What is the optimum target for HbA1c ?

[Adam63]

I have been diagnosed type 2 diabetic for one year and am on four 500grm tablet of Metformin.
I am 63 years old and want to drive my blood sugars down to a level which can slow down any potential degeneration in my sight (and other health factors such as neuropathy).

Last week I had a half yearly check with the diabetic nurse at my GP practice.
My HbA1c was 7.1. I was a bit disappointed by this as I have been trying very hard to avoid sugar in my diet. The nurse told me this was a good figure, and that the Health Board had recently increases the target HbA1c to 7.5.

However, I read on this site that this 7.5 target referred to people who have some risk of hypoglycemia. As I cannot see any reason why I should be of risk of hypoglycemia, am I being given the correct advice ?

I would be happier with a target HbA1c of 6.5 or so, but the nurse was insistant that I had a good HbA1c level.

I would be willing to push even harder on my diet, or even take additional medications to further reduce my blood sugar.

 

[pianoman]

Hi Adam and Welcome

My opinion (and I am not a Doctor) is that the ideal HbA1c (A1c) for a person with Diabetes is: as near to normal as safely and reasonably possible. If it is important enough for a non-diabetic's body to keep it in the normal range then why would I expect that aiming for higher is OK for me?

With an A1c of 7% roughly equating to an average Blood Glucose (BG) of 8.6mmol/L, 6% to around 7mmol/L, and 5% to around 5.4mmol/L -- given that (as I understand it) the normal BG range is around 4.5 - 7mmol/L at all times.

I use the word "safely" because, as you mention, due consideration must be given to the risk of hypoglycaemia -- especially by those injecting insulin or taking medications that increase insulin secretion.

...and "reasonably" because I have to accept that I do have Diabetes and as such I may not be able to achieve truly normal BG numbers at all times -- and I have no desire to spend my life as a slave to my BG control... I want to live it as well :wink:

That is why I use the phrase "aiming for" because although I aim for near normal, I realistically, do not always achieve it... too often not even close.

With all that out of the way I would respectfully suggest that as you (and not your HCP) is the one living with your Diabetes every day for the rest of your life, then it is up to you. For me that number is closer to 6% than 7% but we each have to work within our own limitations, so I try not to compare my "numbers" with others

Dr Ian Blumer (in Canada) says this about A1c... http://www.ourdiabetes.com/faqs.htm#What_is_an_A1C__and_what_should_my_A1C_be__

How important is it to monitor and optimize your A1C level? Well, how about this...the landmark UKPDS study showed that if you drop your A1C by one percent (which is equivalent to about a 2 mmol/L drop in your average blood glucoselevel), you will reduce the likelihood of many diabetes complications by almost 40 perdent! Therefore, even if you aren't yet at the target A1C (and indeed even if you never reach target) it is important that you know that any reduction in your blood glucose (and, hence, your A1C) will substantially reduce your risk of diabetes damaging your body. So if your A1C was 10 and you get it down to 9 pat yourself on the back; you've just reduced your risk of eye and kidney damage by almost 40%!

 

[Unbeliever]

Hi Adam, Just a word of cauion . Try for a gradual reduction in your levels . Steady does it.
A sudden sharp reduction in your levels can actually CAUSE complications

 

[chocoholicnomore]

A sudden sharp reduction in your levels can actually CAUSE complications

Reading this worries me. Can you maybe explain a wee bit more about what you mean?
I went from Hb of 9.5 to 6.8 in just over 2 months (23/09/11 to 08/12/11)
Would that be classed as a sudden sharp reduction? Both the doctor and I were pleased with the result and nobody suggested it could cause complications.
Sorry if I seem a bit paranoid

 

[Grazer]

A sudden sharp reduction in your levels can actually CAUSE complications

Reading this worries me. Can you maybe explain a wee bit more about what you mean?
I went from Hb of 9.5 to 6.8 in just over 2 months (23/09/11 to 08/12/11)
Would that be classed as a sudden sharp reduction? Both the doctor and I were pleased with the result and nobody suggested it could cause complications.
Sorry if I seem a bit paranoid

Don't worry at all. That drop is great and won't cause any problems at all. Adam, don't listen to the safety first comments about 7.5 being good. I agree with earlier comments. We need to be as near normal as poss. 6 is better than 7! You're right to aim lower. Look at our diet pages and you'll get there.

 

[borofergie]

A sudden sharp reduction in your levels can actually CAUSE complications

Reading this worries me. Can you maybe explain a wee bit more about what you mean?
I went from Hb of 9.5 to 6.8 in just over 2 months (23/09/11 to 08/12/11)
Would that be classed as a sudden sharp reduction? Both the doctor and I were pleased with the result and nobody suggested it could cause complications.
Sorry if I seem a bit paranoid

I went from 10.2% to 5.2% in 3 months.

I think you have to balance the risk of high BG levels with the risk of dropping too quick.

In my case I was just desperate to prove that I could get it under control. It wasn't until my BG dropped a bit that I realised just how ill I'd felt for a long time with (undetected) hyperglycemia.

