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. official statement 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.
Can eating to little affect your weight loss?
https://bozmd.com/understanding-keto-food-pyramid/
Watch this video and remember Fat is your friend. Keep the total carbs under 20.
I enjoy your writing style truly enjoying this site.
Love your videos, been clean keto for one year, still learning everyday.
Questions for my daughter who has had her gallbladder removed. She’s having troubles starting Keto. Constipated, slow progress, along with a doctor that says NO KETO. What to do?
Rosemarie,
Gallbladder are a hard one. She needs to start slow and stick with it.
Here is a video that might help you get started. https://youtu.be/pfi_FE9HH2Q
Hi Dr. Boz! I’m new to your blog/YouTube channel. I started keto in 2014 because I got the dreaded T2D diagnosis and I need to lose about 35-40 lbs. I was able to get my A1c down to 5.4, lost about 30 lbs. My doc was pleased, “I don’t know what you’re doing, but keep doing it!”. Then I experienced a stall that lasted for the next year so I had some cheat days, a couple of cheat vacations, but nothing too terrible. I didn’t gain back the weight but I def. quit losing. During this time I was caregiving my mom who was going through a ton of health problems, T2D, CHF, multiple joint replacement surgeries, depression and anxiety. I kept seeing the horrible advice she was given by health professionals through those years and feeling pretty helpless to help her. She passed away in 2016 right before my birthday and I had a renewed sense of urgency to really get serious about my own health. Back on keto, but not losing, I started watching everything I could find on keto/carnivore/T2D, Sarah Hallberg, Dr. Ken Berry, Dr, Eric Westman, David Feldman, Amber O’Hearn, Dr. Ford Brewer, et. al. Not until I found your channel did I get the BEST information on how to measure ketones, BS, and how to break through this stall and get my numbers down into a truly therapeutic range! (Thank you! Dr. Boz Ratio=genius!) I am 58 yo, 5’1.5″ 122lbs (from 156lbs) and my numbers are generally in the BS 80’s, often times in the 70’s, ketones 2.3-4+. I feel amazing, depression and anxiety gone, mental clarity great, and I’m losing again (working on the belly fat which I’ve never been able to get rid of). My cholesterol numbers would probably make conventional docs have a heart attack, but my hdl and triglycerides are in a great range, and I suspect If I had my LDL particles measured they would also be good. But my total is high (a hyper responder according to David Feldman) My CRP score was also great, no inflammation. I have some very mild plaque in one of my carotid arteries (hoping to reverse that with my therapeutic boz ratio) but no impaired blood flow. I’m a keto success story! Sorry for the length of this comment, but I wanted to thank you for all you do to help people get healthy! I appreciate you so much. Understandable information, well done videos, you have a gift for teaching. Thank you! Robin
Found your videos 2 weeks ago after receiving a dire message from my doc and an A1C of 8.5. Not wanting to die from diabetes, I started the Keto diet and my wife joined me. Did our first 12 hour fast! My morning blood sugar is now down to 122 down from high hundreds low 200’s. Ketones are 1.8! Question if you can answer. My anxiety level was through the roof and it has totally disappeared. My BP dropped so low I had to stop taking meds. (Docs order). Is this typical?!
Yes, very typical.
Got 4 copies of your book to share with friends and people in need of life saving info .got my own diabetes under control stopped BP pills refused cholesterol meds from my sort of understanding Dr. Lol have to prove everything for acceptance but it’s also working. Got the suggested reading cookbook it’s also helping.
Hi! I have been on Keto for a month. Been checking my urine and find ketones. However, while I do feel super alert, focused and energized I have not lost any weight. I wondered if you could shed some light on this gor me? I am 30 lbs overweight.
I appreciate your time and advice and really enjoyed your book. I refer to it often
Peace love and blessings
Hi Dr. Boz – I bought your book on audible and loved it! Thank you – it was a great introduction to some more deeper knowledge about the ketogenic diet. I’ve been watching your youtube videos and love them and have just bought a blood monitor and started monitoring my ketones and glucose. My goals are weight loss (I’ve already lost 22kg with only 4kg to go) and auto-immune (inflammation) reduction and have been slowly kicking goals through a low carb 16-hour intermittent fasting strategy (I haven’t yet worked my way up to a full fast and kind of cheating by having a butter coffee at about the 14 hour point). Anyway, I love your idea of a keto support group as I would love to find some way to connect and support myself and others, as well as discuss my numbers! I understand it’s impossible for you to do this for all your followers? Is there any way you can help us create some Dr. Boz groups in different locations? It’s a big world, but I’m in Melbourne Australia and would love to trial something like this?!
https://bozmd.com/consistently-keto
Hi Michelle, if you’re overeating calories even if you are on keto it is very possible you won’t lose weight. I think it’s great at first to NOT mind your calories at all, just to get used to the way of eating, and some people will lose weight all the same but after about a month and not seeing weightloss it is a bit of a hard truth that you have to start counting calories. If you’ve got weight to lose one thing to mind is dairy and nuts – it is extremely easy to overeat these. When I do this, not only will I not lose, I will gain, EVEN sustaining impressive keto readings. I have to count calories. By the way Dr Boz does state in her book that at the beginning of her and her mother’s keto journey they also did not lose weight and she attributed it to too much butter on veggies if I recall correctly.
I can’t seem to download your spreadsheet. Always times out even when I follow the “I’m Not A Robot.” Not sure why. Is there another way to receive or download. Can you send it to me?
Thanks,
Bill Rode
William,
Spreadsheet I use to track all my patients. Start Tracking – http://bit.ly/2GgTSPq
This should work.
I’ve been on strict keto for 50 days now. Yesterday for no reason (diet has not changed) my BG raised to 85 and ketones went down to .8 now I’m showing no ketones on the pee stick. Why? Nothing different- I am stressed though … can emotions knock me out of ketosis?
https://youtu.be/IUHKTLZz_js
Watch this video, cortisol makes a big difference.
I have lost very little weight since I began (May 2020). Starting 184, now in July I am 172.2. I have found hidden sugars everywhere. I love my bulletproof coffee with butter and MTC peptides chocolate. I am only eating meat, like on the carnivores diet. I went from 171.1 to 172.2 over nite. I want to just stop My glucose was 109 this AM first thing and Ketos 0.3. Is there any hope for me?
Carol,
Yes, There is always hope. Keep the carbs under 20. Eat your fat !
Thanks Dr Boz!!! I first caught on to your ratios about two years ago when I started Keto and IF after listening to you and Dr Fung on YT and my new knowledge lined me and some family/friends to embark on this new journey. Starting at 61 yo, 6’3 and 285 lbs I was able to monitor many 2-3 day fasts at first and then a couple 4-5 days fasts resulting in hitting 190 lbs six months later.
Most imposrtantly I was trying to correct blood analysis results that first had about a dozen items in the Severe Risk readings to then be all in the normal readings a year later. Wow! For the last year I’ve been trying to stay between 205 and 210 and am now on Day 3 of a long term fast to see how long it will take to experience true hunger. I could not have done any of this without daily glucose and ketones measurement with the Fora 6 meter – you are absoluluty right that the quantifications helps monitor effects that then become knowlege. Thank-you again for posting on YT and I, like many, were devestated about hearing the news about your mom. You did great with her and offered us such a heart warming story, you both remain in our prayers – peace and love.