Ketones: The Misunderstood Energy Source

There has been, and still is, much misinformation, myth and distortion about the Atkins Lifestyle and the impact of carbohydrate restriction on human health.

One of the most misunderstood sources of energy for the body, commonly associated with Atkins, is ketones or beta-hydroxybutyrate. Ketones are a by-product of fat metabolism, and can be used by the body for fuel. The only cells that cannot use ketones, and therefore require glucose, are the renal medulla (core tissue of the kidney), red blood cells, the cornea, retina, and lens of the eye, and the liver. The glucose needed for these cells is easily supplied by gluconeogenesis. (The creation of glucose in the liver.)

The production of ketones, when consuming less than about 50 grams of carbs daily, has been a major criticism of the diet since the publication of his first book Dr. Atkins’ Diet Revolution in 1972. The medical community, assisted by the media, continues to be in the forefront of furthering inaccurate info about this natural process of utilizing ketones to fuel the body. It is time to set the record straight.

Ketones: I Was Once Uninformed

Decades ago as a nursing student, I was taught that ketones in the urine are a bad sign usually associated with ketoacidosis due to uncontrolled type 1 diabetes. Uncontrolled type 1 diabetes and its complication of metabolic acidosis is a medical emergency that requires immediate attention. If left unrecognized and untreated, coma and death can result.

Uncontrolled type 1 diabetes is characterized by very high glucose levels in the blood and the absence of insulin to carry glucose into the cells and to regulate the release of fat from fat cells. Acidosis can result because of this abnormal metabolic state. Acidosis can also occur in very late stages of type 2 diabetes, when insulin is no longer present,

As medical people we are taught about disease, not nutrition. The idea of “benign dietary ketosis,” as Dr. Atkins sometimes called it, as a normal state was never on the radar. Certainly not mine.

When I began to work with Dr. Atkins I was shocked how well people did on his ketogenic diet, even those with diabetes. My training was certainly incomplete. Decades later this same lack of knowledge persists in the medical community.

Thanks to Drs. Volek and Phinney and their book The Art and Science of Low Carbohydrate Living, our understanding of this process has expanded. They define nutritional ketosis as a benign state that allows the body to survive during times of interruption in food supply or to adapt to changing fuels. This ability of humans to utilize ketones produced in the liver simply by breaking down fats for fuel has allowed the survival of our species. It is not an abnormal acidotic state. In fact, given that a majority of people in the US (66%) are carrying excess body fat, utilizing that fat for fuel makes sense to address obesity, the rapidly expanding diabetes epidemic and the crushing healthcare costs we shoulder.

Even when not low carbing, a state of mild ketosis is common for many of us. In a fed state it is normal for people to have a small amount of ketones: 0.1 mmol/L, after an overnight fast: 0.3mmol/L and dietary ketosis: 1-2mmol/L. In contrast, people with diabetic ketoacidosis have more than 25mmol/L, or more than ten times that concentration. Too, when blood sugar levels are high in the absence of insulin the body loses its ability to control pH.

Controlling both the quality and quantity of carbohydrate foods, and getting intake levels below 50 grams daily, can initiate dietary ketosis, bringing a variety of benefits, without the abnormal metabolism that occurs with ketoacidosis. In dietary ketosis the body is able to maintain a normal pH. This is even true for people with diabetes. One caveat is that because an Atkins type diet is so effective at lowering high blood sugar levels, one must adjust or stop certain meds — especially insulin — to avoid dangerous hypoglycemia. The assistance of a physician is required.

Note that many with type 2 diabetes are able to obtain very good blood sugar control without insulin injections or even oral diabetes meds on a very low carb intake.
People with type 1 diabetes require smaller doses of insulin, and have significantly fewer and smaller swings in blood sugar and fewer hypoglycemic events. A person with diabetes should expect to have urine positive for ketones but negative for glucose when they restrict carbs.

