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Keto Facts

Ketosis and Skin: Why Fibroblasts Increase Collagen Production



Do you have that friend whose skin looks so awesome?  Do you want to know her secret? I am going to tell you … right here.

Touch your face. Those skin cells you are touching were made 2-3 months ago. If you want healthy, glowing skin that’s free from pimples and wrinkles, improve the foundation holding your skin cells. Improve those cells at the base of your skin layer and watch your age reverse over the next 2-3 months. Improved collagen production decreases your wrinkles, hydrates your skin and results in more flexible, resilient, yet firm skin. In a word, it makes you look younger.

ketosis and skin

Cells called fibroblasts create collagen. Collagen establishes the latticework or framework for our skin, bones, tendons and other tissues connecting our body-parts. Think of collagen as different types of glue. Fibroblasts secrete this “glue,” or matrix, providing structural integrity to all of our connective tissues. The composition of that matrix determines the physical properties of the tissue.

Fibroblasts busily provide the architecture connecting one part of our body to the next. Skin is one example. It holds the highest number of fibroblast. These skin fibroblasts paint the pathway for the skin cells to wrap our entire body. Bone-fibroblasts release a slightly different glue. Corneas, tendons, ligaments, and cartilage have their own unique matrixes coming from these essential cells. The degree of mineralization varies with the type of tissue. Rigid collagen becomes bone. Flexible collagen produces the tissue of a tendon. The cartilage of our ear, eyes, or nose is a gradient between those two extremes.

Other fibroblasts make collagen for your blood vessels, the fascia around each muscle fiber, the discs between your backbones, and the dentin in teeth. Each has a different, unique mineralization of collagen from their fibroblasts. Fibroblasts glue our body together.

The power of healthy fibroblasts is apparent when comparing an athletic 17-year-old to a frail 80-year-old. The seventeen-year-old has tighter glue. As we age, fibroblasts slow down their production of collagen. These aging cells become dormant or disappear altogether. Without the collagen supporting the skin, it begins to crease and wrinkle. Those missing platforms lead to fine wrinkles at first. With less and less collagen, come deeper and more pronounced lines.

ketosis and skin

Dormant fibroblasts are called fibrocytes. Fibroblasts and fibrocytes are two states of the same cells. A fibroblast cell has a lifespan of a couple of months, whereas fibrocytes live longer in their “hibernating” state. Fibrocytes lurk through our body waiting for the signal to provide more collagen. Months without any sign that the body needs more of their glue, and they disappear.

When I teach patients and students about the impact of a cell, it helps to show what happens when the cell is defective. When fibroblasts suffer a mutation while trying to outline the bones of a growing teenager, bones turn out fragile instead of healthy. Much like a porcelain vase, bones formed from defective collagen cells shatter with the slightest twist or turn.

Building healthier collagen cells does not stop with those looking for youthful skin.  Sure improved collagen production decreases wrinkles and produces more youthful looking skin. But that’s not all. Improved collagen production keeps bones from cracking, joints from wearing down, eyes with a clear vision and your heart valves firmly sealing shut each beat of the day. From your eardrum to your muscle fibers, collagen is the source of active functions within your body. Even if we set aside all the vast immune system benefits, we could write an encyclopedia of benefits to keeping collagen cells out of their dormant phase.  

Most people don’t care about collagen in their joints, or eyes, or bones.  Most people that know the word collagen, care about their skin.

So what’s the secret to youthful skin?

STEP 1: A Ketogenic Diet.

The chemistry shift behind ketosis at its very core removes inflammation. Two months into producing a steady supply of ketones and the improvements in the skin begin to shine through.  

First, the pimples fade away. No matter your age, ketosis prevents pimples from popping out of your skin by lowering inflammation throughout your body. At the root of any acne problem lives a soupy mess of cells soaking in the grime of inflammation.

Next, the redness and irritation slowly fade. After 90 days you see the first “ketone” based on skin cells. This means the skin cells you made the first week of ketosis are finally at the top layer of skin where you can see them.  Skin cells made during times of lower inflammation show a youthful radiance. These healthy, plump cells outshine any other approach to skin improvement.

Moisturizing creams advertise that they provide a more youthful looking skin. You may find truth in that for a few hours, but not the way ketosis affects your skin. Ketosis provides a much more sustainable process.

