Confused, Ketoacidosis

[stubo]

Hi everyone. I have been using the keto diet to control my Poly Myalgia Rheumatica along with Prednisone and Methotrexate. I have had some good results and not so good, typical ups and downs of PMR. I’m a fan and even try Carnivore, when I feel good I feel better than ever before.

My confusion comes with my daughter. She is over weight, 120kg and was planning a stomach reduction operation. I managed to talk her out of it and proposed that she try keto and do some exercises. She was planning to start on the Monday, so on Sunday before she started we measured her ketones. To my surprise she had a low ketone count 0,5 mmol/L. On Monday she started keto and a 10 minute morning workout and was doing well, lost 4kg in the first 7 days and was enjoying it, fully motivated. On day 8 she bought her own test strips and found she had high ketones 4-8 mmol/L

and zero glucose. Day 10 showed her ketones to be too high 16 mmol/L and still zero glucose. Sho sent me a picture of her test strip and I started to question what was going on, so did she. The first thing that popped up is Ketoacidosis!!! Panic kicks in!!! After much reading I suggest she tries to break her state of ketosis and hope the ketones come down, they are down slightly 4mmol/L after eating pasta last night. She was told she is not diabetic by her doctor and is not using insulin.

Any recommendations or advice, maybe a keto friendly doctor out there??? They are very rare. My doctor doesn’t even know what it is.

Thank you

[Polly1]

The strips are designed for diabetics. If a diabetic has high ketones the risk of ketoacidosis is possibly life threatening. If your daughter is not diabetic it should not be a problem.

BUT I am not a doctor, not a diabetic, do not use ketone strips and have no qualifications to advise you on this. Frankly, in her shoes I would continue the keto diet and not use test strips.

If you or she are worried see your physician.

[CrackerJax]

14. Does low carb cause ketoacidosis?

No. Many people mix up ketoacidosis with ketosis.

Ketoacidosis (also known as diabetic ketoacidosis, or DKA) is a rare and dangerous medical condition that mainly occurs in people with type 1 diabetes if they don’t take insulin, especially if they are ill.

People with type 2 diabetes who take certain medications (eg SGLT2 inhibitors) can also develop DKA, although this is relatively rare.

63

However, eating a ketogenic diet while taking these medications might potentially increase the risk of DKA.

64

Ketosis (sometimes referred to as nutritional ketosis), on the other hand, is a 100% natural and safe state for most people, under full control by the body.

65

It can be caused by a low-carb diet or by a brief period of fasting.

66

Under normal circumstances, a strict low-carb diet never results in ketoacidosis. It results in ketosis, a natural and safe state that enables the body to quickly burn large amounts of fat.

67

These are urine sticks yes? It does seem high, and if the Dr was worried he should have done a blood gas that would have shown whether acidosis was present.
Obviously it is a good thing that there was no glucose present as this would indicate a high blood glucose! Not something seen in someone on a ketogenic diet.
I am not a Dr, but I would advise a diet of maybe 50 - 70 g of carbs a day initially until the body gets used to it and then reduce further!
Well done to both of you and welcome to the forum🙂 I hope that is helpful.

[stubo]

Thank you, she has an appointment on Monday

[Ilana_Rose]

I had exactly that colour when I was starting keto. Even 2.5 years in my urine ketone strips still regularly show levels between the 4-8 mmol range. Dark colour on urine strips is not a problem unless you are diabetic which is why the rest of us don’t have to test at all.

[CFLBob]

Remember urine test strips test what overflows into the urine. Glucose spilling over into urine is a sign of out of control diabetes - and how diabetes was first described. Ketones in the urine mean they’re extra - not being used for fuel.

This is best tested with blood tests, and while nutritional ketosis might put ketones into the 4 to 5 mmol/l range (blood ketones, not urine), ketoacidosis is simultaneously much higher ketones (10 or higher) and high glucose. In nutritional ketosis, ordinarily as ketones go up, glucose goes down.

This graphic from Dr. Steven Phinney is all around the web.

Do I really need to put a disclaimer here that I’m not a doctor, just some dude on the internet? From what I’ve heard, I’d say if your daughter doesn’t feel sick, she’s not in ketoacidosis.

