Diabetes Mellitus – Really the Fourth Stage of Insulin Resistance

Diabetes Epidemic & You

I just completed my reading of Dr. Joseph Kraft’s Diabetes Epidemic & You.  This text originally printed in 2008 and was re-published in 2011.  I am not really sure why I have never seen this book until now, but I could not put it down.  I know, I am a real life medical geek.  But seriously, you should only read this book if you are concerned about your health in the future. Otherwise, don’t read it.

For the first time in 15 years, someone has published and validated what I have been seeing clinically in my office throughout my career.  Dr. Kraft is a pathologist that began measuring both glucose and insulin levels through a three hour glucose tolerance blood test at the University of Illinois, St. Joseph Hospital in Chicago.  This test consists of checking blood sugar and insulin in a fasted state, and then drinking a 100 gram glucose load followed by checking blood sugar and insulin at the 30, 60, 120 and 180 minute marks (a total of three hours).

Dr. Kraft completed and recorded this test over a period of almost 30 years on 14,384 patients between 1972 and 1998. His findings are landmark and both confirm and clarify the results that I have seen and suspected for years.

Type II Diabetes: Really Just the Fourth Stage of Diabetes

I am convinced that our problem with treating obesity, diabetes and the diseases of civilization has been that we defined diabetes as a “disease” based on a lab value and a threshold instead of identifying the underlying disease process.  We have been treating the symptoms of the late stage of a disease that started 15 to 20 years before it is ever actually diagnosed. Diabetes is defined as two fasting BS >126, any random blood sugar >200, or a HbA1c >6.5%.  (Interestingly this “disease” has been a moving target.  When I graduated from medical school it was two fasting blood sugars >140 and the test called hemoglobin A1c (HbA1c) that we use today for diagnosis didn’t even exist).  The semantics associated with this problem is that many of us recognize that the disease is not actually diabetes. The disease is (as far as we understand it today) insulin resistance or hyperinsulinemia.   This is where Dr. Kraft’s data is so useful.  Diabetes, as it is defined above, is really the fourth stage of insulin resistance progression over a 15-20 year period and Dr. Kraft’s data presents enormous and very clear evidence to that effect.


When I first entered private practice 15 years ago, I noticed a correlation and a very scary trend that patients would present with symptoms including elevated triglycerides, elevated fasting blood sugar, neuropathy, microalbuminuria, gout, kidney stones, polycystic ovarian disease, coronary artery disease and hypertension that were frequently associated with diabetes 5-15 years before I ever made the diagnosis of diabetes mellitus.  I began doing 2 hour glucose tolerance tests with insulin levels and was shocked to find that 80-85% of those people were actually diabetic or very near diabetic in their numbers. The problem with a 2 hour glucose tolerance test, is that if you are diabetic or pre-diabetic, you feel miserable due to the very profound insulin spike that occurs.  A few patients actually got quite upset with me for ordering the test, both because of how they felt after the test, and the fact that I was the only physician in town ordering it.  So, in an attempt to find an easier way, I found that the use of fasting insulin > 5 nU/dl, triglycerides > 100 mg/dl and small dense LDL particle number > 500 correlated quite closely clinically with those patients that had positive glucose tolerance tests in my office.  There is absolutely no data in the literature about the use of this triangulation, but I found it to be consistent clinically.

I was ecstatic to see that Dr. Kraft plowed through 30 years and over 14,000 patients with an unpleasant glucose tolerance test and provided the data that many of us have had to clinically triangulate.  (I’m a conservative straight white male, but if Dr. Kraft would have been sitting next to me when I finished the book this afternoon, I was so excited that I probably would have kissed him.)

Insulin resistance or hyperinsulinemia (the over production of insulin between 2-10 times the normal amount after eating carbohydrates) is defined as a “syndrome” not a disease.  What Dr. Kraft points out so clearly is that huge spikes in insulin occur at 1-2 hours after ingestion of carbohydrates 15-20 years prior to blood sugar levels falling into the “diabetic range.”   He also demonstrates, consistently, the pattern that occurs in the normal non-insulin resistant patient and in each stage of insulin resistance progression.

