I have had diabetes for 36 years, I maintain tight control (A1c is never over 6.5%), and I’m trying to find someone to help me understand why I spill ketones so easily. I’ve been told it’s because I don’t weigh enough, don’t eat enough or that my blood sugar is out of control, but I can’t accept any of these explanations. I eat quite well because I have been underweight all my life, and don’t think thin is attractive. The last few times this occurred, my blood sugar was 85 mg/dl [4.7 mmol/L] and stable. The only reason I checked for ketones in the first place was because I had that strange stomachache that accompanies them.

Sometimes you can spill ketones after a low blood sugar. This often happens if you go low during sleep, but your body corrects on its own before you wake up. Many of the hormones that go up to raise a low blood sugar also cause ketones to spill.

I sometimes have patients check for ketones fist thing in the morning if I suspect they are having an undetected low during the night. You might want to check more often during the night or even during the day to see if you are having undetected lows.

TGL
Additional comments from Dr. Stuart Brink:

Ketones, when present in urine or in blood, just indicate that fat is being burned as part of metabolism. This can occur with insulin deficiency and is usually associated with hyperglycemia and can lead to DKA [diabetic ketoacidosis]. Ketonuria or ketonemia [ketones in the blood] can also occur if there is insufficient caloric intake for any reason (starvation, illness) as well as desirable times when weight loss is wanted (obesity). So, you are correct this is not associated with hyperglycemia or illness that there is a temporary condition of burning fat and would usually indicate either mild insulin deficiency (e.g., during exercise) or insufficient calories at that moment. Lastly, during or after hypoglycemia events, your body may trip to “fix” the hypoglycemia on its own. If there is insufficient stored sugar (glycogen), the body would then go to its reserves (fat) and this would also show up in urine or blood ketone testing. If so, then extra food at those times would likely prevent the body’s needs to generate energy from the fat stores.

It sounds like this is not a big problem or something to worry about from your hemoglobin A1c levels being in such excellent range. It’s best to review this with you own diabetes team since they can give you specific advice and look at your own data for problem solving detective work with you.

SB
Additional comments from Dr. David Schwartz:

I agree with Dr. Brink. Are you following a low-carb (hence ketogenic diet)? Another explanation is that there is something wrong with your ketone strips or that there is a cross-reacting substance in the urine.

Ketones may normally be present in urine as described above with fat burning and low glucose levels in the blood (in the non-diabetic), but concentrations may be below the limit of detectability with routine testing methods. However, positive ketone readings are found in normal individuals during fasting and in up to 30% of first morning urine specimens from pregnant women. Urine ketone tests using nitroprusside-containing reagents can give false-positive results in the presence of several sulfhydryl drugs, including the antihypertensive drug captopril.

DS
Additional comments from Dr. Donough O’Brien:

Assuming that you are over age 20, I calculate that your BMI (Body Mass Index) is only 18.2 which is underweight for your height, albeit not strikingly so. Your efforts at tight control are probably making you relatively carbohydrate deficient, and because of that, your body is using some fat to maintain normal energy requirements and this produces ketones. The urine test is an exceedingly sensitive one.

My suggestion is to have your dietitian analyse a typical three-day dietary intake. Appropriate adjustments will probably dispel the ketones without affecting your excellent control.

DOB