Understanding the Science of Hemoglobin A1c

Article written and reviewed by Cyrus Khambatta, PhD and Robby Barbaro, MPH
Published October 23, 2018
Hemoglobin A1c: Understanding the Science, Advantages, and Limitations

Podcast Transcript

Cyrus Khambatta, PhD: What I want you guys to understand is that the food that you put in your mouth is, without question, the number one, most important variable that you have at your disposal for controlling your A1c level, okay.

Regardless of whether you think that going to do more exercise is going to benefit you, or whether you think eating less food is going to benefit you, or if you’re fasting, all those things will manipulate your A1c, but the composition of your diet is, without question, the most powerful tool that you have at your disposal.

Cyrus Khambatta, PhD: Welcome to the Mastering Diabetes Audio Experience, where we teach you how to sit in the driver's seat of your diabetes health for the rest of your life. We’ll teach you how to reverse insulin resistance, achieve your ideal body weight, gain energy and get your best A1c following more than 85 years of evidence-based research in the Mastering Diabetes Program.

Robby Barbaro: Our program teaches you how to reverse prediabetes and type 2 diabetes, and how to simplify your life with type 1 diabetes by maximizing your insulin sensitivity, using food as medicine.

Cyrus Khambatta, PhD: We're on a bold mission to reverse insulin resistance in 1 million people. We're glad to have you joining us.

Cyrus Khambatta, PhD: In today's Podcast episode, you'll have an opportunity to do a deep dive into your hemoglobin A1c. Now, most people living with diabetes around the world have been told that one of the most important indicators of their diabetes health is their A1c. And people living with diabetes are told to manage their blood glucose within acceptable window that represents a normal physiological pattern, and by doing so, then you can bring your A1c down from elevated levels into what's considered the normal range, or even potentially the non-diabetic range.

Now, this is all very helpful information. The problem though, is that most people in the diabetes world are misled into believing that the A1c is actually the most important indicator of their diabetes health, and as a result of only trying to achieve an excellent A1c, they end up missing the bigger picture, and forgetting about many other aspects of their overall total body health that also play incredibly important roles in determining your long-term disease risk.

Now, we like to refer to your A1c as an incomplete indicator of your diabetes health, because it's important, but it's not the end game. So, in today's Podcast episode, we're going to go into detail about exactly why that's the case. And most importantly, why people who have a tunnel vision about trying to achieve their best A1c following a high-fat diet, or a diet that is very low in carbohydrate energy end up increasing their long-term disease risk without even knowing it. And that's the point.

So in today's Podcast episode, we're going to go into a lot of detail as to why that's the case, and get you a little bit more information here, about why your A1c is certainly an important biomarker of your diabetes health, but it is not the end all, and be all, of your diabetes life. Hope you enjoy the Podcast episode. And as always, make sure to let us know what you think. And we will see you soon.

Cyrus Khambatta, PhD: Today we're going to be talking about the ins and outs of your hemoglobin A1c. We're going to be talking about the science of your A1c, the actual biology of what the heck it is, and why it's important. And then we're going to be talking about what are the advantages of using your A1c as a sort of diagnostic indicator. And then also some of the limitations of using your A1c as your, sort of, holy grail of living with diabetes.

Your A1c is very, very important. And the truth is that most people have no idea what it actually is. So here's the question, I want to know in one sentence: Can you explain what your A1c is? That's what I want to know. Okay, so let's just see what types of things roll in here, because we're very interested to see what you guys already do know about your A1c.

Robby Barbaro: Okay, it’s coming in here. It says, three month average. Wow, these answers are flooding in. A snapshot blood glucose level over a three month period. Average of blood sugar. Three months blood sugar average. Three months average of how much sugar is in the blood. Three month average blood glucose. Lot of people talking about three months average blood glucose.

Cyrus Khambatta, PhD: Okay. That's exactly what I was expecting to see, actually. My question, I guess it should have been a little bit more clear. I want to know if you understand the biology, like why three months, what's the whole point? So, we're going to get into it, in detail, here. And hopefully, you guys will be able to have a little bit more of a biochemistry understanding of your A1c, because I do believe it's actually fascinating. It's actually very important.

So here's what we're going to cover. We're going to talk about what your A1c actually is, and what it represents from a biological basis. We're going to talk about what your diet does to influence your A1c: Can your diet increase your A1c, can your diet decrease your A1c? We’ll also talk about exercise, and how does that actually affect your A1c level.

Then, we'll talk about low carbohydrate diets. Because there's something very important that happens when you eat a low carbohydrate diet specifically, with your A1c, that most people even who eat a low carbohydrate diet, don't understand. So we're going to go into that in detail. I want you guys to become world's experts on this particular subject.

And then finally, we're going to talk about why your A1c is, what we call an incomplete indicator of your diabetes health, because it's important, but it is not the holy grail of your diabetes health. And then lastly, but definitely not least, we're gonna be talking about how you can reduce your A1c and gain insulin sensitivity at the same time. So, we got a fun presentation today.

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Real quickly. I think a lot of you guys already know me at this point. So, I'm not going to go into too much detail. My name is Cyrus Khambatta, I have a PhD in Nutritional Biochemistry. I was diagnosed with Type 1 Diabetes in the year 2002, 16 years ago. I was going to Stanford at the time, I was studying mechanical engineering, and my life kind of came to a screeching halt, because I had no energy, I was urinating all the time, and I just did not understand what was happening to me. So I checked myself into the doctor, they diagnosed me with type 1 diabetes overnight, and it fundamentally changed my entire life.

For the first year of living with diabetes, I had no idea what to do. I just ate a low-ish carbohydrate diet, and it didn't work. I couldn't sleep at night, I developed anxiety, my blood glucose was all over the place. And I said, “You know what? This is terrible.” And I switched my diet, I became a low-fat, plant-based, whole-food eater after one year living with diabetes. Greatest single decision of my adult life. Period. End of story. Nothing is more intelligent than that one decision I had made to switch over to a low-fat, plant-based, whole-food diet.

