Normal ketone values?

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SimonP

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Type 1
I note a distinct fear of ketones amongst those new to the fold.

Some people are diagnosed and are in DKA at that point, which will obviously make you weary (I've no idea what state I was in when diagnosed, long long time ago.) There's a risk for T1 on pumps if you have a diffusion set failure, and for T2 diabetics (so I understand.) So there is a risk, but my feeling is that it's perhaps rather overstated for those who are taking insulin and it's working.... but I only have my own experience to go by, and samples n=1 aren't great.

I've been diabetic for ~38 years and certainly haven't tested (or had any way to test) ketones for the last 25-odd years, so while I've always thought people being very concerned about their values is probably rather alarmist, I've never had any numbers to compare. I now have a ketone meter and some test strips.

The NHS guidance (https://www.nhs.uk/conditions/diabetic-ketoacidosis/) is:
  • under 0.6mmol/L is normal
  • 0.6 to 1.5mmol/L is slightly high – test again in 2 hours
  • 1.6 to 3mmol/L means you're at risk of DKA and should speak to your diabetes care team for advice
  • over 3mmol/L is high and means you may have DKA and should call 999 or go to A&E
As with all things that have been simplified, this is apparently not the whole picture - it depends on what you do and what you eat. I'm curious if anyone has actually been diagnosed with DKA with a blood ketone concentration close to 3 mmol/l, where does this guidance come from or is it attempting to get people to fix a problem before DKA occurs (and also accidentally worrying many people who have a reason to have ketones concentrations which are outside of the specified bounds)?

This figure is sometimes shown when people discuss ketones:
1708333246742.png
(Phinney and Volek)

and here is another one I found looking at post-exercise ketones, which shows similar ranges:
1708333440326.png
www.ncbi.nlm.nih.gov

Metabolism of ketone bodies during exercise and training: physiological basis for exogenous supplementation

Optimising training and performance through nutrition strategies is central to supporting elite sportspeople, much of which has focused on manipulating the relative intake of carbohydrate and fat and their contributions as fuels for energy provision. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

I thought it would be interesting to see what sorts of numbers people actually get, whether it's during/post-exercise, just normal life (stress, no stress, etc.) or if on particular diets (keto vs normal/high carb). The NHS guidelines seem very very conservative (I've no idea what cohort type they came from, I will see if I can find out) it would be interesting to see what people actually get in the real world.

To kick it off, here are mine from yesterday and today:

pre-bed yesterday (4h after finishing a long ride):
Ketones: 2.3 mmol/l (BG: 13.3 mmol/l)

pre-breakfast today:
Ketones: 4.9 mmol/l (BG: 4.4 mmol/l)

I'm not low carb, I usually eat ~255g carbs a day (roughly averaging using Tidepool data) and while I didn't eat enough to cover burned calories yesterday (~4100kcal according to Garmin), I did still eat about 240g of carbs over the course of the day with about 150g not requiring bolus during the course of the ride.

My assumption is that rather than calling A&E immediately as per-the NHS guidance, I was simply in a decent fat-burning/keto state while riding and am now in post-exercise ketosis. Hopefully, otherwise this may be my last post for a while! 😉

Edit: The first reading is ketones (with a strip from a little packet), the second one (now crossed out) was in fact blood glucose - I assumed the strips I had were ketone strips, but apparently not! I've now dug out a different ketone meter and double checked it actually has ketone strips and added a reading (so basically a day after the ride) down the bottom of the thread. Shame, as it would have been interesting to see how quickly the ketones wear off. Next time!
 
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Not sure it's any use as a T2 but I was at 5.0 on admission to A&E. It's generally believed that this was as a result of Covid screwing 10 years of good control & sending levels through the roof. My HbA1c was 117 at admission which is why I think all T2s should have access to a meter. If I'd had one I would have caught this long before DKA set in.

Just checked back through my records & my ketones were 1.2 on the day of discharge & 0.4 a week later. I was told no further testing was necessary unless BG was consistently over 15.
 
