Got questions about navigating life with diabetes? Ask D’Mine! Our weekly advice column, that is, hosted by veteran type 1 and diabetes author Wil Dubois.

This week, Wil tackles a question related to pre-diabetes and how long it’s advisable to wait before starting on medications. Of course, that can be a nuanced question for each person, and we don’t offer individual medical advice here, but read on for general information on this topic that may be appropriate to consider before consulting your doctor.

{Got your own questions? Email us at}


Cathy, pre-diabetic from Kentucky, writes: I am a “pre-diabetic” and I am trying to control my blood glucose with diet and exercise alone. How long can I do so without taking diabetic medication? I have heard Metformin causes gastrointestinal upset, and I want to put off taking insulin as long as possible. 

Wil@Ask D’Mine answers: You can possibly wait for the rest of your life. Possibly for only one more day. More on that in a minute, but first, a word or two in support of medication.

Starting with metformin: While it’s true that every once in a great while you come across a person who genuinely just can’t tolerate the stuff, in most cases the GI distress associated with the med is actually caused by incorrect titration to the suitable working dose. Most people need between 1,000mg and 2,000mg for metformin to be effective, but everyone needs to start at 500mg to let the body get used to it.

The best way to start Met is 500 for one week, then add another 500 the next week, a third 500 the third week, and so on. You wouldn’t believe how many people I’ve heard from who were just given a script for a full dose right out of the gate and ended up in the bathroom for a month.

Oh, and for what it’s worth, metformin is not only remarkably effective—waaaaay more effective than the newer, more expensive meds we see advertised on TV a hundred times a day—and it has an astounding safety profile.

Now, you also said that you want to put off taking insulin as long as possible, but you know what? You already are taking insulin (naturally). As do most living things. Heck, even fish take insulin, so it always amazes me that folks get so wigged out about it.

Insulin = the most natural of all medications.

That said, of course, you’re a long, long way from taking insulin that comes in a bottle. And you might not ever need to. A decade ago, I would not have said that. A decade ago I would have told you that there were two exits on the diabetes express way: insulin or a coffin. 

Harsh? Yeah. But type 2 diabetes is a progressive disease that, at the time, was believed to be so unstoppable as to always end in insulin dependence. But that was then. Things have changed, both in our understanding of diabetes, and in our tools to treat it. 

The first thing we learned was that pre-diabetes is a reversible condition. The recipe is to lose around 10% of your body weight in six months’ time. For some people switching from regular soda to diet soda alone will do the trick. (Although switching to water would be even better for you.) The National Diabetes Prevention Program also advocates for the addition of half an hour of physical activity five days per week. 

So, as you’re a pre-diabetic already watching your diet and doing some exercise, upping your game just a small amount could make the pre-diabetes go away—but it might be better to think about it as being in remission, because any ex-pre-diabetic who becomes a couch potato and packs weight back on will be right back where he or she started.

The second thing to know is that we used to think that once you went from pre-diabetic to full-blown diabetic, it was all over. There was no reversing it. Then gastric bypass surgery became vouge. And doctors started noticing that type 2s who had the surgery were suffering hypoglycemia (low blood sugar) afterwards, if their diabetes meds weren’t reduced or even stopped altogether. Suddenly, gastric bypass was trumpeted as the “cure” to type 2. It turns out that those claims were going a little too far, but it clearly showed that type 2 diabetes wasn’t as carved in stone as we thought it was.

Meanwhile, out in the trenches, I began to see people with full-blown diabetes make such profound lifestyle changes that their blood sugars were well in the normal range with no medications whatsoever. They weren’t even classified as pre-diabetic, but I had to keep them listed as having either diabetes or pre-diabetes as there were no diagnosis codes for “ex-diabetic.” The greater medical community wouldn’t even acknowledge that this was possible.

Until now.

A recent paper published in the prestigious journal The Lancet summarized data from the DiRECT Trial showing that, yes, my gosh, type 2 could be reversed after all. At least it can be in the early years post-diagnosis. Here’s how it works: The researchers believe that the smoking gun for active type 2 diabetes is excess fat entwined around the liver and pancreas, with fat around the liver causing the liver to over-produce glucose. The fat around the pancreas triggers “fat-induced metabolic stress” that puts the beta cells into “survival mode,” causing them to basically go into a non-functioning trance-like state. When this fat was removed from the organs, via “substantial” weight loss, damn if things don’t go back to normal for many folks. The liver settles down and the beta cells wake up. Boom! Normal blood glucose. Sans-medication. Normal blood glucose that stayed that way for many of the study subjects, even two years later, which was this year. 

The DiRECT study team sums up their research by saying: “This major change in our understanding of the underlying mechanisms of disease permits a reassessment of advice for people with type 2 diabetes.”

Ya think? 

So… Not only is pre-diabetes reversible, so too, is full-blown type 2 diabetes. 

Which is what led me to say that you might well be able to go your whole life without meds. And what led me to also offer up the less optimistic option that you might need meds tomorrow? Well, despite the good news, the fact remains that type 2 diabetes, and its associated syndromes, are progressive.

You’re mostly swimming upstream.

That said, I’ll put my money on you being an Olympic Gold Swimmer, Cathy, and I’m rooting for you.

But one last thing on your quest to remain medication-free. I fully agree with the notion that less is more, when it comes to medication, and I fully support your efforts to handle this med-free—up to a point. And that point is an A1C result somewhere north of the mid-sevens. At that point the high blood sugar is more dangerous than the medication.

So, absolutely, fight this as long as you can. But if the diabetes catches up to you, don’t be so stubborn in your desire to avoid medications that you let the diabetes hurt you.


This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. Bottom Line: You still need the guidance and care of a licensed medical professional.