I will talk about ketosis tonight – everything you wanted to know and everything that I want to know. I’m going to end with the question of whether we probably should just all be in ketosis all the time. I’m beginning to wonder, and you’ll see my reasoning.
My background
I didn’t come to this through any great personal experience. I came to this area of scholarly work through my patients. We learned in medical school that ketosis is bad; it occurs in cases of uncontrolled diabetes. This is pretty much still the current teaching today. Even over the last 20 years, we’re teaching young doctors and health professionals that ketosis is bad, that it’s all one thing, when it’s not all one thing. Monitors started coming out, not just the urine ketone measurement but now the breath and the blood ketone measurements, which are being done fairly routinely by a lot of people way before any clinical research is being done. This is an area where your experience and other people’s experience – the lived experience – is way ahead of the scientific research and what is thought to be worthy of being studied at the moment, sadly.
Nutritional ketosis vs ketoacidosis
What we know now is that when you’re not eating carbs or when you’re not eating anything for a few days, all humans go into ketosis or fat burning. It might take a few days, but when you don’t eat, we have already stored fat on our bodies and you start burning your body fat. Some of that fat turns into ketones and that’s called nutritional ketosis. If it’s so bad, why do we all do it, or have the capability to do it? The level of ketones when you don’t eat carbs or when you don’t eat food is much lower than the level of diabetic ketoacidosis, which is what doctors are taught ketosis is. DKA, or diabetic ketoacidosis, is very different from nutritional ketosis, which is what happens when you don’t eat carbs or you don’t eat any food for a few days. The levels are very different.
The reason you get acidosis added on to the keto part of it is that the ketones go so high, and ketones are an acid that the blood becomes acidic. The blood pH of the acid-base balance is so regulated; you feel sick when you’re out of range just a little bit. There is no acidosis in nutritional ketosis. The name is not nutritional ketoacidosis; it’s nutritional ketosis. There’s no acidosis. That’s the major difference between what we’re being taught and teaching doctors and nurses in medical education, and the reality of what happens to you when you don’t eat carbs. It’s a very different thing; you’re not sick. Even if you had diabetes, you might even have elevated ketone levels. If you’re getting insulin in some way, you’re not going to get that acidosis. So please don’t worry about diabetic ketoacidosis when you’re not eating carbs. It’s a very different thing.
Ketosis itself is really just fat burning, once your body starts burning its stored energy. We store energy as fat and a very small amount of sugar is stored. A way to think about that is we have a teaspoon of sugar in our blood at any given moment and we have 48 teaspoons of sugar in the form of glycogen in our body stores (liver and muscles). That’s about 2,000 calories, or a day’s supply of glycogen. We can have a year or two-year supply of fat on our body. It’s really unlimited as a storage form of energy. The body draws upon its own fat stores under certain circumstances: total fasting, not eating at all, and then also if you’re not eating carbohydrates. Your body will revert to that ketosis, body fat burning first, and your hunger goes down. You eat less, you lose extra body fat if you have that on your body. Then you get to an equilibrium where what you eat is what you burn, and you store a little bit and burn a little bit. You get into this balance; a fat-burning situation. When you’re eating food that allows you to burn fat, you will at some point normalize or have your body be at an equilibrium of fat storage and fat burning.
For me, now, after 20 years, I don’t really think too much about how much food I eat because I mainly eat zero-carb foods with some vegetables here and there. That’s another thing: if you’re just starting this and you’re looking at the food list, it’s not a requirement to have all those different things on there. You choose what you like from there. At first, we do recommend two cups of leafy greens and one cup of a non-starchy vegetable to meet the guidelines that other experts have about fiber and other nutrients. I don’t enforce that in my clinic. If you end up coming to me eating eggs and other sources of animal protein and fats, I don’t really hammer on or enforce that you have to have the leafy greens and the vegetables every day. If you hate those things and you’re getting excellent nutrition otherwise, I don’t think it’s an absolute must. Even though at first, we teach that you should be under or in that range to get started – we want to make that transition as seamless as possible.
How excess sugar affects our bodies
We have a very limited amount of sugar in our body and a limited ability to store sugar. If you have a little bit of extra sugar and you can’t burn it off by exercise or a fast metabolism, your body is going to turn that sugar into fat. A lot of that happens in the liver and in the fat cells, themselves, which gives this all confusion when it’s really not all that confusing. If you have extra energy going around and it’s in the form of sugar, and your sugar stores are full, somehow it has to become fat. That’s just logical. This is where you now get fatty liver – not because of the fat in the food, but because it’s a carbohydrate being turned into fat. I was reading some summary articles about fatty liver and there’s still that old idea that saturated fat in the food will become the fat in the liver. I think that’s true under some circumstances, but it’s not the garden variety person who’s overconsuming carbs in our real world today. It’s an artificial research situation that’s inappropriately applied to today.
