Ketosis vs Ketoacidosis: Differences and Risks

The ketogenic diet works by putting you into the state of Nutritional Ketosis.

When you are in ketosis, your body no longer predominantly uses glucose for fuel.

It breaks down fat into fatty acids and different levels of ketones, both of which can be used for fuel. Ketones are a by-product of the fat-breakdown process.

Although the brain can use ketones for up to 80 percent of its fuel needs, and glucose for the other 20 percent, the buildup of ketones in the bloodstream can be dangerous when they reach certain level.

However, for most people, keto diet is not dangerous.

Ketosis is often confused with Diabetic Ketoacidosis (DKA), since both words begin with keto, but ketoacidosis is a very different situation that is serious and life-threatening.

Similarities and Differences Between Ketosis and Ketoacidosis

Going into the state of ketosis is the same for both conditions.

The body finds itself short of carbohydrates, and therefore glucose, and in an effort to save your life, it begins to use amino acids, and then a little later on, fat-burning for fuel.

In the case of Nutritional Ketosis, you deliberately deprive the body of the glucose it needs by way of severely restricting your carbohydrate intake and use your dietary fat and protein intake to somewhat control the situation.

For Ketoacidosis, you don’t deliberately go into ketosis.

Having insulin resistance at the fat-cell level or not being able to produce your own insulin puts you into ketosis unknowingly.

However, if you have type 1 diabetes, and don’t know it, you could still go into Ketoacidosis while doing keto.

You’ll want to make sure that you understand what Diabetic Ketoacidosis is, know what to look for as far as symptoms go, and make sure that your ketones are not going too high.

The liver doesn’t actually detect the amount of glucose you have in the bloodstream before breaking down its glycogen stores into glucose. The liver uses the presence of insulin in the bloodstream to tell it whether you have enough glucose to feed your cells, or not.

When insulin is too low, the liver will use gluconeogenesis to get the glucose it needs to supply the brain and other body organs with fuel.

On low-carb diet like keto, carbohydrates are not necessary to get this glucose, as the liver has a variety of methods and substances it can use when carbs are missing.

You don’t have to worry about that.

What you need to know is that in a Type 1 diabetic, who makes very little to no insulin at all, the lack of insulin can be leading cause of death because gluconeogenesis won’t shut off.

When insulin is very low, the liver believes that the body needs fuel right away, so it breaks down its glycogen stores into glucose and dumps the glucose into the bloodstream.

If you are a Type 1 diabetic and want to get on a ketogenic diet, you can still do that, but you’ll need a lot of medical supervision to get your medications dialed in correctly while restricting carbohydrates.

Don’t try to do it on your own.

That can create a very dangerous situation for a Type 1 or Type 1-1/2.

The same thing can happen to a Type 2 diabetic if you have insulin resistance, but it isn’t as common to go into Ketoacidosis as it is for those who have Type 1.

Most individuals with Type 2 diabetes are able to make enough insulin to prevent ketoacidosis from occurring.

But you, too, will need medical supervision to make sure that your ketone level stays within the optimal zone for ketosis.

You can go into ketoacidosis if your food intake and medications are not in balance.

According to Dr. Phinney, the creator of the keto diet, Type 2’s don’t need as much supervision as a Type 1 does, but you still need to be under a doctor’s care.

Without enough insulin to communicate with the liver, there is no ability to get glucose into the cells and blood glucose levels becomes elevated, along with ketones backing up in the bloodstream.

While ketones also build up in Nutritional Ketosis, to some extent, insulin keeps the situation from getting out of hand.

Keto dieting changes the amount of insulin you need to have on a daily basis to achieve normal or nearly normal blood sugars.

What is Ketoacidosis?

Let’s talk about Ketoacidosis first, since this is the condition that most people are afraid of when they say that ketones are dangerous.

There are 3 types of ketoacidosis:

  1. Alcohol Ketoacidosis
  2. Starvation Ketoacidosis
  3. Diabetic Ketoacidosis

The first two types are pretty self explanatory.

You go into Alcohol Ketoacidosis by consuming too much alcohol. You go into Starvation Ketoacidosis when you don’t eat enough or you can’t absorb your food properly.

In Diabetic Ketoacidosis, very high ketones occur in combination with high glucose and dehydration. We are talking about having levels as high as 15 to 20 mmol/L, or even higher.

To put this in perspective, the optimal zone for doing Keto is a mere 0.5 mmol/L to 4.0 mmol/L.

In ketoacidosis, insulin is also very low to none.

The lack of insulin seriously impacts glucose absorption by your body’s cells, so you end up with high blood sugar level, very low insulin, and very high ketones.

Ketone bodies can go up due to:

  • illness
  • a bad infection
  • missing a meal
  • not eating properly
  • being stressed out
  • or not taking enough insulin

Ketoacidosis can happen in as little as 24 hours, so you’ll need to contact your physician just as soon as you begin to feel ill.

While getting into ketoacidosis is generally a slow enough process that you have plenty of time to seek treatment, vomiting can greatly reduce the time it takes for those ketones to build up to an unsafe level.

Risks Associated with Ketoacidosis

The urine testing strips that you use if you’re following the Atkins Diet are actually designed to look for ketoacidosis.

This is why the strips show a light, moderate, or high levels of ketones when you test your urine. That gauge has nothing to do with keto.

These strips are looking at the concentration of acetoacetate ketones and trying to detect if you are in a state of ketoacidosis, or not.

