Retrospective #469: Why Pre-diabetes is actually Type 2 Diabetes

I’m not trying to be alarmist here. It’s just that there’s a broad misunderstanding in the patient population about what type 2 diabetes is. It is perhaps due to a misunderstanding or a reluctance by most clinicians to counsel patients that a diagnosis (Dx) of Pre-diabetes is prima facie evidence of an already failed glucose metabolism. The biomarkers used, an A1c of ≥5.7% (39mmol/mol) and/or an elevated blood sugar (≥100mg/dl or 5.6mmol/L or 6.1 in the UK) is proof.

Most clinicians understand that a Dx of T2DM means that you have Insulin Resistance (IR). IR means that the uptake of glucose by the body is impaired by the failure of the hormone insulin, which accompanies glucose in the blood, to induce receptor cells to open. This results in the level of circulating glucose to stay elevated . The body fights this by sending more insulin. And as long as it sends more insulin, you remain “Pre-diabetic” (and you gain weight).

Here’s the misunderstanding. Your body has been successfully fighting IR by sending more insulin. And because it has been “successful” – keeping your blood glucose levels in the high-normal or even “Pre-diabetic” range – you, and ruefully in most cases your clinician, think you are not already a type 2 diabetic. The truth, however, is that you are because you have IR (the definition of T2DM) and YOUR BODY, by fighting it off, is CONCEALING it from you.

Your pancreas will fight to make enough insulin to keep your blood sugar “normal,” until it no longer can. That failure is what constitutes a clinical diagnosis today, but this late symptom of a dysfunctional glucose metabolism is after the fact. You have had type 2 diabetes all along, and your pancreas has exhausted its ability to make enough insulin. Either the cells that make insulin have died or are so clogged with fat that they are blocked from functioning properly.

So, what should your clinician tell you, or you do, instead? If you have been told that you have a “slightly elevated” or “high-normal” or even a “Pre-Diabetic” blood glucose, accept that 1) you have Insulin Resistance, and 2) that having Insulin Resistance is the definition of T2DM. Now is the time to do something about it. Most clinicians will counsel you to “wait and see.” That’s because under clinical guidelines (and Medicare and other insurance rules), they can’t write you an Rx until you have been “clinically diagnosed.” But by then it’s too late. Your pancreas has already failed.

But up until this point your doctor is in something of a bind. He can tell you to “diet and exercise,” but government’s idea of a “healthy diet” is to eat a “mostly plant-based” or even a “balanced” Mediterranean diet. You’ve also been led to think that exercise is an effective weight loss strategy. It’s not. Your doctor is also unlikely to know or believe that the diet or “lifestyle change” that will work to reverse your dysfunctional glucose metabolism is a LOW CARB diet.

Nevertheless, losing weight is a good prescription, especially losing weight around the waist. Central obesity and belly fat are terms for visceral fat. As distinguished from subcutaneous fat, this is fat within the abdomen, around and within the organs, especially the liver and pancreas. This is why some people who are not obese have T2D. They are “skinny-fat” with a fat-clogged pancreas and probably a fatty liver (NAFLD) as well. Losing this visceral fat can help restore function to pancreas for the obese, overweight and “skinny-fat” or viscerally obese.

Restoring pancreatic function only addresses the failed insulin production aspect of T2DM. Remember, this is the late symptom of a failed glucose metabolism, not the cause of T2DM, which is Insulin Resistance. What can be done to reverse IR? Well, ask yourself, what caused the resistance to insulin? Answer: Too much insulin! And what caused too much insulin? A diet too high in carbohydrates: eating too many carbs all day long, in every meal and in between. Solution: Change what you eat. Cut the refined carbs and simple sugars. Keep an eye on your fasting insulin level.

You got into this mess by eating far, far too many carbs. You can turn this whole thing around by eating far fewer carbs. Personally, I eat a Very Low Carb and usually just One Meal a Day (OMAD) I also use Intermittent Fasting (IF) from time to time. I’ve lost a lot of weight (180 pounds) and put my T2DM (Dx 1986) in remission. I have very good blood markers and I feel great. I did it without hunger (because fat is satiating), and without exercise. You can too.