2

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Ketosis from blood test

Answered on September 12, 2014
Created March 19, 2012 at 3:19 AM

Hello! I began a paleo diet 2 weeks ago and am seeing steady but slow results. Walking through Walgreens today I stumbled upon a blood glucose monitoring system that also measures ketones in the blood! After doing some online searches, it appears this is a more accurate test than urine (sorry no links...). Only problem is, it's geared towards diabetics so I cannot for the life of me find the reference ranges for ketosis, only ketoacidosis.

This is the ketone guide, as printed for diabetics:

below 0.6 mmol/L - normal

0.6-.5 mmol/L - risky

above 1.5 mmol/L - potentially hazardous

The test I did came up as 3.5 mmol/L. Can anyone help me interpret this for ketosis? Is it just simply the reverse? The higher the better? I don't want to assume anything. Thanks! Looking forward to my new lifestyle!

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:11 PM

Optimus, I added some info about ketoacidosis to my answer (see "Edit"). I've found that it's easy to drop to 0.9 occasionally if I eat more than tiny amounts of protein or carbs in a given meal. If your diet is basically ketogenic you'll probably climb back up the 3's quickly as your body uses up the glucogenic substrate that you ate. Like Stephen says, the body hates being in ketosis, and it will drop to low levels if you give it the least opportunity.

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:09 PM

Rob, how have your migraines have been while on this diet? Don't give up hope: there is a chance that, if you keep this up long enough, that your nervous system will change enough that you may someday no longer need to be in such a level of ketosis. It can and does happen. By now I think that epilepsy, and related channelopathies (like migraine) are diseases of civilization like all the others. – Stephen6 hours ago

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:08 PM

Optimus, I added some info about ketoacidosis to my answer (see "Edit"). I've found that it's easy to drop to 0.9 occasionally if I eat more than tiny amounts of protein or carbs in a given meal. If your diet is basically ketogenic you'll probably climb back up the 3's within hours as your body uses up the glucogenic substrate that you ate. Like Stephen says, the body hates being in ketosis, and it will drop to low levels instantly if you give it the least opportunity.

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:04 PM

Optimus, I added some info about ketoacidosis to my answer (see "Edit"). It's easy to drop to 0.9 occasionally if you eat protein or carbs in a given meal. If your diet is basically ketogenic you'll probably climb back up the 3's within hours as your body uses up the glucogenic substrate that you ate. Like Stephen says, the body hates being in ketosis, and it will drop to low levels instantly if you give it the least opportunity.

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 03:55 PM

Stephen, delighted to read your comments, I'll answer later when I have time.

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 02:58 PM

I just did a quick check, and -- holy cow -- they are even more expensive in the US! The lowest price I could find online was $34 for a 10 pack. In Canada I paid 20 bucks over the counter, and even less in Europe. (The strips are manufactured in the UK.) Still, if you are judicious about it, it's worth it. You'll test more in the beginning until get better at maintaining it. When you learn to recognize the signs, you won't need to test so often.

44b03af890ca008101b4ff47bdd722a0

on March 19, 2012
at 02:02 PM

No kidding! They are so expensive. 10 strips for $29 on my gadget, wtf. I guess I should have looked into that before buying the thing. I, too, feel more astute on a ketogenic diet. Just yesterday after realizing this, I was reflecting on some of the great minds of our time. How many of them were/are overweight? Not saying they were all in ketosis, hah, but they were obviously functioning pretty efficiently.

44b03af890ca008101b4ff47bdd722a0

on March 19, 2012
at 01:54 PM

Thanks for the extensive answer and great info, Rob! To confirm, yes, my device measures in beta-hydroxybutyrate. I am not too concerned about ketoacidosis as I am not diabetic and yes, I am trying to lose weight. I've lived on VLC diets in the past with great results and no real side effects aside from occasional fatigue (which is a problem for me no matter what I'm eating). I do think that first test may have been erroneous though, as I tested again after dinner and it was down to 0.9, boo! And no weight loss this morning. Keeping at it!

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:50 AM

Oh, and be warned: the blood ketone strips are insanely expensive: about 1.40 € or 2.00 USD per test strip. If you want to test daily over the whole year, you're looking at the cost of short vacation :)

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:42 AM

I totally agree on the importance of clinical validation of point-of-care-testing devices. But remember that home blood glucose monitoring has been around for decades, and the systems are getting to be pretty good. The problem is more the nature of substance being tested than the device: it's very easy to get screwy results, even with large-volume blood testing in a full laboratory.

