If you just received test results back from your doctor and he/she has indicated that you have an elevated HbA1C (or A1c for short), you may be wondering what that means and just what you can do to lower it to within normal range.
Back in December I decided I wanted to be a Living Kidney Donor. I'm at a point in my life where I'm no longer satisfied with just living a basic life. I want to do more, see more and touch more lives before my time is up.
To become a candidate for living kidney donation you have to go through a battery of tests over the course of several months. The very first round of bloodwork includes testing your HbA1C level to determine if you have diabetes or are considered "pre-diabetic." Obviously you don't have to be looking to donate a kidney to have this test done, as it's something your doctor will do when you have blood sugar issues. Mine was in the pre-diabetic range (5.8%) and it left me trying to figure it out what I needed to do to lower it.
What is HbA1C?
Dr. Manisha Ghei of Praana Integrative Medicine & Holistic Health Center, PLLC told me that, "HbA1C is a test of hemoglobin glycation and hemoglobin is present inside our Red Blood Cells (RBCs). Our RBCs regenerate every 120 days so it will take A1C approximately 3 months to change. A1c is a test of average long-term blood sugar control over the three months prior to the date of the blood test."
Think about what you eat over the course of 3 months. Do you have a few "bad days" where you emotionally eat or go on a chocolate and fried food binge? No? Just me? Well for those of you not in the big fat liars club, Dr. Manisha says that since it is a test of an average of your levels, even a few very high or very low blood sugar readings over the 120 day cycle will unfortunately show up in the average.
Kelli Shallal, Registered Dietitian Nutritionist and Certified Personal Trainer, further explained that, "Hemoglobin is protein found in the red blood cells which carries oxygen, but in an irreversible process it can bind to sugar in the blood helping lower the free sugar in the blood. The levels will not lower until that red blood cell is replaced, usually every 2-3 months. In the mean time the goal is to prevent this process from occuring in new red blood cells."How is HbA1C measured?Stephanie Dunne, Registered Dietitian and Integrative & Functional Nutrition Certified Practitioner, told me that hemoglobin A1C measures how much hemoglobin in the blood is glycated, thereby giving an estimate of how much glucose has been in the blood. This is why the number is reported as a percentage, as it represents the percentage of hemoglobin that is glycated. When you see the A1C number as a percentage, this can be translated to the average blood glucose as follows:
5% A1C = average blood glucose of 97 mg/dL
6% = 126 mg/dL
7% = 154 mg/dL
8% = 183 mg/dL
9% = 212 mg/dL
10% = 240 mg/dL
The reason A1C is a better measure of long-term blood glucose levels than a simple fasting blood glucose number is because a single number only tells you what is happening in that moment. As the body becomes resistant to insulin (also known as prediabetic), the fasting blood glucose number may still be normal, but the A1C number may be inching up as the blood glucose level rises after meals. The A1C number tells us what's happening over a period of time.
A normal A1C is anything under 5.7%. A level of 5.8 - 6.4% is considered pre-diabetic and above that means you either have Type 1 or Type 2 diabetes.
What's the difference between Type 1 and Type 2 diabetes?
Type 1 diabetes, Dr. Manisha explains, is an auto-immune condition where the body's immune system starts attacking itself, specifically the pancreas in this case, so eventually there is absolutely no production of insulin from the pancreas. This leads to severe elevation of blood sugars due to inability of the cells to take in sugar unless an external source of insulin is provided to the patient. This disease usually presents in childhood or young adulthood. Treatment with insulin becomes an absolute necessity for survival. Conventional medicine has no treatment for reversal of this disease.
She told me that Type 2 diabetes is the more common form of diabetes. It is not an autoimmune disease and usually, but not always, presents in adulthood, although the incidence of onset during childhood is now on the rise. This disease starts with cells becoming insulin resistant where they stop responding to insulin and the sugar, though present in high amounts in the blood, cannot enter into our cells and provide energy. Initially this disease can be treated and reversed with diet, exercise and lifestyle changes and if needed, blood sugar lowering oral medications. Gradually over time, the insulin production reduces drastically and insulin treatment may eventually be needed.
My A1C is 5.8% and above, how do I lower it?
First and foremost, create a plan of action with your doctor. For me, that meant further testing to see what my insulin level was (e.g. was I insulin resistant) and a thyroid test to see if my thyroid was contributing. Once both of my tests came back in the normal range, my doctor then scheduled me to see a nutritionist.
