My PCP went ape**** over my 5.4 A1c

My primary care doc wants me between 7.0 to 7.5. Not so for the endo. He wants me lower in the mid 6’s

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BELOW 7 if you can manage. I don’t know if there’s much added benefit to go below 6. But much more important is to reduce time over 140, TIR as they say, as much as possible.

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7 is really an old target. Most doctors want us to be in the low 6s.
Many get lower than that. I was at 6.1 on my last test and I think I never went under 60.
I have been as low as 4.9% but I was having a lot of lows. So on my tandem I generally end up 5.8-6.2.
I’ve accepted this as a reasonable a1c. Even though I would like it lower.
I think if we can get an A1c into the normal range without going low too often is really where outer targets should be.
I have a non diabetic brother who was at 5.1 and I think that’s probably where most non diabetic people are.

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Some people do fine with an A1C of 7.0
Everyone’s body is different. Everyone has a different experience with diabetes and respond differently to meds, etc. My A1C was at 7.0 for ten years and I had no problems at all.

The problem with that is, the effect of high sugar and high levels of insulin is additive.
You can go years with no issues then suddenly you have issues.
I used to think 7 was a fantastic number. I had bouts of being up around 8.0. That was long before I had cgm.
30 years bouncing around 7.0-7.5 has not caught up to me yet.
At least I don’t think so. I do have dupuytrens but so does the rest of my family. Mine is pretty mild.
Buy my eyes are good and my kidneys are fine.
As I age I worry about it.
I want to have a long life, but more importantly a long life where I can be active

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If you can get your PCP to become familiar with the International Consensus on TIR thru the standard or an article on TIR, that might help. The other thing is to communicate your TIR goal(s).

Before CGM, lower HbA1C was associated with too many hypo episodes. Regarding studies that showed low HbA1C risks out weighing benefits, those studies weren’t conducted using TIR and probably without CGM and are therefore out of date.

I’ve been toying with the idea of refusing the HbA1C test. With CGM and TIR, HbA1C’s relevancy IMO is only to verify that there hasn’t been any big change or error in BG/SG data. Refusing HbA1C may be difficult, blood draw is typically at same time as the draw for other tests.

Good luck with educating your PCP.

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The problem with that? Well, everyone responds differently. Every person’s body is different and everyone’s experience with diabetes is different. These are facts. I know a couple of people who have A1Cs of 8.1 and have been for over twenty years. They have no problems at all. They are very active as well. I take blood tests every six months and have done that for ten years. My A1C was stuck at 7.0 even with strict dieting and exercise. Prior to getting covid I ran nine miles five days a week plus other exercises. My A1C never dropped below 7. An endo I saw told me some people do fine at 7, 7.5 and even 8. It isn’t common but it happens. The people who tend to have complications are those that smoke, don’t exercise and are majority sedentary and who don’t clean up their diet.
As for everyone having a different experience with diabetes. I know diabetics who can eat sweets with no problem. They can eat pancakes, take insulin and no problem. Not me. If I touch pancakes, insulin doesn’t work in my case (well it work, but I have to take about 20 units of humalog) I will end up with high blood sugar for a couple of days. I have to do a lot of walking/running to burn up the sugars.
I know diabetics where running spikes their blood sugar, so they don’t run.
Again, our bodies respond differently to different meds, diets, exercise, etc. The cookie cutter mold and the one size fits all mentality is outdated

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I agree with, “every person’s body is different.” My problem with the HbA1c test is it does not take into account intermittent highs and lows. This image from diatribe on 3 possible 7% HbA1c test with very different time in range shows the weakness of relying only on the test.

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Refusing the HbA1c wouldn’t work for anyone on Medicare. Coverage for my Dexcom is dependent upon my taking the test every six months. My endo had said he would just rely on the time in range charts without the A1c except maybe once a year, since for nine years my A1c ranged only between 5.5 and 6.2. But Medicare rules dictated otherwise.

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The only point I was making was that keeping my sugars in normal range is my target.
Most people without diabetes do not get neuropathy and nephritis and an assortment of eye diseases.

A1c is just an indicator that you are out of the normal range.
Without knowing Time in Range, it’s not so useful, but insurers use it still to determine control.

High levels of glucose and insulin is bad for our arteries and delicate tissues like kidneys eyes.

I’m not here to judge anyone who runs higher than I do.
If you look at every study, higher sugars, higher variability, and higher insulin levels lead to worse outcomes.

I only have a single strategy to stay healthy as long as I can, and that is to stay in normal range as much as I can.

There are smokers who never get lung cancer, that doesn’t mean it’s healthy to smoke.

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AMEN, Timothy!

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“Normal” blood sugars are relatively uncommon. According to one study, only 12% of American adults are metabolically healthy. I target normal blood glucose, not typical.

Normal blood glucose usually spans from 70-99 mg/dL, overnight, fasting and between meals and after meal excursions are < 140 mg/dL with 1-2 hour time limits.

These are tough, but possible, for diabetics to reach. These are not “all or nothing” goals. Partially meeting them is definitely worthwhile.

There are no guarantees about blood sugar control and the incidence of complications. It’s a tough game to play while keeping your head in it for the long run.

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Great plan!!

My HbA1C has never been given to Medicare, but insulin for my pump is the only thing I’m getting through Medicare. I get the rest of my diabetes supplies and devices from the Veterans Administration.

I suspect they’d want an inpatient visit first time.

Medicare requires that you be seen every 6 months by your medical professional to continue Dexcom coverage. There is no requirement that there be an A1c test. Does Medicare Cover Dexcom G6 for Type 1-2 Diabetes Patients? | Dexcom Provider

Well, that’s a surprise to me. I could have sworn my former endo said Medicare required both the six month checkup (one checkup a year could have been tele-check during COVID) and the A1c. Might it have been Washington state, instead, that required the A1c, in which case it wouldn’t have ben tied to Dexcom. Or my endo may have just been mistaken about the A1c. Doesn’t really matter at this point, since he’s retired anyway and I won’t be seeing him again.

Dexcom, however, requires you to have been seen within the past 180 days if MDI or 90 days if on a pump, and yes my Dexcom supplies were delayed by Dexcom one year when my visit fell on day 182, technically within 6 months but Dexcom does not budge. The other issue, is that not only does the visit have to fall within the 180 days, but the doctor notes must have been received for the visit before supplies are released.

Yes, I should be more specific. In order to receive Dexcom supplies, you must have been seen in the last 180 days and have active chart notes, I have been surprised recently that my supplier keeps asking me when my next visit is, not my last visit. My main criteria for finding a good endo is whether his/her office fills out my paperwork (actually digital documentation) so that I get what I need when I need it.

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Your criteria for finding a good endo is right on point. I really like my endo. His office manager leaves a lot to be desired. I find I just plan ahead when prescriptions need to be renewed so it hasn’t been a huge hassle yet. A couple of times after exchanges with the office manager on their patient portal or on the phone my endo took care of it, but if I really needed something immediately, it would annoy me even more.