Dear Doctor, Part II: Is a Low HbA1c Number Dangerous?

This is part II in a series of letters to my Doctor.


Dear Doctor:

At our meeting today, you expressed concern that my HbA1c number was too low, that in fact, you thought it was dangerously low and that it might lead to a heart attack. My "low" HbA1c number (which, according to you, means less than 6.5)  is still not in the "normal" range.  I am still at risk for organ damage because the number is too high, and yet you are concerned.

I believe you are mistaken. I have learned more about managing diabetes from a romance novelist (whose books have "bodice ripper" covers) named Jenny Ruhl (nom de plume: Jenny Brown) than from anyone with an M.D., Ph.D., R.N., R.D., or C.D.E. behind their names. She has thoroughly examined and ripped a part the ACCORD study, from whence came the idea that an HbA1c reading lower than 6.5 is dangerous, in several different places. The basic problem: the study participants took Avandia, a drug known to cause heart attacks (it was withdrawn from the market). So is it lowering the HbA1c that is dangerous, or the drug they were taking? She lists other problems with the study and even has a list of seven questions to ask physicians when they suggest that your HbA1c is too low. You may want to ask yourself all of these questions, as they might cause you to reconsider your recommendation. So I won't repeat all of that information here for you, as I know you have an Internet connection as well.

But it might be useful for you to read the statement published in the June 2011 issue of the New England Journal of Medicine. Here is an excerpt from that statement (again, that previously mentioned romance novelist alerted me to this editorial):

44.7% of subjects in the intensive-therapy group, as compared with 25.2% in the standard-therapy group, received rosiglitazone [Avandia] just before the study transition date. According to the 2008 article summarizing the results of the ACCORD trial up to the point of protocol transition, 91.2% of the subjects in the intensive-therapy group, as compared with 57.5% of the patients in the standard-therapy group, had received rosiglitazone...


Although other differences in drug exposure warrant further analysis, we think that the authors [of the ACCORD publications] should consider (and address in a secondary analysis) the role of rosiglitazone in the excess deaths from cardiovascular causes, especially in the absence of biologic plausibility of a glucose-mediated effect. Given unbalanced exposure, we thing that the ACCORD trial is inconclusive and that the recommendation to abandon lower glucose targets is not supported and has unknown consequences for the long-term management of diabetes [emphasis added].


The letter was signed by several prominent researchers and this casts considerable doubt on the idea that a score below 6.5 is dangerous.

In addition, I am a type II diabetic, not type I, and I have never suffered from hypoglycemia. My problem is hyperglycemia, and there is a huge difference. Plus, unlike some of the study participants, I haven't ignored type II diabetes for thirty years (and all of the complications that come with ignoring the disease for that long). I am grabbing hold of my health and making the changes for a more healthy way of living.

So might I suggest that lowering my HbA1c to a level between 5.0 and 5.9 is an appropriate goal for me? I have no wish to suffer any complications of diabetes because you think my HbA1c score is too low.

Sincerely,

HbA1c Results

My doctor (who is somewhat concerned about my low carb diet) wanted to check my HbA1c results. This is supposedly a long term measure of blood glucose, and the lower the reading, the better. She was happy with any result of 7.0 or below, but evidence suggests that your cardiac risk increases in a straight-line fashion for readings above 5.4. The higher the reading, the greater the risk.  Some experts suggest that an HbA1c should be between 5 and 5.9, while "normal" people often have a reading between 4.6 and 5.4. Long term damage to your body from high blood glucose levels will occur when the HbA1c levels exceed 6.0.

So what was my HbA1c reading? It was a disappointing 6.1. I was hoping to be in the 5.0 to 5.9 range. Now put that "disappointing" result in context: six months ago, using insulin and drugs, it was 7.2, and in May 2010, it was as high as 9.5. I am off insulin and am only taking Metformin now, so most of the drop in the number came from dietary changes due to my low carb lifestyle. So this is great progress, in just four months. But I can still do better. I expect the HbA1c reading will change over time as I lose more weight. I still have another 50 pounds to go to reach my goal weight and as I achieve that goal, I expect my blood glucose levels to drop.