reply)
    • Peter Attia  March 10, 2014

      Seems odd. I’ve read one other case study on ketoacidosis in someone who was neither T1D/T2D *or* on a carb-restricted diet. In this case, I wonder what triggered the event? Perhaps an underlying metabolic stress, such as a viral illness?

    • Gin Kuzma  March 11, 2014

      I don’t know what triggered it, but I, too, suspect that more is going on there than the average, sane person who might attempt a ketogenic diet. For instance, it appears from the article that there were multiple events and that the lady wasn’t entirely forthcoming with her doctors about her diet. Once she finally “came clean”, what she revealed seems like a pretty extreme carb restricted for a very long time . It also appears that she wasn’t monitoring her ketone levels, or would have seen the problem coming. Finally, the fact that they had to give her supplemental insulin to reign the episodes in would surely mean she had some kind of insulin dysregulation, wouldn’t it? Not being a doctor myself, I can’t really evaluate those things. What do you think?

      Mainly I just PLEASE need to know what to say on my forum! I definitely want to defend the ketogenic diet, which is helping me immensely. Based on this article should I concede that it IS possible to go into ketoacidosis through ketogenic diet? If so, how is one to know in advance that they are that rare individual for whom it is not safe to even try? I’m rather baffled.

  186. PIETER  March 17, 2014

    I have been in ketosis for quit a while. Short periods I lost it as social circumstances let me eat more carbs than I wished for. I went into this ketogenic life style because I had been diagnosed with type 2 diabetes at the age of 54 after a life long of eating everything or anything, staying slim. I started with Dr Cousen’s raw diet to reverse my diabetes, but found it hard to keep up in Spain (where I live) and changed after about 1 month and a half to the LCHF diet. I feel great during ketosis without using medicines (metformina) but noticed that when out of that for just a short period I regained some to all the symptoms of my diabetes.
    Does the ketogenic diet finally reverses diabetes type 2 like Dr Cousens claims with his Life Food vegan raw diet?

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  187. PIETER  March 17, 2014

    Great, thank you, I understood so much but like to hear it from an expert. Can you tell how long is the time it takes to reverse this disease? I have been on a ketogenic lifestyle now over 1 ½ year. I was a professional golf teacher and do still a lot of golf and cycle 3 to 4 times a week down the mountain I live on and back up (prox. 15 min. over 8 km down and up with an elevation of 450 meters).

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  188. Jennifer Cumming  March 18, 2014

    Hi,
    My daughter, age nine, has been placed on a modified Atkins diet for epilepsy. Her carbohydrate count is limited to 15 a day. She has been on this diet for about a week now and seems to be doing very well. I have started using Morton’s Lite Salt for added potassium in the foods that I cook. I would like to know if this is safe for her as well as my other children, ages six and two? It was emphasized to me that I needed to make sure she was getting adequate electrolytes, especially potassium, and most foods high in potassium, except avocados, are two high in carbohydrates. I know there is a danger with too much potassium and wondering if lite salt would cause this. For example I made sausage balls with one 2lb ground beef and added 2 tsp. of lite salt. This was divided between 5 people, the two adults consuming the most, and eaten throughout the day. There is about 350 mg. of potassium in 1/4 tsp. of lite salt. How much is too much for children under age 10? I have always been on the low end of potassium and have been prescribed potassium pills on three different occasions so I know what low potassium feels like and I don’t want that to happen to her, however, I don’t want to over do it either. It is amazing to see improvements in just one week. I have seen drastic improvement in her handwriting which I didn’t expect. We have always been a whole food eating family without processed sugars so eating this way wasn’t a huge jump for her but I am shocked at the improvements already. Great website by the way.

