Hello Everyone
New member first time posting. To the point. I’ve been keto since 2016. Lost over 40lbs. I am 62yrs old and active, compete in triathlons. I was strict for the first 4 to five years then transitioned to a more low carb carnivore diet. Had blood work done a few weeks back and my A1c came back at 5.7. Needless to say I’m frustrated and concerned. I eat very little carbs below 30gr a day. My fasting gl is always over 100. Really don’t know what to do. Also would like to find a Dr. that understands low carb, any resources to find one? Even throughout the day its difficult to keed my gl below 100. I eat twice a day. I also do IF although not consistent for 16hrs. Sometimes i’ll do an extended one for 36-48hrs. What test should I do for IR?. Should I ask my Dr. for metformin? Thank you.
A1C help
HI Rudy, hang on while we wait for some of our wiser members to chime in. @PaulL @OldDoug @Alecmcq @SomeGuy @Shortstuff
@pjam … I know I am forgetting some… sorry peeps!
But welcome to the forum! Hopefully you’ll find some support, advice, and encouragement here.
The only thing that occurs to me is that blood sugars can and do rise due to things other than diet. For instance an infection, can raise it and maybe because you do hard training, you are causing it to be higher than what one would expect/want.
Additionally, I think you are already doing everything you can to control elevated BG so maybe just don’t worry about it?
I too would like to hear what some of the wiser members have for ideas. And, welcome!
Blimey, I’m suprised and totally thrilled to get on the ‘Wise’ list! 
rudyvfla Welcome to the forum. I’m not that clever but many people here are amazing, really brilliant!
My first thought is your HbA1c is not that high … waiting for more comments
First, HbA1c isn’t a perfect metric, as it depends on how long your red blood cells last. If they live longer, your HbA1c will be higher.
If you’re not doing this, I’d recommend glucose testing to see if they HbA1c is correct, and testing all day long for a few days, maybe every hour. That will give you a nice way of looking at things. I see you say your blood glucose is 100, so maybe you’re doing this, but it has to be all day long.
If you’re competing in triathlons, (1) for me, exercise causes increased blood sugar and you might be the same, (2) your body needs to replace glycogen somehow, and I think does this by raising blood glucose.
If you’re concerned, you could add more carbs. As a guide, I’ve been able to eat 100 grams (carbs, not weight) of rice noodles and still stay in ketosis (blood tests), if that was the first meal after exercise. I also did not get hungry.
By contrast, I tried 100 grams (carbs) on a day I did not exercise. I was still able to stay in ketosis, but I felt much hungrier and worse.
I did not, however, track my blood sugar that well. I assume that my (daily) blood sugar would go down, at least slightly, but I’m not sure.
@rudyvfla Welcome! Sounds like you’re doing everything right by yourself and should have little cause for any concern. But I’ll try to address why I say this and what you might consider…
Given your 7 yr track record, age, and eating habits as described, I’m seeing your HbA1c as being is perfectly fine. I would think that medication would be entirely inappropriate in your context.
Yes, according to the HbA1c tables developed for a population that eats loads of carbs, tends toward insulin-resistance, obesity, etc., 5.7 is right on the borderline of “normal.”
But “normal” is not what you are aiming for at all. You have restricted your carbs. The last thing you want to be is normal! 
You are rather special among a modern world of Western style eaters… as a result, your serum glucose levels are not supply-driven by what you eat. On the contrary, they are demand-driven - produced through your own body’s neoglucogenesis. In other words, it’s the amount of glucose your body actually wants in order to function at a healthy level … and no more than that. It’s all good.
Yes, exercise and time of day, sleep/stress, etc., can all affect glucose levels. But it’s still primarily demand-driven, not merely a reflection of what you may have stuffed in your mouth an hour ago, like it is for most constant carb eaters.
As @ctviggen notes above, there’s also that additional complication involved in interpreting HbA1c in that the life of the erythrocytes (red blood cells) is assumed at the same length for everyone in the world. But there’s a growing belief that carb restriction makes these cells last longer - thereby picking up more cumulative glycation. Put differently, your HbA1c should be assessed on a different scale because they live longer. Keto eaters’ HbA1c may generally be higher without any indication of an adverse health issue.
This is further supported by your approx 100 mg/dL serum glucose level. For a long-time keto’er like you, this is not unusual at all and is quite common (myself included). At first, sure, it’s a bit concerning - but with further research, I’ve now got no worries at all.
Is it safe to assume you’re feeling good? Heck, you run marathons! That says it all … and likely affects also your glucose demand cycle in a great way.
