Pre-Type 2 Diabetes and Lean Vegans

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by Jack Norris

Recently, I have been contacted by a small group of lean, pre-diabetic vegans. I had never heard of thin vegans developing pre-diabetes; it turns out that it’s not uncommon for lean people to develop pre-type-2 diabetes.

Here is an article by Susan Papuga, one of the people who contacted me, who has researched the topic thoroughly. If you aren’t familiar with the normal references for the numbers discussed below, please see Diabetes: Tests and Diagnosis from Mayo Clinic.

Pre-Type 2 Diabetes and Lean Vegans

by Susan Papuga

The majority of people with type 2 diabetes are overweight and suffer from hyperglycemia (high blood sugar) due to insulin resistance. However, there is also a condition in which thin people suffer from hyperglycemia. Few studies have been done on lean diabetics and are primarily on Asian populations. Many of these studies have found that lean type-2 diabetics are suffering from a deficiency of the insulin-producing beta cells rather than from insulin resistance. An even smaller subset rarely mentioned are lean vegans with high blood glucose; further research is needed to determine the cause of their pre-diabetes or diabetes.

The International Diabetes Foundation has developed a document, Guideline for Management of Postmeal Glucose (PDF), which states, “Although control of fasting hyperglycaemia is necessary, it is usually insufficient to obtain optimal glycaemic control. A growing body of evidence suggests that reducing postmeal plasma glucose excursions is as important, or perhaps more important for achieving HbA1c goals.” Their recommendation is that two-hour postmeal (also known as postprandial) plasma glucose should not exceed 140 mg/dl (7.8 mmol/l) as long as hypoglycemia is avoided.

In order to meet that goal for a lean vegan who is pre-diabetic or diabetic, careful consideration needs to be paid to diet. One challenge is how to prevent postprandial spikes while reducing carbohydrate and still maintaining adequate body weight. The Eco-Atkins diet can be an effective path to follow with higher fat and protein consumption from nuts, seeds, avocados, soy foods, and seitan–all helping to provide needed calories. Carbohydrate should be chosen wisely, emphasizing high fiber and low glycemic foods.

The Guideline further states, “Self-monitoring of blood glucose should be considered because it is currently the most practical method for monitoring postmeal glycaemia.” For a lean vegan, this is an important step in taming impaired glucose metabolism. For a few in our group of lean vegans, our fasting glucose was only slightly elevated while an HbA1c test and/or postprandial glucose identified pre-diabetes.

My first indication of impaired glucose metabolism was during a routine lab which showed a slightly elevated fasting glucose of 101. I started testing my fasting and postmeal glucose at home and mentioned to my doctor that I was seeing some high numbers for postmeal, up to 185. A person with normal glucose metabolism rarely goes over 140 postprandial. An oral glucose tolerance test confirmed a pre-diabetes diagnosis, and then began my journey to find a way to lower those numbers while eating a healthy vegan diet.

Personally, I’ve had success at keeping my fasting glucose under 100 mg/dl and postprandial glucose under 140 mg/dl with a diet similar to Eco-Atkins. I found that the processed grains in breads and pasta and many mid- to high-glycemic index foods, even in modest amounts, will cause a high postprandial spike. To keep glucose low and slow, the high fiber carbohydrate are best. I’ve stopped eating dried fruit and eat low glycemic index fresh fruit only in small servings; instead, I fill up with hull-less barley (1), soybeans, legumes, chia seeds, wheat bran, non-starchy vegetables, nuts, seeds, avocado, and seitan.

Tracking daily nutrients on has been invaluable for meeting the RDA targets. Consequently, my lab results are coming back with great numbers: low cholesterol (high HDL), low inflammation, low blood pressure, normal glucose, and HbA1c at 5.0. This diet works well for me and the other vegans in our group. We’ll continue to monitor our glucose and labs, adjusting when needed, but overall we are quite pleased, as are our doctors, with the outcomes.


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1. Barley can be hulled or hull less. Hull less barley has a lower glycemic index and higher nutrient profile.

25 Responses to “Pre-Type 2 Diabetes and Lean Vegans”

  1. Richard Says:

    Is this article saying that thin vegans are at an increased risk for becoming prediabetic or diabetic?

