Why as We Age, Do Doctors Say Raise Your A1C

This seems to be the rule as I age and I have more doctors asking me to raise my HbA1c. When I ask to what level, currently, I am told between 8.0 and 9.0. I am guessing this is because I am on insulin as two others that are on metformin or another oral medication have not been told to raise their A1C.

Allen, who regularly has an A1C below 5.6 percent, has also been advised to raise his A1C, however, he continues to say it will be what it is and I can do no less. He continues to eat very low carb and eats the fats to his satisfaction.

I suspect my A1C will rise because of all the comfort food I have consumed while undergoing the radiation for my prostate cancer. I have not had a PSA test since completing the radiation, but I will have one shortly, as well as the A1c test.

I am beginning to feel better, but other things are creating stress and three good friends are also battling for their lives. These three occupy my thoughts and best wishes are going out to them. I have been reassured by all three that they are not experiencing a lot of pain and one of the three is in an Iowa hospital full time. His daughter is passing information to several of us as she can. The rest of his family is gathering and she says her father is happy to see them.

My friend in North Dakota is ready to be admitted in a hospital, but his family has encouraged him to go to the Memorial Sloan Kettering Cancer Center in New York City. He has resisted so far, but is now considering this as his son has said he will pay for the trip and the family will cover any expense insurance will not cover. They are making calls to Sloan Kettering to see if they will accept him.

Then today, a cousin notified me that another of our relatives has passed. He was killed in an auto accident and it has been proven that the other driver was under the influence and because this is the fourth accident caused by him, at least he is finally being charged and will stand trial.

Stress has been with me the last week as I thought I was healing well after the radiation, but then some of the lining has started to come loose and the pain factor is worse than the pain during radiation. This lasted for 24 hours and I did not get much sleep during this. Now a couple of days later, my system has finally relaxed and I have had two nights of 12 hours of sleep each night. Now to see how much sleep I get for the next two nights.

Hospitals Need to Test More for Diabetes

Hospitals are being urged to test people for diabetes while in the hospital. Patients with high blood sugar and no known history of diabetes were five times more likely to leave the hospital with a diagnosis if given a standard test. Researchers say the high rate of hospital patients with high blood sugar diagnosed with diabetes who had no known history of the condition suggests increased screening is necessary to catch these patients.

Researchers at Touro University and Ohio University found a high rate of missed diabetes diagnoses were caught in the hospital, which they say suggests changes to hospital protocol and increased screening for the condition is necessary. The HbA1C test is used to measure average blood glucose level over the previous 8 to 12 weeks (The test actually measures blood glucose levels for the previous 16 weeks or four months). Often, it detects hyperglycemia, or high blood sugar, which can be ascribed to physiologic stress, illness or medications.

Hyperglycemia is often detected in hospital patients during treatment for conditions such as sepsis or heart attack, and the recent study showing a high proportion of these patients having diabetes or prediabetes suggests there is more doctors can do.

Dr. Jay Shubrook, a researcher at Touro University California, in a press release said, "We are missing opportunities to detect diabetes and initiate treatment for those patients to help manage that disease, which can reduce their long-term cost of care and disease burden."

For the study, published in the Journal of the American Osteopathic Association, the researchers reviewed medical records for 348 hospital patients with hyperglycemia in the hospital.

"From the osteopathic perspective of early detection equals better outcomes, it's easy to make a case for hospital protocols to trigger an HbA1C test when hyperglycemia is detected to distinguish between transient hyperglycemia and chronic disease," Shubrook said.

Understand Your HbA1c

The HbA1C test is known as the A1C test by most people. The A1C test measures the blood glucose level for the last four months. The prior month accounts for 50 percent of the A1C. The month prior to the last month accounts for 25 percent of the A1C, and the third and fourth prior months contribute the remaining 25 percent of the A1C value.

Doctors use the A1C value as a measure of how well you are managing your diabetes or not managing your diabetes. This is the reason we as patients need to use our meters to measure our daily blood glucose readings.

If you did not have diabetes, your typical A1C level would be about 5 percent. For people with diabetes, the experts can't agree on what the A1C target level should be. The American Diabetes Association (ADA) recommends an A1C target of less than or equal to 7 percent. The American Association of Clinical Endocrinologists (AACE) recommends a target of less than or equal to 6.5 percent.

