Ketosis 101 for Practitioners and Coaches

Welcome. Great to have you here today. Today we're going to be talking about ketosis and ketones, which is a very important topic that I feel is relevant to either you or could be relevant to your clients. I'm excited to share this information because this is an exploration for me and it's also something that we need to know more about because our clients are probably asking us about ketosis and how to get into ketosis and you may have some questions and certainly we're here to answer them. So I have two very special women with me who are going to be presenting this information. Our main presenter is Francisca Spritzler and she is a registered dietitian who has been in ketosis for over 10 years now, if I'm not mistaken. And also Genevieve. They are both from Keto Mojo. I'm curious if anyone here uses Keto Mojo for themselves personally or in their practice. Okay, so we've got a few people that are using it, and if you're not on video, that's fine. You can always participate and engage in the chat. So we're going to be interactive today and the goal here is for us to be able to answer any questions that you have. And then at the very end, you'll also have an opportunity to do some Q and A with our lovely co hosts and. And also figure out how you can get your own Keto Mojo device, because that's really where it starts, is having the awareness and a way to track and monitor not only yourself, but your clients as well. So as we wait for our friends to join us and for people to get settled in, let's go ahead and type in the chat where we're all from. So just go ahead and type into the chat where you're from. I'd love to acknowledge all of you for taking time out of your day and being here. And of course, I want to make sure that each and every one of you gets a lot of value today. So we've got people here from Houston, we've got people here from Wyoming, we've got people here from. Wow.

Oklahoma.

Wonderful. It's great to see you here. Thank you. Centerville, Virginia. Fort Worth. Hey, Laura, it's great to see you.

Napa Valley, California. Amazing. Colorado. Cleveland. Toronto. Hey, Dan. Great to see you, Dan.

Okay. Montreal. Hollywood, Florida. All right, so we've got a very, very eclectic group of individuals. And in addition to that, I'd love to know what type of practitioner you are, so maybe you could type that into the chat as well. What type of Practitioner, are you?

Minnesota. I love that.

Okay, so we've got a great group of coaches and other practitioners here as well. Awesome. Well, thank you. Thank you for being here. All right, so let's get right into this because we do have.

Quite a bit of information to cover. And in addition to that, I'm sure you'll have questions, so Genevieve will be trying to answer your questions and compile them as we go on. And then Francisca is going to get us started, so let's jump right in. Francisca, I know you've got a slideshow presentation for us, so let's go ahead and share your screen and we'll jump right in. And again, we'll have some Q and A towards the end, so you need to write your questions down and ask them later, or you can type them in the chat and we'll compile them so that we can get to them towards the end.

Great. Thank you so much, Sasha, and hi, everyone. I'm going to share my screen. Give me just a sec to pull up my presentation.

Okay. Can you all see it?

Yep.

Okay, great. Where should I move things? Okay, I think I'll move people to the top. Welcome to Ketosis 101 from fundamentals to clinical application.

I'm Francisca Spritzler. I'm a registered dietitian and certified diabetes care and education specialist. That's the new term we used to be called certified diabetes educators. I have been working with ketogenic and low carb diets for over 10 years and mainly in diabetes and pre diabetes management and obesity management. I've also worked with some pediatric cancer patients and I'm an experienced writer, speaker and educator in both low carb and ketogenic therapies and disclosures. I do work for Keto Mojo as medical science liaison. I will be talking about our dual blood glucose ketone meter and our mymojo health app and monitoring system in this presentation. So the learning objectives for this afternoon or evening are to understand what nutritional ketosis is and how it's achieved. Identify foods to include on a well formulated ketogenic diet. Compare methods for testing ketone levels in urine, breath and blood, learn how and when to test ketones and apply ketone monitoring and personalized and continuous remote care.

So let's start with a question. What is nutritional ketosis? I'm going to give you a definition and then I'm going to break it down a little bit. It's a metabolic state in which low insulin levels and increased fat oxidation elevate blood ketone concentrations. To a range that provides an alternative, efficient fuel source for the body and brain. So it's basically that your body is switching over from using glucose, which is our default fuel, into using ketones and and fatty acids as its main fuels. There are a few different ways to get into nutritional ketosis. The most well known and reliable way is to follow a ketogenic diet. You can also follow a low carbohydrate diet that is not at ketogenic levels. And combine that with intermittent fasting or extended fasting or exercise, or a combination of all of these.

And let's go into how ketones are produced in the body. Some of you may know this very, very well, but, um, I'm going to go over it anyway. When you eat very few carbohydrates, as on a ketogenic diet, or if you fast for 24 hours or longer, your glucose levels decrease significantly and this prompts your pancreas to change its output of two key hormones, insulin and glucagon. Your pancreas releases less insulin and more glucagon, and that shift in hormones prompts your fat stores to release free fatty acids from into the bloodstream and they're carried to the liver where they're converted into ketones or ketone bodies. And over the course of the next few days, these ketone bodies enter the bloodstream until they reach a threshold of nutritional ketosis, where your body is using ketones and fats as its main fuel sources. And for the first few days, your body's not that efficient at using ketones, but. But by about day four on, it becomes very efficient at using ketones to fuel the brain, the heart and the muscles.

So there are several benefits of nutritional ketosis. I'm going to say there are potential benefits, but they're seen so often in many people that I've worked with and in the literature. First, the ketogenic diets and being ketosis lead to weight loss. They're very effective at helping people lose weight. For one thing, they're in a low insulin state, so they're promoting loss of fat and use of body fat. But they also help to reduce appetite and keep hunger at bay and promote satiety. So people will end up taking in less food without even realizing it. Their hunger and goes down. So even though they're losing weight, they are not hungry. It also lowers blood glucose and insulin levels so effectively that it can reverse type 2 diabetes and pre diabetes. In many cases, people with type 2 diabetes will be able to discontinue medication altogether and People with prediabetes will never progress to type 2 diabetes. And it also improves any insulin related conditions or insulin resistant conditions like polycystic ovary syndrome, metabolic syndrome, fatty liver disease and others that are related to insulin resistance. So not only is insulin lowered in the body the concentration of insulin, but the cells become more sensitive to it. And there's also a decrease in inflammation. Inflammation is at the root of metabolic disease and in besides improving systemic inflammation, it can also improve localized inflammation. We see it in things like osteoarthritis improving with a ketogenic diet. And there's one specific ketone, beta hydroxybutyrate, which I'll be talking about, which has been shown to have very strong anti inflammatory properties. And then finally it increases energy levels. But I want to make a real clear point that this is after keto adaptation, because if people go on a ketogenic diet the first few days they may not be feeling so energetic, but after that they tend to have a lot more energy.

