Think Skinny People Don't Get Type 2 Diabetes? Think Again. | Chris Kresser

Think Skinny People Don’t Get Type 2 Diabetes? Think Again.

by Chris Kresser

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In the last article on diabesity and metabolic syndrome, 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 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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  1. Hi Chris’s, You should have defined skinny, as most men Asian Indian carry high body fat(20+), but overall they are skinny. That means they are on a hypercaloric diet without even knowing about it. Most of them go to gym but remain the same.No changes in body composition. Their body starts consuming more calories to compensate the exercise or running 5kms. Later they blame carbs for the same. They might have low bmi (19 or 20) but low bmi not equal to healthy. Most of the lean and skinny people (bmi 17-18/body fat <20)here develop high bp because Average salt consumption is 8-10gms per day

  2. I’m a 28 year old, 5’7 caucasian female with a BMI of 18.3 who was recently diagnosed with pre-diabetes (stable 5.7 HbA1C for the past year). In the last year had all the warning signs- extreme thirst, hunger after meals, candida infections, fatigue, occasional blurry vision, itchy skin and unexplained mild weight loss (however I had minimal urine production instead of increased). My parents are both pre-diabetic at age 50. My grandparents all have diabetes (including a grandmother who was diagnosed with MODY at age 28). As a new medical doctor, I found this article most helpful in explaining some murky aspects of the development of diabetes in slim people. Thanks!

  3. I’m 55, weigh 170 and just completed an Ironman Triathlon.
    Diagnosed with Type 2 Diabetes 3 years ago. I think it’s easier to be in denial about your Diabetes if you are lean and fit. When I was diagnosed, I told the young Doctor that he was mistaken, and I immediately drove to Dairy Queen and got myself a large Heath Bar Blizzard. That’s Denial! I’m a little wiser now, but it still doesn’t seem fair

    • I have had diabetes 2 for the last 10 years I’m thin exercise extensively. Have NOT had sugary drink for most of my life or white bread, etc. I have been on metformin 650 mg/day. As of this week it seems like my sugar has been going up when I test in the morning 130 – 140. It usually has been 110 – 120mg/dL

  4. Hi, I’m 36, train with weights 3* a week, run 5km twice a week and horse ride every weekend. Im6’3 160 pounds eat well and have a very good PT, but struggled to add muscle mass.
    Diagnosed with diabetes 2 months ago and currently on a TDD around 30 units, seeing some bg readings upwards of 25 3 hours after a meal, yet c-pep is normal.
    Waiting on anti GAD, but it’s a pretty confusing picture right now, this article helped a lot!

  5. I am 47, Asian Indian, Male, 5ft10in, 165lbs now living in USA for past 19yrs diagnosed with hypothyroidism (16yrs) pre-hypertension (7yrs) pre and type-2-diabetes (~2/3 yrs) and borederline cholesterol (few yrs).

    I was diagnosed for Hypothyroidism around 16yrs ago in the US while going thru my annual physical. I did not have any symptoms of hypothyroid (none of weight gain/loss, feeling exhaust etc). My physician recommended me to see the specialist who performed several blood tests over a period of 2yrs and finally told me to get on the medicine and not wait for the symptoms to show up. The readings during those 2yr period was fluctuating so much that he mentioned once it was out of the charts. Note that I was still not on medication during those 2yrs of monitoring. Since then I started on 25mcg of Levothyroxine. 5yrs ago, the dose was increased to 50mcg and this past year to 75mcg and this month to 100mcg.

    During this period, I have been fairly healthy (physically) and been fairly active – running ~10 miles a wk. I was diagnosed with pre-hypertension 6-7 yrs ago and been taking 25mg of Atenolol since then and also my A1C for past 4 yrs have been coming around 6.2/6.3 with the fasting sugar at around 130.

    My cholesterol readings have always been borderline – little low on HDL (36) and high on triglycerides (250-350).

    My physician mentioned that I am no longer pre-diabetic but actually considered a “diabetic on diet control” meaning not yet on medication, but he was recommending me to go on cholesterol medicine because I am diabetic and also changing my hypertension medication from Atenolol to something else that is compatible with diabetic.

    I am very lost with all this diagnosis. Actually, since last year when my physician warned me, I have significantly increased my activity by jogging / brisk-walking 25-45 miles a wk hoping that will help me to reduce any or all of these conditions but with no results.

    My typical diet is vegetarian at home and eat chicken or fish once a week at restaurants and consume couple glasses of red wine once a week.

    Also on my family side, My mom was diagnosed diabetic when she was ~37 and my dad was diagnosed for hypertension when he was ~60 but neither was diagnosed for thyroid (both in India)

    After reading this article I have requested my physician for a referral to an Endocrinologist (My insurance doest not need a referral, but still prefer to keep him in the loop since I still trust his service).

    Thank you for Chris Kresser for the blog / article and for all the participants for sharing their story and contributing to the discussion. Any inputs on my condition will really help me to look into areas that I have not exhausted yet.

    • Have you read the book, “How Not to die?” I’m reading it right now and am finding it pretty amazing. It goes over the top 15 diseases in the USA and their causes and what you can do about it.

