If there was a blood test that could give you valuable information about a major, yet reversible risk factor for Alzheimer’s disease and age related dementia, would you want to take it? What if that same blood test could also give you information about your risk of heart disease, high blood pressure, diabetes, vision loss, cancer and how fast you can expect your body to age? What if the test was really cheap?
Now, what if you knew that what you were going to have to do to reverse your risk of all these conditions was going to be personally challenging, maybe even really hard, would you still want to take the test?
Something to think about, isn’t it?
The test I’m talking about does exist. It’s a simple little test that’s run all the time. It’s full implications are rarely considered, however.
The test
It’s called “hemoglobin A1c” and is sometimes referred to simply as the “A1c” test. In essence, it measures the amount of sugar that has become stuck to the hemoglobin in your red blood cells (hemoglobin is the component in blood that carries oxygen). Because red blood cells live for about 3 to 4 months, the test is usually used to estimate an “average blood sugar” for the previous 3 months. The more sugar floating around in your blood on a daily basis, the higher you A1c value will be.
In conventional medicine the test is used to diagnose and monitor treatment goals for diabetics. The implications of a person’s A1c value run much deeper, however. Sugar within the body doesn’t just stick to hemoglobin. It sticks to many tissues that are made of proteins and fats (this accounts for most tissues in your body by the way) and can bind directly to DNA. The compounds formed by this process are called advanced glycation end products or “AGEs” for short. Clearly, the person who named these compounds was thinking about the big picture because many of the adverse health effects they cause are generally regarded as being a “normal” or “inevitable” part of aging.
As a society, we expect to get sick as we get older. I can’t count the number of times I’ve heard someone say “Getting old isn’t for the faint of heart” or some similar comment. But to what degree are the “ravages of time” truly inevitable as we age, and to what degree are age related illnesses really just a consequence of unhealthy personal and cultural habits? As it turns out a simple little thing like our average blood sugar and the level of advanced glycation end products (AGEs) produced by it seems to be a significant factor in most of the common age related illnesses we dread.
Once AGESs are formed, they cause a whole host of adverse effects in the body, including inflammation, oxidative damage (tissue damage at the molecular level), activation of immune responses against effected tissues and disruption of DNA expression.
For example, it is well established that when AGEs form on the interior surfaces of blood vessels, they promote the development of atherosclerotic plaques. This leads to diminished blood flow to critical tissues and organs such as the heart, brain and kidneys, and puts us at risk for heart attacks, strokes and other blood vessel diseases.
AGEs also damage nerve cells, both peripherally and within the brain and are hence a significant cause of Alzheimer’s disease and other forms of dementia, not to mention the painful neuropathies that many diabetics and older persons suffer from.
One of the hallmarks of aging is a degradation in the function of connective tissue. AGEs damage collagen and other forms of connective tissue leading to many visible and invisible signs of aging such as wrinkles and loss of elasticity in the skin.
Now, at this point you might be thinking “Wait a minute, the body can’t live without a certain amount of sugar in the blood so doesn’t that make damage from AGEs inevitable?”
A matter of balance
As with many things in life, it’s a matter of balance. It’s true that too little sugar in the blood can lead to harmful, even fatal consequences. High blood sugar, on the other hand, creates excessive formation of AGEs and overwhelms the body’s ability to repair itself and maintain health.
As long as the body can repair the amount of damage being done so that all organs and tissues continue to be healthy and function optimally, AGEs are not a problem.
If the amount of AGEs being formed and the damage done by them exceeds the body’s reparative capacity then the degree of damage builds up over time until disease develops.
AGEs were once considered to be permanent once formed. It is now known, however, that they are cleared slowly from the body by two mechanisms:
- When dying cells are broken down and eliminated from the body, the AGEs associated with them are also eliminated. If blood sugar levels improve, then new cells will have a lower level of AGEs and thus be healthier and function better than their predecessors.
- The body produces enzymes that actually remove AGEs from glycated tissues. This means that long living cells, such as neurons and connective tissue cells can heal, so long as the rate at which new AGEs are formed does not exceed the rate at which the body can clear them.
This means that if we improve our blood sugar levels, the degree of damage from glycation in our bodies will also go down over time. In a very real sense, this means we can actually reverse our level of physiological aging to a degree.
