Nezam El-Tayebat Fact CheckA scientific assessment of the “نظام الطيبات” nutrition system
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False Scientifically refuted Certainty of evidence: high provisional C-INS-08

Diabetic ketoacidosis (DKA) does not kill anyone; it should be treated with corticosteroids and complete fasting from food and drink for days, without insulin and without intravenous fluids; giving insulin in this situation is 'the black disaster'.

Safety note: High blood glucose together with ketones (acetone) in urine or blood, especially with nausea, vomiting, abdominal pain, rapid breathing, thirst or drowsiness, can mean diabetic ketoacidosis, a medical emergency. In people taking SGLT2 inhibitors (e.g. dapagliflozin/Forxiga, empagliflozin) ketoacidosis can occur with normal or only mildly raised glucose. Seek emergency care; do not wait or fast it out. Do not stop or reduce insulin on the basis of this claim. In type 1 diabetes and other insulin-deficient states, stopping insulin leads within hours to days to diabetic ketoacidosis, which is life-threatening. Medically accepted position (ADA Standards of Care 2026): insulin treatment is essential for people with type 1 diabetes; people on intensive insulin therapy should not stop basal insulin even when not eating. Any change of diabetes medication should be made together with the treating physician. Corticosteroids and fasting without water are not a treatment for ketoacidosis. Withholding fluids worsens the severe dehydration of ketoacidosis, and fasting speeds up ketone build-up when insulin is missing.
In short: This claim is false. Diabetic ketoacidosis was almost always fatal before insulin and ketoacidosis or diabetic coma still accounts for about one in five deaths of people with type 1 diabetes under 50 in Scotland; it is caused mainly by missing insulin and is treated with insulin, intravenous fluids and potassium, while corticosteroids raise blood sugar and fasting without water speeds up ketoacidosis.
Conclusion: DKA is deadly without treatment and is mainly caused by missing insulin; insulin, fluids and potassium save lives, while cortisone and dry fasting make it worse.
  1. Original statement
  2. Scientific assessment
  3. Scientific evidence in detail
  4. In plain language
  5. Studies on this claim
  6. Regional context
  7. What applies in my country?
  8. References

Original statement

مش عايز محاليل محاليل ايه كورتيكوست لحد ما يفك وصيام اكل وشرب ان بي او لا ايام مش عايز علاج ديكي ايه

verbatim according to source. Translation by the project; the Arabic wording is authoritative.

Translation

Diabetic ketoacidosis (DKA) does not kill anyone; it should be treated with corticosteroids and complete fasting from food and drink for days, without insulin and without intravenous fluids; giving insulin in this situation is 'the black disaster'.

Origin

Source status
Video transcript (own words)
Attribution
Elawady (machine transcript)
Video
الغيبوبات السكرية ؟! (Open source)
Published
30 April 2025
Timestamp
0:49:40 (location in the original video’s automatic YouTube caption track; confirms where the words occur, not who speaks)
Attribution uncertainty
Archive transcript (YouTube CC or AI-generated); no timestamps; 'published' is the date listed by the archive and may be the upload date. Live-stream transcripts can contain viewer comments read aloud; the quoted passage was checked in context to be spoken by Elawady.
Claimed mechanism

Coma in DKA is due to blood pooling in a congested liver/gut; cortisone restores circulation; ketones and glucose are liver products.

Claimed health effect

Denial of DKA as deadly; rejection of insulin and fluids in DKA

Population concerned

People with diabetes in hyperglycaemic crisis

Geographic restriction by Elawady

none found

Diverging source versions

Source status
Video transcript (own words)
Attribution
Elawady (machine transcript)
Video
Dr Diaa Al Awady د ضياء العوضي is live! البروستاتا البنكرياس الكلي الخصيتين ايه وجه الشبه بينهم ؟! (Open source)
Published
29 August 2025
Timestamp
not available (transcript has no timings)
Attribution uncertainty
Archive transcript (YouTube CC or AI-generated); no timestamps; 'published' is the date listed by the archive and may be the upload date. Live-stream transcripts can contain viewer comments read aloud; the quoted passage was checked in context to be spoken by Elawady.
Source status
Video transcript (own words)
Attribution
Elawady (machine transcript)
Video
Dr Diaa Al Awady د ضياء العوضي is live! النسيج البيني التعرق التبول ؟!! (Open source)
Published
15 October 2025
Timestamp
not available (transcript has no timings)
Attribution uncertainty
Archive transcript (YouTube CC or AI-generated); no timestamps; 'published' is the date listed by the archive and may be the upload date. Live-stream transcripts can contain viewer comments read aloud; the quoted passage was checked in context to be spoken by Elawady.

Scientific assessment

False – The statement contradicts the robust evidence.

Certainty of evidence: high – Further research is very unlikely to change the assessment.

1. What was claimed?

DKA is harmless; treatment should be cortisone plus multi-day fasting without food, drink, insulin or fluids.

2. What is demonstrably correct?

Elawady correctly lists three hyperglycaemic emergencies (DKA, hyperosmolar state, lactic acidosis), correctly notes that SGLT2 inhibitors can cause ketoacidosis, sometimes with near-normal glucose (I-ODD-10), and that ketosis occurs in starvation. Fasting can lower blood glucose during insulin deficiency (I-INS-112), and with modern treatment DKA deaths are rare (no deaths among 919 treated children in Middle Eastern ICUs, I-INS-114), which may explain the impression that 'nobody dies' of DKA; this low mortality is the result of insulin and fluids.

