Looking at Urine Ketones: Comparing Several Tests Sticks

Several posts about ketone test strips that measure ketones in urine.

Comparing the Accuracy of Three Different Keto Test Strips I Bought Online (May 12, 2019)

I dipped three different ketone test sticks in my morning urine to compare their relative accuracy. One definitely didn’t work, one was “okay”, and one seemed to be good. There are problems inherent in measuring ketosis with urinalysis strips. Knowing how they work helps you find the best keto strips at a good price.

What is “Keto”?

It usually means the “keto diet” or ketogenic diet, a low-carb, high-fat diet that causes the body to get into ketosis, and stay in ketosis. Ketosis is a state when the body is consuming fat and using it as an energy source.

The body normally prefers to use glucose as its energy source. Glucose is easy to eat, and some foods, like juices, are immediately absorbed and raise the blood glucose level. When blood glucose rises, the pancreas releases insulin, a hormone which assists in “opening up” the cells to use the glucose as an energy source.

When someone eats a low-carbohydrate diet, the shortage of glucose causes the body to use stored fat as an energy source. The liver goes into a state called ketogenesis, which means “creating ketones”. Ketogenesis produces two types of “ketone bodies”, or molecules, which are absorbed by cells, without requiring insulin, and used as an energy source.

The two bodies are: Acetoacetate (AcAc), Beta-Hydroxybutyrate (β-hydroxybutyrate or BHB). The breakdown of AcAc produces Acetone, which is expelled in your breath, and has a flowery smell.

How Do You Test For Ketosis?

There are three technologies to test for ketosis, in order by declining accuracy: measuring acetone in the breath with a breathalyzer, measuring BHB in the blood with a blood test meter (similar to a blood glucose test), and measuring AcAc in the urine with a urinalysis test “stick”.

The reason why people use the AcAc urine test is because it’s the cheapest option, and also available over the counter at drug stores.

Unfortunately, urinalysis test strips are the least accurate.

How Do AcAc Test Strips Work?

A test stick has a small pad impregnated with sodium nitroprusside. When soaked with urine, it reacts and darkens into a purple color if AcAc is present in the urine.

The test strip tube has a ketone levels chart showing the colors. The value is called “UA Ketones”, or urinalysis ketones. You may see that term “ua” because the fact it was measured from urine is important to doctors and nurses.

Always use the chart on the bottle – they aren’t the same across brands. Also, try to use an even, white colored light to view the results — any red or blue colors in the light will influence the way you see the results. (My lights are a bit red, and most people have that at home. Eventually, I’ll have to replace the bathroom lights with something that looks more cold, like a hospital’s lights.)

In ketosis the body consumes AcAc for energy (and expels acetone). Therefore, the AcAc in urine is excess AcAc that’s not been exhaled.

What this means is that you can be in ketosis, and expel only small amounts of AcAc in urine. So, the urine test is inherently less accurate than the acetone breath test.

You are supposed to measure your morning urine, because it’s the most concentrated, and also most likely to contain ketones, because you’ve been fasting (meaning you’re more likely to run out of glucose).

That points to another inherent inaccuracy of urine tests: drinking water dilutes the urine, and will cause a lower reading.

What about the BHB blood test? The BHB blood test, also called a finger stick test, because you poke your finger to draw blood, also suffers from this limitation, because BHB is also consumed as energy during ketosis. However, BHB blood testing is more accurate because it’s measured before the body decides to dump the excess as waste. You’re measuring the liver’s output.

(Additionally, for diabetics, the BHB level rises more than the AcAc level when the body is getting into diabetic ketoacidosis (DKA), so Type 1 diabetics should use the blood test in addition to the urine test.)

Where Can I Buy Ketone Test Strips?

The most straightforward place to buy them is the drugstore, next to the pharmacy, in the shelves of items for diabetics. You should find AcAc ketone test sticks there. I got mine at CVS, but you can find them at all drugstores.

I also purchased two different sticks from two different vendors on Ebay. You can also find them online at the usual places: Amazon, GNC, and anywhere that sells nutritional supplements and diet aids for fitness enthusiasts.

On Ebay, you can buy them from a US vendor, who will ship them quickly, or from an Asian vendor, usually in China, who will ship them slowly (using ePacket). The China vendors are generally the least expensive.

You can also get urine test strips with multiple pads, to measure multiple aspects of urine chemistry. I recommend getting these, because they aren’t too expensive, and it’s more interesting to use. I got one from the same US vendor where I bought the ketone tests.

