"As the body adapts to be an efficient "fat-burning machine," the unnecessary enzymes will be broken down and turned into glucose. This could potentially cause unforeseen fluctuations in blood sugar." Is he saying that access ketones turn into glucose or am I reading this wrong.

No matter what Dr K says, I can assure you that ketones do not, and cannot, turn into glucose.

And yes, starvation ketosis can eventually become ketoacidosis, but only to a very, very mild degree. And starvation ketosis has absolutely nothing to do with diabetic ketoacidosis. Just as benign dietary ketosis also has nothing to do with diabetic ketoacidosis.

I agree with Rosebud. For one thing, ketones are not enzymes. Acetone is an example of a very simple ketone. Wikipedia offers a reasonable, although somewhat technical, description of the molecular structure of ketones:

http://en.wikipedia.org/wiki/Ketones

He never said that they do. The concern about glucose was a separate issue from the ketones. What he did say was that the body contains a lot of enzymes (i.e., proteins) that are used in the digestion and metabolism of food. When a person changes to the Optimal Diet, the enzymes that were needed for the previous way of eating will be broken down and turned to glucose, and will be replaced by enzymes that are suited to the new fat-based energy supply. Thus, there will be some degree of extra glucose in the beginning, even if the person is consuming very few carbs and just an adequate amount of protein.

He says that this changeover of enzymes happens over a period of several weeks -- but its effects, if any, will be strongest in the early days, and will decrease gradually over time. I'd guess it would be more significant for people who are making the transition from a high-carb diet, rather than those who've already been LC for a while. And I don't get the impression that it's been a big issue for most of his patients... he's just being extra careful.


Starvation ketoacidosis is the type he's referring to. Even though it has a different cause from diabetic ketoacidosis, it seems to be a special risk for people who are diabetic. According to JK, if excessive ketosis happens at all, it will only be during the changeover period, especially around days 6-10 after starting the diet (which is the only period when he recommends testing the ketone level). "Initially, as the body reconditions itself for an entirely new metabolism, the liver does its best to force the heart and brain to burn ketone bodies and often overproduces them."

As for the acidosis being "mild"... well, that would make sense. He wouldn't likely recommend that people try implementing this diet at home if there were a significant risk of a severe reaction. But it still seems like something that's worthy of caution. Again, like the glucose issue, it would only need attention in the early days.

I promise I'm not trying to pick on you here, pangolina! But this doesn't make sense either, and I don't want any diabetics reading this to worry unnecessarily.

Starvation ketosis is caused by starvation. Benign dietary ketosis is caused by reducing carbs, and is absolutely, well, benign, whether for diabetics or nondiabetics.

So I think maybe there is a translation problem here. Because showing ketones in the urine is just fine for all of us, as long as our glucose levels are not strongly elevated.

He's absolutely talking about starvation ketosis, not benign dietary ketosis. He specifically says that the kind of ketosis that might affect diabetics in the first couple of weeks of the Optimal Diet, is the same kind that would happen if they were placed on an actual starvation regime to get their condition under control (which I gather was sometimes done in the past, before insulin was available?).


Based on my reading, it's possible, though unusual, to have ketoacidosis with a normal blood glucose. This seems to have only been documented to happen under actual conditions of starvation -- e.g., someone who's stopped eating due to depression -- or with a lesser degree of fasting during times of significant illness or physical stress, such as a sick young child, or a woman who's late in her pregnancy with twins. I looked into this last night, and found several such cases in the medical literature. Most have been in diabetics, though there are some exceptions. A few examples:

Starvation induced true diabetic euglycemic ketoacidosis in severe depression

Normoglycemic diabetic ketoacidosis during pregnancy

Ketoacidosis in a 14 month old child caused by fasting

The Optimal Diet is different from Atkins, Protein Power, Bernstein, and other typical LC diets, as it limits protein as well as carbs. I'm not an expert on all the mechanisms involved, but maybe this could explain why the body might go through a brief period of something resembling "starvation," as it learns how to use its new fuel supply efficiently?

JK doesn't suggest that there's any risk of ketoacidosis after this intial window has passed, even though protein and carbs are still kept at the same level. (He also says that trace ketones are safe at any time.)

BTW, I just wanted to thank you all for not biting my head off. When I saw that the thread had been moved in here, I was somewhat intimidated, as I know this is a sensitive topic. But I really appreciate the opportunity to learn more about diabetes, and see how the material from JK fits into the larger context of mainstream and LC views. Before putting together the summary for Debbie, I hadn't studied this section of his writings thoroughly -- just skimmed through it.

