Know Your A1C: What This Blood Test Can Tell You About Your Risk for Diabetes and Cardiovascular Disease

Know Your A1C: What This Blood Test Can Tell You About Your Risk for Diabetes and Cardiovascular Disease

The higher the A1C level, the greater the risk of developing diabetes-related complications.

By Martin Tibuakuu, M.D., M.P.H. and Erin Michos, M.D., M.H.S. | Aug. 24, 2016, at 6:00 a.m.

Know Your A1C: What This Blood Test Can Tell You About Your Risk for Diabetes and Cardiovascular Disease
Man performing blood test on himself.

After a diabetes diagnosis, A1C is also used for gauging how well treatment controls blood sugar levels. MIKE WATSON IMAGES

A simple blood test can diagnose diabetes, but it also can tell you so much more, including your risk for heart attack and stroke.

Type 2 Diabetes: Who Is at Risk?

Diabetes, which causes chronically high blood sugar levels, is the seventh leading cause of death in the United States, according to the Centers for Disease Control and Prevention. It can also result in serious health complications, including heart disease, blindness, kidney failure and lower-extremity amputations. The CDC reports that close to 29.1 million people are currently living with diabetes in America, meaning about 1 of every 11 people has it. There are different types of diabetes, but Type 2 diabetes accounts for about 90 to 95 percent of all diagnosed diabetes cases.

Risk factors for Type 2 diabetes include older age, obesity, a family history of diabetes, prior history of gestational (pregnancy) diabetes, impaired glucose tolerance, physical inactivity and race/ethnicity. African-Americans, Latinos, American Indians and some Asian-Americans and Pacific Islanders are at particularly high risk for Type 2 diabetes.

What Is Prediabetes?

People with prediabetes have glucose (i.e., blood sugar) levels that do not meet the criteria for diabetes but are too high to be considered normal. These individuals have an increased risk for the development of diabetes and other serious health problems, including heart disease and stroke. According to the CDC, 86 million American adults, or more than 1 of 3 people, have prediabetes. Without lifestyle changes, such as eating healthy foods, getting regular physical activity and maintaining a healthy weight, 15 to 30 percent of these individuals will develop Type 2 diabetes within five years.

What Is the A1C Blood Test?

The term A1C is short for HbA1c, or hemoglobin A1C. It refers to glycated hemoglobin, which develops when hemoglobin – a protein within red blood cells that carries oxygen – becomes coated with glucose or sugar in the blood. The amount of glucose that combines with this protein is directly proportional to the total amount of sugar in a person’s system, and so the higher blood glucose levels are, the higher the A1C level. Red blood cells have a life span of 120 days; by measuring A1C, clinicians are able to determine average blood sugar levels over approximately two to three months. A1C is particularly important in people with diabetes because the higher the A1C level, the greater the risk of developing diabetes-related complications. After a diabetes diagnosis, A1C is also used for gauging how well treatment controls blood sugar levels. In the U.S., A1C results are given as a percentage of hemoglobin that is glycated.

How Does an A1C Test Differ From a Blood Glucose Level?

An A1C measurement is a marker of average blood sugar levels over a period of two to three months, so it is a more stable test assessing longer-term blood sugar control. This means less day-to-day fluctuations to A1C levels due to stress and illness. A1C is often tested using blood samples from the arm, but samples can also be taken from a finger prick. Fasting is not required before A1C testing like it is for the blood glucose test.

On the other hand, the blood glucose level gives us the concentration of glucose in the blood only at the time of the test.

Health care providers measure both A1C and blood glucose to ensure good diabetes control, which informs them of the long-term and day-to-day control of blood sugar levels.

How Do We Diagnose Diabetes and Prediabetes?

Both diabetes and prediabetes may be diagnosed based on either A1C or blood glucose criteria. Blood glucose criteria could either be a blood glucose level measured after an overnight fast or a two-hour blood glucose value after eating 75 grams of sugar.

An international committee of experts from the American Diabetes Association, the European Association for the Study of Diabetes and the International Diabetes Federation recommends that the A1C test be the primary test used to diagnose prediabetes and Type 2 diabetes.

What Are the A1C Criteria for Diabetes and Prediabetes Diagnosis?