The other thing about carbohydrate eating and the insulin rise after eating carbohydrates that has to do with ketosis is that a very small rise in insulin turns off ketones. If you have ever been in the medical world, you may have treated people in the hospital with diabetes and diabetic ketoacidosis. What happens is you put people – diabetics in ketoacidosis – on an insulin drip into the vein and you watch the blood sugars and the ketones come down. You don’t want to do it too fast, but you are actually suppressing the ketone production by that insulin in the vein or IV in the intensive care setting. It also happens when you eat carbs every day. Insulin comes up as a response to eating carbohydrates – the blood sugar goes up and then insulin goes up to lower the blood glucose. That insulin also turns off the ketone production, the fat burning. That’s why some people who get in the mode of just eating carbs, can’t burn the fat and their body stores the carbs as fat. You get into this slow progression of weight gain over time. Those are things that happen with fat burning and or ketosis.
The metabolic processes and the labs that are being checked look different. If you think about it, it’s not “normal” to be in ketosis if you eat carbs, and you have insulin going around all day. If you get a lab value, you’re going to be outside the normal range if you have ketones in the blood, even though it’s normal for you. It’s normal if you’re in ketosis to have some ketones, but it’s not normal for those who eat carbohydrates. The lab values will give you the benchmark of what happens to those who eat carbohydrates, and your labs may not line up into that “normal” range.
Cholesterol levels
We’re also learning that the cholesterol levels are different. The cholesterol processing when you don’t eat carbs is fascinating. You’re not making as many triglycerides or fat molecules in the liver, so you’re not having to export these fatty acids, fat molecules, from the liver into the blood. You make much less VLDL – a carrier of these triglycerides – so that the triglyceride level in your blood goes way down. Your liver isn’t making as many triglycerides and having to put the triglyceride into these VLDLs that get sent around.
Almost once a day someone comes to my office with lab values either in the computer or hand-printed out to go over and compare them. Very few questions are about ketosis or ketones because no one’s really checking ketones in the blood. Those cholesterol levels are being checked everywhere, and people are ready to quickly shoot down the keto diet because of the cholesterol. We can use really shoddy science that’s not even science, and everyone says, “See, I told you.” So, don’t worry about cholesterol levels. Talk to us here in the group or other keto-friendly doctors. The cholesterol levels, the metabolism, is different. I think we’re almost now at the point where someone comes in and says, “My cholesterol went up,” and I’ll say, “Good!” and then just leave it right there because I’m now balancing the emotion that doctors are using today. There was a doctor who was like doing thumb screws and fear-mongering about this LDL level that was gonna kill you, and you gotta go on this drug. If you’ve been in the group a while, you know this is the recurring thing that just doesn’t seem to go away. If you’re new to the group, don’t worry. Don’t get your labs checked for cholesterol until you’re near your goal, as the mere fact of losing weight can perturb the cholesterol levels, and by the time it goes down, most of the time, all of the values actually look better.
Interesting sidebar on the cholesterol levels – even on low-fat diets, while you’re losing weight, the cholesterol can go up. No one calls out, “Oh, see, that low-fat diet is bad for you!” That was published in our first randomized trial paper back in 2004, where we monitored people on a low-fat, low-calorie, and a low-carb diet for six months. It was one of the first randomized trials of its kind, and then it got replicated all over.
Hemoglobin A1C
The other one that we’re very interested in learning more about is the hemoglobin A1C. This is a three-month marker of blood sugar, and it’s now being used as the shortcut to diagnosing diabetes. Hemoglobin A1C is quite a complicated test. It relies upon the red blood cells, the lifespan of red blood cells, and the quality and health of the red blood cells. If you have a problem called sickle cell anemia or thalassemia, red blood cells aren’t normal, so the hemoglobin A1C test will be totally inaccurate. We’re now seeing some people with even a zero-carb diet like a carnivore type diet have A1C levels that you would expect in pre-diabetes. The blood sugar levels also aren’t as high as you expect them to be if someone was a carb eater with that same hemoglobin A1C level. Hemoglobin A1C and the diagnosis of diabetes and all these other health conditions are being done under the conditions of eating carbohydrates, and you don’t want to falsely use those benchmarks to compare yourself to.
