Ketosis vs. Ketoacidosis

While “keto” is the linguistic root of both “ketosis” and “ketoacidosis,” the two words are as different in meaning as “tendon” and “tendonitis.” One word describes something normal and healthy. The other describes a dangerous, unbalanced condition.

Unfortunately, misunderstanding about if and how ketoacidosis is related to the ketogenic diet causes a lot of undue fear and concern. After all, ketoacidosis is a very serious and potentially life-threatening condition.

However, information grounded in facts and science reveal that while the words “ketosis” and “ketoacidosis” are very similar, they describe two different processes that are worlds apart.

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What Is the Difference Between Ketosis and Ketoacidosis?

There are numerous differences between ketoacidosis (also known as diabetic ketoacidosis) and ketosis. The most important of these differences is that ketosis is a normal, natural bodily process through which the body converts fat into energy. Ketoacidosis, on the other hand, is a life-threatening emergency situation triggered by very low insulin levels combined with high blood sugar, which most often occurs in individuals with diabetes (usually type-1 diabetes).

It can be helpful to recognize that that ketosis is the result of stable, healthy insulin levels, while ketoacidosis is the result of uncontrolled blood sugar levels in the absence of insulin.

The crux of both ketosis and ketoacidosis is insulin--the fat-storing, glucose-wrangling hormone secreted by the pancreas. Impaired insulin production is the reason individuals with diabetes must carefully control the amount of sugar in their blood at any given time: too little sugar, and energy production is drastically compromised. Too much sugar, and the body goes into crisis mode, unable to store or process the high levels of sugar in the bloodstream. It’s this impaired insulin production combined with high blood sugar that sets the stage for ketoacidosis. Unable to procure energy from the unused sugar in the bloodstream, the body tries to access fat stores by producing ketones in the liver. However, this process of ketosis--normal and healthy under typical circumstances--is meant to take place in situations of low blood sugar. In the presence of high blood-sugar levels, high ketone levels can make the blood overly acidic and wreak havoc on internal organs.

Is Ketosis Safe?

Ketosis cause ketoacidosis

Not only is ketosis safe--you’ve almost certainly been in ketosis, without even realizing it! The average human body is hardwired with the flexibility to process energy in different ways, to account for a variety of energy sources and circumstances. Otherwise, times of food scarcity or changes in your typical food supply would constitute emergencies.

The fact is, a non-diabetic body can either be fueled by glucose from carbohydrates, or molecules called ketones that are produced in the liver with the sole purpose of turning consumed and stored fat into energy.

With a ready supply of glucose, the body produces very low levels of ketones, since energy sources are abundant. However, in times of food scarcity or very low glucose levels (aka, blood sugar levels), the body amps up its production of ketones in the liver to access stored and consumed fat as an energy source. In an environment of low blood sugar and low insulin levels, the body is able to efficiently and effectively convert stored and consumed fat into energy. This process is called ketosis.

Ketosis is the backbone of the ketogenic diet. And under normal circumstances, for individuals who do not have diabetes, it is completely safe, sustainable, and shown to provide a wide variety of health benefits.

Can a Ketogenic Diet Cause Ketoacidosis?

For most people, the ketogenic diet poses no risk of ketoacidosis. Why? Because people with a healthy pancreas, who are able to regulate their blood sugar levels properly, aren’t at risk of finding themselves in a situation where their bloodstream is filled with both high levels of ketones, high blood sugar, and zero insulin.

In healthy individuals, ketones are only formed when blood sugar levels drop, since that’s the body’s signal to begin switching over to using fat (instead of sugar) for energy. And if a healthy individual in ketosis (with high ketone levels) does suddenly eat a carb-loaded meal, introducing a lot of sugar into the bloodstream, that person’s normally functioning pancreas would kick in with insulin production to process and store that sugar.

Functionally, the only circumstances under which a ketogenic diet could cause ketoacidosis would be if an individual with diabetes started an unsupervised ketogenic diet. It’s for this reason that individuals who have been diagnosed with diabetes (especially type-1 diabetes) should only begin a ketogenic diet under the close supervision of a physician. It is interesting to note, however, that several studies show that the ketogenic diet holds great promise for successfully reversing pre-diabetes and restoring proper insulin function!

Signs and Symptoms of Ketoacidosis

Ketoacidosis signs and symptoms 

For individuals with diabetes, it’s important to know the signs of ketoacidosis, no matter what type of diet you choose to follow. It’s also important for presumably healthy individuals who decide to follow a ketogenic diet to know the symptoms of ketoacidosis, in the event that they have undiagnosed diabetes. One study found that 27 percent of individuals admitted to the hospital for for ketoacidosis did not realize they had type-1 diabetes.

If you notice the following warning signs, especially if your blood sugar levels are higher than 240 mg/dL, combined with elevated ketone levels of 20 mmol/l or higher (you can either check ketone levels with urine strips or a specialized glucose meter), you should call a doctor or head straight to the emergency room:

  • Frequent urination combined with dry mouth and extreme thirst
  • Severe stomach pain, combined with frequent vomiting
  • Strong, fruity, or “nail-polish remover” breath
  • Difficulty breathing
  • Confusion and lethargy

In diabetic individuals, ketoacidosis can be triggered by a number of events, including poor diet management, missing insulin doses, medications that interact with insulin doses, dehydration, and even a urinary tract infection.

Despite the fact that ketosis and ketoacidosis describe two very different processes, it’s important to understand the meaning of both words. Knowing the science behind ketosis can give you confidence in following a diet that flies in the face of conventional wisdom about fat and sugar and help calm the fears of family and friends. And understanding the risk of ketoacidosis for individuals with diabetes (diagnosed and undiagnosed) can encourage a proper medical response in individuals who show warning signs.


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