Why is ketosis a problem only in type 1 diabetes?


What’s the Difference Between Ketosis and Diabetic Ketoacidosis?

Ketosis and ketoacidosis sound similar and are sometimes confused, but don’t mistake these conditions for one another. These involve two different sets of circumstances with considerably different outlooks.

Both are triggered by an increase of ketones in the body, which are acids released into the bloodstream when the body burns fat for energy instead of carbohydrates. But it’s how the body responds to this increase that sets ketosis and ketoacidosis apart from each other.

RELATED: How to Tell the Difference Between Good and Bad Carbs

What Is Ketosis and How Does the Process Work?

“Ketosis is a natural state that occurs when you start to metabolize fat instead of sugar,” says Michael Greenfield, MD, endocrinologist and chief medical officer at El Camino Hospital in Palo Alto, California. “It occurs often when people fast and use up the stores of sugar in their body.”

To understand ketosis, it helps to understand how the body burns energy. Carbohydrates and fat are both energy sources, and the body typically burns carbs (sugar or glucose) first, and then fat. If there aren’t enough carbohydrates in your system, it begins to break down fat for energy, which puts your body into a state of ketosis.

While in this state, the body becomes a fat-burning machine. For this reason, ketosis is the goal of many diets, particularly those that restrict carbohydrate intake and rely on fat for energy, such as the ketogenic diet.

RELATED: What to Eat and Avoid on the Keto Diet

Understanding the Relationship Between the Ketogenic Diet and Ketosis

“The ketogenic diet is a high-fat (60 to 80 percent of your total daily calories), moderate-protein (10 to 15 percent of your total daily calories), and low-carbohydrate diet (less than 10 percent of your total daily calories) that forces your body into ketosis, where it burns fat as its primary source for energy,” says Deborah Malkoff-Cohen, RD, CDE, and founder of City Kids Nutrition, a nutritional consultation service for children in New York City. “Think of the old Atkins plan where your ex-boyfriend would eat slabs of bacon, eggs, and a porterhouse steak, and lose 21 pounds in a month.”

But although the ketogenic diet is similar to Atkins, it’s not the same. Atkins is a high-protein diet, whereas the ketogenic diet is a high-fat diet.

Malkoff explains that the ketogenic diet works by rewiring metabolism so that it can burn fat more efficiently over time, and it uses specific levels of macronutrients (fats, carbs, and proteins) to keep the body in a constant state of ketosis. Because the body can only go into ketosis when it’s using fat for fuel, this is a hard diet to follow, and it often means saying goodbye to starchy veggies, like potatoes, rice, corn, squash, dairy, some fruits, bread, and beans that are too carb-y, she says. The plan has become popular among people with type 2 diabetes because of its potential to lower blood sugar while leading to weight loss.

RELATED: Does the Ketogenic Diet Work for Type 2 Diabetes?

For people who are able to stick with it, the ketogenic diet can reduce appetite and lower triglycerides — a form of fat that can affect heart-disease risk — while contributing to weight loss and sharper brain function. But this doesn’t mean the ketogenic diet is right for everyone. Particularly, people with kidney damage, women who are breast-feeding or pregnant, and some individuals on certain kinds of medication should avoid ketosis. It’s important to discuss your diet goals with your doctor before trying to achieve this state.

Also important to note is there are no long-term studies on ketosis and the ketogenic diet, so it’s unclear what health effects the approach may have on the body if sustained. Some dietitians warn the ketogenic diet may lead to nutritional deficiencies in the long run.

People with type 1 diabetes should not try to achieve ketosis through the ketogenic diet or otherwise. Because people with type 1 diabetes don’t have insulin, they cannot metabolize ketones, which are gradually flushed through urine in people without the disease. For people with type 1 diabetes, ketosis can result in an accumulation of ketone acids in their bloodstream known as diabetic ketoacidosis (DKA), says Dr. Greenfield.

What Is Diabetic Ketoacidosis Exactly?

“ is caused by a lack of insulin available for the cells to adequately uptake the sugar (glucose) in the blood to use for energy,” explains Malkoff-Cohen. “Without enough insulin, your body begins to break down fat for energy, and ketones are then released into the bloodstream, where they cause a chemical imbalance in the blood called metabolic acidosis.”

Whereas ketosis is natural and harmless, diabetic ketoacidosis can be life-threatening if left untreated. Too much acid in the blood can poison the body, causing loss of consciousness and death. Ketoacidosis is most common in people who have type 1 diabetes, but it can sometimes develop in type 2 diabetes due to low insulin levels.

RELATED: Everything You Need to Know About Insulin if You Have Type 2 Diabetes

Ketoacidosis is rare in people without diabetes, but it might occur in cases of starvation. A study published in October 2015 in the Journal of Medical Case Reports found that a low-carbohydrate diet combined with lactation could potentially induce ketoacidosis in women without diabetes, but more research is needed.

Poor diabetes management, or not having enough insulin in your system, is one cause of ketoacidosis. Other factors include developing an infection (such as pneumonia or a urinary tract infection), abusing drugs or alcohol, or taking a medication that affects how your body uses sugar. For example, corticosteroids, which are used for Crohn’s disease and asthma, among other health conditions, can make it harder for your cells to use insulin, whereas diuretics, used for controlling heart disease, can increase blood glucose levels.

Diabetic ketoacidosis can develop quickly, sometimes within 24 hours. The condition is responsible for more than 130,000 admissions to the hospital, as well as 50,000 hospital days per year in the United States, according to an article published in the journal Diabetes Management. According to an article published in March 2013 in American Family Physician, diabetic ketoacidosis is the leading cause of death among people with diabetes who are under age 24.

Symptoms of diabetic ketoacidosis include:

  • Excessive thirst
  • Frequent urination
  • Vomiting
  • Weakness
  • Shortness of breath
  • Fruity-smelling breath
  • Confusion

How to Treat Diabetic Ketoacidosis

If you have diabetes, not only should you monitor your blood sugar on a regular basis, you should also maintain a supply of ketone urine test strips, and then check your ketone level whenever your blood sugar rises above 250 milligrams per deciliter (mg/dL).

If test strips detect ketones in your urine, begin self-treatment by drinking plenty of fluids to flush ketones from your body, and then take insulin to bring down your blood sugar. If your ketone level doesn’t come down, or if you begin vomiting, go to the emergency room.

Hospital treatment involves rehydration to replace fluids lost through excessive urination or vomiting, electrolyte replacement to maintain heart, nerves, and cell function, as well as insulin therapy to regulate your blood sugar level. Your doctor may also screen for infections or modify your medication.

RELATED: 10 Warning Signs of Low Blood Sugar

Tips to Prevent Ketoacidosis

Ketoacidosis is preventable in people who have type 1 and type 2 diabetes. To avoid this potentially life-threatening complication:

  • Take your diabetes medication as directed and don’t skip insulin doses.
  • Monitor your blood sugar and ketones every couple of hours while sick.
  • Drink plenty of fluids while sick to prevent dehydration, about 8 ounces of a caffeine-free beverage every hour.
  • Continue taking insulin while sick, even if you’re not eating a lot.

Physical activity is recommended for people with diabetes, but don’t forget to check your blood sugar level before a workout. Exercising with elevated blood sugar could trigger diabetic ketoacidosis.

RELATED: 6 Diabetes Exercise Mistakes and How to Avoid Them

A safe blood sugar level for exercise is 100 to 250 mg/dL. If your level is lower than 100 mg/dL, eat a preworkout snack to boost your blood sugar and energy (between 15 and 30 grams of carbs). Don’t work out if your blood sugar level is higher than 250 mg/dL.

The Takeaway on Ketosis vs. Diabetic Ketoacidosis

Ketosis and ketoacidosis may sound similar, but these conditions are totally different. Whereas the former can occur from eating a low-carbohydrate diet and isn’t harmful, the latter is a life-threatening complication of type 1 diabetes (and sometimes type 2 diabetes) that can cause a dangerous level of acid in the blood.

Diabetes and the Ketogenic Diet

Is the ketogenic diet one more fad – or could it help manage diabetes?

