- What are ketones?
- What are the causes of ketones in the urine?
- Who should test for urine ketones?
- Are urine ketone test strips reliable?
- What about diabetes and ketones?
- Ketones — Urine
- Symptoms of ketoacidosis
- What causes ketonuria in diabetes?
- When to check urine for ketones
- Managing ketones
- Ketones in Urine: All You Need to Know
- Ketosis and Ketone Metabolism Fundamentals
- Why You Should Test for Urine Ketones
- Ketosis vs. Diabetic Ketoacidosis
- How to Test for Urine Ketones
- Other Ways to Measure Ketones
- Is Urine Ketone Testing for You?
- 16. Get into optimal ketosis
- Video course
- Maximum effect from an LCHF diet
- Measuring ketones
- Ketones in urine
- My personal experience
- How to achieve optimal ketosis
- If it doesn’t work
- Try it
- Blood and Urine Ketones
- WHAT YOU NEED TO KNOW:
- Why do I need to test for ketones?
- When do I need to test for ketones?
- How do I test for urine ketones?
- How do I test for blood ketones?
- How are moderate or large amounts of ketones treated?
- What else can cause ketones in my blood or urine?
- How can I prevent ketones in my blood or urine?
- Call 911 for any of the following:
- When should I seek immediate care?
- When should I contact my healthcare provider?
- Further information
- Ketones in Urine: When and Why to Test for Them and What They Mean
- What Happens During a Ketones in Urine Test?
- When Should I Have a Test for Ketones in Urine?
- What Does an Abnormal Result for a Ketones in Urine Test Mean?
- When Can Ketones in Urine Be a Sign of Ketoacidosis?
- Ketones — The 6 Must-Knows
- 1 – What are ketones?
- 2 – Why can ketones be dangerous?
- 3 – When and how should you check for ketones?
- 4 – Can you get ketones with a high blood sugar?
- 5 – Can you get ketones with a normal or low blood sugar?
- 6 – What should you do if you have ketones?
- Kyla Schmieg, BSN, RN
- Signs of DKA and When to Test for Ketones
- Warning Signs of DKA
- How to Check Urine for Ketones
- What to Do If Ketones Are Present
- Being Prepared When Contacting a Health Provider
- When to Call the Doctor
- When to Go to the Emergency Department
- Checking for Ketones
- Medication Management
What are ketones?
Ketones are produced when the body burns fat for energy. Normally, your body gets the energy it needs from carbohydrate in your diet. But stored fat is broken down and ketones are made if your diet does not contain enough carbohydrate to supply the body with sugar (glucose) for energy or if your body can’t use blood sugar (glucose) properly.
Ketones are usually formed in the liver and are broken down so that very small amounts of ketones appear in the urine. However, when carbohydrates are unavailable (for example, in starvation) or can’t to be used as an energy source (for example, in diabetes), fat becomes the main source of energy and large amounts of ketones are made. Therefore, higher levels of ketones in the urine indicate that the body is using fat as the major source of energy.
High levels of ketones in your body can cause tummy (abdominal) pain, feeling sick (nausea), being sick (vomiting) and diarrhoea. The ketones that most often appear in the urine when fats are burned for energy are called acetoacetate and beta-hydroxybutyric acid.
What are the causes of ketones in the urine?
The causes of high levels of ketones and therefore ketones in your urine include:
- Poorly controlled diabetes.
- Diabetic ketoacidosis (DKA).
- Starvation: not eating for prolonged periods (for example, 12 to 18 hours).
- Anorexia nervosa.
- Bulimia nervosa.
- Alcohol dependency.
- Ketogenic diet (high-fat, low-carbohydrate diet). This can cause an increase in body ketones but much less than DKA and not usually harmful to the body. Ketogenic diets have been used as a treatment for epilepsy.
Who should test for urine ketones?
Ketones can be tested using a blood test or a urine test. The urine test for ketones is performed using test strips. There are several reasons why a ketone test may be needed:
- It is a convenient way to monitor diabetes in addition to monitoring blood sugar (glucose) levels, especially when the glucose levels are high and there is a risk of DKA.
- It is also useful for people on a high-fat or low-carbohydrate diet to monitor ketone levels.
Ketone testing is also used for someone who cannot eat due to fasting or to eating disorders like anorexia. Pregnant women with diabetes should also be monitored with a ketone test.
Are urine ketone test strips reliable?
Occasionally the urine ketone strips are positive but there aren’t any ketones in the urine. The causes of this include:
- If you are taking some medicines – for example, levodopa, sodium valproate.
- If you are taking vitamin C.
- If your body is very dry (dehydration).
One of the main problems with urine testing for ketones is that there is a delay in the urine becoming positive to ketones. You may have a sudden increase in the level of ketones in your blood but there will be a delay in detecting the high level of ketones in your urine.
Equally your urine may also be positive to ketones because ketones have passed into your urine over the previous few hours, even though your blood ketone levels have already started to fall.
On other occasions the urine ketone strips may be negative when there are actually ketones in the urine. Most urine testing kits detect acetoacetate, not the main ketone, which is beta-hydroxybutyrate. It is possible for the test to be negative with high levels of beta-hydroxybutyrate.
What about diabetes and ketones?
Severe insulin deficiency causes an increase in blood sugar (glucose) levels (hyperglycaemia) and a very high level of ketones in the blood and urine (ketoacidosis). Urine is tested for ketones as part of monitoring of type 1 diabetes mellitus.
Monitoring of ketones is important in all people with diabetes:
- When they feel unwell. See the separate leaflet called Advice for People with Diabetes when Unwell for more information.
- When the diet is low in carbohydrates or they are doing a lot of exercise.
- In pregnant women with diabetes and in gestational diabetes.
- When blood sugar levels are high (over 15 mmol/L).
If you have diabetes and there is a high level of ketones in your urine then you should contact your GP or diabetes team immediately. If you feel very unwell or a urine ketone test result is more than 2+ then there’s a high chance you have DKA, requiring emergency medical care and treatment in hospital immediately.
DKA is a serious problem that can occur in people with diabetes if their body starts to run out of insulin. This causes ketones to build up in the body, which can be life-threatening if not spotted and treated quickly. DKA mainly affects people with type 1 diabetes but can sometimes occur in people with type 2 diabetes.
If you have diabetes, it’s important to be aware of the risk and know what to do if DKA occurs. Symptoms of DKA include:
- Needing to pass more urine than usual.
- Feeling very thirsty.
- Feeling sick (nausea) and being sick (vomiting).
- Tummy (abdominal) pain.
- Your breath smelling fruity (like pear drop sweets).
- Your breathing becoming fast and deep.
- Feeling very tired and confused and as though you may collapse.
Ketones — Urine
Ketones build up when the body needs to break down fats and fatty acids to use as fuel. This is most likely to occur when the body does not get enough sugar or carbohydrates.
A urine test can be done to check the level of ketones in your body.
Ketone bodies – urine; Urine ketones
How the test is performed
The test requires a clean catch urine sample.
To obtain a clean catch sample, men or boys should clean the head of the penis. Women or girls need to wash the area between the lips of the vagina with soapy water and rinse well.
As you start to urinate, allow a small amount to fall into the toilet bowl to clear the urethra of contaminants. Then, put a clean container under your urine stream and catch 1 to 2 ounces of urine. Remove the container from the urine stream. Cap and mark the container and give it to the health care provider or assistant.
For infants, thoroughly wash the area around the urethra. Open a urine collection bag (a plastic bag with an adhesive paper on one end), and place it on the infant. For boys, the entire penis can be placed in the bag and the adhesive attached to the skin. For girls, the bag is placed over the labia. Diaper as usual over the secured bag.