A1C can indicate if people have prediabetes or diabetes based on the following:

A1C Percentage
Normal Below 5.7%
Prediabetes 5.7%–6.4%
Diabetes 6.5% or greater

An A1C level of 6.5 percent or more measured on two separate occasions indicates you have diabetes.

If your A1C test returns a reading of 5.7 to 6.4 percent, this indicates you have prediabetes and are at an increased risk of Type 2 diabetes. At this point, you need to talk to your doctor about appropriate lifestyle changes that could reduce your risk of developing full-blown Type 2 diabetes in the future.

It is important to note that normal ranges for A1C levels may vary from one lab to another, so patients who may wish to interpret their own A1C results need to keep this in mind, especially when using a lab that is different from the one used for previous testing.

What Is the Target A1C Level?

For most people with previous diagnoses of diabetes, a target A1C level of 7 percent or less is a common treatment target. However, this is a general target, and health care teams do tailor targets to meet individual goals. A1C values are not indicators of specific diabetes complications, meaning any complications could arise with any A1C value. However, the closer someone’s value is to the normal A1C range, the better. A person’s recommended A1C target should take into account his or her ability to achieve the target without any risk of serious health complications caused by blood sugar levels that are too low (called hypoglycemia).

What Are the Benefits of Lowering A1C?

Studies have shown that reducing A1C by 1 percent in people with diabetes reduces the risk of serious health complications involving small vessels of the eyes and kidneys, as well as nerves by almost 25 percent.

Also, a study published in the journal BMJ revealed that people with Type 2 diabetes who reduce their A1C level by 1 percent are:

  • 19 percent less likely to suffer cataracts
  • 16 percent less likely to suffer heart failure
  • 43 percent less likely to suffer amputation or death due to blood vessel diseases

A lower A1C level in the blood means a lower amount of sugar in the blood on average, which reduces the risk of developing complications caused by high blood sugar levels.

Who Should Get an A1C Test?

  • Everyone with Type 2 diabetes should be offered an A1C test at least once a year.
  • Some may require an A1C test more often. This is especially true for patients who had a recent change in medication(s) or if a health care team wishes to more frequently monitor a patient’s diabetes status to get it under control.
  • For those without diabetes, experts recommend that anyone 45 or older should consider getting tested for A1C, especially if they are overweight. If they are younger than 45 but are overweight and have one or more additional risk factors for diabetes, they should consider getting tested.

What Are the Limitations to A1C Testing for Diabetes?

While A1C tests are usually reliable and widely used, it’s important to acknowledge that the test may not be accurate in people who:

• Have insufficient hemoglobin due excessive bleeding (may have a falsely low A1C reading).

• Have iron-deficiency anemia (may have a falsely high A1C test).

• Have hemoglobin genetic variations or uncommon forms of hemoglobin, commonly found in African-Americans and people of Mediterranean or Southeast Asian heritage.

• Have had a recent blood transfusion or have other forms of hemolytic anemia (may have falsely low A1C results)

• Are pregnant.

What Can You Do to Protect Yourself From Diabetes?

Anyone can benefit from a reduction of long-term diabetes complications, such as heart attack, stroke, kidney failure and diabetic nerve pain, by controlling their A1C levels through adopting healthy lifestyle practices. The benefit of reducing A1C should not be underestimated. To reduce A1C levels, you can:

Eat healthy. By keeping your post-meal blood glucose low, A1C can gradually be reduced in patients with diabetes and prediabetes. Those with diabetes and prediabetes need to eat foods that are high in nutrition and avoid excess calories. A healthy diet is rich in fruits, vegetables, fiber, lean protein and “good” monounsaturated and polyunsaturated fats in moderation. Saturated fats, refined “simple” carbohydrates and processed foods should be limited. For instance, switching white bread and white rice for whole-grain and brown rice will help reduce blood glucose spikes after a meal. Understanding what to eat and what to avoid can be challenging. Talk to a registered dietitian if you need help with food choices and meal planning. Tracking daily food intake using a diet diary or calorie-counter app can help keep things in check.