3. What is wrong or exaggerated?

DKA is a life-threatening emergency. The 2024 consensus states: 'Insulin therapy is the cornerstone of DKA management and should be started as soon as possible after diagnosis', with isotonic fluids at 500-1,000 mL/h initially and potassium replacement; 'Appropriate treatment has reduced mortality owing to DKA to <1%' (I-INS-07). Without optimal treatment DKA has 'appreciable, although largely preventable, morbidity and mortality' (I-INS-08). In the canagliflozin programme, DKA cases were driven by insulin deficiency (autoimmune diabetes, insulin omission or dose reduction) and acute illness, with glucose above 300 mg/dL, which supports insulin treatment rather than withholding it (A-ODD-10). Patients with DKA are severely dehydrated, so withholding fluids and imposing a dry fast would worsen shock and kidney failure. Glucocorticoids 'may precipitate acute and sustained hyperglycemia by countering insulin action' (I-INS-07). The hypothesis of hepatic/intestinal blood pooling as the cause of DKA coma has no supporting evidence.

4. What remains unclear?

Nothing material.

5. Which studies support it?

None for the treatment claim.

6. Which studies contradict it?

I-INS-07, I-INS-08, I-INS-10, A-ODD-10, I-INS-130, I-INS-136 (guidelines); I-INS-101 (pre-insulin era: diabetic coma was the usual cause of death); I-INS-111 (DKA/coma 22% of deaths in T1D under 50 in Scotland); I-INS-108, I-INS-109 (stopping insulin causes about two-thirds of DKA); I-INS-110 (IV fluids safe); I-INS-112 (fasting and dehydration accelerate ketoacidosis); I-INS-115 (severe DKA common in Egyptian children).

7. What applies to Germany and Europe?

German and European emergency practice follows the same consensus (EASD and JBDS are co-authors of I-INS-07).

8. What is known about Egypt?

DKA is a common cause of emergency admission of children and young adults with diabetes in Egypt and the region; delayed treatment increases mortality. Advice to avoid hospitals and insulin is particularly dangerous where access to care is already delayed.

9. What practical conclusion is appropriate?

Suspected DKA requires immediate emergency medical treatment with insulin, fluids and electrolytes. Corticosteroids and fasting are not treatments for DKA.

Assessment details

Rationale for certainty of evidence

International consensus (ADA/EASD/JBDS/AACE/DTS 2024) based on decades of evidence: insulin is 'the cornerstone of DKA management', with IV fluids and potassium. DKA mortality is <1% only with appropriate treatment. Glucocorticoids raise glucose and can precipitate hyperglycaemic crises. Elawady himself says in the same video that cortisone increases ketones and glucose.

Source quality

Own words, machine transcripts of two separate videos (identical lecture published as live and edited version).

Regional transferability

Universal.

Individual exceptions

None.

Regional scope of the claim
general (biological/medical)
Last reviewed
26 October 2026 provisional

Scientific evidence in detail

Scientifically refuted – High-quality evidence shows the opposite, or the claim contradicts well-established physiology.

Research question: Is diabetic ketoacidosis non-lethal, and can it be treated with corticosteroids and complete fasting from food and water without insulin or intravenous fluids?

Research question in detail (PICO)
Population
People with diabetes in ketoacidosis
Intervention or exposure
Corticosteroids plus dry fasting without insulin or IV fluids
Comparison
Guideline treatment (IV fluids, insulin, potassium)
Geographic scope
universal biology; Egyptian/Middle Eastern data
Outcomes
  • Mortality
  • Resolution of acidosis
  • Cerebral oedema/neurological outcome

Study results as reported by the authors. Our assessment follows below.

What speaks for the claim?

What speaks against the claim?

What does the overall evidence say?

Editorial assessment based on the studies above – not itself a study result.

Which position is better supported?

DKA is a life-threatening emergency caused mostly by insulin deficiency/omission; it is treated with IV fluids, insulin and potassium; glucocorticoids raise glucose; fasting and dehydration accelerate ketoacidosis.

Why some studies weigh more

Guidelines, RCT on fluids, national mortality data, physiological experiments and natural history agree; the only 'supporting' trial is implausible and indirect.

Is a causal relationship established? Yes, established Insulin omission precipitates DKA (Musey, Randall); treatment with insulin and fluids lowered DKA mortality to <1%; untreated DKA was uniformly fatal before 1922.

Remaining uncertainty

None material for the claim.

Justified conclusion

False and potentially fatal advice.

Why do studies seem to disagree?

'Nobody dies of DKA' may reflect experience with treated DKA, where mortality is <1% (I-INS-114 found 0 deaths in treated children); this is the result of insulin and fluids, not evidence that DKA is harmless.

Does this depend on the country?
General biological effects
Insulin physiology, autoimmune type 1 diabetes and ketoacidosis are universal human biology.
Eating habits
Egyptian and European diets differ, but no dietary pattern replaces insulin in insulin-deficient diabetes.
Origin of the food
Not relevant.
Contaminants
Not relevant.
National production conditions
Not relevant.
Legal rules
Insulin is an essential medicine (WHO list) in Egypt and the EU; prescription rules not relevant to the scientific question.
Actual monitoring data
In Cairo, 43% of children with T1D presenting to the emergency department had severe DKA, mostly at first diagnosis (I-INS-115); treated paediatric DKA in Middle Eastern ICUs had no deaths (I-INS-114). Advice to avoid insulin, fluids and hospitals would remove the treatment that makes DKA survivable.

A regional difference that changes the conclusion is not supported by robust data.

Statistical re-check
  • Plausibility of reported pH distribution – With mean 6.49 and SD 0.52, about half of patients would have pH <6.5 and about 17% <6.0; post-treatment SD implies 22% with pH >7.45 in the placebo arm; data implausible recalculated
  • Proportion of DKA due to insulin cessation (Wilson CI) – 28/42 = 66.7% (51.6-79.0%) recalculated
  • Proportion due to insulin discontinuation (reconstructed count) – about 111/164 = 67.7% (60.2-74.4%) recalculated
  • Brain injury rate with IV fluids (Wilson CI) – 12/1389 = 0.9% (0.5-1.5%) recalculated
Certainty of the overall evidence (GRADE, simplified)
Main outcome
Mortality of DKA treated without insulin and fluids
Starting level
low (observational studies)
Reasons for upgrading
  • very large effect (near-universal death before insulin vs <1% with treatment)
  • consistent mechanism
Result
high

Simplified assessment by a single reviewer, following the GRADE approach; not a formal GRADE panel. GRADE rates the body of evidence for one outcome, not individual studies.

