Even a thin person can get diabetes

A low-carb strategy
Perhaps I was scared by news of my father's fate or angry that the disease had cut him down. Maybe I was emboldened by the knowledge that type-2 diabetes comes with instructions for defeating it, even if most doctors don't know them.

Whatever the motivation, I was determined to haul off and floor this condition with one ferocious counterpunch. At least initially, I adopted a very-low-carbohydrate approach — specifically the Atkins diet — based on multiple Duke University studies that show it's effective for both lowering blood sugar and reducing heart-disease risk.

It seemed logical: The initial limit of 20 grams of carbohydrates a day would offer my pancreas a reprieve after a lifetime of sugar trauma.

Of course, I didn't know what 20 grams of carbohydrates would mean until I found myself in a supermarket pushing a shopping cart containing nothing but a can of shaving cream, laundry detergent, and a magazine.

Everything in sight contained too much sugar for someone on the verge of diabetes, and some of the bachelor-friendly foods I'd relied on most were among the highest in carbs: frozen dinners and pizzas, cereal, cookies and other desserts, and snack foods. Bread, pasta, rice, and potatoes were gone from my list, too.

What remained was what some hunter-gatherers might have recognized as food had they been foraging on the periphery of a supermarket: fresh fruits and vegetables, nuts, eggs, and meat. The biggest adjustment came when I realized all the things I couldn't drink anymore — regular soda, beer, and fruit juices included. What's more, I'd even have to limit milk, since an 8-ounce glass contains 13 grams of sugar. A typical meal became steak, fish, or chicken accompanied by steamed vegetables and a glass of red wine, a low-carb godsend.

In addition to following my new diet strategy, I planned to torch any excess sugar by working out briefly but intensively 6 days a week: superset-based weight-lifting sessions one day, cardio intervals the next.

Just how powerful an antidote is exercise? A study published recently in the American Journal of Physiology — Endocrinology and Metabolism revealed that insulin resistance in rats decreased more from exercise than from taking metformin, the leading diabetes drug.

Exercise and dieting take effort and discipline, though. And it can be tempting to just take drugs to lower blood sugar and be done with it. After all, the major diabetes organizations have already raised the white flag of surrender and adopted that approach.

"Two years ago, the ADA and the European Association for the Study of Diabetes decided that you really ought to just start people on medicine," says endocrinologist Dr. Larry C. Deeb, a past president for medicine and science at the ADA. "Very few people participate in dietary changes and physical activity, so you end up with patients not taking care of their diabetes. My take is, let me give you a prescription. No rule says I can't take you off the medicine later."

Yeah, except diabetes drugs are about as easy to ditch as crack — most people end up using more, not less. It's a vicious circle: The insulin-resistant patient is shepherded onto a high-carbohydrate diet per ADA guidelines, so his blood sugar stays elevated. As a result, his pancreas secretes more insulin — but with less and less effect. So he's given tablets to make his pancreas produce even more insulin. When that's not enough, he must inject the insulin. In contrast, when you exercise daily with few carbohydrates available for fuel, your body needs less insulin.

By my next doctor's appointment, my fasting blood sugar has fallen from 116 to 102 and my triglycerides from a high 289 to a better-than-average 89. (In the insulin resistant, these blood fats tend to rise with blood sugar.) Most impressive is my score on the hemoglobin A1C test, a 3-month running average of blood-sugar levels. The nondiabetic range is 4 percent to 6 percent. After months of exercising and carb slashing, my results fall squarely in the middle: 5 percent. In a word, perfect.

As I turn to leave, the doctor smiles and pats me on the back. "You're proof that diabetes can be addressed with diet and exercise," he says. "Most people don't do that. You're to be commended."

From high to low
"Actually, this is really bad."

The voice on the other end of the line belongs to Dr. Keith W. Berkowitz. He's the medical director of the Center for Balanced Health in New York City, which specializes in treating patients with serious blood-sugar irregularities. I had faxed the results to his office for a second opinion.

Will you become diabetic? Take this self-test and find out The American Diabetes Association singles out the fasting glucose test as the preferred way to diagnose type-2 diabetes, citing cost and ease. While useful, this blood-sugar snapshot doesn't reveal the excessive swings that indicate insulin resistance before your fasting level is elevated to diabetes or prediabetes. For that, you need to take an oral glucose-tolerance test (OGTT), especially if you have a parent or sibling with type-2 diabetes. Being African American, Latino, Native American, or Asian American also elevates your risk. The symptoms of insulin resistance tend to come in clusters, so if you have one indicator, you're likely to have two or three others. However, under the "definitely" category (below), having just a single factor is cause for concern. In this case, contact your physician and schedule a time for an OGTT. You might need an OGTT if . . . — You often wake up with a headache — You often wake up in the middle of the night — You had acne, numerous cavities, and hair loss in your teens/early 20s — You feel cranky or forgetful after a high-carb breakfast You probably need an OGTT if . . . — Your blood pressure is 140/90 mm/Hg or higher — Your HDL (good) cholesterol is less than 35 mg/dl (milligrams per deciliter) and/or your triglycerides are higher than 250 mg/dl — You're thirsty or you urinate a lot — You tire easily and/or nap frequently, especially 1 to 2 hours after a meal — You're overweight (BMI 25 to 29.9) — You're 45 years old or older You definitely need an OGTT if . . . — Your fasting plasma glucose (FPG) is 100 mg/dl or higher — Your hemoglobin A1C is greater than 6 percent — Any random blood glucose reading is 140 mg/dl or higher — You have any history of cardiovascular disease — You're obese (BMI = 30 or higher)