Figuring out a diet that fuels our body’s needs and keeps us healthy without sacrificing taste is a daunting task for anyone. Factor in diabetes and this task can suddenly seem like an insurmountable obstacle overcome only by the most health-conscious fitness guru. Some diets are clearly fads, popping up into existence seemingly overnight, selling books and recipes and often food itself, only to fade into the twilight and be overtaken the next day by yet another set of guidelines by which we are to become, optimistically, the best self we can be.

There are seemingly endless options to curate a diet to meet every notion or need. However, those living with diabetes may find that these diets don’t always work to balance glycemic control and blood sugar. So what about the ketogenic diet? Is it a fad that will one day be supplanted by the next newest way to eat, or will the science behind it ensure it keeps a lifelong and loyal following? And if the latter, what role can it play in the lives of those living with diabetes?


Ketogenic diets were first proposed as a way to control epileptic seizures in children. Before keto diets, epileptics often fasted to reduce seizures, so the keto diet offered a less restrictive alternative. Though effective, the diet was mostly supplanted by medications – except in a segment of the population suffering from epilepsy that cannot control it with medicine, and for them, the ketogenic diet has had great success. Along with the benefits it offers to epileptics, especially children, the keto diet is also being studied as a possible salve for many neurological conditions and diabetes, too.

What does “ketogenic” mean?

All of our cells need fuel to function. This fuel comes from three sources: fat, carbohydrates and protein, called macronutrients. Too much protein without fat puts us at risk for a handful of complications, so protein can never healthily serve as a primary source of fuel. We are left then with fat and carbohydrates as the main providers of energy – the energy that allow us to do everything from breathing and blinking as we veg out on the couch to swimming the English Channel. Our cells’ preferred fuel comes from carbohydrates, which are easily converted to glucose, which, in turn, is readily converted to energy. This is why athletes “carb load” before they compete. Peak performance occurs when the body has plenty of glucose and glycogen stores available at hand. When glycogen runs out, that’s when the body turns to fat. When there is no more blood sugar for our cells to consume, they seek an alternative form of energy. This energy comes from ketones, which are compounds our body produces from stored fat. So a ketogenic diet is one that is high in fat and very low in carbohydrates, resulting in the production of ketones to be used for fuel instead of glucose.

The word “keto” often has negative associations for people living with diabetes, especially Type 1. DKA, diabetic ketoacidosis, is a life-threatening condition arising when the body produces too many ketones. So how does entering ketosis deliberately through a conscientious diet differ from entering it accidentally? The answer has to do with the level of ketones, the former causing “regulated and controlled production” and the latter causing an overabundance.

What does ketogenic have to offer?

The benefits of a ketogenic diet have been well documented for those living with Type 2 diabetes. Not only does the diet help manage blood sugar but it promotes weight loss as well. The results for those living with Type 1 are less conclusive. Many studies tend to address low carb diets like paleo and Atkins, which focus more on types of low carb food to eat, unlike a keto diet, which pays close attention to macronutrients and staying in ketosis. There seem to be fewer studies exploring the latter, but there is observational information that seems to indicate the diet offers a way to manage A1C levels and glycemic control. Many people with diabetes who abide by the keto diet have found that they significantly reduce their use of insulin.

Meat, meat and more meat

So what makes Keto unlike other diets? Meat, meat and more meat. There is no meat or fish that is off limits on keto, including the usually verboten bacon. Non-starchy vegetables like Brussels sprouts and cauliflower are encouraged, as are oils, butter and lard. Cheese and Greek yogurt can also be staples of a keto diet.

However, this diet isn’t for everyone. If traditional bread, pasta, rice, potatoes and/or fruit are what you live for, then you might just be miserable on keto. However, if you’re open to exploring different tastes, then the good news is there are substitutes for many of these foods. Cauliflower pizza crust, rice, and even gnocchi; zoodles (noodles made from zucchini); almond flour bread and almond milk are all readily available from most stores now. A small amount of berries is acceptable, but for the most part say goodbye to apples, melons, plums and peaches. Booze and sugar are also out, but if you’re living with diabetes, you likely already know how to manage these desires.

Listen to your body … and your doctor

If you are taking insulin, you may immediately need to lower your intake anywhere from 30-50% as soon as you enter ketosis. For those living with Type 1, this can significantly help with controlling highs and hypos.

As with any diet, precautions need to be taken. Pregnant women and those with kidney disease are not good candidates for this diet, and some people with diabetes may find that the diet increases their insulin resistance. Dairy can often spike blood sugar, so avoiding the dairy in a keto diet and taking a Vitamin D supplement might be a better option for some people. It’s important to pay attention to the way your body responds and realize that no diet is a one-size-fits-all model.

The trick to reaping the benefits of the keto diet is to stay in ketosis, which means keeping your carbs at 5% or less of your calories. The 5% can fall anywhere between 20-50 grams a day. However, if an insulin shot is missed while in deep ketosis, there’s a good chance you will find yourself quite sick, so it’s probably best to avoid the risk and keep carbs on the upper end of this spectrum.

This diet might be untenable as a long-term way of life for many people, but if you have iron willpower and the desire to try a restrictive diet that still allows you to indulge yourself with fatty meats and oils, a keto diet might very well be the way for you to help manage your diabetes while managing weight.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2129159/ (2004)

https://www.virtahealth.com/research (2018)

https://www.dietdoctor.com/low-carb/with-diabetes-medications (2018)

https://ketologic.com/keto-faqs/how-many-carbs-a-day-for-ketosis/ (2017)

https://www.nytimes.com/2018/05/07/well/live/low-carb-diet-type-1-diabetes.html (2018)

https://diabetesstrong.com/ketogenic-diet-and-diabetes (2018)


Learn more about Food and Diabetes.

The ketogenic diet has been around for a LONG time. It’s popular. It’s controversial. Some love it. Some hate it. Some even say it can help your blood sugars stay in better control.

After thoroughly reviewing the scientific literature and trying the ketogenic diet myself for over 6 months, I am ready to unfold everything you’ve been hearing and let you decide for yourself what you think about the diet that has taken the world and diabetes community by storm.

In this guide to the ketogenic diet and diabetes, I will cover the following:

Table of Contents

This guide is relevant for people with any type of diabetes. I will mainly talk about insulin when I discuss how a keto diet affects blood sugar, but some studies also show a possible reduction in certain type 2 medications.

Disclaimer: Please always consult with your medical team before you start a new diet, adjust your medication or change your diabetes management routine.

What is a ketogenic diet?

Once upon a time, keto was the original “diabetes diet” prescribed to type 1 diabetes patients before the advent of insulin, as this would prolong their lives as it has less of an impact on blood sugar levels.

The ketogenic diet is a low-carb diet where you get only ~5% of your daily caloric intake from carbohydrates. By restricting your carbohydrate intake so severely, you force your body to get most of its energy from fat. A byproduct of this fat burning is the production of natural ketones in the body, hence the name of the diet.

Burning ketones supplies the body with an alternative form of energy rather than quickly accessible energy from carbs (glucose) and is what makes the ketogenic diet work. (IMPORTANT: natural ketones are different from the “bad” ketones that can lead to diabetic ketoacidosis (DKA). More about that later in this guide).

The two main reasons why a person with diabetes would follow a keto diet are:

  1. To reduce insulin need and avoid blood sugar fluctuations
  2. To aid weight management (weight loss)

In the rest of this guide, I will review the pros and cons of a keto diet and try to answer the obvious questions: “Is a keto diet good for people with diabetes?”

How much fat, protein, and carbs to eat on a keto diet

To follow a keto diet, you’re looking at approximately this split in daily calorie intake:

  • 75-85% fat
  • 10-20% protein
  • 5% carbohydrate or <20-50g

As an example, if we converted this to grams for a person on a 2,000-calorie diet, this equals:

  • 167-182 grams of fat
  • 50-100 grams of protein
  • 25 grams of carbohydrates

NOTE: I am NOT saying that you should eat a 2,000-calorie diet. This is just an example! Please read this post to learn how to calculate your daily calorie need.

Protein is key here, because in the absence of carbohydrates, protein can be converted into glucose via gluconeogenesis. Since it is glucose, it can kick you OUT of ketosis. Thus, don’t overdo your protein if you want true ketosis.

