What is a normal A1C level for diabetics. How often should you get an A1C test. What factors influence your A1C target range. How can you interpret your A1C results. Why is managing your A1C important for diabetes control.

What Is an A1C Test and Why Is It Important?

The A1C test, also known as the hemoglobin A1C, HbA1C, or glycohemoglobin test, is a crucial blood test for diagnosing and managing diabetes. It measures your average blood glucose levels over the past 2 to 3 months, providing a comprehensive picture of your diabetes management.

This test is important because:

• It helps diagnose diabetes and prediabetes
• It indicates how well your diabetes treatment plan is working
• It can predict your risk of diabetes-related complications

Unlike daily blood glucose monitoring, which gives you a snapshot of your current levels, the A1C test offers a broader view of your blood sugar control over time. This makes it an invaluable tool for both patients and healthcare providers in managing diabetes effectively.

Understanding A1C Percentages and Their Meaning

A1C results are reported as percentages, reflecting the amount of glycated hemoglobin in your blood. Here’s what different A1C percentages typically indicate:

• Below 5.7%: Normal (non-diabetic) range
• 5.7% to 6.4%: Prediabetes range
• 6.5% or higher: Diabetes range

For people with diagnosed diabetes, an A1C target of 7% or less is often recommended. However, your individual target may vary based on factors such as age, overall health, and risk of hypoglycemia.

How does A1C relate to average blood glucose levels?

Your A1C percentage can be converted to an estimated average glucose (eAG) level. For instance:

• A1C of 6% ≈ eAG of 126 mg/dL
• A1C of 7% ≈ eAG of 154 mg/dL
• A1C of 8% ≈ eAG of 183 mg/dL

Understanding this relationship can help you better interpret your A1C results in the context of your daily blood glucose readings.

Frequency of A1C Testing: How Often Should You Get Checked?

The frequency of A1C testing depends on various factors, including your diabetes type, current blood sugar control, and treatment plan. Generally:

• People with prediabetes: Once a year
• Type 2 diabetes with good control: Twice a year
• Type 1 diabetes: Three to four times a year
• Type 2 diabetes using insulin or with difficulty achieving target range: Four times a year

Your healthcare provider may recommend more frequent testing if you’ve recently changed your diabetes management plan or started a new medication. Regular A1C testing allows for timely adjustments to your treatment strategy, ensuring optimal diabetes control.

Factors Influencing Your A1C Target Range

While a general A1C target of 7% or less is common for many people with diabetes, your individual target may differ based on several factors:

1. Age: Older adults may have slightly higher targets to reduce the risk of hypoglycemia
2. Duration of diabetes: Longer duration may influence target levels
3. Presence of other health conditions: Cardiovascular disease or other complications may affect targets
4. Risk of severe hypoglycemia: Higher targets may be set if you’re prone to dangerous low blood sugar episodes
5. Life expectancy: Targets may be adjusted based on overall health and life expectancy
6. Individual preferences and goals: Your personal health objectives play a role in setting targets

It’s crucial to work closely with your healthcare team to determine the most appropriate A1C target for your specific situation. This personalized approach ensures that your diabetes management plan aligns with your overall health needs and lifestyle.

Interpreting Your A1C Results: What Do They Mean for Your Health?

Understanding your A1C results is key to managing your diabetes effectively. Here’s how to interpret different A1C levels:

• Below 5.7%: Normal range, low risk of diabetes
• 5.7% to 6.4%: Prediabetes range, increased risk of developing type 2 diabetes
• 6.5% or higher: Diabetes range, requiring diagnosis confirmation and treatment
• 7% or below: Often the target for people with diagnosed diabetes
• Above 8%: May indicate the need for changes in your diabetes management plan

Remember, these ranges are general guidelines. Your healthcare provider will interpret your results in the context of your overall health, diabetes history, and individual circumstances.

What does a rising A1C level indicate?

An increasing A1C level suggests that your blood glucose control is worsening over time. This could be due to various factors, such as:

• Changes in diet or physical activity
• Stress or illness
• Medication effectiveness decreasing
• Natural progression of diabetes

If you notice a consistent upward trend in your A1C results, it’s important to discuss this with your healthcare provider. They may recommend adjustments to your diabetes management plan to help bring your levels back into target range.

The Impact of A1C Levels on Diabetes-Related Complications

Maintaining A1C levels within your target range is crucial for reducing the risk of diabetes-related complications. Higher A1C levels over time are associated with an increased risk of:

• Cardiovascular disease
• Kidney disease (nephropathy)
• Eye problems (retinopathy)
• Nerve damage (neuropathy)
• Foot problems and amputations

Research has shown that even small improvements in A1C can significantly reduce the risk of these complications. For example, a 1% reduction in A1C (e.g., from 8% to 7%) can lead to a 40% decrease in the risk of eye, kidney, and nerve diseases.

How quickly can A1C levels change?

A1C levels reflect your average blood glucose over the past 2-3 months, with more recent weeks having a greater impact. Significant changes in your diabetes management can start to affect your A1C within 3-4 weeks, but it typically takes 2-3 months to see the full effect of these changes reflected in your A1C result.

Strategies for Improving Your A1C Levels

If your A1C is above your target range, there are several strategies you can employ to bring it down:

1. Medication adherence: Take your diabetes medications as prescribed
2. Blood glucose monitoring: Regular checks help you make informed decisions about food, activity, and medication
3. Balanced diet: Focus on whole foods, controlled portions, and consistent carbohydrate intake
4. Regular physical activity: Aim for at least 150 minutes of moderate-intensity exercise per week
5. Stress management: Practice relaxation techniques to reduce stress-induced blood sugar spikes
6. Adequate sleep: Aim for 7-9 hours of quality sleep per night
7. Regular check-ups: Stay in close contact with your healthcare team for ongoing support and adjustments

Remember, small, consistent changes can lead to significant improvements in your A1C over time. It’s important to work closely with your healthcare provider to develop a personalized plan for achieving and maintaining your A1C target.

Can lifestyle changes alone lower A1C levels?

Yes, in many cases, especially for those with prediabetes or early-stage type 2 diabetes, lifestyle changes can significantly lower A1C levels. Studies have shown that a combination of dietary changes, increased physical activity, and weight loss (if needed) can reduce A1C by 0.5% to 1% or more. However, for some individuals, especially those with longer-standing diabetes, a combination of lifestyle changes and medication may be necessary to achieve target A1C levels.

The Role of Continuous Glucose Monitoring in A1C Management

Continuous Glucose Monitoring (CGM) systems have revolutionized diabetes management, providing real-time glucose data throughout the day and night. While A1C remains a crucial metric, CGM offers several advantages that complement A1C testing:

• Immediate feedback on glucose trends
• Insight into glucose variability
• Alerts for high and low glucose levels
• Data on the impact of food, activity, and medication on glucose levels

CGM can help you make more informed decisions about your diabetes management on a day-to-day basis, potentially leading to improved A1C levels over time. Many CGM systems also provide an estimated A1C based on your average glucose levels, giving you a preview of what to expect at your next A1C test.

How does CGM data compare to A1C results?

While CGM provides valuable real-time data, it’s important to note that CGM-derived glucose metrics and A1C results may not always align perfectly. Factors such as red blood cell lifespan, certain medical conditions, and variations in glucose variability can cause discrepancies between CGM-estimated A1C and laboratory A1C results. Therefore, both CGM data and regular A1C testing remain important tools in comprehensive diabetes management.

Beyond A1C: Other Important Metrics in Diabetes Management

While A1C is a crucial measure in diabetes management, it’s not the only metric to consider. Other important factors include:

1. Time in Range (TIR): The percentage of time your blood glucose levels are within target range
2. Glycemic variability: The extent to which your blood glucose levels fluctuate throughout the day
3. Fasting blood glucose: Your blood sugar levels after an overnight fast
4. Postprandial glucose: Your blood sugar levels 1-2 hours after meals
5. Blood pressure and cholesterol levels: Important for overall cardiovascular health

These metrics, along with A1C, provide a more comprehensive picture of your diabetes management and overall health. Your healthcare provider will consider all these factors when assessing your diabetes control and making treatment recommendations.

How does Time in Range complement A1C measurements?

Time in Range (TIR) offers insights that A1C alone cannot provide. While A1C gives an average of your blood glucose levels, TIR shows the percentage of time your glucose levels are within a target range (typically 70-180 mg/dL for most people with diabetes). A higher TIR generally correlates with better overall glucose control and can predict improvements in A1C. However, two people with the same A1C might have very different TIR percentages, highlighting the importance of considering multiple metrics in diabetes management.

Do You Know Your Target?

An A1c test is key if you have diabetes or if your doctor thinks you might have a chance of getting it. It’s a common blood test that gives information about your blood sugar.

What Is an A1c Test?

It’s the main way to find out if someone has diabetes and how they’re managing it. You might hear it called the hemoglobin A1c, HbA1c, or glycohemoglobin test.

The A1c measures your average blood sugar — your doctor may call it blood glucose — over the past 2 to 3 months. The results tell you how well your diabetes treatment plan is working or if you have diabetes.

It’s a lot like a baseball player’s season batting average. A single game doesn’t tell you how a player is performing in their career. One day’s test results don’t give you the complete picture of how your treatment is working.

You should have an A1c test at least two times each year if you have diabetes. It’s not a fasting test. You can take it any time of day, before or after eating.

Why Is It Important?

Your red blood cells have something called hemoglobin that carries oxygen from your lungs to cells all over your body. Glucose goes into your red blood cells and coats molecules of hemoglobin. The more glucose you have in your blood, the more coated hemoglobin molecules you have.

The A1c measures how much of your hemoglobin is coated with sugar. The higher your level, the greater your chance for problems down the road. That means your blood sugar control plan isn’t working at its best.

How Often Do You Need the Test?

Your doctor probably will have you take the A1c test as soon as you’re diagnosed with diabetes. You’ll also have the test if your doctor thinks you may get diabetes. The test will set a baseline level so you can see how well you’re controlling your blood sugar.

How often you’ll need the test after that depends on several things, like:

• The type of diabetes you have
• Your blood sugar control
• Your treatment plan

You’ll probably get tested once a year if you have prediabetes, which means you have a strong chance of developing diabetes.

You may get tested twice each year if you have type 2 diabetes, don’t use insulin, and your blood sugar level is usually in your target range.

You could get it three or four times each year if you have type 1 diabetes.

You’ll likely get four tests per year if you have type 2 diabetes and use insulin, or have trouble keeping your blood sugar level in your target range.

You may also need the test more often if your diabetes plan changes or you start a new medicine.

What Does Your A1c Number Mean?

You will get your results back as a percentage. People without diabetes should be below 5.7%

A result between 5.7% and 6.4% signals prediabetes.

For people with diabetes, an A1c of 7% or less is a common treatment target. Someone who has had untreated diabetes for a long time might have a level above 8%.

If you have diabetes and your level is above your target, your doctor may change your treatment plan to get your level down.

9 Signs Your Blood Sugar Is Out of Control

Blood sugar (glucose) control is crucial when you’re living with type 2 diabetes. Dips and spikes can not only make you feel cranky and sluggish, but they can also wreak havoc on your personal health. (No wonder your primary care doctor was on you about your last A1C checkup.)

The most serious effects of blood sugar swings are a higher risk for diabetes-related health complications such as stroke, heart disease, and nerve damage (neuropathy).

For the record, the American Diabetes Association (ADA) notes that you have diabetes if one of the following applies to you:

• Your blood glucose after fasting (and before a meal) is 126 milligrams per deciliter (mg/dl) or higher.
• Your blood glucose two hours after eating a meal is 200 mg/dl or higher.
• Your hemoglobin A1C (a two- to three-month average measure of how much glucose attaches to the hemoglobin in your red blood cells) is 6.5 or higher.

The tricky part is that with type 2 diabetes you may not feel it when blood sugar levels are too high, according to the ADA. It feels different for everyone. “Not everyone will have the same symptoms, and some individuals will have no symptoms at all,” says Lori Zanini, RD, CDE, a Los Angeles–based former spokesperson for the Academy of Nutrition and Dietetics.

