Understanding HbA1c- requesting your help! Please

Hi everyone. I’m a doc working in diabetes care. I had an idea about getting A1c results directly to UK people with diabetes and the idea has reached the pilot stage.

There are 2 versions of the artwork to support the project- Qu- how to decide which might work best? Ans- ask people with diabetes their view!

I’ve set up a page on my Sandwell Diabetes website which explains the project, shows you the 2 versions of the artwork and has a form to submit your views (takes 2 mins).

If some of the Tu Diabetes community would kindly give me some feedback, I will be most grateful.

You can find the page for this at http://www.sandwelldiabetes.nhs.uk/Sandwell_Diabetes_Care_Updated/Delivering_Results_2_U.html

Many thanks! Meanwhile, if you have any other comments/queries/suggestions, please contact me through Tu Diabetes, or else my other contact details are also on the website.

I think it is a good idea for some patients to receive something like that so they know what their A1c is and have some idea whether that is a good or bad number. I disagree with how you have anything below 7.5% as being good. Most people criticize the ADA’s 7.0 as being a high number. The American Association of Clinical Endocrinologists says it should be below 6.5 and the closer to normal, the better. I think that you are doing your patients a disservice telling them if they have a 7.4 everything is fine.

An aside – that’s really weird how the ADA and the AACE are not in synch. My recent A1C is 6.4 and my endo was really happy, as was I (it came all the way down from 10.6 at diagnosis in June of this year) – she did tell tell me that they like it to be below 6.5 as well. I have to say that I feel MUCH better at this A1C level than I even did when it was at 7.00 back in July.

My preference is the ruler design since it shows it as a continuum.

Agree with Kelly. That’s quite a high A1c to be considered good. I’d be upset with a 7.4 & concerned with a doctor who thought that was acceptable. The closest as possible to normal is my goal.

Thanks Kelly

If you look at the artwork you will see it does not say ‘everything is fine’.

UK guidance is changing right now with worries that aiming for low A1c levels may not be safe for everybody.

This initiative is trying to get UK people with diabetes engaged in knowing + understanding their A1c result. Sadly awareness in the UK is not good at present. Which of the options did you think might work best?

I know it did not exactly state “everything is fine” but it implied that it was because that was the cutoff level for a “good A1c.” I know that there are some groups that might it might not be safe to have a low A1c, but those are in the minority and your chart is implying a high A1c is OK when it is not.

Unfortunately, I don’t think awareness in the US is that great either! I have two T2 neighbors and neither of them really know much about diabetes. I know for a fact that one does not know what her A1c is and would not know what was good or not.

I liked the ruler better than the stop lights.

The scale of your chart is a joke - and not a good one. The below 7 rule is totally outdated. But on the other hand you will have to care a lot for your patients after 20 years or so. If you really intend to encourage people in the wrong belief that below 7.5 is good for them you should have a good lawyer.

My personal chart would look like this:
Above 6.5 = red
6 to 6.5 = yellow
Below 6.0 = green

Not really all that strange. ADA pushes a high carb diet, so they have to set a correspondingly higher A1c. They also get huge funding from the pharm companies, who’d like us to take more meds & more insulin. Years back, the ADA was opposed to home glucose meters. They’re not a progressive organization.

I vote for your chart Holger!

Holger’s chart gets my vote, too.

Holger, that isn’t fair. I am in the UK, I made that clear. In the UK there are 2 thresholds for taking action-
‘Step one’- type 2 diabetes just on metformin- A1c over 6.5%
‘Step 2’ and beyond A1c over 7.5%. That’s why 7.5% is chosen.
UK has no specific Type 1 DM goal, but in the ‘DAFNE’ trial A1c in UK people with T1D was ~9% pre-education, ~8.5% after, seen as a success.

I appreciate that Tu Diabetes, like others, will tend to represent people with ambitious goals. I never judge people on A1c, my job is to help people achieve their personal diabetes goals however ambitious they may be.

