Medically reviewed by Dr. Mike Natter.
Almost everybody who lives with diabetes is already acquainted with 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 continues to be crucial benchmark for glucose administration success, and is the first approach that your medical group will consider the success of your therapy.
The American Diabetes Association categorizes blood sugars by A1C like so:
- Normal – under 5.6 %
- Prediabetes – 5.7 to six.4 %
- Diabetes – 6.5 % 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 problems, 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 medication could 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 advice for all adults with diabetes: purpose for an A1C degree of <7.0%.
This aim, nevertheless, could also be adjusted based mostly on a number of different elements. Making this adjustment will be extra artwork than science, and is one thing greatest determined with the assistance of your major care physician or endocrinologist. There isn’t any official steerage on exactly how one can weigh extra concerns, 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, typically characterised by aggressive use of insulin and different glucose-lowering drugs with a purpose to hold a affected person’s blood sugar nearer to the non-diabetic vary. By distinction, a “less stringent” strategy means a much less intensive glucose management technique, which essentially entails increased blood sugars.
In advising a sure A1C goal, your physician will try and stability 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 motive to take action: they know that they’ve many years of life with diabetes in entrance of them, an awfully very long time to develop problems.
Older sufferers, or people 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 less capable of perceiving the signs of hypoglycemia. This extreme and rapid hazard of low blood sugars could outweigh the long-term hazard related to power hyperglycemia. And, unhappy as it’s to say, older sufferers could have much less motive to fret about among the slow-developing problems 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 turn into pregnant are suggested to aim a lot tighter blood glucose management, as a result of we all know that tighter A1C objectives are correlated with fewer fetal problems.
The Argument for a 6% A1C
It’s honest to say that the majority medical doctors will probably be happy to see any of their (non-pregnant) sufferers with diabetes obtain an A1C at or simply under 7.0 %. Doing so with out an uncommon quantity of glycemic variability (excessive blood sugar highs and lows) confers important reductions within the danger of diabetic problems. Only a minority of sufferers with diabetes attain that benchmark, usually after appreciable effort.
But a smaller minority of individuals with diabetes motive that an A1C slightly below 7.0 % is simply not ok. They imagine that additional lowering their A1C degree, down in the direction of the non-diabetic vary, will present probably the most safety towards diabetes-related problems, or maybe even stop them fully.
The science principally backs this concept 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 possibly can obtain a 6% A1C with out an undue danger of hypoglycemia, that seems to be greatest to your well being, particularly in case you have an extended life expectancy.
As there are quite a few well being benefits to sustaining “normal” blood glucose ranges, it looks like preserving blood glucose within the regular vary as a lot as doable is an inexpensive aim, if it might safely be achieved.
And how about a good decrease A1C? Many wholesome adults with out diabetes have A1C’s round 5.0%, generally 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 medical doctors and diabetes specialists assume {that a} very low A1C is harmful as a result of it essentially entails an elevated danger of hypoglycemia. It is smart: why wouldn’t focusing on decrease blood sugar improve the chance of very low blood sugar?
Much proof has been discovered to assist this rivalry, together with what stands out as 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 power excessive blood sugar with the accelerated improvement of diabetic problems; 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 a bit sweet or juice. This was “severe hypoglycemia,” outlined as hypos that require the help of others, together with people who finish in seizure, coma, and emergency medical therapy. Nevertheless, the specialists concluded that the draw back of elevated danger of hypoglycemia was far outweighed by the long-term well being good points 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 advocate glycemic management in that 6.5-7.0 % A1C vary as a type of blissful medium.
Strict Glucose Control Without Enhanced Hypoglycemia Risks?
A rising refrain of voices within the diabetes neighborhood – each medical doctors and sufferers alike – believes that it’s doable to realize a a lot decrease and even regular A1C, and to do it with out meaningfully growing the danger of extreme hypoglycemia.
In 2018, a group of researchers and low-carbohydrate advocates took an in depth take a look at one such group, members the Facebook group TypeOneGrit. Members of TypeOneGrit are devoted to the therapy methods of Dr. Richard Bernstein, an influential diabetes physician that advises a very-low carbohydrate weight loss program because the lynchpin of a fancy therapy technique.
The findings have been published in the medical journal Pediatrics. Group members that participated within the examine had a median A1C of 5.67 %, virtually precisely on the threshold of pre-diabetes, and much better than any glycemic goal ever beneficial by diabetes authorities. The ADA’s most up-to-date official guidance on glycemic targets don’t handle decrease A1C objectives 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 strategy didn’t improve the hazard of overtreatment with insulin. The article known 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 aspect 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 superb vary. Generally talking, the less glycemic variability, the better.
Patients with very low glucose variability have an enhanced skill to remain regular at a decrease blood glucose degree – say, 80-100 mg/dL – with out risking extreme hypoglycemia. For a affected person with excessive glucose variability, the identical blood sugar degree might get harmful in a short time.
Glucose variability is greatest measured with a steady glucose monitor. One approach to make sure that a decrease A1C was not achieved with extreme hypo danger is to assessment your blood sugar readings together with your healthcare skilled. With CGM knowledge (or very fastidious use of a blood sugar meter), it ought 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 corresponding to “standard of deviation” and “coefficient of variation.” You can discover extra detailed commentary on these numbers in this article from our friends at DiaTribe.
How does one decrease their glycemic variability? The of us examined within the Pediatrics article described above have been dedicated to a very-low-carbohydrate weight loss program, 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 employees have adopted the identical philosophy with success, as have a lot of our readers. But the proof in favor of this strategy stays principally anecdotal.
The Bottom Line
You ought to set your personal A1C aim in partnership with a healthcare skilled. There are many particular person elements that your physician will consider, 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 %), though not generally beneficial by diabetes authorities, are related to a decrease danger of long-term problems. For some sufferers, it might be cheap to make use of stringent glycemic management within the hopes of bringing blood glucose ranges down in the direction of the traditional vary.
However, tried stringent management may also convey 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 group earlier than initiating any adjustments to their diabetes routine.