There are some things like the blood sodium, for example, that is tightly controlled under any nutritional circumstance that I know of. But things like cholesterol is a metabolism that can change. Dave Feldman personally has a high LDL level – he started talking to other people about it, started a Facebook group, and now has a study following people with elevated LDLs, actually getting sent to LA for one of the highest-level quality CT angiograms. It’s not the CT calcium score; it’s a test where you can actually see inside the artery. They now have a hundred people enrolled in this study and they’re going to follow them for a year, then repeat the scans to see even with these super high LDL levels, do they have some disease progressing, or does it stay the same, or does it get better? We really don’t know. If you have any concerns about your cholesterol level, I get information from Dave Feldman at cholesterolcode.com.
Other blood tests may not really be reflective of diabetes because actually you’re fixing the glucose-insulin pathway, unlike any carb eater. You’re reducing the glucose and insulin domain and that axis, if you will, unlike any carb eater being represented in that “normal” range on that lab test. If you fall outside that normal range, it may not be abnormal. It might even be better. That’s a theme that I’m picking out through lots of different snippets of information. In fact, it succeeds now to me that these artificial guardrails of “You can’t go beyond an LDL of blank,” was one of the reasons why this area had never been studied. Another guardrail was that you can’t go beyond ‘x’ percent of fat in the diet. My goodness, what would happen? Researchers were actually artificially contained and confined by these taboo levels that you couldn’t go beyond. It’s very interesting. That’s why the grassroots, you all doing this, finding that it works with monitoring if needed, are really pushing the limit of knowledge.
If you want to participate with your labs, or you’re just curious, or if you don’t want your lab to be found by the insurance company or a doctor, Dave Feldman started a company called Own Your Labs. The idea there is, you sign up; you don’t need a doctor’s order, you go to a LabCorp site, and they draw your blood. It goes to Dave’s company, you go onto their portal, and you get access to your test results. No one else can see it without your permission. You can opt-in to an anonymous research database of what is the normal range of someone who doesn’t eat carbohydrates. Dave has picked up on a pattern with hemoglobin A1C levels. You might ask why I don’t know those levels from my own patients? Well, I don’t have a hundred percent adherence. Can you believe it? Not everyone who comes to my clinic wants to do a keto diet or even knows why they’re in my office. I’m in a practice where people are referred to me, and sometimes they don’t even know why they’re referred, and I set that up on purpose because I wanted to be able to learn within the insurance pay system so that people aren’t super rich, paying out of pocket, or highly motivated, and I’ve learned a lot.
One of my patients taught me that he could lose a massive amount of weight just eating at McDonald’s, and it never would have occurred to me to say, “Hey, just go to McDonald’s and don’t eat the bun or the fries or sugar in the drinks.” I’ve learned a lot, and I learned a lot from your experiences as well. In my clinic, I’m constrained by the insurance company payments for things. I have a minimalist approach where I don’t want to cause someone to pay more out of pocket. I don’t have a full set of labs on everyone who’s come to my clinic, and then I don’t have the perfect knowledge about people following it, like a ketone level or a blood level. That’s why formal investigations like Dave Feldman’s and others like the Virta Health study are so important because they track almost everyone down and have better follow-up to know what happens with these different labs.
Everyone enters ketosis after not eating
I was watching the show Naked and Afraid, which is like Survivor. These people are out in the middle of nowhere, they don’t really eat anything, and they lose a pound a day, on average. The bigger people lose two pounds a day. You see in real-time what happens when people become fat burners. I’m told there’s one episode of Alone where someone said, “I’m in massive ketosis; this is great.” Most of the time they don’t talk about ketosis. We store fat on our bodies, and so when you don’t eat, you have to find some fuel on your body. The blood glucose is maintained by a hormone called glucagon, and you don’t need to eat carbohydrates, and you’ll have a blood glucose that’s pretty steady. If you do prolonged fasting, say 30 days, 60 days, 90 days, let’s say someone truly is starving to death, then the glucose levels will come down. And yet, you could still be awake and alert. I don’t want to go that far. I don’t want you to even do Naked and Afraid starvation for 21 days. I don’t think we have great information that that’s a great thing to do. But it’s just the idea.
If a computer is low on energy – what happens on mine anyway – is a message pops up asking, “Do you want to go into low energy mode? Your energy is low; hook it up to energy,” or “Do you want to go into safe mode?” I say, “Sure, let’s go into safe mode.” Ketosis, burning the fat off your body, is basically like safe mode on your computer. It’s an efficient way to use the stored fat that you already have. I think it could be argued that we store fat on the body because it’s a more concentrated source of energy. You get more calories, more ATP, and more energy molecules out of a gram of fat than a gram of carbohydrate. It’s a more concentrated source to store the energy that’s available for us, and so we go and we use ketones. Ketones are a fuel molecule, where glucose is typically used if you’re a carb-eater and a carb-burner.
