Think skinny people don’t get type 2 diabetes? Think again.

skinnydiabetes

In the last article we discussed the complex relationship between body weight and type 2 diabetes (T2DM). We learned that although obesity is strongly associated with T2DM, a subset of “metabolically healthy obese” (MHO) people have normal blood sugar and insulin sensitivity and don’t ever develop diabetes.

In this article we’re going to talk about the mirror reflection of the MHO: the “metabolically unhealthy nonobese” (MUN). These are lean people with either full-fledged type 2 diabetes or some metabolic dysfunction, such as insulin resistance.

You might even be surprised to learn that skinny people can and do get T2DM. They are rarely mentioned in the media, and there isn’t much written about them in the scientific literature. Perhaps these folks have been overlooked because type 2 diabetes has been historically viewed as a disease of gluttony and sloth, a self-inflicted outcome of eating too much and not and not exercising enough. But the very existence of the MUN phenotype proves that there’s more to T2DM than overeating and a sedentary lifestyle.

Remember that one in three type 2 diabetics are undiagnosed. It’s possible that a significant number of these people that are lean. They don’t suspect they might have T2DM because they’re under the impression that it’s not a condition that affects thin people. This is one of the biggest dangers of the myth that “only fat people get diabetes”.

It’s well-known that high blood sugar can precede the development of T2DM for as long as ten years. It is during this time that many of the complications associated with diabetes – nerve damage, retinal changes, and early signs of kidney deterioration – begin to develop. This is why it’s just as important for lean people to maintain healthy blood sugar as it is for the overweight and obese.

It’s also important to understand that diabetes is not a disease. It’s a symptom. Every single person with T2DM, whether they are rail thin or morbidly obese, shares a single symptom: high blood sugar. Therefore, anything that interferes with the body’s regulation of blood sugar levels will cause type 2 diabetes.

What causes high blood sugar and T2DM in lean people?

Not surprisingly, the causes of T2DM in lean people are similar to the causes of T2DM in the obese. They can be loosely grouped into the following categories:

  1. Genetics
  2. Fatty liver
  3. Inflammation
  4. Autoimmunity
  5. Stress

Let’s discuss each of them in turn.

Genetics

Studies of the lean, otherwise healthy offspring of type 2 diabetics has revealed that they are much more likely to be insulin resistant than the lean offspring of non-diabetics. One explanation for this is an inherited defect that causes mitochondrial dysfunction. People with this defect are not able to burn glucose or fatty acids efficiently, which causes lipotoxicity and an accumulation of fat inside of muscle cells.

I will discuss the contribution of genetics in more detail in the next article. What I want you to understand here is that the genetic mechanisms I described above are capable of causing insulin resistance and high blood sugar independently of overweight or obesity.

Fatty liver

Studies of lean, Asian Indian men have found that they have a 3- to 4-fold higher incidence of insulin resistance than their caucasian counterparts. They also have a much higher prevalence of non-alcoholic fatty liver disease (NAFLD) and hepatic (liver) insulin resistance.

NAFLD is an independent predictor of type 2 diabetes. Cross-sectional studies have shown that fatty liver and metabolic abnormalities occur together. It has also been proposed that fatty liver is not just a result, but also a cause of insulin resistance and type 2 diabetes.

Now, keep in mind that these Asian Indian men with NAFLD were not overweight. They were lean, and in some cases, even underweight. This proves that NAFLD occurs in lean people, and together with the evidence above, suggests that NAFLD may be a primary cause of insulin resistance and T2DM in lean people.

If you’re thinking NAFLD might be a rare problem confined to Asian Indian men, you should know that up to 30% (almost 1 in 3) of people in industrialized nations suffer from it. This is a disturbingly high prevalence of a condition that is known to progress to severe liver inflammation and cancer in a small percentage of people – in addition to contributing to T2DM and metabolic syndrome.

While there may be a genetic component that predisposes people to developing NAFLD, we also know that dietary factors play a significant role. Rodent studies have shown that feeding large amounts of sugar and industrial seed oils (like corn, safflower, sunflower, etc.) promote NAFLD, whereas saturated fats such as butter and coconut oil do not. And in human infants, tube-feeding with industrial seed oils causes severe liver damage, whereas the same amount of fat from fish oil does not.

Fructose, especially the high-fructose corn syrup (HFCS) found in sodas, candy and several packaged and refined foods, is perhaps the most significant dietary cause of NAFLD. The liver processes fructose by converting it to fat. The more fructose consumed, the more fatty the liver becomes. Feeding rodents high amounts of fructose promotes NAFLD, and the consumption of soft drinks (by humans) can increase the prevalence of NAFLD independently of metabolic syndrome.

Let me say that again: high fructose intake can cause fatty liver disease independently of overweight, obesity or type 2 diabetes. Do you think that might be a problem in a country where soft drinks account for nearly 10% of total caloric intake?

Since fructose is handled by the liver in the same way the liver handles alcohol, excess fructose produces a similar range of problems as alcohol abuse: hypertension, high triglycerides and low HDL, obesity, cirrhosis and insulin resistance.

Inflammation

In the study of lean Asian Indian men above with T2DM, it was found that they had a 2-fold increase in plasma levels of the inflammatory protein IL-6 when compared to lean subjects without T2DM. In a previous article I showed that chronic, low-grade inflammation associated is an important mechanism in decreasing insulin signaling and causing insulin resistance in muscle, liver and fat cells.

Also, inflammation has been shown to precede the development of diabetes. Infusion of inflammatory cytokines into healthy, normal weight mice causes insulin resistance, and people with other chronic inflammatory conditions are at higher risk of developing T2DM. For example, about one-third of chronic Hepatitis C patients develop T2DM, and those with rheumatoid arthritis are also at higher risk.

Autoimmunity

Up until recently, type 1 and type 2 diabetes were seen as distinct entities. It was understood that type 1 diabetes (or insulin-dependent diabetes) was caused by autoimmune destruction of the beta cells of the pancreas, leading to decreased insulin production, whereas type 2 diabetes was caused by insulin resistance of the liver, muscle and fat cells.

However, recent research has demonstrated that the line separating these two conditions may be much blurrier than previously thought. It is now known that type 1 diabetes, which normally begins in childhood, may slowly develop later in life. This form is referred to as latent autoimmune diabetes (LADA) or more informally as type 1.5 diabetes.

