Posted by on Tuesday, 27 January 2015

6.5% A1c target - A reply to a comment that got out of hand

I've had a couple of comments on my post about the proposed new HbA1c target in the draft NICE guideline that is currently out for consultation. I was rattling in a 'quick' reply, when I thought - this is *ridiculous*. I can't even see this any more in this tiny box - so I've decided to post it here instead :)

Here are the comments:
Tamer Hassan said...
how do you achieve these numbers?

thanks
Tim said...
These numbers are impossible to reach...
Or at least give me some suggestions on how to reach these levels. Thanks.
Tim

'How to reach these numbers' is a question for your healthcare provider really. Don't just ask some random nutter on the Internet! However (and desperately trying to avoid sounding like Mr Smug of No 22 Smug Gardens, Bigheadshire) I have had a sub 6.5% HbA1c for over 3 years now, so I know that it *is* possible if only perhaps for the lucky few. Plus I've never had fewer hypos in my life with diabetes either - so it's not that I am 'paying' for A1c improvements with the hefty cost of Severe Hypoglycaemia.

I cannot really tell why some people seem to put in so much effort and get such scant rewards, and that is why I think individualised targets are SO important.

But it does seem pretty clear to me that the closer you can get to those standard-issue BG targets (5-7mmol/L waking, 4-7mmol/L pre meals and <9mmol/L by 2 hours after meals) for as many days in the week as you can manage, the closer you will get to these kind of tough, aspirational, borderline non-diabetic A1c targets. My own HbA1c has fallen by around 1.5% in recent years, and I think only around 0.5% of that is attributable to the pump - though Artoo has gone a LONG way to reduce my number of irritating low-level hypoglycaemia dips. When I look back over the changes that I have made in recent years I can see a few things that I think were important. I don't offer these as any kind of guide or advice - it's just what I did.

  1. Education. Get access to proper structured education regarding diabetes management. In the UK we have DAFNE which is highly thought of, but other options are available. Things that should be included (in my opinion) are:
    1. carbohydrate counting, working out how to check and change insulin:carb ratios for different times of the day
    2. SMBG technique - when to test and what to do with the results *including* basal testing to PROPERLY adjust basal on an ongoing basis
    3. correction factors - when and how to correct (with insulin or fast-acting carbs) to aim bring you back into range without jumping aboard the gluco-coaster
    4. exercise and alcohol
    5. dealing with illness
    If structured education courses are not available in your country/area you can do a lot worse than buying 'Think like a pancreas' (Scheiner), 'Type 1 Diabetes' (Hanas) or 'Pumping Insulin' (Walsh/Roberts) which cover much the same ground. Though the benefit of peer support in group sessions should not be underestimated


  2. Test more often AND RECORD THE RESULTS. Find some way of keeping notes daily as you go along. What you are eating, units and timing of doses (how long before... split doses...), exercise, mood, everything! Without a fairly detailed set of records I find it impossible to see what is going on. Personally I still love mySugr for this.


  3. Gadgets - seek out new tech that can help you manage your diabetes more easily. It might be a 0.5u pen; a smartphone tracking app, or copy of 'Carbs and Cals'; or it might be a BG meter with a bolus wizard so that you can have properly fine-tuned ratios without having to worry about keeping the maths easy. Additionally, ask your clinic about access to Insulin Pump therapy and CGM.


  4. Seek peer support - join a forum or two, join Twitter, read some blogs (thanks!) or even *crazy!* join a local group and meet face to face. Living with diabetes is tough, but it's even harder if you are battling on your own. For everyone there's a little corner of the internet that can provide support, encouragement and shared experiences.



At the end of the day we each have to find our own balance between living a life and managing our diabetes. Somewhere in the middle you'll find your perfect A1c and it won't drain all the joy out of life to reach it.

Good luck :)

7 comments:

  1. Great post! I love the fact that you acknowledge that these kinds of numbers are only possible for *some* people.

    I have both addison's and diabetes. My HbA1c is 33 mmol/mol, or 5.2% which is pretty freaking awesome - but is skewed by the fact that because addison's takes away the body's ability to raise blood sugar, I never have a rise in sugar except when I eat or take a dose of my steroids. By around 3am my blood sugar has dropped to around 4.5 and it sits between 3.5 and 4.5 all through the night - I don't get dawn phenomenon.