So now let's talk about the differences between ketogenic diets and low carb diets. There's a lot of overlap, but they are different. So a ketogenic diet is high in fat, moderate in protein and very low in carbs. How low kind of depends on the person is anywhere from 0 to 30 grams of net carbs per day. And I'm going to define net carbs as whole foods subtracting any dietary fiber from those foods. So I don't mean net carbs that you see on a label or where there's a lot of added fiber and sweeteners to it. And then they say it's zero net carbs. I'm talking about whole foods subtracting the fiber from those whole foods to get the net carbs. And this is a powerful medical intervention for many health conditions, including the ones that I already mentioned and several others. A low carbohydrate diet can be moderate to high in fat, moderate to high in protein and low carb to very low carb. So it's a lot more flexible in the macronutrient makeup. Net carbohydrate intake somewhere between about 30 to 100 grams a day. Really? Again, very flexible. And it does include more foods than a ketogenic diet. So it's more flexible. And some people might say it's easier to stick to, but it doesn't have as many benefits for certain health conditions as a ketogenic diet does.

So foods to include on a well formulated ketogenic diet. I think some People when they think of keto diets, they think, okay, weight loss, they're eating butter and bacon and burgers and that's really all they eat. And those foods can be included on a well formulated ketogenic diet. But you can see from the foods listed here, we really want to prioritize nutrient dense whole foods as much as possible. So getting good protein sources, whether that's animal proteins or vegetable proteins like tofu or tempeh, those are all very low in carbs and can help to meet your protein needs. And then fats should be minimally processed, whether they are from animals or plants. So butter would be considered minimally processed fat and so would olive oil and any nuts and seeds. Avocados and olives would be plant sources of fat. And then carbohydrates will come mainly from vegetables, non starchy vegetables. These are typically the type that grow above the ground like leafy greens and all of the cruciferous vegetables like cauliflower, broccoli, Brussels sprouts, but also some others like cucumbers and bell peppers. There's actually too many to list here, but the ones that grow above the ground and then berries in limited amounts. Most other fruits are too high in carbs in very small amounts, perhaps in a recipe they can be included, but it mainly be berries and then dairy, full fat, yogurt, cheese and cream. We recommend full fat because again, this is whole food based and on a ketogenic diet, fat is going to be your primary energy source. So if you're eating like non fat yogurt or something like that, it's okay, but you're going to have to add the fat somewhere else. Why not eat the yogurt in the way that it actually came with the fat and then hydration. Electrolytes are very, very important to pay attention to on a ketogenic diet, especially in the initial stages. This is where keto flu usually comes into play because when the body switches over from using glucose to fats and ketones as its fuel source, there's some metabolic adaptations that take place and you end up losing a of sodium and water. And some of the other electrolytes like potassium, magnesium can also become need to be replenished. So if you really follow this list, you will probably get enough of what you need. You will need to add salt, whether that's salting your food more or consuming salty broth or salty foods that are keto friendly like pickles or olives or sauerkraut. And then you may potentially have to supplement with magnesium or potassium, at least at the beginning. But it's individual.

As far as balanced ketogenic meal planning, it's really going to depend on what you like to eat. There's a long list of foods, much longer than what's actually on the slide that you can choose from. But I think when people see, like, the macronutrient ratios, they're not used to ketogenic diets. They think 60 to 80% fat, that's huge. You're just nothing but globs of fat on your plate. But fat is very energy dense. It's 9 calories per gram compared to 4 for protein and fat. So even though your diet may contain a lot of fat as an energy source, it's not going to be so much fat on your plate. It's mainly going to be the fat that comes with food and then a bit of additional fat, too. So protein, as I mentioned, is very important that you're getting enough 15 to 30% of your energy intake. That's going to depend also on how active you are, your muscle mass and really what you like, because anywhere in there can meet your needs. And then 5 to 10% of your calories will come from carbohydrate. And again, that's less than 30 grams of net carbs per day. So this is just a few examples. These are actually recipes from our website. I'm so sorry, hold on just one moment.

Wendy's has no chicken.

Sorry, that was a phantom TV set that just turned on. Anyway.

These are some recipes from our website, Keto Mojo. But there are many other recipes out there, and it can be as simple as just throwing foods together that fit. But just to show you what it could look like, a day of ketogenic eating. This is a frittata made with lots of vegetables. And then there's a Mediterranean salad made with feta cheese. Again, lots of vegetables and olive oil dressing. And the last dish for dinner is keto jambalaya. So that's shellfish and meat and some herbs and vegetables. And then cauliflower rice in place of the rice. And then I have water shown there because that is the perfect beverage, the only one we need. But of course, coffee and tea are also a zero carb. And even some dry win or a little bit of alcohol that's unflavored could also be included.

All right, now let's talk about measuring ketosis. So if you're following the kind of diet that I just described, where you're eating a lot of healthy fat, you're keeping your carbs low. You're getting enough protein, but not too much protein, and you're avoiding any processed foods or inflammatory foods. Do you need to check ketones? Isn't that kind of diet enough to put you in ketosis? Well, if your clients are following a ketogenic diet to get the benefits of nutritional ketosis, it's important to confirm that they're actually in ketosis, because people get into ketosis at different levels of carb intake, protein intake, and other factors. So testing allows a person to know whether they've successfully entered ketosis and also the degree to which they are in ketosis, because there are different ranges of ketosis, light, moderate, and deep ketosis. And then also by tracking over time, it lets them know whether they're maintaining the level of ketosis they need to for their specific goals, and whether their diet or other factors in their lifestyle need to be adjusted in order for them to continue to meet those goals.

