As an adult, I cannot remember any of my healthcare providers talking to me about ketones. I can’t remember teaching anyone about ketones when I worked with adult patients. So when I started working in a children’s diabetes clinic, it took me a while to understand why almost every conversation included something about ketones. When do they develop and what’s so scary about them? Why are they so important when I hadn’t heard about them since I was a kid?
First off, what are ketones?
Ketones are one of the body’s ways of creating energy from our own stores. We break down stores of glycogen in the liver and muscle and turn them into sugar when we are trying to raise blood sugar (BG), stressed, sick or during activity (depending on the length and type of activity). We can also break down our fat stores into ketones which we can then use like sugar to create energy in our cells (see blog “What is diabetes?” For more information). We start breaking down fat stores when we need additional energy to help us fight off things like illness or when we haven’t eaten much carb for a while. The problem is, just like glucose, ketones need insulin to get into the cells to be converted into energy. In someone who has diabetes, ketone levels in the blood can rise to a dangerous level and if we don’t know to test for them or have a treatment plan, we can end up needing to go to the emergency department (no fun!).
All patients with type 1 diabetes should know that they can monitor for ketones when they are feeling sick or when BG is over 300, especially if BG is not coming down. When we test for ketones, it’s like getting more information about what is going on in your body. Once we have that information, we can treat for ketones at home (typically giving more insulin, drinking lots of water and resting) and hopefully avoid going into DKA (diabetes ketoacidosis). By talking to your health providers, you can create a plan for if you develop ketones but it all starts with monitoring for ketones when they are most likely to develop.
How do you test for ketones?
To test for ketones, take out a strip from the bottle, dip the side with the little sponge on it into your urine or catch a little urine on the strip mid-stream when you pee. Wait 15 seconds and compare the color of the sponge to the side of the ketone strip bottle. The darker the color, the more dangerous the level of ketones.
High levels of ketones in the blood can cause nausea, stomach aches and vomiting. It can also lead to rapid breathing and loss of consciousness. If you have any of those symptoms and have ketones in your urine, call your doctor or go to the emergency room.
Isn’t that just one more prescription and more money I have to fork over? You actually don’t need a prescription for urine ketone strips. They are available at any pharmacy over the counter at around $15 for 50 strips. You can also ask your doctor for a prescription to get them at a lower cost (if covered by your insurance).
Ok, but really. What’s the big deal?
Ketones are acidic. Imagine you had a sore throat and were drinking water. All the sudden, the water turns to lemon juice. Ouch!! Your blood pH is kinda like water – pretty neutral. Ketones are acids and they lower the pH in the blood which is what causes you to feel really sick. Your blood won’t be as acidic as lemon juice, but it does drop to a point that is very dangerous to your body. Ketones also dehydrate your cells. So, when you have high blood sugar, lots of ketones and are dehydrated, we need extra help to correct that.
For those on an pump
If you are using an insulin pump, there is a higher risk that you develop ketones because you don’t have any long-acting insulin to act as a backup if you missed an insulin injection at a meal or it wasn’t absorbed well. If you notice that your blood sugar is running high when you are on a pump (and especially if you just changed your inset), check for ketones. If you have ketones and high blood sugar, chances are you need to change your pump site because the insulin is probably not getting delivered correctly.
So, maybe we don’t talk about Bruno, but let’s talk more about ketones. Know when to check for them and what to do when they are present. If they are negative, you can rule them out as an issue but you may want to check at least one other time during the day for them, just to be sure.