Blood ketone testing is used by people with diabetes and by people on a ketogenic diet.You can test your urine or your blood for ketones. But because urine testing is not as accurate, the American Diabetes Association recommends blood ketone testing with a ketone meter.
MethodTwenty obese participants undertook a VLCK diet for 4 months. Anthropometric and biochemical parameters, and venous blood gases were obtained on four subsequent visits: visit C-1 (baseline); visit C-2, (1-2 months); maximum ketosis; visit C-3 (2-3 months), ketosis declining; and visit C-4 at 4 months, no ketosis.
Results were compared with 51 patients that had an episode of diabetic ketoacidosis as well as with a group that underwent a similar VLCK diet in real life conditions of treatment. IntroductionIn recent decades the prevalence of obesity has increased considerably worldwide and has now reached epidemic proportions –, which implies potentially serious consequences for the health of the population and the economy –.
Hence, finding effective and safe short-term and long-term treatments for this pathology is a priority. In this sense, very low-calorie-ketogenic (VLCK) diets have consistently shown to be useful tools in the treatment of obesity –. In fact, our group recently conducted a nutritional intervention clinical trial in which a VLCK diet was shown to be significantly more effective than a standard low-calorie diet after 1 and 2 years of follow-up ,. Likewise, among various other benefits, a diet-induced weight loss of mainly at the expense of fat-mass and visceral mass, with the preservation of muscle mass and strength has been reported as a clinical advantage of this type of diet.Nonetheless, despite the solid scientific evidence that supports the use of VLCK diets as a useful weight-loss therapy, there is still some fear inherent in their usage because of their mechanism of action –. This type of diet is characterized by a restriction in carbohydrate and/or calorie intake to the point of inducing a shift in metabolism and the production of plasma ketone bodies –. Under standard conditions, glucose constitutes the most important substrate for energy utilization, especially in the central nervous system (CNS) which cannot use fatty acids as an energy source. During the period of a VLCK diet, the low-carbohydrate consumption leads to a depletion of the body’s glucose reserves, and therefore the CNS requires an alternative fuel source ,.
Study populationThe patients attending the Obesity Unit at the Complejo Hospitalario Universitario of Santiago de Compostela, Spain, to receive treatment for obesity were consecutively invited to participate in this study.The inclusion criteria were as follows, age 18 to 65 years, body mass index (BMI) ≥ 30 kg/m 2, stable body weight in the previous 3 months, desire to lose weight, and a history of failed dietary efforts. The main exclusion criteria were diabetes mellitus, obesity induced by other endocrine disorders or by drugs, and participation in any active weight loss program in the previous 3 months. In addition, those patients with previous bariatric surgery, known or suspected abuse of narcotics or alcohol, severe depression or any other psychiatric disease, severe hepatic insufficiency, any type of renal insufficiency or gouts episodes, nephrolithiasis, neoplasia, previous events of cardiovascular or cerebrovascular disease, uncontrolled hypertension, orthostatic hypotension, and hydroelectrolytic or electrocardiographic alterations, were excluded. Females who were pregnant, breast-feeding, or intending to become pregnant, and those with child-bearing potential and not using adequate contraceptive methods, were also excluded. Apart from having obesity and metabolic syndrome, the participants were generally healthy.The study protocol was in accordance with the Declaration of Helsinki and was approved by the Ethics Committee for Clinical Research of Galicia, Santiago de Compostela, Spain (registry 2010/119). Participants gave informed consent before any intervention related to the study.
Participants received no monetary incentive. Nutritional interventionAll the patients followed a VLCK diet according to a commercial weight loss program (PNK method ®), which includes lifestyle and behavioral modification support. The intervention included an evaluation by the specialist physician conducting the study, an assessment by an expert dietician, and exercise recommendations. This method is based on a high-biological-value protein preparations obtained from cow’s milk, soybeans, avian eggs, green peas and cereals. Each protein preparation contained 15 g protein, 4 g carbohydrates, 3 g fat, and 50 mg docohexaenoic acid, and provided 90–100 kcal.The weight loss program has five steps (Supplementary Fig. ) and adheres to the most recent EFSA guidelines of 2015 on total carbohydrates intake.
The first three steps consist of a VLCK diet (600–800 kcal/day), low in carbohydrates (. Schedule of visitsThroughout the study, the patients completed a maximum of 10 visits with the research team (every 15 ± 2 days), of which four were for a complete (C) physical, anthropometric and biochemical assessment, and the remaining visits were to control adherence and to evaluate potential side effects. The four complete visits were made according to the evolution of each patient through the steps of ketosis as follows: visit C-1 (baseline), normal level of ketone bodies; visit C-2, maximum ketosis (approximately 1–2 months of treatment); visit C-3, reduction of ketosis because of partial reintroduction of normal nutrition (2–3 months); visit C-4 at 4 months, no ketosis (Supplementary Fig.
