Keto enthusiasts -- Are you at greater risk of going into DKA without warning?

I visited several websites and they all agree:

1 mmol/L = 1 mM

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Ok, so a question for @Tia_G about the hypothesis: doesnā€™t the huge range of ketone concentrations associated with DKA actually weaken the hypothesis a bit? Youā€™re right that many low-carb or keto type websites suggest that the ketone concentration at which DKA become possible/likely is 15 mM to 25 mM. If, however, the concentrations of ketones associated with actual DKA are as low as 1.8 mM or 3 mM, and ā€œnormal fastingā€ ketone concentrations even in non-low carb individuals can be 1 mM or greaterā€¦

Put those things together, and what it suggests is that concentration of ketones isnā€™t the primary cause of DKA, whether euglycemic or at high BG concentrations. It would seem to be a strong association, likely produced by an underlying cause. From reading in all the sources linked in this thread (both pro- and anti- low carb), it really does seem to me that dehydration, starvation, and co-illness are the most likely primary causes of acidosis (which agrees with the general medical thinking on dangers of starvation and dehydration).

This leads me back to my basic thinking: nutritional ketosis is probably not a primary risk factor for DKA in Type 1s, and is rather something that can put one at risk only if other factors are at play. If one is eating at a serious caloric deficit (which might very well be the case if someone is eating keto for weight loss), is prone to dehydration (also easy on a keto diet), or ill, then even mild ketosis in combination with one of those other factors can be dangerous.

I think there is another sort of anecdotal way to check the hypothesis against reality. There are a lot of Type 1 low-carb eaters, and they tend to share experience in Bernstein forums, Type1 Grit, and /r/diabetes on reddit.com. There seems to be a growing consensus among at least those Type 1s that are active on internet forums that nutritional ketosis (or at least low-carb diets) can be safe for most diabetics.

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Thanks for doing that research! I was out all day yesterday and find doing detailed searches and browsing on my phone cumbersome.

Iā€™m not arguing that low-carb is not safe full stop. Iā€™m arguing that the normal warning signal for DKA may be attenuated on a low-carb diet, and that one of the primary signals ā€“ namely elevated blood sugar ā€“ is not a necessary requirement for DKA, meaning that if you are low-carb dieting and you have an absolute insulin deficiency, your warning system is going to be less effective than it would be for someone who eats a high-carb diet.

Also, normal fasting concentrations of ketones are not 1 mM or greater, at least based on what the ketone meters say. Iā€™ve tested my son so many times and heā€™s never above the ā€œTraceā€ amount of 0.1 or 0.2 ā€“ unless heā€™s actually been disconnected from his pump or was actually operating with an absolute insulin deficiency. Even when he was diagnosed, when he had a 400 blood sugar and presumably his few beta cells were stunned into a coma by the sugar overdose, his ketones were 0.2. So I guess I would argue with your fundamental assertion that a normal, non-low-carb-dieting individual will ordinarily run ketones up to 1 mmol/L Thereā€™s an order of magnitude between 0.1 and 1, and I think a lot of the confusion comes from the fact that people on low-carb forums are throwing out numbers and I personally have no idea where those numbers come from.

Where is the 15-25 mmol/L DKA threshold coming from? I mean from an actual study or medical journal, as opposed to a forum or Dr. Bernstein? Sure ā€“ some people may successfully avoid DKA at a ketone level of 15-25 but I suspect thatā€™s not the norm. I mean, some people survive blood sugars of 2,656 mg/DL!!! People survive being submerged in frozen lakes for hours on end. Some people enjoyed the movie Human Centipede or Little Dorit. I suspect none of those are the norm and we shouldnā€™t use them as the standard threshold for safety.

As for forums, well, I would suspect some forums have a little more of an agenda than others. Some may hush people who bring up concerns. Others may quietly leave when they get spooked by ketones or whatever. And some people may actually have entered the very early stages of DKA and not realized it and written it down as flu symptoms, etcā€¦ Beyond that, I just threw this question out here, and of maybe 5 or 6 individual people who replied, one of them described a situation very similar to what I was proposing; starting a low-carb diet, euglycemic but with symptoms of DKA.