    (reply)
    • Peter Attia  March 18, 2014

      Jennifer, have you been in touch with Charlie Foundation? http://www.charliefoundation.org/
      All of your questions will be answered. Yes, it’s remarkable when I child responds so well to something so “simple”…

  189. Julie  March 22, 2014

    Thank you for your great blog. I have been trying to find answer for KCA versus ketosis. I do however have a question I have not been able to find a satisfactory answer to. I am a type 1 diabetic. I have maintained an AIC of below 6 for over 15 years. I am active and exercise regularly . I have been in KCA twice thru the years. At the time, as aforementioned, my sugars were good and I was physically active. My question is what other reason could that have happened? The answers I have received were late stage and poor control.

    Secondly, what reading should I be looking for while using keto sticks.

    Thank you!

    Julie

    (reply)
    • Peter Attia  March 22, 2014

      DKA in T1D (well-controlled T1D, which it sounds like you are) is often precipitated by a systemic stress, such as infection. While not always the case, there is usually something that gets the patient out of sorts.

  190. Mike.S  March 22, 2014

    Hi Peter,

    Im very interested in going ketogenic at the moment im eating 50g carbs, 140g protein & 170g fat, however im 165lbs and do crossfit type workouts and Olympic weightlifting. How will this make me perform better and would it?? Also I would appreciate if you could let me know about fat to protein ratio? This is all self experiment and also to move away from eating carbs.

    Hope to hearcfrom you soon

    Mike.S

    (reply)
  191. Julie  March 22, 2014

    Sorry . DKA

    (reply)
  192. Tomas  March 23, 2014

    Hi Peter,

    I would have a question and would be happy if you could give me an answer please. I am on low carb diet for about a week (carbs intake as low aprox 25g a day, only from vegetables). During that week I had 3 high intensity trainings. I am meassuring my ketone levels via urine tests. Are these reliable? It showed me ketones in urine on 5th day of LCHF, now after 8 days it shows 8 mmol/l. Does this say something? Should I increase carbs intake from 25 to about 50? Not sure how exact and reliable these urine tests are.

    Many thanks in advance for your answer and also for this excellent page, which is the main source of information on LCHF for me.

    Greetings from Slovakia.

    Tomas

    (reply)
    • Peter Attia  March 23, 2014

      Urine cannot accurately predict/reflect serum ketone level.

  193. Rebakah  March 28, 2014

    Peter,

    I have been on a ketogenic diet for about a year, <20g of carbs, approx. 50g protein, and the rest fat in the form of nuts and coconut oil. No dairy or grains either. I'm 22 years old, 130 lbs, 5ft 3in, and 19%-20% body fat. I workout for about 45min everyday doing weightlifting and interval sprints 1min:1min. What I would like to hear your thoughts on is why my ketones are consistently higher than average. My average ketone level has recently been 5mM, but can easily get to 8mM, and even to the point where my Nova Max meter just flashes "high". My average fasting CBG is usually somewhere around 70 mmol/L, but occasionally it can be in the 80's or 90's and still have a ketone level over 4mM. Why do you think this is?

    Thanks Alot,
    Rebakah

    (reply)
  194. Gift T  March 29, 2014

    Hi,

    I was on ketosis for a long time (about 1-2 years). Eventually, I got really sensitive to carb. Sugar from 1 apple would put me in a food coma (basically I fall asleep) afterwards. I was worried about insulin insensitivity. Eventually I got off the low carb diet and explore other options. I do miss being on the low carb diet and thinking about going back on it again after reading your article.

    I’m just worried that the extreme sensitivity to carb was a bad sign. What would you recommend to be the right balance for this? Perhaps carb re-introduction is necessary?

    Thank you,
    Gift

    (reply)
  195. Sarina  April 20, 2014

    hi

    I have blood ketones between 4.7-5.9 but don’t seem to be dropping the weight.
    What am I doing wrong.
    My macros are 85% fat, 10% protein, 5% carbs.
    Any advice would be appreciated.
    I am new to the keto lifestyle been doing it for 6- 8 weeks.

    (reply)
    • Boundless  April 20, 2014

      > … but don’t seem to be dropping the weight.

