Those Ketone Strips You're Using Probably Aren't Telling You What You Might Think They Are

Composed: Feb 5, 2024

Author: Autumn

Those Ketone Strips You're Using Probably Aren't Telling You What You Might Think They Are

Let's start with what urine ketone strips are

Urine ketone strips were created as a way for Diabetics to be able to determine whether they might be going into diabetic ketoacidosis. Which, is different from ketosis entirely. Diabetic ketoacidosis is a medical emergency and can become fatal if not treated. So, ketone strips were created as a way for Diabetics to be able to test their urine to determine whether they had ketones in their urine. It can tell them whether they have a lot of ketones in their urine (large) or a small amount (trace). Those are the only things urine strips can tell anyone. Whether they have a large amount, a small amount, or no ketones in their urine. This, in large part, works because when your body first starts producing ketones (when you're new to keto or avoiding ketosis by eating a higher carb diet) you will “spill” ketones into your urine. As the body adjusts (keto-adapts) to having ketones in your system, you will “spill” less into your urine.

The urine strips cannot tell those of us who are following a ketogenic lifestyle/way of eating whether or not we're in ketosis because as our bodies adjust to being in a state of ketosis, our bodies will put less of those ketones into our urine. That is a more long-winded way of explaining what people frequently say, which is, ”they're not super accurate”.

But don't Dr. Phinney and Dr. Volek say that 1.5-3.0 mM is the sweet spot for weight loss?

If you've ever read their book, The Art and Science of Low Carbohydrate Living, you may notice that they do not reference any kind of research or studies or anything else that explains why they've defined a state of ketosis as being 0.5 mM or higher on a blood ketone meter.

Likewise, there is no explanation in the literature for why 1.5-3.0 mM is often referred to as optimal for weight or body fat loss. In short, there is no “optimal” level of ketones for weight or body fat loss.

GKI (Glucose Ketone Index) charts are largely marketing strategies, with little to no merit from a medical or research perspective. These very professional looking charts have no references to studies or literature because there is none to support the claims that there is a level of ketone or a GKI value that correlates to body fat or weight loss. Charts supplied by bloggers or companies selling blood ketone meters are marketing materials.

Of note, there is ample evidence to suggest that GKI can be applied to the treatment of several brain cancers and this is discussed in this paper. Still, there is no discussion of a ketone level or GKI value that correlates to weight or body fat loss.

What about for lipedema?

There is nothing in the literature regarding ketone levels and the management of lipedema or body fat loss. What seems to help is being in ketosis, following a low carb diet, getting your electrolytes properly managed, drinking enough (but not too much) water, getting in some movement, eating the right kinds of food for lipedema and for your body, eating enough food to support a healthy metabolism, eating enough dietary fat to support hormonal health, and eating enough protein to support both your lean mass and building new muscle as aged muscle breaks down naturally.

There is literature on dietary interventions that have been successful for managing lipedema. None of the research discusses optimal ketone levels:

There is no sweet spot for ketone levels and managing lipedema. It's not that simple. I wish it was.

So, is there nothing in the literature about ketones?

There certainly is literature on ketones, ketone tesing, and on ketosis.

In contrast to these striking advances in the approach to glucose monitoring, the process by which ketone bodies are measured in urine and blood, and the clinical indications for doing so, have not changed significantly in 25 years. Urine ketone testing remains a time-honored part of patient monitoring, especially for those with Type 1 diabetes, and blood ketone testing remains focussed on diagnosis and management of acute acid-base disturbances such as DKA [diabetic ketoacidosis]. The American Diabetes Association recommends that all people with diabetes should test their urine for ketones during periods of acute illness or stress, when blood glucose levels are consistently in excess of 300 mg/dl, during pregnancy, or when symptoms suggestive of ketoacidosis are present.

Commercial ketone tests for urine and blood rely on the Legal reaction, in which AcAc [acetoacetate] in a specimen of urine or blood reacts in the presence of alkali with nitroprusside (nitroferricyanide) to produce a purple-colored complex on a test strip or a test tablet. If glycine is added to the test reagent, the Legal test can also detect acetone in the specimen, although to a lesser degree. However, none of the commercial tests for ketone bodies reacts to the presence of 3HB [3-β-hydroxybutyrate] in the specimen. The Legal test is semiquantitative; it does not measure the exact amount of ketones in urine or blood.

Some commercial tests for ketone bodies contain glycine and hence can detect both acetone and AcAc, while others only detect AcAc. There is no evidence that any of these commercial tests offer advantages over the others. Multitest urine strips used in the professional office or hospital setting utilize the methodology noted above.

- Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes

In diabetic patients:

Other medical conditions and in fasted patients:

The only study, which mentions 0.5 mM simply refers to it as a "threshold value". Nowhere is it explained why this is a threshold value and nowhere is an optimal level defined for any purpose.

