Recently, I consulted on an elderly woman (in her 90’s) with T2DM and Parkinson’s disease. She has been on ketogenic diet for 8 months and high dose orthomolecular nutrition supplementation based on my previous consultation. Her ketogenic diet is pretty strict since she has a feeding tube and her daily dietary intake is well calculated. She has been maintained relatively well.
Recently she had urinary tract infection, along with seizures. She was admitted to ICU. Lab tests showed metabolic acidosis. But she quickly recovered. Some questions arose whether ketogenic diet was the cause.
The short answer to the above question is No. The ketogenic diet offers more immediate concerns for ketosis and DKA, but with proper management, it can be safer than a conventional diet for long-term metabolic acidosis in T2DM.
When comparing the risks of metabolic acidosis between a ketogenic diet for a T2DM patient accustomed to the ketogenic diet and on multiple nutritional supplements versus a conventional diet, several factors come into play. Let’s break it down:
1. Ketogenic Diet for a T2DM Patient Already Accustomed to It
- Risk of Metabolic Acidosis:
- For a patient already accustomed to the ketogenic diet, the body has likely adapted to ketosis, meaning it has developed the ability to manage ketone production and avoid diabetic ketoacidosis (DKA).
- Chronic ketosis (from long-term adherence to a ketogenic diet) means the body is less likely to enter a dangerous state of DKA unless there are other contributing factors such as insulin resistance, infection, or severe dehydration.
- The presence of nutritional supplements (such as electrolytes, magnesium, potassium, calcium, and B-vitamins) can help mitigate the risks associated with ketosis, including electrolyte imbalances and dehydration, both of which can exacerbate acidosis.
- Insulin management: In T2DM, some insulin production remains, so the risk of DKA is generally lower than in type 1 diabetes, but it still exists if insulin therapy is improperly adjusted (e.g., not reducing insulin doses when switching to ketosis).
- Hydration and electrolytes: If the patient is consuming adequate electrolytes (sodium, potassium, magnesium) through supplements or food, it reduces the risk of dehydration, which can elevate ketone levels and increase acidosis risk.
- Overall, the risk of acidosis is low if the individual is well-adapted to the ketogenic diet, actively managing insulin, and supplementing electrolytes as needed.
2. Conventional Diet for T2DM
- Risk of Metabolic Acidosis:
- The conventional diet for T2DM typically includes higher carbohydrate intake, which can lead to insulin resistance and chronic hyperglycemia if not properly managed. This increases the likelihood of hyperglycemic crises such as hyperosmolar hyperglycemic state (HHS), but not DKA.
- In cases of poorly controlled diabetes, where blood glucose remains chronically high, renal function can deteriorate over time, leading to chronic metabolic acidosis or diabetic nephropathy. This is more related to the progression of T2DM rather than the diet itself.
- If the conventional diet is not optimized with nutritional supplements, especially electrolytes (e.g., magnesium, potassium), vitamins, and minerals, it could lead to nutritional deficiencies or imbalances that contribute to acidosis, especially if kidney function is compromised.
- Chronic insulin resistance in patients with T2DM may lead to metabolic derangements, but the risk of diabetic ketoacidosis is extremely low in the context of a conventional, carbohydrate-rich diet, unless there is an acute event like infection or stress that exacerbates glucose dysregulation.
3. Comparing the Two Approaches:
| Factor | Ketogenic Diet (T2DM, Accustomed & Supplemented) | Conventional Diet (T2DM) |
|---|---|---|
| Risk of Diabetic Ketoacidosis (DKA) | Low to moderate, but unlikely if insulin is managed well, ketosis is adapted, and supplementation is sufficient. Acute risk exists if insulin therapy is mismanaged or if there’s severe dehydration. | Very low. DKA is rare in T2DM on a conventional diet unless severe insulin deficiency or acute illness is present. |
| Chronic Metabolic Acidosis | Very low. Chronic ketosis doesn’t usually lead to acidosis unless there is significant dehydration or kidney issues. Electrolyte supplementation reduces risk. | Moderate. Long-term poorly controlled blood sugar and renal impairment could lead to chronic metabolic acidosis or diabetic nephropathy over time. |
| Electrolyte Imbalance | Lower risk if supplements are used (e.g., magnesium, potassium, sodium). Important to monitor. | Higher risk if not supplementing with essential nutrients, especially if kidney function declines due to poor glucose control. |
| Hydration | Requires careful attention. Dehydration from the ketogenic diet (due to glycogen depletion) could increase ketone production, elevating acidosis risk. | May not require as much attention. However, dehydration can still occur with poorly controlled blood sugar, especially in hot weather or with kidney dysfunction. |
| Kidney Function | Less concern for acidosis unless kidney function is already compromised. Renal function should be monitored. | More concern over time if diabetes is poorly controlled, leading to kidney damage (e.g., diabetic nephropathy) and potential acidosis. |
| Blood Sugar Control | Better control of blood sugar. Ketosis can improve insulin sensitivity in many patients with T2DM. | Varies significantly. Blood sugar control is often harder to maintain with conventional diets, increasing the risk of long-term complications like HHS and kidney damage. |
Summary:
- Ketogenic Diet (Accustomed & Supplemented): For a T2DM patient who is well-accustomed to the ketogenic diet and supplements appropriately, the risk of metabolic acidosis is generally low. The body is more efficient at managing ketones, and with proper hydration and electrolyte balance, the risk of DKA or chronic metabolic acidosis is minimal. However, there is still a potential risk of DKA if insulin or hydration is not carefully managed.
- Conventional Diet: The risk of metabolic acidosis in the conventional diet is primarily linked to long-term uncontrolled diabetes, leading to chronic hyperglycemia and renal complications (e.g., diabetic nephropathy), which could eventually result in acidosis. The risk of DKA is very low, but hyperglycemic crises (HHS) or chronic metabolic acidosis can develop with poor blood sugar management.
Thus, the ketogenic diet offers more immediate concerns for ketosis and DKA, but with proper management, it can be safer than a conventional diet for long-term metabolic acidosis in T2DM.