Diabetes Self-Management Blog

Have you been ordered by your doctor to get your A1C (HbA1c) level up? More people are having this confusing experience, as doctors try to implement the 2013 ADA treatment guidelines. Do these orders make sense? Not much, I’d say.

What is happening here? In 2012, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) changed the targets doctors should aim for in treating diabetes. They went from a one-size-fits-all target of 7.0% HbA1c to a three-tiered guideline.

HbA1c is the test that gives an idea of the average blood glucose level for the previous two months or so. An A1C of 7.0% equals an average blood glucose of around 154 mg/dl, and many people think that number is too high to protect against complications. So there was pressure to lower the guideline.

At the same time, many older people found the 7.0% goal too strict. A few studies found an increased risk of falls in older people who run low glucose levels. There was concern about increased risk of hypoglycemia (low blood glucose).

As Diane Fennell wrote here, many think that aiming for lower A1C levels leads to an increase in low blood glucose episodes. As many readers commented, hypos are dangerous and unpleasant. For many, they are the worst fact of life with diabetes.

So the experts finally recognized that one size does not fit all. Unfortunately, their new guidelines have been misunderstood by some doctors, leading to people being told to raise their A1C numbers, even if doing so increases their complication risk. According to the new guidelines, older or sicker people, or those with many hypoglycemic episodes, might shoot for 7.5% to 8.0%. Younger, healthier, people might want to get their A1C below 6.5%, or even lower. People in between on age and health might continue to have a goal of at or below 7.0%

The target A1C levels are supposed to be individualized. According to ADA President for Medicine and Science Vivian Fonseca, MD,

The message is to choose an appropriate [blood glucose] goal based on the patient’s current health status, motivation level, resources and complications.

This sounds wonderful and easy to understand. But somehow many docs don’t seem to get it. Rather than seeing 7.0% as the upper limit for a person (if that’s the number chosen), they think those who keep their A1C lower than 7.0% are doing something wrong. They want to get those glucose levels up! We know high glucose levels are the main cause of diabetes complications. Is this as crazy as it sounds?

Tight control and hypoglycemia
It doesn’t seem that aiming for a lower A1C actually increases the risk of falls or hypos. According to this study from the University of California at San Francisco,

Achieving lower A1C levels with oral hypoglycemic medications was not associated with more frequent falls, except, among those using insulin, an A1C less than or equal to 6% increased risk of falls.

Below 6% is a pretty rare A1C for an older insulin-using adult.

A large study at Yale University found that

Contrary to conventional wisdom, hypoglycemia occurs just as frequently among those with poor glycemic control (higher A1C) as it does in those achieving near-normal glycemia.

And in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the more people lowered their A1C, the fewer hypoglycemic episodes they had. So there is no reason to assume risk of falls or hypos from tight control. It should be an individual decision.

Confusing tight control with control by drugs
Three large studies are driving the diabetes establishment away from “tight control.” These studies, ACCORD, the Action in Diabetes and Vascular Disease (ADVANCE) Trial, and the Veterans Affairs Diabetes Trial (VADT), showed no significant improvement in death, heart disease, or stroke rates for people with tighter control (lower A1Cs). So why bother with the risks, effort, and expense of tight control if there was no benefit?

But the problem wasn’t the tight control. It was all the drugs doctors used to achieve the control. Those drugs, especially insulin, thiazolidinedioines (TZDs), and sulfonylureas, can have negative effects that sometimes outweigh the benefits of lower A1C.

Those risks or side effects rarely happen to people who control their glucose levels with diet, exercise, metformin, and/or other approaches, or perhaps with incretin drugs. Even the ADA guidelines of 2013 admit that drug reactions may have contributed to the negative effects in the big trials mentioned.

Three sizes fit all
So three sizes fitting all may be better than one size. But it’s still not the same as working with individuals to find what works best for them. It seems that some doctors (not all) can’t give up their habits of bullying patients for their own good. They’re still treating numbers instead of people.

