Ketosis: some myths and facts - The Scribble Pad

The Scribble Pad: Ketosis: some myths and facts

Lately I've encountered questions/comments regarding ketosis which illustrates just how confused most people are about ketosis, what it is, how to achieve it, whether or not it is important, etc. There are a lot of myths about ketosis out and about the blogosphere, usually secondary to confusion fostered by enterprising up and coming quacks and gurus. So, lets clear up those myths shall we!

First: What is ketosis?

There really is no universal definition of ketosis.

Medically, ketosis is associated with metabolic and endocrine diseases like diabetes; in medicine when ketosis is discussed it is in the context of pathology such as insulin deficiency, leads to ketoacidosis and death. A normal person eating a normal diet should never have a significantly elevated level of ketones, even after an overnight fast  they should not be in ketosis if they eat a normal american diet. Some health conscious people who maybe restrict calories and carbohydrates slightly can be in ketosis after a mild overnight fast but most individuals will not until fasting for prolonged periods.

This is not the sort of ketosis we are discussing. That kind of ketosis is pathological, it is physically impossible for a normal person.

So, already we alienate pathological ketosis and isolate the discussion to dietary ketosis: ketotic states induced by food choices or lack there of.

So, what is, as low carb gurus call, benign dietary ketosis? 

Dietary ketosis describes a condition where people elect for foods that promote greater lipolysis: the breaking down of fat to provide energy. Ketones are byproducts of lipolysis, provide energy for metabolic processes. When the level of ketones in blood are elevated beyond a typical baseline, one is said to be in ketosis. Most of us do not test blood ketones, instead we test urine ketones; most "ketosis" is based on a positive urine test.

As blood is filtered through the kidney and wastes are removed in urine, elevated blood ketones will be lost in trace amounts into the urine. A urine ketone test is less sensitive than a blood test. What that means is, if your urine ketone test is positive, you are DEFINITELY experiencing a significantly higher level blood ketones, thus "in ketosis" (i.e. breaking down more fat for energy, leading to elevated ketones in the blood). This of course is assuming you are taking no drugs that can elicit a false positive result. Certain medications share molecular commonality to ketones, such as valproic acid, and will fool the ketosticks with false positives. Medicine that darken the urine, like pyridum, will also lead to a false positive (although, for different reasons than depakote; depakote literally causes the strips to react as if ketones were there, whereas pyridum or vitamin C or sinemet just makes the strips look pink because of urine discoloration).

Is it important to test blood ketones?
Right away the above truth invalidates the "nutritional ketosis" hallmark gimmick of testing the blood. Unless one is medically forced to take a medication such as depakote (which mimics ketones, and induces many changes in the brain and body like ketones), or is taking urine discoloring agent like sinemet/ pyridium / or irrationanlly high doses of vitamin C, there is no reason to prefer a blood ketone test. It is more painful, it is more expensive, and it is more sensitive than urine which is actually BAD for dieters. More sensitive logically means it detects far lower levels of ketones. If you are eating so much brie and bacon that you are peeing on strips making them pink, I assure you that your blood is FILLED with betahydroxybutyrate... the main ketone tested on a blood test. It is impossible to make the strips turn pink otherwise: sans fake ketones ( depakote),  sans orange urine.

Now, if one is testing ketones due to medical ketosis, ketoacidosis, then greater sensitivity is *good* because the goal is to prevent ketosis in this case, you want a maximum sensitivity test, right? You want to know exactly when your ketones are creeping up, which can be a valuable tool for a brittle type 1 diabetic who has a history of DKA repeatedly or something along those lines. But for hopeful dieters, or someone using ketosis to control seizures/mood/migraine, in this case we are *trying* to get ketones to be generated, and there is no benefit to testing blood over testing urine.

There is one benefit of a blood ketone test for dieters: the blood test may contradict a false negative urine test. Often, if one is eating ketotically but strips are failing to change color, a blood test will verify an elevated level of ketones that are simply not appearing in the urine due to dilute polyuria (common for ketotic dieters).

