Chow Time

Where do we start when we’re chubby and prediabetic?

There is no one right answer, but for today, let’s start with introducing meal choices that are tasty and not loaded with lots of carbs.

Changing our diet to be less carb-heavy is critical, but we also want to count our calories. Losing weight and reducing carbs will help us get out of prediabetes land.

Remember, we’re prediabetic, but we’re all different. Your healthcare provider or nutritionist will work with you to figure out a reasonable daily calorie and carb count that’s appropriate for you.

Can’t say this enough: check with your healthcare provider before making any changes to your diet.


Breakfast Cookies

These cookies are full of eggs, almond flour, sausage, and other goodies. You bake them up and store them in the refrigerator or freezer. Grab-and-go food is perfect for work mornings.

Cottage Cheese Bowls

The protein in cottage cheese helps fill you up. Toss in some berries and nuts, bacon and avocado, tomatoes and basil, or other bits to boost the flavor and nutrition.

Smoked Salmon Sandwich

This is higher in calories and takes some prep, but good for a weekend morning.

Cinnamon Cereal

This takes some time to prepare, but you can make a big batch.

Hazelnut Chocolate Chip Scones

Another breakfast that’s not a super low calorie choice. Bake and freeze, pulling one out occasionally for a low carb breakfast option.


Peachy Pork Lettuce Wraps

Easy lunch for home or work. You’ll need to use your carb app to find out the number of carbs and calories.

Shawarma Chicken Bowls

Put in a little prep time and you’re going to have a filling and tasty lunch with plenty of protein and veg.

Stuffed Avocados

You’ll need your carb app again to get the nutritional values, but this is a simple throw-it-together lunch option. Easy to adjust to your personal taste unless you don’t like avocados, in which case this is a nonstarter.

BLT Chicken Salad

The name says it all. Plus, it’s low carb and low calorie.

Eggplant Rollatini

Sliced eggplant with cheese and spinach, plus a few other ingredients – perfect. This recipe makes plenty of leftovers, too.


Stuffed Chicken Breasts

A simple recipe that allows for swapping out vegetables for whatever you like. Easy to fix, and low carb/calorie.

Garlic Shrimp

Add a side salad and you’re good for dinner. Yummy dish with a great cream sauce.


We would cut back on the amount of rice in the dish. And use your carb app to get an accurate idea of the carb and calorie count. Nice dish for the weekend.

Philly Cheese Steak Zucchini Boats

The name says it all. You’ll have to get out the carb app again, but the list of ingredients looks low carb and low calorie.

Spaghetti Squash Lasagna

We couldn’t leave out spaghetti squash. The trick is to make sure it’s dry enough when it’s cooked, or you’ll have soggy food. Once you can do that, you will go back to this squash over and over.

Add your low carb links or recipes in the comments. Sharing is good!

About Your Diet Q&A With Paulette McMillan

Paulette McMillan, MS, RD, LDN, CDE, L.Ac., Dipl.OM, is the co-founder of the Center for Health and Wellness.

She is a registered dietitian and licensed dietitian/nutritionist, a certified diabetes educator, a licensed acupuncturist, and is board certified in oriental medicine with a master’s degree in Human Nutrition and Functional Medicine.

Ms. McMillan recently took time from her practice to chat about prediabetes from the viewpoint of a nutritionist and diabetes educator.

What’s the difference between an RDN (Registered Dietician Nutritionist and a CDE (Certified Diabetes Educator) when it comes to the dietary needs of a prediabetic?

Both are qualified to work with people with prediabetes. The difference is someone who’s a certified diabetes educator has to have a degree in heath care to qualify for the certification. Most CDEs are registered dietitians and nurses. However, there are pharmacists, social workers, medical doctors and other healthcare professionals.

An RDN has at least an undergraduate degree in nutrition and has completed a practice program, or internship, to qualify to take the RD exam. About half of RDNs also have master’s degrees. But they do not have to have a specialty in diabetes education.

Do you consider them equal in their expertise when it comes to instructing prediabetics on food choices?

Depends on the individual, depends on the experience that person has. One doesn’t have to be a CDE to have worked in a clinic where there might be a lot of people with diabetes or prediabetes. So it really depends on their clinical experience.

Should prediabetics visit an RDN or CDE to get guidance on their prediabetes journey and if so, why? 

I would say absolutely. Because prediabetes is reversible and if you wait until you have diabetes, which is sometimes the case, you really can’t reverse diabetes. By then the pancreas is already weakened to the point that they may be able to control it with diet and lifestyle but they will always have diabetes.

This is how I explain it to people: If you don’t have diabetes you can eat a piece of cake and your blood sugar will stay normal. If you have diabetes, even though you have controlled it by eating a low carb diet and now you have great numbers, as soon as you eat a piece of cake, your blood sugars go out of normal range.

With prediabetes you could actually reverse it and conserve your pancreas, your beta cell function.

The other point I want to say about prediabetes is that, once you have prediabetes, you are now at higher risk for cardiovascular disease, so you definitely want to reverse this risk.

