Masthead

The Big D

Diabetes is America’s stealthy killer. One in three Americans could have it by 2050 if current trends continue. What’s more, the disease is striking more young men than ever. Follow this plan to stay out of danger and avoid becoming a statistic.


By Lou Schuler
10 min

Above Image | Spencer Lowell/Trunk Archive

Kevin Mamon has no excuse. He was warned. He knows it, and his medical records prove it. Four years ago, a test showed that he had prediabetes, which, as the name suggests, is the intermediate step between normal, healthy blood sugar levels and full-blown type 2 diabetes. “I fooled myself for a long time, thinking I was healthy, but just a big dude,” he says.

The 6'1" Mamon isn’t kidding about his size, which had peaked north of 400 pounds. By the time he went to see Spencer Nadolsky, D.O., he was no longer so sure about the “healthy” part. It was March 15, 2016, one of many details he remembers with the clarity of a man who’s had a conversion experience. He was a few weeks shy of his 42nd birthday and his weight had recently dropped to 373 pounds without any real effort on his part.

Unintentional weight loss, Mamon now knows, is one of the clearest warning signs of diabetes, along with constant thirst, urinary volume that would worry Seabiscuit, and nap-inducing fatigue after every meal. He was about to become a statistic, one of 1.4 million Americans diagnosed with diabetes each year. (The American Diabetes Association estimates that of the 29 million who have the disease, a quarter don’t know it yet.)

You could be one of them. And your odds of having prediabetes is even higher—the latest research shows that a third of American adults are prediabetic. Because you can’t feel high blood sugar, you wouldn’t know you have it unless a doctor told you. And 90 percent of people with prediabetes haven’t been diagnosed. (Gauge your risk below.)

Mamon was one of the few, the forewarned; the proof is in his patient file. It says that in the spring of 2013, his hemoglobin A1c, a three-month average of his blood sugar levels, was 6.3 percent, just below the 6.5 percent cutoff for diabetes. He simply has no memory of the warning. “If I’d paid more attention, I could’ve saved myself a lot of aggravation,” he says.

By the time he saw Dr. Nadolsky, a family medicine and obesity specialist in Olney, Maryland, Mamon’s A1c had nearly doubled to 12.5. His fasting blood sugar, at 348 milligrams per deciliter, was three-and-a-half times the normal level for a healthy adult.

“He wasn’t just ‘kind of’ diabetic,” Dr. Nadolsky says. “He had severe, uncontrolled diabetes. Most doctors would’ve automatically put him on insulin. That’s how dire it was.” The amount of sugar flowing through Mamon’s blood, combined with his weight, pointed toward potentially catastrophic complications.

When Sugar Attacks

“Diabetes mellitus” comes from the Greek word for siphon, referring to the excess urine that’s a key symptom of the disease, and a Latin word for sweetness, referring to the sugar the body is trying desperately to unload. History doesn’t tell us who the first person was to sample that diabetic piss and observe that it tasted like honey. (Although several people did observe that ants were drawn to it.) We just know that diabetes has been with us for a long time.

Diabetes begins with high blood sugar, either because the body fails to produce enough insulin to shuttle it out of the bloodstream and into muscle or fat cells, or because the body stops responding to its insulin. About 5 percent of people with diabetes have type 1, an autoimmune disease that usually strikes in childhood or young adulthood and requires lifelong management with insulin shots or a pump.

The rest have type 2 diabetes. To understand this kind, imagine your body as a factory. It makes one product: the energy it needs to keep itself running all day, every day.

Every meal or snack is, in effect, a new delivery of raw materials to your factory.

Picture those materials arriving on trucks. Under normal circumstances, they pull up to your plant’s loading dock, your employees (insulin) empty them, and they pull away, clearing room for subsequent deliveries.

Now imagine that there’s a problem: The trucks arrive at their usual hour with their usual cargo, but this time there’s a malfunction with the doors of the loading dock and the workers can’t move the goods off the trucks and into the factory with their usual efficiency.

But rather than slow down the delivery schedule until the doors can be fixed, management sends more workers to the docks. This works for a while, and the bosses celebrate by ordering more products. That means more trucks with more cargo. You don’t need an MBA to predict what happens next: The volume surpasses the workers’ ability to process it, and as the line of trucks gets progressively longer, some of the drivers, in frustration, dump their cargo (sugar) in the parking lot (your blood stream).

