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Hb1Ac please explain NICE guidelines

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BrenDorset

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I don't know why the OK range is so high up to 59 mmol/mol if taking metformin, it is well above the non diabetic range.

HbA1c level is considered OK in NHS, using the NICE guidance:
Pregnancy or diet controlled patients <48 mmol/mol
Tablet treated 48 - 59 mmol/mol
Insulin treated 53 - 59 mmol/mol

Any good reason for this?

Most people in this forum are talking about achieving the much lower levels considered OK for non-diabetic patients. [I sometimes wonder whether the people in this forum actually diabetic or pre-diabetic]
 
Even the current NICE guidelines advocate a consensus target (between patient & doctor -that presupposes some things!) and a target of 48 mmol/l for a single (tablet) medication.
The higher tablet target is for multiple tablets.

Any target is bound to be somewhat arbitrary, particularly for HbA1c,( since HbA1c maps to different average blood glucose in differs people, and targets are often based on a percentile in some sample population).

The UK guidelines seem to heavily follow the US. One piece of research appeared to show that aggressively controlling BG could have be counterproductive, and this appears to have had a (disproportionate?) influence.
 
I most definitely am diabetic, have been so for 10 1/2 years with medication gradually increasing until I’m on 3 tablets, and HbA1c increasing (see my signature below)…….until I started low carb ing early this year followed by HbA1c of 47.

I’ve never discussed a target with any medical professional but my personal target is to get it as close to 40 as I can next year.
 
The HbA1c target may be lower than 48mmol/mol (this is consistent with the NHS guidance).

A combination of diet/lifestyle changes and in some cases medication is required to maintain blood glucose in the 'normal' range. Stabilising and maintaining blood glucose in the normal range is difficult to achieve and maintain, with hypoglycaemia being a concern especially when blood glucose lowering medications are used.

You will find some on the forums have type 2 diabetes which some are able to put in remission, others are type 1 diabetics for which insulin therapy is required to stay alive.
A type 2 diabetic with an HbA1c in the 'normal' range without medication has managed to put their diabetes in remission. A type 1 diabetic will require insulin even if they manage to get their HbA1c in the 'normal' range.
 
BrenDorset said:
I don't know why the OK range is so high up to 59 mmol/mol if taking metformin, it is well above the non diabetic range.

HbA1c level is considered OK in NHS, using the NICE guidance:
Pregnancy or diet controlled patients <48 mmol/mol
Tablet treated 48 - 59 mmol/mol
Insulin treated 53 - 59 mmol/mol

Any good reason for this?

Most people in this forum are talking about achieving the much lower levels considered OK for non-diabetic patients. [I sometimes wonder whether the people in this forum actually diabetic or pre-diabetic]
Click to expand...
Well in my most recent readings I, technically, am non diabetic levels. But I am, I have diabetic retinopathy and potentially Maculopathy and will need to be monitored for life even if I hold in remission so when people say they are, then in general they are. If you have hit the diagnostic levels to be classified, it doesn’t go away, in my opinion

T1 of course is totally different

Also remember these figures are purely arbitrary. I know there have been posters who have said why those figures were chosen

As to why they have a higher range, well because guidance and I guess to give some leeway as to when there will need further interaction. Having too tight a range could move onto more aggressive treatments that would up the cost and the NHS has to count the pennies too
 
I have no idea why NICE chooses to set HbA1c targets so high, but I do know that with two HbA1cs eight days apart with results of 69 and 70 mmols/mol in May 2017 I am definitely diabetic. I take Metformin and eat a diet of less than 45g of carbs per day and maintain my HbA1c in the mid 30’s. I like to keep it that low so that I have a margin for error should something turn up to raise my blood sugars, steroid injections, surgery and Covid are just three things I’ve had since my diagnosis yet my HbA1cs stayed steady :)

Edit for typo
 
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I am definitely diabetic with an HbA1c level on diagnosis of 125 in 2012 and put straight on insulin which quickly dropped my HbA1c to NICE healthy levels.

By 2016 I was in total despair. My 'healthy' HbA1c of between 48 and 52 (achieved with copious amounts of injected fast and slow acting insulin) was causing diabetic macular oedema and escalating the neuropathy in my right foot to scary levels so I am a bit puzzled as to why NICE has set the HbA1c numbers so high.

