SYMPTOMS: Excessive thirst, fatigue, nausea or vomiting, pain in abdomen, fruity smelling breath, rapid breathing, frequent urination, blurred vision, confusion.
DIAGNOSIS: Blood tests show high blood glucose, elevated serum ketones (>3 mmol/l), and an arterial bloodgas analysis with low pH (acidosis) and reduced bicarbonate (which is used as a buffer in the serum to maintain stable pH).
BASIC TREATMENT: Fluids, electrolytes and insulin, with careful monitoring.
WHY AND HOW DOES IT HAPPEN?
In newly diagnosed type 1 diabetics, there is a lack of insulin in the body. Insulin binds to receptors of tissue cells, and helps glucose enter the cells, where it can be used as fuel. With no insulin, the glucose cannot enter the cells and accumulates in the blood. Meanwhile, the body, after emptying the glycogen stores (stored glucose), switches to starvation mode and starts breaking down fats present in fat cells (lipolysis), with the help of hormones like glucagon. The free fatty acids produced are partly used as fuel, and partly converted to ketones in the liver (ketones are a great fuel for the brain). The tissues that can only use glucose (eg. red blood cells), get glucose that is created in the process of gluconeogenesis, where certain amino acids and glycerol (from fat) are converted into glucose in the body.
This process continues unchecked, as glucose cannot enter the cells, and there is no insulin which could counteract the production of ketones. Ketones are acidic, and when the buffer system of the blood is overwhelmed, the blood becomes acidic. Glucose is lost through urine (but not enough to reduce the blood glucose to safe levels!), and because of high glucose in the urine, water is pulled from the blood, leading to dehydration. Dehydration and acidosis are a toxic duo for the body.
In known type 1 diabetics and insulin dependent type 2 diabetics, Diabetic Ketoacidosis can occur when there are certain triggers like insulin pump failure, inadequate blood sugar control, stress due to infections, heart attack, stroke, surgery (stress creates more insulin resistance, the regular insulin dose will not be enough, creating a relative insulin deficiency), pancreatitis, chemotherapy and some drugs like steroids and SGLT2 inhibitors.
KETOACIDOSIS (EUGLYCEMIC) IN DIABETICS AND NON-DIABETICS
Ketoacidosis WITHOUT highly elevated blood sugars (definition in the literature varies from below 250 mg/dl to below 200 mg/dl), can occur in diabetics and non-diabetics, and is called Euglycemic Ketoacidosis.
It occurs with much less frequency than regular Diabetic Ketoacidosis with high blood sugars. Some groups of people are more susceptible to Euglycaemic Ketoacidosis, and since it is a lesser known but equally life threatening condition, it is important to know when to raise the alarm bells.
SYMPTOMS: Tiredness, nausea and vomiting, stomach ache, rapid breathing, fruity smelling breath.
WHO IS AT RISK?
- TYPE ONE DIABETICS AND INSULIN DEPENDENT TYPE TWOs who are pregnant, lactating, involved in heavy exercise without adequate food intake, during an illness with reduced food intake, during extended periods of starvation, those who consume excessive alcohol, and those who take medicines like SGLT2 inhibitors.
- PREGNANT WOMEN
- LACTATING MOTHERS
- HEAVY EXERCISE WITHOUT FOOD INTAKE
- ILLNESS WHICH CAUSES STRESS AND REDUCED FOOD INTAKE
- EXTENDED PERIODS OF STARVATION (in eating disorders, post surgery, etc.)
- USE OF SGLT2 INHIBITORS
- ALCOHOLIC BINGE DRINKERS
- PATIENTS WITH GLYCOGEN STORAGE DISORDERS, with ketoacidosis and hypoglycaemia.
DIAGNOSIS: Blood tests show high ketones, and an arterial blood gas report with low pH, reduced bicarbonate and high anion gap (difference between the main positive and negative ions in the blood).
WHY AND HOW DOES IT HAPPEN?
The conditions leading to ketoacidosis in diabetics and non-diabetics can be summarised as follows:
- Lack of carbohydrate due to increased use (lactation, pregnancy, heavy exercise), less intake in fasting and starvation, glucose lost through medication (SGLT2 inhibitors) or decreased gluconeogenesis (associated with heavy alcohol intake).
- Reduced insulin presence/action due to lack of functioning beta cells, or increased insulin resistance (a relative insulin shortage), or increased sensitivity to insulin, leading to very low insulin levels (as in exercise and fasting). Insulin is part of a negative feedback loop which slows down the production of ketones.
- Increase of counter-regulatory hormones like glucagon, catecholamines, cortisol and growth hormone. They stimulate the breakdown of fat from fat cells, leading to an increase in free fatty acids and ketones.
SOME ROUGH GUIDELINES TO KEEP YOU SAFE:
If you have symptoms of ketoacidosis (with or without high blood sugar), then urgent medical attention is needed.
The urinary ketone test is not reliable enough for diagnosis.
For those on a very low carb or ketogenic diet who have blood ketone testing strips, the following is relevant:
- Blood ketones below 3.0 mmol/l and normal blood sugar, you should be fine. For insulin dependent diabetics nearing 3.0 mmol/l, be alert for any changes in how you feel.
- Blood ketones between 3 and 5 mmol/l and normal blood sugar, and you are feeling fit and energetic, then no action needed. For insulin dependent diabetics it could pose a risk, discuss with your doctor!
- Blood ketones more than 5 mmol/l, normal bloodsugar and feeling good, it depends – if you are not an insulin dependent diabetic and you know your body response well from past experience, then you can be the best judge. Insulin dependent diabetics should consult a doctor. If you are not feeling well always seek medical attention!
The above are guidelines, if in doubt seek medical attention!
WHAT HAS LOW CARB GOT TO DO WITH THE ABOVE MENTIONED CONDITIONS?
A low carb diet will reduce your insulin levels (a good thing since lower insulin levels are linked to reduced risk for many diseases).
Low insulin levels and certain stressors and triggers (see above in the why and how), can lead to accelerated ketone production. If you are a Type 1 diabetic, you should be extra alert for the above mentioned changes. Always keep your hydration optimal, and pay attention to what your body is trying to tell you. There is no one size fits all; some Type 1 diabetics can fast for days with health benefits, and others not.
SO SHOULD PREGNANT AND LACTATING WOMEN AVOID LOW CARB?
I have read the experiences of women who have gone through pregnancy and lactation on a very low carb ketogenic diet without any complication. For the majority of women, perhaps a very low carb ketogenic diet is risky and low carb (about 50-100mg per day) is safer.
If you follow a keto diet, you should be extra alert if you become ill, or involve yourself in sudden increase in exercise. Make sure you take in enough calories, proteins and liquids.
A few interesting references:
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