January 21, 2016

Being Fat Adapted Versus "In Ketosis" (Pt.1/3)

“I got kicked out of ketosis.”

If I never hear or read those six words, in that order, ever again, I’ll be one happy individual.

Based on what I come across on low-carb forums, blogs, and videos, there is a lot of confusion about the correct use of urine ketone test strips (which I’ll sometimes refer to as ketostix, since “ketone test strips” is a mouthful, even when you’re only reading). So allow me to ‘splain a little bit about how to interpret these things, and what role they should play—if any—in your low-carb life.

First and foremost is the most important thing you will read in today’s post. (And it is so important that I will likely repeat it in all the posts to follow in this little series. Plus, you can tell it’s important because it’s red, bold, in italics, and all caps, hehheh.)

You can be in ketosis and not lose body fat, 
and you can lose body fat without being in ketosis.

Here is an exhaustive, comprehensive list of everything urine ketone test strips tell you:
  1. There is acetoacetate in your urine.

That’s it. Nothing more. Nada más. Game over. Finito. The fat lady has sung, and Elvis has left the building.

Here is what they do not indicate: 
  • Your worth as a human being
  • The efficacy of your low-carb or ketogenic diet
  • What your level of ketosis was an hour ago
  • What your level of ketosis will be three hours from now
  • Whether a specific food you ate “kicked you out of ketosis” (or, rather, caused there to be less acetoacetate in your urine)
  • Whether you are fat-adapted
  • Whether you are losing body fat

I’m not saying ketostix are useless for providing any other information besides whether or not there is acetoacetate in your urine. We can certainly use ketostix to speculate about issues other than the presence of acetoacetate, but that’s all it is—speculation, based on your diet, activity levels, stress levels, and more. They provide information, but they do not always provide answers. Are you showing deep purple on your urine test strips but not losing body fat? All that tells you is that being in ketosis doesn’t guarantee fat loss. (Which you already knew, right? Right?!) It doesn’t tell you why you’re not losing fat.

Ketostix are a tool. They give us one measurement, and one measurement only—the approximate concentration of acetoacetate in urine. This single measurement is helpful for hinting at other things we might be interested in, and we can use this acetoacetate indicator to help us arrive at logical conclusions, but we must not let ourselves become beholden to these reagent strips as the end-all and be-all of how we’re doing on a low-carb diet. They’re good, but they ain’t that good, people. (And really, we can say the same thing about blood ketone meters. They tell us only the concentration of beta-hydroxybutyrate [BOHB] in the blood. They tell us nothing about whether we’re losing body fat. And in case you didn’t know, they’re not even really a great indicator of blood glucose levels. There’s a surprising bit of variability in people’s ability to reach and sustain high-ish levels of BOHB. Some people can have a blood glucose in the 90s and still see ketones of  >2.0 or 3.0 mmol/L. Others might have blood glucose in the 70s but blood ketones of <1.0 mmol/L. So there is not an automatic correlation between the two, and we can’t necessarily use one as a proxy for the other. We can, however, assume that blood glucose is relatively low if BOHB and acetoacetate are elevated even slightly. BG might not be as low as the 70s, but it’s unlikely to be, say, 130 mg/dL)  

There’s a lot to cover on this. (So much, in fact, that I ended up having to break this up into 3 parts. I seem to be physically unable to write anything short.) It’s a bit overwhelming, so let’s just ease into things, and little by little, we’ll get to all of it.

Probably the single most important thing to clear up first is:

Being “in ketosis”
versus being fat-adapted

They are not the same thing. You can have one without the other.