I got three strips from three different brands:

Cybow (DFI Co Ltd), Generic URS-1K, and TruePlus by Trividia (note the reddish cast to my bathroom lights)

There’s a brand called “ketostix”, and I think it’s by Bayer, but I didn’t get that.

Please note that all have expiration dates, and the TruePlus has a “date opened” space to write the date opened. These strips all react with air, water, and light, losing accuracy and efficacy with exposure.

In short, you cannot hoard these test sticks. They become useless.

How I Started Suspecting a Problem

My first batch of strips was the TruePlus, and they were reporting that I had AcAc, sometimes, quite a bit. My second batch was the Cybow, and it reported “trace” once or twice, but otherwise showed “neg”.

What seemed weird to me was that it was reporting nothing, but I was losing weight on a reduced carbohydrate diet, and also exercising a little more than in the past. The odds that I was producing and using ketone bodies were high. Remember that the state of nutritional ketogenesis = converting fat to ketones, in the liver.

There are a few ways to lose weight: dehydrate and lose water, lose a limb, get liposuction and remove fat cells, lose muscle mass, or digest body fat the normal way your body uses fat.

I was drinking a lot of water, and didn’t seem to be losing too much muscle mass, so… what was going on?

I cracked open a different pack of strips, and compared. The other strips reported “small”. Aha! Ketones!

How I Tested these Ketone Strips

I imagine a good testing fluid with a known quantity of AcAc in it is available, but I don’t know how to get it. I think the second best way is to put your body into ketogenesis.

How to Get Your Body Into Ketogenesis and Ketosis

If you’re obese like I am, the best way to assure ketogenesis, to produce urine that contains ketones, is to lose weight.

I also don’t think the typical keto diet of foods like bacon wrapped shrimp, steaks, and coffee with coconut oil is necessarily the best way: eating an extremely high fat diet doesn’t sound healthy to me. Also, if you’re eating a lot of fat, of course you’re going to be in ketosis – the body is going to use that fat you just ate instead of your body fat.

You also potentially lose the ability to verify that you’re losing weight. If you eat high fat, and maintain the same weight, how do you know that you’re in ketogenesis? You definitely don’t know.

If you are losing weight, you are probably in ketogenesis.

Exogenous Ketones

Some online promoters have a way to increase ketones in the bloodstream: eat raspberry ketone powder. Basically, it’s full of BHB ketones.

I don’t think these powders are a good idea, especially for diabetics. Ketones are an energy source for the body, but they are also amino acids.

As acids, they cause the blood to become acidic. The balance of acids and bases in the blood is critical to not dying. If you go too far in any direction, you’re going to get sick.

So, your body has multiple ways to deal with elevated or lowered acid levels. In some people, though, these regulatory mechanisms don’t seem to work so well.

Also, if you consume ketones, a source of energy, your body may not consume its fat stores to produce ketons.

How Did I Lose Weight?

I ate a low carb diet, to deal with my diabetes. Low carb, for me, meant between 80g and 150g of carbs a day, leaning more toward 100g than either end. I used Poundaweek to determine carb counts (and note, that is not accurate, either).

My fat consumption was somewhat high, and proteins were really high for a while, but I cut back. I cut calories, down to around 1400 to 1800 for most days, and lost weight. I also did a little exercise, mostly walking briskly and doing squats.

I wasn’t losing weight consistently, but I lost more often than gained. I went from a peak of 240 pounds down to 219, and the period in which I was measuring with the test sticks was around 225 to around 219.

During this time, I could also feel some of the more fatty, bulbous areas turn to softer flab. It was a sensuous experience 🙂

So I was “burning fat”.

(Postscript – after I wrote this article, I reduced my carbohydrate intake down to 50g a day, and that helped me maintain my blood glucose in the 90mg/dl to 110mg/dl for most of the day.)

How Did I Test the Strips? Comparatively

I measured the three strips against each other.

To do this, I gathered my morning urine into a small cup. (Normally, I urinate onto the strip, but for this test, I needed to measure the same batch of urine.)

The strips differed in how long each took to reach a final result. Cybow took 60 seconds. Generic took 40 seconds. Truvidia took 15 seconds. Note that this is another potential source of inaccuracy, because the pad continues to darken after the time period. You need to read it when you reach the designated time.

