Why should my A1C be 7 per cent or less? —

Over the last several years a significant amount of research has proven that control matters, and good control is now defined as an A1C of < 7 per cent.

What is an A1C?

An A1C test shows your blood glucose control over the last 2 or 3 months.

Diabetes Control & Complications Trial (DCCT) 1982-1993

Research from both the Diabetes Control & Complications Trial (DCCT) and its follow up study (EDIC) proves that having an A1C of 7 per cent is definitely worthwhile for persons with type 1 diabetes.

Exactly 1441 volunteers aged 13 to 39, all with type 1 diabetes, took part. These people agreed to randomly be assigned to either conventional treatment – taking about two insulin injections a day – or to intensive treatment (IT) – taking either multiple dose insulin (MDI, about 4 injections a day) or an insulin pump.

During the study the A1C of each group was compared:

• 
  the conventional therapy group had an average A1C of 9. 1 per cent (normal 4-6 per cent)
• 
  the intensive therapy group had an average A1C of 7.2 per cent

The purpose was to finally demonstrate whether or not good blood sugar control was really important to prevent the complications of diabetes. And indeed it is – as you can see below, complications developed at a much lower rate in the intensively treated group compared to the conventional group.

The reduction in risk for eye disease (the primary outcome) was so great that the study was stopped early – and intensive therapy to achieve an A1C of 7 per cent or less became the standard of practice worldwide!

But what do these results mean for you?

For you, a person with type 1 diabetes, lowering your A1C by 1 per cent means a 45 per cent less risk you will develop the chronic complications of diabetes! That’s 45 per cent for each 1 per cent lower! The closer to normal (<6 per cent) the A1C is the better!

The results also mean that an A1C of <7 per cent will also be good for you if you already have some signs of chronic complications. For example, kidney and eye disease may stay stable for years!

At the end of the original DCCT trial, all the people in the conventional group changed to intensive therapy and their A1C lowered. Then both groups went back to their usual diabetes care teams, coming back to the study centre for a once yearly assessment.

This same group of volunteers has remained in the DCCT follow up study called Epidemiology of Diabetes Interventions & Complications (EDIC) since 1993. Now that’s commitment to a research study!

Over time the A1C of the original intensive therapy and the former conventional therapy groups evened out at an average of 8%, but the benefits of intensive therapy remained – much to everyone’s surprise. And for the first time, the benefits of good control on heart/cardiovascular disease were clearly shown.

 

 

DCCT/EDIC Results 1993-2005 (NEJM 2005)

Original Intensive vs. Conventional Therapy Groups: Comparison of Complications Status	EDIC 11 yrs of A1C~ 8% Both testing 4 x per day
Eyes (retinopathy)	75% less progression
Kidney	86% risk reduction in onset of new microalbuminuria
Heart/ Cardiovascular	57% less risk of heart attack (MI), stroke or CV death Intensive group: 31 people with 46 events Conventional group: 52 people with 98 events

  

The latest results (2005) continue to support the earliest possible adoption of intensive therapy to achieve an A1C of <7 per cent. Early and optimal blood glucose control has long term benefits.

That’s why we believe so passionately in using the IT system, and why we want to help you find the best way for you to do this. We know it isn’t easy to act like a pancreas day in and day out. It‘s hard work – and we want to help!

Next page:  Isn’t there more to diabetes control than an A1C?  »»

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.

HOW TO LOWER GLYCATED HEMOGLOBIN – Healsens Digital Preventive Care

Diabetes is a major health problem worldwide and its prevalence is increasing significantly. In turn, an analysis of glycated hemoglobin (A1C) will help you find out how your body copes with sugar. For many, this is an opportunity to prevent a disease or diagnose it at an early stage. After all, the disease does not develop at lightning speed! For us, this is an opportunity to catch a state when the body does not function normally, but has not yet become ill. We are talking about prediabetes. But for people with diabetes, this test is also useful. Mainly because it shows the risks of complications. In this article, we will talk about the situation when the test has already been passed, and its results were outside the healthy range. In addition, we will analyze an integrated approach to the problem, what necessary actions it includes and why it is impossible to do without changing your lifestyle. But let’s go in order. After all, in order to answer the question of how reduce glycated hemoglobin , you need to consider the problem carefully.

