Too good hba1c!?!??

[benjygirl]

I've been told by my GP that my Hba1c of 6.5 is too low and to lower my doses of insulin. I am now getting warning messages on my meter of high patterns. I've been doing as I'm told as I have to have a repeat Hba1c test in a few weeks but bet your life after that I'm going back to my good control where I feel I'm in charge. Ive only ever had 1 hypo in all the 3 years that I've been Type 1. I think the docs have had a circular or something telling them that an Hba1c below 6.5 is too low and we all must be having multiple hypos !!


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[Charles Robin]

The problem all stems down to the way diabetes is perceived by so many doctors. In my experience they don't try to normalise your blood sugars, but instead try damage control and hope for the best. I had a nice long argument with my DSN in January because my HBA1C was 5.5. He just focused on the hypos I had, and told me not to worry about the high blood sugars. I pointed out the problem was that I was always hungry, so was eating too much and trying to course correct and inevitably overshooting. His response was pretty much 'don't have hypos.' Then I said I had started following a low carb diet and all communication became a broken record. I have to say I am rather disillusioned with the NHS. I would advise you do what I am doing, which is to prove the establishment wrong. Note down all your results, trying to maintain as good control as possible. If you are not having the hypos they are afraid of, and you have evidence to prove this, they might sit up and take notice.

 

[Spiker]

To be fair to the NHS, their data on the diabetic population as a whole shows them that below about 7% HBa1c, the risks of hypos on average start to outweigh the benefits of lower HBa1c. Probably the "risks" and "benefits" are viewed as much from the perspective of the healthcare system as from the individual. So I think the NHS are correct to raise an alarm if HBa1c is below 7%.

BUT

"Low" HBa1c does not cause hypos nor does it cause hypo unawareness. It's just an indicator of a possibility. There are two alternatives. Either the person has a low HBa1c and errative blood sugar, in which case they are almost definitely having hypos. Or, they have low HBa1c and stable blood sugar, in which case they are probably not having hypos.

What the NHS don't seem to do in many of these cases is investigate whether the person is having excessive hypos or not. In a lot of these reported cases they just take a one size fits all model that assumes the person's control is erratic, and that therefore the person is having excessive hypos. That shows either ignorance, carelessness, or (worst of all) distrust of the patients. So I am not in favour of that! But I am in favour of doctors giving a warning, and then investigating to see if there is a problem.

 

[Spiker]

It's not a matter of judgement or opinion, even small increases in HbA1c have been shown to dramatically raise the chances of heart disease and other complications.

http://www.cardiab.com/content/10/1/58
("Overall, risk of CVD was significantly 2.4 times higher in individuals with HbA1c ≥6.5% versus <6.0%.")
http://www.ncbi.nlm.nih.gov/pubmed/15381514
("An increase in hemoglobin A1c of 1 percentage point was associated with a relative risk for death from any cause of 1.24 (95% CI, 1.14 to 1.34; P < 0.001) in men and with a relative risk of 1.28 (CI, 1.06 to 1.32; P < 0.001) in women. These relative risks were independent of age, body mass index, waist-to-hip ratio, systolic blood pressure, serum cholesterol concentration, cigarette smoking, and history of cardiovascular disease.")
http://diabetes.diabetesjournals.org/content/41/2/202.full.pdf
("The relative odds of CVD increased 1.39 fold for increases in HBA1c of 1% (eg 5 to 6%)")

True, but...

Doctors (and diabetics) have to look at the absolute probabilities, not just the relative ones. And they have to compare the absolute probabilities of the contrasting events So, just as an example (made up numbers), so if ....

Risk of CVD is 2.4 per trillion at HBa1c > 6.5, vs 1 per trillion at HBa1c < 6.0

whereas

Severe hypo risk is 1 per 100 at HBa1c > 6.5, vs 8 per 100 at HBa1c < 6.0

... you could then see in that case where the doctors are coming from.

(I don't know the actual absolute numbers, I'm using an exaggerated example to illustrate their thought process)

 

[donnellysdogs]

I'm told to keep above 6.5 for my hba1c as
1) my blood meter on my pump actually reads a lot higher than the blood from my vein... So if my meter says I'm 5.0 I am actually going to be lower than that. This is proved from my 90 day readings on my meter which will say for example average of 6.5 and my hba will come in at 5.6.....

2) I have previously almost lost my licence from a driving incident, despite having pulled over and was treating myself. I will never risk that again...

