Ketosis vs. Ketoacidosis

October 25, 2011

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It's a sad fact that some experts who certainly should know better confuse ketosis with ketoacidosis, misleading people into thinking that they are one and the same. Worse, they suggest that a low carb diet can cause the bad one - which is ketoacidosis.

Dr. Oz is one such expert.

The good Dr. Oz wrote in an Time magazine article on September 12th 2011:

Artisanal bakers wept (no carbs means no baguettes), and the uberfaithful (Note: here he is referring to low carbers) began to suffer the bad breath of ketoacidosis, which occurs when glycogen stores are too low.

DOH! No it doesn't - unless you are a type 1 diabetic that is. In other words, you can't enter into the evil netherworld of ketoacidosis unless you are one of those rare people who produces little if any insulin because insulin regulates acidosis as you will learn soon.

Now, was this just an innocent typo made by Dr. Oz's editor? Maybe. But thus far, no retraction has been made - none that I am aware of at least. As I see it, Dr. Oz doesn't understand the difference or doesn't want to. But fear not - I'm here to help!

I feel that it's very important for people (especially doctors) to know the difference between the two so as not to fear diet-induced ketosis caused by a low carb diet or by intermittent fasting. Ketosis is a perfectly normal and healthy state to be in.

Since I have a cursory understanding of the two being a layman, I decided to ask an expert, Dr. Richard Feinman, to spell it out for us.

Here you go:

Ketosis vs. Ketoacidosis

So what is the distinct difference between the two? Both are a condition of high levels of ketone bodies in the blood but one is life threatening and one is not. So why would this be?

1. Ketone bodies in the blood is called ketosis. Ketone bodies in the urine, which is the common way we measure them, is called ketonuria.
2. Ketone bodies are acids.
3. Blood contains several acids, phosphoric acid, carbonic, and these are neutralized (buffered) by the sum of acids and bases.
4. If acid levels exceed a certain point, that is called acidosis.
5. Because ketone bodies are also acids, they could contribute to an acidosis at very high levels. This is referred to as ketoacidosis and like any acidosis is dangerous.
6. Any ketosis might be considered “high” because modern man is rarely in a state of prolonged fasting.
7. Ketosis is the normal response to starvation or dietary carbohydrate restriction.
8. The ketosis from starvation or carbohydrate restriction is regulated by hormones and other metabolic effects to prevent over-production, that is, prevents ketoacidosis.
9. If the regulation breaks down for some reason, notably untreated type 1 diabetes (insulin is a major regulator of ketone body production), then you can have over-production or ketoacidosis.
10. Ketone bodies are normal because not having food all the time was normal. That is why we call ketone bodies "food of our ancestors."

Minor note.
1. The ketone bodies are acetoacetate, beta-hydroxybutyrate. These are the physiologic ketone bodies. Acetone can be produced non-enzymatically and is also considered a ketone body.
2. The term “ketone” is commonly used in discussing the more precise term “ketone bodies.” Organic chemists, curmudgeonly professors and others think it is a good idea to be precise because ketone is a particular type of compound (acetone is one) of which there are an infinite number and, oddly, one of the ketone bodies (beta-hydroxybutyrate) is not actually a ketone. The other acetoacetate is chemically both a ketone and an acid.

Here is a good paper on low carb diets/ketosis.

There you have it. So, next time someone tells you that ketosis is evil (like Dr. McDougall) and that life-threatening ketoacidosis can happen if your carb intake goes too low, print this out and hand it to them.