How high is too high?
The target goal for hemoglobin A1c that conventional doctors are currently trying to reach with their diabetic patients is 7.0. This represents an average blood sugar of about 154 (diabetes is diagnosed when A1c levels exceed 6.4). A hemoglobin A1c of 5.6 or less is considered normal and therefore theoretically should not present any health risk. An A1c of 5.6 equates to an average blood sugar of about 115.
So, how safe is 115?
A recent study in the New England Journal of Medicine involving over 2000 elderly participants found that individuals with average blood sugars of 115 developed dementia at an 18% higher rate than those with an average blood sugar of 100. In other words, an average blood sugar that is at the high end of “normal” is actually disease causing.
Now, if a drug was developed that could reduce your risk of dementia by almost 20% it would be a blockbuster. You would be seeing ads for it everywhere. Guess what, all you have to do is lower your average blood sugar to 100!
Furthermore, it is well established that as hemoglobin A1c levels increase, so does the incidence of coronary artery disease (the kind of heart disease that causes heart attacks). In a recent review of 20 studies examining the relationship between hemoglobin A1c levels and deaths from coronary artery disease it was found that non diabetic patients with elevated A1c levels (i.e. 5.7 to 6.4 or average blood sugar levels between 115 and 135) had an 85% increased risk of mortality from their disease. This is an astounding effect!
A drug that could decrease your risk of death from coronary artery disease by 85% would be heralded as a major breakthrough in medicine! . . . Um . . . you can do that without a drug, just by lowering your A1c to below 5.7 (or your average blood sugar below 115).
So how high is too high? It seems to me that if increasing your average blood sugar from 100 to 115 increases your risk of dementia by almost 20%, then any level of increase above optimum is inducing some level of damage. Because glycation occurs in many tissues, it is likely that damage is occurring in other organs as well at even modest increases above optimum. All of this suggests to me that if we want to maintain a high level of health as we age we need to be serious about bringing our average blood sugar levels to optimum and keeping them there.
What is optimum?
I consider an optimum average blood sugar to be right around 100. Fluctuation over the course of the day should be relatively modest, from about 80 at the low end to about 120 at the high end. These are not recommendations made by an advisory group within conventional medicine, they are the numbers that I have found to be clinically relevant in my practice.
Blood sugar values between 80 and 120 provide optimum levels of fuel for the brain and body tissues and almost never result in blood sugar related symptoms. Values below 80 can leave the brain with inadequate fuel and lead to fatigue, foggy thinking, irritability and tremor. I have also found that truly healthy individuals who are physically well conditioned rarely have blood sugar readings above 120, even after a high carbohydrate meal. This translates to an average blood sugar of about 100 or a hemoglobin A1c of about 5.0. I tell my patients that I want to see their A1c between 4.8 and 5.2.
The view from 30,000 feet
Obviously a major point of this article is that chronically high blood sugars have a dramatic impact on our health as we age and that this fact is grossly under-appreciated. As a society we are sick, and the older we get, the sicker we become. We fear the diseases of old age: cancer, heart disease, diabetes and dementia. We live in a society where the attitude is that it is somehow a part of the natural order of things that many of us will get these diseases and that it is really a matter of chance wether or not we are among the “lucky” or “unlucky”. Of course, luck has very little to do with it.
In the last century we have made dramatic changes to the way we live. As an example, our sugar consumption has more than quadrupled over that period from about 30 lbs per person/year to 130 lbs per person/year. In addition, we have increased our consumption of refined grain products and dramatically decreased our levels of physical activity. (Other aspects of these changes have been detailed in other blog posts).
The point is, while we certainly can’t account for, and don’t have control over all causes of the “diseases of aging”, we do know enough to greatly reduce our risk of these conditions and dramatically enhance our wellbeing along the way.
Good news / bad news
The good news:
It is well within the range of achievability for virtually everyone with high average blood sugars to restore them to optimum values (even diabetics).
The bad news:
It largely has to do with how we eat and how we live.
Making changes
First of all, it’s important to know where you stand. If you are over the age of 45, I would recommend getting a hemoglobin A1c test, regardless of what past testing has shown and regardless of what your conventional doctor has told you. It’s a simple and inexpensive test that will give you extremely valuable information about your health trajectory.