Dr. Manisha suggests keeping your blood sugar consistently in a near normal range over the 120 day period to get a true picture of the control of your pre-diabetes or diabetes over the three months. That means no binging on your favorite high-sugar, high-carb, high-calorie comfort foods.
Easier said than done, I know.
"Eating clean is the way to go, I avoid all things processed and focus on protein and fat. The majority of my carbs come from vegetables. Also, being that I am a type 1, I correct anything over 120," said Allison Caggia, editorial director of Diabetes Daily and Type 1 Diabetic. "Keeping your blood sugar in range at nighttime is also important. This tight control will definitely be reflected in your A1C."
Allison recommends the app MyFitnessPal to help track macros, nutrients and calories. I recently downloaded this app and was so surprised where sugar, fat and carbs would sneak in. So many things in the app are free and will give you a better understanding of the nutritional value of the food you are eating.
"The first thing to cut out is boxed cereals, white bread, white pasta, desserts, pastries and soda pop," reports Michael Ham of Leisure Guy and Type 2 diabetic. Soda, whether it contains calories or not are to be avoided, "The artificial sweeteners sort of trick the body and also maintain the taste for sweets." He recommends staying away from all added sugars. Ham also has a "no bites" rule - "I put food into my mouth only at mealtimes and for the mid-morning and mid-afternoon snack. At all other times, no food allowed, not even a taste of a sample at the grocery store."
Ms. Shallal offered these tips:
1. Limit intake of refined carbohydrates and sugar. Stick to lower glycemic index whole foods such as whole grains, beans, whole potatoes (cooked), and limited quantities of fruit for carbohydrates.
2. Try not to eat more than 30-45 grams of carbohydrates per meal.
3. Never eat a carbohydrate on its own, pair it with a protein or healthy fat.
4. Exercise regularly. Both strength training and cardio are important for promoting pathways that help regulate blood glucose.
Wait, wait, wait did she just say I could eat carbs? So many friends and family who offered advice told me to nix carbs altogether, including vegetables that are considered starchy, as they'll convert to sugar. But she explained that whole grains and whole potatoes are "whole foods" that also contain fiber that will slow down the blood sugar response and are not the same types of carbs that, say, you get from noshing out on a bag of chips. She reminded me that, "a balanced diet is best for long term weight loss."
Does losing weight help lower your A1C?
Weight loss is directly related to A1C change, Ms. Shallal (and my own doctor) confirmed. In my case, I had been lowering calories, but increased carbs and although I was losing weight, it caused my A1C level to increase to 6%. The best thing is to aim for balance, protein, healthy fat, and 30-45 grams of fiber rich low glycemic index carbohydrates per meal.
What about fruit? Doesn't fruit contain sugar? Ms. Shallal clarified that fruit is considered a simple carbohydrate and should be eaten in small amounts timed around your workouts. Berries are best, but whichever fruit you choose, eat it in moderation and don't overdo it, but avoid fruit juice and dried fruits.
Once a dietary change is made, it takes 3 months for the A1C to fully adapt. This is because red blood cells live an average of 3 months in the blood stream. As such, after 3 months, every red blood cell will be new and the A1C number will reflect the dietary change. Of course, all red blood cells are not created or recycled at the same time, so the number will slowly change over the 3 months as the existing red blood cells are recycled and new red blood cells are created, Ms. Dunne explained.
She continued that in order to lower the A1C number, a person has to lower the average amount of glucose in the blood for an extended period of time. What this means is that huge spikes in blood sugar must be avoided as these spikes increase the average over time. The best way to lower blood glucose is to avoid carbohydrate containing foods that are easily digested and absorbed. The faster carbohydrates are digested and absorbed into the blood stream, the bigger the blood sugar spike will be. So as Ms. Shallal mentioned you can eat a simple carb like an apple, or a complex carb like a whole potato because it is also high in fiber.
Ms. Dunne advises that if you do consume easily digestible carbohydrate containing foods, be sure to eat other foods that will slow down the overall digestion and absorption process. This includes protein and fat containing foods, or foods high in fiber. By the way, this is why complex carbs like whole grains and vegetables don't cause a blood sugar spike - the fiber in the food gets in the way of the other carbohydrates being digested and absorbed.
But that doesn't mean go tap out on cake and white flour foods like bread and pasta because these are the big no-no's and will cause your blood sugar to spike. Ms. Dunne explained that if a person changes their diet to have more protein and fat containing foods, as well as carbohydrate containing foods with a lot of water and fiber (like vegetables, fruits and legumes), then the amount of glucose to be absorbed goes down.