  6. I was diagnosed as Type 2 diabetic at age 21, back then I weighed 125lbs and was 5’8ft (Female). People always say T2DM is a lifestyle disease as a result of basically an ill diet, bring overweight and sedentary lifestyle. But I never fit that profile. So where do I fit in? Since I was around 10yrs old (or younger) I had Acanthosis Nigricans (darkening of skin behind neck/in creasefolds as a result of insulin resistance), I was highly underweight, gauntly skinny for most of my childhood until I hit my 20’s. For some reason I could never ever gain weight, yet I had these darkened skin patches no-one could explain at the time. I was an active child just like any other. When I turned 17, I noticed my wounds weren’t healing, or would take longer than usual to heal. When I visited the doctor, she took a basic blood sugar test and it read 121 as my fasting blood sugar. So she disregarded aby possibility of me being diabetic. However at 21, after being unable to recover from the flu, my blood sugar was tested and it read 360. It was then that they did my A1C which was 10 or so (I can’tell recall) but it was then that I was diagnosed as Type 2 and put on Metformin. Then Diamicron. However these tablets basically lost their effectiveness over the next couple of years. I’m 28yrs old & 140lbs now and am insulin dependent. Without injecting insulin, my blood sugar level won’t decrease. I do experience insulin resistance though, and still have Acanthosis Nigricans, so I take Amaryll with insulin to manage my blood sugar. I’m still not certain about what type of diabetic I really am….

    • Have you tried a ketogenic (high fat low carb) diet? Given that you are not overweight, fasting would probably be a bad idea, but putting yourself in ketosis (having your body run on fat) might be the right thing for you.

      • Izabela, good suggestion. I have recently started a Keto diet as I was diagnosed with Type 2 around 3 months ago. I was skinny and have lost 25 lbs and guess as to when the weight will come back with just diet change?

    • I would suggest seeing an endocrinologist if you haven’t already done so. Just as the article explains, you could be an autoimmune Type 1. It’s good that you are on insulin, but an endocrinologist can confirm the correct diagnosis and make sure you are getting the right treatment advice. Either way this would help you know for sure.

      I am a type 1 and was diagnosed at the age of 34. Luckily, my doctor referred me to an endo and did the tests to recognize that I was not type 2. However, many adult type 1’s are often misdiagnosed and may not get the correct treatment for years.

      I am not on a strict ketogenic diet but do eat a fairly low amont of carbs (about 60-80g per day). This keeps my A1C in the 5’s and has been working really well for me. I also still need small amounts of insulin every day, but much less than most people.

  7. 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.

  8. I was diagnosed at 50 with Type 2. I am 6’2″ and at the time weighed 165. I exercised a lot and very active. However, I suspected that the reason for the diabetes was stress, but could for the longest time couldn’t find anything on the internet that actually said stress could be the underlying cause for diabetes. So I’m the skinny guy he is talking about in the article. I changed my diet dramatically with the hope that I could control it with diet alone, but it didn’t work. I have to take metformin to keep it down. I now weigh around 150. But even with metformin and watching what I eat, my HA1C continues to climb. It’s now at 6.8. And I’m pretty certain it is the stress of my job. That’s the next thing I need to work on.

    • Please get tested for type 1. Get your c peptide and insulin checked. If you’re thin, eating right, and metformin is still not working, it sounds to me like type 1.

  9. Hello
    i am having irregular pattern of blood sugar level since last few months . It is below 80 mg/dl during fasting and rises up to 180 mg/dl after 2 hours of meal. then after 6 hours it is again less than 80 mg/dl . i always feel hungry even after a meal. feel weakness as i m very lean . am i diabetic ? What should i do ?

    • It’s my experience that while I had diabetes, my blood sugar was 300-400 and hour or two after a mean abd during a fast I would become weak, nauseous, clamy, sweaty, and cranky. My blood sugar levels would be below 70 . And I couldn’t have any refined sugar only fat free sugar free items. And even with those precautions I was at 250+

  10. I used to be under 140lbs and vegan (27 years old). But then I went into mental hospital. It caused me to have a fat stomach and have difficulties walking ie. the walking ability of about a 60 year old. I didn’t put on a huge amount of weight immediately. But after 2-3 years I put on over 50lbs. I went into the hospital again. This time, when I left I had the walking about of 75 year old. I notied after a few months I was gaining large amounts of weight. So I cut my calories to 1500/day, including calories from fruit. So in essence, I was eating about 2/3 of what I was eating previously. But the most I ever lose is 1lb a month. If I spent a couple of weeks eating 2000 a day I’ll put on like 2lbs which means I have to spend 2 months to get back to where I was.

    Well as you can imagine all of this was very very traumatic. Even though I’m only 33, seeing as I am now about 200lbs and have huge difficulties losing weight, I started to get very concerned that I might get diabetes in the future. So I overcame my trepidation at walking (which is very difficult for me) and started walking each day.

    Unfortunately, this morning my prophesy seems to be correct. I got a phone call from the surgery (American’s say health center?) and they said I was borderline on fasting blood glucose test and need to have another blood test.

    After reading comments on this page I decided to purchase a blood sugar monitor.