Meanwhile this is a genuine effort to get people interested in knowing their result.

That is insane!

What I always find useful when I get my A1C results is some history, the last 5 or 10 results so one can see any improvements quickly.

I do agree that 7.5 is too high for the upper limit. 6.5 would be better.

By the way I’m from the UK, but I left in 1980 before A1C tests or home glucose meters.

They’re not our advocates. Huge institutions rarely represent their alleged constituency.

Dr. Davies, I have a question for you. If you have a patient that comes in and has an A1c of 6.1, is it against the law for you to start that patient on medication? Even in the US, some doctors are fine with the higher A1cs. When people come here asking questions and say that their doctor is not treating them with A1cs that high, we tell them to find another doctor. There are doctors here that are fine with the ADAs outdated A1c policy of anything below 7.0 is OK but people that strive for good control are not fine that policy. Just because guidelines in the UK think that an A1c of 7.4 is OK does not mean that you should not be helping your patients achieve better. The only reason not to would be if it would land you in jail or you would lose your license.

Thanks to the Tu Diabetes community for the responses. I thought I’d give you a little more background:

There is a sms-text version for this, but that only allows a word description of the numerical result, not pictures. As many people understand pictures better than words or numbers, we wanted to try to portray the result pictorially- not an easy feat! We wanted to keep clear of being judgemental- a high result could represent significant improvement; a lower result could mean joy, or disabling hypoglycaemia. Ultimately A1c is only one facet of your diabetes.

As part of the project we asked local people with diabetes how they would like this info- ~60% wanted it in writing, only 14% wanted text. ~14% wanted an email, but because of local governance worries about email we don’t have authority to do that just yet. In the UK, very few people get given their A1c in writing, in my area only 9%. We want that to change, the target is >90%.

When we have made a decision on the design, we can pilot and fine tune. The bands for results are based on UK thresholds for ‘action’, as applied to everyone with diabetes. The descriptions and the ranges for A1c at each level are printed at the time the individual’s result is added. The colours and picture are embedded on a ‘personal mailer’, rather like a salary slip. So using the feedback we get, the text can be altered, whilst we have to stick to the basic design after we order ‘n’ thousand mailers! You can see why we want to choose a design that people with diabetes will find appealing!

My ambitious goals are actually determined by the blood glucose regulation of a healthy person. Whether we live in England or Africa - the tight control of glucose regulation in healthy people is a well known fact. An A1c of 7.5% translates to a mean blood glucose of 164 mg/dL. This will definitely damage the kidneys and can not be seen as good or healthy in any way.

I see it critical that metformin is just prescribed above 6.5%. But this might be the outcome of outweighing the benefits and risks of this medication. This balanced view is something very different to claiming that below 6.5 is healthy or okay.

In the medical field there are many flawed studies - especially for T2. The most questionable conclusion is that tight control might be statistically more dangerous than higher A1c levels. The main danger are cardiovascular problems and the studies often concluded that tight control did nothing against these problems. The flaw is that below 7 was seen as good control and the high tryglyceride levels in this patient group was ignored. Elevated blood glucose leads to complications but in combination with elevated tryglyceride levels this leads to cardiovascular problems and a reduction of lifespan. Better A1c levels and weight reduction can influence the triglyceride levels in a positive way. So tight glucose control is an important element for success but it must be combined with other effords to have benefits against cardiovascular long term problems. Nevertheless good glucose control has many benefits for the quality of life. Can we really recommend an A1c of 7 to a T2 patient with age 60? How high is the risk that this patient will get blind or loose a foot in the next 20 years? By looking at todays charts of projected life expectancy I know we have to set the goals tighter.