If you know now (or discover later) that you do have a high A1c value then the essentials of change are this: cut out all concentrated sugars (including fruit juices); reduce or eliminate refined flour products such as bread, pastries and pasta; focus on whole, unrefined starches like brown rice, quinoa and legumes (beans, peas, lentils); eat lots of fresh, non-starchy vegetables; eat adequate high quality protein every day and finally, increase your physical activity as much as you can.
The degree to which you will need to change depends on where you are starting from. Also, the more you exercise, the fewer dietary changes you will need to make, however, everyone is different. Follow up A1c tests will tell you how you are doing. You will probably be more successful if you work with a knowledgeable health care practitioner.
I am refraining from going into great detail about diet here, partially because people have quite variable needs, but also because I have written about diet quite a bit elsewhere. For further help with making healthy dietary changes please see my posts on the Universal Diet Principles.
A final but important note
Believe me, I understand the pleasures of chocolate chip cookies and Frappuccinos . . . but let’s face it: we eat too much sugar and refined carbohydrates (flour based foods). We all know we eat too many of these foods, but, darn it, they’re comforting, convenient and they taste sooooo good!
Frankly I think changing the diet is one of the hardest things for patients to do. Our diet is part of what defines us: the foods of our culture, the foods of our childhood, those special foods we have discovered that give us a little something special (did I hear somebody say chocolate?). So much is wrapped up in how we eat.
Central to all of this is that we tend to gravitate towards foods that buffer the effects of stress and soothe us emotionally. More than anything, this may be what makes it hard for us to change our dietary habits. I’m afraid steamed broccoli just isn’t much of a comfort food. Our need to buffer our stress and comfort ourselves is real and legitimate. The thing is, if we’re doing it by eating health damaging foods we’re essentially shooting ourselves in the foot by scratching our itch with a loaded pistol.
We need to find healthy ways to manage our stress and provide enjoyment in our lives. When I ask patients to make dietary changes, I often also ask them to identify alternate ways to meet the needs they were meeting with food and then prescribe those activities as part of their treatment plan.
We are whole, integrated beings. We need to meet all of our genuine needs to be truly healthy but we are only really meeting them if we do it in a way that isn’t damaging some other aspect of our health. You can think of dietary and lifestyle changes as a necessary but unpleasant task, or you can think of them as an adventure. If you approach them as an adventure they will be just that. I think you deserve to be truly healthy and to stay healthy as you get older. You deserve to live in a body that is a comfortable and pleasant place. Most importantly, you deserve to be happy. That can only happen if you take all of your needs seriously.
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Bravo!
Very, very informative. I suspected as much. Thanks for the numbers.
On my last blood test my fasting glucose was 83 and my A1C was 5.7% – is there a discordance?
No. A fasting blood glucose represents a moment in time. A hemoglobin A1c represents about a 3 month average of blood sugar levels. You can have normal or even low blood glucose readings and have a high average blood sugar.
Funnily enough, my A1C was 5.1% , yet I have postprandial spikes of over 200 (very high carb).
I have reduced my carb to the point of almost eliminating all of them, but my point was – even with a perfectly “normal” A1C you can have high, dangerous postprandials that are evened out by when the 2nd phase of Insulin response kicks in properly (which happens in my case around the 3rd hour).
Because as you should know, glycated hemoglobin only reflects glucose numbers that persist longer than 3 to 4 hours…
So in the case of early beta cell loss (high postprandials are the first sign of a defective metabolism), a1c doesn’t mean s……quat.
It is true, as Dr. Sandro mentioned, Ha1C is an average number, so it can still be normal, even if there are wild swings between low and high blood sugar – which can still be very uncomfortable at best and dangerous at worst. Thanks for adding this.
I’ve always been healthy. I am in my 60’s. Loosing weight, slowly.
The past 6 months my Glucose has dropped every 6 months from 104 to 100 to now 96.
My Nurse Practitioner says my average Glucose is 126. OUCH! I am too Health
conscious for this !!!
My Total Cholesterol dropped every 6 months.
My LDL Cholesterol dropped every 6 months.