Clinical guidelines and official statements checked
  • ADA/EASD/JBDS/AACE/DTS: Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (I-INS-07) (2024) · Original publication
    Insulin is 'the cornerstone of DKA management'; isotonic fluids 500-1,000 mL/h initially; potassium replacement; treated DKA mortality <1%; glucocorticoids can precipitate hyperglycaemia.
  • ADA: 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2026 (2026) · Original publication
    Rec 16.16 (A): manage DKA/HHS with intravenous fluids, insulin and electrolytes, close monitoring and treatment of the precipitating cause; glucocorticoids induce hyperglycaemia in 56-86% of hospitalised people.
  • ADA: 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026 (2026) · Original publication
    People at risk for DKA should have ketone testing tools and sick-day advice; people on intensive insulin therapy should not stop or hold basal insulin even if not eating; caution with near-normal A1C goals in long-standing T2D using hypoglycaemia-prone drugs (ACCORD).
  • NICE: NG17 Type 1 diabetes in adults (last updated 17 August 2022) (2022) · Original publication
    Basal-bolus insulin for all adults with T1D (1.7.1); ketone monitoring in sick-day rules (1.10.1); DKA: isotonic saline and IV insulin infusion (1.10.5-1.10.7).
  • NICE: NG18 Diabetes in children and young people (last updated 11 May 2023) (2023) · Original publication
    Basal-bolus insulin from diagnosis (1.2.18); blood ketone testing and sick-day rules (1.2.82-1.2.83); DKA is serious and needs urgent hospital IV fluids and insulin (1.4.6, 1.4.21); DKA can occur with normal glucose (1.4.3).
  • JBDS-IP: The management of diabetic ketoacidosis in adults (2022 article; single-page pathway March 2023) (2023) · Original publication
    Within the first hour: 0.9% saline and fixed-rate IV insulin 0.1 unit/kg/h, continue long-acting insulin, potassium replacement.
  • ADA/EASD: The management of type 1 diabetes in adults: updated 2026 consensus report (2026) · Original publication
    'Lifelong insulin therapy is essential in type 1 diabetes'; all individuals need glucose and ketone testing supplies; insulin omission or under-dosing is a DKA precipitant.
  • ISPAD: ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state (Glaser N et al., PMID 36250645) (2022) · Original publication could not be retrieved; content not used
  • ISPAD: ISPAD 2022: Sick day management in children and adolescents with diabetes (Phelan H et al., PMID 36093857) (2022) · Original publication could not be retrieved; content not used
Search strategy

Documented literature searches for this review (search strings in the original database syntax).

DatabaseDateSearchLooking forHitsIncluded
Europe PMC26 October 2026("diabetic ketoacidosis" OR "hyperglycemic crisis") AND (glucocorticoid OR corticosteroid OR steroid OR dexamethasone) AND (precipitat* OR induced OR risk)supporting evidence6061
PubMed26 October 2026(glucocorticoid* OR corticosteroid*) AND ("hyperglycemic crisis" OR "hyperglycaemic emergenc*" OR "diabetic ketoacidosis") AND (cohort OR "case-control")supporting evidence16
PubMed26 October 2026(corticosteroid* OR glucocorticoid* OR dexamethasone OR hydrocortisone) AND "diabetic ketoacidosis"[ti] AND (treatment OR therapy OR management) AND (trial OR cohort OR outcome)supporting evidence19
Europe PMC26 October 2026TITLE:"diabetic ketoacidosis" AND (TITLE:"fasting" OR TITLE:"Ramadan")both directions15
Europe PMC26 October 2026("diabetic ketoacidosis") AND ("Middle East" OR Arab OR "MENA") AND (mortality) AND (TITLE:"systematic review" OR TITLE:"meta-analysis")both directions52
PubMed26 October 2026(diabetic ketoacidosis) AND (mortality) AND (systematic review[pt] OR meta-analysis[pt])contradicting evidence67
PubMed26 October 2026("insulin omission" OR "cessation of insulin" OR "discontinuation of insulin") AND "diabetic ketoacidosis" AND (precipitat* OR cause)contradicting evidence72
PubMed26 October 2026Musey VC[au] AND ketoacidosiscontradicting evidence1
PubMed26 October 2026Randall L[au] AND recurrent diabetic ketoacidosiscontradicting evidence1
PubMed26 October 2026Kuppermann N[au] AND "diabetic ketoacidosis" AND fluid[ti]contradicting evidence6
Europe PMC26 October 2026"diabetic ketoacidosis" AND ("fluid" OR "saline") AND randomized AND children AND (cerebral OR neurologic) AND PUB_YEAR:[2015 TO 2026]contradicting evidence520
PubMed26 October 2026"diabetic ketoacidosis" AND (mortality OR "case fatality") AND trends AND (population-based OR national)contradicting evidence36
PubMed26 October 2026(glucocorticoid* OR corticosteroid*) AND hyperglycemia AND meta-analysis[pt]contradicting evidence112
PubMed26 October 2026diabetic ketoacidosis AND (Egypt OR Egyptian) AND (mortality OR outcome)contradicting evidence38
Europe PMC26 October 2026(TITLE:"Egypt" OR TITLE:"Egyptian") AND (TITLE:"ketoacidosis")contradicting evidence0
Europe PMC26 October 2026(TITLE:"Egypt" OR TITLE:"Egyptian") AND TITLE:"type 1 diabetes" AND (mortality OR "insulin omission" OR adherence OR "ketoacidosis")contradicting evidence22
PubMed26 October 2026Joint British Diabetes Societies diabetic ketoacidosis adults updated guidelineguidelines3
Web search + abcd.care26 October 2026JBDS-IP management of diabetic ketoacidosis in adults abcd.care 2023 guideline (pathway PDF fetched)guidelines10
PubMed26 October 2026ISPAD Clinical Practice Consensus Guidelines 2022 diabetic ketoacidosisguidelines1
Web search + ispad.org26 October 2026ISPAD Clinical Practice Consensus Guidelines 2022 diabetic ketoacidosis chapter pdf ispad.org (Wiley full text returned HTTP 403)guidelines9
PMC (publisher full text)26 October 2026Fetched ADA Standards of Care 2026 sections 2, 6, 8, 10, 14, 16 at pmc.ncbi.nlm.nih.gov/articles/PMC12690183, PMC12690178, PMC12690172, PMC12690187, PMC12690182, PMC12690180guidelines6
Guideline websites (NICE)26 October 2026Fetched https://www.nice.org.uk/guidance/ng17/chapter/Recommendations and /ng18/chapter/Recommendationsguidelines2

