Ketoacidosis Causes, Risk Factors, Symptoms and FAQ Answered

Written by Sara McEvoy
on January 20, 2020

Think people are still interested in the keto diet?

You thought right: according to recent data from Google, "What is keto?" was one of the top health-related internet searches in 2019. But while a ketogenic diet—often called "keto" for short—can do amazing things for your health (and waistline), the terminology can get a little confusing.

Questions Answered:
  • Can you get ketoacidosis without diabetes?
  • Why is ketoacidosis more likely to occur with type 1 diabetes and not type 2 diabetes?
  • What is ketoacidosis?
  • Are ketoacidosis and ketosis the same?
  • Can ketoacidosis kill you?
  • How is ketoacidosis treated?

One example is the confusion over the words ketosis and ketoacidosis. They certainly sound like the same thing. But are they? 

Ketoacidosis Symptoms

Whether you're brand new to keto, have followed a high-fat/low-carb lifestyle for years, have a chronic health condition like type 1 diabetes, or are simply trying to make sense of the latest health-related buzz words, we've got you covered. It's time to chew the fat about ketosis, ketoacidosis, and what you can expect when living ultra low-carb.

What is Ketoacidosis?

Ketoacidosis, also called diabetic ketoacidosis or DKA, is a metabolic state characterized by extremely low levels of insulin, extremely high levels of high blood sugar (> 250 mg/dL), and high levels of ketones.

Insulin is an important hormone produced by the pancreas. It helps shuttle blood sugar (glucose) into cells where the sugar is used for energy. When a person's insulin levels become dangerously low, their blood sugar has no way to get into cells, so sugar starts to build up in the blood. To the body, this looks and feels like starvation. As a result, the body quickly tries to create another energy source by rapidly breaking down stored fat into molecules called ketones. Ketones can be a very efficient fuel source, but if they build up too high and too quickly then blood can become acidic, which can be toxic to the rest of the body. 

Ketoacidosis also throws off the normal balance of electrolytes in the blood, including sodium, bicarbonate, and potassium. Electrolytes are minerals that help regulate the function of the heart, nerve, muscles, and other tissues and organs. Electrolyte imbalances can be extremely dangerous. 

Since ketoacidosis only occurs when there is a dangerously low level of insulin in the body, it usually only affects people with type 1 diabetes. Type 1 diabetes is a chronic health condition that happens when the pancreas makes little to no insulin. People with type 1 diabetes are more likely than other people to experience dangerously low levels of insulin, so they're the most likely to experience ketoacidosis. 

Causes of Ketoacidosis

Ketoacidosis is often caused by: 

  • Being unaware that you have type 1 diabetes, so it's not being treated—this is often how parents first realize their child has type 1 diabetes (because the child becomes very sick and found to be in ketoacidosis when taken to the hospital) 
  • Not taking your diabetes medication as prescribed (e.g., not injecting enough insulin or missing an insulin dose)
  • Malfunctions in your insulin pump, if you have one
  • A sudden illness or infection, like pneumonia, urinary tract infection, or a heart attack
  • The use of drugs or alcohol
  • Certain medications, including SGLT-2 inhibitors, prednisone, or dexamethasone

Risk Factors for Ketoacidosis

As mentioned, ketoacidosis usually just affects people with type 1 diabetes. While rare, ketoacidosis can also affect people with type 2 diabetes, a chronic health condition in which the body makes insulin but doesn't use it properly.

If you or your loved one has diabetes, one the best ways to prevent ketoacidosis is to take your medications exactly as prescribed. It's also helpful to be aware of the risk factors for ketoacidosis. These include:

  • Being younger than 19
  • Feeling highly stressed or recently experienced emotional or physical trauma
  • Having a fever or other type of illness or infection
  • Smoking or using drugs or alcohol 

Ketoacidosis Symptoms: What to Look Out For 

Symptoms of ketoacidosis typically develop quickly, generally within a few hours. Here are the top warning signs and symptoms to look out for:

  • Extreme thirst
  • Frequent urination
  • Signs of dehydration, like abnormal skin turgor (e.g., the skin on the back of the hand stays raised or "tented" after you pinch it)
  • Abdominal pain, nausea, and vomiting
  • Confusion or mental status changes
  • Fruity-smelling breath
  • Flushed face
  • Dry skin and mouth
  • Rapid breathing and heart rate
  • Fatigue
  • High blood sugar levels (typically >250 mg/dL as measured on a blood glucose monitoring kit)
  • High ketone levels (typically > 14 mmol/L as measured on a ketone testing kit) 

If ketoacidosis is triggered by an illness or infection, a person may also experience other symptoms like fever, chills, coughing, chest pain, or joint pain.  

