Keto-Adapted to Target?

We are running head-first into an acute shortage of terminology.

How about:

Optimal Keto-Adaptation                            OKA   (or would that be “OK, eh?”)

Optimal Individualized Keto-Adaptation     OIK     (“oik” – that has some promise)

Monitored Ketogenic Diet                           MKD

Monitored Nutritional Ketosis                     MNK

Targeted Nutritional Ketosis                       TNK

Hmmm, well, none of these say “sha-zam” to me.

Maybe “Keto-Adapted to Target” or “KAT”?

Interest in the health and medical benefits of being in ketosis has expanded faster than the list of commonly accepted terms we can use to clearly express what we mean.

Most recently, there has been a rapid increased interest in using home blood ketone testing as a tool to aid people in using and exploring keto-adaptation as a potential means to achieve medical benefits, as well as improved well-being and better physical performance.  Blood ketone levels are a much more accurate reflection of your degree of ketosis than urine ketone levels, particularly once your body has become adapted to using ketones.

I won’t go in to it all here, as I have other posts and pages on this topic and will be definitely be posting more soon and over time. (Please see my post on blood ketone testing, and see under the heading “Nutritional Ketosis” on the Your Blooming Health site and read about Jimmy Moore’s remarkable story at his site.)

The point about the availability of home blood ketone tests is that they improve the ability of a person (who takes the time to adapt to different levels (“depths”) of ketosis):

  • to discover whether being consistently keto-adapted provides benefits to them
  • to find out how those benefits may be different at different sustained levels of ketosis
  • if there is a level of ketosis that they find beneficial or most beneficial - to learn how to, as much as possible, stay approximately at that level of ketosis
  • to then be able to judge how worthwhile the benefits are versus what the “costs” are in terms of effort, limitation of personal choice, inconvenience, any unpleasant effects or symptoms and any harms and risks, and so on (the worthwhile test).

It seems we are in need of a better vocabulary for discussing these things. Particularly, we seem to struggle with communicating about the degree or depth of ketosis – that is, terminology for amount or quantity or extensiveness. Another thing to communicate is the person’s broadness or narrowness of their target zone (symptom relief target zone as well as their own ketosis range target zone). How do we describe the ketosis range target zone?

(Note my use of the phrase “improve the ability” above. This is just one more tool and definitely is not an essential tool. You can manage quite well without it if you have the right information, are very consistent in your efforts and are careful in your observations, although having at least urine ketone test strips would help. If you are doing well without testing, that is terrific. Some people benefit from having more feedback information from their body. For myself, I have found this tool to be of great help. It definitely passes the “worthwhile” test for me.)

As we try to communicate with each other, this means that different people may be using a word or phrase to mean different things.

It also means that people may not be aware of when they are using terms that actually already have an accepted meaning in nutrition, science and medicine. Until recently, the degree of medical use of ketosis and scientific study of ketosis has been small and very few people not involved with the topic of ketosis would be well familiar with the existing terminology.

The term “ketosis” simply means having ketones in the blood. Since there are always at least some ketones in blood, but generally these are at a very low baseline level, the term, by common usage, refers to a level of ketones in the blood that are above the usual low levels seen under normal eating patterns and eating a general mix of foods.  It does not matter what the cause is, it is just “ketosis”. (see below re: ketoacidosis)

The term “nutritional ketosis” is a very good term and this has been just one of the many remarkable contributions of Dr. Jeff Volek and Dr. Stephen Phinney. It is made by combining together two words with well established meanings. Thus, “nutritional ketosis” means a state of ketosis that has been caused by nutritional means. Since a person’s state of nutrition refers to both the presence and absence of nutrients (as well as their absolute amounts and their relative amounts), technically speaking this term also includes starvation ketosis. Another term with the same meaning also exists, which is “dietary ketosis”.

These terms would also cover ketosis induced by high intakes of medium chain triglycerides, without there necessarily being a low carbohydrate intake. Whether they come from coconut oil or from “MCT” (medium chain triglyceride) oil, this still is nutritional or dietary intake.

