optimal fasting ketone and blood sugar levels in ketosis

optimal ketone and blood sugar levels for ketosis


  • A low carb helps reduce blood sugars and insulin levels and help with many common metabolic diseases (e.g. diabetes, heart disease, stroke, cancer, Parkinson’s and Alzheimer’s).
  • We become insulin resistant when our adipose tissue becomes full and can’t store any more energy.  Excess energy is then stored in the liver, pancreas, heart, brain and other organs that are more insulin sensitive.
  • Endogenous ketosis occurs when we don’t eat and we burn our own body fat (e.g. fasting).  While insulin and blood sugar levels are low we may have lower blood ketones flowing from our fat stores.
  • Exogenous ketosis occurs when we eat lots of fat (e.g. butter, MCT oil) or take exogenous ketones.   Our blood ketones may be higher, but our insulin levels will rise to remove excess energy from the blood.
  • Most of the good things associated with ketosis occur due to endogenous ketosis.
  • Most people following a ketogenic diet have lower blood ketone values than Phinney’s ‘optimal ketosis’ chart, especially once they become fat adapted.
  • If your goal is blood sugar control, longevity or weight loss then tending towards endogenous ketosis with lower blood sugars and lower ketones is likely a better place to be than targeting higher blood ketones.

Introduction

I have seen a lot of interest and confusion recently from people following a ketogenic about ideal ketone and blood sugar levels.

This article reviews blood ketone (BHB), breath ketone (acetone) and blood sugar data from a large number of people who are following a low carb or ketogenic diet to understand what “normal” and “optimal” really look like.

This understanding, based on real life data from people following a ketogenic dietary approach, will to help us fine tune our diet and lifestyle to suit our goals whether they be:

low carb diets reduce blood glucose levels

Many people initiate a low carb diet to manage their blood glucose levels, insulin resistance or diabetes.

As shown in the chart below, foods with less carbohydrate do in fact have a a smaller impact on our blood sugar.[1] [2] [3]

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While not typically recommended by dieticians and diabetes associations, it would appear that, if you are insulin resistant, have prediabetes, or diabetes (Type 1 or Type 2) it make sense to reduce the carbohydrates in your diet to the point where you can achieve the blood glucose levels of a metabolically healthy person.

what are optimal blood sugar levels?

  • “Normal” blood sugar regulation is defined as having a HbA1c of less than 6.0%.
  • Prediabetes is diagnosed when you have a HbA1c between 6.0 and 6.4%.
  • Type 2 diabetes is diagnosed when you have a HbA1c of greater than 6.4%.

However, as you can see from the charts below, this definition of “normal” is far from optimal.

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By the time you have “prediabetes” with a HbA1c of greater than 6.0% you are at risk of many of the most common western diseases of aging and causes of death (i.e. heart disease, stroke, Parkinson’s, Alzheimer’s and cancer).[4] [5]

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If you’re interested in optimal rather than that what currently passes for “normal” health, the table below shows some suggested HbA1c and average blood sugar targets for optimal health and longevity.

risk level

HbA1c

average blood sugar

(%)

(mmol/L)

(mg/dL)

optimal

4.5

4.6

83

excellent

< 5.0

< 5.4

< 97

good

< 5.4

< 6.0

< 108

danger

> 6.5

> 7.8

> 140

ketosis vs hyperinsulinemia

While high glucose levels are bad news in and of themselves (glucose toxicity and excessive glycation), high blood sugars typically go hand in hand with high insulin levels which are also bad news.[6] [7] [8]

A metabolically healthy person will store excess energy in their fat cells for easy access when required later.  But if we continue to fill our fat cells with excess energy, you will get to the point where they cannot expand to accept any more energy.  It is at this point that our adipose tissue becomes insulin resistant.

Ted Naiman does an excellent job explaining this.

The good news is that insulin resistance will slow the expansion of our fat cells (the excess energy can’t get in as easily).

The bad news is that once our fat cells become insulin resistant the excess energy will be re-directed to the parts of our body that are more insulin sensitive such as our liver, pancreas, heart, brain and other vital organs.

Our pancreas will work overtime secreting more insulin to try to keep the energy in the liver as well as put it back into storage.

High insulin levels mean that we will find it harder to release energy from our fat stores when we go without food.[9]  Without easy access to our body fat stores, we will be driven by our appetite to eat again sooner.

Someone who is insulin resistant is more likely to become obese because their chronically elevated insulin levels will drive them to eat more often because, without easy access to their fat stores, they feel bad without a constant flow of glucose for energy.

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Fasting insulin levels in healthy populations range between 2 to 6 mIU/L.[10] [11] [12]  The average insulin levels in western populations are 8.6 mIU/L.   Meanwhile, the official reference range for “normal” fasting insulin is less than 25 mIU/L.[13] [14]  Given that the western world is going through a crisis of metabolic health, it is probably safe to say that, similar to the “normal” blood glucose levels, this cut off for insulin levels is also far from optimal.

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how to manage your dietary insulin load

To help manage your insulin levels and blood sugar you can tailor the insulin load of your diet to suit your current level of insulin resistance.   As shown in the chart below, our insulin response to the food we eat is proportional the net carbs plus about half the protein it contains.

