The Number Your Body Can't Lie About
India has 101 million people with diabetes — more than any other country. Yet studies show that fewer than 30% of diabetics have their HbA1c tested regularly, and most don't understand what the number means.
You could check your fasting sugar every week and see "normal" numbers. But if your HbA1c is elevated, your body is telling a different story — one that a single morning reading can't reveal.
This is why HbA1c is the single most important number for anyone with diabetes or prediabetes. It tells the truth that spot-checks hide.
Fasting Sugar vs. HbA1c: Why the Difference Matters
Here's the critical difference:
Fasting glucose is like checking your speedometer at a red light. You might be stopped now, but it tells you nothing about how you drove all day — the speeding, the sudden brakes, the times you pushed 140 km/h on the highway.
HbA1c is like checking your car's black box. It records everything. The average, the peaks, the patterns. Over the past 90 days, it knows exactly how your blood sugar has been behaving — even when you didn't.
The Science Made Simple:
Glucose in your blood sticks to hemoglobin (the protein in red blood cells that carries oxygen). Once stuck, it stays stuck for the cell's lifetime — about 120 days. HbA1c measures what percentage of your hemoglobin has been "sugared." More glucose = more sticking = higher HbA1c.
Why India Is Ground Zero
The numbers should concern every Indian:
- 101 million Indians have diabetes (and counting)
- 136 million have prediabetes — a loaded gun waiting to fire
- 57% don't know they have it — they'll find out when complications begin
- Indians get diabetes 10 years earlier than Western populations
- We develop complications faster at the same blood sugar levels
Why are Indians so vulnerable? It's not weakness — it's biology.
The "Thin-Fat" Indian Phenotype
Consider Suresh: 42 years old, weighs 68 kg, BMI of 23 — textbook "normal." His company health checkup says he looks healthy. Fasting sugar is 102 mg/dL — "Normal."
But a deeper look reveals visceral fat around his organs, minimal muscle mass, and an HbA1c of 6.3%. Prediabetic. At a "normal" weight.
This is the "thin-fat" phenotype — and it's incredibly common in Indians:
- We store more fat around our organs (visceral fat) than under our skin
- We have higher body fat at lower BMIs
- We develop insulin resistance earlier
- We have a genetic predisposition selected over generations of food scarcity
A BMI of 23 in an Indian carries the same risk as BMI 27 in a European. Yet standard charts still say 25 is the cutoff for "overweight."
Reading Your HbA1c: What the Numbers Mean
| HbA1c Level | Category | Interpretation |
|---|---|---|
| Below 5.4% | Optimal | Metabolically healthy — maintain this level |
| 5.4% - 5.6% | At Risk | Technically normal, but warrants monitoring |
| 5.7% - 6.4% | Prediabetes | The body is struggling — window to reverse |
| 6.5% - 7.0% | Diabetes (Controlled) | Diabetic, but complications unlikely if maintained here |
| 7.0% - 8.0% | Diabetes (Suboptimal) | Improvement needed — damage occurring at this level |
| Above 8.0% | Diabetes (Poor Control) | Every day at this level causes harm — urgent action needed |
The Critical Window: 5.7% to 6.4%
This is prediabetes — and it's the most important range. Why? Because it's reversible. Once HbA1c crosses 6.5%, diabetes is typically lifelong. But in this range, with proper intervention, research shows 60% of people can return to normal glucose metabolism.
The Trajectory Matters More Than the Number
Consider why tracking HbA1c over time is crucial:
Example A — Rising Trajectory
- 2022: HbA1c 5.4%
- 2023: HbA1c 5.6%
- 2024: HbA1c 5.9%
Each reading appears "fine" individually. An annual checkup would say "normal" each year. But the pattern reveals a clear trajectory: moving toward diabetes at 0.25% per year. At this rate, diabetes by age 42.
Example B — Improving Trajectory
- 2022: HbA1c 6.1%
- 2023: HbA1c 5.8%
- 2024: HbA1c 5.5%
This person was prediabetic but made changes — cut refined carbs, started walking, lost 5 kg. The trajectory is downward. Prediabetes reversed.
Same starting point. Opposite futures.
HbA1c to Average Blood Sugar Conversion
The relationship between HbA1c and average blood sugar:
| HbA1c (%) | Estimated Average Glucose (mg/dL) | Estimated Average Glucose (mmol/L) |
|---|---|---|
| 5.0 | 97 | 5.4 |
| 5.5 | 111 | 6.2 |
| 6.0 | 126 | 7.0 |
| 6.5 | 140 | 7.8 |
| 7.0 | 154 | 8.6 |
| 7.5 | 169 | 9.4 |
| 8.0 | 183 | 10.2 |
| 9.0 | 212 | 11.8 |
| 10.0 | 240 | 13.4 |
Formula: Average Glucose (mg/dL) = (HbA1c × 28.7) - 46.7
An HbA1c of 8% means the blood sugar has been averaging 183 mg/dL — high enough to damage blood vessels, nerves, and organs around the clock.
