Is there added benefit to getting A1c lower once it's already < 7%?

All of the studies I've seen say <7% is the target for most people with T1D (Obviously, children, people with reasons, such as hypoglycemic unawareness, and pregnant women have different targets). I know that once A1c is below 7% the studies show that probability of complications drops dramatically. However, beyond that, are the reductions meaningful? Once your A1c is less than 7% and you aren't having tons of highs or lows, does anyone find any benefit to even lower A1c? Personal stories welcome-does it make you feel healthier? reduce symptoms? Or are there known meaningful reductions in complications anyone has read about? Once it's less than 7% and you're not having crazy highs and lows, you're eating healthy, getting to play sports and do the things you want, can you just declare victory?

I strive (,uch to my new Endo's chagrin) to have all of my labs in the normal non-D range. I figure it is my right to want that, and I am willing and able to do all the work to achieve it. I have the tools I need: pump and CGM and was successful in keeping things in range to a large extent. Yeah, I do have some rogue numbers but not often. Or should I say I didn't have rogue numbers... The new Endo thinks it is fine to have bg's in the 140-160 range overnight. To me that's post-prandial and I'm not accepting it. I am still fighting. But to your question, I feel better when I am in the normal range. And I have a sense of pride - that helps avoid D burnout (at least for me). Because start stickers were so effective when I was a kid, I put them on my log on the days when I succeed. Love flipping through the log book and seeing those. I also find that my overall energy level is better.

The biggest evidence of lowered complication rates was from the DCCT trial two decades go. The results showed compelling evidence that lowering A1c dropped complication rates, but a limitation was that most patients only achieved at best A1c in the 6s. Further studies have shown additional reductions of complications like retinopathy down into the 5s.

One has to interpret "meaningful" reductions in your own context. Given that CVD risks double every 1% increase in A1c independent of cholesterol might drive you to try to get your A1c down from 7% to 6%. But it is also important to understand the absolute risk, if you only have a 1% risk of CVD over your lifetime then halving the risk may not be all that meaningful. And as you note, tighter control always has to manage the negative consequences like hypoglycemia.

Bernstein argues that as a Type 1 you have the best chance of positive outcomes if you get your A1c down to below 5%, truly non-diabetic levels. My endo always goes ballistic as my A1c approaches 5%. I always have to "prove" I am not having dangerous hypos.

Studies, by their very nature, make conclusions about the general experience of the groups of study participants. They do not conclude that keeping an A1c below 7% reduces complications; what they really say is that it reduces the risk of complications.

We've all been dealt a genetic hand and our diabetes diagnosis revealed one of our weaknesses. Philosophically, I'd like to set myself up for the best possible outcome, but always realizing that I may not be able to prevent a serious secondary diabetes complication. At least I can feel good about my effort and that will definitely reduce the chances that I will blame myself for not taking the best possible care of my health.

One of my 4 main goals for my diabetes management is to keep time below 70, as measured by my CGM, to <= 5%. This is actually the percentage of time that non-diabetics spend below 70. Doctors are hyper-phobic about low BGs, but their wariness is not without justification. I think they owe it to at least the more attentive and capable of their patients to try and keep BGs at a lower level. They don't seem to be able to discern who, among their patients, is capable of living closer to the edge!

The most under-rated BG metric, in my opinion, is BG variability. Less variability permits a lower and safer BG average without increasing the chance of undue hypoglycemia. It also improves day-to-day quality of life.

Risks for microvascular complications continue to drop below 7% A1C. e.g. Retinopathy rate for 7% A1C is twice what it is for 5.5% A1C. It looks like the risks/complication rates continue to drop even below 5.5%. There's not a lot of long-term data below 5.5%, just very few T1 folks have historically been in that bin.

Risks of extreme hypos rise rapidly as A1C's decrease.

Graphs below from DCCT.

