Ketoacidosis

Nutritional ketosis is a normal, physiological response to carbohydrate and energy restriction.  A ketogenic diet is an effective weight loss strategy for many.  Ketoacidosis, on the other hand, is a pathological condition caused by insulin deficiency.  The common theme is low insulin; however, in ketoacidosis, blood glucose levels are very high.  Ketone levels are elevated in both states, although are 10-20x higher in ketoacidosis (~0.5-2 vs. > 20 mM).  Nutritional ketosis and ketoacidosis should not be confused with one another, and a ketogenic diet doesn’t cause ketoacidosis.

In ketoacidosis, gluconeogenesis occurs at a very high rate and the lack of insulin prevents glucose disposal in peripheral tissues.  Skeletal muscle protein breakdown contributes gluconeogenic substrates, exacerbating the problem.  This can cause blood glucose to reach pathological levels, exceeding 250 mg/dL.

Brownlee’s unifying mechanism

Brownlee, 2005  (technically, this figure shows the theoretical mechanisms underlying the pathology of the long-term effects of moderate hyperglycemia [<180 mg/dL]; not the acute effects seen in ketoacidosis…)

In people on a ketogenic diet, blood glucose levels are not increased.  This is an important aspect differentiating nutritional ketosis from ketoacidosis.   Yes, gluconeogenesis is modestly elevated to partially compensate for the reduced carbohydrate intake…  it only partially compensates for the reduced carbohydrate intake because some tissues decrease their glucose utilization, relying in fats and ketones instead (ie, less glucose is ‘needed’).

DKA

From: Sumithran & Proietto, 2008

Ketone bodies are produced when glycolysis is low & hepatic fatty acid oxidation is high.  Low glycolysis is important because certain byproducts of glucose metabolism inhibit fatty acid oxidation; eg, citrate inhibits CPT-1, which prevents fatty acids from entering the mitochondria.  Also, instead of being available to combine with the acetyl-CoA derived from beta-oxidation, oxaloacetate is instead being used for gluconeogenesis; this doesn’t happen when glycolysis is high.  Ie, oxaloacetate would be be available to shuttle fatty-acid derived acetyl-CoA into the TCA cycle (and away from ketogenesis).

Ketogenesis is significantly higher during ketoacidosis, and certain ketone bodies are acids –> acidosis. ketones

This doesn’t occur during nutritional ketosis because the excess acidity is easily buffered.  Hyperglycemia in ketoacidosis causes dehydration because when glucose levels exceed ~180 mg/dL, some is spilled over into urine causing osmotic diuresis.  This exacerbates acidosis and doesn’t occur in nutritional ketosis because there is no hyperglycemia.pathogenesis

Type 1 diabetics are susceptible to ketoacidosis due to insulin deficiency.  Despite this, there are numerous examples showing ketogenic diets are safe for type 1 diabetics, suggesting the diet itself is not the major precipitating factor.  In fact, some type 1 diabetics do quite well on ketogenic diets.

Type 1 diabetes and epilepsy: efficacy and safety of the ketogenic diet (Dressler et al., 2010)

Successful treatment of type 1 diabetes and seizures with combined ketogenic diet and insulin (Aguirre Castaneda et al., 2012)

Safety of the ketogenic diet has been demonstrated in numerous short-term studies, but also in this very long one in two patients with type II bipolar disorder (>2 years). (yeah, only 2 patients; but also: over 2 years).

keto food pyramid

What is a ketogenic diet?  Carbohydrate & energy restriction.  For example,

Johnstone and colleagues (2008): 4% carbs (<20 g/d), 30% protein (130 g/d), 66% fat (127g/d); 1732 Calories.  They maintained plasma ketone levels of 1.5 mM primarily because of carbohydrate restriction.

Sumithran and colleagues (2013): 50% carbs (65 g/d), 35% protein (46 g/d), 17% fat (10 g/d).  They were able to maintain plasma ketones of 0.5 mM primarily because of severe energy restriction: 525 Calories/d.

Ketogenic dieting is safe, and can be beneficial.  Ketoacidosis is pathological, and can be fatal.