My hypothesis is that this is an underreported condition. Iā€™m guessing people can reverse the early stages of DKA without ever realizing they were in it by beating it down with a lot of insulin, fluids and electrolytes. They feel ill and sick to their stomach, they donā€™t test ketones, but they just drink a bunch of water or gatorade, take some insulin and feel better five or sick hours later. Thatā€™s not unlike a case of the flu or mild stomach upset.

Hrmm, youā€™re right that 1.0 mM is too high for ā€œnormalā€ according to most sources. Iā€™m finding the associations (Canadaā€™s in this case) suggest that less than 0.6 mM is ideal, and 0.6 mM to 1.5 mM is a moderate ā€œrecheck in an hourā€ level. They suggest 3.0 mM or greater is emergency level. But only in cases where blood sugar is elevated above 14 mM (see the guide here). UC-Denver Medical School agrees with those levels (for children) when BG is elevated.

The diabetes association in the UK agrees with the above ranges, again when BG is elevated (they suggest 17 mM or 300 mg/dL as the time to check ketones, or over 13 mM / 230 mg/dL fasting). So those guidelines are pretty consistent across the board. I donā€™t have a scientific reference for those, only the medical ā€œbest practicesā€ as represented in three different countries (CA, US, UK). They are simple: below 0.6 is normal; 0.6 - 1.5 is moderate, recheck in an hour when BG is high; 1.5-3.0 is concerning when BG is high, consult a doctor; over 3.0 is go to the emergency room when BG is high.

I just canā€™t find any recent research on euglycemic DKA outside of the context of SGLT2 inhibitors being used off-label in Type 1s. Even in those cases (and in Type 2s on SGLT2 inhibitors), there are extenuating circumstances according to the FDA investigation:

The FDA also identified potential triggering factors such as intercurrent illness, reduced food and fluid intake, reduced insulin doses, and history of alcohol intakeā€¦

I havenā€™t found any research on ā€œnormal ketoneā€ levels, so Iā€™m not sure where Bernstein and his ilk come up with the 15 mM - 25 mM range. However, I also canā€™t find any discussion in the scientific literature of euglycemic DKA outside the context of SGLT2 use, starvation, dehydration, or concurrent illness. Iā€™m going to link some references below, which are only so useful, but are scientific in nature. Again, the summary is pretty simple: euglycemic DKA is precipitated by ā€œtriggering eventsā€ that affect glucagon and other hormone levels, and doesnā€™t happen in ā€œnormalā€ circumstances.

http://care.diabetesjournals.org/content/32/7/1335.full (full discussion of DKA including a consensus statement)

http://press.endocrine.org/doi/abs/10.1210/jcem.76.5.8496310 (euDKA from fasting while in insulin deficient state)

http://www.bmj.com/content/2/5866/578.abstract (ā€œEuglycemic DKAā€ an original description of the condition, primarily concerned with young children and implicating carbohydrate restriction with increased insulin dosage)

Starvation-induced True Diabetic Euglycemic Ketoacidosis in Severe Depression | Journal of General Internal Medicine (ā€œStarvation induced true diabetic ketoacidosis in severe depressionā€)

And finallyā€¦

Beyond that, I just threw this question out here, and of maybe 5 or 6 individual people who replied, one of them described a situation very similar to what I was proposing; starting a low-carb diet, euglycemic but with symptoms of DKA

While that is true, bear in mind two things: first, that ā€œsymptoms of DKAā€ are not the same as euglycemic DKA, especially since it was resolved without medical intervention; and two, that of the 5-6 individuals who replied, 4 or 5 of those replied basically saying ā€œIā€™ve had no problems with DKA from low-carb diets.ā€ Anecdotal evidence cuts both ways. All in all, Iā€™d say you have sufficient reason to be concerned about your son, but I donā€™t think there is enough evidence to support or not support keto like diets. Youā€™re right that the claims on the forums donā€™t seem to be well supported by the scientific literature. But there also doesnā€™t appear to be any risk of euglycemic DKA outside of illness, starvation, dehydration, or use of SGLT2 inhibitors.

