Ketoacidosis is a potentially dangerous condition characterised by very high, uncontrolled levels of ketone bodies.
Unlike ketoacidosis, nutritional ketosis is a healthy metabolic state that occurs after following a ketogenic diet. After a radical reduction in carbohydrate intake (<50g net carbs per day), the body starts to utilise fatty acids to produce ketone bodies[1].
This initially occurs at low levels for the first few days on a low carbohydrate diet. Within a 2-3 days however, the body starts to produce higher levels of ketone bodies. This higher level of circulating ketone bodies is known as ketosis[2].
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There is sometimes concern in the keto community that the keto diet can lead to ketoacidosis, which can be dangerous. To address these concerns, we’ve taken a look at the scientific literature to give you a science-based understanding of the risks.
What is ketoacidosis?
While ketosis is characterised by an elevated level of circulating ketone bodies (approximately 0.5 to 3 mg/dL while on the keto diet), ketoacidosis is different[2].
Ketoacidosis is a metabolic state that is characterised by dangerously high levels of ketone bodies in the blood and urine[3].
This results in a number of metabolic changes, including a decrease in blood pH, and requires medical intervention.
During ketoacidosis, levels of ketone bodies can reach 5 – 10 times higher than levels seen during ketosis (due to following a keto diet)[3].
There are 3 different types of ketoacidosis; diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA) and starvation ketoacidosis.
Diabetic ketoacidosis (DKA)
The most common type of ketoacidosis and the focus of this article. DKA typically occurs under conditions of hyperglycemia and insufficient insulin production. This leads to unregulated overproduction of ketone bodies[3].
Alcoholic ketoacidosis (AKA)
AKA is the result of chronic alcohol abuse, or periods of binge drinking. It usually occurs after an episode of heavy drinking, followed by a few days where oral nutrition cannot be tolerated[4].
Starvation ketoacidosis
Starvation ketoacidosis is the result of prolonged periods of fasting, after all glucose and glycogen stores have been utilised. The high levels of ketones that build up result in a decrease in blood pH, which can lead to a series of complications[3].
As mentioned, diabetic ketoacidosis is the most common type of ketoacidosis.
What is diabetic ketoacidosis (DKA)?
Diabetic ketoacidosis (DKA) occurs in diabetics and results in extremely high levels of ketone bodies.
It is characterised by a severe lack of insulin production, resulting in hyperglycemia, metabolic acidosis, and very high concentrations of ketone bodies (ketonemia)[5][6].
DKA is a very serious condition, and can be life threatening. Most frequently, it occurs in patients with type I diabetes, but can also occur in patients with type II diabetes[5][6].
How does diabetic ketoacidosis occur?
Diabetic ketoacidosis occurs when there is an imbalance in the ratio of insulin and counterregulatory hormones.
Diabetic patients have insufficient insulin production, which alongside increased glucagon (increases glucose and fatty acids in the bloodstream) levels, leads to hyperglycemia; this can usually be controlled with supplemental insulin[5].
Normally, as blood sugar levels rise, insulin production and secretion is stimulated. This results in the uptake of glucose by body cells, including muscle and fat cells, leading to decreases in blood sugar[5].
In the case of diabetic ketoacidosis, insulin is insufficiently produced, resulting in hyperglycemia. There is also increase in counterregulatory hormones, such as glucagon, cortisol, catecholamines, and growth hormone[5][6].
Insulin deficiency also leads to increased lipolysis (breakdown of fats), which releases fatty acids into the bloodstream. Here, the fatty acids are oxidised and used to produce ketone bodies.
This results in increasing levels of ketone bodies as well as metabolic acidosis (decreasing blood pH)[5][6].
The body will also try to increase urination to remove ketone bodies, which can lead to dehydration. This can further worsen ketoacidosis[5][6].
Untreated, this can lead to a host of health complications, including death.
What are the causes and risk factors of diabetic ketoacidosis?
Risk factors
The most common reasons for DKA is poor insulin management, resulting in insufficient metabolic control[5][6].
As mentioned, diabetic ketoacidosis occurs in people with type I or type II diabetes. In these individuals, DKA results from an imbalance in the ratio of insulin to counterregulatory hormones, such as glucagon, cortisol, catecholamines, and growth hormone[6].
There is also evidence that a number of additional factors are associated with DKA[3]. These include;
- Acute illness
- Pneumonia
- Sepsis
- Myocardial infarction
- Pancreatitis
- Stress
- Trauma
- Surgery
- Infection
- Prolonged fasting
- Excessive exercise
- Certain medication*
- Glucocorticoids
- Certain antipsychotics
In some cases, people presenting with DKA may be individuals with undiagnosed diabetes. In fact, DKA symptoms may be the first signs that a person has uncontrolled diabetes[3].
*Certain medications, such as glucocorticoids, can impact carbohydrate metabolism. These medications can therefore be a trigger for DKA in some individuals.
Can the keto diet cause ketoacidosis in healthy individuals?
Sometimes people following the keto diet have concerns that it could lead to ketoacidosis.
The keto diet however induces the state of ketosis, resulting in a safe level of ketone bodies.
In individuals who are not diabetic, there is no concern about DKA, as your ability to produce insulin, when required, is not compromised.
The only potential concern would be the much rarer, starvation ketoacidosis, after dangerously prolonged periods of fasting[3].
There are very few case reports of non-diabetic individuals experiencing ketoacidosis[7].