Studies suggest that type 1 diabetes in adults is frequently misdiagnosed as T2DM, and up to 10% of adults with T2DM may actually have the autoimmune form.

Even more relevant to this article is the finding that fully 1 in 4 lean people with T2DM produce antibodies to GAD, the same enzyme in the pancreas that is attacked in type 1 autoimmune diabetes.

These findings suggest that a significant number of lean people with T2DM may be suffering from autoimmune diabetes. This will obviously require a different treatment strategy than those who have the non-autoimmune form. (The way to find out whether you’re in this group is to have your GAD antibodies tested. It’s a fairly standard blood test and is available through Labcorp and Quest.)

(Interestingly enough, approximately 5% of patients with autoimmune thyroid conditions also produce antibodies to GAD. So if you have Hashimoto’s or Graves’ disease along with blood sugar symptoms that don’t respond to dietary changes, you should have your GAD antibodies checked.)

Stress

Under conditions of stress, the body produces higher levels of the hormone cortisol. Cortisol plays a number of important roles, but one of it’s primary functions is to raise blood sugar. This is an incredibly helpful evolutionary mechanism that is part of the “fight or flight” response that prepares us to deal with a challenge or threat.

However, that mechanism was only designed for short bursts of stress. Chronic stress as we experience it today – like worrying about getting audited by the IRS, driving in traffic, and suffering from degenerative disease – wasn’t part of our early ancestors’ lives. This means that our bodies aren’t prepared to deal with the effects of chronic stress, which include chronically elevated levels of cortisol.

Why? Because cortisol is capable of raising blood sugar to unhealthy levels even when a person is fasting. What that also means is that you can be lean, eat a perfect diet, and still have high blood sugar (and thus T2DM) if you suffer from chronic stress. I’ll be writing more about the connection between stress and diabetes in a future article.

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Comments Join the Conversation

  1. Patty says

    I’ve just been diagnosed with Type 2 and I’m shocked. I’m 54, not over weight, vegetarian, very food conscious, and I work out regularly. I have, however, been under a great deal of stress particularly over the past year. Is it possible to reverse my diagnosis if I reduce my stress levels?

  2. Sohail says

    Hello Dr. Kresser,

    I would like to schedule an appointment or speak to some one in customer service, However I dont see an option as such in your website. Could you please provide your contact number. Appreciate it

  3. isha says

    Hi!

    I have been healthy until few months back when I started losing weight. There has been a drastic change in my health. I have lost tremendous amount of weight in past couple of months. Blood diagnostics confirmed that I have high blood sugar. Now I am not sure what to eat and what not. I understand that I can’t eat sweet things but what should I eat so that I can put on weight. I don’t want to be this lean. I don’t like it, I look sick and I can’t eat calorie rich food as well to gain weight. Please let me know what should I do?

    • Alan Watson says

      Hi Isha,
      If you have lost a lot of weight without planning to, dieting or taking lots more exercise, then you should try to find out why.

      Eighteen months ago my doctor told me that my blood sugar was high when I was losing weight. When we checked we found that there was a problem with my pancreas. The pancreas does two things: it produces the enzymes that you need to digest food and it produces the insulin that you need to control blood sugar.

      If the problem is with your pancreas, you may find that you have soft, yellowish, smelly stools.

      You can ask for some tests: test your fasting blood insulin at the same time as your fasting blood sugar to see whether your high blood sugar comes from a problem with your pancreas or one with your liver, and test for blood amylase (one of the digestive enzymes) to see whether that is why you are losing weight.

      If a pancreas problem does explain your weight loss, then your doctor should give you replacement enzymes to take with your food, and you and largely adjust your diet to control your blood sugar.

      If the problem is with your pancreas, you doctor will want to more tests to find out what is causing it, and if not, she/he will want to do more tests to find out what is causing your weight loss and high blood sugar.

      As well as giving me pancreatic enzymes, my doctor also told me to reduce fat and fibre in my diet, as they are the hardest thing to digest, and suggested that I had to eat more starch and sugar to put weight back on. (I was seriously underweight.)

      To avoid my blood sugar getting too high, she suggested that I eat six small meals a day rather than three large ones. I also invested in a blood sugar meter to see what happened to the levels after I had eaten and to allow me to fine tune my diet and eating habits to find something that works,

      I hope you find out what’s causing your problems and start finding some solutions.

      Best wishes,

      Alan Watson

  4. Lauren says

    Thanks for this article. I have been sick for about two years. I went to my doctor when I first got sick and my blood work said my blood glucose was fine so my doctor suspected depression or chronic fatigue syndrome. I went on a candida diet (absolutely nothing that creates sugar in your body, not even fruit) and I felt almost completely cured. I was on the diet for a year and started adding some brown rice to my diet. I started feeling bad again. I ate a couple handfuls of dried fruit an got super sick. I decided to test my blood sugar myself. In the morning I ate 1/2 a very small bagel and about 1.5 cups of brown rice. At 1.5 hours my blood glucose read 202. I would be considered under weight (5’6″, 107 lbs). All the info I’ve read so far talks about eating too much and losing weight. I’ve had a very healthy diet for about 12 years, which is when I found out what hydrogenated oils were and became very health conscious. I worked in a health food store for two years. Prior to that I did eat really bad though, so I suppose it’s just catching up with me. However, my life has been tremendously stressful.

  5. Beth says

    Hi, my son Asian-American is 21 yr old and fit 5 ‘7, 160 lbs is newly diagnose w/diabetes. This what happened 6 wks ago, he flew fr Florida to China to stay with us during His summer vacation (he goes to FSU for college, dad works at US Consulate). He said during his flight from Atlanta to China he was very very thirsty and drank a lot of fluids from fruit juices, electrolyte drinks to sodas. During the first wk his appetite is normal, he has big appetite and still very thirsty–he even run 6 miles on the treadmill 3 times that first week.

    Then the following week he started his summer hire part time job at the Consulate. On the third day he went out with the local coworkers for lunch, that night he vomitted and feeling very fatigue (he did go to the bathroom a lot because of the fluids he’s drinking), he still went to work the rest of the week even though he is very weak. My husband and thought it was just a 24-72hrs bug he caught during his travel but on Saturday I told my husband to take him to see a Dr. The Global Doctor predicted and diagnose my son having a Diabetes. He was confined for 5 days in Chinese local hospital and the Endocrinologist say he could be T1 but then the Endo Dr Chief of Staff said my son might be a T1, because the blood test they conducted was all back to normal.

