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Ketosis vs Ketoacidosis: Causes, Symptoms and Takeaway

Published on: August 27, 2019

Ketosis vs Ketoacidosis: Causes, Symptoms and Takeaway

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One question that often comes up in the ketogenic diet space is this: Does ketosis induce ketoacidosis? People often confuse ketosis vs ketoacidosis not only because they sound similar but also because these metabolic states are characterized by the production of ketones.

We are going to clear up any misunderstanding in this guide by explaining their differences as well as the common triggers for ketoacidosis and its symptoms. Keep reading for our complete guide.


What Is the Difference Between Ketosis and Ketoacidosis?

Ketosis is a normal metabolic state in which the body uses its stored fat for energy when glucose supply is low. A person induces nutritional ketosis by limiting his or her carbohydrate intake to 20-50 grams per day, eating moderate protein, and eating healthy fat to satiety [1].

It is important to note that while ketone bodies, as a result of fatty acid breakdown increase in nutritional ketosis, these ketones are produced only in small amounts and do not alter blood pH - i.e. the acidity or alkalinity does not change. Serum ketones range from 0.5 to 5 mM [1, 2].

ketosis-is-a-normal-metabolic-state

Furthermore, there is strong evidence that nutritional ketosis helps with weight loss and the prevention and management of cardiovascular disease, type 2 diabetes, cancer, polycystic ovary syndrome (PCOS), and neurological conditions. Therefore, not only is nutritional ketosis generally safe, it can be potentially curative or preventative as well. [3, 4].

Ketoacidosis, on the other hand, is an abnormal metabolic state and a medical emergency. It is characterized by dangerously high ketone levels, causing a person’s blood pH to become acidotic. In this case, serum ketones range from 15-25 mM [2].


ketosis-and-ketoacidosis

Can Ketosis Cause Ketoacidosis?

Given that a person follows a well-formulated ketogenic diet, the answer is no - ketosis will not cause ketoacidosis.

However, there are rare documented cases where people have suffered from ketoacidosis after following a “ketogenic” diet for some time.

Take, for instance, a 2006 study where a 51-year-old non-diabetic woman who also had no history of diabetes was admitted after strictly adhering to a low-carbohydrate diet for 4 years. According to the study, the woman often restricted her carbohydrate intake to less than 20 grams per day [5].

Another study discussed a 32-year old non-diabetic woman who followed a strict low-carb, high-fat diet while she was breastfeeding her 10-month old son. She restricted her carbohydrates to less than 20 grams per day [6].

In these cases, it is likely the severe carbohydrate restriction over a significantly prolonged period which promoted the onset of ketoacidosis.

calorie-restricting-should-not-be-done-to-attain-nutritional-ketosis

These case scenarios tell us the following things:

One, severe calorie restriction should never be done to attain nutritional ketosis. Restricting calories is not the only way to lose weight if that is your goal. After all, our bodies need calories to function properly.

Two, each person has optimal keto macronutrients depending on his or her weight, activity level, exercise routine, and more. Also, keto macronutrients change over time. Having no carbohydrates, too little carbohydrates, or too little protein could hamper your health.

Three,medical supervision is essential. The reason for this is that a person who has a medical condition and is taking medications or is currently breastfeeding may need certain adjustments on keto to make it work for them.


ketoacidosis-vs-ketosis

What Causes Ketoacidosis?

Now that you know the difference between ketosis and ketoacidosis, we’re going to discuss the common causative factors of ketoacidosis:


1. Poor management of diabetes

Ketoacidosis is common among patients with diabetes, without eating the keto diet. However, it is more common among those with Type 1 Diabetes. One major factor that triggers ketoacidosis is non-compliance to diabetes treatment, especially insulin therapy [7, 8].

During an assessment, medical professionals usually find out that a diabetic patient who’s already taking insulin have a history of reduced or omitted insulin [9]. Keep in mind that insulin plays a vital role by allowing the body to use glucose for fuel. Without insulin, the body breaks down fat and produces ketones [10].


alcoholic ketoacidosis

2. Alcohol use and starvation

Chronic alcohol drinkers may be consuming calories from ethanol; however, they lack nutrients from other dietary sources, resulting in starvation. Their carbohydrate and protein stores become depleted [11].

Another reason for alcoholic ketoacidosis is that starvation and ethanol increases cortisol, a stress hormone. An increase in cortisol also increases the availability of free fatty acids. Some of these free fatty acids will be used for ketogenesis [11, 12].


3. Drug misuse, especially cocaine

Cocaine use has been observed in many adults admitted with diabetic ketoacidosis. A study showed that cocaine users are more likely to fail to take their insulin therapy and practice self-care [13].

In another study, a 57-year-old female who was admitted for euglycemic ketoacidosis was tested positive for cocaine. The patient confirmed that she binged on cocaine for 2 days before hospital admission, and during that binge, she missed her insulin. According to the study, cocaine use is a trigger for diabetic ketoacidosis in many diabetic patients [14].


difference between ketosis and ketoacidosis

Ketoacidosis Symptoms

Signs and of ketoacidosis include the following [7, 15]:

  • Nausea
  • Vomiting
  • Excessive thirst
  • Abdominal pain
  • Fruity breath
  • Rapid and shallow Kussmaul breathing
  • An altered state of consciousness
  • Abnormally low blood pressure

The diagnostic criteria for diabetic ketoacidosis include [7]:

  • Blood glucose level of more than 250 mg/dl
  • Arterial pH of less than 7.3 (blood is acidic)
  • Serum bicarbonate of less than 15 mEq/l
  • Moderate ketonemia and ketonuria
symptoms-for-ketoacidosis

Please take note that while hyperglycemia or an excessively high blood glucose is a common presentation with diabetic ketoacidosis, patients can have different plasma values [16].


Conclusion

One should not get confused between ketosis and ketoacidosis. Again, ketosis is safe while ketoacidosis is a fatal metabolic state that could lead to coma or death. People who decide to enter nutritional ketosis for a health or fitness goal however, should seek medical guidance, especially if they are on medication, have a health condition, or are breastfeeding.


Takeaways

  • Ketosis is a natural state and happens by limiting carbs, eating moderate protein and increasing fat in the diet.
  • Ketoacidosis is a life-threatening condition characterized by very high ketone levels.
  • When a person follows a well-formulated keto diet, ketoacidosis should not occur.
  • Known triggers for ketoacidosis include poor diabetes management, alcoholism, and cocaine abuse. Poor type 1 diabetes management is the most common cause.

References:

  1. Masood W, Uppaluri KR. Ketogenic Diet. Last update: 2019 March 21 - https://www.ncbi.nlm.nih.gov/books/NBK499830/
  2. Phinney S, Virta Team. Ketosis vs ketoacidosis: What is the difference? https://blog.virtahealth.com/ketosis-vs-ketoacidosis/
  3. Paoli A et al. Beyond weight loss: a review of the therapeutic uses of... View all references

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