Hemoglobin A1C (often shortened to “A1C”) is one of the simplest blood tests in modern medicine—yet it’s frequently misunderstood, especially when the result falls into the “pre-diabetic” range. In this video, Dr. Patrick Nemechek explains what the number actually represents, why it’s a powerful risk marker, and why he does not view pre-diabetes as something to casually “watch and wait.”
He also lays out a clinically practical theme that runs through his framework: inflammation drives insulin resistance, and lowering inflammation can help lower A1C. Below is a polished summary of his discussion and the tools he describes.
Educational medical disclaimer: This article summarizes one clinician’s educational discussion and is not medical advice. A1C interpretation and treatment decisions must be individualized with your licensed healthcare professional, especially if you have diabetes, kidney disease, neuropathy symptoms, or are taking glucose-lowering medications.
What A1C measures (and why it’s such a meaningful number)
Dr. Nemechek describes A1C as the average concentration of sugar inside a red blood cell over about three months. Because it’s an average, it reflects what’s happening over time—whether diet and exercise have been consistent or inconsistent.
In his view, A1C is “the best measure we have” for assessing risk related to blood sugar abnormalities, insulin resistance, and diabetes. The concern is not just the single number, but what that number implies about underlying physiology and trajectory.
Normal vs. pre-diabetic vs. diabetic: the cutoffs he emphasizes
In the video, Dr. Nemechek outlines the commonly used categories:
- Normal: A1C 5.6 or less
- Pre-diabetes: A1C 5.7 to 6.4
- Diabetes: A1C 6.5 or greater
He notes that when A1C is normal, the pancreas is normal. As the A1C rises into the pre-diabetic range, he attributes the progression primarily to increasing inflammation driving worsening insulin resistance.
Why Dr. Nemechek does not consider pre-diabetes “mild”
A key message of the talk is that “pre-diabetic” should not be framed as harmless. Dr. Nemechek argues that the inflammation associated with insulin resistance can have real consequences before someone meets the formal threshold for diabetes.
In his description, in the pre-diabetic range the process can be associated with:
- Neuropathy symptoms (such as numbness and burning in the toes and feet) even before diabetes is diagnosed
- Pancreatic damage as insulin resistance worsens
- Increased risk of cancers and heart attacks (as he states in the video)
- Declining kidney function
He also emphasizes the importance of trend over time. As an example, he describes a patient whose A1C rose from 5.8 to 6.0 over about a year and a half, and he argues that dismissing that change may ignore the likely trajectory—potentially reaching diabetes over time if the drivers are not addressed.
What changes at A1C ≥ 6.5, in his framework
Dr. Nemechek explains that once A1C reaches the diabetic range (6.5+), “the sugar itself within the blood vessel can damage the blood vessel,” using a vivid analogy of sugar acting like “Drano” in blood vessels. He associates prolonged higher levels with the classic, severe diabetic complications people fear—such as amputations, blindness, and dialysis.
Lowering A1C by lowering inflammation: tools he lists
Dr. Nemechek’s practical list centers on the premise that lowering inflammation improves insulin resistance, which can lower A1C. He offers multiple ways to start—without suggesting everyone must do everything at once.
1) Reduce body fat (as an inflammation lever)
He states that body fat “makes lots of inflammation,” and emphasizes his interpretation that blood sugars improve with weight loss primarily because less body fat reduces inflammation (not simply because a person is eating less). He mentions multiple approaches people use to reduce body fat, including reduced calories/carbohydrates, gastric surgery, and GLP-1 agonist medications (he cites Ozempic as an example).
2) Reduce processed foods and processed sugar
He lists reducing processed foods and reducing processed sugar as steps that lower inflammation and can improve A1C.
3) Reduce dietary AGEs through cooking choices
He discusses reducing “AES” (advanced glycation end products; commonly abbreviated as AGEs) as a practical, inflammation-focused strategy. He notes that processed foods contain many of these compounds, but that AGEs can also be created at home depending on cooking method. In his description:
- Higher temperatures and drier environments (e.g., smoking meat, barbecuing, grilling) increase AGEs.
- Lower-temperature, higher-moisture cooking (e.g., sautéing, steaming) lowers AGEs.
He states that lowering AGEs through cooking technique has been shown in human studies to reduce A1C, and he gives examples like trying sous vide-style cooking instead of grilling, or steaming vegetables instead of roasting them.
4) Increase extra virgin olive oil intake (Mediterranean-style)
He recommends 30 mL (about 2 tablespoons) of extra virgin olive oil daily, stating it reduces inflammation, improves insulin resistance, and improves blood sugar. He also notes that several of the diet steps he lists essentially map onto a Mediterranean diet pattern.
5) Exercise (consistent, not extreme)
Exercise can lower blood sugar, but he emphasizes that the effect is short-term and requires consistency. He gives a concrete benchmark: a very brisk 30-minute walk, 3–4 days per week, noting that most people can do this without needing intense programs.
6) Address SIBO and gut-driven inflammation (as he describes)
Dr. Nemechek discusses SIBO (small intestine bacterial overgrowth)—described as colon bacteria living in the small intestine—and states many people have it. He mentions rifaximin as a way to reverse SIBO, and notes it has been shown to reduce inflammatory markers and that in people with diabetes, fixing SIBO can lead to weight loss (which he frames as further lowering inflammation).
7) Consider post-COVID inflammation and “leaky gut” (his interpretation)
He also states that COVID can cause its own form of leaky gut with high inflammation, which he says is being associated with higher diabetes risk as part of long COVID. He mentions treating that with a six-week course of glutamine and points viewers to his other videos for details.
8) Vagus nerve stimulation (autonomic tool he cites)
Finally, he describes the vagus nerve as influencing physiology broadly and says that transcutaneous (in-the-ear) vagus nerve stimulation has been shown to reduce insulin resistance, blood sugar levels, and inflammation in diabetics.
How this fits into Dr. Nemechek’s protocol approach
He explains that his clinic’s protocol aims to balance physiology and lower inflammation using tools including rifaximin, olive oil, fish oil, and a vagus nerve stimulator. He reports that, in his clinical experience, the vast majority of people with elevated A1C levels see those values begin to reduce significantly as inflammation is lowered.
Takeaway: don’t ignore the pre-diabetic range
Dr. Nemechek’s bottom line is direct: if your A1C is in the 5.7–6.4 range, it’s “not okay” to treat it as inconsequential. He encourages staying focused on bringing A1C down by addressing inflammation drivers—starting with practical steps and building from there with clinician guidance.
