I like to think of myself as an expert who not only talks the talk but also walks the walk, when it comes to a healthy lifestyle. Imagine my shock and disbelief when my HbA1C level (also called A1C) came back at 5.7% which is considered the lower range standard for diagnosing prediabetes.
Living a healthy life
At age 16 I lost about 50 pounds using the Weight Watchers’ program. From that point on, I maintained a healthy, balanced diet, exercised most days of the week. I did struggle with weight gain during each of two pregnancies, despite maintaining my diet and fitness programs throughout the pregnancies. After each birth, I lost the pregnancy weight over the course of six months and resumed my full workout schedule. When I entered perimenopause and then full menopause I did have to re-think my daily calorie count and restructure my workouts to battle weight creep – this despite maintaining significant muscle mass with weight training. Again, I faced the challenges head on and re-configured my new diet and exercise regimen. Mostly I reduced my grain carbohydrate portions and added new challenges to my weekly workout routine. Those techniques helped me to stabilize my weight.
I have been hypothyroid since the birth of my first child and I take 100 micrograms of Synthroid to treat it. Until this year, my blood work has been stellar. In fact, my HDL or good cholesterol is quite high, sort of “off the charts,” likely due to my commitment to daily exercise for so many years. The only glaring out-of-range number this year was my A1C level (an average of two to three months of blood sugar levels). It was 5.7%. My fasting blood sugar was well within the normal range. What was going on?
How is prediabetes or diabetes diagnosed?
It should be noted that the 5.7% A1C measurement is the American Diabetes Associations’ lower limit for a diagnosis of prediabetes. The actual range used is 5.7% to 6.4% for diagnosing prediabetes. Diabetes is usually diagnosed when the A1C is 6.5% or higher. However, it’s not just the A1C that determines a diagnosis of prediabetes or diabetes. The patient also needs to undergo a fasting blood sugar and an oral glucose tolerance test (GTT). Results from those tests coupled with an abnormal A1C reading are used to determine a confirmed diagnosis of prediabetes or diabetes.
I can tell you after speaking to a number of physicians, that HMOs (and Medicare) are using 6.5% to 7.0% or even 7.2 % for the definitive prediabetes diagnosis, and a reading of over 7.3% for diabetes. I cannot fathom using those numbers given the ADA guidelines and the science that backed those guideline determinations. I would not apply those higher ranges to myself.
Fasting blood sugar and OGTT
The fasting blood sugar is performed after you have not had any food or drink for a minimum of eight hours. Some doctors actually prefer a twelve hour fast. A normal blood sugar reading is below 100 mg/dl. A diagnosis of prediabetes is made when the fasting blood sugar is between 100 mg/dl to 125 mg/dl. Diabetes is diagnosed when the fasting blood sugar is 125 mg/dl or higher.
The oral glucose tolerance test or OGTT checks a fasting or baseline blood sugar test and then another blood sugar level traditionally two hours after drinking a very sweet (300 calorie) drink. Some doctors also like to do a one hour and three hour blood sugar level as well. A normal OGTT two hour blood sugar level is less than 140 mg/dl. Prediabetes is diagnosed within the range of 140 mg/dl – 199 mg/dl. Diabetes is diagnosed when blood sugar at the two hour mark is above 200 mg/dl.
Endocrinologists may also request that you have insulin measurements taken along with your fasting blood sugar and the OGTT. That’s because you may have impaired insulin levels, due to a weakened or an over-worked pancreas. It is also conceivable that if you are obese, your pancreas may be secreting adequate insulin, but your body may be exhibiting a lack of response to the insulin or insulin resistance. Knowing the insulin “picture” can help to form both a diagnosis and a treatment plan.
Other tests that may have some merit
I did seek a second opinion given my A1C level and the endocrinologist recommended that I have the fasting blood sugar, as well as OGTT with insulin levels. He also recommended a series of autoimmune tests, given that I had hypothyroidism (he wanted to make sure that there was not an autoimmune component to that disease that could impact my blood sugar) and he also wanted to make sure that I had not developed an autoimmune process working to damage my pancreas.
My fasting blood sugar was 80 mg/dl – normal
My OGTT was 60 mg/dl – which showed an excellent insulin response at two hours to the sugary drink.
My insulin levels, both fasting and two hours post OGTT were both normal.
My autoimmune panels were all negative.
Interpreting the results
So what now? I could not ignore the elevated A1C level, especially since I found out that Paula Deen’s level was lower than mine (OK, she is on medications right now and has lost quite a bit of weight, but still). The endocrinologist perspective was that I should accept the fact that this is a situation that would simply have “to be monitored.” He recommended a yearly A1C, fasting blood sugar and OGTT to make sure that this one number that is a bit off just remains an unexplained anomaly and not a situation that is signaling a slow move towards prediabetes. He did review my healthy diet and suggested that I simply remain committed to my vigilance. I do allow myself some dark chocolate nightly and he suggested that I try to limit indulgences to a few times a week (a bummer but doable). He certainly felt that I was maximizing my daily exercise and appreciated that I also tried to add movement throughout my day – all exemplary efforts as far as he was concerned.
He did relay that he wished all his patients took their numbers as seriously as I did and he also shared how many of his patients, even those with frank diabetes, seemed unable to embrace healthy lifestyle change with the kind of fervor that I exhibited some 40 years ago. Most, he said, fight the process and deal in denial. We both agreed that lifestyle change can be daunting, but we also acknowledged that it needs to be regarded like any other therapy - sometimes unpleasant, but necessary and with guaranteed positive payoffs. We agreed that personalization to the process of change is necessary.
How you should apply this to your life
Prediabetes is most often an asymptomatic disease. Diabetes can also be present with few or no symptoms until significant damage, for example, a silent heart attack or serious circulatory changes, occur. It is fortunate that modern medicine provides simple blood tests to identify prediabetes or diabetes, well before they entrench. If you are overweight or you have been diagnosed with obesity, or if you have a family history of type 2 diabetes, it is likely that you have a higher risk of developing prediabetes or diabetes. A relatively simple series of blood tests can confirm or rule out the diagnosis. Lifestyle change can often modify your risk or limit the disease.
Let my story inspire you to get a checkup. Let my journey also nudge you to consider some simple initial lifestyle changes. Consider the Mediterranean Diet as a good template to follow and commit to beginning an exercise program. These changes can help to lower your risk of developing prediabetes.
Sources: American Diabetes Association
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