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Diabetic Ketoacidosis vs. Nutritional Ketosis?

Ketones can be the safe result of a strict low-carb diet but ketones resulting from too little insulin can be fatal

What’s the difference between diabetic ketoacidosis (DKA) vs. nutritional ketosis? It’s actually quite simple: one is life-threatening and the other is not.

With ketones becoming a very trendy word across mainstream media and mainstream dieting, it’s easy to confuse the two. And it’s very common to wonder: is a ketogenic diet safe for a person with diabetes if diabetic ketoacidosis is extremely unsafe?

Let’s take a closer look.

What are ketones?

In short, ketones are an acid that is produced when the body burns fatty tissue and breaks it down into fatty acids and amino acids to use for energy.

How to measure ketones

Ketones can be measured with urine ketone strips or with a blood ketone meter. A blood ketone meter is, of course, more accurate, because it measures your ketones in real-time. Urine ketone strips provide a more vague measurement of what your ketone levels were 2 or 3 hours ago because they’re now being expelled through your urine.

Situations that cause the body to produce ketones

There are actually four circumstances during which the human body will produce ketones.

  • Nutritional ketosis: A diet containing less than 20 grams of “net” carbohydrates per day can cause your body to begin burning body fat primarily for energy, which results in the production of ketone acids.
  • Diabetic ketoacidosis (DKA): When the body has too little insulin (primarily in those with type 1 diabetes), it is forced to burn body fat for energy because it cannot make use of glucose in the bloodstream for energy. (Severe alcoholism can also lead to toxic levels of ketones — classified as “ketoacidosis — similar to DKA but not directly related to insulin production.)
  • Starvation ketones: If you have not eaten a meal in a significant number of hours — that 10 to 12-hour mark is a rough estimate for most people — your body can produce small amounts of ketones when it shifts to burning body fat for energy, known as “starvation ketones.” This is common in intermittent fasting and is generally as safe as nutritional ketosis provided you do eventually eat a meal.
  • Illness-induced ketones: When you are sick with a severe cold, stomach virus, infection, or flu, for example, the stress, lack of nutrition, infection, and work your body is doing to combat the illness can result in “illness-induced ketones.” In a person with diabetes, this should be managed with your healthcare team’s support by increasing your insulin dosages to eliminate the presence of ketones. 

Diabetic Ketoacidosis vs. Nutritional Ketosis

The biggest difference between healthy ketones and dangerous ketones is simply the volume of ketones in your bloodstream or urine.

Ketones themselves are not dangerous, but in a healthy body, the role of insulin and glucose is designed to prevent them from accumulating.

In a ketogenic diet (below 20 grams of carbohydrates per day), ketone levels generally accumulate to very low levels between 1 and 3 mmol/L. The fewer carbohydrates consumed, the closer to 3 mmol/L a person could achieve. But simply eating a serving of carbohydrates — even a big bowl of broccoli — can knock some people out of ketosis.

Yes, a person with type 1 or type 2 diabetes can follow a ketogenic diet. As always, however, it’s important to ensure you’re getting adequate insulin and achieving healthy blood sugar levels. 

Some people find their insulin needs increase significantly on ketogenic diets due to the high-fat intake. See this article. This approach to nutrition and weight-loss is not always a fit for everyone.

In diabetic ketoacidosis, ketone levels accumulate either gradually (in someone in the early onset of diabetes) or extremely quickly (in someone with type 1 diabetes who isn’t getting enough insulin or is extremely sick). 

When there isn’t enough insulin to stop the production of ketones, the accumulation of ketones can build up to 20 mmol/L, which is extremely toxic for the human body, and easily fatal if left untreated.

Symptoms of diabetic ketoacidosis include:

  • Vomiting
  • Nausea
  • Extreme thirst
  • Increased need to urinate
  • Abdominal pain
  • Shortness of breath
  • Sour-fruit smelling breath
  • Confusion and exhaustion

Treating DKA: If you are experiencing nausea and vomiting, the only way to treat full-blown diabetic ketoacidosis is to visit an emergency room immediately to receive IV fluids and increased insulin doses to restabilize. 

If a person with type 1 diabetes becomes very sick (with the flu, stomach virus, and vomiting, or an infection), ketone levels can become dangerously high and lead to DKA. The usual treatment plan for the earlier stages of these ketones is to drink plenty of fluids and increase your background insulin doses. 

While your blood sugars may appear in range, the extra insulin will eliminate the ketones without dropping your blood sugar while your body continues to fight the illness or infection. 

People with type 1 diabetes who pursue marathons and triathlons may experience ketones similarly to this due to the stress and starvation. And again, they will likely find they can increase their insulin during the intense athletic event to eliminate the ketones without dropping their blood sugars.

As always, be sure to discuss any insulin dosing changes with your healthcare team — especially if you are experiencing symptoms of DKA or illness-induced symptoms.

Ginger Vieira has lived with Type 1 diabetes and Celiac disease since 1999, and fibromyalgia since 2014. She is the author of 4 books: Pregnancy with Type 1 Diabetes, Dealing with Diabetes Burnout, Emotional Eating with Diabetes, Your Diabetes Science Experiment. Ginger creates content regularly for Diabetes Strong, Healthline, HealthCentral, DiabetesDaily, EverydayHealth and her YouTube Channel. Her background includes a B.S. in Professional Writing, certifications in cognitive coaching, Ashtanga yoga, and personal training with several records in drug-free powerlifting. She lives in Vermont with two kiddos and two dogs.

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