The reason is because I gained tremendous amounts of insulin sensitivity. And we'll go into detail about what that actually means. But in short, I was able to eat a ton more carbohydrate rich foods using less insulin. More carbohydrate, less insulin. And it was so dramatic for me, that I decided to go back to school and study it at the PhD level. And that's why I studied Nutritional Biochemistry for five years.

So here I am today, 15 years after changing my diet, I eat lots of carbohydrate on a daily basis, 500, 600, 700, sometimes 1000 grams, depending on how active I am. I inject approximately 25 units of insulin per day, and my A1c is constantly hovering in the sort of non-diabetic or prediabetic range, which is actually pretty challenging to do, but it's possible if you have a solid plan that you are consistent with. So that's me in a nutshell and I'll turn it over to Robby.

Robby Barbaro: Perfect! We have a comment in the chat box that I think you'll agree with, Cyrus. “Kylie was a great decision in your adult life.”

Cyrus Khambatta, PhD: Oh my lord! Kylie, she's sitting right here. So, low-fat, plant-based, whole-foods was the second best decision of my adult life.

Robby Barbaro: Okay, so I'm sure you guys know me by now as well, so we'll go through a quick intro. My name is Robby Barbaro, and I was diagnosed with type 1 diabetes, just like Cyrus, over 18 years ago. And I, over the years, tried many different diets, trying to get things under control, trying to optimize my health, how I felt, my energy. Had terrible acne, and plantar fasciitis, taken allergy medications year round. Just not feeling my best.

So, I started reading a lot of books, try other things, whether it was the Weston A. Price Foundation diet, which is high in animal products, low in carbohydrates. Whether it was a Gabriel Cousens style, vegan, low-fat, plant-based lifestyle. What ended up working for me was what we teach here, and I've been doing now for over 11 years, a low-fat, plant-based, whole-food diet. You’ve seen this picture. I get to eat plates and plates of figs, mangoes, papaya, all the fruit I want. I love greens. And this food tastes amazing, because my taste buds have come alive.

So, I'm really passionate about sharing this information. Cyrus and I have teamed up now doing Mastering Diabetes for over a year and a half now, and just having a lot of fun. So, really glad to have you joining us tonight. And I think you're going to really enjoy the presentation.

Cyrus Khambatta, PhD: Alright, so let's get into the meat and potatoes of this presentation here. So, here's the first question: What the heck is your A1c, and what does your A1c actually represent? Okay, let's get into it. Hemoglobin, okay, this is where you get to put your science hat on, let's travel back to biology class, and you're at sophomore year of high school, okay, where you were maybe falling asleep, or maybe you are writing some notes to your friends, okay? Hemoglobin, hemoglobin, hemoglobin.

Hemoglobin is this molecule that floats in your blood, it is actually inside of red blood vessels, and there are trillions of red blood vessels that are floating through your cardiovascular system. And these red blood vessels, their main role in life is to trap oxygen and deliver oxygen to tissue. So when you take a deep breath in, when you do this. What you're doing is, you're inhaling oxygen from the outside world, you're inhaling nitrogen mainly, but some oxygen comes in as well. That air goes into your lungs. And in your lungs, you have these things called alveoli, and alveoli are responsible for taking the oxygen in particular from that breath of air and transferring it into your blood. And as soon as it gets into your blood, that oxygen has to be trapped by something. And that's where hemoglobin comes into play.

So, hemoglobin is inside of these red blood cells. And as soon as oxygen becomes available, the hemoglobin traps it and holds on to it. And then, as those red blood cells circulate all throughout your body, they move from your lungs, maybe they go to your heart, maybe they go to your muscle, maybe go to your liver, your pancreas, your spine, your brain, your thyroid gland. Anywhere in your body, where oxygen delivery is needed, hemoglobin will release the oxygen and allow that oxygen to go into that tissue, so that tissue can then use that oxygen for what's called respiration, which is a fancy way, super nerd way of saying to be able to perform reactions, oxidative reactions.

So, red blood cells starts out by trapping oxygen in your lungs, using hemoglobin, and then it circulates all throughout your cardiovascular system, and then at the time it's supposed to release, oxygen is released and it gets transferred to cells that need it, in order to produce energy.

Now, what the heck does this have to do with your A1c? Why in heaven's name, are we talking about oxygen in the first place and red blood cells? Because that has nothing to do with glucose. Okay, well, it turns out, think of this as… There's this cool cartoon that I found online the other day.

This is sort of a description of exactly what happens, why your hemoglobin A1c is used as a marker of your blood glucose control, okay? What happens is that hemoglobin in circulation, there's a lot of it in circulation, and hemoglobin tends to stick to glucose. So, researchers found this out a long time ago. And they noticed that in normal people, non-diabetic people, a certain proportion of all the hemoglobin that was floating in their bloodstream had glucose molecules attached to it. And they thought, “Well, that's weird. Because hemoglobin is not supposed to trap glucose, it’s supposed to trap only oxygen.” But it turns out that glucose can stick to hemoglobin, just naturally, because of its chemical composition.

And then, they found out that people who are actually diabetic, or people who have higher blood glucose, have more glucose attached to those molecules. And so they said, “Wait a second, what if we were to use the amount of glucose attached to hemoglobin as a way of determining whether or not your blood glucose is actually elevated enough.”

So, these red blood cells, that are called freely permeable to glucose. Which means that glucose that's floating in your blood, can get right in the red blood cell. And as soon as it does, it basically attaches to hemoglobin, and then as soon as it attaches to hemoglobin, that's it. It can't un-attach to hemoglobin. So, it's basically permanently bound. And what that means is that, in order to get this glucose to detach from hemoglobin, the hemoglobin has to die.So, hemoglobin lasts in your blood, and is alive in your blood for guess how long. Three months. That's the answer.