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I’ve always been a bit cavalier about Ketones.
I never got prescribed any form of ketone testing, nor was it mentioned when I was first diagnosed. This maybe because I was assumed to be Type 2 to start with, (even though my HbA1c was 16.1%in old money) and that bit of advice slipped through the net. Nobody ever mentioned testing me for ketones at any of my appointments either, and there are none on my records.
Roll on a few years to Covid, and I read that they were finding people with DKA at lower levels of blood glucose than normal, so I asked for some test strips just in case, and got prescribed the ones you dip into urine, because I wasn’t sure if I had a compatible meter. (I was self funding the Libre at the time, and didn’t realise the reader would take Ketone strips).
Never needed them, until I had a horrendous stomach bug last Oct, and decided perhaps I ought to check, as my BG was being difficult. Found that a) the strips were past their use by, and b) it was impossible to tell how far up the colour scale I was. If I used my imagination, I could either interpret them as dangerously high, or kind of in the middle, so I decided to assume it was the middle colour, and they were probs starvation ketones because I was unable to eat. (My BGs were wandering round the teens, but hadn’t got into the 20s by any means) I really didn’t have the energy at the time to ring 111 and certainly didn’t want to be told to present myself at a hospital in the state I was in! (galloping to the loo every half hour)
I lived to tell the tale, and did ask for and receive some blood strips at my last review, on the grounds that I hadn't been able to match the colour of the strips with what was on the pot, with the urine sort.
 
Robin said:
I lived to tell the tale, and did ask for and receive some blood strips at my last review
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Keep an eye on the expiry date as the ketone test strips seem to have a much shorted shelf life. Or at least they do for my Caresens Dual. Although given that they're individually foil sealed I'd be happy using them for indicative purposes past their expiry.
 
I wasn't prescribed ketone strips until I got a pump and, apart from during covid, no one has bothered checking I have any in date.
I have used them once ïn anger" when I had high BG and severe abdominal pain. I think my ketones were around 2 at the time and the pain was unrelated.

I am a bit of a rage boluser when I spot my BG in double figures so rarely see prolonged highs that would require ketone testing. When packing for a recent holiday, I realised my ketone strips went out of date a year ago. I got some more in order to avoid the pain from "kicking myself" if/when my BG gets stubbornly high in the next year.
 
RBZ5416 said:
Not sure it's any use as a T2 but I was at 5.0 on admission to A&E. It's generally believed that this was as a result of Covid screwing 10 years of good control & sending levels through the roof. My HbA1c was 117 at admission which is why I think all T2s should have access to a meter. If I'd had one I would have caught this long before DKA set in.

Just checked back through my records & my ketones were 1.2 on the day of discharge & 0.4 a week later. I was told no further testing was necessary unless BG was consistently over 15.
Click to expand...
Were you admitted with DKA (and if so were you symptomatic?) or was it for "work-out-what-type-of-diabetes-this-person-has" or however it's usually described?
 
SimonP said:
Were you admitted with DKA
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Yes, extreme fatigue & weight loss. Could have been spotted much earlier if I had a meter or even if the paramedic I eventually saw at the GP had carried out a ketone test rather than just ordering an HbA1c that took a further week to come back...
 
helli said:
I wasn't prescribed ketone strips until I got a pump and, apart from during covid, no one has bothered checking I have any in date.
I have used them once ïn anger" when I had high BG and severe abdominal pain. I think my ketones were around 2 at the time and the pain was unrelated.
Click to expand...
I'm pretty sure I threw some very out of date strips out while decluttering my medical cupboard ~15 years ago when I moved and wondered at that point if I should get some new ones. But not recalling ever having used them I didn't bother. They may well have been the ones I was given on discharge.

helli said:
I am a bit of a rage boluser when I spot my BG in double figures so rarely see prolonged highs that would require ketone testing. When packing for a recent holiday, I realised my ketone strips went out of date a year ago. I got some more in order to avoid the pain from "kicking myself" if/when my BG gets stubbornly high in the next year.
Click to expand...
I also bolus if I'm going high (though I don't necessarily "rage" per-se, but I do have IoB), though I will let my BG run higher while exercising simply because bolusing will result in a hypo relatively quickly (though I again have basal on board) and if I go really high I will do a small bolus (and pay for it for the rest of the day by having to eat lots).
 
