Islets of Hope care tips for persons with diabetes

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Article by  Lahle Wolfe, 02/24/2006


Diabetes New Zealand

Joslin Diabetes Center; Ketone testing

Web MD; Ketones

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A ketone urine test is performed to measure either the absence or presence of ketones in the urine.

Purchasing Ketone Test Strips

Ketone test strips should be covered by most insurance plans that cover other diabetes supplies, but your doctor needs to write a prescription for them.

You can purchase ketone test strips over the counter at any pharmacy without a prescription.  They usually cost less than $10.00 for a bottle of 50 strips.

Storing Ketone Test Strips

Once the vial is opened the bottle of ketone test strips is only good for another 30 days.  The expiration date may indicate much longer but ketone strips should be thrown away 30 days after opening.

When you open the bottle, mark the date to help you remember when they were opened. Chances are, if your diabetes is under control you won't be using them very often.

Your doctor can also prescribe ketone test strips that are individually wrapped and sealed. They are more expensive but you don't have to worry about throwing away unused strips after only 30 days.

Do not store ketone strips in bathrooms where you bathe or shower.  While this may seem convenient the strips are sensitive to changes in humidity and temperature.  Instead, store them in a cool, dark place (not the refrigerator) like a closet, or powder room.

Web MD's definition of Ketones:

When fat is broken down for energy, the body produces by-products called ketones (or ketone bodies) and releases them into the urine. Large amounts of ketones in the urine may signal a dangerous condition known as diabetic ketoacidosis. A diet low in sugars and starches (carbohydrates), starvation, or prolonged vomiting may also cause ketones in the urine.

From NHS Direct:

If you are diabetic and you fail to have your injections of  insulin for a prolonged period, you can experience ketoacidosis. The lack of insulin means that your body cannot use glucoseto create energy and ketosis occurs. If left untreated, your body will release so many ketones into your blood that your blood will quickly become dangerously acidic. Untreated diabetic ketoacidosis can lead to coma and death.

Health and Safety

The alcohol in drinks of either low alcohol content (below 15%) or high alcohol content (over 30%) tend to be absorbed into the body more slowly.

Great Books About
Type 1 Diabetes

psyching out diabetes  
Richard R. Rubin, Ph.D., C.D.E.

Psyching Out Diabetes:  
This book examines the psychological obstacles of diagnosis such as panic, fear, anger, shame, and guilt and how to put them into perspective. Through proper maintenance, diet, and education, this book is tailor-made for the diabetic or anyone with a diabetic in their life who wants to overcome the negative emotions associated with this disease and learn the coping skills necessary to integrate diabetes into their daily life.  Dr. Rubin is a faculty member of the John's Hopkins Medical School.

think like a pancreas  Gary Scheiner, CDE
Think Like a Pancreas:  Many books offer advice on managing diabetes, but few focus specifically on the day-to-day issues facing those who use insulin.  Scheiner, a certified diabetes educator and himself an insulin user himself since 1985, gives you the tools to "think like a pancreas"--that is, to successfully master the art and science of matching insulin to the body’s ever-changing needs. Free of medical mumbo jumbo, comprehensive, and packed with useful information not readily available in other books.

101 medication tips for people with diabetes   Betsy Carlisle
101 Medication Tips for People with Diabetes by University of New Mexico Diabetes Care Team.

a diabetic doctor looks at diabetes  Peter A.. Lodewick
A Diabetic Doctor Looks At Diabetes:  Written from the unique perspective of a doctor who has lived with diabetes for the past 30 years, A Diabetic Doctor Looks at Diabetes has been updated to give people with diabetes the up-to-the-minute tools and information they need to understand, cope with, and live with the disease.

Remember that learning to master your diabetes is an ongoing challenge. Don't let bad days discourage you from succeeding the next day!

Join an Islets of Hope Support Group

Medical Disclaimer

Islets of Hope offers free, general information about diabetes and disorders associated with diabetes. This information is not intended to replace the medical advice and care of your physician.  Please discuss your own health questions and concerns with your personal physician before making any changes to your diabetes care plan.

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Testing urine for ketones
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NOTE:  Since many things can cause ketones to register in urine, including following a low-carbohydrate diet, please note that the information on this page is intended as a guideline specifically for persons with diabetes testing for ketones as a means of detecting diabetic ketoacidosis (DKA).  For those who have diabetes, ketones should not be ignored.  Those on ketogenic low-carbohydrate diets or very low-calorie diets, should also read our section on "Benign Dietary Ketoacidosis."

