Can hba1c be too low?

tim2000s

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I think the reason a lot of people don't stick to the guideline levels is because they find it very hard. If you look at the lifestyle changes that you've made and how disciplined you really have to be, it should be no real surprise that many simply don't have what it takes to stick to what's needed.
 
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kimbo1962

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As a t2 non insulin dependent diabetic, I have been controlling my levels with a target of keeping my hba1c as low as possible, as I understood that this would improve my risk of avoiding the most common diabetic complications.

A non diabetic Hba1c was my initial target for reasons that appeared self evident to me. If I can keep my levels the same as a non diabetic then hopefully I am also keeping the risks I am facing down to a similar level as well.

But the non diabetic hba1c range stretches from 4% to 6% so it is quite a wide range. Where within this should i/we actually be aiming for?

I am currently waiting for my latest score but my last hba1c was a non diabetic 5,2% or 33mmol/mol, which led me to question where I go from here.

Do I continue to aim lower hoping perhaps to break into the 4% club with a sub 5% hba1c?

Is there any evidence that such a score is better than my current score or even a slightly higher score?

Conversely, is there evidence that such a low score my actually be an indicator of increased rather than decreased risk of health complications.

My concerns were compounded by reading stories of other non insulin dependent t2s that on recent visits to their doctors were advised to raise their hba1c scores from under 6% (42.1 mmol/mol) to the 6-6,5% (42,1-47,5) pre diabetic range. Advise that did not make sense to me but which I did not immediately dismiss because I am not a doctor and they are, so they must be basing it on some kind of evidence and research.

Which led me to start looking online for relevant literature.

The first question I tried to find the answer to was where within the normal non diabetic range did most non diabetics lie.

I could not find a direct answer to my question but from the sample used in this relevant study

http://www.nejm.org/doi/full/10.1056/NEJMoa0908359#discussion

I got this diagram suggesting that the vast majority of non diabetics have an hba1c higher than 5% (31,1 mmol/mol) with most being in the 5-5,5% band. ( 31.1 - 36.6 mmol/mol)


View attachment 9542

But this study was based on a sample of about 11000 participants who were mainly in their fifties.


By looking at the sample characteristics of this study of 14000 non diabetics

http://m.circoutcomes.ahajournals.org/content/3/6/661.full

I got a similar looking graph

View attachment 9541

The split seemed to be 75:25 in favor of above 5%( 31,1 mmol/mol) Hba1c amongst the participating diabetics, with the 5,0-5,5 ( 31.1-36.6 mmol/mol) band again being the most populous.

So it seems that if the above is correct the average non diabetic has an hba1c of 5-5,5. ( 31.1-36.6 mmol/mol).

But does most common equate to best. What if a smaller number of diabetics had a sub 5% (31.1 mmol) hba1c but these were the non diabetics that faced the least risk.

Two diagrams extracted from these two studies gave similar answers to the above question.

View attachment 9544

View attachment 9545

Both suggest a j shape relationship between all cause mortality and Hba1c I.e the risk of death from any cause decreases with decreasing hba1c as one reduces from the diabetic to the prediabetic to the non diabetic range. But at some point around the 5% 31.1 mmol/mol) mark reducing further actually seems to increase all purpose mortality risk.

Why this should be so I can not answer but this is what I understand from the above studies/graphs.

And both of these are dealing with non diabetics who can achieve these scores without resorting to any intervention whether dietary or medicinal.

I also found this online abstract

http://m.care.diabetesjournals.org/content/early/2014/11/13/dc14-1787.abstract

From a recent German study which concluded that "Excess mortality risk is associated with both known diabetes and undiagnosed diabetes but not for prediabetes, with lowest risk at HbA1c levels 5.4–5.6% (35.5-37.7 mmol/mol) (and a significantly increased risk at ≤5.0% (31.1 mmol) and ≥6.4% ( 46.4 mmol)"

All food for thought and all challenging my basic assumption that lower is necessarily better when it comes to Hba1c

Pavlos
Wow! Pavlos! What a great in-depth post! I need to com back and read more later as obviously the "too low" theory is very much of interest to me right now!! Busy morning but I will come back later
 
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Kezzer4321

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To be honest I wasn't given any guidelines. I was given a bad photocopy about diabetes and a loan of an NHS booklet about the complications of diabetes. I was told the medication would lower my BS and that I should try and loose weight by eating to the eat well plate. The dietician I saw, told me to buy everything low fat, and that a third of every meal should be carbs.more if I could manage it. I was told I didn't have to cut out sugar - that I could eat biscuits cakes etc in moderation... I have never been offered any kind of course and no other information has ever been provided to me by my doctors. I was put straight on to metformin straight away.