This procedure may take a couple of attempts — lively infants can displace the bag. The infant should be checked frequently and the bag changed after the infant has urinated into the bag. The urine is drained into the container for transport to the laboratory.
Urine ketones are usually measured as a “spot test” using a dipstick coated with chemicals that react with ketone bodies. The dipstick is dipped in the urine sample, and a color change indicates the presence of ketones.
How to prepare for the test
You may have to eat a special diet, and you should stop taking any drugs that may affect the test.
If the collection is being taken from an infant, you may need extra collection bags.
How the test will feel
The test involves only normal urination, and there is no discomfort.
Why the test is performed
Ketone testing is most often done if you have type 1 diabetes and:
- Your blood sugar is higher than 240 mg/dL
- You have an illness such as pneumonia, heart attack, or stroke
- Nausea or vomiting occur
- You are pregnant
A negative test result is normal.
Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or test different samples. Talk to your doctor about the meaning of your specific test results.
What abnormal results mean
An abnormal result means you have ketones in your urine. The results are usually listed as small, moderate, or large as follows:
- Small: ; 20 mg/dL
- Moderate: 30 – 40 mg/dL
- Large: > 80 mg/dL
This may be due to diabetic ketoacidosis, a problem that occurs in people with Type 1 diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is little or no insulin. Fat is used for fuel instead.
An abnormal result may also be due to:
- Abnormal food or nutrition intake due to:
- High protein or low carbohydrate diets
- Vomiting over a long period of time
- Disorders of increased metabolism
- Acute or severe illness
- Nursing a baby (lactation)
What the risks are
There are no risks.
Special diets can change test results. For example, a diet low in carbohydrates and high in protein and fat can raise ketone levels in the blood, which can then enter the urine.
Some drugs, including glucocorticoids, can cause false positive measurements.
Review Date: 11/7/2011
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only — they do not constitute endorsements of those other sites. Copyright ©2003 A.D.A.M., Inc., as modified by University of California San Francisco. Any duplication or distribution of the information contained herein is strictly prohibited.
Information developed by A.D.A.M., Inc. regarding tests and test results may not directly correspond with information provided by UCSF Medical Center. Please discuss with your doctor any questions or concerns you may have.
What are ketones? How do they get into your urine, and why should you care?
Ketones are everywhere in nature and in our bodies. We couldn’t live without them. Proteins and fats are largely made of them.
Our bodies normally run on glucose we get from food. When bodies don’t have glucose because of starvation or illness or can’t use glucose because of a lack of insulin, they start burning fat for energy. The fat breaks down into ketones, with these ketones pouring into the blood and some passing into the urine. This release of ketones into the urine is called “ketonuria” (pronounced KEY-tone-ER-ee-uh).
The buildup of ketones in the body is called “ketosis” (key-TOE-sis.) If your glucose is close to normal and you are well-hydrated, ketosis is no problem. Many low-carb diets create ketosis on purpose, as it can be an indicator of fat burning and weight loss.
However, ketones are acids. If you have too many ketones, they can make your blood too acidic. This can lead to a very dangerous and often life-threatening situation called diabetic ketoacidosis (DKA).
Remember, ketones appear in blood and urine because the body is breaking down fats for energy. It should only happen if glucose is low. If you have above-normal glucose and also have ketones in the urine, something is seriously wrong.
Symptoms of ketoacidosis
Most of the classic symptoms of diabetes are symptoms of ketoacidosis:
• Excessive thirst
• Dry mouth
• Frequent urination
• Fruity-smelling breath (ketones have a fruity smell)
Later, more dangerous symptoms include:
• Nausea and vomiting
• Abdominal pain
• Weakness and fatigue
• Shortness of breath
What causes ketonuria in diabetes?
In people with Type 1, ketonuria means they’re not getting enough insulin. Insulin keeps fat from breaking down, so ketones should not form if you’re taking enough insulin.
People with Type 2 can develop ketonuria if they have severe infections, major trauma, or stress. These conditions raise the need for insulin. People can have internal infections without being aware of them.
A study in Chicago evaluated 138 consecutive admissions for DKA at a large academic center. They found that 21.7 percent of those admitted had Type 2 diabetes. Almost half of the people admitted had an identifiable infection. In a Swedish study, 32 percent of DKA cases were people with Type 2.
A subset of people with Type 2 have what is called ketosis-prone diabetes or KPD. In KPD, the pancreas occasionally shuts down insulin production for unknown reasons, making a person subject to DKA.
In Type 1, a common cause of ketonuria is insulin pump failure. A person thinks they are getting insulin, but they’re not. The line has been blocked or the machine is malfunctioning. Without insulin, fat starts breaking down into ketones.
The University of California at San Francisco diabetes education program warns, “There is a higher risk for developing ketones on pump therapy. This is because long-acting insulins are not used, and rapid-acting insulin is delivered in extremely small amounts. If this basal insulin delivery is interrupted for more than an hour, check your blood sugar and ketones.”
Sickness raises the risk of DKA in all people with diabetes, but especially Type 1. Illness often tends to raise the need for insulin but frequently decreases a person’s appetite, resulting in less food intake than usual. Because they’re eating less, some people may decrease their insulin dosages, when they really may need increased amounts of insulin.
When to check urine for ketones
Urine ketone test strips are quite cheap, and you should always have some available. (The Nova Max Plus meter can test the blood for ketones.) Test whenever:
• There is an unexplained rise in your blood sugar, or you have a blood sugar level of more than 250 mg/dl (13.9 mmol/l) for two tests in a row;
• You have symptoms of nausea, vomiting, confusion, or severe fatigue;
• You have any symptoms of ketoacidosis such as increased thirst and urination, stomachache, or dry mouth;
• If you have a flu, infection, or injury;
• When you’re planning to exercise, but your blood sugar is over 250 mg/dl.
• If you are pregnant, check for ketones each morning before breakfast or whenever your glucose goes over 250 mg/dl.
If you have ketones in your urine (or blood):
• Have a sick-day care plan worked out with your doctor. Keep in touch with your health-care providers if you have ketonuria and high glucose. You may need to be checked for an underlying cause or may require additional insulin to bring blood glucose levels down.
• Call your doctor if you’re vomiting. Vomiting can speed up DKA.
• Drink plenty of water (or other calorie-free fluids) to flush the ketones out of your body.
• Monitor blood sugar levels and ketones every three to four hours.
• Avoid exercising when you have ketones and your blood glucose is above 250 mg/dl. This is because when you do not have sufficient insulin, the increased energy demands of exercise will burn fat, producing additional ketones.
• If you are using an insulin pump and have ketones, inject some insulin as needed depending on your blood glucose level and change the pump infusion set and reservoir.
Want to learn more about ketones and diabetes? Read “Ketones: Clearing Up the Confusion” and “Getting to Know Ketones,” then try your hand at the quiz “How Much Do You Know About Ketones?”
Ketones in Urine: All You Need to Know
Years ago, those doing the low-carb, high-fat ketogenic diet represented a small subset of the population. Not anymore. The prevalence of people doing keto has increased exponentially; even your grandma might be saying, “I’m thinking of giving this keto thing a try.”
The increased popularity is for a good reason; several health conditions have been shown to benefit from a low-carb, high-fat lifestyle, including but not limited to neurological disorders, diabetes, polycystic ovary syndrome (PCOS), acne, and respiratory and cardiovascular disease risk.1
This has led to the creation of a variety of consumer products that can be used to measure ketones, which are produced by the body when someone practices carbohydrate or calorie restriction. Data nerds love this, and so do people who like to have concrete feedback about progress. Having something to measure and track is always great, and can help lead to compliance and better results.