In addition to anti-inflammation, ketogenic diets filled with fats support beautiful cell membranes. Call me a geek for pointing this out, but it is true.

Perfect looking skin begins will flawless cells. Without enough healthy fat, your cell membranes fail to form that perfect pattern. Defects formed in the cell’s membranes magnify over time to abnormalities seen in your skin. Skin cells that break open or wrinkle are made with these defective cells. Inflammation hides at the root of these problems.

ketosis and skin

A sunburn provides an easy-to-see example of severely inflamed skin. Lower amounts of skin inflammation aren’t as visible. Low-grade inflammation occurs on a microscopic level. Inflamed skin cells divide into imperfect replicas. These imperfect cells don’t stick together as neatly, forming defects in the skin. These are wrinkles.

As we age, our defective skin cells increase in number. Faulty cells make faulty copies. Those wrinkles around your eyes showed up in your thirties. Maybe the inflammation started after a sunburn. Perhaps it built up during times of high stress. Either way, those cells wrinkled because they were defective. Ten years later, those wrinkles are deeper and more noticeable. In contrast, well-made skin cells are flexible and plump allowing the cell membrane to stretch and squish as needed.

And what about those fibroblasts?  How can we spark those to divide more or coax the fibrocytes out of retirement? Micronized Collagen Particles

STEP 2: Micronized Collagen Particles Increase Collagen Production  

Yes. It works, and studies prove it.  Take collagen parts from a cow, chicken or fish. Now hydrolyzed those particles. Then cut them it into microscopic pieces. Once scoop of those hydrolyzed collagen “snippets,” and you can measure them in your bloodstream within an hour. These tiny specks spark both fibroblasts and fibrocytes into action.

These tiny flecks look like broken down collagen pieces from the cells point of view. The one thing that sparks increased collagen production is the signal that your body is breaking down its collagen. Naturally, this destruction of collagen happens very slowly, causing only a few particles to be present in our system at any time. The increased particle number found in circulation after taking a supplement turns up our collagen produced by the fibroblasts.  That same high particle count in your circulation wakes up sleeping fibrocytes. This little trick is the secret to amazing looking skin.

Signal your fibroblasts to make buckets of collage by adding these particles to your circulation.  I recommend three doses a day into your coffee or tea or bone broth. Any liquid will do. Stay consistent for a full three months and the results are stunning. You will see your skin look younger.

Don’t take my word for it. Or that found in the science articles. Take a picture. Get a close up of those fine wrinkles on your face. Retake the photo in 60 days, 90 days and 120 days. It is remarkable what you will see.

Want to learn more about the keto diet and other health tricks?

Subscribe to our updates now!.  

Would you like to make some of these flexible, radiant, youthful skin cells? Get to the root of your wrinkles, crows feet, smile lines, thinning skin and other problems of your skin.

  1. Pee ketones for 90 days.
  2. Spark your fibroblasts out of retirement with hydrolyzed collagen up to three times a day.
  3. Subscribe to our updates.  We have more to come.

Learn more about which foods are Good. Better. & Best – through my favorite FOOD GUIDE.  I recommend this for beginners or folks that keep falling off that keto-bandwagon.  

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Keto Facts

How to Transition Through Every Ketosis Phase: Part 1



Adapting your body to burn fat instead of carbs involves five specific phases. Each Ketosis phase happens in a predictable order that has been researched and studied. Scientists documented the body’s transitions by entering patients into a fasting study. They fasted for forty days. Each phase marks changes in your blood chemistry and occurs at specific, scientifically predictable times. With hopes of not overwhelming you, I will take three blogs to cover all five phases. Each phase teaches how much of your body is using ketones versus glucose. Take note specifically of what fuels the brain in each phase. This post gets us through phases one and two.  

Ketosis Phase 1: Use Up The Sugar In Blood


  • STATUS: Your fuel is 100% glucose during phase one. The glucose you burn comes from the carbs you just ate or drank. NOT ONE section of your body runs off ketones.  
  • BRAIN: Powered only by glucose.
  • Entering Phase 1 is the easiest part of getting into ketosis. You do this every night when you go to sleep. You simply use up the sugar that’s currently in your bloodstream. Every time you eat more than a spoonful of sugar or a handful of carbs you reset your system back to the beginning of Phase 1.