    We MediVac him to Florida and saw an Endocrinologist 2 weeks ago and has blood test and still the Doctor said she “think” my son is type 1 diabetic even though the blood test is not clear whether my son is T1 or T2.

    I’ve been logging his blood glucose and this week his reading is in the normal range 70s to 120s–of course there are some ups when eating more at dinner or lunch (this with 2 units of fast acting insulin and his night time insulin we reduced to 8 units). This last 4 days his glucose reading are pretty much in the normal range and we decided not to give him 2 units of insulin but still take his Glucophage w/his meal. This morning his fasting reading was 76 then gave him 2 sachet of sugar free oatmeal–post breakfast glucose reading was 208 and went out for 30 mins jogging and his bg reading was 86 this with out taking insulin.

    I am still depress and heart broken that my son who never get sick except for having colds has to go thru this kind of disease for such a young age and he will never get the job he dream of joining the US ArmForces after college.

  6. cindy says

    Alan,

    thanks for taking the time to write such a detailed message. Yes, I am pressing for more information b/c I just don’t understand things right now. There has been no c-peptide test that I can see in my medical records, so that is confusing to me. I would like to know what the root problem of all of this is, and how to fix it. I also don’t understand why I can’t just take insulin if my body isn’t producing enough. I had an Osmolality Calc blood test, which came back out of range, but that test basically shows how the body processes fluids and doesn’t have anything to do with insulin production. (at least to my knowledge). I’ve started taking cinnamon/chromium supplements so we’ll see if that makes any difference in BG levels. Hopefully I will get some answers soon so I can do what needs to be done to get healthy again.

    • Alan Watson says

      c-peptide is a by-product of insulin production. It doesn’t break down as quickly as insulin so some doctors regard it as more reliable than insulin itself; others measure insulin directly. You need one or the other, but not both. The Oxford University calculator, the link to which I sent you, will use either of these and simultaneous fasting blood sugar level to assess whether the problem is in your liver, pancreas or both.

      Best wishes,

      Alan

  7. says

    Thanks for this article Chris. I think too much caffeine can play a big, somewhat unchecked, role in the abundance of stress in people’s lives. Too much can mean too much cortisol. Since I have been caffeine free, I believe my hormones have balanced out and I can really feel the difference.

  8. Cindy says

    My A1C is 6.5 (has been for a year now) and my endo says I’m NOT diabetic, I don’t need to test my glucose levels, and to stop worrying. I recently have been diagnosed with A-Fib, have lost over 20 pounds without trying in the past year. I test my glucose anyway, and even though I eat very low carbs and virtually no sugar my numbers are in the 120’s-140’s after meals (1 hours or 2 hours after). My fasting in the AM is sometimes up to 110. What should I do? I have seen 2 endos now who insist I don’t need meds.

    • Alan Watson says

      Hi Cindy,
      Your endos may well be right: you are not diabetic and you don’t need meds; worrying won’t help, but it sounds as if they are also short sighted; you may well become diabetic in future if things carry on as they are.

      There is some good info on how this cycle progresses if not interrupted here:

      http://www.ncl.ac.uk/magres/research/diabetes/documents/BantingDiabeticMed.pdf

      Your fasting blood sugar is controlled by the combination of two things: 1) how much insulin (and glucagon) your pancreas produces and 2) how your liver responds. If you get a professional test of both glucose and insulin when fasting, you can use a calculator available here:

      http://www.dtu.ox.ac.uk/Homacalculator/index.php

      to tell you whether the problem is with 1 or 2.

      I was already thin (BMI 20) and had blood sugar levels similar to yours despite losing weight without trying to; in my case my problem is with my pancreas. I also found extremely low levels of amylase (a a digestive enzyme) in my blood and am now getting treatment for pancreatic insufficiency.

      More people, however, will find that their problem is with their liver. You can check this by getting some standard liver function tests and an abdominal ultrasound. These are good things to test every now and then anyway as part a general health checkup. If you haven’t had recent cholesterol tests, you should do these too, and you might want to check for the anti-bodies that cause type 1 diabetes.

      You don’t say what your BMI or blood pressure are; many people with high blood sugar also have high blood pressure and cholesterol combined with fatty liver and being overweight – known as the metabolic syndrome. The only known way to reverse this is to lose weight. You may find that cardiologists are more sympathetic to this than endocrinologists.

      Good luck,

      Alan

      • cindy says

        My endo hasnt checked amylase levels, or done any liver function tests. She told me my body isn’t producing enough insulin but I don’t see any c-peptide test or any other one in my history of blood work that indicates that result. She also said that even though my body doesn’t produce enough insulin, she can’t put me on insulin or even oral medications to counter that. I’m completely confused by that.

        As for cholesterol, I just got it down by 65 points by changing my diet for 3 months. It’s still higher than “normal”, but that’s in my genes. I’ve been on BP meds for 5 years now, but it’s well controlled. If I eat only 30-40 carbs per day, no sugar at all, and mostly veggies and protein, my sugar is well managed. It’s very difficult to eat that way on a long-term basis though.

        • Alan Watson says

          Are you saying that your endocrinologist is telling you that you aren’t producing enough insulin, but hasn’t tested either your insulin or C peptide levels? ie that she is telling you things with no facts to support them? You should press her on this.

          If you/she don’t have at least one fasting blood sample with blood sugar and either insulin or c peptide, then you need to get one.

          If this does show that you have too little insulin, then you should also test for islet cell antibodies and amylase. The islet cell antibodies will tell you whether you have type 1 (or compound 1 & 2) diabetes; the amylase will tell you whether you have pancreatitis (if it is too high) or insufficient digestive enzymes (if it is too low). (The pancreas produces both insulin to control blood sugar and enzymes amylase, protase and lipase to digest carbohydrates, proteins and fats.)

          If your pancreas is not producing enough digestive enzymes, you may have some symptoms – unexplained weight loss, constipation, soft, yellowish smelly stools, but these symptoms will only show after your enzyme level has fallen to about 20% of its original level. If you have pancreatitis you may experience sharp pains in your upper abdomen, towards the back.

          If the blood sugar/insulin test does not show that you have too little insulin, it will probably show that your liver is not responding properly, and you should have liver function blood tests.