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Lack of insulin with elevated blood glucose is a requirement for diabetic ketoacidosis DKA. It just isnā€™t a requirement for acidosis or ketoacidosis from one of the other causes. Drug induced dehydration being one of the reasons that you mentioned. Alcoholic ketoacidosis being another.

I think this is simply a misunderstanding of what is, acidosis ā€¦ketoacidosis ā€¦ diabetic ketoacidosis and the various causes.

Bernstein has nothing to do with Low carb dietary ketones. Most people would be kicked out of ketosis by the slightly higher protein anyway. I wouldnā€™t recommend Burnstein for a ketogenic diet.

AFAIC, you are welcome to have a speculative opinion, it doesnā€™t have to be right or wrongā€¦what would help is if you want to make a case, is to have it supported. What you are suggesting would be helped by even a wiki link, let alone a research paper validating a concept.

If you want to think that ketones of 3 to 5 are DKA, itā€™s fine with me. You son isnā€™t ketogenic and shouldnā€™t be running normal ketones above 1 anyway. Few kids will push exercise hard enough to get high ketones from that.

What is of a concern to me, is that you have an unusual concept of basal and bolus insulin management with your son. I think most people would have a hard time getting good, consistent levels that way
I would suggest you contact your Health team and see if you can go on a T1 course. Educating parents of T1 kids is a neglected area.

The person who reported similar symptoms here required hospitalizationā€¦I donā€™t consider that resolving itself without medical intervention!

@jack16, our son is probably better controlled than 95% of t1d toddlers his age. He typically runs an A1C of 6.0 to 6.5 and spends less than 0.5 percent of his time below 55 mg/DL. My conception of basal/bolus is based on spending months watching, analyzing, and doing calculations, running experiments with different approaches and tracking and tabulating the results, while he uses an artificial pancreas algorithm, seeing what it does, and how it impacts BGs. I agree that for people using MDI the basal/bolus method works well. Those distinctions become meaningless if youā€™re giving microboluses of insulin using temp basals every minute or two, and I think theyā€™re fuzzy at best with toddlers. You will find that many people on here who have successfully raised children from toddlerhood to young adulthood with T1D have also mentioned the limited utility of the concept of a basal that ā€œkeeps blood sugar steady in the absence of food.ā€ My endocrinologist herself, when I raised that point initially, told me that, while thatā€™s the dogma, in practice when she sees people with the best control, they are not the ones who strictly adhere to that principle, but instead seem to have higher basal ratios than would be considered necessary based on my basal testing alone. So, yes, I DID consult with my health team. Also, I have been to multiple educational T1 courses. I feel I am as qualified as any parent to manage my sonā€™s blood sugar. Suggesting otherwise is truly insulting.

People who participate in this forum are much better informed about managing diabetes than the general population. Itā€™s why I participate here. I find this discussion enlightening and thought provoking. Letā€™s try to keep it polite and civil. I thank everyone for the contributions they make to this community.

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Thanks for this reminder @Terry4. My nerves are just a little raw because Iā€™m pretty much knee deep in diabetes right now. Had to keep my son home from school two days in a row because of a cold requiring buckets of insulin that is just barely doing the trick at having my son touch down briefly ā€œin rangeā€ before zooming right out, his past sensor site is showing signs of irritation/allergic reaction so Iā€™m waiting to change out a wonky sensor which is giving garbage readings, and heā€™s now refusing to eat his lunch. So itā€™s just frustrating when you feel like youā€™re giving diabetes your all and then some to have someone question your knowledge/ability.

Itā€™s as if the evil-D knows and piles on with making everything wrong at once. One of my last serious hypos occurred during the two-hour Dexcom CGM black-out period.

These are the ā€œwar-storiesā€ that you will pass on later to some parent of a newly diagnosed toddler. These situations are best-avoided but will etch some useful lesson in your knowledge base. Persevere and give thanks that you are the one dealing with these challenges rather than a teacher, school nurse, or some other parental fill-in.