So with new guidelines saying older people should have a target A1C of 7.5% or 8%, somehow older people who are managing quite well with A1Cs in the 6% range are being told they must raise them. I don’t know how widespread this practice is, but I have heard about it from two different readers in different parts of the country.

I wonder just HOW they want people to raise their numbers. Eat more cake? Stop exercising after meals? What sense does this make? What they usually suggest is lowering insulin doses, which might not be a terrible idea, IF that particular person is dealing with hypos.

Other than that, I think people with diabetes should just let these guidelines go. Focus on healthy living and the things that are working for you. Use the A1C test to monitor how well you’re doing, but don’t trip on a specific number goal. Just live the best life you can.

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Comments
  1. Thanks David!

    Well thought out and presented topic.

    “Use the A1C test to monitor how well you’re doing, but don’t trip on a specific number goal.” This says a lot and should be valuable to people where ever they have their goal.

    Posted by Bob Fenton |
  2. I wonder if the falls in older people can be attributed to overuse of blood pressure medication more so than low BG.

    I am an older person and have an A1c below 6% with less lows than before. I have eliminated potato, rice and all grains and their derivatives except for ground flax seed with is very diabetic friendly and possibly heart friendly.

    There are cows, sheep, pigs, fish, cheeses, nuts and a whole lot of non-starchy veggies to eat. Even fruits and tomatoes are fine.

    Posted by calgarydiabetic |
  3. Yes , as Bob Fenton points out, David Spero has done masterfull job tap dancing through this set of thickets. Very interesting and thoughtful.

    Special Thanks.

    Posted by jim snell |
  4. I have had diabetes for over 40 years now, & I’ve found if you wait long enough, advice on medicines & management is gonna change! One would hope for the better, but often it will change in conflicting ways.
    I was in the fore-front on the higher A1c wave & so I let mine drift up. Well, it slowly inched up over about 3 years, to a high of 7.3. As it did, I began to see consequences. Over a period of about 6-9 months, I have brought it down into the 6.2-4 range & feel much better. I am not young & I am on Medicare. Even though my Endo thought I would be better able to manage my diabetes w/a pump, I was not eligible because I had too much circulating insulin. Too much for the pump, not enough to do me any good–plus I am very insulin resistant. So I had to fight w/my provider to get enough strips to test more frequently than the government “thinks” you need to avoid the dangerous lows that a normal-range blood sugar easily causes. Folks, it is all about money. Not about long-term health, but short-term savings!

    Posted by Redneck Angel |
  5. An A1c reading is much more important to your Doctor than it should be to you — the daily pattern of lows and highs is what I worry about. I try to stay in a close to normal range. You know what? Doing that results in a great A1c :)
    I use insulin and don’t get very close to a serious low very often and I react quickly to correct.

    The problem with A1c is that it is an ‘average’ over time and you can have some pretty serious swings without realizing it. If you really want to get serious about good control you better use your Meter - a lot. Begs to ask why the medical profession doesn’t scream very loud about the cost of test strips! If Walmart can sell their house brand for $9 for 50, you just got to know there is a problem here.

    With the ADA diet and a whole bunch of other preferred ‘treatments’ I really don’t know how you could avoid heading to a bad place.

    If your Doctor drops in to see you 3 or 4 times a day and perhaps has some Magic Pills, lucky you. If not it really does become your responsibility to keep your diabetes under control. There lots of information (the good stuff) available and people like David are REALLY appreciated. Such a focused mind.

    Posted by JohnC |
  6. I am an older female on insulin. I read Dr Richard Bernstein’s book. I don’t believe most diabetic are really trained well. Bernstein taught me that low carbs, …6 carbs in the morning, 12 at lunch and 12 at dinner, …mean less high blood sugars. That means I take less insulin, …and have less errors. If I eat something with a large amount of carbs, …let’s say a muffin with 56 carbs in it. I must take into account that food industries give only an approximation in carbs, …and my meter numbers are only an approximation, …and my insulin requirements are only an approximation, ….so what I give myself is literally an approximation. …But if I eat an egg, bacon, and 1/2 a piece of toast with 6 carbs, …..I need very little insulin, …I am less likely to overshoot the mark, ….and if I do take too much insulin, …it is likely to be by ONLY a small amount. My a1c averages 5.4. My daughter is type 1 and so is my 4 year old grandson, …and they have have much more hypoglycemic incidences, …because they do not follow this approach.

