Diabetic Ketoacidosis: What You Need to Know

Fat burning is usually desirable. It’s a prerequisite for fat loss. 

But when someone has diabetic ketoacidosis (DKA), their body burns too much fat and creates too many ketones. The result is a medical emergency that requires prompt and appropriate attention.

Yet DKA shouldn’t be confused with normal, healthy ketone levels on a Keto diet. DKA is a complication of diabetes, not a complication of Keto dieting.  

Stick around for five minutes to learn everything you need to know about diabetic ketoacidosis. Let’s get started, shall we?

What Is Diabetic Ketoacidosis?

Diabetic ketoacidosis is a life-threatening condition of high ketones, high blood sugar, and excess acidity that primarily affects people with type 1 diabetes. In North America alone, there are about 145,000 cases every year.[*]

Most people have mechanisms that prevent ketones from rising too high. When ketones hit a certain level, the body says, “that’s enough!” and shuts down fat burning. 

But people with type 1 diabetes lack these mechanisms. Specifically, they lack the hormone insulin.[*] 

Insulin is an energy regulation hormone that directs your cells to use sugar (glucose) or fat (fatty acids) for energy. High levels of insulin favor glucose metabolism, and low levels favor fatty acid metabolism. 

You might guess where this is going. In the absence of insulin (the hallmark of type 1 diabetics), the body becomes a fat-burning, ketone-producing machine with no off switch. This absolute insulin deficiency (the cause of DKA) is typically triggered by:

• Missing an insulin treatment
• Problems with the insulin pump
• An illness or infection
• Certain medications 
• Alcohol or drug use[*]

Let’s discuss the signs and symptoms of DKA now. 

Diabetic Ketoacidosis Symptoms and Signs

The main clinical signs of DKA are[*]:

1. Ketonemia (high ketone levels)
2. Acidosis (low blood pH)
3. Hyperglycemia (high blood sugar levels)

These complications can lead to symptoms like[*]:

• Extreme thirst
• Frequent urination
• Headache
• Fatigue
• Dry mouth
• Nausea
• Abdominal pain
• Weight loss
• Fruity breath (from a ketone called acetone)
• Rapid heartbeat
• Fast, deep breathing
• Dry skin[*]

Because these symptoms are so variable, clinicians will turn to more objective biomarkers when diagnosing DKA. 

Testing for Diabetic Ketoacidosis

To diagnose DKA, clinicians look at blood sugar, PH, and ketone levels.[*] Specifically, they look for:

• Blood sugar levels over 250 mg/dL
• Arterial PH less than 7.3 (acidity)
• Ketone levels over 3 mmol/L[*]

Over the past several years, ketone testing has replaced blood glucose testing as the preferred DKA diagnostic tool.[*] You can now measure ketones in the blood, breath, and urine, though blood testing is the gold standard.

With the Keto Mojo meter, you can even measure glucose and ketones from your kitchen table, then sync your data and readings with the Carb Manager app. Thank you, modern technology. 

Who’s at Risk for Diabetic Ketoacidosis?

Broadly speaking, people with diabetes are the “at-risk” population. Diabetic ketoacidosis is most common in type 1 diabetics, but it can also affect folks with type 2 diabetes or gestational diabetes. 

Within this population, the following factors increase DKA risk[*]:

• Using SGLT2 inhibitors, a type of glucose-lowering medication
• Using injectable insulin (vs. using insulin pumps)
• Being elderly or having a life-threatening illness (increases mortality risk from DKA)
• Drug or alcohol use

But what about eating Keto?

Does The Keto Diet Cause Diabetic Ketoacidosis?

Before answering, we need to distinguish between diabetic ketoacidosis and nutritional ketosis. 

Diabetic ketoacidosis is a condition of high blood sugar and high ketones. It occurs in specific populations (people with diabetes) who can’t make insulin to shut down fat-burning and ketone production. 

Nutritional ketosis, however, is a safe and beneficial byproduct of carb restriction. And it’s been safe and beneficial for millenia. When our Paleolithic ancestors lacked carbs, ketones fueled their brains and bodies with clean, efficient energy.

As you’ll recall, we have mechanisms to suppress fat burning when ketones start climbing. This is why taking exogenous ketones (aka keto pills) won’t help with fat loss goals. Bring up your ketones, and you’ll bring down your fat burning.[*]

That said, people with diabetes should seek out medical supervision before trying a Keto diet. This is primarily to prevent hypoglycemia (low blood sugar), though there’s at least one case study of someone with type 2 diabetes developing DKA after a prolonged fast in tandem with a Ketogenic diet.[*] 

Treatments for Diabetic Ketoacidosis

DKA is a medical emergency that merits hospitalization. The primary treatments include[*]:

• Insulin therapy. The extra insulin stops DKA at its source by suppressing fat burning and ketone production.
• Fluids. The symptoms of DKA are often driven by dehydration. The fluid loss can be up to 15% of body weight, so fluid replacement is crucial. 
• Electrolytes. Low insulin prompts the loss of electrolytes like sodium and potassium through urine. Replacing these minerals helps restore energy, fluid balance, and muscular function. 
• Antibiotics. A clinician may give antibiotics if they diagnose infection as the DKA trigger. 

Severe cases of DKA may require intubation if respiratory failure sets in, though this tends to be a last resort.  

Preventing Diabetic Ketoacidosis

Preventing DKA starts with assessing your health. If you’re not at risk for diabetes, you don’t have to worry about DKA. 

If you have diabetes—especially type 1 diabetes—you should have a DKA prevention plan. You should:

• Regularly check blood sugar and ketone levels. (The Keto Mojo meter does both.)
• Work with a medical professional to ascertain the optimal insulin therapy.
• Avoid missing medications, especially insulin doses.
• Follow a meal plan to keep blood sugar in a healthy range. (Note: there’s considerable evidence for Keto helping with type 2 diabetes, but not much as much evidence for type 1 diabetes).[*] 
• Be extra careful when you’re sick because infection increases DKA risk.

Follow these steps and you’ll be well-positioned to prevent diabetic ketoacidosis. Fat burning is usually desirable, but not always.