Me personally? I have had A1C's mostly in the 5's and low 6's for past a couple decadea, and a couple of extreme hypos in my 31 years of T1 resulting in ER trips/glucose drips/glucagon etc. And a couple more ones where probably I should've been in the ER with but somehow survived.

And there are other factors that contribute to microvascular complications that can be controlled too. e.g. high blood pressure is also a huge risk factor for retinopathy and kidney disease. Controlling blood pressure will be in most cases almost trivially easy compared to managing an insulin regime. It makes sense to not only control bg’s but also carefully reduce all other risk factors too.

Personally I think it is a very individual thing. I find the lower my A1C the better I feel. I spent decades with A1C's in the 11 to 16 range and had continual yeast infections, got trigger fingers which needed to be repaired surgically and I generally didn't have much energy to exercise or really live and thrive. T1D is physically, mentally, emotionally, financially, and spiritually draining. Since I finally decided to take control and manage my D my A1C has dropped to near non-D levels. My last was 6.1 and it was done with time spent <70 mg/dl of 5%. I have more energy for work, home, family and recreation. I am super competitive and I like the challenge presented by D. So while it may not contribute significantly to reducing my chance of complications until someone shows me evidence that it absolutely doesn't, I'll continue to work to getting my A1C as low as I can without crazy hypos. I'll declare victory when they find a cure.

There has to be. The way I see it, as long as the A1C isn't an average of extreme, just as it is best to have one's BP, weight, lipids etc in the "normal" range, it's good (or better) for us.

Well said, Clare. I completely agree!

Doctors are hyper-phobic about low BGs, but their wariness is not without justification.
Like many aspects of diabetes treatment, this is in my opinion a lagging part of the protocol that has not caught up to the state of the art treatment options PWDs have in 2014.

Simply put, a CGM changes the equation dramatically vis a vis hypos. My own personal experience includes more than I can remember that I avoided because I was watching a CGM, watching me.

Even the improvements in glucometers, lancing devices, and test strips has made testing many times a day much more practical than it used to be. That too alters the landscape for hypo risk.

Many of us can remember those days when they were going to check your BG in the doctors office, and they pulled out that giant meter and the nasty looking BLADE lancet to "lance" your finger. Always about a pint of blood and a bandaid in those days.

Today, with 33 gauge lancets with controlled-depth actuators, and microdrop test strips, checking blood sugar really isn't much of a pain, or an inconvenience. It's pretty much whittled down to a "it's a bummer I have to do this all the time" issue.

Medical treatment regimens will catch up eventually, and we'll see more and more support from docs for lower targets and tigher overall ranges. My endo, relatively young in the profession (approaching 40) is all over my tight control goals, how I'm doing it, etc.

An interesting point to consider is that, if you extrapolate that graph, the risk never reaches 0, even at an a1c of 0%.

Of course, that's not scientifically, mathematically, or medically valid, but it does serve to make two points:

  • Non-diabetics get retinopathy, neuropathy, nephropathy, heart disease, etc. too. Given that, looking at the lower end of the graph, the question of whether or not diabetes is still the dominant cause of these issues when you have excellent BG control becomes pertinent.
  • There is a very real issue of diminishing returns. As with so many things, the effort to drive that a1c lower increases more and more as you try to squeeze another tenth of a percent out of your a1c, while the resultant benefit concomitantly decreases for that effort. So, the issue of Quality of Life becomes more and more of an issue.

I agree with everybody that it can be ok to run lower and I feel pretty strongly like I'm reducing my risk of complications. My A1C has been 5.8 or less since 2008, when I got a pump and my last 3 have been 5.1, 5.4 (holidays, w00t!) and 5.1. I still have minor league complications, e.g. the hair on my legs is falling out occasional slow healing, etc. I don't restrict much of anything diet-wise for diabetes but eat pretty healthily because I feel like it helps me go harder when I work out if I have higher quality fuel than the bag of potato chips I'd like to devour.