    Posted by Karen Okamoto |
  7. This article is great and well-advised by Nurse Spero. Thanks for the research! My Endo wants me to eventually get completely off of insulin and is working with me to eat healthier, exercise (30 min./day, 3-4 times weekly)and generally feel good about myself. She reads articles that I take from my Diabetes Self Management magazine and has already done research on most information herself. If we would trust our doctors and nurses and quit trying to let the government and the insurance industry, (who does not know me or my condition and does not treat me on a regular basis), quantify what is best for us, we just might see our levels of everything drop to normal for our body types. The only person who can dictate to me what is best for me is me. I have all the tools to be a healthier person and I try to use them in conjunction with my Endo and family doctor, who are for me, not against me. I credit them with saving my life a few years ago when I first became diabetic (Type II)and now have a great A1c of 7.0. It will eventually go down to 6 or less as I take even better care of myself. I know what I want it to be. The government doesn’t have to tell me what my body already knows. I also agree with calgarydiabetic!!

    Posted by Becky Cooke |
  8. Good article. I am an older person and proud of it. My last A1C was 6.0 the one before that was 6.5 and 18 months ago it was 7.0 I do not fall but do at times go hypo. I can attribute that to what I eat or do not eat at night. I rarely have snacks during the day and my evening snack determines my low that occurs usually when I am asleep. It actually wakes me up. I feel a lot better and am lowering my Lantus intake and orally meds in conjunction with my Dr. This make me feel great as a senior.

    Posted by Stephen K |
  9. TEST-TEST-TEST…

    Posted by Ruth Metcalf |
  10. Thank you for the update, I always look to see what knew medications are now on the market as I have a nice relationship with my doctor and pa. I tell them after my researching what drugs I want to try, first and foremost are any new drugs that do not make you gain weight, because most of them do.

    Anyone that thinks they shouldn’t keep tabs on what your doctor(s) are subscribing do your homework, there are too many medications out there for diabetes that make you gain weight, and its like overkill, they tell you to lose the weight and then give medications that make you keep it on.

    My problem is I’d have to eat like Twiggy to keep me at 6 for A1C, I found that trying to take two fish oil capsules was making me lose my balance so I had to go back to one, now I’m fine.

    Posted by Bonnie Lu Brehm |
  11. I have been using insulin and dealing with my own bad habits. Not once has any of my doctors suggested that I keep my A1C above 7. I recently got it down in the low 7 range from around 8.6 and I feel better and wish to bring it down further. Ten years ago I had it in the 5.5 range. I rarely have a low but I watch for it. I know my warning signs. Some doctors are so numbers driven that they can’t see the forest for the trees…

    Posted by Steve R. |
  12. Agreed to all of the above. And some studies suggest it is worse to have all the highs and lows to get an A1c of 6.5 for example than to run an A1c of 7 and be more consistent. What you see day to day is more important. It is reflected in the A1c, but the A1c does not tell the whole story as well as your daily blood sugars logged so you can see your patterns.

    Posted by BK CDE |
  13. I am a 54 year old typeI deabetic. I try to keep my A1c around 8 because if it goes lower I have hypoglycemic episodes hat require an emergency room visit. My endocronoligist is cool with keeping it at that level because it works for me. I also eat healthy, do not smoke or drink and exercise at least 6 days per week. I have had diabetes since I was 5 with no major complications. So 8.0 is working fine for me.

    Posted by Laura Grenadier |
  14. i was upset because even with trying hard mine is in the 9’s..from the 6 and 7s..of course i use insulin and i am also on a kidney diet which throws real spanners into the equation for sure..my doc is only worried about all my drops sometimes as many as four a week..and recovery time seems to take longer and longer..and weigh and measure and count diligently..but when i was upset several weeks ago after trying so hard..i got this..you are where you were last time and let’s see if we can maintain that place..what a relief because i was surely at wits end and feeling awful because i was having so much trouble with something that used to seem easier

    Posted by marylittle |
  15. What is this the Twilight Zone!? I cannot believe anyone would make such an absurd suggestion about raising A1c. Unless of course it’s been started by big Pharma who profit by the usage of useless drugs.