  2. Jack Norris RD Says:


    > Is this article saying that thin vegans are at an increased risk for becoming prediabetic or diabetic?

    No, it is not. Two of the people I’ve communicated the most with do not think being vegan caused them to become pre-diabetic. Rather, once someone has pre-diabetes, they think that eating a normal vegan diet makes it hard to keep postprandial blood glucose below 140 mg/dl due to the high carbohydrate load. So they want to make sure any thin vegans with pre-diabetes realize that their condition is different than the typical insulin resistance that overweight people with pre-diabetes might have, and that a vegan diet needs to be carefully monitored if beta cell dysfunction is the problem.

  3. Dax Reiter Says:

    Hi Jack,

    Thanks for this informational post. I really enjoyed the section regarding your food intakes:

    “I’ve stopped eating dried fruit and eat low glycemic index fresh fruit only in small servings; instead, I fill up with hull-less barley (1), soybeans, legumes, chia seeds, wheat bran, non-starchy vegetables, nuts, seeds, avocado, and seitan.”

    I am hoping you could publish more detail about your specific diet plan and the motivations behind your food choices. I recently watched a talk by Dr. Michael Lustgarten regarding the optimization of diet for health and lifespan (it can be seen here if you are interested: His presentation also goes into glucose optimization for reduced health-risk and increased quality-of-life. I’m a slightly-overweight vegan who loves carbs, so I can identify with these issues.

    Thanks again for the interesting post. Take care,


  4. Jack Norris RD Says:


    You should note that this is Susan’s diet (the author of the article), not mine. Maybe Susan will see this and pipe in more about her diet.

  5. Dax Reiter Says:

    Oh, sorry about that! I saw your name on the preface and spaced out that it was a pasted comment.

  6. Gingerann Says:

    Dear Jack,

    You and Ginny Messina are voices in the wildnerness. I NEVER could stick to a vegan diet and always thought something was wrong with me. I would walk around starving. I went on Mcdougall/Forks Over Knives type eating, and never felt so exhausted and sick in my life. I was suffering from protein deficiency. To make a long story short (or a longer story shorter!) I went on the 2 Day Diet by Dr. MIchelle Harvie. I ate very low calorie, low carb but high protein for two consecutive days, and then ate normally the other five. This is known as intermittent fasting. Her book is not vegan, but I did the diet vegan, having low carb plant based shakes and low carb high protein soups (veg broth, yeast flakes, shiratake – sounds disgusting but is entirely delicious) on my fasting days. What I found was that on the remaining five days my insulin levels were normalized, and I no longer had carb food freak-outs. Yes, even too much brown rice just doesn’t work with my blood sugar. I implore you…PLEASE write another book, this time on lower carb vegan eating. There is such a need for it. I wrote the same thing on Ginny Messina’s blog – maybe you two could get together again for another book? It is my strong belief that there are so many people out there who want to go vegan but cannot because of the horrible, politically-correct no-fat/low protein advice out there. For those of us with blood sugar issues, that advice spells DISASTER, and we go back to eating bacon…please consider teaming up with Ginny and having a go at it. You two are much needed voices in the wilderness of vegan craziness. I am finally a healthy vegan, and oh, so grateful Thank you and Ginny for having the courage (gasp!) to even mention Eco Atkins in your blogging.

  7. Susan Papuga Says:

    Hi Dax,
    My diet plan was originally guided by the glycemic index and the Eco-Atkins diet, and I incorporate Dr. Joel Fuhrman’s recommendations, but my diet has evolved as I have learned how foods affect my postprandial glucose. This has been done through frequent blood glucose testing, starting 30-45 minutes after the first bite of my meal, which is when my glucose typically peaks, and then checking after an hour to see if it’s still going up or going down. I occasionally check after 2-3 hours in case there are any surprises lurking – some restaurant foods can really throw you a curve. My target is to stay under 140 mg/dl at all times.

    The carbs which send my glucose the highest, besides the obvious sugar and juice, are breads, pasta, most grains, starchy vegetables, and many fruits. Even foods rated moderate GI can have a fast impact unless they are included in a meal with natural glucose brakes. Those brakes are provided by fiber, fat, protein, and acidity, all of which can slow down a postmeal rise. Exercise after a meal, either walking or something more active, will also lower the postprandial level.

