Ketosis and The Ketogenic Ratio – Q&A

Question: Do you still believe in the ketogenic ratio for getting into ketosis?  I am having trouble showing ketones. Any tips? Sorry to bother you again but can drinking 2 gal of water per day dilute your urine so you don’t show ketones?

Answer: Ok, let me take these on one at a time.

In my first book The Ketogenic Diet, I talked about something called the ketogenic ratio (KR) which is an equation/concept used in the planning of ketogenic diets for epilepsy patients. The equation basically gives you the potential ketone producing potential of a given meal depending on the relative ketogenic or anti-ketogenic effect of the different macronutrients.

So the KR of a given combination of nutrients can be estimated with the following equation:

 

Click to See A Bigger Version

 

Protein turns out to be partially ketogenic (46%) and partially anti-ketogenic (58%), reflecting the fact that some amino acids can be made into ketones, while other are made into glucose).  Carbohydrate is 100% anti-ketogenic and fat is mostly (90%) ketogenic (the 10% anti-ketogenic is due to the fact that the glycerol portion of triglycerides, explained in A Primer on Dietary Fats, can be converted to glucose in the liver).

Quoting from that section of The Ketogenic Diet:

This equation represents the relative tendency for a given macronutrient to either promote or prevent a ketogenic state (1). Recalling from the previous chapter that insulin and glucagon are the ultimate determinants of the shift to a ketotic state, this equation essentially represents the tendency for a given nutrient to raise insulin (anti-ketogenic) or glucagon (pro-ketogenic).

For the treatment of epilepsy, the ratio of K to AK must be at least 1.5 for a meal to be considered ketogenic (1). Typically, this results in a diet containing 4 grams of fat for each gram of protein and carbohydrate, called a 4:1 diet. More details on the development of ketogenic diets for epilepsy can be found in the references, as they are beyond the scope of this book.

However, invariably when people tried to apply the KR to low-carbohydrate fat loss diets, one of two things happened.  If the person set calories appropriately and used the KR, the protein intake ended up being far too low (because dietary fat had to be so damn high).   Alternately, if they set protein appropriately and tried to scale dietary fat to the proper ratio, the caloric intake ended up being too high.

The former was a poor choice from the standpoint of protein sparing; the second limited (or eliminated fat loss).

So basically I threw out the ketogenic ratio.  As noted above, it’s crucial for the development of epilepsy treatment diets (anyone wanting more information on this topic should purchase the excellent The Ketogenic Diet: A Treatment for Epilepsy by Freeman, Freeman and Kelly.

But for dieters and folks seeking body recomposition, it made setting up appropriate diets impossible.

Additionally, there isn’t convincing evidence in my opinion that ketosis is crucial for the benefits of the diet. Yes, ketones are protein sparing but only when dietary protein intake is inadequate in the first place.  When protein is set appropriately (e.g. 1-1.5 g/lb lean body mass as discussed in The Protein Book), the development of ketosis isn’t that critical to spare protein.  Simply, protein is the most protein sparing nutrient and other things (e.g. ketones vs. carbohydrates) only matter if protein is inadequate in the first place.

Even the hunger blunting effects of ketosis is up to debate and much of the recent literature on the topic suggests that it is actually the increased dietary protein intake that is causing the decreased hunger, rather than the presence of ketones per se.

Which is a long way of saying that I don’t think that the ketogenic ratio, or even the development of ketosis is important to the overall success (or failure for that matter) of low-carbohydrate diets.  In the Ultimate Diet 2.0, I addressed this rather explicitly in a section titled “What About Ketosis?”

 

For the most part, I simply see ketosis as a “side-effect” of fat loss (burning to be more accurate), more than something to be explicitly sought out. That is, when you accelerate fat oxidation with the methods above, you tend to enter ketosis. Ketosis in and of itself isn’t any big deal. For that reason, I won’t talk about monitoring ketone levels with Ketostix or anything like that. Frankly, using a low-carbohydrate/ketogenic diet for the fat loss phase of the UD2 has more to do with lowering insulin, raising catecholamines, and ramping up fat oxidation; ketosis is simply a tangential effect.

Which brings me to your second set of questions. For background,  low-carb dieters have often used a product called Ketostix which change color to indicate the concentration of ketones in the urine. Yes, you pee on them and they change color to indicate the presence or absence of ketones in the urine.

There are a number of problems with Ketostix not the least of which is that urinary ketone concentration is at best a very indirect indicator of what’s going on in the body.  True ketosis is defined in terms of blood concentrations (terms ketonemia), not urine (terms ketonuria).  But since you can’t easily measure ketones in the blood (no, you can’t put blood on the Ketostix, I tried it years ago and it doesn’t work), the next best thing is urinary ketones.

