Should I raise my HbA1c

[pjcand]

I've been pursuing a strict low-carb regime in the last 18 months and my most recent HbA1c was 5.6%. In a recent check up my consultant asked me to raise my A1c, her advice was that about 6.5% would be ideal.

On asking why I should consider this she mentioned the ACCORD Study - http://www.nejm.org/doi/full/10.1056/NEJMoa0802743 - on lowering of A1c levels in diabetics and the resulting increase in mortality/complications. This study was however on Type 2 diabetics and I'm therefore struggling to find the relevance to me as a Type 1.

I am wondering if any Type 1's out there know of any solid evidence that a lower A1c can lead to complications.

 

[azure]

My last HbA1C was 28 (4.7) and my consultant was very pleased with that. There was no mention of raising it at all.

As far as I understand it, as long as you're not getting lots of hypos, you're ok. The ideal is a good HbA1C and a smooth line of results. Of course, it's impossible to achieve that all the time, but that's what I aim at.

I know of no research saying Type 1s are at a higher risk of mortality with a good HbA1C so my only thought is that your team are worried you're having bad hypos or may be at risk of them.

Certainly, I'd never aim to get mine at 6.5. Mine has always begun with a 4 or a 5, which I think is ideal. However, it might be different for children, the elderly and other potentially vulnerable groups.

 

[azure]

Also, that study seems to have been very specific - as an attempt to reduce cardiac problems in type 2s who already had them. I don't see any relevance to Type 1s at all. That study certainly can't be applied across the board. The only General thing it shows is that intensive therapy can cause more hypos, which we all know anyway.

A good HbA1C reduces the risk of complications.

The DCCT study being one example that shows that.

 

[Jaylee]

Hi, I had an HbA1c of 6.4 & was told that that was too low... My consultants "Ideal" figure is about 7.5. I respectfully dissagreed.
The worry with the insulin dependant is the frequency & loss of awareness with hypos..

Lol @azure @pjcand . I'd give my right arm for figures like that.. As opposed to loosing a limb from the consultants promoted higher figures..

 

[azure]

Good on you for disagreeing with your consultant - I'd have done the same! Sometimes I think they have a rather patronising attitude. My cousin has Type 1 and her consultant seems to think it's fine that she walks around with an HbA1C of 9. She's had diabetes for 30 years and only recently moved on to MDI.

My current HbA1C is my best, but it's extra good because I'm currently pregnant so I'm being very careful. Not an option for you, Jaylee, I'm guessing : D

 

[pjcand]

Thanks very much for your responses and well played on the 4.7 figure, that's the result I'm aiming for ultimately and I suspect it will frighten my consultant if I ever get there. Glad to hear you currently have a sympathetic and informed consultant, I'm constantly baffled by some of the conclusions my registrars and consultants have reached, it's nice to hear I'm not alone!

 

[tim2000s]

The accord study has a lot of things wrong with it, not least that it isn't a Low Carb diet related study. A lot of it has been countered, and in many cases proven to not be a good representation.

The only reasons that some consultants ask for a higher Hba1C is that they are concerned that a lower one has been developed as a result of too many hypos, and therefore the diabetic in question is at risk of losing their hypo awareness.

When mine hit 6.0 at my last consultation, I was told that I was practically in the "normal person" range. Very well done!

What I'd love to know is whether there have been any studies as to whether there is an ydifference in terms of health risk between a non-diabetic that is in the 4s and one that is in the 5s.

 

[Jaylee]

Good on you for disagreeing with your consultant - I'd have done the same! Sometimes I think they have a rather patronising attitude. My cousin has Type 1 and her consultant seems to think it's fine that she walks around with an HbA1C of 9. She's had diabetes for 30 years and only recently moved on to MDI.

My current HbA1C is my best, but it's extra good because I'm currently pregnant so I'm being very careful. Not an option for you, Jaylee, I'm guessing : D

Not an option for me at all Azure. Though there are still other reasons for a guy to keep the HbA1c in order...!

I actually have a reasonable relationship with my D team.. I think the HbA1c thing was a genuine misguided concern from the nurse, (To which i belayed..) I'm still hypo aware, even at night.. & never needed any outside assistance in the 39 years of diagnosis.. Hypo event frequency hadn't even changed in all that time...Funny enough. i recently had a recurring issue with my chemist over prescription, to which my nurse backed me up on.. i feel they are "onside" just a little dated & restrained by "protocols."

 

[pinewood]

I think too much emphasis is put on HbA1C - being told you're basically the same as a non-diabetic just because your HbA1C is in range is, in my opinion, wrong because it takes no account of fluctuations. Yes, it's a helpful measure and yes we should all be aiming for an HbA1C of a non-diabetic version of ourselves but in my view the medical community does not pay close enough attention on deviation as, from what I have read, this can be nearly as important. Rapidly going from 3mmol to double digits and back and forth again throughout each day could easily give a nice HbA1C but surely those kind of swings aren't good for us?