RELATED: The Best and Worst Foods to Eat in a Type 2 Diabetes Diet

Because blood sugar management is so important to your overall health with type 2 diabetes, you need to take action if you think your levels may be out of control, even if you’re feeling totally fine.

“Symptoms of uncontrolled diabetes may not appear until prolonged hyperglycemia (high blood sugar) has been present,” says Mary Ann Emanuele, MD, an endocrinologist, professor, and medical director of inpatient diabetes at Loyola University Medical Center in Maywood, Illinois. She adds that if your healthcare team determines your glucose isn’t well controlled, adjusting your medication with their help can make a difference.

RELATED: 9 Reasons You May Need to Change Your Type 2 Diabetes Treatment

‘Controlled’ Means Different Things to Different People

There’s no one-size-fits-all recommendation for blood sugar control.

The ADA says that a “reasonable” goal for many nonpregnant adults is to aim for an A1C level of less than 7. Yet some patients may be given a more stringent goal by their healthcare providers, such as 6.5, if that’s reachable without harmful side effects, including hypoglycemia.

On the other hand, if you are elderly, managing other health complications, or reliant on insulin, you may be given less stringent goals. “It really becomes more important to just keep [levels] in the same place,” says Rahil Bandukwala, DO, an endocrinologist at MemorialCare Saddleback Medical Center in Laguna Hills, California. “Keeping A1C between 7.5 and 8.5 may be very reasonable for such a patient,” Dr. Bandukwala adds, echoing the ADA’s recommendations.

Because elderly people are more likely to have blood sugar that swings too far downward, with fewer warning signs, managing their glucose too tightly can put them at greater risk for hypoglycemia, says Bandukwala. When you have low blood sugar, you’re at a higher risk for becoming dizzy and falling or passing out, notes the ADA.

RELATED: 10 Warning Signs of Low Blood Sugar

How (and When) to Check Your Blood Sugar Levels

As Dr. Emanuele says, glucose monitoring can be an important tool to help you get your blood sugar under control. Typically, you would do it yourself using a glucose meter or glucometer, which analyzes a drop of blood that you draw by sticking your finger with a lancet and placing the blood on a disposable test strip that you insert into the meter. Your blood sugar goals are set by you and your doctor, but blood glucose for an adult without diabetes is below 100 mg/dl before meals and at fasting; and less than 140 mg/dl two hours after a meal, notes the ADA.

Some people will check their blood sugar daily or multiple times a day, sometimes using a continuous monitor that is worn on the body — particularly those who have type 1 diabetes or who have type 2 but take insulin. Yet how frequently a person should monitor their blood sugar is based on a number of factors, including but not limited to whether they’re on insulin, whether they’re taking oral medication, and how well their blood sugar is controlled and how old they are.

“It’s an individual discussion with each patient, but in general I tell my patients with type 2 diabetes whose blood sugar is controlled that they don’t need to check it every day,” says Bandukwala. “If they have a glucometer and they want to check it then I will tell them they can do a paired reading once a week, which means a fasting (before eating) reading and then another reading one to two hours after a meal (postprandial).” Checking too often can lead to unwarranted panic over daily fluctuations, as well as unnecessary pain from too-frequent lancet pricks, he adds. The American Academy of Family Physicians is among the organizations advising that daily glucose self-testing has no benefit in patients with type 2 diabetes who are not on insulin or medications associated with hypoglycemia.

RELATED: 10 Ways to Better Control Blood Sugar After Eating

Meanwhile, keep an eye out for these nine key warning signs and symptoms that blood sugar is too high — and talk to your doctor about whether you need to adjust your management plan.

Rethinking A1c goals for type 2 diabetes

“Treat the patient, not the number.” This is a very old and sound medical school teaching. However, when it comes to blood sugar control in diabetes, we have tended to treat the number, thinking that a lower number would equal better health.

Uncontrolled type 2 diabetes (also known as adult-onset diabetes) is associated with all sorts of very bad things: infections, angry nerve endings causing chronic pain, damaged kidneys, vision loss and blindness, blocked arteries causing heart attacks, strokes, and amputations… So of course, it made good sense that the lower the blood sugar, the lower the chances of bad things happening to our patients.

Tracking blood sugar control over time

One easy, accurate way for us to measure a person’s blood sugar over time is the hemoglobin A1c (HbA1c) level, which is basically the amount of sugar stuck to the hemoglobin molecules inside of our blood cells. These cells last for about three months, so, the A1c is thought of as a measure of blood sugars over the prior three months.

Generally, clinical guidelines have recommended an A1c goal of less than 7% for most people (not necessarily including the elderly or very ill), with a lower goal — closer to normal, or under 6.5% — for younger people.

We as doctors were supposed to first encourage diet and exercise, all that good lifestyle change stuff, which is very well studied and shown to decrease blood sugars significantly. But if patients didn’t meet those target A1c levels with diet and exercise alone, then per standard guidelines, the next step was to add medications, starting with pills. If the levels still weren’t at goal, then it was time to start insulin injections.

While all this sounds very orderly and clinically rational, in practice it hasn’t worked very well. I have seen firsthand how enthusiastic attention to the A1c can be helpful as well as harmful for patients.

And so have experts from the Clinical Guidelines Committee of the American College of Physicians, a well-established academic medical organization. They examined findings from four large diabetes studies that included almost 30,000 people, and made four very important (and welcome!) new guidelines around blood sugar control. Here’s the big picture.

Doctors and patients should discuss goals of treatment together and come up with an individual plan

Blood sugar goals should take into account a patient’s life expectancy and general health, as well as personal preferences, and include a frank discussion of the risks, benefits, and costs of medications. This is a big deal because it reflects a change in how we think about blood sugar control. It’s not a simply number to aim for; it’s a discussion. Diabetes medications have many potential side effects, including dangerously low blood sugar (hypoglycemia) and weight gain (insulin can cause substantial weight gain). Yes, uncontrolled blood sugars can lead to very bad things, but patients should get all the information they need to balance the risks and benefits of any blood sugar control plan.

An A1c goal of between 7% and 8% is reasonable and beneficial for most patients with type 2 diabetes…

…though if lifestyle changes can get that number lower, then go for it. For patients who want to live a long and healthy life and try to avoid the complications of diabetes, they will need to keep their blood sugars as normal as possible — that means an A1c under 6.5%. However, studies show that using medications to achieve that goal significantly increases the risk of harmful side effects like hypoglycemia and weight gain. To live longer and healthier and avoid both the complications of diabetes as well as the risks of medications, there’s this amazing thing called lifestyle change. This involves exercise, healthy diet, weight loss, and not smoking. It is very effective. Lifestyle change also can help achieve healthy blood pressure and cholesterol levels, which in turn reduce the risk for heart disease. And heart disease is a serious and common complication of diabetes.

Lifestyle change should be the cornerstone of treatment for type 2 diabetes. The recommendations go on to say that for patients who achieve an A1c below 6.5% with medications, we should decrease or even discontinue those drugs. Doing so requires careful monitoring to ensure that the person stays at the goal set with his or her doctor, which should be no lower than 7%, for the reasons stated above.

We don’t even need to follow the A1c for some patients

Elderly patients, and those with serious medical conditions, will benefit from simply controlling the symptoms they have from high blood sugars, like frequent urination and incontinence, rather than aiming for any particular A1c level. Who would be included in this group? People with a life expectancy of less than 10 years, or those who have advanced forms of dementia, emphysema, or cancer; or end-stage kidney, liver, or heart failure. There is little to no evidence for any meaningful benefit of intervening to achieve a target A1c in these populations; there is plenty of evidence for harm. In particular, diabetes medications can cause low blood sugars, leading to weakness, dizziness, and falls. There is the added consideration that elderly and sick patients often end up on a long list of medications that can (and do) interact, causing even more side effects.

The bottom line

There is no question that type 2 diabetes needs to be taken seriously and treated. But common sense should rule the day. Lifestyle changes are very effective, and the side effects of eating more healthfully and staying more active are positive ones. Every person with type 2 diabetes is an individual. No single goal is right for everyone, and each patient should have a say in how to manage their blood sugars and manage risk. That means an informed discussion, and thoughtful consideration to the number.

Sources

Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: A guidance statement update from the American College of Physicians. Annals of Internal Medicine, March 2018.

An overview of the management of diabetes in non-pregnant adults. MGH Primary Care Office Insite, updated June 2016.

Management of persistent hyperglycemia in type 2 diabetes mellitus. UpToDate, updated April 2017.

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Understanding Your A1C

The A1C is a blood test that helps determine if your diabetes management plan is working well. (Both Type 1 and Type 2 take this test.) It’s done every 2-3 months to find out what your average blood sugar has been. (You may also hear this test called glycosylated hemoglobin, glycohemoglobin, hemoglobin A1c, and HbA1c.) A1c is the most common name for it though.

How the test works

Essentially, the test can tell how much sugar is in the blood stream by looking for proteins (hemoglobins). When glucose (sugar) enters the blood, it binds to the protein in the red blood cells. This binding creates “glycated hemoglobin”. The more sugar in the blood, the more glycated hemoglobin.

It’s important to test your blood sugar levels (BGLs) throughout the day; however, an A1C test gives you a bigger picture with a long-term average of those blood sugar levels.

What do these numbers mean?

The A1c is an average of what your blood sugar levels have been over the 3-month period. In general, the higher your A1C number, the higher your likelihood of diabetes complications. (You don’t want a high A1C; it means there is too much sugar in your blood and your body isn’t absorbing it. )

A1C number

This target range varies between individuals, some people naturally run a little higher, some lower. It is important to note that especially in children a higher A1C (of 7.5) is recommended. The A1C number will help you and your doctor determine though if your diabetes management plan is working well.

Learn more about children’s A1C target range.

Sometimes the test isn’t accurate, and here’s why:

• If you are bleeding a lot, the protein (hemoglobin) in your red bold cells may be low, so it could say your A1C is lower than it actually is.
• If you’ve just had a blood transfusion or have other forms of hemolytic anemia, your A1C test results may be lower than it actually is.
• If you are low in iron in the blood, your A1C test results may be higher than it actually is.
• If you have a special hemoglobin (variant). Most people have Hemoglobin A. With the variant, you can be falsely high or low. A lab test can be done to see which one you are and special lab tests can then give you an accurate A1C. (Hemoglobin variants are mostly found in black, Mediterranean and Southeast Asian populations.)
• A new lab can give different results as well. Keep this in mind if your results were sent away to a new facility. It could account for minor reading variations.

A1c number = how much sugar in the blood?

	A1C level	Estimated average blood sugar level
	5 percent	5. 4 mmol/L97 mg/dL
	6 percent	7.0 mmol/L126 mg/dL
	7 percent	8.6 mmol/L154 mg/dL
	8 percent	10.2 mmol/L183 mg/dL
	9 percent	11.8 mmol/L212 mg/dL
	10 percent	13.3 mmol/L240 mg/dL
	11 percent	14.9 mmol/L269 mg/dL
	12 percent	16.6 mmol/L298 mg/dL
	13 percent	18.1 mmol/L326 mg/dL
	14 percent	19.7 mmol/L355 mg/dL

What’s a “perfect A1C”?

This is often said when someone with diabetes has met their A1C target range, (which is 5-7). Keep in mind that an A1C test like any other BGL reading is just information to guide you in your diabetes management. Some run higher while others run low – it really depends on the individual. This number can vary wildly too throughout your life. Consult your doctor to find a target A1C range and a diabetes plan that works for you.

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The Pros and Cons of Diagnosing Diabetes With A1C

An International Expert Committee was convened in 2008 by the American Diabetes Association (ADA), the European Association for the Study of Diabetes, and the International Diabetes Federation to consider the means for diagnosing diabetes in nonpregnant individuals, with particular focus on the possibility to indicate A1C as an alternative if not a better tool (1). After reviewing the available literature and a thorough discussion on the advantages and the limits of previous diagnostic strategies (essentially based on fasting glucose assessment) and the considered alternative approach (based on A1C measurement), a consensus was reached that the latter (i.e., A1C) should be included among diagnostic tools for diabetes and, with the exception of a number of clinical conditions, should even be preferred in diabetes diagnosis in nonpregnant adults.

