Lessons from Dr. Boz: Importance of Measuring Ketones

No matter which way you measure ketones; it is too easy not to 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.  

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.

Acetone

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?

URINE

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.

BREATH

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.  

BLOOD

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.

“Doc, what BLOOD METER do you recommend?

ANSWER:  FORACARE: http://bit.ly/2QKGmKG

For years my diabetic patients told me this system was great.  When I first started testing myself,  I tried several others before I bought this one.  I can’t count the number of times I have tested my blood only to get an ERROR message from the strip. 

Grrr. I hate that.

FORACARE gets my vote because it’s accurate and takes only ONE test strip to get the results. YES!! Buying a meter can be expensive. The link above connects you to a full meter and kit. The package includes 1 meter that measures both your blood glucose and blood ketones. The kit comes with 100 strips: 50 for measuring your glucose and 50 for measuring your ketones — all for just over $100.  Don’t flinch.  I have seen the blood ketone meters cost that much. Then add up to $7.00 for the ketone strips.  This package gives you the supplies to bio-hack yourself.  Without the supplies, patients can’t study themselves.  They get stingy about checking their numbers because they worry about the costs.

Step over the threshold.  Help your doctor help you.  Get a list of your blood sugars and blood ketones.  The immediate feedback works wonders when changing behavior.  One handful of popcorn at the movie theaters and my blood tests show it the next morning.  Before I started testing I could talk myself into believing it wouldn’t impact the numbers “that much.”  Nope .. I was wrong.

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

As you progress out of beginner-ketone production, this gets much more fun. By fun – I mean you can calculate how your body reverses inflammation and cleans up some of those old, broken cells.  Take a look at this chart … and keep reading.  These next posts get better.

Check out this Video where I explain this ratio a bit better.

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.