Home Diabetes Can Your A1c Be Too Low? – Diabetes Daily

Can Your A1c Be Too Low? – Diabetes Daily

23 min read

Medically reviewed by Dr. Mike Natter.

Almost everybody who lives with diabetes is already aware of the A1C check. Your A1C is an estimate of your common blood sugar ranges over the earlier a number of months; many individuals with diabetes are initially identified with the outcomes of an A1C check. It remains to be an important benchmark for glucose administration success, and is the first method that your medical crew will consider the success of your therapy.

The American Diabetes Association categorizes blood sugars by A1C like so:

  •   Normal – under 5.6 p.c
  •   Prediabetes – 5.7 to six.4 p.c
  •   Diabetes – 6.5 p.c or above

For probably the most half, everybody within the diabetes world agrees {that a} decrease A1C is healthier than the next one. Higher A1C’s are correlated with a faster onset and elevated severity of issues, and it’s well-known that reducing A1C correlates with decreased dangers. But is there such a factor as too low?

This article is written for primarily folks with diabetes, of any kind, that use insulin or sulfonylureas, that are insulin mimetics. Both medicine may cause hypoglycemia. Readers that don’t use both drug are at a considerably decrease danger of hypoglycemia – a lot of the next dialogue won’t apply.

The Official Recommendations

The ADA begins with a blanket suggestion for all adults with diabetes: purpose for an A1C stage of <7.0%.

This objective, nonetheless, could also be adjusted primarily based on a number of different elements. Making this adjustment could be extra artwork than science, and is one thing greatest determined with the assistance of your main care physician or endocrinologist. There is not any official steering on exactly the best way to weigh extra issues, however the next picture from the ADA offers an concept of how these various factors can affect glycemic targets:

Source: ADA, Standards of Care 2021

The phrase “more stringent” right here refers to a extra inflexible or demanding glucose management technique, usually characterised by aggressive use of insulin and different glucose-lowering drugs with a purpose to maintain a affected person’s blood sugar nearer to the non-diabetic vary. By distinction, a “less stringent” method means a much less intensive glucose management technique, which essentially entails greater blood sugars.

In advising a sure A1C goal, your physician will try to steadiness your danger of hypoglycemia towards your danger of hyperglycemia, amongst different elements.

Younger sufferers with fewer well being points are in all probability higher geared up to set a decrease A1C goal and select a extra stringent routine. They additionally could have a greater purpose to take action: they know that they’ve a long time of life with diabetes in entrance of them, an awfully very long time to develop issues. 

Older sufferers, or those who have already got extra severe well being points, could also be suggested to focus on much less stringent glucose management. Elderly sufferers, for instance, could also be much less succesful of perceiving the signs of hypoglycemia. This extreme and fast hazard of low blood sugars could outweigh the long-term hazard related to persistent hyperglycemia. And, unhappy as it’s to say, older sufferers could have much less purpose to fret about among the slow-developing issues of diabetes, as a result of they might not reside lengthy sufficient to endure from them.

There could also be different particular elements at play, too. For instance, ladies who’re pregnant or planning to grow to be pregnant are suggested to aim a lot tighter blood glucose management, as a result of we all know that tighter A1C targets are correlated with fewer fetal issues.

The Argument for a 6% A1C

It’s honest to say that the majority docs shall be happy to see any of their (non-pregnant) sufferers with diabetes obtain an A1C at or simply under 7.0 p.c. Doing so with out an uncommon quantity of glycemic variability (excessive blood sugar highs and lows) confers vital reductions within the danger of diabetic issues. Only a minority of sufferers with diabetes attain that benchmark, usually after appreciable effort.

But a smaller minority of individuals with diabetes purpose that an A1C slightly below 7.0 p.c is simply not ok. They consider that additional reducing their A1C stage, down in direction of the non-diabetic vary, will present probably the most safety towards diabetes-related issues, or even perhaps stop them fully.

The science principally backs this idea up. The ADA confirms that “further lowering of A1C from 7% to 6% is associated with further reduction in the risk of microvascular complications,” though it cautions that there are some diminishing returns: “the absolute risk reductions become much smaller.” 

If you may obtain a 6% A1C with out an undue danger of hypoglycemia, that seems to be greatest to your well being, particularly you probably have an extended life expectancy.

As there are quite a few well being benefits to sustaining “normal” blood glucose ranges, it looks as if preserving blood glucose within the regular vary as a lot as attainable is an inexpensive objective, if it might probably safely be achieved.

And how about an excellent decrease A1C? Many wholesome adults with out diabetes have A1C’s round 5.0%, typically even decrease. Is {that a} cheap goal for a affected person with diabetes? Is it protected?

Strict Glucose Control and The Danger of Hypoglycemia

Many docs and diabetes consultants assume {that a} very low A1C is harmful as a result of it essentially entails an elevated danger of hypoglycemia. It is sensible: why wouldn’t concentrating on decrease blood sugar enhance the chance of very low blood sugar?