My A1c was 5.9. Now 6.0… again since loosing. SO frustrating. I know I do comfort foods due to stress. Just can’t do that. All numbers are dropping. I feel my A1c needs to be taken out for much more exercise.
My triglyceride is 88, but was 78 just 6 months ago and this was when I started cutting way back on bad Carbohydrates. Little potatoes, no Rice, Pasta, or any sweet bread type things. Eat Protein, Veggies, fresh Fruits, Cereal and Toast at times.
I feel I just have to be VERY careful with my sporadic sugar consumption…grocery store, potluck, etc.
I also know I need to exercise more. Husband and I are Square Dancers, but that is not enough.
So, what is the best way to get my A1c Down? Is lots of walking, etc. the main answer?that is what I see I need to do more of Big Time!
Thanks for reading Dr. Sandro…..
Hi Patricia,
The relationship between individual blood sugar readings and hemoglobin A1c can be confusing. Blood sugar represents a moment in time, A1c represents your average blood sugar over a period of about 3 months. I am assuming you are measuring fasting blood sugar. A more revealing approach would be to measure your blood sugar about 1/2 hour after eating “comfort foods”. You will probably find that your sugar is much higher. In general, if you haven’t been having success normalizing your A1c on your own I would recommend finding a naturopath or other alternative health practitioner in your area who has had success with other patients in reversing insulin resistance. It can be difficult to do and often takes more of an effort than we think it will. If you can’t find anyone in your area to work with I would recommend reading “Dr. Bernstein’s Diabetes Solution”. It’s written for diabetics, but the principles for Type II diabetics apply to those with insulin resistance as well.
Thank you for this informative article. Type II diabetes runs in my family big time. My last A1c number was 7.9. Previous to that was 9. I started 18 days ago on a strict regime. I have cut out all sugars and sweeteners. I have cut out all grains. I have cut out all dairy. I eat lean protein, non starchy vegetables and healthy fats. No caffeine. I am exercising daily. I was previously on glipizide/metformin. I have stopped me meds. My fasting glucose is still elevated at an average of 130 since I started, but still lower than my previous fasting glucose with medication but not the strict regime. I’m aiming to make this a way of life and I’m anxious to see what my A1c is in 3 months. I’m also hoping that my body continues to heal. I would love to see my glucose numbers drop lower into the ranges you recommend as optimal. Stress is a factor in my life that I have not yet found a completely effective action plan for. Working on it !!! Thanks again. Food is medicine.
Congratulations on taking your health into your own hands. Remember to be patient. It will take time and you will experience plateaus and setbacks. But, if you stick with it you will succeed. Reducing stress is also important since stress hormones keep blood sugar levels high. There are many ways to address stress so keep looking until you find something that works for you.
So My A1C is 5.2%, Estimated Average Glucose 103 mg/dL
I know I’m in the range you want your patients to shoot for, but I’m here to tell you that your article has helped me to see more succinctly *WHY* I need to work on my troubles with comfort foods (specifically chocolate and binge eating chocolate as a comfort). I’m already working on exercise, etc, but I balked at changing my diet.
I found your article by searching my results for the A1C because I do better when I understand what a test does, what it means, etc and I prefer to try to understand as much as I can rather than rely simply on the doctors because I have to understand why or I won’t be motivated.
The empathy and the wording in your article along with the facts you carefully represented helped me a lot to feel more motivated to make changes.
Thank you.
Jessica, thanks for your comment. It’s nice to hear that people are benefitting from these articles.
Any thoughts about decreasing my A1C without losing weight?
Female, early 60s
Has autoimmune health disorder and being treated for it over 12 months now.
Has Osteoporosis in spine and was treated 12 months with injection drug.
Weight is presently in the low 120 pounds.
A1C is 5.6 as of now.
My first recommendation, given all that you have going on with your health, is to work with a good alternative health care provider. Most naturopathic doctors are very well equipped to help you with everything you are mentioning. On a very general note, if one maintains sufficient calorie, protein and trace nutrient intake they should be able to maintain lean body mass even if they restrict carbohydrates. However, you may have special circumstances due to your other health conditions and I would highly recommend working with a medical professional.
Thanks!