The total ketosis state lasted for 60–90 days only. In all the visits, patients received dietary instructions, individual supportive counsel, and encouragement to exercise on a regular basis using a formal exercise program.
Additionally, a program of telephone reinforcement calls was instituted, and a phone number was provided to all participants to address any concerns. Anthropometric assessmentAll anthropometric measurements were undertaken after an overnight fast (8 to 10 h), under resting conditions, in duplicate, and performed by well-trained health workers.
Participants bodyweights were measured to the nearest 0.1 kg on the same calibrated electronic device (Seca 220 scale, Medical Resources, EPI Inc OH, USA), in underwear and without shoes. BMI was calculated by dividing body weight in kilograms by the square of height in meters (BMI = weight (kg)/height 2 (m)).
Venous blood gasesPeripheral venous blood samples were taken from any easily accessible peripheral vein, although most of the samples were collected from the antecubital vein and were immediately analyzed. A tourniquet was used to facilitate venipuncture, but it was released about 1 min before the sample was drawn to avoid changes induced by local ischemia. The analyzer has several measuring capabilities but only the following parameters were considered for the present study: acidity (pH), partial pressure of CO2 (pCO2), bicarbonate concentration (HCO3–), base excess (BE—amount of H+ required to return blood pH to reference value) and lactic acid. Partial pressure of oxygen is not reported since venous blood gas analyses are not a good reference of oxygenation because oxygen has already been extracted by the tissues by the time the blood reaches the venous circulation.
However, this parameter was not considered necessary for the purposes of the present analysis.We preferred to perform venous blood gases given that arterial punctures are more painful and carry a higher risk of complications compared to venous punctures. Moreover, venous blood gases have proven to be an adequate technique for the diagnosis of disorders in the acid–base balance ,. Determination of levels of ketone bodiesKetosis was determined by measuring ketone bodies, specifically B-hydroxy-butyrate (B-OHB), in capillary blood by using a portable meter (GlucoMen LX Sensor, A.
Menarini Diagnostics, Neuss, Germany). As with anthropometric assessments, all the determinations of capillary ketonemia were made after an overnight fast of 8–10 h. These measurements were performed daily by each patient during the entire VLCK diet, and the corresponding values were reviewed on the machine memory by the research team in order to control adherence.
Additionally, B-OHB levels were determined at each visit by the physician in charge of the patient. The measurements reported as “low value” (. Biochemical parametersDuring the study all the patients were strictly monitored with a wide range of biochemical analyses. However, for the purposes of this work only certain values are reported. Sodium, potassium, chloride, glucose, albumin, creatinine and blood urea nitrogen were performed using an automated chemistry analyzer (Dimension EXL with LM Integrated Chemistry System, Siemens Medical Solutions Inc., USA). Insulin and c-peptide were measured by chemiluminescence using ADVIA Centaur (Bayer Diagnostics, Tarrytown, NY, USA).
All the biochemical parameters were measured at the four complete visits.The anion gap was calculated from serum electrolyte measurements in the following manner: anion gap = (sodium) − (chloride + measured bicarbonate). Whereas osmolarity was estimated according to the following formula: osmolarity = (2 × sodium) + (potassium) + (glucose / 18) + (blood urea nitrogen / 2.8). Finally, HOMA-IR was calculated as follows: HOMA-IR = (insulin × glucose)/405. Reported cases of diet-induced ketoacidosisTo find all the reported cases of ketoacidosis during the course of a ketogenic diet in obese non-diabetic patients we performed a search on the PubMed database using the query “ketoacidosis AND (ketogenic diet OR low carbohydrate diet)”.The search was limited to “English”-language articles, “human” subjects, and publications prior to February, 28, 2017. The eligibility of the studies was assessed by one reviewer.A total of 344 articles were identified from the initial search in PubMed. After reviewing all the articles and excluding papers about other diseases (e.g., epilepsy and diabetes), and articles without reporting on acid–base disturbances, a total of four cases of ketoacidosis were detected. Subsequently a manual review of the PubMed database was conducted and an additional case was detected, resulting in a total of five cases of ketoacidosis –.
In the present work we will try to describe the possible causes that led to the appearance of ketoacidosis in these non-diabetic patients. Diabetic ketoacidosisGiven that the medical state of diet-induced ketosis may be confused with the pathological and life-threatening state of diabetic ketoacidosis, we have included a sub-analysis in which we compare our participants (VLCK diet) with a cohort of patients with diabetic ketoacidosis from another of our centers, with the purpose of finding the possible differences and similarities between both metabolic states.
