The A1c & The Athlete: When Health Metrics (And Identities) Don’t Tell the Whole Story

Until it was totaled, I drove a 2009 all-black Toyota Prius. I would also frequently wear Crocs, sometimes even with business casual attire. I grew my hair out and often wore it in a long braid. And yes, I’ve been soundly beaten in one-on-one basketball games. Each of these occurred at a time when they were perhaps less normalized than today, and each, predictably, was often followed by a joke. Whether it was a crack about my car running on AA batteries, my ‘dorky’ lack of style, a suggestion I buy tampons due to my long hair, or the classic ‘you should give up basketball, you’re terrible’, the jabs would come. The basketball ones always stung the most.

With the GLP-1 agonist boom currently in full swing, every commercial, neighbor, clinic, and pharmacy seemingly abuzz, I decided to add another voice to the conversation. Much like my hopefully nuanced discussion on statins, a similar pattern emerges with GLP-1s. They are heralded; the dramatic weight loss they can induce is often portrayed as a gift from the heavens, making them the ‘it’ drugs of the 21st century. The LEADER trial, evaluating liraglutide, was one of several pivotal trials assessing the cardiovascular safety and benefit profile of this GLP-1 agonist class. In it, we see some of the touted benefits: it lowers blood pressure, A1c, BMI, and body fat percentage — all common proxies for cardiovascular health.

When a proxy for health shifts from being merely a marker to becoming the target of intervention, we often witness a boom in medications and widespread acceptance of pharmacological management to manipulate that metric. This isn’t an unreasonable assumption. Elevated A1c, blood pressure, BMI, and body fat percentage are indeed associated with increased cardiovascular risk. Therefore, the logic follows: shouldn’t we aim to lower each of these metrics? And so, in comes medication. GLP-1 agonists particularly stand out, not only for their dramatic impact on weight but also for their ability to favorably influence multiple cardiovascular risk factors simultaneously. One might safely assume, then, that by positively impacting these risk factors, the drugs would substantially curb actual cardiovascular events. However, when we examine the LEADER trial data, for instance, many cardiovascular outcomes still show ARRs of less than 1%.

These ARRs translate to Numbers Needed to Treat (NNTs) that often range from the high double digits to many hundreds, even thousands for some outcomes (and in the case of retinopathy, a Number Needed to Harm, or NNH). While there may be other significant benefits to GLP-1s, the cardiovascular data prompts reflection: despite their dramatic impact on multiple risk factors simultaneously, the fact that many critical cardiovascular outcomes see an absolute risk reduction of less than 1% (with a few exceptions around 1–1.5%) suggests we might be missing a larger part of the picture, or perhaps overstating the direct translation of proxy improvements to event reduction for every individual.

I mentioned the basketball jokes stung the most. That’s because I had attached a significant part of my identity to an external trait like being an athlete, a basketball player. When that identity was questioned, even through a seemingly innocent joke, it felt like a direct assault on me as a person. Much of my perceived value had become tied to this external perception. The car I drove, the shoes I wore, or the hairstyle I had were not aspects I deeply associated with my core identity; they were simply things peripheral to me. Therefore, those jokes were water on a duck’s back. For others, it might be the shoes, the car, or the hairstyle that forms a cherished part of their external identity, and a joke targeting these can feel like a personal attack rather than harmless teasing. In reality, of course, an individual’s intrinsic value and worth are separate from these external identities.

And just like these external identities we often cling to, health metrics, though internal markers, may not capture the full picture of health. While a car, clothing, hairstyle, or athleticism might reflect certain aspects or preferences of a person, they don’t define the essence or inherent quality of that person. Similarly, while A1c, weight, or cholesterol levels might offer insights into one’s physiological state, they are not, in themselves, the entirety or ‘quality’ of health. Focusing solely on targeting these numbers, and indeed, celebrating their alteration as the ultimate victory, can be an injustice to a more appropriate pursuit of healthcare. Instead of allowing an underlying fire to smolder, merely masked by medications that change the numbers, it’s crucial to recognize that manipulating proxies with pharmaceuticals is not synonymous with achieving genuine, comprehensive health.