The A1c, More Than Just a Number

Melinda Seed writes for Twice Diabetes

I was one of the many pwd who was stunned back in 2015 when the UK’s National Institute for Clinical Excellence (NICE) issued its Guidelines for Type 1 Diabetes in Adults. These guidelines recommended a “target” HBA1c of less than 6.5%.  The previous target was 7.5%

What I found stunning was that so few people managed to achieve an a1c of 7.5% or less and yet here they were setting an even lower target. For the record -the UK National Diabetes Audit showed that 29% of adults with type 1 recorded an a1c <7.5% (or 58mmol in the new measure) in 2015/16 AND fewer than one in fifteen (i.e. less than 10% of pwd) recorded an a1c of less than 6.5%.

It makes you wonder what exactly is the point of setting this number, what does it mean and is it sensible to set a target that appears cannot be achieved by 90% of people.

The anxiety is real for many! (Thanks to Type 1 Diabetes Memes)

 

 

 

 

 

 

 

Generally, when I speak with people with diabetes the target a1c is viewed as a pass/fail kind of thing. If you “score” more than a couple of 0.1 % points above the target then you’re a failure who’s going to bring all sorts of dreadful consequences on yourself, or even worse, your diabetic child.  This tweet sums up what I’d say is a pretty mainstream view of the a1c.
Replying to   
I know parents who dread clinic cause of HBA1C’s! They feel like a failure ifs it’s increased or stayed same.

Study after study shows that very few type 1s record an a1c of less than 6.5% but according to some people, setting the target that low will encourage us to do better than we otherwise might.  What seems to be missing in the communication around A1c targets is that the target is, apparently, “aspirational”.

British Endocrinologist,

The target is the “hole in one”- it’s what we aim for and we get as close as we can: provide skills/tools 2 get as close as they can

and later he elaborates on the aspirational target idea

This approach is taking us a long way from the scientific, evidence base of the a1c and into grey areas of motivational psychology.

The thing about setting targets is that if they are too difficult to achieve then performance is likely to suffer because many people are so discouraged by a target that appears out of reach is that they just give up-(the business world has lots of research on the psychology of targets-they’re usually called budgets).

Diabetes is forever and frankly, “failing” to reach a target every 3 months for the rest of your life is going to have a detrimental impact on many people’s sense of self-efficacy and potentially their mental health.

So what to do?

Let’s acknowledge that the lower your a1c the less risk you have for complications but that is not the only measure of a life well lived with type 1 diabetes. Let’s also acknowledge that the target a1cs, be they 7.5 or 6.5% are REALLY tough to achieve and therefore stop beating ourselves up if we “miss the mark”. Let’s look for practical ways to improve your a1c, I’ve said before if you’re at the Dr’s office ask for 1 implementable suggestion that will help get your a1c down & give it a go.

Unusually, I’m going to give the last word on this to another UK endocrinologist, Dr Partha Kar, who commented on the NICE target as follows

  Apr 2

I am saying no one should be judged by ability to hit a target- which appears to be nigh impossible to get to as per % achievements

Amen to that!

 How do you view the A1c? How has it been presented to you by HCPs? Do orgs etc? Please  let me know in the comments

10 thoughts on “The A1c, More Than Just a Number

  1. I do the best I can to manage my diabetes. The A1c shows if I’m doing a reasonable job (I think). I did get a 6.5 last time – don’t think I’ve got a hope in hell this time. T1 is not co-operating. Bah, humbug!

  2. A1c ‘target’ is a red herring. An illusion. Just aim to keep your BGs 4-5mmol/L before meals and no higher than 9mmol/L by 2 hours after meals for as much of the time as you can and you can ignore your A1c entirely. Keep making small changes to improve results around meals and reduce the number of lows you get and your A1c will look after itself.

    6.5% is not even really a ‘target’ in the context of the guidance you mention. 6.5% is only mentioned as something to *aim for* IN ORDER TO avoid microvascular complications. The data shows that 6.5% is more likely to give slightly better outcomes than 7.5%. But the ACTUAL ‘targets’ that people should be aiming for are supposed to be individually agreed with the person, taking into account their history, lifestyle, experience of hypoglycaemia, employment etc etc.

    Should someone who is currently just about managing to maintain 7.5% with all the effort they can muster be made to feel bad? Of course not!

    Should someone who is cruising at 8% feel that there is no point in trying to tighten things up because they are ‘basically there already?’. Well… maybe, maybe not. But it might be useful for them to know that there are some additional long term gains to be made below 7.5%. They are real, they are measurable and they could make a difference. That 7% for example offers better long term outcomes that where there currently are. And even dropping by 0.5% makes a statistically significant difference.

    Should someone who is at (the UK national average for T1D of) 9.5% be encouraged to aim for 8.5% or lower if they can manage it? Of course!

    Should someone who is (by virtue of luck, effort or fortunate physiology) able to achieve 6% or 6.5% with almost no hypoglycaemia be MADE to increase their A1c to 7.5% because “6.5% is *too low*?” Well the evidence says, no, they should absolutely not.

    The thing is we are all individual. There is no ‘one size fits all’ in this ridiculous, frustrating game.

    My thinking is to ignore A1c altogether. Focus more on the day to day ebb and flow of things. Try to make what small improvements you can, whenever you can. And don’t worry when your diabetes goes off on one and behaves completely illogically.

    Living with T1D is far more ‘art’ than ‘science’. And stressing about HbA1c is getting bound up with paint-by-numbers, when really you’d be better spending time developing skills to draw and paint freehand and creating a little beauty that is all your own.

    1. I think we’re in agreement Mike 🙂 I do understand the thinking behind the setting of the target, I maintain that it’s not the 6.5 per se but the communication and in fact the setting of a blanket “target” at all. Thanks for taking the time to make such a considered response.

  3. Diabetes is a daily challenge and I hate that some endos are so focused on that hb1ac number! They forget that it can be challenging living with a disease that impacts on every part of your life. To be hints I am currently 37 weeks pregnant with the best hb1ac that I’ve had in a long time of 6.1. Yes diabetes and pregnancy is hard work, but didn’t expect it to be that good.
    Ive stop stressing over it and look at my data of my pump and how amazing my numbers are!

  4. The A1c value is just a consequence. Real targets are actually aims: to live well, to avoid hypos and hypers (whether to prevent them somehow, or to react quickly – thank you, Libre!), to find out what usually causes troubles, to be OK generally *in present time*. Regarding numbers, for me there is something I could name as a target: to stay under 10 mmol/L as much time as possible, without hypos of course. Nobody judges me about that, simply because nobody watches my numbers (BGs) so much in detail but me.

    1. I totally agree, I did blog ages ago that the a1c isn’t actually a “SMART Goal” and recommended a balanced score card approach, I like what you said about the a1c being a “consequence”-that’s exactly the right word. I found the Libre great for the trend lines, really helped in the decision making process. Shame it’s so expensive, at least in Australia compared to the other options.

  5. The A1c is an outcome which is realised long after relevant decision points. It is therefore a poor behaviour driver. I believe that I need 2 things from my Dr, first I need good information and second, I need them to help me make good decisions. The A1c does neither of these things. It’s useful clinically, sure, but I am far more interested in learning about my own behaviour drivers, the things that influence my decision making. After all, I will make many many more decisions related to my health than any doctor ever will.

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