I suspect that the time required depends on the amount of sodium nitroprusside in the pad. Cybow reports 23mg. Truvidia says around 7% w/vol. I threw away the paper that came with the generic. In short, I cannot compare at this time.

Personally, I trust strips with shorter times more than those with longer times.

I timed the dipping so that they would all “mature” at the same time. Here are the photos of that:

The results were that the generic and TruePlus pads went to somewhere between “trace” and “small”. The Cybow went only to “negative”.

Cybow was not working.

What is the Best Ketone Test Strip?

I would argue that you cannot say one brand is “best” or “worst”. The test strips will vary based on how they’re stored, how you run the tests, and even manufacturing problems with batches.

It’s entirely possible that Cybow was a bad batch, and is otherwise a good brand. How would the Ebay vendor know? They may have purchased a big case, and trusted their wholesaler. They probably don’t have a neutral test that would be able to push the strips to display the different quantities of ketones.

They wouldn’t know the storage conditions at the wholesaler.

I noticed that the expiration date was 12/2020. That’s far in the future, but not as far as the others.

Likewise, while the generics seem to have good results, but it’s possible that the ones you order will be exposed to heat or cold, because they’ll spend a few weeks in transit.

(The ones I got had a foil seal, so air didn’t get into the bottle. That may have resulted in better results, but if the bottle itself is leaky, the strips can be damaged.)

The most reliable strips, I think, were the TruePlus strips, which, unfortunately, were the most expensive at around $10 per bottle.

They have a short time to test, and were sold at a drugstore with air conditioning. The drugstore handles tons of medications, and nearly all of them need to be stored in climate controlled warehouses, and probably also climate controlled trucks.

So, for myself, I’m going to continue to buy the cheaper strips from Ebay vendors, but test against the expensive strips from the drug store.

I’ll try to make the expensive strips last, and use the cheap strips more often. I test almost every urination at home, and am figuring out how to make a “road kit” to test when I’m away from home.

Urinalysis During Ketosis with 11-way Test Strips (May 21, 2019)

(In addition to the ketone stix I bought, above, I also purchased Qtest brand urinalysis test strips. These were bought from the same US vendor from whom I got the Cybow tests. These strips worked well, and I used them up over the course of a year.)

I did a urinalysis on my diluted pee, following a test where a ketone strip detected a moderate size presence of ketones, a sign I was in ketosis. Here’s the urine test:

Most of the values are way over to the left, indicating a negative test, but a few are not.

Specific Gravity was around 1.020.

pH was between 6 and 6.5.

Ketones were +15.

I think the ketone reading, which was lower than an hour ago, showed that the water drinking I did successfully diluted the ketones in urine.

The normal range for pH is 4.6 to 8. A pH between 6 and 6.5 is normal.

Normal S.G. is 1.000 to 1.030, so my SG is in a normal range.

So, all the numbers are good. I wish I’d done the test right when the ketone test went purple, so I could compare the two results, and see what the water drinking did to my urine.

What are Ketones, Specific Gravity, and pH?

Ketones are a secondary source of energy for the human body. The presence of ketones in urine indicate that there are high levels of ketones in the blood, and the kidney is removing excess and dumping it to urine.

Specific Gravity is the concentration of urine. 1.030 is considered dehydrated, so I was relatively dehydrated. If I drank more water, earlier, this number would have been lower. The SG is the weight of the sample compared to the weight of an equal volume of water.

So urine is more dense than water.

pH is the acidity or alkalinity of a solution. 7 is neutral, and a lower number is acid, a higher number is basic. Urine pH between 4.6 and 8 is normal. Urine between 6.5 and 7.25 is healthy. Urine between 6 and 6.5 is acidic, and indicates that the body is overwhelmed by acid.

In my case, I was in ketosis, and my urine was a little acidic.

I ate some fava bean snacks to try and provide some carbs, and slow down the ketogenesis.

I’m Not Urinating Away Vitamin C, Watching Videos, and Early Testing Numbers (August 3, 2019)

I’ve started to watch more videos about diabetes, insulin resistance, and patient results. They’re going to be compiled into a playlist. My preference in videos is not the “do this to fix your situation”, which I find too strident and commercial-feeling. I like the calmer, maybe “boring” videos. I find them exciting.

Urinating Away Ascorbic Acid

I’ve been checking my pee with the urinalysis test strips, and have never, ever seen the ascorbic acid pad change from dark green. That means there’s no ascorbic acid in my urine.

