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Type 1 HBA1C too low?

Mandy Gay

Mandy Gay

Member
Messages
9
Type of diabetes
Type 1
Treatment type
Insulin
Hi, I’m new here, though not new to diabetes, having had it 35 years.
I came across Dr. Richard Bernstein’s teaching a few years ago and have been reducing my carbs and getting my HBA1C gradually lower since then. In fact I’m now down to the equivalent level that he espouses as giving the best chance of maximum life expectancy without complications...ie 29 in our language, or 83 in his, or 4.8%.
My diabetic nurse told me on Wednesday though that the latest research is showing that an HBA1C that low increases the risk of cognitive decline, brain damage and dementia.
I said I’d do some research to find out more, but haven’t found it yet.
I know that Dr. Bernstein talks about the health authorities recommending higher blood sugars due to the fear of being sued over death by hypoglycaemia, but I’ve not heard him refer to cognitive function.
Has anyone seen the research my nurse might be referring to?
Thanks.
 
@Mandy Gay
I think your DSN is basing her comments on the assumption you can only have a BG that low if you have lots of hypos. I have read research which suggests too many hypos can lead to cognitive decline.
This is a common assumption ... I was told a Hb1AC of 48 was too low because I must be having lots of hypos.
 
helensaramay said:
@Mandy Gay
I think your DSN is basing her comments on the assumption you can only have a BG that low if you have lots of hypos. I have read research which suggests too many hypos can lead to cognitive decline.
This is a common assumption ... I was told a Hb1AC of 48 was too low because I must be having lots of hypos.
Click to expand...
Hi, thanks for your reply. We had the discussion about the number of hypos and because I’m on a trial they’re running with the Freestyle Libre I was able to show her the evidence that that’s not the case. My line is pretty flat, showing a fairly constant blood sugar of in the 4’s. Her response was that it’s a high risk with running it at that level continuously.
 
Mandy Gay said:
My diabetic nurse told me on Wednesday though that the latest research is showing that an HBA1C that low increases the risk of cognitive decline, brain damage and dementia.
Click to expand...

I believe this research may be in reference to resistant diabetics with HbA1c attained through heavy medication. Not really relevant here I don’t think.
 
Mandy Gay said:
Hi, thanks for your reply. We had the discussion about the number of hypos and because I’m on a trial they’re running with the Freestyle Libre I was able to show her the evidence that that’s not the case. My line is pretty flat, showing a fairly constant blood sugar of in the 4’s. Her response was that it’s a high risk with running it at that level continuously.
Click to expand...

Hi and welcome to the forum :-) Wow, to get constant 4s, are you on a very strict low carb diet and do you count and bolus for proteins, I guess ? I’m low carbing for 3 years. I see 6s quite frequently. I wouldn’t worry about what your DN says. We have a medical condition but we are entitled to normal blood sugars if it’s possible at all and it is.
 
michita said:
Hi and welcome to the forum :) Wow, to get constant 4s, are you on a very strict low carb diet and do you count and bolus for proteins, I guess ? I’m low carbing for 3 years. I see 6s quite frequently. I wouldn’t worry about what your DN says. We have a medical condition but we are entitled to normal blood sugars if it’s possible at all and it is.
Click to expand...
Hi, yes, I eat low carb for the main part and bolus for protein.
And yes, we are entitled to normal blood sugars, though my nurse was saying that my level is below normal...though I know Dr. Bernstein would disagree with her.
If there is a risk of brain damage though from running this low I would like to know about it.
 
I also just had another HBA1C couple weeks back and the result was 4.2% which the endo and her nurse thought too low. They repeatedly asked me how often I hypo, but I rarely do as I eat something before I get there. In fact they couldn't understand how my hba1c could be so low as my 'randoms' are higher though still 'within range'. If it weren't for Dr. Bernstein, they'd make me worry but when I hear that I am in a non-diabetic range, I'm thankful. I usually have about 100 to 150 carbs/day.
 
Knikki said:
Hello @Mandy Gay Hypos causing brain damage question is something that comes up every now and then on the forum and if unlike some people you do some digging around it can provide some interesting answers.

