Diet & Weight Magazine

Ketosis Vs. Ketoacidosis (DKA): What Is the Difference?

By Leo Tat @AuthorityDiet
Man looking through a magnifying glass

If you are thinking about starting a low-carb diet, maybe you have mentioned it to some of your family or friends.

And then maybe someone said something to you like, "What are you thinking? Low-carb is a dangerous diet."

You then Googled something like, "low carb dangerous" and found a list of link-bait articles informing you that low-carb is a ketogenic diet, and ketosis is a dangerous metabolic state which can be fatal.

Here’s the thing though … that is all misinformation.

Where do these misperceptions come from?

Well, there are a lot of individuals and companies which all have their own goals and motivations.

Profit motives tend to muddy up the works when it comes to getting clear, factual information about your health.

And some people simply make mistakes.

In this case, maybe mistakes are understandable. Many people who believe that ketosis is dangerous are mixing it up with another state called "ketoacidosis." The two words do sound very similar.

But the states they refer to are nothing alike.

Let’s break it down so that you can understand exactly what ketosis is and how it differs from ketoacidosis.

By the time you finish reading this article, you will understand why low-carb is a safe diet.

Quick Navigation Ketosis vs. Ketoacidosis InfographicWhat Is Ketosis? A Safe Metabolic StateWhy Do People Believe that Ketosis is Dangerous?​What is Ketoacidosis? A Deadly StateDiabetic Ketoacidosis (DKA) Signs and SymptomsWhat Are the Health Benefits of Ketosis?​Can Ketosis Ever Lead to Ketoacidosis or Otherwise Harm Your Health?What about "Low-Carb Flu?"​Take Home Message

Ketosis vs. Ketoacidosis Infographic

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What Is Ketosis? A Safe Metabolic State

Most of us get the majority of our daily fuel from glucose.

Ketosis is a metabolic state where you get most of your daily fuel from fat instead of carbs.

Your body becomes ketogenic when it has limited access to glucose and needs to turn to another energy source for primary fuel.

If you eat a very low-carb diet, you are restricting the glucose available to your body, which causes your body to turn to fat to burn.

This may result in a state of ketosis.

Note that not all low-carb diets produce a ketogenic state. It depends on how much you restrict your carbohydrate intake.

If you are eating between 20-50 grams of carbohydrates per day, you will generally go into a ketogenic state. If you eat more than that, you may never actually establish ketosis.

Where does the name "ketosis" come from?

While you are eating fewer carbs, your insulin levels decrease (1).

Low-carb causes your body to release fatty acids. These fatty acids travel to your liver, where they are oxidized.

Oxidized fatty acids are converted into molecules called "ketones." Your body and brain can use ketones for energy.

KEY POINT: Ketosis is a metabolic state where your body’s primary source of fuel is fat instead of carbohydrates. On a very low-carb diet, you enter a state of ketosis.

Why Do People Believe that Ketosis is Dangerous?

There are several reasons why people think ketosis is a dangerous state.

Brain in head on chalkboard

The first reason is simply that the word "ketosis" is easy to mix up with the word "ketoacidosis."

The second reason is that they believe that your brain is literally unable to function if you are not eating carbohydrates.

The vast majority of your brain does not require glucose as fuel. Some cells do, which is not a problem - more on that in just a moment.

As it turns out, most of your brain cells can switch from getting energy from glucose to getting it from ketones (2, 3, 4).

In fact, this happens naturally when people are starving. After only three days of starvation, the brain gets 25% of its energy from ketones.

During long-term starvation, this number rises to around 60% (27, 28).

What about those few cells still depending on glucose?

No problem. During ketosis, your body engages in a process called gluconeogenesis.

This process allows it to manufacture that little bit of glucose your brain cells need to function.

So your brain is perfectly functional on ketosis.

The third reason that some people think that ketosis is dangerous is simply because of the presence of ketones.

Ketoacidosis is characterized by extremely high levels of ketones, far more than what is observed in ketosis.

But ketones are not "bad" on their own. Your body manufactures them because they are useful. It is all a matter of balance - more on that in the next section.

KEY POINT: Some people worry that ketosis does not supply the brain with fuel, but this is simply not the case. The brain gets everything it needs to function.

While ketosis does lead to the production of ketones, this does not mean that you are in a state of ketoacidosis. Ketosis is a separate, safe, stable metabolic state.

