Is there something like too low HbA1C?

keithd01 said:

For the past 5 years my HbA1c has never been above 6.3 (sorry, still using old money) and have been told that that my diabetes control via insulin pen was excellent. Now, having changed medical practice, I am told that my HbA1c is too low and that I am hypo-unaware! Looking back over the last 5 years, on average I have a low blood sugar, I.e below 4.0, once per month, and an incidence of a reading below 3 of about once every 4 months and these are usually as a result of activity. I am aware of hypos because it physically manifests itself with the usual symptoms, but these symptoms only appear when sugar falls to about 3.7 - so I am NOT hypo-unaware. I adjust my insulin (Mixtard 30) dose based on my glucose reading and am now told that this is wrong too! I am told that I MUST stick to a fixed dose irrespective of glucose reading. This seems wrong to me, and basically makes me ask the question 'why bother doing a glucose test 'cos you ignore the result anyway!' What do others think?

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The reason they say you shouldn't adjust a mixed insulin is because you're not just chopping and changing your bolus insulin, you're pushing extra basal in as well (or not having enough at some times). As far as possible they like you to maintain steady levels of basal simply because as a long acting insulin, you get long lasting effects - depending on the mix the basal could last 10 hours in the system. Too much basal and you will run low for hours which might sound like a good thing but there is a difference in function between the two insulins. The basal is to maintain brain and body function efficiently; it's your background insulin and can't be used to achieve carb control. That is the job of the bolus insulin. What you're trying to do is dose adjust as if you were on MDI.

Your best best might be to ask if you can change to MDI, and then you could carb count and dose adjust without affecting your basal insulin.

I'll tag @kitedoc who can probably explain better than I ever could!

bulkbiker said:

I've never heard anyone here with an HbA1c sub 4.0 % (20.2 mmol/m)
My last few have been 27 mmol/m (4.6%) give or take seem to be fine so far.
Well not dead yet so far as I can tell.

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I really wish they could all make a decision, HbAc1 is usually between 41 - 44, the GP surgery congratulate me, the consultant says get it up to 47. I don't have loads of hypo's. Fasting works best for me

purplesally said:

I really wish they could all make a decision, HbAc1 is usually between 41 - 44, the GP surgery congratulate me, the consultant says get it up to 47. I don't have loads of hypo's. Fasting works best for me

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As a T2 I wouldn't care to comment but yes fasting works well for me too.

There is an assumption that a low HbA1c is due to a series of hypos, so it confuses doctors if we can keep close to 4.0 to 4.5 most of the time.

https://academic.oup.com/ndt/article/23/6/1796/1880161 is interesting

rainbow79 said:

No it was not unexpected. I was diagnosed with type 2 diabetes in July 15 with a HbA1c of 52, within three months dropped to 39, then down to 32, 31, 28 and now 26 through change of life style and losing over 11 stone in weight. Have only been on diet alone option, never needed any medications so I do not finger prick

Add in the weight loss was intention and have been maintaining the weight loss for good few years now

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That’s fantastic. Congratulations.

Goonergal said:

That’s fantastic. Congratulations.

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Thank you

I don't intend to say anything politically incorrect that would alienate anyone but ... it's obvious to many that doctors are more afraid of lows than highs. Lows have resulted in fairly quick deaths attributable to hypoglycemia, whereas it can take years before you die of the complications of highs, and then, what is the proof that whatever it was deemed to be the cause of death resulted from high blood sugar? It's all about getting sued. I have a low hba1c of 4.2% (I think that's around 22). It's the lowest my endo has ever seen. I don't suffer hypos because I can feel when they are coming about 30 minutes before they hit and eat a couple bites of a banana or a carrot to raise bs and consequently avoid them.

The standard A1c range on the Web systems we use to view results are for people who are not taking any drugs/inslin with a risk of hypos. The are not a personal target range, and will not show a target that has been agreed with your doctor. (They mostly just the range that about 95‰ of "healthy" people are in.)