What is your definition of the keto diet? (how many carbs a day)

You know I don’t have that on the top of my head but, bottom line, it is a diet that has no more than 20 to 30 grams of net carbs, and most of the calories come from fat. There are specific ratios you’re supposed to use to do the ketogenic diet properly.

What are your thoughts on the ketogenic diet for prediabetics?

When somebody walks into my office and they’re prediabetic and they’re morbidly obese, and they tell me that nothing they do works to lose weight, the keto diet might be a great option for them. If they’re willing to do it.

If the client is truly motivated to start keto, I explain to them that they must commit to the diet for a certain amount of time, like 3 to 6 months, because it takes at least 3 weeks before the body starts burning body fat as energy. So if they choose to play games and go in and out of ketosis, they are not really doing themselves any favors metabolically.  They will actually lose a greater percentage of muscle.

After that, I explain to them that if they’re someone who is truly sensitive to carbohydrates, they may never be able to eat the amount of carbs that someone who has no problem metabolizing carbohydrates can eat. So if they’re in keto at 30 grams of net carbs daily, they might be able to get up to a 100 or 130 grams of carbs a day, and that might be where they have to stay to maintain a healthier weight. In comparison, a man who is not prediabetic might eat 300 carbs or more a day, and a woman might eat 250 carbs a day.

What is your definition of a low carb diet? (how many carbs)

I give someone 150 grams of carbs a day, and I don’t count the carbs in nonstarchy vegetables, like broccoli or spinach, but I would definitely count the carbs in starchy vegetables like potatoes or corn.

I ask them to spread the 150 carbs evenly throughout the day, so they can’t save them up and eat them all at one or two meals. Think of it like this, if you have prediabetes that means your pancreas isn’t working at 100%.  It’s kind of like weightlifting, you might be able to do 15 reps of 30 pounds each but can’t lift all 450 lbs at once.

If they’re comfortable going a little lower, 100 to 130 carbs a day, that’s fine.  It’s just so individual and it’s not just about the quantity of carb but also the quality.  If you’re eating a piece of cake or a piece of white bread it’s not the same as eating a whole grain or sweet potato or something more natural and less processed.

What are your thoughts on a low carb diet for prediabetics? 

I think it’s a good place to start with clients, to help them understand carbohydrates. We want them to understand carbs. However, with prediabetes it’s not just carbohydrates that we’re talking about. If they’re overeating, the first defense is to feed the body proper amounts. If they’re sedentary they have to get moving. If they don’t get moving, they’re going to stay insulin resistant and stay prediabetic. These two things are very important. 

Weight loss is recommended, if they’re overweight. Not all prediabetics are overweight. As people age, they’re more susceptible to prediabetes.

Is there another way of eating, besides keto or low carb, that you prefer to recommend to prediabetics?

Yes, a Mediterranean style of eating and I do give them guidelines on what that means. I do like this approach a lot because there’s a lot of variety. It is an anti-inflammatory and nutrient dense way of eating.

Is it important to have a balance between carbs, proteins, and fats at each meal or snack? Why? 

From a practical standpoint, people won’t maintain just chicken and a salad and some fat for lunch. I find that they make up for the deficit in their meal with their snacks. Often, people are eating more calories in their snacks than in their meals. When there is a balance in their meals of carbs, fat, and protein, most of the time people are more sated and they’re not looking for more food.

What are your top three general recommendations for those working to reverse their prediabetes?

It’s individual. Who is the person sitting in front of me?  What is their motivation level, knowledge base and abilities?

Are they sedentary? How much activity do they do on a regular basis?

People need to get moving and the minimum requirements are 150 minutes a week of aerobic activity which is moderate walking not a stroll, two to three days of strength training per week, in addition to cardio, because we need to build up muscle mass. Muscle helps our bodies respond to insulin signals and metabolize sugar.

If they’re overweight, aim to lose five to seven % of body weight to start.

Teaching them about carb quality and balance throughout the day.

Any last suggestions for prediabetics that you’d like to share?

Look into the CDC National Diabetes Prevention Program, find a local community group who’s using it.

Also, I’d use an app like My Fitness Pal to track carbs and calories that way, whatever works for them.

And you should look at supplements. Fish oil for omega-3 fatty acids, zinc, magnesium, vitamin D – they’re important for prediabetes and for all of us.

Food and PreD

Most of us are prediabetic because our food choices aren’t healthy, and we don’t get enough exercise. It’s a lifestyle thing.

Multiple studies[1] show that, if you are prediabetic, one of the better ways to reset your body is to lose weight, change your diet, and exercise.

Before going any further, let’s pause for a minute to say: talk to your healthcare provider before changing what you eat or how much you move.

Today, we’re going to talk about food. We’ll save exercise for another time.

Research[2] suggests that when it comes to what we eat, a lower carb regimen of 20-50 net carbs a day is one way to get those blood sugar levels down.

As we launch into this topic, it’s important to remember that what works for one person may not work for another. This journey of resetting what you eat will most likely be a trial-and-error effort for the first few months.