      You might work down the checklist at:
      http://www.wheatbellyblog.com/2012/10/i-lost-the-wheat-but-didnt-lose-weight-2/
      and watch the 3 related videos that Dr. Davis posted to his blog in Feb 2014.

      You already have items #1 and 2 nailed, so it’s apt to be something further down.

      I’m assuming you have item “0” nailed as well (eliminate gluten-bearing grains 100%). FYI, Wheat Belly isn’t just about wheat, and it recommends a macronutrient balance that is only borderline keto.

    • Bob West  April 20, 2014

      Sarina,

      I had a similar experience after I first found this site awhile back, and maintained high ketones but no fat loss.

      I finally figured out that I was too enthusiastic about eating very high fat — the ketones were coming more from the fat I was eating, than from the fat I wanted to lose. I cut back some, while still staying high-fat in a percentage sense, and was never hungry but the weight started to come off. It just took experimentation to find my best balance. Ketones stayed high all along, but now were coming more from my own fat.

      I never counted anything, just played with it until it started to work. Peter has a “fat flux” article that addresses some of that.

      Hope this is of use to you.

      Bob.

  196. Jerry Green  May 10, 2014

    Hi, Dr. Attia! First, I highly respect you and your research. Thank you for all that you are doing! I am just graduating with a degree in nutrition from University of Houston. I want to be a dietitian. I have learned so much from you among others like Gary Taubes, Dr. Jeff Volek, and Dr. Stephen Phinney. It is really sad that all this valuable science you talk of in your articles and lectures are not even mentioned in my nutrition degree program at Uh. Actually I did take a class called research in obesity and the professor had us read “Good Calories Bad Calories” which is what got me researching all this. But the professor didn’t talk much about the science the book was based on. Anyways, I wanted to ask you: my mom has late stage type 2 diabetes where I believe her pancreas burned out (she was on long acting insulin but now on both long and short acting). Would you think it wise to put a late stage type 2 diabetic on a ketogenic diet as long as insulin and ketone levels are watched? Would ketones even need to be watched if blood glucose was kept within normal range. I know you cannot give medical advice online, but theoretically is there a proper protocol for late stage type 2 diabetics on a ketogenic diet? If you cannot answer in a comment I completely understand.
    Thank you,
    Jerry

    (reply)
  197. Pavel Krylov  May 13, 2014

    Hi,
    I am a dietetic intern going through my rotation, I have had a lot of preceptors tell me that ketosis could still cause ketoacidosis, and they told me to go to our hospitals UpToDate website and search for journal articles showing ketoacidosis in some patients. Is this really a possibility? was I looking at bad studies? What would be a great comeback?

    (reply)
  198. Lynette Geris  May 15, 2014

    Hello,
    I’ve stumbled across a comment here about fasting blood glucose rising on low-carb/keto diets; the response was that you hope to write about this topic soon and that was back in 2012. I couldn’t find it by doing a regular search, so I’m wondering if you’ve written about this topic since? I’ve been experimenting with the ketogenic diet since January 2014 (which a Paleo-friendly cheat day once a week) and recently got a fasting blood glucose reading of 109 which really freaked me out, hence my deep investigating and questions now. I’ve found evidence that this is okay, and is apparently even expected on low-carb diets, but I haven’t found anything that makes me feel really confident that I’m not doing any long-term harm on my body. Any information would be greatly appreciated! Thanks so much in advance,
    Lynette

    (reply)
    • Peter Attia  May 17, 2014

      Peter at Hyperlipid wrote something about this. I think I’ve referenced it a few times in comments, but his blog will be quickest way to find it.

    • Boundless  May 17, 2014

      > Peter at Hyperlipid wrote something about this.

      Hyperlipid is a bit clumsy to navigate. Might it be:
      “Physiological insulin resistance”
      at:
      http://high-fat-nutrition.blogspot.com/2007/10/physiological-insulin-resistance.html
      … or not, that was 7 years ago.