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  • Eddie Mitchell

    Diabetics, and even some health professionals, often confuse two quite distinct metabolic processes – ketosis and ketoacidosis. Ketosis is a perfectly natural and healthy state during which the body uses stored or dietary fat for fuel. In order to enter this state, carbohydrate intake needs to fall below a certain level. Ideally, a healthy metabolism should regularly use ketosis, while fasting overnight for example, to fuel the body’s processes and utilise stored fat reserves. Most of the body’s organs, the heart for example, in fact run very efficiently on ketones.

    Ketoacidosis is quite different and is typically the result of a chronic lack of insulin, not a lack of carbohydrate. With insufficient insulin, the body attempts to fuel itself by breaking down fat and protein stores in an uncontrolled way, a process which results in the blood becoming dangerously acidic. In short, ketosis usually occurs when blood sugars are at the lower end of the normal range, and ketoacidosis occurs when blood sugars are dangerously elevated. Ketosis is a result of low carbohydrate intake, ketoacidosis is a result of inadequate insulin levels.

  • http://www.lowcarbdietitian.com/ Franziska Spritzler

    Excellent explanation of ketosis vs.ketoacidosis, Bill. Every Type 1 I’ve spoken with does best on a ketogenic diet. Very small amounts of carbs require very small dosages of insulin, resulting in better BG control with less risk of hypoglycemia (Dr. Bernstein’s Law of Small Numbers). Of course, ketogenic diets are ideal for T2s as well regardless of whether they’re on insulin therapy. Thanks for another great blog post.

    • http://www.caloriesproper.com/ William Lagakos

      Thanks!

      I think it says a lot about the safety of ketogenic diets; that they don’t induce ketoacidosis in type 1’s.

      Maybe we should rename ketoacidosis with its cause instead of its symptoms… something like ‘insulinopenic hyperglycemia?’

      • http://www.lowcarbdietitian.com/ Franziska Spritzler

        Works for me!

      • http://ashsimmonds.com/ Ash Simmonds

        Way too logical to cut mustard.

  • http://ashsimmonds.com/ Ash Simmonds

    Also, a basic summary of ketosis/ketoacidosis from Lyle:

    http://ketogeniclifestyle.com/the-ketogenic-diet-summary-of-lyle-mcdonalds-book/ketosis-vs-ketoacidosis/

    I can’t believe we’re still battling this dumb issue – it’s like confusing having a drink of water with drowning, especially when it’s coming from people “in the medical field”, it seems RNs are the worst offenders in general – taught about diabetic ketoacidosis but not about fat metabolism.

    Here’s a fun thread from a while back when some supposed medico person tried to school r/keto on why it’s dangerous:

    http://www.reddit.com/r/keto/comments/1k8ejn/science_can_someone_help_me_respond_to_this/

    • http://www.caloriesproper.com/ William Lagakos

      Nutritional ketosis is basically not taught at any level. Unless you’re in Richard Feinman’s class.

      • Wenchypoo

        This is why people in the Paleo/Primal/keto/LC communities are so hungry for information on where to find a doctor who knows what the deal is, so they don’t have to continue this uphill battle with every visit.

        • http://ashsimmonds.com/ Ash Simmonds

          Mostly what I find from the “paleo”/primal/keto/etc communities is a deep desire to replace their junk food with a paradigm-fitting version, and a strange addiction to vitamin supplements.

          • http://www.caloriesproper.com/ William Lagakos

            Some of the keto groups on FB are hilarious. Seems like a mostly younger crowd, and they LOVE sugar-free candy… then someone comments: “never trust a fart.” HA!

          • http://ashsimmonds.com/ Ash Simmonds

            The only thing ending in ‘ol’ I care to consume is alcohol.

          • johnnyv

            Cholesterol and polyphenols

          • http://www.caloriesproper.com/ William Lagakos

            touché

          • http://www.caloriesproper.com/ William Lagakos

            Organic Paleo snacks & grass-fed whey protein… seem like pretty good business ideas.

          • greensleeves

            Because after ancient humanity chipped enough flints for the spear tips, they dropped the rocks & ran off to Whole Foods for chia treats? Get real.

          • http://www.caloriesproper.com/ William Lagakos

            Sales & marketing… “Paleo” is a probably a very hot topic in focus groups. Proof? see all the packaged & processed foods sold at Whole Foods.