Perhaps severe seizure patients may benefit from a blood test, in conjunction with monitoring, they may discover that certain levels are more theraputic than other levels; however, in general, seizure patients are very fragile and sensitive to even one missed dose of antiepileptic medication, that can be enough to trigger a seizure episode. Obese people and patients using ketosis for other reasons are not as sensitive as a severe epileptic, and will not suffer if the level of ketones drops temporarily from excessive fluid intake or one slightly higher carb meal or something along those lines.

Again this is reflected in medicine: epileptic patients taking depakote (for example) will take the medication four times per day, at least three times per day, and frequently require drug levels, and a single missed dose is enough to trigger a seizure for many patients. On the other hand if depakote is used for a mood or agitation problem as in non-specific aggressive symptoms or bipolar mania, it's generally twice or once a day, and drug levels only help the doctor know if the patient is toxic, or if there is more room to increase the dose or not. Seizure patients are much more sensitive to slight fluctuations in their drug level.

Needless to say, for an obese person using a ketogenic diet to suppress insulinemia and fat storing processes, it really ISNT THAT IMPORTANT if your levels are super ketotic or mildly ketotic; if you are ketotic at ALL, then logically you are in an elevated state of lipolysis and not subjected to insulin surges that promote hunger and fatigue and exacerbate obesity. The goal of ketosis is merely to eliminate the confounding variable of insulin surges that promote obesity. Thus, if your urine strips are positive, you ARE ketotic, in the relevant definition of the word pertaining to obesity i.e. resistant to insulin swings. Testing the blood just becomes a foolish expensive gimmick.

If I am in ketosis, dose that mean I am losing weight?
Absolutely not. Unfortunately.
Ketosis only indicates lipolysis, it does suggest or describe energy balance (i.e. energy wasted as heat or generated as energy/oxidation). Elevated lipolysis is not inconsistent with fat storing; it is not like a see saw as if one invalidates the other. Lipolysis of dietary fat may be cycled and stored again. It is much more than insulin determining the fate of energy; insulin merely promotes an exaggerated state of fat storing, however that does not logically translate into fat gain being impossible on al ow carb diet. Low carb diets are not hypoinsulinemic diets; low carb diets merely help control insulin signalling problems (hypersecretion, resistance). Obesity is vastly more complex than this, weight loss itself promotes weight regain by decreasing metabolic rate and fat oxidation, adipocytes are very sensitive to even low levels of insulin. Furthermore, every case of obesity is different.

Sometimes ketosis is the result of negative energy balance. For example, a hyperinsulinemic/hypersecreting obese person who goes on an atkins diet, may be in negative energy balance because the insulin normalization results in a much greater liberation of fat from adipocytes. The contents of adipocytes are  subjected to lipolysis and bolsters ketone levels. Appetite is powerfully suppressed without insulin mediated highs and lows of fuel availability. For types of obesity involving insulin hypersecretion in response to carbohydrate (raises hand) this is typically what occurs when one adopts a ketogenic diet. The lack of carbohydrate reduces insulinemia powerfully; distended adipocytes bathed in carbohydrate mediated hyperinsulinemia, then are primed to release tons of fat for energy. Appetite normalizes within hours, and ketosis is extremely dark very quickly. The ketosis is the result of negative energy imbalance, and the negative energy imbalance is a result of normal insulin patterns.

Not all obese people have this kind of obesity, although many do; it is usually more common than uncommon that an obese person starts a ketogenic diet and suddenly loses their chronic hunger pangs, their blood sugar highs and lows, and so their energy is superior + appetite is more normal.
 Low carb diets can be expected to help significantly if a person is very obese but always runs low blood sugar and is prone to hypoglycemic reactions, as this suggests inappropriate insulin hypersecretion. Not all obese people have this pattern, however.

Another example of ketosis in the context of weight loss is common starvation dieting; people who eat nothing at all, or who eat almost no digestible calories, may be in ketosis (even if they are eating carbohydrate) but their energy intake is so insufficient that insulin levels are extremely low and fat tissue is liberating fat for basic energy, with elevated ketones being the result. There is a fad of people who are eating "only potatoes". Most of these people are eating less than half of their caloric needs of basic potatoes, which is really actually more like a fasting diet, and many of these people are in ketosis even though what they eat is made of carbs. It is possible to be in ketosis if you are starving yourself on a very low calorie high carb diet, as all glucose is being used for basic metabolic processes and insulin levels are accordingly very low. Body fat supplies the majority of energy, and so ketones are generated.

