I’d gotten my A1c back last week and was pretty disappointed in myself when I saw that it had risen to 7.5. It led me to stop using my pump (I know…it takes time, etc., etc…but it was the last straw for me), but when I went to visit my NP, she had said that 7.5 was great and that she recommends type 1’s stay above about 6.9. She further explained that going below 6.7 usually requires too many lows, hence the higher recommendation, and as long as I stay below 8, I’d be fine.
I’ve been under the impression that I should be aiming for 5-7 and above 7 isn’t horrific, but isn’t good, let alone great. So I’m wondering, what have your doctors told you should be your target range? I know that plenty of people on here get down to the 5’s and some even manage getting down to the 4’s, but I’m more interested in knowing what other medical teams are recommending, as opposed to your own goals. I’d feel a bit more comfortable having a team that’s pushing me to aim the bar high rather than settling for decent, but if 7.5 is considered good by most docs, I’ll reconsider.
My medical team is very happy with my A1c in the 5s. They ask about lows and my endo sent me to talk to my CDE about reducing the number of them. She had some good suggestions and helped me cut down on the visits to the 50s. My endo said during one appointment that 60s are inevitable if you run around 6.0 or below but he said it in a way that made clear that he didn’t think those mild lows are a problem.
The DCCT demonstrated that complications begin to rise significantly when your A1c runs over 7. That is 20 year old established science.
Jackie, I have multiple medical teams to draw on. 5.5 to 6.5 is great.
The NP is being cautious, exceedingly so. None of them want to see more lows, or increased use of emergency personnel pulling one of their clients out of a low low. They’re afraid of being pointed to by the paramedics.
I can’t be nice in my comments about “staying below 8”.
A 7 - 7.9 means you’re up in the 180s to 200s after meals and hitting that time after time.
Furthermore, going below 6.7 does not mean “too many lows” if you use small numbers as your rule of life. Assuming your basal insulin is keeping you level all day, try eating smaller number of grams of carbs at a time and using smaller numbers of short acting insulin at a time, and you will gain experience that will keep you from then going low. It is all in how you do it that makes the difference.
Another thing, don’t use “if 7.5 is considered good by most docs” as your target decision point. “Most docs” were trained back in the days before meters were the norm. “Most docs” are getting their continuing education on general topics, not the specifics of closely supporting diabetics. “Most docs” is not what you want. You want to know what the docs say who have patients who are managing their chronic disease so it has NO COMPLICATIONS. And you may have to travel widely to find them. And finally, please read Bernstein.
My endo seems pretty happy with the upper 5s and my general health but is always expressing concern about hypo unawareness.
I had a severe hypo (paramedics, waived ER…) at the same time I’d hit a 5.0 but I felt it was more situational (long story) so I was not that concerned about it.
The August one drifted up to 5.6 which I was sort of disappointed about as I liked the “cachet” of the 5.0 (hee hee) but I had a pump fail in July, before which the numbers were getting screwy and then it took a while to get them back. I’m pretty sure it’s likely there or even higher now, as the fall has totally messed up my overnight numbers but I’ll find out soon enough.
My last two A1cs were 6.4 and 6.1. For me, I don’t have too many lows, maybe 1-2 per week, and thats usually on the weekend, when I’m more active during times when the insulin is working. Everything that I have ever seen says that you want to try and keep it under 7 and more like under 6.5. To Leo’s point a 7 is an average of 150, and if I end at 150, meaning I know my insulin is done working, I’ll usually take a short walk or a half unit to bring that closer to 100.
meters have been used since the early 1980s as I always had one? I woudl think that there aren’ t that many pre-meter docs still practicing. I think that it’s institutional inertia and the fact that they don’t figure out a way to study people who run in the 5s to figure out 1) is there a problem and 2) is there a benefit? I would think that health insurers would be interested to kknow as if there was either a problem or no benefit, they could save a lot on test strips. Frankly, I suspect that they probably have data that would clear it up quickly but they are not sharing because of HIPAA and business concerns and the devaluation of the scientific method for social engineering in the USA.
My son’s doctors recommend striving for below 7.0. His last a1c was 5.8 and his medical team was thrilled, especially for a young teen. The team downloads his meter at every appointment and caution against lows but if he can achieve an a1c in the 5s or low 6s, they’re very pleased. From what I gather, having an a1c in that range is not common for their teen patients.
Next week will be his first a1c since he started pumping, and I think he’s been running higher since he switched to the pump. Shortly after he started pumping, his honeymoon started fizzling out, so with the combination of fewer Lantus-fueled lows and the honeymoon petering out, I expect his a1c won’t be as good as it has been. We’ll see what they have to say if it’s over 7.0 this time.
The American Association of Clinical Endocrinologists actually recommends and A1c of less than 6.5 – but they add if it can be achieved safely. I copied this section from their 2011 guidelines. I couldn’t find the one I used to copy that said non-diabetics have an A1c of less than 6.0 and the closer to normal you can stay, the lower the chance of complications.
