Physiological ketosis vs diabetic ketoacidosis

Diabetes nurse educator, Christine Manga, helps us understand the difference between the normal physiological ketosis and diabetic ketoacidosis.


What is physiological ketosis?

Ketosis is a normal metabolic state characterised by elevated serum ketones with a normal blood glucose and blood pH level. This occurs when there is a decreased amount of glucose available to the body for energy and glycogen stores in the liver are depleted. This may be due to fasting, extended periods of exercise or a low carbohydrate or ketogenic diet. It usually takes about three days to enter ketosis. Note, ketosis is a safe state for the body. There is sufficient insulin in the body. 

What are ketones?

Ketones are an acidic chemical by-product produced in your liver and released into the bloodstream when it breaks down stored fat. Your body can use ketones as an alternative energy source.

Ketones can be tested by means of a blood test, urine test or a breathalyser. Blood tests are the most accurate and give real time information.

What is a normal ketone level?

  • A blood ketone level of below 0.6 mmol/L is normal.
  • Between 0.6 mmol/L – 1.5 mmol/L is referred to as light nutritional ketosis.
  • 1.5 mmol/L – 3.0 mmol/L is optimal ketosis and the level for best weight loss results. Not much weight loss benefit is achieved above this level.

Ketogenic (keto) diets

In the 1920s Dr Russell Wilder developed the ketogenic diet to treat epilepsy in children. Up to 50% of the children on a keto diet experienced a 50% reduction in the number of seizures. It’s still used today for children that don’t respond to modern medication. Ketogenic diets are high in fat (60 – 85%), moderate protein (15 – 30%) and low carb (5 – 10%). Some keto diets are slightly lower in fat with a little more protein and carbohydrates allowed.

Why ketosis?

Ketosis has numerous benefits. It has been shown to improve insulin sensitivity, lower HbA1C levels, improve glycaemic control, decrease glucose variability, and may reduce insulin requirements.

One of the best-known benefits of ketosis is weight loss and the curbing of appetite. Ketogenic diets are used for weight loss as your body turns to fat for energy. Following recommendations from a dietitian can prevent macro nutrient deficiency when following a keto diet.

What is diabetic ketoacidosis (DKA)?

DKA is a serious, even life-threatening complication of Type 1 diabetes, however, and to a lesser extent it can occur in people with Type 2 and gestational diabetes.

It occurs when there is insufficient insulin to transport glucose into the cells for energy. Without insulin the body begins to break down fat for energy, leading to an excess build-up of ketones in the bloodstream causing the blood to become acidic, lowering the blood ph.

A blood ketone level of above 2.9 mmol/L  and a glucose level of above 13.8 mmol/L increases the risk of DKA. DKA can lead to coma and even death.

Causes of DKA

Illness, missing insulin doses and a blocked insulin pump are common causes of DKA. Undiagnosed Type1 diabetes can result in DKA and initial diabetes diagnosis. Insulin must be taken even when a person is ill and not eating as the body still needs to deal with glucose produced by the liver.

Medications, such as SGLT2 inhibitors, increase the risk of DKA in people with Type 1 diabetes even when there is a normal blood glucose level. When using these tablets, it’s vital to know the symptoms of DKA. SGLT2 inhibitors aren’t recommended for use in Type 1 diabetes in most countries. Some countries have however given approval.

Symptoms of DKA

  • Extreme thirst and dry mouth
  • Dehydration
  • Presence of ketones
  • High blood glucose level >13.8mmol/L
  • Headache
  • Tired, drowsy, weak
  • Confusion
  • Fruity breath
  • Vomiting, abdominal pain and nausea

Treatment of elevated ketone levels and DKA

Contact your healthcare provider or go to the nearest casualty department. Many practitioners will assist you with a ketone protocol to follow at home.

Fluid, insulin, and electrolyte replacement are critical in reversing DKA and preventing coma or death.