Let’s talk about the simpler of the two first: being “in ketosis.” (I’m going to stop using the quotes now, but you can picture me making the little marks with my fingers every time you see that phrase.) Being in a ketogenic state means that you are breaking down fatty acids at a fairly decent rate, and some of them are being converted into acetoacetate, acetone, and beta-hydroxybutyrate. For those of you who follow low-carb or ketogenic diets, think back to when you first began your low-carb lifestyle. If you jumped in with both feet and went low-carb quickly, rather than making a gradual transition, you likely experienced the “induction flu” or “keto flu” – pounding headache, dizziness, nausea, and some other fun stuff. This is what happens when you are in ketosis but not fat-adapted. Your body is deprived of the copious amounts of carbohydrate it’s accustomed to, and your insulin levels have fallen low enough that you are beginning to break down fats for fuel instead of that endless stream of glucose. However, because it’s only been a couple of days, your body has not yet fully ramped up the enzymes and mitochondrial machinery required to properly and effectively utilize those fatty acids and ketones. So you’re in this hellish limbo we call the induction flu. Your body is producing ketones, but it’s not using them (or fatty acids) very well just yet. (It is still wanting to use glucose. Glycolytic enzymes are going crazy looking for—but not finding—glucose.) This is probably the simplest example I can give of being in ketosis but not being fat-adapted.

We could probably say the same thing about the use of exogenous ketones in an individual who is not following a low-carb diet. Their urine (and blood) would indicate that they are in ketosis, but they don’t have the physiologic machinery in place to keep that ketosis going after the exogenous amount has been metabolized, never mind having their bodies fueled primarily by fat. The state of ketosis induced by exogenous sources is entirely temporary and has nothing to do with the processes the body uses to generate ketones naturally, not to mention ramping up the enzymes and metabolic pathways that make someone a "fat-burner." (I'm not saying exogenous ketones have no role at all in metabolic therapies. I believe they do, but that's a subject for another time. Or maybe I'll see you at this conference!)

Now, let’s look at the other side of this.

You can be fat-adapted without being in ketosis. I know for a fact people can be fat-adapted but not in ketosis because I have personally experienced this many times. In fact, I would say this is my default state most of the time: fat-adapted, but not in ketosis. I follow a low-carb diet, but I’m not always at ketogenic levels of carbohydrate intake, and some days I probably consume enough protein that I wouldn’t see a noticeable change on the ketostix. My carbohydrate intake and resultant insulin levels are low enough to allow my body to be fueled primarily by fat, but my carbohydrate intake is not so low as to have excess acetoacetate perpetually registering in my urine.

Here’s how I gauge my fat-adaptation:  
  • I can comfortably go several hours without eating and feel no hypoglycemic effects whatsoever
  • I have good, steady physical energy levels
  • My mind is sharp and my thinking clear
  • When I do finally start feeling some hunger pangs, I am just that—hungry, rather than hangry. I will seek a protein- and fat-rich meal, and have no desire to jump head-first into a half-gallon of ice cream or consume a cheese danish. (One of my former favorites, waaaay back in the pre-low-carb days.) I have no interest in sweets or starch. I genuinely want something high in fat and protein—something like a burger, a fatty pork chop, sausages, etc. But if I were to pee on a ketostick, there would be no indication of ketones.

The most striking difference I notice when I am in a more deeply ketogenic state, versus just generally running on fat, is my MOOD. I am quite the gloomy Gus, the negative Nancy, the Debbie Downer, and all those other glass-is-half-empty people. (If you follow me on Twitter, you’ve seen this in action a time or three.) My natural state is one of almost crippling pessimism, self-doubt, and self-loathing. But something rather magical happens to my emotional outlook when my ketones are higher. It’s like someone flips a switch on my spirit, and suddenly I feel like I can accomplish anything—and more, that I am worthy of accomplishing more, and that I deserve to have a happy life. Since this is so different from my normal state of mind, this is basically my non-mathematical way of “knowing” I’m in ketosis. I don’t have to check; I can feel it. But sometimes I do check, if only to corroborate what I already know, and the test strips typically confirm that I’m keto-ing pretty hard.