Thank you for the informative article. My fasting glucose has hovered around 100 for years. Just in the last 2 years it has gone up steadily to 114 now. My doctor had me have an A1C that came back 5.6. She has started me on Metformin. I’m not much of a pill taker, but willing to give it a try. I’m 65 and my dad developed type 11 at about my age. I eat pretty healthy. Whole grains, not much sugar. Lots of Vegis and protein. I do have a terrible sweet tooth for chocolate, I like it only dark. I get moderate exercise. I guess my question is, what do you think of this drug? I also need to lose 20 lbs and in spite of everything I can’t seem to lose more than 5 and that comes back easily.
This is an amazingly well written, packed with facts, down to the core article. I’m 50 years old, 45 lbs overweight and I just found out my A1c test results are 5.2. So I was told I do not have diabetes, which is a relief. But I’m still feeling ill everyday. Already struggling with an auto-immune illness that Dr.’s have not actually pinpointed, but agree I have, I never thought sugar or glucose had much to do with it. I kept focusing on gluten, fatty meat and oils as the culprits. While I am not one for sweets, I am a rather new vegan who eats a lot of potatoes, beans and corn. I always thought that was ok and healthy. But because I have not been losing weight, I began to look into diabetes (which both of my parents and most of my siblings have). I knew that these high carb foods will not help me lose weight (white bread, pizza bread, corn muffins, white rice, white sugar, brown sugar, honey, pasta-al types) but I never thought the sugar in these foods would affect my body’s immune response, the elasticity of my skin or my heart and kidneys. I didn’t know that it would inflame my muscles, and affect my nerves. So even if I was recently told I am not a diabetic, I know that I am not in good health, per my excess weight, chronic low grade fevers and over all fatigue and muscle and joint pain. This article has helped me see that I need to make further changes to my already modified diet. Sugar in all forms will be at an all time check point in my house going forward. While I will not say that I will never eat white potatoes & high sugar fruits, I will say I will eat a lot less of them. They will be my cheat foods like a donut is to other people. And I will increase my intake of broccoli, mushrooms & lentils…to name a few! I thank the Dr. who wrote this article. You have given me hope to rid myself of this auto immune illness that has plagues me for about 6 years now. Up with the exercise & down with the sugar consumption!
Dear Dr.Sandro
From Mallorca Spain. On result of a high A1C 8.1% well doubt remains, it showed 128mg/dl average sugars, appreciating they are average! yet seems 8.1% is approx 183mg/dl? the 128mg/dl seems discordant numbers ON THE AIC as this is around
7.1%, I feel a lab typographical error is in place here, for sure there is area of doubt question.
Changed lifestyle, although organic healthy foods eaten and surfing daily, I changed further.
12 months have not eaten bread pasta, potatoes or rice, substituting for far more delicious foods, cauliflour grated as rice, sunflower seed crackers home made instead of bread. Exercised more. min 5lkm walk to 9 klm walk a day and goal of 10,000 steps a day, intermittent fasting 3 mornings a week, i.e. miss breakfast three days,and do a 24 hour fast not eating breakfast or lunch one day a week. Low Carb eating plan, only 3 meals per day, portion size the same as airline meals, and NO SNACKING during the day.
I have found that intermittent fasting the day before a fasting real blood finger test, shows much lower figures also.
RESULT.
Lost 18 kilos in 10 months
in four months reversed lowered A1C by 23% to 6.6%
The 6.6%with what seems a further discordant number on A1C average sugar showing146mg/dl and should be around 141mg/dl? although this is viewed diabetic Spain, if I jump on the plane back home to New Zealand, as their cut off for A1C is 6.7% I am viewed as Pre Diabetic, vast difference between the label of Diabetic and Pre.
My question is due to confusion why do the cut offs for Real Blood finger testing at the time and A1C differ worldwide, the fact i am diabetic in Spain just because of ONE number Cut off spain 6.5% my A1C is 6.6% surely lab inaccuracies of up to 15% should be taken into consideration and age, yet New Zealand I fall under Pre diabetic.
Bascially its Spain v. New Zealand, and I the recipient of the A1C seems where one resides in the world time of diagnosis can be both frightening and concerning to say the very least.
