Keto is unique compared to other diets because there is an objective marker that tells you if you’re on the right track. With an easy at-home test, you can confirm that you are, in fact, in a state of ketosis.
Regular readers probably know I’m not a big data tracker. My energy, sleep, workout performance, stamina, and enjoyment of life tell me almost everything I need to know about how well I’m doing. Nevertheless, I get that some people love to play the self-quantification game. In some medical situations, measuring ketones is advisable, even necessary, as well. I’m not a total curmudgeon about it. Heck, I’ve been known to check in on my blood glucose and ketones from time to time.
If you’re thinking about testing, you should become familiar with the three different methods. Each has its own pros and cons. You’ll want to pick the option that’s right for you.
What Exactly Are You Measuring?
Let’s back up and do a quick refresher on ketogenic diets. These are any diets where carbohydrate intake is restricted below about 50 grams of total carbs per day. When you restrict carbs, you are really restricting how much glucose the body has to meet its energy needs. Without much glucose coming in, the body needs an alternative fuel source, especially for the brain, which doesn’t run well on fat. That fuel source is ketones.
The liver produces ketones from fatty acids when insulin levels are low and liver glycogen (stored glucose) becomes depleted. This happens when you follow a very-low-carb diet, fast, or engage in sustained exercise.
When your liver is producing measurable amounts of ketones, you are said to be in ketosis. This is not to be confused with ketoacidosis, a potentially fatal medical emergency. Keto diets don’t lead to ketoacidosis because the body has a safeguard that prevents ketone levels from becoming dangerously high: insulin. When ketones rise, the pancreas releases insulin, which in turn hinders the release of fatty acids from stored body fat. Fewer fatty acids in the bloodstream mean less substrate (material) for the liver to turn into ketones.
This feedback mechanism keeps ketone levels in safe ranges unless your body can’t produce insulin. Individuals with type 1 diabetes and very advanced type 2 diabetes are at risk for developing ketoacidosis for this reason. Diabetics often monitor their ketones to make sure they are within safe ranges.
For the rest of us, measuring ketones is just a way of checking whether or not we are actually in a state of ketosis. We might want to know that for a number of reasons, discussed later.
Meet The Ketones
In ketogenesis, fatty acids are metabolized in the liver to create ketone bodies. The primary ketone body is acetoacetate (AcAc), which can convert into beta-hydroxybutyrate (BHB). AcAc also spontaneously breaks down into a third ketone body, acetone.
The body primarily uses AcAc and BHB for energy. Although acetone can be converted into pyruvate, it’s generally considered a waste product.
How to Test Ketones at Home
There are three ways to test your ketones at home:
- Urine test strips, which measure AcAc
- Blood tests, which measure BHB
- Breath tests, which measure acetone
Urine Ketone Test Strips
How it works:
You can purchase urine ketone test strips online or in many pharmacies. They are cheap, costing only pennies per strip. Don’t confuse them with urine pH strips.
Simply collect your urine in a sample cup or pee directly on the strip. After a set time—usually 15 seconds, but some strips take longer—the end of the strip will change color. Compare the color on the strip to the key on the package to get your ketosis level. Rather than giving you an exact readout, the color tells you if your urine does not register any AcAc, or if it shows low, medium, or high levels.
It’s straightforward but not foolproof. For one, if you let the strip sit for too long before you interpret the results, the test can be inaccurate. Urine strips also tend to overestimate the amount of AcAc present and can give false positives./’>2 Results can be affected by how well hydrated you are, too.
Although urine tests are shown to correlate decently well with blood and breath tests in diabetics‘>4 AcAc in the urine is considered “spillover.” When you first start a keto diet, your cells aren’t great at utilizing ketones, so some get excreted. You’re measuring ketones the liver made but the body can’t use. As you become more keto-adapted, there should be less spillover.
Most keto dieters do find that their urine ketones decline over time. That’s a good thing, indicating less waste; but it also means the urine tests become less useful. It’s very common for experienced keto dieters to have low or no measurable ketones in their urine despite having plenty in their bloodstreams.