Started cutting carbs mid 2016, then joined this forum and went seriously low carb, came off Insulin and now have an HbA1c of 36.

I consider myself a diet controlled T2D because I still have to keep low carb to achieve a low HbA1c. My excellent Diabetes Nurse fully supports my low carb diet. I was in remission but have now been coded as diabetes resolved but at severe risk of developing diabetes.

Diabetic macular oedema and diabetic neuropathy are now resolved with my much lower Hb1Ac numbers. If I had kept to the NICE guidelines this definitely wouldn't have happened because these issues were deteriorating fast.
 
I think the NICE targets, certainly so far as those for type 2s are concerned, stems from the false belief that it is necessarily a progressive condition.

Like many of those commenting above, my diagnosis with an HbA1c of 108 was very firmly diabetic - no need for a second test to confirm with a number like that!

My personal target is to maintain an A1C at or below 35 mmols, which has been the case for over 4 years now, with the most recent result my best ever of 29.

None of the credit for that goes to NICE or the official guidelines, but much of it goes to this forum.
 
I was diagnosed with an hba1c of 48 after only one test which shot up to 54 after taking statins and then dropped to non diabetic levels after stopping them - all within a year. Since 2013 I’ve been at non diabetic levels with my hba1c mostly in the mid 30s and this year was officially classed as in remission.
 
Call me a complete cynic but I think the targets are set to meet the observations not the other way around. So encourage Type 2 diabetics to continue to follow a slightly modified version of the Eatwell Plate, add in medications, find that it is not really working so adjust the targets to meet the data.
This has been done when, for example, nitrate levels in drinking water were way above EU acceptable limits. Instead of improving water quality acceptable limits were merely doubled. Hey presto: targets met!
Incidentally, I am diabetic and started with an HbA1c of 104. After 6 months of low carbing I reached nondiabetic levels only to be told by the DN 'that you can afford to let your levels go higher'. I remain appalled!
 
BrenDorset said:
I don't know why the OK range is so high up to 59 mmol/mol if taking metformin, it is well above the non diabetic range.

HbA1c level is considered OK in NHS, using the NICE guidance:
Pregnancy or diet controlled patients <48 mmol/mol
Tablet treated 48 - 59 mmol/mol
Insulin treated 53 - 59 mmol/mol

Any good reason for this?

Most people in this forum are talking about achieving the much lower levels considered OK for non-diabetic patients. [I sometimes wonder whether the people in this forum actually diabetic or pre-diabetic]
Click to expand...
I am definitely diabetic even though my HbA1c was never that high, and only just into diabetic range. I had plenty of symptoms, though, and still have a few.

I found a copy of the current NHS "Handbook on Diabetes" by Bilous and Donnelly. It sets out very clearly the NHS view on Type 2 (more about this on my blog). Basically there is a belief that ALL T2s will in due course "progress" to insulin and serious complications and therefore the task for the health service is to manage that decline. The pushing of the high-carb "Eatwell" plate makes no sense for T2s but the NHS does it anyway.

If you look at the HbA1c distribution for the non-diabetic population (example attached) it clusters closely around the 37/40 mark with a very few much higher or lower. I think therefore the medically-led consensus on T2 produces a pessimistic culture in treatment where a HbA1c of 48 is seen as "success". In the UK, paying doctors to diagnose, rather than prevent, T2 adds to this.

So - there is no good patient-based reason for the levels set. There's no good reason for diagnosis at 48, either, in my opinion. And the Eatwell plate is positively harmful. Which is why you'll find so many of us on here with blood sugars in the "normal" range having rejected what the health service advises.
 

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@KennyA . That graph of HbA1c s in nondiabetics is really interesting and explains a lot. I am just so glad that I found this forum 8 years ago and found a valid and workable alternative to the standard NHS advice. The last DN I saw had been recommending a low carbohydrate diet for Type 2 patients for 40 years apparently with great success. When I asked her how she feels about the NHS guidelines she said she regards them as guidance only not mandatory instructions. She says that her records of success speak for themselves. However, when she teaches she find that student nurses are fearful of not following guidelines. I just wish more HCP s had her confidence and knowledge and that her voice was listened to.
 