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:36 AM

Last one: it's not totally fair (or accurate ;) ) to say that blood glucometers are inaccurate. Glucose is fundamentally different from ketones because all tissues in the body use it, and the level can vary depending on where you take the blood sample, and from minute to minute. In other words, it's a much more variable target, and the blood glucometers are as accurate as you can expect from a handheld device testing a pinprick sample. They have to be, since insulin dosing depends on getting an accurate reading, and treating based on a bad reading can have disastrous consequences.

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:32 AM

On citrate: you can get your citrates from a variety of sources, it doesn't have to be potassium citrate. Calcium citrate and magnesium citrate will also do it, and you need calcium and magnesium anyway :)

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:31 AM

Rob, how have your migraines have been while on this diet? Don't give up hope: there is a chance that, if you keep this up long enough, that your nervous system will change enough that you may someday no longer need to be in such a level of ketosis. It can and does happen. By now I think that epilepsy, and related channelopathies (like migraine) are diseases of civilization like all the others.

44b03af890ca008101b4ff47bdd722a0

on March 19, 2012
at 04:15 AM

Oh, and by the way I am not diabetic. Here is a link to the device http://novacares.com/nova_max_plus/

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82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 06:42 AM

I'm glad to see somebody here bought a home blood ketone meter! I used to recommend them here and on other forums, but I stopped because nobody ever listened.

My ketone meters are Precision Xtras (I own three). Until recently the Precision Xtra was the only home ketone blood meter on the market. This is the first time I've heard of the Nova Max.

Here's an article I wrote last year about the Precision Xtra:

Precision Xtra on KetoCure.com

You mentioned references; there are plenty in that linked article.

Edit:

I don't think you need to worry about pathological ketoacidosis. It occurs as a result of disease (e.g. diabetes or alcoholism). I can't find any mention in the literature of it happening to healthy people as a result of diet or fasting, no matter how high their ketone levels climb.

If there were any danger of ketoacidosis in healthy people, I would expect to find it mentioned in Epilepsy and The Ketogenic Diet by Strafstrom and Rho. This is the standard medical textbook on keto diets. It has extensive sections on biochemistry and clinical applications. The book doesn't mention ketoacidosis (I searched a PDF version).

If there were any risk of ketoacidosis, another place I'd expect to see it mentioned is a terrific review paper on fasting from 1982 called "Fasting: The History, Pathophysiology, and Complications" by Kerndt et al. This paper reviews 175 earlier papers on fasting and tabulates every medical complication that had ever been reported. It doesn't mention even a single instance of pathological ketoacidosis.

End of edit

Like all home meters, when you use the Precision Xtra to measure glucose, it's not very accurate. But when you use it with ketone strips to measure beta-hydroxybutyrate, it's a whole other story. The Xtra's ketone strips are incredibly accurate. The Xtra's ability to measure blood ketones has been evaluated about a half dozen times in peer-reviewed scientific publications, and it has been repeatedly found to be very nearly as accurate as reference lab equipment costing many thousands of dollars. It's an incredible little machine.

Any device of this type is probably more accurate than urine strips because urine strips don't measure the thing we're interested in, which is the concentration of ketones in the blood. Moreover, urine strips don't measure urine ketones accurately, and they have a truncated range ... purple is not a very high level, but that's the highest they go.

Maybe the Nova Max is as accurate as the Precision Xtra. I don't know.

In order to evaluate your 3.5 mmol/L number exactly we'd have to know two things:

  1. What substance does the Nova Max measure? Is it beta-hydroxybutyrate? There are three different ketones; beta-hydroxybutyrate is one of them.

  2. Is it reporting a plasma or whole blood number?

I'll assume your machine measures beta-hydroxybutyrate and reports in terms of plasma. That's how the Precision Xtra works.

3.5 mmol/L is a pretty high number. But to put it into context, I've gotten as high as 7.7 on a clinical ketogenic diet -- in other words, I was getting ninety percent of my calories from fat.

