We thank Dr. Poulose for his remarks, and we appreciate his comments. Regarding his first point, we acknowledge that water loss increases serum osmolality but does not affect the serum osmolar gap, thus hypernatremia would produce an increased serum osmolality but would not result in a widened serum osmolar gap. As for the second point, we acknowledge that nonketotic hyperglycemia results in an increased serum osmolality, without a widened osmolar gap. With respect to the statement that starvation ketosis is associated with a normal anion gap, this statement is not entirely correct. There is a mild anion gap acidosis with starvation, but it is not as profound as that observed with diabetic ketoacidosis. During starvation ketosis, lipids become a significant source of fuel following ≥ 3 days of starvation. In addition, low insulin levels and increased serum glucagon concentrations result in the hepatic generation of ketones, and consequently incomplete oxidation of fatty acids and accumulation of ketones results in a mild metabolic acidosis.1–2 During a prolonged fast, the degree of ketosis is limited, likely due to a rise in insulin secretion that is secondary to ketonemia, thereby limiting the availability of free fatty acids.