Diet, when used as a verb, isn’t fun. We start out in a negative place when we go on a diet. It seems like work, and that we’re giving up enjoyable foods for foods that are bleh.

It’s not a journey that we begin with a smile.

Diet, when used as a noun, simply means the food and drink one typically eats.

No negatives there, right?

We’re talking about your diet (what you eat and how that might change) but not about you going on a diet, with all of the negative “celery sticks and rice cakes” connotations.

Most of us don’t like to weigh or measure food, or follow set recipes that don’t even feature foods that we prefer.

We just want to eat and let nutrition figure itself out.

That’s what we want to do, but hey, we put in the work to get ourselves to this chubby and prediabetic state. Now we have to do some work to get out of this mess.

We can lose weight by simply not eating as much food each day. Slash those calories and say bye-bye to a few pounds.

However, unless we also change what we eat[3], we’re less likely to leave prediabetes in the dust.

We can do this. Together, we can trial-and-error ourselves out of prediabetes land.

There is no one-size-fits-all way of eating that will lower your blood sugar and help you lose weight.

You need a personal plan that includes foods you like and leaves out foods you don’t like. Talk to your healthcare provider and get a referral to see a registered dietician or certified diabetes educator. Your local hospital or health clinic may provide this service free of charge.

Until you get the advice of a professional, there are some basics you can follow that apply to most of us.

Do a bit of homework. CDC explains carb basics,[4] and websites like[5] and[6] can start you on a path toward restructuring your diet.

Eat to your meter. The amount of carbs you should eat in a day will be different from the amount another prediabetic should eat. An expert can help you design a diet, but you’ll need to use a meter and test various foods to see what affects you and what doesn’t.

Don’t give up. If you’re disciplined about the trial-and-error approach, you will end up with a way of eating that you like and that (usually) keeps your blood sugar levels in the normal range.

It’s not only about your diet. Other factors can affect your blood sugar, like certain medications[7], stress, lack of sleep, and illness­­—all of which may keep your numbers elevated even if you’ve reduced your carb intake.

[1] Harvard School of Public Health/The Nutrition Source, Simple Steps to Preventing Diabetes, (May 2, 2019).

[2] PLOS ONE, A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabetes, (May 24, 2019).

[3] BMJ Journals/BMJ Open Diabetes Research & Care, Remission of pre-diabetes to normal glucose tolerance in obese adults with high protein versus high carbohydrate diet: randomized control trial, (June 12, 2019).

[4] CDC Centers for Disease Control and Prevention/Diabetes, Diabetes and Carbohydrates, (June 24, 2019).

[5] Endocrineweb, Diabetes Diet: The Best Way to Eat for Type 2 Diabetes,, (June 24, 2019).

[6] American Diabetes Association/Diabetes FoodHub,, (June 24, 2019).

[7] Diabetes in Control, 390 Drugs That Can Affect Blood Glucose Levels, (June 24, 2019).

Eat to Your Meter

Diabetics test their blood sugar several times a day. They do this to check that medications are working as they should, and to see if their blood sugar is too high or too low.[1]

If blood sugar levels are too far outside the norm for a diabetic, that can be a serious health risk.

Why would someone diagnosed with prediabetes choose to self-monitor? It’s not a standard recommendation, but maybe it should be.

If you’ve been diagnosed as prediabetic, you probably get your A1C[2] tested every few months or annually to see if you’ve developed type 2 diabetes. You go to the lab, get a blood draw, and you’re done.

Kind of important to know if you’ve moved from prediabetes to type 2 diabetes.

But, the A1C test is not the only test that is used to diagnose diabetes.

After all, according to the experts, you only need two days of fasting plasma glucose at or greater than 126 mg/dL to be diagnosed diabetic.[3]

It’s possible to be prediabetic and develop full-blown diabetes between those occasional A1C tests.

Self-monitoring your blood sugar can alert you to full-blown diabetes, or that you’re dangerously close to it. This awareness gives you time to immediately stop what you’re doing and try to correct course.

It also helps you to learn what your body tolerates in the way of food and drink, and it shows you what exercise does to your blood sugar levels.

Self-monitoring allows you to learn at a granular level just what’s happening with your blood sugar, and what you can do to affect it.

Use a blood sugar monitor (also called a meter) to discover exactly where your blood sugar is – if you’re prediabetic, normal, or officially a type 2 diabetic.

If you believe you have developed full-blown diabetes, you’ll want to have that confirmed by your healthcare provider, and a medical plan will be put into place.

“Eat to your meter” is a phrase you may hear when chatting to other prediabetics. It means you use the meter to guide you away from foods that make your blood sugar levels go up. Or conversely, toward foods that sustain you and don’t throw your blood sugar out of whack.

Since the goal is to get your blood sugar to stay down in the normal range, rather than the prediabetic range (and definitely not in the diabetic range), it’s necessary to eat more of this and less of that. What “this” and “that” is depends on your body, and that’s what eating to a meter can help you figure out.

