Passing the A1C “Test”…What Do I Need to Score?

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The following is an excerpt from The Born Again Diabetic by William Lee Dubois.

a1c translation chartNo one quite agrees on where your A1C score should be, but we all agree on where it shouldn’t be. The scale does not look anything like the BGL numbers you are used to. For all practical purposes, it runs from 5.0 up to 14.0 where most in-house A1C machines max out.

Labs can test higher, but at 14.0 your doctor will run screaming for the hills anyway, so it really doesn’t matter. At that level your blood sugar is lethal and your body is slowly dissolving, just as if you had battery acid in your veins and arteries.


As a side note, many offices have in-house A1C machines that give results in six minutes. Very handy. I personally love being able to discuss the score with the patient during the visit. Other offices do a “send out.” We generally do them in-house, but if we are also running other lab tests we’ll sometimes piggyback the test onto the blood draw. Both are highly accurate and reliable.

So back to your score. Scores below 6.0 are usually considered to be in the non-diabetic range. At 9.0 we cross the threshold where kidney damage starts. So we can all agree that above 9.0 you are in deep shit and the higher above 9.0 that the number is, the worse off you are because A1C tests are curvilinear. Just like Category 3 hurricanes are much worse than Category 2 storms, or like 7.3 earthquakes are much worse than 7.0s, each increase in your A1C number packs a larger punch than you’d expect.

The Born Again DiabeticThe numbers are sufficiently confusing that the ADA has introduced a new measure called eAG, for estimated average glucose. This is a formula that “translates” an A1C score into a “meter number.” It hasn’t been widely adopted yet and the jury is still out on how useful eAG is. I use it for some patients, but not for others, but I always like to have a lot of tools in my tool box.

If you are at 13.5, don’t panic, but be worried. In other

words, don’t lie awake at night staring at the ceiling, but don’t take your time getting your act together either. I’ve seen newly diagnosed patients with A1Cs in the 13s and 14s bring them into line within 6-9 months. Talk about feeling good when you go to bed at night, knowing you helped someone do that!

So, if 9.0 and up is bad, and below six is normal, shouldn’t we all be as close to six as possible or even in the fives? Hmmmm….well, maybe not.

The practice guidelines from the ADA for quite some time have urged doctors to shoot for less than 7.0 as the number for considering a diabetic “in control.” The Endos’ big organization calls for “as close to 6 as possible without hypoglycemia,” which many Endos feel isn’t possible. Another practice guideline for docs calls for 6.5.

Why all the confusion?

Diabetes History 101

Okay, once upon a time there was a huge clinical trial called the Diabetes Control and Complications Trial. It was the first foray into discovering what really tight control means or doesn’t mean. As it turns out, the lower your blood sugar, the fewer complications you develop. The results were not marginal by any means.

In fact, the improvements in the study group over the control group were so dramatic that the study was shuttered early and all the control group diabetics were added to the intensely controlled group so that they could live longer.

That’s what started the lower is better philosophy.

When Low is Too Low…If You’re on Insulin

Unfortunately, nothing is really that simple. I have a fit and fall in it when one of the patients I work with clocks a 5.8 A1C. Why? Because it can’t always be done safely. If you’ve got an A1C below six, and you are having a lot of low blood sugars, then aiming for an A1C that low isn’t a safe or healthy goal for you. Safety first, A1C second.

There are many diabetics on insulin today achieving A1Cs in the 5s with the support of low-carb diets because that approach reduces your insulin needs significantly which also significantly reduces your risk of low blood sugars–but again, if you’re in the 5s and having a lot of lows, then the more appropriate A1C goal for you would be in the 6s.

Remember? A1C is a game of averages. If you crash to 50 and rebound to 150 the average is 100. Right? Often low A1Cs are a warning sign of frequent hypos. Are frequent hypos a bad thing? Oh, yeah.

First off, they make you feel like hell. Second off, they can kill you. Third off, if you have too many of them you will lose your ability to feel them—like me. I’m a reformed control freak…er…control enthusiast. I burned out my hypo warning system. I do NOT know when I’m going low. It’s dangerous and scary.