      I’ve seen a number of sources (e.g. Jaminets/PHD) claim that FBG creep occurs on VLC or keto diets. The Jaminets advance the solution of increasing consumption of what they call “safe starches” (which is not the same as resistant starches, which they also endorse).

      The questions that arise are:
      1. Is VLC/keto FBG creep real?
      2. Is it universal, or just affecting some people?
      3. What is the cause?
      4. What is the (safe) fix?

      Regarding “universal”, assuming the effect is real, I’ve been closely following the Wheat Belly Blog since its incep. WB advocates a diet that I characterize as VLC/borderline-keto. That blog seems to hear from everyone who doesn’t get textbook results, but no one has to my recollection complained about FBG creep. I’d don’t measure my own BG [yet], so have no personal anecdote to contribute here.

  199. Reta Hudlow  May 17, 2014

    Peter,
    My daughter has type 1 and now has been diagnosed with epilepsy. I thought her seizures were from hypoglycemia,now shes on yucky epilepsy meds. My gut tells me that the seizures are related to her diabetes and nutrition. The endo and neuro docs don’t think so.
    Any studies or docs that I can read up on to help coach her?

    (reply)
    • Peter Attia  May 19, 2014

      Not sure of link between T1D and epilepsy, though, as you probably know, KD is treatment of choice for drug-resistant seizures in children.

    • Eric Tschetter  June 11, 2014

      Reta,

      The book that got me looking at Ketosis in general might be interesting to you:

      http://www.drperlmutter.com/about/grain-brain-by-david-perlmutter/

      I’m not a scientist, nor a doctor, nor any sort of an expert in any way, shape or form. But, the book points towards inflammation as a potential cause for things like that. Specifically, that book is pretty anti-gluten as it apparently causes inflammation in a lot of people (even if they don’t test positive for being a celiac). Anyway, take it or leave it :).

  200. Mihai  May 30, 2014

    Dose 5.3 on my sd freecodec means i’m in ketosiss ?

    (reply)
  201. Robyn  June 1, 2014

    Hi Peter,

    I have type 1 diabetes and I am moderately active (3-4 hours per week of cardio). After years of low carb eating, I have dropped my carbs (four weeks ago) to about 15 grams per day and protein is 60 g per day, and I notice I am requiring more insulin than before (basal change from 12 units per day, increased to 14 units per day).
    With normalized blood sugar, is there any risk?
    I read that with more ketone bodies one might require more insulin. Is that what could be going on?
    Do I need to increase carbs?
    Will the presence of this extra insulin slow down fat loss? I am a little concerned that I have not seen a weight(fat) change.

    (reply)
    • Robyn  June 1, 2014

      I am thinking my basal insulin might be bad (ineffective). So that would explain a lot!

    • Robyn  June 2, 2014

      It would be fine to take off this comment and the following one, as the questions were invalid due to my bad insulin. THank you! Robyn. :-)

  202. Robyn  June 1, 2014

    <>

    Does this quote suggest that a well-controlled type one diabetic cannot or should not do a ketogenic diet? It has been interpreted by some pretty well-informed people as so. I believe that as a type one, I am safe to go ketogenic, and it is indeed my best treatment option as it keeps my glycogen from dumping into my system (especially in these peri-menopausal years.)

    (reply)
    • Bob West  June 2, 2014

      Hi Robyn,
      I’m not Peter, nor an MD, and of course I can’t respond for him or make any medical suggestions.

      But Peter has often referred to the book about diabetes and low-carb diet by Dr. Richard Bernstein, who is an MD, and a Type 1 diabetic, who specializes in diabetes. You may find it worthwhile to look into it. It’s on Amazon.

      Bob.

