Can Your A1c be too low? - Article

[Deleted Account]

Hmm, Helen, that may be true within the diabetes parameters but an extremely low A1c can surely be a cause of other issues, not necessarily associated with hypo's or diabetes. I was reading about it recently and an A1c lower than 4 (it specifically stated in the 2s or 3s) can be a sign of something serious.

That may be true but, being in the Diabetes Daily (from which I concluded), the article only mentioned diabetes.

 

[first14808]

Sooo.. Being T2 and having experienced my first hypo.. How much of a risk is it?

I'm thinking it's a risk if you're doing something hazardous like driving, working with machinery or being away from home. But assuming our liver/pancreas has some function, presumably we can recover more easily? So convert fats, muscle into glucose or ketone bodies and restore function rather than sliding quietly into a coma.

 

[KK123]

That may be true but, being in the Diabetes Daily (from which I concluded), the article only mentioned diabetes.

Yes Helen, of course, I mentioned it not as an insult or criticism but purely so others could give a thought to the fact that a too low A1c is not necessarily a good thing.

 

[Antje77]

I think the risk of hypos applies mostly to T1s, who are more likely to be using some form of CGM?

The hypo risk goes for everyone on insulin, especially mealtime insulin, including type2's. And type1's are more likely to use gcm/flash, but it's still a very small minority that does.

But assuming our liver/pancreas has some function, presumably we can recover more easily?

As far as I know both type1's and type2's can dump glucose from their liver. The difference is that exogenous insulin holds a much bigger risk of misdosing and thus deeper hypo's than tablets. A type2 on insulin has the same problems as a type1, I think. It gets real difficult for the 3C's, who don't have liver dumps of glucose to save them.

 

[LooperCat]

Doctor’s report!

Ok, he’s happy that I’m not having hypos and apologised for the nurse’s cackhanded way of expressing concern. I was right though, I’m only one of two patients at our practice using Libre, so they really have never seen that control this good is even possible. We had quite a long chat about it, apparently one of the big concerns with people who have been T1 as long as I have is that they lose hypo awareness, but mine is still good. He’s happy that I keep well above legal limits to drive and ride, and that I know that a single dextrose tablet will raise my BG by 0.6mmol, so I can adjust it very quickly if I need to. I left him with a list of the books I’ve been referring to with a brief synopsis of each and how it’s helped. He’s totally behind my low carb eating, too.

Cholesterol - while the nurse had said it was high (6.2 total) he agrees with me when I pointed them out that the total:HDL (3.1) and HDL:triglycerides (0.6) ratios are absolutely spot on perfect. He said he wasn’t going to even think about “inflicting” (his word) statins on me, despite NICE guidelines that all T1s should take them as a preventative because I simply don’t need them. @bulkbiker - thanks for all the papers and stuff you’ve posted about statins, I went in well prepared for the statin battle!

At the end of our meeting he said I should train to be a diabetes specialist nurse and that there was probably funding available for (ahem) mature applicants...

 

[Bluetit1802]

@Mel dCP Well done that doctor! You never know, your results and discussion could even lead to him recommending the Libre to other patients

 

[Scott-C]

How much of a risk is it?

There can be huge risks. In the overwhelming majority of cases, we'll pull out of it ok although still a bit worse for wear, but, given the wrong combination of circumstances, seizures, coma and death are possibilities. The very young and very elderly are more at risk.

If, as @Antje77 says, there's been a major bolus mis-calc, sure, the liver and muscles will come to our aid, but if they've recently partly exhausted their glycogen stores through dealing with an earlier hypo, they might simply not have enough in reserve to keep up with a major plummet, and the relative slowness of gluconeogenisis isn't going to be a huge help either.

I made a few major dosing mistakes in my first year after dx. It was thirty years ago, there wasn't much about carb counting and internet access for research barely existed. It was a particularly cold winter, the heating was off in my house for some repairs, had a major hypo, during the course of which I fell out of bed, so I was lying there on the floor dripping with cold sweat in a cold house, unable to move, and getting colder by the minute to the point where I was shivering. The not being able to move was the scariest bit, thinking, ok, am I going to end up unconscious with hypothermia here. Eventually came out of it enough to go stand in the shower at 4 am for about 30 mins to get some heat back in me. Boy, that was scary.

Another one was stumbling into and breaking a dresser mirror. Crawling about hypo on broken glass isn't a good situation.

Nor is having one's spatial judgment impaired by a hypo to the extent that one might walk in front of traffic.

So, yeah, there is serious risk there. It can be mitigated substantially by having cgm which basically wakes us up when we start going low, and it's about time ccgs who are not funding it started realising that, instead of fussing about lack of clinical data and whether it'll make a modest difference to a1c or not.

 

[KK123]

I expect a lot of disagreements on this but I think A1c is a load of cobblers that shouldn't be taken too seriously, at least if you have CGM/FGM that will show you exactly when your levels are where you want them to be and when they're not. Averages are unreliable and can easily be tweaked to suit your argument despite not actually reflecting it if you look at the raw numbers that you can see with your CGM/FGM. This whole obsession over A1c will probably looked back on as a headscratcher once CGM/FGM is the norm and there is proper analysis over how our levels are affected by what we eat and inject and so on rather than just saying you're doing well because your average falls within an agreed upon range with no concern for how that actually happened.

