Prediabetes and Your A1C: What the Number Means, and What Helps

It usually arrives late on a weeknight. Your patient portal sends a cheerful email saying new results are ready, you open it in bed, and there it is: an A1C of 5.9%, with a small red "H" next to it and nobody around to explain it. 30 minutes later, you've read that prediabetes is a ticking time bomb, that carbs are over for you, and that a supplement sold by a ‘doctor’ in a cold plunge can reverse it in 30 days.

You deserve an actual explanation.

What the number is actually measuring

Sugar in your blood sticks to hemoglobin, the protein in red blood cells that carries oxygen. The A1C test measures what percentage of your hemoglobin has glucose attached. Red blood cells live for a few months, so the result reflects your average blood glucose over roughly the past three months, not what you ate last night.

Most labs read it like this. Below 5.7% is the typical range. From 5.7% to 6.4% is prediabetes. At 6.5% or above it's diabetes, usually confirmed with a second test.

Prediabetes means your body is working a little harder than it used to in order to keep glucose in range. Most often that's some degree of insulin resistance: insulin still does its job, it just has to shout a bit to be heard.

You're in very large company. The CDC's National Diabetes Statistics Report estimates 115.2 million US adults have prediabetes. That's a lot of people getting the same late night email, and very few of them getting a decent explanation with it.

Sometimes the test is the one that's off

The A1C is a good test. It's also a test of your red blood cells, which means anything that changes your red blood cells can change the number. According to the NIDDK, iron deficiency can push it up. Inherited hemoglobin variants, for example, can skew it either way. So can recent blood loss, transfusions, sickle cell disease, kidney failure, or liver disease.

If your iron has been low, or your A1C doesn't match your fasting glucose, raise it with your doctor before anyone rearranges your life around one number. Lab reports are very confident documents. They are not always right.

A fork in the road, not a conveyor belt

The internet describes prediabetes as the waiting room for diabetes. The research is more interesting than that. In a community study of older adults in JAMA Internal Medicine, 9% of people with A1C-defined prediabetes developed diabetes over about five years, while 13% moved back into the typical range.

Those were older adults, so the numbers won't map perfectly onto a 35-year-old in Mueller. But the point holds: the label describes where your glucose is today, not where it has to go.

So the most useful response is curiosity. What's going on with sleep, stress, movement, medications, and how regularly you eat? Is something like PCOS in the picture? Those questions lead somewhere. "Never eat bread again" mostly leads to a very long February.

Why "just cut carbs" backfires

This is where people expect a list of forbidden foods. There isn't one, and not because I forgot to print it.

Strict carb rules are hard to keep, and when they break (they usually do), eating tends to get more chaotic than it was before, with a side of guilt. Glucose does not love chaos. Long gaps followed by very large, very hungry meals produce bigger swings, not smaller ones. If you've tried counting your way to better blood sugar, you may recognize the pattern from our post on why calorie and macro counting doesn't hold up.

Prediabetes also tends to arrive with a weight lecture attached. You can improve how your body handles glucose through behaviors, whether or not your body size changes, and the behaviors are the part you control. That's the idea behind our weight-neutral approach.

So the condition improves with steady eating, and the standard advice makes eating less steady. Somebody should really look into that.

The stuff that works

Add fiber you actually like. Fiber slows how quickly glucose reaches your blood and keeps you full in a pleasant, non-punishing way. A large series of reviews in The Lancet found people who ate the most fiber had 15% to 30% lower risk of type 2 diabetes, heart disease, and early death than people who ate the least. Beans in the breakfast taco, berries on the yogurt, oats, lentils, popcorn at the movies. Nothing has to leave the plate for fiber to join it. Our fiber guide has easy places to find it.

Give carbs some company. Carbs are not the villain here. Eaten alongside protein, fat, or fiber, they tend to raise glucose more gently than when they show up alone. That doesn't mean every snack needs a chaperone. Pasta with chicken and a salad, or an apple with peanut butter, is a nice option when it sounds good.

Eat on a rhythm. Regular meals and snacks, timed around your actual life, usually keep glucose steadier than marathon gaps and catch-up eating. If you forget to eat until 3pm and then inhale a sleeve of crackers in the car, you're not lacking discipline. You're lacking lunch.

Move a little after meals, if you can. A meta-analysis in Sports Medicine found that breaking up long sitting with light walking lowered post-meal glucose and insulin. Light means light: a lap around the block, pacing during a phone call. The American Diabetes Association notes that both aerobic and strength training help the body use insulin, so pick the kind you don't dread.

Treat sleep and stress as part of the plan. A meta-analysis of randomized trials found that short sleep makes the body less sensitive to insulin, and stress hormones raise blood sugar by design.

Keep the foods you love. Your mom's rice, kolaches on Saturday, birthday cake at birthdays (or just… days). These stay. When people feel allowed to have the foods that carry culture and joy, they usually eat them in a more relaxed way, and that steadiness helps more than another round of willpower ever has.

Working on it together

We start with your labs, your routine, and your history with food, including every diet that "worked until it didn't." From there we change a few things that matter instead of everything at once, and we track what you can feel and measure: energy, hunger, sleep, and follow-up labs, not the scale. If PCOS, a history of gestational diabetes, or a strong family history is part of the picture, we build that in. You can meet our dietitians here. We see clients in person in Austin and by telehealth anywhere in Texas, and working with a diabetes dietitian for prediabetes is usually covered by insurance.

• What is a " normal " A1C?

  Below 5.7% is the typical range. From 5.7% to 6.4% is prediabetes, and 6.5% or above is diabetes, usually confirmed with a second test. The NIDDK explains how the ranges are set.

• Is an A1C of 5.7% bad?

  It's the starting point of the prediabetes range, which means glucose has been running a little higher than typical over the past few months. It's a useful signal to look at sleep, movement, eating rhythm, and medications, not an emergency.

• Can prediabetes go away?

  Often, yes. In a study of older adults in JAMA Internal Medicine, more people with A1C-defined prediabetes returned to the typical range than went on to develop diabetes over about five years.

• Do I have to stop eating carbs if I have prediabetes?

  No. Adding fiber, pairing carbs with protein or fat when it suits you, and eating regularly tend to help more than strict rules that are hard to keep. Cutting carbs often leads to the restrict-then-overeat swing that makes glucose less steady.

• Can my A1C be wrong?

  It can. Iron deficiency, inherited hemoglobin variants, recent blood loss, and kidney or liver disease can all make A1C read falsely high or low. If it doesn't match your other glucose tests, ask your doctor about it.

• How often should I recheck my A1C?

  That's your doctor's call, but because the test reflects about three months of glucose, rechecking sooner than that usually won't show much. Many people with prediabetes are retested once a year, or sooner if something changes.

• Do I need to lose weight to improve prediabetes?

  No. Regular eating, more fiber, movement you enjoy, and better sleep can improve how your body handles glucose whether or not your weight changes. That's the core of a weight-neutral approach.

• Does insurance cover a dietitian for prediabetes?

  Often, yes. Khan RD is in-network with Aetna, Blue Cross Blue Shield, and UnitedHealthcare, and most clients pay $0 or a copay. You can check your coverage here.

If a portal message and a search bar have been your whole care team so far, you deserve a better one. Khan RD is in-network with Aetna, Blue Cross Blue Shield, and UnitedHealthcare, and most clients pay $0 or a copay.

The content of this blog does not serve as medical advice.