HbA1c and its correlation with blood sugar level - An info for diabetes patients

HbA1c is used for assessment of long term glucose control.This lab test reveals average blood glucose level over the past 2 to 3 months.

Major use of HbA1c

1.Assessment of optimal glycemic control in a given patient.

2.Blood glucose control status in between checkups.

This is a quality control testing. Along with regular blood glucose testing it is also used to assess the success of present treatment and help to make necessary change in the treatment.

HbA1c results are expressed as a percentage. Normal value is 4% to 6%. 1% change in HbA1c represent 30 mg/dl change in mean blood glucose value.

HbA1c and blood glucose value correlation

HbA1c value(%)	Mean blood glucose
14	380
13	350
12	315
11	280
10	250
9	215
8	180
7	150
6	115
5	80
4	50

       

<7%	Excellent control. Those who are on drugs and insulin should be aware of hypoglycemia
7%-8%	Good control. Here the aim is to get a level <7% which indicate there should be attempt for further improvement.
>8%	Poor control, indicate that diabetes is not well controlled.

Frequency of measurement of HbA1c

1.Those people who meet the treatment target it has to be measured once in 6 months

2.Those are not adequately  controlled once in 3months.

3.Special care is required in preconception care of women with diabetes initially monitor in once a month and once glucose level is controlled once in 6 to 8 weeks.This is important for maximum fertility and optimum fetal growth.

Need for strict control of diabetes

Those who have adequate control of HbA1c has lesser complication of diabetes such as

1. Eye problems

2. Kidney problems

3. Nerve related complications

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Advice for diabetic drivers

Driving is a complex activity which requires adequate vision,motor skill and proper judgement.It is required in day to day life.Diabetes can adversely affect driving by producing low blood glucose,decreased vision and neurological problems.

Following are the advice for diabetic drivers

1. Diabetic drivers should inform the licensing authority and motor insurer about the diabetes and its treatment.

2. If there is sudden deterioration in vision they should not drive.

3. Before starting journey they are advised to check the blood glucose (even before short journey) and in between long journey.

4. They should avoid alcohol.

5. Diabetic drivers should take frequent rests with snacks or meals.

6. For emergency use they are advised to keep fast and long acting carbohydrates in the vehicle.

7. All diabetic drivers should carry personal identification indicating that they are diabetic.

8. If they develop hypoglycemia they should stop driving ,switch off the engine and leave the driver seat for treatment.

9. They should not restart driving for 1 hour after  the blood glucose returned to normal level.

Reason for diabetic drivers to stop driving

1. Newly detected diabetic patients who are started on treatment particularly if on insulin shouldn't drive  unless they achieved diabetic control and proper vision.

2. If a diabetic patient develop recurrent severe daytime hypoglycemia.

3.If the diabetic patient has disabling unawareness of hypoglycemia.

4.Reduced vision in both eyes less than 6/12

5.Severe nervous system complication such as loss of pain and touch in limbs.

6.Severe peripheral blood vessel complication.

7. Lower limb amputation.

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Target comprehensive metabolic control and monitoring in diabetes

Diabetes mellitus (DM) is a common metabolic disorders where hyperglycemia is the predominant manifestation. It is a multi system disease because of the  associated metabolic dysregulation. In United states DM is the leading cause of end-stage renal disease (ESRD), adult blindness and non-traumatic lower extremity amputations.It also increases the risk  for cardiovascular disorders. Diabetes is a lifelong disease. Comprehensive diabetes care involves not only  plasma glucose control, but also detect and manage DM-specific complications and modify its risk factors .

Treatment of diabetes:

Old concept

Involves only glucose control

Which prevent only  microangiopathic complication.

Recent treatment

Comprehensive metabolic control, which control blood glucose and other metabolic disturbances

FPG - Fasting plasma glucose

PPG - Postprandial plasma glucose

HbA1C - hemoglobin A1C

LDL-C - Law density cholesterol

Tg - Tryglyceride

BP - Blood pressure

Following things needed to be monitored in diabetic patients

1. Urine glucose has no value.
2. Plasma glucose - Fasting or postprandial weekly.
3. Glycated Hb - 8 to 12 weeks (RBC life–12wks), marker for long term control.
4. HbA1C better co-relates with PPG than FPG.
5. Monitor all 3 parameters (FPG, PPG, HbA1C).
6. BP -  In all sittings, every 3 months.
7. Urine Albumin - Once in year.
8. Lipid profile - Once in 6 months.
9. Fundus/Foot exam - Once in a year.

                      Some blood glucose meters

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Clinical manifestations of hypoglycemia in diabetic patients

Hypoglycemia is a major side effect of insulin treatment. It is a cause of anxiety in patient and the care givers. Hypoglycemia occur more during night and before meals. This  is due to imbalance between insulin administration and requirement.

Recently there is an increase in incidence as an attempt to achieve tight glycemic control. Hypoglycemic episodes are more in those patients whose blood glucose levels are reasonably well controlled. There is a person to person variation in the blood levels at which each patient  experience symptoms of hypoglycemia. Those patients whose glycemic control is poor experience symptoms at somewhat higher level of blood glucose. Thus patients should take extraprecaution during driving ,swimming etc .Patients on insulin are always advised to carry some form of sugar with them.Incidence of hypoglycemia is less in patients taking anti-diabetic drugs.

Hypoglycemia is  defined as plasma glucose level <45-50 mg/dl.Whipple’s triad forms an important frame work for diagnosis of hypoglycemia.

Whipple’s triad include the following 

Symptoms consistent with hypoglycemia

• Low plasma glucose concentration.
• Relief of symptoms after plasma glucose level is raised.
• clinical manifestations of hypoglycemia.

Clinical manifestation vary from mild tiredness to  unconsciousness .Most of the patients experience warning symptoms before severe manifestation occur .Sugar intake at this level can terminate further progression.  Warning symptom may be absent in patients on longstanding diabetes ,In such patients detachment from environment occur that can be easily detected by caregivers ..Most common warning symptoms are tremor and sweating. But periodical numbness is the most specific symptom. Manifestations of hypoglycemia can be neurogenic or neuroglycopenic. Symptoms of decreased glucose availability(neuroglycopenic symptoms) occur  only at later stages.

Symptoms of hypoglycemia

Early warning symptoms

• Adrenergic symptoms
• Palpitations(pounding heartbeat)
• Tremor
• Anxiety
• Cholinergic symptoms 
• Sweating
• Hunger
• Pins and needles in lips and tongue
• Headache (occasionally)

Neuroglycopenia symptoms 

Mild

• Double vision
• Slurring of speech
• Difficulty in concentrating

More advanced 

• Confusion
• Truculence
• Change of behaviour in the form of clumsiness ,irritability  or aggressiveness
• Naughtiness in children

Unconsciousness 

• Restlessness with sweating
• Hemiplegia, especially in older people (but rare)
• Convulsion

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