Monitoring your progress on a ketogenic diet is your prescription for success at losing weight and reversing disease caused by lifestyle choices and inflammation.
It’s important to monitor your progress with some concrete evidence.
I suggest that you do this in a couple of different ways. The first way is going to help you see your progress with actual changes in your blood chemistry and metabolic function over a longer period of time. The second will be a daily monitoring of your depth of ketosis.
This will help you keep track of how your daily dietary choices are affecting patterns of change in weight and biometrics like blood pressure, blood sugar, ketones, etc.
This article may contain affiliate links. I would get a small referral fee at no extra cost to you.
Taking a Long View
We want to keep long-term health as the over-arching goal. In order to help us (and our doctors) see where there’s progress, getting a complete physical with blood work is especially important. If you haven’t seen your Primary Care Provider (PCP) in a while, you should get this done.
This is important for several reasons:
1) An Accurate Picture
No sticking our heads in the sand. Rule out or accurately diagnose any issues you may have before changing your diet (or at least early on in that change).
There are issues that diet alone won’t change, although the dietary changes will increase your ability to heal, sometimes medication or other interventions may be necessary. You should have an accurate understanding of what your medical issues are, and a PCP that will help you achieve your health goals.
A good physical will 1) rule out any underlying issues that you might need your PCP to help with and 2) let you know if you’re dealing with an issue before any dietary changes so that the diet isn’t blamed for something that might already be going on, like high cholesterol, for example.
As time goes by and you see the positive blood chemistry changes along with physical body changes, AND feel the emotional and mental changes, you will have the confidence to know you’re on the right path. These are the kind of motivational changes that will encourage you to practice clean eating habits that will last a lifetime.
Your concrete numbers will dispel the concern your doctor may have for a high-fat type of diet. Saying to a doctor, “I feel this…” or “I think maybe that…” won’t always get heard. A PCP needs to work with and SEE concrete numbers and evidence from which to base decision making. When a PCP can see both your physical changes and positive changes in your blood work, you’ll be a testimony to that person who has their own sphere of influence. Then that doctor’s influence may ultimately be used for other people’s good.
A high fat/low carb or ketogenic diet isn’t for everyone. For example, Dr. Sarah Hallberg, the lead physician in a current 5-year study on reversing diabetes with a ketogenic diet, states that 1 to 2% of the diabetic population seems to get worse on the diet. We don’t know why.
You won’t know if you’re in the 2% unless you’re being diligent about daily monitoring (see below) and working with your PCP to monitor blood markers. The good new is, 98% of the diabetic population gets better! That is a huge percentage! No drug on the market can claim that kind of success rate.
Anyone under the care of a physician or on medications, especially high blood pressure or diabetic meds (insulin AND oral meds) MUST work with their primary care practitioner when starting a ketogenic diet. Naturally lowering your blood pressure and blood sugar without knowing how to adjust medication WILL BE a life-threatening situation!
Daily monitoring should initially be done by anyone starting a ketogenic diet. You can’t know what you don’t monitor.
1) Track your macros
At the very least, you must track the food you eat with a macronutrient counter. Since we’re concerned with overall health, and not just weight loss, the online program that I recommend is Cronometer.com.
There is both a free and a paid version. The free version has always been sufficient for my needs. It allows me to track my daily food intake and look back over the last 4 weeks to track progress of the biometric data that I’ve entered. The paid version allows you to look back further and gives more long-term information like data analysis, food suggestions, and support.
I use Cronometer.com because it gives more nutrition information beyond macro count such as: omega-6 : omega-3 ratio; zinc : copper ratio, potassium : sodium ratio, and calcium : magnesium ratio. These are important ratios to understand when trying to address underlying inflammation and other causes of disease.
The free version of cronometer does not include these ratio numbers. If you’re trying to reverse disease, it may be worth the paid version for you.
All these nutrient ratios are important for monitoring inflammation and electrolyte balance. An unbalanced zinc : copper ratio, for example, has been implicated in many conditions including hormone imbalance (estrogen dominance, thyroid imbalance, e.g.), mental health issues (schizophrenia, depression, anxiety disorder, eating disorders), neurologic issues (migraines, dementia, Alzheimer’s), and many other conditions.
If you’re dealing with a chronic condition or illness, this is a great tool to have while you learn to eat foods that will keep your nutrients balanced and decrease inflammation.
2) Monitoring Urine Ketones
Urine test strips are inexpensive and effective enough to give most people the information they need to know whether or not they have entered ketosis. You don’t only want to know that you are positive for ketones, you also want to know that you’re not getting too deep into ketosis.
Urine test strips are more qualitative than quantitative—they tell you the depth of ketosis for a range value rather than an exact number.
Test twice daily: morning and night. That will give you a wide-angle view of your ketosis for the entire day. Your urine concentration will follow a circadian rhythm (see Dawn Effect below) which will show up on the strips as less ketosis in the morning and stronger as the day goes on.