    • Robyn  June 3, 2014

      Correction to my question (and my quote did not show up!) I have been very tired due to bad insulin and did not articulate myself very well. The quote I meant to include mentions type one diabetics being in danger when having too many ketones. I think Peter meant that if our sugar is up, then it would be likely ketoacidosis. What was a little confusing was the interpreted idea that we cannot keto-adapt without a risk of keto-acidosis. A very good blogger had received some information that led him to believe a type one cannot keto-adapt. I believe this is not so. Although I have been testing for urine ketones, I have ordered the blood tester for beta hydroxy butyrate. I believe I can still keto adapt and the comments about type one diabetics refers to those not eating low-carb with normalized blood sugar.

      And indeed the Bernstein book has been my guideline for some time, thank you. Agreed it is the best book EVER for diabetics. I just was following it with a slight misunderstanding of carb count and a life too busy to keep my diet consistent. I really have NO room for error without some huge blood sugar consequences, at this stage in my life. Now that I have lowered carbs to about 18g I am having much tighter control. The exercise physiology behind low carb was a mystery to me too, and got me into some hot water in the past. Now that I understand more about fat, beta hydroxy butyrate and carb fueling conditions I am hopeful to live with freedom to exercise more when I like without fear of lows.

  203. Eric Tschetter  June 11, 2014

    Peter,

    I’ve been reading your blogs about cholesterol, ketosis and lipidology and I thank you for taking the time to write this stuff.

    I’ve been trying out a low carb diet for the last month+ and have succeeding in getting fasting ketone levels of 15 – 40 mg/dL (so 0.5 ~ 2.1 mmol/L), which is great. I’ve been testing with a urine tester, however, which seems to indicate that it is checking acetoacetic acid. Your blogs talk about beta-hydroxybuterate, though and so I’m wondering if acetoacetic acid is a meaningful proxy.

    Given that you seem to geek out on how various things are tested, I was imagining you would probably have a blog post on how ketones are measured via urine versus via blood versus whatever; but I have yet to find it. Am I just bad at finding stuff on your blog, is there another post somewhere else that you recommend for understanding how that works, and/or can I request a blog post discussing this?

    (reply)
  204. Christine Dufty  June 20, 2014

    Hi
    I am 2 weeks into the Lighter Life diet. I wanted to kickstart. I followed the Atkins diet some years ago and I know from experience that it works. I tested my ketone level yesterday and found it was .5
    Today it is .3 and I have gained 2lb even though I have been religiously sticking to the diet.
    Can you explain why this would happen?

    (reply)
  205. Bryant Hardwick  June 29, 2014

    Hey, quick one. I had heard it is common to find toxic substances in fat; the main point being that in the body any sort of environmental toxic threat could be directed to storage in fat since fat is a chemically neutral environment? I cannot find any seemingly credible sources to justify this or not but was curious if you had come across any literature that suggested risk from high fat diets because of this statement?

    Thank you kindly.

    (reply)
  206. Terra  July 8, 2014

    Hello Peter,

    I have been living with T1D for over 24 years and I am 41 years old. I am the mother of two and I enjoy running road marathons (PR 3:37) and have completed several ultra-marathons. I wear an Omnipod insulin pump for insulin delivery and a Dexcom CGMS.

    Recently a good friend’s son was diagnosed with a brain tumor and it was recommended that he include a KD as part of his treatment protocol. I was incredibly curious about this diet and began my research immediately. IAfter checking with both my primary care physician and my diabetes specialist doctor I began the HFLC way of eating last Monday, 6/30/14.

    I have been showing urine ketones in the level of 0.5 mmol/L – 4.0 mmol/l for 6 days. My glycemic control has been incredible for the past 8 days. I have remained mostly in the 70-110 mg/dL range with my highest blood sugar at 168 mg/dL. As expected, I have reduced my TDD insulin requirement significantly, from around 25-30 units/day to 12-17 units/day. Most days this is 100% basal insulin but I am still adjusting rates. Exercise is particularly challenging at this time of transition. Prior to HFLC eating I would turn down my basal rate 50% for 1.5 hours 30 minutes prior to my run. I would consume a GU packet (22 CHO) about 45 minutes into the effort, depending on the blood glucose trend. Of course it wasn’t always this predictable but you get the picture. Since I began HFLC eating I am trying to figure out how to adjust basal insulin, intensity and duration to remain in stable blood glucose control. I have successfully ran several 3 mile runs doing this with varied intensity.

