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HbA1c Roulette

If you have diabetes, HbA1c is a term that you’ll be well familiar with. Once you get on more familiar terms, it’s OK to call me A1c…

For the uninitiated, let’s do a quick lesson to get you up to speed.

Most people know that diabetes means that you have more sugar in your blood than you should have.

Part of the daily life of a PWD (Person with Diabetes) is that they have to check their ‘sugars’ (blood glucose levels) several times a day to make sure that they are hitting their target. A good result is a reading of say 6mmol/l (mmol/litre – don’t ask!). This can vary from person to person, but it’s not a bad place to start.

Still with me?

So that’s what happens every day. Every 6 months or so, off you trot to get a blood test which is whisked off to the lab. What comes back is your HbA1c reading, which effectively is a 3-month average of your blood glucose levels.

When you open the envelope, what you’re hoping for is a reading somewhere between 5.8 and 7.0. If you get that, you get a big gold star.

The reason for this is that there is a load of data from clinical trials that say if you are in this range, the chances of anything nasty happening are low- about as good as it gets.

But if you’re not in the Goldilocks Zone (GZ)? You’ll either be hypo- or hyperglycaemic.

About hypoglycaemia….

Realistically, if your blood glucose (BG) levels are very low, you won’t have to wait for a lab result before you know something is amiss. By very low, usually this means 4mmols/l. You’ll be having a hypo….

Severe hypos (defined as when you need help from someone else to bail you out) are classed as a medical emergency and can at best be unpleasant, at worst life threatening. Basically you have too little glucose in your blood to keep your brain working properly and it starts to shut down.

You’ll notice some or all of the following:


·   blurry vision·      rapid heartbeat
·      pale skin·      headache
·      shaking·      trouble thinking clearly or concentrating
·      sweating·      loss of consciousness
·      difficulty sleeping·      unexplained fatigue
·      skin tingling·      sudden nervousness
·      hunger·      sudden mood changes

There are lots of places to get advice about what to do – but the quick fix is a glucose gel rubbed into your gums, or a high sugar content drink. After that, some long acting carbohydrates – and hopefully all will be well.

You’ll have got the idea by now that hypos are not great. See table above….

But for some people with diabetes, if they aren’t experiencing mild hypos one or twice or thrice times a day, they feel that their BG levels are too high. This becomes Part I of ‘HbA1c Roulette’.

By running real ‘tight’ BG levels, the thinking is that you reduce the complications that having long-term high BG levels can bring (See ‘HbA1c Roulette- Part II). Which is a good thing.

But…..hypos can come on really, really quickly. If you have a BG of 5.5mmol/l or less, then your risk of a severe hypo is about 1.5 times greater than if you had a reading of 6.5 – and two and a half times greater than an of A1c of 8.

So yes – running tight has its benefits. It takes a lot more discipline and vigilance than running ‘hot’.

But- and it’s a big but….. one of the most common causes of death in young adults that run ‘tight’ is ‘death by tree’. Driving, overwhelming hypo, lose consciousness, drive off road, hit tree…die.

As you have diabetes for longer your ability to ‘feel’ or detect hypos becomes less. Yes you become less sensitive as you get older!

So that’s one half of HbA1c Roulette.

The other side is hyperglycaemia.

Often known as running ‘hot’ , it is often favoured by younger PWDs since you don’t have the worry of a hypo:


·      Excessive thirst·      Blurry vision
·      Excessive urination·      Sores that won’t heal
·      Increased urination at night·      Fatigue

Could be worse I guess- and in lots of ways easier to live with than running tight. The symptoms tend to be mild for the most part and you sort of get used to them. No worries then?

Mmmmm -diabetes is never that easy. So, no.

If your average A1c is around 10.5 over a few years, then the risk of you getting retinopathy (which might mean you going blind) is about 12 times higher than if you had an average A1c of 7.2 (remember the Goldilocks Zone?). Getting neuropathy is about twice as high. Without going on about it, your risk of your kidneys packing in, getting a foot ulcer, having a stroke or heart attack are all higher.

Running hot also opens the door to something called Diabetic Ketoacidosis (DKA). Basically this means that the body is so short of insulin that it starts to burn fatty acids. The body then produces ketones, which have the effect of making the breath smell like ‘pear drops’. DKA can occur in less than 24 hours of not taking enough insulin. Other symptoms include vomiting, laboured breathing, increased heart rate, confusion, disorientation and finally coma.

It is the biggest killer of children and young adults with diabetes….

DKA has been awarded the title of ‘the scariest complication of diabetes’. It is far more prevalent in Type 1, but not unheard of in Type 2. Regardless, the advent of symptoms of DKA are a medical emergency. Get help early and it can be sorted.

Depressing isn’t it?

Run too tight and you might hit a tree, run hot and you might get DKA…

Get the title of this piece now?

You’ve probably worked out that the place to be is in the Goldilocks Zone…not too hot, not too cold…

It means doing the right things well, most of the time. No-one is perfect so sometimes you’ll lose it and wander out of the GZ.

You just have to take ownership of it- it’s not going away any day soon.

Your diabetes, your life, your responsibility…

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