glucosemonitors.net Open in urlscan Pro
50.28.1.120  Public Scan

Form analysis
1 forms found in the DOM

GET https://glucosemonitors.net/

<form role="search" method="get" action="https://glucosemonitors.net/" class="wp-block-search__button-outside wp-block-search__text-button wp-block-search"><label for="wp-block-search__input-1" class="wp-block-search__label">Search</label>
  <div class="wp-block-search__inside-wrapper "><input type="search" id="wp-block-search__input-1" class="wp-block-search__input" name="s" value="" placeholder="" required=""><button type="submit"
      class="wp-block-search__button wp-element-button">Search</button></div>
</form>

Text Content

Skip to content

Menu


HomeDiabetesCan Your A1c Be Too Low?


CAN YOUR A1C BE TOO LOW?

July 25, 2022

Medically reviewed by Dr. Mike Natter.

Almost everyone who lives with diabetes is already familiar with the A1C test.
Your A1C is an estimate of your average blood sugar levels over the previous
several months; many people with diabetes are originally diagnosed with the
results of an A1C test. It is still the most important benchmark for glucose
management success, and is the primary way that your medical team will evaluate
the success of your treatment.

The American Diabetes Association categorizes blood sugars by A1C like so:

  Normal – below 5.6 percent
  Prediabetes – 5.7 to 6.4 percent
  Diabetes – 6.5 percent or above

For the most part, everyone in the diabetes world agrees that a lower A1C is
better than a higher one. Higher A1C’s are correlated with a quicker onset and
increased severity of complications, and it is well-known that lowering A1C
correlates with decreased risks. But is there such a thing as too low?

This article is written for primarily people with diabetes, of any type, that
use insulin or sulfonylureas, which are insulin mimetics. Both drugs can cause
hypoglycemia. Readers that do not use either drug are at a significantly lower
risk of hypoglycemia – much of the following discussion will not apply.

The Official Recommendations

The ADA begins with a blanket recommendation for all adults with diabetes: aim
for an A1C level of <7.0%.

This goal, however, may be adjusted based on several other factors. Making this
adjustment can be more art than science, and is something best decided with the
help of your primary care doctor or endocrinologist. There is no official
guidance on precisely how to weigh additional considerations, but the following
image from the ADA gives an idea of how these different factors can influence
glycemic targets:

Source: ADA, Standards of Care 2021

The phrase “more stringent” here refers to a more rigid or demanding glucose
control strategy, generally characterized by aggressive use of insulin and other
glucose-lowering medications in order to keep a patient’s blood sugar closer to
the non-diabetic range. By contrast, a “less stringent” approach means a less
intensive glucose control strategy, which necessarily entails higher blood
sugars.

In advising a certain A1C target, your doctor will attempt to balance your risk
of hypoglycemia against your risk of hyperglycemia, among other factors.

Younger patients with fewer health issues are probably better equipped to set a
lower A1C target and choose a more stringent regimen. They also may have a
better reason to do so: they know that they have decades of life with diabetes
in front of them, an awfully long time to develop complications. 

Older patients, or those that already have more serious health issues, may be
advised to target less stringent glucose control. Elderly patients, for example,
may be less capable of perceiving the symptoms of hypoglycemia. This severe and
immediate danger of low blood sugars may outweigh the long-term danger
associated with chronic hyperglycemia. And, sad as it is to say, older patients
may have less reason to worry about some of the slow-developing complications of
diabetes, because they may not live long enough to suffer from them.

There may be other special factors at play, too. For example, women who are
pregnant or planning to become pregnant are advised to attempt much tighter
blood glucose control, because we know that tighter A1C goals are correlated
with fewer fetal complications.

The Argument for a 6% A1C

It’s fair to say that most doctors will be pleased to see any of their
(non-pregnant) patients with diabetes achieve an A1C at or just below 7.0
percent. Doing so without an unusual amount of glycemic variability (extreme
blood sugar highs and lows) confers significant reductions in the risk of
diabetic complications. Only a minority of patients with diabetes reach that
benchmark, typically after considerable effort.

But a smaller minority of people with diabetes reason that an A1C just below 7.0
percent is just not good enough. They believe that further decreasing their A1C
level, down towards the non-diabetic range, will provide the most protection
against diabetes-related complications, or perhaps even prevent them completely.

The science mostly backs this theory up. The ADA confirms that “further lowering
of A1C from 7% to 6% is associated with further reduction in the risk of
microvascular complications,” although it cautions that there are some
diminishing returns: “the absolute risk reductions become much smaller.” 

If you can achieve a 6% A1C without an undue risk of hypoglycemia, that appears
to be best for your health, especially if you have a longer life expectancy.

As there are numerous health advantages to maintaining “normal” blood glucose
levels, it seems like keeping blood glucose in the normal range as much as
possible is a reasonable goal, if it can safely be achieved.

And how about an even lower A1C? Many healthy adults without diabetes have A1C’s
around 5.0%, sometimes even lower. Is that a reasonable target for a patient
with diabetes? Is it safe?

Strict Glucose Control and The Danger of Hypoglycemia

Many doctors and diabetes experts assume that a very low A1C is dangerous
because it necessarily involves an elevated risk of hypoglycemia. It makes
sense: why wouldn’t targeting lower blood sugar increase the likelihood of very
low blood sugar?

