Reflections on Life with Type 2 Diabetes

When I was diagnosed in October of 2003, I knew it was possible and that diabetes was in my family. I admit I knew very little about diabetes and that I needed to start learning.

What I didn't appreciate was a doctor calling me a liar about knowing I had diabetes, even after I had told him to check with my doctor. Then I asked my doctor if he had been contacted and the answer was no. Needless to say, things got tense and I demanded an apology in writing from the doctor. Never received one, and two months later the doctor was no longer employed by the hospital.

The reason the doctor was so upset was because I was on the operating table at the time of diagnosis.   The procedure was being done to balloon several arteries and implant a stent in another artery. And yes, healing the area where they started to procedure took longer, but it did heal.

I did have the internet, but was not sure where to start. In talking with my doctor, I did have the loan of two books from his library that were about diabetes. I also did a lot of talking to my pharmacist and she gave me some ideas of where to look – the American Diabetes Association being one of them.

I did learn fast that the teachings of the ADA were not for me. The booklet for recording my blood glucose readings was set for the readings of the ADA suggestions and this seemed overly high for what I was reading on the internet. Several of the diabetes forums also were careful to promote the ADA way and the moderators were busy keeping people from promoting non-ADA positions. Two of the forums are ghost forums today with very little activity.

Research is not backing either of the two schools of thought for blood glucose levels or even the idea that lowering blood glucose levels drastically is an invitation to cardiovascular problems. I remember the ACCORD study that was canceled because the death level was too high. Analyzing the data in hindsight has proven invaluable, proved some ideas, and refuted others.

While the jury is still out since there have been conflicting studies about the good or bad of tight management of blood glucose levels. Yet, the current recommendations for good A1c's still hovers at 6.5% for young people (generally under the age of 60) and at 7.0% for older people (generally over the age of 59). This means that the blood glucose levels look like this:

• 7.0% A1c = 154 mg/dl (recommended by the American Diabetes Association)
• 6.5% A1c = 140 mg/dl (recommended by the American Association of Clinical Endocrinologists)
• 5.9% A1c = 123 mg/dl (this is near the top of the pre-diabetic range)
• 4.5% A1c = 83 mg/dl (this is considered about normal)
• 4.1% A1c = 71 mg/dl (readings below this level can be dangerous for type 2s)

Those first two numbers—154 and 140 mg/dl— are pretty high compared to the three bottom levels. In general, the two official levels are in the range that will promote gradual progression to complications. This is why those of us in our support group attempt to have A1c's at 6% or lower. Some even stay below 5% on a regular basis.

This blog from Diabetes Health makes the several statements which I do not believe in and will never promote, but it may be acceptable to some people, especially doctors.

Frequency Important in HbA1c Testing

I must state that after reading this short piece in Diabetes in Control, I started this blog and then I tried to follow the link at the bottom. This led to more confusion and much doubt. It turns out that the link was not to the correct article in Diabetes Care, but to a Pub Med article titled “The relationship between alcohol consumption and vascular complications and mortality in individuals with type 2 diabetes.” I had expected the article to be behind a pay wall, but not this.

The short article made no mention of where the study happened, but the article alluded to the ADA. False, the study was done in the United Kingdom and in my reading of the full study, kindly provided to me by David Mendosa, I have more questions than answers, to the point of actually thinking junk research.

Some of the points that raise questions include:

#1. Data collected after the fact from laboratory reports.

#2. Data not from a randomized-controlled trail, although this is made as a suggestion by the researchers. Of course, they want more funds for this type of a trial.

#3. Dosage adjustments and other interventions are not documented.

#4. Data for too short a time frame.

#5. Data too general and not specific – example for those receiving quarterly A1c tests and had initial A1c greater than 7% had an A1c reduction of 3.8 percent. If the average were 8%, this would be greater than 7.1%.

I would agree with the research just in the fact that among our support group members, those that test quarterly have a lower overall A1c average than the two individuals that are tested on a six-month schedule.

Then there are those that use the home A1c test on a monthly basis, two members, and they have in general the best A1c levels. One is on insulin and one is on no medications. For more information on home testing read this blog by David Mendosa.

The practice pearls offered by the Diabetes in Control author are reasonable and I will quote them.

1. While clinical guidelines are in place for HbA1c monitoring frequency, the recommended intervals are often not followed appropriately in practice.
2. This study showed that following the recommended testing interval recommendation was associated with a lowered HbA1c, particularly in those patients with HbA1c's of >7%.
3. Patients with testing intervals of 6 months or more were associated with increases in their HbA1c values.