    Posted by camille LoParrino |
  16. A wonderful article. I have had diabetes for over 16 years and have found that keeping my A1C in a moderate range is not difficult. My husband on the other hand had a terrible time until he decided he was taking too much insulin and not really feeling that good. We have a great doctor that will spend time talking to his patients and trying to help them understand that the control and management is a constant thing and really the patients responsibility. My husband changed his eating habits and his insulin use has dropped from 60units twice a day to 15 - 20 units twice a day. And he lost more than 20 pounds and feels much better.

    Posted by Dawn O |
  17. Very good article. I have had diabetes type 2 for nearly 30 years and it has been under control for many year now. My latest A1C was 6.6. I exercise with moderation and I watch my food intake without going to extremes. The doctor told me to keep doing what I am doing. Personally I wouldn’t like to have a higher AIC.

    Posted by Sara VDW |
  18. I was curious when I read ‘raise’ the hba1c. I have type 2, was diagnosed in april 1990. I for all you do to keep us all informed. I work very hard to keep my reading under 7. usually it is between 6.5 and 7. my doctor is very pleased with the way I take care of my diabetes. as long as she is happy, then I am more than happy, too. but I am thankful for the information I receive from your publications. thank you ever so much for all the updated information you make available to us. I am also grateful that you ask for our comments… it helps to know we are listened to. keep up the good work!!!!

    Posted by p j greten |
  19. This I think makes more sense.. I recall a few years ago they had clinical tests shooting for a reading of 6.0 Unfortunately this clinical group died at such an accelerated rate that they stopped the clinical test. They never did seem to find out why!. I don’t actually want to become a doctors experiment…and I do not appreciate being “tweaked”

    Posted by Harold Tu |
  20. Great article. Having had diabetes for 48 years I have seen many many changes. Best thing for me is the pump. It still requires many blood sugar readings daily. The government never understands the needs to keep our health in check as well as the insurance company’s. Doctors who try, and there are many of them, to work with and keep patients educated help us continue on the right path. Thank you for researching this article and sharing.

    Posted by Robin J |
  21. I am 64 and type 1. My doctor told me to raise my A1c. It was 5.6. It is now up to 5.9. She wants it above 6. After I loosened my control, my toes started to tingle and go numb. I plan to tighten up again. They are my toes, not hers. I have an occasional severe low,(in the 40’s) but have never lost consciousness or had to go to the hospital. I try to be very careful with carbs and insulin and probably only have a reading below 60 half a dozen times a year.

    Posted by Becky |
  22. Right on. We r indiviuals, don’t just lay the template on us & say “there u go”. I have had diabetes 4 20 yrs & kept my A1C below 7.0
    until recently. I am 84 & as I have gotten
    older it had risen so Doc prescribed Janovia. However, I have read it is a very dangerous
    drug, have cut the prescribed amt in half &
    I will see what happens. Based on
    prior experence with the medical profession
    I know that it is up 2 each of us 2 obtain as
    much info as we can & reach our OWN
    conclusions. Thanks 4 the input.

    Posted by Plain old Bob |
  23. I`m 84 years old, been a diabetic type 2 for 46 years. My doctor is happy with 7.5 A1C. I`m on metformin. At about 112 I start having symptoms of hypoglycemia. This has been the rule for many years.
    I eat right and exercise daily and have normal BP

    Posted by Catherine Van Eck |
  24. “RAISE” your A1C level?????? Don’t you mean
    lower it? That’s what I have always been taught
    as a diabetic - - one needs to keep it LOW…

    I hope you can explain this contradiction….RDE

    Posted by Robert Eldred |
  25. I’ve been a person with type one diabetes for over 50 years now. My most recent A-1 C was 7.0. I now understand why my endocrinologist was not duly concerned about the increases I have had over this year, from 6.3, 6.7 to its current reading. I do feel great, have almost no neuropathy and no retinopathy, hopefully resulting from exercising regularly, a low carb diet which includes lots of healthy vegetables and fruit, and considerable Bg monitoring . My main objective now is to minimize lows - and getting my Bg back to around 6.5 at the same time. I agree that each individual must gather info from reliable sources and experience
    Thank you for publishing this article. Diabetes care is relentless for the patient !!

