Case 001 — A1c 7.4 → 5.9, 14 weeks, no pharmacotherapy.

Encounter summary

Member presented for the annual visit in late November 2025 with a fasting glucose of 132 mg/dL and an A1c of 7.4% — a new diagnosis of type-2 diabetes by ADA criteria, sitting on the prediabetes-to-diabetes border. BMI 31.4. BP 138/86 (averaged, properly measured per the AHA scientific statement). Lipid panel borderline (LDL-C 134, HDL-C 48, triglycerides 188). MASLD risk by FIB-4 of 1.4 — borderline; FibroScan deferred pending repeat ALT.

The first-visit conversation about GLP-1 receptor agonists was open. Marek presented the case for early semaglutide initiation (weight loss, A1c reduction, cardiovascular risk reduction in T2DM with established cardiovascular disease per SUSTAIN-6¹) and the case against initiation today (no established cardiovascular disease yet; lean-mass concerns at this BMI; weight rebound on cessation; cost on the member's HSA-eligible plan). Member, a research-literate person, asked to defer pharmacotherapy and try a structured lifestyle intervention with a continuous glucose monitor as a teaching aid for fourteen weeks. The bargain we struck: if A1c at week 14 was > 6.5%, semaglutide started immediately. If < 6.5%, we would re-evaluate.

Splits

Split	Date	Event	Reading	Δ
00:00	2025-11-22	Initial visit, A1c, FBG, BP	A1c 7.4%	—
00:48	2025-11-26	CGM (Libre 3) placed; coaching visit 1/8	avg 158	—
03:12	2025-12-15	Coaching visit 3/8; protein-first AM established	avg 142	↓16
06:24	2026-01-05	Coaching visit 5/8; weight −4.2 kg	avg 131	↓11
09:18	2026-01-26	Walk → run progression begins; 30 min ×4/wk	avg 124	↓7
12:00	2026-02-16	Coaching visit 8/8; CGM removed	avg 118	↓6
14:00	2026-03-02	Repeat A1c, FBG, lipids, FIB-4	A1c 5.9%	↓1.5
14:00	2026-03-02	Decision to continue without pharmacotherapy	BP 124/78	↓14/8

Debrief — what was tracking

Three things tracked. First, the CGM was a teaching aid, not a continuous-monitoring device. By week six the member could predict their post-prandial peak within 15 mg/dL without looking, and the coaching shifted from "watch the curve" to "watch the meal composition." Second, the protein-first AM (a 30 g protein breakfast in lieu of the previous bagel-and-coffee) flattened the morning curve more reliably than any other intervention; the literature on protein-first meal sequencing in pre-diabetes is suggestive but not yet definitive², but in this member it was the lever. Third, the 30-min walk ×4/week starting at week 9, progressed to walk-run intervals by week 12, dropped the average glucose another 13 mg/dL.

What didn't track

The lipid panel did not move as much as we hoped — LDL-C 134 → 122, HDL-C 48 → 51, triglycerides 188 → 142. We deferred the statin conversation to the six-month follow-up; ten-year ASCVD risk by the ACC estimator dropped from 8.2% to 6.4%, which is meaningful but does not change the recommendation by guideline. We will re-run the math at six months.

The member also lost about 1.4 kg of lean mass on a DEXA done at week 12, which we'd flagged as a possible concern of any rapid weight-loss program. Resistance training was added to the program — two days a week of compound lifts at the YMCA on West Superior — to address it. The week-26 DEXA will tell us whether that bought the lean mass back.

Plan, T+0

• Repeat A1c, lipid panel, comp metabolic at T+12 weeks (mid-May 2026).
• Continue lifestyle program; no pharmacotherapy initiated.
• Resistance program 2×/week for 12 weeks; DEXA at T+12.
• Statin conversation re-opens at T+12 if LDL-C remains > 130 or 10-year ASCVD risk crosses 7.5%.
• If A1c at T+12 > 6.0%, semaglutide back on the table.

What this case is and isn't

This is not an argument against GLP-1 receptor agonists. They are excellent drugs for the right member at the right time. This is a case in which a 47-year-old with adequate time, adequate research literacy, and adequate motivation chose a 14-week window to try lifestyle first, and the math on that day worked out. Most members do not have those three things lined up, and most members in their first conversation about this decision should be offered a GLP-1 first-line. We mean both halves of that paragraph.