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Reducing the insulin load of your diet can help to reduce your insulin and blood sugar levels to the point where your pancreas and current insulin resistance levels can keep up.  When our insulin levels are low, we can access our body fat for fuel, either from our body or our food.  We then see the ketone levels in our blood rise.  At this point we are deemed to be “in ketosis”.

A person with type 1 diabetes (like my wife Monica) is not able to produce enough insulin.  Without exogenous insulin injections they will see both their blood glucose and blood ketones rise to very high levels.  This is called ketoacidosis which is a dangerous state that requires exogenous insulin as soon as possible to prevent their body from falling apart.

Without insulin people with type 1 diabetes are unable to metabolise glucose and turn to their muscles for energy.  As shown in the image below of JL, one of the first children with type 1 diabetes to receive insulin, they quickly regain weight.

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It’s important to find the optimal amount of insulin.  Lowish blood ketones with healthy blood glucose levels is a normal healthy state where your body fat can more easily be accessed for fuel.

People who switch to a low carb dietary approach often find that their blood glucose and insulin levels plummet and they are not hungry because excess excessive amounts of energy can now flow out of storage (a little bit like someone with uncontrolled type 1 diabetes.

However the problem with a very low insulin load dietary approach (e.g. very high fat therapeutic ketogenic diet), is that it may not contain enough of the vitamins and minerals that you need for optimal function and avoid nutrient cravings in the long term.

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High fat foods also have a high energy density which can make it hard for some people to control portion sizes if their goal is weight loss.  Very high fat foods also tend to be less nutrient dense.

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blood glucose and ketones in fasting

When we go without food, our blood glucose levels will decrease as the glucose in our bloodstream and liver (glycogen) are used up.  The body then turns to our fat stores and our liver converts them into ketones for use.  This is termed “endogenous ketosis” (endogenous = originating from within an organism).

 

As explained by Dr David Sinclair in the video below, there are a ton of beneficial things that occur during endogenous ketosis such as autophagy, mitogenesis, mitophagy, upregulation of SIRT1 and increase of NAD+).

Ketones also increase during this low energy state to keep the brain and muscles well fuelled.  However, while ketones are present, they are not necessarily the cause of these benefits that are often associated with ketosis.

The chart below shows my blood sugar and blood ketone (BHB) during a recent seven day fast.  You can see that as glucose levels decrease, ketone levels rise.

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You can see that the sum of glucose and ketones continues to increase during fasting.  I have termed the sum of glucose and ketone as “total energy” (i.e. glucose + ketones).

Often in fasting it seems that the body will let the total energy in the blood go quite high.  This enables you to be on a state of very high alert ready to find food to survive.  It feels great and I typically feel at my sharpest after not eating for a few days.

exogenous ketosis vs endogenous ketosis

I think it’s important to understand the difference between exogenous ketosis and endogenous ketosis.  

  • Endogenous ketosis is when we eat less than the body needs to maintain energy balance and we are forced to use some of our body fat to make up the difference.  
  • Exogenous ketosis occurs when we eat lots of fat (or take exogenous ketones) and we see blood ketones (beta hydroxybutyrate) build up in the blood.  

Ketones in the blood occur when you are eating more fat than you are burning.  Lower blood ketones are not a cause for concern as long as your blood glucose levels are also low (i.e. low total energy).

The reality is that we will all be somewhere on the spectrum between exogenous and endogenous ketosis.  We need enough energy to get through the day and not fade away.  

But keep in mind that most of the really good stuff that we attribute to ketosis and the ketogenic diet occurs due to endogenous ketosis when fat is coming from our body.  

We may not have high blood ketone levels in exogenous ketosis, but that’s OK because that’s where the good stuff.  

what should your blood sugars and ketone levels be in ketosis?

The ketogenic diet is still evolving and fertile area of research.  Even Keto Clarity co-author Eric Westman recently admitted that there is still a lack of clarity around what constitutes ideal ketone levels.[15]

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The chart below shows the ‘optimal ketone zone’ from Volek and Phinney’s Art and Science of Low Carb Living which is typically referred to as the ultimate guide to optimal ketone values.  The problem, however, is that it is difficult for most people to achieve “optimal ketone levels” (i.e. 1.5 to 3.0mmol/L) without fasting for a number of days or making a special effort to eat a lot of additional dietary fat (which may be counterproductive if you’re trying to lose weight).

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Recently, I had the privilege of having Steve Phinney (pictured below in our kitchen making his famous blue cheese dressing) stay at our place for a night when he spoke at a Low Carb Down Under event in Brisbane.

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I quizzed Steve about the background to this optimal ketosis chart.  He said it was based on the blood ketone levels of participants in two studies.  One was with cyclists who had adapted to ketosis over a period of six weeks and another ketogenic weight loss study.

In both cases these ‘optimal ketone levels’ (i.e. between 1.5 to 3.0mmol/L) were observed in people who had recently transitioned into a state of nutritional ketosis.  

Since the publication of this chart in the Art and Science books, Phinney has noted that well trained athletes who are long term fat adapted (e.g. the athletes in the FASTER study) actually show lower levels of ketones than might be expected.

Over time, many people, particularly metabolically healthy athletes, move beyond the ‘keto adaption’ phase and are able to utilise fat as fuel even more efficiently and their ketone levels reduce further.