Okay. Sorry for that little tangent into the dark recesses of my mind. My point is, there is a difference between being fat-adapted and being in ketosis. Maintaining a perpetual state of ketosis (especially deep-ish ketosis) may be particularly beneficial for certain conditions, such as cancer, Alzheimer’s, multiple sclerosis, epilepsy, and other neurological & neurodegenerative conditions. But as many of us know quite well, ketosis doesn’t guarantee fat loss. For fat loss, it is far more important to be fat-adapted than to shoot for high ketones all the time. This obsession with chasing ketones for the sake of bragging about them on social media has got to go. I feel like we’re getting to a point now of blood glucose & ketone “shaming”—whose are the lowest and highest, respectively. And if your blood ketones aren’t at 2.0+, or your A1c is above 4.8, you’re “doing it wrong.” Sh*t stuff like this makes me want to quit this industry altogether. It’s ridiculous. 

Remember: Amy Berger, M.S., NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition and is not to be used as a substitute for the care and guidance of a physician. Links in this post and all others may direct you to amazon.com, where I will receive a small amount of the purchase price of any items you buy through my affiliate links.


  1. The bullet points referencing a solid ketogenic state are dead on. Energy, mood, appetite control... it's a big difference/advantage over any other style of eating. Eat even a balanced amount of so called GOOD carbs and i will still ride the energy/mood/appetite rollercoaster, needing afternoon coffee etc...

    In addition I pay close attention to the research on various disease states that a ketogenic diet may help. Call it potential prevention or insurance against cancer, alzheimers, parkinsons, etc...

    But ultimately my energy, mood,appetite control, and healthy weight maintanance give me the here and now benefits that most people desire...

    Great post

  2. I love this post! The confusion and misinformation out there makes me feel all stabby. For me, though, knowing that I get a "report" every morning on my Ketostix really does help me not reach for crap, and think more strategically about what I am going to put in my mouth that day. That's a big win in my book. Ketostix are my accountability partner.

    1. Yeah, they can be helpful. (I get to that in part 3.) I don't mean to imply that people shouldn't use them at all. I just want people to stop obsessing and literally basing their self-worth for the day on whether or not they see pink/purple. ;-) I find I tend to be darker a little later on in the day. Morning is usually only light pink, unless I have a bunch of coconut products before bed, which does happen now and then, hehheh. Then, the strips are darker than usual when I first wake up.

    2. I should also note that I didn't start KETO for weight-loss, but for my brain, so keeping the peetones at the darker end was actually important, and what we were trying to achieve. I can testify to KETO not necessarily causing you lose weight, because I didn't. I started to lose weight when my peetones were at the lighter end.

  3. Great Post Amy! A fantastic Job as usual!

  4. My understanding is that you CAN be in ketosis, but not spilling excess acetoacetate into your urine, so a negative ketostick does not necessarily mean you are NOT in ketosis. I see people on social media being very upset because their ketostick was negative, but a negative may not mean anything at all.

    1. If you look closely at that little pink/purple "pillow" on the stick, some areas are lighter and some darker -- Wooo believes that it's the darkest little specks which report your true reading, too.

    2. I've read - in Jimmy Moore's "Keto Clarity" if memory serves - that once the body is, for lack of a better term, used to being in ketosis, the kidneys will keep the ketones in the body instead of letting them spill over in the urine which would result in far less acetoacetate in the urine and therefore a decreased ketostick result. Have you found this to be true Amy?

    3. I have been constantly in ketosis (eating very low carb) since mid-July - so 6 months - and I still register on ketostix.

  5. Very nice post, Amy! I don't use ketostix often; actually, most of the time when I use them it is because I know I ate something that is incompatible with my remaining in ketosis, and I'm verifying how fast I return to that state, and the other is when, on occasion, my body has gone acidic, and I'm peeing too much. I actually get to the darkest color on the scale. When I go and check that, it is because I'm not feeling well, a paradox despite the high level of acetoacetate / ketones. In that case I take some baking soda in water and some potassium gluconate for a couple days and I'm good to go. When I see light pink or no change at all, my heart aches, because it means that there are no ketones available for my brain to use as fuel when my glucose level goes down. When I picture my brain cells going without fuel, I know that's too high a price to pay for a bit more steak than I know I should eat or a single slice of pumpkin pie on Thanksgiving.

