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

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

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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.

150 Comments

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  1. 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!

  2. 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 🙂

  3. 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

  4. 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

  5. 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

  6. 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.

  7. 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.

  8. 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

  9. 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.

  10. 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!

  11. 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.?

  12. 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

  13. 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

  14. 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.

  15. 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!

  16. 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.

  17. 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 :>

  18. 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.)