NUTRITIONAL KETOSIS AND DIABETIC KETOACIDOSIS
Nutritional ketosis is a healthy state and happens irrespective of diabetes status. It is the production of ketone bodies as the end result of the regulated metabolism of fat in the absence of carbohydrates. Ketone bodies (acetone, acetoacetate, and beta-hydroxybutyrate) are water-soluble and energy-dense. Some ketone bodies are a valuable source of energy in themselves. For example, Beta-hydroxybutyrate (BHB) is easily transported to the brain, which can use this molecule for its energy needs.
Ketone levels for people in normoglycemia will vary from 0.3 to 3 mmol/l in the blood of someone in nutritional ketosis. This is safe. It is not uncommon to find up to 3+ of ketones in the urine of patients who are using a very low carbohydrate diet, but the glucose levels will be normal. If ketones are present in excess, they are simply converted to acetoacetate, which is readily excreted in the urine. Ketones can also be converted to acetone, which is excreted through breathing.
Nutritional ketosis is not a state of starvation but represents healthy metabolism. It is the result of choosing to take energy in the form of fats instead of carbohydrates.
In diabetic ketoacidosis (DKA), however, there is a state of insufficient insulin which can happen in Type 1 diabetes due to overconsumption of carbohydrates, infection, or underdosing with insulin, uncontrolled fat-burning ensues. Uncontrolled fat metabolism will lead to increased ketone bodies. These excess ketone bodies will cause acidosis. Insufficient insulin for the needs of the body at that time leads to increased glucose partly generated by the removal of the insulin ‘brake’ on glucagon, partly by dietary carbohydrates. Polyuria, dehydration, and electrolyte disturbances follow. This is a medical emergency. Contrast this with the controlled and intended natural production of ketones in nutritional ketosis when sufficient insulin is present.
It is imperative, however, for patients to understand that they need to be vigilant when in nutritional ketosis. Glucose levels rising might be an indication of insufficient insulin. DKA can also, by itself, cause temporary insulin resistance. It is also essential to make the patient aware of the possibility of attempting to overcorrect a raised blood glucose in this situation. Recovery from DKA can be sudden and might lead to a hypoglycaemic state if treatment is too aggressive. As always, close supervision is recommended.
All people with Type 1 Diabetes will already have been taught how to calculate a corrective dose of insulin for raised glucose levels as part of their routine care, but there is no harm done by enforcing this point.
Sleep, stress, and physical activity play a significant role in the day to day diabetes management, and there are ideas on the varied ways to manage this.