What Elevated HbA1c Does to Your Body
High blood sugar isn't just a number — it's actively damaging tissue:
Blood Vessel Damage
Sugar damages the lining of blood vessels. The body tries to repair this with cholesterol patches, which become plaques. Over years, arteries narrow and harden. Result: heart attacks, strokes.
Nerve Damage (Neuropathy)
High glucose damages nerve fibers, starting at the extremities. First comes tingling and numbness in feet. Then burning pain. Eventually, loss of sensation — which is why diabetics don't feel wounds that become infected.
Kidney Damage (Nephropathy)
The kidneys' filtering units are destroyed by glucose. Protein leaks into urine. Function declines. Many diabetics eventually require dialysis.
Eye Damage (Retinopathy)
Tiny blood vessels in the retina are damaged. They leak, swell, or grow abnormally. Diabetic retinopathy is a leading cause of blindness.
Foot Complications
The combination of nerve damage (can't feel injuries) and blood vessel damage (wounds don't heal) leads to infections, gangrene, and amputations. India performs over 40,000 diabetes-related amputations annually.
The Damage Timeline:
- HbA1c of 7%: Complications rare if maintained; some microvascular risk
- HbA1c of 8%: Complication risk doubles
- HbA1c of 9%: Significant damage occurring; high risk of all complications
- HbA1c of 10%+: Active, progressive damage to eyes, kidneys, nerves, heart
Every 1% reduction in HbA1c reduces complication risk by approximately 25-35%.
When HbA1c Can Be Misleading
In certain conditions, HbA1c may not accurately reflect glucose control:
HbA1c May Be Falsely LOW in:
- Hemolytic anemia (red cells destroyed faster)
- Recent blood transfusion
- Chronic blood loss
- Pregnancy (second and third trimesters)
- Chronic kidney disease (on dialysis)
HbA1c May Be Falsely HIGH in:
- Iron deficiency anemia
- B12 deficiency
- Splenectomy (spleen removal)
- Certain hemoglobin variants
If HbA1c doesn't match symptoms or glucose readings, alternative tests like fructosamine or glycated albumin may be used.
Testing Frequency
| Your Situation | How Often to Test |
|---|---|
| No diabetes, no risk factors | Every 3 years after age 35 |
| Risk factors (family history, obesity, PCOS) | Annually |
| Prediabetes | Every 6 months |
| Diabetes, well-controlled | Every 3-6 months |
| Diabetes, changing treatment or poor control | Every 3 months |
Lowering HbA1c: What Actually Works
Dietary Changes
- Reduce refined carbohydrates: White rice, maida, sugar — the biggest glucose spikes
- Increase fiber: Vegetables, whole grains, legumes — slows glucose absorption
- Protein at every meal: Stabilizes blood sugar, increases satiety
- Healthy fats: Nuts, seeds, olive oil — minimal glucose impact
- Portion control: Even healthy carbs spike glucose in excess
Exercise
- Walking after meals: 15-20 minutes can cut glucose spikes by 30-50%
- Resistance training: Builds muscle, which absorbs glucose better
- Consistency matters: Daily movement trumps occasional intense exercise
Weight Loss
Losing just 5-7% of body weight can dramatically improve insulin sensitivity. For a 75 kg person, that's 4-5 kg.
Medication
When lifestyle isn't enough:
- Metformin: First-line, reduces liver glucose production
- SGLT2 inhibitors: Remove glucose through urine, protect kidneys and heart
- GLP-1 agonists: Improve insulin secretion, promote weight loss
- Insulin: When pancreatic function is significantly impaired
The Impact of Each 1% Reduction
Landmark studies have quantified what HbA1c reduction means:
| Complication | Risk Reduction per 1% HbA1c Drop |
|---|---|
| Microvascular complications (eyes, kidneys, nerves) | 37% reduction |
| Diabetes-related deaths | 21% reduction |
| Heart attacks | 14% reduction |
| Amputations or peripheral vascular disease | 43% reduction |
Dropping HbA1c from 9% to 7% doesn't just improve numbers — it transforms long-term outcomes.
Your HbA1c Action Plan
| Your HbA1c | What It Means | What To Do |
|---|---|---|
| Below 5.7% | Normal | Maintain healthy lifestyle; test every 1-3 years |
| 5.7% - 6.4% | Prediabetes | Lifestyle intervention now; retest in 3-6 months; consider metformin |
| 6.5% - 7.0% | Diabetes, controlled | Continue current management; optimize lifestyle; test every 3-6 months |
| 7.0% - 8.0% | Needs improvement | Review treatment plan; intensify lifestyle; may need medication adjustment |
| Above 8.0% | Poor control | Urgent treatment review; medication adjustment; close monitoring |
Key Takeaways:
- HbA1c reveals what spot-checks hide — the 90-day truth about blood sugar
- Prediabetes is reversible — but only with action
- Track the trajectory — a rising pattern demands intervention before diabetes develops
- Indians are high-risk — don't assume "normal" BMI means metabolic health
- Every 1% matters — dropping from 8% to 7% significantly reduces complications
Track your HbA1c and metabolic health with ExaHealth. Upload your lab reports and monitor your trajectory over time — because the earlier you catch a rising trend, the easier it is to reverse.