    Sorry for the long comment, I suppose I just wanted to share my story. I was wondering if anyone could tell me whether fasting blood sugar can read bad result in people without prediabetes or diabetes? Suppose I have some wishful thinking that it might just be a one off bad test.

    • Here is a link to a blog you should read https://intensivedietarymanagement.com/.

      Read everything there is to read on this blog and you will find your solution. My mother was a type 2 diabetic, on insulin, for 14 years. We stopped her insulin a month ago and she just tested her 3 month average glucose level. It has never been better (it is completely normal). She looks 10 years younger too and lost abdominal fat (the rest of her body is actually skinny).

      Just to be clear, I applied the knowledge that Dr. Fung shares on his blog without the supervision of a doctor, but with regular monitoring of my mother’s blood glucose. The response to the fasting was immediate (within 2 days we saw pre-diabetes fasting glucose levels; a month later she is getting closer and closer to a non-diabetic glucose levels).

      Given that you are not on any diabetes medication, you should be able to apply Dr. Fung’s approach to curing diabetes on your own. You will likely not get the support of your doctor, but please read the blog just the same.

      Here is the link of the first of six video lectures by Dr. Fung on the aetiology of obesity, he is a wonderful lecturer (you will see the other five through the first):
      https://www.youtube.com/watch?v=YpllomiDMX0

      p.s.once you read the info, I am happy to tell you more 🙂

      • Izabella, you don’t cure T2D there is no cure! You can put it in remission by diet and exercise but…slack off and it comes roaring back! Once you have it, you have it for life. You will always be a T2D.

        Diet and exercise may only work for awhile then eventually you will end up on oral meds or insulin.

        I am one of those thin T2 diabetics!

        I read Dr, Fungs blog, He blames T2D solely on diet and claims it is a lifestyle disease. Bah humbug!!! I was thin as a rake when diagnosed, still thin, still have it.

        I keep reading people’s posts saying T2D can be cured by diet. Bollocks, humbug, codswallop!!! YOU CAN’T CURE T2D…NEVER!

        You can only put it in remission. Soon as you stop the exercise and eat foods high in carbs your T2D is knocking at the door again! Go eat that bowl of lasagna then test your numbers….tell me how cured you are when the meter shows a massive spike!

        • Absolutely!I have explained time and time again that diabetes can’t be cured.Managed but not cured.Start eating alot high refined carbs and quit the exercise and it rears it’s ugly head again.

          • Start eating poison (processed garbage) your body wasn’t designed for and you get sick, how shocking!

            Does anyone get type 2 diabetes by getting 95% of their calories from non-processed (single ingredient ) plant sources with the other 5% being from animal sources while eating 75 grams of fiber per day?

        • Agreed, I’m also thin type 2 for 20 plus years. Fasting and the LCHF diet does indeed help but these techniques can not lower my sugars to acceptable levels and I have given it a good honest try over several months. Yes just have a big bowl of spaghetti to prove that diabetes isnt going anywhere

    • I had been given insulin blood sugar kept going up more insulin 2 heart operations exercised my brains out kept gaining weight throwing up I said no more indulin went on keto started to lose weight.
      Be went to 7.3 a1C..Dr fung tapes believe this is way to go gave up all meds and taking supplements d3 5000 magnesium for constipation 250mg tea for water retention high cholesterol taking triple fish oil a baby aspirin 81 mgfor heart.
      Had 2 heart operations 1 open heart then a year later 3 stents..I think meds are killers! I’m allergic to statins and most meds!

  11. I was just diagnosed with diabetes. I am 52, 6′, 190, exercise regularly and have a “reasonably” healthy diet. I went to the doctor as I was not feeling well. My BS was a whopping 550 and the A1C is 10.8. The symptoms of diabetes came on rather quickly. I am on metemorphin (1000 mg in the morning and another 1000mg at night). Over the last 2 weeks my BS has ranged from 250 fasting to 350 after a meal. It is too early for another A1C test. My doctor says it is Type 2, though they have not done the specific autoantibody test.. As high as my levels are, I’m question whether I am type 1 vs. type 2. I am planning on pushing my doctor on this question, but welcome any thoughts.

    • I would strongly recommend seeing a specialist (endocrinologist) to have you tested for a possible type 1, and do this sooner rather than later. Nowadays both types can be diagnosed at any age, respectively, but some old school doctors stick to the idea that type 1 happens to kids and type 2 to older adults.

    • A primary feature of Type 1 is weight loss. You wouldn’t be able to gain much weight even with high caloric intake. This is because Type 1 diabetics do not produce any insulin at all, and insulin is the fat storage hormone. Type 2 is completely different: in Type 2 the body makes insulin, but the somatic cells do not respond to it because they’ve become insulin-resistant. Although overweight people have a higher risk of Type 2 diabetes, thin people get it too! 40% of thin people have metabolic syndrome and don’t know it. Their fat is hidden on the inside, packed around their organs (‘TOFI’). Wishing for you the best of health!

  12. I was diagnosed with T2D last year but should’ve been a few years prior. According to my (former) PCP I had elevated blood sugar for years, yet no one told me. For years, I had symptoms of diabetic neuropathy but didn’t know what it was, and my rheumy doc wrote them off on the account of meds side effect.