Hemoglobin A, a protein found inside red blood cells, carries oxygen throughout the body. When there is glucose in the bloodstream, it can actually stick (glycate) to the hemoglobin A protein. More glucose in the blood means that more glucose sticks to hemoglobin, and a higher percent of hemoglobin proteins become glycated.

Once glucose sticks to a hemoglobin protein, it typically remains for the lifespan of the hemoglobin A protein — as long as 120 days. The A1C test measures how much glucose is actually stuck to hemoglobin A, or more specifically, what percent of hemoglobin proteins are glycated. Thus, having a 7% A1C means that 7% of the hemoglobin proteins are glycated.

This is where disagreement often comes into play. For people with well-managed type 2 diabetes, visits to the doctor may only be required twice a year. However, for those that have poorly managed diabetes or are on insulin (not that these people have poorly managed type 2 diabetes) probably will see their doctor at least four time per year. Always be prepared to see the doctor on a different schedule.

The A1C test, typically performed by a health care professional, often doesn’t hurt. Only a single drop of blood is needed, and the sample is either analyzed on-site or is sent to a laboratory for testing. Some doctors prefer doing the A1C test from a blood draw.

While the A1C is a good measure of overall glucose control, it cannot replace self-monitoring of blood glucose (SMBG). Like other tests, A1C results may vary from lab to lab. The A1C test is not calibrated the same everywhere, though an international effort is underway to standardize the A1C test to a new International Federation of Clinical Chemistry and Laboratory Medicine standard.

A1C results can be misleading when red blood cell survival is prolonged or reduced; some health conditions can result in falsely high A1c results (as in cases of anemia) or falsely low (as in cases of hemolysis). There are other factors that can affect the A1C results.

One piece of good news: When someone has his or her A1C checked, that person does not need to worry about fasting; food eaten on the same day won’t affect the score.

The Difference - A1C and Blood Glucose Monitoring

I do not like doctors and other medical professions that tell people with type 2 diabetes that they don't need to test and that a quarterly A1c test is sufficient. In attempting to find a doctor, I could relate to, I have run the gambit or gauntlet of bad doctors. Two have said they were taking me off insulin and would not give me a reason for doing this. They just stated that I should be on oral medications as a person with type 2 diabetes. One even told me the first statement and that he would not prescribe testing supplies. Needless to say, they obviously were not up to date about diabetes.

This is one reason the blog from the Mayo Clinic really hit home. The author asked, “A1C or blood glucose monitoring: Which one is better? Neither. You need both measurements to ensure you have good diabetes management.” The author discusses both and importantly their differences.

The A1c test: For doctors, this is their bread and butter. It tells them how you are managing your diabetes. Most doctors want this test every 3 to 6 months. How often will often depend on how well you manage your blood glucose levels as a person with type 2 diabetes.

“The goal standard set by the American Diabetes Association is for you to keep your A1c percentage at 7.0 or below. The American Association of Clinical Endocrinologists prefers the percentage to be 6.5 or below. The American Geriatrics Society recommends A1c levels of 7 percent or lower for healthy adults and less stringent levels for less healthy adults of 8 percent or lower.”

Now I don't agree with the upper limits that doctors recommend, but I do work to keep mine under the level set by the American Association of Clinical Endocrinologists. I will now get more technical by quoting from a blog by David Mendosa. “How much glycated hemoglobin we have in our blood depends first on the lifespan of our red blood cells. The “average lifespan is 120 days,” the book says, which is of course four months.

But the glycated hemoglobin in our blood is also “directly proportional to the concentration of glucose in our blood” and “represents integrated values for glucose over the preceding 8 to 12 weeks.” Most people seem to think that our levels at any time during this two to three month period are equal. But they aren’t.

“More recent values,” the book continues, “provide a larger contribution than earlier values.” How much more? “The plasma glucose in the preceding 1 month determines 50% of the HbA1C, whereas days 60 to 120 determine only 25%.” This is the key statement and the one that prompted me to change my testing strategy.” Note: David tests his A1c on a monthly basis.” If you missed reading his blog, you may want to read it. I did leave out some page references that were not adding meaning.

