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The central goal of most people with diabetes and prediabetes is to lower their blood sugar, but experts say that for some people it’s possible for A1C to get too low. A very low A1C could entail a risk of hypoglycemia , and may also be a sign of other problems, such as eating disorders or excessive alcohol consumption.e60dc2a1-f33c-4a05-9b50-8e3e8e597629a3407acd-7574-49a5-909d-e44c829516db
What Is a Healthy A1C? What Is a Healthy A1C? An A1C test assesses your average blood sugar level over the previous several months. It’s often considered the most important measurement for diabetes diagnosis and management.e60dc2a1-f33c-4a05-9b50-8e3e8e597629a0cd1b06-5971-493f-b1f9-ddf5d5e8bbcb “The A1C test is a critical tool to help a clinician diagnose any type of diabetes,” says Aimée José, RN, CDCES, a diabetes educator in private practice in the San Diego area. “It also helps your healthcare team keep an eye on prediabetes and get an overall idea of your blood glucose levels with type 1 or type 2 diabetes.”e60dc2a1-f33c-4a05-9b50-8e3e8e59762908bb0e47-838e-4e8a-a958-fb67a8f29085
High A1C levels are strongly associated with diabetes complications such as kidney disease, vision loss, and nerve damage.e60dc2a1-f33c-4a05-9b50-8e3e8e59762929f1ddff-19f5-49c3-b474-b4b557a3f79c The American Diabetes Association recommends most adults with diabetes aim for an A1C of less than 7 percent,e60dc2a1-f33c-4a05-9b50-8e3e8e597629482e3232-0927-433d-a63a-18a30d164599 and many people with diabetes struggle to achieve this goal.e60dc2a1-f33c-4a05-9b50-8e3e8e597629aac24081-0d6e-4fc9-8550-fdd9acbb7156 But some people with type 1 or type 2 diabetes set an even lower goal for themselves, which may not be ideal. José says it’s not unusual or unhealthy for people without diabetes to have an A1C in the 4 percent range, but in people with diabetes, “an A1C below 5.7 percent suggests extremely tight blood sugar management, which could mean you’re experiencing hypoglycemia.” A low A1C could be a sign of other health issues, including: Excessive alcohol usee60dc2a1-f33c-4a05-9b50-8e3e8e5976291c142ac1-b692-4d66-97ec-774150ec005a Eating disorders, such as a restrictive diet or fastinge60dc2a1-f33c-4a05-9b50-8e3e8e59762969c3e4ac-bf9d-471b-917e-e00762599c6b Overaggressive use of insuline60dc2a1-f33c-4a05-9b50-8e3e8e5976299ecb0b5a-af71-4e30-a347-0d63087f5f3c
Low A1C and Hypoglycemia Low A1C and Hypoglycemia The primary concern with low A1C is the risk of dangerous low blood sugar levels, or hypoglycemia. José says this risk is usually only significant for people with diabetes who use glucose-lowering medications with a known risk of hypoglycemia, particularly insulin , sulfonylureas , and meglitinides. “If you take insulin and you dip below 70 millgrams per deciliter (mg/dL) on a daily basis, or you’re managing your insulin and blood sugar obsessively to stay below 100 mg/dL, I would be concerned.” Low blood sugar can be dangerous. Many people begin to feel the symptoms of hypoglycemia — including shakiness, sweating, and hunger — when their blood sugar drops below 70 mg/dL. When blood sugar drops below 50 mg/dL, people typically begin to experience cognitive impairment, including confusion, and may be unable to treat themselves or ask for help. Severe hypoglycemia can lead to seizures , coma, or even death, and is especially dangerous when it occurs while you are engaged in an activity that requires complete control, such as driving or swimming .e60dc2a1-f33c-4a05-9b50-8e3e8e5976297122e260-9cc6-4cb2-a5ef-7297c772aa9ce60dc2a1-f33c-4a05-9b50-8e3e8e5976294daa6281-4543-41f7-a2c7-a9425b6e5ecc Repeated episodes of hypoglycemia can also lead to hypoglycemia unawareness, a condition in which the body and brain no longer produce the telltale symptoms of low blood sugar. Hypoglycemia unawareness can greatly increase the risk of severe low blood sugar events, because it dulls the body’s natural warning signals.e60dc2a1-f33c-4a05-9b50-8e3e8e597629239e2f7d-33e8-46e2-a0f5-2880b1a2613a There are long-term health risks to hypoglycemia as well. “We know frequent high blood sugar levels aren’t healthy, but frequent lows are stressful for the body, too, especially the brain,” says José. Recurrent hypoglycemia, even when usually mild, carries a risk of permanent brain damage and increased cognitive dysfunction, including Alzheimer’s disease and dementia.e60dc2a1-f33c-4a05-9b50-8e3e8e5976294e369a27-49a3-4205-8186-c518c67de9fe “If your A1C is very low due to frequent hypoglycemia, it can permanently affect brain health and your overall daily safety,” says José. Some people with diabetes have been able to achieve low A1C results without increasing their frequency of low blood sugar events. A study of children and adults with type 1 diabetes who adhered to a low-carbohydrate diet found that they were able to achieve normal or near-normal A1C levels despite a low risk of hypoglycemia.e60dc2a1-f33c-4a05-9b50-8e3e8e597629fd1eb9da-5a08-4876-9a19-b5789c4aeede Such success requires a fastidious approach to lifestyle change and blood sugar management that may be difficult or inappropriate for many people with the condition to sustain.e60dc2a1-f33c-4a05-9b50-8e3e8e597629a40b337d-6939-4923-bbac-06350b76f481