    After dinner last night my blood sugar rose from 80 mg/dL to 149 mg/dL. Instead of taking a bolus dose of insulin to correct the 149 mg/dL down slightly I decided to watch the impact of a newly adjust basal rate through the night. I held at 149 mg/dL for the next 5 hours, completely stable. This morning I woke up to join my running group for our Tuesday track workout and my ketone levels upon urine testing were darker purple than they had been for the previous 5 mornings, possibly 8.0 mmol/L. This concerned me, as my doctors have always advised against exercise if ketones are present and I wasn’t clear why the ketones level had increased. My son also had the flu last night and that was another area of caution from my doctors. Infection/sickness can cause a T1D to enter into DKA rapidly. Though I felt fine, I just didn’t feel comfortable with my understanding of why the ketones would increase, what my risk was as a T1D athlete and how to accommodate to remain in nutritional ketosis. If I felt I was heading toward DKA I would take a dose of insulin and eat carbs as my blood sugar needed.

    My questions:
    How does my reduced insulin levels impact my risk for developing DKA even with blood sugar levels below the typical “alert” level of 250 mg/dL? How does exercise impact this already existing risk of decreased insulin and ketones being present? What is the ketone threshold of caution for a T1D utilizing the HFLC way of eating?

    Cheers, Terra

    (reply)
    • Peter Attia  July 14, 2014

      Complicated question, and not one I can really get into without playing “doctor,” which I can’t do via a blog. T1D is tricky for nutritional ketosis, and requires supervision. It sounds like you have good insight. The reason someone with T1D can get into DKA, while someone without it can’t, is that at high enough levels of BHB, insulin is secreted (in the non-T1D) which acts as a negative feedback loop.

  207. Mumsies  July 15, 2014

    Blood ketones 5.9 o.0

    Hi Peter,
    I am a 12 year type 2 diabetic that went low carb in January then lost 20 lbs after ditching grains and most dairy. I managed to get off of my metformin at the end of March and am now running around 5.5 on HgbA1c. In early December it was 7.9 while on 2,000 mg Metformin ER. I switched to lchf in early June because of a plateau that began April 12th. Nothing has worked to break it to date other than I tried consuming eggs and fat for a day and a half last week and that bumped my ketones higher and I dropped a whole pound, lol.

    Today I checked my ketones this morning and they read 3.1 with a fasting glucose of 106 but now at bedtime (it is late at 1:30am) I am at 5.9 and my glucose is106. Is that number a cause for concern? I just got a small snack to bring that down before bed because that number makes me feel a bit nervous before sleeping even though I feel fine. I just want to stay between 1.5 and 3.0. I have been researching everything to understand what is causing my plateau and I am now thinking that being diabetic and obese that I may have sluggish or possibly fatty liver issue though no doctor has ever mentioned it to me.

    Today’s menu consisted of
    breakfast: bullet proof coffee with 1T kerry gold butter and 1 T coconut oil, 2 eggs, 2 extra T coconut oil on top of coffee;
    lunch: 2 eggs, bpc with 1 T. ea of kerry gold butter and coconut oil;
    dinner: grass fed ribeye 4 oz, 1/4c steamed cauliflower, 1/4c, sauteed mushrooms., 1/2 delicata squash with 1/2 T butter.

    Can you shed any insights into whether I am right about needing liver support and healing to lose more pounds?
    I love this way of eating and don’t want to see my glucose rise again if I add back more carbs. Any comments would be appreciated :D
    Thanks!

