Diabetes & Ketones: Everything You Need to Know

These days, understanding what ketones are can be confusing, because even mainstream society and non-diabetics are talking about ketones.

What has always been something people with diabetes feared, has now become something that low-carb and ketogenic dieters strive for: ketosis.

In this article, we’ll talk about the crucial differences between diabetic ketones (ketoacidosis), starvation ketones, and nutritional ketosis. We’ll also cover what to do if you’ve developed diabetic ketones and how to manage ketones and diabetes during an illness.

What are ketones?

Simply put: ketones are what your body produces when your body can’t adequately burn glucose in your bloodstream or produced from your diet for fuel. Instead, it will burn body fat for fuel which results in different acids, including ketone acids.

While this may seem like a great thing — body fat being burned for fat — it is actually not always a good thing, especially if you have diabetes.

You can’t fully answer the question of “what are ketones” in one sentence because there are several types of ketosis and the several ways ketones can develop in the human body — some are safe, some are very dangerous.

The four types of ketones and “states of being in ketosis” are:

• Diabetic ketoacidosis (DKA)
• Nutritional ketosis
• Starvation ketones
• Illness or infection-induced ketosis

Testing for ketones

No matter what the type of ketosis, all ketones can be measured in the same way: at home with ketone urine strips or an at-home blood ketone meter. Doctors should also measure ketones with a urine strip or blood test if you went to the hospital or urgent care clinic feeling unwell.

Ketone strips are fairly affordable and should be in the medicine cabinet in every home of a person with type 1 diabetes. These little strips can tell you within seconds after being dipped in your urine whether your ketone levels are severely dangerous or only mild.

If the strip is mildly pink or light magenta, the ketones are small to moderate in severity.

If the strip turns dark magenta, your ketones are measuring at a large quantity. This is a sign of serious diabetic ketoacidosis and should be followed with a call to your doctor or a visit to your local urgent care.

A blood ketone meter is much more precise but also more expensive. For those with type 1 diabetes, a blood ketone meter really isn’t necessary. The color ranges on a urine strip are adequate enough when combined with blood glucose readings and your symptoms in telling you how severe your ketone levels have become.

Let’s take a deep look at diabetic ketoacidosis first.

Diabetic ketoacidosis (DKA)

This type of ketosis is quite simply dangerous and life-threatening for a person with any type of diabetes. Generally, people with type 2 diabetes cannot suffer from DKA because their body still produces some insulin. Instead, their symptoms result from persistently high blood sugar levels, not ketones.

For people with type 1 diabetes, DKA is defined by the level of ketones building up in your bloodstream and eventually excreted through your urine. Ketones develop when the body is forced to burn body fat for fuel because there is not enough insulin present to create and use glucose and body fat in a healthy way.

The problem with this production of ketones compared to the ketogenic diets we’ll discuss later is that the amount of ketones produced during DKA becomes a life-threatening quantity.

While everyone — even those without diabetes — occasionally produce small amounts of ketones and don’t know it, DKA is defined by a level of ketones over 20 mmol/L. Levels leading up to DKA, like 15 mmol/L may begin causing symptoms of DKA but DKA is at its worst when that level surpasses 20 mmol/L.

Ketones are generally known to develop when blood sugars are above 250 mg/dL and surpassing 300 mg/dL. The higher over 300 mg/dL your blood sugar is, the more ketones you’re likely producing as your body struggles to create energy without sufficient insulin.

Contrary to common belief, DKA is not caused by high blood sugars alone but by a lack of insulin. A person with type 1 diabetes could potentially have a blood sugar of 400 mg/dL, have a great deal of insulin in their bloodstream (even if it’s not enough to achieve a healthy blood sugar level), and still not be producing ketones.

Pre-diabetes diagnosis DKA vs. sudden DKA with established diabetes

Prior to your type 1 diabetes diagnosis, you were likely in some degree of DKA, but it comes on so slowly — over the course of a few weeks — that the symptoms are equally easy to dismiss as the lingering flu, a need for glasses (blurry vision), a little weight-loss, etc.

What drives us to see the doctor during the pre-diagnosis DKA is when those symptoms eventually worsen enough to become unignorable. But again, this generally develops over the course of weeks or a couple of months as our body’s own insulin production becomes more and more compromised by the attacks of our immune system.

Sudden DKA, on the other hand, is usually the result of a sudden interruption in our usual insulin regimen.

