A1C: predictor of side effects

To go along with what Alan is saying, and to make matters even more confusing, one of the problems with even the best research out there is that there are not enough data available, certainly long term data, for diabetics who do have A1Cs under 6.0. There is plenty of anecdotal evidence but I don’t think, in the long run, I want my team making decisions on my diabetes care based on anecdotal evidence. My endo’s information is only as good as the information that is available to him.

My 2 cts is that we have to be our own best advocates and ask direct questions to get direct answers. If your goal is to have an A1c under 6.0 or even 5.0, then ask your health care provider how you can achieve that goal. If your goal is to tighten your control and have the lowest standard deviation possible, then those are the question you ask. If they can’t or are unwiling to help you achieve your goalsl, then I feel strongly that it would be time to find a new doctor if possible. At the end of the day, it’s up to us to apply what we learn to achieve our goals whether those have been established by ourselves, our doctors, or between the both of us.

Great advise FHS and i agree completely. My personal goal is to have BG as close to normal (non D) as possible. My doctor can help me decide what treatment works best to get/keep me there, but i have to own it. None of the studies are conclusive, and as many have pointed out, most are even flawed in that the patients were either already suffering complications from long term exposure to high BG, were put on high carb, low fat diets among other issues. I try to look at it with common sense. If people without D have a fasting < 100, peak at <120 postprandial and have stable A1c <5.7, that’s what i shoot for. Gain as much knowledge as you can and make up your mind.

I agree with ur view when u said the "diminishing gains but they are not insignificant."
It’s the law of diminishing returns kicks in.

Thank you, everyone, for your very helpful replies to my original post. Much appreciated.

I have a problem with docs or endo’s who go strictly by my A1C…that is an average of what I have been doing. Long ago I read an article written by a young woman who had figured out how to get a great A1C, but have devastating daily numbers.
Her first month she would eat what she wanted, take her meds, and not exercise. Totally not taking care of herself, the second month she would be more careful and eat healthier and the third month (the one before she did her A1C, she would do all that was expected…her A1C’s were in the high 6’s but still very much acceptable as good…her daily numbers never came down past 150 during months 1 & 2…of course, she knew what she was doing, jepordizing her health etc., but living a life of normalacy among her teen peers was more important to her…and she “thought” she had beaten the devil “D”. Until now at 30 she was having many problems…To judge your wife’s control of her “D” by just her A1C is totally off the scale if you ask me. I’d be looking for another endo…

I asked a very well renowned physician, head of endocrinology at a major hospital in Detroit, and a speaker at a local JDRF conference, this specific question and he agreed, years of study shows that a good A1c results in fewer complications. I said I thought it was the constant ups and downs that were more important and he said “definitely not”. My Doc has said the same thing. I’m sure they are basing this on many studies that show this result, they are scientists by nature, and aren’t just guessing but I know, studies can be flawed. I definitely feel the “ideal” would be good A1c’s without the ups and downs and I’m sure they would agree, my Endo always looks at my highest high and lowest low. We should all try for that but it makes me feel better that it’s really been proven that a good A1c is a good indicator no matter how you get there! :slight_smile:

I also asked which takes the worse toll on your body, constant highs or constant lows. He said the constant highs will have a very negative effect on you body. Lows, as long as it doesn’t result in unconsciousness or seizure has a much less negative effect than the highs. I think there is probably a tendency for some to be prone to complications. My Endo has said through his experience if you haven’t developed major complications in 20 or 25 years you probably won’t have too many problems. This also makes me feel good. I’ve always had good A1c’s but never felt I was doing good because I do have a lot of ups and downs and so far after 34 years (knock on wood) have minimal complications. I’ve gotten a CGMS and hope to keep my good A1c’s without the highs and lows. We’ll see…

The A1C is a good test, but its only one piece of the overall control puzzle. I think of it like this: The daily meter checks I do are still photos of my control at that very minute. The CGM is like a movie that lasts for 3 days. If all is well there then my A1C (the replay) should be within a good or acceptable range. Just be aware that A1C’s can be measured, tested, and calculated in different manners. Same blood at one docs office tested in a certain fashion might yield a 6.5, where as the same blood given to a different doc (and therefore a different lab) may read a 7.5 or 8…Its all on how its tested, and the formula (and machine) they use to do the test. But the main thing is to solve the lows first so that she doesn’t have any immediate danger to her health, and then after that you can work on the highs (usually if you solve the lows first then the highs solve themselves)

I agree, Judith. The swings, depending on how severe, are damaging. They feel horrible also. Anything that wipes us out like that, can’t be neutral.