Mini Site Index
What are ketones?
What things can produce ketones?
Why do ketones form?
What is diabetic ketoacidosis (DKA)?
Why should I test for ketones?
When should I test for ketones?
When should I call my doctor?
How do I test for ketones?
Adults & children that are potty trained
Infants and children in diapers
Using a urine bag

What are ketones?

Ketones are formed when your body uses fat for energy; they are a byproduct of rapidly burned fat (or excessive fat burning) and in the case of diabetes, along with hyperglycemia, can build up in the bloodstream to dangerous levels if not corrected.  Urine ketones may also be referred to as acetone, acetoacetic acid, and beta-hydroxybutyric acid.  

What things can produce ketones?

Several things can contribute to the presence of ketones in urine, including:

  • Metabolic disorders, including diabetes or glycogen storage disease
  • Abnormal nutritional conditions, like starvation, fasting, anorexia, bulimia, high protein/low carbohydrate diets, and very low-calorie diets (VLCDs)
  • Protracted vomiting, including hyperemesis gravidarum and cyclic vomiting syndrome (CVS)
  • Disorders of increased metabolism, including hyperthyroidism, fever, acute or severe illness, burns, pregnancy, lactation or post-surgical condition
  • Alcoholism, and
  • Glucocorticoid drugs appear to produce ketones but only give a false positive reading.

Why do ketones form?

Glucose, the simplest form of sugar, is what your body normally uses for energy.  Food and drink, especially those containing carbohydrates (fat and protein, to a lesser extent, can also provide energy) is converted by the body into this useable form of energy (glucose).

In order to move glucose from the bloodstream into cells, insulin is required.  If not enough insulin is present (or, if a person is resistant to insulin as in the case of some with type 2 diabetes and other metabolic disorders) glucose does not move into the cells and can build up in the bloodstream.  Without insulin, two can things happen:

  • hyperglycemia (high blood sugar)
  • cells, organs, tissues, and the brain begin to starve and look for an alternative source of energy (fat stores)

When the body senses cells are not being fed it will turn to fat stores and lean muscle mass as a source of energy.  This happens mainly when a person does not eat enough or there is not enough insulin is in the blood stream.  People often experience weight loss with type 1 diabetes when blood glucose is too high, especially when they are first diagnosed, and may have very high levels of ketones in their urine.

Using fat for energy causes your body to make even more glucose.  This is in addition to the glucose already circulating in the bloodstream that is unable to center cells because there is not enough insulin.  Blood glucose levels rise higher, more fat is burned as the body starves, and more ketones are produced by the burning of fat.  

The kidneys try to cleanse the bloodstream by excreting blood glucose and ketones through the process of urination.  This is why people with high blood glucose levels have to urinate frequently.  But the kidneys become overworked and can no longer keep with the demand and ketones and glucose levels can build up enough to cause organ damage, coma, and even death.  To make matters even worse, the constant urinating can dehydrate a person with diabetes which concentrates glucose and ketones making their effects even more damaging.

Having ketones in your blood or urine causes fruity smelling breath. This odor is sometimes mistaken for alcohol. (When my daughter Elizabeth was first diagnosed at age 4, I recall her breath smelled sweet, like corn, all the time.)  

Why should I test for ketones?

Ketones in urine indicate a body in distress.  Knowing if you are producing ketones can help your doctor determine if you need adjustments to your insulin doses, timing of insulin, different insulin, or in some cases, if you require hospitalization.

Ketones in the urine may indicate diabetic ketoacidosis (DKA), which untreated, can lead to serious, even fatal consequences. Home glucose monitors cannot determine if a person is in DKA, and although DKA typically occurs in blood glucose levels that remain over 240 mg/dL, there are circumstances where it can occur at much lower levels and even over a matter of hours.  

What is diabetic ketoacidosis (DKA)?

Diabetic Ketoacidosis (DKA) - When not enough insulin is present blood glucose runs too high.  The body begins to use fat stores as an energy source.  Ketones, a byproduct of burned fat, are produced and can quickly reach dangerous levels.  High ketones indicate that a person may be in diabetic ketoacidosis which can result in coma or death and usually requires hospitalization to become stable again.  You should never attempt to treat DKA without specific instructions from your physician!  

When should I test for ketones?

Your blood glucose monitor probably has a feature that says "check ketones" when your blood glucose reading is 240 mg/dL or higher.  Some meters are preprogrammed to alert you that your blood glucose levels are high enough that you could be in danger.  "Check ketones" simply is your meter suggesting that it might be wise to check your urine to see if you are producing ketones.

