A1c standards are wrong, IMO

Patrick Krupka, DC, CFMP:

I want to talk for a minute about hemoglobin A1c. It's a kind of three month average test for, or how frequently and how high you would spike your blood sugar. We'll talk more about that in a minute. So I was dealing with a patient recently who brought lab work in from her other practitioner and said, "Oh, doc, I think it's really good news. Doctor, my other doctor said my hemoglobin A1c," or she just called it, "My A1C, came back great, he said. So I think what we're doing is working. I'm doing better." Or her hemoglobin A1c had come down from, I think it was eight something, down to 7.2, 7.1, something like that, still abnormal.

And her other doctor said, "We're doing great. We're right on target. This is where we want you to be. Don't change anything. This is perfect." Well, I had to kind of explain to her that it's not perfect at all. It's what's considered good management of a type 2 diabetic to be kind of in the upper sixes. Some doctors are okay with low sevens, but what's considered normal for someone who's not a type 2 diabetic is under 5.7. That's kind of the sweet spot. Many doctors, especially functional medicine doctors, aim for kind of the low fives for really good management. So let me pause this discussion for just a second and tell you what hemoglobin A1c measures so that you understand the test I'm talking about. If you're not a type 2 diabetic, and this hasn't been a focus of yours, you may have no idea what I'm talking about.

So hemoglobin is part of a red blood cell. Red blood cells carry oxygen around our body. If you didn't have enough of them or if they were really crummy quality, that's where the term anemia would start to be used. So we're talking about the active component of the red blood cells, the part of the red blood cell that actually allows you to carry oxygen. That's the hemoglobin. So hemoglobin A1c is also called glycosylated hemoglobin. Basically, think of taking the hemoglobin and dunking it in sugar like a glazed donut. Right? Now it's sugar damaged hemoglobin. So what the A1C, or hemoglobin A1c tells us is what percentage of your red blood cells are glazed donuts are sugar damaged? And the threshold is basically anything below 5.7 and you have a decreased risk of becoming a type 2 diabetic.

Your insulin resistance is not all that substantial. 5.7 to about six, you are at an increase. Well, 5.7 to about six, they're going to say you're kind of at an average American risk. That's not great, but you're not on the cusp of becoming a type 2 diabetic yet. Between six and about 6.4, you're at high risk of becoming a type 2 diabetic. The process has definitely been initiated. And then above 6.4, you're likely going to qualify for a diagnosis as an insulin or as an insulin resistant patient or a type 2 diabetic, depending on a couple of other parameters. So that's kind of the range that we're looking at. And then good management of a type 2 diabetic is in the upper sixes and low sevens. That's the way the industry sees it pretty much. So this patient is presenting to me with an A1C that has come down substantially with what we're doing, and that's all on her. She's done a lot of really hard work to get to that point.

So it's a milestone on our journey, but we're not done. The medical community generally says, "Hey, that's great management. You're a type 2 diabetic. Don't expect it to ever get much better than that. You're doing fine." My point is basically why don't we hold type 2 diabetics to the same standard that we hold everybody else? Why wouldn't I want that patient to have a hemoglobin A1c below 5.7, or at least in that 5.7 to 6.4 range where there's a risk of becoming a type 2 diabetic, but you're not really there yet. It would make sense that that would be a better place for her to be as we're working with her. The goal, I don't think, should be to be middle of the road for a type 2 diabetic. You should want to work yourself right out of being a type 2 diabetic and not qualify for that diagnosis anymore.

In, I would say, upwards of 90% of the cases of type 2 diabetes it is a lifestyle disease. If you change what you're doing significantly enough, what you're eating, how you're living, how you're sleeping, there are several different components of this. But if you change the way you are living, you should be able to undo that damage and no longer be a type 2 diabetic, again in about 90% of the cases. So I just want to make the point that if you're being told that you're hemoglobin A1c in the low sevens or high sixes is good management from a functional medicine perspective, I think you'll be hard pressed to find many doctors that would agree with that. From an allopathic perspective, they tend to be okay with that. I don't know if it's because you have to keep taking the medication at that point.

You retain your diagnosis, you got to come in for follow-ups and all of that. I don't know if it's keeping you in the system. I don't know if they're not allowed to give the right kind of lifestyle advice. I certainly know that the certified diabetic educators that many people are sent to when they get their diagnosis really are, I mean, they're not helping people figure out how to completely undo this. They're helping people figure out how to live within that diagnosis. But in many cases, they're not even telling them that this can be reversible in a large number of cases. This is not, and I'm not talking about curing type 2 diabetes. This is getting off into a whole nother discussion. But type 2 diabetes is an adaptation to a situation you've put your body in. I don't even consider it really a disease.

I don't know, maybe by the technical term, dis-ease, like your body's not functioning the way it's supposed to, but it's if I stopped breathing I would pass out. Passing out's not a disease. It's a known consequence of the behavior of not breathing. If I took way too much caffeine, my blood pressure would go up. That's not a disease. That's a known impact of taking that much caffeine. So with type 2 diabetes, between inflammatory seed oils, and having an elevated blood sugar on a regular basis, like eating foods that really drive your blood sugar up, having lots of insulin in the system, over time that situation, your body adapts to it by becoming resistant to that insulin. And if that goes far enough, then your A1C gets high enough and you get diagnosed as a type 2 diabetic. If you were to get off the seed oils, get off the sugars, move around, exercise, change your situation, then over time your body just undoes that adaptation and your blood work no longer puts you in qualification for that diagnosis.

It's not a cure, it's not a disease per se, it's just a predictable outcome of a situation you put your body in. So it's a different way of looking at it. I'm fully aware that your family practice doctor, your endocrinologist probably would not describe it that way. They would say, "It's just you've been dealt a bad deck of cards and it was your destiny. Eventually it was going to happen. You're now a type 2 diabetic. You've got to live within this and take your medication and you'll be a type 2 diabetic the rest of your life." I mean, statistically a lot of people are, but I think it's because we don't treat them properly. So anyway, if it's a problem you're dealing with, let me know. If this is stimulated questions in you like, "I didn't know this could be undone." If you want to send this to someone that you understand is not aware that in many cases you can just undo this adaptation, you can stop the behavior that's putting you in this situation.

But now understanding that, let me go back to what I started with, that's why I'm not normally satisfied with a mediocre A1C. With an A1C that keeps you in that type 2 diabetes range, but it's stable and it's kind of in the lower end of that. I mean, that's better than being out of control. But the goal should be to no longer be a type 2 diabetic, to no longer elicit that adaptation in your body, because then all of the risks that go along with being a type 2 diabetic, the nerve damage, the eye damage, the damage to the kidneys, the blood pressure issues, the weight issues, all of those things just pretty much tend to resolve when you no longer meet those requirements. And I think that should be the goal for those patients.

So anyway, that was a little longer than I intended. I was just going to quickly run through the A1C issue, but hopefully that helps you out and that makes some things a little bit more clear. If you find yourself in that situation, give us a shout. We'll be happy to help you out. Okay. Have a good one.


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