I always wonder why, if you had been pregnant and were successful w/ the BG levels there, you'd stop. I've seen posts suggesting that it' work or it's stressful or whatever but I think I find it less work to hit a small, normal target. If it's not there, I don't always do something to get it there but, when I do, it has more chance of hitting that type of goal if the target is there and not a larger or more diffuse target. Although I haven't ever hit 4. I've been at 5.1 maybe 1/2 of the last year, with like one 5.2 and a 5.4 that had me sort of freaked out but was probably holiday carousing or whatever.

AR I achieved those levels during pregnancy - but it was possibly the most stressful time I have ever had. Every single thing I put in my mouth was measured and accounted for by insulin or exercise. This was before CGM's so all the great data I get from Dex were not available to me. And this was before analog insulin as well. So while I was successful and after starting with an A1C in the mid 8's I finished in the low 5's, I am not prepared to put in that kind of effort or be that strict with myself again. I had 2 severe hypoglycemic events during the pregnancy that required ambulance rides to the ER. Living that close to the edge with a drug with a fatal side effect is just not for me.

That's true! R/N would be much more challenging to try that on, although I had a weird period where I hadn't been to the doctor for maybe 5+ years, got my RXs cut off and went to a new doc to fix that and "get back on track" and had a shocking 5.8...

I had a number of exciting ambulance rides during the R/N days (although I've had 2x w/ the pump, one w/ the CGM too, both perhaps related to spring fever and overdoing the exercise and not being careful...not for a few years now though...*knock on wood...*). I would like to see "normalized" numbers considered a possibility, a very long-term goal, something to consider working for. If not totally normal (and mine aren't, I had like the worst two weeks since 08' the weeks before this one...last of a bottle that was the last of a mail order RX shipment maybe? I couldn't get any traction out of the juice. Of course, I figured I was going to blow up but, the new bottle this week, from a fresh shipment seems to have cured it!), then some manner of working towards it, in slow, incremental steps, if that makes sense.

I would have to say that lower is better but my A1c life time average is well below <6.5 and after I started MDI, Pumping, and using a CGMS it has been under <6.0 for almost a decade and I still have some complications. I think the fewer High BG events we have the better off we are in the long run, just like a boxer or football player the damage is cumulative, starting in or early Diabetes lives and we carry the scars of our high BG events to our grave.

I have seen many PWD's that have lived normal lives with BG in the 200+ range everyday, and I have seen individuals that have suffered a long list of complications with much lower BG. I think most of us fit somewhere in the middle. Setting a goal for our high target (say 140mg/dL) and staying below this number is probably more beneficial than haveing a BG average of 100-120 and still going over 180-200 after every meal...JMHO

I wonder, outside of this site, how many Type 1s are achieving an A1c in the 5s. There are certainly some, but I don't think it's a majority or even a large minority. And, while many Type 1s have access to pumps these days, a CGM is still a tool that is unavailable to most.

I haven't tried a CGM, and that may be a game changer when I can finally afford one (or when my work benefits kick in, if they will cover one, which I doubt). But I tried for five years to get my A1c below 6.5% and couldn't do it. This was using a pump, exercising daily, preparing 99% of my own meals, weighing and measuring everything, keeping and reviewing logs, and eating 100g or less of carbs per day.

I ended up feeling like a complete failure. Clearly (in my head) I was incompetent and doing something wrong or completely missing some basic concept that everyone except me understood. I ended up sliding into total burnout. But then I went on a "blind" CGM (so I couldn't see real-time results) and it showed that my blood sugars were actually chaos! The CDE thought they were great, she said she didn't see many people with such a high percentage of readings in range. (I think I had 75% of my readings between 4-10 [70-180] on most days.) But despite my best efforts my blood sugar had high peaks and low valleys every day, and what's more there was NO pattern to the readings whatsoever. I ate the same thing most days and some days I could spike hugely after a meal and some days hardly spike at all. Sometimes exercise dropped me like a rock and sometimes it had no effect. Even during the night, when you'd assume things would be least variable, had no two nights the same.

