Reading several discussions here, one gets the impression that, where A1c numbers are concerned, low is good, lower is better and zero is about right. What’s up with this?
As a T2, I have been told for 15 years by many care providers and much literature that an a1c in the low 6.x range is the target and "normal." But I'm seeing discussions with numbers running in the 4s and 5s and calling them "high." Once I get to a consistent number around 6.3, should I be questioning that this is an appropriate goal? What is the basis for trying to maintain lower numbers?
Hmmm… I am not sure I have seen any discussions at all that would call a 4 or a 5 as “high” as far as A1Cs are concerned. Perhaps, there is some confusion as to what people are really discussing.
While an A1C under 7% is good, for someone who has Diabetes, an A1C above 5.7% is considered HIGH, as far as normal people go (for diagnosis purposes.) If a person without Diabetes starts registering an A1C higher than 5.7%, they are considered as having insulin resistance problems, if not Diabetes itself. A glucose tolerance test would tell for sure how those people are handling a high carbohydrate input.
Yes… An A1C in the 6.X is NOT normal, nor will it ever be normal. It’s just, in my humble opinion, a way Doctors compromise with patients for a large number of reasons. One of those reasons is getting people to actually take care of themselves, and make long lasting changes and sacrifices to their lifestyles; another one is that many folks struggle with bouncing all over the place, and keeping good numbers without too many lows or highs… so they might consider going for a lower A1C to be dangerous.
Some of us can lead stricter lives, and follow a lower carbohydrate diet because it simply gives us less errors, less problems, less bouncing all over the place between highs and lows, less weight gain, and more normal numbers, as well as a higher quality of life, with less complications. But those are personal choices… and the closest to “true” normal we can get, in a safe manner, the better. If you work really hard to get to 6.3, and that’s your closest to normal that you can get, feel proud! That is, after all, what we should do…
From my understanding (and there are many more knowledgeable on here then me), a low A1c greatly reduces the long term risk of complications from Diabetes. Studies have found the average non Diabetic to have A1c score 0f 4.7 to 5.7 the ADA has recently dropped the recommended score for a Diabetic to 6.5 or below. Levels below 4.5 are rare and could be a sign of anemia or other blood issues. The reason the ADA has a higher then average goal is to help avoid hypos and if you are comfortable being a little above average hats your call on weather to shoot for the average or what the ADA recommends. A 0 A1 C level by the way would most likely mean you are dead not a good thing unless your undead.
Hmm… I had been told by one endocrinologist that there is an inverted bell curve for heart complications as a function of A1c with the low bottoming out around 6.0. Moving either higher or lower statistically increases the chance of heart complications. Sadly, I don’t have a reference or citation for this, I’ll investigate.
Some push really super aggressive A1C goals. e.g. Dr. Bernstein claiming that the “right” number is 4.2. Most of us are more than happy to be in the 5’s or 6’s. And lots of folks have A1C’s above the 6’s.
I personally think a goal of the 4’s… is not going to be achievable for most of us. Well, maybe achievable for a little while but pretty soon we’d be dead from all the hypos.
That doesn’t mean that there is a “right” number for your A1C. Lower is better, but lower means more risk of hypos. Read the DCCT result summaries. I can’t emphasize that enough: READ THE DCCT RESULT SUMMARIES.
Just for reference the A1C is not really the best indicator of average bg. The average bg is the best indicator of average bg :-). There’s a lot of A1C variation from lab to lab, and different folks have different amounts of glycation even for the same average bg, and that makes it hard to compare A1C’s even in the same person, much less between different people at different labs. Scatterplots showing A1C vs average bg from the DCCT are attached below.
Talking about the ACCORD study was was debunked because of using a bad control group since all of the percipients were already High risk for heart complications.
As others have noted, advocacy for an A1c 4-5.5/6.0 comes from the normal physiology of a non-diabetic. The goal of <6.5 (and previously <7.0) is set by compiling and interpreting data from several studies on complications. The fact is that the first one will never change, whereas the second one has and may continue to move over time as more and more data are collected and re-examined.
BUT, I’m in complete agreement with Tim. Patients should be taught to focus on keeping their bg in the normal range as much as possible, with as little fluctuation as possible. The A1c will come down as a natural result of what is really important, good glycemic control. It’s good glycemic control – not a low level of glycosylated hemoglobin – that directly leads to better outcomes. It’s a useful tool, but that is it. So, if you’ve done the best that you can to keep your bgs in the normal range and your A1c is 6.x then you should be proud of it. While I strive my best to keep mine <6.0, I wouldn’t be heartbroken by a 6.3!
I’d also note that T2s are often given fewer tools by their health care provider than are T1s. I’m not saying that it’s easier, it most definitely isn’t, but the fact that I’m equipped with insulin, a meter and boxes upon boxes of strips, a cgm and a pump really gives me a lot more personal control over where my bg sits (even if I’d really rather not have that control). But with T1s and T2s, the answer to better control often comes from a combination of what the doctor gives us and what we can learn from others (like on Tu) to do with them:)
