David's Guide to Getting Our A1C Under 6.0

Patient Expert

The A1C test is our best scorecard to show how well we are controlling our diabetes. It measures how much glucose has been sticking to our red blood cells for the previous two or three months. Since our bodies replace each red blood cell with a new one every four months, this test tells us the average of how high our glucose levels have been during the life of the cells.

The experts recommend that we should get our A1C level tested at least twice a year. People who take insulin need to get it about four times a year.

If the test shows that our blood glucose level is high, it means that we have a greater risk of having diabetes problems. Think of the A1C as an early warning system for the insidious complications that we can get down the road when we don't control our condition.

But what do we mean by a "high" A1C level? Here the experts disagree.

The American Diabetes Association says that we need to keep our A1C results below 7.0 percent. The American Association of Clinical Endocrinologists sets the target at 6.5 percent. The International Diabetes Federation, or IDF, also recommends that most people with diabetes keep their levels below 6.5 percent.

The more our A1C level is higher than normal, the greater the likelihood that we will suffer from one or more of the complications of diabetes. And here too the experts disagree with how they define "normal."

People who don't have diabetes have A1C levels below 6.0 percent. That's the gist of what I wrote here recently in "The Normal A1C Level." The IDF agrees. But more aggressive endocrinologists say that a truly normal A1C ranges from 4.2 percent to 4.6 percent. That's what Dr. Richard K. Bernstein wrote in Dr. Bernstein's Diabetes Solution.

No matter what our level is, we can be sure that lower is better. Unless we drive it so low with diabetes drugs that we run risks of hypos or heart problems. Concerns with these risks are the main reasons why our diabetes organizations set a goal that is higher than a normal level -- even though they know from clinical trials, like the UKPDS and the DCCT, that with higher levels we will probably suffer from the serious complications that result from high levels.

Then the question becomes what is our best strategy to bring our A1C level down to normal. Not surprisingly, the experts disagree here too.

The key has to be the level of carbohydrates in our diet. After all, like Dr. Bernstein says, diabetes is a disturbance of carbohydrate metabolism where our blood glucose rises above normal.

But for years the ADA has told us that "The recommended dietary allowance for digestible carbohydrate is 130 grams per day." On the other hand, Dr. Bernstein's diet allows no more than a grand total of 42 grams carbohydrate each day. While his books don't say, he has told me directly that he's talking total carbs, not digestible carbs.

I know from my personal experience that Dr. Bernstein's restrictions on carbohydrate do indeed bring our A1C levels down to normal. My most recent test was 4.8 percent -- without drugs.

Even before 2007, when I began following a very low-carb diet, for about two years after 2005 one diabetes drug helped me reduce my A1C from 6.8 percent. I know that Byetta works to help us achieve diabetes control, especially when we eat fewer carbs, as I began to do then.

The further benefit of both a very low-carb diet and Byetta is that they will help us control our weight far better than anything else. Since more than 85 percent of all of us who have diabetes are overweight or obese, according to a survey by the U.S. Centers for Disease Control and Prevention, I have to conclude that controlling our weight is a key step in controlling our diabetes.

With diet and weight loss alone we may be able to get our A1C level down to 6.0 or better. But we can sure make it easier on ourselves if we ramp up our metabolism. Physical exercise reduces our blood glucose by improving our glucose metabolism, according to recent studies. That's the best reason for us to get at least the recommended minimum of 150 minutes of moderate-intensity exercise each week.

The other leg of diabetes control has always been to take one of the 10 classes of diabetes drugs we can use. Until we bring our A1C level down to normal, taking one of these medications is essential. I know that taking a couple brands of sulfonylureas and then metformin helped me before I was able achieve my greatest benefit from Byetta.

We tend to forget the importance of reducing the stress in our lives through readily available tools like relaxation and meditation. Likewise, we are just beginning to realize the huge role that reducing inflammation can play in getting control of our diabetes.

Even the amount of sleep that we get can help us control our weight, which probably will help us control our blood glucose level. A new study less than a week ago shows that identical twins who slept between 7 and 8.9 hour each night weigh less than those who regularly sleep either less or more.

These tools are the keys to getting our A1C levels down to normal so we can control our diabetes, instead of letting it control us. All of them are important. But nothing works better than a very low-carb diet.