Differences between ketosis and DKA

DKA

  • Unintentional
  • Dangerous, harmful
  • Not beneficial
  • High blood glucose level
  • Low blood pH

Physiological ketosis

  • Intentional
  • Beneficial
  • Normal blood glucose level
  • Normal blood pH
eating time budget

MEET THE EXPERT


Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.


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How your upbringing affects your mindset of health

Lynette Lacock shares how your upbringing affects your mindset of health but adds that it’s never too late to change and become the family health influencer.


During your lifetime you have so many things that influence the way you think about your health. Upbringing is one of them; since you spend most of your formative years with your families, they play a big part in forming your opinions about what you eat, how much you exercise and how well you look after yourself.

In primary school I had a very obese friend in my class. Our health teacher had us all support him in his quest to lose weight. We learned about healthy diets and activities by coming up with different ideas to help him achieve his goal. During this time another student asked him how he put on the excess weight. He told us a story about how his grandmothers and aunties were always giving him food and he was always expected to finish everything on his plate. Because he was an obedient little boy, he did as they expected and overate in the process. His family were first generation immigrants coming from a place where food security was uncertain, and people often went hungry to a place where they now had enough food on a regular basis. So, to them, having a chubby-cheeked little boy was a blessing.

Even though this is an extreme example, you can see how family can influence your behaviour when it comes to the healthy or unhealthy choices you make and the behaviours you may go on to teach our own children one day.

Multiple factors leading to your ultimate health beliefs

The way you live your life and think about your health today goes way back to things that you probably never really thought had anything to do with each other. Even children in the same family may have been influenced differently although they experienced the same things. For instance, one parent may have been active and fit and the other was sedentary and unfit. Many years later, one child emerged as an active adult and the other a sedentary adult.

We have to also look at cultural influences. These influences can play a part in the foods you chose to eat and how much of it you eat. Some ancient civilisations saw obesity a sign of wealth and prosperity. These beliefs still exist today in some parts of the world even though obesity can put you at risk for a variety of chronic conditions.

Are you living the same lifestyle as your parents?

Families share lifestyles and environmental factors that influence choices and decisions regarding health. Some families encourage physical activity, such as hikes and sport, while some encourage watching TV or playing video games. Did your family always snack between meals? Or were you offered a piece of fruit instead?

You will tend to mimic your parents thinking without realising it because that was the way it was done in your family since you were a child.

There are also environmental factors that affect your lifestyle such as water quality, food security, access to healthcare and pollution.

Chronic conditions management in your family

You may have family members that have chronic illnesses such as diabetes or hypertension. How did they deal with the treatment of their chronic illness? Did they change their lifestyle to control that chronic illness? Or did they not take it seriously and make the condition worse? These learned behaviours may influence the way children will address any of these conditions when they grow up.

Where did you learn to eat like that?

Your eating habits are acquired at a young age, again influenced by how meals were consumed in your home. Eating together provides time for families to reconnect and talk about their day and share food together. Gathering for a family meal is still popular today but doesn’t always happen due to everyone’s busy schedules.

Was your family so busy that most of you ate separately and on the run? Did you eat dinner in front of the television? Did you have high carbohydrate snacks available to eat whenever you wanted? Did you have to eat everything on your plate even if you weren’t hungry anymore?