Blood glucose metering: There are several terms that may be used - “blood glucose testing” or “BG testing.” Yes, metering is not a generally used term for blood glucose meter and test strips. Checking your blood glucose level helps you immediately and gives you information to aid in diabetes management decisions.

If you are not on insulin, blood glucose testing several times per week can tell you how well you are managing your diabetes. It will let you know if you need to make lifestyle changes or if you need to contact your doctor.

The two tests together can tell your doctor how well the long-range management has been for the last 120 days. Consider the A1c as a movie for the last 120 days and the blood glucose meter readings as a snap shot in time.

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.

HbA1c Not Adequate to Assess Diabetes Care

Is the measure of HbA1c really inadequate in assessing diabetes care across specialties? According to this presentation at the American Diabetes Association 2013 Scientific Sessions, HbA1c levels for patients cared for by endocrinologists are the same as or better than those for individuals seen by general internists.

Why is this a big deal? Because when patients are compared on a medication basis, the general internists generally held their own except when it came to insulin where the general internists came out ahead. The study authors concluded that this was because primary care physicians were referring these patients to endocrinologists. Then the authors state that this was the reason endocrinologists were seeing patients with higher HbA1c levels. This is the reason the study authors do not believe that HbA1c is an adequate measure and does not allow for an apples-to-apples comparison.

This may be true, but without an age comparison, can we really be confident that the study authors are not concealing something. With the pressure I am receiving to bring my A1c levels up, we know that when we are discussing insulin, that the endocrinologists are fearful of hypoglycemia and in many ways let age govern their individualization instead of individual capabilities. Even a couple of other members of our support group are feeling the pressure to allow their A1c levels to increase.

This article in Medscape states that more elderly are admitted to hospitals for hypoglycemia than hyperglycemia. Unless I missed something, in neither article do they distinguish between types 1 nor type 2 and which may be causing the problems and the conclusions they are drawing. To properly evaluate the statistics in the hypoglycemia and in the study wanting to compare apples-to-apples, without numbers of each type being reported, the results can be misleading.

The apples-to-apples study was generally about type 2 patients, except that type 1 is mentioned here, “Those also using mealtime insulin in addition to basal insulin, with or without other medications (1531). The latter group included patients with type 1 diabetes, Dr. Phillips told Medscape Medical News.” This is where the confusion comes in and we are left wondering which type they are worried about causing the HbA1c problems and preventing the apples-to-apples comparison.

This is probably the reason for this statement - “This coverage is not sanctioned by, nor a part of, the American Diabetes Association.” This I know means that the study has not been peer-reviewed and could be the reason for poor information.

HbA1c Ineffective for Patients on Dialysis

I am not sure why it took so long for the medical community to come up with this study. Maybe it is because no one took time to explain glycation to the doctors and what dialysis does to the blood cells and the effects of chronic kidney disease on the body.

This has to be one of the times common sense was not present, and someone saw a chance to spend some money on a study that should not have been needed. Nonetheless, the Wake Forest Baptist Medical Center saw fit to spend the money and determine that indeed the HbA1c test was not reliable for people undergoing dialysis.

The article about this study also uses many catch phrases and terminology to muddy the water and make it seem like the study was of value. Even the opening statement leaves one wondering when the HbA1c became the gold standard for glucose monitoring. There is still a lot of disagreement about this being the appropriate test for diagnosis of diabetes.

Take into account the shorter life span of red blood cells and anemia in dialysis patients, it is no wonder the HbA1c has limited (no, lets state – no value) in dialysis patients. Another test, the glycated albumin or GA assay, appears to be far more effective for dialysis patients. The GA test used in this study is available in Japan, China and South Korea, but is not yet FDA approved in the United States.

I can see the next request for study funding. They will need to know how to translate the HbA1c into meaningful results for patients on dialysis. There will be a new HbA1c table issued for patients on dialysis. This will be related to the GA results so everyone can be on the same page, until the GA test is approved for use in the US.

The researchers instead issued this warning suggesting physicians not rely on the HbA1c in dialysis patients, instead suggesting that blood glucose levels be directly monitored with multiple daily readings until the GA test is available in the states.

Read the article here.