By the time most people are told they have a metabolic problem, the damage is already done. Their fasting glucose is high. Their HbA1c has crept into the diabetic range. They may already have fatty liver, kidney changes, or early cardiovascular disease. And the conversation begins with medication rather than prevention.
This is the reality for millions of South Africans. And it doesn’t have to be this way.
The Problem With Waiting for a Diagnosis
The standard approach to metabolic health in general practice is largely reactive. We wait for blood sugar to become abnormal, for cholesterol to cross a threshold, for blood pressure to climb high enough to warrant treatment. By the time these markers are flagged, the metabolic dysfunction has often been brewing for years, sometimes decades.
Type 2 diabetes doesn’t appear overnight. It follows a slow, predictable trajectory: from optimal insulin sensitivity, to gradual insulin resistance, to compensatory hyperinsulinaemia (where your pancreas works harder and harder to keep glucose in range), to pre-diabetes, and finally to overt diabetes. The tragedy is that for most of that timeline, your fasting glucose and even your HbA1c may look completely normal.
What I Look For Instead
In my practice, I don’t wait for glucose to become abnormal. I look upstream. The two most useful tools in my metabolic toolkit are fasting insulin and calculated indexes like HOMA-IR and QUICKI.
Fasting insulin is the earliest metabolic marker to shift. Long before your glucose rises, your pancreas starts producing more insulin to compensate for developing resistance at a cellular level. If your fasting insulin is elevated, your body is already working harder than it should to manage blood sugar, even if your glucose and HbA1c are still textbook “normal.”
HOMA-IR and QUICKI are calculated from your fasting glucose and fasting insulin. They give a much more sensitive estimate of how well your cells are responding to insulin than either marker alone. This is where I can identify metabolic risk five, ten, even fifteen years before it would show up on a routine screening test.
I pair this with a thorough lipogram, looking not just at total cholesterol and LDL, but at triglycerides, the triglyceride-to-HDL ratio (a powerful proxy for insulin resistance), and where relevant, inflammatory markers like hsCRP.
The Role of Family History
Here’s something I discuss openly with my patients: your genetics load the gun, but your lifestyle pulls the trigger. And it’s your responsibility to know what you’re working with.
If you have a strong family history of type 2 diabetes, cardiovascular disease, or metabolic syndrome, your baseline risk is higher. That’s not a sentence. It’s information. And it’s incredibly valuable information, because it tells us where to look more carefully and where to intervene earlier.
I’ve seen patients in their 30s with strong family histories and impeccable HbA1c levels who, when we test fasting insulin, are already insulin resistant. Without that deeper look, they would have sailed through routine check-ups for another decade before anything was flagged.
Fine-Tuning, Not Fear
One of the most important things I try to convey to patients is that metabolic health isn’t all or nothing. It’s not “you’re fine” or “you have diabetes.” There’s a vast spectrum in between, and where you sit on that spectrum determines what kind of adjustments will make the most difference for you.
For some patients, the conversation is about meal timing, reducing refined carbohydrates, building muscle mass, and improving sleep. For others, it’s about understanding that their triglycerides respond dramatically to alcohol, or that their sedentary work pattern is a bigger driver than their diet. For some, it’s recognising that despite doing everything “right,” their genetics mean they’ll need closer monitoring and possibly earlier pharmacological support, and that’s okay too.
What Metabolic Syndrome Actually Looks Like
Metabolic syndrome isn’t a disease with a single cause. It’s a cluster of features that together dramatically increase your risk of cardiovascular disease and type 2 diabetes. The classic criteria include:
Central obesity (waist circumference above a certain threshold)
Elevated fasting glucose or insulin resistance
Elevated triglycerides
Low HDL cholesterol
Elevated blood pressure
You don’t need all five. Three out of five meets the criteria. And many people who meet these criteria have never been told they have metabolic syndrome, because each individual marker was addressed (or dismissed) in isolation.
The Bottom Line
If metabolic disease runs in your family, or if you’ve noticed creeping weight gain, fatigue, or changes in your body composition, don’t wait for your fasting glucose to become abnormal. The earliest signs of metabolic dysfunction are visible in your blood work long before a diagnosis, but only if someone is looking for them.
Your genetics are not your destiny. But knowing what they are gives you the power to do something about it.
Dr Robyn Bradfield is the founder of Bloodfields, a virtual investigative blood analysis practice. If you’d like a comprehensive metabolic health assessment that goes beyond standard screening, you can book through our website.