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Urine ketone strips are often considered to be of limited usefulness due to the fact that the body stops excreting ketones as it learns to use them.  Could it be a similar situation with blood ketones (BHB), albeit over a longer period of time?

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As our blood glucose levels decrease, our ketones increase to balance out the fuel deficit.   When we have less glucose available our insulin levels go down, more fat is burned and blood ketone levels rise.  The chart below shows the sum of the blood glucose and ketones (i.e. total energy) from nearly three thousand data points from a broad range of people following a low carb or ketogenic dietary approach.

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[note: In late 2015 I pooled a range of data from myself and a number of people on the Optimal Ketogenic Living (OKL)  Facebook group.  After sharing this data initially a number of other people sent me their data.  Later, Michel Lundell from Ketonix agreed to share a very large set of anonymised data for me to analyse.]

On the left hand side of the chart, we have a low energy situation where insulin levels are also low.  The body will be drawing on stored body fat for fuel to meet the shortfall and weight loss will occur.

On the right hand end of the chart, we have a high energy situation from both glucose and ketones.  This high energy situation causes the pancreas to secrete insulin to control lipolysis (i.e. the release of fat from storage) because there is more than enough energy floating around in the blood.

It’s a slight oversimplification to say that the left hand side of the chart is endogenous ketosis (which is good) and the right is exogenous ketosis (which is bad).

We may or may not see high blood ketone levels when we go without food for a long period.  However replicating high ketone levels with high levels of exogenous ketones or an oversupply of dietary fat is not the same, even though both situation are called “ketosis”.

Based on this data it seems the body tries to maintain a blood glucose level of around 4.9mmol/L and a blood ketone level (BHB) of around 1.5mmol/L.  The table below shows this data in terms of average as well as the 25th percentile and 75th percentile points (i.e. 50% of the values fit between the 25th and 75th percentiles).

 

ketones (mmol/L)

BG (mmol/L)

BG (mg/dL)

HbA1c

GKI

BrAc

total energy (mmol/L)

25th

0.6

4.2

76

4.3

1.8

46

3.4

average

1.5

4.9

89

4.7

7.3

56

6.4

75th

2.1

5.6

101

5.1

14

66

12.9

blood glucose and ketone levels during exogenous ketosis

Some people come to low carb or keto for therapeutic purposes (i.e. to manage chronic conditions such as cancer, epilepsy, traumatic brain injury or dementia).  These people will benefit from high ketone levels to feed the brain when glucose cannot be processed due to high levels of insulin resistance.

Most people however do not require this degree of therapeutic ketosis, particularly if managing insulin resistance or obesity is the priority.  People using low carb to manage diabetes or weight loss goals may end up driving excess energy consumption and a lower than necessary nutrient density, both of which may be counter productive.

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People following a therapeutic ketogenic diet may be fuelling up with MCT oils to achieve high ketone levels and low glucose : ketone index values (GKI) value for therapeutic purposes.  Others will target high levels of ketones for brain performance.  Others will load up on exogenous ketones and glucose to ‘dual fuel’ the system for athletic performance.

One of the benefits of a low carb or keto diet is that it tends to eliminate a lot of hyperpalatable processed foods, and lowers insulin levels which help many people normalise their appetite and eat less.

The danger, however, with trying to drive exogenous ketosis is that it will lead to an energy excess situation which will drive insulin to remove excess energy from your bloodstream, which can worsen insulin resistance.

Even though we are getting most of our energy from fat rather than carbs, the body will still work to bring the total energy back towards optimal levels using insulin, and stop the release of stored glycogen and body fat until you have used up the energy in your blood from your food.  This is why Thomas Seyfried and Dominic D’Agostino talk about the benefits of a calorie restricted ketogenic diet. [16] [17] [18]

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blood glucose and ketone levels for weight loss and endogenous ketosis

Many people embark on a ketogenic dietary approach to manage their diabetes and achieve long term weight loss.  They want lower insulin levels to enable them to burn more body fat for long term insulin sensitivity and health.

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On the left hand side of the total energy chart below we have a situation where we are generating endogenous ketosis, meaning that our own body fat is being burned for fuel.  With a lower total energy level in our blood, our body needs to pull fat from our body fat stores as well as use up the excess stored fat and old proteins in our liver, pancreas, brain and other vital organs (i.e. autophagy).

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In order to understand what all this means I have divided the three thousand data points into five quintiles, from lowest to highest total energy.  For each quintile I have calculated the average, 25th percentile and 75th percentile blood ketone (BHB) value.  Half of the ketone values will fit between the 25th and 75th percentile values.

optimal ketosis

The key takeaway from all this analysis is that the lowest blood sugar levels are associated with lower ketone levels and a lower total energy.

quintile

average BG (mmol/L)

BG (mg/dL)

ketones (mmol/L)

total energy (mmol/L)

25th

average

75th

1

4.5

80

0.3

0.6

0.7

5.0

2

4.9

88

0.4

0.8

1.1

5.7

3

5.1

92

0.6

1.1

1.5

6.2

4

5.1

92

1.2

1.8

2.3

6.9

5

5.1

91 2.2

3.2

4.0

8.3

In the discussion above we see that the lowest risk of the modern diseases of aging and metabolic health occurs when we have a HbA1c of less than 5%.  Dr Richard Bernstein recommends a blood glucose of 83 mg/dL or 4.6 mmol/L as optimal.  It seems that as a general rule (maybe other than when we are fasting or aiming for therapeutic ketosis) being somewhere to the left of this chart is optimal.