The information extrapolated from Dr. Kraft’s research give the following stages:

Stages of Insulin Resistance

Stages of insulin resistance by 3 hr OGTT extrapolated from “Diabetes Epidemic & You”

From the table above, you can see that the current definition of diabetes is actually the fourth and most prolifically damaging stage of diabetes.  From the data gathered in Dr. Kraft’s population, it is apparent that hyperinsulinemia (insulin resistance) is really the underlying disease and that diabetes mellitus type II should be based upon an insulin assay instead of an arbitrary blood sugar number. This would allow us to catch and treat diabetes 10-15 years prior to it’s becoming a problem.  In looking at the percentages of these 14,384 patient, Dr. Kraft’s data also implies that 50-85% of people in the US are hyperinsuliemic, or have diabetes mellitus “in-situ” (1). This means that up to 85% of the population in the U.S. is in the early stages of diabetes and is the reason 2050 projections state that 1 in 3 Americans will be diabetic by 2050 (2).

Insulin resistance is a genetically inherited syndrome, and as demonstrated by the data above has a pattern to its progression.  It is my professional opinion that this “syndrome” was, and actually is, the protective genetic mechanism that protected groups of people and kept them alive during famine or harsh winter when no other method of food preservation was available. It is most likely what kept the Pima Indians of Arizona, and other similar groups, alive while living for hundreds of years in the arid desert. This syndrome didn’t become an issue among these populations until we introduced them to Bisquick and Beer.

The very fascinating and notably exciting aspect of this whole issue is that insulin resistance is made worse by diet and it is completely treatable with diet. This is where the low carbohydrate diet, and even more effective ketogenic diet or lifestyle becomes the powerful tool available.  Simple carbohydrate restriction reverses the insulin spiking and response.  In fact, I witness clinical improvement in the insulin resistance in patients in my office over 18-24 months every day.  You can get a copy of my Ketogenic Diet here in addition to video based low carbohydrate dietary instruction.

Until we are all on the same page and acknowledge that diabetes is really the fourth stage of progression on the insulin resistance slippery slope, confusion and arguments about treatment approaches will continue to be ineffective in reducing the diseases of civilization.


  1. Kraft, JR. Diabetes Epidemic & You: Should Everyone Be Tested? Trafford Publishing, 2008, 2011. p 1-124
  2. Boyle JP et al. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence,  http://www.pophealthmetrics.com/content/8/1/29 Accessed November 22, 2015

17 Comments on “Diabetes Mellitus – Really the Fourth Stage of Insulin Resistance

  1. Have you read Amy Berger’s 8 part analysis of Dr. Kraft’s work at Tuit Nutrition? I think she did a really good job summing it up: http://www.tuitnutrition.com/2015/09/its-the-insulin-1.html.

    The real challenge is getting a health care provider to test INSULIN levels. My HMO won’t by general policy. I don’t understand how they can justify waiting until an individual is in that fourth stage of diabetes before recognizing and treating diabetes–so much damage has already happened (so much for “health maintenance”!). I’m sad when relatives and friends tell me that they have been told they have “pre-diabetes, but it’s ‘OK’ because their doctor is watching it.” UGH! Watching it become full-blown diabetes and doing nothing except giving lip service to lifestyle changes like eat less, move more.

    I really like the term “diabetes in situ”. If that term was used instead of “insulin resistance” or “pre-diabetes” I think the wake-up call would come a lot sooner to people who have it.

  2. I’m wondering if you can help me make a guesstimate of my 2 hr plus 3 hr insulin level. I’ve been a T1D for 50 years and a LCHF dieter for 11 years. When I started eating LCHF, I cut my insulin dose in half. Recently, like the last year or so, my insulin dose has creeped up as well as my weight. So, I’m wondering how far down the T2D path I’ve come.

    I’m 6′ 2″ and weigh about 205 lbs. I take 4.5 units of Lantus in the morning and at bedtime for my basal insulin needs. I take 4 units of regular insulin for each meal. I do snack but rarely enough that it is not worth complicating the calculations by including it. I take 1.5 units of Humalog in the morning and roughly another 1.5 units daily for high blood sugars.

