Low HBA1c

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diabetic gardener

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Type 1
Six months on from a diagnosis of Type 1 my HBA1c is down from 111 to 44.
The GP suggested this is a bit low. So I have some questions:-
  • What is the optimal level for someone with type 1, and why higher is it than the normal diabetes threshold of 42?
  • What are the problems of a lower level?
  • What is the best way to achieve optimal level- do I reckon to reduce insulin slightly, or what?
 
Hi and many congratulations on a fantastic HbA1c reduction! Well done!

Curious to know why your GP has any input into your diabetes management? Just 6 months into diagnosis, you should be under your hospital diabetes clinic ie. consultant and DSNs who are far more qualified to make comment than your GP.

Are you using Freestyle Libre or other CGM sensor? If so and if not, you should be, "Time in Range" is a much better way to assess your diabetes management. The problem with a low HbA1c used to be that you might be having too many hypos in order to achieve it and particularly nocturnal hypos which you might not be aware of in pre sensor days. If you are using a sensor and you are not getting more than 3% time below 3.9 then your HbA1c is fine. If however you are having lots of hypos in order to achieve that low result, then your GP is right and it is too low and you need to run your levels a little higher to avoid having so many hypos. How to do that would depend upon when you suffer the most hypos. If they are nocturnal ones then decreasing your basal insulin might be the way to deal with it (or just decreasing your evening dose if you are using a split dose basal like Levemir) or bumping your bedtime BG levels up a bit with a small snack to prevent dropping into the red whilst you sleep. If they are mostly through the day, then you would try to figure out what was causing them ie were they miscalculations of carbs in meals? or to do with exercise/physical activity? or perhaps just because your daytime basal insulin is a bit too much?. .... Or maybe you are still in the honeymoon period (at 6 months that is pretty likely) and your own insulin production is catching you out from time to time.
 
Thank you, l that is really helpful. Most of my hypo's are daytime, and often exercise related. Plus those days when levels sermon to bear no relationship to carb input or insulin dose!!
What is a "normal" number of hypo’s in a week or over a month?
I think my review with GP was because, at age 68, they do an annual health review, and blood tests.
I've not seen my DBS since I got my Libre 2 in October maybe because I have not needed too much help getting to grips with the basics, or possibly I'm too independent! If I email a question she always respods quickly. However it can feel a bit as if I'm on my own.
 
Have you found the Time in Range/Time in Target feature on your Libre? I use the reader and it may be slightly different to the phone app, if that is what you use. For me using the reader I select "Review History" and then select the down arrow to go to the second page and it is the second option on the second page. If you select that option you can then see the data for the last 7 days but you can also scroll back to the last 14, 30 and 90 days. Ideally you want to keep your % below range as no more than 3% I believe and your Time in Range as 70%+
Did your GP ask about your Time in Range or just comment on the HbA1c result? Most GPs have no idea about Libre or the features available on them and how to interpret them so just looking at your HbA1c alone it would be reasonable for them to suggest that it was a bit low. They also like us to be more careful about avoiding hypos as we get older, because of the risk or falls and injury during hypos.... plus as we get older there is a little less concern about long term risks of slightly higher levels because we simply may not live long enough for them to develop. Not saying you or I are likely to peg out anytime soon, but you can see how a teenager or 20 year old who hopefully has 50+ years ahead of them is likely to be more at risk of long term complications of poorly managed BG levels that those of us with just about 20 years left on our clock..... if we are lucky of course.

Anyway, it sounds like you are doing brilliantly, but maybe need to look at how you might reduce the daytime hypos. It might just be that you need to set your low alarm a bit higher on your Libre, to give you time to ward off a hypo before it happens by having a small snack when you low alarm goes off. I have mine set at 4.2 and a jelly baby or two will stop me dropping into the red most of the time but there is no harm in setting it at 4.5 or even 5.0 so that you get plenty of warning of an impending hypo and therefore prevent it.
 
A lot of type 1s who manage it well get told off for having a low HbA1c, usually by medical professionals who are not diabetes specialists - as @rebrascora says, it's a hangover from the days when people weren't always aware of the hypos they were having, but to a degree it's also ignorance, because it's making the assumption you are having lots of hypos, when it's perfectly possible to have an HbA1c of 44 (which if you think about it is an average of 7.3 mmol/L, not exactly that low) without having any hypos at all.

So I would just say congratulations on your excellent HbA1c, and unless you look at your time in range and realise you are spending a lot of time hypo - or you are having severe hypos and losing hypo awareness - I'd be inclined to ignore your GP and wait and see what your DSN says.

I don't think there is a "normal" number of hypos in a week/month because it varies so much from person to person - some of us have a large number of not usually very low hypos and aren't that bothered by them (so for us 10 hypos in a week doesn't feel like a problem), whereas others have very few but very horrendous hypos (so for them as many as 1 hypo in a month might be an absolute nightmare). I think so long as you remain aware of hypo symptoms, treat them as soon as (or ideally before) they happen, and don't have severe hypos, it's better just to deal with them when they happen rather than aim for a particular number (I say this as someone who has been given different random numbers by different medical professionals and has never managed to keep to any of them!).
 
Well done on your A1c reduction, and on keeping an eye on the
number of hypos.

Sensors can be great for that, especially as you can set alarms above your low limit in order to give you time to consider and respond, heading off a potential low BG before it happens with a more modest treatment - which can help reduce zig-zag bouncebacks from low to high.

Try to keep your time spent below 4.0 as low as you possibly can especially if you are running a lowish A1c. Remember that even 1% time below 4 could mean a 15 minute hypo every single day, which obviously isn’t great!

As we age the benefit of a low A1c begins to be offset against the potentially serious problems of hypos (heart rhythm disruption, confusion, unsteadiness, impaired awareness etc), so while it’s easy ro shrug them off as ‘mild’ and just a bit of a nuisance, as you age they are potentially more serious than having your A1c in the high 50s
 
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