So, “Enough with the caution,” you say, “show me the money!” Well, actually, the caution is worth mentioning again before we get down to the nitty-gritty. T1 diabetics and T2s with impaired insulin production are at risk of diabetic ketoacidosis, and even though nutritional ketosis is not the same thing, learning about what one or the other is, how to differentiate and prevent is an important preliminary. So, if you haven’t read my series of posts on the difference. Please go back and do so. At the very least know that you cannot suffer diabetic ketoacidosis if your blood sugar is in the normal range. So for Pete’s sake, do not stop taking insulin to attain ketosis. If you are an insulin dependent diabetic, the only reason to back off on your insulin doses is if you find your sugar goes too low with your normal dose in any given scenario, or if you are continually slipping low while in a fasted state on your current basal rate.
The range of ketone measurements indicating nutritional ketosis
Obviously if the goal is to get to a state of nutritional ketosis, we have to define a lower and upper limit, and give you some mechanism for measuring that. For these numbers I will defer to the wisdom of Drs. Phinney and Volek, from the Art and Science of Low Carboyhdrate Performance, where they state:
To achieve optimal fuel flow during keto-adaptation you should aim for blood ketone levels between 0.5 and 3.0 millimolar. [1]
They also state in their companion book, The Art and Science of Low Carbohydrate Living that people approach a measurement of 5 mmol/dL on starvation diets, where one is taking in neither carbohydrates nor protein. I think we can all agree that this is not a target to shoot for, and a reading much above 3.0 would be a sign that you are pushing the limits of safety given the fact that you are diabetic.
You want to find a balance where you do not depend on carbs to fuel your metabolism but you do not have so many ketones that you change the pH (acidity) level of your blood. Putting the ceiling at 3.0, where our non-pancreatically-challenged friends stop on a healthy diet is the wise thing for us to do. Remember, the point of this diet for you is not to have high ketones – it’s not even to lose weight – it is to radically decrease amount of insulin required to support a healthy blood sugar level so-as to shake off roller-coaster blood sugars and better your health.
Measuring ketones
You will want to test yourself consistently in a fasting state. Either when you get up in the morning, or long enough after a meal that it is fully digested and your last bolus has run its course. You have three practical ways of measuring your ketone level, all with varying advantages and disadvantages. I list them here in order of decreasing accuracy:
1. Ketone blood meters – Either the Precision Xtra, or the Nova Max. From what I can tell, the Nova Max is the cheaper of the two options when it comes to buying ketone testing strips, but I cannot say anything more in its favor simply because my insurance provided me with the Precision Xtra, which I can’t find any reason to criticize. The pro of these two options are that they are the most accurate and only direct measure of the ketone level in your blood. The con is that the testing strips cost an arm and a leg. If you can’t get insurance to pay for them, you might just want to use this option for occasional fine-tuning. Neither of the links I provided above come with strips included, so that you have the most options with regards to sourcing the cheapest strips you can find.
2. Acetone breathalyzers – This technology measures the acetone on your breath. Acetone is one of the three types of ketone bodies your liver produces when you are in ketosis and is responsible for the ‘fruity breath’ that some people get on low carb diets. The most sensible option is Ketonix, a reusable breathalyzer for roughly $190 US which plugs into USB charger and gives you feedback via different color LED’s, or into the USB port on your Mac or PC and gives you more precise measurements with software that runs on your computer. I purchased a model before they had a computer software component, and did 
not find the LED read out satisfactorily accurate. Now that they have a numerical interface, I might be tempted to buy an upgrade. If it is accurate, it is the cheapest and most appealing option out there for someone who cannot get insurance coverage for a blood meter. There is also the option of the disposable Breath Ketone Test by Metron. This option is just as expensive per test as the blood meters, but not as accurate. Maybe you can think of a reason to buy them, but I can’t.
3. Ketostix – The oldest technology available. It is cheap, but vague and inaccurate. Vague in that you don’t get a precise reading, but rather a graduated scale of 6 colors which indicate ranges. 
Inaccurate because it only measures the amount of excess acetoacetate (another kind of ketone body) spilling into your urine relative to the actual level in your bloodstream. While it is useful for detecting ketoacidosis, it is not as helpful in reliably testing ketosis. Still, it is the cheapest of options, and if you find yourself relying on it for to assess how you are doing, don’t get freaked out by low readings when you are experiencing other signs that you are in ketosis, such as a lack of cravings, and clarity of thought. Remember, ketones aren’t the end goal here as much as is better control over our blood sugars. Depending on the manufacturer of your ketone strips, the reading on the side of the bottle may be measured in mmol/dL or in mg/dL. General guidance is that you should check that it is not deep purple, and remains in the first three shades above the neutral, or ‘negative reading’ base color.