Keep up the good work choccy!

 

[Unbeliever]

Didn't mean to frighten anyone but it is a fact that my levels went from about 11 to 4 meter readings not HBA1C] overnight .because of a change of medication and! suffered a massive retinal bleed as a result.

I had been wrongly referred to the eye clinic with[ before the days of annual screening] only mild background retinopathy. my doctor had relied on his trusty old lens. I was seeing a consultant prior to discharge when the bleed was discovered, It was all vey well documented to the point where the actual day could be pinpointed.

That was four years ago. despite , I believe , the best possible care , the condition does not respond to treatment, or only temporarily. A massive improvement to my levels in the last year also caused furher problems. I recently thought there had been a breakthrough when he leakage appeared to have stopped but it has now begun again. In the past year I have had procedures every 4-6 weeks.
There is nowhere left to laser in my left eye and the steroid injections only last a month or so and I can't have them indefinitely.

My doctor was absoluely thrilled for me when my levels fell overnight and stayed that way . Until the visit to the eye clinic when the side effects of this sudden reduction were discovered.
Apparently anyone who has been undiagnosed for a while, as I was risks side effects of some kind when levels are reduced too quickly. I know I am not alone in having suffered in this way- it is fairly common. Often things right themselves after a time but not always.

There is a real possibility I could lose my sight completely. If I can save anyone else from this by issuing a word of warning I feel obliged to do so.

My GP , at he time , although he had been treating diabetics for several years had never encountered this result before but the hospital saw it as commonplce.

As I said I didn't mean o alarm anyone unneccessarily but this forum is supposed to be about our own acual experiences which may benefit others. We must all make up our own mnds.
of course it is an excellent thing to reduce one's levels but if the body has been used o running at very high levels for some time it is understandable that a sudden dramatic drop could be harmful
surely?


I jus feel an obligation to menion my experience when someone speaks of driving down levels urgently

 

[Grazer]

I think the key is, as you said, that your meter readings dropped rapidly in short time. Chocoholic is talking about an HbA1c drop over months. Also, there was obviously an underlying problem you had to cause your unfortunate results. We weren't having a go at you though - just reassuring Choco with her HbA1c drop

 

[Unbeliever]

Didn't think you were having a go. I pointed out that I was speaking of meter readings not HBA1Cs.

I was just concerned about Eric being determind t
o "drive" his levels down, which suggested drasic action.

My problem arose because I had been put on rosiglitazone for a few months and then asked o be taken off it and was given a glimepiride which worked. -immediately and drastically -probably just as the rosiglitazone had kicked in.

I had no particular problem wih my eyes, One of the Gp's in my practice "thought he could see something on the macular " through his little hand-held lens. he treid so hard to see it he actually strained my eye muscle by forcing me to look in one direction for too long a time.

Once I was in the hospital system they did various checks over 18 months and there was no sign of anything bu the most minor diabetic changes o the retina , such as most people now have on their annnual screening.

When the medication was changed the massive "Bleed" occurred. The underlying problem was the
pressure to bring down my levels in a short time to ensure targets were met.
I am sure you can understand why I want to warn others. I hope chocaholic is now reassured and that Eric is not tempted to overdo things.

 

[carbman]

If you have been running very high BG numbers. Take some time in reducing . Around three-six months is safe. Rapid reduction from very high BG numbers, to non diabetic can cause eye problems.

What is the optimum target for HbA1c ? less than six.

 

[noblehead]

If you have been running very high BG numbers. Take some time in reducing . Around three-six months is safe. Rapid reduction from very high BG numbers, to non diabetic can cause eye problems.

Yes it can for those in the early stages of diabetic retinopathy, here's an article discussing this matter and advising patients to reduce their Hba1c gradually over months rather than weeks:

http://medweb.bham.ac.uk/easdec/retinop ... ession.htm

 

[the east man]

I have been diagnosed type 2 diabetic for one year and am on four 500grm tablet of Metformin.
I am 63 years old and want to drive my blood sugars down to a level which can slow down any potential degeneration in my sight (and other health factors such as neuropathy).

Last week I had a half yearly check with the diabetic nurse at my GP practice.
My HbA1c was 7.1. I was a bit disappointed by this as I have been trying very hard to avoid sugar in my diet. The nurse told me this was a good figure, and that the Health Board had recently increases the target HbA1c to 7.5.

However, I read on this site that this 7.5 target referred to people who have some risk of hypoglycemia. As I cannot see any reason why I should be of risk of hypoglycemia, am I being given the correct advice ?

I would be happier with a target HbA1c of 6.5 or so, but the nurse was insistant that I had a good HbA1c level.

I would be willing to push even harder on my diet, or even take additional medications to further reduce my blood sugar.