You may not always be able to live at a very low total energy level, but as you fast or increase the spacing between your meals your total energy levels will decrease and you will get all the positive benefits of fasting.  (See How to Use Your Blood Sugar Meter as a Fuel Gauge and How to Use Your Bathroom Scale as a Fuel Gauge for objective measures to refine your balance between feasting and fasting to achieve your goals).

You don’t achieve optimal ketone levels by adding fat with super high ketone levels, but rather by managing your energy balance, carbohydrate intake, and meal timing so you can dip into endogenous ketosis on a regular basis through fasting.

When you do eat, you should try to maximise nutrient density to ensure you get the nutrients you need without needing to overeat.  Your blood ketone levels will decrease when you are using insulin to build and repair your muscles.  When you stop eating for a while you will see them rise again as fat flows out of storage.

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Anecdotally it seems that people who are very physically fit may find they have lower blood ketone levels.  Lower blood ketone levels (say greater than or equal to 0.2mmol/L) with low blood glucose levels seems to be a healthy place to be.

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In fact, you could even save your money on testing ketones and just focus on making sure your blood sugars are closer to optimal.

is it the ketones or NAD+ that is really doing the good stuff?

A smart friend of mine, Robert Miller, has been influencing my thinking recently around ketones.

Robert’s theory is that the benefits that people attribute to ketones are actually largely due to an increase in nicotinamide adenine dinucleotide (NAD+).[19] [20]

Adequate levels of NAD are critical to moving energy around our body, from our food to our mitochondria.[21]

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NAD+ declines with age, increases in fasting, during a ketogenic diet or in response to exercise.

When NAD+ rises, SIRT1 helps our body to repair and improve our insulin resistance.[22]

Our NAD+/NADH balance is critical to controlling our appetite and telling the body whether we need more fuel, or if it’s time to tap into our body fat stores.

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We can increase our circulating levels of NAD+ by eating a nutrient dense diet, particularly with adequate niacin (vitamin B3).[23]

There are also a range of NAD+ supplements that seem to have positive benefits for a lot of people.

Nicotinamide Riboside is a close precursor to NAD+ which can be helpful for people who struggle to make NAD+ directly from food.

Image result for niacel

However, Nicotinic Acid (i.e. full flush niacin) is a much cheaper supplement that will work just as well for most people.

NAD+ metabolism is a fascinating rabbit hole if you want to do some research, but for now let’s say that it’s important to have adequate NAD+ to enable your mitochondria to convert the food you eat to energy rather than having it back up in your body.

what about breath ketones (acetone)?

You will likely be aware that three separate types of ketone bodies:

  1. acetone (breath ketones),
  2. acetoacetic acid, and
  3. beta-hydroxybutyric acid (BHB in the blood).

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Fatty acids come to the liver either from our food or lipolysis (mobilisation of fat from our body) and converted to acetoacetate.   Unfortunately, we have no way to directly measure acetoacetate, only BHB in the blood and acetone in the breath.

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The Ketonix is a device that you blow into that measures the acetone which is akin to an exhaust that is released when you burn acetoacetate.

Special thanks to Michel Lundell from Ketonix for sharing the data and Alessandro Ferretti and Weikko Jaross for help with number crunching.

image27

Blood ketones (BHB) are the most well known form of ketone bodies.  There is some relationship blood ketones and breath ketones, but it is not direct.  The chart below is from a study Measuring Breath Acetone for Monitoring Fat Loss: Review (Anderson, 2015)[24] which states

“Endogenous acetone production is a by-product of the fat metabolism process… Breath acetone concentration (BrAc) has been shown to correlate with the rate of fat loss in healthy individuals…  A strong correlation exists between increased BrAce and the rate of fat loss.”  

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The Ketonix data shows a similar relationship but with a lot of scatter!

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Most people at this point throw in the towel and go back to blood ketones (BHB) which appear to be more reliable, but it’s important to note that breath acetone is a stronger marker of burning ketones for fuel, not just buffering energy in the blood.

What I’m trying to illustrate with the dodgy clipart in the chart above is that having high blood ketones and low levels of breath acetone appears to be a sign that you are not burning the fat you’re eating.

By contrast, a high level of breath acetone with a low level of blood ketones (BHB) and low blood glucose may be a sign that you are very effectively burning the fat you eat.

If you had a choice, I think it’s better to have high breath acetone (BrAce) and lower blood ketones (BHB) (which would indicate that you were efficient at burning fat) than high BHB and low BrAc (which would indicate that you were good at eating fat but not necessarily burning fat).

The figure below shows BHB vs BrAc for the different purposes that people nominate for using the Ketonix.  What we see is that people with diabetes (red trend line) have both higher blood glucose and higher blood ketone (BHB) levels (i.e. higher total energy).   Fuelling the mitochondria with the right nutrients that increase NAD+ will both help to burn off the excess energy and manage appetite through the NAD+/NADH ratio.