Dr. Berkowitz noticed a mathematical anomaly. While my A1C test was normal, my fasting-glucose score — taken when my blood sugar should have been at its lowest — was still too high. "For those two numbers to exist side by side means your blood sugar has to be in the 60s much of the time," he says. "Your biggest problem is hypoglycemia — low blood sugar." (Hypoglycemia is defined as less than 70 mg/dl; normal blood sugar, between 70 and 100 mg/dl.) If Dr. Berkowitz was correct, my blood sugar was on a roller-coaster ride, with the perfect A1C averaging two extremes.

Dr. Berkowitz asked me to visit his office in midtown Manhattan, where I would take a stress test for my metabolic system. If fasting glucose is one still image and an A1C is a composite image, the oral glucose-tolerance test (OGTT) is like watching a movie, and it's more revealing as a result. In a study published in the journal Angiology, all three tests were given to 144 patients — none of whom had been previously diagnosed with type-2 diabetes or impaired blood sugar. Yet 94 patients yielded OGTT results that revealed one of those conditions. The fasting-glucose test had missed 62 percent of those cases, and the A1C had missed 83 percent. "The last thing to go up is your fasting glucose," says Dr. Vernon. "The horse is already out of the barn at that point." That means the first signpost doctors are looking for is the last of the indicators to present itself.

My test begins with a technician in a white lab coat handing me a glass of a syrupy orange drink. It contains roughly the amount of sugar you would ingest from drinking two 12-ounce cans of Coke. Three hours into the test, even the technician's gentle arm grab can't shake me from my stupor. But 20 minutes later, I suddenly become anxious, jittery. At 4 hours I start to feel more like myself again. Mercifully, the test ends.

"Sorry to have put you through all that torture," says a smiling Dr. Berkowitz a week later as he opens a manila folder containing my results. He was right — my condition is called reactive hypoglycemia, and it may be diabetes's most brilliant disguise of all. First my blood sugar shoots up to a prediabetic 165, a spike that by itself presents a significant risk factor for cardiovascular disease, according to a paper published in the American Heart Journal.

Because my insulin does a poor job of ushering sugar into cells, my pancreas ends up producing 10 times more insulin than it should, according to Dr. Berkowitz. "That's like using an atomic bomb to take out a small village," he says, except it's my pancreas that will be destroyed over time. The nuke has driven my blood sugar into the 70s an hour later — but my insulin is still blasting away. It drives me down to 59 an hour after that — nap time. Five hours have passed and my blood sugar is still 20 points below where it started.

Granted, my hypoglycemia was induced by a stress test using 75 grams of glucose. But the standard recommendation for people with diabetes (using the American Academy of Family Physicians guidelines) means consuming up to 180 grams of carbohydrates over the course of a day. Split among three squares, as the organization's president, Dr. James King suggests, that's just half an ounce less than an OGTT's worth of carbohydrates at each and every meal. (That's a huge load even with its absorption slowed by some fat and protein.) "We use the OGTT as a metabolic stress test, and yet the mainstream advice prescribes a diet that produces that amount of carbohydrates at every meal," says Raab. "It just highlights the misunderstanding of how carbohydrates impact diabetes."

No wonder people are bonking at their desks all afternoon. Your brain produces no energy itself, yet it sucks up 25 percent of the glucose circulating throughout your body while you're up, and about 60 percent at rest. During hypoglycemia, gray matter is literally starving. (That explains my headaches.) You become shaky, anxious, dizzy, sweaty, tired, and unable to concentrate. Your body does whatever's necessary to protect your brain, and that includes breaking down muscle tissue so that it can be converted to glucose. Which begins to reveal why someone built like my father or me could be fast-tracking his way to type-2 diabetes. Because our insulin resistance results in frequent periods of low blood sugar, our bodies spend a good chunk of the day eating our own muscle.

As a result, we stay thin instead of gaining weight, as is often the case for people with insulin resistance and type-2 diabetes. In fact, insulin resistance is typically thought to cause weight gain, and vice versa. All of which makes the "thin man's diabetes" that much more perplexing. "The physiques of people at high risk of diabetes are becoming less stereotypical, making the disease harder to diagnose," says Dr. Berkowitz. His observations are supported by science: "If you look at distributions of large numbers of people, it's striking that not only do the overweight tend to be insulin resistant, but 10 percent to 15 percent of non-obese people are, as well," says Donald W. Bowden, Ph.D., director of the center for diabetes research at Wake Forest University school of medicine. Clearly, no one should assume he's immune to this disease.

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