This study aimed to evaluate the accuracy and reliability of two blood ketone and glucose meters: Meter 1 - Precision Extra and Meter 2 - Keto Mojo. The meters were both found to be reliable, with a few caveats and limitations:

Both Meter 1 and Meter 2 displayed excellent test-retest reliability for BHB measurement, and interrater reliability between the two meters was also considered excellent. The bias, or average difference between readings for Meter 1 and Meter 2, was 0.056 ± 0.18 mM. That is, Meter 2 produced ketone measurements that were 0.056 mM higher than Meter 1, on average. The variability of each reading was large relative to the bias, but differences between Meter 1 and Meter 2 appeared consistent at all levels of measurement according to the Bland-Altman plot.

Caveats:

False positive results could be encountered as well, in which an athlete is not in NK but the meter indicates that they are. Given that resting ketones in a fasted state are reported to reach 0.1 mM, and a reading 0.4 mM higher than that (the upper limit of agreement between Meters 1 and 2) could be interpreted as being a state of NK [nutritional ketosis].
Early in the KD, before full adaptation has taken place, it may be more likely for Meter 2 to make a false positive (incorrectly indicating NK) or a false negative (incorrectly indicating an absence of ketogenic adaptation). For this reason, it may be best to take multiple measurements at a given time point early on in the adaptation phase (i.e. within the first week of diet adherence) to verify ketone levels and avoid false readings that could impact the decision made regarding a diet.
Following chronic adaptation to the KD (>2 weeks), the resulting higher BHB levels would make Meter 2 less vulnerable to errors when seeking to confirm NK.
Importantly, taking multiple measurements with Meter 2 would still be substantially more cost-effective than a single reading with Meter 1.

Limitations:

The findings of this study are limited by the fact that a field measurement device was used as the reference method for evaluating reliability, rather than the gold standard laboratory method. It is therefore more difficult to accurately interpret the measurements made by Meter 2, despite the fact that Meter 1 displays acceptable agreement with laboratory measurement of ketones up to 3.0 mM. Nonetheless, the measurement of ketone levels using Meter 2 may be deemed acceptable for the purposes of indicating the presence or absence of NK, which requires less precision but is still meaningful.
Another limitation of these findings is that ketone readings above those normally encountered in NK (>3.0 mM) were not measured or evaluated. It would be interesting to observe the accuracy of Meter 2 at these higher levels. There is little to no evidence reporting that different BHB levels are indicative (or causal) of a greater magnitude of adaptations. If any level of BHB indicative of NK (≥ 0.5 mM) results in the same level and speed of adaptation to the KD, then agreeability of the meters above NK levels are not crucial in determining adaptation. Future studies should investigate if different levels of KBs indicate different levels of adaptation to the KD.
All test strips used for the respective meters were from the same lot, so we cannot comment on the reliability of each device using strips from different lots. It is important to keep in mind that the environment that test strips are transported and stored in can impact the integrity of the strips and hence their reliability and validity. For example, if strips are stored in hot (>39 C) or frozen (<-20 C) environments that are not uncommon during sea or parcel freight, they may have a diminished ability to make accurate ketone or glucose readings. For this reason, strips from different lots may yield inconsistent results. It is recommended that test strips are purchased directly from the manufacturer and that the appropriate measures are taken to ensure a well-controlled shipping environment and resulting reliability of the test strip.

A study published in 2021, named Measuring ketone bodies for the monitoring of pathologic and therapeutic ketosis, identifies ketone levels in health individuals as ~0.1 mM for β-hydroxybutyrate (BOHB) [blood] and ~1 part per million for breath acetone (BrAce).

There is ample discussion of the BrAce in patients who were experiencing body fat loss, but no measurements of blood ketone levels are discussed. There is also no follow up to determine whether body fat loss was regained, which is often the outcome of calorically restricted diets. The researchers also suggest that that the "best" diet may, at some point, change from a low carb diet to a high carb diet beause "as weight is lost, the body becomes more insulin sensitive". However, they give no references or data to support this statement. In other words, this is not a very rigorously constructed study and the conclusions drawn about weight and body fat loss are dubious, at best. Even here, there is still no discussion of "optimal" blood ketone levels for weight or body fat loss.

Anecdotal Evidence

Anecdotally, many practitioners of ketogenic dietary approaches have experienced body fat loss and improvement of medical conditions. However, there is no identified commonality among pracitioners of ketogenic dietary interventions as to blood or breath ketone levels and weight or body fat loss.

In other words, there is no optimal ketone level for weight or body fat loss that has been identified or that can be applied universally.

Those Ketone Strips You're Using Probably Aren't Telling You What You Might Think They Are - Autumn All Year

Budget-friendly Cooking, Lipedema, Keto, Carnivore Diets, and Beyond

Composed: Feb 5, 2024

Author: Autumn