So let's talk about the different types of ketones and how they're measured. The first ketone that the liver produces is acetoacetate. It's sometimes called the parent ketone because the other two ketones are created from it. And this one is measured in the urine. Acetone is the second ketone. And acetoacetate can be spontaneously converted into acetone. And this one is very quickly exhaled in the breath. So we measure that one in the breath and. And the final ketone is beta hydroxybutyrate. Acetoacetate can be enzymatically converted into beta hydroxybutyrate. This is the most prevalent ketone in the body, and it's measured in the bloodstream, and it's abbreviated bhb.

So what's the right test? It really depends on what's important to you and how accurate you need to be in testing. So let's talk a little bit about the different ways of testing. So, acetoacetate, you measure in the urine, and it's measured in milligrams per deciliter in the urine, it's very easy. You simply urinate on a stick, or you can urinate into a cup and dip a stick in. Very quickly, the color will change on the strip to reflect the level of ketosis that you're in. And then you can look to see what color it is and see what the numbers are and also what the different descriptions are. So anywhere from negative, which is beige or colorless, all the way down to large, which is purple, to dark purple. Now, there are some definite advantages to testing ketones. In urine, it's easy to teach and perform. As I mentioned, you just urinate and test it very quickly. It's inexpensive, it's non invasive, and it doesn't cause any pain at all. The disadvantages though are that it's influenced by hydration status. So being just a little bit dehydrated can give you a higher level reading than your truly are at. And in the beginning, when you're trying to get into ketosis, that may give you a false sense of security. But even worse is later on, once you've actually become adapted to the keto diet and being in ketosis, you may see false negatives because your body now is urinating fewer, less of the acetoacetate, more of it is being converted into beta hydroxybutyrate, so you're retaining more. So you may be in moderate to deep ketosis, yet seeing a negative or very faint reading on a urine stick. And this method of testing has not been used reliably in clinical trials. And it's also subjective and semi quantitative. If you look at the colors here, it's like, okay, is that light pink or just medium pink? And then the numbers also aren't specific. There's ranges for some of them.

So.

So it's not a very concrete way of determining what level of ketosis someone's at. And they're also designed to detect ketoacidosis. That's a very dangerous condition in which ketone levels are extremely elevated. It typically only happens in people with type 1 diabetes who don't have enough insulin in their system, either because they're newly diagnosed or because their pump, insulin pump has failed or something is wrong with the insulin they've injected. But it's. That's what these strips were designed to do. They're not designed to monitor ketone levels. And people who are following a ketogenic diet for the purposes of being in nutritional ketosis. The next method is acetone testing and breath. So this one, you use a breathalyzer and you breathe into it, the home devices, you breathe into that anywhere from 10 seconds or longer and it will give you a reading of your breath acetone. And it is typically measured in parts per million, meaning one molecule of acetone for every one million molecules of air. You can see the different ranges here for acetone. This is what I have found in the literature, but there is a little bit of discrepancy between some of these values. I don't think there is 100% consensus on exactly where moderate ketosis ends and deep ketosis begins. But most of the reading. The devices that people are using at home are not giving them parts per million numbers. They're giving aces or acetone concentrate estimates, which is intended to estimate the amount of acetone in kind of correlating to the blood measurement in millimole per liter. So one ACE is roughly equivalent to 0.1 millimole per liter. So for those of you who are already using keto, Mojo or whose clients are, let's say a reading of 0.5 millimole per liter, that would be equivalent to 5 ACE. But this is not a direct correspondence, it can vary a lot and it has not been really confirmed in trials. So the pros of testing acetone are that it is a one time upfront purchase. It's not an inexpensive device, but you only have to purchase it once. You don't have to keep buying supplies for it like strips. And you can test as many times as you want over the course of the day and it won't cost you any more. So for people who like to test frequently, this can be very attractive. It's non invasive and pain free. The cons are that it can be influenced by breathing technique. You do need to breathe in for a certain number of seconds in a steady way and that can be difficult for some children, for older people, certainly anyone with breathing problems. And then also based on the available technology today, which are metal oxide sensors, sometimes called MOX sensors, there are two main issues with this. They can give you false positives because the device can misinterpret other volatile compounds in the breath as acetone. There are other gases and compounds on the breath and that can give you a false high reading. Also, over time the sensor can become degraded and you won't get any kind of warning about this. You'll be testing and it could be working just fine. And then from one day to the next it may be reading higher or lower than your true acetone level. And as I said, you won't get any warning about this. So very interesting and attractive, a lot of pros. But also with the current technology we do see some disadvantages. And then finally we have beta hydroxybutyrate testing in the blood. And, and this one is where you prick your finger and you use a strip to collect the blood. Stick that into the meter, actually stick it into the meter first, and then you touch your finger to the meat, to the strip, and it will take the blood and give you a reading. So it's very similar to any blood glucose meter. If you've Used this for diabetes or your clients or patients have. And it is measured in millimole per liter and the ranges are listed here. So anything below 0.5 millimole per liter means you're not in nutritional ketosis, like ketosis somewhere between 0.5 and 1 millimole per liter. It's usually good for people who are just trying to maintain their current metabolic state of health or perhaps just to lose weight if they don't have any other metabolic issues. Moderate ketosis, typically for people wanting to improve their overall metabolic health somewhere in that range. And also for sometimes people who are trying to improve mental health conditions. And then deep or therapeutic ketosis for people who are trying to treat serious health conditions like cancer, epilepsy, where you really need to be in that deeper level of ketosis. And then ketoacidosis I spoke about before, that's typically greater than 10 millimole per liter, but it can happen at lower levels than that as well in people with type 1 diabetes.