There are 3 different types of ketones:

  • acetoacetate ketones
  • beta-hydroxybutyrate ketones
  • acetone ketones

Acetoacetate ketones are the ketones that the urine testing strips can detect.

The concentration of your urine contains some of the other ketones, as well. Unfortunately, these sticks do not give an accurate number measurement.

They can just give you an approximation due to how concentrated your urine is with acetoacetate ketones. This is why it doesn’t matter what color you turn the test strips.

All colors mean you’re in ketosis.

However, excess ketones in the bloodstream will throw the chemical balance in your blood to the acidic side.

This acid negatively impacts your liver and kidneys and can damage them. For that reason, the buildup of ketones to very high levels is quite toxic and puts your life at risk.

The American Diabetes Association recommends that you begin testing for urinary or blood ketones once your blood glucose reaches 240 mg/dl and every 4 to 6 hours when ill.

This is because it’s quite difficult to tell the difference between being sick and being in ketoacidosis by symptoms alone.

If two tests in a row show that your ketones are staying consistently high, you need to contact your doctor right away.

Your health provider can tell you what level of ketones to watch for in your urine or bloodstream, but if you don’t know, then use the moderate reading because it’s better to error on the side of safety than risk the complications for not being treated in a timely manner.

Ketoacidosis is serious. Complications include coma and even death. You don’t want to procrastinate contacting your doctor if you think you might be in ketoacidosis.

Symptoms of Ketoacidosis

There are many symptoms of ketoacidosis.

Some of these symptoms are:

  • extreme thirst
  • frequent urination
  • dehydration
  • nausea or feeling queasy
  • vomiting for longer than 2 hours
  • stomach ache
  • exhaustion
  • fruity breath
  • shortness of breath
  • confusion
  • inability to concentrate

These are similar to the symptoms for diabetes itself, so ketoacidosis is often the very first sign that alerts you to the presence of Type 1 or Type 1-1/2 diabetes, especially if you have been misdiagnosed with Type 2.

However, poor diabetes management is the leading cause of Diabetic Ketoacidosis.

What is Nutritional Ketosis?

Nutritional Ketosis is the metabolic state you move into while doing Keto. It’s triggered by a lack of carbohydrates in the diet once your glycogen stores get low.

The brain needs roughly 120 carbohydrates per day to function at its best, but the liver is able to make glucose from a variety of other things. Ketosis is not triggered by a fall in insulin or a rise in blood glucose and ketones.

Neither is it triggered by consuming dietary fats.

Ketones in the bloodstream are a result of restricting carbohydrates and are used to fulfill the brain’s requirements for energy.

Is Nutritional Ketosis Dangerous?

The metabolic state of Nutritional Ketosis is not dangerous because the body will secrete insulin to take care of the amount of ketones building up in the bloodstream.

In general, this insulin secretion will occur way before your blood ketone level ever reaches 8 mmol/L.

When insulin is elevated in this way, acetoacetate ketones in the blood are sent to the kidneys to be disposed of because a rise in insulin signals the body that glucose is available to the cells.

Ketosis goes into a state of hibernation until the insulin level falls back to normal.

Ketone production is put on hold until the beta-hydroxybutyrate ketones in the bloodstream are used up and the number of ketones in the blood falls back down into a safe level.

This gives the body time to use the excess ketones in the bloodstream.

Benefits of Being in the Optimal Zone for Ketosis

Keto is a very low-carbohydrate diet that has been clearly demonstrated to help you curb your appetite, lose weight, and improve your risks for heart disease, stroke, and blood clots.

When done properly, Keto also helps you to maintain your muscle mass, which will help to keep your metabolism running efficiently.

On the average, getting into the state of ketosis takes about 1 to 3 days, depending on how many carbohydrates you were eating before you went Keto.

Dieters have also reported that they have become more sensitive to insulin, improved their cholesterol counts, and gained better energy and mental clarity.

What is a Safe Level of Ketone?

The safest level of ketones is 4.0 mmol/L, or less. The only exception to this is for endurance athletes who are using Keto to help them increase their physical performance.

If you’re an athlete, and on Keto, you might see levels as high as 5.0 mmol/L, but never anything that comes even close to what you’ll see in ketoacidosis. This is true, provided you are not diabetic.

Allowing your blood ketones to rise above the optimal zone of 0.5 mmol/L to 4.0 mmol/L is counterproductive to what you’re trying to do during the weight-loss phase since insulin will be secreted and ketone production will stop if you go much higher than 4.0 mmol/L.

Fat mobilization also stops when insulin is secreted to bring your ketones back down to within the optimal zone.

Final Thoughts

Ketoacidosis never happens in a healthy individual who doesn’t have diabetes because the body won’t let your ketone level get high enough to put itself in danger. Instead, it will secrete insulin to help clear the blood of those excess ketones.

Ketoacidosis only happens when you don’t make enough insulin to do that.

However, some ketogenic dieters believe that high ketone levels are optimal for weight loss and will drastically lower their protein intake in order to achieve as high a ketone level as possible.

This is not a wise move.

There is no metabolic benefit in taking your ketone level in the blood higher than 4.0 mmol/L. In fact, your weight loss can actually stall if you put your body under stress like that.

Instead, it’s better to focus on getting into the Nutritional Ketosis zone, 0.5 mmol/L to 4.0 mmol/L, and making permanent changes in your attitude, emotional attachments to food, and your mental health.

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