Have a wee look at this site, it covers BG readings pretty well, and it isnt all about your HbA1c readings, but about your after meal readings. bloodsugar101.com

 

[phoenix]

The possible problems with retinopathy worsening if levels are suddenly controlled is well known . (called early worsening). Nevertheless, if people continue to have very high HbA1cs for any length of time then they they are at very high risk of severe retinopathy anyhow. (They are normally talking about high levels as those of 8% and above when writing about it)
From personal experience, I don't know how high my levels were at diagnosis but given the weight I had lost (unitentionally) and the ketones and high levels, I expect my HbA1c would have been high. Normal checks showed no retinopathy. Within 2 months it was down to 6% and hasn't been above 5.8% since then. I went on a pump 3 years later. One of the requirements (in France and because of this potential problem) was, immediately before my pump start, to have a very thorough eye check using fluorescein angiography . TThe opthamologist found that I had 'signs' of retinopathy (tiny bleeds) that showed up with that check. ...so present all along and not detected or possibly induced by the rapid fall after diagnosis .
People with higher HbA1cs than I at pump start, were counselled on gradually lowering their levels, with more frequent eye checks. etc . I still have yearly checks using fluorescein and although the retinopathy hasn't worsened, it hasn't gone away either.
There is some useful information on rapid lowering of HbA1cs and the risk of rapid progression of retinopathy on the Good Hope Hospital site.(edited, took too long writing, same link as Nigels!)
It suggests that lowering of HbA1cs, especially if there is some evidence of retinopathy should take place slowly (up to a year, from very high levels) and that at the same time, good control of BP, lipids and stopping smoking (if relevant) are equally important.
http://medweb.bham.ac.uk/easdec/retinop ... ession.htm

 

[Sid Bonkers]

As I was put straight on insulin after diagnosis I reduced my Ac1 down from 12.9% to 5.something% in just 3 months, my first retinal scan did show background retinopathy caused no doubt by my fast(ish) reduction in bg levels but a year later the second scan showed all clear so whilst fast reduction can cause small bleeds it is still much safer long term than staying at high levels where the damage may not be reversible, IMHO.

I was a bit disappointed by this as I have been trying very hard to avoid sugar in my diet.

Adam it is not just sugar that raises our blood glucose but all carbohydrates do as well, any carbs we eat are turned 100% into glucose in our intestines some faster than others but they all turn to glucose. So a small reduction in your carbohydrate intake should be enough to slowly reduce your blood glucose levels to a lower level, perhaps eat half as much potato as you usually do and substitute Burgen or Wholegrain/Multigrain bread for white bread, wholemeal is the same as White bread in regards to raising bg levels due to its similar GI (glycemic Index) so should really be avoided if possible. :thumbup:

 

[chocoholicnomore]

Thanks for the support and reassurances.

(Glad to have you back Borofergie-have missed your sense of humour-hope you enjoyed your honeymoon)

I am so sorry what you have been through, Unbeliever, and I agree that you should warn others of the risks. After all that's what this forum is about-using your own personal experiences to help and support others. I appreciate that that's what you were doing. I just needed an explanation of what you meant by reducing BG levels too fast. The OP was about Hb levels and that is why I thought you were talking about them. However, you also mention meter readings and my FBG level on diagnosis was 13.9 and within days I had a meter reading of 3.2.

Everything I now know about diabetes I have learned from this forum. It is a good thing that people are willing to share their own experiences in order to help others. As far as I am concerned every day is a learning day and I am glad that you have warned others of the risk or reducing BG levels too fast. I am sure that there are alot of people out there, like me, who didn't know that.

Thanks

Marina

 

[Unbeliever]

No probs Marina. Its hard to get balance sometimes between warning and frightening people.

Hard to explain too. I know that there are those who don't like the suggestion that lowering levels can be anything but good. Of course it can't in the long term but there are dangers if its done too quickly.

As I explained, in my case it happened overnight . My levels fell overnight. The HBA1C {in fact I had two in a month} reflected this drop and everyone was dancing about clapping each other on the back.

A few weeks later it was a otally different story. Although the HBA1c had dropped down to the low sixes they wanted to put me on insulin. I was given blood pressure medication although my bp was normal - this caused me to faint three times in the first week. I then developed full blown white coat syndrome and they wanted to put me on massive doses of medication in spite of the fainting.

The hospital and the gps all blamed each other, there was much communication and some ill wil betwen the two. None of which helped me in the slightest. All that happened was that I lost any confidence I had had in he system.

Things improved later on with a new regime in the eye hospital and I managed to reconcile my GP {who was doing his best} with the hospital but I still find it difficult to trust anyone. This is no bad thing as In my current practtice the DSN runs all hings diabetic and often makes mistakes.

I hold no grudges abou my experience but I found out the hard way that the longed -for low figures may someimes come at too high a price if they come too suddenly.
Often there is nothing anyone can do - particularly if this occurs as a result of medicaion but if individuals want to embark on a programme which might reduce their levels dangerously quickly
I feel obliged to warn them.

Sorry if I confused or worried you.

 

[chocoholicnomore]

Thanks Unbeliever.

It's so sad reading your story. You have been through so much and to have no grudges is admirable.

I am one of those people who like to find out all the pros and cons and also like to be corrected if I have misunderstood something or picked it up wrong so I am glad of your warning. I am learning something new about diabetes every day thanks to everyone on here.

I do hope things improve for you.

Marina