    The diagnosis was finally delivered and I started doing the right thing. My last morning fasting number was 107, and last A1C was 6.1. I am not on any diabetes medications (and hope never will), and I am only seeing a PCP doc but not a specialist, except for an eye doc once a year. I am only on one prescription medication, for my neuropathy, otherwise am watching my diet and being physically active. And blogging on WordPress about it https://comeinsitdown.wordpress.com

    I know that there’s no cure for diabetes, no matter how many times you read about it on the net. Yes, you can still eat sweets even after the diagnosis, but count your carbs. 2 carbs per snack and 3-4 carbs per meal. This works for me.

    Contrary to the popular myths, sugar alone doesn’t cause T2D, it’s more complicated than that.

    • For the vast majority of type 2’s, assuming they’ve been correctly diagnosed, it really isn’t as complicated as some make it out to be.

      There is no cure for Type 1 diabetics, but again, for the vast majority of type 2’s, diet and exercise will effectively cure them of their insulin resistance without medication. (If a T1D could correct their condition with diet and exercise, they would accept that as a “cure”. Why shouldn’t a T2D?)

      It isn’t that “sugar” causes T2D, it’s that habitual consumption of high glycemic index foods and/or habitual avoidance of low glycemic index foods (like wrongly thinking that you should avoid “fatty” foods) will cause spikes in insulin production during meal times. These constant spikes will build your resistance to insulin over time, requiring ever larger spikes, eventually leading to T2D.

      So, no, in the vast majority of cases, I disagree with you. It really is that simple. Turn your diet on its head, move your body, and your insulin resistance will fall.

      Also, an a1c of 6.1 really isn’t anything to worry about. As long as you’re eating right and exercising, you’re going to have a longer life than a healthy type 1 that keeps their a1c around 6.5 — and that type 1 is expected to have a normal lifespan, apart from the incessant testing, calculating, dosing, corrections, consequences of mis-calculation, seizures, etc., that a T2D doesn’t need to worry about.

      This whole “pre-diabetic” thing is hyperbole. 6.1 a1c is normal for some people, especially given the margin of error in the lab test.

      • I appreciate your opinion, however I beg to differ. Linking an increased sugar consumption to T2D is a popular myth that apparently is fine by you and the infamous Reebok CEO. There is no cure or reversal for T2D, those who insist on the other way around, are trying to sell you something. Go ahead, buy it.

        Both T1D and T2D are complicated to a degree, and both can be managed. I can’t vouch for T1D but I can manage my T2D successfully. My A1C number is under control as per last time I had a talk with my PCP, and my fasting numbers are normal. Am not going to check BG more often than that.

        I’m still eating sweets such as cookies, ice cream, yogurt, fruit etc. Just had a tootsie roll yum. I have one measuring cup of milk and 2 squares of graham crackers (2 carbs) every day for my HS snack. Portion control is a keyword here.

        Contrary to the popular belief, milk although it doesn’t taste sweet, still contains sugar (lactose). I don’t use glycemic index in planning my diet; it is not printed on the Nutrition Panels and I see this as an unnecessary hassle. I have something better to do with my time than that. I count carbs and am aware of the Simple as well as Complex carbs, and that’s enough.

        I am staying physically active, I am not overweight, my fasting numbers are normal and I don’t test my BG more often than that.

        I am still in the pre-diabetes phase as per my last bloodwork results. Your disbelief in pre-diabetes is actually moot; as long as you watch your carbs intake and have an active lifestyle, that’s all that matters.

        • Anna said “as long as you watch your carbs intake and have an active lifestyle, that’s all that matters.” That does indeed sound simple to me. John said “. It really is that simple. Turn your diet on its head, move your body, and your insulin resistance will fall.”
          Sounds to me that you two said basically the same thing.
          The medical community wants to maintain the illusion that each chronic disease is “far too complex for us to possibly understand”- that illusion keeps us from doing anything for ourselves. It keeps us dependent on them for all our answers (and pharmaceutical treatments). We are learning that in reality many chronic diseases have a few simple common denominators, and the knowledge of these would put some docs, and perhaps entire specialties, out of business. They want to maintain that aura of mystery . . .

  13. You gave some useful information, but overall, your article is misleading. The big giveaway is when you tackled the same ridiculed culprit, fructose.

    *sigh*

    How many times do we have to bash fructose as the cause of T2D, obesity, heart disease, etc.? It’s false information, your just excusing the American Standard Diet.

    You want to know what acceletates diabetes? Grass-fed beef, corn-fed beef, grass-fed eggs, dairy, chicken, pork, bacon – just about anything with a hole in it.

    There’s a strong correlation with eating fats and diabetes, fact. This is not a problem with fructose. Every cell in the body runs on glucose, not fats (we’re able to produce saturated fats, to some degree).

    If you’re lean, overweight, and have diabetes, then I’d suggest you follow a Dr. McDougall, plant-based starch diet (rice, potatoes, no oil, no meat, limited salt). You can have limited fruit juice, but the main focus is starches.

