HbA1c levels and hypos

[Flower]

As I expected at the pump clinic yesterday I was told in no uncertain terms that my HbA1c of 6.2% or 44 was too low for someone without hypo awareness and I should aim for nothing lower than 6.5%.

I want my HbA1c to be as low as I can sensibly get it as I have a lot of complications and I do understand their concern that the tighter your control the nearer you are to hypo levels.

Have you found it possible to achieve an HbA1c result below 6.5% without suffering from frequent hypos or do the two things have to go together?

 

[DeusXM]

It's absolutely possible, mine's 6.1% and I don't have hypos all the time.

The idea that a lower A1c (or more precisely, a normal A1c) means you must be having lots of hypos is a myth. It is simply not true.

What is true is that usually T1s with lower A1c will be having lots of hypos. Because an A1c is an average. It is not a standard deviation. Someone with BGs constantly swinging between 2 and 10 could get an A1c of less than 6.5%. But...so could someone who keeps their BGs solidly between the 4-7 range. That's a subtle but VERY important distinction to make.

You yourself need to work out which one of those categories you fall into.

If you do have hypo unawareness, you've got two options. One is to deliberately slack off on your control a little bit - not so that you're constantly running high, but maybe push for slightly higher fasting and post-prandial readings to restore your body to hypo awareness. The other is to be more intensive with your control but make it very tight, keeping it in a very narrow range.

The latter is more work and will give you less margin for error.

If I was in your situation, I would personally aim for a slightly higher A1C - say, 6.6, 6.7, but with a view to achieving that with minimal hypos. Assuming that would be possible in 3 months and after that time my hypo awareness returns, I would then look to apply the lessons learned to getting back to a lower A1C again.

The way I achieved my A1C was by eliminating a lot of the variables from my diet.

Modern diabetes management is based on the idea that you bolus, eat, carbs, your blood sugar swings up and then your bolus returns it back to normal. You'll note this means having high blood sugar at one point, so therefore getting a normal A1C means having more hypos too.

So I took out the swing - I drastically cut my carbs which meant I drastically cut my insulin intake, which then drastically cut out the swings. Think of it like driving a car either at 30 or 80. At 30, when you steer, the car only moves a bit. When you drive at 80, it switches about a lot. However I would be cautious about doing this if you are hypo unaware at the moment - you need to keep your glycogen supplies topped up and reducing your carbs will cause problems with that.

 

[Northerner]

My HbA1c numbers have all been in the mid-5s (I know, I'm very lucky, and it's probably because my pancreas still hasn't quite given up on me yet 🙂). Sometimes those have involved quite a few hypos, but others have not. I can sort of see the argument that hypos will bring down your HbA1c, but you'd need to have quite a few to have a significant impact. Since hypos are treated promptly, by their very nature, it seems to me that the time spent low must be much shorter than the time you are above hypo range, if you see my logic.

I seem to remember you have a CGM which hopefully warns you of impending hypos? In which case the time when your levels are low ought to be short. I feel happiest when my HbA1c has been achieved by having good, steady, in range readings, with fewer lows and fewer post-meal spikes or fasting levels, which has certainly proved possible for me 🙂

 

[Lurch]

Hi, Flower. 🙂 So you are told you must change your HBA1c by 0.3% ?

The HBA1c is like someone trying to guess how many ants may have passed through the nest in three months. Okay, maybe an exaggeration.

Averages are suckers. If the real world of BS levels is good, the theoretical one ought to fall in line but to try to increase by 0.3% is a very peculiar piece of advice.

No doubt others will know if this conversion table I found of **average** mmol/Ls for given HBA1c percentages is accurate:-

HBA1c%.....Avg mmol/L (i.e. not the equivalent mmol/mol)

4.0...........3.8
4.5...........4.6
5.0...........5.4
5.5...........6.2
6.0...........7.0
6.5...........7.8
7.0...........8.6
7.5...........9.4
8.0...........10.1
8.5...........10.9
9.0...........11.7
9.5...........12.5

If the lifetime of the undead blood cells at the time tested for HBA1c is taken to be 90 days and your HBA1c turns out to be 6.5%, your average BS level during the period was about 7.8 mmol/L. That's a 'safe' level if an actual reading an hour or two after eating. But this is an average. A HBA1c of 6% means your average BS levels were around 7 mmol/L.

Anyone tried eating, exercising or medding to change their readings by 0.8 mmol/L? Meters can't cope with this.

Hypos are dangerous but this surely doesn't mean 'robbing Peter to pay Paul'.

If you are as nerdy as me you can create a spreadsheet of cells giving 24 BS levels times 90 days. That's 2160 individual blood sugar levels (the body is noticing every second so even this is a huge compromise).

Now for fun stick in what you either know to be an actual BS reading or a best guess level for every one of the 2160 cells in your spreadsheet. Copy/paste and auto-fill are your friend.