If you are someone who is thinking about going keto, or interested in starting to measuring ketones (if you haven’t before), one way to do this is through urine test strips. Read on to learn everything you need to know about testing for ketones in the urine.
Ketosis and Ketone Metabolism Fundamentals
Ketosis is a physiological state that occurs when the body begins to rely on fat-sources for fuel instead of carbohydrates. This happens when carbohydrates are restricted and blood sugar falls, which might be achieved through a low-carbohydrate, high-fat ketogenic diet, fasting, and even prolonged exercise.
During ketosis, the ketone bodies beta-hydroxybutyrate (BHB) and acetoacetate (AcAc) are produced from fatty acids. Fatty acids are released from our internal stores when blood glucose is low. The circulating fatty acids then go to the liver for ketone production. Once these ketones are produced, they can be shuttled through the circulation to other tissues, where they’re taken up and metabolized for energy.
Usually, ketosis is defined as having blood ketone levels greater than 0.5 millimolar (mM). If you really want to know if you’re in ketosis, measuring your ketones is the way to do so.
Why You Should Test for Urine Ketones
Before going into the process of measuring for urine ketones, let’s discuss the reason why we are able to even measure urine ketones in the first place. Aren’t ketones present in the blood?
For the most part, yes.
Glucose, ketones, and other crucial nutrients like minerals are present at varying amounts in the blood. Eventually, blood (and the small-molecule passengers) will pass through the kidney—our body’s filtration system. In the kidney, small molecules are filtered into the urine, while others are reabsorbed back into the circulation.2 This process is important, especially when we are talking about ketones. This reabsorption process prevents what would essentially be a “waste” of energy. You can’t utilize ketones if they’re flushed down the toilet.
At low concentrations, most ketone bodies are reabsorbed by the kidney. However, when blood ketones begin to rise, some ketones (the ones not being utilized) begin getting filtered out. Thus, ketone bodies show up in the urine.
For this reason, if you’re on a keto diet or fasting (i.e. in a fat-burning state) and producing ketones, a simple urine test may provide a quick snapshot of your endogenous ketone production—a proxy for how much fat you’re using.3 That is, higher ketones mean more fat burning.
What about exogenous ketosis? Another way to get into ketosis is using exogenous ketone supplements. Does urine testing work for ketosis achieved this way?
It turns out, urine testing might not be ideal to test for ketosis achieved using ketone supplements, for a variety of reasons. We will discuss these later on.
Here’s how to get into ketosis fast
Subscribe, and we’ll share our list of techniques and supplements to get you get into ketosis faster—and stay in ketosis longer.
Who Should Test?
Anyone can use urine testing, but this method may be particularly useful for two types of individuals.
The group that comes most quickly to mind might be people on a ketogenic diet. And yes, urine test strips might be a great introduction to ketone testing for keto-dieters everywhere, with one caveat.
The reliability of urine tests strips is greatest during the initial phase of a ketogenic diet.
Keto-adaptation might have an influence on test results (read on to find out more about this). Anyone experimenting with fasting or trying to lose weight could also use urine test strips to get a reading on their ketosis level, and perhaps use them as a guide to plan an effective strategy.
Individuals with type I diabetes are sometimes advised to measure urine ketones as well. This might seem odd, but it’s a potentially crucial part of their disease management.
This is because people with type I diabetes can suffer from a condition known as diabetic ketoacidosis (DKA), where large amounts of ketones build up in the blood, causing it to become acidic.4 A positive urine test for ketones in someone with type 1 diabetes (T1D) might be a warning signal of DKA.
But if ketones are so “good”, why is DKA so harmful?
Ketosis vs. Diabetic Ketoacidosis
It’s crucial not to confuse these two terms, as keto diet “haters” and the media have occasionally (and incorrectly) done. Yes, both conditions involve high blood ketones, but their physiology and effects on the body are vastly different.
Physiological (nutritional) ketosis is harmless (beneficial, in fact). Physiological ketosis is the goal of any ketogenic diet or taking exogenous ketone supplements.
What defines ketosis exactly?
As mentioned, when blood BHB levels of >0.5mM are achieved, one is said to be in ketosis. Ketone levels can reach up to 7mM – 8 mM in some instances in healthy individuals.5 However, it seems like levels don’t get much higher than this (under normal conditions). The body’s feedback mechanisms involving several different hormones serve to regulate endogenous ketone production.6
The evidence is clear that physiological ketosis has substantial health benefits, maybe due to the fact that ketosis seems to activate certain “survival” pathways in living organisms. In fact, ketogenic diets have been associated with longevity (in mice).7,8
In addition, ketones are an efficient superfuel which have been shown to yield health benefits like weight loss, improved glucose control, better blood lipid profiles, mental clarity, and even improved athletic performances in some cases9,10,11,12 Long story short, humans seem to benefit from both endogenous and exogenous ketosis.
Diabetic ketoacidosis (DKA), on the other hand, is something to be avoided at all costs! Rather than beneficial, it’s a medical emergency.
DKA is an abnormal and potentially fatal metabolic condition, where not having enough insulin around (which type I diabetics don’t produce) leads to an inability to shuttle blood glucose into muscles and other body tissues for energy. This leads to high blood glucose levels,13 which, on one hand, can lead to fluid and electrolyte imbalances.
But, with low insulin (despite a high blood sugar level) also comes the metabolic signals that tell the liver to start using fatty acids to produce ketone bodies.
Normally, insulin inhibits this signal. High levels of ketones start to accumulate in the blood, often exceeding 20mM or higher, levels drastically above normal fasting levels.3 Ketones are mildly acidic, and this can cause the pH of the blood to drop, making blood more acidic. If not treated, this can be life-threatening, leading to coma and even death.14
Some signs of DKA include dry mouth, excessive thirst, frequent urination, fatigue, nausea, vomiting, abdominal pain, a racing heart beat, and rapid breathing.13
For type I diabetics, urine ketone testing can be invaluable. They’re often advised to measure urine ketones frequently in order to manage their condition. The American Diabetes Association (ADA) recommends testing for ketones if your blood glucose is over 300mg/dl, you feel nauseated, you’re sick or tired all of the time, you have a very dry mouth, or if your breath smells fruity or resembles nail polish remover and you feel confused or “in a fog.” These all may be signs of DKA. People with type 2 diabetes may also benefit from urine ketone testing.
How to Test for Urine Ketones
The ketones BHB, AcAc, and acetone can all be measured in various ways, depending on where each will be the most present. BHB is commonly measured using a blood test/meter, and acetone can be measured using a breath ketone meter.
AcAc is the ketone that is measured when you do a urine ketone test. This method won’t tell you (directly, at least) anything about blood BHB.
The process of urine testing for ketones is relatively straightforward. The first step involves purchasing urine test kit, which can be purchased over-the-counter from most drug stores or ordered online. After you have the test meter and urine test strips, all that is required is a few additional steps (to the bathroom).
To get a reading, pass the testing side of the strip through a urine stream, or dip the strip into a sample of urine and remove immediately. After 15 seconds, match the end of the test strip to the ketone color chart on the container.
Different brands of strips may differ in their exact color-coding, but generally a dark purple color is used to indicate the highest level of ketones. Test strips also have a color corresponding to a “negative” test—these results mean no ketones were detected.
It’s important to follow the 15-second rule. After this period of time, the color may continue to change further, leading to a result that doesn’t match up with reality.
When Should You Test?
The time of day you test might depend on what your goal is, or what you’re trying to see from the reading.
