Is a Ketogenic Diet Safe?

Diabetic Ketoacidosis vs Nutritional Ketosis

Diabetic Ketoacidosis is a very dangerous condition in which you have both hyperglycemia (high blood sugars >250mg/dl) AND elevated urinary ketone readings (>10mmol). This is usually not a concern with the keto diet, because one of the main benefits of the keto diet is that your blood sugars will start to lower since your are no longer consuming blood sugar spiking carbohydrates. Due to the high blood sugar component, there are typically signs and symptoms to watch out for:

• Excessive thirst.
• Frequent urination.
• Nausea and vomiting.
• Stomach pain.
• Weakness or fatigue.
• Shortness of breath.
• Fruity-scented breath.
• Confusion.

Euglycemic Ketoacidosis is a ketoacidotic condition in the presence of blood sugars that are less than 200mg/dl. This condition is rare but can occur in those who might be on SGLT2 medications or insulin (1). There are a few case reports where EKA has occurred during pregnancy (2), or after the onset of an illness (following abdominal pain, severe nausea, vomiting) (3).

A well formulated ketogenic diet allows you to be in nutritional ketosis, NOT diabetic ketoacidosis, which is often confused together. When you restrict your carbohydrate intake (below 50g daily), your blood glucose is much lower and your ketone readings are considerably low as well. To achieve nutritional ketosis, the ketones are typically between [.5mmol (or less) – 3mmol]. Some practitioners of the ketogenic diet might even strive for higher ketone level [5mmol] by increasing their dietary fat consumption if they are using it for therapeutic reasons (cancer, epilepsy).

“Keto-Flu”

The “keto-flu: is typically experienced within the first few days of restricting most of your carbohydrate intake. You will typically feel tired, lightheaded, dizzy, have a headache, you may feel less energized at the gym, and you may likely experience a fruity smell from your breath and urine. Your body is going through an adaptation phase where it is trying to find an energy source. It begins by burning glycogen (stored form of glucose) in the liver and skeletal muscles, which then causes your body to release quite a bit of water weight (usually 5-10 pounds within the first week). Your body then has to adapt even further and begins using dietary and body fat as its new primary fuel source.

This diet causes you to lose electrolytes such as sodium, potassium, calcium and magnesium. It is strongly advised that you replenish these nutrients daily, and to make sure that you are getting enough quantities to help prevent these “flu-like” symptoms, and other more concerning symptoms of deficient electrolytes, such as having an increased awareness of your heartbeat, “faster” heart rate, restless legs at night, dry mouth, and muscle twitching. 

You can mitigate these symptoms by drinking bouillon cubes throughout the day, making sole water, adding in dashes of salt on your food, taking a magnesium and calcium supplement and making sure to get 3-4 cups of green leafy vegetables daily.

Other potential side effects of the ketogenic diet that may occur are bowel disturbances such as diarrhea or constipation, which can be due to not having enough electrolyes, not absorbing fats correctly (or an overstimulation of bile), or microbiome changes caused by the change in your diet which may kill off more of thecarb/fermenting bacteria.

Other signs or symptoms include, the “keto-rash” and right-sided colicky pain if you have a history of gallbladder disease. You may complain that your breath and sweat smells. You may even have concerns with hair loss (or hair fall) if you have taken in minimal amounts of protein or are suffering from low micronutrient intake. 

Physiological adaptive effects

I should also highlight that one other potential concern is that regarding the thyroid, the ketogenic diet may decrease the amount of circulating T3 in the body. This is a physiological adaptive process to further enhance the protein-sparing effect of the ketogenic diet. You can expect for your TSH (thyroid stimulating hormone) and T4 hormone to remain within normal limits but with a slight decrease in T3. If this concerns you and you are currently on a ketogenic diet and or you have a pre-existing thyroid condition then consult with your physician. 

 

1: Diaz-Ramos, Alexis et al. “Euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitor use: a case report and review of the literature.” International journal of emergency medicine vol. 12,1 27. 5 Sep. 2019, doi:10.1186/s12245-019-0240-0

2: Jaber, Johnny F et al. “Euglycemic Diabetic Ketoacidosis in Pregnancy: A Case Report and Review of Current Literature.” Case reports in critical care vol. 2019 8769714. 20 Aug. 2019, doi:10.1155/2019/8769714

3: Shaikh, Safia et al. “Euglycemic Diabetic Ketoacidosis Precipitated by a Keto Diet: Importance of Dietary History in Diagnosis.” Cureus vol. 12,9 e10199. 2 Sep. 2020, doi:10.7759/cureus.10199