The testing of A1c should not replace the testing done by individuals, but as a way of informing patients that their testing is either showing them that they are doing it right, or that they are not testing often enough or at the right time.

The recommendations by the ADA and AACE of relying only on the A1c by patients should never be followed, as this leaves the patient managing his or her diabetes in the dark and makes it more difficult to understand what is being done right or wrong.

If you have made it this far, you should read David's blog from yesterday.  He is able to put a positive light on the study.  I was upset by the false link provided by a fairly reputable service and let my negative side take over.  For this I make no apologies, as we need to be aware of weaknesses in studies and when studies are not telling us the whole story.

Why Are Elderly with Diabetes Discriminated Against?

When one of our support group members told me about his being cut loose by his doctor because of his age and A1c, I was going to vent and write a non-complementary blog about doctors. Now that I have had a few days to cool down and read a couple of other blogs, I know what needs to be said.

Allen had an A1c result of 5.0% and being on insulin, his doctor went ballistic and said he was no longer a patient. That A1c converts to an average blood glucose reading of 97 mg/dl. Allen showed me that he only had two readings below 70 mg/dl, one of 68 and one of 66 mg/dl. He had many readings for the last three months between 80 and 115 mg/dl, but only one reading at 129 mg/dl. Allen is on a low carb – high fat meal plan and has medium protein as part of the meal plan. He does eat a lot of self-caught fish and he does eat other purchased fish.

His doctor did not believe his meter readings and asked where his second meter was to be able to download that. Allen has a very good attitude and replied, “What you have is what you get, there ain't no more. If Dr. Bernstein can do this as a type 1, why can't I as a type 2?” For someone that was interested at one time on going back to oral medications, I don't think we could convince him to stop insulin now. He has even stated this to us, and said when he has problems or memory lapses, he will consider it then.

He is about five pounds under weight and says this is where he feels best and exercise is what he does to keep it there. We are all hoping he can find another doctor, but he does not seem concerned at this time. He says if he needs to rely on his VA doctor, so be it. He has mentioned Dr. Tom, but seems in no hurry.

This is an overt discrimination of the elderly to my way of thinking. Even I am considering a change now as my doctor has been asking me to raise my A1c to above 7.0%. We know what the doctors are afraid of and that is hypoglycemia. Never mind that we are managing our diabetes. I have a long way to improve mine to be at the level Allen is maintaining. In addition, I have more medications and other health problems of high blood pressure and cholesterol which are managed by medications.

Many of our group are concerned now and wondering why doctors have a difficult time assessing us properly and treating us accordingly. I won't use the person's name, but one of our members said that it may be because we are elderly and no longer contributing to society that they don't like us to be concerned about our health. He continued, they wish we would quietly die.

A Type 2 That Does Not Believe in Testing

Recently Allen and I ran into each other at the grocery store. I was on an errand for the wife and he was picking up supplies for the weekend. We stopped and talked briefly and while we were talking, another individual that neither of us knew overheard something I said about working on a blog about a book I had ordered. He interrupted us and asked if I was the person writing a diabetes blog.

When I asked the name of the blog, he had the name of my blog correct, so I acknowledged that I was the author. Then both of us had to listen to a string of profanity and him telling me that I could stop blogging, as I didn't know what I was talking about. Allen asked him what he talking about before I could.

He said testing and I asked for some specifics. He said any testing. Allen said I have different types of blogs on testing. He finally said telling people to test so often to learn what different foods do their bodies. He continued that his doctor says all he needs in a quarterly A1c test to learn what is needed. I asked why he believed his doctor.

The answer was that his doctor was his father and his father followed the ADA. Allen said if that is the case, we could not teach him anything. I said I have one question. What is his father's advice on nutrition? The answer was a total shock. The fellow said his father believed in not eating any whole grains, or starches. He said his father believed in low carb, low to medium protein and high fat.

Good, said Allen. We have that much in common. Next, Allen asked what medication he might be taking. Metformin was the reply and Allen asked how many years he had type 2 diabetes. The fellow answered about six years. I knew where Allen was heading with his question and Allen asked him if his father was testing him for vitamin B12 deficiency. The fellow answered that he had just had a test for vitamin B12 and vitamin D. He explained that his vitamin D was low and he had a shot for that and he was taking a supplement. The vitamin B12 was still in the suggested range, but on the low side. He said his father had suggested that he eat more liver, eggs, and salmon, plus beef and pork. Then in about 10 months, he would be tested again.