Studies have suggested that the reliability of urine ketone testing increases when the test is done in the early morning or in the late evening several hours after dinner.15,16 Wondering how they figured this out? Participants had to provide urine samples for a full 24-hours. Be happy you weren’t part of that study.
Whether you choose to measure at the suggested times or at a different point in your day, it’s probably best to pick a testing time and stick with it for consistency.
Advantages of Urine Ketone Testing
For the cost-conscious, urine testing is one of the cheapest ways to measure ketosis. Typically, a pack of 100 test strips can be purchased for around $10. Plus, urine test strips don’t require a fancy meter to read results—they’re displayed right on the strip.
Urine testing is also super convenient. For one, the strips can be easily purchased. Testing is quick, seamless, and can literally be done anywhere, at any time. And if the thought of sticking your finger multiple times a day makes you queasy, no need to fear. Urine ketone testing is non-invasive—no blood required! It’s a less expensive alternative to other methods of testing ketones.
Disadvantages of Urine Ketone Testing
Something not provided by urine ketone testing? Concrete numbers.
If you like hard data end-points to measure ketosis, urine testing might not be for you. Rather than a concrete number, urine strips give only a semi-quantitative measure of blood ketones, with colors on the strip corresponding to “trace,” “moderate,” and “large” amounts of ketones. Therefore, the test is somewhat subjective.
Many external factors can influence your urine ketone reading, and these could provide a reading higher or lower than what your actual ketone levels might be.
For instance, hydration can influence readings. If you’re under-hydrated, ketones might read high, and vice-versa for someone who’s “over-hydrated.” Certain medications and vitamins (in particular vitamin C) can also skew the results.3
Urine testing may also be a poor way to measure ketosis achieved exogenously. Here’s why.
Exogenous ketone esters (such as monoesters containing the ketone body BHB) will result in rapid, high ketone levels, equivalent to a multi-day fast or weeks of ketogenic dieting.17 But since we’re testing urine, those rapid increases in blood ketone levels won’t show up in the urine tests.
Most are used for energy, and the pattern of metabolism is quite different from that of endogenous ketone production. Only a small amount of exogenous ketones are excreted.17 It has also been shown that at higher blood ketone levels, urinary ketones no longer correlate with blood BHB.18
As we will discuss later, urinary ketone testing might become less accurate over time, such as if you consistently follow a ketogenic diet for many weeks or months.
Urine Testing and Keto Adaptation
Maybe you’ve been using urine test strips for a significant amount of time to measure the success of your ketogenic diet, and now begin to notice a change in your results, despite your habits staying relatively the same. Don’t blame the strips.
In this case, your metabolism has just changed, something reflected in the strips. When you initially start a low-carbohydrate diet, you’re teaching the body to rely on fat-based fuel sources rather than carbohydrates, which most of us have been using as our primary energy sources for our entire lives.
This necessitates an adaptation period (which can sometimes lead to the “keto flu”), and so for the first few days or weeks of a ketogenic diet, you won’t be great at efficiently producing or utilizing ketones for energy. Despite producing some ketones, you aren’t quite yet a proficient “fat burner.”
This is why ketones will appear in the urine. Since they all aren’t being used, they’re filtered into the urine, rather than being reabsorbed or utilized.
But, after some time on a ketogenic diet, keto adaptation will occur—you’re now more capable of producing and using ketones. At this point, it is possible that a larger amount of ketones are reabsorbed and used for energy, and less will appear in the urine.19 One study indicated that during fasting, the amount of AcAc and BHB increased exponentially as the fast grew longer.19 The same study indicated that there exists no maximal transport rate in the kidney for AcAC during physiological ketosis. That is, our ability to reabsorb ketone bodies might have “no limit.” Furthermore, the increased reabsorption of ketones was shown to minimize the loss of body protein during starvation. Although this study didn’t use people in a keto diet, the same concept might hold true. This is definitely a beneficial adaptation during periods of starvation, since during an actual food shortage, the body would need to conserve more ketone bodies and we might see the same thing in those adhering to a keto diet.
As you become more keto adapted, skeletal muscle actually starts to oxidize fatty acids directly. This then leaves more ketones available for our big juicy brains, and other organs that can’t use fats20,21 This means that someone who is better at using ketones will get a lower result on a urine ketone test than they should, maybe even a negative result. Where blood testing might give a high ketone reading, urine test strips might tell another story.
In summary, over time, urine testing becomes less accurate than blood ketone testing.
Quick Tips for Urine Ketone Testing
If you want to improve the accuracy and reliability of your results, there are a few key tips you should follow if you plan to use urine ketone test strips.
Most obvious is that you should consistently check and stay up-to-date on the expiration date on the urine test strips you’ve purchased. Typically, test strips will expire within six months of opening the bottle. Don’t use your urine test strips if the date on the bottle has passed.
Storage is important too. Make sure that you store test strips with the lid closed tight, and keep the bottle in a cool, dry place. Any excess heat or moisture can influence the strips and the chemicals they contain. Do not store in the refrigerator, and protect them from direct sunlight and heat.
Don’t remove the desiccant in the bottle—that’s the tiny white packet. The desiccant holds something called silica gel, which absorbs and holds water vapor, limiting moisture that could potentially ruin the urine test strips.
During testing, make sure you aren’t overly hydrated, and similarly make sure you aren’t dehydrated, as each could skew the test results. This is why early morning testing makes the most sense. Otherwise, test at the same time of day in order to control for outside influences that might affect urine ketone readings.
Last but not least, keep your hands away from the test strip material. Along with the above tips, this will improve the consistency of your results.
Other Ways to Measure Ketones
Urine testing for ketones isn’t the only way to measure your level of ketosis.
The first way involves measuring blood BHB. As the name suggests, this test will give you a reading of how much beta-hydroxybutyrate is in your blood.
This test involves using a BHB meter, and provides the most accurate ketone measurement available (that can be purchased by consumers directly).
For this test, you’ll need test strips along with a BHB meter and a lancet device to prick your finger. You should also probably have some alcohol swabs around to clean the area before pricking your finger and after you have gotten your blood sample. Get a drop of blood, place it on the strip, and feed the strip into the meter.
Advantages of blood testing include the accuracy of measurement. Blood testing also gives you a quantitative reading of BHB (in millimolar; mM).
Disadvantages of blood testing include the need to purchase a device and the strips, which can get costly. The test is also more invasive, requiring a fingerstick to get the drop of blood. This could become bothersome to some people.
The final measurement involves breath testing for acetone. This test device is a newer type of consumer product that measures the amount of acetone excreted in the breath. This involves the one-time purchase of a ketone breath meter from one of several companies that have made these devices available.
Advantages? You only need to purchase one device, and no strips are required.
Disadvantages of this method are that you need a larger handheld device that’s not as convenient as urine test strips. Breath meters are also less accurate than blood or urine testing, and only measure acetone, rather than the two ketones most prominent in the circulation: AcAc and BHB.
Very few studies have been done to validate breath meters or confirm their accuracy. This area of ketone testing is in its early stages.
Is Urine Ketone Testing for You?
Whether or not you opt to use urine test strips will depend on your goals: What do you want to actually measure? How long have you been on a ketogenic diet?
While it’s a quick, convenient, and low-cost option for ketone measurement, it’s also less accurate and far less numerical than other testing methods. Another caveat is that those on a long term ketogenic diet may find less and less utility from urine ketone testing as time goes on.
Urine test strips are probably great if you’re new to a ketogenic diet and want to test if your diet is actually working. Are the foods you’re eating actually getting you into ketosis? Urine strips might help you find out.