The point of the term “nutritional ketosis” is that it pin-points the cause as being outside of the body. With the use of this term, immediately we are informed that there has not been a break-down in that person’s normal metabolic functions. The cause is not inside the person. No-one is about to die. “Calm down.” This is not ketosis caused by an absolute deficiency of insulin in a diabetic.

The term “ketogenic diet” was developed in the 1920s (or soon after, the exact date doesn’t matter enough to me to look it up).  It had long been noticed that many people with epilepsy had temporary improvement when they fasted. The trouble is that continued fasting is starvation, which obviously would lead to a breakdown of health and eventual death. Doctors wondered if there was a way to get the benefits of starvation without the person actually starving. The study of ketones and ketosis was in its early days, but still they knew that one of the features of starvation was high levels of ketones in the urine, spilling into the urine from the blood stream (not nearly as high levels as in diabetic ketoacidosis).

A diet program was figured out that would get enough calories and protein into the person to allow continued life, while causing ketosis. These very strict, rigorous diet plans were much more restrictive and formal than the Atkins diet and included a calorie restriction and strictly prescribed, meticulously measured meals with very low carbohydrates and the minimum protein. When they wanted you in ketosis, they got you in ketosis. There was no home urine ketone testing then, so they needed exceptionally rigid diets to ensure a steady predictable metabolic state day by day. Remember that these patients had epilepsy. A dietary slip-up could have severe consequences and even mean death. Many people had great benefit from these diets.

The advantage of the term “ketogenic diet” is that it is a well-established term and is widely known now in the neurological community, given the dramatic resurgence in the use of this diet for epilepsy treatment over the past 2 decades. This would be considered the long-established term in medicine and there are now many research papers on the topic of the “ketogenic diet”. (Try searching on this term on PubMed.)

Another advantage of the term is that it implies a long-term way of eating.

One aspect of confusion with this term is that the “classic” strict version of the diet is so well established that many neurologists consider the term “ketogenic diet” to only refer to the classic epilepsy-control version of the diet. This, of course, is a mistaken view.  The correct use of the term is that a ketogenic diet is any diet that (intentionally or not) results in a state of ketosis (ketones in the blood above the usual low baseline level).

OK, so you can use a ketogenic diet to be in a sustainable state of nutritional ketosis without starving to death (although it is well established that other nutritional deficiencies can readily develop and the nutritional safety of these diets can not be taken for granted).

If the diet is incredibly strict, detailed and unrelenting, you can reliably achieve this without testing for ketones. Instead of monitoring a ketone test result, you are monitoring (strictly measuring) the un-varying diet intake and monitoring for any changes in the degree of achieved symptom control.

“Keto-adaptation” is a term coined by researcher Dr. Stephen Phinney M.D. to refer to the fact that it takes some weeks and up to 2 months for a person’s body to fully adapt to functioning in a state of nutritional ketosis. That is, to become adapted to using fats and ketones as the predominant fuel, instead of the usual situation, where glucose is used as the predominant fuel. Part of keto-adaptation is that there is a normal, steady  blood level of glucose, with the glucose coming mostly from sources within the body, rather than coming mostly from the digestion and absorption of glucose from food.

This elegant concept is now an essential part of the understanding of sustained states of ketosis. It is essential for development and expansion of the health and medical uses of nutritional ketosis. Neither research nor practical application can proceed effectively without incorporating an understanding of keto-adaptation.

This leaves us still struggling with terms to describe the level of ketones in the blood.  Particularly, we need terms to describe a person’s general level over time. The level of ketones in the blood generally over time has implications for how much that person is using ketones as a fuel source – particularly how much their brain may be using ketones for fuel.

I think the term “keto-adapted” communicates very well with few words.  If I say I am keto-adapted, clearly I am not talking about being in an uncontrolled, unstable diabetic state. Clearly I am talking about being in a state of nutritional ketosis, from following in a sustained way (over at least a month or two) an eating pattern designed to produce ketosis (the technical term for one’s ongoing eating pattern is “diet”).

