Diabetic ketoacidosis knowledge in type 1 diabetes: a Brazilian perspective

Pisani, Renan Bruno Faria; Gonzalez, Virgínia Valiate; Witte, Bruna Rambo; Gonçalves, Taylane Guimarães; Santiago, Lohane Alves; Moreno, Adalgiza Mafra; Siqueira, Rodrigo de Azeredo

doi:10.20945/2359-4292-2025-0036

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original • Arch. Endocrinol. Metab. 69 (04) • 2025 • https://doi.org/10.20945/2359-4292-2025-0036 linkcopy

Diabetic ketoacidosis knowledge in type 1 diabetes: a Brazilian perspective

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: To evaluate the factors associated with knowledge of diabetic ketoacidosis among individuals with type 1 diabetes mellitus and to analyze how sociodemographic, clinical, and healthcare access variables influence understanding of the condition’s prevention and management.

Methods: This cross-sectional study was conducted with 465 individuals with type 1 diabetes mellitus via an online questionnaire. The instrument included sociodemographic and clinical variables and a 13-item test assessing participant’s knowledge of diabetic ketoacidosis. Data analysis employed the Kruskal-Wallis test and the Dwass-Steel-Critchlow-Fligner multiple comparisons to identify variability scores.

Results: The median score was 6.0 (on a scale of zero to 13). The lowest accuracy rates were observed regarding ketonemia thresholds (18.5%) and specific warning signs of diabetic ketoacidosis (26.0%). Participants with prior knowledge of diabetic ketoacidosis scored higher (median 6) than those unfamiliar with the term (median 2). Individuals with glycated hemoglobin levels between 4 and 6% achieved higher scores (median = 6), as did those who received medical guidance (median = 6) compared to those who did not (median = 3). The use of an artificial pancreas was associated with the highest scores.

Conclusion: Prior knowledge of diabetic ketoacidosis, access to insulin pumps, medical guidance, and better glycemic control were associated with a greater understanding of diabetic ketoacidosis. These findings reinforce the need for educational interventions and equitable access to healthcare technologies to improve disease management and reduce diabetic ketoacidosis-related complications.

Keywords
Diabetes mellitus; type 1; Diabetic ketoacidosis; Primary prevention; Patient education as topic

Variables	%
Female sex	80
Level of education
Up to high school	20.6
Undergraduate degree	75
Formal training in the health field	25.6
Monthly income
3-6MWs*	31
1-3MWs	28.4
> 10 MWs	12.3
History of DKA episode
At least one	54.6
Unaware of previous episode	15.3
Possess a ketone meter at home	22.2
Last HbA1c ≥ 8% or did not know	35
Uses insulin pump as primary treatment	27.9
Received medical guidance during consultations	52
Uses private healthcare services	52.7

Item	Correct answer	%
What value is considered normal ketonemia (ketones in the blood)?	0.6 mmol/L	18.5
Which of the following situations is called a “sick day” for someone with type 1 diabetes?	Vomiting or nausea and inability to eat	42.2
Ketones are…	All of the above	49.9
What is true about ketones?	They occur when insulin is insufficient in the body	58.5
Why is DKA classified a medical emergency?	Ketones acidify the blood and impair organ function	55.7
What are the symptoms of DKA?	Vomiting, stomach pain, and difficulty breathing	26.0
When ill, how often should someone with diabetes test blood sugar levels?	Every 2-3 hours until blood sugar values fall below 300	28.2
What is NOT good to eat or drink when feeling nauseous and blood sugar levels are low?	Chocolate milk	48.4
Under what circumstances should insulin administration be discontinued?	Never	58.1
All of the following are indications for ketone testing EXCEPT:	A single blood sugar reading > 300 mg/dL	23.2
When using an insulin pump, what should someone with diabetes do FIRST when ketones and blood sugar are above 300 mg/dL in the morning?	Administer a correction dose with a pen or syringe and replace the pump cannula site	30.1
What is the initial intervention when morning blood sugar is 300 mg/dL, ketone levels are low, and nausea is present?	Administer the morning insulin and reassess glucose and ketones after 2 hours	73.3
A person with diabetes should call or go to the emergency room if…	All of the above	66.5

Variable	χ²	dl	p-value	ɛ²
Monthly income	14.7	5	0.01	0.0318
Healthcare system used	8.03	1	< 0.01	0.0173
Treatment adopted	61.9	3	< 0.01	0.133
Knowledge of DKA	77.1	2	< 0.01	0.166
Guidance received	81.3	4	< 0.01	0.175
Method of measuring ketones at home	36.2	2	< 0.01	0.0779
HbA1c levels during testing	30.5	4	< 0.01	0.0656

Variable	Comparison	M1	M2	W	p-value	MD (%)
Monthly income	6-9 MW versus up to 1 MW	6.0	5.0	4.381	0.02	+ 32.5
Healthcare system used	Private versus public	6.0	5.0	-4.01	< 0.01	+ 12.6
Treatment adopted	Pancreas pump versus scheme	7.0	4.0	-9.73	< 0.	+ 62.9
Knowledge of DKA	Knows versus does not know	6.0	2.0	7.71	< 0.01	+ 206.7
Medical guidance received	During consultations versus never sought	6.0	3.0	12.28	< 0.01	+ 106.3
Method of measuring ketones at home	Blood meter versus none	7.0	5.0	8.49	< 0.01	+ 33.0
HbA1c levels during testing	4-6% versus does not know	6.0	4.0	-4.84	< 0.01	+ 94.1

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Sociedade Brasileira de Endocrinologia e Metabologia Rua Botucatu, 572 - Conjuntos 81/83, CEP: 04023-061 , Tel: +55 (11) 5575-0311 / +55 (11) 9 9768-6933 - São Paulo - SP - Brazil
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[TFN1] ^*
The Brazilian MW stands at R$ 1,518.00 per month, which is approximately US$ 303.60.

[2] MW: minimum wage; DKA: diabetic ketoacidosis; HbA1c: glycated hemoglobin.

3.1 - What value is considered normal for ketonemia (ketones in the blood)? 0.3	mmol/l
0.4	mmol/l
0.6	mmol/l
1.5	mmol/l
3.0	mmol/l