    My dad was recently diagnosed with diabetes, and he’s lean – he reversed it 360 on a high carbohydrate, low fat, vegan diet.

    • You don’t reverse something 360 and go the other way.
      If you go 360, you went in a complete circle and are AGAIN facing the way you were before.
      He reversed it ONE EIGHTY.
      180
      180
      180
      180
      THAT is a half circle. That is making a U-turn. That is going in the opposite direction.

    • My husband has had untreated Diabetes for over 20 years. After his doctor told him that his BS was 600 he followed a low carb diet and walked every day. Over the years he slipped back into a bad diet and then went from weighing 240 to 155 over the last few years. It was only after an optometrist told him he was bleeding in his eyes did he decide to test his blood sugar again. 324 and an A1C of 13. Now, after 4 months of low carb, high fat eating, he still feels MISERABLE with low energy and fluctuating blood sugars between 150 and 205. Your article was very interesting. I have been listening to Dr Robert Morse who has cured diabetics after they went on a fruit fast. Went on one myself for six weeks and lost inches of blubber especially around my waist, go lots more energy and lost my depression and irritability. But then slipped back into eating cooked food due to the Idaho winter. Gabriel Cousins also reverses diabetes with a raw food diet. After reading all of the comments, I believe that GMO’s and climate pollution with chemtrails raining down barium and aluminum and other toxic substances on us may be a big cause of this. My husband played a lot of golf before he got so bad. Golf courses are big sources of pollution from them treating the grass with lots of Roundup…. Now looking into herbs, essential oils, flower essences and energy work as alternative healing sources.

    • Fat does not trigger an insulin response! Protein does to a small degree, but not NEARLY as much as carbohydrate. Excess refined carbohydrate, particularly in the absence of fiber, and exercise, leads to hyperinsulinemia and eventually insulin resistance. Basic biology.

    • Federico- meant to say that I am glad that your dad has found success! If he finds it too monotonous to sustain, maybe he could try Dr. Furhman’s plant-strong “Nutritarian Diet”. Subsisting on just rice & potatoes will result in nutrient deficiencies, including zinc, B12 & possibly protein deficiencies.

    • Yes – If you starve yourself of carbs, of course you blood glucose levels will go down despite you insulin insensitivity. Its mopping up the flooded basement rather than fixing the leak. Insulin resistance will continue to starve your muscles of the glucose they need. But if blood tests are what makes you happy, keep eating fat and restricting carbs. I’d rather reverse my T2D.

    • As I understand it, each organ of the body has its own energy profile, using glucose, free fatty acids, and ketones. As an example: “In resting muscle, fatty acids are the major fuel, meeting 85% of the energy needs.” Glucose is used when muscles are working and require more energy than the FFA can provide. “Fatty acids are the heart’s main source of fuel, although ketone bodies as well as lactate can serve as fuel for heart muscle. In fact, heart muscle consumes acetoacetate in preference to glucose.”
      [http://www.ncbi.nlm.nih.gov/books/NBK22436/]

  14. I am glad you highlighted that thin or healthy weight individuals do get type 2 diabetes. They are often overlooked in the discussion of type 2 diabetes because one of the recommendations is to lose weight. I have clients with type 2 diabetes who did not need to lose weight but definitely needed to work on their diet.

  15. Fall 2014 went through an appendectomy. Spring 2015 had my gallbladder removed. Summer 2015 weighing 145lbs @ 5’5″ height was diagnosed with T2 diabetes. Have tried metformin, failed. I felt like I was dying. My eyes stayed red, and I was sick. My blood sugar levels would be at 187 then magically within 5 minutes would drop to 65. I was then placed on glyxambi, within 2 weeks my kidneys began to hurt and my blood sugar started reacting like it did on metformin. I’m seeing a family practitioner and an endocrinologist. I feel like a test rat. Any advice for a thin T2 diabetic that keeps losing weight and is desperate for healing?

    • Dear Wendy,

      Your situation sounds horrible, and you have my sympathy. You don’t say why you had to have your appendix and spleen out, but to this lay person it seems likely that the underlying causes of these problems are related.

      First, though, you need to find what has been causing your erratic blood sugar and weight loss. Blood sugar control is shared between the liver, which absorbs excess sugar in response to insulin, and the pancreas, which produces the insulin.

      You can tell which is at fault by testing fasting blood sugar and insulin simultaneously and using a calculator provided free on the Oxford university Web site.

      Both the liver and pancreas also contribute to digestion; the liver produces bile acids, which help arrange fats into small globules, and the pancreas produces digestive enzymes to break down fats, proteins and carbohydrates. Testing for bile acid deficiency is difficult, but levels of amylase, the carbohydrate enzyme, show up in the blood.

      You can/ should also have an ultrasound or MRI to check the two organs’ appearance.

      From what you say, the pancreas seems the more likely culprit. (Erratic insulin production.) But facts are better than guesses.

      If the problem is with your pancreas, you should be able to control your weight loss by taking digestive enzymes with your food, and will probably be advised to take extra vitamins A, D, E & K and to get tested for osteoporosis.