But, if you’re a “keto pro,” blood BHB testing might be the best method for you. This is also the case if you’re experimenting with exogenous ketones, which can be more accurately measured by blood testing.
Overall, urine ketone testing gives a quick, practical, and somewhat effective snapshot of ketosis. It’s up to you to decide if this method is adequate for your lifestyle.
Keto for beginners
From keto products to testing ketone levels, our guide is essential for those just starting a keto diet. Subscribe to get it.
Do you want to lose weight? Here’s number 16 of my 18 best tips. All of the published tips can be found on the How to Lose Weight page.
Before we get started, here’s a short recap of the tips so far: The first and most crucial piece of advice was to choose a low-carb diet. The next were eating when hungry, eating real food, eating only when hungry, measuring progress wisely, being persistent, avoiding fruit, beer and artificial sweeteners, review your medications, stressing less and sleeping more, eating less dairy and nut products, stocking up on vitamins and minerals, using intermittent fasting and finally, exercising smart.
This is number sixteen:
16. Get into optimal ketosis
Warning: Not recommended for type 1 diabetics, see below.
We’ve now arrived at tip number 16. If you’re still having trouble losing weight, despite following the 15 pieces of advice listed above, it might be a good idea to bring out the heavy artillery: optimal ketosis. Many people stalling at weight plateaus while on a low carb diet have found optimal ketosis helpful. It’s what can melt the fat off once again.
So how does this work? A quick run-through: The first tip was to eat low carb. This is because a low-carb diet lowers your levels of the fat-storing hormone insulin, allowing your fat deposits to shrink and release their stored energy. This tends to cause you to want to consume less calories than you expend – without hunger – and lose weight. Several of the tips mentioned above are about fine-tuning your diet to better this effect.
Do you know exactly how to eat a low-carb and high fat diet (LCHF)? This is required for ketosis. If not the easiest way is watching this high quality 11-minute video course on how to eat LCHF, and the most important things to think about.
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Maximum effect from an LCHF diet
How do you know you’re getting the maximum hormonal impact from your low-carb diet? You do that by achieving what’s known as “optimal ketosis”.
Ketosis is a state at which the body has an extremely high fat-burning rate. Even the brain runs on fat, via ketone bodies. These are energy molecules in the blood (like blood sugar) which become fuel for our brains after being converted from fat by the liver.
To encourage ketone production, the amount of insulin in your bloodstream must be low. The lower your insulin, the higher your ketone production. And when you have a well-controlled, sufficiently large amount of ketones in your blood, it’s basically proof that your insulin is very low – and therefore, that you’re enjoying the maximum effect of your low-carbohydrate diet. That’s what’s called optimal ketosis.
Today, there are reasonably-priced gadgets available for measuring ketone levels at home. One needle prick of the finger, and in just a few seconds you’ll know your blood ketone level.
Blood ketones are best measured on a fasted stomach in the morning (before breakfast, that is). Here are a few pointers on how to interpret the result:
- Below 0.5 mmol/L is not considered “ketosis”. At this level, you’re far away from maximum fat-burning.
- Between 0.5-1.5 mmol/L is light nutritional ketosis. You’ll be getting a good effect on your weight, but not optimal.
- Around 1.5 – 3 mmol/L is what’s called optimal ketosis and is recommended for maximum weight loss.
- Values of over 3 mmol/L aren’t neccessary. That is, they will achieve neither better nor worse results than being at the 1.5-3 level. Higher values can also sometimes mean that you’re not getting enough food. For type 1 diabetics, it can be caused by a severe lack of insulin, see below.
Ketones in urine
Ketone levels can also be measured in a more old-fashioned way, with urine test sticks (sold prescription-free in pharmacies or on Amazon). Ketone sticks give less reliable results for several reasons, and the above recommendations can’t be straightforwardly applied to them. They are, however, much cheaper.
My personal experience
Feel free to read my accounts of a two-month personal trial:
- Experiment: Optimal ketosis for weight loss and increased performance
- Four weeks of strict LCHF and ketone monitoring
- Final report: Two months of strict LCHF and ketone monitoring
Although I was quite happy with my weight before these trials, they resulted in a further loss of 4.5kgs (10 pounds) and 7cm (3 inches) around my waist – without additional exercise or even the slightest resemblance of hunger.
How to achieve optimal ketosis
Many who firmly believe they are eating a strict low-carb diet are surprised when they measure their blood ketones. They may be at around only 0.2 or 0.5 – quite far off from the sweet spot! Why?
The trick here is not only to avoid all obvious sourced of carbohydrate (sweets, bread, spaghetti, rice, potatoes), but also to be careful with your protein intake. If you eat large amounts of meat, eggs and the like, the excess protein will converted into glucose in the body. Large amounts of protein can also raise your insulin levels somewhat. This compromises optimal ketosis.
The secret to getting around this is usually to eat your fill with more fat. For example, if you have a bigger helping of herb butter to your steak, you might not feel like having a second steak, and instead feel satisfied after the first one.
A popular trick people use to ingest more fat is “fat coffee” (sometimes called “Magic Bullet Coffee” or MBC). It involves adding one tablespoon of butter and one tablespoon of coconut oil to your (morning) coffee, and requires a food blender for the right texture.
More fat in your food will fill you up more. This will ensure you eat less protein, and even less carbohydrate. Your insulin will drop and, hopefully, you’ll be able to reach optimal ketosis. And that’s when many a stubborn weight plateau is overcome.
If it doesn’t work
Being in optimal ketosis for a prolonged period of time (say, a month) will ensure that you experience the maximal hormonal effect from eating a low-carb diet. If this doesn’t result in noticeable weight loss, you can be certain that too many carbs are NOT part of your weight issue and not the obstacle to your weight loss. There are, in fact, other causes of obesity and being overweight. The next three tips in this series might help you.
Order a ketone meter online and start measuring. There are a few different models, the most popular one is probably the Precision Xtra ketone meter. Unfortunately these meters are all quite expensive to use, as the test strips can cost about $5 per test.
Here’s a complete package with everything you need to check your blood ketone levels.
Learn much more about ketogenic diets here:
A ketogenic diet for beginners
What is ketosis?
Watch my video interview with Dr. Peter Attia, on a strictly ketogenic low-carbohydrate diet: Very Low Carb Performance
Read all the tips on the How to lose weight page.
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A word of warning
If you have type 1 diabetes, you should not follow the above advice on optimal ketosis – it may be risky. If you have ketones in your blood at all, you must be sure that your blood sugar levels are normal. If they are, you’re in normal ketosis – just like the ketosis of healthy people who stick to a strict low carb diet.
High blood sugar levels coupled with high blood ketones, on the other hand, will mean that you have a pathologically low level of insulin – something non-diabetics do not suffer from. This can lead to ketoacidosis – a potentially life-threatening condition. If this happens, you’ll need to inject more insulin; if you’re at all unsure of what to do, contact a medical professional. Coveting really high blood ketones for weight control is not worth the risk for type 1 diabetics.
Blood and Urine Ketones
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Medically reviewed by Drugs.com. Last updated on Sep 24, 2019.
- Care Notes
WHAT YOU NEED TO KNOW:
Ketones are made when your body turns fat into energy. This happens when your body does not have enough insulin to turn sugar into energy. Ketones are released into your blood. Your kidneys get rid of ketones in your urine.
Why do I need to test for ketones?
High levels of blood or urine ketones can lead to diabetic ketoacidosis. Diabetic ketoacidosis is a life-threatening condition that can cause seizures, coma, or death. Early treatment of high levels of blood or urine ketones may prevent diabetic ketoacidosis.
When do I need to test for ketones?
