Treating patients with pre-diabetes: Weight loss and carbohydrate restriction

What physician has not stifled a groan when a patient presents with a chief complaint of “I just don’t feel right, Doc.”

About this time last year, I had that “not quite right” feeling and vague, seemingly unrelated symptoms … sweating, mid-morning headaches, and frequent feelings of hunger, which I was accustomed to satisfying with a muffin.

Like most people — patients and clinicians alike — I ignored these subtle signals.

One evening, as my tennis partner was beating me handily in our weekly match, I realized that I was uncharacteristically short of breath.

I began to diagnose myself. No chest pain — hence, no myocardial infarction. No asthma. No history of hypertension or coronary artery disease.

Rather than calling my primary care physician as I should have, I ordered a few standard lab tests. To my utter astonishment, my fasting blood sugar was just over 100.

I made an appointment with my PCP. After a thorough workup, he informed me that I have what we now call pre-diabetes.

He also gave me my new marching orders: I had to lose 5% of my body weight by reducing my carbohydrate intake to 60 gm a day.

No small feat!

I consulted a PhD nutritionist who just happened to make house calls. Taking inventory of my refrigerator and kitchen cupboards, she was appalled. Once she explained the error of my ways, I felt pretty sheepish.

I had been avoiding fatty foods by eating more of the “bad” kind of carbohydrates, especially those with innocent looking labels like “low fat.” And I hadn’t been paying sufficient attention to my protein intake.

Suddenly, I understood what was causing my symptoms. My diet and eating patterns created a scenario in which my body was alternating between hypo- and hyperglycemia and, more than likely, hypo- and hyperinsulinemia.

I was in “carbo hell”!

It took a huge amount of self-discipline, but the payback was quick.

After one month on my new diet, the symptoms had subsided, and by the second month they had disappeared completely.

I lost more than the prescribed 5% along with 3″ in waist circumference.

Here is where a “paradox of life” comes in: Even when a person is doing all the right things, if he or she continues to eat the same diet and exercise the same amount, the average person will gain one pound every year of life after graduating from high school.

Bottom line — we have to keep doing more just to maintain our status quo.

I’ve always made healthy lifestyle behaviors a priority (e.g., appropriate basal metabolic rate, no smoking, eating fruits and vegetables, exercising regularly). Despite this, I find myself with pre-diabetes.

Moreover, I am a board certified internist with unusually easy access to the healthcare system and excellent health insurance. Despite this, I overlooked the insidious symptoms of early metabolic syndrome.

As a result of my personal experience, I have a new appreciation for how complicated and downright scary it is to manage diabetes — knowing that, unless I do things differently, my condition will deteriorate.

Equally important, in gaining empathy for my patients, I recognize that I need to change my approach to those with metabolic syndrome and diabetes.

What are the health policy implications?

To quote my colleague, Dee Edington, “The goal is to not get worse.”

We need to find ways to keep healthy people healthy.

To date, therapy for patients with pre-diabetes is limited to weight loss and carbohydrate restriction. The insidious onset of this disease and its potentially devastating health and economic impact should drive additional studies that look at its full scope.

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Originally published in MedPage Today. Visit for more health policy news.

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  • Andrea Light

    I’m not an internist but I swear by the South Beach Diet. The way a low glycemic diet evens out cravings is amazing to me, and shopping the perimeter of the grocery store is an eye opener. My husband and I are both much healthier as evidenced by our check ups and I’ve lost the weight I gained when I quit smoking 4 years ago.

  • IVF-MD

    I care less what the diet books say and what the media says and care more what I witness my own eyes and ears. After trying myself, my friends and several dozen of my PCOS patients on a diet rich in NON-carbohydrate foods and then tracking it meticulously with daily weight logs and daily subjective energy ratings (on a scale of 1-10), I’m pretty convinced of the evils of sugars, bread, rice, noodles, and tortillas. By cutting out all carbs (even brown rice / black bread) and replacing it with beans beans beans, meats and vegetables for 6 days per week, I have seen patients lose a steady 5-10# every two weeks, claim to have great energy improvement as well as a huge savings in food budget. All the while, they don’t feel hungry (unlike the salad dieters feel) and a lot of their ailments resolve (HTN, plantar fascitis, headaches, generalized edema, joint pain). I’m convinced that he human body was not engineered to eat refined carbs and sugars. They also look forward to that one vacation day per week where they can indulge on all the carbs that they craved during the week. It’s a good balanced lifestyle combining discipline with just enough indulgent reward to keep this pattern sustainable.

  • Weight Watcher

    dear David, I’m happy for you. Congratulations on your weight loss.
    And what are your blood sugar level now?

  • Pratap Reddy

    Recently I too came across the stage of pre-diabetes. With the changes in diet i could manage to lower the glucose level to normal range, but i am unable to reduce my weight .

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