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The second law of thermodynamics states that the total entropy (chaos) of an isolated system can only increase over time.  The total energy concept is novel, but it seems that an organism that is aging will decay and not be able it’s energy packed in storage but rather we will see increasing levels of energy floating around in the blood stream.

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summary

  • Metabolic related diseases such as heart disease, cancer, stroke, diabetes, Alzheimer’s disease, kidney disease are the major causes of death.
  • People with the best metabolic health (i.e. low HbA1c, insulin and blood sugar levels) have the lowest risk of dying from these common western diseases of aging.
  • Keeping your processed and starchy carbohydrates low will help to keep your blood glucose and insulin levels and reduce your risk of obesity.
  • When we fast, our glucose levels decrease and ketones increase to maintain our energy levels.
  • People who are metabolically healthy and insulin sensitive typically have a lower level of total energy (i.e. glucose + ketones) in their bloodstream.
  • We can mimic the rise in ketones with added fats or exogenous ketones that we see in fasting, however the real benefits occur when the body is forced to draw on its own stored energy and we experience autophagy, upregulation of SIRT1, and a rise in NAD+.
  • The benefits that we generally attribute to ketones may also be due to increased NAD+ levels which occur in fasting and / or with a nutrient dense diet.
  • We can only measure beta hydroxybutyrate (in the blood) and acetone (in the breath). We can think the BHB as a buffer ready for use, and acetone as the exhaust showing that the ketones have been burned for fuel.  Higher levels of fat burning with a lower need for buffering is a better place to be than a high buffer in the blood and minimal fat burning.

post last updated May 2017

references

[1] https://optimisingnutrition.com/2015/06/29/trends-outliers-insulin-and-protein/

[2] https://www.researchgate.net/profile/Peter_Petocz/publication/13872119_Holt_SHA_Brand_Miller_JC_Petocz_P_An_insulin_index_of_foods_the_insulin_demand_generated_by_1000-kJ_portions_of_common_foods_Am_J_Clin_Nutr_66_1264-1276/links/00b495189da41714fa000000.pdf/download?version=vs

[3] http://ses.library.usyd.edu.au/handle/2123/11945

[4] http://www.cardiab.com/content/12/1/164

[5] http://www.nejm.org/medicine-and-society-data-watch

[6] https://intensivedietarymanagement.com/tag/hormonal-obesity-theory/

[7] http://carbsanity.blogspot.com.au/2011/09/24hr-profiles-insulin-secretion.html

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC329588/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC329589/

[10] http://wholehealthsource.blogspot.com.au/2009/12/whats-ideal-fasting-insulin-level.html

[11] https://www.ncbi.nlm.nih.gov/pubmed/11994907

[12] https://www.ncbi.nlm.nih.gov/pubmed/10535381

[13] http://emedicine.medscape.com/article/2089224-overview

[14] http://www.newhealthadvisor.com/Normal-Insulin-Levels.html

[15] https://www.facebook.com/AdaptYourLife/videos/vb.1608140252761871/1899686180273942/?type=2&theater

[16] http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0115147

[17] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

[18] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

[20] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852209/

[21] http://www.ketoisland.com/blog/all-aboard-nad/

[22] https://selfhacked.com/2015/09/06/nad-and-sirt1-their-role-in-chronic-health-issues/

[23] http://mitofuel.co.za/mitofuel/

[24] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737348/

[25] https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0009-2

[26] http://care.diabetesjournals.org/content/24/2/362

[27] https://en.wikipedia.org/wiki/Homeostatic_model_assessment

[28] http://www.thebloodcode.com/homa-ir-calculator/

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74 thoughts on “optimal ketone and blood sugar levels for ketosis”

  1. Any thoughts on physiological insulin resistance for those doing ketogenic diets over the long term?

    I have been doing a ketgenic diet (565 days+) with all days having a blood ketone fasting level over 0.5 or greater with the average around 1.8. Over time the levels are reducing while fasting glucose is rising. I still test my fasting blood ketone as over 0.5 but it tends to range in the 0.8 to 1.3 range. I am careful with my tracking so my macros are always 80%+ fat with low protein and carbs.

    Just curious to anyone’s thoughts on this……

    Thanks
    Stats: Female/36 yrs/5’8/117 lbs

    Liked by 1 person

    1. There are a number of possible issue here.

      This paper from Seyfried indicates that a ketogenic diet with excess calories can be an issue. If this was the issue then fasting or cutting back on total calories could be a consideration. It would be interesting to know if you were gaining weight as well as having rising blood sugars. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

      What about insulin levels? C-peptide? Is the pancreas burning out.

      I have also heard Peter Attia discuss this sort of thing but there isn’t much other detail about why a long term keto diet might not trigger insulin resistance.