Now, obviously, if you have ketones in your urine, you certainly have them in your bloodstream.  However, the absence of ketones in the urine doesn’t mean that you’re not still in ketosis (as defined by blood concentrations).  You might be in ketosis as measured by blood levels but simply not be excreting any in the urine.  Or not excreting enough to change the Ketostix.

Basically, there are a variety of things that influence whether or not there are enough ketones present to be excreted in the urine in sufficient quantities to make the Ketostix change colors.  For example, you might not be making ketones in sufficient quantities (this happens in lean people, especially if they are very active), lots of water can dilute your urine and the ketone concentration, some other variables can impact on whether or not you show ketones on the Ketostix.

As you might imagine, at the end of the day, I don’t think focusing on ketosis per se (or the lack thereof) or the Ketostix is very valuable.  You can develop deep ketosis by gorging on dietary fat (especially Medium Chain Triglycerides) but your calories will be so high that you won’t be losing much, if any fat, that way.  And you can lose fat without ever showing a single ketone in the urine.  Basically, there’s just no real correlation between ketosis, what the Ketostix are showing and fat loss.

Basically, I have seen too many dieters focusing on the Ketostix instead of what’s important: relative amounts of fat and lean body mass lost. Focus on the latter, if you’re losing fat and maintaining lean body mass, your diet (low-carbohydrate or otherwise) is working, whether you are in ketosis or not.

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19 thoughts on “Ketosis and The Ketogenic Ratio – Q&A

  1. Hi Lyle,

    Another very informative article there! I see your argument that ketostix are not really an accurate measure of ketosis (and therefore supposed fat loss) because of the reasons you mentioned. But that doesn’t imply that Ketosis itself is a useless state, right? I mean if we consider two athletes, one in ketosis, the other in not ketosis and everything else (calorie deficit, training, body metrics etc) being the same; shouldn’t the one in ketosis be burning more fat in a given day?

  2. Actually, now when I think of it, it brings up another important scenario – Let’s say we have three similar trainees that maintain the same calorie deficit but have diet as follows –

    Trainee 1 – is in ketosis eating proteins/fats
    Trainee 2 – not in ketosis and eating carbs too but only complex low GI carbs
    Trainee 3 – not in ketosis and eating refined sugary carbs (say donuts)

    Since the calorie deficit is the same and their BMR etc are also same, will they all burn fat at the same rate?

    Historically, I’ve gotten excellent results on ketosis but now I wonder if I can be like Trainee3 above and still cut!!

    By the way, I’m thinking about buying one more of your books (already own The Stubborn Fat) to get a deeper insight into how the body works when on low calorie diets, metabolism, hormonal changes etc. Would you recommend UD2 or Ketogenic diet?

  3. It’s a touch more complicated than that as there are interactions with general physiology and phenotype but, in general, yes. Calorie controlled studies (e.g. check out hte research review on ketogenic vs. non-ketogenic diets and fat loss) show that fat loss is identical as long as protein is the same. What may differ is adherence some people find it easier to control caloric intake on lower carb diets that alone can be useful.

  4. Thanks for the reply. It’s interesting to know that I can still eat donuts and lose fat (feels kinda tingly to even write this!). Yes, from personal experience I’ve also realized that I’m the most hungry on days when I actually eat carbs! If I just don’t eat carbs (and possibly go Keto) then I don’t get hungry at all!

    Anyhow, I guess I’ll order your UD2 in a few days as it seems it should give me deeper insights into how body behaves on low calories and at low body fat levels.

  5. Good article Lyle. I spent many frustrated years beating myself up because the ketostix wouldn’t turn purple! Looking back, I think it was just that I didn’t want to believe that I would lose fat by simply eating less. So, I needed evidence that my body was in “fat burning” mode. Man, all the urine I wasted on those damn sticks …

  6. Lyle,

    Is there any truth to body odours and ketosis? Every time on CKD I’ve noticed strange body odour which I never had earlier in my life. It grows during the week and strangely enough it goes away on the weekend when i’m on carb reload. I’ve also read people mentioning this odour thing on some lowcarb or atkins forums.

    I’ve also used ketostix but there was no change in color probably because my body is using up all the ketones (because i’m relatively big and have a calorie defecit) and not much is pushed in the urine.

    Any thoughts on this?

  7. Is there a disadvantage of Atkins diets that do not cycle carbohydrates or have refeeds?
    WIthout reading your book, I’ve tried having a free day every saturday. It would kick me out of ketosis (at least in the stick readings for 3 days).

    Right now, however, I’ve been trying a free day every 2 weeks, so I can go on a strict induction much longer. So far, my body doesn’t like this 2nd induction period. The first time I lost 40 lbs in 7 weeks, but now in 14 days of induction I’ve lost only a pound..and under 1300 calories a day. 3 days of the induction, I had only 800 calories simply cause I was NOT HUNGRY! Atkins takes away all hunger. Who needs hoodia?? It really sucks to have no results. — I also did moderate cardio for 35 minutes 7x during the weeks and weights 2x.