Okay, so everybody wrote in the chat box, they said, “Your A1c is a three month marker of your blood glucose control.” Why three months? The reason is this: Hemoglobin is only alive for three months.

As soon as one hemoglobin molecule dies, another hemoglobin molecule is made in its place. And so, there's this constant recycling program which is happening. So, if the hemoglobin molecule happens to get glucose attached to it, then that glucose stays for the rest of its life, and then approximately three months after it was born, it dies, and a new one is made in its place.

So, hopefully, this is making a lot of sense. The more glucose you have in circulation, the higher your A1c is going to be. So, it turns out that A1c see is basically used as a diagnostic markers, so that means that when you go to the doctor, and you get your A1c measured, your doctor is trying to determine whether you have a normal amount of glycosylated hemoglobin, or whether the amount of glycosylated hemoglobin has gone up over time, which is an indicator that you may have diabetes.

So normal people, okay, the cutoff for a quote unquote, “normal non-diabetic person” is right here at 5.6. So, if you have 5.6% of all the hemoglobin in circulation or less anywhere in this zone right here, then you're considering non-diabetic. Now, if between 5.7 and 6.4% of the hemoglobin in your circulation is glycosylated, that means that you have prediabetes. And then if 6.5% or more of the hemoglobin and circulation has glucose molecules attached to it, then that's an indicator that you actually have type 2 diabetes. So, all we're looking at here is of the proportion of total hemoglobin floating in your blood, how much of it has glucose attached to it.

So here, it says, approximately five to 5.6% of hemoglobin molecules are normally glycosylated in healthy humans, or non-diabetic human. So, I just drew this picture here, this right here, this is your blood stream, obviously, and these hemoglobin molecules are inside of these red blood cells inside of your blood. Okay, so I just drew a lot of hemoglobin right here. And let's just say, for the sake of argument here, that this one blue glucose molecule that has covalently attached to this hemoglobin molecule right here, that this right here represents between 5 and 5.6% of all the hemoglobin that has glucose attached to it. So, this is what you would consider normal.

Now, if between 5.7 and 6.4% of hemoglobin has glycosylated, or has glucose attached to it, then that means you're prediabetic. So we're not talking about a lot, we're talking about just a little bit more, just a little bit more of hemoglobin that has glucose attached to it. And then, by the time you develop type 2 diabetes, now, we're looking at approximately 6.5% or more of the hemoglobin circulation that now has glucose attached to it.

So what I want you guys to understand visually, is that we're talking about not that much more glucose attached. It’s a very, very finely tuned system. It's not like in one situation, it's 2%, and then if you have diabetes, it's 35%. That's a much bigger range. We're talking about fractions of a percent that make a difference. And so that's why it's very important to make sure that the red blood cells in your body are not overly glycosylated, because that can result in a whole host of problems down the road.

Yeah, so that's the biology. That's what's the actual, you know, biochemical interpretation of what your A1c actually is. Now, the next question is, well, how does your diet actually affect your A1c?

So, you have a lot of tools at your disposal for manipulating your A1c value to your advantage. One tool that you have is to eat a certain way, or to use your diet as your control mechanism. Another thing you can do is use exercise. Another thing you can do is fast. Another thing you can do is change the macro nutrient composition of the food you're eating to be a very particular makeup, you can change the amount of food that you're eating. You can do a whole bunch of things to try and manipulate your A1c to your advantage. But not all of them are created equal.

So in this situation, let's take a look at this red line. If you're living with some version of blood glucose instability, or any version of diabetes, chances are, you've seen a red line that looks something like this. Maybe you eat a meal right down here, and then within 60 minutes, your blood glucose has increased, doubled. So now, it's close to 200, and then maybe it starts to come down. And then maybe it does this whole pattern. And before, you know, you look at this in your life, “Hmm, that's not normal. Why is this happening to me?”

As you become better and better at controlling your blood glucose, you can turn this red line into this green light right here. And you can get better blood glucose control, such that when you eat a meal, your blood glucose doesn't vary as much. So the green represents better blood glucose control.

What I want you guys to understand is that the food that you put in your mouth is without question, the number one most important variable that you have at your disposal for controlling your A1c level, okay. Regardless of whether you think that going to do more exercise is going to benefit you, or whether you think eating less food is going to benefit you, or do more fasting, all those things will manipulate your A1c. But the composition of your diet is without question, the most powerful tool that you have at your disposal.

So over the course of time, this red line, if this thing continues, and this happens, maybe for breakfast, and then for lunch, and then maybe for dinner, and then it happens next week, and the week after that, this is going to lead to a high A1c value because there's more glucose floating in your blood, and therefore there's more glucose that can attach to hemoglobin. But if you instead have this green line, then that means that you're A1c is going to be much lower, it's going to be more close to what's considered non-diabetic or normal, simply because there's less excess glucose funding your blood.

So, if you eat a diet that contains primarily low-fat and low-protein foods, so they’re high in carbohydrates, or higher in carbohydrate, they are lower in fat, they are low in protein. And these foods include things like fruits, vegetables, legumes, which are beans, lentils, and peas, and then whole grains, then what ends up happening is, you might have seen this in previous webinars, where your liver and muscle tissue end up storing more blue and less yellow. More glucose and less fatty acids. Because there's more glucose available inside of these foods, and there's less fatty acids available. And therefore, your tissues respond by increasing the amount of glucose that they use as a fuel and increasing as much, or increasing more storage as well.

So the key to understanding this picture is that these foods are low in fat, and these foods are low in protein. And if you do that, then you're going to end up with this picture right here. I can take a snapshot in time and try and look at what foods stored your liver has. And you'll see that your liver is storing predominantly glucose and small amount a fatty acid, and your muscles doing that same thing.