Your healthcare provider will tell you if you need to test your urine or blood. Test for ketones when you have any of the following:
- Your blood sugar level is higher than 300 mg/dl.
- You have nausea, abdominal pain, or are vomiting.
- You have an illness such as a cold or the flu.
- You feel more tired than usual.
- You are more thirsty than normal or have a dry mouth.
- Your skin is flushed.
- You urinate more than usual.
How do I test for urine ketones?
Ask your healthcare provider where to purchase a urine ketone test kit. The kit usually comes with a plastic cup, a bottle of test strips, and directions. Follow the instructions in the ketone test kit. Check the expiration date to make sure the kit has not expired. The following is an overview of how to test your urine for ketones:
- Urinate into a clean container. You can use a clean plastic cup if your kit does not come with a cup.
- Dip the test strip into the sample. The directions will tell you how long to hold the test strip in urine. Gently shake extra urine off of the strip.
- You can also urinate directly onto the test strip. The directions will tell you how long to hold the test strip in your stream of urine. Gently shake extra urine off of the strip.
- Wait for the test strip to change color. The directions will tell you how long you need to wait.
- Hold the test strip next to the color chart on the bottle. Match the color on your strip to a color on the bottle. The color on the bottle will tell you the amount of ketones in your urine. The amount of ketones in your urine may be negative, trace, small, moderate, or large.
- Write down the results.
How do I test for blood ketones?
Ask your healthcare provider where to purchase a meter that tests for blood ketones. The meter is similar to the one you use to check your blood sugar level. Your healthcare provider will teach you how to use this meter. The following is an overview on how to use a meter to test your blood for ketones:
- Follow directions to set up the meter. Insert a test strip.
- Clean your finger with an alcohol wipe. Let your finger dry for 30 seconds.
- Use a lancet to prick your finger. Gently squeeze your finger to make it bleed.
- Touch the end of test strip to the drop of blood. The meter will beep when the strip has enough blood on it.
- The meter will tell you your blood ketone level on a tiny screen. Write down the results.
How are moderate or large amounts of ketones treated?
You may need insulin to decrease your blood sugar levels and stop your body from making ketones. You may need insulin as a shot or in an IV.
What else can cause ketones in my blood or urine?
- A diet that is low in carbohydrates or fat
- Drinking large amounts of alcohol
- Certain medicines such as medicine to treat Parkinson’s disease
- Certain conditions such as seizure disorders or eclampsia in pregnancy
How can I prevent ketones in my blood or urine?
Keep control of your blood sugar levels to prevent your body from making ketones. Do the following to control your blood sugar levels:
- Monitor your blood sugar levels as directed. Report high or low levels to your healthcare provider. You may need more insulin than usual when your blood sugar levels are high. Early treatment of high blood sugar levels may prevent your body from making ketones.
- Take insulin and diabetes medicines as directed. Do not skip a dose of insulin or diabetes medicine.
- Follow your meal plan. Ask your healthcare provider for more information about what you should eat. You may need to meet with a registered dietician to help you plan your meals.
- Follow instructions for sick days. Your blood sugar levels may increase when you are sick. Make changes to your diabetes medicine as directed when you are sick.
Call 911 for any of the following:
- You have a seizure.
- You begin to breathe fast, or are short of breath.
When should I seek immediate care?
- You become weak and confused.
- You have fruity, sweet breath.
- You have severe, new stomach pain and are vomiting.
- You are more drowsy than usual.
When should I contact my healthcare provider?
- Your ketone level is higher than your healthcare provider said it should be.
- Your blood sugar level is lower or higher than your healthcare provider says it should be.
- You have moderate or large amounts of ketones in your urine or blood.
- You have a fever or chills.
- You are more thirsty than usual.
- You are urinating more often than usual.
- You have questions or concerns about your condition or care.
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
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Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Ketones in Urine: When and Why to Test for Them and What They Mean
What Happens During a Ketones in Urine Test?
A test to detect ketones in urine can be administered at home or in a lab. Sometimes patients are asked not to eat or drink for a specified amount of time before they take the test.
When testing in a lab, patients are advised to wash their hands and then clean their genital area via a sterile cleansing pad. Patients must then collect 1 to 2 ounces of urine into a container, and give the sample to the appropriate healthcare provider. (1)
Patients can also test for ketones in urine at home by doing a spot test, which uses urine test strips. You can capture the urine in a clean container and dip the test strip into the container, or you can urinate directly onto the test strip. Follow the instructions to see how long after testing you should read the color of the strip. Then compare the strip color with the color chart on the bottle. (5)
If you are testing for ketones in babies or toddlers who wear diapers, clean cotton wool can also be used to capture urine. (5)
When testing your urine for ketones, it’s important to make sure that the test strips have not expired.
You do not need a prescription to obtain a ketone test kit from your local pharmacy. Talk to your doctor about which test kit could work best for you and provide the most relevant information.
Results of the ketones in urine test can vary from a specific number or be categorized qualitatively as a small, moderate, or large amount of ketones. What’s considered a normal amount of ketones in urine will vary by age, gender, health history, and other factors, so be sure to talk to your doctor about your exercise and diet habits, as well as other factors that might affect your typical level. (1)
When Should I Have a Test for Ketones in Urine?
If you have diabetes or another condition that puts you at risk for high levels of ketones, a healthcare provider will generally advise you to test for ketones every 4 to 6 hours when you experience any of the following: (6)
- Blood glucose level above 240 milligrams per deciliter (mg/dl)
- Vomiting or feelings of nausea
- Abdominal pain
- Other illness, such as cold or flu
- Constant fatigue
- Dry mouth or constant thirst
- Flushed skin
- Fruity-smelling breath
If your child has diabetes and becomes sick, he or she will need extra attention and consultation with doctors. Notify the child’s diabetes team immediately if she has a fever, vomiting, or diarrhea. Also contact a doctor if your child’s urine tests positive for ketones. (5)
What Does an Abnormal Result for a Ketones in Urine Test Mean?
Abnormal results typically break down as follows: (4)
- Small: 20 mg/dl
- Moderate: 30 to 40 mg/dl
- Large: >80 mg/d
Small amounts of ketones in the urine can be normal, especially if a person is trying to lose weight and maintains healthy blood sugar levels. People with diabetes who are trying to lose weight should make sure they monitor their blood sugar and ketone levels closely. (2)
If you test for ketones in your urine and the results indicate a small amount, consult with your doctor and continue retesting every few hours. (6)
If test results show moderate or large amounts of ketones in urine, contact your healthcare provider immediately. It’s also important not to exercise when ketone levels are high or when your blood sugar is high, as this can worsen effects. (6)
If test results show high levels of ketones in your urine, your doctor may check the amount of ketones in your blood and also conduct the following urine tests: (7)
- Blood glucose
- pH (or acid level)
When Can Ketones in Urine Be a Sign of Ketoacidosis?
High levels of ketones detected in your urine are a potential indicator of diabetic ketoacidosis (DKA), a severe complication of diabetes. Diabetic ketoacidosis is often the first sign that a person has diabetes before they are diagnosed. (2)
If you become ill and have diabetes, your blood sugar and ketone levels can rise and cause ketoacidosis. Consult with your healthcare provider about how to monitor your ketone and blood glucose levels and how to prevent ketoacidosis when you’re sick. (2)
Additional symptoms of ketoacidosis can include: (1)
- Trouble breathing
- Unusual thirst
- Fruity-smelling breath
- Flushed skin
- Abdominal pain
It’s important to seek help for DKA immediately, as it can lead to a diabetic coma or even death. (3)
Ketones — The 6 Must-Knows
1 – What are ketones?