    The amount of carbs that I can handle now without glucose spikes averages 30% of my daily calories, with protein around 25% and fat around 45%. This is a bit different from Eco-Atkins, which is also vegan and has 26% carb, 31% protein, and 43% fat, and a far cry from the Atkins diet with it’s heart-stopping estimated 834 mg of cholesterol and 38 g of saturated fat.

    Soybeans, seitan, and hull-less barley (which have twice the fiber and beta-glucans than oats) are mainstays, along with some chia seeds, ground flax, and wheat bran. Plenty of greens, nuts, seeds, avocados, and several servings of fruit complete my diet.

    What’s interesting about including generous amounts of raw nuts, seeds, and avocados in my diet is that they don’t cause me to gain weight when they replace carbs and are very nutritious. More protein can be provided by soy and seitan if I want to cut back on carbs or fats. I’m always analyzing what works and what doesn’t, and thankfully my food cravings are pretty much gone.

    I hope that answered your question!

  8. Gingerann Says:

    Susan, thank you for your detailed account of how you eat lower carb vegan. It was VERY helpful. This is so helpful to those of us who strive to maintain veganism, but just can’t handle all those “healthy carbs” all the politically correct plant based eaters are pushing on us.

    I wish someone(s!) would write a book on this topic. It doesn’t even have to be an Eco Atkins type book, maybe a low glycemic type book for us vegans who just can’t do fat free/low protein. Or maybe a combination of the two.

    I found one new book on amazon titled The Everything Vegan Paleo Cookbook. The author does use some dried fruit and maple syrup (which can easily be substituted for sugar free syrup if one uses that), but other than that, the recipes look quite nice.

    I keep searching amazon, hoping all the wonderful vegan authors out there quit leaving behind those of us with blood sugar issues. And in today’s world, I daresay it’s growing.

  9. Susan Papuga Says:

    Hi Gingerann,
    I’m very glad to hear that this diet plan is useful for you. Low to moderate carb can be done successfully while staying vegan, and a bonus is gained from eating heart-healthy nuts. My cholesterol has never been lower — two weeks ago it was total 134 and HDL 73.

    Some of the vegan cookbooks have good recipes for using nuts in salad dressings and for making nut cheeses and cashew cream. Whenever they include dried fruit like dates or raisins for sweetness, I substitute erythritol or a squirt of liquid stevia. Watch out for the powdered artificial sweeteners which can contain some form of sugar for bulk.

    I’ve started experimenting more with hull-less barley since it’s high fiber content gives it a glycemic index of 22. For breakfast I have some boiled barley kernels plus 5 tablespoons of seeds, maybe a nut butter, and a small amount of fruit. Adding a small serving of barley to other low carb meals during the day takes advantage of the glucose slowing effect of fiber while providing beneficial calories. Type “barley” in the Food Name search box.

    I agree with you that the standard low fat and high carb diet promoted by so many vegan authors leaves us out. We are in dire need of more creative dietary solutions for the growing ranks of those with glucose intolerance.

  10. Gingerann Says:

    Susan, thank you very much for your recommendations. I really appreciate it. Regarding dried fruit, I just learned that dried prunes (not using the newer politically correct term dried PLUMS!!)…has a very low glycemic load. So I’m going to incorporate them into my eating. Here is a link to an excellent article on prunes:

    Yes, hopefully in the next year or so, we’ll see some newer, thoughtful books coming out on how to go vegan without all the blood sugar-provoking carbs. It may very well revolutionize the current vegan movement!

    Take care.

  11. Brandon Becker Says:

    There are some criticisms of the “glycemic index” that are worth considering:

    “Glycemic Index – Not Ready for Prime Time” by John McDougall, MD

    “Why A Food’s Glycemic Index and Glycemic Load Are Only Half The Story” by Vesanto Melina, RD

  12. Jack Norris RD Says:


    I’d be interested to know if you have found that the glycemic index translates into real differences in your blood sugar readings? The argument in the articles Brandon posted–with all due respect to the authors who might be right–strike me as basically saying, “The GI says some processed foods are better than some unprocessed foods, and that can’t be right, so the GI can’t be very useful.” Since you don’t eat processed foods, Sue, I guess your response would only apply to the GI of unprocessed foods (unless you had experimented with it before you stopped eating processed foods).