The main conclusion of the International Expert Committee was implemented in the most recent clinical recommendations issued by the ADA. However, in these guidelines, A1C is indicated as a diagnostic tool alternative but not superior to blood glucose, leaving to the health care professional the decision about what test to use in an individual.

The World Health Organization is currently examining the proposal made by the International Expert Committee and is carefully addressing the controversial issues still remaining, most of which have been the subject of letters to the editor and articles recently published in the literature. Nevertheless, the use of A1C for diagnosing diabetes is rapidly becoming a reality in many Western countries.

In the text that follows, one of us (E.B.) will present the main points supporting A1C (pros) and the other (J.T.) will illustrate the main counterpoints challenging A1C (cons) as the primary tool for diabetes diagnosis. The text has been prepared in full coordination and the final conclusions represent the opinion of both authors. Tables 1 and 2 summarize the pros and cons.

PROs

A1C captures chronic hyperglycemia better than two assessments of fasting or 2-h oral glucose tolerance test plasma glucose

Diabetes has been diagnosed for decades with fasting plasma glucose (FPG) assessment or, much less frequently, with an oral glucose tolerance test (OGTT). Hyperglycemia as the biochemical hallmark of diabetes is unquestionable. However, fasting and 2-h OGTT gauge just a moment of a single day. In addition, the two assessments required to confirm diagnosis might be fallacious in describing a chronic and complex clinical condition. In this respect, there is no doubt that a biochemical or clinical parameter describing the extent of a biological phenomenon over a long period provides a more robust indicator of glycemia than a parameter describing it in the short term or in a given moment only. Accordingly, there are some good examples in medicine: urinary albumin excretion rate provides more reliable information on the presence and the degree of microalbuminuria than spot urinary albumin-to-creatinine ratio; serum IGF-I is definitely more efficacious than serum growth hormone when monitoring patients with acromegaly, etc.

Labeling a person with a diagnosis of diabetes has several psychological and legal implications and requires a robust and reliable approach. The measurement of A1C equals the assessment of hundreds (virtually thousands) of fasting glucose levels and also captures postprandial glucose peaks; therefore, it is a more robust and reliable measurement than FPG and/or 2-h OGTT plasma glucose. This is particularly valid when FPG oscillates above and below the cut point of 126 mg/dL or 2-h plasma glucose (PG) oscillates above and below the cut point of 200 mg/dL. Of note, the 2-h PG had poor reproducibility. From a clinical standpoint, having an FPG of 120 or 130 mg/dL or having a 2-h PG of 185 or 215 is virtually the same, but from the patient’s perspective (perception of having a disease, psychological well-being, health insurance, recognition of particular benefits, or imposition of certain limitations, etc.), it makes a substantial difference. Therefore, a diagnostic tool gauging chronic rather than spot hyperglycemia is certainly preferable.

A1C is better associated with chronic complications than FPG

Different from National Diabetes Data Group criteria, which were essentially based on distribution of glucose levels within the general population, the 1997 ADA criteria (and the subsequently recommended World Health Organization criteria) established diabetic glycemic levels by means of their association with retinopathy, the most exclusive and specific diabetes complication. Various observational studies documented that an increased prevalence of nonproliferative diabetic retinopathy can be observed with fasting glucose levels around 7.0 mmol/L (126 mg/dL) and 2-h PG around 11.1 mmol/L (200 mg/dL). Interestingly, the same studies documented that retinopathy increased with A1C levels around 6.5% (2–4). These results were confirmed in a more recent study including almost 30,000 subjects recruited in several countries. Such study clearly showed that prevalent retinopathy started to increase in the A1C category of 6.5–7.0% (5). Therefore, a cut point of A1C for diagnosing diabetes with an approach similar to the one used with FPG and 2-h PG is available (and indeed already was available in older studies).

It is well known that cardiovascular disease (CVD) is the most frequent chronic complication of diabetes, with incidence rates 5- to 10-fold higher than with microvascular disease. For this reason, the association of A1C with CVD can be considered a major issue when discussing the potential use of A1C for diagnosing diabetes. In this regard, it is worth mentioning that, in the general population, FPG is a poor marker of future CVD events, whereas 2-h OGTT and A1C are good predictors (6,7).

Fasting is not needed for A1C assessment and no acute perturbations (e.g., stress, diet, exercise) affect A1C

Plasma glucose levels are not stable but rather vary throughout the day, mainly in postprandial periods. Although it is believed that fasting glucose levels are reproducible across days, a number of acute perturbations of glucose homeostasis have been described. Acute stress can increase endogenous glucose production substantially and impair glucose utilization. People who are worried about blood sampling or experience a stressful situation in the hours preceding blood sampling can have an increase in fasting glucose concentration. On the contrary, exercise can decrease glucose levels, and an evening or early-morning session of physical exercise can affect the level of fasting glycemia. Moreover, most individuals do not pay attention to the request or are not asked to consume a diet with at least 200 g carbohydrate in the days before testing glucose. Some individuals do not abstain from food in the 8 h before testing, thus arriving to the laboratory in the postabsorptive rather than fasting condition. In addition, smoking or taking certain medications can adversely affect fasting glucose. The lack of appropriate preparation for glucose testing makes FPG less reliable for diabetes diagnosis, with results sometimes falsely elevated and sometimes apparently normal. On the contrary, A1C is not influenced by acute perturbations or insufficient fasting. Indeed, A1C can be measured anytime, irrespective of fasting or feeding.

A1C has a greater pre-analytical stability than plasma glucose

Even when preparation to glucose testing is optimal, plasma glucose values may still be misleading because of pre-analytical instability. In fact, tubes for blood collection do not always contain antiglycolytic substances, and even when they do, significant glucose consumption occurs in blood cells in the first 1–2 h after sampling because glycolysis is inhibited in its more distal steps by NaF or other preservatives. As long as the sample is not processed and plasma and blood cells are separated by centrifugation, a significant glucose loss is observed. In this regard, it must be emphasized that, quite often, blood samples reach the laboratory and are processed hours after withdrawal. Consistently, glucose concentration decreases 5–7% (on average ∼0.5 mmol/L) per hour and even more rapidly in cases of high ambient temperature (8,9). In such cases, glucose levels can show results lower than they are and diabetes diagnosis can be missed. It has been estimated that pre-analytical variability of FPG is 5–10%. On the contrary, pre-analytical variability of A1C is negligible. As for analytical variability, it is superimposable for glucose and A1C, being ∼2%.

Standardization of A1C assay is not inferior to standardization of glucose assay

One of the main concerns surrounding A1C and raising perplexities on its use for diabetes diagnosis is the poor standardization of the assay. Quite surprisingly, the same concerns and perplexities do not extend to A1C use for diabetes monitoring despite the understanding that only when A1C is aligned to the Diabetes Control and Complications Trial (DCCT)/UK Prospective Diabetes Study (UKPDS) standard should the recommended target be pursued (in general <7%). A great effort was made in the U.S. and other countries to make reproducible A1C across laboratories with an effective standardization program. Such a program has been recently completed and is being implemented worldwide to provide more reliable information to physicians who monitor diabetic patients (10). The standardization is expected to minimize laboratory biases and is a prerequisite to use A1C not only for monitoring but also for diagnosing diabetes.

Although it is generally believed that glucose assay is highly reproducible across laboratories, this is not true. A recent survey conducted in 6,000 U.S. laboratories clearly documented a significant bias in glucose assessment in as many as 41% of them, yielding a misclassification of glucose tolerance in 12% of subjects (11). Therefore, the argument that A1C cannot be used for diabetes diagnosis because of poor standardization is no longer tenable.

Biological variability of A1C is lower than that for FPG

When the same subjects have two assessments of the available glucose-related parameters, the correlation is stronger among the individual A1C measurements than among the FPG or 2-h PG measurements. The coefficients of variation of A1C, FPG, and 2-h PG are 3.6, 5.7, and 16.6%, respectively (12). This reflects of course both biological and analytical variability. However, although the latter was similar for A1C and FPG (∼2%), biological variability of A1C was severalfold lower than that of FPG (<1 vs. ∼4%) (13). This finding confirms that the two required assessments of FPG to diagnose diabetes can provide quite unreliable information, whereas A1C, especially if measured twice as recommended, provides more robust clinical information.

Individual susceptibility to glycation might be an additional benefit of A1C assessment

It is a common clinical finding that many subjects have an A1C value lower or higher than expected when examining their daily glycemic profiles. Using the DCCT database, McCarter et al. (14) calculated the hemoglobin glycation index (HGI) as the difference between observed and predicted A1C level and identified categories of patients with low, moderate, or high HGI. Most interestingly, they found that subjects with high HGI had a greater risk of developing retinopathy and nephropathy, even when they had good glucose control, and that subjects with lower HGI had a low incidence of microangiopathy despite high mean blood glucose levels. This finding demonstrates that A1C assessment might provide not only information on chronic hyperglycemia but also a measure of whole-body susceptibility of protein glycation and, therefore, risks of diabetes complications that are more strictly related to this pathogenic mechanism.

Using the same biomarker for diagnosing and monitoring diabetes might be an advantage

A1C is used to monitor diabetes and to establish the degree of metabolic control. Deviation from individualized A1C targets prompts physicians to modify treatment strategies with lifestyle intervention and/or drug titration or changes. The use of A1C for diagnosing diabetes has the advantage that, in subjects with A1C ≥6.5% (i.e., diabetes), baseline A1C is already measured and deviation from target is immediately available (no A1C measurement as a second step after FPG assessment). In subjects with A1C of 6.00–6.49% (i.e., high risk of diabetes), an effective prevention strategy can be immediately undertaken with the awareness that a single A1C is definitely more reliable than a single FPG to stratify the risk of the disease. Yet, in subjects with A1C of 5.50–5.99% plus other diabetes risk factors (e.g., central obesity, atherogenic dyslipidemia, hypertension, and/or metabolic syndrome), counseling can be immediately offered because diabetes risk is substantial, and single A1C assessment is definitely more reliable than single FPG to capture chronically high-normal glucose levels.

Pertinent to this issue is the firm belief that the implementation of the standardization of A1C assay would proceed more rapidly worldwide if A1C were to also be used for diagnosing diabetes. A1C assessment is crucial for diabetes monitoring, and establishing the individual A1C target definitely requires that the parameter is International Federation of Clinical Chemistry (IFCC) standardized and DCCT aligned. In fact, the A1C target and the deviation from it in the single patient remain totally uncertain when the laboratory provides A1C data that are not aligned to standard.

Cost of the assay: savings or no savings?

One of the major concerns raised by critics of the use of A1C for diagnosing diabetes is the higher cost of the assay when compared with FPG. There is no doubt that from an analytical point of view (cost of reagents and equipment), FPG is cheaper than A1C. However, other considerations about cost should be made. FPG assessment requires overnight fasting, whereas A1C can be assessed any time. This means that a person could go or could be driven by a relative/friend to the laboratory, even during lunch or in the late afternoon, avoiding loss of work hours. It is also possible to collect blood for A1C assessment in the evening and hand it to the laboratory in the following days. Yet, in subjects with FPG ≥7 mmol/L (≥126 mg/dL), A1C assessment would be needed the next few days as a second step in a newly diagnosed diabetes workup. On the contrary, when A1C assessment yields a value ≥6.5%, the second step required to initiate diabetes monitoring after diagnosis would be completed, with a substantial savings of both analytical and nonanalytical costs. On the other hand, when using FPG to screen for diabetes and finding a value in the range of 5.6–6.9 mmol/L (100–125 mg/dL; impaired fasting glucose), an OGTT is frequently prescribed (mainly in Europe and less frequently in the U.S.) to establish glucose tolerance. This test requires hours in the laboratory, with additional analytical and nonanalytical costs. In such cases, which represent a sizable portion of the general population, A1C rather than FPG would provide an immediate diabetes diagnosis or a valuable risk stratification (15) without supplementary testing.