3) in my experience and being totally honest.. The lower my hba the more frequent my hypo's. So why would I want more hypo's? I do a lot of physical work and exercise by myself and for me personally it is stupid to risk. Under 6.5's and my hypo's although not severe and I don't need help- but one day I may if they continue frequently.

I always find it harder to raise my hba's than lower them.. As I do try to keep my bloods in 5-8 range. However a few pump failures and hypo's hinder sometimes...

Personally I'm better between 6.5 and 7.1.



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[lizdeluz]

I'm in the process of trying to decrease my hba1c, but my recent test, following 3 months of LCHF diet was 7.5 and I was encouraged with that because it was a big improvement on last year's result. However my dsn was delighted with 7.5 and said it was " perfect" ! and "well done!" But I know you all wouldn't think that, any more than I do. I'm keeping on keeping on and really would be delighted to reach 6.1 !

 

[Spiker]

This is proved from my 90 day readings on my meter which will say for example average of 6.5 and my hba will come in at 5.6.....

%HBa1c is not exactly the same as average blood glucose mmol/L. It's a similar-ish but slightly different number. There are tables you can get to relate a given HBa1c to a given average blood sugar. However the different tables all disagree with each other.

Also your meter will give a straight line average over 90 days, weighted equally across the 90 days, whereas an HBa1c is heavily weighted to the more recent parts of the 90 days and the older parts have a minor influence.

2) I have previously almost lost my licence from a driving incident, despite having pulled over and was treating myself. I will never risk that again...

Did you manage to get the keys out of the ignition, drop them and get in the back seat? That was drilled into me like the fear of God. The idea is you are not in "care and control of a motor vehicle".

3) in my experience and being totally honest.. The lower my hba the more frequent my hypo's. So why would I want more hypo's? I do a lot of physical work and exercise by myself and for me personally it is stupid to risk. Under 6.5's and my hypo's although not severe and I don't need help- but one day I may if they continue frequently.

Thanks for that honest answer DD. It's the same with me if I am also honest. Though the stats on pumps are to offer better HBa1c without worse hypos, so I have my fingers crossed for that.

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[donnellysdogs]

Ooh Spiker... No.. I was still in driver seat. Parked. Ignition off. Glove box open eating sweets...

I never been told to climb in to back seat!!-i can imagine that... Mine are folded down with all my gardening tools in the back!!! The thought of that really makes me chuckle!!

I should have got out or in passenger seat... But it didn't occur to me at time....


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[robert72]

Ooh Spiker... No.. I was still in driver seat. Parked. Ignition off. Glove box open eating sweets...

I never been told to climb in to back seat!!-i can imagine that... Mine are folded down with all my gardening tools in the back!!! The thought of that really makes me chuckle!!

I should have got out or in passenger seat... But it didn't occur to me at time....


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Have you got a garden gnome? You could put him in the driver seat and deny everything

 

[donnellysdogs]

Oops, I do have a concrete gnome at home hidden in my shed!!! Will put him in passenger seat tomorrow and do a swop if necessary!!

**** times when it happened. Worst time of my life in all honesty. I would never risk going through that again...


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[Spiker]

**** times when it happened. Worst time of my life in all honesty. I would never risk going through that again...

Yeah it's bloody miserable. It's happened to me twice. Once I did the drill and got in the back seat but all I had in the car was a bloody apple! (it was a long time ago) I lay down and tried to relax and slow down my metabolism - easier said than done when full of adrenalin. Somehow I made it, I really wasn't expecting to.

Second time I did not make it. I did pull over to the hard shoulder and get into the passenger side. I was well aware of the hypo and in half an hour had eaten literally about four family sized bags of sweets, stashed in both doorwells, but it just wasn't working. I have only just now realised why I wasn't arrested after the emergency services attended the hard shoulder was that my partner was actually driving by that point. Memory is always a bit flaky around hypos eh?


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[benjygirl]

What I REALLY didn't understand was why my Hba1c of 6.5 in 2013 was considered really good but the same reading in 2014 is considered too low. BTW I have only ever had about 4 hypos in the 3 years since being diagnosed and these weren't particularly low roughly 3.7 ish.


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[Spiker]

What I REALLY didn't understand was why my Hba1c of 6.5 in 2013 was considered really good but the same reading in 2014 is considered too low. BTW I have only ever had about 4 hypos in the 3 years since being diagnosed and these weren't particularly low roughly 3.7 ish.


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Benjygirl don't worry about it. You are the exception that proves the rule. If you don't have hypos and you do have hypo awareness then your good, low HBa1c is gloriously irrelevant!

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