Ketones And Ketoacidosis

Individuals with type 1 diabetes and type 2 diabetes need to be careful to routinely check their urine for ketones or possible ketoacidosis (DKA) if blood glucose readings are high. Ketones are naturally produced in the body when fat is broken down, which is exactly what is occurring when blood glucose levels are elevated and insulin is unavailable to the cells. It is most common in people with type 1 diabetes where insulin is not being produced by the pancreas and supplemental insulin was not taken. Individuals with type 2 diabetes can also develop ketoacidosis when blood sugars spike or when insulin is not properly administered.

Causes Of Ketoacidosis

Diabetic ketoacidosis (DKA) is simply high levels of ketones in the blood. Ketones are produced because the fatty acids in the body are being broken down for energy since the glucose is unavailable to the cells. This predominantly occurs in the liver where both fat and proteins are rapidly broken down, releasing unregulated amounts of ketones. These ketones circulate through the body in increasing amounts, causing the pH of the blood to drop dramatically. If the increasingly acidic pH balance of the blood is not restored, the results can be fatal.

When insulin is provided routinely and in a correct dosage, it prevents the overproduction of ketones by regulating the liver’s breakdown of fat and protein. When insulin is not present or not present in the correct amount, the glucose levels rise, which in turn further cause an imbalance in the pH of the blood. Various health conditions such as chronic diseases, bacterial infections, viruses, and any type of physical stress can trigger a higher production of ketones and the risk of developing diabetic ketoacidosis.

For people that develop type 1 diabetes because of a viral infection or injury to the pancreas, the symptoms may develop very rapidly as the insulin production ceases in the body. Unless diabetes has been diagnosed the symptoms may be attributed to several other health conditions. Children and adolescents that are undiagnosed or are not using insulin injections or oral medications correctly are also at higher risk for developing DKA.  It is estimated that as many as 135,000 cases of DKA result in hospitalization per year with younger patients represented in higher numbers than adults. 1  

A study in Ontario, Canada found that of 3947 new cases of diabetes in children, 39.7% of those children less than 3 years of age had at least one incident of DKA and those over three had a 16.3% chance of being seen by a physician for DKA prior to the diagnoses of diabetes. In addition the research also found that children that had an incident of DKA had not had significant medical testing prior to the symptoms. 2 Researchers indicated that physicians and parents needed to become more aware of the symptoms and their link to the diagnosis of diabetes.

Fasting alone can cause a condition known as ketosis, but this is not the same as DKA. Some diets are designed to force the body into a state of metabolic ketosis to speed up the breakdown of fatty tissue in the body.

Symptoms Of DKA

One of the most noticeable symptoms of DKA is very high blood glucose levels over several readings. This is why routine blood testing is so important as, depending on the specific type of diabetes, two or more high readings should trigger a separate check for ketones in the urine. This is done by a simple home test strip that changes color with the acidity of the urine to indicate the level of ketones in the urine.

Other symptoms that may occur include a feeling of a dry mouth accompanied by unusual thirst and frequent urination. Since these are symptoms of both type 1 and type 2 diabetes these are not considered conclusive but, when combined with the other symptoms, such as a change from the normal state, they are indicative of ketoacidosis.

Symptoms may also include dry or flushed skin, exhaustion and mental fatigue, confusion , respiratory problems such as rapid, deep breaths, a fruit-like or acetone smell to the breath and nausea and vomiting. The symptoms may develop very slowly or they can occur relatively quickly, particularly if nausea or vomiting is present. Immediate attention is required, as without treatment, this can be a potentially life-threatening condition.


When blood sugar levels are high, when a person is ill, or if symptoms of DKA are present immediate urine testing is recommended. As mentioned above the test is very simple. A prepared reagent test strip is dipped into a urine sample and the resulting color compared to a chart that comes with the test strips. Other devices that test of ketones with blood glucose are also available and provide highly accurate information.

Treatment And Prevention of Diabetic Ketoacidosis

It is important to immediately seek care from your health care professional immediately if DKA is suspected. Typically hospitalization is required to restore electrolyte levels and rehydrate the body as well as controlling the elevated blood glucose levels until they are at safe and stable level.

For those with type 1 or type 2 diabetes ketoacidosis is largely preventable except in very extreme situations. Recommendations to help prevent high levels of ketones in the blood start with good blood glucose management. This includes:

  • Regular blood glucose monitoring
  • Eating healthy foods and avoiding or limiting foods that cause spikes in blood sugar if you don’t regularly use insulin and be very careful of food intake when blood glucose is over 250 mg/dL
  • Check for ketones when blood glucose readings are elevated or if you are ill
  • Avoid exercising when blood glucose levels are high or ketones are present
  • Never skip insulin treatments
  • Do not skip meals and insulin treatments even when ill or not feeling hungry
  • Exercise regularly when blood glucose levels are normal
  • Check your insulin pump regularly to make sure it is functioning properly
  • Consult with your doctor to know the appropriate ketone range, blood glucose level and medical symptoms to be aware of if ketoacidosis is a concern.

For diabetics with type 1 diabetes, ketoacidosis is much more common. However, both type 1 and type 2 diabetics can minimize the risk of developing DKA by following the points listed above.  In a study of adolescents with poorly controlled type 1 diabetes, it was found that using a behavioral training approach that incorporated management, routine testing and education about diabetes decreased the amount of medical noncompliance and also decreased the reductions in admissions to treat DKA in the study group. 3 This same type of training is highly effective in adults and prevents the additional cost of treatment of this manageable complication of diabetes.


1 Woode, D. e., & Kitabchi, A. E. (2011). Hyperglycemic Crises in Diabetes Mellitus: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Management of Pediatric Obesity and Diabetes , 327-348.

2 Bui, H., To, T., Stein, R., et al. (2009). Is Diabetic Ketoacidosis at Disease Onset a Result of Missed Diagnosis? The Journal of Pediatrics , 472-477.

3 Ellis, D., Naar-King, S., Templin, T., et al. (2008). Multisystemic Therapy for Adolescents With Poorly Controlled Type 1 Diabetes. Diabetes Care , 1746-1747.

This article was originally published July 12, 2012 and last revision and update of it was 9/10/2015.