One of the few cases comes from a 2015 study, in which a 32 year old woman presented to a hospital with nausea and vomiting following initiation of a keto diet[7].
This patient was non-diabetic, however, she had given birth to a child 10 months prior, and was breastfeeding. It is thought that the metabolic demands of breastfeeding were likely the cause of this case of ketoacidosis[7].
A meta-analysis of case reports seems to support this, with lactation-induced ketoacidosis being documented in 18 additional cases. However, ketoacidosis due to lactation is still very rare[8].
According to the literature, the keto diet induces a healthy state of ketosis. In healthy individuals, there is a very small risk of ketoacidosis.
What is the risk of DKA in diabetics following a keto diet?
Diabetes UK and other diabetic organisations state that the keto diet is generally safe for people with diabetes, as long as they are staying on top of their insulin management[9].
For people with type I diabetes (and some with type II) this means ensuring your insulin doses are regular and at the appropriate dosage[9].
However, there have been some case reports in which diabetic individuals undertaking multi-day fasts have initiated starvation ketoacidosis[10].
For example, in one case study, a man entered starvation ketoacidosis after following a keto diet. The man fasted for a period of 5 days, entering into a state of ketoacidosis, which required medical intervention[10].
It should be noted that the man had a history of type II diabetes, which was under control when he was following the keto diet[10].
As a result, it is not recommended to enter into prolonged fasts on the keto diet, especially with a history of diabetes.
From the literature, the only potential concern for ketoacidosis, would be prolonged periods of fasting (>2-3 days). This would be very rare however, and would not represent a risk to people following a traditional keto diet.
Diabetics should ensure that they are not overly restrictive on their keto diets (to allow sufficient insulin production) and not initiate prolonged periods of fasting[9].
It is recommended to consult with a medical professional before embarking on a new diet.
What are the signs and symptoms?
Diabetic ketoacidosis is sometimes the first sign for people with undiagnosed diabetes[11].
It is important to recognise the signs and symptoms to catch it early, as the symptoms usually gradually occur, and get progressively more serious[11].
Common symptoms include[11];
- Frequent urination
- Increased thirst
- Stomach pains
- Nausea and vomiting
- Lethargy and fatigue
- Headaches
- Fruity breath
- Visual impairments
The first signs are often increased thirst and urination, which can lead to subsequent symptoms of increasing severity if left untreated[11].
How is DKA diagnosed and treated?
Diagnosis
Diabetic ketoacidosis is diagnosed by a combination of patient history and biomedical testing.
Medical professionals will normally ask the patient for a brief history of their symptoms, followed by a blood test[12].
Blood tests can be used to measure blood glucose concentration, which if above a certain threshold, could indicate DKA. This will inform whether a test for ketone bodies should be performed[12].
All 3 endogenously produced ketone bodies can be detected with a blood test; This includes β-hydroxybutyrate, acetoacetate and acetone. By measuring the level of ketone bodies in the blood, an accurate picture of DKA can be determined[13].
Blood tests will focus on detection of β-hydroxybutyrate, the most common ketone in the blood[13].
According to the NHS, if you have diabetes, the following ketone levels could indicate the likelihood you have DKA[12];
- Normal – under 0.6mmol/L
- Slightly high – 0.6 to 1.5mmol/L is slightly high (retest after 2 hours)
- High, at risk of DKA – 1.6 to 3mmol/L
- Very high, seek immediate medical attention – over 3mmol/L
As mentioned in our article on ketone bodies, blood tests are generally the gold standard and will usually be relied on by medical professionals[13].
Urine tests however can be useful for individuals to monitor their ketone levels at home, for a quick and cheap solution.
Treatment and management
If diagnosed early enough, treatment can be effectively administrated in most patients.
However, DKA still carries a mortality rate of 0.2 – 2.5% in developing countries. As a result, it is a serious condition and should be treated as a medical emergency[5].
Standard treatment consists of administering IV fluids, electrolytes and insulin. This is usually sufficient to reverse the condition, and enables patients to return home once their levels of ketone bodies have returned to normal[12].
Prevention strategies for DKA
The best way to treat diabetic ketoacidosis is to prevent it in the first place, with a strict insulin management plan.
Prevention strategies proposed for DKA include identification of individuals at greatest risk, based on a set of sociodemographic risk factors. This enables identification of individuals at greatest risk, and provision of subsequent monitoring services[14].
Another proposed prevention strategy is education. By providing a comprehensive education plan for diabetic individuals, you enable them to better understand their disease and recognise the signs and symptoms of DKA[14].
Studies have shown decreased rates of DKA following introduction of comprehensive education plans[14].
In addition to these prevention strategies, regular blood glucose monitoring is advised. This enables early detection of DKA precursors, such as hyperglycemia[12].
It is also advisable for diabetics to track levels of ketone bodies in their urine or blood. This allows constant monitoring and early detection of concerning increases[12].
In conclusion
It is important to understand the difference between ketosis and ketoacidosis. Ketosis is the healthy metabolic state characterised by a higher level of circulating ketones. This is different from diabetic ketoacidosis, which is a potentially serious complication of diabetes.
DKA is not a concern for healthy individuals following well-balanced keto diet. Diabetic individuals can still follow a keto diet and reap numerous benefits, but with a note of caution.
A keto diet can also be a healthy option for diabetics as long as they stay on top of their insulin management.
As always, it is advisable to consult with a medical professional before undertaking a new diet.