Surely, one cut off should be used worldwide, and with 100% medical and clinical support to that chosen figure as i understand, the current cut offs that keep lessening, possible for business and gov pressure, are ARBITRARY, at whim random, as acknowledged by the so called conventional experts, i.e. the figure they decide upon and or change, is recommended only.
So the question is at the end of the day does anyone really know 100% what the cut off level is to base a diagnosis, at the moment, I do not think there is one?
Until the arbitrary cut offs change, I shall opt to view myself as Pre Diabetic and not Diabetic, considering I have no classic symptoms, and my finger testing x 12months had been although initially high normal, now low normal fasting 93mg/dl 2 hr after eat 88mg/dl, random anytime after breakfast 95mg/dl my numbers have NEVER been over the cross over levels in spain or based on UK cut offs.
is there any hope that the world shall follow strict criterial cut off number or will it always be varied and arbitrary set numbers?
Yours faithfully
J.Douglas
You are absolutely right. Cut off points for prediabetes and diabetes are somewhat arbitrary and the estimates of average glucose levels that are given with hemoglobin A1c results are just that, estimates. Diabetes used to be diagnosed in the US with an A1c of 6.0, it is now diagnosed at 6.4. Research suggests that we begin having adverse health effects when our hemoglobin A1c reaches 5.4 or higher. The higher the number, the more severe the adverse effects.
Hello, I practice the vegan lifestyle, I am not vegan. I do eat meat 3 days a month. My glucose a few days ago from my doctor was 83, so I’m wondering why my A1C is still 5.7 same as March this year. My glucose in March was 95. Any idea what’s going on?
Hi Annette,
There is no direct correlation between a serum glucose and a hemoglobin A1c. Your serum glucose was probably a “fasting” glucose. For non-diabetics, that is usually when their blood sugar is at its lowest. A serum glucose records your blood sugar level at a specific moment in time. Hemoglobin A1c, on the other hand, is a measurement of your average blood sugar over about a 3 month period. You might be having high serum glucose levels after meals. If so, you won’t see that on a fasting glucose test but it will show up on a hemoglobin A1c.
This is the best info I have had!!! Thank you so much
Probably the most succinct explanation of relative A1C measurements and the dangers of having too high a reading. Thank you!
It isn’t always as simple as just cleaning up your diet. I work harder than most people on my diet and physical activity – I eat super healthy (mostly unprocessed “clean” diet), limit carbs (I rarely eat bread, fruit, sweets, etc), work out a lot (weights, bodyweight work, high intensity interval cardio), and still my most recent fasting blood sugar was 109 and A1c was 5.6. Sometimes your genetics just work against you. My husband eats whatever crap he wants, exercises once or maybe twice a week, sits in front of the TV most nights, needs to lose about 15 lbs, but his blood sugar is totally normal.
Hi HM, you may have more challenging genetics than your husband but I wouldn’t give up just yet. Check out “Master Your Diabetes” by Mona Morstein ND (even if you don’t have diabetes yet). In my practice I find that most people who are trying to cut back carbs are eating more than they realize. When a person is highly insulin resistant even a small amount of certain types of carbohydrate can make a big difference in blood sugar and, therefore, hemoglobin A1c. Other factors, such as stress or insufficient sleep can play a role as well.
Hi Dr. Sandro,
I am 43, lean, and practice 16/8 intermittent fasting. I thought I was in perfect health. I bought a glucometer recently just to check my blood sugar and was shocked to find that my fasted blood sugar after 8 hours is consistently 115, and it is around 104 after 16 hour fasts. My A1c is good, however, at 5.3 and post meal blood sugar never exceeds 110 and drops to 90 within 2 hours of eating, and to 75 around 2 hours after that. There is so much confusing information out there – some say stop fasting because that is causing this elevated fasted blood sugar, others say that it is normal and the A1C is what matters most. My doctor cannot see me for two weeks so I am finding myself going down the rabbit hole on internet forums and don’t know what to think. Any insight would be truly appreciated. Thank you so much.
John
Hi John, the first thing I would do is try another glucometer and see if you get similar numbers. Home glucometers are not particularly accurate and can be miscalibrated. Perhaps your doctor will be willing to order a fasting glucose to be run at a lab, which will be much more accurate. If that also reads above 100, then there is something going on. My first guess, however, is that your glucometer is reading high.