I will be spending the rest of the article talking from the 20-50g of carbs and moderate protein (~20%) perspective. When I tried the keto diet, I was able to eat that quantity of carbohydrates and up to 150-160g of protein per day and remain in ketosis. Results may vary.

How does a keto diet affect blood sugar?

The premise of the ketogenic diet and diabetes is easy; fewer carbs require less insulin and should result in fewer blood sugar spikes. Fewer blood sugar spikes should lead to improved time in range and better A1c values.

In addition, several studies have shown that the keto diet can improve insulin sensitivity (1), further reducing the need for insulin and making blood sugar control easier.

IF (and that is a big if) you can adhere to it, keto can be a very effective way to manage your blood sugars. The swings will truly start to dissipate, trendlines on CGMs will flatten, and your A1c will quite possibly drop. I had the best A1c of my LIFE while doing keto.

On the flip side, hypos can be an issue, especially early on…and if you treat them too aggressively, they could knock you out of ketosis. I remember my first 3 weeks on keto, my CGM trend line hugged a blood sugar of around 80. It was glorious, but I had to reduce insulin substantially through trial and error and felt like I was low every five seconds.

When I would overtreat a low, I would sometimes push my carbohydrate amount over the keto threshold and end up OUT of ketosis…not that it is the worst thing in the world, but the goal is to remain in ketosis as much as possible.

That keto diets work in real life is exemplified by the fact that the keto diet is perhaps the most popular low-carb diet for people with diabetes and that thousands (if not hundreds of thousands) of people swear by the keto diet for good blood sugar management.


There is also a significant number of people (including Christel Oerum, the owner of Diabetes Strong) who experience the opposite reaction to the keto diet. Instead of increased insulin sensitivity, they experience a drastic increase in their insulin resistance, meaning that they need large amounts of insulin even for a very small amount of carbs.

This phenomenon has not been studied scientifically, but there is enough anecdotal evidence to suggest that not everyone reacts the same to a keto diet, and it may be unsuitable for some people.

Verdict: The keto diet can be very effective for blood sugar management, but there is significant variation between individuals: it does not work for everyone, but is worth a shot!

Is a keto diet effective for weight loss?

Given that the whole idea of the keto diet is to burn fat instead of carbs for energy, it seems logical that the keto diet should be effective for weight loss. While this is also often the case, it’s important to remember that the basic mantra of weight loss still applies:

Calories in (eating) < Calories out (burning) = weight loss.

If you eat more calories than you burn, you will gain weight – no matter what type of diet you follow. To learn more about how many calories to eat, please see my post “How to Lose Weight with Diabetes” and follow the steps in the post “How to Find Your Daily Calorie Need” to calculate your optimal daily calorie intake.

The theory behind using a keto diet for weight loss

Proponents of using a keto diet for weight loss argue that eating carbs drives up insulin production, which increases hunger and causes the body to hold on to fat and suppress calorie burn. When you replace carbs with fat, you decrease the need for insulin, subdue hunger, boost calorie burn, and melt away fat.

Many people also report fat as very satiating, making them full. The same goes for protein. When you feel full, you eat fewer calories and have fewer cravings. When you are at a healthy caloric deficit, you are primed to lose unwanted pounds.

What the science says…

Several comprehensive studies and meta-analyses have demonstrated that after a few months or even a year of a low carb diet versus a moderate/high carb diet, there are no significant differences in the amount of weight lost (2,3,4,5). I will say, however, most of these diets are NOT keto and are simply lower carb (i.e. 20%). Also, long-term effects (beyond 1 year) are not often studied due to budgetary constraints, so interpret results as you wish.

Verdict: A keto diet is not inherently better for weight loss than other diets but can be very effective if it:

  • Helps you manage your blood sugar better than other diets
  • Is easier for you to follow than other diets
  • Works for your general lifestyle

As with most other diets, the main criteria for success is whether or not you can follow the diet for the long term. If you like the keto lifestyle, the diet works great. If you hate it, it probably won’t work for you.

A quick note on keto and water retention

You often hear people who start a keto diet exclaim, “I’ve been keto for a week, and I’ve already lost 6 lbs! I love it!”

While this can be a great motivator to stick to the diet, most of that initial weight lost consists of water due to less glycogen storage.

Why? The old saying goes, “wherever glycogen goes, water follows.”

Because you eat fewer carbs, you will have lesser glycogen stores. Less glycogen means less water retained. Less water retained and, you guessed it…the scale goes down. There is nothing wrong with that – just don’t mistake lost water weight for fat loss.

Keto diet and exercise

Starting on a ketogenic diet can influence your exercise performance in multiple ways, both positive and negative. During the first 1-2 weeks (the “adaption period,” which I will get back to later), you will most likely see a decrease in energy and athletic performance across the board while your body adjusts to the new diet. This is perfectly normal and should NOT be a cause for concern or make you abandon the diet.

When your body has adapted to the ketogenic diet, you will most likely experience that cardio returns to its previous level of difficulty, but strength training may or may not be harder.

You have access to more energy for cardio

Your body stores a lot more energy as fat than it does as glycogen (sugar). A keto diet allows you to tap into that reservoir of stored fat energy more easily.

This is why you sometimes hear about endurance athletes who have successfully switched to keto and continued to perform at a high level because they no longer hit the metaphorical “wall”. They have access to a gigantic reservoir of fuel that was previously more difficult and took longer to access

Strength may suffer, at least for a while

This is ESPECIALLY evident during adaptation, but keto is not really ideal for high-intensity physical activity. Biochemically, this makes sense – intensive bouts need energy quickly, and fat oxidation is not exactly the fastest process in the world.

There is hardly any scientific data on keto diets and strength training, but plenty of anecdotal evidence stating that it can be difficult to even maintain strength.

Personally, all of my lifts dropped 40-50 lbs. for the first 4-6 weeks after I switched to a keto diet. Weights that I used to toss around with ease became tougher to move until I was fully adapted.

It’s not impossible to improve strength while on a keto diet, but it can make the process substantially more difficult.

How difficult is a keto diet to follow?

This is the most important, but also most subjective, question about any diet. If you don’t feel physically and mentally well on a diet, it won’t lead to long-term results, because you won’t adhere to it.

The keto diet is probably one of the post polarizing diets when it comes to people’s opinion on how easy it is to follow. Some people love it almost from day one while others experience major food cravings and even physical discomfort.

This is what my experience with a keto diet was like. Yours may be different:

Keto adaptation is ROUGH

It takes a while to become what is known as “keto adapted,” which is your body’s way of saying “hey, I got this, I’m ready to mainly burn fat!”

According to keto expert Ariel Warren, RD, CD, the exact length of the adaption period usually depends on how many carbohydrates you are used to eating. Around 2 weeks if you have eaten a relatively low-carb diet previously, 2-4 weeks for a more moderate-carb diet, and 4+ weeks for high-carbohydrate diet.

At the start of the adaption period, your body is rebooting what it has known for pretty much your entire life. Your brain is used to running on glucose and suddenly it doesn’t have it. Now, it CRAVES it. You’re in glucose WITHDRAWAL.

Some describe this phenomenon as the “keto flu,” where you basically feel the opposite of everything promised – sick, fatigued, nauseous, mental cloudiness, etc. – it’s not very pleasant.

Oh, and I should probably also mention that low carb means low fiber… pooping could be an issue. It’s often recommended to add extra magnesium, potassium & sodium to your diet (especially in the adaption phase) to help help your digestion elimination process.

However, if we look positively, it also means you’re doing something right if you experience this, but…who wants to self-inflict that kind of discomfort? I did, and it was not fun. On this note…

Adherence can be a problem

If you have tried keto (or really any low-carb diet), even for a day, you can probably resonate with this. You hang in through the first few hours. Maybe through the first day. Maybe even day two or three. Maybe it’s been three months. It really doesn’t matter – it is inevitable that eventually, the cravings start…and they are STRONG.

“Oh, I can have some carbs now, it won’t matter much,” you justify to yourself. You cave.