Type 2 diabetes rates have risen with obesity. That’s no coincidence. The more weight you gain in adulthood, the higher your risk. Harvard’s long-running Health Professionals Follow-Up Study found that the risk of type 2 diabetes doubled for men who gained 11 pounds or more since their undergraduate days, tripled for those who gained 22 pounds or more, and increased six times for those who added 33 pounds or more.

Too much food, consumed over a span of several years (the average age of diagnosis is 54, but 23 percent of adolescents have diabetes or prediabetes), eventually overwhelms your ability to process it. Then all hell breaks loose. Excess sugar can damage the most vulnerable blood vessels in your eyes and kidneys, leading to blindness and organ failure; it can also gum up the nerves and arteries of your penis, turning your reproductive hardware into software. (See below for more on how diabetes causes trouble throughout the body.)

But by far the biggest consequence is cardiovascular disease. Diabetes itself is the seventh most common cause of death in the United States, but most people with diabetes die of heart disease due to high blood pressure and elevated triglycerides and cholesterol, along with their inability to manage blood sugar.

That’s the scary part. The hopeful part is that a disease of excess can be reversed. How? By doing the opposite of what caused it.

A Heavyweight Challenge

Dr. Nadolsky, 33, isn’t someone you’d expect at the forefront of the battle against type 2 diabetes. “He’s probably in better shape than anyone I know,” Mamon says. That may be underselling his doctor’s fitness. Dr. Nadolsky was an academic all-American wrestler at UNC, and at one point ranked fourth in the country as a heavyweight. Even though he later dropped 30 pounds, he still looks the part, with a massive upper torso, thick brow, and just enough scar tissue to make you think that if his genial smile descended into a scowl, he could moonlight as a bouncer.

But just because he looks like the “after” picture in a Bowflex ad doesn’t mean Dr. Nadolsky is a fat-shaming meathead. “It was refreshing to hear his perspective,” Mamon says. “I mean, you know you’re fat. You know you need to lose weight. You don’t need somebody to tell you that you’re fat and you need to lose weight.”

“I talk about it tactfully,” says Dr. Nadolsky, the author of The Natural Way to Beat Diabetes (MensHealth.com/beatdiabetes). “Most people understand that diabetes comes from excess weight. They know that already. I try to get them excited about reversing it through diet and exercise.”

In his patients with prediabetes or with mild and recently diagnosed cases of diabetes, Dr. Nadolsky first proposes the option to try lifestyle changes without medication. “I tell them, ‘The bad news is that you’re in the prediabetic range, and now you have two pathways,’” he says. “‘The good news is that if you take the right one—clean up your diet, lose weight, get serious about exercise—you can nip this in the bud. But if you take the other one, you’ll likely end up with diabetes.’”

The conversation Dr. Nadolsky had with Mamon in 2016 described two very different pathways. Instead of smooth, well-lit roads, he was looking at dark, deeply rutted trails. The lifestyle-management route would include powerful drugs, with the hope of eventually reducing his reliance on them. The “ah, screw it, I’ll be fine” route, the one Mamon chose by default in 2013, included even more powerful drugs, starting with daily injections of insulin, most likely progressing to multiple doses, with a high risk of that insulin causing him to gain weight at a time when he needed to lose it.

“I wasn’t shocked by the diagnosis,” Mamon says. After all, both of his parents had been diagnosed in the previous year. “It wasn’t like cancer, something that just floors you. But it was heavy news. Nobody wants to hear it.”

But then Mamon asked Dr. Nadolsky an important, life-defining question: “Do you think it’s possible for me to reverse diabetes?”

As it happens, a research team in England was ready to provide an answer.

Starving the Beast

Not long after Mamon got his heavy news, researchers at Newcastle University released a bombshell study in Diabetes Care, the official journal of the American Diabetes Association. Type 2 diabetes, they wrote, is “potentially reversible by substantial weight loss,” a finding they described as “an important paradigm shift” with “profound implications for the health of individuals and for the economics of future health care.”

The study included 30 volunteers who ate a maximum of 700 calories a day, most of it from three meal-replacement shakes, for eight weeks. Then that was followed by a two-week period to reintroduce solid food, and then six months of maintenance.