Speaking of normal hemoglobin A1c levels, let’s remember these ranges. For example, for people without diabetes, the healthy range is 4% to 5.6% . If your hemoglobin A1c is between 5.7% and 6.4% , that means you already have prediabetes. Levels 6.5% speak of diabetes.

Targets and Treatments

In the US, 79 million adults have prediabetes and its prevalence is 3 times that of diabetes. And if prediabetes is considered a reversible disease, then diabetes is not yet curable. It is also important to understand that treating diabetes does not prevent all of its complications. That is why prevention is so important.

In this article

1

Goals and treatments

2

How to lower glycated hemoglobin without pills

9000 3 3

Drug approach to prevent diabetes

4

decrease in the level of glycated hemoglobin

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But whether the problem will progress or not depends on many factors. So, how much a person is ready to change his lifestyle will depend on the success of his treatment. Genetics and well-chosen medicines are also important.

In general, there are 4 pillars of effective diabetes management. They include

• diet
• exercise
• Glucose and glycated hemoglobin monitoring
• medication selected by your doctor.

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How to Lower Glycated Hemoglobin Without Pills

In 2002, Knowler et al hypothesized that lifestyle interventions could prevent or delay the onset of diabetes. The researchers randomly assigned patients with prediabetes. Some of them were offered a placebo, others were included in a special lifestyle change program. The goal of this program was to increase physical activity of at least 150 minutes per week and reduce weight by at least 7%. The average age of the participants was 51 years and the BMI was 34.0 kg/m2. The mean follow-up period was 2.8 years. As a result, lifestyle intervention reduced morbidity by 58% compared to placebo ¹ .

Further analysis of this study showed that if people did not change their lifestyle, the majority developed type 2 diabetes within the next 10 years.

Numerous studies have since confirmed these findings. So, in 2013, researchers compared the effectiveness of lifestyle interventions with standard treatment. Seven of 9 studies reported that lifestyle changes reduced the risk of developing diabetes up to 10 years after lifestyle intervention ² .

However, for some people with prediabetes, lifestyle changes are not enough.

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Medication approach to prevent diabetes

Evidence for the potential benefit of pharmacotherapy to prevent diabetes in prediabetic patients was published in 2002.

Researchers have shown that drugs such as metformin reduce the incidence of diabetes. On the other hand, this decrease is not as strong as with lifestyle changes. However, metformin also has a beneficial effect on BMI and lipid concentrations.

In 2010, Lilly and Godwin, after a systematic literature review and meta-analysis, concluded that metformin reduces the risk of developing diabetes by 45% ³ .

Healsens story on glycated hemoglobin

Finally, metformin is currently the only drug recommended by the ADA for the treatment of prediabetes. According to the ADA, it is commonly prescribed for patients at high risk of developing diabetes. It is worth noting that if people fail lifestyle therapy and their glucose levels rise, metformin is a reasonable second choice.

However, despite the widespread use of metformin, the drug is not suitable for everyone. So, to lower glycated hemoglobin, ACE/AACE recommends a two-pronged approach. First, intensive intervention in lifestyle. Namely, an increase in physical activity, walking at least 150 minutes a week. As well as weight loss by 7% if BMI exceeds 25 kg/m2 ⁴ . Secondly, prevention of complications of cardiovascular diseases. In this case, drugs may be prescribed to treat high blood pressure and cholesterol.

Fiber to lower glycated hemoglobin

Increasing dietary fiber is associated with lower glycated hemoglobin (HbA1c), improved lipid profile and weight loss ⁵ . This is because the increased fiber content lowers the glycemic index of foods.

In addition, foods containing dietary fiber are also rich sources of magnesium . We emphasize that magnesium is a co-factor for enzymes involved in glucose metabolism. In turn, dietary magnesium reduces the incidence of type 2 diabetes. Research also suggests that the association of dietary fiber with a reduced risk of diabetes may be partly explained by markers of inflammation. We are talking about markers such as interleukin-6 and tumor necrosis factor α ⁶ .