Phase 1 begins by processing the glucose that’s already in your blood. This glucose came from the food you ate over the last 4 hours. Phase 1 is short. It ends after 4 hours unless you reset things by eating more carbs. Then it starts over. Don’t do that.

Go to bed two hours after your last carbohydrate. Before you wake up, you are through Phase 1.


Ketosis Phase 2  Burn Sugar Stored In Liver

  • TIME: 12+ HOURS
  • STATUS: Your fuel is still 100% glucose, but now your carb fuel is coming from your stored sugar called glycogen.  
  • BRAIN: Powered only by glucose.
  • You burned up those circulating sugars in your bloodstream. With no more food coming into the body through your mouth, your system will use your stored sugar. This stored sugar is called glycogen, and you keep it in your liver cells. Phase 2 fuels your body using this stored energy.

How Long Will Your Storage of Glycogen Last?  Good Question.

The answer depends on a couple of things: the size of your liver and the level of energy usage in Phase 2. Sleeping during this phase takes less fuel than running for 45 minutes. Fighting cancer or infection requires more fuel than living without those issues. Mending a broken bone or repairing from surgery requires more energy than sitting at your desk writing a blog.  

In addition, how large is your storage tank? Asked another way: How big is your liver? I bet you’ve never thought about that. Its size depends on how much stress you’ve put on your life in recent years. Your liver constantly grows new cells to meet your body’s needs.

If you drink excessive alcohol for twenty years, you will make additional liver cells to keep up with your drinking. Similarly, if you eat lots of extra carbohydrates for two decades, your liver will expand to store your extra sugar.   

From my experience, patients with the largest livers are not alcoholics. Instead, the biggest livers belong to my patients addicted to carbs. If they are not already diabetics, they will be. They have overstuffed their livers with the age-old habit of constantly eating carbohydrates. They don’t allow enough time to empty stored sugars before eating more.  

Long before diabetics are diagnosed as such, their livers strain from the pressure of the carbs they eat. They make more and more liver cells to keep up with the carbohydrate onslaught. If they cannot make extra liver cells as fast as they overeat, sugar remains in their bloodstream longer than normal. Insulin works overtime whipping the glucose into the mitochondria’s furnaces or into storage. The danger signal of insulin rings constantly. They keep eating and therefore more sugars enter the bloodstream before the abundant pine needle-like fuel gets burned or stored. The screaming alarm signal of insulin becomes a constant noise. This hormone’s danger signal becomes less and less effective as blood sugars steadily rise.

Diabetes is defined as a state of constantly elevated blood sugars. Diabetics never empty their storage. I do mean NEVER. Their liver cells are stuffed with glycogen. Their cells have no more room. In an attempt to store their extra sugar, they grow additional liver cells.

Did you empty your liver last night? Let’s check. After 12 hours with only water, prick your finger and check your fasting blood sugar.

Don’t roll your eyes. You must know someone who has diabetes and checks their blood sugar. Borrow their glucose monitor for one day. No, they won’t die if they don’t check their sugars for a day.

If you burned through all your glycogen and emptied your storage [emptied your liver] your fasting sugars will fall between 55-80 mg/dL. That’s a surefire sign you have a normal sized liver. If your liver has been stretched and stuffed with too many extra carbs in recent years, you won’t burn through all the storage in 12 hours. It might take you 20 hours to burn all those pine needles. Some severely overweight patients take a week. If your blood sugar is greater than 120 mg/dL at 12 hours of fasting, you have DIABETES. No joke! That’s the rule of how to diagnose a diabetic.

Ideally, your liver should deplete all stored sugar before you eat another bite of food, especially foods filled with carbs. By the end of Phase 2, your body has burned all of your fast-burning fuel.

If you want to learn more about the ketogenic diet, check out the book ANYWAY YOU CAN on Amazon or Audible by Annette Bosworth, MD.


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Quick and Easy Rules of the Keto Diet



rules of keto diet

Rules are important when it comes to tricking your body into altering it’s chemistry. The rules of the keto diet are not complicated but I can assure as weird as some of these guidelines sound they will help you.

Step 1: No sugar. No starch. High fat.