          Whether the problem is in your pancreas, or liver, or both, you would probably be well advised to have at least an ultrasound to check out these organs, your gallbladder and spleen. For fine detail of the pancreas you might need an MRI too.

          If there is a problem with any or all of these organs (I have fatty liver, gallstones and a thickened pancreas) then you would be well advised to see a good specialist in these organs and not just an endocrinologist. The pancreas is a vital organ, and problems in it can lead to cancer which is very difficult to treat.

          As to taking insulin, I rather sympathise with your endocrinologist. My pancreas does not produce enough of anything. I have to take pancreatic enzymes with every meal. Even so, the only things I can digest easily are sugars and refined starches. But injecting insulin is a real pain and it may not help encourage your pancreas to do more. The alternative, taking something like metformin to encourage your liver to work harder, may also not be a good idea if the problem really is with too little insulin.

          From what you say, your current blood sugar levels are not alarming enough for you to be taking drugs, but they are enough of a concern for you to be assertive with your doctors and insist that they investigate logically to find out what is going on, and explain everything to you.

          I have been though a long journey on this myself, having to read lots of journals to make up for doctors who don’t know what they are doing and/or don’t explain. My message is: press your endocrinologist on the insulin/c-peptide test, or organise it yourself somewhere else, check the amylase, antibodies and liver function tests, have an ultrasound and follow where the results lead you in a logical way.

          Best wishes

          Alan

  9. matilda says

    Glad to hear someone addressing the problem of thin and diabetic. I want to address the accuracy of the A1c test.
    Diabetes runs rampant in my family. Once we hit middle age, we get it. I am pre-diabetic, with A1c levels between 5.8 and 6.1 for the past several years. I’m 57, 5’2″, about 130 lbs. My diet is healthy by most standards, I’m not athletic but I do exercise, I expressed my concerns to my doctor, who sent me to a dietitian, who put me on a balanced carb diet (three meals a day, 30 gm each, three snacks a day, 15 gm each). I also kept a food diary and checked my BG in the standard manner, 2 hrs. after eating. For a week, my BG ran between a low of 81 and a high of 136 (brought about, apparently, by a cup of coffee) The average was about 100. I had another A1c test, and it came back 6.1! I’ll be honest, I was hysterical. I made an appointment with my doctor, and before I arrived she called the lab that had performed the test to ask them what the standard margin of error was for the A1c. The response? “Well. we’ll admit to .4 in either direction.” So, in other words, my actual number could have been anywhere between 5.7 and 6.5! My doctor looked me in the eye and said, “We’re going to stop worrying about the A1c and go with the numbers from your BG tests. You’re fine.”
    So what am I supposed to think now? I don’t want to become a slave to some questionable medication, but I don’t want to slowly rot away from complications like my mother did. And incidentally, all the talk about the inevitability of complications for BG levels in my range does nothing to lower my glucose-spiking stress levels either.
    Any other thoughts?

  10. Diana says

    Hi I’ve had a physical exam for my night school class and my CEA was elevated with hx of cervical Ca . Nothing was found n then during my lab class at school my BS was taken and I was at 237. My A1c was 8.1. I was working all day n skipped dinner with family n ate at break in my night class ( box of cookies n water usually) n my stress from constant studying n not exercising ( biking) due to lack of time kept me stressed. A year later I suspected I had throat problem n dx with Thyca III so now I’m on synthroid . My concern is.. Since I graduated snd my stress has subsided and my exercise regime has steadied
    Why am I still tired n achy? My HR is fine now thst my levothyroxine is steady n my diet is low carbs n moderate protein. My sleep pattern is way off. Can my lack of regular sleep be causing poor digestion n my blood sugar to be so high. My bs was 239 at lab last week n my A1c was 7.5. I went up :(
    Usually I walk around block n that lowers my bs but cold weather inhibits that. I’ve been thinking sll along it was my thyroid causing my extreme tiredness n aches but I’m realizing my diabetes is probsbly the culprit. I’m sn active ( sporty)) 55 year old woman who is slightly overweight at 164 lbs at 5’8″

  11. francesca says

    Hi, I just found out I am pre-diabetic and I’m worried. I basically have been eating healthy for years. I do no form of sugar or white flour, no grains, i eat vegetables and protein. I am thin and exercise at least 4 times a week. it must be genetic and don’t know what to do. does anyone have any suggestions?
    Thank you

    • Alan Watson says

      Hi Francesca,
      If you’ve just had a single highish fasting blood sugar reading then you probably shouldn’t worry about it too much. If you are concerned, you could buy a blood sugar monitor and check regularly, fasting, after meals and after a heavy load of starch – Chris suggests baked potato.
      In the long run many things can influence your fasting blood sugar, but there are only two direct influences: the amount of insulin that your pancreas produces and the extent to which your liver responds to it. If you get a blood test for insulin (or c peptide) as well as glucose, then you can find out how the two are performing using the calculator available here
      https://www.dtu.ox.ac.uk/homacalculator/
      I found out that my insulin was off-the-scale low and another test showed that my digestive enzymes were too, explaining the source of digestive problems that I had thought completely unrelated.
      This is rare though. A few people will have the beginnings of late onset type 1 diabetes (you can test for the antibodies). Most will have some kind of fatty liver, which may well have a genetic origin, but which will probably take you back to good diet and exercise.

      Best wishes

      Alan

  12. Judith M says

    Just ran into this article and so happy to see that someone is addressing the subject of skinnky people with type2 . I’m in great shape I eat right exercise regularly and looks great, but yet cannot control my sugar level. I have T2D. My doctor and I are trying everything to get it under control but it is still higher than normal. I’m on oral med but now she is thinking of putting me on insulin, I am not happy about that I’m so active I am fightened that instead of sugar highs I migh have lows and at the worse places, hiking running somewhere I might not be able to get some food reightway. The deal is to continue to aggressively monitor my food intake for another few months and if nothing changes then try insulin. Yes heath conscious people have to worry about diabetes as well as those who are overweight. Everyone on my paternal side either have diabetes or died from complications. So this article makes sense to me.

    • Tim says

      I’ve been a thin type 2 for 6 years.
      Managing sugar levels is about managing carbohydrate intake, not guzzling tablets.
      If you have no carb intake your blood sugar level will never go high. This is not practical, but you get the point.
      My intake is 120gms carbohydrate per day. 50gms consumed at breakfast, 50gms for lunch, 20 for tea and NONE between meals.

