Just reviewed my labs from my physical a month ago and noticed that ketones were 1+ in urinalysis. My bg levels have been essentially perfectly controlled, the doctor never even mentioned it— what is the significance of this and should I be concerned? Thanks

Could have been from exercise or maybe you where fasting(if your skinny and going low carb, you could easily pass some ketones)...I don't think it's uncommon for someone to show trace amounts. If your concerned buy some test strips, trace amounts can be normal under the right circumstances. As long as your not forgetting to take your basal insulin you should be OK.

When you burn fat, the result is Ketones. This is not a worry at 1+ as you may have just been fasting or worked out a lot. I have chronic 1+ ketones too. It really is not a problem unless you are are 3+ or 4+. Then you are likely in Ketosis. I find that I slip into DKA very fast, probably because I always have some ketones swimming about. If my pump set slips out, I will get DKA symptoms in less than an hour. My sugars are well controlled, my last A1c was 5.9% . This due to my CGM mostly. This is why I almost never check ketones anymore, unless I am feeling sick.

If you were told to come in to your appointment fasting, then this is natural. I fast overnight and do my appointments in the morning. No carbs from the night before are going to be affecting my body's fuel supply the next morning. When you fast, your body burns fat by creating ketone bodies and the excess are excreted in your urine. Margin or trace levels (this is +1) of ketones under such conditions are normal.

To be clear, DKA is caused by acidification of the blood because ketones lower serum pH. It is this change in pH that causes the symptoms, and is life-threatening.

This only occurs at relatively high levels where the liver and kidneys are unable to clear the byproducts of ketone metabolism. Generally above 4 mmol/l (units from memory -- may be wildly incorrect!).

A ketogenic diet keeps the level just under that limit.

I agree. High BG plus high ketones alone doesn't equal DKA. I hear lots of people say they have been in DKA but never been hospitalized. Since DKA is a change in the blood's pH level caused by high ketones and high BG, the only way to correct this pH change is with IV fluids, insulin, etc. - in other words, with a trip to the hospital. If you are able to turn things around at home, then you may have been heading for DKA, but you weren't actually there yet.

This morning I woke up with a BG of 17.5 (315 mg/dl) and large ketones (second-to-darkest colour on the strip). Was this DKA? Nope. Was it a possible precursor to DKA if left untreated? Yep. Why did this happen? I have no idea!

According to the Precision Xtra blood ketone meter I have (which I don't currently have strips for), levels above 1.5 mmol/L indicate that you are at risk of developing DKA and should seek medical advice, levels above 3.0 mmol/L warrant a trip to the hospital, and the meter tops out at 8.0 mmol/L and simply says HI after that.

I think a low level of ketones with normal BG is pretty normal, even for people without diabetes.