Which was the point I was making when you said, your son goes low when he doesnā€™t eat. I would think it only makes it harder to manage. I assume you restrict the basal rate, as well as not giving a bolus normally.

His refusing to eat his lunch is stressful not because his basal rate is set high (heā€™s been running high because heā€™s sick so there is not much worry there), but because his refusal means I canā€™t pre-bolus for any amount of his lunch, which means that he will wind up even higher when he does inevitably eat some of it.

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So in summary, I would say that dietary keto isnā€™t ā€œat greater risk of going DKA without warningā€

What hasnā€™t been talked about is the opposite of when hypo. Keto offers some benefit for alternate fuel for the brain. In so doing, people on keto have a reduced awareness of low BG.

I must have lost something somewhere in the thread with its 34 responses. I thought the person described DKA-like symptoms while eating low-carb, but that there wasnā€™t a definitive link between the two. What the person in this thread said:

Short story- hospital with dehydration and mysterious acidosis-like symptoms but without high blood sugarā€¦

I see dehydration and acidosis-like, symptoms, but not a diagnosis of euglycemic DKA. And if it was euDKA, it could certainly be attributed to the dehydration. Even if the person decided to not trust keto afterwards. The truth is more complicated than many of us would like to admit: complications and co occurring illnesses happen in diabetics regardless of doing everything right. Even moderate-high carb Type 1 diabetics with plenty of circulating insulin occasionally have bouts of DKA, for any number of reasons. I think you may be right that being extra aware of ketones while eating low-carb is a useful thing for insulin-dependent Type 1 diabetics (Iā€™d say for any insulin-dependent diabetic).

I do want to make something very clear: Iā€™m not intending at any point in this conversation to argue with you, and Iā€™m sorry if itā€™s come across that way. And Iā€™m sorry youā€™re having to deal with difficulties with managing your sonā€™s diabetes. I was using this thread as an excuse to dive a little deeper into my own assumptions about low-carb and DKA, which have largely been based on the non-scientific practice of reading internet blogs. It appears that some of what I learned was off-base, and Iā€™m happy to re-evaluate my opinions in light of new evidence. Iā€™m also still convinced that the best evidence says keto is safe for Type 1 in the absence of other risk factors. But I do have a clearer idea, now, of what those risk factors are and of what ā€œabnormalā€ levels of ketones are. As far as I can tell, there are no guidelines for what normal levels of serum ketones are in non-insulin dependent diabetics.

Thanks, I donā€™t think at any point you were being uncivil or touching a sore spot with regards to my sonā€™s care (that was someone else on this thread).

Youā€™re right sheā€™s not a confirmed case of DKA (also not clear from the comment whether the dehydration was caused by the diet, by ketones, by whatever was causing her acidosis, or something else). Acidosis can occur with other conditions, clearly, and I wasnā€™t being super precise with my wording. On the other hand, this kind of vague case report without much context or detail is pretty typical for a forum ā€“ and the response of dismissing it, questioning the connection or minimizing it, could certainly make people whoā€™ve had these vague symptoms less likely to pipe up, and as a result that type of experience might be under-documented on threads devoted to low-carbing.

Perhaps doctors will find that euglycemic DKA isnā€™t even technically DKA because it lacks one of the main hallmarks of the condition ā€“ namely the elevated blood sugar. I guess to me though, as a non-doctor who is mainly interested as a way to keep my own loved ones healthy, this level of differential diagnosis is not relevant to me. To me the relevant question is: Whatever the condition is, was it a medical emergency? How commonly does it occur and who is at highest risk? What are the outcomes if it is? Are there situations where this confluence of events (acidosis, high ketones, feeling ill, normal blood sugar) may co-occur? And are there things I can do to avoid this medical emergency?

Also, I donā€™t think eating a keto diet is unsafe. I donā€™t think I ever said that, but itā€™s a long thread, so who knows! I donā€™t even necessarily think that youā€™d be at increased risk of DKAā€¦just that euglycemic acidosis can happen and that if someone was keto, they donā€™t necessarily have the same warning that I might.

