Question: When on a ketogenic diet, it is a problem if ketones are going up to 5 to 6 millimoles per liter?

One of the popular ketogenic advocates was saying that if the ketones are getting above 3, then it's from not eating enough protein. I don't really see it that way. I think that protein will suppress ketogenesis, and so will carbs. Five to 6 millimoles per liter is what you see in therapeutic ketogenic diets.

In terms of how you could bring the ketones down, more carbs or more protein are going to bring them down. Between the two of those, probably protein would be the most important thing to increase as a means of protection against lean mass loss and as a means of keeping neurotransmitters and all the other things that you do with protein healthy. But you could raise the carbs a little bit too. Because remember that your carb demand even on a ketogenic diet is definitely not down to 20 grams of carbs. That's not even feeding your brain on the ketogenic diet.

If you have room to increase carbs, then I think would be great to get the carbs up to at least 30 and then maybe use protein going up to supply the rest of that. Then also pay attention to micronutrients. Do a dietary analysis. If there are certain nutrients that this person is not really getting in that more vegetables would help those micronutrients, then increase the vegetables and the carbs along with them for that purpose. But just on macros alone, I would say go up at least 10 grams on the carbs and go up to, if you can get there, a gram of protein per pound of body weight on the protein, and that will bring the ketones down.

This Q&A can also be found as part of a much longer episode, here: https://chrismasterjohnphd.com/podcast/2019/09/06/ask-anything-nutrition-march-8-2019

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