The overarching concern in the hormonal control of ketone body metabolism is the insulin level. In circumstances where insulin levels are relatively high, such as the fed state, both substrate (free fatty acid, [FFA]) availability and FFA oxidation are suppressed, directing FFA to storage and employing glucose to meet the energy needs of the body. In situations of relative insulin deficiency, such as starvation or type I diabetes, FFA oxidation is increased, driving the production of alternative energy‐producing substrates, ketone bodies, for use by the brain, as well as peripheral tissues. Insulin influences the activity of three key processes: FFA availability (lipolysis), ketone body production (ketogenesis), and disposal in peripheral tissues. All of these processes can be altered in pathophysiologic conditions such as type 1 and type 2 diabetes, obesity, starvation, and hyperthyroidism. The key control point is carnitine palmitoyltransferase‐I (CPT‐I), which mediates the passage of long chain fatty acyl coenzyme A (FA‐CoA) esters across the outer mitochondrial membrane, prior to oxidation or ketogenesis. Insulin regulates CPT‐I both at the level of gene transcription and by influencing the affinity for allosteric modulators. Regulation of hepatic CPT‐I expression or activity holds potential significance as an approach for controlling hyperglycemia and insulin resistance.