  13. says

    I know this thread is old, but if anyone could hook me up with some insight that would be awesome! I had a fasting blood sugar of 109 about a year ago and started getting symptoms of PCOS, mainly thinning hair. My DHEA was a bit elevated as well. I am thin, 98 pounds and 5’2. I began and paleo diet (already ate GF and DF) but cut out a lot fruit, grains, and white potatoes. Digestively I feel great, but Since going so low carb (around 30 grams a day) I am constantly hungry and have moments of hypoglycemia like symptoms. I have in the last few days started eating more carbs and the symptoms have worsened. Any insight or advice? Thanks!

  14. Mark says

    HELP?! Hello Mr. Kresser. I am a low carber and i am concerned about insulin resistance. I have only recently discovered that eating a low carb diet can actually cause diabetes through insulin resistance, so i just wanted to ask what would be a good amount of carbohydrate to aim for per day in order to avoid insulin resistance? And can i also ask if high protein intakes should be avoided for the same reason?
    Thank you,
    Mark.

  15. very interested person says

    Thank you for the good and informative article.
    And I have a question. You briefly mentioned media.
    As an expert, what do you think the television news? It is often the case that whenever they talk about obesity-related issues, the media show video of large-sized people enaged in a negative activities like eating big hamburger greedily. Do you think this visual representation is relevant?

    Also, by definition, are obese people fat people including those having obesity-realted diseases and those who dont have one?

    Your answer will be appreciated greatly. Hope you can answer to my question :>

  16. Nancy says

    Chris, I have a question about exercise, cortisol, and BG… my husband, a lean type 2 for 5 yrs, started a bootcamp 1 yr ago to help control his HgbA1C. (individual pace, intervals of hard exercise (burpies etc) with short rest, lasts for 30 min.) He checks his BG when he gets back and it is very very high… sometimes 250+. It then drops quickly over the next hr. I think it is that his body produces lots of cortisol with the exercise, which causes a glucose spike. How bad is this spike for his body, since it drops quickly over the next 2 hrs? Does he need to switch exercise? This is the first exercise he has really stuck with and it is a very encouraging environment. The spike is much worse in the a.m if he exercises before breakfast. Is there any way to smooth out the spike? He has tried taking his Metformin before he goes, also tried a protein shake thinking his body wouldn’t get the “low BG” message and therefore wouldn’t start the up and down swings, but no luck so far. His A1C is 6.6. (Oh, and he has a very stressful job, so awaiting your article on this and on how to treat the inflammation.)

  17. Mary says

    I have a question?? I’m 5’2″ 125lbs. my morning fasting blood sugar has been between 100-110 for several weeks. I didnt have this problem before?? I’ve recently lost weight (in the last 6months) ?? I figured it was due the diet change…

    I have Hashimotos and a lot of food intolerances… I avoid SOY-GLUTEN-DAIRY-YEAST-CORN-RICE-POTATO….

    I have honey in my morning coffee… I eat very clean…

    Is it the honey?

    doesn’t make sense to to me?

  18. Martin says

    “Since fructose is handled by the liver in the same way the liver handles alcohol, excess fructose produces a similar range of problems as alcohol abuse: hypertension, high triglycerides and low HDL, obesity, cirrhosis and insulin resistance.”

    Here it is a good idea to define “Excess Fructose” because several hundred grams of fructose can be stored as glycogen in the liver before it even starts converting any of it to fat.

    When you say “Excess fructose” I assume you mean unphysiological amounts where it pushes you to a calorific excess? As anything else (Especially when that fructose is derived from fruits) none of the above issues would occur.

    I just feel the point needs to be clarified as the last thing I think you would want to do is scare people off eating plenty of fruit as a part of their daily calories.

  19. Murray says

    Prior to getting pregnant, I was diagnosed with controlled type 2 diabetes (I am 29, 5’5″ and 130 lbs – active). I was diagnosed because of previous miscarriage at 8 weeks and a chemical pregnancy – I have insulin resistance due to PCOS. My a1c was 5.4% (normal). I started taking 500 mg of metformin in the morning and got pregnant the next cycle. I am currently 5 weeks 3 days. My morning fasting numbers have slowly been increasing from mid-low 80’s to 94 today. I am also eating very low carb and have been for about 2-3 months (30-45 g carbs/day and almost all from veggies). My post-meal glucose levels are all low (in the 80’s and 90’s).

    Any suggestions for getting my fasting numbers down to a healthier level?

  20. sad in LA says

    I was always skinny until I had children. I also was hypoglycemic.
    Now I have moderately high blood sugar – gets up to 150 if I forget to take metformin and I am overweight. I feel so bad that I am not skinny anymore. I don’t recognize myself in the mirror. What happened?

  21. Alan Watson says

    Hi,
    I am a 54-year old slim man (BMI 20), with a good diet and lots of exercise. I don’t smoke and I drink in moderation. For about 15 years, I have been taking statins to control my cholesterol and calcium channel inhibitors, other meds to control blood pressure and reduce chest pain from cardiac syndrome x and asprin to reduce risks of CHD in general. A few years ago I also discovered that I had hyperhomocysteinaemia – 50μMols/L, for which I take folic acid and vitamin b complex. Now my cardiologist tells me that I have rising blood sugar (95 and 99 mg/dL fasting at the last two tests), and is very interested in my skin problems, gum disease, hay fever, nosebleeds etc. It seems that I have mild generalised inflammation and may be developing insulin resistance.
    The cardiologist will obviously monitor the situation, but for now his advice is 1) more exercise, 2) more exercise and 3) less carbohydrate intake.
    I am following this, but as I say I am already slim, with a good diet and lots of exercise. Almost all the advice aimed at heading off diabetes talks about losing weight and changing your sedentary lifestyle. What more can those of us who can’t lose weight and do not have a sedentary lifestyle do?