    In fact, my HbA1c has gone *up* since I started insulin, because I can eat more carbohydrate without hitting silly levels. I'm healthier and happier as a result.

    The differences between managing addison's and diabetes together, and "just" managing diabetes make it obvious to me that I have it easy - when I exercise I go down, when I'm sick I go down - until I take extra steroids to bring me up, and I know how much steroid I've taken and can counteract that with insulin if needed.

    For people who have working adrenal glands (the part that is borkened in Addison's) all of this stuff happens in the background - and individual responses to sickness, other hormones, exercise and stress vary a great deal. Basically you guys never know when you're gonna get hit with a dump of sugar. You can do a lot of work to get ideas about what's 'normal for you' - and thus learn to manage exercise, stress and minor illnesses... but inevitably there are days when you don't yet know that you're fighting a virus, you go to the gym and then your boss is a jerk and your sugar is suddenly way out of control.

    I also have really efficient kidneys in terms of clearing glucose, and that's made me aware that some folk will start dumping sugar in their wee at just 9 mmol/L and others hang on to the stuff right up to 20 mmol/L. Those extremes present different challenges - people who have a low-renal-threshold are more likely to have a spectacular hypo if their insulin peak and carb peak don't match perfectly in timing, where folk with a high-renal-threshold are more likely to have long-lasting highs. You might imagine that the low-threshold leads automatically to a better HbA1c but if it means you're terrified of hypos then it might mean taking less insulin to avoid them, and deliberately running high.

    I think the more of this stuff you know about yourself - how you sit relative to other people - the easier it is to interpret generic advice. Like you say, that's all about journalling. To the BG monitoring and carb counting and insulin and exercise diary I would also add regular urine testing, just so you get to find out what your renal-threshold is.

    It's definitely all about finding a balance that suits you. Having a non-diabetic HbA1c but no social life is not 'winning'. If you don't have a GP and diabetes team who are supportive of that then seek ones that are. And yes - get the peer support, I think for these life-long endocrine conditions there is really nothing as valuable as lived experience.

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  2. Thanks betabetic - couldn't agree more!

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  3. This is wonderful advice Mike - peer support in person, and through forums like this one, is invaluable.

    All Type 1 DMs should be encouraged to attend a DAFNE course locally, or do an online course such as the excellent Bournemouth one at www.bdec-e-learning.com

    Gary Scheiner's book is excellent too.

    The next step is making sure that the basal insulin is right - i.e. on a carb-free day the BGs should be stable without highs or lows. This is so much easier to get right with a CGM and the software that comes with it.

    CGMs have become much more reliable and easy to use - and cheaper! I do think we're falling behind in the UK with their adoption for Type 1 diabetics.

    So much of the NHS diabetes budget is spent on dealing with complications - we should really free up some funding for CGMs to achieve better control.

    Very best wishes,

    Ian

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  4. Hi from Belgium
    Thanks for this interesting article.
    What is Artoo?
    Thanks in advance
    MT

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    1. Hehe! Sorry MT Artoo was my joke name for my first insulin pump. Replacement to Pancreas #2 (R2-P2) http://www.everydayupsanddowns.co.uk/2011/11/look-sir-droids.html

      I'm calling my second pump Threepio (after I Collected my Third Pancreas Object).

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  5. Hi
    About the DAFNE course
    Did you do one and did it cater for a diverse group, or for a homogeneous group (IE ages and types of diabetes mixed, or a group for T1 and a group for T2)?
    Is it free of charge?
    How long did your course last?
    Was the group small enough for you to ask all the questions you had?
    Did you make friends and contacts with other diabetics?
    Was it interactive or was it a classroom type setup?
    Thanks

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    1. Hello Anonymous

      DAFNE is a UK-based structured education course for the intensive management of type 1 diabetes. It is offered free of charge in many locations in the UK, but some areas have their own similar courses with different names (e.g. BERTIE). The course lasts for 5 days and is either delivered as an intensive week, or as one day a week for 5 weeks. Discussion and interaction between participants is usually an important part of the course. You can find more here: http://www.dafne.uk.com

      If DAFNE is not run in your area the online e-learning BERTIE course is well thought of, though it lacks the interaction/discussion element among participants. https://www.bertieonline.org.uk

      Hope that helps
      Mike

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