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      1. “Excess calories”, but consider the source: KetoCal

        http://www.myketocal.com/ketocal4-1.aspx

        INGREDIENTS: Refined Vegetable Oils (Palm, Soy, Sunflower), Milk Protein (Casein, Whey), Soy Lecithin, Soy Fiber, Tricalcium Phosphate, Tripotassium Citrate, Arabic Gum, Inulin, Corn Syrup Solids, Sodium Chloride, Magnesium Acetate, Microcrystalline Cellulose, Calcium Chloride, Fructo-oligosaccharides, Corn Starch, Artificial Flavor, Calcium Lactate, L-Cystine, M. Alpina Oil*, C. Cohnii Oil**, Choline Bitartrate, L-Tryptophan, Sodium Caseinate (Milk), Silicon Dioxide, Potassium Chloride, Ferrous Sulfate, Sodium Ascorbate, LPhenylalanine, Natural Flavor, L-Valine, L-Tyrosine, L-Carnitine, Taurine, L-Ascorbic Acid, M-Inositol, Mono and Diglycerides, L-Histidine, Zinc Sulfate, Artificial Sweetener: Sucralose, DL-alpha Tocopheryl Acetate, Niacinamide, Calcium D-Pantothenate, Manganese Sulfate, Copper Sulfate, Thiamine Chloride Hydrochloride, Pyridoxine Hydrochloride, Riboflavin, Vitamin A Acetate, Folic Acid, Ascorbyl Palmitate, Mixed Tocopherols, Potassium Iodide, Chromium Chloride, Sodium Molybdate, Sodium Selenite, Phylloquinone, D-Biotin, Vitamin D3, Cyanocobalamin.

        Whilst they can be interesting, I really don’t like conclusions based on junk keto meal replacement stuff primarily based on processed ingredients and seed oils.

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      2. Noted Ash. Do you have any thoughts on why blood sugars might be drifting up while fat is at 80%. Personally I wonder if it might be better for long term health to run at higher levels of protein (with the proviso that your pancreas can keep up) to maximise nutrients.

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      3. Actually I have continued to lose weight my bmi is currently 17.6 so no weight gain and I eat at a caloric deficit, I weigh my food and track it carefully which is why I was curious about this specific phenomenon so that I look at any high correlations with changes in my glucose and ketone blood levels

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      4. Kathy, do you know if you get higher blood glucose levels with higher protein levels while keeping carbs low? There is heaps of useful nutrients in protein foods that would be good to maximise while keeping within the capacity of your pancreas to keep up. Have you don’t any matched ketone / glucose testing to know what your GKI number is? I would even be interested in adding your data points to this chart?

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      5. I stay on the super low end of the protein spectrum usually lower ranges for the therapeutic benefits of ketosis 30-45 g per day (under the 0.5 x lb/lean body mass).

        I have only increased my cals from fat when I went to under weight. Main sources of fat being mct oil, ghee, coconut oil, olive oil, avocado & avocado based products. I have started to consider keto supplements like ketocana but on the fence still.

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      6. Have you tried intermittent fasting to reset insulin sensitivity? Seems your insulin load is pretty low though so that’s unlikely to be a problem.

        I think it’s probably ideal for most to be at a higher protein intake to increase nutrients, though if you need the therapeutic benefits of keto that’s a whole different issue.

        I think the KeotoForce KetoCaNa is fascinating technology! I got the KetoCaNa in the mail the other day. I have tried it twice. Just a little seemed to kill my appetite for the day! My type 1 diabetic wife tried it and it gave her gut upsets (autoimmune – more sensitive). I’m looking forward to experimenting with it in the future.

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      7. Can’t seem to reply to your reply directly, dunno where this will end up in the stream…

        In the “keto science” communities we’ve come to a gentleman’s agreement to refer to it as adaptive glucose sparing as the term insulin resistance is too scary – much like many medicos and nutritionists are still freaked out by the term ketosis by conflating it with ketoacidosis.

        Eventually it’ll be more widely accepted the nature of insulin:glucagon ratios and such, and why protein can be insulinogenic and even raise blood sugar somewhat, but it’s not really an issue in sane amounts.

        I’m guessing you’ve been following the Unger stuff already.

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      8. Have seen a video by Unger on type 1. Interesting stuff.

        My main interest with protein being insulinogenic is for type 1 diabetics calculating their doses, but I think it’s relevant to some degree for type 2s who might benefit from moderate rather than high levels of protein to manage blood glucose levels.

        Is there any further keto science out there on blood glucose levels drifting up after a long period on strict keto? Jimmy Moore is another interesting case in point. I don’t think it’s a big deal if everything else is going along fine. It would seem to just be a way that your body decides to run at higher blood glucose levels?

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      9. Yeah I’ve been asking for more N=1’s from T1s with regard to protein intake for a while. From a purely observational standpoint it seems like mostly a non-issue. In T2s I don’t see how it could be an issue, if you’ve already got your carbs down to ketogenic levels the amount of protein you consume is never going to have any real effect on BG/insulin – relatively speaking. Some might benefit from an intervention period of a week or month of 4:1 keto, but for the most part cutting the carbs is going to do 90% of the work.

        There’s a fair bit of stuff out there regarding “physiological insulin resistance” and BG float. Again it’s something we’ve come to redefine as benign in the absence of exogenous carbohydrates at worst, and likely a beneficial trade-off in the long-term.

        As for Jimmy – I respect what the guy has done for the community overall, but I’m over the fascination and don’t really consider him an N=1 to follow. 3 years ago I wrote of my misgivings about him probably about to become “our” new ambassador: https://www.reddit.com/r/keto/comments/v2owk/after_8_years_as_a_lc_guru_jimmy_moore_finally/c50rxk1

        Liked by 1 person

      10. I suppose my interest in the GNG issue was sparked by seeing a lot of type 1 diabetics struggling to manage their blood sugar response to protein.

