Recently, the word “keto” has exploded all over the media and the marketing world. What does this mean? The word “keto” is short for ketosis and ketogenic diet. There are thousands of books and cookbooks on “the ketogenic diet” and a full spectrum of “keto” products to buy and eat, drink, and supplement your diet, with promises of weight loss, increased athletic performance, and a “cure” for diabetes. As whole-food proponents, we do not recommend any commercial processed “keto” products.
Ketone bodies are produced mainly in the mitochondria of liver cells, and synthesis can occur in response to an unavailability of blood glucose, such as during fasting. Ketogenesis takes place in the setting of low glucose levels in the blood, after exhaustion of other cellular carbohydrate stores, such as glycogen.
What is Ketosis?
Ketosis is a natural metabolic state in which your body runs primarily on fats and ketone bodies, instead of carbohydrates (i.e., glucose). WebMD says, “Ketosis is a normal metabolic process, something your body does to keep working.”1
The liver produces ketones from the breakdown of adipose tissue (body fat) and dietary fats. Our cells can then burn these ketones for energy. However, the body will first use whatever glucose it has before burning fat. Then the body will use dietary fat before it uses stored body fat. A recent Facebook post from Burn Fat Not Sugar explained it this way: “When it comes to total body energy or circulating energy, carbs and fats both contribute equally isocalorically. Only difference is carbs have to be burned first as they have a higher oxidative priority.”
The process of ketone generation, unsurprisingly, is called ketogenesis, and it’s going on all the time. However, the rate of ketone production and magnitude of your ketogenic state depends mostly on how much dietary carbohydrate (and protein) you eat.
The more carbohydrates you consume, the fewer ketones you will produce. This is because consuming carbohydrates (and protein) elevates insulin levels, which blunts fat breakdown. While your body is running on glucose, it shifts ketogenesis to standby, resulting in a very low blood ketone concentration (about 0.1 mmol/L). “Measuring ketone levels can help much more directly therefore, as the production of ketones is a direct result of fat burning. 1.5-3.0 mmol/l is the ‘sweet spot’.”2
The classic resource on ketosis is the book, Keto Clarity, by Jimmy Moore and Eric C. Westman, MD.3 Read this if you don’t read anything else on the topic of “keto”!
Dr. Jockers’ article, “10 Critical Ketogenic Diet Tips,” has excellent information about nutritional ketosis for anyone who is interested in what it is and how it works. (You just have to ignore the blatant marketing of Dr. Jockers’ products!) The article has lots of infographics that help to clarify the talking points, and Dr. Jockers provides documented references at the end of his article.4
“The modern version of the ketogenic diet has been around since the 1920s, with aspects of it dating back to ancient Egypt. Keto was developed and used to treat epilepsy with great success until about 1938 when the drug diphenylhydantoin was found to control seizures.”5
In terms of “real world” numbers, a typical ketogenic diet6 contains the following macronutrient percentages:
- Fat: 75%
- Protein: 15-20%
- Carbohydrates: 5-10%
Diet Doctor7 has an easy-to-read, comprehensive “course” on how to implement a ketogenic diet.
Ketosis and DKA (Diabetic Ketoacidosis)
The first misconception that I want to clear up is the difference between ketosis and ketoacidosis. These are two different words! They just begin with the same four letters and end with the same three letters. Early in my reversing diabetes journey, I learned about ketosis and I was excited to share my newfound knowledge with my then-very-small Adventist Vegetarian Diabetics™ Facebook group. “Oh, no,” exclaimed one member, “you could die from ketoacidosis!” So I had to explain to her that nutritional ketosis is not the same as diabetic ketoacidosis (DKA).
“Diabetic ketoacidosis (DKA) is a serious problem that can occur in people with diabetes if their body starts to run out of insulin. DKA mainly affects people with type 1 diabetes but can sometimes occur in people with type 2 diabetes.”8 When a diabetic has a diet too high in carbohydrates, it is possible to get ketoacidosis. In addition, there are some common diabetes medications that have been reported to cause ketoacidosis in type 2 diabetics even though their blood sugars are low to normal. (See our chapter on “Diabetes Medications.”)