In my 60s, I found so many accumulated middle-age “issues” all disappeared upon carb-restriction. Hopefully, you are having similar solid success too - as I note your significant weight loss, Can we assume your other biomarkers have generally improved and you’re feeling a bit younger?
Unless there’s some other significantly concerning health issue involved, I’d not be worried one wit about your HbA1c at 5.7.
Having said this, if you haven’t already done so, you might consider getting an NMR Lipid Panel (roughly $100 in the US out-of-pocket). It will tell you about the profile of your cholesterol in ways unseen by simpler cheap lipid panels. More importantly, it will also tell you extent to which you may be insulin sensitive vs insulin resistant. Here’s why this matters…
“Pre-diabetes” on that standard HbA1c scale is all about whether you are becoming insulin resistant. That’s what developing T2D is all about.
If you’re highly insulin sensitive (per the NMR panel results) it would give you additional comfort that your glucose levels of 100’ish are perfectly natural and healthy for you (like they are for me) and demand-driven by your body.
There are more sophisticated tests for insulin activity, glucose tolerance, insulin-specific bloodwork, etc. But the NMR test is easier, cheaper, and reasonably indicative, so I’d certainly reach for that first.
Hope some of this helps. Congratulations on your long-standing lifestyle enhancement and solid results!
P.S. - I don’t want to pick on our friend @ctviggen but this comment caught my eye…
While he is a wealth of great insight and info, I’ll gently push back on this particular idea. It’s unclear to me what adding carbs might accomplish in addressing your concerns? At a minimum, it would likely raise your glucose levels in ways that are the opposite of what you’ve been accomplishing all these years.
Hi Rudy. Given your lifestyle and diet, that indeed is surprising. I agree with other people in this thread - I don’t think it’s ‘dire,’ and there may be normal and benign explanations. How long your red blood cells live is one variable. We all have our own DNA and cellular ‘programming,’ and our life history can affect things as well. Average life for red blood cells is 4 months. If yours are averaging even just one more week, and we correct for that extended time for glycation, it brings that 5.7 down to 5.3 or 5.4.
In general, our insulin resistance increases as we age. Have you had other HbA1C tests? I’d get another one in the future, for comparison.
Good idea.
This too. I’d also be interested to see what your blood sugar is after fasting for 48 (or more) hours.
Not eating is a stressor to the body, and when your body is stressed, you can have higher BG. My A1C came down a little when I went from standard keto to my CKD/TKD Hybrid and stopped fasting.
That said, I’m not anti-Metformin at all, but if you’re spending 16hrs not eating I wouldn’t expect it to do much.
You familiar with Physiological insulin resistance?
Welcome to forum Rudy.
I would also say that this isn’t an abnormal reading.
A handy conversion table:
Your US units 5.7, equals UK units 39…
In UK units, anything below 42 is normal. Anything 42 or over is pre diabetes. Anthing over 48 is Type 2 diabetic.
My last blood HbA1c was 37…which is a similar equivalent reading to yours as 5.5.
With your readings, you aren’t suffering diabetes to warrant taking metformin.
Keep ketoing on! Good luck.
I was 54 at one stage, before dropping to 37 under keto.
(Apologies- I meant to say earlier on…anything over UK units 48 is type 2 diabetic).
Nice to see the UK is as stupid as the US when it comes to diabetes, We measure blood sugar in ng/dL, but then do A1C’s in mmol/L, you guys measure blood sugar in mmol/L, but then do A1C’s in mmol/mol. Funny how it’s so difficult to just use the same units and make life easy for people so there’s nothing to figure out!
That’s why I only buy glucose monitors that you can change the units on, since (for most people) the A1C is what matters, that’s the only unit worth caring about. For the types that spend their whole day spking sky high and crashing into the ground, not so much.
How are you sleeping? Have you ever had your testosterone tested? It could be low. Ask for an OGTT that must include insulin, with samples taken every 30 minutes for a 2-hour period. Most HbA1c is pretty much useless unless it’s very low or very high; intermediate results like what you show offer no insight. I have seen so-called normal fasting glucose and HbA1c, yet after doing the robust version of an OGTT, it showed not only a fasting insulin level 6x normal, but his glycemic and insulin responses showed a picture of profound hyperinsulinemia and dysregulated glucose homeostasis. This person had a CGM installed, had his sleep optimized (making sure his CPAP was working) and from a pharmacology point of view went on metformin and another drug to correct his low testosterone. 100% correctable. If possible, also have your ApoB and Apro-A1c measured. Much better reliability in an overall view of your Lipo profiles and risks.
Why did you transition to Carnivore?
Welcome to the forums!