The results are like the pop-up ads on your Internet browser. “Congratulations! You’ve just restarted the keto adaptation process. Anything you previously did is now for naught. Thanks!” *browser closed automatically*

Granted, the longer you’ve been keto, the easier the re-adaptation process, but during that initial transition, it is IMPERATIVE that one maintains the correct macronutrient split or the adaptation will not occur.

Since that process is neither glamorous nor comfortable, not many can push through with near perfect consistency, myself included.

As you can hear, I found keto to be rough going but, again, your experience may be different.

Is a keto diet safe for people with diabetes?

While there hasn’t been a lot of research done on the long-term effect of following a keto diet, it’s generally considered safe for most people with diabetes.

The main risks when following a keto diet (or any other diet that restrict food choice and calorie intake) are related to mental health. ANY restrictive diet can potentially lead to an unhealthy relationship with food, and, in some cases, eating disorders.

If you find yourself constantly thinking about food, avoiding social situations where food is involved, or struggle with a negative body image, please seek professional help.

NOTE: It’s important to stress that this risk isn’t related specifically to a keto diet but dieting in general!

Keto diet and ketoacidosis

Diabetic ketoacidosis (DKA) occurs when, in an individual with diabetes, there is an absence of insulin or the presence of illness, infection, or severe dehydration. Blood sugars skyrocket, glucose toxicity occurs, and the blood can turn acidic, hence acidosis (6).

What a lovely prognosis. This is NOT related to a ketogenic diet. The ketones you develop on a keto diet never reach dangerous levels, as long as you take the right amount of insulin.

You can easily measure the ketone level in your body with a urine test. You can buy ketone test kits over the counter at most drug stores and pharmacies.

Urine ketone levels

You can also get test kits that use a drop of blood instead of urine. They use a different measuring scale so please always read the packaging carefully before taking any ketone test.

Keto diet and pregnancy

A ketogenic diet is NOT recommended for women who are pregnant, breastfeeding or have gestational diabetes. Not because studies have shown that it’s harmful, but because there haven’t been enough studies to show that it’s SAFE!

Conclusion: Is a keto diet good for people with diabetes?

A keto diet can be very effective for people with diabetes. Some of the potential benefits include:

  • Better blood sugar management
  • Effective weight management
  • A feeling of fullness (fewer cravings)
  • More energy for cardio workouts

However, there are large personal differences in how people react to a keto diet and some experience almost the opposite reaction. I recommend that you try following a keto diet for a while (at least 2-3 weeks as the beginning is always hard) to see how it works for you.

If you feel that a keto diet isn’t working for you after trying it, definitely don’t feel compelled to follow it just because so many people with diabetes recommend it. There are many great alternatives. I tried following a keto diet for a while but eventually went back to a more traditional medium-carb diet. It simply works better for me!

I hope this guide has given you a full view of the ketogenic diet and diabetes. At the end of the day, it’s up to you to decide if you want to try it and see if it has any beneficial effects on your blood sugars, body composition, or just how you feel. If you go for it, a good place to start is with this ketogenic meal plan. Good luck!

If you liked this guide to the ketogenic diet and diabetes, please sign up for our newsletter (and get a sign-up bonus) using the form below. We send out a weekly newsletter with the latest posts and recipes from Diabetes Strong.


Ketogenic Diet

Glucose is the main energy substrate for neurons, however, at certain conditions, e.g. in starvation, these cells could also use ketone bodies (Izumi et al., 1998; Fedorovich and Waseem, 2018). Furthermore, neurons in vivo would rather utilize lactate than glucose according to the astrocyte-neuron lactate shuttle hypothesis. Glucose is taken up by astrocytes which metabolize it into lactate. Lactate is then transported to neurons where it undergoes oxidation in mitochondria (Pellerin and Magistretti, 2012). Monocarboxylates are metabolized directly in Krebs cycle in mitochondria, therefore, they can be considered as non-glycolytic energy substrates. Transition to non-glycolytic energy substrates could remodel neuron functions. The ketogenic diet is based on this approach and may be used to treat clinical conditions (Gano et al., 2014).

The ketogenic diet is actually a biochemical model of fasting. It includes replacing carbohydrates by fats in daily meal. Synthesis of ketone bodies begins once glycogen stores have depleted in the liver. The term ‘ketone bodies’ is historical rather than exact chemical name. β-Hydroxybutirate, acetoacetate and acetone belong to ketone bodies. β-Hydroxybutirate and acetoacetate can be metabolized in mitochondria but not acetone. Interestingly, acetone possesses an anticonvulsive activity at certain conditions (Gasior et al., 2007; McNally and Hartman, 2012). Mechanism of acetone anticonvulsive properties is unknown (Gasior et al., 2007). Furthermore, in the case of ketogenic diet, the level of acetone in the brain appeared to be lower than in experiments where antiepileptic action was demonstrated (McNally and Hartman, 2012). The main ketone body is β-hydroxybutirate. Its concentration reaches 5–6 mM during starvation (Achanta and Rae, 2017). It is reported that in the case of ketogenic diet β-hydroxybutirate plasma level could be about 4–5 mM (Neal et al., 2009). It is suggested that 4–6 mM of β-hydroxybutirate could be considered as neuroprotective.

The ketogenic diet is used in clinic primarily for treatment of epilepsy (Stafstrom and Rho, 2012; Gano et al., 2014). Furthermore different studies have shown it could be advantageous in several neurodegenerative diseases, for instance, Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis (Stafstrom and Rho, 2012). Application of the ketogenic diet to treat tumors and reverse cognitive decline in aging seems to be very promising option (Woolf et al., 2016).

The mechanism of neuroprotective action of ketogenic diet is not very clear. It is shown that ketone bodies influence neurons at three different levels (Fedorovich and Waseem, 2018).

1) Bioenergetics and metabolic level. Ketone bodies can serve as more (Holmgren et al., 2010) or less effective energy substrates compared to glucose. Inhibition of endocytosis in rat brain synaptosomes after glucose replacement by β-hydroxybutirate in incubation medium is the example of less effective energy substrate (Hrynevich et al., 2016). In addition, it is worth noting that glycolysis is bypassed in monocarboxylate-fueled neurons and consequently adenosine triphosphate (ATP) microdomains, which are generated by glycolytic enzymes, are dissipated. Ketone bodies can also influence a balance between glutamate and γ-aminbutiric acid (GABA) synthesis. This leads to excessive accumulation of GABA in central nervous system and prevalence of inhibitory synaptic transmission (Gano et al., 2014).

2) Signaling level. Recently it was shown that a ketone body can function as a ligand for G-protein linked receptor hydroxyl-carboxylic acid (HCA)2 (Blad et al., 2012). Ketogenic diet is able to inhibit activation of microglial cells, promotes a neuroprotective phenotype in microglia and decreases interleukin level that provides anti-inflammatory action in brain (Yang and Cheng, 2010; Ghosh et al., 2018). At least partially, these effects are mediated by HCA2 located in microglial cells (Ghosh et al., 2018). HCA2 belongs to G-protein linked receptors which decrease cyclic adenosine monophosphate (cAMP) level (Blad et al., 2012), however, how they regulate microglial cells is still unknown in details.

3) Epigenetic level. Epigenetic mechanisms provide an adaptive layer of control in the regulation of gene expression that enables an organism to adjust to a changing environment (Stephens et al., 2013). Epigenetic regulation is functionally relevant changes in the genome that do not involve a change in a nucleotide sequence. Examples of mechanisms leading to such changes are DNA methylation and histone modification. β-Hydroxybutirate similarly to butyrate is an inhibitor of histone deacetylase. Inhibition of histone deacetylase leads to the changes in histones folding and increase in synthesis of antioxidants enzymes (Shimazu et al., 2013).

Finally, neuroprotective properties of the ketogenic diet might be explained by rather indirect effect at the whole organism level than direct action on neurons. Changes in microbiome during ketogenic diet followed by involvement of gut-brain axis which has recently been demonstrated can be taken as an example (Olson et al., 2018). Authors showed that the gut microbiota is altered by the ketogenic diet and required for protection against several kinds of seizures. Antibiotics blocked this effect. Furthermore, anticonvulsive strains of microbes can be transferred from one animal to others (Olson et al., 2018).