    I would make my own rough guess, but i don’t know how many mgs of insulin are actually in each unit of the various insulins. Is that info available?

    • Nate, that’s a great question for a direct face to face visit requiring actual lab testing. It isn’t possible to guestimate off of your insulin doses. I’d recommend you get this through your doctor through a &2 or 3 hour glucose tolerance test with insulin levels and C-peptide levels. If your doctor doesn’t do this, then I’m happy to help you with it through a Tele-Medicine visit.

  3. I’m wondering if you could help me guesstimate my 2 hr plus 3 hr insulin levels. I’m a T1D and take the following insulins. For my basal needs, I take 4.5 units of Lantus in the morning and then again before bed. I inject 4 units of Regular insulin for each meal. I do snack but rarely enough that it is not worth complicating the calculations by including it. I take 1.5 units of Humalog in the morning and roughly another 1.5 units throughout the day for high blood sugars.

    I would make my own guesstimate but I don’t know the number of mg’s of insulin in each unit of the various types of insulin. Is that info available?

    The reason I’m curious is that my insulin needs have been creeping up over the last year or more, as well as, my weight.

  4. Thanks, and sorry if I’ve commented twice.

    My C-peptide levels may say that I’m still producing some small amount of insulin. Is that right?

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  7. Hey Dr. Nally – I nearly fell out of my chair when I got Kraft’s book early in 2015. Almost like engineering – neatly fell in to my research-based triangulations. I realised that I had to travel to Chicago from the Emerald Isle to get him on film. I suspect that you will enjoy the interview – myself and Jeffry thoroughly did: http://www.thefatemperor.com/blog/2015/9/5/fat-emperor-productions-present-the-kraft-interview-decoding-diabetes



    note: youtube direct link here: https://www.youtube.com/watch?v=w0nV-_ddXoc

  8. Will the Kraft test give accurate results if you are on a high fat, low carbohydrate diet for an extended period of time or could you get a false positive as in the case of a regular OGTT that calls for three days of 150 g carbohydrate intake prior to the test?

    If not, are there any suitable tests that allow dynamic assessment of metabolism while on a high fat, low carbohydrate diet?

    According to Kraft fasting insulin up to 30 mU/ml does not correlate well with IGT or DMGT. Does that mean HOMA-IR is also not a got indicator of insulin resistance?

    PS: I think you mixed up the unit for insulin in the table. Shouldn’t that be mU/ml?

    • Dear 2669 (whoever you are?!),
      The OGTT does NOT require 150g of carbs “for three days” prior to the test. An oral glucose tolerance test is one in which the person presents to the lab fasting, and after the first blood draw is given 75-150g of carbohydrate based on the testing protocol, then blood work is drawn every 30 minutes thereafter for 2-5 hours (again depending on the test protocols). In answer your question, no, you will not get a “false positive.” The whole point of a high fat, low carbohydrate diet is that when it is used for 18-24 months, reversal of the stages of insulin resistance begin to occur. To that point, what I began and still see today is that many of my patients with diabetes, impaired fasting glucose and insulin resistance, over the last 10 years, now have normal OGTT at the 24 month mark after following a ketogenic diet.
      The OGTT is still a suitable “dynamic” test of the metabolism with a ketogenic or low-carb/high-fat diet.
      In regards to your question about HOMA-IR, HOMA-IR is a fasting test. And, it is based upon the assumption that fasting hyperglycemia will always be present when measuring fasting insulin in the pre-diabetic patient. As Dr. Kraft’s data, and what I’ve seen clinically, point out, there is a vast number of patients with Stage I-II insulin resistance that have a normal fasting blood sugar and don’t demonstrate significant fasting insulin elevation until you challenge them with an adequate OGTT. This is the failure of HOMA-IR.
      Lastly, yes. The units on the table are for blood glucose and should be in mU/ml. Thank you. (I wrote the table on my iPad while on a plane after finishing the book and transposed the units.) Thanks. I’ll correct that.
      Good questions.

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