Be physically active. By keeping physically active, blood glucose is moved from the blood into cells to produce energy for the body, which lowers blood glucose levels. Also, physical activity improves our body’s sensitivity to insulin, a hormone needed to transport glucose into cells. This means that less insulin is needed to transport large amounts of glucose. Everyone should incorporate physical activity into their daily routine. For those without diabetes, being physically active will help to prevent the onset of prediabetes and Type 2 diabetes. For those with diabetes, it will help them maintain good blood sugar levels. The American Diabetes Association recommends aiming for 30 minutes of moderate- to vigorous-intensity aerobic exercise at least five days a week, or a total of 150 minutes per week. Moderate intensity means that you are working hard enough that you can talk but not sing during the activity, while vigorous intensity means you can’t say more than a few words without pausing for a breath during the activity.

Maintain a healthy weight. Losing weight through diet and exercise if you are overweight will significantly improve blood sugar levels, meaning a good A1C measurement.

Monitor your numbers. Carefully monitor both blood sugar and A1C levels if you have diabetes. Your medical team will most likely recommend regular A1C testing to monitor your overall diabetes control over a period of two to three months. However, A1C should never replace blood sugar level monitoring. For instance, people on insulin and other medications that cause hypoglycemia need regular blood glucose monitoring to ensure blood glucose doesn’t get too low.

http://health.usnews.com/health-news/patient-advice/articles/2016-08-24/know-your-a1c-what-this-blood-test-can-tell-you-about-your-risk-for-diabetes-and-cardiovascular-disease

When scientists saw the mouse heads glowing, they knew the discovery was big

May 21
Kari Alitalo had studied lymphatic vessels for more than two decades. So he knew that this network, which carries immune cells throughout the body and removes waste and toxins, didn’t extend into the brain: This had been accepted wisdom for more than 300 years. “Nobody questioned that it stopped at the brain,” says Alitalo, a scientist at the University of Helsinki in Finland.

Three years ago, Alitalo wanted to develop a more precise map of the lymphatic system. To do this, he used genetically modified mice whose lymphatic vessels glowed when illuminated by a particular wavelength of light. (The mice had been given a gene from a species of glowing jellyfish.)

When viewing the modified mice under the light, Aleksanteri Aspelund, a medical student in Alitalo’s laboratory, saw something unexpected: The heads of the mice glowed. At first, he suspected that there was something wrong — with the animals, the lighting or the measuring equipment. But when Alitalo and Aspelund repeated the experiment, they got the same result. It seemed that the lymphatic vessels extended to the brain after all.

This was surprising, to say the least: In the 21st century, major findings involving basic human anatomy are rare. “These days, you don’t make discoveries like this,” Alitalo says. “But every once in a while in science, you stumble on something really unexpected. You open a new door, to a whole new world.”

Alitalo is one of several scientists exploring this new world. Working independently, several other researchers, including Maiken Nedergaard of the University of Rochester and Jonathan Kipnis of the University of Virginia School of Medicine, have also shown that lymphatic vessels extend into the brain.

The discovery is much more than a historical footnote. It has major implications for a wide variety of brain diseases, including Alzheimer’s, multiple sclerosis, stroke and traumatic brain injury.

Researchers have identified two networks: the vessels that lead into and surround the brain, and those within the brain itself. The first is known as the lymphatic system for the brain, while the latter is called the glymphatic system. The “g” added to “lymphatic” refers to glia, the kind of neuron that makes up the lymphatic vessels in the brain. The glymphatic vessels carry cerebrospinal fluid and immune cells into the brain and remove cellular trash from it.

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Alitalo, Nedergaard, Kipnis and others have found evidence that when the systems malfunction, the brain can become clogged with toxins and suffused with inflammatory immune cells. Over decades, this process may play a key rolein Alzheimer’s disease, Huntington’s disease, Parkinson’s disease and other neurodegenerative illnesses, research suggests. “This is a revolutionary finding,” Nedergaard says. “This system plays a huge role in the health of the brain.”

Nedergaard describes the glymphatic system as like a dishwasher for the brain. “The brain is very active,” she says, “and so it produces a lot of junk that needs to be cleaned out.”

In hindsight, she says, the system should have been noticed long ago. When the skull and head are dissected, the vessels are visible to the naked eye. But no one bothered to really look: “Usually the brain is seen only as a bunch of nerve cells. We have come to think of the brain as a computer. And it’s not. It’s a living organ.”