    I should also point out that the GI of table sugar is not as high as potatoes because table sugar is 50% fructose and 50% glucose, while potatoes are about 100% glucose, and the GI is a measure of blood glucose only.

  13. Russell Long Says:

    Ginger Ann, I’m part of Sue’s group of lean, low-carb pre-diabetics. If you’d like to be in touch with us all, I can do that. My email is


  14. Russell Says:

    Ginger Ann, I can put you in contact with Sue and our group of lean pre-diabetics if you want. I’m at

  15. Susan Papuga Says:

    Good luck with the prunes, Gingerann. I’ve read that 3 a day have been shown to have a positive effect on bone density. Dried apricots also have a lower glycemic index value. It just takes testing your blood glucose to see how much of them you can eat.

  16. Susan Papuga Says:

    I’ve definitely found that foods with both a high glycemic index and a high glycemic load will cause a rapid blood sugar spike, whether the food is processed or not. However, there are many variables which influence a postprandial response, like combinations of different foods, quantity of food eaten, stress, and physical activity. Glycemic load seems to be a better indicator of glucose response, but it isn’t infallible. I ultimately only know through testing and experience what will keep my blood sugars at a normal level.

    Muscle contractions from exercise can also transport glucose into the cells independent of insulin, although they attain a maximal effect when acting together.
    Our group of pre-diabetics have identified a toolbox of techniques for minimizing postprandial glucose, both pre-meal and post-meal. Just before or with a meal with extra carbs, these can be helpful additions: a tablespoon or two of lemon juice or vinegar, a glass of wine, R-alpha lipoic acid, extra fiber from food or PGX, fat and protein foods. Diabetics need to use discretion to avoid going into hypoglycemia. Post-meal, the only remedy to lower a quickly rising glucose level is exercise – at least 15 minutes of a brisk walk or more.!whats-normal-with-motion/ccr6

    Dr Richard Bernstein, a type 1 diabetic for almost 70 years, writes about several drawbacks to the glycemic index in his book, The Diabetes Diet. For him, the total number of carbs in a meal is the primary consideration, because whether a carb is fast acting or slow, it needs insulin to transport that glucose from the blood stream into the cells. Dr Bernstein’s very low carb diet and exercise routine enables him to keep his insulin needs lower and to avoid the complications of diabetes.

    Personally, I can manage my blood sugars with a low-moderate carb diet; it’s all a matter of finding what works for you.

  17. Smurf Says:

    I developed type 2 diabetes on a wholefoods vegan diet (+ high triglycerides, anxety, depression and exhaustion).

    The things that have helped me are:

    1-Switching to Keto (70% fat, about 15% protein, 15% carb)
    2-Intermittent fasting
    3-Potassium Gluconate (I’m now so sick I just can’t eat all those bulky veg. Fruit is out of the question except for a teaspoon as a treat).
    4-No grains or legumes because they massacred my digestion (extremely smelly poo).
    5-Focussing on high glycine foods. I need 5g glycine a day, or else I start slipping back again.

    For me these have been the keys. I know exercise is important, but I’m now too sick to do virtually any. Obviously I hope this will change, but I just wanted people who are also too sick to do much except potter around the house to know that even with ”just” dietary changes and a supplement or two, you can still make a big difference.

  18. Smurf Says:

    P.S Forgot to say, anxiety and depression (+ anger) have been wiped out by high glycine diet. I hope this gaunt, starved look will go too. That also seems to be a glycine deficiency issue.

    I do see it in a lot of struggling vegans [Edited out people Smurf named]. It’s only a guess, but, I’m wondering if they need a little more glycine too?

    From what I read, we can create enough glycine when we are well. But under stress, illness or ageing, we need extra, and that’s where diet can make or break you.

  19. Susan Papuga Says:

    I’ve also switched to a nutritional ketogenic diet with similar ratios – 70% fat, 17% carb, and 13% protein. Avocados are a lifesaver! My diet now is low-GI load veggies which are rich in calcium and potassium all day along with avocados, nuts, seeds, and soy foods for fat and protein. My blood glucose levels are finally normal on a ketogenic diet while I test diabetic in the Glucose Tolerance Test.

