Development of Ketones?

[SharpTail]

With some discussion of excercise and high blood glucose in other threads there has been mention of concerns of possible muscle damage. I assume this is related to levels of ketones resulting from high blood glucose and the consequences of exercising with this condition. I am wondering if anyone knows how quickly ketones develop with the high BG level. In other words will ketones be present with a short period of say 2-3 hours of high BG or do the high BG levels have to be present for a long time (several hours or days)? Also, at what level of high BG will ketones start to appear in the blood? I am sure there is some individual variation in this just like almost all of the other things related to diabetes.

[Lizzie G]

thats a really interesting question.....when i was first diagnosed my BG was around 25 I think, yet I only had a really low level of ketones, and an AC1 of 15 or 16, so the medics were mystified that my ketones werent higher, wondered whether i was type 2, all sorts of things, and the conclusion they reached was that it was swimming that was keeping me safe! i routinely test for ketones if i go over 15, and i just never seem to get them (that or the ketostix are out of date!!!)

[shiftzor]

Well the only way to find out for sure is to test, unfortunately although I wish I could help you, I certainly am not going to put myself that high for any period and don't recomend it. If you want to find out then you need Ketostix, basically you p1ss onto the end of the stick and it changes colour depending on how many ketones are in your urine. I think after a couple of hours you should start to see signs of ketosis.

[Mich]

Hi Sharp Tail,

I am pretty sure that ketone production is a variable that is determined by a person's individual metabolism. It would be so easy if it was completely predictable. One of the things I have learned from participating in this group is that some people easily produce ketone bodies and some seem to take longer. Some people have to guard agains keto-acidosis more than others.

Since ketones are a metabolic by-product of burning fat, those of us on a low-carb type of diet tend to produce a few all of the time.

I do know that some muscle & tendon damage is done by high blood sugar itself. It produces a cumulative effect called glycation or glycosylation. (Google those for more info.) Many times mild damage of this sort can be reversed--it's sure worth a try.

There is an excellent article at Journal of the International Society of Sports Nutrition | Full text | Metabolic Effects of the Very-Low-Carbohydrate Diets: Misunderstood "Villains" of Human Metabolism (http://www.jissn.com/content/1/2/7#)

Mich

[Geoff]

Hi Sharptail, as a general rule of thumb ketones production can begin when your bg rises above 13mmol/lt for any amount of time.

Also "pissing on a stick" that is so out of date. get yourself a Medisense Optium Xceed blood glucose meter by Abbott. you just slip in a different test strip, and read the ketones directly from your blood. No more missing and pissing on your hand!!

[BlueSky]

With some discussion of excercise and high blood glucose in other threads there has been mention of concerns of possible muscle damage. I assume this is related to levels of ketones resulting from high blood glucose and the consequences of exercising with this condition. .....
The notion that high blood sugar causes keytones to be produced is a common mis-conception. The production of large amounts of keytones is the result of inadequate insulin. The body starts eating away at itself (especially muscle) in an attempt to access glucose. This is in vain, of course, because inadequate insulin means that this glucose can't be metabolised anyway.

High blood sugars are just another consequence of inadequate insulin. This is why, when there are lots of keytones, blood sugar is high. But high blood sugar does not cause keytones to be produced. If you have adequate circulating insulin to satisfy your metabolic requirements, you won't get muscle damage during exercise, no matter how high your blood glucose is.

The warning not to exercise when blood glucose is over a certain level has been superceded by a better understanding of the metabolic processes. I have certainly found that insulin+exercise will bring any blood sugar down, but it needs to be aerobic exercise.

As Mich pointed out, small to moderate amounts of keytones are normal by-products of losing weight and high-fat eating. They are perfectly healthy.

[Lizzie G]

listen to blue sky guys, he really does know what hes talking about! i also wanted to add that even when i was really high when diagnosed, my doctors told me to keep swimming if i felt well enough - they were surprised i WAS well enough, but there we go and it did good - i tried on type 2 pills first as they werent 100% on my diagnosis, the pills did naff all. i just had another day of getting myself up to 13, running an hour and finishing at 5. some of you may not agree with a temporary high blood sugar, but for me it works, i feel great when i exercise, and it improves my overall control dramaticallly...but it is all individual. you should also check out Runsweet.com-diabetes and sport (http://www.runsweet.com) which is a website about sports and exercise run by an endocrinologist who treats olympic rower steve redgrave - you will see there that many professional and semi professional athletes aim for a high BG before intense exercise and that this appears to be endorsed by the medics. (i dont want to get sued for mis-representing other peoples views and opinions but you should check this stuff out at source).

[Lizzie G]

sorry i just hit submit without finishing a sentence in the middle (dont ask how my mind works)...what i meant to say was that type 2 pills did nothing (this was in the pre insulin days) but a good ole swim brought me down from mid 20s to about 15, so not bad...my next sentence about running and starting at 13 refers to today. i got distracted by the phone!