Are you eating enough fat to supply your body’s energy needs? There is a hypothesis that some people’s glucose eventually starts to rise because they are not getting enough fat. It’s worth a try, in any case. And don’t restrict calories; that’s just asking for trouble. Eat a goodly amount of protein (whatever feels right) and fill in with enough fat to satisfy your hunger.
Dr. Paul Mason, in one of his Low Carb Down Under lectures, says that he is not so concerned about his patients’ absolute levels of glucose, but about whether their glucose stays within a narrow range. The wild highs and lows are what cause damage, he says. If it’s consistently at a higher level but not rising and falling very much, that seems to be fine. So if you can somehow wangle a continuous glucose monitor to wear, you can get a better idea of what’s going on.
Also, there are problems with HbA1C as a rolling average of glucose levels. Do a forum search on HbA1C, and you are sure to turn up a number of discussions about the reasons.
Also known as a Kraft test.
@rudyvfla Be advised that people on a long-term keto diet show an “abnormal” insulin response that can alarm doctors. Prof. Bikman says that this is because the pancreas of someone on a keto diet dispenses with the insulin reserve that is necessary for high-carb eaters, so there is no first-phase insulin response in ketonians. This is perfectly normal, he says, for anyone eating a ketogenic diet. If your doctor understands how a well-formulated ketogenic diet works, the insulin response pattern will not alarm him or her.
And another way to cope is to eat a high-carb diet for a few days before the OGTT, which will rebuild the pancreas’s insulin store and provide a more-“normal” first-phase response. But be warned, a lot of people who have tried this reported feeling really bad from the sudden influx of carbs. Even so, it might be something you have to resort to, if your doctor is rabidly anti-keto.
Unless trapped by your healthcare system, if one’s doctor is rabidly anti-keto and you are diligently restricting carbs, it’s best to find another doctor.
Having a physician who stands rabidly against my own good health is not an abusive relationship I’d want to keep. 
I’m not a doctor so likely ignore everything I’m about to write: your numbers aren’t that bad, but something to figure out because with your healthy lifestyle and body lean mass could be an early indication of something. if your serum glucose is “high” (for a keto/carn) it’s likely because:
-
you have good glucose levels but aren’t producing enough insulin so it’s building up (like type-1 diabetes)
-
you have good glucose and are producing enough insulin but the insulin is not being utilized (like type-2)
-
you are somehow eating too many carbs somewhere (seems unlikely if you are eating Whole Foods, but if you are eating “keto snacks” some have sneaky amounts of carbs)
-
your liver is overproducing glucogon / glucose.
So I’d check your insulin levels to rule out 1, or rule in 2. I’d gather your doctor will see immediately if either 1 or 2 could be the issue. 3 you will know if you eat whole foods (not the grocery store) only, and if you want to be strict carnivore that could likely rule out dietary carbs.
Number 4 would be a conundrum: high cortisol levels? Too much exercise without sufficient rest/recovery? An infection or other issue? Chronic Inflammation? Your doctor will have opinions, and this requires the most tests.
To simply lower serum glucose, metformin has been safely used for decades, and is now being used by the longevity crowd so this may be a nice addition to your “stack” (I’m not on it or anything so I understand if this is an unacceptable suggestion). There also arcarbose which has similar safety profiles and longevity people are taking it as well. There’s also things like carnosine and B5 to reduce glycated proteins (although may not necessarily reduce serum glucose).
So I’d test your insulin, and other tests for pre-diabetes. I’d also get a basic metabolic panel with liver function metrics. I’d also get a lipids panel for triglycerides (I don’t remember if you have this). And maybe thyroid panel to make sure there is no metabolic issue. Probably a blood panel as well (wbc counts etc) to make sure there isn’t a major infection lurking. With these tests you should have enough to know which direction to start thinking about.
You mention multiple serum glucose measurements: do you have a continuous glucose monitor? — they are expensive, but if you have a concern this is something lurking, getting one for 3-6 months may be a good investment. They are amazing: you can see when your glucose goes up and then figure out why. I’m considering it for myself even though I don’t have high serum glucose but A1c of 5.0.
Just my thoughts. Good luck.
I was just thankful to get some blood testing on the NHS and eventually after a couple years a consultation with a good doc who took credit for me (my phenotype, if you will! Fat) going keto on my own bat and online advice , losing weight and reversing T2…phew!
It’s a nice feeling to walk away from outpatients, with your arms no longer needed to be a pin cushion…safe in the knowledge that you have collectively ruined and made somebody’s day at the same time. 
That’ll do alright! x
In not too far off days, there will be riots against such a work of carniverous art, especially as a kilt.
The way the world is going.
We must act now to preserve our woe. And where is Rabbie Burns when ya need him?
He would’ve most definitely came up with a rhetorical retort in the poetic kind…bring on the Haggis.