For the 12 participants labeled as “responders,” fasting blood sugar fell from 160 to 114 milligrams per deciliter, on average, without any medication. It’s an astounding improvement, one that kicked them out of the diabetic range (above 125) and into prediabetic (100 to 125). Five saw their A1c return to normal.

These results aren’t a fluke, says Newcastle professor Roy Taylor, M.D., who led the research team: “Patients of mine have remained nondiabetic for many years by achieving and maintaining substantial weight loss.”

To be sure, we already knew that weight loss helps people with diabetes. The long-running Look AHEAD study, which has more than 5,000 participants, shows that losing just 5 to 10 percent of body weight lowers blood sugar and improves insulin sensitivity. Losing more is even better.

The reason seems pretty straightforward. “If they had not been carrying around their current amount of fat for many years, they would not have developed type 2 diabetes,” Dr. Taylor says. Reversing the disease has to begin with reversing the cause of it.

But not all fat is equally culpable. The subcutaneous fat that hides your abs or pluralizes your chin may be aesthetically inconvenient, but it doesn’t destroy your health. People with diabetes, Dr. Taylor says, store excess fat in their liver, which spills over into the pancreas, eventually crippling that organ’s ability to make enough insulin. Dr. Taylor calls that tipping point the “personal fat threshold.” Although the heaviest people are at the highest risk, nobody can predict when any individual will reach it.

“The average body mass index at diagnosis is around 30,” he says, which is the borderline for obesity. “But more than 70 percent of people with BMIs over 45 don’t have diabetes.” (To put that into perspective, a 6-foot guy who weighs 221 has a BMI of 30. At 332 pounds, his BMI is 45.)

Weight loss reverses diabetes because it releases fat from your body, including the metabolically chaotic fat in your liver and pancreas.

Unfortunately, weight loss is no guarantee of success. All the people in Dr. Taylor’s study lost a lot of weight—an average of 35 pounds for the responders, versus 29 pounds for the others—but the 12 with the best results tended to be younger, with less body fat and lower blood glucose. They were also more recently diagnosed. They’d known about their disease for four years, on average, compared with 10 years for the nonresponders.

That matches Dr. Nadolsky’s experience with his own patients, and it gives Mamon hope.

Beat Diabetes

Mamon estimates that he weighed 185 to 190 in high school, and then “gained the typical 5 to 10 pounds a year.” It wasn’t until he opened a baseball card shop in 1998, when he was 24, that he ballooned. “I couldn’t play sports because we were open until 8 at night,” he says. “I was single and I had business responsibilities, so a lot of times I was eating at Bennigan’s at midnight.”

Seven years later he closed the shop and went into the restaurant business, where long hours on his feet couldn’t mitigate the damage caused by stress-fueled eating and drinking after his shift. Even then, when his weight blew past 300 on its way to 400 and beyond, he told himself he carried it well. “I never thought of myself as a big, fat slob,” he says. “People would always think I was 50 to 100 pounds lighter than I was.”

The time for deceiving himself was long past. With Dr. Nadolsky’s guidance, Mamon started tracking every single bite of food that crossed his lips. “I dropped my calories to 1,000 to 1,200 a day for the first three to four weeks,” he remembers. “When I think about what I would’ve been eating a year ago, I’d say it was easily 4,000 calories or more a day. Easily.” He lost 20 pounds in two weeks, and 40 more in the next four months.

Mamon also became militant about his carbs, for a simple reason. “Lowering carbohydrate intake will automatically lower blood sugar,” Dr. Nadolsky says. The logic: Diabetes begins with insulin resistance. Insulin resistance causes high blood sugar. That sugar comes primarily from the carbohydrates in your diet. The more carbs you eat, the higher it goes, and the more insulin your already-stressed pancreas is forced to produce. Mamon follows these rules:

  • No more than 40 grams of net carbs (total carbs minus fiber) per meal
  • No more than 20 grams of net carbs per snack
  • No meals or snacks that are 100 percent carbohydrate (except an apple)

The cascade also works in reverse. Fewer carbs means less blood sugar, which means less insulin. Over time your insulin sensitivity should return to normal. “If I could get my patients on low-carbohydrate diets, I would,” Dr. Nadolsky says. “But it’s very tough from a practical standpoint.”