Your doctor may offer other guidelines for when to test for ketones including:

  • any time blood glucose levels are over 240 mg/dL
  • during illness (especially dehydrating problems like vomiting and diarrhea), or stressful situations
  • any time you become dehydrated or are urinating frequently
  • randomly the first few weeks after diagnosis when diabetic ketosis (DKA) is most likely to recur  

When should I call my doctor?

Your physician will let you know when he/she wants you to call.  However, most ask that you call any time that your blood glucose is high more than twice in a row, during illness, or any time that your urine tests positive in the moderate to heavy range for ketones.

Reading on Test Strip

  What it Means

Action to Take

(negative results)
(no color change)

Results are negative; there are no ketones in your urine.  Your body is handling blood glucose well and not spilling excess glucose out into urine.

No need to call doctor.  Keep up the good work managing your blood glucose!

Small Ketone Level
Usually, <20 mg/dL

You are spilling small amounts of ketones into your urine.  Try drinking more, and check your blood glucose levels.  Give a correction bolus of insulin if you are too high.

Call doctor if small ketones remain present more than a day, or begin to increase.

Moderate Ketone Level
Usually, 30-40 mg/dL

Ketones are spilling into your urine.  You may need more insulin and could be entering DKA.

Call the doctor as soon as possible.

Usually, >80 mg/dL

Dangerous levels of ketones are present and you may require emergency medical treatment.

Call the doctor immediately.

How do I test for ketones?

Testing for ketones is very simple and only involves soaking a ketone test strip in urine.  

Adults and Children that are Potty Trained

Children and adults can either urinate directly onto the test strip (by holding it in the urine stream).  It is better to begin the urine flow and then put the strip into the flow.  This allows for a "cleaner catch."

You can also collect a urine sample in a clean disposable cup (plastic or paper is fine) and dip the test strip in long enough to saturate the tip.  To do this, begin to urinate for a second or two then stop.  Then urinate into the cup.  By not collecting the first flow of urine you allow for a cleaner "catch" and results will be more accurate.

Using a cup may be a better route to take with children since the strip needs to be read at just the right time in order for the results to be accurate (usually at precisely 15 seconds).  A dawdling child might not hand you the test strip in time to be accurately read.

Note:  Menstruating women, or anyone with a yeast infection should clean the outside genital area first.

Infants (and those not yet potty trained)

If your child (still in diapers) requires ketone testing, you will need to be alert and patient and a little creative. If you are trying to collect a urine sample:

  • Thoroughly wash the urethra/penis and surrounding area.  
  • Do not add baby powder, lotion, or creams.
  • Diaper the baby and check every 15 minutes, or hold them in your lap (you can usually feel a warm spot when the child urinates).
  • Do not use urine samples contaminated with fecal matter.
  • If you cannot get a urine sample within an hour call your doctor for further instructions.

Since urine samples need to be fresh, using old urine will not provide accurate results.  As soon as your baby urinates in his/her diaper it will feel warm to the touch for a few seconds.  Have your test strips and a paper cup ready so you can catch the urine while fresh.

Disposable Diapers.  Remove the diaper and gently squeeze a small amount of urine into the paper/plastic cup.  Insert the test strip immediately.

Cloth Diapers.  If you are using a cloth diaper you may also be able to simply press the test strip into the urine soaked material.  This does not work as well with disposable diapers which tend to quickly absorb urine.  

Tip to Collect Urine from Any Diaper.  You might also try to use something called a "diaper doubler" (they look like giant sanitary napkins and are sold in the diaper section of stores).  You can also use an unscented, plain tampon or sanitary pad. Insert pad/tampon into the diaper (in front for boys, in back for girls) and diaper.  The pad/tampon will absorb urine and make it easier to squeeze out into a cup.  Do not use scented, medicated, or deodorized feminine products which can skew test results.

Using a Urine Bag

A doctor may suggest using a urine bag to collect urine.  To use a urine bag, wash the area around, and including, the urethra/penis.  Open the urine collection bag (a plastic bag with an adhesive paper on one end), and place it on your baby as instructed by your doctor. (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 the child as usual but do not use lotions, powder or creams. Check the bag frequently and remove the bag after the infant has urinated into it.  You can drain the urine into a clean container or simply insert the ketone test strip into the bag.

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Page Updated 07/24/2006