        See this draft article for more on that – https://www.dropbox.com/s/1cl533l2dzb1dzy/Advanced%20dosing%20for%20type%201s.docx?dl=0

        Agree that the nutritional value from protein is highly desirable, but in the absence of exogenous medicating it seems to be a balancing act between maximising nutrition and overloading the system.

        Type 2s certainly seem to struggle to deal with protein more than healthy people. See https://optimisingnutrition.wordpress.com/2015/06/15/the-blood-glucose-glucagon-and-insulin-response-to-protein/

        It’s interesting to note that Metformin works by limiting GNG! http://www.nature.com/nature/journal/v510/n7506/full/nature13270.html

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      1. There’s not a lot written on PIR, however it usually refers to what happens when someone who is eating low carb then goes and has a significant amount of carbs and their blood glucose levels shoot up.

        This is not the case for Kathy as she is just continuing with her therapeutic keto diet.

        The issue could be pancreatic burn out which the c-peptide test would confirm.

        I also wonder if someone at extremely low protein (i.e. very low glucose) is not getting the nutrition they need and this can lead to other issues.

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      2. I plan on increasing protein a bit and tweaking a few other items (IF I have experimented with but didn’t find an impact on trend line; tried the true fast and tried the modified version with bulletproof coffee).

        I feel great health wise no issues with energy, mental clarity, sleep etc. (with some data & tracking ocd still lurking lol)

        Another interesting correlation I will throw out there to see if anyone else is quirky. When I travel for work (flying only car rides do not do this) my ketone levels sky rocket even as I increase water greatly I assume it has something to do with dehydration.

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    2. I’ve just got a glucose meter. And I am still working my way through manual. Lol. But I think I should have got one that tests for ketones too. Although I read somewhere that you can get a good idea just from blood glucose. Oh and I’ve got pee strips. Which are showing deep purple. Do you think I can just track blood glucose or should I shell out for the ketone meter to get my ketone /glucose index
      Can’t wait till someone just makes an iPhone app to do this.

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      1. Ketones are interesting but I think is probably ideal to focus on get get your blood sugar down initially. The chart in this article will give you an idea of what your ketones might be.

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  2. I think this a really useful development of your thoughts. I will certainly be using the GKI ratio myself, to see how I go. My recently started ketone tests seem to vary quite a bit: I don’t know if that is a common exoerience,

    I am a 62 yr old T2 DB in the UK, who is managing my diabetes with LCHF, fasting and HIIT exercise. I am a retired engineer (so I can make time available), and feel much more comfortable to work with some numbers that mean something to me. I have only recently started measuring ketones: the “ketone” label scared me off, until I educated myself. Last HbA1C was 5.1% (32) and my general wellbeing is transformed. As time goes on, I am looking much more at the wider health benefits of LCHF and a ketosis diet, and not just T2DB management.

    As a T2DB, I have often wondered what is the balance of my diabetes, between insulin resistance and low insulin production.

    One of the problems in the UK is that the tests available are fewer than in the USA. It is very difficult to get even one fasting insulin test, so something that is proximal is very useful.

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    1. Thanks Dave. Let us know how you go. I’m eager to add to this dataset as I think understanding the relationship between ketones and glucose is useful, even if just to save money on ketone testing.

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  3. GREAT blog.
    What time of day are the ketone & glucose levels tested? Are these fasting (am) levels?
    I am in very similar situation as Kathy above.

    Liked by 1 person

    1. Correct, I take my levels completely fasted in the morning so that mct oil and other ingested fats are not contributing to the blood ketone levels.

      My fasted state is usually 12 hours + with my last meal around 6 or 7 at night.

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    2. I was usually testing in the morning before food, but sometimes during the day too. I agree that it’s probably better to test in the morning for consistency without the food having an impact. Although I found typically my ketones increased through the day.

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  4. Thank you for the time you spend in putting together this information. Unrelated but the mention of Rosedale reminded of a question re exercise. Rosedale says you should exercise after meals to burn the excess, Keifer says resistance exercise before exercise is optimum for T2. Before or after, what do you think?

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    1. Rosedale and Kiefer are pitching at two very different audiences. Depends if you are sick/diabetic/obese or bodybuilder/figure competitor. A lot of Kiefer’s stuff is about getting an insulin surge to build muscle after periods of extremely low insulin. Most people just need to drop some weight and reduce their overall insulin load.

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  5. I think the priority for type 2s would be to do some training. So whenever it works for you and feels good is probably the priority.

    Resistance training will burn through glycogen stores which are going to be full for most type 2s regardless of whether it’s before or after.

    For bodybuilders he’s saying to work out fasted and then eat afterwards to stop the ongoing breakdown of the muscles. Not as much of a priority if you’re not walking around most of the day with depleted glycogen.

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    1. If fasting insulin levels are low (say 3uIU/mL), how can you be certain it may not be bcs your pancreas is unable to secrete enough insulin to keep glucose levels in check (like with Kathy’s gradually increasing FBG numbers)? Is the only way to know is with C-Peptide test and/or GAD65?
      Would they be definitive?

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      1. Yeah. I’m not a doctor, but a c-peptide test seems logical to confirm that the pancreas is still functioning. If Kathy is using keto for therapeutic purposes (autoimmunity) it is possible that the same issue is also degrading her pancreas.