It is like that as CGM with traces uploaded to people health records become more common, that "time in range" will replace A1c as the gold standard.

keithd01 said:

For the past 5 years my HbA1c has never been above 6.3 (sorry, still using old money) and have been told that that my diabetes control via insulin pen was excellent. Now, having changed medical practice, I am told that my HbA1c is too low and that I am hypo-unaware! Looking back over the last 5 years, on average I have a low blood sugar, I.e below 4.0, once per month, and an incidence of a reading below 3 of about once every 4 months and these are usually as a result of activity. I am aware of hypos because it physically manifests itself with the usual symptoms, but these symptoms only appear when sugar falls to about 3.7 - so I am NOT hypo-unaware. I adjust my insulin (Mixtard 30) dose based on my glucose reading and am now told that this is wrong too! I am told that I MUST stick to a fixed dose irrespective of glucose reading. This seems wrong to me, and basically makes me ask the question 'why bother doing a glucose test 'cos you ignore the result anyway!' What do others think?

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Hi @keithd01, Not sure if you are diagnosed as Type 1, 2 or 3 although if sounds loke you have been on insulin, presumably Mixtard 30 ( ? twice daily), for 5 years.

I would have almost given my arm and leg to have achieved HBA1Cs of 6.3% !!

I presume it is your new GP or nurse reading you the riot act about your HBA1C and demanding you change whatever has allowed to achieve these magnificant results.

Whilst I cannot give you medical advice or opinion, you are entitled to a second opinion and usually someone more experienced in diabetes management such as a diabetes specialist is what most persons seem to do in theses circumstances.

In Australia we also have a saying: If it ain't broke, don't fix it. It maybe that applies to you !!

The last time someone asked me to fix my insulin doses and not vary them was when i was first diagnosed 52 years ago and i have not heard that it has come back in fashion ever since!! But as i now catch up with what @WuTwo has written i am guessing that you have been able to rweak your Mixtard 30 in such a way as to not greatly upset the other insulin effect in the mix.

If my experience is any guide at all, it may or may not for you but over more years ( i think perhaps it was 6 or so I had to change my insulin combination to allow more ability to vary both short and long acting insulin. So at some point in the future Mixtard may not work as well as now, but be reassured that there are plenty of options, just not likely to be the Mix insulins for continued great control.

I shall leave it to you to decide who to see and how - as you will be far more au fait with NHS than a mere Aussie !

As regards this thread, i shall answer @lucas12 in a post below as best i can regards so-called low HBA1C results in diabetics.
Best Wishes, welcome and great work !!

Hi @lucas12 , welcome and you have raised a very interesting point.
Answering as a Type 1 diabetic, with my reading of studies, not as professional advice or opinion:
The ACCORD study mentioned by @bulkbiker , where it was reported that intensive diabetes treatment of Type 2 diabetics which achieved low for recommended HBA1C levels had more cardio-vascular disease (CVD) has been criticised because some of the blood-sugar lowering agents used in higher doses in these individuals were found to cause heart problems e,g. Sulphonlurea agents and the 'glitazones' so this has put doubt into the certainty of the findings.
Also the finding of what they call a J or U shaped curve of 'bad' CVD outcomes in the ACCORD study and also the report mentioned by @Scott-C, and by that type of curve meaning individual Type 2 diabetics with high or low HBA1C results seemed to cop the worst CVD numbers - is a suspicious finding statistically from what i have read.
I do not have sufficient grounding in stats to offered an expert opinion but i have heard this type of statistical problem mentioned in others studies where a U or J shape curve occurs.
The fact that the latter study (see @Scott-C , click the link and read conclusion) the authors point out that if you divide up the CVD outcomes according to 5ths or quintiles as they call them of HBA1Cs in other quoted studies you obtain a relatively straight line where the higher the HBA1C the greater the risk if CVD, but ..... if you do the CVD outcomes vs dividing HBA1Cresults into 4s, called quartiles, you obtain the U or J shape.
Of course it is difficult to know if the studies are close enough, comparable enough to draw firm conclusions but the difference to my less than statistically well trained eye is suspicious.
I shall see if i can find someone expert to comment or reference.
As to the conclusions made and interpreted by health professionals, IN ACCORD study there was one reported death in the intensive treatment, lower HBA1C trending group from definite hypoglycaemia buto 9 deaths from presumed CVD whuch were not proven absolutely proven to be due to CVD. Were these death from unrecognised hypos or jedication side-effects?
But as other posters , such as @JAT1, @Mel dCP, @Scott-C, @purplesally and @TriciaWs ( and i apologise if i have missed anyone) doctors can be petulant if their patient have low-to-their-mind HBA1Cs.! Hypos have been blamed for poor CVD outcomes in ACCORD study rather than taking perhaps a broader view of the study including use cardio-toxic medications, as mentioned above. And maybe if you go hypo whikst on these medications you might increase your risk of death anyway.
And some if the same posters and others like @ringi also point out that with advances like CGM, hypos can be better anticipated and avoided.
I add to this the findings if patients on low carb diets reporting HBAIC, in the 5 % range even with low incidence of hypos also (
https://doi.10.1542/peds.2017-3349. Being young adults and children with TID if will be sometime before they and others achieving low HBA1Cs are going to be able to show how they fare CVD-wise.
My final point: whikst HCPs are perhaps scared of hypos as they fear they might get sued and will take time perhaps to realise that many of their patients are not at risk of hypos, particularly off medication or on minimal least harmful to CVS ( cardio-vascular system) ones and that CGm, better education, insulins insulin pumps all help - no HCPs seem to have noticed that those in ACCORD study did not benfit C-V -wise from being on statins - NO difference !!
Why are they not crowing about that !!