Instead, if you eat a diet that’s high in fat and high in protein, then you'll be eating foods like this. Red meat, white meat, fish, dairy, eggs. All these foods are high in fat and high in protein. So as a result of doing that, because these foods contain more fatty acids, more yellow and less blue, then the tissues are going to shift and the tissues are basically going to try and utilize more fat for energy, and less glucose for energy. So they're going to try and burn more fat, they're also going to try and store more fat. And that's what you'll end up with, this picture right here where you have more yellow and less blue. And again, the key to this is that these foods are high in fat and high in protein. When you eat a diet that’s high in fat and in protein, we're going to see what results.

So left hand side, we have insulin sensitive tissue. So, these are tissues that are using glucose as their primary fuel. Lots of blue, small amounts of yellow. And then over here, on the right hand side, we have tissues that are insulin resistant. And these insulin resistant tissues have more fat stored and less glucose. So, I'm going to pause here for a second. And here's the question. I just told you that the food that you eat will determine what these two tissues look like. Here, there's more blue. Here, there's more yellow. And now I'm telling you that these tissues that are more yellow are more insulin resistant. The question for you is this, and I want you to answer in the chat box. What is insulin resistance? I want a one sentence description of what insulin resistance is. If you had to complete the sentence, “insulin resistance is” blank. What would you say? I want to know your answers.

Robby Barbaro: Okay, let's see what's gonna come in. You know, what's funny, if anybody watched the new testimonial video that we released today, they would learn how Mike was a star student. So let's see what comes in. Somebody says too much glucose storage. Too much fat in tissues. Storage of fat in cells, not designed to store fat.

Cyrus Khambatta, PhD: Who said that?

Robby Barbaro: Actually a lot of people said that. I only really selected answers, because there's just so many scrolling.

Cyrus Khambatta, PhD: Fair enough.

Robby Barbaro: So, inability of insulin to use… Man, it's very difficult to read. It's great, though. I love this enthusiasm. We have over 763 people in the room right now. And you guys participating is very important. That's how you learn. So, we have a lot of answers coming in. Ineffective use of insulin by cells. Insulin resistance is fat in tissues not designed to store fat. I see lots of answers.

Cyrus Khambatta, PhD: Okay. So, I'm going to stop at that last one right there, which I think a lot of you guys wrote, which is: Insulin resistance is caused by the storage of excess fat in tissues that are not designed to store fat. You guys nailed it. What we're talking about here is the storage of excess fat, okay, excess yellow in tissues that are not designed to store fat. Your liver and your muscle were never designed to store large amounts of fat. That is not how they are biochemically designed. They're designed to store large amounts of glucose, and small amounts of fat. So they're actually supposed to look like this. And this is how you actually maximize your longevity and decrease your chronic disease risks.

But when they move from this composition to this composition, then you develop insulin resistance, and this increases your risk for many chronic diseases. So for all of you that said that, give yourself a high five, you crushed it.

Okay. So, if you eat these foods on the left: Fruits, vegetables, legumes, a whole grains, you end up with more insulin sensitivity tissues. You eat meat, chicken, fish, dairy, eggs you end with more insulin resistant tissues. Now, when you become insulin sensitive, it's very straightforward to be able to get your A1c value to between 5 and 6%. And you can achieve this A1c of 5 to 6%, while eating carbohydrate rich foods. And it turns out that these carbohydrate rich foods, which I pictured here, have a very high nutrient density. When I say high nutrient density, I mean high micronutrient density. They’ve got lots of vitamins, lots of minerals, lots of fiber, lots of water, also phytochemicals, and lots of antioxidants.

So, these types of foods are what are called nutrient-dense foods, because they have a lot of micronutrients in them, and by eating these foods, you're able to eat not only foods that contain a lot of carbohydrate, but you'll be able to keep your A1c at the 5.0s, and that's excellent work if you're living with some form of diabetes. Because again, we're trying to move our A1c into the non-diabetic range, or close to the non-diabetic range. And this right here is exactly what we see from hundreds, if not thousands, of people that we support in our Coaching Program.

Now, if instead you eat the foods that are pictured here on the right, you can achieve an A1c, that's even lower. Look at this, your A1c can go as low as 4%, and it's very, very common to see people on the internet, or people who are eating a low carbohydrate diets, especially ketogenic diets report that their A1c is at 4.2, or 4.6, or 4.7. But here's the difference. You can achieve these very low non-diabetic A1cs, however, you cannot eat carbohydrate rich foods. And I say “cannot”, not because they're not allowed, it's because the minute you eat carbohydrate foods, your blood glucose goes through the roof. And the reason for this is because, like I talked about, these foods cause insulin resistance.

So yes, you're able to drop your A1c to a nice, low value, simply because you're avoiding carbohydrate rich anything. And by doing that, you actually develop more insulin resistance. You just never know that you're living with insulin resistance, because there's no carbohydrate to challenge your glucose metabolism. So, people who are eating these low carbohydrate and ketogenic diets, they actually don't know that they're actually living with a high amount of insulin resistance, which is increasing their risk for chronic disease. It's not their fault. But their A1c is low, but their insulin resistance is hot. And that's a huge problem.

So, if we look at it from another way. Insulin sensitive tissues look like this more blue, less yellow, and you can achieve A1c between 5 and 6.0. And this right here is excellent, excellent work. This is the only thing that's actually physiologically necessary. It's not actually required to get your A1c to less than 5.0. Because again, even in non-diabetic individuals, it's not that low. If you eat resistance causing foods, then you end up with more yellow and less blue, you develop more insulin resistance, even though your A1c is nice and low. So this is why people get confused because they say, “What are you talking about? My A1c is a 5.1… It's a 4.6, it's better than your A1c!” right? But what I'm saying is that, that's not enough, because you have a low A1c, but you're living with a lot of insulin resistance.

Now, why is insulin resistant the problem? Here's why. Because insulin resistance is a central node. And what that means is that when you increase your level of insulin resistance, and increase your risk for insulin resistance, you also increase your risk for a whole host of chronic diseases, which you see here. This is not all of them, I just picked out the ones that are most common.