So the advantages of testing blood ketones or beta hydroxybutyrate is that it is internationally recognized as the gold standard for accuracy. This has been shown in multiple clinical trials that are peer reviewed. It reflects your real time metabolic state, so the amount of circulating beta hydroxybutyrate in your bloodstream. And it is relatively affordable. I'm using the term relatively because I understand that some people may think that it's affordable and others may not. Over on the cons, it does require a minimally invasive and minimally painful finger stick. And I realize this is subjective. Some people may find it invasive to poke their finger and see blood. I will say, as far as painful goes, the lances that we use today are so thin compared to the ones that we, you know, people would use 10, 15, 20 years ago. They really don't cause much pain at all. But I know that some people are sensitive and then there is a recurring cost per strip. So if you're just testing once a day or less, I think it can be pretty affordable. But if you're testing multiple times a day, it could get costly.

Now I'm going to talk about the gki. This is combined ketone and glucose monitoring. GKI stands for glucose ketone index. And it is a ratio of the glucose in your blood to the beta hydroxybutyrate in your blood. And it was originally developed by Dr. Thomas Seyfried to monitor patients who were going through ketogenic metabolic therapy for brain cancer and.

Specifically glioblastoma. So glioblastoma tumors use glucose very effectively to grow. They use aerobic glycolysis. They cannot use.

Fats and ketones because they have faulty mitochondria, so they need to use glucose. However, the healthy cells of the brain can use ketones. So by switching to a ketogenic diet and getting into nutrition and ketosis, you're providing the healthy portion of the brain with a fuel it can use, while depriving the cancer cells of fuel they need to grow. But the GKI can also be used to just monitor or give you a better picture of your overall metabolic health by showing how much your brain and body are now using ketones as opposed to glucose. So it is calculated by dividing the glucose in millimole per liter by beta hydroxybutyrate in millimole per liter. In the United States, we measure glucose in milligrams per deciliter. So that means we need to do a calculation, divide that number by 18 in order to get the glucose in millimole per liter. If you use Mymojo Health with Keto Mojo, and I'll talk about that later, it does that calculation for you automatically. And you do need to take the glucose and ketone reading within a few minutes of each other, because they do need to be taken at the same time. And I'm going to briefly go over the GKI results with you. Anything less than 1 is very difficult to do without a doctor's supervision, and it's really not necessary for most people. It was originally thought that this was the degree of ketosis people needed to be in for glioblastoma. They've relaxed that now to less than 2.

For the GKI. So anywhere between 1 and 3 is still going to be for the serious health conditions like cancer, like epilepsy and severe mental health conditions. And then three to six is where most people will find their benefit if they're trying to reverse. And a metabolic disease like type 2 diabetes, prediabetes, polycystic ovary syndrome, or metabolic syndrome. And then a level of 6 to 9 is like ketosis. Again, if you're just trying to maintain your current metabolic state of health or lose weight, and anything above 9 would mean that you're not in ketosis.

All right, let's go on to blood ketone testing and monitoring. We do sell a dual blood glucose ketone meter. My mojo, Sorry, the keto Mojo meter. And I am going to provide this to fashion afterwards as a PDF so that you will have links to how to set up your meter and how to test it. Is very similar to testing, as I said, with just any blood glucose meter. But there are a few different things that you'll want to learn about. And then as far as testing ketones and glucose, there's three basic times to test in the morning while fasted, before lunch or dinner, or before and after eating to identify responses to specific foods that maybe trigger foods for you. Not trigger foods that'll make you want to eat more necessarily, but trigger foods in terms of triggering kind of a response in your system that will lower your ketones and or raise your glucose. So testing in the morning while fasted, it's a wonderful time to get a baseline reading. It is recommended that you wait at least half an hour after getting up in order for certain hormones to clear your system. Your body releases cortisol and growth hormone in the early morning hours before you wake up. It's kind of preparing you for the day. But they do raise your blood glucose, and that automatically will prompt your pancreas to secrete some insulin, and that'll lower your ketones. So if you wait just half an hour or longer than that to test, you will likely see higher ketone readings and lower glucose readings. People who are insulin resistant tend to need to take longer for these hormones to clear their system. So usually recommending like an hour or two. But you can do like testing for a few days in a row to find at what point your ketone levels and glucose levels return to levels that you're happy with. So for the first, for three days in a row, test at 30 minutes, at one hour and two hours to find the right time to test for you. And after that, of course, you only need to test once, at whatever time you've determined is best. And then trying to keep to the same routine, test about the same time every day. And of course, before eating or drinking anything. You can drink water if you're waiting an hour or so, though. And then another time to test is before lunch or dinner, at least three hours after eating. You don't want any food to interfere with your readings. And we all digest and absorb food a little bit differently, and it can take several hours, so I Recommend at least 3 and preferably longer than that. And I've always found that people tend to have their highest readings in the late afternoon, so if they eat lunch around noon, then testing at 4 or 5 or 6 in the evening is best. And again, trying to be as consistent as possible, Testing at the same time relatively every day. You can also test for responses to specific foods. And this one will require three different tests. This would be if you're suspecting a specific food. Like you might think you're sensitive to dairy even though you're eating cheese, which has very few carbs, or nuts, or another food that is keto friendly but you suspect may be problematic for you. So what you would do is you would test your blood glucose and ketones, write that number down and then have a modest portion of the food in question. And and then an hour after that you would test again to determine the peak level because that's about when your glucose would peak and your ketones would fall. Write that number down and then test again three hours after having eaten the food and record all of these readings and then you can interpret what happened. So look at all of your readings. The ketones should not decrease by more than 1 millimole per liter even at the highest point or at the one hour point. And they should return to baseline by three hours. Glucose should not increase by any more than 30 milligrams per deciliter or 1.7 millimole per liter. If you're measuring in millimole and should return to baseline by three hours. If your glucose goes up by more than 30 milligrams per deciliter or it doesn't come back to baseline within three hours, then that food likely is problematic for you or at least in the amount that you ate. You may might want to try with an even smaller amount, but that's the way that you can identify whether there's a specific food that is impacting your blood glucose and ketone levels.