​What is Ketoacidosis? A Deadly State

Male doctor reading medical records over gray background

Now let’s talk about ketoacidosis, a state you do not want to be in.

Ketoacidosis is typically associated with type I diabetes (sometimes type II), which is why it is also called "diabetic ketoacidosis (DKA)."

This happens when patients do not receive sufficient insulin. At this point, their bodies enter a state equivalent to starvation.

Ironically, this can happen even when patients have plenty of glucose available in their blood. They are unable to metabolize it.

At this point, the body attempts to adapt to survive and begins manufacturing ketones. The idea of course is for the body to use the ketones for energy.

The problem is that the patient still cannot produce insulin.

Ketosis is regulated by insulin. This prevents your body from going overboard with ketone production.

In ketoacidosis, the insulin isn’t there to signal the body to stop producing the ketones.

Together with high blood sugar, this can cause the pH level of the blood to become imbalanced.

When the pH of blood gets too low, it becomes dangerously acidic, thus the name "ketoacidosis."

The reason for this is the fact that ketones themselves are acidic.

This acidic state can produce a range of dangerous symptoms.

Diabetic Ketoacidosis (DKA) Signs and Symptoms

The first sign of ketoacidosis is when your blood sugar reaches over 240 mg/dL (13.9 mmol/L), or you show signs of high blood sugar, such as feeling really thirsty, peeing a lot or dry mouth (31).

The following symptoms of ketoacidosis can occur:

A woman caring for her ill boyfriend who has ketoacidosis
  • nausea
  • stomach pains
  • vomiting for more than 2 hours
  • breath smells fruity
  • tiredness
  • confusion
  • wooziness
  • dyhydration
  • hyperventilation
  • shortness of breath
  • low blood pressure

Ketoacidosis can ultimately lead to coma and even death.

In fact, diabetic ketoacidosis is the number one cause of death among diabetics under the age of 24 (32).

The mortality rate for those who suffer ketoacidosis is 2 to 5% (33).

Ketoacidosis can result from a number of situations, but none of them include a safe, healthy low-carb diet.

You can develop ketoacidosis if you are literally starving, or if you seriously over-exercise.

It can result from alcoholism as well, and may also be associated with the use of XTC while over-exercising (this has been documented with some ravers).

"But wait," you may be thinking, "if ketones are acidic, doesn’t that mean that a ketogenic state is also acidic?"

While this is true, the safe state of ketosis is far less acidic than the state of ketoacidosis.

For comparison, nutritional ketosis produces beta-hydroxybutyrate levels between about 0.5 and 3.0 mM. Contrast this with levels of 15-25 mM for ketoacidosis (34, 40).

KEY POINT: Ketoacidosis and ketosis are two completely different states. Ketoacidosis occurs when your body lacks the insulin to regulate ketone production, leading to acidic blood.

So long as you have the insulin you need, you should not be risking ketoacidosis. Your body is very smart. On a low-carb diet, your insulin regulates the process of ketone production, and your ketogenic state remains healthy and stable.

What Are the Health Benefits of Ketosis?

Woman showing double thumbs up

So far we have focused on explaining why ketosis isn’t bad for you. But now let’s take a moment to explore what it is good for you.

Research supports ketosis as a treatment for a broad array of health conditions (17), including:

  • Type 2 diabetes (5)
  • Heart disease (6, 7)
  • Metabolic syndrome (8)
  • Alzheimer’s disease (9)
  • Parkinson’s disease (10)
  • Cancer (11)
  • Acne (12)

Ketosis also has great benefits for patients suffering from epilepsy. For a child or adult suffering from epilepsy, eating LCHF can help to control seizures.

Just how effective is this diet?

According to the Epilepsy Foundation, around half of children who go on the ketogenic diet for epilepsy see a 50% or more reduction in their seizures. Around 10-15% become seizure-free.

While most studies have focused on children (29), the diet also has promising results for adults suffering from epilepsy (30).

This study mentions that the biggest obstacle to this treatment for adults is the high rate of attrition. Some patients find the diet too restrictive.

While there are many apparent obstacles to low-carb, there are also solutions which can help dieters to stick with their new habits (more on this in a future article).

So if you have epilepsy or any of the other health conditions listed, or believe you may be at risk, you are actually doing your body a favor by switching to a ketogenic state.

On top of that, a ketogenic diet is excellent for weight loss (13, 14, 15, 16).