So that includes things like all forms of diabetes are listed here, you increase your risk for cancer, for coronary artery disease, which can lead to a heart attack. For hypertension and atherosclerosis, which can lead to strokes down the road. For obesity, for high cholesterol, for fatty liver. More insulin resistance results in increased difficulty dealing with PCOS, which is polycystic ovarian syndrome, we're going to be writing an article about this very soon.

Did you know that if you increase your level of insulin resistance, you're also at risk for Alzheimer's disease? And there's some really fascinating research which is coming out now showing that Alzheimer’s patients are generally insulin resistant. You increase your risk for neuropathy, for blindness, for kidney failure. For retinopathy, this is what happens to your eyes and say “Why is it becoming very difficult to see?” And for erectile dysfunction.

So, all of these are very real conditions. And the more insulin resistance you have, the more your risk for all these, what I call, satellite complications. So again, take home message of today's webinar, low carbohydrate diets reduce your A1c, but they make you more insulin resistant, and that is going to lead you in the wrong direction over time. So, here's what happens to people in the low carbohydrate world. Again, this is not their fault, because they're unaware that this is happening. But this is the truth. You hear statements like this, “Look my A1c is super low, 4.7. My glucose has never been lower. Never been more controllable. Look, my glucose doesn't budge, it's between 80 and 90 all day long”. They get super excited, just like this dude, right here. Super excited, because they believe this is controllable. All they have to do is avoid eating fruits, vegetables, legumes, and whole grains. If they can do that, boom, no problem.

So you'll see people say, “Oh, look, this is my blood glucose profile before I got to the ketogenic, or low carbohydrate diet. And now that I’m eating a ketogenic diet… Boom! Look at this. Flatline, flatline. No problem controlling my blood glucose.” My question to you is this: Is this good enough? Is this good enough? The answer is no. Because they make you more insulin resistant.

Now, in the long term, here's what can happen to you if you are living with insulin resistance over the course of time. You can end up with an increased risk for heart disease. So this is sort of a text version of that picture I previously showed you. All types of cardiovascular conditions can result. Glucose metabolism disorders can result. You can end up with a fatty liver. That's a huge, huge problem for a lot of people living with that type 2 diabetes.

It significantly increases total body inflammation. And over the course of time, you can end up gaining weight, or not being able to lose weight. You can end up dropping your energy levels, having very difficult GI function, or GI dysfunction. And you can end up with very intense food cravings.

So in the chat box, here's what I want to know from you guys. If you are currently eating a low carbohydrate diet, or if you have eaten a low carbohydrate diet in the past, what types of side effects did you experience? Because I notice side effects that I experienced, and I remember they were terrible, I did not like any of them. But I want to know from you guys, if you've eaten a low carbohydrate diet, or if you're currently doing it right now, what type of side effects have you experienced?

Robby Barbaro: Okay, so the first answer we have coming in is: Food cravings. Now, we have Mandy experiencing foggy brain. Deb had muscle cramping. Food cravings for Christina. Patricia was put on three meds… And now they're starting to just flood in here. Colon cancer, energy fluctuations, diabetes got worse, heart arrhythmia, didn't lose weight, trouble sleeping, constipation, irritability, cholesterol shot up, low energy, brain fog, mood swings, low energy.

Cyrus Khambatta, PhD: Yep, you're hitting them all in the head. Every single one of the ones that you just described are common, common side effects of low carbohydrate diets.

Okay, that's really good news. Sorry, that's not what I meant to say. It's not good news that you experienced that, but it's good news that you guys are now educated about the fact that a low carbohydrate diet can actually be the cause of all that. But here's the best part, you can reverse it. You can reverse it using low-fat, plant-based, whole-food nutrition. Chris, absolutely love this guy. Those of you who are in our Coaching Program have probably interacted with him. He's in our Facebook group. He's very active. He's been on a low-fat, plant-based, whole-food diet for 11 months. Yesterday, he posted an update. He has lost 76 pounds in 11 months. I had no idea he lost that much weight. 76 pounds. His fasting blood glucose has been cut in half. His A1c went from the just over, you know, just in a type 2 diabetes range, all way down to 5.2.

So, let me back up here. Chris has type 1 diabetes. He’s like me, he's like Robby. He has type 1 diabetes, he also has rheumatoid arthritis. He was also put on a whole host of blood pressure medications, and cholesterol medications, and anti-inflammatory medications. He was taking 12 medications. Now, even though he has type 1 diabetes, and his blood glucose control was, I would say it was relatively good, because he was at 6.5. But now that he's eating like a champ, he's dropped his A1c to the low fives, which is I'll be honest, it's better than my A1c. Better than Robby’s A1c, and he's killing it. He's done a great job. And now his basal insulin, and his bolus insulin has gone down significantly.

He just posted this picture yesterday. This is his A1c right here, 5.2 with an estimated average glucose of 103. Here's the best part: Chris eliminated 12 oral medications. He eliminated 12 oral medications, and is now only on insulin, because he has to be for the rest of his life. This is the power of power of plants.

Okay, so here's the second question: How does exercise affect your A1c? Because I told you earlier that you can manipulate your A1c to your advantage, using a number of different variables. Exercise is the second most important of all of them. So, here's one of the most important things that you could learn about how exercise affects your blood glucose. Over here, I have pictured your muscle, your liver and your blood vessels. Now, when you exercise, tissues, namely, your muscle and your liver, are able to take up glucose for free. Now, what do I mean by that? I mean that they're able to take up glucose, without the use of insulin. And that's a big deal.

Under normal circumstances, all tissues require insulin, in order to use glucose, with the exception of your brain. That's the only one that can use glucose for free. Your muscle requires insulin, your liver requires insulin, your pancreas requires insulin, your gallbladder requires insulin, your kidneys, your lung tissue, etc, etc. All these tissues require insulin to use glucose. But in this situation, when you exercise, you can actually put glucose into these tissues without a single drop of insulin.