Some prediabetics can eat carbs from, say, a carrot or even a carrot cake, and their blood sugar blips up then back down. Other prediabetics will get a big long-lasting bounce in their blood sugar if they eat carbs from the same sources.

Because prediabetes can cause some of the same problems as full-blown diabetes, it’s time to get aggressive in the fight against elevated blood sugar.

According to a thoroughly unscientific interview process performed through an online support group, prediabetics who choose to use a meter seem to find that they use it a lot early on. After a few months, they don’t use it as much because they’ve learned what works for them and what doesn’t.

Changes in lifestyle (food choices, exercise levels, weight control) based on what the meter is saying help them move toward normal levels of blood sugar, and soon they find they don’t need to use a meter to know what they should be eating and how much they should be exercising.

If you decide to start using a meter, you can buy one over the counter in your local pharmacy.

Be aware that insurance doesn’t always cover the cost of the meter and the strips.

Each meter will be slightly different so read the instructions before use, but these are the basic steps to using a meter:

  • Wash and dry your hands and then, if possible, use an alcohol wipe on the pad and sides of a fingertip. This is for infection control and to remove any substance which might affect the test results.
  • Insert a strip into the meter.
  • Use the included needle to poke the pad or side of your fingertip. No need to aggressively stab yourself. Keep it shallow, just enough to draw a tiny bit of blood. Squeeze around the hole to get a drop of blood if it isn’t immediately evident.
  • Touch the strip as indicated to the drop of blood, and your meter should tell you your blood sugar level after a few seconds.

Talk with your healthcare provider about what numbers you should be looking for, but generally speaking, as prediabetics our goal is to have numbers in the normal (rather than prediabetic) range:

  • before a meal the meter should read between 70 and 99 mg/dl (3.9–5.5 mmol/L) for normal blood sugar levels
  • two hours after a meal the meter should read less than 140 mg/dl (7.8 mmol/L) for normal blood sugar levels

It’ll be helpful to note what you’re eating. This makes it easier for you to remember foods and amounts that work for you.

Using apps such as the popular Carb Manager (free) or Carb Manager Premium (not free) is a common way to do this. (We are not associated with Carb Manager, but we do use the app.)

There are dozens of helpful apps, so choose one that makes the process of tracking foods and whatever else you want to track the easiest for you.

If you check your blood sugar before eating and it is 105 (a little higher than normal because you’re prediabetic) and two hours after you start eating a banana it is 145, then next time, try eating half a banana. Or cut bananas from your list of foods. For now.

Remember, the goal is to identify how individual foods affect your blood sugar levels, and to stay away from those that make it stay elevated.

[1] Mayo Clinic, Blood sugar testing: Why, when and how, (May 20, 2019).

[2] National Institute of Diabetes and Digestive and Kidney Diseases, Diabetes Tests & Diagnosis, (May 20, 2019).


Sleep and Prediabetes

Sleep seems an unlikely culprit in the blame game for prediabetes.

Did we really develop prediabetes because we stayed up late surfing the Internet? Well . . . maybe.

Or, was it because we zonked out for too many hours?

Research is showing that both short sleep and long sleep may affect our risk of prediabetes.[i]

That last bit was a surprise. Too much sleep can affect our risk of developing prediabetes? Again, maybe, although the science is not as pronounced on this.[ii]

Studies are indicating that short sleep, typically five or six hours[iii] or less, is a risk factor in developing prediabetes and type 2 diabetes. And yes, some studies indicate that long sleep[iv], typically nine hours or more, may also be a risk factor.

It’s not a straight line from poor sleep to prediabetes. Obesity is linked to sleep loss.[v] Obesity is a risk factor for the development of prediabetes. The line then goes sleep poorly, get fat, develop prediabetes. What caused the prediabetes? The obesity, or the lack of quality sleep?

However curvy the line is between poor quality sleep and prediabetes, the two are connected.

Getting adequate sleep each night (or day, if that’s when you get your sleep), is critical to overall health, and will only help in our journey to get out of prediabetes land.

Here are some tips from the NIH to make sleeping a solid seven or eight hours more doable:

  • Try to keep the same sleep schedule on weeknights and weekends. Limit the
    difference to no more than about an hour. Staying up late and sleeping in late
    on weekends can disrupt your body clock’s sleep–wake rhythm.
  • Use the hour before bed for quiet time. Avoid strenuous exercise and bright
    artificial light, such as from a TV or computer screen. The light may signal
    the brain that it’s time to be awake.
  • Avoid heavy and/or large meals within a couple hours of bedtime. (Having a light
    snack is okay.) Also, avoid alcoholic drinks before bed.
  • Avoid nicotine (for example, cigarettes) and caffeine (including caffeinated soda,
    coffee, tea, and chocolate). Nicotine and caffeine are stimulants, and both
    substances can interfere with sleep. The effects of caffeine can last as long
    as 8 hours. So, a cup of coffee in the late afternoon can make it hard for
    you to fall asleep at night.
  • Spend time outside every day (when possible) and be physically active.
  • Keep your bedroom quiet, cool, and dark (a dim night light is fine, if needed).
  • Take a hot bath or use relaxation techniques before bed.
  • Go to bed and wake up at the same time every day.