Take charge and promote good habits in your family

  • Family meals are preferable to eating separately. Children find security in schedules so eating together every night can be soothing for a little one at the end of a busy day. It’s also a good time to encourage that they eat the healthier foods on their plate.
  • Stress increases cortisol and decreases digestion time so make time to settle everyone down before you sit down to eat.
  • Don’t eat in front of the TV too often because you may tend to eat more than you normally would.
  • Avoid eating on the run. A quick, easy meal or snack is more likely to be unhealthy.
  • An easy rule of thumb is that most processed fast foods come in a wrapper or packaging. Since these foods are made in advance they are full of preservatives, salt and, most likely contain, no vegetables. It’s best to avoid them as much as possible.
  • Learn about healthy ways to control chronic conditions if you haven’t already and share this with your children.
  • Try to do a form of exercise that includes the whole family. Walking is the easiest and everyone can go at their own pace.  Let your children get used to being active.
  • Explain good habits and why you are doing them to the elders in the family, so they can understand and help influence the younger children.
  • When everyone is hungry for a snack try to have healthy options on hand.
  • Be aware of what you’re putting in the lunch boxes. Add more fruit rather than chips and sweets.
  • Take advantage of the early years when you, as parents, are the main influence in your child’s life and be a role model when it comes to healthy living.

It’s never too late to change your mindset and become the family health influencer.


References

  1. Family Dynamics and Health http://www.uniteforsight.org/gender-power/module1
  2. How do our family, friends and community influence our health? https://www.health.org.uk/infographic/how-do-our-family-friends-and-community-influence-our-health
  3. How Does Family Play An Important Role In Health? https://www.inlifehealthcare.com/family-and-health/
  4. Family Relationships and Well-Being Patricia A Thomas, PhD,1 Hui Liu, PhD,2 and Debra Umberson, PhD3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954612/
Sr Lynette Lacock

MEET THE EXPERT


Sr Lynette Lacock received her Bachelor’s Degree in Nursing and Biofeedback Certification in Neurofeedback in the US. She has over 30 years’ experience in healthcare which has enabled her to work in the US, UK and South Africa. Initially specialising in Cardiothoracic and Neurological ICU, she now works as an Occupational Health Sister. She is passionate about teaching people how to obtain optimum health while living with chronic conditions.


Supplements

It’s always best to let the food you eat provide your vitamins and minerals by eating a variety of food. Supplements should never replace standard diabetes treatment. 

Just because a product is natural doesn’t mean it’s safe to use. Some of these products can interfere with other treatments and medications. A number of supplements have shown promise as diabetes treatments. These include the following:

Cinnamon

Chinese medicine has been using cinnamon for medicinal purposes for hundreds of years. It has been the subject of numerous studies to determine its effect on blood glucose levels. More studies are being done, but cinnamon is showing promise for helping to treat diabetes by lowering fasting blood glucose.

Chromium

Chromium is a trace element used in the metabolism of carbohydrates. The research is mixed. Low doses are safe for most people but high doses may cause kidney damage.

Vitamin B1

Vitamin B1 is also known as thiamine. Many people with diabetes are thiamine deficient. This may contribute to diabetes complications like heart disease and blood vessel damage. Since vitamin B1 is water soluble, it has some difficulty getting into the cells. Benfotiamine, a supplemental form of thiamine, penetrates the cell membranes more easily but the studies are mixed on whether it actually prevents diabetes complications.

Alpha-lipoic acid

Alpha-lipoic acid (ALA) is a potent antioxidant. Some studies suggest it may reduce oxidative stress and thereby decrease inflammation; lower fasting blood glucose; and decrease insulin resistance. ALA needs to be taken with caution, as it has the potential to lower blood glucose levels to dangerous levels.

Bitter melon

Bitter melon is used to treat diabetes-related conditions in countries like Asia, South America, and others. There is a lot of data on its effectiveness as a treatment for diabetes in animal and lab studies but human data is limited and of poor quality. 

Green tea

Green tea contains the antioxidants, polyphenols. The main antioxidant in green tea is known as epigallocatechin gallate (EGCG). Laboratory studies have suggested that EGCG may have numerous health benefits including decreasing the risk of cardiovascular disease; preventing diabetes, improving blood glucose control, and improved insulin action. Although studies on people with diabetes haven’t shown health benefits, green tea is generally considered safe.

Resveratrol

Resveratrol is a chemical found in wine and grapes. In animal models, it helps prevent high blood glucose, and reduce oxidative stress. However, human data is limited. It’s not certain whether supplementation helps with diabetes.