      Unfortunately, there is no simple treatment for inadequate insulin production. Metformin makes the liver more responsive and may help; injecting insulin is a pain. Better may be to have many small meals, rather than three big ones to avoid getting too much blood sugar at one go.

      The ideal is to find and treat the underlying cause. Infection (eg hepatitis), various auto-immune problems, excessive alcohol, cancer, late onset systic fibrosis or metabolic problems in vitamin b processing can all affect the pancreas and the spleen, and might be worth checking.

      My own experience is of weight loss and elevated blood sugar caused by pancreatic insufficiency. I also have osteopenia, widespread osteoarthritis, gallstones, an inflamed colon, a bent penis, some heart problems, some neurological problems and horribly uncomfortable skin. Despite very extensive tests, no underlying cause has been found, but for the time being I can control my weight and blood sugar with a mixture of digestive enzymes and multiple small meals.

      Let us know how you get on.

      Best wishes,

      Alan

  16. I knew that some lean people have type 2 diabetes and have successfully treated them with dietary changes, but didn’t realize there was a subset that may have autoimmune type 1 diabetes. That’s good news that they can have their GAD antibodies tested at a lab.

    To your point about requiring a different treatment strategy, what would you recommend?

  17. My dad has diabetes and it’s really high and I’m really worried 425 is his blood pressure… my dad is skinny and has diabetes the doctor said ” I may be giving you prescriptions but you take them and don’t come back in a month.
    The last time my dad went to the doctor was 2 years ago.. I need help, for my dad is really hard to lower his blood pressure

    • Hi, give him hibiscus tea frequently. You can find organic hibiscus tea on iherb.com. It is a natural anti-blood pressure medicine proven by researches. I hope everything gets better with your dad and continue to take care of him.

  18. G’day,

    I was diagnosed with type 1 about a year ago when i was in Costa Rica. I have been quite unsure of the diagnosis from the get go and have been treating myself through diet and exercise. I am currently on 9 units of Lantus (basal insulin), whilst maintaining a good diet.
    I haven’t been exercising overly lately and I forgot to take my Lantus today and at 2.30pm before a late lunch my blood glucose levels were at 5.9mmol. Do you have any suggestions as to why this must be?

  19. Did a whole vegan diet for 5 months. Dropped Total cholesterol from 265 to 225. Dropped HA1c from 5.8 to 5.6. I also dropped from 191 lbs to 184 lbs. I am not sure how much was due to the weight loss. I believe the whole foods were helpful, but the meatless part is questionable in my case. I hear it can be an incredible improvement for some.

  20. Is there any discussion regarding GMO diet causing gastritis and any relationship to the development of diabetes with this diet stressor? It might be a long shot, but the added inflammation and physical stress in the gut might be a precursor to developing DM type 2. Any thoughts out there?

    Check out the article and full report at http;://naturallysavvy.com/eat/genetically-modified-corn-and-soy-diet-causes-severe-illness-in-pigs

    I have two girls 14 and 9 both with Hashimotos and gluten intolerance. They have identical results on their gastric biopsies showing gastritis with white points, possibly scarring along the esophagus. The older one is more symptomatic and has recently developed lactose intolerance as well. Gluten intolerance is questionable because symptoms appear on gluten free days sometimes. I have to wonder if GMO corn, soy and the other 7 GMO crops mass produced in the US and found in nearly everything we eat are contributing to our family’s GI distress and illness.

    By the way I am a normal weight woman in her 40’s and have just been diagnosed with DM type 2.

    • Gluten free days? No no no. If your daughters have gluten intolerance they should be having gluten free LIVES. It takes the body up to two months to get the affects of gluten out of its system, and if your daughters aren’t avoiding gluten entirely they are probably not getting better for that reason and that reason alone. Gluten wreaks havoc on all of our bodies, so it’s no surprise they are so sick if you are still feeding them gluten after being told they have an intolerance!
      Hashimotos is an autoimmune disease which means both your daughters have incredibly high levels of inflammation, which in itself can cause a lot of damage to the body. Its possible you also have it which could explain your T2DM. My mother has T2DM and Hashimotos. Her doctors have found that treating her HM has help eradicate her T2DM. Worth looking in to.
      Also, your daughters are too young to be consuming soy products. It can mess with their estrogen and do damage to their reproductive cycles. Almond milk or just lactose free milk are much better options. Personally, I really like the lactose free milk. It tastes just like milk.
      I have gluten intolerance, and possible Lupus (being tested) but I’ve found a lot of relief from strictly following a gluten free diet (completely free!!!) and taking 1 tsp of Diatomaceous Earth every night right before bed (as in I drink it in bed and fall asleep shortly after I’m done drinking it) with orange juice. Do some research on it! It’s great stuff. It helps cleanse the GI Tract and has worked wonders for a lot of people. I highly recommend it.
      I wish you and your little ladies luck with your health.

  21. Dear Chris

    How good a marker is the ESR test (sed rate) for gauging inflammation which appears to be the cause behind virtually all maladies

    Thanks

    • Hi,
      Disclaimer: I am not a doctor and do not have any specialised medical knowledge.

      I think that ESR and CRP (C-reactive protein) are two widely accepted and generally useful measures of systemic inflammation. (You can also have localised inflammation.)

