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Can hba1c be too low?

Discussion in 'Type 2 Diabetes' started by pavlosn, Dec 15, 2014.

  1. tim2000s

    tim2000s Type 1 · Expert
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    Fair enough....

    Reading the Hba1C is unreliable article is also an interesting one, and if anything, pushes you even more towards the Libre/CGM direction. If you know and can see what is going on almost real time, then you have a much better chance of having a much more stable bg level. Regardless of how accurate your Hba1C is really!
     
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  2. Lamont D

    Lamont D Reactive hypoglycemia · Master

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    You say 'none diabetics don't get them'
    I think your referring to symptoms or hypos!
    Well, I'm not diabetic and if I don't stay in 'normal' range I get all the diabetic symptoms and more!
    Or I might be reading into something??
     
  3. tim2000s

    tim2000s Type 1 · Expert
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    I know that a teacher of fine who was a long distance runner used to suffer hypos on runs, and discussion with my parents about me getting them crystallised what was happening to him and how he could manage them. Hypos are not exclusively diabetic.
     
  4. pavlosn

    pavlosn Type 2 · Well-Known Member

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    I was referring to all cause mortality and I actually sited three separate studies ( none of which I claim as my own :))

    But returning to your point it is important to note that the expected relative risk factor for the 4- 4,4/ group was 0,92 compared to the reference group's of 5-5,4% of 1 I.e. An expected improvement of 0.08 for a non diabetic. Within the 95% confidence level this still allows a range of relative risk factor for the lower group of 0,5 to 1,62.

    In order to get to the 4-4,4% group from a 5- 5,4% starting point one has to pass through the 4,5-4,9% band and this does have a worse expected risk factor at 1.06 than the reference 5-5,4% band ( 95% confidence range for the 4,5-4,9% band 0,78-1,42)

    Out of the 14099 original participants only 469 (3,3%) fell in the 4-4,4% band. The study explicitly states that a higher proportion of hepatitis C sufferers fell in this band. So as a proportion of the total sample in model 4 which excludes hepatitis C, they must represent an even smaller percentage.

    So by the above:

    If I was a non diabetic and somehow managed to lower my hba1c from 5-5,4% all the way to 4-4,4% I would expect to lower my expected mortality risk excluding hepatitis c by 8 per cent. But if I missed my target and ended up in the 4,5-4,9 range I would expect to increase the same risk by 6%.

    But I am a diabetic.

    Only a tiny percentage of non diabetics manage 4-4,4%. Is it realistic to expect me or any other diabetic to match them.

    Even the reference 5-5,4% is a tough ask for most diabetics. In order to go even lower would require greatly increased medication or dietary restriction. Any additional risk associated by such increased medication or dietary restrictions is not captured by the above studies which concentrates on non diabetics.
     
  5. Squire Fulwood

    Squire Fulwood Type 2 · Expert

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    Who was it that said that?

    According to my nurse anyone can go hypo although in a healthy person the body makes a recovery without help. A healthy person is unlikely to go hypo so badly and so often as to affect the Hba1c whereas a person taking medication can.

    In his opening paper @pavlosn said "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."

    I mentioned the Libre man to give a possible reason for the doctors advising people to raise their Hba1c.
     
  6. pavlosn

    pavlosn Type 2 · Well-Known Member

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    @jack412

    As I recall our last discussion ended prematurely by both of us being brought to line by a moderator for hijacking someone else's thread, which was probably fair enough I suppose.

    The subject resurfaced in a recent discussion in the "t2 what was you reading in the morning" with a couple of members expressing disappointment with their doctors, who asked them to actually aim for higher hba1c scores.

    In fact what pushed me to open the thread was the following slide

    ImageUploadedByDCUK Forum1418658078.711469.jpg

    Taken from a video link you yourself posted to miked earlier today of a lecture on glucose and lipid blood test measurements.

    I feel that this is an important subject, one that deserves its own thread where more people will have an opportunity to participate in the discussion.