That's where the Libre has been so helpful for me - I can easily keep to an average blood sugar in the 5mmol range at the moment but it's the swings that I've been able to target and nail down on by having CGM.

 

[noblehead]

Yes agreed @pinewood, the SD is a good indicator of how well your diabetes is controlled, in the book Think Like a Pancreas the author says a SD of 2 or below is a sign of good bg control.

@pjcand, provided your excellent Hba1c isn't a result of frequent hypo's and you have good hypo awareness symptoms I wouldn't worry too much, as others have said they assume people who have low Hba1c results are experiencing a lot of hypo's and they worry that they may become hypo unaware.

 

[Jaylee]

I think too much emphasis is put on HbA1C - being told you're basically the same as a non-diabetic just because your HbA1C is in range is, in my opinion, wrong because it takes no account of fluctuations. Yes, it's a helpful measure and yes we should all be aiming for an HbA1C of a non-diabetic version of ourselves but in my view the medical community does not pay close enough attention on deviation as, from what I have read, this can be nearly as important. Rapidly going from 3mmol to double digits and back and forth again throughout each day could easily give a nice HbA1C but surely those kind of swings aren't good for us?

That's where the Libre has been so helpful for me - I can easily keep to an average blood sugar in the 5mmol range at the moment but it's the swings that I've been able to target and nail down on by having CGM.

I would tend to agree... In my experience they only seem to only be interested in the hypoglycaemic low events. Even if the biggest spike you had was at 8.5? The emphasis is on are you eating enough carb to combat the dreaded low...

 

[pinewood]

Yes agreed @pinewood, the SD is a good indicator of how well your diabetes is controlled, in the book Think Like a Pancreas the author says a SD of 2 or below is a sign of good bg control..

Thanks for that noblehead, I have that book and think it's great, but didn't recall it giving a SD target. I've been looking for an idea of a good number, so that's very helpful!

 

[June_C]

Thanks for that noblehead, I have that book and think it's great, but didn't recall it giving a SD target. I've been looking for an idea of a good number, so that's very helpful!

I'm still learning and don't know what "SD" is. I think I can guess, but could you enlighten me? Many thanks.

 

[pjcand]

June_C - I'm assuming it's Standard Deviation - http://www.healthline.com/diabetesmine/standard_deviat.

Thanks all for your input. I agree with Jaylee's comments about medical professionals, if wrong, it usually appears they have outdated information and sometimes inappropriate and therefore irrelevant study results like my case.

pinewood - I'm on the list for a Freestyle Libre, I'm convinced of it's usefulness.

 

[noblehead]

Thanks for that noblehead, I have that book and think it's great, but didn't recall it giving a SD target. I've been looking for an idea of a good number, so that's very helpful!

This is what Scheiner has to say about SD:

The standard deviation (SD) reflects the amount of variability in your readings. Lower is better. If the SD is more than half of your average, your readings include many extreme highs and/or lows. A SD that is less than one third of your average means that your readings are fairly consistent from day to day, without too many in the extreme ranges.

http://integrateddiabetes.com/Articles/gen/downloading meters for diabetes health.pdf

 

[LucySW]

SD, plus mean BG, plus time in target - the golden three for giving you a handle on your control.

I knew nothing about any of this for six months, and then of course I got it from smart people on the forum. But ALL diabetics should know of these tools, if they want to try for good control.

I'm wondering if it should go in Daisy's welcoming post. Except of course it's too much to take in. But once people are six months into diabetes, perhaps there should be a follow-up post ... What D'you think people?

 

[noblehead]

I'm wondering if it should go in Daisy's welcoming post. Except of course it's too much to take in. But once people are six months into diabetes, perhaps there should be a follow-up post ... What D'you think people?

No I don't think its a good idea to add it to the basic information that Daisy provides to new members, it can be a case of information overload sometimes and it can become overwhelming for some people, besides discussions on things like like SD often come up on the forum and people will often ask what they mean (as June C has above), however if you want Lucy you could ask the forum Admin and see is they say.

 

[phoenix]

Recent analysis of ACCORD is far more nuanced than the original headlines.
1) few deaths attributable to hypos
2)intensive-therapy patients had significantly lower rates of nonfatal MI, any MI, unstable angina, coronary revascularization, and combinations of these outcomes (relative risks, 0.81–0.87) than those who received standard therapy
http://www.jwatch.org/na35378/2014/08/07/more-accord-trial-ischemic-heart-disease-outcomes
If you are older and sicker then the risk of reducing levels to the 5s might be important (might not though have any relevance to T1 at all)

I think that the biggest fear is losing hypoawareness .From my own point of view, I think that you have to be honest to yourself about how often hypos occur and at what level you feel them.
My HbA1c was 5.8% the other day, it's been about that level for several years and my doctor no longer says I am 'trop bien equilibre ; ie too tightly controlled.It's changed to ' impeccable' Having said that I had a brief period at 4.9% and that was too low for me, I realised that I was losing hypo awareness