All About Ketones and Diabetes

Ketones Occur When the Body Breaks Down Fat For Energy

Urine Testing
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Ketones are organic compounds that result when body fat is broken down for energy. While this may not sound like a bad thing, for people with diabetes, especially Type 1 diabetes, high levels of ketones in the body can be toxic. Should you develop ketones, you need to know how to identify symptoms, how to check for them, and which levels are considered to be dangerous.

What Are Ketones and When do They Occur in the Body?

Glucose is usually used by cells for energy. But, when there's no insulin to help transport it out of the blood and into the cells, the body has an "energy crisis" and starts to break down body fat into ketones as an alternative fuel source. For people without diabetes, this doesn't present a problem. However, for people with diabetes, high levels of ketones in the body can be toxic when associated with high glucose levels, as they represent lack of insulin and can result in coma or even death if not treated properly and promptly. For people who have had longstanding uncontrolled type 2 diabetes, ketoacidosis can occur if their pancreas shuts down from over-working. This is called Flatbush diabetes.

Symptoms of Ketoacidosis

Persistent levated blood glucose levels (over 250 mg/dl) are one sign that the body may have high levels of ketones circulating in the blood. This can progress to a serious complication called diabetic ketoacidosis. Ketoacidosis can occur in anyone with diabetes, but occurs more commonly in people with Type 1 diabetes. According to the American Diabetes Association, ketoacidosis can occur when:

  • Your body does not have enough insulin either because you did not inject enough or you may need more than usual because you are sick.
  • You are sick and are unable to eat enough food.
  • Your blood sugar drops too low while you are sleeping and results in high levels of ketones in the morning. 
  • Your insulin is not working properly and insulin is not being delivered as it should

Ketoacidosis usually happens slowly, but in the event you are vomiting and having symptoms you should seek emergency help right away. The following are early symptoms: 

  • Thirst or a dry mouth
  • Frequent urination
  • High blood glucose (blood sugar) levels
  • High levels of ketones in urine

Other symptoms that can occur include: 

  • Constant tiredness
  • Dry or flushed skin 
  • Nausea, vomiting, or abdominal pain
  • Difficulty breathing 
  • Fruity odor on breath 
  • Confusion or difficulty paying attention


If ketoacidosis is left untreated it can result in a diabetic coma or death. Early detection of ketones can help to prevent the progression to ketoacidosis. 

When Should You Check for Ketones? 

Some experts recommend that you check for ketones when your blood sugar is repeatedly over 240 mg/dl for no apparent reason, while other sources say to check when you blood sugar is above 300 mg/dL. Ask your health care provider what's best for you. Another time to test for ketones would be if your blood sugar is high (250-300 mg/dL or more) and you are feeling ill (for instance, with cold or flu symptoms, nausea, vomiting, or excessive tiredness). 

Testing for Ketone Build Up

Testing the urine is one way to check for ketones. Most pharmacies carry ketone strips or you can ask your physician to get you a prescription. Some blood glucose meters also check for ketones. Find out if your glucose meter can also measure your ketone levels. All people with Type 1 diabetes should have a way to measure ketones — if you don't ask your health care provider. 

Ketone Testing Results

Depending upon how long your body has been using fat for fuel you may have trace, small, or moderate to high levels of ketones in your urine. If your results are trace or small this can mean that ketone buildup is starting and you can retest in a few hours. However, moderate or large amounts of ketones is dangerous and should result in a phone call to health care provider right away. If you are ever uncertain of what to do in the event of ketones, call you doctor immediately. Depending on the severity of the ketones and how you are feeling, you maybe instructed to hydrate and take more insulin or be told to go to the emergency room.

Treatment for High Ketones

The treatment for ketones will depend if they are trace, small, moderate, or high. Make sure to draft an emergency plan and sick day guidelines with your doctor, so that you know exactly what to do, should you develop ketones. If your ketone level is moderate or high, you should still contact your doctor right away or seek emergency care (especially if you are exhibiting symptoms). If you have low levels of ketones, you may need to take more insulin. Low levels of ketones, may also mean that you should: 

  • Test your blood sugar more frequently, usually every 3-4 hours
  • Drink plenty of water to flush the ketones out
  • Do not exercise if you have ketones as this can cause them to raise even higher 

If you've been diagnosed with DKA, as a result of high ketones, your treatment will include resolution of hyperglycemia, correction of electrolyte imbalance and ketosis, and restoration of circulatory volume. Additionally, it will be important to correct any underlying cause of DKA, such as sepsis.

Depending on how complicated the situation is, people with DKA will be treated with intravenous or subcutaneous insulin and fluid management.

High Ketone Level Prevention

If you have diabetes, the best way to prevent high ketone levels is to keep your blood sugars controlled. To do so, aim to: 

Eat a balanced diet

Excessive carbohydrate intake, especially in the form of sugary drinks and processed carbohydrates can cause blood sugars to rise rapidly. Managing carbohydrate intake and insulin needs can help to keep your diabetes controlled. Formulate a meal plan that works for you schedule and keeps your blood sugar controlled. If you don't have one, ask your registered dietitian or certified diabetes educator to help you make one. 

Take your medicines regularly

Omitting insulin or other glucose lowering medication can increase your risk for ketones. Under-dosing or improper storage of insulin (which can reduce insulin potency) can also increase your risk for ketones, by increasing your risk for hyperglycemia. 

Self monitoring of blood sugars

Checking your blood sugars is a great way to pattern manage your blood sugar control, keep your blood sugars in target range, and prevent emergency situations. In the event that your blood sugars are greater than 250-300 mg/dL, the American Diabetes Association, recommends that you check for ketones. 

Check for ketones

You should test for ketones, if your blood sugar is elevated (around 250-300 mg/dL) and you have symptoms, such as:

  • Nausea, vomiting, or, abdominal pain
  • Common cold or flu
  • Tiredness all the time
  • Thirsty or very dry mouth
  • Flushed skin 
  • Difficulty breathing
  • Confusion
  • Fruity breath

Detecting ketones early can help to treat them quickly and prevent an emergency. 

Having a sick day plan with your provider 

Illness puts stress on the body and can increase the risk of elevated blood sugar, which can put people with diabetes at risk for developing ketones. It's important to develop a sick day plan with your provider so that should you get sick, you can prevent an emergency. 

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  2. Kanikarla-marie P, Jain SK. Hyperketonemia and ketosis increase the risk of complications in type 1 diabetes. Free Radic Biol Med. 2016;95:268-77. doi:10.1016/j.freeradbiomed.2016.03.020

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