Now, how often to test this is going to be individual. We do recommend testing more often at the beginning, like twice a day for the first two to four weeks. Just so that you can first of all establish that you are or your client is in ketosis. And also helps to identify the range that they feel best at. You know, there is a pretty large range in there. I said 1 to 3 millimole per liter. Some people actually feel better kind of at the lower range and others seem to get more benefit at the moderate to higher range. So finding out what level they feel best at and then after that people can test less frequently. They can continue to test every day if they like to. And some people do like to test every day, but really anywhere from once a day to once a week is fine. And then occasionally testing for triggers or food triggers or food sensitivities. This is our bio individuality. So it's more about curiosity about what foods could possibly be causing Any issues? Okay, now let's talk about the continuous remote care model and my mojo health. So when it comes to ketogenic lifestyle and being ketosis, personalization is so important. I mean, testing is so important to personalize the diet, because I mentioned before, the people get into ketosis and maintain levels of ketosis at different ranges of carbohydrate intake. It can also be differences in protein or fat or their meal timing. So all of these things should be taken into consideration when you're looking and interpreting ketone values and deciding whether things need to be changed up in order to improve ketone levels. And this is done by your clients on their own when they test. And it gives them valuable feedback. And they can see that their food, the choice, the food choices they make are impacting their ketone and glucose levels. But as a practitioner, you can also work with them by looking at their readings and looking for patterns and helping them kind of in a collaborative way, decide whether they need to be making changes and what changes they'd like to make. Also, as I mentioned, finding out what level they really feel most comfortable at and then doing what needs to be done to maintain that level of ketosis.

So we're very pro continuous remote care. It's really started.

Back in the pandemic times where many people were doing remote care with their practitioners. But at Virta Health, which is a large company focused on diabetes reversal, they have been doing this back since back in 2015 or 2016 when they started. And this is where the patient is at the center, and they are connected to their clinician and perhaps a health coach or other members on the team, and their data is being viewed on a regular basis by members of the team. And there's communication that's going back and forth. The provider is reaching out if they notice that the patient hasn't tested their ketones or glucose, or if they see that the patterns are all of a sudden reversing from the way that they were before and they're. Or they're going in a negative way, they can reach out and correct it quickly before the person gets off track. And Dr. Sarah Hallberg, who unfortunately passed away in 2022, was the medical director at Virta. She was also the PI on their long continuous remote care study looking at ketosis in diabetes reversal. And she was just a really very special person. She was a huge advocate for ketogenic diets for people with diabetes and prediabetes and for the benefits of nutritional ketosis, but also for the benefits of continuous remote care. And this is a quote from her. Continuous remote care with a data driven, proactive outreach to patients represents a decisive step forward, in contrast to the currently available episodic, reactive, patient initiated care. It makes a big difference. If you are in regular communication with a patient, they can feel more supported and it helps you as a clinician see what's going on rather than having to kind of backtrack if you see them every three months and looking at a hemoglobin A1C and trying to figure out what was going on for all the days of those three months, rather than having all of that data coming into you on a regular basis and talking to the patient about it. So our remote monitoring platform is My Mojo Health and my Mojo Health app is something that your patients can download, it's completely free and it allows them to track their blood glucose and ketone and GKI levels over time. It's very secure, it is HIPAA compliant. And they can view their data in many different ways, not just as straight numbers, but in graphs and bar charts. And they can look at their data, you know, and compare it from one day to the next, one week to the next, one month to the next, and kind of see how they're trending, whether they're going in the direction they want to or things need to be changed. And you can open up a My Mojo Health Practitioner platform and you can invite your patients to join you. So they can be testing their blood glucose and ketones at home and all of that information can be sent to you so that you can view it in real time and you can the time and range is highlighted there. You and your client together can come up with the ranges that they want to aim for for blood glucose, ketones and gki. And you can adjust it at any time. You can also see their last readings to see how recently they checked. And if you notice that they haven't checked for a while, you can send them a quick, you know, email or use our chat function to just find out, hey, are you testing, is it, you know, is everything okay? So it's really nice to be able to have that level of engagement with your patient. And they can of course reach out to you as well. But this is just a few ways that you can look at the data. This is the bar chart of the glucose, ketones and GKI over about a one month period. And then something that patients often like to look at is the line graph view of the glucose and ketones. You can only view two different data.

Two different types of data. On the graph, the the bars, you can look at many different types, but you can plot them kind of against each other and look to see where things might have gone off. You can see here there's some dips in the glucose, sorry, in the ketones and increases in the glucose. And you and the patient together can look at those values and kind of figure out what was going on and have a plan to hopefully help keep the levels a little more near target for in the future.

So we do have a lot of other information about My Mojo Health, about our meter on our site, we also have a lot of different articles about ketogenic diets, ketosis, metabolic health. We have tons of recipes, we have a mymojo calculator. You can calculate your macros to help you stay in ketosis and still meet all of your protein needs and other needs. We have infographics. We have too many things for me to talk about here, but we do have a very functional website that you can check out at any time. And then I have my contact information here and links to mymojo Health. And if you would like to sign up for a practitioner account or learn more about it, you can go to that link. There's also videos for practitioners showing you how to use my Mojo Health and then our Keto Mojo website. So that's the end of my presentation and I went, I think about the right amount that I thought and I'm going to stop sharing my screen and be happy to take any questions.

Amazing. Thank you. And for those of you wondering, we will be sharing the resources with you. I'll share all the links and the replay as well so you can watch this. And so just keep an eye out for an email and that will have all of the details. And I also got verification from Genevieve that we'll be sharing the slides with you too. So thank you for that as well. Very gracious of you. A few questions that did come up, I want to make sure that we answer those. One was particularly related, more of a technical question in terms of does this connect with different apps like biochanic? So if you are using Biochanic as your ehr, it does integrate from what I understand. So that's a huge plus. And of course, naturally a question that I have is, is there a cost for the Keto Mojo platform for practitioners to use and if so, how is that calculated? Because I'm sure people have that question too.