Impact of changing the diagnostic laboratory parameter on epidemiology of diabetes

A further critique to the program of moving from FPG to A1C for diabetes diagnosis comes from people who state that epidemiology of the disease is based on FPG and that the scenario would change if A1C were used instead of FPG. A recent report based on the U.S. population (16) showed that the use of A1C rather than FPG would not significantly change diabetes prevalence and that the categorization would not change in as many as 97.7% of subjects. Moreover, this study showed that half of the subjects with FPG ≥7 mmol/L (≥126 mg/dL) had an A1C value in the 6.00–6.49% range, thus deserving strict monitoring and an intervention. In this regard, however, it should be emphasized that any comparison of A1C with FPG (or 2-h OGTT PG) is equivocal because a true gold standard is not available. FPG, which in classic studies relating glucose parameters (including A1C) to retinopathy was measured just one time and with less than optimal pre-analytical and analytical procedures, cannot be taken as the gold standard. Therefore, any study examining sensitivity and specificity of A1C for diagnosing diabetes suffers from these limitations and is questionable. At present, the gold standard is probably the combination of FPG, 2-h PG, and A1C assessments with optimal pre-analytical, analytical, and standardized procedures and confirmatory testing for all parameters. This is not feasible on a large-scale basis and cannot be recommended. A1C seems to be a reasonable approach for all reasons discussed above (summarized in Table 1).

Table 1

Reasons to prefer A1C compared with plasma glucose determination for diagnosing diabetes

CONs

Diabetes is clinically defined by high blood glucose and not by glycation of proteins

The introduction of A1C as the diagnostic tool for diabetes, in particular, if this parameter is considered the primary tool, will lead to a major change in the pathophysiological paradigm that defines the syndrome called “diabetes.” So far, diabetes has been defined as “a clinical condition of elevated glucose concentration in blood”. High A1C represents high glycation of proteins in the body, which is a substantially different biochemical abnormality, although it is certainly secondary to high blood glucose. In medicine, it is important to pay attention to primary phenomena before emphasizing the secondary ones. Moreover, high A1C is only observed subsequently to an increase in blood glucose, but there are few data on how long the delay is. Regardless of the length of this delay (weeks, months), diagnosis of diabetes using A1C would occur later than with blood glucose assessment. In many cases, such a delay might have negative clinical consequences.

A1C is a poor marker of important pathophysiological abnormalities featuring diabetes

OGTT and 2-h post-glucose levels do reflect the pathophysiology behind diabetes better than any other glycemic parameter, since they provide information on what occurs in the postprandial state, when glucose levels are at the highest levels during the day and when the health of the pancreatic β-cell is essential. On the contrary, fasting glucose is the least informative among glycemic parameters, since in most subjects, it corresponds to the lowest glucose level during the day and it reflects the long nocturnal period when there is no intake of food and no particular stress for β-cells. However, humans spend most of their time in postprandial or postabsorptive states that are deranged in diabetes. A1C is a poor indicator of what occurs in the postprandial state. A1C captures only chronic hyperglycemia, but it will miss acute hyperglycemia. Normal blood glucose levels 2 h after glucose load indicates a good β-cell capacity, whereas high 2-h OGTT glucose levels document an impairment of β-cell function (17). This means that only 2-h OGTT PG can provide reliable information on the key pathophysiological defect of diabetes, also providing advice regarding the correct therapy to overcome it. This can be compared with ambulatory blood pressure monitoring (ABPM), where the main features predicting cardiovascular events are not only the long-term average blood pressure but the daily variation in blood pressure (especially the lack of a physiological nocturnal dip). Thus, ABPM is clinically useful in finding out blood pressure patterns, not estimating the long-term average. Recently, the Insulin Resistance Atherosclerosis Study (IRAS) showed that A1C is a weaker correlate of insulin resistance and insulin secretion in studies of metabolism compared with FPG and 2-h PG (18).

A1C has a poor sensitivity in diabetes diagnosis and would change the epidemiology of diabetes

Diabetes diagnosis based on A1C misses a large proportion of asymptomatic early cases of diabetes that can only be identified by the OGTT. According to a recent Chinese study, A1C sensitivity is inferior compared with fasting blood glucose at the population level (19). Also, people with impaired glucose tolerance (IGT), in whom the efficacy of diabetes prevention has been unequivocally proven (20), cannot be detected by A1C.

Epidemiological studies carried out in the general population showed that A1C and plasma glucose (FPG and/or 2-h OGTT) identify partially different groups of diabetic subjects (21). A1C ≥6.5% identifies ~30–40% of previously undiagnosed patients with diabetes (16). A larger percentage is detected by FPG (~50%) and 2-h PG (~90%). These findings are based on several recent studies, including the 2003–2006 NHANES (30% of diabetic individuals detected by A1C ≥6.5%, 46% by FPG ≥126 mg/dL, and 90% by 2-h PG ≥200 mg/dL) (18) and the IRAS (32, 45, and 87%, respectively) (18). In Qingdao, China, the ≥6.5% A1C cut point detects 30% of individuals with diabetes according to 2003 ADA criteria (19). In Chennai, India, however, A1C ≥6.5% detects 78% of individuals with newly diagnosed diabetes according to these criteria (22). In the IRAS, A1C of 5.7–6.4% predicted type 2 diabetes better with increasing BMI, and there were significant ethnic differences in the performance of A1C of 5.7–6.4% to detect diabetes (18). The ethnic differences in A1C compared with glucose measurements were also well demonstrated in the Diabetes Prevention Program population (23) and in a recent multiethnic database by Christensen et al. (24) that showed that there are no systematic interpretations as to why a shift to an A1C-based diagnosis for diabetes has substantially different consequences for diabetes prevalence across ethnic groups and populations.

2-h Glucose level and IGT are stronger predictors of CVD than A1C

Because high glucose is toxic and causes many types of tissue damage, any indicator of hyperglycemia is predictive of diabetes complications. In the general population, FPG is a poor marker of mortality and future CVD events, whereas 2-h PG and A1C are better predictors (8,10,25–27). When analyzed jointly, only 2-h PG remains a statistically significant predictor of mortality and CVD (28,29). The findings regarding associations of FPG, 2-h PG, and A1C with retinopathy from the Pima Indians in the ADA 1997 report describing diagnostic thresholds of each glycemic parameter were derived by univariate analyses, and the multivariate analysis aiming at identifying the best glycemic parameters for diagnosis has never been reported. One of the main issues is that people with IGT have ~40% increased mortality compared with normoglycemic people, and these individuals cannot be identified by measuring FPG or A1C. In addition, lifestyle intervention has been shown to prevent the progression from IGT to diabetes and also reduce their mortality risk to the level observed among normoglycemic people (30,31). Such prevention trial evidence does not exist for A1C or FPG, and this evidence should not be forgotten when deciding the approaches to identify intermediate hyperglycemia. Moreover, these results indicate that early intervention is effective in reducing mortality in people with IGT, and therefore, we should attempt to make the diagnosis of hyperglycemia as early as possible.

Fasting is not essential to identify perturbation in glucose metabolism

Measuring blood glucose in the fasting state in nondiabetic individuals is probably the least efficient way to identify early signs of perturbations in glucose metabolism. Because excessive postprandial glucose excursions are marking the first signs of abnormal glucose regulation and they also seem to best predict cardiovascular outcome, fasting is not really the central issue. It is likely that fasting has been overemphasized in diagnosing type 2 diabetes. We may pay attention to approaches used in the diagnosis of high blood pressure that also vary markedly during the day, but despite this variation, we are able to identify individuals with hypertension, even though measurements are not restricted to certain hours of the day but are done at any time.

Standardization of A1C assay is very poor and standardization of glucose assay is easier to implement

Inaccuracies in measurement and poor standardization of A1C assays are still a common problem, even in Western countries. Although a less than perfect standardization also exists for plasma glucose, this assay might be more easily aligned to a standard than A1C. Such programs now exist in the U.S., Japan, and Sweden, but there is still a long way to a global standardization of the A1C assays. Actually, all glycemic assessments require confirmation to make the diagnosis of diabetes correctly, mainly to avoid errors in sample handling and laboratory procedures.

A1C assay is unreliable and cannot be used in many subjects

Abnormal hemoglobin traits are not uncommon in many regions of the world, and they significantly interfere with A1C assay (32), leading to spurious results. Also, there are several clinical conditions that influence erythrocyte turnover (e.g., malaria, chronic anemia, major blood loss, hemolysis, uremia, pregnancy, smoking, and various infections) that are responsible for misleading A1C data. Still, we are aware of ethnic differences in the relation between blood glucose and A1C levels (33) as well as an effect of aging. If different cut points regarding all these conditions need to be considered, A1C cannot be easily used to diagnose diabetes.

Within-day biological variability of plasma glucose might unveil disturbance of glucose metabolism

Biological variability in plasma glucose reflects our daily patterns of diet, physical and mental activity, sleep, etc., and also depends on possible pathophysiological processes that may underlie type 2 diabetes. By definition, postprandial, and also 2-h PG, vary more than FPG. In this regard, A1C, which does not have any substantial biological variability, provides little information on pathophysiological processes leading to type 2 diabetes. The variability in A1C is entirely due to other phenomena, not pathophysiological disturbances.

Individual susceptibility to glycation of hemoglobin is not relevant to diabetes diagnosis

The HGI was calculated in patients with type 1 diabetes from the DCCT (17). This parameter is not relevant to the diagnosis of diabetes in the general population, in which 99% of subjects have A1C levels definitely lower than patients with type 1 diabetes. Subjects with high HGI had a greater risk of developing retinopathy and nephropathy, even when they had good glucose control (i.e., FPG was not very high), whereas subjects with lower HGI had a very low incidence of microangiopathy despite high mean blood glucose levels. This finding indicates that postprandial glucose excursions must have been very high in the former and very low in the latter. A1C reflects high mean exposure to glucose but not glucose fluctuations during the day. Unfortunately, in this analysis with HGI, postprandial glucose excursions and daily glucose variability were not taken into account.

Using the same biomarker for diagnosing and monitoring diabetes might not have positive effects only

This approach may be useful, but it also may lead to problems in two ways. First, people who have diabetes (based on their glucose values) will remain undiagnosed and untreated, since they are considered “nondiabetic” according to their A1C. Also, if the intermediate level of A1C (6.00–6.49 or 5.70–6.49%) was used to predict diabetes, it performed less well than impaired fasting glucose and/or IGT (18). Whereas the 6.5% A1C threshold misses a large percentage of previously undiagnosed diabetes, its clinical consequences remain unknown. It is important to recognize this problem. One obvious consequence is that with a less sensitive test, individuals who fall below the threshold are not considered in cardiovascular management algorithms as high-risk individuals and are probably treated less effectively for other risk factors.

Second, a large proportion of newly diagnosed diabetic patients based on current glucose criteria have A1C <6.5%. In the Finnish Diabetes Prevention Study, the sensitivity of A1C ≥6.5% to diagnose diabetes was only 39%, i.e., 61% of newly diagnosed case subjects had A1C <6.5% (34). If this same threshold were to be used for treatment, these patients would not be accepted to be treated, even though their glucose levels were twice the glucose threshold for diabetes. This would also mean that in 61% of high-risk people who were regularly monitored for diabetes, the actual diagnosis would have been delayed—for how long, we do not know, since diabetic people were referred to antidiabetic therapy based on their high glucose values.

Cost of the assay: glucose is unquestionably cheaper than A1C

Whichever way we calculate the assay costs, A1C assay is more expensive than glucose assay, and it will thus remain so despite the speculative claim that the cost of A1C assay will become less expensive when used more extensively. In addition, many individuals at high risk of diabetes would need other laboratory tests that require fasting (e.g., lipid profile, hepatic profile, etc.), and therefore adding a glucose determination to the panel is not really a major issue. Also, the vast majority of laboratories in primary care collect samples in the morning, and they do not operate after “working hours.” This makes the claim that A1C can be measured “any time of the day” rather theoretical.