          • greensleeves

            Agreed. Gimme my almond/chocolate/coconut/stevia sweet bread AND GIVE IT TO ME NOW. Because baked goods are totally paleo.

          • http://itsthewooo.blogspot.com/ Jane Plain (Woo)

            Speaking personally vitamin supplements have helped substantially and I can cite what each supplement I take does.

            I seek greater well being at the expense of greater complication, although I appreciate some people don’t like all the rigamarole and details and seek the opposite of simplification.

          • Jack Kruse

            BOOM Nice truth bomb.

  • http://praguestepchild.blogspot.com/ Praguestepchild

    A problem with ketogenic diet, it can apparently register a false positive on breathalyzers. But I’m sure if you just explain to the nice ocifer that it’s just your liver making ketones that sometimes get reduced to isopropanol I’m sure he’ll understand and let you go with a smile and a wave.

    http://www.ncbi.nlm.nih.gov/pubmed/16894360

    • http://www.caloriesproper.com/ William Lagakos

      Also, beware to all those using vinegar therapeutically as I think something similar occurs.

      • Wenchypoo

        And god forbid–don’t EVER eat a poppy seed-covered bagel the morning before a drug test! Poppy seeds will pop you positive for opiates.

      • http://ashsimmonds.com/ Ash Simmonds

        Seriously?

        So if I’m mainlining MCTs and snorting ACV I shouldn’t drive for fear of DUI?

        • http://www.caloriesproper.com/ William Lagakos

          hahaha, it’s possible. But perhaps the pro-cognitive effects of MCTs/ketosis will help you pass the sobriety test 😉

        • http://praguestepchild.blogspot.com/ Praguestepchild

          We were somewhere around Barstow on the edge of the desert when the MCT and ACV began to take hold.

          • http://www.caloriesproper.com/ William Lagakos

            Ha! nice callback.

        • greensleeves

          I resemble this remark.

  • Galina L.

    My son’s friend , who is a RN, was absolutely shocked when he told her he went to ketosis for 2 – 3 days because was feeling he could be developing a flu. (he is very thin). She told him ketosis was very dangerous and it left him confused, he called me in a panic. .

    • http://www.caloriesproper.com/ William Lagakos

      I don’t think her response is very uncommon. Nutritional ketosis isn’t covered in any of the nutrition or medical textbooks I’ve seen… and any on-the-job training will likely be about type 1 diabetics, where the only time ketosis is mentioned is in the context of ketoacidosis.

      • Galina L.

        Thank you, Bill.

  • Thomas Hemming Larsen

    Is the reason for the increased urination on a ketogenic diet the low insulin level which makes the kidneys excrete more glucose through the urine?

    • Wenchypoo

      I’ve heard that as we age, we don’t hold as much water in our tissues, and the whole digestive system becomes more efficient. I know I myself drink about a gallon of water a day,since going keto and hitting 50.

    • http://www.caloriesproper.com/ William Lagakos

      Increased urination is a big component of ketoacidosis… on a ketogenic diet, it’s not as much of an issue, but might be related to salt wasting in susceptible people.

      • Thomas Hemming Larsen

        Hmm, I’m quite thirsty throughout the day and piss all the time. I also often crave salt and can get dizzy if I don’t get it.
        I’m thinking if this should concern me…

        • http://ashsimmonds.com/ Ash Simmonds

          Are you new to LC/keto?

          I cover some of the basics on this here:

          http://ketogeniclifestyle.com/water-weight-and-fluid-management/

          Scroll down to “the body isn’t stupid”.

          • Thomas Hemming Larsen

            Thanks Ash. I’ve been doing it for >1y. I still get lightheaded from doing weight training and have fatigue to varying degrees.
            I have read all of what you also mention before but I haven’t fully overcome my symptoms.

          • greensleeves

            More salt. Seriously. And check your sodium/calcium/potassium balance. Make sure you’re eating enough of each to keep your ratios correct.

          • Thomas Hemming Larsen

            Yeah, I’m trying that. I can’t really check my ratios without a blood test and all of the ones I’ve had are showing that they are within normal range. The caveat is obviously that they only show the serum concentration.

          • http://www.caloriesproper.com/ William Lagakos

            nice!