For instance, my sonā€™s levels are always at the ā€œtraceā€ 0.1 to 0.2 mmol/L pretty much all the time. So even if his blood sugar is a perfect 100, a ketone level of 3.4 IS abnormal and a sign that something is up. Was he 2 hours away from a hospital admission? Who knows! Either way, though, it was a call to action for sure. (In any case high ketones should always be used as data because in and of themselves they make people more insulin resistant, meaning youā€™ll need more insulin for any meals or corrections, etc.)

If he was low-carb heā€™d be running much higher ketones habitually, so maybe that 3.4 wouldnā€™t be as much of a red flag as it might otherwise. Thatā€™s all Iā€™m saying. Iā€™m not saying a person who is keto should go out and buy 80 gazillion ketone blood tests and test themselves 8 times a day or anything. Iā€™m just throwing out there that maybe they have less of a warning system.

Personally, if my son were on a low-carb diet (heā€™s not), his bodyā€™s responses so far would spur me to test his ketones any time he was disconnected from a pump, exercising or at altitude, getting sick, or skipping a meal, even with normal blood sugar, just based on the experiences Iā€™ve had and what Iā€™ve read in the literature about SGLT2s. Those would be situations when there could be a sharp mismatch between how much insulin different tissues need and how much glucose different tissues need ā€“ so maybe most organs actually need more insulin to keep working at altitude, but the muscles have also just worked out harder and are taking in glucose without as much insulin as they typically need, leading to an insulin deficit for most of the body but apparently normal blood sugar.

As an adult (and especially someone like you who is not on insulin because you are not at an absolute deficit), I probably wouldnā€™t be concerned at all. IF I was an adult on a pump who was completely dependent on it, I would probably test a bit more than typically recommended, but less than I would with my son.

Actually, one of the reasons Iā€™m very interested in this topic is because I am likely to be eating low-carb and at an absolute deficit at some point in the future. Although my doctors arenā€™t concerned about my eating low-carb now, they do want me to be extra-attentive to signs of DKA because of my situation (insulin deficient, eating low-carb, not on exogenous insulin). If nothing else, you are making me think I want to invest in urine ketone strips and maybe even the abbot precision xtra meter. Iā€™m pretty sure I run at higher-than-normal ketone levels even for keto dieters (Iā€™m not actually on keto myself) due to low-carb and lots of exercise. So, they want me to be vigilant for precisely the reasons you are concerned about: my eating low-carb may mean I donā€™t have the warning signs (high BG) that often precede DKA in Type 1s, even after my beta cells canā€™t keep up with the minimal demands I place on them.

So again, I want to thank you for bringing this up. I have gotten into the habit of low-carb eating because it works for me right now. But I also got into that way of eating when I thought I was Type 2. With a changed diagnosis, I have to be a bit flexible in my thinking, obviously.

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Iā€™ve also found this discussion interesting and very relevant to me at the moment.

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I second or third the appreciation for this topic. Iā€™m planning on having surgery for my gastroparesis as a LADA Iā€™m concerned about the pre and post liquid diets and how the nurses and Dr will deal with this and prevent DKA. There are going to be several months where iā€™m- all protein no carb, being on insulin (no insulin production at all in my case) I was worried about DKA vs Ketosisā€¦this has helped me understand so I can communicate with the Dr ā€¦

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I read an article today that made me think of the discussion of ketones and DKA with normal blood sugar in this post. It says, in part:

ā€œVery prolonged exercise, like mountain trekking and marathons, may increase ketones to dangerous levels in people with Type 1 diabetes, and this increase in ketone levels may not be associated with high blood sugar. This is because the skeletal muscle can utilize blood sugar as a fuel even when insulin levels are very low. [ā€¦] New guidelines published in Lancet Diabetes & Endocrinology recommend not beginning exercise if ketones are elevated and treating elevated ketone levels with insulin and carbohydrates if necessary before exercise begins. This means that it is always wise to monitor both blood sugar and ketone levels before and after exercise.ā€

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