Type 1: Hba1c too low

My HBa1c varies from 39 to 42 and I also get reprimanded for keeping it too low for a T1 by my DSN and diabetes Dr (actually I'm a T3c, but let's not go there!).


I rarely have hypos, perhaps one a month when I've left it too long before eating, but apparently I'm probably having hypos without realising: in between finger-prick tests (even though I test 5 or 6 times a day). As far as I'm concerned, my hypo awareness is good: I get the "sensations" in the low 4s unless I'm ill (in which case I can get confused with other symptoms).


I don't have a pump or CGM and I can't LCHF due to chronic pancreatitis and gallbladder problems. I just do my best and I'd love to lower my Hba1c further towards non-diabetic levels.

I do understand my DSN and Dr's concern (they specifically warned of the risk of brain damage from hypos, including these potential hypos I'm unaware of). Initially, I was very focused on hyperglycaemia, due to my late Father's T2 medical conditions (kidney and eye problems; and eventual blindness). I use my insulin to target a value of 6mmol, rather than 5, but don't stress if it goes a little over 7 before meals (I used to hate it going higher and would definitely stress if it went above 9, which it still does occasionally mainly due to other chronic conditions).

Well done @drahawkins_1973 and everyone else for your low Hba1c numbers.

I'm sorry if my interest in everything is bothersome - I was wondering if being in ketosis, that is the benign state of burning ketones rather than glucose for energy due to eating a low carb diet, would be protective when blood glucose is low - using ketones to fuel the metabolism takes some time to get into, but once established, there would be less need for glucose in the blood.
Medical people, used to dealing with the general population would regard low levels of blood glucose as potentially dangerous as they would regard it as being on the red line of the fuel tank, not realising that ketosis is like having a separate electric motor able to take over and run the metabolism just like a hybrid car.

Resurgam said:

I'm sorry if my interest in everything is bothersome - I was wondering if being in ketosis, that is the benign state of burning ketones rather than glucose for energy due to eating a low carb diet, would be protective when blood glucose is low - using ketones to fuel the metabolism takes some time to get into, but once established, there would be less need for glucose in the blood.
Medical people, used to dealing with the general population would regard low levels of blood glucose as potentially dangerous as they would regard it as being on the red line of the fuel tank, not realising that ketosis is like having a separate electric motor able to take over and run the metabolism just like a hybrid car.

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Yer not "bothersome" at all @Resurgam ,

These professionals do interpret a low A1c as a potential for the patient to wind up in a coma, without looking at the history of the indevidual not being treated for hypoglycemia by a third party let alone not actually passing out!
Their concern is the meds & thus the lack of carbs to feed it..

I've been T1 for over 40 years & pride myself for never needing any assistance in treating a hypo!

Quite frankly? I've heard of higher incidence in hypo related hospitalisation/ambulance attendance through Ds with crazy high A1s..

Resurgam said:

I'm sorry if my interest in everything is bothersome - I was wondering if being in ketosis, that is the benign state of burning ketones rather than glucose for energy due to eating a low carb diet, would be protective when blood glucose is low - using ketones to fuel the metabolism takes some time to get into, but once established, there would be less need for glucose in the blood.
Medical people, used to dealing with the general population would regard low levels of blood glucose as potentially dangerous as they would regard it as being on the red line of the fuel tank, not realising that ketosis is like having a separate electric motor able to take over and run the metabolism just like a hybrid car.

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I tried to ask my doctor this, he was not impressed. But if seems pretty logical to me.

Jaylee said:

Quite frankly? I've heard of higher incidence in hypo related hospitalisation/ambulance attendance through Ds with crazy high A1s.

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Historically there has been limited detail on this, with the majority of the studies seeming to show that lower Hba1C had higher hypo incidence.

More recently, there was some research shown (if not published fully) that lower Hba1C doesn't correlate to higher incidence of Hypos, as long as CGM is used. I think it was presented by Nick Oliver. Interesting stuff...

drahawkins_1973 said:

I had my annual Hba1c result today and it was 29 mmol/mol. My consultant was worried it was too low. I do appreciate it is low but I eat a low carb diet and so generally don't have big spikes. Therefore I quite often will stay between 4-5 for a lot of the day. My consultant thinks it's bad because I will get used to being 'reasonably' low all day and lose hypo sensitivity.
I'm not sure what response I'm expecting as I don't really know what my question is but do others feel comfortable being in that range. I do use a libre so I have a pretty clear idea of what is happening. Maybe I'm too controlling???

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That's an amazing result and you should be really pleased with yourself. My doctor said mine was on the low side for the same reasons at 39 but I'm not intending to purposely increase it that would seem ridiculous. I also use the libre and love it.

Resurgam said:

I'm sorry if my interest in everything is bothersome - I was wondering if being in ketosis, that is the benign state of burning ketones rather than glucose for energy due to eating a low carb diet, would be protective when blood glucose is low - using ketones to fuel the metabolism takes some time to get into, but once established, there would be less need for glucose in the blood.
Medical people, used to dealing with the general population would regard low levels of blood glucose as potentially dangerous as they would regard it as being on the red line of the fuel tank, not realising that ketosis is like having a separate electric motor able to take over and run the metabolism just like a hybrid car.

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I have been looking at this same issue recently and came across this study, where they defined hypoglycemic as ~ 2.8mmol. You may find this study helpful in answering part of your question. Perhaps opening another thread on the T2D or general discussion area may be appropriate.

Medium-Chain Fatty Acids Improve Cognitive Function in Intensively Treated Type 1 Diabetic Patients and Support In Vitro Synaptic Transmission During Acute Hypoglycemia

This study tested the hypothesis that oral medium-chain triglycerides could provide an alternative fuel source to prevent the deterioration of higher brain function caused by acute hypoglycemia in intensively treated type 1 diabetic subjects.

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http://diabetes.diabetesjournals.org/content/58/5/1237

I went to a diabetes education session today where it was stated that the brain needs glucose - I said 'are you sure about that?' and they modified it to 'ketones as well' - so there is some knowledge of the true situation around - but they'll not tell you unless you already know. Dr Atkins mentions using the medium chain fatty acids - also that they are not always tolerated in the diet, but that was in print back in 1992.

drahawkins_1973 said:

Hi tim2000s.
I always like your comments, you're really knowledgeable about research and studies that have been carried out. Apologies if you've explained before but how do you get your hands on this info?

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Thank you @drahawkins - much appreciated. I've many fingers in many pies, is probably the best way to look at it. I am linked to loads of people on Twitter, Facebook and the GBDOC that attend the various conferences and research events, and then tweet pictures of slides. I also write my blog, which usually requires some form of evidence, and to get that I end up searching, which often throws up new and interesting things.

There's always new stuff coming out, and once you find the way into the network, there is a generic flood fo information!