The Three Questions That Change Diabetes Treatment Before the Blood Work Comes Back

If you have been managing type 2 diabetes for any length of time, you know the routine. You go to the lab. You wait for the results. You sit in the exam room. The doctor looks at the A1c number and adjusts your medication up or down. That is the standard playbook.

But what if the playbook is answering the wrong question?

In Diabetes in the Real World, Dr. Fernandez argues that focusing on the A1c before understanding the patient’s physical state leads to a lot of wrong turns. He points out that two patients can walk in with the exact same A1c of nine percent, the same age, and the same body weight, yet require completely opposite treatments. Giving one patient the other patient’s prescription would be a disaster. The lab number alone cannot tell them apart. The body can. You just have to know what to look for.

Dr. Fernandez trains physicians to ask three specific questions before they even glance at the lab sheet. These are questions you can ask yourself at home. They reveal whether your diabetes is in a catabolic state or an anabolic state.

The first question is about the belt, not the scale. Which direction are your belt notches moving over the last few months? Are you tightening your belt even though the number on the scale has not changed much? Or are you loosening it? If your waist is shrinking unintentionally, that is a red flag. It often means your body is not able to use glucose for energy because insulin is too low. Your body is breaking down muscle and fat to survive. That is a state of insulin deficiency. You cannot fix that with a pill that makes your body more sensitive to insulin. You need insulin itself. If your belt is getting tighter, you are in an anabolic state driven by high insulin resistance. Adding more insulin to that situation just packs on more weight and worsens the problem.

The second question is about your blood pressure relative to what it should be. If you are a heavier person, your blood pressure usually runs a bit higher. But if you check it and it is oddly low, say 115 over 66, and your heart rate is elevated to 100 beats per minute while you are just sitting there, that combination is a distress signal. It means you are volume depleted. Your kidneys are spilling sugar into your urine and taking water with it. You are dehydrated. That low blood pressure and high heart rate confirm the catabolic, insulin deficient state. If your blood pressure is elevated as expected, you are likely in the high insulin resistance camp.

The third question is about the texture of your fatigue. Everyone with high blood sugar is tired. But the quality of that exhaustion tells a story. Ask yourself if the fatigue feels hollow, like you are running on fumes and a small snack briefly brings you back to life. That is starvation quality fatigue. It is common in catabolic states where glucose cannot enter the cells. Or does the fatigue feel heavy, like you are walking through deep water and nothing relieves it? That is inflammatory fatigue common in anabolic states.

These three data points take less than sixty seconds to gather. Belt trend. Blood pressure expectation. Fatigue texture. Together, they form a clinical picture that is often more reliable than the A1c for deciding what to do next.

For the catabolic patient whose belt is shrinking, blood pressure is low, and fatigue is hollow, the answer is usually basal insulin started sooner rather than later. For the anabolic patient whose belt is expanding, blood pressure is high, and fatigue is heavy, the answer is a GLP-1 medication combined with an SGLT2 inhibitor to reduce weight and protect the heart and kidneys.

This framework is a game changer for primary care. It turns a complex metabolic disease into a straightforward physical exam. It stops doctors from throwing insulin at a problem that needs weight loss and stops them from withholding insulin from a patient who is literally wasting away without it. Diabetes in the Real World is the manual for getting this right at the first visit.