We've been very fortunate not to have to deal with diabetes in our family, but my three children (soon to be four) are at increased risk for T1, as both my husband and I, as well as some other members of our immediate family, have various autoimmune disorders. My youngest child is also considered to be at high risk for T2 and metabolic syndrome, because she had a congenital disorder that led to severe intrauterine growth restriction, i.e. she was effectively starved before birth. It seems very common for people who've gone through this to be skinny as children, then become obese later on. Ever since she started eating solids, I've been torn between whether to "fatten her up" by encouraging high-calorie foods, or just offer her a typical mixed diet and let her pick out what she wants, even if she stays on the small and skinny side. There seems to be no information out there as to which approach is better. Interestingly, though, it turns out that she LOVES the high-fat Optimal foods, and will always choose e.g. butter over fruit.

??? I can't think of one advantage of feeding a kid to cause them to get fat.

choosing butter over fruit? I've heard of putting butter over a vegetable, such as over brocolli or corn, but I can't think of a fruit on which I'd put butter over it....

When people talk about "fattening up" a thin child, they don't usually mean literally causing them to get fat. But it's considered normal and healthy for babies and toddlers to have some stored fat on board. They use it during their growth spurts, to build their bodies and brains.

Pangolina, I still think that Dr K is either mistaken or there is a translation problem.

I know I'm repeating myself, but why would you get starvation ketosis at the beginning of his diet? Starvation ketosis doesn't occur unless someone is literally starving, ie not eating anything at all for weeks.
And just for anyone new wandering through, it is simply not possible for a diabetic to have ketoacidosis as long as their blood sugars are normal.

What happens at the beginning of many low carb plans (especially Atkins of course) is benign dietary ketosis, which absolutely cannot turn into ketoacidosis. No way no how.

Thanks for all the information you are providing, pangolina. Maybe you or someone else with the book(s) will be able at some point to write a summary of the diet for our Plans. The guidelines for summary writing are here.

I'm not sure; I'll try to decipher some of the Polish pages, and see if he explains this in more detail. As I said, maybe it has something to do with the protein restriction? As far as I know, he hasn't said that these cautions would apply to people beginning other LC diets.

If JK is to be believed, there are a fair number of "medically anomalous" things that can happen when people go on the Optimal Diet. Some, like this one, are temporary. Others (all of them neutral or beneficial, in his view) are long-lasting. As I mentioned in my first post, he says that it's common for fasting blood glucose in non-diabetics to actually increase above what it was prior to starting on the diet, into a range that's conventionally considered a sign of diabetes. In addition, some people develop astronomically high total cholesterol (though they have very good HDL/LDL ratios). Based on his 40 years of clinical experience, JK is very confident that these readings -- while somewhat alarming by mainstream standards -- are in the normal range for "optimally nourished" people.


Starvation ketoacidosis appears to sometimes come on quickly, especially in children. In the case of the article I posted, with the baby who was required to fast before surgery, it was 36 hours. And this site says that it typically takes 3-14 days to reach maximum severity, but that it can begin even after an overnight fast.

As for ketoacidosis not being possible with normal blood sugars, again, this doesn't fit with what Medline came up with; see the first two articles I've linked to in my last post. If you do a web search for "euglycemic ketoacidosis," or "normoglycemic ketoacidosis," you'll find additional cases. It may be rare, and something that only happens under fairly extreme metabolic conditions, but it's possible. As for how it fits with the Optimal Diet... well, that's the big mystery.

Sounds like my nephew, who used to happily eat plain butter by the stick when he was a kid, much to the horror of everyone around him! (including me at the time, I have to say). He was an exceptionally fat and round baby (all my sister's three babies were the roundest butterballs you would ever want to see) who grew into a skinny toddler, child, and now a thin young man. Since he is 6'2" however, I can't say that his growth was stunted in any way. Though, since his brother is 6'6", perhaps it was.

You can't? I sure can. Apples sautéed in butter with some cinnamon, peaches ditto. Serve with freshly whipped cream. Back in the days when I still baked pies I always put plenty of butter in my apple pies. Heck, blueberry pies got plenty of butter, so did rhubarb pies. All my fruit pies got lots of butter.

I was thinking about fresh fruit, but you're like in a different ball park..

So, how about some buttered pecan ice cream, buttered popcorn... ..... ....

As usual, I warn: T1 cannot be cured with diet. I think it is very irresponsible to pass on this type of information. T1 is an autoimmune disease. During the honeymoon period, when the Beta cells have not yet died, you can prolong the insulin response., but never restore it. Anyone who argues the opposite is a charlatan. 'nuf said.

V., type 1