    (reply)
  208. Peter Aston  July 23, 2014

    Hi Peter,

    I’ve been on the KD for 8 months, and I feel it has improved my health significantly

    What I’m having trouble with is that somehow the KD has made my stress response bigger. For instance I have bouts of adrenaline/angst while driving, or sitting in class, and I previously did not have these problems. Like I said, I otherwise feel much healthier.

    Can you think of any nutritional reasons why this might be the case?
    What do you think about supplementing potassium? (All I could think of as an explanation is a high sodium-potassium ratio)

    Thank you for your time!

    (reply)
  209. Kasey Bordas  July 24, 2014

    Hi Peter,
    I am a student of clinical herbology as well as holistic nutrition and wellness. My particular interest is in cancer prevention and treatment. I am confused. Everything I have studied thus far clearly states an alkaline state prevents the proliferation of cancer. In Ketosis isnt the body in a more acidic state? I understand it will not have the glucose needed to fuel cancer growth but what about the pH level? Im so glad I found your blog. Thanks for all of your expertise and guidance.

    Kasey Bordas

    (reply)
    • Peter Attia  July 24, 2014

      Kasey, I’ve addressed your questions elsewhere in the blog and comments.

  210. Peter A  July 26, 2014

    Hi Peter,

    What do you make of elevated norepinephrine levels and high blood pressure when on the ketogenic diet. Is this cause for concern, or is it common and transient?

    Thank you

    (reply)
    • Peter Attia  July 26, 2014

      Haven’t seen it. That usually speaks (if clinically significant) to pheo.

  211. Mike  August 7, 2014

    Hi Peter.

    I just got back from an urgent care visit with my 3 year old daughter. We thought she might have a UTI. We brought her in and they did a Urine test. No UTI, just rash from a lot of pool time, causing stinging and withholding. But the doctor was concerned with the level of Keytones in her urine. There was no glucose in her urine, but he started mentioning diabetes as a primary cause for ketones in the urine. We have been on a mostly paleo diet for about 6 months that has basically solved my joint inflammation issues and my daughter’s instant constipation when she eats food with flour or starch – so we are pretty happy with the outcomes. That said, are there “normal” levels of keytones to be expected in the urine when on a diet like this? Is the doctor right to be concerned? Thanks for all this info, this story and blog made me a little less worried.

    (reply)
    • Peter Attia  August 8, 2014

      Impossible for me to say without knowing everything and seeing all lab values.

  212. Carol  August 12, 2014

    This morning, I’m at 6.0 mM ketones. Should I be worried? Should I intentionally bring it down? I’m not diabetic of any kind, but this high a number makes me nervous. (And no, I’m not starving.) Thanks for any help! :-)

    (reply)
  213. Anne  August 20, 2014

    Thank you so much for your excellent article! I have not been able to read through all 400+ comments above so please forgive me if you have already addressed this question.
    My husband is a Type 1 insulin-dependent diabetic. He has witnessed the great benefits I have experienced by being on a ketogenic diet over the past several months and wants to join me. If he cuts out most of his carbs he finds that he needs little to no insulin. Can he reach ketosis or will he become sick by taking little to no insulin? Can a Type 1 diabetic reach nutritional ketosis or are their bodies unable to reach this state? Thank you for all the information on your website – much appreciated!

    (reply)
    • Peter Attia  August 22, 2014

      Varies by case and needs a smart endocrinologist to be involved.

  214. jesse  August 22, 2014

    Hi Dr. Attia,
    Please put me down as one more reader who would love to see your take on the low carb/keto relationship to hypothyroidism debate. I did find on Jimmy Moore’s site a presentation of the two sides of the issue, with interviews with Chris Kresser and Volek/Phinney. There are few references to this issue in the above string and it sounds like an issue you are thinking about. Any info would be much appreciated!

    Thank you for all the well presented info!