The best summary of this diet is “no sugar, no starch, high fat.” Say those words out loud. Again. No sugar. No starch. High fat.

Step 2: Remember the Number 2

It is critical as I will explain later. For now, commit this number to memory:

Step 3: Buy Urine Ketone Strips

rules of keto dietI hate even to have to say this, but I recommend you buy something. Yes, as a physician who has been subjected to more multi-level marketing pitches than I care to admit, typing this recommendation makes me uncomfortable. But it is necessary.

To succeed at switching your fuel source from sugar to fat, you need to know if you are producing ketones. Spend some money. Ketone strips typically cost about $15.

Buy the smallest quantity you can. I buy bottles of 50 strips. I have put them in every single bathroom at my clinic and my house. I have even been known to leave a bottle at a friend’s house because she always complained that she could not lose weight.  

It is super important because the keto diet is measurable! Here is my favorite part.

I have coached patients for decades that come in and say “Doctor, doctor, my diet is just not working for me.” And they’re right. The scale didn’t move.

These changes seem strange to most everyone I advise. Keto strips allow me to measure patients’ compliance. More importantly, the strips allow patients themselves to monitor their progress.

In the first two weeks, I want you peeing ketones as quickly as possible. Burning fat for fuel is the basis of this diet. Getting to the other side has proven to be unique to each patient. You will need the feedback that what you’re doing in YOUR SPECIFIC situation is the right thing for you.  

Some patients, usually men, stumble into ketosis. They pee ketones within 24 hours of changing habits. They may not always stay there, but they can pee a ketone mighty quickly.  Other patients may take several weeks to burn through their stored sugar and struggle with their body chemistry due to insulin resistance.  

Sometimes this is because they don’t know what they’re doing. But more often than not, the bodies were merely locked into using only sugar for fuel for years-if, not decades.

Some have been living with chronically high insulin levels for years. It can take weeks to burn up all the extra stored glucose in the body and finally see their insulin fall back to normal range. Remember, you can’t produce ketones until both your blood sugar and your insulin comes down.

How resistant is your body to insulin?  

There is a blood test you can take to get the answer. I offer this to my patients when I see them in the clinic, but I don’t routinely recommend it. The test is expensive and coupled with the cost of a doctor’s visit. It won’t tell you anything you don’t already know you are addicted to sugar and have been for a long time. You have gained weight and can’t seem to lose it because of your body’s insulin cycle.

You will have a rotten time giving up carbs initially. Most people don’t need a blood test to tell them that. Spend your efforts and money measuring something that does matter: The time it took for you to start producing ketones. Start using those urine sticks! If they turn pink, this means you made ketones. Pat yourself on the back, jot down how long it took you to pee that first ketone-and keep going!

Step 3.5:  Buy MCT C8: C10

We will get into how to use this powdered fat supplement later. For now, click on BUY and get it shipped to your home. Local stores are not likely to have this on hand, so I recommend searching the internet for direct delivery. Search these words: MCT C8: C10

Step 4: Empty Your Cupboards  

It is a challenging step. Empty out your cupboards.

One of the hardest changes you will have to make when adjusting to a high fat, low-carb diet is dealing with temptations. You need to put a lot of distance between yourself and the high carb foods you previously loved to eat. Do yourself a big favor and rid your home entirely of these distractions and temptations. Cleanse the places you control.

rules of keto diet

When walking addicts through a recovery plan, we start with asking a friend to help them cleanse their environments. It means throwing away all the signals that tempt you to go back to your old habits.

For an alcoholic, this means booze bottles stashed in the silliest places. For a drug addict, it involves needles, spoons, and lighters. For a carb addict, your enemy is processed food. The more food has been prepared, the quicker it ends up in your mouth. Moments later, your system is crammed with glucose molecules ruining your ketosis.

Even when you have cleansed the areas you control, be prepared for temptation. The devil has placed carbohydrates everywhere-from gas stations to coffee shops to your workplace. Protect the sanctuary of your home. Keep carbs out.  

How do you know which food items to throw away when rifling through your cupboard?

Look at each item’s label. Any item with a high level of carbohydrates or sugars needs to go. When trying to decide to keep or throw something, another rule-of-thumb centers around processing.