Macronutrient Ratios and Nutritional Ketosis
When I reference the term “macronutrients” throughout my posts I’m referring to the three basic sources of calories in any diet: protein, carbohydrates and fat. Vitamins and minerals that may come along for the ride when you put caloric foodstuffs in your mouth are “micronutrients” and are very important as well. I will touch on them briefly further down and follow-up with a more in-depth article in the future.
Attaining nutritional ketosis merely means that you have changed the ratios of the macronutrients you eat so that you need to inject (insulin dependent diabetics) or produce (everyone else) sufficiently little insulin that your body begins converting fat into a moderate amount of ketone body’s for use as fuel. Too much insulin, and your body doesn’t produce a meaningful amount of ketones and rather stores the fat away for the long, barren winter from which civilization has largely spared us. Going further than that and becoming keto-adapted means that you have maintained this state long enough that your metabolism has become optimally adapted to using ketones for energy than it is currently. What follows is a brief explanation of the reasons for the ratios of each macronutrient.
Carbohydrates:
The amount of carb restriction required for you to meet and maintain a state of nutritional ketosis may vary. Of course your mass and body composition comes into play. A 110 pound woman with 16% body fat will need less carbs than a 200 pound man with 24% body fat. Also, some very active people can tolerate more carbs immediately surrounding their workouts. Some more insulin sensitive people can tolerate more carbs in general.
If you are reading this, and are:
- a T2 diabetic,
- pre-diabetic,
- approaching retirement age while being either inactive or overweight,
…then you are likely insulin resistant. The more insulin resistant you are, the more insulin you need to produce to clear the glucose from your blood stream. The more insulin you produce, the further away from ketosis you creep. So if you meet any of these conditions, you will want to restrict carbs more severely. The guidance for carbs is generally to consume under 30 grams a day, but up to 50 grams if you can tolerate it. Tolerating it, means able to eat at that amount while still maintaining a state of ketosis.
I recommend everyone attempting to eat a ketogenic diet start at the low-end of those recommendations, and once ketones are measurable in your blood or urine, you can experiment with adding more carbs. If you fall out of satisfactory ketosis, and you are accurately estimating your macronutrient amounts, you now know the upper limit to your daily carb intake. (plus or minus a few grams due to exercise, stress, protein intake, etc) When in doubt, always err by setting your goal on the low-end of the 30 to 50g/day range.
Protein:
Amino acids are the building blocks of protein, and your digestive system breaks down the protein you eat into constituent amino acids in order to use them to build muscles and organs. But not every gram of protein you eat becomes the brick and mortar of your cells.
Remember, your body only has a couple of “tanks” where it stores excess energy:
- Glycogen for glucose storage – when you eat more carbs than your body needs at the moment, some of it gets stored in glycogen deposits in your muscles, liver and other organs, some of it (if you are diabetic) gets released in your urine, and the rest gets converted to fat. This more atherosclerotic (prone to produce heart disease) form of glucose generated fat is just as likely to get caught on arterial walls and form plaque as it is to get stored in the next storage tank…
- Fat (adipose) tissue for fat storage – Dietary fat gets digested and packaged up into LDL and HDL particles for transport through your blood to your fat tissue. Visceral fat what we call the fat that gets packed around your internal organs while subcutaneous fat is the fat that is stored under your skin.
- Absolutely nothing for protein storage! – There is no third storage tank for protein. There is no place for excess amino acids to go after your muscles and organs finish building cells with them. But your liver has a work-around for that. It converts excess amino acids into glucose in a process called gluconeogenesis. And of course, if you have more glucose than you need between ingested carbs and gluconeogenesis, it gets stored as glycogen or fat.
The glucose produced from amino acids by the liver requires insulin to process and that insulin will move you away from ketosis.[2] So to keep insulin needs low, and thus fatty acid release high enough to put you into ketosis, we need to limit protein consumption to only the amount you need to satisfy your body’s maintenance requirements. There are plenty of resources online for calculating based upon your age, body type, weight and gender what is the approximate amount of protein you require to meet this need. I’ll be recommending one resource further down.
Fat:
Unless you are this woman or someone with similar tastes, carbs, fat and protein make up 100% of the calories you eat. If you are limiting your intake of carbs and protein to limit your insulin requirements, then you need to eat enough fat needs to make up for the difference in your daily caloric requirements. Fat has no insulin requirement. Eat as much as you like, and your insulin needs won’t rise one whit. And if your insulin needs are low enough, that fat will convert to ketones and be burned as fuel (hence the phrase ketogenic diet). As your insulin needs rise however, you switch from a fat burning mode to a fat storage mode and start to rely on carbs and glucose almost exclusively for energy.
It makes no difference whether you are getting the fatty acids from your diet, or from the fat stored on your hips.[3] If you have enough ketones floating around in your blood stream to meet the definition of a “ketogenic state,” you will have an extra buffer against hunger. You will find that while a gram of fat has 2.2 times the energy that a gram of either protein or glucose have, it can also sate your appetite much more than carbohydrates.[4] Ingested fat also slows the digestive process, giving your pancreas or insulin injection a fighting chance at keeping your blood sugar spike lower over the hours following a meal.