I asked what his last A1c had been and he said that after diagnosis of 12.0%, he was consistently between 5.0 to 5.8%. He continued that he was only taking 500 mg per day of metformin. I said he was fortunate that his father could monitor him and advise him on nutrition as it had helped him.

Allen stated that not everyone was as fortunate and received an education about diabetes, as he had been receiving. Then the secret came out. He stated that his mother was a doctor of nutrition and he had her for guidance. Allen and I said almost in unison, “No wonder you don't need to test.” He agreed and asked why I was pushing testing.

Allen said that not everyone receives the education and can have family available to help. Most of us need to learn on our own and testing is about the only avenue to available to help us learn.

I said I would continue to emphasize testing because without it, most are operating in the blind and would have no idea if they were improving or if their blood glucose numbers were becoming worse. I said he could ask his mother how hard it was for many people that believed the high carb, low fat doctrine that has been preached for so many decades.

I said I had to leave. Allen told me later that they had talked for almost an hour more. He said that the follow was a lot more positive when he left. He was in town visiting his sister and lived about three hours distant.

Testing with a Purpose

For people with type 2 diabetes, having limits on the number of test strips can create real problems. Our medical professionals often do not tell us about blood glucose testing. Then our medical insurance companies limit the number of test strips they will cover.  What makes me upset is the number of people with diabetes that refuse to learn the advantages of testing.

I have met individuals that are saying they are testing only for their doctors because this is what their doctors have requested. When I ask them if their doctors have looked at their testing logs or downloaded their meters, they admit that the doctor does not do either. At this point, I ask how many strips their insurance or Medicare/Medicaid pays for or reimburses them to use. Most have no idea and this tells me they don't care or don't understand the value of testing.

I even had two people say that they would not fill out and return the log required by Medicare to continue receiving testing supplies. Both had stopped testing as a result. I did take time to explain why Medicare wanted the number of times per day and month. One just said it was none of their business and clearly stated he would not do this. The other did ask for assistance and after I covered the first sheet, felt he could handle it. I took time to ask which medication he was using. He was on one of the sulfonylureas and had some days when he tested two to four times more because of a low.

Further investigation revealed the lows happened on days when he was not feeling well and often did not eat a meal or two. I advised him to talk with his doctor and see if he should not be taking one or two doses of his medication. He said he normally tested his fasting blood glucose level as soon as he was awake in the morning and that he did not have another test that day unless he felt sweaty or shaky later in the day. I asked him what his blood glucose readings were in the mornings. He said generally in the 85 to 105 mg/dl range, but about once a week or ten days, it could get up to 115 mg/dl.

He stated that he was supposed to take one pill in the morning and one in the evening. I asked if breakfast was one of the times he would not eat. He indicated that it was. I suggested that he not wait to talk to his doctor, but call immediately so that the doctor could call him back that day. I said that his blood glucose levels were such that taking his morning medication would cause hypoglycemia and thus his sweating and shakiness resulted when he did not eat.

I also suggested that on the mornings he was not feeling well and might not eat breakfast that he forego his testing and test before his evening meal to see what his blood glucose level was. He stated that his doctor had always advised him to test in the morning shortly after getting up for the day. I said that is often the case, but with what you are experiencing; he should allow what I suggested. I said because Medicare is only allowing one test strip per day, and with you on a sulfonylurea, testing alternatives should be allowed by your doctor.

At that point he opened up and said that he had a second meter and purchased extra test strips from a mass merchandise retailer and they were what he was using for testing when needed for lows. He had not told his doctor about this and I said there is no need. I said what the doctor is looking for or wanting you to look for is trends in your morning readings. He said the doctor is not looking at his testing log to see if there are trends. I asked if his A1c levels had varied up and down from one test to the next. He asked what A1c tests were.

I knew then I had to do more education. That will be included in my next blog.

Inaccurate Results from the A1c Test - Causes

Below is a simple graphic image of a red blood cell. One of the functions of the red blood cells is to carry oxygen to all the cells in the body. Hemoglobin within the red blood cells is the part that carries this oxygen. A vital part of the hemoglobin molecule is a fraction called hemoglobin A.



