Which metabolic state leads to diabetic ketoacidosis?

• A. Hyperinsulinemia with decreased lipolysis
• B. Insulin deficiency with increased lipolysis and ketogenesis
• C. Increased glucose oxidation
• D. Hypoglycemia

Answer: (B)

Diabetic ketoacidosis occurs when insulin activity is very low, allowing unchecked lipolysis and ketogenesis. Without insulin, hormone-sensitive lipase in adipose tissue is activated, releasing free fatty acids into the bloodstream. The liver then converts those fatty acids into ketone bodies, leading to metabolic acidosis and hyperglycemia driven by increased glucose production and reduced utilization. The presence of low insulin with elevated counterregulatory hormones like glucagon and epinephrine creates this catabolic state with markedly increased lipolysis and ketogenesis, which best explains DKA. Hyperinsulinemia would suppress lipolysis and ketogenesis, increased glucose oxidation would favor using glucose rather than producing ketones, and hypoglycemia is not characteristic of DKA.