Open questions

ISPAD 2022 DKA and sick-day chapters could not be read (publisher HTTP 403); not needed for the conclusion.

How deeply was this checked?

17 linked studies: 11 checked in full text (2 of them with a structured risk-of-bias assessment), 6 on the basis of the abstract, 0 bibliographically only. No formal assessment with two independent reviewers and no independent human expert review has taken place yet.

Last scientific review: 26 October 2026

History of the verdict
  1. 25 October 2026 · Phase 1 · Initial assessment: False (high)
  2. 26 October 2026 · Phase 4 (systematic evidence review) · Re-examined with extended evidence; verdict unchanged: False (high)
    Deep search added national mortality data, insulin-omission studies, an RCT on fluids, physiology of fasting/dehydration and Egyptian/Middle Eastern data. The only randomised 'supporting' study for steroids is implausible and indirect.
    New sources: I-INS-101 I-INS-108 I-INS-109 I-INS-110 I-INS-111 I-INS-112 I-INS-113 I-INS-114 I-INS-115 I-INS-130 I-INS-136

In plain language

Diabetic ketoacidosis happens when the body has far too little insulin: blood sugar and acids rise, and the body loses a lot of water. It is an emergency. Hospitals treat it with fluids through a drip, insulin and salts such as potassium; with this treatment fewer than 1 in 100 adults die. Cortisone raises blood sugar and fasting without water makes dehydration worse, so the advice in this video could be fatal.

Studies on this claim

Studies supporting the claim (0)

No studies in this group.

Studies contradicting or limiting the claim (15)

  • International guideline on diabetic ketoacidosis

    Umpierrez GE et al.. Diabetes Care 2024 · PMID 39052901 · DOI 10.2337/dci24-0032
    Guideline / position statementindependent cross-checkfull text checked★ key study

    Insulin, fluids and potassium are the core treatment; with this, fewer than 1% of adults die.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Diagnosis and management of DKA and HHS in adults

    How was the study done?

    International consensus report based on systematic examination of literature since 2009 (ADA, EASD, JBDS, AACE, DTS)

    How many people, animals or samples were studied?

    not applicable; Adults with diabetes

    What was actually found?

    Insulin is the cornerstone; glucocorticoids worsen hyperglycaemia.

    How large was the observed effect?

    Mortality <1% with treatment

    What do the results mean in everyday life?

    Ketoacidosis needs hospital treatment with insulin.

    What are the study's limitations?

    Consensus, not trial

    What does it say about Elawady's specific claim?

    Directly contradicts C-INS-08; supports danger in C-FAST-03; contradicts C-INS-07, C-INS-10.

    Do the results apply to Germany and Europe?

    EASD and JBDS (UK) co-authored; directly applicable.

    What can explicitly not be concluded from this study?

    Outcomes of untreated DKA quantitatively.

    Scientific details →

  • Review on diabetic ketoacidosis

    Dhatariya KK et al.. Nat Rev Dis Primers 2020 · PMID 32409703 · DOI 10.1038/s41572-020-0165-1
    Narrative reviewindependent cross-checkfull text, structured risk-of-bias assessment

    DKA is an emergency that can kill; it is treated with fluids, insulin and salts, and insulin must not be stopped in type 1 diabetes even when not eating.

    Does the study support the specific claim? No · Methodological quality: moderate · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Epidemiology, pathogenesis, diagnosis and management of DKA

    How was the study done?

    Narrative expert review (Nature Reviews Disease Primers)

    How many people, animals or samples were studied?

    not applicable; Adults and children with diabetes

    What was actually found?

    DKA is diagnosed by high glucose, ketones and acid; it kills <1% when treated in rich countries but up to 26-41% where treatment is lacking; treatment is fluids, insulin and potassium, and insulin must never be stopped in type 1 diabetes even when not eating.

    How large was the observed effect?

    not applicable

    What do the results mean in everyday life?

    DKA is an emergency.

    What are the study's limitations?

    Narrative expert review without systematic methods; one author has research support from insulin makers.

    What does it say about Elawady's specific claim?

    Contradicts C-INS-08, C-INS-02, C-FAST-01, C-FAST-03.

    Do the results apply to Germany and Europe?

    International.

    What can explicitly not be concluded from this study?

    Quantitative estimates.

