a1c and complications

Sorry guys, another couple of questions, your probably all sick of me!

1) Going for another a1c blood draw tomorrow (first one was 5.7%, i know i will be a bit higher this time as my needs have increased and i went through a bit of a process to sometimes needing 1 unit, sometimes 2 etc so a bit all over the shop with bolus), however today im having a bit of a 'high day'. Nothing over 7.5 but thats high for me. Will this directly affect my a1c tomorrow? I know its supposedly an average of the last 2-3months, but do they get slightly skewed from really recent results?

2) I have been reading a few different sources and opinions on complications. With regards to nueropathy/retinopathy, many physicians are claiming that this can occur even with a1c's of mid 5's. Is there a 'fairly' definitive point on blood sugar averages or a1c's which put you at risk of such complications? For example, constant bs readings over 8 for a several years and your likely to end up with 'x'? Or is this something which is too individualized in that some folk can ride high their whole life without issues, where as others can have tight control but still end up with complications? I thank bernstein and ruhl for the scare-mongering if your above 5mmols!!!

I'm not sure if one "high day" will throw off an A1C. I usually try to run around 80 when I drop off the blood but I'm generally trying to run around 80 anyway?

I don't think there's any certainty with complications. It's more probability than certainty? There are lots of people around the board who survived the "dark ages" before BG meters and are doing ok. I don't have any "obvious" complications, e.g. blindness, missing toes, etc. but seem to be losing hair on my legs/ feet which I believe is likely a complication as well? I was concerned I was going blind as I was having a lot of trouble reading and the eye doctor said "your eyes are shot...you need bifocals or readers..." which, while annoying, was a relief too?

I would say if your A1c is 5.7 your doing better than most. There are people that have no D related complications and have a average BG of 200 (11) or more and there are indaviduls that have near normal BG and still have all kinds of complications. Most of us fall somewhere in between. Just do the best you can and enjoy your life...there are too many other hazards in life besides D...Even going to a Bat-Man move could be your final moment.

I personally think too much emphasis has been put on the A1C. I think there needs to also be equal emphasis on things like standard deviation and the role that the lack of other hormones (c-peptide, amylin, etc) play on the development of complications. I sometimes wonder if we're just putting too much emphasis on one piece of the puzzle.

I'm not sure I'd agree that there's "too much emphasis" on A1C tests, the long-term perspective it provides is very useful to know how things had been going. I'm not sure whether or not the next piece, "my A1C isn't where I want it to be, how do I fix it?" is readily available for a lot of people.

I'd add too that I'm not sure approaching it "tactically" like "if I had some out of whack BG, will it mess up my test?" or "if I drop off some blood when I'm lower, will that improve my score?" is totally useful? I'm also not entirely sure of the need for @ home tests, except maybe for the cost of it? If those tests were as accurate as the lab tests (which I don't think is the case?), perhaps insurers should cut off the pricier lab tests in favor of @ home ones? The fact that they haven't makes me very suspicious of the @ home ones. Perhaps they are useful if you don't see your doc that often?

This is the graph from the Diabetes Control and Complications Trial (DCCT). This is what most people are refering to when they say things like if you drop your A1C 1% point then your risk of X complication drops this much.


Beyond these averages I think our risks are all unique. You should also be aware that if a high may cause damage, but your body can also likely repair it give a normal BG and some time.

1) I believe that more recent events (hypos or hypers) have a more direct impact on your A1C test. Meaning that having a week of mild highs 3 months ago wouldn't probably be as significant as week directly before the test.

2) From what I see and read, I think its safe to say that as much as the A1C test is a very good indicator on how good your control is, there are other factors that should be taken into account. One that stands out is genetic susceptibility. As others have already said, you could see someone coasting on the low 200s for his whole life and has no severe complications as much as you could see someone with a fairly good grip on his/her numbers and still suffer from one form or anothe of complications. Take me for example, I've only had diabetes for 3 years. The first two years my A1C, on an average, was 8.8 most of the time. I still got -very mild- cataracts. Its nothing to worry about but it gives you the idea. Another factor would be how well you're doing as a whole and not just on the diabetes front. Having a strong healthy body certainly helps.

In conclusion, there really isn't a one-size-fits-all when it comes to diabetes, I think your A1C rocks and if you keep up the good work you have nothing to worry about. And oh, if you really want to know more about it, I'd recommend that you take a look at the DCCT findings. Its a pretty solid research and might put your mind at ease.

I'm not so sure that AIC is the total picture. I think a lot has to do with how you got there. You can have constant high and low swings and still have a fair A1C and all the while be causing damage. Or you can shoot for stable BS reads like Acidrock says and try to stay around 80 or whatever your target is and be doing yourself more good than focusing on just the AIC number.

I think I also just agreed with what MyBustedPancreas said. She and Acid both speak words of wisdom.

Sometimes it's just in the genes all we can do is give it our best efforts.

Gary S

I've had my A1C done 3 times this year. I was at 7.7 in January, dropped to 7.1 when I got into the pump program. I went down to 6.6, which I thought was terrific. Then my CDE said I was having too many lows, and would rather see my A1C 7+ and avoid the lows. She actually wants my blood sugars between 6 and 12. It works good for me. I am mostly around 10 or 11 now with my blood sugars and I feel great.

You're kidding, right? You are willingly going as high as 12 (216) to avoid lows?

Your CDE is reciting the party line which says if you have a decent A1C you achieve it at the expense of too many lows. This is not true. Your CDE is encouraging you to run your blood sugars at highs that have been shown to cause complications.

