18/10/2025
With yesterday's comments about ketones in the comments, I thought this was worth a repost. Unfortunately much of the medical community is not aware of the difference between DKA (diabetic ketoacidosis) and Nutritional Ketosis and sadly, parents are not taught that ketones are not always harmful.
What about ketones?
I see this question so frequently from those new to therapeutic carbohydrate reduction. Most people's experience with ketones is a scary, life-altering event which included a very sick individual, ICU time, and perhaps even almost losing that person, so of course most people panic when they see them.
Most doctors are not familiar with nutritional ketosis, which is truly unfortunate. The emergency room doctor or endocrinologist frequently sees patients in DKA and that is where their mind goes when they see ketones. They forget that information they learned way back in biochemistry about nutritional ketosis.
If you just started TCR, you may be seeing ketones. There is no reason to panic! Nutritional ketosis is a natural, healthy state in which the body is using ketones for fuel instead of glucose (some glucose is required but the body can use ketones to a great extent). They are simply a byproduct of burned fat.
So what is the difference between DKA and nutritional ketosis? The answer is insulin. Insulin regulates ketones and prevents them from spiraling out of control. In DKA there is an insulin deficiency whether it be a new onset-type1 diabetes (or possibly type 2) who is making little to no insulin, a patient who forgot to take their basal insulin, a result of an insulin pump failure or as a result of dehydrating illness. During illness, insulin needs are increased and if they aren't matched with a proper increase of insulin, the combination of low insulin (which results in high blood sugar) and dehydration equal DKA.
There has been a lot of talk lately about euglycemic DKA (DKA with normal blood sugar) due to the increased popularity of SGLT-2 inhibitors. These medications cause a person to pass glucose through the urine at a lower threshold, thereby lowering blood sugar without insulin. There is still an insulin deficiency however, and combined with dehydration from the increased urination, there can be DKA with normal blood sugars. EDKA is pretty rare though.
When SGLT-2's are NOT a factor, it is even MORE rare. The VERY few cases I have seen always included prolonged fasting (which I do not recommend for a person using insulin), and usually dehydrating illness or other dehydrating factor such as nursing a baby. When one fasts for a long period of time, they become much more insulin sensitive and either make or need less insulin (t1's will see blood sugars plummet and will accordingly lower their insulin). Again we have insulin deficiency. Insulin has many functions, not just transporting glucose into the cell.
Did you know that newborn babies have ketones in their umbilical cord blood and ketones are found in the placenta? Babies who are breast fed tend to be in ketosis as well. Pregnant women easily fall into ketosis and women who have morning sickness have them almost definitely!
The point to take home here is that a low carb diet is NEVER the cause of DKA. If you are told by a doctor that you are in DKA based only on the presence of ketones, this is incorrect! The diagnostic criteria for DKA includes an arterial blood pH of less than 7.3, a bicarbonate level of less than 18, an anion gap of more than 10, and blood sugar greater than 250mg/dL (though this can be lower with SGLT-2's etc). If the doctor did not check arterial blood gases or the other things mentioned, they cannot diagnose you as being in DKA!
Again, DKA is NEVER CAUSED BY A LOW CARB DIET!!!