DKA happens primarily in type 1 diabetics when they don’t have adequate insulin and their body starts producing ketones, but they keep eating high amounts of carbohydrates, resulting in high blood sugar. It is the combination of high ketones and high blood sugar that is so deadly.
Nutritional ketosis is a normal metabolic state when the body does not have sufficient carbohydrates (sugars and starches) to burn for fuel (energy) and so it burns ketones made from body fat. “Ketosis is not dangerous because ketosis is not the same thing as ketoacidosis.”9 Ketosis, in fact, is the natural state of human metabolism, according to some experts. All newborn babies are in nutritional ketosis at birth!
Being in nutritional ketosis as brought on by a low-carb high-fat (LCHF) diet will absolutely not cause DKA (diabetic ketoacidosis)!
What Is the Ketogenic Diet?
The second misconception I want to dispel is that there is no “a” or “the” or “one” ketogenic diet. Any dietary protocol that allows one to achieve and maintain ketosis (as described below) is the ketogenic diet for that person. There are no set dietary rules for a ketogenic diet. We define a “ketogenic diet” as “the nutrition used to achieve and support the state of ketosis,” according to CaliDiet magazine. “‘Keto’ broadly refers to the ketogenic state—when the body uses ketone bodies for energy instead of glycogen derived from carbohydrates. This is only achieved when you strictly limit your consumption of dietary carbohydrates and eat plenty of fats to support ketone production.”10
Some people have reported being “in ketosis” while eating as much as 50 grams of carbohydrates per day, while others need to go as low as 20 or even 10 grams of carbohydrates per day. But nutritional ketosis experts agree that carbohydrates from sugars, grains, and other starches will keep you “out of ketosis.”
One of the most important sources for vegetarians is this article on “The Vegetarian Ketogenic Diet.”
“To implement the diet correctly, you must follow these rules:
- Limit your total carbohydrate consumption to 35 grams or less per day.
- Eliminate all animal flesh from your diet (e.g.,, meat, fish, and poultry).
- Eat plenty of low-carb vegetables.
- Get at least 70% of your calories from fat.
- Consume around 25% of your calories from plant-based proteins, eggs, and dairy [products].
- Supplement with nutrients that you may not be getting enough of like vitamins D3, B12, DHA and EPA, iron, and zinc.
- Use [a] keto calculator to figure out your calorie and macronutrient needs.
Continue reading [the referenced article] for more precise recommendations for vegetarian ketogenic dieters.”11
WebMD, in all its cautious simplicity, says: “Ketosis is a normal metabolic process, something your body does to keep working. When it doesn’t have enough carbohydrates from food for your cells to burn for energy, it burns fat instead. As part of this process, it makes ketones. Ketones are substances that are made when the body breaks down fat for energy. When you cut way back on your calories or carbs, your body will switch to ketosis for energy.”12
But the clearest explanation of ketosis is from the classic volume, Keto Clarity, by Jimmy Moore with Eric C. Westman, MD,13 from which I quote:
“Ketosis (pronounced KEY-TOE-SIS) is a metabolic state that happens when you consume a very low-carb, moderate-protein, high-fat diet that causes your body to switch from using glucose as its primary source of fuel to running on ketones. Ketones themselves are produced when the body burns fat, and they’re primarily used as an alternative fuel source when glucose isn’t available. In other words, your body changes from a sugar-burner to a fat-burner…. So ‘being in ketosis’ just means that you are burning fat.
“If you consume a diet with very few carbohydrates, moderate levels of protein, and plenty of healthy saturated and monounsaturated fats, then these ketones will begin to increase until they dominate the way your body is fueled, to the point that very little glucose is needed to function.”
How Ketosis Works
Keto Clarity lists three types of ketone bodies:
- Acetoacetate (AcAc), the primary ketone body in the urine. Urine test sticks are only useful in the early stages of ketosis. Once you are fat-adapted, the urine ketones disappear.
- Beta-hydroxybutyrate (BHB), the primary ketone body in the blood. This testing is the most precise.
- Acetone, the primary ketone body in the breath. This testing is least invasive and correlates well to BHB testing.