How to Maintain Healthy A1C Numbers Maintaining Healthy A1C Numbers Your A1C is largely a reflection of your lifestyle habits and the accuracy of your insulin doses if you take them, says Jones. Chris Szoke, NP, CDCES , a nurse practitioner and diabetes specialist based in Tucson, Arizona, says that if you have diabetes and experience regular low blood sugar, you need to check in with your healthcare providers. “This is a clear sign that your insulin doses aren’t meeting your body’s needs. You need to work with your team to adjust them.” Szoke recommends starting by testing your blood sugar more often. “If you have diabetes or you’re concerned about your A1C, your doctor can help you get a glucose meter or a continuous glucose monitor (CGM) to look more closely at your blood sugar levels.” A CGM allows you to better anticipate and measure your risk of hypoglycemia. And today, newer insulin pumps can work in tandem with a CGM to automatically adjust your insulin rates, making it easier to stay in a healthy blood sugar range. These devices, known as automated insulin delivery (AID) systems or hybrid closed-loop insulin pumps, may be able to lower your A1C even while reducing the risk of hypoglycemia.e60dc2a1-f33c-4a05-9b50-8e3e8e59762982f7ac5f-a8bd-4c03-94fb-afce96f302ea Diabetes authorities also recommend higher A1C targets for certain populations. Children and teens, for example, tend to have an especially difficult time managing their blood sugar levels, and may not be able to target a lower A1C.e60dc2a1-f33c-4a05-9b50-8e3e8e597629a800217d-f707-4f81-8b03-b22f857db7d3 And Szoke says that older people with diabetes may experience some hypoglycemia unawareness after decades with the disease. “That means it simply isn’t safe for them to aim for tight blood sugar levels and a target range between 70 and 140 mg/dL,” he says. “Instead, they may need to aim a bit higher for their daily safety, and this will correlate with a higher A1C level, too, closer to 8 percent instead of below 7.” People with heart disease and chronic kidney disease are also at particularly high risk if they develop hypoglycemia, and they may need to set higher glycemic targets, too. It’s important to consult with your endocrinologist or doctor to decide what your own blood sugar targets should be, and how careful you need to be about the risk of hypoglycemia.
Low Blood Sugar in People Without Diabetes People Without Diabetes Low A1C is not a common problem in people without diabetes. There is some evidence, however, that people with naturally very low A1C levels (< 4.0 percent) have an enhanced risk of poor health outcomes, possibly due to inflammation, inhibited liver function, or aberrations in red blood cell anatomy.e60dc2a1-f33c-4a05-9b50-8e3e8e597629517d444e-8dfb-4065-b7da-0ae5cf61e205 A number of other conditions can cause a short-term danger of low blood sugar levels in people without diabetes, including heavy alcohol consumption, organ failure, gastric bypass surgery, and anorexia.e60dc2a1-f33c-4a05-9b50-8e3e8e597629618d1620-66b2-4b45-825b-0cf374b0d317 Hypoglycemia is also an occasional side effect of certain medications and can occur during a variety of health crises, such as severe infections.e60dc2a1-f33c-4a05-9b50-8e3e8e5976294e450ec3-b721-486b-afbd-9c710397fc32 Very rarely, dangerously low blood sugars are caused by tumors in the pancreas that produce insulin or other even less common tumors elsewhere in the body that make insulin-like substances.
The Takeaway For most people with or without diabetes, a low A1C is a sign of good metabolic health. People with diabetes who use glucose-lowering medications, particularly insulin, need to be careful when targeting a lower A1C because of the risk of low blood sugar (hypoglycemia). A low A1C could also be a result of other unhealthy behaviors, such as alcohol abuse or an eating disorder. If you use insulin to manage your diabetes, work closely with your healthcare team to develop dosing practices that keep your blood sugar in a healthy range with a low risk of hypoglycemia.
Resources We Trust Mayo Clinic: A1C TestCleveland Clinic: Hypoglycemia (Low Blood Sugar)Harvard Health Publishing: Rethinking A1C Goals for Type 2 DiabetesJohns Hopkins Medicine: Guide to DiabetesCenters for Disease Control and Prevention: Treatment of Low Blood Sugar (Hypoglycemia)