  • John Lushefski

    I’ve seen that citric acid is antiketogenic: the reason is that it inhibits CPT1? …So don’t drink lemon juice+water on a low carb diet?

    • http://www.caloriesproper.com/ William Lagakos

      I can definitely see the rationale (good one, btw), although I don’t think the dose of citrate would be high enough to have a biologically meaningful impact on CPT1…

      Tl;dr: squeezing some lemon into your water is probably A-OK.

      • http://ashsimmonds.com/ Ash Simmonds

        This is why I only consume lemon juice in vodka or gin – the acetyl-CoA conversion properties of excess ethanol are a precursor to ketone bodies, thereby neutralising the anti ketogenic properties of the citric acid brah.

        • http://www.caloriesproper.com/ William Lagakos

          Ha! I’ll take one of those.

    • http://itsthewooo.blogspot.com/ Jane Plain (Woo)

      At reasonable intakes i have never observed any effect of lemon juice.

      I’m usually a neurotic one hypersensitive to everything BTW.

      • http://www.caloriesproper.com/ William Lagakos

        “hypersensitive to everything BTW” …tend to agree; who else gets over-stimulated by ginseng?!

        • John Lushefski

          I used to drink it a lot during workouts; I like the sour taste.

  • Amy

    From S. Henderson: http://www.ncbi.nlm.nih.gov/pubmed/18625458

    “Ketosis is frequently viewed as an abnormal condition. This is probably an artifact of modern diets. Throughout much of human evolution, ketosis likely served as a valuable survival mechanism to fuel brain metabolism during times of food scarcity. Hence, in some ways, the modern diet can be considered “keto-deficient.”

    “Keto-deficient” — love it!

    Full text available here:http://download.springer.com/static/pdf/967/art%253A10.1016%252Fj.nurt.2008.05.004.pdf?auth66=1389475059_ef48c3b5c0d70f6955046a0df5860fdb&ext=.pdf

    • http://ashsimmonds.com/ Ash Simmonds

      Does my head in that modern biochem manuals still conflate absence of carbohydrates with starvation – yeah, let’s pick the non-essential macronutrient and say that when you don’t have this unnecessary “nutrient” available – like when you have a giant mammoth meat feast in front of you but no bread – then you are starving.

      Lack of bread and chips and icecream and Coke is literally starvation to biochem students.

      “Keto-deficient” seems more sensible – how about hypoketonemic… Is that even a word? If not I’m claiming it! :p

    • http://www.caloriesproper.com/ William Lagakos

      “‘Keto-deficient’ — love it!” <– agreed!

      • RIchard Feinman

        There really can be such a thing as keto-deficiency. The inborn error of medium chain fatty acyl-CoA dehydrogenase deficiency means that medium and long chain fatty acids cannot be adequately processed. Under conditions of fasting, patients must rely on glucose since the lower availability of fatty acids means low ketone bodies, the normal response to fasting. For adults who have a certain amount of glycogen this may be okay but for children who have less glycogen it can be fatal. Such children have to be fed regularly — I think not necessarily carbohydrate but regularly. This sometimes means waking the child up in the middle of the night to take in food. The symptom is called hypoketotic hypoglycemia.

        • http://ashsimmonds.com/ Ash Simmonds

          Yeah discovered that malady when googling “hypoketonemic”, but it basically means low in ketones AND sugar, which makes me wonder just how low sugar can go if ketone-replete…?

          A couple years ago when I was doing the glucose/ketone testing I was often what would be known as hypoglycemic but I feel fine/better with “low” BG and moderate/high BOHB.

          Volek mentioned in a recent video that levels as low as 25mg/dl BG is fine on a deeply ketogenic diet but would be just about comatose on a glycolitic diet – can’t remember the specific numbers/details so will have to watch again:

          http://ketogeniclifestyle.com/video-keto-adaptation-health-performance-and-beyond-jeff-volek/

        • http://www.caloriesproper.com/ William Lagakos

          Children with some variants of glycogen storage disease are treated with round-the-clock cornstarch; this prevents hypoglycemia but still causes enlarged liver… seems like ketones could benefit both cases (eg, ketone salts for MCAD deficiency; MCTs & ketogenic diet for GSD).