- Least expensive method of testing
- Does not require blood—no finger pricks
- Least accurate, especially after keto-adaptation period
- Affected by how well hydrated you are
- Does not tell you exact ketone levels
Blood Tests for Ketones
How it works:
Blood tests measure the level of BHB in the bloodstream. This is considered the gold standard in ketone testing. They require an initial investment in a meter, plus ongoing purchases of test strips. You also need a lancing device and sterile lancets to prick your finger and draw a droplet of blood. If you’re planning on testing several times a day, it can get expensive fast, not to mention your sore fingertips.
The two most popular meters in the U.S. are the Keto Mojo() and Precision Xtra. Both also measure blood glucose, but you need separate test strips. The Precision Xtra meter runs around $25 depending on where you purchase it. Ketone test strips cost about $1.20 each, and glucose test strips about $0.65.
You can get a Keto Mojo starter kit on the company’s website that includes the meter, lancing device, 10 lancets, 10 ketone test strips, 10 glucose test strips, and a travel case for $59.99. Additional ketone test strips cost $49.50 for a 50-pack. Glucose test strips are $14.99 for a 50-pack. They also offer a Bluetooth connector for $9.95 that allows you to upload your test results to an app.
Understanding blood test results:
Your meter will give you a reading of 0 or “Lo” if you aren’t in ketosis. On a typical keto diet, you might be anywhere from 0.3 to around 2.0 mmol (millimole). Fasting and exercise can each drive BHB up to 4.0 mmol or higher. Ketoacidosis occurs above 10 mmol.
In The Art and Science of Low Carbohydrate Living, renowned researchers Jeff Volek and Stephen Phinney proposed that ketosis begins at 0.5 mmol. The designated 1.0 to 2.5 mmol as the “optimal ketone zone.” Don’t get too hung up on these numbers, though. Some individuals produce high levels of ketones on a normal keto diet, while others barely register any unless they fast or use exogenous ketones (which contain BHB). I have friends who have been strictly keto for years and consistently hover around 0.3 or 0.4 mmol. We don’t really understand why these individual differences exist. I’ve offered some hypotheses, but it’s still a bit of a mystery.
Anyway, higher numbers don’t mean that you’re doing better than the next person. In certain medical situations, such as for seizure control, high BHB levels are desirable. For the average person doing keto for weight loss or general wellness, there’s no evidence that it makes a big difference. More recently, Phinney and Volek have started to talk about the “effective therapeutic range”—where you can expect to reap benefits from being in ketosis—as being anywhere between 0.5 and 4.0 mmol.‘>6
Breath acetone does reliably correlate with blood BHB. Multiple studies also show that acetone readings are correlated with weight loss when participants follow a calorie-restricted diet.‘>8 Blood tests were otherwise fairly steady throughout the day, with a modest decline in the afternoon. Urine tests showed higher ketones as the day progressed, also with a small mid-afternoon dip. The highest levels occurred before bed, at 10 p.m.
Do You Need to Test?
No, but there are some reasons you might want to.
As I said up top, those using a ketogenic diet therapeutically might need to track ketone levels. For certain conditions like epilepsy, patients might aim for ketone levels of 4.0 mmol or higher./’>10 A blood BHB measurement is required to calculate GKI.
You might want to track your ketones if you’re running an n=1 experiment. Maybe you want to see what happens when you eat more protein or carbs, or you’re gauging your reactions to certain foods.‘>1 we can’t hang our hats on it. First off, total cholesterol is limited because it’s only telling us the amount of cholesterol contained in all our lipoproteins without saying anything about what kind of lipoproteins we have or how many there are. Second, total cholesterol is limited because it’s determined by a bizarre formula – HDL-C+LDL-C+(Triglycerides/5) – that reduces various types of blood lipids, each with a different role in the body and a unique impact on our risk for illness, to mere numbers. Someone with low HDL and high triglycerides could easily have the same TC as someone with high HDL and low triglycerides, so long as the numbers work out. Whether it’s being used to predict wellness or disease, total cholesterol by itself is mostly meaningless.
Standard view: “Good” cholesterol. It’s the “garbage truck” that cleans up “excessive” cholesterol and fat from tissues, so the higher the better! Though men and women should strive for levels exceeding 60 mg/dl, above 40 is acceptable for the former and above 50 is acceptable for the latter.