Changing Fuel Sources

When one decreases carb intake the body must adapt to a change in primary fuel sources — from glucose burning to fat burning. This adjustment can take time. Many people who experience the symptoms discussed below assume that ketones are harmful and they will continue to feel unwell on low carb. NOT TRUE. Once you are off the Western diet and have adapted, you’ll feel a whole lot better and your blood tests will look a whole lot better too.

• Within 12 hours or so on a 20 gram low carb diet some people (not all) will have withdrawal symptoms such as headache, fatigue and irritability. These symptoms can last 4 and occasionally up to 7 days. Once they are gone one should feel good and have plenty of energy.
• When first cutting carbs water is lost. Minerals such as salt, magnesium and potassium can be lost in excess. This is especially likely if there is excessive urination at the start. A simple solution is to add 2 cups of salty broth daily. If you haven’t already, take Dr. Atkins advice and add a good multi-vitamin/mineral supplement.
• If these strategies don’t work 100% and some symptoms remain simply add 5 more grams of carbs from the vegetable list and remaining symptoms usually resolve.

This adaptation period is sometimes called the “Atkins flu.” Not all people who begin carb restriction suffer withdrawal or have difficulty adjusting to Atkins. Yes, this can happen, but in my experience it is not the majority of people.

A Researcher Speaks Out About Ketones

Dr. Richard Veech, an NIH researcher who has studied ketones for decades, says “Doctors are scared of ketones. They’re always worried about ketoacidosis. But ketosis is the normal physiological state. I would argue that is it the normal state of man”. He continues “Rather than being poison, which is how the press often refers to ketones. They make the body run more efficiently and provide a back-up fuel source for the brain.” He calls ketones “magic,” and has demonstrated that the heart and brain run 25% more efficiently on ketones than blood sugar. What if it’s Been a Big Fat Lie, NYT, Taubes, 2002

The benefits of ketosis derived by controlling carbs, and demonstrated by research on Atkins type diets, include loss of body fat while maintaining lean mass, decreased hunger, all of the benefits of a stable blood sugar and insulin, reduced inflammation, support of mitochondrial function, enhanced energy production, increased insulin and leptin sensitivity.

The utilization of ketones by the brain is so important that research is continuing on ketogenic diets for epilepsy, brain cancer, Alzheimer’s, ALS, Parkinson’s and other diseases of the nervous system.

More Myths

Ketones and the lack of high quantities of dietary carbohydrates, common in the Western diet, are given as reasons why the Atkins Lifestyle is supposedly so unhealthy. In the last 12 years or so more and more research has been published that supports the health benefits of low carb. I hope that the presentation of these findings will finally begin to silence the myths.

Debunking a few:

• Atkins is not high protein but moderate protein. The levels recommended are well within the Institute of Medicine’s recommended protein ranges.
• None of the studies have demonstrated negative effects of even a 20 gram level of carb intake on kidney, liver function or endothelial function. In fact, in our clinical practice, it was common to see elevated liver function tests caused by obesity normalize very quickly.
• Rather than increasing cardiovascular risks, improvement in many aspects of cardiovascular risk factors has been shown.
• There is no evidence of osteoporosis.
• There is improvement in a variety of medical conditions and common symptoms that usually require long term drug use.

A word about hair loss

It is natural to go through periodic random phases of shedding hair whether you are on a diet or not. Any weight-loss regimen may lower the metabolic rate, which can result in hair loss. Compared to calorie-restricted diets, Atkins is less likely to contribute to hair loss because the higher caloric content keeps the body from behaving as though it is in a starvation mode. Another cause of hair loss is losing weight too rapidly. Be sure to consume adequate calories and avoid skipping meals. If hair loss continues, advance to a higher carb intake following the Atkins ladder .
If you still have questions about carbohydrate restriction be sure to educate yourself by taking the time to obtain the facts by reading in full any of Dr. Atkins books. It is worth the investment in your health and that of your family.

More Low-Carb Articles by Jacqueline A. Eberstein, RN