The reality is that glucose metabolism and insulin production are not simple things, she reminded me.
What causes the A1C level to rise?
Whenever there is excessive amounts of sugar in the blood stream, Dr. Manisha explains, it attaches to hemoglobin in our Red Blood Cells (RBCs). This causes a change in the protein structure of the hemoglobin molecule. We call this change, glycation, and the glycated hemoglobin is the known as Hemoglobin A1C. The higher the sugar in the blood, the more it attaches to hemoglobin, thus the higher the HbA1C.
"Because we are incredible systems of thousands of interworking parts, there are many things that can cause blood glucose to go up," Ms. Dunne explained. Some other factors that can cause an A1C number specifically to increase are:
Iron deficiency anemia
Uremia (abnormally high levels of waste products in the blood)
Hemoglobinopathies (genetic disorders of hemoglobin, like sickle-cell anemia)
PCOS (polycystic ovary syndrome)
Beyond those things that are specific to an increased A1C, the following chronic conditions can cause blood glucose levels to be higher:
Stress or other causes of amped up adrenal glands
Pancreatitis (acute or chronic inflammation of the pancreas)
Chronic liver disease
Chronic kidney disease
Chronic use of some medications, including steroids, epinephrine, furosemide, thiazides, phenytoin and statins
Inflammatory bowel conditions
Toxicity from environmental toxins like plastics and polluted air
Excess testosterone (when produced internally, as opposed to using steroids as mentioned above)
So, if someone was eating well and sticking to the low glycemic index, she recommends to have your doctor start looking for other potential causes that aren't related to the diet.
Another area that would contribute to elevated blood sugars and diabetes are nutrient deficiencies of certain key nutrients like chromium, magnesium and certain B vitamins that help the body process the sugar load adequately. If someone is deficient in these due to malabsorption or any other reason, their ability to handle even normal amounts of carbohydrate loads will be reduced, explains Dr. Manisha.
To Ms. Dunne's point above about stress, Dr. Manisha concurs and says we cannot underestimate the role of stress in raising blood sugars. Under stress our body produces the stress hormone known as cortisol. Cortisol causes the release of sugar from stores in the liver. Unless we are able to lower cortisol levels with mindfulness and relaxation techniques on a daily basis, this will continue to not only cause elevated blood sugars but also possibly to high blood pressure, lowered immune function and many other chronic diseases. Addressing some of the above root causes can most certainly lead to resolution of pre-diabetes and diabetes.
Sandra J. Eleczko, DDS, brought up another good point - periodontal disease and diabetes are interrelated and will effect each other.
Good oral hygiene is essential to maintaining a healthy A1C. The bacteria and the inflammatory mediators that these bacteria stimulate will enter the blood stream and effect the entire body, reeking havoc everywhere in the body. So one of the things that you need to do to decrease your A1C is to see a dentist and have your teeth cleaned and make sure you floss every day.
Can your A1C still be pre-diabetic if you lead a healthy lifestyle?
According to Dr. Manisha, a "healthy lifestyle" may differ from person to person. Her area of expertise is Functional Medicine, which involves an individualized approach to any chronic disease including diabetes mellitus. "In Functional Medicine, we believe that it is important to get down to the root cause of any disease and the root cause(s) for the very same disease may vary in different individuals. One of the areas to look at, regarding the root cause of diabetes could be food allergies and food sensitivities which can both impact gut health and cause inflammation."
In her experience with her patients, she has seen blood sugars drop dramatically once the trigger foods are eliminated from that person's diet. She believes that testing for trigger foods can have benefits in the management of diabetes. Gut health should also be looked at with a comprehensive digestive stool analysis, so that if there is gut inflammation or imbalance in the gut bacteria, it can be addressed as well.
Some books Ham recommends reading to understand sugar are:
“Why We Get Fat and What to Do about It,” by Gary Taubes
"The Case Against Sugar" by Gary Taubes
"The Big Fat Surprise" by Nina Teicholz
I also plan to get "Zero Sugar Diet" by David Zinczenko and "Blast the Sugar Out" by Dr. Ian K Smith because I honestly feel like I have no idea how to do this when there is sugar in absolutely everything.
If you've had an elevated A1C and were able to lower it, I'd love to hear about it! Please leave a comment!
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