lucas12 said:

Read something about hba1c U shape and increased mortality for those with a1c lower than 5%. Is that actual thing? or some internet
rubbish.

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My mom a t2 manage to have a a1c of 4.8 to 5.2 for close to a decade of her life (before she passed). She did rather well for being t2 for 40+ years of her life in keeping her glucose in check through diet alone.

As a T1 best I've managed with MDI is 5.2 to 6.5 and at 5.2 i was having to many hypos 5.5 was better but still min of two under 3.5 a day so not great at 6 I still have at least one hypo a day but it isn't to bad and though my Endo isn't pleased with the daily hypos he doesn't berate me for it.

kitedoc said:

doctors can be petulant if their patient have low-to-their-mind HBA1Cs.!

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Things are starting to slowly change, kitedoc.

I'm lucky enough to live in an area which basically gives libre to any T1 who wants it, and the last I read was that the area had about 1000 on it, so they're accustomed now to seeing libre stats and agp graphs.

So, while they do still use a1c as an important metric, the docs I've seen have been ok with me showing them the stats re time in range, mean, median and relative standard deviation, which show how the a1c is made up and show it's not through having lots of hypos but more or less by not going above 8 or 9 that often.

It's going to take time but I'm optimistic that cgm will become more liberally prescribed and docs will start paying more attention to time in range than a1c.

It's just not been available to them before but it is now.

My GP once said to me, "hmm, maybe 40 will be the new 50!"

Scott-C said:

Things are starting to slowly change, kitedoc.

I'm lucky enough to live in an area which basically gives libre to any T1 who wants it, and the last I read was that the area had about 1000 on it, so they're accustomed now to seeing libre stats and agp graphs.

So, while they do still use a1c as an important metric, the docs I've seen have been ok with me showing them the stats re time in range, mean, median and relative standard deviation, which show how the a1c is made up and show it's not through having lots of hypos but more or less by not going above 8 or 9 that often.

It's going to take time but I'm optimistic that cgm will become more liberally prescribed and docs will start paying more attention to time in range than a1c.

It's just not been available to them before but it is now.

My GP once said to me, "hmm, maybe 40 will be the new 50!"

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I hope you are right and I will patiently wait to get libre prescription. It’s a great tool and we should all have access to :-D

michita said:

I hope you are right and I will patiently wait to get libre prescription. It’s a great tool and we should all have access to :-D

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History is repeating itself, Michita.

I was dx'd in 1988, and was lucky enough to miss the testing via a tablet in a pot of pee method, as colour-changing strips had just been brought out, massive drop of blood on the strip, wait a minute, wipe, wait another minute, compare the colour to a chart.

My dsn at the time, the wonderful Sister Carmichael, told me these are new and very expensive so I should cut the strips in half to double each pot.

Then meters came out and, again, these were the new expensive things.

Now we're onto cgm, and it's the same old story - new, expensive, why do they need them? That meme has run through all these stages: they managed on what went before so why do they need this now?