As another bonus, you may feel fewer cravings while you are on a ketogenic diet. Ketosis may increase satiety (18, 19).

For a more detailed look at the health benefits, check out ​what I wrote on the 15 health benefits of ketogenic diets.

KEY POINT: Ketosis isn’t just a harmless metabolic state, it is a beneficial one. Switching to a ketogenic diet may help you treat or prevent a number of different diseases.

​Can Ketosis Ever Lead to Ketoacidosis or Otherwise Harm Your Health?

Are there any documented cases of people developing ketoacidosis while on a low-carb diet?

Mother breastfeeding newborn

There are, but they are very rare, and there must be another risk factor present. There have been several cases of women breastfeeding on a low-carb diet developing ketoacidosis (20, 21, 22).

The reality is though, the cases above are debatable.

In one of them for example, the woman in question stated that she was suffering from severe loss of appetite, and "barely consumed any food at all." In other words, she may very well have been starving.

The media of course got hold of this story and chose to emphasize her low-carb, high-fat diet instead of the fact that she wasn’t eating.

With that in mind, you should of course proceed with caution if you decide to do low-carb high fat (LCHF) while pregnant or breastfeeding - it is always best to play it safe.

But there is no reason to be afraid that a LCHF ketogenic diet will lead to ketoacidosis.

What if you have type 1 diabetes?

You may think that you shouldn’t be experimenting with reducing your blood glucose levels. But low-carb has helped many patients with type 1 diabetes (35, 36, 37).

Remember, it is high blood sugar plus high ketones in the blood that leads to ketoacidosis. Reducing blood sugar will not worsen the problem.

However, diabetics should consult the doctor on their medication adjustments while on a ketogenic diet.

Are there any other documented harmful effects? Some children with epilepsy have developed kidney stones while on a ketogenic diet (23, 24, 25).

That’s it at this point. Again, ketosis leading to ketoacidosis is extremely rare, and should not happen in a healthy, non-breastfeeding person with sufficient insulin.

KEY POINT: Harmful effects of ketosis are incredibly rare and have so far only been reported in highly specific situations. You may want to avoid ketosis if you are breastfeeding, but there is no reason to panic about it.

What about "Low-Carb Flu?"

woman yawning

It is common for people switching to a low-carb diet to develop what is known colloquially as “low-carb flu.”

This is a temporary state which typically lasts for a few weeks while your body adjusts to a ketogenic state.

This state is characterized by symptoms such as fatigue, headache, and gastrointestinal disturbances (26).

Again, this state is nothing to be concerned about.

Your body is undergoing a major metabolic shift, and it is normal for that process to be accompanied by some discomfort.

Once your body adjusts, the symptoms should pass. Many people quit before they get to this point, and declare that low-carb was “bad” for them.

Note that ketosis is not an optimum state for everyone - some people never take to it.

But most do, so if you give it a chance and get through "low-carb flu," you will probably come out the other side feeling better than ever.

There are things you can do to shorten your experience of low-carb flu and reduce its intensity.

Here are a few simple suggestions:

  • Drink plenty of water and get extra electrolytes. Salt deficiency can cause low-carb flu symptoms, as can dehydration. You will be shedding excess water weight during this time, so it is important to replenish.
  • Be sure you are getting sufficient energy. Remember, this is a low-carb, high-fat diet, not simply “low-carb.” Fat is going to be your primary fuel source when you are ketogenic, so be sure you are eating enough of it. This is a tough psychological transition for many people who have been brought up to believe that fat is evil.
  • Get your exercise. It is the last thing you will probably feel like doing, but it will increase your metabolic flexibility (38, 39). This in turn will help your body to adapt faster to a ketogenic state.

KEY POINT: Low-carb flu is a real, but it is a transitional state and does not indicate anything wrong in your body. It is neither unhealthy nor unsafe.

​Take Home Message

A lot of people avoid trying a low-carb diet because they are afraid of ketosis, and that is a tragedy.

Ketosis is not the same thing as ketoacidosis. Ketoacidosis is a dangerous, unstable metabolic state; ketosis is safe, natural healthy, and stable.

Ketosis has numerous benefits for your health. So if you do decide to give low-carb a try, you should soon be feeling and functioning better than you ever have before.

And remember, if you still feel unsure about ketosis, you can always try a low-carb diet that isn’t ketogenic!

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