Magnesium

Magnesium is a nutrient that helps regulate blood pressure and also insulin sensitivity. Supplemental magnesium may improve insulin sensitivity in people with diabetes, and it also may help to prevent diabetes.

As you can see from this list, there are a number of natural supplements that can be used to manage diabetes. However, even for those on this list, it’s important that you talk to your doctor before adding any supplement or vitamin to your diabetes plan since they may still have a negative interaction with some of your medications.

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Medical resolutions and planning for the next decade

Dr Louise Johnson updates us on the latest changes in the diabetes arena to help you plan your medical resolutions for the next decade.


The basis of diabetes treatment has always revolved around the ‘three wild horses’: diet, exercise, and medication. Going into a new decade, there are quite a few dramatic changes in this arena.

SMART

The American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) 2018/19 consensus report has coined the acronym SMART. The goals that you and your doctor set must be SMART. This is:

S – Simple. Goals should be one step at a time and easy to follow.

M – Measurable. Blood pressure, cholesterol, HbA1c, fasting and postprandial (after meals) glucose, kidney function, eye       check annually, feet examination once a year by a podiatrist. Stop smoking.

A – Achievable. Goals should be small enough. A problem is like an elephant. You eat it bite by bite.

R – Realistic. Weight loss should be five to 10% of total weight and re-evaluated regularly.

T – Time limited. The time frame set on this is three months until goals are met. This is important with all goals set.

Goals for 2020 onwards:

Get your body mass index (BMI) between 18 and 24

This is calculated by length multiply by length (in meters). The weight in kg is divided by this number. For example: 1,6 x 1,6m = 2,56. Weight (80 kg) divided by 2,56 = 31,1. This is the BMI. There are a few diets to try to lose weight effectively.

The number one diet is still the Mediterranean diet. The Predimed trial (NEJM) showed weight loss and improvement in cardiovascular health with this diet.

The best weight loss diet for 2020 is still Weight Watchers. This is a low-carbohydrate diet with good nutrition.

Talk to a dietitian about the correct diet for you. The goal waist circumference for females is 80 cm and for males 94 cm.

People who battle to lose weight can consider bariatric surgery for permanent weight loss and reversal of Type 2 diabetes. Contact a qualified bariatric team for this.

Stop smoking

Vaping can be used as an interim measure to help stop smoking without gaining weight. Set a clear three-month goal of lesser nicotine vape liquid and then stop after month three.

Exercise

The newest data, in The Journal of the American Medical Association (JAMA), for 2020, showed that in 17 000 women, it was found that the cut-off to improve mortality is 4 400 steps per day.

There are many apps and smart watches available to assist in the achievement of exercise goals. Remember the guidelines for diabetic exercise is cardio-training (30 minutes) five times per week.

Blood pressure

Your blood pressure should be measured regularly and should not be above 140/90mmHg. Get yours checked at every doctor’s visit. Consider buying your own electronic upper arm blood pressure machine should you suffer from ‘white coat hypertension’ (high blood pressure in doctor’s office).

Lipogram

The risk of cardiovascular disease (heart attacks, strokes and peripheral vascular disease (leg blood vessels) are closely linked to low-density lipoprotein (LDL). The bad cholesterol. In people living with diabetes, the LDL should be 1,8 mmol/L or lower. Get your number and push to target. Remember there are a few different cholesterol-lowering drugs that your doctor can prescribe. Some have fewer side effects.

HbA1c

This is the three-month glucose average. In 2020, the range is from 6,5 to 8,0%. This variation depends on the duration of diabetes, existence of comorbid diseases, such a kidney failure and cardiovascular disease, and age. This range will be discussed and determined by your doctor.

Time in range (TIR)

This is a brand-new term for 2020 and equates to the percentage of 24 hours that your blood glucose can stay in the range decided on by your doctor. Usually 5 mmol/L to 8 to 10 mmol\L.