Glycosylation is the process of glucose binding to the hemoglobin areas of the red blood cells. Elevated blood glucose levels means more glycosylation happens.
A small, but measurable part of the hemoglobin A labeled A1 is formed when A is glycosylated. A further fraction of the A1 known as the hemoglobin A1c can also be measured. This A1c fraction is the area used for measuring the effective level of blood glucose management.


Red blood cells typically live for about 120 days, after which they die and are removed from circulation. New red blood cells are produced to replace those taken out of circulation. Therefore, at any given time, there are red blood cells that have just been born and those that are about to die. The average age for all the red blood cells present in the human body at a given time is about 2 months old, or half the total lifespan. Glycosylation occurs continually throughout the life span of the red blood cell. The amount of glycosylation of the hemoglobin depends on the level of blood glucose in the body, the higher the blood glucose level, the more glycosylation will occur.


Because the average age of the total pool of red blood cells is 2 months, the A1C measured represents predominantly, but not totally, the level of management during the previous 2-month period. This means that the higher the result of the A1c level, the poorer the diabetes management was during the preceding two months. Since the Joslin Diabetes Center follows the ADA guidelines, I can only suggest that what they advise should be adjusted for your own goals. Joslin says for any A1c 7.0% or higher, the treatment regimen needs to be adjusted. This is from Joslin's Diabetes Deskbook, Chapter 2.


Despite how much is dependent on the A1c test, there are conditions that cause inaccurate results. They include people with:
#1. Sickle cell anemia
#2. Women in early stages of pregnancy because the fetus produces its own red blood cells
#3. Recently had blood transfusions, many red cells have not been present the entire time in the patient.
#4. Splenectomy, which causes red blood cells to live longer
#5. Anemias, because many of the red cells can average younger in age


There are a few other conditions, which can cause erroneous A1c's, but in general, these are rare. Even with the above A1c problems, the use of the test is still a powerful tool in the battle of diabetes management.


For another view on the value of A1c and using the home A1c kit, read this blog by David Mendosa.

What Level of Glucose Control Is Best?

This is a difficult question and has many answers depending on the perspective from which you are viewing it. I am discovering this more and more among doctors specializing in diabetes, they will not commit to many rules. Most doctors will not commit to any specific goals except for the organization they believe in the most. This means 7.0% for those that follow the dogma of the American Diabetes Association and 6.5% if they follow the teachings of the American Association of Clinical Endocrinologists.  The most difficult goal is to have a doctor actually do an assessment and individualize any level of A1c goal for you as an individual.

I had thought what I was hearing was a result of my age, but in talking with other diabetes patients, much seems to depend on the medication the person is taking or not taking. Most doctors seem to expect HbA1c's below 5.0% if the person is managing with a meal plan and exercise. Once a person is on medications of any type, the expected level seems to be age variable and medication variable, but generally starts above 5.5% and moves up rapidly depending on the medication. The minimum level for people over the age of 64 seems to be 6.5%, but I have heard one patient say his doctor wanted him at a minimum of 7.5%. I could understand 7.0%.

Before going further, the method of collecting my data is not scientific and is just from asking questions when I find myself in a position to do so. I can say with some confidence that hypoglycemia is the force behind the numbers in most cases and this must keep doctors up at night. The first time I got below 5.9%, the endocrinologist wanted my meter readings and insisted I bring my meter with me to all appointments. I almost had a panic on my hands at the next appointment when I was at 5.6% until they had scoured my meter readings and found no reading below 76 mg/dl. I was, because I was short of 68 years of age, given a stern warning to bring my blood glucose level back over 6.0% and closer to 6.5%. Now they want it to be over 6.5% and I will continue to rebel.

Several of the support group on insulin have been maintaining their A1c's below 6.0% and being lectured about their levels. Allen had a recent A1c of 5.4% with no hypoglycemia episodes and only one reading below 80 at 79 mg/dl. Yet, he is the eldest of our support group and says he was read the riot act and told to raise his A1c. When he asked what was wrong with his readings and A1c, they could not tell him and he just said it will be what it is.

As a support group, we have concluded that hypoglycemia is what drives the concerns of doctors and they are very concerned to the point of being fearful of anything smelling like hypoglycemia. Our youngest support group member is the person that has been off medications the longest and as Sue says, her A1c of 5.2% only earned her a congratulation and keep up the good work. We now have three more members, Sue's husband, A.J., and John that have become medication free in the last two months.