If the food is highly processed, lose it. In our family, we took a box and everything that was made with flour, rice, corn or had sugar in it, we simply put in the box and took to the community food pantry.

This was therapeutic for my household. My kids helped with this. If they considered keeping it, I had them count how many ingredients were in the product. If it had more than 8 ingredients, we tossed it. Keto can be very stressful. Do this with a friend and make sure you don’t quit until it’s done.

Here are just a few things that ended up in the box that we took to the food pantry:

  • Hamburger Helper
  • Bags of pasta
  • Bags of rice
  • Flour
  • Sugar
  • Refried beans
  • Cans of corn
  • Cans of pears and other fruits (remember, fruit is evil)
  • Ketchup   

Step 5: PAUSE

After the cupboards are bare, STOP.  PAUSE. Do not rush the next steps. Grocery shopping will still be there tomorrow. Just pause long enough to understand these following few steps.

Step 6: Remember That Number?

What was that number you were supposed to remember?  Yep: Twenty.  20. To start on your path to ketosis, you are allowed 20 grams of carbohydrates per day. The only thing I want you counting in a day is carbohydrates. Not calories. Not grams of fiber or fat or protein. Not pounds or inches. I only wish you focused on carbohydrate grams.

Forget about net carbs. Forget about dietary fiber. Don’t distract yourself with ‘sugars.’ Just remember 20 and start counting carbohydrates! Restrict yourself to only 20 carbohydrate grams per day.

Transitioning people’s behaviors starts with clear instructions and something measurable.

The clear instructions?

  • 20 grams of carbohydrates per day.  

The measurable factor?  

  • Peeing ketones.

Here’s an objection I usually get when I discuss this step with my patients:

“Doc, calories matter. Why aren’t you telling us to count calories?”

For the last four decades, the medical establishment in the US has been preaching that calories matter. The truth? They don’t matter when insulin is ruling your body. We can talk about calorie balance after you’re keto-adapted. But the first thing you need to focus on is reducing your bloodstream insulin level, and that means HIGH FATS, LOW CARBS. Your mission right now is to get rid of those carbohydrates!

Step 7: Eat Enough Fat to Feel Full

It is what sets this diet apart-there is no starvation! There is no want for food. I’m not exaggerating. With this approach, there’s enough fat feeding your body that you don’t feel hunger. Your brain receives a powerful chemical message of fullness from your system. This process begins when you eat fat after cutting out sugar or carbs.

rules of keto diet

Don’t believe me? You have my permission to begin your day tomorrow by eating a stick of butter. Yep. You read that correctly. After not eating anything for several hours (because you were asleep) you can have a stick of butter for breakfast. Add salt for added taste if you like. Pair it with water or black coffee. Still, the only ‘food’ you should eat is butter. Don’t imagine this story. Do it. Listen carefully to what your body is saying. Notice the sensation your brain sends to your body? Your brain detects the signal that you are full when fat fills your stomach.

No wonder, so many of my patients boast about how sustainable and satisfying the ketogenic diet is.

Step 8: Eat Only When You Are Hungry

Do not sabotage your system’s chemical transition from sugar to fat by snacking unnecessarily.

Your habits may seem so automatic that you hardly become aware that you’re snacking until the bag is empty. Recognize these habits. Bring the habit out of your subconscious by keeping a food log.   

My downfall was morning breakfast. For so long I told myself that breakfast was the most important meal of the day, that I did not stop to ask myself if I was starving or just eating breakfast out of habit. After two months of keto eating, I challenged myself: No calories until I felt hungry. When hunger hit, I would take in my favorite foods first: coffee with heavy whipping cream. Before long I stopped eating breakfast, sipped on my favorite coffee with cream until well into the afternoon.

If you’re suffering from anxiety or stress, make sure you only eat when you’re hungry instead of eating for comfort. If you do choose to snack, reach for fat instead of carbs!

Step 9: Restrict Protein

Nearly every person I have coached at some point overate protein. They are confusing boosting fats by loading up on protein. Perfectly understandable. The notion of a high protein diet as a healthy option has been around for a long time. Bodybuilders and health food promoters all have a protein supplement to help you remain healthy. In our minds, it all seems natural that protein is healthy. Those same people think high-fat diets are unnatural. According to this ‘conventional wisdom,’ it is safe to eat lots of protein, and it is unhealthy to load up on fat.   

rules of keto diet

What’s going on here? Lipophobia: the fear of fat. The media won this game. They successfully frightened us from enjoying fat.