The TIR is important since this determines your glucose variability (GV). This means how much your glucose is going up and down, which can be easily monitored with a continuous glucose monitor (CGM).

The International Diabetes Federation (IDF) suggest that all Type 1 diabetes patients use a CGM.

Medication

Obtain the correct medication. This will be a tablet or injection that lowers blood glucose without gaining weight and without causing unnecessary hypoglycaemia (low blood glucose levels).

Immunisation

Get your Prevnar 13 injection to prevent streptococcus infections life-long and influenza injections yearly around the end of March to prevent influenza.

Mouth hygiene

See your dentist and get your teeth cleaned annually to lower inflammation.

For females

Regular bone mineral density tests are important since diabetes patients have an increased risk of osteoporosis. Also go for regular mammograms since diabetes patients have a 4-fold increase risk of cancer.

For men

Go for regular urology visits to examine the prostate since diabetes patients have a 4-fold increase risk of cancer. Should erectile dysfunction (ED) or impotence occur, visit your specialist physician, and cardiologist for a coronary evaluation since there is an increase in cardiovascular disease in men with ED.

Type 2 ‘hot-off-the-press-trials’

In the Type 2 diabetes portfolios, there is a new class with dramatic data. Most Type 2 diabetes patients should be on this class should they qualify.

Medication and trials

  • DAPAHF trial

The dapagliflozin heart failure trial is the most talked about trial of 2019. Dapagliflozin is a sodium glucose cotransporter 2 inhibitor (SGLT2i).

This class of drug works in the kidney on the proximal tubule (top absorbing pipe). It prevents the re-absorption of glucose into the circulation by blocking the enzyme SGLT2. This causes an increase of glucose in the urine. The amount of sugar lost is 14 teaspoons per day which equals 70g of carbs.

It is quite clear to deduct that this will cause weight loss (3 to 6kg), lowering in blood pressure and lowering in blood glucose. It also causes lowering in gout levels (uric acid).

The group of SGLT2 inhibitors that are available in South Africa is dapagliflozin (Forxiga) and empagliflozin (Jardiance).

The DAPA-HF trial was of interest because it looked at people with heart failure with poor heart function (less than 40%) with and without Type 2 diabetes.

This drug showed after 18 months of taking the active drug versus the placebo that heart failure occurrence was reduced by 16%. This is currently the ‘wonder drug’ in cardiology and diabetes and there are a lot of investigations to exactly establish all the mechanisms of action. Some people called it a ‘smart diuretic’ (tablet causing loss of water by producing more passing of urine). There are many more mechanisms involved.

  • CREDENCE trial

This trial was done with canagliflozin, a SGLT2i, in people with impaired kidney function. The estimated glomerular filtration rate (eGFR) (average kidney function) was between 30 and 60ml/min.

This trial was stopped early due to its phenomenal outcome. It improves the kidney function and the lower the number the better the result. The two drugs available in South Africa, dapagliflozin (Forxiga) and empagliflozin (Jardiance), will have their data at the end of the year and next year.

This is good news for all Type 2 diabetes patients. The data with these classes of drugs are still ongoing and should not be used in Type 1 diabetes due to the risk of diabetic ketoacidosis.

Smart things coming for Type 1 diabetes

The newer and faster short-acting insulins will launch in the last part of 2020.

There are two basal (background) insulins that last longer than 24-hours available: Glargine U300 (Toujeo) and Degludec (Tresiba). They both have less hypoglycaemia effects.

The newer, smart ‘artificial pancreas’ is available with a pump that stops insulin if glucose levels goes too low and increases insulin if glucose levels go too high. This is done with the help of a sensor that sends data via Bluetooth to the pump. Unfortunately, this is still very pricey.

Remember that every person living with diabetes is a unique individual and needs unique individual attention and treatment. Find your unique team and start working together.

Dr Louise Johnson

MEET THE EXPERT


Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.


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