Can your a1c be too low type 1 diabetes statistics

Almost everyone who lives with diabetes is probably familiar with the A1c test. In the diabetes online community (DOC), much discussion can be found about how to lower that number. This makes sense since it is well-known that lowering A1c correlates to a decreased risk of developing diabetes complications. What is Recommended

The American Diabetes Association (ADA) recommends that adults aim for an A1c level of 7.0%, and highlight that this goal may be adjusted based on patient demographics. For example, a young person who wears a CGM may be more likely to set a lower A1c target, whereas an older individual who does not frequently check their blood glucose level may opt for more relaxed control. Furthermore, for women who are pregnant or planning to become pregnant, much tighter blood glucose control is advised.


The Controversy

As there are numerous biological reasons for maintaining normal blood glucose levels, it follows that keeping blood glucose in the normal range as much as possible is a reasonable goal, if it can safely be achieved. Can People with Diabetes have a Normal A1C Level?

In recent years, I have come across numerous social media posts about people with diabetes having A1c levels that are “too low.” In particular, I was floored by posts about medical practitioners automatically telling their patients that their normal A1c levels were unsafe and that they should aim higher.

Time and time again, I have seen stories of endocrinologists and general practitioners discouraging patients from an A1c level in the 4.5-5.5% range, with some even advocating for an A1c level of no lower than 6% or even 7%! Moreover, I have seen such reports from pregnant women, which is astounding, since optimizing blood glucose control is especially critical during pregnancy.

I’d like to think that a truly knowledgeable endocrinologist would never give bad advice about blood glucose targets. I imagine that upon being confronted with a normal A1c level in a patient with diabetes, the practitioner would evaluate how frequently hypoglycemia occurs and how severe it is. In other words, is the patient successfully achieving a normal blood glucose levels for a vast majority of the time, or are they swinging wildly above and below their optimal range to achieve a normal average?

With enough blood glucose testing, and better yet, with the use of a CGM, this is easy to determine. For example, the Dexcom Clarity app provides the standard deviation, a measure of variance among the blood glucose values. This can also be calculated using an Excel spreadsheet or another tool, as long as enough blood glucose values are available.

Here is an example of what blood glucose levels from two individuals with the same A1c level of 5.1% may look like over the course of ten days. Although both individuals have the same blood glucose average of 101 mg/dL, one of them is achieving this without much fluctuation from normal blood glucose levels. This is a fantastic result. However, the individual with the higher standard deviation is experiencing frequent episodes of severe hypoglycemia, which can be very dangerous.

Unfortunately, it appears that some practitioners still operate on the assumption that if a person with diabetes has achieved a normal A1c level (i.e., 4.5 – 5.6%), the patient must be experiencing frequent and/or severe hypoglycemic episodes. Of course, this way of thinking is short-sighted. The patient’s time in range and risk of severe hypoglycemia must be considered to have a full understanding of the scope of control to make the appropriate recommendation.

It is likely that a long history of generally suboptimal control has influenced some practitioners to assume that getting very close to maintaining normal blood glucose levels is not possible for people with diabetes. However, with advances in medications, technology, and treatment strategies, some people are achieving normal A1c levels with little variance in their blood glucose levels. The Bottom Line

Certainly, if a normal A1c level is attained through extreme blood glucose fluctuations and severe hypoglycemic episodes, this poses a considerable risk to the patient. However, if one achieves normal blood glucose values consistently, spending little time outside of their desired blood glucose range, it is reasonable to assume that their normal A1c value is safely attained.

Today, in particular, with the availability of CGM technology, which can provide a comprehensive picture of the time spent in range, while helping to safeguard from severe hypo- and hyperglycemia, I think it is very reasonable for individuals to set their sights on tighter control. After all, normal blood glucose values are physiologically important and provide many short-term and long-term physical and emotional health benefits.

Maria Muccioli was diagnosed with type 1 diabetes in 2008, as an undergraduate student studying biochemistry. This event largely inspired her graduate study in immunology. She actively conducted and disseminated her research in ovarian cancer immunology throughout her graduate career, obtaining her Ph.D. in Molecular and Cellular Biology from Ohio University in 2014. She completed a two-year postdoctoral appointment at the Ohio State University where her research projects focused on folate signaling pathways in the context of birth defects, and was later employed as a postdoctoral fellow at the Brigham and Women’s Hospital and Harvard Medical School where she investigated circulating biomarkers for the detection and prognosis of multiple sclerosis. Currently, she teaches biology for the Stratford University online division and also works as a freelance science writer and editor at Accdon, LLC. Maria is passionate about diabetes research, advocacy, and patient empowerment through providing up-to-date evidence-based information and peer support. Maria lives in NH with her husband, daughter, and many pets. In her free time, she enjoys traveling, hiking, and gardening.