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Why A1C Isn't Enough: Insights from Dr. Ben Bikman

In this discussion, metabolic experts Dr. Ben Bikman and Dr. Ken Berry dive into why the medical community's obsession with blood glucose and A1C often misses the earliest signs of metabolic disease: Insulin.

The Insulin-Centric View​

Most clinicians are trained to focus on glucose. However, insulin is a much more sensitive and earlier marker of metabolic derangement.

  • Beta Cell Myth: Contrary to popular belief, beta cells in Type 2 diabetics don't simply "burn out." In many cases, insulin production remains multiples higher than normal for years, even as glucose begins to rise [00:03:10].
  • The Danger of Exogenous Insulin: Giving more insulin to a Type 2 diabetic to lower glucose can actually worsen outcomes and increase mortality [00:03:52].

Fasting Insulin Reference Ranges​

Dr. Bikman suggests the following markers for fasting insulin (micro units per mL):

  • 0–6: Optimal insulin sensitivity.
  • 7–17: A "warning range" where metabolic issues may be starting.
  • 18+: Clear sign of metabolic compromise [00:05:46].

The Flaws of the A1C Test​

HbA1C measures the glycation (sugar coating) of red blood cells over roughly 120 days. While useful, it has significant blind spots:

1. Red Blood Cell (RBC) Longevity​

The A1C score is heavily influenced by how long your red blood cells live:

  • False Positives: If your RBCs live longer than average (common in healthy, nutrient-dense diets like carnivore), they have more time to gather glycation, leading to a higher A1C despite low glucose [00:12:42].
  • False Negatives: If RBCs turn over quickly (due to anemias or B12/Iron deficiencies), A1C may look "normal" even if blood sugar is dangerously high [00:13:24].

2. The Fructose Factor​

A1C primarily measures glucose glycation. It does not measure fructose glycation ("fructation"), which is 7 times more reactive than glucose [00:22:45].

  • People consuming high amounts of fruit juice or smoothies may have a "normal" A1C while suffering massive internal glycation damage [00:23:18].

Glycation Beyond the Blood​

Glycation is a non-enzymatic process where sugar binds to proteins, DNA, or lipids. It happens everywhere, not just in red blood cells:

  • Kidneys: Leading to kidney failure.
  • Blood Vessels: Contributing to atherosclerosis [00:09:47].
  • Skin: Damaging collagen and causing premature aging/wrinkles.

Uric Acid and Ketones​

Since there is no commercial "fructation" test, Dr. Bikman suggests Uric Acid as a surrogate marker for fructose metabolism [00:23:45].

  • Fructose vs. Meat: Uric acid is driven more by fructose consumption than by meat or fish.
  • The Ketone Advantage: New research suggests that ketones can inhibit the inflammation typically caused by elevated uric acid, explaining why ketogenic patients often see improved health markers even if uric acid remains temporarily high [00:27:14].

Source: Why A1C Isn't Enough - Dr. Ben Bikman with Dr. Ken Berry