If you're trying to lose weight, I think 3.5 is a fine number. Ketosis of that level and higher often suppresses appetite and you may be able to get yourself into a virtuous circle where your appetite gets so low that you practically stop eating, in which case you'll be in high ketosis, which suppresses appetite... around and around. Nutrient-dense foods like eggs and liver and kale are your friends if that happens.

If you're not trying to lose weight, I'm not sure 3.5 is healthy over the long run. I've been at that level or higher for a year and a half in order to control my migraines, and I don't like it. My gut feeling is that it's not healthy. I'm only doing it because of my headaches.

There's a lot of scientific literature about the effects of long term ketosis on kids, but very little about adults.

I would watch for any of the following warning signs and reduce the level of ketosis if they appear.

You can reduce the level of ketosis by eating a spoonful of rice syrup mixed in water. I do this a few times a week whenever my ketosis feels too high. The doctors who prescribe keto diets for children tell them to use orange juice for this purpose, but I think rice syrup is healthier since it metabolizes to nearly pure glucose.

  1. Lethargy, listlessness, fatigue.

  2. Dry mucus membranes.

  3. Impaired immmune system.

  4. Elevated or irregular heart beat.

  5. A feeling of stress or fight or flight response.

  6. Severe orthostatic hypotension (the feeling that you might faint when you stand up suddenly).

Another thing to consider is that clinical ketogenic diets have been shown to increase the risk of kidney stones by a pretty large factor. Doctors often prescribe huge amounts of potassium citrate to kids on clinical keto diets as a precaution. My urologist told me the best precaution against kidney stones is to drink lots of water so the urine doesn't become concentrated. I don't know if this is an effective precaution against the type of kidney stone associated with ketogenic diets, but I've been following my doctor's advice for the last year and a half and so far it's working, despite my history of kidney stones.

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 03:55 PM

Stephen, delighted to read your comments, I'll answer later when I have time.

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:32 AM

On citrate: you can get your citrates from a variety of sources, it doesn't have to be potassium citrate. Calcium citrate and magnesium citrate will also do it, and you need calcium and magnesium anyway :)

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:36 AM

Last one: it's not totally fair (or accurate ;) ) to say that blood glucometers are inaccurate. Glucose is fundamentally different from ketones because all tissues in the body use it, and the level can vary depending on where you take the blood sample, and from minute to minute. In other words, it's a much more variable target, and the blood glucometers are as accurate as you can expect from a handheld device testing a pinprick sample. They have to be, since insulin dosing depends on getting an accurate reading, and treating based on a bad reading can have disastrous consequences.

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:31 AM

Rob, how have your migraines have been while on this diet? Don't give up hope: there is a chance that, if you keep this up long enough, that your nervous system will change enough that you may someday no longer need to be in such a level of ketosis. It can and does happen. By now I think that epilepsy, and related channelopathies (like migraine) are diseases of civilization like all the others.

44b03af890ca008101b4ff47bdd722a0

on March 19, 2012
at 01:54 PM

Thanks for the extensive answer and great info, Rob! To confirm, yes, my device measures in beta-hydroxybutyrate. I am not too concerned about ketoacidosis as I am not diabetic and yes, I am trying to lose weight. I've lived on VLC diets in the past with great results and no real side effects aside from occasional fatigue (which is a problem for me no matter what I'm eating). I do think that first test may have been erroneous though, as I tested again after dinner and it was down to 0.9, boo! And no weight loss this morning. Keeping at it!

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:04 PM

Optimus, I added some info about ketoacidosis to my answer (see "Edit"). It's easy to drop to 0.9 occasionally if you eat protein or carbs in a given meal. If your diet is basically ketogenic you'll probably climb back up the 3's within hours as your body uses up the glucogenic substrate that you ate. Like Stephen says, the body hates being in ketosis, and it will drop to low levels instantly if you give it the least opportunity.

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:42 AM

I totally agree on the importance of clinical validation of point-of-care-testing devices. But remember that home blood glucose monitoring has been around for decades, and the systems are getting to be pretty good. The problem is more the nature of substance being tested than the device: it's very easy to get screwy results, even with large-volume blood testing in a full laboratory.

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:11 PM

Optimus, I added some info about ketoacidosis to my answer (see "Edit"). I've found that it's easy to drop to 0.9 occasionally if I eat more than tiny amounts of protein or carbs in a given meal. If your diet is basically ketogenic you'll probably climb back up the 3's quickly as your body uses up the glucogenic substrate that you ate. Like Stephen says, the body hates being in ketosis, and it will drop to low levels if you give it the least opportunity.