Well, how does that work? Okay, so when you're exercising, your muscle sends out a signal that says, “Hey, I need glucose. I need lots of it. Because I'm being used right now. I'm expanding, contracting, expanding, contracting, expand and contract. I'm doing a lot of work, give me fuel”. And your liver also says, “Yes, I need glucose as well”, because your liver is responsible for giving glucose to your muscles, and giving glucose to actively working muscles. So, glucose is going into your muscle, and it's being burned quickly, your liver is giving up glucose, and therefore it needs to be replenished. So, what ends up happening to both of these tissues, saying, “I need glucose”, “I need glucose”. And so, the glucose that's present in your blood, gets a free ride into both of these tissues.

So, the glucose that's already present in circulation, that's floating in your blood goes, “Oh, hey, look! I can get into the muscle for free”, and then it does. And then it says, “Oh, hey, look. I can get into your liver for free”, and then it does. So, this is what's called insulin independent glucose uptake, and this is something that happens during exercise, and something that happens after exercise as well, for a short window of time.

Now, when you are done performing exercise, and you're in the resting state, the truth is you can still take up small amounts of glucose for free in your muscle and in your liver, but what ends up happening in this state, when you're done, when you're resting, is that both of these tissues require insulin, they just require a fraction of what they used to require before exercise.

So, this is insulin pictured here in green. I showed you one molecule of insulin for your muscle, and one molecule of insulin for your liver. That's an exaggeration. What I'm trying to say is that you don't need very much. So, small amounts of insulin is necessary for your muscle and for your liver to be able to take glucose. So, what insulin says is, insulin goes “Hey, muscle, knock, knock. I got some glucose in the blood. Do you want to take it up?” And it goes to your liver, “Hey, liver, knock, knock. I got some glucose in the blood. Do you want to take it up?” Both of these tissues say, “Oh, heck yeah! I definitely want this stuff, because I'm still hungry. I'm still hungry”, because you just went and did that class. You just went and swam, you ran, you did a hike. You did jazzercise, maybe you did a CrossFit class, maybe you went with a soccer ball outside.

Doesn't really matter. But these tissues are hungry. So, the glucose that's in your blood is able to get inside of these tissues, using only a small amount of insulin. Before exercise, you would have needed maybe 50% to 100% more. So, insulin has basically… Exercise has sensitize you to insulin, in the sense that only a small amount is necessary to get this glucose right here into tissues.

So, what exercise does is, it reduces your A1c value, because number one, it allows glucose to get into tissues without the use of insulin, and that drops the amount of glucose in your blood, which is a good thing, because that drops the amount of hemoglobin which is going to get exposed to insulin. Number two, exercise makes insulin more powerful when you rest, just like we talked about, okay. And number three, exercise reduces your blood glucose both during and after exercise, which means that overall hemoglobin, no matter where it lives, is less exposed to glucose. And that's a good thing.

So, as you adopt a regular exercise regimen, your A1c value is likely to start out, let's say it started out as a 6.3, the more you exercise, the more you can drop your A1c value closer, and closer, and closer to this non-diabetic range where we're trying to end up.

Now, it's important understand a couple of things. Number one, consistent movement is the second most powerful insulin sensitizer after your diet. It is not necessary to move your body at a high intensity, all we're asking you to do is move your body approximately six days per week, for approximately 30 minutes per day. This is consistency. So, this is a total of about 180 minutes of exercise for the week. I did not say perform one hour on Sunday, and one hour on Wednesday, and then sit on your butt the rest of the time. No, no, no, I'm saying do 30 minutes of exercise, at the minimum, every single day and take one day off. If you do that you're consistent. And that's how you get a net reduction in your A1c.

Like I said earlier, you do not need to exercise a high intensity. There's this common misconception that because high intensity interval training actually does work. And then it can make significant performance improvements in a short period of time, that the only way to exercise is by going out and just killing yourself. I can tell you with a lot of confidence, it is not necessary to go out and do sprints. You do not need to go out and join CrossFit. You don't need to do any of that. All you need to do is move your body and get your heart rate elevated. And if you can get your heart elevated for approximately 30 minutes per day, six days a week, that right there is going to drop your A1c significantly.

So, here's how you can do this. Simply split your exercise. My recommendation here would be to choose three of those days and do cardiovascular based movements: Running, hiking, biking, swimming, jogging, Tae Bo, Zumba. Any of these movements, which just get your heart rate elevated. That's really, really, really good stuff for your blood vessels, for your liver, and for your muscles.

The other three days, I would try and focus on doing some type of resistance movement, which is things like: Body weight resistance training, it could be weightlifting, it could be P90X, it could be CrossFit. It could be anything that involves things like squats, and push-ups, and sit-ups, where you're moving your body against the resistance of gravity. That's how you can split up your movement patterns between cardiovascular and resistance movement, and when you do it this way, you can maximize your insulin sensitivity very easily.

Here's a perfect example, Lindsay. I love this girl. We've been working with Lindsay now for probably close to two years at this point. She started out, she has type 1 diabetes similar to Chris. Her A1c started out at 7.2, her A1c is currently, I think it's even lower than a 5.8 if I’m not mistaken. But last time we checked, it was a 5.8. Her insulin use came down by 33%, she lost 17 pounds, and her cholesterol level came down by was approximately one third. She did this by eating a low-fat, plant-based, whole-food diet, as you can see right here, and exercise.

This girl lives to exercise. She runs, she does yoga, she also does CrossFit. She does some combination throughout the week of all those three different types of exercise. She's super active, she loves being active. And I love talking with her about that, because I'm also addicted to exercise. So she uses her diet and exercise as her two most powerful weapons. And as a result of that, look at her A1c. She's doing a fantastic job, and my hat goes off to her.

Last thing here, your A1c is an incomplete indicator of your diabetes health. Well, what the heck do I mean by that? Most people who are living with diabetes, throw the all of their eggs into the A1c basket. It's like if you're a poker player, and you go all-in on one hand, and you're like, “You know what? I'm going to give all my chips in, because I believe so confidently in my hand”. Your A1c is important, but your A1c is not that important.

