I had a patient come in a couple of weeks ago with an interesting situation on his blood work that I wanted to share. And this is all surrounding blood sugar, type two diabetes, A1C, that kind of stuff.

So he had had blood done at his previous doctor's office and came in for some general wellness work. And in going through reviewing his labs I noticed that there were some tests that I normally like to see that were not included in his labs. And he was told by his previous doctor that he was pre-diabetic and they had put him on metformin. So in looking through his labs and getting the new ones to fill in the blanks he had already shown up with a fasting blood sugar of about 106 and his hemoglobin A1C was sitting at 6.0. That's why he was told he was pre-diabetic.

So in doing our labs I looked at a few other things. His triglycerides were 165, which indicates that there's probably some problem with blood sugar and we already knew that, but we looked at his fasting insulin level. Now, typically, and just in case you don't know for a hemoglobin A1C we like it to be below 5.7, right? If you can get in the lower fives, you're in pretty good shape. 5.7 to six, you're lightly pre-diabetic. Between six and six and a half, you're really strongly pre-diabetic. And then above six and a half you have type two diabetes. That's generally the breakdown on hemoglobin A1C. And what it's measuring is how many red blood cells, this is important in a second, how many red blood cells have been damaged by spiking your blood sugar too high.

So let's say you eat a meal, you spike your blood sugar high, and then over the next few hours you get it back down into the normal range. Your fasting blood sugar can look relatively normal but that spike did damage, right? It's going to damage some of the red blood cells, and so there's a certain percentage of the red blood cells that are damaged. And that's that 6.0 that this patient had. 6% of the red blood cells were damaged by sugar. You get to 6.5% and you're a type two diabetic. So that's what we're measuring with hemoglobin A1C. It's a percentage of red blood cells.

Now, his fasting insulin level, which should be below 10. If it's really tightly controlled, it will be around six, maybe a little bit less. But below 10 is pretty good for most people that aren't putting concerted effort toward it. But they're metabolically healthy. Most of my type two diabetics when they come into the office and they're new, we haven't been working with them, it's not well controlled. Then they'll come in with a fasting insulin level in the low 30s, maybe the mid-30s. So this gentleman's fasting insulin level was 48.9, so call it 49, right? So way out of control. No way he should have a fasting insulin level that high, especially already being on metformin.

So that was our clue that something wasn't right. The A1C was indicating pre-diabetes but the fasting insulin was saying full-blown, out of control type two diabetes. So I dug a little further. Well, he has a lung issue and therefore doesn't exchange oxygen well. When you don't do that, what tends to happen is you make extra red blood cells. So his red blood cell count, which normally tops out at about 5.5, he is all the way up at 6.5. So he's got considerably more red blood cells than the average person.

Well, if you have the same number of damaged red blood cells, but your total pool of red blood cells is larger than the lab would expect, the A1C is going to be skewed down. It's going to be artificially lowered because it's a percentage of the total red blood cells. On the opposite side of the spectrum if this patient had been anemic, if he didn't have enough red blood cells then the A1C, because it's a percentage of the total red blood cells, would have been skewed upward and would've looked worse than it really is. So there's a significant chance this patient has been under-diagnosed and likely under-managed because whoever was looking at it didn't understand that the A1C is assuming that you have a normal red blood cell count. And that if you don't have that normal red blood cell count it's either going to be skewed up or skewed down based on whether you have too many or too few red blood cells. So in this case, patient had more red blood cells than the average person. So the A1C had been skewed down.

Now, I can't do a calculation to figure out what an accurate A1C would be but that's why, when we look at blood sugar situations, metabolic health, however you want to phrase it, we look at the fasting blood sugar, we look at triglycerides, we look at an A1C and we look at the fasting insulin. Those four together should give you a pretty clear picture, or they should at least let you know that something doesn't match and you need to look further, right? Maybe the patient didn't fast for the test or whatever. There are a number of different things that can pop up. But this is a fairly uncommon situation where the patient has extra red blood cells and that skews the A1C down.

So just throwing out there, probably more to the practitioners the patients, that this kind of situation can happen. I think it's probably more common to have anemia and the A1C is skewed up. That would get you in trouble because if you start to treat the patient like they've got high blood sugar and it's not as high as you think you'll bottom them out and they'll feel crummy. And you won't understand why, because you've gotten the A1C in the normal range. If the patient feels bad, look at the anemia. It's skewing the A1C number and you're over treating the patient.

So anyway, wanted to throw that out there. It was an interesting situation. Like I said, you don't run across it all that often. So we're treating him much more like an out-of-control type two diabetic and hopefully we'll get better results in how he feels than he was getting with his previous treatment protocol.

So anyway, wanted to throw it out there. If you have any questions or if you've run into a situation like that, leave me a note underneath here. I'd be curious how many of you double check numbers like A1C to make sure that they're legit and they make sense?

All right, have a great one. We'll see you on the next video.