We are going to be taking a look at Nutritional Ketosis and Diabetic Ketoacidosis( DKA). They are two different metabolic states that are not associated. They do sound the same when spoken because they both have ‘keto’ and ‘osis’ in one of the words, but the similarity ends there. In the same way as ‘understood’ or ‘misunderstood’. Sounds similar but completely different meaning.
A lot of people quite rightly worry about ketones in a ketogenic diet. Whatever type of diabetic diet you are using, Diabetic Ketoacidosis is always a risk due to other factors than diet complicating your condition. But, reassuringly, a study of people with Type 1 diabetes who were on a ketogenic diet, was reported by Dr. David Ludwig. He analysed a sample of people with Type 1 diabetes who were members of the Facebook group # Type1Grit. He found a remarkably low rate of Diabetic Ketoacidosis of 1% requiring hospital admission. This is at least half if not more than with conventional management that is high carbohydrates, but exact figures are difficult to get.
What is the difference between Nutritional Ketosis and Diabetic Ketoacidosis?
Nutritional Ketosis is a safe and natural way to burn fuel. When we enable the body to burn fat as fuel instead of carbohydrates, the result of the fat burning is a small molecule called a ketone body hence the term ‘ketogenic.’ Nutritional Ketosis happens when you eat a high-fat diet, also called a ketogenic diet. Ketosis also happens in starvation, and some people will confuse Nutritional Ketosis with starvation. The difference is that in Nutritional Ketosis, there is no calorie restriction. Starvation is caused by calorie restriction. Then fat stores are used for survival. When you are on a low carb diet, you burn fat stores because it is the only fuel available. But this is not a bad thing. Many people will argue that ketones are a preferred fuel for the body, and especially the majority of nerve tissue. The brain seems to thrive on ketones. Nutritional Ketosis is also associated with reduced inflammation.
In Nutritional Ketosis, your bloodstream will have more ketones compared with someone who is not on a ketogenic diet. This is because fat burning mobilises ketone bodies to be used as energy. The ketones are not raised to dangerous levels. The confusion comes because the accepted normal range for ketones is based on a high carb diet. Carbohydrate metabolism does not generate ketone bodies. So, the normal range with carbohydrate-rich metabolism is 0-0.3mmol/l. If the whole population were on a ketogenic diet, then the ‘normal’ range for ketones would be 0.3-3.5mmol/l. It is not a dangerous level, but typical for someone who is on a ketogenic diet
To recap. Burning fat in preference to carbohydrates will generate higher levels of ketone bodies in the blood compared with carbohydrates. With a well-regulated insulin management regimen, you will be at no risk of Diabetic Ketoacidosis, because these ketone levels will be in the Nutritional Ketosis range. You will also have much smoother and better-controlled glucose levels as a result of a low-carbohydrate, ketogenic.
Diabetic Ketoacidosis (DKA) is a condition brought about by why a lack of sufficient insulin for the body’s needs at that particular time. 80% of people who are diagnosed with Type 1 diabetes present with Diabetic Ketoacidosis. So, when the pancreas stops producing insulin to cause Type 1 diabetes, glucose can no longer be metabolised. Insulin is required to get glucose out of the bloodstream. The primary sites of insulin action are the liver, muscles and fat stores. It is not possible to clear the glucose to safe levels with insufficient or no insulin. Insulin also directly regulates the effect of the hormone glucagon. Glucagon is a hormone that works primarily in the liver to raise blood glucose. With no insulin or insufficient insulin available, the effect of glucagon is unregulated. Dietary and glucagon-derived glucose cause an increase in blood glucose levels. This is followed by an increase in urination, then thirst because of the osmotic effect of glucose in the bloodstream.
What happens then is that the body shifts its fuel source from glucose to fat. This is a metabolic crisis. The body has no choice. There is effectively no energy to be extracted from glucose, so the fat stores are mobilised but in an unregulated way. Fat metabolism itself is regulated by insulin and glucagon, and in the case of insufficient insulin, there is uncontrolled fat metabolism as well. This overwhelms the body’s ability to control the by-products metabolism, mainly ketones and the ketone levels rise in the bloodstream. The body excretes as much ketone as possible in the form of acetoacetate in the urine and acetone in the breath. The acetone in the breath gives the typical ‘pear drops’ odour. Without insulin, the ketone levels continue to rise and overwhelm the ability of the body to keep up. This causes acidity in the urine because ketones are acidic. There then ensues an imbalance of electrolytes which regulate the acid-base of the blood. Ketone levels are often in the Range 10 to 15 millimoles per litre which is far higher than the Nutritional Ketosis range of 0.3-3mmol/l
The symptoms of Diabetic Ketoacidosis include:
• An unusual smell on the breath –sometimes compared to the smell of pear drops or nail polish
• Deep laboured breathing or hyperventilation
• Rapid heartbeat
• Confusion and disorientation
If ketoacidosis is suspected, it is crucial to call for emergency medical help immediately. In Type 1, ketoacidosis is caused most often by a relative lack of insulin. At diagnosis, it is usually because of a total lack of insulin. It is essential to ensure that insulin is regularly injected according to your usual regimen. If glucose is rising and ketones are rising as well, this is likely because you have insufficient insulin and will need to consider injecting a correction dose.
One of the most common causes of Diabetic Ketoacidosis is infection. People using a ketogenic diet should be equally as vigilant for Diabetic Ketoacidosis as people who use higher amounts of carbohydrates. It is strongly recommended that you have access to blood ketone testing strips. These are the most accurate measure of Diabetic Ketoacidosis. Other common reasons for Diabetic Ketoacidosis are forgetting insulin doses, damaged pens, and pumps, omitting insulin doses.
Of course, most people to test blood glucose regularly and take corrective action with insulin doses. You will most likely have a plan for sick day rules, which you will have worked out with your diabetes specialist. This will give you a strategy for approaching illness.
Don’t forget to regularly measure your blood ketones if your blood sugar is rising. Check your plan.
IMPORTANT: A point to bear in mind. An infection will cause raised blood glucose because of stress hormones. Sometimes this leads to temporary insulin resistance. This means that your raised glucose might not respond to insulin injections in the usual way and remain high. Be careful not to micro-manage your blood glucose to try to get to normal levels too quickly during an infection. Because, when you start to recover from the infection, you might relatively quickly become more insulin sensitive, and then, if you have injected too much insulin, you may be vulnerable to a
potentially dangerous hypoglycaemic attack. As long as you are injecting sufficient insulin, then a few hours or days of higher glucose levels will do no long-term harm. You will, of course, need to monitor your ketone levels throughout an illness to ensure you are not going into ketoacidosis. It requires a combination of insulin management, fluid management and ketone monitoring to manage an impending ketoacidosic episode effectively.
Everyone has their unique type of diabetes. Only broad principles can be discussed here. Your Healthcare Professional is your skilled ally in personal management. Gastrointestinal upset is a concern for Type 1 diabetes, and insulin management should be undertaken with specialist advice. Fluid management can be an issue; likewise, hypoglycaemia, if it happens, can also be an issue to resolve if vomiting is present. Glucagon is a useful hormone in this situation; everyone should have glucagon available for such scenarios.
To recap. Nutritional Ketosis is a safe and natural metabolism for someone who chooses to go low carb.
Nutritional Ketosis is not a risk factor for Diabetic Ketoacidosis.
Diabetic Ketoacidosis is about insulin management and needs skilled help to treat it effectively.
People on keto diets are less likely to be admitted to hospital with Diabetic Ketoacidosis.
A keto diet does not protect you from Diabetic Ketoacidosis