Adherence is the biggest stumbling block. For example, a 2010 study in the journal Obesity assigned 70 volunteers with diabetes to follow a diet with just 30 grams of carbs a day—the equivalent of an English muffin or a medium-to-large banana. At the beginning of the study they were eating about 200 grams a day. But by the end of the study they were only down to 193 grams. And that’s simply because they were eating less total food. Their percentage of calories from carbs actually went up.

That’s an extreme example, of course, but it highlights the unfortunate disconnect between the logic of cutting carbs and the reality of it for people who have diabetes. Short-term studies sometimes show dramatic results for one diet or another, while long-term research shows little difference. How much weight you lose matters far more than how you lose it.

There is, however, one other way to fight diabetes.

Every Step Matters

If you don’t have type 2 diabetes, you have three ways to avoid getting it:

  • Stay lean. For every 1-point increase in your BMI (for a 6-footer, it would mean gaining about 8 pounds), your risk of developing diabetes goes up 8.4 percent.
  • Maintain your waist size. A 1-inch gain in waist size boosts your risk by 8 percent.
  • Exercise more. Physical activity cuts your risk by a whopping 50 to 80 percent, not least because it helps prevent weight and fat gain.

And if it’s too late for prevention? You won’t be surprised to learn that exercise can help you roll it back. For example, a 2016 Duke University study took a group of inactive middle-aged people with prediabetes and had them exercise for six months. The ones who walked at a casual pace for an average of 11 miles a week saw significant blood sugar improvements.

Dr. Taylor’s team at Newcastle University tried for something much more challenging. Those who did 12 weeks of high-intensity interval training (HIIT) decreased their liver fat by an average of 39 percent while also improving postmeal glucose tolerance and several aspects of cardiovascular function. The protocol they followed three times a week is as complex as any you’ll find in published research. They started with five two-minute intervals the first week and advanced to nearly four-minute intervals in week 12, all at an intensity described as “very hard.” They also did 60 seconds of upper-body exercises with resistance bands during the three-minute recovery periods between intervals. (Dr. Taylor adds that they were supervised “by a very motivational person.”)

But it doesn’t need to be that complicated to be useful. “People think they need to do P90X or something,” Dr. Nadolsky says. “They have a cartoonish idea about what exercise is, and that extreme training is the only way for it to be effective. They don’t realize something that feels good is actually beneficial.” That’s why he encourages his patients to start by simply walking, preferably after meals, when it does the most to reduce blood sugar.

But strength training is almost equally valuable. A 2014 study in Sports Medicine comparing published research found that those who did aerobics lowered their A1c 18 percent more than those who lifted. Practically, though, there’s no reason to choose one over the other, and most guidelines recommend doing both. What matters most is that you do something, and common sense tells us that you’re most likely to do more of something you enjoy. (See “Cool Off Your Risk” below for a particularly effective workout idea.)

“Exercise is very good for you,” Dr. Taylor says, which should not come as a shock to anybody. For people who have diabetes, any type of exercise helps keep excess postmeal blood sugar from flowing into the liver, where it’s converted to havoc-wreaking fat. But he follows that ray of sunshine with a grim reminder: “Most people who’ve eaten themselves into a state of diabetes simply cannot exercise themselves out of it.”

The Long Road Back

For his part, Mamon is sold on the benefits of regular exercise. He and his wife walk 3 miles almost every morning, and when weather permits, they walk again after work. “We found some nice trails locally that we do on the weekends as well,” he says. He also plans to get back into the gym, although with a full-time job and night classes (he’s working toward a master’s certificate in supply-chain management), his schedule remains tight.

Mamon has now lost 83 pounds, which is 22 percent of his diagnosis-day weight. At his last appointment with Dr. Nadolsky, his fasting blood sugar was 89 and his A1c was 5.5 percent, both well below the cutoffs for prediabetes. That’s with the help of three drugs, none of which is insulin. His long-term goal is to reduce his need for them, especially one that’s frequently advertised on TV. Mamon says he’s never gotten used to seeing the commercials and realizing, “Hey, I take that!”

At moments like those, or when his progress stalls, he admits it’s hard to keep a positive attitude. But that’s when he most appreciates Dr. Nadolsky’s optimism. “I can be pretty pessimistic,” Mamon says. “But he’s like, ‘Are you kidding me? You lost weight! You’re healthier!’”

