Let's test your knowledge: What are ketones?         

1. Large amounts of sugar in the urine
2. Chemicals made when the body burns fat
3. Large amounts of protein in the urine
4. Small amounts of blood in the urine

As part of continuing education for our families, we developed a "ketone quiz." This quiz is the first of multiple "quizzes" that we will be giving our practice over the next few years to access our patient's knowledge about different diabetes related concepts. The quiz was given to all of our patients (type 1, type 2, etc.) who are seen in all of our locations. It was given to newly diagnosed patients who recently attended "Survival Skills" and "Concepts Class" as well as those with long-standing diabetes.

The results: The most popular answers were the following:

A.    Large amounts of sugar in the urine (most popular) and

C.    Large amounts of protein in the urine (second most popular).

More than 90 percent of our patients provided incorrect answers. It did not matter if their hb A1c was 6.5 or 10 percent, most patients (and family helpers) chose A. In fact, one of the more astounding findings was that children and adolescents with well-controlled diabetes knew less about ketone physiology because of the fact that they have never had them! People who have had episodes of ketosis were a bit more familiar with the ketone quiz due to real-life experience. What was the take home lesson? We learned that it was necessary to provide important information in a mini-refresher format! Adult learners tend to learn what they need to know now. If they are not confronted with an immediate problem, the information is less important and perhaps stored for future use and forgotten.

The correct answer... B: ketones are chemicals made when the body burns fat.

Let's review one of my favorite biochemistry pathways: aerobic metabolism (and more specifically glycolysis and the TCA cycle). For those who wonder why doctors choose their specific specialties... I have been entranced with this pathway since taking Advanced Biology in high school. In medical school biochemistry, we reviewed this important pathway and an endocrinologist said that this elegant pathway was blocked IF the insulin hormone was not available. WHAT? If insulin was not there to facilitate glucose into the cells, then this beautiful pathway with the circular TCA cycle and ATP production was non-functional? Yes, he replied. And thus began my interest in insulin-dependant diabetes.

If insulin is not available in suitable amounts, glucose cannot enter the cells and glycolysis is not available to provide energy through the usual pathway of glucose metabolism. Instead the pathway goes in the reverse direction and ketones are formed. Ketones are produced when fat is the substrate used for energy due to the lack of glucose in the cells. Fat is metabolized to fatty acids and triglycerides. The fatty acids are then metabolized and ketones develop.