    Scientific details →

  • ADA guideline 2026: blood sugar goals and emergencies

    American Diabetes Association Professional Practice Committee for Diabetes* . Diabetes Care 2026 · PMID 41358894 · DOI 10.2337/dc26-S006
    Guideline / position statementindependent cross-checkfull text checked★ key study

    Most adults should aim for HbA1c below 7%, avoid low sugar, and measure ketones when at risk.

    Does the study support the specific claim? Partly · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Glycaemic goals, hypoglycaemia and hyperglycaemic crises

    How was the study done?

    Clinical practice guideline (ADA Standards of Care 2026, Section 6)

    How many people, animals or samples were studied?

    not applicable; People with diabetes

    What was actually found?

    Individual targets; do not stop basal insulin when not eating.

    How large was the observed effect?

    not applicable

    What do the results mean in everyday life?

    Moderate targets and safety rules.

    What are the study's limitations?

    US-centred; Partially read

    What does it say about Elawady's specific claim?

    Supports C-INS-04, C-INS-11; contradicts C-FAST-01, C-FAST-03, C-DIAB-02.

    Do the results apply to Germany and Europe?

    Consistent with EASD guidance.

    What can explicitly not be concluded from this study?

    Not applicable.

    Scientific details →

  • Ketoacidosis with canagliflozin

    Erondu N et al.. Diabetes Care 2015 · PMID 26203064 · DOI 10.2337/dc15-1251
    Othercited by the Tayebat archivefull text, structured risk-of-bias assessment

    Ketoacidosis was rare (7 per 10,000 patients), often with insulin deficiency or triggers.

    Does the study support the specific claim? Partly · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Incidence of DKA with canagliflozin

    How was the study done?

    Pooled safety analysis of randomised trials

    How many people, animals or samples were studied?

    17,596; Type 2 diabetes in canagliflozin program

    What was actually found?

    DKA 0.07%.

    How large was the observed effect?

    0.52-0.76 vs 0.24 per 1,000 PY

    What do the results mean in everyday life?

    Rare but real risk.

    What are the study's limitations?

    Analysed and written by manufacturer employees; only 12 cases; based on investigator reports (may miss cases).

    What does it say about Elawady's specific claim?

    Supports C-ODD-02; mixed for C-INS-08.

    Do the results apply to Germany and Europe?

    Multinational/US/UK data; transferable to EU practice.

    What can explicitly not be concluded from this study?

    Precise relative risk; that euglycaemic DKA is common (cases here had high glucose).

    Scientific details →

  • Stopping insulin is the main cause of ketoacidosis in an urban US hospital

    Musey VC et al.. Diabetes Care 1995 · PMID 7497857 · DOI 10.2337/diacare.18.4.483
    Case series / case reportindependent cross-checkabstract checked★ key study

    Two out of three ketoacidosis episodes in people with known diabetes followed stopping insulin.

    Stopping insulin is the main trigger of DKA.

    Does the study support the specific claim? No · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Find the causes of DKA.

    How was the study done?

    Interviews and records of consecutive patients.

    How many people, animals or samples were studied?

    56 DKA episodes.

    What was actually found?

    Stopping insulin caused 67% of episodes in known diabetes.

    How large was the observed effect?

    67% (95% CI about 52-79%).

    What do the results mean in everyday life?

    Stopping insulin, even when not eating, can lead to ketoacidosis.

    What are the study's limitations?

    Small, old, single centre.

    What does it say about Elawady's specific claim?

    Contradicts advice to treat or prevent DKA without insulin.

    Do the results apply to Germany and Europe?

    Mechanism universal; social reasons vary.

    What can explicitly not be concluded from this study?

    Cannot give population rates.

    Scientific details →

  • Why people with diabetes end up in hospital with ketoacidosis again and again

    Randall L et al.. Diabetes Care 2011 · PMID 21775761 · DOI 10.2337/dc11-0701
    Cross-sectional studyindependent cross-checkabstract checked★ key study

    In 164 adults admitted with ketoacidosis, stopping insulin was the main trigger in 68%.

    Insulin discontinuation caused 68% of DKA.

    Does the study support the specific claim? No · Methodological quality: moderate · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Find the drivers of recurrent DKA.

    How was the study done?

    Bedside interviews.

    How many people, animals or samples were studied?

    164 adults.

    What was actually found?

    Insulin stopped in 68%.

    How large was the observed effect?

    68% (about 60-74%).

    What do the results mean in everyday life?

    Stopping insulin is dangerous.

    What are the study's limitations?

    Single centre.

    What does it say about Elawady's specific claim?

    Contradicts insulin-free management of DKA.

    Do the results apply to Germany and Europe?

    Mechanism universal.

    What can explicitly not be concluded from this study?

    Cannot give population incidence.

    Scientific details →

  • How fast to give drip fluids to children with ketoacidosis

    Kuppermann N et al.. N Engl J Med 2018 · PMID 29897851 · DOI 10.1056/NEJMoa1716816
    Randomised controlled trialindependent cross-checkabstract checked★ key study

    Faster or slower fluids, with more or less salt, gave the same brain outcomes; brain injury was rare (0.9%).

    IV fluid therapy (with insulin) is safe across rates; no basis for withholding fluids.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Test fluid rates and types in childhood DKA.

    How was the study done?

    Randomised trial, 13 hospitals.

    How many people, animals or samples were studied?

    1,389 DKA episodes.

    What was actually found?

    No differences between fluid strategies.

    How large was the observed effect?

    Brain injury 0.9% overall.

    What do the results mean in everyday life?

    Drip fluids, given with insulin, are a safe part of DKA treatment.

    What are the study's limitations?

    Did not compare against no fluids.

    What does it say about Elawady's specific claim?

    Contradicts 'no IV fluids' in DKA.

    Do the results apply to Germany and Europe?

    Applicable to Europe.

    What can explicitly not be concluded from this study?

    Cannot say anything about steroid treatment.