I so agree! It's a shame they won't give everybody a CGM though, how can they expect us to try to predict what we need to do by randomly pricking our fingers every few hours, it's such an ancient method.

 

[Scott-C]

I so agree! It's a shame they won't give everybody a CGM though, how can they expect us to try to predict what we need to do by randomly pricking our fingers every few hours, it's such an ancient method.

I agree too. History is repeating itself here.

I started off 30 yrs ago with colour changing strips and was told they were the new thing to replace urine tests, and were expensive so I should cut them in half so I'd get 100 tests from a pack of 50.

Then, meters came in, they were expensive, but made the colour changing strips look primitive. It was only a matter of time before meters became the de facto standard and people were scratching their heads about why they there had been issues with funding them.

Same now with cgm. It's another step-change. It's the new expensive kid on the block, bean counters are saying, oh, why do they need them, what's wrong with meters, but I reckon there's a slow, subtle shift going on which will lead to some of the ccgs who are not currently funding doing a face-palm and wondering why they didn't fund sooner.

 

[michita]

Doctor’s report!

Ok, he’s happy that I’m not having hypos and apologised for the nurse’s cackhanded way of expressing concern. I was right though, I’m only one of two patients at our practice using Libre, so they really have never seen that control this good is even possible. We had quite a long chat about it, apparently one of the big concerns with people who have been T1 as long as I have is that they lose hypo awareness, but mine is still good. He’s happy that I keep well above legal limits to drive and ride, and that I know that a single dextrose tablet will raise my BG by 0.6mmol, so I can adjust it very quickly if I need to. I left him with a list of the books I’ve been referring to with a brief synopsis of each and how it’s helped. He’s totally behind my low carb eating, too.

Cholesterol - while the nurse had said it was high (6.2 total) he agrees with me when I pointed them out that the total:HDL (3.1) and HDL:triglycerides (0.6) ratios are absolutely spot on perfect. He said he wasn’t going to even think about “inflicting” (his word) statins on me, despite NICE guidelines that all T1s should take them as a preventative because I simply don’t need them. @bulkbiker - thanks for all the papers and stuff you’ve posted about statins, I went in well prepared for the statin battle!

At the end of our meeting he said I should train to be a diabetes specialist nurse and that there was probably funding available for (ahem) mature applicants...

I'm glad you are having success with your doctors and they are supportive of low carb diet. I'm actually envious!

I'm considering self-funding libre just so that I can prove to doctors that my low hba1c is not because I am having lots of hypos. But 100 pounds a month is quite expensive >_< ..

I have been asked by one of the consultants if I am one of those patients who intentionally have hypo to get a low hba1c (can't believe if anyone would do that). Even if I tell them I rarely have a hypo they don't believe me ...?

 

[Antje77]

At the end of our meeting he said I should train to be a diabetes specialist nurse and that there was probably funding available for (ahem) mature applicants...

Please do, then move to Friesland NL and become my DN!

 

[JohnEGreen]

Content removed as was completely out of place.
Again sorry for the error

 

[JohnEGreen]

Sorry my post was a little out of place forgot where I was.

 

[Bluetit1802]

Sorry my post was a little out of place forgot where I was.

I did wonder.

 

[LooperCat]

Did I miss something interesting?

 

[JohnEGreen]

Did I miss something interesting?

Not really just me being silly and posting in the wrong thread basically about the depressive effects on my blood sugars of having to increase my prednisolone. They have gone way up.

 

[LooperCat]

Not really just me being silly and posting in the wrong thread basically about the depressive effects on my blood sugars of having to increase my prednisolone. They have gone way up.

Aw, that sucks, mate. Sending a virtual hug, for what that’s worth!

 

[Oldvatr]

Hmm, Helen, that may be true within the diabetes parameters but an extremely low A1c can surely be a cause of other issues, not necessarily associated with hypo's or diabetes. I was reading about it recently and an A1c lower than 4 (it specifically stated in the 2s or 3s) can be a sign of something serious.

Agree. There are some blood conditions that affect the glycation process that the test measures, such that either the blood does not absorb the glucose at the expected rate, or the blood cells die off prematurely. Some types of anemia can give this problem. Sufferers of these conditions need to ask for the alternative test that the labs can do, but it is not a standard test that GP's provide. Not sure what that test is called. Anybody? Think it is described here
https://www.ncbi.nlm.nih.gov/pubmed/8114262

 

[Bluetit1802]

Agree. There are some blood conditions that affect the glycation process that the test measures, such that either the blood does not absorb the glucose at the expected rate, or the blood cells die off prematurely. Some types of anemia can give this problem. Sufferers of these conditions need to ask for the alternative test that the labs can do, but it is not a standard test that GP's provide. Not sure what that test is called. Anybody? Think it is described here
https://www.ncbi.nlm.nih.gov/pubmed/8114262

The Fructosamine test is used for those with shorter lived red blood cells, but there are very few labs that process it in the UK and it is expensive. It is not routinely done. I did ask my surgery once about it and was told "we never do these tests".

 

[bruciebonus]

They told me mine was far too low, stop taking metformin and eat a lot more carbs, can't believe some of the things the docs. Come out with. Then another told me if I don't take the metformin I would fall into a hypoglycemic coma and die. Unbelievable.