When To Worry About Ketones

When To Worry About Ketones?

“Your blood sugar is over 250. We’ll have to test for ketones, just to make sure you’re not spilling any.”

The nurse stuck a label featuring my name and date of birth onto a plastic cup. “The bathroom is down the hall and to the right,” she said. By now, I was familiar with the drill, having experienced it a handful of times in the past: Provide urine sample to endocrinologist and keep my fingers crossed that it’s negative. Fortunately, it was—no ketones spilled. Though we often toss the word ketones around when we talk about diabetes, there tends to be confusion about what ketones are and when they’re dangerous.


What are ketones?

Ketone bodies are produced by the liver and are byproducts of fat metabolism. They occur when muscles in the body (which normally uses glucose as fuel) begin to use fat instead. This can happen when a person restricts carbohydrates (i.e., following a ketogenic diet—see below), eats too little, or feels ill. Simply put, ketones are markers of fat burning in the body.

People with diabetes need to be concerned about ketones, though, because they can be a sign of a life-threatening condition. The presence of ketones makes the blood acidic and can result in an illness known as diabetic ketoacidosis (DKA), which occurs when blood sugar levels are very high. DKA can be caused by not getting enough insulin, and it may occur prior to a diagnosis of type one diabetes.

DKA symptoms of concern include a dry mouth, blood sugar levels greater than 240 mg/dL, strong thirst, and frequent urination. Without treatment, these symptoms can worsen into confusion, extreme fatigue, flushed skin, fruity-smelling breath, nausea, vomiting, stomach pain, and difficulty breathing.

The most serious effects include swelling in the brain, loss of consciousness, diabetic coma, or even death. This is why it’s essential for individuals with type 1 diabetes to monitor ketones when indicated.

It’s easy to test for ketones. Most pharmacies carry tests that may be purchased without a prescription. Tests are most commonly conducted using a urine sample that will indicate the presence of ketones in trace, moderate, or large quantities. Test results can also be negative, meaning there are no ketones in the urine. Blood test strips and meters may also be used to check for ketones. Abbott makes a dual glucose and ketone testing meter and urine strips are available for purchase at stores like Walgreens and CVS.

Generally speaking, individuals with type 1 diabetes should conduct a ketones test when blood sugar is above 250 mg/dL or in case of illness. It’s a good idea to check anytime an unexplained high blood sugar occurs, or even when nausea or other sickness is present, in spite of fine blood sugar levels.

People with type one diabetes should consider devising a protocol to follow with an endocrinologist or other physician in case ketones are spilled. Usually, it’s recommended to drink plenty of water to flush the ketones from the body. It’s also wise to monitor blood sugar by testing every few hours and taking additional ketones tests if necessary. It’s best to avoid exercise until blood sugar is back to a normal level. If these steps are not followed, the risk for DKA is greater.


Nutritional Ketosis vs DKA

You may have heard about the ketogenic diet.  A ketogenic diet consists of high-fat, adequate protein, and very low- or no-carbohydrate meals. This forces the body to burn fat for fuel instead of carbohydrates, and can result in ketosis. 

Ketosis is not to be confused with DKA.  Nutritional ketosis, “is a state, achieved through significant reduction of carbohydrate intake (typically to less than 50 grams per day), where the body changes from relying on glycogen as its main source of energy to relying on fat. Specifically, the brain shifts from being primarily dependent on glucose, to being primarily dependent on beta-hydroxybutyrate. This has nothing to do with what a diabetic patient is experiencing in DKA, but does illustrate how poorly informed and quick to react the medical community is. DKA and nutritional ketosis (or keto-adaptation) have as much in common as a house fire and a fireplace. the level of ketones in the blood can range from normal to very high.”


Is a ketogenic diet safe for people with diabetes?

A ketogenic diet may help lower blood sugar levels and reduce use of diabetes medication, however, it’s important for people with diabetes to speak with a doctor before deciding to follow a ketogenic diet, and it should always be done under the guidance of a healthcare provider.

For more information on ketones and a ketogenic diet, speak with your endocrinologist or diabetes educator.

Molly Johannes
Molly Johannes

Molly Johannes was diagnosed with type 1 diabetes in 1997 at the age of four. She controls her diabetes with an OmniPod insulin pump, Dexcom continuous glucose monitor, and daily exercise. Molly graduated cum laude from the University of Massachusetts Amherst in December 2014 with a degree in English. Currently, she works fulltime as an associate editor for a financial company. In her spare time, Molly enjoys spending time with her loved ones, reading books, watching movies, and playing games. She’s an avid fan of Disney, dark chocolate, wine, Harry Potter, and fun times. While Molly does not know a life without diabetes, she is determined to defy the daily obstacles the disease presents.

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Sharon Harris
Sharon Harris
7 years ago

My grandson Tony is now 6. He was diagnosed w T1 at 2 1/2 & has worn a pump since 6 weeks after diagnosis. As time went on he’s shown dif personality traits along w not meeting all milestones. We would try to correlate outbursts with his numbers. We found no correlation. After vigorous testing he was found to have ADHD . He takes Adderal in the morning, with a booster after lunch in conjunction with a mood stabilizer every day. This has led to great problems with his T1. We often have a vicious circle of not eating &… Read more »

6 years ago
Reply to  Sharon Harris

I’m sorry to hear that, I have diabetes and almost died but since after I changed my diet; my doctor slowly removed me from insulin and medications. I’m on very low carb but high fat and moderate protein diet called Keto. I know lots of people that are cured from diabetes of any type and I would suggest checking it out especially he is that young and he has all his life to live happily without no worries.

6 years ago
Reply to  CLements

Type 1 can’t be cured by any means of a diet. T1 make no insulin. T2, can often be “cured” by modifying diet & lifestyle. It never really gets cured, but T2 can easily be managed unless someone has go so far they burn out the pancreas.

Sue Malone
Sue Malone
7 years ago

This article is very good, but I wish it also explained ‘starvation keytones’ as Rick Phillips mentioned a few days ago.

6 years ago
Reply to  Sue Malone

He didn’t speak about starvation keytone; it speaks about fasting for 8 to 16 hours then eat for 8 hours. ( when you sleeping = 8 hours minimum-> you’re not eating so you already on fasting mode then skip breakfast = 16 hours) instead of going back to eat a chunk of fast food and carb food, eat healthy like a chicken salad or beef with spinach. The result will WOW you. Take care of your body, you only got one.

Rick Phillips
rick phillips
7 years ago

This past fall, I tested positive for ketones. I seldom have ever had that happen in 42 years. Mostly because I do not test very often. So when it happened, I called my doctor and she asked about illness and eating. I told her in fact, I was very ill and not eating. She said ahh no issue then, “look you not eating so it will correct when you start”. It certainly did.

Who knew? Live and learn.

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