[PaulL]

Diabetic ketoacidosis has caused death in the past, so it is right to be concerned. It was very common for Type I diabetics a century ago, before the discovery of insulin, and can still happen when a Type I diabetic mismanages or fails to take his or her insulin. Diabetic ketoacidosis also involves abnormally high serum glucose as well as abnormally high serum ketones.

However, ketoacidosis is not a problem, so long as the pancreas is secreting even a modest amount of insulin, so it is not generally a concern with Type II diabetes, unless it goes untreated for a very long time and the pancreas β-cells all burn out.

The exceptions are firstly, women who are pregnant or lactating while eating a ketogenic diet. Such women must not fast. Second, as already mentioned, people taking SGLT2 inhibitors. Both cases are liable to what is called “euglycaemic ketoacidosis” (i.e., the blood sugar is normal, but the ketones are high), which can be just as dangerous as diabetic ketoacidosis.

@stubo I suspect that there is some problem with your daughter’s meter. She should not have been showing a serum glucose of 0.0 under any circumstances, so it is likely that the strips she was using are either bad or improperly calibrated. Blood sugar can go quite low and still be safe when we are on a ketogenic diet, but certain cells require glucose, so there has to be a minimum level in the blood.

On the other hand, 16 mmol/L of β-hydroxybutyrate is decidely high, and almost never seen in nutritional ketosis, so you are right to be concerned.

[stubo]

I Googled non diabetic ketoacidosis and found some interesting information. My daughter is not pregnant or just given birth, but this shows it is possible. We will check her blood and make a call. Thank you for all the response, looks like we might have a rare case here. I will keep everyone informed. I thought the keto diet was safe and didn’t think twice before recommending it to her.

Summary

Ketoacidosis occurring during lactation has been described infrequently. The condition is incompletely understood, but it appears to be associated with a combination of increased metabolic demands during lactation, reduction in carbohydrate intake and acute illness. We present a case of a 27-year-old woman, 8 weeks post-partum, who was exclusively breastfeeding her child whilst following a low carbohydrate diet. She developed gastroenteritis and was unable to tolerate an oral diet for several days. She presented with severe metabolic acidosis on admission with a blood 3-hydroxybutyrate of 5.4 mmol/L. She was treated with intravenous dextrose and intravenous sodium bicarbonate, and given dietary advice to increase her carbohydrate intake. She made a rapid and full recovery. We provide a summary of the common causes of ketoacidosis and compare our case with other presentations of lactation ketoacidosis.

[PaulL]

Keto generally is safe, since we evolved eating that way, but there is no telling what genetic variants may have crept into the genome. I’m really sorry about your daughter’s experience. I still think that the first step is to make sure the blood meter is properly calibrated, however, because good data are vital for figuring out what’s going on.

That case you posted sounds familiar. If it’s the one I’m thinking of, the patient in question developed ketoacidosis on the second day of a fast. I don’t believe it was simply lack of carbohydrate that did her in, despite the doctors’ conclusion. There are only two or three such cases that I was able to turn up in my search on PubMed.

[Ilana_Rose]

On the other hand, 16 mmol/L of β-hydroxybutyrate is decidely high, and almost never seen in nutritional ketosis, so you are right to be concerned.

Yes, but it’s not β-hydroxybutyrate in the blood but rather an acetoacetate reading of the urine for someone in early days of ketosis. Both my husband and I saw this result regularly when we started. It happened whenever our urine wasn’t hydrated enough.

[collaroygal]

That color can also indicate she is dehydrated. Even Atkins group has said they are not a reliable measure of ketones.

Try a device like blood monitor like keto-mojo or an old school, cheap breathalyzer instead.

If you go to the Resources sub-forum, there are several posts with keto friendly health care givers listed in the there.

All the best to your daughter in her weight loss efforts.

[ctviggen]

Waaaaay back when I used urine strips, they would get incredibly dark after a long bike ride in the summer…when I was likely down a lot of water. I stopped using them for this reason and that they no longer worked at all after a while. I have many tests where both breath and blood ketones showed a result and the urine ones didn’t, so I stopped using them.

For any of these tests, how do you feel? If you feel OK, you likely are OK. If you feel bad, you need to reevaluate.