This cohort of patients is formed by all the patients with diabetes of any type that were admitted consecutively to the emergency room of the Hospital del Mar, Barcelona, Spain, with a diagnosis of diabetic ketoacidosis between January 2010 and December 2011. Statistical analysisContinuous variables are presented as mean (standard deviation), whereas categorical variables are presented as frequencies (percentages). All statistical analyses were carried out using Stata statistical software, version 12.0 (Stata, College Station, TX). Data are presented as mean ± standard deviation and counts − calculated percentages (.)Anion gap = (sodium) − (chloride + measured bicarbonate)Osmolarity = (2 × sodium) + (potassium) + (glucose /18) + (blood urea nitrogen / 2.8)HOMA-IR = (insulin × glucose)/405a P. Changes in BMI, glucose, venous blood pH and capillary ketone bodies (B-hydroxy-butyrate) during the study. Data are presented as mean ± standard deviation. BMI body mass index.
The broken line represents the level at which it is defined the existence of diabetic ketoacidosis ( b) and ketosis ( c)The blood pH was not significantly different from the baseline at any time during the study, and their values were always within the normal range (Table and Fig. At baseline the blood pH level was 7.37 ± 0.03, at visit C-2 after near 40 days of diet and at the point of maximum ketosis the pH was 7.37 ± 0.02, at visit C-3 the venous pH remained unchanged (7.36 ± 0.02), as in the final visit (7.37 ± 0.02). A blood pH level of ≤7.30 is used in the literature to define diabetic ketoacidosis, but in our study no individual had a measurement below this level at any time point (Fig.
Metabolic acidosis may also be expressed as a decrease in bicarbonate because it is used to compensate for (buffer) acid metabolites. In the present study, there were also no significant variations in bicarbonate values (mmol/l) during the VLCK diet (24.7 ± 2.5 (baseline), 23.6 ± 2.4 (visit C-2), 24.1 ± 2.4 (visit C-3), and 25.8 ± 2.0 (visit C-4)). It is notable that these values remained unchanged and within the normal ranges even at the visit of the highest level of B-OHB (Table and Fig. Lactic acid did not show significant variations during the study, and the calculated anion gap was always in the reference range (Table and Fig.
Importantly, serum albumin levels were within the limits of normality throughout the study. Although there were some differences in electrolytes and blood urea nitrogen over the 4 months of dieting, none of them was considered as clinically relevant (Table ). Changes in venous blood gases parameters during the study.
Data are presented as mean ± standard deviation. HCO3, measured bicarbonate. The broken line represents the level at which it is defined the existence of hypobicarbonatemia ( a) and lacticemia ( b), and the normal range of the anion gap ( c)The hypothesis regarding the possible association between ketoacidosis and altered insulin function was assessed by a strict analysis of the glucose metabolism.
A considerable improvement in insulin sensitivity was observed in accordance with bw reduction (Table ). This observation agrees with the idea that in patients with an acceptable insulin function a ketogenic diet induces a well-tolerated ketosis rather than ketoacidosis. Diet-induced ketosis vs.
Diabetic ketoacidosisTo investigate the similarities and differences between the two metabolic states (i.e., diet-induced ketosis and diabetic ketoacidosis), we compared our study sample and a cohort of diabetic patients with ketoacidosis. Blood pH was significantly lower in the diabetic patients with ketoacidosis than in our study sample (7.16 ± 0.12 vs.
7.37 ± 0.02, P. VLCK dietDiabetic ketoacidosisP valueNumber of patients2051Age (years)47.2 ± 10.239.0 ± 13.50.016Venous blood gasespH7.37 ± 0.027.16 ± 0.12.
Diet-induced ketosis in real life conditionsWith the purpose of confirming the moderate production of ketones during the course of a VLCK diet, here we reported several capillary B-OHB determinations during different steps of a VLCK diet corresponding to a cohort of patients undergoing treatment for obesity in a real life setting. Interestingly, none of the patients reached values greater than 6 mmol/l at any point of the diet and the majority of the determinations were less than 3 mmol/l (Fig. We would like to thank A. Menarini Diagnostics Spain for providing free of charge the portable ketone meters for all the patients. We acknowledge the PronoKal Group ® for providing the diet for all the patients free of charge and for support of the study. The funding source had no involvement in the study design, recruitment of patients, study interventions, data collection, or interpretation of the results. The Pronokal personnel (IS) was involved in the study design and revised the final version of the manuscript, without intervention in the analysis of data, statistical evaluation and final interpretation of the results of this study.
Wondering how to use the Precision Xtra Ketone Meter? Here's a complete step-by-step guide to getting an accurate ketone reading for those on a ketogenic diet.
Here I use a complete kit to measure.Get yours at:Why a kit? I thought it was the best bang for the buck. You get a handy case to put your supplies inside- your lancing meter, your lancing gauges and your ketone testing strips. You could even include some of the alcohol pads included in kit within the case if you find yourself needing to test your ketone levels and unable to wash your hands.Kit also includes a separate lancing device called the 'Slight Touch.'
I just use the regular Precision Xtra meter and keep it dialed down to 2 or 3 (you'll see why in video).Hi there YouTube friend I’m Petrina Hamm, an online fitness coach & social media marketing strategist. I help busy people build fitter bodies and stronger businesses.
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