Ketones are chemicals that build up when your body starts to burn fat for energy. The most common cause of ketones in diabetics is insulin deficiency. Without enough insulin, glucose builds up in the blood stream and can’t enter cells. The cells then burn fat instead of glucose. This results in ketones forming in the blood and eventually spilling into urine.
2 – Why can ketones be dangerous?
Having ketones can indicate that your body needs more insulin. (Always monitor your blood sugar levels to know how much insulin you need.) If you have a build up of ketones, this can lead to Diabetic Ketoacidosis (DKA). Signs of DKA include moderate or large ketones, nausea, vomiting, abdominal pain, fruity or acetone (think nail polish remover) breath, rapid breathing, flushed skin, and lack of energy. If left untreated, it can lead to a serious and life-threatening diabetic coma or death. High levels of ketones are toxic to the body and if you’re experiencing these, you should seek out medical attention.
3 – When and how should you check for ketones?
You should be checked anytime your blood sugar is above 240 mg/dl (13.3 mmol/l) or any time you are sick. This includes any minor illness such as a cold.
There are a few different ways to check for ketones, and there are positives and negatives for each method. The most reliable way of checking for ketones is by using blood ketone meters, which measure BHB (the primary ketone found when in DKA). The actual way that one uses a ketone meter is exactly like a blood glucose meter, since you are using a blood sample. These meters required typically cost between $30 and $60, and the test strips are upwards of $1 each. You can find these meters at Walmart or Amazon.
You can also use breath ketone meters to measure acetone, a type of ketone that is found in breath. This method is convenient and only requires a one time purchase of a breath ketone meter. However, these meters are expensive, and can cost around $200. This might be economical if you are expecting to be regularly checking for ketones.
Another, less reliable, way to check for ketones is by using ketone strips, which use a urine sample to measure a particular ketone released through urine. These strips are very cheap, and cost about a quarter each. However, they are not as accurate as a blood ketone meter because it takes longer for ketones to reach urine and hydration can also effect results. You can find ketone strips at drug stores.
4 – Can you get ketones with a high blood sugar?
Ketones typically accompany high blood sugar. They indicate that your body needs more insulin. Most often if your body needs more insulin, it means you probably have a high blood sugar. Also, when an illness is present, your body releases hormones in response to the stress. These hormones lead to elevated blood glucose. That is why it’s recommended to test ketone levels during illness.
5 – Can you get ketones with a normal or low blood sugar?
Ketones can also be present when your blood sugar is normal or low. These are sometimes referred to as “starvation ketones” or “nutritional ketones.” During an illness or extreme diet change, if you have a significant decrease in carb intake, this can lead to the body using fat for energy because there are not enough carbs present to burn. Your blood sugar could remain normal or even be low in this case but your body could still be producing ketones.
6 – What should you do if you have ketones?
It is recommended that you drink 8 ounces of water or carb/caffeine free beverage every 30-60 minutes to help flush out the ketones. Again, ketones are a sign that your body needs more insulin. Some people might already have an insulin dosing plan in place related to ketones. It’s typically a percentage of your daily long-acting dose or percentage of your total daily basal volume (for pump users) based on whether ketones are small, moderate or large. It is always best to call your endocrinologist to verify what they recommend when ketones are present.
This piece is part of Beyond Type 1’s resources on DKA + managing ketones – find the complete collection of resources here.
Kyla Schmieg, BSN, RN
Kyla Schmieg, BSN, RN, currently works as a Pediatric Endocrinology RN in Cincinnati, Ohio, working on the same unit she was diagnosed at 26 years ago. She was diagnosed with Type 1 in 1990. She loves that her job allows her to work with newly diagnosed Type 1 kids and families. She loves educating people about diabetes; it’s the main reason she became a nurse! She also believes it’s important to put out there that although Type 1 needs to be taken seriously, it is not something that should impact or limit your dreams or ambitions.
Diabetic Ketoacidosis (KEY toe as i DOE sis), also known as DKA, is a serious complication of diabetes. When the cells in the body cannot use glucose for energy, there is a buildup of acids called “ketones” in the blood. For the cells to use glucose for energy both glucose and insulin need to be in the blood. Insulin acts like a key to unlock the cell door. It allows glucose in to be used for energy.
When cells do not have glucose to use for energy:
- The body starts to use fat for energy.
- Ketones are made when fat is used for energy.
- Ketones are present in the blood and in the urine.
- Ketones cause the blood to become more acidic.
- If untreated, this leads to DKA and life-threatening problems.
- Not enough insulin
- Missing doses of insulin
- Infection, illness or injury (which causes the body to need more insulin)
- Insulin doses too small
- If using insulin pump, interruption in delivery of insulin
Signs of DKA and When to Test for Ketones
You may or may not feel any different when you begin to have ketones. The only way to know is by checking the urine or blood for the presence of ketones.
- Check for ketones if blood glucose is higher than 300 mg/dl.
- Check for ketones when ill (fever, flu or vomiting) even if blood glucose is not higher than 300 mg/dl.
Warning Signs of DKA
- Fast breathing
- Fruity smell to the breath
- Hard to wake up
- Feeling sick to the stomach (nausea), belly pain, or vomiting
How to Check Urine for Ketones
You can also check blood for ketones. Your health care team can provide more information about this choice.
What to Do If Ketones Are Present
Taking action when ketones first appear can stop DKA from happening.
If ketones are small, moderate or large:
- Drink 1 cup (8 ounces) of fluids every 30 to 60 minutes.
- If blood glucose is higher than 150, drink something that does not have carbohydrates.
- If blood glucose is lower than 150, drink something that does have carbohydrates.
- Give extra rapid-acting insulin for ketones every 3 hours until ketones are negative. This is called a ketone bolus. If you are not sure how much extra insulin to give for the ketone bolus, contact your health care provider. Continue to check blood glucose and ketones every 3 hours.
- Follow sick day guidelines provided by your diabetes team or contact your diabetes health care provider for advice.
- Do not skip meals. Continue eating or drinking carbohydrates and take extra rapid-acting insulin with meals.
- Continue to take the same dose of long-acting Lantus insulin that you usually take.
- Do not exercise if ketones are present.
Being Prepared When Contacting a Health Provider
When you contact your child’s healthcare provider, have the following information ready:
- Child’s name and birthdate
- Last blood glucose reading
- Ketone results
- Current insulin doses and time last rapid-acting insulin dose given
- Your name and relationship to the child
When to Call the Doctor
- You have treated moderate to large ketones two times with rapid acting insulin and ketones are still moderate to large.
- You have treated a low blood glucose two times and it is still low.
- You have thrown up (vomited) three times within 2 hours.
- As instructed by your diabetes health care provider.
When to Go to the Emergency Department
DKA can be life-threatening. Go to the local emergency department if you have any of these alarming signs of DKA.
- Fast breathing
- Fruity smell to the breath
- Hard to wake up
- Vomiting for more than 2 hours
Diabetes: Ketoacidosis (DKA) (PDF)
HH-I-23 9/80, Revised 12/15 Copyright 1980, Nationwide Children’s Hospital
Even if you work hard at your diabetes management and use technology to help keep your numbers in range, you can still experience high blood glucose, which can escalate to diabetic ketoacidosis (DKA). While DKA can be scary if left untreated, it is preventable if you know what to look for and what to do. Senior District Clinical Manager, Melinda Turenne, BSN, RN, CDE, has more than 15 years of diabetes clinical experience. Today she shares some valuable DKA risk factors and prevention tips.
