JIMHICR

Another “D” in MUDPILES? A Review of Diet-Associated Nondiabetic Ketoacidosis

Ketogenic diet or very-low-carbohydrate diet gained widespread popularity in the 1990s due to their favorable effects on weight loss and diabetes among others with good short-term safety data. People on ketogenic diets exist in a state of “dietary ketosis” in which the body production of ketone is equal to consumption and no harmful effects of ketonemia occur. However, in face of stress, the harmless “dietary ketosis” can lead to profound acid-base disturbances due to massive overproduction of ketone bodies that overwhelms the acid buffer system of the body. A handful of case reports have been published on this topic calling the safety of ketogenic diet into question. In this article, we chronicle a unique case of ketogenic (Atkins) diet–associated ketoacidosis, and we present a comprehensive literature review on the etiology of ketoacidosis.

Read the full case report here

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Clinical Cases

• Male 27 years old: Complaints of fever, chills, and joint ache for 3 days. On the fourth day, he complains of polyuria (around 20x a day). Random blood glucose test shows 220 mg/dL. At the 5th day, patient loses consciousness and is admitted to the hospital diagnosed as diabetic ketoacidosis. Random blood sugar 534, ketone +, and metabolic acidosis. HbA1c is 5.2%, c-peptide results are awaiting.
• A 45-year-old man diagnosed with type 2 diabetes was seen for management of diabetes and chronic kidney disease stage 1. Background history of stable retinopathy and hypertension, treated with an ACE inhibitor. Initially weighed 210 lbs and lost over 100 lbs through dietary changes (an Atkins-like high-protein, low-carbohydrate diet). Improvements noted in fasting triglycerides and blood pressure measures.

Diet Studies

• Do low glycaemic index or low glycaemic load diets help people with overweight or obesity to lose weight?

  • Key Messages:
    • Low glycaemic index and low glycaemic load diets probably result in little to no difference in weight, compared to higher glycaemic index or load diets or any other diets.
    • We are very uncertain of the effects of these diets on people's quality of life, side effects, and death.
  • What is a low glycaemic index or a low glycaemic load diet?
    • Low glycaemic index and low glycaemic load diets consist of foods that produce a milder or delayed peak in blood sugar. This may cause the body to produce less insulin, which could lead to weight loss.
  • What did we want to find out?
    • We wanted to evaluate the effects of following these diets in people with overweight or obesity. We checked the effects on weight, quality of life, side effects, and death.
  • What did we find?
    • We included 10 studies with 1210 people (4.1% of participants were children and 1.9% were adults over 65 years old). Half of the studies were carried out in the USA.
    • Main Results:
      • Low glycaemic index or glycaemic load diets likely result in little to no difference in body weight change compared to any other diets. Participants reported experiencing unwanted effects, including eating disorders, kidney stones, and diverticulitis.
    • Limitations of the evidence:
      • We were most certain about the findings related to weight, but there were greater uncertainties for other results. Not all studies reported on quality of life or deaths, and most studies were small.

• A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. An ECG was performed, and he was promptly referred to the emergency department.

• A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back, with no recent travel or exposure to new environments. Physical examination revealed multiple small vesicles on the lumbar region and left gluteal area.

• A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Multiple small pustules with surrounding inflammation were present on the chin and a few scattered papules on the chest.