          • RIchard Feinman

            The problem with all therapeutic use of ketone bodies is that they are metabolized. One of the solutions is to use esters of the ketone bodies which will be hyrdrolyzed slowly. One of the compounds used that is being tried is an ester of butane diol which when hydrolyzed the butane diol will be oxidized to beta-hydroxybutyrate generating another mole of ketone bodies. Very clever.

          • http://www.caloriesproper.com/ William Lagakos

            Cahill speculated another problem with ketone salts would be the incredible salt load.

            Regarding the ketone esters… interesting! Seems like something Richard Veech would have been brewing in his kitchen.

            3-hydroxybutyryl-3-hydroxybutyrate: http://www.food.gov.uk/multimedia/pdfs/hydroxybester.pdf

            “Butanediol diacetoacetate” https://www.ketoresearchchem.com/ketone-ester.html

            also some other potential candidates, via Sigma-Aldrich:
            poly-3-hydroxybutyrate: http://www.sigmaaldrich.com/catalog/product/aldrich/363502?lang=en&region=US

            3-hydroxybutyrate ethyl ester: http://www.sigmaaldrich.com/catalog/product/aldrich/w342807?lang=en&region=US

          • RIchard Feinman

            Veech was definitely involved in this. So was Kieran Clarke who previously was a real Atkins-basher. She is now part of one of those companies trying to market ketone body-esters. There is nothing like the sound of a cash register to help a cardiologist understand science.

  • John Lushefski

    Efficacy of Intravenous Sodium Bicarbonate Therapy in the Treatment of Diabetic Ketosis has some intetesting information if anyone is interested.

    • http://www.caloriesproper.com/ William Lagakos

      I’ve requested a copy of the full text… but in the meantime, I’m assuming they’re referring to ketoacidosis…?

      • John Lushefski

        I can send the pdf if you’d like. I assume that “diabetic ketosis” = ketoacidosis. Basically it is that NaHCO3 reduced urinary ketones but increased them in the blood–just something to look into perhaps.

        • http://www.caloriesproper.com/ William Lagakos

          Hi John, thanks. I’d like to take a look at it. DrLagakos@gmail.com.

  • http://readandgetrich.com/ Chris

    Bill, good job on clearing things up on ketoacidosis and nutritional ketosis. The common efforts that we, the advocates of ketogenic diets, make will eventually pay off. I’m pretty sure of it!

    • http://www.caloriesproper.com/ William Lagakos

      Thanks, Chris!

      It would be nice if ketogenic diets got a few minutes of lecture time in college-level nutrition classes…

      • http://readandgetrich.com/ Chris

        Bill, since we are on this topic…I’ve been researching vlc diets for several months now…However, I’m not sure if I understand something correctly and maybe you know it better…

        Once you are in ketosis fully adapted, and you get out of ketosis…does it take another 2-3 weeks to become fully ketoadapted again?

        for example if one day I have 100g of net carbs and I’m out of ketosis, would it take 2-3 weeks to be fully ketoadapted again?

        I’m intrigued of this because Phinney said it in this video: http://www.youtube.com/watch?v=OFD2q5iqevY

        what do you know about it?

        • http://www.caloriesproper.com/ William Lagakos

          Hi Chris, that’s a pretty long video; when does he say it?

          In the meantime, here’s my understanding: it would take more than 100 grams of carbs to reverse ketoadaptation (http://caloriesproper.com/?p=2786). One component of ketoadaptation that seems to be pretty important is mitochondrial proliferation… and those mitochondria won’t disappear overnight (or after 100 grams of carbs).

          Your ketones may register 0/low, but they should recover in a day or so (especially if combined with energy deficit)…

          Tl;dr: transiently ‘kicked out of ketosis’ =/= no longer ketoadapted.

          • http://readandgetrich.com/ Chris

            sounds reasonable. how sure are you about these claims? i’m having a great time under ketosis!

          • http://www.caloriesproper.com/ William Lagakos

            …they’re mostly what I’d like to think are ‘educated’ guesses :)

            However, the studies simply haven’t been done. Does Phinney suggest something different?

          • http://ashsimmonds.com/ Ash Simmonds

            I’d like to reframe the situation and consider that through most of history keto-adapted was the default state. (note I’m not talking about being “in ketosis” here)

            With that in mind, what we’ve got is people who’ve instead become “glyco-adapted” over years/decades of being fed the stuff.