An example of ketosis in the context of positive energy balance, would be someone like jimmy moore who acheives ketosis by eating a lot of butter, bacon, oils, fats, etc. Or, myself, when I am positive for ketones, but eat a tremendous amount of dietary fat. I will absolutely store body fat, but I will also be breaking down so much of that dietary fat for energy that ketones are elevated. When I gain weight, it is not because I cheat with carbs, it's because I eat a lot of macadamia nuts and the excess energy is stored in my small adipocytes, which are supersensitive to even low levels of insulin. If I was very obese, or even if I was slightly heavier than I am now, I would probably not be able to store any of the food I eat while in ketosis; I would experience symptoms like nausea and powerful food aversion as occurs to normal thin people who force feed themselves to gain weight. If my adipocytes were larger, it would be very difficult to store energy while in ketosis. Indeed, I observe as I gain weight (I weigh 5+ pounds heavier now than I did last year or when I was quite underweight) it becomes much much more difficult to gain more weight in ketosis.

Unlike eating a high carbohydrate diet which may promote hyperinsulinemia that powerfully drives new adipocyte growth, a ketotic diet with its very weak insulinogenic potential limits itself regarding how obese one can become and how much fat they can store; typically, fat *regain* is only possible, gaining new body fat is generally impossible as the insulin levels required for ketosis are insufficient to abnormally/pathologically distend adipose and promote hyperplasia of adipocytes. Nausea, anorexia, is typically observed. I've never observed an obese person continue to gain weight on a ketogenic diet, anyway. Plenty have regained some weight though.

Oh, BTW, # of adipocytes is hugely influential in metabolism, leptin levels, weight maintenance, resistance to fat growth. More adipocytes, more fat storage required. WEight loss pathologially elevates adiponectin which powerfully stimulates adipogenesis. Cortisol, which is elevated in starvation and food restriction, also powerfully promotes adipogenesis. Leptin terminates abnormal fat cell growth, in contrast. People keep gainign weight after cyclical weight shifting because of the endocrine state induced by food deprivation and weight loss, it promotes an abnormal florish of new fat cell growth, that permanently raises the set point.

For example, after having skin removal surgery, I am VASTLY "fatter" metabolically speaking at 122 #s, than I was 6 years ago at this same weight. My face is full and round, my shoulders and neck is covered in fat, my fat cells are clearly much larger. Endocrinologcially speaking, I have regular menstrual cycles, no signs of severe starvation, I am not cold all the time, I am always warm and easily walk outside in 30 degree weather without a coat, I easily resist weight gain eating even 1900 calories... in the past, I was basically like a starving person at this weight, and that is a direct result of uncorrected adipocyte hyperplasia in the past. My endocrine system, 6 years ago, was like someone who was maybe 100 pounds, because of such an excess of fat cells, and indeed I looked it in my face and obesity resistant body parts, which were bones and thin skin.

I still likely have significantly more fat cells than normal people, but no longer do I have the fat tissue of a 300 pound person. I do not have inappropriate hypothalamic amenorrhea at 120 pounds, for example.

If I was pathologically obese, all of these symptoms of weight stability afforded by a ketogenic diet would be exaggerated - normal appetite would become anorexia and nausea (from extreme ketone concentration), I would hardly ever have to eat and feel fine all the same. I know because I went through it already.

At this point, however, I am still thin enough to pretty easily regain some body fat in ketosis if I eat too much. I do not become totally anorexic and nauseated, I store fat in ketosis rather easily within moderate limits.

When I was morbidly obese, the strips were vibrant purple, they could not be any darker, and again that's because my fat tissue was positively hemorrhaging fat secondary to normalizing insulin levels... like a healthy/functional form of what diabetics experience with pathological insulin deficiency.
I consider all of this normal/expected. Tiny fat cells are not going to be leaking lots of fat, even in a total fast, this is really only possible in pathological insulin deficiency, resistance, or extreme obesity.

The take home message is that ketosis does not mean or cause weight loss. Ketosis may be a sign of weight loss, or it might not be. Weight gain in ketosis is possible. Generally, for very obese people, ketosis means weight loss, but for people who are not very obese and have already lost some weight, ketosis without weight loss is entirely possible.