Common causes of sudden mild or severe DKA

• A failure in your insulin pump site or pod
• A drastic mismatch of insulin versus food
• Forgetting to take your insulin
• Using insulin accidentally damaged by cold or hot temperatures
• Purposefully consuming a large quantity of food without taking insulin
• Severe illness like a stomach virus or flu
• Certain medications with a risk of inducing DKA, like Invokana

Symptoms of Diabetic Ketoacidosis (or “diabetic ketones”)

While some of these symptoms are similar, remember that the symptoms of sudden DKA in a person with established type 1 diabetes are more severe than the symptoms of DKA that gradually develop when your body is first developing diabetes.

Pre-diabetes diagnosis DKA (ketone levels gradually increasing, 10 to 20+ mmol/L):

• Sudden extreme thirst
• Abnormally frequent need to pee
• Abnormal fatigue and tiredness
• Unexplained weight-loss
• Blurred vision
• Rotten-fruit smelling breath
• Yeast infections in women
• Craving sugar
• Dry bowel movements in diapers of young children

Small to Moderate ketones (ketone levels between 10 to 20 mmol/L):

• Increased thirst
• Frequent urination
• Lack of energy
• Craving sugar

Large ketones / DKA (ketone levels over 20 mmol/L):

• Severe nausea & vomiting
• Severe thirst
• Frequent urination
• Severe fatigue
• Blood sugar levels that won’t budge
• Craving sugar
• Rotten-fruit smelling breath

Causes of Diabetic Ketoacidosis (DKA)

While anyone — again, even those without diabetes — can develop small levels of ketones, developing enough ketones to put you in a state of DKA is generally the result of three different issues:

You did not take your insulin as prescribed.

Maybe you forgot. Maybe you were feeling rebellious or burnt out and you skipped it on purpose. Maybe you thought you took it, but you really didn’t.

While missing a few units of insulin isn’t going to lead to DKA, skipping multiple doses, skipping your background insulin, or eating a large amount of carbohydrates and skipping your insulin can all lead to DKA.

While you may hope you can simply take your insulin and fix it, if you’re experiencing symptoms of DKA versus small to moderate ketones, you’ll likely need to visit an emergency or urgent care clinic immediately.

There was a malfunction in your insulin pump.

Technology is great but technology can fail. While most of today’s insulin pumps and pods have safety features to alert patients when insulin isn’t getting administered properly, it still happens.

Sometimes, the first warning you’ll have that your pump is malfunctioning is a sudden and extreme spike in your blood sugar levels. In addition to changing your pump site and potentially calling customer support, you may also want to take an injection insulin to ensure you get insulin properly into your system.

If you’re experiencing symptoms of DKA versus small to moderate ketones, you’ll likely need to visit an emergency or urgent care clinic immediately.

Your body is struggling with a severe illness or infection.

While the common cold might cause a small number of ketones, it isn’t likely going to put you into DKA. However, the flu or a serious infection can create so much stress within your body that moderate to large ketones develop.

Any time a person with diabetes becomes sick — especially someone who takes insulin — it is critical that you communicate with your healthcare team to adjust your insulin needs. Illness can require more overall insulin while your body fights whatever you’re sick with. And infections — left untreated — can become life-threatening or threaten the wellbeing of an entire limb if ignored.

Treating & Managing Diabetic Ketoacidosis (DKA)

There’s no arguing that DKA is absolutely life-threatening, and should be treated with great concern and immediate action.

First, test your blood sugar. Call your doctor, and take an appropriate dose of insulin to help bring your blood sugar levels and ketones down. You may find that when you have moderate to large ketones, normal doses of insulin won’t have any impact on your blood sugar. Talk to your doctor about increasing your insulin dose to make an impact on your blood sugar and ketone levels.

Secondly, drink some water. Ketones are flushed out through your urine. To help your body do this, drink more water (or any non-caloric, non-caffeinated beverage…but preferably plain water). However, be careful, you can drink so much water in an effort to flush out the ketones that you can induce vomiting by putting too much pressure on your digestive system.

Thirdly, if you begin to vomit — for any reason — visit your local urgent care or emergency room immediately. When a person with type 1 diabetes begins vomiting from ketones, it means your ketosis has surpassed a level that can be treated and managed at home. By visiting a clinic or hospital, you can get your body rehydrated and blood sugars regulated through intravenous fluid and insulin.