We cannot take this information and apply it in undiluted form to our individual case histories. Each body is different, and the sleep requirements to maintain health will be different.

Too much or too little sleep on its own is unlikely to be the reason we developed prediabetes. But every risk factor that we can address and fix, for lack of a better word, is worth looking at.

[i] JAMA Internal Medicine, Association of Sleep Time With Diabetes Mellitus and Impaired Glucose Tolerance, (March 11, 2019).

[ii] NCBI NLM/NIH, Sleep disorders and the development of insulin resistance and obesity, (March 12, 2019).

[iii] Diabetic Medicine, Association between duration and quality of sleep and the risk of pre-diabetes: evidence from NHANES, (March 11, 2019).

[iv]  (March 11, 2019).

[v] NCBI NLM/NIH, Sleep and Obesity, (March 13, 2019).

Rare Causes of Prediabetes

Everybody knows what causes prediabetes. It’s eating too many carbs, right? Those donuts and cookies pack on the inches and can lead to a sugary downfall.

That’s true for some, but what about the people with prediabetes who are moderate in their diet choices, or don’t have an obvious trigger? How do they end up in the mess with the rest of us?

The answer could lie in a few directions:

Monogenic diabetes (or prediabetes) makes up less than 5 percent of all reported cases of diabetes.[i]

Humans have approximately 20,500 genes.[ii] Genes are a small part of our DNA that determine things like our hair color and eye color.

Type 1 and type 2 diabetes are the result of several genes changing or mutating – they’re polygenic. In the case of monogenic diabetes, only one gene has changed or mutated.

If it’s the right one, a single mutated gene is enough to make it difficult for some bodies to create the necessary amount of insulin or to create well-functioning insulin. If the insulin can’t control the blood sugar, this can lead to prediabetes or even full-blown diabetes.

Monogenic diabetes presents itself primarily as neonatal diabetes mellitus (NDM) or maturity-onset diabetes of the young (MODY).[iii]

NDM usually occurs in babies under six months of age, although it has been diagnosed in older babies. It may be temporary, or it may be a lifelong battle.

MODY occurs in older children and even young adults. It might never move beyond a prediabetic stage, or it might be quite severe, depending on which gene has mutated.[iv]

Because such cases are rare, they’re not always properly diagnosed.[v]

If you have been diagnosed with type 1 or 2 diabetes, but you’re not ticking all the typical boxes for that diagnosis, ask your provider if genetic testing would be appropriate. Proper diagnosis of diabetes is important to find the most effective treatment options.

Schizophrenia and other severe mental illnesses may be linked to the development of prediabetes/type 2 diabetes.[vi]

The connection may be genetic, or lifestyle choices, lack of medical care, antipsychotic medication, or a host of other factors.

Medications, both prescription and over-the-counter (OTC), may be responsible for your prediabetes.[vii] A chat with the healthcare professional who prescribed your medication as well as the pharmacist who filled it, or who sold you the OTC drug, is worth your time. It could be that a different medication will provide the same benefit but not elevate your blood sugar.

Latent autoimmune diabetes in adults (LADA)[viii] is sometimes called type 1.5 diabetes, because it has characteristics of both type 1 and type 2 diabetes. Some scientists believe it’s a subtype of type 1 diabetes, while others believe it’s a stand-alone type. Because it comes on later in life, it tends to get misdiagnosed as type 2 diabetes.

Those living with LADA find that their pancreas stops producing enough insulin and eventually, months or even years after diagnosis, regular insulin shots are required.

Gestational diabetes mellitus (GDM) develops during pregnancy and generally goes away after delivery. It acts the same way in our bodies as prediabetes[ix], and puts those affected at high risk of developing full-blown diabetes at some point in life.

There are other forms or types of diabetes, including brittle diabetes, cystic fibrosis-related diabetes, chronic pancreatitis-associated diabetes, and Wolfram syndrome.

They have complicated relationships with type 1 or type 2 diabetes, or diabetes is only one of many symptoms characteristic of these conditions.

Does knowing what’s causing your prediabetes matter? Yes. If they know exactly what’s causing your prediabetes, or diabetes, your healthcare professionals have a better chance of figuring out the best treatment for you. Even if that treatment is to knock off the donut bingeing and get on a treadmill once a day.

Your primary healthcare provider has to know a lot about a lot, but it’s not easy staying on top of the details of every ailment. If you are diagnosed as prediabetic, it’s worth your time to visit a specialist in diabetic care, such as an endocrinologist.

Find out if the root cause is too many donuts, or something else. If it’s something else, the specialist will be able to determine what that something else is, and figure out the most effective treatment options for you.

[i] NIH/National Institute of Diabetes and Digestive and Kidney Diseases, Monogenic Diabetes (Neonatal Diabetes Mellitus & MODY), (March 20, 2019).

[ii] NIH/National Human Genome Research Institute, An Overview of the Human Genome Project,  (March 20, 2019).