    Scientific details →

  • Why young people with type 1 diabetes die in Scotland

    O'Reilly JE et al.. Diabetologia 2020 · PMID 32451572 · DOI 10.1007/s00125-020-05173-w
    Cohort studyindependent cross-checkfull text checked★ key study

    Ketoacidosis or diabetic coma caused about one in five deaths before age 50, and four in five of these deaths happened outside hospital.

    DKA/coma caused 22% of deaths in T1D under 50; 79% outside hospital.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Analyse trends and causes of early death in T1D.

    How was the study done?

    National register linkage.

    How many people, animals or samples were studied?

    27,935 people, 1138 deaths.

    What was actually found?

    DKA/coma 22% of deaths; mostly out of hospital.

    How large was the observed effect?

    SMR 3-4.

    What do the results mean in everyday life?

    Ketoacidosis remains a leading killer, especially when not treated in hospital.

    What are the study's limitations?

    Combines DKA and hypoglycaemic coma.

    What does it say about Elawady's specific claim?

    Contradicts 'DKA does not kill anyone'.

    Do the results apply to Germany and Europe?

    UK data, directly applicable.

    What can explicitly not be concluded from this study?

    Cannot separate DKA from hypoglycaemia deaths exactly.

    Scientific details →

  • Fasting, lack of water and ketoacidosis in type 1 diabetes

    Burge MR et al.. Metabolism 2001 · PMID 11229425 · DOI 10.1053/meta.2001.20194
    Otherindependent cross-checkabstract checked★ key study

    When insulin was stopped, prior fasting lowered blood sugar but made ketones and acid build up faster; lack of water raised both sugar and ketones.

    Fasting and dehydration accelerate ketosis and acidosis during insulin deficiency; fasting lowers glucose (kernel).

    Does the study support the specific claim? No · Methodological quality: moderate · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Study how fasting and dehydration influence DKA development.

    How was the study done?

    Short insulin withdrawal experiments.

    How many people, animals or samples were studied?

    25 adults with T1D.

    What was actually found?

    Fasting: lower glucose but faster ketosis; dehydration: higher glucose and faster ketosis.

    How large was the observed effect?

    Not given in abstract.

    What do the results mean in everyday life?

    Fasting can hide danger: sugar falls while acid rises.

    What are the study's limitations?

    Small study.

    What does it say about Elawady's specific claim?

    Contradicts dry fasting as DKA treatment.

    Do the results apply to Germany and Europe?

    Universal physiology.

    What can explicitly not be concluded from this study?

    Cannot give clinical outcome rates.

    Scientific details →

  • Ketoacidosis in Egyptian children with type 1 diabetes during COVID-19

    Abdou M et al.. Front Endocrinol (Lausanne) 2022 · PMID 35360079 · DOI 10.3389/fendo.2022.814991
    Cross-sectional studyindependent cross-checkabstract checked★ key study

    43% of 324 children arrived with severe ketoacidosis, often at first diagnosis; delays made it worse.

    Severe DKA common in Egyptian children; delay worsens severity.

    Does the study support the specific claim? No · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Describe DKA in Egyptian children during COVID-19.

    How was the study done?

    Hospital records, Cairo.

    How many people, animals or samples were studied?

    324 children.

    What was actually found?

    43% severe DKA; two-thirds new diagnoses.

    How large was the observed effect?

    43.2% severe DKA.

    What do the results mean in everyday life?

    Late arrival at hospital makes ketoacidosis more dangerous.

    What are the study's limitations?

    Single centre.

    What does it say about Elawady's specific claim?

    Contradicts delaying insulin and hospital care.

    Do the results apply to Germany and Europe?

    Egyptian setting.

    What can explicitly not be concluded from this study?

    Cannot give death rates.

    Scientific details →

  • US diabetes standards 2026: hospital care and ketoacidosis

    American Diabetes Association Professional Practice Committee for Diabetes. Diabetes Care 2026 · PMID 41358892 · DOI 10.2337/dc26-S016
    Guideline / position statementindependent cross-checkfull text checked★ key study

    Ketoacidosis must be treated with drip fluids, insulin and salts such as potassium; steroids raise blood sugar.

    Rec 16.16 (A): IV fluids, insulin, electrolytes; glucocorticoids cause hyperglycaemia.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Guide hospital diabetes care.

    How was the study done?

    Evidence-graded guideline.

    How many people, animals or samples were studied?

    Not applicable.

    What was actually found?

    DKA = life-threatening; fluids + insulin + electrolytes (grade A).

    How large was the observed effect?

    Not applicable.

    What do the results mean in everyday life?

    Ketoacidosis is an emergency for hospital treatment.

    What are the study's limitations?

    Guideline.

    What does it say about Elawady's specific claim?

    Contradicts C-INS-08 directly.

    Do the results apply to Germany and Europe?

    Same approach in Europe (JBDS, NICE).

    What can explicitly not be concluded from this study?

    Not applicable.

    Scientific details →

  • UK protocol for treating ketoacidosis in adults

    Dhatariya KK et al. (JBDS-IP). Diabet Med 2022 · PMID 35224769 · DOI 10.1111/dme.14788
    Guideline / position statementindependent cross-checkfull text checked★ key study

    Treatment starts within the first hour with drip fluids and an insulin infusion, plus potassium.

    IV saline and fixed-rate IV insulin within the first hour.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Guide adult DKA treatment.

    How was the study done?

    National guideline and pathway.

    How many people, animals or samples were studied?

    Not applicable.

    What was actually found?

    Saline + insulin 0.1 unit/kg/h from the first hour.

    How large was the observed effect?

    Not applicable.

    What do the results mean in everyday life?

    Ketoacidosis needs fluids and insulin straight away.

    What are the study's limitations?

    Guideline.

    What does it say about Elawady's specific claim?

