Ketosis vs Ketoacidosis: Ending the Confusion

Ketosis vs Ketoacidosis. What is the difference? What are ketones anyway and why is everyone talking about them? Isn’t it dangerous to be in ketosis? There is a lot of confusion out there, even among medical practitioners who should know better, and this article will clear up the confusion once and for all about whether a ketosis diet causes a dangerous condition called ketoacidosis.

What are Ketones

Ketones, also called ketone bodies, are molecules produced by the liver that can be used as energy for the body in place of glucose (also known as blood sugar). 1 In other words, when no carbohydrates (all carbohydrates turn into glucose in the body) are eaten, and the body’s storage of glucose in the liver, a substance called glycogen, has been used up, the body institutes ketones as a back up system.

This back-up system, known as ketosis, produces a secondary source of energy in the form of those ketones we mentioned earlier, in order to ensure there is always an abundant energy source to feed the muscles and, in particular, the brain.

Your Brain on Ketones

In fact, the brain loves ketones and chooses it over glucose whenever it’s available. 2 This interesting fact has enabled ketones to be utilized in a wide variety of treatments for neurologic conditions from seizures to Alzheimer’s disease. 3

What is a Ketosis Diet

Now that we know what ketones are, we can discuss how one gets them. You can get ketones one of 3 ways:

  • Fasting- meaning the complete absence of food
  • A low or very low carbohydrate diet
  • Taking supplements

A Ketosis diet is also called nutritional ketosis, and this occurs when the absence of carbohydrates causes a switch in the body to create ketones for fuel once glycogen in the muscles is depleted. It has nothing to do with ‘starvation’, although those who are in starvation also produce ketones.

Anyone can get into nutritional ketosis fairly easily by restricting carbohydrates for a few days, either through a low carbohdrate diet or fasting, and then exercising moderately. For many, that’s enough to cause nutritional ketosis, although your mileage may vary and many are more resistant to getting into ketosis. It’s a natural metabolic state that we can switch into and out of rather quickly, especially once the body has become used to being in ketosis.

Blood ketone levels from a ketosis diet start from about 0.5-1 mmol/L and go up to as high as 7-8 mmol/L for doctor supervised regulation of drug resistant epilepsy or various types of cancer. 4 5

Is Ketosis Dangerous?

Ketosis is a normal human biologic condition that healthy humans can easily switch in and out of while maintaining excellent health. On the contrary, an extreme condition called ketoacidosis, also called diabetic ketoacidosis, or DKA, is an abnormal metabolic condition signaling a serious, and potentially even deadly, health condition that almost certainly requires intensive emergency treatment. So, is ketosis dangerous? No, only ketoacidosis is dangerous.

“It is now known that (in nondiabetic individuals), owing to the blood’s efficient buffering capacity, plasma KB [ketone body] levels can increase to 6–8 mM during a prolonged fast [or a low carb diet] without giving rise to clinically hazardous acidosis”

Ketone body therapy: from the ketogenic diet to the oral administration of ketone ester

The two conditions are so different that they should never be confused with one another. Sadly, even many doctors don’t know the difference, and will often frighten patients on low carb diets into believing that the presence of ketones is a dangerous condition and should be immediately stopped. But this just shows the ignorance of the doctor who does not know the difference between nutritional ketosis and DKA.

Ketoacidosis is entirely different

Now, lets compare and contrast Nutritional ketosis with ketoacidosis. Studies have defined DKA as having: 6 7

  • A capillary blood pH of < 7.3
  • Blood glucose >11 mmol/L (196 mg/dl)
  • 2+ ketones in the blood
  • Blood bicarbonate levels <15 mmol/L
  • Feeling poorly, often extremely ill, particularly with excessive urination, excessive thirst, fatigue, and abdominal pain
ketoacidosis vs ketosis

Additionally, those in ketoacidosis will have been on no diet in particular, while someone in ketosis will either have been not eating at all, eating very little, or eating a low carbohydrate diet. It’s important to differentiate these from each other since ketosis is not dangerous and ketoacidosis is. At first, it might be hard to differentiate between the two since many diabetics with high blood sugar might be on a ketogenic diet and go to the hospital feeling ill for any number of reasons.

However, very often those showing up with diabetic ketoacidosis are children or newly diagnosed diabetics with extremely high blood sugars. The main difference between someone who might just be a diabetic who is sick for another reason and happens to be on a ketogenic diet, and someone who is in dangerous ketoacidosis is the blood pH.

PH is Extremely Important

Every fluid on earth has a particular pH, which is it’s measure of how acidic or alkaline it is. The pH of blood is a steady 7.35-7.45. There is a complex feedback mechanism that keeps it in that zone.

Despite what you might have heard about ‘eating alkaline’, your food choices won’t change your blood pH, only severe illness will tax the body’s delicate buffering system so much that your pH will go as low as 7.31, which is what happens in DKA.

“Unfortunately, some physicians still fail to distinguish between the safe “physiological” hyperketonemia that occurs in healthy individuals during fasting or adherence to a ketogenic diet (KD), and the pathological, out-of-control hyperketonemia associated with insulin-defi cient diabetes.”

Ketone body therapy: from the ketogenic diet to the oral administration of ketone ester

This can happen because the ketones we talked about are acidic. 8 While small amounts of these proton donors do not cause a problem, and can even have many beneficial effects, once a tipping point of ‘too many’ of them is reached, this can change the blood pH and it will then be considered ketoacidosis.

Ketoacidosis is an emergency, or at least an urgent situation that will almost certainly require hospitalization for problems such as: dehydration, electrolyte imbalance, blood sugar management, and even too high of pressure in the brain. Considering that a high number of patients with DKA are children, this condition is even more delicate.

While ketoacidosis is quite a dangerous situation and usually occurs in someone eating no particular diet, ketosis will always be associated with fasting, severe calorie restriction, or a low carbohydrate diet. If you happen to be on a low carbohydrate diet and happen to go see a doctor, one should mention this so the doctor so they do not get concerned if your blood or urine shows the presence of ketones. It’s not a dangerous situation, and absolutely nothing needs to be fixed for those in ketosis on a low carbohydrate diet.

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