March 16, 2013

What Is Your Risk Tolerance Level?

Emails can be interesting and have some of the most difficult questions to answer. Like Tom Ross (page down to Feb 26), I do get questions about what do I recommend for an A1c. I can only reply, what is your tolerance level? Or, the question will be something about the point on the A1c scale that prevents diabetes complications. To this, I always respond there are no A1c levels that will prevent complications, only reduce the risk level for complications to develop, unless you die first.

Most people do not understand what I mean by tolerance level. They are looking for numbers that they can remember and have as a goal. I then need to remind them that I could give them numbers upon numbers, they would not be able to achieve them, and they don't believe me. I ask them what their last three A1c readings were. I will use an example of 5.8%, 6.1%, 5.6%. In this case, it is a total of 17.5. Now divide this by 3 and the answer if 5.83%. Now if you are lucky, you might be able to obtain the next A1c of 5.8%, but most people will not. This person said she would not even try, as she wanted to go lower than the 5.6%. She actually did achieve an A1c of 5.3% for her next A1c.

This is an excellent A1c and some people are able to get this. She is following Dr. Richard Bernstein’s “Diabetes Solution” and hopes to obtain 5.0% and maintain the level within a few tenths. That is her goal and tolerance level. She does not wish to be above 5.2% after that.

My tolerance level is not to get above 6.5%. I have bounced all over the place and don't like this. Generally, I am between 5.9 and 6.6%, but have had lower and higher, but for the last two years, this has been the range. One doctor has emphatically told me to bring it up above 6.5%. I said that was not in my tolerance level and I wished to be closer to 6.0%. When he persisted, I asked if he was asking me to leave his practice. He claimed he that he was not, but for my age, this is where he felt I should be. I did tell him that I did not appreciate him pushing me to speed up the development of complications and that next time he said to bring my A1c up, I would not be back. We will see what happens.

Therefore, if you want to think of comfort zone instead of tolerance level or risk level, that will work. Everyone has their comfort zone they wish to maintain and this is good. I do encourage not being above 6.5% and the younger you are, the lower your comfort zone should be. I don't know that I will ever be comfortable above 6.5%, even as I grow older, but I will cross that bridge when I get there.

The higher the A1c level, the higher the level of risk you are willing to endure with diabetes. You are always at risk for development of any complication, but the closer you are able to maintain your A1c to the normal for healthy people, the less risk you are under. The recommended A1c of 6.5% by the American Association of Clinical Endocrinologists is not ideal and the risk level for diabetes complications is higher than an A1c of 6.0%. I do not understand why the American Diabetes Association sets their recommendation of A1c at 7.0%.

The table of the estimated average glucose (mg/dl) to A1c% is here and I suggest that you use the table to aid you in finding your comfort zone. The medication(s) you are on will also help you decide the risk, tolerance, or comfort level you wish to have as your goal.

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