In a large part of the world, A1C is not available, and its cost is so high that it is meaningless to even discuss whether it should be given a priority over simple and inexpensive glucose measurements. This step would divide the world into two categories: developed societies in which diabetes diagnosis is made with A1C and less developed societies (between and within countries) in which diabetes diagnosis is made with plasma glucose: such a division should be avoided. It would add to the inequities in health and health care.⇓

Table 2

Reasons not to prefer A1C compared with plasma glucose determination for diagnosing diabetes

CONCLUSIONS

There is no doubt that hyperglycemia is the biochemical hallmark of diabetes and is a prerequisite for diagnosis. In this respect, moving from blood glucose to A1C might sound like a sort of heresy. There is also no doubt that all epidemiological data based on blood glucose assessment might be considered less important if the disease were mainly diagnosed with A1C. This might create confusion, disappointment, anxiety, and concern in all who lived a glucocentric existence. Partly rewarding would be the fact that, in several clinical conditions, A1C could not be used and blood glucose assessment would remain the standard diagnostic procedure. In all other conditions (most subjects), A1C could become the reference method, provided that its assay be aligned to international standards. Also mandatory is that the cost of assay declines and becomes affordable in less developed societies. Longitudinal studies should also reassure us about the relative benignity of clinical conditions in which A1C is below the diagnostic threshold of 6.5% but FPG and/or 2-h OGTT PG are above the thresholds of 7 or 11 mmol/L, respectively. This is currently one of the most relevant worries related to potentially missing diagnosis.

Glucose assessment is familiar and cheaper, but A1C seems to provide several advantages, especially in a scenario in which OGTT is rarely used and never repeated as a confirmatory testing. Perhaps accepting a double diagnostic approach in which both blood glucose and A1C do coexist as diagnostic tools is reasonable. In the meantime, epidemiological and clinical studies will hopefully provide further data to better understand whether the current recommendations to replace FPG with A1C are well founded.

We agree that the research and debate on the pros and cons of using A1C versus glucose assay as a diagnostic tool for diabetes should continue in a constructive manner until a larger and truly evidence-based consensus is reached.

Prediabetes and Your Child

You’ve been told that your child has prediabetes. This means that your child’s blood sugar (glucose) is too high. Your child is at risk for developing type 2 diabetes.

In type 2 diabetes, the body isn’t able to use insulin very well. Insulin is needed to use the sugar in the blood. This is different than type 1 diabetes. In type 1 diabetes, the body doesn’t make enough insulin. It’s most often from the body’s immune system damaging the cells in the pancreas. The pancreas is the organ where insulin is made.

Over time, high blood sugar (hyperglycemia) can lead to many health problems. For example, when your child is older, he or she may develop heart, eye, or kidney disease. You can take action now to lower your child’s blood glucose level and help prevent diabetes in your child.

What is prediabetes?

Prediabetes means your child has a higher than normal level of sugar in his or her blood. Lab tests to check blood sugar include:

• Fasting blood sugar (FBS). This test measures blood sugar after not eating for at least 8 hours, often overnight. A normal FBS should be less than 100 mg/dL.

• Glucose tolerance test (GTT). This test measures blood sugar 2 hours after drinking a special high-sugar drink. A normal 2-hour GTT should be less than 140 mg/dL.

• Hemoglobin A1C (glycated hemoglobin, A1C). This test measures the average blood sugar over time. A normal A1C should be less than 5.7%.

This means that your child had an FBS level of 100 to 125 at least once. Your child may also have had a 2-hour GTT result of 140 to 199, or an A1C of 5.7% to 6.4%. Higher values than these ranges normally mean that your child has diabetes.

Who is at risk for prediabetes?

Diabetes often runs in families. African-American, Latino, Native American, Asian American, and Pacific Islander families are often affected. Your child may be more likely to develop diabetes if:

• He or she spends more time sitting than being active

• He or she is overweight for his or her age and height

• A parent or sibling has diabetes

• The mother had gestational diabetes (diabetes during pregnancy)

Talk with your child’s healthcare provider about these and other risks.

You can help prevent type 2 diabetes

You can help decrease your child’s risk of getting diabetes. Work with your child’s healthcare provider on the following:

• Healthy eating. Make sure your child is eating many different kinds of foods. Focus on fresh fruits and vegetables, lean meats, whole grains, and low-fat dairy. Limit sugars and fats. And limit processed, prepackaged foods and fast foods, such as burgers, fries, and shakes. Stay away from sugary drinks, such as nondiet soda, sports drinks, lemonade, and sweet tea. These foods are high in calories, fat, and sodium. They are also low in nutrition.

• Physical activity. Being active helps your child’s body use glucose. Try for at least 60 minutes of active playtime every day. It doesn’t have to be all at once. A few playtimes of 10 to 20 minutes add up.

• Weight loss. Ask your healthcare provider for a referral to a lifestyle intervention program. This program will help your child get to and stay at a 7% weight loss and increase physical activity. Even a loss of 5% to 7% of body weight may help your child’s body use glucose better

To learn more

For more information about diabetes, visit these websites:

• American Diabetes Association www.diabetes.org

• Children with Diabetes www.childrenwithdiabetes.com

• American Association of Diabetes Educators www.aadenet.org

• American Association of Clinical Endocrinologists www.aace.com

• National Diabetes Information Clearinghouse www.diabetes.niddk.nih.gov

• Endocrine Society www.endocrine.org/topics/diabetes

When “Normal” Blood Sugar Isn’t Normal (Part 2)

In the last article I explained the three primary markers we use to track blood sugar: fasting blood glucose (FBG), oral glucose tolerance test (OGTT) and hemoglobin A1c (A1c). We also looked at what the medical establishment considers as normal for these markers. The table below summarizes those values. In this article, we’re going to look at just how “normal” those normal levels are—according to the scientific literature. We’ll also consider which of these three markers is most important in preventing diabetes and cardiovascular disease.

But before we do that, I’d like to make an important point: context is everything.

In my work with patients, I never use any single marker alone to determine whether someone has a blood sugar issue. I run a full blood panel that includes fasting glucose, A1c, fructosamine, uric acid and triglycerides (along with other lipids), and I also have them do post-meal testing at home over a period of 3 days with a range of foods.

If they have a few post-meal spikes and all other markers or normal, I’m not concerned. If their fasting BG, A1c and fructosamine are all elevated, and they’re having spikes, then I’m concerned and I will investigate further.

On a similar note, I’ve written that A1c is not a reliable marker for individuals because of context: there are many non-blood sugar-related conditions that can make A1c appear high or low. So if someone is normal on all of the other blood sugar markers, but has high A1c, I’m usually not concerned.

With all of that said, let’s take a look at some of the research.

Fasting blood sugar

According to continuous glucose monitoring studies of healthy people, a normal fasting blood sugar is 83 mg/dL or less. Many normal people have fasting blood sugar in the mid-to-high 70s.

While most doctors will tell you that anything under 100 mg/dL is normal, it may not be. In this study, people with FBG levels above 95 had more than 3x the risk of developing future diabetes than people with FBG levels below 90. This study showed progressively increasing risk of heart disease in men with FBG levels above 85 mg/dL, as compared to those with FBG levels of 81 mg/dL or lower.

What’s even more important to understand about FBG is that it’s the least sensitive marker for predicting future diabetes and heart disease. Several studies show that a “normal” FBG level in the mid-90s predicts diabetes diagnosed a decade later.

Far more important than a single fasting blood glucose reading is the number of hours a day our blood sugar spends elevated over the level known to cause complications, which is roughly 140 mg/dl (7.7 mmol/L). I’ll discuss this in more detail in the OGGT section.

One caveat here is that very low-carb diets will produce elevated fasting blood glucose levels. Why? Because low-carb diets induce insulin resistance. Restricting carbohydrates produces a natural drop in insulin levels, which in turn activates hormone sensitive lipase. Fat tissue is then broken down, and non-esterified fatty acids (a.k.a. “free fatty acids” or NEFA) are released into the bloodstream. These NEFA are taken up by the muscles, which use them as fuel. And since the muscle’s needs for fuel has been met, it decreases sensitivity to insulin. You can read more about this at Hyperlipid.

So, if you eat a low-carb diet and have borderline high FBG (i.e. 90-105), it may not be cause for concern. Your post-meal blood sugars and A1c levels are more important.

Hemoglobin A1c

In spite of what the American Diabetes Association (ADA) tells us, a truly normal A1c is between 4.6% and 5.3%.

But while A1c is a good way to measure blood sugar in large population studies, it’s not as accurate for individuals. An A1c of 5.1% maps to an average blood sugar of about 100 mg/dL. But some people’s A1c results are always a little higher than their FBG and OGTT numbers would predict, and other people’s are always a little lower.

This is probably due to the fact that several factors can influence red blood cells. Remember, A1c is a measure of how much hemoglobin in red blood cells is bonded (glycated) to glucose. Anything that affects red blood cells and hemoglobin – such as anemia, dehydration and genetic disorders – will skew A1c results.

A number of studies show that A1c levels below the diabetic range are associated with cardiovascular disease. This study showed that A1c levels lower than 5% had the lowest rates of cardiovascular disease (CVD) and that a 1% increase (to 6%) significantly increased CVD risk. Another study showed an even tighter correlation between A1c and CVD, indicating a linear increase in CVD as A1c rose above 4.6% – a level that corresponds to a fasting blood glucose of just 86 mg/dL. Finally, this study showed that the risk of heart disease in people without diabetes doubles for every percentage point increase above 4.6%.

Studies also consistently show that A1c levels considered “normal” by the ADA fail to predict future diabetes. This study found that using the ADA criteria of an A1c of 6% as normal missed 70% of individuals with diabetes, 71-84% with dysglycemia, and 82-94% with pre-diabetes. How’s that for accuracy?

What we’ve learned so far, then, is that the fasting blood glucose and A1c levels recommended by the ADA are not reliable cut-offs for predicting or preventing future diabetes and heart disease. This is problematic, to say the least, because the A1c and FBG are the only glucose tests the vast majority of people get from their doctors.

OGTT / post-meal blood sugars

If you recall, the oral glucose tolerance test (OGTT) measures how our blood sugar responds to drinking a challenge solution of 75 grams of glucose. I don’t recommend this test, because A) it’s not realistic (no one ever drinks 75 grams of pure glucose), and B) it can produce horrible side effects for people with poor glucose control.

However, there’s another more realistic and convenient way to achieve a similar measurement, and that is simply using a glucometer to test your blood sugar one and two hours after you eat a meal. This is called post-prandial (post-meal) blood sugar testing. As we go through this section, the numbers I use apply to both OGTT and post-meal testing.

As the table at the beginning of this article indicates, the ADA considers OGTT of between 140 – 199 two hours after the challenge to be pre-diabetic, and levels above 200 to be diabetic.

But once again, continuous glucose monitoring studies suggest that the ADA levels are far too high. Most people’s blood sugar drops below 120 mg/dL two hours after a meal, and many healthy people drop below 100 mg/dL or return to baseline.

A continuous glucose monitoring study showed that sensor glucose concentrations were between 71 – 120 mg/dL for 91% of the day. Sensor values were less than or equal to 60 or 140 mg/dL for only 0.2% and 0.4% of the day, respectively.

On the other hand, some studies suggest that even healthy people with no known blood sugar problems can experience post-meal spikes above 140 mg/dL at one hour. As I said in the beginning of the article, context is everything and all of the markers for blood sugar must be interpreted together.

If post-meal blood sugars do rise above 140 mg/dL and stay there for a significant period of time, the consequences are severe. Prolonged exposure to blood sugars above 140 mg/dL causes irreversible beta cell loss (the beta cells produce insulin) and nerve damage. Diabetic retinopathy is an extremely common (and serious) diabetic complication. Cancer rates increase as post-meal blood sugars rise above 160 mg/dL. This study showed stroke risk increased by 25% for every 18 mg/dL rise in post-meal blood sugars. Finally, 1-hour OGTT readings above 155 mg/dL correlate strongly with increased CVD risk.

What does it all mean?

Let’s take a look again at what the ADA thinks is “normal” blood sugar:

But as we’ve seen in this article, these levels depend highly on context and whether all markers are elevated, or just a few of them.

If you’re interested in health and longevity – instead of just slowing the onset of serious disease by a few years – you might consider shooting for these targets. But remember to interpret the numbers together, and also remember that blood sugar is highly variable. If you wake up one morning and have a fasting blood sugar of 95, but your A1c and post-meal numbers are still normal, that’s usually no cause for concern. Likewise, if you see a one-hour post-meal spike of 145 mg/dL, but all of your other numbers are normal, that is also usually no cause for concern.

