My blood sugar is under control and I’m doing enough insulin but I keep getting ketones. I’m not eating much and I’m not urinating like I should, so why do I keep getting ketones? My last A1c was 9, but they have slowly been going up and my ketones are high.

You indicated that your blood glucoses are under control and that you are taking (“doing”?) enough insulin, YET your recent HbA1c value is 9% AND you recognize that you keeping getting high ketones. These observations are NOT compatible!

Adequate glucose control and adequate insulin DOES NOT FIT with the presence of ketones. In someone with diabetes mellitus, ketones occur BECAUSE there is NOT ADEQUATE insulin. You indicate that you are not urinating like you should. I’m not sure exactly what you mean by that, but I will presume it means that you believe you need to pass urine more often than others normally do. Excessive urination is another means the body has to try to get rid of excessive glucose, so this is another piece of evidence to suggest that your glucose levels are indeed not where they should be. Glucose begins to “spill” into the urine when your blood glucose level is elevated to about 180 mg/dl [10.0 mmol/L].

As a teenager, you should be targeting your HbA1c values to be less than 7.5% or even lower!

You probably know that the optimal way to control your diabetes is to have a good balance of meal intake, insulin dosing, and physical exercise. You did not indicate how you watch your diet; you did not indicate what routine physical activity you perform; and you did not indicate your actual insulin regimen (types of insulin and dosages and when they are taken). Since different types of insulin have different onsets of action and different durations of action, (and some have predictable – but different – timing of “peak” action), then your insulin regimen should be matched more specifically to your meal plan and activity.

I concede that there is the possibility that there may be a miscommunication in how you are measuring for ketones. There is a special blood ketone meter and strip, but it gives the ketone reading with a number value and not as “negative” or “small” or “high.” Since you indicated that your ketones are “high,” then I will presume that you are measuring ketones in urine (which is very adequate and certainly less expensive than measuring for blood ketones). Urine ketones strips may be distinct but often are on the same chemical strip as measuring for urine glucose. The little “color square areas” on the urine strips for glucose testing and ketone testing are different but could be confusing. The glucose reaction test areas turn bluish to brownish if there is glucose sugar in the urine. In contrast, the special ketone testing reaction areas turns from beige-ish to pinkish to maroonish in color if there are ketones in the urine. I would want to be certain that you are indeed reporting urine ketones (and not accidentally reporting on urine glucose by mistake). Since you have diabetes, it would not at all be uncommon for you to sometimes have glucose in your urine.

So, all in all, I think that you probably are not in as good as glucose and overall diabetes control as you think you are – or should be. Please talk with your own diabetes specialist and certified diabetes educator to review your insulin and meal plans and activities and relay the issue that you have raised here on this web site. Maybe they think you have been doing the best you have been able to do in the past but maybe it is time to ramp up your control plan. Go ahead and copy this letter and take it with you.

DS