    Alan

  22. MAS says

    Type 2 diagnosis @ age 64. Turn 66 2wks. Never overweight: heaviest ever @ 136 lb. never over 120 until 45 yrs old. 5’8″. Always very active & have always eaten right, growing much of my own food. Most people think I’m age 45-50, by appearance. Mother in mid-90’s no problems. Sisters both fine, even the overweight one. (I’m middle of 3 girls.) So why, why, why? On Metformin 500 mg qd, fasting glucose stuck at 108-110. A1c running stuck 5.6-5.8. VERY discouraged. Women in my family 5 gens make it to late 80s at least, usually 90s. Seems like no hope for me in spite of strict care…

    • says

      Hi MAS,
      Don’t fret. Type 2 diabetes is not the worst thing that could happen. If you stay active and continue to eat right (as you are already doing) and definitely stay compliant with your medications, your DM should stay well-controlled. What you want to avoid are the complications of DM. If you want to lower your A1c try shaking things up with your exercise routine, perhaps your body is used to your current workout and your body needs to be challenged in a different way than it is used to. I don’t know what your current routine is but increasing aerobic exercise is a good way to go, even if you’re already doing aerobic exercise now, just trying stepping it up. Anyway, sorry to go on and on, it’s just that I saw your post and thought I would try to share some encouraging words.

  23. Jayne Lees says

    I am skinny and type 2 diabetes but want to know if there is anything I can do to stop getting any thinner I am 5 ‘ 8″ and 136 lbs

    • Brad says

      Hey Jayne, the only way you will be able to gain weight is to eat more carbs. It will lower the amount of fat you burn. I just happened on here but thought I would give you my input. I am type 1.

  24. Tim Mylward says

    IFCC (International Federation of Clinical Chemistry) is MMOL/MOL whereas the traditional HbA1c in the UK, is a percentage. I understand that from June 2011 the UK is switching to IFCC.

  25. Chris Kresser says

    My functional range only goes up to 5.2. Studies clearly show that heart disease risk increases in a linear fashion as A1c moves above 4.6. From 4.6 to 5.2 the increase is small, but after 5.3 it begins to go up considerably.

  26. Lynn says

    Maybe it was a functional range of 4.8 to 5.9? Though a functional range would be more likely to be up to 5.3 or 5.5.

  27. Chris Kresser says

    I was guessing the decimal was in the wrong place, i.e. 4.8 – 5.9, but that still doesn’t make a lot of sense.

  28. Chris Kresser says

    You’re not misunderstanding anything according to the conventional model, but keep in mind what a spectacular failure that model has been. Diabetes and heart disease are epidemic, and getting worse. My advice is not to follow their advice, because their advice is obviously not helping. The stats don’t lie.

    The laboratory ranges are simply bell curves of the results of people who get tested. And who gets tested? People who are sick. Therefore the lab ranges don’t reflect what’s optimum for health, but instead what is average for sick people.

    • Jina says

      Can you tell me where I can find a good, simple book with basic meal plans based on what you’re saying? I seem to have everything you’ve mentioned – fatty liver (many yrs ago and nothing was said about it). Meed to lose 100 lbs. chrinic pain head to toe. Dx’ed w type 2 diabetes 1.5 yrs ago. How many carb grams a day do u recommend? If I test 2 hrs post eating what # am I trying for? I was also told a 7 a1C was my target! What does one eat to fix a fatty liver? I desperately need to change. Thanks for any help.

  29. Tim Mylward says

    Chris.

    Thanks for that. I’ll see what I can do to reduce further…

    Just 1 thing. On my last test it was 6.6. The document from the laboratory also provided it as (IFCC) which was 48.6.
    In that document they state that the normal range is (48 – 59) which would put me at the low end, or have I misunderstood something ?

  30. Chris Kresser says

    I doubt he’s lying – it’s possible an A1c of 7 is the best of his patients. But that’s hardly “good control”. Many T2DM patients can get their A1c down in the 5s with a low-carb diet and, in some cases, a relatively low dose of metformin. An A1c of 7 is too high, as evidence suggests that complications begin as A1c climbs above 5.4. I’ll be writing about this very soon.

  31. Tim Mylward says

    Lynn.

    Thanks, I’ll take a look.

    Chris.

    A1c of 7 is high ?
    My doctor has told me that 7 is the best of all his type 2 patients.
    Is he talking rubbish ?

  32. Chris Kresser says

    Yes, Tim, an A1c of 7 is alarmingly high. It’s not something to “maintain”, but something to address as if your house is on fire (which it is, in a manner of speaking).

  33. Tim says

    At 18 went to my GP with indigestion. Every night my sleep was disrupted and I was guzzling antacids. I was checked for ulcers and later Celiacs Disease and the verdicts were both negative.
    I lived with this for 35 years and was diagnosed as diabetic when having a standard blood test due to my age.
    I have been managing my blood sugar quite well for 5 years now simply with diet. I test my blood sugar level 2 hours after meals and adjust my next meal accordingly.

    Now the interesting bit…
    During this period I have experimented with various foods and have discovered that my indigestion problem completely disappears when I cut out wheat products. In addition my blood sugar is much easier to control and I can even eat ice-cream and have sugar in my tea and still maintain an HbA1c of 7.

  34. Chris Kresser says

    Michael,

    Thanks for your comment.  I couldn’t agree more about measuring post-meal blood sugars. I’ll be writing an article about that in this series.  It’s a fantastic, affordable and highly effective way to measure carbohydrate tolerance.

  35. says

    I am a thin type 2 diabetic. I am what is called a Ketosis Prone Type 2 diabetic. I don’t particularly disagree with what you are saying. It is more a point of emphasis. KPD’s can be a mix of BMI’s so weight isn’t that grand of an issue. In fact, heavier KPD’s tend to have lower A1c’s then thin ones. KPD’s also tend to be people of color. This is largely due to the fact that darker skinned people tend to live where Malaria is endemic. What we seem to have is a genetic adaptation that gives us some resistance to malaria. Think about it, this adaptation has been around for thousands of years but our susceptibility of going DKA really only becomes an issue in the last fifty.
    As I see it, this is an issue purely of diet. What we are eating is at some level poisonous. What those things are, it seems to me are myriad. Rather than pass out more advice on diet, I have rather opted to suggest to people that the one thing they can do is test their blood sugars and see how they are effected by what they eat. This simple bit of advice would have saved me and a lot of KPD’s much suffering.

  36. Chris Kresser says

    TimL:

    It’s not just refined vs. non-refined, because we have to consider the impact of toxins present in whole grains.  That’s why even whole wheat bread and other whole grain products are problematic.

    I think a LC diet is useful for weight loss (for most people), and I recommend it and use it with my patients.  But I don’t believe it’s necessary for the general population.

