Managing Ketosis: The Ins and Outs of Keeping Ketosis Safe

Content Contributor: Taylor Parrish, RDN, CLC, LD

Ketones, ketones, ketones…..when you or your child are on a ketogenic diet it may feel like ketones are running your life! Your doctor asks your ketone level, your dietitian asks your ketone level, and you are likely tracking your ketone levels at home but what is all this business about ketones really about? Let’s take a deep dive into what factors impact ketones and why you may notice your ketone levels vary! 

What factors can lower your ketone level?  

• Illness & Stress: Sickness (without vomiting and diarrhea) may lead to a decrease in ketone levels. Additionally, stress hormones (often a factor with illness) can lead to an increase in glucose levels which then can lower your ketones.  

• Weight Gain: While normal weight gain is appropriate and necessary for children, excessive weight gain can lead to lower ketone levels. Your dietitian will keep a close eye on your child’s weight gain to make sure it’s appropriate for her/his individualized plan. 

• Hidden Carbohydrates: Have you stopped measuring? Have you started eyeballing portions? If so, has your “eyeballing” portions gotten a bit incorrect?  Double check your portion sizes and make sure they are accurate. In addition, remember carbs can be hiding in many medications, sweeteners and herb/spice blends. 

• New Foods: If you have added a new food into your keto plan (especially a “keto” marketed food), double check the amount of sweetener and fiber in the product. Even if it’s a keto approved sweetener or sugar alcohol, some people respond differently to these ingredients – this is why it’s important to track, especially when trying new foods, to see a response.  It is important to also note that some sweeteners can take up to 24 hours to take effect. 

• Inadequate Carnitine: Carnitine is an important factor in fat metabolism because it helps fat get used for energy.  Ketogenic diet therapy utilizes more fat than those not on keto so the need for carnitine increases. It is common to have insufficient carnitine when on ketogenic diet therapy so be sure to keep up with your regularly scheduled lab work to get an accurate measure of your carnitine levels.   

• Time of Day: Ketones are generally lower in the morning due to the dawn phenomenon which is when cortisol (a hormone) is released in the morning. Cortisol tells your liver to use up stored glucose (glycogen) because your body has gone more than 4-5 hours without energy (food). The pancreas then secretes insulin. Insulin can decrease ketones. In addition, as you eat fat throughout the day your ketone level generally increases.  

• Inadequate Fat Intake: Be sure you are eating your recommended amount of fat daily. If you aren’t eating enough fat as prescribed by your keto team, you likely will have lower ketone levels. 

• Hydration: Remember that urine ketones are hydration dependent. If you drank a much larger amount of fluids than normal, it may decrease the reading on your urine ketone strips due to your urine being more diluted.  

• Body Care Products: Some individuals may be sensitive to carbohydrates in body care products such as lotions and shampoos.  While this may not apply to all individuals, if you are really struggling with ketosis and you’ve exhausted all other avenues, take a deep look into your body care products. The Charlie Foundation and the Keto Hope Foundation collaborate each year on the resource, “No and Low Carb Personal Care Products Guide,” which is available for download from the Charlie Foundation store for $8.99.  It can be very helpful to find products such as sunscreen, toothpaste, shampoo and lotion (to name a few) that are keto friendly.

What factors can increase your ketone level?  

• Dehydration: Ketogenic diet therapy has a diuretic effect, so getting enough hydration is essential in maintaining a safe level of ketosis. Being in ketosis puts your body into more of an acidic state, which is why your keto team looks at your CO2 (bicarbonate) levels– a measure of acidosis. The goal is to induce ketosis but prevent excessive acidosis which can be exacerbated when we are dehydrated. 

• Weight Loss: If you are losing weight due to inadequate calorie intake, you will start to burn your own fat stores which means higher ketones. 

• Medium Chain Triglycerides (MCT) Oil: MCTs are easily absorbed and bypass much of the digestion process. Because of this easier digestion, MCTs provide a quick energy source for ketone production. If you want to learn more about MCT oil, check out our blog, The Adventures of MCT Oil. 

How Do I Best Manage Ketosis? 

• Eat meals and snacks at the same time each day as prescribed by your keto team. Avoid skipping any meals/snacks. 

• Monitor weight closely. 

• Communicate with your keto team frequently. Keep them informed of ketone levels, glucose levels (if applicable), seizure control and your child’s behavior. 

• Track your ketones as recommended by your keto team. Whether you are using urine or blood ketone measurements on your ketogenic journey, it’s important to track and report your levels to your keto team. They may ask you to check once a day or several times a day – everyone’s plan is different, but your keto team can use this information to tweak your ketogenic diet to obtain the best seizure control possible. 

• Track your meals in a food tracking application such as MyFitness Pal (Note: This applies to those on a Modified Atkins Diet or Low Glycemic Index Treatment.) 

• Stay hydrated. If you do not know your fluid goal, ask your keto team! 

• Be aware of signs/symptoms of excessive ketosis including nausea, vomiting, rapid or shallow breathing, extreme sleepiness, and/or facial flushing in combination with high ketones. Typically, excessive ketosis cannot be identified by just ketone levels alone – it’s best to look at the big picture of symptoms alongside high ketone levels. If your child has any signs/symptoms of excessive ketosis, notify your keto team. 

Disclaimer: The advice mentioned in this article is not medical advice and should not be taken as medical advice. You should always check with your medical provider if you have any questions about your ketone level.