Other than protein, carbohydrate and fat, a number of other nutritional substances can affect the ability to establish and maintain ketosis. While not all have been studied with respect to their effects on ketosis, anecdotal evidence can help to determine which substances may or may not affect ketosis. The substances discussed in this chapter are water, alcohol, caffeine, and citric acid/aspartame.
Strictly speaking, water intake should have no direct effect on ketogenesis (at least in terms of a direct effect at either the liver or the fat cell). However, water intake may affect the measurement of ketosis in more subtle ways.
As discussed in chapter 4, high concentrations of blood ketones tend to prevent further ketone body production by raising insulin and decreasing fat release from the fat cell. In theory, this might be seen to slow fat loss when ketone concentrations become high. By extension, a high water intake might dilute blood ketone levels and prevent this from occurring. Additionally, it seems possible that a high fluid intake might wash ketones out of the bloodstream into the kidneys (for excretion), causing more bodyfat to be used to synthesize more ketones.
Neither of these ideas have been studied directly. When the ketogenic diet is used to treat epilepsy, fluids of all types are restricted in an attempt to keep blood ketone concentrations very high, as high ketone body levels are thought to be part of the mechanism by which the diet works. This suggests that a high water intake might dilute blood ketone levels and prevent the rise in insulin which can occur.
However, a high water intake may also dilute urinary ketone levels, making it more difficult to determine if one actually is in ketosis or not. Anecdotally, individuals who consume very large amounts of water tend to show very light levels of urinary ketones on the Ketostix (tm) (which are discussed in detail in chapter 15).
From a purely health standpoint, a high water intake is necessary on a ketogenic diet due to the dehydrating effects of ketosis. Some of the side effects which occur in epileptic children (i.e. kidney stones) may be related to the dehydration which is imposed and individuals are suggested to keep water intake high as a general rule.
Although alcohol intake has been discussed briefly in previous sections, its effects on ketosis need to be discussed here, especially since many individuals want to know if alcohol is allowed on a ketogenic diet. In general, once ketosis is established alcohol tends to deepen the level of ketosis seen. Additionally, the pathological state of alcoholic ketoacidosis (which occurs when individuals consume nothing except alcohol for long periods) is known to result in potentially dangerous levels of ketones in the bloodstream. Alcohol may affect ketone body production in the
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