I correct this thinking by educating patients that we are solving a human biochemistry puzzle. Our body’s chemistry controls weight loss. The most crucial piece of the puzzle is insulin. Keep insulin down, and weight loss happens.  

In the absence of carbohydrates, fat does not spike your insulin. Fat also sends a robust hormonal message to your brain to stop eating. This chemical shift is what makes the keto diet so powerful and effective. Fat does not spike insulin. Carbs spike insulin. Excess protein spikes insulin, too. For me, the most challenging pantry item to throw away was the protein powder.

On a ketogenic diet, how much protein does it take to spike your insulin?

Here’s the formula I teach my patients: write down your ideal body weight-the weight you want to be. I’m 5’3” and would love to be 125 lbs again. Divide 125 (your ideal body weight in pounds) by 2.2. This is the number of protein grams per day that you should eat. In my case that is about 56 grams of protein per day. If I stay under that goal for the day, my insulin does not surge. The first month when I failed and failed and failed to produce my first ketone, I was adding a scoop of protein powder to heavy whipping cream. That one scoop had 50 grams of protein and blocked my insulin from falling. No ketosis.  

The number 20 was the only number you need to insist remember-I you stick to that for now. This protein number only surfaces when patients are having trouble. If you are in week 2 and you still haven’t peed ketones, you have a problem. The culprit? You’re probably eating a high protein diet instead of a high-fat one. This is the most common mistake I see.  

Eat too many proteins, and your body will start to squirt out insulin. Insulin is the enemy of ketones. For more information on the benefits of a ketogenic diet, check out the book ANYWAY YOU CAN written and recorded by Dr. Bosworth.

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Keto Facts

Lessons from Dr. Bosworth: Importance of Measuring Ketones



No matter which way you measure ketones; it is too easy to not do. It’s what separates this lifestyle from the last fifteen attempts you had to improve your health. People fail when changing habits without accurate, real-time feedback. Ketones are unique. You don’t accidentally start making ketones. Measure them. Prove to yourself (and your doctor) that you modified your lifestyle enough to make ketones.  

How to Measure Ketones

There are three ways to check if you’re producing ketones: blood, urine, and breath. These tests check for three types of molecules:

  • AcetoAcetate
  • Beta-Hydroxybutyrate
  • Acetone  

Two of these chemicals are energy sources or fuel for your body: AcetoAcetate and Beta-HydroxyButyrate. Your body produces acetone from leftover ketones. Too many ketones waiting to be used as fuel, and your body gets rid of them. One way is through acetone.

Last week I had a new patient ask me, “Isn’t this the diet where your body gets so whacked out that you start producing fingernail polish remover?”

This objection truly made me laugh. But, the question does hold some truth. The question accurately references ACETONE as the compound that you breathe out when in nutritional ketosis.

Fuel your body with fat, and you produce ketones. Most Americans haven’t produced ketones in a long time. Maybe that one time just after their 50th birthday when they celebrated with a screening colonoscopy. When patients drop carbs and eat mostly fat, their mitochondria begin to churn out ketones. The presence of ketones after years of eating high carbs pushes their body to ‘remember’ how to use FAT-based (ketone-based) energy. While your system adapts, extra ketones circulate. Your bloodstream holds quite a bit of extra ketones. Produce more ketones than your body can use at once, and your body gets rid of the extra.

  • You can pee them out.  
  • You can breathe them out.  
  • You can even sweat them out.  

Acetoacetate, abbreviated AcAc, is the name of the extra ketones wasted in your urine. In your breath, the AcAc ketone breaks down further to acetone.  

measure ketones

Yes, THAT acetone-the same chemical found in fingernail polish remover. Breath-acetone does validate this urban myth-minus all the drama.  

Acetoacetate (AcAc)

This ketone is one of the two ketones found in the blood. It is made inside your liver cell’s mitochondria. AcetoAcetate exits liver cells and enters into your circulation to fuel other cells looking for energy. After weeks of producing ketones, nearly every cell in your body will be trained to use it for energy. This state is called keto-adaptation. When your liver gets busy making fuel from fat, you can find too much of this compound in your bloodstream. When it gets too high, your body needs to do something.