A bottle of 50 strips will be a 25-day supply which is enough time to begin to understand how your body is responding to the changes. Once you’re familiar with your dietary changes and your body’s response, testing once daily (in the afternoon/evening) will probably be sufficient for most people except those with insulin resistance issues like diabetics.
If your pharmacy doesn’t keep urine ketone strips stocked, your pharmacist can order them for you.
There are several brands, some more expensive than others. They’re all the same, so don’t overspend. I recently bought a 50 count bottle of TruePlus 50 urine strips for a little over $7.
3) Monitoring Blood Ketones
Anyone who is serious about using a ketogenic diet to reverse disease should consider investing in a blood ketone monitor. This is especially essential for those with pre-diabetes/diabetes, or other insulin resistance issues like PCOS and metabolic syndrome.
I would encourage anyone with diabetes not to ONLY use urine strips.
Nutritional ketosis (as opposed to diabetic ketoacidosis) occurs when blood levels on your meter are between 0.5 mmol/L to about 5 mmol/L. Where you allow yourself to be depends on your goals and whether or not you have medical supervision. Here is a rough idea of what level is needed to achieve your health goals:
|0.5 mmol/L and above||Increased Athletic Performance|
|1.5 to 3 mmol/L||Increased Mental Performance|
|3 to 5 mmol/L||Therapeutic (under doctor supervision)|
Blood monitoring should be done with a machine that can measure both blood glucose and blood ketones. This will give a much more accurate view of the depth of ketosis you’re in, what’s happening to blood sugars, and how your body is responding to certain foods since you will see blood sugar changes happen within half an hour, or so, of eating.
Blood ketone changes happen more slowly. However, in addition to macronutrient monitoring on Cronometer.com and blood sugar monitoring, you can make adjustments to your diet as necessary.
Initially, you may see numbers heading into the high concentration ranges. Until the body gets used to using fat instead of sugar for energy, a lot of ketones will be released into the blood, but not efficiently used up for energy. This results in high concentrations in the blood and urine.
Over time, you will see that it is harder to stay in a deep ketotic state. This is believed to happen for a couple of reasons: 1) your body won’t have as much fat to burn as you lose weight, 2) your body will become more efficient as using up to ketone bodies for energy, so you won’t have so many floating around in the blood.
So, seeing a bit of a lower number as time goes on is a good sign. It means your body is becoming a more efficient user of fat for energy!
Test sugar and ketones at least twice daily (probably more if you’re diabetic)–morning before breakfast and evening before dinner. This will give you an idea of where your overall ketosis is during an entire day.
If you already have a blood glucose machine, you can certainly use that to monitor blood sugar. There are only a few machines that also have strips to monitor ketones.
The main problem with these machines is that the ketone strips are very expensive—sometimes as much as $5 per strip. A box of 10 strips can cost upwards of $50!
This is how the manufacturers of blood glucose machines make their money. They practically give the machines away, but the monthly glucose strips can be $50 a month with insurance, and they don’t usually pay for the ketone strips at all.
I recommend the KetoMojo blood glucose and blood ketone monitor. The company owner is committed to a healthy lifestyle and created a quality product without the exorbitant cost of strips. They have great customer service, and informative “How-To” videos on their website.
This is an affiliate link (I may get a small referral fee when you buy through my link), but I only recommend it because I trust the company and feel that it’s a great product for a much better price than you can find otherwise.
If you buy through my affiliate link, you will get 15% off any Kit purchase (applies to kits only–not strips alone).
KetoMojo is currently running a sale (as of today 1/30/19)—I recently bought an $89 kit through my affiliate link for $51 with free shipping!
Those on medications should seriously consider long term monitoring with a blood glucose meter that will also test for blood ketones. You don’t have to guess about what is going on inside your body. You have the tools to help you do this safely:
- your primary care provider,
- an online macronutrient counter, like Cronometer.com
- urine or blood ketone and blood sugar testing machine.
- Weigh Yourself. The last thing you will use for more frequent monitoring is a bathroom scale. Initially, you will probably weigh yourself daily because you will see the weight drop so fast, it seems unbelievable. That’s certainly what I did.
But don’t become a slave to the scale. As a habit, weigh yourself once a week or less. Weight is something we can use to measure progress, but our real concern is with overall health and disease management, something that your bathroom scale can’t measure.
The Dawn Effect (A.K.A. The Dawn Phenomenon)
One last note on monitoring for diabetics.
There is a normal circadian rhythm that happens to everyone early in the morning: a series of hormones is released to cause the body to begin waking up. These hormones include cortisol, epinephrine, growth hormone, and glucagon.
Each hormone has a different role, but the overall effect is to increase blood sugar as part of the body getting ready for the day ahead. The increase in blood sugar will decrease blood and urine ketone concentration.
Non-diabetics will see the effects of these hormonal changes when they monitor urine or blood ketones: the ketones will be less concentrated in the morning, and more concentrated in the evening.