It could be that over time you adapt so that there are no ketones in the urine, which would make sense because it’s an energy molecule – if you’re conserving all of your energy, that first ketosis that you see in the urine will probably go away. You also don’t normally see glucose in the urine. It’s only when the elevation of blood glucose is 180 mg/dL (10.0 mmol/L), which is a pretty high diabetic range.
Everyone goes into ketosis when we don’t eat for two days. Everyone. The first thing we could do is prove that although it’s maybe like proving the sun’s going to come up tomorrow, it’s very likely. Everyone goes into ketosis. How can that be bad for you? What system would be created or evolved that when you didn’t have food around you’d self-destruct and go into ketosis, which is harmful, and you just wither away? No, a system that would survive long-term or be designed by a human would turn the organism or the computer into a more efficient machine to draw upon its own energy. This wouldn’t be harmful. In fact, if anything, it’d probably be less harmful because you’re not getting the daily vitamins and minerals and energy.
Should we always be in ketosis?
Is ketosis really the state we should be in all the time? I had to be sure scientifically that it was okay for humans not to eat carbs. One of the first things that I made sure was that there were multiple experts and good data in humans to show that there is no need for humans to eat carbohydrates. You can make all the molecules you need and get all the vitamins and minerals from other foods without eating carbohydrates. The other way to say that is there’s no essential (meaning you have to eat it) carbohydrate. Flipping it upside down, do you have to eat carbs? Then, how many carbs are better or worse or optimal?
I’m pretty sure we’ve all come through the lens, the human experience, of eating carbs and now we’ve cut them back. Children and babies are born in ketosis, they’re not eating carbs; they’re actually in ketosis. It’s the consumption of carbs that blocks ketosis. At the Low Carb Denver meeting, I met a speaker who had been featured in National Geographic and a nurse practitioner who measured her own breast milk as she was nursing her child. You can send away your breast milk to a lab at UCLA for a small fee and they calculate all of the different components. I saw her at Keto Salt Lake the year before, and then she came to Denver and had assembled her information in a spreadsheet of her breast milk under different conditions. I got the two of them to briefly speak about this and actually it was his thought that the lactose and the breast milk isn’t used by the baby, it’s used by the gut bacteria. This was news to me, but he said he uses lactose to ferment things, and cultures around the world would use that milk to ferment, so the bacteria use it. He asked the nurse practitioner, “Did you check the ketones?” And she said, “Yes, a couple of times. My baby’s ketones mirrored my ketones in the blood.” I’m not a neonatologist, I’m an internist, so I don’t know a lot about babies and neonates especially. The idea that lactose in the milk would turn off ketosis was really interesting. I knew based on a couple of residents, who had done our rotation and had looked at breastfeeding, that the breast milk was qualitatively different. There was more fat if you were a keto mother breastfeeding the baby. The idea that you’re actually feeding the gut bacteria with the lactose, the baby could really still be in ketosis while breastfeeding, especially if there was more fat. The mom who was breastfeeding was keto.
I then saw Laura Buchanan, a young doctor who trained in Winston-Salem, North Carolina with her husband Matt Calkins, and she’s pregnant now. She’s having a keto baby. They’re in their mid-30s, and they’ve come through my clinic, and they’re all on fire about using keto diets in their practices. I first heard about keto babies and keto moms when I was at a conference in Indonesia. A dad reasoned that he should put his son with cerebral palsy on a keto diet. I hold that information and don’t give talks and write home about it as policy because it’s still kind of hearsay evidence, but it’s real. In a Muslim culture, during Ramadan, a lot of the people don’t eat during the day and then do keto at night. The idea that even for pregnant women and moms breastfeeding it’s okay to be fat burning is growing and growing. Yet, the politics of saying this in the Western World with the litigious society that if something happens to a baby that you’re outside the medical establishment mainstream teaching, it puts a kibosh on people saying, “It’s okay, don’t eat carbs during pregnancy.” We were so close to getting an OB GYN group to get started studying this. There was someone who reached out to us, and yet, then the pandemic hit, and I haven’t heard from them since. But babies are born in ketosis; mothers can have children without eating carbs. I’ve treated people in later ages, and they’re in ketosis; it seems fine. It’s the default way of being, really. If you don’t eat anything for a day or two, you’re going to be in ketosis. How can that be bad for you?
Watch the full video here.