The truth is that we did manage, but very often, we didn't manage that well.

At the induction meeting we had when I got my libre script, the doc said there had been a lot of politics going on with the bean-counters, and then said the reason they decided to approve it was that, "we know how tough T1 is; if we were T1, we would want it, so we're not going to deny it to you guys."

That was a wonderful display of how this about the humanity of it, not the money.

But money does play a part in the real world. ABCD is doing a national audit of libre use, and there's been indications that quite a lot of money been saved in the short term by avoiding ambulance callouts and admissions for dka and severe hypos, so maybe the bean-counters will take note of that.

It seems that a few ccgs have more or less thrown a huff at being told to comply with the RMOC guidelines. If you test more than 8 times a day and can show a clinical need for that, you fit the guidelines, and Partha Kar has said that he wants to hear about denials and will take it up with the ccg involved, so maybe that's a route into it for you?

https://mobile.twitter.com/parthaskar?ref_src=twsrc^google|twcamp^serp|twgr^author

Scott-C said:

History is repeating itself, Michita.

I was dx'd in 1988, and was lucky enough to miss the testing via a tablet in a pot of pee method, as colour-changing strips had just been brought out, massive drop of blood on the strip, wait a minute, wipe, wait another minute, compare the colour to a chart.

My dsn at the time, the wonderful Sister Carmichael, told me these are new and very expensive so I should cut the strips in half to double each pot.

Then meters came out and, again, these were the new expensive things.

Now we're onto cgm, and it's the same old story - new, expensive, why do they need them? That meme has run through all these stages: they managed on what went before so why do they need this now?

The truth is that we did manage, but very often, we didn't manage that well.

At the induction meeting we had when I got my libre script, the doc said there had been a lot of politics going on with the bean-counters, and then said the reason they decided to approve it was that, "we know how tough T1 is; if we were T1, we would want it, so we're not going to deny it to you guys."

That was a wonderful display of how this about the humanity of it, not the money.

But money does play a part in the real world. ABCD is doing a national audit of libre use, and there's been indications that quite a lot of money been saved in the short term by avoiding ambulance callouts and admissions for dka and severe hypos, so maybe the bean-counters will take note of that.

It seems that a few ccgs have more or less thrown a huff at being told to comply with the RMOC guidelines. If you test more than 8 times a day and can show a clinical need for that, you fit the guidelines, and Partha Kar has said that he wants to hear about denials and will take it up with the ccg involved, so maybe that's a route into it for you?

https://mobile.twitter.com/parthaskar?ref_src=twsrc^google|twcamp^serp|twgr^author

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Thank u for the response. The issue for me is my bs level is not bad enough because I’m low carbing and I can’t say I have a clinical need.. I don’t mind waiting around. I hope it’ll be available to all in future to type 1 and 2 and 3. I’d also like to say I admire how well you manage. Yes I think the time is changing for the better.

michita said:

Thank u for the response. The issue for me is my bs level is not bad enough because I’m low carbing and I can’t say I have a clinical need.. I don’t mind waiting around. I hope it’ll be available to all in future to type 1 and 2 and 3. I’d also like to say I admire how well you manage. Yes I think the time is changing for the better.

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Lol, M, I'd recommend being a wild child for three months: steak-bakes, cheesecake, beer, maybe pass out in a Soho gutter at 3am a couple of times with a severe hypo for added affect - you'll be a total shoo-in for a libre script after that!

Scott-C said:

Lol, M, I'd recommend being a wild child for three months: steak-bakes, cheesecake, beer, maybe pass out in a Soho gutter at 3am a couple of times with a severe hypo for added affect - you'll be a total shoo-in for a libre script after that!

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Where I live the chance is very low to get libre on prescription even if I pass out in a gutter with a sever hypo. Not worth it for me.... but I get what you are saying. it’s like catch 22

Is it not easy for anyine to test more then 8 times a day for at least a few months before they are next due to see their consultant?

ringi said:

Is it not easy for anyine to test more then 8 times a day for at least a few months before they are next due to see their consultant?

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Some folks are deliberately doing that.

I'd be tempted to give a spare meter to my nephew, tell him there's 50 quid in this for you if you test a lot...