I do remember reading somewhere (but can't remember where) that in the US the level for diagnosing T2 was set at a point some years ago and is due a review shortly. They base the point (the level, the number) for diagnosis on the percentage of the population that has it, so as thier population gets heavier and more and more people have Hba1c done and they get more data the level for diagnosing will rise. This is also why different countries have different levels at which diabetes 2 is diagnosed. Basically bg is a continuum and the point of diagnosis can be slid along it at will.
The US may well set their next level at 50. Maybe the UK will follow suit or go even higher to get several of us out of the system!

I've always thought it strange there is the one number irrespective of size of person. Surely a 6ft large man should have a different level to a slight 5ft man
 
Dr Snoddy said:
@KennyA . That graph of HbA1c s in nondiabetics is really interesting and explains a lot. I am just so glad that I found this forum 8 years ago and found a valid and workable alternative to the standard NHS advice. The last DN I saw had been recommending a low carbohydrate diet for Type 2 patients for 40 years apparently with great success. When I asked her how she feels about the NHS guidelines she said she regards them as guidance only not mandatory instructions. She says that her records of success speak for themselves. However, when she teaches she find that student nurses are fearful of not following guidelines. I just wish more HCP s had her confidence and knowledge and that her voice was listened to.
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You have a big bureaucratic organization that sets rules and guidelines for its staff, and then can't ever change them, because that looks like an admission that the previous regime was wrong. If it hadn't been for this place....

I found one NHS dietitian on my intro course who was prepared to back low carb openly. He was working alongside a DN who was advocating the Eatwell plate. They directly contradicted each other. Result, a roomful of confused newly diagnosed T2s.
 
Only NICE can really explain why their guidelines appear to be unhelpful/harmful. I don't understand them either.
 
MrsA2 said:
I do remember reading somewhere (but can't remember where) that in the US the level for diagnosing T2 was set at a point some years ago and is due a review shortly. They base the point (the level, the number) for diagnosis on the percentage of the population that has it, so as thier population gets heavier and more and more people have Hba1c done and they get more data the level for diagnosing will rise. This is also why different countries have different levels at which diabetes 2 is diagnosed. Basically bg is a continuum and the point of diagnosis can be slid along it at will.
The US may well set their next level at 50. Maybe the UK will follow suit or go even higher to get several of us out of the system!

I've always thought it strange there is the one number irrespective of size of person. Surely a 6ft large man should have a different level to a slight 5ft man
Click to expand...
According to Bilous and Donnelly, the 48 level for diagnosis was set (by an international group of medics including the WHO and the ADA) some years back because beneath that threshold moderate retinal damage is rare. That appears to be the sole rationale. It was supposed to be a measure to ensure that every country would agree that anyone with a reading of 48 was "officially" recognized as diabetic, and therefore enable comparisons across countries. You wouldn't then have countries individually deciding that (eg) a 65 reading was where they would diagnose.

What's happened in practice, at least in the UK, is that only people with readings of 48 are recognized as diabetic, or as "having diabetic symptoms" if you like. The UK Government incentivizes doctors to make a diagnosis, but does not incentivize doctors to help anyone interested in achieving a BG reduction.
 
I so agree with Mrs.A2 about size of person being important. After all, if our weight changes significantly it makes an appreciable difference, so why don't the Powers That Be factor in height and build? Similarly with medication - shouldn't body size be relevant?
 
Outlier said:
I so agree with Mrs.A2 about size of person being important. After all, if our weight changes significantly it makes an appreciable difference, so why don't the Powers That Be factor in height and build? Similarly with medication - shouldn't body size be relevant?
Click to expand...
HbA1c is the fraction of haemoglobin molecules that have glucose attached. As it is a fraction, the size of the person doesn't matter. As regards medication, doses are approximate anyway and are rounded to pill sizes, only children and babies normally get reduced doses.
 
There’s a strong school of thought - and I’d agree - that measuring fasting insulin would be a far better measure than HbA1c (or any blood glucose test) to identify those who are metabolically unhealthy earlier, making dietary interventions earlier and reducing incidence of diabetes. Unfortunately this test is not currently available on the NHS.
 
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