      I have chronic and acute inflammation of my colon (colonoscopy), inflammation around my heart (echo cardiogram), non-alcoholic fatty liver, gallstones, kidney stones and enlarged prostate and a mildly enlarged spleen (echo/MRI/xray), pancreatic insufficiency (not enough insulin or digestive enzymes), osteo arthritis in various joints and degenerative bone disease in my spine (x-ray, MRI). I have painful skin, Peyronie’s disease (a bent penis) and have had a silent stroke (MRI).

      My cardiologist and pancreas doctor say that it is absolutely obvious to them that I have some kind of systemic inflammation, but my ESR and CRP (and all other auto-immune tests except antibodies causing hay fever) are normal. So too are other tests for systemic diseases – alph anti trypsin, Wilsons, cystic fibrosis, Crohn’s …

      The auto-immune doctors say that I don’t have systemic inflammation. I conclude that there are some types of immune system reactions that we don’t yet understand.

      Best wishes,

      Alan

      • Don’t you think your best bet is to go on a diet that rules out inflammatory reactions from foods.. ? If I were you I would do a 2 week juice fast. Juicing mostly veges with apples. This worked for me. got rid of inflammation in my hands and feet and all arthritis disappeared. Doctors do not understand everything so I wouldn’t even go to them once you get that initial diagnosis..just google inflammation and stuff and see what you come up with..just clean up your diet.. from all fats even healthy ones to see what is not being processed right. I found I could not digest and process nuts and avocados..it took cleaning up my gallbladder with phosfood (standard process supplement) and then I was able to now have flaxseed oil and that has changed my life.. Fats however prior to this were causing all my autoimmune issues. I had adrenal fatigue, insomnia, aches and pains..etc.. good luck!!

        • Jenn,
          Did you seriously just tell readers on a diabetes forum to not even go to their doctors and just read about inflammation on the internet? Please no not encourage people with endocrine disorders/diseases to avoid medical care. That is irresponsible of you and, while I believe you mean well, your comments could be leading people down the wrong path. Yes, lifestyle changes of diet and exercise are the 1st-line recommendations for all forms of diabetes to prevent negative outcomes (heart attacks, blindness, dialysis, neuropathy and infections), but it is a progressive disease that most often requires medicine to help control blood sugars. Stop pushing GMO-free diets and gluten-free diets for people who aren’t celiac because there is no proof that they have any benefit. They are fad diets, nothing more. Diatomaceous earth worked for you, but again there is no substantial study to show that it works for whatever imaginary condition you are talking about. I’m sorry if this is insulting. But you discouraging people from seeking medical care is insulting to myself and every other healthcare professional who spends years going to school, specializing in diabetes care and basing decisions on evidence-based medicine. Do any of your claims have any decent studies to support them? Please do some research, and no, I don’t think doctors are perfect either.

      • Allen, I also have an inflamed immune system, but my ESR’s are only slightly elevated, and my CRP is negative. I have APS/Hughes syndrome where my body produces antibodies to phospholipids that cause my blood to be sticky and clot up easier than a normal person. I also have fatty liver, elevated bilirubin, and blood clots. Have you ever been tested for APS/Hughes Syndrome? That might be the reason why you’ve had a silent stroke. It can also be the reason why your spleen is enlarged and your pancreas is not functioning properly. You could have sludgy blood or clots tat have decreased blood flow to those organs and have caused them to become damaged. I think there is more to being fat than having type 2 diabetes. I think being fat is a symptom of the disease and not the cause.

  22. Hi all,
    I’m a 16 yr old girl, 110 lbs at 5’4″. I have an 18.6 BMI and am on my high school’s varsity basketball team, and work out with my team 5 days a week for an hour a day (6 days a week during winter for season). I try to eat right as well, avoiding eating sweets, soft drinks, & greasy foods except on special occasions. My family has no history of either type of diabetes but I just got my lab results back with a 6.0 aCi reading and I was told I am borderline type 2 diabetic (aka prediabetic). My family has a history of high cholesterol too and I did too when I was 14 but have now lowered that to a manageable level. I have a very high metabolism too.

    I really just want to know what’s going on with my body. Lately I’ve been getting sick often too (twice so far this year), and now this prediabetes. I’m really confused. What am I doing wrong with my lifestyle and habits?

    Any and all feedback is appreciated.

    Thanks!
    B.

      • Bee,

        I doesn’t seem that there’s anything wrong with your lifestyle, but you may have a genetic disposition to high blood sugar.

        I think it’s fairly important to find out why. Your doctors should be able to do various tests, such as for the antibodies that can cause late onset type 1 diabetes and they should be able to work out whether the problem (if any) lies in your pancreas, your liver or your skeletal muscle.

        If they are already doing more tests for you, good luck! If not, you should press them.

        Best wishes,

        Alan

    • Bee, there are so many things that can go wrong with our bodies that it’scs hard to say. But a couple possibilities come to mind. First there are other things that can spike blood sugar, wheat and other grains, especially refined ones, and too much meat at once. Also possibly some sort of auto immune problem causing problems with your insulin response. Wheat can often be a culprit in this too, but there could be many things that cause it. If It were me, I would try cutting out all grains for two weeks and see if it makes a difference. Up your veggies and natural fats quite a bit to keep from being hungry. Hope you find your answers!

