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K is for Ketones


Ketones are good for you. No, they’re bad.

With one exception, I don’t think that there’s any diabetes disagreement that is more serious than this one about ketones. The exception is whether a low-carbohydrate diet is something that you should follow, particularly if you want to lose weight.

Is a low-carb diet good or bad for you? Actually, some of the reason that we differ on the answer to that diet question is because we can’t agree on ketones.

We do know what ketones are. Ketones are acids released into the blood when your body breaks down its stores of fat and burns it for energy. Two things can cause your body to do that. One is when you don’t have enough glucose to use for energy. The other is when your insulin level is too low. In either case your body then make ketones, which are waste products that might cause the acid level in your blood to become too high.

Since ketones are a waste produce, you pass them in the urine. That means you can detect them with a urine test, which has been the traditional, but sometimes messy way check them. Now, however, you can do that with a blood test that measures a specific ketone called beta-hydroxybuyric acid.

In fact, two meters will measure either your ketones or your blood glucose. Abbott Diabetes Care offers the Precision Xtra. Polymer Technology Systems has the CardioChek, which can also measure lipid levels.

It’s handy to have a meter that measures both, because when are your blood glucose level is higher than 240 mg/dl (13.3 mmol/L), you need to test for ketones too. But it’s not only when your blood glucose is high that you might have ketones in your blood. You may have ketones if you are pregnant and have diabetes. That’s the third major type of diabetes, which we call gestational diabetes. And if you have any type of diabetes and are sick, under stress, or have any symptoms of high ketones, the usual recommendation is to test for them.

So, what are the symptoms? Unfortunately, they aren’t so specific as to be easy for you to diagnose. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says that they are “nausea, vomiting, and stomach pain.”

A high ketone level may not be easy to diagnose, but at least the experts pretty much agree about what it is. The disagreement is with the relationship between ketones, sometimes called ketone bodies, and diabetic ketoacidosis, sometimes called ketoacidosis.

Worse, the experts tell me that when you have diabetic ketoacidosis you may also have these same symptoms. But the NIDDK also lists “fruity breath odor and rapid breathing” among the symptoms of diabetic ketoacidosis. It goes on to say that untreated diabetic ketoacidosis can lead to coma and even death.

So it’s no wonder that controversy rages about ketones. This stuff is something that all of us need to take seriously.

Then, why would anyone even suggest that ketones might be good for you? The guru of low carb, Dr. Robert C. Atkins, certainly thinks that they are a good sign.

Ketosis in people who are overweight is “benign,” he said when he spoke at the “Great Nutrition Debate” that then U.S. Secretary of Agriculture Dan Glickman convened in Washington seven years ago. When dieters who put out too much insulin cut way back on carbohydrates, Dr. Atkins says, this benign dietary ketosis leads to a normal pH. “There is no acidosis.”

But, he says that diabetic ketoacidosis is “diametrically opposed” to this, caused by an increased intake of carbohydrates in the absence of or deficiency of insulin. Thus ketones are a good thing because having them means losing weight on the Atkins low-carb diet.

Not surprisingly the advocates of diets that are moderate or high in carbohydrate have a radically different take on this question.

“The longer you stay in ketosis, you turn yourselves into fat magnets, and you accumulate body fat more readily,” Dr. Barry Sears of the Zone diet told the same debate. “The longer you stay in ketosis, you begin to oxidize lipoproteins, so these are long-term consequences which begin to explain why high protein diets fail.”

Dr. John McDougall, the author of The McDougall Plan, picked up on the comparison that Dr. Atkins made of his diet to fasting. That’s because, Dr. McDougall says, that “nature has designed us so that if we don’t have food and we are starving to death, it doesn’t hurt so much to die, so we develop ketosis, which suppresses the hunger drive.”

Dr. McDougall says that we also get ketosis when we are severely ill and that the reason for that is that we are supposed to be recuperating then, not gathering and preparing food. “That’s why I call them the ‘make yourself sick diets.'”

I think the jury is still out on whether ketones are good or bad. But the verdict is in on ketoacidosis, and it’s clear that you don’t want to go there.

The two conditions are certainly linked. They even have more in common. The NIDDK’s list of symptoms of ketoacidosis include fruity breath. But I don’t see fruity breath on its list of symptoms of high levels of ketones.

Yet, Dr. Atkins himself talks about the breath of his followers. “Whether the sweet smell of ketones is considered bad breath or just sweet breath,” he said, “is a matter of opinion.”

The debate’s moderator, Carolyn O’Neil, however, seemed to like the smell. That breath, she said as she closed the debate, “smells like money.” That’s really what these diets are all about.

This article is based on an earlier version of my article published by HealthCentral.

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  • Joe at

    Very informative article, I have been on a keto diet for the last three weeks and you have to be very careful with your macros. I still enjoy doing research on ketones. Thanks for the share!

  • Greg at

    Perhaps someone could educate me on the value of ketone testing.

    When I test my blood sugar and get a high reading, my course of action is to shoot the appropriate amount of insulin to bring it down. Also, if it’s high enough, I need to avoid exercise until it comes down.

    So let’s say the reading was high enough to suggest ketone testing, and I test for them, and the test was positive. How does my course of action differ from the above?

  • jackie at

    Has anyone heard of a recent study (cited by my endo) that say that:
    in ketosis, the body shuts off the production of a substance made in the bone marrow which removes/prevents the build-up of lipids and plaques in the arteries?
    He used this study to say that a ketotic diet IS harmful. I cannot find the study. I will ask him more when I see him in August.

    • David Mendosa at

      Dear Jackie,

      I haven’t heard of that study. But please let me know what you find out from your doctor.