To date, there have been at least 34 comments to my September 3rd post about “Hemoglobin A1c Guidelines: Latest American Diabetes Association Recommendations,” ranging from rage at The Affordable Care Act to concerns that hb A1cs are too low. The following is a recap of these now somewhat controversial guidelines for non-pregnant people with diabetes:
- Less than 18 years of age: recommended hb A1c less than 7.5 percent
- Over 18 years of age: recommended hb A1c less than 7.0 percent
- Older, healthy adults: recommended hb A1c less than 7.5 percent
- Older adults with complex or intermediate health: recommended hb A1c less than 8.0 percent
- Older adults with very complex or poor health recommended hb A1c less than 8.5 percent
Please remember: target levels must be individualized based on each patient’s circumstances.
Many of the comments on my previous blog came from people with type 1 and type 2 diabetes. Clearly, these guidelines have created an enormous amount of confusion and concern for not only young children with type 1 diabetes, the group in which I thought these changes would be most difficult for, but for people of all ages. Several people with diabetes were noting that their healthcare providers were actually trying to increase their hb A1cs based on these new guidelines! Others were commenting that they have been able to control their type 2 diabetes by careful attention to exercising and diet, specifically adhering to low-carbohydrate diets. Indeed, low carbohydrate diets make sense for adults with both type 1 and type 2 diabetes; however, in children and adolescents that are still growing, carbohydrates must be consumed in moderation and balanced with other food groups.
Pharmaceutical companies also were mentioned in various comments; there seems to be a fear of conspiracy by the drug companies to provide additional products in order to further lower hb A1cs. My counter proposal is that the pharmaceutical company that provides the appropriate regimen to cure either type 1 or type 2 diabetes would stand to reap the most benefits as people will still continue to develop the disease even with a cure available.
Another comment discussed serum fructosamine as a more accurate means to evaluate blood sugars in the short term, two to four weeks. Indeed, we do use fructosamine levels when the hb A1c does not reflect blood sugar control based on self-blood glucose monitoring. Typical conditions in which the hb A1c is not accurate include those diseases with rapid blood cell turnover, such as G6PD deficiency, cystic fibrosis related diabetes, sickle cell disease, and other hemolytic anemias. As such, a hemoglobin electrophoresis would be helpful if hb A1cs do not appear to support blood sugar records. Algorithms are available to compare blood sugar averages with both the hb A1c and fructosamine levels.
A much more sobering question inquired about the accuracy of hb A1c levels. After discussing with one of the company representatives that provides the machines to measure hb A1c (point of care), I was given the scary fact that these hb A1cs reflect 0.5 percent over or under the actual reported result. So, yes, I suppose that it is possible that if your hb A1c is 7.0, it may actually range from 6.5 to 7.5 percent. Indeed, this reflects my own experience upon repeating a hb A1c that did not match blood sugars or seemed incorrect. We rarely actually get the same exact measurement twice.
So, how does one reconcile this information? After speaking to patients, families, and other healthcare providers, it seems that we should be evaluating several factors in addition to the hb A1c. These primarily include blood sugar fluctuations and the amount of time people are continually hypoglycemic or hyperglycemic. This information is available via frequent self-blood glucose monitoring and continuous glucose sensors. The goal, of course, is to try to avoid marked fluctuations in blood sugars as well as to decrease time spent in either hypoglycemia or hyperglycemia.
In addition, along with the current American Diabetes Association guidelines, blood sugar ranges and goals must be based on individual needs in conjunction with input from family and caregivers. Please advocate for yourself and share what works for you. As I often say to my patients, “if it isn’t broken, don’t fix it!”
In summary, if you have a hb A1c of 5.1 percent, are in good health with a good quality of life, and are experiencing no hypoglycemia, congratulations! You will get no complaints from this healthcare provider (however, you are most likely out of my pediatric practice age range).
Published On: December 01, 2014