In summary, there is no single target for the ketogenic diet. It is suggested that different targets or group of targets, which interact with each other, are involved depending on a disease.

Ketone bodies are transported through blood brain barrier and neuronal plasma membrane by monocarboxylate transporters (MCT). The expression of MCT in rats is variable increasing during starvation or in a ketogenic diet and decreasing with age (Leino et al., 1999; Vannucci and Simpson, 2003). This is explained by the fact that suckling is actually a certain type of natural ketogenic diet because a suckling rodent consumes ‘high fat’ maternal milk. Age dependency of MCT expression underlies the efficacy of clinical application of ketogenic diet in childhood epilepsy compared to adults.

The classical ketogenic diet is 4:1 diet. This means combining 4 parts of fats with 1 part of carbohydrates and proteins in food. However, other modifications of ketogenic diet exist as well.

Middle chain triglyceride diet. In this diet, daily meal is enriched by middle chain triglyceride. Generally there are derivatives of coconut oil. It is believed that middle chain fatty acids are more effective precursors for ketone bodies compared to other lipids. Moreover, middle chain fatty acids may have intrinsic anticonvulsive properties.

In modified Atkins diet, the significant part of calories comes not only from fats. Proteins are also significant contributors.

The low-glycemic index treatment is based on sophisticated calculation of glycemic index for different kinds of meal. While it is generally based on restriction of carbohydrates in daily meal similarly to the ketogenic diet.

Intermittent fasting. This treatment is most similar to the main principle of the ketogenic diet-based fasting. This type of therapy includes days when individuals do not consume any food. Human body starts to use fats from own deposits with the following ketosis (Gano et al., 2014).

Is the Keto Diet Good or Bad? Is Ketosis a Good Way to Lose Weight?

With Michael J. Gonzalez-Campoy, MD, PhD, Zarabi, RD, and Amy M. Goss, PhD, RD

Given all the buzz, adopting a ketogenic diet may be the perfect weight loss plan, especially if you have diabetes, or want to try this approach to lose those troublesome extra pounds. After all, it’s a very low-carb meal plan that promises effective weight loss while also lowering your blood sugar to the point where you could possibly stop taking medication. By all accounts, the “keto” diet, as it’s widely known, may even reverse type 2 diabetes, at least for some lucky individuals.

Another advantage to the keto diet: It can help reduce systemic inflammation, which can have a variety of negative effects on your entire body.

You can create meals that are appealing and delicious when following a keto diet. Photo: 123rf

Unlike some of the other popular low-carb diets, which typically are high in animal protein, the keto diet focuses on getting to the body to burn stored body fat instead of sugar as the main fuel. When body fat is broken down in the liver instead of glucose, s an energy byproduct known as ketones are produced.

Make Certain Your Keto Diet is Well Formulated

While like any diet, you need to find the right proportion and balance of macronutrients (ie, fat, protein, carbs) in order for your body to begin burning accumulated fat rather than stored glucose.

The amount of fat you eat when following a keto diet is quite a bit higher than on most other diets. You’ll want to aim to consume about 60 to 75% of your calories come from dietary fat and 15 to 30% protein, with the remaining calories for carbs, says Sharon Zarabi, RD, director of the bariatric program at Lenox Hill Hospital in New York City.

“There is still some debate on the effects of saturated fats and what constitutes a healthy dose. There has been quite a bit of buzz around grass-fed cows producing cream, dairy, and butter. Ghee has been popular on the market as well, as a clarified form of butter,” Ms. Zarabi says. “It’s really the trans fats that I think people need to understand and the harmful effects on the heart and cholesterol.”

It’s really the trans fats that you’ll want to avoid completely. “Trans fats are highly processed, and heated to a point where they create free radicals in the body, which increase your risk of cancer.,” she says, “Trans fats are found in hydrogenated oils (be on the lookout for this form of fat listed on the ingredients), and these are mostly used in the preparation of processed crackers and packaged foods.”

The best low-carb foods include peppers, cauliflower, greens (eg, spinach, arugula, kale), and zucchini. When starting a keto diet, your goal should be to gradually reduce your carb intake to about 20 grams for at least two weeks but aim for six weeks in order to allow your body to adjust to this fat-burning process.


Once you’ve reached ketosis, you will gain the benefits and be able to take a keto holiday (more on this later), which is necessary to manage for as long as you need to.

Working with a dietitian may be the easiest and more efficient way to find the right dietary balance for your physiological needs and overall health.

“The purpose of the keto diet is to push your body into a state of ketosis, where the body uses fat stores instead of its preferred form of energy, which is glucose,” says Amy M. Goss, PhD, RD, an assistant professor of nutrition sciences in the School of Health Professions at the University of Alabama at Birmingham.

The Pros and Cons of Following a Keto Diet

Is it Healthy to Push Your Body into Ketosis?
“The major benefit of the keto diet is that it does work so you lose weight,” says Ms. Zarabi. “But then again, it is a diet and like all diets, it is a short term solution, something you do, then you stop. It is not really a sustainable diet in real life situations. More importantly, your goal is not just to lose weight—anyone can lose weight. The more necessary goal is to keep the lost weight off.”

The keto diet can be an effective way to reduce excess body fat but there are several cons that should be noted by anyone wanting to follow this eating plan, says Ms. Zarabi says. In fact, the keto diet has serious risks. For one thing, it’s high in saturated fat, which has been linked to heart disease. Additionally, a nutrient deficiency and constipation could occur since the keto diet is very low in fibrous foods such as fruits, vegetables, and whole grains.

Liver problems for those with existing liver conditions could possibly worsen since the keto diet puts stress on the liver, and kidney problems could also occur. 4

If you are considering going on the keto diet, work with a knowledgeable practitioner or seek out a registered dietitian with experience in prescribing it and following you to avoid any adverse effects, Dr. Goss says.

Fair Warning: There Are Challenges to Choosing a Keto Diet

  • The first few days are extremely difficult as your body tries to acclimate to such a low level of carbs. During this adjustment to burning fat instead of glucose, the side effects will make you feel awful; hence the term, keto flu.
  • You’ll be depriving yourself in social situations
  • You’ll need to prepare meals ahead and take them with you since you are confined to eating specific foods.

3 Common Mistakes to Keep In Mind When On a Keto Diet

  • Use Fat Wisely Rather Than Excessively. While the keto diet means your food choices are geared to a low carb/high fat intake, it does not mean adding fat to everything you eat. You do not need to fall for one of the most trendy keto tricks— adding a pat of butter to your coffee. This might be useful at the very beginning as you transition away from a high carb diet but should not be continued once you are past the initial shift once your body has adapted to this new eating rhythm. Instead, listen to your body for cues. If you are feeling hungry right after a meal, you probably didn’t have enough protein or fat. When followed correctly, a keto-based meal will leave you feeling full and satiated for hours.
  • Seek Nutritional Ketosis, Not Higher Ketone Levels. To gain the most benefit from this diet, you’ll want to aim for a level of ketosis between 1.5-3.0 mol/L on a blood ketone meter. You’ll be there when you are eating well-designed meals that carry you through to the next meal without hunger or other adverse symptoms (ie, nausea, insomnia, crankiness, inability to exercise). Higher ketone levels suggest you have more circulating ketones in your blood but don’t confuse this with efficient fat burning, which is the goal of this diet.
  • Ketosis Isn’t Forever. It’s recommended that you follow this diet to arrive at a state in which your body adapts to burning fat and glucose stores for fuel. Then you’ll want to take an occasional ketosis holiday, adding a serving of unprocessed, whole grains to allow your body to chance to work less hard. Staying in ketosis long-term—without breaks— can cause muscle aches, nausea, and fatigue.

Adhering to the keto diet puts your body into a state of ketosis, which sounds similar to ketoacidosis. However, don’t confuse these terms as ketosis and ketoacidosis are two very different physiological states, Dr. Goss explains.

Know the Difference Between Ketosis and Ketoacidosis

“Ketosis is a normal physiological response that occurs when you eat a high fat, low carb diet, while ketoacidosis is more pathological,” she says. “It happens in people with diabetes whose blood glucose is very high (hyperglycemia). You can’t put yourself into ketoacidosis the way you can put yourself into ketosis.”