Author Craig Clark writes, “Ketosis is a natural process the body initiates to help us survive when food intake is low. During this state, we produce ketones, which are produced from the breakdown of fats in the liver…. The end goal of a properly maintained keto diet is to force your body into this metabolic state. We don’t do this through starvation of calories but starvation of carbohydrates.”14
The NIH published a more complex, scientific explanation, and I have excerpted it: “Ketone bodies synthesized in the body can be easily utilized for energy production by heart, muscle tissue, and the kidneys. Ketone bodies also can cross the blood-brain barrier to provide an alternative source of energy to the brain. RBCs [red blood cells] and the liver do not utilize ketones due to lack of mitochondria and enzyme diaphorase, respectively. Ketone body production depends on several factors such as resting basal metabolic rate (BMR), body mass index (BMI), and body fat percentage. Ketone bodies produce more adenosine triphosphate [ATP] in comparison to glucose, sometimes aptly called a ‘super fuel.’ One hundred grams of acetoacetate generates 9400 grams of ATP, and 100 grams of beta-hydroxybutyrate yields 10,500 grams of ATP; whereas 100 grams of glucose produces only 8,700 grams of ATP. This allows the body to maintain efficient fuel production even during a caloric deficit. Ketone bodies also decrease free radical damage and enhance antioxidant capacity.”15
Benefits of Ketosis
Living Life Keto16 says, “There is no real way to test if you are keto-adapted, but there are plenty of ways to tell by simply observing changes in your life and how you feel.” Some immediate effects of ketosis are:
- You do not get hungry as often! The natural partner of ketosis is intermittent fasting. (And that’s another whole topic!)
- You feel more mentally alert and can think more clearly. “Brain fog” diminishes significantly.
- Your energy levels even out and usually increase from their pre-keto levels. Instead of the roller coaster rise and fall of energy that accompanies a carb-filled diet, fat burners enjoy a steady stream of fuel regardless of when they’ve eaten last.
- You may feel calmer without hunger and carb cravings or low energy.
- You may exercise/workout more easily. You can just feel your body running more efficiently.
More significant benefits include:
- Weight loss is easy, accompanied by a reduction in body measurements and clothing sizes.
- Lowering of blood glucose and insulin levels. Diabetics experience lower A1C and fasting blood glucose numbers.
- Other health issues respond to ketosis, such as lower blood pressure, lower triglycerides, higher HDL, improved thyroid health, and many others.
How to Achieve and Maintain Ketosis
Some things that will sabotage a ketogenic diet are:
- Not restricting carbs enough
- Not eating enough healthy fats
- Eating too much protein
- Eating too much of anything, or eating too often
- Not getting enough electrolytes (sodium, magnesium, potassium)
Finally, I can give you my own experience with ketosis. After five and a half years of eating low-carb, I bought a blood ketone meter (KetoCoach Starter Kit) and tested for ketosis. In the first 8 tests that I did, 6 of my numbers were within the “sweet spot” of nutritional ketosis.
1Khatri, Minesh. “What is ketosis?” WebMD (May 15, 2020). https://www.webmd.com/diabetes/qa/what-is-ketosis (accessed on 7/31/2020).
2Editor. “Measuring ketosis on a ketogenic diet,” Diabetes.co.uk (updated January 15, 2019). https://www.diabetes.co.uk/keto/measuring-ketosis-on-a-keto-diet.html#:~ (accessed on 7/31/2020).
3Moore, Jimmy, and Eric C. Westman, MD. Keto Clarity: Your Definitive Guide to the Benefits of a Low-Carb, High-Fat Diet. Las Vegas: Victory Belt Publishing, 2014. https://www.amazon.com/Keto-Clarity-Definitive-Benefits-Low-Carb/dp/1628600071/
4Jockers, Dr. David, DNM, DC, MS. “10 Critical Ketogenic Diet Tips,” DrJockers, n.d. https://drjockers.com/10-critical-ketogenic-diet-tips/ (accessed on 7/31/2020).
5Nicole. “Keto 101 – The basics of the ketogenic diet,” Living Life Keto (February 2, 2018). https://livinglifeketo.com/keto-101-the-basics-of-the-ketogenic-diet/ (accessed on 7/31/2020).