    There’s no single cause of diabetes & MetS.  As I explained in my most recent article, several factors (genetics, toxic load and gut permeability – among others) contribute and are interrelated.  For one person, eating bread may not be a huge problem.  For another, it might be a life-threatening problem (i.e. someone with celiac).  Also, there’s some evidence that the gluten in Europe even today is much less toxic than the gluten in the U.S. grain products.

    • Catherine says

      Could you explain more what that means (gluten toxicity in Europe vs US) or suggest a reference? Thanks.

  37. TimL says

    Chris and Russ,
     
    Thanks so much for addressing these questions, I learn almost as much from these comments as I do from the posts.
     
    So one question I have is this — you say that the difference is between refined vs. not refined, but wouldn’t that mean that “whole grains” are a-ok then? I obviously ask that because I’ve read here and elsewhere to the contrary — that all wheat/grains, regardless of refining, are bad.
     
    And besides the diabetes issue, what about general weight/obesity? Management of diet based on GI/GL/Carbs has been a hugely successful strategy for people to lose weight. How does that stack up with your position? Are you recommending that people stop modifying their diets this way, even though it’s been very successful for so many?
     
    Finally, a burning question I’ve had regarding advice against grains/wheat/refined flour:
     
    Cultures throughout the world, especially Europe, have been eating these things for centuries (bread, pasta, etc.). Diabetes/metabolic syndrome/cardiovascular disease are largely modern, 20th century diseases (certainly in terms of prevalence). Why didn’t these problems develop much earlier? Why didn’t we see these rates of disease before now?

  38. says

    I should have been more clear about the weight I lost as well. Because of my background – I wasn’t ‘obese’ to begin with, even though I did lose 30 pounds. I went from a bodyweight of 235 @ 16-17% bodyfat (still in the healthy range), to a weight of 205 pounds and bodyfat percentage of 11-12%. So while losing 30 pounds sounds wonderful, it should also be noted almost half of that was LEAN tissue.

    My eating habits were not the best – but they were essentially masked by my training. Leaving me to wonder how much local enivromental factors and/or various protein supplements played a role in developing Type I at my age. One silver lining being my wallet is a lot fatter now having realized that all the protein supplements and what not are largely un-necessary; if not completely un-necessary for the majority.

  39. says

    No worries Chris, I am in agreement with you. The ROOT is imflammation – I am simply making a non-exhaustive list of the most likely suspects inducing the imflammation.

  40. says

    ..which as Chris alluded to all induce imflammation – something at that root of just about everything that may ail the human body.

    These are just my perspectives as a fitness professional/former competitive athlete diagnosed with diabetes around age 30 – though not type II – who once went through the low-carb honeymoon dropping 30 pounds and 5-6% bodyfat until my health starting turning for the worse – who now enjoys 3-5 pounds of potatoes, rice and other evil foods on a weekly basis and now has much better blood sugar control, mood, and a return of my strength.

  41. Chris Kresser says

    Russ: I was speaking only in the context of carbs and certain dietary factors.  As you’ll see as I continue this series, I agree with you that the overall picture involves several other factors – some in our control, and some not.

    Still, I maintain that many of the other factors like pollutants and toxins that contribute to diabetes do so via inflammation and oxidative damage.

  42. says

    …I would say it would be more accurate to say diabetes and metabolic syndrome are more likely caused by a storm of factors that include:

    – overconsumption of calories in general combined with lack of movement (note this doesn’t mean exercise or working out; there is a difference between sitting in front of a TV/computer/desk for 10-12 hours/day and simply getting off your butt and MOVING every now and then)
    – consumption of processed and franken-foods
    – omega 3/6 imbalance
    – insulin resistance resulting from an ever disappearing full nights sleep that gets shorter and shorter each decade. It only takes one night of insufficient sleep to induce a 25% increase in insulin resistance. Multiply that effect on a daily basis for an entire career. 
    – known/unknown enviromental factors – this week a national study was released that linked air pollution and diabetes. I live in Pittsburgh, and the southwest area of PA has a disproportionately large population of folks with diabetes/diabetes complications/metabolic syndrome. We also were the world’s largest steel producer for decades – the smoke stacks are still visible. One wonders how much that has detrimentally effected the local population’s health over the past century – as from talking to friends we also have higher rates of Down’s.

    • Not Diana says

      (1) Down syndrome is caused by chromosomal non-disjunction, (2) lack of sleep does not cause a 25% increase in insulin resistance (and you can’t even describe insulin resistance in that way – you can decrease insulin sensitivity but not increase insulin resistance), (3) “franken foods” as you call them do not cause diabetes, you clearly don’t understand genetics or transgenics at all, and (4) your area probably has a high rate of diabetes and obesity due to poor diet and lack of exercise, not the random assortment of fake facts you listed.

  43. Chris Kresser says

    The idea that diabetes/metabolic syndrome is caused by carbohydrate intake and high GI foods is a gross oversimplification- especially when one does not take into account whether whatever carbohydrate is ingested in processed/refined or not.

    Couldn’t have said it better myself, Russ.  The idea that high carbohydrate intake alone causes diabetes is false.  Otherwise, the Kitavans and traditional Asian cultures that eat a lot of white rice would have high rates of T2DM – which they don’t.

    The key question regarding carbohydrates is whether they’re refined or not. And the reason that probably makes such a difference is that refined carbs are pro-inflammatory, whereas natural carbs are not.

    The idea that even natural carbs in excess cause diabetes is based on the “tired pancreas” theory (i.e. repeated intake of high carb meals causes excess insulin secretion, which exhausts the beta cells and causes insulin resistance).  Turns out that theory doesn’t hold water, with the Kitvans and Asian cultures being a case in point.

    Instead, my argument is that inflammation is the primary mechanism driving diabetes.  That means that anything in the diet that causes inflammation (food toxins like refined flour, seed oils and liquid fructose in particular) will contribute to diabetes, but natural carbs alone do not.

  44. says

    TimL,

    I am sure Chris will chime in when he gets time but…

    Why or how is it pretty much fact?  

    The idea that diabetes/metabolic syndrome is caused by carbohydrate intake and high GI foods is a gross oversimplification- especially when one does not take into account whether whatever carbohydrate is ingested in processed/refined or not.

    Foods are also generally not even in a vacuum like they were for the GI testing – by adding fats and proteins to your meals like you normally would – you get an ENTIRELY different GI response as compared to the GI itself.