When in ketosis, the body begins to burn stored fats for energy, and this results in the build-up of acids, known as ketones, in your blood. A person following the keto diet aims to burn unwanted fat by actually pushing the body to rely on fat, not carbohydrates, for energy. This process occurs when there isn’t enough glucose available to burn, so the body turns to stored fats instead.

You are likely to realize that your body has achieved ketosis because you may have a dry mouth, increased thirst, and find yourself needing to urinate more frequently, Dr. Goss says. “You are ridding your body not only of ketones but electrolytes such as sodium, potassium, and magnesium,” which may lead to dehydration, she says, so drinking plenty of fluids will help reduce any problems even if it means more trips the bathroom. “Bad breath is also commonly noticed as a result of the body trying to eliminate acetones produced during ketosis.”

Ketoacidosis most commonly arises with people with diabetes. Diabetic ketoacidosis occurs in response to a severe lack of proper insulin activity whereas alcoholic ketoacidosis is a harmful metabolic condition arising when someone consumes alcohol but no food, explains Michael J. Gonzalez-Campoy, MD, PhD, medical director and CEO of the Minnesota Center for Obesity, Metabolism, and Endocrinology, in Eagan, Minnesota. Either way, this is a dangerous situation.

“Both alcoholic ketoacidosis and diabetic ketoacidosis create medical emergencies due to the rapid change in the body’s acid-base balance,” Dr. Gonzalez-Campoy says. “The rapid drop in the pH of the blood, which is called acidosis, can depress the nervous system and muscle function, causing a person to become unconsciousness due to vascular collapse.”

Common complications of diabetic ketoacidosis include very low blood sugar, or hypoglycemia, and swelling of the brain (cerebral edema). As such, when a person is in ketoacidosis, there is such a high level of ketones produced that can push a person into cardiac arrest (heart attack) or kidney failure. Hence, the very important reason for taking occasional keto breaks go give your body a bit more nourishing carbs.

The Story Behind How the Ketogenic Diet Came to Be

The ketogenic diet was originally formulated by doctors to help treat people with epilepsy, and it was found especially effective in children who didn’t respond to medication.1,2 Indeed, the keto diet has been found to reduce the frequency and intensity of seizures, which are common complications of this condition.

This high fat/low carb diet may also help improve certain other neurological disorders like Alzheimer’s disease and Parkinson’s disease,3 according to the Epilepsy Foundation. More than half the children with epilepsy who were put on the diet experienced half as many seizures, while 10 to 15 percent of the patients who followed this diet became seizure-free.

The keto diet has also been studied as a possible cancer therapy. In a study focusing on people with cancer who followed the ketogenic diet as a medical therapy,4 the authors reported: “There is a great need for complementary approaches that have limited patient toxicity while selectively enhancing therapy responses in cancer versus normal tissues.

Ketogenic diets could represent a potential dietary manipulation that could be rapidly implemented for the purpose of exploiting inherent oxidative metabolic differences between cancer cells and normal cells to improve standard therapeutic outcomes by selectively enhancing metabolic oxidative stress in cancer cells.”

In another study looking at ketogenic diets as a treatment for cancer,5 this research team concluded, “based on the results of rigorous preclinical and clinical studies performed thus far, the KD would appear to be a promising and powerful option for adjuvant therapy for a range of cancers. Cancer-specific recommendations await the findings of randomized controlled clinical trials.”

Proponents of the keto diet say that when and followed precisely, it does not “starve” the body. “A well-formulated keto diet includes all the food groups and therefore provides adequate intake of micronutrients,” says Dr. Goss. “There is ample scientific evidence from randomized clinical trials supporting the therapeutic effects of the diet in treating a number of chronic disease conditions besides epilepsy, including type 2 diabetes , non-alcoholic fatty liver disease, even obesity.”

She adds that the research supports the safety and effectiveness of following a keto diet even in older adults with obesity as it seems to help improve body composition and improve metabolic health.6 “We saw significant reduction in body fat while lean mass was preserved and significant improvements in insulin sensitivity and the lipid profile in response to a ketogenic diet when compared to a standard ‘balanced’ diet,” Dr. Goss explains.

Anyone who takes medications for diabetes or hypertension should consult with a physician before starting on the keto diet, she adds. And it is not for everyone: Individuals who are dependent on insulin (those with type 1 diabetes) should never follow the keto diet, says Dr. Goss.

Additionally, since ketosis can be harmful to a fetus, the keto diet should be avoided during pregnancy. “Also, ketones are harmful to patients who cannot correct the metabolic acidosis caused by them, ie, those with liver, kidney, or pulmonary disease,” Dr. Gonzalez-Campos adds.

The keto diet is not for children or adolescents either, and a long-term complication can be growth retardation in children.5

If you decide to follow the diet, you’ll want to have an individualized meal plan, stresses Dr. Gonzalez-Campos. “The best possible clinical outcome is for each individual to meet her nutritional needs from well-balanced meals,” he says. “Ideally, we should all have the benefit of medical nutrition therapy and we should all avoid extremes in nutrient restrictions.”

Last updated on 02/26/2019 Continue Reading Mediterranean Diet: Anti Inflammatory Foods Behind Health Benefits

November is Diabetes Awareness Month and one of the most popular discussions this time of year is food, the relevance of which to this article will become apparent shortly. We wanted to address perhaps one of the most important distinctions that should be made in the context of diabetes: the difference between nutritional ketosis and diabetic ketoacidosis; one being a natural, healthy response to a very low carbohydrate diet and the other being a life-threatening condition seen in uncontrolled type 1 diabetes.

What are ketones?

Ketones, or ketone bodies, are molecules that are produced from the breakdown of fats in the liver. These are then transported in the blood and act as efficient energy sources for the body’s cells, especially in the brain.

Our body produces three different ketones: beta-hydroxybutyrate (BHB), acetoacetate (AcAc) and acetone. BHB is the main ketone produced and is what is measured with a blood ketone test, the most accurate way of measuring ketones. AcAc is measured by urine sticks and acetone is measured by ketone breathalysers, but these methods are less accurate and informative than blood testing.

Everyone produces a low level of ketones under normal conditions and has a low level (under 0.5 mmol/L) in the blood at any given time.

What is nutritional ketosis?

Every person is burning at least some fat for energy, which is why low levels of ketones are always being produced. When dietary carbohydrate is greatly reduced, down to around 20-50g per day, the body adapts to this lack of carbohydrate energy by increasing its burning of fat. Therefore, higher levels of ketones are produced in the liver and blood ketones rise (to around 0.5 – 3.0 mmol/L), placing the body in a state known as ‘nutritional ketosis’.

A very low carb diet which results in nutritional ketosis is therefore called a ketogenic diet. Outside of type 1 diabetes, the body regulates this level of ketones in multiple ways and prevents them from rising too high. A ketogenic diet can be used for both weight loss and weight maintenance because the fat being burned can come from either the diet or the body’s own fat stores. A ketogenic diet that does not aim to shed a large amount of weight is therefore usually high in fat.

It can take some time, often two weeks or more, before the body becomes fully adapted to making proper use of this higher level of ketones. During the first week or two, some people may experience side effects such as low energy, dizziness and muscle cramps. This is sometimes referred to as ‘keto flu’.

After the body is properly adapted, nutritional ketosis is considered to give a significant metabolic health benefit. Because of this, ketogenic diets have applications in weight management, general health and wellbeing, athletic performance and in the treatment or management of various metabolic diseases, such as type 2 diabetes, Alzheimer’s disease, epilepsy and some cancers.

What is diabetic ketoacidosis (DKA)?

In contrast to nutritional ketosis, DKA is a very different ball game. This is a very dangerous, potentially life-threatening condition. DKA occurs in people with type 1 diabetes who have not taken enough insulin. This includes people with undiagnosed type 1 diabetes, predominantly children, who have not received insulin.

DKA develops when ketone levels are around ten times the levels seen in nutritional ketosis. Dangerously high levels of ketones make the blood acidic, resulting in tiredness, dizziness, nausea, extreme thirst, breathlessness and eventually coma and death if left untreated. Symptoms of DKA usually develop over the course of a day, but can come on faster.