Ascorbic acid is vitamin C, and women need 75mg, and men 90mg a day. Any excess goes away into the urine.

I am usually taking a multivitamin with 90mg vitamin C. I also eat leafy greens, which contain vitamin C. So where is the vitamin C being pissed away?

I’ll need to either increase my intake and see if it gets urinated out, or test right after taking a supplement, to see if it’s excreted quickly.

Vitamin C is associated with increased risk of kidney stones (see the wikipedia article, “Exceretion” section). I’m talking magnesium citrate to try and avoid kidney stones, and to de-acidify my urine. See this for reasons why.

Because I’m on the diabetic LCHF diet, which stipulates that fruit not be eaten, one of my sources of vitamin C has been removed. I probably don’t get enough C, except from broccoli (a C superfood).

Citrate, a salt of citric acid, is not vitamin C. I got this confused for a long time, probably because citrus fruits contain both vitamin C and citric acid.

Vitamin C increases risk of kidney stones because it can be converted to oxalate, which causes calcium to bind together into stones of calcium oxalate. This is too bad, because vitamin C is a necessary nutrient.

Citrate binds with calcium, and also prevents calcium from crystalizing. I think magnesium citrate would give up a magnesium, which is generally okay. Magnesium RDA is 320mg for women, and 420mg for men, but the typical diet doesn’t provide that. A diet with whole foods, leafy greens, and nuts, would.

Given these facts, I get the impression that drinking lemon juice is the quick way to increase both ascorbic acid and citric acid, safely.

Urinalysis Test Strip Numbers

I’ve been tracking the 11-way test strips a few days, and have some numbers. All the pads except Specific Gravity, Ketones, and pH, read “neg” and don’t change. (That doesn’t mean the values aren’t changing – it just means I can’t see them on the pads.)

These were all measured at the start of the day, first urination.

Testing in the morning helps, because the urine is supposed to be more concentrated. Later in the day, after drinking water, it should be more dilute. That would raise the pH, reduce the ketone concentration, and lower the specific gravity.

Ketones: 15, 15, 5, 15, 15 mm/dL

Specific Gravity: 1.018, 1.018, 1.020, 1.015, 1.020

pH: 6, 6.5, 6.5, 7, 6.5

Also, note that all these values are an average of all the urine in your bladder. If it took 2 hours to fill the bladder, it means the numbers are the average of 2 hours of body activity.

Morning tests measure the past night of body activity. Daytime tests measure the interval since the last urination.

Has Magnesium Citrate Helped My Urine pH?

I have been taking 1000mg of magnesium citrate, hoping to raise my pH. I can’t tell if it has had any effect. Maybe it has. Prior to this, I’d been seeing 6 and 6.5 on the urine test strips, and once saw 5. So I was afraid of excess acid.

pH of 6 to 7 is normal.

What Does High Specific Gravity Mean?

Specific Gravity reveals if you’re dehydrated. 1.005 to 1.015 is normal. My values around 1.018 show I’m slightly dehydrated. Given that this is the morning, and I haven’t had a drink in around 7 or 8 hours, it makes sense. I tend to need a lot of water – and being diabetic and sometimes working outside, I do need to drink more water.

It’s also possible that I have kidney disease, and the kidneys aren’t pushing enough water through. Different websites list different concentrations as “normal”.

Ketones and Ketosis

Ketones show the amount of excess Acetoacetate (AcAc) being dumped in my urine. Unlike the pH and SG, which I observe to see how my pee is doing, I’m looking at the ketones pad to make a guess about what’s happening in my blood.

I hope that’s clear: the ketones measured on the pad indicate that my body has excess ketones, and is dumping them out. My muscles and brain aren’t using up the ketones.

Also, AcAc is just one ketone. It gets converted to beta-hydroxybutyrate (BH). Both AcAc and BHB are used as an energy source in the body. So, when you’re in ketosis, fat is turned into triglyceride droplets, which is converted into ketones (Acetone, AcAc), and AcAc is converted to BHB. Most of the ketones are BHB.

So, my number of 15 shows I’m in ketosis. I had a dip to 5. However, this doesn’t really tell the whole story. I could be burning my fats more efficiently when it’s at 5.