  23. I wanted to thank you for your article I found it very informative. As a nurse I am well-educated and highly experienced with diabetes but, being underweight, I was very surprised to get a gestational diabetes, and then subsequent pre-diabetes diagnosis. I do have a positive ANA so I wonder if your suggestion of autoimmunity is my problem. I will get that tested for sure. My problem now is, my weight is too low and I am having trouble gaining weight on a diabetic friendly diet. My fasting sugars and A-1 C are great, but my postprandial are pretty bad and I’m symptomatic. Wish me luck 🙂

  24. 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?

    • I’m 58, a so-called “borderline diabetic” (A1c 6.1) with a high genetic risk of diabetes. I’m not overweight, good diet, exercise regularly, all that good stuff, but I too wonder about the stress in my life and how that is affecting my BG. But how does one reduce stress? If you are alive, stress is pretty much inevitable, isn’t it? Your reaction to stress is manageable only up to a point. Any suggestions out there?

    • you need to stop your Vegan diet and start a high protein diet , fish , chicken , beans , white eggs , chicken peas , no wheat , no white flour , no pasta , no rice and drink lots of filter water or distill water with some squeeze lemon 8 glasses a day . Eat organic and don’t eat red meat it cause inflammation .

      read this book called ;
      The Protein Power Lifeplan Paperback – June 1, 2001

      by Michael R. Eades (Author), Mary Dan Eades (Author)

      • drink lemon squeezed with filtered water it bring sugar down , 8 glasses of water will clear sugar out of your blood best supplements to take is alpha-lipoic acid , milk thistle and no wheat , no white flour , no process foods , no fresh fries , no pasta , no oils ..only olive oil or coconut oil . high protein diet stay away from carbs and fruit . read book called ;

        The Protein Power Lifeplan Paperback – June 1, 2001

        by Michael R. Eades (Author), Mary Dan Eades (Author)

        take cinnamon/chromium supplements

  25. 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

  26. 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?

    • 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

  27. 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.

  28. 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.

  29. 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.

    • 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

  30. 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.

  31. 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.

    • 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

      • 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.

        • 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

      • A little over 3 years ago, I was shocked to find that my blood sugar level was 367. I am 46, am 5′ 1 & 1/2″ tall, about 100 lbs, have never been overweight in my life. The first endocrinologist I saw initially put me on insulin, and I thank God that I didn’t take nearly as much as he told me to, because come to find out, I am extremely sensitive to insulin. If I use 3 units, I crash and have a low, even if I were to eat an entire cake. I have been tested for everything the doctors can think of. My blood pressure runs on the low side, my cholesterol level is great, my liver and kidneys are in fantastic shape, I have tested negative for the antibodies, my pancreas produces some insulin, I am not insulin resistant. There is another type out there that rarely gets mentioned if at all, especially here in the U.S. – it’s monogenic diabetes, MODY, an inherited gene. I strongly urge anyone who’s diabetes just doesn’t make sense to look into this. I have not confirmed this finding yet with a gene test, my doctors seem to dragging their feet on getting me set up with one. My levels are all over the place, all of the time. It’s very frustrating! I can say that when I eat protein, my levels actually drop. I am on a small dose of Glimepiride, and when exercising regularly, that seems to help some. I wish everyone the best!

  32. 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?

    • i have one is this one size fits all, a1c near 7 is fine and if they tested everyone in usa the 110 reading is a fantasy for some
      but not reality, my mom had it with atreal fib of the heat odd
      that she lived to 89 yrs old out lived some dr,s no heart attacks,but the fear they preach kept her on edge i think the gov, put something out there and we were quiney pigs
      they have put drugs in peoples drink in 40’s thru 50’s and the great test goes on………..

      • I heard about the goverment spraying people with chemicals but never putting stuff in drinks..is there proof? or are you just fantasising.?

  33. 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″

    • well i drove trucks then bam i have it later i was disabled
      my dr said i burnt the candle at both ends when you stress
      to be the best dr,meds,and everything i climb 3 flights of steps
      feel like colasping had a chemical stress test came back good
      every drug makes me feel bad, maybe that is whats upwith you

  34. 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

    • 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

  35. 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.

    • 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.

  36. 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!

  37. 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.

  38. 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 :>

  39. 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.)

  40. 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?

  41. “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.

  42. 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?

  43. 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?

  44. 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

  45. 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…

    • 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.

  46. 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

    • 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.

  47. 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.

  48. 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.

  49. 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.

  50. 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.

    • 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.

  51. 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 ?

  52. 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.

  53. 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 ?

  54. 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).

  55. 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.

  56. 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.

  57. 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.

  58. 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.

  59. 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?

  60. 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.

  61. 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.

  62. ..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.

  63. 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.

  64. …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.

    • (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.

  65. 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.

  66. 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.

  67. 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.

  68. 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.

  69. 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.

  70.  
    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.

  71. 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.

  72. 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?

     

    • 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.

  73. 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?

    • 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.

  74. 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?

    • 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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