Age seems to be a factor and while there is concern for people below 65 years of age, they are not lectured as hard unless they have several episodes of hypoglycemia. Therefore, I will not state that any one level of A1c is better than another. Each person needs to analyze their meter readings and decide what level they wish to achieve. Even I would be remiss in saying that if you have many episodes of severe hypoglycemia, the higher your A1c should probably be.

I hope this answers a few of the questions I have received lately. While I answered the emails individually, I felt this was a topic for a blog. I have enjoyed the questions asked and hope that I have answered them to your satisfaction. One person has thanked me for my answer and is asking more questions which I have enjoyed answering as he is looking for answers that are specific to him. He wants to see what he is capable of and realizes that even though he is receiving A1c's under 6.0, he is fighting very hard to prevent hypoglycemia and therefore realizes he has to be extremely careful. I have suggested that he discuss this with his endocrinologist and discuss maybe adjusting the insulin to carbohydrate ratio and possibly his correction ratio.

Another good read on A1c's is by Tom Ross, here.

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.

Is Your A1c Just Another Number?

Do you consider your A1c just another number? I admit I do not understand people that treat it this way and ignore what it is telling them and their doctor. One of the people in our informal group looks at the A1c just this way. Granted, his current A1c was a great improvement over his last A1c of 7.3%. He is unexcited with this one and says it is just one more reading. Yes, 6.6% is still above the AACE (American Association of Clinical Endocrinologists) recommendation of 6.5%; and he is still in an area where his complications can continue to develop.

When the three of us that were with him asked what number would excite him, his answer was none. He said he does not pay attention to the A1c's and only watches his daily blood glucose readings. He says those are important to him and is worth the extra cost of test strips as he tests as high as nine times a day.

Why do I care? Because I see articles on this almost on a quarterly basis and like this one, they are too short and often have missing information. Can the A1c be used initially to screen for diabetes? Some doctors do use it for screening. Other doctors prefer a fasting blood glucose (FBG), the oral glucose tolerance test (OGTT), and the A1c before they will diagnose diabetes. Another test in the diagnosis arsenal is the fasting plasma glucose (FPG) test. Still other doctors will use other tests to make sure it is type 2 and not type 1 or LADA. The C-peptide is also used to determine insulin resistance or the amount of insulin your body is producing. Levels of autoantibodies to insulin and the beta cells can be of some value but even these do not lead to an airtight diagnosis. This is because not all people with type 1 have these antibodies. Therefore, the diagnosis is still largely a clinical one.

There are others writing about A1c tests. David Mendosa has an explanation I have not seen before and you can read it here. I was aware that there is a variation in how long our red blood cells do live and that this can affect our A1c readings. David's blog covers much information that needs to be learned and retained by everyone. Tom Ross blogs about the A1c almost monthly lately by listing some of the search questions bringing people to his site. They are also very informative and he often adds some humor. The October blog is here and the September blog is here.  Next we can read Gretchen Becker's blog here about the A1c as she discusses accuracy.

The source that I use and depend on is the lab tests online dot org website. The reason I like it for my reference is that it covers topics most blogs and articles about the A1c do not even mention. Did you know that the A1c is not reliable for the following?

1. diagnosis in pregnant women,

2. people who have had recent severe bleeding or blood transfusions,

3. those with chronic kidney, liver disease, or are on dialysis.

4. people with blood disorders such as iron-deficiency anemia, vitamin B12 anemia, and hemoglobin variants.

“Only A1c tests that have been referenced to an accepted laboratory method (standardized) should be used for diagnostic or screening purposes.” Too many doctors tend to ignore this statement and diagnose anyway. This begs the question of what doctors are thinking when an A1c test results in excess of 7.0% and you are only given this statement, “Be care what you eat as your blood sugar is a little high.” Oh really – do they think they are being kind when they don't schedule you for more tests or have you return another day for the other tests to check if you are a person with diabetes. Any A1c over 7.0% should require more testing to determine if you have diabetes.

Other facts you may be wise to know:

1. The A1c test will not reflect temporary, acute blood glucose increases or decreases. The glucose swings of someone who has "brittle" diabetes will not be reflected in the A1c.

2. If you have a hemoglobin variant, such as sickle cell hemoglobin (hemoglobin S), you will have a decreased amount of hemoglobin A. This may limit the usefulness of the A1c test in diagnosing and/or monitoring your diabetes.

3. If you have anemia, hemolysis, or heavy bleeding, your test results may be falsely low.

4. If you are iron deficient, you may have an increased A1c measurement.

5. If you have had a recent transfusion, then your A1c will be falsely increased (blood preservative solutions contain high glucose levels) and not accurately reflect your glucose control for 2 to 3 months.