It seems that many HCP in UK and USA fear people hypoing because, as others have pointed out, being sued which in some respects I get. Last Hb1Ac I had was 37 or 5.5% of which I was told "well done"

The body during a hypoglycaemic event will do all it can to protect the brain which is where the liver dump of glycogen comes in, unfortunately in server hypo events where the person ends up in a coma then there is chance of possible brain trauma.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711670/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1838950/

http://diabetes.diabetesjournals.org/content/59/4/1055

The papers linked above are interesting but it would appear that in primates if blood sugar levels are kept at 1.1mmol for more than 5-6 hours then brain trauma can occur. In the real world this would very rarely happen
Click to expand...
Hmm, thanks Knikki. The third of those links looks the most significant to me...suggesting that the research is showing that prolonged mild hypoglycaemia can in fact protect the brain from the effects of a severe hypoglycaemic episode...interesting, as you say.
 
Mandy Gay said:
Hi, thanks for your reply. We had the discussion about the number of hypos and because I’m on a trial they’re running with the Freestyle Libre I was able to show her the evidence that that’s not the case. My line is pretty flat, showing a fairly constant blood sugar of in the 4’s. Her response was that it’s a high risk with running it at that level continuously.
Click to expand...


Hi, Mandy, I see you're trialling libre.

If you use it for an extended period, you can nip into the related software and make it create a graph called an Ambulatory Glucose Profile, AGP.

Why, you may ask?

Cos' they are incredibly useful to take along to consultations to show docs how the a1c is arrived at, and, in particular, whether it's through nice, steady, consistent lines, or lots of loop-de-loo rollercoasters.

Your a1c is an estimation of average bg levels over 90 days, going by how much glucose is stuck to blood cells, so it doesn't really drill down into how that number is arrived at.

As you know, two folks can get the same a1c by different routes, one involving stability, the other involving wild fliers, and it is the latter which docs tend to assume for lower a1cs, and assume there must be lots of hypos.

But, instead, the AGP graph takes 90 days worth of 24 hrs per day libre readings, strips out the top and bottom 10% outliers, and patches the rest together to show where that middle 80% is falling.

That way, when a doc says to you, hmm, low a1c, you must be having lots of hypos, you can then say to them, ok, doc, you've got 1 number, I've got 90 days worth of 24 hr readings, and this here collated graph of them all isn't showing major dips into hypoland, nor much time above 9.

The key thing to get across is that lower a1cs are totally achievable just by not going above 9 that much.

And also pointing out that if there was lots of hypos, they would be able to see that in big dips on the agp graph. If they can't see those, you've proved your point.

It depends on which area you are in. Docs in my area are up to speed with AGP graphs and are very receptive, liking the additional info it gives them on how an a1c has been arrived at; in other areas, less so, but that will change as libre access improves.

AGPs are also very useful for us. A1cs really don't tell us much at all, but if we set the graph to various periods, say, 7, 14, 30 days, it's way easier to see recurring patterns which we might miss on the daily graphs, eg, persistent lows at 3am suggesting a basal tweak, or 4pm highs suggesting a lunch bolus ratio change.

I've not got a libreview agp handy, but here's an example from the libre/miaomiao/xdrip+
kit I'm running, the light blue band is where 50% of readings are sitting, the darker band is the rest minus the top and bottom 10%:

Screenshot_2019-03-11-15-26-09.png
 
Scott-C said:
Hi, Mandy, I see you're trialling libre.

If you use it for an extended period, you can nip into the related software and make it create a graph called an Ambulatory Glucose Profile, AGP.

Why, you may ask?

Cos' they are incredibly useful to take along to consultations to show docs how the a1c is arrived at, and, in particular, whether it's through nice, steady, consistent lines, or lots of loop-de-loo rollercoasters.

Your a1c is an estimation of average bg levels over 90 days, going by how much glucose is stuck to blood cells, so it doesn't really drill down into how that number is arrived at.

As you know, two folks can get the same a1c by different routes, one involving stability, the other involving wild fliers, and it is the latter which docs tend to assume for lower a1cs, and assume there must be lots of hypos.

But, instead, the AGP graph takes 90 days worth of 24 hrs per day libre readings, strips out the top and bottom 10% outliers, and patches the rest together to show where that middle 80% is falling.

That way, when a doc says to you, hmm, low a1c, you must be having lots of hypos, you can then say to them, ok, doc, you've got 1 number, I've got 90 days worth of 24 hr readings, and this here collated graph of them all isn't showing major dips into hypoland, nor much time above 9.

The key thing to get across is that lower a1cs are totally achievable just by not going above 9 that much.