The thing that comforts me the most is seeing other users like yourself who have lived for a lot longer with the disease and done very well. I’m not entirely convinced that swings aren’t important but you still provide inspiration!

I don’t think any doctor would advising going for just A1c or just the lows and highs. The issue here can we safely conclulde that an A1c of 6.0 is good without worrying about the SD?? I don’t think so if you maintaining a 5.5 with swings then it is detrimental. It is better to be at 6.0 and reduce the swings.

The highs will destroy the organs. The lows don’t destroy the organs but effect the mental ability to a great extent. They could lead to mood swings, anxiety issues. I know there is no research into studying the effects of lows on brain. But i believe our brain gets starved of oxygen during a low and hence our inability to comprehend stuff during the low.

Thanks bubbaluv - best advice to date

Totally agree with Jud. All the LENGTHY studies like DCCT and UKPDS which they are basing main A1c assumptions on are done with old background insulins. This is one reason why Lantus took so long to get funding from Australian and canadian governemnts and other places around the world - no long term studies and we had to go against these studies showing the swings in sugars were detrimental long term. This hence shows that why people who do present with good A1cs on OLDER insulins still get complications. They are indeed swinging - not on own accord but purely due to design of the insulins and unpredictable peaking from day to day. My suggestion as with others - aim for targets of those without D. From postings on here, many know more than GPs and a few endo who dont have diabetes as a passion. Many say D is just unavoidable and hence part of their practice. (Type 2 mainly), many dont want anything to do with type 1 as many concerntrate on other endocrine issue. Important to find the endo that is passionate about type 1 - nothing like walking the walk though.

Your partner’s endo is correctly representing the scientific literature about the average being more important than how it achieved, at least as far as I have found. I ran across this paper CLICK LINK that supports his view that the A1c, whether it was achieved by stable or flucuating BG, is what’s important: “This study has shown that blood glucose variability does not appear to be an additional factor in the development of microvascular complications.” (I was surprised when I ran across this paper so I printed it out). It’s possible there are other papers or more recent one (this is from 2006) that draw different conclusions.

As to the second part of your post, that “people with A1cs consistently below 7 just do not incur complications”, I wonder if that’s what he really said - if he did then that is NOT supported by the scientific literature, which would say that the lower the A1c, the better the outcome as far as microvascular complications.

As others have noted, there are very real and serious drawbacks to volatile BGs independent of the risk of developing complications. Stabilizing my BGs is therefore almost as important to me as lowering my A1c’s.

Thanks for this info! I also believe there is a predisposition to complications. Some are more prone than others, just a thought, no proof.

I could be one of those : NO predisposition to complications ??? Almost 30 years of diabetes , no complications …never had an A1C below 6.8 ; prior to pump with NPH more like 7.3 …and I keep on wondering and asking , if my A1C test is " not telling the truth " …is there something in my blood make-up ? My meter , CGMS averages a lot lower , that the last A1C of 6.9 equals average 8.4 ( x 18 ) ?? …on the other hand a good reason for me to carry on doing , what I am doing .
Overall quality of life , without the lows is my aim .

sometimes i think you have to throw into the mix the ability for the body to heal itself. Some people just have better healing capabilities than others and a higher tolerance for pain. I know we are not all Lance Armstrongs and Michael Phelps but they are an example of humans who have the ability to recover from intense workouts by flusing out lactic acid and having muscles recover. I think this helped Lance fight his cancer. Their bodies are condition to take some insane workouts along with good genetics.

So maybe some people with diabetes can tolerate the damage better and recover better than others so that no complication are seen within different A1Cs. How is it that some people can DKA at over 1000 and some die at lower numbers. Some people have stronger immune system than others. Genetics and evolution I would think would play what our bodies can tolerate based on how our immidiate blood line has been able to adapt to our ever changing environment.

And last but not last maybe faith in God helps a little bit.

I’ve heard that there is a genetic component to the tendency to develop complications. In fact I was talking to the CEO of a high tech company who told me they were considering developing a genetic test that could test for this, but he wasn’t sure there was a market since people often don’t want to know what’s in their genes - if you find you are less likely to get complications you may let your control go all to hell (leading to worse problems) and if you find you are more likely to get complication you may give up as it being hopeless (leading to worse problems). In any case, this was several years ago and I haven’t seen him for a few years, but I don’t think this ever made it to market - either they dropped the idea as unmarketable or they couldn’t get it working.

Jag1, that article is very helpful, and, perhaps even more importantly, the site includes a long list of articles published since that refer to it. I’ve got at least a month’s reading ahead of me.

I’m very grateful for your having taken the time to post so informatively and for providing the link.

I came across this study that suggests that lower BG variability is desirable: Click here