The cause of DKA is subtly, yet importantly different from the mechanism behind nutritional ketosis. When a person with type 1 diabetes has not taken enough insulin, the body enters a state of ‘internal starvation’. This is when there are high levels of glucose in the blood, but no way to get this glucose into the cells to use for energy, so the body believes that it is starving. In order to make more energy available, the body begins to rapidly break down fat into ketones in an emergency fashio, causing ketone levels to shoot up far above those seen in nutritional ketosis. This emergency breakdown of fat is also why rapid, unhealthy weight loss is seen in uncontrolled type 1 diabetes.

It is recommended by the NHS for people with type 1 diabetes to check their ketone levels, either with a blood test or urine test, if the blood glucose level is over 11 mmol/L. Increased ketone levels alongside high blood glucose levels indicate an increased risk of DKA. In addition, ‘fruity’ breath is a sign of DKA since high levels of acetone are expelled by the breath in this situation.

Outside of type 1 diabetes, there have been rare occurrences of ‘euglycemic ketoacidosis’ in people with type 2 diabetes taking SGLT2 inhibitor drugs, also known as gliflozins. This means that it is possible for ketoacidosis to occur alongside normal blood glucose levels with use of these drugs.

The take-home message

Ketones are, at physiological levels up to around 3.0 mmol/L, efficient energy sources for the body that may provide a metabolic benefit in many situations. These levels of ketones are produced during nutritional ketosis, which usually occurs when restricting carbohydrates down to around 20-50g per day, with or without high amounts of dietary fat.

DKA occurs in people with type 1 diabetes with a relative lack of insulin, causing a situation of internal starvation and much higher levels of ketones that are damaging to the body. This life-threatening condition should not be confused with nutritional ketosis.

This article was reviewed by Eric Klett, M.D., endocrinologist and associate professor of medicine and nutrition at the University of North Carolina at Chapel Hill, on November 19, 2018.

If you’ve ever seen a commercial for a diabetes drug, you’ve probably heard the term ketoacidosis thrown around as a potential “scary side effect.” (If not, just turn on cable at 2 a.m.—you’ll find one.)

Well, keto dieters may note that the term actually sounds a lot like ketosis—in which a low-carb diet helps your body burn fat instead of carbs for weight loss.

In fact, they sound crazy similar. So…are ketosis and ketoacidosis linked at all, or are their similarities just an unfortunate spelling coincidence?

All right, what is ketosis again?

Ketosis typically occurs when you’re eating very few carbs, like on the super-popular keto diet. (Think: 60 to 75 percent of your calories from fat, 15 to 30 percent from protein, and five to 10 percent from carbs.)

When your carb intake is that low, your body can’t burn glucose (a.k.a the sugar from carbs) for energy like it normally would. So instead, it burns fat for energy, a process that then releases ketones as a byproduct, says Eric Klett, M.D. an endocrinologist and associate professor of medicine and nutrition at the University of North Carolina at Chapel Hill. (This process explains why people on the keto diet see such crazy weight-loss results.)

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While, yes, ketosis can have a number of effects on your body (especially if you’re newly adjusting to it) like keto breath or diarrhea, going into ketosis on the keto diet is generally considered normal and safe.

So…what is ketoacidosis then?

Ketoacidosis typically only occurs in people with untreated type 1 diabetes, according to Klett. And yes, it’s very dangerous.

. 100+ Amazing Keto Recipes That Will Change Your Life amazon.com $24.95

When a type 1 diabetic doesn’t have adequate insulin to drive glucose utilization, they will start burning fat in excess and over-producing ketones in a way that goes way beyond fat-burning.

A little background: When someone has type 1 diabetes, their immune system attacks and destroys the cells in the pancreas that make insulin (hence why diabetics have very low insulin levels), per the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Insulin is important because it helps your body convert the glucose (mostly from the carbs you eat) in your blood into energy in your cells, per the NIDDK. But people with type 1 diabetes don’t produce enough insulin for this to happen naturally.

Now, if a diabetic is taking daily insulin injections that pretty much solves the problem. If not, all hell breaks loose.

If a diabetic’s insulin levels drop very low, they produce ketones at a pretty fast rate—and all those ketones make a diabetic’s blood super-acidic, which eventually affects their organs. Plus, because of their insulin deficiency, diabetics actually produce ketones at a much faster rate than an average, healthy person on the keto diet ever could.

If someone experiencing diabetic ketoacidosis (DKA) doesn’t inject themselves with the insulin they need, and get hooked up to an IV ASAP, their chances of death are super high—like within-24-hours high, says Klett.

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Luckily, DKA has some pretty glaring signs, so someone experiencing it can get help ASAP—symptoms include rapid and heavy breathing, having to pee a lot, and thirst that can’t be quenched, says Klett. As things progress, they’ll also “get confused, become delirious, and eventually have cardiovascular collapse because the blood pH gets so low,” and their organs will stop functioning properly. So again, treatment is necessary.

So… are ketosis and ketoacidosis connected at all?

Yeah, but loosely. Both involve the body being in a ketotic state, but one’s totally normal and the other’s when ketosis goes too far (again, in those with type 1 diabetes) and gets pretty scary.

It’s possible for your keto diet, for example, to lead to ketoacidosis, but that would be extremely uncommon. (Again, because you’re not eating an “absolutely zero carb” diet and because, as an average person, you can retain their insulin levels better than a diabetic and not over-produce ketones.)

But that doesn’t mean it could never, ever happen—in fact, it actually did happen to one women on a “no-carbohydrate” diet, according to a 2006 case report in the New England Journal of Medicine. According to the case report, the woman was on a strict low-carb regimen for four years (she ate fewer than 20 grams of carbs a day—20 grams per day is the minimum on the keto diet, but most people eat 50 grams per day), but her ketoacidosis cleared up after she was put on a diet with normal carbohydrate intake.

Of course, all of this also begs the question as to whether someone with diabetes can do the keto diet—and according to Klett, they can…as long as they’re taking their insulin injections, it shouldn’t be a problem, he says.

Aryelle Siclait Assistant Editor Aryelle Siclait is an assistant editor at Women’s Health where she writes about relationship trends, sexual health, pop-culture news, food, and physical health for verticals across WomensHealthMag.com and the print magazine.

Ketoacidosis versus Ketosis

Some medical professionals confuse ketoacidosis, an extremely abnormal form of ketosis, with the normal benign ketosis associated with ketogenic diets and fasting states in the body. They will then tell you that ketosis is dangerous.

Ketosis is NOT Ketoacidosis

The difference between the two conditions is a matter of volume and flow rate*:

  • Benign nutritional ketosis is a controlled, insulin regulated process which results in a mild release of fatty acids and ketone body production in response to either a fast from food, or a reduction in carbohydrate intake.
  • Ketoacidosis is driven by a lack of insulin in the body. Without insulin, blood sugar rises to high levels and stored fat streams from fat cells. This excess amount of fat metabolism results in the production of abnormal quantities of ketones. The combination of high blood sugar and high ketone levels can upset the normal acid/base balance in the blood and become dangerous. In order to reach a state of ketoacidosis, insulin levels must be so low that the regulation of blood sugar and fatty acid flow is impaired.
  • *See this reference paper.

Here’s a table of the actual numbers to show the differences in magnitude:

Here’s a more detailed explanation:

Fact 1: Every human body maintains the blood and cellular fluids within a very narrow range between being too acidic (low pH) and too basic (high pH). If the blood pH gets out of the normal range, either too low or too high, big problems happen.

Fact 2: The human pancreas is an organ which secretes insulin, a hormone that helps the body manage blood sugar and fat storage. Without insulin, the body cannot utilize glucose for fuel in the cells, AND cannot store fat in the fat cells.

This is why one of the symptoms of Type 1 diabetes is unexplained weight loss. Type 1 diabetics have pancreatic damage which results in a complete lack of insulin production, and as a consequence, their fat cells have no insulin message telling them to “hold on to those fatty acids”.

Without that message from insulin, large quantities of fatty acids flow out of the fat cells and are broken down in the liver into a ketone body called acetoacetic acid which is then converted to two other circulation ketone bodies, beta-hydroxybutyrate and acetone.