            So for a properly keto-(re)adapted person it’s just as difficult to glyco-adapt.

            There is a ton of anecdata about this, ketards call it “cheating” and report “glyco flu” even more hardcore than any “keto flu”, and even after days/weeks of carb-creep it seems easy enough for a keto-adapted person to land back in VLC with little to no problems with shedding collected water weight and “re-adapting”.

            (personal sidebar: I just spent nearly a month O/S eating a very mixed mostly plant diet – not high carb, but definitely not low either and certainly anti-ketogenic. Upon returning I had no problem returning to meat-only, but after a week of meat-only I had one Thai meal and it messed me up for the whole next day – *sigh*)

            I didn’t want to bring too much broscience here – but the fact is we don’t have the real stuff yet, so we have to make tentative arguments based on experience, logic, anecdotes, and best guesses – and for now, that’s mine.

          • http://readandgetrich.com/ Chris

            Even though I find that you’re focusing on abstracting things up, thanks for the comment. I read through the lines and I want to keep that not being in ketosis does not mean to not being keto-adapted.
            This is what I want to focus on. It kind of makes some sense to me.

            Thanks Ash!

          • http://www.caloriesproper.com/ William Lagakos

            Physiologically speaking, I think healthy ppl are pretty much always “glyco-adapted.” Ie, it takes weeks of VLC until RQ is consistently low; switch over to high carb and RQ is high within a day or two.

          • http://readandgetrich.com/ Chris

            He just said that it can takes quite some time (weeks) until the body gets fully ketoadapted after getting out of ketosis

          • http://ashsimmonds.com/ Ash Simmonds

            I’d defer to Phinney/Volek any time, but that doesn’t sound right.

            Not being “in ketosis” “not ketogenic”.

            Lots of nots in that last sentence. :/

            I’ve got a whole write up on the various etymology and general zeitgeist understanding of all the words with “keto” in them somewhere. There’s still significant confusion/misinformation/lies about all the terms, and whilst there is some overlap measurably, biologically all dozen or so of the main keto terms are quite distinct as to their meaning.

            This post itself is tribute to that – the difference between ketosis and ketoacidosis. There are at least another 10 keto-related medical terms that are thrown around irresponsibly/interchangeably.

          • http://www.caloriesproper.com/ William Lagakos

            I agree, Ash; that doesn’t sound right. If you’re out of ketosis for a few weeks, then ketoadaptation is probably coming undone… but not after 1 or 2 high carb meals. (I’m basing this on my ketoadaptaion = mitochondrial proliferation hypothesis)

          • Thomas Hemming Larsen

            Phinney is pretty strict on never ‘cheating’. If you have read their you’ll notice the same. I’m saying he’s right – just that its his ‘philosophy’. He doesn’t see any benefit in carb-loading at any point.

          • Jack Kruse

            even higher levels of carbs can be tolerated and still remain in ketosis Bill. In summer time when I am upping carbs I still find at night time checks I bounce back into ketosis. Granted it has been ten yrs of eating this way for me but I think we have to be careful about axiomatic statements about adaptation. I find that what the body human can do it more a function of how we train our mitochondria and its biogenetic pathways epigenetically. Good post.

  • http://itsthewooo.blogspot.com/ Jane Plain (Woo)

    Good post Bill; clarify the basics ketosis is NOT ketoacidosis, the two are as similar as fracturing a leg vs having orthopedic surgery .

    • johnnyv

      Or maybe more like fracturing a leg vs walking, both activities involve legs. One is traumatic the other benign and ordinary.

  • Michael

    Hi Bill, OT: my packet of Bimuno states that it is best taken with a HOT beverage. Now I don’t know anything about GOS so it’s probably correct to take hot, but just asking since PS must not be taken hot. Do you know?

    • http://www.caloriesproper.com/ William Lagakos

      Hi Michael,
      In this context, GOS and PS are completely different. Bimuno recommends GOS taken in a hot beverage because it’s not very water-soluble… neither is PS, but exposure of PS to heat significantly reduces the amount of resistant starch.

      Keep us posted! Mario has been posting updates on his PS experiments for a while. Very interesting.

