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 |
| Men | 6 | 7 | 0 |
| Women | 24 | 17 | 17 |
| 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 |
| Men | 6 | 3 | 5 |
| Women | 9 | 2 | 5 |
| Children via parents | 0 | 0 | 0 |
| Teen self-report | 1 | 1 | 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.)
You decide.
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{ 6 comments… read them below or add one }
I saw the question and didnt respond. Partly out of busyness and partly out of guilt. My 6yr old son (turning 7 on Sunday) has Type1 Diabetes. He was diagnosed at age 4 and his A1C has never been in the 7 range. Although it has gotten better since diagnosed, his last A1C in January at his Endo appointment was 8.6…. He is constantly up and down with his blood glucose and constantly getting ill. Diabetes IS hard to manage and very ecpensive. I am a very careful mother and extremely paranoid when it comes to my son’s health. He is big for his age but his height and weight are compatible and neither too much. He is very active and eats really well. I am constantly seeking medical advice to get his BG where it is “supposed” to be. Fortunately, he has never had a detrimental high or low; although, his lows are worse than his highs.
All that being said, I am always nervous to see his A1C at his Endo appointments every 3 months because I feel like a failure when they come back and don’t meet the standard I am supposed to achieve with him. Everyone is so different when it comes to diabetics and how their body responds or doesnt respond to insulin, illness, activity, sleep, foods, etc. I think its difficult to expect a (nearly) 7 yr old child to have the same A1C as an adult who say, has had diabetes for 20 yrs and knows their body well. We are still “learning” and he is ever changing… Do I strive to have his glucose and A1C in the perfect range? Absolutely. But is that a reality of his day to day life? Not even close.
I was just going to type my response and then was amazed to see Beth’s above. I wondered if I’d typed it without remembering! Same name, same story. Too busy to respond to the post the other day, my 7 year old’s A1C has always hovered just above 8% since his diagnosis a year and a half ago, we dread getting the number from the endo. The only difference is that my son is tiny for his age. We struggle to keep his numbers in range, but he zooms from highs to lows everyday with seemingly no rhyme or reason. So count us as a “8%” and another “super difficult”.
I am a mother of a high school senior – an athlete too – being recruited by colleges for soccer and his A1C tends to define us also. He is one of four and life can be difficult. He was diagnosed 4 years ago and we have worked diligently to stay under 7.0. He is unaware of lows so I have for the past 4 years gotten up at least every 2 hours through the night to take a blood sugar or look at his CGM (if he is wearing it). The alarm isn’t loud enough to wake him. He tests 10 times a day on average because of the amount of exercise he gets daily – it’s not easy but I say it’s worth it. I am dreading him going off to college but know that he will manage. He does and will have to get up through the night after games to take his blood sugar but until something new comes along this is the best we can do and it’s working for now. There is no doubt it is difficult!!
I am 30 and a type 1 diabetic as a result of chronic pancreatitis since my early teens. Last October after a long run of this horrible illness I finally had a total pancreatectomy. I have a host of gi issues along with the diabetes (malabsorbtion, gastroparesis, etc…) So it’s constant roller coaster with the blood sugar. I take a shot, eat, then vomit and have a low….or my gastroparesis sends me to a low then a super high high when my stomach finally empties. And diabetes can just be unpredictable with so many different variables…exercise and go low, sleep in and go high, it’s a friggin tuesday morning so for the heck of it why not wake up with a 500. If my a1c is an 8, especially “a steady 8″ I am sooo excited about it. I get so frustrated over this a1c stuff. Endos, other diabetics, or the usual “experts” who knows someone with the “bad kind of diabetes” who ate cinnamon for a month and cured it….I can’t stand it when others criticize my numbers. It’s hard enough to live with this disease and never a break. Would I love a “good number” sure of course I would but I have had an a1c of 6% before and still had several low lows and just as many highs that you mentioned. I would rather be at a steady 180 or 200 than 45-600 over the spand of hours. I come from a family of type 2s which adds a whole other level of diabetes drama to my life…because if I would just take this pill, eat cinnamon, adjust my dose of insulin, drink only diet whatever….then of course that 300 wouldn’t be on my meter. (I’m not one of those diabetics that hates on other diabetics either…I do think diabetes just sucks…type 1, 2, 1.5 whatever kind…it all just sucks!) I am super excited to be getting a pump though. Maybe I will get to that glorious steady 180 soon! One can dream.
My latest Hba1c was 6,9%
I am trying LCHF diet. I am tired of stuffing myself with carbs when I do sports, taking a lot of insulin at other times, always trying to manage carbs vs. Insulin. So now I try this after having read a lot. It is huge in Scandinavia and has been around for a while. Will report on my Hba1c in a couple of months, hoping it to get down to 6,5%. -After one week I am doing fine, very few lows/hypos, some highs and no problem with energy. Will get back!
http://www.dietdoctor.com/lchf
http://www.dietdoctor.com/page/2
I am a type 1 diabetic and have been for 23 years (I am 27 now). My latest A1c was 6.3, but that was a long and hard battle to get to that number. Just a year ago my A1c was over 9. We do judge ourselves by that number as diabetics, but I am incredibly proud of where i have come from and the control that I have in this moment.
As a diabetic, I have to live my life one day at a time and stop looking back at my success or failures, this is a battle and a journey, I am just grateful for everything that we have that makes it just slightly easier to manage. The CGM was a life saver for me in my disease, and I look forward to what else will come out for us struggling with this disease.