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


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

Physiological ketosis

  • Intentional
  • Beneficial
  • Normal blood glucose level
  • Normal blood pH
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.


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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