Much proof has been discovered to help this competition, together with what will be the most well-known and vital kind 1 diabetes trial ever performed. The Diabetes Control and Complications Trial (DCCT) was the experiment that definitively linked persistent excessive blood sugar with the accelerated growth of diabetic issues; it solidified the advice that folks with kind 1 diabetes should make use of “intensive” insulin administration to advertise long-term well being.

But the DCCT additionally confirmed that intensive administration entailed “a threefold increased risk of hypoglycemia.” And we’re not speaking about minor low blood sugar occasions that the sufferers simply handled themselves with slightly sweet or juice. This was “severe hypoglycemia,” outlined as hypos that require the help of others, together with those who finish in seizure, coma, and emergency medical therapy. Nevertheless, the consultants concluded that the draw back of elevated danger of hypoglycemia was far outweighed by the long-term well being features related to intensive administration.

Even so, the concern that extra aggressive insulin administration may end in much more extreme hypoglycemic occasions has helped encourage diabetes authorities to suggest glycemic management in that 6.5-7.0 p.c A1C vary as a type of completely happy medium.

Strict Glucose Control Without Enhanced Hypoglycemia Risks?

A rising refrain of voices within the diabetes group – each docs and sufferers alike – believes that it’s attainable to attain a a lot decrease and even regular A1C, and to do it with out meaningfully growing the danger of extreme hypoglycemia.

In 2018, a crew of researchers and low-carbohydrate advocates took a detailed take a look at one such group, members the Facebook group SortOneGrit. Members of SortOneGrit are devoted to the therapy methods of Dr. Richard Bernstein, an influential diabetes physician that advises a very-low carbohydrate eating regimen because the lynchpin of a fancy therapy technique.

The findings have been revealed within the medical journal Pediatrics. Group members that participated within the examine had a median A1C of 5.67 p.c, nearly precisely on the threshold of pre-diabetes, and much better than any glycemic goal ever advisable by diabetes authorities. The ADA’s most up-to-date official steering on glycemic targets don’t handle decrease A1C targets for sufferers with kind 1.

But was it protected? Critically, sufferers noticed within the examine additionally reported “low rates of hypoglycemia and other adverse events,” suggesting that their extraordinarily stringent method didn’t enhance the hazard of overtreatment with insulin. The article referred to as the outcomes “without precedent,” a sentiment that was echoed in main media protection. But this was merely a small observational examine – not a rigorous double-blinded and randomized trial – and authors additionally warning that the “generalizability of the findings is unknown.” 

The Importance of Glucose Variability

A1C is just one a part of the blood glucose image. Another vital factor is glucose variability – how wildly your blood sugar swings up and down. A affected person with a low variability will solely expertise gentle blood sugar swings, whereas one with a excessive variability will expertise a lot better swings each above and under their splendid vary. Generally talking, the much less glycemic variability, the higher.

Patients with very low glucose variability have an enhanced capability to remain regular at a decrease blood glucose stage – say, 80-100 mg/dL – with out risking extreme hypoglycemia. For a affected person with excessive glucose variability, the identical blood sugar stage might get harmful in a short time. 

Glucose variability is greatest measured with a steady glucose monitor. One method to make sure that a decrease A1C was not achieved with extreme hypo danger is to evaluate your blood sugar readings together with your healthcare skilled. With CGM knowledge (or very fastidious use of a blood sugar meter), it needs to be plain to see how typically any affected person experiences harmful hypos. 

The smartphone apps for the Dexcom and Freestyle Libre techniques monitor glucose variability with statistics equivalent to “standard of deviation” and “coefficient of variation.” You can discover extra detailed commentary on these numbers in this text from our buddies at DiaTribe.

How does one decrease their glycemic variability? The people examined within the Pediatrics article described above have been dedicated to a very-low-carbohydrate eating regimen, which each reduces postprandial glucose spikes and likewise permits sufferers to make use of much less mealtime insulin, reducing the danger of postprandial glucose lows. Dr. Bernstein has influentialy described this as “the law of small numbers.” Several previous and current members of the Diabetes Daily workers have adopted the identical philosophy with success, as have lots of our readers. But the proof in favor of this method stays principally anecdotal.

The Bottom Line

You ought to set your individual A1C objective in partnership with a healthcare skilled. There are many particular person elements that your physician will take into accounts, together with your age, your well being, and your danger of extreme hypoglycemia.

Blood glucose ranges at or approaching the “normal” vary (outlined as an A1C under 5.6 p.c), though not generally advisable by diabetes authorities, are related to a decrease danger of long-term issues. For some sufferers, it might be cheap to make use of stringent glycemic management within the hopes of bringing blood glucose ranges down in direction of the traditional vary.

However, tried stringent management can even carry an enhanced danger of hypoglycemia, particularly with administration methods that don’t sufficiently scale back glycemic variability. Patients ought to proceed very rigorously, and with full cooperation of their medical crew earlier than initiating any modifications to their diabetes routine.

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Read extra about A1c, American Diabetes Association (ADA), blood glucose monitoring, steady glucose monitor (CGM), Dexcom, diabetes administration, Diabetes Online Community (DOC), freestyle, insulin, Intensive administration, libre, low blood sugar (hypoglycemia), kind 1 diabetes, kind 2 diabetes.

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