What is "Pre-diabetes" anyway?

Reclaiming Agency in the Glucose Gray Zone

Apr 01, 2025

ICYMI 👉

This Friday’s LIVE Q&A is all about Pre-Diabetes & Metabolic Health. Join me HERE on Friday 4/4 at 3 pm ET!

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A patient I'll call Maria sat across from me last month, visibly distressed. She had previewed her lab test results on the patient portal the day before our visit. When she saw the words “PRE-DIABETES” next to her elevated hemoglobin A1C blood level, she froze.

Her mother had diabetes and developed heart disease and kidney failure. “Am I going to get diabetes too?" I could see Maria was already envisioning a future filled with insulin injections and complications.

Another one of my patients, James, had the same lab result but a completely different reaction. He shrugged it off: "It's only pre-diabetes, right? Not the real thing. I don't need to worry yet," he said, as if he needed to reassure me about the lab result.

Both of these reactions—panic and dismissal—stem from the same problem: the term "pre-diabetes" itself. (They also demonstrate the downsides of interpreting one’s own lab results!)

I will talk about the latter issue another time. But today, I want to explore why this term “pre-diabetes” matters, what your hemoglobin A1C (or “A1C” number actually means, and most importantly, how understanding the nuance can put you back in the driver's seat of your metabolic health.

ice with cherry on top — Photo by Myriam Zilles on Unsplash

What Your A1C Actually Means

First, let's demystify what we're measuring. The hemoglobin A1C is a blood test that provides a snapshot of your average blood glucose levels over the previous 2-3 months. Unlike a single glucose reading that captures a single moment in time, the A1C gives us the bigger picture of how your body is handling sugar over time.

Here's how we categorize the results:

Below 5.7%: Generally considered normal
5.7% to 6.4%: The "gray zone" traditionally labeled as ”prediabetes”
6.5% or higher: Diabetes diagnosis (when confirmed with a second test)

When your healthcare provider tells you your A1C is 6.1%, they're saying that over the past 2-3 months, your blood sugar has been running higher than optimal—but not yet at the threshold we use to diagnose diabetes.

The Problem with "Pre" Anything

Now, let's talk about that loaded prefix: "pre." It suggests an inevitability—that you're on a one-way street to diabetes. It implies you're in a waiting room, about to be called into the main event of full-blown disease.

But this isn’t necessarily the case.

The gray zone between normal blood sugar and diabetes is not condition—it's simply as description of a degree of blood sugar elevation over time that exists on a continuum. Unlike what the term suggests, it is not a guaranteed precursor to diabetes.

Studies show that only about 5-10% of people with so-called "pre-diabetes" progress to diabetes each year. Many remain in this middle zone indefinitely. Some even return to normal blood sugar levels. Your trajectory depends on multiple factors, including your age, genetics, medications, hormonal status, eating habits, exercise/movement, lean muscle mass, body fat percentage, stress levels, sleep quality, and your even gut health.

In other words, your A1C is more than just a piece of lab data; it reflects your whole health ecosystem.

The problem with the term "pre-diabetes" is that it can create either undue panic (as with Maria) or false complacency (as with James). Better than reacting to the number is to understanding what you can do about it.

A Better Framework

Instead of thinking about "pre-diabetes," I encourage my patients to think about "metabolic flexibility"—your body's ability to efficiently switch between using carbohydrates and fats for energy.

When your A1C falls in that 5.7% to 6.4% range, it's an early signal that your metabolic flexibility is compromised. Your cells aren't responding to insulin as effectively as they could be (insulin resistance), and your pancreas may be working overtime to keep blood sugars in check.

But—and this is the crucial part—this situation is remarkably dynamic. Your metabolic health responds to changes in:

What you eat and drink: Reducing processed carbohydrates, simple sugars and alcohol while increasing fiber, protein, and healthy fats can make a significant difference in your A1C levels.
How you move: Regular physical activity—both aerobic exercise and strength training—enhances insulin sensitivity at the cellular level. Adding muscle mass to your frame can help boost your base metabolic rate.
How you sleep: Poor sleep quality directly impacts blood sugar regulation the next day. In addition, who doesn’t notice the urge to snack on sweets when you haven’t slept? 🙋🏻‍♀️
How you manage stress: Chronic stress elevates cortisol levels, which in turn raises blood sugar levels. Under sustained stress, high cortisol levels can elevate the A1C. Mindfulness techniques and taking care of your mental health have been shown to improve glycemic control.
Your hormone status: Low estrogen states (e.g., menopause) and low testosterone levels can promote insulin resistance. I have written quite a lot about the benefits of menopausal hormone therapy and testosterone supplementation, when appropriate, for metabolic health.
Your medication approach: Certain medications (such as oral steroids) can elevate blood sugars. Sometimes, medications like metformin can be appropriate tools to help restore metabolic balance. Ozempic is its own animal. I’m happy to talk about this—and all of the above!—during Friday’s live chat.

The upshot: the dynamic nature of blood sugars means you have multiple levers to pull. In short, an elevated A1C is an active invitation to engage with your health.

Real-Life Changes

Let me tell you about Maria three months later. After we reframed her situation, she made modest adjustments to her routine—walking for 30 minutes most days, reducing her portion sizes of rice and bread, and prioritizing seven hours of sleep. Her A1C dropped from 6.2% to 5.8%.

And James? Once he understood that dismissing his 6.0% A1C meant missing an opportunity to prevent more serious issues, he worked with a nutritionist to revamp his eating habits. Six months later, his A1C was 5.5%—technically "normal" again.

These aren't rare cases. They represent the rule, not the exception, when people are given the right information and support.

The Numbers Matter, But So Do You

While the medical community debates the exact thresholds and terminology, here's what I want you to take away: The numbers matter because they give us information, but they don't define your future.

An A1C of 6.0% is information—valuable information. It tells you that some aspects of your metabolism could use attention. It gives you a chance to intervene early, before more significant issues develop. It's a gift, not a curse.

Think of it like a check engine light in your car. It's not telling you the engine is about to explode; it's suggesting you might want to look under the hood and make some adjustments before more serious problems develop.

Moving Forward

If you've been told you have "prediabetes," I suggest reframing it as "early metabolic change" or simply "elevated blood sugar." Then ask yourself and your healthcare provider these questions:

What factors might be contributing to my elevated A1C? (Diet, activity level, stress, sleep, medications, family history)
What specific changes would have the biggest impact for me personally? (The answer varies by individual)
How often should we recheck my A1C to track progress? (Usually every 3-6 months)
What resources would help me implement sustainable changes? (Nutritionist, exercise program, stress management techniques)

Remember, the goal isn't just to avoid diabetes—it's to optimize your overall metabolic health, which affects everything from your energy levels and mood to your long-term risk of heart disease, dementia, and other conditions.

Your metabolic health is not fixed or predetermined. It's responsive, adaptable, and largely within your influence. And that's something worth knowing, no matter what label we put on it.

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So, tell me - what are your questions for our Friday live chat about pre-diabetes and metabolic health?