Elevated fasting glucose with normal A1c

What is a possible explanation(s) for someone consistently, for over a decade, having elevated fasting glucose say in the range of 105-140, yet consistently having normal a1c results?
Other biomarkers measured normal as well.
I’m not really clear on what I have found or been told on this? Sorry if it is a dumb question.

Thanks!

Fasting glucose measurements between 100 and 125 mg/dL are known as “Impaired Fasting Glucose”, whereas having more than one fasting measurement of 126 mg/dL or higher is considered diagnostic for diabetes. IFG is a risk factor for progression to diabetes, as well as for “macrovascular” disease (i.e., heart attack, stroke, and peripheral vascular disease).

As for the discrepancy you’ve noted between your fasting glucose and A1c measurement, it’s thought that there may be different mechanisms at play between those who have IFG versus those who have “impaired glucose tolerance” (IGT) – i.e., those whose glucose measurements rise abnormally high after eating a meal.

It is thought that people with isolated IFG have hepatic insulin resistance (e.g., possibly related to fatty liver disease), whereas those with isolated IGT have muscular insulin resistance, and having both obviously increases the risk of diabetes. You may be in the former category, such that your daytime post-meal glucose levels do not rise high enough (on average) to result in elevations in your A1c.

Okay thanks that gives me a much better understanding of the mechanism involved.

Your explanation makes perfect sense to me. I think that those “thoughts” are probably very accurate, at least in my circumstance.

I did a glucose tolerance test before which was normal in result. I have a fatty liver, which has gotten “less” fatty over the last few years on an ultrasound. I have seen a corresponding drop, in that my fasting glucose used to generally be in the 120’s and now is between 100 and 110.

I will be curious to see if this goes down further as I get rid of more of the fat. I guess I will leave the Gallon Of Bourbon A Day diet to you kids! :slight_smile:

I always appreciate and respect your knowledge and thoughtful responses.

I’m not sure if this is another question or just a frustration. I read a bunch of studies and found basically the “safe and effective” recommendation is to “lose weight”. In every study they had people change their diet and engage in exercise. Why is it automatically assumed it is a “diet” thing, why are we so fixated on food? Perhaps the exercise had something to do with it? However it is rarely separated out. I find this bizarre.

Okay maybe I have a real question. Does the presence of fat in the liver, in and of itself, indicate a health risk?

In trying to reduce hepatic fat does it make any sense to lose weight if you are not obese? E.g. I am 71 inches tall, weigh 202 lbs and have maybe 20% body fat. (I don’t really know a good method to estimate bf, I wear 34 pants and the biggest part of my waist, around my navel, is 36.5 inches.) My lipid numbers and other labs are good.

Is there a method to specifically increase hepatic insulin sensitivity?

Thanks!

I’m not quite sure what you’re asking here.

Yes, hepatic steatosis is an independent cardiovascular risk factor.

It would make sense for you to reduce your bodyfat, as you say you’re at 20% (which means you’re likely higher than that, given most people’s poor ability to estimate this).

Anything that reduces your hepatic & visceral adipose tissue would be beneficial here. For example, a combination of strength & conditioning exercise will help. Medications such as metformin and thiazolidinediones (e.g., pioglitazone) improve insulin sensitivity, though the TZDs come with their own issues as well. More anecdotally, supplemental choline is thought to have benefits in fatty liver disease, and may be worth considering.

Thank you.

If I am understanding you then in my particular situation I should skew my training and nutrition focus towards continuing to get stronger and losing fat, not towards just getting “bigger and stronger”. I had cut out conditioning work being in my NLP, but it sounds like I can add some conditioning in?

Do you have a suggestion on some way a normal human can reasonably estimate fat without spending a bunch of money? Take a picture maybe?

Phosphatidyl Choline? Would betaine help as well?

That would be our recommendation, assuming you are primarily interested in improving health outcomes, versus just wanting to be as big and strong as possible.

No, this is not going to be particularly accurate either. While you could pursue something like DXA scanning, I would argue that you don’t need a highly accurate bodyfat estimate, because it’s not going to change how we manage your training.

There is some evidence for both choline and betaine; however, this is not surprising as betaine (trimethylglycine) is a metabolite of choline, and is the necessary precursor for exporting triglycerides from the liver. I don’t know whether there are any additional, synergistic, or adverse effects from supplementing with both. I would need to do a lot more literature digging on this. If you’d like, you can look into the details under their respective supplement pages at Examine.com

Thanks Austin.

Yes, at 47 i think health is my priority. I do want to continue to gain strength but I am already much stronger than ever in my life and I am not in a hurry. As I age into my 5th decade and beyond I also realize maintaining my strength is a form of progress.

You win your argument about the fat thing.

I will look into choline and betaine myself as you suggested.

Okay, sorry one more thing…
If body fat isn’t realistically measurable, and I’m not going to get a ultrasound of my liver every 3 months or whatever. Would it seem reasonable to shoot for trying to achieve some kind of body composition where my fasting glucose is no longer impaired?
Or is there some other measurable goal I should consider?
I have a basic understanding of how to skew weight loss towards losing more fat, but I think you always lose some muscle and I want to still maintain my training.

I really appreciate all the help. If I didn’t have such a good job, and now such a great in person SSC. I would move somewhere you guys are licensed and hire you as my Dr.

If I strike it rich I will pay for your licensure here. :slight_smile:

The specific percentage of fat here is not the outcome we are most concerned with. And again, similar to the DXA question – how would getting an ultrasound every 3 months change what you do in training?

It’s the consequences of the fatty liver that we care about, as evidenced by your fasting glucose measurements. So yes, aiming to get your fasting sugars back down below 90-100 would reflect significant improvement in your metabolic health.