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  6. Hi I’ve just recently been on the ketogenic diet for about 6 months working with Dr. Fung because I have type 2 diabetes and not sure if I’m Keto adapted or not yet. This morning I tested my ketones and they were a 2.7 mmol and my blood glucose was a 6.0 mmol. Any thoughts as to why this is since I thought if ketones went up blood glucose should go down? Could it be that my body is still not Keto adapted?

    Thanks,

    Eric

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    1. Lots of people benefit from keto initially. Eventually you will want to see if you can build up your protein levels slowly to a point that you can heal your body and improve your insulin resistance with good food as well as fasting.

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  7. Well look and you shall find. My fg was 90 ies with less than .5 ketone. A1c 5.7, so today i did glucose and ketone 2.5 hr after my lg meal. Glucose 84 (4.6) and ketone .7. With a GKI of about 6.6. Does this sound right, maybe im missing something, but I’m pretty sure im keto adapted. I need positive feedback, my A1c has got me bummed. Also, fg seens to be higher than evening glucose.

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  8. Hi Marty.

    Keep up the good work I find your stuff very useful.
    My 2 cents on Glucose/Ketones.

    I have been restricting carbs for about 2 years now but have found it difficult to get ketones much above .5 mmol/l, even with glucose around 5 mmol/l. This was eating 1 or two meals a day and snacks.

    This changed dramatically when I went to 1 meal/day and fasting for 2 days/week. Ketones went to and stayed between 2-5 and glucose dropped further to about 4.6.

    Seems like a harsh regime but it actually isn’t. I never feel hungry weight is stable, I look forward to the fasting days as energy goes up and my mood elevates.

    We will see.
    Thanks for all your info.

    Tim.

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  9. Very interesting piece. I was directed here after increasong ketone levels. I eat a Low Carb High Fat diet, and do not fast as such. Some days I may naturally do intermittent fasting, just due to lack of hunger. My blood glucose levels have consistently been in the 3s, and my ketones are usually in the mid 2s at their lowest, but over the last few days have been in the 4s and even as high as 5.2.

    Liked by 1 person

  10. I am a bit concerned as my fasting is 76 and would not rise above 78 even after I eating and would remain between 76 and 78 all day unless I dont eat or if I eat a low fat meal. I have tried researching but I have not come accross a definitive answer as to why fasting/not eating would raise my blood sugar. I have been on the ketogenic diet for 2 months now and would like some advice.

    Thanks,
    Regards
    Vivian Peters

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  11. Hello Marty,
    I’ve been doing Keto since Sept. In the past month I have started IF – usually 24/1 eat lunch only with a tea for breakfast with a tb of coconut oil or MTC. I have no medical issues other than overweight. My BG is always around 3.4- 3.6 and ketones get as high as 7.1
    Is this ok?? I’ve asked this question on so many fb pages and no one seems to be able to answer me – I am hoping you will.
    Thank you so very much!!
    Sheila

    Like

    1. Do you feel and look OK? That level of ketones would be of more of a concern if your BGs were high too. Seems your insulin levels are very low. If your insulin levels are too low then you may be losing muscle mass and too much weight. If this was as problem you could see how you feel with a bit more protein and green vegies.

      Like

  12. I’ve been doing low carb for about 4 months now and I have lost over 70lbs. I’m pretty sure that I am/was insulin resistant. I have done two fast so far, one lasting 7 days and the other 4 days. I usually IF daily if I’m not doing a water fast. My question is, I saw a video by Dr. Jockers that stated that you’re not in NK with a bg of 80 and above. My fbg is usually 79-84 again unless I’m on the water fast. My bg is usually 65. Is a bg of 83-87 optimal for nk? What would the ketone be? I dont have a ketone meter.

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    1. The table above shows the relationship between Ketones and glucose. Sounds like you’re in a pretty great place. If you try to chase higher ketones with more dietary fat you may stall your fat loss. Glucose may come down a little but more with more fasting and weight loss.

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  13. Are you still wanting GKI numbers? I’ve been tracking the past 3 weeks and will continue for a while yet. Average seems about 5 which seems great but I’m T2D with NAFLD so must be IR?? Expected a higher number.

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  14. Hi

    Please can people comment on the best time to test. I understand the best time in the morning fasted but not sure I understand why. Wouldn’t it be better to test after eating? And if so at what point?
    Thanks charlene

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  15. Marty I am a type 1 diabetic (25+years) and recently started measuring my ppm acetone every morning (ketostix). How do I use this information and what is it tell me about my LCHF diet?

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    1. Keeping minimal ketones in the urine mean you have adequate insulin on board so as not to be going into ketoacidosis. It’s more your blood sugars that will help guide your food choices.

      Like

  16. Great post! Quick question…

    I was always under the impression that eating globs of fat would only prevent the body from burning it’s own fat but that it still wouldn’t affect insulin whatsoever.

    Are you saying that the production of ketones is not demand-driven but more so supply-driven, and that more fat consumed = more ketones in the blood = higher insulin response?

    Also, in regards to PSMF, would 0.8g/kg prevent LBM loss in the absence of carbs/fats, or is it necessary to raise protein?

    Like

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