    Regards

    Pavlos
     
  7. sanguine

    sanguine Type 2 · Well-Known Member

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    1) Noted
    2) "Your order has despatched and it's too late to cancel, mwahahaha"

    :woot:
     
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  8. jack412

    jack412 Type 2 · Expert

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    4-4.4% is all-cause mortality, minus hepatitis C, a bump between that and 5.5 shows the variance within a population who die in 8 years of study, you are taking it as an absolute.
    I'm struggling to see what you are trying show?

    as to your "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."

    the diabetic got the standard advice meant for insulin or hypo inducing meds without those meds you can have 4%
    stating to take everything a dr or nurse says as right can be dangerous
     
    #28 jack412, Dec 15, 2014 at 3:46 PM
    Last edited by a moderator: Dec 15, 2014
  9. jack412

    jack412 Type 2 · Expert

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    yes, but we would need to find that study and see what and why things were said and measured, before we took at face value all diabetics should be 5-5.5 which is the range of good heart stuff
     
  10. douglas99

    douglas99 I reversed my Type 2 · Well-Known Member

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    It is actually a very meaningless study to be honest.
    Mortality of all subjects will be 100%.
    HbA1c will have no effect on the outcome, and as the figures are 'adjusted' the results are as good as the algorithm for the adjustments.
    And there are a lot to get through.

    quote ' Adjusted hazard ratios for the association between HbA1c and all-cause mortality among participants without diabetes using a quadratic spline with knots at the 2.5, 10, 50, 90, and 97.5 percentiles. Adjusted for age, race-ethnicity, sex, lifestyle factors (education, income, current smoking, alcohol consumption, physical activity, body mass index, and aspirin use), cardiovascular factors (systolic blood pressure, antihypertensive medication use, total cholesterol, HDL cholesterol, log triglycerides, elevated C-reactive protein, and history of CVD), metabolic factors (prior diagnosis of thyroid disease, thyroid-stimulating hormone, estimated glomerular filtration rate, and albuminuria), red blood cell indices (hemoglobin, red blood cell distribution width, mean cell volume, and serum folate), iron storage indices (serum albumin, ferritin, and transferrin saturation), and liver function indices (hepatitis C seropositivity, AST, and ALT)'
     
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  11. pavlosn

    pavlosn Type 2 · Well-Known Member

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    Conversely I could argue that dismissing everything a doctor states as bad advise, when one is not a doctor oneself may be more dangerous.

    I do not put blind belief in my or any other doctor, as you can see I have tried to research the matter, and I am on record as still targeting non diabetic hba1c levels myself. But neither do I distrust it just because it came from a doctor.

    Let's not forget that the NICE guideline for t2 diabetics not on hypo inducing meds as quoted by this very site is 6,5% or 48 mmol.

    http://www.diabetes.co.uk/what-is-hba1c.html

    The corresponding targets for anyone at risk of hypos is 7,5% or 59 mmol.

    So the doctor did not give advice meant for someone else if he followed these guidelines,
     
  12. Lamont D

    Lamont D Reactive hypoglycemia · Master

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  13. douglas99

    douglas99 I reversed my Type 2 · Well-Known Member

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    I said

    'I know that direct complications come from having too much BG in the blood.
    So some effects are a straight causality, so those I can hope to avoid.
    None diabetics don't get them, so if I keep my BG in the normal range, hopefully I won't. But normal will do me, I don't need to go lower.
     
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  14. jack412

    jack412 Type 2 · Expert

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    have a google for optimum control, it isn't 6.5 or 7.5,
     
  15. douglas99

    douglas99 I reversed my Type 2 · Well-Known Member

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    But does google say it's 4?
     
  16. pavlosn

    pavlosn Type 2 · Well-Known Member

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    Jack

    The first link in my original post is a link to the full study from which this diagram was taken.

    The 4 graph photo in my original post is also from this study.

    I believe the study does not claim increased risk of CVD deaths below 5% but does claim increased risk all cause mortality.
     
  17. Lamont D

    Lamont D Reactive hypoglycemia · Master

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    Ok I think I've got it now!

    But I do and would get the complications of higher blood sugars.

    I'm not diabetic!
     
  18. Lamont D

    Lamont D Reactive hypoglycemia · Master

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    We are all different and unique, depending on complications there can be no exact figure for optimum control!
     
  19. pavlosn

    pavlosn Type 2 · Well-Known Member

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    No argument from anyone that once you are above diabetic levels or even before, risk increases with Hba1c so in practical terms the advise is that you should keep it as low as possible especially if you can do it without high doses of medication.

    Even better advise would be to not become diabetic:)
     
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  20. Lamont D

    Lamont D Reactive hypoglycemia · Master

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    Totally agree!
     
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