3.Q5.1.1. Outpatient Glucose Targets for Nonpregnant
Adults
• R15. Glucose targets should be individualized and take into account residual life expectancy, duration of disease, presence or absence of microvascular and macrovascular complications, CVD risk factors, comorbid conditions and risk for severe hypoglycemia. Glucose targets should also be formulated in the context of the patient’s psychological, social, and economic status (Grade A; BEL 1). In general, therapy should target a A1C level of 6.5% or less for most nonpregnant adults, if it can be achieved safely (Grade D, BEL 4) (Table 7) (3,4). To achieve this target A1C level, FPG should usually be less than 110 mg/dL and the 2-hour postprandial glucose concentration should be less than 140 mg/dL (Grade B, BEL 2) (Table 7) (3).
I have consistently had A1Cs ranging from 5.1 to 5.6. I have actually worked on loosening my control a bit, as I do have a lot of lows, all treatable with alerts from my CGM. It is really hard for me, as I hate to have a BG over 150.
In reality, I reflect still young at hearts response. Generally endos love my numbers and I do feel it has really controlled the onset of complications. Overall, if I consistently hit 5.5, I would be a happy camper–fewer lows and good control.
I do not agree with your NP. I have always wanted to ask Drs what they would do in my shoes? Would they be happy with an A1C of 7.9? I doubt it. I believe your NP is quoting the very questionable ACCORD study. In abstract, the study used T2s with pre-existing heart conditions and other ailments that were under “poor control”. The patient were blindly selected for a few different areas: lower A1C with agressive therapy, using Avandia? (I think - the drug that you sometimes see lawsuit comercials about), and no action, etc. The study found that lowering these patient’s A1C dramatically increased their risk of a heart attack/death. It does not take a wizard to see that this study is likely bunk (due to Avandia) and likely should not be extrapolated to the well controled T1 community.
The 20 year DCCT study shows that increased A1Cs leads to dramatically increased risks of complications from diabetes and this is the study I choose to believe. I believe the biggest threat to a diabetics life is hypo and hyperglycemia. From a discussion with my endo I believe a diabetic does not harm themselves in the 60s, as non-diabetics can have fasting BG there. But you have absolutely no room for error in the 60s. Hyperglycemia is what I consider my major daily battle as it is likely a cumulative effect that may eventually catch up with you.
My endo is ecstatic if I can reach the 5s, but will always recomend some basal or I:C ratio change “because I am hitting the 50s too consistently” at a specific time of day. As for any other Dr. I may see, I do not praticurally care about their A1C opinions and would not spend much time worrying about it.
My Dr. says 7. My last one was 6.7 and my Doc. was not happy. Thats because I was having a lot more lows. I also wonder about my Doc. because in the past looking over a weeks worth of readings, I had about 4 or 5 lows. In a week I check about 70 times. Anyways she was stuck on them few lows ignoring the 20-30 highs. That irritates me and I remind her that I am Diabetic lows will happen. Lets focus on all the highs.
I’ll amend this to say that the pre-meter docs unfortunately taught the post-meter docs and the post-meter docs didn’t get educated enough by their patients! Ha ha! And more: Every time I go into see each of my doctors, I give them an education. It’s something we all need to do!
My doctor loves me at my current level (mid to high 5s) and wants me to stay there. I already have a complication (retinopathy) and his big goal for me is to avoid any further complications and to avoid the retinopathy getting bad again - and he believes I can do these things by keeping my A1c at 6.0 and below.
My endo cited the ACCORD study when I went from 5.9 to 6.6 and was disappointed. She told me an A1C of 7 is fine and striving for anything lower is not going to make a difference. It really annoys me that she couldn’t distinguish between my type 1 diabetes and a type 2 person on Avandia.
I read through this thread again and note the concern for hypos and I think that hypos are more “tactical” than A1C? An A1C is sort of the sum of all the numbers. From the sound of it, it may be that there’s a ratio or rate off, or maybe a little of both? I would probably look at those things rather than focus a lot on A1C. Go one test at a time and try to get rid of the outlying extreme numbers? A lot of times the really low hypos end up being from overcorrecting highs and when I run smoother, it’s not “high” or “low” but in the middle. The other thing about a lower A1C goal is that it sort of motivates you in one direction and I always overlook lows when I’m looking for probles. They don’t bother me that much but still represent a loss of control? And, as you point out, can be dangerous.
I’m not sure I would consider an “average” of 65 optimal? I can force myself to read at that level but it’s much harder. It’s also where any IOB and even relatively nondescript activities like shopping require adjustment. It’s also sort of wierd that doctors will generally tell you to aim for the 6s. Mine always tell me “you are doing great!” in the 5s but I don’t think they’d be much help to get there if I wasn’t there on my own?
I completely agree. I think the only way to get a 65 would to be sedentary and not leave the couch or running the 20’s to balance out the 100’s. Personally I think anything 6.0 or below is optimal with a goal of 6.5 being reasonable.