[iv] Hormone Health Network, Monogenic Diabetes, (March 20, 2019).

[v] The Baltimore Sun, University of Maryland School of Medicine researchers are studying a rare form of diabetes, (March 20, 2019).

[vi] Wiley Online Library, World Psychiatry Official Journal of the World Psychiatric Association (WPS), Diabetes mellitus in people with schizophrenia, bipolar disorder and major depressive disorder: a systematic review and large scale meta-analysis, (March 20, 2019).

[vii] Diabetes In Control, 390 Drugs That Can Affect Blood Glucose Levels, (March 20, 2019).

[viii] American Diabetes Association, Diabetes Spectrum, Recognizing and Appropriately Treating Latent Autoimmune Diabetes in Adults, (March 26, 2019).

[ix] Thomas A. Buchanan, MD, email to author, March 27, 2019.

The Harm in Prediabetes

Your doctor says you’re prediabetic.

So what? What does it mean?

Is it like preseason baseball (which is really just practice)?

Maybe it’s like preschool, which is all-day recess with a few rules. Not really school with homework and a teacher who can chill your bones with one glance.

Or, maybe it’s a preview of what’s going to happen to your sorry self if you don’t wake up and take care of business before you’re into full-blown diabetes.

Too harsh? Too bad.

High blood sugar speeds up cognitive decline[1]. It doesn’t have to be a super high level of blood sugar. What are classified as prediabetic levels will do it.

Our ability to reason, remember, use good judgment—all of those can start to slip when we live with high blood sugar for too long a period.

Prediabetes also increases our risk of having a stroke or heart attack or (simply) cardiovascular disease[2].

One of the most common complications of diabetes is also a complication of prediabetes. Nerve damage, or diabetic neuropathy[3]. And guess what? Nerve damage can happen not just in the feet, but throughout the body, affecting, well, pretty much everything.

Prediabetes isn’t benign. It’ll throw you to the ground and stomp on you.

It’s not OK to cruise along in a prediabetic state and just hope we don’t develop full-blown diabetes. High blood sugar is hurting us. We all need to act now to get that blood sugar down to normal levels.

[1] Science Direct, Prediabetes and diabetes accelerate cognitive decline and predict microvascular lesions: A population-based cohort study, (April 15, 2019).

[2] BMJ, Association between prediabetes and risk of cardiovascular disease and all cause mortality: systematic review and meta-analysis, (April 15, 2019).

[3] Science Direct, Deep phenotyping neuropathy: An underestimated complication in patients with pre-diabetes and type 2 diabetes associated with albuminuria, (April 15, 2019).

Highlights of the Prediabetes Consensus Statement

In 2008, endocrinologists got together and came out with a consensus statement on prediabetes,[1] which seems to be the most current prediabetes consensus statement from this group.

Not much has changed over the years, except for the number of people affected by prediabetes. That figure continues to grow.

You can read the statement online, but who doesn’t love the highlights-only version of pretty much anything that has 33 words in the title?

Here goes:


There are hundreds of millions of people around the world with prediabetes.

The scary side of diabetes (stroke, nerve damage, heart disease, and so much more) seems to begin before full-blown diabetes sets in. If you’re prediabetic, you’re at risk for many of the medical complications that affect diabetics.

There are no FDA-approved medications for prediabetes. It was true in 2008, and is still true today.[2]

The Tests

The endocrinologists agree on what the blood work looks like for those who have normal blood sugar, those who have high blood sugar but aren’t yet diabetic (aka prediabetics), and those who are diabetic.

In the statement, they don’t mention using the A1C test as a first measurement of prediabetes, but it’s common to do so now. Therefore, it’s included here.

This test snaps a picture of what your blood sugar has been doing for the last two or three months. It’s called the Hemoglobin (A1C) test and is usually the first one providers use when diagnosing prediabetes.

  • A1C below 5.7 percent is normal.
  • A1C between 5.7 and 6.4 percent is prediabetes.
  • A1C 6.5 percent or higher in tests done on two different days is type 2 diabetes.

Next is the Fasting Blood Sugar test, or Impaired Fasting Glucose test.

Blood is taken after you’ve been fasting for eight hours or overnight. You should not be active or drink anything, such as coffee, before the test that would affect carb metabolism.

  • Fasting blood sugar below 100 mg/dL is normal.
  • Fasting blood sugar between 100 and 125 mg/dL is prediabetes.
  • Fasting blood sugar 126 mg/dL or higher (in tests done on two different days) is type 2 diabetes.

The third test is called the Oral Glucose Tolerance test, or the Impaired Glucose Tolerance test.

After fasting for eight hours or overnight your blood is tested. You then drink a sugary concoction and two hours later your blood is tested again. You shouldn’t be active or smoke prior to this test.

Note that the endocrinologists consider this test to be the more important one because it 1) identifies those who have undiagnosed diabetes and 2) indicates those who have a greater risk of becoming diabetic.