Yes, we do have integrations with several EHRs, Biochanic, Serbo.

Athena, Jen, help me with that, Help me With our integrations.

Oh, no, I was saying for ehr. For ehr.

Epic elation.

Yeah, but then. Thank you. Yeah, thanks, Jen then. But yes, it is free. So the platform is completely free to use and you can also invite other people on your team to it. So there'd be one practice owner and then if you have multiple people that you want to join, you can invite them. And it's free for everyone to use and HIPAA compliant and triple encrypted for protecting patient data.

That's awesome. Thank you. Thank you for doing that because, you know, you could easily charge for it, but it's, it's great that it's available to us as, as a resource that we could use in our practices and monitor our clients should we choose to. Another question that came up, and these are probably more. A little bit more clinical, so I'll pass them on to you. Is related to lactation and pregnancy any contraindications? And really like, maybe that's. Maybe that may be one or not, but maybe you can talk about pregnancy and lactation and if there are any contraindications in terms of recommending a ketogenic diet.

Yeah, that's a great question and I'm really glad you asked. You can definitely do a ketogenic diet while pregnant, but it's very important to make sure that you're getting all of your nutrient needs met. And the one thing that I see with women, and I have not personally worked with a lot of pregnant women on ketogenic diets, but I've, I've had some and I know people who have. Sometimes women don't want to eat ketogenic diet. It's what they can handle at the time. Some women need to be in ketosis. If you have epilepsy, if you are treating a serious condition that you need to be in ketosis, certainly, or women with glute 1 deficiency who become pregnant, they will need to continue it. But for many women, there are food aversions and things that happen and a ketogenic diet may not be possible at different parts of your pregnancy. I would still say lower carb is going to be beneficial because again, you don't. One of the biggest problems is erratic blood sugar control in women. Even women who didn't have a blood sugar issue before getting pregnant often develop gestational diabetes. And so keeping carbs low, as low as you can while still feeling well is what I would say for pregnancy and for lactation, a ketogenic diet can be done, but it's very, very important. To make sure that you stay well hydrated in addition to staying well nourished. There have been some reported cases of women becoming acidotic and going to the hospital. There are case reports published. Women who were trying to lose weight shortly after having a baby and did a ketogenic diet were not staying adequately nourished nor hydrated, and they ended up getting very sick. And that is the worst thing to happen to a new mom with a baby. So I would say be very careful with it. And I always say, you know, it's best to have some medical supervision or working with a dietitian or a nutritionist if you are pregnant or, or breastfeeding and want to do a ketogenic diet.

Yeah, thank you. I'm curious, is there any sort of certification to be like a ketogenic provider or anything like that? Like, are there trainings that people can go through so that, you know, they feel comfortable being that supervising clinician?

There definitely are. The Nutrition Network has some. For any dietitians or Nutritionists, there are two women who I think between them, they have 50 or 60 years experience. They were both epilepsy dietitians to start. Beth Zubeckania and Denise Potter. They run several classes teaching nutritionists and dietitians to become ketogenic dietitians, nutritionists. So I would highly recommend their courses and also Nutrition Network and there may be even others, but those are the ones that come to mind first.

Okay, another great question coming in from Amy.

And that was like, when determining the best morning time to test, are we looking at the test time? Hang on, the question disappeared. Okay, are we looking at the. At the test time? At the test time that gives us the lowest GKI as being the most reliable time for testing. Maybe you can clarify that when the best time to test is or determine that.

Yes, thank you. And you know what, you mentioned gki, but that would be because I'm saying it's the best time to get the lowest glucose and the highest ketones in the morning. So that would give you the lowest gki, because those are the two variables that go into the gki. So I would say yes, waiting. But again, I think that doing that three day test to see when your lowest gki, highest ketone and lowest glucose would be is important because I just know that for me it doesn't seem to make much of a difference if I test at half an hour versus an hour or two hours later. But for other people it might make a big difference. So I would definitely do that test to see if it even really is much of a difference for you, but, yeah, that's a great question. Thanks.

Yeah, of course. Thank you, Amy. So I posted a link for those of you that are interested, if you haven't already done so, as mentioned earlier, Keto Mojo makes a fantastic, you know, tester. And you get a beautiful kit that has all the strips and everything that you need in it. And you just take these strips and you put it. You prick your finger and you put it into the reader and within, you know, just less than a minute, you have the results. So you can track yourself throughout the day and throughout the journey that you're going on, and perhaps you're taking your clients on. And when I met these lovely ladies, it was at Naysha Winters Metabolic Health Day event. And the thing that kind of shocked me is how affordable it is. So for around $99, you get a whole bunch of strips. I think it's 60 strips of each, and then you get the tester as well. So, you know, if you're curious, if you're kind of wanting to try this out and start with yourself, that's where most of us should start, then I would highly recommend just going to that link I posted. Choose your region and then you can see the different options. And maybe it might be helpful. Francisca, if there's a place that you recommend clinicians start in terms of particular kit or anything that you recommend that they start with.

Genevieve has her hand up. She may have an idea about this. Jen, do you want to take that one? Yeah, sure, I'll take it.

But I also had. There's a question that we did miss that I think it'd be interesting for Francisca to answer. But. Okay, so to answer it, the best thing to do is to buy the promo bundle like you said, session where you get the meter kit. In that meter kit, you have 10 strips of each, and then you also get the lancet device. And lancets start you out and you get the meter and then you get an additional box of a combo strip, pack of 60 strips of ketones and glucose. And so I really always encourage people to do the picture promo because by the time you get used to your testing method, you've gone through your 10 strips. So it just, it's just nice to be able to have them to. So you get in the rhythm and you get in the pattern and you, you get your testing down. And there was this one question by Christy, what about someone who had gastric bypass and can't handle lots of fat without duck ox bile, high dose yes.

Okay. Yes, I know what she's asking. So you can, yeah, the ox bile. You can do the ox bile. I would say it is very individual for people who have had gastric bypass. I know people who have been able to do a ketogenic diet, but it is.