    Jesse

    (reply)
  215. Anne  August 26, 2014

    You mention in your article that a person in nutritional ketosis normally has B-OHB in the region of 0.5 – 3.0. For the past 5 or 6 weeks My blood tests have been ranging from 4.0 – 6.0 with my blood glucose being steady around 4.0- 4.5. I stopped losing weight and added extra calories about 4 weeks ago. I am consistent about being around 20g carbs and eat about 75-80% fat and about 1g protein per kg weight. Are my ketone measurements too high and if so how do I reduce them without putting on weight??

    (reply)
  216. Chrissy  August 27, 2014

    Hi Peter,

    Your blog was recommended to me by a friend who has started a ketogenic lifestyle to lose weight and it certainly has a plethora of interesting information in it. My friend has recommended I start this type of diet because I am an endurance athlete. I am a competitive marathon runner and Ironman athlete and he says by being in a state of ketosis I will not have to take food with me on long training runs or during my races. I have to confess I find it hard to believe that I could run a 3.5 hr marathon without food and am even more skeptical I could survive an 11 hour Ironman simply by surviving off my own body fat (which is at a healthy 18% according to my latest PodPod results – 46 year old female).

    I eat a varied whole foods diet that consists of fruits, veggies, nuts, seeds, oils, lean meats, diary, legumes and grains. I rarely eat anything out of a box or a bag so my ingestion of wheat & refined sugars is very limited except for the high sugar chews I take on training runs over 16 miles and bike rides covering 60 miles or more. Since weight loss is not a concern what would the benefits of a ketogenic diet have on me and my endurance performance?

    Thanks!

    (reply)
  217. Bob  September 19, 2014

    Dr A.

    I’ve been reading your blog and started eating a ketogenic diet about 3 months ago.

    My new blood labs showed that it has SLASHED my Small LDL P levels in half. From 1000 to 500!

    But……………My liver enzymes are now elevated. ALT = 69, AST = 42

    Can beginning a ketogenic diet lead to elevated liver enzymes?

    (reply)
  218. Kelly  October 23, 2014

    Hi, great article.
    Just wondering what your references are for this? Not because I’m questioning you, but because I would like to use some of this information in my uni assignment, and they will not accept a website reference. Any texts or journal articles that explain this would be great, I have looked but without a lot of success.

    Thank you :)

    (reply)
  219. Steve Kruzich  October 24, 2014

    Hi, i was wondering if the type of diet your using is similar to what the Marine Corp uses at paris island for new recruits. They typically are consuming high calories in a day. For example a MRE contains 3500 calories in one MRE.
    I remember my son writing telling me that they load them up on milk, eggs, bacon, very very little bread, for breakfast at the camp and then off to training they go. But the Corp breaks their bodies down, removes the fat, then builds up muscle and not much of that but conditions the muscle to becoming denser tighter.

    (reply)

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  19. Best article on DKA vs dietetic ketosis?  September 7, 2013
  20. nutritional ketosis – don’t try this at home! | burn and learn  October 11, 2013
  21. Nutritional Ketosis – consequences of a high fat diet | burn and learn  October 23, 2013
  22. Zoek en je zult vinden ? | Ketogeen… Wat ?  November 27, 2013
  23. Low and No Carb Diets | Diabetic Desi  December 5, 2013
  24. Je ketóza nebezpe?ná? | Celé Zdraví  December 13, 2013
  25. Fat Links! | Ketoz Cookies Away From Me!  January 14, 2014
  26. Ketosis- Dangerous Metabolic State or Naturally Occurring Bodily Process? - Low Carb Genesis | Low Carb Genesis  January 14, 2014
  27. Back to basics: CARBOHYDRATES/SUGAR | The Lamwich  January 28, 2014
  28. Nutritional Ketosis - The what, the how and the why...  February 12, 2014
  29. Diet Tweaking & Paleo Keto | Nutty About Health  March 21, 2014
  30. Ketosis Blog  June 28, 2014