I’ll not go into the whole question of targets, that is a topic for a long discussion. As to your specific question, I really have to ask you exactly what is the point of the direct feedback to patients. Is it to get patients to take be more aggressive in their treatment if they are not meeting goals? If that is the case then I think you might want to reconsider this whole approach. If a patient is diligent and trying hard to meet targets, they will already know what their HbA1c means, they probably ask about it, they will write it down and track it even if you don’t directly give it to them. On the other hand, some patients will just go to the doctor, ignore any test results and only want to know whether they need to take more or less medication. For those patients, direct results can make a difference, but only when coupled with a patient centered approach to management.

But this raises the question, your informal survey was not particularly useful in gauging whether direct feedback on HbA1c makes a difference, the people that responded probably were not the target population you wanted, and their desires are not what you care about, you care about whether the information would change an endpoint.

Given, that you are going forward, I would suggest that you change the text, rather than ambiguous “make changes,” tell the patient what to do. If the patient has an HbA1c that is too high (and I personally consider a"good" HbA1c < 6%), then they should do what? Well they could increase testing, decrease the number of carbs in their diet, take a (refesher) course on DAFNE, talk to their doctor about a move to a more aggressive medication/insulin regime, … The actionable items that you list are “wishy washy.” If you want to effect a patient population, you need to write things that a patient can act upon and make progress in their control.

In terms of the specific feedback, I would agree with others that a change in wording is needed for the <7.5% group. It should at least indicate that medical benefits do exist for lowering an A1c below 7.5, and even below 6.5.

Personally, I would rather see no target than a high target. While setting a low bar like 7.5 may comfort people who are unwilling or unable to achieve better control, it is a false sense of security for those that can do better. Compare it to training students or athletes. You’ll have some that are more able and more willing to put the time and effort in. You do a huge disservice to them by setting the bar too low. You should encourage everyone across the spectrum to do better and right now the artwork doesn’t do that.

I realize that your target audience is not likely as well controlled as the average Tu user, but many of us are victims of the ‘7.0 is good enough’ mentality which is why you see such strong opposition here. Don’t take it personally, it isn’t. We simply don’t want to reinforce an antiquated definition of ‘good control’ that may help some but keep others from reaching their full potential.

I also agree with Alan more generally that there is an unhealthy obsession over a single #. A1c is a great, clinically useful tool for identifying at-risk patients, but in the absence of bg logs it has no meaningful information. You can’t give any suggestions to a patient solely based on an A1c, except that they have to ‘do better.’ In that respect, knowing your A1c and only your A1c doesn’t really make you any better off than not knowing your A1c. Encouraging more testing may be of greater public health benefit.

Re studies that prove tight control for T2’s increases risk. Dr. Davies I guess you realize by now you’ve really stirred up a hornet’s nest. But the advice most of us received at diagnosis upsets many of us because it guaranteed we would deteriorate. I believe other recent studies seem to suggest that this might not be true.

1 In a recent study which claimed to prove tight control was dangerous, the target for tight control was set way too high. <6 or even < 5.5 would be my definition of tight control

2 To lower the studies patients A1C the study kept adding more drugs and increased their amounts. Almost all of these drugs have an increased risk of cardiovascular risks.

Is it any surprise they had problems. To study tight control you need to start with diet. The high carb low fat approach pushed by the ADA and other large diabetes organizations won’t cut it for many of us. In my opinion if the standard diet fails the next step should be an eat to you meter approach, eliminating foods that cause unacceptable spikes. If this does not achieve the desired results metformin should be added. Only then should the more dangerous drugs or insulin be added. My take on the study is that drugs alone won’t work for many of us. Diet must be addressed.

I wound up on a restricted carb diet because that is what my meter told me I needed. I realize this diet isn’t for everyone but it makes me mad that I had to research this all myself to develop my treatment plan. It should have been presented as an option in the literature I received upon diagnosis.

Finally I think there should be different goals for T1s and T2s. From participating in this forum I realize that for a T1 avoiding dangerous lows is at least as important as A1C. Some can acheive tight control others can’t. But for me as a T2 you can’t tell me that lower is not better.

PS I liked the graduated ruler better