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:09 PM

Rob, how have your migraines have been while on this diet? Don't give up hope: there is a chance that, if you keep this up long enough, that your nervous system will change enough that you may someday no longer need to be in such a level of ketosis. It can and does happen. By now I think that epilepsy, and related channelopathies (like migraine) are diseases of civilization like all the others. – Stephen6 hours ago

82166cc32b6cf26de33b69f58fb583b1

on March 19, 2012
at 04:08 PM

Optimus, I added some info about ketoacidosis to my answer (see "Edit"). I've found that it's easy to drop to 0.9 occasionally if I eat more than tiny amounts of protein or carbs in a given meal. If your diet is basically ketogenic you'll probably climb back up the 3's within hours as your body uses up the glucogenic substrate that you ate. Like Stephen says, the body hates being in ketosis, and it will drop to low levels instantly if you give it the least opportunity.

1
121a16aded2bed8dca492d3c9662ef4c

on March 19, 2012
at 09:28 AM

I was actually going to comment on Rob's post, but it ended up being pretty long, so I will answer here.

First, I have to second Rob. I have found the urine strips to be essentially useless, and I am glad he put me on to the Precision Xtra, which I've owned for three weeks. One of the best purchases I've ever made. No more guessing. Guessing is for amateurs.

3.5 mmol/L ??-hydroxybutyrate is most definitely ketosis, but not an immediate danger to someone who is not a diabetic. As I have quickly discovered, the body absolutely hates being in ketosis and will use any and every excuse and opportunity to get out of it, because it is essentially a starvation state. For a diabetic, a level above 1.5 mmol/L may be an indicator of runaway ketoacidosis, and would demand action. For a healthy non-diabetic, the system takes care of that for you.

A ketogenic diet is a sort of "bait and switch": reducing caloric intake so that the body starts reaching for stores, then feeding with fat exclusively, leaves the system no alternative.

This state is very difficult to maintain.

I was able to get myself to a about 3.5 - 3.7 mmol/L, but it was not easy, and pretty soon I started having some of those symptoms Rob listed. For one thing, my blood pressure dropped (hooray) and I started having dizzy spells (boo) when I stood up (orthostatic hypotension). I also felt like I'd been run over by a truck. Maintaining my weight was a herculean struggle. I was never hungry and after two weeks couldn't stand the sight of food (or maybe I should say fat, since that was just about all I was eating by that point).

This makes getting adequate nutrition hard, which is why I would say that for most people, ketosis is probably not something you want to sustain over the longer term. For some people, like Rob, it's the only thing that has worked.

I will definitely say that my mind has never been clearer than while in ketosis. Emily Deans has written about the benefits of ketosis for the brain, and ketogenic diets have been used to treat a variety of neurological conditions, not least being epilepsy.

44b03af890ca008101b4ff47bdd722a0

on March 19, 2012
at 02:02 PM

No kidding! They are so expensive. 10 strips for $29 on my gadget, wtf. I guess I should have looked into that before buying the thing. I, too, feel more astute on a ketogenic diet. Just yesterday after realizing this, I was reflecting on some of the great minds of our time. How many of them were/are overweight? Not saying they were all in ketosis, hah, but they were obviously functioning pretty efficiently.

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 09:50 AM

Oh, and be warned: the blood ketone strips are insanely expensive: about 1.40 € or 2.00 USD per test strip. If you want to test daily over the whole year, you're looking at the cost of short vacation :)

121a16aded2bed8dca492d3c9662ef4c

(1327)

on March 19, 2012
at 02:58 PM

I just did a quick check, and -- holy cow -- they are even more expensive in the US! The lowest price I could find online was $34 for a 10 pack. In Canada I paid 20 bucks over the counter, and even less in Europe. (The strips are manufactured in the UK.) Still, if you are judicious about it, it's worth it. You'll test more in the beginning until get better at maintaining it. When you learn to recognize the signs, you won't need to test so often.

0
7aa201361eb6a5334d43dd051658fcff

on May 08, 2012
at 10:41 AM

Hi, I think you should drink more lemon juice or the powdered soft drink mix citricdiet, as having acetone so high may be harmful for your kidney

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