Living with diabetes involves a lot of duties. You are checking your blood glucose (BG), counting your carbohydrates, exercising, and keeping doctors’ appointments. I am sure you remember your doctor or diabetes educator telling you to check for ketones too, right? Checking my what? One more thing to add to my to-do list! Yes, and here is WHY.
Ketones are acid molecules produced when we burn fat for energy or fuel. As fat is broken down, ketones build up in the blood and urine. In high levels, ketones are toxic and can make you very sick. When combined with dehydration, it can lead to Diabetic Ketoacidosis (DKA), a life threatening condition.
Why would DKA happen?
DKA occurs when there is not enough insulin present in the body. Without enough insulin, glucose builds up in the blood, causing high BG levels. Since the body is unable to use glucose without insulin for energy, it breaks down fat instead. This can occur for several reasons:
- Infection, injury, or serious illness
- A lack of insulin in the body due to missed injections, spoiled insulin, poor absorption
- Severe dehydration
- Combination of these things
What are the signs of DKA?
- High BG levels
- Ketones (in blood and urine)
- Nausea, vomiting, and abdominal pain (cramps)
- Tired, sluggish, or weak
- Flushed, hot, dry skin
- Blurred vision
- Rapid, deep breathing and shortness of breath
- Excessive thirst and frequent urination
- Fruity scented breath
When do I check for ketones?
Most experts recommend testing ketones:
- Anytime you have unexplained high BG, or if your glucose is over 250 mg/dL for two BG tests in a row
- If you experience nausea, vomiting, and have abdominal pain
- If you feel ill (i.e., cold, flu, stomach virus). Illness, infections, or injuries can cause BG’s to run higher than normal. Therefore, the risk of developing DKA increases when you’re ill.
How do I check for ketones?
You can check for ketones using a urine test or blood test, which are available at most pharmacies.
- A simple urine test that involves peeing on a Ketostix or dipping the Ketostix into a cup of urine, and observing the color change on the strip. Positive ketones are indicated by small or greater ketones.
- A blood test can be done with special ketone test strips. It is like testing your BG, except a ketone measurement is given. Positive ketones are indicated by a blood test that indicates the presence of Beta-Hydroxybutyrate.
What do I do if ketones are present?
- Correct high BG with insulin using a syringe
- If you use an insulin pump, change infusion site, infusion set, reservoir, and insulin, and troubleshoot pump
- Drink non-carbohydrate fluids
- Call your doctor immediately. Don’t delay!
- Seek emergency care if you can’t reach your doctor
- Follow any instructions you are given by your healthcare team
- Using an insulin pump with continuous glucose monitoring (CGM) can help you keep an eye on your glucose trends, and you can set alerts to let you know when your sensor glucose goes above a certain threshold. Sensor glucose isn’t the same as blood glucose, so be sure to still check your BG 4-6 times a day, and before making any therapy decisions (like giving yourself more insulin).
- The risk for DKA is higher when you’re sick because illness related stress can raise your BG. DKA symptoms are similar to flu and stomach virus symptoms, so when you’re sick be sure to:
- Check your BG every two hours
- Check your urine for ketones each time you urinate during illness
- If you haven’t been given special instructions on how to manage your diabetes during illness, contact your healthcare team for advice
- Immediately check for ketones if you’re nauseous or vomiting
- Follow your doctors’ instructions for correcting high BG and testing for ketones
- Learn to recognize the signs and symptoms of DKA
Recovery can vary depending on different complications that can occur, and each person is different. The most important aspects of DKA treatment is fluids and insulin so BG levels, dehydration, and ketosis are corrected slowly. Here are a few things to keep in mind when recovering from DKA:
- Drink non-carbohydrate fluids
- Closely monitor BG by checking every one to two hours, in addition to watching your CGM graph; give correction boluses when needed
- Closely monitor ketones
- Call your doctor or seek emergency care if ketones are still positive
You and your loved ones may find this Safety Rules Quick Reference Guide for ways to treat high blood glucose levels helpful, too.
Guest Blogger – Melinda Turenne, BSN, RN, CDE
Melinda Turenne is a Registered Nurse, Clinical Diabetes Educator, and Medtronic Senior Diabetes Clinical Manager. Melinda enjoys providing people with diabetes the information, knowledge, and support they need to improve their diabetes management. Prior to working for Medtronic, she worked as a Clinical Diabetes Educator for five years at a large hospital system.
IMPORTANT SAFETY INFORMATION
– Medtronic Diabetes insulin infusion pumps, continuous glucose monitoring systems and associated components are limited to sale by or on the order of a physician and should only be used under the direction of a healthcare professional familiar with the risks associated with the use of these systems.
– Successful operation of the insulin infusion pumps and/or continuous glucose monitoring systems requires adequate vision and hearing to recognize alerts and alarms.
Medtronic Diabetes Insulin Infusion Pumps
– Insulin pump therapy is not recommended for individuals who are unable or unwilling to perform a minimum of four blood glucose tests per day.
– Insulin pumps use rapid-acting insulin. If your insulin delivery is interrupted for any reason, you must be prepared to replace the missed insulin immediately.
Medtronic Diabetes Continuous Glucose Monitoring (CGM) Systems
– The information provided by CGM systems is intended to supplement, not replace, blood glucose information obtained using a home glucose meter. A confirmatory fingerstick is required prior to treatment.
– Insertion of a glucose sensor may cause bleeding or irritation at the insertion site. Consult a physician immediately if you experience significant pain or if you suspect that the site is infected.
For more information, please visit http://www.medtronicdiabetes.com/important-safety-information.
Tags: diabetes management, diabetic ketoacidosis, DKA, high blood glucose, ketones
Checking for Ketones
What are ketones? If ketones are present in your urine, it can be a sign that the body is breaking down fat stores for energy instead of sugars/glucose due to the lack of insulin.
How do I test for ketones? Get a sample of urine in a clean container. Put a ketone test strip in the urine sample. (Ketone testing strips can be obtained by prescription from your doctor). Follow the directions on the container of ketone strips, typically waiting for the strip pads to change color. Compare the strip to the color chart on the side of strip container for the range of ketones in your urine.
What do my test result mean? Moderate to larger amounts of ketones present in the urine can be a danger sign in a person with diabetes. High levels of ketones can cause an imbalance in blood that alters body chemistry and affects how the body functions. Typically high levels of ketones in the urine is a sign that diabetes is out of control. Talk to your doctor as soon as possible about your results for guidance on managing your diabetes.
When should I test my urine for ketones? Any of these warning signs can be an indication or cause high ketone levels:
- When blood glucose is greater than 250-300 mg/dl
- You are sick with cold or flu, have uncontrolled nausea or vomiting
- You have difficulty breathing
- Your breath has a “fruity” odor
- Confusion or disorientation
Diet and exercise alone may not be enough to help keep your blood glucose level in your target range. Medication may be the next step to get better control over your diabetes to prevent long-term health problems related to poorly controlled diabetes. Diabetes medications can be a pill, injecting insulin or wearing an insulin pump. The best type of diabetes medication for you should be determined by doctor who can evaluate blood sugar control and Lifestyle factors.
Many people with diabetes can control their diabetes with oral pill(s) without the use of injectable forms of insulin. People with type 1 diabetes typically have to depend on injectable insulin to control their diabetes. Diabetes pills often work well for individuals with type 2 diabetes, but may lose their effectiveness or stop working over years of having diabetes. It may mean you need more than one type of oral diabetes medication or a combination of oral pills and insulin to best control blood sugars.
There are many different types of oral diabetic pills to choose from, so talk to your doctor about options that can work best for you. Talk to your pharmacist or doctor about when to take your medication, considering your meal plan, exercise patterns and lifestyle.