And also pointing out that if there was lots of hypos, they would be able to see that in big dips on the agp graph. If they can't see those, you've proved your point.

It depends on which area you are in. Docs in my area are up to speed with AGP graphs and are very receptive, liking the additional info it gives them on how an a1c has been arrived at; in other areas, less so, but that will change as libre access improves.

AGPs are also very useful for us. A1cs really don't tell us much at all, but if we set the graph to various periods, say, 7, 14, 30 days, it's way easier to see recurring patterns which we might miss on the daily graphs, eg, persistent lows at 3am suggesting a basal tweak, or 4pm highs suggesting a lunch bolus ratio change.

I've not got a libreview agp handy, but here's an example from the libre/miaomiao/xdrip+
kit I'm running, the light blue band is where 50% of readings are sitting, the darker band is the rest minus the top and bottom 10%:

View attachment 33295
Click to expand...
Hi Scott-C, thanks...it was that that we were looking at in my appointment, which was causing the nurse to air her concern...even though it was showing a fairly narrow mid-band and not too much deviation either with the wider band, showing the A1c as being achieved by a fairly steady glucose level rather than a rollercoaster ride. Nevertheless, her concern was over me having the majority of my readings in the 4’s...saying that 4.6 is nearly hypo...to which I replied “but it’s not hypo, in fact I understand it to be spot on...And if I’m running at that level fairly steadily then that’s good isn’t it?” ...but that’s where she said that running in the 4’s...however steadily, is where the increased risk of brain damage is coming in...it’s just too low a level to be running at. And she wasn’t talking about the risk of hypos here. It was simply having blood sugar in the 4’s and the link with brain damage.
 
Most non diabetics run consistently in the 3s and 4s with nobody even vaguely concerned they may get brain damage from it...
 
Mandy Gay said:
it was that that we were looking at in my appointment
Click to expand...

Aah, well, if you were running the agp past her with an intelligent analysis of it and she was stll saying nay, I'd probably just nod politely/ignore, pick up my next script and carry on as usual!

I think things are changing and cgm users are at the forefront of it.

It's understandable to an extent - historically, strips alone gave very limited insight into bg levels, many of us ended up with horrendous hypos, so I can understand hcps being cautious about lower ac1s, because it's based on the limited info which was previously available to them and us.

I'm running at 28 too, can't remember the last time I had a serious hypo, but the encouraging thing is that my docs have been receptive and willing to listen to how that has been done, without being critical - I think they are starting to see how powerful cgm can be.

Regular users of cgm can play a part in explaining this to them - they've read about cgm, maybe worn one for 2 weeks; we've used them for years - of course we know more about them.

My gp said to me jokingly that maybe 40 is the new 50!
 
Scott-C said:
I'm running at 28 too, can't remember the last time I had a serious hypo
Click to expand...
Me too, I’m just not getting those severe drops like I used to...it’s more that I just dip slightly now and take a dextrose tab or even half of one and get back up in line. I was explaining this to her, and how much easier life is now, rather than riding that old rollercoaster, which would knock me out of being able to function properly all day sometimes. She agreed that the level of control is exemplary, but said if it were a bit higher it would be spot on. Anyway, I’ve emailed her to see if she’ll let me know the specific research she was referring to, and I’ve also written to Dr Bernstein’s website asking what he thinks about the brain damage fear.
 
If you look at this from the perspective of there being no human requirement for exogenous glucose, and that in those who choose not to consume it (with our without autoimmune or resistant diabetes), their HbA1c can often be around this figure or less, then one has to ask the question - why would the body choose a level of glucose homeostasis that makes us lose our marbles? Personally I believe the answer is that it wouldn’t, and doesn’t. I don’t see why someone with diabetes would have a different glucose homeostasis requirement than someone who doesn’t.
 
Jim Lahey said:
If you look at this from the perspective of there being no human requirement for exogenous glucose, and that in those who choose not to consume it (with our without autoimmune or resistant diabetes), their HbA1c can often be around this figure or less, then one has to ask the question - why would the body choose a level of glucose homeostasis that makes us lose our marbles? Personally I believe the answer is that it wouldn’t, and doesn’t. I don’t see why someone with diabetes would have a different glucose homeostasis requirement than someone who doesn’t.
Click to expand...
Oh, that was another discussion we had about the body’s need for exogenous glucose or not lol. But, yes, I get your point...though her argument was that I’m running lower than she is and she’s not diabetic.
 
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