An overabundance of ketones in the bloodstream is dangerous, and your body has protections built in not to allow that. Your body has several ways to eliminate the excess ketones from your system before they create a toxic, acidic, biochemical mess called ketoacidosis.  

One option is to remove acetoacetate through your urine. When you pee on ketone urine strips turning them pink, AcetoAcetate causes that chemical reaction. Whenever I see my ketone urine strip turn positive, I remind myself that these are extra calories that I just peed out. The weight loss headline should read, ‘Ketosis: Pee Out Those Extra Fat Calories.’

Beta-hydroxybutyrate (BHB)

Like AcAc, this ketone is a fuel that circulates in your blood. It also travels from liver cells to other cells’ mitochondria. Once in the furnaces, BHB is converted into energy. Ketone blood tests measure the amount of this compound in your circulation. This is the most accurate measurement of nutritional ketosis.


Not a fuel. Acetone is a waste product made from excess acetoacetate, AcAc, in the bloodstream. Acetone escapes from the body through our breath.

Which is the best way of measuring your ketones? Urine, blood, or breath?


I tell all patients to start with urine strips. These strips are cheap and portable. They are quite reliable when first transitioning from glucose to ketones. For the first several weeks, this is all I recommend. Personally, I used this approach for over six months before I splurged on a blood ketone testing kit.  

How come? In the first few weeks of any behavior change, beware of your past patterns.

Choose anything you have tried to change: smoking, drinking, better sleeping habits, exercising, dealing with an annoying coworker.

The biggest threat to your changed behavior comes from your past habits. The behavior change sticks around for awhile, but when stress or boredom strikes, your old ways show up again. Before long, your new habit has all but disappeared. Given this reality, I want patients to be on the lookout for their past habits.

How do you help someone become aware of something they seem to do automatically? Check urine ketones to be certain you are avoiding old patterns. Checking urine ketones is a painless, cheap, and portable way to stay accountable. Verify your ketone state by placing a few urine ketone strips in your pocket at the start of each day. Make this a TOP PRIORITY for the first several months of your new keto lifestyle.


Special breathalyzers can detect acetone molecules in the air flowing through them. The presence of acetone in the air leaving your lungs means you have extra ketones. When acetone is in your breath, you are in ketosis. This innovative tool has many advantages and will likely continue to grow in popularity.  



Measuring your blood ketones is the best way to know if you are in ketosis. Unlike the extra, wasted ketones found in your urine or breath, the ketones in your blood are a direct measurement of your ketone energy supply. This test measures the ketone Beta-hydroxybutyrate abbreviated BHB.

Thankfully, you don’t need to go to a lab or hospital to measure BHB. Home monitors, like those used by people with diabetes to measure blood sugars, are available without a prescription. Prick your finger and assess your ketone level in that blood drop. Within seconds, you have your answer. Real-time, accurate feedback. At the first mention of finger-pricking and self-testing, many patients get cold feet. Don’t. The process can seem intrusive at first glance. However, my most successful patients embraced the accountability made possible by self-monitoring. Much like stepping on a scale provides feedback, so does testing your blood ketones and blood glucose.

Ketone blood levels range from 0.5 to 10 millimoles per liter. Any number greater than 0.5 mmol/L translates to nutritional ketosis. Good job!

After you first cross the ketosis threshold, your blood ketone numbers can soar into the high 3.0-6.0 mmol/L range. As your cells remember how to process a ‘new’ fuel type, your BHB numbers settle into the 0.5-1.5 mmol/L range.

Blood ketone levels have different ranges for different goals.

Urine ketone sticks turn positive when blood ketones are 0.5 mmol/L or higher.  

My recommendations are:  

  • Weight-loss: above 0.5 mmol/L   (as long as your blood sugars are less than 90 most of the time.)
  • Improved athletic performance: above 0.5 mmol/L
  • Improved mental performance: 1.0-3 mmol/L
  • Therapeutic (e.g., to help with specific medical problems): 2-6 mmol/L

Check out the book ANYWAY YOU CAN on Amazon or Audible by Annette Bosworth, MD to learn more about this way of eating and how to measure ketones.

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