Where is your A1C “supposed” to be?

At my clinic we used the 6.0 to 6.9 score range as “in control” up until recently. At 7.0 and above you were considered out of control but we didn’t begin to panic until you were above

8.0. As I mentioned before, if you are below 6.0 and reporting frequent hypoglycemia, we administer intravenous Twinkies and cut your meds back a bit.

Just when everyone was comfortable with that, everything changed again. My mother is still hopping mad that after years of eating margarine, which she hated, it was decided that butter was better for you after all. Well, that’s just the way things go. As time passes we all learn more, understand more, and things change more.

The smoke hasn’t cleared yet as of this writing, but a National Institutes of Health study called ACCORD, that was designed to push control into the non-diabetic range, was shut down early because the participants started dropping like flies. No one is quite sure why yet, but it has called into question the whole concept of low blood sugar as the Holy Grail.

Theories advanced include that maybe trying to drive diabetic blood sugars that low caused heart damage or that there might have been frequent hypos and rebounds that were hard on the heart. I can personally attest to the fact that a wicked low followed by a rebound can leave you feeling like the LAPD just beat the crap out of you. If you can feel it, it must being having some effect on your body. Or maybe it was just the stress of trying that hard to control blood sugars that gave people heart attacks. Who knows?

Let me tell you the tale of two patients…

First patient: We’ve got a T-1 who is in the final, advanced stages of kidney failure. His A1C is 6.2. WTF? you ask. Ahhh, but you must look at his meter download. He has hypos into the 20s. Sometimes his meter says “Hi” and it’s not just being friendly (in this case that means over 500).

For years and years and years his “perfect” A1C scores covered up the fact he had no frickin’ idea what he was doing. He was never properly instructed on how to care for his diabetes. Sloppy medical “professionals” just looked at his A1Cs and told him to keep doing what he was doing. And he did.

Now it is too late.

Second patient: Type-2 with an A1C in the high 8s for years, and years, and years with no hint whatsoever of any trouble. His meter shows his BGLs are remarkably stable. Always high, but always stable. Hmmmmmmmmm….

As continuous monitoring goes mainstream I think we will find that within the sub 9.0 range, excursions will play a larger part in causing problems than average blood sugar will. “Excursion” is a word for rapid changes in blood sugar, upwards.

So you eat the fudge-fudge walnut brownie sundae at the Elephant Bar, a carb-packed creation originally designed to provide dessert for an entire African village for a week. Of course you eat the whole thing yourself. In fifteen minutes. Yes, guilty as charged, I have actually done this….but only in the interest of clinical research, of course.

And of course, your sugar explodes upwards…125…159…173…206… 282…341…414…

You just had an excursion. Now if you’re a T-1 like me, you took insulin before you ate that monster. A lot of insulin. But the body, medicated or not, can’t deal with that kind of sugar load. Usually, 3-4 hours after an excursion you are back in normal range, but…well, we are still trying to understand the details, but it sure looks like excursions may be damaging to cellular tissue, probably causing micro-vascular damage. In other words, damaging your capillaries. Time and scientific research will tell us more. In the meantime, I can attest to the fact that if I’ve had a bad excursion I feel like crap; my body is sending me a message that I’d be wise to heed.

But enough of an excursion about excursions, let’s get back to the A1C. Until we know more, for now I think if your A1C is between 6.5 and 7.5 you should consider yourself in control. And you should strive for stable numbers that change slowly from hour to hour.

An A1C test is run quarterly, twice a year, or once a year, depending on how good or bad your control is; how good or bad your insurance is; and your provider’s approach to diabetes care.

Even in healthy, well-controlled patients, I like to run the test every quarter. If something is starting to change I want to jump on it right away. Remember: all diabetes is chronic and progressive and the body eventually adapts to all meds; they will lose their effectiveness. One of the few constants in the universe is that your diabetes will get worse no matter how hard you try. But remember, that is not a death sentence by any means. Diabetes gets worse, but we have a never-ending supply of tools to meet the menace and keep it in check.

Diabetes really isn’t that hard to control; but it does, to paraphrase Thomas Jefferson, require eternal vigilance.

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