      • Michael

        Thanks, Bill, for confirming that. Will let you know if anything interesting happens – good or bad.

  • Michael

    Another OT wrt to recent discussion about reduced requirement of vitamins on VLC I found this:

    “[…] large amounts of vitamin B complex and minerals such as sodium, potassium, calcium and magnesium, etc., are required to assimilate and metabolize carbohydrates.”
    http://www.arltma.com/Articles/SugarCarbIntolDoc.htm
    Unfortunately no reference given for the claim. Very similar claim made in Atkins’s original 1972 book, again no ref. I wonder if there are any actual sources for this claim?

    • http://www.caloriesproper.com/ William Lagakos

      Speculation for a lot of this has been going around for a while now. Much of it makes sense, but there are no RCTs that I know of.

      The quote about Na & K also makes sense, but in practice I think VLC typically increases the requirements for salts due to: low insulin –> salt wasting.

      • http://ashsimmonds.com/ Ash Simmonds

        Again, I tend to think that’s only an induction/adaptation thing that goes wonky for most. Some report maintaining increased added salt/electrolyte needs over the long-term – but I and many others are with Stefansson on this, after a long enough period without salt, you realise it’s unnecessary – and even not particularly appetising/good for wellbeing.

        FWIW the “many others” I speak of typically have low-to-zero plant intake. It seems the more mixed/veggie-laden your diet, the more salt you crave/require, from a wide-angle view at least.

        • Michael

          Interesting about the salt. I forgot about the fact that Stefansson didn’t use salt, but do remember reading it now somewhere (maybe it was in Not By Bread Alone – read it a long time ago).
          I will try Amber’s suggestion of meat only very soon. I already don’t eat much in the way of fruit & vege, save chocolate & nuts. Since they are nice prebiotics I’m currently trialling some bimuno instead and cutting the nuts to start with. Tried PS for a couple of months total – it was terrible. Psyllium added into the mix was even worse. Never again. Of course, prebiotics may be orthogonal in the context of meat only. Who knows…

          • http://www.caloriesproper.com/ William Lagakos

            Yeah, PS seems hit or miss. Works well for some; disaster for others.

            On another note, Gerard Pinzone is experimenting, trying to replace sugar with PS to make a low carb ice cream… if it works, I might actually try PS :)

  • dave

    Cheese is the way to go (Im french lol) ?

    • dave

      In all seriousness, what could be wrong with cheese? How different is a ketogenic diet from a low carb/ HF diet? Any good website in terms of puting a ketogenic diet to practice : recipees)?

      • http://www.caloriesproper.com/ William Lagakos

        Nothing is wrong with cheese!

        A ketogenic diet is generally just a *very* low carb diet. Also, ketosis could arise on a standard low carb diet if you’re in negative energy balance.

        I recently discovered: http://www.ruled.me; recipes look pretty good…

        • Michael

          Really, all you need is Ash’s own website:
          http://highsteaks.com/mega-meatballs-cheese-filled-beef-and-chorizo-bombs-video/
          I mean, video, transcript, pics. What more do you need? Hilarious video, too. Only downside was that Ash’s ‘adequate hydration’ directions plus my own questionable knife skills did lead to a small disaster…

          • http://www.caloriesproper.com/ William Lagakos

            Hahaha yes, this is true; Ash has quite the ‘database.’

      • http://ashsimmonds.com/ Ash Simmonds
        • http://www.caloriesproper.com/ William Lagakos

          Personally, I’m more Ash-like & Paleo-Carnivore in this aspect, but if anyone wants more LC-friendly stuff… –> http://www.reddit.com/r/ketorecipes

  • http://batman-news.com Angelo Capistrano

    Hi Bill- I am so glad to ran into your blog and read the entire discussion about “Ketoacidosis”. I am a newbie (4mos) on Keto with a goal to improve my cycling performance. To make this comment short, my brother made a negative comment about my Keto lifestyle, that my liver will eventually produced Ketoacidosis in the long run and his advised is not to stay on a long term basis.
    That made everyone specially my wife so concern about my future health in Ketosis. BTW my brother in law was on Adkins years ago and dropped out after he claims lost 25lbs weight now back to normal diet. This topic is a great handout to everyone around.

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