Lastly, even without vomiting, if your ketones persist for several hours and continue to be moderate to large on your urine ketone strips, you should visit your local urgent care or emergency room. Clearly, these ketones need intravenous fluids and insulin to help bring your body back to a healthy and safe state.

Left untreated, DKA can and likely will be fatal. It should be addressed with great concern and prevented as much as possible.

Nutritional Ketosis

Nutritional ketosis is the result of a strict low-carb diet. While a generalized “low-carb diet” refers to eating fewer than 50 grams of carbohydrates per day, following a “ketogenic diet” is far more strict.

When carbohydrate consumption drops significantly, the body starts burning body fat for fuel instead of glucose from your bloodstream and from the food you eat.

Generally, the recommendation to push the body into ketosis through carbohydrate restriction is to limit your net carbohydrate consumption to less than 20 grams per day. That includes the carbohydrates found in healthy foods like bell peppers, tomatoes, and nearly all fruit except the avocado!

This form of ketone production is safe because the amount of ketones produced is small. Generally no more than 3 mmol/L. Whether or not you have diabetes.

And no, buying “raspberry ketones” from the diet section in your grocery store is not going to help you get into ketosis. The “ketones” in raspberries have nothing to do with actual ketones produced in the body.

Most who pursue this nutritional lifestyle do so for the sake of fat-loss. But it has also proven to be especially effective for patients with epilepsy and other brain-related conditions. Some patients with gastroparesis have also found it helpful for managing diabetes and preventing flare-ups.

Some studies report that the brain operates at a higher level when relying on ketones for fuel versus glucose. Others warn of the dangers of this low-carb, high-fat lifestyle.

While it can be beneficial for people with diabetes, because carbohydrates are the number one nutrient that raise blood sugar levels and require insulin doses, it isn’t ideal for everyone. For some, this low-carb, high-fat lifestyle leads to increased insulin resistance, higher blood sugar levels, and higher insulin needs.

If you have type 1 diabetes and begin following a ketogenic diet, you should still be taking insulin daily but your doses will likely need to be adjusted as your body adapts to the new diet. Frequent low blood sugars are a sign your insulin doses need to be reduced.

For those with type 2 diabetes taking insulin, you may see a reduction in your diabetes medications or insulin doses with an increase in low blood sugars. Check your blood sugars carefully and talk about any medication changes with your healthcare team.

Read more about following a ketogenic diet with diabetes.

Starvation ketones

Quite simply, starvation ketones are the result of not eating for a significant number of hours. Many people — especially pregnant women — will show small ketone levels in their urine when they first wake up in the morning because their body has been burning fat for fuel overnight.

It’s a natural part of the human body’s way of taking care of itself when you aren’t eating frequently.

Intermittent fasting is another form of “starvation” that can result in burning body fat for fuel and producing ketones. Again, it’s safe because the amount of ketones produced is small. Generally no more than 3 mmol/L.

It isn’t dangerous. If ketone levels rise to a moderate or large amount, the cause of your ketones is most likely not from skipping a meal or two. Contact your healthcare team immediately or visit your local emergency or urgent care clinic.

Illness-induced ketones

For people without diabetes, this is not generally a concern. For those with diabetes who take insulin, testing your ketone levels when you are sick should be a routine part of your self-care.

When the body is fighting a virus — like the flu, for example — it is under a great deal of stress. This can lead to inflammation, insulin resistance, and ketones.

Especially for those with type 1 diabetes, these ketones can be cleared or prevented by increasing your insulin doses with support from your healthcare team. While your blood sugars may seem as though you don’t need more insulin, the sign of ketones in your urine during an illness says otherwise. You may be surprised to find that increasing your insulin doses doesn’t lead to low blood sugars but does help clear and eliminate the ketones while you continue fighting the illness.

Infection-induced ketones

An infection, on the other hand, can be a much more serious issue.

While a common and mild infection like a urinary tract infection (UTI) or a sinus infection can lead to small or moderate ketones, an adjustment in your insulin doses while following protocol to manage your infection will usually be adequate.

Other types of infections should be treated much more seriously and carefully.

People with diabetes face a higher risk of infections because excess glucose in the bloodstream feeds the growth of bacteria and infections, and reduces the rate of healthy blood flow and oxygen to areas like your fingers and toes.

If you suspect you may have an infection, contact your healthcare team immediately and visit your local emergency room. Waiting too long could put your limb or life in serious danger.

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