Ketosis vs Ketoacidosis

Here's the main point to remember about ketosis vs ketoacidosis: they are NOT the same thing!

Ketosis is a normal, healthy, and generally safe metabolic state your body enters when you follow a ketogenic diet. A ketogenic diet features a high amount of fat, a moderate amount of protein, and a very low amount of carbohydrates. Since you're not consuming a lot of carbs on keto, your body must break down stored body fat for fuel instead. This is one of the reasons why a keto diet is so effective for fat loss. 

Nutritional ketosis usually leads to ketone levels of around 0.5 to 3.0 mmol/L. This is high enough to be in the beneficial state of ketosis but not so high that your blood becomes acidic and toxic. With ketoacidosis, ketone levels become dangerously high—as high as 14 mmol/L or more. Unlike ketosis, ketoacidosis is also associated with dangerously high blood sugar levels and dangerously low insulin levels. 

In other words, ketoacidosis is a dangerous and abnormal physiological state that occurs when something goes "wrong" in the body. Ketosis is a normal and generally healthy state that occurs in response to a ketogenic diet.

Frequently Asked Questions About Ketoacidosis

Can you get ketoacidosis without diabetes? 

It's very unlikely to get ketoacidosis if you don't have diabetes. It may be possible in the case of extreme starvation or in people who have severe alcoholism. It's also possible but extremely unlikely for a ketogenic diet to lead to ketoacidosis. If you're breastfeeding or have a chronic health condition like type 1 diabetes or type 2 diabetes, you should talk to your doctor before experimenting with a keto diet. 

Why is ketoacidosis more likely to occur with type 1 diabetes and not type 2 diabetes?

Ketoacidosis is more likely to occur in people with type 1 diabetes because these individuals are the most likely to experience severely low levels of insulin. People with type 1 diabetes make little to no insulin, whereas people with type 2 diabetes make insulin but just don't use it properly. Ketoacidosis can happen in people with type 2 diabetes, especially if they have one or more risk factors like infection or drug use, but it's considered relatively rare. 

Can ketoacidosis kill you?

Ketoacidosis can be fatal and may kill you if it's not treated quickly. In severe cases, ketoacidosis can lead to seizures, brain and organ damage, irregular heart beats, swelling in the lungs and brain, coma, and yes—death. Research actually shows that DKA is the leading cause of death in young people (age 24 and under) who have diabetes.

For these reasons, ketoacidosis is considered a medical emergency. If you or a loved one has diabetes and begins to show signs and symptoms of ketoacidosis, call 911 and get to a hospital immediately. 

How is ketoacidosis treated?

Ketoacidosis is a medical emergency and must be treated by healthcare professionals. Doctors will use a combination of therapies to manage DKA, including:

  • Insulin replacement: to raise insulin levels (which will lower blood sugar to a safer range, typically less than 240 mg/dL)
  • Fluid replacement, either orally or through an IV: to treat dehydration, which can raise blood sugar levels even more
  • Electrolyte replacement, usually through an IV: to restore the balance of important minerals like potassium which help the heart, nerves, and other tissues function properly, and which tend to drop to very low levels when insulin levels are very low, too

Doctors will also use additional therapies to address any other health issues that are also present. For example, a doctor may prescribe antibiotics if a person has an active infection or illness, which could have caused ketoacidosis to develop in the first place.


Ketoacidosis is a life-threatening condition and requires immediate medical treatment. It almost always affects people with diabetes, especially type 1 diabetes, and is considered a medical emergency.

Ketoacidosis causes dangerously highly levels of blood sugar and ketones, electrolyte imbalances, and complications including dehydration, organ damage, and death. It's diagnosable through lab work and clinical examination, and can be treated using multiple therapies including injectable insulin and IV fluids. 

Ketosis is a normal and usually healthy response to a very low carbohydrate diet, such as the ketogenic diet. Ketosis (along with the ketogenic diet) has been studied and used for decades as a way to treat epilepsy, promote fat loss, and more.

Looking for some healthy and delicious fat sources to flavor up your keto diet? Be sure to check out our full range of nut butters


    Author: Sara McEvoy

    Published: Jan. 20, 2020

    Sara McEvoy, PT, DPT is a licensed and board-certified doctor of physical therapy. She earned her degree in 2011 from Boston University. Sara is also a professional freelance writer and copywriter. She researches and writes almost exclusively within the health and wellness field.

    Written by Sara McEvoy

    Published: January 20, 2020