Nedergaard and Helene Benveniste, a scientist at Yale University, have found evidence linking problems in the lymphatic and glymphatic systems to Alzheimer’s. In a study on mice, they showed that glymphatic dysfunction contributes to the buildup in the brain of amyloid beta, a protein that plays a key role in the disease.

Last year, Jeff Iliff, a neuroscientist at Oregon Health & Science University, and several colleagues examined postmortem tissue from 79 human brains. They focused on aquaporin-4, a key protein in glymphatic vessels. In the brains of people with Alzheimer’s, this protein was jumbled; in those without the disease, the protein was well organized. This suggests that glymphatic breakdowns may play a role in the disease, Iliff says.

The vessels have also been implicated in autoimmune disease. Researchers knew that the immune system has limited access to the brain. But at the same time, the immune system kept tabs on the brain’s status; no one knew exactly how. Some researchers theorize that the glymphatic system could be the conduit and that in diseases such as multiple sclerosis — where the body’s immune system attacks certain brain cells — the communication may go awry.

The system may also play a role in symptoms of traumatic brain injury. Nedergaard has shown that in mice, the injuries can produce lasting damage to the glymphatic vessels, which are quite fragile. Mice are a good model, she says, because their glymphatic systems are very similar to humans’. She and Iliff found that even months after being injured, the animals’ brains were still not clearing waste efficiently, leading to a buildup of toxic compounds, including amyloid beta. Nedergaard returns to the dishwasher analogy. “It’s like if you only use a third of the water when you turn on the machine,” she says. “You won’t get clean dishes.”

Recent research has also found evidence that the glymphatic system may extend into the eye. For decades, scientists have noted that many people with Alzheimer’s disease also have glaucoma, in which damage to the optic nerve causes vision loss. But they struggled to find a common mechanism; the glymphatic system may be the link.

In January, Belgian and Swiss researchers identified a rich network of glymphatic vessels within the optic nerve. The scientists also found that when these vessels malfunction, they seem to leave behind deposits of amyloid beta as well as other neurotoxins that damage the optic nerve.

And in March, Harvard University researchers reported that glymphatic flow is significantly decreased in the period just before a migraine. The intense pain in these headaches is caused largely by inflamed nerves in the tissue that surrounds the brain. Neuroscientists Rami Burstein and Aaron Schain, the lead authors, theorize that faulty clearance of molecular waste from the brain could trigger inflammation in these pain fibers.

One key to glymphatic performance seems to be sleep. Nedergaard has shown that at least in mice, the system processes twice as much fluid during sleep as it does during wakefulness. She and her colleagues focused on amyloid beta; they found that the lymphatic system removed much more of the protein when the animals were asleep than when they were awake. She suggests that over time, sleep dysfunction may contribute to Alzheimer’s and perhaps other brain illnesses. “You only clean your brain when you’re sleeping,” she says. “This is probably an important reason that we sleep. You need time off from consciousness to do the housekeeping.”

Sleep position

Nedergaard and Benveniste have also found that sleep position is crucial. In an upright position — someone who is sitting or standing — waste is removed much less efficiently. Sleeping on your stomach is also not very effective; sleeping on your back is somewhat better, while lying on your side appears to produce the best results. The reason for these differences remains unclear, but Nedergaard suspects that it is probably related to the mechanical engineering of the lymphatic vessels and valves; she suggests that the healthiest approach may be to move periodically while you sleep.

Sleep is probably not the only way to improve glymphatic flow. For instance, a paper published in January by Chinese researchers reported that in mice, omega-3 fatty acidsimproved glymphatic functioning.

Benveniste is examining dexmedetomidine, an anesthetic that may have the ability to improve glymphatic flow. And in a small human study, other scientists have found that deep breathing significantly increases the glymphatic transport of cerebrospinal fluid into the brain.

Alitalo is experimenting with growth factors, compounds that can foster regrowth of the vessels in and around the brain. He has used this method to repair lymphatic vessels in pigs and is now testing the approach in the brains of mice that have a version of Alzheimer’s.

“Right now there are no clinical therapies in this area,” he says. “But give it a little time. This has only just been discovered.”


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