Should Geezers run Higher A1c's?

Edd - I am blessed in that my PCP is also my endo, and he’s VERY good at it. I’m soon to be 75, and my last 3 A1c’s have been 5.6, 5.8, and 5.9. The 5.6 did include too many lows, but not the 5.8 and 5.9, and he is fine with me having those numbers.

I would say that as long as you don’t have severe hypo unawareness, you should keep doing what you’ve been doing, and if your doctor has a problem with it, find another doctor (unless she’s willing to listen).

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With good CGM, Time In Range is the best criteria for BG (with individualized, appropriate targets). A1C is now largely irrelevant. Good TIR will result in a good A1C and poor control won’t be masked by hypos/hypers cancelling each other out.

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Kenneth’s post was really aimed at emphasizing the importance of avoiding hypoglycemic episodes, especially in older patients. I appreciate that.

Before CGM, it made sense for Endos and PCPs alike to order A1C’s. Studies in those days showed that most very low A1C’s involved many hypoglycemic episodes.

With CGM, the whole world has changed, though unfortunately, many PCPs have not caught up, and even some Endos.

A1C is still a quick way to find out about a new patient, but CGM data should be how both patient and doctor manage T1D these days.

If you have a CGM but your doctor uses A1C tests as the primary method for giving you guidance, I would find a new doctor as soon as possible.

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There are many. If you are interested in reading actual science, and not rehashed blog memes like “disregard ACCORD study”, it is well worth spending time on the pubmed site. There are too many to cite “them”, but I happened upon an example when researching something else. It is not the full paper but only the abstract, though there are many more papers, some of them with full text discussing this J shaped risk curve, if you look for them. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(18)30048-2/fulltext

“We did a 5-year retrospective cohort study using The Health Improvement Network database, which includes data from 587 UK primary care practices. We included patients of either sex who were aged 70 years and older with type 1 or type 2 diabetes.”

“The cohort consisted of 54 803 people, of whom 17 680 (8614 [30·7%] of 28 017 women and 9066 [33·8%] of 26 786 men) died during the observation period.”

“The data showed a J-shaped distribution for mortality risk in both sexes, with significant increases with HbA1c values greater than 8% (64 mmol/mol) and less than 6% (42 mmol/mol)”

“Both low and high levels of glycaemic control were associated with an increased mortality risk”

The data showed a J-shaped distribution for mortality risk in both sexes, with significant increases with HbA1c values greater than 8% (64 mmol/mol) and less than 6% (42 mmol/mol)”

My question is why people with a less than 6% HbAlc are dying. Just saying that they are dying tells me nothing! I will look at the Lancet article and maybe do some more research.

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If you question “why” those with low A1c are dying, why don’t you also question “why” those with high A1c are dying? This study isn’t about “why” for anybody, because that is a much different data set. This is simply showing that those with very low, and very high, A1c ARE dying at a significantly higher rate. That is what I stated at the outset, which is supported by studies like these.

Now it is certainly reasonable to want to know “why”, but for that you’ll need to look for different studies, and it is harder to find large data sets there because cause of death is not tested for and reported uniformly, making causation difficult to ascertain definitively. Nevertheless the studies I’ve read that look into “why” tend to suggest heart disease, with cases that point to excessive low BG causing heart issues. We know that low BG mobilizes Adrenalin and other hormones, so it is reasonable to me that an excessive hit of counter regulatory hormones could cause age-weakened hearts to have problems. Just as an excessive hit of hormones in young people with weak hearts is usually used to explain “dead in bed” syndrome for young people.https://www.acc.org/latest-in-cardiology/articles/2020/05/11/11/36/sudden-cardiac-death-in-young-people-with-diabetes

If you’re serious about investigating this subject, there are a lot of papers at pubmed you can find.

I think we know some of the many reasons why folks with higher A1c’s die, but death for people over 70 who are having heart issues because of low A1c’s is new to me. I am interested in finding out how that can be ascertained since so many seniors have heart problems anyway.

I was wondering how many of the deaths of older people with low A1c’s could be blamed on hypoglycemic events which could possibly lead to falls or confusion. Those reasons at this point, wouldn’t make me raise my A1c, but convincing statistical proof of heart issues would make me change my mind.

I have had a non diabetic A1c for almost 2 decades. I would find it challenging to try to change that.

I think that I need to do some more research.

@Jag1 I am curious about this too, although I can’t believe just the act of keeping low BG levels causes a higher mortality. Unless you go “too low” and I’m not sure they have a complete answer on what that too low is. But if you have a TIR at a higher percent and you don’t hardly ever drop below 55 how could it be harmful? Unless at some point you drop too low, pass out and die. But I would strongly suspect the people that venture into dangerous hypo range more often are more likely poorly controlled. (not always someones fault)

But I just ran across someone that had a 5.9 A1c and just got a cgm and while her doctor and her thought she was doing really good it turns out she was having huge peaks and drops…so now she is working on better control.

CGM’s are relatively newer and really newer for a much wider amount of people. The UK information would not be very many people with CGM’s. The UK is priding themselves on giving Libres to 17% of Type 1 diabetics, with kids at the top of the list. It can be very hard to get a cgm there, you literally have to be considered poorly controlled.

So any UK study could have a huge amount of people with peaks and valleys because when you finger stick you have a tendency to check before you eat, when you first rise and go to bed. So an A1c can hide that data. And the UK study was 2003-2006 with follow up 2007-2012. That’s significant as I was still misdiagnosed in 2010 and I had a pcp telling me that I couldn’t be a type 1 because medications worked some on me. So knowledge was severely lacking even 10 years ago. They also mentioned that less variability seemed to play a role in mitigating risk.

Cgm’s being widely used by a bigger range of people is more of a recent US thing, although some countries are working on supplying them to more people, So there is not a lot of available data on lower A1c’s with a good TIR attached to it. But with the years advancement, extra tools and knowledge, you can look at how many more Joslyn long term diabetics there are now versus even a few years ago.

We are probably the new data they will use to help try to figure it out.

EDITED to add dates and variablity quoted in study.

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I also read that those with less than 6.5% tend to have poorer surgical outcomes
with those who are over 8%. Healing issues and hypoglycemic events were attributed to poor results and increased length of stay. Also the lengths of the surgery was a factor

I’ve been running in the 5.5 range for almost a year now. Before that, I was high 6s. But I almost never have hypos anymore.
My pump corrects most of those before they happen, and otherwise, I can feel it.
I don’t think running under 6 means you are at risk. I really think it’s the opposite. If you can have a low a1c and very few lows, I think you are in the best spot you can be.

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That makes no sense to me. I haven’t had much surgery, but for the minor surgery I have had, I agree to let the surgeon keep my glucose level a bit higher during the surgery itself, but bring it right down once the surgery is over.

I heal well and quickly.

It sure seems like a person with a non diabetic A1c would heal better than someone with a diabetic A1c.

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You would think so. I have been reviewing research articles that are reporting this. I will be getting surgery soon so I wanted to familiarize myself with information in this area. Good thing you heal well.

Good that you are researching. I hope that your surgery goes very well! Please keep us posted.

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For surgery concerns, I started a thread a few years ago about 2 surgeries I had 1 week apart at two different hospitals. At the time I could find very little information about BG levels and type 1 so I had to follow my endos guidance. She was a great endo and type 1, but sadly lacking with much information about surgery, surgery process etc. I think that’s probably because it doesn’t help that we can vary so much and the hospital care can vary so much.

So a few years later people off and on would ask in the middle of threads and it would get buried, so I decided to start one and I asked for input from everyone so that there would be a little more information about our experience with having surgery.

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