What is a good HbA1c for type 1 diabetics

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Louise Willis posted on Thu, May 24 2012 2:34 PM

My daughter is a 21-year-old college student who has had type 1 diabetes for 16 years. Her last two HBa1c's were 7.7 and 7.8 respectively. Her doctor tore into her for not "rotten" HbA1c's. I think for a brittle diabetic these were very good numbers. She tends to "crash" a lot, so the goal was to not crash and keep her A1c's as low as she could. Are these bad numbers? The pump did not work for her and she really cannot afford it anyway. She gives herself 6-10 shots a day after checking her sugar readings as many times (or more) so she is keeping up with it as best she can.

Thank you.

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amrad replied on Thu, May 24 2012 10:19 PM

7.0 or less is the goal. I would question the 6-10 shots per day. It sounds like she is snacking alot between meals, or not counting her carbs correctly.

My advice is for her to get some more diabetes education.

from the Boulder Medical Center website on brittle diabetes:

Brittle Diabetes Mellitus

Thomas Higgins, M.D.

Brittle Diabetes is a subjective term and the diagnosis often depends on the experience of the patient, family and physician involved. The most useful definition of brittle diabetes is a functional one: "the patient whose life is constantly disrupted by episodes of hyper- or hypoglycemia, whatever their cause". While these patients are rare (less than one percent diabetics), they cause a considerable burden on hospital, social, and family resources due to multiple hospital admissions.

Many early studies tried to identify possible physiological mechanisms for the brittleness but with increasing study, it has become clear that the majority of cases are due to psychological factors. Metabolic abnormalities are a rare cause of poor glycemic control.

Natural History:

Brittleness may be in the form of hyperglycemic brittleness, hypoglycemic brittleness or a combination of both. Brittle diabetics followed over a long period of time have been noted to have certain characteristics:

  • Most patients were consistent in whether their recurrent episodes were hyperglycemic or hypoglycemic in nature. Only occasional patients showing "mixed brittleness".
  • Women predominate in most studies of brittle diabetes but men frequently also are found to be brittle. In my own experience, brittleness is more common during puberty in both sexes.
  • There is a significant mortality rate. Among survivors, the insulin dose tends to drop over time and episodes of hyperglycemia and severe hypoglycemia become less frequent.
  • Diabetic complications seem to be more frequent in brittle diabetics and are most likely related to poorer metabolic control.

Cause of Brittle diabetes:

It is clear that the brittleness in most patients is related to a specific unhappy life situation; when this resolves, so does the brittleness.

Hyperglycemic brittleness is rarely related to a chronic cryptic infection.

Hypoglycemic brittleness is rarely related to diabetic gastroparesis where the stomach has a delay in emptying or hypoglycemic unawareness where the patient can not sense a low blood sugar.

Treatment:

The approach to management will obviously vary depending on the specific cause in each case. In evaluating a patient with brittle diabetes (who may have mountainous medical records!), it may be beneficial to start fresh with a new physician and diabetes care team. A fresh look is helpful in remaining objective, decreasing the ability of the patient to manipulate the care team and possibly spot a metabolic cause which may have been missed.

It is important to take a detailed history and do a detailed physical exam. It should also be determined if there was a period of "stable" diabetes preceding the brittleness, and what happened in the patient's life circumstances coincident with the onset of brittleness.

A diabetic educational assessment is important to evaluate whether the patient knows how to manage diabetes, and whether the current insulin regimen is reasonable. In addition, as many as one third of patients with brittle diabetes have been found to have a "communication disorder" (which can be diagnosed by speech language pathologists) as the major cause of their brittleness; specific treatment is beneficial in 75% of cases.

A psychological evaluation is always warranted, since psychotherapy has been shown to be effective in selected patients. Family counseling is also often necessary.

For severe cases of brittle diabetes, a structured hospital admission may be necessary. Generally these admissions are prolonged, lasting for two to three weeks. Pre-hospital planning is important and insurance pre-certification is often necessary. Early in the hospital course, the patient must be monitored closely and have all diabetes care done by the hospital staff. Gradually, the patient is allowed to become more involved in his or her own care. Intensive diabetes education is necessary as well as ongoing psychological support.

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ckdsite replied on Mon, May 28 2012 5:05 AM

Hba1c, as most diabetics know, stand for the hemoglobin A1c examination. This is a measure of the percentage of red blood cells that have become glycosylated. That means they have been “caramelized” by constant exposure to high glucose levels. Different from daily blood sugar tests, Hba1c is test can give a full picture of your average blood sugar levels in the past three months.

Have a look at what your hba1c level means:

Normal A1c should be 4 to 5%

5.8 to 6% is an indicator for pre-diabetes

Hba1c 6%, representing average blood sugar level 135mg/dl on an average of three months, usually means type 2 diabetes has developed, but is not always the case. Other tests are needed to determine risk factors.