My take: Higher HDL-Cs correlate strongly with better cardiovascular health. No real argument here. Higher HDLs are desirable. Just remember, it’s only a snapshot of a glimpse into the cholesterol content of your HDL particles. Among most groups tested, the TC:HDL ratio is actually a strong indicator of heart disease risk, with higher ratios corresponding to higher risks. Note, though, that no Primal Blueprint adherents were among the groups analyzed, ever.
Standard view: Get it as low as humanly possible! I want that low density lipoprotein so low as to be nearly nonexistent. Your body obviously hates you; otherwise, it wouldn’t be producing a potently toxic substance and sending it directly into your endothelial cells to form atherosclerotic plaque! Of course, we’re not actually measuring the number of low density lipoproteins, just the amount of cholesterol contained in them, but still!
My take: While a high LDL-C may indicate a problem, remember that LDL-C only indicates the total amount of cholesterol in your LDL particles. You could easily have a few large particles (good) or a bunch of smaller, denser ones (bad, might indicate poor LDL receptor activity and an LDL that likes to hang out in the blood), but LDL-C alone isn’t enough to know. It’s also just a moment in time, whereas what you’re interested in is the trend. If the trend indicates a steady rise in LDL-C, however, that could hint at poorer LDL clearance and lower LDL receptor activity (and greater susceptibility to oxidation).
Standard view: Lower would be better, sure, but you really gotta do something about that LDL! Anything less than 150 mg/dl is fine.
My take: High triglycerides correlate strongly with low HDL and smaller, denser LDL. High triglycerides, then, could indicate more oxidized (or oxidizable) LDL. The triglycerides of most Primal eaters, especially those on the lower carb side of things, usually hover well below 100 mg/dl. Triglycerides come packaged in VLDL, or very low density lipoproteins (which are calculated by dividing your triglyceride count by 5).
So, what can we learn from a standard lipid test? If we take a series of regular ol’ lipid measurements, preferably one pre- and several peri-Primal, we can get an idea of our metabolic health. Look for:
- Trends – Are your triglycerides going down over time? That’s great. Is your HDL trending up? Also good.
- Normal fluctuations – Your numbers can jump around 20-30 points in either direction between readings without it necessarily meaning anything.
- TC:HDL-C ratio – Lower is better and indicates fewer LDL particles.‘>3‘>5 If you have a lot of ApoB, you have a lot of LDL particles, which could mean the LDL receptor activity is down-regulated. Or, it could mean you’re losing weight, which can affect lipid values in multiple ways. Or, it could mean that today was a particularly “high ApoB day” and that getting it tested next week will give a different result, simply due to natural fluctuations. You just don’t know.
And that’s actually the main issue with all cholesterol readings, however advanced: They are snapshots in time. They do not capture the natural fluctuations and trends of the biomarkers. Your cholesterol was elevated today at 12 noon. What does that say about your levels tomorrow at six in the evening? Next week? Nothing. To account for natural fluctuations, get tested at regular intervals and observe the trends.
If you can’t get the ApoB test, total cholesterol/HDL ratio is a good indicator of how long LDL is hanging around in the blood and remains the best standard assessment of heart disease risk. Another good one is triglyceride/HDL ratio, which is a strong surrogate marker for insulin resistance. In both cases, lower is better. An ideal T/HDL ratio is 1:1; 2:1 is about as high as you want to go. An ideal TC/HDL ratio is 3.5:1 or lower.
Okay, so by whatever metric you want to use, your numbers are “elevated” and you’ve taken enough readers to get a general trend. It’s not just an isolated number. Should you worry?
Is High Cholesterol a Problem?
Oh, boy. There’s the million dollar question.
First off, let’s go back to the evolutionary prism. As a naturally self-regulating system, the body isn’t going to produce something that is intrinsically pathological. Maybe that could happen in really rare genetic mutations, but everyone produces, utilizes, and relies upon cholesterol. It simply doesn’t make sense that cholesterol is evil.
Adequate cholesterol isn’t available for the body’s repair system, for the uptake of serotonin, for the full initiation of Vitamin D and hormone production and their regulation of blood sugar and inflammation, etc., etc. What does your logic tell you here? Yup, nothing is running the way it should.