Two hours after drinking the sugary concoction:

  • Blood sugar below 140 mg/dL is normal.
  • Blood sugar between 140 and 199 mg/dL is prediabetes.
  • Blood sugar 200 mg/dL or higher is type 2 diabetes.

Another note: The statement suggests the possibility that the higher end of “normal” is actually prediabetic because, in large population studies, physical abnormalities associated with prediabetes/diabetes are cropping up in those with high “normal” numbers.

And one more note: the endocrinologists say that prediabetes is diagnosed by either the fasting blood sugar test, the oral glucose tolerance test, or diagnosed metabolic syndrome, which is considered to be the same as prediabetes.

Get tested for prediabetes if you have one or more of these risk factors, as listed in the statement:

  • Family history of diabetes
  • Cardiovascular Disease
  • Being overweight or obese
  • Sedentary lifestyle
  • Non-white ancestry
  • Previously identified IGT, IFG, and/or metabolic syndrome
  • Hypertension
  • Increased levels of triglycerides, low concentrations of high-density lipoprotein cholesterol, or both
  • History of gestational diabetes
  • Delivery of a baby weighing more than 9 lb (4 kg)
  • Polycystic ovary syndrome
  • Receiving antipsychotic therapy for schizophrenia and severe bipolar disease


The goal is to get blood sugar back to the normal range and treat high blood pressure and excess lipids (cholesterol and other fats in the blood) through medication. Controlling the blood sugar alone won’t automatically prevent heart disease or stroke associated with prediabetes and diabetes.

Meet with your healthcare provider to talk about where you are and where you want to be. Agree on the lifestyle changes you need to make to get you off the path to diabetes.

It boils down to:

Eat less, move more.

Cut calories, eat more fiber, go for healthy choices rather than simple carbs, which include fries, donuts, bread . . . and the list goes on. A nutritionist will lay it all out for you and help you figure out the crazy world of carbs.

You and your healthcare provider should decide if, in addition to cutting calories, drug therapy or other medical treatment is needed to help with weight loss.

Exercise, but don’t start out thinking you have to run a marathon. Your provider will suggest a safe level of exercise for you.

There is no FDA-approved drug therapy to prevent type 2 diabetes or to treat prediabetes, but your provider may decide to try some drugs off-label, depending on your risk factors. That’s another conversation you’ll need to have as you’re working on changing your lifestyle.

There’s more information in the consensus statement. A lot more, for those who love tackling sciencey jargon.

For those who prefer the CliffsNotes® version, we’re done!

[1] American Association of Clinical Endocrinologists, Diagnosis and Management of Prediabetes in the Continuum of Hyperglycemia—When Do the Risks of Diabetes Begin? A Consensus Statement From the American College of Endocrinology and the American Association of Clinical Endocrinologists, (April 25, 2019).

[2] Medscape, What are the FDA-approved drugs for treatment of prediabetes or prevention of type 2 diabetes mellitus (DM)?, (April 29, 2019).

Nutrition For Prediabetics


Yulia Brockdorf, RD, LD, CDE, CST, MA, NCC, LPC, BC-ADM, is the Clinical Director of Nutrition For Success, LLC.

Ms. Brockdorf is a registered dietitian, a licensed dietitian, a certified diabetes educator, and a certified sex therapist. She holds a master’s degree in clinical mental health counseling and is a national certified counselor and licensed professional counselor, as well as holding a board certified—advanced diabetes management credential.

In her spare time, she serves as chair of the Oregon Board of Licensed Dietitians, counsels patients to explore and move through their relationship with food and nutrition, and sits on the Editorial Board for Multinational Association of Supportive Care in Cancer Journal and the Research Advisory Board with the Community-Academic Consortium for Research on Alternative Sexualities.

When asked if she would answer some questions about prediabetes and food, she said, “Sure, send them over!” She took time after work and between patients to provide thorough responses, and that valuable information is what follows.

What’s the difference between an RDN (Registered Dietician Nutritionist) and a CDE (Certified Diabetes Educator) when it comes to the dietary needs of a prediabetic?

A registered dietitian nutritionist is a professional who has an in-depth knowledge and training that pertains to all areas of human nutrition, as well as medical nutrition therapy in treatment of the disease.

A certified diabetes educator is a licensed healthcare provider who demonstrated competency and experience in treating, educating and supporting people with diabetes.  This can be a licensed nurse, dietitian, pharmacist, physician, psychologist or another licensed provider (please see page 4 here).

A certified diabetes educator is required to meet nutrition competencies standards. However, their knowledge of nutrition is often not as in-depth as is that of a registered dietitian nutritionist.

When it comes to intricacies and nuances of applying nutrition recommendation, standards of practice, and latest research in practical everyday life, meeting with a registered dietitian nutritionist who is also a CDE may be beneficial for a patient.

Do you consider them equal in their expertise when it comes to instructing prediabetics on food choices?

While some providers who are CDEs gained the knowledge and mastered a sufficient skill set, in general, since there are so many professions that are eligible to become CDEs, not all will have the in-depth training, understanding of nutrition, nutrition biochemistry, and nutrition relationship between health and disease development, as most registered dietitians do. A CDE is a diabetes expert and an RDN is a nutrition expert, but most RDN training also includes an in-depth study of diabetes and prediabetes prevention and treatment.