You need to be careful and go slowly. I would probably recommend, or maybe this isn't even for you, it's for a client. But I would recommend starting with low carb and gradually upping the fat rather than doing it all at once. You know, like going right into keto from whatever diet they're doing right now. So I'd recommend doing very slowly. And yes, using ox bio can be helpful. But yeah, I, I, I did work with one person who had had gastric bypass. And what her issue was was she ended up having kind of like dumping syndrome. She, she had to be really careful and we kind of had to like back off and go really slow. And then she eventually was able to tolerate more fat, but it took several months. So that's the one thing is they, hopefully they won't give up. And low carb can already bring some benefits. But, but that's what I would recommend is going slow. Thank you for your question.

And there's one more that I have here. How long are you recommending people stay in ketosis for diabetes reversal? And once they reverse their metabolic condition, how do you maintain?

Okay, so here's something that I personally feel.

I feel that a ketogenic, it should be a ketogenic lifestyle. If you were able to reverse your type 2 diabetes and pre diabetes with a ketogenic diet lifestyle, you should continue to follow that lifestyle. Once you are in, have reversed the condition or are in remission, it can be sustained long time. I, long term, I know Sachin said, I've been doing it for over 10 years, I think 14 years now. It is very doable if people want to perhaps be more flexible with their carb intake afterwards and they can tolerate it. And that is the whole thing. You know, if not like a very strict ketogenic diet, at least a flexible low carb diet that allows them to be in ketosis for periods of time is going to help keep them healthy, keep the inflammation levels low, keep their blood glucose and insulin levels low. Those are the things that we really want to see and want to extend throughout the life. So that's what I would recommend is once they're done, is they continue to eat the same way. It's just that now they, you know, their blood glucose levels are controlled and they're not taking medication anymore. And that can take a while too. When I said there's reversal as possible. It is possible in the vast majority of cases. Some people may need to take medication long term. Some people even take years to reverse type 2 diabetes and completely get off of insulin or other medications. But.

It'S a journey. So that's what I would say. I would not recommend going back to eating a lot more carbs, maybe being a little more flexible, and again, using your meter to let you know exactly how much you can tolerate.

Thank you. Another great question from Laura. I have a question about APOB levels which are typically high on a ketogenic diet. Is that expected and not of concern or would further testing be recommended? So it kind of leads me into perhaps her question as well. Is there any additional labs that we should be considering for clients who are on a ketogenic diet just to make sure they're isn't anything else that's being thrown out of balance.

Okay, great question. In the, in the ketogenic community, it's very controversial question about APOB levels or LDL particle levels increasing on a ketogenic diet. It can happen. We tend to actually see it more often in people who are lean. They're called lean mass hyper responders. Not so much in people who are overweight or carrying excess weight. When they lose weight, they're APOB and LDL particle and LDL cholesterol levels don't seem to change much. Sometimes they get better. But we have seen some pretty significant elevations in leaner people. Is that a problem? The jury is still out on that. I personally am not comfortable with very high APOB levels in anyone at this point. I don't think we have enough information to say that's okay. There are things you can do to mitigate it. You can watch your saturated fat intake. You can take things like red yeast rice up your fiber intake, other things like that. I would recommend people on a ketogenic diet, especially if they have family history of heart disease, to have a complete like an NMR profile or advanced level protein. So you do have the APOB and the LDL particles Also to see are the LDL particles the smaller type because those are especially.

Can be especially harmful or especially increased risk for cardiovascular events to have a lot of small LDL particles. So I would look at them until we have better information long term on people living with very high APOB LDL levels on a ketogenic diet. I wouldn't feel comfortable saying don't worry about it. Everything else is fine. Because I think that's the argument that people make sometimes is everything else got better and that got worse. And I agree. I would not recommend giving up a ketogenic diet because of it. But I would look at what are some ways that we can bring the LDL particles or apob down.

Thank you. What are some. You said there's about four days. Some people call it the keto flu. What are ways to reduce those symptoms or ease people into it? Because that could be a roadblock for some people to stay in that state, right?

Absolutely. Absolutely. Now. So I didn't go into. I didn't want to take too much time because I had a feeling I'd have questions, which is great. I didn't want to take too much time. We do have information about this on our site, but it is really paying attention to repleting the fluid and the sodium primarily through getting enough broth. And if you do this from the very beginning on your first day, you may not have any symptoms of the keto flu because you're kind of, you know, being very proactive about it rather than waiting for the symptoms to come and trying to relieve those symptoms. So more like broth or salting foods heavily or having those salty foods that I mentioned that are low in carbs like pickles. And then magnesium and potassium are found in a lot of keto friendly foods like leafy greens, nuts, seeds, fatty fish meat, avocado. But you can also take supplemental magnesium or potassium as well for the first few days. And the keto flu can last, you know, if you actually have it anywhere from a day to a week, in some cases, not usually that long. If you are taking these steps, you really should have minimal symptoms. It is. People used to get it a lot worse when they didn't realize that they could take steps to kind of mitigate those symptoms.

Where do sugar, alcohols and stevia and monk fruit in that, stuff like that fit into this?

Okay, so, okay, it depends on the sugar, alcohol, but stevia and monk food are great. I like sweeteners. So some people like sweetener, some people don't. And I am really like whatever you like. If you don't believe in sweeteners, that's fine if you like them and they don't cause cravings. Some people find that anything sweet can cause them to crave sugar. Then I would say, you know, avoid them and just get used to the taste of natural food without any sweetener. But monk fruit, stevia, those are two of my favorites. Erythritol is another one that is very. Has a very minimal glycemic response and insulin response. Some of the others have a little more like xylitol. That one, you know, that would be used only in tiny little amounts. Actually they should all be used in very small amounts. And then allulose. So that's actually a rare sugar. It's not a sugar alcohol. But this is one of the newer sweeteners out there that a lot of people like and that one tends to have the least impact on blood glucose. And in fact in some people with type 1 diabetes they reported that it actually lowers their glucose slightly but not because it increases insulin, because of course they don't have any insulin. So we can learn a lot from people with type 1 diabetes and seeing how their bodies respond because they actually don't have insulin. So I would say sweeteners in small amount is fine if you tolerate them. If they don't cause cravings. And if you want to avoid sweeteners altogether, that's absolutely fine as well.