    Contradicts C-INS-08.

    Do the results apply to Germany and Europe?

    UK/European practice.

    What can explicitly not be concluded from this study?

    Not applicable.

    Scientific details →

  • What happened to people with diabetes before insulin existed

    Mazur A. Nutr J 2011 · PMID 21396115 · DOI 10.1186/1475-2891-10-23
    Narrative reviewindependent cross-checkfull text checked★ key study

    Before 1922, children with diabetes usually died of diabetic coma within months to a few years, even on strict fasting diets; some starved to death.

    Diabetic coma (ketoacidosis) was 'always the cause of death' in Joslin's child patients; fasting did not prevent death.

    Does the study support the specific claim? No · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    To explain why fasting diets were used for diabetes before insulin and how patients fared.

    How was the study done?

    Historical analysis of published case series and textbooks.

    How many people, animals or samples were studied?

    Patients of Allen (76 published cases) and Joslin, 1914-1922.

    What was actually found?

    Most children died of coma within months to years; 43% of Allen's cases were dead by 1917; four died of starvation; diabetes was not cured.

    How large was the observed effect?

    43% mortality within a few years (Allen's series).

    What do the results mean in everyday life?

    Diet and fasting alone cannot keep insulin-deficient diabetes alive; insulin changed this.

    What are the study's limitations?

    Historical, uncontrolled data; diabetes types not distinguished.

    What does it say about Elawady's specific claim?

    Contradicts claims that diet can replace insulin or that ketoacidosis does not kill.

    Do the results apply to Germany and Europe?

    Universal biology.

    What can explicitly not be concluded from this study?

    Cannot give exact survival curves or separate type 1 from type 2 cases.

    Scientific details →

  • NICE guideline NG17: Type 1 diabetes in adults: diagnosis and management

    National Institute for Health and Care Excellence (NICE). NICE guideline 2015
    Guideline / position statementindependent cross-checkfull text checked★ key study

    UK guideline: insulin is standard for all adults with T1D; DKA treated with IV saline and IV insulin.

    DKA: isotonic saline and IV insulin infusion.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    National guidance.

    How was the study done?

    Evidence-based guideline.

    How many people, animals or samples were studied?

    Not applicable.

    What was actually found?

    Rec 1.7.1: offer multiple daily injection basal-bolus insulin regimens as the regimen of choice for all adults with T1D. Rec 1.10.1: consider ketone monitoring as part of sick-day rules. Recs 1.10.5-1.10.7: use isotonic saline for fluid replacement in DKA and give intravenous insulin by infusion. Misdiagnosis of T1D as T2D 'could lead to the person not receiving insulin treatment and a subsequent risk of diabetic ketoacidosis'.

    How large was the observed effect?

    Not applicable.

    What do the results mean in everyday life?

    UK guideline: insulin is standard for all adults with T1D; DKA treated with IV saline and IV insulin.

    What are the study's limitations?

    Guideline.

    What does it say about Elawady's specific claim?

    Contradicts insulin-free management.

    Do the results apply to Germany and Europe?

    UK.

    What can explicitly not be concluded from this study?

    Not applicable.

    Scientific details →

  • NICE guideline NG18: Diabetes (type 1 and type 2) in children and young people: diagnosis and management

    National Institute for Health and Care Excellence (NICE). NICE guideline 2015
    Guideline / position statementindependent cross-checkfull text checked★ key study

    UK paediatric guideline: insulin from diagnosis; DKA needs urgent hospital IV fluids and insulin; honeymoon phase is temporary.

    DKA is serious; IV fluids and IV insulin.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    National guidance.

    How was the study done?

    Evidence-based guideline.

    How many people, animals or samples were studied?

    Not applicable.

    What was actually found?

    Rec 1.2.18: offer children and young people with T1D a multiple daily injection basal-bolus insulin regimen from diagnosis. Recs 1.2.82-1.2.83: sick-day rules including blood ketone monitoring; offer blood ketone strips and meter. Rec 1.4.3: children taking insulin may develop DKA with normal blood glucose. Rec 1.4.6: explain that DKA is serious and needs urgent hospital assessment. Rec 1.4.21: treat DKA with intravenous fluids and intravenous insulin if the child is not alert, nauseated/vomiting or clinically dehydrated. Rec 1.2.25: explain the partial remission ('honeymoon') phase with low insulin needs.

    How large was the observed effect?

    Not applicable.

    What do the results mean in everyday life?

    UK paediatric guideline: insulin from diagnosis; DKA needs urgent hospital IV fluids and insulin; honeymoon phase is temporary.

    What are the study's limitations?

    Guideline.

    What does it say about Elawady's specific claim?

    Contradicts insulin-free management.

    Do the results apply to Germany and Europe?

    UK.

    What can explicitly not be concluded from this study?

    Not applicable.

    Scientific details →

Studies with mixed or unclear results (2)

  • A small Chinese trial of dexamethasone in ketoacidosis with pancreatitis

    Zhang J et al.. Medicine (Baltimore) 2023 · PMID 37832092 · DOI 10.1097/MD.0000000000035320
    Randomised controlled trialindependent cross-checkfull text checked★ key study

    The trial reported better results with dexamethasone, but its numbers are physiologically implausible and it did not replace insulin and fluids.

    Strongest 'supporting' item found for steroids: tests dexamethasone as add-on in DKA with pancreatitis, not as replacement for insulin/fluids; data implausible.

    Does the study support the specific claim? No · Methodological quality: very low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Test dexamethasone in DKA with acute pancreatitis.

    How was the study done?

    Single-centre randomised trial.

    How many people, animals or samples were studied?

    106 patients.

    What was actually found?

    Reported better labs and fewer adverse events with dexamethasone.

    How large was the observed effect?

    Glucose 9.5 vs 14.6 mmol/L (reported).