    Interesting that Smurf has added potassium gluconate (although you need to be careful with potassium supplements). There’s a study examining the role of potassium in Type 2 diabetes.

  20. Will Says:

    Susan – I need to do what you have done in terms of doing vegan keto. Every day for me is a blood sugar rollercoaster – i gety hypergylcemic if I eat even things like sweet potato and then suffer hypoglycemic episodes about 30/40 minutes later. I know people like McDougall argue that very low fat and high carb whole food plant based can solve it but I’ve tried and tried and I think I have to accept that I have a poor glucose tolerance. I also have huge problems with eating too much at a time, as I don’t get easily satiated at all – which compounds the problem. One thing I am concerned about is the long term health outcomes of ketogenic and especially vegan ketogenic diets. That said I need to change something.

  21. Will Says:

    Susan if you could make a post, a blog, or even a single facebook page just saying how to do what you are doing as a vegan – including all the stuff about how to manage post prandial glucose using the methods you described I would be so grateful and would happily help to manage it. I am one of your clan of lean vegans with a poor glucose tolerance and I know there are more of us. We need you guys help!

  22. Will Says:

    I would also add that this is an utterly fantastic article on these topics and I reccomend the read to anyone and everyone concerned or interested – seriously

  23. Jack Norris RD Says:

    Will—Susan asked me to post her response to you:

    Will, that blood sugar roller coaster is very familiar to me and I was only able to get off it with a very low carb diet. The healthy vegan foods I used to eat, like whole grains, beans, and sweet potatoes, drove my blood sugar waaay too high. I would wonder why I got so sleepy an hour later and became hypoglycemic 3-4 hours later. As a lean diabetic who is insulin sensitive the cause can’t be placed on simply insulin resistance. Listen to your body, test your blood sugars.

    To fill up at meals have you tried more high fiber, low carb foods like avocados, lupini beans, soy beans, hemp, flax, and chia seeds? My favorite breakfast now is chia pudding (1/2c vegan milk, 3T chia, 2T erythritol – all soaked for 20 min) topped with sprouted sunflower and pumpkin seeds. Cooked greens, salads, stir fry veggies, and broccoli slaw can be very filling sprinkled with hemp seeds along with some tofu, tempeh, or seitan. I had to go cold turkey to quit the chips, carby snacks, and grains before those cravings finally disappeared. Nuts provide a nice crunch now instead of chips. This website has some good charts on low carb options.

    There are several Facebook groups who are vegan or vegetarian and keto:
    Vegan Keto Made Simple
    The Vegetarian Low Carb Diabetic Healthy Diet Society

    Good luck!

  24. Incognito Says:

    Could you please post the citations for this:

    “Few studies have been done on lean diabetics and are primarily on Asian populations. Many of these studies have found that lean type-2 diabetics are suffering from a deficiency of the insulin-producing beta cells rather than from insulin resistance.”

    I definitely would like to see that.

  25. Susan Papuga Says:

    The International Diabetes Federation ( had an excellent summary of “The Asian diabetes phenotypes: challenges and opportunities” in their March 2014 edition of Diabetes Voice. The references at the end of the article are good to pursue.

    Diabetes Voice stated:
    “Biologically, there is evidence to show that Asians are more likely to develop diabetes for the same level of body mass index or waist circumference than their Caucasian counterparts. This is thought to be partly due to their propensity to store fat viscerally rather than subcu- taneously, which is not captured in the traditional measures of adiposity such as body mass index and waist circumference. Besides, even in relatively lean subjects, Asians are more insulin resistant than non-Asians with increased concentrations of free fatty acids and inflammatory markers. Further, Asian subjects exhibit higher glucose excursion during oral glucose challenge, suggesting lower beta cell function to overcome insulin resistance than non-Asians.”

    An abstract of the main study is here:

    You might be interested in reading this study about lean diabetes mellitus which suggests that the key defect causing hyperglycemia might be impaired pancreatic insulin secretion. Predisposing factors could be genetics, adverse prenatal or early postnatal nutrition, or lifestyle choices like smoking and alcoholism. More studies are definitely needed!

    I hope this helps.

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