Finally, several studies have shown that after all dietary fibers were separated into grain, fruit and plant fibers, grain fibers were the most effective in reducing the incidence of type 2 diabetes ⁷ .

This article was last checked by Dr. Baloban S.V. June 11, 2020. Last modified on February 22, 2020.

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Source: ©️2019 Healsens B.V.

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2. Prediabetes and Lifestyle Modification: Time to Prevent a Preventable Disease
3. Prediabetes and Lifestyle Modification: Time to Prevent a Preventable Disease
4. Prediabetes and Lifestyle Modification: Time to Prevent a Preventable Disease
5. Fiber in Diet Is Associated with Improvement of Glycated Hemoglobin and Lipid Profile in Mexican Patients with Type 2 Diabetes
6. Associations Between Dietary Fiber and Inflammation, Hepatic Function, and Risk of Type 2 Diabetes in Older Men

Diabetes Mellitus: An Umbrella Review of Meta-analyses

What is glycated hemoglobin A1c

Contents

• What is the best HbA1c value?
• How often should an HbA1c test be done?
• What is the difference between A1c and eAG?

The glycated hemoglobin (hemoglobin A1c, HbA1c) test is a complete blood test used to diagnose diabetes and monitor its treatment. This test is usually done to detect type 1 and type 2 diabetes.

HbA1c test shows the average blood sugar level over the past two to three months. It shows how much hemoglobin has been glycated (i.e. has been linked to glucose).

Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to other parts of the body. Glucose enters the red blood cells and glycates (combines) with hemoglobin molecules. The more glucose in the blood, the more hemoglobin will be glycated.

The average amount of glucose in the blood can be determined by measuring the level of hemoglobin A1c. If your glucose has been high for the past two to three months, the A1c test will show this with great accuracy.

A high A1c test indicates a high glucose level, which in turn increases the risk of diabetes.

See high blood sugar diet.

According to the National Institutes of Health (USA), the most common complications in patients with high blood glucose levels are:0052

Researchers at Bloomberg University (JHSPH, USA) report in the journal NEJM that glycated hemoglobin can predict disease risk with greater accuracy than conventional fasting glucose .

What is the best HbA1c value?

HbA1c test results show the following:

• between 4% and 5.6% – people are healthy , the risk of developing diabetes is minimal
• between 5.7% and 6.4% – the person has a high risk of developing diabetes
• 6.5% or more – the person has diabetes nemia and host vitamin supplements (vitamins C and E), patients with high blood cholesterol, and people with liver or kidney disease may have poor HbA1c test results. If you are taking vitamin supplements, tell your doctor.

  Non-caregivers (diabetes) with high HbA1c levels have a much higher risk of developing complications.

  The American Diabetes Association considers the maximum glycated hemoglobin for diabetic patients to be 7%.

  How often should the HbA1c test be done?

  If you have type 2 diabetes, you need to have your hemoglobin A1c tested every quarter of (three months) to make sure your level is below 7%.

  If your blood sugar levels are good for a certain amount of time, your doctor may allow you to get tested once every six months.

  What is the difference between A1c and eAG?

  Some doctors may tell you your A1c result as an eAG (mean blood glucose) test. eAG is directly related to A1c.

  • A1c is calculated as a percentage, eg 7%
  • eAG is calculated in millimoles per liter (mmol/l, mmol/L) in blood glucose meters, eg 5.4 ml/dl.
  • A1c having a value of 5 is equal to 4.5 eAG; A1c, having a value of 7, is equal to 8.3 eAG; A1c having a value of 8 is equal to 10.0 eAG; A1c, having a value of 9, is equal to 11.6 eAG.

  A study published in The Lancet in 2010 suggests that for diabetic patients, low HbA1c levels can be just as dangerous as high . It also contributes to the development of cardiovascular diseases and, often, with a fatal outcome. After reviewing the research, the Society of Endocrinologists of the United States stated that any changes in glycemic indicators are dangerous.