Mamon knows he could’ve gotten here sooner and made his road back to health smoother and easier if he had paid attention to that initial warning, the one that told him his blood sugar was elevated and he was heading for a disease he wouldn’t wish on his worst enemy.

But considering the condition he was in a year ago, what he’s accomplished is very much worth celebrating. In moderation, of course. Followed by a long walk.


1. Do You Have Prediabetes?

It’s the first step toward the big D, and it’s dangerous in its own right. People with prediabetes—defined by a fasting blood sugar level between 100 and 125—also have an elevated risk of heart attack and stroke, according to a BMJ study review. Go to doihaveprediabetes.org to assess your risk, and consider the warning signs below.

Bulging Gut

Belly fat is bad for your metabolism. Divide your waist circumference by your height (both in inches). If the result is higher than 0.5, you may have an increased diabetes risk, Korean research suggests.

Sugary Drink Habit

In a Journal of Nutrition study, people who drank more than three a week had a 46 percent higher risk of prediabetes than abstainers. When you glug sweets, your liver makes molecules that curb insulin function.

Family History

If you’re between the ages of 18 and 29, your odds of developing prediabetes in the next five years are 79 percent higher if you have a parent with diabetes, a recent study from Emory University suggests.

A Sedentary Life

Lack of physical activity is a key predictor of diabetes. If you’ve been a couch potato and start exercising just 30 minutes a day, your odds of insulin resistance can dip by 13 percent, say researchers at the University of Michigan.


2. How Diabetes Corrodes Your Body

If your blood sugar levels are chronically elevated, toxic byproducts can build up and cause damage to sensitive parts of your body.

When sugar byproducts damage blood vessels in your retinas, bulging aneurysms can form, which can leak and rupture (or hemorrhage), impairing your vision. This is diabetic retinopathy, a top cause of blindness. But the damage can be happening before you notice. “You may think your vision is fine but have significant diabetic eye disease,” says Allen C. Ho, M.D., director of retina research at Wills Eye Hospital in Philadelphia. That’s why anyone with diabetes should have an annual ophthalmology exam.

You’ve probably had numb toes on a cold day. But nerve damage from diabetes makes feet consistently numb and tingly, and occasionally painful, says Bijan Najafi, Ph.D., a researcher of vascular surgery at Baylor College of Medicine. High blood sugar robs nerves of nutrients and blunts your ability to process waste products. Then the starved, damaged nerves can’t conduct impulses that give you feeling. “I’ve seen cases where people step on a nail and it goes into their bone but they don’t feel it,” says Najafi.

Excess blood sugar can wreak havoc on your ticker. For one thing, it can cause narrowing of the blood vessels that provide energy for your heart to function. The extra sugar can also damage your heart muscle tissue, which could curtail its pumping efficiency. At the same time, elevated blood sugar levels can cause hardening of the arteries, leading to high blood pressure and increased resistance to bloodflow. As a result, your heart has to work even harder to shuttle blood through your body.

Your kidneys normally function like sieves, which keep useful stuff on top and release wastewater into the sink. When a sieve is damaged, it lets good stuff hit the sink or fails to filter, so that water stays on top. Similarly, damaged kidneys leak useful blood proteins into your urine and retain water, causing high blood pressure. The end result: Your kidneys shut down. “ Diabetes is the leading cause of kidney failure,” says Mark Cooper, Ph.D., an expert in diabetic complications at Australia’s Monash University.

More than half of men with diabetes have trouble achieving an erection. Nerve damage is yet again to blame for this problem. Sensitive nerves in your penis coordinate its enlargement when you’re in the mood for action. When these nerves are damaged, this process doesn’t work so well. For this reason, drugs like Viagra, which only work on bloodflow to the penis, are often less effective in people with diabetes. If you keep your blood sugar under control, you may reduce your risk of developing problems.


3. Your Race Against Diabetes

Diabetes rates differ by race and ethnic background as shown below, although it’s unclear whether DNA or cultural habits create the differences in risk. Some hospitals and clinics offer diabetes programs tailored to specific ethnicities, which can work better than one-size-fits-all plans.

16%

American Indians/Alaska Natives

13%

Non-Hispanic Black Americans

13%

Hispanics

9%

Asian Americans

8%

Non-Hispanic White Americans