Let me also add that everyone’s cholesterol profile is going to be different, no matter what. And I acknowledge that a very small percentage of people out there genuinely have *true* hereditary high blood cholesterol, familial hypercholesterolemia, a metabolic condition with impaired or even lack of ability to metabolize cholesterol. This condition can have serious health consequences. By the way, this condition, in its heterozygous form affects at most 1 in 500 people. Total serum cholesterol in these folks is in the 400 mg/dl range (as opposed to the 200 recommended). The homozygous form affects about 1 in 250,000. You likely don’t know anyone in this category because their disorder almost always ends their lives at a very young age. But even the heart disease common in familial hypercholesterolemia might not be caused solely by high LDL, but by poor coagulation./’>7 That’s right: higher LDL, less heart disease deaths. Plus, most people who have major heart attacks have “normal cholesterol.”
I’ve said it before, and I’ll say it again. Sound and reliable medical research hasn’t proven that lowering (or low) cholesterol in and of itself reduces risk of death from heart disease across a population. What does this tell you? There must be some other piece or pieces to the cholesterol/heart disease story.
Based on my examination of the evidence over the years, it all boils down to oxidative stress and inflammation.
The inflammatory response and subsequent oxidative stress load is ultimately responsible for the oxidation of the LDL, while inflammatory cytokines produced at the atherosclerotic site can weaken and loosen the plaque, thus setting the stage for (and even causing) a rupture. In fact, inflammation is intimately involved in nearly every aspect of heart disease.‘>9
Furthermore, nearly every study suggests that LDL is only a true threat when it’s oxidized. What increases the risk of oxidized LDL?
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- Having LDL particles that hang out longer in the blood.
- Eating too much linoleic acid (it’s the polyunsaturated fat in the lipoprotein that oxidizes)./’>11
- Failing to eat grass-fed dairy./’>13
- Not eating extra virgin olive oil and fish oil.‘>1 and a few surrounding areas, where the conditions are just right to grow and harvest the small, orange-sized fruits.
Monk fruit belongs to the cucurbit family alongside squash, cucumber, and watermelon. Fresh off the vine, the mini melons have a bitter outer rind encasing a sweet edible pulp and seeds. But unless you know someone who’s managed to cultivate monk fruit in their garden, you’re unlikely to eat a fresh monk fruit. The flesh degrades quickly, meaning most manufacturers dry monk fruit or process it so that it will make it to market.
Most monk fruit finds its way to American shelves as a concentrated natural sweetener. As always, the nature of that sweetener can vary markedly depending on how it was processed.
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Is Monk Fruit Keto?
An average serving of pure monk fruit extract contains virtually no carbs, calories or sugars, which makes it a great choice to sweeten keto desserts and drinks.
It derives almost all of its sweetness from a group of antioxidants ‘>4 the key ingredient is generally mogroside V. This is easily the sweetest-tasting of all the compounds in monk fruit. Very conveniently, your body does not metabolize it in the same fashion as simple sugars like glucose or fructose. Your digestive system does not readily absorb Mogroside V. This accounts for the “zero calorie” claims of monk fruit extract products. It spells good news for those looking to satiate their sweet tooth while avoiding calorie loading or blood sugar spikes.
Potential Benefits Of Monk Fruit
While the extraction and refining processes remove most of the original natural compounds from fresh monk fruit, research indicates that the mogrosides and other flavonoids that remain can still benefit your body. Here’s a brief look at some of the benefits (preventative and otherwise) you might enjoy using monk fruit sweeteners.
Monk Fruit May Combat Obesity
As Primal folks know, sugar (not fat) is the leading dietary cause of the obesity epidemic. And as the world has ever-so-slowly awakened to the notion that sugar might be doing the most damage, there’s been a push towards sweeteners that don’t elicit the same insulin-meddling, inflammation-elevating, liver-damaging effects as sugar. Preliminary evidence suggests that the mogrosides in monk fruit sweeteners might be just the ticket. A 2012 study showed that total mogrosides extracted from monk fruit “suppressed the increase in body weight, abdominal and epididymal fats weight” in mice placed on a high-fat diet (presumably not good fats).‘>6 Researchers thought that the mogrosides achieved this anti-obesity effect by “enhancing fat metabolism and antioxidative defenses.”
We need more research to verify these findings, especially in humans. But its a promising start.
READ NEXT: Does Monk Fruit Break a Fast?