Sum and average the result.

Play around with the lows and the highs. Watch the average change.

Doing this will reveal the nonsense of being told to get your future average HBA1c higher by 0.3% to avoid hypos.

 

[everydayupsanddowns]

I have recently slightly changed my position on this - perhaps I've just come to understand it better...

I've read parts of some studies on hypoglycemia recently which measured exactly when cognitive impairment kicked in. One 'clamp' study (where they sytematically lower blood glucose and get subjects to perform thinking tasks) noted that cognitive impairment kicked in at levels below 3.0. I *think* that a study I read a couple of years ago used the figure of 3.5.

Many of the guidelines refer to 'treating at levels below 4.0 to avoid hypoglycaemia'. Normal non-diabetic people can quite easily dip into the high-mid 3's with no symptoms and no one bats an eyelid.

For us, of course... caution is healthy addition to the mix, since our system is on the fritz and our bodies will not shut off (ultra-rapid) insulin and kick out glycogen immediately to rectify lowish blood glucose. Our lowish BGs are altogether more serious, even if not strictly speaking hypos.

So my current view is that '4 is the floor' is a very useful and prudent measure to avoid hypoglycemia, but that not having clanging warning signs for every single 3.7 or 3.8 does not necessarily indicate hypoglycaemia unawareness or even IAH impaired awareness of hypoglycaemia.

I think one of the important questions to ask yourself is how often do you experience hypoglycaemia which requires 3rd party intervention - not just paramedics, but family and friends. If this is happening more than once a year, then you could ask to be referred to some specialist education focussing on regaining hypo awareness (unless you've done that already!)

Hypoglycaemia is serious stuff, and IAH is associated with significant increase in risk of severe hypooglycaemia (6-fold I think). And the more low numbers you have, even of only high 3's the less likely you are to feel them.

In your shoes, if I were to make a change, it would perhaps to be to shift the midpoint of my perfect range very slightly to try to lose some of those low-ish BGs so rather than thinking of 4-6 as being perfect, go for 5-7 and try to pull numbers to that target. (eg if 4.x before a meal, the pump knocks a smidge off the bolus to aim to end nearer 6 than 5).

Absolutely agree with what others have said though in that the range of your results overall is worth focussing on.

Good luck with your decision and congratulations on a great A1c.

 

[everydayupsanddowns]

Oh... and forgot to say. last A1c was 5.9% and I've had no (family intervention) severe hypoglycaemia for the last 3-4 years. Luckily I've never had to call the paramedics out either.

 

[Flower]

Thanks everyone, it is good to know a sub 6.5% HbA1c can be achieved without risking hypos.

I haven't had any hypo awareness for over 10 years now and have had a lot of hypos where I have gone unconscious and needed paramedic/family help. Since using CGM things have improved a lot. I have now raised the hypo warning limit on my CGM so that I get an alarm at a higher glucose level to try and reduce the time my blood sugar has been under 4, which should in turn raise my HbA1c.

I can understand their concern as the percentage of low readings I have had were sufficient to influence my HbA1c. Without any of my own early hypo warning systems it is only sensible to aim slightly higher. With serious complications I am torn between trying to stay as low as I can whilst avoiding hypos. Back on the diabetes tightrope.

 

[trophywench]

My view on complications and A1c are personal and I daresay fairly controversial.

I believe there is something more than just good A1c working for the people that don't get complications. Is it genes, hazel eyes, or a sarky sense of humour? Who knows.

My A1c has NEVER been below 7 since 1972 except for 12 months when I first got my pump. I'm beginning to think (well I've thought for a while now) that my A1c does not actually wish to be below 7 at all - my body just doesn't LIKE it. And won't stay there, unless I spend so much of my life chasing my BGs spontaneity (ie a normal lifestyle) is out of the window.

And I agree with Mike mainly (except I believe that 3.3 is the danger number) but the crux of the thing is, my hospital clinic insist that 3.999r is hypo and 4.0 isn't so as soon as they see anything below 4.0 on my meter print-out, that's it, I've had a hypo. They hope I treated it ? Yes of course I did! (with contempt, but only tell them the first bit) Bet your sweet bippy if I tested again immediately after from another finger it would be different anyway, but why waste test strips? Sigh. So there's absolutely no point in my being perfectly satisfied with 3.7 or 8 - because I'll still be whinged at and lectured for having too many hypos. I am satisfied - and they can do the other thing if they so desire.

Even with a CGM, just because your interstitial fluid at that exact cannula ending said that, if you had several CGMs at different points of your body - would they all read the same thing at the same moment? (I don't know the answer to that question - but somehow, I doubt it. No metering equipment is THAT precisely accurate, surely?)

Just do your best, within the confines of your life, is ALL anyone can do.