If I eat junk food, will it break my ketosis?

Depends what the food is made of.

Some of the best foods for ketosis are things that hysterical dieters are afraid of: cream with erythritol, crushed mixed nuts and sugar free chocolate sauce...macadamia nuts, peanut butter, so on.  If one has an interest in maintaining ketosis for reasons other than dieting (e.g. calming effect or seizure control) then there is no reason not to eat these sorts of foods; when ones diet is so limited, why needlessly limit it more and deprive of perfectly delicious foods that preserve or augment ketosis?

Artificial sweetners do not interrupt ketosis, as they are non-nutritive they have no ability to raise insulin and inhibit lipolysis.

There are rumors that AS raise insulin. Now perhaps this is true for some people, but those people will know because they will experience predictable hypoglycemic reactions. I tend to think people assume AS raise insulin because their interest in eating is greater for a sweet tasting food than it is for hamburger without bun... but,  really, this is cut and dry; if something raises insulin but contributes no calories you get a hypoglycemic reaction. Fact. Hunger itself does not indicate hypoglycemia, it only indicates desire/interest in eating,
On the other hand, hunger that occurs after sweating, shaking, nervousness, trembling, mental confusion: that indicates insulin.

I am not saying absolutely that AS is neutral regarding insulin secretion, but for most of us, it is neutral. Most of us will discover no matter how much splenda we eat and how many splenda drinks we consume, we do not get hypoglycemia or inappropriate hunger, although our interest in food may be higher if we are already hungry/not full secondary to greater variety and pleasantness of taste. It tastes yummier to eat chicken with splenda sweetened bbq sauce than it does boiled chicken, but that doesn't mean the former is insulinogenic.

Of relevance here, and to obesity, is pathological insulin reactions that cause blood nutrient swings, blood nutrient storage as fat, and compensatory eating. Little day to day things like sweet tasting food (sans nutrition) is not going to affect body weight in the long run, assuming the nutritional composition of food is identical (protein, fat, carbs). Of course if you are a moron who believes in the most crude manifestations of the FR hypothesis you would disagree with that statement, but if so, you probably aren't reading this ;).

If you are concerned with ketosis, it does not matter if you eat junk or if you eat orthorexic fare, all that matters is how much insulin you stimulate and how much fat you consume. The less of the latter and more of the former = less ketones. Less of the former and more of the latter = more ketones.

I don't care about seizures or any of that. I only care about weight loss. Should I aim for maximum ketosis?

IMO? No. Not at all.

If your goal is weight loss, you should not be racing to get the darkest ketone pee, because as I stated earlier  ketosis DOES NOT CAUSE WEIGHT LOSS, it is merely a sign of weight loss sometimes, and it is not an absolute sign of weight loss. This is the mistake jimmy moore made and that's part of the reason he regained so much weight : he ate a lot of dietary fat to try to increase ketosis, but increasing ketosis does not translate into decreasing body weight.
Now jimmy moore is losing body fat, but it's not because his ketosis increased; his ketosis increased because he is fasting all day and losing body fat.
Whereas before he was in a ketosis made out of sour cream and sausage meals, now he is in ketosis made out of day long fasts (i.e. body fat) and only like, one sour cream/sausage meal per day or so.

Speaking personally, when I am losing weight, my ketones in urine are always lightest.  The reason is because I am eating less dietary fat, and my body fat is supplying my energy needs more; my level of FA and ketones are then  lower (relative to my typical weight maintenance ketogenic state), which means less spill into urine.

When I want to lose weight I don't increase macadamia nuts or cheese or cream. I REDUCE those things. I am apt to eat very non-caloric things such as vegetation and vinegar. I also eat a higher % of protein in my meals which helps me to do with less calories for a longer period of time, with superior energy.

Yes, my ketosis may decrease but the reason my ketosis decreases is because I am taking in less fat, and less fat is stored along with less ketones. More of my body fat provides energy, with ketosis being a bit lower along the way. Weight loss results in a (partially temporary) metabolic depression as a homeostatic measure to prevent excessive weight loss/starvation. It's only partially temporary, metabolism does increase when more food is consumed, but metabolism is always depressed in a weight reduced state and this does not terminate.