I agree, acid, Many of my type 2 friends with a1c's consistently 8 or 9 do not like it there, but they are on oral meds, go to GP's. and they really do not know how to fix it. And Nobody is telling them how. Unfortunately, many diabetics , particularly those who have to rely on doctors in the free or low cost government clinics, (other than the V.A.) being poor and less educated is a factor in whether they can keep ther a1c's down. For such diabetics in the US ,proper education/treatment is not always, as Acid wrote, "readily available". Even when they can get a referral to the government clinic endo,it takes 4-6 months. Then, they float around with highs for that long. Or longer. So much for a1c adjusting.

Timmy,One high reading will not adversely effect your A1C. You will be ok. Do not sweat it. and I have had a1c's that range from 5.7 to 7.9 for the past 15 or so years I that I havr had it regulary assessed. Prior to 1992, I do not know many diabetics that had their a1c tested regularly. I know I didn't. Maybe once or twice a year....if then.

No major copolications, some foot tingling, muscle tightness, and back pain, but my neuro says that these symptoms may be from remnants of a bad bout of pernicious anemia a decade ago,and from bulged nerves in my spine. Not directly diabetes related complications.Who knows why I do not have significant complications at 43 years w/type one????
I am not saying to not lower your A1c. I personally feel the best around 6.0-6.5; so I am working at lowering mine of 7.8, which testing revealed the month after my father's death in April. It was definitely Higher than I wanted, but to be expected, after the stress. I did not get overly concerned nor "freak out" about it;and nor did my endo.. to get it lower for the next time, I just started working harder this summer at exercising more, eating healthier and more low carbish; and at readjusting my basal and bolus. I'm cool for now. Too blessed to be stressed.

God bless,

The answer is, it depends. Retinopathy is the complication that appears to be most sensitive to blood sugar control. Over 5.5%, rates start to increase and they increase exponentially, not linearly. What is surprising is that diabetics are vulnerable to retinopathy independent of A1c, as though there is something about diabetes that inherently causes retinopahty above and beyond damage from blood sugars.

Other key facts, the risk of CVD with an A1c of 6% is double that of non-diabetic populations. The magic value of 7% was chosen based on complication rates observed in the DCCT study, there is lots to read there. That 7% value was chosen as the knee of the complication rate, where complication rates affected a high number of patients over a decade. And part of the controversy was that the DCCT did not seek really tight blood sugar control, so the evidence for A1cs < 7% in terms of complications was skimpy. Later studies such as the EPIC Norfolk showed that complication risks were reduced all the way down to A1cs of 5.5%

But for the most part, all this evidence is really "association." Besides the DCCT, there has basically been no controlled intervention trials involving lowered blood sugars. Pretty much all the studies have been with drugs (like the ACCORD) and generally they have declined to ask these questions, focusing instead on trying to prove the effectiveness of drugs.

you were right guys, the higher readings the day previous didnt matter too much, my a1c was 5.5. Very happy, so since dx i have been 5.7 and 5.5 :)

Nice! Haven’t had my second a1c since dx yet. First was 5.9. Hope mine is as good as yours!!

When I was diagnosed 5 years ago my A1C was 9. I don't believe I'd had high blood sugar for long, I had no symptoms whatsoever. Within 3 months it was down in the low 5's on diet alone. Since then it has never been over 5.5. However, I had diabetic amyotrophic neuropathy (the nerves and muscles in my legs deteriorated) and couldn't walk for a long time (now I can lurch around), I have lost 1 and 1/3 toes, I have severe neuropathy up to my knees, I've had Charcot (a foot complication), I have autonomic neuropathy, I have had lots of complications that supposedly only result from ongoing high blood sugar. My cousin had Charcot for 2 years, I think, before she was diagnosed with diabetes. So I agree with Super Sally that genetics and individual susceptibility play a big role. In my family the diabetics generally have problems with their feet, the upper body problems do not occur - kidneys, heart and eyesight are fine. In fact, since I was diagnosed and have kept on a low carb diet, I've had to have my glasses prescription changed every year because my eyes keep improving. The prescription is less than half what it used to be and my retinas are very healthy. So, until someone does a definitive study that includes oddballs like me, I'd have to guess that determining complications strictly by A1C is a crapshoot.

On the complications... no data for diabetics shows that there is an A1C below which there is zero risk for complications. Others here promise a magic A1C or bg below which there are no complications but I've never seen it in any actual research data.

At the same time, all the data shows that the higher the A1C the higher the risks for all the microvascular complications with a very strong correlation. For the macrovascular and other complications, there is a relation but it's not quite as strong.

There is a "point of diminishing returns". Risk of hypos rises as average bg's goes down for insulin using diabetics.

An A1C of 5.7% is wonderfully excellent.

Since you bring up the DCCT... for the DCCT subjects (T1's) as A1C drops, especially below 7%, there was a rapid increase in the rate of severe hypos (e.g. hypos requiring glucagon or hospitalization or a 911 call or at least help from others). I don't know of a follow-up study to the DCCT that attempted or shows this relation.

Even though the DCCT divided its subjects into "intensive" and "non-intensive" groups, perhaps the most convincing outputs of the DCCT were those that showed complication rates over the several years of the study vs A1C. The DCCT came along very shortly after (or about the same time! cause and effect are hard to disentangle) as the A1C tests and home bg tests, became widely available and popular.

The DCCT "intensive treatment" branch most certainly involved increased use of drugs to treat diabetes. You might recall... before the DCCT the "conventional" insulin therapy was just one or two shots of insulin a day. I'm not saying that nobody's still on such a therapy, but most every T1 I know today is at least on MDI if not a pump. Most non-diabetics, and even a lot of diabetics, would regard MDI or a pump as extremely intensive drug therapy. Here of course the T1's just kinda shrug it off but don't underestimate the non-D point of view.