  6. Ready to read parts 2 and 3! After losing 50 lbs I'm not losing any more.

  7. Thank you for posting this! I say ALL the time...ketosis does NOT equal fat loss! I will be at the conference next week :)

  8. Hi Amy.

    The reason you feel great is norepinephine levels go up. Try fasting, they go up more.
    Feeling great is a nice thing, well a great thing actually and high ketone levels carry great benefits. But, and there is always a but...right? You can be a candidate for adrenal fatigue or thyroid problems. So glad you feel great but as always listen to your body.

    1. Yes, I most definitely have thyroid problems. (Guess you haven't stumbled upon me mentioning that yet, even though it looks like you're going through all my posts like a speed-reader!) ;-)

  9. I think I may been a candidate too, although I was never diagnosed, I guess because I never went to see the doc. I used to be a coffee hound, 15 to 20 cups/day and always high stress jobs, plus inter racial marriage (try that for stress) and raising kids and constant travel. Plus I used to hit the booze pretty hard, especially on road trips. I remember I burned out once, took me over a year to get back. But all's well that ends well. Looking back however I would definitely have done things differently.

  10. Hi Amy,
    Great post as always. I eat a high fat, moderate protein and low-carb diet (carbs coming from veggies and a small amount of fruit only) and can easily fast for 16-20 hours without any issues other than sometimes feeling a bit peckish; so I would imagine I am fat adapted and possible in ketosis fairly often. But hey; I can still put on weight in the form a belly fat and thunder thighs without even trying! Oh the joys of being a menopausal woman!

  11. I am "fat-adapted" on a potato diet as well. No need to eat high fat. To be fat adapted, all you have to do is to be alive. Fat is used all the time as energy. Depriving yourself of dietary glucose is ludicrous. All you need to do to lose weight is to eat less and / or be active so that your energy balance is negative. You can achieve that by eating carb sources as well such as potatoes without adding anything to them. The "fat-adaptation" myth is just that, a myth.

    1. Absolutely. I fully support people finding what works for them. I certainly believe there is no one-size-fits all approach to this, and I try not to get dragged into zealotry from any side. And potatoes are plenty delicious...especially the purple sweet potatoes! Oh, man...delish. http://www.tuitnutrition.com/2015/06/keto-carbs-stop.html

    2. How I envy you.

      I love mashed potatoes but dare not touch them (glucose spikes and insulin too). So your solution is calorie restriction "All you need to do to lose weight is to eat less and / or be active so that your energy balance is negative." How do you square this with the fact that calorie restricted diets simply don't work? The overwhelming majority of people on calorie restriction eventually give up and any weight lost is regained. Calorie restriction induces two metabolic responses, reduced energy output and increased hunger

      https://intensivedietarymanagement.com/category/lectures/the-aetiology-of-obesity-lecture-series/ see part 1.

      I'm glad it works for you, sadly not for anyone else.

  12. Amy what happens if I have 2-ketogenic meals and 1 non-ketogenic meal every day? I know I will not be in ketosis so I won't burn fat as my source of fuel. But will the 2 high fat meals per day negatively impact my lipids by increasing my cholesterol and LDL? Is it better than having a slow carb diet?

    1. Only one way to find out! (Honestly, though, this basically sounds like Carb Backloading, so it can be effective, but it is *very* context-dependent. I wouldn't recommend it for a sedentary person trying to repair years of metabolic derailment. For a bodybuilder? Maybe.

  13. Amy,

    very useful three pages. However I do have one area which still isn't clear.