*If you’re following a low-carb diet, fasting blood sugars in the 90s and even low 100s may not be a problem, provided your A1c and post-meal blood sugars are within the normal range.

Another key takeaway from this article is that fasting blood glucose and A1 are not often reliable for predicting diabetes or CVD risk. Post-meal blood sugars are a more accurate marker for this purpose. And the good news is that this can be done cheaply, safely and conveniently at home, without a doctor’s order and without subjecting yourself to the brutality of an OGTT.

90,000 what we know about him / State Budgetary Healthcare Institution of the Yamal-Nenets Autonomous Okrug “Labytnangskaya City Hospital”

High blood sugar levels were found, and the doctor was stunned by the diagnosis of prediabetes? This is a serious reason to think about health and revise your lifestyle.

If you have prediabetes, after a couple of years this borderline condition can turn into a serious disease – diabetes mellitus. But until then, everything is fixable: prediabetes can be dealt with.

What is prediabetes
Prediabetes (also called impaired glucose tolerance) is a condition that is intermediate between health and diabetes.

With prediabetes, the body cannot maintain normal blood sugar levels, so blood glucose levels fall outside the normal range. Although glucose does not rise as dramatically as in diabetes, it has serious consequences.

In people with glucose tolerance, blood vessels are affected, which increases the risk of heart attack and stroke.But the most unpleasant thing is that a person does not even suspect that he has health problems, because there are no unpleasant sensations and alarming symptoms in prediabetes.

Pre-diabetes risk groups:
The diagnosis of “prediabetes” is often included in the medical record of overweight people who have crossed the forty-year line.

However, prediabetes is not an age-related disease, as impaired glucose tolerance can develop at any age. Even obese children are diagnosed with borderline diabetes.

Risk factors for prediabetes:
Stomach ulcer
Hypertensive disease
Relatives with type 2 diabetes
Polycystic ovary
Gestational diabetes during pregnancy

Prediabetes: how to suspect that something is wrong with tolerance
As a rule, people do not have a violation of glucose … Sometimes a person with prediabetes begins to notice the first “bells”, but does not always pay attention to them, attributing a slight malaise to fatigue, stress and nutritional errors.

Signs that may indicate the development of prediabetes:
Migraines;
Itching of the skin;
Insomnia;
Night cramps;
“Blurred” vision;
Increased appetite;
Numbness of the limbs;
Increased fatigue;
Long-lasting healing wounds;
Thirst and frequent urination.
Prediabetes: diagnosis

If you suspect diabetes or a predisposition to it, the patient is first asked to donate blood from a finger on an empty stomach.

Laboratory tests to suspect prediabetes
1.Elevated fasting glucose
Fasting sugar should not exceed 5.5 mmol / L. If the level of glucose in capillary blood on an empty stomach is higher than 6 mmol / L, this indicates the onset of prediabetes (when taking blood from a vein, values ​​up to 6.1 are considered normal).
The concentration of glucose in capillary blood in the range of 6.1-7.0 mmol / l indicates a state bordering on diabetes.

2. Increased level of glycated hemoglobin
Glycated hemoglobin (HbA1c) – the amount of hemoglobin irreversibly bound to glucose.The formation of such a connection takes a long time, therefore, the level of glycated hemoglobin makes it possible to assess the degree of “sugariness” of the blood for 3 months. Normally, this figure does not exceed 4-6%. The impaired glucose tolerance is indicated by the level of HbA1c in the range of 6.0-6.5%.

3. Elevated levels of cholesterol and triglycerides
Norms of cholesterol and triglycerides may differ in different laboratories. However, people with prediabetes tend to have higher cholesterol and triglyceride levels than the norm on the form.

4. Increased glucose values ​​during glucose tolerance test
To clarify the diagnosis, a glucose tolerance test is often prescribed. This test allows you to identify, including the so-called latent diabetes. Blood is taken on an empty stomach, and then the analysis is repeated at a certain time after the patient drinks the glucose solution.
In a healthy person, a couple of hours after glucose load, the sugar level will not exceed 7.8 mmol / l. At a level from 7.8 to 11.0 mmol / l, one speaks of impaired glucose tolerance.A blood glucose level of more than 11.0 mmol / L indicates the presence of diabetes mellitus.
For the results of the glucose tolerance test to be as correct as possible, it is important that the person adheres to his usual diet and physical activity for at least three days before the test. For 10-14 hours before the study, you should not eat and alcohol, as well as smoke, and before the study, take certain medications.

It is not recommended to conduct a glucose tolerance test if a person is under stress, after surgery and childbirth, serious illness, during menstruation, or if glucose absorption is impaired due to diseases of the gastrointestinal tract.To clarify the diagnosis, it is recommended to pass the test twice.

When to get tested
If you have one or more symptoms, you should see a doctor and check your blood sugar.

At least once every three years, such an analysis should be passed to all healthy people over forty years old.
Once every three years, glucose tests should also be taken for tridcytogenic people if they are obese, hypertensive, have high cholesterol and other predisposing factors.
An annual blood glucose test is necessary for people over forty, suffering from overweight and chronic diseases, especially if their close relatives (parents) suffered from diabetes.
How to cure prediabetes
To prevent prediabetes from becoming diabetes, it is often enough to normalize your diet, exercise more, and control the level of potassium in the blood. Sometimes it makes sense to try herbal medicine.

1. Physical activity
Walking, swimming, yoga, dancing and any other physical activity are suitable.

2. Proper nutrition
Particular attention should be paid to your diet. The ban includes sweets, honey, preserves and jams, buns made from butter or puff pastry, grapes, bananas, strawberries, dates and raisins, fruit juices and soda.

If it is difficult to give up sweets, sweeteners and desserts for people suffering from diabetes will come to the rescue. When choosing a sweetener, go for stevia.

Do not lean on cheese and other fatty dairy products, use mayonnaise and products containing margarine, salty and spicy sauces.Eliminate fatty meats, salted and smoked foods and canned food from the diet.

Vegetable salad, peas, mushrooms, Jerusalem artichoke, juice from fresh cabbage leaves and fresh potatoes are useful for prediabetes.

It is better to steam food. It is acceptable to bake or stew food with a minimum of oil. It makes sense to switch to fractional meals: eat in small portions five to six times a day.

3. Controlling the level of potassium in the blood
Another important point: for the prevention of prediabetes and its treatment, it is important to exclude potassium deficiency.This trace element can be obtained both with food and in tablet form. The dosage in this case is selected by the doctor.

4. Herbal medicine
In the fight against prediabetes, you can try herbal medicine as an additional tool in addition to proper nutrition and a healthy lifestyle.

Bilberry leaves, oat infusion, juice of fresh wild strawberries have a sugar-reducing effect. Special fees for glucose monitoring can be purchased at the pharmacy.
Ginseng root, Leuzea extract, Zamanihi tincture and Eleutherococcus extract indirectly normalize carbohydrate metabolism.
However, you should not “prescribe” phytopreparations yourself. It is better to consult a doctor beforehand. Take care of yourself, listen to your own body, and be healthy!
# national project demography89

Determination of the level of glycosylated hemoglobin (HBA1C) in diabetes mellitus

Determination value of glycosylated hemoglobin

Glycosylated hemoglobin, also called hemoglobin A1c or HbA1c, or glycohemoglobin, is an important blood count used to determine how well your diabetes is being controlled.Hemoglobin A1c shows the average blood sugar level over a period of 12 weeks, and its determination is carried out in conjunction with monitoring the level of sugar at home in order to choose the right antidiabetic medication for you.

Hemoglobin is a substance that is located inside red blood cells and carries oxygen throughout the body. In the absence of control of diabetes mellitus (that is, when your blood sugar is high), sugar builds up in the blood and binds to hemoglobin, making it glycosylated.Therefore, the average amount of sugar in your blood can be determined by measuring the level of glycosylated hemoglobin. If your blood glucose has been high over the past few weeks, your hemoglobin A1c will also be elevated. The amount of glycosylated hemoglobin will reflect your blood sugar level over the past few weeks, typically covering a period of 120 days.

What is the normal glycosylated hemoglobin assay?

In people without diabetes, the normal level of glycosylated hemoglobin ranges from 4% to 6%.Because research has repeatedly shown that lack of control of diabetes mellitus leads to complications, the target hemoglobin A1c level in people with diabetes is 7%. The higher the level, the higher the risk of developing complications associated with diabetes.

People with diabetes should have this test every three months to determine if their blood sugar has reached the target control level. Those with diabetes mellitus are well controlled may take longer breaks between blood tests, but experts recommend checking this indicator at least 2 times a year.

Patients with conditions that affect hemoglobin, such as anemia, may receive abnormal results from this test. Other conditions that can affect the hemoglobin A1c result include dietary supplements such as vitamins C and E and high cholesterol. Also, kidney and liver diseases can affect the level of glycosylated hemoglobin.

Testing for glycosylated hemoglobin can be done in any treatment room of the OLYMPUS network of laboratories.

90,000 Are raisins able to normalize blood glucose levels?

Eating raisins 3 times a day can significantly help normalize blood sugar levels, according to a study presented at the American Diabetes Association’s annual scientific conference.

A team led by Harold Bays, a researcher at the Louisville Metabolic and Atherosclerosis Research Center, USA, analyzed data from about 50 adults who had high glucose levels and were not diagnosed “diabetes”.

The researchers randomly assigned the participants into 2 groups. The 1st group ate raisins 3 times a day for 12 weeks, while the 2nd – other foods that did not contain vegetables or fruits, including raisins.

In the course of the study, scientists found that the participants from the 1st group after eating raisins by 16% lower their glucose levels and compared with the initial. In addition, the scientists noted a favorable effect after a long period of its inclusion in the diet in the participants of the 1st group due to a decrease in the level of glycated hemoglobin (a standard test for monitoring blood glucose levels in diabetes mellitus) compared to the baseline level.

The specialists of the 2nd group did not register significant changes in the level of glucose and glycated hemoglobin.

It should be noted that glycated hemoglobin (hemoglobin A1c) is a biochemical blood index reflecting the average blood glucose level over a long period (up to 3 months), in contrast to blood glucose measurement, which gives an idea of ​​the glucose value only at the time of the study …

According to James Painter, a researcher at the Louisville Research Center, raisins have a relatively low glycemic index and are rich in fiber and antioxidants, which in turn help normalize blood sugar levels.It is important to control normal blood glucose and hemoglobin A1c levels, scientists say, as this can prevent the risk of heart and circulatory system diseases.

Based on materials from www.medicalnewstoday.com

90,000 Target glucose levels to prevent and progress diabetic kidney disease

What is the problem?

In many parts of the world, diabetes is the most common cause of kidney failure requiring treatment with a kidney transplant or dialysis.The disability or disability (blindness, loss of limbs, kidney failure) caused by diabetes is caused by high levels of glucose (sugar) in the blood. An important question is whether adjunctive treatment to regulate blood glucose to near normal levels can safely prevent diabetes-related health consequences, including lower life expectancy and loss of kidney function, without causing problems such as low blood glucose leading to loss of consciousness and seizures.Some diabetes care includes close monitoring of blood glucose to lower blood glucose (determined by a blood test called an HbA1C glycosylated hemoglobin blood test) with additional medications and careful monitoring of blood glucose by healthcare professionals.

What have we done?

We reviewed evidence of tighter blood glucose control (lower blood glucose in the long term, namely HbA1c <7%) versus less tight control (HbA1c> 7%) in people with type 1 or 2 diabetes …Blood glucose levels have been achieved with any type of medication, including pills or insulin.

What have we found?

Fourteen studies involving 29,319 people at risk of diabetes complications were included, and 11 studies with 29,141 people were included in our analysis. Tighter control of blood glucose did not show any benefit for patients compared to less tight control. There was no difference in patient risk for kidney failure, death, or heart disease complications.A very small number of patients (1 in 1000 treated per year) can avoid a heart attack with more intense blood glucose control. Although decreased renal excretion of protein has been suggested in some patients, the long-term clinical impact of this benefit is not clear. Potential problems with treatment, such as side effects and risks of very low blood glucose (hypoglycemia), were generally not measured in studies.

Our findings

From this review, it can be concluded that, in the long term, with tighter blood glucose control, people with diabetes receive uncertain benefits and the immediate complications of this treatment approach are difficult to know for sure.

