When Normal Labs Hide Prediabetes: Two Physicians’ Hidden Metabolic Crisis
We’re both physicians. We both had normal labs. We both had prediabetes.
If it happened to us with medical degrees, access to testing, and decades of clinical experience, it’s happening to you.
The Setup
I’m Sara Szal, an OB/GYN with three decades in women’s health. My fasting glucose was 110 mg/dL. Standard labs flagged it as borderline. My doctor said to watch it. Case closed.
Except nobody looked at my fasting insulin. It was in the 20s, more than three times the optimal level. My body was asking for help while my blood sugar stayed just shy of diabetes. The canary in the coal mine was singing at full volume, but we weren’t listening.
Brad Jacobs is a functional medicine physician. His fasting glucose? 92 mg/dL. By conventional standards, his metabolic health looked excellent. But when we ran a 2-hour oral glucose tolerance test, his levels stayed dangerously elevated long after they should have normalized. Standard screening would have missed it completely. He was prediabetic with excellent routine labs.
What Medical School Didn’t Teach Us
In medical school, we were taught to advise patients to exercise more and eat less if they wanted to lose weight. The prescription was simple: willpower plus calorie restriction equals health.
What we weren’t taught: how insulin actually drives weight gain, why women’s hormones complicate everything, how to use nutrition as medicine, or that insulin resistance shows up years, sometimes decades, before glucose dysregulation becomes apparent on standard testing.
As a result, I had to teach myself how to address these metabolic issues. Fortunately, I had an ideal patient, one who struggled with multiple hormone problems: me.
Understanding Insulin: The Hormone Nobody Explains
Insulin’s primary job is to move glucose from your bloodstream into your cells, thereby lowering the glucose in your blood. It’s a key hormone in the treatment and prevention of diabetes.
When insulin works properly, you have stable energy, balanced mood, and easy weight maintenance.
When it doesn’t, your pancreas compensates by making more and more insulin to force glucose into increasingly resistant cells. Your blood glucose looks normal or borderline while your insulin levels skyrocket. You’re told you’re fine while your metabolism quietly breaks down.
The scientific literature demonstrates that dietary and lifestyle approaches to diabetes work better than medications, a condition in which cells become numb to the hormone insulin. These approaches likely succeed because they don’t disrupt normal biochemistry and instead help an individual return to a state of homeostasis, or balance.<sup>1</sup> Yet few physicians, myself included, learned how to use nutritional intervention or how to guide changes to behavior and lifestyle.
The Female Factor
My personal struggle to balance my hormones has informed my career as a physician and writer. I come to this topic as a doctor and scientist, but also as a case study.
In my thirties, I began to battle depression, premenstrual syndrome, and belly fat. I wrestled with my weight because my levels of testosterone, growth hormone, estrogen, and progesterone were too low, and my insulin and cortisol were too high.
When I followed the eat less, move more advice I’d been taught to give patients, I made my hormone imbalance worse. The essential role of metabolic hormones, and how they function in women, was missing from the equation.
Women develop insulin resistance differently than men. We’re vulnerable during specific hormone transitions: postpartum, perimenopause, and menopause. Chronic stress and elevated cortisol accelerate the process. For many women, insulin resistance is the hidden driver of what gets dismissed as hormonal chaos.
It’s not about willpower. It’s about biochemistry that nobody explained to us.
The Hidden Epidemic
Insulin resistance is the root cause of type 2 diabetes, polycystic ovary syndrome, Alzheimer’s disease increasingly understood as type 3 diabetes, heart disease, many cases of hormonal weight gain, and accelerated aging.
And standard screening misses it until you’re years into the problem.
Most physicians test fasting glucose and perhaps hemoglobin A1c. These markers become abnormal late in the disease process. By the time your fasting glucose is consistently elevated, you’ve likely had insulin resistance for years. The horse has left the barn.
What Your Doctor Isn’t Testing
The labs that actually reveal early metabolic dysfunction:
- Fasting insulin with optimal levels less than 5 μIU/mL, not just under the standard reference range of 25 μIU/mL
- 2-hour oral glucose tolerance test that reveals how your body handles a glucose load, not just how it performs in a fasted state
- Hemoglobin A1c with optimal levels less than 5.3%, not the normal cutoff of 5.7%
- Fasting glucose with optimal levels less than 90 mg/dL, not under 100 mg/dL
My labs were borderline. Brad’s were hidden. Both of us were prediabetic, but conventional screening nearly missed it.
Good News and the Bad News
The good news is that dietary and lifestyle interventions work better than medications for insulin resistance and prediabetes. They restore homeostasis rather than disrupting normal biochemistry with pharmaceutical intervention.
The bad news is that most physicians, including us initially, never learned how to prescribe nutrition, guide meaningful lifestyle change, or interpret optimal versus normal lab values.
So we had to teach ourselves. On ourselves.
Your Next Steps
If you’ve ever been told your labs are fine while your body tells you otherwise, if you’re battling unexplained weight gain, crushing fatigue, mood instability, or hormonal chaos despite normal results, it’s time to question the screening, not your body.
Ask your physician for fasting insulin not just glucose, full glucose tolerance testing especially if you have a family history of diabetes, hemoglobin A1c interpreted with optimal ranges not just standard cutoffs, and a provider who treats the data as information rather than dismissing your symptoms.
Your body isn’t failing you. The screening is.
Insulin resistance is complex but legible. Your sensitivity is appropriate processing of real physiological changes. Your exhaustion is data, not a character flaw.
Time to test what matters. If you want a guide to tracking your blood sugar, go here. Our goal is to reverse the metabolic crisis that 93 percent of us are experiencing but may not know about.
Endnotes
- Sarah Hallberg et al., “Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study,” Diabetes Therapy 9, no. 2 (2018): 583-612, https://doi.org/10.1007/s13300-018-0373-9; Roy Taylor et al., “Remission of Human Type 2 Diabetes Requires Decrease in Liver and Pancreas Fat Content but Is Dependent upon Capacity for β Cell Recovery,” Cell Metabolism28, no. 4 (2018): 547-556, https://doi.org/10.1016/j.cmet.2018.07.003.
- Jill Kanaley et al., “Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine,” Medicine & Science in Sports & Exercise 54, no. 2 (2022): 353-368, https://doi.org/10.1249/MSS.0000000000002800; Gretchen Reynolds, “How Exercise Affects Our Insulin Sensitivity,” New York Times, July 25, 2024, https://www.nytimes.com/2024/07/25/well/move/exercise-insulin-diabetes.html.
- Suzanne de la Monte, “Type 3 Diabetes Is Sporadic Alzheimer’s Disease: Mini-Review,” European Neuropsychopharmacology 24, no. 12 (2014): 1954-1960, https://doi.org/10.1016/j.euroneuro.2014.06.008; Joshua Joseph et al., “Comprehensive Management of Cardiovascular Risk Factors for Adults with Type 2 Diabetes: A Scientific Statement from the American Heart Association,” Circulation 145, no. 9 (2022): e722-e759, https://doi.org/10.1161/CIR.0000000000001040.
- Virta Health Research Team, “Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 5-Year Non-Randomized Clinical Trial,” Frontiers in Endocrinology 14 (2023): 1251360, https://doi.org/10.3389/fendo.2023.1251360; William Yancy et al., “A Randomized Trial of a Low-Carbohydrate Diet vs Orlistat Plus a Low-Fat Diet for Weight Loss,” Archives of Internal Medicine 170, no. 2 (2010): 136-145, https://doi.org/10.1001/archinternmed.2009.492.