I do think that if/when I have a CGM long term I will start learning what foods to really avoid. But if that week of CGM data taught me anything, it's that there are definitely factors outside of my control that wreck havoc on my blood sugar. I happened to catch, on the CGM, the effects of the hormonal cycle on my readings—I went from 75% of readings "in range" (between 70-180) to only 25% of readings below 180 over the course of one night, with no change in insulin dose or any other controllable factor.

Would lowering standards help? Maybe. My endo (new as of about a year ago and who has Type 1 himself) really, really wants my A1c below 7%. Yet, even HE is unable to spot any patterns in my readings, and each appointment ends with either no suggestions or a guess at a change in pump settings that may help. If doctors are going to help those of us who have tried on our own for YEARS and failed to achieve a great A1c, then something is going to have to change. Sometimes it frustrates me when doctors act as if my A1c is high because of a lack of effort. Maybe I'm wrong, but I truly believe that I put in just as much effort as mot others on this site—maybe more than most, given that I weigh and measure everything I eat—and I still struggle to meet that 7% goal that people complain is not tight enough. If I and others like me are going to achieve an even tighter goal, then a lot of people are going to feel like constant failures if they are not able to achieve it. Either that, or something has to change so that new tools are available to help patients who struggle despite having knowledge and (most of) the right tools.

Anyway, sorry for the rant. I wasn't ranting at you! Just some thoughts from someone who does not, and has never had, an A1c consistently meet even conventional targets.

In recent publications, as many as one out of ten T1's have A1C's below 6%.

e.g. Below is from 2011 data from Japan.

Jen - Don't beat yourself up. The fact is even with your best effort - which you are obviously putting in. This article from insulin nation put it all in perspective for me.

"Here I was patting myself on the back for thinking that I was taking such great care of my patients, when in reality, I learned that comparing A1Cs for people with and without diabetes was like comparing apples and oranges. Even patients who used insulin pumps, ate the same meals every day, exercised daily and “did everything right” can hardly hope to achieve the glucose levels of a person without diabetes. I realized I needed to stop blaming my patients or thinking myself superior. -- But I no longer blame my patients, their diets, activity level, or even the cake, candy or snacks for their A1C levels. It comes down to physiology. At the time of diagnosis of Type 1 diabetes, there is a reduction of 90% of the beta cell mass; Type 2 patients experience a reduction of as much as 75%. Diabetes is the fault of a pancreas that has too few functioning islets.
The term “non-compliant patient” doesn’t exist in my vocabulary when it comes to the treatment of diabetes; I now know better.

I stopped blaming myself and I also stopped dreaming that I could achieve normal blood sugar levels without any functioning islets. What I have learned as you have is there are so many things outside my control that affect blood sugar. I eat well, I exercise, I am blessed to have a CGM and Pump and I do what I can to keep healthy. Beyond that a number is a number, it's not going to ruin my day.

With that data, at least, the sample size was 3,365, and 188 achieved an A1c below 6.0%, which is just over 5% of the sample—or 1 in 20 Type 1s.

But over 68% of that sample are not meeting even the current standards with an A1c of 7.0% or above.

I think if almost everyone were meeting the current goals they would be lowered. I think the fact that the goal remains 7.0% indicates that a lot of people are still not achieving that goal. If it were lowered even further, I don't think that would magically result in a bunch more people suddenly achieving tighter control (talking Type 1s here, Type 2s are probably a whole different story).

I found that NIH and CDC had some histograms/distributions for A1C's for all diabetics, and that would include a lot of T2's. If you include all diabetics then more than half are now below the 7% standard. And the decrease of those above 9% is very pronounced:

You are absolutely correct... posters to tudiabetes are a self-selected group mostly with good to excellent control.

You raise a good point, should we work hard to get those few at 6.3% to 5.8% (Kinda typical of what many frequent tudiabetes posters are trying), or should we work less hard to get those at 8.5% to 8.0% (more typical in real life)? I think a good endo will enable both.