Treatment of type 1 diabetes mellitus in Israel: prices 2021

Leading endocrinologist Dr. G. Schenkerman is engaged in the treatment of type 1 diabetes in Ichilov (Israel).

Although type 1 diabetes requires consistent care, advances in blood sugar and insulin monitoring have made life easier for patients and their parents.

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How is the diagnosis of diabetes mellitus 9000 – First checkup ,

Pediatrician Dr. A. Yaron sees small patients

Day Two – Diagnostic:

Together with the coordinator who carries out medical transfer and support, the patient undergoes the prescribed examinations:

• Test for blood sugar level to be taken not on an empty stomach. Regardless of when the patient last ate, a random blood sugar level of 200 mg / dL (11.1 mmol / L) or higher favors diabetes.
• A glycated hemoglobin (A1C) test indicates the average blood sugar level over the past two to three months. An A1C of 6.5% or higher indicates diabetes.
• Determination of fasting blood sugar less than 100 mg / dL (5.6 mmol / L) is the norm. A level of 100 to 125 mg / dL (5.6 to 6.9 mmol / L) is considered a pre-diabetic condition. A level of 126 mg / dL (7 mmol / L) or higher indicates diabetes mellitus.
• Blood tests to detect autoantibodies, which are always present in type 1 diabetes, to help distinguish between type 1 and type 2 diabetes.
• The presence of ketones (a byproduct of fat breakdown) in the urine also indicates type 1 diabetes rather than type 2 diabetes.

Day three – Treatment plan:

To summarize the examination and draw up a treatment plan, the patient is referred to a specialist endocrinologist, Dr. G. Schenkerman.

The specialist will select the optimal insulin therapy and the method of insulin administration.

The time spent in Israel to fulfill the above plan on an outpatient basis is 4-5 working days.

Price for diagnostics of type 1 diabetes mellitus – $ 2312.

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Insulin and other medications

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Any patient with type 1 diabetes should receive insulin replacement therapy to survive.Because gastric enzymes break down insulin when taken by mouth, the only way to administer insulin is by injection.

Types of insulin:

• Fast-acting insulin starts to work in 5-15 minutes and the peak of its action is from 30 to 90 minutes after the moment of administration.
• Short-acting insulin begins to work 30-60 minutes after injection with a peak after two to four hours.
• Insulin is long-acting, does not peak and lasts 20-26 hours, providing a 24-hour baseline insulin level.
• Intermediate insulins, start working after 1-3 hours with a peak after 8 hours.

In Ichilov, treatment depends on the patient’s age and individual needs, the doctor can prescribe a mixture of different types of insulin.

Insulin delivery options:

Often, insulin is injected using a fine needle syringe or “insulin pen” with a cartridge filled with insulin.

Insulin pump is a convenient option for children.The pump is a device about the size of a mobile phone. It can be programmed to provide an acceptable level of insulin depending on the diet, the level of activity of the person and the level of blood sugar ^{[3, 4]} .

The cost of the device is at least 3rd generation, installation and adjustment of an insulin pump – $ 8950.

New technologies have emerged that make life much easier for patients with type 1 diabetes. For example, there are special sensors that are attached to the body, detect blood sugar levels and transmit the results to a smartphone or other device.The most advanced devices allow these sensors to communicate with your insulin pump and adjust the amount of insulin delivered according to your blood sugar level. This technology was named “artificial pancreas” , because it accurately mimics the work of the pancreas.

Dr. Carlos Ben-Bassat

Senior Physician, Department of Endocrinology

About Type 1 Diabetes

Type 1 diabetes usually begins in childhood and is characterized by a condition in which the pancreas does not produce insulin.Type 1 diabetes is also known as juvenile diabetes, or insulin-dependent diabetes.

Symptoms of type 1 diabetes mellitus:

• Increased thirst and increased urination. When excess sugar builds up in the blood, fluid begins to flow from the tissues into the bloodstream to dilute the high sugar concentration. Dehydration of the tissues causes thirst, and as a result, the child drinks and urinates more than usual.
• Unquenchable hunger. Without enough insulin to move sugar into cells, energy is depleted in muscles and organs, causing intense hunger.
• Weight loss. Although a sick child eats more than usual to satisfy his hunger, he still loses weight very quickly. Without the energy that glucose provides, muscle tissue and fat depot shrink. Unexplained weight loss is often the first sign parents look for.
• Fatigue. If the cells are deprived of sugar and the energy it provides, the child becomes tired and lethargic.
• Irritability or unusual behavior. A child with undiagnosed type 1 diabetes may suddenly become moody and irritable.
• Blurred vision. If blood sugar is too high, fluid can move out of the chambers of the eye, altering the curvature of the eyeball and impairing vision.
• Fungal infections can cause diaper rash and genital candidiasis.

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Dr. Galina Schenkerman on the treatment of type 1 diabetes in Israel

How much does the treatment of type 1 diabetes cost in Israel

How does the disease develop?

The exact cause of type 1 diabetes is unknown.Scientists know that most people with this condition have the body’s own immune system, which normally fights harmful bacteria and viruses, mistakenly destroys the insulin-producing cells in the pancreas. Genetics and exposure to certain viruses may play a role in the development of type 1 diabetes.

Whatever the cause, once the insulin-producing cells are destroyed, the body produces little or no insulin. If everything is working properly, when a person eats, the pancreas releases a large portion of insulin into the blood.Insulin acts as a key to unlocking the microscopic doors through which sugar enters the cells of the body. Insulin lowers the amount of sugar in the blood, and as soon as the level drops, the pancreas stops making and releasing insulin.

The liver acts as a storehouse for glucose. When insulin levels are low (if the person has not eaten for more than 8 hours), the liver releases stores of glycogen, which is then converted into glucose to keep blood glucose levels within the normal range.

In type 1 diabetes, there is no or very little insulin, not enough for glucose to enter the cells. Instead of being transported to cells in the body, sugar accumulates in the blood, where it can cause life-threatening conditions.

Risk factors for type 1 diabetes mellitus:

Known risk factors include:

• Family history. Anyone with a parent or sibling with type 1 diabetes has a slightly increased risk of developing the disease.
• Genes. The presence of certain genes indicates an increased risk of developing type 1 diabetes.

Photo: Ichilov hospital departments

Possible risk factors for developing type 1 diabetes include:

• Exposure to Epstein-Barr virus, Coxsackie virus , mumps and cytomegalovirus can cause autoimmune destruction of pancreatic cells.
• Low vitamin D . Research shows that vitamin D may protect against type 1 diabetes.
• Drinking water , which contains nitrates, may increase the risk of developing type 1 diabetes.

Complications of diabetes mellitus:

1. Diseases of the heart and blood vessels. Diabetes mellitus significantly increases the risk of various cardiovascular diseases, including coronary heart disease, heart attack, stroke, atherosclerosis, and high blood pressure.
2. Nerve damage (neuropathy). Excess sugar can damage the capillary walls that feed nerve fibers. It can cause tingling, numbness, burning, or pain. Nerve damage usually occurs gradually over a long period of time.
3. Kidney damage (nephropathy). Diabetes can damage numerous tiny blood vessel clusters that filter waste from the body. Severe damage can lead to kidney failure or irreversible kidney disease requiring dialysis or a kidney transplant.
4. Eye damage. Diabetes can damage the blood vessels in the retina (diabetic retinopathy), which in turn leads to blindness. Diabetes can also lead to cataracts and increase the risk of developing glaucoma (Israel).
5. The defeat of the small branches of the arteries on the legs in diabetes leads to ischemia, trophic disorders on the legs, more often on the feet, in the form of trophic ulcers and necrosis, which over time lead to changes called “diabetic foot”.With the progression of ischemia, gangrene of the foot and lower leg develops.
6. Skin diseases. Diabetes can make a person more susceptible to skin conditions, including bacterial infections, fungal infections, and itching.
7. Osteoporosis. Diabetes can lead to a decrease in bone mineral density, increasing the risk of osteoporosis in adulthood.
8. Brain problems. Although the exact reason is not clear, people with diabetes are at increased risk of developing dementia and Alzheimer’s disease.

Contact the Ichilov clinic

How to get diagnosed and treatment of diabetes mellitus in the Top Ichilov

1. Call the clinic right now:
   • Israeli number + 972-37621629
   • Russian number + 7-495-7773802 (your call will be automatically and free of charge transferred to a Russian-speaking doctor – consultant in Israel)
   • by the Ukrainian number + 380-443922180 (your call will be automatically and free of charge transferred to a Russian-speaking doctor – consultant in Israel)
2. Or fill out this form.Our doctor will contact you within 2 hours.

Notes

1. Type 1 diabetes
   https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31320-5/fulltext

2. Advances in technology for management of type 1 diabetes
   https://pubmed.ncbi.nlm.nih.gov/31533908/

3. Is insulin pump therapy effective in Type 1 diabetes?
   https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.13793

4. Psychosocial benefits of insulin pump therapy in children with diabetes type 1 and their families: The pumpkin multicenter randomized controlled trial
   https: / / onlinelibrary.wiley.com/doi/abs/10.1111/pedi.12777

Article author

Professor Shmuel Levit

Head of the clinic for diabetes and endocrinology

List of works

https: //www.ncbi.nlm.nlm. gov / pubmed /? term = Levit + S

Frequently asked questions

Is diabetes mellitus inherited?

This disease is not always found in those whose close relatives suffered from diabetes mellitus. However, having a family history of diabetes mellitus slightly increases the risk of developing the disease.

Can type 1 diabetes mellitus be cured?

Unfortunately, today this disease is incurable. However, with the correct treatment and use of modern insulin pumps, patients with type 1 diabetes mellitus live for many years and have a high quality of life.

What are the reviews on the treatment of type 1 diabetes mellitus in Israel?

On this page you can find video reviews of our patients about treatment at Top Ichilov. However, individual feedback does not give a sufficiently complete picture of the quality of treatment in the clinic.More accurate information can be obtained from statistics: 99% of patients with type 1 diabetes reported a significant improvement in well-being and quality of life after correcting their treatment at Top Ichilov.

How much does the treatment of type 1 diabetes mellitus cost in Israel in 2021?

A complete examination for diabetes mellitus at Top Ichilov (including a final consultation with a leading endocrinologist and correction of treatment) costs 2312 dollars. Selection of a modern insulin pump in Top Ichilov will cost about 20% less than in large clinics in Western Europe, including Germany.

Which Supplement Will Quickly / Dramatically Reduce Blood Sugar Levels In Type 2 Diabetes?

Type 2 diabetes is usually analyzed using:

Glycated hemoglobin (A1C) test. This blood test shows normal glucose levels for several months. Typical sizes are below 5.7%, and an outcome anywhere in the 5.7 to 6.4% range is considered prediabetes. An A1C measurement of 6.5% or higher on two separate tests means you have diabetes.

If your A1C test is not available, or if you have certain conditions, such as an exceptional type of hemoglobin (known as hemoglobin variation) that can affect the A1C test, your specialist may use companion tests to test for diabetes:

Irregular glucose test. Glucose estimates are reported in milligrams per deciliter (mg / dL) or millimoles per liter (mmol / L). Although the last time you ate, a blood test showing your glucose level is 200 mg / dL (11.1 mmol / L) or higher recommends diabetes, especially in case you also have signs and the side effects of diabetes, such as urine and extraordinary thirst.

Fasting glucose test. A blood test is taken after a mid-term fasting. Overvoltage is typically less than 100 mg / dL (5.6 mmol / L). Measuring 100 to 125 mg / dL (5.6 to 6.9 mmol / L) is considered prediabetes.

If you are not likely to have a fasting glucose level of 126 mg / dL (7 mmol / L) or higher on two separate tests, you have diabetes.

Oral glucose resistance test. This test is used less frequently than others besides pregnancy. You will have to drink the sweet liquid quickly and medium-term in the specialist’s office.Glucose levels are sampled periodically for the next two hours.

Glucose levels below 140 mg / dL (7.8 mmol / L) are common. Scrolling anywhere in the range of 140 to 199 mg / dL (7.8 mmol / L and 11.0 mmol / L) indicates prediabetes. Drinking 200 mg / dL (11.1 mmol / L) or higher for two hours is indicative of diabetes.