The following formula ADAG (A1c-Derived Average Glucose) is used to calculate your estimated Average Glucose (eAG) from your A1c result.

28.7 X A1c – 46.7 = eAG

An example of this is an A1c of 6%. The calculation for this would be:

28.7 X 6 – 46.7 = 126 mg/dl

for an estimated average glucose of 126 mg/dl. I repeat this is an estimated average because your blood glucose readings from your meter will generally not be close to this average. The variance is due to the timing of your meter readings and will not reflect an average.

What this means is that for every one percent that your A1c goes up, it is equivalent to your average glucose going up by about 29 mg/dl. For a printable chart conversion table for eAG click on this link.

Another Reason for Not Diagnosing Based on A1c

Ever since the American Diabetes Association made the recommendation of using the A1c for diagnosing diabetes and prediabetes, more studies are showing this to be a questionable decision. One study that I had found in the past is no longer available as when I click on the link the message I get is “page not found.” Apparently, there were some reasons for the study to have been pulled.

The A1c has been proven ineffective for use on people undergoing dialysis. This is not done for diagnosis, but should cast some serious doubts on the reliability of the A1c test for all tests. There is still a lot of discussion that for non-whites, the test is not an accurate reflection as it is for white Anglo-Saxons. Some are openly stating that the A1c test needs to be standardized for each ethnic group.

This makes sense as each ethnic group can be very different and react to medications differently. My own wife reacts very differently to medications that do not create problems for me.

Now we learn that another study proclaiming that the A1c cannot be used for diagnosis on people with iron-deficiency anemia. This study does come out of India, but highlights a very real problem in populations that are iron-deficient. Iron-deficiency increases erythrocyte survival. This elevates HbA1c concentrations at a glycemic level disproportionately.

This in turn gives a diagnosis of prediabetes or diabetes when in fact neither may be the case or prediabetes may be the correct diagnosis. The study clearly points out the problems for nutritionally compromised populations, in other words, more than half of the world's population.

Our Goals for A1c

Maryam Elarbi writing for Diabetes Self-management had a very well thought out blog about A1c goals. As one of the readers commented, “How mature of you to take this attitude!” And for a young person with type 1, she could not be more right.

Often, we read about young people her age that are off to college, completely coming at odds with diabetes and letting diabetes take a toll on their health. And then in later life realizing how foolish they were back when.

Maryam's blog is worth the time to read. Before I get to what I wanted to say about A1c goals her statement here is most important, “At 18 years old, I’m finally at the point where I understand that “being good” at diabetes isn’t for my parents’, CDE’s, or endo’s approval. I’m accepting the responsibility that I need to take the best control of my diabetes for me.”

Now how does this apply to type 2's? I can no longer say that maturity gets us to this point quicker when we develop diabetes in our later years, too many young people are now developing type 2 in their preteen and teen years. They are facing the same type of problems this type 1 has, accepting responsibility for their diabetes.

Denial is an ugly part of our lives that needs conquering, not only to get on with life, but to take care of diabetes and prolong life. Some get stuck in denial for periods long enough that the complications get a strong foothold on our bodies and recovery is impossible. I actually thought I was immune when denial did not happen shortly after my diagnosis. Yes, I had the anger of getting diabetes, but I knew that my family history said I was at very high risk.

It was not until the third year that I had any denial. I was on insulin four months after diagnosis and quite happy with the success I was having. My A1c's were improving and I was living with diabetes. I think that denial maybe came with the depression of dealing with diabetes 24/7. Or maybe it was a little self-blame. Again, I was fortunate that this did not last long and I was back to myself again. I must also give credit to starting my second marriage shortly before the denial/depression happened.

The American Association of Clinical Endocrinologists (AACE) recommends A1c's of 6.5 for the upper limit and in 4 of 5 times I will be under their limit. It is that fifth time that seems to grab my attention. I have, since shortly after my diagnosis, been able to maintain my A1c below 7.0 and a few times below 6.0. I had wanted to get below 5.5 regularly, but that has not happened.

As I continue to age, I have reset my goal to keep my A1c near 6.0, which has worked out very well. I have learned the hard way that if you set realistic short-term goals and can achieve them, then the long-term goals will generally take care of themselves. Yes, you may have glitches (or bumps) along the way, but you will not fail to achieve the short-term goals if they are realistic and well thought out.