So, basically, ketosis does not really correlate weight weight loss, other than to say ketosis is sometimes a sign of negative energy balance, and the food choices that result in ketosis, can sometimes promote negative energy balance. However, ketosis itself does not mean negative energy balance and this is one fact that has eluded so many hopeful dieters. If one assumes ketosis CAUSES weight loss, they run into problems like J.M. or even myself, where I will become too liberal with fatty foods when I would rather not gain weight.

That sucks woo, you are such a downer/idiot/wrong/etc. What should I do then to lose weight?

Eat low carb, but don't fuss about your perfection of ketosis. That's a gimmick.
If you really want to 'tweak", you need to focus on the energy out side of things, and no it's not about carbs/insulin. Insulin only is about lipolysis, lipolysis however doesn't translate into energy and weight loss (as discussed earlier it is perfectly possible to have accelerated lipolysis occuring with fat storing/depressed oxidation).
Fat loss is more about increasing metabolic rate, fat OXIDATION. This especially becomes a concern after some weight loss has occurred and one is hypoleptinemic or relatively leptin depressed; the SNS goes to hell and T3 is depressed and woops look at that your RMR is 1100 calories and you feel like crapstore. Decreasing carbs further and further is not going to help with this, any more than eating less calories is going to help. Sure you'll lose more weight, but only at the expense of looking and feeling worse.

Taking mild stimulants such as caffeine, EGCG, tyrosine - all of this can greatly help how easy it is to keep off weight because they help correct the endocrine/metabolic/nervous system defects induced by weight loss. But none of it remotely compares to the root of the problem, that the body tries to regain lost body fat and this is true on most all diets.
IMO if you are concerned of weight loss you are much better to increase the sympathetic nervous system (the major deficiency induced by weight loss) than you are to try to increase your ketosis (and, bonus points, the former will increase the latter, secondary to correcting a sluggish fat oxidation!) . There are whole classes of prescription diet drugs that do just this (e.g. phen/fen, or the older dieter's choice, trucker speed). It's not very kosher now days though, too many people dying of heart attacks and psychosis and all that nasty stuff. Remember that scene in requiem for a dream, when the older woman goes mad on her diet pills? Yep. Stimulant psychosis, she had it. Although, more commonly, the dieter just has a fatal arrythmia or something. Most starlets and models just stick to good old COCAINE though. :) There's a reason Leelo always looks like an anoretic when she's partying and gets chunky fresh from rehab. Furthermore, models/actresses given the pressures to be thin, are often dieting pathologically starving themselves, which creates dopamine supersensitivity making cocaine addiction very likely. There is a reason every actress and every model seems to have a cocaine habit specifically; one it helps with weight control and two they are simply predisposed to it, like a bipolar alcoholic writer stereotype... or a depressive with an opiate addiction... so is the coke addled model/actress also a stereotype, and there is a biochemical reason for that. These *specific* types of drug addictions cluster because they meet a need/vulnerability for that person.

For the boring working classes who hope to similarly control body fat, there's just the mild not wild version of caffeine, coffee, or red bull, or my preference: diet rockstar (cheers)! The reason you see skinny / dieting people with caffeine all the time is because coffee gives energy when food is decreased. It corrects depressed glucose and depressed fat oxidation, which is a consequence of dieting and weight loss. I mean, it's not cocaine, but it will have to do. Ha.

Some more extreme types take up a nicotine habit to help with weight control. I highly do not suggest this as it is powerfully addictive, promotes almost life long metabolic disorder/obesity when you attempt to quit, and it causes cancer secondary to the toxic additives in cigarettes. Keep it safe n' basic, stick to caffeine and supplemental l-tyrosine, and egcg from fresh brewed green tea.

I highly recommend fat cell removal surgeries for massive weight loss patients, it is a maintenance therapy and a good way to help normalize leptin levels (the overwhelming cause of weight regain in dieted people).

As of this time, leptin therapy is a million years behind if it will ever become a reality, but leptin therapy absolutely prevents weight regain, and I know because I was on it. GOD I MISS LEPTIN. Could cry forever.

So, there's my 2 cents myths 'n facts regarding ketosis, and what it is, and how to acheive it, and what it means, and its role in weight loss.