Should prediabetics visit an RDN or CDE to get guidance on their prediabetes journey and if so, why?

Yes, they should. And oftentimes the services of a registered dietitian are covered under health insurance as preventive care. This may not be the case for all those who have CDE certification.

What is your definition of the keto diet?

The classic ketogenic diet distributes macronutrients in a ratio of 4-1.  For each 4 g of fat, which accounts for about 90% of the total calories, one consumes 1 g of protein (6% of total calories) and carbohydrate (4% of total calories) combined, with protein being the more dominant macronutrient of the two.  It’s very seldom that this diet is implemented in its classic form.  And there are many variations of ketogenic diet currently circulating online.

What are your thoughts on the ketogenic diet for prediabetics?

Research supports caloric restriction as a means of prediabetes treatment. This may be accomplished with a ketogenic diet. I would like to emphasize that we are discussing nutritional ketosis, not a life-threatening diabetic ketoacidosis.   

One of the outcomes of a ketogenic or modified ketogenic diet is a reduction of circulating insulin and an increased cellular responsiveness to insulin. A ketogenic diet can be successful in decreasing the total glucose burden in the cells of the body.

If embarking on a ketogenic diet, I strongly urge prediabetics to meal plan to ensure an adequate intake of fiber and micronutrients which may be missing when carbohydrate-containing foods that provide them are removed. Grains, for example, provide manganese, b vitamins, fiber, magnesium, and phosphorus.  I do not recommend implementation of a ketogenic diet without the supervision of a trained professional.  

What is your definition of a low carb diet?

This definition varies a lot from under 130 grams per day, or under 100, or between 30-60 or under 40, or below 20 (now venturing into keto world).

What are your thoughts on a low carb diet for prediabetics?

Decreasing carbohydrates does appear to have a benefit in prediabetes. 

Like any diet, carb restriction will lead to weight loss and improved metabolic profiles. But research does not show that these benefits have a long-term viability. 

If prudent carbohydrate intake that is both nutrient rich and portion controlled is incorporated into a long-term lifestyle change, consumption of under 100 grams a day may be a sustainable practice.

I do not support long-term carbohydrate restriction, but rather a reasonable carbohydrate intake.  This number is individual for each person with prediabetes.

Is there another way of eating, besides keto or low carb, that you prefer to recommend to prediabetics?

The POUNDS LOST study looked at four diets with fat, protein, and carbohydrate distribution:  20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35%. They concluded that reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.

There has been a lot of research supporting the Mediterranean diet as a means to prevent diabetes and reduce blood pressure.

Plant-based diets were associated with significant improvement in emotional well-being, physical well-being, depression, quality of life, general health, HbA1c levels, weight, total cholesterol and low-density lipoprotein cholesterol, compared with several diabetic associations’ official guidelines and other comparator diets. (BMJ )

Most recently, there is an increased surge in research looking into various forms of fasting: intermittent fasting, restricted feeding, etc. 

A recent study published in the Obesity journal showed that fasting not only improved postprandial glucose response (the blood sugar after eating) but also fasting glucose. Do not attempt fasting on your own without proper support.  Long-term fasting may lead to death or severe and dangerous complications such as refeeding syndrome.

Is it important to have a balance between carbs, proteins, and fats at each meal or snack? Why?

It is important to consume balanced and nutrient-dense foods. Such foods would be high in necessary micronutrients such as vitamins, minerals, and various phytonutrients, while also delivering necessary energy (in the form of protein, fat, and carbohydrate). 

This balance is the balance of the whole lifestyle. While each individual meal and snack can lean more toward one macronutrient or another, overall balance of food consumed in a given day, in a given span of time is important. 

Including fiber will support a sense of satiety, and may help with reducing cardiometabolic risks, as well as promoting gastrointestinal health. 

On the other hand, consumption of high fat and high carbohydrate foods in one meal may have a deleterious impact on prediabetes. This may result in an elevation of blood sugar, and this elevation may be sustained over a longer period of time. 

As far as the balance of carbohydrates, proteins, and fats, it’s based on the lifestyle of a person and the advice of their healthcare provider. The ratio may vary. 

I do advise that whichever approach is chosen, this decision is made on an individual basis and is sustainable as part of an overall healthy lifestyle.

What are your top five general recommendations for those working to reverse their prediabetes?

Don’t eat too much, and eat mostly plants


Get enough sleep

Do things that bring joy to your heart

Spend time in nature and practice non-violence, respect, and kindness toward self and others

Which online resources for prediabetes could you recommend and share?

Keto and low carb resources:

Diet Doctor


JAMA Network

Fasting resources:

The Fasting Method

Obesity: A Research Journal

Metabolic Health Summit

Plant based:


Spectrum Diabetes Journals

Vegetarian Diets and Incidence of Diabetes

Does a Vegetarian Diet Reduce the Occurrence of Diabetes