[JediSurfer]

Ketones are caused by lack of carbohydrates, not lack of insulin, lack of insulin is the cause but not why it happens. Ketones are basically fat which the body breaks down into little packages when it craves energy. The muscle damge is caused when proteins from the musles are ripped from the muscle tissue itself when creating ketones.

[Lizzie G]

Ketones are caused by lack of carbohydrates, not lack of insulin, lack of insulin is the cause but not why it happens. Ketones are basically fat which the body breaks down into little packages when it craves energy. The muscle damge is caused when proteins from the musles are ripped from the muscle tissue itself when creating ketones.

jedi, its not the lack of carbohydrate but an inability to deal with the products of carb metabolism - ie simple sugars. ketones are a by product of fat metabolism, a pathway the body turns to in the absence of sugars....and its a lack of insulin that leads the body to behave in a way as if sugar were absent and hence trigger fat metabolism and hence production of ketones.

[shiftzor]

Without wishing to hijack this thread, but if I was to dropped my insulin dosage by 20% before sport as advised by my endo could this cause ketosis during exercise and thus leads to muscle damage. Maybe I should experiment by doing a ketone check after a workout/sport. The worry is that I am only taking a small dose of insulin (12.5 average tdd) and I am unsure if I am putting myself in more danger of ketosis. I don’t want to lose weight and am on a low carb diet.

[Subby]

The notion that high blood sugar causes keytones to be produced is a common mis-conception. The production of large amounts of keytones is the result of inadequate insulin.

Thanks for the this post Bluesky. Wonderful information.


The warning not to exercise when blood glucose is over a certain level has been superceded by a better understanding of the metabolic processes. I have certainly found that insulin+exercise will bring any blood sugar down, but it needs to be aerobic exercise.

I remember I was told that exercising when high could cause further spikes as it would put the body "under pressure" (yeah, really clear that). A long time ago, I took this to mean that you may have stress hormones being released as the body comes under general physiological stress and that these hormones etc may interfere with insulin absorption. Thus even if insulin is present, it cannot be utilised well, leading to further stress as you up the requirements through exercise. Is that in any way a valid concern?

The other thing I wonder is how to know when insulin is successfully "circulating"... is it safe to just go on typical absorption experience? I presume waiting a while to allow a dose to absorb would be a good precaution before commencing exercise.

I must admit that if I get really high (say 16 mm/l) exercise can _seem_ to make it worse for a few hours. Of course it may take a little to "turn the ship around" so to speak. I have extremely variable insulin absorption rates/resistances, it may simply be at my worst times with poor absorption that this occurs.

[Subby]

shiftzor, the lowering of insulin requirements is in anticipation of lowered insulin requirements through the sport. In other words, this is the correct thing to do by your blood sugar levels.

The 20% is an estimate and needs to be informed by testing, to see if it's accurate to keep you in a good BG range.

Ketones will come only alongside high blood sugar levels. That's the time you need to worry about ketones.

As far as muscle damage, read the post by Bluesky, this is not caused by ketoacidosis but lack of insulin - and if you think about it these are two different things. You can be high and with Ketoacidosis, but be dosed with sufficient insulin. I don't know the details of knowing if insulin is circulating or not in these situations, myself.

[shiftzor]

shiftzor, the lowering of insulin requirements is in anticipation of lowered insulin requirements through the sport. In other words, this is the correct thing to do by your blood sugar levels.

The 20% is an estimate and needs to be informed by testing, to see if it's accurate to keep you in a good BG range.

Ketones will come only alongside high blood sugar levels. That's the time you need to worry about ketones.

As far as muscle damage, read the post by Bluesky, this is not caused by ketoacidosis but lack of insulin - and if you think about it these are two different things. You can be high and with Ketoacidosis, but be dosed with sufficient insulin. I don't know the details of knowing if insulin is circulating or not in these situations, myself.

hehe, thanks for clearing that up. So assuming that I have a reasonable amount of bg control during the day, then I must have enough insulin in my system. When I play sport I often fight lows which means I must have enough insulin if not too much, if I reduce my insulin, I should check for ketones after playing to ensure that I had enough insulin during the activity and then correct insulin dose pre-sport accordingly.

[BlueSky]

... I remember I was told that exercising when high could cause further spikes as it would put the body "under pressure" (yeah, really clear that). A long time ago, I took this to mean that you may have stress hormones being released as the body comes under general physiological stress and that these hormones etc may interfere with insulin absorption. Thus even if insulin is present, it cannot be utilised well, leading to further stress as you up the requirements through exercise. Is that in any way a valid concern? ...
This advice sounds familiar to me too (from way back). It doesn't make sense to me, and I don't think it is a valid concern. Having said that, I am not an expert on this. I base my ideas on common sense and personal experience ;) .

...The other thing I wonder is how to know when insulin is successfully "circulating"... is it safe to just go on typical absorption experience? I presume waiting a while to allow a dose to absorb would be a good precaution before commencing exercise....

