Yesterday, I asked a question on the Diabetes 24-7 Facebook page, and received a very intense response. The question was asked in response to a previous post reviewing a scientific paper that concluded only 52% of all diabetes patients achieve targets (<7%).
Is achieving an A1c <7% too difficult? (pls indicate if you are T1 or T2)
Numbers often define who we are – especially in the “eligibility” profile world of today’s insurance market. On paper what does the insurer visualize when he looks at an application of a 55-year-old salesman versus a 28-year-old corporate lawyer? Numbers give us opportunities or force us to admit weaknesses. Scores and grades can define what we appear to be, as can household income or tax rates. I could go on but I think you get the point.
So, what does the HbA1c result say?
If I look at the responses from the FB post, all I can say is WOW. See the RESULTS Page for actual comments (no FB names are mentioned). Patient comments tell me that the HbA1c is EVERYTHING to most people with diabetes (Type 1s and Type 2s). It’s obvious HbA1c reflects an individual’s circumstance, ability and perceived or acknowledged achievement, and patients (and parents) have stories to tell about that journey, especially if they haven’t arrived yet. Let’s just say responses were either a chance to brag a little (and why not, for goodness sake!), or confess or just weigh in that “Hell yeah, it’s hard!” (From a Type 1).
|Type 1 = 98||<7.0%||>7.1%||No HbA1c result, but A1c opinion|
|Children via parents||10||5||0|
|Teen via parents and 2 self-report||0||6||0|
|Type 2 = 32||<7.0%||>7.0%||No HbA1c result, but A1c opinion|
|Children via parents||0||0||0|
About 20 responses were discussions or not relevant. Before we head off interpreting my very non-academic study, I think it is important to address a few facts:
- HbA1c is an 8-12 week average of overall blood plasma glucose but a very good number like 6.0% can reflect a great deal of very low results with very high. Bouncing is absolutely the worst situation as low-lows and highs can result in coma, cardiac arrest or death. A smooth consistent line representing no huge divergencies resulting in something like 7% (and even a little higher) is much, much better.
- HbA1c diagnostic machines VARY in accuracy. Home tests are usually not good. Your doctor’s desktop series can range from bad to OK to accurate. Ask your doctor if the machine is CERTIFIED. This is very important. If it is not, then I would ask for a lab report. Lab results are usually spot on. (Bad to accurate can be the difference between a 6.5% to a 7.5% – yes margin of error can be as high as 1-3%!)
- Resources make all the difference for good versus poor diabetes health. Often this is not a case of funding but availability of good doctors and professional diabetes teams in certain geographic locations is non-existent.
- Diabetes is expensive.
- Diabetes control collapses in the midst of stress, and another illness.
Now that we have that out of the way, here are some very basic observations from the responses. Nearly 9000 people clicked the FB post, yet only 150 people wrote down either an HbA1c number or their thoughts about whether it was difficult to achieve 7% or not. About 170 shared or “liked” – I didn’t count them. Most everyone who thought getting to 7% was “easy” or “not difficult” had Type 2; any Type 1 who answered this directly mentioned words like “hard” or “difficult, but achievable” “horrible” or “<7% hasn’t happened.” The figure of 160 is tiny – just under 2% of the 8700. Why? It could be the low response rate indicates that patients didn’t like the question, or didn’t feel it was relevant for them. It could mean that the ADA researchers are right and 7% is too hard. It could mean many things – except for nothing.
But back to that number…from what I can gather, people perceive an HbA1c result under 7% as good, but not perfect for a Type 1 patient. Alternatively, a result under 6.5 is God-like. Ditto for under 6%. Opinions vary, but the perception that lowest is optimal is incorrect because of the risks associated with a severe hypoglycaemic episode. If you still produce insulin – don’t include yourself in this conversation. Type 1 teens are faring the worst which I believe has been acknowledged by medical experts but not addressed. Women seem to be more concerned about their health (as usual) but men seem to be more transparent. Young children seem to get the very best care. Who can argue with that? Insulin pumps and CGMs are cited most often as being the “lifesaver” or the device that allows for best numbers/targets.
For the Type 2s who responded, it is all about restricting food intake, losing weight and exercise. Many of those who left a comment wrote they had lost 30 pounds or went from a 10 to a 6% in 3 months. Motivation for T2 patients seems to be coming off insulin injections. There was a sense of rightness and wrongness in their tone. Getting A1cs down is the “right” thing to do! Fair enough.
What do you think? Are self-reports real? Should we allow the HbA1c number to define us so simplistically? Are we too quick to judge our diabetes comrades? Is the diabetes community fearful or confident? Will patient integrity (trust) and (mental) instability always be what doctors use as the reason why patients’ cannot achieve targets? (Ooy, saying that almost made me feel ill.)