Even before patients step into my examination room, I know they are walking the tightrope to diabetes.  

Ninety-nine percent of human beings are, too. Almost all of us have a disorder of carbohydrate (sugar) metabolism that is associated with insulin resistance, and will advance to prediabetes and diabetes. But conventional medicine doesn’t typically screen for diabetes until symptoms of the disease emerge. What’s worse, the threshold for a diabetes diagnosis is too high, allowing people to think they are healthy when they are not. 

I’m not an alarmist. I’m a realist. As a practicing endocrinologist for 25 years, trained at Yale School of Medicine and a clinical researcher at the National Institutes of Health, I’ve seen the writing on the wall. It’s penned in my patient’s blood, and it describes a situation much more dire than even the published predictions suggest. Today, the number of American adults with diabetes is woefully underestimated at 38.4 million. Prediabetes is now believed to affect 98 million people (also an underestimation). And most don’t know they have it.  

Twenty-two percent of people with full-blown diabetes are unaware of their condition, too. Diabetes is typically first detected in a hospital emergency department when someone has a related complaint like an infection, COVID, or a heart attack. Worldwide, projections show that more than 1.31 billion people could be living with diabetes by 2050. Even more alarming, a study published in Diabetes Care in 2023 predicted that the number of American youths under age 20 with diabetes will surge nearly 700% by 2060. Remember, this is a disease with high rates of mortality, is directly associated with cardiovascular disease, kidney failure, blindness, amputations, cancers, neuropathy, and causes life-altering morbidity. Diabetes is a pandemic far worse than COVID-19, one that will kill millions worldwide in the coming decades.  

But who is sounding the alarm for detection and prevention?  

If anyone is, it’s falling on deaf ears because the criteria for a diabetes diagnosis is based on an average value derived from a large population study. Take, for example “hemoglobin A1c,” the widely used diabetes test that determines the average glucose level over the past 100 days by measuring glycated red blood cells. Researchers have concluded that a diagnosis of diabetes should be made from A1c levels at or above 6.5%. Why? Because a common microvascular complication of diabetes called retinopathy is rarely if ever seen in people whose A1c is under 6.5%.  So, your A1c of slightly under 6.5% is considered “not yet diabetes” simply because you are not experiencing blurred vision, the early sign of the leading cause of blindness. Most physicians will send you home saying, “we’ll keep an eye on it,” and you’ll leave thinking you’re healthy when that is far from the truth. 

 In 20+ years of practice, I have yet to see a patient who has optimal sugars. The peak of the bell curve is a mean of6.5%, yet that doesn’t mean everything’s hunky dory. In my book, you are diabetic, and I will start aggressive treatment. Likewise, a so-called “normal”A1c level is below 5.7%, but I consider any A1c value over 5% to be suboptimal and interventions are indicated to stop progression to diabetes. Without acting, your A1c will continue to rise. Why wait for overt diabetes to trigger associated disease? 

The danger in relying on averages to determine diagnoses is that humans are not all average. Each of us is unique. In any bellcurve analysis, there are ranges, out to + 3 and -3 standard deviations. We ignore those outliners to our detriment. Applying an average value to everyone is not applicable to each of us. A physician who declares our blood test result “normal” will give us a false sense of security. It allows us to ignore a problem that isn’t going to go away without active interventions.  

Even when a patient’s A1c is optimal, his or her fasting and postprandial (after eating or drinking) glucose and insulin, or testosterone is typically suboptimal, indicating the initial stages of disease—that disorder of carbohydrate metabolism present in all humans. In everyone. Everyone who is obese, everyone who is just a little overweight, even those of us who are skinny.  

Being overweight is not a character flaw. It’s not a reflection of laziness or the inability to stop eating Oreos. Don’t blame Coca-Cola or McDonalds for putting you on the path to diabetes. Blame Darwin. We humans evolved to store sugar as fat. In times of severe famine, we either starved to death or we survived because of a genetic proclivity to store fat to sustain us in lean times. Cave dwellers gorged in days of plenty and developed the ability to save that energy on their skeletons for use in times when the animal herds moved on. The ones who made it through the famine could pass those hardy survival genes onto their offspring, who passed them along to theirs and so on and so on to you and me.  

Now we’re well prepared for a famine that never comes. While certainly there are hungry people living in our wealthy nation, most of us have 24/7 access to cheap, energy-dense processed foods. We no longer burn calories hunting and gathering when we have a DoorDash app. 

Our inherited survival mechanism, that well-oiled, sugar-into-fat storage machine, is now killing us. It’s filling the last 30 years of our lives with disease, pain, and suffering, and keeping us from enjoying life to the fullest. The irony is longer life only avails us of extended years for diseases of aging to emerge. Now that life expectancy has increased, with many living to 100 and beyond, disease is rampant. The Greatest Generation was the first to experience life extension with chronic diseases. But we have the opportunity now to avoid that fate—if we recognize that the march toward diabetes begins much earlier than we recognize.  

Starting in our 30s, our predisposition for sugar storage coupled with hormonal shifts, loss of muscle and reduced metabolism, creaks open the doorway to diabetes, heart disease, cancer, dementia, and other disorders we associate with the elderly. Those “old person”problems don’t happen overnight. They begin at the cellular level when we are young. And if we recognize them early, we have the best chance of avoiding the diagnosis in our collective destiny—diabetes.  

How do you begin to turn the tide against this devastating disorder? Acknowledge the enemy. Ask your doctor to test you for diabetes and prediabetes even if you are having no symptoms and particularly if diabetes, heart disease, strokes, kidney failure and dementia run in your family. At my practice, we cover our bases with a minimum of five metabolic diagnostic tests: fasting glucose, fasting insulin, A1c, cholesterol risk ratio, and free testosterone. Ask for them. Results from those tests will yield a clear picture of your current metabolic health and, more important, where it’s headed, so you can intervene now to ensure a healthspan that matches along and active lifespan. 

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