For many people, following a ketogenic eating plan can be highly beneficial. Keto diets can lead to weight loss and improve symptoms of other health conditions like heart disease and type 2 diabetes. However, some people may be at risk of ketoacidosis, which can be life-threatening. Before you begin a keto plan, it is important to understand the difference between ketosis and ketoacidosis and know how to prevent potentially serious complications.
What is Ketosis?
Ketosis, sometimes called nutritional ketosis [1], is a metabolic state where your body shifts from burning glucose for energy to burning fat. Glucose is a type of sugar found in carbohydrates. When you eat food containing glucose, your body uses that sugar for immediate energy and stores the remainder in your liver. Over time, the excess glucose converts to fat.
If you reduce the quantity of carbohydrates in your diet, your body starts burning stored fat for energy. The fat breaks down into chemicals called ketones, which can replace glucose as your body's main source of energy. Over time, maintaining a state of ketosis helps you burn stored fat and reduce your body weight.
You can tell if you are in ketosis by monitoring the level of ketones in your urine, blood, or breath. Ketone levels of 0.5 to 3.0 millimoles per liter (mmol/L) in blood or urine indicate that you are in nutritional ketosis.
Color key of a urine ketone test. When on a keto diet, trace to moderate levels of ketones in the urine is a sign of nutritional ketosis. Large levels of ketones in urine for an extended duration put you at risk of ketoacidosis.
What is Ketoacidosis?
Non-diabetic ketoacidosis
Non-diabetic ketoacidosis is a metabolic state characterized by a high level of ketones in the body. It occurs when you've deprived your body of glucose for a prolonged period of time. If your body runs out of fat stores to use as fuel, it begins burning muscle tissue instead.
In rare cases, ketoacidosis and the keto diet can be connected. Ketoacidosis can be the result of eating too few calories or combining a keto diet with intermittent fasting for periods longer than 24 hours. Ketoacidosis can also be triggered by underlying health conditions [3].
Alcoholic ketoacidosis (AKA)
Alcoholic ketoacidosis can occur if excess alcohol is consumed in a short period of time. It can also be caused when chronic alcohol abuse leads to liver damage that affects the metabolism. In either case, the liver is unable to produce glucose, which the body needs for energy. Instead, the liver produces ketones from the breakdown of fat for energy. This results in a build-up of ketone bodies in the blood, making it acidic.
Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) occurs when low insulin levels result in hyperglycemia (i.e., high blood glucose). Due to the absence of insulin, the body is unable to utilize glucose in the bloodstream and instead breaks down fat to produce ketones. In diabetic patients, excess of ketones in the bloodstream results in DKA. It is a potentially life-threatening complication causing blood to become too acidic. In diabetic ketoacidosis, both glucose and ketone levels in the blood are elevated; that's how you can differentiate it from non-diabetic ketoacidosis.
Starvation ketoacidosis (SKA)
Starvation ketoacidosis occurs when you don't take in sufficient amounts of food. Prolonged fasting, malnutrition, and extreme calorie restriction can cause SKA. Over time, ketoacidosis leads to wasting, low blood pressure, reduced heart rate, hair loss, low body temperature, and tooth decay. If left untreated, it can result in serious health problems or death.
How to tell the difference between ketosis and ketoacidosis?
Ketone levels in ketoacidosis are significantly higher than in nutritional ketosis. If you have ketone levels of 3.0 millimoles per liter (mmol/L) or higher, it is considered high levels of ketones in the body. During nutritional ketosis, ketone levels may temporarily elevate during a fast or intense exercise; however, 1 - 3 mmol/L is a desirable range for optimum ketosis. If your ketone levels are persistently elevated, you are at risk for ketoacidosis. Ketone levels higher than 8.0 mmol/L significantly increase the risk of ketoacidosis, and you should call your doctor if they stay elevated.
Relationship of body ketone levels with different stages of ketosis. The optimum range is between 1.0-3.0 mmol/L in blood or urine.
It is essential to remember that even trace levels of ketones in diabetic patients can be troublesome. If you have diabetes and have a positive blood or urine ketone test, you should immediately seek medical help.
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Can the keto diet cause ketoacidosis?
It's very rare for people without underlying risk factors to experience ketoacidosis. If you have risk factors for ketoacidosis, such as diabetes, a history of alcohol abuse, liver disease, or a history of eating disorders, talk to your doctor before trying a keto diet. You may also have a risk of ketoacidosis during pregnancy, especially if you have diabetes.
If you are healthy enough to start a keto diet, you should develop a meal plan that limits your carb intake to about 5-10% of your total calories. Balance that with sufficient healthy fats and proteins, as well as drinking plenty of water to stay hydrated. A supervised keto diet is a great choice to keep your macros in check. In a supervised keto diet, a nutritionist or dietitian will develop a custom meal plan that is optimally suited to your unique body and its nutritional needs.
A calibrated diet plan can help in ensuring that your dietary intake is optimized to your health goals and physique, so you achieve nutritional ketosis quickly and safely.
How to check ketone levels in the body?
You can check ketone levels in your body with a ketone blood, urine, or breath test. A ketone blood test shows the level of ketone bodies in the bloodstream. It is a finger prick test and requires a blood ketone meter. Since it is an invasive test, it can be painful. Urine and breath tests are non-invasive alternatives to blood tests. Excess ketones in the blood are excreted through urine, which can be checked using a urine test strip.
You can easily monitor your urine ketone levels using KetoNOX urinalysis ketone test strips. These affordable strips have reagent pads that change color to indicate your ketone levels. The strips can let you know if your levels are safe or if the levels have gotten too high. The strips are helpful for people on a keto diet or to monitor ketones in urine during pregnancy. You can modify your eating in response to your results.
Ketones in urine can be checked using a simple non-invasive dipstick test.
Rebekah has been writing about culture, health, and politics since 2010. She has a masters degree in Arts Policy and Administration from The Ohio State University. Her work has been seen at WebMD, The Candidly, MedicineNet, YourTango, Ravishly, Babble, Scary Mommy, Salon, Role Reboot, The Good Men Project, SheSaid, Huffington Post, and Mamamia. She is a former cohost of the weekly podcast The More Perfect Union. Rebekah lives in Maryland with her husband, two kids, and a dog who sheds a lot.
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