Ketosis vs. Ketoacidosis

Is it a trendy-yet-effective way to slim down, or life-threatening condition? A couple syllables can make a huge difference.

For people with diabetes, especially those with type 1, ketoacidosis (or DKA for diabetic ketoacidosis) is a familiar term because it has to be. The condition will make someone extremely ill and likely land them in the hospital. Meanwhile, many people actively seek to enter a state of ketosis. Nutritional ketosis causes some unpleasant side effects, but it’s usually safe and promotes quick weight loss.

But because of the similar names, it’s easy to confuse ketosis with ketoacidosis or vice-versa. Both conditions result from the body producing ketones, but while one can end with you in a smaller dress size, the other could end with you in the hospital, or worse.

Here we talk about what makes ketosis and ketoacidosis similar and what makes them very, very different.

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The body uses a balance of glucose (carbohydrates) from our diet and stored fat for fuel. The ratio of glucose and fat use depends on diet and how hard the body is working at the time. When the body burns fat as its main energy source, it enters into ketosis. When ketosis is induced from a low-carbohydrate diet, it’s called nutritional ketosis. It’s often the goal of the ketogenic diet and intermittent fasting.

When the body goes into ketosis, it produces ketones as a by-product of the fat-burning process. Ketones are always present at some level in the body, and they help make up proteins and fats. Ketones levels can be approximated with an over-the-counter urine testing strip.

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As the body burns more fat and therefore produces more ketones, someone may experience what’s called the “keto flu.” Symptoms may include bad breath, headaches, thirst, upset stomach, cramps, and fatigue. These symptoms generally go away after anywhere from a few days to a few weeks.

The dangers of ketosis are generally small, though it can cause nutritional imbalances if people aren’t getting sufficient carbohydrates or enough variety in their diet. Insulin helps regulate blood sugar and keep the body from producing unsafe levels of ketones. It also ensures that the body is getting some glucose so it’s not burning only fat.

But people with type 1 diabetes don’t produce insulin, and that can make producing ketones dangerous.

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Because insulin regulates blood sugar and stops the overproduction of ketones, it’s rare for someone without type 1 diabetes to experience ketoacidosis. People with type 2 diabetes can go into ketoacidosis if their diabetes is uncontrolled. It is extremely rare for someone without diabetes to go into ketoacidosis and would only be possible in the case of extreme carbohydrate deprivation. In the United States, about one third of ketoacidosis cases are among those with type 2 diabetes and about two-thirds of cases happen in those with type 1.

Like ketosis, ketoacidosis starts when the body starts burning fat as its primary fuel. Ketones are produced and released in the bloodstream, but without enough insulin, ketone production isn’t properly regulated. Ketones are produced at a much higher rate than in nutritional ketosis, causing the blood to become acidic and toxic.

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Early symptoms of ketoacidosis are extreme thirst, increased urination, fruity breath (think overripe or rotting fruit), nausea, fatigue, and high blood glucose. Symptoms will progress to include abdominal pain, vomiting, behavior changes, confusion, lethargy, and blurry vision. Note that not everyone will experience every symptom.

People with type 1 diabetes should check their urine for ketones if their blood glucose is greater than 250 mg/dl twice in a row or more or if they are sick.

Ketone levels

Below are what different levels of blood ketones indicate according to Diabetes Self Management:

  • 0.6 millimoles of ketones per liter and below is considered normal.
  • 0.6 to 1.5 mmol/liter is a moderate level and indicates a high level of fat burning. People with diabetes should talk to their doctor and diabetes educator before attempting to purposely produce ketones as even these levels may be dangerous.
  • 1.6 to 3.0 mmol/liter indicates a high level of ketones and risk for ketoacidosis for those with diabetes. People with diabetes should contact their doctor at this level.
  • 3.0 mmol/liter and above requires emergency medical care for those with diabetes.

Ketone testing strips designed for urine testing will be able to tell someone approximate ketone levels. The ketogenic diet may be safe for people with diabetes so long as they are taking prescribed insulin, but people with diabetes (any type) should talk to their doctor before starting any type of diet, including low-carb diets.

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