However, the term keto-adapted does not itself distinctly communicate the degree or “depth” of ketosis that I am adapted to or whether I am actually very aware of what my degree of ketosis or keto-adaptation generally is over time. Yes, Dr. Volek and Dr. Phinney have proposed that a blood level of 0.5 to 3.0 is the most optimal range for achieving the benefits of keto-adaptation. However, the term itself does not intrinsically imply that the person is generally in that target range.

Also, there is still a very small body of research and experience with keto-adaptation.   As with everything else in health and medicine, it can be expected that keto-adaptation to different ketone blood levels will be more and less beneficial (and more and less optimal or worthwhile) to different individuals.

For now, I think I’ll go with “keto-adapted to target”.

This implies an intended target and a process for choosing that target. It implies the use of a process for monitoring achievement of the target.  It also implies that the target is generally achieved over a sustained period of time (enough for adaptation to occur).  It also implies that there is some benefit that makes all this worthwhile.

Everyone’s actual target is their best health and well-being (with the least costs, risks, limitations to freedom, etc.). The proxy target is the range of blood ketone level they currently find most worthwhile to be keto-adapted to (obviously only for those who find any level of keto-adaptation to be worthwhile).

For some people this may not be a very deep level of ketosis. Some people may not find any need for testing ketone levels because they are enjoying their desired health benefits reliably without requiring that step. Some people will find it very worthwhile to do blood and/or urine testing for ketones in order to secure the health or wellness benefits they have found. Certainly, I have.

Still, this does not do enough to address the lack of vocabulary for the quantity or level or amount or “depth” of ketosis.  My feeling on this is that, for now, we should probably mostly use test result numbers as much as possible, rather than descriptive terms such as “high”. We are in the sand-box still in understanding and using ketosis. Useful ways of talking about quantity or level will likely emerge over time.

…….. I don’t know … maybe “OIK” works for you?

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It would be convenient if we could say that the term “ketosis” means something clearly and unmistakably different from what is occurring in “ketoacidosis”. I wish this was true, it would make things so much easier. Unfortunately, it is not true.  In ketoacidosis, it is a perfectly valid use of the term to say that the person is in a very high degree of ketosis. There is far more than that going on, of course, including an acidotic state of the blood related to the fact that ketones are acids and this acidity matters when the levels of ketones get very high. Also, consider the fact that the ketones don’t suddenly go from almost nothing to being very high the next minute.  The level of ketones go from very little, to more and then more and more.  In the earlier stages of this process, the accurate term to use is to say the person is in ketosis.  It would not be accurate to say they were in ketoacidosis, because the blood will not yet be acidic at that stage.

So, if we want to communicate the reason why there are ketones in the blood – the background cause of the ketosis – we have to include other terms.

A century ago it was pretty simple. There was ketosis produced by fasting/starvation and there was ketosis that could occur in diabetics, which would indicate a very dire state. Doctors became very concerned about even small rises in ketones in diabetics, because it signalled that a very dangerous state could be developing very rapidly. The person could be dead within hours.

It became critically important for hospitals to be able to quickly provide ketone test results. Urine tests were used because they were available and because they were accurate enough to be useful in that circumstance.  For a long time now test strips have been available to test urine ketone levels at home.  The need for people with diabetes to watch out for ketones was the entire reason these test strips were developed.

The transition from understanding that ketones were a feature of starvation and diabetes to understanding how to alter the diet to produce a sustainable state of ketosis was the next step in development.

The availability of home urine ketone testing and the understanding that ketones would show in the urine of some-one following a very low carbohydrate diet (such as had been advocated so famously by William Banting in the 1800s) came together in the use of urine ketone testing recommended by Dr. Atkins to monitor your state of nutritional ketosis. He was aware of the limitations of this technique, but it was what was available then. Certainly Dr. Atkins would have been incredibly thrilled if blood ketone testing had become available while he was still alive. Undoubtably it would have had a profound affect on his practice.

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NOTE: Page about nutritional ketosis in process and almost ready to post.

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