This is ketosis, but an unrestrained, abnormally excessive ketogenesis.

The danger is in the amount of ketone bodies being released. Because ketone bodies are slightly acidic in nature, and so many are released at once in a uncontrolled event, they build up in the bloodstream.

The sheer volume quickly overwhelms the delicate acid-base buffering system of the blood, and the blood pH becomes more acidic than normal. A change in blood pH causes many unhealthy downstream effects. It is not the ketone bodies which are dangerous, it is the low blood pH, a condition called acidosis.

Acidosis symptoms include fruity breath (from the acetone), nausea, hyperventilation, (deep, rapid breathing) dehydration and low blood pressure, as the body tries to rid itself of the abnormal amounts of ketones through the lungs and urine.

If left untreated, acidosis can result in a coma and death. Treatment includes the administration of insulin to slow the ketogenensis and fluid replacement to correct dehydration.

Type 1 diabetics can develop diabetic ketoacidosis if they don’t inject enough insulin, and this usually occurs during a period of illness or injury, or it may be the precipitating condition which results in the diagnosis of their type 1 diabetic disease.

Ketogenic acidosis can also happen during:

  • extended periods of starvation (over months)
  • prolonged severe exercise
  • alcoholic binges (this condition is called alcoholic ketoacidosis)
  • This paper published in Diabetic Medicine discusses several cases in which the drug Ecstasy combined with the excessive movements of rave dancing caused acidosis.

Benign Dietary Ketosis is Controlled

The condition of nutritional ketosis which is associated with a properly formulated ketogenic diet is not dangerous and is regulated by insulin levels within the body.

Nutritional ketosis is simply the metabolic process of burning your own body fat for fuel, and unless you are diabetic and lacking insulin, or you are a raging alcoholic, it is perfectly safe. Levels for adults with a working pancreas and insulin production rarely get above 8-10 mmol/L, even after more than 30 days of total fasting.

Here’s another explanation from Dr. Peter Attia, a physician with extensive knowledge about ketosis.

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What is the Difference Between Ketosis and Ketoacidosis?

Ketoacidosis is a dangerous condition, where toxic levels of ketone bodies build up in the blood because the body is not producing insulin. Ketosis, on the other hand, results when the body has exhausted its stored glycogen and begins to burn fatty tissue for energy.


The process of ketosis is the basis of the many low-carb diets marketed to the public. In ketosis, the body does not have sufficient glucose or glycogen available to give cells what they need to create energy. The body then turns to fat cells as an energy source. Ketone bodies in the bloodstream are a natural product of this process.

These diets work, and ketosis is achieved, when carbohydrates are essentially eliminated from the diet. With minimal carbohydrate intake, there is little sugar to convert to glycogen. Without glycogen, the body breaks down and excretes fat cells, leaving ketones behind in the blood. In an ideal situation, this results in weight loss.

Ketones in the body can be toxic in high enough concentrations. The body often has small amounts of ketones in the bloodstream, including during the overnight period. This is a mild, natural reaction, with low levels of ketones (blood ketones at 1-3 millimolar) and a normal pH of 5, which reverses in the morning when the nightly fast is broken. Low levels of ketones in the bloodstream do not represent a danger to health.

Ketoacidosis occurs when blood sugar levels are high (meaning they are not being metabolized properly in the absence of insulin) and the body is experiencing dehydration. This means the normally small concentration of ketones in the bloodstream becomes much larger.

Ketoacidosis is a pathological condition where the body cannot control the level of ketones building up in the blood. The ketones are being excreted in the urine, but not fast enough to prevent the blood from becoming acidic. Acetone is the simplest ketone, so it is not uncommon that the breath of the patient smells like acetone, or has a “fruity” odor.

This increase in acidity of the blood causes significant damage to organs within the body. It is a serious condition that requires emergency treatment. Untreated ketoacidosis can be life-threatening.

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) can develop quickly, often within 24 hours. Excessive thirst, frequent urination, abdominal pain, nausea and vomiting, shortness of breath, weakness or fatigue, mental confusion, and fruity-smelling breath are all symptoms. If these symptoms occur in conjunction with hyperglycemia and high levels of ketones in the urine (which may be tested with test strips available at the pharmacy), immediate medical attention should be sought.

Triggers for the development of Ketoacidosis might include illness (particularly one where there is a high fever and/or vomiting and diarrhea), failure to take insulin treatments in a timely manner, stress, heart attack, physical or emotional trauma or surgery. Alcohol or drug abuse – particularly cocaine – are also triggers.

DKA more commonly occurs in type 1 diabetes patients, or in late-stage type 2 diabetes patients who no longer manufacture insulin.

Sources: Mayo Clinic, Living Healthy360
Photo: Pexels


What is ketoacidosis?

Diabetic ketoacidosis is a dangerous short-term complication of diabetes that results from uncontrolled high blood glucose. A rare complication in people with type 2 diabetes, ketoacidosis occurs when elevated blood glucose persists and is uncorrected, resulting in chemicals called ketones accumulating in the blood. Because a person with diabetes is unable to use glucose for energy, if they are not being treated properly, their body may burn fat instead to get energy. Burning fat causes the production of ketones, which can be toxic if they build up in the blood. While ketoacidosis is a complication that mostly affects people with type 1 diabetes, it can sometimes occur in people with type 2 diabetes.1

What causes ketoacidosis?

Ketoacidosis can affect someone with type 2 or type 1 diabetes who is not taking insulin as directed (in some cases, their insulin pump may not be working properly), or someone who is not getting a sufficient amount of insulin, or someone who is taking certain medications or illegal drugs that affect how insulin works. Additionally, a person with type 1 diabetes who has a major health problem, such as a heart attack or infection, is at risk for ketoacidosis. Ketoacidosis may also occur in a person with undiagnosed type 2 diabetes.1

Causes of ketoacidosis

Untreated diabetes
  • Body unable to use glucose, burns fat instead causing a build-up of ketones in blood
Major illness
  • Certain major illnesses (eg, heart attack, kidney disease, pancreatitis, stroke, infections)
Medications or illict drugs
  • Certain medications (eg, glucocorticoids, high-dose thiazide diuretics) or illegal drugs (cocaine) may interfere with carbohydrate metabolism
Insulin not taken as directed
  • Failure to take insulin as directed or faulty insulin pump operation can interfere with body’s ability to use glucose
Fasting or alcohol abuse
  • Both fasting and consumption of large amounts of alcohol may affect blood glucose levels

What are symptoms of ketoacidosis?

There are several signs and symptoms of ketoacidosis including1,2:

  • Sweet- or fruity-smelling breath
  • Extreme thirst
  • Frequent urination (including during the night)
  • Fatigue
  • Stomach ache
  • Nausea or vomiting
  • Difficulty thinking clearly
  • Weight loss

In extreme cases, ketoacidosis can cause a person to go into a coma. Ketoacidosis should be treated as a medical emergency. If you experience any of the symptoms listed above, you should consult your doctor or nurse immediately.1,2

How is ketoacidosis detected?

A variety of tests are useful in determining if a person has ketoacidosis, including serum glucose, serum electrolytes, and urinalysis and urine ketones. Blood glucose levels in people with ketoacidosis are typically less than 800 mg/dL, but may be greater than 1000 mg/dL. Urine analysis will be done to determine levels of ketones in your urine. Ketoacidosis can affect how your heart operates, so your doctor may have you undergo an electrocardiogram to check the electrical activity in your heart.1,2

How is ketoacidosis treated?

If you have ketoacidosis, your body has lost fluids and important chemicals that your body requires to function normally. Treatment for ketoacidosis requires replacing lost fluids and electrolytes (chemicals including potassium and sodium) and re-establishing the normal healthy balance of these components in your blood. This is done with an intravenous infusion of fluids and electrolytes. Treatment for ketoacidosis also requires making sure that your body has the insulin it needs to use glucose for energy.1

How can I prevent ketoacidosis?

As with many complications of diabetes, ketoacidosis can be prevented by closely monitoring your blood sugar and maintaining it at the right level and taking your insulin, as directed.1

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