    Being "fat adapted" presumably means that your body has switched to being able to burn fats as a primary energy source. If you are doing this then I assume also that the "fat energy" is being burned as ketones, and these ketones are being transported around the blood stream to the brain. [I'm not sure if the muscles take in fats from the blood stream and burn them directly.]

    So if you are fat adapted - for example you can exercise vigorously for a couple of hours in the morning without eating any carbohydrates beforehand - I assume that there must be some level of ketones in your blood stream at all times. However ketones showing on Ketostix (or keto breath) indicates that your body has too many ketones in the blood stream and is getting rid of some. So the lack of colour change when testing may just mean that your body is in balance and isn't throwing away a potential energy source.

    It would be good to see some testing with Ketostix and a blood ketone meter to show what the levels of ketones in the blood are when the urine test isn't showing ketones.

  14. So grateful for this article! My ketones have been very low but I have not had the craving s either. .I have most of the benefits of being fat adapted. .been doing keto x 2.5 months. My only concern is I just don't seem to have the limitless energy others talk about. I have been working 50 hour weeks with excessive stress for the last several months. .not sleeping well at night. Just would like to have the energy. .do have the mental clarity. The appetite is decreased. Cravings gone. Etc..just this one thing. .

    1. Glad my blog has been helpful. :)
      Based on what you've said here, I'm not surprised you're not bursting with energy. The ketogenic diet is not magic, despite what other people might claim. It is very powerful in a number of ways, yes, but it can't "undo" the fact that you work 50 hours a week, have excessive stress, and don't sleep well. At least you're experiencing many of the *other* benefits of eating this way, but, sadly, it ca't fix *everything,* y'know. ;-) You can't "out-keto" a very stressful life and chronic sleep debt. Try to work on those other issues to the best of your ability. Easier said than done, I know, but don't look for a ketogenic diet to fix your entire life.

  15. GARRR. I've been fasting 48hrs+ (black coffee and water with a few drops of lemon juice, ONLY) Ketostix negative everytime. I shouldn't be keto adapted, since my diet has always been HCLF. I understand, trust me, the theory, use and limitations of Ketostix – I've read enough dismissals of this testing device. It is still frustrating never having had a concrete confirmation that my body is making ketones adequately enough to generate some detectable ketonuria! That's all I desire, folks, a touch of confirmation, a smidgen of affirmation – is that too much to ask?

    I'm weighing, seriously, ending this fast I'm on (when I do, in a day or two) with a tub of butter. Just in hopes of getting some purple on the 'stix, provoked by my ketogenic piss.

    1. ...Or, you could get a blood meter. After a 48 hour fast and already being low carb for a long time, I would imagine your blood ketones would reflect elevation, even if your urinary acetoacetate doesn't. I'm not necessarily recommending a blood meter -- if anything, I would recommend just chilling out about this -- but if you really want to see what your body is doing, the blood BOHB might be more interesting for you.

  16. Hello Amy,

    I am trying to find any info on the impact (if any!) of following a ketogenic diet on secondary adrenal insufficiency. Should you be able to point me in a direction, my gratitude to you. I keep reading that keto diet is no good for people with adrenal fatigue (which to my rather limited knowledge is not SAI), so I got worried. Like you, I got thyroid issues (pre-keto) and I can honestly say that eating the keto way has given me my old self to quite a degree (pre-thyroid issues). So I'd really like to keep at it, with a clear conscience that I'm not burning down my adrenals.

    Great article, congratulations. It's great on so many levels, many of which I haven't considered before.

    1. Hi there,
      I don't know much about about SAI, so I can't comment intelligently on this issue. Do you know what your adrenals are being insufficient secondary *to*? Meaning, *why* are your adrenals not producing adequate hormones? (Cortisol, I assume. Have you actually had it tested, or are you going by assumptions based on your symptoms?) It's hard to comment without knowing what else is going on with your endocrine system. It's obviously not only the adrenals, since this is "secondary" to something else. (Something else is out of whack, and the adrenals are getting "messed up" as a natural response to whatever that other thing is.)