American Diabetes Association indicates hba1c should be controlled under 7 for diabetes. New research suggests the treatment goal should be closer to 6%.

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floydf replied on Sat, Jul 21 2012 1:58 PM

I found that the fast acting insulin was too fast for me to control.

It follows a philosophy that the patient intakes calories, then tries to match the units and release of insulin against the calorie intake. This makes calories and insulin both variables, a moving target each day(or even 6 times a day)

The philosophy of intermediate and long lasting insulin is to match the intake of calories against the release of insulin. This allows me to maintain an A1c in the 6.0 range, with a minimum of hypoglycemic problems.

This does mean that I follow a specified units of insulin injection(1 injection per 24 hours) and calorie intake schedule to match the release of insulin.

Exercise is treated as an adjustment in calorie intake for each hour of exercise.

Only her medical provider can determine the best method to control her diabetes.

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floydf replied on Sat, Jul 21 2012 7:33 PM

The word brittle can be expressed by the rise in blood sugar for a specified calorie intake. For example, 1 slice bread will raise my blood sugar by 20-25 points, 1 fruit by 25-30 points.

The test method I used was to measure my blood sugar early in the morning, intake 1 fruit, wait 30 minutes before measuring my blood sugar again, wait another 30 minutes and measure my blood sugar again. Then start my normal day. The test measurements give me a good idea of the affect on blood sugar for 1 fruit. If your blood sugar goes over 140 the test can be distorted by the threshold for the kidneys lowering the blood sugar.

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For a response to this post by Joslin's Chief of Pediatric, Adolescent and Young Adult Section, please see the "Parents" discussion board under "Pediatrics". The posting is entitled "Response to question about A1c goals for young adults."

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Debbie replied on Tue, Aug 14 2012 1:31 PM

I will also post Dr Laffel's reply here as well.

-Debbie Butler, MSW, CDE, Pediatric Discussion Board Moderator

"Thanks for voicing your concerns about your daughter. Diabetes management takes a lot of time and effort. Often, there is a focus on ‘numbers’ – blood glucose numbers, A1c numbers, weight, blood pressure, cholesterol, etc.  Yet, it is always most important to focus on the person with diabetes, like you are doing for your daughter. It sounds like she is working very hard to care for her diabetes by checking her blood glucose levels at least 6-10 times daily, taking insulin 6-10 times a day, and seeing her diabetes health care team regularly. The A1c goal for your daughter is generally decided by both the diabetes health care team and the patient - your daughter - working together. For a person of your daughter’s age, the American Diabetes Association recommends an A1c less than 7% - but the specific goal for your daughter would likely take into account many other factors than just her age – factors such as history of severe low blood sugars (hypoglycemia), pregnancy planning, etc. Most importantly, one should recognize the hard work and the effort that your daughter is giving to her diabetes management. And then if goals are not being met, your daughter along with her diabetes team can put into place a realistic plan to work towards achieving those goals. THANKS for sharing your caring thoughts about your daughter as many other parents and loved ones of patients likely feel the same burden about the “numbers” as you do. Keep us posted with your thoughts and progress."

-Lori Laffel, MD, MPH

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Thank you so much for your thoughtful reply.  She, indeed, is a person, working hard in college with one year to go and maintaining A average. She takes her diabetes seriously. I will show her your reply and perhaps that will give her some positive feedback for a change, for all her efforts. Thank you, again.

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floydf replied on Wed, Aug 15 2012 5:18 PM

amrad emailed me a link to the relationship of A1c and consequences of diabetes that you may find helpful. Google NDIC (National Diabetes Information Clearing house) and look at statistics. The Dr was viewing the information and trying to emphasize the effects of an elevated A1c value.

The 'crash a lot' is the nature of fast acting insulin, it is difficult to set an objective goal for blood sugar value when the response time is so short.

If she could set a routine for calorie intake, specified type and amount of calories and time, then maybe she could adjust the insulin amount and time according to actual blood sugar measurements , following a strict routine each day. The more she can keep the variables fixed, the greater the control.

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bjkiah replied on Mon, Jan 21 2013 10:36 PM

I know it's been a while since you posted but I though I would respond. I have had Diabetes for almost 54 years and all of my young years I heard Brittle which I found out later meant I just didn't understand how to manage my disease. As someone answered earlier your daughter needs more education on how to manage your Diabetes. Why she crashes is because of all those shots she gives herself, whether they're for snacks or corrections. She's not considering the IOB means insulin on board that she previously gave herself. I hope by now she has acquired more knowledge regarding how to manage her Diabetes.

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