However my sister who was diagnosed after me and lives in a different area had completely different treatment. Her doctor has sent her and her husband on several courses and her doctors gave her 6 months to try to manage her diabetes with diet and exercise alone. They had a support group which my sister and sometimes her husband attended. Where people talked about their diabetes, issues and successes - and where they were given advice on what to eat and how to exercise. They were also encouraged to buddy up on the exercise for motivation. Although LCHF wasn't particularly recommended - those that were successful in lowing their BS, seemed to drift this way and therefore enouraged the other newer members to do so.

Therefore until the difference in treatment available to people based on where you live is rectified, it is no wonder that some people, myself included at the time, don't take diabetes as serious, or don't understand the implication of badly managed diabetes. I know I didn't. It was only when I saw the liver specialist, who was blunt with the truth and I hit rock bottom, did I seek alternative help.
 
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NoCrbs4Me

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To be honest I wasn't given any guidelines. I was given a bad photocopy about diabetes and a loan of an NHS booklet about the complications of diabetes. I was told the medication would lower my BS and that I should try and loose weight by eating to the eat well plate. The dietician I saw, told me to buy everything low fat, and that a third of every meal should be carbs.more if I could manage it. I was told I didn't have to cut out sugar - that I could eat biscuits cakes etc in moderation... I have never been offered any kind of course and no other information has ever been provided to me by my doctors. I was put straight on to metformin straight away.

Sounds extremely familiar.
 
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NoCrbs4Me

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I think the reason a lot of people don't stick to the guideline levels is because they find it very hard. If you look at the lifestyle changes that you've made and how disciplined you really have to be, it should be no real surprise that many simply don't have what it takes to stick to what's needed.
I think the main reason is that it is impossible for 90% of type 2 diabetics to keep their blood sugar at normal levels while eating the officially recommended "healthy" high carb/low fat diet. The only way most of us on this forum have succeeded doing it is by ignoring the official dietary advice.
 
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douglas99

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I think the main reason is that it is impossible for 90% of type 2 diabetics to keep their blood sugar at normal levels while eating the officially recommended "healthy" high carb/low fat diet. The only way most of us on this forum have succeeded doing it is by ignoring the official dietary advice.

Not really.
Working with the HCP to refine the diet is a good way.
 

NoCrbs4Me

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Not really.
Working with the HCP to refine the diet is a good way.
That's why I used the word "most" and not "all" (duh!). Also, I think it's the rare exception that a dietician, nurse or doctor will accept a low carb or a very low carb diet/high fat diet as being healthy and encourage a type 2 diabetic to try it. If the recommended high carb/low fat diet does not work, the next step is drugs.
 
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douglas99

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That's why I used the word "most" and not "all" (duh!). Also, I think it's the rare exception that a dietician, nurse or doctor will accept a low carb or a very low carb diet/high fat diet as being healthy and encourage a type 2 diabetic to try it. If the recommended high carb/low fat diet does not work, the next step is drugs.

I don't low carb remember?
Or as you say (duh!)
Many that's why I work with my HCP, as I accept it works as well, rather than insist there is only one possible recommended diet?
 

NoCrbs4Me

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I don't low carb remember?
Or as you say (duh!)
Many that's why I work with my HCP, as I accept it works as well, rather than insist there is only one possible recommended diet?
So you disagree that the only way most of us on this forum have succeeded doing it is by ignoring the official dietary advice?
 

douglas99

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So you disagree that the only way most of us on this forum have succeeded doing it is by ignoring the official dietary advice?

I keep saying it, I'll only speak for me, if you decide you can talk for others, that's down to you.
 

jack412

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That's why I used the word "most" and not "all" (duh!). Also, I think it's the rare exception that a dietician, nurse or doctor will accept a low carb or a very low carb diet/high fat diet as being healthy and encourage a type 2 diabetic to try it. If the recommended high carb/low fat diet does not work, the next step is drugs.
I'm Ok with my Dr, he's right behind me with the LCHF and is very pleased with my progress, one of the lucky ones I guess, or it could be that he's aussies and a long way from NHS :)
though out dietitians went to the same school
 

jack412

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I don't low carb remember?
Or as you say (duh!)
Many that's why I work with my HCP, as I accept it works as well, rather than insist there is only one possible recommended diet?
doug, 30% is low carb and 30% is high fat to most
 

jack412

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I know, you keep claiming I'm LCHF.
I'm good to advise on that diet my way if you agree?
do what you like, just don't say you don't do low carb....it's not a good balance of fat and carb, one should be higher and the other lower, it seems it doesn't matter which with some diets. IMO from what I have read I would say it's messing with you blood fats and looking at CVD
 

douglas99

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Good BMI,
good fasting BG
good HbA1c
goood weight,
good trigs, LDL, HDL,

I'd say I'm ok on a low GI/GL diet.
 
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tim2000s

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I have decided that the best diet is 50% alcohol and the rest can come from other stuff. Or is there an issue with that?
 
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