Find the Ratios and Amounts of Macronutrients that Work for You
The regimen I try to follow is:
Less than 30 grams of carbohydrate per day
Just enough protein (110 grams) to maintain my lean body mass
The remainder of calories in my diet come from fat
Your ratios and amounts will be different from mine, depending on your body size, activity level and insulin sensitivity. You can calculate your own ratios with one of many calculators for followers of this diet. My very favorite is, Keto Calculator by Martin Ankerl.
On a steady, weight maintenance diet my macronutrient ratio would be 5% carbohydrate (120 calories), 17.4% protein (440 calories) and 77.8% fat (1840 calories) for a total of 2400 calories a day. If I were trying to lose weight, I would eat exactly the same amount of proteins, decrease my carbs to the degree I can without feeling deprived, and cut my fat down even more. Remember, your liver is indifferent whether it is producing ketones from dietary fat or your stored fat. Paradoxically, the less carbs you eat (protein remaining constant) the more satiated you become on a lower calorie diet. This is because you are producing or injecting less insulin, so more of your fat can work free from your fat cells and become available for fuel.
If you ever had the hunch that carbs fuel a hunger for more carbs, turns out you are right. Absent any food whatsoever, your bloodstream would be full of enough fuel (ketones) for weeks. Start eating carbs and the ketones go away, and then you get stuck on a meal-to-meal roller-coaster of blood sugar highs and lows. You feel logy on the highs and starved with an insatiable need for more carbohydrates during your lows because there isn’t enough fuel in the bloodstream.
Concern about micronutrients
On a diet of between 30 and 50 grams of carbohydrates a day, how does one eat enough fruits and vegetables to meet his or her daily requirements of various vitamins and minerals? Essentially, you have a couple of choices. Focus on getting nutrient dense vegetables and low glycemic fruit in your diet, and/or eat organ meats.[5]
Fruits and vegetables
For the fruit route, if you absolutely must, restrict yourself to low glycemic berries. The list includes blueberries, blackberries, raspberries, strawberries, huckleberries, etc. Be sure to eat the whole, unprocessed form of the berry (ie. whole cranberries, not canned or cooked with sugar!) Good luck though, maintaining a severely restricted carb intake, with fresh fruit around the house.
I lean more toward having salads daily, with high nutrient, low glycemic vegetables like kale, chard, spinach, arugula and a variety of lettuces as the base, then throwing on broccoli, green onion, chia, sunflower or sesame seeds, or walnuts. For packing lunch on the go, I’ll hollow out a green pepper and stuff it with a mixture of tunafish, mayo, mustard and chives. Or I’ll cut up an avocado and hard-boiled egg into a bowl and add walnuts, salt and pepper, and oil and vinegar.
Organ meats
American cultural food has largely thrown organ meats to the side and focused on both lean and fatty cuts of muscle. More traditional, ancestral diets did not let any part of the animal go to waste, and for good reasons other than scarcity – they noticed that people are healthier if they eat organ meat. While our ancestors never knew about the need for vitamins, nutrients and antioxidants, they made a basic part of their diets the portions of an animal that we’ve come to find are packed with them: the liver, kidneys, pancreas, heart, tongue and brains (for you zombies out there).
Conclusion
This post is about a week overdue, already 3000 words long and I can see your eyelids are getting heavy from all my blabbering, so I’m going to go ahead and push it now, but in future posts I will take on the subjects of micronutrients and concerns about consuming fats in more detail and link back to them from here. In the meantime, please visit my Resources page for my favorite YouTube videos on the subject.
Yours in health,
Mac
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[1] Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 89). Beyond Obesity LLC. Kindle Edition.↩
[2] It should also be noted that protein itself requires insulin to pass through cell walls. There has been experimentation as recently as 2010 where researchers compared insulin response to between carbs and proteins in healthy subjects, and observed a greater insulin response with a high protein diet that they did in a high carbohydrate diet. While this may be explained by both the existence of gluconeogenesis and the fact that protein stimulates glucagon production, which in turn stimulates glucose release from glycogen stores, the definitive reason hasn’t been determined yet. This however further supports the need to limit protein to the amount absolutely needed to support lean body-mass.↩
[3] Playing with the amount of fat you eat with the goal of reducing the size of said hips is beyond the scope of this article, but rest assured I will take the subject on in future posts.↩
[4] Protein is king in this regard, but we are limiting its intake for reasons given above.↩
[5] There is a third option: take dietary supplements in tablet form. But that is neither satisfying, nor necessarily healthy, as the supplement industry is unregulated and there is less of a guarantee that you are getting whats on the label.↩