    What do the results mean in everyday life?

    This does not show that cortisone can treat ketoacidosis.

    What are the study's limitations?

    Implausible pH data; unclear methods; no registration.

    What does it say about Elawady's specific claim?

    Cannot support steroid-only treatment of DKA.

    Do the results apply to Germany and Europe?

    Not applicable.

    What can explicitly not be concluded from this study?

    Cannot be used to change DKA treatment.

    Scientific details →

  • Children with ketoacidosis in Middle Eastern intensive care units

    Ali NM et al.. Cureus 2026 · PMID 41859577 · DOI 10.7759/cureus.103735
    Meta-analysisindependent cross-checkabstract checked★ key study

    More than a third had severe ketoacidosis, but none died with intensive-care treatment.

    Treated DKA has very low mortality (kernel of 'nobody dies'), but only because of insulin, fluids and ICU care.

    Does the study support the specific claim? Partly · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Summarise paediatric DKA outcomes in Middle Eastern ICUs.

    How was the study done?

    Systematic review of 6 studies.

    How many people, animals or samples were studied?

    919 children (Saudi Arabia, Egypt, Iran).

    What was actually found?

    37% severe; 0 deaths with ICU care; frequent kidney injury.

    How large was the observed effect?

    Mortality 0% (upper bound about 0.4%).

    What do the results mean in everyday life?

    Ketoacidosis is survivable when treated promptly in hospital.

    What are the study's limitations?

    Small, low-quality evidence.

    What does it say about Elawady's specific claim?

    Partly explains 'I never saw anyone die' but only for treated DKA.

    Do the results apply to Germany and Europe?

    Similar to European results.

    What can explicitly not be concluded from this study?

    Cannot show what happens without treatment.

    Scientific details →

Regional context

Germany / EU

German and European emergency practice follows the same consensus (EASD and JBDS are co-authors of I-INS-07).

Egypt

DKA is a common cause of emergency admission of children and young adults with diabetes in Egypt and the region; delayed treatment increases mortality. Advice to avoid hospitals and insulin is particularly dangerous where access to care is already delayed.

What applies in my country?

General scientific assessment

False DKA is deadly without treatment and is mainly caused by missing insulin; insulin, fluids and potassium save lives, while cortisone and dry fasting make it worse.

This statement concerns biological or medical relationships. The scientific assessment above applies regardless of the country; country-specific food data do not change it.

References

  1. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report.. Umpierrez GE et al.. Diabetes Care 2024 · PMID 39052901 · DOI 10.2337/dci24-0032
  2. Diabetic ketoacidosis.. Dhatariya KK et al.. Nat Rev Dis Primers 2020 · PMID 32409703 · DOI 10.1038/s41572-020-0165-1
  3. 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026.. American Diabetes Association Professional Practice Committee for Diabetes* . Diabetes Care 2026 · PMID 41358894 · DOI 10.2337/dc26-S006
  4. Diabetic Ketoacidosis and Related Events in the Canagliflozin Type 2 Diabetes Clinical Program.. Erondu N et al.. Diabetes Care 2015 · PMID 26203064 · DOI 10.2337/dc15-1251
  5. Diabetes in urban African-Americans. I. Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis.. Musey VC et al.. Diabetes Care 1995 · PMID 7497857 · DOI 10.2337/diacare.18.4.483
  6. Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors.. Randall L et al.. Diabetes Care 2011 · PMID 21775761 · DOI 10.2337/dc11-0701
  7. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis.. Kuppermann N et al.. N Engl J Med 2018 · PMID 29897851 · DOI 10.1056/NEJMoa1716816
  8. Time trends in deaths before age 50 years in people with type 1 diabetes: a nationwide analysis from Scotland 2004-2017.. O'Reilly JE et al.. Diabetologia 2020 · PMID 32451572 · DOI 10.1007/s00125-020-05173-w
  9. Differential effects of fasting and dehydration in the pathogenesis of diabetic ketoacidosis.. Burge MR et al.. Metabolism 2001 · PMID 11229425 · DOI 10.1053/meta.2001.20194
  10. Presentations, Complications, and Challenges Encountered During Management of Type 1 Diabetes in Egyptian Children During COVID-19 Pandemic: A Single-Center Experience.. Abdou M et al.. Front Endocrinol (Lausanne) 2022 · PMID 35360079 · DOI 10.3389/fendo.2022.814991
  11. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2026.. American Diabetes Association Professional Practice Committee for Diabetes. Diabetes Care 2026 · PMID 41358892 · DOI 10.2337/dc26-S016
  12. The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care.. Dhatariya KK et al. (JBDS-IP). Diabet Med 2022 · PMID 35224769 · DOI 10.1111/dme.14788
  13. Why were "starvation diets" promoted for diabetes in the pre-insulin period?. Mazur A. Nutr J 2011 · PMID 21396115 · DOI 10.1186/1475-2891-10-23
  14. NICE guideline NG17: Type 1 diabetes in adults: diagnosis and management. National Institute for Health and Care Excellence (NICE). NICE guideline 2015
  15. NICE guideline NG18: Diabetes (type 1 and type 2) in children and young people: diagnosis and management. National Institute for Health and Care Excellence (NICE). NICE guideline 2015
  16. Clinical efficacy of dexamethasone on diabetic ketoacidosis complicated with acute pancreatitis: A randomized controlled study.. Zhang J et al.. Medicine (Baltimore) 2023 · PMID 37832092 · DOI 10.1097/MD.0000000000035320
  17. Prevalence, Clinical Profile, and Outcomes of Diabetic Ketoacidosis (DKA) in Pediatric ICU Patients in the Middle East: A Systematic Review and Meta-Analysis.. Ali NM et al.. Cureus 2026 · PMID 41859577 · DOI 10.7759/cureus.103735

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