The American Diabetes Department prescribes regular screening for type 2 diabetes at age 45, especially if you are overweight.If it is likely that the results will be normal, review the test regularly. If the results are unlikely to be insignificant, ask your healthcare professional when to return for a second exam.

The examination is additionally assigned to persons under 45 years of age and overweight if there are other risk factors for the development of ischemic disease or diabetes, for example, stationary lifestyle, family origin of type 2 diabetes, individual history of gestational diabetes or pulse 140/90 millimeters of mercury pillar (mm Hg.Art.).

In the event that you think you have diabetes, the specialist may do different tests to recognize type 1 and type 2 diabetes, as the two conditions regularly require different medications.

Post-Test

A1C levels should be checked somewhere between two and four times a year. Talk to your professional about your A1C goal as it can change based on your age and different components. For the vast majority, the American Diabetes Organization proposes an A1C level below 7 percent.

An elevated A1C level may indicate a need to adjust your recipe, dinner plan, or movement level.

Despite the A1C test, your specialist will check your pulse and periodically have blood and urine tests to check your cholesterol, thyroid, liver and kidney function. Normal eye and foot tests are also important.

Treatment

Leaders of Type 2 Diabetes Include:

Weight Loss

Smart Diet

Routine Exercise

Possibly Prescribed Diabetes or Insulin Treatment

Glucose Monitoring

These remedies will help keep your glucose levels closer to typical, which can delay or anticipate confusion.

Weight loss

Weight loss can lower your glucose levels. Losing as little as 5 to 10 percent of your body weight can have any effect, despite the fact that continuing weight loss of 7 percent or more of your base weight is, by all accounts, ideal. This means that a person who weighs 180 pounds (82 kilograms) will need to lose just under 13 pounds (5.9 kilograms) to affect glucose levels.

Part control and nutrition is a simple approach to weight loss.

Good Diet

Contrary to popular observation, there is no specific diabetic diet. However, it’s important to rotate your diet around:

Fewer calories

Less refined sugars, especially desserts

Less dipped fat content

More vegetables and organic foods

More fiber extracts

Registered dietitian can help you create a meal plan that suits your wellbeing goals, living habits and lifestyle.The person in question may also show you how to check for starch intake and think about how much starch you should eat during lunch and bites to keep your blood glucose more and more stable.

Physical Action

Everyone needs standard high-performance exercise, and people with type 2 diabetes are not special. Before starting an exercise program, get it from your specialist. Select exercises that you enjoy, such as walking, swimming and cycling, so that you can incorporate them into your daily schedule.

For a few days a week, do something like 30-30 hours of moderate (or 15-30 minutes of incredible) oxygen consumption activity. A combination of activities – oxygen-consuming activities such as walking or moving on most days, combined with preparation for sports activities such as weightlifting or yoga twice a week – offers more benefits than one of the activities alone.

Be aware that physical action lowers glucose levels.Check your glucose level before any action. You may need to eat a pre-workout tidbit to help lower your glucose levels if you’re not taking glucose-lowering diabetes medications.

It is also important to reduce the amount of time you spend on hidden exercises, such as watching TV. Try to move somewhat evenly.

Monitoring your glucose

Depending on your treatment plan, you may need to check and record your glucose periodically or, if you are taking insulin, on different days over several days.Ask your healthcare provider how often a person who needs it needs to have their glucose checked. A thorough check is the best way to make sure your glucose remains within your target range.

Diabetes Medication and Insulin Therapy

Several people with type 2 diabetes can achieve their target glucose levels through diet and exercise alone, but many require additional diabetes medication or insulin treatment.Which recipes are best depends on many ingredients, including your glucose levels and some other medical problems you have. Your healthcare professional may combine different drug classes so that you can control your glucose in several different ways.

Examples of possible drugs for type 2 diabetes include:

Metformin (Glucophage, Glumetza, etc.). For the most part, metformin is the main prescription for type 2 diabetes.It works by lowering the production of glucose in the liver and improving your body’s ability to act on insulin so that your body can use insulin more and more vigorously.

Bowel soreness and weakness are possible symptoms of metformin. These reactions can go away when your body gets used to the medication or if you take the medication with dinner. In the event that metformin and lifestyle changes are insufficient to control glucose levels, other oral or infusion drugs may be included.

Sulfonylureas. These medications help your body release more insulin. Models include glyburide (DiaBeta, Glynase), glipizide (Glucotrol), and glimepiride (Amaryl). Possible symptoms include low glucose levels and weight gain.

Meglitinides. These recipes – like Prandin and nateglinide (Starlix) – work like sulfonylureas, stimulating the pancreas to release more insulin, but they work faster and last for a shorter duration.Plus, they can lead to lower glucose levels and weight gain.

Thiazolidinediones. Like metformin, these drugs, including rosiglitazone (Avandia) and pioglitazone (Actos), make body tissues more sensitive to insulin. These drugs have been associated with weight gain and other, more and more genuine symptoms, such as an increased risk of heart frustration and weakness. In light of these dangers, these prescriptions are not, for the most part, first-choice drugs.

DPP-4 inhibitors. These drugs – sitagliptin (Januvia), saxagliptin (Onglyza), and linagliptin (Tradjenta) – help lower glucose levels but are generally subtle. They do not cause weight gain, but they can cause joint agony and increase the risk of pancreatitis.

GLP-1 receptor agonists. These injectables soften absorption and help lower glucose levels. Their use is often associated with weight loss. Possible reactions include nausea and an increased risk of pancreatitis.

Exenatide (Byetta, Bydureon), liraglutide (Victoza) and semaglutide (Ozempic) are examples of GLP-1 receptor agonists. Current research has shown that liraglutide and semaglutide can reduce the risk of heart attack and stroke in those at high risk of these conditions.

SGLT2 inhibitors. These medicines prevent the kidneys from absorbing sugar into the bloodstream. Rather, the sugar is dumped into the urine. Models include canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance).

Medications in this class of drugs can reduce the risk of heart attack and stroke in people at high risk of these conditions. Reactions can include vaginal yeast disease, urinary tract pollution, low circulation, and an increased risk of diabetic ketoacidosis. Canagliflozin, yet not a different drug in the class, has been associated with an increased risk of removing the lower epididymis.

Insulin. Several people with type 2 diabetes need insulin treatment.In the past, insulin treatment was used when all else failed, but today it is often recommended earlier because of its benefits. Low glucose (hypoglycemia) is a possible insulin response.

Normal absorption interferes with insulin intake, therefore insulin must be administered. Depending on your needs, your specialist may recommend a mixture of insulin types for use throughout the day and night. There are numerous t

90,000 Can BCG Vaccine Treat Type 1 Diabetes?

Andrew X’s answer is only slightly correct, 3 patients had only the first phase of the first phase (ha), the total appears to be 9; however, this appeal is controversial that there was enough hint at the source used for the question (at the end of the article, several experts warned about the small sample size).Another article uses thinner gloves … on either side of the question:

While the results from only nine patients should be replicated in a broader study, said Dr. Joseph Bellanti of Georgetown University Medical Center, “ if what they found is true, they really have something here. ” Bellanti, who was not involved in the study, said eight years of observation and the use of a placebo control group made him “cautiously optimistic” that two doses of BCG vaccine “could lower A1c levels,” a measure of blood glucose levels that predicts the likelihood of serious complications. such as stroke and kidney failure.

JDRF (formerly Juvenile Diabetes Research Foundation), Joslin Diabetes Center and several university diabetes centers declined to talk about Faustman’s findings. She has been a voice in the desert of diabetes for nearly two decades, angering the diabetic establishment community by pursuing low-tech research that is very different from more popular approaches like embryonic stem cells and immunosuppression.

Critics went so far as to send letters to newspapers highlighting her work apologizing to patients “on behalf of Dr. Faustman” for “having severely overstated their expectations.”She also competed for funding, receiving most of her research support from the private Iacocca family foundation rather than federal grants.

In Faustman’s phase 1 clinical trial, three participants with type 1 diabetes received two doses of BCG vaccine, one month apart. After the vaccine showed signs of effectiveness, six more patients were vaccinated five years ago, and 111 more recently. A new paper and presentation, scheduled for the American Diabetes Association meeting this weekend, focuses on patients who have been followed for more than five years.

“We wanted it to be good, but we didn’t know it would be that good,” Faustman said.

According to her, all patients remain on insulin, but less. They may also be less likely to monitor their blood sugar levels, which can be several times an hour. (The standard of care is continuous glucose monitoring, in which a tube is inserted into the abdomen, as well as an insulin pump.) “If we can gradually move people to a place where they can control their blood sugar, their daily lifestyle could be greatly improved.” Faustman said.

Reducing A1c can also provide significant health benefits. Studies show that every 10% reduces complications such as stroke and heart attack by about a third. The BCG vaccine reduced A1c levels from 9 percent to 16 percent.

A Phase 2 clinical trial for BCG is currently underway in Massachusetts. He is testing multiple doses of BCG in 150 patients with long-term type 1 diabetes.

Although BCG research is being conducted worldwide on diabetes and other autoimmune diseases, including multiple sclerosis, American researchers had little interest outside of Faustman’s lab.

“There is not much enthusiasm because we are all rewarded for discovering commercial drugs,” she said. “Potential sponsors come [to my laboratory] and ask, ‘How can we make money from this? »

BCG, of which Merck’s Organon Teknika subsidiary is the only US licensed manufacturer, costs less than a dollar per dose. (Faustman used a strain made by Sanofi.) The US market for insulin meters and insulin pumps is $ 20 billion.“When everyone thinks they need a pump and a meter, if you come with an inexpensive vaccine that can change that standard of care, then of course there will be a rollback,” Faustman said.

So I doubt this will have a satisfactory answer until a larger one (150 patient study) is completed.

In addition, Reuters reported that some of the putative mechanisms of action are being investigated and possibly even replicated (by others) in mice, so part of Andrew’s answer seems to be wrong.I myself am not in a position to assess the plausibility of this mechanism, and of course, some other researchers seem to have rejected it:

However, the study is in line with current efforts to treat diabetes, says cell immunologist Raphael Klines of the Berry Center, who did not take part in the study.

“People assumed that by the time patients had open-ended diabetes, all of their islet cells had been destroyed,” Klines said. “We now know that islet cells persist many years ago.The idea is that if you can get rid of the inflammatory, autoimmune response, the islet cells can regenerate. ”

Faustman’s studies in laboratory mice, begun in the 1990s, showed that one way to get them to do this was a compound in the body called tumor necrosis factor. TNF is difficult to obtain commercially, but the BCG vaccine increases the body’s production.

Faustman reported that increasing TNF levels with vaccine-cured type 1 diabetes in mice ten years ago: when autoimmune T cells disappeared, islet cells regenerated and began to produce healthy amounts of insulin.The journal that published the study insisted Faustman not use the word “rebirth,” so controversial was the idea that the islets could come back to life. She replaced “recovery”.

By 2006, other scientists, including those who attacked Faustman’s claims of regeneration, had replicated key findings from her studies in mice, laying the foundation for a clinical trial.

Three long-term diabetic patients received two BCG injections four weeks apart.Three others received saline injections serving as placebo controls.

Scientists reported on Wednesday that in two out of three BCG patients, levels of islet-attacking T cells dropped. The dead autoimmune cells were released into the bloodstream, a hint that TNF killed them as intended. Insulin production has increased. The only placebo patient with similar results contracted the Epstein-Barr virus, which also triggers the production of TNF.

In other respects, Reuters coverage echoes the criticism with more details:

Faustman has already faced serious problems with her theory.The JDRF denied her funding requests and circulated a 2003 letter from two of her colleagues at Harvard Medical School questioning her work and apologizing to diabetics for “raising their expectations cruelly” in their stories of her research.

The response to this study was not much better. “The article shows that BCG is associated with temporary improvement in several patients, but it is difficult to conclude that TNF is a causative factor,” said Klins of Colombia.

“This is certainly interesting and deserves further study,” said JDRF Chief Executive Jeffrey Brewer. “But it is very important to be careful with how we interpret early results.