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Lower HBA1C, higher risk?

M

Martin864

Member
Messages
11
Type of diabetes
Type 1
Treatment type
Insulin
I am a type 1 diabetic I'm my 30s and have had the condition for 4 years. I am controlled by MDI and have used a Freestyle Libre since they came out.

I have had an HBA1C 5.6 / 38 for the last 3 years and it never varies.

I manage my condition by eating lower carb and as a result I tend not to get hypos.

During my twice yearly reviews, I normally get told that my HBA1C is too low and that I must be getting hypos, however with my Libre readings I can prove that I do not.

Surprisingly on my most recent review I was told by the DSN that I really need to raise my HBA1C not due to hypos as I don't get them, but because my HBA1C means I have a higher risk of heart disease than if it was in the 6 to 6.5 range.

I have been asked to go in and speak to my GP about it because the DSN couldn't explain why when I challenged.

Based on the evidence I am familiar with there is a direct correlation between a increasing HBA1C and heart disease/ other complication risk. A quick Google search will support this.

Is anyone aware credible evidence that supports what the DSN has said?
 
Martin864 said:
I have been asked to go in and speak to my GP about it because the DSN couldn't explain why when I challenged.

Based on the evidence I am familiar with there is a direct correlation between a increasing HBA1C and heart disease/ other complication risk. A quick Google search will support this.

Is anyone aware credible evidence that supports what the DSN has said?
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No, have not come across anything that says lower HbA1c is associated with heart disease/complications. That is a new line of argument to me...
 
There was something called the ACCORD study which made the conclusion "low HbA1c = heart problems" in T2 diabetes. This study is somewhat controversial, but as you are a T1 it does not apply to you so as long as you don't have hypos you can safely continue getting 5.6%.
 
This is yet another example of the fact that nobody really seems to know anything.

I have been give a billion different numbers by a billion different people, all contradicting each other, people telling me various things about how much variation is and isn't OK. It's not so much that I'm scared of getting it wrong, I know I'm getting it wrong, I am hopeless and there is nothing I can do about it, but I don't even really know what "right" is.
 
I am pretty sure if you have hypo awareness and are not getting hypos that your low HbA1c is good and not a worry. The earlier post is correct that in the ACCORD study there was an intensively treated group whereby lower HbA1c was tried to be obtained by putting Insulin doses up which led to more hypos and arguably poorer outcomes because of the increased hypo’s. Hope this makes some sense.
 
It does get confusing...so I track this Type 1 group for inspiration and direction, because they have to work on it for life, so they choose what they think is best for 3 yr old to 83 yr old.

https://www.facebook.com/Type1Grit/...65366/888003311358428/?type=3&hc_location=ufi

22467648_888003311358428_5647506511574243411_o.jpg
 
Hi @Martin864,

Yes, I agree with @phdiabetic. I believe this advice stems from the ACCORD study, where a lower HbA1c was associated with higher CVD risk. However, there are some things to consider. First, this study was done on T2s -- as mentioned above. Second, blood sugars were lowered agressively using medication. As T2s are generally insulin resistant, this often involved massive amounts of insulin or medication increasing insulin production. This in itself is argued by some researcher to be a problem as very high insulin levels may affect your cardiovascular system. Also aggressively medicating, of course, led to more hypos. So imo, the findings of the ACCORD trial wouldn't apply to you.
 
Thanks everyone for the swift and very helpful replies. I really appreciate your advice. Feel vindicated for challenging the DSN.
 
Hi @Martin864 - here's a few more pieces of reading for you in relation to Accord. Definitely worth sharing with the DSN as what she is saying is downright dangerous and worth reporting:

ACCORD is about the most discredited study that you can find in relation to mortality in type 2 diabetics thanks to more than 90% of the participants in the intensive arm of the study being on Avandia, which as @Brunneriahas stated, has been banned by most countries due to the increased risk of heart failure.

Further to this, even the original researchers said that the results were inconclusive and further review of the data (http://care.diabetesjournals.org/content/33/5/983) showed that lower Hba1C was not co-incident with higher mortality.

People also tend to cite the Veteran's Study, which has the same issue - it used Avandia as well.

So the bottom line is that ACCORD actually proved that not lowering A1c was more likely to cause a heart attack.
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The DCCT long term study unequivocally demonstrated that there is an exponential relationship between increased risk of complications and Hba1C level in Type 1 diabetes, in that once you get to around 6.5%, for every percentage point above that you go, you multiply the risk of complications relative to a non-diabetic (as per the graph below).
slide_8.jpg


The ACCORD study that ended early due to unexpected higher levels of mortality in those treated intensively. It should be made very clear that this was a study primarily looking at CVD amongst Type 2s and used a drug in the intensive arm (primarily nearly 92% were taking Avandia, which is Rosiglitazone) which is no longer given to Type 2s due to the risk of heart attacks it induces. It is considered so dangerous that is was withdrawn from most global markets in 2010.
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