Diabetes Ketoacidosis (DKA) is a serious and potentially life-threatening complication of diabetes that occurs when the body does not have enough insulin to use glucose for energy, leading it to break down fat and produce acids called ketones. When ketones accumulate in the blood to dangerous levels, it disrupts the body’s chemical balance, resulting in DKA. Recognizing ketone levels and knowing when to seek emergency care is vital for anyone managing diabetes.
It’s truly astonishing—and concerning—that many newly diagnosed families are not given the vital education they need about diabetic ketoacidosis (DKA), its warning signs, and how to respond when ketones are present. DKA can be life-threatening. I meet so many parents who have never learned about it directly from their medical providers – even months after diagnosis – leaving families to rely on incomplete or inconsistent information from other sources, or learning by surprise when DKA happens.
Yes, many children are admitted to the hospital in DKA at the time of their Type 1 Diabetes diagnosis, but this is not the same thing as educating parents about what to do when DKA happens in the future after diagnosis. Yes, I said “WHEN”. It’s not likely “IF.” Diabetes is a life-long journey, and parents should be empowered from day one to recognize symptoms, check ketone levels, know when to give extra insulin, and understand when to call for help or seek medical care immediately. We also need to pass that wisdom on to our children so that they know what to do as adults living with the condition. And if you are an adult who was recently diagnosed with Type 1 and are reading this, and your medical team has not explained the ins and outs of DKA to you, please revert back to them for guidance, as this information is critical.
What’s even more surprising is that essential topics like sick day management and emergency use of glucagon—which can save lives in critical moments—are sometimes missing from initial education. Without this knowledge, families are at risk of being caught off guard during illness or other emergencies. Every diabetes team should make it a priority to provide comprehensive, multidisciplinary guidance that includes practical steps for ketone monitoring, responding to illness, and using emergency treatments like glucagon right from the start.
What is DKA?
DKA develops most commonly in people with Type 1 Diabetes, but it can also affect those with Type 2 Diabetes. When insulin is absent or severely low, the body burns fat for energy, producing ketones. Excess ketones make the blood acidic, which can cause severe symptoms and become life-threatening if untreated.
Ketone Levels Explained
- Trace Ketones: Small amounts may be detected if blood glucose is slightly elevated or after fasting. Monitoring is needed, but it’s generally not urgent if there are no symptoms.
- Raised Ketones (1.5–3 mmol/L): This level may indicate the early stages of DKA, especially if other symptoms like nausea or abdominal pain occur. Contact your doctor or someone on your diabetes care team for advice.
- High/Urgent Ketones (>3 mmol/L): High ketones, especially accompanied by symptoms such as vomiting, rapid breathing, or abdominal pain, are urgent. This requires immediate medical attention, and you should go to the emergency department for treatment. DKA is deadly is not treated.
Misconceptions About Ketones
There are several misconceptions about ketones and diabetes. One common myth is that you only get ketones when your blood sugar is very high. Even if blood sugar isn’t extremely elevated. Illness, fasting, or certain medications can lead to a condition called euglycemic DKA, where ketones rise to dangerous levels even if your blood sugar stays lower than expected. Additionally, ketosis can occur without diabetes—such as while on a low-carb diet—but only diabetic ketoacidosis (DKA) is dangerous due to the combination of high ketones and lack of insulin regulation.
Is The Keto Diet Safe For People With Diabetes?
For people with Type 1 Diabetes or those taking SGLT2 inhibitors, the keto diet can occasionally trigger DKA, even if blood sugars aren’t extremely high—a phenomenon called euglycemic DKA.
A keto diet involves eating very low amounts of carbohydrates, which forces the body to produce ketones for energy—a process called ketosis. In people with diabetes, particularly those on insulin or certain medications, this dietary change can have both benefits and risks. Close medical supervision is crucial because the keto diet can increase the risk of dangerous complications like hypoglycemia (low blood sugar) and diabetic ketoacidosis (DKA), especially if insulin therapy isn’t properly adjusted.
Since ketosis from a keto diet is not like the dangerous state of ketoacidosis. However, the presence of insulin is a key safety factor; without it, blood acidity can climb to life-threatening levels. Therefore, anyone with diabetes considering a ketogenic diet should first consult with their healthcare team and ensure frequent monitoring of both glucose and ketone levels to prevent complications.
When to Seek Emergency Care
- Ketone levels are above 3 mmol/L.
- You’re vomiting or can’t keep fluids down.
- You are unable to control your glucose or ketone levels.
- You have symptoms like abdominal pain, vomiting, fruity-smelling breath, fast breathing, or feel very unwell.
You do not need to have all symptoms to need emergency medical support.
Summary Tips
- Check your ketones regularly if you have the flu or feel unwell.
- Check ketone levels if your blood sugar is high.
- Contact your care team if ketone levels are moderately raised or symptoms occur.
- Do not wait to get medical advice and support.
A diabetes diagnosis in a child is frightening and traumatizing for everyone. Maybe physicians and healthcare providers who don’t talk about DKA and sick day management are trying to lessen the burden. I appreciate that they are thinking of our feelings, but families deserve to be confident, prepared, and supported—not left to piece together lifesaving information after leaving the clinic. The biggest benefit I had in the early days of my son’s diagnosis was that the doctor we saw was honest. Even if the realities felt harsh, it was the best preparation for the journey ahead.
The diabetes community is always there to inform and share information, but I’ve said on too many occasions, “Go back to your doctor and ask them to train you on what to do on sick days and in DKA emergency situations.” It starts with consistent, thorough education for every parent, every time a child is diagnosed.