There has been plenty of research into the potential antidiabetic effect of mogrosides found in monk fruit sweeteners. In one study, mogroside extracts from monk fruit administered to diabetic rats significantly eased symptoms and protected against biochemical abnormalities.‘>8
Yet another study showed that both crude monk fruit extract and mogroside V helped to stimulate the secretion of insulin in pancreatic beta cells.‘>10 used mogroside IV, extracted from monk fruit, to inhibit the proliferation of both colorectal and throat cancer cells and suppress tumor growth. An earlier study ‘>13
More than half of a more recent study demonstrated the ability of mogroside V to lower induced lung inflammation in mice.‘>15 We can assume that this is at least partially attributed to monk fruit’s anti-inflammatory compounds.
Monk and Immunity
The health-giving powers of monk fruit sweeteners may even extend to immune function. In one study, scientists fed groups of diabetic mice low-dose mogrosides, high-dose mogrosides, or a saline control solution over a month.‘>17 further solidify the immune-boosting effect and prevent the growth of common bacterial pathogens like Streptococcus mutans, Porphyromonas gingivalis, and Candida albicans.
Are Monk Fruit Sweeteners Safe?
Long-term, multi-year toxicity trials the best way to evaluate safety, but so far, no tests have yet revealed anything of concern. People sometimes report digestive discomfort with monk fruit, but some say that it would be due to other things that are mixed with the monk fruit (like xylitol or erythritol) and not the monk fruit itself.
The FDA gave monk fruit products their generally recognized as safe (GRAS) seal of approval in 2010, and it’s of some note that monk fruit has been cultivated and eaten since at least the 13th century, albeit at far lower concentrations.
Limited trials in humans haven’t reported any adverse effects, and a study in mice showed that, mice who consumed high dosages did not experience toxic or mutagenic effects.‘>1
- Sustained low doses of curcumin were actually more effective in reducing beta-amyloid plaques, the hallmark of Altzheimer’s disease, than higher doses.‘>3 like in India (compared to the United States) and in East Asia (compared to Europe).‘>5 Here are a few of the research studies we have so far.
- Curcumin was shown to induce breast cancer cell apopstosis (where cancer cells destroy themselves).‘>7
- Disrupted cell growth is a large factor in cancer development, and curcumin may have a regulatory effect on cell function.‘>9
Turmeric and Curcumin for Arthritis, Aches, and Pains
- Turmeric extract high in curcumin shows promise as a safe and effective approach to rheumatoid arthritis‘>11
- Topical curcumin may speeds up the healing of wounds‘>13
How to Take Turmeric
In general, you can use turmeric powders in cooking, or you can take a turmeric or curcumin supplement in capsule form.
Here are a few ways to experiment with turmeric powder in the kitchen:
- Turmeric pairs well with fish, often accompanied by little else than salt, pepper, and some lemon juice.
- Make a creamy cup of “Golden Milk,” or turmeric tea.
- For roasted chicken, I’ll sometimes rub the dry, raw bird with a turmeric-butter mixture before it enters the oven.
- You can turn that same turmeric butter into turmeric ghee – in Ayurvedic tradition, turmeric and ghee have a potent synergistic effect. Just mix softened butter with turmeric a couple hours before clarifying it.
- Add a few teaspoons to your chili for a subtle earthy flavor.
- The next time you roast a winter squash, sprinkle the finished flesh with turmeric, cinnamon, and butter.
- Make some easy turmeric scrambled eggs.
- Roast fresh cauliflower dusted with turmeric, cumin, salt, and pepper and tossed in your cooking fat of choice.
- Try this hearty lamb and kale soup with turmeric.
Turmeric Supplements, and More Concentrated Curcumin Supplements
Since it’s difficult to get a functional dose of curcumin from turmeric spice powder alone, a lot of people turn to curcumin supplements. They are easy to find and relatively inexpensive. To bolster absorption, look for a supplement that contains a small amount of black pepper or piperine (the active ingredient in black pepper).
Curcumin Dosage: How Much Turmeric Should You Take?
Most of the research on turmeric has revolved around curcumin, an active, antioxidant component of the spice. By weight, curcumin content of turmeric powder goes no higher than 3.14% – not a terribly large amount, considering the therapeutic curcumin dosages being studied.