RBZ5416 said:
Yes, extreme fatigue & weight loss. Could have been spotted much earlier if I had a meter or even if the paramedic I eventually saw at the GP had carried out a ketone test rather than just ordering an HbA1c that took a further week to come back...
Click to expand...
Is this actually DKA though or is it the effect of insufficient insulin/high blood glucose?
 
When my daughter was diagnosed, her BG was apparently 46 and she was “going into DKA” I think is what they said. She was very ill though, didn’t even have the strength to stand up any more, hubby had to carry her into A&E. Blood pH was something like 7.1 (should be 7.4). Unfortunately I have no idea what her ketones were, other than high! She was doing the kussmaul breathing and the consultant said she probably would have been unconscious within 24 hours if we hadn’t got her to A&E when we did.

Once we got her stabilised we have always been given ketone strips because she’s on a pump, I don’t find them terribly useful though; every time they registered anything above normal we knew exactly why and they went straight back down again once the problem was resolved. So we very rarely bother to test them any more. One time when her cannula fell out sometime overnight and she’d had no insulin for several hours they still only went up to 0.9!
 
From those I’ve compared notes with at diabetes events over the years, I’ve got the feeling that some people are more adept at making ketones than others?

I don’t know if that’s known as a ‘Well duh! Of course!” thing by medics, or whether it’s never really been studied (it might be tricky to do so ethically!)

But I’ve known T1s and pumpers who have to be very careful about set failures, or periods of illness because their ketones can escalate with alarming rapidity.

I seem to be able to cruise at elevated levels for hours and hours without a whiff of a ketone!
 
As a type 2 not on medications I tend to sit around 0.5 - 1.00 on a low carb diet. If I’m sticking to keto it hovers around 2 to 2.5. No exercise involved.

My non diabetic carb guzzling OH with a hba1c in the low 30’s has hit just under 2 after extended bike riding (3+ hrs mostly in zone 4) carbed up night before, fasted outset, gels/bananas on route as required.
 
After a day of normal eating and insulin and being in range for 82% (stayed in range after supper too which is unusual - post-exercise insulin sensitivity) my ketones are now 0.4 mmol/l (BG is 6.8 mmol/l)

I also made a mistake with my post above - I didn't realise my meter was dual use and the pot of strips I was given were for blood glucose not ketones! The first reading post-exercise was ketones (from a little individual packet), but not the one from this morning (from the pot) - I'll amend the post above to explain also! I did wonder how my ketones were still above 5 even now, which made me look at what the pot said.... doh!
 
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Can't remember last time tested for ketones, have a meter but strips will be well out of date by now, not something I worry about but should get some new strips in case of illness at some point.
 
Keytone check 0.2 BG 9.1 just now, but don’t normally check them.
 
FWIW the advice from our paeds team is to treat anything over 1. Kids can go downhill very quickly so it tends to be more cautious guidelines than for adults.


Even with high BG and the odd illness we’ve only have one case of ketones in 5 years and that was only around 1.0 but he felt very rough and needed treatment immediately
 
Another long/hilly ride (just under 100 miles), and I've actually remembered to test ketones 2.3 mmol/l

BG is high 16.9mmol/l (having thought I might run low if I took normal dose for supper, having run low for the final 3h of the ride and nursed myself along with skittles and kendal mintcake I didn't want to eat (note to self, eat something proper for lunch, even if they've stopped serving!) Lots of IoB as I started stacking once I realised it wasn't dropping off a cliff as I was expecting.

Looks like 2.3 mmol/l is my standard post-ride value (from a sample size of two, almost ready for a journal publication 😉)
 
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