My history of ketones goes like this. In the mid 2010s, I went on a diet and tried to track ketones. I had no idea what a keto diet was. I’d only heard of the Atkins diet. I focused on carbs because I was convinced that I had gained weight from carbs when I went vegetarian. My ketone numbers were typically 0 or “none”, and a few times went up to “trace” or 5. In the process, I modified my diet to generally be lower in carbs, though I did go high-carb when I baked bread. That said, I rarely ate as much rice or pasta as I had before this change.

Then, due to a lot of life events, I increased my weight from around 225 to 240 lbs. I was feeling like crap, like I was going to die slowly and painfully, so went on a diet. The diet app I used, Poundaweek, let me track carbs, so I lowered carbs along with calories. I lost weight. My body went into ketosis. I was targeting 100 to 130g of carbs per day, but probably went much lower.

I started to feel crappy, but in a different way. I felt really sick, not just generally sick. I felt like I might die that week! So I bought some ketone strips, and found I was “moderate” or at 40mg/dL. This was just below “high”.

I also got my friend to give me a sugar test, and my blood glucose was 213 mg/dL. I was way the hell up. I was already suspecting diabetes, and had done reading in that direction. I had read about diabetic ketoacidosis, and acidosis in general. During this time, my ketones fluctuated, but I tried to keep them low or negative. I also tasted my pee – because sweet urine indicates that the BG is higher than 180 mg/dL. Fortunately, it was sweet only two tastings.

I went to the doctors and got diagnosed as type 2 diabetic.

I pulled myself out of ketosis for a couple weeks, and then found the LCHF Type 2 group on Facebook, and started to get into that diet over the course of a few weeks. My ketones strips were measuring from “trace” or 5 mg/dL to “small” or 15 mg/dL.

Sometimes, the reading would go up to 40mg/dL or “moderate”. Then, I’d freak out a little and drink water. I sometimes increased my carb intake to hit the 50g a day mark.

Vitamin C and the Testing Pads

Jumping back to vitamin C – it affects the readings of hemoglobin and glucose, causing those pads to read negative when they are actually positive.

So, the ascorbic acid/vitamin c pad is on there to check for presence of C. If C is present, then the values for hemoglobin and glucose are wrong.

In my case, there’s no ascorbic acid in the urine, and also no hemoglobin or glucose, either. So that’s all good.

If you got this far in this long article, you’ll probably enjoy: Things Your Pee Can Tell You.

14-Way Urinalysis Test Strips Reviewed (July 26, 2020)

I purchased these on eBay from the vendor, CompleteNaturalProducts, for around $15. They’re similar to the Qtest 11 way sticks reviewed above, but with more pads.

The additional pads are Creatinine, Calcium, and Microalbumin.

These additional tests can help evaluate urinary tract infections (UTI) and kidney health. The relationship between the tests and different organs is summarized on the label.

The main thing I noticed was that the colors on these test pads was brighter than in the Qtest strips. This makes it easier to see the different colors.

Recently, my mother had been having problems with UTIs, so I got these more for UTI testing than for ketone testing. Depending on how far the infection had persisted, the tests showed an increase in in Leukocytes, and then Nitrites.

Additionally, due to a kidney infection, the Blood pad would also show changes in color, ranging from spots of green, to blobs of green, or a general change in color from orange toward green.

Like all the other test sticks, these need to be read after waiting a specific amount of time after dipping. Most pads take 60 seconds, but some are faster, and the times are listed on the label.

If you wait longer, the colors will get darker, and you’ll get a high reading.

I’ve used these for my own testing, but, they generally turn up negative across most of the pads. My weight has plateaued, and I rarely see ketones in any tests.

A Clean Catch

I recently learned the term “clean catch”, which is a clean urine sample, uncontaminated by material in the urethra. You’re supposed to start urinating, and then take a sample 1/2 second after starting.

Around here, we use a tofu tray. It’s around 4 x 6 inches, and can hold a lot of urine, so there’s no risk of overflowing. It’s also wide enough that dipping the long test stick is easy.

The tray’s white color probably helps us resolve the color on the pads more accurately than against other colors, too. I recommend using a tofu tray to capture urine.

One response to “Looking at Urine Ketones: Comparing Several Tests Sticks”

  1. “the body is going to use that fat you ate instead of your body fat.” Not necessarily true. You say later you cut down to 1400 to 1800 kCal a day so the shortfall between that and your daily requirement would be made up from burning body fat.

    I have just lost 30kg in 5 months simply by working down through LCHF to going keto at about 20g carbs a day. My protein intake is slightly higher then they recommend but I am 72 year old so I need it.