Your A1c can only truly be interpreted in the context of a whole host of biomarkers, in order to determine your total body health. It's just one indicator of your blood glucose average. And it is not the end all and be all of your diabetes health. However, most people, and most physicians believe that your A1c is the end all and be all of your diabetes health.

So again, here's Jonathan, same dude I showed you earlier. The guy’s got a great A1c, it's a 4.7. His blood glucose has never been lower in his life. And his blood glucose is between 80 and 90 all day long. Let's do a quick case study on Jonathan, because even though his books control is excellent, there's something fishy about his health. And we're going to try and figure out what it is.

So, Jonathan had lab tests taken in April, and he had lab test taken in July. So that's three months separated. In April his A1c was at 8.4%. So as we've talked about, that way elevated. So as a result of that, he was diagnosed with type 2 diabetes, and he was told to adopt some diet, and some exercise regimen to drop that number. Three months later, he comes back, he checks his A1c, it's a 5.3%. He's happy.

Next thing is body weight. He started out at 189 pounds, he's now 163 pounds, he lost 26 pounds in three months. No wonder he's got such a big smile on his face. He's a happy, happy camper. His BMI, his body mass index, a healthy individual has a body mass index between 20 and 25. Anything beyond 25 indicates being either overweight or obese. And anything between 20 and 25 indicates being healthy. So, he started out in the overweight category. And then three months later, he's now right smack dab in the middle of the happy zone. So, his A1c improved, he lost 26 pounds and his BMI went from being overweight to normal. So, things are looking awesome for Jonathan right now.

Here's the question: Is Jonathan insulin sensitive? In the chat box I want you guys to write whether or not Jonathan is insulin sensitive. If we don't know the answer to that question, tell me why we don't have the answer that question. Go.

Robby Barbaro: Okay. Let's see what comes in. So the question is… Gina says “Nope”. Leticia says yes. Kathy says, “Who knows?” Bonnie says no. Bruce says “Yes, he is” Sharon says no. Stephanie says no. Anne says he's insulin resistant. Rose says “No, he is not insulin sensitive” Hope says “We don't know yet” Peter says, “I don't know” Ann says no. Barbara says “Most definitely”. There’s answers all over the place Cyrus.

Cyrus Khambatta, PhD: Answers all over the place. Okay, so if you said yes, Jonathan, is insulin sensitive, that's a good guess, but the answer is, we don't have enough information. That is the right answer, okay? So for those of you who said, “We don't know, I don't have enough information, he could be insulin sensitive, he could be insulin resistant. It's a giant question mark”, give yourself a high five, because we don't have enough information.

The information that we're looking at right here is basically indicating to us that things are moving in the right direction. He's got a lower A1c, he lost 26 pounds, and he improved his BMI. So, this is all good, good, good. This is what happens. You go to the doctor's office, and your doctor looks at this and the doctor is like, “Hey, things are looking good for you. High five, whatever you doing, just keep it up. You're doing a great job”, right? The problem is that, it's not that your doctor is wrong, or that your doctor is a bad person. Not at all. Your doctor is trying to help you out as much as possible. It's that we don't have enough information, because we're not measuring the right things. We're not measuring enough biomarkers to actually know whether or not your insulin sensitive.

So, what do we need to measure in order to actually determine whether or not Jonathan is insulin sensitive. That's the question. So, what we developed, actually what Kylie developed because she's so smart. She's so brilliant. She's been a nurse for 18 years. She came up with the insulin resistance checklist. And the insulin resistance checklist is actually an article that we've published, I believe, last week or the week before. And the insulin resistance checklist is basically a collection of biomarkers that you can track over the course of time, in order to determine if you're actually insulin sensitive. I would love for there to be one thing that you could measure, that would say “Yup, look, you’re insulin sensitive”, but it's not that simple. Because it's a complicated concept. So, the things that you need to measure are using this acronym PILAF, okay? So, just think rice Pilaf. PILAF, right here.

The first one is “Pressure”, for your blood pressure. We do not know Jonathan's blood pressure. Without knowing his blood pressure, we cannot determine whether or not he's insulin sensitive. I stands for “Ideal body weight”. We can calculate his ideal body weight. He is actually at his ideal body weight. So he's doing a great job. We know the answer to this question.

His “Lipid panel”, his cholesterol, LDL, HDL, triglycerides. We don't know that information. He could have incredibly high cholesterol, or he could have good cholesterol. We don't know. That's why I said unknown here. His ”A1c”, we know the answer. And his “Fasting blood glucose”, we know the answer.

So, we know three out of the five of these things. But these two unknowns are so important that if we don't know them, then we cannot conclude anything about his insulin sensitivity. Another thing that we don't actually know in the situation, is we don't know the composition of his diet. We don't know if he's eating low-fat, plant-based, whole-food, or whether he's eating a low carbohydrate or ketogenic diet. We don't know. He could be somewhere in the middle. He could be eating a standard American diet, we all know how terrible that is for your health.

So again, without any of these biomarkers of these PILAFs, or knowing the composition of his diet, it's a giant question mark. We just don't know the answer. So, if you saw the blog article, and you were able to download the insulin resistance checklist, awesome for you. In the chat box, Kylie is actually putting the URL to the blog article, you can click on it and get the insulin resistance checklist from there.

It basically allows you to print this out, and then stick it on your fridge, and check off the things that you have accomplished so far. And what you might find over the course of time, is that maybe you have 50% of these checked off today. And then three months down the road, you have a couple more things checked off. And then a couple more months down the road, you have a couple more of these checked out. The idea here is to have a checkbox in every single one of these. If you can get a checkbox in every single one of these, then you are truly insulin sensitive. But if not, then that means that there's still a little bit more work to do.

So, Kylie is going to put this link into the chat box, I think it's already there, but www.masteringdiabetes.org/insulin-resistance-checklist, so you can go there, and you can download this checklist.