Yeah, I think some of the. I think allulose increases GLP1 activity. So that's the mechanism that that's supporting there.

Yeah, it does. It definitely does. And that's another thing is it can help you to feel full I with all of these will the sugar, alcohols and alulis though I would say they're almost self limiting because they can cause GI upset if you do more than a small amount. So that's one good thing is hard to overdo with them. And then stevia and monk fruit are so sweet that you only need a little bit.

So yeah, awesome. I know we're at the top of the hour so I just wanted to share my screen real quick. For those of you that are interested in taking action, I did drop a link and I'll. I'll drop it in here again in just a minute. But where it'll bring you is to this particular website. So you'll choose a region that you're in. So you can see that we probably have most of you covered. If you live in the United States, you'll just click United States and then you'll see the different bundles that are available to you. So I know somebody asked about getting a new meter if you wanted to get the basic kit. It's only $49, but as Genevieve suggested, and what I would recommend too is start with the bundle because then you get the glucose and ketone monitor. You also get additional strips that go along with that. 60 additional strips to the 10 that you would normally get. So it's a great place to start and a wonderful place to, you know, test yourself. Very affordable and accessible and something that allows you to play with and assess where you're at. You know, when I first met these ladies, they were so kind and gracious, and we spent about an hour on a call and we were trying to figure out how I can get more into ketosis without supplementing. Right. Because you can take BHB and all kinds of supplements to increase ketones in the body. Maybe that would be a good question too, is where that sits in the spectrum of ketosis. But, you know, it was an. It's an experiment. Right. And being vegetarian for myself wasn't easy. Right, because you're really having to figure out what you're going to eat. And generally speaking, a lot of the protein that I would eat would also have carbs if you're eating lentils and beans and things like that. So it's been a journey for me to experiment with this and kind of get a sense of how I feel when I'm in ketosis. And I would recommend all of you do the same. I mean, you owe it to yourself to find out, and I think you owe it to your patients because if they come in asking, I think that we should all have, you know, this in our tool belt. And now we've got a wonderful resource with Keto Mojo that, you know, allows us to do this in a very affordable and easy to track way. So I think that's the other beautiful thing about it, is the app is really easy to use. The finger prick is, for the most part, painless, and it takes, you know, literally less than a minute to test yourself. And I also love that there's a lot of support resources that Keto Mojo provides. So you have no shortage of recipes, no shortage of technical information and clinical information to support you. And, you know, my experience with them has been extremely positive. So I love, I love supporting companies that support us clinicians doing the good work that we do.

I would love to pass the mic on to you, Francisca and Genevieve, if you have any final and closing thoughts to share.

No, but thank you all so much for your wonderful questions and for attending. I really appreciate the level of engagement. And, yeah, feel free to email me. I'm going to send Sashin again a PDF of this after we get off and he can make that available to all of you. And thank you so much again.

Absolutely. My pleasure. And maybe one last question since I brought it up and I won't be able to sleep unless you answer it. Where, where do exogenous ketones fit into this whole equation?

So exogenous ketones are, as you said, there are supplements that you can take to increase your ketone levels and it will increase them regardless of your, you know, whether you're following a ketogenic diet or not. If you're following a ketogenic diet, it will tend to increase them more because you're at a higher level of ketosis. We don't know enough about them yet to know if you get the same benefits from them as you do as endogenous ketones that you produce on your own. So for people, I would really prefer that people try to get into ketosis and maintain it without supplements and occasionally using supplements as needed. Like if you need an extra boost because you didn't sleep well enough, or if you are treating a serious condition and need to be at a certain level of ketosis at all times, and you, for whatever reason, are not because you, again, didn't sleep well or under stress. But overall, I'm a fan of doing it naturally and having your body produce the ketones. And I'm not against ketone supplementation, but I think it really should be an adjunct to a ketogenic lifestyle that's done through food rather than just relying on supplements to increase ketones.

Yeah, yeah. Because that wouldn't, not that wouldn't occur in nature. Right. Like that would. There would be no circumstances under which that would occur naturally. Is that correct?

Absolutely. And our ancestors were on ketosis a great majority of the time. As they were looking for food, they went for days without eating and sometimes they would eat nothing but meat for a while and then they'd eat carbs. So they were very metabolically flexible, which is great. But yeah, there was no such thing as taking exogenous ketones. They had to produce them on their own.

Okay, wonderful. Well, thank you again for this fantastic presentation. And I know there's a lot deeper that we can go into this topic, but this is a 101, so maybe we'll have you back and, and do a deeper dive for us or certainly if you want to go deeper, then the website has a ton of resources. I'll send a email that has the links and so that you'll be able to go down the rabbit hole and educate yourself further. But I think the first thing to do for everyone is to get your own meter, if you don't have one, and get tested and become self aware so that you can then support others. In their journey if ketosis is the right next step for them.

All right, folks, have a wonderful evening. Thank you. Genevieve, did you want to say anything? I want to make sure.

I just.

I just wanted to thank you. It's just been a great pleasure meeting you and having this opportunity and meeting all your practitioners and your influence. It's beautiful.

Oh, it's my honor and pleasure. So, with that being said, and we want to honor everyone's biology, so make sure you get a good night's sleep. Turn off all your overhead lights, turn off your screenshots. Have a wonderful sleep. I see Christina's got the right idea. She's got her blue blockers on. Look at her. I've got my orange light on, and my screen is red. I know you can't see that, but thank you all for joining us today. And here's to an amazing night's rest and getting into ketosis. Have a wonderful rest of your evening.

Thank you, Sasha. Bye, everyone. Thank you, everyone.

Take care.