You will know that there is not enough insulin circulating when blood sugar shoots up and there are keytones, at the same time. I had problems some years back with blood sugar going through the roof during and after exercise. Here is how I figured this out :

I had started exercising at the gym before breakfast. My blood sugar was going up during and after exercise, and I was having great difficulty getting it down again. I was trying to build muscle, in an attempt to improve insulin sensitivity. But I was dismayed to discover after doing the gym for a while that, if anything, I was losing muscle.

I was mystified by this and the CDE suggested that maybe I was running out of insulin. This didn't make sense to me as the NPH I was injecting before bed should have been peaking in the morning. But a test revealed that there were moderate keytones after the gym sessions. It verified that insulin levels were in fact low, explaining why blood glucose was going high and muscle was being lost.

I fixed this by bolusing and eating breakfast before going to the gym. I don't particularly enjoy exercising after eating, but my blood sugars immediately stabilised. I was able to regain and build additional muscle by focusing on resistance exercises. I also injected more insulin after exercise and drank a protein shakes.

All this highlighted the importance of having adequate circulating insulin. If exercise is making blood glucose go haywire, this is the first thing that should be checked out. ;)

[REDLAN]

muscle damage, and exercising when BG is high.

Concur with Bluesky - ketone production is caused by lack of insulin, not high blood sugar. You need to correct this to continue exercising.

In a normal person Ketone production is a response to gluconeogenesis - which occurs in response to low body glucose/glycogen. You get this either through a very low carbohydrate diet, or lack of food - starvation to be precise.

with uncontrolled diabetes - the lack of insulin mimics the effects of starvation. Your body's response is to unload glucose into the body, by breaking down proteins. Blood sugar rises, and ketones appear.

the issue with exercise, high blood sugar, and with ketones.

first is dehydration - the spare glucose appears quite rapidly in the urine, drawing water with it by osmosis, just at the time when the body's normal physiological response to exercise is to concentrate the urine to conserve water.

the second is ketones - ketones acidify the blood and body tissues. lowering pH - normally this is buffered by the blood (using calcium carbonate) to maintain the body's pH, but there are limits. lowered pH damages enzymes and proteins in the body stopping them functioning - add to this dehydration, which will further increase the effective concentration of ketones and so enhance the pH lowering effect.

You can then make this much worse by exercising hard in the belief that this will lower BG, when in fact the body's response to lactate (i.e. hard exercise) is to synthesis yet more glucose, and increase the body's demand for insulin even further.

I do exercise when I'm above 13 (230), but I calculate a correction (I usually correct to 8 mmol). When I start I make sure that I take plenty of fluids, and that the exercise at the start is firmly in the aerobic zone. When I'm cycling this means low gears high cadence on hills, no pushing, and no standing on the pedals, Until my BG starts to return to normal - usually takes about half hour to 45 minutes for the insulin to start working.

[JediSurfer]

Lack of insulin causes high blood sugar, high blood sugar causes the body to starve and start producing ketone's because it needs energy. Lack of any insulin is the starting process but the cause is the bodies need for energy. no or little insulin=high blood glucose=starvation=ketone production=Kussmaul breathing

If you guys are gonna read lot of medical information on line you should first learn how to extrapolate the info like a doctor would do.

[Subby]

Redlan, what you say makes a lot of sense to me, although some of the metabolic actions you describe I will have to take on faith. The dehydration in particular is an important point to make. I think that first 40 - 1 hour after taking an injection to come down, should be treated carefully as you say.

An approach might be the idea of a short aerobic exercise at the start, to encourage circulation and absorption, then a break to allow for the insulin to kick in and fluids to hydrate, with a return to exercise when you witness your BG in a downward movement, in the 30 in to 40 min hour. I think I will try this approach, if faced with lots of exercise/activity.

[REDLAN]

no or little insulin=high blood glucose=starvation=ketone production=Kussmaul breathing

I think this is more or less what I said - except that I maintained that lack of insulin causes both the high blood sugar AND the production of ketones. Rather than high blood sugar per se leads to ketone production.

but I think that is splitting hairs somewhat.:)

[lilituc]

You don't have to have high bg to have high ketones. It's rare, and it generally only happens in children or adults that are really sick, but it can happen. There were even people on here who ended up in the ER with an insulin and glucose drip simultaneously. I don't know if they're still around here, though. Just sayin'.

[BlueSky]

You don't have to have high bg to have high ketones. It's rare, and it generally only happens in children or adults that are really sick, but it can happen. ...
I think the earlier discussion was limited to people in good health. But you are quite right. The presence of sickness changes the ball game entirely, especially with children. Ketones can increase to dangerous levels very quickly. And it is not always accompanied by high blood sugar.

I haven't been able to find a logical explanation for this. Presumably the sickness causes intense insulin resistance, denying access to blood glucose, hence the ketones. And the liver fails to respond with a glucose dump. In an ER, they deal with it by using simultaneous glucose and insulin IV drips. The glucose raises BG and insulin forces it into cells, so ketones come down.