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Ketoacidosis vs Ketosis: What’s the Difference?

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Ketoacidosis vs Ketosis: What’s the Difference?

You might be curious about ketones, and for very good reasons. The ketogenic, or “keto,” diet has surged in popularity over the past few years. But you might also be wondering about ketones in relation to your diabetes. What are ketoacidosis and ketosis, and do you need to worry about them?

What are ketones?

Ketones, or ketone bodies, are substances that are formed from the breakdown of fat. When there isn’t enough glucose available to meet the body’s energy needs, the liver makes ketones as an alternative source of energy.

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Ketones are made when someone is fasting (i.e., not eating) or dieting. In these instances, insulin levels in the body are low, while glucagon and epinephrine (hormones that raise blood sugar) levels are normal. As a result, the body releases fat from fat cells. The fat travels to the liver, where it is made into ketones. The ketones then enter the bloodstream, traveling to tissues and cells, where they are used for fuel.

Ketones can also be formed in people with diabetes (generally those with type 1 diabetes) when there isn’t enough insulin to help lower blood sugar and move glucose into cells for energy. As a result, ketones can build up in the bloodstream, making the blood very acidic and possibly leading to a condition called diabetic ketoacidosis, or DKA.

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Checking for ketones

There are two ways to check for ketones: with a urine test or with a blood test. With a urine test, you use a ketone kit that you purchase in the pharmacy or online (no prescription is needed). To do the test, you need to make sure the ketone strip is saturated with urine. Then, you compare the color on the strip to the color chart that comes with the kit; a change in color may indicate that you have small, moderate, or large amount of ketones in your urine. If you have diabetes and have moderate or large ketones, you should call your provider right away.

You can also check for ketones with a home ketone meter, which is like a blood glucose meter. With a ketone meter, you prick your finger and put a drop of blood on the ketone strip (you will likely need a bigger drop of blood to check for ketones than for blood sugar). The meter will give you a reading in a few seconds. These three blood glucose meters also check for ketones:

  • Precision Xtra, from Abbott Diabetes Care
  • Nova Max Plus, from Nova Biomedical
  • FORA 6 Connect, from ForaCare

Ketoacidosis

Ketoacidosis is the same as diabetic ketoacidosis, or DKA. This is a potentially life-threatening condition that occurs because of extremely high levels of ketones in the blood, along with high blood sugar.

People with type 1 diabetes are at a higher risk of developing DKA. People with type 2 diabetes can get DKA, too, but it’s less common and usually less severe, and often triggered by prolonged uncontrolled blood sugar, missing doses of medicines, or a severe illness or infection.

DKA may be the first indication that someone has type 1 diabetes, but it can occur at any time if the body doesn’t get enough insulin.

Causes of DKA

Causes of DKA include:

  • Missing doses of insulin or taking the wrong dose
  • “Bad” or expired insulin
  • Illness, infection, or surgery
  • Insulin pump issues such as trouble with insulin delivery or a kink in the tubing

Check your urine for ketones every four to six hours anytime your blood sugar is higher than 240 mg/dl, as well as when you are ill or have symptoms of DKA. If levels of ketones are moderate or large, contact your provider.

Symptoms of DKA

DKA tends to come on slowly. Early on, symptoms include:

  • High blood sugars
  • High levels of ketones in the urine
  • Being very thirsty
  • Urinating much more than usual

Left untreated, these DKA symptoms can quickly appear:

  • Fast or trouble breathing
  • Stomach pain
  • Muscle aches or stiffness
  • Nausea and vomiting
  • Fruity-smelling breath
  • Headache
  • Being very tired
  • Confusion and being unable to pay attention
  • Loss of consciousness

The American Diabetes Association states that DKA is very dangerous and serious; if you have any of the above symptoms, you should contact your health care provider or go to the nearest emergency room of your local hospital immediately. Treatment for DKA includes fluid and electrolyte replacement via an IV, insulin, and treating any underlying illness or infection.

Ketosis

Ketosis is a condition that occurs when the body makes ketones for energy. This happens due to not eating enough carbohydrate, including being on a low-carbohydrate or keto eating plan, or not eating at all (fasting). With ketosis, ketone levels build up in the blood.

The aim of the keto diet is to deliberately force the body into ketosis, which causes the body to burn fat, resulting in weight loss. On a keto diet, you consume a high amount of fat, less protein, and even less carbohydrate. The breakdown of these nutrients is approximately:

  • 70% to 80% of total calories from fat
  • 10% to 20% of total calories from protein
  • 5% to 10% of total calories from carbohydrate

To know if you’re in ketosis, you check your urine (using ketone strips) or blood (using a meter) for ketones.

Women who have gestational diabetes are at risk of getting ketosis. This is because hormones produced during pregnancy can interfere with the action of insulin, leading to high blood sugar. Also, if a woman with gestational diabetes goes too long without eating (for example, overnight or due to skipping a meal), ketones in the urine can indicate that the woman or her baby aren’t getting enough calories and nutrition, shares Kathy Casper, RN, CDCES, at Newton-Wellesley Hospital. It’s recommended to check for ketones in the morning (at least at the start of the pregnancy); if levels are moderate or high, eating a bedtime snack that contains 15 to 30 grams of carbohydrate can help.

Side effects of ketosis

Side effects of ketosis include:

  • Headache
  • Feeling tired
  • Dizziness
  • Mood changes
  • Brain fog (confusion, forgetfulness, lack of focus)
  • Dry mouth
  • Nausea
  • Constipation
  • Bad breath
  • Cramps

Many of these symptoms can pass, especially if they occur due to following a keto diet. But they can be annoying and have an impact on your quality of life. A keto diet is not recommended for pregnant or breastfeeding women. Notify your provider if you have these symptoms and they don’t go away.

Keep in mind that ketosis is a normal metabolic condition that occurs from eating a higher-fat, low-carb eating plan, whereas diabetic ketoacidosis results from a lack of insulin and can be life-threatening if not caught and treated promptly.

Want to learn more about diabetic ketoacidosis? Read “DKA: What to Know and How to Deal.”

Amy Campbell, MS, RD, LDN, CDCES

Amy Campbell, MS, RD, LDN, CDCES

Amy Campbell, MS, RD, LDN, CDCES on social media

A Registered Dietitian and Certified Diabetes Educator at Good Measures, LLC, where she is a CDE manager for a virtual diabetes program. Campbell is the author of Staying Healthy with Diabetes: Nutrition & Meal Planning, a co-author of 16 Myths of a Diabetic Diet, and has written for  publications including Diabetes Self-Management, Diabetes Spectrum, Clinical Diabetes, the Diabetes Research & Wellness Foundation’s newsletter, DiabeticConnect.com, and CDiabetes.com

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