Much evidence has been found to support this contention, including what may be
the most famous and important type 1 diabetes trial ever conducted. The Diabetes
Control and Complications Trial (DCCT) was the experiment that definitively
linked chronic high blood sugar with the accelerated development of diabetic
complications; it solidified the recommendation that people with type 1 diabetes
ought to employ “intensive” insulin management to promote long-term health.

But the DCCT also showed that intensive management entailed “a threefold
increased risk of hypoglycemia.” And we’re not talking about minor low blood
sugar events that the patients easily treated themselves with a little candy or
juice. This was “severe hypoglycemia,” defined as hypos that require the
assistance of others, including those that end in seizure, coma, and emergency
medical treatment. Nevertheless, the experts concluded that the downside of
increased risk of hypoglycemia was far outweighed by the long-term health gains
associated with intensive management.

Even so, the fear that more aggressive insulin management might result in even
more severe hypoglycemic events has helped inspire diabetes authorities to
recommend glycemic control in that 6.5-7.0 percent A1C range as a sort of happy
medium.

Strict Glucose Control Without Enhanced Hypoglycemia Risks?

A growing chorus of voices in the diabetes community – both doctors and patients
alike – believes that it is possible to achieve a much lower and even normal
A1C, and to do it without meaningfully increasing the risk of severe
hypoglycemia.

In 2018, a team of researchers and low-carbohydrate advocates took a close look
at one such group, members the Facebook group TypeOneGrit. Members of
TypeOneGrit are dedicated to the treatment strategies of Dr. Richard Bernstein,
an influential diabetes doctor that advises a very-low carbohydrate diet as the
lynchpin of a complex treatment strategy.

The findings were published in the medical journal Pediatrics. Group members
that participated in the study had an average A1C of 5.67 percent, almost
exactly at the threshold of pre-diabetes, and far better than any glycemic
target ever recommended by diabetes authorities. The ADA’s most recent official
guidance on glycemic targets do not address lower A1C goals for patients with
type 1.

But was it safe? Critically, patients observed in the study also reported “low
rates of hypoglycemia and other adverse events,” suggesting that their extremely
stringent approach did not increase the danger of overtreatment with insulin.
The article called the results “without precedent,” a sentiment that was echoed
in major media coverage. But this was merely a small observational study – not a
rigorous double-blinded and randomized trial – and authors also caution that the
“generalizability of the findings is unknown.” 

The Importance of Glucose Variability

A1C is only one part of the blood glucose picture. Another important element is
glucose variability – how wildly your blood sugar swings up and down. A patient
with a low variability will only experience mild blood sugar swings, while one
with a high variability will experience much greater swings both above and below
their ideal range. Generally speaking, the less glycemic variability, the
better.

Patients with very low glucose variability have an enhanced ability to stay
steady at a lower blood glucose level – say, 80-100 mg/dL – without risking
severe hypoglycemia. For a patient with high glucose variability, the same blood
sugar level could get dangerous very quickly. 

Glucose variability is best measured with a continuous glucose monitor. One way
to ensure that a lower A1C was not achieved with severe hypo risk is to review
your blood sugar readings with your healthcare professional. With CGM data (or
very fastidious use of a blood sugar meter), it should be plain to see how often
any patient experiences dangerous hypos. 

The smartphone apps for the Dexcom and Freestyle Libre systems track glucose
variability with statistics such as “standard of deviation” and “coefficient of
variation.” You can find more detailed commentary on these numbers in this
article from our friends at DiaTribe.

How does one lower their glycemic variability? The folks examined in the
Pediatrics article described above were committed to a very-low-carbohydrate
diet, which both reduces postprandial glucose spikes and also allows patients to
use less mealtime insulin, lowering the risk of postprandial glucose lows. Dr.
Bernstein has influentialy described this as “the law of small numbers.” Several
past and present members of the Diabetes Daily staff have followed the same
philosophy with success, as have many of our readers. But the evidence in favor
of this approach remains mostly anecdotal.

The Bottom Line

You should set your own A1C goal in partnership with a healthcare professional.
There are many individual factors that your doctor will take into consideration,
including your age, your health, and your risk of severe hypoglycemia.

Blood glucose levels at or approaching the “normal” range (defined as an A1C
below 5.6 percent), although not commonly recommended by diabetes authorities,
are associated with a lower risk of long-term complications. For some patients,
it may be reasonable to employ stringent glycemic control in the hopes of
bringing blood glucose levels down towards the normal range.

However, attempted stringent control can also bring an enhanced risk of
hypoglycemia, especially with management strategies that do not sufficiently
reduce glycemic variability. Patients should proceed very carefully, and with
full cooperation of their medical team before initiating any changes to their
diabetes regimen.




RELATED POSTS

DIABETES AND FOOT HEALTH

ELI LILLY SLASHES INSULIN PRICES, CAPPING COST AT $35 FOR MANY DIABETES PATIENTS

SUGAR SUBSTITUTE ERYTHRITOL MAY INCREASE RISK FOR BLOOD CLOTTING AND STROKE

ABOUT THE AUTHOR

ADMIN



Search
Search


RECENT POSTS

 * Desperate for Ozempic and Mounjaro, Some People Are Turning to DIY Versions
 * Pioglitazone Is the Forgotten Diabetes Drug
 * Brenzavvy, an SGLT-2 Inhibitor for Type 2 Diabetes, Now Available for Less
   Than $50 Month
 * Dexcom Will Release a CGM Just for Type 2 Diabetes
 * 5 High-Protein and Flavorful Shrimp Recipes


© 2023 Glucose Monitor | WordPress Theme by Superb WordPress Themes
Back to Top ↑
Generated by Feedzy