So, here's a perfect example, Tammy. Tammy, she within the first four and a half months of adopting a low-fat, plant-based, whole-food diet she lost 37 pounds. Since that time, she's actually gone on to lose a lot more weight. Her fasting blood glucose was close to the type 2 diabetic range, she was actually diagnosed with type 2. But on the day that she was measuring her fasting blood glucose, it was sort of in mid 120s. Now, it's sub 100, practically every single day. Her A1c has gone into the very low fives. Again, that's a really good indicator, this is a non-diabetic A1c. Her cholesterol has gone down, her LDL cholesterol has gone down. And she stopped using Metformin. This is a perfect example of somebody who has made improvements, not only in her A1c, but in a whole bunch of different biomarkers. And unless, and until, we know how these other biomarkers are changing, we cannot determine whether or not she's actually moving in the right direction.

Okay, you can see here, earlier she was actually significantly overweight. And by adopting this Program, she's not slimmed down tremendously. And like I said, she's lost 37 pounds of the first four and a half months, but she's gone on to lose a lot more weight since then.

And then Sharon's another perfect example. She’s living with type 1 diabetes. Her A1c is now in the close to the non-diabetic range. She lost 25 pounds, she uses 40% less insulin, she was on an oral medication called Symlin, she's no longer on that, she's only on insulin, and her carbohydrate intake has skyrocketed.

So these are the types of results you see over, and over, and over, and over, and over again, it’s what happened to Robby, it’s what happened to me, it’s what's happening to all of our clients, or many of our clients. And this is something that's very real, because this is the power, this is the true power of a low-fat, plant-based, whole-food diet.

So, real quick recap. This is what we've covered so far. Now, you guys are experts, you know what your A1c actually represents from a biological perspective. You can now go to someone and explain that your A1c is a three month indicator of your blood glucose average, because it's measuring the amount of glucose it's attached to hemoglobin that's in circulation. And hemoglobin has a lifespan of approximately 120 days.

You know how your diet affects your A1c level. You know how you can drop your A1c using both a low-fat diet, and a low carbohydrate diet, but that a low carbohydrate diet makes you more insulin resistant. Now, you know how your exercise regimen, you can use that to drop your A1c level, simply because you can see simulate both non-insulin dependent glucose uptake, and you can gain insulin sensitivity in the resting state.

And now you know that your A1c is incomplete indicator your diabetes health because just knowing your A1c is not enough information, you have to know the entire acronym PILAF. If you don't know PILAF, you don't whether you're insulin sensitive.

Cyrus Khambatta, PhD: We hope you enjoyed this episode, and can apply some of these principles to your personal life. Now, we have an Online Group Coaching Program that has helped thousands of people living with all forms of diabetes, reverse insulin resistance, drop their A1c, lose weight, and gain tons of energy. And also reduce their need for oral medication and insulin using, their food as medicine.

We like to call ourselves the world's most robust, and ridiculously affordable, Online Coaching Program for people with diabetes. And we've helped people living with type 1 diabetes, type 1.5 diabetes, prediabetes, type 2 diabetes, and gestational diabetes living all around the world.

Now we provide you with three tools that are specifically designed to put you in the driver's seat of your diabetes health. The first is an Online Course that gives you step by step instructions on how to change your diet. Starting with breakfast, then lunch, then dinner.

We teach you exactly which foods to increase, which foods to limit, and which foods to avoid entirely. The course is designed with you in mind. We provide you with relevant information, and we do our best to reduce overwhelm, because we know just how confusing the internet can be these days, when searching for simple ways to improve your blood glucose control.

The second tool is even better than the first. We provide you with access to our online community, with thousands of people that are going through this process with you. You'll be able to interact with our team of coaches, including Kylie Buckner, a Registered Nurse who is brilliant. She also happens to be my wife, and is one of the most kind and compassionate human beings that I've ever met. Adam Sud. He reversed type 2 diabetes. He lost more than 160 pounds and he de-addicted himself from both food and prescription medication at the same time.

You'll also get to interact with Mark Ramirez, who lost more than 50 pounds, reversed type 2 diabetes, and is a certified Food For Life Instructor, through the Physicians Committee for Responsible Medicine. You'll also get the ability to interact with both Robby and myself in the online community. And we guarantee that we’ll answer your question within 24 hours to help you solve problems in real time.

The third tool is a twice monthly Q&A video conference, where you can ask our team of coaches any question that you have about your personal program, and meet others that are going through this process with you. Now, we're proud to say that our coaching program is very popular, and because of that, we've instituted a waiting list to join. The reason we created the waiting list in the first place is because we have more than 2000 active members in our program and want to provide excellent service to our existing members. You can still join the program, but in order to do so you have to put yourself on the waiting list and you'll be notified of when we open next. When we do, we'll send you a personal invitation to join.

To join the waiting list simply go to www.masteringdiabetes.org and click on Coaching in the navigation bar at the top of the screen, or click the link below in the show notes. We can't wait to help you transform your diabetes health from the inside out. We hope to see you on the inside.

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About the author 

Cyrus Khambatta, PhD and Robby Barbaro, MPH

Cyrus Khambatta, PhD, and Robby Barbaro, MPH are the coauthors of the New York Times bestselling book Mastering Diabetes: The Revolutionary Method to Reverse Insulin Resistance Permanently in Type 1, Type 1.5, Type 2, Prediabetes, and Gestational Diabetes. They are the cofounders of Mastering Diabetes, a coaching platform that teaches people how to reverse insulin resistance via low-fat, plant-based, whole-food nutrition. Cyrus has been living with type 1 diabetes since 2002, and has an undergraduate degree from Stanford University and a PhD in Nutritional Biochemistry from UC Berkeley. Robby was diagnosed with type 1 diabetes in 2000, and has been living a plant-based lifestyle since 2006. He worked at Forks Over Knives for 6 years, and earned a Master’s in Public Health in 2019.