    Posted by Rhea Feldman |
  26. Yes, very interesting article. I am 65, is that “older?” LOL Type 2. Had gastric bypass and lost over 100 lbs, so far. Although I have not reached my target goal yet, but I have got my A1C down to 5.2. I find that amazing. I don’t take any meds for diabetes, just diet and exercise. But I do have to be careful to watch for lows. If I am not religious about eating correctly, I will get a low episode. I think it’s great to not have a “one fits all” A1C. Each of our bodies are different and they handle things differently. I’m glad it will eventually become a number to fit the individual. I was happy to read this article. Good job!

    Posted by Juanita |
  27. I have been T1 for 14 yrs and my A1c’s are always below 7, usually around 5.8. I can say that when at 7 or above, I do not feel as well as I do at my current A1c levels. Having said that an A1c in the 7 range may be fine for someone else. I agree it’s not a one number fits all disease. Like mentioned, the A1c is an average and in that average there could be drastic blood sugar swings, so if you are able to prevent the swings with an A1c of 7 then that will probably work better than sugar yoyo’s at 6. It is upsetting that some dr’s think it is a “one way is for all” disease when clealy time and time again it proves otherwise. Not every diabetes patient is the same. It’s my belief that testing your sugar often whether your T1 or T2 is a must with this disease and more dr’s need to realize this.. and noncomplient patients too. It’s also my belief that there are PCP’s that take on treating people with diabetes when they really sould refer them to an endocrinologist or specialist. I also agree about the test strip statement. When walmart/relion charges $9 for 50 and others are double/tripple that cost there’s definitely something wrong.

    Posted by Traicy |
  28. This suggested raising of the A1C level is idiotic. This is in tune with the scholars that want to lower the passing grade in academics to a lowere level so all students can graduate. This is another example of the USA constantly lowereing our standards instead of raising them to compete with other countries.

    Raising the A1C level should not be taken seriously. Remember that not all medical professionals got an “A” in medical school or their field of study. Maybe we should alter the scales on what is considered overweight, obese, etc.

    We seem to seek out the easy way of addressing the treatment of a serious disease because the alternative requires effort.

    Posted by Mr. Gregg |
  29. I’ve been diabetic for 3 years and I’ve never heard the term “hypos.”What does that mean?

    Posted by Janet Roberts |
  30. I suspect that ‘Redneck Angel’ gets his health care through VA. I’m a female vet–a former Army Nurse. Before I was on insulin, I was allowed enough strips to test 2Xweek. Now that I’m on insulin, they allow 2Xday. I personally think this is substandard care. What do you think, David?

    Posted by Butterfly13 |
  31. The point about not just the A1C but how you get there was a good one. I’m 52 and an endurance athlete. Sometimes before a marathon I’ll let my BG run about 180 and drop my basal rate so I don’t go low in the race. Sometimes I’ll just pull back on my basal rate early and let it climb up (less carbs that way). Years ago, when discussing BGs with my then-endocrinologist, she insisted on increasing my insulin prior to races! Hello?! I switched to an endo who was an endurance runner and he helped me manage deliberately raising my BG before endurance events in a productive way, while I managed my diet to avoid carbs except before and immediately after long endurance events. Is my A1C perfect? No. But what’s better, a perfect A1C or the benefits of vigorous exercise plus a DECENT A1C (mine is around 6)?

    Posted by Don M |

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Blood Glucose Monitoring
Potential A1C Test Alternative; Glucose Meter Recall (01/21/14)
Why Do Test Strips Cost So Much? (Part 2) (09/25/13)
Why Do Test Strips Cost So Much? (09/24/13)

 

 

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