In diabetics, this normal process is exaggerated because of insulin resistance which doesn’t allow the blood sugar to be taken out of the blood. So, they will have high fasting blood sugars in the morning. We’ve termed this “The Dawn Phenomenon” or “The Dawn Effect”.
Until the insulin resistance is reversed with diet, the Dawn Effect will cause high morning blood sugars in diabetics. Glucose levels stabilize over time.
Some days you will get what seem to be erratic readings—up and down during the day or high during the morning, but more stable as the day goes on. As long as you aren’t feeling sick or your blood sugars aren’t outrageously high, you will be fine. Those numbers will begin to normalize as time goes by, and insulin resistance is corrected. It won’t be overnight.
How high is “outrageously high”? That is for you and your doctor to determine based on your personal history and your doctor’s medical advice.
Keto Side Effects
This is one of the first “side-effects” most people will experience. Called “flu” because it has some of the same symptoms as a viral infection but not the same cause. Keto flu will happen within the first week of going low carb and will only last for a day or two for most people.
Symptoms include headache, dizziness, nausea, fatigue, palpitations, muscle cramps, brain fog.
All of these symptoms are caused by the body beginning to transition from sugar burning to fat burning, and/or to a loss of water and electrolytes.
Do these 3 things to ease the transition:
1) Go slower. Since your monitoring your ketones (!), add a few more carbs in so that you slow the process down, while still maintaining ketosis.
2) Add more fat to your diet to give your body that extra energy source until you’ve become “fat-adapted”, and don’t restrict calorie intake.
3) Consume more water and salt to replace what’s being lost in urine. Don’t use table salt. Use Pink Himalayan or a good unrefined sea salt like Sea-90 which is what I use. Use up to a 1/2 teaspoonful daily in the my homemade electrolyte solution.
For my easy and economical homemade electrolyte solution, read “Ketogenic Diet Rules for Beginners”.
2) Keto Rash
Keto rash isn’t the most common side effect, but when it happens it’s a real pain.
The rash generally appears on areas of the body where sweat accumulates: on the scalp, chest, trunk, under the breasts line, the back of the neck, middle of the back, or under the armpits. In fact, it seems to get worse in the heat or after exercising.
The rash looks like pimples. It is itchy and may start to ooze as the rash progresses or gets scratched.
I got a keto rash 2 summers ago, and the only thing that helped was getting out of ketosis by eating a higher amount of carbs.
I’ve seen recommendations online from people who used steroid creams and even oral antibiotics which help short term but aren’t going to really deal with the problem long term. It’s certainly NOT a reason to take antibiotics.
Although we don’t know for sure what the cause is, it is probable that it is as simple as too high of a concentration of ketones in the sweat.
If you get a keto-rash, increase your carb count by 5 grams ever other day or so, until you start to see a positive response. You can do a relaxed keto-plan at about 50 grams of carbs (or more, if needed) until you feel comfortable trying to go lower once the rash is resolved.
You won’t necessarily get the rash again. The more weight you lose, the lower the ketone concentration will be overtime, since you don’t have as much fat to burn.
Bowel changes are going to come with the territory as your microbiome adapts to your dietary changes. Really, constipation is one of the most common problems that Americans deal with even when they’re not on a ketogenic diet.
It can be made worse by a ketogenic diet because of the increase in urination which can cause dehydration because of a loss of water and electrolytes.
The cure is simple:
- a) increase water and salt with my homemade electrolyte solution (Read Beginnner Rules)
- b) increase fiber intake. I recommend ground flax seed. Read this post on “The Five Powerful Benefits of Flax Seed”.
Don’t increase fiber without increasing water intake! That will only make the situation worse.
Dealing with constipation is so important! As your body begins to break down fat, fat soluble toxins will be released from those fat stores. Your body will try to get rid of those toxins by elimination from the intestines. Your intestines can’t do their job if you’re constipated.
In fact, getting your intestines moving before you start a keto diet is a great idea!
Some will get diarrhea rather than constipation. There are two possible reasons for this:
- a) the bowel microbiome is changing, and the bowels need time adjust to that change.
- b) the bowels aren’t used to the amount of fat added to the diet and are not absorbing it efficiently.
The cure here is the same as for constipation:
1) increase fiber and water with electrolytes. The increase in fiber will absorb excessive amounts of bacteria, fat, and water, which will help to balance the bowels.
2) decrease fat intake a little and slow the process down until the intestines begin to be able to deal with the increase in fat consumption.
You’ll have the greatest success on a ketogenic diet if you include your primary care physician and learn how to monitor ketones.
For most people, slow and steady wins the race. These are lifetime lifestyle changes, so don’t try to go too deep for too long. You’ll have just as much success with less side effects and still have a ton of energy if you go slow.
How about you? Feel free to share your experiences with side effects (and how you dealt with them) and monitoring.