6Schinetsky, Robert. “Everything You Need to Know About the Keto Diet,” Nutrex (September 16, 2019). https://www.nutrex.com/articles/everything-you-need-to-know-about-the-keto-diet/ (accessed on 7/31/2020).
7Eenfeldt, Dr. Andreas, MD; medical review by Dr. Bret Scher, MD. “A ketogenic diet for beginners,” Diet Doctor (updated July 18, 2020). https://www.dietdoctor.com/low-carb/keto (accessed on 7/31/2020).
8“Diabetic ketoacidosis,” NHS (last reviewed May 1, 2020). https://www.nhs.uk/conditions/diabetic-ketoacidosis/ (accessed on 7/31/2020).
9Gustin, Dr. Anthony. “Is Ketosis Dangerous? No, Because Ketosis is not Ketoacidosis,” Dr. Anthony Gustin, n.d. https://dranthonygustin.com/ketosis-dangerous-no-ketosis-not-ketoacidosis/ (accessed on 7/31/2020).
10California Health Living Center. “What is the Keto Diet – and What Isn’t It?,” CaliDiet (June 22, 2017). http://calidiet.com/keto-diet-tips/ (accessed on 7/31/2020).
11Clarke, Craig. “Comprehensive Guide To The Vegetarian Ketogenic Diet,” Ruled.me (updated June 20, 2020). https://www.ruled.me/comprehensive-guide-vegetarian-ketogenic-diet/ (accessed on 7/31/2020).
12“Ketosis,” WebMD, n.d. https://www.webmd.com/diabetes/type-1-diabetes-guide/what-is-ketosis#1 (accessed on 10/12/2020).
13Moore & Westman, Keto Clarity.
14Clarke, Craig; medical review by Dr. Pouya Shalipour, MD. “What is a Keto Diet?” Ruled.me (updated June 2, 2020). https://www.ruled.me/guide-keto-diet/ (accessed on 7/31/2020).
15Masood, Wajeed; Pavan Annamaraju; and Kalyan R. Uppaluri. “Ketogenic Diet,” StatPearls (last update June 22, 2020). https://www.ncbi.nlm.nih.gov/books/NBK499830/ (accessed on 7/31/2020).
16Nicole. Living Life Keto, n.d. https://livinglifeketo.com/ (accessed on 10/12/2020). A practical guide to low-carb success.
Additional Information & References
What is the Keto Diet – and What Isn’t It?
“Keto” broadly refers to the ketogenic state – when the body uses ketone bodies for energy instead of glycogen derived from carbohydrates. This is only achieved when you strictly limit your consumption of dietary carbohydrates, and eat plenty of fats to support ketone production – which is commonly referred to as the “keto diet”.
Don’t think of the keto diet as a set of dietary rules, think of it as the nutrition used to achieve and support the state of ketosis. This typically involves consuming less than 50g of carbohydrates per day, and consuming about 60-70% of daily calories from healthy fat sources.
To achieve ketosis most people:
- Eliminate sugars and grains from their diet entirely
- Limit starchy vegetables
- Increase dietary fats from healthy sources: coconut oil, grass-fed meats, avocado oil, dairy, seeds, nuts
- Supplement intelligently with electrolytes
Do NOT confuse ketosis with diabetic ketoacidosis!
KETOSIS IS NOT KETOACIDOSIS.
Why DKA & Nutritional Ketosis Are Not The Same
Confusing ketosis with ketoacidosis
8 Common Misconceptions About Ketogenic Diets
Trashing ketogenic diets has become a trend in some areas. Most use the studies from years ago that reportedly “prove” their points. This post is intended to clear up the “8 common misconceptions about ketogenic diets” and inaccuracies of those studies and posts.
THE SCIENCE BEHIND KETOGENICS A LOW CARB HIGH FAT DIET
NOT SECURE http://www.bodyenvy.ca/ketogenics-a-low-carb-high-fat-diet/
- Blood Glucose
- Carb Calculations
- Cholesterol in Food
- Complications of Diabetes
- Dawn Phenomenon
- Diabetes Medications
- Gluconeogenesis & Glycolysis
- Glycemic Index/Glycemic Load
- Insulin Resistance
- Ketosis and Ketogenic Diet
- Older Diabetics
- Reversing Diabetes