  45. TimL says

    Chris,
    Thoroughly enjoying this series, as well as the rest of your blog.
    One question I have regarding this series and your writing in general is that dietary carbohydrate intake and glycemic index/load hardly figure in at all. My understanding for a while has been that diabetes and metabolic syndrome in general are at least partially caused by overconsumption of carbohydrates and high GI foods. At the very least, they trigger your body to put on fat, which generally isn’t healthy.
    But lately I’ve been reading writing from you and others (like Stephan Guyenet) that high GI carb consumption isn’t really a problem. How can that be? Isn’t it pretty much fact that those things make many people fat, and that many people have lost weight as a result of going on low-carb diets? What am I missing?
    Thanks so much for all the work you do, please keep it up.

  46. says

    Just wanted to say thanks for writing an article that actually mentions us who develop Type 1 as adults – even while lean – it seems we don’t exist in the medical world! I should have the GAD’s tested to confirm – but only needing about 6 units of insulin a day seems to indicate I don’t have much of an insulin sensitivity issue. I also fare much better on a more moderate carb intake than a VLC intake.

  47. Byron says

    Great article, Chris, thanks.
    Stress is really a huge factor today. Nothing in balance, everything in chaos. That´s for sure not healthy. As others before mentioned I also ate tons of fat+protein on keto/VLC and gained sometimes weight, had elevated cortisol levels and low fT3. Now I slowly reintroduced some carbs, first carrots than potatoes. I estimated to regain some weight but it´s still stable. BG is fine with 90 after eating a huge meal of carbs (+fat). Finding is, it´s important to take some things easy. Long ago fat was my biggest enemy now I make peace again with carbs. Everything´s in balance. It´s just food.

  48. westie says

     
    When I strarted my scientific journey with T2DM more than four years ago I had one idea where I started: “hepatic insulin resistance is a cause for type 2 diabetes.” Fat content of the liver goes hand in hand with the severity of the disease so fat in the liver is related to the problems.
     
    When I looked what causes BG to rise in T2DM I found out that adipose tissue derived lactate might explain atleast part of that. Increased lactate from AT was a result metabolic malfunction of the adipocytes (low mitochondrial oxidation & increased flux of glucose to lactate) which is related to activation of the Randle cycle. Randle cycle activation is caused by increased lipolysis from triglyserides. Then we come back to the question how is lipolysis regulated?
     
    Some studies says that inflammation in the AT will lead to the decreased adipogenesis and perhaps increased FFA avaibility in the visceral deposit:
     
    http://www.ncbi.nlm.nih.gov/pubmed/20018865

    High sucrose diet or ethanol use will lead to the development fatty liver and T2DM but I’m not sure that it is in causal relation to increased de novo lipogenesis in the liver by fructose or ethanol because happenings in the AT has such a big effect on the liver metabolism. Importance of this is seen studies with PPARg agonists which reverse metabolic dysfunction.

  49. Elizabeth O. says

    I figured out last winter that I’m something of a cortisol junkie and will invent stress where little or none exists, just to feel “normal”. Your post above about cortisol and blood sugar made my relationship to food make a lot more sense. I’m looking forward to hearing more on the subject.

    I don’t check my blood sugar (so far), but I have noticed that like Lynn, I do better on a moderate carb diet compared to a VLC. And for me, the best news about that is that I managed to just accept it as being the best fit for my body (n=1), and not stress over “failing” at VLC. For a cortisol junkie, that’s progress!

    Thanks so much for your very helpful posts.

  50. lynn says

    My blood sugars are MUCH better since switching from a VLC to a moderate carb diet. Now, I did start natural thyroid around about the same time, so maybe that is a confounding variable. However, I always felt hungry and craving on VLC no matter how much meat I ate. So, I am thinking that in certain people, ketosis does not reduce appetite (I found it did the opposite for me) and hence the person eats way too much protein and blood sugar rises. Not good.
    My current diet of meat, vegetables, fruit, gluten free bread, potatoes and dark chocolate keeps me satiated and my blood sugar is normally in the 95-105 range two hours after eating. I want to get it even lower and your website (along with optimising my potassium levels) is helping me with that. I do feel inflammation is a huge factor for me, so I eagerly await your posts on HOW to reduce inflammation, since I already have the common bases of a gluten free diet and careful carb intake covered.
    Finally, can you tell me why my post meal sugars have really improved, but my fasting blood sugar is still in the 90’s? Is the fasting figure the last to improve?

     

    • Jay M says

      To reduce inflammation, try shifting to a low-fat, minimally-processed plant-based diet (see Dr Esselstyn, Ornish, McDougall, Barnard). Most breads, even gluten-free, are not healthful. Excess animal products, especially animal fats are inflammatory. Fats carry the bacterial products (ie LPS, cell wall remnants) which trigger inflammation. Because most animals are raised in crowded/stressful/unsanitary conditions, fed a diet to maximize growth and body fat, they are typically prone to infections. A large portion of all antibiotics goes to keeping such animals alive. Unfortunately rampant antibiotic use promotes antibiotic-resistant strains which can occasionally mutate to infect humans.

  51. Joel says

    In your view, can eating a low-carb diet result in a level of blood sugar that would spur the secretion of cortisol, thus leading not only to an increased blood glucose level but also a higher-than-usual heart rate and hypertension?

    • Chris Kresser says

      This would only be likely on an extremely low-carb (i.e. ketogenic) diet that is also low in protein. With 200 calories of glucose and 400 calories of protein (which most low-carb dieters easily get), the body’s glucose needs will be met. However, the maintenance of stable blood sugar throughout the day (in addition to fasting glucose and A1c) is crucial, and any significant fluctuations can provoke cortisol release (and epinephrine/adrenaline if cortisol is low). Repeated adrenaline stimulation could certainly cause CVD and hypertension.

  52. Lynn says

    This may seem like a silly question, but what exactly is generalised inflammation? I know inflammation is associated with conditions such as arthritis and such, but what exactly do you mean by inflammation in regards to diabetes? Could you write or have you written an intro on the specific phenomenon of inflammation?

    • Chris Kresser says

      Wikipedia is often a good source for this type of general information. Check out their entry on inflammation. It’s our body’s way of handling harmful stimuli, so it’s a natural response to acute injury or illness. The problem is when inflammation becomes chronic, due to continued activation of the immune system by dietary toxins, pathogens, stress, altered gut flora or autoimmunity.

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