    I’m not sure which book of yours I need to buy. Your Ketosis diet book? Or rapid fat loss? It looks like all of your books are good, but I can only afford one. I also know I would like to maintain a lean body. On any strict diet that you lose fat, its easier to put it back on.

    Male: 174 lb, 18% bodyfat

    Thank you

  8. Please read the Comparing the Diets series for plenty of comparison of cyclical and non-cyclical diets.

    I’d probably suggest Guide to Flexible Dieting for you.

  9. Hi Lyle

    I read somewhere that ketosis is an inefficient process in which your body essentially “loses” calories as it burns fat for fuel. That is, the conversion essentially wastes calories such that a gram of fat may only provide 7cal after processing in the liver. I also read that the ketone bodies in your bloodstream cannot be re-converted into fat and so when an individual gets off his ketogenic diet, he/she essentially urinates that reservoir of ketone-bodied energy. Do these statements have any truth to them as far as you know?

    For the second part, maybe that also has implications for delayed fat loss?

  10. I looked and looked and never found anything to support the idea that ketones were metabolic inefficient in that manner. One gram of ketones produced something like 4.5 kcal but 1 gram fat (9 kcal) was producing 2 grams of ketones so it all balanced. As far as urinary excretion, the total amount doesn’t add up to very much so I doubt that has much to do with it.

  11. 4:1 ratio for ketogenic diets to treat epilepsy is calculated for the calorie unrestricted diet. When treating kids it is essential to adjust the calories to their weight maintenance levels and then calculate the protein requirements to allow for growth in this kids. Here we have a different situation when fully grown person wants to drop fat. If you consider that when you restrict calories you eat your own fat than the ratio of total oxidised fat to protein would approximate the classic ketogenic ratio easily.

    Example:
    Protein RDA for a grown male is set as 0.8 g per kilogram of weight. Consider that we have a typical chubby male weighing 180 lb who wants to drop fat to end up being a 160 lb slimmer version of himself. RDA for 160 lb male would be 58g. Let’s assume that his maintenance caloric needs are a conservative figure of 15 times his desired weight 160*15=2400. Now if you subtract 240 calories from dietary protein from this maintenance figure you end up with 232 grams of fat (dietary or oxidised from body’s stores). The ratio would work out to be exaclty 4:1 of fat to protein in grams.

    You could adjust the diet fat content to less than 232 g of fat and keep protein at 58 and in a day you will lose as much fat as the difference between 232 and daily dietary fat grams. Obviously it will be beneficial to not restrict the calories too much and not shock the thyroid but a 1500k diet made up with 58 grams of dietary protein and 135 dietary fat would work fine and make our chubbo achieve the ideal after 3 months of hunger free nutrition.

  12. Hi

    I don’t THINK you answered this in your article but my apologies if you did.

    What I’d like to know is whether going into Ketosis means greater fat loss for the same gross calorific deficit than other dieting methods. People often mention how ketogenic diets are burning the body’s own fat for fuel and conclude that therefore the diet must be better than say a balanced, calorie controlled one. This is touted as the reason why Atkins produces strong weightloss in the initial very low carb phase.

    What is the truth?

    Thanks

  13. When doing the RFLD, and you do the free meal or the refeed, does your body come out of ketosis and therefor you have to start back over to get back in ketosis (day three afterwards). I know this is getting really technical, but am curious. Thanks, great site and articles! Very information!

  14. I have looked on the internet and can’t seem to find the answers to this question. If a child is on the Ketogenic diet for Epilepsy and is testing in the highest range on the Ketostix and three days later is tested again and now no longer even detecs any ketones in the urine how many carbs does it take? Did the child sneak a bite of a cookie or did they go off the diet completely for 3 days?

  15. I see this is a very old thread and the last question was not answered so wonder if this one would be either but here goes anyways:
    I am 56 female and prediabetic. I am doing low carb high fat and believe I have become keto adapted. I rarely have a ketostix turn color anymore as they did in the beginning many shades of purple but now maybe once ia great while I get a pink. The thing Is is that I am NOT losing one single pound and in fact have gained 3 pounds from this way of eating. I was on 2000 mg of metformin and lost 7 pounds but my Dr. took me off it cause my numbers were so good but then I gained all that weight back and then some without even changing a thing. I don’t eat hardly any carbs except some veggie carbs and maybe about 20 a day. I don’t do much exercising either because I take a beta blocker and I have very little to no energy most days but have been this way for about 5 years now. Soooooo why am I gaining all this extra weight and i’m not doing anything different then when I was on metformin? Any thoughts?

  16. May I ask the origin of the Ketogenic / Antiketogenic values for macronutrients you present here such as 46% ketogenic, 58% antiketogenic for protein?

  17. Source: Withrow CD. The ketogenic diet: mechanism of anticonvulsant action. Adv Neurol (1980) 7: 635-642.

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